CFOC3 updated final

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1 Caring for Our Children: National Health and Safety Performance Standards; Guidelines for Early Care and Education Programs, Third Edition A Joint Collaborative Project of American Academy of Pediatrics 141 Northwest Point Boulevard Elk Grove Village, IL 60007-1019 American Public Health Association 800 I Street, NW Washington, DC 20001-3710 National Resource Center for Health and Safety in Child Care and Early Education University of Colorado, College of Nursing 13120 E 19th Avenue Aurora, CO 80045 Support for this project was provided by the Maternal and Child Health Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services (Cooperative Agreement #U46MC09810)

2 Copyright © 2011 by American Academy of Pediatrics American Public Health Association National Resource Center for Health and Safety in Child Care and Early Education Second printing with minor corrections noted by asterisks, August 2011. Go to http://nrckids.org for future changes/additions to this publication. All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form or by any means, including photocopying, or utilized by any information storage and retrieval system without prior written permission from the publisher. To request permission to reproduce material from this book, please contact the Permissions Editor at the American Academy of Pediatrics by fax (847/434-8780), mail (PO Box 927, Elk Grove Village, IL 60007- 1019), or email ([email protected]). Suggested Citation: American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education. 2011. Caring for our children: National health and safety performance standards; Guidelines for early care and education programs . 3rd Edition. Elk Grove Village, IL: American Academy of Pediatrics; Washington, DC: American Public Health Association. Also available at http://nrckids.org. 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. ISBN 978-1-58110-483-7 (American Academy of Pediatrics) MA0552 (American Academy of Pediatrics) Printed and bound in the United States of America Design & Typesetting: Lorie Bircher, Betty Geer, Susan Paige Lehtola, Garrett T. Risley 2 3 4 5 6 7 8 9 10

3 Caring for Our Children: National Health and Safety Performance Standards Table of Contents Acknowledgements*** ix ... Introduction ... xvii Guiding Principles ... xix Advice to the User xxi ... New and Significant Changes in Caring for Our Children (CFOC) Standards Since the 2nd Edition ... xxiv Chapter 1: Staffing ... 1 1.1 Child:Staff Ratio, Group Size, and Minimum Age ... 3 3 1.1.1 Child:Staff Ratio and Group Size ... 1.1.2 Minimum Age ... 7 1.2 Recruitment and Background Screening ... 9 1.3 Pre-service Qualifications ... 10 1.3.1 Director’s Qualifications ... 10 1.3.2 Caregiver’s/Teacher’s and Other Staff Qualifications ... 12 1.3.3 Family Child Care Home Caregiver/Teacher Qualifications ... 18 1.4 Professional Development/Training ... 19 1.4.1 Pre-service Training ... 19 1.4.2 Orientation Training ... 21 1.4.3 First Aid and CPR Training ... 24 26 1.4.4 Continuing Education/Professional Development ... 1.4.5 Specialized Training/Education ... 29 31 1.4.6 Educational Leave/Compensation ... 32 1.5 Substitutes ... 1.6 Consultants ... 33 1.7 Staff Health ... 40 1.8 Human Resource Management ... 43 ... 1.8.1 Benefits 43 1.8.2 Evaluation ... 44 Chapter 2: Program Activities for Healthy Development ... 47 2.1 Program of Developmental Activities ... 49 2.1.1 General Program Activities ... 49 2.1.2 Program Activities for Infants and Toddlers from Three Months to Less Than Thirty-Six Months ... 57 61 2.1.3 Program Activities for Three- to Five-Year-Olds ... 2.1.4 Program Activities for School-Age Children ... 63 2.2 Supervision and Discipline ... 64 2.3 Parent/Guardian Relationships ... 77 2.3.1 General ... 77 2.3.2 Regular Communication ... 78 2.3.3 Health Information Sharing ... 80 2.4 Health Education ... 81 2.4.1 Health Education for Children ... 81 2.4.2 Health Education for Staff ... 83 2.4.3 Health Education for Parents/Guardians ... 84 ***Addition to Table of Contents in second printing, August 2011. Table of Contents iii

4 Caring for Our Children: National Health and Safety Performance Standards Chapter 3: Health Promotion and Protection 87 ... 89 3.1 Health Promotion in Child Care ... 89 3.1.1 Daily Health Check ... 3.1.2 Routine Health Supervision ... 89 3.1.3 Physical Activity and Limiting Screen Time ... 90 96 3.1.4 Safe Sleep ... 3.1.5 Oral Health ... 101 3.2 Hygiene ... 104 3.2.1 Diapering and Changing Soiled Clothing ... 104 3.2.2 Hand Hygiene ... 110 3.2.3 Exposure to Body Fluids ... 114 3.3 Cleaning, Sanitizing, and Disinfecting ... 116 3.4 Health Protection in Child Care ... 118 118 3.4.1 Tobacco and Drug Use ... 3.4.2 Animals ... 119 3.4.3 Emergency Procedures ... 122 3.4.4 Child Abuse and Neglect ... 123 3.4.5 Sun Safety and Insect Repellent ... 126 3.4.6 Strangulation ... 129 3.5 Care Plans and Adaptations ... 129 3.6 Management of Illness ... 131 3.6.1 Inclusion/Exclusion Due to Illness ... 131 3.6.2 Caring for Children Who Are Ill ... 137 3.6.3 Medications ... 141 144 3.6.4 Reporting Illness and Death ... Chapter 4: Nutrition and Food Service ... 149 151 4.1 Introduction ... 4.2 General Requirements ... 152 4.3 Requirements for Special Groups or Ages of Children ... 162 4.3.1 Nutrition for Infants ... 162 4.3.2 Nutrition for Toddlers and Preschoolers ... 174 4.3.3 Nutrition for School-Age Children ... 175 4.4 Staffing ... 176 4.5 Meal Service, Seating, and Supervision ... 177 4.6 Food Brought From Home ... 182 4.7 Nutrition Learning Experiences for Children and Nutrition Education for Parents/Guardians ... 183 4.8 Kitchen and Equipment ... 185 4.9 Food Safety ... 188 195 4.10 Meals from Outside Vendors or Central Kitchens ... Chapter 5: Facilities, Supplies, Equipment, and Environmental Health ... 197 5.1 Overall Requirements ... 199 5.1.1 General Location, Layout, and Construction of the Facility ... 199 5.1.2 Space per Child ... 203 5.1.3 Openings ... 204 5.1.4 Exits ... 206 5.1.5 Steps and Stairs ... 208 5.1.6 Exterior Areas ... 209 5.2 Quality of the Outdoor and Indoor Environment ... 211 211 5.2.1 Ventilation, Heating, Cooling, and Hot Water ... Table of Contents iv

5 Caring for Our Children: National Health and Safety Performance Standards 5.2.2 Lighting ... 217 218 5.2.3 Noise ... 219 5.2.4 Electrical Fixtures and Outlets ... 5.2.5 Fire Warning Systems ... 221 5.2.6 Water Supply and Plumbing ... 221 5.2.7 Sewage and Garbage ... 225 5.2.8 Integrated Pest Management ... 226 5.2.9 Prevention and Management of Toxic Substances ... 228 5.3 General Furnishings and Equipment ... 237 5.3.1 General Furnishings and Equipment Requirements ... 237 5.3.2 Additional Equipment Requirements for Facilities Serving Children with Special Health Care Needs ... 244 5.4 Space and Equipment in Designated Areas ... 245 5.4.1 Toilet and Handwashing Areas ... 245 5.4.2 Diaper Changing Areas ... 248 5.4.3 Bathtubs and Showers ... 250 5.4.4 Laundry Area ... 251 5.4.5 Sleep and Rest Areas ... 251 5.4.6 Space for Children Who Are Ill, Injured, or Need Special Therapies ... 255 5.5 Storage Areas ... 256 5.6 Supplies ... 257 5.7 Maintenance ... 259 Chapter 6: Play Areas/Playgrounds and Transportation ... 263 6.1 Play Area/Playground Size and Location ... 265 6.2 Play Area/Playground Equipment ... 269 6.2.1 General Requirements ... 269 272 6.2.2 Use Zones and Clearance Requirements ... 273 6.2.3 Play Area and Playground Surfacing ... 6.2.4 Specific Play Equipment ... 274 6.2.5 Inspection of Play Areas/Playgrounds and Equipment ... 277 6.3 Water Play Areas (Pools, Etc.) ... 278 6.3.1 Access to and Safety Around Bodies of Water ... 278 6.3.2 Pool Equipment ... 281* 6.3.3 Pool Maintenance ... 281 6.3.4 Water Quality of Pools ... 282 6.3.5 Other Water Play Areas ... 283 6.4 Toys ... 283 6.4.1 Selected Toys ... 283 6.4.2 Riding Toys and Helmets ... 286 6.5 Transportation ... 287 6.5.1 Transportation Staff ... 287 6.5.2 Transportation Safety ... 289 6.5.3 Vehicles ... 293 Chapter 7: Infectious Diseases ... 295 7.1 How Infections Spread ... 297 7.2 Immunizations ... 297 7.3 Respiratory Tract Infections ... 300 7.3.1 Group A Streptococcal (GAS) Infections ... 300 *Corrected page number in second printing, August 2011. v Table of Contents

6 Caring for Our Children: National Health and Safety Performance Standards 7.3.2 Type B (HIB) ... 301 Haemophilus Influenzae 303 7.3.3 Influenza ... ... 304 7.3.4 Mumps Neisseria Meningitidis (Meningococcus) ... 305 7.3.5 7.3.6 Parvovirus B19 ... 306 7.3.7 Pertussis ... 306 7.3.8 Respiratory Syncytial Virus (RSV) ... 307 7.3.9 Streptococcus Pneumoniae ... 308 7.3.10 Tuberculosis ... 309 7.3.11 Unspecified Respiratory Tract Infection ... 311 ... 7.4 Enteric (Diarrheal) Infections and Hepatitis A Virus (HAV) 311 7.5 Skin and Mucous Membrane Infections ... 315 7.5.1 Conjunctivitis ... 315 7.5.2 Enteroviruses ... 316 7.5.3 Human Papillomaviruses (Warts) ... 316 7.5.4 Impetigo ... 317 7.5.5 Lymphadenitis ... 317 7.5.6 Measles ... 318 7.5.7 Molluscum Contagiosum... 318 7.5.8 Pediculosis Capitis (Head Lice) ... 319 7.5.9 Tinea Capitis and Tinea Cruris (Ringworm) ... 319 320 7.5.10 Staphylococcus Aureus Skin Infections Including MRSA ... 7.5.11 Scabies ... 321 321 7.5.12 Thrush ... 7.6 Bloodborne Infections ... 321 7.6.1 Hepatitis B Virus (HBV) ... 321 7.6.2 Hepatitis C Virus (HCV) ... 324 7.6.3 Human Immunodeficiency Virus (HIV) ... 324 7.7 Herpes Viruses ... 326 7.7.1 Cytomegalovirus (CMV) ... 326 7.7.2 Herpes Simplex ... 327 7.7.3 Herpes Virus 6 and 7 (Roseola) ... 327 7.7.4 Varicella-Zoster (Chickenpox) Virus ... 328 7.8 Interaction with State or Local Health Departments ... 329 7.9 Note to Reader on Judicious Use of Antibiotics ... 329 Chapter 8: Children with Special Health Care Needs and Disabilities ... 331* 8.1 Guiding Principles for This Chapter and Introduction*** ... 333 ... 335 8.2 Inclusion of Children with Special Needs in the Child Care Setting 8.3 Process Prior to Enrolling at a Facility ... 336 8.4 Developing a Service Plan for a Child with a Disability or a Child with Special Health Care Needs ... 337 8.5 Coordination and Documentation ... 340 8.6 Periodic Reevaluation ... 341 8.7 Assessment of Facilities for Children with Special Needs ... 341 8.8 Additional Standards for Providers Caring for Children with Special Health Care Needs ... 342 Chapter 9: Administration** ... 345* 9.1 Governance*** ... 347 *Corrected page number in second printing, August 2011. **Corrected to “Administration” from “Policies” in second printing, August 2011. ***Addition to Table of Contents in second printing, August 2011. vi Table of Contents

7 Caring for Our Children: National Health and Safety Performance Standards 9.2 Policies ... 348 348 9.2.1 Overview ... 351 9.2.2 Transitions ... 9.2.3 Health Policies ... 353 9.2.4 Emergency/Security Policies and Plans ... 364 9.2.5 Transportation Policies ... 373 374 9.2.6 Play Area Policies ... 375 9.3 Human Resource Management ... 9.4 Records ... 377 9.4.1 Facility Records/Reports ... 377 9.4.2 Child Records ... 386 9.4.3 Staff Records ... 392 Chapter 10: Licensing and Community Action ... 395 10.1 Introduction ... 397 10.2 Regulatory Policy ... 397 10.3 Licensing Agency ... 398 10.3.1 The Regulation Setting Process ... 398 10.3.2 Advisory Groups ... 399 10.3.3 Licensing Role with Staff Credentials, Child Abuse Prevention, and ADA Compliance ... 400 10.3.4 Technical Assistance from the Licensing Agency ... 402 10.3.5 Licensing Staff Training ... 406 10.4 Facility Licensing ... 407 10.4.1 Initial Considerations for Licensing ... 407 10.4.2 Facility Inspections and Monitoring ... 409 10.4.3 Procedures for Complaints, Reporting, and Data Collecting ... 410 10.5 Health Department Responsibilities and Role ... 411 414* 10.6 Caregiver/Teacher Support ... 10.6.1 Caregiver/Teacher Training ... 414* 10.6.2 Caregiver/Teacher Networking and Collaboration 416 ... 10.7 Public Policy Issues and Resource Development ... 416* ... 419 Appendices 421 Appendix A: Signs and Symptoms Chart ... 426 Appendix B: Major Occupational Health Hazards ... Appendix C: Nutrition Specialist, Registered Dietitian, Licensed Nutritionist, Consultant, and Food 427 Service Staff Qualifications ... 428 Appendix D: Gloving ... Appendix E: Child Care Staff Health Assessment ... 429 Appendix F: Enrollment/Attendance/Symptom Record ... 430 Appendix G: Recommended Childhood Immunization Schedule ... 431 Appendix H: Recommended Adult Immunization Schedule ... 434 Appendix I: Recommendations for Preventive Pediatric Health Care ... 439 Appendix J: Selecting an Appropriate Sanitizer or Disinfectant ... 440 Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting ... 447 Appendix L: Cleaning Up Body Fluids ... 449 Appendix M: Clues to Child Abuse and Neglect ... 450 Appendix N: Protective Factors Regarding Child Abuse and Neglect ... 454 Appendix O: Care Plan for Children with Special Health Care Needs ... 456 ... Appendix P: Situations that Require Medical Attention Right Away 463 *Corrected page number in second printing, August 2011. Table of Contents vii

8 Caring for Our Children: National Health and Safety Performance Standards Appendix Q: Getting Started with MyPlate ... 464 465 Appendix R: Choose MyPlate: 10 Tips to a Great Plate ... 466 Appendix S: Physical Activity: How Much Is Needed? ... 467 Appendix T: Foster Care ... ... 469 Appendix U: Recommended Safe Minimum Internal Cooking Temperatures Appendix V: Food Storage Chart ... 470 Appendix W: Sample Food Service Cleaning Schedule ... 472 Appendix X: Adaptive Equipment for Children with Special Health Care Needs ... 473 Appendix Y: Non-Poisonous and Poisonous Plants ... 475 Appendix Z: Depth Required for Shock-Absorbing Surfacing Materials for Use Under Play Equipment ... 477 Appendix AA: Medication Administration Packet ... 479 Appendix BB: Emergency Information Form for Children with Special Health Care Needs ... 484 Appendix CC: Incident Report Form ... 486 487 ... Appendix DD: Injury Report Form for Indoor and Outdoor Injuries Appendix EE: America’s Playgrounds Safety Report Card ... 489 492 Appendix FF: Child Health Assessment ... 493 Appendix GG: Licensing and Public Regulation of Early Childhood Programs ... Appendix HH: Use Zones and Clearance Dimensions for Single-and Multi-Axis Swings ... 501 Appendix II: Bicycle Helmets: Quick-Fit Check ... 504 Appendix JJ: Our Child Care Center Supports Breastfeeding ... 506 Appendix KK: Authorization for Emergency Medical/Dental** Care ... 507 Appendix LL: Conversion Table - Second Edition Standard Numbering to Third Edition Standard Numbering ... 508 Appendix MM: Conversion Table - Third Edition Standard Numbering to Second Edition Standard Numbering ... 528 Acronyms/Abbreviations** ... 546* Glossary ... 549* Index ... 563* *Corrected page number in second printing, August 2011. **Corrected to “Medical/Dental” from “Medical” in second printing, August 2011. **Corrected to “Acronyms/Abbreviations” from “Acronyms” in second printing, August 2011 viii Table of Contents

9 Caring for Our Children: National Health and Safety Performance Standards field. We are pleased to build upon their foundational work ACKNOWLEDGMENTS in this Third Edition with new science and research. The National Resource Center for Health and Safety in Child Care would like to acknowledge the outstanding Technical Panel Chairs and Members contributions of all persons and organizations involved in the revision of Caring for Our Children: National Health and Child Abuse Safety Performance Standards: Guidelines for Out-of-Home Anne B. Keith, DrPH, RN, C-PNP, Chair; Child Care Programs, Third Edition . The collaboration of New Gloucester, ME the American Academy of Pediatrics, the American Public Melissa Brodowski, MSW, MPH; Washington, DC Health Association, and the Maternal and Child Health Gilbert Handal, MD, FAAP; El Paso, TX Bureau provided a wide scope of technical expertise from Carole Jenny, MD, MBA, FAAP; Providence, RI their constituents in the creation of this project. The subject- Salwa Khan, MD, MHS; Baltimore, MD specific Technical Panels as listed provided the majority Ashley Lucas, MD, FAAP; Baton Rouge, LA of the content and resources. Over 180 organizations and Hannah Pressler, MHS, PNP-BC; Portland, ME individuals were asked to review and validate the accuracy Sara E. Schuh, MD, FAAP; Charleston, SC of the content and contribute additional expertise where applicable. The individuals representing these organizations Child Development are listed in Stakeholder Reviewers/Additional Contributors Angela Crowley, PhD, APRN, CS, PNP-BC, Chair; (see below). This broad collaboration and review from the New Haven, CT best minds in the field has led to a more comprehensive and George J. Cohen, MD, FAAP; Rockville, MD useful tool. Christine Garvey, PhD, RN; Chicago, IL In a project of such scope, many individuals provide Walter S. Gilliam, PhD; New Haven, CT valuable input to the end product. We would like to Peter A. Gorski, MD, MPA; Tampa, FL acknowledge those individuals whose names may have Mary Louise Hemmeter, PhD; Nashville, TN been omitted. Michael Kaplan, MD; New Haven, CT Cynthia Olson, MS; New Haven, CT Steering Committee Deborah F. Perry, PhD; Baltimore, MD June Solnit Sale, MSW; Los Angeles, CA Danette Swanson Glassy, MD, FAAP Co-Chair, American Academy of Pediatrics; Children with Special Health Care Needs Mercer Island, WA Herbert J. Cohen, MD, FAAP, Chair; Bronx, NY Jonathan B. Kotch, MD, MPH, FAAP Elaine Donoghue, MD, FAAP; Neptune, NJ Co-Chair, American Public Health Association; Lillian Kornhaber, PT, MPH; Bronx, NY Chapel Hill, NC Jack M. Levine, MD, FAAP; New Hyde Park, NY Cordelia Robinson Rosenberg, PhD, RN; Aurora, CO Barbara U. Hamilton, MA Sarah Schoen, PhD, OTR; Greenwood Village, CO Project Officer, U.S. Department of Health and Human Nancy Tarshis, MA, CCC/SP; Bronx, NY Services, Health Resources and Services Administration, Melanie Tyner-Wilson, MS; Lexington, KY Maternal and Child Health Bureau; Rockville, MD Marilyn J. Krajicek, EdD, RN, FAAN Environmental Quality Director, National Resource Center for Health and Safety in Steven B. Eng, MPH, CIPHI(C), Chair; Port Moody, BC Child Care and Early Education; Aurora, CO Darlene Dinkins; Washington, DC Phyllis Stubbs-Wynn, MD, MPH Hester Dooley, MS; Portland, OR Former Project Officer, U.S. Department of Health Bettina Fletcher; Washington, DC and Human Services, Health Resources and Services C. Eve J. Kimball, MD, FAAP; West Reading, PA Administration, Maternal and Child Health Bureau; Kathy Seikel, MBA; Washington, DC Rockville, MD Richard Snaman, REHS/RS; Arlington, VA Brooke Stebbins, BSN; Concord, NH Caring for Our Children, The 3rd Ed. Steering Committee Nsedu Obot Witherspoon, MPH; Washington, DC would like to express special gratitude to the Co-Chairs of the First and/or Second Editions: General Health Dr. Susan Aronson, MD, FAAP; CAPT. Timothy R. Shope, MD, MPH, FAAP, Chair; Dr. Albert Chang, MD, MPH, FAAP; and Portsmouth, VA Dr. George Sterne, MD, FAAP. Abbey Alkon, RN, PNP, PhD; San Francisco, CA Paul Casamassimo, DDS, MS; Columbus, OH Their leadership and dedication in setting the bar high Sandra Cianciolo, MPH, RN; Chapel Hill, NC for quality health and safety standards in early care and Beth A. DelConte, MD, FAAP; Broomall, PA education ensured that children experienced healthier and Karen Leamer, MD, FAAP; Denver, CO safer lives and environments in child care and provided a Judy Romano, MD, FAAP; Martins Ferry, OH valuable and nationally recognized resource for all in the Acknowledgments ix

10 Caring for Our Children: National Health and Safety Performance Standards Linda Satkowiak, ND, RN, CNS; Denver, CO Lead Organizations’ Reviewers Karen Sokal-Gutierrez, MD, MPH, FAAP; Berkeley, CA American Academy of Pediatrics Sandra G. Hassink, MD, MPH, FAAP Infectious Diseases Jeanne VanOrsdal, MEd Larry Pickering, MD, FAAP, Chair; Atlanta, GA American Public Health Association Ralph L. Cordell, PhD; Atlanta, GA Elizabeth L. M. Miller, BSN, RN, BC; Newtown Square, PA Dennis L. Murray, MD; Augusta, GA Barbara Schwartz, PhD; New York, NY Thomas J. Sandora, MD, MPH; Boston, MA Andi L. Shane, MD, MPH; Atlanta, GA U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Injury Prevention Child Health Bureau Seth Scholer, MD, MPH, Chair; Nashville, TN R. Lorraine Brown, RN, BS, CPHP; Rockville, MD Laura Aird, MS; Elk Grove Village, IL CAPT. Stephanie Bryn, MPH; Rockville, MD Sally Fogerty, BSN, Med; Newton, MA Denise Sofka, MPH, RD; Rockville, MD Paula Deaun Jackson, MSN, CRNP, LNC; Philadelphia, PA National Resource Center for Health and Safety in Child Rhonda Laird; Nashville, TN Care and Early Education Project Team Sarah L. Myers, RN; Moorhead, MN Marilyn J. Krajicek, EdD, RN, FAAN; Director Susan H. Pollack, MD, FAAP; Lexington, KY Jean M. Cimino, MPH; Professional Research Assistant Ellen R. Schmidt, MS, OTR; Washington, DC Betty Geer, MSN, RN, CPNP; Research Assistant Alexander W. (Sandy) Sinclair; Washington, DC Barbara U. Hamilton, MA; Former Assistant Director Donna Thompson, PhD; Cedar Falls, IA Susan Paige Lehtola, BBA, BS; Research Assistant David Merten, BS; Former Research Assistant Nutrition Garrett T. Risley, MBA-HA; Research Assistant Catherine Cowell, PhD, Chair; New York, NY Linda Satkowiak, ND, RN, CNS; Nurse Consultant Sara Benjamin Neelon, PhD, MPH, RD; Durham, NC Gerri Steinke, PhD; Evaluator Donna Blum-Kemelor, MS, RD, LD; Alexandria, VA Ginny Torrey, BA; Program Specialist Robin Brocato, MHS; Washington, DC Kristen Copeland, MD, FAAP; Cincinnati, OH Stakeholder Reviewers/Additional Suzanne Haydu, MPH, RD; Sacramento, CA Contributors Janet Hill, MS, RD, IBCLC; Sacramento, CA Susan L. Johnson, PhD; Aurora, CO Kenneth C. Akwuole, PhD Ruby Natale, PhD, PsyD; Miami, FL U.S. Administration for Children and Families, Office of Child Jeanette Panchula, BSW, RN, PHN, IBCLC Care, DC Shana Patterson, RD; Denver, CO Barbara Polhamus, PhD, MPH, RD; Atlanta, GA Duane Alexander, MD, FAAP Susan Schlosser, MS, RD; Chappaqua, NY National Institute of Child Health and Denise Sofka, MPH, RD; Rockville, MD Human Development, MD Jamie Stang, PhD, MPH, RD; Minneapolis, MN Abbey Alkon, RN, PNP, MPH, PhD Organization and Administration American Academy of Pediatrics, Section on Early Christopher A. Kus, MD, MPH, Chair; Albany, NY Education and Child Care, IL Christine Ross–Baze; Topeka, KS University of California San Francisco, California Childcare Janet Carter; Dover, DE Health Program, CA Sally Clausen, ARNP, BSN; Des Moines, IA Judy Collins; Norman, OK Krista Allison, RN, BSN Pauline Koch; Newark, DE Parent, CO Jackie Quirk; Raleigh, NC Jamie Anderson, RNC, IBCLC Staff Health New Jersey Department of Health and Senior Services, Amy C. Cory, PhD, RN, CPNP, PCNS, BC, Chair; Division of Family Health Services, NJ Valparaiso, IN Kristie Applegren, MD Patricia S. Cole; Indianapolis, IN American Academy of Pediatrics, Council on Susan Eckelt, CDA; Tulsa, OK Communication and Media, IL Bethany Geldmaker, PNP, PhD; Richmond, VA Stephanie Olmore, MA; Washington, DC Lois D. W. Arnold, PhD, MPH Barbara Sawyer; Arvada, CO National Commission on Donor Milk Banking, American Breastfeeding Institute, MA x Acknowledgments

11 Caring for Our Children: National Health and Safety Performance Standards Charles Cappetta, MD, FAAP Susan Aronson, MD, FAAP American Academy of Pediatrics, Council on Sports Healthy Child Care America Pennsylvania, Pennsylvania Medicine and Fitness, IL Chapter of the American Academy of Pediatrics, PA Anne Carmody, BS Robert Baker, MD, PhD, FAAP Wisconsin Department of Children and Families, Bureau of Gastroenterology, Hepatology, and Therapeutics, NY Early Care Regulation, WI Polly T. Barey, RN, MS Anna Carter Connecticut Nurses Association, CT North Carolina Division of Child Development, NC Molly Bauer, ARNP, CPNP, RN Susan Case University of Iowa Health Care, IA Oklahoma Department of Human Services, OK Kristen Becker Dimitri Christakis, MD, FAAP Parent, WA American Academy of Pediatrics, Council on Debbie Beirne Communication and Media, IL Virginia Department of Social Services and Division of Tom Clark, MD, FAAP Licensing, VA Task Force of the Youth Futures Authority, GA Nancy P. Bernard, MPH Indoor Air Quality/ Washington State Department of Health, Sally Clausen, ARNP, BSN School Environmental Health and Safety, WA Healthy Child Care America, IA Wendy Bickford, MA Abby J. Cohen, JD Buell Early Childhood Leadership Program, CO National Child Care Information and Technical Assistance Center, CA Julia D. Block, MD, MPH, FAAP American Academy of Pediatrics, NY Herbert J. Cohen, MD, FAAP Council on Children with Disabilities, MD Kathie Boe Knowledge Learning Corporation, OR Albert Einstein College of Medicine, Department of Pediatrics, NY Kathie Boling Zero to Three, DC Teresa Cooper, RN Washington Early Childhood Comprehensive Systems, State Suzanne Boulter, MD, FAAP Department of Health, WA American Academy of Pediatrics, Section on Pediatric Dentistry and Oral Health, IL Kristen A. Copeland, MD, FAAP Cincinnati Children’s Hospital Medical Center, OH Laurel Branen, PhD, RD, LD University of Idaho, School of Family and Consumer Ron Coté, PE Sciences, ID National Fire Protection Association, MA Marsha R. Brookins William Cotton, MD, FAAP U.S. Administration for Children and Families, DC American Academy of Pediatrics, Council on Community Pediatrics, IL Mary Jane Brown Centers for Disease Control and Prevention, Environment Melissa Courts Division, GA Ohio Early Childhood Comprehensive Systems, Healthy Child Care America, OH Oscar Brown, MD, FAAP American Academy of Pediatrics, Committee on Practice in Debby Cryer, PhD Ambulatory Medicine and Immunizations, IL University of North Carolina-Chapel Hill, FPG Child Development Institute, NC Heather Brumberg, MD, MPH, FAAP American Academy of Pediatrics, Committee on Edward Curry, MD, FAAP Environmental Health, IL American Academy of Pediatrics, Committee on Practice in Ambulatory Medicine and Immunizations, IL Barbara Cameron, MA, MSW University of North Carolina, Carolina Breastfeeding Institute, NC Acknowledgments xi

12 Caring for Our Children: National Health and Safety Performance Standards Nancy M. Curtis Daniel Frattarelli, MD, FAAP Maryland Health and Human Services, American Academy of Pediatrics, Section on Clinical Montgomery County, MD Pharmacology and Therapeutics/Committee on Drugs, IL Cynthia Devore, MD, FAAP Doris Fredericks, MEd, RD, FADA American Academy of Pediatrics, Child Development, Inc., Choices for Children, CA Council on School Health, IL Gilbert Fuld, MD, FAAP Ann Ditty, MA American Academy of Pediatrics, Council on National Association for Regulatory Administration, KY Communication and Media, IL Steven M. Donn, MD, FAAP Jill Fussell, MD, FAAP American Academy of Pediatrics, Committee on Medical American Academy of Pediatrics, Committee on Early Liability and Risk Management, IL Childhood, Adoption, and Dependent Care, Section on Developmental and Behavioral Pediatrics, IL Elaine Donoghue, MD, FAAP American Academy of Pediatrics, Committee on Early Carol Gage Childhood, Adoption, and Dependent Care, IL U.S. Administration for Children and Families, Office of Child American Academy of Pediatrics, Section on Early Care, DC Education and Child Care, IL Robert Gilchick, MD, MPH Adrienne Dorf, MPH, RD, CD Los Angeles County Department of Public Health, Child and Public Health - Seattle and King County, WA Adolescent Health Program and Policy, CA Jacqueline Douge, MD, FAAP Frances Page Glascoe, PhD American Academy of Pediatrics, Council on American Academy of Pediatrics, Section on Developmental Communication and Media, IL and Behavioral Pediatrics, IL Benard Dreyer, MD, FAAP Mary P. Glode, MD, FAAP American Academy of Pediatrics, Council on American Academy of Pediatrics, Committee on Infectious Communication and Media, IL Diseases, IL Jose Esquibel Eloisa Gonzalez, MD, MPH Colorado Department of Public Health and Environment, CO Los Angeles County Department of Public Health, Physical Activity and Cardiovascular Health Program, CA Karen Farley, RD, IBCLC California WIC Association, CA Rosario Gonzalez, MD, FAAP American Academy of Pediatrics, Council on Rick Fiene, PhD Communication and Media, IL Penn State University, Capital Area Early Childhood Training Institute, PA David Gremse, MD, FAAP Gastroenterology, Hepatology, and Therapeutics, AL Margaret Fisher, MD, FAAP American Academy of Pediatrics, Disaster Preparedness Joseph Hagan, MD, FAAP Advisory Council, IL American Academy of Pediatrics, Bright Futures, IL American Academy of Pediatrics, Section on Infectious Diseases, IL Michelle Hahn, RN, PHN, BSN Healthy Child Care Minnesota, MN Thomas Fleisher, MD, FAAP American Academy of Pediatrics, Section on Allergy and Cheryl Hall, RN, BSN, CCHC Immunology, IL Maryland State Department of Education, U.S. Administration for Children and Families, Office of Child Janice Fletcher, EdD Care, MD University of Idaho, School of Family and Consumer Sciences, ID Lawrence D. Hammer, MD, FAAP American Academy of Pediatrics, Committee on Practice in Carroll Forsch Ambulatory Medicine and Immunizations, IL South Dakota Department of Social Services, Division of Child Care Services, SD xii Acknowledgments

13 Caring for Our Children: National Health and Safety Performance Standards Anne Hulick, RN, MS, JD Gil Handal, MD, FAAP Connecticut Nurses Association, CT American Academy of Pediatrics, Council on Community Pediatrics, IL Tammy Hurley American Academy of Pediatrics, Section on Child Abuse Patty Hannah and Neglect, IL KinderCare Learning Centers, OH Mary Anne Jackson, MD, FAAP Jodi Hardin, MPH American Academy of Pediatrics, Committee on Infectious Early Childhood Systems, CO Diseases, IL Thelma Harms, PhD Paula Deaun Jackson, MSN, CPNP, CCHC University of North Carolina-Chapel Hill, NC Pediatric Nurse Practitioner and Child Care Health Consultant, PA Sandra Hassink, MD, FAAP American Academy of Pediatrics, Obesity Initiatives, IL Paula James Contra Costa Child Care Council, Child Health and Nutrition Leo Heitlinger, MD, FAAP Program, CA Gastroenterology, Hepatology, and Therapeutics, PA Laura Jana, MD, FAAP James Henry American Academy of Pediatrics, Section on Early U.S. Administration for Children and Families, Office of Child Education and Child Care, IL Care, DC Renee Jarrett, MPH Mary Ann Heryer, MA American Academy of Pediatrics, Section on Early University of Missouri at Kansas City, Institute of Human Education and Child Care, IL Development, MO Paula Jaudes, MD, FAAP Karen Heying American Academy of Pediatrics, Committee on Early National Infant and Toddler Child Care Initiative, Zero to Childhood, Adoption, and Dependent Care, IL Three, DC Lowest Jefferson, REHS/RS, MS, PHA Pam High, MD, MS, FAAP Department of Health, WA American Academy of Pediatrics, Committee on Early Childhood Adoption and Dependent Care, IL Mark Jenkerson Missouri Department of Health and Senior Services, MO Chanda Nicole Holsey, DrPH, MPH, AE-C San Diego State University, Graduate School of Public Lynn Jezyk Health, CA U.S. Administration for Children and Families, Office of Child Care Licensing, DC Sarah Hoover, MEd University of Colorado School of Medicine, Veronnie Faye Jones, MD, FAAP JFK Partners, CO American Academy of Pediatrics, Committee on Early Childhood, Adoption, and Dependent Care, IL Gail Houle, PhD U.S. Department of Education, Early Childhood Programs Mark Kastenbaum Office of Special Education, DC Department of Early Learning, WA Bob Howard Harry L. Keyserling, MD, FAAP Division of Child Day Care Licensing and Regulatory American Academy of Pediatrics, Committee on Infectious Services, SC Diseases, IL Julian Hsin-Cheng Wan, MD, FAAP Matthew Edward Knight, MD, FAAP American Academy of Pediatrics, Section on Urology, IL American Academy of Pediatrics, Section on Clinical Pharmacology and Therapeutics/Committee on Drugs, IL Moniquin Huggins U.S. Administration for Children and Families, Office of Child Pauline Koch Care, DC National Association for Regulatory Administration, DE Acknowledgments xiii

14 Caring for Our Children: National Health and Safety Performance Standards 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, Office of Advisory Council, IL Early Learning, NC Mae Kyono, MD, FAAP Ellen McGuffey, CPNP American Academy of Pediatrics, Section on Early National Association of Pediatric Education and Child Care, IL Nurse Practitioners , NJ Miriam Labbok, MD, MPH, FACPM, FABM, IBCLC Kandi Mell University of North Carolina, Carolina Breastfeeding Juvenile Products Manufacturers Association, NJ Institute, NC Shelly Meyer, RN, BSN, PHN, CCHC Mary LaCasse, MS, EdD Missoula City-County Health Department, Child Care Department of Mental Health and Hygiene, MD Resources, MT James Laughlin, MD, FAAP Joan Younger Meek, MD, MS, RD, IBCLC American Academy of Pediatrics, Committee on Practice in Orlando Health, Arnold Palmer Hospital for Children, Florida Ambulatory Medicine and Immunizations, IL State University College of Medicine, FL Sharis LeMay Angela Mickalide, PhD, CHES Alabama Department of Public Health, Healthy Child Care Home Safety Council, DC Alabama, AL Jonathan D. Midgett, PhD Vickie Leonard, RN, FNP, PhD U.S. Consumer Product Safety Commission, MD University of California San Francisco, California Childcare Health Program, CA Mark Minier, MD, FAAP American Academy of Pediatrics, Herschel Lessin, MD, FAAP Council on School Health, IL American Academy of Pediatrics, Committee on Practice in Ambulatory Medicine and Immunizations, IL Mary Beth Miotto, MD, FAAP American Academy of Pediatrics, Council on Michael Leu, MD, MS, MHS, FAAP Communication and Media, IL American Academy of Pediatrics, Council on Communication and Media, IL Antoinette Montgomery, BA Parent, VA Katy Levenhagen, MS, RD Snohomish Health District, WA Rachel Moon, MD, FAAP American Academy of Pediatrics, Task Force on Infant Linda L. Lindeke, PhD, RN, CNP Positioning and SIDS, IL American Academy of Pediatrics, Medical Home Initiatives, IL Len Morrissey ASTM International, PA Michelle Macias, MD, FAAP American Academy of Pediatrics, Section on Developmental Jane Morton, MD, FAAP and Behavioral Pediatrics, IL American Academy of Pediatrics, Section on Breastfeeding, IL Karin A. Mack, PhD Centers for Disease Control and Prevention, GA Robert D. Murray, MD, FAAP American Academy of Pediatrics, Maxine M. Maloney Council on School Health, IL U.S. Administration for Children and Families, Office of Child Care, DC Scott Needle, MD, FAAP American Academy of Pediatrics, Disaster Preparedness Barry Marx, MD, FAAP Advisory Council, IL U.S. Office of Head Start, DC Sara Benjamin Neelon, PhD, MPH, RD Duke University Medical Center, Duke Global Health Institute, NC xiv Acknowledgments

15 Caring for Our Children: National Health and Safety Performance Standards Lori Saltzman Jeffrey Okamoto, MD, FAAP, FAACPDM U.S. Consumer Products Safety Commission, MD American Academy of Pediatrics, Council on School Health, IL Teresa Sakraida, PhD, MS, MSEd, BSN University of Colorado, College of Nursing, CO Isaac Okehie U.S. Administration for Children and Families, Office of Child Kim Sandor, RN, MSN, FNP Care, DC Connecticut Nurses Association, CT Stephanie Olmore Karen Savoie, RDH, BS National Association for the Education of Colorado Area Health Education Center System, Cavity Free Young Children, DC at Three, CO John Pascoe, MD, MPH, FAAP Barbara Sawyer American Academy of Pediatrics, Committee on National Association for Family Child Care, CO Psychosocial Aspects of Child and Family Health, IL Beverly Schmalzried Shana Patterson, RD National Association of Child Care Resource and Referral Colorado Physical Activity and Nutrition Program, CO Agencies, VA Jerome A. Paulson, MD, FAAP David J. Schonfeld, MD, FAAP American Academy of Pediatrics, Committee on American Academy of Pediatrics, Disaster Preparedness Environmental Health, IL Advisory Council, IL Kathy Penfold, MSN, RN Gordon E. Schutze, MD, FAAP Department of Health and Human Services, MO American Academy of Pediatrics, Committee on Infectious Diseases, IL Leatha Perez-Chun, MS U.S. Administration for Children and Families, Office of Child Lynne Shulster, PhD Care, DC Centers for Disease Control and Prevention, GA Christine Perreault, RN, MHA Steve Shuman The Children’s Hospital, CO Consultant, CA Lauren Pfeiffer Benjamin S. Siegel, MD, FAAP Juvenile Products Manufacturers Association, NJ American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health, IL Lisa Albers Prock, MD, MPH American Academy of Pediatrics, Section on Adoption and Geoffrey Simon, MD, FAAP Foster Care, IL American Academy of Pediatrics, Committee on Practice in Ambulatory Medicine and Immunizations, IL Susan K. Purcell, BS, MA Grandparent, CO Heather Smith Parent, MO Dawn Ramsburg, PhD U.S. Administration for Children and Families, Office of Child Linda J. Smith, BSE, FACCE, IBCLC, FILCA Care, DC Bright Future Lactation Resource Centre, OH Chadwick Rodgers, MD, FAAP Karen Sokal-Gutierrez, MD, MPH, FAAP American Academy of Pediatrics, Committee on Practice in UCB-UCSF Joint Medical Program, CA Ambulatory Medicine and Immunizations, IL Robin Stanton, MA, RD, LD Judy Romano, MD, FAAP Oregon Public Health Division, American Academy of Pediatrics, Section on Early Adolescent Health Section, OR Education and Child Care, IL Brooke Stebbins Kate Roper, EdM Healthy Child Care New Hampshire, Department of Public Massachusetts Early Childhood Comprehensive Systems, Health Services, NH State Department of Public Health, MA Kathleen M. Stiles, MA Bobbie Rose, RN Colorado Office of Professional Development, CO University of California San Francisco, California Childcare Health Program, CA Acknowledgments xv

16 Caring for Our Children: National Health and Safety Performance Standards 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 Taara Vedvik 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 Grace Whitney, PhD, MPA Connecticut Head Start Collaboration Office, CT Karen Cachevki Williams, PhD University of Wyoming, Department of Family and Consumer Sciences, WY David Willis, MD, FAAP American Academy of Pediatrics, Section on Early Education and Child Care, IL Cindy Young, MPH, RD, CLE County of Los Angeles Department of Public Health, CA xvi Acknowledgments

17 Caring for Our Children: National Health and Safety Performance Standards The revision of the standards for the third edition of Caring INTRODUCTION was an extensive process. The third edition for Our Children Every day millions of children attend early care and educa- benefited from the contribution of eighty-six technical ex- tion programs. It is critical that they have the opportunity to perts in the field of health and safety in early care and edu- grow and learn in healthy and safe environments with caring cation. Reviews and recommendations were received from and professional caregivers/teachers. Following health and 184 stakeholder individuals - those representing consumers safety best practices is an important way to provide quality of the information and organizations representing major early care and education for young children. The American constituents of the early care and education community. Academy of Pediatrics (AAP), the American Public Health Caregivers/teachers, parents/guardians, families, health care Association (APHA), and the National Resource Center for professionals, safety specialists, early childhood educators, Health and Safety in Child Care and Early Education (NRC) early care and education advocates, regulators, and federal, Caring for Our Chil- are pleased to release the 3rd edition of military, and state agencies all brought their expertise and dren: National Health and Safety Performance Standards; experience to the revision process. A complete listing of the . These Guidelines for Early Care and Education Programs Steering Committee, Lead Organizations’ reviewers, Techni- national standards represent the best evidence, expertise, cal Panel members, and Stakeholder contributors appears and experience in the country on quality health and safety on the Acknowledgment pages. practices and policies that should be followed in today’s The process of revising the standards and the consensus early care and education settings. building was organized in stages: History 1) Technical panel chairs recruited members to their panels In 1992, the American Public Health Association (APHA) and and reviewed the standards from the second edition. Us- the American Academy of Pediatrics (AAP) jointly pub- ing the best evidence available (peer reviewed scientific Caring for Our Children: National Health and Safety lished studies, published reports, and best practice information) Performance Standards; Guidelines for Out-of-Home Child they removed standards that were no longer applicable or Care Programs (1). The publication was the product of a out-of-date, identified those that were still applicable (in five year national project funded by the U.S. Department of their original or in a revised form), and formulated many new Health and Human Services, Health Resources and Services standards that were deemed appropriate and necessary. Administration, Maternal and Child Health Bureau (MCHB). 2) Telephone conference calls were convened among This comprehensive set of health and safety standards was technical panel chairs to bring consensus on standards that a response to many years of effort by advocates for quality bridge several technical areas. child care. In 1976, Aronson and Pizzo recommended devel- opment and use of national health and safety standards as 3) A draft of these revised standards was sent to a national part of a report to Congress in association with the Federal and state constituency of stakeholders for their comments Interagency Day Care Requirements (FIDCR) Appropriate- and suggestions. (2). In the years that followed, experts repeatedly ness Study 4) This feedback was subsequently reviewed and consid- reaffirmed the need for these standards. For example, while ered by the technical panels and a decision was made to was underway, the work to prepare Caring for Our Children further revise or not to revise a standard. It should be noted Who Cares for the National Research Council’s report, that the national review called attention to many important America’s Children? Child Care Policy for the 1990s , called points of view and new information for additional discussion for uniform national child care standards (3). Subsequently and debate. a second edition of Caring for Our Children was published 5) The edited standards were then sent to review teams of in 2002 addressing new knowledge generated by increas- the AAP, the APHA and the MCHB. Final copy was approved ing research into health and safety in early care and educa- by the Steering Committee representing the four organiza- tion programs. The increased use of the standards both in tions (AAP, APHA, NRC and MCHB). practical onsite applications and in research documents the value of the standards and validates the importance In projects of this scope and magnitude, the end product is Caring for Our of keeping the standards up-to-date (4). only as good as the persons who participate in the effort. It Children has been a yardstick for measuring what has been is hard to enumerate in this introduction the countless hours done and what still needs to be done, as well as a technical of dedication and effort from contributors and reviewers. manual on how to do it. The project owes each of them a huge debt of gratitude. Their reward will come when high-quality early care and Review Process education services become available to all children and their The Maternal and Child Health Bureau’s continuing fund- families! ing since 1995 of a National Resource Center for Health Overview of Content and Format Changes and Safety in Child Care and Early Education (NRC) at the University of Colorado, College of Nursing supported the Caring for Our Children, 3rd Edition contains work to coordinate the development of the second and third ten chapters of 686 Standards and thirty-nine editions. Appendices. We have made the following significant content and format changes in the third edition: Introduction xvii

18 Caring for Our Children: National Health and Safety Performance Standards related to child health; the U.S. Department of Defense has Total of fifty-eight new standards and fifteen new • standards for military child care; the Office of Child Care appendices. (OCC) produces health and safety standards for tribal child • Developed new and revised standards in all areas. care; the National Fire Protection Association has standards Some key areas of change include: for fire safety in child care settings. The Office of Child Care о Use of early childhood mental health consultants administers the Child Care and Development Fund (CCDF) and early education consultants; which provides funds to states, territories, and tribes to as- Monitoring children’s development and obtaining о sist low-income families, families receiving temporary public consent for screening; assistance, and those transitioning from public assistance in о Positive behavior management; obtaining child care so that they can work or attend train- Limiting screen time; о ing/education. Caregivers/teachers serving children funded Promoting physical activity; о by CCDF must meet basic health and safety requirements Swaddling; о set by states and tribes. All of these are valuable resources, MyPlate Healthy eating (including о , the United as are many excellent state publications. By addressing States Department of Agriculture (USDA) new health and safety as an integrated component of early care primary food icon); and education, contributors to Caring for Our Children have о Encouraging breastfeeding; made every effort to ensure that these standards are consis- о Hand sanitizers; tent with and complement other child care requirements and Sun safety and sunscreen; о recommendations. о Integrated pest management; о Influenza control; and Continuing Improvement Environmentally friendly settings and use of least о Standards are never static. Each year the knowledge base toxic products. increases, and new scientific findings become available. Updated and added new appendices including: • New areas of concern and interest arise. These standards Care plan for children with special health care о will assist individuals and organizations who are involved needs; in the continuing work of standards improvement at every о Helmet safety; level: in early care and education practice, in regulatory ad- о Helping children in foster care make successful ministration, in research in early childhood systems building, transitions; in academic curricula, and in the professional performance о Medication administration forms; of the relevant disciplines. о A poster on encouraging breastfeeding in early Each of these areas affects the others in the ongoing pro- care and education settings; cess of improving the way we meet the needs of children. Authorization for emergency medical/dental care. о Possibly the most important use of these standards will be Healthier eating as shown in the USDA о , MyPlate to raise the level of understanding about what those needs which replaces to support healthier MyPyramid are, and to contribute to a greater willingness to commit food choices. more resources to achieve quality early care and education For the list of new and significantly revised standards and where children can grow and develop in a healthy and safe appendices, see pages xxiv-xxix. See the Table of Contents environment. for a list of all Appendices. Steering Committee Caring for Our Children, 3rd Edition • Created new numbering system to differentiate Danette Swanson Glassy, MD, FAAP third edition standards from the second edition. See Jonathan B. Kotch, MD, MPH, FAAP Appendices LL and MM for conversion charts of the Barbara U. Hamilton, MA numbering system; Marilyn Krajicek, EdD, RN, FAAN Phyllis Stubbs-Wynn, MD, MPH Updated references for the rationale and comment • sections and moved the references to be placed with REFERENCES: the standard instead of at the back of the chapter; 1. American Public Health Association, American Academy of Pediatrics. 1992. Caring for our children. National health and safety • Added related standards at the bottom of each performance standards: Guidelines for out-of-home child care standard for easy referral. Washington, DC: APHA. programs. 2. USDHEW, Office of the Assistant Secretary for Planning and Requirements of Other Organizations Policy issues in day care: Summaries of 21 Evaluation. 1977. We recognize that many organizations have requirements papers, 109-15. 3. National Research Council, National Academy of Sciences. 1990. and recommendations that apply to out-of home early Who Cares for America’s Children? Child Care Policy in the 1990s. care and education. For example, the National Association Washington, DC: National Academy Press. for the Education of Young Children (NAEYC) publishes 4. Crowley, A. A., J. Kulikowich. 2009. Impact of training on child requirements for developmentally appropriate practice 35:93- Ped Nurs care health consultant knowledge and practice. and accreditation of child care centers; Head Start follows 100. Performance Standards; the AAP has many standards Introduction xviii

19 Caring for Our Children: National Health and Safety Performance Standards 6. Children with special health care needs encompass those GUIDING PRINCIPLES who have or are at increased risk for a chronic physical, The following are the guiding principles used in writing these developmental, behavioral, or emotional condition and who standards: also require health and related services of a type or amount 1. The health and safety of all children in early care and beyond that generally required by children. This includes education settings is essential. The child care setting offers children who have intermittent and continuous needs in all many opportunities for incorporating health and safety aspects of health. No child with special health care needs education and life skills into everyday activities. Health should be denied access to child care because of his/her education for children is an investment in a lifetime of good disability(ies), unless one of the four reasons for denying health practices and contributes to a healthier childhood care exists: level of care required; physical limitations of the and adult life. Modeling of good health habits, such as site; limited resources in the community, or unavailability of healthy eating and physical activity, by all staff in indoor and specialized, trained staff. Whenever possible, children with outdoor learning/play environments, is the most effective special health care needs should be cared for and provided method of health education for young children. services in settings including children without special health care needs. 2. Child care for infants, young children, and school-age children is anchored in a respect for the developmental 7. Developmental programs and care should be based on needs, characteristics, and cultures of the children and their a child’s functional status, and the child’s needs should be families; it recognizes the unique qualities of each individual described in behavioral or functional terms. Children with and the importance of early brain development in young special needs should have a comprehensive interdisciplinary children and in particular children birth to three years of age. or multidisciplinary evaluation if determined necessary. 3. To the extent possible, indoor and outdoor learning/play 8. Written policies and procedures should identify facility activities should be geared to the needs of all children. requirements and persons and/or entities responsible for implementing such requirements including clear guidance 4. The relationship between parent/guardian/family and child as to when the policy does or does not apply. is of utmost importance for the child’s current and future de- velopment and should be supported by caregivers/teachers. 9. Whenever possible, written information about facility Those who care for children on a daily basis have abundant, policies and procedures should be provided in the native rich observational information to share, as well as offer in- language of parents/guardians, in a form appropriate for struction and best practices to parents/guardians. Parents/ parents/guardians who are visually impaired, and also in an guardians should share with caregivers/teachers the unique appropriate literacy/readability level for parents/guardians behavioral, medical and developmental aspects of their who may have difficulty with reading. However, processes children. Ideally, parents/guardians can benefit from time should never become more important than the care and spent in the child’s caregiving environment and time for the education of children. child, parent/guardian and caregiver/teacher to be together 10. Confidentiality of records and shared verbal informa- should be encouraged. Daily communication, combined tion must be maintained to protect the child, family, and with at least yearly conferences between families and the staff. The information obtained at early care and education principal caregiver/teacher, should occur. Communication programs should be used to plan for a child’s safe and ap- with families should take place through a variety of means propriate participation. Parents/guardians must be assured and ensure all families, regardless of language, literacy level, of the vigilance of the staff in protecting such information. or special needs, receive all of the communication. When sharing information, such as referrals to services that 5. The nurturing of a child’s development is based on would benefit the child, attainment of parental consent to knowledge of the child’s general health, growth and de- share information must be obtained in writing. It is also im- velopment, learning style, and unique characteristics. This portant to document key communication (verbal and written) nurturing enhances the enjoyment of both child and parent/ between staff and parents/guardians. guardian as maturation and adaptation take place. As 11. The facility’s nutrition activities complement and supple- shown by studies of early brain development, trustworthy ment those of home and community. Food provided in a relationships with a small number of adults and an environ- child care setting should help to meet the child’s daily nu- ment conducive to bonding and learning are essential to the tritional needs while reflecting individual, cultural, religious, healthy development of children. Staff selection, training, and philosophical differences and providing an opportunity and support should be directed to the following goals: - for learning. Facilities can contribute to overall child devel Promoting continuity of affective relationships; a) opment goals by helping the child and family understand Encouraging staff capacity for identification with and b) the relationship of nutrition to health, the importance of empathy for the child; positive child feeding practices, the factors that influence c) Emphasizing an attitude of involvement as an adult in food practices, and the variety of ways to meet nutritional the children’s play without dominating the activity; needs. All children should engage in daily physical activity in Being sensitive to cultural differences; and d) a safe environment that promotes developmentally appro- Being sensitive to stressors in the home environment. e) priate movement skills and a healthy lifestyle. Guiding Principles xix

20 Caring for Our Children: National Health and Safety Performance Standards 12. The expression of, and exposure to, cultural and ethnic diversity enriches the experience of all children, families, and staff. Planning for cultural diversity through the provi- sion of books, toys, activities and pictures and working with language differences should be encouraged. 13. Community resources should be identified and informa- tion about their services, eligibility requirements, and hours of operation should be available to the families and utilized as much as possible to provide consultation and related services as needed. 14. Programs should continuously strive for improvement in health and safety processes and policies for the improve- ment of the overall quality of care to children. 15. An emergency or disaster can happen at any time. Programs should be prepared for and equipped to respond to any type of emergency or disaster in order to ensure the safety and well-being of staff and children, and communi- cate effectively with parents/guardians. 16. Young children should receive optimal medical care in a family-centered medical home. Cooperation and collabora- tion between the medical home and caregivers/teachers lead to more successful outcomes. 17. Education is an ongoing, lifelong process and child care staff need continuous education about health and safety related subject matter. Staff members who are current on health related topics are better able to prevent, recog- nize, and correct health and safety problems. Subjects to be covered include the rationale for health promotion and information about physical and mental health problems in the children for whom the staff care. If staff turnover is high, training on health and safety related subjects should be repeated frequently. 18. Maintaining a healthy, toxic-free physical environment positively impacts the health and well-being of the children - and staff served. Environmental responsibility is an impor tant concept to teach and practice daily. xx Guiding Principles

21 Caring for Our Children: National Health and Safety Performance Standards principals to implement good practice in early care and ADVICE TO THE USER education programs. The intended users of the standards include all who care States and localities who fund subsidized care and • for young children in early care and education settings and can use the stan- services for income-eligible families who work toward the goal of ensuring that all children from dards to determine the level and quality of service to be day one have the opportunity to grow and develop appro- expected. priately, to thrive in healthy and safe environments, and to develop healthy and safe behaviors that will last a lifetime. • of early childhood education University/College Faculty programs can instill healthy practices in their students All of the standards are attainable. Some may have al- to model and use with young children upon entering the ready been attained in individual settings; others can be early childhood workplace and transfer the latest research implemented over time. For example, any organization into their education. that funds early care and education should, in our opinion, adopt these standards as funding requirements and should Definitions set a payment rate that covers the cost of meeting them. We have defined many terms in the Glossary found on page Recommended Use 549. Some of these are so important to the user that we are emphasizing them here as well. Caregivers/Teachers can use the standards to develop • and implement sound practices, policies, and staff train- Types of Requirements: ing to ensure that their program is healthy, safe, age- A standard is a statement that defines a goal of practice. It appropriate for all children in their care. differs from a recommendation or a guideline in that it car - • can build integrated health Early Childhood Systems ries greater incentive for universal compliance. It differs from and safety components into their systems that promote a regulation in that compliance is not necessarily required healthy lifestyles for all children. for legal operation. It usually is legitimized or validated based on scientific or epidemiological data, or when this • Families have sound information from the standards to evidence is lacking, it represents the widely agreed upon, select quality programs and/or evaluate their child’s cur - state-of-the-art, high-quality level of practice. rent early care and education program. They can work in partnership with caregivers/teachers in promoting healthy The agency, program, or health practitioner that does not and safe behavior and practice for their child and fam- meet the standard may incur disapproval or sanction from ily. Families may also want to incorporate many of these within or without the organization. Thus, a standard is the healthy and safe practices at home. strongest criterion for practice set by a health organization or association. For example, many manufacturers advertise can assist families and con- Health Care Professionals • that their products meet ASTM standards as evidence to the sult with caregivers/teachers by using the standards as consumer of safety, while those products that cannot meet guidance on what makes a healthy and safe and age ap- the standards are sold without such labeling to undiscerning propriate environment that encourages children’s devel- purchasers. opment of healthy and safe habits. Consultants may use the standards to develop guidance materials to share with is a statement of advice or instruction pertain- guideline A both caregivers/teachers and parents/guardians. ing to practice. It originates in an organization with acknowl- edged professional standing. Although it may be unsolic- • Licensing Professionals/Regulators can use the evi- ited, a guideline often is developed in response to a stated dence-based rationale to develop or improve regulations request or perceived need for such advice or instruction. For that require a healthy and safe learning environment at a example, the American Academy of Pediatrics (AAP) has a critical time in a child’s life and develop lifelong healthy guideline for the elements necessary to make the diagnosis behaviors in children. of Attention-Deficit/Hyperactivity Disorder. National Private Organizations that will update stan- • A regulation takes a previous standard or guideline and for accreditation or guidance purposes for a special dards makes it a requirement for legal operation. A regulation discipline can draw on the new work and rationales of the originates in an agency with either governmental or official third edition just as Caring for Our Children’s expert con- authority and has the power of law. Such authority is usually tributors drew upon the expertise of these organizations in accompanied by an enforcement activity. Examples of regu- developing the new standards. lations are: State regulations pertaining to child:staff ratios Policy-Makers • are equipped with sound science to meet in a licensed child care center, and immunizations required emerging challenges to children’s development of lifelong to enter an early care and education program. The compo- healthy behaviors and lifestyles. nents of the regulation will vary by topic addressed as well State Departments of Education (DOEs) and lo- • as by area of jurisdiction (e.g., municipality or state). Be - can use the standards to cal school administrations cause a regulation prescribes a practice that every agency guide the writing of standards for school operated child or program must comply with, it usually is the minimum or care and preschool facilities, and this guidance will help the floor below which no agency or program should operate. Advice to User xxi

22 Caring for Our Children: National Health and Safety Performance Standards Types of Facilities: Functional Definition (By Age Developmental Level) Child care offers developmentally appropriate care and edu- cation for young children who receive care in out-of-home Birth-12 Birth to ambulation Infant settings (not their own home). Several types of facilities are months covered by the general definition of child care and educa- Ambulation to tion. Although there are generally understood definitions for 13-35 accomplishment of self-care child care facilities, states vary greatly in their legal defini- Toddler months routines such as use of the tions, and some overlap and confusion of terms still exists in toilet defining child care facilities. Although the needs of children From achievement of self- do not differ from one setting to another, the declared intent 36-59 Pre-schooler care routines to entry into of different types of facilities may differ. Facilities that oper - months regular school ate part-day, in the evening, during the traditional work day and work week, or during a specific part of the year may call Entry into regular school, School-Age themselves by different names. These standards recognize 5-12 years including kindergarten Child that while children’s needs do not differ in any of these through 6th grade settings, the way children’s needs are met may differ by Format and Language whether the facility is in a residence or a non-residence and whether the child is expected to have a longer or only a very Each standard unit has at least three components: the short-term arrangement for care. Type of , and the applicable itself, the Standard Rationale section, a Facility . Most standards also have a Comment A Small family child care home provides care section and a section. The Related Standards References , including the one to six children and education of reader will find the scientific reference and/or epidemiologi- caregiver’s/teacher’s own children in the home of the cal evidence for the standard in the rationale section of each caregiver/teacher. Family members or other helpers standard. The Rationale explains the intent of and the need may be involved in assisting the caregiver/teacher, but for the standard. Where no scientific evidence for a standard often, there is only one caregiver/teacher present at any is available, the standard is based on the best available one time. professional consensus. If such a professional consensus provides care and A Large family child care home has been published, that reference is cited. The Rationale , including the seven to twelve children education of both justifies the standard and serves as an educational caregiver’s/teacher’s own children in the home of the tool. The Comments section includes other explanatory caregiver/teacher, with one or more qualified adult information relevant to the standard, such as applicability of assistants to meet child: staff ratio requirements. the standard and, in some cases, suggested ways to mea- is a facility that provides care and education A Center sure compliance with the standard. Although this document , any number of children in a nonresidential setting of - reflects the best information available at the time of publica or thirteen or more children in any setting if the facility is tion, as was the case with the first and second editions, this open on a regular basis. third edition will need updating from time to time to reflect changes in knowledge affecting early care and education. For definitions of other special types of child care – drop-in, school-age, for the mildly ill – see Standard 10.4.1.1: Uni- is available at no cost online at Caring for Our Children form Categories and Definitions. http://nrckids.org. It is also available in print format for a fee from the American Academy of Pediatrics (AAP) and the The standards are to guide all the types of programs listed American Public Health Association (APHA). above. Standards have been written to be measurable and enforce- Age Groups: able. Measurability is important for performance standards in a contractual relationship between a provider of service Although we recognize that designated age groups and de- and a funding source. Concrete and specific language helps velopmental levels must be used flexibly to meet the needs caregivers/teachers and facilities put the standards into of individual children, many of the standards are applicable practice. Where a standard is difficult to measure, we have to specific age and developmental categories. The following provided guidance to make the requirement as specific as . categories are used in Caring for Our Children possible. Some standards required more technical terminol- ogy (e.g., certain infectious diseases, plumbing and heating terminology). We encourage readers to seek interpretation by appropriate specialists when needed. Where feasible, we have written the standards to be understood by readers from a wide variety of backgrounds. Advice to User xxii

23 Caring for Our Children: National Health and Safety Performance Standards that these standards are addressed appropriately in their The Steering Committee agreed to consistent use of the regulatory systems. Although the licensing requirements are terms below to convey broader concepts instead of using a most usually affected, it may be more appropriate to revise multitude of different terms. the health or building codes to include certain standards, Caregiver/teacher – for the early care and education/ • and it may be necessary to negotiate conflicts among ap- child care professional that provides care and plicable codes. learning opportunities to children—instead of child The National Standards are for reference purposes only care provider, just caregiver or just teacher; and should not be used as a substitute for medical or • Parents/guardians – for those adults legally legal consultation, nor be used to authorize actions be- responsible for a child’s welfare; yond a person’s licensing, training, or ability. Primary care provider – for the licensed health • professional, to name a few: pediatrician, pediatric nurse practitioner, family physician, who has responsibility for the health supervision of an individual child; Child abuse and neglect – for all forms of child • maltreatment; • Children with special health care needs – to encompass children with special needs, children with disabilities, children with chronic illnesses, etc. Relationship of the Standards to Laws, Ordinances, and Regulations The members of the technical panels could not annotate the standards to address local laws, ordinances, and regula- tions. Many of these legal requirements have a different intent from that addressed by the standards. Users of this document should check legal requirements that may apply to facilities in particular locales. In general, child care is regulated by at least three different legal entities or jurisdictions. The first is the building code jurisdiction. Building inspectors enforce building codes to protect life and property in all buildings, not just child care facilities. Some of the standards should be written into state or local building codes, rather than into the licensing requirements. The second major legal entity that regulates child care is the health system. A number of different codes are intended to prevent the spread of disease in restaurants, hospitals, and other institutions where hazards and risky practices might exist. Many of these health codes are not specific to child care; however, specific provisions for child care might be found in a health code. Some of the provisions in the stan- dards might be appropriate for incorporation into a health code. The third legal jurisdiction applied to child care is child care licensing. Usually, before a child care operator receives a license, the operator must obtain approvals from health and building safety authorities. Sometimes a standard is not included as a child care licensing requirement because it is covered in another code. Sometimes, however, it is not covered in any code. Since children need full protection, the issues addressed in this document should be addressed in some aspect of public policy, and consistently addressed - within a community. In an effective regulatory system, differ ent inspectors do not try to regulate the same thing. Advo- cates should decide which codes to review in making sure Advice to User xxiii

24 Caring for Our Children: National Health and Safety Performance Standards Standard 2.2.0.4: Supervision Near Bodies of Water. NEW AND SIGNIFICANT CHANGES IN Caring Adds concept that supervising adult is within an arm’s ( for Our Children ) STANDARDS SINCE CFOC length, providing, “touch supervision.” THE 2ND EDITION Enhanced with Standard 2.2.0.6: Discipline Measures. Most of the 3rd Edition Standards have had some CFOC information on positive behavior management and very changes. Below are those standards and appendices that limited use of time-out. are new in the 3rd Edition or have had significant updates/ Standard 2.2.0.7: Handling Physical Aggression, Biting, changes to the content since the 2nd Edition. Enhanced with more guidance on biting. and Hitting. CHAPTER 1 STAFFING Standard 2.2.0.8: Preventing Expulsions, Suspensions, Standard 1.1.1.2: Ratios for Large Family Child Care. and Other Limitations in Services – Includes recom- NEW. Lowered ratios for infants and toddlers to be more in line mends procedures and policies for handling challenging with small family child care. behaviors to minimize expulsions. Standard 1.1.2.1: Minimum Age to Enter Child Care – Standard 2.2.0.10: Using Physical Restraint. Updates NEW. Recommends healthy full-term infants can be safely language on what a care plan should cover for the rare ex- enrolled in child care settings beginning at three months of ception of a child with a special behavioral or mental health This standard reflects a desirable goal Reader’s Note: age. issue that may exhibit a behavior that endangers his/her when sufficient resources are available; it is understood that safety and others. for some families, waiting until three months of age to enter Standard 2.4.1.2: Staff Modeling of Healthy and Safe their infant in child care may not be possible. Behavior and Health and Safety Education Activities. Changed termi- Standard 1.2.0.2: Background Screening. Enhanced with examples in the area of nutrition and physi- nology from background checks to background screening. cal activity. Standard 1.4.3.1: First Aid and CPR Training for Staff. CHAPTER 3 HEALTH PROMOTION AND Updated to be in compliance with the American Health As - PROTECTION sociation’s 2010 recommendations on CPR. Standard 3.1.2.1: Routine Health Supervision and Growth Standard 1.6.0.3: Early Childhood Mental Health Consul- Monitoring. Updated to include tracking BMI. tants – NEW. Recommends consultants engage with a mini- mum of quarterly visits, and outlines experience, knowledge Standard 3.1.3.1: Active Opportunities for Physical Activ- base, and role of the mental health consultant. Includes number, type, and frequency of physical NEW. ity – activity by age group. Standard 1.6.0.4: Early Childhood Education Consultants – Recommends consultants engage with a minimum NEW. Standard 3.1.3.3: Protection from Air Pollution while of semi-annual visits, and outlines the experience, knowl- Recommends frequency of NEW. Children are Outside – edge base, and role of an education consultant. checking air quality index. Standard 3.1.3.4: Caregivers’/Teachers’ Encouragement CHAPTER 2 PROGRAM ACTIVITIES NEW. of Physical Activity – Recommends staff promotion Standard 2.1.1.3: Coordinated Child Care Health Pro- of children’s active play throughout the day. Provides guidelines for coordinating NEW. gram Model – Standard 3.1.4.1: Safe Sleep Practices and SIDS/Suffo- care, including eight interactive components. cation Risk Reduction. Updated with new information on Standard 2.1.1.4: Monitoring Children’s Development/ inappropriate infant sleeping equipment, pacifier use and Defines the role NEW. Obtaining Consent for Screening – swaddling. of caregivers/teachers in monitoring a child’s development, Recommends that NEW. Standard 3.1.4.2: Swaddling – and includes policies on developmental screening, and swaddling is not needed in child care settings. sharing observation with parents/guardians. Standard 3.1.4.3: Pacifier Use – Follows current NEW. Standard 2.1.1.6: Transitioning within Programs and American Academy of Pediatrics’ recommendations and Indoor and Outdoor Learning/Play Environments – NEW. recommends written policy on use. Recommends ensuring positive transitions for children when entering a new program and beginning new routines or Includes Standard 3.1.5.2: Toothbrushes and Toothpaste. activities within existing program. addition that toothbrushes should be replaced at least every three to four months. Standard 2.2.0.2: Limiting Infant/Toddler Time in Crib, Guidelines to specific High Chair, Car Seat, etc. – NEW. Standard 3.2.1.5: Procedure for Changing Children’s limit of time children should be confined in equipment. Outlines Soiled Underwear/Pull-Ups and Clothing – NEW. procedure consistent with and complimentary to the diaper Standard 2.2.0.3: Limiting Screen Time - Media, Com- changing procedure. puter Time – NEW. Provides specific limits outlined by age group and recommends what screen time is allowed be free Standard 3.2.2.5: Hand Sanitizers – NEW. Describes ap- of advertising. Also includes two exceptions. propriate use of hand sanitizers as alternative to traditional New and Significant Changes xxiv

25 Caring for Our Children: National Health and Safety Performance Standards health care provider and written permission from a parent/ handwashing for children twenty-four months and older guardian. Exception: Non-prescription sunscreen and insect This change is also reflected in Note to Reader: and staff. repellent must have parental consent but do not require several related standards. instructions from each child’s primary care provider. Standard 3.2.3.1 - Procedures for Nasal Secretions and Standard 3.6.3.2: Labeling, Storage, and Disposal of Use of Nasal Bulb Syringes. Provides guidance on the use Recommends participating in community Medications. of nasal bulb syringes. drug “take back” programs if available. Standard 3.2.3.2: Cough and Sneeze Etiquette – NEW. Describes appropriate etiquette to reduce the spread of CHAPTER 4 NUTRITION respiratory pathogens. breastfeeding Overall: Strengthens the encouragement of Standard 3.3.0.1: Routine Cleaning, Sanitizing, and Dis- throughout the document by incorporating supportive word- infecting. Moved chart to Appendix K and updated defini- ing throughout the infant-related standards. tions of sanitizer and disinfectant. Overhauls detail Standard 4.2.0.4: Categories of Foods. Standard 3.4.2.1: Animals that Might Have Contact with information including limiting juice serving sizes, limiting fat Children and Adults. Updated with more specificity to content of milk, and avoiding concentrated sweets and limit types of animals allowed and under what conditions. salty food. these changes are also reflected Note to Reader: Updated with more Standard 3.4.2.2: Prohibited Animals. in several related standards. specificity on types of animals that are prohibited and why. Discusses Standard 4.2.0.5: Meal and Snack Pattern. Standard 3.4.2.3: Care for Animals. Updated with more breastfed infant feeding patterns in collaboration with fami- specificity on caring for animals in child care settings. lies. Standard 3.4.4.3: Preventing and Identifying Shaken Standard 4.2.0.11: Ingestion of Substances that Do Not NEW. Baby Syndrome/Abusive Head Trauma – Discusses monitoring of children NEW. Provide Nutrition – to prevent ingestion of non-nutritive substances. Standard 3.4.4.5: Facility Layout to Reduce Risk of Child Abuse and Neglect. Removed recommending use of video En- Standard 4.2.0.12: Vegetarian/Vegan Diets – NEW. surveillance due to privacy concerns. courages accommodation of these diets in the child care setting. NEW. Standard 3.4.5.1: Sun Safety Including Sunscreen – Explains procedures for protecting children from over expo- Standard 4.3.1.2: Feeding Infants on Cue By a Consis- sure and the proper use and types of sunscreen. tent Caregiver/Teacher. Changes terminology and detail from “on demand” to “on cue”. Standard 3.4.5.2: Insect Repellent - Protection from NEW. Outlines appropriate use Vector Borne Diseases – Standard 4.3.1.3: Preparing, Feeding, and Storing Human and types of insect repellent; also instructions on protecting Provides new guidelines on storage; use of glass or Milk. children and staff from ticks and proper removal of ticks. BPA-free plastic bottles; enhancement of preparing. Standard 3.5.0.1: Care Plan for Children with Special Standard 4.3.1.4: Feeding Human Milk to Another Health Care Needs. Describes for whom a care plan should Mother’s Child. Adds information about previous treatment be prepared and gives example in new Appendix O. Former - related to potential HIV transmission, along with hepatitis B ly, there was a separate standard on care plan for asthma. and C transmission issues. Standard 3.6.1.1: Inclusion/Exclusion/Dismissal of Chil- Standard 4.3.1.5: Preparing, Feeding, and Storing Infant Provides updated information on those conditions for dren. Formula. Adds more on safe handling and specifics on which children should or should not be temporarily excluded powdered formula. from child care. Standard 4.3.1.6: Use of Soy-Based Formula and Soy Standard 3.6.1.2: Staff Exclusion for Illness. Provides up- Milk – - Discusses allowing soy products with par NEW. dated information on those conditions for which staff should ent/guardian request. Encourages families and caregivers/ or should not be temporarily excluded from child care. teachers in securing community resources for soy-based formula. Standard 3.6.1.3: Thermometers for Taking Human Tem- Describes types of thermometers to use. peratures – NEW. Adds Standard 4.3.1.8: Techniques of Bottle Feeding. type of nipple to use and good example where breastfeed- Standard 3.6.2.10: Inclusion and Exclusion of Children ing is interlaced (i.e., bottle feeding should mimic approach- Provides from Facilities that Serve Children Who are Ill. es to breastfeeding). updated information on those conditions for which children should or should not be temporarily excluded from child Standard 4.3.1.9: Warming Bottles and Infant Foods. care. Recommends BPA free plastics. Reflects Standard 3.6.3.1: Medication Administration. Standard 4.3.1.11: Introduction of Age-Appropriate Solid changes that no prescription or non-prescription medica- Foods for Infants. Clarifies that solid foods should be tion (OTC) should be given without orders from a licensed New and Significant Changes xxv

26 Caring for Our Children: National Health and Safety Performance Standards Standard 5.2.8.1: Integrated Pest Management. Expands introduced no sooner than four months and preferably at six guidance on adopting an integrated pest management pro- months. gram encouraging pest prevention and monitoring and then Standard 4.3.2.2: Serving Size for Toddlers and Pre- use of products that pose the least exposure hazard first. schoolers. Increases emphasis on age-appropriate portion Standard 5.2.9.5: Carbon Monoxide Detectors – NEW. size and eating from developmentally appropriate tableware Recommends installing in child care programs. and cups. Standard 5.2.9.8: Use of Play Dough and Other Manipu- Standard 4.5.0.3: Activities that are Incompatible with Describes appro- NEW. lative Art or Sensory Materials – Adds that watching TV and playing on a computer Eating. priate procedures when using manipulative art or sensory are incompatible with eating. materials. Promotes Standard 4.5.0.4: Socialization During Meals. Standard 5.2.9.9: Plastic Containers and Toys – NEW. using teachable moments on limiting portion size for those Recommends avoiding plastic materials used in child care who need that. that contain PVC, BPA, or phthalates. Standard 4.5.0.8: Experience with Familiar and New Standard 5.2.9.12: Treatment of CCA Pressure-Treated Increases emphasis on introduction of a variety of Foods. NEW. Becomes a standalone standard on type Wood – “healthful” foods; food acceptance may take eight to fifteen of treatment for materials that have CCA treated surfaces; times of offering food. previously only covered for playground equipment. Standard 4.6.0.1: Selection and Preparation of Food Standard 5.2.9.15: Construction and Remodeling During Brought from Home. Adds that sweetened treats are highly Adds recommendation to use low Hours of Operation. discouraged. If provided, portion size should be small. Care- volatile organic compound (VOC) paints. givers/teachers encouraged to inform families of healthy alternatives. NEW. Standard 5.3.1.2: Product Recall Monitoring – Recommends staff seek information regularly on recalls for Standard 4.7.0.1: Nutrition Learning Experiences for juvenile products. Strongly emphasizes teaching appropriate portion Children. sizes. Standard 5.3.1.4: Surfaces of Equipment, Furniture, Toys, Adds recommendation to choose ma- and Play Materials. Standard 4.7.0.2: Nutrition Education for Parents/Guard- terials with the least probability of containing materials that Emphasizes using teachable moments throughout ians. off-gas toxic elements. year and importance of good nutrition and appropriate physical activity to prevent obesity. Standard 5.3.1.5: Placement of Equipment and Furnish- ings. Adds that televisions must be anchored or mounted to Standard 4.9.0.8: Supply of Food and Water for Disas- prevent tipping over. ters. Increases allotment of food and water to seventy-two hour supply. Standard 5.3.1.10: Restrictive Infant Equipment Re- NEW. Revises guidelines to specific limit of quirements – CHAPTER 5 FACILITIES time children should be confined in equipment (max fifteen minutes, twice a day). Jumpers (attached to a door frame or Overall: Standardizes height of fences to four to six feet ceiling) and infant walkers prohibited. Former 2nd Ed. Baby (minimum four feet). Specifies use of nontoxic products if walker standard merged into this standard. available and use of least toxic product for the job. NEW . Standard 5.3.1.11: Exercise Equipment – Prohibits Standard 5.1.1.5: Environmental Audit of Site Location. children from having access to adult exercise equipment. Emphasizes comprehensive audit for environmental con- taminants along with safety issues. Standard 5.4.5.1: Sleeping Equipment and Supplies. Adds that screens are not recommended to separate sleep- Standard 5.1.1.9: Unrelated Business in a Child Care ing children. The ends of cribs do not suffice as screens. Area. Adds elimination of residue in the air or on surfaces or Also references new CPSC standards for toddler beds. materials/equipment that may be from activities performed in a child care area when children are not there. Standard 5.4.5.2: Cribs. Recommends programs follow current CPSC crib standards. Cribs with drop sides not per - Changes Standard 5.1.2.1: Space Required by Child. mitted. Addition of information on evacuation cribs. minimum space per child from thirty-five to forty-two square feet of useable floor space per child. Fifty square feet is Advises against NEW. Standard 5.4.5.3: Stackable Cribs – preferred. use of stackable. Standard 5.2.1.12: Fireplaces, Fireplace Inserts, and Standard 5.5.0.6: Inaccessibility to Matches, Candles, Wood/Corn Pellet Stoves. Adds that wood/corn pellet and Lighters. Adds candles as items to be inaccessible to stoves should be inaccessible to children and should be children. certified that they along with fireplaces and fireplace inserts, Standard 5.6.0.1: First Aid and Emergency Supplies. meet air emission standards. Adds items such as a flashlight, whistle, etc.; deletes syrup of ipecac. New and Significant Changes xxvi

27 Caring for Our Children: National Health and Safety Performance Standards is a medical contraindication or philosophical or religious Standard 5.6.0.4: Microfiber Cloths, Rags, Disposable objection. Towels, and Mops Used for Cleaning. Adds microfiber cloths and mops as preferable for cleaning. Standard 7.3.3.2: Influenza Control – Encourages NEW. parents/guardians to keep children with symptoms of acute CHAPTER 6 PLAY AREAS/PLAYGROUNDS respiratory tract illness with fever at home until their fever AND TRANSPORTATION has subsided for at least twenty-four hours without use of fever reducing medication. Same for caregivers/teachers. Moved selected standards from Overall: New Chapter. Chapters 2 and 5. All play- Caring for Our Children, 2nd Ed. NEW. Standard 7.3.3.3: Influenza Prevention Education – ground requirements updated to conform to latest CPSC Recommends refresher training for all staff and children on and ASTM requirements. hand hygiene, cough and sneeze control, and influenza vac- cine at beginning of influenza season. Ad- Standard 6.1.0.8: Enclosures for Outdoor Play Areas. vises appropriate testing and treatment of fences and play Standard 7.3.4.1: Mumps – Recommends that chil- NEW. structures for Chromated Copper Arsenate (CCA). dren and staff with mumps should be excluded for five days following onset of parotid gland swelling. Standard 6.2.4.3: Sensory Table Materials – NEW. Requires using nontoxic materials and age-appropriate ma- Standard 7.3.8.1: Attendance of Children with Respira- terials that do not cause choking. Children under eighteen tory Syncytial Virus (RSV) Respiratory Tract Infection months should not use sensory tables. – Recommends that children may return to child NEW. care once symptoms have resolved and temperature has . Prohibits trampo- NEW Standard 6.2.4.4: Trampolines – returned to normal. lines in child care programs both onsite and during field trips. Standard 7.3.10.1: Measures for Detection and Control Updated that TB status of adolescents of Tuberculosis. Standard 6.2.4.5: Ball Pits – Prohibits children from NEW. and caregivers/teachers present with children should be as- playing in ball pits. sessed with a tuberculin skin test (TST) or interferon-gamma Updated in accor Standard 6.3.1.6: Pool Drain Covers. - release assay (IGRA) blood test before caregiving activities dance with Virginia Grame Baker Pool and Spa Safety Act. are initiated. Tests on those with negative results do not have to be repeated on a regular basis unless individual is at Standard 6.4.2.1: Riding Toys with Wheels and Wheeled - risk of acquiring new infection or state/local health depart Equipment. Updated to include requirements of riding toys ment requires. and wheeled equipment including scooters and all riders should wear helmets. Recommends that NEW. Standard 7.5.1.1: Conjunctivitis – children with conjunctivitis should not be excluded unless Standard 6.4.2.2: Helmets. Updated on age requirements, meet certain criteria. use when riding any riding toy, bike, and meet CPSC stan- dards. Recom- NEW. Standard 7.5.2.1: Enterovirus Infections – mends children with enterovirus infections should not be Standard 6.5.2.2: Child Passenger Safety. Updated on excluded unless meet certain criteria. current requirements for car safety seats, booster seats, seat belts, or harnesses. Standard 7.5.3.1: Human Papillomaviruses (HPV) (WARTS) – NEW. Recommends children with warts should Recommends Standard 6.5.3.1: Passenger Vans – NEW. not be excluded unless meet certain criteria. to avoid use of fifteen-passenger vans and use vehicles meeting definition of a school bus. Standard 7.5.4.1: Impetigo – Explains process for NEW. inclusion/exclusion of children or staff with impetigo. CHAPTER 7 INFECTIOUS DISEASES Standard 7.5.5.1: Lymphadenitis – Outlines process NEW. Updated standards on immunizations to the cur - Overall: for inclusion/exclusion of children or staff with lymphadeni- rent Centers for Disease Control and Prevention’s Recom- tis. mended immunization schedules for persons aged 0 through 18 years - United States, 2011. Users should always Standard 7.5.6.1: Immunization for Measles – NEW. www.cdc.gov/vaccines/. check for the current version at Recommends all children have age appropriate immuniza- Standards on immunizations moved from Chapter 3 to tions, and those not immunized or not age appropriately Note: Infectious Diseases was formerly Chapter Chapter 7. immunized should be excluded immediately if there are 6 in the 2nd Ed. documented cases. Standard 7.2.0.3: Immunization of Caregivers/Teachers. Standard 7.5.7.1: Molluscum Contagiosum – NEW. Rec- Adds immunizations - Td/Tdap, HPV (ages eleven to twenty- ommends not excluding children with molluscum contagio- six), seasonal influenza for all staff (no age restriction). sum. Standard 7.3.3.1: Influenza Immunizations for Children Skin Infec- Staphylococcus Aureus Standard 7.5.10.1: and Caregivers/Teachers – NEW. Recommends written tions Including MRSA – NEW. Recommends not exclud- documentation that a child six months of age and older has ing children and staff unless meet certain criteria. Lesions current annual vaccination against influenza unless there should be covered. New and Significant Changes xxvii

28 Caring for Our Children: National Health and Safety Performance Standards Standard 9.2.4.7: Sign-In/Sign-Out System – NEW. Rec- NEW. Standard 7.5.12.1: Thrush (Candidiasis) – Recom- system to track who has entered and exited the ommends mends not excluding children. facility as a means of security and of notification in case of NEW. STANDARD 7.7.3.1: Roseola – Recommends not situation requiring evacuation. excluding children unless meet certain criteria. Standard 9.2.4.8: Authorized Persons to Pick Up Child. Expanded to include procedures for verifying persons who CHAPTER 8 CHILDREN WITH SPECIAL are not on the authorized list to pick up or to deny ability to HEALTH CARE NEEDS AND DISABILITIES pick up. Improved consistency of language, referring to Overall: Standard 9.2.4.10: Documentation of Drop-Off, Pick- children with special health care needs. Note: Targeted Up and Daily Attendance of Child, and Parent/Provider was Children with Special Health Care Needs information on Expanded to include information on Communication. formerly Chapter 7 in the 2nd Ed. documenting whether or not a child is in attendance and communication procedures with parents/guardians. CHAPTER 9 ADMINISTRATION Standard 9.2.5.1: Transportation Policy for Centers and Overall: Encompasses policy and record changes reflect- Expanded to include policies such Large Family Homes. ing major changes in process and procedures throughout as procedures to ensure that no child is left in the vehicle document. Note: Administration was formerly Chapter 8 in at the end of the trip or left unsupervised outside or inside 2nd Ed. CFOC, the the vehicle during loading and unloading the vehicle, use Standard 9.2.3.1: Policies and Practices that Promote of passenger vans, vehicle selection to safely transport NEW. Physical Activity – Outlines what policies should children and others. include: benefits, duration, setting, and clothing. Standard 9.3.0.2: Written Human Resource Management Standard 9.2.3.9: Written Policy on Use of Medications. NEW. for Small Family Child Care Homes – Addresses Updated to include prohibition of administering OTC cough need for policies for caregivers/teachers in small family and cold, policies on prescriptions and OTC medications. child care homes that address vacation leave, holidays, professional development leave, sick leave, and scheduled Standard 9.2.3.11 Food and Nutrition Service Policies : increases of small family child care home fees. Adds to list of policies needed: Menu and meal and Plans. planning, emergency preparedness for nutrition services, Standard 9.4.1.16: Evacuation and Shelter-In-Place Drill food brought from home, age-appropriate portion sizes, Adds need for records of shelter-in-place drills. Record. age-appropriate eating utensils and tableware, promotion of breastfeeding, and provision of community resources to CHAPTER 10 LICENSING AND COMMUNITY support mothers. ACTION Standard 9.2.3.14: Oral Health Policy – Outlines NEW. Changed “Recommendations” to “Standards” for Overall: elements to be included in an oral health policy such as - the first section of each standard. Chapter had major rear contact information for each child’s dentist/dental home; rangement. Most standards stayed but in different order. provides resource list for children without a dentist/dental Note: Licensing and Community Action was formerly Chap- home; explains implementation of daily tooth brushing, ter 9 in the 2nd Ed. CFOC restriction of sippy cup, etc. Standard 10.3.2.2: State Early Childhood Advisory Coun- Standard 9.2.4.1: Written Plan and Training for Handling : Changed terminology from old “Commission on Child cil Expanded Urgent Medical Care or Threatening Incidents. Care” to reflect updated requirements from Head Start. to cover mental health emergencies, emergencies involving parents/guardians/guests, and if/when threatening individual Standard 10.3.3.5: Licensing Agency Role in Communi- accesses the program. cating the Importance of Compliance with Americans NEW. – Explains that licensing agen- with Disabilities Act Standard 9.2.4.3: Disaster Planning, Training and Com- cies should inform child care programs on compliance with Outlines comprehensive approach on the munication. the ADA. details to be covered in an emergency/disaster plan, training requirements, and communication procedures with parents/ Standard 10.3.4.3: Support for Consultants to Provide guardians. Technical Assistance to Facilities. Expands types of consultants by adding early childhood education consultant, Standard 9.2.4.4: Written Plan for Seasonal and Pan- dental health consultant, and physical activity consultant. NEW. Recommends contents of a plan demic Influenza – in the areas of planning and coordination, infection control Standard 10.4.1.1: Uniform Categories and Definitions. policy and procedures, communications planning, and child Updates definitions and completely revises the definition for learning and program operations. drop-in care. - Standard 9.2.4.5: Emergency and Evacuation Drills/Exer Standard 10.4.1.2: Quality Rating and Improvement cises Policy. Expands on types of events to have drills and Systems – NEW. Recommends that states develop QRIS exercises. systems. New and Significant Changes xxviii

29 Caring for Our Children: National Health and Safety Performance Standards Standard 10.4.2.1: Frequency of Inspections for Child Care Centers, Large Family Child Care Homes, and Small Family Child Care Homes. Increased inspections to two a year of which one should be unannounced. APPENDICES NEW. Includes Appendix A: Signs and Symptoms Chart – signs and symptoms of illness, whether to notify a child care health consultant, whether to notify parent/guardian, whether to exclude child and if excluded, when to readmit. Appendix H: Recommended Adult Immunization Sched- ule – NEW. Appendix J: Selecting an Appropriate Sanitizer and Disinfectant. Updated definitions on terms and expanded information. Appendix K: Routine Schedule for Cleaning, Sanitizing and Disinfecting. Updated with new categories. Appendix N: Protective Factors Regarding Child Abuse and Neglect – NEW. Includes early care and education program strategies to build protective factors. Appendix O: Care Plan for Children with Special Health Care Needs – NEW. Appendix Q: Getting Started with MyPlate – NEW. Dis- plays new primary food icon for healthy eating. Appendix R: Choose MyPlate: 10 Tips to a Great Plate – Shows food choices for a healthy lifestyle can be NEW. simple. Appendix S: Physical Activity: How Much Is Needed? – NEW. A guide to age-appropriate physical activity. Appendix T: Helping Children in Foster Care Make Successful Transitions Into Child Care – NEW. Includes advice for both foster parents and caregivers/teachers on how to make successful transitions for children into an early care and education program. Appendix U: Recommended Safe Minimum Internal Cooking Temperatures – NEW. Appendix AA: Medication Administration Packet – NEW. Includes authorization form to give medication, checklist on receiving medication, medication log, medication incident report form, and checklist for preparing to give medication. Appendix DD: Injury Report Form for Indoor and Out- door Injuries – NEW. Appendix HH: Use Zones for Clearance Dimensions for Single- and Multi-Axis Swings – NEW. Appendix II: Bicycle Helmets: Quick-Fit Check – NEW. Appendix JJ: Our Child Care Center Supports Breast- feeding – NEW. Displays poster for programs to use to encourage breastfeeding at the program. Appendix KK: Authorization for Emergency Medical/ NEW. Dental Care – New and Significant Changes xxix

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31 Chapter 1 Staffing

32

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

34 Caring for Our Children: National Health and Safety Performance Standards RELATED STANDARDS: During nap time for children birth through thirty months of 1.1.1.3 Ratios for Facilities Serving Children with Special Health age, the child:staff ratio must be maintained at all times Care Needs and Disabilities regardless of how many infants are sleeping. They must also Standard 1.1.2.1: Minimum Age to Enter Child Care be maintained even during the adult’s break time so that REFERENCES: ratios are not relaxed. 1. Zero to Three. 2007. The infant-toddler set-aside of the Child Child Care Centers Care and Development Block Grant: Improving quality child care for infants and toddlers. Washington, DC: Zero to Three. http://main Age Maximum Maximum .zerotothree.org/site/DocServer/Jan_07_Child_Care_Fact Child:Staff Group Size _Sheet.pdf. Ratio 2. National Institute of Child Health and Human Development The NICHD study of early child care and youth (NICHD). 2006. ≤ 12 months 6 3:1 development: Findings for children up to age 4 1/2 years. Rockville, 13-35 months 8 4:1 MD: NICHD. http://www.nichd.nih.gov/publications/pubs/upload/ seccyd_051206.pdf. 3-year-olds 14 7:1 Supporting growth 3. Goldstein, A., K. Hamm, R. Schumacher. 8:1 4-year-olds 16 and development of babies in child care: What does the research 16 8:1 5-year-olds Washington, DC: Center for Law and Social Policy (CLASP); say? Zero to Three. http://main.zerotothree.org/site/DocServer/ 10:1 6- to 8-year- 20 ChildCareResearchBrief.pdf. olds 4. De Schipper, E. J., J. M. Riksen-Walraven, S. A. E. Geurts. 24 9- to 12-year- 12:1 2006. Effects of child-caregiver ratio on the interactions between caregivers and children in child-care centers: An experimental olds 77:861-74. Child Devel study. During nap time for children ages thirty-one months and NFPA 101: Life 5. National Fire Protection Association (NFPA). 2009. older, at least one adult should be physically present in the 2009 ed. Quincy, MA: NFPA. safety code. same room as the children and maximum group size must 13 indicators of quality child care: Research 6. Fiene, R. 2002. be maintained. Children over thirty-one months of age can Washington, DC: U.S. Department of Health and Human update. Services, Office of the Assistant Secretary for Planning and usually be organized to nap on a schedule, but infants and Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/. toddlers as individuals are more likely to nap on different A vision for universal 7. Zigler, E., W. S. Gilliam, S. M. Jones. 2006. schedules. In the event even one child is not sleeping the , 107-29. New York: Cambridge University preschool education child should be moved to another activity where appropriate Press. supervision is provided. 8. Stebbins, H. 2007. State policies to improve the odds for the If there is an emergency during nap time other adults should healthy development and school readiness of infants and toddlers. Washington, DC: Zero to Three. http://main.zerotothree.org/site/ be on the same floor and should immediately assist the staff DocServer/NCCP_article_for_BM_final.pdf. supervising sleeping children. The caregiver/teacher who is in the same room with the children should be able to sum- Ratios for Large Family STANDARD 1.1.1.2: mon these adults without leaving the children. Child Care Homes and Centers When there are mixed age groups in the same room, the child:staff ratio and group size should be consistent with the Child:staff ratios in large family child care homes and age of most of the children. When infants or toddlers are in centers should be maintained as follows during all hours of the mixed age group, the child:staff ratio and group size for operation, including in vehicles during transport. infants and toddlers should be maintained. In large fam- Large Family Child Care Homes ily child care homes with two or more caregivers/teachers caring for no more than twelve children, no more than three Maximum Maximum Age children younger than two years of age should be in care. Group Size Child:Staff Ratio Children with special health care needs or who require more attention due to certain disabilities may require additional 6 ≤ 12 months 2:1 staff on-site, depending on their special needs and the ex- 8 2:1 13-23 months tent of their disabilities (1). See Standard 1.1.1.3. 24-35 months 3:1 12 At least one adult who has satisfactorily completed a course 3-year-olds 7:1 12 in pediatric first aid, including CPR skills within the past 4- to 5-year- 8:1 12 three years, should be part of the ratio at all times. olds RATIONALE: These child:staff ratios are within the range 6- to 8-year- 12 10:1 of recommendations for each age group that the National olds Association for the Education of Young Children (NAEYC) uses in its accreditation program (5). The NAEYC recom- 12 9- to 12-year- 12:1 mends a range that assumes the director and staff members olds are highly trained and, by virtue of the accreditation pro- Chapter 1: Staffing 4

35 Caring for Our Children: National Health and Safety Performance Standards Ratios are required to be maintained for children thirty cess, have formed a staffing pattern that enables effective months and younger during nap time due to the need for staff functioning. The standard for child:staff ratios in this closer observation and the frequent need to interact with document uses a single desired ratio, rather than a range, younger children during periods while they are resting. Close for each age group. These ratios are more likely than less proximity of staff to these younger groups enables more stringent ratios to support quality experiences for young rapid response to situations where young children require children. more assistance than older children, e.g., for evacuation. Low child:staff ratios for non-ambulatory children are essen- The requirement that a caregiver/teacher should remain in tial for fire safety. The National Fire Protection Association the sleeping area of children thirty-one months and older , recommends that (NFPA), in its NFPA 101: Life Safety Code is not only to ensure safety, but also to prevent inappropri- no more than three children younger than two years of age ate behavior from taking place that may go undetected if be cared for in large family child care homes where two staff a caregiver/teacher is not present. While nap time may be members are caring for up to twelve children (6). the best option for regular staff conferences, staff lunch Children benefit from social interactions with peers. Howev- breaks, and staff training, one staff person should stay in the er, larger groups are generally associated with less positive nap room, and the above staff activities should take place interactions and developmental outcomes. Group size and in an area next to the nap room so other staff can assist if ratio of children to adults are limited to allow for one to one emergency evacuation becomes necessary. If a child with a interaction, intimate knowledge of individual children, and potentially life-threatening special health care need is pres- consistent caregiving (7). ent, a staff member trained in CPR and pediatric first aid and one trained in administration of any potentially required Studies have found that children (particularly infants and medication should be available at all times. toddlers) in groups that comply with the recommended ratio receive more sensitive and appropriate caregiving and score COMMENTS: The child:staff ratio indicates the maximum higher on developmental assessments, particularly vocabu- number of children permitted per caregiver/teacher (8). lary (1,9). These ratios assume that caregivers/teachers do not have time-consuming bookkeeping and housekeeping duties, so As is true in small family child care homes, Standard 1.1.1.1, they are free to provide direct care for children. The ratios child:staff ratios alone do not predict the quality of care. do not include other personnel (such as bus drivers) neces- Direct, warm social interaction between adults and children sary for specialized functions (such as driving a vehicle). is more common and more likely with lower child:staff ratios. Caregivers/teachers must be recognized as performing a Group size is the number of children assigned to a care- job for groups of children that parents/guardians of twins, giver/teacher or team of caregivers/teachers occupying an triplets, or quadruplets would rarely be left to handle alone. individual classroom or well-defined space within a larger In child care, these children do not come from the same room (8). The “group” in child care represents the “home family and must learn a set of common rules that may differ room” for school-age children. It is the psychological base from expectations in their own homes (10). with which the school-aged child identifies and from which the child gains continual guidance and support in various Similarly, low child:staff ratios are most critical for infants activities. This standard does not prohibit larger numbers and young toddlers (birth to twenty-four months) (1). Infant of school-aged children from joining in occasional collec- development and caregiving quality improves when group tive activities as long as child:staff ratios and the concept of size and child:staff ratios are smaller (2). Improved verbal in- “home room” are maintained. teractions are correlated with lower ratios (3). For three- and four-year-old children, the size of the group is even more Unscheduled inspections encourage compliance with this important than ratios. The recommended group size and standard. child:staff ratio allow three- to five-year-old children to have These standards are based on what children need for quality continuing adult support and guidance while encouraging nurturing care. Those who question whether these ratios are independent, self-initiated play and other activities (4). affordable must consider that efforts to limit costs can result In addition, the children’s physical safety and sanitation in overlooking the basic needs of children and creating a routines require a staff that is not fragmented by excessive highly stressful work environment for caregivers/teachers. demands. Child:staff ratios in child care settings should be Community resources, in addition to parent/guardian fees sufficiently low to keep staff stress below levels that might and a greater public investment in child care, can make criti- result in anger with children. Caring for too many young chil- cal contributions to the achievement of the child:staff ratios dren, in particular, increases the possibility of stress to the and group sizes specified in this standard. Each state has its caregiver/teacher, and may result in loss of the caregiver’s/ own set of regulations that specify child:staff ratios. To view teacher’s self-control (11). a particular state’s regulations, go to the National Resource Center for Health and Safety in Child Care and Early Educa- Although observation of sleeping children does not require tion’s (NRC) Website: http://nrckids.org. the physical presence of more than one caregiver/teacher for sleeping children thirty-one months and older, the staff TYPE OF FACILITY: Center; Large Family Child Care Home needed for an emergency response or evacuation of the children must remain available on site for this purpose. Chapter 1: Staffing 5

36 Caring for Our Children: National Health and Safety Performance Standards RELATED STANDARDS: activities. Adjustment of the ratio produces flexibility without Standards 1.1.1.3-1.1.1.5: Ratios and Supervision for Certain resulting in a need for care that is greater than the staff can Scenarios provide without compromising the health and safety of other Standards 1.4.3.1-1.4.3.3: First Aid and CPR Training children. The facility should seek consultation with parents/ REFERENCES: guardians, a child care health consultant (CCHC), and other . The infant-toddler set-aside of the Child 1. Zero to Three. 2007 professionals, regarding the appropriate child:staff ratio. The Care and Development Block Grant: Improving quality child care for facility may wish to increase the number of staff members if infants and toddlers. Washington, DC: Zero to Three. http://main the child requires significant special assistance (1). .zerotothree.org/site/DocServer/Jan_07_Child_Care_Fact These ratios do not include personnel who COMMENTS: _Sheet.pdf. have other duties that might preclude their involvement in 2. National Institute of Child Health and Human Development The NICHD study of early child care and youth (NICHD). 2006. needed supervision while they are performing those duties, Rockville, development: Findings for children up to age 4 1/2 years. such as therapists, cooks, maintenance workers, or bus MD: NICHD. http://www.nichd.nih.gov/publications/pubs/upload/ drivers. seccyd_051206.pdf. TYPE OF FACILITY: Center; Large Family Child Care Home; Small 3. Goldstein, A., K. Hamm, R. Schumacher. Supporting growth Family Child Care Home and development of babies in child care: What does the research say? Washington, DC: Center for Law and Social Policy (CLASP); REFERENCES: Zero to Three. http://main.zerotothree.org/site/DocServer/ 1. University of North Carolina at Chapel Hill, FPG Child ChildCareResearchBrief.pdf. Development Institute. The national early childhood technical 4. De Schipper, E. J., J. M. Riksen-Walraven, S. A. E. Geurts. assistance center. http://www.nectac.org. 2006. Effects of child-caregiver ratio on the interactions between caregivers and children in child-care centers: An experimental STANDARD 1.1.1.4: Ratios and Supervision study. Child Devel 77:861-74. During Transportation 5. National Association for the Education of Young Children Early childhood program standards and (NAEYC). 2007. Child:staff ratios established for out-of-home child care accreditation criteria. Washington, DC: NAEYC. should be maintained on all transportation the facility 6. National Fire Protection Association (NFPA). 2009. NFPA 101: Life provides or arranges. Drivers should not be included in the 2009 ed. Quincy, MA: NFPA. safety code. ratio. No child of any age should be left unattended in or 7. Bradley, R. H., D. L. Vandell. 2007. Child care and the well-being around a vehicle, when children are in a car, or when they of children. Arch Ped Adolescent Med 161:669-76. are in a car seat. A face-to-name count of children should 8. Murph, J. R., S. D. Palmer, D. Glassy, eds. 2005. Health in child be conducted prior to leaving for a destination, when the 4th ed. Elk Grove Village, IL: care: A manual for health professionals. destination is reached, before departing for return to the American Academy of Pediatrics. 9. Vandell, D. L., B. Wolfe. 2000. Child care quality: Does it facility and upon return. Caregivers/teachers should also matter and does it need to be improved? Washington, DC: U.S. remember to take into account in this head count if any chil- Department of Health and Human Services. http://aspe.hhs.gov/ dren were picked up or dropped off while being transported hsp/ccquality00/. away from the facility. 10. Fiene, R. 2002. 13 indicators of quality child care: Research RATIONALE: Children must receive direct supervision update . Washington, DC: U.S. Department of Health and Human when they are being transported, in loading zones, and Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/. when they get in and out of vehicles. Drivers must be able 11. Wrigley, J., J. Derby. 2005. Fatalities and the organization of to focus entirely on driving tasks, leaving the supervision 70:729-57. Am Socio Rev child care in the United States. of children to other adults. This is especially important with young children who will be sitting in close proximity to one STANDARD 1.1.1.3: Ratios for Facilities another in the vehicle and may need care during the trip. Serving Children with Special Health Care In any vehicle making multiple stops to pick up or drop off children, this also permits one adult to get one child out and Needs and Disabilities take that child to a home, while the other adult supervises Facilities enrolling children with special health care needs the children remaining in the vehicle, who would otherwise - and disabilities should determine, by an individual assess be unattended for that time (1). Children require supervision ment of each child’s needs, whether the facility requires a at all times, even when buckled in seat restraints. A head lower child:staff ratio. count is essential to ensure that no child is inadvertently The child:staff ratio must allow the needs of RATIONALE: left behind in or out of the vehicle. Child deaths in child the children enrolled to be met. The facility should have care have occurred when children were mistakenly left in sufficient direct care professional staff to provide the vehicles, thinking the vehicle was empty. required programs and services. Integrated facilities with Center; Large Family Child Care Home TYPE OF FACILITY: fewer resources may be able to serve children who need RELATED STANDARDS: fewer services, and the staffing levels may vary accord- Standard 5.6.0.1: First Aid and Emergency Supplies ingly. Adjustment of the ratio allows for the flexibility needed REFERENCES: to meet each child’s type and degree of special need and 1. Aird, L. D. 2007. Moving kids safely in child care: A refresher encourage each child to participate comfortably in program 6 Chapter 1: Staffing

