The Standard of the Month
washing hands

The AAP has published national health and safety recommendations and guidelines for children in family- and center-based child care programs in Caring for Our Children: National Health and Safety Performance Standards; Guidelines for Early Care and Education Programs, 3rd Edition and Preventing Childhood Obesity in Early Care and Education Programs along with the American Public Health Association and National Resource Center for Health and Safety in Child Care.

Caring for Our Child can be an overwhelming publication for child care providers. Where do they start and how can they implement the standards? To help child care providers and child care health consultants successfully implement the Caring for Our Children standards, we will be focusing on one standard each month. With a team of experienced pediatricians, child care health consultants, child care directors, and family child care providers, we collected stories, ideas, and strategies that support "The Standard of the Month".

Feel free to share this information in your newsletters. Please do not alter the text. If you are stating specific standards (this includes the comments and rationale), please cite Preventing Childhood Obesity in Early Care and Education Programs or Caring for Our Children, depending on where the standard came from. If you are using the "Learn From Your Peers" section, please cite this Web page.

To subscribe to our listserv to receive "The Standard of the Month", click here.

For additional materials to help you implement health and safety standards, visit the Resource Library.

May 2012

Standard 5.4.5.2 Cribs

Facilities should check each crib before its purchase and use to ensure that it is in compliance with the current U.S. Consumer Product Safety Commission (CPSC) and ASTM safety standards.

Recalled or second-hand cribs should not be used or stored in the facility. When it is determined that a crib is no longer safe for use in the facility, it should be dismantled and disposed of appropriately.

Staff should only use cribs for sleep purposes and should ensure that each crib is a safe sleep environment. No child of any age should be placed in a crib for a time-out or for disciplinary reasons. When an infant becomes large enough or mobile enough to reach crib latches or potentially climb out of a crib, they should be transitioned to a different sleeping environment (such as a cot or sleeping mat).

Each crib should be identified by brand, type, and/or product number and relevant product information should be kept on file (with the same identification information) as long as the crib is used or stored in the facility.

Staff should inspect each crib before each use to ensure that hardware is tightened and that there are not any safety hazards. If a screw or bolt cannot be tightened securely, or there are missing or broken screws, bolts, or mattress support hangers, the crib should not be used.

Safety standards document that cribs used in facilities should be made of wood, metal, or plastic. Crib slats should be spaced no more than two and three-eighths inches apart, with a firm mattress that is fitted so that no more than two fingers can fit between the mattress and the crib side in the lowest position. The minimum height from the top of the mattress to the top of the crib rail should be twenty inches in the highest position. Cribs with drop sides should not be used. The crib should not have corner post extensions (over one-sixteenth inch). The crib should have no cutout openings in the head board or footboard structure in which the head of a child could become entrapped. The mattress support system should not be easily dislodged from any point of the crib by an upward force from underneath the crib. All cribs should meet the ASTM F1169-10a Standard Consumer Safety Specification for Full-Size Baby Cribs, F406-10b Standard Consumer Safety Specification for Non-Full-Size Baby Cribs/Play Yards, or the CPSC 16 CFR 1219, 1220, and 1500 - Safety Standards for Full-Size Baby Cribs and Non-Full-Size Baby Cribs; Final Rule.

Cribs should be placed away from window blinds or draperies.

As soon as a child can stand up, the mattress should be adjusted to its lowest position. Once a child can climb out of his/her crib, the child should be moved to a bed. Children should never be kept in their crib by placing, tying, or wedging various fabric, mesh, or other strong coverings over the top of the crib.

Cribs intended for evacuation purpose should be of a design and have wheels that are suitable for carrying up to five non-ambulatory children less than two years of age to a designated evacuation area. This crib should be used for evacuation in the event of fire or other emergency. The crib should be easily moveable and should be able to fit through the designated fire exit.

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-Standard Rationale

Standards have been developed to define crib safety, and staff should make sure that cribs used in the facility meet these standards to protect children and prevent injuries or death (1-3). Significant changes to the ATSM and CPSC standards for cribs were published in December 2010. As of June 28, 2011 all cribs being manufactured, sold or leased must meet the new stringent requirements. Effective December 28, 2012 all cribs being used in early care and education facilities including family child care homes must also meet these standards. For the most current information about these new standards please go to http://www.cpsc.gov/info/cribs/index.html.

More infants die every year in incidents involving cribs than with any other nursery product (4). Children have become trapped or have strangled because their head or neck became caught in a gap between slats that was too wide or between the mattress and crib side.

An infant can suffocate if its head or body becomes wedged between the mattress and the crib sides (6).

Corner posts present a potential for clothing entanglement and strangulation (5). Asphyxial crib deaths from wedging the head or neck in parts of the crib and hanging by a necklace or clothing over a corner post have been well-documented (6).

Children who are thirty-five inches or taller in height have outgrown a crib and should not use a crib for sleeping (4). Turning a crib into a cage (covering over the crib) is not a safe solution for the problems caused by children climbing out. Children have died trying to escape their modified cribs by getting caught in the covering in various ways and firefighters trying to rescue children from burning homes have been slowed down by the crib covering (6).

CPSC has received numerous reports of strangulation deaths on window blind cords over the years (7).

-Type of Facility

Center; Large Family Child Care Home; Small Family Child Care Home

-Comments

For more information on articles in cribs, see Standard 5.4.5.1: Sleeping Equipment and Supplies and Standard 6.4.1.3: Crib Toys.

A safety-approved crib is one that has been certified by the Juvenile Product Manufacturers Association (JPMA).

If portable cribs and those that are not full-size are substituted for regular full-sized cribs, they must be maintained in the condition that meets the ASTM F406-10b Standard Consumer Safety Specification for Non-Full-Size Baby Cribs/Play Yards. Portable cribs are designed so they may be folded or collapsed, with or without disassembly. Although portable cribs are not designed to withstand the wear and tear of normal full-sized cribs, they may provide more flexibility for programs that vary the number of infants in care from time to time.

Cribs designed to be used as evacuation cribs, can be used to evacuate infants, if rolling is possible on the evacuation route(s).

To keep window blind cords out of the reach of children, staff can use tie-down devices or take the cord loop and cut it in half to make two separate cords. Consumers can call 1-800-506-4636 or visit the Window Covering Safety Council Website at http://windowcoverings.org to receive a free repair kit for each set of blinds.

-Standard References

  1. ASTM International. 2010. ASTM F1169-10a: Standard consumer safety specification for full-size baby cribs. West Conshohocken, PA: ASTM

  2. ASTM International. 2010. ASTM F406-10b: Standard consumer safety specification for non-full-size baby cribs/play yards. West Conshohocken, PA: ASTM.

  3. U.S. Consumer Product Safety Commission (CPSC). 2010. Safety standards for full-size baby cribs and non-full-size baby cribs; final rule. 16 CFR 1219, 1220, and 1500. http://www.cpsc
    .gov/businfo/frnotices/fr11/cribfinal.pdf.

  4. U.S. Consumer Product Safety Commission (CPSC). 1997. The safe nursery. Washington, DC: CPSC. http://www.cpsc.gov/cpscpub/pubs/202.pdf.

  5. Juvenile Products Manufacturers Association. 2007. Safe and sound for baby: A guide to juvenile product safety, use, and selection. 9th ed. Moorestown, NJ: JPMA. http://www.jpma.org/content/retailers/safe-and-sound/.

  6. U.S. Consumer Product Safety Commission (CPSC). 1996. CPSC warns parents about infant strangulations caused by failure of crib hardware. Document #5025. http://www.cpsc.gov/cpscpub/pubs/5025.html.

  7. U.S. Consumer Product Safety Commission (CPSC). Are your window coverings safe? http://www.cpsc.gov/cpscpub/pubs/5009a.pdf.

 


April 2012

Standard 9.2.4.5: Emergency and Evacuation Drills/Exercises Policy

The facility should have a policy documenting that emergency drills/exercises should be regularly practiced for geographically appropriate natural disasters and human generated events such as:

  • Fire, monthly;
  • Tornadoes, on a monthly basis in tornado season;
  • Floods, before the flood season;
  • Earthquakes, every six months;
  • Hurricanes, annually;
  • Threatening person outside or inside the facility;
  • Rabid animal;
  • Toxic chemical spill;
  • Nuclear event.

All drills/exercises should be recorded. Please see Standard 9.4.1.16: Evacuation and Shelter-in-Place Drill Record for more information.

A fire evacuation procedure should be approved and certified in writing by a fire inspector for centers, and by a local fire department representative for large and small family child care homes, during an annual on-site visit when an evacuation drill is observed and the facility is inspected for fire safety hazards.

Depending on the type of disaster, the emergency drill may be within the existing facility such as in the case of earthquakes or tornadoes where the drill might be moving to a certain location within the building (basements, away from windows, etc.) Evacuation drills/exercises should be practiced at various times of the day, including nap time, during varied activities and from all exits. Children should be accounted for during the practice.

The facility should time evacuation procedures. They should aim to evacuate all persons in the specific number of minutes recommended by the local fire department for the fire evacuation, or recommended by emergency response personnel.

Cribs designed to be used as evacuation cribs, can be used to evacuate infants, if rolling is possible on the evacuation route(s).

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-Standard Rationale

Regular emergency and evacuation drills/exercises constitute an important safety practice in areas where these natural or human generated disasters might occur. The routine practice of such drills fosters a calm, competent response to a natural or human generated disaster when it occurs (1). The extensive turnover of both staff and children, in addition to the changing developmental abilities of the children to participant in evacuation procedures in child care, necessitates frequent practice of the exercises.

-Type of Facility

Center; Large Family Child Care Home; Small Family Child Care Home

-Comments

Fire inspectors or local fire department representatives can contribute their expertise when observing evacuation plans and drills. They also gain familiarity with the facility and the facility’s plans in the event they are called upon to respond in an emergency. In family child care homes, the possibility of infant rooms or napping areas being located on levels other than the main level makes having consideration and written approval from the fire inspector or local fire department representative of the program’s evacuation plan especially important since infants require more assistance compared to other age groups during an evacuation.

-Standard References

  1. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/.

March 2012

Standard 2.1.3.6 Fostering Language Development of Three- to Five- Year-Olds

The indoor and outdoor learning/play environment should be rich in first-hand experiences that offer opportunities for language development. They should also have an abundance of books of fantasy, fiction, and nonfiction, and provide chances for the children to relate stories. Caregivers/teachers should foster language development by

  • Speaking with children rather than at them;
  • Encouraging children to talk with each other by helping them to listen and respond;
  • Giving children models of verbal expression;
  • Reading books about the child’s culture and history, which would serve to help the child develop a sense of self;
  • Reading to children and re-reading their favorite books;
  • Listening respectfully when children speak;
  • Encouraging interactive storytelling;
  • Using open-ended questions;
  • Provide opportunities during indoor and outdoor learning/play to use writing supplies and printed materials;
  • Provide and read books relevant to their natural environment outdoors (for example, books about the current season, local wildlife, etc.);
  • Provide settings that encourage children to observe nature, such as a butterfly garden, bird watching station, etc.;
  • Providing opportunities to explore writing, such as through a writing area or individual journals.

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-Standard Rationale

Language reflects and shapes thinking. A curriculum should be created to match preschoolers’ needs and interests enhances language skills. First-hand experiences encourage children to talk with each other and with adults, to seek, develop, and use increasingly more complex vocabulary, and to use language to express thinking, feeling, and curiosity (1-3).

-Type of Facility

Center; Large Family Child Care Home; Small Family Child Care Home

-Comments

Compliance with development should be measured by structured observation. Examples of verbal encouragement or verbal expression are: “ask Johnny if you may play with him”; “tell him you don’t like being hit”; “tell Sara what you saw downtown yesterday;” “can you tell Mommy about what you and Johnny played this morning?” These encouraging statements should be followed by respectful listening, without pressuring the child to speak.

