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 Children 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.

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


August 2014

Standard 2.1.2.2: Interactions with Infants and Toddlers


Caregivers/teachers should provide consistent, continuous and inviting opportunities to talk, listen to, and otherwise interact with young infants throughout the day (indoors and outdoors) including feeding, changing, playing with, and cuddling them.

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-Standard Rationale

Richness of language increases by nurturing it through verbal interactions between the child and adults and peers. Adults’ speech is one of the main channels through which children learn about themselves, others, and the world in which they live. While adults speaking to children teach the children facts, the social and emotional communications and the atmosphere of the exchange are equally important. Reciprocity of expression, response, the initiation and enrichment of dialogue are hallmarks of the social function and significance of the conversations (2-5). Infants and toddlers learn through meaningful relationships and interaction with consistent adults and peers.

The future development of the child depends on his/her command of language (1). Richness of language increases as it is nurtured by verbal interactions of the child with adults and peers. Basic communication with parents/guardians and children requires an ability to speak their language. A language-rich environment and warm, responsive interactions between staff and children are among the elements that produce positive impacts (6).

-Comments

Live, real-time interaction with caregivers/teachers is preferred. For example, caregivers/teachers naming objects in the indoor and outdoor learning/play environment or singing rhymes to all children supports language development. Children’s stories and poems presented on recordings with a fixed speed for sing-along can actually interfere with a child’s ability to participate in the singing or recitation. With fixed-speed activities, the pace may be too fast for some children, and the activity may have to be repeated for some children or the caregiver/teacher will need to try a different method for learning.

-Type of Facility

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

-References
  1. Moerk, E. L. 2000. The guided acquisition of first language skills. Advances Applied Dev Psychol 20:248.
  2. Baron, N., L. W. Schrank. 1997. Children learning language: How adults can help. Lake Zurich, Ill: Learning Seed.
  3. 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.
  4. Kontos, S., A. Wilcox-Herzog. 1997. Teachers’ interactions with children: Why are they so important? Young Child 52:4-12.
  5. Snow, C. E., M. S. Burns, P. Griffin. 1999. Language and literacy environments in preschools. ERIC Digest (January).
  6. National Forum on Early Childhood Program Evaluation, National Scientific Council on the Developing Child. 2007. A science-based framework for early childhood policy: Using evidence to improve outcomes in learning, behavior, and health for vulnerable children. Cambridge, MA: Center on the Developing Child, Harvard University. http://developingchild.harvard.edu/index.php/library/reports_and_working_papers/policy_framework/.

July 2014

Standard 9.2.6.1: Policy on Use and Maintenance of Play Area


Child care facilities should have a policy on the use and maintenance of play areas that address the following:

  1. Safety, purpose, and use of indoor and outdoor equipment for gross motor play;
  2. Selection of age-appropriate equipment;
  3. Supervision of indoor and outdoor play spaces;
  4. Staff training (to be addressed as employees receive training for other safety measures);
  5. Recommended inspections of the facility and equipment, as follows:
    1. Inventory, once at the time of purchase, and updated when changes to equipment are made in the playground;
    2. Audits of the active (gross motor) play areas (indoors and outdoors) by an individual with specialized training in playground inspection, once a year;
    3. Monthly inspections to check for U.S. Consumer Product Safety Commission (CPSC) recalled or hazard warnings on equipment, broken equipment or equipment in poor repair that requires immediate attention;
    4. Daily safety check of the grounds for safety hazards such as broken bottles and toys, discarded cigarettes, stinging insect nests, and packed surfacing under frequently used equipment like swings and slides;
    5. Whenever injuries occur.

For centers, the policy should be written. Documentation of the recommended inspections should be maintained in a master file.

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-Standard Rationale

Properly laid out outdoor play spaces, age-appropriate, properly designed and maintained equipment, installation of energy-absorbing surfaces, and adequate supervision of the play space by caregivers/teachers/parents/guardians help to reduce both the potential and the severity of injury (2). Indoor play spaces must also be properly laid out with care given to the location of equipment and the energy-absorbing surface under the equipment. A written policy with procedures is essential for education of staff and may be useful in situations where liability is an issue. The technical issues associated with the selection, maintenance, and use of playground equipment and surfacing are complex and specialized training is required to conduct annual inspections. Active play areas are associated with the most frequent and the most severe injuries in child care (1).

-Comments

Increasing awareness and understanding of issues in child safety highlight the importance of developing and maintaining safe play spaces for children in child care settings (3). Parents/guardians expect that their child will be adequately supervised and will not be exposed to hazardous play environments, yet will have the opportunity for free, creative play.

To obtain information on identifying a Certified Playground Safety Inspector (CPSI) to inspect a playground, contact the National Recreation and Park Association (NRPA) at http://www.nrpa.org/Content.aspx?id=3531.

The National Program for Playground Safety (NPPS) is another source of information on playground safety at http://www.uni.edu/playground/.

-Type of Facility

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

-References
  1. Rivara, F. P., J. J. Sacks. 1994. Injuries in child day care: An overview. Pediatrics 94:1031-33.
  2. U.S. Consumer Product Safety Commission. 2008. Public playground safety handbook. Washington, DC: CPSC. http://www.cpsc.gov/cpscpub/pubs/325.pdf.
  3. Quality in Outdoor Environments for Child Care. POEMS Website. http://www.poemsnc.org.

June 2014

Standard 3.1.3.1 Active Opportunities for Physical Activity

The facility should promote children’s active play every day. Children should have ample opportunity to do moderate to vigorous activities such as running, climbing, dancing, skipping, and jumping. All children, birth to six years, should participate daily in:

  1. Two to three occasions of active play outdoors, weather permitting (see Standard 3.1.3.2: Playing Outdoors for appropriate weather conditions);
  2. Two or more structured or caregiver/teacher/adult-led activities or games that promote movement over the course of the day—indoor or outdoor;
  3. Continuous opportunities to develop and practice age-appropriate gross motor and movement skills.

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

  1. Outdoor play:
    1. Infants (birth to twelve months of age) should be taken outside two to three times per day, as tolerated. There is no recommended duration of infants’ outdoor play;
    2. Toddlers (twelve months to three years) and preschoolers (three to six years) should be allowed sixty to ninety total minutes of outdoor play. These outdoor times can be curtailed somewhat during adverse weather conditions in which children may still play safely outdoors for shorter periods, but should increase the time of indoor activity, so the total amount of exercise should remain the same;
  2. Total time allotted for moderate to vigorous activities:
    1. Toddlers should be allowed sixty to ninety minutes per eight-hour day for moderate to vigorous physical activity, including running;
    2. Preschoolers should be allowed ninety to one hundred and twenty minutes per eight-hour day (4).

Infants should have supervised tummy time every day when they are awake. Beginning on the first day at the early care and education program, caregivers/teachers should interact with an awake infant on their tummy for short periods of time (three to five minutes), increasing the amount of time as the infant shows s/he enjoys the activity (27).

Time spent outdoors has been found to be a strong, consistent predictor of children’s physical activity (1-3). Children can accumulate opportunities for activity over the course of several shorter segments of at least ten minutes each. Because structured activities have been shown to produce higher levels of physical activity in young children, it is recommended that caregivers/teachers incorporate two or more short structured activities (five to ten minutes) or games daily that promote physical activity.

Opportunities to be actively enjoying physical activity should be incorporated into part-time programs by prorating these recommendations accordingly, i.e., twenty minutes of outdoor play for every three hours in the facility.

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

Infants should not be seated for more than fifteen minutes at a time, except during meals or naps. Infant equipment such as swings, stationary activity centers (ex. exersaucers), infant seats (ex. bouncers), molded seats, etc. if used should only be used for short periods of time. A least restrictive environment should be encouraged at all times (5,6,26).

Children should have adequate space for both inside and outside play.


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-Standard Rationale

Free play, active play and outdoor play are essential components of young children’s development (2). Children learn through play, developing gross motor, socio-emotional, and cognitive skills. In outdoor play, children learn about their environment, science, and nature.

Infants’ and young children’s participation in physical activity is critical to their overall health, development of motor skills, social skills, and maintenance of healthy weight (7). Daily physical activity promotes young children’s gross motor development and provides numerous health benefits including improved fitness and cardiovascular health, healthy bone development, improved sleep, and improved mood and sense of well-being. Tummy time prepares infants for the time when they will be able to slide on their bellies and crawl. As infants grow older and stronger they will need more time on their tummies to build their own strength (27).

Daily physical activity is an important part of preventing excessive weight gain and childhood obesity. Some evidence also suggests that children may be able to learn better during or immediately after bursts of physical activity, due to improved attention and focus (8,9).

Numerous reports suggest that children are not meeting daily recommendations for physical activity, and that children spend 70% (10) to 87% (11) of their time in early care and education being sedentary, (i.e., sitting or lying down). Excluding nap time, children are sedentary 83% of the time (11). Children may only spend about 2% to 3% of time being moderately or vigorously active (11).

Very young children are entirely dependent on their caregivers/teachers for opportunities to be active (12-15). Especially for children in full-time care and for children who live in unsafe neighborhoods, the early care and education facility may provide the child’s only daily opportunity for active play. Evidence suggests that physical activity habits learned early in life may track into adolescence and adulthood supporting the importance for children to learn lifelong healthy physical activity habits while in the early care and education program (13,16-25).

-Comments

There are many ways to promote tummy time with infants:

  1. Place yourself or a toy just out of the infant’s reach during playtime to get him to reach for you or the toy;
  2. Place toys in a circle around the infant. Reaching to different points in the circle will allow him/her to develop the appropriate muscles to roll over, scoot on his/her belly, and crawl;
  3. Lie on your back and place the infant on your chest. The infant will lift his/her head and use his/her arms to try to see your face (27).

There are a multitude of short, structured activities that are appropriate for toddlers and preschoolers. Structured activities could include popular children’s games such as Simon Says, Mother May I, Red Rover, Get the Wiggles Out, Musical Chairs, or a simple walk through the neighborhood. For training materials and more ideas of effective and age-appropriate games for young children, consider the following resources:

  1. “Nutrition and Physical Activity Self Assessment for Child Care - NAP SACC Program” – http://www.napsacc.org;
  2. “Color Me Healthy Preschoolers Moving and Eating” – http://www.colormehealthy.com;
  3. “Let’s Move, Learn, and Have Fun” physical activity curriculum from Kansas State University;
  4. “I am Moving I am Learning: Intervention in Head Start” – http://eclkc.ohs.acf.hhs.gov/hslc/tta-system/health/center/healthy-active-living/imil/IamMovingIam.htm;
  5. “Moving and Learning: The Physical Activity Specialists for Birth through Age 8” – http://www.movingandlearning.com/;
  6. “How to Lower Your Risk for Type 2 Diabetes: National Diabetes Education Program” – http://www.ndep.nih.gov/media/youthtips_lowerrisk_eng.pdf;
  7. “Motion Moments” – http://nrckids.org/index.cfm/products/videos/motion-moments1/.

Experts disagree about the appropriate amount of physical activity for toddlers and preschoolers, what proportion of children’s physical activity should be structured, and to what extent structured activities are effective in producing children’s physical activity. Researchers do agree that toddlers and preschoolers generally accumulate moderate to vigorous physical activity over the course of the day in very short bursts (fifteen to thirty seconds) (23). For additional recommendations by other national groups and experts, see:

  1. The National Association for Sport and Physical Education’s Active Start: A Statement of Physical Activity Guidelines for Children From Birth to Age 5, 2nd Edition and Physical Activity for Children: A Statement of Guidelines for Children 5 - 12, 2nd Edition
  2. U.S. Department of Health and Human Services’ 2008 Physical Activity Guidelines for Americans at http://www.health.gov/PAGuidelines/Report/pdf/CommitteeReport.pdf;
  3. U.S. Department of Health and Human Services and the U.S. Department of Agriculture’s Dietary Guidelines for Americans, 2010 at http://www.cnpp.usda.gov/DGAs2010-DGACReport.htm.