37 Caring for Our Children: National Health and Safety Performance Standards (January/February): 25-28. http:// course. Child Care Exchange wading/water play activities while they are performing those www.childcareexchange.com/library/5017325.pdf. duties. This ratio excludes cooks, maintenance workers, or lifeguards from being counted in the child:staff ratio if they STANDARD 1.1.1.5: Ratios and Supervision for are involved in specialized duties at the same time. Proper ratios during swimming activities with infants are important. Swimming, Wading, and Water Play Infant swimming programs have led to water intoxication The following child:staff ratios should apply while children and seizures because infants may swallow excessive water are swimming, wading, or engaged in water play: when they are engaged in any submersion activities (1). Child:Staff Ratio Developmental Levels TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home Infants 1:1 RELATED STANDARDS: Toddlers 1:1 Standard 2.2.0.4: Supervision Near Bodies of Water 4:1 Preschoolers Standard 6.3.1.3: Sensors or Remote Monitors Standard 6.3.1.4: Safety Covers for Swimming Pools 6:1 School-age Children Standard 6.3.1.7: Pool Safety Rules Constant and active supervision should be maintained Standard 6.3.2.1: Lifesaving Equipment when any child is in or around water (4). During any swim- Standard 6.3.2.2: Lifeline in Pool ming/wading/water play activities where either an infant or Standard 6.3.5.2: Water in Containers Standard 6.3.5.3: Portable Wading Pools a toddler is present, the ratio should always be one adult to one infant/toddler. The required ratio of adults to older REFERENCES: children should be met without including the adults who are 1. American Academy of Pediatrics, Committee on Injury, Violence, required for supervision of infants and/or toddlers. An adult and Poison Prevention. 2010. Policy statement: Prevention of should remain in direct physical contact with an infant at all Pediatrics drowning. 126:178-85. Pool and 2. U.S. Consumer Product Safety Commission (CPSC). times during swimming or water play (4). Whenever children spa safety: The Virginia Graeme Baker pool and spa safety act. thirteen months and up to five years of age are in or around http://www.poolsafely.gov/wp-content/uploads/VGBA.pdf. water, the supervising adult should be within an arm’s length 3. Gipson, K. 2008. Pool and spa submersion: Estimated injuries providing “touch supervision” (6). The attention of an adult Bethesda, MD: U.S. Consumer and reported fatalities, 2008 report. who is supervising children of any age should be focused Product Safety Commission. http://www.cpsc.gov/LIBRARY/ on the child, and the adult should never be engaged in other poolsub2008.pdf. distracting activities (4), such as talking on the telephone, 4. U.S. Consumer Product Safety Commission (CPSC). 2009. CPSC socializing, or tending to chores. warns of in-home drowning dangers with bathtubs, bath seats, buckets. Release #10-008. http://www.cpsc.gov/cpscpub/prerel/ A lifeguard should not be counted in the child:staff ratio. prhtml10/10008.html. RATIONALE: The circumstances surrounding drownings Submersions related to non-pool and non-spa 5. Gipson, K. 2008. and water-related injuries of young children suggest that Washington, DC: U.S. Consumer Product products, 2008 report. Safety Commission. http://www.cpsc.gov/library/FOIA/FOIA09/OS/ staffing requirements and environmental modifications may nonpoolsub2008.pdf. reduce the risk of this type of injury. Essential elements are 6. American Academy of Pediatrics, Committee on Injury, Violence, close continuous supervision (1,4), four-sided fencing and and Poison Prevention, J. Weiss. 2010. Technical report: Prevention self-locking gates around all swimming pools, hot tubs, 126: e253-62. Pediatrics of drowning. and spas, and special safety covers on pools when they 7. Consumer Product Safety Commission. Steps for safety around are not in use (2,7). Five-gallon buckets should not be used the pool: The pool and spa safety act. Pool Safely. http://www for water play (4). Water play using small (one quart) plastic .poolsafely.gov/wp-content/uploads/360.pdf. pitchers and plastic containers for pouring water and plastic dish pans or bowls allow children to practice pouring skills. 1.1.2 Minimum Age Between 2003 and 2005, a study of drowning deaths of chil- dren younger than five years of age attributed the highest STANDARD 1.1.2.1: Minimum Age to Enter percentage of drowning reports to an adult losing contact Child Care or knowledge of the whereabouts of the child (5). During the time of lost contact, the child managed to gain access to Reader’s Note: This standard reflects a desirable goal when the pool (3). sufficient resources are available; it is understood that for some families, waiting until three months of age to enter Water play includes wading. Touch supervi- COMMENTS: their infant in child care may not be possible. sion means keeping swimming children within arm’s reach and in sight at all times. Drowning is a “silent killer” and Healthy full-term infants can be enrolled in child care set- children may slip into the water silently without any splash- tings as early as three months of age. Premature infants or ing or screaming. those with chronic health conditions should be evaluated by their primary care providers and developmental specialists Ratios for supervision of swimming, wading and water play to make an individual determination concerning the appro- do not include personnel who have other duties that might priate age for child care enrollment. preclude their involvement in supervision during swimming/ Chapter 1: Staffing 7

38 Caring for Our Children: National Health and Safety Performance Standards ranked twentieth in terms of unpaid and paid parental RATIONALE: Brain anatomy, chemistry, and physiology un- leave available to two-parent families with the birth of their dergo rapid development over the first ten to twelve weeks child (18,21). Although Switzerland ranked twenty-first with of life (1-6). Concurrently, and as a direct consequence of fourteen versus twenty-four weeks as compared to the U.S. these shifts in central nervous system structure and func- for both parents/guardians, eleven weeks of leave are paid tion, infants demonstrate significant growth, irregularity, and in Switzerland. In this study of twenty-one countries, only eventually, organization of their behavior, physiology, and Australia and the U.S. do not provide for paid leave after the social responsiveness (1-3,5). Arousal responses to stimula- birth of a child (18). tion mature before the ability to self-regulate and control such responses in the first six to eight weeks of life causing Major social policies in the U.S. were established with the infants to demonstrate an expanding range and fluctuation Social Security Act in 1935 at a time when the majority of of behavioral state changes from quiet to alert to irritable (1- women were not employed (19,20). The Family and Medi- 3,6). Infant behavior is most disorganized, most difficult to cal Leave Act (FMLA) of 1993, which allows twelve weeks read and most frustrating to support at the six to eight week of leave, established for the first time job protected ma- period (2,3). At approximately eight to twelve weeks after ternity leave for qualifying employees (16,20). Despite the birth, full term infants typically undergo changes in brain importance of FMLA, only about 60% of the women in the - function and behavior that helps caregivers/teachers under workforce are eligible for job protected maternity leave. stand and respond effectively to infants’ increasingly stable FMLA does not provide paid leave, which may force many sleep-wake states, attention, self-calming efforts, feed- women to return to work sooner than preferred (18). FMLA ing patterns and patterns of social engagement. Over the is not transferable between parents/guardians. However, course of the third month, infants demonstrate an emerging five U.S. states support five to six weeks of paid maternity capacity to sustain states of sleep and alert attention. leave and a few companies allow generous paid leaves for select employees (21). Infants, birth to three months of age, can become seriously ill very quickly without obvious signs (7). This increased risk In a nationally representative sample, 84% of women and to infants, birth to three months makes it important to mini- 74% of men supported expansion of the FMLA; furthermore, mize their exposure to children and adults outside their fam- 90% of women and 72% of men reported that employers ily, including exposures in child care (8). In addition, infants and government should do more to support families (21). of mothers who return to work, particularly full-time, before Substantial evidence exists to strengthen social policies, twelve weeks of age, and are placed in group care may be specifically job protected paid leave for all families, for at at even greater risk for developing serious infectious dis- least the first twelve weeks of life, in order to promote the eases. These infants are less likely to receive recommended health and development of children and families (22). Invest- well-child care and immunizations and to be breastfed or ing in families during an important life transition, the birth are likely to have a shorter duration of breastfeeding (16,22). or adoption of a child, reflects a society’s values and may Researchers report that breastfeeding duration was sig- in fact contribute to a healthier and more productive work nificantly higher in women with longer maternity leaves as force. compared to those with less than nine to twelve weeks TYPE OF FACILITY: Center; Large Family Child Care Home; Small leave (9,22). A leave of less than six weeks was associated Family Child Care Home with a much higher likelihood of stopping breastfeeding RELATED STANDARDS: (10,22). Continuing breastfeeding after returning to work Standard 2.1.1.5: Helping Families Cope with Separation may be particularly difficult for lower income women who may have fewer support systems (11). REFERENCES: 1. Staehelin, K., P. C. Bertea, E. Z. Stutz. 2007. Length of maternity It takes women who have given birth about six weeks to Int J Public Health leave and health of mother and child–a review. return to the physical health they had prior to pregnancy 52:202-9. (12). A significant portion of women reported child birth 2. Guendelman, S., J. L. Kosc, M. Pearl, S. Graham, J. Goodman, related symptoms five weeks after delivery (17). In contrast, M. Kharrazi. 2009. Juggling work and breastfeeding: Effects of women’s general mental health, vitality, and role function 123: maternity leave and occupational characteristics. Pediatrics were improved with maternity leaves at twelve weeks or e38-e46. longer (13). 3. Kimbro, R. T. 2006. On-the-job moms: Work and breastfeeding initiation and duration for a sample of low-income women. Maternal Birth of a child or adoption of a newborn, especially the Child Health J 10:19-26. first, requires significant transition in the family. First time 4. Cunningham, F. G., F. F. Gont, K. J. Leveno, L. C. Gilstrap, J. C. parents/guardians are learning a new role and even with Hauth, K. D. Wenstrom. 2005. Williams obstretrics. 21st ed. New subsequent children, integration of the new family member York: McGraw Hill. requires several weeks of adaptation. Families need time to 5. McGovern P., B. Dowd, D. Gjerdingen, I. Moscovice, L. Kochevar, adjust physically and emotionally to the intense needs of a W. Lohman. 1997. Time off work and the postpartum health of 35:507-21. Medical Care employed women. newborn (14,15). The expanded family life 6. Carter, B., M. McGoldrick, eds. 2005. In an analysis of twenty-one wealthy coun- COMMENTS: 3rd ed. New York: cycle: Individual, family, and social perspectives. tries including Australia, New Zealand, Canada, United Allyn and Bacon Classics. States, Japan, and several European countries, the U.S. 7. Ishimine, P. 2006. Fever without source in children 0-36 months. Chapter 1: Staffing 8

39 Caring for Our Children: National Health and Safety Performance Standards Pediatric 53:167. Clinics North Am and tolerance for individuals on the staff who are competent 8. Harper, M. 2004. Update on the management of the febrile infant. caregivers/teachers with different background and orienta- 5:5-12. Clin Pediatric Emerg Med tion in their private lives. Children need to see successful 9. Carey, W. B., A. C. Crocker, E. R. Elias, H. M. Feldman, W. L. role models from their own ethnic and cultural groups and . 4th ed. . Developmental-behavioral pediatrics Coleman. 2009 be able to develop the ability to relate to people who are dif- Philadelphia: W. B. Saunders. ferent from themselves (1). 10. Parmelee, A. H. Jr, W. Weiner, H. Schultz. 1964. Infant sleep 65:576-82. patterns: From birth to 16 weeks of age. J Pediatrics The goal of the ADA in employment is to reasonably accom- 11. Brazelton, T. B. 1962. Crying in infancy. 29:579-88. Pediatrics modate applicants and employees with disabilities, to pro- 12. Huttenlocher, P. R., C. de Courten. 1987. The development of vide them equal employment opportunity and to integrate Human Neurobiology synapses in striate cortex of man. 6:1-9. them into the program’s staff to the extent feasible, given 13. Anders, T. F. 1992. Sleeping through the night: A developmental the individual’s limitations. Under the ADA, employers are Pediatrics perspective. 90:554-60. expected to make reasonable accommodations for persons 14. Edelstein, S., J. Sharlin, S. Edelstein. 2008. Life cycle nutrition: with disabilities. Some disabilities may be accommodated, An evidence-based approach . Boston: Jones and Bartlett. whereas others may not allow the person to do essential 15. Robertson, S. S. 1987. Human cyclic motility: Fetal-newborn tasks. The fairest way to address this evaluation is to define Devel Psychobiology continuities and newborn state differences. 20:425-42. the tasks and measure the abilities of applicants to perform 16. Berger, L. M., J. Hill, J. Waldfogel. 2005. Maternity leave, early them (2). maternal employment and child health and development in the US. COMMENTS: In staff recruiting, the hiring pool should 115: F29-F47. Economic J extend beyond the immediate neighborhood of the child’s 17. McGovern, P., B. Dowd, D. Gjerdingen, C. R. Gross, S. Kenney, residence or location of the facility, to reflect the diversity L. Ukestad, D. McCaffrey, U. Lundberg. 2006. Postpartum health of the people with whom the child can be expected to have Annals Fam Med of employed mothers 5 weeks after childbirth. 4:159-67. contact as a part of life experience. Parental leave policies 18. Ray, R., J. C. Gornick, J. Schmitt. 2009. Reasons to deny employment include the following: in 21 countries: Assessing generosity and gender equality. Rev. ed. a) The applicant or employee is not qualified or is un- Washington, DC: Center for Economic and Policy Research. able to perform the essential functions of the job with 19. Social Security Act. 1935. 42 USC 7. or without reasonable accommodations; 20. Family and Medical Leave Act. 1993. 29 USC 2601. 21. Lovell, V., E. O’Neill, S. Olsen. 2007. Maternity leave in the b) Accommodation is unreasonable or will result in United States: Paid parental leave is still not standard, even among undue hardship to the program; the best U.S. employers. Washington, DC: Institute for Women’s The applicant’s or employee’s condition will pose a c) Policy Research. http://iwpr.org/pdf/parentalleaveA131.pdf. significant threat to the health or safety of that indi- Failing its families: Lack of paid 22. Human Rights Watch. 2011. vidual or of other staff members or children. http://www.hrw.org/en/ leave and work-family supports in the U.S. Accommodations and undue hardship are based on each reports/2011/02/23/failing-its-families-0/. individual situation. The U.S. Equal Employment Opportunity Commission 1.2 Recruitment and Background (EEOC) does not enforce the protections that prohibit Screening discrimination and harassment based on sexual orientation, status as a parent, marital status, or political affiliation. How- STANDARD 1.2.0.1: Staff Recruitment ever, other federal agencies and many states and munici- palities do. For assistance in locating your state or local Staff recruitment should be based on a policy of non-dis- agency’s rules go to http://www.eeoc.gov/field/ (3). crimination with regard to gender, race, ethnicity, disability, - or religion, as required by the Equal Employment Oppor Caregivers/teachers can obtain copies of the EEOA and the tunity Act (EEOA). Centers should have a plan of action for ADA from their local public library. Facilities should consult recruiting and hiring a diverse staff that is representative of with ADA experts through the U.S. Department of Educa- the children in the facility’s care and people in the commu- tion funded Disability and Business Technical Assistance nity with whom the child is likely to have contact as a part Centers (DBTAC) throughout the country. These centers can of life experience. Staff recruitment policies should adhere be reached by calling 1-800-949-4232 (callers will be routed to requirements of the Americans with Disabilities Act (ADA) to the appropriate region), or by visiting http://www.adata as it applies to employment. The job description for each .org/Static/Home.aspx. position should be clearly written, and the suitability of an Center; Large Family Child Care Home; Small TYPE OF FACILITY: applicant should be measured with regard to the applicant’s Family Child Care Home qualifications and abilities to perform the tasks required in REFERENCES: the role. 1. Chang, H. 2006. Developing a skilled, ethnically and linguistically RATIONALE: Child care businesses must adhere to federal Getting ready diverse early childhood workforce. Adapted from for quality: The critical importance of developing and supporting - law. In addition, child care businesses should model diver a skilled, ethnically and linguistically diverse early childhood sity and non-discrimination in their employment practices to http://www.buildinitiative.org/files/DiverseWorkforce.pdf. workforce. enhance the quality of the program by supporting diversity Chapter 1: Staffing 9

40 Caring for Our Children: National Health and Safety Performance Standards 2. U.S. Department of Justice, Civil Rights Division, Disability Rights To ensure their safety and physical and mental RATIONALE: Section. 1997. Commonly asked questions about child care centers health, children should be protected from any risk of abuse and the Americans with Disabilities Act. http://www.ada.gov/ or neglect. Although few persons will acknowledge past childq&a.htm. child abuse or neglect to another person, the obvious at- 3. U.S. Equal Employment Opportunity Commission. Discrimination tention directed to the question by the licensing agency or based on sexual orientation, status as a parent, marital status and caregiver/teacher may discourage some potentially abusive political affiliation. http://www.eeoc.gov/federal/otherprotections.cfm. individuals from seeking employment in child care. Perform- ing diligent background screenings also protects the child STANDARD 1.2.0.2: Background Screening care facility against future legal challenges (1). Having a Directors of centers and caregivers/teachers in large and state credentialing system can reduce the time required to small family child care homes should conduct a complete ensure all those caring for children have had the required background screening before employing any staff member background screening review. (including substitutes, cooks, clerical staff, transportation COMMENTS: Directors who are conducting screenings staff, bus drivers, or custodians who will be on the premises and caregivers/teachers who are asked to submit a back- or in vehicles when children are present). The background ground screening record should contact their state child screening should include: care licensing agency for the appropriate documentation a) Name and address verification; required. Fingerprinting can be secured at local law enforce- b) Social Security number verification; ment offices or the State Bureau of Investigation. Court c) Education verification; records are public information and can be obtained from Employment history; d) county court offices and some states have statewide online Alias search; e) court records. When checking for prior arrests or previous f) Driving history through state Department of Motor court actions, the facility should check for misdemeanors Vehicles records; as well as felonies. Driving records are available from the Background screening of: g) State Department of Motor Vehicles. A social security trace State and national criminal history records; 1) is a report, derived from credit bureau records that will 2) Child abuse and neglect registries; return all current and reported addresses for the last seven Licensing history with any other state agencies 3) to ten years on a specific individual based on his or her (i.e., foster care, mental health, nursing homes, social security number. If there are alternate names (aliases) etc.); these are also reported. State child abuse registries can be 4) Fingerprints; and accessed at http://www.hunter.cuny.edu/socwork/nrcfcpp/ Sex offender registries; 5) downloads/policy-issues/State_Child_Abuse_Registries Court records; h) .pdf. Sex offender registries can be accessed at http://www i) References. .prevent-abuse-now.com/register.htm. Companies also offer All family members over age ten living in large and small background check services. The National Association of family child care homes should also have background Professional Background Screeners (http://www.napbs.com) screenings. provides a directory of their membership. Drug tests may also be incorporated into the background For more information on state licensing requirements re- screening. Written permission to obtain the background garding criminal background screenings, see the National screening (with or without a drug screen) should be ob- Association for Regulatory Administration’s (NARA) current tained from the prospective employee. Consent to the Licensing Study at http://www.naralicensing.org. background investigation should be required for employ- Center; Large Family Child Care Home; Small TYPE OF FACILITY: ment consideration. Family Child Care Home When checking references and when conducting employee REFERENCES: or volunteer interviews, prospective employers should spe- 1. Privacy Rights Clearinghouse. 2011. Fact sheet 16: Employment cifically ask about previous convictions and arrests, inves- background checks: A jobseeker’s guide. http://www.privacyrights tigation findings, or court cases with child abuse/neglect .org/fs/fs16-bck.htm. or child sexual abuse. Failure of the prospective employee to disclose previous history of child abuse/neglect or child 1.3 Pre-service Qualifications sexual abuse is grounds for immediate dismissal. Persons should not be hired or allowed to work or volunteer 1.3.1 Director’s Qualifications in the child care facility if they acknowledge being sexually attracted to children or having physically or sexually abused STANDARD 1.3.1.1: General Qualifications of children, or are known to have committed such acts. Directors Background screenings should be repeated periodically The director of a center enrolling fewer than sixty children taking into consideration state laws and/or requirements. should be at least twenty-one-years-old and should have all Screenings should be repeated more frequently if there are the following qualifications: additional concerns. 10 Chapter 1: Staffing

41 Caring for Our Children: National Health and Safety Performance Standards depend largely upon the knowledge, skills, and dependable a) Have a minimum of a Baccalaureate degree with at presence of a director who is able to respond to long-range least nine credit-bearing hours of specialized college- and immediate needs and able to engage staff in decision- level course work in administration, leadership, or making that affects their day-to-day practice (5,6). Manage- management, and at least twenty-four credit-bearing ment skills are important and should be viewed primarily as hours of specialized college-level course work in a means of support for the key role of educational leader - early childhood education, child development, ship that a director provides (6). A skilled director should elementary education, or early childhood special know how to use early care and education consultants, education that addresses child development, learning such as health, education, mental health, and community from birth through kindergarten, health and safety, resources and to identify specialized personnel to enrich and collaboration with consultants OR documents the staff’s understanding of health, development, behavior, meeting an appropriate combination of relevant and curriculum content. Past experience working in an early education and work experiences (6); childhood setting is essential to running a facility. A valid certificate of successful completion of b) pediatric first aid that includes CPR; Life experience may include experience rearing one’s own Knowledge of health and safety resources and c) children or previous personal experience acquired in any access to education, health, and mental health child care setting. Work as a hospital aide or at a camp for consultants; children with special health care needs would qualify, as d) Knowledge of community resources available to would experience in school settings. This experience, how- children with special health care needs and the ability ever, must be supplemented by competency-based training to use these resources to make referrals or achieve to determine and provide whatever new skills are needed to interagency coordination; care for children in child care settings. Administrative and management skills in facility e) COMMENTS: The profession of early childhood education operations; is being informed by research on the association of devel- f) Capability in curriculum design and implementation, - opmental outcomes with specific practices. The exact com ensuring that an effective curriculum is in place; bination of college coursework and supervised experience is Oral and written communication skills; g) still being developed. For example, the National Association h) Certificate of satisfactory completion of instruction in for the Education of Young Children (NAEYC) has published medication administration; Standards for Early Childhood Professional Preparation the i) Demonstrated life experience skills in working with (4). The National Child Care Association (NCCA) Programs children in more than one setting; has developed a curriculum based on administrator compe- j) Interpersonal skills; tencies; more information on the NCCA is available at http:// Clean background screening. k) www.nccanet.org. Knowledge about parenting training/counseling and ability Center TYPE OF FACILITY: to communicate effectively with parents/guardians about developmental-behavioral issues, child progress, and in RELATED STANDARDS: Standards 1.3.1.2-1.3.2.3: General Qualifications for all Caregivers/ creating an intervention plan beginning with how the center Teachers, Including Directors, of All Types of Facilities will address challenges and how it will help if those efforts Standards 1.4.2.1-1.4.2.3: Orientation Training are not effective. Standards 1.4.3.1-1.4.3.3: First Aid and CPR Training The director of a center enrolling more than sixty children Standards 1.4.4.1-1.4.6.2: Continuing Education/Professional should have the above and at least three years experience Development as a teacher of children in the age group(s) enrolled in the REFERENCES: center where the individual will act as the director, plus at Children 1. Roupp, R., J. Travers, F. M., Glantz, C. Coelen. 1979. least six months experience in administration. Vol. 1 of at the center: Summary findings and their implications. . Cambridge, MA: Abt Final report of the National day care study RATIONALE: The director of the facility is the team leader Associates. of a small business. Both administrative and child develop- 2. Howes, C. 1997. Children’s experiences in center-based child ment skills are essential for this individual to manage the care as a function of teacher background and adult:child ratio. facility and set appropriate expectations. College-level Merrill-Palmer Q 43:404-24. coursework has been shown to have a measurable, positive Cost, quality and child outcomes in child 3. Helburn, S., ed. 1995. effect on quality child care, whereas experience per se has care centers. Denver, CO: University of Colorado at Denver. not (1-3,5). 4. National Association for the Education of Young Children Standards for early childhood professional (NAEYC). 2009. The director of a center plays a pivotal role in ensuring the Washington, DC: NAEYC. http://www.naeyc preparation programs. day-to-day smooth functioning of the facility within the .org/files/naeyc/file/positions/ProfPrepStandards09.pdf. framework of appropriate child development principles and 13 indicators of quality child care: Research 5. Fiene, R. 2002. knowledge of family relationships (6). . Washington, DC: U.S. Department of Health and Human update Services, Office of the Assistant Secretary for Planning and The well-being of the children, the confidence of the Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/. parents/guardians of children in the facility’s care, and the high morale and consistent professional growth of the staff Chapter 1: Staffing 11

42 Caring for Our Children: National Health and Safety Performance Standards 6. National Association for the Education of Young Children (1). The NAEYC requirements include development of an (NAEYC). 2007. NAEYC early childhood program standards employee compensation plan to increase salaries and bene- and accreditation criteria: The mark of quality in early childhood fits to ensure recruitment and retention of qualified staff and Washington, DC: NAEYC. education. continuity of relationships (2). The NAEYC’s recommenda- tions should be consulted in conjunction with the standards STANDARD 1.3.1.2: Mixed Director/Teacher in this document. Role Center TYPE OF FACILITY: Centers enrolling thirty or more children should employ a REFERENCES: non-teaching director. Centers with fewer than thirty children 1. National Association for the Education of Young Children may employ a director who teaches as well. Accreditation criteria and procedures of the (NAEYC). 2005. National Academy of Early Childhood Programs. Washington, DC: RATIONALE: The duties of a director of a facility with more NAEYC. than thirty children do not allow the director to be involved 2. National Association for the Education of Young Children in the classroom in a meaningful way. Standards for early childhood professional (NAEYC). 2009. preparation programs. Washington, DC: NAEYC. http://www.naeyc COMMENTS: This standard does not prohibit the director .org/files/naeyc/file/positions/ProfPrepStandards09.pdf. from occasional substitute teaching, as long as the substi- 3. Whitebook, M., C. Howes, D. Phillips. 1998. Worthy work, tute teaching is not a regular and significant duty. Occasion- unlivable wages: The national child care staffing study, 1988-1997. al substitute teaching may keep the director in touch with Washington, DC: Center for the Child Care Workforce. the caregivers’/teachers’ issues. Center TYPE OF FACILITY: STANDARD 1.3.2.2: Qualifications of Lead Teachers and Teachers 1.3.2 Caregiver’s/Teacher’s and Other Lead teachers and teachers should be at least twenty-one Staff Qualifications years of age and should have at least the following educa- tion, experience, and skills: STANDARD 1.3.2.1: Differentiated Roles A Bachelor’s degree in early childhood education, a) school-age care, child development, social work, Centers should employ a caregiving/teaching staff for direct nursing, or other child-related field, or an associate’s work with children in a progression of roles, as listed in degree in early childhood education and currently descending order of responsibility: working towards a bachelor’s degree; a) Program administrator or training/curriculum A minimum of one year on-the-job training in b) specialists; providing a nurturing indoor and outdoor environment b) Lead teachers; and meeting the child’s out-of-home needs; c) Teachers; c) One or more years of experience, under qualified d) Assistant teachers or teacher aides. supervision, working as a teacher serving the ages Each role with increased responsibility should require in- and developmental abilities of the children in care; creased educational qualifications and experience, as well A valid certificate in pediatric first aid, including CPR; d) as increased salary. Thorough knowledge of normal child development e) A progression of roles enables centers to offer RATIONALE: and early childhood education, as well as knowledge career ladders rather than dead-end jobs. It promotes a of indicators that a child is not developing typically; mix of college-trained staff with other members of a child’s f) The ability to respond appropriately to children’s own community who might have entered at the aide level needs; and moved into higher roles through college or on-the-job The ability to recognize signs of illness and safety/ g) training. injury hazards and respond with prevention interventions; Professional education and pre-professional in-service train- Oral and written communication skills; h) ing programs provide an opportunity for career progression i) Medication administration training (8). and can lead to job and pay upgrades and fewer turnovers. Turnover rates in child care positions in 1997 averaged 30% Every center, regardless of setting, should have at least (3). one licensed/certified lead teacher (or mentor teacher) who meets the above requirements working in the child care COMMENTS: Early childhood professional knowledge must facility at all times when children are in care. be required whether programs are in private centers, public schools, or other settings. The National Association for the Additionally, facilities serving children with special health Education of Young Children’s (NAEYC) Academy of Early care needs associated with developmental delay should Childhood Programs recommends a multi-level training pro- employ an individual who has had a minimum of eight hours gram that addresses pre-employment educational require- of training in inclusion of children with special health care ments and continuing education requirements for entry-level needs. assistants, caregivers/teachers, and administrators. It also establishes a table of qualifications for accredited programs Chapter 1: Staffing 12

43 Caring for Our Children: National Health and Safety Performance Standards RATIONALE: Child care that promotes healthy development STANDARD 1.3.2.3: Qualifications for is based on the developmental needs of infants, toddlers, Assistant Teachers, Teacher Aides, and and preschool children. Caregivers/teachers are chosen for Volunteers their knowledge of, and ability to respond appropriately to, Assistant teachers and teacher aides should be at least the 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 child- and participate in on-the-job training, including a structured hood and special educational experience are useful in a orientation to the developmental needs of young children center. Caregivers/teachers that have received formal edu- and access to consultation, with periodic review, by a su- cation from an accredited college or university have shown pervisory staff member. At least 50% of all assistant teach- to have better quality of care and outcomes of programs. ers and teacher aides must have or be working on either a Those teachers with a four-year college degree exhibit opti- Child Development Associate (CDA) credential or equivalent, mal teacher behavior and positive effects on children (6). or an associate’s or higher degree in early childhood educa- Caregivers/teachers are more likely to administer medica- tion/child development or equivalent (9). tions than to perform CPR. Seven thousand children per Volunteers should be at least sixteen years of age and year require emergency department visits for problems should participate in on-the-job training, including a struc - related to cough and cold medication (7). tured orientation to the developmental needs of young COMMENTS: The profession of early childhood education children. Assistant teachers, teacher aides, and volunteers is being informed by the research on early childhood brain should work only under the continual supervision of lead development, child development practices related to child teacher or teacher. Assistant teachers, teacher aides, and outcomes (5). For additional information on qualifications volunteers should never be left alone with children. Volun- Standards for Early Child- for child care staff, refer to the teers should not be counted in the child:staff ratio. from the National hood Professional Preparation Programs All assistant teachers, teacher aides, and volunteers should Association for the Education of Young Children (NAEYC) possess: (4). Additional information on the early childhood education a) The ability to carry out assigned tasks competently profession is available from the Center for the Child Care under the supervision of another staff member; Workforce (CCW). An understanding of and the ability to respond b) TYPE OF FACILITY: Center appropriately to children’s needs; RELATED STANDARDS: Sound judgment; c) Standards 1.4.3.1-1.4.3.3: First Aid and CPR Training Emotional maturity; and d) REFERENCES: e) Clearly discernible affection for and commitment to 1. National Institute of Child Health and Human Development the well-being of children. (NICHD) Early Child Care Research Network. 1996. Characteristics While volunteers and students can be as RATIONALE: of infant child care: Factors contributing to positive caregiving. Early young as sixteen, age eighteen is the earliest age of legal Child Res Q 11:269-306. consent. Mature leadership is clearly preferable. Age Developmentally 2. Bredekamp, S., C. Copple, eds. 1997. twenty-one allows for the maturity necessary to meet the re- appropriate practice in early childhood programs. Rev ed. Washington, DC: National Association for the Education of Young sponsibilities of managing a center or independently caring Children. for a group of children who are not one’s own. 3. U.S. Department of Justice. 2011. Americans with Disabilities Child care that promotes healthy development is based on Act. http://www.ada.gov. the developmental needs of infants, toddlers, preschool, 4. National Association for the Education of Young Children and school-age children. Caregivers/teachers should be Standards for early childhood professional (NAEYC). 2009. Washington, DC: NAEYC. http://www.naeyc preparation programs. chosen for their knowledge of, and ability to respond appro- .org/files/naeyc/file/positions/ProfPrepStandards09.pdf. priately to, the general needs of children of this age and the 5. Committee on Integrating the Science of Early Childhood unique characteristics of individual children (1,3-5). Development, Board on Children, Youth, and Families. 2000. Staff training in child development and/or early childhood Ed. J. P. Shonkoff, D. A. Phillips. From neurons to neighborhoods. education is related to positive outcomes for children. This Washington, DC: National Academy Press. training enables the staff to provide children with a variety The early care and 6. Kagan, S. L., K. Tarrent, K. Kauerz. 2008. 44-47, 90-91. New education teaching workforce at the fulcrum, of learning and social experiences appropriate to the age of York: Teachers College Press. the child. Everyone providing service to, or interacting with, 7. U.S. Department of Health and Human Services. 2008. CDC children in a center contributes to the child’s total experi- study estimates 7,000 pediatric emergency departments visits ence (8). linked to cough and cold medication: Unsupervised ingestion Adequate compensation for skilled workers will not be given accounts for 66 percent of incidents. Centers for Disease Control and Prevention (CDC). http://www.cdc.gov/media/pressrel/2008/ priority until the skills required are recognized and valued. r080128.htm. Teaching and caregiving requires skills to promote develop- 8. American Academy of Pediatrics, Council on School Health. ment and learning by children whose needs and abilities 2009. Policy statement: Guidance for the administration of change at a rapid rate. Pediatrics medication in school. 124:1244-51. Chapter 1: Staffing 13

44 Caring for Our Children: National Health and Safety Performance Standards Experience and qualifications used by the COMMENTS: STANDARD 1.3.2.4: Additional Qualifications Child Development Associate (CDA) program and the Na- for Caregivers/Teachers Serving Children tional Child Care Association (NCCA) credentialing program, Three to Thirty-Five Months of Age and included in degree programs with field placement are Caregivers/teachers should be prepared to work with infants valued (10). Early childhood professional knowledge must and toddlers and, when asked, should be knowledgeable be required whether programs are in private homes, centers, - and demonstrate competency in tasks associated with car public schools, or other settings. Go to http://www ing for infants and toddlers: .cdacouncil.org/the-cda-credential/how-to-earn-a-cda/ to Diapering and toileting; a) view appropriate training and qualification information on Bathing; b) the CDA Credential. Feeding, including support for continuation of c) The National Association for the Education of Young breastfeeding; Children’s (NAEYC) National Academy for Early Childhood d) Holding; Program Accreditation, the National Early Childhood Pro- Comforting; e) gram Accreditation (NECPA) and the National Association of f) Practicing safe sleep practices to reduce the risk of Family Child Care (NAFCC) have established criteria for staff Sudden Infant Death Syndrome (SIDS) (3); qualifications (2,6,7). g) Providing warm, consistent, responsive caregiving Caregivers/teachers who lack educational qualifications and opportunities for child-initiated activities; may be employed as continuously supervised personnel Stimulating communication and language h) while they acquire the necessary educational qualifications development and pre-literacy skills through play, if they have personal characteristics, experience, and skills shared reading, song, rhyme, and lots of talking; in working with parents, guardians and children, and the po- i) Promoting cognitive, physical, and social emotional tential for development on the job or in a training program. development; j) Preventing shaken baby syndrome/abusive head States may have different age requirements for volunteers. trauma; TYPE OF FACILITY: Center; Large Family Child Care Home Promoting infant mental health; k) RELATED STANDARDS: l) Promoting positive behaviors; Standard 6.5.1.2: Qualifications for Drivers Setting age-appropriate limits with respect to safety, m) health, and mutual respect; REFERENCES: n) Using routines to teach children what to expect from 1. National Institute of Child Health and Human Development caregivers/teachers and what caregivers/teachers (NICHD) Early Child Care Research Network. 1996. Characteristics Early of infant child care: Factors contributing to positive caregiving. expect from them. Child Res Q 11:269-306. Caregivers/teachers should demonstrate knowledge of de- 2. National Association for the Education of Young Children velopment of infants and toddlers as well as knowledge of (NAEYC). 2005. Accreditation and criteria procedures of the indicators that a child is not developing typically; knowledge Washington, DC: National Academy of Early Childhood Programs. of the importance of attachment for infants and toddlers, the NAEYC. 3. National Association for the Education of Young Children importance of communication and language development, (NAEYC). 2009. Developmentally appropriate practice in early and the importance of nurturing consistent relationships on childhood programs serving children from birth through age 8. fostering positive self-efficacy development. Washington, DC: NAEYC. http://www.naeyc.org/files/naeyc/file/ - To help manage atypical or undesirable behaviors of chil positions/position statement Web.pdf. dren, caregivers/teachers, in collaboration with parents/ 4. U.S. Department of Justice. 2011. Americans with Disabilities guardians, should seek professional consultation from the Act. http://www.ada.gov. 5. National Association for the Education of Young Children child’s primary care provider, an early childhood mental (NAEYC). 2009. Standards for Early Childhood professional health professional, or an early childhood mental health con- Washington, DC: NAEYC. http://www.naeyc preparation programs. sultant. .org/files/naeyc/file/positions/ProfPrepStandards09.pdf. The brain development of infants is particu- RATIONALE: 6. National Child Care Association (NCCA). NCCA official Website. larly sensitive to the quality and consistency of interpersonal http://www.nccanet.org. 7. National Association for Family Child Care (NAFCC). NAFCC relationships. Much of the stimulation for brain development official Website. http://nafcc.net. comes from the responsive interactions of caregivers/teach- 8. Da Ros-Voseles, D., S. Fowler-Haughey. 2007. Why children’s ers and children during daily routines. Children need to be dispositions should matter to all teachers. Young Children allowed to pursue their interests within safe limits and to be (September): 1-7. http://www.naeyc.org/files/yc/file/200709/ encouraged to reach for new skills (1-7). DaRos-Voseles.pdf. Since early childhood mental health profes- COMMENTS: 9. National Association for the Education of Young Children (NAEYC). Candidacy requirements. http://www.naeyc.org/academy/ sionals are not always available to help with the manage- pursuing/candreq/. ment of challenging behaviors in the early care and educa- 10. Council for Professional Recognition. 2011. How to obtain a tion setting early childhood mental health consultants may CDA. http://www.cdacouncil.org/the-cda-credential/ be able to help. The consultant should be viewed as an how-to-earn-a-cda/. 14 Chapter 1: Staffing

45 Caring for Our Children: National Health and Safety Performance Standards with stress, problem solve and engage in conflict important part of the program’s support staff and should resolution, and successfully establish friendships; collaborate with all regular classroom staff, consultants, and Cognitive, language, early literacy, scientific inquiry, c) other staff. Qualified potential consultants may be identified and mathematics development of children; by contacting mental health and behavioral providers in the d) Cultural backgrounds of the children in the facility’s local area, as well as accessing the National Mental Health care; Information Center (NMHIC) at http://store.samhsa.gov/ e) Talking to parents/guardians about observations and mhlocator/ and Healthy Child Care America (HCCA) at concerns and referrals to parents/guardians; http://www.healthychildcare.org/Contacts.html. f) Changing needs of populations served, e.g., culture, Center; Large Family Child Care Home; Small TYPE OF FACILITY: income, etc. Family Child Care Home - To help manage atypical or undesirable behaviors of chil RELATED STANDARDS: dren three to five years of age, caregivers/teachers serv- Standards 1.3.1.1-1.3.2.3: General Qualifications for all Caregivers/ Teachers, Including Directors, of All Types of Facilities ing this age group should seek professional consultation, Standards 1.4.2.1-1.4.2.3: Orientation Training in collaboration with parents/guardians, from the child’s Standards 1.4.3.1-1.4.3.3: First Aid and CPR Training primary care provider, a mental health professional, a child Standards 1.4.4.1-1.4.6.2: Continuing Education/Professional care health consultant, or an early childhood mental health Development consultant. Standard 1.6.0.3: Early Childhood Mental Health Consultants Three- and four-year-old children continue to RATIONALE: Standard 3.1.4.1: Safe Sleep Practices and SIDS/Suffocation Risk Reduction depend on the affection, physical care, intellectual guid- Standards 4.3.1.1-4.3.1.12: Nutrition for Infants ance, and emotional support of their caregivers/teachers (1,2). REFERENCES: 1. Shore, R. 1997. Rethinking the brain: New insights into early A supportive, nurturing setting that supports a demonstra- development. New York: Families and Work Inst. tion of feelings and accepts regression as part of develop- 2. National Forum on Early Childhood Policy and Programs, ment continues to be vital for preschool children. Preschool National Scientific Council on the Developing Child. 2007. A children need help building a positive self-image, a sense of science-based framework for early childhood policy: Using evidence self as a person of value from a family and a culture of which to improve outcomes in learning, behavior, and health for vulnerable they are proud. Children should be enabled to view them- children. http://developingchild.harvard.edu/index.php/library/ selves as coping, problem-solving, competent, passionate, reports_and_working_papers/policy_framework/. 3. Moon, R. Y., T. Calabrese, L. Aird. 2008. Reducing the risk of expressive, and socially connected to peers and staff (3). sudden infant death syndrome in child care and changing provider Center; Large Family Child Care Home; Small TYPE OF FACILITY: Pediatrics practices: Lessons learned from a demonstration project. Family Child Care Home 122:788-98. 4. Fiene, R. 2002. 13 indicators of quality child care: Research RELATED STANDARDS: Washington, DC: U.S. Department of Health and Human update. Standards 1.3.1.1-1.3.2.3: General Qualifications for all Caregivers/ Services, Office of the Assistant Secretary for Planning and Teachers, Including Directors, of All Types of Facilities Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/. Standards 1.4.2.1-1.4.2.3: Orientation Training 5. Centers for Disease Control and Prevention. Learn the signs. Act Standards 1.4.3.1-1.4.3.3: First Aid and CPR Training early. http://www.cdc.gov/ncbddd/actearly/. Standards 1.4.4.1-1.4.6.2: Continuing Education/Professional From neurons to 6. Shonkoff, J. P., D. A. Phillips, eds. 2000. Development neighborhoods: The science of early childhood development. REFERENCES: Washington, DC: National Academy Press. 1. National Institute of Child Health and Human Development Helping 7. Cohen, J., N. Onunaku, S. Clothier, J. Poppe. 2005. (NICHD) Early Child Care Research Network. 1999. Child outcomes young children succeed: Strategies to promote early childhood when child center classes meet recommended standards for social and emotional development. Washington, DC: National 89:1072-77. Am J Public Health quality. Conference of State Legislatures; Zero to Three. http://main Rethinking the brain: New insights into early 2. Shore, R. 1997. .zerotothree.org/site/DocServer/help_yng_child_succeed.pdf. New York: Families and Work Inst. development. 13 indicators of quality child care: Research 3. Fiene, R. 2002. STANDARD 1.3.2.5: Additional Qualifications Washington, DC: U.S. Department of Health and Human update. Services, Office of the Assistant Secretary for Planning and for Caregivers/Teachers Serving Children Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/. Three to Five Years of Age Caregivers/teachers should demonstrate the ability to apply STANDARD 1.3.2.6: Additional Qualifications - their knowledge and understanding of the following to chil for Caregivers/Teachers Serving School-Age dren three to five years of age within the program setting: Children a) Typical and atypical development of three- to five- year-old children; Caregivers/teachers should demonstrate knowledge about Social and emotional development of children, b) and competence with the social and emotional needs and including children’s development of independence, developmental tasks of five- to twelve-year old children, be their ability to adapt to their environment and cope able to recognize and appropriately manage difficult behav- Chapter 1: Staffing 15

46 Caring for Our Children: National Health and Safety Performance Standards Standard 2.2.0.8: Preventing Expulsions, Suspensions, and Other iors, and know how to implement a socially and cognitively Limitations in Services enriching program that has been developed with input from parents/guardians. Issues that are significant within school- REFERENCES: age programs include having a sense of community, bully- 1. Deschenes, S. N., A. Arbreton, P. M. Little, C. Herrera, J. B. Engaging older youth: Grossman, H. B. Weiss, D. Lee. 2010. ing, sexuality, electronic media, and social networking. Program and city-level strategies to support sustained participation With this age group as well, caregivers/teachers, in col- http://www.hfrp.org/out-of-school-time/ in out-of-school time. laboration with parents/guardians, should seek professional publications-resources/engaging-older-youth-program-and-city consultation from the child’s primary care provider, a mental -level-strategies-to-support-sustained-participation-in-out-of health professional, a child care health consultant, or an -school-time/. early childhood mental health consultant to help manage 2. New York State Department of Social Services, Cornell Cooperative Extension. 2004. A parent’s guide to child care for atypical or undesirable behaviors. school-age children. National Network for Child Care. http://www RATIONALE: A school-age child develops a strong, secure .nncc.org/choose.quality.care/parents.sac.html#anchor68421/ sense of identity through positive experiences with adults . references and peers (1,2). An informal, enriching environment that 3. Fiene, R. 2002. 13 indicators of quality child care: Research encourages self-paced cultivation of interests and relation- update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and ships promotes the self-worth of school-age children (1). Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/. Balancing free exploration with organized activities includ- Family engagement as 4. Harvard Family Research Project. 2010. ing homework assistance and tutoring among a group of a systemic, sustained, and integrated strategy to promote student children also supports healthy emotional and social devel- achievement. http://www.hfrp.org/publications-resources/browse opment (1,3). -our-publications/family-engagement-as-a-systemic-sustained When children display behaviors that are unusual or difficult -and-integrated-strategy-to-promote-student-achievement/. to manage, caregivers/teachers should work with parents/ guardians to seek a remedy that allows the child to succeed STANDARD 1.3.2.7: Qualifications and in the child care setting, if possible (4). Responsibilities for Health Advocates COMMENTS: The first resource for addressing behavior Each facility should designate at least one administrator or - problems is the child’s primary care provider. School per staff person as the health advocate to be responsible for sonnel, including professional serving school-based health policies and day-to-day issues related to health, develop- clinics may also be able to provide valuable insights. Sup- ment, and safety of individual children, children as a group, port from a mental health professional may be needed. If the staff, and parents/guardians. In large centers it may be child’s primary care provider cannot help or obtain help from important to designate health advocates at both the center a mental health professional, the caregiver/teacher and the and classroom level. The health advocate should be the pri- family may need an early childhood mental health consultant mary contact for parents/guardians when they have health to advise about appropriate management of the child. Local concerns, including health-related parent/guardian/staff mental health agencies or pediatric departments of medical observations, health-related information, and the provision schools may offer help from child psychiatrists, psycholo- of resources. The health advocate ensures that health and gists, other mental health professionals skilled in the issues safety is addressed, even when this person does not directly of early childhood, and pediatricians who have a subspe- perform all necessary health and safety tasks. cialty in developmental and behavioral pediatrics. Local or The health advocate should also identify children who area education agencies serving children with special health have no regular source of health care, health insurance, or or developmental needs may be useful. State Title V (Chil - positive screening tests with no referral documented in the dren with Special Health Care Needs) may be contacted. All child’s health record. The health advocate should assist the state Maternal Child Health (MCH) programs are required - child’s parent/guardian in locating a Medical Home by refer to have a toll-free number to link consumers to appropriate ring them to a primary care provider who offers routine child programs for children with special health care needs. The health services. toll-free number listing is located at https://perfdata.hrsa .gov/MCHB/MCHReports/search/program/prgsch16.asp. For centers, the health advocate should be licensed/ Dismissal from the program should be the last resort and certified/credentialed as a director or lead teacher or should only after consultation with the parent/guardian(s). be a health professional, health educator, or social worker who works at the facility on a regular basis (at least weekly). Center; Large Family Child Care Home; Small TYPE OF FACILITY: Family Child Care Home The health advocate should have documented training in the following: RELATED STANDARDS: Control of infectious diseases, including Standard a) Standards 1.3.1.1-1.3.2.3: General Qualifications for all Caregivers/ Teachers, Including Directors, of All Types of Facilities Precautions, hand hygiene, cough and sneeze Standards 1.4.2.1-1.4.2.3: Orientation Training etiquette, and reporting requirements; Standards 1.4.3.1-1.4.3.3: First Aid and CPR Training b) Childhood immunization requirements, record- Standards 1.4.4.1-1.4.6.2: Continuing Education/Professional keeping, and at least quarterly review and Development Chapter 1: Staffing 16

47 Caring for Our Children: National Health and Safety Performance Standards the child (2,3). Caregivers/teachers who are better trained follow-up for children who need to have updated are more able to prevent, recognize, and correct health and immunizations; safety problems. An internal advocate for issues related to Child health assessment form review and follow-up c) health and safety can help integrate these concerns with of children who need further medical assessment or other factors involved in formulating facility plans. updating of their information; d) How to plan for, recognize, and handle an Children may be current with required immunizations when emergency; they enroll, but they sometimes miss scheduled immuniza- e) Poison awareness and poison safety; tions thereafter. Because the risk of vaccine-preventable f) Recognition of safety, hazards, and injury prevention disease increases in group settings, assuring appropriate interventions; immunizations is an essential responsibility in child care. Safe sleep practices and the reduction of the risk of g) Caregivers/teachers should contact their child care health Sudden Infant Death Syndrome (SIDS); consultant or the health department if they have a question How to help parents/guardians, caregivers/teachers, h) regarding immunization updates/schedules. They can also and children cope with death, severe injury, and provide information to share with parents/guardians about natural or man-made catastrophes; the importance of vaccines. i) Recognition of child abuse, neglect/child Child health records are intended to provide information maltreatment, shaken baby syndrome/abusive that indicates that the child has received preventive health head trauma (for facilities caring for infants), and services to stay well, and to identify conditions that might knowledge of when to report and to whom suspected interfere with learning or require special care. Review of the abuse/neglect; information on these records should be performed by some- j) Facilitate collaboration with families, primary care one who can use the information to plan for the care of the providers, and other health service providers to child, and recognize when updating of the information by create a health, developmental, or behavioral care the child’s primary care provider is needed. Children must plan; be healthy to be ready to learn. Those who need accom- k) Implementing care plans; modation for health problems or are susceptible to vaccine- l) Recognition and handling of acute health related preventable diseases will suffer if the staff of the child care situations such as seizures, respiratory distress, program is unable to use information provided in child allergic reactions, as well as other conditions as health records to ensure that the child’s needs are met (5,6). dictated by the special health care needs of children; m) Medication administration; COMMENTS: The director should assign the health advo- Recognizing and understanding the needs of children n) cate role to a staff member who seems to have an interest, with serious behavior and mental health problems; - aptitude, and training in this area. This person need not per Maintaining confidentiality; o) form all the health and safety tasks in the facility but should p) Healthy nutritional choices; serve as the person who raises health and safety concerns. q) The promotion of developmentally appropriate types This staff person has designated responsibility for seeing and amounts of physical activity; that plans are implemented to ensure a safe and healthful r) How to work collaboratively with parents/guardians facility (1). and family members; A health advocate is a regular member of the staff of a s) How to effectively seek, consult, utilize, and center or large or small family child care home, and is not collaborate with child care health consultants, and the same as the child care health consultant recommended in partnership with a child care health consultant, in Child Care Health Consultants, Standard 1.6.0.1. The how to obtain information and support from other health advocate works with a child care health consultant on education, mental health, nutrition, physical activity, health and safety issues that arise in daily interactions (4). oral health, and social service consultants and For small family child care homes, the health advocate will resources; usually be the caregiver/teacher. If the health advocate is t) Knowledge of community resources to refer children not the child’s caregiver/teacher, the health advocate should and families who need health services including work with the child’s caregiver/teacher. The person who is access to State Children’s Health Insurance (SCHIP), most familiar with the child and the child’s family will rec- importance of a primary care provider and medical ognize atypical behavior in the child and support effective home, and provision of immunizations and Early communication with parents/guardians. 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 The effectiveness of an intentionally designat- RATIONALE: daily. A plan for personal contact and documentation of a ed health advocate in improving the quality of performance designated caregiver/teacher as health advocate will ensure in a facility has been demonstrated in all types of early specific attempts to have the health advocate communicate childhood settings (1). A designated caregiver/teacher with directly with caregivers/teachers and families on health- health training is effective in developing an ongoing relation- related matters. ship with the parents/guardians and a personal interest in Chapter 1: Staffing 17

48 Caring for Our Children: National Health and Safety Performance Standards meet the general requirements specified in Standard 1.3.2.4 The immunization record/compliance review may be accom- through Standard 1.3.2.6, based on ages of the children plished by manual review of child health records or by use served, and those in Section 1.3.3, and should have the fol- of software programs that use algorithms with the currently lowing education, experience, and skills: recommended vaccine schedules and service intervals to a) Current accreditation by the National Association test the dates when a child received recommended services for Family Child Care (NAFCC) (including entry-level and the child’s date of birth to identify any gaps for which qualifications and participation in required training) referrals should be made. On the Website of the Centers for and a college certificate representing a minimum Disease Control and Prevention (CDC), individual vaccine of three credit hours of early childhood education recommendations for children six years of age and younger leadership or master caregiver/teacher training can be checked at http://www.cdc.gov/vaccines/recs/ or hold an Associate’s degree in early childhood scheduler/catchup.htm. education or child development; Center; Large Family Child Care Home; Small TYPE OF FACILITY: b) A provider who has been in the field less than twelve Family Child Care Home months should be in the self-study phase of NAFCC RELATED STANDARDS: accreditation; Standards 1.3.1.1-1.3.2.3: General Qualifications for all Caregivers/ c) A valid certificate in pediatric first aid, including CPR; Teachers, Including Directors, of All Types of Facilities Pre-service training in health management in child d) Standards 1.4.2.1-1.4.2.3: Orientation Training care, including the ability to recognize signs of illness, Standards 1.4.3.1-1.4.3.3: First Aid and CPR Training knowledge of infectious disease prevention and Standards 1.4.4.1-1.4.6.2: Continuing Education/Professional safety injury hazards; Development Standard 1.6.0.1: Child Care Health Consultants e) If caring for infants, knowledge on safe sleep - Standard 3.1.2.1: Routine Health Supervision and Growth Monitor practices including reducing the risk of sudden infant ing death syndrome (SIDS) and prevention of shaken Standards 3.1.3.1-3.1.3.4: Physical Activity and Limiting Screen baby syndrome/abusive head trauma (including how Time to cope with a crying infant); Standard 7.2.0.1: Immunization Documentation f) Knowledge of normal child development, as well as Standard 7.2.0.2: Unimmunized Children knowledge of indicators that a child is not developing Standards 8.7.0.3: Review of Plan for Serving Children With Dis- typically; abilities or Children With Special Health Care Needs The ability to respond appropriately to children’s g) Appendices G and H: Immunization Schedules for Children and needs; Adults Good oral and written communication skills; h) REFERENCES: i) Willingness to receive ongoing mentoring from other 1. Ulione, M. S. 1997. Health promotion and injury prevention in a teachers; 12:148-54. J Pediatr Nurs child development center. j) Pre-service training in business practices; 2. Kendrick, A. S., R. Kaufmann, K. P. Messenger, eds. 1991. Healthy young children: A manual for programs. Washington, DC: Knowledge of the importance of nurturing adult-child k) National Association for the Education of Young Children. relationships on self-efficacy development; Health in child 3. Murph, J. R., S. D. Palmer, D. Glassy, eds. 2005. l) Medication administration training (6). care: A manual for health professionals . 4th ed. Elk Grove Village, IL: Additionally, large family child care home caregivers/teach- American Academy of Pediatrics. ers should have at least one year of experience serving the 4. Alkon, A., J. Bernzweig, K. To, J. K. Mackie, M. Wolff, J. Elman. ages and developmental abilities of the children in their large 2008. Child care health consultation programs in California: Models, 25:126-39. Public Health Nurs services, and facilitators. family child care home. 5. Centers for Disease Control and Prevention (CDC). 2011. Assistants, aides, and volunteers employed by a large family Immunization schedules. http://www.cdc.gov/vaccines/recs/ child care home should meet the qualifications specified in schedules/. Standard 1.3.2.3. Bright 6. Hagan, J. F., J. S. Shaw, P. M. Duncan, eds. 2008. futures: Guidelines for health supervision of infants, children, and In both large and small family child care RATIONALE: 3rd ed. Elk Grove Village, IL: American Academy of adolescents. homes, staff members must have the education and experi- Pediatrics. ence to meet the needs of the children in care (7). Small family child care home caregivers/teachers often work alone 1.3.3 Family Child Care Home and are solely responsible for the health and safety of small numbers of children in their care. Caregiver/Teacher Qualifications Most SIDS deaths in child care occur on the first day of STANDARD 1.3.3.1: General Qualifications care or within the first week; unaccustomed prone (tummy) of Family Child Care Caregivers/Teachers to sleeping increases the risk of SIDS eighteen times (3). Operate a Family Child Care Home Shaken baby syndrome/abusive head trauma is completely preventable. Pre-service training and frequent refresher All caregivers/teachers in large and small family child care training can prevent deaths (4). homes should be at least twenty-one years of age, hold an official credential as granted by the authorized state agency, 18 Chapter 1: Staffing

49 Caring for Our Children: National Health and Safety Performance Standards Caregivers/teachers are more likely to administer medica- STANDARD 1.3.3.2: Support Networks for tions than to perform CPR. Seven thousand children per Family Child Care year require emergency department visits for problems Large and small family child care home caregivers/teachers related to cough and cold medications (5). should have active membership in a national, and/or state Age eighteen is the earliest age of legal consent. Mature and local early care and education organization(s). National leadership is clearly preferable. Age twenty-one is more organizations addressing concerns of family child care likely to be associated with the level of maturity necessary home caregivers/teachers include the American Academy of to independently care for a group of children who are not Pediatrics (AAP), the National Association for Family Child one’s own. Care (NAFCC), and the National Association for the Educa - tion of Young Children (NAEYC). In addition, belonging to a The NAFCC has established an accreditation process to local network of family child care home caregivers/teachers enhance the level of quality and professionalism in small that offers education, training and networking opportunities and large family child care (2). provides the opportunity to focus on local needs. Child care A large family child care home caregiver/ COMMENTS: resource and referral agencies may provide additional sup- teacher, caring for more than six children and employing port networks for caregivers/teachers that include profes- one or more assistants, functions as the primary caregiver sional development opportunities and information about as well as the facility director. An operator of a large family- electronic networking. child-care home should be offered training relevant to the Membership in peer professional organiza- RATIONALE: management of a small child care center, including training tions shows a commitment to quality child care and also on providing a quality work environment for employees. provides a conduit for information to otherwise isolated For more information on assessing the work environment caregivers/teachers. Membership in a family child care as- of family child care employees, see Creating Better Family sociation and attendance at meetings indicate the desire to a publication by Child Care Jobs: Model Work Standards, gain new knowledge about how to work with children (1). the Center for the Child Care Workforce (CCW) (1). COMMENTS: For more information about family child care Large Family Child Care Home; Small Family TYPE OF FACILITY: associations, contact the NAFCC at http://nafcc.net and/or Child Care Home the NAEYC at http://www.naeyc.org. Also, caregivers/teach- RELATED STANDARDS: ers should check to see if their state has specific accredita- Standards 1.3.1.1-1.3.2.6: Qualifications for all Caregivers/Teach- tion standards. ers, Including Directors, of All Types of Facilities Large Family Child Care Home; Small Family TYPE OF FACILITY: Section 1.3.3: Family Child Care Home Caregiver/Teacher Qualifica- Child Care Home tions Standards 1.4.3.1-1.4.3.3: First Aid and CPR Training RELATED STANDARDS: Standard 3.1.4.1: Safe Sleep Practices and SIDS/Suffocation Risk Standards 1.3.1.1-1.3.2.3: General Qualifications for all Caregivers/ Reduction Teachers, Including Directors, of All Types of Facilities Standards 1.4.2.1-1.4.2.3: Orientation Training REFERENCES: Standards 1.4.3.1-1.4.3.3: First Aid and CPR Training 1. Center for Child Care Workforce. 1999. Creating better family Standards 1.4.4.1-1.4.6.2: Continuing Education/Professional Washington, DC: Center for child care jobs: Model work standards. Development Child Care Workforce. Standard 10.6.2.1: Development of Child Care Provider Organiza- 2. National Association for Family Child Care. NAFCC official tions and Networks Website. http://nafcc.net. 3. Moon, R. Y., T. Calabrese, L. Aird. 2008. Reducing the risk of REFERENCES: sudden infant death syndrome in child care and changing provider 13 indicators of quality child care: Research 1. Fiene, R. 2002. Pediatrics practices: Lessons learned from a demonstration project. Washington, DC: U.S. Department of Health and Human update. 122:788-98. Services, Office of the Assistant Secretary for Planning and 4. Centers for Disease Control and Prevention. Learn the signs. Act Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/. early. http://www.cdc.gov/ncbddd/actearly/. 5. U.S. Department of Health and Human Services. 2008. CDC study estimates 7,000 pediatric emergency departments visits 1.4 Professional Development/ linked to cough and cold medication: Unsupervised ingestion accounts for 66 percent of incidents. Centers for Disease Control Training and Prevention (CDC). http://www.cdc.gov/media/pressrel/2008/ r080128.htm. 1.4.1 Pre-service Training 6. American Academy of Pediatrics, Council on School Health. 2009. Policy statement: Guidance for the administration of STANDARD 1.4.1.1: Pre-service Training . Pediatrics 124:1244-51. medication in school 7. National Association for Family Child Care (NAFCC). 2005. In addition to the credentials listed in Standard 1.3.1.1, Quality standards for NAFCC accreditation. 4th ed. Salt Lake City, upon employment, a director or administrator of a center UT: NAFCC. or the lead caregiver/teacher in a family child care home should provide documentation of at least thirty clock-hours of pre-service training. This training should cover health, Chapter 1: Staffing 19

50 Caring for Our Children: National Health and Safety Performance Standards r) Nutrition and age-appropriate child-feeding including psychosocial, and safety issues for out-of-home child care food preparation, choking prevention, menu planning, facilities. Small family child care home caregivers/teachers and breastfeeding supportive practices; may have up to ninety days to secure training after opening Physical activity, including age-appropriate activities s) except for training on basic health and safety procedures and limiting sedentary behaviors; and regulatory requirements. t) Prevention of childhood obesity and related chronic All directors or program administrators and caregivers/ diseases; teachers should document receipt of pre-service training Knowledge of environmental health issues for both u) prior to working with children that includes the following children and staff; content on basic program operations: v) Knowledge of medication administration policies and Typical and atypical child development and a) practices; appropriate best practice for a range of w) Caring for children with special health care needs, developmental and mental health needs including mental health needs, and developmental disabilities knowledge about the developmental stages for the in compliance with the Americans with Disabilities ages of children enrolled in the facility; Act (ADA); b) Positive ways to support language, cognitive, social, Strategies for implementing care plans for children x) and emotional development including appropriate with special health care needs and inclusion of all guidance and discipline; children in activities; c) Developing and maintaining relationships with y) Positive approaches to support diversity; families of children enrolled, including the resources z) Positive ways to promote physical and intellectual to obtain supportive services for children’s unique development. developmental needs; RATIONALE: The director or program administrator of a d) Procedures for preventing the spread of infectious center or large family child care home or the small family disease, including hand hygiene, cough and sneeze child care home caregiver/teacher is the person accountable etiquette, cleaning and disinfection of toys and for all policies. Basic entry-level knowledge of health and equipment, diaper changing, food handling, health safety and social and emotional needs is essential to admin - department notification of reportable diseases, and ister the facility. Caregivers/teachers should be knowledge- health issues related to having animals in the facility; able about infectious disease and immunizations because e) Teaching child care staff and children about infection properly implemented health policies can reduce the spread control and injury prevention through role modeling; of disease, not only among the children but also among staff f) Safe sleep practices including reducing the risk of members, family members, and in the greater community Sudden Infant Death Syndrome (SIDS) (infant sleep (1). Knowledge of injury prevention measures in child care position and crib safety); is essential to control known risks. Pediatric first aid training Shaken baby syndrome/abusive head trauma g) that includes CPR is important because the director or small prevention and identification, including how to cope family child care home caregiver/teacher is fully responsible with a crying/fussy infant; for all aspects of the health of the children in care. Medica- Poison prevention and poison safety; h) tion administration and knowledge about caring for children i) Immunization requirements for children and staff; with special health care needs is essential to maintaining j) Common childhood illnesses and their management, the health and safety of children with special health care including child care exclusion policies and needs. Most SIDS deaths in child care occur on the first day recognizing signs and symptoms of serious illness; of child care or within the first week due to unaccustomed k) Reduction of injury and illness through environmental prone (on the stomach) sleeping; the risk of SIDS increases design and maintenance; eighteen times when an infant who sleeps supine (on the l) Knowledge of U.S. Consumer Product Safety back) at home is placed in the prone position in child care Commission (CPSC) product recall reports; (2). Shaken baby syndrome/abusive head trauma is com- Staff occupational health and safety practices, m) pletely preventable. It is crucial for caregivers/teachers to such as proper procedures, in accordance with be knowledgeable of both syndromes and how to prevent Occupational Safety and Health Administration them before they care for infants. Early childhood expertise (OSHA) bloodborne pathogens regulations; is necessary to guide the curriculum and opportunities for n) Emergency procedures and preparedness for children in programs (3). The minimum of a Child Develop- disasters, emergencies, other threatening situations ment Associate credential with a system of required contact (including weather-related, natural disasters), and hours, specific content areas, and a set renewal cycle in ad- injury to infants and children in care; dition to an assessment requirement would add significantly Promotion of health and safety in the child care o) to the level of care and education for children. setting, including staff health and pregnant workers; p) First aid including CPR for infants and children; The National Association for the Education of Young Chil- q) Recognition and reporting of child abuse and neglect dren (NAEYC), a leading organization in child care and early in compliance with state laws and knowledge of childhood education, recommends annual training based on protective factors to prevent child maltreatment; 20 Chapter 1: Staffing

51 Caring for Our Children: National Health and Safety Performance Standards training for caregivers/teachers is also available through the needs of the program and the pre-service qualifications some state agencies. of staff (4). Training should address the following areas: Health and safety (specifically reducing the risk a) For more information on social-emotional training, contact of SIDS, infant safe sleep practices, shaken baby the Center on the Social and Emotional Foundations for syndrome/abusive head trauma), and poison Early Learning (CSEFEL) at http://csefel.vanderbilt.edu. prevention and poison safety; TYPE OF FACILITY: Center; Large Family Child Care Home; Small b) Child growth and development, including motor Family Child Care Home development and appropriate physical activity; RELATED STANDARDS: c) Nutrition and feeding of children; Standard 1.3.1.1: General Qualifications of Directors d) Planning learning activities for all children; Standard 1.4.1.1: Pre-service Training e) Guidance and discipline techniques; Standard 1.4.3.1: First Aid and CPR Training for Staff f) Linkages with community services; Standard 1.7.0.1: Pre-Employment and Ongoing Adult Health Ap- Communication and relations with families; g) praisals, Including Immunization Detection and reporting of child abuse and neglect; h) Chapter 3: Health Promotion and Protection i) Advocacy for early childhood programs; Standard 9.2.4.5: Emergency and Evacuation Drills/Exercises Policy j) Professional issues (5). Standard 9.4.3.3: Training Record Standards 10.6.1.1-10.6.1.2: Caregiver/Teacher Training In the early childhood field there is often “crossover” regard- ing professional preparation (pre-service programs) and on- REFERENCES: 1. Hayney M. S., J. C. Bartell. 2005. An immunization education going professional development (in-service programs). This program for childcare providers. J of School Health 75:147-49. field is one in which entry-level requirements differ across 2. Moon R. Y., R. P. Oden. 2003. Back to sleep: Can we influence various sectors within the field (e.g., nursing, family support, child care providers? 112:878-82. Pediatrics and bookkeeping are also fields with varying entry-level 3. Fiene, R. 2002. 13 indicators of quality child care: Research requirements). In early childhood, the requirements differ Washington, DC: U.S. Department of Health and Human update. across center, home, and school based settings. An individ- Services, Office of the Assistant Secretary for Planning and ual could receive professional preparation (pre-service) to be Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/. a teaching staff member in a community-based organization 4. Ritchie, S., B. Willer. 2008. Teachers: A guide to the NAEYC and receive subsequent education and training as part of an early childhood program standard and related accreditation criteria. ongoing professional development system (in-service). The Washington, DC: National Association for the Education of Young Children (NAEYC). same individual could also be pursuing a degree for a role 5. National Association for the Education of Young Children. 2010. as a teacher in a program for which licensure is required— , 12. Eds. Definition of early childhood professional development this in-service program would be considered pre-service M. S. Donovan, J. D. Bransford, J. W. Pellegrino. Washington, DC: education for the certified teaching position. Therefore, the National Academy Press. and in-service pre-service must be seen as related labels to a position in the field, and not based on the individual’s 1.4.2 Orientation Training professional development program (5). COMMENTS: Training in infectious disease control and STANDARD 1.4.2.1: Initial Orientation of All injury prevention may be obtained from a child care health Staff consultant, pediatricians, or other qualified personnel of All new full-time staff, part-time staff and substitutes should children’s and community hospitals, managed care compa- be oriented to the policies listed in Standard 9.2.1.1 and any nies, health agencies, public health departments, EMS and other aspects of their role. The topics covered and the dates fire professionals, pediatric emergency room physicians, or of orientation training should be documented. Caregivers/ other health and safety professionals in the community. teachers should also receive continuing education each For more information about training opportunities, con- year, as specified in Continuing Education, Standard 1.4.4.1 tact the local Child Care Resource and Referral Agency through Standard 1.4.6.2. (CCRRA), the local chapter of the American Academy of Orientation ensures that all staff members RATIONALE: Pediatrics (AAP) (AAP provides online SIDS and medica- receive specific and basic training for the work they will be tion administration training), the Healthy Child Care America doing and are informed about their new responsibilities. Project, the National Resource Center for Health and Safety Because of frequent staff turnover, directors should institute in Child Care and Early Education (NRC), or the National orientation programs on a regular basis (1). Training Institute for Child Care Health Consultants (NTI) at the University of North Carolina at Chapel Hill. California Orientation and ongoing training are especially important Childcare Health Program (CCHP) has free curricula for for aides and assistant teachers, for whom pre-service health and safety for caregivers/teachers to become child educational requirements are limited. Entry into the field at care health advocates. The curriculum (English and Spanish) the level of aide or assistant teacher should be attractive is free to download on the Web at http://www.ucsfchildcare and facilitated so that capable members of the families and health.org/html/pandr/trainingcurrmain.htm, and is based cultural groups of the children in care can enter the field. on NTI’s curriculum for child care health consultants. Online Training ensures that staff members are challenged and Chapter 1: Staffing 21

52 Caring for Our Children: National Health and Safety Performance Standards stimulated, have access to current knowledge (2), and have STANDARD 1.4.2.2: Orientation for Care of access to education that will qualify them for new roles. Children with Special Health Care Needs Use of videos and other passive methods of training should When a child care facility enrolls a child with special health be supplemented by interactive training approaches that care needs, the facility should ensure that all staff members help verify content of training has been learned (3). have been oriented in understanding that child’s special health care needs and have the skills to work with that child Health training for child care staff protects the children in in a group setting. care, staff, and the families of the children enrolled. Infec- tious disease control in child care helps prevent spread of Caregivers/teachers in small family child care homes, who infectious disease in the community. Outbreaks of infectious care for a child with special health care needs, should meet diseases and intestinal parasites in young children in child with the parents/guardians and meet or speak with the care have been shown to be associated with community child’s primary care provider (if the parent/guardian has outbreaks (4). provided prior, informed, written consent) or a child care health consultant to ensure that the child’s special health Child care health consultants can be an excellent resource care needs will be met in child care and to learn how these for providing health and safety orientation or referrals to needs may affect his/her developmental progression or play resources for such training. with other children. COMMENTS: Many states have pre-service education and In addition to Orientation Training, Standard 1.4.2.1, the experience qualifications for caregivers/teachers by role and orientation provided to staff in child care facilities should function. Offering a career ladder and utilizing employee be based on the special health care needs of children who incentives such as Teacher Education and Compensation will be assigned to their care. All staff oriented for care of Helps (TEACH) will attract individuals into the child care children with special health needs should be knowledge- field, where labor is in short supply. Colleges, accredit- able about the care plans created by the child’s primary care ing bodies, and state licensing agencies should examine provider in their medical home as well as any care plans cre- teacher preparation guidelines and substantially increase ated by other health professionals and therapists involved the health content of early childhood professional prepara- in the child’s care. A template for a care plan for children tion. with special health care needs can be found in Appendix O. Child care staff members are important figures in the lives Child care health consultants can be an excellent resource of the young children in their care and in the well-being of for providing health and safety orientation or referrals to families and the community. Child care staff training should resources for such training. This training may include, but is include new developments in children’s health. For example; not limited to, the following topics: a new training program could discuss up-to-date informa- a) Positioning for feeding and handling, and risks for tion on the prevention of obesity and its impact on early injury for children with physical/mental disabilities; onset of chronic diseases. b) Toileting techniques; TYPE OF FACILITY: Center; Large Family Child Care Home; Small c) Knowledge of special treatments or therapies (e.g., Family Child Care Home PT, OT, speech, nutrition/diet therapies, emotional support and behavioral therapies, medication RELATED STANDARDS: Standards 1.4.4.1-1.4.6.2: Continuing Education/Professional administration, etc.) the child may need/receive in the Development child care setting; Standard 1.6.0.1: Child Care Health Consultants Proper use and care of the individual child’s adaptive d) Standard 9.2.1.1: Content of Policies equipment, including how to recognize defective Standard 9.4.3.3: Training Record equipment and to notify parents/guardians that REFERENCES: repairs are needed; 1. Fiene, R. 2002. 13 indicators of quality child care: Research e) How different disabilities affect the child’s ability to update. Washington, DC: U.S. Department of Health and Human participate in group activities; Services, Office of the Assistant Secretary for Planning and f) Methods of helping the child with special health Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/. care needs or behavior problems to participate in 2. Moon R. Y., R. P. Oden. 2003. Back to sleep: Can we influence the facility’s programs, including physical activity child care providers? Pediatrics 112:878-82. programs; 3. National Association for the Education of Young Children Role modeling, peer socialization, and interaction; g) Leadership and management: A guide to (NAEYC). 2008. h) Behavior modification techniques, positive behavioral the NAEYC early childhood program standards and related supports for children, promotion of self-esteem, and Washington, DC: NAEYC. accreditation criteria. 4. Crowley, A. A. 1990. Health services in child day-care centers: A other techniques for managing behavior; survey. J Pediatr Health Care 4:252-59. i) Grouping of children by skill levels, taking into account the child’s age and developmental level; j) Health services or medical intervention for children with special health care problems; k) Communication methods and needs of the child; 22 Chapter 1: Staffing

53 Caring for Our Children: National Health and Safety Performance Standards of the children. The staff is assumed to have the training l) Dietary specifications for children who need to avoid described in Orientation Training, Standard 1.4.2.1, includ- specific foods or for children who have their diet ing child growth and development. These additional topics modified to maintain their health, including support will extend their basic knowledge and skills to help them for continuation of breastfeeding; work more effectively with children who have special health m) Medication administration (for emergencies or on an care needs and their families. The number of hours offered ongoing basis); in any in-service training program should be determined by n) Recognizing signs and symptoms of impending the staff’s experience and professional background. Service illness or change in health status; plans in small family child care homes may require a modi- Recognizing signs and symptoms of injury; o) fied implementation plan. p) Understanding temperament and how individual behavioral differences affect a child’s adaptive skills, The parent/guardian is responsible for solving equipment motivation, and energy; problems. The parent/guardian can request that the child q) Potential hazards of which staff should be aware; care facility remedy the problem directly if the caregiver/ r) Collaborating with families and outside service teacher has been trained on the maintenance and repair of providers to create a health, developmental, and the equipment and if the staff agrees to do it. behavioral care plan for children with special needs; TYPE OF FACILITY: Center; Large Family Child Care Home; Small Awareness of when to ask for medical advice and s) Family Child Care Home arise recommendations for non-emergent issues that RELATED STANDARDS: in school (e.g., head lice, worms, diarrhea); Standard 1.4.2.1: Initial Orientation of All Staff t) Knowledge of professionals with skills in various Standard 3.5.0.1: Care Plan for Children with Special Health Care conditions, e.g., total communication for children with Needs deafness, beginning orientation and mobility training Standard 9.4.3.3: Training Record for children with blindness (including arranging the Appendix O: Care Plan for Children With Special Health Care Needs physical environment effectively for such children), REFERENCES: language promotion for children with hearing- 1. U.S. Department of Justice. 2011. Americans with Disabilities impairment and language delay/disorder, etc.; Act. http://www.ada.gov. How to work with parents/guardians and other u) professionals when assistive devices or medications STANDARD 1.4.2.3: Orientation Topics are not consistently brought to the child care program or school; During the first three months of employment, the director How to safely transport a child with special health v) of a center or the caregiver/teacher in a large family home care needs. should document, for all full-time and part-time staff mem- bers, additional orientation in, and the employees’ satisfac - RATIONALE: A basic understanding of developmental dis- tory knowledge of, the following topics: abilities and special care requirements of any child in care a) Recognition of symptoms of illness and correct is a fundamental part of any orientation for new employees. documentation procedures for recording symptoms Training is an essential component to ensure that staff mem- of illness. This should include the ability to perform a bers develop and maintain the needed skills. A comprehen- daily health check of children to determine whether sive curriculum is required to ensure quality services. How- any children are ill or injured and, if so, whether a ever, lack of specialized training for staff does not constitute child who is ill should be excluded from the facility; grounds for exclusion of children with disabilities (1). Exclusion and readmission procedures and policies; b) Staff members need information about how to help children Cleaning, sanitation, and disinfection procedures and c) use and maintain adaptive equipment properly. Staff mem- policies; bers need to understand how and why various items are Procedures for administering medication to children d) used and how to check for malfunctions. If a problem oc- and for documenting medication administered to curs with adaptive equipment, the staff must recognize the children; problem and inform the parent/guardian so that the parent/ Procedures for notifying parents/guardians of an e) guardian can notify the health care or equipment provider infectious disease occurring in children or staff within of the problem and request that it be remedied. While the the facility; parent/guardian is responsible for arranging for correc- f) Procedures and policies for notifying public health tion of equipment problems, child care staff must be able officials about an outbreak of disease or the to observe and report the problem to the parent/guardian. occurrence of a reportable disease; Routine care of adaptive and treatment equipment, such as g) Emergency procedures and policies related to nebulizers, should be taught. unintentional injury, medical emergency, and natural disasters; These training topics are generally appli- COMMENTS: h) Procedure for accessing the child care health cable to all personnel serving children with special health consultant for assistance; care needs and apply to child care facilities. The curricu- lum may vary depending on the type of facility, classifica- tions of disabilities of the children in the facility, and ages Chapter 1: Staffing 23

54 Caring for Our Children: National Health and Safety Performance Standards Records of successful completion of training in pediatric i) Injury prevention strategies and hazard identification first aid should be maintained in the personnel files of the procedures specific to the facility, equipment, etc.; facility. j) Proper hand hygiene. To ensure the health and safety of children in RATIONALE: Before being assigned to tasks that involve identifying and a child care setting, someone who is qualified to respond responding to illness, staff members should receive orienta- to life-threatening emergencies must be in attendance at tion training on these topics. Small family child care home all times (1). A staff trained in pediatric first aid, including pe- caregivers/teachers should not commence operation before diatric CPR, coupled with a facility that has been designed receiving orientation on these topics in pre-service training or modified to ensure the safety of children, can mitigate the (1). consequences of injury, and reduce the potential for death Children in child care are frequently ill (2). RATIONALE: from life-threatening conditions. Knowledge of pediatric Staff members responsible for child care must be able to first aid, including pediatric CPR which addresses manage- recognize illness and injury, carry out the measures required ment of a blocked airway and rescue breathing, and the to prevent the spread of communicable diseases, handle confidence to use these skills, are critically important to the ill and injured children appropriately, and appropriately outcome of an emergency situation. administer required medications (4). Hand hygiene is one of Small family child care home caregivers/teachers often work the most important means of preventing spread of infectious - alone. They must have the necessary skills to manage emer disease (3). gencies while caring for all the children in the group. RELATED STANDARDS: Standard 3.1.1.1: Conduct of Daily Health Check Children with special health care needs who have compro- Standard 3.1.1.2: Documentation of the Daily Health Check mised airways may need to be accompanied to child care Standard 9.4.3.3: Training Record with nurses who are able to respond to airway problems TYPE OF FACILITY: Center; Large Family Child Care Home; Small (e.g., the child who has a tracheostomy and needs suction- Family Child Care Home ing). REFERENCES: First aid skills are the most likely tools caregivers/teach- 1. Fiene, R. 2002. 13 indicators of quality child care: Research ers will need. Minor injuries are common. For emergency Washington, DC: U.S. Department of Health and Human update. situations that require attention from a health professional, Services, Office of the Assistant Secretary for Planning and first aid procedures can be used to control the situation until Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/. a health professional can provide definitive care. However, 2. Aronson, S. S., T. R. Shope, eds. 2009. Managing infectious management of a blocked airway (choking) is a life-threat- diseases in child care and schools: A quick reference guide. 2nd ed. ening emergency that cannot wait for emergency medical Elk Grove Village, IL: American Academy of Pediatrics. personnel to arrive on the scene (2). 3. Centers for Disease Control and Prevention (CDC). 2011. Handwashing: Clean hands save lives. http://www.cdc.gov/ Documentation of current certification of satisfactory handwashing/. - completion of pediatric first aid and demonstration of pedi 4. American Academy of Pediatrics, Council on School Health. atric CPR skills in the facility assists in implementing and in 2009. Policy statement: Guidance for the administration of monitoring for proof of compliance. medication in school. 124:1244-51. Pediatrics COMMENTS: The recommendations from the American 1.4.3 First Aid and CPR Training Heart Association (AHA) changed in 2010 from “A-B-C” (Airway, Breathing, Chest compressions) to “C-A-B” (Chest STANDARD 1.4.3.1: First Aid and CPR Training compressions, Airway, Breathing) for adults and pediatric patients (children and infants, excluding newborns). Except for Staff for newborns, the ratio of chest compressions to ventila- The director of a center or a large family child care home tions in the 2010 guidelines is 30:2. CPR skills are lost and the caregiver/teacher in a small family child care home without practice and ongoing education (3,5). should ensure all staff members involved in providing direct The most common renewal cycle required by organizations care have documentation of satisfactory completion of train - that offer pediatric first aid and pediatric CPR training is to ing in pediatric first aid and pediatric CPR skills. Pediatric require successful completion of training every three years CPR skills should be taught by demonstration, practice, (4), though the AHA requires successful completion of CPR and return demonstration to ensure the technique can be class every two years. performed in an emergency. These skills should be current according to the requirement specified for retraining by the Inexpensive self-learning kits that require only thirty minutes organization that provided the training. to review the skills of pediatric CPR with a video and an in- flatable manikin are available from the AHA. See “Infant CPR At least one staff person who has successfully completed Anytime” and “Family and Friends CPR Anytime” at http:// training in pediatric first aid that includes CPR should be in www.heart.org/HEARTORG/. attendance at all times with a child whose special care plan indicates an increased risk of needing respiratory or cardiac Child care facilities should consider having an Automated resuscitation. External Defibrillators (AED) on the child care premises for 24 Chapter 1: Staffing

55 Caring for Our Children: National Health and Safety Performance Standards s) Electric shock; potential use with adults. The use of AEDs with children t) Drowning; would be rare. Heat-related injuries, including heat exhaustion/heat u) Center; Large Family Child Care Home; Small TYPE OF FACILITY: stroke; Family Child Care Home Cold related injuries, including frostbite; v) RELATED STANDARDS: Moving and positioning injured/ill persons; w) Standard 1.4.3.2: Topics Covered in First Aid Training x) Illness-related emergencies (such as stiff neck, Standard 1.4.3.3: CPR Training for Swimming and Water Play inexplicable confusion, sudden onset of blood-red or Standard 9.4.3.3: Training Record purple rash, severe pain, temperature above 101°F Standards 10.6.1.1-10.6.1.2: Caregiver/Teacher Training [38.3°C] orally, above 102°F [38.9°C] rectally, or 100°F REFERENCES: [37.8°C] or higher taken axillary [armpit] or measured 1. Alkon, A., P. J. Kaiser, J. M. Tschann, W. T. Boyce, J. L. Genevro, by an equivalent method, and looking/acting severely M. Chesney. 1994. Injuries in child-care centers: Rates, severity, ill); Pediatrics 94:1043-46. and etiology. Standard Precautions; y) 2. Stevens, P. B., K. A. Dunn. 1994. Use of cardiopulmonary z) Organizing and implementing a plan to meet an J School Health resuscitation by North Carolina day care providers. emergency for any child with a special health care 64:381-83. need; 3. American Heart Association (AHA). 2010 AHA guidelines for Addressing the needs of the other children in the aa) cardiopulmonary resuscitation and emergency cardiovascular care group while managing emergencies in a child care science. 122: S640-56. Circulation Pediatric first aid for caregivers and 4. Aronson, S. S., ed. 2007. setting; teachers. Rev. 1st ed. Elk Grove Village, IL: American Academy of Applying first aid to children with special health care ab) Pediatrics; Sudbury, MA: Jones and Bartlett. needs. 5. American Heart Association (AHA). 2010. Hands-only CPR. First aid for children in the child care set- RATIONALE: http://handsonlycpr.org. ting requires a more child-specific approach than standard adult-oriented first aid offers. To ensure the health and STANDARD 1.4.3.2: Topics Covered in First safety of children in a child care setting, someone who is Aid Training qualified to respond to common injuries and life-threat- First aid training should present an overview of Emergency ening emergencies must be in attendance at all times. A Medical Services (EMS), accessing EMS, poison center ser - staff trained in pediatric first aid, including pediatric CPR, vices, accessing the poison center, safety at the scene, and coupled with a facility that has been designed or modified isolation of body substances. First aid instruction should to ensure the safety of children, can reduce the potential for include, but not be limited to, recognition and first response death and disability. Knowledge of pediatric first aid, includ- of pediatric emergency management in a child care setting ing the ability to demonstrate pediatric CPR skills, and the of the following situations: confidence to use these skills, are critically important to the Management of a blocked airway and rescue a) outcome of an emergency situation (1). breathing for infants and children with return Small family child care home caregivers/teachers often work demonstration by the learner (pediatric CPR); alone and are solely responsible for the health and safety of b) Abrasions and lacerations; children in care. Such caregivers/teachers must have pedi- Bleeding, including nosebleeds; c) atric first aid competence. d) Burns; e) Fainting; Other children will have to be supervised COMMENTS: f) Poisoning, including swallowed, skin or eye contact, while the injury is managed. Parental notification and com- and inhaled; munication with emergency medical services must be care- g) Puncture wounds, including splinters; fully planned. First aid information can be obtained from the h) Injuries, including insect, animal, and human bites; American Academy of Pediatrics (AAP) at http://www i) Poison control; .aap.org and the American Heart Association (AHA) at http:// j) Shock; www.heart.org/HEARTORG/. k) Seizure care; Center; Large Family Child Care Home; Small TYPE OF FACILITY: l) Musculoskeletal injury (such as sprains, fractures); Family Child Care Home m) Dental and mouth injuries/trauma; RELATED STANDARDS: Head injuries, including shaken baby syndrome/ n) Standard 1.4.3.1: First Aid and CPR Training for Staff abusive head trauma; Standard 9.4.3.3: Training Record o) Allergic reactions, including information about when REFERENCES: epinephrine might be required; 1. Aronson, S. S., ed. 2007. Pediatric first aid for caregivers and Asthmatic reactions, including information about p) Rev. 1st ed. Elk Grove Village, IL: American Academy of teachers. when rescue inhalers must be used; Pediatrics; Sudbury, MA: Jones and Bartlett. q) Eye injuries; r) Loss of consciousness; Chapter 1: Staffing 25

56 Caring for Our Children: National Health and Safety Performance Standards STANDARD 1.4.3.3: CPR Training for 1.4.4 Continuing Education/ Swimming and Water Play Professional Development Facilities that have a swimming pool should require at least STANDARD 1.4.4.1: Continuing Education for one staff member with current documentation of success- ful completion of training in infant and child (pediatric) CPR Directors and Caregivers/Teachers in Centers (Cardiopulmonary Resuscitation) be on duty at all times and Large Family Child Care Homes during business hours. All directors and caregivers/teachers of centers and large At least one of the caregivers/teachers, volunteers, or other family child care homes should successfully complete at adults who is counted in the child:staff ratio for swimming least thirty clock-hours per year of continuing education/ and water play should have documentation of successful professional development in the first year of employment, completion of training in basic water safety, proper use of sixteen clock-hours of which should be in child develop- swimming pool rescue equipment, and infant and child CPR ment programming and fourteen of which should be in child according to the criteria of the American Red Cross or the health, safety, and staff health. In the second and each of American Heart Association (AHA). the following years of employment at a facility, all directors and caregivers/teachers should successfully complete at For small family child care homes, the person trained in wa- least twenty-four clock-hours of continuing education based ter safety and CPR should be the caregiver/teacher. Written on individual competency needs and any special needs of verification of successful completion of CPR and lifesaving the children in their care, sixteen hours of which should be training, water safety instructions, and emergency proce- in child development programming and eight hours of which dures should be kept on file. should be in child health, safety, and staff health. RATIONALE: Drowning involves cessation of breathing and Programs should conduct a needs assessment to identify rarely requires cardiac resuscitation of victims. Nevertheless, areas of focus, trainer qualifications, adult learning strate- because of the increased risk for cardiopulmonary arrest gies, and create an annual professional development plan related to wading and swimming, the facility should have for staff based on the needs assessment. The effectiveness personnel trained to provide CPR and to deal promptly with of training should be evident by the change in performance a life-threatening drowning emergency. During drowning, as measured by accreditation standards or other quality as- cold exposure provides the possibility of protection of the surance systems. brain from irreversible damage associated with respiratory and cardiac arrest. Children drown in as little as two inches Because of the nature of their caregiving/ RATIONALE: of water. The difference between a life and death situation teaching tasks, caregivers/teachers must attain multifaceted is the submersion time. Thirty seconds can make a differ - knowledge and skills. Child health and employee health are ence. The timely administration of resuscitation efforts by a integral to any education/training curriculum and program caregiver/teacher trained in water safety and CPR is critical. management plan. Planning and evaluation of training Studies have shown that prompt rescue and the presence of should be based on performance of the staff member(s) a trained resuscitator at the site can save about 30% of the involved. Too often, staff members make training choices victims without significant neurological consequences (1). based on what they like to learn about (their “wants”) and not the areas in which their performance should be im- Center; Large Family Child Care Home; Small TYPE OF FACILITY: Family Child Care Home proved (their “needs”). Participation in training does not ensure that the participant will master the information and RELATED STANDARDS: skills offered in the training experience. Therefore, caregiver/ Standard 1.1.1.5: Ratios and Supervision for Swimming, Wading, teacher change in behavior or the continuation of appropri- and Water Play ate practice resulting from the training, not just participation Standard 2.2.0.4: Supervision Near Bodies of Water Standard 2.2.0.5: Behavior Around a Pool in training, should be assessed by supervisors and directors Standard 6.3.1.7: Pool Safety Rules (4). Standard 6.4.1.1: Pool Toys In addition to low child:staff ratio, group size, age mix of Standard 9.4.3.3: Training Record children, and stability of caregiver/teacher, the training/edu- REFERENCES: cation of caregivers/teachers is a specific indicator of child Pediatric first aid for caregivers and 1. Aronson, S. S., ed. 2007. care quality (2). Most skilled roles require training related Rev. 1st ed. Elk Grove Village, IL: American Academy of teachers. to the functions and responsibilities the role requires. Staff Pediatrics; Sudbury, MA: Jones and Bartlett. members who are better trained are better able to prevent, recognize, and correct health and safety problems. The number of training hours recommended in this standard reflects the central focus of caregivers/teachers on child development, health, and safety. Children may come to child care with identified special health care needs or special needs may be identified while attending child care, so staff should be trained in recogniz- 26 Chapter 1: Staffing

57 Caring for Our Children: National Health and Safety Performance Standards in child care settings and to comfort an injured child and ing health problems as well as in implementing care plans children witnessing an injury. for previously identified needs. Medications are often re- quired either on an emergent or scheduled basis for a child COMMENTS: Tools for assessment of training needs are to safely attend child care. Caregivers/teachers should be part of the accreditation self-study tools available from the well trained on medication administration and appropriate NAEYC, the National Association for Family Child Care policies should be in place. (NAFCC), National Early Childhood Professional Accredita- tion (NECPA), Association for Christian Education Interna- The National Association for the Education of Young Chil- tional (ACEI), National AfterSchool Association (NAA), and dren (NAEYC), a leading organization in child care and early the National Child Care Association (NCCA). Successful childhood education, recommends annual training/profes- completion of training can be measured by a performance sional development based on the needs of the program and test at the end of training and by ongoing evaluation of the pre-service qualifications of staff (1). Training should performance on the job. address the following areas: a) Promoting child growth and development correlated Resources for training on health and safety issues include: with developmentally appropriate activities; State and local health departments (health education, a) Infant care; b) environmental health and sanitation, nutrition, public c) Recognizing and managing minor illness and injury; health nursing departments, fire and EMS, etc.); d) Managing the care of children who require the special b) Networks of child care health consultants; procedures listed in Standard 3.5.0.2; Graduates of the National Training Institute for Child c) Medication administration; e) Care Health Consultants (NTI); f) Business aspects of the small family child care home; Child care resource and referral agencies; d) g) Planning developmentally appropriate activities in e) University Centers for Excellence on Disabilities; mixed age groupings; f) Local children’s hospitals; h) Nutrition for children in the context of preparing State and local chapters of: g) nutritious meals for the family; American Academy of Pediatrics (AAP), including 1) i) Age-appropriate size servings of food and child AAP Chapter Child Care Contacts; feeding practices; 2) American Academy of Family Physicians (AAFP); j) Acceptable methods of discipline/setting limits; 3) American Nurses’ Association (ANA); Organizing the home for child care; k) 4) American Public Health Association (APHA); l) Preventing unintentional injuries in the home (e.g., 5) Visiting Nurse Association (VNA); falls, poisoning, burns, drowning); - National Association of Pediatric Nurse Practitio 6) Available community services; m) ners (NAPNAP); n) Detecting, preventing, and reporting child abuse and National Association for the Education of Young 7) neglect; Children (NAEYC); Advocacy skills; o) National Association for Family Child Care 8) p) Pediatric first aid, including pediatric CPR; (NAFCC); Methods of effective communication with children q) National Association of School Nurses (NASN); 9) and parents/guardians; 10) National Training Institute for Child Care Health r) Socio-emotional and mental health (positive Consultants (NTI); approaches with consistent and nurturing 11) Emergency Medical Services for Children (EMSC) relationships); National Resource Center; s) Evacuation and shelter-in-place drill procedures; National Association for Sport and Physical Edu- 12) t) Occupational health hazards; cation (NASPE); Infant safe sleep environments and practices; u) American Dietetic Association (ADA); 13) v) Standard Precautions; 14) American Association of Poison Control Centers w) Shaken baby syndrome/abusive head trauma; (AAPCC). x) Dental issues; - For nutrition training, facilities should check that the nutri y) Age-appropriate nutrition and physical activity. tionist/registered dietician (RD), who provides advice, has There are few illnesses for which children should be ex- experience with, and knowledge of, child development, cluded from child care. Decisions about management of - infant and early childhood nutrition, school-age child nutri ill children are facilitated by skill in assessing the extent to tion, prescribed nutrition therapies, food service and food which the behavior suggesting illness requires special man- safety issues in the child care setting. Most state Maternal agement (3). Continuing education on managing infectious and Child Health (MCH) programs, Child and Adult Care diseases helps prepare caregivers/teachers to make these Food Programs (CACFP), and Special Supplemental Nutri- decisions devoid of personal biases (5). Recommendations tion Programs for Women, Infants, and Children (WIC) have regarding responses to illnesses may change (e.g., H1N1), a nutrition specialist on staff or access to a local consultant. so caregivers/teachers need to know where they can find If this nutrition specialist has knowledge and experience in the most current information. All caregivers/teachers should early childhood and child care, facilities might negotiate for be trained to prevent, assess, and treat injuries common Chapter 1: Staffing 27

58 Caring for Our Children: National Health and Safety Performance Standards Projects and Outreach: Early Childhood Research and this individual to serve or identify someone to serve as a Evaluation Projects, Midwest Child Care Research Con- consultant and trainer for the facility. sortium at http://ccfl.unl.edu/projects_outreach/projects/ Many resources are available for nutritionists/RDs who pro- current/ecp/mwcrc.php, identifies the number of hours for vide training in food service and nutrition. Some resources education of staff and fourteen indicators of quality from a to contact include: study conducted in four Midwestern states. a) Local, county, and state health departments to locate TYPE OF FACILITY: Center; Large Family Child Care Home MCH, CACFP, or WIC programs; State university and college nutrition departments; b) RELATED STANDARDS: Home economists at utility companies; c) Standard 1.8.2.2: Annual Staff Competency Evaluation State affiliates of the American Dietetic Association; d) Standard 3.5.0.2: Caring for Children Who Require Medical Proce- dures e) State and regional affiliates of the American Public Standard 3.6.3.1: Medication Administration Health Association; Standard 9.4.3.3: Training Record f) The American Association of Family and Consumer Standard 10.3.3.4: Licensing Agency Provision of Child Abuse Services; Prevention Materials National Resource Center for Health and Safety in g) Standard 10.3.4.6: Compensation for Participation in Multidis- Child Care and Early Education; ciplinary Assessments for Children with Special Health Care or h) Nutritionist/RD at a hospital; Education Needs i) High school home economics teachers; Standards 10.6.1.1-10.6.1.2: Caregiver/Teacher Training j) The Dairy Council; Appendix C: Nutrition Specialist, Registered Dietician, Licensed The local American Heart Association affiliate; k) Nutritionist, Consultant, and Food Service Staff Qualifications l) The local Cancer Society; REFERENCES: m) The Society for Nutrition Education; 1. National Association for the Education of Young Children n) The local Cooperative Extension office; (NAEYC). 2009. Standards for early childhood professional o) Local community colleges and trade schools. preparation programs. Washington, DC: NAEYC. http://www.naeyc .org/files/naeyc/file/positions/ProfPrepStandards09.pdf. Nutrition education resources may be obtained from the 2. Whitebook, M., C. Howes, D. Phillips. 1998. Worthy work, Food and Nutrition Information Center at http://fnic.nal. unlivable wages: The National child care staffing study, 1988-1997. usda.gov. The staff’s continuing education in nutrition may Washington, DC: Center for the Child Care Workforce. be supplemented by periodic newsletters and/or literature 3. Crowley, A. A. 1990. Health services in child care day care (frequently bilingual) or audiovisual materials prepared or 4:252-59. J Pediatr Health Care centers: A survey. recommended by the Nutrition Specialist. 4. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Caregivers/teachers should have a basic knowledge of Services, Office of the Assistant Secretary for Planning and special health care needs, supplemented by specialized Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/. training for children with special health care needs. The type 5. Aronson, S. S., T. R. Shope, eds. 2009. Managing infectious of special health care needs of the children in care should diseases in child care and schools: A quick reference guide. 2nd ed. influence the selection of the training topics. The number of Elk Grove Village, IL: American Academy of Pediatrics. hours offered in any in-service training program should be determined by the experience and professional background STANDARD 1.4.4.2: Continuing Education for of the staff, which is best achieved through a regular staff Small Family Child Care Home Caregivers/ conference mechanism. Teachers Financial support and accessibility to training programs Small family child care home caregivers/teachers should requires attention to facilitate compliance with this standard. have at least thirty clock-hours per year (2) of continuing Many states are using federal funds from the Child Care and education in areas determined by self-assessment and, Development Block Grant to improve access, quality, and where possible, by a performance review of a skilled mentor affordability of training for early care and education profes- or peer reviewer. sionals. College courses, either online or face to face, and RATIONALE: In addition to low child:staff ratio, group size, training workshops can be used to meet the training hours age mix of children, and continuity of caregiver/teacher, requirement. These training opportunities can also be con- the training/education of caregivers/teachers is a specific ducted on site at the child care facility. Completion of train- indicator of child care quality (1). Most skilled roles require - ing should be documented by a college transcript or a train training related to the functions and responsibilities the ing certificate that includes title/content of training, contact role requires. Caregivers/teachers who engage in on-going hours, name and credentials of trainer or course instructor training are more likely to decrease morbidity and mortality and date of training. Whenever possible the submission of in their setting (3) and are better able to prevent, recognize, documentation that shows how the learner implemented and correct health and safety problems. the concepts taught in the training in the child care program should be documented. Although on-site training can be Children may come to child care with identified special costly, it may be a more effective approach than participa- health care needs or may develop them while attending tion in training at a remote location. child care, so staff must be trained in recognizing health 28 Chapter 1: Staffing

59 Caring for Our Children: National Health and Safety Performance Standards w) Shaken baby syndrome/abusive head trauma; problems as well as in implementing care plans for previ- x) Dental issues; ously identified needs. Age-appropriate nutrition and physical activity. y) Because of the nature of their caregiving/teaching tasks, Small family child care home caregivers/teachers should caregivers/teachers must attain multifaceted knowledge and maintain current contact lists of community pediatric prima- skills. Child health and employee health are integral to any ry care providers, specialists for health issues of individual education/training curriculum and program management children in their care and child care health consultants who plan. Planning and evaluation of training should be based on could provide training when needed. performance of the caregiver/teacher. Provision of work- shops and courses on all facets of a small family child care In-home training alternatives to group training for small fam- business may be difficult to access and may lead to caregiv- ily child care home caregivers/teachers are available, such ers/teachers enrolling in training opportunities in curriculum as distance courses on the Internet, listening to audiotapes related areas only. Too often, caregivers/teachers make or viewing media (e.g., DVDs) with self-checklists. These training choices based on what they like to learn about training alternatives provide more flexibility for caregivers/ (their “wants”) and not the areas in which their performance teachers who are remote from central training locations or should be improved (their “needs”). have difficulty arranging coverage for their child care duties to attend training. Nevertheless, gathering family child care Small family child care home caregivers/teachers often home caregivers/teachers for training when possible pro- work alone and are solely responsible for the health and vides a break from the isolation of their work and promotes safety of small numbers of children in care. Peer review is networking and support. Satellite training via down links at part of the process for accreditation of family child care and local extension service sites, high schools, and community can be valuable in assisting the caregiver/teacher in the colleges scheduled at convenient evening or weekend times identification of areas of need for training. Self-evaluation is another way to mix quality training with local availability may not identify training needs or focus on areas in which and some networking. the caregiver/teacher is particularly interested and may be skilled already. TYPE OF FACILITY: Small Family Child Care Home The content of continuing education for small COMMENTS: RELATED STANDARDS: family child care home caregivers/teachers should include Standard 1.4.4.1: Continuing Education for Directors and Caregiv- the following topics: ers/Teachers in Centers and Large Family Child Care Homes Standard 1.7.0.4: Occupational Hazards Promoting child growth and development correlated a) Standard 3.5.0.2: Caring for Children Who Require Medical Proce- with developmentally appropriate activities; dures b) Infant care; Standards 9.2.4.3-9.2.4.5: Emergency and Evacuation Plans, Train- c) Recognizing and managing minor illness and injury; ing, and Communication d) Managing the care of children who require the special Standard 9.4.3.3: Training Record procedures listed in Standard 3.5.0.2; Appendix B: Major Occupational Health Hazards e) Medication administration; REFERENCES: f) Business aspects of the small family child care home; 1. Whitebook, M., C. Howes, D. Phillips. 1998. , Worthy work Planning developmentally appropriate activities in g) unlivable wages: The national child care staffing study, 1988-1997. mixed age groupings; Washington, DC: Center for the Child Care Workforce. Nutrition for children in the context of preparing nutri- h) 2. The National Association of Family Child Care (NAFCC). 2005. tious meals for the family; 4th ed. Salt Lake City, Quality standards for NAFCC accreditation. i) Age-appropriate size servings of food and child feed- UT: NAFCC. http://www.nafcc.org/documents/QualStd.pdf. ing practices; 3. Fiene, R. 2002. 13 indicators of quality child care: Research j) Acceptable methods of discipline/setting limits; update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and k) Organizing the home for child care; Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/. l) Preventing unintentional injuries in the home (falls, poisoning, burns, drowning); Available community services; m) 1.4.5 Specialized Training/Education Detecting, preventing, and reporting child abuse and n) neglect; STANDARD 1.4.5.1: Training of Staff Who o) Advocacy skills; Handle Food p) Pediatric first aid, including pediatric CPR; All staff members with food handling responsibilities should q) Methods of effective communication with children obtain training in food service and safety. The director of a and parents/guardians; center or a large family child care home or the designated r) Socio-emotional and mental health (positive ap- supervisor for food service should be a certified food pro- proaches with consistent and nurturing relationships); - tection manager or equivalent as demonstrated by complet Evacuation and shelter-in-place drill procedures; s) ing an accredited food protection manager course. Small t) Occupational health hazards; family child care personnel should secure training in food Infant-safe sleep environments and practices; u) service and safety appropriate for their setting. Standard Precautions; v) Chapter 1: Staffing 29