-Standard References

  1. Szanton, E. S., ed. 1997. Creating child-centered programs for infants and toddlers, birth to 3 year olds, step by step: A Program for children and families. New York: Children’s Resources International.

  2. Snow, C. E., M. S. Burns, P. Griffin. 1999. Language and literacy environments in preschools. ERIC Digest (January).
  3. Maschinot, B. 2008. The changing face of the United States: The influence of culture on early child development. Washington, DC: Zero to Three. http://www.zerotothree.org/site/DocServer/Culture_book.pdf?docID=6921.

 

February 2012

Standard 5.3.1.2 Product Recall Monitoring - NEW

Staff should, on a monthly basis, seek information on recalls of juvenile products that may be in use at the facility. Of particular importance are recalls related to cribs, bassinets, and portable play yards that may be used for infant sleep. Additionally, caregivers/teachers should be aware of recalls of toys, playground equipment, strollers, and any other product routinely used by children in the child care facility.

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-Standard Rationale

Product recalls are often ineffective at removing hazardous products from use because the owners/users are not aware of the recall. Children have died in child care settings from injury related to sleep equipment that had been recalled.

-Type of Facility

Center; Large Family Child Care Home; Small Family Child Care Home

-Comments

The U.S. Consumer Product Safety Commission (CPSC) offers a free subscription email service for product recall notices at http://www.cpsc.gov/cpsclist.aspx. Subscribers can note that they only want to receive recalls related to juvenile products.

-Learn From Your Peers

All information on product recalls should be clearly posted in the center and shared with parents through parent newsletters.  Many parents may not be aware of recalls or how to track them.
--- Child Development Specialist

Specific staff members should be assigned to check for recalls to ensure accountability.  The items could be divided into categories and distributed among staff members so that it is not so overwhelming.  Documentation is recommended.  I recommend that all programs register for the emails regarding recalls on the CPSC Web site.
--- Child Care Health Consultant

Child care practitioners need to be cautious when accepting donations of used goods or when purchasing items from yard sales, flea markets and auctions.  Although manufacturers are not permitted to sell recalled items, these items sometimes stay in the market through good intentions of donors and original owners of the product who may be unaware of the dangers.  Even unused, packaged items could be a previously recalled product.  It is best to reference the CPSC recall list to check the safety of any such donations/purchases.

The CPSC also has a smart phone application to alert consumers to recalled items.
--- ECE Specialist

January 2012

Standard 9.2.3.14 Oral Health Policy

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

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

 

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-Standard Rationale

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

-Type of Facility

Large Family Child Care Home; Small Family Child Care Home

-Standard References

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

-Learn From Your Peers

I feel it is important to lead by example. Therefore at our tooth brushing times, I brush my teeth as well. Each child has his/her own toothbrush that is kept separate from the other children’s. Each time toothpaste is purchase, it is researched to make sure it is safe and the parents are shown what their chid(ren) will be using.
To build families knowledge of good dental health, tip sheets and websites are sent home. We do a month long unit on good oral health. Activities are sent home, so that what the children in the home carries across to their homes.
In a former classroom, we had a dentist and hygienist come and speak to the children. They then checked each child’s teeth. If there were issues and the family had no dentist/ insurance, then he would provide services for free.
--- Family Day Care Provider

In regards to implementing tooth brushing, there are many things to consider including in an oral health policy. Things such as the following:

  • Tooth brushing should take place at a “clean” sink.  A “clean” sink is defined as a sink that is not used for toileting/diapering or a sink that has been disinfected before and after use.
  • Tooth brushes should be stored open to air, bristles up, not touching other brushes.
  • Toothbrushes should be labeled.
  • Toothbrushes should be stored out of the children’s reach and not over or around a toilet. In centers, toothbrushes cannot be stored in the bathroom.
  • Toothbrushes should be replaced every 3 months and after an illness such as strep throat.
  • Toothpaste is not required to use, but if used, it is important to use the recommended amount for the age of child.  Children should each have their own labeled toothpaste; however,  if the toothpaste tube is shared by several children, it is important to distribute it in a sanitary manner by applying to paper towel or cup instead of directly placing the toothpaste on each toothbrush.
  • Fluoride toothpaste is recommended to be kept out of the reach of children.  Toothbrushing should be supervised.
  • Only one child should be allowed to brush at the sink at a time to prevent children from spitting on each other and spreading germs.
  • Written parental permission is recommended to obtain for using toothpaste

--- Child Care Health Consultant

Oral Health:

  • Check for family eligibility for state/federally funded dental programs
  • Have a dentist check children’s teeth at the program every six months
  • Brush teeth before rest time/nap time starting at 2 years old.  All toothbrushes are labeled and stored according to state/federal health regulations and toothpaste used is acceptable by state/federal guideline

--- State Coordinator

 

December 2011

Standard 2.1.1.6 Transitioning within Programs and Indoor and Outdoor Learning/Play Environments

Caregivers/teachers should take into consideration the individual needs of children when transitioning them to a new indoor and outdoor learning/play environment. The transitioning child/children should be offered the opportunity to visit the new space with a familiar caregiver/teacher with enough time to allow them to display comfort in the new space. The program should allow time for communication with the families regarding the process and for each child to follow through a comfortable time line of adaptation to the new indoor and outdoor learning/play environment, caregiver/teachers, and peers.

Children need time to manipulate, explore and familiarize themselves with the new space and caregivers/teachers. This should be done before they are part of a new group to allow them time to explore to their personal satisfaction. Eating is a primary reinforcer and need. The opportunity to share food within the new space will help reassure a child and help adults assess how the transition is going. Toileting involves another level of trust. Diapering/toileting should be introduced in the new space with a familiar teacher.

New routines should be introduced by the new staff with a familiar caregiver/teacher present to support the child/children. Transitions to the indoor and outdoor learning/play environment, especially if the space is different than the one from which they are familiar, should follow similar procedures as moving to another indoor space. Parents/guardians should be part of the transition as they too are in the process of learning to trust a new indoor and outdoor learning/play environment for their child. Primary needs need to be met to support a smooth transition.

Transitions should be planned in advance, based on the child’s readiness. A written plan should be developed and shared with parents/guardians, describing how and when the transition will occur. Children should not be moved to a new indoor and outdoor learning/play environment for the sole purpose of maintaining child: staff ratios.

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-Standard Rationale

Supporting the achievement of developmental tasks for young children is essential for their social and emotional health. Establishing trust with caregivers/teachers and successful adaptation to a new indoor and outdoor learning/play environment is a critical component of quality care. Young children need predictability and routine. They need to feel secure and to understand the expectations of their environment. By taking time to allow them to familiarize themselves with their new caregivers/teachers and environment, they are better able to handle the emotional, cognitive, and social requirements of their new space (1-5)

-Type of Facility

Center; Large Family Child Care Home; Small Family Child Care Home

-Standard References

  1. Erikson, E. H. 1950. Childhood and society. New York: W.W. Norton and Co.

  2. Gorski, P. A., S. P. Berger. 2005. Emotional health in child care. In Health in child care: A manual for health professionals, ed. J. R. Murph, S. D. Palmer, D. Glassy, 173-86. Elk Grove Village, IL: American Academy of Pediatrics.
  3. Lally, R. L., L. Y. Torres, P. C. Phelps. 1994. Caring for infants and toddlers in groups: Necessary considerations for emotional, social, and cognitive development. Zero to Three 14:1-8.
  4. Mahler, M., F. Pine, A. Bergman. 1975. The Psychological birth of the human infant. New York: Basic Books.
  5. Maslow, A. 1943. A theory of human motivation. Psychological Review 50:370-96

-Learn From Your Peers

In my experience this standard addresses a key opportunity for relationship building and a potential focal point for anxiety on the part of both parents and children. This is especially true when parents of infants and toddlers are unsure their child is prepared for or will get the care they are accustomed to in the “next room”. Often times this is not just an adjustment to new caregivers, but significantly different staff:child ratios and classroom routines. This standard provides some ideas such as visits and observations, meals and toileting, but I would also suggest a mentoring or “buddy” system where a parent is able to speak to another parent in the new room prior to and after the child’s move. For toddlers and preschoolers, preparing a slightly older child in the new room to guide the new child (perhaps give him/her a “tour” or sit next to them at a meal or activity) might also ease the adjustment. It also builds a spirit of nurturing that is essential to maintaining trusting relationships.
--- T/TA Specialist

For school-age youth, group transitions provide opportunities for creative solutions!  Some teachers use chants or songs to ensure their students effectively transition.  Some children struggle with transition times as they may want to complete their current tasks.  Frequent reminders or countdowns can not only help improve their compliance, but can be fun ways to infuse number and time concepts.  Students enjoy the peaceful way our countdown song flows and can add their own rhyming lines as the time goes by.  “Five more minutes till P.E. time, five more minutes till P.E. time, five more minutes till P.E. time, so let’s get ready to go” shows advance notice.  Counting down from 60 seconds in the final minute with everyone getting in line can also replace stressful times for class leaders.  “60 more seconds till P.E. time, we’re getting closer to heading out, 50 more seconds and we’ll be gone, etc.” 
--- Team Leader

Transitioning toddlers and young preschoolers from outdoor to indoor spaces is an often overlooked sensitive period.  Providers should carefully and frequently count the children while they are engaged in play outside.  They also need to carefully search the playground area for distracted children before bringing the class or group back inside.  Toddlers and preschoolers are often highly engaged in play or rest outside and do not respond to their names when called.  It is advisable to count the children before, during, and after each transition i.e. before going outdoors, while they are playing, before going inside, and once inside.  Checking any tunnels or difficult to view play areas such as doll houses or other structures is also important.
--- Educational Consultant, former Director and Teacher

October 2011

Standard 7.3.3.1 Influenza Immunizations for Children and Caregivers/Teachers

The parent/guardian of each child six months of age and older should provide written documentation of current an­nual vaccination against influenza unless there is a medical contraindication or philosophical or religious objection. Children who are too young to receive influenza vaccine before the start of influenza season should be immunized annually beginning when they reach six months of age.

Staff caring for all children should receive annual vaccina­tion against influenza. Ideally people should be vaccinated before the start of the influenza season (as early as August or September) and immunization should continue through March or April.

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-Standard Rationale

The American Academy of Pediatrics (AAP) and the Advisory Committee on Immunization Practices (ACIP) recommend that influenza vaccination of all children, begins at six months of age, and adolescents and adults begin before or during the influenza season. Children who are at high risk of influenza complications and respiratory tract infections such as influenza commonly are scattered in out-of-home child care settings. The risk of complica­tions from influenza is greater among children less than two years of age. Infants less than six months of age represent a particularly vulnerable group because they are too young to receive the vaccine. Therefore, people responsible for caring for these children should be immunized (1,2).

Seasonal influenza vaccine should be offered to all children as soon as the vaccine is available, even as early as August or September; a protective response to immunization re­mains throughout the influenza season. Immunization efforts should continue throughout the entire influenza season, even after influenza activity has been documented in a com­munity. Each influenza season often extends well into March and beyond, and there may be more than one peak of activ­ity in the same season. Thus, immunization through at least May 1st can still protect recipients during that particular season and also provide ample opportunity to administer a second dose of vaccine to children requiring two doses in that season (1).

Children who are too young to receive the influenza vaccine before the start of influenza season should be immunized when they reach six months of age, if influenza vaccination is still recommended at that time. Child contacts who are vaccine-eligible should be vaccinated.

-Type of Facility

Center; Large Family Child Care Home; Small Family Child Care Home

-Standard References

  1. American Academy of Pediatrics, Committee on Infectious Disease. 2010. Recommendations for prevention and control of influenza in children, 2010-2011. Pediatrics 126:816-28.

  2. Centers for Disease Control and Prevention. 2010. Update: Recommendations of the ACIP regarding use of CSL seasonal influenza vaccine (Afluria) in the United States during 2010-2011. MMWR 59 (31): 989-92. http://www.cdc.gov/mmwr/preview/ mmwrhtml/mm5931a4.htm.