-Type of Facility

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

-References
  1. Brown, W. H., K. A. Pfeiffer, K. L. Mclver, M. Dowda, C. L. Addy, R. R. Pate. 2009. Social and environmental factors associated with preschoolers’ nonsedentary physical activity. Child Devel 80:45-58
  2. Burdette, H. L., R. C. Whitaker. 2005. Resurrecting free play in young children: Looking beyond fitness and fatness to attention, affiliation, and affect. Arch Pediatr Adolesc Med 159:46-50.
  3. Burdette, H. L., R. C. Whitaker, S. R. Daniels. 2004. Parental report of outdoor playtime as a measure of physical activity in preschool-aged children. Arch Pediatr Adolesc Med 158:353-57.
  4. Bower, J. K., D. P. Hales, D. F. Tate, D. A. Rubin, S. E. Benjamin, D. S. Ward. 2008. The childcare environment and children’s physical activity. Am J Prev Med 34:23-29.
  5. Benjamin, S. E., A. Ammerman, J. Sommers, J. Dodds, B. Neelon, D. S. Ward. 2007. The nutrition and physical activity self-assessment for child care (NAP SACC). Rev ed. Raleigh and Chapel Hill, NC: UNC Center for Health Promotion and Disease Prevention, Center of Excellence for Training and Research Translation. http://www.center-trt.org/downloads/obesity_prevention/interventions/napsacc/NAPSACC_Template.pdf.
  6. National Association for Sport and Physical Education (NASPE). 2002. Active start: A statement of physical activity guidelines for children birth to five years. Washington, DC: NASPE.
  7. Patrick, K., B. Spear, K. Holt, D. Sofka, eds. 2001. Bright futures in practice: Physical activity. Arlington, VA: National Center for Education in Maternal and Child Health. http://www.brightfutures.org/physicalactivity/pdf/index.html.
  8. Pellegrini, A., C. Bohn. 2005. The role of recess in children’s cognitive performance and school adjustment. Educ Res 34:13-19.
  9. Mahar, M. T., S. K. Murphy, D. A. Rowe, J. Golden, A. T. Shields, T. D. Raedeke. 2006. Effects of a classroom-based program on physical activity and on-task behavior. Med Sci Sports Exerc 38:2086-94.
  10. Pate, R. R., K. A. Pfeiffer, S. G. Trost, P. Ziegler, M. Dowda. 2004. Physical activity among children attending preschools. Pediatrics 114:1258-63.
  11.  Pate, R. R., K. McIver, M. Dowda, W. H. Brown, A. Cheryl. 2008. Directly observed physical activity levels in preschool children. J Sch Health 78:438-44.
  12. McKenzie, T. L., J. F. Sallis, J. P. Elder, C. C. Berry, P. L. Hoy, P. R. Nader, M. M. Zive, S. L. Broyles. 1997. Physical activity levels and prompts in young children at recess: A two-year study of a bi-ethnic sample. Res Q Exerc Sport 68:195-202.
  13. Sallis, J. F., T. L. McKenzie, J. P. Elder, S. L. Broyles, P. R. Nader. 1997. Factors parents use in selecting play spaces for young children. Arch Pediatr Adolesc Med 151:414-17.
  14. Sallis, J. F., P. R. Nader, S. L. Broyles, J. P. Elder, T. L. McKenzie, J. A. Nelson. 1993. Correlates of physical activity at home in Mexican-American and Anglo-American preschool children. Health Psychol 12:390-98.
  15. Davis, K., K. K. Christoffel. 1994. Obesity in preschool and school-age children: Treatment early and often may be best. Arch Pediatr Adolesc Med 148:1257-61.
  16. Sallis, J. F., C. C. Berry, S. L. Broyles, T. L. McKenzie, P. R. Nader. 1995. Variability and tracking of physical activity over 2 yr in young children. Med Sci Sports Exerc 27:1042-49.
  17. Pate, R. R., T. Baranowski, S. G. Trost. 1996. Tracking of physical activity in young children. Med Sci Sports Exerc 28:92-96.
  18. Birch, L. L., J. O. Fisher. 1998. Development of eating behaviors among children and adolescents. Pediatrics 101:539-49.
  19. Sallis, J. F., J. J. Prochaska, W. C. Taylor. 2000. A review of correlates of physical activity of children and adolescents. Med Sci Sports Exerc 32:963-75.
  20. Skinner, J. D., B. R. Carruth, W. Bounds, P. Ziegler, K. Reidy. 2002. Do food-related experiences in the first 2 years of life predict dietary variety in school-aged children? J Nutr Educ Behav 34:310-15.
  21. Skinner, J. D., B. R. Carruth, B. Wendy, P. J. Ziegler. 2002. Children’s food: A longitudinal analysis. J Am Diet Assoc 102:1638-47.
  22. Oliver, M., G. M. Schofield, G. S. Kolt. 2007. Physical activity in preschoolers: Understanding prevalence and measurement issues. Sports Med 37:1045-70.
  23. American Academy of Pediatrics, Council on Sports Medicine and Fitness, and Council on School Health. 2006. Active healthy living: Prevention of childhood obesity through increased physical activity. Pediatrics 117:1834-42.
  24. Physical Activity Guidelines Advisory Committee. 2008. Physical activity guidelines advisory committee report, 2008. Washington, DC: U.S. Department of Health and Human Services. http://www.health.gov/PAGuidelines/Report/pdf/CommitteeReport.pdf.
  25. American Physical Therapy Association. 2008. Lack of time on tummy shown to hinder achievement of developmental milestones, say physical therapists. News Release.
  26. American Academy of Pediatrics (AAP). 2008. Back to sleep, tummy to play. Elk Grove Village, IL: AAP. http://www.healthychildcare.org/pdf/SIDStummytime.pdf

May 2014

Standard 9.2.1.1 Content of Policies

The facility should have policies to specify how the caregiver/teacher addresses the developmental functioning and individual or special health care needs of children of different ages and abilities who can be served by the facility, as well as other services and procedures. These policies should include, but not be limited to, the following:

  1. Admissions criteria, enrollment procedures, and daily sign-in/sign-out policies, including authorized individuals for pick-up and allowing parent/guardian access whenever their child is in care;
  2. Inclusion of children with special health care needs;
  3. Nondiscrimination;
  4. Payment of fees, deposits, and refunds;
  5. Termination of enrollment and parent/guardian notification of termination;
  6. Supervision;
  7. Staffing, including caregivers/teachers, the use of volunteers, helpers, or substitute caregivers/teachers, and deployment of staff for different activities;
  8. A written comprehensive and coordinated planned program based on a statement of principles;
  9. Discipline;
  10. Methods and schedules for conferences or other methods of communication between parents/guardians and staff;
  11. Care of children and staff who are ill;
  12. Temporary exclusion for children and staff who are ill and alternative care for children who are ill;
  13. Health assessments and immunizations;
  14. Handling urgent medical care or threatening incidents;
  15. Medication administration;
  16. Use of child care health consultants and education and mental health consultants;
  17. Plan for health promotion and prevention (e.g., tracking routine child health care, health consultation, health education for children/staff/families, oral health, sun safety, safety surveillance, preventing obesity, etc.);
  18. Disasters, emergency plan and drills, evacuation plan, and alternative shelter arrangements;
  19. Security;
  20. Confidentiality of records;
  21. Transportation and field trips;
  22. Physical activity (both outdoors and when children are kept indoors), play areas, screen time, and outdoor play policy;
  23. Sleeping, safe sleep policy, areas used for sleeping/napping, sleep equipment, and bed linen;
  24. Sanitation and hygiene;
  25. Presence and care of any animals on the premises;
  26. Food and nutrition including food handling, human milk, feeding and food brought from home, as well as a daily schedule of meals and snacks;
  27. Evening and night care plan;
  28. Smoking, tobacco use, alcohol, prohibited substances, and firearms;
  29. Human resource management;
  30. Staff health;
  31. Maintenance of the facility and equipment;
  32. Preventing and reporting child abuse and neglect;
  33. Use of pesticides and other potentially toxic substances in or around the facility;
  34. Review and revision of policies, plans, and procedures.

The facility should have specific strategies for implementing each policy. For centers, all of these items should be written. Facility policies should vary according to the ages and abilities of the children enrolled to accommodate individual or special health care needs. Program planning should precede, not follow the enrollment and care of children at different developmental levels and abilities and with different health care needs. Policies, plans, and procedures should generally be reviewed annually or when any changes are made. A child care health consultant can be very helpful in developing and implementing model policies.


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-Standard Rationale

Neither plans nor policies affect quality unless the program has devised a way to implement the plan or policy. Children develop special health care needs and have developmental differences recognized while they are enrolled in child care (2). Effort should be made to facilitate accommodation as quickly as possible to minimize delay or interruption of care (1). For examples of policies see Model Child Care Health Policies at http://www.ecels-healthychildcarepa.org/publications/manuals-pamphlets-policies/item/248-model-child-care-health-policies and the California Childcare Health Program at http://www.ucsfchildcarehealth.org. Nutrition and physical activity policies for child care developed by the NAP SACC Program, Center for Health Promotion and Disease Prevention, University of North Carolina are available at http://www.center-trt.org.

-Comments

Reader’s note: Chapter 9 includes many standards containing additional information on specific policies noted above.

-Type of Facility

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

-References
  1. Aronson, S. S., ed. 2002. Model child care health policies. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics.
  2. Child Care Law Center. 2009. Questions and answers about the Americans with Disabilities Act: A quick reference for child care providers. Updated Version. http://www.childcarelaw.org/pubs-issue.shtml#disabilities.

April 2014

Standard 1.3.2.7 Qualifications and Responsibilities for Health Advocates

Each facility should designate at least one administrator or staff person as the health advocate to be responsible for policies and day-to-day issues related to health, development, and safety of individual children, children as a group, staff, and parents/guardians. In large centers it may be important to designate health advocates at both the center and classroom level. The health advocate should be the primary contact for parents/guardians when they have health concerns, including health-related parent/guardian/staff observations, health-related information, and the provision of resources. The health advocate ensures that health and safety is addressed, even when this person does not directly perform all necessary health and safety tasks.

The health advocate should also identify children who have no regular source of health care, health insurance, or positive screening tests with no referral documented in the child’s health record. The health advocate should assist the child’s parent/guardian in locating a Medical Home by referring them to a primary care provider who offers routine child health services.

For centers, the health advocate should be licensed/certified/credentialed as a director or lead teacher or should be a health professional, health educator, or social worker who works at the facility on a regular basis (at least weekly).

The health advocate should have documented training in the following:

  1. Control of infectious diseases, including Standard Precautions, hand hygiene, cough and sneeze etiquette, and reporting requirements;
  2. Childhood immunization requirements, record-keeping, and at least quarterly review and follow-up for children who need to have updated immunizations;
  3. Child health assessment form review and follow-up of children who need further medical assessment or updating of their information;
  4. How to plan for, recognize, and handle an emergency;
  5. Poison awareness and poison safety;
  6. Recognition of safety, hazards, and injury prevention interventions;
  7. Safe sleep practices and the reduction of the risk of Sudden Infant Death Syndrome (SIDS);
  8. How to help parents/guardians, caregivers/teachers, and children cope with death, severe injury, and natural or man-made catastrophes;
  9. Recognition of child abuse, neglect/child maltreatment, shaken baby syndrome/abusive head trauma (for facilities caring for infants), and knowledge of when to report and to whom suspected abuse/neglect;
  10. Facilitate collaboration with families, primary care providers, and other health service providers to create a health, developmental, or behavioral care plan;
  11. Implementing care plans;
  12. Recognition and handling of acute health related situations such as seizures, respiratory distress, allergic reactions, as well as other conditions as dictated by the special health care needs of children;
  13. Medication administration;
  14. Recognizing and understanding the needs of children with serious behavior and mental health problems;
  15. Maintaining confidentiality;
  16. Healthy nutritional choices;
  17. The promotion of developmentally appropriate types and amounts of physical activity;
  18. How to work collaboratively with parents/guardians and family members;
  19. How to effectively seek, consult, utilize, and collaborate with child care health consultants, and in partnership with a child care health consultant, how to obtain information and support from other education, mental health, nutrition, physical activity, oral health, and social service consultants and resources;
  20. Knowledge of community resources to refer children and families who need health services including access to State Children’s Health Insurance (SCHIP), importance of a primary care provider and medical home, and provision of immunizations and Early Periodic Screening, Diagnosis, and Treatment (EPSDT).


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-Standard Rationale

The effectiveness of an intentionally designated health advocate in improving the quality of performance in a facility has been demonstrated in all types of early childhood settings (1). A designated caregiver/teacher with health training is effective in developing an ongoing relationship with the parents/guardians and a personal interest in the child (2,3). Caregivers/teachers who are better trained are more able to prevent, recognize, and correct health and safety problems. An internal advocate for issues related to health and safety can help integrate these concerns with other factors involved in formulating facility plans.

Children may be current with required immunizations when they enroll, but they sometimes miss scheduled immunizations thereafter. Because the risk of vaccine-preventable disease increases in group settings, assuring appropriate immunizations is an essential responsibility in child care. Caregivers/teachers should contact their child care health consultant or the health department if they have a question regarding immunization updates/schedules. They can also provide information to share with parents/guardians about the importance of vaccines.

Child health records are intended to provide information that indicates that the child has received preventive health services to stay well, and to identify conditions that might interfere with learning or require special care. Review of the information on these records should be performed by someone who can use the information to plan for the care of the child, and recognize when updating of the information by the child’s primary care provider is needed. Children must be healthy to be ready to learn. Those who need accommodation for health problems or are susceptible to vaccine-preventable diseases will suffer if the staff of the child care program is unable to use information provided in child health records to ensure that the child’s needs are met (5,6).

-Comments

The director should assign the health advocate role to a staff member who seems to have an interest, aptitude, and training in this area. This person need not perform all the health and safety tasks in the facility but should serve as the person who raises health and safety concerns. This staff person has designated responsibility for seeing that plans are implemented to ensure a safe and healthful facility (1).

A health advocate is a regular member of the staff of a center or large or small family child care home, and is not the same as the child care health consultant recommended in Child Care Health Consultants, Standard 1.6.0.1. The health advocate works with a child care health consultant on health and safety issues that arise in daily interactions (4). For small family child care homes, the health advocate will usually be the caregiver/teacher. If the health advocate is not the child’s caregiver/teacher, the health advocate should work with the child’s caregiver/teacher. The person who is most familiar with the child and the child’s family will recognize atypical behavior in the child and support effective communication with parents/guardians.

A plan for personal contact with parents/guardians should be developed, even though this contact will not be possible daily. A plan for personal contact and documentation of a designated caregiver/teacher as health advocate will ensure specific attempts to have the health advocate communicate directly with caregivers/teachers and families on health-related matters.

The immunization record/compliance review may be accomplished by manual review of child health records or by use of software programs that use algorithms with the currently recommended vaccine schedules and service intervals to test the dates when a child received recommended services and the child’s date of birth to identify any gaps for which referrals should be made. On the Website of the Centers for Disease Control and Prevention (CDC), individual vaccine recommendations for children six years of age and younger can be checked at https://www.vacscheduler.org/.

-Type of Facility

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

-References
  1. Ulione, M. S. 1997. Health promotion and injury prevention in a child development center. J Pediatr Nurs 12:148-54.
  2. Kendrick, A. S., R. Kaufmann, K. P. Messenger, eds. 1991. Healthy young children: A manual for programs. Washington, DC: National Association for the Education of Young Children.
  3. Murph, J. R., S. D. Palmer, D. Glassy, eds. 2005. Health in child care: A manual for health professionals. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics.
  4. Alkon, A., J. Bernzweig, K. To, J. K. Mackie, M. Wolff, J. Elman. 2008. Child care health consultation programs in California: Models, services, and facilitators. Public Health Nurs 25:126-39.
  5. Centers for Disease Control and Prevention (CDC). 2011. Immunization schedules. http://www.cdc.gov/vaccines/schedules/index.html.
  6. Hagan, J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Bright futures: Guidelines for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics.

March 2014

Standard 2.2.01 Methods of Supervision of Children

Caregivers/teachers should directly supervise infants, toddlers, and preschoolers by sight and hearing at all times, even when the children are going to sleep, napping or sleeping, are beginning to wake up, or are indoors or outdoors. School-age children should be within sight or hearing at all times. Caregivers/teachers should not be on one floor level of the building, while children are on another floor or room. Ratios should remain the same whether inside or outside.