60 Caring for Our Children: National Health and Safety Performance Standards RATIONALE: Education about the manifestations of child RATIONALE: Outbreaks of foodborne illness have occurred maltreatment can increase the likelihood of appropriate in many settings, including child care facilities. Some of reports to child protection agencies and law enforcement these outbreaks have led to fatalities and severe disabilities. agencies (1-3). Young children are particularly susceptible to foodborne ill- ness, due to their body size and immature immune systems. Child abuse and neglect materials should COMMENTS: Because large centers serve more meals daily than many be designed for non-medical audiences. Resources are restaurants do, the supervisors of food handlers in these available from the American Academy of Pediatrics (AAP) at settings should have successfully completed food service http://www.aap.org, the Child Welfare Information Gateway certification, and the food handlers in these settings should at http://www.childwelfare.gov, and Prevent Child Abuse have successfully completed courses on appropriate food America at http://www.preventchildabuse.org. handling (1). TYPE OF FACILITY: Center; Large Family Child Care Home; Small COMMENTS: Sponsors of the Child and Adult Care Food Family Child Care Home Program (CACFP) provide this training for some small family RELATED STANDARDS: child care home caregivers/teachers. For training in food Standard 2.2.0.9: Prohibited Caregiver/Teacher Behaviors handling, caregivers/teachers should contact the state or lo- Standards 3.4.4.1-3.4.4.5: Child Abuse and Neglect cal health department, or the delegate agencies that handle Standard 9.4.3.3: Training Record nutrition and environmental health inspection programs for REFERENCES: the child care facility. Training for food workers is mandatory 1. American Academy of Pediatrics. Children’s health topics: Child - in some jurisdictions. Other sources for food safety infor abuse and neglect. http://www.aap.org/healthtopics/ Food mation are the Food and Drug Administration (FDA) childabuse.cfm. , family child care associations, child care resource Code 2. New York State Office of Children and Family Services. Child - and referral agencies, licensing agencies, and state depart abuse and children with disabilities: A New York State perspective. ments of education. http://childabuse.tc.columbia.edu. Recognition of child abuse 3. Giardino, A. P., E. R. Giardino. 2002. Center; Large Family Child Care Home; Small TYPE OF FACILITY: 3rd ed. St. Louis, MO: G. W. Medical for the mandated reporter. Family Child Care Home Publishing. RELATED STANDARDS: Standard 9.4.3.3: Training Record STANDARD 1.4.5.3: Training on Occupational REFERENCES: Risk Related to Handling Body Fluids 1. U.S. Department of Health and Human Services, Public All caregivers/teachers who are at risk of occupational Health Service, Food and Drug Administration (FDA). 2009. Food exposure to blood or other blood-containing body fluids College Park, MD: FDA. http://www.fda.gov/Food/ code 2009. should be offered hepatitis B immunizations and should FoodSafety/RetailFoodProtection/FoodCode/FoodCode2009/ default.htm. receive annual training in Standard Precautions and expo- sure control planning. Training should be consistent with STANDARD 1.4.5.2: Child Abuse and Neglect applicable standards of the Occupational Safety and Health Administration (OSHA) Standard 29 CFR 1910.1030, “Oc- Education cupational Exposure to Bloodborne Pathogens” and local Caregivers/teachers should use child abuse and neglect occupational health requirements and should include, but prevention education to educate and establish child abuse not be limited to: and neglect prevention and recognition measures for the Modes of transmission of bloodborne pathogens; a) children, caregivers/teachers, and parents/guardians. The b) Standard Precautions; education should address physical, sexual, and psychologi- c) Hepatitis B vaccine use according to OSHA cal or emotional abuse and neglect. The dangers of shaking requirements; infants and toddlers and repeated exposure to domestic Program policies and procedures regarding exposure d) violence should be included in the education and preven- to blood/body fluid; tion materials. Caregivers/teachers should also receive Reporting procedures under the exposure control e) education on promoting protective factors to prevent child plan to ensure that all first-aid incidents involving maltreatment. Caregivers/teachers should be able to identify exposure are reported to the employer before the end signs of stress in families and assist families by providing of the work shift during which the incident occurs (1). support and linkages to resources when needed. Children RATIONALE: Providing first aid in situations where blood with disabilities are at a higher risk of being abused. Special is present is an intrinsic part of a caregiver’s/teacher’s job. training in child abuse and neglect and children with disabili- Split lips, scraped knees, and other minor injuries associ- ties should be provided (2). ated with bleeding are common in child care. Caregivers/teachers are mandatory reporters of child abuse Caregivers/teachers who are designated as responsible for or neglect. Caregivers/teachers should be trained in compli- rendering first aid or medical assistance as part of their job ance with their state’s child abuse reporting laws. Child duties are covered by the scope of this standard. abuse reporting requirements are known and available from the child care regulation department in each state. 30 Chapter 1: Staffing

61 Caring for Our Children: National Health and Safety Performance Standards tion until compensation for work done in child care is much COMMENTS: OSHA has model exposure control plan ma- more equitable. Many child care workers also employed in terials for use by child care facilities. Using the model expo- another vocation work at other jobs to make a living wage sure control plan materials, caregivers/teachers can prepare and would miss income from their other jobs or risk losing a plan to comply with the OSHA requirements. The model that employment. Additionally, the caregiver/teacher may plan materials are available from regional offices of OSHA. incur stress in their family life when required to take time Center; Large Family Child Care Home TYPE OF FACILITY: outside of child care hours to participate in work-related RELATED STANDARDS: training. Standard 9.4.3.3: Training Record COMMENTS: Professional development in child care often Appendix L: Cleaning Up Body Fluids takes place when the participant is not released from other REFERENCES: - work-related duties, such as caring for children or answer 1. U.S. Department of Labor, Occupational Safety and Health ing phones. Providing substitutes and released time during Toxic and hazardous substances: Bloodborne Administration. 2008. work hours for such training is likely to enhance the ef- pathogens. http://www.osha.gov/pls/oshaweb/owadisp.show fectiveness of training; and improve employee satisfaction/ _document?p_table=STANDARDS&p_id=10051. retention. STANDARD 1.4.5.4: Education of Center Staff Large family child care homes employ staff in the same way as centers, except for size and location in a residence. For Centers should educate staff to support the cultural, lan- small family child care home caregivers/teachers, released guage, and ethnic backgrounds of children enrolled in the time and compensation while engaged in training can be program. In addition, all staff members should participate in arranged only if the small family child care home caregiver/ diversity training that will ensure respectful service delivery teacher is part of a support network that makes such ar - to all families and a staff that works well together (2). rangements. This standard does not apply to small fam- Young children’s identities cannot be sepa- RATIONALE: ily child care home caregivers/teachers independent of rated from family, culture, and their home language. Children networks. need both to see successful role models from their own eth- The Fair Labor Standard Act mandates payment of time nic and cultural groups and to develop the ability to relate to and a half for all hours worked in excess of forty hours in a people who are different from themselves (1). week. TYPE OF FACILITY: Center Center; Large Family Child Care Homes; Small TYPE OF FACILITY: RELATED STANDARDS: Family Child Care Homes Standard 9.4.3.3: Training Record REFERENCES: REFERENCES: 1. Center for the Child Care Workforce, American Federation of 1. Chang, H. 2006. Developing a skilled, ethnically and linguistically Teachers (AFT). 2009. Wage data: Early childhood workforce hourly Getting ready diverse early childhood workforce. Adapted from 2009 ed. Washington, DC: AFT. http://www.ccw.org/ wage data. for quality: The critical importance of developing and supporting storage/ccworkforce/documents/04-30-09 wwd fact sheet.pdf. a skilled, ethnically and linguistically diverse early childhood workforce. http://www.buildinitiative.org/files/DiverseWorkforce.pdf. STANDARD 1.4.6.2: Payment for Continuing 2. National Association for the Education of Young Children (NAEYC). 2009. Quality benchmark for cultural competence project. Education Washington, DC: NAEYC. http://www.naeyc.org/files/naeyc/file/ Directors of centers and large family child care homes policy/state/QBCC_Tool.pdf. should arrange for continuing education that is paid for by the government, by charitable organizations, or by the 1.4.6 Educational Leave/Compensation facility, rather than by the employee. Small family child care home caregivers/teachers should avail themselves of train- STANDARD 1.4.6.1: Training Time and ing opportunities offered in their communities or online and Professional Development Leave claim their educational expenses as a business expense on tax forms. A center, large family child care home or a support agency for a network of small family child care homes should make RATIONALE: Caregivers/teachers often make low wages provisions for paid training time for staff to participate in and may not be able to pay for mandated training. A major - required professional development (that includes training ity of child care workers earnings are at or near minimum as well as education) during work hours, or reimburse staff wage (1). for time spent attending professional development outside TYPE OF FACILITY: Center; Large Family Child Care Home; Small of regular work hours. Any hours worked in excess of forty Family Child Care Home hours in a week must be paid according to state and federal REFERENCES: wage and hour regulations. 1. Center for the Child Care Workforce, American Federation of Most caregivers/teachers work long hours and RATIONALE: Teachers. 2009. Wage data: Early childhood workforce hourly wage most are poorly paid (1). Using personal time for education data. 2009 ed. Washington, DC: AFT. http://www.ccw.org/storage/ required as a condition of employment is an unfair expecta- ccworkforce/documents/04-30-09 wwd fact sheet.pdf. Chapter 1: Staffing 31

62 Caring for Our Children: National Health and Safety Performance Standards REFERENCES: 1.5 Substitutes 1. National Association for Family Child Care (NAFCC). NAFCC official Website. http://nafcc.net. STANDARD 1.5.0.1: Employment of Substitutes STANDARD 1.5.0.2: Orientation of Substitutes Substitutes should be employed to ensure that child:staff The director of any center or large family child care home ratios and requirements for direct supervision are main- and the small family child care home caregiver/teacher tained at all times. Substitutes and volunteers should be at should provide orientation training to newly hired substi- least eighteen years of age and must meet the requirements tutes to include a review of ALL the program’s policies and specified throughout Standards 1.3.2.1-1.3.2.6. Those with- procedures (listed below is a sample). This training should out licenses/certificates should work under direct supervi- include the opportunity for an evaluation and a repeat dem- sion and should not be alone with a group of children. onstration of the training lesson. In all child care settings the orientation should be documented. Substitutes should have A substitute should complete the same background screen- background screenings. ing processes as the caregiver/teacher. Obtaining substi- tutes to provide medical care for children with special health All substitutes should be oriented to, and demonstrate care needs is particularly challenging. A substitute nurse competence in, the tasks for which they will be responsible. should be experienced in delivering the expected medical On the first day a substitute caregiver/teacher should be services. Decisions should be made on whether a parent/ oriented on the following topics: guardian will be allowed to provide needed on-site medi- a) Safe infant sleep practices if an infant is enrolled in cal services. Substitutes should be aware of the care plans the program; (including emergency procedures) for children with special b) Any emergency medical procedure/medication needs health care needs. of the children; Any nutrition needs of the children. c) The risk to children from care by unqualified RATIONALE: caregivers/teachers is the same whether the caregiver/ All substitute caregivers/teachers, during the first week of teacher is a paid substitute or a volunteer (1). employment, should be oriented to, and should demon- strate competence in at least the following items: Substitutes are difficult to find, especially at COMMENTS: a) The names of the children for whom the caregiver/ the last minute. Planning for a competent substitute pool is teacher will be responsible, and their specific essential for child care operation. Requiring substitutes for developmental needs; small family child care homes to obtain first aid and CPR b) The planned program of activities at the facility; certification forces small family child care home caregiv- Routines and transitions; c) ers/teachers to close when they cannot be covered by a d) Acceptable methods of discipline; competent substitute. Since closing a child care home has a Meal patterns and safe food handling policies of the e) negative impact on the families and children they serve, sys- facility (special attention should be given to life- tems should be developed to provide qualified alternative threatening food allergies); homes or substitutes for family child care home caregivers/ f) Emergency health and safety procedures; teachers. General health policies and procedures as g) The lack of back-up for family child care home caregivers/ appropriate for the ages of the children cared for, teachers is an inherent liability in this type of care. Parents/ including but not limited to the following: guardians who use family child care must be sure they have 1) Hand hygiene techniques, including indications for suitable alternative care, such as family or friends, for situ- hand hygiene; ations in which the child’s usual caregiver/teacher cannot Diapering technique, if care is provided to children 2) provide the service. in diapers, including appropriate diaper disposal and diaper changing techniques, use and wearing Substitutes should have orientation and training on basic of gloves; health and safety topics. Substitutes should not have an The practice of putting infants down to sleep 3) infectious disease when providing care. positioned on their backs and on a firm surface Center; Large Family Child Care Home; Small TYPE OF FACILITY: along with all safe infant sleep practices to reduce Family Child Care Home the risk of Sudden Infant Death Syndrome (SIDS), RELATED STANDARDS: as well as general nap time routines for all ages; Standards 1.1.1.1-1.1.1.5: Child:Staff Ratio and Group Size 4) Correct food preparation and storage techniques, Standards 1.3.2.1-1.3.2.6: General Qualifications for All Caregivers/ if employee prepares food; Teachers Proper handling and storage of human milk when 5) Standard 1.3.3.1: General Qualifications of Family Child Care Care- applicable and formula preparation if formula is givers/Teachers to Operate a Family Child Care Home handled; Standard 1.3.3.2: Support Networks for Family Child Care Standard 1.5.0.2: Orientation of Substitutes Bottle preparation including guidelines for human 6) Standard 1.7.0.1: Pre-Employment and Ongoing Adult Health Ap- milk and formula if care is provided to children praisals, Including Immunization with bottles; Chapter 1: Staffing 32

63 Caring for Our Children: National Health and Safety Performance Standards Proper use of gloves in compliance with 7) 1.6 Consultants Occupational Safety and Health Administration (OSHA) bloodborne pathogens regulations; STANDARD 1.6.0.1: Child Care Health Injury prevention and safety including the role 8) Consultants of mandatory child abuse reporter to report any A facility should identify and engage/partner with a child suspected abuse/neglect. care health consultant (CCHC) who is a licensed health Emergency plans and practices; h) professional with education and experience in child and i) Access to list of authorized individuals for releasing community health and child care and preferably specialized children. training in child care health consultation. Upon employment, substitutes should be able RATIONALE: CCHCs have knowledge of resources and regulations and to carry out the duties assigned to them. Because facilities are comfortable linking health resources with child care and the children enrolled in them vary, orientation programs facilities. for new substitutes can be most productive. Because of frequent staff turnover, child care programs must institute The child care health consultant should be knowledgeable in orientation programs as needed that protect the health and the following areas: safety of children and new staff (1-3). a) Consultation skills both as a child care health consultant as well as a member of an interdisciplinary Most SIDS deaths in child care occur on the first day of team of consultants; care or within the first week due to unaccustomed prone (on National health and safety standards for out-of-home b) stomach) sleeping. Unaccustomed prone sleeping increases child care; the risk of SIDS eighteen times (4). c) Indicators of quality early care and education; COMMENTS: Anyone who substitutes regularly should be d) Day-to-day operations of child care facilities; up to date on all basic training as specified in this standard. e) State child care licensing and public health Center; Large Family Child Care Home; Small TYPE OF FACILITY: requirements; Family Child Care Home f) State health laws, Federal and State education laws RELATED STANDARDS: (e.g., ADA, IDEA), and state professional practice acts Standard 1.2.0.2: Background Screening for licensed professionals (e.g., State Nurse Practice Section 2.1: Program of Developmental Activities Acts); Standards 2.2.0.6-2.2.0.9: Discipline g) Infancy and early childhood development, social and Standard 3.1.4.4: Scheduled Rest Periods and Sleep Arrangements emotional health, and developmentally appropriate Standard 3.2.1.1: Type of Diapers Worn practice; Standards 3.2.2.1-3.2.2.5: Hand Hygiene h) Recognition and reporting requirements for infectious Standard 3.2.3.4: Prevention of Exposure to Blood and Bodily diseases; Fluids i) American Academy of Pediatrics (AAP) and Early Standards 3.4.3.1-3.4.3.3: Emergency Procedures and Periodic Screening, Diagnosis, and Treatment Chapter 4: Nutrition and Food Service Standards 5.4.1.1-5.4.1.9: Sanitation, Disinfection, and Mainte- (EPSDT) screening recommendations and nance of Toilet Learning/Training Equipment, Toilets, and Bathrooms immunizations schedules for children; Standards 5.4.5.1-5.4.5.5: Sleep and Rest Areas j) Importance of medical home and local and state Standard 9.2.2.3: Exchange of Information at Transitions resources to facilitate access to a medical home as Standard 9.2.3.11: Food and Nutrition Service Policies and Plans well as child health insurance programs including Standard 9.2.3.12: Infant Feeding Policy Medicaid and State Children’s Health Insurance Standard 9.2.4.1: Written Plan and Training for Handling Urgent Program (SCHIP); Medical Care or Threatening Incidents k) Injury prevention for children; Standard 9.2.4.2: Review of Written Plan for Urgent Care l) Oral health for children; Standard 9.4.1.18: Records of Nutrition Service Nutrition and age-appropriate physical activity m) Appendix D: Gloving recommendations for children including feeding of REFERENCES: infants and children, the importance of breastfeeding 1. Gore, J. S. 1997. Does school-age child care staff training make and the prevention of obesity; vol. 6. http://www.canr School-Age Connections, a difference? n) Inclusion of children with special health care needs, .uconn.edu/ces/child/newsarticles/SAC643.html. and developmental disabilities in child care; 2. Crosland, K. A., G. Dunlap, W. Sager, et al. 2008. The effects of staff training on the types of interactions observed at two group Safe medication administration practices; o) 18:410-20. Research Soc Work homes for foster care children. p) Health education of children; 3. Cain, D. W., L. C. Rudd, T. F. Saxon. 2007. Effects of professional q) Recognition and reporting requirements for child development training on joint attention engagement in low-quality abuse and neglect/child maltreatment; childcare centers. 177:159-85. Early Child Devel Care r) Safe sleep practices and policies (including reducing 4. Moon, R. Y., T. Calabrese, L. Aird. 2008. Reducing the risk of the risk of SIDS); sudden infant death syndrome in child care and changing provider Pediatrics practices: Lessons learned from a demonstration project. 122:788-98. Chapter 1: Staffing 33

64 Caring for Our Children: National Health and Safety Performance Standards p) Interpreting standards, regulations and accreditation Development and implementation of health and s) requirements related to health and safety, as well safety policies and practices including poison as providing technical advice, separate and apart awareness and poison prevention; from an enforcement role of a regulation inspector or t) Staff health, including adult health screening, determining the status of the facility for recognition; occupational health risks, and immunizations; q) Understanding and observing confidentiality Disaster planning resources and collaborations within u) requirements; child care community; r) Assisting in the development of disaster/emergency v) Community health and mental health resources for medical plans (especially for those children with child, parent/guardian and staff health; special health care needs) in collaboration with Importance of serving as a healthy role model for w) community resources; children and staff. s) Developing an obesity prevention program in The child care health consultant should be able to perform consultation with a nutritionist/registered dietitian or arrange for performance of the following activities: (RD) and physical education specialist; Assessing caregivers’/teachers’ knowledge of health, a) t) Working with other consultants such as nutritionists/ development, and safety and offering training as RDs, kinesiologists (physical activity specialists), indicated; oral health consultants, social service workers, early b) Assessing parents’/guardians’ health, development, childhood mental health consultants, and education and safety knowledge, and offering training as consultants. indicated; The role of the CCHC is to promote the health and develop- Assessing children’s knowledge about health and c) ment of children, families, and staff and to ensure a healthy safety and offering training as indicated; and safe child care environment (11). d) Conducting a comprehensive indoor and outdoor health and safety assessment and on-going The CCHC is not acting as a primary care provider at observations of the child care facility; the facility but offers critical services to the program and Consulting collaboratively on-site and/or by e) families by sharing health and developmental expertise, telephone or electronic media; assessments of child, staff, and family health needs and f) Providing community resources and referral for community resources. The CCHC assists families in care health, mental health and social needs, including coordination with the medical home and other health and accessing medical homes, children’s health insurance developmental specialists. In addition, the CCHC should programs (e.g., CHIP), and services for special health collaborate with an interdisciplinary team of early childhood care needs; consultants, such as, early childhood education, mental g) Developing or updating policies and procedures for health, and nutrition consultants. child care facilities (see comment section below); In order to provide effective consultation and support to h) Reviewing health records of children; programs, the CCHC should avoid conflict of interest related i) Reviewing health records of caregivers/teachers; to other roles such as serving as a caregiver/teacher or j) Assisting caregivers/teachers and parents/guardians regulator or a parent/guardian at the site to which child care in the management of children with behavioral, social health consultation is being provided. and emotional problems and those with special health care needs; The CCHC should have regular contact with the facility’s ad- Consulting a child’s primary care provider about k) ministrative authority, the staff, and the parents/guardians in the child’s individualized health care plan and the facility. The administrative authority should review, and coordinating services in collaboration with parents/ collaborate with the CCHC in implementing recommended guardians, the primary care provider, and other health changes in policies and practices. In the case of consulting care professionals (the CCHC shows commitment about children with special health care needs, the CCHC to communicating with and helping coordinate the should have contact with the child’s medical home with child’s care with the child’s medical home, and may permission from the child’s parent/guardian. assist with the coordination of skilled nursing care Programs with a significant number of non-English-speaking services at the child care facility); families should seek a CCHC who is culturally sensitive and l) Consulting with a child’s primary care provider about knowledgeable about community health resources for the medications as needed, in collaboration with parents/ parents’/guardians’ native culture and languages. guardians; Teaching staff safe medication administration m) RATIONALE: - CCHCs provide consultation, training, infor practices; mation and referral, and technical assistance to caregivers/ Monitoring safe medication administration practices; n) teachers (10). Growing evidence suggests that CCHCs Observing children’s behavior, development and o) support healthy and safe early care and education settings health status and making recommendations if needed and protect and promote the healthy growth and develop- to staff and parents/guardians for further assessment ment of children and their families (1-10). Setting health and by a child’s primary care provider; safety policies in cooperation with the staff, parents/guard- Chapter 1: Staffing 34

65 Caring for Our Children: National Health and Safety Performance Standards sociation grants recognition to an individual who has met ians, health professionals, and public health authorities will predetermined qualifications specified by the agency or help ensure successful implementation of a quality program association. Certification is applied for by individuals on a (3). The specific health and safety consultation needs for an voluntary basis and represents a professional status when individual facility depend on the characteristics of that facil - achieved. Typical qualifications include 1) graduation from ity (1-2). All facilities should have an overall child care health - an accredited or approved program and 2) acceptable per consultation plan (1,2,10). formance on a qualifying examination. While there is no na- The special circumstances of group care may not be part tional accreditation of CCHC training programs or individual of the health care professional’s usual education. Therefore, CCHCs at this time, this is a future goal. Contact NTI at [email protected] caregivers/teachers should seek child care health consul- unc.edu for additional information. - tants who have the necessary specialized training or experi CCHC services may be provided through the public health ence (10). Such training is available from instructors who are system, resource and referral agency, private source, local graduates of the National Training Institute for Child Care community action program, health professional organiza- Health Consultants (NTI) and in some states from state- tions, other non-profit organizations, and/or universities. level mentoring of seasoned child care health consultants Some professional organizations include child care health known to chapter child care contacts networked through the consultants in their special interest groups, such as the Healthy Child Care America (HCCA) initiatives of the AAP. AAP’s Section on Early Education and Child Care and the Some professionals may not have the full range of knowl- National Association of Pediatric Nurse Practitioners (NAP - edge and expertise to serve as a child care health consul- NAP). tant but can provide valuable, specialized expertise. For CCHCs who are not employees of health, education, fam- example, a sanitarian may provide consultation on hygiene ily service or child care agencies may be self-employed. and infectious disease control and a Certified Playground Compensating them for their services via fee-for-service, an Safety Inspector would be able to provide consultation hourly rate, or a retainer fosters access and accountability. about gross motor play hazards. Listed below is a sample of the policies and procedures The U.S. Department of Health and Human COMMENTS: child care health consultants should review and approve: Services Maternal and Child Health Bureau (MCHB) has a) Admission and readmission after illness, including supported the development of state systems of child care inclusion/exclusion criteria; health consultants through HCCA and State Early Childhood Health evaluation and observation procedures on in- b) Comprehensive Systems grants and continues to support take, including physical assessment of the child and the NTI. Child care health consultants provide services to other criteria used to determine the appropriateness centers as well as family child care homes through on-site of a child’s attendance; visits as well as phone or email consultation. Approximately Plans for care and management of children with com- c) twenty states are funding child care health consultant initia- municable diseases; tives through a variety of funding sources, including Child Plans for prevention, surveillance and management of d) Care Development Block Grants, TANF, and Title V. In some illnesses, injuries, and behavioral and emotional prob- states a wide variety of health consultants, e.g., nutrition, lems that arise in the care of children; kinesiology (physical activity), mental health, oral health, Plans for caregiver/teacher training and for com- e) environmental health, may be available to programs and munication with parents/guardians and primary care those consultants may operate through a team approach. providers; Connecticut is an example of one state that has devel- f) Policies regarding nutrition, nutrition education, age- oped interdisciplinary training for early care and education appropriate infant and child feeding, oral health, and consultants (health, education, mental health, social service, physical activity requirements; nutrition, and special education) in order to develop a multi- Plans for the inclusion of children with special health g) disciplinary approach to consultation (8). or mental health care needs as well as oversight of Certificates are provided for graduates of the NTI upon their care and needs; completion of the course and continuing education units are Emergency/disaster plans; h) awarded. Some states offer CCHC training. Not all states i) Safety assessment of facility playground and indoor implement CCHC training as modeled by the NTI. Some play equipment; states offer continuing education units, college credit, and/ j) Policies regarding staff health and safety; or certificate of completion. Credentialing is an umbrella k) Policy for safe sleep practices and reducing the risk term referring to the various means employed to designate of SIDS; that individuals or organizations have met or exceeded l) Policies for preventing shaken baby syndrome/abu- established standards. These may include accreditation of sive head trauma; and certification, registration, or programs or organizations Policies for administration of medication; m) Accreditation refers to a legitimate individuals. licensure of n) Policies for safely transporting children; state or national organization verifying that an educational Policies on environmental health – handwashing, o) program or organization meets standards. Certification is sanitizing, pest management, lead, etc. the process by which a non-governmental agency or as- Chapter 1: Staffing 35

66 Caring for Our Children: National Health and Safety Performance Standards TYPE OF FACILITY: Center; Large Family Child Care Home; Small care needs. Written documentation of CCHC visits should Family Child Care Home be maintained at the facility. RELATED STANDARDS: Almost everything that goes on in a facility RATIONALE: Standard 1.6.0.3: Early Childhood Mental Health Consultants and almost everything about the facility itself affects the Standard 1.6.0.4: Early Childhood Education Consultants health of the children, families, and staff. (1-4). Because REFERENCES: infants are developing rapidly, environmental situations 1. Alkon, A., J. Bernzweig, K. To, J. K. Mackie, M. Wolff, J. Elman. can quickly create harm. Their rapid changes in behavior 2008. Child care health consultation programs in California: Models, make regular and frequent visits by the CCHC extremely services, and facilitators. Public Health Nurs 25:126-39. important (2-4). More frequent visits should be arranged 2. Alkon, A., J. Farrer, J. Bernzweig. 2004. Roles and responsibilities for those facilities that care for children with special health Pediatric of child care health consultants: Focus group findings. care needs and those programs that experience health 30:315-21. Nurs and safety problems and high turnover rate to ensure that 3. Crowley, A. A. 2000. Child care health consultation: The staff have adequate training and ongoing support (2). In Connecticut experience. Maternal Child Health J 4:67-75. one study, 84% of child care directors who were required 4. Gupta, R. S., S. Shuman, E. M. Taveras, M. Kulldorff, J. A. Finkelstein. 2005. Opportunities for health promotion education in to have weekly health consultation visits considered the child care. Pediatrics 116:499-505. visits critical for children’s health and program health and 5. Farrer, J., A. Alkon, K. To. 2007. Child care health consultation safety (2). Growing evidence suggests that frequent visits Maternal Child Health J programs: Barriers and opportunities. by a trained health consultant improves health policies and 11:111-18. health and safety practices and improves children’s im- 6. Heath, J. M., et al. 2005. Creating a statewide system of multi- munization status, access to a medical home, enrollment in disciplinary consultation system for early care and education in health insurance, timely screenings, and potentially reduces Farmington, CT: Child Health and Development Connecticut. the prevalence of obesity with a targeted intervention (5-11). Institute of Connecticut. http://nitcci.nccic.acf.hhs.gov/ Furthermore, in one state, child care center medication resources/10262005_93815_901828.pdf. administration regulatory compliance was associated with 7. Crowley, A. A., J. M Kulikowich. 2009. Impact of training on child Pediatric Nurs care health consultant knowledge and practice. weekly visits by a trained nurse child care health consultant 35:93-100. who delivered a standardized best practice curriculum (12). 8. Crowley, A. A., R. M. Sabatelli. 2008. Collaborative child care State child care regulations display a wide COMMENTS: health consultation: A conceptual model. J for Specialists in range of frequency and recommendations in states that 3:74-88. Pediatric Nurs 1 require CCHC visits, from as frequently as once a week for 9. Dellert, J. C., D. Gasalberti, K. Sternas, P. Lucarelli, J. Hall. 2006. programs serving children under three years of age to twice Outcomes of child care health consultation services for child care Pediatric Nurs providers in New Jersey: A pilot study. 32:530-37. a year for programs serving children three to five years of 10. Alkon, A., J. Bernzweig, K. To, M. Wolff, J. F. Mackie. 2009. age (2,5,6). Child care health consultation improves health and safety policies Center; Large Family Child Care Home; Small TYPE OF FACILITY: Academic Pediatrics 9:366-70. and practices. Family Child Care Home 11. Crowley, A. A. 2001. Child care health consultation: An ecological model. J Society Pediat Nurs 6:170-81. RELATED STANDARDS: Standard 1.1.1.3: Ratios for Facilities Serving Children with Special Health Care Needs and Disabilities STANDARD 1.6.0.2: Frequency of Child Care Standard 1.6.0.1: Child Care Health Consultants Health Consultation Visits Standard 1.6.0.5: Specialized Consultation for Facilities Serving The child care health consultant (CCHC) should visit each Children with Disabilities Standard 3.6.2.7: Child Care Health Consultants for Facilities That facility to review and give advice on the facility’s health com- Care for Children Who Are Ill ponent and review the overall health status of the children Standard 4.4.0.1: Food Service Staff by Type of Facility and Food and staff (1-4). Early childhood programs that serve any Service child younger than three years of age should be visited at Standard 4.4.0.2: Use of Nutritionist/Registered Dietitian least once monthly by a health professional with general Standard 9.4.1.17: Documentation of Child Care Health Consulta- knowledge and skills in child health and safety and health tion/Training Visits consultation. Child care programs that serve children three Standard 10.3.4.3: Support for Consultants to Provide Technical to five years of age should be visited at least quarterly and Assistance to Facilities programs serving school-age children should be visited Standard 10.3.4.4: Development of List of Providers of Services to at least twice annually. In all cases the frequency of visits Facilities should meet the needs of the composite group of children REFERENCES: and be based on the needs of the program for training, 1. Alkon, A., J. Bernzweig, K. To, J. K. Mackie, M. Wolff, J. Elman. support, and monitoring of child health and safety needs, 2008. Child care health consultation programs in California: Models, including (but not limited to) infectious disease, injury pre- 25:126-39. Public Health Nurs services, and facilitators. 2. Crowley, A. A. 2000. Child care health consultation: The vention, safe sleep, nutrition, oral health, physical activity 4:67-75. Connecticut experience. Maternal Child Health J and outdoor learning, emergency preparation, medication 3. Dellert, J. C., D. Gasalberti, K. Sternas, P. Lucarelli, J. Hall. 2006. administration, and the care of children with special health Outcomes of child care health consultation services for child care Chapter 1: Staffing 36

67 Caring for Our Children: National Health and Safety Performance Standards 32:530-37. Pediatric Nursing providers in New Jersey: A pilot study. consultants, to effectively support directors and 4. Gupta, R. S., S. Shuman, E. M. Taveras, M. Kulldorff, J. A. caregivers/teachers. Finkelstein. 2005. Opportunities for health promotion education in The role of the early childhood mental health consultant 116:499-505. Pediatrics child care. should be focused on building staff capacity and be both 5. Healthy Child Care Consultant Network Support Center, proactive in decreasing the incidence of challenging class- The influence of child care health CHT Resource Group. 2006. consultants in promoting children’s health and well-being: A room behaviors and reactive in formulating appropriate report on selected resources. http://hcccnsc.jsi.com/resources/ responses to challenging classroom behaviors and should publications/CC_lit_review_Screen_All.pdf. include: 6. Alkon, A., J. Bernzweig, K. To, M. Wolff, J. F. Mackie. 2009. Developing and implementing classroom curricula a) Child care health consultation improves health and safety policies regarding conflict resolution, emotional regulation, and practices. Academic Pediatrics 9:366-70. and social skills development; 7. Crowley, A. A. & Kulikowich, J. Impact of training on child care Developing and implementing appropriate screening b) health consultant knowledge and practice. Pediatric Nursing.,2009, and referral mechanisms for behavioral and mental 35 (2): 93-100. health needs; 8. Nurse Consultant Intervention Improves Nutrition and Physical Forming relationships with mental health providers c) Activity Knowledge, Policy, and Practice and Reduces Obesity in Child Care. A. Crowley, A. Alkon, B Neelon, S. Hill, P. Yi, E. Savage, and special education systems in the community; V. Ngyuen, J. Kotch. Head Start Research Conference, Washington, d) Providing mental health services, resources and/or DC. June 20, 2012. referral systems for families and staff; 9. Benjamin, S. E., A. Ammerman, J. Sommers, J. Dodds, B. Helping staff facilitate and maintain mentally healthy e) Neelon, D. S. Ward. 2007. Nutrition and physical activity self- environments within the classroom and overall assessment for child care (NAP SACC): Results from a pilot inter- system; vention. Journal of Nutrition Education and Behavior 39(3):142-9. f) Helping address mental health needs and reduce job 10. Bryant, D. “Quality Interventions for Early Care and Education.” stress within the staff; Early Developments, Spring 2013, http://fpg.unc.edu/sites/default/ g) Improving management of children with challenging files/resources/early-developments/FPG_EarlyDevelopments_ behaviors; v14n1.pdf. 11. Isbell P, Kotch JB, Savage E, Gunn E, Lu LS, Weber DJ. Preventing the development of problem behaviors; h) Improvement of child care programs’ policies, practices, and i) Providing a classroom climate that promotes positive children’s access to health care linked to child care health social-emotional development; consultation. NHSA Dialog: A Research to Practice Journal 2013;16 j) Recognizing and appropriately responding to the (2):34-52 (ISSN:1930-1395). needs of children with internalizing behaviors, such 12. Crowley, A. A. & Rosenthal, M. S. IMPACT: Ensuring the health as persistent sadness, anxiety, and social withdrawal; and safety of Connecticut’s early care and education programs. k) Actively teaching developmentally appropriate social 2009. Farmington, CT: The Child Health and Development Institute skills, conflict resolution, and emotional regulation; of Connecticut. l) Addressing the mental health needs and daily 13. National Resource Center for Health and Safety in Child stresses of those who care for young children, such Care and Early Education. 2010. Child care health consultant requirements and profiles by state. http://nrckids.org/default/assets/ as families and caregivers/teachers; File/CCHC%20by%20state%20NOV%202012_FINAL.pdf. Helping the staff to address and handle unforeseen m) crises or bereavements that may threaten the mental STANDARD 1.6.0.3: Early Childhood Mental health of staff or children and families, such as the death of a caregiver/teacher or the serious illness of Health Consultants a child. A facility should engage a qualified early childhood mental RATIONALE: As increasing numbers of children are spend- health consultant who will assist the program with a range ing longer hours in child care settings, there is an increasing of early childhood social-emotional and behavioral issues need to build the capacity of caregivers/teachers to attend and who will visit the program at minimum quarterly and to the social-emotional and behavioral well-being of children more often as needed. as well as their health and learning needs. Early childhood The knowledge base of an early childhood mental health mental health underlies much of what constitutes school consultant should include: readiness, including emotional and behavioral regulation, Training, expertise and/or professional credentials in a) social skills (i.e., taking turns, postponing gratification), mental health (e.g., psychiatry, psychology, clinical the ability to inhibit aggressive or anti-social impulses, and social work, nursing, developmental-behavioral the skills to verbally express emotions, such as frustration, medicine, etc.); anger, anxiety, and sadness. Supporting children’s health, b) Early childhood development (typical and atypical) of mental health and learning requires a comprehensive ap- infants, toddlers, and preschool age children; proach. Child care programs need to have health, educa- c) Early care and education settings and practices; tion, and mental health consultants who can help them Consultation skills and approaches to working d) implement universal, selected and targeted strategies to as a team with early childhood consultants from improve school readiness in young children in their care other disciplines, especially health and education (1-5). Mental health consultants in collaboration with educa - Chapter 1: Staffing 37

68 Caring for Our Children: National Health and Safety Performance Standards http://www.challengingbehavior.org/explore/policy_docs/prek tion and child care health consultants can reduce the risk _expulsion.pdf. for children being expelled, can reduce levels of problem 8. Gilliam, W. S., G. Shahar. 2006. Preschool and child care behaviors, increase social skills and build staff efficacy and expulsion and suspension: Rates and predictors in one state. capacity (1-11). Infants Young Children 19:228-45. COMMENTS: Access to an early childhood mental health Early Childhood Consultation 9. Gilliam, W. S. 2007. Partnership: Results of a random-controlled evaluation. consultant should be in the context of an ongoing relation- New Haven, CT: Yale Universty. http://www.chdi.org/admin/ ship, with at least quarterly regular visits to the classroom uploads/5468903394946c41768730.pdf. to consult. However, even an on-call-only relationship is 10. American Academy of Pediatrics, Committee on School Health. better than no relationship at all. Regardless of the fre- 2003. Policy statement: Out-of-school suspension and expulsion. quency of contact, this relationship should be established Pediatrics 112:1206-9. before a crisis arises, so that the consultant can establish a 11. Duran, F., K. Hepburn, M. Irvine, R. Kaufmann, B. Anthony, useful proactive working relationship with the staff and be N. Horen, D. Perry. 2009. What works?: A study of effective early quickly mobilized when needs arise. This consultant should Washington, DC: childhood mental health consultation programs. be viewed as an important part of the program’s support Georgetown University Center for Child and Human Development. staff and should collaborate with all regular classroom staff, http://gucchdtacenter.georgetown.edu/publications/ECMHCStudy _Report.pdf. administration, and other consultants such as child care health consultants and education consultants, and support STANDARD 1.6.0.4: Early Childhood Education staff. In most cases, there is no single place in which to look for early childhood mental health consultants. Quali- Consultants fied potential consultants may be identified by contacting - A facility should engage an early childhood education con mental health and behavioral providers (e.g., child clinical sultant who will visit the program at minimum semi-annually and school psychologists, licensed clinical social workers, and more often as needed. The consultant must have a child psychiatrists, developmental pediatricians, etc.), as minimum of a Baccalaureate degree and preferably a Mas- well as training programs at local colleges and universities ter’s degree from an accredited institution in early childhood where these professionals are being trained. Colleges and education, administration and supervision, and a minimum universities may be a good place to find well-supervised of three years in teaching and administration of an early consultants-in-training at a potentially reasonable cost, care/education program. The facility should develop a writ- although consultant turnover may be higher. ten plan for this consultation which must be signed annually Center; Large Family Child Care Home; Small TYPE OF FACILITY: by the consultant. This plan should outline the responsibili- Family Child Care Home ties of the consultant and the services the consultant will RELATED STANDARDS: provide to the program. Standard 1.6.0.1: Child Care Health Consultants The knowledge base of an early childhood education con- Standard 1.6.0.4: Early Childhood Education Consultants sultant should include: REFERENCES: Working knowledge of theories of child development a) 1. Brennan, E. M., J. Bradley, M. D. Allen, D. F. Perry. 2008. The and learning for children from birth through eight evidence base for mental health consultation in early childhood years across domains, including socio-emotional settings: A research synthesis addressing staff and program development and family development; Early Ed Devel outcomes. 19:982-1022. b) Principles of health and wellness across the domains, 2. National Scientific Council on the Developing Child. 2008. Mental including social and emotional wellness and health problems in early childhood can impair learning and behavior approaches in the promotion of healthy development for life. Working Paper no. 6. http://developingchild.harvard.edu/ library/reports_and_working_papers/working_papers/wp6/. and resilience; 3. Perry, D. F., M. D. Allen, E. M. Brennan, J. R. Bradley. 2010. The c) Current practices and materials available related evidence base for mental health consultation in early childhood to screening, assessment, curriculum, and settings: A research synthesis addressing children’s behavioral measurement of child outcomes across the domains, 21:795-824. Early Ed Devel outcomes. including practices that aid in early identification and Early childhood 4. Perry, D. F., R. Kaufmann, J. Knitzer. 2007. individualizing for a wide range of needs; social and emotional health: Building bridges between services and d) Resources that aid programs to support inclusion systems. Baltimore, MD: Paul Brookes Publishing. of children with diverse health and learning needs 5. Perry, D. F., M. C. Dunne, L. McFadden, D. Campbell. 2008. and families representing linguistic, cultural, and Reducing the risk for preschool expulsion: Mental health economic diversity of communities; consultation for young children with challenging behaviors. J Child Fam Studies 17:44-54. Methods of coaching, mentoring, and consulting that e) 6. Committee on Integrating the Science of Early Childhood meet the unique learning styles of adults; Development, Board on Children, Youth, and Families. 2000. f) Familiarity with local, state, and national regulations, Ed. J. P. Shonkoff, D. A. Phillips. From neurons to neighborhoods. standards, and best practices related to early Washington, DC: National Academy Press. education and care; Prekindergarteners left behind: Expulsion 7. Gilliam, W. S. 2005. g) Community resources and services to identify and Foundation for Child rates in state prekindergarten programs. serve families and children at risk, including those Development (FCD). Policy Brief Series no. 3. New York: FCD. 38 Chapter 1: Staffing

69 Caring for Our Children: National Health and Safety Performance Standards REFERENCES: related to child abuse and neglect and parent 1. Dunn, L., K. Susan. 1997. What have we learned about education; 52:4-13. Young Children developmentally appropriate practice? h) Consultation skills as well as approaches to working 2. Wesley, P. W., V. Buysse. 2006. Ethics and evidence in as a team with early childhood consultants from other 26:131-41. consultation. Topics Early Childhood Special Ed disciplines, especially child care health consultants, 3. Wesley, P. W., S. A. Palsha. 1998. Improving quality in early to effectively support program directors and their childhood environments through on-site consultation. Topics Early staff. Childhood Special Ed 18:243-53. Consultation in early childhood 4. Wesley, P. W., V. Buysee. 2005. The role of the early childhood education consultant should settings. Baltimore, MD: Brookes Publishing. include: 5. Bredekamp, S., C. Copple, eds. 2000. Developmentally Review of the curriculum and written policies, plans a) appropriate practice in early childhood programs serving children and procedures of the program; Rev ed. National Association for the from birth through age 8. b) Observations of the program and meetings with the Education of Young Children (NAEYC). Publication no. 234. director, caregivers/teachers, and parents/guardians; Washington, DC: NAEYC. http://www.naeyc.org/files/naeyc/file/ c) Review of the professional needs of staff and positions/position statement Web.pdf. program and provision of recommendations of 6. The Connecticut Early Education Consultation Network. CEECN: Guidance, leadership, support. http://ctconsultationnetwork.org. current resources; 7. Connecticut Department of Public Health. Child day care d) Reviewing and assisting directors in implementing licensing program. http://www.ct.gov/dph/cwp/view and monitoring evidence based approaches to .asp?a=3141&Q=387158&dphNav_GID=1823/. classroom management; e) Maintaining confidences and following all Family STANDARD 1.6.0.5: Specialized Consultation Educational Rights and Privacy Act (FERPA) for Facilities Serving Children with Disabilities regulations regarding disclosures; f) Keeping records of all meetings, consultations, When children at the facility include those with special recommendations and action plans and offering/ health care needs, developmental delay or disabilities, and providing summary reports to all parties involved; mental health or behavior problems, the staff or document- Seeking and supporting a multidisciplinary approach g) ed consultants should involve any of the following consul- to services for the program, children and families; tants in the child’s care, with prior informed, written parental h) Following the National Association for the Education consent and as appropriate to each child’s needs: of Young Children (NAEYC) Code of Ethics; a) A registered nurse, nurse practitioner with pediatric i) Availability by telecommunication to advise regarding experience, or child care health consultant; practices and problems; A physician with pediatric experience, especially b) j) Availability for on-site visit to consult to the program; those with developmental-behavioral training; k) Familiarity with tools to evaluate program quality, c) A registered dietitian; such as the Early Childhood Environment Rating d) A psychologist; Scale–Revised (ECERS–R), Infant/Toddler e) A psychiatrist; Environment Rating Scale–Revised (ITERS–R), f) A physical therapist; Family Child Care Environment Rating Scale–Revised g) An adaptive equipment technician; (FCCERS–R), School-Age Care Environment Rating h) An occupational therapist; Scale (SACERS), Classroom Assessment Scoring i) A speech pathologist; System (CLASS), as well as tools used to support j) An audiologist for hearing screenings conducted on- various curricular approaches. site at child care; A vision screener; k) The early childhood education consultant RATIONALE: l) A respiratory therapist; provides an objective assessment of a program and essen- m) A social worker; tial knowledge about implementation of child development A parent/guardian of a child with special health care n) principles through curriculum which supports the social needs; and emotional health and learning of infants, toddlers and Part C representative/service coordinator; o) preschool age children (1-5). Furthermore, utilization of an A mental health consultant; p) early childhood education consultant can reduce the need q) Special learning consultant/teacher (e.g., teacher for mental health consultation when challenging behaviors specializing in work with visually impaired child or are the result of developmentally inappropriate curriculum sign language interpreters); (6,7). Together with the child care health consultant, the r) A teacher with special education expertise; early childhood education consultant offers core knowledge s) The caregiver/teacher; for addressing children’s healthy development. t) Individuals identified by the parent/guardian; TYPE OF FACILITY: Center; Large Family Child Care Home; Small u) Certified child passenger safety technician with Family Child Care Home training in safe transportation of children with special RELATED STANDARDS: needs. Standard 1.6.0.1: Child Care Health Consultants Standard 1.6.0.3: Early Childhood Mental Health Consultants Chapter 1: Staffing 39

70 Caring for Our Children: National Health and Safety Performance Standards RATIONALE: Caregivers/teachers need to be physically RATIONALE: The range of professionals needed may vary and emotionally healthy to perform the tasks of providing with the facility, but the listed professionals should be avail- care to children. Performing their work while ill can spread able as consultants when needed. These professionals need infectious disease and illness to other staff and the children not be on staff at the facility, but may simply be available in their care (2). Under the Americans with Disabilities Act when needed through a variety of arrangements, including (ADA), employers are expected to make reasonable ac- - contracts, agreements, and affiliations. The parent’s par commodations for persons with disabilities. Under ADA, ticipation and written consent in the native language of the accommodations are based on an individual case by case parent, including Braille/sign language, is required to include situation. Undue hardship is defined also on a case by case outside consultants (1). basis. Accommodation requires knowledge of conditions TYPE OF FACILITY: Center; Large Family Child Care Home; Small that must be accommodated to ensure competent function Family Child Care Home of staff and the well-being of children in care (3). REFERENCES: Since detection of tuberculosis using screening of healthy Liability exposure and child care health 1. Cohen, A. J. 2002. http://www.ucsfchildcarehealth.org/pdfs/forms/ consultation. individuals has a low yield compared with screening of CCHCLiability.pdf. contacts of known cases of tuberculosis, public health authorities have determined that routine repeated screening of healthy individuals with previously negative skin tests is 1.7 Staff Health not a reasonable use of resources. Since local circumstanc- es and risks of exposure may vary, this recommendation STANDARD 1.7.0.1: Pre-Employment and should be subject to modification by local or state health Ongoing Adult Health Appraisals, Including authorities. Immunization Child care facilities should provide the job de- COMMENTS: scription or list of activities that the staff person is expected All paid and volunteer staff members should have a health to perform. Unless the job description defines the duties of appraisal before their first involvement in child care work. the role specifically, under federal law the facility may be The appraisal should identify any accommodations required required to adjust the activities of that person. For example, of the facility for the staff person to function in his or her child care facilities typically require the following activities of assigned position. caregivers: Health appraisals for paid and volunteer staff members Moving quickly to supervise and assist young chil- a) should include: dren; a) Physical exam; b) Lifting children, equipment, and supplies; b) Dental exam; c) Sitting on the floor and on child-sized furniture; c) Vision and hearing screening; Washing hands frequently; d) The results and appropriate follow up of a d) e) Responding quickly in case of an emergency; tuberculosis (TB) screening, using the Tuberculin Skin f) Eating the same food as is served to the children (un- Test (TST) or IGRA (interferon gamma release assay), less the staff member has dietary restrictions); once upon entering into the child care field with Hearing and seeing at a distance required for play- g) subsequent TB screening as determined by history of ground supervision or driving; high risk for TB thereafter; h) Being absent from work for illness no more often than e) A review and certification of up-to-date immune the typical adult, to provide continuity of caregiving status per the current Recommended Adult relationships for children in child care. Immunization Schedule found in Appendix H, , from the Healthy Young Children: A Manual for Programs including annual influenza vaccination and up to date National Association for the Education of Young Children Tdap; (NAEYC), provides a model form for an assessment by f) A review of occupational health concerns based on Model Child Care Health a health professional. See also the performance of the essential functions of the job. , from NAEYC and from the American Academy of Policies All adults who reside in a family child care home who are Pediatrics (AAP). considered to be at high risk for TB, should have completed Concern about the cost of health exams (particularly when TB screening (1) as specified in Standard 7.3.10.1. Adults many caregivers/teachers do not receive health benefits and who are considered at high risk for TB include those who earn minimum wage) is a barrier to meeting this standard. are foreign-born, have a history of homelessness, are HIV- When staff members need hepatitis B immunization to meet infected, have contact with a prison population, or have Occupational Safety and Health Administration (OSHA) contact with someone who has active TB. requirements (4), the cost of this immunization may or may Testing for TB of staff members with previously negative not be covered under a managed care contract. If not, the skin tests should not be repeated on a regular basis unless cost of health supervision (such as immunizations, dental required by the local or state health department. A record of and health exams) must be covered as part of the em- test results and appropriate follow-up evaluation should be on file in the facility. Chapter 1: Staffing 40

71 Caring for Our Children: National Health and Safety Performance Standards a demonstration of how to implement this standard, see the ployee’s preparation for work in the child care setting by the video series, Caring for Our Children , available from National prospective employee or the employer. Child care workers Association for the Education of Young Children (NAEYC) are among those for whom annual influenza vaccination is and the American Academy of Pediatrics (AAP) (1). strongly recommended. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Facilities should consult with ADA experts through the U.S. Family Child Care Home Department of Education funded Disability and Business Technical Assistance Centers (DBTAC) throughout the REFERENCES: country. These centers can be reached by calling 1-800- 1. Baldwin D., S. Gaines, J. L. Wold, A. Williams. 2007. The health J of female child care providers: Implications for quality of care. 949-4232 (callers are routed to the appropriate region) or by 24:1-7. Comm Health Nurs accessing regional center’s contacts directly at http://adata Health in child 2. Murph, J. R., S. D. Palmer, D. Glassy, eds. 2005. .org/Static/Home.aspx. care: A manual for health professionals . 4th ed. Elk Grove Village, IL: TYPE OF FACILITY: Center; Large Family Child Care Home; Small American Academy of Pediatrics. Family Child Care Home RELATED STANDARDS: STANDARD 1.7.0.3: Health Limitations of Staff Standard 1.7.0.3: Health Limitations of Staff Staff and volunteers must have a primary care provider’s Standard 1.7.0.4: Occupational Hazards release to return to work in the following situations: Standards 7.2.0.1-7.2.0.3: Immunizations a) When they have experienced conditions that Standard 7.3.10.1: Measures for Detection, Control, and Reporting may affect their ability to do their job or require of Tuberculosis an accommodation to prevent illness or injury in Standard 7.3.10.2: Attendance of Children with Latent Tuberculosis Infection or Active Tuberculosis Disease child care work related to their conditions (such as Appendix B: Major Occupational Health Hazards pregnancy, specific injuries, or infectious diseases); Appendix E: Child Care Staff Health Assessment b) After serious or prolonged illness; Appendix H: Recommended Adult Immunization Schedule When their condition or health could affect promotion c) REFERENCES: or reassignment to another role; 1. Centers for Disease Control and Prevention. 2015. Before return from a job-related injury; d) Recommended adult immunization schedule – United States, 2015. If there are workers’ compensation issues or if the e) http://www.cdc.gov/vaccines/schedules/easy-to-read/adult.html. facility is at risk of liability related to the employee’s 2. Baldwin, D., S. Gaines, J. L. Wold, A. Williams. 2007. The health or volunteer’s health problem. J of female child care providers: Implications for quality of care. If a staff member is found to be unable to perform the activi- 24:1-7. Comm Health Nurs 3. Keyes, C. R. 2008. Adults with disabilities in early childhood ties required for the job because of health limitations, the Child Care Info Exchange settings. 179:82-85. staff person’s duties should be limited or modified until the 4. Occupational Safety and Health Administration. 2008. health condition resolves or employment is terminated be- Bloodborne pathogens. Title 29, pt. 1910.1030. http://www.osha cause the facility can prove that it would be an undue hard- .gov/pls/oshaweb/owadisp.show_document?p_table=standards&p ship to accommodate the staff member with the disability. _id=10051. RATIONALE: Under the Americans with Disabilities Act (ADA), employers are expected to make reasonable accom- STANDARD 1.7.0.2: Daily Staff Health Check modations for persons with disabilities. Under ADA, accom- On a daily basis, the administrator of the facility or care- modations are based on an individual case by case situation giver/teacher should observe staff members, substitutes, (1). Undue hardship is defined also on a case by case basis (1). and volunteers for obvious signs of ill health. When ill, staff Facilities should consult with ADA experts COMMENTS: members, substitutes and volunteers may be directed to go through the U.S. Department of Education funded Disability home. Staff members, substitutes, and volunteers should be and Business Technical Assistance Centers throughout the responsible for reporting immediately to their supervisor any country. These centers can be reached by calling 1-800- injuries or illnesses they experience at the facility or else - 949-4232 and callers are routed to the appropriate region or where, especially those that might affect their health or the accessing contacts directly at http://adata.org/Static/ health and safety of the children. It is the responsibility of Home.aspx. the administration, not the staff member who is ill or injured, to arrange for a substitute caregiver/teacher. TYPE OF FACILITY: Center; Large Family Child Care Home RATIONALE: Sometimes adults report to work when feel- RELATED STANDARDS: ing ill or become ill during the day but believe it is their Standard 7.6.1.4: Informing Public Health Authorities of HBV Cases responsibility to stay. The administrator’s or caregiver’s/ Standard 7.6.3.4: Ability of Caregivers/teachers with HIV Infection to Care for Children teacher’s observation of illness followed by sending the staff member home may prevent the spread of illness. Arranging REFERENCES: for a substitute caregiver/teacher ensures that the children 1. ADA National Network. The Americans with Disabilities Act (ADA) receive competent care (1,2). from a civil rights perspective. http://adaanniversary.org/2010/ ap03_ada_civilrights/03_ada_civilrights_09_natl.pdf. Administrators and caregivers/teachers need COMMENTS: guidelines to ensure proper application of this standard. For Chapter 1: Staffing 41

72 Caring for Our Children: National Health and Safety Performance Standards f) Regular work breaks and paid time-off; STANDARD 1.7.0.4: Occupational Hazards Appropriate child:staff ratios; g) Written personnel policies of centers and large family child Liability insurance for caregivers/teachers; h) care homes should address the major occupational health i) Staff lounge separate from child care area with adult hazards for workers in child care settings. Special health size furniture; concerns of pregnant caregivers/teachers should be care- j) The use of sound-absorbing materials in the fully evaluated, and up-to-date information regarding oc- workspace; cupational hazards for pregnant caregivers/teachers should k) Regular performance reviews which, in addition to be made available to them and other workers. The occupa- addressing any areas requiring improvement, provide tional hazards including those regarding pregnant workers constructive feedback, individualized encouragement listed in Appendix B, Major Occupational Health Hazards, and appreciation for aspects of the job well should be referenced and used in evaluations by caregivers/ performed; teachers and supervisors. l) Stated provisions for back-up staff, for example, to Employees must be aware of the risks to RATIONALE: allow caregivers/teachers to take necessary time off which they are exposed so they can weigh those risks and when ill without compromising the function of the take countermeasures (2). As a workforce composed pri- center or incurring personal negative consequences marily of women of childbearing age, pregnancy is common from the employer (this back-up should also include among caregivers/teachers in child care settings. In a study a stated plan to be implemented in the event a of child care personnel, one quarter of the study’s sample staff member needs to have a short, but relatively reported becoming pregnant since beginning work in child immediate break away from the children); care, with higher pregnancy rates for directors (33%) and Adult size furniture in the classroom for the staff; m) family home caregivers/teachers (36%) than for center staff n) Access to experts in child development and behavior (15%) (1). to help problem solve child specific issues. Center; Large Family Child Care Home TYPE OF FACILITY: RATIONALE: One of the best indicators of quality child care is consistent staff with low turnover rates (5,6). RELATED STANDARDS: Appendix B: Major Occupational Health Hazards According to the Bureau of Labor Statistics’ Website, “in REFERENCES: 2007, hourly earnings of nonsupervisory workers in the child 1. The National Association of Family Child Care (NAFCC). 2005. day care services industry averaged $10.53” (1). About 42% . 4th ed. Salt Lake City, Quality standards for NAFCC accreditation of all child care workers have a high school degree or less, UT: NAFCC. http://www.nafcc.org/documents/QualStd.pdf. reflecting the minimal training requirements for most jobs. Managing infectious 2. Aronson, S. S., T. R. Shope, eds. 2009. Many child care workers leave the industry due to stressful diseases in child care and schools: A quick reference guide. 2nd ed. working conditions and dissatisfaction with benefits and pay Elk Grove Village, IL: American Academy of Pediatrics. (1). STANDARD 1.7.0.5: Stress Stress reduction measures (particularly adequate wages and reasonable health care benefits) contribute to decreased Caregivers/teachers should be able to: staff turnover and thereby promote quality care (2). The a) Identify risks associated with stress; health, welfare, and safety of adult workers in child care Identify stressors specific to child caregiving; b) determine their ability to provide care for the children. Identify specific ways to manage stress in the child c) care environment. Serious physical abuse sometimes occurs when the care- giver/teacher is under high stress. Too much stress can The following measures to lessen stress for the staff should not only affect the caregiver’s/teacher’s health, but also the be implemented to the maximum extent possible: quality of the care that the adult is able to give. A caregiver/ Wages and benefits (including health care insurance) a) teacher who is feeling too much stress may not be able to that fairly compensate the skills, knowledge, and offer the praise, nurturing, and direction that children need performance required of caregivers/teachers, at for good development (3). Regular breaks with substitutes the levels of wages and benefits paid for other jobs when the caregiver/teacher cannot continue to provide safe that require comparable skills, knowledge, and care can help ensure quality child care. performance; b) Job security; Sound-absorbing materials in the work area, break times, c) Training to improve skills and hazard recognition; and a separate lounge allow for respite from noise and from d) Stress management and reduction training; non-auditory stress. Unwanted sound, or noise, can be e) Written plan/policy in place for the situation in damaging to hearing as well as to psychosocial well-being. which a caregiver/teacher recognizes that s/he or a The stress effects of noise will aggravate other stress fac- colleague is stressed and needs help immediately tors present in the facility. Lack of adequate sound reduc- (the plan should allow for caregivers/teachers who tion measures in the facility can force the caregiver/teacher feel they may lose control to have a short, but - to speak at levels above those normally used for conver relatively immediate break away from the children at sation, and thus may increase the risk of throat irritation. times of high stress); 42 Chapter 1: Staffing

73 Caring for Our Children: National Health and Safety Performance Standards Centers and large family child care homes should have writ- When caregivers/teachers raise their voices to be heard, the ten policies that detail these benefits of employees at the children tend to raise theirs, escalating the problem. facility. COMMENTS: Documentation of implementation of stress RATIONALE: The quality and continuity of the child care reduction measures should be on file in the facility. workforce is the main determining factor of the quality of Rest breaks of twenty minutes or less are customary in care. Nurturing the nurturers is essential to prevent burnout industry and are customarily paid for as working time. Meal and promote retention. Fair labor practices should apply to periods (typically thirty minutes or more) generally need not child care as well as other work settings. Child care workers be compensated as work time as long as the employee is should be considered as worthy of benefits as workers in completely relieved from duty for the entire meal period (4). other careers. For resources on respite or crisis care, contact the ARCH Medical coverage should include the cost of the health National Respite Network at http://archrespite.org. appraisals and immunizations required of child care work- Caregivers/teachers who use tobacco can experience ers, and care for the increased incidence of communicable stress related to nicotine withdrawals. For help dealing with disease and stress-related conditions in this work setting. stress from tobacco addiction, see the Tobacco Research - The potential for acquiring injuries and infections when car booklet on smok- Forever Free and Intervention Program’s ing for young children is a health and safety hazard for child ing, stress, and mood at http://www.smokefree.gov/pubs/ care workers. Information abounds about the risk of infec- FFree6.pdf. Or, for help quitting smoking, visit the Smoke tious disease for children in child care settings. Children are Free Website at http://www.smokefree.gov. reservoirs for many infectious agents. Staff members come TYPE OF FACILITY: Center; Large Family Child Care Home; Small into close and frequent contact with children and their ex- Family Child Care Home cretions and secretions and are vulnerable to these illness- RELATED STANDARDS: es. In addition, many child care workers are women who are Standards 1.1.1.1-1.1.1.5: Child:Staff Ratio and Group Size planning a pregnancy or who are pregnant, and they may be REFERENCES: vulnerable to potentially serious effects of infection on the 1. U.S. Department of Labor, Bureau of Labor Statistics. 2010. outcome of pregnancy (2). Career guide to industries: Child day care services, 2010-11 Edition. Sick leave is important to minimize the spread of commu- http://www.bls.gov/oco/cg/cgs032.htm. nicable diseases and maintain the health of staff members. 2. U.S. Department of Labor, Bureau of Labor Statistics. 2010. Occupational employment statistics: occupational employment and Sick leave promotes recovery from illness and thereby http://www.bls.gov/oes/current/oes399011.htm. wages, May 2009. decreases the further spread or recurrence of illness. ). Stress management for 3. Healthy Childcare Consultants (HCCI Workplace benefits contribute to higher morale and less child caregivers. Pelham, AL: HCCI. staff turnover, and thus promote quality child care. Lack of 4. U.S. Department of Labor, Wage and Hour Division. 2009. Fact benefits is a major reason reported for high turnover of child sheet #46: Daycare centers and preschools under the Fair Labor Rev. ed. http://www.dol.gov/whd/regs/ Standards Act (FLSA). care staff (1). compliance/whdfs46.pdf. Staff benefits may be appropriately ad- COMMENTS: 5. Fiene, R. 2002. 13 indicators of quality child care: Research dressed in center personnel policies and in state and update. Washington, DC: U.S. Department of Health and Human federal labor standards. Not all the material that has to be Services, Office of the Assistant Secretary for Planning and addressed in these policies is appropriate for state child Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/. care licensing requirements. Having facilities acknowledge 6. National Institute of Child Health and Human Development (NICHD). 2006 . The NICHD study of early child care and youth which benefits they do provide will help enhance the general Rockville, development: Findings for children up to age 4 1/2 years. awareness of staff benefits among child care workers and MD: NICHD. other concerned parties. Currently, this standard is difficult for many facilities to achieve, but new federal programs and shared access to small business benefit packages will 1.8 Human Resource help. Many options are available for providing leave benefits and education reimbursements, ranging from partial to full Management employer contribution, based on time employed with the facility. 1.8.1 Benefits Caregivers/teachers should be encouraged to have health STANDARD 1.8.1.1: Basic Benefits insurance. Health benefits can include full coverage, partial coverage (at least 75% employer paid), or merely access The following basic benefits should be offered to staff: to group rates. Some local or state child care associations a) Affordable health insurance; offer reduced group rates for health insurance for child care Paid time-off (vacation, sick time, personal leave, b) facilities and individual caregivers/teachers. holidays, family, parental and medical leave, etc.); Social Security or other retirement plan; c) Center; Large Family Child Care Home; Small TYPE OF FACILITY: Workers’ compensation; d) Family Child Care Home e) Educational benefits. Chapter 1: Staffing 43

74 Caring for Our Children: National Health and Safety Performance Standards RELATED STANDARDS: RELATED STANDARDS: Standard 1.4.6.1: Training Time and Professional Development Standards 1.4.4.1-1.4.6.2: Continuing Education/Professional Leave Development Standard 1.4.6.2: Payment for continuing Education Standard 1.8.2.2: Annual Staff Competency Evaluation Standard 9.3.0.1: Written Human Resource Management Policies REFERENCES: for Centers and large Family Child Care Homes 1. National Association for the Education of Young Children Leadership and management: A guide to REFERENCES: (NAEYC). 2008. Worthy work, 1. Whitebook, M., C. Howes, D. Phillips. 1998. the NAEYC early childhood program standards and related accreditation criteria. Washington, DC: NAEYC. unlivable wages: The National child care staffing study, 1988-1997. 2. Owens, C. 1997. Washington, DC: Center for the Child Care Workforce. Rights in the workplace: A guide for child care teachers. Washington, DC: Worker Option Resource Center. 2. National Association for the Education of Young Children Leadership and management: A guide to (NAEYC). 2008. the NAEYC early childhood program standards and related STANDARD 1.8.2.3: Staff Improvement Plan accreditation criteria. Washington, DC: NAEYC. When a staff member of a center or a large family child care home does not meet the minimum competency level, that 1.8.2 Evaluation employee should work with the employer to develop a plan to assist the person in achieving the necessary skills. The STANDARD 1.8.2.1: Staff Familiarity with plan should include a timeline for completion and conse- Facility Policies, Plans and Procedures quences if it is not achieved. All caregivers/teachers should be familiar with the provisions Children must be protected from incompetent RATIONALE: of the facility’s policies, plans, and procedures, as described caregiving. A system for evaluation and a plan to promote in Chapter 9, Administration. The compliance with these continued development are essential to assist staff to meet policies, plans, and procedures should be used in staff per - performance requirements (1). formance evaluations and documented in the personnel file. COMMENTS: Whether the caregiver/teacher meets the Written policies, plans and procedures provide RATIONALE: minimum competency level is related to the director’s as- a means of staff orientation and evaluation essential to the sessment of the caregiver’s/teacher’s performance. operation of any organization (1). TYPE OF FACILITY: Center; Large Family Child Care Home Center; Large Family Child Care Home TYPE OF FACILITY: RELATED STANDARDS: RELATED STANDARDS: Standard 1.4.1.1: Pre-service Training Chapter 9: Administration Standards 1.4.2.1-1.4.2.3: Orientation Training Standard 1.4.3.1: First Aid and CPR Training for Staff REFERENCES: Standards 1.4.4.1-1.4.6.2: Continuing Education/Professional 1. Boone, L. E., D. L. Kurtz. 2010. Contemporary business. Development Hoboken, NJ: John Wiley and Sons. Standard 9.4.3.1: Maintenance and Content of Staff and Volunteer Records : Annual Staff Competency STANDARD 1.8.2.2 REFERENCES: Evaluation 1. University of California Berkeley Human Resources. Guide to For each employee, there should be a written annual self- managing human resources. Chapter 7: Performance management. - evaluation, a performance review from the personnel super http://hrweb.berkeley.edu/guides/managing-hr/managing -successfully/performance-management/introduction/. visor, and a continuing education/professional development plan based on the needs assessment, described in Stan- dard 1.4.4.1 through Standard 1.4.5.4. STANDARD 1.8.2.4: Observation of Staff A system for evaluation of employees is a RATIONALE: Observation of staff by a designee of the program director basic component of any personnel policy (1). Staff members should include an assessment of each member’s adherence who are well trained are better able to prevent, recognize, to the policies and procedures of the facility with respect to and correct health and safety problems (2). sanitation, hygiene, and management of infectious diseases. Routine, direct observation of employees is the best way COMMENTS: Formal evaluation is not a substitute for con- to evaluate hygiene and safety practices. The observation tinuing feedback on day-to-day performance. Performance should be followed by positive and constructive feedback appraisals should include a customer satisfaction compo - to staff. Staff will be informed in their job description and/or nent and/or a peer review component. Compliance with this employee handbook that observations will be made. standard may be determined by licensing requirements set by the state and local regulatory processes, and by state RATIONALE: Ongoing observation is an effective tool to and local funding requirements, or by accrediting bodies evaluate consistency of staff adherence to program policies (1). In some states, a central Child Development Personnel and procedures (1). It also serves to identify areas for ad- Registry may track and certify the qualifications of staff. ditional orientation and training. Center; Large Family Child Care Home TYPE OF FACILITY: COMMENTS: Videotaping of these assessments may be a useful way to provide feedback to staff around their adher - 44 Chapter 1: Staffing

75 Caring for Our Children: National Health and Safety Performance Standards ence to policies and procedures regarding hygiene and safety practices. If videotaping includes interactions with children, parent/guardian permission must be obtained before taping occurs. Desirable interactions can be en- couraged and discussing methods of improvement can be facilitated through videotaping. Videotaped interactions can also prove useful to caregivers/teachers when informing, illustrating and discussing an issue with the parents/guard- ians. 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. If the staff follows the National Association for the Education of Young Children (NAEYC) Code of Ethical Conduct, peers are expected to observe, support and guide peers. In ad- dition within the role of the child care health consultant and the education consultant are guidelines for observation of staff within the classroom. It should be within the role of the director and assistant director guidelines for direct observa- tion of staff for health, safety, developmentally appropri- ate practice, and curriculum. For more information on the NAEYC Code of Ethical Conduct, go to http://www.naeyc. org/files/naeyc/file/positions/PSETH05.pdf. TYPE OF FACILITY: Center; Large Family Child Care Home REFERENCES: 1. Nolan, Jr., J. F., L. A. Hoover. 2010. Teacher supervision and Hoboken, NJ: John Wiley and Sons. evaluation. STANDARD 1.8.2.5: Handling Complaints About Caregivers/Teachers When complaints are made to licensing or referral agencies about caregivers/teachers, the caregivers/teachers should receive formal notice of the complaint and the resulting action, if any. Caregivers/teachers should maintain records of such complaints, post substantiated complaints with correction action, make them available to parents/guardians on request, and post a notice of how to contact the state agency responsible for maintaining complaint records. Parents/guardians seeking child care should RATIONALE: know if previous complaints have been made, particularly if the complaint is substantiated. This information should be easily accessible to the parents/guardians. Parents/guard- ians can then evaluate whether or not the complaint is valid, and whether the complaint has been adequately addressed and necessary changes have been made. COMMENTS: This policy requires program development by licensing agencies. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home Chapter 1: Staffing 45

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77 Chapter 2 Program Activities for Healthy Development

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79 Caring for Our Children: National Health and Safety Performance Standards Reviews of children’s performance after at- RATIONALE: 2.1 Program of Developmental tending out-of-home child care indicate that children attend- ing facilities with well-developed curricula achieve appropri- Activities ate levels of development (1,2). 2.1.1 General Program Activities Early childhood specialists agree on the: a) Inseparability and interdependence of cognitive, STANDARD 2.1.1.1: Written Daily Activity Plan physical, emotional, communication and social and Statement of Principles development. Social-emotional capacities do not develop or function separately; Facilities should have a written comprehensive and coordi- Influence of the child’s health and safety on all these b) nated planned program of daily activities based on a state- areas; ment of principles for the facility and each child’s individual Central importance of continuity and consistent c) development, as well as appropriate activities for groups of relationships with affectionate care that is the children at each stage of early childhood. The objective of formation of strong, nurturing relationships between the program of daily activities should be to foster incremen- caregivers/teachers and children; tal developmental progress in a healthy and safe environ- d) Relevance of the phase or stage concept; ment and should be flexible to capture the interests of the Importance of action (including play) as a mode of e) children and the individual abilities of the children. learning, and to express self (3). Centers, large and small family child care homes should Those who provide child care and early education must be develop a written statement of principles that set out the ba- able to articulate components of the curriculum they are sic elements from which the daily indoor/outdoor program implementing and the related values/principles on which the is to be built. These principles should include the following curriculum is based. In centers and large family child care elements: homes, because more than two caregivers/teachers are a) Overall child health and safety; involved in operating the facility, a written statement of prin- Physical development, which facilitates small and b) ciples helps achieve consensus about the basic elements large motor skills; from which all staff will plan the daily program (4). Family development, which acknowledges the role of c) the family, including culture and language; A written description of the planned program of daily activi- d) Social development, which leads to cooperative ties allows staff and parents/guardians to have a common play with other children and the ability to make understanding and gives them the ability to compare the relationships with other children and adults and program’s actual performance to the stated intent. Child children of other backgrounds and ability levels; care is a “delivery of service” involving a contractual rela- Emotional development, which facilitates self e) tionship between the caregiver/teacher and the consumer. awareness and self confidence; A written plan helps to define the service and contributes f) Cognitive development, which includes an to specific and responsible operations that are conducive understanding of the world and environment in which to sound child development and safety practices and to they live and leads to understanding science, math, positive consumer relations (4). For infants and toddlers who and literacy concepts, as well as increasing the use learn through healthy and ongoing relationships with primary and understanding of language to express feelings caregivers/teachers, a relationship-based plan should be and ideas. shared with parents/guardians that include opportunities for parents/guardians to be an integral partner and member of The planned program should provide for the incorporation of this relationship system. Professional development is often specific health education topics on a daily basis throughout required to enable staff to develop proficiency in the devel- the year. Topics of health education should include health opment and implementation of a curriculum that they use to promotion and disease prevention topics, e.g., handwash- carry out daily activities appropriately (6). ing, oral health, nutrition, physical activity, etc. Planning ensures that some thought goes into indoor and Health and safety behaviors should be modeled by staff in outdoor programming for children. The plans are tools for order to insure that children and parents/guardians under - monitoring and accountability. Also, a written plan is a tool stand the need for a safe indoor and outdoor learning/play for staff orientation. environment and feel comfortable. COMMENTS: The National Association for the Educa- Continuity and consistency by a caring staff is vital so that tion of Young Children (NAEYC) Accreditation Criteria and children and parents/guardians know what to expect. All of Procedures, the National Association for Family Child Care the principles should be developed with play being the foun- (NAFCC) accreditation standards, and the National Child dation of the planned curriculum. Material such as blocks, Care Association (NCCA) standards can serve as resources clay, paints, books, puzzles, and/or other manipulatives for planning program activities. should be available indoors and outdoors to the children to further the planned curriculum. Parents/guardians and staff can experience mutual learning in an open, supportive setting. Suggestions for topics and Chapter 2: Program Activities 49

80 Caring for Our Children: National Health and Safety Performance Standards understand why these rules were created. National guide- methods of presentation are widely available. For example, lines for children birth to age five encourage their engage- the publication catalogs of the NAEYC and of the American ment in daily physical activity that promotes movement, Academy of Pediatrics (AAP) contain many materials for motor skills and the foundations of health-related fitness (4). child, parent/guardian, and staff education on child develop- Physical activity is important to overall health and to over - ment, the importance of attachment and temperament, and weight and obesity prevention (5). other health issues. A certified health education specialist (CHES) can also be a source of assistance. The American COMMENTS: Resources for activities can be found at: Association for Health Education (AAHE) at http://www • Fit Source – http://nccic.acf.hhs.gov/fitsource/; .aahperd.org/AAHE/, and the National Commission for • Go Out and Play – http://www.cdc.gov/ncbddd/ Health Education Credentialing (NCHEC) at http://www actearly/pdf/ccp_pdfs/GOP_kit.pdf; and .nchec.org, provide information on this specialty. • Center of Excellence for Training and Research Center; Large Family Child Care Home; Small TYPE OF FACILITY: Translation – http://www.center-trt.org. Family Child Care Home Center; Large Family Child Care Home; Small TYPE OF FACILITY: RELATED STANDARDS: Family Child Care Home Standard 2.1.1.3: Coordinated Child Care Health Program Model RELATED STANDARDS: Standard 2.1.1.8: Diversity in Enrollment and Curriculum Standard 2.1.1.3: Coordinated Child Care Health Program Model Section 2.1.2: Program Activities for Infants and Toddlers from Standard 3.1.3.1: Active Opportunities for Physical Activity Three to Less Than Thirty-Six Months Standard 4.5.0.4: Socialization During Meals Section 2.1.3: Program Activities for Three- to Five-Year-Olds Standard 4.5.0.8: Experience with Familiar and New Foods Section 2.1.4: Program Activities for School-Age Children Standard 4.7.0.1: Nutrition Learning Experiences for Children Section 2.4: Health Education Appendix S: Physical Activity: How Much Is Needed? REFERENCES: REFERENCES: 1. Colker L. J., A. L. Dombro, D. T. Dodge. 1996. Curriculum for 1. Fleer, M., ed. 1996. Play through profiles: Profiles through play . 112:74-78. Child Care Info Exch infants and toddlers: Who needs it? Watson, Australia: Australian Early Childhood Association. Child 2. Smith A. B. 1996. Quality programs that care and educate. 2. Evaldsson, A., W. A. Corsaro. 1998. Play and games in the peer Education 72:330-36. cultures of preschool and preadolescent children: An interpretative 3. Dimidjian, V. J., ed. 1992 . Play’s place in public education for Childhood 5:377-402. approach. . National Education Association Early Childhood young children Children and 3. Petersen, E. A. 1998. The amazing benefits of play. Education Series. Washington, DC: NEAECE. 17:7-8, 10. Families 4. The Family Child Care Accreditation Project, Wheelock College 4. National Association for Sport and Physical Education (NASPE). and The National Association for Family Child Care. 2005. Quality Active start: A statement of physical activity guidelines for 2009. standards for NAFCC accreditation . 4th ed. http://www.nafcc.org/ children birth to five years . 2nd ed. Reston, VA: NASPE. documents/QualStd.pdf. 5. U.S. Department of Health and Human Services, U.S. 5. National Child Care Information Center (NCCIC). NCCIC Dietary guidelines for Americans Department of Agriculture. 2010. . resources. U.S. Department of Health and Human Services, 7th ed. Washington, DC: Government Printing Office. http://www Administration for Children and Families. http://nccic.acf.hhs.gov/ .cnpp.usda.gov/Publications/DietaryGuidelines/2010/PolicyDoc/ nccic-resources/. PolicyDoc.pdf. 6. Nell, M. 2009. Using the integrative research approach to facilitate early childhood teacher planning. J Early Child Teach Edu STANDARD 2.1.1.3: Coordinated Child Care 30:79-88. Health Program Model STANDARD 2.1.1.2: Health, Nutrition, Physical Caregivers/teachers should follow these guidelines for Activity, and Safety Awareness implementing coordinated health programs in all early care and education settings. These coordinated health programs Early care and education programs should have and imple- should consist of health and safety education, physical ment written program plans addressing the health, nutri- activity and education, health services and child care health tion, physical activity, and safety aspects of each formally consultation, nutrition services, mental health services, structured activity documented in the written curriculum. healthy and safe indoor and outdoor learning environment, These plans should include daily opportunities to learn health and safety promotion for the staff, and family and health habits that prevent infection and significant injuries, community involvement. The guidelines consist of the fol- and health habits that support healthful eating, nutrition lowing eight interactive components: education, and physical motor activity. Awareness of healthy and safe behaviors, including good nutrition and physical 1. Health Education: A planned, sequential, curriculum that activity, should be an integral part of the overall program. addresses the physical, mental, emotional, and social di- mensions of health. The curriculum is designed to motivate Young children learn better through experienc- RATIONALE: and assist children in maintaining and improving their health, ing an activity and observing behavior than through didactic preventing disease and injury, and reducing health-related methods (1). There may be a reciprocal relationship between risk behaviors (1,2). learning and play so that play experiences are closely re- lated to learning (2,3). Children can live by rules about health 2. Physical Activity and Education: A planned, sequential and safety when their personal experience helps them to curriculum that provides learning experiences in a variety of 50 Chapter 2: Program Activities

81 Caring for Our Children: National Health and Safety Performance Standards care’s overall coordinated health program. This personal activity areas such as basic movement skills, physical fit- commitment often transfers into greater commitment to the ness, rhythms and dance, games, sports, tumbling, outdoor health of children and creates positive role modeling. Health learning and gymnastics. Quality physical activity and edu- promotion activities have improved productivity, decreased cation should promote, through a variety of planned physi- absenteeism, and reduced health insurance costs (1,2). cal activities indoors and outdoors, each child’s optimum physical, mental, emotional, and social development, and 8. Family and Community Involvement: An integrated child should promote activities and sports that all children enjoy care, parent/guardian, and community approach for enhanc- and can pursue throughout their lives (1,2,6). ing the health and safety, and well-being of children. Parent/ guardian-teacher health advisory councils, coalitions, and 3. Health Services and Child Care Health Consultants: broadly based constituencies for child care health can build Services provided for child care settings to assess, pro- support for child care health program efforts. Early care and tect, and promote health. These services are designed to education settings should actively solicit parent/guardian ensure access or referral to primary health care services or involvement and engage community resources and services both, foster appropriate use of primary health care services, to respond more effectively to the health-related needs of prevent and control communicable disease and other health children (1,2). problems, provide emergency care for illness or injury, promote and provide optimum sanitary conditions for a safe RATIONALE: Early care and education settings provide a child care facility and child care environment, and provide structure by which families, caregivers/teachers, administra- educational opportunities for promoting and maintaining tors, primary care providers, and communities can promote individual, family, and community health. Qualified profes- optimal health and well-being of children (3,4). The coordi- sionals such as child care health consultants may provide nated child care health program model was adapted from these services (1,2,4,5). the Center for Disease Control and Prevention (CDC) Divi- sion of Adolescent and School Health’s (DASH) Coordinated 4. Nutrition Services: Access to a variety of nutritious and School Health Program (CSHP) model (2). appealing meals that accommodate the health and nutrition needs of all children. School nutrition programs reflect the Center; Large Family Child Care Home; Small TYPE OF FACILITY: U.S. Dietary Guidelines for Americans and other criteria to Family Child Care Home achieve nutrition integrity. The school nutrition services offer REFERENCES: children a learning laboratory for nutrition and health educa- 1. Centers for Disease Control and Prevention. 2008. Healthy tion and serve as a resource for linkages with nutrition-relat- youth! Coordinates school health programs. http://www.cdc.gov/ ed community services (1,2). healthyyouth/CSHP/. 2. Cory, A. C. 2007. The role of the child care health consultant in 5. Mental Health Services: Services provided to improve promoting health literacy for children, families, and educators in children’s mental, emotional, and social health. These early care and education settings. Paper presented at the annual services include individual and group assessments, inter - meeting of the American School Health Association. ventions, and referrals. Organizational assessment and 13 indicators of quality child care: Research 3. Fiene, R. 2002. consultation skills of mental health professionals contribute update . Washington, DC: U.S. Department of Health and Human not only to the health of students but also to the health of Services, Office of the Assistant Secretary for Planning and the staff and child care environment (1,2). Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/. 4. U.S. Department of health and Human Services, Office of Child 6. Healthy Child Care Environment: The physical and Coordinating child care consultants: Combining Care. 2010. aesthetic surroundings and the psychosocial climate and multiple disciplines and improving quality in infant/toddler care culture of the child care setting. Factors that influence the http://nitcci.nccic.acf.hhs.gov/resources/consultation settings. physical environment include the building and the area _brief.pdf. surrounding it, natural spaces for outdoor learning, any 5. Coordinated Health/Care. Maximize your benefits: FAQs about biological or chemical agents that are detrimental to health, care coordination. https://www.cchcare.com/router indoor and outdoor air quality, and physical conditions such .php?action=about. 6. Friedman, H. S., L. R. Martin, J. S. Tucker, M. H. Criqui, M. L. as temperature, noise, and lighting. Unsafe physical envi- Kern, C. A. Reynolds. 2008. Stability of physical activity across the ronments include those such as where bookcases are not J Health Psychol lifespan. 13:1092-1104. attached to walls and doors that could pinch children’s fin- gers. The psychological environment includes the physical, STANDARD 2.1.1.4: Monitoring Children’s emotional, and social conditions that affect the well-being of Development/Obtaining Consent for children and staff (1,2). Screening 7. Health Promotion for the Staff: Opportunities for caregiv- ers/teachers to improve their own health status through ac- Child care settings provide daily indoor and outdoor op- tivities such as health assessments, health education, help portunities for promoting and monitoring children’s devel- in accessing immunizations, health-related fitness activi- opment. Caregivers/teachers should monitor the children’s ties, and time for staff to be outdoors. These opportunities development, share observations with parents/guardians, encourage caregivers/teachers to pursue a healthy lifestyle and provide resource information as needed for screenings, that contributes to their improved health status, improved evaluations, and early intervention and treatment. Care- morale, and a greater personal commitment to the child givers/teachers should work in collaboration to monitor a Chapter 2: Program Activities 51

82 Caring for Our Children: National Health and Safety Performance Standards and for making referrals for diagnostic assessment and child’s development with parents/guardians and in con- possible intervention for children who screen positive. All junction with the child’s primary care provider and health, programs should use methods of ongoing developmental education, mental health, and early intervention consultants. assessment that inform the curricular approaches used by Caregivers/teachers should utilize the services of health the staff. Care must be taken in communicating the results. and safety, education, mental health, and early intervention Screening is a way to identify a child of a develop- at risk consultants to strengthen their observation skills, collabo- mental delay or disorder. It is not a diagnosis. rate with families, and be knowledgeable of community resources. If the screening or any observation of the child results in any concern about the child’s development, after consultation Programs should have a formalized system of developmen- with the parents/guardians, the child should be referred to tal screening with all children that can be used near the be- his or her primary care provider (medical home), or to an ginning of a child’s placement in the program, at least yearly appropriate specialist or clinic for further evaluation. In some - thereafter, and as developmental concerns become appar situations, a direct referral to the Early Intervention System ent to staff and/or parents/guardians. The use of authentic in the respective state may also be required. assessment and curricular-based assessments should be an ongoing part of the services provided to all children (5-9). Seventy percent of children with developmen- RATIONALE: The facility’s formalized system should include a process tal disabilities and mental health problems are not identi- for determining when a health or developmental screening fied until school entry (10). Daily interaction with children or evaluation for a child is necessary. This process should and families in early care and education settings offers an include parental/guardian consent and participation. important opportunity for promoting children’s development as well as monitoring developmental milestones and early Parents/guardians should be explicitly invited to: signs of delay (1-3). Caregivers/teachers play an essential a) Discuss reasons for a health or developmental role in the early identification and treatment of children with assessment; developmental concerns and disabilities (6-8) because Participate in discussions of the results of their child’s b) of their knowledge in child development principles and evaluations and the relationship of their child’s needs milestones and relationship with families (4). Coordination to the caregivers’/teachers’ ability to serve that child of observation findings and services with children’s primary appropriately; care providers in collaboration with families will enhance c) Give alternative perspectives; children’s outcomes (6). d) Share their expectations and goals for their child and have these expectations and goals integrated with Parents/guardians need to be included in the COMMENTS: any plan for their child; process of considering, identifying and shaping decisions Explore community resources and supports that e) about their children, (e.g., adding, deleting, or changing a might assist in meeting any identified needs that service). To provide services effectively, facilities must rec- child care centers and family child care homes can ognize parents’/guardians’ observations and reports about provide; the child and their expectations for the child, as well as the f) Give written permission to share health information family’s need of child care services. A marked discrepancy with primary health care professionals (medical between professional and parent/guardian observations of, home), child care health consultants and other or expectations for, a child necessitates further discussion professionals as appropriate; and development of a consensus on a plan of action. The facility should document parents’/guardians’ presence Consideration should be given to utilizing parent/guardian- at these meetings and invitations to attend. completed screening tools, such as the Ages and Stages Questionnaire (ASQ) (for a list of validated developmental If the parents/guardians do not attend the screening, the screening tools, see the American Academy of Pediatric’s caregiver/teacher should inform the parents/guardians of [AAP] list of developmental screening tools at http://www the results, and offer an opportunity for discussion. Efforts .medicalhomeinfo.org/downloads/pdfs/DPIPscreeningtool should be made to provide notification of meetings in the grid.pdf). The caregiver/teacher should explain the results primary language of the parents/guardians. Formal evalu- to parents/guardians honestly, with sensitivity, and without ations of a child’s health or development should also be using technical jargon (11). shared with the child’s medical home with parent/guardian consent. Resources for implementing a program that involves a formalized system of developmental screening are available Programs are encouraged to utilize validated screening at the Centers for Disease Control and Prevention (CDC) at tools to monitor children’s development, as well as various http://www.cdc.gov/ncbddd/actearly/ and the AAP at http:// measures that may inform their work facilitating children’s www.healthychildcare.org. development and providing an enriching indoor and outdoor environment, such as authentic-based assessment, work Scheduling meetings at times convenient for parent/guard- sampling methods, observational assessments, and assess- ian participation is optimal. Those conducting an evaluation, ments intended to support curricular implementation (5,9). and when subsequently discussing the findings with the Programs should have clear policies for using reliable and family, should consider parents’/guardians’ input. Parents/ valid methods of developmental screening with all children 52 Chapter 2: Program Activities

83 Caring for Our Children: National Health and Safety Performance Standards a) Encouraging parents/guardians to spend time in the guardians have both the motive and the legal right to be facility with the child and supporting the separation included in decision-making and to seek other opinions. transition; A second, independent opinion could be provided by the b) Providing a comfortable setting both indoors and program’s child care health consultant or the child’s primary outdoors for parents/guardians to be with their care provider. children to transition or to have conversation with Center; Large Family Child Care Home; Small TYPE OF FACILITY: staff; Family Child Care Home Having established routines for drop-off and pick-up c) RELATED STANDARDS: times to assist with transition; Standard 1.3.2.5: Additional Qualifications for Caregivers/Teachers Enabling the child to bring to child care tangible d) Serving Children Three to Five Years of Age reminders of home/family (such as a favorite toy or a Standard 1.3.2.7: Qualifications and Responsibilities for Health picture of self and parent/guardian); Advocates Encouraging parents/guardians to reassure the child e) Standard 3.1.4.5: Conduct of Daily Health Check of their return and to calmly say “goodbye”; Standard 9.4.1.3: Written Policy on Confidentiality of Records f) Helping the child play out themes of separation and REFERENCES: reunion; Developmentally appropriate 1. Copple, C., S. Bredekamp. 2009. Frequently exchanging information between the g) practice in early childhood programs serving children at birth child’s parents/guardians and caregivers/teachers, . 3rd ed. Washington, DC: National Association for the through age 8 including activities and routine care information Education of Young Children. particularly during greeting and departing; 2. Dworkin, P. H. 1989. British and American recommendations Reassuring the child about the parent’s/guardian’s h) for developmental monitoring: The role of surveillance. Pediatrics return; 84:1000-1010. i) Ensuring the caregivers/teachers are consistent both 3. Brothers, K. l., F. Glascoe, N. Robertshaw. 2008. PEDS: Developmental milestones - An accurate brief tool for surveillance within the parts of a day and across days; Clinical Pediatrics and screening. 47:271-79. j) Requesting assistance from early childhood mental 4. Kostelnik, M. J., A. K. Soderman, A. P. Whiren. 2006. health consultants, mental health professionals, Developmentally appropriate curriculum best practices in early developmental-behavioral pediatricians, parent/ childhood education. Upper Saddle River, NJ: Prentice Hall. guardian counselors, etc. when a child’s adjustment 5. Squires, J., D. Bricker. 2009. Ages and stages questionnaires . continues to be problematic over time; Baltimore: Brookes Publishing. k) When a family is experiencing separation due to a 6. Centers for Disease Control and Prevention. Learn the signs. Act military deployment, explore changes in children’s early. http://www.cdc.gov/ncbddd/actearly/. behavior that may be related to feelings of anger, fear, 7. American Academy of Pediatrics, Council on Children With sadness, or uncertainty related to changes in family Disabilities, Section on Developmental Behavioral Pediatrics, Bright Futures Steering Committee and Medical Home Initiatives for structure as a result of deployment. Work with the Children With Special Needs Project Advisory Committee. 2006. parent/guardian at home to help the child adjust to Identifying infants and young children with developmental disorders these changes, including providing activities that help in the medical home: An alogorithm for developmental surveillance the child remain connected to the deployed parent/ 118:405-20. Pediatrics and screening. guardian and manage their emotions throughout the Bright 8. Hagan, J. F., J. S. Shaw, P. M. Duncan, eds. 2008. deployment cycle. futures: Guidelines for health supervision of infants, children, and 3rd ed. Elk Grove Village, IL: American Academy of adolescents. For the parents/guardians, this should be accomplished by: Pediatrics. a) Validating their feelings as a universal human 9. Gilliam, W. S., S. Meisels, L. Mayes. 2005. Screening and experience; surveillance in early intervention systems. In A developmental Providing parents/guardians with information about b) systems approach to early intervention: National and international the positive effects for children of high quality perspectives, ed. M. J. Guralnick, 73-98. Baltimore, MD: Brookes facilities with strong parent/guardian participation; Publishing. Encouraging parents/guardians to discuss their c) 10. Glascoe, F. P. 2005. Screening for developmental and behavioral feelings; problems. 11:173-79. Mental Retardation Develop Disabilities Providing parents/guardians with evidence, such as d) ASQ: Assessing school age child care 11. O’Connor, S., et al. 1996. quality . Wellesly, MA: Center for Research on Women. photographs, that their child is being cared for and is enjoying the activities of the facility; STANDARD 2.1.1.5: Helping Families Cope Ask parents/guardians to bring pictures from e) home that may be placed in the room or cubby with Separation and displayed throughout the indoor and outdoor The staff of the facility should engage strategies to help a learning/play environment at the child’s eye level; child and parents/guardians cope with the experience of f) Where a family is experiencing separation due to separation and reunion, such as death of family members, a military deployment, collaborate with the parent/ divorce, or placement in foster care. guardian at home to address changes in children’s For the child, this should be accomplished by: behavior that may be related to the deployment, Chapter 2: Program Activities 53

84 Caring for Our Children: National Health and Safety Performance Standards months of age is particularly vulnerable to separation issues providing parents/guardians with information about and may show visible distress when experiencing separation activities in care and at home may help promote from parents/guardians. Entry into child care at this age may their child’s positive adjustment throughout the trigger behavior problems, such as difficulty sleeping. Even deployment cycle (connect parents/guardians with for the child who has adapted well to a child care arrange- services/resources in the community that can help to ment before this developmental stage, such difficulties can support them); occur as the child continues in care and enters this devel- Requesting assistance from early childhood mental g) opmental stage. For younger children, who are working on health consultants, mental health professionals, understanding object permanence (usually around nine to developmental-behavioral pediatricians, parent/ twelve months of age), parents/guardians who sneak out af- guardian counselors, etc. when a child’s adjustment ter bringing their children to the child care facility may create continues to be problematic over time. some level of anxiety in the child throughout the day. Sneak- In childhood, some separation experiences fa- RATIONALE: ing away leaves the child unable to discern when someone cilitate psychological growth by mobilizing new approaches the child trusts will leave without warning. Parents/guardians for learning and adaptation. Other separations are painful and caregivers/teachers reminding a child that the parent/ and traumatic. The way in which influential adults provide guardian returned as promised reinforces truthfulness and support and understanding, or fail to do so, will shape the trust. Parents/guardians of children of any age should be child’s experience (1). encouraged to visit the facility together before the child care Many parents/guardians who prefer to care for their young officially begins. Parents/guardians of infants may benefit children only at home may have no other option than to from feeling assured by the caregivers/teachers themselves. place their children in out-of-home child care before three Depending on the child’s temperament and prior care expe- months of age. Some parents/guardians prefer combin- rience, several visits may be recommended before enrolling ing out-of-home child care with parental/guardian care to as well opportunities to practice the process and consisten- provide good experiences for their children and support for cy of a separation experience in the first weeks of entering other family members to function most effectively. Whether the child care. Using a phasing-in period can also be helpful parents/guardians view out-of-home child care as a neces- (e.g., spend only a part of the day with parents/guardians sary accommodation to undesired circumstances or a on the first day, half-day on the second day, and parents/ benefit for their family, parents/guardians and their children guardians leave earlier, etc.) need help from the caregivers/teachers to accommodate Center; Large Family Child Care Home; Small TYPE OF FACILITY: the transitions between home and out-of-home settings (2). Family Child Care Home Many parents/guardians experience distress at separation. RELATED STANDARDS: For most parents/guardians, the younger their child and Standard 1.1.2.1: Minimum Age to Enter Child Care the less experience they have had with sharing the care of Standard 1.6.0.3: Early Childhood Mental Health Consultants their children with others, the more intense their distress at Standard 2.3.1.1: Mutual Responsibility of Parents/Guardians and Staff separation (3). REFERENCES: Although children’s responses to deployment separation will 1. Blecher-Sass, H. 1997. Good-byes can build trust. Young Child vary depending on age, personality, and support received, 52:12-14. children will be aware of a parent’s/guardian’s long-term 2. Kim, A. M., J. Yeary. 2008. Making long-term separations easier absence and may mourn. Children may feel uncertain, sad, Young Children 63:32-37. for children and families. afraid, or angry. These feelings can manifest as increased 3. Gonzalez-Mena, J. 2007. Separation: Helping children clinginess, aggression, withdrawal, changes in sleeping 50 Early childhood strategies for working and and families. In or eating patterns, regression or other behaviors. Young 96-97. Upper Saddle River, communicating with diverse families, children don’t often have the vocabulary to express their NJ: Prentice Hall. emotions, and may need support to express their feelings in healthy and safe ways (2). Additionally, the parent/guardian STANDARD 2.1.1.6: Transitioning within at home may be experiencing stress, anxiety, depression, or Programs and Indoor and Outdoor Learning/ fear. These parents/guardians may benefit from additional Play Environments outreach from caregivers/teachers, who are part of their Caregivers/teachers should take into consideration the community support system, and can help them with strate- individual needs of children when transitioning them to a gies to promote children’s adjustment and connect them new indoor and outdoor learning/play environment. The with resources in the community (3). transitioning child/children should be offered the opportunity COMMENTS: Depending on the child’s developmental to visit the new space with a familiar caregiver/teacher with stage, the impact of separation on the child and parent/ enough time to allow them to display comfort in the new guardian will vary. Child care facilities should understand space. The program should allow time for communication and communicate this variation to parents/guardians and with the families regarding the process and for each child to work with parents/guardians to plan developmentally ap- follow through a comfortable time line of adaptation to the propriate coping strategies for use at home and in the child care setting. For example, a child at eighteen to twenty-four 54 Chapter 2: Program Activities

85 Caring for Our Children: National Health and Safety Performance Standards new indoor and outdoor learning/play environment, care- STANDARD 2.1.1.7: Communication in Native giver/teachers, and peers. Language Other Than English Children need time to manipulate, explore and familiarize At least one member of the staff should be able to commu- themselves with the new space and caregivers/teachers. nicate with the parents/guardians and children in the fam- This should be done before they are part of a new group ily’s native language (sign or spoken), or the facility should to allow them time to explore to their personal satisfaction. work with parents/guardians to arrange for a translator to Eating is a primary reinforcer and need. The opportunity to communicate with parents/guardians and children. Efforts share food within the new space will help reassure a child should be made to support a child’s and family’s native and help adults assess how the transition is going. Toileting language while providing resources and opportunities for involves another level of trust. Diapering/toileting should be learning English (2). Children should not be used as transla- introduced in the new space with a familiar teacher. tors. They are not developmentally able to understand the meaning of all words as used by adults, nor should they New routines should be introduced by the new staff with participate in all conversations that may be regarding the a familiar caregiver/teacher present to support the child/ child. children. Transitions to the indoor and outdoor learning/ play environment, especially if the space is different than RATIONALE: The future development of the child depends the one from which they are familiar, should follow similar on his/her command of language (1). Richness of language procedures as moving to another indoor space. Parents/ increases as a result of experiences as well as through the guardians should be part of the transition as they too are in child’s verbal interaction with adults and peers. Basic com- the process of learning to trust a new indoor and outdoor munication with parents/guardians and children requires learning/play environment for their child. Primary needs an ability to speak their language. Learning English while need to be met to support a smooth transition. maintaining a family’s native language enriches child devel- opment and strengthens family cultural traditions. Transitions should be planned in advance, based on the child’s readiness. A written plan should be developed and For resources on bilingual and dual language COMMENTS: shared with parents/guardians, describing how and when learning, see the American Academy of Pediatrics Section the transition will occur. Children should not be moved to a on Developmental and Behavioral Pediatrics (SODBP) at new indoor and outdoor learning/play environment for the http://www.aap.org/sections/dbpeds/. sole purpose of maintaining child: staff ratios. Center; Large Family Child Care Home; Small TYPE OF FACILITY: Supporting the achievement of developmen- RATIONALE: Family Child Care Home tal tasks for young children is essential for their social and REFERENCES: emotional health. Establishing trust with caregivers/teach- 1. Moerk, E. L. 2000. The guided acquisition of first language skills. ers and successful adaptation to a new indoor and outdoor Advances Applied Dev Psychol 20:248. learning/play environment is a critical component of quality 2. Olsen, L. 2006. Ensuring academic success of English learners. care. Young children need predictability and routine. They 2006. U.C. Linguistic Minority Research Institute 15:1-7. need to feel secure and to understand the expectations of their environment. By taking time to allow them to familiarize STANDARD 2.1.1.8: Diversity in Enrollment themselves with their new caregivers/teachers and environ- and Curriculum ment, they are better able to handle the emotional, cogni- Programs should work to increase understanding of cultural, tive, and social requirements of their new space (1-5). ethnic, and other similarities and differences by enrolling Center; Large Family Child Care Home; Small TYPE OF FACILITY: children who reflect the cultural and ethnic diversity of the Family Child Care Home community. Programs should provide cultural curricula RELATED STANDARDS: that engage children and families and teach multicultural Standard 2.1.2.5: Toilet Learning/Training learning activities. Indoor and outdoor learning/play environ- ments should have an array of toys, materials, posters, etc. REFERENCES: that reflect diverse cultures and ethnicities. Stereotyping of . New York: W.W. Childhood and society 1. Erikson, E. H. 1950. Norton and Co. any culture must be avoided. 2. Gorski, P. A., S. P. Berger. 2005. Emotional health in child care. RATIONALE: Children who participate in programs that Health in child care: A manual for health professionals In , ed. J. reflect and show respect for the cultural diversity of their R. Murph, S. D. Palmer, D. Glassy, 173-86. Elk Grove Village, IL: - communities learn to understand and value cultural diver American Academy of Pediatrics. sity. This learning in early childhood enables their healthy 3. Lally, R. L., L. Y. Torres, P. C. Phelps. 1994. Caring for infants and toddlers in groups: Necessary considerations for emotional, social, participation in a democratic pluralistic society (peaceful and cognitive development. 14:1-8. Zero to Three coexistence of different interests, convictions, and lifestyles) The Psychological birth of 4. Mahler, M., F. Pine, A. Bergman. 1975. throughout life (1-3,11,12). By facilitating the expression of the human infant . New York: Basic Books. cultural development or ethnic identity and by encouraging 5. Maslow, A. 1943. A theory of human motivation. Psychological familiarity with different groups and practices through ordi- 50:370-96 Review nary interaction and activities integrated into a developmen - tally appropriate curriculum, a facility can foster children’s Chapter 2: Program Activities 55