-Learn From Your Peers

My parents are advised by their pediatricians to have children in child care immunized for flu, and they are very good about doing so.
--- Owner and Director

The flu vaccine is very safe.  It is only a myth that you can get the flu itself from the vaccine.  There are around 200,000 hospitalizations due to flu complications every year in this country, and about half of those are children.  Infants, toddlers, and children with chronic health problems are the most at-risk.  Many of those children cannot receive the vaccine, so it is critical that they be protected as much as possible by everyone around them being vaccinated.  Child care centers offer an easy source of spread for this virus to their enrolled children, staff, and the rest of the community.  Most pediatricians promote flu vaccines for their patients, but there are many barriers, including the fact that a seasonal vaccine causes many children to get missed.  Center directors should also take a leading role in promoting the flu vaccine by either requiring or highly encouraging it for all children and staff.
--- Pediatrician

In order to encourage influenza vaccine for staff and children, a few child care programs have provided an on-site “flu shot clinic” at their child care facility with help from their public health unit or an independent nursing service.  Posting information on influenza vaccine is also helpful, along with tracking infants and giving their parents reminders when they become 6 months old and are eligible for the flu vaccine.
--- Child Care Health Consultant

All employees at our center were required to either get the immunization or fill out a form stating that they would opt out. If they did not get it they were required to wear a face mask any time they were in contact with others, including in the halls and elevators. All ID badges were color coded, red for those who had received the vaccine, green for those who had not. People hated it and thought it was an invasion of privacy, but there were no cases of staff-passed flu in the hospital or our affiliated child development center this year.
--- Director


September 2011

September is "National Preparedness" month. With the recent hurricanes, tornadoes, and earthquakes that have occurred in the United States, it is more important than ever to prepare, plan and stay informed. This month we will highlight the necessary components of an Emergency/Disaster Plan, suggested training for staff and essential information for communicating with parents. With that in mind, in lieu of "Learn From Your Peer" this month, additional resources have been provided.

Standard 9.2.4.3 Disaster Planning, Training and Communication

Facilities should consider how to prepare for and respond to emergency or natural disaster situations and develop written plans accordingly. All programs should have procedures in place to address natural disasters that are relevant to their location (such as earthquakes, tornados, tsunamis or flash floods, storms, and volcanoes) and all hazards/disasters that could occur in any location including acts of violence, bioterrorism/terrorism, exposure to hazardous agents, facility damage, fire, missing child, power outage, and other situations that may require evacuation, lock-down, or shelter-in-place.

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-Standard Rationale

The only way to prepare for disasters is to consider various worst case or unique scenarios, and to develop contingency plans. By brainstorming and thinking through a variety of “what if...” situations and developing re­cords, protocols/procedures, and checklists, facilities will be better able to respond to an unusual emergency or disaster situation.

Providing clear, accurate, and helpful information to parents/guardians as soon as possible is crucial. Sharing writ­ten policies with parents/guardians when they enroll their child, informing them of routine practices, and letting them know how they will receive information and updates, will help them understand what to expect. Notifying parents/guardians about emergencies or disaster situations without causing alarm or prompting inappropriate action is challenging. The content of such communications will depend on the situation. Sometimes, it will be necessary to provide infor­mation to parents/guardians before all details are known. In a serious situation, the federal government, the governor, or the state or county health official may announce or declare a state of emergency, a public health emergency, or a disaster. If a facility is unsure of what to do, the first point of contact in any situation should be the local health authority. The local health authority, in partnership with emergency personnel and other officials will know how to engage the appropriate public health and other professionals for the situation.

-Standard Comments

Disaster planning and response protocols are unique, and they are typically customized to the type of emergency or disaster; geographical area; identified needs and available resources; applicable federal, state, and local regulations; and the incident command structure in place at the time. The U.S. Department of Homeland Security and the Federal Emergency Management Agency (FEMA) operate under a set of principles and authorities described in various laws and the National Response Framework (see http://www.fema.gov/emergency/nrf/ for details). Each state is required to maintain a state disaster preparedness plan and a separate plan for responding to a pandemic influenza. These plans may be developed by separate agencies, and the point person or the key contact for a child care facility can be the State Emergency Coordinator, a representative in the State Department of Health, an individual associated with the agency that licenses child care facilities for that state, or another official. The State Child Care Administrator is a key contact for any facility that receives federal support.

To develop an Emergency/Disaster Plan that is effective and in compliance with state requirements, the facility must identify who their key contact would be (and what the requirements for their program might be in an emergency or disaster situation) in advance of an unexpected situation. Identifying and connecting with the appropriate key contact before a disaster strikes is crucial for many reasons, but particularly because the identified official may not know how to contact or connect with individual child care facilities.

-Standard References


  1. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine, Task Force on Terrorism. 2006. Policy statement: The pediatrician and disaster preparedness. Pediatrics 117:560-65.

  2. National Association of Child Care Resource and Referral and Save the Children, Domestic Emergencies Unit. 2010. Protecting children in child care during emergencies.

-Written Emergency/Disaster Plan

Facilities should develop and implement a written plan that describes the practices and procedures they use to prepare for and respond to emergency or disaster situations. This Emergency/Disaster Plan should include:

a) Information on disasters likely to occur in or near the facility, county, state, or region that require advance preparation and/or contingency planning;

b) Plans (and a schedule) to conduct regularly scheduled practice drills within the facility and in collaboration with community or other exercises;

c) Mechanisms for notifying and communicating with parents/guardians in various situations (e.g., Website postings; email notification; central telephone number, answering machine, or answering service messaging; telephone calls, use of telephone tree, or cellular phone texts; and/or posting of flyers at the facility and other community locations);

d) Mechanisms for notifying and communicating with emergency management public officials;

e) Information on crisis management (decision-making and practices) related to sheltering in place, relocating to another facility, evacuation procedures including how non-mobile children and adults will be evacuated, safe transportation of children including children with special health care needs, transporting necessary medical equipment obtaining emergency medical care, responding to an intruder, etc.;

f) Identification of primary and secondary meeting places and plans for reunification of parents/ guardians with their children;

g) Details on collaborative planning with other groups and representatives (such as emergency management agencies, other child care facilities, schools, emergency personnel and first responders, pediatricians/health professionals, public health agencies, clinics, hospitals, and volunteer agencies including Red Cross and other known groups likely to provide shelter and related services);

h) Continuity of operations planning, including backing up or retrieving health and other key records/files and managing financial issues such as paying employees and bills during the aftermath of the disaster;

i) Contingency plans for various situations that address:

1)
Emergency contact information and procedures;
2) How the facility will care for children and account for them, until the parent/guardian has accepted responsibility for their care;
3) Acquiring, stockpiling, storing, and cycling to keep updated emergency food/water and supplies that might be needed to care for children and staff for up to one week if shelter-in-place is required and when removal to an alternate location is required;
4) Administering medicine and implementing other instructions as described in individual special care plans;
5) Procedures that might be implemented in the event of an outbreak, epidemic, or other infectious disease emergency (e.g., reviewing relevant immunization records, keeping symptom records, implementing tracking procedures and corrective actions, modifying exclusion and isolation guidelines, coordinating with schools, reporting or responding to notices about public health emergencies);
6) Procedures for staff to follow in the event that they are on a field trip or are in the midst of transporting children when an emergency or disaster situation arises;
7) Staff responsibilities and assignment of tasks (facilities should recognize that staff can and should be utilized to assist in facility preparedness and response efforts, however, they should not be hindered in addressing their own personal or family preparedness efforts, including evacuation).

 

Details in the Emergency/Disaster Plan should be reviewed and updated bi-annually and immediately after any relevant event to incorporate any best practices or lessons learned into the document.

Facilities should identify in advance which agency or agen­cies would be the primary contact for them regarding child care regulations, evacuation instructions, and other direc­tives that might be communicated in various emergency or disaster situations.

-Training

Staff should receive training on emergency/disaster plan­ning and response. Training should be provided by emer­gency management agencies, educators, child care health consultants, health professionals, or emergency personnel qualified and experienced in disaster preparedness and response. The training should address:

a) Why it is important for child care facilities to prepare for disasters and to have an Emergency/Disaster Plan;

b) Different types of emergency and disaster situations and when and how they may occur;

1)

Natural Disasters

2)

Terrorism (i.e., biological, chemical, radiological, nuclear

3)

Outbreaks, epidemics, or other infectious disease emergencies



c) The special and unique needs of children, appropriate response to children’s physical and emotional needs during and after the disaster, including information on consulting with pediatric disaster experts;

d) Providing first aid, medications, and accessing emergency health care in situations where there are not enough available resources;

e) Contingency planning including the ability to be flexible, to improvise, and to adapt to ever-changing situations;

f) Developing personal and family preparedness plans;

g) Supporting and communicating with families;

h) Floor plan safety and layout;

i) Location of emergency documents, supplies, medications, and equipment needed by children and staff with special health care needs;

j) Typical community, county, and state emergency procedures (including information on state disaster and pandemic influenza plans, emergency operation centers, and incident command structure);

k) Community resources for post-event support such as mental health consultants, safety consultants;

l) Which individuals or agency representatives have the authority to close child care programs and schools and when and why this might occur;
m) Insurance and liability issues;

n) New advances in technology, communication efforts, and disaster preparedness strategies customized to meet children’s needs.

-Communicating with Parents/Guardians:

Facilities should share detailed information about facility disaster planning and preparedness with parents/guardians when they enroll their children in the program, including:

a) Portions of the Emergency/Disaster Plan relevant to parents/guardians or the public;

b) Procedures and instructions for what parents/ guardians can expect if something happens at the facility;

c) Description of how parents/guardians will receive information and updates during or after a potential emergency or disaster situation;

d) Situations that might require parents/guardians to have a contingency plan regarding how their children will be cared for in the unlikely event of a facility closure.

Facilities should conduct an annual drill, test, or “practice use” of the communication options/mechanisms that are selected.

-Addtional Resources

Child Care Resources for Disasters and Emergencies

Head Start Emergency Preparedness Manual

Children and Disasters website:  National Association of Child Care Resource and Referral Agencies (NACCRRA)

Centers for Disease Control and Prevention, Emergency Preparedness and Response

Ready.gov
Ready.gov is a national public service advertising (PSA) campaign designed to educate and empower Americans to prepare for and respond to emergencies including natural and man-made disasters.

AAP Children & Disasters: Child Care Providers
The following resources will be helpful for early education and child care providers, child care health consultants, pediatricians, and others working to strengthen disaster preparedness in child care programs.


August 2011

Standard 7.3.3.3 Influenza Prevention Education

The child care facility should provide refresher training for all staff and children to include emphasis on the value of influenza vaccine, respiratory hygiene, cough etiquette, and hand hygiene at the beginning of each influenza season (usually considered to be September or October with a peak in February and March). Staff and children should be en­couraged to practice these behaviors. Necessary equipment and supplies (e.g., disposable tissues and hand hygiene materials) should be made available.

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-Standard Rationale

Although immunization is the single best way to prevent influenza, appropriate hygiene including respira­tory hygiene, cough etiquette, and hand hygiene have been shown to reduce spread of respiratory tract infections.

In order to be effective, hygiene-based interventions need to be periodically reinforced. Influenza immunizations are rec­ommended for healthy children and adolescents six months through eighteen years of age, for all adults including household contacts and caregivers/teachers of all children younger than five years and health care professionals (1).

