A Plant Where Plastic 2-liter Bottles Are Manufactured Probably Uses a ________ Layout.

Special Collection

Caring for Infants and Toddlers in Early Care and Education (I/T)

Copyright © 2014
American Academy of Pediatrics
American Public Health Association
National Resource Center for Health and Safety in Child Care and Early Education

Caring for Infants and Toddlers in Child Care and Early Education may be reproduced without permission only for educational purposes and/or personal use. To reproduce any portion of this publication, in any form, for commercial purposes, please contact the Permissions Editor at the American Academy of Pediatrics by fax (847/434-8780), mail (PO Box 927, Elk Grove Village, IL 60007-1019), or email (marketing@aap.org).

This project was supported by Grant Number U46MCO9810 from the U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.

Suggested Citation:

American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education. 2014. Caring for infants and toddlers in child care and early education. Applicable standards from: Caring for our children: National health and safety performance standards; Guidelines for early care and education programs, 3rd Edition. Elk Grove Village, IL: American Academy of Pediatrics; Washington, DC: American Public Health Association.

Available at http://nrckids.org.

The Caring for Our Children, 3rd Edition Standards are for reference purposes only and shall not be used as a substitute for medical or legal consultation, nor be used to authorize actions beyond a person's licensing, training, or ability.

Document Design & Layout: Betty Geer, Lorina Washington

Caring for Infants and Toddlers in Early Care and Education (I/T) Comparison/Compliance Checklist - PDF (Updated January 2019)

Suggestions for Use of the Compliance/Comparison Checklist:

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

I. Enrollment and Admission

1.1.2.1 Minimum Age to Enter Child Care
9.2.1.3 Enrollment Information to Parents/Guardians and Caregivers/Teachers
9.4.2.3 Contents of Admission Agreement Between Child Care Program and Parent/Guardian

Staffing, Consultants, and Supervision

1.6.0.1 Child Care Health Consultants
1.6.0.2 Frequency of Child Care Health Consultation Visits
1.6.0.3 Infant and Early Childhood Mental Health Consultants
1.6.0.4 Early Childhood Education Consultants
1.1.1.1 Ratios for Small Family Child Care Homes
1.1.1.2 Ratios for Large Family Child Care Homes and Centers
1.1.1.3 Ratios for Facilities Serving Children with Special Health Care Needs and Disabilities
1.1.1.4 Ratios and Supervision During Transportation
1.1.1.5 Ratios and Supervision for Swimming, Wading, and Water Play
2.2.0.1 Methods of Supervision of Children
2.2.0.4 Supervision Near Bodies of Water
4.5.0.6 Adult Supervision of Children Who Are Learning to Feed Themselves

Staff Qualifications and Training

1.2.0.2 Background Screening
1.3.1.1 General Qualifications of Directors
1.3.2.2 Qualifications of Lead Teachers and Teachers
1.3.2.3 Qualifications for Assistant Teachers, Teacher Aides, and Volunteers
1.3.2.4 Additional Qualifications for Caregivers/Teachers Serving Children Birth to Thirty-Five Months of Age
1.3.2.7 Qualifications and Responsibilities for Health Advocates
1.3.3.1 General Qualifications of Family Child Care Caregivers/Teachers to Operate a Family Child Care Home
1.4.1.1 Pre-service Training
1.4.2.2 Orientation for Care of Children with Special Health Care Needs
1.4.2.3 Orientation Topics
1.4.3.1 First Aid and Cardiopulmonary Resuscitation Training for Staff
1.4.5.2 Child Abuse and Neglect Education
1.5.0.2 Orientation of Substitutes
7.4.0.2 Staff Education and Policies on Enteric (Diarrheal) and Hepatitis A Virus (HAV) Infections
7.7.1.1 Staff Education and Policies on Cytomegalovirus (CMV)

Consultants

Supervision

Environment and Equipment

Building and Environment: Inside and Outside

5.1.1.5 Assessment of the Environment at the Site Location
5.1.1.7 Use of Basements and Below Grade Areas
5.1.1.12 Multiple Use of Rooms
5.1.2.1 Space Required per Child
5.1.3.2 Possibility of Exit from Windows
5.2.1.1 Ensuring Access to Fresh Air Indoors
5.2.1.2 Indoor Temperature and Humidity
5.2.1.6 Ventilation to Control Odors
5.2.1.11 Portable Electric Space Heaters
5.2.6.2 Testing of Drinking Water Not From Public System
5.2.6.3 Testing for Lead and Copper Levels in Drinking Water
5.2.8.1 Integrated Pest Management
5.2.9.4 Radon Concentrations
5.2.9.10 Prohibition of Poisonous Plants
5.2.9.13 Testing for and Remediating Lead Hazards
5.2.9.14 Shoes in Infant Play Areas
5.4.1.1 General Requirements for Toilet and Handwashing Areas
5.4.1.4 Preventing Entry to Toilet Rooms by Infants and Toddlers
6.1.0.1 Size and Location of Outdoor Play Area
6.1.0.2 Size and Requirements of Indoor Play Area
6.1.0.4 Elevated Play Areas
6.3.1.1 Enclosure of Bodies of Water

Equipment, Materials, and Toys

Facility

3.4.6.1 Strangulation Hazards
5.1.5.4 Guards at Stairway Access Openings
5.1.6.6 Guardrails and Protective Barriers
5.2.4.2 Safety Covers and Shock Protection Devices for Electrical Outlets
5.2.5.1 Smoke Detection Systems and Smoke Alarms
5.2.9.1 Use and Storage of Toxic Substances
5.2.9.5 Carbon Monoxide Detectors
5.2.9.6 Preventing Exposure to Asbestos or Other Friable Materials
5.3.1.1 Safety of Equipment, Materials, and Furnishings
5.3.1.3 Size of Furniture
5.3.1.4 Surfaces of Equipment, Furniture, Toys, and Play Materials
5.3.1.7 Facility Arrangements to Minimize Back Injuries
5.4.1.6 Ratios of Toilets, Urinals, and Hand Sinks to Children
5.4.1.7 Toilet Learning/Training Equipment
5.4.2.1 Diaper Changing Tables
5.4.2.4 Use, Location, and Setup of Diaper Changing Areas
5.4.2.5 Changing Table Requirements
5.4.1.10 Handwashing Sinks
5.4.1.11 Prohibited Uses of Handwashing Sinks
5.4.2.2 Handwashing Sinks for Diaper Changing Areas in Centers
5.4.2.3 Handwashing Sinks for Diaper Changing Areas in Homes
5.4.5.1 Sleeping Equipment and Supplies
5.4.5.2 Cribs
5.4.5.3 Stackable Cribs
5.4.5.4 Futons
5.5.0.7 Storage of Plastic Bags
5.5.0.8 Firearms
6.3.3.4 Pool Water Temperature
6.3.5.1 Hot Tubs, Spas, and Saunas
6.3.5.2 Water in Containers
6.4.1.5 Balloons
6.5.2.2 Child Passenger Safety
6.5.2.4 Interior Temperature of Vehicles

Food Preparation and Feeding Area

4.5.0.2 Tableware and Feeding Utensils
4.8.0.1 Food Preparation Area
4.8.0.8 Microwave Ovens
5.3.1.8 High Chair Requirements

Play Areas

5.2.9.7 Proper Use of Art and Craft Materials
5.3.1.9 Carriage, Stroller, Gate, Enclosure, and Play Yard Requirements
6.2.1.1 Play Equipment Requirements
6.2.1.7 Enclosure of Moving Parts on Play Equipment
6.2.1.9 Entrapment Hazards of Play Equipment
6.2.4.3 Sensory Table Materials
6.4.1.2 Inaccessibility of Toys or Objects to Children Under Three Years of Age
6.4.1.3 Crib Toys
6.4.2.1 Riding Toys with Wheels and Wheeled Equipment
6.4.2.2 Helmets

Program Activities for Healthy Development

Developmentally Appropriate Practice

2.1.1.4 Monitoring Children's Development/Obtaining Consent for Screening
2.1.1.5 Helping Families Cope with Separation
2.1.1.6 Transitioning within Programs and Indoor and Outdoor Learning/Play Environments
2.1.1.7 Communication in Native Language Other Than English
2.1.1.9 Verbal Interaction
2.1.2.1 Personal Caregiver/Teacher Relationships for Infants and Toddlers
2.1.2.2 Interactions with Infants and Toddlers
2.1.2.3 Space and Activity to Support Learning of Infants and Toddlers
2.1.2.4 Separation of Infants and Toddlers from Older Children
2.1.2.5 Toilet Learning/Training
2.2.0.2 Limiting Infant/Toddler Time in Crib, High Chair, Car Seat, Etc.
2.2.0.3 Screen Time/Digital Media Use
2.2.0.5 Behavior Around a Pool
2.3.1.1 Mutual Responsibility of Parents/Guardians and Staff
3.1.4.4 Scheduled Rest Periods and Sleep Arrangements
5.3.1.10 Restrictive Infant Equipment Requirements
9.2.1.1 Content of Policies
9.2.2.1 Planning for Child's Transition to New Services

Positive Behavior Management

2.2.0.6 Discipline Measures
2.2.0.7 Handling Physical Aggression, Biting, and Hitting
2.2.0.8 Preventing Expulsions, Suspensions, and Other Limitations in Services
2.2.0.9 Prohibited Caregiver/Teacher Behaviors
2.2.0.10 Using Physical Restraint
4.5.0.11 Prohibited Uses of Food
9.2.1.6 Written Discipline Policies

Healthy Weight Promotion

Physical Activity

3.1.3.1 Active Opportunities for Physical Activity
3.1.3.2 Playing Outdoors
9.2.3.1 Policies and Practices that Promote Physical Activity

B. Nutrition

4.2.0.2 Assessment and Planning of Nutrition for Individual Children
4.2.0.3 Use of US Department of Agriculture Child and Adult Care Food Program Guidelines
4.2.0.4 Categories of Foods
4.2.0.5 Meal and Snack Patterns
4.2.0.6 Availability of Drinking Water
4.2.0.7 100% Fruit Juice
4.2.0.8 Feeding Plans and Dietary Modifications
4.2.0.9 Written Menus and Introduction of New Foods
4.2.0.12 Vegetarian/Vegan Diets
4.3.1.1 General Plan for Feeding Infants
4.3.1.2 Feeding Infants on Cue by a Consistent Caregiver/Teacher
4.3.1.6 Use of Soy-Based Formula and Soy Milk
4.3.1.7 Feeding Cow's Milk
4.3.1.8 Techniques for Bottle Feeding
4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants
4.3.1.12 Feeding Age-Appropriate Solid Foods to Infants
4.3.2.1 Meal and Snack Patterns for Toddlers and Preschoolers
4.3.2.2 Serving Size for Toddlers and Preschoolers
4.3.2.3 Encouraging Self-Feeding by Older Infants and Toddlers
4.5.0.1 Developmentally Appropriate Seating and Utensils for Meals
4.5.0.4 Socialization During Meals
4.5.0.8 Experience with Familiar and New Foods
4.7.0.1 Nutrition Learning Experiences for Children
9.2.3.11 Food and Nutrition Service Policies and Plans
9.2.3.12 Infant Feeding Policy

Safe and Healthy Practices and Procedures

Safe Food Practices

4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.1.4 Feeding Human Milk to Another Mother's Child
4.3.1.5 Preparing, Feeding, and Storing Infant Formula
4.3.1.9 Warming Bottles and Infant Foods
4.5.0.3 Activities that Are Incompatible with Eating
4.5.0.5 Numbers of Children Fed Simultaneously by One Adult
4.5.0.9 Hot Liquids and Foods
4.5.0.10 Foods that Are Choking Hazards
4.8.0.4 Food Preparation Sinks
4.9.0.2 Staff Restricted from Food Preparation and Handling
4.9.0.3 Precautions for a Safe Food Supply
5.2.9.9 Plastic Containers and Toys

Health Promotion and Protection

3.1.2.1 Routine Health Supervision and Growth Monitoring
3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
3.1.4.2 Swaddling
3.1.4.3 Pacifier Use
3.1.5.1 Routine Oral Hygiene Activities
3.1.5.2 Toothbrushes and Toothpaste
3.2.1.1 Type of Diapers Worn
3.2.1.2 Handling Cloth Diapers
3.2.1.3 Checking For the Need to Change Diapers
3.2.1.4 Diaper Changing Procedure
3.2.1.5 Procedure for Changing Children's Soiled Underwear, Disposable Training Pants and Clothing
3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.2.2.3 Assisting Children with Hand Hygiene
3.2.2.5 Hand Sanitizers
3.4.1.1 Use of Tobacco, Electronic Cigarettes, Alcohol, and Drugs
3.4.5.1 Sun Safety Including Sunscreen
3.4.5.2 Insect Repellent and Protection from Vector-Borne Diseases
3.5.0.1 Care Plan for Children with Special Health Care Needs
3.5.0.2 Caring for Children Who Require Medical Procedures
4.2.0.10 Care for Children with Food Allergies
9.4.1.9 Records of Injury

C. Cleaning/Sanitizing/Disinfecting Practices

3.2.3.1 Procedure for Nasal Secretions and Use of Nasal Bulb Syringes
3.3.0.1 Routine Cleaning, Sanitizing, and Disinfecting
3.3.0.2 Cleaning and Sanitizing Toys
3.3.0.3 Cleaning and Sanitizing Objects Intended for the Mouth
3.3.0.4 Cleaning Individual Bedding
3.3.0.5 Cleaning Crib Surfaces
4.3.1.1 General Plan for Feeding Infants
5.4.2.6 Maintenance of Changing Tables
9.2.3.10 Sanitation Policies and Procedures

Infection Control/Disease Prevention and Management

3.1.1.1 Conduct of Daily Health Check
3.2.3.4 Prevention of Exposure to Blood and Body Fluids
3.6.1.1 Inclusion/Exclusion/Dismissal of Children
3.6.1.2 Staff Exclusion for Illness
3.6.1.3 Thermometers for Taking Human Temperatures
3.6.4.1 Procedure for Parent/Guardian Notification About Exposure of Children to Infectious Disease
3.6.4.2 Infectious Diseases That Require Parent/Guardian Notification
3.6.4.4 List of Excludable and Reportable Conditions for Parents/Guardians
5.2.7.4 Containment of Soiled Diapers
5.2.7.5 Labeling, Cleaning, and Disposal of Waste and Diaper Containers
5.5.0.1 Storage and Labeling of Personal Articles
7.2.0.1 Immunization Documentation
7.2.0.2 Unimmunized Children
7.2.0.3 Immunization of Caregivers/Teachers
7.3.2.1 Immunization for Haemophilus Influenzae Type B (HIB)
7.3.3.1 Influenza Immunizations for Children and Caregivers/Teachers
7.3.5.1 Recommended Control Measures for Invasive Meningococcal Infection in Child Care
7.3.7.3 Exclusion for Pertussis
7.3.8.1 Attendance of Children with Respiratory Syncytial Virus (RSV) Respiratory Tract Infection
7.3.11.1 Attendance of Children with Unspecified Respiratory Tract Infection
7.4.0.1 Control of Enteric (Diarrheal) and Hepatitis A Virus (HAV) Infections
7.5.1.1 Conjunctivitis (Pinkeye)
7.5.10.1 Staphylococcus Aureus Skin Infections Including MRSA
7.5.12.1 Thrush (Candidiasis)
7.7.2.1 Disease Recognition and Control of Herpes Simplex Virus

Medication Administration

3.6.3.1 Medication Administration
3.6.3.2 Labeling, Storage, and Disposal of Medications
3.6.3.3 Training of Caregivers/Teachers to Administer Medication
9.4.2.6 Contents of Medication Record

Abuse/Neglect

3.4.4.1 Recognizing and Reporting Suspected Child Abuse, Neglect, and Exploitation
3.4.4.3 Preventing and Identifying Shaken Baby Syndrome/Abusive Head Trauma
3.4.4.5 Facility Layout to Reduce Risk of Child Abuse and Neglect
3.6.4.5 Death
5.6.0.1 First Aid and Emergency Supplies
9.2.4.3 Disaster Planning, Training, and Communication
9.2.4.4 Written Plan for Seasonal and Pandemic Influenza
9.2.4.5 Emergency and Evacuation Drills/Exercises Policy

Appendices

Appendix A: Signs and Symptoms Chart
Appendix D: Gloving
Appendix F: Enrollment/Attendance/Symptom Record
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting
Appendix L: Cleaning Up Body Fluids
Appendix M: Recognizing Child Abuse and Neglect
Appendix N: Protective Factors Regarding Child Abuse and Neglect
Appendix U: Recommended Safe Minimum Internal Cooking Temperatures
Appendix Y: Non-Poisonous and Poisonous Plants
Appendix Z: Depth Required for Shock-Absorbing Surfacing Materials for Use Under Play Equipment
Appendix AA: Medication Administration Packet
Appendix DD: Injury Report Form for Indoor and Outdoor Injuries
Appendix EE: America's Playgrounds Safety Report Card
Appendix II: Bike and Multi-Sport Helmets: Quick-Fit Check
Appendix JJ: Our Child Care Center Supports Breastfeeding
Appendix KK: Authorization for Emergency Medical/Dental Care
Appendix NN: First Aid and Emergency Supply Lists
Appendix P: Situations that Require Medical Attention Right Away
Appendix A: Signs and Symptoms Chart
Appendix G: Recommended Childhood Immunization Schedule
Appendix H: Recommended Adult Immunization Schedule
Appendix J: Selecting an Appropriate Sanitizer or Disinfectant
Appendix Q: MyPlate: Make It Yours
Appendix C: Nutrition Specialist, Registered Dietitian, Licensed Nutritionist, Consultant, and Food Service Staff Qualifications
Appendix O: Care Plan for Children with Special Health Care Needs
Appendix R: Choose MyPlate: 10 Tips to a Great Plate
Appendix S: Physical Activity: How Much Is Needed?
Appendix CC: Incident Report Form

I. Enrollment and Admission

Standard 1.1.2.1: Minimum Age to Enter Child Care

Reader's Note: This standard reflects a desirable goal when sufficient resources are available; it is understood that for some families, waiting until three months of age to enter their infant in child care may not be possible.

Healthy full-term infants can be enrolled in child care settings as early as three months of age. Premature infants or those with chronic health conditions should be evaluated by their primary care providers and developmental specialists to make an individual determination concerning the appropriate age for child care enrollment.

RATIONALE

Brain anatomy, chemistry, and physiology undergo rapid development over the first ten to twelve weeks of life (1-6). Concurrently, and as a direct consequence of these shifts in central nervous system structure and function, infants demonstrate significant growth, irregularity, and eventually, organization of their behavior, physiology, and social responsiveness (1-3,5). Arousal responses to stimulation mature before the ability to self-regulate and control such responses in the first six to eight weeks of life causing infants to demonstrate an expanding range and fluctuation of behavioral state changes from quiet to alert to irritable (1-3,6). Infant behavior is most disorganized, most difficult to read and most frustrating to support at the six to eight week period (2,3). At approximately eight to twelve weeks after birth, full term infants typically undergo changes in brain function and behavior that helps caregivers/teachers understand and respond effectively to infants' increasingly stable sleep-wake states, attention, self-calming efforts, feeding patterns and patterns of social engagement. Over the course of the third month, infants demonstrate an emerging capacity to sustain states of sleep and alert attention.

Infants, birth to three months of age, can become seriously ill very quickly without obvious signs (7). This increased risk to infants, birth to three months makes it important to minimize their exposure to children and adults outside their family, including exposures in child care (8). In addition, infants of mothers who return to work, particularly full-time, before twelve weeks of age, and are placed in group care may be at even greater risk for developing serious infectious diseases. These infants are less likely to receive recommended well-child care and immunizations and to be breastfed or are likely to have a shorter duration of breastfeeding (16,22).

Researchers report that breastfeeding duration was significantly higher in women with longer maternity leaves as compared to those with less than nine to twelve weeks leave (9,22). A leave of less than six weeks was associated with a much higher likelihood of stopping breastfeeding (10,22). Continuing breastfeeding after returning to work may be particularly difficult for lower income women who may have fewer support systems (11).

It takes women who have given birth about six weeks to return to the physical health they had prior to pregnancy (12). A significant portion of women reported child birth related symptoms five weeks after delivery (17). In contrast, women's general mental health, vitality, and role function were improved with maternity leaves at twelve weeks or longer (13).

Birth of a child or adoption of a newborn, especially the first, requires significant transition in the family. First time parents/guardians are learning a new role and even with subsequent children, integration of the new family member requires several weeks of adaptation. Families need time to adjust physically and emotionally to the intense needs of a newborn (14,15).

COMMENTS

In an analysis of twenty-one wealthy countries including Australia, New Zealand, Canada, United States, Japan, and several European countries, the U.S. ranked twentieth in terms of unpaid and paid parental leave available to two-parent families with the birth of their child (18,21). Although Switzerland ranked twenty-first with fourteen versus twenty-four weeks as compared to the U.S. for both parents/guardians, eleven weeks of leave are paid in Switzerland. In this study of twenty-one countries, only Australia and the U.S. do not provide for paid leave after the birth of a child (18).

TYPE OF FACILITY

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

RELATED STANDARDS

2.1.1.5 Helping Families Cope with Separation

REFERENCES

Staehelin, K., P. C. Bertea, E. Z. Stutz. 2007. Length of maternity leave and health of mother and child–a review. Int J Public Health 52:202-9.
Guendelman, S., J. L. Kosc, M. Pearl, S. Graham, J. Goodman, M. Kharrazi. 2009. Juggling work and breastfeeding: Effects of maternity leave and occupational characteristics. Pediatrics 123: e38-e46.
McGovern P., B. Dowd, D. Gjerdingen, I. Moscovice, L. Kochevar, W. Lohman. 1997. Time off work and the postpartum health of employed women. Medical Care 35:507-21.
Cunningham, F. G., F. F. Gont, K. J. Leveno, L. C. Gilstrap, J. C. Hauth, K. D. Wenstrom. 2005. Williams obstretrics. 21st ed. New York: McGraw Hill.
Kimbro, R. T. 2006. On-the-job moms: Work and breastfeeding initiation and duration for a sample of low-income women. Maternal Child Health J 10:19-26.
Carter, B., M. McGoldrick, eds. 2005. The expanded family life cycle: Individual, family, and social perspectives. 3rd ed. New York: Allyn and Bacon Classics.
Ishimine, P. 2006. Fever without source in children 0-36 months. Pediatric Clinics North Am 53:167.
Harper, M. 2004. Update on the management of the febrile infant. Clin Pediatric Emerg Med 5:5-12.
Carey, W. B., A. C. Crocker, E. R. Elias, H. M. Feldman, W. L. Coleman. 2009. Developmental-behavioral pediatrics. 4th ed. Philadelphia: W. B. Saunders.
Parmelee, A. H. Jr, W. Weiner, H. Schultz. 1964. Infant sleep patterns: From birth to 16 weeks of age. J Pediatrics 65:576-82.
Brazelton, T. B. 1962. Crying in infancy. Pediatrics 29:579-88.
Huttenlocher, P. R., C. de Courten. 1987. The development of synapses in striate cortex of man. Human Neurobiology 6:1-9.
Anders, T. F. 1992. Sleeping through the night: A developmental perspective. Pediatrics 90:554-60.
Edelstein, S., J. Sharlin, S. Edelstein. 2008. Life cycle nutrition: An evidence-based approach. Boston: Jones and Bartlett.
Robertson, S. S. 1987. Human cyclic motility: Fetal-newborn continuities and newborn state differences. Devel Psychobiology 20:425-42.
Berger, L. M., J. Hill, J. Waldfogel. 2005. Maternity leave, early maternal employment and child health and development in the US. Economic J 115: F29-F47.
McGovern, P., B. Dowd, D. Gjerdingen, C. R. Gross, S. Kenney, L. Ukestad, D. McCaffrey, U. Lundberg. 2006. Postpartum health of employed mothers 5 weeks after childbirth. Annals Fam Med 4:159-67.
Ray, R., J. C. Gornick, J. Schmitt. 2009. Parental leave policies in 21 countries: Assessing generosity and gender equality. Rev. ed. Washington, DC: Center for Economic and Policy Research.
Social Security Act. 1935. 42 USC 7.
Family and Medical Leave Act. 1993. 29 USC 2601.
Lovell, V., E. O'Neill, S. Olsen. 2007. Maternity leave in the United States: Paid parental leave is still not standard, even among the best U.S. employers. Washington, DC: Institute for Women's Policy Research. http://iwpr.org/pdf/parentalleaveA131.pdf.
Human Rights Watch. 2011. Failing its families: Lack of paid leave and work-family supports in the U.S. http://www.hrw.org/en/reports/2011/02/23/failing-its-families-0/.

Standard 9.2.1.3: Enrollment Information to Parents/Guardians and Caregivers/Teachers

At enrollment, and before assumption of supervision of children by caregivers/teachers at the facility, the facility should provide parents/guardians and caregivers/teachers with a statement of services, policies, and procedures, including, but not limited, to the following:

The licensed capacity, child:staff ratios, ages and number of children in care. If names of children and parents/guardians are made available, parental/guardian permission for any release to others should be obtained;
Services offered to children including a written daily activity plan, sleep positioning policies and arrangements, napping routines, guidance and discipline policies, diaper changing and toilet learning/training methods, child handwashing, medication administration policies, oral health, physical activity, health education, and willingness for special health or therapy services delivered at the program (special requirements for a child should be clearly defined in writing before enrollment);
Hours and days of operation;
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;
Payment of fees, deposits, and refunds;
Methods and schedules for conferences or other methods of communication between parents/guardians and staff.

Policies on:

Staffing, including caregivers/teachers, the use of volunteers, helpers, or substitute caregivers/teachers, and deployment of staff for different activities;
Inclusion of children with special health care needs;
Nondiscrimination;
Termination and parent/guardian notification of termination;
Supervision;
Discipline;
Care of children and caregivers/teachers who are ill;
Temporary exclusion and alternative care for children who are ill;
Health assessments and immunizations;
Handling urgent medical care or threatening incidents;
Medication administration;
Use of child care health consultants, education and mental health consultants;
Plan for health promotion and prevention (tracking routine child health care, health consultation, health education for children/staff/families, oral health, sun safety, safety surveillance, etc.);
Disasters, emergency plan and drills, evacuation plan, and alternative shelter arrangements;
Security;
Confidentiality of records;
Transportation and field trips;
Physical activity (both outdoors and when children are kept indoors), play areas, screen time, and outdoor play policy;
Sleeping, safe sleep policy, areas used for sleeping/napping, sleep equipment, and bed linen;
Sanitation and hygiene;
Presence and care of any animals on the premises;
Food and nutrition including food handling, human milk, feeding and food brought from home, as well as a daily schedule of meals and snacks;
Evening and night care plan;
Smoking, tobacco use, alcohol, prohibited substances, and firearms;
Preventing and reporting child abuse and neglect;
Use of pesticides and other potentially toxic substances in or around the facility.

Parents/guardians and caregivers/teachers should sign that they have reviewed and accepted this statement of services, policies, and procedures. Policies, plans and procedures should generally be reviewed annually or when any changes are made.

RATIONALE

Model Child Care Health Policies, available at http://www.ecels-healthychildcarepa.org/content/MHP4thEd Total.pdf, has text to comply with many of the topics covered in this standard. Each policy has a place for the facility to fill in blanks to customize the policies for a specific site. The text of the policies can be edited to match individual program operations. Starting with a template such as the one in Model Child Care Health Policies can be helpful.

COMMENTS

For large and small family child care homes, a written statement of services, policies, and procedures is strongly recommended and should be added to the "Parent Handbook." Conflict over policies can lead to termination of services and inconsistency in the child's care arrangements. If the statement is provided orally, parents/guardians should sign a statement attesting to their acceptance of the statement of services, policies and procedures presented to them. can be adapted to these smaller settings.

TYPE OF FACILITY

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

RELATED STANDARDS

1.1.1.1 Ratios for Small Family Child Care Homes
1.1.1.2 Ratios for Large Family Child Care Homes and Centers
1.1.1.3 Ratios for Facilities Serving Children with Special Health Care Needs and Disabilities
1.1.1.4 Ratios and Supervision During Transportation
1.1.1.5 Ratios and Supervision for Swimming, Wading, and Water Play
2.1.1.1 Written Daily Activity Program and Statement of Principles
1.6.0.1 Child Care Health Consultants
3.1.1.1 Conduct of Daily Health Check
3.1.1.2 Documentation of the Daily Health Check
3.1.2.1 Routine Health Supervision and Growth Monitoring
3.1.3.1 Active Opportunities for Physical Activity
3.1.3.2 Playing Outdoors
3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
3.1.5.1 Routine Oral Hygiene Activities
3.1.5.2 Toothbrushes and Toothpaste
3.1.5.3 Oral Health Education
3.2.1.1 Type of Diapers Worn
3.2.1.2 Handling Cloth Diapers
3.2.1.3 Checking For the Need to Change Diapers
3.2.1.4 Diaper Changing Procedure
3.2.1.5 Procedure for Changing Children's Soiled Underwear, Disposable Training Pants and Clothing
3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.2.2.3 Assisting Children with Hand Hygiene
3.2.2.4 Training and Monitoring for Hand Hygiene
3.2.2.5 Hand Sanitizers
3.3.0.1 Routine Cleaning, Sanitizing, and Disinfecting
3.3.0.2 Cleaning and Sanitizing Toys
3.3.0.3 Cleaning and Sanitizing Objects Intended for the Mouth
3.3.0.4 Cleaning Individual Bedding
3.3.0.5 Cleaning Crib Surfaces
3.4.1.1 Use of Tobacco, Electronic Cigarettes, Alcohol, and Drugs
3.4.2.1 Animals that Might Have Contact with Children and Adults
3.4.2.2 Prohibited Animals
3.4.2.3 Care for Animals
3.4.3.1 Medical Emergency Procedures
3.4.3.2 Use of Fire Extinguishers
3.4.3.3 Response to Fire and Burns
3.6.1.1 Inclusion/Exclusion/Dismissal of Children
3.6.2.1 Exclusion and Alternative Care for Children Who Are Ill
3.6.2.2 Space Requirements for Care of Children Who Are Ill
3.6.2.3 Qualifications of Directors of Facilities That Care for Children Who Are Ill
3.6.2.4 Program Requirements for Facilities That Care for Children Who Are Ill
3.6.2.5 Caregiver/Teacher Qualifications for Facilities That Care for Children Who Are Ill
3.6.2.6 Child-Staff Ratios for Facilities That Care for Children Who Are Ill
3.6.2.7 Child Care Health Consultants for Facilities That Care for Children Who Are Ill
3.6.2.8 Licensing of Facilities That Care for Children Who Are Ill
3.6.2.9 Information Required for Children Who Are Ill
3.6.2.10 Inclusion and Exclusion of Children from Facilities That Serve Children Who Are Ill
3.6.3.1 Medication Administration
3.6.3.2 Labeling, Storage, and Disposal of Medications
3.6.3.3 Training of Caregivers/Teachers to Administer Medication
4.2.0.1 Written Nutrition Plan
4.2.0.2 Assessment and Planning of Nutrition for Individual Children
4.2.0.3 Use of US Department of Agriculture Child and Adult Care Food Program Guidelines
4.2.0.4 Categories of Foods
4.2.0.5 Meal and Snack Patterns
4.2.0.6 Availability of Drinking Water
4.2.0.7 100% Fruit Juice
4.2.0.8 Feeding Plans and Dietary Modifications
4.2.0.9 Written Menus and Introduction of New Foods
4.2.0.10 Care for Children with Food Allergies
4.2.0.11 Ingestion of Substances that Do Not Provide Nutrition
4.2.0.12 Vegetarian/Vegan Diets
4.3.1.1 General Plan for Feeding Infants
4.3.1.2 Feeding Infants on Cue by a Consistent Caregiver/Teacher
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.1.4 Feeding Human Milk to Another Mother's Child
4.3.1.5 Preparing, Feeding, and Storing Infant Formula
4.3.1.6 Use of Soy-Based Formula and Soy Milk
4.3.1.7 Feeding Cow's Milk
4.3.1.8 Techniques for Bottle Feeding
4.3.1.9 Warming Bottles and Infant Foods
4.3.1.10 Cleaning and Sanitizing Equipment Used for Bottle Feeding
4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants
4.3.1.12 Feeding Age-Appropriate Solid Foods to Infants
4.3.2.1 Meal and Snack Patterns for Toddlers and Preschoolers
4.3.2.2 Serving Size for Toddlers and Preschoolers
4.3.2.3 Encouraging Self-Feeding by Older Infants and Toddlers
4.3.3.1 Meal and Snack Patterns for School-Age Children
4.6.0.1 Selection and Preparation of Food Brought From Home
4.6.0.2 Nutritional Quality of Food Brought From Home
9.2.1.1 Content of Policies
9.2.3.2 Content and Development of the Plan for Care of Children and Staff Who Are Ill
9.2.3.9 Written Policy on Use of Medications
9.2.3.11 Food and Nutrition Service Policies and Plans
9.2.3.12 Infant Feeding Policy
9.2.3.13 Plans for Evening and Nighttime Child Care
9.2.3.15 Policies Prohibiting Smoking, Tobacco, Alcohol, Illegal Drugs, and Toxic Substances
9.2.3.16 Policy Prohibiting Firearms
9.2.4.1 Written Plan and Training for Handling Urgent Medical Care or Threatening Incidents
9.2.4.2 Review of Written Plan for Urgent Care and Threatening Incidents
9.2.4.3 Disaster Planning, Training, and Communication
9.2.4.4 Written Plan for Seasonal and Pandemic Influenza
9.2.4.5 Emergency and Evacuation Drills/Exercises Policy
9.2.4.6 Use of Daily Roster During Evacuation Drills
9.2.4.7 Sign-In/Sign-Out System
9.2.4.8 Authorized Persons to Pick Up Child
9.2.4.9 Policy on Actions to Be Followed When No Authorized Person Arrives to Pick Up a Child
9.2.4.10 Documentation of Drop-Off, Pick-Up, Daily Attendance of Child, and Parent/Provider Communication
9.4.1.3 Written Policy on Confidentiality of Records
9.4.2.3 Contents of Admission Agreement Between Child Care Program and Parent/Guardian
2.1.1.2 Health, Nutrition, Physical Activity, and Safety Awareness
2.1.1.3 Coordinated Child Care Health Program Model
2.1.1.4 Monitoring Children's Development/Obtaining Consent for Screening
2.1.1.5 Helping Families Cope with Separation
2.1.1.6 Transitioning within Programs and Indoor and Outdoor Learning/Play Environments
2.1.1.7 Communication in Native Language Other Than English
2.1.1.8 Diversity in Enrollment and Curriculum
2.1.1.9 Verbal Interaction
2.1.2.1 Personal Caregiver/Teacher Relationships for Infants and Toddlers
2.1.2.2 Interactions with Infants and Toddlers
2.1.2.3 Space and Activity to Support Learning of Infants and Toddlers
2.1.2.4 Separation of Infants and Toddlers from Older Children
2.1.2.5 Toilet Learning/Training
2.1.3.1 Personal Caregiver/Teacher Relationships for Three- to Five-Year-Olds
2.1.3.2 Opportunities for Learning for Three- to Five-Year-Olds
2.1.3.3 Selection of Equipment for Three- to Five-Year-Olds
2.1.3.4 Expressive Activities for Three- to Five-Year-Olds
2.1.3.5 Fostering Cooperation of Three- to Five-Year-Olds
2.1.3.6 Fostering Language Development of Three- to Five-Year-Olds
2.1.3.7 Body Mastery for Three- to Five-Year-Olds
2.1.4.1 Supervised School-Age Activities
2.1.4.2 Space for School-Age Activity
2.1.4.3 Developing Relationships for School-Age Children
2.1.4.4 Planning Activities for School-Age Children
2.1.4.5 Community Outreach for School-Age Children
2.1.4.6 Communication Between Child Care and School
2.2.0.1 Methods of Supervision of Children
2.2.0.2 Limiting Infant/Toddler Time in Crib, High Chair, Car Seat, Etc.
2.2.0.3 Screen Time/Digital Media Use
2.2.0.4 Supervision Near Bodies of Water
2.2.0.5 Behavior Around a Pool
2.2.0.6 Discipline Measures
2.2.0.7 Handling Physical Aggression, Biting, and Hitting
2.2.0.8 Preventing Expulsions, Suspensions, and Other Limitations in Services
2.2.0.9 Prohibited Caregiver/Teacher Behaviors
2.2.0.10 Using Physical Restraint
2.4.1.2 Staff Modeling of Healthy and Safe Behavior and Health and Safety Education Activities
2.4.1.3 Gender and Body Awareness
2.4.2.1 Health and Safety Education Topics for Staff
2.4.3.1 Opportunities for Communication and Modeling of Health and Safety Education for Parents/Guardians
2.4.3.2 Parent/Guardian Education Plan
6.4.2.2 Helmets
6.4.2.3 Bike Routes
6.5.1.1 Competence and Training of Transportation Staff
7.2.0.1 Immunization Documentation
7.2.0.2 Unimmunized Children
7.2.0.3 Immunization of Caregivers/Teachers

Standard 9.4.2.3: Contents of Admission Agreement Between Child Care Program and Parent/Guardian

The file for each child should include an admission agreement signed by the parent/guardian at enrollment. The admission agreement should contain the following topics and documentation of consent:

General topics:
1. Operating days and hours;
2. Holiday closure dates;
3. Payment for services;
4. Drop-off and pick-up procedures;
5. Family access (visiting site at any time when their child is there and admitted immediately under normal circumstances) and involvement in child care activities;
6. Name and contact information of any primary staff person designation, especially primary caregivers/teachers designated for infants and toddlers, to make parent/guardian contact of a caregiver/teacher more comfortable.
Health topics:
1. Immunization record;
2. Breast feeding policy;
3. For infants, statement that parent/guardian(s) has received and discussed a copy of the program's infant safe sleep policy;
4. Documentation of written consent signed and dated by the parent/guardian for:
5. Any health service obtained for the child by the facility on behalf of the parent/guardian. Such consent should be specific for the type of care provided to meet the tests for "informed consent" to cover on-site screenings or other services provided;
6. Administration of medication for prescriptions and non-prescription medications (over-the-counter [OTC]) including records and special care plans (if needed).
Safety topics:
1. Prohibition of corporal punishment in the child care facility;
2. Statement that parent/guardian has received and discussed a copy of the state child abuse and neglect reporting requirements;
3. Documentation of written consent signed and dated by the parent/guardian for:
4. Emergency transportation;
5. All other transportation provided by the facility;
6. Planned or unplanned activities off-premises (such consent should give specific information about where, when, and how such activities should take place, including specific information about walking to and from activities away from the facility);
7. Swimming, if the child will be participating;
8. Release of any information to agencies, schools, or providers of services;
9. Written authorization to release the child to designated individuals other than the parent/guardian.

RATIONALE

These records and reports are necessary to protect the health and safety of children in care.

These consents are needed by the person delivering the medical care. Advance consent for emergency medical or surgical service is not legally valid, since the nature and extent of injury, proposed medical treatment, risks, and benefits cannot be known until after the injury occurs, but it does allow the parent/guardian to guide the caregiver/teacher in emergency situations when the parent/guardian cannot be reached (1). See Appendix KK: Authorization for Emergency Medical/Dental Care for an example.

The parent/guardian/child care partnership is vital.

TYPE OF FACILITY

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

RELATED STANDARDS

9.2.1.3 Enrollment Information to Parents/Guardians and Caregivers/Teachers
Appendix KK: Authorization for Emergency Medical/Dental Care

REFERENCES

American Academy of Pediatrics, Committee on Pediatric Emergency Medicine. 2007. Policy statement: Consent for emergency medical services for children and adolescents. Pediatrics 120:683-84.

Staffing, Consultants, and Supervision

Standard 1.6.0.1: Child Care Health Consultants

COVID-19 modification as of May 21, 2021

*STANDARD UNDERGOING FULL REVISION*

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

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

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

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

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

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

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

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

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

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

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

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

COVID-19 modification as of May 21, 2021

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

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

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

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

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

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

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

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

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

Additional Resources:

Centers for Disease Control and Prevention.COVID-19 Vaccine Toolkit for School Settings and Childcare Programs American Academy of Pediatrics.Guidance Related to Childcare During COVID-19

Center for Health Care Strategies.COVID-19 and the Decline of Well-Child Care: Implications for Children, Families, and StatesChild Care Aware of America.Conducting Child Care Program Visits During COVID-19 (childcareaware.org)

RATIONALE

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

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

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

COMMENTS

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

NOTES

COVID-19 modification as of May 21, 2021

Standard 1.6.0.2: Frequency of Child Care Health Consultation Visits

Content in the STANDARD was modified on 8/22/2013.

The child care health consultant (CCHC) should visit each facility as needed to review and give advice on the facility's health component and review the overall health status of the children and staff (1-4). Early childhood programs that serve any child younger than three years of age should be visited at least once monthly by a health professional with general knowledge and skills in child health and safety and health consultation. Child care programs that serve children three to five years of age should be visited at least quarterly and programs serving school-age children should be visited at least twice annually. In all cases, the frequency of visits should meet the needs of the composite group of children and be based on the needs of the program for training, support, and monitoring of child health and safety needs, including (but not limited to) infectious disease, injury prevention, safe sleep, nutrition, oral health, physical activity and outdoor learning, emergency preparation, medication administration, and the care of children with special health care needs. Written documentation of CCHC visits should be maintained at the facility.

RATIONALE

Almost everything that goes on in a facility and almost everything about the facility itself affects the health of the children, families, and staff. (1-4). Because infants are developing rapidly, environmental situations can quickly create harm. Their rapid changes in behavior make regular and frequent visits by the CCHC extremely important (2-4). More frequent visits should be arranged for those facilities that care for children with special health care needs and those programs that experience health and safety problems and high turnover rate to ensure that staff have adequate training and ongoing support (2). In one study, 84% of child care directors who were required to have weekly health consultation visits considered the visits critical for children's health and program health and safety (2). Growing evidence suggests that frequent visits by a trained health consultant improves health policies and health and safety practices and improves children's immunization status, access to a medical home, enrollment in health insurance, timely screenings, and potentially reduces the prevalence of obesity with a targeted intervention (5-11). Furthermore, in one state, child care center medication administration regulatory compliance was associated with weekly visits by a trained nurse child care health consultant who delivered a standardized best practice curriculum (12).

COMMENTS

State child care regulations display a wide range of frequency and recommendations in states that require CCHC visits (5,6,13), from as frequently as once a week for programs serving children under three years of age to twice a year for programs serving children three to five years of age (2,5,6,13).

TYPE OF FACILITY

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

RELATED STANDARDS

1.6.0.1 Child Care Health Consultants
1.1.1.3 Ratios for Facilities Serving Children with Special Health Care Needs and Disabilities
1.6.0.5 Specialized Consultation for Facilities Serving Children with Disabilities
10.3.4.3 Support for Consultants to Provide Technical Assistance to Facilities
10.3.4.4 Development of List of Providers of Services to Facilities
3.6.2.7 Child Care Health Consultants for Facilities That Care for Children Who Are Ill
4.4.0.1 Food Service Staff by Type of Facility and Food Service
4.6.0.2 Nutritional Quality of Food Brought From Home
9.4.1.17 Documentation of Child Care Health Consultation/Training Visits

REFERENCES

National Resource Center for Health and Safety in Child Care and Early Education. 2010. Child care health consultant requirements and profiles by state. http://nrckids.org/default/assets/File/CCHC%20by%20state%20NOV%202012_FINAL.pdf.
Crowley, A. A. & Rosenthal, M. S. IMPACT: Ensuring the health and safety of Connecticut's early care and education programs. 2009. Farmington, CT: The Child Health and Development Institute of Connecticut.
Isbell P, Kotch JB, Savage E, Gunn E, Lu LS, Weber DJ. Improvement of child care programs' policies, practices, and children's access to health care linked to child care health consultation. NHSA Dialog: A Research to Practice Journal 2013;16 (2):34-52 (ISSN:1930-1395).
Bryant, D. "Quality Interventions for Early Care and Education." Early Developments, Spring 2013, http://fpg.unc.edu/sites/default/files/resources/early-developments/FPG_EarlyDevelopments_v14n1.pdf.
Benjamin, S. E., A. Ammerman, J. Sommers, J. Dodds, B. Neelon, D. S. Ward. 2007. Nutrition and physical activity self-assessment for child care (NAP SACC): Results from a pilot intervention. Journal of Nutrition Education and Behavior 39(3):142-9.
Nurse Consultant Intervention Improves Nutrition and Physical Activity Knowledge, Policy, and Practice and Reduces Obesity in Child Care. A. Crowley, A. Alkon, B Neelon, S. Hill, P. Yi, E. Savage, V. Ngyuen, J. Kotch. Head Start Research Conference, Washington, DC. June 20, 2012.
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.
Crowley, A. A. & Kulikowich, J. Impact of training on child care health consultant knowledge and practice. Pediatric Nursing.,2009, 35 (2): 93-100.
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.
Healthy Child Care Consultant Network Support Center, CHT Resource Group. 2006. The influence of child care health consultants in promoting children's health and well-being: A report on selected resources. http://hcccnsc.jsi.com/resources/publications/CC_lit_review_Screen_All.pdf.
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.
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 Nursing 32:530-37.
Crowley, A. A. 2000. Child care health consultation: The Connecticut experience. Maternal Child Health J 4:67-75.

NOTES

Content in the STANDARD was modified on 8/22/2013.

Standard 1.6.0.3: Infant and Early Childhood Mental Health Consultants

COVID-19 modification as of May 21, 2021

*STANDARD UNDERGOING FULL REVISION*

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

A facility should engage a qualified infant and early childhood mental health consultant (IECMHC) 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 IECMHC should include:

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

The role of the IECMHC 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:

Developing and implementing classroom curricula regarding conflict resolution, emotional regulation, and social skills development;
Developing and implementing appropriate screening and referral mechanisms for behavioral and mental health needs;
Forming relationships with mental health providers and special education systems in the community;
Providing mental health services, resources and/or referral systems for families and staff;
Helping staff facilitate and maintain mentally healthy environments within the classroom and overall system;
Helping address mental health needs and reduce job stress within the staff;
Improving management of children with challenging behaviors;
Preventing the development of problem behaviors;
Providing a classroom climate that promotes positive social-emotional development;
Recognizing and appropriately responding to the needs of children with internalizing behaviors, such as persistent sadness, anxiety, and social withdrawal;
Actively teaching developmentally appropriate social skills, conflict resolution, and emotional regulation;
Addressing the mental health needs and daily stresses of those who care for young children, such as families and caregivers/teachers;
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.

COVID-19 modification as of May 21, 2021

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

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

Infant and early childhood mental health consultants (IECMHCs) can support recovery and reduce harm from the social, emotional, and mental health challenges children and families face during COVID-19, such as:

Changes in families routines (e.g., physical distance from family, friends, worship community)
Disrupted learning environments (e.g., virtual learning environments, technology access)
Disrupted health care access (e.g., missed well-child and immunization visits, limited access to mental, speech, and occupational health services)
Missed significant life events (e.g., important events/celebrations, vacation plans, and/or milestones)
Lost security and safety (e.g., food insecurity and housing, increased exposure to violence and online harms, threat of physical illness and future uncertainty)

Refer to the Centers for Disease Control and Prevention's COVID-19 Parental Resources Kit:

Ensuring Children and Young People's Social, Emotional, and Mental Well-being to support children and families with these challenges.

Use IECMHCs to deliver:

Individual and group staff consultation to guide their work with children and families
Child and family consultation and connect to resources and services as needed
Timely staff trainings virtually
Consider alternatives to IECMHCs onsite consultation and schedule other methods for delivering services:
Use Virtual video visits or phone to review child social and emotional health needs, address health and safety issues and any training needs
Plan outdoor visits, if weather allows, using face mask and physical distancing

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

Additional Resources:

Center of Excellence for Infant and Early Childhood Mental Health Consultation. COVID-19 and Infant and Early Childhood Mental Health Consultation (IECMHC): How to Provide Services When Everything Is Different

Center for Early Childhood Mental Health Consultation. https://www.ecmhc.org/
Early Childhood Learning and Knowledge Center. Head Start Heals Campaign
American Academy of Pediatrics. Guidance Related to Childcare During COVID-19

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).

COMMENTS

Access to an early childhood mental health consultant should be in the context of an ongoing relationship, with at least quarterly regular visits to the classroom to consult. However, even an on-call-only relationship is better than no relationship at all. Regardless of the frequency of contact, this relationship should be established before a crisis arises, so that the consultant can establish a useful proactive working relationship with the staff and be quickly mobilized when needs arise. This consultant should be viewed as an important part of the program's support staff and should collaborate with all regular classroom staff, administration, and other consultants such as child care health consultants and education consultants, and support staff. In most cases, there is no single place in which to look for early childhood mental health consultants. Qualified potential consultants may be identified by contacting mental health and behavioral providers (e.g., child clinical and school psychologists, licensed clinical social workers, child psychiatrists, developmental pediatricians, etc.), as well as training programs at local colleges and universities where these professionals are being trained. Colleges and universities may be a good place to find well-supervised consultants-in-training at a potentially reasonable cost, although consultant turnover may be higher.

TYPE OF FACILITY

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

RELATED STANDARDS

1.6.0.1 Child Care Health Consultants
1.6.0.4 Early Childhood Education Consultants

REFERENCES

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.
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.
American Academy of Pediatrics, Committee on School Health. 2003. Policy statement: Out-of-school suspension and expulsion. Pediatrics 112:1206-9.
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.
Gilliam, W. S., G. Shahar. 2006. Preschool and child care expulsion and suspension: Rates and predictors in one state. Infants Young Children 19:228-45.
Gilliam, W. S. 2005. Prekindergarteners left behind: Expulsion rates in state prekindergarten programs. Foundation for Child Development (FCD). Policy Brief Series no. 3. New York: FCD. http://www.challengingbehavior.org/explore/policy_docs/prek
_expulsion.pdf.
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.
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.
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.
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/.
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.

NOTES

COVID-19 modification as of May 21, 2021

Standard 1.6.0.4: Early Childhood Education Consultants

A facility should engage an early childhood education consultant who will visit the program at minimum semi-annually and more often as needed. The consultant must have a minimum of a Baccalaureate degree and preferably a Master's degree from an accredited institution in early childhood education, administration and supervision, and a minimum of three years in teaching and administration of an early care/education program. The facility should develop a written plan for this consultation which must be signed annually by the consultant. This plan should outline the responsibilities of the consultant and the services the consultant will provide to the program.

The knowledge base of an early childhood education consultant should include:

Working knowledge of theories of child development and learning for children from birth through eight years across domains, including socio-emotional development and family development;
Principles of health and wellness across the domains, including social and emotional wellness and approaches in the promotion of healthy development and resilience;
Current practices and materials available related to screening, assessment, curriculum, and measurement of child outcomes across the domains, including practices that aid in early identification and individualizing for a wide range of needs;
Resources that aid programs to support inclusion of children with diverse health and learning needs and families representing linguistic, cultural, and economic diversity of communities;
Methods of coaching, mentoring, and consulting that meet the unique learning styles of adults;
Familiarity with local, state, and national regulations, standards, and best practices related to early education and care;
Community resources and services to identify and serve families and children at risk, including those related to child abuse and neglect and parent education;
Consultation skills as well as approaches to working as a team with early childhood consultants from other disciplines, especially child care health consultants, to effectively support program directors and their staff.

The role of the early childhood education consultant should include:

Review of the curriculum and written policies, plans and procedures of the program;
Observations of the program and meetings with the director, caregivers/teachers, and parents/guardians;
Review of the professional needs of staff and program and provision of recommendations of current resources;
Reviewing and assisting directors in implementing and monitoring evidence based approaches to classroom management;
Maintaining confidences and following all Family Educational Rights and Privacy Act (FERPA) regulations regarding disclosures;
Keeping records of all meetings, consultations, recommendations and action plans and offering/providing summary reports to all parties involved;
Seeking and supporting a multidisciplinary approach to services for the program, children and families;
Following the National Association for the Education of Young Children (NAEYC) Code of Ethics;
Availability by telecommunication to advise regarding practices and problems;
Availability for on-site visit to consult to the program;
Familiarity with tools to evaluate program quality, such as the Early Childhood Environment Rating Scale–Revised (ECERS–R), Infant/Toddler Environment Rating Scale–Revised (ITERS–R), Family Child Care Environment Rating Scale–Revised (FCCERS–R), School-Age Care Environment Rating Scale (SACERS), Classroom Assessment Scoring System (CLASS), as well as tools used to support various curricular approaches.

RATIONALE

The early childhood education consultant provides an objective assessment of a program and essential knowledge about implementation of child development principles through curriculum which supports the social and emotional health and learning of infants, toddlers and preschool age children (1-5). Furthermore, utilization of an early childhood education consultant can reduce the need for mental health consultation when challenging behaviors are the result of developmentally inappropriate curriculum (6,7). Together with the child care health consultant, the early childhood education consultant offers core knowledge for addressing children's healthy development.

TYPE OF FACILITY

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

RELATED STANDARDS

1.6.0.1 Child Care Health Consultants
1.6.0.3 Infant and Early Childhood Mental Health Consultants

REFERENCES

Connecticut Department of Public Health. Child day care licensing program. http://www.ct.gov/dph/cwp/view
.asp?a=3141&Q=387158&dphNav_GID=1823/.
The Connecticut Early Education Consultation Network. CEECN: Guidance, leadership, support. http://ctconsultationnetwork.org.
Bredekamp, S., C. Copple, eds. 2000. Developmentally appropriate practice in early childhood programs serving children from birth through age 8. Rev ed. National Association for the Education of Young Children (NAEYC). Publication no. 234. Washington, DC: NAEYC. http://www.naeyc.org/files/naeyc/file/positions/position statement Web.pdf.
Wesley, P. W., V. Buysee. 2005. Consultation in early childhood settings. Baltimore, MD: Brookes Publishing.
Wesley, P. W., S. A. Palsha. 1998. Improving quality in early childhood environments through on-site consultation. Topics Early Childhood Special Ed 18:243-53.
Wesley, P. W., V. Buysse. 2006. Ethics and evidence in consultation. Topics Early Childhood Special Ed 26:131-41.
Dunn, L., K. Susan. 1997. What have we learned about developmentally appropriate practice? Young Children 52:4-13.

Standard 1.1.1.1: Ratios for Small Family Child Care Homes

COVID-19 modification as of September 21, 2021

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

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

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

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

COVID-19 modification as of September 21, 2021

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

Follow guidance from your state and local health department as well as your state licensing agency to make decisions on appropriate group sizes.
Keep the same group of children (cohort), and staff together each day.
Ensure that everyone two years old and older wears a well-fitted mask except when eating or sleeping.
Limit mixing between groups so there is minimal or no interaction between groups or cohorts.
The number of cohorts or groups may vary depending on child care program type (centers versus homes) and size, with smaller programs having fewer cohorts than larger ones.
Maintain at least 6 feet between children and staff from different cohorts.
Provide physical guides, such as wall signs or tape on floors, to help maintain distance between cohorts in common areas.
Stagger use of communal spaces between cohorts.

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

RATIONALE

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

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

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

COMMENTS

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

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

Unscheduled inspections encourage compliance with this standard.