86 Caring for Our Children: National Health and Safety Performance Standards ability to relate to people who are different from themselves, STANDARD 2.1.1.9: Verbal Interaction their sense of possibility, and their ability to succeed in a The child care facility should assure that a rich environ- diverse society, while also promoting feelings of belonging ment of spoken language by caregivers/teachers surrounds and identification with a tradition. and includes all children with opportunities to expand their COMMENTS: Sharing information about the child on a language communication skills. Each child should have at daily basis with the children’s families shows respect for the least one speaking adult person who engages the child in children’s cultures by creating an opportunity to learn more frequent verbal exchanges linked to daily events and experi - about the families’ background, beliefs, and traditions (5-9). ences. To encourage the development of language, the Materials, displays, and learning activities must represent - caregiver/teacher should demonstrate skillful verbal com the cultural heritage of the children and the staff to instill a munication and interaction with the child. sense of pride and positive feelings of identification in all a) For infants, these interactions should include children and staff members (4). In order to enroll a diverse responses to, and encouragement of, soft infant group, the facility should market its services in a culturally sounds, as well as identifying objects, feelings, and sensitive way and should make sincere efforts to employ desires by the caregiver/teacher. staff members that represent the culture of the children and For toddlers, the interactions should include naming b) their families (10). Children need to see members of their of objects, feelings, listening to the child and own community in positions of influence in the services they responding, along with actions and supporting, but use. Scholarships and tuition assistance can be used to not forcing, the child to do the same. increase the diversity among enrolled children. For preschool and school-age children, interactions c) should include respectful listening and responses TYPE OF FACILITY: Center; Large Family Child Care Home; Small to what the child has to say, amplifying and Family Child Care Home clarifying the child’s intent, and not reinforcing REFERENCES: mispronunciations (e.g., Wambulance instead of 1. Wardle, F. 1998. Meeting the needs of multicultural and Ambulance). multiethnic children in early childhood settings. Early Child Frequent interchange of questions, comments, and d) 26:7-11. Education J responses to children, including extending children’s Teaching and learning in a diverse world: 2. Ramsey, P. G. 1998. . 2nd ed. New York: Multicultural education for young children utterances with a longer statement, by teaching staff. Teachers College Press. For children with special needs, alternative methods e) 3. Ramsey, P. G. 1995. Growing up with the contradictions of race of communication should be available, including but Young Child 50:18-22. and class. not limited to: sign language, assistive technology, 4. Maschinot, B. 2008. The changing face of the United States: The picture boards, picture exchange communication influence of culture on early child development . Washington, DC: systems (PECS), FM systems for hearing aids, etc. Zero to Three. http://www.zerotothree.org/site/DocServer/Culture Communication through methods other than verbal _book.pdf?docID=6921. communication can result in the same desired 5. Williams, K. C., M. H. Cooney. 2006. Young children and social outcomes. justice. 61:75-82. Young Children f) Profanity should not be used at any time. Diversity in early care and education: 6. Gonzalex-Mena, J. 2008. Honoring differences . 5th ed. Boston: McGraw-Hill. Conversation with adults is one of the main RATIONALE: 7. Gonzalez-Mena, J. 2007. 50 early childhood strategies for channels through which children learn about themselves, . Upper Saddle working and communicating with diverse families others, and the world in which they live. While adults River, NJ: Pearson Merrill Prentice Hall. speaking to children teaches the children facts and relays 8. Bradely, J., P. Kibera. 2006. Closing the gap: Culture and information, the social and emotional communications and promotion of inclusion in child care. Young Children 61:34-40. the atmosphere of the exchange are equally important. 9. Romero, M. 2008. Promoting tolerance and respect for diversity in early childhood: Toward a research and practice agenda. Report Reciprocity of expression, response, and the initiation and of the Promoting Tolerance and Respect for Diversity in Early enrichment of dialogue are hallmarks of the social function Childhood Meeting, Brooklyn, NY, June 25, 2007. http://www.nccp and significance of the conversations (1-4). .org/publications/pdf/text_812.pdf. The future development of the child depends on his/her 10. Matthews, H. 2008. Supporting a diverse and culturally command of language (5). Research suggests that language competent workforce: Charting progress for babies in child care. Charting Progress for Babies in Child Care: A CLASP Child Care experiences in a child’s early years have a profound influ- and Early Education Project, Washington, DC. http://www.clasp ence on that child’s language and vocabulary development, .org/babiesinchildcare/recommendations?id=0005. which in turn has an impact on future school success (6). 11. Parent Services Project (PSP). Making room in the circle. Richness of the child’s language increases as it is nurtured Training Curriculum, PSP, San Rafael, CA. by verbal interactions and learning experiences with adults 12. Fox, R. K. 2007. One of the hidden diversities in schools: and peers. Basic communication with parents/guardians Families with parents who are Lesbian or Gay. Childhood Education and children requires an ability to speak their language. Dis- 83:277-81. cussing the impact of actions on feelings for the child and others helps to develop empathy. 56 Chapter 2: Program Activities

87 Caring for Our Children: National Health and Safety Performance Standards Center; Large Family Child Care Home; Small TYPE OF FACILITY: unique to each child. This leads to a sense of trust of the Family Child Care Home adult by the infant that the infant’s needs will be understood and met promptly (5). Studies of infant behavior show that REFERENCES: infants have difficulty forming trusting relationships in set- 1. Mayr, T., M. Ulich. 1999. Children’s well-being in day care Int J Early Years Education centers: An exploratory empirical study. tings where many adults interact with a child, e.g., in hospi- 7:229-39. talization of infants when shifts of adults provide care (4,6). Children learning language: How 2. Baron, N., L. W. Schrank. 1997. This difficulty occurs even if each of the many adults is very . Lake Zurich, IL: Learning Seed. adults can help caring in their interaction with the child (7). There should be Creating child-centered programs 3. Szanton, E. S., ed. 1997. breaks at least every four hours and in accordance with U.S. for infants and toddlers, birth to 3 year olds, step by step: A Department of Labor laws. . New York: Children’s Resources Program for children and families International, Inc. Hugging, holding, and cuddling infants and COMMENTS: 4. Kontos, S., A. Wilcox-Herzog. 1997. Teachers’ interactions with children are expressions of wholesome love that should be Child 52:4-12. Young children: Why are they so important? encouraged. Caregivers/teachers should be advised that it 5. Moerk, E. L. 2000. The guided acquisition of first language skills. is alright to demonstrate affection for children of both sexes. Advances in Applied Dev Psychol 20:248. At all times, caregivers/teachers should respect the wishes Teaching and developing 6. Pikulski, J. J., Templeton, S. 2004. of children, regardless of their ages, with regard to physical Geneva, IL: vocabulary: Key to long-term reading success. contact and their comfort or discomfort with it. Caregiv- Houghton Mifflin Company. http://www.eduplace.com/state/author/ ers/teachers should avoid even “friendly contact” (such pik_temp.pdf. as touching the shoulder or arm) with a child if the child is uncomfortable with it. 2.1.2 Program Activities for Infants and Center; Large Family Child Care Home; Small TYPE OF FACILITY: Toddlers from Three Months to Less Family Child Care Home Than Thirty-Six Months REFERENCES: 1. Creyer, D., S. Hurwitz, M. Wolery. 2003. Continuity of caregiver STANDARD 2.1.2.1: Personal Caregiver/ for infants and toddlers. ERIC Clearinghouse on Elementary and Early Care Education. http://www.ericdigests.org/2004-3/ Teacher Relationships for Infants and Toddlers infants.html. The facility should practice a relationship-based philosophy 2. Theilheimer, R. 2006. Molding to the children: Primary caregiving that promotes consistency and continuity of caregivers/ 26:50-54. Zero to Three and continuity of care. teachers for infants and toddlers. The facility should limit the 3. Baron, N., L. W. Schrank. 1997. Children learning language: How number of caregivers/teachers who interact with any one adults can help . Lake Zurich, IL: Learning Seed. infant (1,2) to no more than five caregivers/teachers across 4. Botkin, D., et al. 1991. Children’s affectionate behavior: Gender 2:270-86. Early Education Dev differences. the period that the child is an infant in child care. The care- Handbook of attachment: 5. Cassidy J., Shaver, P., eds. 1999. giver/teacher should: , 671-87. 2nd ed. New Theory, research and clinical applications Hold and comfort children who are upset; a) York: Guilford Press. b) social Engage in frequent, multiple, and rich 6. Raikes, H. 1996. A secure base for babies: Applying attachment interchanges such as smiling, talking, touching, concepts to the infant care setting. Young Children 51:59-67. singing, and eating; 7. Lally, R. J. 2000. Infants have their own curriculum: A responsive Be play partners as well as protectors; c) approach to curriculum planning for infants and toddlers. U.S. Be attuned to children’s feelings and reflect them d) Department of Health and Human Services, Administration for back; Children and Families, Early Childhood Learning and Knowledge Communicate consistently with parents/guardians; e) Center. http://eclkc.ohs.acf.hhs.gov/hslc/tta-system/teaching/ eecd/Curriculum/Definition and Requirements/edudev_ f) Interact with children and develop a relationship in art_00032_071005.html. the context of everyday routines (diapering, feeding, etc.) STANDARD 2.1.2.2: Interactions with Infants Opportunities should be provided for each child to develop and Toddlers a personal and affectionate relationship with, and attach- ment to, that child’s parents/guardians and one or a small Caregivers/teachers should provide consistent, continuous number of caregivers/teachers whose care for and respon- and inviting opportunities to talk, listen to, and otherwise siveness to the child ensure relief of distress, experiences of interact with young infants throughout the day (indoors and comfort and stimulation, and satisfaction of the need for a outdoors) including feeding, changing, playing with, and personal relationship. cuddling them. RATIONALE: Trustworthy adults who give of themselves as Richness of language increases by nurtur - RATIONALE: they provide care and learning experiences play a key role ing it through verbal interactions between the child and in a child’s development as an active, self-knowing, self-re- adults and peers. Adults’ speech is one of the main chan- specting, thinking, feeling, and loving person (3,6). Limiting nels through which children learn about themselves, others, the number of adults with whom an infant interacts fosters and the world in which they live. While adults speaking to reciprocal understanding of communication cues that are children teach the children facts, the social and emotional Chapter 2: Program Activities 57

88 Caring for Our Children: National Health and Safety Performance Standards door play and learning settings should provide opportunities communications and the atmosphere of the exchange are for the child to act upon the environment by experiencing equally important. Reciprocity of expression, response, the age-appropriate obstacles, frustrations, and risks in order initiation and enrichment of dialogue are hallmarks of the to learn to negotiate environmental challenges. The facility social function and significance of the conversations (2-5). should provide opportunities for play that: Infants and toddlers learn through meaningful relationships a) Lessen the child’s anxiety and help the child adapt to and interaction with consistent adults and peers. reality and resolve conflicts; The future development of the child depends on his/her b) Enable the child to explore and experience the command of language (1). Richness of language increases natural world; as it is nurtured by verbal interactions of the child with Help the child practice resolving conflicts; c) adults and peers. Basic communication with parents/guard- Use symbols (words, numbers, etc.); d) ians and children requires an ability to speak their language. Manipulate objects; e) A language-rich environment and warm, responsive interac- f) Exercise physical skills; tions between staff and children are among the elements g) Encourage language development; that produce positive impacts (6). h) Foster self-expression; COMMENTS: Live, real-time interaction with caregivers/ i) Strengthen the child’s identity as a member of a teachers is preferred. For example, caregivers/teachers family and a cultural community; naming objects in the indoor and outdoor learning/play envi- j) Promote sensory exploration. ronment or singing rhymes to all children supports language For infants and toddlers the curriculum should be based development. Children’s stories and poems presented on on the child’s development at the time and connected to a recordings with a fixed speed for sing-along can actually sound understanding as to where they are in their develop- interfere with a child’s ability to participate in the singing or mental course. recitation. With fixed-speed activities, the pace may be too Opportunities to be an active learner are vitally RATIONALE: fast for some children, and the activity may have to be re- important for the development of motor competence and peated for some children or the caregiver/teacher will need awareness of one’s own body and person, the development to try a different method for learning. - of sensory motor skills, the ability to demonstrate initia Center; Large Family Child Care Home; Small TYPE OF FACILITY: tive through active outdoor and indoor play, and feelings of Family Child Care Home mastery and successful coping. Coping involves original, RELATED STANDARDS: imaginative, and innovative behavior as well as previously Standard 2.2.0.3: Limiting Screen Time – Media, Computer Time learned strategies. REFERENCES: Learning to resolve conflicts constructively in childhood is 1. Moerk, E. L. 2000. The guided acquisition of first language skills. essential in preventing violence later in life (1,2). A physical 20:248. Advances Applied Dev Psychol and social environment that offers opportunities for active Children learning language: How 2. Baron, N., L. W. Schrank. 1997. mastery and coping enhances the child’s adaptive abili- . Lake Zurich, Ill: Learning Seed. adults can help 3. Szanton, E. S., ed. 1997. Creating child-centered programs ties (3,4,9). The importance of play for developing cognitive for infants and toddlers, birth to 3 year olds, step by step: A skills, for maintaining an affective and intellectual equilib- Program for children and families . New York: Children’s Resources rium, and for creating and testing new capacities is well International. recognized (8). Play involves a balance of action and sym- 4. Kontos, S., A. Wilcox-Herzog. 1997. Teachers’ interactions with bolization, and of feeling and thinking (5-7). Children need 52:4-12. Young Child children: Why are they so important? access to age-appropriate toys and safe household objects. 5. Snow, C. E., M. S. Burns, P. Griffin. 1999. Language and literacy environments in preschools. (January). ERIC Digest COMMENTS: For more information regarding appropriate 6. National Forum on Early Childhood Program Evaluation, National play materials for young children, see “Which Toy for Which A science- Scientific Council on the Developing Child. 2007. Child: A Consumer’s Guide for Selecting Suitable Toys” from based framework for early childhood policy: Using evidence to the U.S. Consumer Product Safety Commission (CPSC) improve outcomes in learning, behavior, and health for vulnerable and “The Right Stuff for Children Birth to 8: Selecting Play children . Cambridge, MA: Center on the Developing Child, Harvard Materials to Support Development” from the National As- University. http://developingchild.harvard.edu/index.php/library/ sociation for the Education of Young Children (NAEYC). For reports_and_working_papers/policy_framework/. information regarding appropriate materials for outdoor play, see POEMS: Preschool Outdoor Environment Measurement STANDARD 2.1.2.3: Space and Activity to Scale (10). Support Learning of Infants and Toddlers Center; Large Family Child Care Home; Small TYPE OF FACILITY: The facility should provide a safe and clean learning envi- Family Child Care Home ronment, both indoors and outdoors, colorful materials and RELATED STANDARDS: equipment arranged to support learning. The indoor and Standard 3.1.3.1: Active Opportunities for Physical Activity outdoor learning/play environment should encourage and Standard 5.1.2.1: Space Required Per Child be comfortable with staff on the floor level when interacting Standard 5.2.9.14: Shoes in Infant Play Areas - with active infant crawlers and toddlers. The indoor and out Standard 5.3.1.1: Safety of Equipment, Materials, and Furnishings 58 Chapter 2: Program Activities

89 Caring for Our Children: National Health and Safety Performance Standards Standard 5.3.1.5: Placement of Equipment and Furnishings Groups of younger infants should receive care in closed Chapter 6: Play Areas/Playgrounds and Transportation room(s) that separates them from other groups of toddlers and older children. REFERENCES: ERIC 1. Massey, M. S. 1998. Early childhood violence prevention. When partitions are used, they must control interaction be- (October). Digest tween groups, provide separated ventilation of the spaces Teaching young children in violent times: 2. Levin, D. E. 1994. and control sound transmission. The acoustic controls Building a peaceable classroom, A preschool-grade 3 violence should limit significant transmission of sound from one prevention and conflict resolution guide . Cambridge, MA: Educators group’s activity into other group environments. for Social Responsibility. 3. Mayr, T., M. Ulich. 1999. Children’s well-being in day care RATIONALE: Infants need quiet, calm environments, away Int J Early Years Education centers: An exploratory empirical study. from the stimulation of older children. Younger infants 7:229-39. should be cared for in rooms separate from the more bois- 4. Cartwright, S. 1998. Group trips: An invitation to cooperative terous toddlers. In addition to these developmental needs 124:95-97. Child Care Infor Exch learning. of infants, separation is important for reasons of disease 5. Evaldsson, A., W. A. Corsaro. 1998. Play and games in the peer prevention. Rates of hospitalization for all forms of acute cultures of preschool and preadolescent children: An interpretative infectious respiratory tract diseases are highest during 5:377-402. Childhood approach. 6. Petersen, E. A. 1998. The amazing benefits of play. Child Family the first year of life, indicating that respiratory tract illness 17:7-8. becomes less severe as the child gets older (1). Therefore, 7. Pica, R. 1997. Beyond physical development: Why young infants should be a focus for interventions to reduce the 52:4-11. Young Child children need to move. incidence of respiratory tract diseases. Handwashing and Play in the early years: Key to school 8. Tepperman, J., ed. 2007. sanitizing practices are key. . El Cerrito, CA: Early Childhood Funders. success, a policy brief Depending on the temperament of the child, an increase http://www.4children.org/images/pdf/play07.pdf. 9. Torelli, L., C. Durrett. 1996. Landscape for learning: The impact of in transitions can increase anxiety in young children by Early Childhood News 8 classroom design on infants and toddlers. reducing the opportunity for routine and predictability (2), (March-April): 12-17. http://www.spacesforchildren.com/landc1.pdf. and it increases basic health and safety concerns of cross 10. DeBord, K., L. Hestenes, R. Moore, N. Cosco, J. McGinnis. contamination with older children who have more contact 2005. Preschool outdoor environment measurement scale . with the environment. Lewisville, NC: Kaplan Early Learning Co. COMMENTS: This separation of younger children from older children ideally should be implemented in all facilities, STANDARD 2.1.2.4: Separation of Infants and but may be less feasible in small or large family child care Toddlers from Older Children homes. Infants and toddlers younger than three years of age should Separation of groups of children by low partitions that divide be cared for in a closed room(s) that separates them from a single common space is not acceptable. Without sound older children, except in small family child care homes with attenuation, limitation of shared air pollutants including closed groups of mixed aged children. airborne infectious disease agents, or control of interactions In facilities caring for three or more children younger than - among the caregivers/teachers who are working with differ three years of age, activities that bring children younger than ent groups, the separate smaller groups are essentially one three years of age in contact with older children should be large group. prohibited, unless the younger children already have regular TYPE OF FACILITY: Center contact with the older children as part of a group. RELATED STANDARDS: Pooling, as a practice in larger settings where the infants/ Standard 3.2.2.2: Handwashing Procedure toddlers are not part of the group all day – as in home care – Chapter 7: Infectious Disease should be avoided for the following reasons: Appendix J: Selecting an Appropriate Sanitizer or Disinfectant a) Unfamiliarity with caregivers/teachers if not the - Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disin primary one during the day; fecting Concerns of noise levels, space ratios, social- b) REFERENCES: emotional well-being, etc.; 1. Izurieta, H. S., W. W. Thompson, P. Kramarz, et al. 2000. Influenza c) Occurs at times when children are least able to and the rates of hospitalization for respiratory disease among handle transitions; infants and young children. 342:232-39. New England J Med d) Increases the number of transitions for children, (August/ 2. Poole, C. 1998. Routine matters. Scholastic Parent Child September). e) Increases the number of adults caring for infants and toddlers, a practice to be avoided if possible. STANDARD 2.1.2.5: Toilet Learning/Training Caregivers/teachers of infants should not be responsible for The facility should develop and implement a plan that the care of older children who are not a part of the infants’ teaches each child how and when to use the toilet. Toilet closed child care group. learning/training, when initiated, should follow a prescribed, sequential plan that is developed and coordinated with the Chapter 2: Program Activities 59

90 Caring for Our Children: National Health and Safety Performance Standards tion and urinary tract problems (4). Also, unless reminded, parent’s/guardian’s plan for implementation in the home many children forget to correctly wash their hands after environment. Toilet learning/training should be based on the toileting. child’s developmental level rather than chronological age. COMMENTS: The area of toilet learning/training for children To help children achieve bowel and bladder control, caregiv- with special health care needs is difficult because there are ers/teachers should enable children to take an active role in no age-related, disability-specific rules to follow. As a result, using the toilet when they are physically able to do so and support and counseling for parents/guardians and caregiv- when parents/guardians support their children’s learning to ers/teachers are required to help them deal with this issue. use the toilet. Some children with multiple disabilities do not demonstrate Diapering/toilet training should not be used as rationale for any requisite skills other than being dry for a few hours. not spending time outdoors. Practices and policies should Establishing a toilet routine may be the first step toward be offered to address diapering/toileting needs outdoors learning to use the toilet, and at the same time, improv- such as providing staff who can address children’s needs, or ing hygiene and skin care. The child care health consultant - provide outdoor diapering and toileting that meets all sanita should be considered a resource to assist is supporting tion requirements. special health care needs. Caregivers/teachers should take into account the prefer - Sometimes children need to increase their fluid intake to ences and customs of the child’s family. help a medical condition and this can lead to increased uri- For children who have not yet learned to use the toilet, the nation. Other conditions can lead to loose stools. Children facility should defer toilet learning/training until the child’s should be given unrestricted access to toileting facilities, family is ready to support this learning and the child demon- especially in these situations. Children who are recovering strates: from gastrointestinal illness might temporarily lose conti- a) An understanding of the concept of cause and effect; nence, especially if they are recently toilet trained, and may b) An ability to communicate, including sign language; need to revert to diapers or training pants for a short period c) The physical ability to remain dry for up to two hours; of time. Children who are experiencing stress (e.g., a new An ability to sit on the toilet, to feel/understand the d) infant in the family) may regress and also return to using sense of elimination; diapers for a period of time. A demonstrated interest in autonomous behavior. e) For more information on toilet learning/training, see “Toilet For preschool and school-age children, an emphasis should Training: Guidelines for Parents,” available from the Ameri- be placed on appropriate handwashing after using the toilet can Academy of Pediatrics (AAP) at http://www.aap.org and and they should be provided frequent and unrestricted op- the AAP Section on Developmental and Behavioral Pediat- portunities to use the toilet. rics at http://www.aap.org/sections/dbpeds/. Children with special health care needs may require specific Center; Large Family Child Care Home; Small TYPE OF FACILITY: instructions, training techniques, adapted toilets, and/ Family Child Care Home or supports or precautions. Some children will need to be RELATED STANDARDS: taught special techniques like catheterization or care of - Standard 3.2.1.5: Procedure for Changing Children’s Soiled Under ostomies. This can be provided by trained staff or older wear/Pull-Ups and Clothing children can sometimes learn self-care techniques. Any Standards 5.4.1.1-5.4.1.7: Toilets and Toilet Learning/Training Equipment special techniques should be documented in a written care Standards 5.4.1.8-5.4.1.9: Sanitation, Disinfection, and Mainte- plan. The child care health consultant can provide training nance of Toilet Learning/Training Equipment, Toilets, and Bathrooms or coordinate resources necessary to accommodate special toileting techniques while in child care. REFERENCES: 1. Mayo Clinic. 2009. Potty training: How to get the job done. http:// Cultural expectations of toilet learning/training need to be www.mayoclinic.com/health/potty-training/CC00060/. recognized and respected. 2. American Academy of Pediatrics. 2009. When is the right time to start toilet training? http://www.aap.org/publiced/BR A child’s achievements of motor and cognitive RATIONALE: _ToiletTrain.htm. or developmental skills assist in determining when s/he is 3. Anthony-Pillai, R. 2007. What’s potty about early toilet training? ready for toilet learning/training (1). Physical ability/neuro- British Med J 334:1166. logical function also includes the ability to sit on the toilet 4. Schmitt, B. D. 2004. Toilet training problems: Underachievers, and to feel/understand the sense of elimination. refusers, and stool holders. Contemporary Pediatrics 21:71-77. Toilet learning/training is achieved more rapidly once expec- tations from adults across environments are consistent (3). The family may not be prepared, at the time, to extend this learning/training into the home environment (2). School-age and preschool children may not respond when their bodies signal a need to use the toilet because they are involved in activities or embarrassed about needing to use the toilet. Holding back stool or urine can lead to constipa - Chapter 2: Program Activities 60

91 Caring for Our Children: National Health and Safety Performance Standards reorder, to make mistakes and find solutions, and to move 2.1.3 Program Activities for Three- to from the concrete to the abstract in learning. Five-Year-Olds The most meaningful learning has its source in RATIONALE: the child’s self-initiated activities. The learning environment STANDARD 2.1.3.1: Personal Caregiver/ that supports individual differences, learning styles, abili- Teacher Relationships for Three- to Five-Year- ties, and cultural values fosters confidence and curiosity in Olds learners (1,2). Facilities should provide opportunities for each child to build Center; Large Family Child Care Home; Small TYPE OF FACILITY: long-term, trusting relationships with a few caring caregiv- Family Child Care Home ers/teachers by limiting the number of adults the facility REFERENCES: permits to care for any one child in child care to a maxi- 1. Rodd, J. 1996. Understanding young children’s behavior: A guide mum of eight adults in a given year and no more than three for early childhood professionals . New York: Teacher’s College primary caregivers/teachers in a day. Children with special Press. health care needs may require additional specialists to 2. Ritchie, S., B. Willer. 2008. Teaching: A guide to the NAEYC early promote health and safety and to support learning; however, Washington, childhood standard and related accreditation criteria. relationships with primary caregivers/teachers should be DC: National Association for the Education of Young Children. supported. STANDARD 2.1.3.3: Selection of Equipment for RATIONALE: Children learn best from adults who know and Three- to Five-Year-Olds respect them; who act as guides, facilitators, and support- ers within a rich learning environment; and with whom they The program should select, for both indoor and outdoor play have established a trusting relationship (1,2). When the facil- and learning, developmentally appropriate equipment and ity allows too many adults to be involved in the child’s care, materials, for safety, for its ability to provide large and small the child does not develop a reciprocal, sustained, respon- motor experiences, and for its adaptability to serve many sive, and trusting relationship with any of them. different ideas, functions, and forms of creative expression. Children should have continuous friendly and trusting RATIONALE: An aesthetic, orderly, appropriately stimulat- relationships with several caregivers/teachers who are ing, child-oriented indoor and outdoor learning/play environ- reasonably consistent within the child care facility. Young ment contributes to the preschooler’s sense of well-being children can extract from these relationships a sense of and control (1,2,4,5). themselves with a capacity for forming trusting relationships “Play and learning settings that motivate chil- COMMENTS: and self-esteem. Relationships are fragmented by rapid staff dren to be physically active include pathways, trails, lawns, turnover, staffing reassignment, or if the child is frequently loose parts, anchored playground equipment, and layouts moved from one room to another or one child care facility to - that stimulate all forms of active play” (3). If traditional play another. ground equipment is used, caregivers/teachers may want COMMENTS: Compliance should be measured by staff to consult with an early childhood specialist or a certified and parent/guardian interviews. Turnover of staff lowers playground inspector for recommendations on develop- the quality of the facility. High quality facilities maintain low mentally appropriate play equipment. For more information turnover through their wage policies, training and support on play equipment also contact the National Program for for staff (3). Playground Safety (http://www.uni.edu/playground/). TYPE OF FACILITY: Center; Large Family Child Care Home; Small TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home Family Child Care Home REFERENCES: RELATED STANDARDS: Understanding young children’s behavior: A guide 1. Rodd, J. 1996. Standard 5.2.9.9: Plastic Containers and Toys for early childhood professionals . New York: Teacher’s College Standard 5.2.9.12: Treatment of CCA Pressure-Treated Wood Press. Chapter 6: Play Areas/Playgrounds and Transportation Character development: Encouraging self- 2. Greenberg, P. 1991. REFERENCES: . esteem and self-discipline in infants, toddlers, and two-year-olds 1. Torelli, L., C. Durrett. 1996. Landscape for learning: The impact Washington, DC: National Association for the Education of Young of classroom design on infants and toddlers. Early Child News Children. 8:12-17. Taking on turnover: An action 3. Whitebook, M., D. Bellm. 1998. 2. Center for Environmental Health. The safe playgrounds project. . Washington, DC: guide for child care center teachers and directors http://www.safe2play.org. Center for the Child Care Workforce. 3. DeBord, K., L. Hestenes, R. Moore, N. Cosco, J. McGinnis. 2005. Preschool outdoor environment measurement scale . Lewisville, NC: STANDARD 2.1.3.2: Opportunities for Learning Kaplan Early Learning Co. for Three- to Five-Year-Olds St. 4. Banning, W., G. Sullivan. 2009. Lens on outdoor learning. Paul, MN: Red Leaf Press. Programs should provide children a balance of guided and 5. Keeler, R. 2008. Natural playscapes: Creating outdoor play self-initiated play and learning indoors and outdoors. These environments for the soul . Redmond, WA: Exchange Press. should include opportunities to observe, explore, order and Chapter 2: Program Activities 61

92 Caring for Our Children: National Health and Safety Performance Standards Speaking with children rather than at them; a) STANDARD 2.1.3.4: Expressive Activities for b) Encouraging children to talk with each other by Three- to Five-Year-Olds helping them to listen and respond; Caregivers/teachers should encourage and enhance expres- Giving children models of verbal expression; c) sive activities that include play, painting, drawing, storytell- Reading books about the child’s culture and history, d) ing, sensory play, music, singing, dancing, and dramatic which would serve to help the child develop a sense play. of self; e) Reading to children and re-reading their favorite RATIONALE: Expressive activities are vehicles for socializa- books; tion, conflict resolution, and language development. They f) Listening respectfully when children speak; are vital energizers and organizers for cognitive develop- Encouraging interactive storytelling; g) ment (2). Stifling the preschooler’s need to play damages a h) Using open-ended questions; natural integration of thinking and feeling (1). i) Provide opportunities during indoor and outdoor Center; Large Family Child Care Home; Small TYPE OF FACILITY: learning/play to use writing supplies and printed Family Child Care Home materials; REFERENCES: j) Provide and read books relevant to their natural 1. Cooney, M., L. Hutchinson, V. Costigan. 1996. From hitting to environment outdoors (for example, books about the tattling to communication and negotiation: The young child’s stages current season, local wildlife, etc.); of socialization. Early Child Education J 24:23-27. Provide settings that encourage children to observe k) Play in the early years: Key to school 2. Tepperman, J., ed. 2007. nature, such as a butterfly garden, bird watching success, a policy brief . El Cerrito, CA: Early Childhood Funders. station, etc.; http://www.4children.org/images/pdf/play07.pdf. l) Providing opportunities to explore writing, such as through a writing area or individual journals. STANDARD 2.1.3.5: Fostering Cooperation of Three- to Five-Year-Olds - Language reflects and shapes thinking. A cur RATIONALE: riculum created to match preschoolers’ needs and interests Programs should foster a cooperative rather than a com- enhances language skills. First-hand experiences encourage petitive indoor and outdoor learning/play environment. children to talk with each other and with adults, to seek, RATIONALE: As three-, four-, and five-year-olds play and develop, and use increasingly more complex vocabulary, work together, they shift from almost total dependence on and to use language to express thinking, feeling, and curios- the adult to seeking social opportunities with peers that ity (1-3). still require adult monitoring and guidance. The rules and Compliance with development should be COMMENTS: responsibilities of a well-functioning group help children measured by structured observation. Examples of verbal of this age to internalize impulse control and to become encouragement of verbal expression are: “ask Johnny if increasingly responsible for managing their behavior. A dy- you may play with him”; “tell him you don’t like being hit”; namic curriculum designed to include the ideas and values “tell Sara what you saw downtown yesterday;” “can you tell of a broad socioeconomic group of children will promote Mommy about what you and Johnny played this morn- socialization. The inevitable clashes and disagreements are ing?” These encouraging statements should be followed by more easily resolved when there is a positive influence of respectful listening, without pressuring the child to speak. the group on each child (1). Center; Large Family Child Care Home; Small TYPE OF FACILITY: COMMENTS: Encouraging communication skills and at- Family Child Care Home tentiveness to the needs of individuals and the group as a RELATED STANDARDS: whole supports a cooperative atmosphere. Adults need to Standard 2.3.2.3: Support Services for Parents/Guardians model cooperation. REFERENCES: Center; Large Family Child Care Home; Small TYPE OF FACILITY: 1. Szanton, E. S., ed. 1997. Creating child-centered programs Family Child Care Home for infants and toddlers, birth to 3 year olds, step by step: A REFERENCES: . New York: Children’s Resources Program for children and families 1. Pica, R. 1997. Beyond physical development: Why young International. children need to move. Young Child 52:4-11. 2. Snow, C. E., M. S. Burns, P. Griffin. 1999. Language and literacy (January). ERIC Digest environments in preschools. STANDARD 2.1.3.6: Fostering Language The changing face of the United States: The 3. Maschinot, B. 2008. . Washington, DC: influence of culture on early child development Development of Three- to Five-Year-Olds Zero to Three. http://www.zerotothree.org/site/DocServer/Culture The indoor and outdoor learning/play environment should _book.pdf?docID=6921. be rich in first-hand experiences that offer opportunities for language development. They should also have an abun- STANDARD 2.1.3.7: Body Mastery for Three- dance of books of fantasy, fiction, and nonfiction, and pro- to Five-Year-Olds vide chances for the children to relate stories. Caregivers/ The caregivers/teachers should offer children opportuni- teachers should foster language development by: ties, indoors and outdoors, to learn about their bodies and 62 Chapter 2: Program Activities

93 Caring for Our Children: National Health and Safety Performance Standards a) Free choice of play; how their bodies function in the context of socializing with b) Opportunities, both indoors and outdoors, for others. Caregivers/teachers should support the children in vigorous physical activity which engages each child their curiosity and body mastery, consistent with parental/ daily for at least sixty minutes and are not limited to guardian expectations and cultural preferences. Body mas- opportunities to develop physical fitness through a tery includes feeding oneself, learning how to use the toilet, program of focused activity that only engages some running, skipping, climbing, balancing, playing with peers, of the children in the group; displaying affection, and using and manipulating objects. c) Opportunities for concentration, alone or in a group, Achieving the pleasure and gratification of RATIONALE: indoors and/or outdoors; feeling physically competent on a voluntary basis is a basic d) Time to read or do homework, indoors and/or component of developing self-esteem and the ability to outdoors; socialize with adults and other children inside and outside Opportunities to be creative, to explore the arts, e) the family (1-5). sciences, and social studies, and to solve problems, Self-stimulatory behaviors, such as thumb COMMENTS: indoors and/or outdoors; sucking or masturbation, should be ignored. If the mastur - f) Opportunities for community service experience bation is excessive, interferes with other activities, or is no- (museums, library, leadership development, elderly ticed by other children, the caregiver/teacher should make a citizen homes, etc.); brief non-judgmental comment that touching of private body Opportunities for adult-supervised skill-building g) parts is normal, but is usually done in a private place (7,8). and self-development groups, such as scouts, After making such a comment, the caregiver/teacher should team sports, and club activities (as transportation, offer friendly assistance in going on to other activities. distance, and parental permission allow); These behaviors may be signs of stress in the child’s life, or h) Opportunities to rest; simply a habit. If the child’s sexual play is more explicit or i) Opportunities to seek comfort, consolation, and forceful toward other children or the child witnessed or was understanding from adult caregivers/teachers; exposed to adult sexuality, the caregiver/teacher may need j) Opportunities for exercise and exploration out of to consider that abuse is possible (6). doors. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Programs organized for older children after RATIONALE: Family Child Care Home school or during vacation time should provide indoor and REFERENCES: outdoor learning/play environments that meet the needs of 1. Botkin, D., et al. 1991. Children’s affectionate behavior: Gender these children for physical activity, recreation, responsible Early Education Dev 2:270-86. differences. completion of school work, expanding their interests, learn- 2. Mayr, T., M. Ulich. 1999. Children’s well-being in day care ing cultural sensitivity, exploring community resources, and Int J Early Years Education centers: An exploratory empirical study. practicing pro-social skills (1,2). 7:229-39. COMMENTS: For more information on school-age stan- 3. Cartwright, S. 1998. Group trips: An invitation to cooperative Child Care Infor Exch 124:95-97. learning. dards, see [ The NAA Standards for Quality School-Age Understanding young children’s behavior: A guide 4. Rodd, J. 1996. Care, ] available from the National AfterSchool Association . New York: Teacher’s College for early childhood professionals (NAA). Press. Center; Large Family Child Care Home; Small TYPE OF FACILITY: 5. Cooney, M., L. Hutchinson, V. Costigan. 1996. From hitting to Family Child Care Home tattling to communication and negotiation: The young child’s stages 24:23-27. Early Child Education J of socialization. RELATED STANDARDS: 6. Kellogg, N., American Academy of Pediatrics Committee on Child Standard 3.1.3.1: Active Opportunities for Physical Activity Abuse and Neglect. 2005. Clinical report: The evaluation of sexual REFERENCES: 116:506-12. Pediatrics abuse in children. ERIC 1. Coltin, L. 1999. Enriching children’s out-of-school time. Understanding children’s sexual behaviors: 7. Johnson, T. C. 2007. Digest (May). What’s natural and healthy . San Diego: Institute on Violence, Abuse 2. Fashola, O. S. 1999. Implementing effective after-school and Trauma. Here’s How 17:1-4 programs. 8. Friedrich, W. N., J. Fisher, D. Broughton, M. Houston, C. R. Shafran. 1998. Normative sexual behavior in children: A STANDARD 2.1.4.2: Space for School-Age 101: e9. contemporary sample. Pediatrics Activity 2.1.4 Program Activities for School- The facility should provide a space for indoor and outdoor activities for children in school-age child care. Age Children RATIONALE: A safe and secure environment that fosters STANDARD 2.1.4.1: Supervised School-Age the growing independence of school-age children is es- Activities sential for their development (1,2). Active connection with nature promotes children’s sensitivity, confidence, explora- The facility should have a program of supervised activities tion, and self-regulation. designed especially for school-age children, to include: Chapter 2: Program Activities 63

94 Caring for Our Children: National Health and Safety Performance Standards REFERENCES: Center; Large Family Child Care Home; Small TYPE OF FACILITY: 1. Taras, H. L. 2005. School-aged child care. In Health in child care: Family Child Care Home A manual for health professionals, ed. J. R. Murph, S. D. Palmer, D. RELATED STANDARDS: Glassy, 411-21. 4th ed. Elk Grove Village, IL: American Academy of Chapter 6: Playgrounds/Play Areas and Transportation Pediatrics. REFERENCES: 1. Greenspan, S. L. 1997. Building children’s minds: Early childhood STANDARD 2.1.4.6: Communication Between development for a better future. Our Child 23:6-10. Child Care and School 2. Maxwell, L. E. 1996. Designing early childhood education environments: A partnership between architect and educator. Facilities that accept school-age children directly from 33:15-17. Education Facility Planner school should arrange a system of communication with the child’s school teacher. Families should be included in this STANDARD 2.1.4.3: Developing Relationships communication loop. for School-Age Children RATIONALE: Activities and experiences that occurred The facility should offer opportunities to school-age children during the school day may be important in anticipating and for developing trusting, supportive relationships with the understanding children’s after-school behavior (1). The con- staff and with peers. nection between children’s learning at school experience and their out-of-school activities is important (1). RATIONALE: Although school-age children need more in- dependent experiences, they continue to need the guidance This communication may be facilitated by COMMENTS: and support of adults. Peer relationships take on increasing phone or email between the child’s teacher and the school- importance for this age group. Community service opportu- age child care facility. School-age child care programs nities can be valuable for this age group. should include parent/guardian permissions which allow school teachers to communicate relevant information to Center; Large Family Child Care Home; Small TYPE OF FACILITY: caregivers/teachers. Parents/guardians should also be Family Child Care Home notified of any significant event so that a system of commu- nication is established between and among family, school, STANDARD 2.1.4.4: Planning Activities for and caregivers/teachers. The child’s school teacher and a School-Age Children staff member from the facility should meet at least once to The facility should offer a program based on the needs exchange telephone numbers and to offer a contact in the and interests of the age group, as well as of the individuals event relevant information needs to be shared. within it. Children should participate in planning the pro- Center; Large Family Child Care Home; Small TYPE OF FACILITY: gram activities. Parents/guardians should be engaged and Family Child Care Home their work commitments should be honored when planning RELATED STANDARDS: program activities. Standard 9.4.1.3: Written Policy on Confidentiality of Records A child care facility for school-age children RATIONALE: REFERENCES: should provide an enriching contrast to the formal school 1. National Association of Elementary School Principals, National program, but also offer time for children to complete home- AfterSchool Association. . http:// Leading a new day for learning work assignments. Programs that offer a wide range of www.naaweb.org/downloads/Principal Documents/leading_joint activities (such as team sports, cooking, dramatics, art, mu- _statement-r3_.pdf. sic, crafts, games, open time, quiet time, outdoor play and learning, and use of community resources) allow children to explore new interests and relationships. 2.2 Supervision and Discipline Center; Large Family Child Care Home; Small TYPE OF FACILITY: STANDARD 2.2.0.1: Methods of Supervision of Family Child Care Home Children STANDARD 2.1.4.5: Community Outreach for Caregivers/teachers should directly supervise infants, tod- School-Age Children dlers, and preschoolers by sight and hearing at all times, even when the children are going to sleep, napping or sleep- The facility should provide opportunities for school-age chil- ing, are beginning to wake up, or are indoors or outdoors. dren to participate in community outreach and involvement, School-age children should be within sight or hearing at all such as field trips and community improvement projects. times. Caregivers/teachers should not be on one floor level RATIONALE: As the world of the school-age child encom- of the building, while children are on another floor or room. passes the larger community, facility activities should reflect Ratios should remain the same whether inside or outside. this stage of development. Field trips and other opportu - School-age children should be permitted to participate in nities to explore the community should enrich the child’s activities off the premises with appropriate adult supervision experience (1). and with written approval by a parent/guardian and by the TYPE OF FACILITY: Center; Large Family Child Care Home; Small caregiver. If parents/guardians give written permission for Family Child Care Home the school-age child to participate in off-premises activities, 64 Chapter 2: Program Activities

95 Caring for Our Children: National Health and Safety Performance Standards f) Focusing on the positive rather than the negative the facility would no longer be responsible for the child dur - to teach a child what is safe for the child and other ing the off-premises activity and not need to provide staff for children; the off-premises activity. g) Teaching children the developmentally appropriate Caregivers/teachers should regularly count children (name and safe use of each piece of equipment (e.g., using to face on a scheduled basis, at every transition, and when- a slide correctly – feet first only – and teaching why ever leaving one area and arriving at another), going indoors climbing up a slide can cause injury, possibly a head or outdoors, to confirm the safe whereabouts of every child injury). at all times. Additionally, they must be able to state how Primary caregiving systems, small group sizes, and low many children are in their care at all times. child:staff ratios unique to infant/toddler settings support Developmentally appropriate child:staff ratios should be met staff in properly supervising infants and toddlers. These during all hours of operation, including indoor and outdoor - practices encourage responsive interactions and under play and field trips, and safety precautions for specific areas standing each child’s strengths and challenges. When staff and equipment should be followed. No center-based facility connect deeply with the children in their care, they are more or large family child care home should operate with fewer in tune to children’s needs and whereabouts. Ultimately, than two staff members if more than six children are in carefully planned environments; staffing that supports care, even if the group otherwise meets the child:staff ratio. nurturing, individualized, and engaged caregiving; and well- Although centers often downsize the number of staff for the planned, responsive care routines support active supervi- early arrival and late departure times, another adult must be sion in infant and toddler environments. present to help in the event of an emergency. The supervi- Children are going to be more active in the outdoor learning/ sion policies of centers and large family child care homes play environment and need more supervision rather than should be written policies. less outside. Playground supervisors need to be desig- RATIONALE: Supervision is basic to safety and the preven- nated and trained to supervise children in play areas (1). tion of injury and maintaining quality child care. Parents/ Supervision of the playground is a strategy of watching all guardians have a contract with caregivers/teachers to su- the children within a specific territory and not engaging in pervise their children. To be available for supervision or res- prolonged dialog with any one child or group of children cue in an emergency, an adult must be able to hear and see (or other staff). Other adults not designated to supervise the children. In case of fire, a supervising adult should not may facilitate outdoor learning/play activities and engage need to climb stairs or use a ramp or an elevator to reach in conversations with children about their exploration and the children. Stairs, ramps, and elevators may become un- discoveries. Facilitated play is where the adult is engaged in stable because they can be pathways for fire and smoke. helping children learn a skill or achieve specific outcome of Children who are presumed to be sleeping might be awake an activity. Facilitated play is not supervision (2). and in need of adult attention. A child’s risk-taking behavior Children need spaces, indoors and out, in which they can must be detected and illness, fear, or other stressful behav- withdraw for alone-time or quiet play in small groups. How- iors must be noticed and managed. ever, program spaces should be designed with visibility that The importance of supervision is not only to protect children allows constant unobtrusive adult supervision. To protect from physical injury, but from harm that can occur from top- children from maltreatment, including sexual abuse, the ics discussed by children or by teasing/bullying/inappropri- environment layout should limit situations in which an adult ate behavior. It is the responsibility of caregivers/teachers to or older child is left alone with a child without another adult monitor what children are talking about and intervene when present (3,4). necessary. Many instances have been reported where a child has Children like to test their skills and abilities. This is particu- hidden when the group was moving to another location, larly noticeable around playground equipment. Even if the or where the child wandered off when a door was opened highest safety standards for playground layout, design and for another purpose. Regular counting of children (name to surfacing are met, serious injuries can happen if children face) will alert the staff to begin a search before the child are left unsupervised. Adults who are involved, aware, and gets too far, into trouble, or slips into an unobserved loca- appreciative of young childrens’ behaviors are in the best tion. position to safeguard their well-being. Active and positive Caregivers/teachers should record the count on an atten- supervision involves: dance sheet or on a pocket card, along with notations of a) Knowing each child’s abilities; any children joining or leaving the group. Caregivers/teach- b) Establishing clear and simple safety rules; ers should do the counts before the group leaves an area c) Being aware of and scanning for potential safety and when the group enters a new area. The facility should hazards; assign and reassign counting responsibility as needed to d) Placing yourself in a strategic position so you are maintain a counting routine. Facilities might consider count- able to adapt to the needs of the child; ing systems such as using a reminder tone on a watch or Scanning play activities and circulating around the e) musical clock that sounds at timed intervals (about every area; fifteen minutes) to help the staff remember to count. Chapter 2: Program Activities 65

96 Caring for Our Children: National Health and Safety Performance Standards Institute, University of North Carolina. http://ers.fpg.unc.edu/ Caregivers/teachers should be ready to provide help and node/84/. guidance when children are ready to use the toilet correctly Chen, X., M. Beran, R. Altkorn, S. Milkovich, K. Gruaz, G. Rider, and independently. Caregivers/teachers should make sure A. Kanti, J. Ochsenhirt. 2006. Frequency of caregiver supervision children correctly wash their hands after every use of the Intl J Injury Control and Safety of young children during play. toilet, as well as monitor the bathroom to make sure that the 14:122-24. Promotion toilet is flushed, the toilet seat and floor are free from stool Schwebel, D. C., A. L. Summerlin, M. L. Bounds, B. A. Morrongiello. or urine, and supplies (toilet paper, soap, and paper towels) 2006. The stamp-in-safety program: A behavioral intervention to are available. reduce behaviors that can lead to unintentional playground injury in J Pediatric Psychology a preschool setting. 31:152-62. Older preschool children and school-age children may use U.S. Consumer Product Safety Commission (CPSC). 2010. Public toilet facilities without direct visual observation but must playground safety handbook. http://www.cpsc.gov/cpscpub/ remain within hearing range in case children need assis- pubs/325.pdf. tance and to prevent inappropriate behavior. If toilets are not on the same floor as the child care area or within sight or STANDARD 2.2.0.2: Limiting Infant/Toddler hearing of a caregiver/teacher, an adult should accompany Time in Crib, High Chair, Car Seat, Etc. children younger than five years of age to and from the toilet area. Younger children who request privacy and have shown A child should not sit in a high chair or other equipment that capability to use toilet facilities properly should be given constrains his/her movement (1,2) indoors or outdoors for permission to use separate and private toilet facilities. longer than fifteen minutes, other than at meals or snack time. Children should never be left out of the view and at- Planning must include advance assignments, monitoring, tention of adult caregivers/teachers while in these types of - and contingency plans to maintain appropriate staffing. Dur equipment/furniture. A least restrictive environment should ing times when children are typically being dropped off and be encouraged at all times. Children should not be left to picked up, the number of children present can vary. There sleep in equipment, such as car seats, swings, or infant should be a plan in place to monitor and address unantici- seats that does not meet ASTM International (ASTM) prod- pated changes, allowing for caregivers/teachers to receive uct safety standards for sleep equipment. additional help when needed. Sufficient staff must be main- tained to evacuate the children safely in case of emergency. Children are continually developing their RATIONALE: Compliance with proper child:staff ratios should be mea- physical skills. They need opportunities to use and build sured by structured observation, by counting caregivers/ on their physical abilities. This is especially true for infants teachers and children in each group at varied times of the and toddlers who are eagerly using their bodies to explore day, and by reviewing written policies. their environment. Extended periods of time in the crib, high chair, car seat, or other confined space limits their physi- TYPE OF FACILITY: Center; Large Family Child Care Home; Small cal growth and also affects their social interactions. Injuries Family Child Care Home and Sudden Infant Death Syndrome (SIDS) have occurred RELATED STANDARDS: when children have been left to sleep in car seats or infant Standards 1.1.1.1-1.1.1.5: Child:Staff Ratios seats when the straps have entrapped body parts, or the Standard 3.4.4.5: Facility Layout to Reduce Risk of Child Abuse and children have turned the seats over while in them. Sleeping Neglect in a seated position can restrict breathing and cause oxygen Standard 5.4.1.2: Location of Toilets and Privacy Issues desaturation in young infants (3). Sleeping should occur in REFERENCES: equipment manufactured for this activity. When children are 1. National Program for Playground Safety. 2006. Playground awake, restricting them to a seat may limit social interac - supervision training for childcare providers. University of Northern tions. These social interactions are essential for children to Iowa. http://www.playgroundsafety.org/training/online/childcare/ gain language skills, develop self-esteem, and build relation- course_supervision.htm. ships (4). 2. National Program for Playground Safety. 2006. NPPS Website. http://www.playgroundsafety.org. Center; Large Family Child Care Home; Small TYPE OF FACILITY: 3. National Association for the Education of Young Children. 1996. Family Child Care Home Position Statement. Prevention of child abuse in early childhood RELATED STANDARDS: programs and the responsibilities of early childhood professionals Standard 3.1.3.1: Active Opportunities for Physical Activity to prevent child abuse. Standard 3.1.4.1: Safe Sleep Practices and SIDS/Suffocation Risk 13 indicators of quality child care: Research 4. Fiene, R. 2002. Reduction update . Washington, DC: U.S. Department of Health and Human Standard 5.3.1.10: Restrictive Infant Equipment Requirements Services, Office of the Assistant Secretary for Planning and Standard 5.4.5.1: Sleeping Equipment and Supplies Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/. Standard 5.4.5.2: Cribs ADDITIONAL READINGS: REFERENCES: Harms, T., R. M. Clifford, D. Cryer. 2005. Early childhood 1. Kornhauser Cerar, L., C.V. Scirica, I. Stucin Gantar, D. Osredkar, environment rating scale, revised ed. Frank Porter Graham Child D. Neubauer, T.B. Kinane. 2009. A comparison of respiratory Development Institute, University of North Carolina. http://ers.fpg patterns in healthy term infants placed in care safety seats and .unc.edu/node/82/. beds. Pediatrics 124:e396-e402. Harms, T., D. Cryer, R. M. Clifford. 2005. Infant/toddler environment 2. Benjamin, S.E., S.L. Rifas-Shiman, E.M. Taveras, J. Haines, J. rating scale, revised ed. Frank Porter Graham Child Development Chapter 2: Program Activities 66

97 Caring for Our Children: National Health and Safety Performance Standards Finkelstein, K. Kleinman, M.W. Gillman. 2009. Early child care and Studies have shown a relationship between TV viewing and Pediatrics 124:555-62. adiposity at ages 1 and 3 years. overweight in young children. For example, watching more 3. Bass, J. L., M. Bull. 2008. Oxygen desaturation in term infants in than eight hours of television per week has been associ- 110:401-2. car safety seats. Pediatrics ated with an increased risk of obesity in young children 4. New York State Office of Children and Family Services. Website. and exposure to two or more hours of television per day http://www.ocfs.state.ny.us/main/. increased the risk of overweight for three- to five-year-olds (5,6). Among four-year-olds, research has shown that as STANDARD 2.2.0.3: Limiting Screen Time – body mass index increases, average hours of TV viewing Media, Computer Time increases (7). Also, young children who watch TV have been shown to have poor diet quality. For each one-hour incre- In early care and education settings, media (television [TV], ment of TV viewing per day, three-year-olds were found to video, and DVD) viewing and computer use should not be have higher intakes of sugar-sweetened beverage and lower permitted for children younger than two years. For children fruit and vegetable intakes (8). Children are exposed to two years and older in early care and early education set- extensive advertising for high-calorie and low-nutrient dense tings, total screen time should be limited to not more than foods and drinks and very limited advertising of healthful thirty minutes once a week, and for educational or physi- foods and drinks during their television viewing. Television cal activity use only. During meal or snack time, TV, video, advertising influences the food consumption of children or DVD viewing should not be allowed (1). Computer use two-to eleven-years-old (9). should be limited to no more than fifteen-minute increments except for school-age children completing homework as- About two-thirds (66%) of children ages six months to six signments (2) and children with special health care needs years watch television every day. About a quarter (24%) who require and consistently use assistive and adaptive watch videos or DVDs every day, and nearly two-thirds computer technology. (65%) watch them several times a week or more. Addition- ally, young children engage in other forms of screen activity Parents/guardians should be informed if screen media are several times a week or more including using a computer used in the early care and education program. Any screen (27%), playing console video games (13%), and playing media used should be free of advertising and brand place- handheld video games (8%) (10). Survey data show that by ment. TV programs, DVD, and computer games should be three months of age, about 40% of infants regularly watch reviewed and evaluated before participation of the children television, DVDs, or videos. By twenty-four months, this to ensure that advertising and brand placement are not rose to 90% (1). present. Caregivers/teachers cannot determine which child does and In the first two years of life, children’s brains RATIONALE: does not watch TV at home. It is important for early care and bodies are going through critical periods of growth and and education programs to limit TV viewing so that the AAP development. It is important for infants and young children goal of less than two hours a day, accompanied by more to have positive interactions with people and not sit in front physical activity and increased interaction with reading, can of a screen that takes time away from social interaction be achieved. A study of TV viewing in early care and educa- with parents/guardians and caregivers/teachers. Before age tion settings reported that, on average, preschool-aged chil- three, television viewing can have modest negative effects dren watched more than four times as much television while on cognitive development of children (3). For that reason, at home-based programs than at center-based programs the American Academy of Pediatrics (AAP) recommends (1.39 hours per day vs. 0.36 hours per day); with significant television viewing be discouraged for children younger than differences between groups in the type of television content two years of age (4). Interactive activities that promote brain viewed, and in the proportions of programs in which no tele- development can be encouraged, such as talking, playing, vision viewing occurred at all. The proportion of programs singing, and reading together. where preschool-aged children watched no television during For children two years and older, the AAP recommends the early care and education day was 65% in center-based limiting children’s total (early care and education, and home) programs and 11% in home-based programs (11). media time (with entertainment media) to no more than one It is important for caregivers/teachers to be a COMMENTS: to two hours of quality programming per twenty-four hour role model for children in early care and education settings period (3). Because children may watch television before by not watching TV during the care day. In addition, when and after attending early care and education settings, limit- adults watch television (including the news) in the pres- ing media time during their time in early care and education ence of children, children may be exposed to inappropriate settings will help meet the AAP recommendation. When TV language or frightening images. The USDA has tips on limit- watching is intended to be interactive, with the adult inter - ing media time – “How Much Inactive Time Is Too Much” at acting with children about what they are watching, caregiv- http://www.choosemyplate.gov/foodgroups/physicalactiv- ers/teachers can sing along and comment on what children ity_why.html. are watching. Caregivers/teachers should always consider whether children could learn the skill better in another way The AAP provides a description of the TV programming through hands-on experiences. rating scale and tips for parents/guardians at http://www. healthychildren.org/English/family-life/Media/Pages/TV Chapter 2: Program Activities 67

98 Caring for Our Children: National Health and Safety Performance Standards Technology and interactive media as tools in early childhood -Ratings-A-Guide-for-Parents.aspx. Caregivers/teachers are prpograms serving children from birth through age 8. Position discouraged from having a TV in a room where children are Statement. http://www.naeyc.org/files/naeyc/PS_technology_WEB. present. pdf. Caregivers/teachers should begin reading to children when Martinez-Gomez, D., J. Tucker, K. A. Heelan, G. J. Welk, J. C. they are six months of age and facilities should have age- Eisenmann. 2009. Associations between sedentary behavior Arch Pediatr Adolesc Med and blood pressure in young children. appropriate books available for each cognitive stage of 163:724-30. development. See “Reach Out and Read” at http://www. Nixon, G. M., J. M. D. Thompson, D. Y. Han, et al. 2009. Falling reachoutandread.org for more information. 94:686- asleep: The determinants of sleep latency. Arch Dis Child Center; Large Family Child Care Home; Small TYPE OF FACILITY: 89. Family Child Care Home McMurray, R. G., S. I. Bangdiwala, J. S. Harrell, L. D. Amorim. 2008. Adolescents with metabolic syndrome have a history of low aerobic RELATED STANDARDS: Dynamic Med 7:5. fitness and physical activity levels. Standard 3.1.3.1: Active Opportunities for Physical Activity McDonough, P. 2009. TV viewing among kids at an eight-year high. Appendix S: Physical Activity: How Much Is Needed? Nielsen Wire (October 26). http://blog.nielsen.com/nielsenwire/ REFERENCES: media_entertainment/tv-viewing-among-kids-at-an-eight 1. Zimmerman, F. J., D. A. Christakis, A. N. Meltzoff. 2007. -year-high/. Television and DVD/video viewing in children younger than 2 years. Tandon, P. S., C. Zhou, P. Lozano, D. A. Christakis. 2010. 161:473-79. Arch Pediatric Adolescent Med Preschoolers’ total daily screen time at home and by type of child 2. Harms, T., R. M. Clifford, D. Cryer. 2005. Early childhood care. J Pediatr 158:297-300. environment rating scale, revised ed. Frank Porter Graham Child Development Institute, University of North Carolina. http://ers.fpg STANDARD 2.2.0.4: Supervision Near Bodies .unc.edu/node/82/. of Water 3. Zimmerman, F. J., D. A. Christakis. 2005. Children’s television Arch Pediatric Adolescent Med viewing and cognitive outcomes. Constant and active supervision should be maintained when 159:619-25. any child is in or around water (1). During any swimming/ 4. American Academy of Pediatrics, Council on Communications wading/water play activities where either an infant or a tod- and Media. 2009. Policy statement: Media violence. Pediatrics dler is present, the ratio should always be one adult to one 124:1495-1503. infant/toddler. Children ages thirteen months to five years 5. Reilly, J. J., J. Armstrong, A. R. Dorosty. 2005. Early life risk of age should not be permitted to play in areas where there British Medical J factors for obesity in childhood: Cohort study. 330:1357. is any body of water, including swimming pools, ponds and 6. Lumeng, J. C., S. Rahnama, D. Appugliese, N. Kaciroti, R. irrigation ditches, built-in wading pools, tubs, pails, sinks, or H. Bradley. 2006. Television exposure and overweight risk in toilets unless the supervising adult is within an arm’s length 160:417-22. Arch Pediatric Adolescent Med preschoolers. providing “touch supervision”. 7. Levin, S., M. W. Martin, W. F. Riner. 2004. TV viewing habits Caregivers/teachers should ensure that all pools meet the and Body Mass Index among South Carolina Head Start children. 14:336-39. Ethnicity and Disease Virginia Graeme Baker Pool and Spa Safety Act, requir - 8. Miller, S. A., E. M. Taveras, S. L. Rifas-Shiman, M. W. Gillman. ing the retrofitting of safe suction-type devices for pools 2008. Association between television viewing and poor diet quality and spas to prevent underwater entrapment of children in in young children. Int J Pediatric Obesity 3:168-76. such locations with strong suction devices that have led to 9. Committee on Food Marketing and the Diets of Children and deaths of children of varying ages (2). Food marketing to children and youth: Threat or Youth. 2006. Small children can drown within thirty sec- RATIONALE: . Ed. J. M. McGinnis, J. A. Gootman, V. I. Kraak. opportunity Washington, DC: National Academies Press. onds, in as little as two inches of liquid (3). 10. Taveras, E. M., T. J. Sandora, M. C. Shih, D. Ross-Degnan, D. In a comprehensive study of drowning and submersion in- A. Goldmann, M. W. Gillman. 2006. The association of television cidents involving children under five years of age in Arizona, and video viewing with fast food intake by preschool-age children. California, and Florida, the U.S. Consumer Product Safety Obesity 14:2034-41. Commission (CPSC) found that: 11. Christakis, D. A., M. M. Garrison, F. J. Zimmerman. 2006. Television viewing in child care programs: A national survey. Submersion incidents involving children usually a) Communication Reports 19:111-20. happen in familiar surroundings; Pool submersions involving children happen quickly, b) ADDITIONAL READINGS: 77% of the victims had been missing from sight for Dennison, B. A., T. A. Erb, P. L. Jenkins. 2002. Television viewing five minutes or less; and television in bedroom associated with overweight risk among Pediatrics low-income preschool children. 109:1028-35. Child drowning is a silent death, and splashing may c) Funk, J. B., J. Brouwer, K. Curtiss, E. McBroom. 2009. Parents not occur to alert someone that the child is in trouble of preschoolers: Expert media recommendations and ratings (4). knowledge, media-effects beliefs, and monitoring practices. Drowning is the second leading cause of unintentional 123:981-88. Pediatrics injury-related death for children ages one to fourteen (5). National Association for the Education of Young Children. 1994. Media violence in children’s lives. Position Statement. http://www. In 2006, approximately 1,100 children under the age of naeyc.org/files/naeyc/file/positions/PSMEVI98.PDF. twenty in the U.S died from drowning (11). A national study National Association for the Education of Young Children. 2012. Chapter 2: Program Activities 68

99 Caring for Our Children: National Health and Safety Performance Standards The need for constant supervision is of particular concern in that examined where drowning most commonly takes place dealing with very young children and children with signifi- concluded that infants are most likely to drown in bathtubs, - cant motor dysfunction or developmental delays. Super toddlers are most likely to drown in swimming pools and vising adults should be CPR-trained and should have a older children and adolescents are most likely to drown in telephone accessible to the pool and water area at all times freshwater (rivers, lakes, ponds) (11). should emergency services be required. While swimming pools pose the greatest risk for toddlers, Center; Large Family Child Care Home; Small TYPE OF FACILITY: about one-quarter of drowning among toddlers are in fresh- Family Child Care Home water sites, such as ponds or lakes. RELATED STANDARDS: The American Academy of Pediatrics (AAP) recommends: Standard 1.1.1.5: Ratios and Supervision for Swimming, Wading, a) Swimming lessons for children based on the child’s and Water Play frequency of exposure to water, emotional maturity, Standard 1.4.3.3: CPR Training for Swimming and Water Play physical limitations, and health concerns related to Standard 6.3.1.1: Enclosure of Bodies of Water swimming pools; Standard 6.3.1.7: Pool Safety Rules “Touch supervision” of infants and young children b) REFERENCES: through age four when they are in the bathtub or 1. U.S. Consumer Product Safety Commission. 2009. CPSC warns around other bodies of water; of in-home drowning dangers with bathtubs, bath seats, buckets. Installation of four-sided fencing that completely c) Release #10-008. Washington, DC: CPSC. http://www.cpsc.gov/ separates homes from residential pools; cpscpub/prerel/prhtml10/10008.html. Use of approved personal flotation devices (PFDs) d) 2. U.S. Congress. 2007. Virginia Graeme Baker Pool and Spa Safety when riding on a boat or playing near a river, lake, . 15 USC 8001. http://www.cpsc.gov/businfo/vgb/pssa.pdf. Act 3. American Academy of Pediatrics, Committee on Injury, Violence, pond, or ocean; and Poison Prevention. 2010. Policy statement-prevention of e) Teaching children never to swim alone or without Pediatrics 126: 178-85. drowning. adult supervision; 4. U.S. Consumer Product Safety Commission. 2002. How to f) Stressing the need for parents/guardians and teens . Publication plan for the unexpected: Preventing child drownings to learn first aid and cardiopulmonary resuscitation #359. Washington, DC: CPSC. http://www.cpsc.gov/CPSCPUB/ (CPR) (3). PUBS/359.pdf. 5. Centers for Disease Control and Prevention (CDC). 2010. Deaths and nonfatal injuries have been associated with Unintentional drowning: Fact sheet. http://www.cdc.gov/ infant bathtub “supporting ring” devices that are supposed HomeandRecreationalSafety/Water-Safety/waterinjuries to keep an infant safe in the tub. These rings usually contain -factsheet.html. three or four legs with suction cups that attach to the bot- Drowning 6. U.S. Consumer Product Safety Commission. 1994. tom of the tub. The suction cups, however, may release sud- Document #5084. hazard with baby “supporting ring” devices. denly, allowing the bath ring and infant to tip over. An infant Washington, DC: CPSC. http://www.cpsc.gov/cpscpub/pubs/ also may slip between the legs of the bath ring and become 5084.html. trapped under it. Caregivers/teachers must not rely on these 7. Rauchschwalbe, R., R. A. Brenner, S. Gordon. 1997. The role devices to keep an infant safe in the bath and must never of bathtub seats and rings in infant drowning deaths. Pediatrics leave an infant alone in these bath support rings (1,6,7). 100:e1. 8. U.S. Consumer Product Safety Commission. 1994. Infants and Thirty children under five years of age died from drowning toddlers can drown in 5-gallon buckets: A hidden hazard in the in buckets, pails, and containers from 2003-2005 (10). Of all home . Document #5006. Washington, DC: CPSC. http://www.cpsc buckets, the five-gallon size presents the greatest hazard .gov/cpscpub/pubs/5006.html. to young children because of its tall straight sides and its 9. U.S. Consumer Product Safety Commission. 1997. CPSC weight with even just a small amount of liquid. It is nearly . reminds pool owners that barriers, supervision prevent drowning Release #97-152. Washington, DC: CPSC. http://www.cpsc.gov/ impossible for top-heavy (their heads) infants and toddlers CPSCPUB/PREREL/PRHTML97/97152.html. to free themselves when they fall into a five-gallon bucket Submersions related to non-pool and non-spa 10. Gipson, K. 2008. head first (8). Washington, DC: U.S. Consumer Product products, 2008 report. The Centers for Disease Control (CDC) National Center for Safety Commission. http://www.cpsc.gov/library/FOIA/FOIA09/OS/ Injury Prevention and Control recommends that whenever nonpoolsub2008.pdf. young children are swimming, playing, or bathing in water, 11. American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention, J. Weiss. 2010. Technical report: Prevention an adult should be watching them constantly. The supervis- 126: e253-62. Pediatrics of drowning. ing adult should not read, play cards, talk on the telephone, mow the lawn, or do any other distracting activity while STANDARD 2.2.0.5: Behavior Around a Pool watching children (1,9). When children are in or around a pool, caregivers/teach- COMMENTS: “Touch supervision” means keeping swim- ers should teach age-appropriate behavior and safety skills ming children within arm’s reach and in sight at all times. including not pushing each other, holding each other under Flotation devices should never be used as a substitute for water, or running at the poolside. Children should be shown supervision. Knowing how to swim does not make a child the depth of the water at different part of the pool. They drown-proof. should be taught that when going into a body of water, they Chapter 2: Program Activities 69

100 Caring for Our Children: National Health and Safety Performance Standards providing engaging materials based on children’s should go in feet first the first time to check the depth. Chil- interests and ensuring that the learning environment dren should be instructed what an emergency would be and Well- promotes active participation of each child. to only call for help only in a real/genuine emergency. They designed child care environments are ones that are should be taught to never dive in shallow water. supportive of appropriate behavior in children, and - RATIONALE: Caregivers/teachers should take the oppor are designed to help children learn about what to tunities to explain how certain behaviors could injure other expect in that environment and to promote positive children. Also such behavior can distract caregivers/teach- interactions and engagement with others; ers from supervising other children, thereby placing the Modifying the learning/play environment (e.g., e) other children at risk (1). schedule, routine, activities, transitions) to support Center; Large Family Child Care Home; Small TYPE OF FACILITY: the child’s appropriate behavior; Family Child Care Home f) Creating a predictable daily routine and schedule. REFERENCES: When a routine is predictable, children are more 1. U.S. Department of Health and Human Services, Maternal and likely to know what to do and what is expected Child Health Bureau. 1999. Basic emergency lifesaving skills (BELS): of them. This may decrease anxiety in the child. A framework for teaching emergency lifesaving skills to children and When there is less anxiety, there may be less acting adolescents . Newton, MA: Children’s Safety Network, Education out. Reminders need to be given to the children Development Center. http://bolivia.hrsa.gov/emsc/Downloads/ so they can anticipate and prepare themselves for BELS/BELS.htm. transitions within the schedule. Reminders should be individualized such that each child understands and STANDARD 2.2.0.6: Discipline Measures anticipates the transition; Reader’s Note: The word discipline means to teach and Using encouragement and descriptive praise. When g) guide. Discipline is not punishment. The discipline standard clear encouragement and descriptive praise are used therefore reflects an approach that focuses on preventing to give attention to appropriate behaviors, those behavior problems by supporting children in learning appro- behaviors are likely to be repeated. Encouragement priate social skills and emotional responses. and praise should be stated positively and descriptively. Encouragement and praise should Caregivers/teachers should guide children to develop provide information that the behavior the child self-control and appropriate behaviors in the context of engaged in was appropriate. Examples: “I can tell you relationships with peers and adults. Caregivers/teachers are ready for circle time because you are sitting on should care for children without ever resorting to physical your name and looking at me.” “Your friend looked so punishment or abusive language. When a child needs as- happy when you helped him clean up his toys.” “You sistance to resolve a conflict, manage a transition, engage must be so proud of yourself for putting on your coat in a challenging situation, or express feelings, needs, and all by yourself.” Encouragement and praise should wants, the adult should help the child learn strategies for label the behaviors, not the child (e.g., good listening, dealing with the situation. Discipline should be an ongoing good eating, instead of good boy); process to help children learn to manage their own behavior Using clear, direct, and simple commands. When h) in a socially acceptable manner, and should not just occur in clear commands are used with children, they are response to a problem behavior. Rather, the adult’s guid- more likely to follow them. The caregiver/teacher ance helps children respond to difficult situations using should tell the child what to do rather than what NOT socially appropriate strategies. To develop self-control, to do. The caregiver/teacher should limit the number children should receive adult support that is individual to of commands. The caregiver/teacher should use if/ the child and adapts as the child develops internal controls. then and when/then statements with logical and This process should include: natural consequences. These practices help children Forming a positive relationship with the child. When a) understand they can make choices and that choices children have a positive relationship with the adult, have consequences; they are more likely to follow that person’s directions. i) Showing children positive alternatives rather than just This positive relationship occurs when the adult telling children “no”; spends time talking to the child, listening to the child, j) Modeling desired behavior; following the child’s lead, playing with the child, and Using planned ignoring and redirection. Certain k) responding to the child’s needs; behaviors can be ignored while at the same time b) Basing expectations on children’s developmental the adult is able to redirect the children to another level; activity. If the behavior cannot be ignored, the adult Establishing simple rules children can understand c) should prompt the child to use a more appropriate (e.g., you can’t hurt others, our things, or yourself) behavior and provide positive feedback when the and being proactive in teaching and supporting child engages in the behavior; children in learning the rules; l) Individualizing discipline based on the individual d) Adapting the physical indoor and outdoor learning/ needs of children. For example, if a child has a play environment or family child care home to hard time transitioning, the caregiver/teacher can encourage positive behavior and self regulation by 70 Chapter 2: Program Activities

101 Caring for Our Children: National Health and Safety Performance Standards teach new skills to replace the behavior. Listed below are identify strategies to help the child with the transition guidelines when using time-out (8): (individualized warning, job during transition, a) Time-outs should be used for behaviors that are per - individual schedule, peer buddy to help, etc.) If a sistent and unacceptable, used infrequently and used child has a difficult time during a large group activity, only for children who are at least two years of age. the child might be taught to ask for a break; Time-outs can be considered an extended ignore or a Using time-out for behaviors that are persistent m) time-out from positive enforcement; and unacceptable. Time-out should only be used in b) The caregiver/teacher should explain how time-out combination with instructional approaches that teach works to the child BEFORE s/he uses it the first time. children what to do in place of the behavior problem. The adult should be clear about the behavior that will (See guidance for time-outs below.) lead to time-out; Expectations for children’s behavior and the facility’s poli- c) When placing the child in time-out, the caregiver/ cies regarding their response to behaviors should be written teacher should stay calm; and shared with families and children of appropriate age. While the child is in time-out, the caregiver/teacher d) Further, the policies should address proactive as well as should not talk to or look at the child (as an extended reactive strategies. Programs should work with families ignore). However, the adult should keep the child in to support their children’s appropriate behaviors before it sight. The child could 1) remain sitting quietly in a becomes a problem. chair or on a pillow within the room or 2) participate in Common usage of the word “discipline” has RATIONALE: some activity that requires solitary pursuit (painting, corrupted the word so that many consider discipline as coloring, puzzle, etc.) If the child cannot remain in the synonymous with punishment, most particularly corporal room, s/he will spend time in an alternate space, with punishment (2,3). Discipline is most effective when it is supervision; consistent, reinforces desired behaviors, and offers natural e) Time-outs do not need to be long. The caregiver/ and logical consequences for negative behaviors. Research teacher should use the one minute of time-out for studies find that corporal punishment has limited effective- each year of the child’s age (e.g., three-years-old = ness and potentially harmful side effects (4-9). Children have three minutes of time-out); to be taught expectations for their behavior if they are to f) The caregiver/teacher should end the time-out on a develop internal control of their actions. The goal is to help positive note and allow the child to feel good again. children learn to control their own behavior. Discussions with the child to “explain WHY you were in time-out” are not usually effective; COMMENTS: Children respond well when they receive g) If the child is unable to be distracted or consoled, descriptive praise/attention for behaviors that the caregiver/ parents/guardians should be contacted. teacher wants to see again. It is best if caregivers/teachers are sincere and enthusiastic when using descriptive praise. How to respond to failure to cooperate during time-out: On the contrary, children should not receive praise for unde- Caregivers/teachers should expect resistance from children sirable behaviors, but instead be praised for honest efforts who are new to the time-out procedure. If a child has never towards the behaviors the caregivers/teachers want to see experienced time-out, s/he may respond by becoming very repeated (1). Discipline is best received when it includes emotional. Time-out should not turn into a power struggle positive guidance, redirection, and setting clear-cut limits with the child. If the child is refusing to stay on time-out, the that foster the child’s ability to become self-disciplined. In caregiver/teacher should give the child an if/then statement. order to respond effectively when children display chal- For example, “if you cannot take your time-out, then you lenging behavior, it is beneficial for caregivers/teachers to cannot join story time.” If the child continues to refuse the understand typical social and emotional development and time-out, then the child cannot join story time. Note that behaviors. Discipline is an ongoing process to help chil- children should not be restrained to keep them in time-out. dren develop inner control so they can manage their own More resources for caregivers/teachers on discipline can behavior in a socially approved manner. A comprehensive be found at the following organizations’ Websites: a) Center behavior plan is often based first on a positive, affectionate on the Social and Emotional Foundations for Early Learning relationship between the child and the caregiver/teacher. (CSEFEL) at http://csefel.vanderbilt.edu and b) Technical As- Measures that prevent behavior problems often include sistance Center on Social Emotional Intervention (TACSIE) at developmentally appropriate environments, supervision, http://www.challengingbehavior.org. routines, and transitions. Children can benefit from receiv- ing guidance and repeated instructions for navigating the TYPE OF FACILITY: Center; Large Family Child Care Home; Small various social interactions that take place in the child care Family Child Care Home setting such as friendship development, problem-solving, RELATED STANDARDS: and conflict-resolution. Standard 2.1.1.6: Transitioning Within Programs and Indoor and Outdoor Learning/Play Environments Time-out (also known as temporary separation) is one Standard 2.2.0.7: Handling Physical Aggression, Biting, and Hitting strategy to help children change their behavior and should Standard 2.2.0.8: Preventing Expulsions, Suspensions, and Other - be used in the context of a positive behavioral support ap Limitations in Services proach which works to understand undesired behaviors and Chapter 2: Program Activities 71

102 Caring for Our Children: National Health and Safety Performance Standards Standards 3.4.4.1-3.4.4.5: Child Abuse and Neglect STANDARD 2.2.0.7: Handling Physical Standard 9.2.1.1: Content of Policies Aggression, Biting, and Hitting Standard 9.2.1.3: Enrollment Information to Parents/Guardians and Caregivers/Teachers Caregivers/teachers should intervene immediately when a Standard 9.2.1.6: Written Discipline Policies child’s behavior is aggressive and endangers the safety of Standard 9.4.1.6: Availability of Documents to Parents/Guardians others. It is important that the child be clearly told verbally, “no hitting” or “no biting.” The caregiver/teacher should use REFERENCES: 1. Henderlong, J., M. Lepper. 2002 The effects of praise on age–appropriate interventions. For example, a toddler can Psychological children’s intrinsic motivation: A review and synthesis. be picked up and moved to another location in the room if Bulletin 128:774-95. s/he bites other children or adults. A preschool child can be 2. Hodgkin, R. 1997. Why the “gentle smack” should go: Policy invited to walk with you first but, if not compliant, taken by Child Soc 11:201-4. review. the hand and walked to another location in the room. The 3. Fraiberg, S. H. 1959. The Magic Years . New York: Charles caregiver/teacher should remain calm and make eye contact Scribner’s Sons. with the child telling him/her the behavior is unacceptable. If 4. Straus, M. A., et al. 1997. Spanking by parents and subsequent the behavior persists, parents/guardians, caregivers/teach- Arch Pediatric Adolescent Medicine antisocial behavior of children. ers, the child care health consultant and the early childhood 151:761-67. mental health consultant should be involved to create a plan 5. Deater-Deckard, K., et al. 1996. Physical discipline among African American and European American mothers: Links to children’s targeting this behavior. For example, a plan may be devel- Dev Psychol 32:1065-72. externalizing behaviors. oped to recognize non-aggressive behavior. Children who 6. Weiss, B., et al. 1992. Some consequences of early harsh might not have the social skills or language to communicate discipline: Child aggression and a maladaptive social information appropriately may use physical aggression to express them- processing style. Child Dev 63:1321-35. selves and the reason for and antecedents of the behavior 7. American Academy of Pediatrics, Committee on School Health. must be considered when developing a plan for addressing Pediatrics 2006. Policy statement: Corporal punishment in schools. the behavior. 118:1266. 8. Dunlap, S., L. Fox, M. L. Hemmeter, P. Strain. 2004. The role of RATIONALE: Caregiver/teacher intervention protects chil- time-out in a comprehensive approach for addressing challenging dren and encourages children to exhibit more acceptable behaviors of preschool children . CSEFEL What Works Series. http:// behavior (1). csefel.vanderbilt.edu/briefs/wwb14.pdf. Biting is a phase. Here are some specific COMMENTS: 9. Fiene, R. 2002. 13 indicators of quality child care: Research update . Washington, DC: U.S. Department of Health and Human steps to deal with biting: Services, Office of the Assistant Secretary for Planning and If a child bites another child, the caregiver/teacher Step 1: Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/. should comfort the child who was bitten and remind the ADDITIONAL READINGS: biter that biting hurts and we do not bite. Children should Gross, D., C. Garvey, W. Julion, L. Fogg, S. Tucker, H. Mokos. 2009. be given some space from each other for an appropriate Efficacy of the Chicago Parent Program with low-income multi- amount of time. 10:54-65. ethnic parents of young children. Preventions Science Breitenstein, S., D. Gross, I. Ordaz, W. Julion, C. Garvey, A. Ridge. Step 2: The caregiver/teacher should follow first aid instruc- 2007. Promoting mental health in early childhood programs serving tions (available from the American Academy of Pediatrics families from low income neighborhoods. J Am Psychiatric Nurses [AAP] and the American Red Cross) and use the Center for Assoc 13:313-20. Disease Control and Prevention’s (CDC’s) Standard Precau- Gross, D., C. Garvey, W. Julion, L. Fogg. 2007. Preventive parent tions to handle potential exposure to blood. training with low-income ethnic minority parents of preschoolers. Handbook of parent training: Helping parents prevent and solve In The caregiver/teacher should allow for “dignity Step 3: . Ed. J. M. Briesmeister, C. E. Schaefer. 3rd ed. problem behaviors of risk,” and let the children back in the same space with Hoboken, NJ: Wiley. increased supervision. Interactions should be structured Young Children Gartrell, D. 2007. He did it on purpose! 62:62-64. between children such that the child learns to use more ap- Gartrell, D. 2004. The power of guidance: Teaching social-emotional propriate social skills or language rather than biting. If there skills in early childhood classrooms . Clifton Park, NY: Thomson is another incident, caregivers/teachers should repeat step Delmar Learning; Washington, DC: NAEYC. one. The biter can play with children they have not bitten. Gartrell, D., K. Sonsteng. 2008. Promoting physical activity: It’s pro- 63:51-53. Young Children active guidance. The adult needs to shadow the biter to ensure Step 4: Shiller, V. M., J. C. O’Flynn. 2008. Using rewards in the early safety of the other children. This can be challenging but Young Children childhood classroom: A reexamination of the issues. imperative for the biter. 63:88, 90-93. Step 5: For all transitions when the biter would be in close Reineke, J., K. Sonsteng, D. Gartrell. 2008. Nurturing mastery Young Children motivation: No need for rewards. 63:89, 93-97. contact, the caregiver/teacher should hold him/her on her/ Ryan, R. M., E. L. Deci. 2000. When rewards compete with nature: his hip or if possible hold hands, keep a close watch, and The undermining of intrinsic motivation and self-regulation. In keep the biter from close proximity with peers. Intrinsic and extrinsic motivation: The search for optimal motivation The child (biter) should play with one or two other Step 6: , ed. C. Sanstone, J. M. Harackiewicz, 13-54. San and performance children whom they have not bitten with a favored adult in a Diego, CA: Academic Press. section separate from the other children. Sometimes, until Chapter 2: Program Activities 72

103 Caring for Our Children: National Health and Safety Performance Standards RELATED STANDARDS: a phase (biting is a phase) passes, the caregiver/teacher Standard 2.2.0.6: Discipline Measures needs to extinguish the behavior by not allowing it to hap- Standard 2.2.0.8: Preventing Expulsions, Suspensions, and Other pen and thereby reducing the attention given to the behav- Limitations in Services ior. Standard 2.3.1.1: Mutual Responsibility of Parents/Guardians and Parents/guardians of both children of the incident Step 7: Staff Standard 3.2.3.3: Cuts and Scrapes should be informed. Standard 3.2.3.4: Prevention of Exposure to Blood and Body Fluids Step 8: The caregiver/teacher should determine whether the Standard 9.4.1.9: Records of Injury incident necessitates documentation (see Standard 9.4.1.9). REFERENCES: If so, s/he should complete a report form. 1. Rush, K. L. 1999. Caregiver-child interactions and early literacy Caregivers/teachers need to consider why the child is biting development of preschool children from low-income environments. and teach the child a more appropriate way to communicate Topics Early Child Special Education 19:3-14. 2. Ross, Scott W., Horner, Robert H. 2009. Bully prevention in the same need. Possible reasons why a child would bite J Applied Behavior Analysis positive behavior support. 42:747-59. include: Lack of words (desire to stop the behavior of another a) STANDARD 2.2.0.8: Preventing Expulsions, child); b) Teething; Suspensions, and Other Limitations in Tired (is nap time too late?); c) Services d) Hungry (is lunch time too late?); - Child care programs should not expel, suspend, or other e) Lack of toys – consider buying duplicates of popular wise limit the amount of services (including denying outdoor items; time, withholding food, or using food as a reward/punish- f) Lack of supervision – more staff should be added, ment) provided to a child or family on the basis of challeng- staff are near children during transitions, and room is ing behaviors or a health/safety condition or situation unless set up to ensure visibility; the condition or situation meets one of the two exceptions Child is bored – too much sitting, activities are too g) listed in this standard. frustrating; Child has oral motor needs – teethers are offered; h) Expulsion refers to terminating the enrollment of a child or i) Child is avoiding something, and biting gets him/her family in the regular group setting because of a challenging out of it; behavior or a health condition. Suspension and other limita- j) Lack of attention – child receives attention when biting. tions in services include all other reductions in the amount of time a child may be in attendance of the regular group Other important strategies to consider: setting, either by requiring the child to cease attendance for a) The caregiver/teacher should point out the effect a particular period of time or reducing the number of days or of the child’s biting on the victim: “Emma is crying. amount of time that a child may attend. Requiring a child to Biting hurts. Look at her face. See how sad she is?” attend the program in a special place away from the other Label feelings and give victims the words to respond. children in the regular group setting is included in this defini- “Emma, you can say ‘No biting!’ to Josh”; tion. b) The child should help the victim feel better. He can get a wet paper towel, a blankie or favorite toy for the Child care programs should have a comprehensive disci- victim and sit near them until the other child is feeling pline policy that includes an explicit description of alterna- better. This encourages children to take responsibility tives to expulsion for children exhibiting extreme levels of for their actions, briefly removes the child from other challenging behaviors, and should include the program’s activities and also lets the child experience success protocol for preventing challenging behaviors. These poli- as a helper. cies should be in writing and clearly articulated and com - municated to parents/guardians, staff and others. These Discussing aggressive behavior in group time with the chil- policies should also explicitly state how the program plans dren can be an effective way to gain and share understand- to use any available internal mental health and other sup- ing among the children about how it feels when aggressive port staff during behavioral crises to eliminate to the degree behavior occurs. Although bullying has not been studied possible any need for external supports (e.g., local police in the preschool population, it is a form of aggression (2). departments) during crises. Here are some helpful Websites: http://stopbullying.gov and http://www.eyesonbullying.org/preschool.html. Staff should have access to in-service training on both a proactive and as-needed basis on how to reduce the likeli- For more helpful strategies for handling aggression, see hood of problem behaviors escalating to the level of risk for Center on the Social and Emotional Foundations for Early expulsion and how to more effectively manage behaviors Learning Website at http://csefel.vanderbilt.edu. In addition, throughout the entire class/group. Staff should also have a child care health consultant or child care mental health access to in-service training, resources, and child care consultant can help when the biting behavior continues. health consultation to manage children’s health conditions in Center; Large Family Child Care Home; Small TYPE OF FACILITY: collaboration with parents/guardians and the child’s primary Family Child Care Home care provider. Programs should attempt to obtain access Chapter 2: Program Activities 73

104 Caring for Our Children: National Health and Safety Performance Standards facilitated, and a detailed transition plan from this program to behavioral or mental health consultation to help estab - to a more appropriate setting should be developed with the lish and maintain environments that will support children’s - family and followed. This transition could include a differ - mental well-being and social-emotional health, and have ac ent private or public-funded child care or early education cess to such a consultant when more targeted child-specific program in the community that is better equipped to ad- interventions are needed. Mental health consultation may be dress the behavioral concerns (e.g., therapeutic preschool obtained from a variety of sources, as described in Standard programs, Head Start or Early Head Start, prekindergarten 1.6.0.3. programs in the public schools that have access to addi- When children exhibit or engage in challenging behaviors tional support staff, etc.), or public-funded special education that cannot be resolved easily, as above, staff should: services for infants and toddlers (i.e., Part C early interven- a) Assess the health of the child and the adequacy of tion) or preschoolers (i.e., Part B preschool special educa- the curriculum in meeting the developmental and tion). educational needs of the child; To the degree that safety can be maintained, the child b) Immediately engage the parents/guardians/family should be transitioned directly to the receiving program. The in a spirit of collaboration regarding how the program should assist parents/guardians in securing the child’s behaviors may be best handled, including more appropriate placement, perhaps using the services appropriate solutions that have worked at home or in - of a local child care resource and referral agency. With par other settings; ent/guardian permission, the child’s primary care provider c) Access an early childhood mental health consultant should be consulted and a referral for a comprehensive as- to assist in developing an effective plan to address sessment by qualified mental health provider and the appro- the child’s challenging behaviors and to assist the priate special education system should be initiated. If abuse child in developing age-appropriate, pro-social skills; or neglect is suspected, then appropriate child protection Facilitate, with the family’s assistance, a referral for d) services should be informed. Finally, no child should ever be an evaluation for either Part C (early intervention) or expelled or suspended from care without first conducting an Part B (preschool special education), as well as any assessment of the safety of alternative arrangements (e.g., other appropriate community-based services (e.g., Who will care for the child? Will the child be adequately and child mental health clinic); safely supervised at all times?) (1). Facilitate with the family communication with the e) child’s primary care provider (e.g., pediatrician, family RATIONALE: The rate of expulsion in child care programs medicine provider, etc.), so that the primary care has been estimated to be as high as one in every thirty-six provider can assess for any related health concerns children enrolled, with 39% of all child care classes per year and help facilitate appropriate referrals. expelling at least one child. In state-funded prekindergarten programs, the rate has been estimated as one in every 149 The only possible reasons for considering expelling, sus- children enrolled, with 10% of prekindergarten classes per pending or otherwise limiting services to a child on the basis year expelling at least one child. These expulsions prevent of challenging behaviors are: children from receiving potentially beneficial mental health Continued placement in the class and/or program a) services and deny the child the benefit of continuity of qual- clearly jeopardizes the physical safety of the child ity early education and child care services. Mental health and/or his/her classmates as assessed by a qualified consultation has been shown in rigorous research to help early childhood mental health consultant AND all - reduce the likelihood of behaviors leading to expulsion deci possible interventions and supports recommended sions. Also, research suggests that expulsion decisions may by a qualified early childhood mental health be related to teacher job stress and depression, large group consultant aimed at providing a physically safe sizes, and high child:staff ratios (1-6). environment have been exhausted; or b) The family is unwilling to participate in mental health Mental health services should be available to staff to help consultation that has been provided through the child address challenging behaviors in the program, to help care program or independently obtain and participate improve the mental health climate of indoor and outdoor in child mental health assistance available in the learning/play environments and child care systems, to better community; or provide mental health services to families, and to address Continued placement in this class and/or program c) job stress and mental health needs of staff. clearly fails to meet the mental health and/or social- Center; Large Family Child Care Home; Small TYPE OF FACILITY: emotional needs of the child as agreed by both the Family Child Care Home staff and the family AND a different program that is RELATED STANDARDS: better able to meet these needs has been identified Standard 1.6.0.1: Child Care Health Consultants and can immediately provide services to the child. Standard 1.6.0.3: Early Childhood Mental Health Consultants In either of the above three cases, a qualified early child- Standard 1.6.0.5: Early Childhood Education Consultants hood mental health consultant, qualified special education Standard 2.2.0.6: Discipline Measures staff, and/or qualified community-based mental health care Standard 2.2.0.7: Handling Physical Aggression, Biting, and Hitting provider should be consulted, referrals for special education Standard 2.2.0.9: Prohibited Caregiver/Teacher Behaviors services and other community-based services should be 74 Chapter 2: Program Activities

105 Caring for Our Children: National Health and Safety Performance Standards Standard 2.2.0.10: Using Physical Restraint condone, an act of abuse or neglect of a child by Standards 3.4.4.1-3.4.4.5: Child Abuse and Neglect an older child, employee, volunteer, or any person Standard 4.5.0.11: Prohibited Uses of Food employed by the facility or child’s family; Standard 9.2.1.6: Written Discipline Policies h) Abusive, profane, or sarcastic language or verbal REFERENCES: abuse, threats, or derogatory remarks about the child 1. American Academy of Pediatrics, Committee on School Health. or child’s family; 2008. Policy statement: Out-of-school suspension and expulsion. i) Any form of public or private humiliation, including Pediatrics 122:450. threats of physical punishment (1); 2. Gilliam, W. S. 2005. Prekindergarteners left behind: Expulsion j) Physical activity/outdoor time should not be taken rates in state prekindergarten programs. Foundation for Child away as punishment. Development, Policy Brief Series no. 3. http://medicine.yale.edu/ childstudy/zigler/Images/National Prek Study_expulsion brief Corporal punishment may be physical abuse RATIONALE: _tcm350-34775.pdf. or may easily become abusive. Corporal punishment is 3. Gilliam, W. S., G. Shahar. 2006. Preschool and child care clearly prohibited in family child care homes and centers in expulsion and suspension: Rates and predictors in one state. the majority of states (2-4). Research links corporal pun- 19:228-45. Infants Young Children ishment with negative effects such as later aggression (5) 4. Gilliam, W. S. 2008. Implementing policies to reduce behavior problems in school (6,7), antisocial and criminal the likelihood of preschool expulsion. Foundation for Child behavior, and impairment of learning (8-12). Development, Policy Brief Series no. 7. http://medicine.yale.edu/ childstudy/zigler/Images/PreKExpulsionBrief2_tcm350-34772.pdf. Factors supporting prohibition of certain methods of disci- 5. National Scientific Council on the Developing Child. 2008. Mental pline include current child development theory and practice, health problems in early childhood can impair learning and behavior legal aspects (namely, that a caregiver/teacher does not for life. Working paper #6. http://developingchild.harvard.edu/ foster a relationship with the child in place of the parents/ library/reports_and_working_papers/working_papers/wp6/. guardians), and increasing liability suits. The American 6. Perry, D. F., M. C. Dunne, L. McFadden, D. Campbell. 2008. - Academy of Pediatrics (AAP) is opposed to the use of cor Reducing the risk for preschool expulsion: Mental health poral punishment (12). Physicians, educators, and caregiv- J Child consultation for young children with challenging behaviors. ers/teachers should neither inflict nor sanction corporal 17:44-54. Family Studies punishment (11). STANDARD 2.2.0.9: Prohibited Caregiver/ COMMENTS: Appropriate alternatives to corporal punish- Teacher Behaviors ment vary as children grow and develop. As infants become more mobile, the caregiver/teacher must create a safe The following behaviors should be prohibited in all child care space and impose limitations by encouraging activities that settings and by all caregivers/teachers: distract them from harmful situations. Brief verbal expres- The use of corporal punishment. Corporal a) sions of disapproval help prepare infants and toddlers for punishment means punishment inflicted directly on later use of reasoning. However, the caregiver/teacher the body including, but not limited to: cannot expect infants and toddlers to be controlled by Hitting, spanking (refers to striking a child with an 1) verbal reprimands. Preschoolers have begun to develop an open hand on the buttocks or extremities with the understanding of rules and can be expected to understand intention of modifying behavior without causing “time-out” (out-of-group activity) under adult supervision as physical injury), shaking, slapping, twisting, a consequence for undesirable behavior. School-age chil- pulling, squeezing, or biting; dren begin to develop a sense of personal responsibility and Demanding excessive physical exercise, excessive 2) self-control and will recognize the removal of privileges (12). rest, or strenuous or bizarre postures; This standard covers any behaviors that threaten the safety 3) Compelling a child to eat or have in his/her mouth and security of children. This would include behaviors that soap, food, spices, or foreign substances; occur among or between staff. Children should not see hit- Exposing a child to extremes of temperature. 4) ting, ridicule, etc. among staff members. Even though adults b) Isolating a child in an adjacent room, hallway, closet, may state that the behaviors are “playful,” children cannot darkened area, play area, or any other area where a distinguish this. child cannot be seen or supervised; c) Binding or tying to restrict movement, such as in a “In the wake of well-publicized allegations of child abuse car seat (except when travelling) or taping the mouth; in out-of-home settings and increased concerns regarding d) Using or withholding food as a punishment or reward; liability, some programs have instituted no-touch policies, e) Toilet learning/training methods that punish, demean, either explicitly or implicitly. No-touch policies are misguided or humiliate a child; efforts that fail to recognize the importance of touch to chil- f) Any form of emotional abuse, including rejecting, dren’s healthy development. Touch is especially important terrorizing, extended ignoring, isolating, or corrupting for infants and toddlers. Warm, responsive touches convey a child; regard and concern for children of any age. Adults should g) Any abuse or maltreatment of a child, either as be sensitive to ensuring that their touches (such as pats on an incident of discipline or otherwise. Any child the back, hugs, or ruffling the child’s hair) are welcomed by care program must not tolerate, or in any manner the children and appropriate to their individual characteris- Chapter 2: Program Activities 75

106 Caring for Our Children: National Health and Safety Performance Standards of restraint in the event of behavior that endangers his or tics and cultural experience. Careful, open communication her safety or the safety of others, a behavioral care plan between the program and families about the value of touch should be developed with input from the child’s primary care in children’s development can help to achieve consensus provider, mental health provider, parents/guardians, center as to acceptable ways for adults to show their respect and director/family child care home caregiver/teacher, child support for children in the program” (13). care health consultant, and possibly early childhood mental Center; Large Family Child Care Home; Small TYPE OF FACILITY: health consultant in order to address underlying issues and Family Child Care Home reduce the need for physical restraint. RELATED STANDARDS: That behavioral care plan should include: Standard 2.2.0.6: Discipline Measures Biting, and Hitting Standard 2.2.0.7: Handling Physical Aggression, An indication and documentation of the use of other a) Standard 2.2.0.10: Using Physical Restraint behavioral strategies before the use of restraint Standards 3.4.4.1-3.4.4.5: Child Abuse and Neglect and a precise definition of when the child could be Standard 4.5.0.11: Prohibited Uses of Food restrained; Standard 9.2.1.6: Written Discipline Policies b) That the restraint be limited to holding the child as REFERENCES: gently as possible to accomplish the restraint; 1. New York State Office of Children and Family Services. Child care c) That such child restraint techniques do not violate the forms, licensed/ registered provider. http://www.ocfs.state.ny.us/ state’s mental health code; main/forms/day_care/. d) That the amount of time the child is physically . 2. The Children’s Foundation. Family child care licensing study restrained should be the minimum necessary 2000. Washington, DC: The Children’s Foundation. to control the situation and be age-appropriate; 3. Azer, S., D. Eldred. 1998. Training requirements in child care reevaluation and change of strategy should be used . Boston, MA: Center for Career Development licensing regulations every few minutes; in Early Care and Education, Wheelock College. That no bonds, ties, blankets, straps, car seats, e) 4. Meadows, A., ed. 1991. Caring for America’s Children . heavy weights (such as adult body sitting on child), or Washington, DC: National Academy of Sciences and National Research Council. abusive words should be used; 5. Gershoff, E. T. 2002. Corporal punishment by parents and f) That a designated and trained staff person, who associated child behaviors and experiences: A meta-analytic and should be on the premises whenever this specific Psychological Bulletin 128:539-79. theoretical review. child is present, would be the only person to carry 6. Slade, E. P., L. S. Wissow. 2004. Spanking in early childhood and out the restraint. later behavior problems: A prospective study of infants and young Pediatrics 113:1321-30. toddlers. RATIONALE: A child could be harmed if not restrained 7. Grogan-Kaylor, A. 2005. Corporal punishment and the growth properly (1). Therefore, staff who are doing the restraining trajectory of children’s antisocial behavior. Child Maltreatment must be trained. A clear behavioral care plan needs to be in 10:283-92. place. And, clear documentation with parent/guardian noti- 8. Straus, M. A., et al. 1997. Spanking by parents and subsequent fication needs to be done after a restraining incident occurs Arch Pediatric Adolescent Medicine antisocial behavior of children. in order to conform with the mental health code. 151:761-67. 9. Deater-Deckard, K., et al. 1996. Physical discipline among African If all strategies described in Standard 2.2.0.6 COMMENTS: American and European American mothers: Links to children’s are followed and a child continues to behave in an unsafe externalizing behaviors. Dev Psychology 32:1065-72. manner, staff need to physically remove the child from the 10. Weiss, B., et al. 1992. Some consequences of early harsh situation to a less stimulating environment. Physical removal discipline: Child aggression and a maladaptive social information of a child is defined according the development of the child. 63:1321-35. Child Dev processing style. If the child is able to walk, staff should hold the child’s hand 11. American Academy of Pediatrics, Committee on School Health. and walk him/her away from the situation. If the child is not Pediatrics 2006. Policy statement: Corporal punishment in schools. ambulatory, staff should pick the child up and remove him/ 188:1266. her to a quiet place where s/he cannot hurt themselves or 12. American Academy of Pediatrics, Committee on Psychological others. Staff need to remain calm and use a calm voice Aspects of Child and Family Health. 2004. Policy statement: 114:1126. Guidance for effective discipline. Pediatrics when directing the child. Certain procedures described in 13. National Association for the Education of Young Children. 1996. Standard 2.2.0.6 can be used at this time, including not Position Statement. Prevention of child abuse in early childhood giving a lot of attention to the behavior, distracting the child programs and the responsibilities of early childhood professionals and/or giving a time-out to the child. If the behavior persists, to prevent child abuse. a plan needs to be made with parental/guardian involve- ment. This plan could include rewards or a sticker chart STANDARD 2.2.0.10: Using Physical Restraint and/or praise and attention for appropriate behavior. Or, loss Reader’s Note: It should never be necessary to physically re- of privileges for inappropriate behavior can be implemented, strain a typically developing child unless his/her safety and/ if age-appropriate. Staff should request or agree to step out or that of others are at risk. of the situation if they sense a loss of their own self-control and concern for the child. When a child with special behavioral or mental health is- sues is enrolled who may frequently need the cautious use 76 Chapter 2: Program Activities