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

Caregivers/teachers should regularly count children (name to face on a scheduled basis, at every transition, and whenever leaving one area and arriving at another), going indoors or outdoors, to confirm the safe whereabouts of every child at all times. Additionally, they must be able to state how many children are in their care at all times.

Developmentally appropriate child:staff ratios should be met during all hours of operation, including indoor and outdoor play and field trips, and safety precautions for specific areas and equipment should be followed. No center-based facility or large family child care home should operate with fewer than two staff members if more than six children are in care, even if the group otherwise meets the child:staff ratio. Although centers often downsize the number of staff for the early arrival and late departure times, another adult must be present to help in the event of an emergency. The supervision policies of centers and large family child care homes should be written policies.

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-Standard Rationale

Supervision is basic to safety and the prevention of injury and maintaining quality child care. Parents/guardians have a contract with caregivers/teachers to supervise their children. To be available for supervision or rescue in an emergency, an adult must be able to hear and see the children. In case of fire, a supervising adult should not need to climb stairs or use a ramp or an elevator to reach the children. Stairs, ramps, and elevators may become unstable because they can be pathways for fire and smoke.

Children who are presumed to be sleeping might be awake and in need of adult attention. A child’s risk-taking behavior must be detected and illness, fear, or other stressful behaviors must be noticed and managed.

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

Children like to test their skills and abilities. This is particularly noticeable around playground equipment. Even if the highest safety standards for playground layout, design and surfacing are met, serious injuries can happen if children are left unsupervised. Adults who are involved, aware, and appreciative of young childrens’ behaviors are in the best position to safeguard their well-being. Active and positive supervision involves:

  1. Knowing each child’s abilities;
  2. Establishing clear and simple safety rules;
  3. Being aware of and scanning for potential safety hazards;
  4. Standing in a strategic position;
  5. Scanning play activities and circulating around the area;
  6. Focusing on the positive rather than the negative to teach a child what is safe for the child and other children;
  7. Teaching children the appropriate and safe use of each piece of equipment (e.g., using a slide correctly – feet first only – and teaching why climbing up a slide can cause injury, possibly a head injury).

Children are going to be more active in the outdoor learning/play environment and need more supervision rather than less outside. Playground supervisors need to be designated and trained to supervise children in play areas (1). Supervision of the playground is a strategy of watching all the children within a specific territory and not engaging in prolonged dialog with any one child or group of children (or other staff). Other adults not designated to supervise may facilitate outdoor learning/play activities and engage in conversations with children about their exploration and discoveries. Facilitated play is where the adult is engaged in helping children learn a skill or achieve specific outcome of an activity. Facilitated play is not supervision (2).

Children need spaces, indoors and out, in which they can withdraw for alone-time or quiet play in small groups. However, program spaces should be designed with visibility that allows constant unobtrusive adult supervision. To protect children from maltreatment, including sexual abuse, the environment layout should limit situations in which an adult or older child is left alone with a child without another adult present (3,4).

Many instances have been reported where a child has hidden when the group was moving to another location, or where the child wandered off when a door was opened for another purpose. Regular counting of children (name to face) will alert the staff to begin a search before the child gets too far, into trouble, or slips into an unobserved location.

Caregivers/teachers should record the count on an attendance sheet or on a pocket card, along with notations of any children joining or leaving the group. Caregivers/teachers should do the counts before the group leaves an area and when the group enters a new area. The facility should assign and reassign counting responsibility as needed to maintain a counting routine. Facilities might consider counting systems such as using a reminder tone on a watch or musical clock that sounds at timed intervals (about every fifteen minutes) to help the staff remember to count.

Caregivers/teachers should be ready to provide help and guidance when children are ready to use the toilet correctly and independently. Caregivers/teachers should make sure children correctly wash their hands after every use of the toilet, as well as monitor the bathroom to make sure that the toilet is flushed, the toilet seat and floor are free from stool or urine, and supplies (toilet paper, soap, and paper towels) are available.

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

Planning must include advance assignments, monitoring, and contingency plans to maintain appropriate staffing. During times when children are typically being dropped off and picked up, the number of children present can vary. There should be a plan in place to monitor and address unanticipated changes, allowing for caregivers/teachers to receive additional help when needed. Sufficient staff must be maintained to evacuate the children safely in case of emergency. Compliance with proper child:staff ratios should be measured by structured observation, by counting caregivers/teachers and children in each group at varied times of the day, and by reviewing written policies.

-Type of Facility

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

-References
  1. National Program for Playground Safety. 2006. Playground supervision training for childcare providers. University of Northern Iowa. http://www.playgroundsafety.org/training/online-training/available-courses/childcare-providers.
  2. National Program for Playground Safety. 2006. NPPS Website. http://www.playgroundsafety.org.
  3. National Association for the Education of Young Children. 1996. Position Statement. Prevention of child abuse in early childhood programs and the responsibilities of early childhood professionals to prevent child abuse.
  4. 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/.

February 2014

Standard 4.5.0.4 Socialization During Meals

Caregivers/teachers and children should sit at the table and eat the meal or snack together. Family style meal service, with the serving platters, bowls, and pitchers on the table so all present can serve themselves, should be encouraged, except for infants and very young children who require an adult to feed them. A separate utensil should be used for serving. Children should not handle foods that they will not be consuming. The adults should encourage, but not force, the children to help themselves to all food components offered at the meal. When eating meals with children, the adult(s) should eat items that meet nutrition standards. The adult(s) should encourage social interaction and conversation, using vocabulary related to the concepts of color, shape, size, quantity, number, temperature of food, and events of the day. Extra assistance and time should be provided for slow eaters. Eating should be an enjoyable experience at the facility and at home.

Special accommodations should be made for children who cannot have the food that is being served. Children who need limited portion sizes should be taught and monitored.

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-Standard Rationale

“Family style” meal service promotes and supports social, emotional, and gross and fine motor skill development. Caregivers/teachers sitting and eating with children is an opportunity to engage children in social interactions with each other and for positive role-modeling by the adult caregiver/teacher. Conversation at the table adds to the pleasant mealtime environment and provides opportunities for informal modeling of appropriate eating behaviors, communication about eating, and imparting nutrition learning experiences (1-3,5-7). The presence of an adult or adults, who eat with the children, helps prevent behaviors that increase the possibility of fighting, feeding each other, stuffing food into the mouth and potential choking, and other negative behaviors. The future development of children depends, to no small extent, on their command of language. Richness of language increases as adults and peers nurture it (5). Family style meals encourage children to serve themselves which develops their eye-hand coordination (3-5). In addition to being nourished by food, infants and young children are encouraged to establish warm human relationships by their eating experiences. When children lack the developmental skills for self-feeding, they will be unable to serve food to themselves. An adult seated at the table can assist and be supportive with self-feeding so the child can eat an adequate amount of food to promote growth and prevent hunger.

-Type of Facility

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

-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. http://eclkc.ohs.acf.hhs.gov/hslc/Head Start Program/Program Design and Management/Head Start Requirements/Head Start Requirements/45 CFR Chapter XIII/45 CFR Chap XIII_ENG.pdf.
  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. http://nti.unc.edu/course_files/curriculum/nutrition/making_food_healthy_and_safe.pdf.
  3. Endres, J. B., R. E. Rockwell. 2003. Food, nutrition, and the young child. 4th ed. New York: Macmillan.
  4. U.S. Department of Agriculture (USDA). 2002. Making nutrition count for children - Nutrition guidance for child care homes. Washington, DC: USDA. http://www.fns.usda.gov/tn/Resources/nutritioncount.html.
  5. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.
  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. Sigman-Grant, M., E. Christiansen, L. Branen, J. Fletcher, S. L. Johnson. 2008. About feeding children: Mealtimes in child-care centers in four western states. J Am Diet Assoc 108:340-46.

January 2014

Standard 3.1.3.2 Playing Outdoors

Children should play outdoors when the conditions do not pose a safety risk, individual child health risk, or significant health risk of frostbite or of heat related illness. Caregivers/teachers must protect children from harm caused by adverse weather, ensuring that children wear appropriate clothing and/or appropriate shelter is provided for the weather conditions. 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°F and heat index at or above 90°F, as identified by the National Weather Service (NWS).

Sunny weather:

  1. 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;
  2. Children should wear sun-protective clothing, such as hats, when playing outdoors between the hours of 10 AM and 4 PM.

Warm weather:

  1. Children should be well hydrated before engaging in prolonged periods of physical activity and encouraged to drink water during periods of prolonged physical activity;
  2. Caregivers/teachers should encourage parents/guardians to have children dress in clothing that is light-colored, lightweight, and limited to one layer of absorbent material that will maximize the evaporation of sweat;
  3. 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.

Cold weather:

  1. Children should wear layers of loose-fitting, lightweight clothing. Outer garments such as coats should be tightly woven, and be at least water repellent when precipitation is present, such as rain or snow;
  2. Children should wear a hat, coat, and gloves/mittens kept snug at the wrist;
  3. Caregivers/teachers should check children’s extremities for maintenance of normal color and warmth at least every fifteen minutes.

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). Short 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.

Children need protection from adverse weather and its effects. 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 NWS and are announced routinely.

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.

-Type of Facility

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

-References
  1. American Academy of Pediatrics, Committee on Sports Medicine and Fitness. 2007. Policy statement: Climatic heat stress and the exercising child and adolescent. Pediatrics 120:683-84.
  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.
  3. Mayo Clinic. 2009. Hypothermia: Symptoms. http://www.mayoclinic.com/health/hypothermia/DS00333/.
  4. Kids Health. 2008. Frostbite. Nemours. http://kidshealth.org/parent/firstaid_safe/emergencies/frostbite.html.

December 2013

Standard 2.1.1.9 Verbal Interaction

The child care facility should assure that a rich environment of spoken language by caregivers/teachers surrounds and includes all children with opportunities to expand their language communication skills. Each child should have at least one speaking adult person who engages the child in frequent verbal exchanges linked to daily events and experiences. To encourage the development of language, the caregiver/teacher should demonstrate skillful verbal communication and interaction with the child.

  1. For infants, these interactions should include responses to, and encouragement of, soft infant sounds, as well as identifying objects, feelings, and desires by the caregiver/teacher.
  2. For toddlers, the interactions should include naming of objects, feelings, listening to the child and responding, along with actions and supporting, but not forcing, the child to do the same.
  3. For preschool and school-age children, interactions should include respectful listening and responses to what the child has to say, amplifying and clarifying the child’s intent, and not reinforcing mispronunciations (e.g., Wambulance instead of Ambulance).
  4. Frequent interchange of questions, comments, and responses to children, including extending children’s utterances with a longer statement, by teaching staff.
  5. For children with special needs, alternative methods of communication should be available, including but not limited to: sign language, assistive technology, picture boards, picture exchange communication systems (PECS), FM systems for hearing aids, etc. Communication through methods other than verbal communication can result in the same desired outcomes.
  6. Profanity should not be used at any time.

 

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-Standard Rationale

Conversation with adults is one of the main channels through which children learn about themselves, others, and the world in which they live. While adults speaking to children teaches the children facts and relays information, the social and emotional communications and the atmosphere of the exchange are equally important. Reciprocity of expression, response, and the initiation and enrichment of dialogue are hallmarks of the social function and significance of the conversations (1-4).

The future development of the child depends on his/her command of language (5). Research suggests that language experiences in a child’s early years have a profound influence on that child’s language and vocabulary development, which in turn has an impact on future school success (6). Richness of the child’s language increases as it is nurtured by verbal interactions and learning experiences with adults and peers. Basic communication with parents/guardians and children requires an ability to speak their language. Discussing the impact of actions on feelings for the child and others helps to develop empathy.

-Type of Facility

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

-References
  1. Mayr, T., M. Ulich. 1999. Children’s well-being in day care centers: An exploratory empirical study. Int J Early Years Education 7:229-39.
  2. Baron, N., L. W. Schrank. 1997. Children learning language: How adults can help. Lake Zurich, IL: Learning Seed.
  3. 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, Inc.
  4. Kontos, S., A. Wilcox-Herzog. 1997. Teachers’ interactions with children: Why are they so important? Young Child 52:4-12.
  5. Moerk, E. L. 2000. The guided acquisition of first language skills. Advances in Applied Dev Psychol 20:248.
  6. Pikulski, J. J., Templeton, S. 2004. Teaching and developing vocabulary: Key to long-term reading success. Geneva, IL: Houghton Mifflin Company. http://www.eduplace.com/state/author/pik_temp.pdf.

November 2013

Standard 8.4.0.4 Designation and Role of Staff Person Responsible for Coordinating Care in the Child Care Facility

If a child has an Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP), or any plan for medical services, the child care facility should designate one person in the child care setting to be responsible for coordinating care within the facility and with any caregiver/teacher or coordinator in other service settings, in accordance with the written plan. The role of the designated person should include:

  1. Documentation of coordination;
  2. Written or electronic communication with other care or service providers for the child, including their medical home, to ensure a coordinated, coherent service plan;
  3. Sharing information about the plan, staff conferences, written reports, consultations, and other services provided to the child and family (informed, written parental/guardian consent must be sought before sharing this confidential information);
  4. Ensuring implementation of the components of the plan that is relevant to the facility.

When the evaluators who are to determine if the child has special health care needs or is eligible for services under the Individuals with Disabilities Education Improvement Act (IDEA) are not part of the child care staff, the lead agency should develop a formal mechanism for coordinating reevaluations and program revisions. The designated staff member from the facility should routinely be included in the evaluation process and team conferences. Any care plan should be updated whenever the child is hospitalized or has a significant change in therapy.

 

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-Standard Rationale

One person being responsible for coordinating all elements of services avoids confusion and allows easier and more consistent communication with the family. When carrying out coordination duties, this person is called a child care coordinator or service coordinator. Each child should have a care coordinator/service coordinator assigned in the child care facility at the time the service plan is developed.

With more than half of all mothers in the workforce, caregivers other than the parents/guardians (such as teachers, grandparents, foster parents, or neighbors) frequently spend considerable time with the children. These caregivers/teachers need to know and understand the aims and goals of the service plan; otherwise, program approaches will not carry over into the home environment.

This requirement does not preclude outside agencies or caregivers/teachers from having their own care coordinator, service coordinator, or case manager. The intent is to ensure communication and coordination among all the child’s sources of care, both in the facility and elsewhere in the community. The child’s care coordinator or service coordinator does not have responsibility for directly implementing all program components but, rather, is accountable for checking to make sure the plans in the facility are being carried out, encouraging implementation of the service plan, and helping obtain or gain access to services.