-Standard Comments


For more information, see the Centers for Disease Control and Prevention’s (CDC) “Preventing the Spread of Influenza (the Flu) in Child Care Settings: Guid­ance for Administrators, Care Providers, and Other Staff” at http://www.cdc.gov/flu/professionals/infectioncontrol/childcaresettings.htm

-Standard References


  1. Centers for Disease Control and Prevention. 2010. Update: Recommendations of the ACIP regarding use of CSL seasonal influenza vaccine (Afluria) in the United States during 2010-2011. MMWR 59 (31): 989-92. http://www.cdc.gov/mmwr/preview/ mmwrhtml/mm5931a4.htm

-Learn From Your Peers

Health consultants can share a list of local health departments, pharmacies, hospitals, physicians, or other organizations which provide flu immunizations for caregivers, children, and families. 
--- Pediatrician

Hand-washing should be incorporated into the individualized morning greeting and health check for each child.  Asking the parent to assist the child in washing hands saves time, reinforces good habits for families, and reduces germ levels in the program. The morning greeting and health check is also a good opportunity to talk to parents about annual flu vaccination.  Post information about where to get flu vaccination in your community.  You may also want to post a flu prevention poster such as this example:  www.ucsfchildcarehealth.org/pdfs/posters/stop_disease/PreventingFlu_en0909.pdf
--- Child Care Health Consultant

I encourage programs to include parents in their prevention education through the use of newsletters, posters, and parent meetings.   Ideally, good healthy practices at home will reinforce those learned at school.   To ensure proper hand-washing practices, I encourage child care providers to supervise children washing their hands whenever possible and to frequently review the procedure with the children. 
In order to encourage influenza vaccine for staff and children, a few child care programs have provided an on-site “flu shot clinic” at their child care facility.
--- Child Care Health Consultant

While it is clear that immunization of child care professionals is very important in the overall effort to reduce the burden of influenza, it can be quite challenging to get them immunized. Like the general public, many are resistant because they don’t understand the potential severity of the infection and because they have doubts about the safety and effectiveness of the vaccine.  Staff should be educated annually about their duty to protect not only themselves but also the children/families they care for.

Since child care providers often juggle inflexible work schedules with other personal demands, it can be very useful to arrange for a visiting nurse to come to one of the center’s monthly mandatory staff meetings, thus making the low-cost immunizations as easy to get as possible.
--- Pediatrician

 

July 2011

Meal and Snack Patterns

The facility should ensure that the following meal and snack pattern occurs:

  • Children in care for eight and fewer hours in one day should be offered at least one meal and two snacks or two meals and one snack.
  • Children in care more than eight hours in one day should be offered at least two meals and two snacks or three snacks and one meal
  • A nutritious snack should be offered to all children in mid morning (if they are not offered to all children in mid morning (if they are not offered a breakfast on site that is provided within three hours of lunch) and in the middle of the afternoon.
  • Children should be offered food at intervals at least two hours apart and not more than three hours apart unless the child is asleep. Some very young infants may need to be fed at shorter intervals than every two hours to meet their nutritional needs, especially breastfed infants being fed expressed human milk. Lunch service may need to be served to toddlers earlier than the preschool-aged children due to their need for an earlier nap schedule. Children must be awake prior to being offered a meal/snack.
  • Children should be allowed time to eat their food and not be rushed during the meal or snack service. They should not be allowed to play during these times.
  • Caregivers/teachers should discuss the breasted infants’ feeding patterns with the parents/guardians because the frequency of breastfeeding at home can vary. For example, some infants may still be feeding frequently at night, while others may do the bulk of their feeding during the day. Knowledge about the infant’s feeding patterns over twenty-four hours will help caregivers/teachers assess the infant’s feeding during his/her time with the caregiver/teacher.

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-Standard Rationale


Young children, under the age of six need to be offered food every two to three hours. Appetite and interest in food varies form one meal or snack to the next. To ensure that the child’s daily nutritional needs are met, small feedings of nourishing food should be scheduled over the course of a day. Snacks should be nutritious, as they often are a significant part of a child’s daily intake. Children in care for more than eight hours need additional food because this period represents a majority of a young child’s waking hours.

-Standard Comments


Caloric needs vary greatly from one child to another. A child may require more food during growth spurts.

-Standard References


  1. U.S. Department of Health and Human Services, Administration for Children and Families, Office of Head Start. 2009. Head Start program performance standards. Rev. ed. Washington, DC: U.S. Government Printing Office.
  2. Benjamin, S.E., ed. 2007. Making food healthy and safe for children: How to meet the national health and safety performance standards—Guidelines for out of home child care programs. 2nd ed. Chapel Hill, NC: National Training Institute for Child Care Health Consultants.
  3. Pipes, P.L., C.M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.
  4. Butte, N., S.K. Cobb. 2004. The Start Healthy feeding guidelines for infants and children. J Am Diet Assoc. 104:442-54.
  5. Kleinman, R.E., ed. 2009. Pediatric nutrition handbook, 6th ed. Elk Grove Village, IL: American Academy of Pediatrics..
  6. Plemas, C., B. M. Popkin. 2010. Trends in snacking among U.S. Children. Health Affairs. 29:399-404.

-Learn From Your Peers

Try cooking with children.  Cooking projects are a great way to teach kids about new foods. This is important if we expect children to eat a variety of fruits, vegetables and whole grains. Children love to eat and share foods that they have prepared. Cooking activities also incorporate reading, math and safety skills, and are wonderfully tactile. Children’s storybooks can serve as inspiration for cooking ideas and can teach children about foods from different cultures.  Be prepared for spills and lots of fun!.
--- Child Health Care Consultant

While it is important to have regularly scheduled meals and snacks, providers also need to be flexible enough to meet individual children’s needs. Children who come from homes with food insecurity (inconsistent access to food) may need additional nutrition while they are in care. Children who arrive after breakfast has been cleared or need to leave before an evening meal may benefit from having a meal at a nontraditional time in order to ensure that they are getting enough to eat.
--- Child Care Health Consultant

I recommend that providers be flexible for children, especially infants and toddlers when it comes to meal times.  I ask that they allow for a child to eat later if the child falls asleep, instead of waking a child or keeping a child awake for a meal.  Experience has shown that the child typically doesn’t eat well and the child’s behavior is usually not very cooperative when they are tired. 

The other issue I talk to providers about is the importance of feeding infants on demand.  Infants should not be fed according to a strict schedule unless the parents obtain a written order from the child’s health care provider with specific instructions.  There is nothing worse than trying to console/comfort a hungry infant and you are not allowed to feed them.
--- Child Care Health Consultant

Every other year we do a full evaluation of our meal and snack menus. We invite input from all the parents, and the dieticians at the hospital are involved as well. We consider not only nutrition but scheduling and cost as well. This year we switched to organic milk and brown rice, achieving better nutrition with no cost increase.
--- Director

June 2011

Care for Children with Food Allergies

When Children with food allergies attend the early care and education facility, the following should occur: a) each child with a food allergy should have a care plan prepared for the facility by the child’s primary care provider, to include: 1) written instructions regarding the food(s) to which the child is allergic and steps that need to be taken to avoid that food 2) detailed treatment plan to be implemented in the event of an allergic reaction. The plan should include specific symptoms that would indicate the need to administer one or more medications; b) based on the child’s care plan, the child’s caregivers/teachers should receive training, demonstrate competence in and implement measures for 1) preventing exposure to the specific food(s) to which the child is allergic; 2) recognizing the symptoms of an allergic reaction and 3) treating allergic reactions; c) Parents/guardians and staff should arrange for the facility to have necessary medications and for proper storage of such medications d) Caregivers/teachers should promptly and properly administer prescribed medications in the event of an allergic reaction e) the facility should notify parents/guardians immediately of any suspected allergic reactions f) the facility should recommend to the family that the child’s primary care provider be notified if the child has required treatment by the facility g) the facility should contact emergency medical services system immediately whenever epinephrine has been administered h) Parents/guardians of all children in the child’s class should be advised to avoid any known allergens in class treats or special foods brought into the care setting i) individual child’s food allergies should be posted prominently in the classroom where staff can view and/or wherever food is served; j) the written child care plan, a mobile phone, and the proper medications for appropriate treatment if the child develops an acute allergic reaction should be routinely carried out on field trips.

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-Standard Rationale


Food allergy is common, occurring in between 2% and 8% of infants and children (1). Food allergic reactions can range from mild skin or gastrointestinal symptoms to severe, life-threatening reactions with respiratory and/or cardiovascular compromise. Intensive efforts to avoid exposure to the offending food (s) are therefore warranted. The maintenance of detailed care plans and the ability to implement such plans for the treatment of reactions are essential for all food-allergic children

-Standard Comments


Successful food avoidance requires a cooperative effort that must include the parents/guardians, the child, the child’s primary care provider, and the early care and education staff. The parents/guardians, with the help of the child’s primary care provider, must provide detailed information on the specific foods to be avoided. Some children with a food allergy will have mild reactions and will only need to avoid the problem food(s). Others will need to have an antihistamine or epinephrine available to be used in the event of a reaction.

-Standard References


  1. Burks, A.W., J.S. Stanley. 1998. Food allergy. Curr Opin Pediatrics 10:588-93.
  2. U.S. Department of Health and Human Services, Administration for Children and Families, Office of Head Start. 2009. Head Start program performance standards. Rev. Ed. Washington, DC: U.S. Government Printing Office.
  3. Kleinman, R.E. ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.
  4. Samour, P. Q., K. King 2005. Handbook of pediatric nutrition. 3rd ed. Lake Dallas, TX: Helm.
  5. Branum, A.M., S.L. Lukacks. 2008 Food allergy among U.S. children: Trends in prevalence and hospitalizations. NCHS data brief, no. 10. Hyattsville, MD: National Center for Health Statistics.

  6. Muraro, A., et at. 2010. The management of the allergic child at school: EAACI/GA2LEN Task Force on the allergic child at school. Allergy. 65:681-89.

-Learn From Your Peers

It is important to track expiration dates on rarely-used emergency medications.  Note the expiration date on your calendar, with reminders several months ahead. Give parents adequate time to get a refill or new prescription, and be sure to complete new documentation for each medication.
Programs also need a system to ensure that emergency medications “follow the child,” particularly for those who are transported on a daily basis. Medications should not be exposed to extreme temperatures and should not be left on the bus.
Allergens can appear in unexpected places. A colleague of mine worked in a program that used large plastic tubs of peanut butter. After they were emptied, the tubs were run through an industrial dishwasher and used to store small toys and supplies. A child with a peanut allergy had a reaction after handling crayons that were stored in the tub. It never occurred to the staff that there would be enough peanut oil remaining in the container to cause a reaction.
--- Child Health Care Consultant

I recommend that each child with food allergies have 3 copies of his care plan.  One copy can be posted in the classroom, one should be kept with his emergency medications, and one should be in his office file.  Epi-Pens should be accessible and unlocked, but out of the children’s reach.  They should be stored away from heat and light, and monthly checks of expiration dates should be documented. 
The area where emergency medications are stored should be labeled and easily located by all staff members.  When outside of the classroom, emergency medications can be kept in a belt pack so that they are not misplaced or left accessible to children.
--- Child Care Health Consultant

If your center is a “nut safe” center, be sure your staff understands that this includes eliminating items that they bring into the center, including the break room. Remind them that if they are consuming nut products prior to entering the building, it is important that they follow thorough hand washing procedures before returning to their classroom. To avoid errors when parents bring in items for a special celebration, it is helpful to provide a list of suggested items. Check all labels before allowing items to be brought into your center.
--- Director

In our center, our concern has always been that short-term staff members might not know the children well enough.  Lists of children with food allergies are posted in every room.  Any staff member new to a room is instructed to read the list and learn to identify each child on the list.
--- Director

May 2011

Introducing Age-Appropriate Solid Foods to Infants

A plan to introduce age-appropriate solid foods (complementary foods) to infants should be made in consultation with the child’s parent/guardian and primary care provider. Age-appropriate solid foods may be introduced no sooner than when the child has reached the age of four months, but preferably six months and as indicated by the individual child’s nutritional and developmental needs.
For breastfed infants, gradual introduction of iron-fortified foods may occur no sooner than around four months, but preferably six months and to complement the human milk. Modification of basic food patterns should be provided in writing by the child’s primary care provider. One new food should be introduced at a time, followed by waiting a couple of days before introducing another new food.