107 Caring for Our Children: National Health and Safety Performance Standards ians should meet with their child’s caregiver/teacher or the The use of safe physical restraint should occur rarely and director annually to discuss how their child is doing in the only for brief periods to protect the child and others. Staff program. On a daily basis, parents/guardians and caregiv- should be alert to repeated instances of restraint for indi- ers/teachers should share information about the child’s vidual children or within a indoor and outdoor learning/play health, changes in drop-off or pick-up times, and changes in environment and seek consultation from health and mental family routines or family events. Caregivers/teachers should health consultants in collaboration with families to develop communicate regularly with parents/guardians by providing more appropriate strategies. injury report forms if their child sustains an injury, posting TYPE OF FACILITY: Center; Large Family Child Care Home; Small notices of exposures to infectious diseases, and greeting Family Child Care Home the parent/guardian at drop-off each day. Parents/guardians RELATED STANDARDS: should receive a copy of the child care programs’ written Standard 2.2.0.6: Discipline Measures policies, including health and safety policies. REFERENCES: Caregivers/teachers should informally share with parents/ 1. Safe and Responsive Schools. 2003. Effective responses: guardians daily information about their child’s needs and Physical restraint. http://www.unl.edu/srs/pdfs/physrest.pdf. activities. Transition reports on any symptoms that the child devel- 2.3 Parent/Guardian Relationships oped, differences in patterns of appetite or urinating, and activity level should be exchanged to keep parents/guard- 2.3.1 General ians informed. RATIONALE: This plan will help achieve the important goal STANDARD 2.3.1.1: Mutual Responsibility of of carryover of facility components from the child care set- Parents/Guardians and Staff ting to the child’s home environment. The child’s learning of The quality of the relationship between parents/guardians new skills is a continuous process occurring both at home and caregivers/teachers has an influence on the child. There and in child care. should be a reciprocal responsibility of the family and care- Research, practice, and accumulated wisdom attest to the givers/teachers to observe, participate, and be trained in the crucially important influence of children’s relationships with - care that each child requires, and they should be encour those closest to them. Children’s experience in child care aged to work together as partners in providing care. will be most beneficial when parents/guardians and caregiv- During the enrollment process, caregivers/teachers should ers/teachers develop feelings of mutual respect and trust. clarify who is/are the legal guardian(s) of the child. All In such a situation, children feel a continuity of affection and relevant legal documents, court orders, etc., should also be concern, which facilitates their adjustment to separation and collected and filed during the enrollment process (1). Care- use of the facility. Especially for infants and toddlers, atten- givers/teachers should comply with court orders and written tion to consistency across settings will help minimize stress consent from the parent/guardian with legal authority, and that can result from notable differences in routines across not try to make the determination themselves regarding the caregivers/teachers and settings. best interests of the child. Another ongoing source of stress for an infant or a young All aspects of child care programs should be designed child is the separation from those they love and depend to facilitate parent/guardian input and involvement. Non- upon. Of the various programmatic elements in the facility custodial parents should have access to the same devel- that can help to alleviate that stress, by far the most impor - opmental and behavioral information given to the custodial tant is the comfort in knowing that parents/guardians and parent/guardian, if they have joint legal custody, permission caregivers/teachers know the children and their needs and by court order, or written consent from the custodial parent/ wishes, are in close contact with each other, and can re- guardian. spond in ways that enable children to deal with separation. Caregivers/teachers should also clarify with whom the child The encouragement and involvement of parents/guard- spends significant time and with whom the child has primary ians in the social and cognitive leaps of the child provides relationships as they will be key informants for the caregiv- parents/guardians with the confidence vital to their sense of ers/teachers about the child and his/her needs. competence. Caregivers/teachers should be able to direct parents/guardians to sources of information and activities Parent/guardian involvement is needed at all levels of that support child’s development and learning and be able the program, including program planning for indoors and to assist them to obtain appropriate screening and assess- outdoors, provision of quality care, screening for children ment when there are concerns. Communication should be who are ill, and support for other parents/guardians. Com- sensitive to ethnic and cultural practices. The parent/guard- munication between the administrator, caregiver/teacher ian/caregiver/teacher partnership models positive adult and parent/guardian are essential to facilitate the involve- behavior for school-age children and demonstrates a mutual ment and commitment of parents/guardians. Parents/ concern for the child’s well-being (2-16). guardians should be invited to participate on the program board or planning meetings for the program. Parents/guard- Chapter 2: Program Activities 77

108 Caring for Our Children: National Health and Safety Performance Standards and that, under normal circumstances, they will be admit- In families where the parents/guardians are separated, it is ted without delay. This open-door policy should be part of usually in the child’s best interest for both parents/guardians the “admission agreement” or other contract between the to be involved in the child’s care, and informed about the parent/guardian and the facility/caregiver/teacher. Parents/ child’s progress and problems in care. However, it is up to guardians should be welcomed and encouraged to speak the courts to decide who has legal custody of the child. freely to staff about concerns and suggestions. Parents/ Center; Large Family Child Care Home; Small TYPE OF FACILITY: guardians must be informed what appropriate and inappro- Family Child Care Home priate parental/guardian behavior is and the consequences RELATED STANDARDS: for inappropriate behavior. Standard 2.1.1.5: Helping Families Cope with Separation Standard 2.1.1.7: Communication in Native Language Other than Authorized family members and parents/guardians should English check in with the facility staff every visit to ensure safety of Standard 2.1.1.8: Diversity in Enrollment and Curriculum the children in the facility. Standard 2.1.1.9: Verbal Interaction Requiring unrestricted access of parents/ RATIONALE: REFERENCES: guardians to their children is essential to preventing the 1. Public Counsel Law Center in California. Guidelines for Releasing abuse and neglect of children in child care (1,2). When ac- Children and Custody Issues. http://www.publiccounsel.org/ cess is restricted, areas observable by the parents/guard- publications/release.pdf. ians may not reflect the care the children actually receive. 2. Mayr, T., M. Ulich. 1999. Children’s well-being in day care centers: An exploratory empirical study. nt J Early Years Educ I COMMENTS: Caregivers/teachers should not release 7:229-39. a child to a parent/guardian who appears impaired (see 3. Marshall, N. L. 1991. Empowering low-income parents: The role Standard 9.2.4.1). Caregivers/teachers should not attempt of child care . Boston, MA: EDRS. on their own to handle an unstable (e.g., intoxicated) parent/ 4. Greenman, J. 1998. Parent partnerships: What they don’t teach guardian who wants to be admitted but whose behavior you can hurt. Child Care Infor Exch 124:78-82. poses a risk to the children. Caregivers/teachers should A call to action: Family involvement as a 5. Shores, E. J. 1998. consult local police or the local child protection agency . Tallahassee, FL: critical component of teacher education programs about their recommendations for how staff can obtain sup- Southeastern Regional Vision for Education. 6. Massachusetts State Office for Children. Establishing a port from law enforcement authorities. . successful family daycare home: A resource guide for providers Parents/guardians can be interviewed to see if the open- 1990. Boston: MA State Office for Children. door policy is consistently implemented. 7. Tijus, C. A., et al. 1997. The impact of parental involvement on 5:7-20. Int J Early Years Educ the quality of day care centers. Center; Large Family Child Care Home; Small TYPE OF FACILITY: 8. Jones, R. 1996. Producing a school newsletter parents will read. Family Child Care Home 107:91-3. Child Care Infor Exch RELATED STANDARDS: ASQ: Assessing school age child care 9. O’Connor, S., et al. 1996. Standard 2.1.1.7: Communication in Native Language Other than . Wellesly, MA: Center for Research on Women. quality English 10. Powell, D. R. 1998. Reweaving parents back into the fabric of Standards 2.3.2.1-2.3.3.1: Parent/Guardian Involvement 53:60- early childhood programs: Research in review. Young Child Standard 9.2.1.1: Content of Policies 67. Standard 9.2.1.3: Enrollment Information to Parents/Guardians and 11. Miller, S. H., et al. 1995. Family support in early education and Caregivers/Teachers child care settings: Making a case for both principles and practices. Standard 9.2.4.1: Written Plan and Training for Handling Urgent 23:26-29. Child Today Medical Care or Threatening Incidents 12. Dombro, A. L. 1995. Sharing the care: What every provider and parent needs to know. Child Today 23:22-5. REFERENCES: 13. Larner, M. 1995. Linking family support and early childhood 1. Koralek, D., U.S. Department of Health and Human Services. programs: Issues, experiences, opportunities: Best practices Caregivers of young children: Preventing and responding to 1992. project , 1-40. Chicago, IL: Family Resource Coalition. . Rev ed. The user manual series. McLean, VA: child maltreatment 14. Endsley, R. C., et al. 1993. Parent involvement and quality day Circle, Inc. 7:53-61. care in proprietary centers. J Res Child Educ Handbook on quality child 2. Baglin, C. A., M. Bender, eds. 1994. 15. Fagan, J. 1994. Mother and father involvement in day care . San care for young children: Settings standards and resources Early Child Dev Care centers serving infants and young toddlers. Diego, CA: Singular Publishing Group. 103:95-101. 16. Seibel, N. L., L. G. Gillespie, and T. Temple. 2008. The role of 2.3.2 Regular Communication Zero to Three 28:33- child care providers in child abuse prevention. 40. STANDARD 2.3.2.1: Parent/Guardian Conferences STANDARD 2.3.1.2: Parent/Guardian Visits - Along with short informal daily conversations between par Parents/guardians are welcome any time their child is in ents/guardians and caregivers/teachers, and as a supple- attendance. ment to the collaborative relationships caregivers/teachers Caregivers/teachers should inform all parents/guardians that and parents/guardians form specifically to support infants they may visit the site at any time when their child is there, and toddlers, periodic and regular planned communication Chapter 2: Program Activities 78

109 Caring for Our Children: National Health and Safety Performance Standards Review of the health record can be a valuable educational (e.g., parent/guardian conferences) should be scheduled tool for parents/guardians, through better understanding of with at least one parent/guardian of every child in care: the health report and immunization requirements (1). A goal a) To review the child’s adjustment to care and of out-of-home care of infants and children is to identify development over time; parents/guardians who are in need of instruction so they To reach agreement on appropriate disciplinary b) can provide preventive health/nutrition/physical activity care measures; at a critical time during the child’s growth and development. To discuss the child’s strengths, specific health c) It is in the child’s best interest that the staff communicates issues, special needs, and concerns; with parents/guardians about the child’s needs and prog- To stay informed of family issues that may affect the d) ress. Parent/guardian support groups and parent/guardian child’s behavior in care; involvement at every level of facility planning and delivery To identify goals for the child; e) are usually beneficial to the children, parents/guardians, f) To discuss resources that parents/guardians can and staff. Communication among parents/guardians whose access; children attend the same facility helps the parents/guardians g) To discuss the results of developmental screening. to share useful information and to be mutually supportive. At these planned conferences a caregiver/teacher should The need for follow-up on needed interven- COMMENTS: review with the parent/guardian the child’s health report, tion increases when an understanding of the need and and the health record and assessments of development and motivation for the intervention has been achieved through learning that the program may do to identify medical and personal contact. A health history ensures that all informa- developmental issues that require follow-up or adjustment tion needed to care for the child is available to the appropri- by the facility. ate staff member. Special instructions, such as diet, can be Each review should be documented in the child’s health re- copied for everyday use. Compliance can be assessed by cord with the signature of the parent/guardian and the staff reviewing the records of these planned communications. reviewer. These planned conferences should occur: Parents/guardians who use child care services should be a) As part of the intake process; regarded as active participants and partners in facilities that At each health update interval; b) meet their needs as well as their children’s. Especially for c) On a calendar basis, scheduled according to the infants and toddlers, authentic relationships are crucial to child’s age: the optimal development of the child. Compliance can be 1) Every six months for children under six years measured by interviewing parents/guardians and staff. of age and for children with special health care needs; Center; Large Family Child Care Home; Small TYPE OF FACILITY: Every year for children six years of age and older; 2) Family Child Care Home Whenever new information is added to the child’s d) RELATED STANDARDS: facility health record. Standard 1.3.2.7: Qualifications and Responsibilities for Health Advocates Additional conferences should be scheduled if the parent/ Standard 4.2.0.2: Assessment and Planning of Nutrition for Indi- guardian or caregiver/teacher has a concern at any time vidual Children about a particular child. Any concern about a child’s health Standards 9.2.3.4-9.2.3.8: Plan for Child Health Services or development should not be delayed until a scheduled Standards 9.4.2.1-9.4.2.8: Health Reports/Records conference date. REFERENCES: Notes about these planned communications should be . 4th ed. Bryn 1. Aronson, S. 2002. Model Child Care Health Policies maintained in each child’s record at the facility and should Mawr, PA: American Academy of Pediatrics, Pennsylvania Chapter. be available for review. 2. Connell, C. M., R. J. Prinz. 2002. The impact of childcare and parent–child interactions on school readiness and social skills Parents/guardians and caregivers/teachers RATIONALE: J of School development for low-income African American children. alike should be aware of, and should have arrived at, an Psychology 40:177-93. agreement concerning each other’s beliefs and knowledge about how to care for children. Reviewing the health record STANDARD 2.3.2.2: Seeking Parent/Guardian with parents/guardians ensures correct information and can Input be a valuable teaching and motivational tool (1). It can also be a staff learning experience, through insight gained from At least twice a year, each caregiver/teacher should seek parents/guardians on a child’s special circumstances. the views of parents/guardians about the strengths and needs of the indoor and outdoor learning/play environment Studies have shown that parent–child interactions charac- and their satisfaction with the services offered. Caregivers/ terized as structured and responsive to the child’s needs teachers should honor parents’/guardians’ requests for and emotions were positively related to school readiness, more frequent reviews. Anonymous surveys can be offered social skills, and receptive communication skills develop- as a way to receive parent/guardian input without parents/ ment (2). guardians feeling concerned if they have negative com- A health history is the basis for meeting the child’s health, ments or concerns about the facility or practices within a mental, safety, and social needs in the child care setting (1). facility. Chapter 2: Program Activities 79

110 Caring for Our Children: National Health and Safety Performance Standards ents’/guardians’ knowledge of administration of the facility Parents/guardians and caregiver/teacher alike RATIONALE: and develops and enhances advocacy efforts (1). recognize that parents/guardians have essential rights in helping to shape the kind of child care service their children Encouraging parents’/guardians’ communication is simple, receive (1). inexpensive, and beneficial. Such communication may include the exchange of positive aspects of the facility and Asking parents/guardians about their con- COMMENTS: positive knowledge about children’s peers. If parents/guard- cerns and observations is essential so they can share issues ians communicate with each other, they can share concerns and engage with staff in collaborative problem-solving. about the behavior of a specific caregiver/teacher and can Small and large family child care homes should have group identify patterns of action suggestive of abuse/neglect. meetings of all parents/guardians once or twice a year. This Parents/guardians can encourage each other to report all standard avoids mention of procedures that are inappro- concerns to the director or owner of the program. priate to small family child care, as it does not require any explicit mechanism (such as a parent/guardian advisory Parent/guardian meetings within a facility are COMMENTS: council) for obtaining or offering parental/guardian input. useful means of communication that supplement mailings Individual or group meetings with parents/guardians would and indirect contacts. suffice to meet this standard. Seeking consumer input is a Center; Large Family Child Care Home; Small TYPE OF FACILITY: cornerstone of facility planning and evaluation. Centers can Family Child Care Home offer parents/guardians the chance to respond in writing. REFERENCES: Accreditation organizations such as the National Association 1. National Association of Child Care Resource and Referral for the Education of Young Children (NAEYC) or the National Agencies. It’s a win-win situation: When parents and providers work Association for Family Child Care (NAFCC) have guidance together. Child Care Aware. http://ccaapps.childcareaware.org/en/ on conducting parent/guardian surveys. subscriptions/dailyparent/volume.php?id=29. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 2.3.2.4: Parent/Guardian REFERENCES: Complaint Procedures 1. National Association of Child Care Resource and Referral Facilities should have in place complaint resolution proce- Agencies. It’s a win-win situation: When parents and providers work dures to jointly resolve with parents/guardians any problems together. Child Care Aware. http://ccaapps.childcareaware.org/en/ that may arise. Arrangements for hearing (or receiving) the subscriptions/dailyparent/volume.php?id=29. complaint and the actions (or discussion) resulting in resolu- tion should be documented along with dates and people STANDARD 2.3.2.3: Support Services for involved. Facilities should develop mechanisms for holding Parents/Guardians formal and informal meetings between staff and groups Caregivers/teachers should establish parent/guardian of parents/guardians. Substantiated complaints and their groups and parent/guardian support services. Caregivers/ resolution(s) should be posted in a prominent location. Fa- teachers should have a regularly established means of cilities should post the complaint and resolution procedure communicating to parents/guardians the existence of these where parents/guardians can easily see (or view) them. groups and support services. Caregivers/teachers should - Coordination between the facility and the par RATIONALE: document these services and should include intra-agency ents/guardians is essential to promote their respective child activities or other community support group offerings. The care roles and to avoid confusion or conflicts surrounding caregiver/teacher should record parental/guardian participa- values. In addition to routine meetings, special meetings can tion in these on-site activities in the facility record. deal with crises and unique problems. Complaint and reso- One strategy for supporting parents/guardians is to facili- lution documentation records can help program directors tate communication among parents/guardians. The facility assess problem areas of the facility, staff, and services. should give consenting parents/guardians a list of names COMMENTS: Special meetings could identify facility needs, and phone numbers of other consenting parents/guard- assist in developing resources, and recommend facility and ians whose children attend the same facility. The list should policy changes to the governing body. It is most helpful to include an annotation encouraging parents/guardians whose document the proceedings of these meetings to facilitate children attend the same facility to communicate with one future communications and to ensure continuity of service another about the service. The facility should update the list delivery. Facility-sponsored activities could take place out- at least annually. side facility hours and at other venues. Parental/guardian involvement at every level RATIONALE: Center; Large Family Child Care Home; Small TYPE OF FACILITY: of program planning and delivery and parent/guardian Family Child Care Home support groups are elements that are usually beneficial to RELATED STANDARDS: the children, parents/guardians, and staff of the facility (1). Standard 1.8.2.5: Handling Complaints About Caregivers/Teachers The parent/guardian association group facilitates mutual Standard 9.1.0.1: Governing Body of the Facility understanding between the program and parents/guardians. Standard 9.1.0.2: Written Delegation of Administrative Authority Parental/guardian involvement also helps to broaden par - Standard 9.4.1.4: Access to Facility Records 80 Chapter 2: Program Activities

111 Caring for Our Children: National Health and Safety Performance Standards Standard 10.4.3.1: Procedure for Receiving Complaints Specialists should use the facility’s sign in/sign out system for accurate tracking of their interactions with or on behalf of the child. 2.3.3 Health Information Sharing Therapeutic services must be coordinated RATIONALE: STANDARD 2.3.3.1: Parents’/Guardians’ with the child’s general education program and with the Provision of Information on Their Child’s parents/guardians and caregivers/teachers so everyone un- derstands the child’s needs. To be most useful, the service Health and Behavior providers must share the therapeutic techniques with the The facility should ask parents/guardians for information caregivers/teachers and parents/guardians and integrate regarding the child’s health, nutrition, level of physical activ- them into the child’s daily routines, not just at therapy ses- ity, and behavioral status upon registration or when there sions. Parent/guardian consent to share information may be has been an extended gap in the child’s attendance at the necessary. A child care health consultant can be helpful in facility. The child’s health record should be updated if s/ coordinating these techniques and treatments. he have had any changes in their health or immunization TYPE OF FACILITY: Center; Large Family Child Care Home; Small status. Parents/guardians should be encouraged to sign a Family Child Care Home release of information/agreement so that child care workers can communicate directly with the child’s medical home/ RELATED STANDARDS: Standard 9.2.4.7: Sign-In/Sign-Out System primary care provider. Standards 9.4.2.1-9.4.2.8: Child Records Admission of children without this informa- RATIONALE: tion will leave the center unprepared to deal with daily and emergent health needs of the child, other children, and staff 2.4 Health Education if there is a question of communicability of disease. It would be helpful to also have updated in- COMMENTS: 2.4.1 Health Education for Children formation about the health status of parents/guardians and siblings, noting any special conditions, circumstances, or STANDARD 2.4.1.1: Health and Safety stress that may be affecting the child in care. Some parents/ Education Topics for Children guardians may resist providing this information. If so, the Health and safety education for children should include caregiver/teacher should invite them to view this exchange physical, oral, mental, emotional, nutritional, and social of information as an opportunity to express their own con- health and should be integrated daily into the program of cerns about the facility (1). activities, to include such topics as: Center; Large Family Child Care Home; Small TYPE OF FACILITY: Body awareness and use of appropriate terms for a) Family Child Care Home body parts; RELATED STANDARDS: Families (including information that all families b) Standards 3.6.1.1-3.6.1.2: Inclusion/Exclusion Due to Illness are different and have unique beliefs and cultural Standard 9.2.1.3: Enrollment Information to Parents/Guardians and heritage); Caregivers/Teachers c) Personal social skills such as sharing, being kind, Standard 9.4.2.1: Contents of Child’s Records helping others, and communicating appropriately; REFERENCES: d) Expression and identification of feelings; 1. Crowley, A. A., G. C. Whitney. 2005. Connecticut’s new e) Self-esteem; comprehensive and universal early childhood health assessment f) Nutrition, healthy eating (preventing obesity); J School Health form. 75:281-85. g) Outdoor learning/play; Fitness and age-appropriate physical activity; h) STANDARD 2.3.3.2: Communication from i) Personal and dental hygiene including wiping, Specialists flushing, handwashing, cough and sneezing etiquette and toothbrushing; Health and safety, education, and other specialists/profes- j) Safety (such as home, vehicular car seats and safety sionals who come into the facility to furnish special ser - belts, playground, bicycle, fire, and firearms, water vices to a child should communicate at each visit with the safety, personal safety, what to do in an emergency, caregiver/teacher at the facility. The specialist/professional getting help and/or dialing 9-1-1 for emergencies); must also be certain that all communication shared with k) Conflict management, violence prevention, and caregivers/teachers is shared directly with the parent/guard- bullying prevention; ian. These specialists may include, but are not limited to, l) Age-appropriate first aid concepts; physicians, registered nurses, child care health consultants, Healthy and safe behaviors; m) behavioral consultants (e.g., psychologists, counselors, Poisoning prevention and poison safety; n) clinical social workers), occupational therapists, physical Awareness of routine preventive and special health o) therapists, speech therapists, educational therapists, regis- care needs; tered dietitians, and play facilitator. The discussions should p) Importance of rest and sleep; be documented in the child’s Care Plan. q) Health risks of secondhand smoke; Chapter 2: Program Activities 81

112 Caring for Our Children: National Health and Safety Performance Standards Caregivers/teachers should talk about and model healthy r) Taking medications; and safe behaviors while they carry out routine daily activi- s) Handling food safely; and - ties. Activities should be accompanied by words of encour t) Preventing choking and falls. agement and praise for achievement. For young children, health and safety edu- RATIONALE: Facilities should encourage and support staff who wish to cation are inseparable from one another. Children learn breastfeed their own infants and those who engage in gar - about health and safety by experiencing risk taking and dening to enhance interest in healthy food, science, inquiries risk control, fostered by adults who are involved with them. and learning. Staff are consistently a model for children and Whenever opportunities for learning arise; caregivers/teach- should be cognizant of the environmental information and ers should integrate education to promote healthy and safe print messages they bring into the indoor and outdoor learn- behaviors (1). Health and safety education does not have to ing/play environment. The labels and print messages that be seen as a structured curriculum, but as a daily compo- are present in the indoor and outdoor learning/play environ- nent of the planned program that is part of child develop- ment or family child care home should be in line with the ment. Health and safety education supports and reinforces healthy and safe behaviors and attitudes they wish to impart a healthy and safe lifestyle (1,2). to the children. COMMENTS: Teaching children the appropriate names for Facilities should use developmentally appropriate health and their body parts is a good way to increase self esteem and safety education materials in the children’s activities and personal safety. Learning about routine health maintenance should also share these with the families whenever possible. practices such as receiving vaccines, having vision screen- ing, blood pressure screening, oral health examinations, All health and safety education activities should be geared and blood tests helps children understand these activities to the child’s developmental age and should take into ac- and appreciate their value rather than fearing them. Simi- count individual personalities and interests. larly, learning about the importance of fitness choices helps RATIONALE: Modeling is an effective way of confirming children make responsible healthful decisions when facing that a behavior is one to be imitated. Young children are abundant temptation to do otherwise. particularly dependent on adults for their nutritional needs Certified health education specialists (CHES) are good in both the home (1) and child care environment (2). Thus, resources for this instruction. The American Association modeling healthy and safe behaviors is an important way for Health Education (AAHE), the National Commission for to demonstrate and reinforce healthy and safe behaviors of Health Education Credentialing. (NCHEC), and the State and caregivers/teachers and children. Young children learn bet- Territorial Injury Prevention Directors’ Association (STIPDA) ter through experiencing an activity and observing behav- provide information on this specialty. ior than through didactic training (3,4). Learning and play Center; Large Family Child Care Home; Small TYPE OF FACILITY: have a reciprocal relationship; play experiences are closely Family Child Care Home related to learning (5). REFERENCES: - Caregivers/teachers impact the nutrition habits of the chil 1. Gupta, R. S., S. Shuman, E. M. Taveras, M. Kulldorff, J. A. dren under their care, not only by making choices regard- Finkelstein. 2005. Opportunities for health promotion education in ing the types of foods that are available but by influencing Pediatrics 116: e499-e505. child care. children’s attitudes and beliefs about that food as well as 2. Hemmeter, M. L., L. Fox, S. Jack, L. Broyles. 2007. A program- social interactions at mealtime. This provides a unique wide model of positive behavior support in early childhood settings. opportunity for programs to guide children’s choices by J Early Intervention 29:337-55. assigning parents/guardians and caregivers/teachers to the role of nutritional gatekeepers for the young children in their STANDARD 2.4.1.2: Staff Modeling of Healthy care. Such intervention is consistent with the USDA and and Safe Behavior and Health and Safety U.S. Department of Health and Human Services (DHHS) re- Education Activities cent release of 2010 Dietary Guidelines for Americans. The The program should strongly encourage all staff members Dietary Guidelines focus on increased healthy eating and to model healthy and safe behaviors and attitudes in their physical activity to reduce the current rate of overweight or contact with children in the indoor and outdoor learning/ obesity in American children (one in three in the nation) (6). play environment, including, eating nutritious foods, drinking The effectiveness of health and safety education is en- water or nutritious beverages when with the children, sitting hanced when shared between the caregiver/teacher and the with children during mealtime, and eating some of the same parents/guardians (7). foods as the children. Caregivers/teachers should engage in COMMENTS: Caregivers/teachers are important in the lives daily movement and physical activity, limiting sedentary be- of the young children in their care. They should be educated haviors when in the outdoor learning/play environment (e.g., and supported to be able to interact optimally with the not sitting in structured chairs), not watching TV, and should children in their care. Compliance should be documented by comply with tobacco and drug use policies and handwash- observation. Consultation can be sought from a child care ing protocols. health consultant or certified health education specialist. The American Association for Health Education (AAHE) and 82 Chapter 2: Program Activities

113 Caring for Our Children: National Health and Safety Performance Standards 6. U.S. Department of Agriculture, “USDA and HHS Announce New the National Commission for Health Education Credentialing Dietary Guidelines to Help Americans Make Healthier Food Choices (NCHEC) provide information on this specialty. and Confront Obesity Epidemic,” press release June 2, 2011. An extensive education program to make such experiential 7. Holmes, M., et al. 1996. Promising partnerships: How to develop learning possible indoors and outdoors should be sup- . Alexandria, VA: National successful partnerships in your community ported by strong community resources in the form of both Head Start Association. 8. Gupta, R. S., S. Shuman, E. M. Taveras, M. Kulldorff, J. A. consultation and materials from sources such as the health Finkelstein. 2005. Opportunities for health promotion education in department, nutrition councils, and so forth. Suggestions for Pediatrics child care. 116: e499-505. topics and methods of presentation are widely available (8). 9. Kendrick, D., L. Groom, J. Stewart, M. Watson, C. Mulvaney, R. Examples include, but are not limited to, routine preventive Casterton. 2007. Risk Watch: Cluster randomized controlled trial care by health professionals, nutrition education and physi- Injury Prevention 13:93-99. evaluating an injury prevention program. cal activity to prevent obesity, crossing streets safely, how to develop and use outdoor learning/play environments, car STANDARD 2.4.1.3: Gender and Body restraint safety, poison safety, latch key programs, health Awareness risks from secondhand smoke, personal hygiene, and oral health, including limiting sweets, rinsing the mouth with The facility should prepare caregivers/teachers to appropri- water after sweets, and regular tooth brushing. It can be ately discuss with the children anatomical facts related to helpful to place visual cues in the indoor and outdoor learn- gender identity and sex differences. When talking with par - ing/play environments to serve as reminders (e.g., posters). ents/guardians, caregivers/teachers should take a general “Risk Watch” is a prepared curriculum from the National approach, while respecting cultural differences, acknowl- Fire Protection Association (NFPA) offering comprehensive edging that all children engage in fantasy play, dressing up injury prevention strategies for children in preschool through and trying out different roles (1). Caregivers/teachers should eighth grade (9). give children messages that contrast with stereotypes, such as men and women in non-traditional roles (2). Facilities TYPE OF FACILITY: Center; Large Family Child Care Home; Small - should strive for developing common language and under Family Child Care Home standing among all the partners. RELATED STANDARDS: Standard 2.2.0.3: Limiting Screen Time – Media, Computer Time Open discussions among adults concerning RATIONALE: Standard 2.4.1.1: Health and Safety Education Topics for Children childhood sexuality increase their comfort with the subject. Standard 3.1.3.1: Active Opportunities for Physical Activity The adults’ comfort may reduce children’s anxiety about Standard 3.1.3.2: Playing Outdoors sexuality (3,4). Standard 3.1.3.4: Caregivers’/Teachers’ Encouragement of Physical Discussing sexuality and gender identity COMMENTS: Activity Standard 3.2.2.1: Situations that Require Handwashing topics with young children is not always easy because Standard 3.2.2.2: Handwashing Procedure the views of facility administrators, caregivers/teachers, Standard 3.4.1.1: Use of Tobacco, Alcohol, and Illegal Drugs parents/guardians, and community leaders on these topics Standard 4.2.0.1: Written Nutrition Plan may differ. Standard 4.2.0.6: Availability of Drinking Water Center; Large Family Child Care Home; Small TYPE OF FACILITY: Standard 4.3.1.1: General Plan for Feeding Infants Family Child Care Home Standard 4.3.1.3: Preparing, Feeding, and Storing Human Milk Standard 4.3.2.2: Serving Size for Toddlers and Preschoolers REFERENCES: Standard 4.3.3.1: Meal and Snack Patterns for School-Age Children 1. Stein, M., K. Zuckert, S. Dixon. 2001. Sammy: Gender identity Standard 4.5.0.4: Socialization During Meals concerns in a six year old boy. Pediatrics 107:850-854. Standard 4.5.0.7: Participation of Older Children and Staff in Meal- 2. National Association for the Education of Young Children time Activities Teaching young children to resist bias (NAEYC). 1997. . Early Years Standard 4.6.0.2: Nutritional Quality of Food Brought from Home are Learning Years Series. Washington, DC: NAEYC. Standard 4.7.0.1: Nutrition Learning Experiences for Children 3. Couchenour, D., K. Chrisman. 2002. Healthy sexuality . development: A guide for early childhood educators and families REFERENCES: Washington, DC: National Association for the Education of Young 1. Lindsay, A. C., K. M. Sussner, J. Kim, S. Gortmaker. 2006. The Children. Future Child 16:169- role of parents in preventing childhood obesity. The transgender child: A handbook 4. Brill, S. A., R. Pepper. 2008. 86. for families and professionals . San Francisco: Cleis. 2. McBean, L. D., G. D. Miller. 1999. Enhancing the nutrition of 18:563-71. America’s youth. J Am College of Nutrition 3. Evaldsson, A., W. A. Corsaro. 1998. Play and games in the peer 2.4.2 Health Education for Staff cultures of preschool and preadolescent children: An interpretative 5:377-402. Childhood approach. STANDARD 2.4.2.1: Health and Safety 4. Hemmeter, M. L., L. Fox, S. Jack, L. Broyles. 2007. A program- Education Topics for Staff wide model of positive behavior support in early childhood settings. 29:337-55. J Early Intervention Health and safety education for staff should include physi- 5. Petersen, E. A. 1998. The amazing benefits of play. Child Fam cal, oral, mental, emotional, nutritional, physical activity, and 17:7-8. social health of children. In addition to the health and safety Chapter 2: Program Activities 83

114 Caring for Our Children: National Health and Safety Performance Standards RELATED STANDARDS: topics for children in Standard 2.4.1.1, health education top- Standards 1.4.2.1-1.4.6.2: Professional Training, Education, and ics for staff should include: Compensation Promoting healthy mind and brain development a) Standard 2.4.1.1: Health Education Topics for Children through child care; REFERENCES: Healthy indoor and outdoor learning/play b) 1. Gupta, R. S., S. Shuman, E. M. Taveras, M. Kulldorff, J. A. environments; Finkelstein. 2005. Opportunities for health promotion education in Behavior/discipline; c) 116: e499-e505. Pediatrics child care. Managing emergency situations; d) 2. Alkon, A., J. Bernzweig, K. To, M. Wolff, J. F. Mackie. 2009. Child Monitoring developmental abilities, including e) care health consultation improves health and safety policies and indicators of potential delays; practices. Academic Pediatrics 9:366–70. f) Nutrition (i.e., healthy eating to prevent obesity); 3. Crowley, A. A., M. S. Rosenthal. 2009. Ensuring the health g) Food safety; and safety of Connecticut’s early care and education programs. Water safety; h) Farmington, CT: The Child Health and Development Institute of i) Safety/injury prevention; Connecticut. http://www.chdi.org/admin/uploads/ 3074013304b154ef428c1a.pdf. j) Safe use, storage, and clean-up of chemicals; 4. Snohomish Health District: Child Care Health Program. Child care k) Hearing, vision, and language problems; health consultation: Evidence based effectiveness. http://www l) Physical activity and outdoor play and learning; .napnap.org/docs/CCS_SIG_Evidence_ Based_ CCHP.pdf. m) Appropriate antibiotic use; 5. Rosenthal, M. S., A. A. Crowley, L. Curry. 2009. Promoting child Immunizations; n) development and behavioral health: Family child care providers’ Gaining access to community resources; o) perspectives. J Pediatric Health Care 23:289-97. p) Maternal or parental/guardian depression; q) Exclusion policies; 2.4.3 Health Education for Parents/ r) Tobacco use/smoking; Guardians s) Safe sleep environments and SIDS prevention; t) Breastfeeding support (1); STANDARD 2.4.3.1: Opportunities for Environmental health and reducing exposures to u) environmental toxins; Communication and Modeling of Health and Children with special needs; v) Safety Education for Parents/Guardians w) Shaken baby syndrome and abusive head trauma; Parents/guardians should be given opportunities to observe Safe use, storage of firearms; x) staff members modeling healthy and safe behavior and y) Safe medication administration. facilitating child development, both indoors and outdoors. When child care staff are knowledgeable in RATIONALE: Parents/guardians should also have opportunities to ask health and safety practices, programs are more likely to questions and to describe how effective the modeling has be healthy and safe (2). Compliance with twenty hours per been. For parents/guardians who may not have the op- year of staff continuing education in the areas of health, portunity to visit their child or observe during the day, there safety, child development, and abuse identification was the should be alternate forms of communication between the most significant predictor for compliance with state child staff and the parents/guardians. This can be handouts, care health and safety regulations (3). Child care staff often written journals that would go between facility and home, receive their health and safety education from a child care newsletters, electronic communication, or events. health consultant. Data support the relationship between Modeling and communication about healthy RATIONALE: child care health consultation and the increased health and and safe behaviors that promote positive development can safety of a center (4,5). be an effective educational tool (1,2). COMMENTS: Community resources can provide written Center; Large Family Child Care Home; Small TYPE OF FACILITY: health- and safety-related materials. Consultation or training Family Child Care Home can be sought from a child care health consultant (CCHC) or REFERENCES: certified health education specialist (CHES). 1. Lehman, G. R., E. S. Geller. 1990. Participative education for Child care programs should consider offering “credit” for children: An effective approach to increase safety belt use. J Appl health education classes or encourage staff members to at- 23:219-25. Behav Anal tend accredited education programs that can give education 2. Lindsay, A. C., K. M. Sussner, J. Kim, S. Gortmaker. 2006. The credits. Future Child 16:169- role of parents in preventing childhood obesity. 86. The American Association for Health Education (AAHE), the National Commission for Health Education Credentialing STANDARD 2.4.3.2: Parent/Guardian (NCHEC), and the National Training Institute for Child Care Education Plan Health Consultants (NTI) provide information on certified health education specialists. The content of a parent/guardian education plan should be individualized to meet each family’s needs and should Center; Large Family Child Care Home; Small TYPE OF FACILITY: be sensitive to cultural values and beliefs. Written material, Family Child Care Home Chapter 2: Program Activities 84

115 Caring for Our Children: National Health and Safety Performance Standards ducting parent/guardian education (1,2). Parental/guardian at a minimum, should address the most important health behavior can be modified by education. Parents/guardians and safety issues for all age groups served, should be in a should be involved closely with the facility and be actively language understood by families, and may include the top- involved in planning parent/guardian education activities. If ics listed in Standard 2.4.1.1, with special emphasis on the done well, adult learning activities can be effective for edu- following: cating parents/guardians. If not done well, there is a danger a) Safety (such as home, community, playground, of demeaning parents/guardians and making them feel less, firearm, seat belts, safe medication administration rather than more, capable (1,2). procedures, poison awareness, vehicular, or bicycle, and awareness of environmental toxins and healthy The concept of parent/guardian control and empowerment choices to reduce exposure); is key to successful parent/guardian education in the child b) Value of developing healthy and safe lifestyle choices care setting. Support and education for parents/guardians early in life and parental/guardian health (such as lead to better parenting skills and abilities. exercise and routine physical activity, nutrition, weight Knowing the family will help the staff such as the health and control, breastfeeding, avoidance of substance abuse safety advocate determine content of the parent/guardian and tobacco use, stress management, maternal education plan and method for delivery. Specific attention depression, HIV/AIDS prevention); should be paid to the parents’/guardians’ need for sup- Importance of outdoor play and learning; c) port and consultation and help locating resources for their Importance of role modeling; d) problems. If the facility suggests a referral or resource, this e) Importance of well-child care (such as immunizations, should be documented in the child’s record. Specifics of hearing/vision screening, monitoring growth and what the parent/guardian shared need not be recorded. development); f) Child development and behavior including bonding COMMENTS: Community resources can provide writ- and attachment; ten health- and safety-related materials. School-age child g) Domestic and relational violence; care facilities may incorporate child health education into h) Conflict management and violence prevention; their programs as they can be integrated into their regular i) Oral health promotion and disease prevention; activities, (e.g., handwashing before snack, making health- j) Effective toothbrushing, handwashing, diapering, and ful snack choices, pointing out why screen time limits are in sanitation; place to promote physical activity, safe playground behav- Positive discipline, effective communication, and k) iors, and where possible, making an attempt to coordinate behavior management; with formal health education enrollees receive in school). l) Handling emergencies/first aid; Center; Large Family Child Care Home; Small TYPE OF FACILITY: m) Child advocacy skills; Family Child Care Home n) Special health care needs; RELATED STANDARDS: Information on how to access services such as the o) Standard 1.3.2.7: Qualifications and Responsibilities for Health supplemental food and nutrition program (i.e., The Advocates Women, Infants and Children [WIC] Supplemental Standard 2.4.1.1: Health Education Topics for Children Food Program), Food Stamps (SNAP), food pantries, REFERENCES: as well as access to medical/health care and services 1. Gonzalez-Mena, J. 1996. When values collide: Exploring a cross for developmental disabilities for children; 108:30-32. Child Care Infor Exch cultural issue. p) Handling loss, deployment, and divorce; 2. Hendricks, C., M. Russell, C. J. Smith. 1997. Staying healthy: The importance of routines and traditions (including q) Strategies for helping parents ensure their children’s health and well reading and early literacy) with a child. being. Child Fam 16:10-17. Health and safety education for parents/guardians should utilize principles of adult learning to maximize the potential for parents/guardians to learn about key concepts. Facilities should utilize opportunities for learning, such as the case of an illness present in the facility, to inform parents/guardians about illness and prevention strategies. The staff should introduce seasonal topics when they are relevant to the health and safety of parents/guardians and children. RATIONALE: Adults learn best when they are motivated, comfortable, and respected; when they can immediately apply what they have learned; and when multiple learning strategies are used. Individualized content and approaches are needed for successful intervention. Parent/guardian at- titudes, beliefs, fears, and educational and socioeconomic levels all should be given consideration in planning and con - Chapter 2: Program Activities 85

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117 Chapter 3 Health Promotion and Protection

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119 Caring for Our Children: National Health and Safety Performance Standards guardians and staff can exchange information when face-to- 3.1 Health Promotion in Child face is not possible. Care Center; Large Family Child Care Home; Small TYPE OF FACILITY: Family Child Care Home 3.1.1 Daily Health Check RELATED STANDARDS: Standard 1.6.0.1: Child Care Health Consultants STANDARD 3.1.1.1: Conduct of Daily Health Standard 3.6.1.1: Inclusion/Exclusion/Dismissal of Children Appendix A: Signs and Symptoms Chart Check Appendix F: Enrollment/Attendance/Symptom Record Every day, a trained staff member should conduct a health Appendix G: Recommended Immunization Schedules for Persons check of each child. This health check should be conducted Aged 0 Through 18 Years–United States, 2011 as soon as possible after the child enters the child care facility and whenever a change in the child’s behavior or STANDARD 3.1.1.2: Documentation of the appearance is noted while that child is in care. The health Daily Health Check check should address: The caregiver/teacher should conduct and document a daily a) Reported or observed illness or injury affecting health check of each child upon arrival. The daily health the child or family members since the last date of check documentation should be kept for one month. attendance; b) Reported or observed changes in behavior of RATIONALE: The vast majority of infectious diseases of the child (such as lethargy or irritability) or in the concern in child care have incubation periods of less than appearance (e.g., sad) of the child from the previous twenty-one days (1). This information may be helpful to pub- day at home or the previous day’s attendance at child lic health authorities investigating occasional outbreaks. care; The documentation should note that the daily COMMENTS: Skin rashes, impetigo, itching or scratching of c) health check was done and any deviation from the usual the skin, itching or scratching of the scalp, or the status of the child and family. presence of one or more live crawling lice; A temperature check if the child appears ill (a daily d) Center; Large Family Child Care Home; Small TYPE OF FACILITY: Family Child Care Home screening temperature check is not recommended); Other signs or symptoms of illness and injury (such e) RELATED STANDARDS: as drainage from eyes, vomiting, diarrhea, cuts/ Standards 9.4.1.9-9.4.1.11: Incidence Logs of Illness, Injury, and lacerations, pain, or feeling ill). Other Problems Standards 9.4.2.1-9.4.2.8: Child Records The caregiver/teacher should gain information necessary to REFERENCES: complete the daily health check by direct observation of the 1. California Childcare Health Program. CCHP health and safety child, by querying the parent/guardian, and, where appli- checklist. Rev. ed. http://www.ucsfchildcarehealth.org/html/pandr/ cable, by conversation with the child. formsmain.htm#hscr/. RATIONALE: Daily health checks seek to identify potential concerns about a child’s health including recent illness or 3.1.2 Routine Health Supervision injury in the child and the family. Health checks may serve to reduce the transmission of infectious diseases in child care STANDARD 3.1.2.1: Routine Health settings by identifying children who should be excluded, Supervision and Growth Monitoring and enable the caregivers/teachers to plan for necessary The facility should require that each child has routine health care while the child is in care at the facility. supervision by the child’s primary care provider, according The daily health check should be performed COMMENTS: to the standards of the American Academy of Pediatrics in a relaxed and comfortable manner that respects the (AAP) (3). For all children, health supervision includes routine family’s culture as well as the child’s body and feelings. screening tests, immunizations, and chronic or acute illness The child care health consultant should train the caregiver/ monitoring. For children younger than twenty-four months of teacher(s) in conducting a health check. The items in the age, health supervision includes documentation and plotting standard can serve as a checklist to guide learning the pro- of sex-specific charts on child growth standards from the cedure until it becomes routine. World Health Organization (WHO), available at http://www. The obtaining of information from the parent/guardian who.int/childgrowth/standards/en/, and assessing diet and should take place at the time of transfer of care from the activity. For children twenty-four months of age and older, parent/guardian to the staff of the child care facility. If this sex-specific height and weight graphs should be plotted by exchange of information happens outside the facility (e.g., the primary care provider in addition to body mass index when the child is put on a bus), the facility should use an (BMI), according to the Centers for Disease Control and Pre- alternative means to accurately convey important informa- vention (CDC). BMI is classified as underweight (BMI less tion. Handwritten notes, electronic communications, health than 5%), healthy weight (BMI 5%-84%), overweight (BMI checklists, and/or daily logs are examples of how parents/ 85%-94%), and obese (BMI equal to or greater than 95%). Chapter 3: Health Promotion 89

120 Caring for Our Children: National Health and Safety Performance Standards The Special Supplemental Nutrition Program for Women, Follow-up visits with the child’s primary care provider that Infants, and Children (WIC) can also be a source for the BMI include a full assessment and laboratory evaluations should data with parental/guardian consent, as WIC tracks growth be scheduled for children with weight for length greater than and development if the child is enrolled. 95% and BMI greater than 85% (5). For BMI charts by sex and age, see http://www.cdc.gov/ School health services can meet this standard for school- growthcharts/clinical_charts.htm. age children in care if they meet the AAP’s standards for school-age children and if the results of each child’s exami- Center; Large Family Child Care Home; Small TYPE OF FACILITY: nations are shared with the caregiver/teacher as well as with Family Child Care Home the school health system. With parental/guardian consent, RELATED STANDARDS: pertinent health information should be exchanged among Standard 4.2.0.2: Assessment and Planning of Nutrition for Indi- the child’s routine source of health care and all participants vidual Children in the child’s care, including any school health program REFERENCES: involved in the care of the child. Clinical nutrition. 2nd ed. St. Louis: Mosby. 1. Paige, D. M. 1988. RATIONALE: Provision of routine preventive health services Pediatric nutrition handbook. 6th ed. Elk 2. Kleinman, R. E. 2009. for children ensures healthy growth and development and Grove Village, IL: American Academy of Pediatrics. 3. Hagan, J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Bright helps detect disease when it is most treatable. Immunization futures: Guidelines for health supervision of infants, children, and prevents or reduces diseases for which effective vaccines 3rd ed. Elk Grove Village, IL: American Academy of adolescents. are available. When children are receiving care that involves Pediatrics. the school health system, such care should be coordinated 4. Story, M., K. Holt, D. Sofka, eds. 2002. Bright futures in practice: by the exchange of information, with parental/guardian Nutrition. 2nd ed. Arlington, VA: National Center for Education in permission, among the school health system, the child’s Maternal and Child Health. medical home, and the caregiver/teacher. Such exchange 5. Centers for Disease Control and Prevention. 2011. About BMI for will ensure that all participants in the child’s care are aware children and teens. http://www.cdc.gov/healthyweight/assessing/ of the child’s health status and follow a common care plan. bmi/childrens_bmi/about_childrens_bmi.html. The plotting of height and weight measurements and plot- 3.1.3 Physical Activity and Limiting ting and classification of BMI by the primary care provider or school health personnel, on a reference growth chart, Screen Time will show how children are growing over time and how they compare with other children of the same chronological age STANDARD 3.1.3.1: Active Opportunities for and sex (1,3,4). Growth charts are based on data from na- Physical Activity tional probability samples, representative of children in the The facility should promote children’s active play every day. general population. Their use by the primary care provider Children should have ample opportunity to do moderate may facilitate early recognition of growth concerns, lead- to vigorous activities such as running, climbing, dancing, ing to further evaluation, diagnosis, and the development skipping, and jumping. All children, birth to six years, should of a plan of care. Such a plan of care, if communicated to participate daily in: the caregiver/teacher, can direct the caregiver’s/teacher’s a) Two to three occasions of active play outdoors, attention to disease, poor nutrition, or inadequate physical weather permitting (see Standard 3.1.3.2: Playing activity that requires modification of feeding or other health Outdoors for appropriate weather conditions); practices in the early care and education setting (2). Two or more structured or caregiver/teacher/adult-led b) COMMENTS: Periodic and accurate height and weight activities or games that promote movement over the measurements that are obtained, plotted, and interpreted course of the day—indoor or outdoor; by a person who is competent in performing these tasks c) Continuous opportunities to develop and practice provide an important indicator of health status. If such age-appropriate gross motor and movement skills. measurements are made in the early care and education The total time allotted for outdoor play and moderate to facility, the data from the measurements should be shared vigorous indoor or outdoor physical activity can be adjusted by the facility, subject to parental/guardian consent, with for the age group and weather conditions. everyone involved in the child’s care, including parents/ Outdoor play: a) guardians, caregivers/teachers, and the child’s primary care 1) Infants (birth to twelve months of age) should provider. The child care health consultant can provide staff be taken outside two to three times per day, as training on growth assessment. It is important to maintain tolerated. There is no recommended duration of strong linkage among the early care and education facil- infants’ outdoor play; ity, school, parent/guardian, and the child’s primary care Toddlers (twelve months to three years) and 2) provider. Screening results (physical and behavioral) and preschoolers (three to six years) should be allowed laboratory assessments are only useful if a plan for care can sixty to ninety total minutes of outdoor play. These be developed to initiate and maintain lifestyle changes that outdoor times can be curtailed somewhat during incorporate the child’s activities during their time at the early adverse weather conditions in which children may care and education program. 90 Chapter 3: Health Promotion

121 Caring for Our Children: National Health and Safety Performance Standards for the time when they will be able to slide on their bellies still play safely outdoors for shorter periods, but and crawl. As infants grow older and stronger they will need should increase the time of indoor activity, so the more time on their tummies to build their own strength (27). total amount of exercise should remain the same; Total time allotted for moderate to vigorous activities: b) Daily physical activity is an important part of preventing ex- 1) Toddlers should be allowed sixty to ninety minutes cessive weight gain and childhood obesity. Some evidence per eight-hour day for moderate to vigorous also suggests that children may be able to learn better physical activity, including running; during or immediately after bursts of physical activity, due to Preschoolers should be allowed ninety to one 2) improved attention and focus (8,9). hundred and twenty minutes per eight-hour day Numerous reports suggest that children are not meeting (4). daily recommendations for physical activity, and that chil- Infants should have supervised tummy time every day when dren spend 70% (10) to 87% (11) of their time in early care they are awake. Beginning on the first day at the early care and education being sedentary, (i.e., sitting or lying down). and education program, caregivers/teachers should interact Excluding nap time, children are sedentary 83% of the time with an awake infant on their tummy for short periods of (11). Children may only spend about 2% to 3% of time be- time (three to five minutes), increasing the amount of time as ing moderately or vigorously active (11). the infant shows s/he enjoys the activity (27). Very young children are entirely dependent on their caregiv- Time spent outdoors has been found to be a strong, ers/teachers for opportunities to be active (12-15). Espe- consistent predictor of children’s physical activity (1-3). cially for children in full-time care and for children who live in Children can accumulate opportunities for activity over the unsafe neighborhoods, the early care and education facility course of several shorter segments of at least ten minutes may provide the child’s only daily opportunity for active play. each. Because structured activities have been shown to Evidence suggests that physical activity habits learned early produce higher levels of physical activity in young children, in life may track into adolescence and adulthood supporting it is recommended that caregivers/teachers incorporate two the importance for children to learn lifelong healthy physical or more short structured activities (five to ten minutes) or activity habits while in the early care and education program games daily that promote physical activity. (13,16-25). Opportunities to be actively enjoying physical activity should COMMENTS: There are many ways to promote tummy time be incorporated into part-time programs by prorating these with infants: recommendations accordingly, i.e., twenty minutes of out- a) Place yourself or a toy just out of the infant’s reach door play for every three hours in the facility. during playtime to get him to reach for you or the toy; b) Place toys in a circle around the infant. Reaching Active play should never be withheld from children who mis- to different points in the circle will allow him/her to behave (e.g., child is kept indoors to help another caregiver/ develop the appropriate muscles to roll over, scoot teacher while the rest of the children go outside) (5). How- on his/her belly, and crawl; ever, children with out-of-control behavior may need five c) Lie on your back and place the infant on your chest. minutes or less to calm themselves or settle down before The infant will lift his/her head and use his/her arms resuming cooperative play or activities. to try to see your face (27). Infants should not be seated for more than fifteen minutes at There are a multitude of short, structured activities that a time, except during meals or naps. Infant equipment such are appropriate for toddlers and preschoolers. Structured as swings, stationary activity centers (ex. exersaucers), in- activities could include popular children’s games such as fant seats (ex. bouncers), molded seats, etc. if used should Simon Says, Mother May I, Red Rover, Get the Wiggles Out, only be used for short periods of time. A least restrictive Musical Chairs, or a simple walk through the neighborhood. environment should be encouraged at all times (5,6,26). For training materials and more ideas of effective and age- Children should have adequate space for both inside and appropriate games for young children, consider the follow- outside play. ing resources: Free play, active play and outdoor play are RATIONALE: “Nutrition and Physical Activity Self Assessment for a) essential components of young children’s development (2). Child Care - NAP SACC Program” – http://www Children learn through play, developing gross motor, socio- .napsacc.org; emotional, and cognitive skills. In outdoor play, children b) “Color Me Healthy Preschoolers Moving and Eating” learn about their environment, science, and nature. – http://www.colormehealthy.com; “Let’s Move, Learn, and Have Fun” physical activity c) Infants’ and young children’s participation in physical activ- curriculum from Kansas State University; ity is critical to their overall health, development of motor d) “I am Moving I am Learning: Intervention in Head skills, social skills, and maintenance of healthy weight (7). Start” – http://eclkc.ohs.acf.hhs.gov/hslc/tta-system/ Daily physical activity promotes young children’s gross health/Health/Nutrition/Nutrition Program Staff/ motor development and provides numerous health ben- IamMovingIam.htm; efits including improved fitness and cardiovascular health, healthy bone development, improved sleep, and improved mood and sense of well-being. Tummy time prepares infants Chapter 3: Health Promotion 91

122 Caring for Our Children: National Health and Safety Performance Standards 5. Benjamin, S. E., A. Ammerman, J. Sommers, J. Dodds, B. e) “Moving and Learning: The Physical Activity Special- The nutrition and physical activity self- Neelon, D. S. Ward. 2007. ists for Birth through Age 8” – http://www Rev ed. Raleigh and Chapel assessment for child care (NAP SACC). .movingandlearning.com; Hill, NC: UNC Center for Health Promotion and Disease Prevention, f) “How to Lower Your Risk for Type 2 Diabetes: Na- Center of Excellence for Training and Research Translation. http:// tional Diabetes Education Program” – http://ndep.nih www.center-trt.org/downloads/obesity_prevention/interventions/ .gov/media/kids-tips-lower-risk.pdf; napsacc/NAPSACC_Template.pdf. “Motion Moments” – http://nrckids.org/Motion g) 6. National Association for Sport and Physical Education (NASPE). _Moments/. 2002. Active start: A statement of physical activity guidelines for children birth to five years. Washington, DC: NASPE. Experts disagree about the appropriate amount of physical 7. Patrick, K., B. Spear, K. Holt, D. Sofka, eds. 2001. Bright futures activity for toddlers and preschoolers, what proportion of in practice: Physical activity. Arlington, VA: National Center for children’s physical activity should be structured, and to what Education in Maternal and Child Health. http://www.brightfutures extent structured activities are effective in producing chil- .org/physicalactivity/pdf/index.html. dren’s physical activity. Researchers do agree that toddlers 8. Pellegrini, A., C. Bohn. 2005. The role of recess in children’s and preschoolers generally accumulate moderate to vigor - cognitive performance and school adjustment. 34:13-19. Educ Res ous physical activity over the course of the day in very short 9. Mahar, M. T., S. K. Murphy, D. A. Rowe, J. Golden, A. T. Shields, T. D. Raedeke. 2006. Effects of a classroom-based program on bursts (fifteen to thirty seconds) (23). For additional recom- physical activity and on-task behavior. Med Sci Sports Exerc mendations by other national groups and experts, see: 38:2086-94. The National Association for Sport and Physical Edu- a) 10. Pate, R. R., K. A. Pfeiffer, S. G. Trost, P. Ziegler, M. Dowda. Active Start: A Statement of Physical Activity cation’s 2004. Physical activity among children attending preschools. Guidelines for Children From Birth to Age 5, 2nd Edi- Pediatrics 114:1258-63. tion at http://www.aahperd.org/naspe/standards/ 11. Pate, R. R., K. McIver, M. Dowda, W. H. Brown, A. Cheryl. 2008. Physical nationalGuidelines/ActiveStart.cfm and J Directly observed physical activity levels in preschool children. Activity for Children: A Statement of Guidelines for 78:438-44. Sch Health at http://www.aahperd Children 5 - 12, 2nd Edition 12. McKenzie, T. L., J. F. Sallis, J. P. Elder, C. C. Berry, P. L. Hoy, P. .org/naspe/standards/nationalGuidelines/PA R. Nader, M. M. Zive, S. L. Broyles. 1997. Physical activity levels and prompts in young children at recess: A two-year study of a bi- -Children-5-12.cfm; 68:195-202. ethnic sample. Res Q Exerc Sport b) U.S. Department of Health and Human Services’ 13. McKenzie, T. L., J. F. Sallis, P. R. Nader, S. L. Broyles, J. A. 2008 Physical Activity Guidelines for Americans at Nelson. 1992. Anglo- and Mexican-American preschoolers at home http://www.health.gov/PAGuidelines/Report/pdf/ J Dev and at recess: Activity patterns and environmental influences. CommitteeReport.pdf; Behav Pediatr 13:173-80. c) U.S. Department of Health and Human Services and 14. Sallis, J. F., T. L. McKenzie, J. P. Elder, S. L. Broyles, P. R. Nader. Dietary Guide- the U.S. Department of Agriculture’s 1997. Factors parents use in selecting play spaces for young lines for Americans, 2010 at http://www.cnpp.usda 151:414-17. Arch Pediatr Adolesc Med children. .gov/DGAs2010-DGACReport.htm. 15. Sallis, J. F., P. R. Nader, S. L. Broyles, J. P. Elder, T. L. McKenzie, J. A. Nelson. 1993. Correlates of physical activity at home in TYPE OF FACILITY: Center; Large Family Child Care Home; Small Mexican-American and Anglo-American preschool children. Health Family Child Care Home 12:390-98. Psychol RELATED STANDARDS: 16. Davis, K., K. K. Christoffel. 1994. Obesity in preschool and Standard 2.1.1.2: Health, Nutrition, Physical Activity, and Safety Arch school-age children: Treatment early and often may be best. Awareness 148:1257-61. Pediatr Adolesc Med Standard 3.1.3.2: Playing Outdoors 17. Sallis, J. F., C. C. Berry, S. L. Broyles, T. L. McKenzie, P. R. Standard 3.1.3.4: Caregivers’/Teachers’ Encouragement of Physical Nader. 1995. Variability and tracking of physical activity over 2 yr in Activity 27:1042-49. Med Sci Sports Exerc young children. Standard 5.3.1.10: Restrictive Infant Equipment Requirements 18. Pate, R. R., T. Baranowski, S. G. Trost. 1996. Tracking of Standard 9.2.3.1: Policies and Practices that Promote Physical Med Sci Sports Exerc 28:92-96. physical activity in young children. Activity 19. Birch, L. L., J. O. Fisher. 1998. Development of eating behaviors Appendix S: Physical Activity: How Much Is Needed? among children and adolescents. Pediatrics 101:539-49. 20. Sallis, J. F., J. J. Prochaska, W. C. Taylor. 2000. A review of REFERENCES: correlates of physical activity of children and adolescents. Med Sci 1. Brown, W. H., K. A. Pfeiffer, K. L. Mclver, M. Dowda, C. L. Addy, Sports Exerc 32:963-75. R. R. Pate. 2009. Social and environmental factors associated with 21. Skinner, J. D., B. R. Carruth, W. Bounds, P. Ziegler, K. Reidy. preschoolers’ nonsedentary physical activity. Child Devel 80:45-58. 2002. Do food-related experiences in the first 2 years of life predict 2. Burdette, H. L., R. C. Whitaker. 2005. Resurrecting free play in 34:310- dietary variety in school-aged children? J Nutr Educ Behav young children: Looking beyond fitness and fatness to attention, 15. affiliation, and affect. Arch Pediatr Adolesc Med 159:46-50. 22. Skinner, J. D., B. R. Carruth, B. Wendy, P. J. Ziegler. 2002. 3. Burdette, H. L., R. C. Whitaker, S. R. Daniels. 2004. Parental 102:1638- J Am Diet Assoc Children’s food: A longitudinal analysis. report of outdoor playtime as a measure of physical activity in 47. Arch Pediatr Adolesc 158:353-57. preschool-aged children. Med 23. Oliver, M., G. M. Schofield, G. S. Kolt. 2007. Physical activity in 4. Bower, J. K., D. P. Hales, D. F. Tate, D. A. Rubin, S. E. Benjamin, preschoolers: Understanding prevalence and measurement issues. D. S. Ward. 2008. The childcare environment and children’s physical 37:1045-70. Sports Med activity. Am J Prev Med 34:23-29. 92 Chapter 3: Health Promotion

123 Caring for Our Children: National Health and Safety Performance Standards 24. American Academy of Pediatrics, Council on Sports Medicine b) Children should wear a hat, coat, and gloves/mittens and Fitness, and Council on School Health. 2006. Active healthy kept snug at the wrist; living: Prevention of childhood obesity through increased physical c) Caregivers/teachers should check children’s 117:1834-42. Pediatrics activity. extremities for maintenance of normal color and 25. Physical Activity Guidelines Advisory Committee. 2008. Physical warmth at least every fifteen minutes. Washington, activity guidelines advisory committee report, 2008. DC: U.S. Department of Health and Human Services. http://www Caregivers/teachers should also be aware of environmental .health.gov/PAGuidelines/Report/pdf/CommitteeReport.pdf. hazards such as contaminated water, loud noises, and lead Lack of time on 26. American Physical Therapy Association. 2008. in soil when selecting an area to play outdoors. Children tummy shown to hinder achievement of developmental milestones, should be observed closely when playing in dirt/soil, so that say physical therapists. News Release. no soil is ingested. Play areas should be secure and away . Back to sleep, 27. American Academy of Pediatrics (AAP). 2008 from heavy traffic areas. tummy to play. Elk Grove Village, IL: AAP. http://www .healthychildcare.org/pdf/SIDStummytime.pdf. Outdoor play is not only an opportunity for RATIONALE: learning in a different environment; it also provides many STANDARD 3.1.3.2: Playing Outdoors health benefits. Outdoor play allows for physical activity that supports maintenance of a healthy weight (2). Short Children should play outdoors when the conditions do not exposure of the skin to sunlight promotes the production of pose a safety risk, individual child health risk, or significant vitamin D that growing children require. health risk of frostbite or of heat related illness. Caregiv- ers/teachers must protect children from harm caused by Open spaces in outdoor areas, even those confined to adverse weather, ensuring that children wear appropri- screened rooftops in urban play spaces, encourage children ate clothing and/or appropriate shelter is provided for the to develop gross motor skills and fine motor play in ways weather conditions. Outdoor play for infants may include that are difficult to duplicate indoors. Nevertheless, some riding in a carriage or stroller; however, infants should be of- weather conditions make outdoor play hazardous. fered opportunities for gross motor play outdoors, as well. Children need protection from adverse weather and its Weather that poses a significant health risk should include effects. Wind chill conditions that pose a risk of frostbite wind chill factor at or below minus 15°F and heat index at as well as heat and humidity that pose a significant risk of or above 90°F, as identified by the National Weather Service heat-related illness are defined by the NWS and are an- (NWS). nounced routinely. Sunny weather: Heat-induced illness and cold injury are preventable. a) Children should be protected from the sun by using Children have greater surface area-to-body mass ratio shade, sun-protective clothing, and sunscreen with than adults. Therefore, children do not adapt to extremes UVB-ray and UVA-ray protection of SPF 15 or higher, of temperature as effectively as adults when exposed to a with permission from parents/guardians; high climatic heat stress or to cold. Children produce more b) Children should wear sun-protective clothing, such metabolic heat per mass unit than adults when walking or as hats, when playing outdoors between the hours of running. They also have a lower sweating capacity and can- 10 AM and 4 PM. not dissipate body heat by evaporation as effectively (1). Warm weather: Generally, infectious disease organisms are less concen- a) Children should be well hydrated before engaging trated in outdoor air than indoor air. in prolonged periods of physical activity and COMMENTS: Wind chill temperature is the temperature encouraged to drink water during periods of it “feels like” outside and is based on the rate of heat loss prolonged physical activity; from exposed skin caused by the effects of wind and cold. Caregivers/teachers should encourage parents/ b) As the wind increases, the body is cooled at a faster rate guardians to have children dress in clothing that is causing the skin temperature to drop. Many layers of cloth- light-colored, lightweight, and limited to one layer of ing traps air between the layers and provides better insula- absorbent material that will maximize the evaporation tion than one thick layer of clothing. of sweat; The NWS provides up to date weather information and c) On hot days, infants receiving human milk in a bottle warnings. The NWS Website will inform the public when can be given additional human milk in a bottle but wind chill conditions reach critical thresholds. A Wind Chill should not be given water, especially in the first six Warning is issued when wind chill temperatures are life months of life. Infants receiving formula and water threatening. A Wind Chill Advisory is issued when wind chill can be given additional formula in a bottle. temperatures are potentially hazardous. Cold weather: The NWS provides convenient color-coded guides for Children should wear layers of loose-fitting, a) caregivers/teachers to use to determine which weather lightweight clothing. Outer garments such as coats conditions are comfortable for outdoor play, which require should be tightly woven, and be at least water caution, and which are dangerous. These guides are avail- repellent when precipitation is present, such as rain able on the NWS Website at http://www.nws.noaa.gov/om/ or snow; Chapter 3: Health Promotion 93

124 Caring for Our Children: National Health and Safety Performance Standards Winter can be problematic for children with asthma for two windchill/index.shtml for wind chill and http://www.nws reasons. Indoor allergens such as dust and dust mites are .noaa.gov/om/heat/index.shtml for heat index. common triggers for asthma symptoms and levels of these The National Oceanic and Atmospheric Administration allergens can become elevated during the winter, when (NOAA) Weather Radio All Hazards (NWR) broadcasts con- doors and windows are kept shut to keep out cold air. Cold tinuous weather information twenty-four hours a day, seven temperatures also may, in some cases, serve as a trigger days a week, directly from the nearest NWR office. NWR is to asthma symptoms for children with asthma. Children for an “All Hazards” radio network, making it a single source whom cold weather is an asthma trigger may be helped by for comprehensive weather and emergency information. wearing a scarf during periods of cold weather. All children In conjunction with Federal, State, and Local Emergency with asthma can safely play outdoors as long as their asth- Managers and other public officials, NWR also broadcasts ma is well controlled, and the parents/guardians of children warning and post-event information for all types of hazards with asthma should be encouraged to work with their child’s – including natural (such as earthquakes or avalanches), primary care provider to develop a plan the child can self- environmental (such as chemical releases or oil spills), and manage that incorporates opportunities for outdoor play. public safety (such as AMBER alerts or 9-1-1 telephone The thought is often expressed that children are more likely outages). NWR requires a special radio receiver or scanner to become sick if exposed to cold air, however upper respi- capable of picking up the signal. NWR radios/receivers can ratory infections and flu are caused by viruses, not exposure usually be found in most electronic store chains across the to cold air. These viruses spread easily during the winter country or you can also purchase NOAA weather radios when children are kept indoors in close proximity. The best online at http://www.noaaweatherradios.com. protection against the spread of illness is regular and proper Email and Text Message Weather Alerts: These weather hand hygiene for children and caregivers/teachers, as well alert services send out weather warnings, watches, and as proper sanitation procedures during mealtimes, and hurricane information. Alerts are sent to subscribers in the when there is any contact with bodily fluids. warned areas via text messages and email. Select a service TYPE OF FACILITY: Center; Large Family Child Care Home; Small that sends warnings based on county, state, or national Family Child Care Home advisories. Some alerts may be delayed or missed because of problems on the Internet or the cell-phone network. Thus, RELATED STANDARDS: do not rely solely on this system. Weather radio or local Standard 3.1.3.1: Active Opportunities for Physical Activity Standard 3.1.3.4: Caregivers’/Teachers’ Encouragement of Physical news affiliates should also be monitored for weather warn- Activity ings. Standard 3.4.5.1: Sun Safety Including Sunscreen Some flexibility is needed depending on the location of the Standard 8.2.0.1: Inclusion in All Activities program. For example, in some climates where children do Appendix S: Physical Activity: How Much Is Needed? not have warm winter clothing even 20°F could be too cold. REFERENCES: In some southern climates it is always above 90°F, but older 1. American Academy of Pediatrics, Committee on Sports Medicine children are acclimated and can play in shaded areas. and Fitness. 2007. Policy statement: Climatic heat stress and the 120:683-84. Pediatrics exercising child and adolescent. To access the latest local weather information and warnings, 2. Hagan, J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Promoting contact the National Weather Service at http://www.weather Bright futures: Guidelines for health supervision physical activity. In .gov. of infants, children, and adolescents, 147-54. 3rd ed. Elk Grove Frostbite is an injury to the body caused by freezing body Village, IL: American Academy of Pediatrics. 3. Mayo Clinic. 2009. Hypothermia: Symptoms. http://www tissue. The most susceptible parts of the body are the .mayoclinic.com/health/hypothermia/DS00333/. extremities such as fingers, toes, ear lobes, or the tip of the 4. Kids Health. 2008. Frostbite. Nemours. http://kidshealth.org/ nose. Symptoms include a loss of feeling in the extrem- parent/firstaid_safe/emergencies/frostbite.html. ity and a white or pale appearance. Medical attention is needed immediately for frostbite. The affected area should STANDARD 3.1.3.3: Protection from Air be SLOWLY re-warmed by immersing frozen areas in warm Pollution While Children Are Outside water (around 100° Fahrenheit) or apply warm compresses for thirty minutes. If warm water is not available, wrap gently Supervising adults should check the air quality index (AQI) in warm blankets (4). each day and use the information to determine whether all or only certain children should be allowed to play outdoors. Hypothermia is a medical emergency that occurs when the body loses heat faster than it can produce heat, causing a RATIONALE: Children need protection from air pollution. Air - dangerously low body temperature. An infant with hypother pollution can contribute to acute asthma attacks in sensitive mia may have bright red, cold skin and very low energy. A children and, over multiple years of exposure, can contrib- child‘s symptoms may include shivering, clumsiness, slurred ute to permanent decreased lung size and function (1,2). speech, stumbling, confusion, poor decision making, drows- COMMENTS: The federal Clean Air Act requires that the iness or low energy, apathy, weak pulse, or shallow breath- Environmental Protection Agency (EPA) establish ambient ing (3). Call 9-1-1 if a child has these symptoms. air quality health standards. Most local health departments monitor weather and air quality in their jurisdiction and make Chapter 3: Health Promotion 94

125 Caring for Our Children: National Health and Safety Performance Standards d) Provide prompts for children to be active (3,4), e.g., appropriate announcements. AQI is usually reported with lo- “good throw”; cal weather reports on media outlets or individuals can sign Encourage children’s physical activities that are e) up for email or text message alerts at http://www appropriate and safe in the setting, e.g., do not .enviroflash.info. prohibit running on the playground when it is safe to The AQI (available at http://www.airnow.gov) is a cumulative run; indicator of potential health hazards associated with local f) Have orientation and annual training opportunities to or regional air pollution. T he AQI is divided into six catego- learn about age-appropriate gross motor activities ries; each category corresponds to a different level of health and games that promote children’s physical activity concern. The six levels of health concern and what they (1,3); mean are: g) Limit screen time (TV, DVD, computer, etc.), except a) “Good” AQI is 0 - 50. Air quality is considered satis- for 1) school-age children completing homework factory, and air pollution poses little or no risk. assignments and 2) children with special health care b) “Moderate” AQI is 51 - 100. Air quality is acceptable, needs who require and consistently use assistive and - however, for some pollutants there may be a moder adaptive computer technology. ate health concern for a very small number of people. RATIONALE: Children learn from the modeling of healthy For example, people who are unusually sensitive to and safe behavior. ozone may experience respiratory symptoms. “Unhealthy for Sensitive Groups” AQI is 101 - 150. c) Chairs for adults on playgrounds inhibit the promotion of Although general public is not likely to be affected at children’s physical activity. They may also pose a safety this AQI range, people with heart and lung disease, hazard if caregivers/teachers sitting in them cannot see all older adults, and children are at a greater risk from parts of the playground. exposure to ozone and the presence of particles in Caregivers/teachers may not feel comfort- COMMENTS: the air. able promoting active play, perhaps due to inhibitions about “Unhealthy” AQI is 151 - 200. Everyone may begin to d) their own physical activity skills, or due to lack of training. experience some adverse health effects, and mem- Caregivers/teachers may feel that their sole role on the play- bers of the sensitive groups may experience more ground is to supervise and keep children safe, rather than to serious effects. promote physical activity. Continuing education activities are e) “Very Unhealthy” AQI is 201 - 300. This would trigger useful in disseminating knowledge about effective games to a health alert signifying that everyone may experience promote physical activity in early care and education while more serious health effects. keeping children safe (1). Caregivers/teachers should con- f) “Hazardous” AQI greater than 300. This would trigger sider incorporating structured activities into the curriculum a health warning of emergency conditions. The entire indoors, or after children have been on playground for ten to population is more likely to be affected. fifteen minutes, as children tend to be less active after the Center; Large Family Child Care Home; Small TYPE OF FACILITY: first ten to fifteen minutes on the playground. Caregivers/ Family Child Care Home teachers, if they are facilitating physical activity with a small RELATED STANDARDS: group, must ensure that there is adequate supervision of all Standard 3.1.3.2: Playing Outdoors children on the playground. Standard 5.2.1.1: Fresh Air Caregivers/teachers should be aware that there is often a REFERENCES: high level of TV and computer exposure in the home. Early 1. Gauderman, W. J., E. Avol, F. Gilliland, et al. 2004. The effect of care and education settings offer caregivers/teachers the N air pollution on lung development from 10 to 18 years of age. opportunity to model the limitation of media and computer Engl J Med 351:1057-67. time and to educate parents/guardians about alternative 2. Hao, M., S. Comier, M. Wang, J. J. Lee, A. Nel. 2003. Diesel activities that families can do with their children (3). exhaust particles exert acute effects on airway inflammation and function in murine allergen provocation models. J Allergy Clin TYPE OF FACILITY: Center; Large Family Child Care Home; Small 112:905-14. Immunol Family Child Care Home RELATED STANDARDS: STANDARD 3.1.3.4: Caregivers’/Teachers’ Media, Computer, Etc. – Standard 2.2.0.3: Limiting Screen Time Encouragement of Physical Activity Standard 3.1.3.1: Active Opportunities for Physical Activity Standard 3.1.3.2: Playing Outdoors Caregivers/teachers should promote children’s active play, Standard 9.2.3.1: Policies and Practices that Promote Physical and participate in children’s active games at times when Activity they can safely do so. Caregivers/teachers should: Appendix S: Physical Activity: How Much Is Needed? a) Lead structured activities to promote children’s REFERENCES: activities two or more times per day; 1. Ward, D. S., A. Vaughn, C. McWilliams, D. Hales. 2010. b) Wear clothing and footwear that permits easy and Interventions for increasing physical activity at child care. Med Sci safe movement (2); Sports Exercise 42:526-34. Not sit during active play; c) Chapter 3: Health Promotion 95

126 Caring for Our Children: National Health and Safety Performance Standards 2. Copeland, K. A., S. N. Sherman, C. A. Kendeigh, B. E. Saelens, immediately remove the sleeping infant from this seat H. J. Kalkwarf. 2009. Flip-flops, dress clothes and no coat: Clothing and place them in the supine position in a safe sleep Int J barriers to children’s physical activity in child-care centers. environment (i.e., the infant’s assigned crib); Behav Nutr Activ 74(6). e) If an infant falls asleep in any place that is not a safe 3. Trost, S. G., D. S. Ward, M. Senso. 2010. Effects of child care sleep environment, staff should immediately move Med Sci Sports policy and environment on physical activity. the infant and place them in the supine position in Exercise 42:520-25. their crib; 4. Brown, W. H., K. A. Pfeiffer, K. L. McIver, M. Dowda, C. L. Addy, f) Only one infant should be placed in each crib R. R. Pate. 2009. Social and environmental factors associated with (stackable cribs are not recommended); 80:45-58. Child Devel preschoolers’ nonsedentary physical activity. Soft or loose bedding should be kept away from g) sleeping infants and out of safe sleep environments. 3.1.4 Safe Sleep These include, but are not limited to: bumper pads, pillows, quilts, comforters, sleep positioning devices, STANDARD 3.1.4.1: Safe Sleep Practices and sheepskins, blankets, flat sheets, cloth diapers, bibs, SIDS/Suffocation Risk Reduction etc. Also, blankets/items should not be hung on the Facilities should develop a written policy that describes the sides of cribs. Swaddling infants when they are in a practices to be used to promote safe sleep when infants are crib is not necessary or recommended, but rather napping or sleeping. The policy should explain that these one-piece sleepers should be used (see Standard practices aim to reduce the risk of sudden infant death syn- 3.1.4.2 for more detail information on swaddling); drome (SIDS) or suffocation death and other infant deaths Toys, including mobiles and other types of play h) that could occur when an infant is in a crib or asleep. equipment that are designed to be attached to any part of the crib should be kept away from sleeping All staff, parents/guardians, volunteers and others approved infants and out of safe sleep environments; to enter rooms where infants are cared for should receive i) When caregivers/teachers place infants in their a copy of the Safe Sleep Policy and additional educational crib for sleep, they should check to ensure that the information and training on the importance of consistent use temperature in the room is comfortable for a lightly of safe sleep policies and practices before they are allowed clothed adult, check the infants to ensure that they to care for infants (i.e., first day of employment/volunteering/ are comfortably clothed (not overheated or sweaty), subbing). Documentation that training has occurred and that and that bibs, necklaces, and garments with ties or these individuals have received and reviewed the written hoods are removed (clothing sacks or other clothing policy should be kept on file. designed for sleep can be used in lieu of blankets); All staff, parents/guardians, volunteers and others who j) Infants should be directly observed by sight and care for infants in the child care setting should follow these sound at all times, including when they are going to required safe sleep practices as recommended by the sleep, are sleeping, or are in the process of waking American Academy of Pediatrics (AAP) (1): up; a) Infants up to twelve months of age should be k) Bedding should be changed between children, and placed for sleep in a supine position (wholly on their if mats are used, they should be cleaned between back) for every nap or sleep time unless the infant’s uses. primary care provider has completed a signed waiver The lighting in the room must allow the caregiver/teacher to indicating that the child requires an alternate sleep see each infant’s face, to view the color of the infant’s skin, position; and to check on the infant’s breathing and placement of the Infants should be placed for sleep in safe sleep b) pacifier (if used). environments; which includes: a firm crib mattress covered by a tight-fitting sheet in a safety-approved A caregiver/teacher trained in safe sleep practices and ap - crib (the crib should meet the standards and proved to care for infants should be present in each room guidelines reviewed/approved by the U.S. Consumer at all times where there is an infant. This caregiver/teacher Product Safety Commission [CPSC] and ASTM should remain alert and should actively supervise sleeping International [ASTM]), no monitors or positioning infants in an ongoing manner. Also, the caregiver/teacher devices should be used unless required by the child’s should check to ensure that the infant’s head remains un- primary care provider, and no other items should be covered and re-adjust clothing as needed. in a crib occupied by an infant except for a pacifier; The construction and use of sleeping rooms for infants c) Infants should not nap or sleep in a car safety seat, separate from the infant group room is not recommended bean bag chair, bouncy seat, infant seat, swing, due to the need for direct supervision. In situations where jumping chair, play pen or play yard, highchair, chair, there are existing facilities with separate sleeping rooms, futon, or any other type of furniture/equipment that is facilities should develop a plan to modify room assignments not a safety-approved crib (that is in compliance with and/or practices to eliminate placing infants to sleep in the CPSC and ASTM safety standards) (4); separate rooms. If an infant arrives at the facility asleep in a car safety d) seat, the parent/guardian or caregiver/teacher should 96 Chapter 3: Health Promotion

127 Caring for Our Children: National Health and Safety Performance Standards Loose or ill-fitting sheets have caused infants to be stran- Facilities should be aware of the current recommendation gled or suffocated (8). of the AAP about pacifier use (1). If pacifiers are allowed, facilities should have a written policy that describes relevant COMMENTS: Background: Deaths of infants who are procedures and guidelines. Pacifier use outside of a crib in asleep in child care (whether attributable to SIDS, suffoca- rooms and programs where there are mobile infants or tod- tion, or other causes) may be under-reported because of dlers is not recommended. the lack of consistency in training and regulating death scene investigations and determining and reporting cause of Despite the decrease in deaths attributed to RATIONALE: death. Not all states require documentation that clarifies that SIDS and the decreased frequency of prone (tummy) infant an infant died while being cared for by someone other than sleep positioning over the past two decades, many caregiv- their parents/guardians. ers/teachers continue to place infants to sleep in positions or environments that are not safe. Deaths in child care facili- Although the cause of SIDS is not known, researchers ties attributable to SIDS continue to occur at an alarming believe that some infants develop in a manner that makes rate, with a majority occurring in the first day or first week it challenging for them to be aroused or to breathe when that an infant starts attending a child care program (2,3). they experience a life-threatening challenge during sleep. Many of these deaths appear to be associated with prone Although some state regulations require that caregivers/ positioning, especially when the infant is unaccustomed to teachers “check on” sleeping infants every ten, fifteen, being placed in that position (2,4). or thirty minutes, an infant can suffocate or die in only a few minutes. It is for this reason that the standards above Infants who are cared for by adults other than their parent/ discourage toys or mobiles in cribs and recommend direct, guardian or primary caregiver/teacher are at increased risk active, and ongoing supervision when infants are falling to for dying from SIDS. Recent research and demonstration sleep, are sleeping, or are becoming awake. This is also why projects (2) have revealed that: describes a safe sleep environment Caring for Our Children a) Caregivers/teachers are unaware of the dangers as one that includes a safety-approve crib, firm mattress, or risks associated with prone or side infant sleep firmly fitted sheet, and the infant placed on their back at all positioning, and many believe that they are using the times, in comfortable, safe garments, but nothing else – not safest practices possible, even when they are not; even a blanket. Although training programs are effective in improving b) the knowledge of caregivers/teachers, these When infants are being dropped off, staff may be busy. programs alone do not always lead to changes in Requiring parents/guardians to remove the infant from the caregiver/teacher practices, beliefs, or attitudes; car seat and re-position them in the supine position in their Caregivers/teachers report the following major c) crib (if they are sleeping), will reinforce safe sleep practices barriers to implementing safe sleep practices: and reassure parents/guardians that their child is in a safe They have been misinformed about methods 1) position before they leave the facility. shown to reduce the risk of SIDS; Challenges: National recommendations for reducing the risk 2) Facilities do not have or use written “safe sleep” of SIDS or suffocation and other infant deaths are provided policies or guidelines; for use in the general population. Most research reviewed State child care regulations do not mandate the 3) to guide the development of these recommendations was use of supine (wholly on their back) sleep position not conducted on children in child care. Because infants are for infants in child care and/or training for infant at increased risk for dying from SIDS in child care (5) and caregivers/teachers; because caregivers/teachers are liable for their actions, they 4) Other caregivers/teachers or parents/guardians must err on the side of caution and must provide the safest have objections to use of safe sleep practices, sleep environment for the infants in their care for liability and either because of their concern for choking or other reasons. aspiration, and/or their concern that some infants do not sleep well in the supine position; When hospital staff or parents/guardians of infants who may 5) Parents/guardians model their practices after attend child care place the infant in a position other than what happens in the hospital or what others supine for sleep, the infant becomes accustomed to this recommend. Infants who were placed to sleep and can have a more difficult time adjusting to child care, in other positions in the hospital or home especially when they are placed for sleep in a new unfamiliar environments may have difficulty transitioning to position. supine positioning at home and later in child care. Parents/guardians and caregivers/teachers want infants to Training that includes observations and addresses barri- transition to child care facilities in a comfortable and easy ers to changing caregiver/teacher practices would be most manner. It can be challenging for infants to fall asleep in a effective. Use of safe sleep policies, continued education of new environment because there are different people, equip- parents/guardians, expanded training efforts for child care ment, lighting, noises, etc. When infants sleep well in child professionals, statewide regulations and mandates, and care, adults feel better. Placing personal items in cribs with increased monitoring and observation are critical to reduce infants and covering or wrapping infants with blankets may the risk of SIDS and other infant deaths in child care (3). help the adults to believe that the child is more comfort- Chapter 3: Health Promotion 97

128 Caring for Our Children: National Health and Safety Performance Standards swaddled in the hospital setting. Although parents/guard- able or feels comforted. However, this may or may not be ians may choose to continue this practice at home, swad- true. These practices are not the safest practices for infants dling infants when they are being placed to sleep or are in child care, and they should not be allowed. Efforts to sleeping in a child care facility is not necessary or recom- educate the public about reducing the risk of SIDS and mended. See Standard 3.1.4.2 for more detailed informa- suffocation and promoting the use of consistent safe sleep tion. practices need to continue. Concern about Plagiocephaly: If parents/guardians or Special Care Plans: Some facilities require staff to place caregivers/teachers are concerned about positional plagio- infants in a supine position for sleep unless there is docu- cephaly (flat head or flat spot on head), they can continue to mentation in a child’s special care plan indicating a medical use safe sleep practices but also do the following: need for a different position. This can provide the caregiver/ Offer infants opportunities to be held upright and a) teacher with more confidence in implementing the safe participate in supervised “tummy time” when they are sleep policy and refusing parental demands that are not awake; consistent with safe sleep practices. It is likely that an infant b) Alter the position of the infant, and thereby alter - will be unaccustomed to sleeping supine if his or her par the supine position of the infant’s head and face. ents/guardians object to the supine position (and are there- This can easily be accomplished by alternating the fore placing the infant prone to sleep at home). By providing placement of the infant in the crib – place the infant educational information on the importance of consistent use to sleep with their head facing to one side for a week of safe sleep policies and practices to expectant parents, and then turning the infant so that their head and facilities will help raise awareness of these issues, promote face are placed the other way. Infants typically turn infant safety, and increase support for proper implementa- their head to one side toward the room or door, so tion of safe sleep policies and practices in the future. if they are placed with their head toward one side of Use of Blankets: AAP recommendations state that blankets the bed for one sleep time and then placed with their 1 may be hazardous, and use of blankets is not advisable. head toward the other side of the bed the next time, Use of Pacifiers: Caregivers/teachers should be aware of the this changes the area of the head that is in contact current recommendation of the AAP about pacifier use to with the mattress. reduce the risk of SIDS. While using pacifiers to reduce the A common question among caregivers/teachers and risk of SIDS seems prudent (especially if the infant is already parents/guardians is whether they should return the infant sleeping with a pacifier at home), pacifier use has also been to the supine position if they roll onto their side or their tum- shown to be associated with an increased risk of ear infec- mies. Infants up to twelve months of age should be placed tions. Keeping pacifiers clean and limiting their use to sleep wholly supine for sleep every time. In fact, all children time is best. Using pacifiers in a sanitary and safe fashion in should be placed (or encouraged to lie down) on their backs group care settings requires special diligence. to sleep. When infants are developmentally capable of roll- Pacifiers should be inspected for tears before use. Pacifiers ing comfortably from their backs to their fronts and back should not be clipped to an infant’s clothing or tied around again, there is no evidence to suggest that they should be an infant’s neck. re-positioned into the supine position. For children in the general population, the AAP recom- The California Childcare Health Program has available a mends: Safe Sleep Policy for infants in child care programs at http:// Consider offering a pacifier when placing the infant a) ucsfchildcarehealth.org/pdfs/forms/SafeSleep_policy1108. down for nap and sleep time; pdf (6). AAP provides a free online course on safe sleep b) If the infant refuses the pacifier, s/he should not be practices at http://www.healthychildcare.org/sids.html. forced to take it; 1 Caring For This represents a change from the printed version of If the infant falls asleep and the pacifier falls out of c) rd based on the AAP’s new policy statement Edition Our Children, 3 the infant’s mouth, it should be removed from the crib on SIDS and other sleep-related infant deaths (http://pediatrics. and does not need to be reinserted. A pacifier has aappublications.org/content/early/2011/10/12/peds.2011-2284) . been shown to reduce the risk of SIDS, even if the TYPE OF FACILITY: Center; Large Family Child Care Home; Small pacifier falls out during sleep (1); Family Child Care Home Pacifiers should not be coated in any sweet solution, d) and they should be cleaned and replaced regularly; RELATED STANDARDS: e) For breastfed infants, delay pacifier introduction until Standard 3.1.4.2: Swaddling Standard 3.1.4.3: Pacifier Use fifteen days of age to ensure that breastfeeding is Standard 3.1.4.4: Scheduled Rest Periods and Sleep Arrangements well-established (7); Standard 3.6.4.5: Death f) Written permission from the child’s parent/guardian is Standard 4.3.1.1: General Plan for Feeding Infants required for pacifier use in the facility. Standard 4.5.0.3: Activities That are Incompatible With Eating Swaddling: Hospital personnel or physicians, particularly Standard 5.4.5.1: Sleeping Equipment and Supplies those who work in neonatal intensive care units or infant Standard 5.4.5.2: Cribs Standard 6.4.1.3: Crib Toys nurseries in hospitals may recommend that newborns be 98 Chapter 3: Health Promotion

129 Caring for Our Children: National Health and Safety Performance Standards REFERENCES: TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home 1. American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome. 2009. Policy statement: The changing concept RELATED STANDARDS: of SIDS: Diagnostic coding shifts, controversies regarding the Standard 3.1.4.1: Safe Sleep Practices and SIDS/Suffocation Risk sleeping environment, and new variables to consider in reducing Reduction Pediatrics 123:188. risk. REFERENCES: 2. Moon R. Y., T. Calabrese, L. Aird. 2008. Reducing the risk of 1. Van Sleuwen, B. E., A. C. Engelberts, M. M. Boere-Boonekamp, sudden infant death syndrome in child care and changing provider W. Kuis, T. W. J. Schulpen, M. P. L’Hoir. 2007. Swaddling: A Pediatrics practices: Lessons learned from a demonstration project. Pediatrics systematic review. 120:e1097-e1106. 122:788-79. 2. Franco, P., N. Seret, J. N. Van Hees, S. Scaillet, J. Groswasser, 3. American Academy of Pediatrics, Back to Sleep, Healthy Child A. Kahn. 2005. Influence of swaddling on sleep and arousal Reducing the risk of SIDS in child Care America, First Candle. 2008. characteristics of healthy infants. Pediatrics 115:1307-11. care . http://www.healthychildcare.org/pdf/SIDSfinal.pdf. 3. Contemporary Pediatrics. 2004. Guide for parents: Swaddling 4. ECELS, Healthy Child Care Pennsylvania. 2007. Car seats and 101 . http://www.aap.org/sections/scan/practicingsafety/Toolkit Health Link Online 18:1-2. http:// swings are not safe for sleeping. _Resources/Module1/swadling.pdf. ecels-healthychildcarepa.org/publications/heath-link-online/ 4. Richardson, H. L., A. M. Walker, R. S. Horne. 2010. Influence item/36-spring-2007. of swaddling experience on spontaneous arousal patterns and Health and safety notes: Reducing the risk 5. Leonard, V. 2009. J Pediatrics 157:85-91. autonomic control in sleeping infants. of SIDS for infants in our care . Berkeley, CA: California Childcare 5. Mahan, S. T., Kasser J. R. 2008. Does Swaddling Influence Health Program. http://www.ucsfchildcarehealth.org/pdfs/ Developmental Dysplasia of the Hip? 121:177-78. Pediatrics healthandsafety/SIDS_en1009.pdf. Safe 6. California Childcare Health Program (CCHP). 2008. . Berkeley, CA: CCHP. http:// sleep policy for infants in child care STANDARD 3.1.4.3: Pacifier Use ucsfchildcarehealth.org/pdfs/forms/SafeSleep_policy1108.pdf. Facilities should be informed and follow current recommen- 7. Jenik, A. G., N. E. Vain, A. N. Gorestein, N. E. Jacobi, Pacifier and dations of the American Academy of Pediatrics (AAP) about Breastfeeding Trial Group. 2009. Does the recommendation to use pacifier use (1-3). a pacifier influence the prevalence of breastfeeding? J Pediatrics 155:350-54. If pacifiers are allowed, facilities should have a written policy 8. National MCH Center for Child Death Review. Sudden infant that indicates: death syndrome (SIDS)/Sudden unexplained infant death (SUID): a) Rationale and protocols for use of pacifiers; Fact sheet. http://www.childdeathreview.org/causesSI.htm. Written permission and any instructions or b) preferences from the child’s parent/guardian; STANDARD 3.1.4.2: Swaddling If desired, parent/guardian should provide at least c) In child care settings, swaddling is not necessary or recom- two new pacifiers (labeled with their child’s name mended. using a waterproof label or non-toxic permanent marker) on a regular basis for their child to use. RATIONALE: There is evidence that swaddling can increase The extra pacifier should be available in case a the risk of serious health outcomes, especially in certain replacement is needed; situations. The risk of sudden infant death is increased if an d) Staff should inspect each pacifier for tears or cracks infant is swaddled and placed on his/her stomach to sleep (and to see if there is unknown fluid in the nipple) (4) or if the infant can roll over from back to stomach. Loose before each use; blankets around the head can be a risk factor for sudden Staff should clean each pacifier with soap and water e) infant death syndrome (SIDS) (3). With swaddling, there is before each use; an increased risk of developmental dysplasia of the hip, a f) Pacifiers with attachments should not be allowed; hip condition that can result in long-term disability (1,5). Hip pacifiers should not be clipped, pinned, or tied to an dysplasia is felt to be more common with swaddling be- infant’s clothing, and they should not be tied around cause infants’ legs can be forcibly extended. With excessive an infant’s neck, wrist, or other body part; swaddling, infants may overheat (i.e., hyperthermia) (2). g) If an infant refuses the pacifier, s/he should not be COMMENTS: Most infants in child care centers are at least forced to take it; six-weeks-old. Even with newborns, research does not If the pacifier falls out of the infant’s mouth, it does h) provide conclusive data about whether swaddling should not need to be reinserted; or should not be used. Benefits of swaddling may include i) Pacifiers should not be coated in any sweet solution; decreased crying, increased sleep periods, and improved j) Pacifiers should be cleaned and stored open to air; temperature control. However, temperature can be main- separate from the diapering area, diapering items, or tained with appropriate infant clothing and/or an infant other children’s personal items. sleeping bag. Although swaddling may decrease crying, Infants should be directly observed by sight and sound at all there are other, more serious health concerns to consider, times, including when they are going to sleep, are sleeping, including SIDS and hip disease. If swaddling is used, it or are in the process of waking up. The lighting in the room should be used less and less over the course of the first few must allow the caregiver/teacher to see each infant’s face, weeks and months of an infant’s life. to view the color of the infant’s skin, and to check on the infant’s breathing and placement of the pacifier. Chapter 3: Health Promotion 99

130 Caring for Our Children: National Health and Safety Performance Standards good for your baby? http://www.mayoclinic.com/health/pacifiers/ Pacifier use outside of a crib in rooms and programs where PR00067/. there are mobile infants or toddlers is not recommended. Caregivers/teachers should work with parents/guardians STANDARD 3.1.4.4: Scheduled Rest Periods to wean infants from pacifiers as the suck reflex diminishes and Sleep Arrangements between three and twelve months of age. Objects which provide comfort should be substituted for pacifiers (6). The facility should provide an opportunity for, but should not require, sleep and rest. The facility should make available a RATIONALE: Mobile infants or toddlers may try to remove regular rest period for preschool and school-aged children, a pacifier from an infant’s mouth, put it in their own mouth, if the child desires. For children who are unable to sleep, the or try to reinsert it in another child’s mouth. These behaviors facility should provide time and space for quiet play. can increase risks for choking and/or transmission of infec- tious diseases. Facilities that offer infant care should use a written Safe Sleep Policy that describes the practices to be used to Cleaning pacifiers before and after each use is recom- reduce the risk of sudden infant death syndrome (SIDS) and mended to ensure that each pacifier is clean before it is other infant deaths. inserted into an infant’s mouth (5). This protects against un- known contamination or sharing. Cleaning a pacifier before Conditions conducive to sleep and rest for RATIONALE: each use allows the caregiver/teacher to worry less about younger children include a consistent caregiver, a routine whether the pacifier was cleaned by another adult who may quiet place, regular times for rest (1), and use of similar rou- have cared for the infant before they did. This may be of tines and safe practices. Most preschool children in all-day concern when there are staffing changes or when parents/ care benefit from scheduled periods of rest. This rest may guardians take the pacifiers home with them and bring them take the form of actual napping, a quiet time, or a change back to the facility. of pace between activities. The times of naps will affect behavior at home (1). If a caregiver/teacher observes or suspects that a paci- fier has been shared, the pacifier should be cleaned and Studies suggest that sleep is essential for optimal health sanitized. Caregivers/teachers should make sure the nipple and growth for young children. There are studies that show is free of fluid after cleaning to ensure the infant does not in- the amount of time young children sleep in a twenty-four- gest it. For this reason, submerging a pacifier is not recom- hour period is related to obesity later in life (2). Preschool mended. If the pacifier nipple contains any unknown fluid, or children who sleep less than other children are at higher risk if a caregiver/teacher questions the safety or ownership, the of being obese adults. In a meta-analysis of the association pacifier should be discarded (4). between sleep duration and childhood obesity, children with shorter sleep durations had a 58% higher risk of developing While using pacifiers to reduce the risk of sudden infant obesity compared to children with longer sleep durations (3). death syndrome (SIDS) seems prudent (especially if the in- Children with ten hours or less of sleep ages six to seven fant is already sleeping with a pacifier at home), pacifier use years of age are more likely to be obese adults than children has been associated with an increased risk of ear infections who sleep more than ten hours. and oral health issues (7). In a nationally representative sample, three-year-olds slept COMMENTS: To keep current with the AAP’s recommenda- an average of ten and one-half hours and five-year-olds tions on the use of pacifiers, go to http://www.aap.org. slept an average of ten hours on weekdays (2). Daytime Center; Large Family Child Care Home; Small TYPE OF FACILITY: naps supplement the nighttime sleep period to meet the Family Child Care Home total sleep requirement. Daily sleep duration of less than REFERENCES: twelve hours during infancy also appears to be a risk factor 1. American Academy of Pediatrics, Task Force on Sudden Infant for overweight and adiposity in preschool-aged children (4). Death Syndrome. 2009. Policy statement: The changing concept COMMENTS: In the young infant, favorable conditions for of SIDS: Diagnostic coding shifts, controversies regarding the sleep and rest include being dry, well-fed, and comfort- sleeping environment, and new variables to consider in reducing able. Infants may need one or two (or sometimes more naps Pediatrics 123:188. risk. 2. Hauck, F. R. 2006. Pacifiers and sudden infant death syndrome: during the time they are in child care). As infants age, they What should we recommend? Pediatrics 117:1811-12. typically transition to one nap per day, and having one nap 3. Mitchell, E. A., P. S. Blair, M. P. L’Hoir. 2006. Should pacifiers per day is consistent with the schedule that most facilities be recommended to prevent sudden infant death syndrome? follow. A facility that includes preschool and school-age Pediatrics 117:1755-58. children should make available books, board games and 4. Reeves, D. L. 2006. Pacifier use in childcare settings. Healthy other forms of quiet play. Different practices such as rock- Child Care 9:12-13. ing, holding a child while swaying, singing, reading, patting 5. Cornelius, A. N., J. P. D’Auria, L. M. Wise. 2008. Pacifier use: an arm or back, etc. could be included. Lighting does not J Pediatric A systematic review of selected parenting web sites. need to be turned off during nap time. Health Care 22:159-65. 6. American Academy of Pediatrics, Back to Sleep, Healthy Child Center; Large Family Child Care Home; Small TYPE OF FACILITY: Reducing the risk of SIDS in child Care America, First Candle. 2008. Family Child Care Home http://www.healthychildcare.org/pdf/SIDSfinal.pdf. care. 7. Mayo Clinic. 2009. Infant and toddler health. Pacifiers: Are they Chapter 3: Health Promotion 100

131 Caring for Our Children: National Health and Safety Performance Standards RELATED STANDARDS: brush is after eating. The caregiver/teacher should either Standard 3.1.4.1: Safe Sleep Practices and SIDS/Suffocation Risk brush the child’s teeth or supervise as the child brushes his/ Reduction her own teeth. Disposable gloves should be worn by the Standard 5.2.2.1: Levels of Illumination caregiver/teacher if contact with a child’s oral fluids is antici- Standard 5.4.5.1: Sleeping Equipment and Supplies pated. The younger the child, the more the caregiver/teach- Standard 5.4.5.2: Cribs er needs to be involved. The caregiver/teacher should be REFERENCES: able to evaluate each child’s motor activity and to teach the Health in child 1. Murph, J. R., S. D. Palmer, D. Glassy, eds. 2005. child the correct method of tooth brushing when the child is Elk Grove Village, IL: care: A manual for health professionals. capable of doing this activity. The caregiver/teacher should American Academy of Pediatrics. monitor the tooth brushing activity and thoroughly brush the 2. Snell, E. K., E. K. Adam, G. J. Duncan. 2007. Sleep and body child’s teeth after the child has finished brushing, preferably mass index and overweight status of children and adolescents. for a total of two minutes. Children whose teeth are brushed Child Development. 78:309-23. at home twice a day may be exempted since additional 3. Chen, Z., M. A. Beydoun, Y. Wang. 2008. Is sleep duration brushing has little additive benefit and may expose a child associated with childhood obesity? A systematic review and meta- analysis. 16:265-74. Obesity. to excess fluoride toothpaste. 4. Taveras, E. M., S. L. Rifas-Shiman, E. Oken, E. P. Gunderson, The cavity-causing effect of frequent exposure to food or M. W. Gillman. 2008. Short sleep duration in infancy and risk of juice should be reduced by offering the children rinsing childhood overweight. 162:305-11. Arch Pediatr Adolesc Med water after snacks and meals when tooth brushing is not possible. Local dental health professionals can facilitate STANDARD 3.1.4.5: Unscheduled Access to compliance with these activities by offering education and Rest Areas training for the child care staff and providing oral health All children should have access to rest or nap areas when- presentations for the children and parents/guardians. ever the child desires to rest. These rest or nap areas should RATIONALE: Regular tooth brushing with fluoride tooth- be set up to reduce distraction or disturbance from other paste is encouraged to reinforce oral health habits and activities. All facilities should provide rest areas for children, prevent gingivitis and tooth decay. There is currently no including children who become ill, at least until the child (strong) evidence that shows any benefit to wiping the leaves the facility for care elsewhere. Children need to be gums of a baby who has no teeth. Good oral hygiene is within sight and hearing of caregivers/teachers when rest- as important for a six-month-old child with one tooth as it ing. is for a six-year-old with many teeth (2). Tooth brushing at Any child, especially children who are ill (1), RATIONALE: least once a day reduces build-up of decay-causing plaque may need more opportunity for rest or quiet activities. (2,3). The development of tooth decay-producing plaque begins when an infant’s first tooth appears in his/her mouth TYPE OF FACILITY: Center; Large Family Child Care Home; Small (1). Tooth decay cannot develop without this plaque which Family Child Care Home contains the acid-producing bacteria in a child’s mouth. The RELATED STANDARDS: ability to do a good job brushing the teeth is a learned skill, Standard 3.1.4.1: Safe Sleep Practices and SIDS/Suffocation Risk improved by practice and age. There is general consensus Reduction that children do not have the necessary hand eye coordina- Standard 3.1.4.4: Scheduled Rest Periods and Sleep Arrangements tion for independent brushing until around age six so either Standards 3.6.2.2-3.6.2.10: Caring for Children Who Are Ill Standard 5.4.5.1: Sleeping Equipment and Supplies caregiver/teacher brushing or close supervision is necessary Standard 5.4.6.1: Space for Children Who Are Ill in the preschool child. Tooth brushing and activities at home may not suffice to develop this skill or accomplish the nec- REFERENCES: essary plaque removal, especially when children eat most of 1. Pickering, L. K., C. J. Baker, D. W. Kimberlin, S. S. Long, eds. their meals and snacks during a full day in child care. 2009. Red book: 2009 report of the Committee on Infectious Diseases, 153. 28th ed. Elk Grove Village, IL: American Academy of The caregiver/teacher should use a small COMMENTS: Pediatrics. amount of fluoride toothpaste (a smear about the size of a rice grain spread across the width of the toothbrush for 3.1.5 Oral Health children under two years of age and a pea-sized amount for children two years of age and over). Children should attempt STANDARD 3.1.5.1: Routine Oral Hygiene to spit out excess toothpaste after brushing. Fluoride is the Activities single most effective way to prevent tooth decay. Brushing of teeth with fluoridated toothpaste is the most efficient way Caregivers/teachers should promote the habit of regular to apply fluoride to the teeth. Young children may occasion- tooth brushing. All children with teeth should brush or have ally swallow a small amount of toothpaste and this is not a their teeth brushed at least once during the hours the child health risk. However, if children swallow more than recom- is in child care. Children under two years of age should have mended amounts of fluoride toothpaste on a consistent only a smear of fluoride toothpaste (rice grain) on the brush basis, they are at risk for fluorosis, a condition caused by when brushing. Those over two years of age should use a ingesting excessive levels of fluoride (6). Other products pea-sized amount of fluoride toothpaste. An ideal time to Chapter 3: Health Promotion 101