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

NOTES

COVID-19 modification as of September 21, 2021

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

COVID-19 modification as of September 21, 2021

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

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

Large Family Child Care Homes

Age	Maximum Child:Staff Ratio	Maximum Group Size

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

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

Child Care Centers

Age	Maximum Child:Staff Ratio	Maximum Group Size

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

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

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

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

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

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

COVID-19 modification as of September 21, 2021

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

Follow guidance from your state and local health department as well as your state licensing agency to make decisions on appropriate group sizes.
Keep the same group of children (cohort), and staff together each day.
Ensure that everyone two years old and older wears a well-fitted mask except when eating or sleeping.
Limit mixing between groups so there is minimal or no interaction between groups or cohorts.
The number of cohorts or groups may vary depending on child care program type (centers versus homes) and size, with smaller programs having fewer cohorts than larger ones.
Maintain at least 6 feet between children and staff from different cohorts.
Provide physical guides, such as wall signs or tape on floors, to help maintain distance between cohorts in common areas.
Stagger use of communal spaces between cohorts.

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

RATIONALE

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

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

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

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

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

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

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

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

COMMENTS

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

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

Unscheduled inspections encourage compliance with this standard.

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

NOTES

COVID-19 modification as of September 21, 2021

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

COVID-19 modification as of September 21, 2021

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

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

COVID-19 modification as of September 21, 2021

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

Follow guidance from your state and local health department as well as your state licensing agency to make decisions on appropriate group sizes.
Keep the same group of children (cohort), and staff together each day.
Ensure that everyone two years old and older wears a well-fitted mask except when eating or sleeping.
Limit mixing between groups so there is minimal or no interaction between groups or cohorts.
The number of cohorts or groups may vary depending on child care program type (centers versus homes) and size, with smaller programs having fewer cohorts than larger ones.
Maintain at least 6 feet between children and staff from different cohorts.
Provide physical guides, such as wall signs or tape on floors, to help maintain distance between cohorts in common areas.
Stagger use of communal spaces between cohorts.

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

RATIONALE

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

COMMENTS

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

NOTES

COVID-19 modification as of September 21, 2021

Standard 1.1.1.4: Ratios and Supervision During Transportation

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

RATIONALE

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

TYPE OF FACILITY

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

RELATED STANDARDS

5.6.0.1 First Aid and Emergency Supplies

REFERENCES

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

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

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

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

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

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

RATIONALE

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

COMMENTS

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

Standard 2.2.0.1: Methods of Supervision of Children

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

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

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

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

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

6. Engage and Redirect

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

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

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

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

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

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

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

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

RATIONALE

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

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

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

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

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

COMMENTS

TYPE OF FACILITY

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

RELATED STANDARDS

REFERENCES

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

NOTES

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

Standard 2.2.0.4: Supervision Near Bodies of Water

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

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

RATIONALE

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

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

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

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

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

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

The American Academy of Pediatrics (AAP) recommends:

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

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

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

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

COMMENTS

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

Standard 4.5.0.6: Adult Supervision of Children Who Are Learning to Feed Themselves

Children in mid-infancy who are learning to feed themselves should be supervised by an adult seated within arm's reach of them at all times while they are being fed. Children over twelve months of age who can feed themselves should be supervised by an adult who is seated at the same table or within arm's reach of the child's highchair or feeding table. When eating, children should be within sight of an adult at all times.

RATIONALE

A supervising adult should watch for several common problems that typically occur when children in mid-infancy begin to feed themselves. "Squirreling" of several pieces of food in the mouth increases the likelihood of choking. A choking child may not make any noise, so adults must keep their eyes on children who are eating. Active supervision is imperative. Supervised eating also promotes the child's safety by discouraging activities that can lead to choking (1). For best practice, children of all ages should be supervised when eating. Adults can monitor age-appropriate portion size consumption.

COMMENTS

Adults can help children while they are learning, by modeling active chewing (i.e., eating a small piece of food, showing how to use their teeth to bite it) and making positive comments to encourage children while they are eating. Adults can demonstrate how to eat foods on the menu, how to serve food, and how to ask for more food as a way of helping children learn the names of foods (e.g., "please pass the bowl of noodles").

TYPE OF FACILITY

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

RELATED STANDARDS

4.3.2.3 Encouraging Self-Feeding by Older Infants and Toddlers
4.5.0.4 Socialization During Meals
4.5.0.5 Numbers of Children Fed Simultaneously by One Adult

REFERENCES

American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement: Prevention of choking among children. Pediatrics 125:601-7.

Staff Qualifications and Training

Standard 1.2.0.2: Background Screening

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

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

The background screening should include (1-4).

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

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

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

RATIONALE

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

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

COMMENTS

The following resources can help the director screen individual applicants:

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

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

TYPE OF FACILITY

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

REFERENCES

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

NOTES

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

Standard 1.3.1.1: General Qualifications of Directors

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

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

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

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

RATIONALE

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

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

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

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

COMMENTS

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

Standard 1.3.2.2: Qualifications of Lead Teachers and Teachers

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

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

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

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

RATIONALE

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

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

COMMENTS

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

Standard 1.3.2.3: Qualifications for Assistant Teachers, Teacher Aides, and Volunteers

Assistant teachers and teacher aides should be at least eighteen years of age, have a high school diploma or GED, and participate in on-the-job training, including a structured orientation to the developmental needs of young children and access to consultation, with periodic review, by a supervisory staff member. At least 50% of all assistant teachers and teacher aides must have or be working on either a Child Development Associate (CDA) credential or equivalent, or an associate's or higher degree in early childhood education/child development or equivalent (9).

Volunteers should be at least sixteen years of age and should participate in on-the-job training, including a structured orientation to the developmental needs of young children. Assistant teachers, teacher aides, and volunteers should work only under the continual supervision of lead teacher or teacher. Assistant teachers, teacher aides, and volunteers should never be left alone with children. Volunteers should not be counted in the child:staff ratio.

All assistant teachers, teacher aides, and volunteers should possess:

The ability to carry out assigned tasks competently under the supervision of another staff member;
An understanding of and the ability to respond appropriately to children's needs;
Sound judgment;
Emotional maturity; and
Clearly discernible affection for and commitment to the well-being of children.

RATIONALE

While volunteers and students can be as young as sixteen, age eighteen is the earliest age of legal consent. Mature leadership is clearly preferable. Age twenty-one allows for the maturity necessary to meet the responsibilities of managing a center or independently caring for a group of children who are not one's own.

Child care that promotes healthy development is based on the developmental needs of infants, toddlers, preschool, and school-age children. Caregivers/teachers should be chosen for their knowledge of, and ability to respond appropriately to, the general needs of children of this age and the unique characteristics of individual children (1,3-5).

Staff training in child development and/or early childhood education is related to positive outcomes for children. This training enables the staff to provide children with a variety of learning and social experiences appropriate to the age of the child. Everyone providing service to, or interacting with, children in a center contributes to the child's total experience (8).

Adequate compensation for skilled workers will not be given priority until the skills required are recognized and valued. Teaching and caregiving requires skills to promote development and learning by children whose needs and abilities change at a rapid rate.

COMMENTS

Experience and qualifications used by the Child Development Associate (CDA) program and the National Child Care Association (NCCA) credentialing program, and included in degree programs with field placement are valued (10). Early childhood professional knowledge must be required whether programs are in private homes, centers, public schools, or other settings. Go to http://www
.cdacouncil.org/the-cda-credential/how-to-earn-a-cda/ to view appropriate training and qualification information on the CDA Credential.

TYPE OF FACILITY

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

RELATED STANDARDS

6.5.1.2 Qualifications for Drivers

REFERENCES

U.S. Department of Justice. 2011. Americans with Disabilities Act. http://www.ada.gov.
National Association for Family Child Care (NAFCC). NAFCC official Website. http://nafcc.net.
National Child Care Association (NCCA). NCCA official Website. http://www.nccanet.org.
Council for Professional Recognition. 2011. How to obtain a CDA. http://www.cdacouncil.org/the-cda-credential/
how-to-earn-a-cda/.
National Association for the Education of Young Children (NAEYC). Candidacy requirements. http://www.naeyc.org/academy/pursuing/candreq/.
Da Ros-Voseles, D., S. Fowler-Haughey. 2007. Why children's dispositions should matter to all teachers. Young Children (September): 1-7. http://www.naeyc.org/files/yc/file/200709/
DaRos-Voseles.pdf.
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.
National Association for the Education of Young Children (NAEYC). 2009. Developmentally appropriate practice in early childhood programs serving children from birth through age 8. Washington, DC: NAEYC. http://www.naeyc.org/files/naeyc/file/positions/position statement Web.pdf.
National Association for the Education of Young Children (NAEYC). 2005. Accreditation and criteria procedures of the National Academy of Early Childhood Programs. Washington, DC: NAEYC.
National Institute of Child Health and Human Development (NICHD) Early Child Care Research Network. 1996. Characteristics of infant child care: Factors contributing to positive caregiving. Early Child Res Q 11:269-306.

Standard 1.3.2.4: Additional Qualifications for Caregivers/Teachers Serving Children Birth to Thirty-Five Months of Age

Caregivers/teachers should be prepared to work with infants and toddlers and, when asked, should be knowledgeable and demonstrate competency in tasks associated with caring for infants and toddlers:

Diapering and toileting;
Bathing;
Feeding, including support for continuation of breastfeeding;
Holding;
Comforting;
Practicing safe sleep practices to reduce the risk of Sudden Infant Death Syndrome (SIDS) (3);
Providing warm, consistent, responsive caregiving and opportunities for child-initiated activities;
Stimulating communication and language development and pre-literacy skills through play, shared reading, song, rhyme, and lots of talking;
Promoting cognitive, physical, and social emotional development;
Preventing shaken baby syndrome/abusive head trauma;
Promoting infant mental health;
Promoting positive behaviors;
Setting age-appropriate limits with respect to safety, health, and mutual respect;
Using routines to teach children what to expect from caregivers/teachers and what caregivers/teachers expect from them.

Caregivers/teachers should demonstrate knowledge of development of infants and toddlers as well as knowledge of indicators that a child is not developing typically; knowledge of the importance of attachment for infants and toddlers, the importance of communication and language development, and the importance of nurturing consistent relationships on fostering positive self-efficacy development.

To help manage atypical or undesirable behaviors of children, caregivers/teachers, in collaboration with parents/guardians, should seek professional consultation from the child's primary care provider, an early childhood mental health professional, or an early childhood mental health consultant.

RATIONALE

The brain development of infants is particularly sensitive to the quality and consistency of interpersonal relationships. Much of the stimulation for brain development comes from the responsive interactions of caregivers/teachers and children during daily routines. Children need to be allowed to pursue their interests within safe limits and to be encouraged to reach for new skills (1-7).

COMMENTS

Since early childhood mental health professionals are not always available to help with the management of challenging behaviors in the early care and education setting early childhood mental health consultants may be able to help. The consultant should be viewed as an important part of the program's support staff and should collaborate with all regular classroom staff, consultants, and other staff. Qualified potential consultants may be identified by contacting mental health and behavioral providers in the local area, as well as accessing the National Mental Health Information Center (NMHIC) at http://store.samhsa.gov/
mhlocator/ and Healthy Child Care America (HCCA) at http://www.healthychildcare.org/Contacts.html.

TYPE OF FACILITY

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

RELATED STANDARDS

1.6.0.3 Infant and Early Childhood Mental Health Consultants
1.3.1.1 General Qualifications of Directors
1.3.2.2 Qualifications of Lead Teachers and Teachers
1.3.2.3 Qualifications for Assistant Teachers, Teacher Aides, and Volunteers
1.3.1.2 Mixed Director/Teacher Role
1.4.2.1 Initial Orientation of All Staff
1.4.2.2 Orientation for Care of Children with Special Health Care Needs
1.4.2.3 Orientation Topics
1.4.3.1 First Aid and Cardiopulmonary Resuscitation Training for Staff
1.4.3.2 Topics Covered in Pediatric First Aid Training
1.4.3.3 Cardiopulmonary Resuscitation Training for Swimming and Water Play
1.4.4.1 Continuing Education for Directors and Caregivers/Teachers in Centers and Large Family Child Care Homes
1.4.4.2 Continuing Education for Small Family Child Care Home Caregivers/Teachers
1.4.5.1 Training of Staff Who Handle Food
1.4.5.2 Child Abuse and Neglect Education
1.4.5.3 Training on Occupational Risk Related to Handling Body Fluids
1.4.5.4 Education of Center Staff
1.4.6.1 Training Time and Professional Development Leave
1.4.6.2 Payment for Continuing Education
3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
4.3.1.1 General Plan for Feeding Infants
4.3.1.2 Feeding Infants on Cue by a Consistent Caregiver/Teacher
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.1.4 Feeding Human Milk to Another Mother's Child
4.3.1.5 Preparing, Feeding, and Storing Infant Formula
4.3.1.6 Use of Soy-Based Formula and Soy Milk
4.3.1.7 Feeding Cow's Milk
4.3.1.8 Techniques for Bottle Feeding
4.3.1.9 Warming Bottles and Infant Foods
4.3.1.10 Cleaning and Sanitizing Equipment Used for Bottle Feeding
4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants
4.3.1.12 Feeding Age-Appropriate Solid Foods to Infants

REFERENCES

Centers for Disease Control and Prevention. Learn the signs. Act early. http://www.cdc.gov/ncbddd/actearly/.
Cohen, J., N. Onunaku, S. Clothier, J. Poppe. 2005. Helping young children succeed: Strategies to promote early childhood social and emotional development. Washington, DC: National Conference of State Legislatures; Zero to Three. http://main.zerotothree.org/site/DocServer/help_yng_child_succeed.pdf.
Shonkoff, J. P., D. A. Phillips, eds. 2000. From neurons to neighborhoods: The science of early childhood development. Washington, DC: National Academy Press.
Shore, R. 1997. Rethinking the brain: New insights into early development. New York: Families and Work Inst.
Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.
Moon, R. Y., T. Calabrese, L. Aird. 2008. Reducing the risk of sudden infant death syndrome in child care and changing provider practices: Lessons learned from a demonstration project. Pediatrics 122:788-98.
National Forum on Early Childhood Policy and Programs, 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. http://developingchild.harvard.edu/index.php/library/reports_and_working_papers/policy_framework/.

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:

Control of infectious diseases, including Standard Precautions, hand hygiene, cough and sneeze etiquette, and reporting requirements;
Childhood immunization requirements, record-keeping, and at least quarterly review and follow-up for children who need to have updated immunizations;
Child health assessment form review and follow-up of children who need further medical assessment or updating of their information;
How to plan for, recognize, and handle an emergency;
Poison awareness and poison safety;
Recognition of safety, hazards, and injury prevention interventions;
Safe sleep practices and the reduction of the risk of Sudden Infant Death Syndrome (SIDS);
How to help parents/guardians, caregivers/teachers, and children cope with death, severe injury, and natural or man-made catastrophes;
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;
Facilitate collaboration with families, primary care providers, and other health service providers to create a health, developmental, or behavioral care plan;
Implementing care plans;
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;
Medication administration;
Recognizing and understanding the needs of children with serious behavior and mental health problems;
Maintaining confidentiality;
Healthy nutritional choices;
The promotion of developmentally appropriate types and amounts of physical activity;
How to work collaboratively with parents/guardians and family members;
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;
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).

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).

TYPE OF FACILITY

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

RELATED STANDARDS

1.6.0.1 Child Care Health Consultants
1.3.1.1 General Qualifications of Directors
1.3.2.2 Qualifications of Lead Teachers and Teachers
1.3.2.3 Qualifications for Assistant Teachers, Teacher Aides, and Volunteers
1.3.1.2 Mixed Director/Teacher Role
1.3.2.1 Differentiated Roles
1.4.2.1 Initial Orientation of All Staff
1.4.2.2 Orientation for Care of Children with Special Health Care Needs
1.4.2.3 Orientation Topics
1.4.3.1 First Aid and Cardiopulmonary Resuscitation Training for Staff
1.4.3.2 Topics Covered in Pediatric First Aid Training
1.4.3.3 Cardiopulmonary Resuscitation Training for Swimming and Water Play
1.4.4.1 Continuing Education for Directors and Caregivers/Teachers in Centers and Large Family Child Care Homes
1.4.4.2 Continuing Education for Small Family Child Care Home Caregivers/Teachers
1.4.5.1 Training of Staff Who Handle Food
1.4.5.2 Child Abuse and Neglect Education
1.4.5.3 Training on Occupational Risk Related to Handling Body Fluids
1.4.5.4 Education of Center Staff
1.4.6.1 Training Time and Professional Development Leave
1.4.6.2 Payment for Continuing Education
3.1.2.1 Routine Health Supervision and Growth Monitoring
3.1.3.1 Active Opportunities for Physical Activity
3.1.3.2 Playing Outdoors
3.1.3.3 Protection from Air Pollution While Children Are Outside
3.1.3.4 Caregivers'/Teachers' Encouragement of Physical Activity
8.7.0.3 Review of Plan for Serving Children with Disabilities or Children with Special Health Care Needs
7.2.0.1 Immunization Documentation
7.2.0.2 Unimmunized Children

REFERENCES

Hagan, J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Bright futures: Guidelines for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics.
Centers for Disease Control and Prevention (CDC). 2011. Immunization schedules. http://www.cdc.gov/vaccines/recs/schedules/.
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.
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.
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.
Ulione, M. S. 1997. Health promotion and injury prevention in a child development center. J Pediatr Nurs 12:148-54.

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

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

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

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

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

RATIONALE

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

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

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

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

COMMENTS

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

Standard 1.4.1.1: Pre-service Training

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

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

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

RATIONALE

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

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

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

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

COMMENTS

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

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

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

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

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

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

RATIONALE

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

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

COMMENTS

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

Standard 1.4.2.3: Orientation Topics

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

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

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

RATIONALE

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

Standard 1.4.3.1: First Aid and Cardiopulmonary Resuscitation Training for Staff

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

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

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

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

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

RATIONALE

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

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

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

COMMENTS

Additional Resources:

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

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

NOTES

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

Standard 1.4.5.2: Child Abuse and Neglect Education

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

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

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

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

RATIONALE

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

COMMENTS

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

TYPE OF FACILITY

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

RELATED STANDARDS

3.4.4.1 Recognizing and Reporting Suspected Child Abuse, Neglect, and Exploitation
3.4.4.2 Immunity for Reporters of Child Abuse and Neglect
3.4.4.3 Preventing and Identifying Shaken Baby Syndrome/Abusive Head Trauma
3.4.4.4 Care for Children Who Have Experienced Abuse/Neglect
3.4.4.5 Facility Layout to Reduce Risk of Child Abuse and Neglect
9.2.1.1 Content of Policies
9.4.3.3 Training Record
2.2.0.9 Prohibited Caregiver/Teacher Behaviors
2.4.2.1 Health and Safety Education Topics for Staff

REFERENCES

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

NOTES

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

Standard 1.5.0.2: Orientation of Substitutes

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

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

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

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

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

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

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

1. Hand hygiene techniques, including indications for hand hygiene

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

3. Preventing shaken baby syndrome/abusive head trauma

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

5. Early brain development and its vulnerabilities

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

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

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

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

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

_h. Emergency plans and practices

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

RATIONALE

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

NOTES

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

Standard 7.4.0.2: Staff Education and Policies on Enteric (Diarrheal) and Hepatitis A Virus (HAV) Infections

Content in the STANDARD was modified on 4/5/2017.

To prevent and control infections of the gastrointestinal tract (mainly diarrhea) and hepatitis A, facilities should follow these guidelines, conduct staff education, and follow policies:

a. The facility should conduct continuing education for staff members to address:

1. Methods of germ transmission that cause diarrhea and hepatitis A;
2. Symptoms of diarrhea and disease associated with hepatitis A virus (HAV) infection; and
3. Prevention of diarrhea and disease associated with hepatitis A virus (HAV) infection.

b. All caregivers/teachers, food handlers, and maintenance staff should receive continuing education and monitoring concerning hand hygiene and cleaning of environmental surfaces as specified in the facility's plan.

c. At least annually, the director should review all procedures related to preventing diarrhea and HAV infections. Each caregiver/teacher, food handler, and maintenance person should review a written copy of these procedures or view a video, which should include age-specific criteria for inclusion and exclusion of children who have a diarrheal illness or HAV infection and infection control procedures.

d. Guidelines for administration of immunization against HAV should be enforced to prevent infection in contacts of children and adults with hepatitis A disease (1,2).

RATIONALE

Routine immunization of infants with rotavirus vaccine (3) and of toddlers and older children with hepatitis A vaccine has decreased rates of these diseases in child care centers (4,5). In addition, staff training in hygiene and monitoring of staff compliance reduces the spread of diarrhea (1).
Caregivers/teachers should observe children for signs of disease to identify early detection and implement of control measures. Facilities should consult the local health department to determine whether the increased frequency of diarrheal illness requires public health intervention.

COMMENTS

Hepatitis A vaccine is not recommended for routine administration to caregivers/teachers but it can be administered to any person seeking protection from HAV (2). Caregivers/teachers should be informed of the availability of hepatitis A vaccine.
Hepatitis A vaccine is recommended for all children beginning at twelve months of age (6). Unimmunized infants and toddlers can develop HAV. They are usually asymptomatic or mildly ill and can easily transmit infection to susceptible adults who often develop signs and symptoms of disease including jaundice and who may become seriously ill.
For additional information regarding enteric (diarrheal) and HAV infections, consult the current edition of the Red Bookfrom the American Academy of Pediatrics (AAP).

TYPE OF FACILITY

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

RELATED STANDARDS

3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.2.2.3 Assisting Children with Hand Hygiene
3.2.2.4 Training and Monitoring for Hand Hygiene
3.2.2.5 Hand Sanitizers
3.3.0.1 Routine Cleaning, Sanitizing, and Disinfecting
3.3.0.2 Cleaning and Sanitizing Toys
3.3.0.3 Cleaning and Sanitizing Objects Intended for the Mouth
3.3.0.4 Cleaning Individual Bedding
3.3.0.5 Cleaning Crib Surfaces
3.6.1.1 Inclusion/Exclusion/Dismissal of Children
3.6.1.2 Staff Exclusion for Illness
3.6.1.3 Thermometers for Taking Human Temperatures
3.6.1.4 Infectious Disease Outbreak Control
7.4.0.1 Control of Enteric (Diarrheal) and Hepatitis A Virus (HAV) Infections
Appendix G: Recommended Childhood Immunization Schedule
Appendix H: Recommended Adult Immunization Schedule

REFERENCES

Centers for Disease Control and Prevention. 2009. Prevention of rotavirus gastroenteritis among infants and children.MMWR 58 (RR02). http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5802a1.htm.
Centers for Disease Control and Prevention. 2006. Prevention of hepatitis A through active or passive immunization.MMWR55 (RR07). http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5507a1.htm.
American Academy of Pediatrics, Committee on Infectious Diseases. 2007. Policy statement: Hepatitis A vaccine recommendations.Pediatrics 120:189-99.
Centers for Disease Control and Prevention. 2016. Hepatitis A questions and answers for the public. https://www.cdc.gov/hepatitis/hav/afaq.htm#overview.
ADDITIONAL REFERENCE:
Centers for Disease Control and Prevention. 2016. Viral hepatitis - Hepatitis A information. https://www.cdc.gov/hepatitis/hav/havfaq.htm#B1.
Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4^th Edition. Elk Grove Village, IL: American Academy of Pediatrics.
American Academy of Pediatrics. School Health In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases . 31st Edition. Itasca, IL: American Academy of Pediatrics; 2018: 138-146
American Academy of Pediatrics. Hepatitis A Virus (HAV) In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases . 31st Edition. Itasca, IL: American Academy of Pediatrics; 2018: 392-400

NOTES

Content in the STANDARD was modified on 4/5/2017.

Standard 7.7.1.1: Staff Education and Policies on Cytomegalovirus (CMV)

Content in the STANDARD was modified on 3/31/17.

Cytomegalovirus (CMV) is a viral infection that is common in children. Up to 70% of children ages 1 to 3 years in group care settings excrete the virus (1).
Staff of childbearing age who care for infants and children should be provided the following information:

The increased probability of exposure to cytomegalovirus (CMV) in the child care setting;
The potential for fetal damage when CMV is acquired during pregnancy;
The importance of hand hygiene measures (especially handwashing and avoiding contact with urine, saliva, and nasal secretions) to lower the risk of CMV;
The availability of counseling and testing for serum antibody to CMV to determine the caregiver/teacher's immune status.

Female employees of childbearing age should be referred to their primary health care provider or to the health department authority for counseling about their risk of CMV infection. This counseling may include testing for serum antibodies to CMV to determine the employee's immunity against CMV infection.
Since saliva can transmit CMV, staff should be advised not to share cups or eating utensils, kiss children on the lips, or allow children to put their fingers or hands in another person's mouth.

RATIONALE

CMV is the leading cause of congenital infection in the United State and approximately 1% of live born infants are infected prenatally (1). While most infected fetuses likely escape resulting illness or disability, 10% to 20% may have hearing loss, developmental delay, cerebral palsy, or vision disturbances (1). Although maternal immunity does not entirely prevent congenital CMV infection, evidence indicates that acquisition of CMV during pregnancy (primary maternal infection) carries the greatest risk for resulting illness or disability of the fetus (2).

Children enrolled in child care facilities are more likely to acquire CMV than are children cared for at home (2). Epidemiologic data, as well as laboratory testing of viral strains, has provided evidence for child-to-child transmission of CMV in the child care setting (1). Rates of CMV excretion vary among facilities and between class groups within a facility. Children between one and three years of age have the highest rates of excretion; published studies report excretion rates between 30% and 40% (2). Many children excrete CMV asymptomatically and intermittently for years.

With regard to child-to-staff transmission, studies have shown increased rates of infection with CMV in caregivers/teachers ranging from 8% to 20% (2). The increased risk for exposure to CMV and high rates of acquisition of CMV in caregivers/teachers could lead to increased rates of congenital CMV infection. Meticulous hand hygiene can reduce the rates of infection by preventing CMV transmission. With current knowledge on the risk of CMV infection in child care staff members and the potential consequences of gestational CMV infection, child care staff members should receive counseling in regard to the risks of acquiring CMV from their primary health care provider. However, it is also important for the child care center director to inform infant caregivers/teachers of the increased risk of exposure to CMV during pregnancy (1).

COMMENTS

TYPE OF FACILITY

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

RELATED STANDARDS

3.6.1.1 Inclusion/Exclusion/Dismissal of Children

REFERENCES

Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4^th Edition.Elk Grove Village, IL: American Academy of Pediatrics.
American Academy of Pediatrics. Cytomegalovirus (CMV) Infection In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases . 31st Edition. Itasca, IL: American Academy of Pediatrics; 2018: 310-317

NOTES

Content in the STANDARD was modified on 3/31/17.

Consultants

Standard 1.6.0.1: Child Care Health Consultants

COVID-19 modification as of May 21, 2021

*STANDARD UNDERGOING FULL REVISION*

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

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

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

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

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

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

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

COVID-19 modification as of May 21, 2021

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

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

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

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

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

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

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

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

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

Additional Resources:

Centers for Disease Control and Prevention.COVID-19 Vaccine Toolkit for School Settings and Childcare Programs American Academy of Pediatrics.Guidance Related to Childcare During COVID-19

RATIONALE

COMMENTS

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

NOTES

COVID-19 modification as of May 21, 2021

Standard 1.6.0.2: Frequency of Child Care Health Consultation Visits

Content in the STANDARD was modified on 8/22/2013.

RATIONALE

COMMENTS

TYPE OF FACILITY

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

RELATED STANDARDS

REFERENCES

National Resource Center for Health and Safety in Child Care and Early Education. 2010. Child care health consultant requirements and profiles by state. http://nrckids.org/default/assets/File/CCHC%20by%20state%20NOV%202012_FINAL.pdf.
Crowley, A. A. & Rosenthal, M. S. IMPACT: Ensuring the health and safety of Connecticut's early care and education programs. 2009. Farmington, CT: The Child Health and Development Institute of Connecticut.
Isbell P, Kotch JB, Savage E, Gunn E, Lu LS, Weber DJ. Improvement of child care programs' policies, practices, and children's access to health care linked to child care health consultation. NHSA Dialog: A Research to Practice Journal 2013;16 (2):34-52 (ISSN:1930-1395).
Bryant, D. "Quality Interventions for Early Care and Education." Early Developments, Spring 2013, http://fpg.unc.edu/sites/default/files/resources/early-developments/FPG_EarlyDevelopments_v14n1.pdf.
Benjamin, S. E., A. Ammerman, J. Sommers, J. Dodds, B. Neelon, D. S. Ward. 2007. Nutrition and physical activity self-assessment for child care (NAP SACC): Results from a pilot intervention. Journal of Nutrition Education and Behavior 39(3):142-9.
Nurse Consultant Intervention Improves Nutrition and Physical Activity Knowledge, Policy, and Practice and Reduces Obesity in Child Care. A. Crowley, A. Alkon, B Neelon, S. Hill, P. Yi, E. Savage, V. Ngyuen, J. Kotch. Head Start Research Conference, Washington, DC. June 20, 2012.
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.
Crowley, A. A. & Kulikowich, J. Impact of training on child care health consultant knowledge and practice. Pediatric Nursing.,2009, 35 (2): 93-100.
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.
Healthy Child Care Consultant Network Support Center, CHT Resource Group. 2006. The influence of child care health consultants in promoting children's health and well-being: A report on selected resources. http://hcccnsc.jsi.com/resources/publications/CC_lit_review_Screen_All.pdf.
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.
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 Nursing 32:530-37.
Crowley, A. A. 2000. Child care health consultation: The Connecticut experience. Maternal Child Health J 4:67-75.

NOTES

Content in the STANDARD was modified on 8/22/2013.

Standard 1.6.0.3: Infant and Early Childhood Mental Health Consultants

COVID-19 modification as of May 21, 2021

*STANDARD UNDERGOING FULL REVISION*

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

The knowledge base of an IECMHC should include:

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

Developing and implementing classroom curricula regarding conflict resolution, emotional regulation, and social skills development;
Developing and implementing appropriate screening and referral mechanisms for behavioral and mental health needs;
Forming relationships with mental health providers and special education systems in the community;
Providing mental health services, resources and/or referral systems for families and staff;
Helping staff facilitate and maintain mentally healthy environments within the classroom and overall system;
Helping address mental health needs and reduce job stress within the staff;
Improving management of children with challenging behaviors;
Preventing the development of problem behaviors;
Providing a classroom climate that promotes positive social-emotional development;
Recognizing and appropriately responding to the needs of children with internalizing behaviors, such as persistent sadness, anxiety, and social withdrawal;
Actively teaching developmentally appropriate social skills, conflict resolution, and emotional regulation;
Addressing the mental health needs and daily stresses of those who care for young children, such as families and caregivers/teachers;
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.

COVID-19 modification as of May 21, 2021

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

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

Changes in families routines (e.g., physical distance from family, friends, worship community)
Disrupted learning environments (e.g., virtual learning environments, technology access)
Disrupted health care access (e.g., missed well-child and immunization visits, limited access to mental, speech, and occupational health services)
Missed significant life events (e.g., important events/celebrations, vacation plans, and/or milestones)
Lost security and safety (e.g., food insecurity and housing, increased exposure to violence and online harms, threat of physical illness and future uncertainty)

Refer to the Centers for Disease Control and Prevention's COVID-19 Parental Resources Kit:

Ensuring Children and Young People's Social, Emotional, and Mental Well-being to support children and families with these challenges.

Use IECMHCs to deliver:

Individual and group staff consultation to guide their work with children and families
Child and family consultation and connect to resources and services as needed
Timely staff trainings virtually
Consider alternatives to IECMHCs onsite consultation and schedule other methods for delivering services:
Use Virtual video visits or phone to review child social and emotional health needs, address health and safety issues and any training needs
Plan outdoor visits, if weather allows, using face mask and physical distancing

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

Additional Resources:

RATIONALE

COMMENTS

TYPE OF FACILITY

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

RELATED STANDARDS

1.6.0.1 Child Care Health Consultants
1.6.0.4 Early Childhood Education Consultants

REFERENCES

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.
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.
American Academy of Pediatrics, Committee on School Health. 2003. Policy statement: Out-of-school suspension and expulsion. Pediatrics 112:1206-9.
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.
Gilliam, W. S., G. Shahar. 2006. Preschool and child care expulsion and suspension: Rates and predictors in one state. Infants Young Children 19:228-45.
Gilliam, W. S. 2005. Prekindergarteners left behind: Expulsion rates in state prekindergarten programs. Foundation for Child Development (FCD). Policy Brief Series no. 3. New York: FCD. http://www.challengingbehavior.org/explore/policy_docs/prek
_expulsion.pdf.
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.
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.
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.
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/.
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.

NOTES

COVID-19 modification as of May 21, 2021

Standard 1.6.0.4: Early Childhood Education Consultants

The knowledge base of an early childhood education consultant should include:

Working knowledge of theories of child development and learning for children from birth through eight years across domains, including socio-emotional development and family development;
Principles of health and wellness across the domains, including social and emotional wellness and approaches in the promotion of healthy development and resilience;
Current practices and materials available related to screening, assessment, curriculum, and measurement of child outcomes across the domains, including practices that aid in early identification and individualizing for a wide range of needs;
Resources that aid programs to support inclusion of children with diverse health and learning needs and families representing linguistic, cultural, and economic diversity of communities;
Methods of coaching, mentoring, and consulting that meet the unique learning styles of adults;
Familiarity with local, state, and national regulations, standards, and best practices related to early education and care;
Community resources and services to identify and serve families and children at risk, including those related to child abuse and neglect and parent education;
Consultation skills as well as approaches to working as a team with early childhood consultants from other disciplines, especially child care health consultants, to effectively support program directors and their staff.

The role of the early childhood education consultant should include:

Review of the curriculum and written policies, plans and procedures of the program;
Observations of the program and meetings with the director, caregivers/teachers, and parents/guardians;
Review of the professional needs of staff and program and provision of recommendations of current resources;
Reviewing and assisting directors in implementing and monitoring evidence based approaches to classroom management;
Maintaining confidences and following all Family Educational Rights and Privacy Act (FERPA) regulations regarding disclosures;
Keeping records of all meetings, consultations, recommendations and action plans and offering/providing summary reports to all parties involved;
Seeking and supporting a multidisciplinary approach to services for the program, children and families;
Following the National Association for the Education of Young Children (NAEYC) Code of Ethics;
Availability by telecommunication to advise regarding practices and problems;
Availability for on-site visit to consult to the program;
Familiarity with tools to evaluate program quality, such as the Early Childhood Environment Rating Scale–Revised (ECERS–R), Infant/Toddler Environment Rating Scale–Revised (ITERS–R), Family Child Care Environment Rating Scale–Revised (FCCERS–R), School-Age Care Environment Rating Scale (SACERS), Classroom Assessment Scoring System (CLASS), as well as tools used to support various curricular approaches.

RATIONALE

TYPE OF FACILITY

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

RELATED STANDARDS

1.6.0.1 Child Care Health Consultants
1.6.0.3 Infant and Early Childhood Mental Health Consultants

REFERENCES

Connecticut Department of Public Health. Child day care licensing program. http://www.ct.gov/dph/cwp/view
.asp?a=3141&Q=387158&dphNav_GID=1823/.
The Connecticut Early Education Consultation Network. CEECN: Guidance, leadership, support. http://ctconsultationnetwork.org.
Bredekamp, S., C. Copple, eds. 2000. Developmentally appropriate practice in early childhood programs serving children from birth through age 8. Rev ed. National Association for the Education of Young Children (NAEYC). Publication no. 234. Washington, DC: NAEYC. http://www.naeyc.org/files/naeyc/file/positions/position statement Web.pdf.
Wesley, P. W., V. Buysee. 2005. Consultation in early childhood settings. Baltimore, MD: Brookes Publishing.
Wesley, P. W., S. A. Palsha. 1998. Improving quality in early childhood environments through on-site consultation. Topics Early Childhood Special Ed 18:243-53.
Wesley, P. W., V. Buysse. 2006. Ethics and evidence in consultation. Topics Early Childhood Special Ed 26:131-41.
Dunn, L., K. Susan. 1997. What have we learned about developmentally appropriate practice? Young Children 52:4-13.

Supervision

Standard 1.1.1.1: Ratios for Small Family Child Care Homes

COVID-19 modification as of September 21, 2021

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

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

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

COVID-19 modification as of September 21, 2021

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

Follow guidance from your state and local health department as well as your state licensing agency to make decisions on appropriate group sizes.
Keep the same group of children (cohort), and staff together each day.
Ensure that everyone two years old and older wears a well-fitted mask except when eating or sleeping.
Limit mixing between groups so there is minimal or no interaction between groups or cohorts.
The number of cohorts or groups may vary depending on child care program type (centers versus homes) and size, with smaller programs having fewer cohorts than larger ones.
Maintain at least 6 feet between children and staff from different cohorts.
Provide physical guides, such as wall signs or tape on floors, to help maintain distance between cohorts in common areas.
Stagger use of communal spaces between cohorts.

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

RATIONALE

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

COMMENTS

Unscheduled inspections encourage compliance with this standard.

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

NOTES

COVID-19 modification as of September 21, 2021

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

COVID-19 modification as of September 21, 2021

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

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

Large Family Child Care Homes

Age	Maximum Child:Staff Ratio	Maximum Group Size

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

Child Care Centers

Age	Maximum Child:Staff Ratio	Maximum Group Size

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

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

COVID-19 modification as of September 21, 2021

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

Follow guidance from your state and local health department as well as your state licensing agency to make decisions on appropriate group sizes.
Keep the same group of children (cohort), and staff together each day.
Ensure that everyone two years old and older wears a well-fitted mask except when eating or sleeping.
Limit mixing between groups so there is minimal or no interaction between groups or cohorts.
The number of cohorts or groups may vary depending on child care program type (centers versus homes) and size, with smaller programs having fewer cohorts than larger ones.
Maintain at least 6 feet between children and staff from different cohorts.
Provide physical guides, such as wall signs or tape on floors, to help maintain distance between cohorts in common areas.
Stagger use of communal spaces between cohorts.

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

RATIONALE

COMMENTS

Unscheduled inspections encourage compliance with this standard.

TYPE OF FACILITY

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

RELATED STANDARDS

REFERENCES

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

NOTES

COVID-19 modification as of September 21, 2021

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

COVID-19 modification as of September 21, 2021

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

COVID-19 modification as of September 21, 2021

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

Follow guidance from your state and local health department as well as your state licensing agency to make decisions on appropriate group sizes.
Keep the same group of children (cohort), and staff together each day.
Ensure that everyone two years old and older wears a well-fitted mask except when eating or sleeping.
Limit mixing between groups so there is minimal or no interaction between groups or cohorts.
The number of cohorts or groups may vary depending on child care program type (centers versus homes) and size, with smaller programs having fewer cohorts than larger ones.
Maintain at least 6 feet between children and staff from different cohorts.
Provide physical guides, such as wall signs or tape on floors, to help maintain distance between cohorts in common areas.
Stagger use of communal spaces between cohorts.

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

RATIONALE

COMMENTS

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

NOTES

COVID-19 modification as of September 21, 2021

Standard 1.1.1.4: Ratios and Supervision During Transportation

RATIONALE

TYPE OF FACILITY

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

RELATED STANDARDS

5.6.0.1 First Aid and Emergency Supplies

REFERENCES

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

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

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

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

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

RATIONALE

COMMENTS

TYPE OF FACILITY

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

RELATED STANDARDS

REFERENCES

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

Standard 2.2.0.1: Methods of Supervision of Children

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

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

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

6. Engage and Redirect

RATIONALE

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

COMMENTS

TYPE OF FACILITY

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

RELATED STANDARDS

REFERENCES

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

NOTES

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

Standard 2.2.0.4: Supervision Near Bodies of Water

RATIONALE

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

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

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

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

The American Academy of Pediatrics (AAP) recommends:

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

COMMENTS

TYPE OF FACILITY

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

RELATED STANDARDS

REFERENCES

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

Standard 4.5.0.6: Adult Supervision of Children Who Are Learning to Feed Themselves

RATIONALE

COMMENTS

TYPE OF FACILITY

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

RELATED STANDARDS

4.3.2.3 Encouraging Self-Feeding by Older Infants and Toddlers
4.5.0.4 Socialization During Meals
4.5.0.5 Numbers of Children Fed Simultaneously by One Adult

REFERENCES

American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement: Prevention of choking among children. Pediatrics 125:601-7.

Environment and Equipment

Building and Environment: Inside and Outside

Standard 5.1.1.5: Assessment of the Environment at the Site Location

Frequently Asked Questions/CFOC Clarifications

Reference: 5.1.1.5

Date: 10/13/2011

Topic & Location:
Chapter 5
Facilities
Standard 5.1.1.5: Environmental Audit of Site Location

Question:
Has the recommendation for minimum distance between a playground site and hazards, such as electrical transformers and high voltage power lines changed since the CFOC, 2^nd Ed., which stated 30 feet?

Answer:
Yes, specific distances are no longer recommended as distances may differ according to local municipalities and states.
Please consult your local ordinance for appropriate information.

Content in the STANDARD was modified on 8/25/2016,01/23/2020 .

An assessment of the environment at an early care and education site location should be conducted before children receive care at the site. This includes assessment of the site prior to occupying an existing building, before renovating or constructing a building, and after a natural disaster. If an assessment identifies health and safety risks, and the risks cannot be wholly mitigated to protect children's health, the site should be avoided as an early care and education location.

The assessment of the environment should evaluate safety hazards; potential environmental exposures from air, water, drinking water, and soil contamination; and noise. The assessment should include consideration of

Completed past environmental assessments at the site, if available
Land use or deed restrictions for the site
Previous uses of the site or previous activities in the nearby area and any potential environmental contaminants and safety hazards that may remain
Current nearby businesses or activities that may result in environmental exposures at the early care and education site

Source of drinking water for the early care and education facility and any potential contamination of the drinking water
Naturally occurring sources of potential contamination, such as radon or arsenic in soil or drinking water
Potential noise hazards in the community surrounding the site

Guidance for environmental assessments is available.^1–3 If potential safety hazards or environmental exposures are identified, conduct further assessment or environmental sampling and mitigation, or avoid sites where children's health could be compromised. Consider consulting with environmental health professionals, such as the state or county health department. State environmental agencies can also be important resources, particularly with regard to assessment, sampling, and mitigation. Keep on file any documentation of the site assessment, sampling, and remediation actions taken.

RATIONALE

Evaluation of environmental health and safety risks associated with the physical location of an early care and education site can identify potential risks to children's health and development and options for mitigating those risks.

A range of potential environmental exposures may exist. These include air pollution from nearby industries, businesses, or busy roadways; noise from an airport; drinking water contaminants; and contaminants in the soil such as arsenic, lead, or pesticides from past site use. Contamination in the soil or groundwater may enter indoor air spaces through a process known as vapor intrusion. The size of the area to look for possible exposure sources can vary by the route of exposure (air, water, drinking water, or soil) and the emissions' characteristics. For example, a smelter may affect a larger area than a dry cleaner.

Children can be exposed to harmful substances contained in the indoor and outdoor air they breathe and water they drink. Additionally, children can be exposed to harmful substances in soil or dust when they play on the ground. Children have higher exposures to some harmful substances than adults due to their unique behavior, such as crawling and hand-to-mouth activity. They also eat, drink, and breathe more than adults do relative to their body size. In addition, children are much more vulnerable to harm from exposures to contaminated materials than adults because their bodies and organ systems are still developing. Disruption of this development could result in permanent damage with lifelong health and developmental consequences.⁴

The assessment of the environment at the site can identify issues that may affect children's health. Methods to identify risks include reviewing the property history and understanding what the site was used for in the past, reviewing maps and records to determine what activities and contaminants may be nearby, visiting the site to look for indications of hazards and potential environmental exposures, reviewing environmental investigation and remediation reports previously prepared for the site, and consulting federal or state environmental agency staff about the regulatory status of the site.

Awareness of site-related environmental health risks and actions to mitigate or avoid those risks can reduce exposure to hazards that adversely affect health and development.¹ For example, if an early care and education facility is considering locating in a building that also has a dry cleaner (or other business that uses hazardous chemicals), contaminated air could migrate into the early care and education site from the adjacent business. Options to reduce risk may include reducing migration of hazardous substances to non-harmful levels or choosing a different location for the early care and education facility. Another example is an early care and education facility proposed to be built on former agricultural land that has soil contamination from past pesticide use. To mitigate the potential exposure to chemicals in the soil, the contaminated soil could be removed, covered with pavement or artificial turf, or made inaccessible to children.

COMMENTS

State or local environmental health programs may be able to help answer questions about identified concerns. In addition, guidance and tools have been created to assist in conducting assessments. The Agency for Toxic Substances and Disease Registry Choose Safe Places for Early Care and Education program has guidance to help ensure that environmental exposures are considered for early care and education facilities where children spend time.¹ The US Environmental Protection Agency School Siting Guidelines, although aimed at schools, provide helpful information on types of environmental issues that are important to address to help protect children from environmental exposures.^3(p53–64) The Environmental Law Institute has identified existing state policies for addressing environmental site hazards at early care and education facilities, highlighting policy considerations to advance safe siting.⁵

ADDITIONAL RESOURCES

Eco-Healthy Child Care. Safe siting of child care facilities. https://cehn.org/wp-content/uploads/2019/05/Safe-Siting-FAQ-FINAL-5.1.19.pdf . Accessed August 21, 2019

TYPE OF FACILITY

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

RELATED STANDARDS

5.1.1.2 Inspection of Buildings
5.1.1.6 Structurally Sound Facility
5.1.1.7 Use of Basements and Below Grade Areas
5.7.0.7 Structure Maintenance

REFERENCES

Agency for Toxic Substances and Disease Registry. Choose safe places for early care and education. https://www.atsdr.cdc.gov/safeplacesforece/index.html. Reviewed March 6, 2019. Accessed August 21, 2019
Somers TS, Harvey ML, Rusnak SM. Making child care centers SAFER: a non-regulatory approach to improving child care center siting. Public Health Rep. 2011;126(Suppl 1):34–40
US Environmental Protection Agency, Office of Children's Health Protection. School Siting Guidelines. Washington, DC: US Environmental Protection Agency, Office of Children's Health Protection; 2011. https://www.epa.gov/schools/view-download-or-print-school-siting-guidelines . Accessed August 21, 2019
American Academy of Pediatrics Council on Environmental Health. Pediatric Environmental Health. Etzel RA, Balk SJ, eds. 4th ed. Itasca, IL: American Academy of Pediatrics; 2019
Environmental Law Institute. Addressing Environmental Site Hazards at Child Care Facilities: A Review of State Policy Strategies. Washington, DC: Environmental Law Institute; 2018. https://www.eli.org/research-report/addressing-environmental-site-hazards-child-care-facilities-review-state-policy-strategies . Published May 2018. Accessed August 21, 2019

NOTES

Content in the STANDARD was modified on 8/25/2016,01/23/2020 .

Standard 5.1.1.7: Use of Basements and Below Grade Areas

Finished basements or areas that are partially below grade may be used for children who independently ambulate and who are two years of age or older, if the space is in compliance with applicable building and fire codes. Environmental health factors may be reviewed with county or city public health departments.

RATIONALE

Basement and partially below grade areas can be quite habitable and should be usable as long as building, fire safety (1), and environmental quality is satisfactory.

COMMENTS

To "independently ambulate" means that children are able to walk from place to place with or without the use of assistive devices.

TYPE OF FACILITY

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

RELATED STANDARDS

5.1.1.8 Buildings of Wood Frame Construction
5.1.2.1 Space Required per Child
5.1.2.2 Floor Space Beneath Low Ceiling Heights
5.1.4.1 Alternate Exits and Emergency Shelter
5.1.4.2 Evacuation of Children with Special Health Care Needs and Children with Disabilities
5.2.1.1 Ensuring Access to Fresh Air Indoors
5.2.2.1 Levels of Illumination
5.2.9.4 Radon Concentrations
5.2.9.5 Carbon Monoxide Detectors
5.2.9.6 Preventing Exposure to Asbestos or Other Friable Materials

REFERENCES

National Fire Protection Association (NFPA). 2009. NFPA 101: Life Safety Code. 2009 ed. Quincy, MA: NFPA.

Standard 5.1.1.12: Multiple Use of Rooms

Playing, eating, and napping may occur in the same area (exclusive of diaper changing areas, toilet rooms, kitchens, hallways, and closets), provided that:

The room is of sufficient size to have a defined area for each of the activities allowed there at the time the activity is under way;
The room meets other building requirements;
Programming is such that use of the room for one purpose does not interfere with use of the room for other purposes.

RATIONALE

Except for toilet and diaper changing areas, which must have no other use, the use of common space for different activities for children facilitates close supervision of a group of children, some of whom may be involved simultaneously in more than one of the activities listed in the standard (1).

COMMENTS

Compliance is measured by direct observation.

TYPE OF FACILITY

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

REFERENCES

Olds, A. 2001. Zoning a group room. In Child care design guide, 137-65. New York: McGraw-Hill.

Standard 5.1.2.1: Space Required per Child

In general, the designated area for children's activities should contain a minimum of forty-two square feet of usable floor space per child. A usable floor space of fifty square feet per child is preferred.

This excludes floor area that is used for:

Circulation (e.g., walkways around the activity area);
Classroom support (e.g., staff work areas and activity equipment storage that may be adjacent to the activity area);
Furniture (e.g., bookcases, sofas, lofts, block corners, tables and chairs);
Center support (e.g., administrative office, washrooms, etc.)

Usable, indoor floor space for the children's activity area depends on the design and layout of the child care facility, and whether there is an opportunity and space for outdoor activities.

RATIONALE

Numerous studies have explored child care space requirements that are necessary to:

Provide an environment that is highly functional for program delivery and to encourage strong, positive staff-to-child relationships;
Accommodate the recommended group size and staff-to-child ratio; and
Efficiently use space and incorporates ease of supervision.
Recommendations from research studies range between forty-two to fifty-four square feet per child (1).

Studies have shown that the quality of the physical designed environment of early child care centers is related to children's cognitive, social, and emotional development (e.g., size, density, privacy, well-defined activity settings, modified open-plan space, a variety of technical design features and the quality of outdoor play spaces). In addition to meeting the needs of children, caregivers/teachers require space to implement programs and facilitate interactions with children.

A review of the literature indicates that in the past ten years, there has been growing research and study into how the physical design of child care settings affects child development. Historically, a standard of thirty-five square feet was used. Recommendations from research studies range between forty-two to fifty-four square feet per child. Comments from researchers indicate that other factors must also be considered when assessing the context of usable floor space for child care activities (1,5-8).

Although each child's development is unique to that child, age groups are often used to categorize developmental needs. To meet these needs, the use of activity space for each age group will be inherently different.

Child behavior tends to be more constructive when sufficient space is organized to promote developmentally appropriate skills. Crowding has been shown to be associated with increased risk of developing upper respiratory infections (2). Also, having sufficient space will reduce the risk of injury from simultaneous activities.

Children with special health care needs may require more space than typically developing children (1).

COMMENTS

The usable floor space for children's activities in this standard refers to indoor space that is used as the primary play space. Consideration should also be given to the presence or absence of secondary indoor play space that might be shared between programs as well as to outdoor play space.

TYPE OF FACILITY

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

RELATED STANDARDS

REFERENCES

Olds, A. R. 2001. Child care design guide. New York: McGraw-Hill.
The Family Child Care Accreditation Project, Wheelock College. 2005. Quality standards for NAFCC accreditation. 4th ed. Salt Lake City, UT: National Association for Family Child Care. http://www.nafcc.org/documents/QualStd.pdf.
White, R., V. Stoecklin. 2003. The great 35 square foot myth. http://www.whitehutchinson.com/children/articles/
35footmyth.shtml.
Moore, G. T., T. Sugiyama, L. O'Donnell. 2003. Children's physical environments rating scale. Paper presented at the Australian Early Childhood Education 2003 Conference, Hobart, Australia. http://sydney.edu.au/architecture/documents/ebs/AECA_2003_paper.pdf.
Beach J., M. Friendly. 2005. Child care centre physical environments. Working Documents, Child Care Resource and Research Unit. http://www.childcarequality.ca/wdocs/QbD
_PhysicalEnvironments.pdf.
U.S. General Services Administration (GSA). 2003. Child care center design guide. New York: GSA Public Buildings Service, Office of Child Care. http://www.gsa.gov/graphics/pbs/designguidesmall.pdf.
National Child Care Information and Technical Assistance Center and the National Association for Regulatory Administration. 2009. The 2007 licensing child care study. http://www.naralicensing.org/associations/4734/files/2007 Licensing Study_full_report.pdf.
Fleming, D. W., S. L. Cochi, A. W. Hightower, et al. 1987. Childhood upper respiratory tract infections: To what degree is incidence affected by daycare attendance? Pediatrics 79:55-60.

Standard 5.1.3.2: Possibility of Exit from Windows

All windows in areas used by children under five years of age should be constructed, adapted, or adjusted to limit the exit opening accessible to children to less than four inches, or be otherwise protected with guards that prevent exit by a child, but that do not block outdoor light. Where such windows are required by building or fire codes to provide for emergency rescue and evacuation, the windows and guards, if provided, should be equipped to enable staff to release the guard and open the window fully when evacuation or rescue is required. Opportunities should be provided for staff to practice opening these windows, and such release should not require the use of tools or keys. Children should be given information about these windows, relevant safety rules, as well as what will happen if the windows need to be opened for an evacuation.

RATIONALE

To prevent children from falling out of windows, standards from the U.S. Consumer Product Safety Commission (CPSC) and the ASTM International (ASTM) require the opening size to be four inches to prevent the child from getting through or the head from being entrapped (1,2). Some children may be able to pass their body through a slightly larger opening but then get stuck and hang from the window opening with their head trapped inside. Caregivers/teachers must not depend on screens to keep children from falling out of windows. Windows to be used as fire exits must be immediately accessible. Staff should supervise children when they are near these windows, and incorporate safety information and relevant emergency procedures and drills into their day-to-day curriculum so that children will better understand the safety issues and what will happen if they need to leave the building through the windows.

COMMENTS

"Screens" are intended to prevent flying insects from coming into the facility whereas window "guards" are the type of devices commonly used to provide building security and prevent intruders.

TYPE OF FACILITY

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

REFERENCES

ASTM International. ASTM F2090-08 Standard specification for window fall prevention devices with emergency escape (egress) release mechanisms. West Conshohocken, PA: ASTM.
U.S. Consumer Product Safety Commission (CPSC). New standards for window guards to help protect children from fails. Release #00-126. Washington, DC: CPSC. http://www.cpsc.gov/en/Newsroom/News-Releases/2000/New-Standards-for-Window-Guards-To-Help-Protect-Children-From-Falls-/.

Standard 5.2.1.1: Ensuring Access to Fresh Air Indoors

Content in the STANDARD was modified on 8/25/2016.

COVID-19 Modification as of 09/22/2021.

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

As much fresh outdoor air as possible should be provided in rooms occupied by children. Screened windows should be opened whenever weather and the outdoor air quality permits (1). When windows are not able to be opened, rooms should be ventilated, as specified in Standards 5.2.1.1-5.2.1.6 . The specified rates at which outdoor air must be supplied to each room within the facility range from fifteen to sixty cubic feet per minute per person (cfm/p). The rate depends on the activities that normally occur in that room. Indoor air should be kept as free from unnecessary chemicals as possible, including those emitted from air fresheners and other fragrances, cleaning products containing chemicals, aerosol sprays, and some furnishings.