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-Standard Rationale

Early introduction of age-appropriate solid food and fruit juice interferes with the intake of human milk or iron-fortified formula that the infant needs for growth. Age-appropriate solid food given before an infant is developmentally ready may be associated with allergies and digestive problems (1,7). Around about six months of age, breastfed infants may require an additional source of iron. Vitamin drops with iron may be needed. Infants who are not exclusively fed human milk should consume iron-fortified formula as the substitute for human milk (8). In the United States, major non-milk sources of iron in the infant diet are iron-fortified cereal and meats (1). Zinc is important for healthy growth and proper immune func­tion. Infant stores of zinc may subsidize the intake from human milk for several months. Age-appropriate solid foods such as meat (a good source of zinc) are needed be­ginning at six months (1). A full daily allowance of vitamin C is found in human milk (2). The American Academy of Pediatrics (AAP) recommends that all breastfed or partially breastfed infants receive a minimum daily intake of 400 IU of vitamin D supplementation beginning soon after birth until they consume sufficient vitamin D fortified milk (about one quart per day) to meet the 400 IU daily requirements (3). These supplements should be given at home by the parents/guardians to take the burden off the caregiver/teacher.

The transitional phase of feeding age-appropriate solid foods which occurs no sooner than four months and preferably six months of age is a critical time for develop­ment of gross, fine, and oral motor skills. When an infant is able to hold his/her head steady, open her/his mouth, lean forward in anticipation of food offered, close the lips around a spoon, and transfer from front of the tongue to the back and swallow, he/she is ready to eat semi-solid foods. The process of learning a more mature style of eat­ing begins because of physical growth occurring concur­rently with social, cultural, sociological, and physiological development.


-Standard Comments

Many infants find fruit juices appealing and may be satisfied by the calories in age-appropriate solid foods so that they subsequently drink less human milk or formula. When fruit juice is introduced at one year of age, it should be by cup rather than a bottle or other container (such as a box) to decrease the occurrence of dental caries. Infants, birth up to one year of age, should not be served juice. Whole fruit, mashed or pureed, is appropriate for infants seven months up to one year of age. Children one year of age through age six should be limited to a total of four to six ounces of juice per day.

Many people believe that infants sleep better when they start to eat age-appropriate solid foods, however research shows that longer sleeping periods are develop­mentally and not nutritionally determined in mid-infancy (1,4).
An important goal of early childhood nutrition is to ensure children’s present and future health by foster­ing the development of healthy eating behaviors (1,8). Caregivers/teachers are responsible for providing a variety of nutritious foods, defining the structure and timing of meals and creating a mealtime environment that facili­tates eating and social exchange (6). Children are respon­sible for participating in choices about food selection and should be allowed to take responsibility for determining how much is consumed at each eating occasion (1).

Good communication between the caregiver/teacher and the parents/guardians cannot be over-emphasized and is essential for successful feeding in general, including when and how to introduce age-appropriate solid foods. The decision to feed specific foods should be made in con­sultation with the parent/guardian. Caregivers/teachers should be given written instructions on the introduction and feeding of foods from the infant’s parent/guardian and primary care provider. Caregivers/teachers can use or develop a take-home sheet for parents/guardians in which the caregiver/teacher records the food consumed, how much, and other important notes on the infant, each day. Caregivers/teachers should continue to consult with each infant’s parents/guardians concerning which foods they have introduced and are feeding. This schedule of intro­ducing new foods one at a time with at least a two-day trial period enables parents and caregivers/teachers to pinpoint any problems a child might have with any specific food (9). Following this schedule for introducing new foods, the caregiver/teacher can more easily identify an infant’s possible food allergy or intolerance. Consistency between home and the early care and education setting is essential during the period of rapid change when infants are learning to eat age-appropriate solid foods (5,7)


-Standard References

  1. Kleinman, R.E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.
  2. Lawrence, R.A., R. Lawrence. 2005. Breast feeding: A guide for the medical profession. 6th ed. St. Louis: Mosby.
  3. Wagner, C.L., F.R. Greer, Section on Breastfeeding, Committee on Nutrition. 2008. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Pediatrics 122:1142-52
  4. Lally, J.R., A. Griffin, E. Fenichel, M. Segal, E. Szanton, B. Weissbourd. 2003. Caring for infants and toddlers in groups: Developmentally appropriate practice. Arlington, VA: Zero to Three.
  5. U.S. Department of Agriculture, Food and Nutrition Service. 2002. Feeding infants: A guide for use in the child nutrition programs. Rev ed. Alexandria, VA: USDA, FNS. http://www.fns.usda.gov/tn/resources/feeding_infants.pdf
  6. Branscomb, K. R., C.B. Goble. 2008 Infants and toddlers in group care: Feeding practices that foster emotional health. Young Children 63-28-33.
  7. Grummer-Strawn, L.M., K.S. Scanlon, S.B. Fein. 2008. Infant feeding and feeding transitions during the first year of life. Pediatrics 122:S36-42.
  8. Griffiths, L.J., L. Smeeth, S.S. Hawkins, T.J. Cole, C. Dezateaux. 2008. Effects of infant feeding practice on weight gain from birth to 3 years. Arch Dis Child (November): 1-17.
  9. Pipes, P.L., C.M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.


-Learn From Your Peers

There should be no rush in transitioning young infants to solid foods.  Until 6 months of age, the ideal nutrition is breast milk or, alternatively, formula.  Introduction of solids should be based on developmental signs and the infant’s interest level rather than on the age.  Contrary to popular opinion, there is no good reason to introduce foods in any certain order.  It is important to keep the choices healthy during this critical period when children are developing their taste preferences.  Also, there are no set volumes of solid food which should be consumed.  Children should learn to listen to their own body signals – eat when hungry, stop when full.

Pediatrician


It is important to remember that solid food needs to be fed in a sanitary and safe manner.  The infant’s hands should be washed. The highchair tray should be washed and sanitized prior to use. The safety straps on the highchair should always be used.  Check the expiration dates on the containers of food before serving.  The food should be removed and placed in a separate serving dish, instead of feeding directly from the container, unless the entire container of food will be eaten.  Unused portions of food can only be kept in the refrigerator for 24 hours.  Make sure all food is age appropriate to prevent choking.  If food is warmed, make sure to stir well and test it before serving to prevent burns.  Protect the infant’s clothing with a clean bib.  Expect infants to get messy; they are learning to eat.  Do not hold their hands down while you feed them.  If they keep trying to touch the spoon, give them one to hold.  Take your time when feeding them so that it is an enjoyable experience.  Sit at their level, so you can interact with them while you are feeding them. 

Child Care Health Consultant

March 2011

Playing Outdoors

Children should play outdoors daily when weather and environmental conditions do not pose a significant health or safety risk. Outdoor play for infants may include riding in a carriage or stroller; however, infants should be offered opportunities for gross motor play outdoors, as well. Weather that poses a significant health risk should include wind chill factor at or below minus 15 degrees F and heat index at or above 90 degrees F, as identified by the National Weather Service.
Children should be protected from the sun by using shade, sun-protective clothing, and sunscreen with UVB-ray and UVA-ray protection of SPF 15 or higher, with permission from parents/guardians. Before prolonged physical activity in warm weather, children should be well hydrated and should be encouraged to drink water during the activity. On hot days, infants receiving human milk in a bottle can be given additional human milk in a bottle but should not be given water, especially in the first six months of life. Infants receiving formula and water can be given additional formula in a bottle. In warm weather, children's clothing should be light-colored, lightweight, and limited to one layer of absorbent material to facilitate the evaporation of sweat. Children should wear sun-protective clothing, such as hats, when playing outdoors between the hours of 10 AM and 2 PM.
In cold weather, children's clothing should be layered and dry. Caregivers/teachers should check children's extremities for maintenance of normal color and warmth at least every fifteen minutes when children are outdoors in cold weather. When precipitation is present (such as rain or snow), children should be properly clothed (boots, gloves, hats, etc.) to participate in outdoor play.
Caregivers/teachers should also be aware of environmental hazards such as contaminated water, loud noises, and lead in soil when selecting an area to play outdoors. Children should be observed closely when playing in dirt/soil, so that no soil is ingested. Play areas should be secure and away from heavy traffic areas.

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-Standard Rationale

Outdoor play is not only an opportunity for learning in a different environment; it also provides many health benefits. Outdoor play allows for physical activity that supports maintenance of a healthy weight (2). Light exposure of the skin to sunlight promotes the production of vitamin D that growing children require. Open spaces in outdoor areas, even those confined to screened rooftops in urban play spaces, encourage children to develop gross motor skills and fine motor play in ways that are difficult to duplicate indoors. Nevertheless, some weather conditions make outdoor play hazardous.
Caregivers/teachers must protect children from adverse weather and air quality. Wind chill conditions that pose a risk of frostbite as well as heat and humidity that pose a significant risk of heat-related illness are defined by the National Weather Service and are announced routinely. The federal government has established health standards for a number of air pollutants. Caregivers/teachers should consult this information. Heat-induced illness and cold injury are preventable. Children have greater surface area-to-body mass ratio than adults. Therefore, children do not adapt to extremes of temperature as effectively as adults when exposed to a high climatic heat stress or to cold. Children produce more metabolic heat per mass unit than adults when walking or running. They also have a lower sweating capacity and cannot dissipate body heat by evaporation as effectively (1). Generally, infectious disease organisms are less concentrated in outdoor air than indoor air.


-Standard Comments

The National Weather Service provides convenient color-coded guides for caregivers/teachers to use to determine which weather conditions are comfortable for outdoor play, which require caution, and which are dangerous. These guides are available on the National Weather Service Website for wind chill and for heat index. The federal Clean Air Act requires that the Environmental Protection Agency (EPA) establish ambient air quality health standards. Most local health departments monitor weather and air quality in their jurisdiction and make appropriate announcements.
To access the latest local weather information and warnings, contact the National Weather Service at http:// www.weather.gov/. Winter can be problematic for children with asthma for two reasons. Indoor allergens such as dust and dust mites are common triggers for asthma symptoms and levels of these allergens can become elevated during the winter, when doors and windows are kept shut to keep out cold air. Cold temperatures also may, in some cases, serve as a trigger to asthma symptoms for children with asthma. Children for whom cold weather is an asthma trigger may be helped by wearing a scarf during periods of cold weather. All children with asthma can safely play outdoors as long as their asthma is well controlled, and the parents/guardians of children with asthma should be encouraged to work with their childs primary care provider to develop a plan the child can self-manage that incorporates opportunities for outdoor play. The thought is often expressed that children are more likely to become sick if exposed to cold air, however upper respiratory infections and flu are caused by viruses, not exposure to cold air. These viruses spread easily during the winter when children are kept indoors in close proximity. The best protection against the spread of illness is regular and proper handwashing for both children and caregivers/ teachers, as well as proper sanitation procedures during mealtimes, and when there is any contact with bodily fluids.


-Standard References
  1. American Academy of Pediatrics, Committee on Sports Medicine and
    Fitness. 2000. Climatic heat stress and the exercising child and adolescent.
    Pediatrics 106:158-59.
  2. Hagan, J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Promoting physical activity.
    In Bright futures: Guidelines for health supervision of infants, children,
    and adolescents, 147-54. 3rd ed. Elk Grove Village, IL: American Academy
    of Pediatrics.

-Learn From Your Peers

Our center is getting very serious about the need to focus on movement and structured physical activities. We believe it is important for children's health, and it prepares them for the physical education programs that they may encounter later in elementary school. It instills, at an early age, positive attitudes about fitness. We also educate our families about the less obvious benefits of regular exercise such as stress-relief and better self- esteem. We recognize that children get hot and thirsty when they are physically active. We encourage older children to bring in a labeled water bottle which they can drink from whenever they like.