132 Caring for Our Children: National Health and Safety Performance Standards 7. Centers for Disease Control and Prevention. 2009. Community such as fluoride rinses can pose a poisoning hazard if water fluoridation. Other fluoride products. http://www.cdc.gov/ ingested (7). fluoridation/other.htm. The children can also rinse with water and spit out after a 8. Marinho, V. C., et al. 2002. Fluoride varnishes for preventing snack or a meal if their teeth have already been brushed Cochrane Database dental caries in children and adolescents. earlier. Rinsing with water helps to remove food particles 3, no. CD002279. http://www2.cochrane.org/reviews/ System Rev en/ab002279.html. from teeth, diluting sugars and may help prevent cavities. 9. American Academy of Pediatric Dentistry. 2006. Talking points: A sink is not necessary to accomplish tooth brushing in AAPD perspective on physicians or other non-dental providers child care. Each child can use a cup of water for tooth applying fluoride varnish. Dental Home Resource Center. http:// brushing. The child should wet the brush in the cup, brush www.aapd.org/dentalhome/1225.pdf. and then spit excess toothpaste into the cup. STANDARD 3.1.5.2: Toothbrushes and Caregivers/teachers should encourage replacement of Toothpaste toothbrushes when the bristles become worn or frayed or approximately every three to four months (4,5). In facilities where tooth brushing is an activity, each child should have a personally labeled, age-appropriate tooth- Caregivers/teachers should encourage parents/guardians brush. No sharing or borrowing should be allowed. After to establish a dental home for their child within six months use, toothbrushes should be stored on a clean surface with after the first tooth erupts or by one year of age, whichever the bristle end of the toothbrush up to air dry in such a is earlier (1). The dental home is the ongoing relationship way that the toothbrushes cannot contact or drip on each between the dentist and the patient, inclusive of all aspects other and the bristles are not in contact with any surface (6). of oral health care delivered in a comprehensive, continu- Racks and devices used to hold toothbrushes for storage ously accessible, coordinated and family-centered way. should be labeled and disinfected as needed. The tooth - Currently there are insufficient numbers of dentists who are brushes should be replaced at least every three to four able to incorporate infants and toddlers into their practices months, or sooner if the bristles become frayed (2-4,6). so primary care providers may provide oral health screening When a toothbrush becomes contaminated through contact during well child care in this population while promoting the with another brush or use by more than one child, it should establishment of a dental home (2). be discarded and replaced with a new one. Fluoride varnish applied at primary care visits reduce decay If toothpaste is used, each child should have his/her own rates by one-third, and lead to significant cost savings in re- labeled toothpaste tube. If toothpaste from a single tube is storative dental care and associated hospital costs. Cou- shared among the children, it should be dispensed onto a pled with parent/guardian and caregiver/teacher education, clean piece of paper or paper cup for each child rather than fluoride varnish is an important tool to improve children’s directly on the toothbrush (1,6). Children under two years health (8,9). of age should have only a smear of fluoride toothpaste (rice Center; Large Family Child Care Home; Small TYPE OF FACILITY: grain) on the brush when brushing. Those over two years of Family Child Care Home age should use a pea-sized amount of fluoride toothpaste. RELATED STANDARDS: Toothpaste should be stored out of children’s reach. Standard 3.1.5.2: Toothbrushes and Toothpaste Standard 3.1.5.3: Oral Health Education When children require assistance with brushing, caregiv- Standards 9.4.2.1-9.4.2.8: Child Records ers/teachers should wash their hands thoroughly between brushings for each child. Caregivers/teachers should wear REFERENCES: gloves when assisting such children with brushing their 1. American Academy of Pediatrics, Section on Pediatric Dentistry. teeth. 2009. Policy statement: Oral health risk assessment timing and 124:845. Pediatrics establishment of the dental home. RATIONALE: Toothbrushes and oral fluids that collect in the 2. American Academy of Pediatrics, Section on Pediatric Dentistry. mouth during tooth brushing are contaminated with infec- Pediatrics 2008. Preventive oral health intervention for pediatricians. tious agents and must not be allowed to serve as a conduit 122:1387-94. of infection from one individual to another (6). Individually 3. American Academy of Pediatric Dentistry, Clinical Affairs labeling the toothbrushes will prevent different children from Committee, Council on Clinical Affairs. 2008-2009. Guideline on periodicity of examination, preventive dental services, anticipatory sharing the same toothbrush. As an alternative to racks, guidance/counseling, and oral treatment for infants, children, and children can have individualized, labeled cups and their . Pediatric Dentistry 30:112-18. adolescents brush can be stored bristle-up in their cup. Some bleed- 4. American Academy of Pediatric Dentistry. Early childhood caries. ing may occur during tooth brushing in children who have Chicago: AAPD. http://www.aapd.org/assets/2/7/ECCstats.pdf. inflammation of the gums. In child care, saliva is considered 5. American Dental Association. ADA positions and statements. an infectious vehicle if it contains blood, so caregivers/ ADA statement on toothbrush care: Cleaning, storage, and teachers should protect themselves from exposure to blood replacement. Chicago: ADA. http://www.ada.org/1887.aspx. in such situations, as required by standard precautions. 6. Centers for Disease Control and Prevention, Fluoride The Occupational Safety and Health Administration (OSHA) Recommendations Work Group. 2001. Recommendations for using regulations apply where there is potential exposure to blood. fluoride to prevent and control dental caries in the United States. 50(RR14): 1-42. MMWR 102 Chapter 3: Health Promotion

133 Caring for Our Children: National Health and Safety Performance Standards e) Regularly scheduled dental visits. Children can use an individually labeled or COMMENTS: disposable cup of water to brush their teeth (6). Adolescent children should be informed about the effect of tobacco products on their oral health and additional reasons Toothpaste is not necessary if removal of food and plaque to avoid tobacco. is the primary objective of tooth brushing. However, no anti-caries benefit is achieved from brushing without fluoride Caregivers/teachers and parents/guardians should be toothpaste. taught to not place a child’s pacifier in the adult’s mouth to clean or moisten it or share a toothbrush with a child due Some risk of infection is involved when numerous children to the risk of promoting early colonization of the infant oral brush their teeth into sinks that are not sanitized between cavity with Streptococcus mutans (5). uses. Caregivers/teachers should limit juice consumption to Toothbrushing ability varies by age. Preschool children most no more than four to six ounces per day for children one likely will require assistance. Adults helping children brush through six years of age. their teeth not only help them learn how to brush, but also improve the removal of plaque and food debris from all teeth Studies have reported that the oral health of RATIONALE: (5). participants improved as a result of educational programs Center; Large Family Child Care Home; Small TYPE OF FACILITY: (1). Family Child Care Home Caregivers/teachers are encouraged to COMMENTS: RELATED STANDARDS: advise parents/guardians on the following recommendations Standard 3.1.5.1: Routine Oral Hygiene Activities for preventive and early intervention dental services and Standard 3.1.5.3: Oral Health Education education: Standard 3.6.1.5: Sharing of Personal Articles Prohibited a) Dental or primary care provider visits to evaluate the Standard 5.5.0.1: Storage and Labeling of Personal Articles need for supplemental fluoride therapy (prescription REFERENCES: pills or drops if tap water does not contain fluoride) 1. Davies, R. M., G. M. Davies, R. P. Ellwood, E. J. Kay. 2003. starting at six months of age, and professionally ap- Prevention. Part 4: Toothbrushing: What advice should be given to plied topical fluoride treatments for high risk children patients? 195:135-41. Brit Dent Jour (4); 2. American Dental Association, Council on Scientific Affairs. First dental visit within six months after the first tooth b) 2005. ADA statement on toothbrush care: Cleaning, storage, and erupts or by one year of age, whichever is earlier replacement. http://www.ada.org/1887.aspx. and whenever there is a question of an oral health Early childhood 3. American Academy of Pediatric Dentistry. 2004. http://www.aapd.org/media/ECCstats.pdf. caries (ECC). problem; 4. American Dental Hygienists’ Association. http:// Proper brushing. Dental sealants generally at six or seven years of age c) www.adha.org/oralhealth/brushing.htm. for first permanent molars, and for primary molars if 5. 12345 First Smiles. 2006. Oral health considerations for children deep pits and grooves or other high risk factors are with special health care needs (CSHCN). http://www present (2,3). .first5oralhealth.org/page.asp?page_id=432. Caregivers/teachers should provide education for parents/ 6. Centers for Disease Control and Prevention. 2005. Infection control in dental settings: The use and handling of toothbrushes. guardians on good oral hygiene practices and avoidance of http://www.cdc.gov/OralHealth/InfectionControl/factsheets/ behaviors that increase the risk of early childhood caries, toothbrushes.htm. such as inappropriate use of a bottle, frequent consumption of carbohydrate-rich foods, and sweetened beverages such STANDARD 3.1.5.3: Oral Health Education as juices with added sweeteners, soda, sports drinks, fruit 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 Child mentally appropriate oral health education that includes: Care, a parent handout in English and Spanish, developed Information on what plaque is; a) by the National Resource Center for Health and Safety in b) The process of dental decay; Child Care and Early Education at http://nrckids.org/ Diet influences on teeth, including the contribution c) dentalchecklist.pdf; of sugar-sweetened beverages and foods to cavity Bright Futures for Oral Health at http://brightfutures.aap.org/ development; and practice_guides_and_other_resources.html; d) The importance of good oral hygiene behaviors. Health and Safety in the California Childcare Health Program additional School-age children should receive information - Child Care Setting: Promoting Children’s Oral Health A Cur including: (in riculum for Health Professionals and Child Care Providers a) The preventive use of fluoride; English and Spanish) at http://www.ucsfchildcarehealth.org Dental sealants; b) and its 12345 first smiles program at http://first5oralhealth c) Mouth guards for protection when playing sports; .org; and The importance of healthy eating behaviors; and d) Chapter 3: Health Promotion 103

134 Caring for Our Children: National Health and Safety Performance Standards child care facility. No rinsing or dumping of the contents of National Training Institute for Child Care Health Consultant’s cloth diapers should be performed at the child care facil- Healthy Smiles Through Child Care Health Consultation ity. Soiled cloth diapers should be completely wrapped in course at http://nti.unc.edu/healthy_smiles/. a non-permeable material, stored in a location inaccessible TYPE OF FACILITY: Center to children, and given directly to the parent/ guardian upon RELATED STANDARDS: discharge of the child. Section 2.4: Health Education Gastrointestinal tract disease caused by RATIONALE: Standard 3.1.4.3: Pacifier Use Standard 3.1.5.1: Routine Oral Hygiene Activities bacteria, viruses, parasites, and hepatitis A virus infection Standard 3.1.5.2: Toothbrushes and Toothpaste of the liver are spread from infected persons through fecal Standard 4.2.0.7: 100% Juice contamination of objects in the environment and hands of Standard 9.2.3.14: Oral Health Policy caregivers/teachers and children. Procedures that reduce fecal contamination, such as minimal handling of soiled REFERENCES: 1. Dye, B. A., J. D. Shenkin, C. L. Ogden, T. A. Marshould, S. M. diapers and clothing, thorough hand hygiene, and contain- Levy, M. J. Kanellis. 2004. The relationship between healthful eating ment of fecal matter and articles containing fecal matter practices and dental caries in children aged 2-5 years in the United control the spread of these diseases. Diapering practices 135:55-66. States. J Am Dent Assoc that require significant manipulation of the diaper and wa- 2. American Academy of Pediatrics, Section on Pediatric Dentistry. terproof covering, particularly reuse of the covering before it 2009. Policy statement: Oral health risk assessment timing and is cleaned and disinfected, present increased opportunities establishment of the dental home. Pediatrics 124:845. for fecal contamination of the caregivers/teachers’ hands, 3. American Academy of Pediatrics, Section on Pediatric the child, and consequently, objects and surfaces in the Dentistry.2008. Preventive oral health intervention for pediatricians. environment. Environmental contamination has been associ- Pediatrics 122:1387-94. ated with increased diarrheal rates in child care facilities (1). 4. American Academy of Pediatric Dentistry, Clinical Affairs Committee, Council on Clinical Affairs. 2008-2009. Guideline on Fecal contamination in the center environment may be less periodicity of examination, preventive dental services, anticipatory when single-use, disposable diapers are used than when guidance/counseling, and oral treatment for infants, children, and cloth diapers worn with pull-on waterproof pants are used adolescents. Pediatric Dentistry 30:112-18. (3). When clothes are worn over either disposable or cloth 5. American Academy of Pediatrics, Oral Health Initiative. Protecting diapers with pull-on waterproof pants, there is a reduction in all children’s teeth (PACT): A pediatric oral health training program. contamination of the environment (1,3). Factors in development: Bacteria. http://www.aap.org/oralhealth/ pact/ch4_sect2.cfm. Diaper dermatitis occurs frequently in diapered children. - Diapering practices that reduce the frequency and sever ity of diaper dermatitis will require less application of skin 3.2 Hygiene creams and ointments, thereby decreasing the likelihood for fecal contamination of caregivers/teachers’ hands. Most 3.2.1 Diapering and Changing Soiled common diaper dermatitis represents an irritant contact dermatitis; the source of irritation is prolonged contact of Clothing the skin with urine, feces, or both (1). The action of fecal digestive enzymes on urinary urea and the resulting pro- STANDARD 3.2.1.1: Type of Diapers Worn duction of ammonia make the diapered area more alkaline, Diapers worn by children should be able to contain urine which has been shown to damage skin (1,2). Damaged skin and stool and minimize fecal contamination of children, is more susceptible to other biological, chemical, and physi - caregivers/teachers, environmental surfaces, and objects in cal insults that can cause or aggravate diaper dermatitis (1). the child care setting. Only disposable diapers with absor - Frequency and severity of diaper dermatitis are lower when bent material (e.g., polymers) may be used unless the child diapers are changed more often, regardless of the diaper has a medical reason that does not permit the use of dis- used (1). The use of modern disposable diapers with absor - posable diapers (such as allergic reactions). When children bent material has been associated with less frequent and cannot use disposable diapers for a medical reason, the less severe diaper dermatitis in some children than with the reason should be documented by the child’s primary care use of cloth diapers and pull-on pants made of a waterproof provider. Children of all ages who are incontinent of urine or material (3). stool should wear a barrier method to prevent contamina- COMMENTS: Several types of diapers or diapering systems tion of their environment. are currently available: disposable paper diapers, reusable If cloth diapers are used, the diaper should have an absor - cloth diapers worn with pull-on waterproof pants, reusable - bent inner lining completely contained within an outer cover cloth diapers worn with a modern front closure waterproof ing made of waterproof material that prevents the escape cover, and single unit reusable diaper systems with an in- of feces and urine. An alternative is the use of cloth diapers ner cotton lining attached to an outer waterproof covering. that contain a waterproof cover that is adherent to the cloth Two types of diapers meet the physical requirements of the material. If a cloth diaper with a separate lining is used, the standard: modern disposable paper diapers with absorbent outer covering and inner lining should be changed together material, and single unit reusable diaper systems with an in- at the same time as a unit and should not be reused in the ner cotton lining attached to an outer waterproof covering. A 104 Chapter 3: Health Promotion

135 Caring for Our Children: National Health and Safety Performance Standards soiled cloth diapers should not be accessible to any child third type, reusable cloth diapers worn with a modern front (1). closure waterproof cover, meets the standard only: a) If the cloth diaper and cover are removed simultane- Containing and minimizing the handling of RATIONALE: ously as a unit and are not removed as two separate soiled diapers so they do not contaminate other surfaces is pieces; and essential to prevent the spread of infectious disease. Putting If the cloth diaper and outer cover are not reused until b) stool into a toilet in the child care facility increases the likeli- both are cleaned and disinfected. hood that other surfaces will be contaminated during the disposal (2). There is no reason to use the toilet for stool if Caregivers/teachers should follow this recommendation un- disposable diapers are being used. Commercial diaper laun- less they have a care plan noting a different procedure from dries use a procedure that separates solid components from the child’s primary care provider. the diapers and does not require prior dumping of feces into Reusable cloth diapers worn either without a covering or the toilet. with pull-on pants made of waterproof material do not meet Center; Large Family Child Care Home; Small TYPE OF FACILITY: the physical requirements of the standard and should not be Family Child Care Home permitted in facilities. Whichever diapering system is used in the facility, clothes should be worn over diapers while the RELATED STANDARDS: child is in the facility. Rigorous protocols should be imple- Standard 3.2.1.1: Type of Diapers Worn mented for diaper handling and changing, personal hygiene, REFERENCES: and environmental decontamination. While single unit reus- 2006. http://www 1. Healthy Child Care. Diapering . able diaper systems, with an inner cloth lining attached to .globalhealthychildcare.org/default.aspx?page=poi&content an outer waterproof covering, and reusable cloth diapers, _id=4&language=content. worn with a modern front closure waterproof cover, meet 2. Pickering, L. K., C. J. Baker, D. W. Kimberlin, S. S. Long, eds. 2009. Red book: 2009 report of the Committee on Infectious the physical criteria of this standard (if used as described), Diseases. 28th ed. Elk Grove Village, IL: American Academy of they have not been evaluated for their ability to reduce fecal Pediatrics. - contamination, or for their association with diaper dermati tis. Moreover, it has not been demonstrated that the water - STANDARD 3.2.1.3: Checking For the Need to proof covering materials remain waterproof with repeated Change Diapers cleaning and disinfecting. Therefore, single-use disposable diapers should be encouraged for use in child care facilities. Diapers should be checked for wetness and feces at least hourly, visually inspected at least every two hours, and Center; Large Family Child Care Home; Small TYPE OF FACILITY: Family Child Care Home - whenever the child indicates discomfort or exhibits behav ior that suggests a soiled or wet diaper. Diapers should be RELATED STANDARDS: changed when they are found to be wet or soiled. Standard 3.2.1.2: Handling Cloth Diapers Standard 3.2.1.4: Diaper Changing Procedure Frequency and severity of diaper dermatitis RATIONALE: Standards 3.2.2.1-3.2.2.5: Hand Hygiene is lower when diapers are changed more often, regardless Standard 5.2.7.4: Containment of Soiled Diapers of the type of diaper used (1). Diaper dermatitis occurs fre- Standard 5.4.1.10: Handwashing Sinks quently in diapered children. Most common diaper derma- REFERENCES: titis represents an irritant contact dermatitis; the source of 1. Van, R., A. L. Morrow, R. R. Reves, L. K. Pickering. 1991. irritation is prolonged contact of the skin with urine, feces, Am J Environmental contamination in child day care centers. or both (2). The action of fecal digestive enzymes on urinary 133:460-70. Epidemiol urea and the resulting production of ammonia make the 2. Gorski, P. A. 1999. Toilet training guidelines: Day care providers- diapered area more alkaline, which has been shown to dam- the role of the day care provider in toilet training. Pediatrics age skin (1,2). Damaged skin is more susceptible to other 103:1367-68. biological, chemical, and physical insults that can cause or 3. Kubiak, M., B. Kressner, W. Raynor, J. Davis, R. E. Syverson. 1993. Comparison of stool containment in cloth and single-use aggravate diaper dermatitis (2). Pediatrics 91:632-36. diapers using a simulated infant feces. Modern disposable diapers can be checked for wetness by feeling the diaper through the clothing and fecal contents STANDARD 3.2.1.2: Handling Cloth Diapers can be assessed by odor. Nonetheless, since these meth- If cloth diapers are used, soiled cloth diapers and/or soiled ods of checking may be inaccurate, the diaper should be training pants should never be rinsed or carried through the opened and checked visually at least every two hours. Even child care area to place the fecal contents in a toilet. Reus- though modern disposable diapers can continue to absorb able diapers should be laundered by a commercial diaper moisture for an extended period of time when they are wet, service. Soiled cloth diapers should be stored in a labeled they should be changed after two hours of wearing if they container with a tight-fitting lid provided by an accredited are found to be wet. This prevents rubbing of wet surfaces commercial diaper service, or in a sealed plastic bag for against the skin, a major cause of diaper dermatitis. removal from the facility by an individual child’s family. The TYPE OF FACILITY: Center; Large Family Child Care Home; Small sealed plastic bag should be sent home with the child at Family Child Care Home the end of the day. The containers or sealed diaper bags of Chapter 3: Health Promotion 105

136 Caring for Our Children: National Health and Safety Performance Standards REFERENCES: child does not contaminate these surfaces with stool 1. Healthy Children. 2010. Ages and stages: When diaper rash or urine during the diaper changing. strikes. http://www.healthychildren.org/English/ages-stages/baby/ Step 3: Clean the child’s diaper area. diapers-clothing/Pages/When-Diaper-Rash-Strikes.aspx. a) Place the child on the diaper change surface and Caring for your baby and 2. Shelov, S. P., T. R. Altmann, eds. 2009. unfasten the diaper, but leave the soiled diaper under 5th ed. Elk Grove Village, IL: American young child: Birth to age 5. Academy of Pediatrics. the child; If safety pins are used, close each pin immediately b) STANDARD 3.2.1.4: Diaper Changing once it is removed and keep pins out of the child’s reach (never hold pins in your mouth); Procedure Lift the child’s legs as needed to use disposable c) The following diaper changing procedure should be posted wipes, or a dampened cloth or wet paper towel to in the changing area, should be followed for all diaper clean the skin on the child’s genitalia and buttocks changes, and should be used as part of staff evaluation and prevent recontamination from a soiled diaper. of caregivers/teachers who diaper. The signage should be Remove stool and urine from front to back and use a simple and should be in multiple languages if caregivers/ fresh wipe, or a dampened cloth or wet paper towel teachers who speak multiple languages are involved in each time you swipe. Put the soiled wipes or paper diapering. All employees who will diaper should undergo towels into the soiled diaper or directly into a plastic- training and periodic assessment of diapering practices. lined, hands-free covered can. Reusable cloths Caregivers/teachers should never leave a child unattended should be stored in a washable, plastic-lined, tightly on a table or countertop, even for an instant. A safety strap covered receptacle (within arm’s reach of diaper or harness should not be used on the diaper changing table. changing tables) until they can be laundered. The If an emergency arises, caregivers/teachers should bring cover should not require touching with contaminated any child on an elevated surface to the floor or take the child hands or objects. with them. Step 4: Remove the soiled diaper and clothing without An EPA-registered disinfectant suitable for the surface contaminating any surface not already in contact with stool material that is being disinfected should be used. If an EPA- or urine. registered product is not available, then household bleach Fold the soiled surface of the diaper inward; a) diluted with water is a practical alternative. All cleaning and Put soiled disposable diapers in a covered, plastic- b) disinfecting solutions should be stored to be accessible to lined, hands-free covered can. If reusable cloth the caregiver/teacher but out of reach of any child. Please diapers are used, put the soiled cloth diaper and its refer to Appendix J, Selecting an Appropriate Sanitizer or contents (without emptying or rinsing) in a plastic bag Disinfectant or into a plastic-lined, hands-free covered can to give Step 1: Get organized. Before bringing the child to the dia- to parents/guardians or laundry service; per changing area, perform hand hygiene, gather and bring c) Put soiled clothes in a plastic-lined, hands-free supplies to the diaper changing area: plastic bag; Non-absorbent paper liner large enough to cover a) Check for spills under the child. If there are any, use d) the changing surface from the child’s shoulders to the corner of the paper to fold the paper that extends beyond the child’s feet; under the child’s feet over the soiled area so a fresh, Unused diaper, clean clothes (if you need them); b) unsoiled paper surface is now under the child’s Wipes, dampened cloths or wet paper towels for c) buttocks; cleaning the child’s genitalia and buttocks readily If gloves were used, remove them using the proper e) available; technique (see Appendix D) and put them into a d) A plastic bag for any soiled clothes or cloth diapers; plastic-lined, hands-free covered can; Disposable gloves, if you plan to use them (put e) f) Whether or not gloves were used, use a fresh wipe to gloves on before handling soiled clothing or diapers) wipe the hands of the caregiver/teacher and another and remove them before handling clean diapers and fresh wipe to wipe the child’s hands. Put the wipes clothing; into the plastic-lined, hands-free covered can. f) A thick application of any diaper cream (e.g., zinc Step 5: Put on a clean diaper and dress the child. oxide ointment), when appropriate, removed from the a) Slide a fresh diaper under the child; container to a piece of disposable material such as b) Use a facial or toilet tissue or wear clean disposable facial or toilet tissue. glove to apply any necessary diaper creams, Step 2: Carry the child to the changing table, keeping soiled discarding the tissue or glove in a covered, plastic- clothing away from you and any surfaces you cannot easily lined, hands-free covered can; clean and sanitize after the change. c) Note and plan to report any skin problems such as Always keep a hand on the child; a) redness, skin cracks, or bleeding; If the child’s feet cannot be kept out of the diaper or b) Fasten the diaper; if pins are used, place your hand d) from contact with soiled skin during the changing between the child and the diaper when inserting the process, remove the child’s shoes and socks so the pin. 106 Chapter 3: Health Promotion

137 Caring for Our Children: National Health and Safety Performance Standards able on this issue. Wet paper towels or a damp cloth may be Step 6: Wash the child’s hands and return the child to a used as an alternative to commercial baby wipes. supervised area. Use soap and warm water, between 60°F and 120°F, a) - If the child’s clean buttocks are put down on a soiled sur at a sink to wash the child’s hands, if you can. face, 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 num- If clothing was soiled, securely tie the plastic bag b) ber of organisms carried into the environment in this way. used to store the clothing and send home; Infectious organisms are present on the skin and diaper Remove any visible soil from the changing surface c) even though they are not seen. To reduce the contamination with a disposable paper towel saturated with water of clean surfaces, caregivers/teachers should use a fresh and detergent, rinse; wipe to wipe their hands after removing the gloves, or, if no d) Wet the entire changing surface with a disinfectant gloves were used, before proceeding to handle the clean that is appropriate for the surface material you are diaper and the clothing. treating. Follow the manufacturer’s instructions for Some states and credentialing organizations may recom- use; mend wearing gloves for diaper changing. Although gloves e) Put away the disinfectant. Some types of may not be required, they may provide a barrier against disinfectants may require rinsing the change table surface contamination of a caregiver/teacher’s hands. This surface with fresh water afterwards. may reduce the presence of enteric pathogens under the Step 8: Perform hand hygiene according to the procedure in fingernails and on hand surfaces. Even if gloves are used, Standard 3.2.2.2 and record the diaper change in the child’s caregivers/teachers must perform hand hygiene after each daily log. child’s diaper changing to prevent the spread of disease- In the daily log, record what was in the diaper and a) causing agents. To achieve maximum benefit from use any problems (such as a loose stool, an unusual odor, of gloves, the caregiver/teacher must remove the gloves blood in the stool, or any skin irritation), and report as properly after cleaning the child’s genitalia and buttocks and necessary (2). removing the soiled diaper. Otherwise, retained contaminat- ed gloves could transfer organisms to clean surfaces. Note RATIONALE: The procedure for diaper changing is de- that sensitivity to latex is a growing problem. If caregivers/ signed to reduce the contamination of surfaces that will teachers or children who are sensitive to latex are present in later come in contact with uncontaminated surfaces such the facility, non-latex gloves should be used. See Appendix as hands, furnishings, and floors (1,3). Posting the multi- D, for proper technique for removing gloves. step procedure may help caregivers/teachers maintain the routine. A safety strap cannot be relied upon to restrain the child and - could become contaminated during diaper changing. Clean Assembling all necessary supplies before bringing the child ing and disinfecting a strap would be required after every to the changing area will ensure the child’s safety, make the diaper change. Therefore safety straps on diaper changing change more efficient, and reduce opportunities for con- surfaces are not recommended. tamination. Taking the supplies out of their containers and leaving the containers in their storage places reduces the Prior to disinfecting the changing table, clean any visible - likelihood that the storage containers will become contami soil from the surface with a detergent and rinse well with nated during diaper changing. water. Always follow the manufacturer’s instructions for use, application and storage. If the disinfectant is applied using Commonly, caregivers/teachers do not use disposable a spray bottle, always assume that the outside of the spray paper that is large enough to cover the area likely to be bottle could be contaminated. Therefore, the spray bottle contaminated during diaper changing. If the paper is large should be put away before hand hygiene is performed, (the enough, there will be less need to remove visible soil from last and essential part of every diaper change) (4). surfaces later and there will be enough paper to fold up so the soiled surface is not in contact with clean surfaces while Diaper-changing areas should never be located in food dressing the child. 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 If parents use the diaper changing area, they should be procedure, the foot coverings can become contaminated required to follow the same diaper changing procedure to and subsequently spread contamination throughout the minimize contamination of the diaper changing area and child care area. child care. Some experts believe that commercial baby wipes may TYPE OF FACILITY: Center; Large Family Child Care Home; Small cause irritation of a baby’s sensitive tissues, such as inside Family Child Care Home the labia, but currently there is no scientific evidence avail- Chapter 3: Health Promotion 107

138 Caring for Our Children: National Health and Safety Performance Standards RELATED STANDARDS: diluted with water is a practical alternative. All cleaning and Standard 3.2.1.1: Type of Diapers Worn disinfecting solutions should be stored to be accessible to Standard 3.2.1.2: Handling Cloth Diapers the caregiver/teacher but out of reach of any child. Please Standard 3.2.1.3: Checking for the Need to Change Diapers refer to Appendix J, Selecting an Appropriate Sanitizer or Standard 3.2.2.1: Situations that Require Hand Hygiene Disinfectant. Standard 3.2.2.2: Handwashing Procedure Standard 3.3.0.1: Routine Cleaning, Sanitizing, and Disinfecting Step 1: Get organized and determine whether to change the Standard 5.2.7.4: Containment of Soiled Diapers child lying down or standing up. Before bringing the child to Standard 5.4.4.2: Location of Laundry Equipment and Water the changing area, perform hand hygiene, and gather and Temperature for Laundering bring supplies to the changing area. Appendix D: Gloving Non-absorbent paper liner large enough to cover the a) REFERENCES: changing surface; 1. Pickering, L. K., C. J. Baker, D. W. Kimberlin, S. S. Long, eds. Unused pull-up or underwear, clean clothes (if you b) Red book 2009: Report of the Committee on Infectious 2009. need them); 28th ed. Elk Grove Village, IL: American Academy of Diseases. c) Wipes, dampened cloths or wet paper towels for Pediatrics. cleaning the child’s genitalia and buttocks readily 2. National Association for the Education of Young Children. available; Rev ed. 2007. Keeping healthy: Parents, teachers, and children. A plastic bag for any soiled clothes, including d) Washington, DC: NAEYC. underwear, or pull-ups; 13 indicators of quality child care: Research 3. Fiene, R. 2002. e) Disposable gloves, if you plan to use them (put . Washington, DC: U.S. Department of Health and Human update gloves on before handling soiled clothing or pull-ups) Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/. and remove them before handling clean pull-ups or 4. North Carolina Child Care Health and Safety Resource Center. underwear and clothing. Diapering procedure poster. http://www.healthychildcarenc.org/ Step 2: Avoid contact with soiled items. PDFs/diaper_procedure_english.pdf. a) If the child is standing, it may cause the clothing, shoes and socks to become soiled. The caregiver/ STANDARD 3.2.1.5: Procedure for Changing teacher must remove these items before the change Children’s Soiled Underwear/Pull-Ups and begins; Clothing b) To avoid contaminating the child’s clothes, have the child hold their shirt, sweater, etc. up above The following changing procedure for soiled pull-ups or their waist during the change. This keeps the child’s underwear and clothing should be posted in the changing hands busy and the caregiver/teacher knows where area, should be followed for all changes, and should be the child’s hands are during the changing process. used as part of staff evaluation of caregivers/teachers who Caregivers/teachers can also use plastic clothes change pull-ups or underwear and clothing. The signage pins that can be washed and sanitized to keep the should be simple and should be in multiple languages if clothing out of the way; caregivers/teachers who speak multiple languages are If disposable pull-ups were used, pull the sides apart, c) involved in changing pull-ups or underwear. All employees rather than sliding the garment down the child’s legs. who will change pull-ups or underwear and clothing should If underwear is being changed, remove the soiled undergo training and periodic assessment of these prac- underwear and any soiled clothing, doing your best tices. to avoid contamination of surfaces; Changing a child from the floor level or on a chair puts d) To avoid contamination of the environment and/or the adult in an awkward position and increases the risk of the increased risk of spreading germs to the other contamination of the environment. Using a toddler chang- children in the room, do not rinse the soiled clothing ing table helps establish a well-organized changing area for in the toilet or elsewhere. Place all soiled garments in both the child and the caregiver/teacher. Changing tables a plastic-lined, hands-free plastic bag to be cleaned with steps that allow the child to climb with the caregiver/ at the child’s home; teacher’s help and supervision are a good idea. This would If the child’s shoes are soiled, the caregiver/teacher e) help reduce the risk of back injury for the adults that may must wash and sanitize them before putting them occur from lifting the child onto the table (1). back on the child. It is a good idea for the child care Caregivers/teachers should never leave a child unattended facility to request a few extra pair of socks and shoes on a table or countertop, even for an instant. A safety strap from the parent/caregiver to be kept at the facility in or harness should not be used on the changing surface. If case these items become soiled (1). an emergency arises, caregivers/teachers should bring any Step 3: Clean the child’s skin and check for spills. child on an elevated surface to the floor or take the child Lift the child’s legs as needed to use disposable a) with them. wipes, or a dampened cloth or wet paper towel to An EPA-registered disinfectant suitable for the surface clean the skin on the child’s genitalia and buttocks. material that is being disinfected should be used. If an EPA- Remove stool and urine from front to back and use a registered product is not available, then household bleach fresh wipe, dampened cloth or wet paper towel each Chapter 3: Health Promotion 108

139 Caring for Our Children: National Health and Safety Performance Standards ing. Changing these undergarments can lead to risk for time you swipe. Put the soiled wipes or paper towels spreading infection due to the contamination of surfaces into the soiled pull-up or directly into a plastic-lined, from urine or feces (1). The procedure for changing a child’s hands-free covered can. Reusable cloths should be soiled undergarment and clothing is designed to reduce the stored in a washable, plastic-lined, tightly covered contamination of surfaces that will later come in contact receptacle (within arm’s reach of diaper changing with uncontaminated surfaces such as hands, furnishings, tables) until they can be laundered. The cover should and floors (2,4). Posting the multi-step procedure may help not require touching with contaminated hands or caregivers/teachers maintain the routine. objects; Check for spills under the child. If there are any, use b) Assembling all necessary supplies before bringing the child the paper that extends beyond and under the child’s to the changing area will ensure the child’s safety, make the feet to fold over the soiled area so a fresh, unsoiled change more efficient, and reduce opportunities for con- paper surface is now under the child’s buttocks; tamination. Taking the supplies out of their containers and c) If gloves were used, remove them using the proper leaving the containers in their storage places reduces the technique (see Appendix D) and put them into a likelihood that the storage containers will become contami - plastic-lined, hands-free covered can; nated during changing. d) Whether or not gloves were used, use a fresh wipe to Commonly, caregivers/teachers do not use disposable wipe the hands of the caregiver/teacher and another paper that is large enough to cover the area likely to be fresh wipe to wipe the child’s hands. Put the wipes contaminated during changing. If the paper is large enough, into the plastic-lined, hands-free covered can. there will be less need to remove visible soil from surfaces Step 4: Put on a clean pull-up or underwear and clothing, if later and there will be enough paper to fold up so the soiled necessary. surface is not in contact with clean surfaces while dressing Assist the child, as needed, in putting on a clean a) the child. disposable pull-up or underwear, then in re-dressing If the child’s foot coverings are not removed during chang- (1); ing, and the child kicks during the changing procedure, the Note and plan to report any skin problems such as b) foot coverings can become contaminated and subsequently redness, skin cracks, or bleeding; spread contamination throughout the child care area. c) Put the child’s socks and shoes back on if they were removed during the changing procedure (1). Some experts believe that commercial baby wipes may cause irritation of a toddler’s sensitive tissues, such as Step 5: Wash the child’s hands and return the child to a inside the labia, but currently there is no scientific evidence supervised area. available on this issue. Wet paper towels or a damp cloth Use soap and warm water, between 60°F and 120°F, a) may be used as an alternative to commercial baby wipes. at a sink to wash the child’s hands, if you can. - If the child’s clean buttocks are put down on a soiled sur Step 6: Clean and disinfect the changing surface. face, the child’s skin can be resoiled. Dispose of the disposable paper liner used on the a) changing surface in a plastic-lined, hands-free Children’s hands often stray into the changing area (the area covered can; - of the child’s body covered by the soiled pull-ups or under If clothing was soiled, securely tie the plastic bag b) wear) during the changing process and can then transfer used to store the clothing and send home; fecal organisms to the environment. Washing the child’s c) Remove any visible soil from the changing surface hands will reduce the number or organisms carried into the with a disposable paper towel saturated with water environment in this way. Infectious organisms are present and detergent, rinse; on the skin and pull-ups or underwear even though they are Wet the entire changing surface with a disinfectant d) not seen. To reduce the contamination of clean surfaces, that is appropriate for the surface material you are caregivers/teachers should use a fresh wipe to wipe their treating. Follow the manufacturer’s instructions for hands after removing the gloves or, if no gloves were used, use; before proceeding to handle the clean pull-up or underwear Put away the disinfectant. Some types of e) and the clothing. disinfectants may require rinsing the change table Some states and credentialing organizations may recom- surface with fresh water afterwards. mend wearing gloves for changing. Although gloves may not Step 7: Perform hand hygiene according to the procedure in be required, they may provide a barrier against surface con- Standard 3.2.2.2 and record the change in the child’s daily tamination of a caregiver/teacher’s hands. This may reduce log. the presence of enteric pathogens under the fingernails and In the daily log, record what was in the pull-up or a) on hand surfaces. Even if gloves are used, caregivers/teach- underwear and any problems (such as a loose stool, ers must perform hand hygiene after each child’s changing an unusual odor, blood in the stool, or any skin to prevent the spread of disease-causing agents. To achieve irritation), and report as necessary (3). maximum benefit from use of gloves, the caregiver/teacher must remove the gloves properly after cleaning the child’s Children who are learning to use the toilet RATIONALE: genitalia and buttocks and removing the soiled pull-up or may still wet/soil their pull-ups or underwear and cloth- Chapter 3: Health Promotion 109

140 Caring for Our Children: National Health and Safety Performance Standards Standard 3.2.2.2: Handwashing Procedure underwear. Otherwise, retained contaminated gloves could Standard 3.3.0.1: Routine Cleaning, Sanitizing, and Disinfecting transfer organisms to clean surfaces. Note that sensitivity to Standard 5.2.7.4: Containment of Soiled Diapers latex is a growing problem. If caregivers/teachers or children Standard 5.4.4.2: Location of Laundry Equipment and Water who are sensitive to latex are present in the facility, non- Temperature for Laundering latex gloves should be used. See Appendix D for proper Appendix D: Gloving technique for removing gloves. Appendix J: Selecting an Appropriate Sanitizer or Disinfectant A safety strap cannot be relied upon to restrain the child and REFERENCES: could become contaminated during changing. Cleaning and 1. ECELS-Healthy Child Care Pennsylvania. Changing soiled disinfecting a strap would be required after every change. underwear for toddlers. http://www.ecels-healthychildcarepa.org/ Therefore safety straps on changing surfaces are not recom- content/2-11-10 v2ChangingSoiledUnderwear.pdf. 2. Pickering, L. K., C. J. Baker, D. W. Kimberlin, S. S. Long, eds. mended. 2009. Red book 2009: Report of the Committee on Infectious Prior to disinfecting the changing table, clean any visible Diseases. 28th ed. Elk Grove Village, IL: American Academy of soil from the surface with a detergent and rinse well with Pediatrics. water. Always follow the manufacturer’s instructions for use, 3. National Association for the Education of Young Children. application and storage. If the disinfectant is applied using Keeping healthy: Parents, teachers, and children. 2007. Rev ed. Washington, DC: NAEYC. a spray bottle, always assume that the outside of the spray 4. Fiene, R. 2002. 13 indicators of quality child care: Research bottle could be contaminated. Therefore, the spray bottle update. Washington, DC: U.S. Department of Health and Human should be put away before hand hygiene is performed (the Services, Office of the Assistant Secretary for Planning and last and essential part of every change) (5). Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/. Changing areas should never be located in food preparation 5. North Carolina Child Care Health and Safety Resource Center. areas and should never be used for temporary placement of Diapering procedure poster. http://www.healthychildcarenc.org/ PDFs/diaper_procedure_english.pdf. food, drinks, or eating utensils. Children with disabilities may require diaper - COMMENTS: 3.2.2 Hand Hygiene ing and the method of diapering will vary according to their abilities. However, principles of hygiene should be con- STANDARD 3.2.2.1: Situations that Require sistent regardless of method. Toddlers and preschool age Hand Hygiene children without physical disabilities frequently have toileting issues as well. These soiling/wetting episodes can be due All staff, volunteers, and children should follow the proce- to rapid onset gastroenteritis, distraction due to the intensity dure in Standard 3.2.2.2 for hand hygiene at the following of their play, and emotional disruption secondary to new times: transition. These include new siblings, stress in the family, Upon arrival for the day, after breaks, or when a) or anxiety about changing classrooms or programs, all of moving from one child care group to another; which are based on their inability to recognize and articulate Before and after: b) their stress and to manage a variety of impulses. 1) Preparing food or beverages; 2) Eating, handling food, or feeding a child; Development is not a straight trajectory, but rather a Giving medication or applying a medical ointment 3) cycle of forward and backward steps as children gain or cream in which a break in the skin (e.g., sores, mastery over their bodies in a wide variety of situations. It cuts, or scrapes) may be encountered; is normal and developmentally appropriate for children to 4) Playing in water (including swimming) that is used revert to immature behaviors as they gain developmental by more than one person; milestones while simultaneously dealing with immediate 5) Diapering; struggles which they are internalizing. Even for preschool c) After: and kindergarten aged children, these accidents happen 1) Using the toilet or helping a child use a toilet; and these incidents are called ‘accidents’ because of the Handling bodily fluid (mucus, blood, vomit), 2) frequency of these episodes among normally developing from sneezing, wiping and blowing noses, from children. It is important for caregivers/teachers to recognize mouths, or from sores; that the need to assist young children with toileting is a Handling animals or cleaning up animal waste; 3) critical part of their work and that their attitude regarding the 4) Playing in sand, on wooden play sets, and incident and their support of children as they work toward outdoors; self regulation of their bodies is a component of teaching 5) Cleaning or handling the garbage. young children. Situations or times that children and staff should perform TYPE OF FACILITY: Center; Large Family Child Care Home; Small hand hygiene should be posted in all food preparation, Family Child Care Home hand hygiene, diapering, and toileting areas. RELATED STANDARDS: Hand hygiene is the most important way to RATIONALE: Standard 2.1.2.5: Toilet Learning/Training reduce the spread of infection. Many studies have shown Standard 3.2.1.3: Checking for the Need to Change Diapers that improperly cleansed hands are the primary carriers of Standard 3.2.2.1: Situations that Require Hand Hygiene Chapter 3: Health Promotion 110

141 Caring for Our Children: National Health and Safety Performance Standards C. McGilchrist. 2000. Effect of infection control measures on the infections. Deficiencies in hand hygiene have contributed to frequency of upper respiratory infection in child care: A randomized, many outbreaks of diarrhea among children and caregivers/ Pediatrics 105:738-42. controlled trial. teachers in child care centers (1). 4. Niffenegger, J. P. 1997. Proper handwashing promotes wellness In child care centers that have implemented hand hygiene 11:26-31. in child care. J Pediatr Health Care training program, the incidence of diarrheal illness has de- 5. Donowitz, L. G., ed. 1996 . Infection control in the child care , 18, 19, 68. 2nd ed. Baltimore, MD: Williams center and preschool creased by 50% (2). Several studies demonstrate a reduc- and Wilkins. tion in upper respiratory symptoms (colds) when frequent 6. Palmer, S. R., L. Soulsby, D. I. H. Simpson, eds. 1998. Zoonoses: and proper hand hygiene practices were incorporated into a Biology, clinical practice, and public health control . New York: child care center’s curriculum (2-4). Oxford University Press. Hand hygiene after exposure to soil and sand will reduce 7. Weinberg, A. N. and D. J. Weber, eds. 1991. Respiratory opportunities for the ingestion of zoonotic parasites that Infect Dis Clin North Am 5:649- infections transmitted from animals. 61. could be present in contaminated sand and soil (6,7). 8. Mayo Clinic. 2010. Secondhand smoke: Avoid dangers in the air. Thorough handwashing with soap for at least twenty http://www.mayoclinic.com/health/secondhand-smoke/CC00023/. seconds using comfortably warm, running water (between 60°F and 120°F) removes organisms from the skin and al- STANDARD 3.2.2.2: Handwashing Procedure lows them to be rinsed away (5). Hand hygiene is effective Children and staff members should wash their hands using in preventing transmission of disease. Hand hygiene with the following method: an alcohol-based sanitizer is an alternative to traditional Check to be sure a clean, disposable paper (or a) handwashing with soap and water when visible soiling is not single-use cloth) towel is available; present. b) Turn on warm water, between 60°F and 120°F, to a Infectious organisms may be spread in a variety of ways: comfortable temperature; a) In human waste (urine, stool); Moisten hands with water and apply soap (not c) b) In body fluids (saliva, nasal discharge, secretions antibacterial) to hands; from open injuries; eye discharge, blood); Rub hands together vigorously until a soapy lather d) c) Cuts or skin sores; appears, hands are out of the water stream, and d) By direct skin-to-skin contact; continue for at least twenty seconds (sing Happy e) By touching an object that has live organisms on it; Birthday silently twice) (2). Rub areas between f) In droplets of body fluids, such as those produced by fingers, around nail beds, under fingernails, jewelry, sneezing and coughing, that travel through the air. and back of hands. Nails should be kept short; acrylic nails should not worn (3); Since many infected people carry infectious organisms Rinse hands under running water, between 60°F and e) without symptoms and many are contagious before they 120°F, until they are free of soap and dirt. Leave the experience a symptom, caregivers/teachers routine hand water running while drying hands; hygiene is the safest practice (4). f) Dry hands with the clean, disposable paper or single If caregivers/teachers smoke off premises before start- use cloth towel; ing work, they should wash their hands before caring for If taps do not shut off automatically, turn taps off with g) children to prevent children from receiving third-hand smoke a disposable paper or single use cloth towel; exposure (8). Throw the disposable paper towel into a lined trash h) TYPE OF FACILITY: Center; Large Family Child Care Home; Small container; or place single-use cloth towels in the Family Child Care Home laundry hamper; or hang individually labeled cloth towels to dry. Use hand lotion to prevent chapping of RELATED STANDARDS: Standard 3.2.2.2: Handwashing Procedure hands, if desired. Standard 3.2.2.3: Assisting Children with Hand Hygiene The use of alcohol based hand sanitizers is an alternative Standard 3.2.2.4: Training and Monitoring for Hand Hygiene to traditional handwashing with soap and water by children Standard 3.2.2.5: Hand Sanitizers over twenty-four months of age and adults on hands that Standard 3.4.1.1: Use of Tobacco, Alcohol, and Illegal Drugs are not visibly soiled. A single pump of an alcohol-based REFERENCES: sanitizer should be dispensed. Hands should be rubbed 1. Hawks, D., J. Ascheim, G. S. Giebink, S. Graville, A. J. Solnit. together, distributing sanitizer to all hand and finger surfaces 1994. Science, prevention, and practice VII: Improving child and hands should be permitted to air dry. day care, a concurrent summary of the American Public Health Association/American Academy of Pediatrics National health and Situations/times that children and staff should wash their safety guidelines for child-care programs; featured standards and hands should be posted in all handwashing areas. implementation. Pediatrics 94:1110-12. Use of antimicrobial soap is not recommended in child care 2. Soto. J. C., M. Guy, L. Belanger. 1994. Science, prevention and practice II: Preventing infectious diseases, abstracts on settings. There are no data to support use of antibacterial handwashing and infection control in day-care centers. Pediatrics soaps over other liquid soaps. 94:1030. 3. Roberts, L., E. Mapp, W. Smith, L. Jorm, M. Pate, R. M. Douglas, Chapter 3: Health Promotion 111

142 Caring for Our Children: National Health and Safety Performance Standards J Med 27:24-28. Children and staff who need to open a door to leave a bath- room or diaper changing area should open the door with a STANDARD 3.2.2.3: Assisting Children with disposable towel to avoid possibly re-contaminating clean hands. If a child can not open the door or turn off the faucet, Hand Hygiene they should be assisted by an adult. Caregivers/teachers should provide assistance with hand- Running water over the hands removes visible RATIONALE: washing at a sink for infants who can be safely cradled in soil. Wetting the hands before applying soap helps to create one arm and for children who can stand but not wash their a lather that can loosen soil. The soap lather loosens soil hands independently. A child who can stand should either and brings it into solution on the surface of the skin. Rinsing use a child-height sink or stand on a safety step at a height the lather off into a sink removes the soil from the hands at which the child’s hands can hang freely under the running that the soap brought into solution. Warm water, between water. After assisting the child with handwashing, the staff 60°F and 120°F, is more comfortable than cold water; using member should wash his or her own hands. Hand hygiene warm water also promotes adequate rinsing during hand- with an alcohol-based sanitizer is an alternative to hand- washing (1). washing with soap and water by children over twenty-four months of age and adults when there is no visible soiling of Acceptable forms of soap include liquid and powder. hands (1). COMMENTS: Pre-moistened cleansing towelettes do Encouraging and teaching children good hand RATIONALE: not effectively clean hands and should not be used as a hygiene practices must be done in a safe manner. A “how substitute for washing hands with soap and running water. to” poster that is developmentally appropriate should be When running water is unavailable or impractical, the use of placed wherever children wash their hands. alcohol-based hand sanitizer (Standard 3.2.2.5) is a suitable alternative. For examples of handwashing posters, see: Outbreaks of disease have been linked to shared wash California Childcare Health Program at http://www water and wash basins (4). Water basins should not be used .ucsfchildcarehealth.org; as an alternative to running water. Camp sinks and portable North Carolina Child Care Health and Safety Resource Cen- commercial sinks with foot or hand pumps dispense water ter at http://www.healthychildcarenc.org/training as for a plumbed sink and are satisfactory if filled with fresh _materials.htm. water daily. The staff should clean and disinfect the water TYPE OF FACILITY: Center; Large Family Child Care Home; Small reservoir container and water catch basin daily. Family Child Care Home Single-use towels should be used unless an automatic elec- RELATED STANDARDS: tric hand-dryer is available. Standard 3.2.2.1: Situations that Require Hand Hygiene The use of cloth roller towels is not recommended for the Standard 3.2.2.2: Handwashing Procedure Standard 3.2.2.5: Hand Sanitizers following reasons: Children often use cloth roll dispensers improperly, a) REFERENCES: resulting in more than one child using the same sec- 1. Centers for Disease Control and Prevention. 2009. Preventing tion of towel; and the spread of influenza (the flu) in child care settings: Guidance for b) Incidents of unintentional strangulation have been administrators, caregivers/teachers, and other staff. http://www .cdc.gov/flu/professionals/infectioncontrol/childcaresettings.htm. reported (U.S. Consumer Product Safety Commission Data Office, pers. comm.) STANDARD 3.2.2.4: Training and Monitoring TYPE OF FACILITY: Center; Large Family Child Care Home; Small for Hand Hygiene Family Child Care Home The program should ensure that staff members and children RELATED STANDARDS: Standard 3.2.2.1: Situations that Require Hand Hygiene who are developmentally able to learn personal hygiene are Standard 3.2.2.3: Assisting Children with Hand Hygiene instructed in, and monitored on performing hand hygiene as Standard 3.2.2.5: Hand Sanitizers specified in Standard 3.2.2.2. Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disin - Education of the staff and children regarding RATIONALE: fecting hand hygiene and other cleaning procedures can reduce the REFERENCES: occurrence of illness in the group of children in care (1,2). 1. Donowitz, L. G., ed. 1996. Infection control in the child care center and preschool. 2nd ed. Baltimore, MD: Williams and Wilkins. Staff training and monitoring of hand hygiene has been 2. Centers for Disease Control and Prevention. 2011. Handwashing: shown to reduce transmission of organisms that cause Clean hands save lives. http://www.cdc.gov/handwashing/. disease (3-6). Periodic training and monitoring is needed to 3. McNeil, S. A., C. L. Foster, S. A. Hedderwick, C. A. Kauffman. result in sustainable changes in practice (7). 2001. Effect of hand clensing with antimicrobial soap or alcohol- Training programs may utilize some type COMMENTS: based gel on microbial colonization of artificial fingernails worn by 32:367-72. Clin Infect Dis health care workers. of verbal cue such as singing the alphabet song, twinkle, 4. Ogunsola, F. T., Y. O. Adesiji. 2008. Comparison of four methods twinkle little star or the birthday song during handwashing. West Afr of hand washing in situations of inadequate water supply. 112 Chapter 3: Health Promotion

143 Caring for Our Children: National Health and Safety Performance Standards TYPE OF FACILITY: Center; Large Family Child Care Home; Small 0.32 gal (1.2 L) for dispensers in rooms, corridors, b) Family Child Care Home and areas open to corridors; 0.53 gal (2.0 L) for dispensers in suites of rooms; c) RELATED STANDARDS: d) Where aerosol containers are used, the maximum Standard 3.2.2.1: Situations that Require Hand Hygiene Standard 3.2.2.2: Handwashing Procedure capacity of the aerosol dispenser should be 18 oz. (0.51 kg) and should be limited to Level 1 aerosols as REFERENCES: defined in NFPA 30B: Code for the Manufacture and 1. Hawks, D., J. Ascheim, G. S. Giebink, S. Graville, A. J. Solnit. Storage of Aerosol Products; 1994. Science, prevention, and practice VII: Improving child Wall mounted dispensers should be separated from e) day care, a concurrent summary of the American Public Health Association/American Academy of Pediatrics national health and each other by horizontal spacing of not less than 48 safety guidelines for child-care programs; featured standards and in. (1,220 mm); implementation. 95:1110-12. Pediatrics f) Wall mounted dispensers should not be installed 2. Roberts, L., E. Mapp, W. Smith, L. Jorm, M. Pate, R. M. Douglas, above or adjacent to ignition sources such as C. McGilchrist. 2000. Effect of infection control measures on the electrical outlets; frequency of upper respiratory infection in child care: A randomized, g) Wall mounted dispensers installed directly over controlled trial. Pediatrics 105:738-42. carpeted floors should be permitted only in child care 3. Black, R. E., A. C. Dykes, K. E. Anderson. 1981. Handwashing to facilities protected by automatic sprinklers (1). prevent diarrhea in day care centers . Am J Epidemiol 113:445-51. 4. Roberts, L., L. Jorm, M. Patel, W. Smith, R. M. Douglas, C. RATIONALE: Studies have demonstrated that using an McGilchrist. 2000. Effect of infection control measures on the alcohol-based hand sanitizer after washing hands with soap frequency of diarrheal episodes in child care: A randomized, and water is effective in reducing illness transmission in 105:743-46. Pediatrics controlled trial. the home, in child care centers and in health care settings 5. Carabin, H., T. W. Gyorkos, J. C. Soto, L. Joseph, P. Payment, (2-5). Hand sanitizer products may be dangerous or toxic if J. P. Collet. 1999. Effectiveness of a training program in reducing ingested in amounts greater than the residue left on hands 10:219- Epidemiol infections in toddlers attending daycare centers. after cleaning. It is important for caregivers/teachers to 27. 6. Bartlett, A. V., B. A. Jarvis, V. Ross, T. M. Katz, M. A. Dalia, S. J. monitor children’s use of hand sanitizers to ensure the prod- Englender, L. J. Anderson. 1988. Diarrheal illness among infants uct is being used appropriately. and toddlers in day care centers: Effects of active surveillance Alcohol-based hand sanitizers have the potential to be and staff training without subsequent monitoring. Am J Epidemiol toxic due to the alcohol content if ingested in a significant 127:808-17. amount. As with any hand hygiene product, supervision of 7. Alkon, A., J. Bernzweig, K. To, M. Wolff, J. F. Mackie. 2009. Child children is required to monitor effective use and to avoid care health consultation improves health and safety policies and practices 9:366-70. . Academic Pediatrics potential ingestion or inadvertent contact with eyes and mucous membranes. STANDARD 3.2.2.5: Hand Sanitizers Even in health care settings, the Centers for COMMENTS: The use of hand sanitizers by children over twenty-four Disease Control and Prevention (CDC) guidelines recom- months of age and adults in child care programs is an ap- mend washing hands that are visibly soiled or contaminated propriate alternative to the use of traditional handwashing with organic material with soap and water as an adjunct to with soap and water. For visibly dirty hands, rinsing under the use of alcohol-based sanitizers (6). running water or wiping with a water-saturated towel should Some hand sanitizing products contain non-alcohol and be used to remove as much dirt as possible before using a “natural” ingredients. The efficacy of non-alcohol contain- hand sanitizer. ing hand sanitizers is variable and therefore a non-alcohol- Hand sanitizers using an alcohol-based active ingredient based product is not recommended for use. must contain 60% to 95% alcohol in order to be effective to Center; Large Family Child Care Home; Small TYPE OF FACILITY: kill germs, including multi-drug resistant pathogens. Child Family Child Care Home care programs should follow the manufacturer’s instructions RELATED STANDARDS: for use, check instructions to determine how long the hand Standard 3.2.2.1: Situations that Require Hand Hygiene sanitizer needs to remain on the skin surface to be effective. Standard 3.2.2.2: Handwashing Procedure Standard 5.5.0.5: Storage of Flammable Materials*** Supervision of children is required to monitor effective use and to avoid potential ingestion or inadvertent contact of REFERENCES: hand sanitizers with eyes and mucous membranes. 1. National Fire Protection Association (NFPA). 2009. NFPA 101: Life safety code. 2009 ed. Quincy, MA: NFPA. When alcohol based hand sanitizers are offered in a child 2. Boyce, J. M., D. Pittet, Healthcare Infection Control Practices care facility, the facility should encourage parents/guardians Advisory Committee, HICPAC/SHEA/APIC/IDSA Hand Hygiene Task to teach their children about their use at home. Force. 2002. Guideline for hand hygiene in health-care settings. MMWR 25:1-45. Where alcohol-based hand sanitizer dispensers are used: 3. Lennell, A., S. Kuhlmann-Berenzon, P. Geli, K. Hedin, C. a) The maximum individual dispenser fluid capacity Petersson, O. Cars, et al. 2008. Alcohol-based hand-disinfection should be as follows: reduced children’s absence from Swedish day care centers. Acta ***Addition to Related Standards in second printing, August 2011 Chapter 3: Health Promotion 113

144 Caring for Our Children: National Health and Safety Performance Standards 97:1672-80. Paediatrica a cough or sneeze that could result in the spread of respira- 4. Sandora, T. J., E. M. Taveras, M. C. Shih, E. A. Resnick, G. M. tory droplets to the skin. Lee, D. Ross-Degnan, et al. 2005. A randomized, controlled trial of Proper respiratory etiquette can prevent trans- RATIONALE: a multifaceted intervention including alcohol-based hand sanitizer mission of respiratory pathogens (1). and hand-hygiene education to reduce illness transmission in the Pediatrics home. 116:587-94. COMMENTS: Multi-lingual videos, posters, and handouts 5. Vessey, J. A., J. J. Sherwood, D. Warner, D. Clark. 2007. should be part of an active educational effort of caregivers/ Comparing hand washing to hand sanitizers in reducing elementary teachers and children to reinforce this practice. For free 33:368-72. Pediatric Nurs school students’ absenteeism. downloadable posters and flyers in multiple languages, go 6. U.S. Department of Health and Human Services, Centers for to http://www.cdc.gov/flu/protect/covercough.htm. Disease Control and Prevention. 2011. Handwashing: Clean hands save lives! http://www.cdc.gov/handwashing/. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home 3.2.3 Exposure to Body Fluids RELATED STANDARDS: Standard 3.2.2.1: Situations that Require Hand Hygiene STANDARD 3.2.3.1: Procedure for Nasal Standard 3.2.2.2: Handwashing Procedure Standard 3.2.2.3: Assisting Children with Hand Hygiene Secretions and Use of Nasal Bulb Syringes Standard 3.2.2.5: Hand Sanitizers Staff members and children should blow or wipe their noses REFERENCES: with disposable, single use tissues and then discard them 1. Centers for Disease Control and Prevention. 2010. Seasonal flu: in a plastic-lined, covered, hands-free trash container. After Cover your cough. http://www.cdc.gov/flu/protect/covercough.htm. blowing the nose, they should practice hand hygiene, as specified in Standards 3.2.2.1 and 3.2.2.2. STANDARD 3.2.3.3: Cuts and Scrapes Use of nasal bulb syringes is permitted. Nasal bulb syringes Cuts or sores that are actively dripping, oozing, or draining should be provided by the parents/guardians for individual body fluids should be covered with a dressing to avoid con- use and should be labeled with the child’s name. tamination of surfaces in child care. The caregiver/teacher If nasal bulb syringes are used, facilities should have a writ- should wear gloves if there is contact with any wound (cut ten policy that indicates: or scrape) that has material that could be transmitted to Rationale and protocols for use of nasal bulb a) another surface. syringes; A child or caregiver/teacher with a cut or sore that is leaking b) Written permission and any instructions or a body fluid that cannot be contained or cannot be covered preferences from the child’s parent/guardian; with a dressing, should be excluded from the facility until c) Staff should inspect each nasal bulb syringe for tears the cut or sore is scabbed over or healed. or cracks (and to see if there is unknown fluid in the Touching a contaminated object or surface RATIONALE: nasal bulb syringe) before each use; may spread infectious organisms. Body fluids may contain d) Nasal bulb syringes should be cleaned with warm infectious organisms (1). soapy water and stored open to air. Gloves can provide a protective barrier against infectious Hand hygiene is the most effective way to RATIONALE: organisms that may be present in body fluids. reduce the spread of infection (1). Covering sores on lips and on eyes is difficult. COMMENTS: Center; Large Family Child Care Home; Small TYPE OF FACILITY: Family Child Care Home Children or caregivers/teachers who are unable to prevent contact with these exposed lesions should be excluded until RELATED STANDARDS: lesions do not present a risk of transmission of a pathogen. Standard 3.2.2.2: Handwashing Procedure Standard 3.2.2.3: Assisting Children with Hand Hygiene Center; Large Family Child Care Home; Small TYPE OF FACILITY: Family Child Care Home REFERENCES: 1. Pickering, L. K., C. J. Baker, D. W. Kimberlin, S. S. Long, eds. RELATED STANDARDS: 2009. Red book: 2009 report of the Committee on Infectious Standard 3.6.1.1: Inclusion/Exclusion/Dismissal of Children . 28th ed. Elk Grove Village, IL: American Academy of Diseases REFERENCES: Pediatrics. 1. Pickering, L. K., C. J. Baker, D. W. Kimberlin, S. S. Long, eds. 2009. Red book: 2009 report of the Committee on Infectious STANDARD 3.2.3.2: Cough and Sneeze Diseases . 28th ed. Elk Grove Village, IL: American Academy of Etiquette Pediatrics. Staff members and children should be taught to cover their STANDARD 3.2.3.4: Prevention of Exposure to mouths and noses with a tissue when they cough or sneeze. Blood and Body Fluids Staff members and children should also be taught to cough or sneeze into their inner elbow/upper sleeve and to avoid Child care facilities should adopt the use of Standard Pre- covering the nose or mouth with bare hands. Hand hygiene, cautions developed for use in hospitals by The Centers for as specified in Standards 3.2.2.1 and 3.2.2.2, should follow 114 Chapter 3: Health Promotion

145 Caring for Our Children: National Health and Safety Performance Standards surface may be necessary. Caregivers/teachers Disease Control and Prevention (CDC). Standard Precau- should consult with local health departments for tions should be used to handle potential exposure to blood, additional guidance on cleaning contaminated including blood-containing body fluids and tissue discharg- floors, rugs, and carpeting. es, and to handle other potentially infectious fluids. Prior to using a disinfectant, clean the surface with a de- In child care settings: tergent and rinse well with water. Facilities should follow a) Use of disposable gloves is optional unless blood the manufacturer’s instruction for preparation and use of or blood containing body fluids may contact hands. disinfectant (3,4). For guidance on disinfectants, refer to Ap- Gloves are not required for feeding human milk, pendix J, Selecting an Appropriate Sanitizer or Disinfectant. cleaning up of spills of human milk, or for diapering; Gowns and masks are not required; b) If blood or bodily fluids enter a mucous membrane (eyes, c) Barriers to prevent contact with body fluids include nose, mouth) the following procedure should occur. Flush moisture-resistant disposable diaper table paper, the exposed area thoroughly with water. The goal of wash- disposable gloves, and eye protection. ing or flushing is to reduce the amount of the pathogen to which an exposed individual has contact. The optimal Caregivers/teachers are required to be educated regarding length of time for washing or flushing an exposed area Standard Precautions to prevent transmission of bloodborne is not known. Standard practice for managing mucous pathogens before beginning to work in the facility and at membrane(s) exposures to toxic substances is to flush the least annually thereafter. Training must comply with require- affected area for at least fifteen to twenty minutes. In the ments of the Occupational Safety and Health Administration absence of data to support the effectiveness of shorter (OSHA). periods of flushing it seems prudent to use the same fifteen Procedures for Standard Precautions should include: to twenty minute standard following exposure to bloodborne a) Surfaces that may come in contact with potentially pathogens (5). infectious body fluids must be disposable or of a RATIONALE: Some children and adults may unknowingly material that can be disinfected. Use of materials that be infected with HIV or other infectious agents, such as can be sterilized is not required. hepatitis B virus, as these agents may be present in blood The staff should use barriers and techniques that: b) or body fluids. Thus, the staff in all facilities should adopt 1) Minimize potential contact of mucous membranes Standard Precautions for all blood spills. Bacteria and vi- or openings in skin to blood or other potentially ruses carried in the blood, such as hepatitis B, pose a small infectious body fluids and tissue discharges; and but specific risk in the child care setting (3). Blood and body Reduce the spread of infectious material within 2) fluids containing blood (such as watery discharges from the child care facility. Such techniques include injuries) pose a potential risk, because bloody body fluids avoiding touching surfaces with potentially contain the highest concentration of viruses. In addition, contaminated materials unless those surfaces hepatitis B virus can survive in a dried state in the environ- are disinfected before further contact occurs with ment for at least a week and perhaps even longer. Some them by other objects or individuals. other body fluids such as saliva contaminated with blood When spills of body fluids, urine, feces, blood, saliva, c) or blood-associated fluids may contain live virus (such as nasal discharge, eye discharge, injury or tissue hepatitis B virus) but at lower concentrations than are found discharges occur, these spills should be cleaned up in blood itself. Other body fluids, including urine and feces, immediately, and further managed as follows: do not pose a risk for bloodborne infections unless they are For spills of vomit, urine, and feces, all floors, 1) visibly contaminated with blood, although these fluids may walls, bathrooms, tabletops, toys, furnishings and pose a risk for transmission of other infectious diseases. play equipment, kitchen counter tops, and diaper- changing tables in contact should be cleaned Touching a contaminated object or surface may spread ill- and disinfected as for the procedure for diaper nesses. Many types of infectious germs may be contained changing tables in Standard 3.2.1.4, Step 7; in human waste (urine, feces) and body fluids (saliva, nasal 2) For spills of blood or other potentially infectious discharge, tissue and injury discharges, eye discharges, body fluids, including injury and tissue discharges, blood, and vomit). Because many infected people carry the area should be cleaned and disinfected. Care infectious diseases without having symptoms, and many are should be taken and eye protection used to avoid contagious before they experience a symptom, staff mem- splashing any contaminated materials onto any bers need to protect themselves and the children they serve mucus membrane (eyes, nose, mouth); by adhering to Standard Precautions for all activities. Blood-contaminated material and diapers should 3) Gloves have proven to be effective in preventing transmis- be disposed of in a plastic bag with a secure tie; sion of many infectious diseases to health care workers. Floors, rugs, and carpeting that have been 4) Gloves are used mainly when people knowingly contact or contaminated by body fluids should be cleaned suspect they may contact blood or blood-containing body by blotting to remove the fluid as quickly as fluids, including blood-containing tissue or injury dis- possible, then disinfected by spot-cleaning with charges. These fluids may contain the viruses that transmit a detergent-disinfectant. Additional cleaning by HIV, hepatitis B, and hepatitis C. While human milk can be shampooing or steam cleaning the contaminated Chapter 3: Health Promotion 115

146 Caring for Our Children: National Health and Safety Performance Standards Use appropriate work practices to reduce the chance c) contaminated with blood from a cracked nipple, the risk of of reactions to latex; transmission of infection to caregivers/teachers who are When wearing latex gloves, do not use oil-based d) feeding expressed human milk is almost negligible and this hand creams or lotions (which can cause glove represents a theoretical risk. Wearing of gloves to feed or deterioration); clean up spills of expressed human milk is unnecessary, but After removing latex gloves, wash hands with a mild e) caregivers/teachers should avoid getting expressed human soap and dry thoroughly; milk on their hands, if they have any open skin or sores on f) Practice good housekeeping, frequently clean areas their hands. If caregivers/teachers have open wounds they and equipment contaminated with latex-containing should be protected by waterproof bandages or disposable dust; gloves. g) Attend all latex allergy training provided by the facility Cleaning and disinfecting rugs and carpeting that have been and become familiar with procedures for preventing contaminated by body fluids is challenging. Extracting as latex allergy; much of the contaminating material as possible before it Learn to recognize the symptoms of latex allergy: h) penetrates the surface to lower layers helps to minimize this skin rash; hives; flushing; itching; nasal, eye, or sinus challenge. Cleaning and disinfecting the surface without symptoms; asthma; and (rarely) shock. damaging it requires use of special cleaning agents de- Natural fingernails that are long or wearing artificial finger - signed for use on rugs, or steam cleaning (3). Therefore, nails or extenders is not recommended. Child care facilities alternatives to the use of carpeting and rugs are favored in should develop an organizational policy on the wearing of the child care environment. non-natural nails by staff (2). COMMENTS: The sanctions for failing to comply with For more information on safety with blood and body fluids, OSHA requirements can be costly, both in fines and in consult Healthy Child Care Pennsylvania’s “Keeping Safe health consequences. Regional offices of OSHA are listed at When Touching Blood or Other Body Fluids” at http://www http://www.epa.gov/aboutepa/index.html#regional/ and in .ecels-healthychildcarepa.org/content/Keeping Safe 07-27 the telephone directory with other federal offices. -10.pdf. Either single-use disposable gloves or utility gloves should TYPE OF FACILITY: Center; Large Family Child Care Home; Small be used when disinfecting. Single-use disposable gloves 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 Standard 3.2.1.4: Diaper Changing Procedure Standard 7.6.1.3: Staff Education on Prevention of Bloodborne dipped in disinfectant solution up to the wrist. The gloves Diseases should then be allowed to air dry. The wearing of gloves Appendix D: Gloving does not prevent contamination of hands or of surfaces Appendix J: Selecting an Appropriate Sanitizer or Disinfectant touched with contaminated gloved hands. Hand hygiene Appendix L: Cleaning Up Body Fluids and sanitizing of contaminated surfaces is required when REFERENCES: gloves are used. 1. De Queiroz, M., S. Combet, J. Berard, A. Pouyau, H. Genest, Ongoing exposures to latex may result in allergic reac- P. Mouriquand, D. Chassard. 2009. Latex allergy in children: tions in both the individual wearing the latex glove and the Modalities and prevention. Pediatric Anesthesia 19:313-19. individual who contacts the latex glove. Reports of such 2. Siegel, J. D., E. Rhinehart, M. Jackson, L. Chiarello, Healthcare reactions have increased (1). Infection Control Practices Advisory Committee. 2007. 2007 Guideline for isolation precautions: Preventing transmission of Caregivers/teachers should take the following steps to pro- infectious agents in healthcare settings http://www.cdc.gov/ . tect themselves, children, volunteers, and visitors from latex ncidod/dhqp/pdf/guidelines/Isolation2007.pdf. exposure and allergy in the workplace (6): 3. Kotch, J. B., P. Isbell, D. J. Weber, et al. 2007. Hand-washing and Use non-latex gloves for activities that are not likely a) diapering equipment reduces disease among children in out-of- to involve contact with infectious materials (food 120: e29-e36. Pediatrics home child care centers. preparation, diapering, routine housekeeping, general 4. Rutala, W. A., D. J. Weber, HICPAC. 2008. Guideline for disinfection and sterilization in healthcare facilities Center for . maintenance, etc.); Disease Control and Prevention. http://www.cdc.gov/ncidod/dhqp/ Use appropriate barrier protection when handling b) pdf/guidelines/Disinfection_Nov_2008.pdf. infectious materials. Avoid using latex gloves BUT if 5. Email communication from Amy V. Kindrick, MD, MPH, Senior latex gloves are chosen, use powder-free gloves with Consultant, National Clinicians’ Post-Exposure Prophylaxis Hotline reduced protein content; (PEPline), UCSF School of Medicine at San Francisco General 1) Such gloves reduce exposures to latex protein and Hospital to Elisabeth L.M. Miller, BSN, RN, BC, PA Chapter thus reduce the risk of latex allergy; American Academy of Pediatrics, Early Childhood Education Hypoallergenic latex gloves do not reduce the 2) Linkage System – Healthy Child Care Pennsylvania. November 11, risk of latex allergy. However, they may reduce 2009. reactions to chemical additives in the latex (allergic 6. American Association of Nurse Anesthetists. 2003. Creating a contact dermatitis); 116 Chapter 3: Health Promotion

147 Caring for Our Children: National Health and Safety Performance Standards latex-safe school for latex-sensitive children. http://www To reduce germs on inanimate surfaces Sanitize .anesthesiapatientsafety.com/patients/latex/school.asp. to levels considered safe by public health codes or regulations. 3.3 Cleaning, Sanitizing, and Disinfect To destroy or inactivate most germs on any inanimate object, but not bacterial Disinfecting spores. STANDARD 3.3.0.1: Routine Cleaning, Note: The term “germs” refers to bacteria, viruses, fungi and molds that may cause infectious disease. Bacterial spores Sanitizing, and Disinfecting are dormant bacteria that have formed a protective shell, Keeping objects and surfaces in a child care setting as enabling them to survive extreme conditions for years. The clean and free of pathogens as possible requires a combi- spores reactivate after entry into a host (such as a person), nation of: where conditions are favorable for them to live and repro- a) Frequent cleaning; and duce (6). When necessary, an application of a sanitizer or b) Only U.S. Environmental Protection Agency (EPA)-registered disinfectant. products that have an EPA registration number on the label Facilities should follow a routine schedule of cleaning, sani- can make public health claims that can be relied on for tizing, and disinfecting as outlined in Appendix K: Routine reducing or destroying germs. The EPA registration label will Schedule for Cleaning, Sanitizing, and Disinfecting. also describe the product as a cleaner, sanitizer, or disinfec- Cleaning, sanitizing and disinfecting products should not be tant. It is important to use the least toxic cleaner, sanitizer used in close proximity to children, and adequate ventila- and disinfectant for the particular job. Products that are tion should be maintained during any cleaning, sanitizing or labeled as “green” sanitizers and disinfectants should be disinfecting procedure to prevent children and caregivers/ EPA-registered. Products must be used according to manu- teachers from inhaling potentially toxic fumes. facturer’s instructions. RATIONALE: Young children sneeze, cough, drool, use Employers should provide staff with hazard information, diapers and are just learning to use the toilet. They hug, including access to and review of the Material Safety Data kiss, and touch everything and put objects in their mouths Sheets (MSDS) as required by the Occupational Safety and (1). Illnesses may be spread in a variety of ways, such as by Health Administration (OSHA), about the presence of toxic coughing, sneezing, direct skin-to-skin contact, or touching substances such as, cleaning, sanitizing and disinfecting a contaminated object or surface. Respiratory tract secre- supplies in use in the facility. The MSDS explain the risk of tions that can contain viruses (including respiratory syncytial exposure to products so that appropriate precautions may virus and rhinovirus) contaminate environmental surfaces be taken. and may present an opportunity for infection by contact Center; Large Family Child Care Home; Small TYPE OF FACILITY: (2-4). Family Child Care Home The terms cleaning, sanitizing and disinfect- COMMENTS: RELATED STANDARDS: ing are sometimes used interchangeably which can lead Standard 3.3.0.2: Cleaning and Sanitizing Toys Standard 3.3.0.3: Cleaning and Sanitizing Objects Intended for the to confusion and result in cleaning procedures that are not Mouth effective (3). Standard 5.2.1.6: Ventilation to Control Odors For example, a spray bottle containing a mixture of bleach - Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disin and water might be incorrectly used as the “first step” to fecting clean a soiled diaper change table or a table surface after REFERENCES: a meal. The solution in the spray bottle cannot be used as 1. California Childcare Health Program. 2009. Sanitize safely and a “first step” because the purpose of the bleach and water Health effectively: Bleach and alternatives in child care programs. solution is to sanitize (it is not designed to clean and is not and Safety Notes (July). http://www.ucsfchildcarehealth.org/pdfs/ effective as a disinfectant on dirty surfaces). In this example, healthandsafety/SanitizeSafely_En0709.pdf. cleaning with detergent and water, and then rinsing the 2. Thompson, S. C. 1994. Infectious diarrhoea in children: J Paediatric Child Controlling transmission in the child care setting. surface with water, should occur before spraying the surface 30:210-19. Health with the bleach and water solution (5). 3. Butz, A. M., P. Fosarelli, D. Dick, et al. 1993. Prevalence of Each term has a specific purpose and there are many meth- rotavirus on high-risk fomites in day-care facilities. Pediatrics ods that may be used to achieve such purpose. 92:202-5. 4. Grenier, D., D. Leduc, eds. 2008. Well beings: A guide to health in Purpose Task child care. 3rd ed. Ottawa, Ontario: Canadian Paediatric Society. 5. North Carolina Child Care Health and Safety Resource Center. To physically remove all dirt and Clean Diapering procedure poster. http://www.healthychildcarenc.org/ contamination. The friction of clean- training_materials.htm. ing removes most germs and exposes 6. Microbiology Procedure. Sporulation in bacteria. http://www any remaining germs to the effects of a .microbiologyprocedure.com/microorganisms/sporulation-in sanitizer or disinfectant used later. -bacteria.htm. Chapter 3: Health Promotion 117

148 Caring for Our Children: National Health and Safety Performance Standards TYPE OF FACILITY: Center; Large Family Child Care Home; Small STANDARD 3.3.0.2: Cleaning and Sanitizing Family Child Care Home Toys RELATED STANDARDS: Toys that cannot be cleaned and sanitized should not be Standard 3.1.4.3: Pacifier Use used. Toys that children have placed in their mouths or that Standard 3.3.0.1: Routine Cleaning, Sanitizing, and Disinfecting are otherwise contaminated by body secretion or excre- Standard 3.6.1.3: Thermometers for Taking Human Temperatures tion should be set aside until they are cleaned by hand with Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disin - fecting water and detergent, rinsed, sanitized, and air-dried or in a mechanical dishwasher that meets the requirements of REFERENCES: Standard 4.9.0.11 through Standard 4.9.0.13. Play with Well 1. Grenier, D., D. Leduc, eds. 2008. Preventing infections. In plastic or play foods, play dishes and utensils, should be . 3rd ed. Ottawa, Ontario: Canadian Paediatric Society. beings closely supervised to prevent shared mouthing of these toys. STANDARD 3.3.0.4: Cleaning Individual Bedding Machine washable cloth toys should be used by one in- dividual at a time. These toys should be laundered before Bedding (sheets, pillows, blankets, sleeping bags) should be being used by another child. of a type that can be washed. Each child’s bedding should be kept separate from other children’s bedding, on the bed Indoor toys should not be shared between groups of infants or stored in individually labeled bins, cubbies, or bags. Bed - or toddlers unless they are washed and sanitized before be- ding that touches a child’s skin should be cleaned weekly or ing moved from one group to the other. before use by another child. RATIONALE: Contamination of hands, toys and other RATIONALE: Toddlers often nap or sleep on mats or cots objects in child care areas has played a role in the trans- and the mats or cots are taken out of storage during nap mission of diseases in child care settings (1). All toys can time, and then placed back in storage. Providing bedding spread disease when children put the toys in their mouths, for each child and storing each set in individually labeled touch the toys after putting their hands in their mouths dur - bins, cubbies, or bags in a manner that separates the ing play or eating, or after toileting with inadequate hand personal articles of one individual from those of another are hygiene. Using a mechanical dishwasher is an acceptable appropriate hygienic practices (1). labor-saving approach for sanitizing plastic toys as long as the dishwasher can wash and sanitize the surfaces and TYPE OF FACILITY: Center; Large Family Child Care Home; Small dishes and cutlery are not washed at the same time (1). Family Child Care Home Small toys with hard surfaces can be set COMMENTS: RELATED STANDARDS: Standard 5.4.5.1: Sleeping Equipment and Supplies aside for cleaning by putting them into a dish pan labeled “soiled toys.” This dish pan can contain soapy water to be- REFERENCES: gin removal of soil, or it can be a dry container used to bring 1. Pickering, L. K., C. J. Baker, D. W. Kimberlin, S. S. Long, eds. the soiled toys to a toy cleaning area later in the day. Having 2009. Red book: 2009 report of the Committee on Infectious Diseases, 153. 28th ed. Elk Grove Village, IL: American Academy of enough toys to rotate through cleaning makes this method Pediatrics. of preferred cleaning possible. TYPE OF FACILITY: Center; Large Family Child Care Home; Small STANDARD 3.3.0.5: Cleaning Crib Surfaces Family Child Care Home Cribs and crib mattresses should have a nonporous, easy- RELATED STANDARDS: to-wipe surface. All surfaces should be cleaned as recom- Standard 3.3.0.1: Routine Cleaning, Sanitizing, and Disinfecting mended in Appendix K, Routine Schedule for Cleaning, Standards 4.9.0.11-4.9.0.13: Dishwashing Appendix J: Selecting an Appropriate Sanitizer or Disinfectant Sanitizing, and Disinfecting. - Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disin Contamination of hands, toys and other RATIONALE: fecting objects in child care areas has played a role in the transmis- REFERENCES: sion of diseases in child care settings (1). 1. Grenier, D., D. Leduc, eds. 2008. Preventing infections. In Well Center; Large Family Child Care Home; Small TYPE OF FACILITY: beings. 3rd ed. Ottawa, Ontario: Canadian Paediatric Society. Family Child Care Home STANDARD 3.3.0.3: Cleaning and Sanitizing RELATED STANDARDS: Standard 5.4.5.1: Sleeping Equipment and Supplies Objects Intended for the Mouth Standard 5.4.5.2: Cribs Thermometers, pacifiers, teething toys, and similar objects REFERENCES: should be cleaned, and reusable parts should be sanitized 1. Grenier, D., D. Leduc, eds. 2008. Preventing infections. In Well between uses. Pacifiers should not be shared. . 3rd ed. Ottawa, Ontario: Canadian Paediatric Society. beings Contamination of hands, toys and other RATIONALE: objects in child care areas has played a role in the transmis- sion of diseases in child care settings (1). 118 Chapter 3: Health Promotion

149 Caring for Our Children: National Health and Safety Performance Standards REFERENCES: 3.4 Health Protection in Child Children 1. U.S. Department of Health and Human Services. 2007. . Excerpts from the health and secondhand smoke exposure Care consequences of involuntary exposure to tobacco smoke: A report of the Surgeon General. Atlanta, GA: U.S. Department of Health 3.4.1 Tobacco and Drug Use and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for STANDARD 3.4.1.1: Use of Tobacco, Alcohol, Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. and Illegal Drugs 2. Schwartz, J., K. L. Timonen, J. Pekkanen. 2000. Respiratory Tobacco use, alcohol, and illegal drugs should be prohibited effects of environmental tobacco smoke in a panel study of on the premises of the program (both indoor and outdoor asthmatic and symptomatic children. Am J Resp Crit Care Med environments) and in any vehicles used by the program at 161:802-6. all times. Caregivers/teachers should not use tobacco, al- 3. Stenstrom, R., P. A. Bernard, H. Ben-Simhon. 1993. Exposure to environmental tobacco smoke as a risk factor for recurrent acute cohol, or illegal drugs off the premises during the child care Inter J Pediatr otitis media in children under the age of five years. program’s paid time including break time. Otorhinolaryngol 27:127-36. RATIONALE: Scientific evidence has linked respiratory 4. Pershagen, G. 1999. Accumulating evidence on health hazards of health risks to secondhand smoke. No children, especially Acta Paediatr passive smoking. 88:490-92. those with respiratory problems, should be exposed to 5. Gergen, P. J., J. A. Fowler, K. R. Maurer, et al. 1998. The burden additional risk from the air they breathe. Infants and young of environmental tobacco smoke exposure on the respiratory health of children 2 months through 5 years of age in the United States: children exposed to secondhand smoke are at risk of de- Third national health and nutritional examination survey, 1988 to veloping bronchitis, pneumonia, and middle ear infections 101: e8. Pediatrics 1994. when they experience common respiratory infections (1-5). 6. Winickoff, J. P., J. Friebely, S. E. Tanski, C. Sherrod, G. E. Matt, Separation of smokers and nonsmokers within the same air M. F. Hovell, R. C. McMillen. 2009. Beliefs about the health effects space does not eliminate or minimize exposure of nonsmok- 123: Pediatrics of “thirdhand” smoke and home smoking bans. ers to secondhand smoke. Tobacco smoke contamination e74-e79. lingers after a cigarette is extinguished and children come in 7. Runyan, C. W., S. I. Bangdiwala, M. A. Linzer, et al. 1992. Risk hirdhand smoke exposure also contact with the toxins (6). T N Eng J Med 327:856-63. factors for fatal residential fires. presents hazards. Thirdhand smoke refers to gases and par - 8. Brigham, P. A., A. McGuire 1995. Progress towards a fire-safe ticles clinging to smokers’ hair and clothing, cushions and 16:433-39. J Public Health Policy cigarette. 9. Ballard, J. E., T. D. Koepsell, F. Rivara. 1992. Association of carpeting, and outdoor equipment, after tobacco smoke has smoking and alcohol drinking with residential fire injuries. Am J dissipated (1). The residue includes heavy metals, carcino- 135:26-34. Epidemiol gens and radioactive materials that young children can get on their hands and ingest, especially if they’re crawling or 3.4.2 Animals playing on the floor. Residual toxins from smoking at times when the children are not using the space can trigger asth- STANDARD 3.4.2.1: Animals that Might Have ma and allergies when the children do use the space (1,2). Contact with Children and Adults Cigarettes used by adults are the leading cause of ignition of fatal house fires (7-9). The following domestic animals may have contact with children and adults if they meet the criteria specified in this Adults under the influence of alcohol and other drugs can- standard: Alcohol not take care of young children and keep them safe. a) Dog; use, illegal drug use and misuse of prescription or over Cat; b) the counter (OTC) drugs prevent caregivers/teachers from c) Ungulate (e.g., cow, sheep, goat, pig, horse); providing appropriate care to infants and children by impair - d) Rabbit; ing motor coordination, judgment, and response time. Safe e) Rodent (e.g., mice, rats, hamsters, gerbils, guinea child care necessitates alert, unimpaired caregivers/teach- pigs, chinchillas). ers. Fish are permissible but must be inaccessible to children. The use of alcoholic beverages in family child care homes after children are not in care is not prohibited. Any animal present at the facility, indoors or outdoors, should be trained/adapted to be with young children, in The age, defenselessness, and dependence COMMENTS: good health, show no evidence of carrying any disease, upon the judgment of caregivers/teachers of the children fleas or ticks, be fully immunized, and be maintained on an under care make this prohibition an absolute requirement. intestinal parasite control program. A current (time-spec- TYPE OF FACILITY: Center; Large Family Child Care Home; Small ified) certificate from each animal’s attending veterinarian Family Child Care Home should be on file in the facility, stating that all animals on the RELATED STANDARDS: facility premises meet these conditions and meet local and Standard 9.2.3.15: Policy on Prohibiting Tobacco, Alcohol, Illegal state requirements. Drugs, and Toxic Substances Chapter 3: Health Promotion 119

150 Caring for Our Children: National Health and Safety Performance Standards Special precautions may be needed to minimize the risk of Only animals that do not pose a health or safety risk will be disease transmission to immunocompromised children (13). allowed on the premises of the facility. When animals are taken out of their natural environment and The caregiver/teacher should instruct children on the hu- are in situations unusual to them, the stress that the animals mane and safe procedures to follow when in close proximity experience may cause them to act aggressively or attempt to animals (for example, not to provoke or startle animals or to escape (the “flight or fight” phenomenon). Appropriate re- touch them when they are near food). straint devices will allow the holder to react quickly, prevent - All contact between animals and children should be super harm to children and/or the escape of the animal (9). vised by a caregiver/teacher who is close enough to remove Pregnant women need to be aware of a potential risk asso- the child immediately if the animal shows signs of distress ciated with contact with cats’ feces (stool). Toxoplasmosis is (e.g., growling, baring teeth, tail down, ears back) or the . an infection caused by a parasite called Toxoplasma gondii child shows signs of treating the animal inappropriately. This parasite is carried by cats and is passed in their feces. Children should not be allowed to feed animals directly from Toxoplasmosis can cause problems with pregnancy, includ- their hands. ing abortion (8). The CDC advises pregnant women to avoid No food and beverages should be allowed in animal areas. pet rodents because of the risk of lymphocytic choriomenin- In addition, adults and children should not carry toys, use gitis virus (6,12). pacifiers, cups, and infant bottles in animal areas. COMMENTS: Bringing animals and children together has The animals should be housed within some “barrier” that both risks and benefits. Animals teach children about how protects them from competition by other animals while be- to be gentle and responsible, about life and death, and ing fed which would also provide protection for the children about unconditional love (9). Nevertheless, animals can yet they could still observe the animals eating. Animal food pose serious health and safety risks. dishes should not be placed in areas accessible to children Special accommodations for children with allergies may be during hours when children are present. necessary. Cleaning air filters more often if animals are in Children should be discouraged from “kissing” animals or childcare areas may be helpful in reducing animal dander. having them in close contact with their faces. Some dogs complete training and are certified as part of All children and caregivers/teachers who handle animals or “dog-assisted therapy programs.” Certification requires that animal-related equipment (e.g., leashes, dishes, toys, etc.) dogs meet specific criteria, complete screening/training, should be instructed to use hand hygiene immediately after and be a member of Therapy Dogs International for liability handling. purposes. Although these programs are typically based in hospitals, certified therapy animals also help with disaster Immunocompromised children, such as children with organ relief and other efforts. Facilities that want to offer educa- transplants, human immunodeficiency virus (HIV), acquired tional information to staff or hands-on learning opportunities immunodeficiency syndrome (AIDS), or currently receiving for children may find it helpful to contact their local hospital cancer chemotherapy or radiation therapy, and/or children to identify a trainer for dog-assisted therapy programs. For with allergies, should have an individualized health care plan more information on this program and resources, contact in place that specifies if there are precautionary measures to Therapy Dogs International at http://www.tdi-dog.org. be taken before the child has direct or indirect contact with animals or equipment. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home Uncaged animals, such as dogs and cats, should wear a RELATED STANDARDS: proper collar, harness, and/or leash when on the facility Standards 3.2.2.1-3.2.2.5: Hand Hygiene premises and the owner or responsible adult should stay Standard 3.4.2.2: Prohibited Animals with the animal at all times. Animals should not be permitted Standard 3.4.2.3: Care for Animals in food preparation or service areas at any time. REFERENCES: RATIONALE: The risk of injury, infection, and aggravation of 1. Gilchrist, J., J. J. Sacks, D. White, M. J. Kresnow. 2008. Dog allergy from contact between children and animals is signifi- bites: Still a problem? Injury Prevention 14:296-301. cant. The staff must plan carefully when having an animal in 2. Reisner, I. R., F. S. Shofer. 2008. Effects of gender and parental the facility and when visiting a zoo or local pet store (5,9,10). status on knowledge and attitudes of dog owners regarding dog Children should be brought into direct contact only with ani- 233:1412-19. aggression toward children. J Am Vet Med Assoc mals known to be friendly and comfortable in the company 3. Information from Your Family Doctor. 2004. Dog bites: Teaching 69:2653. your child to be safe . Am Family Physician of children. 4. Bernardo, L. M., M. J. Gardner, R. L. Rosenfield, B. Cohen, R. Dog bites to children under four years of age usually occur Pitetti. 2002. A comparison of dog bite injuries in younger and older at home, and the most common injury sites are the head, children treated in a pediatric emergency department. Pediatric face, and neck (1-4). Many human illnesses can be acquired 18:247-49. Emergency Care from animals (5,7,8,11). Many allergic children have symp- 5. National Association of State Public Health Veterinarians. 2007. Compendium of measures to prevent disease associated with toms when they are around animals. animals in public settings. MMWR 56:1-13. 6. U.S. Department 120 Chapter 3: Health Promotion

151 Caring for Our Children: National Health and Safety Performance Standards of Health and Human Services, Centers for Disease Control and i) Psittacine birds unless tested for psittacosis - Prevention. 2009. Appendix D: Guidelines for animals in school and Inclusive of parrots, parakeets, budgies, and child-care settings. 58:20-21. MMWR cockatiels. Psittacine birds can carry diseases that 7. U.S. Department of Health and Human Services, Centers for can be transferred to humans; Disease Control and Prevention. 2000. Compendium of measures j) Ferrets - Ferrets have a propensity to bite when to control Chlamydia psittaci infection among humans (psittacosis) startled; MMWR and pet birds (avian chlamydiosis). 49:3-17. Animals in estrus - Female dogs and cats should k) 8. U.S. Department of Health and Human Services, Centers be determined not to be in estrus (heat) when at the for Disease Control and Prevention. Pregnant women and child care facility; Toxoplasmosis. http://www.cdc.gov/healthypets/pregnant.htm. l) Animals less than one year of age - Incorporating Animals in Kansas schools: Guidelines 9. Hansen, G. R. 2004. for visiting and resident pets. Topeka, KS: Kansas Department of young animals (animal that are less than one year Health and Environment. http://www.kdheks.gov/pdf/hef/ of age) into child care programs is not permitted ab1007.pdf. because of issues regarding unpredictable behavior 10. Massachusetts Department of Public Health Division of and elimination control. Additionally, the immune Epidemiology and Immunization. 2001. Recommendations for systems of very young puppies and kittens are not petting zoos, petting farms, animal fairs, and other events and completely developed, thereby placing the health of exhibits where contact between animals and people is permitted. these animals at risk. http://www.mass.gov/Eeohhs2/docs/dph/cdc/rabies/reduce_zoos _risk.pdf. Animals, including pets, are a source of illness RATIONALE: 11. Pickering, L. K., N. Marano, J. A. Bocchini, F. J. Angulo. 2008. for people, and people may be a source of illness for ani- Exposure to nontraditional pets at home and to animals in public mals (1-2,4-5). Reptiles usually carry salmonella and pose a settings: risks to children. Pediatrics 122:876-86. risk to children who are likely to put unwashed hands in their 12. Centers for Disease Control and Prevention. 2010. Lymphocytic mouths (3,5). choriomeningitis (LCMV). http://www.cdc.gov/ncidod/dvrd/spb/ mnpages/dispages/lcmv.htm. Center; Large Family Child Care Home; Small TYPE OF FACILITY: 13. Hemsworth, S., B. Pizer. 2006. Pet ownership in Family Child Care Home immunocompromised children – A review of the literature and RELATED STANDARDS: Eur J Oncol Nurs 10:117-27. survey of existing guidelines. Standard 3.4.2.1: Animals That Might Have Contact with Children and Adults STANDARD 3.4.2.2: Prohibited Animals Standard 3.4.2.3: Care for Animals The following animals should not be kept at or brought onto REFERENCES: the grounds of the child care facility (4,6,7): 1. Weinberg, A. N., D. J. Weber, eds. 1991. Respiratory infections a) Bats; transmitted from animals. 5:649-61. Infect Dis Clin North Am 2. National Association of State Public Health Veterinarians. 2007. b) Hermit crabs; Compendium of measures to prevent disease associated with c) Poisonous animals - Inclusive of spiders, venomous 56:1-13. MMWR animals in public settings. insects, venomous reptiles (including snakes), and Animals in Kansas schools: Guidelines 3. Hansen, G. R. 2004. venomous amphibians; Topeka, KS: Kansas Department of for visiting and resident pets. Wolf-dog hybrids - These animals are crosses d) Health and Environment. http://www.kdheks.gov/pdf/hef/ between a wolf and a domestic dog and have shown ab1007.pdf. a propensity for aggression, especially toward young 4. U.S. Department of Health and Human Services, Centers for children; Disease Control and Prevention. 2009. Appendix D: Guidelines for e) Stray animals - Stray animals should never be animals in school and child-care settings. 58:20-21. MMWR present at a child care facility because the health and 5. Pickering, L. K., N. Marano, J. A. Bocchini, F. J. Angulo. 2008. Exposure to nontraditional pets at home and to animals in public vaccination status of these animals is unknown; 122:876-86. Pediatrics settings: risks to children. f) Chickens and ducks - These animals excrete E. 6. PETCO Animal Supplies. 2006. Hermit crab: Care sheet. http:// , Salmonella coli O157:H7, Campylobacter , S. www.petco.com/caresheets/invertebrates/HermitCrab.pdf. paratyphoid ; The Merck veterinary manual. 7. Kahn, C. M., S. Line, eds. 2010. g) Aggressive animals - Animals which are bred 10th ed. Whitehouse Station, NJ: Merck. or trained to demonstrate aggression towards humans or other animals, or animals which have STANDARD 3.4.2.3: Care for Animals demonstrated such aggressive behavior in the The facility should care for all animals as recommended by past, should not be permitted on the grounds of the health department and in consultation with licensed vet - the child care facility. Exceptions may be sentry or erinarian. When animals are kept on the premises, the facil- canine corps dogs for a demonstration. These dogs ity should write and adhere to procedures for their humane must be under the control of trained military or law care and maintenance. When animals are kept in the child enforcement officials; care facility, the following conditions should be met: Reptiles and amphibians - Inclusive of non-venomous h) snakes, lizards, and iguanas, turtles, tortoises, Humane Care: An environment will be maintained in which terrapins, crocodiles, alligators, frogs, tadpoles, animals experience: salamanders, and newts; Chapter 3: Health Promotion 121

152 Caring for Our Children: National Health and Safety Performance Standards Just as food intended for human consumption may become a) Good health; contaminated, an animal’s food can become contaminated b) Are able to effectively cope with their environment; by standing at room temperature, or by being exposed to Are able to express a diversity of species specific c) animals, insects, or people. behaviors. Pregnant woman can acquire toxoplasmosis from infected Health Care: Proof of appropriate current veterinary certifi- cat waste. The infection can be transmitted to her unborn cate meeting local and state health requirement is kept on - child. Congenital toxoplasmosis infection can lead to mis file at the facility for each animal kept on the premises or carriage or an array of malformations of the developing child visiting the child care facility. prior to birth. Cat litter boxes should be cleaned daily since Animal care: Specific areas should be designated for animal it takes one to five days for feces containing toxoplasma contact. oocysts to become infectious with toxoplasmosis (3). Live animals should be prohibited from: COMMENTS: Ensuring animal welfare is a human respon- a) Food preparation, food storage, and dining areas; sibility that includes consideration for all aspects of animal b) The vicinity of sinks where children wash their hands; well-being, inclusive of secure housing, suitable tempera- Clean supply rooms; c) ture, adequate exercise and proper diet, disease prevention Areas where children routinely play or congregate d) and treatment, humane handling, and, when necessary, (e.g., sandboxes, child care facility playgrounds). humane euthanasia (6). Animal well-being also includes con- The living quarters of animals should be enclosed and kept tinued care of animals during the days that child care is not clean of waste to reduce the risk of human contact with this in session and in the event of an emergency evacuation. waste. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Animal food supplies should be kept out of reach of chil- Family Child Care Home dren. RELATED STANDARDS: Standards 3.2.2.1-3.2.2.5: Hand Hygiene Animal litter boxes should not be located in areas accessible Standard 3.4.2.1: Animals That Might Have Contact with Children to children. Children and food handlers should not handle or and Adults clean up any form of animal waste (feces, urine, blood, etc). Standard 3.4.2.2: Prohibited Animals All animal waste and litter should be removed immediately REFERENCES: from children’s areas and will be disposed of in a way where 1. Weinberg, A. N., D. J. Weber, eds. 1991. Respiratory infections children cannot come in contact with the material, such as transmitted from animals. Infect Dis Clin North Am 5:649-61. in a plastic bag or container with a well-fitted lid or via the 2. National Association of State Public Health Veterinarians. 2007. sewage waste system for feces. Compendium of measures to prevent disease associated with MMWR animals in public settings. 56:1-13. Used fish tank water should be disposed of in sinks that are 3. Centers for Disease Control and Prevention (CDC). Pregnant not used for food preparation or used for obtaining water for women and toxoplasmosis. http://www.cdc.gov/healthypets/ human consumption. pregnant.htm. 4. Hansen, G. R. 2004. Animals in Kansas schools: Guidelines Disposable gloves should be used when cleaning aquariums . Topeka, KS: Kansas Department of for visiting and resident pets and hands should be washed immediately after cleaning Health and Environment. http://www.kdheks.gov/pdf/hef/ is finished. Eye and oral contamination by splashing of ab1007.pdf. contaminated water during the cleaning process should be 5. U.S. Department of Health and Human Services, Centers for prevented. Children should not be involved in the cleaning Disease Control and Prevention. 2009. Appendix D: Guidelines for of aquariums. animals in school and child-care settings. MMWR 58:20-21. 6. American Veterinary Medical Association. Animal welfare Areas where feeders, water containers, and cages are principles. http://www.avma.org/issues/animal_welfare/default.asp. cleaned should be disinfected after cleaning activity is finished. 3.4.3 Emergency Procedures Pregnant persons should not handle cat waste or litter. Cat litter boxes should be cleaned daily. STANDARD 3.4.3.1: Emergency Procedures All persons who have contact with animals, animal prod- When an immediate emergency medical response is ucts, or animal environments should wash their hands im- required, the following emergency procedures should be mediately after the contact. utilized: RATIONALE: Animals, including pets, are a source of illness a) First aid should be employed and an emergency for people; likewise, people may be a source of illness for medical response team should be called such as animals (1). All contact with animals, and animal wastes 9-1-1 and/or the poison center if a poison emergency should occur in a fashion that minimizes staff and children’s (1-800-222-1222); risk of injury, infection and aggravation of allergy (2,4,5). b) The program should implement a plan for emergency Hand hygiene is the most important way to reduce the transportation to a local emergency medical facility; spread of infection. Unwashed or improperly washed hands The parent/guardian or parent/guardian’s emergency c) are primary carriers of germs which may lead to infections. contact person should be called as soon as practical; Chapter 3: Health Promotion 122