Ionizers or products that use UV lights are not recommended. Do not use air cleaner devices with ozonators, ultraviolet (UV) lights, or ionization features, since they are unnecessary and some produce ozone, which can be harmful and trigger respiratory problems such as asthma.

COVID-19 modification as of 09/22/2021

Improving ventilation is an important COVID-19 prevention strategy that can reduce the number of virus particles in the air. In response to the Centers for Disease Control and Prevention's guidance on ventilation, it is recommended that staff:

Allow fresh, outdoor air into the building to help keep virus particles from remaining indoors.

Increase the flow of air from outside, using caution in highly polluted areas. See CDC's webpage for more information about local air quality.
Open all screened doors and windows, when safe to do so. Even slightly opened windows can help.
Do not open windows and doors if doing so is unsafe for children and staff (e.g. risk of falling, triggering asthma symptoms). Have window guards in place on all windows.
When opening windows or doors is unsafe, consider other approaches for reducing the amount of virus particles in the air, such as portable air filters and exhaust fans.
Use child safe portable fans or ceiling fans to increase the circulation of fresh air from open windows. Placing a fan by an open window to blow inside air out encourages airflow throughout the room.
Run heating, ventilation, air conditioning (HVAC) systems at maximum outside airflow for 2 hours before and after the center or home is in use for child care. If units do not have air conditioning, run the "fan" setting.

Ensure exhaust fans in areas such as restroom, kitchens, cooking areas are functional and running at full capacity.

Clean and change filters as recommended by manufacturer. If system allows, ensure filters are MERV 13 (Minimum Efficiency Reporting Value 13) or higher, as recommended by the American Society of Heating, Refrigeration and Air Conditioning Engineers (ASHRAE).
- ASHRAE currently recommends using a minimum MERV 13 filter, which is at least 85% efficient at capturing particles including SARS-CoV-2 virus particles.

Consult with your building's facility staff or administrators to ensure your ventilation systems operate properly and provide acceptable indoor air quality for the current occupancy level for each space. Work with a ventilation consultant as needed.

See COVID modification to Standard 5.2.1.3: Heating and Ventilation Equipment Inspection and Maintenance for reopening guidance.

If your program does not have an HVAC system, or programs want extra filtration, consider using a portable high-efficiency particulate air (HEPA) cleaner. HEPA cleaners trap particles exhaled when breathing, talking, singing, coughing, and sneezing.

Select HEPA cleaners of the right size for the room(s). For example, select a HEPA fan system with a Clean Air Delivery Rate (CADR) that meets or exceeds the square footage of the room. See EPA's Guide to Air Cleaners in the Home for more information.

Spend more time outside, as weather permits.

Wh en Transporting Children

Allow fresh air to pass through the vehicle through vents or windows while transporting children in and out of vehicles as weather permits.
Minimize contact between vehicle drivers, other staff, and families. If possible, adults should stay at least 6 feet apart from each other.
Masks and hand hygiene supplies should be readily available. Children (2 years and older) and staff should be encouraged to use hand sanitizer when boarding the vehicle/bus and wear masks.
Open windows on transport vehicles (cars, vans, etc.) when safe to do so.
Allow fresh air to pass through the vehicle through vents or windows as weather permits while transporting children.
For more information see CFOC Standard 6.5.2.3: Child Behavior During Transportation

Additional Resources :

American Society of Heating and Air-Conditioning Engineers (ASHRAE)

ASHRAE STANDARDS AND GUIDELINES: Resources to Address COVID-19
Guidance for Building Operations During the COVID-19
ASHRAE In-room air cleaner guidance for reducing COVID19 in air in your space/room
Core Recommendations for Reducing Airborne Infectious Aerosol Exposure

California Childcare Health Program

Healthy Air in Your Child Care Facility
Healthy Air in Your Child Care Facility (Poster)

Centers for Disease Control and Prevention

Ventilation in Schools and Childcare Programs: How to use CDC building recommendations in your setting
Ventilation in Buildings

Children's Environmental Health Network

How to Choose a Portable Air Cleaner
COVID-19: INDOOR AIR QUALITY IN CHILD CARE FACILITIES

New Jersey Department of Health

Guidance on Air Cleaning Devices for Indoor Spaces

Environmental Protection Agency (EPA)

EPA Air Cleaners, HEPA Filters, and COVID
Creating Healthy Indoor Air Quality in Schools
EPA's IAQ Tools for Schools Guidance
IAQ Tools for Schools: Preventive Maintenance Guidance

Harvard School of Public Health and UC, Colorado Boulder

Portable Air Cleaner Calculator for Schools
Healthy Buildings for Health: 5-Step Guide to Checking Ventilation Rates in a Classroom
Schools for Health: Risk Reduction Strategies for Reopening Schools, June 2020

RATIONALE

The health and well-being of both the staff and the children can be greatly affected by indoor air quality. The air people breathe inside a building can be contaminated with germs shared between people, chemicals emitted from common consumer products and furnishings, and polluted outdoor air entering into the program.^{1, 2}Additionally, the presence of dirt, moisture, and warmth encourages the growth of mold and other contaminants, which can trigger allergic reactions and asthma.³

Children's exposure to contaminated or polluted air (indoor and outdoor) is associated numerous health effects such as respiratory problems including increased asthma incidence, allergies, preterm birth, low birth weight, neurodevelopmental disorders, some cancers, IQ loss, and risk for adult chronic diseases .^2-5 Children are more vulnerable to air pollution because their organs (respiratory, central nervous system, etc.) are still developing and they breathe in more air relative to their weight than adults.⁵Air circulation is essential to clear infectious disease agents, odors, and toxic substances in the air.

Carbon dioxide levels are an indicator of the quality of ventilation. Higher Oxygen levels and lower Carbon Dioxide from fresh air promotes a better learning environment.⁷ Air circulation can be adjusted by a properly installed and adjusted heating, ventilation, air conditioning, and cooling (HVAC) system as well as by using fans and open windows.

Qualified engineers can ensure heating, ventilation, air conditioning (HVAC) systems are functioning properly and that applicable standards are being met. The American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE) Website includes the qualifications required of its members and the location of the local ASHRAE chapter. The contractor who services the HVAC system should provide evidence of successful completion of ASHRAE or comparable courses.

COMMENTS

ADDITIONAL RESOURCES

National Heart, Lung and Blood Institute.
- How Asthma Friendly is your Child Care Setting?
Asthma and Allergy Foundation of America. New England Chapter.
- ASTHMA – FRIENDLY CHILD CARE: A Checklist for Parents and Providers

The following organizations can provide further information on air quality and on ventilation:

The American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE)
The U.S. Environmental Protection Agency (EPA) Public Information Center
The American Gas Association (AGA)
The Edison Electric Institute (EEI)
The American Lung Association (ALA)
The U.S. Consumer Product Safety Commission (CPSC)
The Safe Building Alliance (SBA)

TYPE OF FACILITY

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

RELATED STANDARDS

3.1.3.2 Playing Outdoors
3.1.3.3 Protection from Air Pollution While Children Are Outside
5.2.1.2 Indoor Temperature and Humidity
5.2.1.3 Heating and Ventilation Equipment Inspection and Maintenance
5.2.1.4 Ventilation When Using Art Materials
5.2.1.5 Ventilation of Recently Carpeted or Paneled Areas
5.2.1.6 Ventilation to Control Odors
5.2.9.5 Carbon Monoxide Detectors

REFERENCES

Marcotte D. Something in the air? Air quality and children's educational outcomes. Economics of education review. 2017;56. doi:10.1016/j.econedurev.2016.12.003
American Society of Heating, Refrigeration and Air Conditioning Engineers. Standard 62.1 -2019: Ventilation for Acceptable Indoor Air Quality. ISSN 1041-2336. Published October 2019. Accessed July 28, 2021. https://www.ashrae.org/technical-resources/standards-and-guidelines
Brumberg, H. L., Karr, C.J.. Ambient Air Pollution: Health Hazards to Children.Pediatrics. 2021: 147.6.
Danh C. Vu, Thi L. Ho, Phuc H. Vo, et al. Assessment of indoor volatile organic compounds in Head Start child care facilities. Atmospheric Environment. 2019; 215 ( 116900):1352-2310, https://doi.org/10.1016/j.atmosenv.2019.116900
Gaspar, F. W., et al. Ultrafine, fine, and black carbon particle concentrations in California child‐care facilities. Indoor air. 2018;28.1: 102-111. Accessed July 28, 2021. https://onlinelibrary.wiley.com/doi/full/10.1111/ina.12408
United States Environmental Protection Agency. Volatile Organic Compounds' Impact on Indoor Air Quality. Accessed July 28, 2021. https://www.epa.gov/indoor-air-quality-iaq/volatile-organic-compounds-impact-indoor-air-quality
American Lung Association. Ventilation: How Buildings Breathe. Updated April 8, 2020. Accessed July 28, 2021. https://www.lung.org/clean-air/at-home/ventilation-buildings-breathe

NOTES

Content in the STANDARD was modified on 8/25/2016.

COVID-19 Modification as of 09/22/2021.

Standard 5.2.1.2: Indoor Temperature and Humidity

A draft-free temperature of 68°F to 75°F should be maintained at thirty to fifty percent relative humidity during the winter months. A draft-free temperature of 74°F to 82°F should be maintained at thirty to fifty percent relative humidity during the summer months (1,2). All rooms that children use should be heated and cooled to maintain the required temperatures and humidity.

RATIONALE

These requirements are based on the standards of the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE), which take both comfort and health into consideration (1,2). High humidity can promote growth of mold, mildew, and other biological agents that can cause eye, nose, and throat irritation and may trigger asthma episodes in people with asthma (3). These precautions are essential to the health and well-being of both the staff and the children. When planning construction of a facility, it is healthier to build windows that open. Some people need filtered air that helps control pollen and other airborne pollutants found in raw outdoor air.

COMMENTS

Simple and inexpensive devices that measure the ambient relative humidity indoors may be purchased in hardware stores or toy stores that specialize in science products. The ASHRAE Website (http://www.ashrae.org) has a list of membership chapters, and membership criteria that help to establish expertise on which caregivers/teachers could rely in selecting a contractor.

TYPE OF FACILITY

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

RELATED STANDARDS

5.2.1.3 Heating and Ventilation Equipment Inspection and Maintenance

REFERENCES

U.S. Environmental Protection Agency (EPA). 2008. Care for your air: A guide to indoor air quality. Washington, DC: EPA. http://www.epa.gov/iaq/pdfs/careforyourair.pdf.
American Society of Heating, Refrigerating and Air-conditioning Engineers (ASHRAE). 2007. Standard 55-2007: Thermal conditions for human occupancy. Atlanta: ASHRAE.
American Society of Heating, Refrigeration and Air-Conditioning Engineers, American Institute of Architects, Illuminating Engineering Society of North America, U.S. Green Building Council, U.S. Department of Energy. 2008. Advanced energy design guide for K-12 school buildings, 148. Atlanta, GA: ASHRAE.

Standard 5.2.1.6: Ventilation to Control Odors

Content in the STANDARD was modified on 8/25/2016.

Odors in toilets, bathrooms, diaper changing areas, and other inhabited areas of the facility should be controlled by ventilation and appropriate cleaning and disinfecting. Toilets and bathrooms, janitorial closets, and rooms with utility sinks or where wet mops and chemicals are stored should be mechanically ventilated to the outdoors with local exhaust mechanical ventilation to control and remove odors in accordance with local building codes. Air fresheners or sanitizers (both manmade and natural) should not be used. Adequate ventilation should be maintained during any cleaning, sanitizing, or disinfecting procedure to prevent children and caregivers/teachers from inhaling potentially toxic fumes.

RATIONALE

Air fresheners or sanitizers (both manmade and natural) may cause nausea, an allergic or asthmatic (airway tightening) response in some children (1). Ventilation and sanitation help control and prevent the spread of disease and contamination. The Safety Data Sheet (SDS) for every chemical product that the facility uses should be checked and available to anyone who uses or who might be exposed to the chemical in the child care facility to be sure that the chemical does not pose a risk to children and adults.

COMMENTS

The SDS gives legally required information about the presence of Volatile Organic Compounds (VOCs) and the risk of exposure from all the chemicals in the product. The Occupational Safety and Health Administration (OSHA) requires the availability of the SDS to the workers who use chemicals (2). In addition these sheets should be available to anyone who might be exposed to the chemical in the child care facility.

TYPE OF FACILITY

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

RELATED STANDARDS

3.3.0.1 Routine Cleaning, Sanitizing, and Disinfecting
4.8.0.7 Ventilation Over Cooking Surfaces

REFERENCES

U.S. Occupational Safety and Health Administration. 2009. Hazard communication: Foundation of workplace chemical safety programs. http://www.osha.gov/dsg/hazcom/index.html.
Elliott, L., M. P. Longnecker, G. E. Kissling, S. J. London. 2006. Volatile organic compounds and pulmonary function in the Third National Health and Nutrition Examination Survey, 1988-1994. Environmental Health Perspective 114:1210-14.

NOTES

Content in the STANDARD was modified on 8/25/2016.

Standard 5.2.1.11: Portable Electric Space Heaters

Portable electric space heaters should:

Be attended while in use and be off when unattended;
Be inaccessible to children;
Have protective covering to keep hands and objects away from the electric heating element;
Bear the safety certification mark of a nationally recognized testing laboratory;
Be placed on the floor only and at least three feet from curtains, papers, furniture, and any flammable object;
Be properly vented, as required for proper functioning;
Be used in accordance with the manufacturer's instructions;
Not be used with an extension cord.

The heater cord should be inaccessible to children as well.

RATIONALE

Portable electric space heaters are a common cause of fires and burns resulting from very hot heating elements being too close to flammable objects and people (1).

COMMENTS

To prevent burns and potential fires, space heaters must not be accessible to children. Children can start fires by inserting flammable material near electric heating elements. Curtains, papers, and furniture must be kept away from electric space heaters to avoid potential fires. Some electric space heaters function by heating oil contained in a heat-radiating portion of the appliance. Even though the electrical heating element is inaccessible in this type of heater, the hot surfaces of the appliance can cause burns. Cords to electric space heaters should be inaccessible to the children. Heaters should not be placed on a table or desk. Children and adults can pull an active unit off or trip on the cord.

TYPE OF FACILITY

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

RELATED STANDARDS

5.2.1.13 Barriers/Guards for Heating Equipment and Units

REFERENCES

U.S. Consumer Product Safety Commission (CPSC). 2001. What you should know about space heaters. Washington, DC: CPSC. http://www.nnins.com/documents/WHATYOUSHOULDKNOWABOUTSPACEHEATERS.pdf.

Standard 5.2.6.2: Testing of Drinking Water Not From Public System

Content in the STANDARD was modified on 8/27/2020

If an early care and education program's drinking water does not come from a public water system, the water source should be approved and tested every year, or as required by the local health department, for bacteriologic quality, nitrates, total dissolved solids, pH levels, and other water quality indicators.^1,2 Early care and education programs with infants 6 months or younger should get water tested for nitrate regularly.²

Drinking water from nonpublic sources includes private or household wells or rainwater collection systems (ie, cisterns).

Testing of private water supplies should be completed by a state-certified laboratory. Most testing laboratories or services supply their own sample containers. Samples for bacteriologic testing must be collected in sterile containers and under sterile conditions. Laboratories may sometimes send a trained technician to collect the sample. For more information, contact the local health authority or view the US Environmental Protection Agency list of state certification programs.³

After a disaster such as a flood, earthquake, or chemical spill, drinking water systems can become contaminated. Routine or new testing should be done to ensure safe drinking water.¹

RATIONALE

Public water systems are responsible for complying with all regulations, including monitoring, reporting, and performing treatment techniques. Environmental Protection Agency and state regulations do not apply to privately owned drinking water systems. Individual owners and operators of the water system are responsible for ensuring the water is safe.⁴

Unsafe water supplies may cause acute illness, such as diarrhea from microorganisms, or other health problems that are harder to identify and have long-lasting health effects. Chemicals can contaminate nonpublic water supplies from a variety of sources, and water quality testing is often the only way to identify the contamination. Some contamination can come from naturally occurring contaminants, such as arsenic, in groundwater. Other chemicals, such as pesticides, can enter drinking water systems from past or adjacent site use.⁵Many of these contaminants cannot be detected via smell, taste, or color.

Infants younger than 6 months who drink water containing nitrate in excess of the maximum concentration limit of 10 mg/L could become seriously ill and, if untreated, may die.²

Regular testing is valuable because it establishes a record of water quality. A water supply that is safe and free of harmful substances and microorganisms and does not spread disease is essential to the health of children enrolled in early care and education programs.

Contamination of nonpublic drinking water supplies may occur after disasters, and additional or repeat testing of water may be necessary to ensure drinking water quality.¹The types of potential drinking water contamination may vary by disaster. State and local health officials may be helpful in determining if water testing is needed after a disaster.

COMMENTS

Public water systems are responsible for complying with all regulations, including monitoring, reporting, and performing treatment techniques. Testing of private water supplies should be completed by a state certified laboratory (1). Most testing laboratories or services supply their own sample containers. Samples for bacteriological testing must be collected in sterile containers and under sterile conditions. Laboratories may sometimes send a trained technician to collect the sample. For further information, contact the local health authority or the U.S. Environmental Protection Agency (EPA).

TYPE OF FACILITY

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

RELATED STANDARDS

5.2.6.1 Water Supply
5.2.6.3 Testing for Lead and Copper Levels in Drinking Water
5.2.6.4 Water Test Results

REFERENCES

US Environmental Protection Agency. Potential well water contaminants and their impacts. https://www.epa.gov/privatewells/potential-well-water-contaminants-and-their-impacts . Updated August 8, 2019. Accessed May 18, 2020
US Environmental Protection Agency. Protecting your home's water. Testing wells to safeguard your water. https://www.epa.gov/privatewells/protect-your-homes-water#how . Updated August 8, 2019. Accessed May 18, 2020
US Environmental Protection Agency. Certification of laboratories for drinking water. Contact information for certification programs and certified laboratories for drinking water. https://www.epa.gov/dwlabcert/contact-information-certification-programs-and-certified-laboratories-drinking-water . Updated March 26, 2020. Accessed May 18, 2020
Centers for Disease Control and Prevention. Drinking water. Private water systems. https://www.cdc.gov/healthywater/drinking/private/index.html . Reviewed January 17, 2014. Accessed May 18, 2020
Agency for Toxic Substances and Disease Registry. Choose Safe Places for Early Care and Education (CSPECE) Guidance Manual. https://www.atsdr.cdc.gov/safeplacesforECE/cspece_guidance/index.html . Reviewed October 30, 2018. Accessed May 18, 2020

NOTES

Content in the STANDARD was modified on 8/27/2020

Standard 5.2.6.3: Testing for Lead and Copper Levels in Drinking Water

Drinking water, including water in drinking fountains, should be tested and evaluated in accordance with the assistance of the local health authority or state drinking water program to determine whether lead and copper levels are safe.

RATIONALE

Lead and copper in pipes can leach into water in harmful amounts and present a potential serious exposure. Lead exposure can cause: lower IQ levels, hearing loss, reduced attention span, learning disabilities, hyperactivity, aggressive behavior, coma, convulsion, and even death (2,3). Copper exposure can cause stomach and intestinal distress, liver or kidney damage, and complications of Wilson's disease. Children's bodies absorb more lead and copper than the average adult because of their rapid development (2,3).

It is especially important to test and have safe water at child care facilities because of the amount of time children spend in these facilities.

Caregivers/teachers should always run cold water for fifteen to thirty seconds before using for drinking, cooking, and making infant formula (3). Cold water is less likely to leach lead from the plumbing.

COMMENTS

Lead is not usually found in water that comes from wells or public drinking water supply systems. More commonly, lead can enter the drinking water when the water comes into contact with plumbing materials that contain lead (2,4).

TYPE OF FACILITY

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

RELATED STANDARDS

5.2.6.2 Testing of Drinking Water Not From Public System
4.2.0.6 Availability of Drinking Water
5.2.6.1 Water Supply
5.2.6.4 Water Test Results
5.2.9.13 Testing for and Remediating Lead Hazards

REFERENCES

Zhang, Y., A. Griffin, M. Edwards. 2008. Nitrification in premise plumbing: Role of phosphate, pH and pipe corrosion. Environ Sci Tech 42:4280-84.
U.S. Environmental Protection Agency (EPA). 2005. 3Ts for reducing lead in drinking water in child care facilities: Revised guidance. Washington, DC: EPA, Office of Water. http://www.epa.gov/safewater/schools/pdfs/lead/toolkit_leadschools_guide_3ts_childcare.pdf.
U.S. Environmental Protection Agency (EPA). 2005. Lead and copper rule: A quick reference guide for schools and child care facilities that are regulated under the safe Drinking Water Act. Washington, DC: EPA, Office of Water. http://www.epa.gov/safewater/schools/pdfs/lead/qrg_lcr_schools.pdf.
U.S. Environmental Protection Agency (EPA). 2009. Drinking water in schools and child care facilities. http://water.epa.gov/infrastructure/drinkingwater/schools/index.cfm.

Standard 5.2.8.1: Integrated Pest Management

Facilities should adopt an integrated pest management program (IPM) to ensure long-term, environmentally sound pest suppression through a range of practices including pest exclusion, sanitation and clutter control, and elimination of conditions that are conducive to pest infestations. IPM is a simple, common-sense approach to pest management that eliminates the root causes of pest problems, providing safe and effective control of insects, weeds, rodents, and other pests while minimizing risks to human health and the environment (2,4).

Pest Prevention: Facilities should prevent pest infestations by ensuring sanitary conditions. This can be done by eliminating pest breeding areas, filling in cracks and crevices; holes in walls, floors, ceilings and water leads; repairing water damage; and removing clutter and rubbish on the premises (5).

Pest Monitoring: Facilities should establish a program for regular pest population monitoring and should keep records of pest sightings and sightings of indicators of the presence of pests (e.g., gnaw marks, frass, rub marks).

Pesticide Use: If physical intervention fails to prevent pest infestations, facility managers should ensure that targeted, rather than broadcast applications of pesticides are made, beginning with the products that pose least exposure hazard first, and always using a pesticide applicator who has the licenses or certifications required by state and local laws.

Facility managers should follow all instructions on pesticide product labels and should not apply any pesticide in a manner inconsistent with label instructions. Safety Data Sheets (SDS) are available from the product manufacturer or a licensed exterminator and should be on file at the facility Facilities should ensure that pesticides are never applied when children are present and that re-entry periods are adhered to.

Records of all pesticides applications (including type and amount of pesticide used), timing and location of treatment, and results should be maintained either on-line or in a manner that permits access by facility managers and staff, state inspectors and regulatory personnel, parents/guardians, and others who may inquire about pesticide usage at the facility.

Facilities should avoid the use of sprays and other volatilizing pesticide formulations. Pesticides should be applied in a manner that prevents skin contact and any other exposure to children or staff members and minimizes odors in occupied areas. Care should be taken to ensure that pesticide applications do not result in pesticide residues accumulating on tables, toys, and items mouthed or handled by children, or on soft surfaces such as carpets, upholstered furniture, or stuffed animals with which children may come in direct contact (3).

Following the use of pesticides, herbicides, fungicides, or other potentially toxic chemicals, the treated area should be ventilated for the period recommended on the product label.

Notification: Notification should be given to parents/guardians and staff before using pesticides, to determine if any child or staff member is sensitive to the product. A member of the child care staff should directly observe the application to be sure that toxic chemicals are not applied on surfaces with which children or staff may come in contact.

Registry: Child care facilities should provide the opportunity for interested staff and parents/guardians to register with the facility if they want to be notified about individual pesticide applications before they occur.

Warning Signs: Child care facilities must post warning signs at each area where pesticides will be applied. These signs must be posted forty-eight hours before and seventy-two hours after applications and should be sufficient to restrict uninformed access to treated areas.

Record Keeping: Child care facilities should keep records of pesticide use at the facility and make the records available to anyone who asks. Record retention requirements vary by state, but federal law requires records to be kept for two years (7). It is a good idea to retain records for a minimum of three years.

Pesticide Storage: Pesticides should be stored in their original containers and in a locked room or cabinet accessible only to authorized staff. No restricted-use pesticides should be stored or used on the premises except by properly licensed persons. Banned, illegal, and unregistered pesticides should not be used.

RATIONALE

Children must be protected from exposure to pesticides (1). To prevent contamination and poisoning, child care staff must be sure that these chemicals are applied by individuals who are licensed and certified to do so. Direct observation of pesticide application by child care staff is essential to guide the pest management professional away from surfaces that children can touch or mouth and to monitor for drifting of pesticides into these areas. The time of toxic risk exposure is a function of skin contact, the efficiency of the ventilating system, and the volatility of the toxic substance. Spraying the grounds of a child care facility exposes children to toxic chemicals. Studies and a recent consensus statement address the risk of neurodevelopmental effects from exposure to pesticides (6). Exposure to pesticides has been linked to learning and developmental disorders. Children are more vulnerable as their metabolic, enzymatic, and immunological systems are immature. Pesticides should only be used as an emergency application to eliminate threats to human health (6).

COMMENTS

Manufacturers of pesticides usually provide product warnings that exposure to these chemicals can be poisonous.

TYPE OF FACILITY

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

REFERENCES

South Dakota State University, Department of Plant Science. Restricted use pesticide record keeping: Pesticide recordkeeping is more than just a good idea -- it's the law! http://www.sdstate.edu/ps/extension/pat/pesticide-record.cfm.
Gilbert, S. G. 2007. Scientific consensus statement on environmental agents associated with neurodevelopmental disorders. Bolinas, CA: Collaborative on Health and the Environment (CHE). http://www.neep.org/uploads/NEEPResources/id27/lddistatement.pdf.
University of California, Agriculture and Natural Resources. UC IPM online: Statewide integrated pest management program. How to manage pests. http://www.ipm.ucdavis.edu.
The IPM Institute of North America. IPM standards for schools. http://ipminstitute.org/school.htm.
U.S. Environmental Protection Agency. Integrated pest management (IPM) in child care.
http://www.epa.gov/pesticides/controlling/childcare-ipm.htm.
U.S. Environmental Protection Agency. Integrated pest management (IPM) in schools. http://www.epa.gov/pesticides/ipm/index.htm.
Tulve, N. S., P. A. Jones, M. G. Nishioka, R. C. Fortmann, C. W. Croghan, J. Y. Zhou, A. Fraser, C. Cave, W. Friedman. 2006. Pesticide measurements from the First National Environmental Health Survey of Child Care Centers using a multi-residue GC/MS analysis method. Environ Sci Tech 40:6269-74.

Standard 5.2.9.4: Radon Concentrations

Content in the STANDARD was modified on 05/17/2016.

Radon concentrations inside a home or building used for child care must be less than four picocuries (pCi) per liter of air. All facilities must be tested for the presence of radon, according to U.S. Environmental Protection Agency (EPA) testing protocols for long-term testing (i.e., greater than ninety days in duration using alpha-track or electret test devices). Radon testing should be conducted after a major renovation to the building or HVAC system (1,2).

RATIONALE

Radon is a colorless, odorless, radioactive gas that comes from the natural breakdown of uranium in soil, rock and water, and gets into the air you breath. It can be found in soil, water, building materials, and natural gas. Radon from the soil is the main cause of radon problems. Radon typically moves up through the ground to the air above and into a home or building through cracks and other holes in the foundation. Radon can get trapped inside the home or building where it can build up. In a small number of homes, the building materials can give off radon, but the materials themselves rarely cause problems. If radon is present in the water supply, most of the risk is related to radon released into the air when water is used for showering or other household purposes (1). When radon gas is inhaled, it can cause lung cancer. Radon levels can be easily measured to determine if acceptable levels have been exceeded. The risk can be reduced by lowering the levels of radon in the home or building. Fixing buildings to reduce radon exposure may entail sealing cracks in the foundation or ventilating the area under the foundation.

COMMENTS

The average indoor radon level is estimated to be about 1.3 pCi per liter of air, and about 0.4 pCi per liter is normally found in the outside air. Most homes today can be reduced to two picocuries per liter or below (1).

TYPE OF FACILITY

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

RELATED STANDARDS

5.1.1.7 Use of Basements and Below Grade Areas
5.2.1.3 Heating and Ventilation Equipment Inspection and Maintenance
5.2.9.15 Construction and Remodeling

REFERENCES

U.S. Environmental Protection Agency (EPA). 1993. Radon measurement in schools: Revised edition. https://www.epa.gov/sites/production/files/2014-08/documents/radon_measurement_in_schools.pdf.
U.S. Environmental Protection Agency (EPA). 2012. A citizen's guide to radon: The guide to protecting yourself and your family from radon. https://www.epa.gov/radon/citizens-guide-radon-guide-protecting-yourself-and-your-family-radon.

NOTES

Content in the STANDARD was modified on 05/17/2016.

Standard 5.2.9.10: Prohibition of Poisonous Plants

Poisonous or potentially harmful plants are prohibited in any part of a child care facility that is accessible to children. All plants not known to be nontoxic should be identified and checked by name with the local poison center (1-800-222-1222) to determine safe use.

RATIONALE

Plants are important to our health and well-being and are a great lesson in learning to understand and respect our environment. However, some plants can be harmful when eaten or touched (1,2). Plants are among the most common household substances that children ingest. Determining the toxicity of every commercially available household plant is difficult. A more reasonable approach is to keep any unknown plant out of the environment that children use. All outdoor plants and their leaves, fruit, and stems should be considered potentially toxic (1).

COMMENTS

Cuttings, trimmings, and leaves from potentially harmful plants must be disposed of safely so children do not have access to them.

TYPE OF FACILITY

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

RELATED STANDARDS

Appendix Y: Non-Poisonous and Poisonous Plants

REFERENCES

Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.
American Academy of Pediatrics. 2011. Handbook of common poisonings in children. 4th ed. Elk Grove Village, IL: AAP.

Standard 5.2.9.13: Testing for and Remediating Lead Hazards

Content in the standard was modified on 08/15/2014 and 04/27/2021.

Lead can be found in all parts of our environment-the air, the soil, the water, and even inside our homes. Because of the highly toxic nature of lead, early care and education (ECE) programs should test and remediate lead hazards in paint and dust, water, soil, and consumer products.

Paint and Dust: Paint and other surface-coating materials used in ECE facilities, including family child care homes (both rental and owned), should be labeled for residential (not industrial) applications only.

All ECE facilities built before 1978

Should be inspected and tested for lead-based paint hazards by a certified lead inspector or certified risk assessor for the following reasons
- If lead is identified in either the interior or exterior paint of the facility, ECE facilities should consult their state or local childhood lead poisoning prevention program, public health agency, and/or a certified risk assessor to determine the best steps for lead hazard control work.
- Surfaces found to have lead-based paint hazards should not be used and should be made inaccessible to children and staff until remediated.
- ECE facilities should hire a certified lead abatement contractor to do lead hazard control work. ECE facilities should be sure to test for lead dust clearance to ensure proper cleanup was done after lead hazard control work.
- ECE facilities should implement an occupant protection plan during lead remediation work.
Should conduct annual inspections of paint and perform routine maintenance to ensure that paint remains intact
Should use an Environmental Protection Agency (EPA)-certified lead-safe contractor (also known as a renovation, repair, and painting, or RRP, contractor) if any repair or renovation work (not lead hazard control work) is needed

Water: ECE facilities should learn the source (public or private) of their water and determine whether the facility has a lead service line or lead-containing pipes, fixtures, or solder. They should test water for lead and take steps to remediate sources if the water contains lead.

Soil: Bare soil around ECE facilities should be tested by an EPA-recognized National Lead Laboratory Accreditation Laboratory (NLLAP) or covered with mulch, plantings, or grass.

Consumer Products: Caregivers/teachers should check the U.S. Consumer Product Safety Commission's website ( http://www.cpsc.gov ) for warnings of potential lead exposure to children and recalls of play equipment, toys (especially antique and imported), jewelry used for play, imported vinyl mini-blinds, and food contact materials. If they are found to have lead, the items should be removed from the facility.

Only a certified lab can accurately test toys and products for lead contamination. "Test it yourself" kits or lead wipes (often purchased online or from large home improvement stores) are not recommended. Kits and wipes do not show how much lead is present, and their reliability at detecting low levels of lead has not been established.

Caregivers/teachers should not give children in their care imported candy, herbal remedies, or folk medicines.

RATIONALE

Lead is especially dangerous to children, because their brains and nervous systems are more sensitive to lead's damaging effects, and their young bodies are able to absorb more lead. Plus, babies and young children often put their hands and other objects in their mouths. These objects may have lead dust on them, particularly if a child is crawling on floors contaminated with lead dust. Once ingested, lead competes with calcium and can be stored in bones, teeth, and organs for decades, making lead poisoning difficult to treat. Lead-based paint is the most common source of lead exposure and poisoning in children.^1,2

Children under the age of 6 are at the greatest risk for lead poisoning. Most children with lead poisoning do not look or act sick. A blood lead test is the only way to know if children are being lead poisoned. The U.S. Centers for Disease Control and Prevention (CDC) uses a blood lead reference value of 5 micrograms per deciliter (mcg/dL) to identify children with blood lead levels that are much higher than most children's levels.^3,4 Lead is a neurotoxin. Even at low levels of exposure, children can suffer seriously from lead poisoning, leading to behavior and learning problems, lower IQ, hyperactivity, slowed growth, hearing problems, and anemia. There is no safe blood lead level in children.⁵

Lead may be present in paint, dust, water, or soil. It may also be present in consumer products like food, candies, spices, pottery/dishes, traditional medicines, cosmetics, toys, jewelry, and painted furniture.

Paint and Dust: The manufacture of residential lead-based paint was banned in the United States in 1978, but many older homes around the country still contain it. When lead-based paint inside a home deteriorates or is located on a friction surface, chips and dust settle on surfaces children can easily reach, such as windowsills and floors. Contaminated dust can be inhaled or ingested and is hazardous even if the particles are too small to see.

Water: ECE facilities built after 1986 likely do not have a lead service line; however, all ECE facilities, regardless of age, may have pipes and fixtures that contain lead (such as brass fixtures). In addition, unforeseen events (such as the one that occurred in Flint, MI, in 2014) may cause public drinking water to become contaminated with lead.

Soil: Lead can be found in soil as a result of the historic use of lead-based paint on building interiors and exteriors and leaded gasoline for cars, the current use of leaded gas by small airplanes, and industries that put lead into the environment. Soil on the property could be contaminated if the facility is next to a busy highway or high-traffic road or if it was built before 1978. In addition, if the facility is located in or near a current or former industrial area, the soil could be contaminated with lead.

Children may be exposed to lead-contaminated soil by playing in bare dirt. The main way children get lead from soil into their bodies is ingestion, most commonly by touching dirt and putting their hands in their mouths.

Consumer Products: Certain children's products are known to have a higher risk of containing lead such as inexpensive children's jewelry, imported pottery, antique toys, and imported toys. The use of lead in plastics has not been banned, so certain plastic toys made with vinyl/ polyvinyl chloride (PVC) [including bath books, teethers, rubber duckies, bath toys, dolls, beach balls, backpacks, pencil cases, and shower curtains] may contain lead. Lead may also be present in certain herbal remedies, folk medicines, and imported spices and foods.

COMMENTS

A state or local childhood lead poisoning prevention program, health department, and/or a certified risk assessment professional can help ECE facilities write a remediation plan to reduce any identified paint, water, or soil hazards. This plan may call for one of two types of lead hazard control work

● Interim Controls: These are measures that minimize lead hazards and include dust removal, paint stabilization, and/or control of friction/abrasion points. These measures ensure no one is exposed to lead-based paint hazards. Some intact lead-based paint may remain in the facility if it will not pose a hazard. These controls have been found to be effective, while less expensive than full abatement.

● Lead Abatement: These are measures that permanently remove lead-based paint and include component replacement (such as windows and windowsills), paint removal, enclosure, or encapsulation of lead-based paint. Lead abatement involves specialized techniques and must be conducted by EPA-certified lead abatement contractors.^6,7

EPA certifies lead abatement contractors to conduct either interim controls or lead abatement. These lead hazard control activities disturb lead-based paint and can create lead dust. Lead clearance testing will determine if contractors properly cleaned up after lead hazard control work and if work areas are safe for reoccupancy.⁷

For RRP work conducted independently from lead hazard control work in pre-1978 homes, EPA certifies lead-safe contractors, also known as RRP contractors. RRP contractors are trained to use lead-safe work practices when conducting tasks that may disturb lead-based paint, but they are not trained to perform lead hazard control work.

State-level programs and local funding resources may be available if financial support is needed for inspection, risk assessment, or remediation services.

Below is a list of general contact information and resources to answer questions, locate lead professionals, and handle other issues:

ADDITIONAL RESOURCES

General Contacts

● EPA regional offices can respond to inquiries about lead and lead poisoning. A list of regional contacts is on at EPA's Contacts in EPA Regional Offices for Lead Poisoning Prevention Efforts website.

● ECE facilities can call the National Lead Information Center and speak with an information specialist Monday through Friday, 8:00 am to 6:00 pm Eastern, at 800-424-LEAD.

● The CDC has a list of state and local childhood lead poisoning prevention programs .

● More resources available on the Lead-Safe Toolkit for Home-Based Child Care: General Resources Web page.

Lead in Paint Contacts

● An EPA booklet called Protect Your Family from Lead in Your Home explains the dangers of lead and how to protect your family and those in your care from lead-based paint hazards.

● EPA's webpage, Locate Certified Renovation and Lead Dust Sampling Technician Firms, can help ECE facilities find an inspection or risk assessment firm. This website also contains RRP contractor information.

● A local health department or childhood lead poisoning prevention program may be able to provide information on lead-based paint inspection and testing. The National Association of County and City Health Officials maintains a searchable Directory of Local Health Departments .

● RRP contractors must provide a copy of the EPA pamphlet The Lead-Safe Certified Guide to Renovate Right to ECE facilities and general renovation information to families whose children attend those ECE facilities.

● A description of steps to identify if ECE facilities have lead in paint hazards and more lead in paint resources are in The Lead-Safety Toolkit for Home-Based Child Care: Lead in Paint .

Lead in Soil Contacts

Labs for soil analysis are on EPA's list of NLLAP labs. The lab may go to the facility and collect the soil samples, or it may provide instructions, sampling materials, and forms so the facility can collect and submit the samples. State and local lead poisoning prevention programs may have more instructions. A description of steps to identify if ECE facilities have lead in soil hazards and more lead in soil resources are in The Lead-Safe Toolkit for Home-Based Child Care: Lead in Soil.

Lead in Water Contacts

● ECE facilities can call EPA's Safe Drinking Water Hotline at 800-426-4791 to find local contact information for testing water.

● If facility water comes from a community water system, local water utility staff may be able to test the water or provide a referral to an EPA-accredited lab in your region (see the NLLAP website ).

● Module 6 of EPA's 3Ts: Training, Testing, Taking Action , Remediation and Establishing Routine Practices , lists short- and long-term (permanent) measures to reduce exposures to lead-contaminated drinking water. The document also contains information about how to hire a licensed contractor to replace lead service lines or other lead-containing pipes and fixtures.

● EPA' s pamphlet How to Identify Lead Free Certification Marks for Drinking Water System & Plumbing Products contains information on how to identify lead-free plumbing.

● A description of steps to take when identifying if ECE facilities have lead in water hazards and more lead in water resources can be found in The Lead-Safe Toolkit for Home-Based Child Care: Lead in Drinking Water .

Lead in Consumer Products Contacts

● ECE facilities are encouraged to consult the United States Consumer Product Safety Commission (CPSC)'s web site, www.cpsc.gov , or more information on product recalls.

● ECE programs are encouraged to consult CPSC recall notices, as well as state and local governments, for more information about proper disposal of lead-contaminated consumer products.

● A description of steps to take to identify if ECE facilities have lead in consumer products hazards and a list of additional lead in consumer product resources can be found in The Lead-Safe Toolkit for Home-Based Child Care: Lead in Consumer Products Worksheet.

● The CDC provides more information on potential lead levels in spices, herbal remedies, and ceremonial powders in Lead in Spices, Herbal Remedies, and Ceremonial Powders Sampled from Home Investigations for Children with Elevated Blood Lead Levels — North Carolina, 2011–2018.

TYPE OF FACILITY

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

RELATED STANDARDS

5.2.6.3 Testing for Lead and Copper Levels in Drinking Water
5.2.9.15 Construction and Remodeling
5.3.1.2 Product Recall Monitoring

REFERENCES

Centers for Disease Control and Prevention. Blood Lead Levels in Children. Reviewed May 28, 2020. Accessed March 9, 2021. https://www.cdc.gov/nceh/lead/prevention/blood-lead-levels.htm
Advisory Committee on Childhood Lead Poisoning Prevention, Centers for Disease Control and Prevention. Low Level Lead Exposure Harms Children: A Renewed Call for Primary Prevention. Published January 4, 2012. Accessed March 9, 2021. http://www.cdc.gov/nceh/lead/acclpp/final_document_030712.pdf
National Center for Healthy Housing. Lead-Safe Toolkit for Home-Based Child Care: General Resources. Accessed March 9, 2021. https://nchh.org/tools-and-data/technical-assistance/protecting-children-from-lead-exposures-in-child-care/toolkit/general/
Centers for Disease Control and Prevention. Lead in Paint. Reviewed November 24, 2020. Accessed March 9, 2021. https://www.cdc.gov/nceh/lead/prevention/sources/paint.htm
Centers for Disease Control and Prevention. Lead Poisoning Prevention. Reviewed May 30, 2019. Accessed March 9, 2021. https://www.cdc.gov/nceh/lead/prevention/default.htm
U.S. Environmental Protection Agency. Lead Abatement Versus Lead RRP. Accessed March 9, 2021. https://www.epa.gov/lead/lead-abatement-vs-lead-rrp
Department of Housing and Urban Development. Guidelines for the Evaluation and Control of Lead-Based Paint Hazards in Housing . 2012 Edition. Accessed March 9, 2021. https://www.hud.gov/program_offices/healthy_homes/lbp/hudguidelines

NOTES

Content in the standard was modified on 08/15/2014 and 04/27/2021.

Standard 5.2.9.14: Shoes in Infant Play Areas

Adults and children should remove or cover shoes before entering a play area used by a specific group of infants. These individuals, as well as the infants playing in that area, may wear shoes, shoe covers, or socks that are used only in the play area for that group of infants.

RATIONALE

When infants play, they touch the surfaces on which they play with their hands, and then put their hands in their mouths. Lead and other toxins in soil around a facility can be a hazard when tracked into a facility on shoes (1).

COMMENTS

Facilities can meet this standard in several ways. The facility can designate contained play surfaces for infant play on which no one walks with shoes. Individuals can wear shoes or slippers that are worn only to walk in the infant play area or they can wear clean cloth or disposable shoe covers over shoes that have been used to walk outside the infant play area.

TYPE OF FACILITY

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

REFERENCES

U.S. Environmental Protection Agency. 2009. Lead in paint, dust and soil: Basic information. http://www.epa.gov/lead/pubs/
leadinfo.htm.

Standard 5.4.1.1: General Requirements for Toilet and Handwashing Areas

Clean toilet and handwashing facilities should be located in the best place to meet the developmental needs of children.

For infant areas, toilets and handwashing facilities are for adult rather than child use. They should be located within the infant area to reduce staff absence.

For toddler areas, toilet and handwashing facilities should be located in or adjacent to the toddler rooms.

For preschool and school-age children, toilet and handwashing facilities should be located near the entrance to the group room and near the entrance to the playground. If both entrances are close to each other, then only one set of toilet and handwashing facilities is needed.

RATIONALE

Young children have poor bowel and bladder control and cannot wait long when they have to use the toilet (1). Young children must be able to get to toilet facilities quickly. Staff must have easy access to hand washing facilities to wash their hands at the times when it is appropriate and still maintain supervision of the children.

TYPE OF FACILITY

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

RELATED STANDARDS

3.2.2.3 Assisting Children with Hand Hygiene

REFERENCES

Olds, A. R. 2001. Child care design guide. New York: McGraw-Hill.

Standard 5.4.1.4: Preventing Entry to Toilet Rooms by Infants and Toddlers

Toilet rooms should have barriers that prevent entry by infants and toddlers who are unattended. Infants and toddlers should be supervised by sight and sound at all times.

RATIONALE

Infants and toddlers can drown in toilet bowls, play in the toilet, have contact with contaminated items or surfaces, or otherwise engage in potentially injurious behavior if they are not supervised in toilet rooms.

TYPE OF FACILITY

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

Standard 6.1.0.1: Size and Location of Outdoor Play Area

The facility or home should be equipped with an outdoor play area that directly adjoins the indoor facilities or that can be reached by a route that is free of hazards and is no farther than one-eighth mile from the facility. The playground should comprise a minimum of seventy-five square feet for each child using the playground at any one time.

The following exceptions to the space requirements should apply:

A minimum of thirty-three square feet of accessible outdoor play space is required for each infant;
A minimum of fifty square feet of accessible outdoor play space is required for each child from eighteen to twenty-four months of age.

There should be separated areas for play for the following ages of children:

Ages six through twenty-three months
Ages two to five years*
Ages five to twelve years**

*These areas may be further sub-divided into ages two to three years and four to five years.

** These areas may be further sub-divided into grades K-1, 2-3, and 4-6.

The outdoor playground should include an open space for running that is free of other equipment (4).

RATIONALE

Play areas must be sufficient to allow freedom of movement without collisions among active children.

Providing more square feet per child may correspond to a decrease in the number of injuries associated with gross motor play equipment (1). An aggregate size of greater than 4,200 square feet that includes all of a facility's playgrounds has been associated with significantly greater levels of children's physical activity (5).

In addition, meeting proposed Americans with Disabilities Act (ADA) outdoor play area requirements for accessible routes, and developing natural, outdoor play yards with variety and shade can only be achieved if sufficient outdoor play space is provided.

The space exceptions are based on early childhood and playground professionals' experience (2). This follows the developmental ages used for the development of the Standards for play equipment for children.

COMMENTS

Children benefit from being outside as much as possible and it is important to provide sufficient outdoor space to accommodate the full enrollment of children (2). If a facility has less than seventy-five square feet of outdoor space per child, then the facility should augment the outdoor space by providing a large indoor play area (see Standard 6.1.0.2).

TYPE OF FACILITY

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

RELATED STANDARDS

5.1.1.5 Assessment of the Environment at the Site Location
3.1.3.1 Active Opportunities for Physical Activity
3.1.3.2 Playing Outdoors
3.1.3.4 Caregivers'/Teachers' Encouragement of Physical Activity
6.1.0.2 Size and Requirements of Indoor Play Area

REFERENCES

Dowda, M., W. H. Brown, C. Addy, K. A. Pfeiffer, K. L. McIver, R. R. Pate. 2009. Policies and characteristics of the preschool environment and physical activity of young children. Pediatrics 123: e261-66.
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.
Architectural and Transportation Barriers Compliance Board (U.S. Access Board). 2005. Accessible play areas: A summary of accessibility guidelines for play areas. http://www.access-board.gov/play/guide/guide.pdf.
Olds, A. R. 2001. Child care design guide. New York: McGraw-Hill.
Ruth, L. C. 2008. Playground design and equipment. Whole Building Design Guide. http://www.wbdg.org/resources/
playground.php.

Standard 6.1.0.2: Size and Requirements of Indoor Play Area

If a facility has less than seventy-five square feet of accessible outdoor space per child or provides active play space indoors for other reasons, a large indoor activity room that meets the requirement for seventy-five square feet per child may be used if it meets the following requirements:

It provides for types of activities equivalent to those performed in an outdoor play space;
The area is ventilated with fresh, temperate air at a minimum of five cubic feet per minute per occupant when open windows are not possible;
The surfaces and finishes are shock-absorbing, as required for outdoor installations in Standard 6.2.3.1;
The play equipment meets the requirements for outdoor installation as stated in Standards 6.2.1.3-6.2.1.6 and Standards 6.2.2.3-6.2.2.4.

There should be separated areas for play for the following ages of children:

Ages six through twenty-three months
Ages two to five years*
Ages five to twelve years**

*These areas may be further sub-divided into ages two to three years and four to five years.

** These areas may be further sub-divided into grades K-1, 2-3, and 4-6.

RATIONALE

This standard provides facilities located in inner-city areas or areas with extreme weather with an alternative that allows gross motor play when outdoor spaces are unavailable or unusable. Indoor gross motor play must provide an experience like outdoor play, with safe and healthful environmental conditions that match the benefits of outdoor play as closely as possible. These spaces may be interior if ventilation is adequate to prevent undue concentration of organisms, odors, carbon dioxide, humidity and other substances consistent with ASHRAE's "Standard 62: Ventilation for Acceptable Indoor Air Quality." This follows the developmental ages used for the development of the Standards for play equipment for children (1,2).

COMMENTS

For days in which weather does not permit outdoor play, the facility is encouraged to provide an alternate place for gross motor activities indoors for children of all ages. This space could be a dedicated gross motor room or a gym, a large hallway, or even a classroom in which furniture has been pushed aside. The room should provide adequate space for children to do vigorous activities including running.

TYPE OF FACILITY

Center, Early Head Start, Head Start

RELATED STANDARDS

3.1.3.1 Active Opportunities for Physical Activity
3.1.3.2 Playing Outdoors
3.1.3.4 Caregivers'/Teachers' Encouragement of Physical Activity
6.2.1.3 Design of Play Equipment
6.2.1.4 Installation of Play Equipment
6.2.1.5 Play Equipment Connecting and Linking Devices
6.2.1.6 Size and Anchoring of Crawl Spaces
6.2.1.7 Enclosure of Moving Parts on Play Equipment
6.2.1.8 Material Defects and Edges on Play Equipment
6.2.1.9 Entrapment Hazards of Play Equipment
6.2.2.1 Use Zone for Fixed Play Equipment
6.2.2.2 Arrangement of Play Equipment
6.2.3.1 Prohibited Surfaces for Placing Climbing Equipment

REFERENCES

U.S. Consumer Product Safety Commission (CPSC). 2008. Public playground safety handbook. Bethesda, MD: CPSC. http://www.cpsc.gov/cpscpub/pubs/325.pdf.
Olds, A. R. 2001. Child care design guide. New York: McGraw-Hill.

Standard 6.1.0.4: Elevated Play Areas

Elevated play areas that have been created using a retaining wall should have a guardrail, protective barrier, or fence running along the top of the retaining wall.

If the exposed side of the retaining wall is higher than two feet, a fence not less than six feet high should be installed. The bottom edge of the fence should be less than three and one-half inches from the base and should be designed to prevent children from climbing it. Fences should be designed so all spaces are less than three and one-half inches (1). If the height of the exposed side of the retaining wall is two feet or lower, a guardrail should be installed if caring for preschool and school-age children. The space between the bottom of the guardrail and the ground should be more than nine inches but less than or equal to twenty-three inches. For school-age children, the space between the bottom of the guardrail and the ground should be more than nine inches but less than or equal to twenty-eight inches. If caring for infants or toddlers, a protective barrier should be installed. The space between the barrier and the ground should be less than three and one-half inches and should be from four to six feet in height.

RATIONALE

Children falling from elevated play areas may suffer fatal head injuries. All spaces in fences or barriers are recommended to be less than three and one-half inches to prevent head entrapment (1,4) and climbing.

Guardrails are designed to protect against falls from elevated surfaces, but do not discourage climbing or protect against climbing through or under. Protective barriers protect against all three and provide greater protection. Guardrails are not recommended to use for infant and toddlers; protective barriers should be used instead.

COMMENTS

If the exposed side of the retaining wall is less than two feet high, additional safety can be provided by placing shock-absorbing material at the base of the exposed side of the retaining wall. A Certified Playground Safety Inspector (CPSI) can be utilized for guidance in assisting with elevated play areas.

TYPE OF FACILITY

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

RELATED STANDARDS

6.1.0.8 Enclosures for Outdoor Play Areas
6.2.3.1 Prohibited Surfaces for Placing Climbing Equipment
Appendix Z: Depth Required for Shock-Absorbing Surfacing Materials for Use Under Play Equipment

REFERENCES

ASTM International (ASTM). 2009. Standard safety performance specification for fences/barriers for public, commercial, and multi-family residential use outdoor play areas. ASTM F2049-09b. West Conshohocken, PA: ASTM.
ASTM International (ASTM). 2009. Standard specification for impact attenuation of surfacing materials within the use zone of playground equipment. ASTM F1292-09. West Conshohocken, PA: ASTM.ASTM International (ASTM). 2009. Standard specification for impact attenuation of surfacing materials within the use zone of playground equipment. ASTM F1292-09. West Conshohocken, PA: ASTM.
ASTM International (ASTM). 2009. Standard guide for ASTM standards on playground surfacing. ASTM F2223-09. West Conshohocken, PA: ASTM.
U.S. Consumer Product Safety Commission (CPSC). 2008. Public playground safety handbook. Bethesda, MD: CPSC. http://www.cpsc.gov/cpscpub/pubs/325.pdf.

Standard 6.3.1.1: Enclosure of Bodies of Water

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

All water hazards, such as pools, swimming pools, stationary wading pools, ditches, fish ponds, and water retention or detention basins, should be enclosed with a permanent fence, wall, building wall, or combination thereof that is 4 to 6 feet in height or higher. The barrier must measure a distance of 3 feet horizontally from the swimming pool or body of water.¹ The maximum vertical clearance (or gapping) allowed between the ground and the fence shall be 2 inches from surfaces that are not solid, such as grass or gravel, and measured on the side of the barrier that faces away from the vessel.^1(p25)

Openings in the fence should be no greater than 3.5 inches.¹ The fence should be constructed to discourage children and unwanted visitors from climbing and be kept in good repair. A house exterior wall can constitute one side of a fence if the wall has no openings capable of providing direct access to the pool (eg, doors, windows).

If the fence is made of horizontal and vertical members (like a typical wooden fence) and the distance between the tops of the horizontal parts of the fence is less than 45 inches, the horizontal parts should be on the swimming pool side of the fence.^1(p26) The spacing of the vertical members and/or all mesh barriers should not exceed 1.75 inches.^1(p26)

Exit and entrance points should have self-closing, positive latching gates with locking devices a minimum of 54 inches from the ground.^1(p26–27)

If the facility has a water play area, the following requirements should be met:

Water play areas should conform to all state and local health regulations.
Water play areas should not include hidden or enclosed spaces.
Spray areas and water-collecting areas should have a nonslip surface, such as asphalt.
Water play areas, particularly those that have standing water, should not have sudden changes in depth of water.
Drains, streams, waterspouts, and hydrants should not create strong suction effects or water-jet forces.
All toys and other equipment used in and around the water play area should be made of sturdy plastic or metal (no glass should be permitted).
Water play areas in which standing water is maintained for more than 24 hours should be treated according to Standard 6.3.4.1: Pool Water Quality and inspected for glass, trash, animal excrement, and other foreign material.