Director

When dressed appropriately for the weather, people can safely enjoy a wide range of climate conditions. Adapting to the extremes is a rich learning experience. Rain, cold, dry air, sunshine, heat and humidity provide valuable teachable moments. Applying sun screen to a group of children efficiently can be challenging. There is no reason to have each child provide a different sunscreen preparation or to wear gloves when the skin of the teacher and that of the child is intact. Such measures just make the task harder than necessary.

Pediatrician


Treat the outdoors as another classroom. Children can draw with chalk on the sidewalk (art), pour water and sand (sensory), use bug catchers to explore the grass (science) and put on plays (dramatic). Keep a waist-pack with basic supplies: tissues, hand sanitizer, gloves, band-aids, cell phone, etc. Scheduling regular outdoor playtime helps children to focus better and sit still longer when they go indoors. If you notice that you are spending a lot of time redirecting children at a particular time of the day, consider adding outdoor play to that part of the schedule and see if it makes a difference after a week.

Child Care Health Consultant

The two biggest barriers to taking children outside are parent objections and lack of proper clothing. I recommend that facilities have a policy clearly stating that all children will go outside daily (weather permitting) unless they have a written order from a health care provider. I recommend using signs and letters to remind parents to send in proper clothing. As a health consultant, I have written letters to parents explaining the importance of children going outside. Providers say it often helps to convince parents when the letter comes from an outside source instead of from them.

Child Care Health Consultant

February 2011

Caregivers/Teachers' Encouragement of Physical Activity

Caregivers/teachers should promote children's active play, and participate in children's active games at times when they can safely do so. Caregivers/ teachers should:
a) Lead structured activities to promote children's activities two or more times per day;
b) Wear clothing and footwear that permits easy and safe movement;
c) Not sit during active play;
d) Provide prompts for children to be active, e.g., "good throw";
e) Encourage children's physical activities that are appropriate and safe in the setting , e.g. do not prohibit running on the playground when it is safe to run;
f ) Have orientation and annual training opportunities to learn about age-appropriate gross motor activities and games that promote children's physical activity;
g) Limit screen time (TV, DVD, computer)

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-Standard Rationale

Children learn from the modeling of healthy and safe behavior. Chairs for adults on playgrounds inhibit the promotion of children's physical activity. They may also pose a safety hazard if caregivers/teachers sitting in them cannot see all parts of the playground.


-Standard Comments

Caregivers/teachers may not feel comfortable promoting active play, perhaps due to inhibitions about their own physical activity skills, or due to lack of training. Caregivers/teachers may feel that their sole role on the playground is to supervise and keep children safe, rather than to promote physical activity. Continuing education activities are useful in disseminating knowledge about effective games to promote physical activity in early care and education while keeping children safe. Caregivers/ teachers should consider incorporating structured activities into the curriculum indoors, or after children have been on playground for ten to fifteen minutes, as children tend to be less active after the first ten to fifteen minutes on the playground. Caregivers/teachers, if they are facilitating physical activity with a small group, must ensure that there is adequate supervision of all children on the playground. Caregivers/teachers should be aware that there is often a high level of TV and computer exposure in the home. Early care and education settings offers caregivers/ teachers the opportunity to model the limitation of media and computer time and to educate parents/guardians about alternative activities that families can do with their children.


-Standard References
  1. Trost, S. G., B. Fees, D. Dzewaltowski. 2008. Feasibility and efficacy of
    a "move and learn" physical activity curriculum in preschool children. J
    Phys Act Health 5:88-103.
  2. McWilliams, C., S. G. Ball, S. E. Benjamin, D. Hales, A. Vaughn, D. S. Ward. 2009. Best-practice guidelines for physical activity at child care. Pediatrics 124:1650-59.
  3. Copeland, K. A., S. N. Sherman, C. A. Kendeigh, B. E. Saelens, H. J.
    Kalkwarf. 2009. Flip flops, dress clothes, and no coat: Clothing barriers to
    children's physical activity in child-care centers identified from a qualitative
    study. Int J Behav Nutr and Physical Activity 6, no. 74 (November 6).
    http://ijbnpa.org/content/6/1/74.

-Learn From Your Peers

"There are many resources which can assist development of physical activities for early childhood settings. Children spend so much of their time at home in front of screens. It is very important that we encourage regular exercise at our centers. It is part of our mission as educators.

Director

 

"Incorporate physical activity throughout the day, not just during scheduled outdoor play! Giving children opportunities to use their bodies not only helps them work their wiggles out, but also promotes learning through another avenue. Children can count jumps, bend their bodies into the shapes of letters, and practice following directions during "Simon Says." Identify physical activities that are tied to books you are reading. Children can act out the plot or imitate characters. Stomp like "wild things," climb and squish on a bear hunt, and shake your fists like monkeys in "Caps for Sale." Even if you're not an athlete, you can make small changes in how you interact with the children outdoors. If you usually sit, make it a habit to walk around the playground. This also allows better supervision. Play a gentle game of catch or twirl one end of the jump rope. Serve as the referee for a game of kickball. Participating in even simple ways tells children that physical activity is important. Encourage children to try a variety of physical activities by introducing new playground games. Look for opportunities or grants to get free stencils to paint games onto your hard surface area or to purchase new outdoor equipment."

Child Care Health Consultant

 

"The biggest obstacle is that caregivers don't know what physical activities to do with the children. Directors can help by posting a list of ideas for the teachers. Sample activities can be demonstrated at staff meetings, and teachers should be encouraged to share their activities with each other."

Child Care Health Consultant

 

"Adults who do not engage in playground activities with the children tend to cluster with each other, using the break for adult-adult socialization. However, playground time should be highly interactive for everyone. The physical activity period can also add to the curriculum by merging health benefits with learning opportunities. Engaging in structured physical activity with the children is not only good role-modeling, but also a great way to relieve stress. "

Pediatrician

 

January 2011

Nutritional Quality of Food Brought from Home

The facility should provide parents/guardians with written guidelines that the facility has established a comprehensive plan to meet the nutritional requirements of the children in the facility's care and suggested ways parents/guardians can assist the facility in meeting these guidelines.

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-Standard Rationale

The caregiver/teacher/facility has a responsibility to follow feeding practices that promote optimum nutrition supporting growth and development in infants, toddlers, and children. Caregivers/teachers who fail to follow best feeding practices, even when parents/guardians wish such counter practices to be followed, negate their basic responsibility of protecting a child's health, social, and emotional well being.


-Standard Comments

Some local health and/or licensing jurisdictions prohibit any foods being brought from home.


-Standard References
  1. Sweitzer, S., M. E. Briley, C. Robert-Gray. 2009. Do sack lunches provided by parents meet the nutritional needs of young children who attend child care? J Am Diet Assn 109:141-44.
  2. Contra Costa Child Care Council, Child Health and Nutrition Program. CHOICE: Creating healthy opportunities in child care environments. Concord, CA: Contra Costa Child Care Council, Child Health and Nutrition Program. http://w2.cocokids.org/_cs/downloadables/cc-healthnutrition-choicetoolkit.pdf

-Learn From Your Peers

"We recently had our first experience with a family requesting that their child bring in food from home in order to preserve the child's culture as long as possible. Initially, the child ate food provided by the Child and Adult Care Food Program (CACFP), but when the mother became dissatisfied, we had her sign paperwork to document her request. We then provided the family with the United States Department of Agriculture (USDA) guidelines and requirements, and they agreed to bring in similar items from their culture's food. We have been lucky that these parents have complied, and they have been very happy with the openness and service of our center."

Director

 

"Providers should always consider food safety. Food provided by parents must be stored properly so that food does not spoil and cause illness; providers must provide refrigerator space or require parents to provide ice packs with insulated lunch bags/boxes. Some foods, while healthy, can be a safety hazard for younger children. To prevent choking, it is the provider's responsibility to make sure that food items are cut up into appropriately sized pieces for those children under the age of three (1/4" for infants and 1/2" for toddlers). I also recommend rinsing all fresh fruits and vegetables before preparing/serving in case this is not the parents' practice. Educating parents about food safety may help improve their practices at home."

Child Care Health Consultant

 

"Parents appreciate ideas for packed lunches, particularly child-tested options. Look for brochures (such as those on the USDA website) to send home or to use in newsletters. Make a list of favorite healthy options that children in the program already bring. Children are more likely to try a new food when friends bring it too. Encourage children to be investigators and to check their lunches for recommended servings. It is a great opportunity to talk about what a fruit or vegetable is and why they are important. Have posters in the eating area that illustrate the categories. If a significant number of children are consistently bringing inadequate lunches, consider whether you could provide meals onsite. Even if you don't have a kitchen, you may be able to contract with a vendor to deliver the lunches, such as a local school or hospital. Find out who provides the lunches for Meals on Wheels. You may be eligible to participate in the CACFP and get reimbursed for the lunches. Talk to your local health district to see what your food service options are."

Child Care Health Consultant

 

"Programs should encourage families who provide food from home to use containers for perishable food items that can keep the food at or below 40 degrees Fahrenheit. Cold packs are useful, or food can be pre-frozen so that it remains cold but thaws by mealtime. When possible, encourage families to choose containers that children can open themselves. Few teachers have extra support at mealtime to lay out each child's food, and maintaining proper food handling practices while laying out food for each child is challenging. Some programs set dessert items aside, offering them after the child eats the other parts of the meal. When you suggest items for parents to pack from home, try to avoid a food if a classmate is allergic to it. Allergic children can be seated so that they are unlikely to have food shared with them. Some programs notify parents during enrollment that the program will have to charge for substitute meals when the food from home repeatedly does not meet age-appropriate nutrition guidelines. Many programs send leftovers home as a way of showing the family what the child ate. However, this practice increases the risk that children will eat unsafe food. If children need a snack on the way home, then that food should be packed and stored separately until it is time to go home."

Pediatrician

 

 

December 2010

Limiting Screen Time - Media, Computer Time

In early care and education settings, media (television [TV], video, and DVD) viewing and computer use should not be permitted for children younger than two years. For children two years and older in early care and early education settings, total media time should be limited to not more than thirty minutes once a week, and for educational or physical activity use only. During meal or snack time, TV, video, or DVD viewing should not be allowed (1). Computer use should be limited to no more than fifteen-minute increments except for school-age children completing homework assignments (2).

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-Standard Rationale

In the first two years of life, children's brains and bodies are going through critical periods of growth and development. It is important for infants and young children to have positive interactions with people and not sit in front of a screen that takes time away from social interaction with parents/guardians and caregivers/teachers. Before age three, television viewing can have modest negative effects on cognitive development of children (3). For that reason, the American Academy of Pediatrics (AAP) recommends television viewing be discouraged for children younger than two years of age (4). Interactive activities that promote brain development can be encouraged, such as talking, playing, singing, and reading together.
For children two years and older, the AAP recommends limiting children's total (early care and education, and home) media time (with entertainment media) to no more than one to two hours of quality programming per twenty-four hour period (3). Because children may watch television before and after attending early care and education settings, limiting media time during their time in early care and education settings will help meet the AAP recommendation. When TV watching is intended to be interactive, with the adult interacting with children about what they are watching, caregivers/teachers can sing along and comment on what children are watching. Caregivers/teachers should always consider whether children could learn the skill better in another way through hands-on experiences.
Studies have shown a relationship between TV viewing and overweight in young children. For example, watching more than eight hours of television per week has been associated with an increased risk of obesity in young children and exposure to two or more hours of television per day increased the risk of overweight for three-to five-year-olds (5,6). Among four-year-olds, as body mass index increased, average hours of TV viewing increased (7). Also, young children who watch TV have been shown to have poor diet quality. For each one-hour increment of TV viewing per day, three-year-olds were found to have higher intakes of sugar-sweetened beverage and lower fruit and vegetable intakes (8). Children are exposed to extensive advertising for high-calorie and low-nutrient dense foods and drinks and very limited advertising of healthful foods and drinks during their television viewing. Television advertising influences the food consumption of children two- to eleven-years-old (9).