153 Caring for Our Children: National Health and Safety Performance Standards emergency personnel, and who should locate/use the fire d) A staff member should accompany the child to the extinguishers. These efforts can take place simultaneously. hospital and will stay with the child until the parent/ guardian or emergency contact person arrives. Child Center; Large Family Child Care Home; Small TYPE OF FACILITY: to staff ratio must be maintained, so staff may need Family Child Care Home to be called in to maintain the required ratio. RELATED STANDARDS: Programs should develop contingency plans for emergen- Standard 9.2.4.3: Disaster Planning, Training, and Communication cies or disaster situations when it may not be possible or REFERENCES: feasible to follow standard or previously agreed upon emer - 1. American Academy of Pediatrics, Committee on Injury and gency procedures (see also Standard 9.2.4.3, Disaster Plan- Poison Prevention. 2000. Reducing the number of deaths and ning, Training, and Communication). Children with known 105:1355-57. injuries from residential fires. Pediatrics medical conditions that might involve emergent care require a Care Plan created by the child’s primary care provider. STANDARD 3.4.3.3: Response to Fire and All staff need to be trained to manage an emergency until Burns emergency medical care becomes available. Children who are developmentally able to understand, The staff must know how to carry out the writ- RATIONALE: - should be instructed to STOP, DROP, and ROLL when gar ten disaster and emergency plans as described in Standard ments catch fire. Children should be instructed to crawl on 9.2.4.3 to help prevent or minimize severe injury to children the floor under the smoke if necessary when they evacuate and other staff. The staff should review and practice the the building. This instruction is part of ongoing health and emergency plan regularly (1). safety education and fire drills/exercise. COMMENTS: First aid instructions are available from the Cool water should be applied to burns immediately. The American Academy of Pediatrics (AAP) and the American injury should be covered with a loose bandage or clean, dry Red Cross. cloth. Medical assessment/care should be immediate. Center; Large Family Child Care Home; Small TYPE OF FACILITY: RATIONALE: Running when garments have been ignited Family Child Care Home will fan the fire. Removing heat from the affected area will RELATED STANDARDS: prevent continued burning and aggravation of tissue dam- Standard 9.2.4.3: Disaster Planning, Training, and Communication age. Asphyxiation causes more deaths in house fires than Appendix P: Situations that Require Medical Attention Right Away does thermal injury (1). REFERENCES: Stop, Drop, For resources for children: see COMMENTS: 1. Aronson, S. 2005. Pediatric first aid for caregivers and teachers. and Roll – A Jessica Worries Book: Fire Safety . Sudbury, MA: Jones and Bartlett; Elk Grove Village, IL: American Academy of Pediatrics. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.4.3.2: Use of Fire Extinguishers RELATED STANDARDS: Appendix P: Situations that Require Medical Attention Right Away - The staff should demonstrate the ability to locate and oper ate the fire extinguishers. Facilities should develop a plan REFERENCES: 1. American Academy of Pediatrics, Committee on Injury and for responding in the event of a fire in or near the facility Poison Prevention. 2000. Reducing the number of deaths and that includes staff responsibilities and protocols regarding 105:1355-57. injuries from residential fires. Pediatrics evacuation, notifying emergency personnel, and using fire extinguishers. The staff should demonstrate the ability to 3.4.4 Child Abuse and Neglect recognize a fire that is larger than incipient stage and should not be fought with a portable fire extinguisher. STANDARD 3.4.4.1: Recognizing and RATIONALE: A fire extinguisher may be used to put out a Reporting Suspected Child Abuse, Neglect, small fire or to clear an escape path (1). Developing a plan and Exploitation that includes staff use of fire extinguishers and conducting fire drills/exercises can increase preparedness and help staff Each facility should have a written policy for reporting child better understand what to do to respond to a fire. It is just abuse and neglect. Caregivers/teachers are mandated as important that staff know when not to try to fight a fire reporters of child abuse and neglect. The facility should with portable fire extinguishers. report to the child abuse reporting hotline, department of social services, child protective services, or police as - Staff should be trained that the first prior COMMENTS: required by state and local laws, in any instance where there ity is to remove the children from the facility safely and is reasonable cause to believe that child abuse and neglect quickly. Putting out the fire is secondary to the safe exit of has occurred. Every staff person should be oriented to what the children and staff. However, depending upon the situa- and how to report. Phone numbers and reporting system as tion at hand and the number of available staff, the facility’s required by state or local agencies should be clearly posted plan could identify which caregivers/teachers evacuate the by every phone. children, where they will all meet outside, who should call Chapter 3: Health Promotion 123

154 Caring for Our Children: National Health and Safety Performance Standards at http://www.childwelfare.gov/responding/mandated.cfm. Caregivers/teachers should receive initial and ongoing train- Information regarding specific state laws is accessible via ing to assist them in preventing child abuse and neglect and the Child Welfare Information Gateway at http://www in recognizing signs of child abuse and neglect. Programs .childwelfare.gov/systemwide/laws_policies/state/. are encouraged to partner with primary care providers, child care health consultants and/or child protection advocates to Center; Large Family Child Care Home; Small TYPE OF FACILITY: provide training and to be available for consultation. Family Child Care Home Employees and volunteers in centers and large family child RELATED STANDARDS: care homes should receive an instruction sheet about child Standard 1.6.0.1: Child Care Health Consultants Standard 1.7.0.5: Stress abuse and neglect reporting that contains a summary of Standard 3.4.4.2: Immunity for Reporters of Child Abuse and the state child abuse reporting statute and a statement that Neglect they will not be discharged/disciplined solely because they Standard 3.4.4.3: Preventing and Identifying Shaken Baby Syn- have made a child abuse and neglect report. Some states drome/Abusive Head Trauma have specific forms that are required to be completed when Standard 3.4.4.4: Care for Children Who Have Been Abused/Ne- abuse and neglect is reported. Some states have forms that glected are not required but assist mandated reporters in document- Standard 9.4.1.9: Records of Injury ing accurate and thorough reports. In those states, facilities Appendix M: Clues to Child Abuse and Neglect should have such forms on hand and all staff should be Appendix N: Protective Factors Regarding Child Abuse and Neglect trained in the appropriate use of those forms. REFERENCES: 1. Hussey, J. M., J. J. Chang, J. B. Kotch. 2006. Child maltreatment Parents/guardians should be notified upon enrollment of the in the United States: Prevalence, risk factors, and adolescent health facility’s child abuse and neglect reporting requirement and 118:933-42. Pediatrics consequences. procedures. 2. Jenny, C. 2007. Recognizing and responding to medical neglect. While caregivers/teachers are not expected to RATIONALE: Pediatrics 120:1385-89. - diagnose or investigate child abuse and neglect, it is impor 3. U.S. Department of Health and Human Services, Administration tant that they be aware of common physical and emotional for Children and Families, Administration on Children, Youth, and Families, and Children’s Bureau. Child welfare information gateway: signs and symptoms of child maltreatment (see Appendix State statutes. http://www.childwelfare.gov/systemwide/laws M, Clues to Child Abuse and Neglect) (1,2,4). _policies/state/. All states in the U.S. have laws mandating the reporting of 13 indicators of quality child care: Research 4. Fiene, R. 2002. child abuse and neglect to child protection agencies and/ Washington, DC: U.S. Department of Health and Human update. or police. Laws about when and to whom to report vary by Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/. state (3). Failure to report abuse and neglect is a crime in all 5. U.S. Department of Health and Human Services, Administration states and may lead to legal penalties. for Children and Families, Administration on Children, Youth, and COMMENTS: Child abuse includes physical, sexual, Families, and Children’s Bureau. What is child abuse and neglect? psychological, and emotional abuse. Other components of Child Welfare Information Gateway. http://www.childwelfare.gov/ abuse include shaken baby syndrome/acute head trauma pubs/factsheets/whatiscan.cfm. and repeated exposure to violence including domestic violence. Neglect occurs when the parent/guardian does not STANDARD 3.4.4.2: Immunity for Reporters of meet the child’s basic needs and includes physical, medical, Child Abuse and Neglect educational, and emotional neglect (5). Caregivers/teachers Caregivers/teachers who report suspected abuse and and health professionals may contact individual state hot- neglect in the settings where they work should be immune lines where available. While almost all states have hotlines, from discharge, retaliation, or other disciplinary action for they may not operate twenty-four-hours a day, and some toll that reason alone, unless it is proven that the report was free numbers may only be accessible within that particular malicious. state. ChildHelp USA provides a national hotline: 1-800-4-A- CHILD or 1-800-422-4453. RATIONALE: Cases which are reported suggest that some- times workers are intimidated by superiors in the centers Many health departments will be willing to provide contact where they work, and for that reason, fail to report abuse for experts in child abuse and neglect prevention and rec- and neglect (1). In some cases the abuser may be a staff ognition. The American Academy of Pediatrics (AAP), http:// member or superior. www.aap.org, can also assist in recruiting and identifying physicians who are skilled in this work. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home The caregiver/teacher is still liable for reporting even when RELATED STANDARDS: their supervisor indicates they don’t need to or says that Standard 3.4.4.1: Recognizing and Reporting Suspected Child someone else will report it. Caregivers/teachers who report Abuse, Neglect, and Exploitation in good faith may do so confidentially and are protected by law. For more information on Mandated Reporting, go to the Child Welfare Information Gateway, Mandated Reporting 124 Chapter 3: Health Promotion

155 Caring for Our Children: National Health and Safety Performance Standards STATES/states.htm. Standard 3.4.4.3: Preventing and Identifying Shaken Baby Syn- 3. Calm a Crying Baby. Shaken baby syndrome prevention. http:// drome/Abusive Head Trauma www.calmacryingbaby.com. Standard 3.4.4.4: Care for Children Who Have Been Abused/Ne- glected Standard 3.7.0.5: Stress STANDARD 3.4.4.4: Care for Children Who Standard 9.4.1.9: Records of Injury Have Been Abused/Neglected Appendix M: Clues to Child Abuse and Neglect Appendix N: Protective Factors Regarding Child Abuse and Neglect Caregivers/teachers should have access to specialized training and expert advice for children with behavioral ab- REFERENCES: normalities related to abuse or neglect. 1. Goldman, R. 1990. An educational perspective on abuse. In Children at risk: An interdisciplinary approach to child abuse and All children who have been abused or ne- RATIONALE: neglect. Ed. R. Goldman, R. Gargiulo. Austin, TX: Pro-Ed. glected have had their physical and emotional boundaries violated and crossed. With this violation often comes a STANDARD 3.4.4.3: Preventing and Identifying breach of the child’s sense of security and trust. Abused Shaken Baby Syndrome/Abusive Head Trauma and neglected children may come to believe that the world is not a safe place and that adults are not trustworthy. All child care facilities should have a policy and procedure Abused and neglected children may have more emotional to identify and prevent shaken baby syndrome/abusive head needs and may require more individual staff time and at- trauma. All caregivers/teachers who are in direct contact tention than children who are not maltreated. Children who with children including substitute caregivers/teachers and are victims of abuse or neglect, in addition to having more volunteers, should receive training on preventing shaken developmental problems, also have behavior problems such baby syndrome/abusive head trauma, recognition of poten- as emotional lability, depression, and aggressive behaviors tial signs and symptoms of shaken baby syndrome/abusive (3). These problems may persist long after the maltreatment head trauma, strategies for coping with a crying, fussing or occurred and may have significant psychiatric and medical distraught child, and the development and vulnerabilities of consequences into adulthood. In particular, children who the brain in infancy and early childhood. have suffered abuse or neglect or been exposed to violence, Over the past several years there has been RATIONALE: including domestic violence, often have excessive re- increasing recognition of shaken baby syndrome/abusive sponses to environmental stress. Their responses are often head trauma which is the occurrence of brain injury in young misinterpreted by caregivers/teachers and responded to in- children under three years of age due to shaking a child. appropriately which, in turn, reinforces their hyper-vigilance Even mild shaking can result in serious, permanent brain and maladaptive behavior in a counter-productive feedback damage or death. The brain of the young child may bounce cycle (1,2). Child care staff may need to work closely with inside of the skull resulting in brain damage, hemorrhag- the child’s primary care provider, therapist, social worker, ing, blindness, or other serious injuries or death. There have and parents/guardians to formulate a more personalized been several reported incidents occurring in child care (1). behavior management plan. Caregivers/teachers experience young children who may COMMENTS: Centers serving children with a history of be fussy or constantly crying. It is important for caregivers/ maltreatment related behavior problems may require profes- teachers to be educated about the risks of shaking and sionally trained staff. Resources on caring for a child who provided with strategies to cope if they are frustrated (3). has been abused or neglected are available from the Nation- Many states have passed legislation requiring education and al Children’s Advocacy Center at http://www.nationalcac training for caregivers/teachers. Caregivers/teachers should .org/professionals/. check their individual state’s specific requirements (2). Staff can also recognize the signs and symptoms of shaken baby TYPE OF FACILITY: Center syndrome/abusive head trauma in children in their care. RELATED STANDARDS: Standard 1.6.0.1: Child Care Health Consultants For more information and resources on COMMENTS: shaken baby syndrome/abusive head trauma, contact the REFERENCES: National Center on Shaken Baby Syndrome at http://www 1. American Academy of Pediatrics. 2008. Understanding the .dontshake.org. Pediatrics behavioral and emotional consequences of child abuse. 122:667-73. TYPE OF FACILITY: Center; Large Family child Care Home; Small 2. Felitti, V. J., R. F. Anda, P. Nordenber, D. F. Williamson, A. M. Family child Care Home Spitz, V. Edwards, M. P. Koss, J. S. Marks. 1998. Relationship of RELATED STANDARDS: childhood abuse and household dysfunction to many of the leading Standard 3.4.4.1: Recognizing and Reporting Suspected Child causes of death in adults. The Adverse Childhood Experiences Abuse, Neglect, and Exploitation 14:245-58. Am J Prev Med (ACE) Study. 3. Child Welfare Information Gateway. 2008. Parenting a child who REFERENCES: has been sexually abused: A guide for foster and adoptive parents 1. American Academy of Pediatrics, Committee on Child Abuse Washington, DC: U.S. Department of Health – factsheet for families. and Neglect. 2009. Abusive head trauma in infants and children. and Human Services. http://www.childwelfare.gov/pubs/f_abused/. 123:1409-11. Pediatrics 2. National Resource Center for Health and Safety in Child Care and Early Education. State licensing database. http://nrckids.org/ Chapter 3: Health Promotion 125

156 Caring for Our Children: National Health and Safety Performance Standards c) Limit sun exposure between 10 AM and 4 PM, when STANDARD 3.4.4.5: Facility Layout to Reduce UV rays are strongest; Risk of Child Abuse and Neglect Wear child safe shatter resistant sunglasses with at d) The physical layout of facilities should be arranged so that least 99% UV protection; there is a high level of visibility in the inside and outside e) Apply sunscreen (1). areas as well as diaper changing areas and toileting areas Over-the-counter ointments and creams, such as sunscreen used by children. All areas should be viewed by at least that are used for preventive purposes do not require a writ- one other adult in addition to the caregiver/teacher at all ten authorization from a primary care provider with prescrip- times when children are in care. For center-based programs, tive authority. However, parent/guardian written permission rooms should be designed so that there are windows to the is required, and all label instructions must be followed. If the hallways to keep classroom activities from being too private. skin is broken or an allergic reaction is observed, caregiv- Ideally each area of the facility should have two adults at ers/teachers should discontinue use and notify the parent/ all times. Such an arrangement reduces the risk of child guardian. abuse and neglect and the likelihood of extended periods of time in isolation for individual caregivers/teachers with If parents/guardians give permission, sunscreen should be children, especially in areas where children may be partially applied on all exposed areas, especially the face (avoiding undressed or in the nude. the eye area), nose, ears, feet, and hands and rubbed in well especially from May through September. Sunscreen is Caregivers/teachers should have increased awareness re- needed on cloudy days and in the winter at high altitudes. garding risk of abuse and neglect when a caregiver/teacher Sun reflects off water, snow, sand, and concrete. “Broad is alone with a child. Other caregivers/teachers should spectrum” sunscreen will screen out both UVB and UVA periodically walk into a room with one caregiver/teacher to rays. Use sunscreen with an SPF of 15 or higher, the higher ensure there is no abuse and neglect. the SPF the more UVB protection offered. UVA protection is The presence of multiple caretakers greatly re- RATIONALE: designated by a star rating system, with four stars the high- duces the risk of serious abusive injury. Maltreatment tends est allowed in an over-the-counter product. to occur in privacy and isolation, and especially in toileting Sunscreen should be applied thirty minutes before going areas (1). A significant number of cases of abuse have been outdoors as it needs time to absorb into the skin. If the chil- found involving young children being diapered in diaper dren will be out for more than one hour, sunscreen will need changing areas (1). to be reapplied every two hours as it can wear off. If children This standard does not mean to disallow COMMENTS: are playing in water, reapplication will be needed more privacy for children who are developmentally able to toilet frequently. Children should also be protected from the sun independently and who may need privacy (2). by using shade and sun protective clothing. Sun exposure should be limited between the hours of 10 AM and 4 PM TYPE OF FACILITY: Center; Large Family child Care Home; Small Family child Care Home when the sun’s rays are the strongest. RELATED STANDARDS: Sunscreen should be applied to the child at least once by Standard 2.1.2.5: Toilet Learning/Training the parents/guardians and the child observed for a reaction Standards 5.4.1.1-5.4.1.9: Toilets and Toilet Learning/Training to the sunscreen prior to its use in child care. Equipment Sun exposure from ultraviolet rays (UVA and RATIONALE: REFERENCES: UVB) causes visible and invisible damage to skin cells. 1. Goldman, R. 1990. An educational perspective on abuse. In Visible damage consists of freckles early in life. Invisible Children at risk: An interdisciplinary approach to child abuse and damage to skin cells adds up over time creating age spots, R. Goldman, R. Gargiulo, eds. Austin, TX: Pro-Ed. neglect. wrinkles, and even skin cancer (2,4). 2. Child Development Institute. 2010. Child development. http:// childdevelopmentinfo.com/development/. Exposure to UV light is highest near the equator, at high altitudes, during midday (10 AM to 4 PM), and where light is 3.4.5 Sun Safety and Insect Repellent reflected off water or snow (5). COMMENTS: Protective clothing must be worn for infants STANDARD 3.4.5.1: Sun Safety Including younger than six months. For infants older than six months, Sunscreen apply sunscreen to all exposed areas of the body, but be careful to keep away from the eyes (3). If an infant rubs Caregivers/teachers should implement the following proce- sunscreen into her/his eyes, wipe the eyes and hands clean dures to ensure sun safety for themselves and the children with a damp cloth. Unscented sunblocks or sunscreen with under their supervision: titanium dioxide or zinc oxide are generally safer for children Keep infants younger than six months out of direct a) and less likely to cause irritation problems (6). If a rash de- sunlight. Find shade under a tree, umbrella, or the velops, have parents/guardians talk with the child’s primary stroller canopy; care provider (1). b) Wear a hat or cap with a brim that faces forward to shield the face; 126 Chapter 3: Health Promotion

157 Caring for Our Children: National Health and Safety Performance Standards 417. Sunscreen needs to be applied every two hours because it wears off after swimming, sweating, or just from absorbing STANDARD 3.4.5.2: Insect Repellent and into the skin (1). Protection from Vector-Borne Diseases There is a theoretical concern that daily sunscreen use will lower vitamin D levels. UV radiation from sun exposure Insect repellents offer varying levels of protection from causes the important first step in converting vitamin D in insect bites. Most insects do not carry human disease and the skin into a usable form for the body. Current medical most bites only cause mild irritation. Insect repellents may research on this topic is not definitive, but there does not be used with children in child care in areas of the country appear to be a link between daily normal sunscreen use and due to specific disease outbreaks and alerts. Parents/guard- lower vitamin D levels (7). This is probably because the vita- ians and caregivers/teachers should decide about the use of min D conversion can still occur with sunscreen use at lower repellents depending upon the likelihood that local insects levels of UV exposure, before the skin becomes pink or tan. are carrying diseases (e.g., local cases of meningitis from However, vitamin D levels can be influenced significantly by mosquito bites). Caregivers/teachers should consult with a amount of sun exposure, time of the day, amount of protec- child care health consultant, the primary care provider, or tive clothing, skin color and geographic location (8). These the local health department about the appropriateness of factors make it difficult to apply a safe sunscreen policy use. for all settings. A health consultant may assist the program Insect repellent used for preventive purposes does not develop a local sunscreen policy that may differ from above require a written authorization from a primary care provider. if there is a significant public health concern regarding low Parent/guardian written permission is required, and all label vitamin D levels. instructions must be followed. If the skin is broken or an EPA provides specific UV Index information by City Name, allergic reaction is observed, discontinue use and notify the Zip Code or by State, to view go to http://www.epa.gov/ parent/guardian. sunwise/uvindex.html. Repellents with 10%-30% DEET offer the broadest protec- A good resource for reading materials for young children tion against mosquitoes, ticks, flies, chiggers, and fleas. The and parents/guardians can be found at Healthy Child Care concentration of DEET that is used should be dependent Pennsylvania’s Self Learning Module “Sun Safety” at http:// upon how much time the child will be exposed. Products www.ecels-healthychildcarepa.org/content/Sun Safey SLM with 10% DEET are effective for approximately two hours 6-23-10 v5%20.pdf. whereas products with 24% DEET offers protection for approximately five hours. Caregivers/teachers should read TYPE OF FACILITY: Center; Large Family Child Care Home; Small the product label and confirm that the product is safe for Family Child Care Home children and contains a concentration of 30% DEET or less. RELATED STANDARDS: Some repellents may contain up to 100% DEET and could Standard 3.4.5.2: Insect Repellent and Protection from Vector- be very dangerous if applied to a child. DEET is not ap- Borne Diseases proved for infants less than two months of age. Standard 3.6.3.1: Medication Administration Standard 6.1.0.7: Shading of Play Area Application of this product for children older than two REFERENCES: months is acceptable using the following guidelines: 1. American Academy of Pediatrics. 2008. Sun safety. http://www. a) Apply insect repellent to the caregiver/teacher’s healthychildren.org/english/safety-prevention/at-play/pages/Sun- hands first and then put it on the child; Safety.aspx. Use just enough repellent to cover exposed skin; b) 2. American Academy of Dermatology. 2010. Skin, hair and nail c) Do not apply under clothing; care: Protecting skin from the sun. Kids Skin Health. Do not use DEET on the hands of young children; d) http://www.kidsskinhealth.org/grownups/skin_habits_sun.html. e) Avoid applying to areas around the eyes and mouth; 3. Kenfield, S., A. Geller, E. Richter, S. Shuman, D. O’Riordan, H. f) Do not use over cuts or irritated skin; Koh, G. Colditz. 2005. Sun protection policies and practices at child Do not use near food; g) 30:491-503. J Comm Health care centers in Massachusetts. h) Do not use products that combine insect repellent 4. Maguire-Eisen, M., K, Rothman, M. F. Demierre. 2005. The ABCs of sun protection for children. 17:419-22,431-33. Dermatology Nurs and sunscreen. If sunscreen is used, apply sunscreen 5. Weinberg, N., M. Weinberg, S. Maloney. Traveling safely with first; infants and children. Medic8. http://www.medic8.com/travel/child i) Do not apply a second application to the skin (1); -safety.htm. j) DEET concentration should not exceed 30% for use 6. Yan, X. S., G. Riccardi, M. Meola, A. Tashjian, J. SaNogueira, T. with children (1); Schultz. 2008. A tear-free, SPF50 sunscreen product. Cutan Ocul After returning indoors, wash treated skin k) Toxicol 27:231-39. immediately with soap and water; 7. Norval, M., H. C. Wulf. 2009. Does chronic sunscreen use reduce l) If the child gets a rash or other bad reaction from an vitamin D production insect repellent, stop using the repellent, wash the to insufficient levels? British J Dermatology 161:732-36. repellent off with mild soap and water, and call a local 8. Misra, M., D. Pacaud, A. Petryk, P. F. Collett-Solberg, M. Kappy. 2008. Vitamin D deficiency in children and its management: Review poison center (1-800-222-1222) for further guidance. of current knowledge and recommendations. Pediatrics 122:398- (1,3,4) Chapter 3: Health Promotion 127

158 Caring for Our Children: National Health and Safety Performance Standards If a product gets in the eyes, flush with water and consult Oil of lemon and eucalyptus products should NOT be used the poison center at 1-800-222-1222. on CHILDREN UNDER THREE YEARS OF AGE (1). Most product labels for registrations containing DEET recommend How to Remove a Tick: consultation with a physician if applying to a child less than It is important to remove the tick as soon as possible. Use six months of age. the following steps: Picaridin and IR3535 are other products registered at the a) If possible, clean the area with an antiseptic solution Environmental Protection Agency (EPA) identified as provid- or soap and water. Take care not to scrub the tick too ing repellent activity sufficient to help people avoid the bites hard. Just clean the skin around it; of disease carrying mosquitoes (3). b) Use blunt, fine tipped tweezers or gloved fingers to grasp the tick as close to the skin as possible; Caregivers/teachers should practice hand hygiene after ap - c) Pull slowly and steadily upwards to allow the tick to plying insect repellent to the children in the group. release; Written parent/guardian permission is required before apply- If the tick’s head breaks off in the skin, use tweezers d) ing any insect repellent to children. to remove it like you would a splinter; In places where ticks are likely to be found, caregivers/ e) Wash the area around the bite with soap; teachers should take the following steps to protect children f) Following the removal of the tick, wash your hands, in their care from ticks: the tweezers, and the area thoroughly with soap and Wear light colored clothing, long sleeves and pants, a) warm water. tuck pants into socks; Take care not to do the following: Conduct tick checks when returning indoors (2). b) a) Do not use sharp tweezers. Caregivers/teachers should also take the following c) b) Do not crush, puncture, or squeeze the tick’s body. protective measures against ticks and mosquitoes Do not use a twisting or jerking motion to remove the c) with children’s play areas: tick. Remove stagnant water sources to prevent breeding d) d) Do not handle the tick with bare hands. grounds for mosquito larvae; Do not try to make the tick let go by holding a hot e) e) Remove leaf litter and clear tall grasses and brush match or cigarette close to it. around homes and buildings and at the edges of f) Do not try to smother the tick by covering it with lawns; petroleum jelly or nail polish. f) Place wood chips or gravel between lawns and Several resources are available on reducing exposure to wooded areas to restrict tick migration to recreational ticks and mosquitoes based on habits, protective attire, and areas; insect repellent use. The following Websites offer detailed Mow the lawn and clear brush and leaf litter g) information on preventing exposure to ticks and mosquitoes frequently; which may cause disease: “Integrated Pest Management Keep playground equipment, decks, and patios away h) (IPM) of Mosquitoes in Early Childhood Education (ECE) from yard edges and trees. Settings” by the California Childcare Health Program at Ticks and mosquitoes can carry pathogens RATIONALE: http://www.ucsfchildcarehealth.org/pdfs/healthandsafety/ that may cause life threatening diseases (i.e., vector-borne Mosquitoes_en_0709.pdf, and Protect Yourself from Tick diseases such as Lyme Disease) (2). Bites by the Centers for Disease Control and Prevention at COMMENTS: Repellent does not have to contain DEET but http://www.cdc.gov/ncidod/dvbid/lyme/Prevention/ld must be approved for use in the child’s age range. If not ap- _Prevention_Avoid.htm. proved, the parent/guardian must obtain a prescription from Additional resources: the child’s primary care provider. http://www.cdc.gov/ncidod/diseases/list • Aerosol sprays are not recommended. Pump sprays are a _mosquitoborne.htm; better choice. Regardless of the type of spray used, caregiv- http://www.epa.gov/pesticides/health/mosquitoes/ • ers/teachers should spray the insect repellent into her/his ai_insectrp.htm; and hand and then apply to the child. It is not recommended to http://www.lymediseaseassociation.org/index • directly spray the child with the insect repellent to prevent .php?option=com_content&view=category&id=29&It unintentional injury to eyes and mouth. Preschool children, emid=180. toddlers, and infants should not apply insect repellent to Center; Large Family Child Care Home; Small TYPE OF FACILITY: themselves. School age children can apply insect repellent Family Child Care Home to themselves if they are supervised to make sure that they RELATED STANDARDS: are applying it correctly. Standard 3.2.2.1: Situations that Require Hand Hygiene Parents/guardians should be notified when insect repellent Standard 3.4.5.1: Sun Safety Including Sunscreen is applied to their child since it is recommended that treated Standard 5.2.8.1: Integrated Pest Management skin is washed with soap and water. 128 Chapter 3: Health Promotion

159 Caring for Our Children: National Health and Safety Performance Standards REFERENCES: (CPSC) has reported deaths and injuries involving the en- 1. American Academy of Pediatrics, Committee on Environmental tanglement of children’s clothing drawstrings (3). Health. 2003. Follow safety precautions when using DEET on Children’s outerwear that has alternative COMMENTS: 22. http://aapnews.aappublications.org/cgi/ children. AAP News closures (e.g., snaps, buttons, hook and loop, and elastic) content/full/e200399v1/. are recommended (3). 2. Centers for Disease Control and Prevention, Division of Vector- Borne Infectious Diseases. 2010. Lyme disease: Protect yourself It is advisable that caregivers avoid wearing necklaces or from tick bites. http://www.cdc.gov/ncidod/dvbid/lyme/Prevention/ clothing with drawstrings that could cause entanglement. ld_Prevention_Avoid.htm. 3. Centers for Disease Control and Prevention, Division of Vector- For additional information regarding the prevention of stran- Borne Infectious Diseases. 2009. West nile virus: Updated gulation from strings on toys, window coverings, clothing, information regarding insect repellents. http://www.cdc.gov/ncidod/ contact the CPSC. See http://www.windowcoverings.org for dvbid/westnile/RepellentUpdates.htm. the latest blind cord safety information. 4. Roberts J. R., Weil W. B., Shannon, M. W. 2005. DEET RELATED STANDARDS: alternatives considered to be effective mosquito repellents. AAP Standard 5.3.1.1: Safety of Equipment, Materials, and Furnishings http://aap.org/family/wnv-jun05.htm. News. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home 3.4.6 Strangulation REFERENCES: STANDARD 3.4.6.1: Strangulation Hazards 1. U.S. Consumer Product Safety Commission. Strings and straps on toys can strangle young children. http://www.cpsc.gov/ Strings and cords (such as those that are parts of toys and CPSCPUB/PUBS/5100.html. those found on window coverings) long enough to en- 2. Window Covering Safety Council. Basic cord safety. http://www circle a child’s neck should not be accessible to children in .windowcoverings.org/basic_cord_safety.html. child care. Miniblinds and venetian blinds should not have 3. U.S. Consumer Product Safety Commission (CPSC). 1999. looped cords. Vertical blinds, continuous looped blinds, and Bethesda, MD: Guidelines for drawstrings on children’s outerwear. drapery cords should have tension or tie-down devices to CPSC. http://www.cpsc.gov/cpscpub/pubs/208.pdf. hold the cords tight. Inner cord stops should be installed. Are your 4. U.S. Consumer Product Safety Commission (CPSC). Washington, DC: CPSC. window coverings safe? Shoulder straps on guitars and chin straps on hats should 5. Window Covering Safety Council. 2011. New study released on be removed (1). window covering safety awareness. http://www.windowcoverings Straps/handles on purses/bags used for dramatic play .org/nr_2011-3.html. should be removed or shortened. Ties, scarves, necklaces, and boas used for dramatic play should not be used for chil- dren under three years. If used by children three years and 3.5 Care Plans and Adaptations over, children should be supervised. STANDARD 3.5.0.1: Care Plan for Children Pacifiers attached to strings or ribbons should not be placed with Special Health Care Needs around infants’ necks or attached to infants’ clothing. Reader’s Note: Children with special health care needs are Hood and neck strings from all children’s outerwear, defined as “...those who have or are at increased risk for a including jackets and sweatshirts, should be removed. chronic physical, developmental, behavioral, or emotional Drawstrings on the waist or bottom of garments should not condition and who also require health and related services extend more than three inches outside the garment when - of a type or amount beyond that required by children gener it is fully expanded. These strings should have no knots or ally” (1). toggles on the free ends. The drawstring should be sewn to the garment at its midpoint so the string cannot be pulled Any child who meets these criteria should have a Routine out through one side. and Emergent Care Plan completed by their primary care provider in their medical home. In addition to the information RATIONALE: Window covering cords are associated with specified in Standard 9.4.2.4 for the Health Report, there strangulation of young children under (2,4). Infants can be- should be: come entangled in cords from window coverings near their a) A list of the child’s diagnosis/diagnoses; cribs. Since 1990, more than 200 infants and young children b) Contact information for the primary care provider and have died from unintentional strangulation in window cords any relevant sub-specialists (i.e., endocrinologists, (5). oncologists, etc.); Cords and ribbons tied to pacifiers can become tightly Medications to be administered on a scheduled c) twisted, or can catch on crib cornerposts or other protru- basis; sions, causing strangulation. d) Medications to be administered on an emergent basis with clearly stated parameters, signs, and symptoms Clothing strings on children’s clothing, necklaces and that warrant giving the medication written in lay scarves can catch on playground equipment and strangle language; children. The U.S. Consumer Product Safety Commission e) Procedures to be performed; Chapter 3: Health Promotion 129

160 Caring for Our Children: National Health and Safety Performance Standards Insurance Portability and Accountability Act (commonly f) Allergies; known as HIPAA) (4). g) Dietary modifications required for the health of the child; For additional information on care plans and approaches for Activity modifications; h) the most prevalent chronic diseases in child care see the i) Environmental modifications; following resources: j) Stimulus that initiates or precipitates a reaction or Asthma: How Asthma-Friendly Is Your Child-Care Setting? series of reactions (triggers) to avoid; at http://www.nhlbi.nih.gov/health/public/lung/asthma/ Symptoms for caregiver/teachers to observe; k) chc_chk.htm; l) Behavioral modifications; m) Emergency response plans – both if the child has a Autism: Learn the Signs/ACT Early at http://www.cdc.gov/ medical emergency and special factors to consider in ncbddd/autism/actearly/; programmatic emergency, like a fire; Food Allergies: Guides for School, Childcare, and Camp at Suggested special skills training and education for n) http://www.foodallergy.org/section/guidelines1/; staff. Diabetes: “Diabetes Care in the School and Day Care Set- A template for a Care Plan for children with special health ting” at http://care.diabetesjournals.org/content/29/suppl_1/ care needs is provided in Appendix O. s49.full; The Care Plan should be updated after every hospitaliza- Seizures: Seizure Disorders in the ECE Setting at http:// tion or significant change in health status of the child. The www.ucsfchildcarehealth.org/pdfs/healthandsafety/ Care Plan is completed by the primary care provider in the SeizuresEN032707_adr.pdf. medical home with input from parents/guardians, and it is Center; Large Family Child Care Home; Small TYPE OF FACILITY: implemented in the child care setting. The child care health Family Child Care Home consultant should be involved to assure adequate informa- tion, training, and monitoring is available for child care staff. RELATED STANDARDS: Standard 3.6.3.1: Medication Administration RATIONALE: Children with special health care needs could Standard 4.2.0.10: Care for Children with Food Allergies have a variety of different problems ranging from asthma, Chapter 8: Children with Special Health Care Needs and Disabilities diabetes, cerebral palsy, bleeding disorders, metabolic Standard 9.4.2.4: Contents of Child’s Primary Care Provider’s As- problems, cystic fibrosis, sickle cell disease, seizure dis- sessment order, sensory disorders, autism, severe allergy, immune Appendix P: Situations that Require Medical Attention Right Away deficiencies, or many other conditions (2). Some of these REFERENCES: conditions require daily treatments and some only require 1. McPherson, M., P. Arango, H. Fox, C. Lauver, M. McManus, observation for signs of impending illness and ability to P. Newacheck, J. Perrin, J. Shonkoff, B. Strickland. 1998. A new respond in a timely manner (3). definition of children with special health care needs. Pediatrics 102:137-40. COMMENTS: A collaborative approach in which the primary 2. U.S. Department of Health and Human Services, Health care provider and the parent/guardian complete the Care Resources and Services Administration. The national survey of Plan and the parent/guardian works with the child care staff children with special health care needs: Chartbook 2005-2006. to implement the plan is helpful. Although it is usually the http://mchb.hrsa.gov/cshcn05/. primary care provider in the medical home completing the 3. American Association of Nurse Anesthetists. 2003. Creating a Care Plan, sometimes management is shared by special- latex-safe school for latex-sensitive children. http://www ists, nurse practitioners, and case managers, especially with .anesthesiapatientsafety.com/patients/latex/school.asp. conditions such as diabetes or sickle cell disease. Managing chronic health 4. Donoghue, E. A., C. A. Kraft, eds. 2010. needs in child care and schools: A quick reference guide. Elk Grove Child care health consultants are very helpful in assisting in Village, IL: American Academy of Pediatrics. implementing Care Plans and in providing or finding train- ing resources. The child care health consultant may help STANDARD 3.5.0.2: Caring for Children Who in creating the care plan, through developing a draft and/ Require Medical Procedures or facilitate the primary care provider to provide specific directives to follow within the child care environment. The A facility that enrolls children who require the following med- child care health consultant should write out directives into ical procedures: tube feedings, endotracheal suctioning, a “user friendly” language document for caregivers/teachers supplemental oxygen, postural drainage, or catheterization and/or staff to implement with ease. daily (unless the child requiring catheterization can perform this function on his/her own), checking blood sugars or any Communication between parents/guardians, the child care other special medical procedures performed routinely, or program and the primary care provider (medical home) who might require special procedures on an urgent basis, requires the free exchange of protected medical informa- should receive a written plan of care from the primary care tion (4). Confidentiality should be maintained at each step in provider who prescribed the special treatment (such as a compliance with any laws or regulations that are pertinent urologist for catheterization). Often, the child’s primary care to all parties such as the Family Educational Rights and provider may be able to provide this information. This plan Privacy Act (commonly known as FERPA) and/or the Health of care should address any special preparation to perform 130 Chapter 3: Health Promotion

161 Caring for Our Children: National Health and Safety Performance Standards TYPE OF FACILITY: Center; Large Family Child Care; Small Family routine and/or urgent procedures (other than those that Child Care Home might be required in an emergency for any typical child, such as cardiopulmonary resuscitation [CPR]). This plan of RELATED STANDARDS: care should include instructions for how to receive training Standard 1.4.3.1: First Aid and CPR Training for Staff Standard 1.6.0.1: Child Care Health Consultants in performing the procedure, performing the procedure, a Standard 3.5.0.1: Care Plan for Children with Special Health Care description of common and uncommon complications of the Needs procedure, and what to do and who to notify if complica- Chapter 8: Children with Special Health Care Needs and Disabilities tions occur. Specific/relevant training for the child care staff should be provided by a qualified health care professional in REFERENCES: 1. Donoghue, E. A., C. A. Kraft, eds. 2010. Managing chronic health accordance with state practice acts. Facilities should follow needs in child care and schools: A quick reference guide. Elk Grove state laws where such laws require RN’s or LPN’s under Village, IL: American Academy of Pediatrics. RN supervision to perform certain medical procedures. Updated, written medical orders are required for nursing procedures. 3.6 Management of Illness RATIONALE: The specialized skills required to implement these procedures are not traditionally taught to early child- 3.6.1 Inclusion/Exclusion Due to Illness hood caregivers/teachers, or educational assistants as part of their academic or practical experience. Skilled nursing STANDARD 3.6.1.1: Inclusion/Exclusion/ care may be necessary in some circumstances. Dismissal of Children Parents/guardians are responsible for sup- COMMENTS: (Adapted from: Aronson, S. S., T. R. Shope, eds. 2009. plying the required equipment. The facility should offer staff Managing infectious diseases in child care and schools: A training and allow sufficient staff time to carry out the neces- 39-43. 2nd ed. Elk Grove Village, IL: quick reference guide, sary procedures. Caring for children who require intermittent American Academy of Pediatrics.) catheterization or maintaining supplemental oxygen is not Preparing for managing illness: as demanding as it first sounds, but the implication of this standard is that facilities serving children who have complex Caregivers/teachers should: medical problems need special training, consultation, and a) Encourage all families to have a backup plan for child monitoring. care in the event of short or long term exclusion; b) Review with families the inclusion/exclusion criteria Before enrolling a child who will need this type of care, care- and clarify that the program staff (not the families) will givers/teachers can request and review fact sheets, instruc- make the final decision about whether children who tions, and training by an appropriate health care profes- are ill may stay based on the program’s inclusion/ sional that includes a return demonstration of competence exclusion criteria and their ability to care for the child of the caregivers/teachers for handling specific procedures. who is ill without compromising the care of other Often, the child’s parents/guardians or clinicians have these children in the program; materials and know where training is available. If possible, Develop, with a child care health consultant, c) parents/guardians should be present and take part in the protocols and procedures for handling children’s training. The primary care provider is responsible for provid- illnesses, including care plans and an inclusion/ ing the health care plan for the child; the plan can be com- exclusion policy; municated to the caregiver/teacher by the parent/guardian d) Request the primary care provider’s note to readmit with the help of the child care health consultant who can a child if the primary care provider’s advice is needed then assist in training the staff. When the specifics are to determine whether the child is a health risk to known, caregivers/teachers can make a more responsible others, or if the primary care provider’s guidance is decision about what would be required to serve the child. needed about any special care the child requires (1); A caregiver/teacher should not assume care for a child with Rely on the family’s description of the child’s behavior e) special medical needs unless comfortable with training to determine whether the child is well enough to received and approved for that role by the child care health return, unless the child’s status is unclear from the consultant or consulting primary care provider. family’s report. Communication between parents/guardians, the child care Daily health checks as described in Standard 3.1.1.1 should program and the primary care provider (medical home) be performed upon arrival of each child each day. Staff requires the free exchange of protected medical informa- should objectively determine if the child is ill or well. Staff tion (1). Confidentiality should be maintained at each step in should determine which children with mild illnesses can compliance with any laws or regulations that are pertinent remain in care and which need to be excluded. to all parties such as the Family Educational Rights and Privacy Act (commonly known as FERPA) and/or the Health Staff should notify the parent/guardian when a child de- Insurance Portability and Accountability Act (commonly velops new signs or symptoms of illness. Parent/guardian known as HIPAA) (1). notification should be immediate for emergency or urgent issues. Staff should notify parents/guardians of children who Chapter 3: Health Promotion 131

162 Caring for Our Children: National Health and Safety Performance Standards otherwise require exclusion. Known MRSA carriers or have symptoms that require exclusion and parents/guard- colonized individuals should not be excluded; ians should remove the child from the child care setting as Cytomegalovirus infection; n) soon as possible. For children whose symptoms do not o) Chronic hepatitis B infection; require exclusion, verbal or written notification of the parent/ Human immunodeficiency virus (HIV) infection; p) guardian at the end of the day is acceptable. Most condi- q) Asymptomatic children who have been previously tions that require exclusion do not require a primary care evaluated and found to be shedding potentially provider visit before reentering care. infectious organisms in the stool. Children who are Conditions/symptoms that do not require exclusion: continent of stool or who are diapered with formed a) Common colds, runny noses (regardless of color or stools that can be contained in the diaper may return consistency of nasal discharge); to care. For some infectious organisms, exclusion b) A cough not associated with a infectious disease is required until certain guidelines have been met. (such as pertussis) or a fever; Note: These agents are not common and caregivers/ Watery, yellow or white discharge or crusting eye c) teachers will usually not know the cause of most discharge without fever, eye pain, or eyelid redness; cases of diarrhea; d) Yellow or white eye drainage that is not associated r) Children with chronic infectious conditions that can with pink or red conjunctiva (i.e., the whites of the be accommodated in the program according to the eyes); legal requirement of federal law in the Americans Pink eye (bacterial conjunctivitis) indicated by pink e) with Disabilities Act. The act requires that child care or red conjunctiva with white or yellow eye mucous programs make reasonable accommodations for drainage and matted eyelids after sleep. Parents/ children with disabilities and/or chronic illnesses, guardians should discuss care of this condition with considering each child individually. their child’s primary care provider, and follow the Key criteria for exclusion of children who are ill: primary care provider’s advice. Some primary care providers do not think it is necessary to examine the When a child becomes ill but does not require immediate child if the discussion with the parents/guardians medical help, a determination must be made regarding suggests that the condition is likely to be self-limited. whether the child should be sent home (i.e., should be tem- If two unrelated children in the same program have porarily “excluded” from child care). Most illnesses do not conjunctivitis, the organism causing the conjunctivitis require exclusion. The caregiver/teacher should determine if may have a higher risk for transmission and a child the illness: health care professional should be consulted; a) Prevents the child from participating comfortably in f) Fever without any signs or symptoms of illness in activities; children who are older than six months regardless Results in a need for care that is greater than the staff b) of whether acetaminophen or ibuprofen was given. can provide without compromising the health and Fever (temperature above 101°F [38.3°C] orally, safety of other children; above 102°F [38.9°C] rectally, or 100°F [37.8°C] or c) Poses a risk of spread of harmful diseases to others. higher taken axillary [armpit] or measured by an If any of the above criteria are met, the child should be equivalent method) is an indication of the body’s excluded, regardless of the type of illness. Decisions about response to something, but is neither a disease nor caring for the child while awaiting parent/guardian pick-up a serious problem by itself. Body temperature can should be made on a case-by-case basis providing care be elevated by overheating caused by overdressing that is comfortable for the child considering factors such or a hot environment, reactions to medications, and as the child’s age, the surroundings, potential risk to others response to infection. If the child is behaving normally and the type and severity of symptoms the child is exhibit- but has a fever of below 102ºF per rectum or the ing. The child should be supervised by someone who knows equivalent, the child should be monitored, but does the child well and who will continue to observe the child for not need to be excluded for fever alone; new or worsening syptoms. If symptoms allow the child to Rash without fever and behavioral changes; g) remain in their usual care setting while awaiting pick-up, the Lice or nits (exclusion for treatment of an active lice h) child should be separated from other children by at least infestation may be delayed until the end of the day); 3 feet until the child leaves to help minimize exposure of i) Ringworm (exclusion for treatment may be delayed staff and children not previously in close contact with the until the end of the day); child. All who have been in contact with the ill child must j) Molluscum contagiosum (do not require exclusion or wash their hands. Toys, equipment and surfaces used by covering of lesions); the ill child should be cleaned and disinfected after the child Thrush (i.e., white spots or patches in the mouth or k) leaves. on the cheeks or gums); l) Fifth disease (slapped cheek disease, parvovirus B19) Temporary exclusion is recommended when the child once the rash has appeared; has any of the following conditions: Methicillin-resistant Staphylococcus aureus, or m) a) The illness prevents the child from participating MRSA, without an infection or illness that would comfortably in activities; 132 Chapter 3: Health Promotion

163 Caring for Our Children: National Health and Safety Performance Standards j) Rash with fever or behavioral changes, until the b) The illness results in a need for care that is greater primary care provider has determined that the illness than the staff can provide without compromising the is not a infectious disease; health and safety of other children; Active tuberculosis, until the child’s primary care k) c) An acute change in behavior - this could include provider or local health department states child is on lethargy/lack of responsiveness, irritability, persistent appropriate treatment and can return; crying, difficult breathing, or having a quickly l) Impetigo, until treatment has been started; spreading rash; Streptococcal pharyngitis (i.e., strep throat or other m) d) Fever (temperature above 101°F [38.3°C] orally, streptococcal infection), until twenty-four hours after above 102°F [38.9°C] rectally, or 100°F [37.8°C] or treatment has been started; higher taken axillary [armpit] or measured by an n) Head lice until after the first treatment (note: equivalent method) and behavior change or other exclusion is not necessary before the end of the signs and symptoms (e.g., sore throat, rash, vomiting, program day); diarrhea). An unexplained temperature above 100°F o) Scabies, until after treatment has been given; (37.8°C) axillary (armpit) or 101°F (38.3°C) rectally in Chickenpox (varicella), until all lesions have dried or p) a child younger than six months should be medically crusted (usually six days after onset of rash); evaluated. Any infant younger than two months Rubella, until six days after the rash appears; q) of age with any fever should get urgent medical r) Pertussis, until five days of appropriate antibiotic attention. See COMMENTS Below for important treatment; information about taking temperatures; s) Mumps, until five days after onset of parotid gland Diarrhea is defined by watery stools or decreased e) swelling; form of stool that is not associated with changes of t) Measles, until four days after onset of rash; diet. Exclusion is required for all diapered children Hepatitis A virus infection, until one week after onset u) whose stool is not contained in the diaper and of illness or jaundice if the child’s symptoms are toilet-trained children if the diarrhea is causing soiled mild or as directed by the health department. (Note: pants or clothing. In addition, diapered children with immunization status of child care contacts should be diarrhea should be excluded if the stool frequency confirmed; within a fourteen-day period of exposure, exceeds two or more stools above normal for that incompletely immunized or unimmunized contacts child, because this may cause too much work for from one through forty years of age should receive the caregivers/teachers. Readmission after diarrhea the hepatitis A vaccine as post exposure prophylaxis, can occur when diapered children have their stool unless contraindicated.) Other individuals may contained by the diaper (even if the stools remain receive immune globulin. Consult with a primary care loose) and when toilet-trained children are continent. provider for dosage and recommendations; Special circumstances that require specific exclusion Any child determined by the local health department v) criteria include the following (2): to be contributing to the transmission of illness during 1) Shigella E. coli Toxin-producing or infection, until an outbreak. stools are formed and the test results of two stool cultures obtained from stools produced twenty- Procedures for a child who requires exclusion: four hours apart do not detect these organisms; The caregiver/teacher will: 2) Salmonella serotype Typhi infection, until diarrhea Make decisions about caring for the child while a) resolves. In children younger than five years with awaiting parent/guardian pick-up on a case-by-case serotype Typhi, three negative stool Salmonella basis providing care that is comfortable for the child cultures obtained with twenty-four-hour intervals considering factors such as the child’s age, the are required; people five years of age or older may surroundings, potential risk to others and the type return after a twenty-four-hour period without a and severity of symptoms the child is exhibiting. The diarrheal stool. Stool cultures should be collected child should be supervised by someone who knows from other attendees and staff members, and all the child well and who will continue to observe the infected people should be excluded; child for new or worsening symptoms. If symptoms f) Blood or mucus in the stools not explained by dietary allow the child to remain in their usual care setting change, medication, or hard stools; while awaiting pick-up, the child should be separated Vomiting more than two times in the previous twenty- g) from other children by at least 3 feet until the child four hours, unless the vomiting is determined to be leaves to help minimize exposure of staff and children caused by a non-infectious condition and the child not previously in close contact with the child. All who remains adequately hydrated; have been in contact with the ill child must wash their h) Abdominal pain that continues for more than two hands. Toys, equipment and surfaces used by the hours or intermittent pain associated with fever or ill child should be cleaned and disinfected after the other signs or symptoms of illness; child leaves; i) Mouth sores with drooling unless the child’s primary b) Ask the family to pick up the child as soon as care provider or local health department authority possible; states that the child is noninfectious; Chapter 3: Health Promotion 133

164 Caring for Our Children: National Health and Safety Performance Standards conditions are common and generally do not need to c) Discuss the signs and symptoms of illness with be reported. the parent/guardian who is assuming care. Review guidelines for return to child care. If necessary, Caregivers/teachers should work with their child care health provide the family with a written communication consultants to develop policies and procedures for alerting that may be given to the primary care provider. staff and families about their responsibility to report illnesses The communication should include onset time to the program and for the program to report diseases to the of symptoms, observations about the child, vital local health authorities. signs and times (e.g., temperature 101.5°F at 10:30 Excluding children with mild illnesses is un- RATIONALE: AM) and any actions taken and the time actions likely to reduce the spread of most infectious agents (germs) were taken (e.g., one children’s acetaminophen caused by bacteria, viruses, parasites and fungi. Most infec- given at 11:00 AM). The nature and severity of tions are spread by children who do not have symptoms. symptoms and or requirements of the local or state They spread the infectious agent (germs) before or after health department will determine the necessity of their illnesses and without evidence of symptoms. Exposure medical consultation. Telephone advice, electronic to frequent mild infections helps the child’s immune system transmissions of instructions are acceptable without develop in a healthy way. As a child gets older s/he devel- an office visit; ops immunity to common infectious agents and will become d) Follow the advice of the child’s primary care provider; ill less often. Since exclusion is unlikely to reduce the spread Contact the local health department if there is a e) of disease, the most important reason for exclusion is the question of a reportable (harmful) infectious disease ability of the child to participate in activities and the staff to in a child or staff member in the facility. If there care for the child. are conflicting opinions from different primary care providers about the management of a child with a The terms contagious, infectious and communicable have reportable infectious disease, the health department similar meanings. A fully immunized child with a contagious, has the legal authority to make a final determination; infectious or communicable condition will likely not have an f) Document actions in the child’s file with date, time, illness that is harmful to the child or others. Children attend- symptoms, and actions taken (and by whom); sign ing child care frequently carry contagious organisms that and date the document; do not limit their activity nor pose a threat to their contacts. In collaboration with the local health department, g) Hand and personal hygiene is paramount in preventing notify the parents of contacts to the child or staff transmission of these organisms. Written notes should not member with presumed or confirmed reportable be required for return to child care for common respiratory infectious infection. illnesses that are not specifically listed in the excludable condition list above. The caregiver/teacher should make the decision about whether a child meets or does not meet the exclusion For specific conditions, Managing Infectious Diseases in criteria for participation and the child’s need for care relative Child Care and Schools: A Quick Reference Guide, 2nd to the staff’s ability to provide care. If parents/guardians and Edition has educational handouts that can be copied and the child care staff disagree, and the reason for exclusion distributed to parents/guardians, health professionals, and relates to the child’s ability to participate or the caregiver’s/ caregivers/teachers. This publication is available from the teacher’s ability to provide care for the other children, the American Academy of Pediatrics (AAP) at http://www caregiver/teacher should not be required to accept respon- .aap.org. sibility for the care of the child. For more detailed rationale regarding inclusion/exclusion, Reportable conditions: return to care, when a health visit is necessary, and health department reporting for children with specific symptoms, The current list of infectious diseases designated as notifi- please see Appendix A, Signs and Symptoms Chart. able in the United States at the national level by the Centers for Disease Control and Prevention (CDC) are listed at http:// State licensing law or code defines the conditions or symp- wwwn.cdc.gov/nndss/conditions/notifiable/2015/infectious. toms for which exclusion is necessary. States are increas- ingly using the criteria defined in Caring for Our Children and - The caregiver/teacher should contact the local health de the Managing Infectious Diseases in Child Care and Schools partment: publications. Usually, the criteria in these two sources are a) When a child or staff member who is in contact with more detailed than the state regulations so can be incorpo- others has a reportable disease; rated into the local written policies without conflicting with If a reportable illness occurs among the staff, b) state law. children, or families involved with the program; For assistance in managing a suspected outbreak. c) , the exclusion cri- Caring for Our Children In this edition of Generally, an outbreak can be considered to be teria for bacterial conjunctivitis (pink eye) and diarrhea have two or more unrelated (e.g., not siblings) children changed. Exclusion is no longer required for pink eye and with the same diagnosis or symptoms in the same treatment is not required. This change reflects the recogni- group within one week. Clusters of mild respiratory tion that conjunctivitis is a self-limiting infection and there illness, ear infections, and certain dermatological is not any evidence that treatment or exclusion reduces its 134 Chapter 3: Health Promotion

165 Caring for Our Children: National Health and Safety Performance Standards A facility should not deny admission to or send home a staff spread. Children with diarrhea may remain in care as long as member or substitute with illness unless one or more of the the stool is contained in the diaper or the child can maintain following conditions exists. The staff member should be continence. If additional criteria are met, such as an inability excluded as follows: to participate in activities or requiring more care than staff Chickenpox, until all lesions have dried and crusted, a) can provide, then a child should be excluded until the crite - which usually occurs by six days; ria for return of care are met. A provision was included that if b) Shingles, only if the lesions cannot be covered by the stool frequency is two or more stools per day above the clothing or a dressing until the lesions have crusted; normal then exclusion could be indicated. This accounts for Rash with fever or joint pain, until diagnosed not to c) the increased staff time involved in diaper changing. Infants be measles or rubella; should routinely receive rotavirus vaccine, which has been d) Measles, until four days after onset of the rash (if the the most common cause of viral diarrhea in this age group. staff member or substitute is immunocompetent); COMMENTS : When taking a child’s temperature, remember e) Rubella, until six days after onset of rash; that: f) Diarrheal illness, stool frequency exceeds two or - a) The amount of temperature elevation varies at differ more stools above normal for that individual or blood ent body sites; in stools, until diarrhea resolves; if E. coli 0157:H7 or b) The height of fever does not indicate a more or less is isolated, until diarrhea resolves and two Shigella severe illness; serotype Salmonella stool cultures are negative, for The method chosen to take a child’s temperature de- c) Typhi, three stool cultures collected at twenty-four pends on the need for accuracy, available equipment, hour intervals and resolution of diarrhea is required; the skill of the person taking the temperature, and the Vomiting illness, two or more episodes of vomiting g) ability of the child to assist in the procedure; during the previous twenty-four hours, until vomiting d) Oral temperatures are difficult to take for children resolves or is determined to result from non- younger than four years of age; infectious conditions; e) Rectal temperatures should be taken only by persons Hepatitis A virus, until one week after symptom onset h) with specific health training in performing this proce- or as directed by the health department; dure and permission given by parents/guardians; i) Pertussis, until after five days of appropriate antibiotic f) Axillary (armpit) temperatures are accurate only when therapy; the thermometer remains within the closed armpit for j) Skin infection (such as impetigo), until treatment has the time period recommended by the device; been initiated; exclusion should continue if lesion is Electronic devices for measuring temperature require g) draining AND cannot be covered; periodic calibration and specific training in proper Tuberculosis, until noninfectious and cleared by a k) technique; health department official or a primary care provider; Any device used improperly may give inaccurate h) l) Strep throat or other streptococcal infection, until results; twenty-four hours after initial antibiotic treatment and i) Mercury thermometers should not be used; end of fever; j) Aural (ear) devices may underestimate fever and m) Head lice, from the end of the day of discovery until should not be used in children less than four months. after the first treatment; TYPE OF FACILITY: Center; Large Family Child Care Home; Small Scabies, until after treatment has been completed; n) Family Child Care Home o) Haemophilus influenzae type b (Hib), prophylaxis, RELATED STANDARDS: until antibiotic treatment has been initiated; Standard 3.1.1.1: Conduct of Daily Health Check p) Meningococcal infection, until appropriate therapy Standard 3.6.1.2: Staff Exclusion for Illness has been administered for twenty-four hours; Standard 3.6.1.3: Thermometers for Taking Human Temperatures q) Respiratory illness, if the illness limits the staff Standard 3.6.1.4: Infectious Disease Outbreak Control member’s ability to provide an acceptable level of Chapter 7: Infectious Diseases child care and compromises the health and safety of Appendix A: Signs and Symptoms Chart the children. REFERENCES: Caregivers/teachers who have herpes cold sores should not 1. Aronson, S. S., T. R. Shope, eds. 2009. Managing infectious be excluded from the child care facility, but should: diseases in child care and schools: A quick reference guide. 2nd ed. a) Cover and not touch their lesions; Elk Grove Village, IL: American Academy of Pediatrics. 2. Pickering, L. K., C. J. Baker, D. W. Kimberlin, S. S. Long, eds. Carefully observe hand hygiene policies. b) 2009. Red book: 2009 report of the Committee on Infectious Adults are as capable of spreading infectious RATIONALE: Diseases. 28th ed. Elk Grove Village, IL: American Academy of disease as children (1-3). See also the rationale for Standard Pediatrics. 3.6.1.1 Inclusion/Exclusion/Dismissal of Children. STANDARD 3.6.1.2: Staff Exclusion for Illness TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home Please note that if a staff member has no contact with the RELATED STANDARDS: children, or with anything with which the children come into Standard 3.6.1.1: Inclusion/Exclusion/Dismissal of Children contact, this standard may not apply to that staff member. Chapter 3: Health Promotion 135

166 Caring for Our Children: National Health and Safety Performance Standards Standard 3.6.1.4: Infectious Disease Outbreak Control health-issues/conditions/fever/pages/How-to-Take-a Chapter 7: Infectious Diseases -Childs-Temperature.aspx. REFERENCES: Safety and child abuse concerns may arise when using rec- 1. Reves, R. R., L. K. Pickering. 1992. Impact of child day care on tal thermometers. Caregivers/teachers should be aware of 6:239-50. Infect Dis Clin North Amer infectious diseases in adults. these concerns. If rectal temperatures are taken, steps must 2. Pickering, L. K., C. J. Baker, D. W. Kimberlin, S. S. Long, eds. be taken to ensure that all caregivers/teachers are trained . Red book: 2009 report of the Committee on Infectious 2009 properly in this procedure and the opportunity for abuse 28th ed. Elk Grove Village, IL: American Academy of Diseases. is negligible (for example, ensure that more than one adult Pediatrics. present during procedure). Rectal temperatures should be 3. Murph, J. R., S. D. Palmer, D. Glassy, eds. 2005. Health in child taken only by persons with specific health training in per - care: A manual for health professionals. Elk Grove Village, IL: American Academy of Pediatrics. forming this procedure and permission given by parents/ guardians. STANDARD 3.6.1.3: Thermometers for Taking Many state or local agencies operate facilities that collect Human Temperatures used mercury thermometers. Typically, the service is free. For more information on household hazardous waste collec- Digital thermometers should be used with infants and young tions in your area, call your State environmental protection children when there is a concern for fever. Tympanic (ear) agency or your local health department. thermometers may be used with children four months and older. However, while a tympanic thermometer gives quick TYPE OF FACILITY: Center; Large Family Child Care Home; Small results, it needs to be placed correctly in the child’s ear to Family Child Care Home be accurate. REFERENCES: 1. Healthy Children. 2010. Health issues: How to take a child’s Glass or mercury thermometers should not be used. Mer - temperature. American Academy of Pediatrics. http://www. cury containing thermometers and any waste created from healthychildren.org/English/health-issues/conditions/fever/pages/ the cleanup of a broken thermometer should be disposed of How-to-Take-a-Childs-Temperature.aspx. at a household hazardous waste collection facility. 2. Dodd, S. R., G. A. Lancaster, J. V. Craig, R. L. Smyth, P. R. Rectal temperatures should be taken only by persons with Williamson. 2006. In a systematic review, infrared ear thermometry J Clin Epidemiol for fever diagnosis in children finds poor sensitivity. specific health training in performing this procedure. Oral 59:354-57. (under the tongue) temperatures can be used for children over age four. Individual plastic covers should be used on STANDARD 3.6.1.4: Infectious Disease oral or rectal thermometers with each use or thermometers should be cleaned and sanitized after each use according Outbreak Control to the manufacturer’s instructions. Axillary (under the arm) During the course of an identified outbreak of any report- temperatures are less accurate, but are a good option for able illness at the facility, a child or staff member should be infants and young children when the caregiver/teacher has excluded if the health department official or primary care not been trained to take a rectal temperature. provider suspects that the child or staff member is con- RATIONALE: When using tympanic thermometers, too tributing to transmission of the illness at the facility, is not much earwax can cause the reading to be incorrect. Tym- adequately immunized when there is an outbreak of a vac- panic thermometers may fail to detect a fever that is actually cine preventable disease, or the circulating pathogen poses present (1). Therefore, tympanic thermometers should not an increased risk to the individual. The child or staff member be used in children under four months of age, where fever should be readmitted when the health department official detection is most important. or primary care provider who made the initial determination decides that the risk of transmission is no longer present. Mercury thermometers can break and result in mercury tox- icity that can lead to neurologic injury. To prevent mercury RATIONALE: Secondary spread of infectious disease has toxicity, the American Academy of Pediatrics (AAP) encour - been proven to occur in child care. Control of outbreaks of ages the removal of mercury thermometers from homes. infectious diseases in child care may include age-appro- This includes all child care settings as well (1). priate immunization, antibiotic prophylaxis, observing well children for signs and symptoms of disease and for de- Although not a hazard, temporal thermometers are not as creasing opportunities for transmission of that may sustain accurate as digital thermometers (2). an outbreak. Removal of children known or suspected of COMMENTS: The site where a child’s temperature is taken contributing to an outbreak may help to limit transmission of (rectal, oral, axillary, or tympanic) should be documented the disease by preventing the development of new cases of along with the temperature reading and the time the tem- the disease (1). perature was taken, because different sites give different TYPE OF FACILITY: Center; Large Family Child Care Home; Small results and affect interpretation of temperature. Family Child Care Home More information about taking temperatures can be found RELATED STANDARDS: on the AAP Website http://www.healthychildren.org/English/ Standard 3.6.1.1: Inclusion/Exclusion/Dismissal of Children Standard 3.6.1.2: Staff Exclusion for Illness 136 Chapter 3: Health Promotion

167 Caring for Our Children: National Health and Safety Performance Standards Standard 3.6.4.1: Procedure for Parent/Guardian Notification About pation in the usual child care activities. Most state regula- Exposure of Children to Infectious Disease tions require that children with certain conditions be exclud- Chapter 7: Infectious Diseases ed from their usual care arrangement (2). To accommodate Standard 9.2.4.4: Written Plan for Seasonal and Pandemic Influenza situations where parents/guardians cannot provide care for REFERENCES: their own children who are ill, several types of alternative 1. Siegel, J. D., E. Rhinehart, M. Jackson, L. Chiarello, Healthcare care arrangements have been established. The majority of Infection Control Practices Advisory Committee. 2007. 2007 viruses are spread by children who are asymptomatic, there- guideline for isolation precautions: Preventing transmission of fore, exposure of children to others with active symptoms or infectious agents in healthcare settings. http://www.cdc.gov/ who have recently recovered, does not significantly raise the hicpac/pdf/isolation/Isolation2007.pdf. risk of transmission over the baseline (3). TYPE OF FACILITY: Center; Large Family Child Care Home; Small STANDARD 3.6.1.5: Sharing of Personal Family Child Care Home Articles Prohibited RELATED STANDARDS: Combs, hairbrushes, toothbrushes, personal clothing, Standard 3.6.1.1: Inclusion/Exclusion/Dismissal of Children bedding, and towels should not be shared and should be Standards 3.6.2.2-3.6.2.10: Caring for Children Who are Ill labeled with the name of the child who uses these objects. REFERENCES: Respiratory and gastrointestinal infections are RATIONALE: J 1. Crowley, A. 1994. Sick child care: A developmental perspective. Pediatric Health Care . 8:261-67. common infectious diseases in child care. These diseases 2. National Resource Center for Health and Safety in Child Care are transmitted by direct person-to-person contact or by and Early Education. 2010. Individual states child care licensure sharing personal articles such as combs, brushes, towels, regulations. http://nrckids.org/STATES/states.htm. clothing, and bedding. Prohibiting the sharing of personal 3. Aronson, S. S., T. R. Shope, eds. 2009. Managing infectious articles and providing space so that personal items may diseases in child care and schools: A quick reference guide. 2nd ed. be stored separately helps prevent these diseases from Elk Grove Village, IL: American Academy of Pediatrics. spreading. Center; Large Family Child Care Home; Small TYPE OF FACILITY: STANDARD 3.6.2.2: Space Requirements for Family Child Care Home Care of Children Who Are Ill RELATED STANDARDS: Environmental space utilized for the care of children who are Standard 5.5.0.1: Storage and Labeling of Personal Articles ill with infectious diseases and cannot receive care in their usual child care group should meet all requirements for well 3.6.2 Caring for Children Who Are Ill children and include the following additional requirements: a) If the program for children who are ill is in the same STANDARD 3.6.2.1: Exclusion and Alternative facility as the well-child program, well children should Care for Children Who Are Ill not use or share furniture, fixtures, equipment, or supplies designated for use with children who are ill At the discretion of the person authorized by the child care unless it has been cleaned and sanitized before use provider to make such decisions, children who are ill should by well children; be excluded from the child care facility for the conditions Indoor space that the facility uses for children who b) defined in Standard 3.6.1.1. When children are not permitted are ill, including hallways, bathrooms, and kitchens, to receive care in their usual child care setting and cannot should be separate from indoor space used with receive care from a parent/guardian or relative, they should well children; this reduces the likelihood of mixing be permitted to receive care in one of the following arrange- supplies, toys, and equipment. The facility may ments, if the arrangement meets the applicable standards: use a single kitchen for ill and well children if the a) Care in the child’s usual facility in a special area for kitchen is staffed by a cook who has no child care care of children who are ill; responsibilities other than food preparation and who Care in a separate small family child care home b) does not handle soiled dishes and utensils until after or center that serves only children with illness or food preparation and food service are completed for temporary disabilities; any meal; c) Care by a child care provider in the child’s own home. c) Children whose symptoms indicate infections of the Young children who are developing trust, RATIONALE: gastrointestinal tract (often with diarrhea) who receive autonomy, and initiative require the support of familiar care- care in special facilities for children who are ill should givers and environments during times of illness to recover receive this care in a space separate from other physically and avoid emotional distress (1). Young children children with other illnesses to reduce the likelihood enrolled in group care experience a higher incidence of mild of disease being transmitted between children by illness (such as upper respiratory infections or otitis media) limiting child-to-child interaction, separating staff and other temporary disabilities (such as exacerbation of responsibilities, and not mixing supplies, toys, and asthma) than those who have less interaction with other equipment; children. Sometimes, these illnesses preclude their partici- Chapter 3: Health Promotion 137

168 Caring for Our Children: National Health and Safety Performance Standards If the facility cares for children with chickenpox, these d) STANDARD 3.6.2.3: Qualifications of Directors children require a room with separate ventilation with of Facilities That Care for Children Who Are Ill exhaust to, and air exchange with, the outside (3); The director of a facility that cares for children who are ill e) Each child care room should have a handwashing should have the following minimum qualifications, in ad- sink that can provide a steady stream of water, dition to the general qualifications described in Director’s between 60°F and 120°F, at least for ten seconds. Qualifications, Standards 1.3.1.1 and 1.3.1.2: Soap and disposable paper towels should be At least forty hours of training in prevention and a) available at the handwashing sink at all times. A hand control of infectious diseases and care of children sanitizing dispenser is an alternative to traditional who are ill, including subjects listed in Standard handwashing; 3.6.2.5; f) Each room where children who wear diapers receive b) At least two prior years of satisfactory performance care should have its own diaper changing area as a director of a regular facility; adjacent to a handwashing sink and/or hand sanitizer c) At least twelve credit hours of college-level training in dispenser. child development or early childhood education. RATIONALE: Transmission of infectious diseases in child RATIONALE: The director should be college-prepared in care settings may be influenced by the design, construction, early childhood education and have taken college-level and maintenance of the physical environment (2). The popu- courses in illness prevention and control, since the director lation that uses centers should in time become less suscep- is the person responsible for establishing the facility’s poli- tible to chickenpox through immunization. Some children, cies and procedures and for meeting the training needs of however, are too young to be routinely immunized and may new staff members (1). be susceptible; and, although universal immunization with varicella vaccine is recommended, full compliance with the Center TYPE OF FACILITY: recommendation has not been achieved. RELATED STANDARDS: Standards 1.3.1.1-1.3.1.2: Director’s Qualifications Chickenpox is readily spread by airborne droplets (1) or Standard 3.6.2.5: Caregiver/Teacher Qualifications for Facilities that direct contact. Care for Children Who are Ill Handwashing sinks should be stationed in each room, to REFERENCES: promote hand hygiene and also to give the caregivers/ 1. Fiene, R. 2002. 13 indicators of quality child care: Research teachers an opportunity for continuous supervision of the Washington, DC: U.S. Department of Health and Human update. other children in care when washing their hands. The sink Services, Office of the Assistant Secretary for Planning and must deliver a consistent flow of water for ten seconds so Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/. that the user does not need to touch the faucet handles. Diaper changing areas should be adjacent to sinks to foster STANDARD 3.6.2.4: Program Requirements for cleanliness and also to enable caregivers/teachers to pro- Facilities That Care for Children Who Are Ill vide continuous supervision of other children in care. The Any facility that offers care for the child who is ill of any age provision of alcohol-based hand sanitizing dispensers may should: be an alternative to traditional handwashing with soap and a) Provide a caregiver/teacher who is familiar to the water. child; Some facilities have staffed “get well” rooms COMMENTS: Provide care in a place with which the child is familiar b) typically caring for fewer than six children who are ill. and comfortable away from other children in care; TYPE OF FACILITY: Center; Large Family Child Care Home; Small Involve a caregiver/teacher who has time to give c) Family Child Care Home individual care and emotional support, who knows of the child’s interests, and who knows of activities that RELATED STANDARDS: appeal to the level of child development age group Chapter 7: Infectious Diseases and to a sick child; REFERENCES: d) Offer a program with trained personnel planned in 1. Pickering, L. K., C. J. Baker, D. W. Kimberlin, S. S. Long, eds. consultation with qualified health care personnel and Red book: 2009 report of the Committee on Infectious 2009. with ongoing medical direction. Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics. RATIONALE: When children are ill, they are stressed by the 2. Staes, C., S. Balk, K. Ford, R. J. Passantino, A. Torrice. 1994. illness itself. Unfamiliar places and caregivers/teachers add Environmental factors to consider when designing and maintaining to the stress of illness when a child is sick. Since illness 94:1048-50. Pediatrics a child’s day-care environment. tends to promote regression and dependency, children who Managing infectious 3. Aronson, S. S., T. R. Shope, eds. 2009. are ill need a person who knows and can respond to the diseases in child care and schools: A quick reference guide. 2nd ed. child’s cues appropriately. Elk Grove Village, IL: American Academy of Pediatrics. Because children are most comfortable in a COMMENTS: familiar place with familiar people, the preferred arrange- ment for children who are ill will be the child’s home or the 138 Chapter 3: Health Promotion

169 Caring for Our Children: National Health and Safety Performance Standards needs is essential (1). Work experience in child care facilities child’s regular child care arrangement, when the child care will help the caregiver/teacher develop these skills. States facility has the resources to adapt to the needs of such that have developed rules regulating facilities have recog- children. nized the need for training in illness prevention and control Center; Large Family Child Care Home; Small TYPE OF FACILITY: and management of medical emergencies. Staff members Family Child Care Home caring for children who are ill in special facilities or in a get RELATED STANDARDS: well room in a regular center should meet the staff qualifica- Standard 3.6.2.2: Space Requirements for Care of Children Who tions that are applied to child care facilities generally. Are Ill Standards 3.6.4.1-3.6.4.5: Reporting Illness and Death Caregivers/teachers have to be prepared for handling illness Standard 10.5.0.1: State and Local Health Department Role and must understand their scope of work. Special train- ing is required of caregivers/teachers who work in special STANDARD 3.6.2.5: Caregiver/Teacher facilities for children who are ill because the director and the Qualifications for Facilities That Care for caregivers/teachers are dealing with infectious diseases and need to know how to prevent the spread of infection. Each Children Who Are Ill caregiver/teacher should have training to decrease the risk Each caregiver/teacher in a facility that cares for children of transmitting disease (1). who are ill should have at least two years of successful work TYPE OF FACILITY: Center; Large Family Child Care Home; Small experience as a caregiver/teacher in a regular well-child Family Child Care Home facility prior to employment in the special facility. In addi- tion, facilities should document, for each caregiver/teacher, RELATED STANDARDS: Standards 1.4.2.1-1.4.2.3: Orientation Training twenty hours of pre-service orientation training on care of Standard 10.5.0.1: State and Local Health Department Role children who are ill beyond the orientation training specified in Standards 1.4.2.1 through Standard 1.4.2.3. This training REFERENCES: should include the following subjects: 1. Heymann, S. J., P. Hong Vo, C. A. Bergstrom. 2002. Child care providers’ experiences caring for sick children: Implications for a) Pediatric first aid and CPR, and first aid for choking; 172:1-8. Early Child Devel Care public policy. b) General infection-control procedures, including: Hand hygiene; 1) STANDARD 3.6.2.6: Child-Staff Ratios for Handling of contaminated items; 2) Use of sanitizing chemicals; 3) Facilities That Care for Children Who Are Ill 4) Food handling; Each facility for children who are ill should maintain a child- 5) Washing and sanitizing of toys; to-staff ratio no greater than the following: 6) Education about methods of disease transmission. c) Care of children with common mild childhood Age of Children Child to Staff Ratio illnesses, including: 3 children to 1 staff 3-35 months Recognition and documentation of signs and 1) member symptoms of illness including body temperature; 36-71 months 4 children to 1 staff 2) Administration and recording of medications; member Nutrition of children who are ill; 3) Communication with parents/guardians of children 4) 72 months and older 6 children to 1 staff who are ill; member Knowledge of immunization requirements; 5) Some states stipulate the ratios for caring for RATIONALE: 6) Recognition of need for medical assistance and children who are ill in their regulations. The expert consen- how to access; sus is based on theories of child development including 7) Knowledge of reporting requirements for infectious attachment theory and recognition of children’s temporary diseases; emotional regression during times of illness (1-3); the lowest 8) Emergency procedures. ratios used per age group seem appropriate. d) Child development activities for children who are ill; e) Orientation to the facility and its policies. These ratios do not include other personnel, COMMENTS: such as bus drivers, necessary for specialized functions This training should be documented in the staff personnel such as transportation. files, and compliance with the content of training routinely TYPE OF FACILITY: Center; Large Family Child Care Home; Small evaluated. Based on these evaluations, the training on care Family Child Care Home of children who are ill should be updated with a minimum of six hours of annual training for individuals who continue to REFERENCES: provide care to children who are ill. 1. Davies, D. 1999. Child development: A practitioner’s guide . New York: The Guilford Press. RATIONALE: Because meeting the physical and psycho- 2. Schumacher, R. 2008. Charting progress for babies in child care: logical needs of children who are ill requires a higher level of CLASP center ratios and group sizes – Research based rationale. skill and understanding than caring for well children, a com- http://www.clasp.org/admin/site/babies/make_the_case/files/ mitment to children and an understanding of their general cp_rationale6.pdf. Chapter 3: Health Promotion 139

170 Caring for Our Children: National Health and Safety Performance Standards 3. Crowley, A. A. 1994. Sick child care: A developmental f) American Academy of Family Physicians (AAFP); 8:261-67. perspective. J Pediatric Health Care National Association of Pediatric Nurse Practitioners g) (NAPNAP); STANDARD 3.6.2.7: Child Care Health National Association for the Education of Young h) Children (NAEYC); Consultants for Facilities That Care for i) National Association for Family Child Care (NAFCC); Children Who Are Ill j) National Association of School Nurses (NASN); Each special facility that provides care for children who are k) Emergency Medical Services for Children (EMSC) ill should use the services of a child care health consultant National Resource Center; - for ongoing consultation on overall operation and develop l) National Training Institute for Child Care Health Con- ment of written policies relating to health care. The child sultants (NTI); care health consultant should have the knowledge, skills State or local health department (especially public m) and preparation as stated in Standard 1.6.0.1. health nursing, infectious disease, and epidemiology departments). The facility should involve the child care health consultant in development and/or implementation, review, and sign-off of TYPE OF FACILITY: Center; Large Family Child Care Home; Small the written policies and procedures for managing specific ill- Family Child Care Home nesses. The facility staff and the child care health consultant RELATED STANDARDS: should review and update the written policies annually. Standard 1.6.0.1: Child Care Health Consultants The facility should assign the child care health consultant REFERENCES: the responsibility for reviewing written policies and proce- Infection control in the child care 1. Donowitz, L. G., ed. 1996. dures for the following: center and preschool, 18-19, 68. 2nd ed. Baltimore, MD: Williams a) Admission and readmission after illness, including and Wilkins. 2. Churchill, R. B., L. K. Pickering. 1997. Infection control challenges inclusion/exclusion criteria; in child care centers. Infect Dis Clin North Am 11:347-65. Health evaluation procedures on intake, including b) 3. Crowley A. A. 2000. Child care health consultation: The physical assessment of the child and other criteria . Matern Child Health J Connecticut experience 4:67-75. used to determine the appropriateness of a child’s attendance; STANDARD 3.6.2.8: Licensing of Facilities Plans for health care and for managing children with c) That Care for Children Who Are Ill infectious diseases; Plans for surveillance of illnesses that are admissible d) A facility may care for children with symptoms requiring and problems that arise in the care of children with exclusion provided that the licensing authority has given illness; approval of the facility, written plans describing symptoms e) Plans for staff training and communication with and conditions that are admissible, and procedures for daily parents/guardians and primary care providers; care. In jurisdictions that lack regulations and licensing ca- f) Plans for injury prevention; pacity for facilities that care for children who are ill, the child Situations that require medical care within an hour. g) care health consultant with the local health authority should review these plans and procedures annually in an advisory Appropriate involvement of child care health RATIONALE: capacity. consultants is especially important for facilities that care for children who are ill. Facilities should use the expertise of RATIONALE: Facilities for children who are ill generally are primary care providers to design and provide a child care required to meet the licensing requirements that apply to all environment with sufficient staff and facilities to meet the facilities of a specific type, for example, small or large family needs of children who are ill (2,3). The best interests of the child care homes or centers. Additional requirements should child and family must be given primary consideration in the apply when children who are ill will be in care. care of children who are ill. Consultation by primary care This standard ensures that child care facilities are continu- providers, especially those whose specialty is pediatrics, is ally reviewed by an appropriate state authority and that fa- critical in planning facilities for the care of children who are cilities maintain appropriate standards in caring for children ill (1). who are ill. Caregivers/teachers should seek the services COMMENTS: COMMENTS: If a child care health consultant is not avail- of a child care health consultant through state and local able, than the local health authority should review plans and professional organizations, such as: procedures annually. a) Healthy Child Care Consultant Network Support Center (maintains a national registry of NTI-trained TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home CCHCs); Local chapters of the American Academy of Pediat- b) RELATED STANDARDS: rics (AAP); Standard 3.6.2.10: Inclusion and Exclusion of Children from Facili- Local Children’s hospital; c) ties that Serve Children Who Are Ill Standard 10.2.0.1: Regulation of All Out-of-Home Child Care American Nurses Association (ANA); d) Standard 10.3.1.1: Operation Permits Visiting Nurse Association (VNA); e) 140 Chapter 3: Health Promotion

171 Caring for Our Children: National Health and Safety Performance Standards STANDARD 3.6.2.10: Inclusion and Exclusion STANDARD 3.6.2.9: Information Required for of Children from Facilities That Serve Children Children Who Are Ill Who Are Ill For each day of care in a special facility that provides care for children who are ill, the caregiver/teacher should have Facilities that care for children who are ill who have condi- the following information on each child: tions that require additional attention from the caregiver/ a) The child’s specific diagnosis and the individual teacher, should arrange for or ask the child care health providing the diagnosis (primary care provider, consultant to arrange for a clinical health evaluation, by a parent/guardian); licensed primary care provider, for each child who is admit- Current status of the illness, including potential for b) ted to the facility. These facilities should include children contagion, diet, activity level, and duration of illness; with conditions listed in Standard 3.6.1.1 if their policies and c) Health care, diet, allergies (particularly to foods plans address the management of these conditions, except or medication), and medication and treatment for the following conditions which require exclusion from all plan, including appropriate release forms to obtain types of child care facilities that are not medical care institu- emergency health care and administer medication; tions (such as hospitals or skilled nursing facilities): Communication with the parent/guardian on the d) a) Fever (see COMMENTS section for definition of fever) child’s progress; and a stiff neck, lethargy, irritability, or persistent e) Name, address, and telephone number of the child’s crying; source of primary health care; Diarrhea (loose stools, not contained in the diaper, b) f) Communication with the child’s primary care provider. that are two or more greater than normal frequency) and one or more of the following: Communication between parents/guardians, the child care Signs of dehydration, such as dry mouth, no tears, 1) program and the primary care provider (medical home) lethargy, sunken fontanelle (soft spot on the head); requires the free exchange of protected medical informa- 2) Blood or mucus in the stool until it is evaluated for tion (2). Confidentiality should be maintained at each step in organisms that can cause dysentery; compliance with any laws or regulations that are pertinent Salmonella 3) Campylobacter , , Diarrhea caused by to all parties such as the Family Educational Rights and or 0157:H7 until specific E.coli Shigella , Giardia Privacy Act (commonly known as FERPA) and/or the Health criteria for treatment and return to care are met. Insurance Portability and Accountability Act (commonly c) Vomiting with signs of dehydration and inability to known as HIPAA) (2). maintain hydration with oral intake; The caregiver/teacher must have child-specif- RATIONALE: Contagious stages of pertussis, measles, mumps, d) ic information to provide optimum care for each child who is chickenpox, rubella, or diphtheria, unless the child ill and to make appropriate decisions regarding whether to is appropriately isolated from children with other include or exclude a given child. The caregiver/teacher must illnesses and cared for only with children having the have contact information for the child’s source of primary same illness; health care or specialty health care (in the case of a child e) Untreated infestation of scabies or head lice; with asthma, diabetes, etc.) to assist with the management f) Untreated infectious tuberculosis; of any situation that arises. Undiagnosed rash WITH fever or behavior change; g) h) Abdominal pain that is intermittent or persistent and COMMENTS: For school-age children, documentation of is accompanied by fever, diarrhea, or vomiting; the care of the child during the illness should be provided to i) Difficulty in breathing; the parent to deliver to the school health program upon the j) An acute change in behavior; child’s return to school. Coordination with the child’s source k) Undiagnosed jaundice (yellow skin and whites of of health care and school health program facilitates the eyes); overall care of the child (1). l) Other conditions as may be determined by the TYPE OF FACILITY: Center; Large Family Child Care Home; Small director or child care health consultant; Family Child Care Home m) Upper or lower respiratory infection in which signs or REFERENCES: symptoms require a higher level of care than can be 1. Beierlein, J. G., J. E. Van Horn. 1995. Sick child care. National appropriately provided. Network for Child Care. http://www.nncc.org/eo/emp.sick.child .care.html. RATIONALE: These signs and symptoms may indicate 2. Donoghue, E. A., C. A. Kraft, eds. 2010. Managing chronic health a significant systemic infection that requires professional Elk Grove needs in child care and schools: A quick reference guide. medical management and parental care (1). Diarrheal illness- Village, IL: American Academy of Pediatrics. es that require an intensity of care that cannot be provided appropriately by a caregiver/teacher could result in tempo- rary exclusion. Fever is defined as a temperature above COMMENTS: 101°F (38.3°C) orally, above 102°F (38.9°C) rectally, or 100°F Chapter 3: Health Promotion 141

172 Caring for Our Children: National Health and Safety Performance Standards the medication. Signatures from the primary care provider (37.8°C) or higher taken axillary (armpit) or measured by an and one of the child’s parents/guardians must be obtained equivalent method. on the special care plan. Care plans should be updated as TYPE OF FACILITY: Center; Large Family Child Care Home; Small needed, but at least yearly. Family Child Care Home Medicines can be crucial to the health and RATIONALE: RELATED STANDARDS: wellness of children. They can also be very dangerous if the Standard 1.6.0.1: Child Care Health Consultants Standard 3.6.1.1: Inclusion/Exclusion/Dismissal of Children wrong type or wrong amount is given to the wrong per - Standard 3.6.1.4: Infectious Disease Outbreak Control son or at the wrong time. Prevention is the key to prevent Chapter 7: Infectious Diseases poisonings by making sure medications are inaccessible to children. REFERENCES: 1. Pickering, L. K., C. J. Baker, D. W. Kimberlin, S. S. Long, eds. All medicines require clear, accurate instruction and medi- 2009. Red book: 2009 report of the Committee on Infectious cal confirmation of the need for the medication to be given 28th ed. Elk Grove Village, IL: American Academy of Diseases. while the child is in the facility. Prescription medications Pediatrics. can often be timed to be given at home and this should be encouraged. Because of the potential for errors in medica- 3.6.3 Medications tion administration in child care facilities, it may be safer for a parent/guardian to administer their child’s medicine at STANDARD 3.6.3.1: Medication Administration home. The administration of medicines at the facility should be Over the counter medications, such as acetaminophen and limited to: ibuprofen, can be just as dangerous as prescription medi- a) Prescription or non-prescription medication (over- cations and can result in illness or even death when these the-counter [OTC]) ordered by the prescribing products are misused or unintentional poisoning occurs. health professional for a specific child with written Many children’s over the counter medications contain a permission of the parent/guardian. Written orders combination of ingredients. It is important to make sure the from the prescribing health professional should child isn’t receiving the same medications in two different specify medical need, medication, dosage, and products which may result in an overdose. Facilities should length of time to give medication; not stock OTC medications (1). Labeled medications brought to the child care facility b) Cough and cold medications are widely used for children to by the parent/guardian in the original container (with treat upper respiratory infections and allergy symptoms. Re- a label that includes the child’s name, date filled, cently, concern has been raised that there is no proven ben- prescribing clinician’s name, pharmacy name and efit and some of these products may be dangerous (2,3,5). phone number, dosage/instructions, and relevant Leading organizations such as the Consumer Healthcare warnings). Products Association (CHPA) and the American Academy of Facilities should not administer folk or homemade remedy Pediatrics (AAP) have recommended restrictions on these medications or treatment. Facilities should not administer a products for children under age six (4-7). medication that is prescribed for one child in the family to If a medication mistake or unintentional poisoning does another child in the family. occur, call your local poison center immediately at 1-800- No prescription or non-prescription medication (OTC) 222-1222. should be given to any child without written orders from a Parents/guardians should always be notified in every prescribing health professional and written permission from instance when medication is used. Telephone instructions a parent/guardian. Exception: Non-prescription sunscreen from a primary care provider are acceptable if the caregiver/ and insect repellent always require parental consent but do teacher fully documents them and if the parent/guardian not require instructions from each child’s prescribing health initiates the request for primary care provider or child care professional. health consultant instruction. In the event medication for a Documentation that the medicine/agent is administered to child becomes necessary during the day or in the event of the child as prescribed is required. an emergency, administration instructions from a parent/ “Standing orders” guidance should include directions for guardian and the child’s prescribing health professional are facilities to be equipped, staffed, and monitored by the required before a caregiver/teacher may administer medica- primary care provider capable of having the special health tion. care plan modified as needed. Standing orders for medica- TYPE OF FACILITY: Center; Large Family Child Care Home; Small tion should only be allowed for individual children with a Family Child Care Home documented medical need if a special care plan is provided RELATED STANDARDS: by the child’s primary care provider in conjunction with the Standard 3.4.5.1: Sun Safety Including Sunscreen standing order or for OTC medications for which a primary Standard 3.4.5.2: Insect Repellent and Protection from Vector- care provider has provided specific instructions that define Borne Diseases the children, conditions and methods for administration of 142 Chapter 3: Health Promotion

173 Caring for Our Children: National Health and Safety Performance Standards Standard 3.6.2.9: Information Required For Children Who Are Ill guardian for disposal. In the event medication cannot be Standard 3.6.3.1: Medication Administration returned to the parent or guardian, it should be disposed Standard 3.6.3.2: Labeling, Storage, and Disposal of Medication of according to the recommendations of the US Food and Drug Administration (FDA) (1). Documentation should be REFERENCES: 1. American Academy of Pediatrics, Committee on Drugs. 2009. kept with the child care facility of all disposed medications. Pediatrics Policy statement: Acetaminophen toxicity in children. The current guidelines are as follows: 123:1421-22. a) If a medication lists any specific instructions on how 2. Schaefer, M. K., N. Shehab, A. Cohen, D. S. Budnitz. 2008. to dispose of it, follow those directions. Adverse events from cough and cold medications in children. If there are community drug take back programs, b) 121:783-87. Pediatrics participate in those. 3. Centers for Disease Control and Prevention. 2007. Infant deaths c) Remove medications from their original containers MMWR associated with cough and cold medications: Two states. and put them in a sealable bag. Mix medications 56:1-4. with an undesirable substance such as used coffee 4. Consumer Healthcare Products Association. Makers of OTC grounds or kitty litter. Throw the mixture into the cough and cold medicines announce voluntary withdrawal of oral infant medicines. http://www.chpa-info.org/10_11_07 regular trash. Make sure children do not have access _OralInfantMedicines.aspx. to the trash (1). 5. U.S. Department of Health and Human Services, Food Child-resistant safety packaging has been RATIONALE: and Drug Administration. 2008. Public Health advisory: shown to significantly decrease poison exposure incidents FDA recommends that over-the-counter (OTC) cough and in young children (1). cold products not be used for infants and children under 2 years of age. http://www.fda.gov/Drugs/DrugSafety/ Proper disposal of medications is important to help ensure a PostmarketDrugSafetyInformationforPatientsandProviders/ healthy environment for children in our communities. There DrugSafetyInformationforHeathcareProfessionals/ is growing evidence that throwing out or flushing medica- PublicHealthAdvisories/ucm051137.htm. tions into our sewer systems may have harmful effects on 6. Vernacchio, L., J. Kelly, D. Kaufman, A. Mitchell. 2008. Cough the environment (1-3). and cold medication use by U.S. children, 1999-2006: Results from 122: e323-29. Pediatrics the Slone Survey. COMMENTS: A small lock box can be kept in the refrigera- . AAP Urges caution in use 7. American Academy of Pediatrics. 2008 tor to hold medications. Programs may also consult with of over-the-counter cough and cold medicines. http://www.aap their local pharmacy regarding disposal. For more informa- .org/advocacy/releases/jan08coughandcold.htm. tion on medication take back programs see Teleosis Insti- tute at http://www.teleosis.org/gpp-national.php. STANDARD 3.6.3.2: Labeling, Storage, and TYPE OF FACILITY: Center; Large Family Child Care Home; Small Disposal of Medications Family Child Care Home Any prescription medication should be dated and kept in REFERENCES: the original container. The container should be labeled by a 1. U.S. Food and Drug Administration. 2010. Disposal by pharmacist with: flushing of certain unused medicines: What you should know. • The child’s first and last names; http://www.fda.gov/Drugs/ResourcesForYou/Consumers/ • The date the prescription was filled; BuyingUsingMedicineSafely/ The name of the prescribing health professional who • EnsuringSafeUseofMedicine/SafeDisposalofMedicines/ wrote the prescription, the medication’s expiration ucm186187.htm. 2. U.S. Environmental Protection Agency. 2009. Pharmaceuticals date; and personal care products as pollutants (PPCPs). http://www.epa • The manufacturer’s instructions or prescription label .gov/ppcp/. with specific, legible instructions for administration, 13 indicators of quality child care: Research 3. Fiene, R. 2002. storage, and disposal; update. Washington, DC: U.S. Department of Health and Human • The name and strength of the medication. Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/. Over-the-counter medications should be kept in the original container as sold by the manufacturer, labeled by the par - STANDARD 3.6.3.3: Training of Caregivers/ ent/guardian, with the child’s name and specific instruc- tions given by the child’s prescribing health professional for Teachers to Administer Medication administration. Any caregiver/teacher who administers medication should All medications, refrigerated or unrefrigerated, should: complete a standardized training course that includes skill Have child-resistant caps; • and competency assessment in medication administra- • Be kept in an organized fashion; tion. The trainer in medication administration should be a • Be stored away from food; licensed health professional. The course should be repeated Be stored at the proper temperature; • according to state and/or local regulation. At a minimum, Be completely inaccessible to children. • skill and competency should be monitored annually or whenever medication administration error occurs. In facili- - Medication should not be used beyond the date of expira ties with large numbers of children with special health care tion. Unused medications should be returned to the parent/ - needs involving daily medication, best practice would indi Chapter 3: Health Promotion 143

174 Caring for Our Children: National Health and Safety Performance Standards Center; Large Family Child Care Home; Small TYPE OF FACILITY: cate strong consideration to the hiring of a licensed health Family Child Care Home care professional. Lacking that, caregivers/teachers should be trained to: RELATED STANDARDS: a) Check that the name of the child on the medication Standard 3.6.3.1: Medication Administration Standard 3.6.3.2: Labeling, Storage, and Disposal of Medications and the child receiving the medication are the same; Standard 9.2.3.9: Written Policy on Use of Medications b) Check that the name of the medication is the same Appendix O: Care Plan for Children with Special Health Care Needs as the name of the medication on the instructions to Appendix AA: Medication Administration Packet give the medication if the instructions are not on the medication container that is labeled with the child’s REFERENCES: 1. Heschel, R. T., A. A. Crowley, S. S. Cohen. 2005. State policies name; regarding nursing delegation and administration in child care Read and understand the label/prescription directions c) Policy, Politics, and Nursing Practice settings: A case study. 6:86- or the separate written instructions in relation to the 98. measured dose, frequency, route of administration 2. Qualistar Early Learning. 2008. Colorado Medication (ex. by mouth, ear canal, eye, etc.) and other special Administration Curriculum. 5th ed. http://www.qualistar.org/ instructions relative to the medication; medication-administration.html. d) Observe and report any side effects from 13 indicators of quality child care: Research 3. Fiene, R. 2002. medications; update . Washington, DC: US Department of Health and Human e) Document the administration of each dose by the Services, Office of the Assistant Secretary for Planning and time and the amount given; Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/. 4. Calder, J. 2004. Medication administration in child care f) Document the person giving the administration and Berkeley, CA: California programs. Health and Safety Notes. any side effects noted; Childcare Health Program. http://www.ucsfchildcarehealth.org/pdfs/ g) Handle and store all medications according to label healthandsafety/medadminEN102004_adr.pdf. instructions and regulations. 5. Vernacchio, L., J. P. Kelly, D. W. Kaufman, A. A. Mitchell. 2009. The trainer in medication administration should be a Medication use among children <12 years of age in the United States: Results from the Slone Survey 124:446-54. . Pediatrics licensed health professional: Registered Nurse, Advanced Practice Registered Nurse (APRN), MD, Physician’s Assis- tant, or Pharmacist. 3.6.4 Reporting Illness and Death Administration of medicines is unavoidable RATIONALE: STANDARD 3.6.4.1: Procedure for Parent/ as increasing numbers of children entering child care take Guardian Notification About Exposure of medications. National data indicate that at any one time, a significant portion of the pediatric population is taking Children to Infectious Disease medication, mostly vitamins, but between 16% and 40% are Caregivers/teachers should work collaboratively with local taking antipyretics/analgesics (5). Safe medication admin- and state health authorities to notify parents/guardians istration in child care is extremely important and training of about potential or confirmed exposures of their child to a caregivers/teachers is essential (1). infectious disease. Notification should include the following Caregivers/teachers need to know what medication the information: child is receiving, who prescribed the medicine and when, a) The names, both the common and the medical name, for what purpose the medicine has been prescribed and of the diagnosed disease to which the child was what the known reactions or side effects may be if a child exposed, whether there is one case or an outbreak, has a negative reaction to the medicine (2,3). A child’s and the nature of the exposure (such as a child or reaction to medication can be occasionally extreme enough staff member in a shared room or facility); to initiate the protocol developed for emergencies. The Signs and symptoms of the disease for which the b) medication record is especially important if medications are parent/guardian should observe; frequently prescribed or if long-term medications are being Mode of transmission of the disease; c) used (4). d) Period of communicability and how long to watch for signs and symptoms of the disease; COMMENTS: Caregivers/teachers need to know the state e) Disease-prevention measures recommended by the laws and regulations on training requirements for the admin- health department (if appropriate); istration of medications in out-of-home child care settings. f) Control measures implemented at the facility; These laws may include requirements for delegation of med- g) Pictures of skin lesions or skin condition may be ication administration from a primary care provider. Train- helpful to parents/guardians (i.e., chicken pox, spots ing on medication administration for caregivers/teachers is on tonsils, etc.) Model Child Care Health Policies, available in several states. from Healthy Child Care Pennsylvania is available at 2nd Ed. The notice should not identify the child who has the infec- http://www.ecels-healthychildcarepa.org/content/ tious disease. MHP4thEd Total.pdf, and contains sample polices and RATIONALE: Effective control and prevention of infectious forms related to medication administration. diseases in child care depends on affirmative relationships Chapter 3: Health Promotion 144

175 Caring for Our Children: National Health and Safety Performance Standards RELATED STANDARDS: between parents/guardians, caregivers/teachers, public Standard 3.6.1.4: Infectious Disease Outbreak Control health authorities, and primary care providers. Chapter 7: Infectious Diseases COMMENTS: The child care health consultant can locate REFERENCES: appropriate photographs of conditions for parent/guardian 1. Aronson, S. S., T. R. Shope, eds. 2009. Managing infectious information use. Resources for fact sheets and photographs diseases in child care and schools: A quick reference guide. 2nd ed. Managing Infectious Diseases in Child Care and include: Elk Grove Village, IL: American Academy of Pediatrics. (1) and the Centers for Disease Control Schools, 2nd Edition and Prevention Website on conditions and diseases at STANDARD 3.6.4.3: Notification of the Facility http://www.cdc.gov/DiseasesConditions/. For a sample let- About Infectious Disease or Other Problems ter to parents notifying them of illness of their child or other by Parents enrolled children, see Healthy Young Children, available from the National Association for the Education of Young Children Upon registration of each child, the facility should inform (NAEYC) at http://www.naeyc.org. parents/guardians that they must notify the facility within twenty-four hours after their child or any member of the Center; Large Family Child Care Home; Small TYPE OF FACILITY: immediate household has developed a known or suspected Family Child Care Home infectious or vaccine-preventable disease (1). When a child RELATED STANDARDS: has a disease that may require exclusion, the parents/guard- Standard 3.6.1.4: Infectious Disease Outbreak Control ians should inform the facility of the diagnosis. Chapter 7: Infectious Diseases Appendix A: Signs and Symptoms Chart The facility should encourage parents/guardians to inform the caregivers/teachers of any other problems which may REFERENCES: 1. Aronson, S. S., T. R. Shope, eds. 2009. Managing infectious affect the child’s behavior. 2nd ed. diseases in child care and schools: A quick reference guide. RATIONALE: This requirement will facilitate prompt report- Elk Grove Village, IL: American Academy of Pediatrics. ing of disease and enable the caregiver/teacher to provide better care. Disease surveillance and reporting to local STANDARD 3.6.4.2: Infectious Diseases That health authorities is crucial to preventing and controlling Require Parent/Guardian Notification diseases in the child care setting. The major purpose of sur - In cooperation with the child care regulatory authority and veillance is to allow early detection of disease and prompt health department, the facility or the health department implementation of control measures. If it is known that the should inform parents/guardians if their child may have been child attends another center or facility, all facilities should - exposed to the following diseases or conditions while at be informed (for example, if the child attends a Head Start tending the child care program, while retaining the confiden- program and a child care program that are separate–then tiality of the child who has the infectious disease: both need to be notified and the notification of local health a) (meningitis); Neisseria meningitidis authority should name both facilities). Pertussis; b) Ascertaining whether a child who is ill is attending a facility c) Invasive infections; - is important when evaluating childhood illnesses. Ascertain Varicella-zoster (Chickenpox) virus; d) ing whether an adult with illness is working in a facility or is e) Skin infections or infestations (head lice, scabies, and a parent/guardian of a child attending a facility is important ringworm); when considering infectious diseases that are more com- f) Infections of the gastrointestinal tract (often with monly manifest in adults. Cases of illness in family member diarrhea) and hepatitis A virus (HAV); such as infections of the gastrointestinal tract (with diar - g) Haemophilus influenzae type B (Hib); rhea), or infections of the liver may necessitate question- h) Parvovirus B19 (fifth disease); ing about possible illness in the child attending child care. i) Measles; Information concerning infectious disease in a child care j) Tuberculosis; attendee, staff member, or household contact should be Two or more affected unrelated persons affiliated with k) communicated to public health authorities, to the child care the facility with a vaccine-preventable or infectious director, and to the child’s parents/guardians. disease. Center; Large Family Child Care Home; Small TYPE OF FACILITY: Early identification and treatment of infectious RATIONALE: Family Child Care Home diseases are important in minimizing associated morbidity RELATED STANDARDS: and mortality as well as further reducing transmission (1). Standard 3.6.1.1: Inclusion/Exclusion/Dismissal of Children Notification of parents/guardians will permit them to discuss REFERENCES: with their child’s primary care provider the implications of Managing infectious 1. Aronson, S. S., T. R. Shope, eds. 2009. the exposure and to closely observe their child for early 2nd ed. diseases in child care and schools: A quick reference guide. signs and symptoms of illness. Elk Grove Village, IL: American Academy of Pediatrics. Center; Large Family Child Care Home; Small TYPE OF FACILITY: Family Child Care Home Chapter 3: Health Promotion 145

176 Caring for Our Children: National Health and Safety Performance Standards For information on assisting families in finding a medical STANDARD 3.6.4.4: List of Excludable and home or primary care provider, consult the local chapter Reportable Conditions for Parents/Guardians of the American Academy of Pediatrics (AAP), the facility’s The facility should give to each parent/guardian a written child care health consultant, Nurse Practitioner Central (3), list of conditions for which exclusion and dismissal may be the local public health department, or the American Acad - indicated (2). emy of Family Physicians (AAFP). For more information, see also the AAP Managing Infectious Diseases in Child Care For the following symptoms, the caregiver/teacher should , available at http://www.aap.org. and Schools, 2nd ed. ask parents to have the child evaluated by a primary care provider. The advice of the primary care provider should be Center; Large Family Child Care Home; Small TYPE OF FACILITY: documented for the caregiver/teacher in the following situ- Family Child Care Home ations: RELATED STANDARDS: The child has any of the following conditions: a) Standard 3.6.1.1: Inclusion/Exclusion/Dismissal of Children fever, lethargy, irritability, persistent crying, difficult Chapter 7: Infectious Diseases breathing, or other manifestations of possible severe Appendix P: Situations that Require Medical Attention Right Away illness; REFERENCES: The child has a rash with fever and behavioral b) 1. Pickering, L. K., C. J. Baker, D. W. Kimberlin, S. S. Long. 2009. change; Red book: 2009 report of the Committee on Infectious Diseases. c) The child has tuberculosis that has not been 28th ed. Elk Grove Village, IL: American Academy of Pediatrics. evaluated; 2. Donowitz, L. G., ed. 1996. Infection control in the child care d) The child has scabies; center and preschool, 18-19, 68. 2nd ed. Baltimore, MD: Williams and Wilkins. The child has a persistent cough with inability to e) 3. Nurse Practitioner Central. 2003. National nurse practitioner practice respiratory etiquette. directory. http://www.npclinics.com. The facility should have a list of reportable diseases pro- vided by the health department and should provide a copy STANDARD 3.6.4.5: Death to each parent/guardian. Each facility should have a plan in place for responding Vomiting with symptoms such as lethargy RATIONALE: to any death relevant to children enrolled in the facility and/or dry skin or mucous membranes or reduced urine and their families. The plan should describe protocols the output may indicate dehydration, and the child should be program will follow and resources available for children, medically evaluated. Diarrhea with fever or other symp- families, and staff. toms usually indicates infection. Blood and/or mucus may - If a facility experiences the death of a child or adult, the fol indicate shigellosis or infection with 0157:H7, which E. coli lowing should be done: should be evaluated. Effective control and prevention of If a child or adult dies while at the facility: a) infectious diseases in child care depend on affirmative rela- 1) The caregiver/teacher(s) responsible for any tionships between parents, caregivers, health departments, children who observed or were in the same and primary care providers (1). room where the death occurred, should take COMMENTS: If there is more than one case of vomiting in the children to a different room, while other staff the facility, it may indicate either contagious illness or food tend to appropriate response/follow-up. Minimal poisoning. explanations should be provided until direction is received from the proper authorities. Supportive If a child with abdominal pain is drowsy, irritable, and and reassuring comments should be provided to unhappy, has no appetite, and is unwilling to participate children directly affected; in usual activities, the child should be seen by that child’s Designated staff should: 2) primary care provider. Abdominal pain may be associated i) Immediately notify emergency medical with viral, bacterial, or parasitic gastrointestinal tract illness, personnel; which is contagious, or with food poisoning. It also may be ii) Immediately notify the child’s parents/guardians a manifestation of another disease or illness such as kidney or adult’s emergency contact; disease. If the pain is severe or persistent, the child should iii) Notify the Licensing agency and law be referred for medical consultation (by telephone, if neces- enforcement the same day the death occurs; sary). Follow all law enforcement protocols regarding iv) If the caregiver/teacher is unable to contact the parent/ the scene of the death: guardian, medical advice should be sought until the parents a. Do not disturb the scene; can be located. b. Do not show the scene to others; The facility should post the health department’s list of infec- Reserve conversation about the event until c. tious diseases as a reference. The facility should inform having completed all interviews with law parents/guardians that the program is required to report enforcement. infectious diseases to the health department. Provide age-appropriate information for v) children, parents/guardians and staff; 146 Chapter 3: Health Promotion