All areas must be visible to allow caregivers/teachers adequate active supervision of all children.²

RATIONALE

Fenced enclosures around swimming pools and spas provide an adequate barrier to prevent unwanted and unsupervised access.³ Drownings can occur in fresh water, often in home swimming pools within a few feet of safety and in the presence of a supervising adult.⁴ An effective fence is one that prevents a child from getting over, under, or through it and keeps the child from gaining access to the pool or body of water except when supervising adults are present. Fences are not childproof, but they provide a layer of protection for a child who strays from supervision. Fence heights are a matter of local ordinances with minimum heights being 5 feet.

TYPE OF FACILITY

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

RELATED STANDARDS

6.2.5.1 Inspection of Indoor and Outdoor Play Areas and Equipment
6.2.5.2 Inspection of Play Area Surfacing
6.3.1.2 Accessibility to Above-Ground Pools
6.3.1.3 Sensors or Remote Monitors
6.3.1.7 Pool Safety Rules
6.3.4.1 Pool Water Quality

REFERENCES

International Code Council, The Association of Pool & Spa Professionals. 2012 International Swimming Pool and Spa Code. Country Club Hills, IL: International Code Council; 2011. https://www.waterparks.org/docs/ISPSC-PV1.pdf . Accessed August 21, 2019
US Department of Health and Human Services, Administration for Children and Families, Head Start Early Childhood Learning and Knowledge Center. Safety practices. Active supervision. https://eclkc.ohs.acf.hhs.gov/safety-practices/article/active-supervision . Updated January 29, 2019. Accessed August 21, 2019
American Red Cross. Swimming and Water Safety. https://www.redcross.org/store/swimming-and-water-safety-manual-rev-04-14/651327.html?cgid=sp-lifeguarding-and-learn-to-swim. Accessed August 21, 2019
Leavy JE, Crawford G, Leaversuch F, Nimmo L, McCausland K, Jancey J. A review of drowning prevention interventions for children and young people in high, low and middle income countries. J Community Health. 2016;41(2):424–441

NOTES

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

Equipment, Materials, and Toys

Facility

Standard 3.4.6.1: Strangulation Hazards

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

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

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

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

RATIONALE

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

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

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

COMMENTS

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

TYPE OF FACILITY

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

RELATED STANDARDS

5.3.1.1 Safety of Equipment, Materials, and Furnishings

REFERENCES

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

Standard 5.1.5.4: Guards at Stairway Access Openings

Securely installed, effective guards (such as gates) should be provided at the top and bottom of each open stairway in facilities where infants and toddlers are in care. Gates should have latching devices that adults (but not children) can open easily in an emergency. "Pressure gates" or accordion gates should not be used. Gate design should not aid in climbing. Gates at the top of stairways should be hardware mounted (e.g., to the wall) for stability. Basement stairways should be shut off from the main floor level by a full door. This door should be self-closing and should be kept locked to entry when the basement is not in use. No door should be locked to prohibit exit at any time.

RATIONALE

Falls down stairs and escape upstairs can injure infants and toddlers. A gate with a difficult opening device can cause entrapment in an emergency (1).

TYPE OF FACILITY

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

RELATED STANDARDS

5.1.6.6 Guardrails and Protective Barriers

REFERENCES

U.S. Consumer Product Safety Commission (CPSC). Old accordion style baby gates are dangerous. http://www.cpsc.gov/CPSCPUB/PUBS/5085.pdf.

Standard 5.1.6.6: Guardrails and Protective Barriers

Guardrails, a minimum of thirty-six inches in height, should be provided at open sides of stairs, ramps, and other walking surfaces (e.g., landings, balconies, porches) from which there is more than a thirty-inch vertical distance to fall. Spaces below the thirty-six inches height guardrail should be further divided with intermediate rails or balusters as detailed in the next paragraph.

For preschoolers, bottom guardrails greater than nine inches but less or equal to twenty-three inches above the floor should be provided for all porches, landings, balconies, and similar structures. For school age children, bottom guardrails should be greater than nine inches but less or equal to twenty inches above the floor, as specified above.

For infants and toddlers, protective barriers should be less than three and one-half inches above the floor, as specified above. All spaces in guardrails should be less than three and a half inches. All spaces in protective barriers should be less than three and one-half inches. If spaces do not meet the specifications as listed above, a protective material sufficient to prevent the passing of a three and one-half inch diameter sphere should be provided.

Where practical or otherwise required by applicable codes, guardrails should be a minimum of forty-two inches in height to help prevent falls over the open side by staff and other adults in the child care facility.

RATIONALE

Structures such as porches, landings, balconies, and other similar structures that are raised more than thirty inches above an adjacent ground or floor, pose increased risk for fall injuries. Spaces between three and one-half inches and nine inches are a head entrapment hazard (1).

Guardrails are designed to protect against falls from elevated surfaces, but do not discourage climbing or protect against climbing through or under. Protective barriers protect against all three and provide greater protection. Guardrails are not recommended to use for infants and toddlers; protective barriers should be used instead.

A top guardrail with a minimum height of forty-two inches serves the needs of all occupants – children as well as adults (2). The minimum thirty-six-inch guardrail height detailed in this standard is based solely on the needs of children.

TYPE OF FACILITY

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

REFERENCES

U.S. Consumer Product Safety Commission (CPSC). 2008. Public playground safety handbook. Bethesda, MD: CPSC. http://www.cpsc.gov/cpscpub/pubs/325.pdf.
National Fire Protection Association (NFPA). 2009. NFPA 101: Life Safety Code. 2009 ed. Quincy, MA: NFPA.

Standard 5.2.4.2: Safety Covers and Shock Protection Devices for Electrical Outlets

All electrical outlets accessible to children who are not yet developmentally at a kindergarten grade level of learning should be a type called "tamper-resistant electrical outlets." These types of outlets look like standard wall outlets but contain an internal shutter mechanism that prevents children from sticking objects like hairpins, keys, and paperclips into the receptacle (2). This spring-loaded shutter mechanism only opens when equal pressure is applied to both shutters such as when an electrical plug is inserted (2,3).

In existing child care facilities that do not have "tamper-resistant electrical outlets," outlets should have "safety covers" that are attached to the electrical outlet by a screw or other means to prevent easy removal by a child. "Safety plugs" should not be used since they can be removed from an electrical outlet by children (2,3).

All newly installed or replaced electrical outlets that are accessible to children should use "tamper-resistant electrical outlets."

In areas where electrical products might come into contact with water, a special type of outlet called Ground Fault Circuit Interrupters (GFCIs) should be installed (2). A GFCI is designed to trip before a deadly electrical shock can occur (1). To ensure that GFCIs are functioning correctly, they should be tested at least monthly (2). GFCIs are also available in a tamper-resistant design.

RATIONALE

Tamper-resistant electrical outlets or securely attached safety covers prevent children from placing fingers or sticking objects into exposed electrical outlets and reduce the risk of electrical shock, electrical burns, and potential fires (2). GFCIs provide protection from electrocution when an electric outlet or electric product may come into contact with water (1).

Approximately 2,400 children are injured annually by inserting objects into the slots of electrical outlets (2,3). The majority of these injuries involve children under the age of six (2,3).

Plastic safety plugs inserted into electric outlets are not the safest option since they can easily be removed by children and, depending on their size, present a potential choking hazard if placed in a child's mouth (3).

COMMENTS

One type of outlet cover replaces the outlet face plate with a plate that has a spring-loaded outlet cover, which will stay in place when the receptacle is not in use. For receptacles where the facility does not intend to unplug the appliance, a more permanent cap-type cover that screws into the outlet receptacle is available. Several effective outlet safety devices are available in home hardware and infant/children stores (4).

TYPE OF FACILITY

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

RELATED STANDARDS

5.2.4.3 Ground-Fault Circuit-Interrupter for Outlets Near Water

REFERENCES

National Electrical Manufacturers Association. Real safety with tamper-resistant receptacles.http://www.childoutletsafety.org.
National Fire Protection Association. National electrical code fact sheet: Tamper-resistant electrical receptacles. http://www.nfpa.org/public-education/by-topic/top-causes-of-fire/electrical/tamper-resistant-electrical-receptacles.
Electrical Safety Foundation International (ESFI). 2008. Know the dangers in your older home Rosslyn, VA: ESFI. http://files.esfi.org/file/Know-The-Dangers-of-Your-Older-Home.pdf
National Fire Protection Association (NFPA). 2010. NFPA 70: National electrical code. 2011 ed. Quincy, MA: NFPA.

Standard 5.2.5.1: Smoke Detection Systems and Smoke Alarms

In centers with new installations, a smoke detection system (such as hard-wired system detectors with battery back-up system and control panel) or monitored wireless battery operated detectors that automatically signal an alarm through a central control panel when the battery is low or when the detector is triggered by a hazardous condition should be installed with placement of the smoke detectors in the following areas:

Each story in front of doors to the stairway;
Corridors of all floors;
Lounges and recreation areas;
Sleeping rooms.

In large and small family child care homes, smoke alarms that receive their operating power from the building electrical system or are of the wireless signal-monitored-alarm system type should be installed. Battery-operated smoke alarms should be permitted provided that the facility demonstrates to the fire inspector that testing, maintenance, and battery replacement programs ensure reliability of power to the smoke alarms and signaling of a monitored alarm when the battery is low and that retrofitting the facility to connect the smoke alarms to the electrical system would be costly and difficult to achieve.

Facilities with smoke alarms that operate using power from the building electrical system should keep a supply of batteries and battery-operated detectors for use during power outages.

RATIONALE

Because of the large number of children at risk in a center, up-to-date smoke detection system technology is needed. Wireless smoke alarm systems that signal and set off a monitored alarm are acceptable. In large and small family child care homes, single-station smoke alarms are acceptable. However, for all new building installations where access to enable necessary wiring is available, smoke alarms should be used that receive their power from the building's electrical system. These hard-wired detecting systems typically have a battery operated back-up system for times of power outage. The hard-wired and wireless smoke detectors should be interconnected so that occupants receive instantaneous alarms throughout the facility, not just in the room of origin. Single-station batteries are not reliable enough; single-station battery-operated smoke alarms should be accepted only where connecting smoke detectors to existing wiring would be too difficult and expensive as a retrofitted arrangement.

COMMENTS

Some state and local building codes specify the installation and maintenance of smoke detectors and fire alarm systems. For specific information, see the (1) and the from the National Fire Protection Association.

TYPE OF FACILITY

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

RELATED STANDARDS

5.1.1.3 Compliance with Fire Prevention Code

REFERENCES

National Fire Protection Association (NFPA). 2009. NFPA 101: Life Safety Code. 2009 ed. Quincy, MA: NFPA.

Standard 5.2.9.1: Use and Storage of Toxic Substances

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

The following items should be used as recommended by the manufacturer and should be stored in the original labeled containers:

Cleaning materials;
Detergents (in all forms, including pods);
Automatic dishwasher detergents (in liquid or solid forms, including pods);
Aerosol cans;
Pesticides;
Health and beauty aids;
Medications;
Lawn care chemicals;
Marijuana (in all forms, including oils, liquids, and edible products);
Liquid nicotine and tobacco products; and
Other toxic materials. (1-6)

Safety Data Sheets (SDS) must be available onsite for each hazardous chemical that is on the premises.

These substances should be used only in a manner that will not contaminate play surfaces, food, or food preparation areas, and that will not constitute a hazard to the children or staff. When not in active use, all chemicals used inside or outside should be stored in a safe and secure manner in a locked room or cabinet, fitted with a child-resistive opening device, inaccessible to children, and separate from stored medications and food.

Chemicals used in lawn care treatments should be limited to those listed for use in areas that can be occupied by children.

Medications can be toxic if taken by the wrong person or in the wrong dose. Medications should be stored safely (see Standard 3.6.3.1) and disposed of properly (see Standard 3.6.3.2).

The telephone number for the poison center should be posted in a location where it is readily available in emergency situations (e.g., next to the telephone). Poison centers are open twenty-four hours a day, seven days a week, and can be reached at 1-800-222-1222.

RATIONALE

There are over two million human poison exposures reported to poison centers every year. Children under six years of age account for over half of those potential poisonings. The substances most commonly involved in poison exposures of children are cosmetics and personal care products, cleaning substances, and medications (7).

The SDS explains the risk of exposure to products so that appropriate precautions may be taken.

COMMENTS

Many child-resistant types of closing devices can be installed on doors to prevent young children from accessing poisonous substances. Many of these devices are self-engaging when the door is closed and require an adult hand size or skill to open the door. A locked cabinet or room where children cannot gain access is best but must be used consistently. Child-resistant containers provide another level of protection.

In states that permit recreational and/or medicinal use of marijuana, special care is needed to store edible marijuana products securely and apart from other foods. State regulations typically require that these products be clearly labeled as containing an intoxicating substance and stored in the original packaging that is tamper-proof and child-proof. Any legal edible marijuana products in a family child care home should be kept in a locked or child-resistant storage device.

TYPE OF FACILITY

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

RELATED STANDARDS

5.2.8.1 Integrated Pest Management
3.4.1.1 Use of Tobacco, Electronic Cigarettes, Alcohol, and Drugs
3.6.3.1 Medication Administration
3.6.3.2 Labeling, Storage, and Disposal of Medications
5.2.9.3 Informing Staff Regarding Presence of Toxic Substances
9.2.3.15 Policies Prohibiting Smoking, Tobacco, Alcohol, Illegal Drugs, and Toxic Substances
6.3.2.3 Pool Equipment and Chemical Storage Rooms
6.3.4.2 Chlorine Pucks

REFERENCES

Wang, G.S., Le Lait, M.C., Deakyne, S.J., Bronstein, A.C., Bajaj, L., Roosevelt, G. 2016. Unintentional Pediatric Exposures to Marijuana in Colorado, 2009-2015. JAMA Pediatr. 2016;170(9):e160971. doi:10.1001/jamapediatrics.2016.0971.
American Academy of Pediatrics Council on Environmental Health. Pesticide exposure in children. Pediatrics. 2012:130(6). http://pediatrics.aappublications.org/content/130/6/e1757.
Davis, M.G., Casavant, M.J., Spiller, H.A., Chounthirath, T., Smith, G.A. 2016. Pediatric Exposures to Laundry and Dishwasher Detergents in the United States: 2013–2014. Pediatrics. doi: 10.1542/peds.2015-4529. http://pediatrics.aappublications.org/content/early/2016/04/21/peds.2015-4529.
McKenzie, L.B., Ahir, N., Stolz, U. Nelson, N.G. Household cleaning product-related injuries treated in US emergency departments in 1990–2006. Pediatrics. 2010:126(3). http://pediatrics.aappublications.org/content/pediatrics/126/3/509.full.pdf.
American Association of Poison Control Centers' National Poison Data System. 2015. Poison center data snapshot - 2014. https://aapcc.s3.amazonaws.com/pdfs/annual_reports/2014_Annual_Report_Snapshot_FINAL.pdf.
Safe Kids Grand Forks, Altru Health System. 2016. Electronic cigarette safety tips. http://safekidsgf.com/Documents/6053-0375-E-cigaretteSafetyTips.pdf.
American Academy of Pediatrics News. 2014. Liquid nicotine used in e-cigarettes can kill children.
http://www.aappublications.org/content/early/2014/12/17/aapnews.20141217-1.

NOTES

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

Standard 5.2.9.5: Carbon Monoxide Detectors

Carbon monoxide detector(s) should be installed in child care settings if one of the following guidelines is met:

The child care program uses any sources of coal, wood, charcoal, oil, kerosene, propane, natural gas, or any other product that can produce carbon monoxide indoors or in an attached garage;
If detectors are required by state/local law or state licensing agency.

Facilities must meet state or local laws regarding carbon monoxide detectors. Detectors should be tested monthly. Batteries should be changed at least yearly. Detectors should be replaced at least every five years.

RATIONALE

Carbon monoxide (CO) is a deadly, colorless, odorless, poisonous gas. It is produced by the incomplete burning of various fuels, including coal, wood, charcoal, oil, kerosene, propane, and natural gas. Products and equipment powered by internal combustion engine-powered equipment such as portable generators, cars, lawn mowers, and power washers also produce carbon monoxide. Carbon monoxide detectors are the only way to detect this substance.

Carbon monoxide poisoning causes symptoms that mimic the flu; mild symptoms are typically headache, dizziness, fatigue, nausea, and diarrhea. Prolonged exposure can cause confusion, shortness of breath, unconsciousness, and even death.

On average, about 170 people in the United States die every year from carbon monoxide produced by non-automotive consumer products (1). These products include malfunctioning fuel-burning appliances such as furnaces, ranges, water heaters, and room heaters; engine-powered equipment such as portable generators; fireplaces; and charcoal that is burned in homes and other enclosed areas. In 2005 alone, the U.S. Consumer Product Safety Commission (CPSC) staff was aware of at least ninety-four generator-related carbon monoxide poisoning deaths (1). Still others die from carbon monoxide produced by non-consumer products, such as cars left running in attached garages. The Centers for Disease Control and Prevention (CDC) estimate that several thousand people go to hospital emergency rooms every year to be treated for carbon monoxide poisoning (1).

COMMENTS

Carbon monoxide detectors should be installed according to the manufacturer's instructions. One carbon monoxide detector should be installed in the hallway outside the bedrooms in each separate sleeping area. Carbon monoxide detectors may be installed into a plug-in receptacle or high on the wall. Hard-wired or plug-in carbon monoxide detectors should have battery backup. Installing carbon monoxide detectors near heating vents, locations that can be covered by furniture or draperies, above fuel-burning appliances or in kitchens should be avoided (1).

TYPE OF FACILITY

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

REFERENCES

Safe Kids Worldwide. Home Safety Fact Sheet. http://www.safekids.org/fact-sheet/home-safety-fact-sheet-2015-pdf.
Cowling, T. 2007. Safety first: Carbon monoxide poisoning. Healthy Child Care 10(5): 6-7. http://www.safekids.org/safetytips/field_risks/carbon-monoxide.
Tremblay, K. R., Jr. 2006. Preventing carbon monoxide problems. Colorado State University Extension. http://www.ext.colostate.edu/pubs/consumer/09939.html.

Standard 5.2.9.6: Preventing Exposure to Asbestos or Other Friable Materials

Any asbestos, fiberglass, or other friable material or any material that is in a dangerous condition found within a facility or on the grounds of the facility should be repaired or removed. Repair usually involves either sealing (encapsulating) or covering asbestos material. Any repair or removal of asbestos should be done by a contractor certified to do in accordance with existing regulations of the U.S. Environmental Protection Agency (EPA). No children or staff should be present until the removal and cleanup of the hazardous condition have been completed.

Pipe and boiler insulation should be sampled and examined in an accredited laboratory for the presence of asbestos in a friable or potentially dangerous condition.

Non-friable asbestos should be identified to prevent disturbance and/or exposure during remodeling or future activities.

RATIONALE

Removal of significant hazards will protect the staff, children, and families who use the facility. Asbestos dust and fibers that are inhaled and reach the lungs can cause lung disease (1,2).

COMMENTS

The mere presence of asbestos in a child care facility, home, or a building is not hazardous. The danger is that asbestos materials may become damaged over time. Damaged asbestos may release asbestos fibers and become a health hazard (2,3). The best thing to do with asbestos material that is in good condition is to leave it alone. Disturbing it may create a health hazard where none existed before (1).

TYPE OF FACILITY

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

REFERENCES

U.S. Department of Health and Human Services, Agency for Toxic Substances and Disease Registry. 2001. Toxicological profile for asbestos. http://www.atsdr.cdc.gov/ToxProfiles/tp61-p.pdf.
U.S. Consumer Product Safety Commission (CPSC). Asbestos in the home. http://www.cpsc.gov/cpscpub/pubs/453.html.
Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.

Standard 5.3.1.1: Safety of Equipment, Materials, and Furnishings

Equipment, materials, furnishings, and play areas should be sturdy, safe, and in good repair and should meet the recommendations of the U.S. Consumer Product Safety Commission (CPSC) for control of the following safety hazards:

Openings that could entrap a child's head or limbs;
Elevated surfaces that are inadequately guarded;
Lack of specified surfacing and fall zones under and around climbable equipment;
Mismatched size and design of equipment for the intended users;
Insufficient spacing between equipment;
Tripping hazards;
Components that can pinch, sheer, or crush body tissues;
Equipment that is known to be of a hazardous type;
Sharp points or corners;
Splinters;
Protruding nails, bolts, or other components that could entangle clothing or snag skin;
Loose, rusty parts;
Hazardous small parts that may become detached during normal use or reasonably foreseeable abuse of the equipment and that present a choking, aspiration, or ingestion hazard to a child;
Strangulation hazards (e.g., straps, strings, etc.);
Flaking paint;
Paint that contains lead or other hazardous materials;
Tip-over hazards, such as chests, bookshelves, and televisions.

RATIONALE

The hazards listed in this standard are those found by CPSC to be most commonly associated with injury (1).

A study conducted by the Center for Injury Research and Policy of The Research Institute at Nationwide Children's Hospital found that from 1990-2007 an average of nearly 15,000 children younger than eighteen years of age visited emergency departments annually for injuries received from furniture tip-overs (2).

COMMENTS

Equipment and furnishings that are not sturdy, safe, or in good repair, may cause falls, entrap a child's head or limbs, or contribute to other injuries. Disrepair may expose objects that are hazardous to children. Freedom from sharp points, corners, or edges should be judged according to the Code of Federal Regulations, Title 16, Section 1500.48, and Section 1500.49. Freedom from small parts should be judged according to the Code of Federal Regulations, Title 16, Part 1501. To obtain these publications, contact the Superintendent of Documents of the U.S. Government Printing Office. For assistance in interpreting the federal regulations, contact the CPSC; the CPSC also has regional offices.

TYPE OF FACILITY

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

RELATED STANDARDS

3.4.6.1 Strangulation Hazards
5.1.6.6 Guardrails and Protective Barriers
5.1.3.5 Finger-Pinch Protection Devices
5.3.1.2 Product Recall Monitoring
5.4.5.2 Cribs

REFERENCES

Gottesman, B. L., L. B. McKenzie, K. A. Conner, G. A. Smith. 2009. Injuries from furniture tip-overs among children and adolescents in the United States, 1990-2007. Clin Pediatrics 48:851.
U.S. Consumer Product Safety Commission (CPSC). 2008. Public playground safety handbook. Bethesda, MD: CPSC. http://www.cpsc.gov/cpscpub/pubs/325.pdf.

Standard 5.3.1.3: Size of Furniture

Furniture should be durable and child-sized or adapted for children's use. Tables should be between waist and mid-chest level of the intended child-user and allow the child's feet to rest on a firm surface while seated for eating.

RATIONALE

Children cannot safely or comfortably use furnishings that are not sized for their use. When children eat or work at tables that are above mid-chest level, they must reach up to get their food or do their work instead of bringing the food from a lower level to their mouth and having a comfortable arrangement when working to develop their fine-motor skills. When eating, this leads to scooping food into the mouth instead of eating more appropriately. When working, this leads to difficulty succeeding with hand-eye coordination. When children do not have a firm surface on which to rest their feet, they cannot reposition themselves easily if they slip down. This can lead to poor posture and increased risk of choking. When children use chairs that are too high for them, they are at risk for falling.

TYPE OF FACILITY

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

Standard 5.3.1.4: Surfaces of Equipment, Furniture, Toys, and Play Materials

Frequently Asked Questions/CFOC Clarifications

Reference: 5.3.1.4

Date: 10/13/2011

Topic & Location:
Chapter 5
Facilities
Standard 5.3.1.4: Surfaces of Equipment, Furniture, Toys, and Play Materials

Question:
Do all pressed wood items contain formaldehyde?

Answer:
All pressed wood items do not contain added formaldehyde; however, all wood naturally contains some formaldehyde. Pressed wood products that have the highest formaldehyde emissions are those that are made with urea-formaldehyde resins. Products designed for interior use, such as hardwood plywood, medium density fiberboard, and particleboard, are more likely to contain urea-formaldehyde than those designed for exterior use such as oriented strand board or structural plywood. However, hardwood plywood, medium density fiberboard, and particleboard don't necessarily contain added formaldehyde; they are sometimes made with no added formaldehyde based resins. Many companies are choosing to make products with no added formaldehyde (NAF) based resins as well as ultra low-emitting formaldehyde (ULEF) based resins both to market their products as green and to comply with California regulations on composite wood products. Some products are currently labeled as made with NAF or ULEF resins under the California regulations, and once EPA regulations are proposed and go into effect, more products will be labeled to inform consumers about formaldehyde content.

Equipment, furnishings, toys, and play materials should have smooth, nonporous surfaces or washable fabric surfaces that are easy to clean and sanitize, or be disposable.

Walls, ceilings, floors, furnishings, equipment, and other surfaces should be suitable to the location and the users. They should be maintained in good repair, free from visible soil and in a clean condition. Programs should choose materials with the least probability of containing materials that off-gas toxic elements such as volatile organic compounds (VOCs), formaldehyde, or toxic flame retardants (polybrominated diphenylethers [PBDE]). Carpets, porous fabrics, and other surfaces that trap soil and potentially contaminated materials should not be used in toilet rooms, diaper change areas, and areas where food handling occurs (1).

Areas used by staff or children who have allergies to dust mites or components of furnishings or supplies should be maintained according to the recommendations of primary care providers.

RATIONALE

Few young children practice good hygiene. Messy play is developmentally appropriate in all age groups, and especially among very young children, the same group that is most susceptible to infectious disease. These factors lead to soiling and contamination of equipment, furnishings, toys, and play materials. To avoid transmission of disease within the group, these materials must be easy to clean and sanitize.

Formaldehyde and toxic flame retardants are the toxins of most concern in household furnishings, as they are both commonly found in furniture and carpets. Formaldehyde is a flammable, colorless gas that has a pungent odor. It is a human carcinogen, an asthma trigger, and a suspected neurological, reproductive, and liver toxin. People are exposed by breathing contaminated air from pressed wood furniture, flooring, and after application of certain paints, fabrics, and household cleaners. Toxic Flame Retardants (PBDEs) are widely used in furniture foam, carpet padding, back coatings for draperies and upholstery, plastics, building materials, and electrical appliances. It is believed that more than 80% of PBDE exposure is from house dust. PBDEs persist in the environment and accumulate in living things. Health concerns associated with PBDE exposure include liver, thyroid, and neurodevelopmental toxicity.

Carpets and porous fabrics are not appropriate for some areas because they are difficult to clean and sanitize. Disease-causing microorganisms have been isolated from carpets. Caregivers/teachers must remove illness-causing materials. Many allergic children have allergies to dust mites, which are microscopic insects that ingest the tiny particles of skin that people shed normally every day. Dust mites live in carpeting and fabric but can be killed by frequent washing and use of a clothes dryer or mechanical, heated dryer. Restricting the use of carpeting and furnishings to types that can be laundered regularly helps. Other children may have allergies to animal products such as those with feathers, fur, or wool, while some may be allergic to latex.

COMMENTS

Toys that can be washed in a mechanical dishwasher that meets the standard for cleaning and sanitizing dishes can save labor, if the facility has a dishwasher. Otherwise, after the children have used them, these toys can be placed in a tub of detergent water to soak until the staff has time to scrub, rinse, and sanitize the surfaces of these items. Except for fabric surfaces, nonporous surfaces are best because porous surfaces can trap organic material and soil. Fabric surfaces that can be laundered provide the softness required in a developmentally appropriate environment for young children. If these fabrics are laundered when soiled, the facility can achieve cleanliness and sanitation. When a material cannot be cleaned and sanitized it should be discarded.

TYPE OF FACILITY

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

RELATED STANDARDS

5.2.9.15 Construction and Remodeling

REFERENCES

Eco-Healthy Child Care (EHCC). Furniture and carpets. Washington, DC: EHCC. http://www.oeconline.org/resources/publications/factsheetarchive/Furniture and carpets.pdf.
U.S. Environmental Protection Agency. Polybrominated diphenylethers (PBDEs). http://www.epa.gov/oppt/pbde/.

Standard 5.3.1.7: Facility Arrangements to Minimize Back Injuries

The child care setting should be organized to reduce the risk of back injuries for adults provided that such measures do not pose hazards for children or affect the implementation of developmentally appropriate practice. Furnishings and equipment should enable caregivers/teachers to hold and comfort children and enable their activities while minimizing the need for bending and for lifting and carrying heavy children and objects. Caregivers/teachers should not routinely be required to use child-sized chairs, tables, or desks.

RATIONALE

Back strain can arise from adult use of child-sized furniture. Analysis of worker compensation claims shows that employees in the service industries, including child care, have an injury rate as great as or greater than that of workers employed in factories. Back injuries are the leading type of injury (1). Appropriate design of work activities and training of workers can prevent most back injuries. The principles to support these recommendations (see Comments) are standard principles of ergonomics, in which jobs and workplaces are designed to eliminate biomechanical hazards.

In a statewide (Wisconsin) survey of health status, behaviors, and concerns, 446 randomly selected early childhood professionals, directors, center teachers, and family providers, reported dramatic changes in frequency of backache and fatigue symptoms since working in child care (2).

COMMENTS

Some approaches to reduce risk are:

TYPE OF FACILITY

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

RELATED STANDARDS

1.7.0.1 Pre-Employment and Ongoing Adult Health Appraisals, Including Immunization
1.7.0.2 Daily Staff Health Check
1.7.0.3 Health Limitations of Staff
1.7.0.4 Occupational Hazards
1.7.0.5 Stress

REFERENCES

Grantz, R. R., A. Claffey. 1996. Adult health in child care: Health status, behaviors, and concerns of teachers, directors, and family child care providers. Early Child Res Q. 11:243-67.
Brown, M. Z., S. G. Gerberich. 1993. Disabling injuries to childcare workers in Minnesota, 1985 to 1990: An analysis of potential risk factors. J Occup Med 1993 35:1236-43.

Standard 5.4.1.6: Ratios of Toilets, Urinals, and Hand Sinks to Children

Toilets and hand sinks should be easily accessible to children and facilitate adult supervision. The number of toilets and hand sinks should be subject to the following minimums:

Toddlers:
1. If each group size is less than ten children, provide one sink and one toilet per group.
Preschool-age children:
1. If each group size is less than ten children, provide one sink and one toilet per group;
2. If each group size is between ten to sixteen children, provide two sinks and two flush toilets for each group.
School-age children:
1. If each group size is less than ten children, provide one sink and one toilet per group;
2. If each group size is between ten to twenty children, provide two sinks and two toilets per group. Provide separation of male and female toilets.

For toddlers and preschoolers, the maximum toilet height should be eleven inches, and maximum height for hand sinks should be twenty-two inches. Urinals should not exceed 30% of the total required toilet fixtures and should be used by one child at a time. For school-age children, standard height toilet, urinal, and hand sink fixtures are appropriate.

Non-flushing equipment in toilet learning/training should not be counted as toilets in the toilet:child ratio.

RATIONALE

The environment can become contaminated more easily with multiple simultaneous users of urinals, because at least one of the children must assume an off-center position in relationship to the fixture during voiding.

Young children use the toilet frequently and cannot wait long when they have to use the toilet. The ratio of 1:10 is based on best professional experience of early childhood educators who are facility operators (1). This ratio also limits the group that will be sharing facilities (and infections).

COMMENTS

The ratios of toilets and hand sinks to children provided above takes into consideration the maximum group size specified under Standard 1.1.1.2. Local building codes also dictate toilet and sink requirements based on number of children utilizing them.

TYPE OF FACILITY

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

RELATED STANDARDS

1.1.1.2 Ratios for Large Family Child Care Homes and Centers

REFERENCES

Olds, A. R. 2001. Child care design guide. New York: McGraw-Hill.

Standard 5.4.1.7: Toilet Learning/Training Equipment

Equipment used for toilet learning/training should be provided for children who are learning to use the toilet. Child-sized toilets or safe and cleanable step aids and modified toilet seats (where adult-sized toilets are present) should be used in facilities. Non-flushing toilets (i.e., potty chairs) should be strongly discouraged.

If child-sized toilets, step aids, or modified toilet seats cannot be used, non-flushing toilets (potty chairs) meeting the following criteria should be provided for toddlers, preschoolers, and children with disabilities who require them. Potty chairs should be:

Easily cleaned and disinfected;
Used only in a bathroom area;
Used over a surface that is impervious to moisture;
Out of reach of toilets or other potty chairs;
Cleaned and disinfected after each use in a sink used only for cleaning and disinfecting potty chairs.

Equipment used for toilet learning/training should be accessible to children only under direct supervision.

The sink used to clean and disinfect the potty chair should also be cleaned and disinfected after each use.

RATIONALE

Child-sized toilets that are flushable, steps, and modified toilet seats provide for easier use and maintenance. Sanitary handling of potty chairs is difficult. Flushable toilets are superior to any type of device that exposes the staff to contact with feces or urine. Many infectious diseases can be prevented through appropriate hygiene and disinfection methods. Surveys of environmental surfaces in child care settings have demonstrated evidence of fecal contamination (1). Fecal contamination has been used to gauge the adequacy of disinfection and hygiene.

COMMENTS

If potty chairs are used, they should be constructed of plastic or similar nonporous synthetic products. Wooden potty chairs should not be used, even if the surface is coated with a finish. The finished surface of wooden potty chairs is not durable and, therefore, may become difficult to wash and disinfect effectively.

TYPE OF FACILITY

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

REFERENCES

Gorski, P. A. 1999. Toilet training guidelines: Day care providers-the role of the day care provider in toilet training. Pediatrics 103:1367-68.

Standard 5.4.2.1: Diaper Changing Tables

The facility should have at least one diaper changing table per infant group or toddler group to allow sufficient time for changing diapers and for cleaning and sanitizing between children. Diaper changing tables and sinks should be used only by the children in the group whose routine care is provided together throughout their time in child care. The facility should not permit shared use of diaper changing tables and sinks by more than one group.

RATIONALE

Diaper changing requires time, as does cleaning the changing surfaces. When caregivers/teachers from different groups use the same diaper changing surface, disease spreads more easily from group to group. Child care facilities should not put the diaper changing tables and sinks in a buffer zone between two classrooms, because doing so effectively joins the groups from the perspective of cross-contamination.

TYPE OF FACILITY

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

RELATED STANDARDS

1.1.1.1 Ratios for Small Family Child Care Homes
1.1.1.2 Ratios for Large Family Child Care Homes and Centers
5.4.2.4 Use, Location, and Setup of Diaper Changing Areas

Standard 5.4.2.4: Use, Location, and Setup of Diaper Changing Areas

Infants and toddlers should be diapered only in the diaper changing area. Children should be discouraged from remaining in or entering the diaper changing area. The contaminated surfaces of waste containers should not be accessible to children.

Diaper changing areas and food preparation areas should be physically separated. Diaper changing should not be conducted in food preparation areas or on surfaces used for other purposes. Food and drinking utensils should not be washed in sinks located in diaper changing areas.

The diaper changing area should be set up so that no other surface or supply container is contaminated during diaper changing. Bulk supplies should not be stored on or brought to the diaper changing surface. Instead, the diapers, wipes, gloves, a thick layer of diaper cream on a piece of disposable paper, a plastic bag for soiled clothes, and disposable paper to cover the table in the amount needed for a specific diaper change will be removed from the bulk container or storage location and placed on or near the diaper changing surface before bringing the child to the diaper changing area.

Conveniently located, washable, plastic-lined, tightly covered, hands-free receptacles, should be provided for soiled cloths and linen containing body fluids.

Where only one staff member is available to supervise a group of children, the diaper changing table should be positioned to allow the staff member to maintain constant sight and sound supervision of children.

RATIONALE

The use of a separate area for diaper changing or changing of soiled underwear reduces contamination of other parts of the child care environment (1-2). Children cannot be expected to avoid contact with contaminated surfaces in the diaper changing area. They should be in this area only for diaper changing and be protected as much as possible from contact with contaminated surfaces. The separation of diaper changing areas and food preparation areas prevents transmission of disease. Using diaper changing surfaces for any other purpose increases the likelihood of contamination and spreading of infectious disease agents.

Bringing storage containers for bulk supplies to the diaper changing table is likely to result in their contamination during the diaper changing process. When these containers stay on the table or are replaced in a storage location, they become conduits for transmitting disease agents. Bringing to the table only the amount of each supply that will be consumed in that specific diaper changing will prevent contamination of diapering supplies and the environment.

Hands-free receptacles prevent environmental contamination so the children do not come into contact with disease-bearing body fluids.

Often, only one staff person is supervising children when a child has to be changed. Orienting the diaper changing table so the staff member can maintain direct observation of all children in the room allows adequate supervision.

TYPE OF FACILITY

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

RELATED STANDARDS

3.2.1.4 Diaper Changing Procedure
5.2.7.4 Containment of Soiled Diapers
5.4.2.5 Changing Table Requirements

REFERENCES

Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.
Aronson, S. S. 1999. The ideal diaper changing station. Child Care Information Exchange 130:92.

Standard 5.4.2.5: Changing Table Requirements

Changing tables should meet the following requirements:

Have impervious, nonabsorbent, smooth surfaces that do not trap soil and are easily disinfected;
Be sturdy and stable to prevent tipping over;
Be at a convenient height for use by caregivers/teachers (between twenty-eight and thirty-two inches high);
Be equipped with railings or barriers that extend at least six inches above the change surface.

RATIONALE

This standard is designed to prevent disease transmission and falls and to provide safety measures during diapering. Commercial diaper change tables vary as much as ten inches in height. Many standard-height thirty-six inch counters are used as the diaper change area. When a railing or barrier is attached, shorter staff members cannot change diapers without standing on a step.

Back injury is a common occupational injury for caregivers/teachers (3,5). Using changing tables that are sized for caregiver/teacher comfort and convenience can help prevent back injury (1,3-4). Railings of two inches or less in height have been observed in some diaper change areas and when combined with a moisture-impervious diaper changing pad approximately one inch thick, render the railing ineffective. A change table height of twenty-eight inches to thirty-two inches (standard table height) plus a six-inch barrier will reduce back strain on staff members and provide a safe barrier to prevent children from falling off the changing table.

Data from the U.S. Consumer Product Safety Commission (CPSC) show that falls are a serious hazard associated with infant changing tables (2). Safety straps on changing tables are provided to prevent falls but they trap soil and they are not easily disinfected. Therefore, diaper changing tables should not have safety straps.

COMMENTS

An impervious surface is defined as a smooth surface that does not absorb liquid or retain soil. While changing a child, the adult must hold onto the child at all times.

TYPE OF FACILITY

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

REFERENCES

Gratz, R., A. Claffey, P. King, G. Scheuer. 2002. The physical demands and ergonomics of working with young children. Early Child Devel Care 172:531-37.
ASTM International. 2008. ASTM F2388-08. Baby changing tables for domestic use. West Conshohocken, PA: ASTM.
U.S. Consumer Product Safety Commission (CPSC). 1997. The safe nursery. Washington, DC: CPSC. http://www.cpsc.gov/cpscpub/pubs/202.pdf.
Aronson, S. S. 1999. The ideal diaper changing station. Child Care Info Exch 130:92.
Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.

Standard 5.4.1.10: Handwashing Sinks

Content in the STANDARD was modified on 8/9/2017.

A handwashing sink should be accessible without barriers (such as doors) to each child care area. In areas for toddlers and preschoolers, the sink should be located so the caregiver/teacher can visually supervise the group of children washing their hands. Sinks should be placed at the child's height or be equipped with a stable step platform to make the sink available to children. If a platform is used, it should have slip-proof steps and platform surface. In addition, each sink should be equipped so that the user has access to:

Clean, running water (1);
A foot-pedal operated, electric-eye operated, open, self-closing, slow-closing, or metering faucet that provides a flow of water for at least thirty seconds without the need to reactivate the faucet;
A supply of hand-cleansing non-antibacterial, unscented liquid soap;
Disposable single-use cloth or paper towels or a heated-air hand-drying device with heat guards to prevent contact with surfaces that get hotter than 120°F.

A steam tap or a water tap that provides water that is hotter than 120°F may not be used at a handwashing sink.

RATIONALE

Transmission of many infectious diseases can be prevented through handwashing (1). To facilitate routine handwashing at the many appropriate times, sinks must be close at hand and permit caregivers/teachers to provide continuous supervision while children wash their hands. The location, access, and supporting supplies to enable adequate handwashing are important to the successful integration of this key routine. Foot-pedaled operated or electric-eye operated handwashing sinks and liquid soap dispensers are preferable because they minimize hand contamination during and after handwashing. The flow of water must continue long enough for the user to wet the skin surface, get soap, lather for at least twenty seconds, and rinse completely.

Comfortably warm water helps to release soil from hand surfaces and provides comfort for the person who is washing the hands. When the water is too cold or too hot for comfort, the person is less likely to wet and rinse long enough to lather and wash off soil. Having a steam tap or a super-heated hot water tap available at a handwashing sink poses a significant risk of scald burns.

COMMENTS

Shared access to soap and disposable towels at more than one sink is acceptable if the location of these is fully accessible to each person. There is no evidence that antibacterial soap reduces the incidence of illness among children in child care.

TYPE OF FACILITY

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

RELATED STANDARDS

3.2.2.2 Handwashing Procedure
3.6.2.2 Space Requirements for Care of Children Who Are Ill
4.8.0.4 Food Preparation Sinks
4.8.0.5 Handwashing Sink Separate from Food Zones
5.2.1.14 Water Heating Devices and Temperatures Allowed
5.2.6.9 Handwashing Sink Using Portable Water Supply

REFERENCES

Centers for Disease Control and Prevention (CDC). 2015. Handwashing: Clean hands save lives.http://www.cdc.gov/handwashing/.

NOTES

Content in the STANDARD was modified on 8/9/2017.

Standard 5.4.1.11: Prohibited Uses of Handwashing Sinks

Handwashing sinks should not be used for rinsing soiled clothing, for cleaning equipment that is used for toileting, or for the disposal of any waste water used in cleaning the facility.

RATIONALE

The sink used to wash/rinse soiled clothing or equipment used for toileting becomes contaminated during this process and can be a source of transmission of disease to those who wash their hands in that sink (1).

TYPE OF FACILITY

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

REFERENCES

Laborde, D. J., K. A. Weigle, D. J. Weber, J. B. Kotch. 1993. Effect of fecal contamination on the diarrheal illness rates in day-care centers. Am J Epidemiol 138:243-55.

Standard 5.4.2.2: Handwashing Sinks for Diaper Changing Areas in Centers

Handwashing sinks in centers should be provided within arm's reach of the caregiver/teacher to diaper changing tables and toilets. A minimum of one handwashing sink should be available for every two changing tables. Where infants and toddlers are in care, sinks and diaper changing tables should be assigned for use to a specific group of children and used only by children and adults who are in the assigned group as defined by Standard 5.4.2.1. Handwashing sinks should not be used for bathing or removing smeared fecal material.

RATIONALE

Sinks must be close to where the diapering takes place to avoid transfer of contaminants to other surfaces en route to washing the hands of staff and children. Having sinks close by will help prevent the spread of contaminants and disease.

When sinks are shared by multiple groups, cross-contamination occurs. Many child care centers put the diaper changing tables and sinks in a buffer zone between two classrooms, effectively joining the groups through cross-contamination.

COMMENTS

Shared access to soap and disposable towels at more than one sink is acceptable if the location of these is fully accessible to each person.

TYPE OF FACILITY

Center, Early Head Start, Head Start

RELATED STANDARDS

5.4.2.1 Diaper Changing Tables
5.4.2.4 Use, Location, and Setup of Diaper Changing Areas

REFERENCES

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

Standard 5.4.2.3: Handwashing Sinks for Diaper Changing Areas in Homes

Handwashing sinks in large and small family child care homes should be supplied for diaper changing, as specified in Standard 5.4.2.2, except that they should be within ten feet of the changing table if the diapering area cannot be set up so the sink is adjacent to the changing table. If diapered toddlers and preschool-age children are in care, a stepstool should be available at the handwashing sink, as specified in Standard 5.4.1.10, so smaller children can stand at the sink to wash their hands. Handwashing sinks should not be used for bathing or removing smeared fecal material.

RATIONALE

When children from more than one family are in care, the diaper changing area should be arranged to be as close as possible to a non-food sink to avoid fecal-oral transmission of infection.

TYPE OF FACILITY

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

RELATED STANDARDS

5.4.2.4 Use, Location, and Setup of Diaper Changing Areas
5.4.1.10 Handwashing Sinks
5.4.2.2 Handwashing Sinks for Diaper Changing Areas in Centers

Standard 5.4.5.1: Sleeping Equipment and Supplies

Content in the STANDARD was modified on 3/31/2017.

COVID-19 modification as of September 20, 2021.

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

Facilities should have an individual crib, cot, sleeping bag, bed, mat, or pad for each child who spends more than four hours a day at the facility. No child should simultaneously share a crib, bed, or bedding with another child. Facilities should ensure that furniture and surfaces for sleeping are in compliance with the current U.S. Consumer Product Safety Commission (CPSC) and ASTM safety standards and have not been recalled by the manufacturer (1).
Clean linens should be provided for each child. Beds and bedding should be washed between uses if used by different children. Regardless of age group, bed linens should not be used as rest equipment in place of cots, beds, pads, or similar approved equipment. Bed linens used under children on cots, cribs, futons, and playpens should be tight-fitting. Sheets for an adult bed should not be used on a crib mattress because they could become loose and entangle an infant (2). See Standard 5.4.5.2 for crib specifications.
When pads are used, they should be enclosed in washable covers and should be long enough so the child's head or feet do not rest off the pad. Mats and cots should be made with a waterproof material that can be easily washed and sanitized. Plastic bags or loose plastic material should never be used as a covering.

No child should sleep on a bare, uncovered surface. Seasonally appropriate covering, such as sheets, sleep garments, or blankets that are sufficient to maintain adequate warmth, should be available and should be used by each child below school-age. Pillows, blankets, and sleep positioners should not be used with infants (2). If pillows are used by toddlers and older children, pillows should have removable cases that can be laundered, be assigned to a child, and used by that child only while s/he is enrolled in the facility. (Pillows are not required for older children.) Each child's pillow, blanket, sheet, and any special sleep item should be stored separately from those of other children.

Pads and sleeping bags should not be placed directly on any floor that is cooler than 65°F when children are resting. Cribs, cots, sleeping bags, beds, mats, or pads in/on which children are sleeping should be placed at least three feet apart (3). If the room used for sleeping cannot accommodate three feet of spacing between children, it is recommended for caregivers/teachers to space children as far as possible from one another and/or alternate children head to feet. Screens used to separate sleeping children are not recommended because screens can affect supervision, interfere with immediate access to a child, and could potentially injure a child if pushed over on a child. If unoccupied sleep equipment is used to separate sleeping children, the arrangement of such equipment should permit the staff to observe and have immediate access to each child. The ends of cribs do not suffice as screens to separate sleeping children.

The sleeping surfaces of one child's rest equipment should not come in contact with the sleeping surfaces of another child's rest equipment during storage.

Caregivers/teachers should never use strings to hang any object, such as a mobile, or a toy or a diaper bag, on or near the crib where a child could become caught in it and strangle (2).

Infant monitors and their cords and other electrical cords should never be placed in the crib or sleeping equipment.

Crib mattresses should fit snugly and be made specifically for the size crib in which they are placed. Infants should not be placed on an inflatable mattress due to potential of entrapment or suffocation (2).

COVID-19 modification as of September 20, 2021

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

Allow additional square footage whenever possible during naptime, as children are unmasked and need to be further apart
Place children head to toe on alternating mats (or cribs)

RATIONALE

Separate sleeping and resting, even for siblings, reduces the spread of disease from one child to another.

Droplet transmission occurs when droplets containing microorganisms generated from an infected person, primarily during coughing, sneezing, or talking are propelled a short distance (three feet) and deposited on the eyes, nose, or mouth (3).

Because respiratory infections are transmitted by large droplets of respiratory secretions, a minimum distance of three feet should be maintained between cots, cribs, sleeping bags, beds, mats, or pads used for resting or sleeping (3). A space of three feet between cribs, cots, sleeping bags, beds, mats, or pads will also provide access by the staff to a child in case of emergency. If the facility uses screens to separate the children, their use must not hinder observation of children by staff or access to children in an emergency.

Scabies and ringworm are diseases transmitted by direct person-to-person contact. For example, ringworm is transmitted by the sharing of personal articles such as combs, brushes, towels, clothing, and bedding. Prohibiting the sharing of personal articles helps prevent the spread of diseases.
Head lice is not commonly transmitted through the sharing of personal articles, though sharing hats, headgear, towels, and bedding is discouraged. Head lice transmission occurs with direct head-to-head contact with infested hair (4).

From time to time, children drool, spit up, or spread other body fluids on their sleeping surfaces. Using cleanable, waterproof, nonabsorbent rest equipment enables the staff to wash and sanitize the sleeping surfaces. Plastic bags may not be used to cover rest and sleep surfaces/equipment because they contribute to suffocation if the material clings to the child's face.

Canvas cots are not recommended for infants and toddlers. The end caps require constant replacement and the cots are a cutting/pinching hazard when end caps are not in place. A variety of cots are made with washable sleeping surfaces that are designed to be safe for children.

COMMENTS

Although children freely interact and can contaminate each other while awake, reducing the transmission of infectious disease agents on large airborne droplets during sleep periods will reduce the dose of such agents to which the child is exposed overall. In small family child care homes, the caregiver/teacher should consider the home to be a business during child care hours and is expected to abide by regulatory expectations that may not apply outside of child care hours. Therefore, child siblings related to the caregiver/teacher sleeping in the same bed during the hours of operation is discouraged.

TYPE OF FACILITY

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

RELATED STANDARDS

3.4.6.1 Strangulation Hazards
3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
3.3.0.4 Cleaning Individual Bedding
5.4.5.2 Cribs
9.2.4.5 Emergency and Evacuation Drills/Exercises Policy

REFERENCES

Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4^th Edition.Elk Grove Village, IL: American Academy of Pediatrics.
Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. Recommendations for care of children in special circumstances. In: Red Book: 2015 Report to the Committee of Infectious Diseases. 30^th Ed. Elk Grove Village, IL: American Academy of Pediatrics.
American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: Updated 2016 recommendations for a safe infant sleeping environment. Pediatrics. 2016;138(6):e20162938. http://pediatrics.aappublications.org/content/early/2016/10/20/peds.2016-2938.
U.S. Consumer Product Safety Commission (CPSC). 2011. CPSC approves new mandatory standard for toddler beds. https://www.cpsc.gov/newsroom/news-releases/2011/cpsc-approves-new-mandatory-standard-for-toddler-beds.

NOTES

Content in the STANDARD was modified on 3/31/2017.

COVID-19 modification as of September 20, 2021.

Standard 5.4.5.2: Cribs

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

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

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

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

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

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

Cribs should be placed away from window blinds or draperies.

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

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

RATIONALE

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

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

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

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

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

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

COMMENTS

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

TYPE OF FACILITY

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

RELATED STANDARDS

5.4.5.1 Sleeping Equipment and Supplies
3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
5.4.5.3 Stackable Cribs
6.4.1.3 Crib Toys

REFERENCES

U.S. Consumer Product Safety Commission (CPSC). Are your window coverings safe?http://www.cpsc.gov/cpscpub/pubs/5009a.pdf.
Juvenile Products Manufacturers Association. 2007. Safe and sound for baby: A guide to juvenile product safety, use, and selection. 9th ed. Moorestown, NJ: JPMA. http://www.jpma.org/content/retailers/safe-and-sound/.
U.S. Consumer Product Safety Commission (CPSC). 1996. CPSC warns parents about infant strangulations caused by failure of crib hardware. http://www.ridgevfd.org/content/prevent/sleepwear.pdf
U.S. Consumer Product Safety Commission (CPSC). 1997. The safe nursery. Washington, DC: CPSC.http://www.cpsc.gov/cpscpub/pubs/202.pdf.
U.S. Consumer Product Safety Commission (CPSC). 2010. Safety standards for full-size baby cribs and non-full-size baby cribs; final rule. 16 CFR 1219, 1220, and 1500.http://www.cpsc.gov/businfo/frnotices/fr11/cribfinal.pdf.
ASTM International. 2010. ASTM F406-10b: Standard consumer safety specification for non-full-size baby cribs/play yards. West Conshohocken, PA: ASTM.
ASTM International. 2010. ASTM F1169-10a: Standard consumer safety specification for full-size baby cribs. West Conshohocken, PA: ASTM.

Standard 5.4.5.3: Stackable Cribs

Use of stackable cribs (i.e., cribs that are built in a manner that there are two or three cribs above each other that do not touch the ground floor) in facilities is not advised. In older facilities, where these cribs are already built into the structure of the facility, staff should develop a plan for phasing out the use of these cribs.

If stackable cribs are used, they must meet the current Consumer Product Safety Commission's (CPSC) federal standard for non-full-size cribs, 16 CFR 1220. In addition they should be three feet apart and staff placing or removing a child from a crib that cannot reach from standing on the floor, should use a stable climbing device such as a permanent ladder rather than climbing on a stool or chair. Infants who are able to sit, pull themselves up, etc. should not be placed in stackable cribs.

RATIONALE

Stackable cribs are designed to save space by having one crib built on top of another. Although they may be practical from the standpoint of saving space, infants on the top level of stackable cribs will be positioned at a height that will be several feet from the floor. Infants who fall from several feet or more can have an intracranial hemorrhage (i.e., serious bleed inside of the skull). While no injury reports have been filed, there is a potential for injury as a result of either latch malfunction or a caregiver/teacher who slips or falls while placing or removing a child from a crib. It is best practice to place an infant to sleep in a safe sleep environment (safety-approved crib with a firm mattress and a tight-fitting sheet) at a level that is close to the floor.

A minimum distance of three feet between cribs is required because respiratory infections are transmitted by large droplets of respiratory secretions, which usually are limited to a range of less than three feet from the infected person (1,2).

Young children placed to sleep in stackable cribs may have difficulties falling asleep because they may not be used to sleeping in this type of equipment. In addition, requiring staff to use stackable cribs may cause them concern and fear regarding their liability if an injury occurs.

COMMENTS

Many state child care licensing regulations prohibit the use of stackable cribs. If stackable cribs are not prohibited in the caregiver's/teacher's state and they are used, parents/guardians should be informed and extreme care should be taken to ensure that no infant falls from the higher level cribs due to the potential for injury. Any injury that is suspected to be related to the use of stackable cribs should be reported to the U.S. Consumer Product Safety Commission (CPSC) at 1-800-638-2772 or http://www.cpsc.gov.

TYPE OF FACILITY

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

RELATED STANDARDS

5.4.5.1 Sleeping Equipment and Supplies
5.4.5.2 Cribs

REFERENCES

Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4^th Edition. Elk Grove Village, IL: American Academy of Pediatrics.
Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015.Red book: 2015 report to the committee of infectious diseases.30^th Ed. Elk Grove Village, IL: American Academy of Pediatrics.

Standard 5.4.5.4: Futons

Child-sized futons should be used only if they meet the following requirements:

Not on a frame;
Easily cleanable;
Encased in a tight-fitting waterproof cover;
Meet all other standards on sleep and rest areas (Section 5.4.5).

REFERENCES

American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement: Prevention of drowning. Pediatrics 126:178-85.
U.S. Consumer Product Safety Commission (CPSC). 2009. CPSC warns of in-home drowning dangers with bathtubs, bath seats, buckets. Release #10-008. http://www.cpsc.gov/cpscpub/prerel/prhtml10/10008.html.
Gipson, K. 2008. Pool and spa submersion: Estimated injuries and reported fatalities, 2008 report. Atlanta: U.S. Consumer Product Safety Commission. http://www.cpsc.gov/LIBRARY/poolsub2008.pdf.