-Standard Comments


It is important for caregivers/teachers to be a role model for children in early care and education settings by not watching TV during the care day. In addition, when adults watch television (including the news) in the presence of children, children may be exposed to inappropriate language or frightening images. MyPyramid has tips on limiting media time - "How Much Inactive Time Is Too Much" at http://www.mypyramid.gov/preschoolers/PhysicalActivity/inactivetime.html.
The AAP provides a description of the TV programming rating scale and tips for parents/guardians at movie ratings and what they mean. Caregivers/teachers are discouraged from having a TV in a room where children are present. Caregivers/teachers should begin reading to children when they are six months of age and facilities should have age-appropriate books available for each cognitive stage of development. See "Reach Out and Read" at http://www.reachoutandread.org/ for more information.


-Standard References
  1. Zimmerman, F. J., D. A. Christakis, A. N. Meltzoff. 2007. Television and DVD/video viewing in children younger than 2 years. Arch Pediatric Adolescent Med 161:473-79.
  2. Harms, T., R. M. Clifford, D. Cryer. 2005. Early childhood environment rating scale, revised ed. Frank Porter Graham Child Development Institute, University of North Carolina. http://www.fpg.unc.edu/~ECERS/.
  3. Zimmerman, F. J., D. A. Christakis. 2005. Children's television viewing and cognitive outcomes. Arch Pediatric Adolescent Med 159:619-25.
  4. American Academy of Pediatrics, Council on Communications and Media. 2009. Policy statement: Media violence. Pediatrics 124:1495-1503.
  5. Reilly, J. J., J. Armstrong, A. R. Dorosty. 2005. Early life risk factors for obesity in childhood: Cohort study. British Medical J 330:1357.
  6. Lumeng, J. C., S. Rahnama, D. Appugliese, N. Kaciroti, R. H. Bradley.
  7. Mass Index among South Carolina Head Start children. Ethnicity and Disease 14:336-39.
  8. Miller, S. A., E. M. Taveras, S. L. Rifas-Shiman, M. W. Gillman. 2008. Association between television viewing and poor diet quality in young children. Int J Pediatric Obesity 3:168-76.
  9. Committee on Food Marketing and the Diets of Children and Youth. 2006. Food marketing to children and youth: Threat or opportunity. Eds. J. M. McGinnis, J. A. Gootman, V. I. Kraak. Washington, DC: National Academies Press.
  10. Taveras, E. M., T. J. Sandora, M. C. Shih, D. Ross-Degnan, D. A. Goldmann, M. W. Gillman. 2006. The association of television and video viewing with fast food intake by preschool-age children. Obesity 14:2034-41.
  11. Christakis, D. A., M. M. Garrison, F. J. Zimmerman. 2006. Television viewing in child care programs: A national survey. Communication Reports 19:111-20.

-Learn From Your Peers

"Children in ECE programs should be provided with interactive activities that promote brain development, such as talking, playing, singing, and reading together. Time watching TV or playing on computers should not be provided or limited to 10-15 minute intervals."

- PNP and Researcher

 

"I have found even the best teacher can be seduced by the siren call of video viewing! I have had to make it a center-wide rule that there is to be no more than 30 minutes per week of "screen time." The teachers are told to use only short videos that have age-appropriate, educational content that relates to their lesson plans. I will relent and relax the rule on the fourth rainy day in a row or when everyone is in need of "down time" such as Halloween Parade day or Santa visit day! Computers are not an issue because I refuse to have them in the center."

- Child Care Center Director

 

"Sitting a child in front of a television is often just a way to offer parents/teachers a break and it their is not beneficial to the child. In fact, as the percentages show us, it can actually be harmful. We need to offer parents ideas on what they can do to limit screen time. Perhaps via parent seminars and sharing our policies of not using television in our centers at all and the reasoning behind it, we can help them to better understand the impact it can have on their child. Focusing on Wellness and Fitness should be a priority right now for everyone in the US. If programs and parents could put more effort toward wellness and being fit, we could eliminate this issue of obesity and limit if not eliminate screen time. Bright Horizons offers multiple resources to parents so that they have the tools that they need to keep their children challenged and active with out using screen time at all. On the Bright Horizons website, anyone can access resources such as B-Fit, Growing Readers, Growing Scientists, etc to get ideas on what they can do, since often times this is the issue; not knowing what to do. Also, if we could include a one page document in our registration packets to parents that explains our outlook and the benefits of limiting screen time and working toward being fit, we could all lead much healthier lives and be happier human beings."

- Child Care Center Director

 

"As a child care health consultant, I would look to see that the daily routine included physical activities every day. I observe active play and that the outside equipment is in good shape and the appropriate size for the children that are using it. Newsletters and bulletin boards are another method to educate parents about proper use of TV and computers and the need for physical activities for children on a daily basis."

- Child Care Health Consultant

 

"By making screen time limited only to educational dvds/videos or programs and requiring the teachers to "check out" the permissible videos (imax, etc) and TV cart from the front office before they show any, we are able to keep close contol of screen time. We've also found that limiting movie time in our child care setting to only once every month or two makes it so the children don't even expect or ask for it. With a fully laid out curriculum, plenty of toys, games and activities, plenty of outdoor play space and time, and lots of books in every classroom, we are more than able to fill the 12 hour days that our center is open without enlisting the "help" of electronic media. Again, I point this out to touring parents by reinforcing the limited screen time recommendations, and reassuring them that while most parents find themselves resorting to using the TV as a babysitter at one time or another, they certainly don't need to pay us to do so! This also flows into our age-appropriate curriculum and the value of high-quality education approach to child care, rather than just babysitting."

- Pediatrician and Child Care Center Director

 

"I encourage all teachers to not rely on technology as a substitute for teaching. This is a time in children's lives where they need to be more imaginative and physically active. Teachers should think of some creative ways to engage their children in learning. Center directors should be providing staff with consistent professional development so that all staff can get the training they need to create lesson plans that rely less on technology."

- Coordinator, National Black Child Development Institute

November 2010

Standard 2.004: Helping Families Cope With Separation

The staff of the facility shall help the child and parents cope with the experience of separation and loss.

For the child, this shall be accomplished by:
  a) Encouraging parents to spend time in the facility with the child;
  b) Enabling the child to bring to child care tangible reminders of home/family (such as a favorite toy or a picture of self and parent);
  c) Helping the child to play out themes of separation and reunion;
  d) Frequently exchanging information between the child's parents and caregivers, including activities and routine care information;
  e) Reassuring the child about the parent's return;
  f) Ensuring that the caregiver(s) are consistent both within the parts of a day and across days.

 

For the parents, this shall be accomplished by:
  a) Validating their feelings as a universal human experience;
  b) Providing parents with information about the positive effects for children of high quality facilities with strong parent participation;
  c) Encouraging parents to discuss their feelings;
  d) Providing parents with evidence, such as photographs, that their child is being cared for and is enjoying the activities of the facility.

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-Standard Rationale

In childhood, some separation experiences facilitate psychological growth by mobilizing new approaches for learning and adaptation. Other separations are painful and traumatic. The way in which influential adults provide support and understanding, or fail to do so, will shape the child's experience (1).

Many parents who prefer to care for their young children only at home may have no other option than to place their children in out-of-home child care before 6 weeks of age, because many employers do not provide parental leave. In most other industrialized countries (such as France, Sweden, Norway, Finland, Denmark, and Holland) family leave with pay is available for a minimum of 6 months and can be taken by either mother or father or in some combination. Some parents prefer combining out-of-home child care with parental care to provide good experiences for their children and support for other family members to function most effectively. Whether parents view out-of-home child care as a necessary accommodation to undesired circumstances or a benefit for their family, parents and their children need help from the child care staff to accommodate the transitions between home and out-of-home settings.

Many parents experience pain at separation. For most parents, the younger their child and the less experience they have had with sharing the care of their children with others, the more intense their pain at separation.


-Standard Comments


Depending on the child's developmental stage, the impact of separation on the child and parent will vary. Child care facilities should understand and communicate this variation to parents and work with parents to plan developmentally appropriate coping strategies for use at home and in the child care setting. For example, a child at 18 to 24 months of age is particularly vulnerable to separation stress. Entry into child care at this age may trigger behavior problems, such as difficulty sleeping. Even for the child who has adapted well to a child care arrangement before this developmental stage, such difficulties can occur as the child continues in care and enters this developmental stage. For younger children, who are working on understanding object permanence (usually around 9 to 12 months of age), parents who sneak out after bringing their children to the child care facility may create some level of anxiety in the child throughout the day. Sneaking away leaves the child unable to discern when someone the child trusts will leave without warning.


-Standard References
  1. Blecher-Sass H. Good-byes can build trust. Young Child. 1997;52:12-14.

-Learn From Your Peers

“It is not uncommon for a new parent to leave the center in tears when their child starts child care. During prospective parent tours, I make a point of telling parents that they are welcome to call any time to see how their child is faring. I inform them that they will be able to speak directly to their child’s teacher and to hear all the details of how and what their child is doing. I encourage either parent to call as often as they like in order to put their minds at rest while they are separated from their child. Prospective parents leave knowing that parental difficulty with separation is normal and that they have our empathy.”

- Child Care Center Director

 

“A huge part of easing parental anxiety is allowing them to visit prior to enrollment to spend some time in the classroom getting to know the teacher as well as the other children. Caregivers can help in the first days by e-mailing a photo of the child or by calling the parent in the middle of the day to update the parent about how their child is doing. To ease parents’ uncertainty after a tearful drop-off, they can be invited to return for observation a little later in the day once things have calmed down. It is also helpful to offer parent-teacher conferences during transition times and as requested.”

- Child Care Center Director

 

“Remind parents during the admission process that separation anxiety is a common response. Give tips on how to handle the situation such as ‘be prepared for the extra time that it may take to separate during the first few days.’ Remind parents that separation problems can also pop up at any time as children progress into new developmental stages or as they react to changes such as a new teacher or the birth of a sibling.”

- Child Care Health Consultant

 

“One center I visit deals with this issue particularly well. During registration, they provide the parents with a brief bio of the staff in their child’s class and a copy of the typical activity schedule. This allows the parent to begin talking with the child about the new people who will be in their life and what to expect. This center assigns a primary caregiver to each child who makes a point to greet the child and parent each day (particularly in the first month of care). They allow photos of the child’s family to be posted in the classroom and/or for the child to carry around. Last, they foster a connection with the parent/guardian by asking a few questions when the child starts care (What is your favorite memory of your child? What do you want for your child? How can we help?). These are posted in the class and serve as a reminder that everyone is working together.”

- Child Care Health Consultant

 

“Include extra information on the child’s daily communication form about something specific that the child said or did that day. After obtaining written parental permission for photographs, send pictures of the child dressing up, playing, or participating in an activity to connect parents to their child’s ‘child care life’. The pictures are also precious keepsakes. I also think it is helpful if providers make parents feel welcome in the classroom. If possible, provide a bench or comfortable loveseat where parents can sit to cuddle, take their child’s coat off, or read their child a story before leaving. Invite parents to stay and play (after they wash hands of course). “

- Child Care Health Consultant

 

“We routinely discourage sneaking out.  We also reassure parents that we will let them know honestly how their child is doing throughout the day. While this means letting them know if their child is happy and tear-free 20 minutes after drop-off, it also means letting them know if a child seems sad/distressed throughout the day.”

- Pediatrician and Child Care Center Director

 

“Often, parents struggle with the separation more than the children! There are a variety of strategies that can ease the process:

Talk to parents about the child’s temperament. Does he enjoy jumping into group activities or prefer a quiet environment with time to get comfortable?
Most children are excited by the sight of a new playground. Have the child visit during outdoor time to get to know some of the children during play. She may then be more comfortable visiting a room with a few familiar faces.
Some programs maintain a password-protected blog where parents can view photos and read about daily activities.
Encourage parents to develop a consistent routine so that drop-off is predictable. A few small rituals can also add to the comfort – wash hands together, say good morning to the fish, read a book, or share a special phrase or physical exchange (a kiss on each cheek, a hand sign, etc.)
Have books on hand about separation that can be read on-site or taken home. Good examples are The Kissing Hand and Owl Babies.
Allow access to comfort items during the day (as safety permits).