A facility assuming responsibility for serving children with disabilities or children with special health care needs must develop mechanisms for identifying the needs of the children and families and obtaining appropriate services, whether or not those children have an IEP/IFSP. The child care coordinator will be responsible for coordination of health services with the program child care health consultant, as needed.

-Type of Facility

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

-Related Standards

1.3.2.7 Qualifications and Responsibilities for Health Advocates
1.6.0.1 Child Care Health Consultants
10.3.4.5 Resources for Parents/Guardians of Children with Special Health Care Needs
10.3.4.6 Compensation for Participation in Multidisciplinary Assessments for Children with Special Health Care or Education Needs

-Comments

Usually, the person who coordinates care or services within the child care facility will not be the person assigned to coordinate overall care or provide overall case management for the child and family. Nevertheless, the facility may assume both roles if the parents/guardians so request and state law permits. The components and the role may vary, and each facility will determine these components and roles, which may depend on the roles and responsibilities of the staff in the facility and the responsibilities assumed by the family and care providers in the community. The person who coordinates care or services within the child care facility may be the Health Advocate or someone else who is working closely with the child’s family and the teaching staff in the facility.


October 2013

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

(Disclaimer: Caring for our Children Standards are considered the Gold Standard. Each state determines the number of continuing education hours required to meet compliance. If you are unsure of the number of continuing education hours required by your state, you can find this information at www.nrckids.org.)

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

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

 

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-Standard Rationale

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

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

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

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

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

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

-Type of Facility

Center, Large Family Child Care Home

-Standard References

  1. National Association for the Education of Young Children (NAEYC). 2009. Standards for Early Childhood professional preparation programs. Washington, DC: NAEYC. http://www.naeyc
    .org/files/naeyc/file/positions/ProfPrepStandards09.pdf
    .
  2. Whitebook, M., C. Howes, D. Phillips. 1998. Worthy work, unlivable wages: The National child care staffing study, 1988-1997. Washington, DC: Center for the Child Care Workforce.
  3. Crowley, A. A. 1990. Health services in child care day care centers: A survey. J Pediatr Health Care 4:252-59.
  4. 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/
  5. Aronson, S. S., T. R. Shope, eds. 2009. Managing infectious diseases in child care and schools: A quick reference guide. 2nd ed. Elk Grove Village, IL: American Academy of Pediatrics.

-Learn From Your Peers

One of the best components of the educational industry is seeing our students achieve one of their goals. Participating in continuing education signifies that Directors and Teachers recognize the importance of professional development.  It also indicates that we care about the children that we serve and are interested in obtaining the knowledge and ability to make a significant contribution in the development of young children. 

If we are to be role models for children it is important that we are lifelong learners.  In the child development and education industry there is something new to learn each and every day.  New insight and skills into how to be more effective on the job, keep us from getting weary and becoming a hindrance to the development of our colleagues and students. 
--- Educational Consultant


September 2013

Standard 1.6.0.3 Early Childhood Mental Health Consultants

A facility should engage a qualified early childhood mental health consultant who will assist the program with a range of early childhood social-emotional and behavioral issues and who will visit the program at minimum quarterly and more often as needed.

The knowledge base of an early childhood mental health consultant should include:

  1. Training, expertise and/or professional credentials in mental health (e.g., psychiatry, psychology, clinical social work, nursing, developmental-behavioral medicine, etc.);
  2. Early childhood development (typical and atypical) of infants, toddlers, and preschool age children;
  3. Early care and education settings and practices;
  4. Consultation skills and approaches to working as a team with early childhood consultants from other disciplines, especially health and education consultants, to effectively support directors and caregivers/teachers.

The role of the early childhood mental health consultant should be focused on building staff capacity and be both proactive in decreasing the incidence of challenging classroom behaviors and reactive in formulating appropriate responses to challenging classroom behaviors and should include:

  1. Developing and implementing classroom curricula regarding conflict resolution, emotional regulation, and social skills development;
  2. Developing and implementing appropriate screening and referral mechanisms for behavioral and mental health needs;
  3. Forming relationships with mental health providers and special education systems in the community;
  4. Providing mental health services, resources and/or referral systems for families and staff;
  5. Helping staff facilitate and maintain mentally healthy environments within the classroom and overall system;
  6. Helping address mental health needs and reduce job stress within the staff;
  7. Improving management of children with challenging behaviors;
  8. Preventing the development of problem behaviors;
  9. Providing a classroom climate that promotes positive social-emotional development;
  10. Recognizing and appropriately responding to the needs of children with internalizing behaviors, such as persistent sadness, anxiety, and social withdrawal;
  11. Actively teaching developmentally appropriate social skills, conflict resolution, and emotional regulation;
  12. Addressing the mental health needs and daily stresses of those who care for young children, such as families and caregivers/teachers;
  13. Helping the staff to address and handle unforeseen crises or bereavements that may threaten the mental health of staff or children and families, such as the death of a caregiver/teacher or the serious illness of a child.

 

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-Standard Rationale

As increasing numbers of children are spending longer hours in child care settings, there is an increasing need to build the capacity of caregivers/teachers to attend to the social-emotional and behavioral well-being of children as well as their health and learning needs. Early childhood mental health underlies much of what constitutes school readiness, including emotional and behavioral regulation, social skills (i.e., taking turns, postponing gratification), the ability to inhibit aggressive or anti-social impulses, and the skills to verbally express emotions, such as frustration, anger, anxiety, and sadness. Supporting children’s health, mental health and learning requires a comprehensive approach. Child care programs need to have health, education, and mental health consultants who can help them implement universal, selected and targeted strategies to improve school readiness in young children in their care (1-5). Mental health consultants in collaboration with education and child care health consultants can reduce the risk for children being expelled, can reduce levels of problem behaviors, increase social skills and build staff efficacy and capacity (1-11).

-Type of Facility

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

-Standard References

  1. Brennan, E. M., J. Bradley, M. D. Allen, D. F. Perry. 2008. The evidence base for mental health consultation in early childhood settings: A research synthesis addressing staff and program outcomes. Early Ed Devel 19:982-1022.
  2. National Scientific Council on the Developing Child. 2008. Mental health problems in early childhood can impair learning and behavior for life. Working Paper no. 6. http://developingchild.harvard.edu/library/reports_and_working_papers/working_papers/wp6/.
  3. Perry, D. F., M. D. Allen, E. M. Brennan, J. R. Bradley. 2010. The evidence base for mental health consultation in early childhood settings: A research synthesis addressing children’s behavioral outcomes. Early Ed Devel 21:795-824.
  4. Perry, D. F., R. Kaufmann, J. Knitzer. 2007. Early childhood social and emotional health: Building bridges between services and systems. Baltimore, MD: Paul Brookes Publishing.
  5. Perry, D. F., M. C. Dunne, L. McFadden, D. Campbell. 2008. Reducing the risk for preschool expulsion: Mental health consultation for young children with challenging behaviors. J Child Fam Studies 17:44-54.
  6. Committee on Integrating the Science of Early Childhood Development, Board on Children, Youth, and Families. 2000. From neurons to neighborhoods. Ed. J. P. Shonkoff, D. A. Phillips. Washington, DC: National Academy Press.
  7. Gilliam, W. S. 2005. Prekindergarteners left behind: Expulsion rates in state prekindergarten programs. Foundation for Child Development (FCD). Policy Brief Series no. 3. New York: FCD. http://www.challengingbehavior.org/explore/policy_docs/prek_expulsion.pdf.
  8. Gilliam, W. S., G. Shahar. 2006. Preschool and child care expulsion and suspension: Rates and predictors in one state. Infants Young Children 19:228-45.
  9. Gilliam, W. S. 2007. Early Childhood Consultation Partnership: Results of a random-controlled evaluation. New Haven, CT: Yale Universty. http://www.chdi.org/admin/uploads/5468903394946c41768730.pdf.
  10. American Academy of Pediatrics, Committee on School Health. 2003. Policy statement: Out-of-school suspension and expulsion. Pediatrics 112:1206-9.
  11. Duran, F., K. Hepburn, M. Irvine, R. Kaufmann, B. Anthony, N. Horen, D. Perry. 2009. What works?: A study of effective early childhood mental health consultation programs. Washington, DC: Georgetown University Center for Child and Human Development. http://gucchdtacenter.georgetown.edu/publications/ECMHCStudy_Report.pdf.

-Learn From Your Peers

Mental health professionals can be a tremendous asset to organizations.  We invited them to speak at our monthly parent teacher organization meetings.  They helped parents to identify signs and symptoms of developmental delays and disorders. 
--- Educational Consultant


August 2013

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

The 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).

-Type of Facility

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

-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

Child care licensers in our state provide technical support and resources to all licensed facilities regarding the importance of influenza immunizations.  Public Health nurses provide additional information to new child care providers during the mandatory Medication Administration training.  Licensers review immunization records during route licensing inspections.
--- State Licensing Supervisor

 

And

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

Small Family Child Care Home, Center, Large 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

I try to encourage the staff/directors to be vaccinated so they are able to help protect the children who are not vaccinated.  Another option may be to bring in the local health department or private group to provide an on-site vaccination clinic, or provide parents/staff with a list of places offering influenza vaccinations.
--- Child Care Health Consultant.

Vaccination requirements vary from state to state, please check the NRC Web site for more details regarding your licensing requirements, www.nrckids.org

At this point, licensing does not determine which immunizations need to be completed. Our rule states: Immunization records and reports shall be completed and maintained by the provider as required by W.S. 14-4-116 and the Department of Health, Immunization Program, except for school age children who are attending public school. In programs that are operated on a drop-in basis, immunization records for children are not required, but recommended to be on file. If attendance on a drop-in basis exceeds thirty (30) calendar days, immunization records are required.
--- State Licensing Supervisor


July 2013

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

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

Developmental Levels

Child:Staff Ratio

Infants

1:1

Toddlers

1:1

Preschoolers

4:1

School-age Children

6:1


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

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

 

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-Standard Rationale

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

-Type of Facility

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

-Standard References

  1. American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement: Prevention of drowning. Pediatrics 126:178-85.
  2. U.S. Consumer Product Safety Commission (CPSC). Pool and spa safety: The Virginia Graeme Baker pool and spa safety act. http://www.poolsafely.gov/wp-content/uploads/VGBA.pdf.
  3. U.S. Consumer Product Safety Commission (CPSC). 2009. CPSC warns of in-home drowning dangers with bathtubs, bath seats, buckets. Release #10-008. http://www.cpsc.gov/cpscpub/prerel/prhtml10/10008.html.
  4. Gipson, K. 2008. Submersions related to non-pool and non-spa products, 2008 report. Washington, DC: U.S. Consumer Product Safety Commission. http://www.cpsc.gov/library/FOIA/FOIA09/OS/nonpoolsub2008.pdf.
  5. American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention, J. Weiss. 2010. Technical report: Prevention of drowning. Pediatrics 126: e253-62.
  6. Consumer Product Safety Commission. Steps for safety around the pool: The pool and spa safety act. Pool Safely. http://www.poolsafely.gov/wp-content/uploads/360.pdf.
  7. Gipson, K. 2008. Pool and spa submersion: Estimated injuries and reported fatalities, 2008 report. Bethesda, MD: U.S. Consumer Product Safety Commission. http://www.cpsc.gov/LIBRARY/poolsub2008.pdf.

-Learn From Your Peers

We recruited volunteers to assist with water activities (including water play in tables).  This way the students were not limited in activities.  We were able to maintain 1:1 or 1:2 ratios.  Parents signed up for these days at the beginning of the school year.  We provided a 30 minute volunteer orientation to provide guidance for volunteer supervision (e.g. any lesson plan objectives, discipline policies, and basic health and safety procedures concerning hand washing, and so forth).  This is a great time to invite parents that love messy fun and take the party outside.
--- Educational Consultant


June 2013

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

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

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

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

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

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

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

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

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

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

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

 

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-Standard Rationale

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

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

-Type of Facility

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

-Standard References

  1. American Academy of Pediatrics, Committee on School Health. 2008. Policy statement: Out-of-school suspension and expulsion. Pediatrics 122:450.
  2. Gilliam, W. S. 2005. Prekindergarteners left behind: Expulsion rates in state prekindergarten programs. Foundation for Child Development, Policy Brief Series no. 3. http://medicine.yale.edu/childstudy/zigler/Images/National Prek Study_expulsion brief_tcm350-34775.pdf.
  3. Gilliam, W. S., G. Shahar. 2006. Preschool and child care expulsion and suspension: Rates and predictors in one state. Infants Young Children 19:228-45.
  4. Gilliam, W. S. 2008. Implementing policies to reduce the likelihood of preschool expulsion. Foundation for Child Development, Policy Brief Series no. 7. http://medicine.yale.edu/childstudy/zigler/publications/34772_PreKExpulsionBrief2.pdf.
  5. National Scientific Council on the Developing Child. 2008. Mental health problems in early childhood can impair learning and behavior for life. Working paper #6. http://developingchild.harvard.edu/library/reports_and_working_papers/working_papers/wp6/.
  6. Perry, D. F., M. C. Dunne, L. McFadden, D. Campbell. 2008. Reducing the risk for preschool expulsion: Mental health consultation for young children with challenging behaviors. J Child Family Studies 17:44-54.