Standard 6.3.5.2: Water in Containers

Bathtubs, buckets, diaper pails, and other open containers of water should be emptied immediately after use.

RATIONALE

In addition to home swimming and wading pools, young children drown in bathtubs and pails (4). Bathtub drownings are equally distributed in both sexes. Any body of water, including hot tubs, pails, and toilets, presents a drowning risk to young children (1,2,4,5).

From 2003-2005, eleven children under the age of five died from drowning in buckets or containers that were being used for cleaning (4). Of all buckets, the five-gallon size presents the greatest hazard to young children because of its tall straight sides and its weight with even just a small amount of liquid. It is nearly impossible for top-heavy infants and toddlers to free themselves when they fall into a five-gallon bucket head first (3).

TYPE OF FACILITY

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

REFERENCES

Rivera, F. P. 1999. Pediatric injury control in 1999: Where do we go from here?Pediatrics 103:883-88.
U.S. Consumer Safety Commission (CPSC). How to plan for the unexpected: Preventing child drownings. Document #359. https://www.cpsc.gov/s3fs-public/359.pdf.
U.S. Consumer Products Safety Commission (CPSC). In home danger: CPSC warns of children drowning in bathtubs, bath seats and buckets more than 400 deaths estimated over a five-year. period. 2012. https://www.cpsc.gov/Newsroom/News-Releases/2012/In-Home-Danger-CPSC-Warns-of-Children-Drowning-in-Bathtubs-Bath-Seats-and-Buckets-More-than-400-deaths-estimated-over-a-five-year-period/.
U.S. Consumer Products Safety Commission (CPSC). Submersions related to non-pool and non-spa products, 2009 report. 2010. https://www.cpsc.gov/s3fs-public/pdfs/nonpoolsub2009.pdf.
American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement: Prevention of drowning. Pediatrics 126:178-85.

Standard 6.4.1.5: Balloons

Infants, toddlers, and preschool children should not be permitted to inflate balloons, suck on or put balloons in their mouths nor have access to uninflated or underinflated balloons. Children under eight should not have access to latex balloons or inflated latex objects that are treated as balloons and these objects should not be permitted in the child care facility.

RATIONALE

Balloons are an aspiration hazard (1). The U.S. Consumer Product Safety Commission (CPSC) reported eight deaths from balloon aspiration with choking between 2006 and 2008 (1). Aspiration injuries occur from latex balloons or other latex objects treated as balloons, such as inflated latex gloves. Latex gloves are commonly used in child care facilities for diaper changing, but they should not be inflated (2). When children bite inflated latex balloons or gloves, these objects may break suddenly and blow an obstructing piece of latex into the child's airway. Exposure to latex balloons could trigger an allergic reaction in children with latex allergies.

Underinflated or uninflated balloons of all types could be chewed or sucked and pieces potentially aspirated.

TYPE OF FACILITY

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

RELATED STANDARDS

6.4.1.2 Inaccessibility of Toys or Objects to Children Under Three Years of Age

REFERENCES

American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement: Prevention of choking among children. Pediatrics 125:601-7.
Garland, S. 2009. Toy-related deaths and injuries, calendar year 2008. Bethesda, MD: U.S. Consumer Product Safety Commission. http://www.cpsc.gov/library/toymemo08.pdf.

Standard 6.5.2.2: Child Passenger Safety

When children are driven in a motor vehicle other than a bus, school bus, or a bus operated by a common carrier, the following should apply:

A child should be transported only if the child is restrained in developmentally appropriate car safety seat, booster seat, seat belt, or harness that is suited to the child's weight, age, and/or psychological development in accordance with state and federal laws and regulations and the child is securely fastened, according to the manufacturer's instructions, in a developmentally appropriate child restraint system.
Age and size-appropriate vehicle child restraint systems should be used for children under eighty pounds and under four-feet-nine-inches tall and for all children considered too small, in accordance with state and federal laws and regulations, to fit properly in a vehicle safety belt. The child passenger restraint system must meet the federal motor vehicle safety standards contained in the Code of Federal Regulations, Title 49, Section 571.213 (especially Federal Motor Vehicle Safety Standard 213), and carry notice of such compliance.
For children who are obese or overweight, it is important to find a car safety seat that fits the child properly. Caregivers/teachers should not use a car safety seat if the child weighs more than the seat's weight limit or is taller than the height limit. Caregivers/teachers should check the labels on the seat or manufacturer's instructions if they are unsure of the limits. Manufacturer's instructions that include these specifications can also be found on the manufacturer's Website.
Child passenger restraint systems should be installed and used in accordance with the manufacturer's instructions and should be secured in back seats only.
All children under the age of thirteen should be transported in the back seat of a car and each child not riding in an appropriate child restraint system (i.e., a child seat, vest, or booster seat), should have an individual lap-and-shoulder seat belt (2).
For maximum safety, infants and toddlers should ride in a rear-facing orientation (i.e., facing the back of the car) until they are two years of age or until they have reached the upper limits for weight or height for the rear-facing seat, according to the manufacturer's instructions (1). Once their seat is adjusted to face forward, the child passenger must ride in a forward-facing child safety seat (either a convertible seat or a combination seat) until reaching the upper height or weight limit of the seat, in accordance with the manufacturer's instructions (10). Plans should include limiting transportation times for young infants to minimize the time that infants are sedentary in one place.
A booster seat should be used when, according to the manufacturer's instructions, the child has outgrown a forward-facing child safety seat, but is still too small to safely use the vehicle seat belts (for most children this will be between four feet nine inches tall and between eight and twelve years of age) (1).
Car safety seats, whether provided by the child's parents/guardians or the child care program, should be labeled with the child passenger's name and emergency contact information.
Car safety seats should be replaced if they have been recalled, are past the manufacturer's "date of use" expiration date, or have been involved in a crash that meets the U.S. Department of Transportation crash severity criteria or the manufacturer's criteria for replacement of seats after a crash (3,11).
The temperature of all metal parts of vehicle child restraint systems should be checked before use to prevent burns to child passengers.

If the child care program uses a vehicle that meets the definition of a school bus and the school bus has safety restraints, the following should apply:

The school bus should accommodate the placement of wheelchairs with four tie-downs affixed according to the manufactures' instructions in a forward-facing direction;
The wheelchair occupant should be secured by a three-point tie restraint during transport;
At all times, school buses should be ready to transport children who must ride in wheelchairs;
Manufacturers' specifications should be followed to assure that safety requirements are met.

RATIONALE

According to the National Center for Health Statistics, motor vehicle crashes are the leading cause of death among children ages three to fourteen in the United States (4). Safety restraints are effective in reducing death and injury when they are used properly. The best car safety seat is one that fits in the vehicle being used, fits the child being transported, has never been in a crash, and is used correctly every time. The use of restraint devices while riding in a vehicle reduces the likelihood of any passenger suffering serious injury or death if the vehicle is involved in a crash. The use of child safety seats reduces risk of death by 71% for children less than one year of age and by 54% for children ages one to four (4). In addition, booster seats reduce the risk of injury in a crash by 45%, compared to the use of an adult seat belt alone (5).

The safest place for all infants and children under thirteen years of age is to ride in the back seat. Head-on crashes cause the greatest number of serious injuries. A child sitting in the back seat is farthest away from the impact and less likely to be injured or killed. Additionally, new cars, trucks and vans have had air bags in the front seats for many years. Air bags inflate at speeds up to 200 mph and can injure small children who may be sitting too close to the air bag or who are positioned incorrectly in the seat. If the infant is riding in the front seat, a rapidly inflating air bag can hit the back of a rear-facing infant seat behind a baby's head and cause severe injury or death. For this reason, a rear-facing infant must NEVER be placed in the front seat of a vehicle with active passenger air bags.

Infants under one year of age have less rigid bones in the neck. If an infant is placed in a child safety seat facing forward, a collision could snap the infant's head forward, causing neck and spinal cord injuries. If an infant is placed in a child safety seat facing the rear of the car, the force of a collision is absorbed by the child restraint and spread across the infant's entire body. The rigidity of the bones in the neck, in combination with the strength of connecting ligaments, determines whether the spinal cord will remain intact in the vertebral column. Based on physiologic measures, immature and incompletely ossified bones will separate more easily than more mature vertebrae, leaving the spinal cord as the last link between the head and the torso (6). After twelve months of age, more moderate consequences seem to occur than before twelve months of age (7). However, rear-facing positioning that spreads deceleration forces over the largest possible area is an advantage at any age. Newborns seated in seat restraints or in car beds have been observed to have lower oxygen levels than when placed in cribs, as observed over a period of 120 minutes in each position (8).

As of March 1, 2010, all but three states required booster seat use for children up to as high as nine years of age. Child passenger restraints are recommended increasingly for older children. State child restraint requirements are listed by state at: http://www.iihs.org/laws/ChildRestraint.aspx. Booster seats are recommended for use only with both lap and shoulder belts; NEVER install a booster seat with the lap belt only. When the vehicle safety belts fit properly, the lap belt lies low and tightly across the child's upper thighs (not the abdomen) and the shoulder belt lies flat across the chest and shoulder, away from the neck and face.

COMMENTS

A Child Passenger Safety Technician may be able to help find a car safety seat that fits a larger child. Car safety seat manufacturers increasingly are making car safety seats that fit larger children. To locate a Child Passenger Safety Technician see https://ssl13.cyzap.net/dzapps/dbzap.bin/apps/assess/webmembers/tool?pToolCode=TAB9&pCategory1=TAB9_CERTSEARCH&Webid=SAFEKIDSCERTSQL. See http://www.healthychildren.org/English/safety-prevention/on-the-go/pages/Car-Safety-Seats
-Product-Listing-2010.aspx for a list of available car safety seats. For toddlers or young children whose behavior will not yet allow safe use of a booster seat but who are too large for a forward-facing seat with a harness, caregivers/teachers can consider using a travel vest (9).

TYPE OF FACILITY

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

RELATED STANDARDS

9.2.5.1 Transportation Policy for Centers and Large Family Homes
9.2.5.2 Transportation Policy for Small Family Child Care Homes
2.2.0.2 Limiting Infant/Toddler Time in Crib, High Chair, Car Seat, Etc.
6.5.3.1 Passenger Vans

REFERENCES

Durbin, D. R., American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2011. Policy statement: Child passenger safety. Pediatrics 127:788-93.
Child Restraint Safety. Manufacture and expiration. http://www.childrestraintsafety.com/manufacture-expiration.html.
American Academy of Pediatrics. 2015. Car safety seats: Information for families for 2015. http://www.healthychildren.org/English/safety-prevention/on-the-go/Pages/Car-Safety-Seats-Information-for-Families.aspx
American Academy of Pediatrics. Obese children and car safety seats: Suggestions for parents. http://www.healthychildren.org/English/safety-prevention/on-the-go/Pages/Car-Safety-Seats-and-Obese-Children-Suggestions-for-Parents.aspx
Cerar, L. K., C. V. Scirica, I. S. Gantar, D. Osredkar, D. Neubauer, T. B. Kinane. 2009. A comparison of respiratory patterns in healthy term infants placed in car safety seats and beds.Pediatrics124: e396-e402.
Weber, K., D. Dalmotas, B. Hendrick. 1993.Investigation of dummy response and restraint configuration factors associated with upper spinal cord injury in a forward-facing child restraint. Warrendale, PA: Society of Automotive Engineers.
Huelke, D. F., G. M. Mackay, A. Morris, M. Bradford. 1993.Car crashes and non-head impact cervical spine injuries in infants and children. Warrendale, PA: Society of Automotive Engineers.
Arbogast, K. B., J. S. Jermakian, M. J. Kallan, D. R. Durbin. 2009. Effectiveness of belt positioning booster seats: An updated assessment.Pediatrics124:1281-86
National Highway Traffic Safety Administration's National Center for Statistics and Analysis 2008.Traffic safety facts, 2008, Children. http://www-nrd.nhtsa.dot.gov/Pubs/811157.PDF.
National Highway Traffic Safety Administration. Child restraint re-use after minor crashes.http://www.nhtsa.dot.gov/people/injury/childps/ChildRestraints/ReUse/index.htm.
National Highway Trafic Safety Administration. Questions and answers about air bag safety. Safe and Sober Campaign. http://www.nhtsa.gov/people/injury/alcohol/Archive/Archive/safesobr/12qp/airbag.html.

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.

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):

After ten minutes: 99°F inside car;
After twenty minutes: 109°F;
After thirty minutes 114°F;
After forty minutes: 118°F;
After fifty minutes: 120°F;
After sixty minutes: 123°F.

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).

TYPE OF FACILITY

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

REFERENCES

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.
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.

Food Preparation and Feeding Area

Standard 4.5.0.2: Tableware and Feeding Utensils

Tableware and feeding utensils should meet the following requirements:

Dishes should have smooth, hard, glazed surfaces and should be free from cracks or chips. Sharp-edged plastic utensils (intended for use in the mouth) or dishes that have sharp or jagged edges should not be used;
Imported dishes and imported ceramic dishware or pottery should be certified by the regulatory health authority to meet U.S. standards and to be safe from lead or other heavy metals before they can be used;
Disposable tableware (such as plates, cups, utensils made of heavy weight paper, food-grade medium- weight or BPA- or phthalates-free plastic) should be permitted for single service if they are discarded after use. The facility should not use foam tableware for children under four years of age (1,2);
Single-service articles (such as napkins, paper placemats, paper tablecloths, and paper towels) should be discarded after one use;
Washable bibs, placemats, napkins, and tablecloths, if used, should be laundered or washed, rinsed, and sanitized after each meal. Fabric articles should be sanitized by being machine-washed and dried after each use;
Highchair trays, plates, and all items used in food service that are not disposable should be washed, rinsed, and sanitized. Highchair trays that are used for eating should be washed, rinsed, and sanitized just before and immediately after they are used for eating. Children who eat at tables should have disposable or washed and sanitized plates for their food;
All surfaces in contact with food should be lead-free (3);
Tableware and feeding utensils should be child-sized and developmentally appropriate.

RATIONALE

Clean food service utensils, napkins, bibs, and tablecloths prevent the spread of microorganisms that can cause disease. The surfaces that are in contact with food must be sanitary.

Food should not be put directly on the table surface for two reasons. First, even washed and sanitized tables are more likely to be contaminated than disposable plates or washed and sanitized dishes. Second, eating from plates reduces contamination of the table surface when children put down their partially eaten food while they are eating.

Although highchair trays can be considered tables, they function as plates for seated children. The tray should be washed and sanitized before and after use (4). The use of disposable items eliminates the spread of contamination and disease and fosters safety and injury prevention. Single-service items are usually porous and should not be washed and reused. Items intended for reuse must be capable of being washed, rinsed, and sanitized.

Medium-weight plastic should be chosen because lighter-weight plastic utensils are more likely to have sharp edges and break off small pieces easily. Sharp-edged plastic spoons can cut soft oral tissues, especially when an adult is feeding a child and slides the spoon out of the child's closed mouth. Older children can cut their mouth tissues in the same way.

Foam can break into pieces that can become choking hazards for young children.

Imported dishware may be improperly fired and may release toxic levels of lead into food. U.S. government standards prevent the marketing of domestic dishes with lead in their glazes. There is no safe level of lead in dishware.

COMMENTS

Ideally, food should not be placed directly on highchair trays, as studies have shown that highchair trays can be loaded with infectious microorganisms. If the highchair tray is made of plastic, is in good repair, and is free from cracks and crevices, it can be made safe if it is washed and sanitized before placing a child in the chair for feeding and if the tray is washed and sanitized after each child has been fed. Food must not be placed directly on highchair trays made of wood or metal, other than stainless steel, to prevent contamination by infectious microorganisms or toxicity from metals.

TYPE OF FACILITY

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

RELATED STANDARDS

4.9.0.9 Cleaning Food Areas and Equipment
5.2.9.9 Plastic Containers and Toys

REFERENCES

Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. Recommendations for care of children in special circumstances. In:Red Book: 2015 Report to the Committee of Infectious Diseases.30^th Ed. Elk Grove Village, IL: American Academy of Pediatrics.
Center for Disease Control and Prevention. 2017. Lead. https://www.cdc.gov/nceh/lead/.
Safer Chemicals, Healthy Families. 2017. Styrene and styrofoam 101.
http://saferchemicals.org/2014/05/26/styrene-and-styrofoam-101-2/.
Eco-Healthy Child Care. 2016. Plastics & plastic toys. http://cehn.org/wpcontent/uploads/2015/12/Plastics_Plastic_Toys_6_16.pdf.

Standard 4.8.0.1: Food Preparation Area

The food preparation area of the kitchen should be separate from eating, play, laundry, toilet, and bathroom areas and from areas where animals are permitted. The food preparation area should not be used as a passageway while food is being prepared. Food preparation areas should be separated by a door, gate, counter, or room divider from areas the children use for activities unrelated to food, except in small family child care homes when separation may limit supervision of children.

Infants and toddlers should not have access to the kitchen in child care centers. Access by older children to the kitchen of centers should be permitted only when supervised by staff members who have been certified by the nutritionist/registered dietitian or the center director as qualified to follow the facility's sanitation and safety procedures.

In all types of child care facilities, children should never be in the kitchen unless they are directly supervised by a caregiver/teacher. Children of preschool-age and older should be restricted from access to areas where hot food is being prepared. School-age children may engage in food preparation activities with adult supervision in the kitchen or the classroom. Parents/guardians and other adults should be permitted to use the kitchen only if they know and follow the food safety rules of the facility. The facility should check with local health authorities about any additional regulations that apply.

RATIONALE

The presence of children in the kitchen increases the risk of contamination of food and the risk of injury to children from burns. Use of kitchen appliances and cooking techniques may require more skill than can be expected for children's developmental level. The most common burn in young children is scalding from hot liquids tipped over in the kitchen (1).

The kitchen should be used only by authorized individuals who have met the requirements of the local health authority and who know and follow the food safety rules of the facility so they do not contaminate food and food surfaces for food-related activities. Under adult supervision, school-age children may be encouraged to help with developmentally appropriate food preparation, which increases the likelihood that they will eat new foods.

TYPE OF FACILITY

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

RELATED STANDARDS

Appendix C: Nutrition Specialist, Registered Dietitian, Licensed Nutritionist, Consultant, and Food Service Staff Qualifications

REFERENCES

Ring, L. M. 2007. Kids and hot liquids–A burning reality. J Pediatric Health Care 21:192-94.

Standard 4.8.0.8: Microwave Ovens

Microwave ovens should be inaccessible to all children, with the exception of school-age children under close adult supervision. Any microwave oven in use in a child care facility should be manufactured after October 1971 and should be in good condition. While the microwave is being used, it should not be left unattended.

If foods need to be heated in a microwave:

Avoid heating foods in plastic containers;
Avoid transferring hot foods/drinks into plastic containers;
Do not use plastic wrap or aluminum foil in the microwave;
Avoid plastics for food and beverages labeled "3" (PVC), "6" (PS), and "7" (polycarbonate);
Stir food before serving to prevent burns from hot spots.

RATIONALE

Young children can be burned when their faces come near the heat vent. The issues involved with the safe use of microwave ovens (such as no metal and steam trapping) make use of this equipment by preschool-age children too risky. Older ovens made before the Federal standard went into effect in October 1971 can expose users or passers-by to microwave radiation. If adults or school-age children use a microwave, it is recommended that they do not heat food in plastic containers, plastic wrap or aluminum foil due to concerns of releasing toxic substances even if the container is specified for use in a microwave (1).

COMMENTS

If school-age children are allowed to use a microwave oven in the facility, this use should be closely supervised by an adult to avoid injury. See Standard 4.3.1.9 for prohibition of use of microwave ovens to warm infant feedings.

TYPE OF FACILITY

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

RELATED STANDARDS

4.3.1.9 Warming Bottles and Infant Foods
5.2.9.9 Plastic Containers and Toys

REFERENCES

Institute for Agriculture and Trade Policy (IATP), Food and Health Program. 2005. Smart plastics guide: Healthier food uses of plastics for parents and children. Minneapolis, MN: IATP.

Standard 5.3.1.8: High Chair Requirements

High chairs, if used, should have a wide base and a securely locking tray, along with a crotch bar/guard to prevent a child from slipping down and becoming entrapped between the tray and the seat. High chairs should also be equipped with a safety strap to prevent a child from climbing out of the chair. The safety strap should be fastened with every use. Caps or plugs on tubing should be firmly attached. Folding high chairs should have a locking device that prevents the high chair from collapsing. High chairs should be labeled or warranted by the manufacturer in documents provided at the time of purchase or verified thereafter by the manufacturer as meeting the ASTM International current Standard F404-08 Consumer Safety Specification for High Chairs. High chairs should be used in accordance with manufacturer's instructions including following restrictions based on age and minimum/maximum weight of children.

Highchairs should be kept far enough away from a table, counter, wall or other surface so that the child can't use them to push off or to grab potentially dangerous cords or objects.

RATIONALE

High chairs offer potential for entrapment, falls and other injuries. Current ASTM Standard F404-08 Consumer Safety Specifications for High Chairs covers:

Sharp edges;
Locking devices;
Drop tests of the tray;
Disengagement of the tray;
Load and stability of the chair;
Protection from coil springs and scissoring;
Maximum size of holes;
Restraining system tests;
Labeling;
Instructional literature.

COMMENTS

The general age of high chair users is about six-months- to three-years-old (1). Caregivers/teachers should transition children from high chairs to small tables and chairs as soon as they are capable of using them.

TYPE OF FACILITY

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

REFERENCES

Lerner, N. D., R. W. Huey, B. M. Kotwal. 2001. Product profile report, 19. Rockville, MD: Westat.
U.S. Consumer Product Safety Commission (CPSC). Tips for your baby's safety. http://www.nchh.org/Portals/0/Contents/CPSC_Baby_Safety_Checklist.pdf

Play Areas

Standard 5.2.9.7: Proper Use of Art and Craft Materials

Only art and craft materials that are approved by the Art and Creative Materials Institute (ACMI) should be used in the child care facility. Art and craft materials should conform to all applicable ACMI safety standards. Materials should be labeled in accordance with the chronic hazard labeling standard, ASTM D4236.

The facility should prohibit use of unlabeled, improperly labeled old, or donated materials with potentially harmful ingredients.

Caregivers/teachers should closely supervise all children using art and craft materials and should make sure art and craft materials are properly used, cleaned up, and stored in original containers that are fully labeled. Materials should be age-appropriate. Children should not eat or drink while using art and craft materials.

Caregivers/teachers should have emergency protocols in place in the event of an injury, poisoning, or allergic reaction. If caregivers/teachers suspect a poisoning may have occurred they should call their poison center at 1-800-222-1222. Rooms should be well ventilated while using art and craft materials.

Only ACMI-approved unscented water-based markers should be used for children's art projects and work.

RATIONALE

Contamination and injury may occur if art and craft materials are improperly used or labeled. Labels are required on art supplies to identify any hazardous ingredients, risks associated with their use, precautions, first aid, and sources of further information (1).

Art material, approved by the ACMI, has been tested for both chronic and acute health hazards. The ACMI AP (Approved Product) Seal, with or without Performance Certification, identifies art materials that are safe and that are certified in a toxicological evaluation by a medical expert to contain no materials in sufficient quantities to be toxic or injurious to humans, including children, or to cause acute or chronic health problems. This seal is currently replacing the previous non-toxic seals: CP (Certified Product), AP (Approved Product), and HL Health Label (Non-Toxic) over a ten-year phase-in period. Such products are certified by ACMI to be labeled in accordance with the chronic hazard labeling standard, ASTM D4236, and the U.S. Labeling of Hazardous Art Materials Act (LHAMA). Additionally, products bearing the AP Seal with Performance Certification or the CP Seal are certified to meet specific requirements of material, workmanship, working qualities, and color developed by ACMI and others through recognized standards organizations, such as the American National Standards Institute (ANSI) and ASTM International. Some products cannot attain this performance certification because no quality standard currently exists for certain types of products (1).

Children have been known to try and eat fruit-scented markers. Solvent-based/permanent markers can trigger headaches and/or asthma (3).

COMMENTS

Non-toxic art and craft supplies intended for children are readily available.

TYPE OF FACILITY

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

RELATED STANDARDS

5.2.1.4 Ventilation When Using Art Materials

REFERENCES

Art and Creative Materials Institute. 2010. Safety - what you need to know. http://www.acminet.org/Safety.htm.
U.S. Consumer Product Safety Commission (CPSC). Art and craft safety guide. Bethesda, MD: CPSC. http://www.cpsc.gov/cpscpub/pubs/5015.pdf.
Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.

Standard 5.3.1.9: Carriage, Stroller, Gate, Enclosure, and Play Yard Requirements

Each carriage, stroller, gate, enclosure, and play yard used should meet the corresponding ASTM International standard and should be so labeled on the equipment.

Carriages/strollers: ASTM F833-10 Standard Consumer Safety Performance Specification for Carriages and Strollers;
Gates/enclosures: ASTM F1004-10 Consumer Safety Specification for Expansion Gates and Expandable Enclosures;
Play yards: ASTM F406-10 Consumer Safety Specification for Non-Full-Size Baby Cribs/Play Yards.

RATIONALE

The presence of a Juvenile Products Manufacturers Association (JPMA) certification seal on products that are made for children ensures that the product is in compliance with the requirements of the current safety standard for that product at the time of manufacture.

COMMENTS

ASTM also maintains a website at http://www.astm.org with the latest standards on high chair specifications. For more information, contact the JPMA or the ASTM.

TYPE OF FACILITY

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

Standard 6.2.1.1: Play Equipment Requirements

Play equipment and materials in the facility should meet the recommendations of the U.S. Consumer Product Safety Commission (CPSC) and the ASTM International (ASTM) for public playground equipment. Equipment and materials intended for gross-motor (active) play should conform to the recommendations in the CPSC Public Playground Safety Handbook and the provisions in the ASTM "Standard F1487-07ae1: Consumer Safety Performance Specifications for Playground Equipment for Public Use."

All play equipment should be constructed, installed, and made available to the intended users in such a manner that meets CPSC guidelines and ASTM standards, as warranted by the manufacturers' recommendations. A Certified Playground Safety Inspector (CPSI) who has been certified by the National Recreation and Park Association (NRPA) should conduct an inspection of playground plans for new installations. Previously installed playgrounds should be inspected at least once each year, by a CPSI or local regulatory agency, and whenever changes are made to the equipment or intended users.

Inspectors should specifically test wooden play equipment structures for chromated copper arsenate (CCA). The wood in many playground sets can contain potentially hazardous levels of arsenic due to the use of CCA as a wood preservative.

Play equipment and materials should be deemed appropriate to the developmental needs, individual interests, abilities, and ages of the children, by a person with at least a master's degree in early childhood education or psychology, or identified as age-appropriate by a manufacturer's label on the product package. Enough play equipment and materials should be available to avoid excessive competition and long waits.

The facility should offer a wide variety of age-appropriate portable play equipment (e.g., balls, jump ropes, hoops, ribbons, scarves, push/pull toys, riding toys, rocking and twisting toys, sand and water play toys) in sufficient quantities that multiple children can play at the same time (1-5).

Children should always be supervised when playing on playground equipment.

RATIONALE

The active play areas of a child care facility are associated with frequent and severe injuries (8). Many technical design and installation safeguards are addressed in the ASTM and CPSC standards. Manufacturers who guarantee that their equipment meets these standards and provide instructions for use to the purchaser ensure that these technical requirements will be met under threat of product liability. Certified Playground Safety Inspectors (CPSI) receive training from the NPRA in association with the National Playground Safety Institute (NPSI). Since the training received by CPSIs exceeds that of most child care personnel, obtaining a professional inspection to detect playground hazards before they cause injury is highly worthwhile.

Playgrounds designed for older children might present intrinsic hazards to preschool-age children. Equipment that is sized for larger and more mature children poses challenges that younger, smaller, and less mature children may not be able to meet.

The health effects related to arsenic include: irritation of the stomach and intestines, birth or developmental effects, cancer, infertility, and miscarriages in women. CCA is a wood preservative and insecticide that is made up of 22% arsenic, a known carcinogen. Much of the wood in playground equipment contains high levels of this toxic substance. In 2004, CCA was phased-out for residential uses; however, older, treated wood is a still a health concern, particularly for children (6).

COMMENTS

Compliance should be measured by structured observation.

TYPE OF FACILITY

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

RELATED STANDARDS

2.2.0.1 Methods of Supervision of Children
3.3.0.2 Cleaning and Sanitizing Toys
6.2.3.1 Prohibited Surfaces for Placing Climbing Equipment
6.2.5.1 Inspection of Indoor and Outdoor Play Areas and Equipment

REFERENCES

Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.
ASTM International (ASTM). 2007. Standard consumer safety performance specification for playground equipment for public use. ASTM F1487-07ae1. West Conshohocken, PA: ASTM.
American Academy of Pediatrics (AAP), Committee on Environmental Health. 2003. Arsenic. In Pediatric environmental health, ed. R. A. Etzel. Elk Grove Village, IL: AAP.
Dowda, M., W. H. Brown, et al. 2009. Policies and characteristics of the preschool environment and physical activity of young children. Pediatrics 123: e261-66.
Brown, W. H., K. A. Pfeiffer, et al. 2009. Social and environmental factors associated with preschoolers' nonsedentary physical activity. Child Development 80:45-58.
Bower, J. K., D. P. Hales, et al. 2008. The childcare environment and children's physical activity. Am J Prev Med 34:23-29.
Ammerman, A. S., D. S. Ward, et al. 2007. An intervention to promote healthy weight: Nutrition and physical activity self-assessment for child care (NAP SACC) theory and design. Prev Chronic Dis 4 (July).
Ammerman, A., S. E. Benjamin, et al. 2004. The nutrition and physical activity self assessment for child care (NAP SACC). Raleigh and Chapel Hill, NC: Division of Public Health, Center for Health Promotion and Disease Prevention.

Standard 6.2.1.7: Enclosure of Moving Parts on Play Equipment

All pieces of play equipment should be designed so moving parts (swing components, teeter-totter mechanism, spring-ride springs, and so forth) will be shielded or enclosed. Teeter-totters should not be used by preschool-age children unless they are equipped with a spring centering device and have an appropriate shock-absorbing material underneath the seats. Use of teeter totters is prohibited for infants and toddlers (1-3).

RATIONALE

Playground injuries often involve pinching, catching, or crushing of body parts or clothing by equipment mechanisms (4).

COMMENTS

For more information on play equipment with moving parts, see the U.S. Consumer Product Safety Commission (CPSC) and ASTM International (ASTM) standards "F1487-07ae1: Standard Consumer Safety Performance Specification for Playground Equipment for Public Use" and "F2373-08: Standard Consumer Safety Performance Specification for Public Use Play Equipment for Children 6 Months through 23 Months."

TYPE OF FACILITY

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

REFERENCES

Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.
ASTM International (ASTM). 2008. Standard consumer safety performance specification for public use play equipment for children 6 months through 23 months. ASTM F2373-08. West Conshohocken, PA: ASTM.
ASTM International (ASTM). 2007. Standard consumer safety performance specification for playground equipment for public use. ASTM F1487-07ae1. West Conshohocken, PA: ASTM.
U.S. Consumer Product Safety Commission (CPSC). 2008. Public playground safety handbook. Bethesda, MD: CPSC. http://www.cpsc.gov/cpscpub/pubs/325.pdf.

Standard 6.2.1.9: Entrapment Hazards of Play Equipment

All openings in pieces of play equipment should be designed too large for a child's head to get stuck in or too small for a child's body to fit into, in order to prevent entrapment and strangulation. Openings in exercise rings (overhead hanging rings such as those used in a ring trek or ring ladder) should be smaller than three and one-half inches or larger than nine inches in diameter. Rings on long chains are prohibited. A play structure should have no openings with a dimension between three and one-half inches and nine inches. In particular, side railings, stairs, and other locations where a child might slip or try to climb through should be checked for appropriate dimensions.

Protrusions such as pipes, wood ends, or long bolts that may catch a child's clothing are prohibited. Distances between two vertical objects that are positioned near each other should be less than three and one-half inches to prevent entrapment of a child's head. No opening should have a vertical angle of less than fifty-five degrees. To prevent entrapment of fingers, openings should not be larger than three-eighths inch or smaller than one inch. A Certified Playground Safety Inspector (CPSI) is specially trained to find and measure various play equipment hazards.

RATIONALE

Any equipment opening between three and one-half inches and nine inches in diameter presents the potential for head entrapment. Similarly, openings between three-eighths inch and one inch can cause entrapment of the child's fingers (1-2).

COMMENTS

To locate a CPSI, check the National Park and Recreation Association (NPRA) registry at https://ipv
.nrpa.org/CPSI_registry/.

TYPE OF FACILITY

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

REFERENCES

Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.
U.S. Consumer Product Safety Commission (CPSC). 2008. Public playground safety handbook. Bethesda, MD: CPSC. http://www.cpsc.gov/cpscpub/pubs/325.pdf.

Standard 6.2.4.3: Sensory Table Materials

All materials used in a sensory table should be nontoxic and should not be of a size or material that could cause choking. Sensory table activities should not be used with children under eighteen months of age. For toddlers, materials should be limited to water, sand and fixed plastic objects. All sensory table activities should be supervised for toddlers and preschool children. When water is used in a sensory table, the requirements of Standard 6.2.4.2, Water Play Tables should be met.

RATIONALE

According to the federal government's small parts standard on safe-size toys for children under three years of age, a prohibited small part is any object that fits completely into a specially designed test cylinder two and one-quarter inches long by one and one-quarter inches wide, which approximates the size of the fully expanded throat of a child under three-years-old. Since round objects are more likely to choke children because they can completely block a child's airway, balls and toys with parts that are spheroid, ovoid, or elliptical with a diameter smaller than one and three-quarter inches should be banned for children under three years old (4,5); any part smaller than this is a potential choking hazard (5). Injury and fatality from aspiration of small parts is well-documented (4). Eliminating small parts from children's environment will greatly reduce this risk.

According to the U.S. Food and Drug Administration (FDA), eating as few as four or five uncooked kidney beans can cause severe nausea, vomiting, and diarrhea. In addition to their toxicity, raw kidney beans are small objects that could be inserted by a child into his nose or ear; beans can potentially get stuck, swell, and be difficult to remove (1). Styrofoam peanuts could cause choking. Flour could be aspirated and affect breathing; if spilled on the floor, flour could cause slipping. If soil is used, it must be free from chemicals such as fertilizer or pesticides.

Sensory table activities/materials are not developmentally appropriate for children under the age of eighteen months; the potential health and safety hazards outweigh the benefits for use with this age group. Supervision is required for toddlers and preschool-age children to ensure that they are using materials appropriately (2,3).

Sand used in sensory tables should be new "sterilized" natural sand that is labeled for use in children's sandboxes or labeled as play sand. Water used in sensory tables must be potable and clean.

COMMENTS

Children's hands should be washed before and after using the sensory table. Children with open areas (cuts/sores) should not be allowed to use the sensory table.

TYPE OF FACILITY

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

RELATED STANDARDS

3.2.2.1 Situations that Require Hand Hygiene
3.3.0.2 Cleaning and Sanitizing Toys
6.2.4.1 Sandboxes
6.2.4.2 Water Play Tables
6.4.1.2 Inaccessibility of Toys or Objects to Children Under Three Years of Age

REFERENCES

American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement: Prevention of choking among children. Pediatrics 125:601-7.
U.S. Consumer Product Safety Commission (CPSC). 2004. CPSC warns parents about choking hazards to young children, announces new recall of toys posing choking hazards. Release #04-216. http://www.cpsc.gov/cpscpub/prerel/prhtml04/04216.html.
Cryer, D., T. Harms, C. Riley. 2004. All about the ITERS-R. Lewisville, NC: Kaplan Early Learning.
Harms, T., D. Cryer, R. M. Clifford. 2006. Infant/toddler environment rating scale. Rev ed. New York: Teachers College Press. http://ers.fpg.unc.edu/
infanttoddler-environment-rating-scales-iters-r/.
California Childcare Health Program, University of California San Francisco School of Nursing. Health and safety tip. Child Care Health Connections 16:1. http://www.ucsfchildcarehealth.org/pdfs/newsletters/2003/CCHPJul_Aug03.pdf.

Standard 6.4.1.2: Inaccessibility of Toys or Objects to Children Under Three Years of Age

Small objects, toys, and toy parts available to children under the age of three years should meet the federal small parts standards for toys. The following toys or objects should not be accessible to children under three years of age:

Toys or objects with removable parts with a diameter less than one and one-quarter inches and a length between one inch and two and one-quarter inches;
Balls and toys with spherical, ovoid (egg shaped), or elliptical parts that are smaller than one and three-quarters inches in diameter;
Toys with sharp points and edges;
Plastic bags;
Styrofoam objects;
Coins;
Rubber or latex balloons;
Safety pins;
Marbles;
Magnets;
Foam blocks, books, or objects;
Other small objects;
Latex gloves;
Bulletin board tacks;
Glitter.

RATIONALE

Injury and fatality from aspiration of small parts is well-documented (1,2). Eliminating small parts from children's environment will greatly reduce the risk (2). Objects should not be small enough to fit entirely into a child's mouth.

According to the federal government's small parts standard on a safe-size toy for children under three years of age, a small part should be at least one and one-quarter inches in diameter and between one inch and two and one-quarter inches long; any part smaller than this has a potential choking hazard.

Magnets generally are small enough to pass through the digestive tract, however, they can attach to each other across intestinal walls, causing obstructions and perforations within the gastrointestinal tract (5).

Glitter, inadvertently rubbed in eyes, has been known to scratch the surface of the eye and is especially hazardous in children under three years of age (3).

Toys can also contain many chemicals of concern such as lead, phthalates found in many polyvinylchloride (PVC) plastics, cadmium, chlorine, arsenic, bromine, and mercury. When children put toys in their mouths, they may be exposed to these chemicals.

COMMENTS

Toys or games intended for use by children three to five years of age and that contain small parts should be labeled "CHOKING HAZARD--Small Parts. Not for children under three." Because choking on small parts occurs throughout the preschool years, small parts should be kept away from children at least up to three years of age. Also, children occasionally have choked on toys or toy parts that meet federal standards, so caregivers/teachers must constantly be vigilant (2).

TYPE OF FACILITY

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

REFERENCES

Centers for Disease Control and Prevention. 2006. Gastrointestinal injuries from magnet ingestion in children — United States, 2003-2006. MMWR 55:1296-1300.
HealthyStuff.org. Chemicals of concern: Introduction. http://www.healthystuff.org/departments/toys/chemicals.introduction.php.
Southern Daily Echo. 2009. Dr. John Heyworth from Southampton General Hospital warns about festive injuries. http://www.dailyecho.co.uk/news/4814667.City_doctor_warns_about_bizarre_Christmas_injuries/.
Chowdhury, R. T., U.S. Consumer Product Safety Commission. 2008. Toy-related deaths and injuries, calendar year 2007. Washington, DC: CPSC. http://www.cpsc.gov/LIBRARY/toymemo07.pdf.
American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement: Prevention of choking among children. Pediatrics 125:601-7.

Standard 6.4.1.3: Crib Toys

Crib gyms, crib toys, mobiles, mirrors, and all objects/toys are prohibited in or attached to an infant's crib. Items or toys should not be hung from the ceiling over an infant's crib.

RATIONALE

Falling objects could cause injury to an infant lying in a crib.

The presence of crib gyms presents a potential strangulation hazard for infants who are able to lift their head above the crib surface. These children can fall across the crib gym and not be able to remove themselves from that position (1).

The presence of mobiles, crib toys, mirrors, etc. present a potential hazard if the objects can be reached and/or pulled down by an infant (1). Some stuffed animals and other objects that dangle from strings can wrap around a child's neck (2).

Soft objects/toys can cause suffocation.

COMMENTS

Ornamental or small toys are often hung over an infant to provide stimulation; however, the crib should be used for sleep only. The crib is not recommended as a place to entertain an infant or to "contain" an infant. If an infant is not content in a crib, the infant should be removed.

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome. 2005. Policy statement: The changing concept of sudden infant death syndrome: Diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk. Pediatrics 116:1245-55.
U.S. Consumer Product Safety Commission (CPSC). CPSC warns of strangulation with crib toys. Consumer Product Safety Alert. http://www.cpsc.gov/cpscpub/pubs/5024.pdf.

Standard 6.4.2.1: Riding Toys with Wheels and Wheeled Equipment

Riding toys (such as tricycles) and wheeled equipment (such as scooters) used in the child care setting should:

Be spokeless;
Be capable of being steered;
Be of a size appropriate for the child;
Have a low center of gravity;
Be in good condition, work properly, and free of sharp edges or protrusions that may injure the children;
Be non-motorized (excluding wheelchairs).

All riders should wear properly fitting helmets. See Standard 6.4.2.2 Helmets, regarding proper usage and type of helmet. Helmets should be removed once children are no longer using wheeled riding toys or wheeled equipment. Children should wear knee and elbow pads in addition to helmets when using wheeled equipment such as scooters, skateboards, rollerblades, etc.

Children should be closely supervised when using riding toys or wheeled equipment.

When not in use, riding toys with wheels and wheeled equipment should be stored in a location where they will not present a physical obstacle to the children and caregivers/teachers. The staff should inspect riding toys and wheeled equipment at least monthly for loose or missing hardware/parts, protrusions, cracks, or rough edges that can lead to injury.

RATIONALE

Riding toys can provide much enjoyment for children. However, because of their high center of gravity and speed, they often cause injuries in young children. Wheels with spokes can potentially cause entrapment injuries. Wearing helmets when children are learning to use riding toys or wheeled equipment teaches children the practice of wearing helmets while using any riding toy or wheeled equipment. Children should remove their helmets when they are no longer using a riding toy or wheeled equipment because helmets can be a potential strangulation hazard if they are worn for other activities (such as playing on playground equipment, climbing trees, etc.) and/or worn incorrectly.

Motorized wheeled equipment (excluding wheelchairs) used by children in a child care setting does not promote good physical activity (2). Vehicles used by children in child care need to be child propelled rather than battery propelled.

The U.S. Consumer Product Safety Commission (CPSC) and Centers for Disease Control and Prevention (CDC) reported in 2000 that 23% of children treated in emergency departments for scooter-related injuries were age eight or under (1).

Helmet use is associated with a reduction in the risk of any head injury by 69%, brain injury by 65%, and severe brain injuries by 74%, and recommended for all children one year of age and over (3).

COMMENTS

Concern regarding the spreading of head lice in sharing helmets should not override the practice of using helmets. The prevention of a potential brain injury heavily outweighs a possible case of head lice. While it is best practice for each child to have his/her own helmet, this may not be possible. If helmets need to be shared, it is recommended to clean the helmet between users. Wiping the lining with a damp cloth should remove any head lice, nits, or fungal spores. More vigorous washing of helmets, using detergents, cleaning chemicals, and sanitizers, is not recommended because these chemicals may cause the physical structure of the impact-absorbing material to deteriorate inside the helmet. The use of these chemicals can also deteriorate the straps used to hold the helmet on the head.

TYPE OF FACILITY

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

RELATED STANDARDS

6.4.1.5 Balloons
6.4.1.2 Inaccessibility of Toys or Objects to Children Under Three Years of Age
6.4.1.3 Crib Toys
3.3.0.2 Cleaning and Sanitizing Toys
3.3.0.3 Cleaning and Sanitizing Objects Intended for the Mouth
6.4.1.4 Projectile Toys
6.4.2.2 Helmets
Appendix II: Bike and Multi-Sport Helmets: Quick-Fit Check

REFERENCES

Thompson, D. C., F. P. Rivara, R. S. Thompson. 1996. Effectiveness of bicycle safety helmets in preventing head injuries: A case-control study. JAMA 276:1968-73.
Griffin, R., C. T. Parks, L. W. Rue, III, G. McGwin, Jr. 2008. Comparison of severe injuries between powered and nonpowered scooters among children age 2 to 12 in the United States. Academic Pediatrics 8:379-82.
Kubiak, R., T. Slongo. 2003. Unpowered scooter injuries in children. Acta Paediatrics 92:50-54.

Standard 6.4.2.2: Helmets

Content in the STANDARD was modified on 3/31/2017.

All children one year of age and over should wear properly fitted and approved helmets while riding toys with wheels (tricycles, bicycles, etc.) or using any wheeled equipment (rollerblades, skateboards, etc.). Helmets should be removed as soon as children stop riding the wheeled toys or using wheeled equipment. Approved helmets should meet the standards of the U.S. Consumer Product Safety Commission (CPSC) (1). The standards sticker should be located on the bike helmet. Bike helmets should be replaced if they have been involved in a crash, the helmet is cracked, when straps are broken, the helmet can no longer be worn properly, or according to recommendations by the manufacturer (usually after three years).
It is not recommended that infants (children under the age of one year) wear helmets or ride as a passenger on wheeled equipment (2).

RATIONALE

Injuries occur when riding tricycles, bicycles, and other riding toys or wheeled equipment. Helmet use is associated with a reduction in the risk of any head injury by 69%, brain injury by 65%, and severe brain injuries by 74%, and recommended for all children one year of age and over (2-4).

Helmets can be a potential strangulation hazard if they are worn for activities other than when using riding toys or wheeled equipment and/or when worn incorrectly.

Infants are just learning to sit unsupported at about nine months of age. Until this age, infants have not developed sufficient bone mass and muscle tone to enable them to sit unsupported with their backs straight. Pediatricians advise against having infants sitting in a slumped or curled position for prolonged periods due to the underdevelopment of their neck muscles (5). This situation may even be exacerbated by the added weight of a bicycle helmet on the infant's head.

COMMENTS

The CPSC helmet standard was published in March 1998 (6). Bike helmets manufactured or imported for sale in the U.S. after January 1999 must meet the CPSC standard. Helmets made before this date will not have a CPSC approval label. However, helmets made before this date should have an ASTM International (ASTM) approval label. The American National Standard Institute (ANSI) standard for helmet approval has been withdrawn, and ANSI approval labels will no longer appear on helmets. The Snell Memorial Foundation also no longer certifies bike helmets.

TYPE OF FACILITY

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

RELATED STANDARDS

6.4.2.1 Riding Toys with Wheels and Wheeled Equipment

REFERENCES

ADDITIONAL REFERENCE:
Centers for Disease Control and Prevention. 2015. Head injuries and bicycle safety. http://www.cdc.gov/healthcommunication/toolstemplates/entertainmented/tips/headinjuries.html.
U.S. Consumer Product Safety Commission (CPSC). 2017. CPSC's Bicycle Helmet Standard. http://www.helmets.org/cpscstd.htm.
Bicycle Helmet Safety Institute. 2016. Should you take your baby along? http://www.helmets.org/little1s.htm.
Head Start. An Office of the Administration of Children and Families Early Childhood Learning & Knowledge Center (ECLKC). 2014. Play it safe: Walking and biking safely. https://eclkc.ohs.acf.hhs.gov/hslc/tta-system/family/for-families/safety/safety-prevention/PlayitSafeWal.htm.
Thompson, D. C., F. P. Rivara, R. S. Thompson. 1996. Effectiveness of bicycle safety helmets in preventing head injuries: A case-control study.JAMA 276:1968-73.
U.S. Consumer Product Safety Commission. 2016. CPSC guidelines for age-related activities. Bicycle Helmet Safety Institute. http://www.helmets.org/ageguide.htm.
U.S. Consumer Product Safety Commission (CPSC). 1998. Safety standard for bicycle helmets. http://www.bhsi.org/cpscstd.pdf.

NOTES

Content in the STANDARD was modified on 3/31/2017.

Program Activities for Healthy Development

Developmentally Appropriate Practice

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

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

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

Parents/guardians should be explicitly invited to:

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

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

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

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

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

RATIONALE

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

COMMENTS

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

Standard 2.1.1.5: Helping Families Cope with Separation

The staff of the facility should engage strategies to help a child and parents/guardians cope with the experience of separation and reunion, such as death of family members, divorce, or placement in foster care.

For the child, this should be accomplished by:

Encouraging parents/guardians to spend time in the facility with the child and supporting the separation transition;
Providing a comfortable setting both indoors and outdoors for parents/guardians to be with their children to transition or to have conversation with staff;
Having established routines for drop-off and pick-up times to assist with transition;
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/guardian);
Encouraging parents/guardians to reassure the child of their return and to calmly say "goodbye";
Helping the child play out themes of separation and reunion;
Frequently exchanging information between the child's parents/guardians and caregivers/teachers, including activities and routine care information particularly during greeting and departing;
Reassuring the child about the parent's/guardian's return;
Ensuring the caregivers/teachers are consistent both within the parts of a day and across days;
Requesting assistance from early childhood mental health consultants, mental health professionals, developmental-behavioral pediatricians, parent/guardian counselors, etc. when a child's adjustment continues to be problematic over time;
When a family is experiencing separation due to a military deployment, explore changes in children's behavior that may be related to feelings of anger, fear, sadness, or uncertainty related to changes in family structure as a result of deployment. Work with the parent/guardian at home to help the child adjust to these changes, including providing activities that help the child remain connected to the deployed parent/guardian and manage their emotions throughout the deployment cycle.

For the parents/guardians, this should be accomplished by:

Validating their feelings as a universal human experience;
Providing parents/guardians with information about the positive effects for children of high quality facilities with strong parent/guardian participation;
Encouraging parents/guardians to discuss their feelings;
Providing parents/guardians with evidence, such as photographs, that their child is being cared for and is enjoying the activities of the facility;
Ask parents/guardians to bring pictures from home that may be placed in the room or cubby and displayed throughout the indoor and outdoor learning/play environment at the child's eye level;
Where a family is experiencing separation due to a military deployment, collaborate with the parent/guardian at home to address changes in children's behavior that may be related to the deployment, providing parents/guardians with information about activities in care and at home may help promote their child's positive adjustment throughout the deployment cycle (connect parents/guardians with services/resources in the community that can help to support them);
Requesting assistance from early childhood mental health consultants, mental health professionals, developmental-behavioral pediatricians, parent/guardian counselors, etc. when a child's adjustment continues to be problematic over time.

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/guardians 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 three months of age. Some parents/guardians prefer combining out-of-home child care with parental/guardian care to provide good experiences for their children and support for other family members to function most effectively. Whether parents/guardians view out-of-home child care as a necessary accommodation to undesired circumstances or a benefit for their family, parents/guardians and their children need help from the caregivers/teachers to accommodate the transitions between home and out-of-home settings (2).

Many parents/guardians experience distress at separation. For most parents/guardians, the younger their child and the less experience they have had with sharing the care of their children with others, the more intense their distress at separation (3).

Although children's responses to deployment separation will vary depending on age, personality, and support received, children will be aware of a parent's/guardian's long-term absence and may mourn. Children may feel uncertain, sad, afraid, or angry. These feelings can manifest as increased clinginess, aggression, withdrawal, changes in sleeping or eating patterns, regression or other behaviors. Young children don't often have the vocabulary to express their emotions, and may need support to express their feelings in healthy and safe ways (2). Additionally, the parent/guardian at home may be experiencing stress, anxiety, depression, or fear. These parents/guardians may benefit from additional outreach from caregivers/teachers, who are part of their community support system, and can help them with strategies to promote children's adjustment and connect them with resources in the community (3).

COMMENTS

Depending on the child's developmental stage, the impact of separation on the child and parent/guardian will vary. Child care facilities should understand and communicate this variation to parents/guardians and work with parents/guardians to plan developmentally appropriate coping strategies for use at home and in the child care setting. For example, a child at eighteen to twenty-four months of age is particularly vulnerable to separation issues and may show visible distress when experiencing separation from parents/guardians. 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 nine to twelve months of age), parents/guardians 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. Parents/guardians and caregivers/teachers reminding a child that the parent/guardian returned as promised reinforces truthfulness and trust. Parents/guardians of children of any age should be encouraged to visit the facility together before the child care officially begins. Parents/guardians of infants may benefit from feeling assured by the caregivers/teachers themselves. Depending on the child's temperament and prior care experience, several visits may be recommended before enrolling as well opportunities to practice the process and consistency of a separation experience in the first weeks of entering the child care. Using a phasing-in period can also be helpful (e.g., spend only a part of the day with parents/guardians on the first day, half-day on the second day, and parents/guardians leave earlier, etc.)

TYPE OF FACILITY

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

RELATED STANDARDS

1.1.2.1 Minimum Age to Enter Child Care
1.6.0.3 Infant and Early Childhood Mental Health Consultants
2.3.1.1 Mutual Responsibility of Parents/Guardians and Staff

REFERENCES

Gonzalez-Mena, J. 2007. Separation: Helping children and families. In 50 Early childhood strategies for working and communicating with diverse families, 96-97. Upper Saddle River, NJ: Prentice Hall.
Kim, A. M., J. Yeary. 2008. Making long-term separations easier for children and families. Young Children 63:32-37.
Blecher-Sass, H. 1997. Good-byes can build trust. Young Child 52:12-14.

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.

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

RELATED STANDARDS

2.1.2.5 Toilet Learning/Training

REFERENCES

Maslow, A. 1943. A theory of human motivation. Psychological Review 50:370-96
Mahler, M., F. Pine, A. Bergman. 1975. The Psychological birth of the human infant. New York: Basic Books.
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.
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.
Erikson, E. H. 1950. Childhood and society. New York: W.W. Norton and Co.

Standard 2.1.1.7: Communication in Native Language Other Than English

At least one member of the staff should be able to communicate with the parents/guardians and children in the family's native language (sign or spoken), or the facility should work with parents/guardians to arrange for a translator to communicate with parents/guardians and children. Efforts should be made to support a child's and family's native language while providing resources and opportunities for learning English (2). Children should not be used as translators. They are not developmentally able to understand the meaning of all words as used by adults, nor should they participate in all conversations that may be regarding the child.

RATIONALE

The future development of the child depends on his/her command of language (1). Richness of language increases as a result of experiences as well as through the child's verbal interaction with adults and peers. Basic communication with parents/guardians and children requires an ability to speak their language. Learning English while maintaining a family's native language enriches child development and strengthens family cultural traditions.

COMMENTS

For resources on bilingual and dual language learning, see the American Academy of Pediatrics Section on Developmental and Behavioral Pediatrics (SODBP) at http://www.aap.org/sections/dbpeds/.

TYPE OF FACILITY

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

REFERENCES

Olsen, L. 2006. Ensuring academic success of English learners. 2006. U.C. Linguistic Minority Research Institute 15:1-7.
Moerk, E. L. 2000. The guided acquisition of first language skills. Advances Applied Dev Psychol 20:248.

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.

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.
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.
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).
Frequent interchange of questions, comments, and responses to children, including extending children's utterances with a longer statement, by teaching staff.
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.
Profanity should not be used at any time.

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

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

REFERENCES

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.
Moerk, E. L. 2000. The guided acquisition of first language skills. Advances in Applied Dev Psychol 20:248.
Kontos, S., A. Wilcox-Herzog. 1997. Teachers' interactions with children: Why are they so important? Young Child 52:4-12.
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.
Baron, N., L. W. Schrank. 1997. Children learning language: How adults can help. Lake Zurich, IL: Learning Seed.
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.