177 Caring for Our Children: National Health and Safety Performance Standards 3. Moon, R. Y., L. Kotch, L. Aird. 2006. State child care regulations Make resources for support available to staff, vi) regarding infant sleep environment since the Healthy Child Care parents and children; America – Back to Sleep Campaign. Pediatrics 118:73-83. For a suspected Sudden Infant Death Syndrome b) 4. Boston Medical Center. Good grief program. http://www.bmc. (SIDS) death or other unexplained deaths: org/pediatrics-goodgrief.htm. Seek support and information from local, state, or 1) 5. Rivlin, D. The good grief program of Boston Medical Center: national SIDS resources; What do children need? Boston Medical Center. http://www. Provide SIDS information to the parents/guardians 2) wayland.k12.ma.us/claypit_hill/GoodGriefHandout.pdf. of the other children in the facility; 6. Trozzi, M. 1999. Talking with children about Loss: Words, 3) Provide age-appropriate information to the other strategies, and wisdom to help children cope with death, divorce, children in the facility; and other difficult times. New York: Berkley Publishing Group. 7. Knapp, J., D. Mulligan-Smith, Committee on Pediatric Emergency 4) Provide appropriate information for staff at the Medicine. 2005. Death of a child in the emergency department. facility; Pediatrics 115:1432-37. If a child or adult known to the children enrolled in the c) facility dies while not at the facility: 1) Provide age-appropriate information for children, parents/guardians and staff; Make resources for support available to staff, 2) parents and children. Facilities may release specific information about the circum- stances of the child or adult’s death that the authorities and the deceased member’s family agrees the facility may share. If the death is due to suspected child maltreatment, the caregiver/teacher is mandated to report this to child protec- tive services. Depending on the cause of death (SIDS, suffocation or other infant death, injury, maltreatment etc.), there may be a need for updated education on the subject for caregivers/teach- ers and/or children as well as implementation of improved health and safety practices. Following the steps described in this standard RATIONALE: would constitute prudent action (1-3). Accurate informa- tion 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 ne- glect. The licensing agency and/or a SIDS agency support group (e.g., CJ Foundation for SIDS at http://www.cjsids .org, the National Sudden and Unexpected Infant/Child Death and Pregnancy Loss Resource Center at http://www .sidscenter.org, and First Candle at http://www.firstcandle .org) can offer support and counseling to caregivers/teach- ers. Center; Large Family Child Care Home; Small TYPE OF FACILITY: Family Child Care Home RELATED STANDARDS: Standard 3.1.4.1: Safe Sleep Practices and SIDS/Suffocation Risk Reduction Standards 3.4.4.1-3.4.4.5: Child Abuse and Neglect REFERENCES: 1. Moon, R. Y., K. M. Patel, S. J. M. Shaefer. 2000. Sudden infant death syndrome in child care settings. 106:295-300. Pediatrics 2. Moon, R. Y., T. Calabrese, L. Aird. 2008. Reducing the risk of sudden infant death syndrome in child care and changing provider practices: Lessons learned from a demonstration project. Pediatrics 122:788-98. Chapter 3: Health Promotion 147

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181 Caring for Our Children: National Health and Safety Performance Standards proper handling of human milk and feeding of breastfed 4.1 Introduction infants. One of the basic responsibilities of every parent/guardian Mothers who formula feed can also establish healthy and caregiver/teacher is to provide nourishing food daily attachment. A mother may choose not to breastfeed her that is clean, safe, and developmentally appropriate for infant for reasons that may include: human milk is not children. Food is essential in any early care and education available, there is a real or perceived inadequate supply setting to keep infants and children free from hunger. of human milk, her infant fails to gain weight, there is Children also need freely available, clean drinking water. an existing medical condition for which human milk is Feeding should occur in a relaxed and pleasant environment contraindicated, or a mother desires not to breastfeed. that fosters healthy digestion and positive social behavior. Today there is a range of infant formulas on the market Food provides energy and nutrients needed by infants that vary in nutrient content and address specific needs of and children during the critical period of their growth and individual infants. A primary care provider should prescribe development. the specific infant formula to be used to meet the nutritional Feeding nutritious food everyday must be accompanied by requirements of an individual infant. When infant formula is offering appropriate daily physical activity and play time for used to supplement an infant being breastfed, the mother the healthy physical, social, and emotional development should be encouraged to continue to breastfeed or to pump of infants and young children. There is solid evidence that human milk since her milk supply will decrease if her milk physical activity can prevent a rapid gain in weight which production isn’t stimulated by breastfeeding or pumping. leads to childhood obesity early in life. The early care and Given adequate opportunity, assistance, and age- education setting is an ideal environment to foster the goal appropriate equipment, children learn to self-feed as age- of providing supervised, age-appropriate physical activity appropriate solid foods are introduced. Equally important during the critical years of growth when health habits and to self-feeding is children’s attainment of normal physical patterns are being developed for life. The overall benefits growth, motor coordination, and cognitive and social skills. of practicing healthy eating patterns, while being physically Modeling of healthy eating behavior by early care and active daily are significant. Physical, social, and emotional education staff helps a child to develop lifelong healthy habits are developed during the early years and continue eating habits. This period, beginning at six months of age, is into adulthood; thus these habits can be improved in early an opportune time for children to learn more about the world childhood to prevent and reduce obesity and a range of around them by expressing their independence. Children chronic diseases. Active play and supervised structured pick and choose from different kinds and combinations of physical activities promote healthy weight, improved foods offered. To ensure programs are offering a variety overall fitness, including mental health, improved bone of foods, selections should be made from these groups of development, cardiovascular health, and development of food: social skills. The physical activity standards outline the a) Grains – especially whole grains; blueprint for practical methods of achieving the goal of promoting healthy bodies and minds of young children. b) Vegetables – dark, green leafy and deep yellow; Breastfeeding sets the stage for an infant to establish c) Fruits – deep orange, yellow, and red whole fruits, healthy attachment. The American Academy of Pediatrics, 100% fruit juices limited to no more than four to six the United States Breastfeeding Committee, the Academy ounces per day for children one year of age and over; of Breastfeeding Medicine, the American Academy of d) Milk – whole milk, or reduced fat (2%) milk for chil- Family Physicians, the World Health Organization, and the dren at risk for obesity or hypercholesterolemia, for United Nations Children’s Fund (UNICEF) all recommend children from one year of age up to two years of age; that women should breastfeed exclusively for about the first skim or 1% for children two years or older, unsweet- six months of the infant’s life, adding age-appropriate solid ened low-fat yogurt or low-fat cheese (e.g. cottage, foods (complementary foods) and continuing breastfeeding farmer’s); for at least the first year if not longer. Meats and Beans – baked or broiled chicken, fish, e) Human milk, containing all the nutrients to promote optimal lean meats, dried peas and beans; and growth, is the most developmentally appropriate food f) Oils – vegetable. for infants. It changes during the course of each feeding and over time to meet the growing child’s changing Current research supports a diet based on a variety of nutritional needs. All caregivers/teachers should be trained nutrient dense foods which provide substantial amounts to encourage, support, and advocate for breastfeeding. of essential nutrients – protein, carbohydrates, oils, and Caregivers/teachers have a unique opportunity to support vitamins and minerals – with appropriate calories to meet breastfeeding mothers, who are often daunted by the the child’s needs. For children, the availability of a variety prospect of continuing to breastfeed as they return to of clean, safe, nourishing foods is essential during a period work. Early care and education programs can reduce a of rapid growth and development. The nutrition and food breastfeeding mother’s anxiety by welcoming breastfeeding service standards, along with related appendices, address families and providing a staff that is well-trained in the age-appropriate foods and feeding techniques beginning Chapter 4: Nutrition and Food Service 151

182 Caring for Our Children: National Health and Safety Performance Standards 7. Dalton, S. 2004. Our overweight children: What parents, schools, with the very first food, preferably human milk and when and communities can do to control the fatness epidemic. Berkeley, not possible, infant formula based on the recommendation CA: University of California Press. of the infant’s primary care provider and family. As part of their developing growth and maturity, toddlers often exhibit changed eating habits compared to when they were infants. 4.2 General Requirements One may indulge in eating sprees, wanting to eat the same food for several days. Another may become a picky eater, STANDARD 4.2.0.1: Written Nutrition Plan picking or dawdling over food, or refusing to eat a certain The facility should provide nourishing and attractive food food because it is new and unfamiliar with a new taste, col- for children according to a written plan developed by a or, odor, or texture. If these or other food behaviors persist, qualified nutritionist/registered dietitian. Caregivers/teach- parents/guardians, caregivers/teachers, and the primary ers, directors, and food service personnel should share the care provider together should determine the reason(s) and responsibility for carrying out the plan. The administrator come up with a plan to address the issue. The consistency is responsible for implementing the plan but may delegate - of the plan is important in helping a child to build sound eat tasks to caregivers/teachers and food service personnel. ing habits during a time when they are focused on develop- Where infants and young children are involved, special at- ing as an individual and often have erratic, unpredictable tention to the feeding plan may include attention to sup- appetites. Family homes and center-based out-of-home porting mothers in maintaining their human milk supply. The early care and education settings have the opportunity to nutrition plan should include steps to take when problems guide and support children’s sound eating habits and food require rapid response by the staff, such as when a child learning experiences (1-3). chokes during mealtime or has an allergic reaction to a food. Early food and eating experiences form the foundation of The completed plan should be on file, easily accessible to attitudes about food, eating behavior, and consequently, staff, and available to parents/guardians upon request. food habits. Responsive feeding, where the parents/guard- If the facility is large enough to justify employment of a ians or caregivers/teachers recognize and respond to infant full-time nutritionist/registered dietitian or child care food and child cues, helps foster trust and reduces overfeeding. service manager, the facility should delegate to this person Sound food habits are built on eating and enjoying a variety the responsibility for implementing the written plan. of healthful foods. Including culturally specific family foods is a dietary goal for feeding infants and young children. Some children may have medical conditions that require Current research documents that a balanced diet, combined special dietary modifications. A written care plan from with daily and routine age-appropriate physical activity, can the primary care provider, clearly stating the food(s) to be reduce diet-related risks of overweight, obesity, and chronic avoided and food(s) to be substituted should be on file. This disease later in life (1). Two essentials – eating healthy foods information should be updated periodically if the modifica - and engaging in physical activity on a daily basis – promote tion is not a lifetime special dietary need. Staff should be a healthy beginning during the early years and throughout trained about a child’s dietary modification to ensure that no and the 2010 Dietary Guidelines for Americans the life span. child in care ingests inappropriate foods while at the facility. U.S. Department of Agriculture’s ChooseMyPlate.gov are The proper modifications should be implemented whether designed to support lifestyle behaviors that promote health, the child brings their own food or whether it is prepared on including a diet composed of a variety of healthy foods and site. The facility needs to inform all families and staff if cer - physical activity at two years of age and older (1-2,4-7). tain foods, such as nut products (example: peanut butter), TYPE OF FACILITY: Center; Large Family Child Care Home; Small should not be brought from home because of a child’s life- Family Child Care Home threatening allergy. Staff should also know what procedure to follow if ingestion occurs. In addition to knowing ahead REFERENCES: of time what procedures to follow, staff must know their 1. U.S. Department of Health and Human Services, U.S. designated roles during an emergency. The emergency plan Department of Agriculture. 2010. Dietary guidelines for Americans, . 7th ed. Washington, DC: U.S. Government Printing 2010 should be dated and updated. Office. http://www.health.gov/dietaryguidelines/dga2010/ RATIONALE: Nourishing and attractive food is the corner - DietaryGuidelines2010.pdf stone for children’s health, growth, and development as well 2. U.S. Department of Agriculture. 2011. MyPlate . http://www as developmentally appropriate learning experiences (1-9). .choosemyplate.gov. Nutrition and feeding are fundamental and required in every 3. Zero to Three. 2007. Healthy from the start—How feeding nurtures your young child’s body, heart, and mind . Washington, DC: facility. Because children grow and develop more rapidly Zero to Three. during the first few years of life than at any other time, the 4. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and child’s home and the facility together must provide food that childhood . 6th ed. New York: McGraw-Hill. is adequate in amount and type to meet each child’s growth 5. Marotz, L. R. 2008. Health, safety, and nutrition for the young and nutritional needs. Children can learn healthy eating hab- . 7th ed. Clifton Park, NY: Delmar Learning. child its and be better equipped to maintain a healthy weight if Working with young children 6. Herr, J. 2008. . 4th ed. Tinley Park, they eat nourishing food while attending early care and edu- IL: Goodheart-Willcox Company. cation settings and if they are allowed to feed themselves and determine the amount of food they will ingest at any Chapter 4: Nutrition and Food Service 152

183 Caring for Our Children: National Health and Safety Performance Standards one sitting. The obesity epidemic makes this an important STANDARD 4.2.0.2: Assessment and Planning lesson today. of Nutrition for Individual Children Meals and snacks provide the caregiver/teacher an opportu- As a part of routine health supervision by the child’s primary nity to model appropriate mealtime behavior and guide the care provider, children should be evaluated for nutrition-re- conversation, which aids in children’s conceptual, sensory lated medical problems such as failure to thrive, overweight, language development, and eye/hand coordination. In larger obesity, food allergy, reflux disease, and iron-deficiency facilities, professional nutrition staff must be involved to as- anemia. The nutritional standards throughout this document sure compliance with nutrition and food service guidelines, are general recommendations that may not always be ap- including accommodation of children with special health propriate for some children with medically-identified special care needs. nutrition needs. Caregivers/teachers should communicate with the child’s parent/guardian and primary care provider to Making Food Healthy and Safe for Children, COMMENTS: adapt nutritional offerings to individual children as indicated 2nd Ed . (http://nti.unc.edu/course_files/curriculum/nutrition/ and medically-appropriate. Caregivers/teachers should work making_food_healthy_and_safe.pdf) contains practical tips with the parent/guardian to implement individualized feed- for implementing the standards for culturally diverse groups ing plans developed by the child’s primary care provider to of infants and children. meet a child’s unique nutritional needs. These plans could Center; Large Family Child Care Home; Small TYPE OF FACILITY: include, for instance, additional iron-rich foods to a child Family Child Care Home who has been diagnosed as having iron-deficiency anemia. RELATED STANDARDS: For a child diagnosed as overweight, the plan would focus Standard 4.2.0.2: Assessment and Planning of Nutrition for Indi- on controlling portion sizes. Also, calorie dense foods like vidual Children sugar sweetened juices, nectars, and beverages should not Standard 4.2.0.8: Feeding Plans and Dietary Modifications be served. Denying a child food that others are eating is dif- Standard 4.4.0.2: Use of Nutritionist/Registered Dietitian ficult to explain and difficult for some children to understand Standard 4.7.0.1: Nutrition Learning Experiences for Children and accept. Attention should be paid to teaching about Standard 9.2.3.11: Food and Nutrition Service Policies and Plans proper portion sizes and the average daily caloric intake of Appendix C: Nutrition Specialist, Registered Dietitian, Licensed Nutritionist, Consultant, and Food Service Staff Qualifications the child. REFERENCES: Some children require special feeding techniques such as 1. U.S. Department of Health and Human Services, Administration thickened foods or special positioning during meals. Other for Children and Families, Office of Head Start. 2009. Head Start children will require dietary modifications based on food . Rev. ed. Washington, DC: U.S. program performance standards intolerances such as lactose or wheat (gluten) intolerance. Government Printing Office. http://eclkc.ohs.acf.hhs.gov/hslc/ Some children will need dietary modifications based on cul- Head Start Program/Program Design and Management/Head Start tural or religious preferences such as vegetarian or kosher Requirements/Head Start Requirements/45 CFR Chapter XIII/45 diets. CFR Chap XIII_ENG.pdf. Bright 2. Hagan, Jr., J. F., J. S. Shaw, P. M. Duncan, eds. 2008. RATIONALE: The early years are a critical time for children’s futures: Guidelines for health supervision of infants, children, and growth and development. Nutritional problems must be . 3rd ed. Elk Grove Village, IL: American Academy of adolescents identified and treated during this period in order to prevent Pediatrics. serious or long-term medical problems. The early care and Bright futures in practice: 3. Story, M., K. Holt, D. Sofka, eds. 2002. education setting may be offering a majority of a child’s daily . 2nd ed. Arlington, VA: National Center for Education in Nutrition nutritional intake especially for children in full-time care. It Maternal and Child Health. http://www.brightfutures.org/nutrition/ is important that the facility ensures that food offerings are pdf/frnt_mttr.pdf. 4. Wardle, F., N. Winegarner. 1992. Nutrition and Head Start. Child congruent with nutritional interventions or dietary modifica - 21:57. Today tions recommended by the child’s primary care provider in Making food healthy and safe for 5. Benjamin, S. E., ed. 2007. consultation with the nutritionist/registered dietitian to make children: How to meet the national health and safety performance certain that intervention is child specific. standards – Guidelines for out of home child care programs . 2nd Center; Large Family Child Care Home; Small TYPE OF FACILITY: ed. Chapel Hill, NC: National Training Institute for Child Care Health Family Child Care Home Consultants. http://nti.unc.edu/course_files/curriculum/nutrition/ making_food_healthy_and_safe.pdf. RELATED STANDARDS: 6. Dietz, W. H., L. Stern, eds. 1998. American Academy of Standard 3.1.2.1: Routine Health Supervision and Growth Monitoring . New York: Villard. Pediatrics guide to your child’s nutrition Standard 4.2.0.8: Feeding Plans and Dietary Modifications . 6th ed. 7. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook Elk Grove Village, IL: American Academy of Pediatrics. STANDARD 4.2.0.3: Use of USDA - CACFP 8. Lally, J. R., A. Griffin, E. Fenichel, M. Segal, E. Szanton, B. Guidelines Caring for infants and toddlers in groups: Weissbourd. 2003. Developmentally appropriate practice . Arlington, VA: Zero to Three. All meals and snacks and their preparation, service, and 9. Enders, J. B., R. E. Rockwell. 2003. Food, nutrition, and the storage should meet the requirements for meals of the young child . 4th ed. New York: Macmillan. child care component of the U.S. Department of Agriculture Chapter 4: Nutrition and Food Service 153

184 Caring for Our Children: National Health and Safety Performance Standards (USDA), Child and Adult Care Food Program (CACFP), and the 7 Code of Federal Regulations (CFR) Part 226.20 (1,5). RATIONALE: The CACFP regulations, policies, and guid- ance materials on meal requirements provide the basic guidelines for sound nutrition and sanitation practices. Meals and snacks offered to young children should provide a variety of nourishing foods on a frequent basis to meet the nutritional needs of infants from birth to children age twelve (2-4). The CACFP guidance for meals and snack patterns ensures that the nutritional needs of infants and children, including school-age children up through age twelve, are met based on current scientific knowledge (5). Programs not eligible for reimbursement under the regulations of CACFP should use the CACFP food guidance. COMMENTS: The staff should use information on the child’s growth in developing individual feeding plans. For the current CACFP meal patterns, go to http://www.fns.usda. gov/cnd/care/ProgramBasics/Meals/Meal_Pattern.htm. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home RELATED STANDARDS: - Standard 3.1.2.1: Routine Health Supervision and Growth Monitor ing Standard 4.2.0.4: Categories of Foods Standard 4.2.0.5: Meal and Snack Patterns Standard 4.3.2.1: Meal and Snack Patterns for Toddlers and Pre- schoolers Standard 4.3.3.1: Meal and Snack Patterns for School-Age Children REFERENCES: 1. Lally, J. R., A. Griffin, E. Fenichel, M. Segal, E. Szanton, B. Caring for infants and toddlers in groups: Weissbourd. 2003. . Arlington, VA: Zero to Three. Developmentally appropriate practice 2. U.S. Department of Agriculture (USDA), Child and Adult Care Food Program (CACFP). 2002. Menu magic for children: A menu planning guide for child care . Washington, DC: USDA. http://www .fns.usda.gov/tn/resources/menu_magic.pdf. 3. U.S. Department of Agriculture (USDA), Team Nutrition. 2000. Building blocks for fun and healthy meals: A menu planner for the child and adult care food program . Washington, DC: USDA. http:// teamnutrition.usda.gov/Resources/buildingblocks.html. 4. U.S. Department of Agriculture, Team Nutrition. 2010. Child care providers: Healthy meals resource system. http://healthymeals.nal .usda.gov/nal_display/index.php?tax_level=1&info_center=14&tax _subject=264/. 5. U.S. Department of Agriculture, Food and Nutrition Service. 2011. Child and Adult Care Food Program (CACFP). http://www.fns .usda.gov/cnd/care/. 154 Chapter 4: Nutrition and Food Service

185 Caring for Our Children: National Health and Safety Performance Standards STANDARD 4.2.0.4: Categories of Foods Children in care should be offered items of food from the following categories: Making Healthy Food Choices* † USDA Food CFOC Guidelines for Young Children Groups Eat a variety, especially whole fruits • All fresh, frozen, canned, Fruits • dried fruits, and fruit Whole fruit, mashed or pureed, for infants seven months up to one year of age • juices No juice before twelve months of age 4 to 6 oz juice /day for one- to six-year-olds • 8 to 12 oz juice/day for seven- to twelve-year-olds • Vegetables Dark green, red, and • Dark green, red, orange, deep yellow vegetables Other vegetables, including starchy ones like potatoes orange; beans and • • peas (legumes); starchy Other root vegetables, such as viandas Dried peas and beans (legumes) vegetables; other veg- • etables Whole grains and en- Grains Whole and enriched grains, breads, cereals, crackers, pasta, and rice • riched grains Seafood, meat, poultry, Protein • Fish, chicken, lean meat, eggs • eggs, nuts, seeds, and Nuts and seeds (if appropriate) Foods soy products • Avoid fried fish, meat, and chicken Dairy Milk • Human milk, infant formula for infants at least up to one year of age • Whole milk for children ages on up to two years of age or reduced fat (2%) milk for those at risk for obesity or hypercholesterolemia • 1% or skim milk for children two years of age and older • Other milks such as soy when recommended Other milk equivalent products such as yogurt and cottage cheese (low-fat for • children two years of age and older) • Oils Oils, soft margarines, Choose monounsaturated and polyunsaturated fats (olive oil, safflower oil) • Soft margarines includes vegetable, nut, and fish oils and • Avoid trans fats, saturated fats and fried foods soft vegetable oil table spreads that have no trans fats Solid Fats Limit calories (% of • Avoid concentrated sweets such as candy, sodas, sweetened drinks, fruit nectars, and Added calories) of these food and flavored milk groups • Limit salty foods such as chips and pretzels Sugar *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 Dietary Guidelines for Americans, 2010 . † Recommends: Find your balance between food and physical activity. . http://www Additional Resources: • U.S. Department of Agriculture. 2011. MyPlate U.S. Department of Health and Human Services (DHHS). • .choosemyplate.gov. 2010. The Surgeon General’s vision for a healthy and fit The RATIONALE: Dietary Guidelines for Americans, 2010 nation . Washington, DC: DHHS, Office of the Surgeon and “The Surgeon General’s Call to Action to Support General. http://www.surgeongeneral.gov/library/ Breast Feeding” support feeding nutritious foods and obesityvision/obesityvision2010.pdf. healthy lifestyles to prevent the onset of overweight and U.S. Department of Health and Human Services, U.S. • Dietary guidelines for Department of Agriculture. 2011. obesity and chronic diseases (1,2). From the very first feed- Americans, 2010 . 7th ed. Washington, DC: U.S. Government ing of an infant begins setting the stage for lifetime eating Printing Office. http://www.health.gov/dietaryguidelines/ behavior. Using the food groups as a tool is a practical dga2010/DietaryGuidelines2010.pdf. approach to select foods high in essential nutrients and U.S. Department of Health and Human Services, Office of • moderate in calories/energy. Meals and snacks planned Disease Prevention and Health Promotion (ODPHP). 2008. based on the five food groups promote normal growth . Rockville, 2008 physical activity guidelines for Americans and development of children as well as reduce their risk of MD: ODPHP. http://www.health.gov/paguidelines/guidelines/ overweight, obesity and related chronic diseases later in life. default.aspx. Age-specific guidance for meals and snacks is outlined in • Story, M., K. Holt, D. Sofka, eds. 2002. Bright futures in CACFP guidelines and accessible at http://www.fns.usda. . 2nd ed. Arlington, VA: National Center for practice: Nutrition Education in Maternal and Child Health. http://www gov/cnd/care/ProgramBasics/Meals/Meal_Pattern.htm (3). .brightfutures.org/nutrition/pdf/frnt_mttr.pdf. Early care and education settings provide the opportunity Chapter 4: Nutrition and Food Service 155

186 Caring for Our Children: National Health and Safety Performance Standards d) Children should be offered food at intervals at least for children to learn about the food they eat, to develop and two hours apart and not more than three hours apart strengthen their fine and gross motor skills, and to engage unless the child is asleep. Some very young infants in social interaction at mealtimes (4). may need to be fed at shorter intervals than every COMMENTS: Early Care and education settings should two hours to meet their nutritional needs, especially encourage mothers to breastfeed their infants. Scientific breastfed infants being fed expressed human milk. evidence documents and supports the nutritional and health Lunch service may need to be served to toddlers contributions of human milk (2). For more information on earlier than the preschool-aged children due to their portion sizes and types of food, see CACFP Guidelines at need for an earlier nap schedule. Children must be http://www.fns.usda.gov/cnd/care/ProgramBasics/Meals/ awake prior to being offered a meal/snack. Meal_Pattern.htm. Children should be allowed time to eat their food and e) TYPE OF FACILITY: Center; Large Family Child Care Home; Small not be rushed during the meal or snack service. They Family Child Care Home should not be allowed to play during these times. RELATED STANDARDS: f) Caregivers/teachers should discuss the breastfed Standard 4.2.0.5: Meal and Snack Patterns infant’s feeding patterns with the parents/guardians Standard 4.2.0.7: 100% Fruit Juice because the frequency of breastfeeding at home can Standard 4.2.0.8: Feeding Plans and Dietary Modifications vary. For example, some infants may still be feeding Standard 4.3.1.3: Preparing, Feeding, and Storing Human Milk frequently at night, while others may do the bulk of Standard 4.3.1.5: Preparing, Feeding, and Storing Infant Formula their feeding during the day. Knowledge about the Standard 4.3.1.7: Feeding Cow’s Milk infant’s feeding patterns over twenty-four hours will Standard 4.3.2.1: Meal and Snack Patterns for Toddlers and Pre- help caregivers/teachers assess the infant’s feeding schoolers during his/her time with the caregiver/teacher. Standard 4.3.3.1: Meal and Snack Patterns for School-Age Children Standard 4.7.0.1: Nutritional Learning Experiences for Children RATIONALE: Young children, under the age of six, need to Standard 4.7.0.2: Nutrition Education for Parents/Guardians be offered food every two to three hours. Appetite and inter - Appendix Q: Getting Started with MyPlate est in food varies from one meal or snack to the next. To Appendix R: Choose MyPlate: 10 Tips to a Great Plate ensure that the child’s daily nutritional needs are met, small REFERENCES: feedings of nourishing food should be scheduled over the 1. U.S. Department of Health and Human Services, U.S. course of a day (1-6). Snacks should be nutritious, as they Department of Agriculture. 2011. Dietary guidelines for Americans, often are a significant part of a child’s daily intake. Chil- 2010 . 7th ed. Washington, DC: U.S. Government Printing dren in care for more than eight hours need additional food Office. http://www.health.gov/dietaryguidelines/dga2010/ because this period represents a majority of a young child’s DietaryGuidelines2010.pdf. waking hours. 2. U.S. Department of Health and Human Services (HHS). The Surgeon General’s call to action to support 2011. Caloric needs vary greatly from one child COMMENTS: breastfeeding . Washington, DC: HHS, Office of the Surgeon to another. A child may require more food during growth General. http://www.surgeongeneral.gov/topics/breastfeeding/ spurts. Some states have regulations indicating suggested calltoactiontosupportbreastfeeding.pdf. times for meals and snacks. By regulation, in the Child and 3. U.S. Department of Agriculture, Food and Nutrition Service. Adult Care Food Program (CACFP), centers and family child 2011. Child and adult care food program (CACFP). http://www.fns care homes may be approved to claim up to two reimburs- .usda.gov/cnd/care/. able meals (breakfast, lunch or supper) and one snack, or Best practices 4. Nemours Health and Prevention Services. 2008. for healthy eating: A guide to help children grow up healthy . Version two snacks and one meal, for each eligible participant, each 2. Newark, DE: Nemours Foundation. http://www.nemours.org/ day. Many after-school programs provide before school content/dam/nemours/www/filebox/service/preventive/nhps/ care or full day care when elementary school is out of ses- heguide.pdf. sion. Many of these programs offer either a breakfast and/ or a morning snack. After-school care programs may claim STANDARD 4.2.0.5: Meal and Snack Patterns reimbursement for serving each child one snack, each day. In some states after-school programs also have the option The facility should ensure that the following meal and snack of providing a supper. These are reimbursed by CACFP pattern occurs: if they meet certain guidelines and timeframes. For more Children in care for eight and fewer hours in one day a) information on CACFP meal reimbursement see the CACFP should be offered at least one meal and two snacks Website at http://www.fns.usda.gov/cnd/care/CACFP/ or two meals and one snack. aboutcacfp.htm. Children in care more than eight hours in one day b) should be offered at least two meals and two snacks Center; Large Family Child Care Home; Small TYPE OF FACILITY: or three snacks and one meal. Family Child Care Home A nutritious snack should be offered to all children in c) RELATED STANDARDS: midmorning (if they are not offered a breakfast on-site Standard 4.3.2.1: Meal and Snack Patterns for Toddlers and Pre- that is provided within three hours of lunch) and in the schoolers middle of the afternoon. Standard 4.3.3.1: Meal and Snack Patterns for School-Age Children 156 Chapter 4: Nutrition and Food Service

187 Caring for Our Children: National Health and Safety Performance Standards REFERENCES: are thirsty. Drinking fountains should be kept clean and sani- 1. U.S. Department of Health and Human Services, Administration tary and maintained to provide adequate drainage. for Children and Families, Office of Head Start. 2009. Head Start TYPE OF FACILITY: Center; Large Family Child Care Home; Small program performance standards . Rev. ed. Washington, DC: U.S. Family Child Care Home Government Printing Office. http://eclkc.ohs.acf.hhs.gov/hslc/ Head Start Program/Program Design and Management/Head Start RELATED STANDARDS: Requirements/Head Start Requirements/45 CFR Chapter XIII/45 Standard 3.1.3.2: Playing Outdoors CFR Chap XIII_ENG.pdf. Standard 4.3.1.3: Preparing, Feeding, and Storing Human Milk Making food healthy and safe for 2. Benjamin, S. E., ed. 2007. Standard 4.3.1.5: Preparing, Feeding, and Storing Infant Formula children: How to meet the national health and safety performance REFERENCES: . 2nd standards – Guidelines for out of home child care programs . 6th ed. Pediatric nutrition handbook 1. Kleinman, R. E., ed. 2009. ed. Chapel Hill, NC: National Training Institute for Child Care Health Elk Grove Village, IL: American Academy of Pediatrics. Consultants. http://nti.unc.edu/course_files/curriculum/nutrition/ 2. Manz, F. 2007. Hydration in children. J Am Coll Nutr making_food_healthy_and_safe.pdf. 26:562S-569S. Nutrition in infancy and 3. Pipes, P. L., C. M. Trahms, eds. 1997. Bright futures in practice: 3. Casamassimo, P., K. Holt, eds. 2004. . 6th ed. New York: McGraw-Hill. childhood Oral health–pocket guide . Washington, DC: National Maternal and 4. Butte, N., S. K. Cobb. 2004. The Start Healthy feeding guidelines Child Oral Health Resource Center. http://www.mchoralhealth.org/ J Am Diet Assoc for infants and children. 104:442-54. PDFs/BFOHPocketGuide.pdf. 5. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook . 6th ed. 4. Centers for Disease Control and Prevention. 2011. Community Elk Grove Village, IL: American Academy of Pediatrics. water fluoridation. http://www.cdc.gov/fluoridation/. 6. Plemas, C., B. M. Popkin. 2010. Trends in snacking among U.S. children. Health Affairs 29:399-404. STANDARD 4.2.0.7: 100% Fruit Juice STANDARD 4.2.0.6: Availability of Drinking - The facility should serve only full-strength (100%) pasteur ized fruit juice or full-strength fruit juice diluted with water Water from a cup to children twelve months of age or older. Juice Clean, sanitary drinking water should be readily available, in should have no added sweeteners. The facility should offer indoor and outdoor areas, throughout the day. Water should juice at specific meals and snacks instead of continuously not be a substitute for milk at meals or snacks where milk is throughout the day. Juice consumption should be no more a required food component unless it is recommended by the than a total of four to six ounces a day for children aged one child’s primary care provider. to six years. This amount includes juice served at home. On hot days, infants receiving human milk in a bottle can be Children ages seven through twelve years of age should given additional human milk in a bottle but should not be consume no more than a total of eight to twelve ounces of given water, especially in the first six months of life. Infants fruit juice per day. Caregivers/teachers should ask parents/ receiving formula and water can be given additional formula guardians if they provide juice at home and how much. This in a bottle. Toddlers and older children will need additional information is important to know if and when to serve juice. water as physical activity and/or hot temperatures cause Infants should not be given any fruit juice before twelve their needs to increase. Children should learn to drink water months of age. Whole fruit, mashed or pureed, is recom- from a cup or drinking fountain without mouthing the fixture. mended for infants seven months up to one year of age. They should not be allowed to have water continuously in Whole fruit is more nutritious than fruit juice RATIONALE: hand in a “sippy cup” or bottle. Permitting toddlers to suck and provides dietary fiber. Fruit juice which is 100% offers continuously on a bottle or sippy cup filled with water, in no nutritional advantage over whole fruits. order to soothe themselves, may cause nutritional or in rare Limiting the feeding of juice to specific meals and snacks instances, electrolyte imbalances. When tooth brushing is will reduce acids produced by bacteria in the mouth that not done after a feeding, children should be offered water to cause tooth decay. The frequency of exposure, rather than drink to rinse food from their teeth. the quantity of food, is important in determining whether RATIONALE: When children are thirsty between meals foods cause tooth decay. Although sugar is not the only and snacks, water is the best choice. Encouraging children dietary factor likely to cause tooth decay, it is a major factor to learn to drink water in place of fruit drinks, soda, fruit in the prevalence of tooth decay (1,2). nectars, or other sweetened drinks builds a beneficial habit. Drinks that are called fruit juice drinks, fruit punches, or fruit Drinking water during the day can reduce the extra caloric nectars contain less than 100% fruit juice and are of a lower intake which is associated with overweight and obesity (1). nutritional value than 100% fruit juice. Liquids with high Drinking water is good for a child’s hydration and reduces sugar content have no place in a healthy diet and should be acid in the mouth that contributes to early childhood car - avoided. Continuous consumption of juice during the day ies (1,3,4). Water needs vary among young children and has been associated with a decrease in appetite for other increase during times in which dehydration is a risk (e.g., hot nutritious foods which can result in feeding problems and summer days, during exercise, and in dry days in winter) (2). overweight/obesity. Infants should not be given juice from Clean, small pitchers of water and single-use COMMENTS: bottles or easily transportable, covered cups (e.g., sippy paper cups available in the classrooms and on the play- cups) that allow them to consume juice throughout the day. grounds allow children to serve themselves water when they Chapter 4: Nutrition and Food Service 157

188 Caring for Our Children: National Health and Safety Performance Standards The American Academy of Pediatrics (AAP) recommends STANDARD 4.2.0.8: Feeding Plans and Dietary that children aged one to six years drink no more than four Modifications to six ounces of fruit juice a day (3). This amount is the total Before a child enters an early care and education facility, quantity for the whole day, including both time at early care the facility should obtain a written history that contains any and education and at home. Caregivers/teachers should special nutrition or feeding needs for the child, including not give the entire amount while a child is in their care. For use of human milk or any special feeding utensils. The staff breastfed infants, AAP recommends that gradual introduc- should review this history with the child’s parents/guardians, tion of iron-fortified foods may occur no sooner than around clarifying and discussing how parental/guardian home feed- four months, but preferably six months to complement the ing routines may differ from the facility’s planned routine. human milk. Infants should not be given juice before they The child’s primary care provider should provide written in- reach twelve months of age. formation about any dietary modifications or special feeding Overconsumption of 100% fruit juice can contribute to techniques that are required at the early care and education overweight and obesity (3-6). One study found that two- to program and these plans should be shared with the child’s five-year-old children who drank twelve or more ounces of parents/guardians upon request. fruit juice a day were more likely to be obese than those If dietary modifications are indicated, based on a child’s who drank less juice (2). Excessive fruit juice consumption medical or special dietary needs, the caregiver/teacher may be associated with malnutrition (over nutrition and should modify or supplement the child’s diet to meet the in- under nutrition), diarrhea, flatulence, and abdominal disten - dividual child’s specific needs. Dietary modifications should tion (3). Unpasteurized fruit juice may contain pathogens be made in consultation with the parents/guardians and that can cause serious illnesses (3). The U.S. Food and Drug the child’s primary care provider. Caregivers/teachers can Administration requires a warning on the dangers of harmful consult with a nutritionist/registered dietitian. bacteria on all unpasteurized juice or products (7). Reasons for modification of a child’s diet may be related to Caregivers/teachers, as well as many par - COMMENTS: food sensitivity. Food sensitivity includes a range of condi- ents/guardians, should strive to understand the relation- tions in which a child exhibits an adverse reaction to a food ship between the consumption of sweetened beverages that, in some instances, can be life threatening. Modification and tooth decay. Drinks with high sugar content should be of a child’s diet may be related to a food allergy, inability to avoided because they can contribute to childhood obesity digest or to tolerate certain foods, need for extra calories, (2,5,6), tooth decay, and poor nutrition. need for special positioning while eating, diabetes and the Center; Large Family Child Care Home; Small TYPE OF FACILITY: need to match food with insulin, food idiosyncrasies, and Family Child Care Home other identified feeding issues. Examples include celiac RELATED STANDARDS: disease, phenylketonuria, diabetes, severe food allergy (ana- Standard 4.2.0.4: Categories of Food phylaxis), and others. In some cases, a child may become ill if the child is unable to eat, so missing a meal could have a REFERENCES: Bright futures in practice: 1. Casamassimo, P., K. Holt, eds. 2004. negative consequence, especially for diabetics. Oral health–pocket guide . Washington, DC: National Maternal and For a child identified with special health care needs for Child Oral Health Resource Center. http://www.mchoralhealth.org/ dietary modification or special feeding techniques, written PDFs/BFOHPocketGuide.pdf. instructions from the child’s parent/guardian and the child’s 2. Dennison, B. A., H. L. Rockwell, S. L. Baker. 1997. Excess fruit primary care provider should be provided in the child’s juice consumption by preschool-aged children is associated with record and carried out accordingly. Dietary modifications 99:15-22. Pediatrics short stature and obesity. 3. American Academy of Pediatrics, Committee on Nutrition. 2007. should be recorded. These written instructions must identify: Policy statement: The use and misuse of fruit juice in pediatrics. a) The child’s full name and date of instructions; 119:405. Pediatrics The child’s special needs; b) 4. Faith, M. S., B. A. Dennison, L. S. Edmunds, H. H. Stratton. 2006. Any dietary restrictions based on the special needs; c) Fruit juice intake predicts increased adiposity gain in children from Any special feeding or eating utensils; d) low-income families: Weight status-by-environment interaction. Any foods to be omitted from the diet and any foods e) Pediatrics 118:2066-75. to be substituted; 5. Dubois, L., A. Farmer, M. Girard, K. Peterson. 2007. Regular f) Limitations of life activities; sugar-sweetened beverage consumption between meals increases g) Any other pertinent special needs information; risk of overweight among preschool-aged children. J Am Diet Assoc What, if anything, needs to be done if the child is h) 107:924-34. 6. Dennison, B. A., H. L. Rockwell, M. J. Nichols, P. Jenkins. 1999. exposed to restricted foods. Children’s growth parameters vary by type of fruit juice consumed. The written history of special nutrition or feeding needs J Am Coll Nutr 18:346-52. should be used to develop individual feeding plans and, Safe handling of raw 7. U.S. Food and Drug Administration. collectively, to develop facility menus. Disciplines related to . New York: produce and fresh-squeezed fruit and vegetable juices special nutrition needs, including nutrition, nursing, speech, JMH Education. http://www.fda.gov/Food/ResourcesForYou/ Consumers/ucm114299.htm. occupational therapy, and physical therapy, should partici- pate when needed and/or when they are available to the Chapter 4: Nutrition and Food Service 158

189 Caring for Our Children: National Health and Safety Performance Standards RELATED STANDARDS: facility. The nutritionist/registered dietitian should approve Standard 4.2.0.2: Assessment and Planning of Nutrition for Indi- menus that accommodate needed dietary modifications. vidual Children The feeding plan should include steps to take when a situ- REFERENCES: ation arises that requires rapid response by the staff, such 1. Samour, P. Q., K. King. 2005. Handbook of pediatric nutrition . 3rd as a child’s choking during mealtime or a child with a known ed. Lake Dallas, TX: Helm. history of food allergies demonstrating signs and symp- American Academy of 2. Dietz, W. H., L. Stern, eds. 1998. toms of anaphylaxis (severe allergic reaction, e.g., difficulty . New York: Villard. Pediatrics guide to your child’s nutrition breathing or severe redness and swelling of the face or 3. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook . 6th ed. mouth). The completed plan should be on file and acces- Elk Grove Village, IL: American Academy of Pediatrics. sible to the staff and available to parents/guardians upon 4. Lally, J. R., A. Griffin, E. Fenichel, M. Segal, E. Szanton, B. Weissbourd. 2003. Caring for infants and toddlers in groups: request. Developmentally appropriate practice . Arlington, VA: Zero to Three. RATIONALE: Children with special health care needs may have individual requirements related to diet and swallow- STANDARD 4.2.0.9: Written Menus and ing, involving special feeding utensils and feeding needs Introduction of New Foods that will necessitate the development of an individual plan prior to their entry into the facility (1-3). A number of children Facilities should develop, at least one month in advance, with special health care needs have difficulty with feeding, written menus showing all foods to be served during that including delayed attainment of basic chewing, swallow- month and should make the menus available to parents/ ing, and independent feeding skills. Food, eating style, food guardians. The facility should date and retain these menus utensils, and equipment, including furniture, may have to be for six months, unless the state regulatory agency requires adapted to meet the developmental and physical needs of a longer retention time. The menus should be amended to individual children (1-3). reflect any and all changes in the food actually served. Any substitutions should be of equal nutrient value. Some children have difficulty with slow weight gain and need their caloric intake monitored and supplemented. To avoid problems of food sensitivity in very young children Others with special needs, such as those with diabetes, under eighteen months of age, caregivers/teachers should may need to have their diet matched to their medication obtain from the child’s parents/guardians a list of foods that (insulin if they are on a fixed dose of insulin). Some children have already been introduced (without any reaction), and are unable to tolerate certain foods because of their allergy then serve some of these foods to the child. As new foods to the food or their inability to digest it. In children, foods are considered for serving, caregivers/teachers should share are the most common cause of anaphylaxis. Nuts, seeds, and discuss these foods with the parents/guardians prior to eggs, soy, milk, and seafood are among the most common their introduction. allergens for food-induced anaphylaxis in children (3). Staff Planning menus in advance helps to ensure RATIONALE: members must know ahead of time what procedures to fol- that food will be on hand. Parents/guardians need to be low, as well as their designated roles during an emergency. informed about food served in the facility to know how to As a safety and health precaution, the staff should know in complement it with the food they serve at home. If a child advance whether a child has food allergies, inborn errors of has difficulty with any food served at the facility, parents/ - metabolism, diabetes, celiac disease, tongue thrust, or spe guardians can address this issue with appropriate staff cial health care needs related to feeding, such as requiring members. Some regulatory agencies require menus as a special feeding utensils or equipment, nasogastric or gastric part of the licensing and auditing process (2). tube feedings, or special positioning. These situations COMMENTS: Caregivers/teachers should be aware that require individual planning prior to the child’s entry into early new foods may need to be offered between eight to fifteen care and education and on an ongoing basis (3,4). times before a food may be accepted (3,5). Posting menus In some cases, dietary modifications are based on religious in a prominent area and distributing them to parents/guard- or cultural beliefs. Detailed information on each child’s spe- ians helps to inform them about proper nutrition. Sample cial needs whether stemming from dietary, feeding equip- menus and menu planning templates are available from ment, or cultural needs, is invaluable to the facility staff in most state health departments, the state extension service, meeting the nutritional needs of that child. and the Child and Adult Care Food Program (CACFP). Close collaboration between the home and COMMENTS: Good communication between the caregiver/teacher and the facility is necessary for children on special diets. Par - the parents/guardians is essential for successful feeding, in ents/guardians may have to provide food on a temporary general, including when introducing age-appropriate solid or, even, a permanent basis, if the facility, after exploring all foods (complementary foods). The decision to feed specific community resources, is unable to provide the special diet. foods should be made in consultation with the parents/ guardians. It is recommended that the caregiver/teacher be Center; Large Family Child Care Home; Small TYPE OF FACILITY: given written instructions on the introduction and feeding of Family Child Care Home foods from the parents/guardians and the infant’s primary care provider. Caregivers/teachers should use or develop a Chapter 4: Nutrition and Food Service 159

190 Caring for Our Children: National Health and Safety Performance Standards specific symptoms that would indicate the need to take-home sheet for parents/guardians on which the care- administer one or more medications; giver/teacher records the food consumed each day or, for Based on the child’s care plan, the child’s caregivers/ b) breastfed infants, the number of breastfeedings, and other teachers should receive training, demonstrate important notes on the infant. Caregivers/teachers should competence in, and implement measures for: continue to consult with each infant’s parents/guardians Preventing exposure to the specific food(s) to 1) concerning foods they have introduced and are feeding. which the child is allergic; In this way, the caregiver/teacher can follow a schedule of 2) Recognizing the symptoms of an allergic reaction; introducing new foods one at a time and more easily identify Treating allergic reactions; 3) possible food allergies or intolerances. Caregivers/teach- Parents/guardians and staff should arrange for c) ers should let parents/guardians know what and how much the facility to have necessary medications, proper their infant eats each day. Consistency between home and storage of such medications, and the equipment and the early care and education setting is essential during the training to manage the child’s food allergy while the period of rapid change when infants are learning to eat age- child is at the early care and education facility; appropriate solid foods (1,4,6). Caregivers/teachers should promptly and properly d) Center; Large Family Child Care Home; Small TYPE OF FACILITY: administer prescribed medications in the event of an Family Child Care Home allergic reaction according to the instructions in the RELATED STANDARDS: care plan; Standard 4.3.1.1: General Plan for Feeding Infants e) The facility should notify the parents/guardians Standard 4.3.1.11: Introduction of Age-Appropriate Solid Foods to immediately of any suspected allergic reactions, the Infants ingestion of the problem food, or contact with the Standard 4.5.0.8: Experience with Familiar and New Foods problem food, even if a reaction did not occur; REFERENCES: f) The facility should recommend to the family that Making food healthy and safe for 1. Benjamin, S. E., ed. 2007. the child’s primary care provider be notified if the children: How to meet the national health and safety performance child has required treatment by the facility for a food . 2nd standards – Guidelines for out-of-home child care programs allergic reaction; ed. Chapel Hill, NC: National Training Institute for Child Care Health g) The facility should contact the emergency medical Consultants. http://nti.unc.edu/course_files/curriculum/nutrition/ making_food_healthy_and_safe.pdf. services system immediately whenever epinephrine 2. Benjamin, S. E., K. A. Copeland, A. Cradock, E. Walker, M. M. has been administered; Slining, B. Neelon, M. W. Gillman. 2009. Menus in child care: A Parents/guardians of all children in the child’s class h) J Am Diet comparison of state regulations to national standards. should be advised to avoid any known allergens in Assoc 109:109-15. class treats or special foods brought into the early 3. Sullivan, S. A., L. L. Birch. 1990. Pass the sugar, pass the salt: care and education setting; Experience dictates preference. 26:546-51. Devel Psych i) Individual child’s food allergies should be posted 4. U.S. Department of Agriculture, Food and Nutrition Service prominently in the classroom where staff can view (FNS). 2001. Feeding infants: A guide for use in the child nutrition and/or wherever food is served; . Rev ed. Alexandria, VA: FNS. http://www.fns.usda.gov/ programs j) The written child care plan, a mobile phone, and the tn/resources/feeding_infants.pdf. 5. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and proper medications for appropriate treatment if the . 6th ed. New York: McGraw-Hill. childhood child develops an acute allergic reaction should be 6. Grummer-Strawn, L. M., K. S. Scanlon, S. B. Fein. 2008. Infant routinely carried on field trips or transport out of the feeding and feeding transitions during the first year of life. Pediatrics early care and education setting. 122: S36-S42. Food allergy is common, occurring in between RATIONALE: 2% and 8% of infants and children (1). Food allergic reac- STANDARD 4.2.0.10: Care for Children with tions can range from mild skin or gastrointestinal symptoms Food Allergies to severe, life-threatening reactions with respiratory and/ When children with food allergies attend the early care and or cardiovascular compromise. Hospitalizations from food education facility, the following should occur: allergy are being reported in increasing numbers (5). A major a) Each child with a food allergy should have a care plan factor in death from anaphylaxis has been a delay in the prepared for the facility by the child’s primary care administration of life-saving emergency medication, particu- provider, to include: larly epinephrine (6). Intensive efforts to avoid exposure to Written instructions regarding the food(s) to which 1) the offending food(s) are therefore warranted. The mainte- the child is allergic and steps that need to be nance of detailed care plans and the ability to implement taken to avoid that food; such plans for the treatment of reactions are essential for all A detailed treatment plan to be implemented in 2) food-allergic children (2-4). the event of an allergic reaction, including the COMMENTS: Successful food avoidance requires a coop- names, doses, and methods of administration of erative effort that must include the parents/guardians, the any medications that the child should receive in child, the child’s primary care provider, and the early care the event of a reaction. The plan should include and education staff. The parents/guardians, with the help 160 Chapter 4: Nutrition and Food Service

191 Caring for Our Children: National Health and Safety Performance Standards REFERENCES: of the child’s primary care provider, must provide detailed Curr Opin 1. Burks, A. W., J. S. Stanley. 1998. Food allergy. information on the specific foods to be avoided. In some 10:588-93. Pediatrics cases, especially for children with multiple food allergies, 2. U.S. Department of Health and Human Services, Administration the parents/guardians may need to take responsibility for Head Start for Children and Families, Office of Head Start. 2009. providing all of the child’s food. In other cases, the early . Rev. ed. Washington, DC: U.S. program performance standards care and education staff may be able to provide safe foods Government Printing Office. http://eclkc.ohs.acf.hhs.gov/hslc/ as long as they have been fully educated about effective Head Start Program/Program Design and Management/Head Start food avoidance. Requirements/Head Start Requirements/45 CFR Chapter XIII/45 CFR Chap XIII_ENG.pdf. Effective food avoidance has several facets. Foods can be 3. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook . 6th ed. listed on an ingredient list under a variety of names, such as Elk Grove Village, IL: American Academy of Pediatrics. milk being listed as casein, caseinate, whey, and/or lacto- Handbook of pediatric nutrition . 3rd 4. Samour, P. Q., K. King. 2005. globulin. Food sharing between children must be prevented ed. Lake Dallas, TX: Helm. by careful supervision and repeated instruction to the child Food allergy among U.S. 5. Branum, A. M., S. L. Lukacs. 2008. about this issue. Exposure may also occur through contact children: Trends in prevalence and hospitalizations . NCHS data between children or by contact with contaminated surfaces, brief, no. 10. Hyattsville, MD: National Center for Health Statistics. 6. Muraro, A., et al. 2010. The management of the allergic child at such as a table on which the food allergen remains after eat- school: EAACI/GA2LEN Task Force on the allergic child at school. ing. Some children may have an allergic reaction just from 65:681-89. Allergy being in proximity to the offending food, without actually ingesting it. Such contact should be minimized by wash- STANDARD 4.2.0.11: Ingestion of Substances ing children’s hands and faces and all surfaces that were in that Do Not Provide Nutrition contact with food. In addition, reactions may occur when a food is used as part of an art or craft project, such as the All children should be monitored to prevent them from eat- use of peanut butter to make a bird feeder or wheat to make ing substances that do not provide nutrition (often referred play dough. to as Pica). The parents/guardians of children who repeat- edly place non-nutritive substances in their mouths should Some children with a food allergy will have mild reactions be notified and informed of the importance of their child and will only need to avoid the problem food(s). Others will visiting their primary care provider. need to have an antihistamine or epinephrine available to be used in the event of a reaction. For all children with a history Children who ingest paint chips or con- RATIONALE: of anaphylaxis (severe allergic reaction), or for those with taminated soil can develop lead toxicity which can lead to peanut and/or tree nut allergy (whether or not they have had developmental delays and neurodevelopmental disability. anaphylaxis), epinephrine should be readily available. This Children who regularly ingest non-nutritive substances can will usually be provided as a pre-measured dose in an auto- develop iron deficiency anemia. Eating soil or drinking con- injector, such as the EpiPen or EpiPen Junior. Specific indi- taminated water could result in an infection with a parasite. cations for administration of epinephrine should be provided In collaboration with the child’s parent/guardian, an as- in the detailed care plan. Within the context of state laws, sessment of the child’s eating behavior and dietary intake appropriate personnel should be prepared to administer should occur along with any other health issues to begin epinephrine when needed. In virtually all cases, Emergency an intervention strategy. Dietary intake plays an important Medical Services (EMS) should be called immediately and role because certain nutrients such as a diet high in fat or children should be transported to the emergency room by lecithin increase the absorption of lead which can result in ambulance after the administration of epinephrine. A single toxicity (1). dose of epinephrine wears off in fifteen to twenty minutes and many experts will recommend that a second dose be Currently there is consensus that repeated ingestion of available for administration. some non-food items results in an increased lead burden of the body (1,2). Early detection and intervention in non-food For more information on food allergies, contact the Food ingestion can prevent nutritional deficiencies and growth/ Allergy and Anaphylaxis Network or visit their Website at developmental disabilities. http://www.foodallergy.org. The occasional ingestion of non-nutritive substances can be Some early care and education/school settings require a part of everyday living and is not necessarily a concern. that all foods brought into the classroom are store-bought For example, ingestion of non-nutritive substances can in their original packaging so that a list of ingredients is occur from mouthing, placing dirty hands in the mouth, or included, in order to prevent exposure to allergens. eating dropped food. Pica involves the recurrent ingestion of TYPE OF FACILITY: Center; Large Family Child Care Home; Small substances that do not provide nutrition. Pica is most preva- Family Child Care Home lent among children between the ages of one and three RELATED STANDARDS: years (1). Among children with intellectual developmental Standard 4.2.0.2: Assessment and Planning of Nutrition for Indi- disability and concurrent mental illness, the incidence ex- vidual Children ceeds 50% (1). Standard 4.2.0.8: Feeding Plans and Dietary Modifications Appendix P: Situations that Require Medical Attention Right Away Chapter 4: Nutrition and Food Service 161

192 Caring for Our Children: National Health and Safety Performance Standards especially vitamin D (400 IU of vitamin D are recommended COMMENTS: Lead-based paint (old housing as well as lead for infants six months to adulthood unless there is certainty water pipes), neighborhoods with heavy traffic (leaded fuel), of having the daily allowance met by foods); infants under and the storage of acidic foods in open cans or ceramic six months who are exclusively or partially breastfed and containers with a lead glaze are sources of lead and should who receive less than sixteen ounces of formula per day be addressed concurrently with a nutritionally adequate diet should receive 400 IU of vitamin D (4). as prevention strategies. Community water supply may be a source of lead and should be analyzed for its lead con- COMMENTS: For older children who have more choice tent and other metals. Once a child is identified with lead about what they chose to eat and drink, effort should be toxicity, it is important to control the child’s exposure to the made to provide accurate nutrition information so they make source of lead and promote a healthy and balanced diet. the wisest food choices for themselves. Both the early care This health problem can be addressed through collaboration and education program/school and the caregiver/teacher among the child’s parents/guardians, primary care provider, have an opportunity to inform, teach, and promote sound local childhood lead poisoning prevention program, and the eating practices along with the consequences when poor comprehensive child care team of health, education, and food choices are made (1). Sensitivity to cultural factors nutrition staff. including beliefs and practices of a child’s family should be Center; Large Family Child Care Home; Small TYPE OF FACILITY: maintained. Family Child Care Home Changing lifestyles, convictions and beliefs about food and REFERENCES: religion, what is eaten and what foods are restricted or never Pediatric nutrition in chronic 1. Ekvall, S. W., V. K. Ekvall, eds. 2005. consumed, have some families with infants and children disease and developmental disorders: Prevention, assessment, and practicing several levels of vegetarian diets. Some parents/ treatment . 2nd ed. New York: Oxford University Press. guardians indicate they are vegetarians, semi-vegetarian, or 2. Mitchell, M. K. 2002. Nutrition across the life span . 2nd ed. strict vegetarians because they do not or seldom eat meat. Philadelphia: W. R. Saunders Co. Others label themselves lacto-ovo vegetarians, eating or drinking foods such as eggs and dairy products. Still others STANDARD 4.2.0.12: Vegetarian/Vegan Diets describe themselves as vegans who restrict themselves Infants and children, including school-age children from strictly to ingesting only plant-based foods, avoiding all and families practicing any level of vegetarian diet, can be ac - any animal products. commodated in an early care and education environment Center; Large Family Child Care Home; Small TYPE OF FACILITY: when there is: Family Child Care Home a) Written documentation from parents/guardians on RELATED STANDARDS: the detailed and accurate dietary history about food Standard 3.1.2.1: Routine Health Supervision and Growth Monitor - choices - foods eaten, levels of limitations/restrictions ing to foods, and frequency of foods offered; Standard 4.2.0.2: Assessment and Planning of Nutrition for Indi- b) An up-to-date health record of the child available to vidual Children the caregivers/teachers, including information about Standard 4.3.1.6: Use of Soy-Based Formula and Soy Milk linear growth and rate of weight gain, or consistent REFERENCES: poor appetite (these indicators can be warning signs 1. Kleinman, R. E., ed. 2009. . 6th ed. Pediatric nutrition handbook of growth deficiencies); Elk Grove Village, IL: American Academy of Pediatrics. c) Collaboration among early care and education staff, 2. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and especially the sharing of updated information on the . 6th ed. New York: McGraw-Hill. childhood child’s health with the parents/guardians by the child . 2nd ed. Nutrition across the life span 3. Mitchell, M. K. 2002. care health consultant and the nutritionist/registered Philadelphia: W. R. Saunders Co. dietitian; 4. Wagner, C. L., F. R. Greer. 2008. Prevention of rickets and vitamin d) Sound health and nutrition information that is D deficiency in infants, children, and adolescents. Pediatrics 122:1142-52 culturally relevant to the family to ensure that the child receives adequate calories and essential nutrients which promote adequate growth and 4.3 Requirements for Special development of the child. Groups or Ages of Children RATIONALE: Infants and young children are at highest risk for nutritional deficiencies for energy levels and essential nutrients including protein, calcium, iron, zinc, vitamins B6, 4.3.1 Nutrition for Infants B12, and vitamin D (1-3). The younger the child the more critical it is to know about family food choices, limitations STANDARD 4.3.1.1: General Plan for Feeding and restrictions because the child is dependent on family Infants food (2). Also due to the rapid growth in the early years, it is At a minimum, meals and snacks the facility provides for imperative that a child’s diet should consist of a variety of infants should contain the food in the meal and snack pat- nourishing food to support growth during this critical period. terns of the Child and Adult Care Food Program (CACFP). All vegetarian/vegan children should receive multivitamins, 162 Chapter 4: Nutrition and Food Service

193 Caring for Our Children: National Health and Safety Performance Standards Breastfeeding also lowers the mother’s risk of diabetes, Food should be appropriate for the infant’s individual nutri- breast cancer, and heart disease (17). tion requirements and developmental stages as determined by written instructions obtained from the child’s parent/ Except in the presence of rare medical conditions, the clear guardian or primary care provider. advantage of human milk over any formula should lead to vigorous efforts by caregivers/teachers to promote and The facility should encourage, provide arrangements for, sustain breastfeeding for mothers who are willing to nurse and support breastfeeding. The facility staff, with appro- their infants whenever they can, and to pump and supply priate training, should be the mother’s cheerleader and their milk to the early care and education facility when direct enthusiastic supporter for the mother’s plan to provide her feeding from the breast is not possible. Even if infants re- milk. Facilities should have a designated place set aside ceive formula during the child care day, some breastfeeding for breastfeeding mothers who want to come during work or expressed human milk from their mothers is beneficial (8). to breastfeed, as well as a private area with an outlet (not a bathroom) for mothers to pump their breast milk (2-8). A Iron-fortified infant formula is an acceptable alternative place that mothers feel they are welcome to breastfeed, to human milk as a food for infant feeding even though it pump, or bottle feed can create a positive environment lacks any anti-infective or immunological components. An when offered in a supportive way. adequately nourished infant is more likely to achieve normal physical and mental development, which will have long-term Infants may need a variety of special formulas such as soy- positive consequences on health (12,13). based formula or elemental formulas which are easier to digest and less allergenic. Elemental or special non-allergic COMMENTS: Some ways to help a mother to breastfeed formulas should be specified in the infant’s care plan. successfully in the early care and education facility (3): If she wishes to breastfeed her infant or child when a) Age-appropriate solid foods (complementary foods) may she comes to the facility, offer or provide her a: be introduced no sooner than when the child has reached Quiet, comfortable, and private place to breast- 1) the age of four months, but preferably six months and as feed (this helps her milk to letdown); indicated by the individual child’s nutritional and develop- 2) Place to wash her hands; mental needs. For breastfed infants, gradual introduction of Pillow to support her infant on her lap while nurs- 3) iron-fortified foods may occur no sooner than around four ing if requested; months, but preferably six months to complement the hu- 4) Nursing stool or stepstool if requested for her feet man milk. so she doesn’t have to strain her back while nurs- RATIONALE: Human milk, as an exclusive food, is best ing; and suited to meet the entire nutritional needs of an infant from Glass of water or other liquid to help her stay 5) birth until six months of age, with the exception of recom- hydrated; mended vitamin D supplementation. In addition to nutrition, Encourage her to get the infant used to being fed b) breastfeeding supports optimal health and development. her expressed human milk by another person before Human milk is also the best source of milk for infants for at the infant starts in early care and education, while least the first twelve months of age and, thereafter, for as continuing to breastfeed directly herself; long as mutually desired by mother and child. Breastfeeding c) Discuss with her the infant’s usual feeding pattern protects infants from many acute and chronic diseases and and whether she wants the caregiver/teacher to feed has advantages for the mother, as well (4). the infant by cue or on a schedule, also ask her if she Research overwhelmingly shows that exclusive breastfeed- wishes to time the infant’s last feeding so that the ing for six months, and continued breastfeeding for at least infant is hungry and ready to breastfeed when she a year or longer, dramatically improves health outcomes arrives, also, ask her to leave her availability schedule Objec- Healthy People 2010 for children and their mothers. with the early care and education program and ask tive 16 includes increasing the proportion of mothers who her to call if she is planning to miss a feeding or is breastfeed their infants, and increasing the duration of going to be late; breastfeeding and of exclusively breastfeeding (1). d) Encourage her to provide a back-up supply of frozen or refrigerated expressed human milk with the infant’s Importance of breastfeeding to the infant includes reduc- full name on the bottle or other clean storage con- tion of some of the risks that are greater for infants in group tainer in case the infant needs to eat more often than care. Many advantages of breastfeeding are documented usual or the mother’s visit is delayed; - by research, including reduction in the incidence of diar e) Share with her information about other places in rhea, respiratory disease, otitis media, bacteremia, bacterial the community that can answer her questions and meningitis, botulism, urinary tract infections, necrotizing concerns about breastfeeding, for example, local enterocolitis, SIDS, insulin-dependent diabetes, lymphoma, lactation consultants (14,16); allergic disease, ulcerative colitis, ear infections, and other f) Ensure that all staff receive training in breastfeeding chronic digestive diseases (4,13,15).Evidence suggests that support and promotion; breastfeeding is associated with enhanced cognitive devel - g) Ensure that all staff are trained in the proper handling opment (6,10). Additionally, some evidence suggests that and feeding of each milk product, including human breastfeeding reduces the risk of childhood obesity (9,11). milk or infant formula; Chapter 4: Nutrition and Food Service 163

194 Caring for Our Children: National Health and Safety Performance Standards Provide culturally appropriate breastfeeding materials h) STANDARD 4.3.1.2: Feeding Infants on Cue by including community resources for parents/guardians a Consistent Caregiver/Teacher that include appropriate language and pictures of Caregivers/teachers should feed infants on the infant’s cue multicultural families to assist families to identify with unless the parent/guardian and the child’s primary care them. provider give written instructions otherwise (6). Whenever Center; Large Family Child Care Home; Small TYPE OF FACILITY: possible, the same caregiver/teacher should feed a spe- Family Child Care Home cific infant for most of that infant’s feedings. Cues such as RELATED STANDARDS: opening the mouth, making suckling sounds, and moving Standard 4.2.0.9: Written Menus and Introduction of New Foods the hands at random all send information from an infant to Standard 4.3.1.3: Preparing, Feeding, and Storing Human Milk a caregiver/teacher that the infant is ready to feed. Caregiv- Standard 4.3.1.5: Preparing, Feeding, and Storing Infant Formula ers/teachers should not feed infants beyond satiety, just as Standard 4.3.1.11: Introduction of Age-Appropriate Solid Foods to hunger cues are important in initiating feedings, observing Infants satiety cues can limit overfeeding. Standard 4.3.1.12: Feeding Age-Appropriate Solid Foods to Infants Appendix JJ: Our Child Care Center Supports Breastfeeding Cue feeding meets the infant’s nutritional and RATIONALE: emotional needs and provides an immediate response to REFERENCES: the infant, which helps ensure trust and feelings of security. Healthy 1. U.S. Department of Health and Human Services. 2000. people 2010: Understanding and improving health . 2nd ed. Cues such as turning away from the nipple, increased atten- Washington, DC: U.S. Government Printing Office. tion to surroundings, keeping mouth closed, and saying no 2. Dietitians of Canada, American Dietetic Association. 2000. are all indications of satiation (1,2,6). Manual of clinical dietetics . 6th ed. Chicago: ADA. When the same caregiver/teacher regularly works with 3. U.S. Department of Agriculture, Food and Nutrition Service (FNS). a particular child, that caregiver/teacher is more likely to Breastfed babies welcome here! 1993. Alexandria, VA: FNS. 4. American Academy of Pediatrics, Section on Breastfeeding. understand that child’s cues and to respond appropriately. 2005. Policy statement: Breastfeeding and the use of human milk. Feeding infants on cue rather than on a schedule may help Pediatrics 115:496-506. prevent childhood obesity (3,6). Early relationships between 5. Uauy, R., I. DeAndroca. 1995. Human milk and breast feeding for an infant and caregivers/teachers involving feeding set the 125:2278-80. optimal brain development. J Nutr stage for an infant to develop eating patterns for life (1,4). 6. Wang, Y. S., S. Y. Wu. 1996. The effect of exclusive breast COMMENTS: Caregivers/teachers should be gentle, pa- J Hum feeding on development and incidence of infection in infants. 12:27-30. Lactation tient, sensitive, and reassuring by responding appropriately 7. Quandt, S. 1998. Ecology of breast feeding in the US: An applied to the infant’s feeding cues (1). Waiting for an infant to cry perspective. Am J Hum Biol 10:221-28. to indicate hunger is not necessary or desirable. Crying may 8. Hammosh, M. 1996. Breast feeding and the working mother. indicate that feeding cues have been missed and adequate Pediatrics 97:492-98. attention has not been paid to the infant (5). Nevertheless, 9. Kramer M. S., L. Matush, I. Vanilovich, et al. 2007. Effects of feeding children who are alert and interested in interpersonal prolonged and exclusive breastfeeding on child height, weight, interaction, but who are not showing signs of hunger, is not adiposity, and blood pressure at age 6.5 y: Evidence from a large appropriate. Cues for hunger or interaction-seeking may randomized trial. Am J Clin Nutr 86:1717–21. vary widely in different infants. A pacifier should not be of- 10. Lawrence, R. A., R. Lawrence. 2005. Breast feeding: A guide for fered to a hungry infant, they need food first. the medical profession . 6th ed. St. Louis: Mosby. 11. Birch, L., W. Dietz, eds. 2008. Eating behaviors of the young A series of trainings on infant cues can be found at NCAST- . Elk Grove child: Prenatal and postnatal influences on healthy eating AVENUW, University of Washington at http://www.ncast.org/ Village, IL: American Academy of Pediatrics. index.cfm?category=16. 12. Dietz, W. H., L. Stern, eds. 1998. American Academy of Pediatrics guide to your child’s nutrition . New York: Villard. TYPE OF FACILITY: Center; Large Family Child Care Home; Small 13. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook . 6th ed. Family Child Care Home Elk Grove Village, IL: American Academy of Pediatrics. RELATED STANDARDS: 14. U.S. Department of Agriculture, Food and Nutrition Service Standard 4.3.1.1: General Plan for Feeding Infants Feeding infants: A guide for use in the child nutrition (FNS). 2002. Standard 4.3.1.8: Techniques for Bottle Feeding programs . Rev ed. Alexandria, VA: FNS. http://www.fns.usda.gov/ tn/resources/feeding_infants.pdf. REFERENCES: 15. Ip, S., M. Chung, G. Raman, P. Chew, N. Magula, D. DeVine, 1. Branscomb, K. R., C. B. Goble. 2008. Infants and toddlers in Breastfeeding and maternal and infant T. Trikalinos, J. Lau. 2007. Young group care: Feeding practices that foster emotional health. . Rockville, MD: Agency for health outcomes in developed countries 63:28-33. Children Healthcare Research and Quality. Nutrition and infancy in 2. Trahms, C. M., P. L. Pipes, eds. 1997. 16. U.S. Department of Agriculture, Food and Nutrition Service. . 6th ed. New York: McGraw-Hill. childhood Benefits and services: Breastfeeding promotion and support in WIC. 3. Taveras, E. M., S. L. Rifas-Shiman, K. S. Scanlon, L. M. http://www.fns.usda.gov/wic/breastfeeding/mainpage.HTM. Grummer-Strawn, B. Sherry, M. W. Gillman. 2006. To what extent 17. Stuebe, A. M., E. B. Schwarz. 2009. The risks and benefits is the protective effect of breastfeeding on future overweight of infant feeding practices for women and their children. J explained by decreased maternal feeding restriction? Pediatrics Perinatology (July 16). 118:2341-48. Chapter 4: Nutrition and Food Service 164

195 Caring for Our Children: National Health and Safety Performance Standards 4. Hodges, E. A., S. O. Hughes, J. Hopkinson, J. O. Fisher. 2008. curdled, smells rotten, and/or has not been stored follow- Maternal decisions about the initiation and termination of infant ing the storage guidelines of the Academy of Breastfeeding Appetite feeding. 50:333-39. Medicine as shown later in this standard, should be returned Bright 5. Hagan, Jr., J. F., J. S. Shaw, P. M. Duncan, eds. 2008. to the mother. futures: Guidelines for health supervision of infants, children, and Some children around six months to a year of age may be 3rd ed. Elk Grove Village, IL: American Academy of adolescents. Pediatrics. developmentally ready to feed themselves and may want Child of mine: Feeding with love and good sense 6. Satter, E. 2000. . to drink from a cup. The transition from bottle to cup can 3rd ed. Boulder, CO: Bull Publishing. come at a time when a child’s fine motor skills allow use of a cup. The caregiver/teacher should use a clean small cup STANDARD 4.3.1.3: Preparing, Feeding, and without cracks or chips and should help the child to lift and Storing Human Milk tilt the cup to avoid spillage and leftover fluid. The caregiver/ teacher and mother should work together on cup feeding Expressed human milk should be placed in a clean and of human milk to ensure the child is receiving adequate sanitary bottle with a nipple that fits tightly or into an equiva - nourishment and to avoid having a large amount of human lent clean and sanitary sealed container to prevent spilling milk remaining at the end of feeding. Two to three ounces of during transport to home or to the facility. Only cleaned and human milk can be placed in a clean cup and additional milk sanitized bottles, or their equivalent, and nipples should be can be offered as needed. Small amounts of human milk used in feeding. The bottle or container should be properly (about an ounce) can be discarded. labeled with the infant’s full name and the date and time the milk was expressed. The bottle or container should immedi- ately be stored in the refrigerator on arrival. The mother’s own expressed milk should only be used for her own infant. Likewise, infant formula should not be used for a breastfed infant without the mother’s written permis- sion. Bottles made of plastics containing BPA or phthalates should be avoided (labeled with #3, #6, or #7). Glass bottles or plastic bottles labeled BPA-free or with #1, #2, #4, or #5 are acceptable. Non-frozen human milk should be transported and stored in the containers to be used to feed the infant, identified with a label which will not come off in water or handling, bearing the date of collection and child’s full name. The filled, la- beled containers of human milk should be kept refrigerated. Human milk containers with significant amount of contents remaining (greater than one ounce) may be returned to the mother at the end of the day as long as the child has not fed directly from the bottle. Frozen human milk may be transported and stored in single use plastic bags and placed in a freezer (not a compartment within a refrigerator but either a freezer with a separate door or a standalone freezer). Human milk should be defrosted in the refrigerator if frozen, and then heated briefly in bottle warmers or under warm running water so that the tempera- ture does not exceed 98.6°F. If there is insufficient time to defrost the milk in the refrigerator before warming it, then it may be defrosted in a container of running cool tap water, very gently swirling the bottle periodically to evenly distrib - ute the temperature in the milk. Some infants will not take their mother’s milk unless it is warmed to body temperature, around 98.6°F. The caregiver/teacher should check for the infant’s full name and the date on the bottle so that the old- est milk is used first. After warming, bottles should be mixed gently (not shaken) and the temperature of the milk tested before feeding. Expressed human milk that presents a threat to an in- fant, such as human milk that is in an unsanitary bottle, is Chapter 4: Nutrition and Food Service 165

196 Caring for Our Children: National Health and Safety Performance Standards Human milk can be stored using the following guidelines from the Academy of Breastfeeding Medicine: Guidelines for Storage of Human Milk Temperature Duration Comments Location 6-8 hours Room tempera- Containers should be covered and kept as cool as possible; covering Countertop, table ture (up to 77°F the container with a cool towel may keep milk cooler. or 25°C) Insulated cooler bag 5°F – 39°F or 24 hours Keep ice packs in contact with milk containers at all times, limit open - -15°C – 4°C ing cooler bag. Store milk in the back of the main body of the refrigerator. 5 days 39°F or 4°C Refrigerator 2 weeks 5°F or -15°C Freezer compartment Store milk toward the back of the freezer, where temperature is most constant. Milk stored for longer durations in the ranges listed is safe, of a refrigerator but some of the lipids in the milk undergo degradation resulting in lower quality. 3-6 months Freezer compartment 0°F or -18°C of refrigerator with separate doors Chest or upright deep -4°F or -20°C 6-12 freezer months Source: Academy of Breastfeeding Medicine Protocol Committee. 2010. Clinical protocol #8: Human milk storage information for home 5:127-30. http://www.bfmed.org/Media/Files/Protocols/Protocol%208%20 Breastfeeding Med use for healthy full term infants, revised. -%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. Although human milk is a body fluid, it is not COMMENTS: RATIONALE: Labels for containers of human milk should be necessary to wear gloves when feeding or handling human resistant to loss of the name and date/time when washing milk. Unless there is visible blood in the milk, the risk of ex- and handling. This is especially important when the frozen posure to infectious organisms either during feeding or from bottle is thawed in running tap water. There may be several milk that the infant regurgitates is not significant. bottles from different mothers being thawed and warmed at the same time in the same place. Returning unused human milk to the mother informs her of the quantity taken while in the early care and education By following this standard, the staff is able, when necessary, program. to prepare human milk and feed an infant safely, thereby reducing the risk of inaccuracy or feeding the infant unsani- TYPE OF FACILITY: Center; Large Family Child Care Home; Small tary or incorrect human milk (2,5). Written guidance for both Family Child Care Home - staff and parents/guardians should be available to deter RELATED STANDARDS: mine when milk provided by parents/guardians will not be Standard 4.3.1.1: General Plan for Feeding Infants served. Human milk cannot be served if it does not meet the Standard 4.3.1.4: Feeding Human Milk to Another Mother’s Child requirements for sanitary and safe milk. Standard 4.3.1.7: Feeding Cow’s Milk Standard 4.3.1.8: Techniques for Bottle Feeding Excessive shaking of human milk may damage some of the Standard 4.3.1.9: Warming Bottles and Infant Foods cellular components that are valuable to the infant. Standard 5.2.9.9: Plastic Containers and Toys It is difficult to maintain 0°F consistently in a freezer com- REFERENCES: partment of a refrigerator or freezer, so caregivers/teachers 1. American Academy of Pediatrics, Section on Breastfeeding. should carefully monitor, with daily log sheets, temperature 2005. Policy statement: Breastfeeding and the use of human milk. of freezers used to store human milk using an appropriate 115:496-506. Pediatrics working thermometer. Human milk contains components 2. Clark, A., J. Anderson, E. Adams, S. Baker. 2008. Assessing the that are damaged by excessive heating during or after thaw- knowledge, attitudes, behaviors and training needs related to infant Matern feeding, specifically breastfeeding, of child care providers. ing from the frozen state (1). Currently, there is nothing in the 12:128-35. Child Health J research literature that states that feedings must be warmed . 6th ed. Pediatric nutrition handbook 3. Kleinman, R. E., ed. 2009. at all prior to feeding. Frozen milk should never be thawed Elk Grove Village, IL: American Academy of Pediatrics. in a microwave oven as 1) uneven hot spots in the milk may 4. Samour, P. Q., K. King. 2005. . 3rd Handbook of pediatric nutrition cause burns in the infant and 2) excessive heat may destroy ed. Lake Dallas, TX: Helm. beneficial components of the milk. 5. Lawrence, R. A., R. Lawrence. 2005. Breast feeding: A guide for . 6th ed. St. Louis: Mosby. the medical profession By following safe preparation and storage techniques, nurs- Food, nutrition, and the 6. Endres, J. B., R. E. Rockwell. 2003. ing mothers and caregivers/teachers of breastfed infants . 4th ed. New York: Macmillan. young child and children can maintain the high quality of expressed human milk and the health of the infant (3,4,6). 166 Chapter 4: Nutrition and Food Service

197 Caring for Our Children: National Health and Safety Performance Standards soon as possible. If human milk from a hepatitis B-positive STANDARD 4.3.1.4: Feeding Human Milk to woman is given mistakenly to a an unimmunized child, the Another Mother’s Child child may receive HBIG (Hepatitis B Immune Globulin) as If a child has been mistakenly fed another child’s bottle of soon as possible within seven days, but it is not necessary expressed human milk, the possible exposure to hepatitis because of the low risk of transmission (3). The hepatitis B B, hepatitis C, or HIV should be treated as if an exposure to vaccine series should be initiated and completed as soon as other body fluids had occurred. For possible exposure to possible. hepatitis B, hepatitis C, or HIV, the caregiver/teacher should: RATIONALE: The risk of hepatitis B, hepatitis C, or HIV Inform the mother who expressed the human milk a) transmission from expressed human milk consumed by about the mistake and when the bottle switch another child is believed to be low because: occurred, and ask: In the United States, women who are HIV-positive a) When the human milk was expressed and how 1) and aware of that fact are advised NOT to breastfeed it was handled prior to being delivered to the their infants and therefore the potential for exposure caregiver/teacher or facility; to milk from an HIV-positive woman is low; 2) Whether she has ever had a hepatitis B, hepatitis b) In the United States, women with high hepatitis C, or HIV blood test and, if so, the date of the test C antiviral loads or who have cracked or bleeding and would she be willing to share the results with nipples might transmit the infection through the parents/guardians of the child who was fed the breastfeeding. Therefore, they are advised to refrain incorrect milk; from breastfeeding (3,4); 3) If she does not know whether she has ever been c) Chemicals present in human milk act, together with tested for hepatitis B, hepatitis C, or HIV, would time and cold temperatures, to destroy the HIV she be willing to contact her primary care provider present in expressed human milk; and find out if she has been tested; d) Transmission of HIV from a single human milk 4) If she has never been tested for hepatitis B, exposure has never been documented (1). hepatitis C, or HIV, would she be willing to be tested and share the results with the parents/ Because parents/guardians may express concern about guardians of the other child; the likelihood of transmitting these diseases through human Discuss the mistake of giving the wrong milk with the b) milk, this issue is addressed in detail to assure there is a parents/guardians of the child who was fed the wrong very small risk of such transmission occurring. bottle: Among known HIV-positive women in Africa (where HIV- Inform them that their child was given another 1) positive women are still advised to breastfeed only if they child’s bottle of expressed human milk and the are located in areas where the water supply is unreliable), a date it was given; study found that the transmission rate among infants who Inform them that the risk of transmission of 2) were fed infected human milk exclusively for several months hepatitis B, hepatitis C, or HIV and other infectious was found to be 4%; thirteen infants out of 324 (2). diseases is low; TYPE OF FACILITY: Center; Large Family Child Care Home; Small Encourage the parents/guardians to notify the 3) Family Child Care Home child’s primary care provider of the exposure; 4) Provide the family with information including the RELATED STANDARDS: Standard 4.3.1.3: Preparing, Feeding, and Storing Human Milk time at which the milk was expressed and how the milk was handled prior to its being delivered to the REFERENCES: caregiver/teacher so that the parents/guardians 1. Centers for Disease Control and Prevention. What to do if an may inform the child’s primary care provider; infant or child is mistakenly fed another woman’s expressed breast 5) Inform the parents/guardians that, depending milk. http://www.cdc.gov/breastfeeding/recommendations/other _mothers_milk.htm. upon the results from the mother whose milk was 2. Becquet, R., D. K. Ekouevi, H. Menan, C. Amani-Bosse, L. given mistakenly (1), their child may soon need to Bequet, I. Viho, F. Dabis, M. Timite-Konan, V. Leroy. 2008. Early undergo a baseline blood test for hepatitis B (also mixed feeding and breastfeeding beyond 6 months increase the risk see below), hepatitis C, or HIV; Prev Med of postnatal HIV transmission. 47:27-33. Assess why the wrong milk was given and develop c) 3. Pickering, L. K., C. J. Baker, D. W. Kimberlin, S. J. Long, eds. a prevention plan to be shared with the parents/ Red book: 2009 report of the Committee on Infectious 2009. guardians as well as the staff in the facility. Diseases . Elk Grove Village, IL: American Academy of Pediatrics. 4. Philip Spradling, CDC, email message to the NRC, May 12, 2010. If the human milk given mistakenly to a child is from a woman who does not know her hepatitis B status, the STANDARD 4.3.1.5: Preparing, Feeding, and caregiver/teacher should determine if the child has received Storing Infant Formula the complete hepatitis B vaccine series. If the child has not been vaccinated or is incompletely vaccinated, then the Formula provided by parents/guardians or by the facility parent/guardian of the child who received the milk should should come in a factory-sealed container. The formula seek vaccination of the child. The child should complete should be of the same brand that is served at home and the recommended childhood hepatitis B vaccine series as Chapter 4: Nutrition and Food Service 167

198 Caring for Our Children: National Health and Safety Performance Standards safely, thereby reducing the risk of inaccuracy or feeding should be of ready-to-feed strength or liquid concentrate to the infant unsanitary or incorrect formula. Written guidance be diluted using water from a source approved by the health for both staff and parents/guardians must be available to department. Powdered infant formula, though it is the least determine when formula provided by parents/guardians will expensive formula, requires special handling in mixing be- not be served. Formula cannot be served if it does not meet cause it cannot be sterilized. The primary source for proper the requirements for sanitary and safe formula. and safe handling and mixing is the manufacturer’s instruc- tions that appear on the can of powdered formula. Before If a child has a special health problem, such as reflux, or opening the can, hands should be washed. The can and - inability to take in nutrients because of delayed develop plastic lid should be thoroughly rinsed and dried. Caregiv- ment of feeding skills, the child’s primary care provider ers/teachers should read and follow the manufacturer’s di- should provide a written plan for the staff to follow so that rections. If instructions are not readily available, caregivers/ the child is fed appropriately. Some infants are allergic to teachers should obtain information from the World Health milk and soy and need to be fed an elemental formula which Safe Preparation, Storage and Handling of Organization’s does not contain allergens. Other infants need supplemental at http://www.who.int/ Powdered Infant Formula Guidelines calories because of poor weight gain. foodsafety/publications/micro/pif2007/en/index.html (8). The Infants should not be fed a formula different from the one local WIC program can also provide instructions. the parents/guardians feed at home, as even minor differ - Formula mixed with cereal, fruit juice, or any other foods ences in formula can cause gastrointestinal upsets and should not be served unless the child’s primary care pro- other problems (6). vider provides written documentation that the child has a Excessive shaking of formula may cause foaming that in- medical reason for this type of feeding. creases the likelihood of feeding air to the infant. Iron-fortified formula should be refrigerated until immedi- Formula should not be used beyond the stated shelf life ately before feeding. For bottles containing formula, any period (1). contents remaining after a feeding should be discarded. The intent of this standard is to protect a COMMENTS: Bottles of formula prepared from powder or concentrate child’s health by ensuring safe and sanitary conditions for or ready-to-feed formula should be labeled with the child’s transporting and feeding infant formula prepared at home full name and time and date of preparation. Any prepared and brought to the facility, and by ensuring that all infants formula must be discarded within one hour after serving to get the proper formula. an infant. Prepared powdered formula that has not been given to an infant should be covered, labeled with date and Parents/guardians should supply enough clean and steril- time of preparation and child’s full name, and may be stored ized bottles to be used throughout the day. The bottles must in the refrigerator for up to twenty-four hours. An open be sanitary, properly prepared and stored, and must be the container of ready-to-feed, concentrated formula, or formula same brand in the early care and education program and at prepared from concentrated formula, should be covered, home. refrigerated, labeled with date of opening and child’s full Staff preparing formula should thoroughly wash their hands name, and discarded at forty-eight hours if not used (7,9). prior to beginning preparation of infant feedings of any type. The caregiver/teacher should always follow manufacturer’s Water used for mixing infant formula must be from a safe instructions for mixing and storing of any formula prepara- water source as defined by the local or state health depart- tion. ment. If the caregiver/teacher is concerned or uncertain Bottles made of plastics containing BPA or phthalates about the safety of the tap water, s/he may use bottled should be avoided (labeled with #3, #6, or #7). Glass bottles water or bring cold tap water to a rolling boil for one minute or plastic bottles labeled BPA-free or with #1, #2, #4, or #5 (no longer), then cool the water to room temperature for no are acceptable. more than thirty minutes before it is used. Warmed water should be tested in advance to make sure it is not too hot Some infants will require specialized formula because for the infant. To test the temperature, the caregiver/teacher of allergy, inability to digest certain formulas, or need for should shake a few drops on the inside of her/his wrist. A extra calories. The appropriate formula should always be bottle can be prepared by adding powdered formula and available and should be fed as directed. For those infants room temperature water from the tap just before feeding. getting supplemental calories, the formula may be prepared Bottles made in this way from powdered formula can be in a different way from the directions on the container. In ready for feeding as no additional refrigeration or warming those circumstances, either the family should provide the would be required. prepared formula or the caregiver/teacher should receive special training, as noted in the infant’s care plan, on how to Caregivers/teachers should only use the scoop that comes prepare the formula. with the can and not interchange the scoop from one prod- uct to another, since the volume of the scoop may vary from RATIONALE: This standard promotes the feeding of infant manufacturer to manufacturer and product to product. Also, formula that is familiar to the infant and supports family a scoop can be contaminated with a potential allergen from feeding practice. By following this standard, the staff is another type of formula. Although many infant formulas are able, when necessary, to prepare formula and feed an infant made from powder, the liquid preparations are diluted with 168 Chapter 4: Nutrition and Food Service

199 Caring for Our Children: National Health and Safety Performance Standards based formula. Soy milk should be available for the children water at the factory. Concentrated infant formula, not ready- of parents/guardians participating in the Women, Infants, to feed, must be diluted with water. Sealed, ready-to-feed and Children (WIC) Supplemental Food Program, Child and bottles are easy to use, however they are the most expen- Adult Care Food Program (CACFP), or Food Stamp Pro- sive approach to feeding formula. gram. If concentrated liquid or powdered infant formulas are used, RATIONALE: The American Academy of Pediatrics (AAP) it is very important to prepare them properly, with accurate recommends use of hypoallergenic formula (not soy-based dilution, according to the directions on the container. Adding formula) for infants who are allergic to cow’s milk proteins. too little water to formula puts a burden on an infant’s kid- Soy-based formulas are appropriate for children with ga- neys and digestive system and may lead to dehydration (4). lactosemia or congenital lactose intolerance (1). Because Adding too much water dilutes the formula. Diluted formula there is a lot of confusion in the public regarding cow’s milk may interfere with an infant’s growth and health because it proteins and lactose intolerance, these indications should provides inadequate calories and nutrients and can cause be documented by the child’s primary care provider and water intoxication. Water intoxication can occur in breastfed not based on parental/guardian possible misinterpretation or formula-fed infants or children over one year of age who of symptoms. Soy-based formulas are made from soy meal are fed an excessive amount of water. Water intoxication (plant based) with added methionine, carbohydrates, and can be life-threatening to an infant or young child (5). oils (soy or vegetable) and are fortified with vitamins and TYPE OF FACILITY: Center; Large Family Child Care Home; Small minerals (2). In the U.S., all soy-based formula is fortified Family Child Care Home with iron. Soy meal does not contain lactose, so it is used RELATED STANDARDS: for feeding infants with primary care provider documented Standard 4.3.1.1: General Plan for Feeding Infants congenital lactose intolerance. Standard 4.3.1.8: Techniques for Bottle Feeding The taste of soy milk is similar to cow’s milk. COMMENTS: Standard 4.3.1.9: Warming Bottles and Infant Foods Standard 5.2.9.9: Plastic Containers and Toys Because soy formula and soy milk are derived from a plant source, parents/guardians may choose these products for REFERENCES: dietary (e.g., vegan) or religious reasons. In such cases, soy- . 6th ed. Pediatric nutrition handbook 1. Kleinman, R. E., ed. 2009. based formula is used for infant feeding and unflavored soy Elk Grove Village, IL: American Academy of Pediatrics. milk is the choice for young children. 2. Dietitians of Canada, American Dietetic Association. 2000. . 6th ed. Chicago: ADA. Manual of clinical dietetics Caregivers/teachers should encourage parents/guardians of Nutrition in infancy and 3. Pipes, P. L., C. M. Trahms, eds. 1997. children with primary care provider documented indications childhood . 6th ed. New York: McGraw-Hill. for soy formula, participating in WIC and/or Food Stamp 4. Institute for Safe Medication Practices. Infant formula: Read Programs, to learn how they can obtain soy-based infant and follow the label instructions! http://www.ismp.org/consumers/ formula or soy milk/products. Formula.asp. 5. U.S. Department of Agriculture, Food and Nutrition Service Infants may need a variety of special or elemental formulas (FNS). 2001. Feeding infants: A guide for use in the child nutrition which are easier to digest and less allergenic. Elemental programs . Rev ed. Alexandria, VA: FNS. http://www.fns.usda.gov/ or special non-allergic formulas should be specified in the tn/resources/feeding_infants.pdf. infant’s care plan. 6. American Academy of Pediatrics, Section on Breastfeeding. 2005. Policy statement: Breastfeeding and the use of human milk. Center; Large Family Child Care Home; Small TYPE OF FACILITY: Pediatrics 115:496-506. Family Child Care Home 7. Fomon, S. J. 1993. . St. Louis: Mosby. Nutrition of normal infants RELATED STANDARDS: 8. World Health Organization (WHO), Food and Agriculture Standard 4.2.0.12: Vegetarian/Vegan Diets Organization of the United Nations. 2007. Safe preparation, storage Standard 4.3.1.5: Preparing, Feeding, and Storing Infant Formula and handling of powdered infant formula: Guidelines . Geneva: WHO. REFERENCES: 9. International Formula Council. Guidelines for traveling with 1. Bhatia, J., F. Greer, Committee on Nutrition. 2008. Use of soy infants: Keeping formula safe and sound. http://www.infantformula Pediatrics protein-based formulas for infant feeding. 121:1062-68. .org/for-parents/traveling-infants/. 2. Dietitians of Canada, American Dietetic Association (ADA). 2000. Manual of clinical dietetics . 6th ed. Chicago: ADA. STANDARD 4.3.1.6: Use of Soy-Based STANDARD 4.3.1.7: Feeding Cow’s Milk Formula and Soy Milk The facility should not serve cow’s milk to infants from birth Soy-based formula or soy milk should be provided to a child to twelve months of age, unless provided with a written whose parents/guardians present a written request be- exception and direction from the child’s primary care pro- cause of family dietary restrictions on foods produced from vider and parents/guardians. Children between twelve and animals (i.e., cow’s milk and other dairy products). Both twenty-four months of age, who are not on human milk or soy-based formula and soy milk should be labeled with the prescribed formula, can be served whole pasteurized milk, infant’s or child’s full name and date and stored properly. or reduced fat (2%) pasteurized milk for those children who The caregiver/teacher should collaborate with parents/ are at risk for hypercholesterolemia or obesity (1). Children guardians in exploring community resources to secure soy- Chapter 4: Nutrition and Food Service 169

200 Caring for Our Children: National Health and Safety Performance Standards two years of age and older should be served skim or 1% STANDARD 4.3.1.8: Techniques for Bottle pasteurized milk. Feeding RATIONALE: For children between twelve months and Infants should always be held for bottle feeding. Caregiv- twenty-four months of age, for whom overweight or obesity ers/teachers should hold infants in the caregiver’s/teacher’s is a concern or who have a family history of obesity, dyslip- arms or sitting up on the caregiver’s/teacher’s lap. Bottles idemia, or early cardiovascular disease, the use of reduced should never be propped. The facility should not permit fat (2%) milk is appropriate (1). The child’s primary care pro- infants to have bottles in the crib. The facility should not vider may also recommend reduced fat (2%) milk for some permit an infant to carry a bottle while standing, walking, or children this age. Studies show no compromise in growth, running around. and no difference in height, weight, or percentage of body Bottle feeding techniques should mimic approaches to fat and neurological development in toddlers fed reduced fat breastfeeding: (2%) milk compared with those fed whole milk (2,8,9). The a) Initiate feeding when infant provides cues (rooting, American Academy of Pediatrics recommends that cow’s sucking, etc.); milk not be used during the first year of life (3-7). b) Hold the infant during feedings and respond to Sometimes early care and education pro- COMMENTS: vocalizations with eye contact and vocalizations; grams have children ages eighteen months to three years of Alternate sides of caregiver’s/teacher’s lap; c) age in one classroom and staff report it is difficult to serve d) Allow breaks during the feeding for burping; different types of milk (1% and 2%) to specific children. Pro- e) Allow infant to stop the feeding. grams can use a different color label for each type of milk A caregiver/teacher should not bottle feed more than one on the container or pitcher. Caregivers/teachers can explain infant at a time. to the children the meaning of the color labels and identify which milk they are drinking. Bottles should be checked to ensure they are given to the appropriate child, have human milk, infant formula, or water TYPE OF FACILITY: Center; Large Family Child Care Home; Small in them. Family Child Care Home When using a bottle for a breastfed infant, a nipple with a RELATED STANDARDS: Standard 4.2.0.4: Categories of Foods cylindrical teat and a wider base is usually preferable. A Standard 4.9.0.3: Precautions for a Safe Food Supply shorter or softer nipple may be helpful for infants with a hypersensitive gag reflex, or those who cannot get their lips REFERENCES: well back on the wide base of the teat (22). 1. Daniels, S. R., F. R. Greer, Committee on Nutrition. 2008. Lipid screening and cardiovascular health in childhood. Pediatrics The use of a bottle or cup to modify or pacify a child’s be- 122:198-208. havior should not be allowed (1,16). 2. Wosje, K. S., B. L. Specker, J. Giddens. 2001. No differences in growth or body composition from age 12 to 24 months between RATIONALE: The manner in which food is given to infants toddlers consuming 2% milk and toddlers consuming whole milk. is conducive to the development of sound eating habits for 101:53-56. J Am Diet Assoc life. Caregivers/teachers should promote proper feeding 3. Dietz, W. H., L. Stern, eds. 1998. American Academy of practices and oral hygiene including proper use of the bottle . New York: Villard. Pediatrics guide to your child’s nutrition for all infants and toddlers. Bottle propping can cause chok- 4. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook . 6th ed. ing and aspiration and may contribute to long-term health Elk Grove Village, IL: American Academy of Pediatrics. issues, including ear infections (otitis media), orthodontic 5. Dietitians of Canada, American Dietetic Association. 2000. problems, speech disorders, and psychological problems Manual of clinical dietetics . 6th ed. Chicago: ADA. (1-6). When infants and children are “cue fed”, they are in 6. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood . 6th ed. New York: McGraw-Hill. control of frequency and amount of feedings. This has been 7. American Academy of Pediatrics, Committee on Nutrition. 1992. found to reduce the risk of childhood obesity. 89:1105-9. Pediatrics The use of whole cow’s milk in infancy. Any liquid except plain water can cause early childhood car - 8. Rask-Nissila, L., E. Jokinen, P. Terho, A. Tammi, H. Lapinleimu, ies (7-18). Early childhood caries in primary teeth may hold T. Ronnemaa, J. Viikari, R. Seppanen, T. Korhonen, J. Tuominen, I. significant short-term and long-term implications for the Valimaki, O. Simell. 2000. Neurological development of 5-year-old child’s health (7-18). Frequently sipping any liquid besides children receiving a low-saturated fat, low-cholesterol diet since 284:993-1000. infancy: A randomized controlled trial. JAMA plain water between feeds encourages tooth decay. 9. Niinikoski, H. Lapinleimu, , J. Viikari, H. Lapinleimu, T. Rönnemaa, Children are at an increased risk for injury when they walk E. Jokinen, R. Seppänen, P. Terho, J. Tuominen, I. Välimäki, around with bottle nipples in their mouths. Bottles should O. Simell. 1997. Growth until 3 years of age in a prospective, not be allowed in the crib or bed for safety and sanitary randomized trial of a diet with reduced saturated fat and reasons and for preventing dental caries. It is difficult for a Pediatrics 99:687-94. cholesterol. caregiver/teacher to be aware of and respond to infant feed- ing cues when the child is in a crib or bed and when feeding more than one infant at a time. 170 Chapter 4: Nutrition and Food Service

201 Caring for Our Children: National Health and Safety Performance Standards 8. Ramos-Gomez, F. J. 2005. Clinical considerations for an infant COMMENTS: Caregivers/teachers and parents/guardians 26:17-23. Compend Contin Educ Dent oral health care program. need to understand the relationship between bottle feeding 9. Ramos-Gomez, F. J., B. Jue, C. Y. Bonta. 2002. Implementing an and emotional security. Caregivers/teachers should hold J Calif Dent Assoc infant oral care program. 30:752-61. infants who are bottle feeding whenever possible, even if 10. U.S. Department of Health and Human Services (DHHS). 2000. the children are old enough to hold their own bottle. Oral health in America: A report of the surgeon general–Executive . Rockville, MD: DHHS, National Institute of Dental and summary Caregivers/teachers should offer children fluids from a cup Craniofacial Research, National Institutes of Health. as soon as they are developmentally ready. Some children 11. Section on Pediatric Dentistry and Oral Health. 2008. Preventive may be able to drink from a cup around six months of age, oral health intervention for pediatricians. Pediatrics 122:1387-94. while for others it is later (2). Weaning a child to drink from 12. New York State Department of Health. 2006. Oral health care a cup is an individual process, which occurs over a wide during pregnancy and early childhood: Practice guidelines. Albany, range of time. The American Academy of Pediatric Dentistry NY: New York State Department of Health. http://www.health.state (AAPD) recommends weaning from a bottle by the child’s .ny.us/publications/0824.pdf. first birthday (1-3,6-9). Instead of sippy cups, caregivers/ 13. American Dental Association. 2004. From baby bottle to cup: teachers should use smaller cups and fill halfway or less to Choose training cups carefully, use them temporarily. J Am Dent prevent spills as children learn to use a cup (19-21). If sippy Assoc 135:387. 14. American Dental Association. ADA statement on early childhood cups are used, it should only be for a very short transition caries. http://www.ada.org/2057.aspx. period. 15. The American Academy of Pediatric Dentistry (AAPD). 2002. Some children around six months to a year of age may be Policy on baby bottle tooth decay (BBTD)/early childhood caries developmentally ready to feed themselves and may want to 23. Chicago, IL: AAPD. Reference manual 2002-2003, (ECC). In drink from a cup. The transition from bottle to cup can come http://www.aapd.org/members/referencemanual/pdfs/02-03/Baby at a time when a child’s fine motor skills allow use of a cup. Bottle Tooth Decay.pdf. 16. American Academy of Pediatrics. 2007. Brushing up on oral The caregiver/teacher should use a clean small cup without Healthy Children (Winter): 14-15. health: Never too early to start. cracks or chips and should help the child to lift and tilt the http://www.healthychildren.org/english/healthy-living/oral-health/ cup to avoid spillage and leftover fluid. The caregiver/teach- pages/Brushing-Up-on-Oral-Health-Never-Too-Early-to-Start.aspx. er and parent/guardian should work together on cup feeding 17. Tinanoff, N., C. Palmer. 2000. Dietary determinants of dental of human milk to ensure the child’s receiving adequate caries and dietary recommendations for preschool children. J Public nourishment and to avoid having a large amount of human Health Dent 60:197-206. milk remaining at the end of feeding. Two to three ounces of 18. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and human milk can be placed in a clean cup and additional milk childhood . 6th ed. New York: McGraw-Hill. can be offered as needed. Small amounts of human milk 19. Prolonged use of sippy cups under scrutiny. 2002. Dentistry (about an ounce) can be discarded. Today 21:44. 20. Behrendt, A., F. Szlegoleit, V. Muler-Lessmann, G. Ipek-Ozdemir, Infants should be burped after every feeding and preferably W. F. Wetzel. 2001. Nursing-bottle syndrome caused by pro