-Learn From Your Peers

I try to encourage programs to get outside help as soon as possible to help them work with the children before they are expelled. Having a consultant come into the program to observe what is happening can be very helpful.  An outside perspective may see things that a provider/program is not seeing.  It is also important to consider that the child care environment may be affecting the child’s behavior.  Sometimes the child’s behavior can be dramatically improved by making changes in the classroom/house. Finally, it is important for all programs/providers to try to help the child instead of letting the child go so easily.  Many times the child is hurting; the child’s behavior is just the outlet for the child’s internal struggles.  When these children are passed from one child care center to another, it makes things even worse for them.
--- Child Care Health Consultant

 


May 2013

Standard 2.1.1.4 Monitoring Children's Development/ Obtaining Consent for Screening

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

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

Parents/guardians should be explicitly invited to:

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

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

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

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

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

 

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-Standard Rationale

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

-Type of Facility

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

-Standard References

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

-Comments

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

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

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

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

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

-Learn From Your Peers

While screening children is very important, more emphasis should be put on making services available once a child’s challenges are detected.  Identifying these challenges early serves little purpose if we cannot secure the appropriate services for addressing them.
--- Manager

All caregivers should be knowledgeable about child development milestones in order to help them recognize when a child may be delayed.  Equip those who are not educated in this area with training and resources.  Caregivers can also educate parents on child development through handouts, posters, newsletters, etc.  Informed parents may be able to pick up on their child’s delays sooner and will be more receptive in the event that their child has a problem detected.  Preparing caregivers in how they approach parents about their concerns regarding a child is also crucial…it is all in the delivery.
---Early Childhood Systems Professional

When monitoring children’s development, early childhood professionals need easy access to writing materials for making quick notes.  It is helpful to have post-it notes or index cards ready in a pocket; these notes can be used later to write a complete observation for the child’s records.  Many teachers prefer to wear an attractive apron or smock with pockets for observation materials, tissues and disposable gloves.  When meeting with parents or guardians to discuss the development of a child, it is important that care is given to ensure that the atmosphere is conducive for sharing information.  Seating should be planned so all individuals engaged in the discussion are on an equal level and can easily see each other. A person sitting behind a desk can be intimidating.  If appropriate, coffee, tea or water can be offered to help ease a potentially stressful experience.  It is wise to start the conversation with a true and sincere positive statement about the child.  A difficult situation can be made easier for all concerned when care is given to the feelings of all involved in the discussion.  
--- Early Childhood Professor

 


April 2013

Standard 1.6.0.1 Child Care Health Consultants

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

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

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

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

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

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

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

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

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

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

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

 

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-Standard Rationale

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

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

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

-Type of Facility

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

-Standard References

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

-Comments

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

Certificates are provided for graduates of the NTI upon completion of the course and continuing education units are awarded. Some states offer CCHC training. Not all states implement CCHC training as modeled by the NTI. Some states offer continuing education units, college credit, and/or certificate of completion. Credentialing is an umbrella term referring to the various means employed to designate that individuals or organizations have met or exceeded established standards. These may include accreditation of programs or organizations and certification, registration, or licensure of individuals. Accreditation refers to a legitimate state or national organization verifying that an educational program or organization meets standards. Certification is the process by which a non-governmental agency or association grants recognition to an individual who has met predetermined qualifications specified by the agency or association. Certification is applied for by individuals on a voluntary basis and represents a professional status when achieved. Typical qualifications include 1) graduation from an accredited or approved program and 2) acceptable performance on a qualifying examination. While there is no national accreditation of CCHC training programs or individual CCHCs at this time, this is a future goal. Contact NTI at nti@unc.edu for additional information.

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

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

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

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

 


March 2013

Standard 3.6.1.1 Inclusion/Exclusion/Dismissal of Children

Preparing for managing illness:

Caregivers/teachers should:

  1. Encourage all families to have a backup plan for child care in the event of short or long term exclusion;
  2. Review with families the inclusion/exclusion criteria and clarify that the program staff (not the families) will make the final decision about whether children who are ill may stay based on the program’s inclusion/exclusion criteria and their ability to care for the child who is ill without compromising the care of other children in the program;
  3. Develop, with a child care health consultant, protocols and procedures for handling children’s illnesses, including care plans and an inclusion/exclusion policy;
  4. Request the primary care provider’s note to readmit a child if the primary care provider’s advice is needed to determine whether the child is a health risk to others, or if the primary care provider’s guidance is needed about any special care the child requires (1);
  5. Rely on the family’s description of the child’s behavior to determine whether the child is well enough to return, unless the child’s status is unclear from the family’s report.

Daily health checks as described in Standard 3.1.1.1 should be performed upon arrival of each child each day. Staff should objectively determine if the child is ill or well. Staff should determine which children with mild illnesses can remain in care and which need to be excluded.

Staff should notify the parent/guardian when a child develops new signs or symptoms of illness. Parent/guardian notification should be immediate for emergency or urgent issues. Staff should notify parents/guardians of children who have symptoms that require exclusion and parents/guardians should remove the child from the child care setting as soon as possible. For children whose symptoms do not require exclusion, verbal or written notification of the parent/guardian at the end of the day is acceptable. Most conditions that require exclusion do not require a primary care provider visit before reentering care.

Conditions/symptoms that do not require exclusion:

  1. Common colds, runny noses (regardless of color or consistency of nasal discharge);
  2. A cough not associated with a infectious disease (such as pertussis) or a fever;
  3. Watery, yellow or white discharge or crusting eye discharge without fever, eye pain, or eyelid redness;
  4. Yellow or white eye drainage that is not associated with pink or red conjunctiva (i.e., the whites of the eyes);
  5. Pink eye (bacterial conjunctivitis) indicated by pink or red conjunctiva with white or yellow eye mucous drainage and matted eyelids after sleep. Parents/guardians should discuss care of this condition with their child’s primary care provider, and follow the primary care provider’s advice. Some primary care providers do not think it is necessary to examine the child if the discussion with the parents/guardians suggests that the condition is likely to be self-limited. If two unrelated children in the same program have conjunctivitis, the organism causing the conjunctivitis may have a higher risk for transmission and a child health care professional should be consulted;
  6. Fever without any signs or symptoms of illness in children who are older than six months regardless of whether acetaminophen or ibuprofen was given. Fever (temperature above 101°F [38.3°C] orally, above 102°F [38.9°C] rectally, or 100°F [37.8°C] or higher taken axillary [armpit] or measured by an equivalent method) is an indication of the body’s response to something, but is neither a disease nor a serious problem by itself. Body temperature can be elevated by overheating caused by overdressing or a hot environment, reactions to medications, and response to infection. If the child is behaving normally but has a fever of below 102ºF per rectum or the equivalent, the child should be monitored, but does not need to be excluded for fever alone;
  7. Rash without fever and behavioral changes;
  8. Lice or nits (exclusion for treatment of an active lice infestation may be delayed until the end of the day);
  9. Ringworm (exclusion for treatment may be delayed until the end of the day);
  10. Molluscum contagiosum (do not require exclusion or covering of lesions);
  11. Thrush (i.e., white spots or patches in the mouth or on the cheeks or gums);
  12. Fifth disease (slapped cheek disease, parvovirus B19) once the rash has appeared;
  13. Methicillin-resistant Staphylococcus aureus, or MRSA, without an infection or illness that would otherwise require exclusion. Known MRSA carriers or colonized individuals should not be excluded;
  14. Cytomegalovirus infection;
  15. Chronic hepatitis B infection;
  16. Human immunodeficiency virus (HIV) infection;
  17. Asymptomatic children who have been previously evaluated and found to be shedding potentially infectious organisms in the stool. Children who are continent of stool or who are diapered with formed stools that can be contained in the diaper may return to care. For some infectious organisms, exclusion is required until certain guidelines have been met. Note: These agents are not common and caregivers/teachers will usually not know the cause of most cases of diarrhea;
  18. Children with chronic infectious conditions that can be accommodated in the program according to the legal requirement of federal law in the Americans with Disabilities Act. The act requires that child care programs make reasonable accommodations for children with disabilities and/or chronic illnesses, considering each child individually.

Key criteria for exclusion of children who are ill:

When a child becomes ill but does not require immediate medical help, a determination must be made regarding whether the child should be sent home (i.e., should be temporarily “excluded” from child care). Most illnesses do not require exclusion. The caregiver/teacher should determine if the illness:

  1. Prevents the child from participating comfortably in activities;
  2. Results in a need for care that is greater than the staff can provide without compromising the health and safety of other children;
  3. Poses a risk of spread of harmful diseases to others.

If any of the above criteria are met, the child should be excluded, regardless of the type of illness. The child should be removed from direct contact with other children and should be monitored and supervised by a single staff member known to the child until dismissed from care to the care of a parent/guardian or a primary care provider. The area should be where the toys, equipment, and surfaces will not be used by other children or adults until after the ill child leaves and after the surfaces and toys have been cleaned and disinfected.

Temporary exclusion is recommended when the child has any of the following conditions:

  1. The illness prevents the child from participating comfortably in activities;
  2. The illness results in a need for care that is greater than the staff can provide without compromising the health and safety of other children;
  3. An acute change in behavior - this could include lethargy/lack of responsiveness, irritability, persistent crying, difficult breathing, or having a quickly spreading rash;
  4. Fever (temperature above 101°F [38.3°C] orally, above 102°F [38.9°C] rectally, or 100°F [37.8°C] or higher taken axillary [armpit] or measured by an equivalent method) and behavior change or other signs and symptoms (e.g., sore throat, rash, vomiting, diarrhea). An unexplained temperature above 100°F (37.8°C) axillary (armpit) or 101°F (38.3°C) rectally in a child younger than six months should be medically evaluated. Any infant younger than two months of age with any fever should get urgent medical attention. See COMMENTS Below for important information about taking temperatures;
  5. Diarrhea is defined by watery stools or decreased form of stool that is not associated with changes of diet. Exclusion is required for all diapered children whose stool is not contained in the diaper and toilet-trained children if the diarrhea is causing soiled pants or clothing. In addition, diapered children with diarrhea should be excluded if the stool frequency exceeds two or more stools above normal for that child, because this may cause too much work for the caregivers/teachers. Readmission after diarrhea can occur when diapered children have their stool contained by the diaper (even if the stools remain loose) and when toilet-trained children are continent. Special circumstances that require specific exclusion criteria include the following (2):
    1. Toxin-producing E. coli or Shigella infection, until stools are formed and the test results of two stool cultures obtained from stools produced twenty-four hours apart do not detect these organisms;
    2. Salmonella serotype Typhi infection, until diarrhea resolves. In children younger than five years with Salmonella serotype Typhi, three negative stool cultures obtained with twenty-four-hour intervals are required; people five years of age or older may return after a twenty-four-hour period without a diarrheal stool. Stool cultures should be collected from other attendees and staff members, and all infected people should be excluded;
  6. Blood or mucus in the stools not explained by dietary change, medication, or hard stools;
  7. Vomiting more than two times in the previous twenty-four hours, unless the vomiting is determined to be caused by a non-infectious condition and the child remains adequately hydrated;
  8. Abdominal pain that continues for more than two hours or intermittent pain associated with fever or other signs or symptoms of illness;
  9. Mouth sores with drooling unless the child’s primary care provider or local health department authority states that the child is noninfectious;
  10. Rash with fever or behavioral changes, until the primary care provider has determined that the illness is not a infectious disease;
  11. Active tuberculosis, until the child’s primary care provider or local health department states child is on appropriate treatment and can return;
  12. Impetigo, until treatment has been started;
  13. Streptococcal pharyngitis (i.e., strep throat or other streptococcal infection), until twenty-four hours after treatment has been started;
  14. Head lice until after the first treatment (note: exclusion is not necessary before the end of the program day);
  15. Scabies, until after treatment has been given;
  16. Chickenpox (varicella), until all lesions have dried or crusted (usually six days after onset of rash);
  17. Rubella, until six days after the rash appears;
  18. Pertussis, until five days of appropriate antibiotic treatment;
  19. Mumps, until five days after onset of parotid gland swelling;
  20. Measles, until four days after onset of rash;
  21. Hepatitis A virus infection, until one week after onset of illness or jaundice if the child’s symptoms are mild or as directed by the health department. (Note: immunization status of child care contacts should be confirmed; within a fourteen-day period of exposure, incompletely immunized or unimmunized contacts from one through forty years of age should receive the hepatitis A vaccine as post exposure prophylaxis, unless contraindicated.) Other individuals may receive immune globulin. Consult with a primary care provider for dosage and recommendations;
  22. Any child determined by the local health department to be contributing to the transmission of illness during an outbreak.

Procedures for a child who requires exclusion:

The caregiver/teacher will:

  1. Provide care for the child in a place where the child will be comfortable and supervised by someone who knows the child well and who will continue to observe the child for new or worsening symptoms. A potentially contagious child should be separated from other children by at least three feet. Each facility should have a predetermined physical location(s) where an ill child(ren) could be placed until care can be transferred to a parent/guardian or primary care provider;
  2. Ask the family to pick up the child as soon as possible;
  3. Discuss the signs and symptoms of illness with the parent/guardian who is assuming care. Review guidelines for return to child care. If necessary, provide the family with a written communication that may be given to the primary care provider. The communication should include onset time of symptoms, observations about the child, vital signs and times (e.g., temperature 101.5°F at 10:30 AM) and any actions taken and the time actions were taken (e.g., one children’s acetaminophen given at 11:00 AM). The nature and severity of symptoms and or requirements of the local or state health department will determine the necessity of medical consultation. Telephone advice, electronic transmissions of instructions are acceptable without an office visit;
  4. Follow the advice of the child’s primary care provider;
  5. Contact the local health department if there is a question of a reportable (harmful) infectious disease in a child or staff member in the facility. If there are conflicting opinions from different primary care providers about the management of a child with a reportable infectious disease, the health department has the legal authority to make a final determination;
  6. Document actions in the child’s file with date, time, symptoms, and actions taken (and by whom); sign and date the document;
  7. In collaboration with the local health department, notify the parents of contacts to the child or staff member with presumed or confirmed reportable infectious infection.

The caregiver/teacher should make the decision about whether a child meets or does not meet the exclusion criteria for participation and the child’s need for care relative to the staff’s ability to provide care. If parents/guardians and the child care staff disagree, and the reason for exclusion relates to the child’s ability to participate or the caregiver’s/teacher’s ability to provide care for the other children, the caregiver/teacher should not be required to accept responsibility for the care of the child.

Reportable conditions:

The current list of infectious diseases designated as notifiable in the United States at the national level by the Centers for Disease Control and Prevention (CDC) are listed at http://www.cdc.gov/osels/ph_surveillance/.

The caregiver/teacher should contact the local health department:

  1. When a child or staff member who is in contact with others has a reportable disease;
  2. If a reportable illness occurs among the staff, children, or families involved with the program;
  3. For assistance in managing a suspected outbreak. Generally, an outbreak can be considered to be two or more unrelated (e.g., not siblings) children with the same diagnosis or symptoms in the same group within one week. Clusters of mild respiratory illness, ear infections, and certain dermatological conditions are common and generally do not need to be reported.