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

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

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

The caregiver/teacher should:

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

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

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

RATIONALE

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

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

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

3.4.4.1 Recognizing and Reporting Suspected Child Abuse, Neglect, and Exploitation
3.4.4.2 Immunity for Reporters of Child Abuse and Neglect
3.4.4.3 Preventing and Identifying Shaken Baby Syndrome/Abusive Head Trauma
3.4.4.4 Care for Children Who Have Experienced Abuse/Neglect
Appendix M: Recognizing Child Abuse and Neglect
Appendix N: Protective Factors Regarding Child Abuse and Neglect

REFERENCES

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

NOTES

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

Standard 2.1.2.2: 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.

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

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

RELATED STANDARDS

2.2.0.3 Screen Time/Digital Media Use

REFERENCES

Snow, C. E., M. S. Burns, P. Griffin. 1999. Language and literacy environments in preschools. ERIC Digest (January).
Kontos, S., A. Wilcox-Herzog. 1997. Teachers' interactions with children: Why are they so important? Young Child 52:4-12.
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/.
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.
Baron, N., L. W. Schrank. 1997. Children learning language: How adults can help. Lake Zurich, Ill: Learning Seed.
Moerk, E. L. 2000. The guided acquisition of first language skills. Advances Applied Dev Psychol 20:248.

Standard 2.1.2.3: Space and Activity to Support Learning of Infants and Toddlers

The facility should provide a safe and clean learning environment, both indoors and outdoors, colorful materials and equipment arranged to support learning. The indoor and outdoor learning/play environment should encourage and be comfortable with staff on the floor level when interacting with active infant crawlers and toddlers. The indoor and outdoor play and learning settings should provide opportunities for the child to act upon the environment by experiencing age-appropriate obstacles, frustrations, and risks in order to learn to negotiate environmental challenges. The facility should provide opportunities for play that:

Lessen the child's anxiety and help the child adapt to reality and resolve conflicts;
Enable the child to explore and experience the natural world;
Help the child practice resolving conflicts;
Use symbols (words, numbers, etc.);
Manipulate objects;
Exercise physical skills;
Encourage language development;
Foster self-expression;
Strengthen the child's identity as a member of a family and a cultural community;
Promote sensory exploration.

For infants and toddlers the curriculum should be based on the child's development at the time and connected to a sound understanding as to where they are in their developmental course.

RATIONALE

Opportunities to be an active learner are vitally important for the development of motor competence and awareness of one's own body and person, the development of sensory motor skills, the ability to demonstrate initiative through active outdoor and indoor play, and feelings of mastery and successful coping. Coping involves original, imaginative, and innovative behavior as well as previously learned strategies.

Learning to resolve conflicts constructively in childhood is essential in preventing violence later in life (1,2). A physical and social environment that offers opportunities for active mastery and coping enhances the child's adaptive abilities (3,4,9). The importance of play for developing cognitive skills, for maintaining an affective and intellectual equilibrium, and for creating and testing new capacities is well recognized (8). Play involves a balance of action and symbolization, and of feeling and thinking (5-7). Children need access to age-appropriate toys and safe household objects.

COMMENTS

For more information regarding appropriate play materials for young children, see "Which Toy for Which Child: A Consumer's Guide for Selecting Suitable Toys" from the U.S. Consumer Product Safety Commission (CPSC) and "The Right Stuff for Children Birth to 8: Selecting Play Materials to Support Development" from the National Association for the Education of Young Children (NAEYC). For information regarding appropriate materials for outdoor play, see POEMS: Preschool Outdoor Environment Measurement Scale (10).

TYPE OF FACILITY

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

RELATED STANDARDS

5.1.2.1 Space Required per Child
5.2.9.14 Shoes in Infant Play Areas
5.3.1.1 Safety of Equipment, Materials, and Furnishings
3.1.3.1 Active Opportunities for Physical Activity
5.3.1.5 Placement of Equipment and Furnishings

REFERENCES

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.
Evaldsson, A., W. A. Corsaro. 1998. Play and games in the peer cultures of preschool and preadolescent children: An interpretative approach. Childhood 5:377-402.
DeBord, K., L. Hestenes, R. Moore, N. Cosco, J. McGinnis. 2005. Preschool outdoor environment measurement scale. Lewisville, NC: Kaplan Early Learning Co.
Torelli, L., C. Durrett. 1996. Landscape for learning: The impact of classroom design on infants and toddlers. Early Childhood News 8 (March-April): 12-17. http://www.spacesforchildren.com/landc1.pdf.
Tepperman, J., ed. 2007. Play in the early years: Key to school success, a policy brief. El Cerrito, CA: Early Childhood Funders. http://www.4children.org/images/pdf/play07.pdf.
Pica, R. 1997. Beyond physical development: Why young children need to move. Young Child 52:4-11.
Petersen, E. A. 1998. The amazing benefits of play. Child Family 17:7-8.
Cartwright, S. 1998. Group trips: An invitation to cooperative learning. Child Care Infor Exch 124:95-97.
Levin, D. E. 1994. Teaching young children in violent times: Building a peaceable classroom, A preschool-grade 3 violence prevention and conflict resolution guide. Cambridge, MA: Educators for Social Responsibility.
Massey, M. S. 1998. Early childhood violence prevention. ERIC Digest (October).

Standard 2.1.2.4: Separation of Infants and Toddlers from Older Children

Infants and toddlers younger than three years of age should be cared for in a closed room(s) that separates them from older children, except in small family child care homes with closed groups of mixed aged children.

In facilities caring for three or more children younger than three years of age, activities that bring children younger than three years of age in contact with older children should be prohibited, unless the younger children already have regular contact with the older children as part of a group.

Pooling, as a practice in larger settings where the infants/toddlers are not part of the group all day – as in home care – should be avoided for the following reasons:

Unfamiliarity with caregivers/teachers if not the primary one during the day;
Concerns of noise levels, space ratios, social-emotional well-being, etc.;
Occurs at times when children are least able to handle transitions;
Increases the number of transitions for children,
Increases the number of adults caring for infants and toddlers, a practice to be avoided if possible.

Caregivers/teachers of infants should not be responsible for the care of older children who are not a part of the infants' closed child care group.

Groups of younger infants should receive care in closed room(s) that separates them from other groups of toddlers and older children.

When partitions are used, they must control interaction between groups, provide separated ventilation of the spaces and control sound transmission. The acoustic controls should limit significant transmission of sound from one group's activity into other group environments.

RATIONALE

Infants need quiet, calm environments, away from the stimulation of older children. Younger infants should be cared for in rooms separate from the more boisterous toddlers. In addition to these developmental needs of infants, separation is important for reasons of disease prevention. Rates of hospitalization for all forms of acute infectious respiratory tract diseases are highest during the first year of life, indicating that respiratory tract illness becomes less severe as the child gets older (1). Therefore, infants should be a focus for interventions to reduce the incidence of respiratory tract diseases. Handwashing and sanitizing practices are key.

Depending on the temperament of the child, an increase in transitions can increase anxiety in young children by reducing the opportunity for routine and predictability (2), and it increases basic health and safety concerns of cross contamination with older children who have more contact with the environment.

COMMENTS

This separation of younger children from older children ideally should be implemented in all facilities, but may be less feasible in small or large family child care homes.

TYPE OF FACILITY

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

RELATED STANDARDS

3.2.2.2 Handwashing Procedure
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting

REFERENCES

Poole, C. 1998. Routine matters. Scholastic Parent Child (August/September).
Izurieta, H. S., W. W. Thompson, P. Kramarz, et al. 2000. Influenza and the rates of hospitalization for respiratory disease among infants and young children. New England J Med 342:232-39.

Standard 2.1.2.5: Toilet Learning/Training

The facility should develop and implement a plan that teaches each child how and when to use the toilet. Toilet learning/training, when initiated, should follow a prescribed, sequential plan that is developed and coordinated with the parent's/guardian's plan for implementation in the home environment. Toilet learning/training should be based on the child's developmental level rather than chronological age.

To help children achieve bowel and bladder control, caregivers/teachers should enable children to take an active role in using the toilet when they are physically able to do so and when parents/guardians support their children's learning to use the toilet.

Diapering/toilet training should not be used as rationale for not spending time outdoors. Practices and policies should be offered to address diapering/toileting needs outdoors such as providing staff who can address children's needs, or provide outdoor diapering and toileting that meets all sanitation requirements.

Caregivers/teachers should take into account the preferences and customs of the child's family.

For children who have not yet learned to use the toilet, the facility should defer toilet learning/training until the child's family is ready to support this learning and the child demonstrates:

An understanding of the concept of cause and effect;
An ability to communicate, including sign language;
The physical ability to remain dry for up to two hours;
An ability to sit on the toilet, to feel/understand the sense of elimination;
A demonstrated interest in autonomous behavior.

For preschool and school-age children, an emphasis should be placed on appropriate handwashing after using the toilet and they should be provided frequent and unrestricted opportunities to use the toilet.

Children with special health care needs may require specific instructions, training techniques, adapted toilets, and/or supports or precautions. Some children will need to be taught special techniques like catheterization or care of ostomies. This can be provided by trained staff or older children can sometimes learn self-care techniques. Any special techniques should be documented in a written care plan. The child care health consultant can provide training or coordinate resources necessary to accommodate special toileting techniques while in child care.

Cultural expectations of toilet learning/training need to be recognized and respected.

RATIONALE

A child's achievements of motor and cognitive or developmental skills assist in determining when s/he is ready for toilet learning/training (1). Physical ability/neurological function also includes the ability to sit on the toilet and to feel/understand the sense of elimination.

Toilet learning/training is achieved more rapidly once expectations from adults across environments are consistent (3). The family may not be prepared, at the time, to extend this learning/training into the home environment (2).

School-age and preschool children may not respond when their bodies signal a need to use the toilet because they are involved in activities or embarrassed about needing to use the toilet. Holding back stool or urine can lead to constipation and urinary tract problems (4). Also, unless reminded, many children forget to correctly wash their hands after toileting.

COMMENTS

The area of toilet learning/training for children with special health care needs is difficult because there are no age-related, disability-specific rules to follow. As a result, support and counseling for parents/guardians and caregivers/teachers are required to help them deal with this issue. Some children with multiple disabilities do not demonstrate any requisite skills other than being dry for a few hours. Establishing a toilet routine may be the first step toward learning to use the toilet, and at the same time, improving hygiene and skin care. The child care health consultant should be considered a resource to assist is supporting special health care needs.

TYPE OF FACILITY

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

RELATED STANDARDS

5.4.1.1 General Requirements for Toilet and Handwashing Areas
5.4.1.4 Preventing Entry to Toilet Rooms by Infants and Toddlers
5.4.1.6 Ratios of Toilets, Urinals, and Hand Sinks to Children
5.4.1.7 Toilet Learning/Training Equipment
3.2.1.5 Procedure for Changing Children's Soiled Underwear, Disposable Training Pants and Clothing
5.4.1.2 Location of Toilets and Privacy Issues
5.4.1.3 Ability to Open Toilet Room Doors
5.4.1.5 Chemical Toilets
5.4.1.8 Cleaning and Disinfecting Toileting Equipment
5.4.1.9 Waste Receptacles in the Child Care Facility and in Child Care Facility Toilet Room(s)

REFERENCES

Schmitt, B. D. 2004. Toilet training problems: Underachievers, refusers, and stool holders. Contemporary Pediatrics 21:71-77.
Anthony-Pillai, R. 2007. What's potty about early toilet training? British Med J 334:1166.
American Academy of Pediatrics. 2009. When is the right time to start toilet training? http://www.aap.org/publiced/BR_ToiletTrain.htm.
Mayo Clinic. 2009. Potty training: How to get the job done. http://www.mayoclinic.com/health/potty-training/CC00060/.

Standard 2.2.0.2: Limiting Infant/Toddler Time in Crib, High Chair, Car Seat, Etc.

Frequently Asked Questions/CFOC Clarifications

Reference: 2.2.0.2

Date: 10/13/2011

Topic & Location:
Chapter 2
Program Activities
Standard 2.2.0.2: Limiting In-fant/Toddler Time in Crib, High Chair, Care Seat, Etc.

Question:
Please provide more contexts surrounding the research that informed the recommendation that "children should not be left to sleep in equipment, such as car seats, swings, or infants seats that do not meet the ASTM International (ASTM) product safety standards for sleep equipment."

Is part of the intent regarding this standard to educate parents about safe infant sleep practices or is it actually dangerous for infants to sleep sitting up, or both?

Answer:
Both. Extended periods of time in the crib, high chair, car seat, or other confined space limits infants' physical growth (gross motor development) and also affects their social interactions. Injuries and Sudden Infant Death Syndrome (SIDS) have occurred when children have been left to sleep in car seats or infants seats.

Please see the Standard's rationale and references for information on related injuries and SIDS.

A child should not sit in a high chair or other equipment that constrains his/her movement (1,2) indoors or outdoors for longer than fifteen minutes, other than at meals or snack time. Children should never be left out of the view and attention of adult caregivers/teachers while in these types of equipment/furniture. A least restrictive environment should be encouraged at all times. Children should not be left to sleep in equipment, such as car seats, swings, or infant seats that does not meet ASTM International (ASTM) product safety standards for sleep equipment.

RATIONALE

Children are continually developing their physical skills. They need opportunities to use and build on their physical abilities. This is especially true for infants and toddlers who are eagerly using their bodies to explore their environment. Extended periods of time in the crib, high chair, car seat, or other confined space limits their physical growth and also affects their social interactions. Injuries and Sudden Infant Death Syndrome (SIDS) have occurred when children have been left to sleep in car seats or infant seats when the straps have entrapped body parts, or the children have turned the seats over while in them. Sleeping in a seated position can restrict breathing and cause oxygen desaturation in young infants (3). Sleeping should occur in equipment manufactured for this activity. When children are awake, restricting them to a seat may limit social interactions. These social interactions are essential for children to gain language skills, develop self-esteem, and build relationships (4).

TYPE OF FACILITY

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

RELATED STANDARDS

5.4.5.1 Sleeping Equipment and Supplies
5.4.5.2 Cribs
3.1.3.1 Active Opportunities for Physical Activity
3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
5.3.1.10 Restrictive Infant Equipment Requirements

REFERENCES

New York State Office of Children and Family Services. Website. http://www.ocfs.state.ny.us/main/.
Bass, J. L., M. Bull. 2008. Oxygen desaturation in term infants in car safety seats. Pediatrics 110:401-2.
Benjamin, S.E., S.L. Rifas-Shiman, E.M. Taveras, J. Haines, J. Finkelstein, K. Kleinman, M.W. Gillman. 2009. Early child care and adiposity at ages 1 and 3 years. Pediatrics 124:555-62.
Kornhauser Cerar, L., C.V. Scirica, I. Stucin Gantar, D. Osredkar, D. Neubauer, T.B. Kinane. 2009. A comparison of respiratory patterns in healthy term infants placed in care safety seats and beds. Pediatrics 124:e396-e402.

Standard 2.2.0.3: Screen Time/Digital Media Use

Frequently Asked Questions/CFOC Clarifications

Reference: 2.2.0.3

Date: 3/8/2012

Topic & Location:
Chapter 2
Program Activities
Standard 2.2.0.3: Limiting Screen Time - Media, Computer Time

Question:
This standard states that children two years and older in early care and education settings should not be exposed to more than thirty minutes per week of screen time and that computer use should be limited to no more than fifteen minute increments.

Is the fifteen minute increment for computer use included in the total screen time of thirty minutes per week?

Answer:
Yes.

Content in the STANDARD was modified on 10/12/2017.

Please note: For the purposes of this standard "screen time/digital media" refers to media content viewed on cell/mobile phone, tablet, computer, television (TV), video, film, and DVD. It does not include video-chatting with family.

Screen time/digital media should not be used with children ages 2 and younger in early care and education settings. For children ages 2 to 5 years, total exposure (in early care and education and at home combined) to digital media should be limited to 1 hour per day of high-quality programming [1], and viewed with an adult who can help them apply what they are learning to the world around them (1).

Children ages 5 and older may need to use digital media in early care and education to complete homework. However, caregivers/teachers should ensure that entertainment media time does not displace healthy activities such as exercise, refreshing sleep, and family time, including meals.

For children of all ages, digital media and devices should not be used during meal or snack time, or during nap/rest times and in bed. Devices should be turned off at least one hour before bedtime. When offered, digital media should be free of advertising and brand placement, violence, and sounds that tempt children to overuse the product.

Caregivers/teachers should communicate with parents/guardians about their guidelines for home media use. Caregivers/teachers should take this information into consideration when planning the amount of media use at the child care program to help in meeting daily recommendations (1).

Programs should prioritize physical activity and increased personal social interactions and engagement during the program day. It is important for young children to have active social interactions with adults and children. Media use can distract children (and adults), limit conversations and play, and reduce healthy physical activity, increasing the risk for overweight and obesity. Media should be turned off when not in use since background media can be distracting, and reduce social engagement and learning. Overuse of media can also be associated with problems with behavior, limit-setting, and emotional and behavioral self-regulation; therefore, caregivers/teachers should avoid using media to calm a child down (1).

Note: The guidance above should not limit digital media use for children with special health care needs who require and consistently use assistive and adaptive computer technology (2). However, the same guidelines apply for entertainment media use. Consultation with an expert in assistive communication may be necessary.

[1] designed with child psychologists and educators to meet specific educational goals

RATIONALE

The first two years of life are critical periods of growth and development for children's brains and bodies, and rapid brain development continues through the early childhood years. To best develop their cognitive, language, motor, and social-emotional skills, infants and toddlers need hands-on exploration and social interaction with trusted caregivers (1). Digital media viewing do not promote such skills development as well as "real life".

Excessive media use has been associated with lags in achievement of knowledge and skills, as well as negative impacts on sleep, weight, and social/emotional health. (1). For example, among 2-year-olds, research has shown that body mass index (BMI) increases with greater weekly media consumption (3).

COMMENTS

TYPE OF FACILITY

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

RELATED STANDARDS

2.2.0.1 Methods of Supervision of Children
2.1.2.1 Personal Caregiver/Teacher Relationships for Infants and Toddlers
3.1.3.1 Active Opportunities for Physical Activity
2.1.3.1 Personal Caregiver/Teacher Relationships for Three- to Five-Year-Olds
2.1.4.3 Developing Relationships for School-Age Children
Appendix S: Physical Activity: How Much Is Needed?

REFERENCES

American Academy of Pediatrics Council on Communications and Media. Media and young minds. Pediatrics. 2016;138(5):e20162591. http://pediatrics.aappublications.org/content/pediatrics/138/5/e20162591.full.pdf
Reid CY, Radesky J, Christakis D, et al., American Academy of Pediatrics Council on Communications and Media. Children and adolescents and digital media. Pediatrics. 2016;138(5):e2016593.
http://pediatrics.aappublications.org/content/early/2016/10/19/peds.2016-2593.
Wen LM, Baur LA, Rissel C, Xu H, Simpson, JM. Correlates of body mass index and overweight and obesity of children aged 2 years: finding from the healthy beginnings trial. Obesity. 2014;22(7):1723-1730.
American Academy of Pediatrics. Council on Early Childhood. Literacy promotion: an essential component of primary care pediatric practice. Pediatrics. 2014;134(2):1-6. http://pediatrics.aappublications.org/content/early/2014/06/19/peds.2014-1384.
American Academy of Pediatrics Council on Communications and Media. Media use in school-aged children and adolescents. Pediatrics. 2016;138(5):e20162592. http://pediatrics.aappublications.org/content/138/5/e20162592.

NOTES

Content in the STANDARD was modified on 10/12/2017.

Standard 2.2.0.5: Behavior Around a Pool

When children are in or around a pool, caregivers/teachers should teach age-appropriate behavior and safety skills including not pushing each other, holding each other under water, or running at the poolside. Children should be shown the depth of the water at different part of the pool. They should be taught that when going into a body of water, they should go in feet first the first time to check the depth. Children should be instructed what an emergency would be and to only call for help only in a real/genuine emergency. They should be taught to never dive in shallow water.

RATIONALE

Caregivers/teachers should take the opportunities to explain how certain behaviors could injure other children. Also such behavior can distract caregivers/teachers from supervising other children, thereby placing the other children at risk (1).

TYPE OF FACILITY

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

REFERENCES

U.S. Department of Health and Human Services, Maternal and Child Health Bureau. 1999. Basic emergency lifesaving skills (BELS): A framework for teaching emergency lifesaving skills to children and adolescents. Newton, MA: Children's Safety Network, Education Development Center. http://bolivia.hrsa.gov/emsc/Downloads/BELS/BELS.htm.

Standard 2.3.1.1: Mutual Responsibility of Parents/Guardians and Staff

The quality of the relationship between parents/guardians and caregivers/teachers has an influence on the child. There should be a reciprocal responsibility of the family and caregivers/teachers to observe, participate, and be trained in the care that each child requires, and they should be encouraged to work together as partners in providing care.

During the enrollment process, caregivers/teachers should clarify who is/are the legal guardian(s) of the child. All relevant legal documents, court orders, etc., should also be collected and filed during the enrollment process (1). Caregivers/teachers should comply with court orders and written consent from the parent/guardian with legal authority, and not try to make the determination themselves regarding the best interests of the child.

All aspects of child care programs should be designed to facilitate parent/guardian input and involvement. Non-custodial parents should have access to the same developmental and behavioral information given to the custodial parent/guardian, if they have joint legal custody, permission by court order, or written consent from the custodial parent/guardian.

Caregivers/teachers should also clarify with whom the child spends significant time and with whom the child has primary relationships as they will be key informants for the caregivers/teachers about the child and his/her needs.

Parent/guardian involvement is needed at all levels of the program, including program planning for indoors and outdoors, provision of quality care, screening for children who are ill, and support for other parents/guardians. Communication between the administrator, caregiver/teacher and parent/guardian are essential to facilitate the involvement and commitment of parents/guardians. Parents/guardians should be invited to participate on the program board or planning meetings for the program. Parents/guardians should meet with their child's caregiver/teacher or the director annually to discuss how their child is doing in the program. On a daily basis, parents/guardians and caregivers/teachers should share information about the child's health, changes in drop-off or pick-up times, and changes in family routines or family events. Caregivers/teachers should communicate regularly with parents/guardians by providing injury report forms if their child sustains an injury, posting notices of exposures to infectious diseases, and greeting the parent/guardian at drop-off each day. Parents/guardians should receive a copy of the child care programs' written policies, including health and safety policies.

Caregivers/teachers should informally share with parents/guardians daily information about their child's needs and activities.

Transition reports on any symptoms that the child developed, differences in patterns of appetite or urinating, and activity level should be exchanged to keep parents/guardians informed.

RATIONALE

This plan will help achieve the important goal of carryover of facility components from the child care setting to the child's home environment. The child's learning of new skills is a continuous process occurring both at home and in child care.

Research, practice, and accumulated wisdom attest to the crucially important influence of children's relationships with those closest to them. Children's experience in child care will be most beneficial when parents/guardians and caregivers/teachers develop feelings of mutual respect and trust. In such a situation, children feel a continuity of affection and concern, which facilitates their adjustment to separation and use of the facility. Especially for infants and toddlers, attention to consistency across settings will help minimize stress that can result from notable differences in routines across caregivers/teachers and settings.

Another ongoing source of stress for an infant or a young child is the separation from those they love and depend upon. Of the various programmatic elements in the facility that can help to alleviate that stress, by far the most important is the comfort in knowing that parents/guardians and caregivers/teachers know the children and their needs and wishes, are in close contact with each other, and can respond in ways that enable children to deal with separation.

The encouragement and involvement of parents/guardians in the social and cognitive leaps of the child provides parents/guardians with the confidence vital to their sense of competence. Caregivers/teachers should be able to direct parents/guardians to sources of information and activities that support child's development and learning and be able to assist them to obtain appropriate screening and assessment when there are concerns. Communication should be sensitive to ethnic and cultural practices. The parent/guardian/caregiver/teacher partnership models positive adult behavior for school-age children and demonstrates a mutual concern for the child's well-being (2-16).

In families where the parents/guardians are separated, it is usually in the child's best interest for both parents/guardians to be involved in the child's care, and informed about the child's progress and problems in care. However, it is up to the courts to decide who has legal custody of the child.

TYPE OF FACILITY

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

RELATED STANDARDS

2.1.1.5 Helping Families Cope with Separation
2.1.1.7 Communication in Native Language Other Than English
2.1.1.9 Verbal Interaction
2.1.1.8 Diversity in Enrollment and Curriculum

REFERENCES

O'Connor, S., et al. 1996. ASQ: Assessing school age child care quality. Wellesly, MA: Center for Research on Women.
Seibel, N. L., L. G. Gillespie, and T. Temple. 2008. The role of child care providers in child abuse prevention. Zero to Three 28:33-40.
Fagan, J. 1994. Mother and father involvement in day care centers serving infants and young toddlers. Early Child Dev Care 103:95-101.
Endsley, R. C., et al. 1993. Parent involvement and quality day care in proprietary centers. J Res Child Educ 7:53-61.
Larner, M. 1995. Linking family support and early childhood programs: Issues, experiences, opportunities: Best practices project, 1-40. Chicago, IL: Family Resource Coalition.
Dombro, A. L. 1995. Sharing the care: What every provider and parent needs to know. Child Today 23:22-5.
Miller, S. H., et al. 1995. Family support in early education and child care settings: Making a case for both principles and practices. Child Today 23:26-29.
Powell, D. R. 1998. Reweaving parents back into the fabric of early childhood programs: Research in review. Young Child 53:60-67.
Jones, R. 1996. Producing a school newsletter parents will read. Child Care Infor Exch 107:91-3.
Tijus, C. A., et al. 1997. The impact of parental involvement on the quality of day care centers. Int J Early Years Educ 5:7-20.
Massachusetts State Office for Children. Establishing a successful family daycare home: A resource guide for providers. 1990. Boston: MA State Office for Children.
Shores, E. J. 1998. A call to action: Family involvement as a critical component of teacher education programs. Tallahassee, FL: Southeastern Regional Vision for Education.
Greenman, J. 1998. Parent partnerships: What they don't teach you can hurt. Child Care Infor Exch 124:78-82.
Marshall, N. L. 1991. Empowering low-income parents: The role of child care. Boston, MA: EDRS.
Mayr, T., M. Ulich. 1999. Children's well-being in day care centers: An exploratory empirical study. Int J Early Years Educ 7:229-39.
Public Counsel Law Center in California. Guidelines for Releasing Children and Custody Issues. http://www.publiccounsel.org/publications/release.pdf.

Standard 3.1.4.4: Scheduled Rest Periods and Sleep Arrangements

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

The facility should provide an opportunity for, but should not require, sleep and rest. The facility should make available a regular rest period for all children and age appropriate sleep/nap environment (See Standard 5.4.5.1). For children who are unable to sleep, the facility should provide time and space for quiet play. A facility that includes preschool-aged and school-aged children should make books, board games, and other forms of quiet play available.

Facilities that offer infant care should provide a safe sleep environment and use a written safe sleep policy that describes the practices they follow to reduce the risk of sudden infant death syndrome and other infant deaths. For example, when infants fall asleep, they must be put down to sleep on their back in a crib with a firm mattress and no blankets or soft objects.

RATIONALE

Conditions conducive to sleep and rest for younger children include a consistent caregiver, a routine quiet place, regular times for rest, and use of routines and safe practices. Most preschool-aged children in all-day care benefit from scheduled periods of rest. This rest may take the form of actual napping, a quiet time, or a change of pace between activities. The times and duration of naps will affect behavior at home (1).

Young children need to develop healthy sleep habits for optimal development. Yet, sleep problems, i.e. short sleep duration, behavioral sleep problems, and sleep-disordered breathing all peak during the preschool years. In 2016, the National Sleep Foundation issued recommended sleep durations for newborns (14–17 hours), infants (12–15 hours), toddlers (11–14 hours), and preschoolers (10–13 hours), which include both daytime and nighttime sleep (2,3).Getting sufficient sleep helps prevent pediatric obesity. In meta-analyses, short sleep duration before 5 years of age is associated with 30% to 90% increased odds of overweight/obesity at later ages (4,5). To prevent early childhood obesity, the Institute of Medicine recommends that child care providers be required to adopt practices that promote age-appropriate sleep duration and that staff be trained to counsel parents about recommended sleep durations (6). Behavioral sleep problems (i.e., difficulty getting to/falling asleep) at 18 months of age are associated with a 60% to 80% increased risk of emotional and behavioral problems at 5 years of age (7). Irregular bedtimes throughout early childhood are associated with reduced reading, math, and spatial ability scores (8). Sleep-disordered breathing (e.g., snoring, apnea) in early childhood is associated with a 60% to 80% increase in social and emotional difficulties at 7 years of age (9).

COMMENTS

In the young infant, favorable conditions for sleep and rest include being dry, well fed, and comfortable. Infants may need 1 or 2 (or sometimes more) naps during the time they are in child care. As infants age, they typically transition to 1 nap per day, and having 1 nap per day is consistent with the schedule that most facilities follow. Different practices, such as rocking, holding a child while swaying, singing, reading, or patting an arm or back, could be used to calm the child. Lighting does not need to be turned off during nap time.

TYPE OF FACILITY

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

RELATED STANDARDS

5.4.5.1 Sleeping Equipment and Supplies
5.4.5.2 Cribs
3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
5.2.2.1 Levels of Illumination

REFERENCES

National Sleep Foundation. How much sleep do we really need? https://sleepfoundation.org/how-sleep-works/how-much-sleep-do-we-really-need. Accessed November 14, 2017
Paruthi S, Brooks LJ, D'Ambrosio C, et al. Consensus statement of the American Academy of Sleep Medicine on the recommended amount of sleep for healthy children: methodology and discussion. J Clin Sleep Med. 2016;12(11):1549–1561
Fatima Y, Doi SA, Mamun AA. Longitudinal impact of sleep on overweight and obesity in children and adolescents: a systematic review and bias-adjusted meta-analysis. Obes Rev. 2015;16(2):137–149
Li L, Zhang S, Huang Y, Chen K. Sleep duration and obesity in children: a systematic review and meta-analysis of prospective cohort studies. J Paediatr Child Health. 2017;53(4):378–385
Institute of Medicine. Early Childhood Obesity Prevention Policies: Goals, Recommendations, and Potential Actions. Washington, DC: Institute of Medicine; 2011. http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2011/Early-Childhood-Obesity-Prevention-Policies/Young%20Child%20Obesity%202011%20Recommendations.pdf. Published June 2011. Accessed November 14, 2017
Sivertsen B, Harvey AG, Reichborn-Kjennerud T, Torgersen L, Ystrom E, Hysing M. Later emotional and behavioral problems associated with sleep problems in toddlers: a longitudinal study. JAMA Pediatr. 2015;169(6):575–582
Kelly, Y; Kelly, J; Sacker, A; (2013) Time for bed: associations with cognitive performance in 7-year-old children: a longitudinal population-based study. Journal of Epidemiology and Community Health , 67 (11) pp. 926-931.
Bonuck K, Freeman K, Chervin RD, Xu L. Sleep-disordered breathing in a population-based cohort: behavioral outcomes at 4 and 7 years. Pediatrics. 2012;129(4):e857–e865

NOTES

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

Standard 5.3.1.10: Restrictive Infant Equipment Requirements

Restrictive infant equipment such as swings, stationary activity centers (e.g., exersaucers), infant seats (e.g., bouncers), molded seats, etc., if used, should only be used for short periods of time (a maximum of fifteen minutes twice a day) (1). Infants should not be placed in equipment until they are developmentally ready. Infants should be supervised when using equipment. Safety straps should be used if provided by the manufacturer of the equipment. Equipment should not be placed on elevated surfaces, uneven surfaces, near the top of stairs, or within reach of safety hazards. Stationary activity centers should be used with the stabilizing legs down in a locked position. Infants should not be allowed to sleep in equipment that was not manufactured as infant rest/sleep equipment. The use of jumpers (attached to a door frame or ceiling) and infant walkers is prohibited.

RATIONALE

Keeping an infant confined in a piece of infant equipment prevents an infant from active movement. Infants need the opportunity to play on the floor in a safe open area to develop their gross motor skills. If infants are not given the opportunity for floor time, their development can be hindered or delayed (2). The shape of an infant's head can be affected if pressure is applied often and for long periods of time. This molding of the skull is called plagiocephaly. Due to the recommendation for back sleeping, an infant's skull already experiences a great amount of time with pressure on the back of the head. When an infant is kept in a piece of infant equipment such as an infant seat or a swing, the pressure again is applied to the back of an infant's head; thus, increasing the likelihood of plagiocephaly. To prevent plagiocephaly and to promote normal development, infants should spend time on their tummies when awake and supervised (3).

Infants are not well-protected in restrictive infant equipment and can be injured by animals or other children. Other children or animals can hang, climb, or jump on or into the equipment; therefore, supervision is required during use. Safety straps must be used to prevent injuries and deaths of infants; infants have fallen out of equipment or have been strangled when safety straps have not been used (10).

Equipment must always be placed on the floor and away from the top of stairs to prevent falls; infants have been injured when equipment has been pushed or pulled off an elevated surface or the top of stairs. The surface or floor under the equipment needs to be level to prevent the risk of the equipment tipping over. It is imperative for equipment to be placed out of the reach of potential safety hazards such as furniture, dangling appliance cords, curtain pulls, blind cords, hot surfaces, etc., so infants cannot reach them. The guideline of twenty minutes twice a day was designated so that use could be clearly measured and monitored (1).

Infants should not be placed in equipment, such as stationary activity centers, that require them to support their heads on their own unless they have mastered this skill. Allowing infants to sleep in infant equipment is not recommended due to the documented decrease in an infant's oxygen saturation caused by the downward flexion of an infant's head and neck due to an infant's underdeveloped head and neck muscles (8,9). If an infant falls asleep in a piece of equipment, the infant should be promptly removed and placed flat on the infant's back in a safety approved crib.

If the stabilizing legs on stationary activity centers are not down and locked in place, this puts an infant at risk of tipping over in the equipment as well as creates an unstable piece of equipment for a mobile infant to use to pull himself up.

Infant walkers are dangerous because they move children around too fast and to hazardous areas, such as stairs. The upright position also can cause children in walkers to "tip over" or can bring children close to objects that they can pull down onto themselves. In addition, walkers can run over or run into others, causing pain or injury. Many injuries, some fatal, have been associated with infant walkers (4-7). There have been several reports of spring/clamp breaking on various models of jumpers (jump-up seats) according to the CPSC (7).

TYPE OF FACILITY

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

RELATED STANDARDS

3.1.3.4 Caregivers'/Teachers' Encouragement of Physical Activity

REFERENCES

Warda, L., G. Griggs. 2006. Childhood Falls in Manitoba: CHIRPP Report: An assessment of injury severity and fall events by age group. Winnipeg: The Injury Prevention Centre of Children's Hospital. http://www.mpeta.ca/documents/IOI/Falls.pdf.
Kornhauser, C. L., C. V. Scirica, I. S. Gantar, D. Osredkar, D. Neubauer, T. B. Kinane. 2009. A comparison of respiratory patterns in healthy term infants placed in car safety seats and beds. Pediatrics 124: e396-e402.
Kinane, T. B., J. Murphy, J. L. Bass, M. J. Corwin. 2006. Comparison of respiratory physiologic features when infants are placed in car safety seats or car beds. Pediatrics 118:522-27.
Chowdhury, R. T. 2009. Nursery product-related injuries and deaths among children under age five. Washington, DC: U.S. Consumer Product Safety Commission. http://www.cpsc.gov/library/nursery07.pdf.
Shields, B. J., G. A. Smith. 2006. Success in the prevention of infant walker-related injuries: An analysis of national data, 1990-2001. Pediatrics 117: e452-59.
DiLillo, D., A. Damashek, L. Peterson. 2001. Maternal use of baby walkers with young children: Recent trends and possible alternatives. Injury Prevention 7:223-27.
American Academy of Pediatrics, Committee on Injury and Poison Prevention. 2008. Policy statement: Injuries associated with infant walkers. Pediatrics 122:450.
American Academy of Pediatrics (AAP), Healthy Child Care America. 2008. Back to sleep, tummy to play. Elk Grove Village, IL: AAP. http://www.healthychildcare.org/pdf/SIDStummytime.pdf.
American Physical Therapy Association (APTA). 2008. Lack of time on tummy shown to hinder achievement of developmental milestones, say physical therapists. Press release.
National Association for Family Child Care, The Family Child Care Accreditation Project, Wheelock College. 2005. Quality standards for NAFCC accreditation, standard 4.5. 4th ed. Salt Lake City, UT: NAFCC. http://www.nafcc.org/documents/QualStd.pdf.

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:

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;
Inclusion of children with special health care needs;
Nondiscrimination;
Payment of fees, deposits, and refunds;
Termination of enrollment and parent/guardian notification of termination;
Supervision;
Staffing, including caregivers/teachers, the use of volunteers, helpers, or substitute caregivers/teachers, and deployment of staff for different activities;
A written comprehensive and coordinated planned program based on a statement of principles;
Discipline;
Methods and schedules for conferences or other methods of communication between parents/guardians and staff;
Care of children and staff who are ill;
Temporary exclusion for children and staff who are ill and alternative care for children who are ill;
Health assessments and immunizations;
Handling urgent medical care or threatening incidents;
Medication administration;
Use of child care health consultants and education and mental health consultants;
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.);
Disasters, emergency plan and drills, evacuation plan, and alternative shelter arrangements;
Security;
Confidentiality of records;
Transportation and field trips;
Physical activity (both outdoors and when children are kept indoors), play areas, screen time, and outdoor play policy;
Sleeping, safe sleep policy, areas used for sleeping/napping, sleep equipment, and bed linen;
Sanitation and hygiene;
Presence and care of any animals on the premises;
Food and nutrition including food handling, human milk, feeding and food brought from home, as well as a daily schedule of meals and snacks;
Evening and night care plan;
Smoking, tobacco use, alcohol, prohibited substances, and firearms;
Human resource management;
Staff health;
Maintenance of the facility and equipment;
Preventing and reporting child abuse and neglect;
Use of pesticides and other potentially toxic substances in or around the facility;
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.

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-healthy
childcarepa.org/content/MHP4thEd Total.pdf 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

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

RELATED STANDARDS

1.8.2.1 Staff Familiarity with Facility Policies, Plans and Procedures

REFERENCES

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/docs/
ADA Q and A 2009 Final 3 09.pdf.
Aronson, S. S., ed. 2002. Model child care health policies. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics.

Standard 9.2.2.1: Planning for Child's Transition to New Services

If a parent/guardian requests assistance with the transition process from the facility to a public school or another program, the designated care or service coordinator at the facility should review the child's records, including needs, learning style, supports, progress, and recommendations. The designated care or service coordinator should obtain written informed consent from the parent/guardian prior to sharing information at a transition meeting, in a written summary, or in some other verbal or written format.

The process for the child's departure should also involve sharing and the exchange of progress reports with other care providers for the child and the parents/guardians of the child within the realm of confidentiality guidelines.

Any special health care need of the child and successful strategies that have been employed while at child care should be shared. For children who are receiving services under Part C of IDEA 2004, a transition plan is required, usually at least ninety days prior to the time that the child will leave the facility or program.

In the case of a child who may be eligible for preschool services, with approval of the family of the child, a conference should be convened among the lead agency, the family, and the local educational agency not less than ninety days (and at the discretion of all such parties, not more than nine months) before the child is eligible for the preschool services, to discuss any such services that the child may receive. In the case of a child who may not be eligible for such preschool services, with the approval of the family, reasonable efforts should be made to convene a conference among the lead agency, the family, and providers of other appropriate services, to discuss the appropriate services that the child may receive; to review the child's program options; for the period from the child's third birthday through the remainder of the school year; and to establish a transition plan, including as appropriate, steps to exit from the program. A plan also requires description of efforts to promote collaboration among Early Head Start programs under section 645A of the Head Start Act, early education and child care programs.

The facility should determine in what form and for how long archival records of transitioned children should be maintained by the facility.

RATIONALE

All children and their families will experience one or more program transitions during early childhood. One of the most common transitions is from preschool to kindergarten. Families in transition benefit when support and advocacy are available from a facility representative who is aware of their needs and of the community's resources (1). This process is essential in planning the child's departure or transition to another program. Information regarding successful behavior strategies, motivational strategies, and similar information may be helpful to staff in the setting to which the child is transitioning.

COMMENTS

Some families are capable of advocating effectively for themselves and their children; others require help negotiating the system outside of the facility. An interdisciplinary process is encouraged. Though coordinating and evaluating health and therapeutic services for children with special health care needs is primarily the responsibility of the school district or regional center, staff from the child care facility (one of many service providers) should participate, as staff members have had a unique opportunity to observe the child. In small and large family child care homes where an interdisciplinary team is not present, the caregivers/teachers should participate in the planning and preparation along with other care or treatment providers, with parent/guardian written consent.

TYPE OF FACILITY

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

RELATED STANDARDS

9.2.2.2 Format for the Transition Plan
9.4.1.3 Written Policy on Confidentiality of Records
9.4.1.4 Access to Facility Records
9.4.1.5 Availability of Records to Licensing Agency
9.4.1.6 Availability of Documents to Parents/Guardians

REFERENCES

Harbin, G., B. Rous, N. Peeler, J. Schuster, K. McCormick. 2007. Research brief: Desired family outcomes of the early childhood transition process. http://community.fpg.unc.edu/connect/

Positive Behavior Management

Standard 2.2.0.6: Discipline Measures

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

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

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

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

RATIONALE

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

COMMENTS

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

ADDITIONAL RESOURCES

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

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

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

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

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

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

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

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

Standard 2.2.0.7: Handling Physical Aggression, Biting, and Hitting

Caregivers/teachers should intervene immediately when a child's behavior is aggressive and endangers the safety of others. It is important that the child be clearly told verbally, "no hitting" or "no biting." The caregiver/teacher should use age–appropriate interventions. For example, a toddler can be picked up and moved to another location in the room if s/he bites other children or adults. A preschool child can be invited to walk with you first but, if not compliant, taken by the hand and walked to another location in the room. The caregiver/teacher should remain calm and make eye contact with the child telling him/her the behavior is unacceptable. If the behavior persists, parents/guardians, caregivers/teachers, the child care health consultant and the early childhood mental health consultant should be involved to create a plan targeting this behavior. For example, a plan may be developed to recognize non-aggressive behavior. Children who might not have the social skills or language to communicate appropriately may use physical aggression to express themselves and the reason for and antecedents of the behavior must be considered when developing a plan for addressing the behavior.

RATIONALE

Caregiver/teacher intervention protects children and encourages children to exhibit more acceptable behavior (1).

COMMENTS

Biting is a phase. Here are some specific steps to deal with biting:

TYPE OF FACILITY

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

RELATED STANDARDS

2.3.1.1 Mutual Responsibility of Parents/Guardians and Staff
2.2.0.6 Discipline Measures
3.2.3.3 Cuts and Scrapes
3.2.3.4 Prevention of Exposure to Blood and Body Fluids
9.4.1.9 Records of Injury
2.2.0.8 Preventing Expulsions, Suspensions, and Other Limitations in Services

REFERENCES

Ross, Scott W., Horner, Robert H. 2009. Bully prevention in positive behavior support. J Applied Behavior Analysis 42:747-59.
Rush, K. L. 1999. Caregiver-child interactions and early literacy development of preschool children from low-income environments. Topics Early Child Special Education 19:3-14.

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

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

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

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

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

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

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

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

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

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

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

RATIONALE

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

Standard 2.2.0.9: Prohibited Caregiver/Teacher Behaviors

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

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

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

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

RATIONALE

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

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

NOTES

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

Standard 2.2.0.10: Using Physical Restraint

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

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

That behavioral care plan should include:

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

RATIONALE

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

COMMENTS

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

TYPE OF FACILITY

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

RELATED STANDARDS

2.2.0.6 Discipline Measures

REFERENCES

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

Standard 4.5.0.11: Prohibited Uses of Food

Caregivers/teachers should not force or bribe children to eat nor use food as a reward or punishment.

RATIONALE

Children who are forced to eat or, for whom adults use food to modify behavior, come to view eating as a tug-of-war and are more likely to develop lasting food dislikes and unhealthy eating behaviors. Offering food as a reward or punishment places undue importance on food and may have negative effects on the child by promoting "clean the plate" responses that may lead to obesity or poor eating behavior (1-5).

COMMENTS

All components of the meal should be offered at the same time, allowing children to select and enjoy all of the foods on the menu.

TYPE OF FACILITY

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

REFERENCES

Birch, L. L., J. O. Fisher, K. K. Davison. 2003. Learning to overeat: Maternal use of restrictive feeding practices promotes girls' eating in the absence of hunger. Am J Clin Nutr 78:215-20.
Murph, J. R., S. D. Palmer, D. Glassy, eds. 2005. Health in child care: A manual for health professionals. Elk Grove Village, IL: American Academy of Pediatrics.
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.
Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.
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.

Standard 9.2.1.6: Written Discipline Policies

Each facility should have a written discipline policy reflective of the positive methods of guidance appropriate to the ages of the children enrolled outlined in Standard 2.2.0.6 and prohibited caregiver behaviors as outlined in Standard 2.2.0.9.

The facility should have policies for dealing with biting, hitting, and other undesired behavior by children and written protocol reflective guidance outlined in Standard 2.2.0.7.

Policies should explicitly prohibit corporal punishment, psychological abuse, humiliation, abusive language, binding or tying to restrict movement, restriction of access to large motor physical activities, and the withdrawal or forcing of food and other basic needs.

All caregivers/teachers should sign an agreement to implement the facility's discipline policies. A policy explicitly stating the consequence for staff who do not follow the discipline policies should be reviewed and signed by each staff member prior to hiring.

RATIONALE

Caregivers/teachers are more likely to avoid abusive practices if they are well-informed about effective, non-abusive methods for managing children's behaviors. Positive methods of discipline create a constructive and supportive social group and reduce incidents of aggression.

Corporal punishment may be physical abuse or may become abusive very easily. Research links corporal punishment with negative effects such as later criminal behavior and impairment of learning (1-3). Primary factors supporting the prohibition of certain methods of punishment include current child development theory and practice, legal aspects (namely that a caregiver/teacher is not acting in place of parents/guardians with regard to the child), and increasing liability suits. According to the NARA 2008 Child Care Licensing Study, forty-eight states prohibit corporal punishment in centers; forty-three of forty-four states that license small family child care homes prohibit corporal punishment and only one state does not prohibit corporal punishment in large family child care homes (4).

COMMENTS

Parents/guardians should be encouraged to utilize similar positive discipline methods at home in order to encourage these practices and to provide a more consistent discipline approach for the child.

TYPE OF FACILITY

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

RELATED STANDARDS

REFERENCES

American Academy of Pediatrics, Committee on School Health. 2006. Policy statement: Corporal punishment in the schools. Pediatrics 106:343.
Education Commission of the States. 1999. Collection of clearinghouse notes, 1998-1999. Denver, CO: ECS.
Paintal, S. 1999. Banning corporal punishment of children: A position paper. Child Educ 76:36-39.

Healthy Weight Promotion

Physical Activity

Standard 3.1.3.1: Active Opportunities for Physical Activity

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

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

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

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

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

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

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

Outdoor play

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

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

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

Total time allotted for moderate to vigorous activities:

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

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

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

There are many ways to promote tummy time with infants:

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

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

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

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

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

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

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

Children should have adequate space for indoor and outdoor play.

RATIONALE

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

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

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

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

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

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

COMMENTS

Additional Resources

Choosy Kids (https://choosykids.com)

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

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

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

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

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

Spark (www.sparkpe.org)

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

NOTES

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

Standard 3.1.3.2: Playing Outdoors

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

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

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

Sunny weather

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

Warm weather

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

Cold weather

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

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

RATIONALE

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

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

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

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

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

COMMENTS

Additional Resources

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

National Weather Service, National Oceanic and Atmospheric Administration. Wind chill safety. https://www.weather.gov/bou/windchill. Accessed January 11, 2018
Centers for Disease Control and Prevention. Increasing Access to Drinking Water and Other Healthier Beverages in Early Care and Education Settings. Atlanta, GA: US Department of Health and Human Services; 2014. https://www.cdc.gov/obesity/downloads/early-childhood-drinking-water-toolkit-final-508reduced.pdf. Accessed January 11, 2018
Söderström M, Boldemann C, Sahlin U, Mårtensson F, Raustorp A, Blennow M. The quality of the outdoor environment influences children's health—a cross-sectional study of preschoolers. Acta Paediatr. 2013;102(1):83–91
KidsHealth from Nemours. Heat illness. http://kidshealth.org/en/parents/heat.html. Reviewed February 2014. Accessed January 11, 2018
American Academy of Pediatrics. Children & disasters. Extreme temperatures: heat and cold. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Children-and-Disasters/Pages/Extreme-Temperatures-Heat-and-Cold.aspx. Accessed January 11, 2018
Cleland V, Crawford D, Baur LA, Hume C, Timperio A, Salmon J. A prospective examination of children's time spent outdoors, objectively measured physical activity and overweight. Int J Obes (Lond). 2008;32(11):1685–1693
American Academy of Pediatrics. Winter safety tips from the American Academy of Pediatrics. https://www.aap.org/en-us/about-the-aap/aap-press-room/news-features-and-safety-tips/Pages/AAP-Winter-Safety-Tips.aspx. Published January 2018. Accessed January 11, 2018
American Academy of Pediatrics. Extreme temperature exposure. HealthyChildren.org Web site. https://www.healthychildren.org/English/health-issues/injuries-emergencies/Pages/Extreme-Temperature-Exposure.aspx. Updated November 21, 2015. Accessed January 11, 2018

NOTES

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

Standard 9.2.3.1: Policies and Practices that Promote Physical Activity

Content in the Standard was modified on 08/25/2016 and 05/30/2018.

The facility should have written policies for the promotion of indoor and outdoor physical activity and the removal of potential barriers to physical activity participation. Policies should cover the following areas:

a. Benefits: benefits of physical activity and outdoor play.

b. Duration: Children will spend 60 to 120 minutes each day outdoors depending on their age, weather permitting. Policies will describe what will be done to ensure physical activity

and provisions for gross motor activities indoors on days with more extreme conditions (ie, very wet, very hot, or very cold).

c. Type: Structured (caregiver/teacher-initiated) versus unstructured activity.

d. Setting: provision of covered areas for shade and shelter on playgrounds, if feasible (1).

e. Clothing: Clothing should protect children from sun exposure and permit easy movement (not too loose and not too tight) that enables full participation in active play; footwear

should provide support for running and climbing. Hats and sunglasses should be worn to protect children from sun exposure.

Examples of appropriate clothing/footwear include:

a. Gym shoes or sturdy gym shoe equivalent.

b. Clothes for the weather, including heavy coat, hat, and mittens in the winter/snow; raincoat and boots for the rain; and layered clothes for climates in which the temperature can

vary dramatically on a daily basis. Lightweight, breathable clothing, without any hood and neck strings, should be worn when temperatures are hot to protect children from sun

exposure.

Examples of inappropriate clothing/footwear include:

a. Footwear that can come off while running or that provides insufficient support for climbing (2)

b. Clothing that can catch on playground equipment (eg, those with drawstrings or loops)

If children wear "dress clothes" or special outfits that cannot be easily laundered, caregivers/teachers should talk with the children's parents/guardians about the program's goals in providing physical activity during the program day and encourage them to provide a set of clothes that can be used during physical activities.

Facilities should discuss the importance of this policy with parents/guardians on enrollment and periodically thereafter.

RATIONALE

If appropriately dressed, children can safely play outdoors in most weather conditions. Children can learn math, science, and language concepts through games involving movement (3,4).

Having a policy on outdoor physical activity that will take place on days when there are adverse weather conditions informs all caregivers/teachers and families about the facility's expectations. The policy can make clear that outdoor activity may require special clothing in colder weather or arrangements for cooling off when it is warm. By having such a policy, the facility encourages caregivers/teachers and families to anticipate and prepare for outdoor activity when cold, hot, or wet weather prevails.

The inappropriate dress of a child is often a barrier in reaching recommended amounts of physical activity in child care centers. Sometimes, children cannot participate in physical activity because of their inappropriate clothes. Caregivers/teachers can be helpful by having extra clean clothing on hand (5). Children can play in the rain and snow and in low temperatures when wearing clothing that keeps them dry and warm. When it is very warm, children can play outdoors, if they play in shady areas, and wear sunscreen, sun-protective clothing, and insect repellent, if necessary (6). Caregivers/teachers should have water available for children to mist, sprinkle, and drink while in warmer weather.

COMMENTS

For assistance in creating and writing physical activity policies, Nemours provides several resources and best practice advice on program implementation. Information is available at https://www.nemours.org/service/health/growuphealthy/activity/educators.html.

TYPE OF FACILITY

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

RELATED STANDARDS

6.1.0.2 Size and Requirements of Indoor Play Area
3.4.6.1 Strangulation Hazards
5.3.1.1 Safety of Equipment, Materials, and Furnishings
3.1.3.1 Active Opportunities for Physical Activity
3.1.3.2 Playing Outdoors
3.1.3.4 Caregivers'/Teachers' Encouragement of Physical Activity
3.4.5.1 Sun Safety Including Sunscreen
3.4.5.2 Insect Repellent and Protection from Vector-Borne Diseases
9.2.6.1 Policy on Use and Maintenance of Play Areas
Appendix S: Physical Activity: How Much Is Needed?

REFERENCES

Weinberger N, Butler, AG, Schumacher P. Looking inside and out: perceptions of physical activity in childcare spaces. Early Child Development and Care. 2014;184(2):194-210
Tandon PS, Walters KM, Igoe BM, Payne EC, Johnson DB. Physical activity practices, policies and environments in Washington state child care settings: results of a statewide survey. Matern Child Health J. 2017;21(3):571–582
Bento G, Dias G. The importance of outdoor play for young children's healthy development. Porto Biomed J. 2017;2(5):157–160. http://dx.doi.org/10.1016/j.pbj.2017.03.003. Accessed January 11, 2018
Jayasuriya A, Williams M, Edwards T, Tandon P. Parents' perceptions of preschool activities: exploring outdoor play. Early Educ Dev. 2016;27(7):1004–1017
Henderson KE, Grode GM, O'Connell ML, Schwartz MB. Environmental factors associated with physical activity in childcare centers. Int J Behav Nutr Phys Act. 2015;12:43
American Academy of Pediatrics. Choosing an insect repellent for your child. HealthyChildren.org Web site. https://www.healthychildren.org/English/safety-prevention/at-play/Pages/Insect-Repellents.aspx. Updated March 1, 2017. Accessed January 11, 2018

NOTES

Content in the Standard was modified on 08/25/2016 and 05/30/2018.

B. Nutrition

Standard 4.2.0.2: Assessment and Planning of Nutrition for Individual Children

Content in the STANDARD was modified on 11/9/2017.