Always take time to greet children and parents and let them know you are happy to see them!"

- Child Care Health Consultant
 
 

October 2010

Standard 3.005: Immunization Documentation

The facility shall require that all children enrolling in child care provide written documentation of immunizations appropriate for the child's age. Infants, toddlers, older children, and adolescents shall be immunized as specified in the Recommended Childhood Immunization Schedule developed by the American Academy of Pediatrics (AAP), the Advisory Committee on Immunization Practice of the Centers for Disease Control and Prevention (CDC), and the American Academy of Family Practice (AAFP) (AA). Children whose immunizations are late or not given according to the schedule shall be immunized as recommended by the American Academy of Pediatrics (1). Because of frequent changes, an updated schedule is published by the AAP every January and shall be consulted for current information (2).

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-Standard Rationale

Routine immunization at the appropriate age is the best means of preventing vaccine-preventable diseases. Laws requiring the age-appropriate immunization of children attending licensed facilities exist in almost all states. Parents of children who attend unlicensed child care should be encouraged to comply with the Recommended Childhood Immunization Schedule for infants and children. Immunization is particularly important for children in child care because preschool-aged children currently have the highest age-specific incidence of many vaccine-preventable diseases (specifically, measles, pertussis, rubella, varicella, and Haemophilus influenzae type b disease).


-Standard Comments


In addition to publication in print, as shown in Appendix G, the current Recommended Childhood Immunization Schedule is posted on the Web site of the American Academy of Pediatrics: www.aap.org; and the Web site of the Centers for Disease Control and Prevention: www.cdc.gov.


-Standard References
  1. American Academy of Pediatrics, Committee on Infectious Diseases. Red book 2000: Report of the committee on infectious diseases. Elk Grove Village, Ill: American Academy of Pediatrics; 2000.
  2. American Academy of Pediatrics, Committee on Infectious Disease. Recommended childhood immunization schedule - United States, January - December 2001. Pediatrics. 2001;107:202-204.

-Learn From Your Peers

“Parents should be encouraged to have their child fully immunized to protect not only their child but also others in the community, including the early childhood program.”

- PNP and researcher

 

“Under-immunized children can put all children and staff at risk for preventable illness.  Recent outbreaks provide evidence that many children are not fully immunized. Economics can argue for fully immunized children in child care. If a center is exposed to a disease or has an outbreak, it may need to close for a time, which costs everyone money.”

- Child Care Health Consultant

 

“I would make sure that the child care centers and parents have a copy of the Centers for Disease Control’s immunization schedule (www.cdc.gov/vaccines) for both the children and adults.”

- Child Care Health Consultant

 

“I have a computer program that allows me to enter each child's immunization dates. I enter the child's immunization record into the program along with the registration information. If a child is close to needing a specific immunization, the box will be highlighted green.  If the child is past due for an immunization, it will be highlighted pink.  I can easily flip through each child's immunization card on the computer and tell who is up to date in a matter of minutes.”

- Child Care Center Director

 

“WellCare Tracker is an immunization tracking and child care health record quality improvement tool developed by Stuart T. Weinberg, MD, FAAP, in collaboration with the Pennsylvania Chapter of the American Academy of Pediatrics. For more information, providers can visit www.wellcaretracker.org.”

- Child Care Health Consultant

 

“When a child does not have current immunizations, this may be an indication that the child lacks health insurance. Early childhood professionals can link families to the state’s CHIP or Medicaid program to see if they are eligible. Programs can keep application forms available along with a list of free or low-cost clinics and vaccination locations. Some states use a centralized online registry to track immunizations. If children have received immunizations at various locations, paper records may not reflect the entire vaccination history. Look into how your state tracks immunizations.”

- Child Care Health Consultant

 

“Flu shots are an important infection control measure for children and staff members in child care. Influenza is highly contagious, very common, and poses a huge economic burden on parents every year. Young children often develop complications such as ear infections, wheezing, and dehydration. Child care providers are in a good position to promote the vaccine and to dispel some of the misconceptions about it. Educational materials are available at www.flu.gov.”

-Pediatrician

September 2010

100% Fruit Juice (from Preventing Childhood Obesity in Early Care and Education Programs)

The facility should serve only full-strength (100%) pasteurized fruit juice or full-strength fruit juice diluted with water from a cup to children twelve months of age or older. Juice should have no added sweeteners. The facility should offer juice at specific meals and snacks instead of continuously throughout the day. Juice consumption should be no more than a total of four to six ounces a day for children aged one to six years. This amount includes juice served at home. Children ages seven through twelve years of age should consume no more than a total of eight to twelve ounces of fruit juice per day. Caregivers/teachers should ask parents/guardians if they provide juice at home and how much. This information is important to know if and when to serve juice. Infants should not be given any fruit juice before twelve months of age. Whole fruit, mashed or pureed, is recommended for infants seven months up to one year of age.

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-Standard Rationale

Whole fruit is more nutritious than fruit juice and provides dietary fiber. Fruit juice which is 100% offers no nutritional advantage over whole fruits.

Limiting the feeding of juice to specific meals and snacks will reduce acids produced by bacteria in the mouth that cause tooth decay. The frequency of exposure, rather than the quantity of food, is important in determining whether foods cause tooth decay. Although sugar is not the only dietary factor likely to cause tooth decay, it is a major factor in the prevalence of tooth decay (1,2).

Drinks that are called fruit juice drinks, fruit punches, or fruit nectars contain less than 100% fruit juice and are of a lower nutritional value than 100% fruit juice. Liquids with high sugar content have no place in a healthy diet and should be avoided. Continuous consumption of juice during the day has been associated with a decrease in appetite for other nutritious foods which can result in feeding problems and overweight/obesity. Infants should not be given juice from bottles or easily transportable, covered cups (e.g. sippy cups) that allow them to consume juice throughout the day.

The American Academy of Pediatrics (AAP) recommends that children aged one to six years drink no more than four to six ounces of fruit juice a day (3). This amount is the total quantity for the whole day, including both time at early care and education and at home. Caregivers/teachers should not give the entire amount while a child is in their care. For breastfed infants, AAP recommends that gradual introduction of iron-fortified foods may occur no sooner than around four months, but preferably six months to complement the human milk. Infants should not be given juice before they reach twelve months of age.

Overconsumption of 100% fruit juice can contribute to overweight and obesity (3-6). One study found that two- to five-year-old children who drank twelve or more ounces of fruit juice a day were more likely to be obese than those who drank less juice (2). Excessive fruit juice consumption may be associated with malnutrition (over nutrition and under nutrition), diarrhea, flatulence, and abdominal distention (3). Unpasteurized fruit juice may contain pathogens that can cause serious illnesses (3). The U.S. Food and Drug Administration requires a warning on the dangers of harmful bacteria on all unpasteurized juice or products (7).


-Standard Comments


Caregivers/teachers, as well as many parents/ guardians, should strive to understand the relationship between the consumption of sweetened beverages and tooth decay. Drinks with high sugar content should be avoided because they can contribute to childhood obesity (2,5,6), tooth decay, and poor nutrition.


-Standard References
  1. Casamassimo, P., K. Holt, eds. 2004. Bright futures in practice: Oral health–pocket guide. Washington, DC: National Maternal and Child Oral Health Resource Center. http://www.mchoralhealth.org/PDFs/BFOHPocketGuide.pdf.
  2. Dennison, B. A., H. L. Rockwell, S. L. Baker. 1997. Excess fruit juice consumption by preschool-aged children is associated with short stature and obesity. Pediatrics 99:15-22.
  3. American Academy of Pediatrics, Committee on Nutrition. 2007. Policy statement: The use and misuse of fruit juice in pediatrics. Pediatrics 119:405.
  4. Faith, M. S., B. A. Dennison, L. S. Edmunds, H. H. Stratton. 2006. Fruit juice intake predicts increased adiposity gain in children from low-income families: Weight status-by-environment interaction. Pediatrics 118:2066-75.
  5. Dubois, L., A. Farmer, M. Girard, K. Peterson. 2007. Regular sugar-sweetened beverage consumption between meals increases risk of overweight among preschool-aged children. J Am Diet Assoc 107:924-34.
  6. Dennison, B. A., H. L. Rockwell, M. J. Nichols, P. Jenkins. 1999. Children's growth parameters vary by type of fruit juice consumed. J Am Coll Nutr 18:346-52.

  7. U.S. Food and Drug Administration. Safe handling of raw produce and fresh-squeezed fruit and vegetable juices. New York: JMH Education. http://www.fda.gov/Food/ResourcesForYou/Consumers/ucm114299.htm.


-Learn From Your Peers

“This standard comes in handy when parents send in juice for their infant (sometimes due to a recommendation from a pediatrician or a respected family member). We simply provide parents with a copy of the standard. This allows us to provide expert information without caregivers being perceived as judgmental or critical. It is wonderful to have an independent, authoritative source to which parents can be referred for education and support.”

- Child Care Center Director

 

“We all have to remember that it is okay to give toddlers and children water and to limit their juice intake. Perhaps our registration packets could include a nutrition guideline. Every nutrition article out there states that none of us are consuming enough water. So when in doubt, serve water.”

- Child Care Center Director

 

“Sometimes it is difficult to find the time to measure out the exact amount of juice the children are supposed to have. We use 6 oz disposable plastic cups and fill them up half way. What I have found is that the kids are often still thirsty and request more. It has taken me a while to figure out that you don't have to offer more juice; offer water instead!”

- Child Care Center Director

 

“At my center, we follow a basic rule of milk with meals and water with snacks, and promote this healthy approach to parents even when they are touring the center. I routinely explain that while juice does not need to be eliminated from young children’s diets altogether, our students are likely to get plenty outside of child care. At the same time, we have the ability to introduce water to children who might otherwise never be offered water. I reinforce the fact that whole fruit is more nutritious than fruit juice, and that we provide whole fruit (without relying on fruit juice) to satisfy food group requirements. Serving water instead of juice not only introduces to children a lifelong healthy habit, but it also saves money!”

- Pediatrician and Child Care Center Director

 

“The North Dakota Child Care Resource and Referral (as part of our star rating system for child care programs) recently gave us a copy of the Nutrition and Physical Activity Self-Assessment for Child Care. Our program will receive higher points when we offer fruit (not juice), when fruit is in its own juice (not syrup) and when 100% fruit juice is offered no more than 2 times per week. One barrier is that fresh fruit is more expensive than fruit juice, and it is harder to keep fresh supplies. Child care programs need financial support to make these quality improvements in their food programs.”

- Child Care Center Director

 

“Serving water eliminates one source of sticky spills and allows children to freely practice pouring to serve themselves. Young children can get the hang of drinking from an open cup without dumping stain-producing juice down their shirt or on the floor.”

- Child Care Health Consultant

 

“The following is a good teaching activity for child care health consultants to use when teaching parents and child care providers:
  • Display containers of unsweetened apple juice, orange juice, or guava juice.  Allow the learners to look at the nutrition content listed on the container (calories, vitamin content, sugar content, etc).
  • Pour 4 oz of each kind of juice into a cup. This shows the learners what a typical serving should look like.
  • Have them use the nutrition labeling to calculate the calories, sugar content, and vitamin C content for each serving.
  • Emphasize that products whose labels state ‘100% juice’ are not equal in nutrition content.”

- Public Health Nutritionist

Healthy Child Care America would like to thank the workgroup volunteers for
contributing to this project by sharing their ideas and experiences,
and Ashley Lucas, MD, FAAP, for her guidance on this project!
 
 



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