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

 

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-Standard Rationale

Excluding children with mild illnesses is unlikely to reduce the spread of most infectious agents (germs) caused by bacteria, viruses, parasites and fungi. Most infections are spread by children who do not have symptoms. They spread the infectious agent (germs) before or after their illnesses and without evidence of symptoms. Exposure to frequent mild infections helps the child’s immune system develop in a healthy way. As a child gets older s/he develops immunity to common infectious agents and will become ill less often. Since exclusion is unlikely to reduce the spread of disease, the most important reason for exclusion is the ability of the child to participate in activities and the staff to care for the child.

The terms contagious, infectious and communicable have similar meanings. A fully immunized child with a contagious, infectious or communicable condition will likely not have an illness that is harmful to the child or others. Children attending child care frequently carry contagious organisms that do not limit their activity nor pose a threat to their contacts. Hand and personal hygiene is paramount in preventing transmission of these organisms. Written notes should not be required for return to child care for common respiratory illnesses that are not specifically listed in the excludable condition list above.

For specific conditions, Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide, 2nd Edition has educational handouts that can be copied and distributed to parents/guardians, health professionals, and caregivers/teachers. This publication is available from the American Academy of Pediatrics (AAP) at http://www
.aap.org.

For more detailed rationale regarding inclusion/exclusion, return to care, when a health visit is necessary, and health department reporting for children with specific symptoms, please see Appendix A, Signs and Symptoms Chart.

State licensing law or code defines the conditions or symptoms for which exclusion is necessary. States are increasingly using the criteria defined in Caring for Our Children and the Managing Infectious Diseases in Child Care and Schools publications. Usually, the criteria in these two sources are more detailed than the state regulations so can be incorporated into the local written policies without conflicting with state law.

In this edition of Caring for Our Children, the exclusion criteria for bacterial conjunctivitis (pink eye) and diarrhea have changed. Exclusion is no longer required for pink eye and treatment is not required. This change reflects the recognition that conjunctivitis is a self-limiting infection and there is not any evidence that treatment or exclusion reduces its spread. Children with diarrhea may remain in care as long as the stool is contained in the diaper or the child can maintain continence. If additional criteria are met, such as an inability to participate in activities or requiring more care than staff can provide, then a child should be excluded until the criteria for return of care are met. A provision was included that if the stool frequency is two or more stools per day above the normal then exclusion could be indicated. This accounts for the increased staff time involved in diaper changing. Infants should routinely receive rotavirus vaccine, which has been the most common cause of viral diarrhea in this age group.

-Type of Facility

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

-Standard References

  1. Aronson, S. S., T. R. Shope, eds. 2009. Managing infectious diseases in child care and schools: A quick reference guide. 2nd ed. Elk Grove Village, IL: American Academy of Pediatrics.
  2. Pickering, L. K., C. J. Baker, D. W. Kimberlin, S. S. Long, eds. 2009. Red book: 2009 report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics.

-Comments

When taking a child’s temperature, remember that:

  1. The amount of temperature elevation varies at different body sites;
  2. The height of fever does not indicate a more or less severe illness;
  3. The method chosen to take a child’s temperature depends on the need for accuracy, available equipment, the skill of the person taking the temperature, and the ability of the child to assist in the procedure;
  4. Oral temperatures are difficult to take for children younger than four years of age;
  5. Rectal temperatures should be taken only by persons with specific health training in performing this procedure and permission given by parents/guardians;
  6. Axillary (armpit) temperatures are accurate only when the thermometer remains within the closed armpit for the time period recommended by the device;
  7. Electronic devices for measuring temperature require periodic calibration and specific training in proper technique;
  8. Any device used improperly may give inaccurate results;
  9. Mercury thermometers should not be used;
  10. Aural (ear) devices may underestimate fever and should not be used in children less than four months.

-Learn From Your Peers

The Americans with Disabilities Act (ADA) is a civil rights law that gives everyone the right to ask for changes when policies, practices or conditions cause exclusions or disadvantages. Enacted January 26, 1992, the law mandates that public entities ensure full access to and equal enjoyment of all facilities, programs, goods, and services for all, including those individuals with disabilities.  Therefore, a pre-school cannot refuse to enroll children because of medication requirements, adaptation for allergies, or other manageable needs.  Extra staff training and higher insurance rates are not considered reasons to exclude a child.  Early intervention (EI) providers can help child care providers find ways to make modifications which allow full participation of special-needs children. There are numerous resources available for free at the www.cdc.gov Web site.  Early intervention promotes competence and developmental gains for every child.
--- Trainer

Providers should remember that, in most cases, exclusion is for the comfort of the sick child, not for the prevention of illness being spread to others.  Most illnesses do not require exclusion; many illnesses are spread before symptoms are even seen.  It is most important to base exclusion on the following criteria: the child cannot participate comfortably in regular activities; the child is requiring more care than the staff can adequately provide (compromising the care for the other children); and/or the illness poses a risk of spread of harmful diseases to others. The more specific programs make their exclusion guidelines, the better.  It is also important for programs to post their exclusion guidelines, follow them consistently, and direct parents repeatedly to them to prevent confusion and discrepancies.
---Child Care Health Consultant

There is controversy around a few diagnoses.  Lice and pink-eye are two for which AAP guidelines differ from public perceptions and most centers’ policies.  Neither requires exclusion from child care anymore.  Pink-eye is usually caused by the same germs which cause colds, sinus infections, and ear infections, and we do not exclude for those conditions (as long as the child is acting ok, participating in regular activities, etc).  The child may ultimately need to receive treatment, but a pink eye with discharge is not that different than a green runny nose.  Relatively uncommon, contagious Adenovirus conjunctivitis, indicated by more than one child in the same classroom developing pink-eye, is the exception.  According to the guidelines, a child with lice can also wait to go home until the end of the day, but I never seem to win that argument.
--- Pediatrician


February 2013

Standard 1.4.1.1 Pre-service Training

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

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

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

 

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-Standard Rationale

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

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

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

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

-Type of Facility

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

-Standard References

  1. Hayney M. S., J. C. Bartell. 2005. An immunization education program for childcare providers. J of School Health 75:147-49.
  2. Moon R. Y., R. P. Oden. 2003. Back to sleep: Can we influence child care providers? Pediatrics 112:878-82.
  3. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/.
  4. Ritchie, S., B. Willer. 2008. Teachers: A guide to the NAEYC early childhood program standard and related accreditation criteria. Washington, DC: National Association for the Education of Young Children (NAEYC).
  5. National Association for the Education of Young Children. 2010. Definition of early childhood professional development, 12. Eds. M. S. Donovan, J. D. Bransford, J. W. Pellegrino. Washington, DC: National Academy Press.

-Comments

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

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

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

-Learn From Your Peers

The primary purpose of pre-service training and other professional development is to increase the effectiveness of all who are engaged in the teaching-learning process. Each member of the professional staff must commit to developing her knowledge and skills.  Positive environments should be created which cultivate the potential in every team member.  A full week of orientation which includes training in the following areas is invaluable:  facility policies and procedures, state health and safety requirements, physical environment and equipment, safety and emergency response, food service and nutrition, the employee's assigned duties and responsibilities, reporting requirements, medication administration, Sudden Infant Death Syndrome (SIDS) prevention, etc.
--- Trainer

Many programs are unfortunately not able to provide pre-service training, or it is not required by licensing.   Even if pre-service training is not available or required, it is crucial for all providers to be informed of safe sleeping practices and emergency procedures on the first day they take care of children.  Most SIDS deaths occur on the first day of child care or within the first week due to infants being placed on their stomach when they are used to sleeping on their back. Emergencies can happen at any time, so providers need to know CPR and first aid. They need to know how to get children out of the house/building if there is a fire, where to go in a tornado, etc.  It is also helpful to post information for providers to refer to; however, this should not be a substitute for training.  
--- CCHC

These are critical years for early brain development.  All teachers should have an ability to develop an age-appropriate learning program as well as a working knowledge of typical and atypical child development.  Teachers should also be able to assess children and identify those who need to be evaluated for learning or behavior problems.
--- Educator

While taking care of children may seem natural to many, the complexities of infection control, emergency preparedness, developmentally appropriate learning environments, medication administration, recognition of child abuse, choking prevention, safe sleep, and so many other factors are necessary for a child care provider to reduce liability and optimally care for children.  No license is required to be a parent, but the stakes are actually higher when the child is not your own.
--- Pediatrician


December 2012

Standard 4.9.0.3 Precautions for a Safe Food Supply

All foods stored, prepared, or served should be safe for human consumption by observation and smell (1-2). The following precautions should be observed for a safe food supply:

  1. Home-canned food; food from dented, rusted, bulging, or leaking cans, and food from cans without labels should not be used;
  2. Foods should be inspected daily for spoilage or signs of mold, and foods that are spoiled or moldy should be promptly and appropriately discarded;
  3. Meat should be from government-inspected sources or otherwise approved by the governing health authority (3);
  4. All dairy products should be pasteurized and Grade A where applicable;
  5. Raw, unpasteurized milk, milk products; unpasteurized fruit juices; and raw or undercooked eggs should not be used. Freshly squeezed fruit or vegetable juice prepared just prior to serving in the child care facility is permissible;
  6. Unless a child’s health care professional documents a different milk product, children from twelve months to two years of age should be served only human milk, formula, whole milk or 2% milk (6). Note: For children between twelve months and two years of age for whom overweight or obesity is a concern or who have a family history of obesity, dyslipidemia, or CVD, the use of reduced-fat milk is appropriate only with written documentation from the child’s primary health care professional (4). Children two years of age and older should be served skim or 1% milk. If cost-saving is required to accommodate a tight budget, dry milk and milk products may be reconstituted in the facility for cooking purposes only, provided that they are prepared, refrigerated, and stored in a sanitary manner, labeled with the date of preparation, and used or discarded within twenty-four hours of preparation;
  7. Meat, fish, poultry, milk, and egg products should be refrigerated or frozen until immediately before use (5);
  8. Frozen foods should be defrosted in one of four ways: In the refrigerator; under cold running water; as part of the cooking process, or by removing food from packaging and using the defrost setting of a microwave oven (5). Note: Frozen human milk should not be defrosted in the microwave;
  9. Frozen foods should never be defrosted by leaving them at room temperature or standing in water that is not kept at refrigerator temperature (5);
  10. All fruits and vegetables should be washed thoroughly with water prior to use (5);
  11. Food should be served promptly after preparation or cooking or should be maintained at temperatures of not less than 135°F for hot foods and not more than 41°F for cold foods (12);
  12. All opened moist foods that have not been served should be covered, dated, and maintained at a temperature of 41°F or lower in the refrigerator or frozen in the freezer, verified by a working thermometer kept in the refrigerator or freezer (12);
  13. Fully cooked and ready-to-serve hot foods should be held for no longer than thirty minutes before being served, or promptly covered and refrigerated;
  14. Pasteurized eggs or egg products should be substituted for raw eggs in the preparation of foods such as Caesar salad, mayonnaise, meringue, eggnog, and ice cream. Pasteurized eggs or egg products should be substituted for recipes in which more than one egg is broken and the eggs are combined, unless the eggs are cooked for an individual child at a single meal and served immediately, such as in omelets or scrambled eggs; or the raw eggs are combined as an ingredient immediately before baking and the eggs are fully cooked to a ready-to-eat form, such as a cake, muffin or bread;
  15. Raw animal foods should be fully cooked to heat all parts of the food to a temperature and for a time of; 145°F or above for fifteen seconds for fish and meat; 160°F for fifteen seconds for chopped or ground fish, chopped or ground meat or raw eggs; or 165°F or above for fifteen seconds for poultry or stuffed fish, stuffed meat, stuffed pasta, stuffed poultry or stuffing containing fish, meat or poultry.

 

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-Standard Rationale

Safe handling of all food is a basic principle to prevent and reduce foodborne illnesses (14). For children, a small dose of infectious or toxic material can lead to serious illness (13). Some molds produce toxins that may cause illness or even death (such as aflatoxin or ergot).

Keeping cold food below 41°F and hot food above 135°F prevents bacterial growth (1,6,12). Food intended for human consumption can become contaminated if left at room temperature.

Foodborne illnesses from Salmonella and E. coli 0157:H7 have been associated with consumption of contaminated, raw, or undercooked egg products, meat, poultry, and seafood. Children tend to be more susceptible to E. coli 0157:H7 infections from consumption of undercooked meats, and such infections can lead to kidney failure and death.

Home-canned food, food from dented, rusted, bulging or leaking cans, or leaking packages/bags of frozen foods, have an increased risk of containing microorganisms or toxins. Users of unlabeled food cans cannot be sure what is in the can and how long the can has been stored.

Excessive heating of foods results in loss of nutritional content and causes foods to lose appeal by altering color, consistency, texture, and taste. Positive learning activities for children, using their senses of seeing and smelling, help them to learn about the food they eat. These sensory experiences are counterproductive when food is overcooked. Children are not only shortchanged of nutrients, but are denied the chance to use their senses fully to learn about foods.

Caregivers/teachers should discourage parents/guardians from bringing home-baked items for the children to share as it is difficult to determine the quality of the ingredients used and the cleanliness of the environment in which the items are baked and transported. Parents/guardians should be informed why home baked items like birthday cake and cupcakes are not the healthiest choice and the facility should provide ideas for healthier alternatives such as fruit cups or fruit salad to celebrate birthdays and other festive events.

Several states allow the sale of raw milk or milk products. These products have been implicated in outbreaks of salmonellosis, listeriosis, toxoplasmosis, and campylobacteriosis and should never be served in child care facilities (7,8). Only pasteurized milk and fruit juices should be served. Foods made with uncooked eggs have been involved in a number of outbreaks of Salmonella infections. Eggs should be well-cooked before being eaten, and only pasteurized eggs or egg substitutes should be used in foods requiring raw eggs.

The American Academy of Pediatrics (AAP) recommends that children from twelve months to two years of age receive human milk, formula, whole milk, or 2% milk. For children between twelve months and two years of age for whom overweight or obesity is a concern or who have a family history of obesity, dyslipidemia, or CVD, the use of reduced-fat milk is appropriate only with written documentation from the child’s primary health care professional (4). Children two years of age and older can drink skim, or 1%, milk (6,9-11).