As a part of routine health supervision by a primary health care provider, children should be evaluated for nutrition-related medical problems, such as failure to thrive, overweight, obesity, food allergy, reflux disease, and iron-deficiency anemia (1). The nutritional standards throughout this document are general recommendations that may not always be appropriate for some children with medically identified special nutrition needs. Caregivers/teachers should communicate with the child's parent/guardian and pediatrician/other physician to adapt nutritional offerings to individual children as indicated and medically appropriate. Caregivers/teachers should work with the parent/guardian to implement individualized feeding plans developed by the child's primary health care provider to meet a child's unique nutritional needs. These plans could include, for instance, additional iron-rich foods for a child who has been diagnosed as having iron-deficiency anemia. For a child diagnosed as obese or overweight, the plan would focus on controlling portion sizes and creating a menu plan in which calorie-dense foods, like sugar-sweetened juices, nectars, and beverages, should not be served. Using these nutritional differences as educational moments will help children understand why they can or cannot eat certain food items. Some children require special feeding techniques, such as thickened foods or special positioning during meals. Other children will require dietary modifications based on food intolerances, such as lactose or wheat (gluten) intolerance. Some children will need dietary modifications based on cultural or religious preferences, such as vegan, vegetarian, or kosher diets, or halal foods.

RATIONALE

The early years are a critical time for children's growth and development. Nutritional problems must be identified and treated during this period to prevent serious or long-term medical problems. Strong evidence shows a relationship between preschool-aged children being presented with larger sized portions and increased energy intake, prompting the importance of implementing proper portion sizing as soon as 2 years of age for children at risk of being overweight (2). The early care and education setting may be offering most of a child's daily nutritional intake, especially for children in full-time care. It is important that the facility ensures that food offerings are congruent with nutritional interventions or dietary modifications recommended by the child's pediatrician/other physician, in consultation with the nutritionist/registered dietitian, to make certain the intervention is child specific.

TYPE OF FACILITY

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

RELATED STANDARDS

3.1.2.1 Routine Health Supervision and Growth Monitoring
4.2.0.8 Feeding Plans and Dietary Modifications
4.3.1.2 Feeding Infants on Cue by a Consistent Caregiver/Teacher

REFERENCES

McAllister JW. Achieving a Shared Plan of Care with Children and Youth with Special Health Care Needs. Palo Alto, CA: Lucille Packard Foundation for Children's Health; 2014. http://www.lpfch.org/sites/default/files/field/publications/achieving_a_shared_plan_of_care_full.pdf. Accessed September 7, 2017
McCrickerd K, Leong C, Forde CG. Preschool children's sensitivity to teacher-served portion size is linked to age related differences in leftovers.Appetite. 2017;114:320–328
ADDITIONAL RESOURCE
US Department of Health and Human Services, US Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th ed. Washington, DC: US Department of Health and Human Services; 2015. https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_Guidelines.pdf. Accessed September 7, 2017

NOTES

Content in the STANDARD was modified on 11/9/2017.

Standard 4.2.0.3: Use of US Department of Agriculture Child and Adult Care Food Program Guidelines

Content in the STANDARD was modified on 11/9/2017.

All meals and snacks and their preparation, service, and storage should meet the requirements for meals (7 CFR §226.20) of the child care component of the US Department of Agriculture Child and Adult Care Food Program (CACFP) (1-3).

RATIONALE

The CACFP regulations, policies, and guidance materials on meal requirements provide basic guidelines for sound nutrition and sanitation practices. The CACFP guidance for meals and snack patterns ensures that the nutritional needs of infants and children, including school-aged children through 12 years, are met based on the Dietary Guidelines for Americans (4,5) as well as other evidence-based recommendations (6,7). Programs not eligible for reimbursement under the regulations of CACFP should still use the CACFP food guidance.

COMMENTS

Staff should use information about the child's growth and CACFP meal patterns to develop individual feeding plans (6).

ADDITIONAL RESOURCE

US Department of Agriculture. Child and Adult Care Food Program: best practices. US Department of Agriculture, Food and Nutrition Service Web site. https://www.fns.usda.gov/sites/default/files/cacfp/CACFP_factBP.pdf . Accessed September 7, 2017

TYPE OF FACILITY

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

RELATED STANDARDS

3.1.2.1 Routine Health Supervision and Growth Monitoring
4.2.0.4 Categories of Foods
4.2.0.5 Meal and Snack Patterns
4.3.1.2 Feeding Infants on Cue by a Consistent Caregiver/Teacher
4.3.2.1 Meal and Snack Patterns for Toddlers and Preschoolers
4.3.3.1 Meal and Snack Patterns for School-Age Children

REFERENCES

US Department of Agriculture, Food and Nutrition Service. Independent Child Care Centers: A Child and Adult Care Food Program Handbook. Washington, DC: US Department of Agriculture; 2014. https://fns-prod.azureedge.net/sites/default/files/cacfp/Independent%20Child%20Care%20Centers%20Handbook.pdf. Accessed September 7, 2017
US Department of Health and Human Services, US Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th ed. Washington, DC: US Department of Health and Human Services; 2015. https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_Guidelines.pdf. Accessed September 7, 2017
US Department of Agriculture, Food and Nutrition Service. Child and Adult Food Program (CACFP). Nutrition standards for CACFP meals and snacks. https://www.fns.usda.gov/cacfp/meals-and-snacks. Updated March 27, 2017. Accessed September 7, 2017
US Department of Agriculture, Healthy Meals Resource System, Team Nutrition. CACFP wellness resources for child care providers. https://healthymeals.fns.usda.gov/cacfp-wellness-resources-child-care-providers. Accessed September 7, 2017
US Department of Agriculture, Food and Nutrition Service. Requirements for meals. US Government Publishing Office Web site. https://www.ecfr.gov/cgi-bin/text-idx?SID=9c3a6681dbf6aada3632967c4bfeb030&mc=true&node=pt7.4.226&rgn=div5#se7.4.226_120. Accessed September 7, 2017
US Department of Agriculture, Food and Nutrition Service. Child and Adult Care Food Program (CACFP). Regulations. https://www.fns.usda.gov/cacfp/regulations. Updated September 7, 2017. Accessed September 7, 2017
Lally JR, Griffin A, Fenichel E, Segal M, Szanton E, Weissbourd B. Caring for Infants and Toddlers in Groups: Developmentally Appropriate Practice. 2nd ed. Arlington, VA: Zero to Three; 2008

NOTES

Content in the STANDARD was modified on 11/9/2017.

Standard 4.2.0.4: Categories of Foods

Content in the STANDARD was modified on 2/2012, 11/16/2017 and 02/27/2020.

The early care and education program should ensure the following food groups are being served to children in care. When incorporated into a child's diet, these food groups make up foundational components of a healthy eating pattern.

Making Healthy Food Choices ^a
Food Groups/Ingredients	USDA^b	CFOC Guidelines for Young Children
Fruits	Whole Fruits Includes fresh, frozen, canned (packed in water or 100% fruit juice), and dried varieties that include good sources of potassium (e.g., bananas, dried plums) Fruit Juice 100% juice (i.e., without added sugars)	Eat a variety of whole fruits. Whole fruit, mashed or pureed, for infants. Do not serve juice to infants younger than 12 months. No more than 4 oz of juice per day for 1- to 3-year-olds. No more than 4–6 oz of juice per day for 4- to 6-year-olds. No more than 8 oz of juice per day for 7- to 12-year-olds.
Vegetables	Includes fresh, frozen, canned, and dried varieties Vegetable Subgroups Dark green Red and orange Beans and peas (legumes) Starchy vegetables Other vegetables	Include a variety of vegetables from the vegetable subgroups. Select low-sodium options when serving canned vegetables.
Grains	Whole Grains Contain the entire grain kernel (e.g., whole wheat flour, bulgur, oatmeal, brown rice) Refined Grains Enriched grains that have been milled, processed, and stripped of vital nutrients	Limit the amount of refined grains. Make half the grains served whole grains or whole-grain products.
Protein Foods (Meat and Meat Alternatives)	Includes food from animal and plant sources (e.g., seafood, lean meat, poultry, eggs, yogurt, cheese, soy products, nuts and seeds, cooked [mature] beans and peas)	Fish, poultry, lean meat, eggs. Unsalted nuts and seeds (if developmentally and age appropriate). Legumes (beans and peas) may also be considered a protein source. Limit processed meats and poultry. Avoid fried fish and poultry.
Dairy	Fat-free or low-fat (1%) milk or soy milk	Human milk and/or iron-fortified infant formula for infants 0–12 months of age. Unflavored whole milk for children 1–2 years of age. 2% (reduced-fat) milk for those children at risk for obesity or hypocholesteremia. Unflavored low-fat (1%) or fat-free milk for children 2 years and older. Nondairy milk substitutes that are nutritionally equivalent to milk. Yogurt must not contain more than 23 g of sugar per ounce.
Abbreviations: CFOC, Caring for Our Children: National Health and Safety Performance Standards; USDA, US Department of Agriculture. ^a All foods are assumed to be in nutrient-dense forms, lean or low-fat, and prepared without added fats, sugars, or salt. Solid fats and added sugars may be included up to the daily maximum limit identified in the 2015–2020 Dietary Guidelines for Americans. ^b The USDA recommends finding a balance between food and physical activity.

OTHER RECOMMENDATIONS

Trans-fatty acids (trans fat) should be avoided.
Avoid concentrated sweets (eg, candy, cake, cookies) and sugar-sweetened beverages (eg, sodas, sports and energy drinks, fruit nectars, flavored milk).¹ Offer foods and beverages that have little or no added sugars. Early care and education programs should establish water as the preferred safe and accessible beverage.²
Limit salty foods such as chips and pretzels. When buying foods, choose no salt added, low-sodium, or reduced sodium versions, and prepare foods without adding salt. Use herbs or no-salt spice mixes instead of salt, soy sauce, ketchup, barbeque sauce, pickles, olives, salad dressings, butter, stick margarine, gravy, or cream sauce with seasonal vegetables and other dishes.
Avoid caffeine.

ADDITIONAL RESOURCES

American Academy of Pediatrics. American Academy of Pediatrics recommends no fruit juice for children under 1 year. https://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/American-Academy-of-Pediatrics-Recommends-No-Fruit-Juice-For-Children-Under-1-Year.aspx. Published May 22, 2017. Accessed August 21, 2019
Holt K, Wooldridge N, Story M, Sofka D.Bright Futures: Nutrition. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2011
US Department of Agriculture. ChooseMyPlate.gov. Children. http://www.choosemyplate.gov/children. Updated August 26, 2015. Accessed August 21, 2019
US Department of Health and Human Services. Physical Activity Guidelines for Americans. 2nd ed. Washington, DC: US Department of Health and Human Services; 2018. https://health.gov/paguidelines/second-edition. Accessed August 21, 2019

RATIONALE

The2015–2020 Dietary Guidelines for Americans andThe Surgeon General's Call to Action to Support Breastfeeding support patterns of healthy eating to promote a healthy weight and lifestyle that, in turn, prevent the onset of overweight and obesity in children.^3,4 Incorporating each of the food groups by providing children with appropriate meals and snacks helps set the stage for a lifetime of healthy eating behaviors. Research reinforces the following suggestions as being a practical approach to selecting foods high in essential nutrients and moderate in calories/energy:

Meals and snacks planned based on the food groups in the Making Healthy Food Choices Table promote normal growth and development of children as well as reduce children's risk of overweight, obesity, and related chronic diseases later in life. Age-specific guidance for meals and snacks is outlined in the US Department of Agriculture Child and Adult Care Food Program (CACFP) guidelines.⁵
Early care and education settings provide the opportunity for children to learn about the food they eat, to develop and strengthen their fine and gross motor skills, and to engage in social interaction at mealtimes.
"Energy" or sports beverages are typically high in added sugars and, therefore, not recommended for consumption. They contain many nonnutritive stimulants, such as caffeine, that have a history of harmful effects on a child's developing heart, brain, and nervous system.⁶

COMMENTS

Early care and education settings should encourage mothers to breastfeed their infants. Scientific evidence documents and supports the nutritional and health contributions of human milk.⁴ For more information on portion sizes and types of food, see the CACFP guidelines.⁵

TYPE OF FACILITY

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

RELATED STANDARDS

4.2.0.5 Meal and Snack Patterns
4.2.0.7 100% Fruit Juice
4.2.0.8 Feeding Plans and Dietary Modifications
4.3.1.2 Feeding Infants on Cue by a Consistent Caregiver/Teacher
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.1.5 Preparing, Feeding, and Storing Infant Formula
4.3.1.7 Feeding Cow's Milk
4.3.2.1 Meal and Snack Patterns for Toddlers and Preschoolers
4.3.3.1 Meal and Snack Patterns for School-Age Children
4.7.0.1 Nutrition Learning Experiences for Children
4.7.0.2 Nutrition Education for Parents/Guardians
Appendix Q: MyPlate: Make It Yours
Appendix R: Choose MyPlate: 10 Tips to a Great Plate

REFERENCES

Muth ND, Dietz WH, Magge SN, Johnson RK; American Academy of Pediatrics Section on Obesity and Committee on Nutrition; American Heart Association. Public policies to reduce sugary drink consumption in children and adolescents. Pediatrics. 2019;143(4):e20190282
Centers for Disease Control and Prevention. Increasing Access to Drinking Water and Other Healthier Beverages in Early Care and Education Settings. Atlanta, GA: US Department of Health and Human Services; 2014. https://www.cdc.gov/obesity/downloads/early-childhood-drinking-water-toolkit-final-508reduced.pdf. Accessed August 21, 2019
US Department of Health and Human Services, US Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th ed. https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_Guidelines.pdf. Published December 2015. Accessed August 21, 2019
Office of the Surgeon General, Centers for Disease Control and Prevention, Office on Women's Health. The Surgeon General's Call to Action to Support Breastfeeding. https://www.hhs.gov/surgeongeneral/reports-and-publications/breastfeeding/index.html. Reviewed May 14, 2019. Accessed August 21, 2019
US Department of Agriculture Food and Nutrition Service. Child and Adult Care Food Program. Ensuring children and adults have access to nutritious meals and snacks. https://www.fns.usda.gov/cacfp/child-and-adult-care-food-program. Accessed August 21, 2019
Centers for Disease Control and Prevention. CDC Healthy Schools. The buzz on energy drinks. https://www.cdc.gov/healthyschools/nutrition/energy.htm. Reviewed March 22, 2016. Accessed August 21, 2019

NOTES

Content in the STANDARD was modified on 2/2012, 11/16/2017 and 02/27/2020.

Standard 4.2.0.5: Meal and Snack Patterns

Content in the STANDARD was modified on 11/9/2017.

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

a. Children in care for 8 or fewer hours in 1 day should be offered at least 1 meal and 2 snacks or 2 meals and 1 snack (1).
b. A nutritious snack should be offered to all children in midmorning (if they are not offered a breakfast on-site that is provided within 3 hours of lunch) and in mid-afternoon.
c. Children should be offered food at intervals at least 2 hours apart but not more than 3 hours apart unless the child is asleep. Some very young infants may need to be fed at shorter intervals than every 2 hours to meet their nutritional needs, especially breastfed infants being fed expressed human milk. Lunch may need to be served to toddlers earlier than preschool-aged children because of their need for an earlier nap schedule. Children must be awake prior to being offered a meal/snack.
d. 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.
e. Caregivers/teachers should discuss breastfed infants' feeding patterns with their 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 infants' feeding patterns over 24 hours will help caregivers/teachers assess infants' feeding schedules during their time together.

RATIONALE

Children younger than 6 years need to be offered food every 2 to 3 hours. Appetite and interest in food varies from one meal or snack to the next. Appropriate timing of meals and snacks prevents children from snacking throughout the day and ensures that children maintain healthy appetites during mealtimes (2,3). Snacks should be nutritious, as they often are a significant part of a child's daily intake. Children in care for longer than 8 hours need additional food because this period represents most of a young child's waking hours.

COMMENTS

Caloric needs vary greatly from one child to another. A child may require more food during growth spurts (4). Some states have regulations that indicate suggested times for meals and snacks. By regulation, under the US Department of Agriculture Child and Adult Care Food Program (CACFP), centers and family child care homes may be approved to claim up to 2 reimbursable meals (breakfast, lunch, or supper) and 1 snack, or 2 snacks and 1 meal, for each eligible participant, each day. Many after-school programs provide before-school care or full-day care when elementary school is out of session. Many of these programs offer breakfast and/or a morning snack. After-school care programs may claim reimbursement for serving each child one snack, each day. In some states after-school programs also have the option of providing supper. These are reimbursed by CACFP if they meet certain guidelines and time frames (5).

TYPE OF FACILITY

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

RELATED STANDARDS

4.3.1.2 Feeding Infants on Cue by a Consistent Caregiver/Teacher
4.3.2.1 Meal and Snack Patterns for Toddlers and Preschoolers
4.3.3.1 Meal and Snack Patterns for School-Age Children

REFERENCES

Kleinman RE, Greer FR, eds. Pediatric Nutrition. 7th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2014
US Department of Agriculture, Food and Nutrition Service. Child and Adult Care Food Program (CACFP). Why CACFP is important. https://www.fns.usda.gov/cacfp/why-cacfp-important. Published September 22, 2014. Accessed September 19, 2017
American Academy of Pediatrics Committee on Nutrition. Childhood nutrition. American Academy of Pediatrics HealthyChildren.org Web site. https://www.healthychildren.org/English/healthy-living/nutrition/Pages/Childhood-Nutrition.aspx. Updated March 3, 2016. Accessed September 19, 2017
Shield JE, Mullen M. When should my kids snack? Academy of Nutrition and Dietetics Web site. http://www.eatright.org/resource/food/nutrition/dietary-guidelines-and-myplate/when-should-my-kids-snack. Published February 13, 2014. Accessed September 19, 2017
US Department of Agriculture, Food and Nutrition Service. Independent Child Care Centers: A Child and Adult Care Food Program Handbook. Washington, DC: US Department of Agriculture; 2014. https://www.fns.usda.gov/sites/default/files/cacfp/Independent%20Child%20Care%20Centers%20Handbook.pdf. Published May 2014. Accessed September 19, 2017

NOTES

Content in the STANDARD was modified on 11/9/2017.

Standard 4.2.0.6: Availability of Drinking Water

Content in the STANDARD was modified on 11/9/2017, 03/22/2019 and 05/21/2019.

Clean, sanitary drinking water should be readily available and offered throughout the day in indoor and outdoor areas.^1,2Water should not be a substitute for milk at meals or snacks at which milk is a required food component unless recommended by the child's primary health care provider.

On hot days, infants receiving human milk in a bottle can be given additional human milk in a bottle but should not be given water, especially in the first 6 months after birth.¹ Infants receiving formula and water can be given additional formula in a bottle. Toddlers and older children will need additional water as physical activity and/or hot temperatures cause their needs to increase. Toddlers should learn to drink water from a cup or drinking fountain without mouthing the fixture. They should not be allowed to have water continuously in hand in a sippy cup or bottle. Permitting toddlers to suck continuously on a bottle or sippy cup filled with water, to soothe themselves, may cause nutritional or, in rare instances, electrolyte imbalances. When toothbrushing is not done after a feeding, children should be offered water to drink to rinse food from their teeth.

Drinking fountains should be kept clean and sanitary and maintained to provide adequate drainage.

RATIONALE

When children are thirsty between meals and snacks, water is the best choice. Young children may not be able to request water on their own prompting the need for caregivers/teachers to offer water throughout the day.² Additionally, having clean, small pitchers of water and single-use paper cups available in classrooms and on playgrounds allows children to serve themselves water when they are thirsty. Drinking water during the day can keep children hydrated while reducing calorie intake if the water replaces high-caloric beverages, such as fruit drinks/nectars and sodas, which are associated with overweight and obesity.³ Personal and environmental factors, such as age, weight, gender, physical activity level, outside air temperature, heat, and humidity, can affect an individual child's water needs.⁴ Fluoride has been added to the tap (faucet) water in many communities. Drinking fluoridated water and keeping teeth "bathed" in low levels of fluoride protect a child's teeth by decreasing the likelihood of early childhood caries (cavities) when consumed throughout the day, especially between meals and snacks.^5–7

TYPE OF FACILITY

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

RELATED STANDARDS

5.2.6.3 Testing for Lead and Copper Levels in Drinking Water
3.1.3.2 Playing Outdoors
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.1.5 Preparing, Feeding, and Storing Infant Formula

REFERENCES

Centers for Disease Control and Prevention. Increasing Access to Drinking Water and Other Healthier Beverages in Early Care and Education Settings. Atlanta, GA: US Department of Health and Human Services; 2014. https://www.cdc.gov/obesity/downloads/early-childhood-drinking-water-toolkit-final-508reduced.pdf. Accessed January 11, 2018
US Department of Agriculture, Food and Nutrition Service. Child and Adult Care Food Program: meal pattern revisions related to the Healthy, Hunger-Free Kids Act of 2010. Final rule. Fed Regist. 2016;81(79):24347–24383
Muckelbauer R, Sarganas G, Grüneis A, Müller-Nordhorn J. Association between water consumption and body weight outcomes: a systematic review.Am J Clin Nutr.2013;98(2):282–299
Wolfram T. Water: how much do kids need? Academy of Nutrition and Dietetics Eat Right website. http://www.eatright.org/resource/fitness/sports-and-performance/hydrate-right/water-go-with-the-flow . Published August 10, 2018. Accessed December 20, 2018
American Academy of Pediatrics Committee on Nutrition. Pediatric Nutrition. Kleinman RE, Greer FR, eds. 7th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2014
Casamassimo P, Holt K, eds. Bright Futures: Oral Health Pocket Guide. 3rd ed. Washington, DC: National Maternal and Child Oral Health Resource Center; 2016. https://www.mchoralhealth.org/PDFs/BFOHPocketGuide.pdf. Accessed September 19, 2017
Early Childhood Learning and Knowledge Center, US Department of Health and Human Services Administration for Children and Families, Head Start. Encouraging your child to drink water. https://eclkc.ohs.acf.hhs.gov/publication/encouraging-your-child-drink-water . Updated September 11, 2018. Accessed December 20, 2018

NOTES

Content in the STANDARD was modified on 11/9/2017, 03/22/2019 and 05/21/2019.

Standard 4.2.0.7: 100% Fruit Juice

Content in the STANDARD was modified on 11/9/2017.

Fruit or vegetable juice may be served once per day during a scheduled meal or snack to children 12 months or older (1). All juices should be pasteurized and 100% juice without added sugars or sweeteners.

Age	Maximum Allowed (1)
0–12 mo	Do not offer juices to infants younger than 12 months.
1–3 y	Limit consumption to 4 oz/day (½ cup).
4–6 y	Limit consumption to 4–6 oz/day (½–¾ cup).
7–18 y	Limit consumption to 8 oz/day (1 cup).

100% juice should be offered in an age-appropriate cup instead of a bottle (2). These amounts include any juices consumed at home. Caregivers/teachers should ask parents/guardians if any juice is provided at home when deciding if and when to serve fruit juice to children in care. Whole fruit, mashed or pureed, is recommended for infants beginning at 4 months of age or as developmentally ready (3).

RATIONALE

While 100% fruit juice can be included in a healthy eating pattern, whole fruit is more nutritious and provides many nutrients, including dietary fiber, not found in juices (4).

Limiting overall juice consumption and encouraging children to drink water in-between meals will reduce acids produced by bacteria in the mouth that cause tooth decay. The frequency of exposure and liquids being pooled in the mouth are important in determining the cause of tooth decay in children (5). Beverages labeled as "fruit punch," "fruit nectar", or "fruit cocktail" contain less than 100% fruit juice and may be higher in overall sugar content. Routine consumption of fruit juices does not provide adequate amounts of vitamin E, iron, calcium, and dietary fiber—all essential in the growth and development of young children (6). Continuous consumption of fruit juice may be associated with decreased appetite during mealtimes, which may lead to inadequate nutrition, feeding issues, and increases in a child's body mass index—all of which are considered risk factors that may contribute to childhood obesity (7).

Serving pasteurized juice protects against the possible outbreak of foodborne illness because the process destroys any harmful bacteria that may have been present (8).

Drinks high in sugar and caffeine should be avoided because they can contribute to childhood obesity, tooth decay, and poor nutrition (9).

TYPE OF FACILITY

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

RELATED STANDARDS

4.2.0.4 Categories of Foods
4.2.0.6 Availability of Drinking Water
3.1.5.1 Routine Oral Hygiene Activities
3.1.5.3 Oral Health Education
4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants

REFERENCES

US Department of Health and Human Services, US Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th ed. Washington, DC: US Department of Health and Human Services; 2015. https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_Guidelines.pdf. Accessed September 19, 2017
American Academy of Pediatrics. Starting solid foods. American Academy of Pediatrics HealthyChildren.org Web site. https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Switching-To-Solid-Foods.aspx. Updated April 7, 2017. Accessed September 19, 2017
American Academy of Pediatrics. Fruit juice and your child's diet. American Academy of Pediatrics HealthyChildren.org Web site. https://www.healthychildren.org/English/healthy-living/nutrition/Pages/Fruit-Juice-and-Your-Childs-Diet.aspx. Updated May 22, 2017. Accessed September 19, 2017
Heyman MB, Abrams SA; American Academy of Pediatrics Section on Gastroenterology, Hepatology, and Nutrition and Committee on Nutrition. Fruit juice in infants, children, and adolescents: current recommendations. Pediatrics. 2017;139(6):e20170967
Centers for Disease Control and Prevention. Healthy schools. The buzz on energy drinks. https://www.cdc.gov/healthyschools/nutrition/energy.htm. Updated March 22, 2016. Accessed September 19, 2017.
US Food and Drug Administration. Talking about juice safety: what you need to know. https://www.fda.gov/food/resourcesforyou/consumers/ucm110526.htm. Updated September 19, 2017. Accessed September 19, 2017
Shefferly A, Scharf RJ, DeBoer MD. Longitudinal evaluation of 100% fruit juice consumption on BMI status in 2–5?year?old children. Pediatr Obes. 2016;11(3):221–227
Crowe-White K, O'Neil CE, Parrott JS, et al. Impact of 100% fruit juice consumption on diet and weight status of children: an evidence-based review. Crit Rev Food Sci Nutr. 2016;56(5):871–884
Casamassimo P, Holt K, eds. Bright Futures: Oral Health Pocket Guide. 3rd ed. Washington, DC: National Maternal and Child Oral Health Resource Center; 2016. https://www.mchoralhealth.org/PDFs/BFOHPocketGuide.pdf. Accessed September 19, 2017

NOTES

Content in the STANDARD was modified on 11/9/2017.

Standard 4.2.0.8: Feeding Plans and Dietary Modifications

Content in the STANDARD was modified on 11/9/2017.

Before a child enters an early care and education facility, the facility should obtain a written history that contains any special nutrition or feeding needs for the child, including use of human milk or any special feeding utensils. The staff should review this history with the child's parents/guardians, clarifying and discussing how the parents'/guardians' home feeding routines may differ from the facility's planned routine. The child's primary health care provider should provide written information to the parent/guardian about any dietary modifications or special feeding techniques that are required at the early care and education program so they can be shared with and implemented by the program.

If dietary modifications are indicated, based on a child's medical or special dietary needs, caregivers/teachers should modify or supplement the child's diet to meet the individual child's specific needs. Dietary modifications should be made in consultation with the parents/guardians and the child's primary health care provider. Caregivers/teachers can consult with a nutritionist/registered dietitian.

A child's diet may be modified because of food sensitivity, a food allergy, or many other reasons. Food sensitivity includes a range of conditions in which a child exhibits an adverse reaction to a food that, in some instances, can be life-threatening. Modification of a child's diet may also be related to a food allergy, an inability to digest or to tolerate certain foods, a need for extra calories, a need for special positioning while eating, diabetes and the need to match food with insulin, food idiosyncrasies, and other identified feeding issues, including celiac disease, phenylketonuria, diabetes, and severe food allergy (anaphylaxis). In some cases, a child may become ill if he/she is unable to eat, so missing a meal could have a negative consequence, especially for children with diabetes.

For a child with special health care needs who requires dietary modifications or special feeding techniques, written instructions from the child's parent/guardian and the child's primary health care provider should be provided in the child's record and carried out accordingly. Dietary modifications should be recorded. These written instructions must identify

a. The child's full name and date of instructions
b. The child's special health care needs
c. Any dietary restrictions based on those special needs
d. Any special feeding or eating utensils
e. Any foods to be omitted from the diet and any foods to be substituted
f. Any other pertinent information about the child's special health care needs
g. What, if anything, needs to be done if the child is exposed to restricted foods

The written history of special nutrition or feeding needs should be used to develop individual feeding plans and, collectively, to develop facility menus. Health care providers with experience in disciplines related to special nutrition needs, including nutrition, nursing, speech therapy, occupational therapy, and physical therapy, should participate when needed and/or when they are available to the facility. If available, the nutritionist/registered dietitian should approve menus that accommodate needed dietary modifications.

The feeding plan should include steps to take when a situation arises that requires rapid response by the staff, such as a child choking during mealtime or a child with a known history of food allergies demonstrating signs and symptoms of anaphylaxis (severe allergic reaction), such as difficulty breathing and severe redness and swelling of the face or mouth. The completed plan should be on file and accessible to staff and available to parents/guardians on request.

RATIONALE

Children with special health care needs may have individual requirements related to diet and swallowing, involving special feeding utensils and feeding needs that will necessitate the development of an individual plan prior to their entry into the facility (1). Many children with special health care needs have difficulty with feeding, including delayed attainment of basic chewing, swallowing, and independent feeding skills. Food, eating style, food utensils, and equipment, including furniture, may have to be adapted to meet the developmental and physical needs of individual children (2,3,).

Some children have difficulty with slow weight gain and need their caloric intake monitored and supplemented. Others, such as those with diabetes, may need to have their diet matched to their medication (e.g., insulin, if they are on a fixed dose of insulin). Some children are unable to tolerate certain foods because of their allergy to the food or their inability to digest it. The 8 most common foods to cause anaphylaxis in children are cow's milk, eggs, soy, wheat, fish, shellfish, peanuts, and tree nuts (3). Staff members must know ahead of time what procedures to follow, as well as their designated roles, during an emergency.

As a safety and health precaution, staff should know in advance whether a child has food allergies, inborn errors of metabolism, diabetes, celiac disease, tongue thrust, or special health care needs related to feeding, such as requiring special feeding utensils or equipment, nasogastric or gastric tube feedings, or special positioning. These situations require individual planning prior to the child's entry into an early care and education program and on an ongoing basis (2).

In some cases, dietary modifications are based on religious or cultural beliefs. Detailed information on each child's special needs, whether stemming from dietary, feeding equipment, or cultural needs, is invaluable to the facility staff in meeting the nutritional needs of all the children in their care.

COMMENTS

Close collaboration between families and the facility is necessary for children on special diets. Parents/guardians may have to provide food on a temporary, or even permanent, basis, if the facility, after exploring all community resources, is unable to provide the special diet.

Programs may consider using the American Academy of Pediatrics (AAP) Allergy and Anaphylaxis Emergency Plan, which is included in the AAP clinical report, Guidance on Completing a Written Allergy and Anaphylaxis Emergency Plan (4).

TYPE OF FACILITY

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

RELATED STANDARDS

4.2.0.2 Assessment and Planning of Nutrition for Individual Children
3.5.0.1 Care Plan for Children with Special Health Care Needs
4.2.0.1 Written Nutrition Plan
4.2.0.12 Vegetarian/Vegan Diets
4.3.1.2 Feeding Infants on Cue by a Consistent Caregiver/Teacher
4.5.0.10 Foods that Are Choking Hazards

REFERENCES

Wang J, Sicherer SH; American Academy of Pediatrics Section on Allergy and Immunology. Guidance on completing a written allergy and anaphylaxis emergency plan. Pediatrics. 2017;139(3):e20164005
Kleinman RE, Greer FR, eds. Pediatric Nutrition. 7th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2014
Kaczkowski CH, Caffrey C. Pediatric nutrition. In: Blanchfield DS, ed. The Gale Encyclopedia of Children's Health: Infancy Through Adolescence. Vol 3. 3rd ed. Farmington Hills, MI: Gale; 2016:2063–2066
Samour PQ, King K. Pediatric Nutrition. 4th ed. Sunbury, MA: Jones and Bartlett Learning; 2010

NOTES

Content in the STANDARD was modified on 11/9/2017.

Standard 4.2.0.9: Written Menus and Introduction of New Foods

Content in the STANDARD was modified on 11/9/2017.

Facilities should develop, at least one month in advance, written menus that show all foods to be served during that month and should make the menus available to parents/guardians. The facility should date and retain these menus for 6 months, unless the state regulatory agency requires a longer retention time. The menus should be amended to reflect any and all changes in the food actually served. Any substitutions should be of equal nutrient value.

Caregivers/teachers should use or develop a take-home sheet for parents/guardians on which caregivers/teachers record the food consumed each day or, for breastfed infants, the number of times they are fed and other important notes. Caregivers/teachers should continue to consult with each infant's parent/guardian about foods they have introduced and are feeding to the infant. In this way, caregivers/teachers can follow a schedule of introducing new foods one at a time and more easily identify possible food allergies or intolerances. Caregivers/teachers should let parents/guardians know what and how much their infants eat each day.

To avoid problems of food sensitivity in infants younger than 12 months, caregivers/teachers should obtain from infants' parents/guardians a list of foods that have already been introduced (without any reaction) and serve those items when appropriate. As new foods are considered for serving, caregivers/teachers should share and discuss these foods with parents/guardians prior to their introduction.

RATIONALE

Planning menus in advance helps to ensure that food will be on hand. Posting menus in a prominent area and distributing them to parents/guardians helps to inform parents/guardians about proper nutrition Parents/guardians need to be informed about food served in the facility to know how to complement it with the food they serve at home. If a child has difficulty with any food served at the facility, parents/guardians can address this issue with appropriate staff members. Some regulatory agencies require menus as a part of the licensing and auditing process (1).

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 (1-3).

COMMENTS

Caregivers/teachers should be aware that new foods may need to be offered between 8 and 15 times before they may be accepted (2,4). Sample menus and menu planning templates are available from most state health departments and the US Department of Agriculture (5) and its Child and Adult Care Food Program (6).

Good communication between caregivers/teachers and parents/guardians is essential for successful feeding, in general, including when introducing age-appropriate solid foods (complementary foods). The decision to feed specific foods should be made in consultation with the parents/guardians. It is recommended that caregivers/teachers be given written instructions on the introduction and feeding of foods from the parents/guardians and the infants' primary health care providers.

TYPE OF FACILITY

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

RELATED STANDARDS

4.3.1.1 General Plan for Feeding Infants
4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants
4.5.0.8 Experience with Familiar and New Foods

REFERENCES

American Academy of Pediatrics Committee on Nutrition. Childhood nutrition. American Academy of Pediatrics HealthyChildren.org Web site. https://www.healthychildren.org/English/healthy-living/nutrition/Pages/Childhood-Nutrition.aspx. Updated March 3, 2016. Accessed September 20, 2017
US Department of Agriculture, Food and Nutrition Service. Child and Adult Care Food Program (CACFP). https://www.fns.usda.gov/cacfp/child-and-adult-care-food-program. Published March 29, 2017. Accessed September 20, 2017
US Department of Agriculture. Menu planning tools for child care providers. https://healthymeals.fns.usda.gov/menu-planning/menu-planning-tools/menu-planning-tools-child-care-providers. Accessed September 20, 2017
Savage JS, Fisher JO, Birch LL. Parental influence on eating behavior: conception to adolescence. J Law Med Ethics. 2007;35(1):22–34
Coulthard H, Sealy A. Play with your food! Sensory play is associated with tasting of fruits and vegetables in preschool children. Appetite. 2017;113:84–90
Benjamin SE, Copeland KA, Cradock A, et al. Menus in child care: a comparison of state regulations with national standards. J Am Diet Assoc. 2009;109(1):109–115

NOTES

Content in the STANDARD was modified on 11/9/2017.

Standard 4.2.0.12: Vegetarian/Vegan Diets

Content in this standard was modified on November 10, 2017.

Infants and children, including school-aged children from families practicing a vegetarian diet, can be accommodated in an early care and education environment when there is:

Written documentation from parents/guardians with a detailed and accurate dietary history of food choices—foods eaten, levels of limitations/restrictions to foods, and frequency of foods offered;
A current health record of the child available to the caregivers/teachers, including information about height and rate of weight gain, or consistent poor appetite (warning signs of growth deficiencies);
Sharing of updated information on the child's health with the parents/guardians and the early care and education staff by the child care health consultant and the nutritionist/registered dietitian; and
Sharing sound health and nutrition information that is culturally-relevant to the family to ensure that the child receives adequate calories and essential nutrients.

RATIONALE

Infants and young children are at highest risk for nutritional deficiencies for energy levels and essential nutrients, including protein, calcium, iron, zinc, vitamins B₆ and B₁₂, and vitamin D (1-3). The younger the child, the more critical it is to know about family food choices, limitations, and restrictions because the child is dependent on family food (2).

Also, it is important that a child's diet consist of a variety of nourishing food to support the critical period of rapid growth in the early years after birth. All children who are vegetarian/vegan should receive multivitamins, especially vitamin D (400 IU of vitamin D is recommended from 6 months of age to adulthood unless there is certainty of having the daily allowance met by foods); infants younger than 6 months who are exclusively or partially breastfed and who receive less than 16 oz of formula per day should receive 400 IU of vitamin D (4). If the facility participates in the US Department of Agriculture Child and Adult Care Food Program, guidance for meals and snack patterns must be followed for any child consuming a vegetarian or vegan diet (5).

COMMENTS

For older children who have more choice about what they eat and drink, effort should be made to provide accurate nutrition information so they make the wisest food choices for themselves. Both the early care and education program/school and the caregiver/teacher have an opportunity to inform, teach, and promote sound eating practices, along with the consequences when poor food choices are made (1). Sensitivity to cultural factors, including beliefs and practices of a child's family, should be maintained.

Changing lifestyles and convictions and beliefs about food and religion, including what is eaten and what foods are restricted or never consumed, have some families with infants and children practicing several levels of vegetarian diets. Some parents/guardians indicate they are vegetarians, semi-vegetarian, or strict vegetarians because they do not or seldom eat meat. Others label themselves lacto-ovo vegetarians, eating or drinking foods such as eggs and dairy products. Still others describe themselves as vegans who restrict themselves to ingesting only plant-based foods, avoiding all and any animal products.

ADDITIONAL RESOURCES

US Department of Agriculture. 10 tips: healthy eating for vegetarians. ChooseMyPlate.gov Web site. https://www.choosemyplate.gov/ten-tips-healthy-eating-for-vegetarians . Updated July 25, 2017. Accessed September 20, 2017

US Department of Agriculture, US Department of Health and Human Services. Meat and meat alternates: build a healthy plate with protein. In: Nutrition and Wellness Tips for Young Children: Provider Handbook for the Child and Adult Care Food Program. Alexandria, VA: US Department of Agriculture; 2012.

https://www.fns.usda.gov/sites/default/files/protein.pdf . Accessed September 20, 2017

TYPE OF FACILITY

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

RELATED STANDARDS

4.2.0.2 Assessment and Planning of Nutrition for Individual Children
3.1.2.1 Routine Health Supervision and Growth Monitoring
4.3.1.6 Use of Soy-Based Formula and Soy Milk
4.4.0.2 Use of Nutritionist/Registered Dietitian

REFERENCES

Kleinman RE, Greer FR, eds. Pediatric Nutrition. 7th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2014
Hayes D. Feeding vegetarian and vegan infants and toddlers. Academy of Nutrition and Dietetics Web site. http://www.eatright.org/resource/food/nutrition/vegetarian-and-special-diets/feeding-vegetarian-and-vegan-infants-and-toddlers. Published May 4, 2015. Accessed September 20, 2017
Mangels R, Driggers J. The youngest vegetarians. Vegetarian infants and toddlers. Infant Child Adolesc Nutr. 2012;4(1):8–20
Hollis BW, Wagner CL, Howard CR, et al. Maternal versus infant vitamin D supplementation during lactation: a randomized controlled trial. Pediatrics. 2015;136(4):625–634
US Department of Agriculture, Food and Nutrition Service. Independent Child Care Centers: A Child and Adult Care Food Program Handbook. Washington, DC: US Department of Agriculture; 2014. https://www.fns.usda.gov/sites/default/files/cacfp/Independent%20Child%20Care%20Centers%20Handbook.pdf. Accessed September 20, 2017

NOTES

Content in this standard was modified on November 10, 2017.

Standard 4.3.1.1: General Plan for Feeding Infants

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

The facility should keep records detailing whether an infant is breastfed or formula fed, along with the type of formula being served. An infant feeding record of human (breast) milk and/or all formula given to the infant should be completed daily. Infant meals and snacks should follow the meal and snack patterns of the Child and Adult Care Food Program. Food should be appropriate for the infant's individual nutrition requirements and developmental stage as determined by written instructions obtained from the child's parent/guardian or primary health care provider.

The facility should encourage breastfeeding by providing accommodations and continuous support to the breastfeeding mother. Facilities should have a designated place set aside for breastfeeding mothers who want to visit the classroom during the workday to breastfeed, as well as a private area (not a bathroom) with an outlet for mothers to pump their breast milk (1,2). The private area also should have access to water or hand hygiene. A place that parents/guardians feel they are welcome to breastfeed, pump, or bottle-feed can create a positive and supportive environment for the family.

Infants may need a variety of special formulas, such as soy-based formula or elemental formulas, that are easier to digest and less allergenic. Elemental or special hypoallergenic formulas should be specified in the infant's care plan. Age-appropriate solid foods other than human milk or infant formula (ie, complementary foods) should be introduced no sooner than 6 months of age or as indicated by the individual child's nutritional and developmental needs. Please refer to standards 4.3.1.11 and 4.3.1.12 for more information.

RATIONALE

Human milk, as an exclusive food, is best suited to meet the entire nutritional needs of an infant from birth until 6 months of age, with the exception of recommended vitamin D supplementation. In addition to nutrition, breastfeeding supports optimal health and development. Human milk is also the best source of milk for infants for at least the first 12 months of age and, thereafter, for as long as mutually desired by mother and child. Breastfeeding protects infants from many acute and chronic diseases and has advantages for the mother, as well (3).

Research overwhelmingly shows that exclusive breastfeeding for 6 months, and continued breastfeeding for at least a year or longer, dramatically improves health outcomes for children and their mothers. Healthy People 2020 outlines several objectives, including increasing the proportion of mothers who breastfeed their infants and increasing the duration of breastfeeding and exclusive breastfeeding (4).

Incidences of common childhood illnesses, such as diarrhea, respiratory disease, bacterial meningitis, botulism, urinary tract infections, sudden infant death syndrome, insulin-dependent diabetes, ulcerative colitis, and ear infections, and overall risk for childhood obesity are significantly decreased in breastfed children (5,6). Similarly, breastfeeding, when paired with other healthy parenting behaviors, has been directly related to increased cognitive development in infants (7). Breastfeeding also has added benefits to the mother: it decreases risk of diabetes, breast and ovarian cancers, and heart disease (8).

Mothers who want to supplement their breast milk with formula may do so, as the infant will continue to receive breastfeeding benefits (4,5,7). Iron-fortified infant formula is an acceptable alternative to human milk as a food for infant feeding even though it lacks any anti-infective or immunological components. Regardless of feeding preference, an adequately nourished infant is more likely to achieve healthy physical and mental development, which will have long-term positive effects on health (9).

COMMENTS

The ways to help a mother breastfeed successfully in the early care and education facility are (2,6,8):

If she wishes to breastfeed her infant or child when she comes to the facility, offer or provide her a
1. Quiet, comfortable, and private place to breastfeed (This helps her milk to let down.)
2. Place to wash her and her infant's hands before and after breastfeeding
3. Pillow to support her infant on her lap while nursing
4. Nursing stool or step stool for her feet so she doesn't have to strain her back while nursing
5. Glass of water or other liquid to help her stay hydrated
Encourage her to get the infant used to being fed her expressed human milk by another person before the infant starts in early care and education, while continuing to breastfeed directly herself.
Discuss with her the infant's usual feeding pattern and the benefits of feeding the infant based on the infant's hunger and satiety cues rather than on a schedule; ask her if she wishes to time the infant's last feeding so that the infant is hungry and ready to breastfeed when she arrives; and ask her to leave her availability schedule with the early care and education program as well as to call if she is planning to miss a feeding or is going to be late.
Encourage her to provide a backup supply of frozen or refrigerated expressed human milk; properly label the infant's full name, date, and time on the bottle or other clean storage container in case the infant needs to eat more often than usual or the mother's visit is delayed.
Share with her information about other places or people in the community who can answer her questions and concerns about breastfeeding, such as local lactation consultants.
1. Provide culturally appropriate breastfeeding materials, including community resources for parents/guardians that include appropriate language and pictures of multicultural families to assist families in identifying with them.
Ensure that all staff receive training in breastfeeding support and promotion.
Ensure that all staff are trained in the proper handling, storing, and feeding of each milk product, including human milk or infant formula.

Additional Resources

Breastfeeding, US Department of Health and Human Services Office on Women's Health ( https://www.womenshealth.gov/printables-and-shareables/health-topic/breastfeeding)
Feeding Infants: A Guide for Use in the Child Nutrition Programs, US Department of Agriculture (USDA) Food and Nutrition Service (https://wicworks.fns.usda.gov/wicworks/Topics/FG/CompleteIFG.pdf)
Infant Meal Pattern, USDA ( https://fns-prod.azureedge.net/sites/default/files/cacfp/CACFP_infantmealpattern.pdf)
Strategy 6, Support for Breastfeeding in Early Care and Education, Centers for Disease Control and Prevention ( https://www.cdc.gov/breastfeeding/pdf/strategy6-support-breastfeeding-early-care.pdf)
Updated Child and Adult Care Food Program Meal Patterns: Infant Meals, USDA (https://fns-prod.azureedge.net/sites/default/files/cacfp/CACFP_InfantMealPattern_FactSheet_V2.pdf)

TYPE OF FACILITY

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

RELATED STANDARDS

4.2.0.9 Written Menus and Introduction of New Foods
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.1.5 Preparing, Feeding, and Storing Infant Formula
4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants
4.3.1.12 Feeding Age-Appropriate Solid Foods to Infants
Appendix JJ: Our Child Care Center Supports Breastfeeding

REFERENCES

Binns C, Lee M, Low WY. The long-term public health benefits of breastfeeding. Asia Pac J Public Health. 2016;28(1):7–14
Gibbs BG, Forste R. Breastfeeding, parenting, and early cognitive development. J Pediatr. 2014;164(3):487–493
American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827–e841
Furman L. Breastfeeding: what do we know, and where do we go from here? Pediatrics. 2017;139(4):e20170150
Healthy People 2020. Maternal, infant, and child health. HealthyPeople.gov Web site. https://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-child-health/objectives. Accessed January 11, 2018
Darmawikarta D, Chen Y, Lebovic G, Birken CS, Parkin PC, Maguire JL. Total duration of breastfeeding, vitamin D supplementation, and serum levels of 25-hydroxyvitamin D. Am J Public Health. 2016;106(4):714–719
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); US Department of Agriculture Food and Nutrition Service. Breastfeeding Policy and Guidance. https://www.fns.usda.gov/sites/default/files/wic/WIC-Breastfeeding-Policy-and-Guidance.pdf. Published July 2016. Accessed January 11, 2018
Centers for Disease Control and Prevention. Strategies to Prevent Obesity and Other Chronic Diseases: The CDC Guide to Strategies to Support Breastfeeding Mothers and Babies. Atlanta, GA: US Department of Health and Human Services; 2013. http://www.cdc.gov/breastfeeding/pdf/BF-Guide-508.pdf. Accessed January 11, 2018
Danawi H, Estrada L, Hasbini T, Wilson DR. Health inequalities and breastfeeding in the United States of America. Int J Childbirth Educ. 2016;31(1)

NOTES

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

Standard 4.3.1.2: Feeding Infants on Cue by a Consistent Caregiver/Teacher

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

Caregivers/teachers should feed infants on cue unless the parent/guardian and the child's primary health care provider give written instructions stating otherwise (1). Caregivers/teachers should be gentle, patient, sensitive, and reassuring when responding appropriately to the infant's feeding cues (2). Responsive feeding is most successful when caregivers/teachers learn how infants externally communicate hunger and fullness. Crying alone is not a cue for hunger unless accompanied by other cues, such as opening the mouth, making sucking sounds, rooting, fast breathing, clenched fingers/fists, and flexed arms/legs (1,2). Whenever possible, the same caregiver/teacher should feed a specific infant for most of that infant's feedings (3). Caregivers/teachers should not feed infants beyond satiety; just as hunger cues are important in initiating feedings, observing satiety cues can limit overfeeding. An infant will communicate fullness by shaking the head or turning away from food (1,4,5).

A pacifier should not be offered to an infant prior to being fed.

RATIONALE

Responsive feeding meets the infant's nutritional and emotional needs and provides an immediate response to the infant, which helps ensure trust and feelings of security (6). A caregiver/teacher is more likely to understand how a particular infant communicates hunger/satiety when consistent, reliable feedings and interactions are done regularly over time. Early relationships between an infant and caregivers/teachers involving feeding set the stage for an infant to develop eating patterns for life (1-5). Responsive feeding may help prevent childhood obesity (5-7).

TYPE OF FACILITY

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

RELATED STANDARDS

4.3.1.1 General Plan for Feeding Infants
4.3.1.8 Techniques for Bottle Feeding

REFERENCES

Redsell SA, Edmonds B, Swift JA, et al. Systematic review of randomised controlled trials of interventions that aim to reduce the risk, either directly or indirectly, of overweight and obesity in infancy and early childhood. Matern Child Nutr. 2016;12(1):24–38
Early Head Start National Resource Center. Observation: The Heart of Individualizing Responsive Care. Washington, DC: Early Head Start National Resource Center; 2013. https://eclkc.ohs.acf.hhs.gov/sites/default/files/pdf/ehs-ta-paper-15-observation.pdf. Accessed November 14, 2017
Buvinger E, Rosenblum K, Miller AL, Kaciroti NA, Lumeng JC. Observed infant food cue responsivity: associations with maternal report of infant eating behavior, breastfeeding, and infant weight gain. Appetite. 2017;112:219–226
US Department of Agriculture, Special Supplemental Nutrition Program for Women, Infants, and Children. Infant hunger and satiety cues. https://wicworks.fns.usda.gov/wicworks/WIC_Learning_Online/support/job_aids/cues.pdf. Updated October 2016. Accessed November 14, 2017
Zero to Three. How to care for infants and toddlers in groups. 4. Continuity of care. https://www.zerotothree.org/resources/77-how-to-care-for-infants-and-toddlers-in-groups#chapter-38. Published February 8, 2010. Accessed November 14, 2017
Blaine RE, Davison KK, Hesketh K, Taveras EM, Gillman MW, Benjamin Neelon SE. Child care provider adherence to infant and toddler feeding recommendations: findings from the Baby Nutrition and Physical Activity Self-Assessment for Child Care (Baby NAP SACC) Study.Child Obes. 2015;11(3):304–313
Pérez-Escamilla R, Segura-Pérez S, Lott M, on behalf of the Robert Wood Johnson Foundation HER Expert Panel on Best Practices for Promoting Healthy Nutrition, Feeding Patterns, and Weight Status for Infants and Toddlers From Birth to 24 Months. Feeding Guidelines for Infants and Young Toddlers: A Responsive Parenting Approach. Guidelines for Health Professionals. Durham, NC: Healthy Eating Research; 2017. http://healthyeatingresearch.org/wp-content/uploads/2017/02/her_feeding_guidelines_brief_021416.pdf. Published February 2017. Accessed November 14, 2017

NOTES

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

Standard 4.3.1.6: Use of Soy-Based Formula and Soy Milk

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

Soy-based formula or soy milk should be provided to a child whose parents/guardians present a written request because of family or religious dietary restrictions on foods produced from animals (ie, cow's milk and other dairy products). Both soy-based formula and soy milk should be labeled with the infant's or child's full name and date and stored properly.

Soy milk should be available for the children of parents/guardians participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); Child and Adult Care Food Program; or Supplemental Nutrition Assistance Program (SNAP). Caregivers/teachers should encourage parents/guardians of children with primary health care provider–documented indications for soy formula, who are participating in WIC and/or SNAP, to learn how they can obtain soy-based infant formula or soy milk products.

RATIONALE

The American Academy of Pediatrics recommends use of hypoallergenic or soy formula for infants who are allergic to cow's milk proteins (1). Soy-based formula and soy milk are plant-based alternatives to cow's milk, often chosen by parents/guardians due to dietary or religious reasons. Soy-based formulas are appropriate for children with galactosemia or congenital lactose intolerance (2). Soy-based formulas are made from soy protein isolate with added methionine, carbohydrates, and oils (soy or vegetable) and are fortified with vitamins and minerals (3). In the United States, all soy-based formula is fortified with iron. Soy-based formula does not contain lactose, so it is used for feeding infants with documented congenital lactose intolerance. There are known differences between allergies to cow's milk proteins and intolerance to lactose. The child's specific health concerns (allergy versus intolerance) should be documented by the child's primary health care provider and not based on possible parental/guardian misinterpretation of symptoms.

TYPE OF FACILITY

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

RELATED STANDARDS

4.2.0.12 Vegetarian/Vegan Diets
4.2.0.10 Care for Children with Food Allergies
4.3.1.5 Preparing, Feeding, and Storing Infant Formula

REFERENCES

Greer FR, Sicherer SH, Burks AW; American Academy of Pediatrics Committee on Nutrition and Section on Allergy and Immunology. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. Pediatrics. 2008;121(1):183–191
American Academy of Pediatrics. Where we stand: soy formulas. HealthyChildren.org Web site. https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Where-We-Stand-Soy-Formulas.aspx. Updated November 21, 2015. Accessed November 14, 2017
US Department of Agriculture. Infant feeding guide. WIC Works Web site. https://wicworks.fns.usda.gov/infants/infant-feeding-guide. Modified October 31, 2017. Accessed November 14, 2017

NOTES

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

Standard 4.3.1.7: Feeding Cow's Milk

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

The facility should not serve cow's milk to infants from birth to 12 months of age, unless provided with a written exception and direction from the infant's primary health care provider and parents/guardians. Children between 12 and 24 months of age can be served whole pasteurized milk (1). Children 2 years and older should be served low-fat (1%) or nonfat (skim, fat-free) pasteurized milk (1). With proper documentation from a child's primary health care provider, reduced fat (2%, 1%, nonfat) pasteurized milk may be served to those children who are at risk for high cholesterol or obesity after 12 months of age (2).

RATIONALE

Milk provides many nutrients that are essential for the growth and development of young children. The fat content in whole milk is critical for brain development as well as satiety in children 12 to 24 months of age (3). For those children whom overweight or obesity is a concern or who have a family history of obesity, dyslipidemia, or early cardiovascular disease, the primary health care provider may request low-fat or nonfat milk (2).

It is not recommended that children consume cow's milk in place of human (breast) milk or infant formula during the first year after birth (1,4). Some early care and education programs have children between the ages of 18 months and 3 years in one classroom. To avoid errors in serving inappropriate milk, programs can use individual milk pitchers clearly labeled for each type of milk being served. Caregivers/teachers can explain to the children the meaning of the colored labels and identify which milk they are drinking.