Soil particles and contaminants that adhere to fruits and vegetables can cause illness. Therefore, all fruits or vegetables to be eaten and used to make fresh juice at the facility should be thoroughly washed first.

Thawing frozen foods under conditions that expose any of the food’s surfaces to temperatures between 41°F and 135°F promotes the growth of bacteria that may cause illness if ingested. Storing perishable foods at safe temperatures in the refrigerator or freezer reduces the rate at which microorganisms in these foods multiply (12).

-Type of Facility

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

-Standard References

  1. Enders, J. B. 1994. Food, nutrition and the young child. New York: Merrill.
  2. U.S. Department of Agriculture (USDA). 2002. Making nutrition count for children - Nutrition guidance for child care homes. Washington, DC: USDA. http://www.fns.usda.gov/tn/Resources/nutritioncount.html.
  3. U.S. Department of Agriculture (USDA), Food Safety and Inspection Service. 2000. Keeping kids safe: A guide for safe handling and sanitation, for child care providers. Rev ed. Washington, DC: USDA. http://teamnutrition.usda.gov/resources/appendj.pdf.
  4. Daniels, S. R., F. R. Greer, Committee on Nutrition. 2008. Lipid screening and cardiovascular health in childhood. Pediatrics 122:198-208.
  5. Food Marketing Institute (FMI), U.S. Department of Agriculture, Food Safety and Inspection Service. 1996. Facts about food and floods: A consumer guide to food quality and safe handling after a flood or power outage. Washington, DC: FMI.
  6. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.
  7. Potter, M. E. 1984. Unpasteurized milk: The hazards of a health fetish. JAMA 252:2048-52.
  8. Sacks, J. J. 1982. Toxoplasmosis infection associated with raw goat’s milk. JAMA 246:1728-32.
  9. Dietz, W.H., L. Stern, eds. 1998. Guide to your child’s nutrition. Elk Grove Village, IL: American Academy of Pediatrics.
  10. Chicago Dietetic Association. 1996. Manual of clinical dietetics. 5th ed. Chicago, IL: American Dietetic Association.
  11. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.
  12. U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration (FDA). 2009. 2009 Food code. College Park, MD: FDA. http://www.fda.gov/downloads/Food/FoodSafety/RetailFoodProtection/FoodCode/FoodCode2009/UCM189448.pdf.
  13. Cowell, C., S. Schlosser. 1998. Food safety in infant and preschool day care. Top Clin Nutr 14:9-15.
  14. U.S. Department of Health and Human Services, U.S. Department of Agriculture. 2010. Dietary guidelines for Americans, 2010. 7th ed. Washington, DC: U.S. Government Printing Office. http://www.health.gov/dietaryguidelines/dga2010/DietaryGuidelines2010.pdf.

-Comments

The use of dairy products fortified with vitamins A and D is recommended (4).

The FDA provides the following Website for caregivers/teachers to check status of foods and food products that have been recalled, see http://www.fda.gov.

Temperatures come from the FDA 2009 Food Code (12). Local or state regulations may differ. Caregivers/teachers should consult with the health department concerning questions on proper cooking temperatures for specific foods.

-Learn From Your Peers

A steamer is a great investment for a program.   It helps food service staff to avoid overcooking vegetables in order to preserve texture and color for eye appeal. 
--- Trainer

Parents should be required to bring in store-prepared items for birthday parties and snacks.  No homemade food should be permitted. Unfortunately, while grocery stores and bakeries must meet certain standards by law, there is no assurance of quality-control with homemade foods.
--- Manager

Since many classrooms do not have refrigerators, some programs keep milk cartons on ice during meals/snacks.  It is important for providers to wash fresh fruits and vegetables before cutting and serving them to the children; possible contaminates (germs, chemicals, etc.) on the outer surface need to be removed.  Keeping food covered until it is served and throughout the meals can help keep food warm and protected from contamination.  The tops of cans should always be washed before opening; can openers should be cleaned between uses to prevent any food contamination. 
--- Child Care Health Consultant

In reality, we are limited in our ability to keep colds and most other viral illnesses from spreading through the center.  But, food poisoning can and should be prevented!  All food should be stored properly and inspected before use.  When in doubt, throw it out!
--- Pediatrician


November 2012

Standard 1.2.0.2 Background Screening

Directors of centers and caregivers/teachers in large and small family child care homes should conduct a complete background screening before employing any staff member (including substitutes, cooks, clerical staff, transportation staff, bus drivers, or custodians who will be on the premises or in vehicles when children are present). The background screening should include:

  1. Name and address verification;
  2. Social Security number verification;
  3. Education verification;
  4. Employment history;
  5. Alias search;
  6. Driving history through state Department of Motor Vehicles records;
  7. Background screening of:
    1. State and national criminal history records;
    2. Child abuse and neglect registries;
    3. Licensing history with any other state agencies (i.e., foster care, mental health, nursing homes, etc.);
    4. Fingerprints; and
    5. Sex offender registries;
  8. Court records;
  9. References.

All family members over age ten living in large and small family child care homes should also have background screenings.

Drug tests may also be incorporated into the background screening. Written permission to obtain the background screening (with or without a drug screen) should be obtained from the prospective employee. Consent to the background investigation should be required for employment consideration.

When checking references and when conducting employee or volunteer interviews, prospective employers should specifically ask about previous convictions and arrests, investigation findings, or court cases with child abuse/neglect or child sexual abuse. Failure of the prospective employee to disclose previous history of child abuse/neglect or child sexual abuse is grounds for immediate dismissal.

Persons should not be hired or allowed to work or volunteer in the child care facility if they acknowledge being sexually attracted to children or having physically or sexually abused children, or are known to have committed such acts.

Background screenings should be repeated periodically taking into consideration state laws and/or requirements. Screenings should be repeated more frequently if there are additional concerns.

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-Standard Rationale

To ensure their safety and physical and mental health, children should be protected from any risk of abuse or neglect. Although few persons will acknowledge past child abuse or neglect to another person, the obvious attention directed to the question by the licensing agency or caregiver/teacher may discourage some potentially abusive individuals from seeking employment in child care. Performing diligent background screenings also protects the child care facility against future legal challenges (1). Having a state credentialing system can reduce the time required to ensure all those caring for children have had the required background screening review.

-Type of Facility

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

-Standard References

  1. Privacy Rights Clearinghouse. 2011. Fact sheet 16: Employment background checks: A jobseeker’s guide. http://www.privacyrights.org/fs/fs16-bck.htm.

-Comments

Directors who are conducting screenings and caregivers/teachers who are asked to submit a background screening record should contact their state child care licensing agency for the appropriate documentation required. Fingerprinting can be secured at local law enforcement offices or the State Bureau of Investigation. Court records are public information and can be obtained from county court offices and some states have statewide online court records. When checking for prior arrests or previous court actions, the facility should check for misdemeanors as well as felonies. Driving records are available from the State Department of Motor Vehicles. A social security trace is a report, derived from credit bureau records that will return all current and reported addresses for the last seven to ten years on a specific individual based on his or her social security number. If there are alternate names (aliases) these are also reported. State child abuse registries can be accessed at http://www.hunter.cuny.edu/socwork/nrcfcpp/downloads/policy-issues/State_Child_Abuse_Registries.pdf
Sex offender registries can be accessed at http://www.prevent-abuse-now.com/register.htm. Companies also offer background check services. The National Association of Professional Background Screeners (http://www.napbs.com) provides a directory of their membership.

-Learn From Your Peers

Programs should require that employment candidates submit to background screening prior to an interview.  Candidates are often unaware that they have committed a violation which prevents them from working in the early education field.  We provide the forms and instructions for requesting a national criminal background check. This saves time and hiring costs for our program.  We also require pre-employment drug testing for drivers.
--- Child Care Health Consultant

Background checks for new employees only are not really enough to continually protect children. Sometimes it takes a while for reporting systems to "catch up” with a conviction. Periodic checks help ensure safety on an ongoing basis. Public policy and public funding should support enforcement and safety for all children. Most states have automated systems for background clearances.  Connecting early childhood programs to these systems is key for safety.
--- Program Monitoring Manager

In Texas, background checks are required when an individual is hired and every 24 months after that. Background checks need to be completed regularly and any time an individual has a name change (due to marriage or divorce). The name on the background check must be current when licensing performs their inspection.
---Child Care Health Consultant

I screen all individuals (over the age of 14) involved in my child care environment every three years.  This includes any visiting relatives, and screenings are done prior to any scheduled visit to the home during business hours.  Each individual has a criminal background check, DSS check, and sex offender check.  Copies of all screenings are available for families to view.  All workers who come in to do home repairs must prove they are licensed, and I check with their company to make sure that they have had some type of background check. Salesmen are refused entrance; there is no way to do on-the-spot screenings, and the safety of the children in my care is more important than the product they are selling.
--- Family Home Child Care Provider

Our state requires a Central Registry background check for all individuals over the age of 18 living in a home daycare or working in a center.  If the pre-screen indicates a criminal history, the individual is required to complete a finger print screening with our Division of Criminal Investigation (DCI).  Wyoming rules are specific about convictions of crimes against children or vulnerable adults, violent crimes, and child abuse/neglect.  Unfortunately, The DCI and pre-screens only pick up crimes committed in Wyoming.  I believe that licensing agencies should be afforded the same background check systems that the Department of Corrections has available to them.  In one instance, upon inspecting a home provider unannounced, I found that her husband was living in the house when she had stated that she was divorced.  I was able to attain a law enforcement check which revealed that he was wanted for murder, abuse, and drug distribution in other states. In another case, an applicant for home child care swore that her husband was no longer involved in drugs.  Weeks later, he severely beat her and her infant, and officials uncovered large amounts of meth, cocaine, and heroin in the home.  In my years of experience, I have learned that the best cover for a drug operation is child care.  No one ever questions cars coming and going or people carrying diaper bags.  Children could be better protected by more in-depth, national background checks.  Costs incurred by better screenings could never reach the cost of one child’s life.
---Child Care Licensing Officer


October 2012

Standard 6.5.2.4 Interior Temperature of Vehicles

The interior of vehicles used to transport children should be maintained at a temperature comfortable to children. When the vehicle’s interior temperature exceeds 82°F and providing fresh air through open windows cannot reduce the temperature, the vehicle should be air-conditioned. When the interior temperature drops below 65°F and when children are feeling uncomfortably cold, the interior should be heated. To prevent hyperthermia, all vehicles should be locked when not in use, head counts of children should be taken after transporting to prevent a child from being left unintentionally in a vehicle, and children should never be intentionally left in a vehicle unattended.

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-Standard Rationale

Some children have problems with temperature variations. Whenever possible, opening windows to provide fresh air to cool a hot interior is preferable before using air conditioning. Over-use of air conditioning can increase problems with respiratory infections and allergies. Excessively high temperatures in vehicles can cause neurological damage in children (1).

Children’s bodies overheat three to five times faster than
adults because the hypothalamus regions of their brains, which control body temperature, are not as developed (1).

About thirty-seven children die every year from hyperthermia when they’re left in cars and the cars quickly heat up. Even with comfortable temperatures outdoors, the temperature in an enclosed car climbs rapidly.

Temperature increase inside a car with an outside temperature of 80°F (elapsed time in minutes) (2):

  1. After ten minutes: 99°F inside car;
  2. After twenty minutes: 109°F;
  3. After thirty minutes 114°F;
  4. After forty minutes: 118°F;
  5. After fifty minutes: 120°F;
  6. After sixty minutes: 123°F.

-Type of Facility

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

-Standard References

  1. Guard, A., S. S. Gallagher. 2005. Heat related deaths to young children in parked cars: An analysis of 171 fatalities in the United States, 1995-2002. Injury Prevention 11:33-37.

  2. McLaren, C., J. Null, J. Quinn. 2005. Heat stress from enclosed vehicles: Moderate ambient temperatures cause significant temperature rise in enclosed vehicles. Pediatrics 116: e109-12.

-Comments

In geographical areas that are prone to very cold or very hot weather, a small thermometer should be kept inside the vehicle. In areas that are very cold, adults tend to wear very warm clothing and children tend to wear less clothing than might actually be required. Adults in a vehicle, then, may be comfortable while the children are not. When air conditioning is used, adults might find the cool air comfortable, but the children may find that the cool air is uncomfortably cold. To determine whether the interior of the vehicle is providing a comfortable temperature to children, a thermometer should be used and children in the vehicle should be asked if they are comfortable. Non-verbal children and infants should be assessed by an adult for signs of hypo- or hyperthermia. Signs of hypothermia include: cold skin, very low energy, and may be non-responsive. Young infants do not shiver when cold. Signs of hyperthermia include: dizziness, disorientation, agitation, confusion, sluggishness, seizure, hot dry skin that is flushed but not sweaty, loss of consciousness, rapid heartbeat, hallucinations (2).

-Learn From Your Peers

In addition to the standard’s recommendation for head counts of children after transportation, it would also be a good idea to keep attendance while transporting.  Each child should be logged by name.  If a child is added during the transport and manages to hide in the vehicle, a simple head count may not detect his absence.  If staff only count heads at the beginning and end of travel, they could easily forget about any children added during the transport.  Some programs keep a checklist; when a vehicle is emptied, the designated staff must go back through and check the whole vehicle and then sign the checklist when that inspection is completed.
--- Child Care Licensing Officer

As a Kids Safe volunteer, I have assisted with car seat safety checkpoints and bike rodeos. I have access to vehicle thermometers and additional educational materials which I can share with child care professionals and families.  Our licensing rules state that children being transported can never be left in a vehicle.
--- Child Care Licensing Officer

To help prevent children from being left unintentionally in vehicles, providers can make it a policy to call the parents of children who have not arrived at their scheduled time to check on them.
--- Child Care Health Consultant


September 2012

Standard 4.3.1.7 Feeding Cow's Milk

The facility should not serve cow’s milk to infants from birth to twelve months of age, unless provided with a written exception and direction from the child’s primary care provider and parents/guardians. Children between twelve and twenty-four months of age, who are not on human milk or prescribed formula, can be served whole pasteurized milk, or reduced fat (2%) pasteurized milk for those children who are at risk for hypercholesterolemia or obesity (1). Children two years of age and older should be served skim or 1% pasteurized milk.

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-Standard Rationale

For children between twelve months and twenty-four months of age, for whom overweight or obesity is a concern or who have a family history of obesity, dyslipidemia, or early cardiovascular disease, the use of reduced fat (2%) milk is appropriate (1). The child’s primary care provider may also recommend reduced fat (2%) milk for some children this age. Studies show no compromise in growth, and no difference in height, weight, or percentage of body fat and neurological development in toddlers fed reduced fat (2%) milk compared with those fed whole milk (2,8,9). The American Academy of Pediatrics recommends that cow’s milk not be used during the first year of life (3-7).

-Type of Facility

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

-Standard References

  1. Daniels, S. R., F. R. Greer, Committee on Nutrition. 2008. Lipid screening and cardiovascular health in childhood. Pediatrics 122:198-208.
  2. Wosje, K. S., B. L. Specker, J. Giddens. 2001. No differences in growth or body composition from age 12 to 24 months between toddlers consuming 2% milk and toddlers consuming whole milk.
    J Am Diet Assoc 101:53-56.
  3. Dietz, W. H., L. Stern, eds. 1998. American Academy of Pediatrics guide to your child’s nutrition. New York: Villard.
  4. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.
  5. Dietitians of Canada, American Dietetic Association. 2000. Manual of clinical dietetics. 6th ed. Chicago: ADA.
  6. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.
  7. American Academy of Pediatrics, Committee on Nutrition. 1992. The use of whole cow’s milk in infancy. Pediatrics 89:1105-9.
  8. Rask-Nissila, L., E. Jokinen, P. Terho, A. Tammi, H. Lapinleimu, T. Ronnemaa, J. Viikari, R. Seppanen, T. Korhonen, J. Tuominen, I. Valimaki, O. Simell. 2000. Neurological development of 5-year-old children receiving a low-saturated fat, low-cholesterol diet since infancy: A randomized controlled trial. JAMA 284:993-1000.

-Comments

    Sometimes early care and education programs have children ages eighteen months to three years of age in one classroom and staff report it is difficult to serve different types of milk (1% and 2%) to specific children. Programs can use a different color label for each type of milk on the container or pitcher. Caregivers/teachers can explain to the children the meaning of the color labels and identify which milk they are drinking.

-Learn From Your Peers

When families come for their initial visit, I explain that meal types are determined by age.  Children younger than one year do not receive cow’s milk without a medical statement.  Older children who cannot have cow’s milk for medical reasons are also required to have a medical statement on file.  To help families understand the reasons behind this policy, I talk to them about the USDA food program and give them written information about the differences between the various types of milk.
--- Family home child care provider

With many rural areas, we have had concerns about child care professionals serving milk from their farm or a neighbor’s farm.  Wyoming licensing rules now require that pasteurized, inspected, and approved milk (produced under sanitary conditions) is served at all meals.  Exceptions require written documentation on file. 
--- Licensing officer

It is important to remember that cups of milk should be discarded if sipped from or left unrefrigerated for more than one hour.  Cups which have been served to a child should not be put back in the refrigerator to be served later. Cartons of milk should also not be left unrefrigerated for more than one hour.
--- Child care health consultant

We keep a list of enrolled children on a spreadsheet so that, each month, we can update every child's exact age. This helps teachers meet the age-appropriate requirements for milk and other foods, and it helps remind us when immunizations and well-child exams are due.
--- Program monitoring manager


August 2012

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

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

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-Standard Rationale

Over the past several years there has been increasing recognition of shaken baby syndrome/abusive head trauma which is the occurrence of brain injury in young children under three years of age due to shaking a child. Even mild shaking can result in serious, permanent brain damage or death. The brain of the young child may bounce inside of the skull resulting in brain damage, hemorrhaging, blindness, or other serious injuries or death. There have been several reported incidents occurring in child care (1). Caregivers/teachers experience young children who may be fussy or constantly crying. It is important for caregivers/teachers to be educated about the risks of shaking and provided with strategies to cope if they are frustrated (2). Many states have passed legislation requiring education and training for caregivers/teachers. Caregivers/teachers should check their individual state’s specific requirements (3). Staff can also recognize the signs and symptoms of shaken baby syndrome/abusive head trauma in children in their care.

-Type of Facility

Center; Large Family child Care Home; Small Family child Care Home

-Standard References

  1. American Academy of Pediatrics, Committee on Child Abuse and Neglect. 2009. Abusive head trauma in infants and children. Pediatrics 123:1409-11.
  2. Calm a Crying Baby. Shaken baby syndrome prevention. http://www.calmacryingbaby.com.
  3. National Resource Center for Health and Safety in Child Care and Early Education. State licensing database. http://nrckids.org/STATES/states.htm.

-Comments

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

-Learn From Your Peers

I have placed updated information in the parent resource book. As I find articles and flyers on these two issues, they are sent home. To ensure my knowledge stays current, take courses. The information received is then placed in my professional resource binder for future refernces.
---Family Child Care Provider

Encourage staff working in stressful situations to take a short 10-15 minute break outdoors.  The outdoor natural environment, combined with a short walk, are wonderful for helping individuals de-stress so they can return to the classroom with a more positive mindset.
---Retired Early Childhood Professor

Education is key.  In addition to requiring all staff to attend training on Shaken Baby Syndrome/Abusive Head Trauma, posting information in classrooms as reminders for staff.  Reviewing information with new employees, subs, or volunteers before they are able to care for children.  Providing information for parents is very important as well.
---Nurse, Child Care Health Consultant


July 2012

Standard 4.2.0.6 Availability of Drinking Water

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

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

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-Standard Rationale

When children are thirsty between meals and snacks, water is the best choice. Encouraging children to learn to drink water in place of fruit drinks, soda, fruit nectars, or other sweetened drinks builds a beneficial habit. Drinking water during the day can reduce the extra caloric intake which is associated with overweight and obesity (1). Drinking water is good for a child’s hydration and reduces acid in the mouth that contributes to early childhood caries (1,3,4). Water needs vary among young children and increase during times in which dehydration is a risk (e.g., hot summer days, during exercise, and in dry days in winter) (2).

-Type of Facility

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

-Standard References

  1. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.

  2. Manz, F. 2007. Hydration in children. J Am Coll Nutr 26:562S-569S.

  3. 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.

  4. Centers for Disease Control and Prevention. 2011. Community water fluoridation. http://www.cdc.gov/fluoridation/.

-Comments

    Clean, small pitchers of water and single-use paper cups available in the classrooms and on the playgrounds allow children to serve themselves water when they are thirsty. Drinking fountains should be kept clean and sanitary and maintained to provide adequate drainage.

-Learn From Your Peers

I like to purchase bottled water or fill a cooler with ice water. The children can come and get water, as they need it. The older children (three years and older), have small, disposable cups available for them to pour their own water. The younger ones come and bring me their Sippy cups to be filled. This is especially important during the warm weather days. Too often they do not want to stop and go inside for water.
I have noticed that when the children drink less juice and more water their eating habits have improved.
--- Family Child Care Provider

Short original verse on topic:

Mary, Mary, quite contrary,
Why are you fretting so?

I’m hot, and tired, and thirsty, too,
But lack the words to let you know.

When working hard at play you see,
Water hydrates both you and me!

If paper cups are used when providing water to children outdoors, please be sure cups are provided in a cup dispenser so children do not touch the drinking surface of cups used by other children. Remember that children are outdoors to play, discover and learn which includes touching leaves, soil, worms, rocks and other natural items, so little hands are not sanitary.

Brain development research tells us that “the brain needs to be properly hydrated in order to be alert. Children who do not get enough water may appear bored, listless, and drowsy.” (p.44)

Coffee, tea, and many sodas contain caffeine, which acts as a diuretic and reduces the hydration of the body and the brain. The body identifies fruit joices as a food because of their sugar content. The body triggers the digestive process, which also drains water from the body. Only water provides proper hydration.” (p.44)

Schiller, P. (1999). Start smart: Building brain power in the early years. Beltsville, MD: Gryphon House.

Be creative when providing children water on outdoor playgrounds where no water fountain is available. Health and safety of the children are our top priority so beware of cross contamination caused by children touching cups of other children and water pitchers.
--- Retired Early Childhood Professor

It is also important to remember health and safety when serving water to children. Infants and toddlers should be seated when drinking to prevent falls. If disposable cups are used, Styrofoam should not be used with infants and toddlers. If water bottles are used, they should be labeled, emptied and washed daily. If drinking fountains are available, providing step stools is important so children are able to reach the fountain safely. If children are able to drink from a bathroom sink or a sink used after diapering/toileting, the sink should be disinfected to prevent cross-contamination. If a classroom only has one sink that is used for food prep and diapering, obtaining a jug of water daily from a clean water source, such as from the kitchen, is recommended to prevent cross-contamination.
--- Nurse, Child Care Health Consultant

Getting children in the habit of drinking water is great. I wish someone taught me as a child that water should be everyone’s drink of choice throughout the day.
--- Manager, Child Care Services

Our children love to be the ‘water carrier.” They carry a container full of water. Teachers keep small paper cups in their outdoor packs and offer water breaks during outdoor play time. 

Taking official breaks encourages the youngest children to take a drink when they may not realize that they are even thirsty during hot weather outdoor play. 

Also practicing drinking small amounts of water from paper cups outdoors is an easy way to improve drinking out of a cup without all the mess!!

Using 2 or 4 cup measuring cups with a handle and spout are an easy way for children to learn to pour their own water during lunch or snack times.

With such a small amount of daily juice recommended for children ages birth to five (4-6oz of 100% fruit juice) we leave the fruit juice intake to parents to do at home! Offering water and milk during the day at the center. Even those children whose parents insist they won’t drink water, do so willingly. It is amazing what presentation and peers can do to help a child make good choices.
--- Child Care Provider

Wyoming Licensing rules require the facilities to provide adequate fluids throughout the day. Some providers have labeled cups containing water available throughout the day. Larger centers have labeled cups and water pitchers on the counters for the children to pour a drink when needed. Others have the bottled water dispensers available with small paper/plastic cups available for the children to get a drink when necessary.
--- Licensing Officer

Our best practices around drinking water are to add fruit (lemons, orange slices, cucumber slices, berries) to the family-style pitchers made available throughout program times.  We’ve also increased water intake during hot months through special water bottle refill promotions where we will chart the number of refills.  We accompany those promotions with information for parents on the importance of hydration.  (Kids may exaggerate how much they drink by turning cups into bottles and sending parents into fears of over-hydration, so education is key!)
--- Child Care Provider


June 2012

Standard 9.2.5.1 Transportation Policy for Centers and Large Family Homes

Written policies should address the safe transport of children by vehicle to or from the facility, including field trips, home pick-ups and deliveries, and special outings. The transportation policy should include:

  1. Licensing of vehicles and drivers;

  2. Vehicle selection to safely transport children, based on vehicle design and condition;

  3. Operation and maintenance of vehicles;

  4. Driver selection, training, and supervision;

  5. Child:staff ratio during transport;

  6. Accessibility to first aid kit, emergency ID/contact and pertinent health information for passengers, cell phone, or two-way radio;

  7. Permitted and prohibited activities during transport;

  8. Backup arrangements for emergencies;

  9. Use of seat belt and car safety seat, including booster seats;

  10. Drop-off and pick-up plans;

  11. Plan for communication between the driver and the child care facility staff;

  12. Maximum travel time for children (no more than forty-five minutes in one trip);

  13. Procedures to ensure that no child is left in the vehicle at the end of the trip or left unsupervised outside or inside the vehicle during loading and unloading the vehicle;

  14. Use of passenger vans

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-Standard Rationale

Motor vehicle crashes are the leading cause of death in children two to fourteen years of age in the United States (1). It is necessary for the safety of children to require that the caregiver/teacher comply with requirements governing the transportation of children in care, in the absence of the parent/guardian. Not all vehicles are designed to safely transport children, especially young children. The National Highway Traffic Safety Administration (NHTSA) recommends that preschool and school aged children should not be transported in twelve- or fifteen-passenger vehicles due to safety concerns (2,3). Children have died because they have fallen asleep and been left in vehicles. Others have died or been injured when left outside the vehicle when thought to have been loaded into the vehicle. The process of loading and unloading children from a vehicle can distract caregivers/teachers from adequate supervision of children either inside or outside the vehicle. Policies and procedures must account for the management of these risks.

-Type of Facility

Center; Large Family Child Care Homes

-Standard References

  1. National Safety Council (NSC). 2009. Injury facts. 2009 ed. Chicago: NSC.

  2. National Highway Traffic Safety Association. Safecar.gov. http://www.safercar.gov.

  3. National Highway Traffic Safety Association. Passenger van safety. http://www.safercar.gov/Vehicle+Shoppers/Passenger+Van+Safety/.

-Comments

    Maintenance should include an inspection checklist for every trip. Vehicle maintenance service should be performed according to the manufacturer’s recommendations or at least every three months.

-Learn From Your Peers

In Wyoming, we require the providers to take their emergency medical authorization, first aid kit, emergency contact information, permission authorization, and attendance records.  Their child care policies need to state the items they are required to take with them. Here in Campbell County, I have worked diligently with law enforcement and emergency management.  We have listed all licensed facilities with the law enforcement agencies dispatch centers on the Speelman system.  We utilized the computer aided dispatch (CAD) systems.  Anytime a provider places an emergency call, the dispatch computer recognizes they are a child care facility with multiple children and multiple adults present.  I have also met with law enforcement, the fire department staff and EMT’s to make them aware of the documentation each facility is required to have with them on transportation and field trips.  
--- Licensing Officer

I am so glad it was noted not to use fifteen passenger vans.  They are too dangerous for children.  We purchased a small bus for transporting our children.  In my opinion, there is no reason to take any child under 4 years of age out of a facility for a field trip.
--- Child Care Services Manager

[In the event of an accident and the adults were unable to communicate with first responders, one recommendation is] for the adults to carry cards with the child’s picture along with emergency contact information so the child can be properly identified if needed.
--- Child Care Health Consultant

[In case of an emergency,] the approach many recommend is to label the child with the name of the child care program so that EMS can contact the facility for specific information about the child if such information is not available from adults who are supervising and caring for the child. It is counter to security recommendations to visibly label children with their names so as to avoid abduction/seduction.
--- Pediatrician


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 even.

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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