TYPE OF FACILITY

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

RELATED STANDARDS

4.2.0.4 Categories of Foods
4.2.0.10 Care for Children with Food Allergies
4.9.0.3 Precautions for a Safe Food Supply

REFERENCES

American Academy of Pediatrics. Why formula instead of cow's milk? HealthyChildren.org Web site. https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Why-Formula-Instead-of-Cows-Milk.aspx. Updated November 21, 2015. Accessed January 11, 2018
Singhal S, Baker RD, Baker SS. A comparison of the nutritional value of cow's milk and nondairy beverages. J Pediatr Gastroenterol Nutr. 2017;64(5):799–805
Oldfield B, Misra S, Kwiterovich P. Prevention of cardiovascular disease in pediatric populations. In: Wong ND, Amsterdam EA, Blumenthal RS, eds. ASPC Manual of Preventive Cardiology. New York, NY: Demos Medical Publishing; 2015:184–194
Holt K, Wooldridge N, Story M, Sofka D. Cow's Milk / Children's need for. In: Bright Futures: Nutrition. Chicago, IL: American Academy of Pediatrics; 2011: 69

NOTES

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

Standard 4.3.1.8: Techniques for Bottle Feeding

Frequently Asked Questions/CFOC Clarifications

Reference: 4.3.1.8

Date: 10/13/2011

Topic & Location:
Chapter 4
Nutrition and Food Service
Standard 4.3.1.8: Techniques for Bottle Feeding

Question:
Can infants who are able to sit and hold their own bottles feed themselves or should all infants through 12 months be held during feedings?

Answer:
Infants should always be held for bottle feeding. Caregivers/teachers and parents/guardians need to understand the relationship between bottle feeding and emotional security.

COVID-19 modification as of July 13, 2021.

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

Infants should always be held for bottle feeding. Caregivers/teachers should hold infants in the caregiver's/teacher's arms or sitting up on the caregiver's/teacher's lap. Bottles should never be propped. The facility should not permit infants to have bottles in the crib. The facility should not permit an infant to carry a bottle while standing, walking, or running around.

Bottle feeding techniques should mimic approaches to breastfeeding:
a.    Initiate feeding when infant provides cues (rooting, sucking, etc.);
b.    Hold the infant during feedings and respond to vocalizations with eye contact and vocalizations;
c.     Alternate sides of caregiver's/teacher's lap;
d.    Allow breaks during the feeding for burping;
e.    Allow infant to stop the feeding.

A caregiver/teacher should not bottle feed more than one infant at a time.

Bottles should be checked to ensure they are given to the appropriate child, have human milk or infant formula in them. When using a bottle for a breastfed infant, a nipple with a cylindrical teat and a wider base is usually preferable. A shorter or softer nipple may be helpful for infants with a hypersensitive gag reflex, or those who cannot get their lips well back on the wide base of the teat (1).

The use of a bottle or cup to modify or pacify a child's behavior should not be allowed (2).

COVID-19 modification as of July 13, 2021

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

Modifications for bottle feeding include:

Continue to hold infants when bottle feeding. Physical distancing does not provide infants with the safety and comfort required for feeding.
Staff can protect themselves, when feeding or holding infants, by wearing a large, washable apron, smock, or shirt that covers their clothes completely, and can be changed between infants. Wash these coverings daily.
Wear long hair up so it is off the neck/collar and out of the face.
Wear a mask and consider using googles or a face shield when feeding a child, per facility and state/local public health guidelines.
Have extra changes of clothing for children and staff available in case clothing is soiled during feeding. Follow guidance in Standard 5.5.0.1 regarding storage and labeling of personal articles.

Additional Resources:

The Centers for Disease Control and Prevention

Child Care Food Handling Procedures During COVID-19
CDC - Handwashing
How to Clean, Sanitize, and Store Infant Feeding Items
General Business Frequently Asked Questions: COVID-19

RATIONALE

The manner in which food is given to infants is conducive to the development of sound eating habits for life. Caregivers/teachers and parents/guardians need to understand the relationship between bottle feeding and emotional security. Caregivers/teachers should hold infants who are bottle feeding whenever possible, even if the children are old enough to hold their own bottle. Caregivers/teachers should promote proper feeding practices and oral hygiene including proper use of the bottle for all infants and toddlers. Bottle propping can cause choking and aspiration and may contribute to long-term health issues, including ear infections (otitis media), orthodontic problems, speech disorders, and psychological problems (3). When infants and children are fed on cue, they are in control of frequency and amount of feedings. This has been found to reduce the risk of childhood obesity. Any liquid except plain water can cause early childhood caries (4). Early childhood caries in primary teeth may hold significant short-term and long-term implications for the child's health (5). Frequently sipping any liquid besides plain water between feeds encourages tooth decay.

Children are at an increased risk for injury when they walk around with bottle nipples in their mouths. Bottles should not be allowed in the crib or bed for safety and sanitary reasons and for preventing dental caries. It is difficult for a caregiver/teacher to be aware of and respond to infant feeding cues when the child is in a crib or bed and when feeding more than one infant at a time. Infants should be burped after every feeding and preferably during the feeding as well.

Caregivers/teachers should offer children fluids from a cup as soon as they are developmentally ready. Some children may be able to drink from a cup around six months of age, while for others it is later (6). Weaning a child to drink from a cup is an individual process, which occurs over a wide range of time. The American Academy of Pediatric Dentistry (AAPD) recommends weaning from a bottle by the child's first birthday (7). Instead of sippy cups, caregivers/teachers should use smaller cups and fill halfway or less to prevent spills as children learn to use a cup (8). If sippy cups are used, it should only be for a very short transition period.

Some children around six months to a year of age may be developmentally ready to feed themselves and may want to drink from a cup. The transition from bottle to cup can come at a time when a child's fine motor skills allow use of a cup. The caregiver/teacher should use a clean small cup without cracks or chips and should help the child to lift and tilt the cup to avoid spillage and leftover fluid. The caregiver/teacher and parent/guardian should work together on cup feeding of human milk to ensure the child's receiving adequate nourishment and to avoid having a large amount of human milk remaining at the end of feeding. Two to three ounces of human milk can be placed in a clean cup and additional milk can be offered as needed. Small amounts of human milk (about an ounce) can be discarded.

TYPE OF FACILITY

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

RELATED STANDARDS

4.3.1.2 Feeding Infants on Cue by a Consistent Caregiver/Teacher
4.3.1.9 Warming Bottles and Infant Foods

REFERENCES

Holt K, Wooldridge N, Story M, Sofka D. Breast Milk/ microwaving, storage of, advantages of. In: Bright Futures: Nutrition. Chicago, IL: American Academy of Pediatrics; 2011: 27, 118, 120
Rupal, C. 2016. Stopping the Bottle. Nemours, KidsHealth. http://kidshealth.org/en/parents/no-bottles.html#.
Hirsch, L. 2017. Feeding your 4- to 7-month old. Nemours, KidsHealth. http://kidshealth.org/en/parents/feed47m.html#
Çolak, H., Dülgergil, Ç. T., Dalli, M., & Hamidi, M. M. 2013. Early childhood caries update: A review of causes, diagnoses, and treatments. Journal of natural science, biology, and medicine, 4(1), 29.
American Academy of Pediatrics, Healthy Children. 2015. How to prevent tooth decay in your baby. https://www.healthychildren.org/English/ages-stages/baby/teething-tooth-care/Pages/How-to-Prevent-Tooth-Decay-in-Your-Baby.aspx.
American Academy of Pediatrics, Healthy Children. 2015. Practical bottle feeding tips. https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Practical-Bottle-Feeding-Tips.aspx.
Lerner, C., & Parlakian, R. 2016. Colic and crying. Zero to three. https://www.zerotothree.org/resources/197-colic-and-crying.
Ben-Joseph, E. 2015. Formula feeding FAQs: Getting started. Nemours: KidsHealth. http://kidshealth.org/en/parents/formulafeed-starting.html#

NOTES

COVID-19 modification as of July 13, 2021.

Standard 4.3.1.11: Introduction of Age-Appropriate Solid Foods to Infants

Content in the STANDARD was modified on 05/31/2018.

A plan to introduce complementary, age-appropriate solid foods to infants should be made in consultation with the child's parent/guardian and primary health care provider. Complementary foods are foods other than human (breast) milk or infant formula (liquids, semisolids, and solids) introduced to an infant to provide nutrients (1). Age-appropriate solid foods may be introduced at 6 months of age with the flexibility to introduce sooner or later based on the child's developmental status (2). However, recommendations on the introduction of complementary foods provided to caregivers of infants should take into account:

- The infant's developmental stage and nutritional status

- Coexisting medical conditions

- Social factors

- Cultural, ethnic, and religious food preferences of the family

- Financial considerations

- Other pertinent factors discovered through the nutrition assessment process (1)

For infants who are exclusively breastfed, the amount of certain nutrients in the body - such as iron and zinc - begins to decrease after 6 months of age. Therefore, pureed meats/meat substitutes and iron-fortified cereals should be gradually introduced first (3). Iron-fortified cereals, pureed meats, and pureed fruits/vegetables are all appropriate foods to introduce. The first food introduced should be a single-ingredient food that is served in a small portion for 2 to 7 days (3). Gradually increase variety and portion of foods, one at a time, as tolerated by the infant (4). There are several signs that caregivers/teachers should use when determining when the infant is ready for solid foods. These include sitting up with minimal support, proper head control, ability to chew well, or grabbing food from the plate. Additionally, infants will lose the tongue-thrusting reflex and begin acting hungry after formula feeding or breastfeeding (3). Caregivers/teachers should use or develop a take-home sheet for parents/guardians in which the caregiver/teacher records the food consumed, how much, and other important notes on the infant, each day. Caregivers/teachers should continue to consult with each infant's parents/guardians concerning which foods they have introduced and are feeding. When appropriate, modification of basic food patterns should be provided in writing by the infant's primary health care provider.

If nutritional supplements are to be given by caregivers/teachers, written orders from the prescribing health care provider should specify medical need, medication, dosage, and length of time to give medication.

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 foods given before an infant is developmentally ready may be associated with allergies and digestive problems (5). Age-appropriate solid foods, such as meat and fortified cereals, are needed beginning at 6 months of age to make up for any potential losses in zinc and iron during exclusive breastfeeding (3). Typically, low levels of vitamin D are transferred to infants via breast milk, warranting the recommendation that breastfed or partially breastfed infants receive a minimum daily intake of 400 IU of vitamin D supplementation beginning soon after birth (6). These supplements are given at home by the parents/guardians, unless otherwise specified by the primary health care provider.

Many caregivers/teachers and parents/guardians believe that infants sleep better when they start to eat age-appropriate solid foods; however, research shows that longer sleeping periods are developmentally (not nutritionally) determined in mid-infancy and, therefore, shouldn't be the sole reason for deciding when to introduce solid foods to infants (7,8). Additionally, for infants who are exclusively formula fed or given a combination of formula and human milk, evidence for introducing complementary foods in a specific order has not been established.

Good communication between the caregiver/teacher and the parents/guardians cannot be overemphasized and is essential for successful feeding in general, including when and how to introduce age-appropriate solid foods.

Additional Resource

Feeding Infants: A Guide for Use in the Child Nutrition Programs, US Department of Agriculture Food and Nutrition Service (https://wicworks.fns.usda.gov/wicworks/Topics/FG/CompleteIFG.pdf)

TYPE OF FACILITY

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

RELATED STANDARDS

4.5.0.6 Adult Supervision of Children Who Are Learning to Feed Themselves
4.2.0.7 100% Fruit Juice
4.2.0.9 Written Menus and Introduction of New Foods
4.2.0.12 Vegetarian/Vegan Diets
3.6.3.1 Medication Administration
4.2.0.10 Care for Children with Food Allergies
4.5.0.8 Experience with Familiar and New Foods

REFERENCES

US Department of Agriculture, Food and Nutrition Service. Child and Adult Care Food Program: meal pattern revisions related to the Healthy, Hunger-Free Kids Act of 2010. Final rule. Fed Regist. 2016;81(79):24347–24383
US Department of Agriculture, Food and Nutrition Service. Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Chapter 5: Complementary foods. In: Infant Nutrition and Feeding. Washington, DC: US Department of Agriculture; 2009:101–128 https://wicworks.fns.usda.gov/wicworks/Topics/FG/CompleteIFG.pdf. Accessed January 11, 2018
American Academy of Pediatrics. Working together: breastfeeding and solid foods. HealthyChildren.org Web site. https://www.healthychildren.org/English/ages-stages/baby/breastfeeding/Pages/Working-Together-Breastfeeding-and-Solid-Foods.aspx. Updated November 21, 2015. Accessed January 11, 2018
World Health Organization. Infant and young child feeding. http://www.who.int/mediacentre/factsheets/fs342/en. Updated July 2017. Accessed January 11, 2018
Abrams EM, Becker AB. Introducing solid food: age of introduction and its effect on risk of food allergy and other atopic diseases. Can Fam Physician. 2013;59(7):721–722
Thiele DK, Ralph J, El-Masri M, Anderson CM. Vitamin D3 supplementation during pregnancy and lactation improves vitamin D status of the mother-infant dyad. J Obstet Gynecol Neonatal Nurs. 2017;46(1):135–147
Walsh A, Kearney L, Dennis N. Factors influencing first-time mothers' introduction of complementary foods: a qualitative exploration. BMC Public Health. 2015;15:939
Robert Wood Johnson Foundation Healthy Eating Research. Feeding Guidelines for Infants and Young Toddlers: A Responsive Parenting Approach. Guidelines for Health Professionals. http://healthyeatingresearch.org/wp-content/uploads/2017/02/her_feeding_guidelines_brief_021416.pdf. Published February 2017. Accessed January 11, 2018

NOTES

Content in the STANDARD was modified on 05/31/2018.

Standard 4.3.1.12: Feeding Age-Appropriate Solid Foods to Infants

Content in the STANDARD was modified on 05/31/2018.

Caregivers/teachers should thoroughly wash hands prior to serving any foods to infants/children. All jars of baby food should be washed with soap and warm water and rinsed with clean, running warm water before opening. All commercially packaged baby food should be served from a dish and spoon, not directly from a factory-sealed container or jar (1). A dish should be cleaned and sanitized before use to reduce the likelihood of surface contamination.

Age-appropriate solid food should not be fed in a bottle or an infant feeder unless doing so is written in the child's care plan by the child's primary health care provider. Caregivers/teachers should ensure that there are no food safety recalls (2), and examine the food carefully when removing it from the jar to make sure there are no glass pieces or foreign objects in the food. Caregivers/teachers should discard uneaten food left in dishes from which they have fed a child because it may contain potentially harmful bacteria from the infant's saliva (3). If left out, all food should be discarded after 2 hours (4). The portion of the food that is touched by a utensil should be consumed or discarded.

Any food brought from home should not be served to other children. This will prevent cross contamination and reinforce the policy that food sent to the facility is for the designated child only.

Food should not be shared among children using the same dish or spoon.

Unused portions in opened factory-sealed baby food containers or food brought in containers prepared at home should be stored in the refrigerator and discarded if not consumed after 24 hours of storage. Prior to refrigeration, the opened container or jar should be labeled with the child's full name and the date and time the food container was opened.

RATIONALE

Feeding of age-appropriate solid foods in a bottle to a child is often associated with premature feeding (ie, when the infant is not developmentally ready for solid foods) (5,6).

The external surface of a commercial container or jar may be contaminated with disease-causing microorganisms during shipment or storage and may contaminate the food product during removal of food for placement in the child's serving dish.

TYPE OF FACILITY

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

RELATED STANDARDS

4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants

REFERENCES

Lester J. Nutrition 411: introducing solid foods. Promise powered by Nemours Children's Health System Web site. https://blog.nemours.org/2016/02/nutrition-411-introducing-solid-foods. Published February 22, 2016. Accessed January 11, 2018
US Department of Agriculture. Food Safety and Inspection Service Web site. https://www.fsis.usda.gov/wps/portal/fsis/home. Accessed January 11, 2018
US Department of Health and Human Services. Baby food and infant formula. Foodsafety.gov Web site. https://www.foodsafety.gov/keep/types/babyfood/index.html. Accessed January 11, 2018
US Department of Health and Human Services, US Food and Drug Administration. Food safety for moms to be: once baby arrives. https://www.fda.gov/food/resourcesforyou/healtheducators/ucm089629.htm>. Updated November 8, 2017. Accessed January 11, 2018
Robert Wood Johnson Foundation Healthy Eating Research. Feeding Guidelines for Infants and Young Toddlers: A Responsive Parenting Approach. Guidelines for Health Professionals. http://healthyeatingresearch.org/wp-content/uploads/2017/02/her_feeding_guidelines_brief_021416.pdf. Published February 2017. Accessed January 11, 2018
US Department of Agriculture Food and Nutrition Service. Feeding Infants: A Guide for Use in the Child Nutrition Programs. Publication FNS-258. Alexandria, VA: US Department of Agriculture; 2017. https://www.fns.usda.gov/tn/feeding-infants-guide-use-child-nutrition-programs. Accessed January 11, 2018

NOTES

Content in the STANDARD was modified on 05/31/2018.

Standard 4.3.2.1: Meal and Snack Patterns for Toddlers and Preschoolers

Content in the STANDARD was modified on 05/31/2018.

Meals and snacks should contain the minimum amount of foods shown in the meal and snack patterns for toddlers and preschoolers described in the Child and Adult Care Food Program (CACFP).

When incorporating CACFP, caregivers/teachers should (1):

-Provide a variety of fruits and vegetables.

-Serve a fruit and/or vegetable during scheduled snacks.

-Provide one serving each of dark-green vegetables, red and orange vegetables, beans and peas, starchy vegetables, and other vegetables weekly.

-Serve whole grains and whole-grain products.

-Limit yogurt to no more than 23 grams of sugar per 6 ounces.

-Limit processed foods to once per week.

Flavored milks contain higher amounts of added sugars and should not be served. Facilities are encouraged to incorporate seasonal/locally produced foods into meals. Water should not be offered to children during mealtimes; instead, offer water throughout the day.

With limited appetites and selective eating by toddlers and preschoolers, less nutritious foods should not be served because they can displace more nutritious foods from the child's diet.
Early care and education settings should check with state regulators about the timing between meals. State agencies may require any institution or facility to allow a specific amount of time to elapse between meal services or require that meal services not exceed a specified duration (2).

RATIONALE

Following CACFP guidelines ensures that all children enrolled receive a greater variety of vegetables and fruits and more whole grains and less added sugar and saturated fat during their meals while in care (3). Even during periods of slower growth, children must continue to eat nutritious foods. Picky or selective eating is common among toddlers. They may decide to eat a meal/snack one day but not the next. Over time, with consistent exposure, toddlers are more likely to accept new foods (4).

Additional Resource

US Department of Agriculture Food and Nutrition Service CACFP Nutrition Standards for CACFP Meals and Snacks (www.fns.usda.gov/cacfp/meals-and-snacks)

US Department of Agriculture Healthy Tips for Picky Eaters (https://wicworks.fns.usda.gov/wicworks/Topics/TipsPickyEaters.pdf)

TYPE OF FACILITY

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

RELATED STANDARDS

4.2.0.3 Use of US Department of Agriculture Child and Adult Care Food Program Guidelines
4.2.0.4 Categories of Foods
4.2.0.5 Meal and Snack Patterns

REFERENCES

US Department of Agriculture Food and Nutrition Service. Child and Adult Care Food Program: meal pattern revisions related to the Healthy, Hunger-Free Kids Act of 2010. Final rule. Fed Regist. 2016;81(79):24347–24383. https://www.gpo.gov/fdsys/pkg/FR-2016-04-25/pdf/2016-09412.pdf. Accessed January 11, 2018
US Department of Agriculture. Child and Adult Care Food Program: best practices. https://www.fns.usda.gov/sites/default/files/cacfp/CACFP_factBP.pdf. Accessed January 11, 2018
US Department of Agriculture Food and Nutrition Service. Independent Child Care Centers: A Child and Adult Care Food Program Handbook. Washington, DC: US Department of Agriculture; 2014. https://fns-prod.azureedge.net/sites/default/files/cacfp/Independent%20Child%20Care%20Centers%20Handbook.pdf. Accessed January 11, 2018
US Department of Agriculture. Updated Child and Adult Care Food Program meal patterns: child and adult meals. https://www.fns.usda.gov/sites/default/files/cacfp/CACFP_MealBP.pdf. Accessed January 11, 2018

NOTES

Content in the STANDARD was modified on 05/31/2018.

Standard 4.3.2.2: Serving Size for Toddlers and Preschoolers

Content in the STANDARD was modified on 05/31/2018.

The facility should serve toddlers and preschoolers small, age-appropriate portions. The facility should permit children to have one or more additional servings of nutritious foods that are low in fat, sugar, and sodium as required to meet the caloric needs of the individual child. Serving dishes should contain, at minimum, the amount of food based on serving sizes or portions recommended for each child outlined in the Child and Adult Care Food Program (CACFP). Young children should learn what appropriate portion size is by being served plates, bowls, and cups that are developmentally and age appropriate.

Food service staff and/or a caregiver/teacher is responsible for preparing the amount of food based on the recommended age-appropriate amount of food per serving for each child to be fed. Usually a reasonable amount of additional food is prepared to respond to any spills or to children requesting a second serving.

Children should continue to be exposed to new foods, textures, and tastes throughout infancy, toddlerhood, and preschool. Children should not be required or forced to eat any specific food items. Caregivers/teachers should create a supportive environment that promotes positive, sound eating behaviors (1).

RATIONALE

A child will not eat the same amount each day because appetites vary and food jags are common (2). Eating habits established in infancy and early childhood may contribute to optimal eating patterns later in life. These habits include nutritious meals/snacks consumed in a pleasant, clean, supportive mealtime atmosphere with age-appropriate plates/utensils (1). The quality of snacks for young and school-aged children is especially important, and small, frequent feedings are recommended to achieve the total desired daily intake.

Strong evidence supports that larger plates, bowls, and cups, when paired with sustained long-term exposure of oversized portions, promote overeating (3). Allowing children to decide how much to eat, through family-style dining, may also help promote self-regulation in children (3).

COMMENTS

The CACFP guidelines for meal and snack patterns can be found at www.fns.usda.gov/cacfp/meals-and-snacks.

TYPE OF FACILITY

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

RELATED STANDARDS

4.2.0.3 Use of US Department of Agriculture Child and Adult Care Food Program Guidelines
4.3.2.1 Meal and Snack Patterns for Toddlers and Preschoolers
4.3.2.3 Encouraging Self-Feeding by Older Infants and Toddlers

REFERENCES

McCrickerd K, Leong C, Forde CG. Preschool children's sensitivity to teacher-served portion size is linked to age related differences in leftovers.Appetite. 2017;114:320–328
Green RJ, Samy G, Miqdady MS, et al. How to improve eating behavior during early childhood. Pediatric Gastroenterol Hepatol Nutr. 2015;18(1):1–9
Mita SC, Gray SA, Goodell LS. An explanatory framework of teachers' perceptions of a positive mealtime environment in a preschool setting. Appetite. 2015;90:37–44

NOTES

Content in the STANDARD was modified on 05/31/2018.

Standard 4.3.2.3: Encouraging Self-Feeding by Older Infants and Toddlers

Content in the STANDARD was modified on 05/31/2018.

Caregivers/teachers should encourage older infants and toddlers to:

-hold and drink from an appropriate child-sized cup,

-use a child-sized spoon (short handle with a shallow bowl like a soup spoon), and

-use a child-sized fork (short, blunt tines and broad handle, similar to a salad fork).

All of which are developmentally appropriate for young children to feed themselves. Children can also use their fingers for self-feeding. Children in group care should be provided with opportunities to serve and eat a variety of food for themselves. Foods served should be appropriate to the toddler's developmental ability and cut small enough to avoid choking hazards.

RATIONALE

As children enter the second year after birth, they are interested in doing things for themselves. Self-feeding appropriately separates the responsibilities of adults and children. The caregivers/teachers and parents/guardians are responsible for providing nutritious food, and the child is responsible for deciding how much of it to eat (1,2). To allow for the proper development of motor skills and eating habits, children need to be allowed to practice feeding themselves as early as 9 months of age (3,4). Children will continue to self-feed using their fingers even after mastering the use of a utensil.

TYPE OF FACILITY

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

RELATED STANDARDS

4.5.0.6 Adult Supervision of Children Who Are Learning to Feed Themselves
4.3.2.2 Serving Size for Toddlers and Preschoolers
4.5.0.5 Numbers of Children Fed Simultaneously by One Adult
4.5.0.10 Foods that Are Choking Hazards

REFERENCES

Fewtrell M, Bronsky J, Campoy C, et al. Complementary feeding: a position paper by the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) Committee on Nutrition. J Pediatr Gastroenterol Nutr. 2017;64(1):119–132
Williamson C, Beatty C. Weaning and childhood nutrition. InnovAiT. 2015;8(3):141–145
American Academy of Pediatrics Committee on Nutrition. Pediatric Nutrition. Kleinman RE, Greer FR, eds. 7th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2014
McCrickerd K, Leong C, Forde CG. Preschool children's sensitivity to teacher-served portion size is linked to age related differences in leftovers.Appetite. 2017;114:320–328

NOTES

Content in the STANDARD was modified on 05/31/2018.

Standard 4.5.0.1: Developmentally Appropriate Seating and Utensils for Meals

The child care staff should ensure that children who do not require highchairs are comfortably seated at tables that are between waist and mid-chest level and allow the seated child's feet to rest on a firm surface.

All furniture and eating utensils that a child care facility uses should make it possible for children to eat at their best skill level and to increase their eating skill.

RATIONALE

Proper seating while eating reduces the risk of food aspiration and improves comfort in eating (7,9).

Suitable furniture and utensils, in addition to providing comfort, enable the children to perform eating tasks they have already mastered and facilitate the development of skill and coordination in handling food and utensils (4-6,8,9).

COMMENTS

Eating utensils should be unbreakable, durable, attractive, and suitable in function, size, and shape for use by children. Dining areas, whether in a classroom or in a separate area, should be clean and cheerful (1-6).

TYPE OF FACILITY

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

RELATED STANDARDS

4.5.0.2 Tableware and Feeding Utensils

REFERENCES

U.S. Department of Agriculture (USDA), Food and Nutrition Service. 2009. USDA recipes for child care. http://teamnutrition
.usda.gov/Resources/childcare_recipes.html.
Hagan, Jr., 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.
Holt K, Wooldridge N, Story M, Sofka D. Nutrition Education/ curriculum for, aspects of. In: Bright Futures: Nutrition. Chicago, IL: American Academy of Pediatrics; 2011: 10, 55
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.
Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.
Fletcher, J., L. Branen, E. Price. 2005. Building mealtime environments and relationships: An inventory for feeding young children in group settings. Moscow, ID: University of Idaho. http://www.cals.uidaho.edu/feeding/pdfs/BMER.pdf.
U.S. Department of Agriculture (USDA). 2002. Making nutrition count for children - Nutrition guidance for child care homes. Washington, DC: USDA. http://www/gpo.gov/fdsys/pkg/ERIC-ED482991/pdf/ERIC-ED482991.pdf.
U.S. Department of Health and Human Services, Administration for Children and Families (ACF). 2006. Head Start Program Performance Standards and other Regulations. Rev ed. Washington, DC: ACF, Head Start Bureau.
Enders, J. B. 1994. Food, nutrition and the young child. New York: Merrill.

Standard 4.5.0.4: Socialization During Meals

COVID-19 modification as of September 20, 2021.

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

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. 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.

COVID-19 modification as of September 20, 2021

Programs may resume family style meals if the following implement strategies are followed:

Keep masks on until children and adults are eating.
Set up the table with serving dishes, water pitchers, and utensils prior to the meal.
Seat children farther apart.
Provide as much fresh air as possible.
Wash hands prior to and immediately after eating.
Children eat outdoors or in well ventilated spaces.
Clean and sanitize food surfaces before and after meals.

Programs should continue to:

Serve meal components in serving sizes as specified in the Child and Adult Care Food Program (CACFP)
Hold conversations at the table with children to guide their decisions about how much they want to eat.
Ensure that children are not sharing food or touching each other during mealtime.
Practice physical distancing during mealtimes.

Create smaller groups and stagger mealtimes if space is limited.

Inform families of changes to mealtime practices and communicate how their children respond.

Additional Resources:

Centers for Disease Control and Prevention. Food and coronavirus disease 2019 (COVID-19)
Early Childhood Learning & Knowledge Center. Family Style Meals
USDA. FNS responses to COVID

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.

COMMENTS

Compliance is measured by structured observation. Use of small pitchers, a limited number of portions on service plates, and adult assistance to enable children to successfully serve themselves helps to make family style service possible without contamination or waste of food.

TYPE OF FACILITY

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

RELATED STANDARDS

4.2.0.8 Feeding Plans and Dietary Modifications
4.3.2.2 Serving Size for Toddlers and Preschoolers
4.3.2.3 Encouraging Self-Feeding by Older Infants and Toddlers
4.7.0.1 Nutrition Learning Experiences for Children

REFERENCES

Endres, J. B., R. E. Rockwell. 2003. Food, nutrition, and the young child. 4th ed. New York: Macmillan.
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.
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.
Pipes, P. L., C. M. Trahms, eds. 1997.Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.
U.S. Department of Agriculture (USDA). 2002.Making nutrition count for children - Nutrition guidance for child care homes. Washington, DC: USDA. http://www.gpo.gov/fdsys/pkg/ERIC-ED482991/pdf/ERIC-ED482991.pdf
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.
Branscomb, K. R., C. B. Goble 2008. Infants and toddlers in group care: Feeding practices that foster emotional health.Young Children 63:28-33.

NOTES

COVID-19 modification as of September 20, 2021.

Standard 4.5.0.8: Experience with Familiar and New Foods

In consultation with the family and the nutritionist/registered dietitian, caregivers/teachers should offer children familiar foods that are typical of the child's culture and religious preferences and should also introduce a variety of healthful foods that may not be familiar, but meet a child's nutritional needs. Experiences with new foods can include tasting and swallowing but also include engagement of all senses (seeing, smelling, speaking, etc.) to facilitate the introduction of these new foods.

RATIONALE

By learning about new food, children increase their knowledge of the world around them, and the likelihood that they will choose a more varied, better balanced diet in later life. Eating habits and attitudes about food formed in the early years often last a lifetime. New food acceptance may take eight to fifteen times of offering a food before it is eaten (1).

TYPE OF FACILITY

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

RELATED STANDARDS

4.2.0.9 Written Menus and Introduction of New Foods
4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants

REFERENCES

Sullivan, S. A., L. L. Birch. 1990. Pass the sugar, pass the salt: Experience dictates preference. Developmental Psychology 26:546-51.

Standard 4.7.0.1: Nutrition Learning Experiences for Children

The facility should have a nutrition plan that integrates the introduction of food and feeding experiences with facility activities and home feeding. The plan should include opportunities for children to develop the knowledge and skills necessary to make appropriate food choices.

For centers, this plan should be a written plan and should be the shared responsibility of the entire staff, including directors and food service personnel, together with parents/guardians. The nutrition plan should be developed with guidance from, and should be approved by, the nutritionist/registered dietitian or child care health consultant.

Caregivers/teachers should teach children about the taste, smell, texture of foods, and vocabulary and language skills related to food and eating. The children should have the opportunity to feel the textures and learn the different colors, sizes, and shapes of foods and the nutritional benefits of eating healthy foods. Children should also be taught about appropriate portion sizes. The teaching should be evident at mealtimes and during curricular activities, and emphasize the pleasure of eating. Caregivers/teachers need to be aware that children between the ages of two- and five-years-old are often resistant to trying new foods and that food acceptance may take eight to fifteen times of offering a food before it is eaten (14).

RATIONALE

Nourishing and attractive food is a foundation for developmentally appropriate learning experiences and contributes to health and well-being (1-13,15). Coordinating the learning experiences with the food service staff maximizes effectiveness of the education. In addition to the nutritive value of food, infants and young children are helped, through the act of feeding, to establish warm human relationships. Eating should be an enjoyable experience for children and staff in the facility and for children and parents/guardians at home. Enjoying and learning about food in childhood promotes good nutrition habits for a lifetime (17,18).

COMMENTS

Parents/guardians and caregivers/teachers should always be encouraged to sit at the table and eat the same food offered to young children as a way to strengthen family style eating which supports child's serving and feeding him or herself (19). Family style eating requires special training for the food service and early care and education staff since they need to monitor food served in a group setting. Portions should be age-appropriate as specified in Child and Adult Care Food Program (CACFP) guidelines. The use of serving utensils should be encouraged to minimize food handling by children. Children should not eat directly out of serving dishes or storage containers. The presence of an adult at the table with children while they are eating is a way to encourage social interaction and conversation about the food such as its name, color, texture, taste, and concepts such as number, size, and shape; as well as sharing events of the day. These are some practical examples of age-appropriate information for young children to learn about the food they eat. The parent/guardian or adult can help the slow eater, prevent behaviors that might increase risk of fighting, of eating each others' food, and of stuffing food in the mouth in such a way that it might cause choking.

TYPE OF FACILITY

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

RELATED STANDARDS

4.5.0.4 Socialization During Meals
4.5.0.8 Experience with Familiar and New Foods
4.2.0.1 Written Nutrition Plan
4.5.0.7 Participation of Older Children and Staff in Mealtime Activities
4.7.0.2 Nutrition Education for Parents/Guardians
9.2.3.11 Food and Nutrition Service Policies and Plans
2.1.1.2 Health, Nutrition, Physical Activity, and Safety Awareness
Appendix C: Nutrition Specialist, Registered Dietitian, Licensed Nutritionist, Consultant, and Food Service Staff Qualifications

REFERENCES

Hagan, Jr., 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.
Tamborlane, W. V., J. Warshaw, eds. 1997. The Yale guide to children's nutrition. New Haven, CT: Yale University Press.
Benjamin, S. E., D. F. Tate, S. I. Bangdiwala, B. H. Neelon, A. S. Ammerman, J. M. Dodds, D. S. Ward. 2008. Preparing child care health consultants to address childhood overweight: A randomized controlled trial comparing web to in-person training. Maternal Child Health J 12:662-69.
Ammerman, A. S., D. S. Ward, S. E. Benjamin, et al. 2007. An intervention to promote healthy weight: Nutrition and physical activity self-assessment for child care theory and design. Public Health Research, Practice, Policy 4:1-12.
Story, M., K. M. Kaphingst, S. French. 2006. The role of child care settings in the prevention of obesity. The Future of Children 16:143-68
Dietz, W., L. Birch. 2008. Eating behaviors of young child: Prenatal and postnatal influences on healthy eating. Elk Grove Village, IL: American Academy of Pediatrics.
Murph, J. R., S. D. Palmer, D. Glassy, eds. 2005. Health in child care: A manual for health professionals. Elk Grove Village, IL: American Academy of Pediatrics.
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.
William, C. O., ed. 1998. Pediatric manual of clinical dietetics. Chicago: American Dietetic Association.
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.
Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.
Sullivan, S. A., L. L. Birch. 1990. Pass the sugar, pass the salt: Experience dictates preference. Devel Psych 26:546-51.
Endres, J. B., R. E. Rockwell. 2003. Food, nutrition, and the young child. 4th ed. New York: Macmillan.
Wardle, F., N. Winegarner. 1992. Nutrition and Head Start. Child Today 21:57.
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.
Dietz, W. H., L. Stern, eds. 1998. American Academy of Pediatrics guide to your child's nutrition. New York: Villard.
Holt K, Wooldridge N, Story M, Sofka D. Nutrition Education/ curriculum for, aspects of. In: Bright Futures: Nutrition. Chicago, IL: American Academy of Pediatrics; 2011: 10, 55
Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.
Stang, J., C. T. Bayerl, M. M. Flatt. 2006. Position of the American Dietetic Association: Child and adolescent food and nutrition programs. J American Dietetic Assoc 106:1467-75.

Standard 9.2.3.11: Food and Nutrition Service Policies and Plans

Content in the STANDARD was modified on 05/21/2019.

Early care and education programs should have food handling, feeding, and written nutrition policies and plans under the direction of the administration that address the following items:

Age-appropriate eating utensils and tableware
Age-appropriate portion sizes to meet nutritional needs
Emergency preparedness for water and nutrition services
Food allergies and special dietary restrictions, including family/cultural food preferences
Food brought from home, including food brought for celebrations
Food budget
Food safety, sanitation, preparation, and service
Food procurement and storage
Kitchen and meal service staffing
Kitchen layout
Menu and meal planning
Nutrition education for children, staff, and parents/guardians
Promotion of breastfeeding and provision of community resources to support mothers

A nutritionist/registered dietitian and a food service expert should provide input for and facilitate the development and implementation of a written nutrition plan for the early care and education program.¹

RATIONALE

Children spend a significant amount of time in out-of-home care; this requires 1 or 2 meals to be served during the day.² Having a plan that clearly assigns responsibility and that encompasses the pertinent nutrition elements will promote the optimal health of all children and staff in early care and education settings. Centers following safe steps in food handling, cooking, and storage safeguard against foodborne illness.³

TYPE OF FACILITY

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

RELATED STANDARDS

4.2.0.9 Written Menus and Introduction of New Foods
4.3.1.1 General Plan for Feeding Infants
4.3.1.2 Feeding Infants on Cue by a Consistent Caregiver/Teacher
4.3.2.2 Serving Size for Toddlers and Preschoolers
4.7.0.1 Nutrition Learning Experiences for Children
4.2.0.1 Written Nutrition Plan
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.4.0.2 Use of Nutritionist/Registered Dietitian
4.6.0.1 Selection and Preparation of Food Brought From Home
4.6.0.2 Nutritional Quality of Food Brought From Home
4.7.0.2 Nutrition Education for Parents/Guardians
4.9.0.8 Supply of Food and Water for Disasters
5.2.6.5 Emergency Safe Drinking Water and Bottled Water
Appendix JJ: Our Child Care Center Supports Breastfeeding
Appendix C: Nutrition Specialist, Registered Dietitian, Licensed Nutritionist, Consultant, and Food Service Staff Qualifications

REFERENCES

Swindle T, Sigman-Grant M, Branen LJ, Fletcher J, Johnson SL. About feeding children: factor structure and internal reliability of a survey to assess mealtime strategies and beliefs of early childhood education teachers. Int J Behav Nutr Phys Act. 2018;15(1):85
School Nutrition Association. School nutrition professionals: roles & responsibilities. https://schoolnutrition.org/AboutSchoolMeals/SNPRolesResponsibilities. Accessed December 20, 2018
US Department of Agriculture, Food Safety and Inspection Service. Basics for handling food safely. https://www.fsis.usda.gov/wps/portal/fsis/topics/food-safety-education/get-answers/food-safety-fact-sheets/safe-food-handling/basics-for-handling-food-safely/ct_index. Modified March 24, 2015. Accessed December 20, 2018

NOTES

Content in the STANDARD was modified on 05/21/2019.

Standard 9.2.3.12: Infant Feeding Policy

A policy about infant feeding should be developed with the input and approval from the nutritionist/registered dietitian and should include the following:

Storage and handling of expressed human milk;
Determination of the kind and amount of commercially prepared formula to be prepared for infants as appropriate;
Preparation, storage, and handling of infant formula;
Proper handwashing of the caregiver/teacher and the children;
Use and proper sanitizing of feeding chairs and of mechanical food preparation and feeding devices, including blenders, feeding bottles, and food warmers;
Whether expressed human milk, formula, or infant food should be provided from home, and if so, how much food preparation and use of feeding devices, including blenders, feeding bottles, and food warmers, should be the responsibility of the caregiver/teacher;
Holding infants during bottle-feeding or feeding them sitting up;
Prohibiting bottle propping during feeding or prolonging feeding;
Responding to infants' need for food in a flexible fashion to allow cue feedings in a manner that is consistent with the developmental abilities of the child (policy acknowledges that feeding infants on cue rather than on a schedule may help prevent obesity) (1,2);
Introduction and feeding of age-appropriate solid foods (complementary foods);
Specification of the number of children who can be fed by one adult at one time;
Handling of food intolerance or allergies (e.g., cow's milk, peanuts, orange juice, eggs, wheat).

Individual written infant feeding plans regarding feeding needs and feeding schedule should be developed for each infant in consultation with the infant's primary care provider and parents/guardians.

RATIONALE

Growth and development during infancy require that nourishing, wholesome, and developmentally appropriate food be provided, using safe approaches to feeding. Because individual needs must be accommodated and improper practices can have dire consequences for the child's health and safety, the policy for infant feeding should be developed with professional nutritionists/registered dietitians. The infant feeding plans should be developed with each infant's parents/guardians and, when appropriate, in collaboration with the child's primary care provider.

TYPE OF FACILITY

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

RELATED STANDARDS

4.8.0.8 Microwave Ovens
4.3.1.1 General Plan for Feeding Infants
4.3.1.2 Feeding Infants on Cue by a Consistent Caregiver/Teacher
4.3.1.8 Techniques for Bottle Feeding
4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants
4.3.1.12 Feeding Age-Appropriate Solid Foods to Infants
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.1.4 Feeding Human Milk to Another Mother's Child
4.3.1.5 Preparing, Feeding, and Storing Infant Formula
4.3.1.9 Warming Bottles and Infant Foods
Appendix JJ: Our Child Care Center Supports Breastfeeding

REFERENCES

Taveras, E. M., S. L. Rifas-Shiman, K. S. Scanlon, L. M. Grummer-Strawn, B. Sherry, M. W. Gillman. 2006. To what extent is the protective effect of breastfeeding on future overweight explained by decreased maternal feeding restriction? Pediatrics 118:2341-48.
Birch, L., W. Dietz. 2008. Eating behaviors of young child: Prenatal and postnatal influences on healthy eating, 59-93. Elk Grove Village, IL: American Academy of Pediatrics.

Safe and Healthy Practices and Procedures

Safe Food Practices

Standard 4.3.1.3: Preparing, Feeding, and Storing Human Milk

Frequently Asked Questions/CFOC Clarifications

Reference: 4.3.1.3

Date: 10/17/2011

Topic & Location:
Chapter 4
Nutrition and Food Service
Standard 4.3.1.3: Preparing, Feed-ing, and Storing Human Milk

Question:
I cannot find any information in the new CFOC as to how long a bottle of breast milk can be kept after it is fed to an infant. It states that a bottle of formula should be discarded after one hour. I would think that it should be the same, since saliva is introduced into the bottle regardless of its contents, but I want to make sure.
Can you offer some guidance?

Answer:
This Standard provides two references at the end of the "Guide-lines for Storage of Human Milk" chart on page 166. Both re-sources state that breast milk should be discarded after it is fed to an infant.

The Academy of Breastfeeding Medicine Protocol Committee states: "Milk left in the feeding container after a feeding should be discarded and not used again."
The Centers for Disease Control (CDC) states: "Do not save milk from a used bottle for use at another feeding."

A specific amount of time is not given (similar to the formula standard). The milk could be used again if it's the same feeding (for example, if the infant takes a short break from eating), but if it is clearly a different feeding, it should be thrown away.

Content in the STANDARD was modified on 8/23/2016 and 06/10/2020.

Expressed human milk should be transported and stored in clean and sanitary bottles with nipples that fit tightly or in equivalent clean and sanitary sealed containers to prevent spilling during transport to home or to the facility. Only cleaned and sanitized bottles, or their equivalent, and nipples should be used in feeding. The bottle or container should be properly labeled with the child's full name and the date and time the milk was expressed.¹The filled, labeled bottles or containers of human milk should immediately be stored in the refrigerator on arrival.

Frozen human milk may be transported and stored in single-use plastic bags and placed in a freezer with a separate door or a stand-alone freezer, and not in a compartment within a refrigerator. To prevent intermittent rewarming due to opening the freezer door regularly, frozen human milk should be stored in the back of the freezer and caregivers/teachers should carefully monitor, with daily log sheets, temperature of freezers used to store human milk using an appropriate working thermometer.

Expressed milk brought by a parent/guardian should only be used for that child. Likewise, infant formula should not be used for a breastfed child without the parent/guardian's written permission. Labels for containers of human milk should be resistant to loss of the name and date/time when washing and handling. This is especially important when a frozen bottle is thawed in running tap water. There may be several bottles for different children being thawed and warmed at the same time in the same place.

The caregiver/teacher should check the child's full name and the date on the bottle so that the oldest milk is used first. Human milk should be thawed in the refrigerator if frozen. If there is insufficient time to thaw the milk in the refrigerator before serving, it may be thawed in a container of warm water, gently swirling the bottle periodically to evenly distribute the temperature in the milk and mix the fat, which may have separated. Frozen milk should never be thawed in a microwave oven because uneven hot spots in the milk may cause burns in the child and excessive heat may destroy beneficial components of the milk.^1–3

Human milk containers with significant amount of contents remaining after a feeding (>1 oz) may be returned to the parent/guardian at the end of the day as long as the child has not fed directly from the bottle. Returning unused human milk to the parent/guardian informs the parent/guardian of the quantity taken while in the early care and education program.

Although human milk does not need to be warmed, some children prefer their milk warmed to body temperature, around 98.6°F (37°C). When warming human milk, it is important to keep the container sealed while warming to prevent contamination. Human milk can be warmed

In a waterless warmer
By placing the container of human milk into a separate container of warm water
By placing the container of human milk under running warm (not hot) tap water for a few minutes

Human milk should never be warmed directly on the stove or in the microwave. After warming the milk, caregivers/teachers should test the temperature before feeding by putting a few drops on their wrist. It should feel warm, not hot.²

Avoid bottles made of plastics containing bisphenol A (BPA) or phthalates, sometimes labeled with recycling code 3, 6, or 7.⁴ Use glass bottles with a silicone sleeve or silicone bottle jacket to prevent breakage, or use those made with safer plastics, such as polypropylene or polyethylene (labeled BPA-free) or plastics with a recycling code of 1, 2, 4, or 5.

Expressed human milk that presents a threat to a child, such as human milk that is in an unsanitary bottle, is curdled, smells rotten, and/or has not been stored following the storage guidelines of the Academy of Breastfeeding Medicine (see Human Milk Storage Guidelines table), should be returned to the parent/guardian.² Written guidance for staff and parents/guardians should be available to determine when milk provided by parents/guardians will not be served. Human milk cannot be served if it does not meet the requirements for sanitary and safe milk.¹

Although human milk is a body fluid, it is not necessary to wear gloves when feeding or handling human milk.⁵ The risk of exposure to infectious organisms during feeding or from milk that the child regurgitates is not significant.²

Some infants around 6 months to 1 year of age may be developmentally ready to feed themselves and may want to drink from a cup. The transition from bottle to cup can come at a time when a child's fine motor skills allow use of a cup. The caregiver/teacher should use a clean, small cup without cracks or chips and should help the child to lift and tilt the cup to avoid spillage and leftover fluid. The caregiver/teacher and family should work together on cup feeding of human milk to ensure the child is receiving adequate nourishment and to avoid having a large amount of human milk remaining at the end of the feeding.⁶ Two to 3 ounces of human milk can be placed in a clean cup and additional milk can be offered as needed. Small amounts of human milk (≤1 oz) can be discarded.

There are many different factors that can affect how long human milk can be stored in various locations, such as storage temperature, temperature fluctuations, and cleanliness while expressing and handling human milk. These factors make it difficult to recommend exact times for storing human milk in various locations, but the Human Milk Storage Guidelines table can be helpful.

Human Milk Storage Guidelines
Storage Locations and Temperatures
	Countertop 77°F (25°C) or colder (room temperature)	Refrigerator 40°F (4°C)	Freezer 0°F (-18°C) or colder
Freshly Expressed or Pumped Human Milk	Up to 4 hours	Up to 4 days	Within 6 months is best. Up to 12 months is acceptable.
Thawed, Previously Frozen Human Milk	1–2 hours	Up to 1 day (24 hours)	Never refreeze human milk after it has been thawed.
Leftover Human Milk From a Feeding (baby did not finish the bottle)	Use within 2 hours after the baby is finished feeding.
Sources Eglash A, Simon L; Academy of Breastfeeding Medicine. ABM clinical protocol #8: human milk storage information for home use for full-term infants, revised 2017. Breastfeed Med. 2017;12(7):390–395. https://abm.memberclicks.net/assets/DOCUMENTS/PROTOCOLS/8-human-milk-storage-protocol-english.pdf . Accessed October 24, 2019 Centers for Disease Control and Prevention. Proper storage and preparation of breast milk. https://www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htm . Reviewed August 6, 2019. Accessed October 24, 2019

RATIONALE

By following this standard, early care and education staff is able, when necessary, to prepare human milk and feed a child safely, thereby reducing the risk of inaccuracy or feeding the child unsanitary or incorrect human milk.^1,2 In addition, following safe preparation and storage techniques helps nursing mothers and caregivers/teachers of breastfed children maintain the high quality of expressed human milk and the health of the child.^7,8

TYPE OF FACILITY

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

RELATED STANDARDS

4.3.1.1 General Plan for Feeding Infants
4.3.1.7 Feeding Cow's Milk
4.3.1.8 Techniques for Bottle Feeding
4.3.1.4 Feeding Human Milk to Another Mother's Child
4.3.1.9 Warming Bottles and Infant Foods
5.2.9.9 Plastic Containers and Toys

REFERENCES

Centers for Disease Control and Prevention. Proper storage and preparation of breast milk. https://www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htm . Reviewed August 6, 2019. Accessed October 24, 2019
Eglash A, Simon L; Academy of Breastfeeding Medicine. ABM clinical protocol #8: human milk storage information for home use for full-term infants, revised 2017. Breastfeed Med. 2017;12(7):390 – 395. https://abm.memberclicks.net/assets/DOCUMENTS/PROTOCOLS/8-human-milk-storage-protocol-english.pdf . Accessed October 24, 2019
Extension Alliance for Better Child Care. Guidelines for child care providers to prepare and feed bottles to infants. https://articles.extension.org/pages/25404/guidelines-for-child-care-providers-to-prepare-and-feed-bottles-to-infants . Published August 15, 2019. Accessed October 24, 2019
Eco-Healthy Child Care. Plastics & plastic toys. Children's Environmental Health Network website. https://cehn.org/wp-content/uploads/2017/07/Plastics_Plastic_Toys_6_16.pdf . Published June 2016. Accessed October 24, 2019
La Leche League International. Storing human milk. https://www.llli.org/breastfeeding-info/storingmilk . Accessed October 24, 2019
American Academy of Pediatrics. Working together: breastfeeding and solid foods. HealthyChildren.org website. https://www.healthychildren.org/English/ages-stages/baby/breastfeeding/Pages/Working-Together-Breastfeeding-and-Solid-Foods.aspx . Updated February 23, 2012. Accessed October 24, 2019
Boué G, Cummins E, Guillou S, Antignac JP, Le Bizec B, Membré JM. Public health risks and benefits associated with breast milk and infant formula consumption. Crit Rev Food Sci Nutr. 2018;58(1):126–145
Binns C, Lee M, Low WY. The long-term public health benefits of breastfeeding. Asia Pac J Public Health. 2016;28(1):7–14

NOTES

Content in the STANDARD was modified on 8/23/2016 and 06/10/2020.

Standard 4.3.1.4: Feeding Human Milk to Another Mother's Child

Content in the STANDARD was modified on 8/24/2017 and 06/10/2020.

Parents/guardians may express concern about the likelihood of disease transmission to their child if their child has been mistakenly fed another child's bottle of expressed human milk. This issue is addressed in detail to reassure parents/guardians that the risk of transmission of infectious diseases via human milk is small.

If a child has been mistakenly fed another child's bottle of expressed human milk, steps should be taken to minimize fear and manage the situation in a timely manner. When a milk mix-up occurs, any decisions about medical management and diagnostic testing of the child who received another mother's milk should be based on the details of the individual situation and determined collaboratively between the child's primary care provider and parents/guardians.¹

The early care and education program should

Inform the mother who expressed the human milk about the mistake and when the bottle switch occurred, and ask her the following questions¹:
- When was the human milk expressed and how was it handled prior to being delivered to the early care and education program?
- Would she be willing to share information about her current medication use, recent infectious disease history, and presence of cracked or bleeding nipples during milk expression with the other family or the child's primary care provider?
Discuss the event with the parents/guardians of the child who was given another mother's milk.¹
- Inform them that their child was given another mother's expressed human milk.
- Inform them that the risk of transmission of infectious diseases is small.
- If possible, provide the family with information on when the milk was expressed and how the milk was handled prior to its being delivered to the early care and education program.
- Encourage them to notify the child's primary care provider of the situation and share any specific details known.
Assess why the wrong milk was given and develop policies and procedures to prevent future mistakes related to labeling, storing, preparing, and feeding human milk in the early care and education program. Share these policies and procedures with parents/guardians as well as the early care and education staff.

Few illnesses are transmitted via human milk, and in fact, the unique properties of human milk help protect children from colds and other typical childhood viruses. Nonetheless, both families need to be notified when there is a milk mix-up, and they should be informed that the risk of transmission of infectious diseases via human milk is small.¹

RATIONALE

Despite significant efforts to prevent mix-ups, expressed human milk is occasionally given to a child in error.¹ Common concerns about human milk mistakenly fed to an child include transmission of HIV and hepatitis B and C, as well as medication exposure.

The risk of HIV transmission from expressed human milk consumed by another child is believed to be low because¹

Transmission of HIV from a single human milk exposure has never been documented.
In the United States, women who know they are HIV positive are advised not to breastfeed their children. Thus, it is unlikely that a mother living with HIV would be providing expressed milk for her own child at an early care and education program center.

Hepatitis B and C cannot be spread from a woman to a child through breastfeeding unless there is exposure to blood.^2–4

The risk of hepatitis B and C transmission from expressed human milk consumed by another child is believed to be low because²

Infants born to mothers with hepatitis B receive the hepatitis B vaccine at birth.

While mothers with hepatitis B and C can breastfeed,^4,5 hepatitis B and C are spread by infected blood. If the nipples and/or surrounding areola of the mother with hepatitis B or C are cracked and bleeding, she should be advised to stop nursing or providing expressed milk to her child temporarily (until she is healed).²

Although many medications pass into human milk, most have little or no effect on a child's well-being. Few medications are contraindicated while breastfeeding, and risk of adverse effects from a single exposure to a medication through human milk is very low.¹

TYPE OF FACILITY

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

RELATED STANDARDS

4.3.1.3 Preparing, Feeding, and Storing Human Milk

REFERENCES

Centers for Disease Control and Prevention. What to do if an infant or child is mistakenly fed another woman's expressed breast milk. http://www.cdc.gov/breastfeeding/recommendations/other_mothers_milk.htm . Reviewed January 24, 2018. Accessed October 24, 2019
Centers for Disease Control and Prevention. Hepatitis B or C infections. https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/maternal-or-infant-illnesses/hepatitis.html . Reviewed January 24, 2018. Accessed October 24, 2019
Centers for Disease Control and Prevention. Hepatitis B questions and answers for the public. https://www.cdc.gov/hepatitis/hbv/bfaq.htm#bFAQ13 . Reviewed September 10, 2019. Accessed October 24, 2019
Centers for Disease Control and Prevention. Hepatitis C questions and answers for the public. https://www.cdc.gov/hepatitis/hcv/cfaq.htm#cFAQ37 . Reviewed September 10, 2019. Accessed October 24, 2019
American Academy of Pediatrics. Human milk. In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018–2021 Report of the Committee on Infectious Diseases. 31st ed. Itasca, IL: American Academy of Pediatrics; 2018:113–122

NOTES

Content in the STANDARD was modified on 8/24/2017 and 06/10/2020.

Standard 4.3.1.5: Preparing, Feeding, and Storing Infant Formula

Content in the STANDARD was modified on 11/5/2013 and 8/25/2016.

Formula provided by parents/guardians or by the facility should come in a factory-sealed container. The formula should be of the same brand that is served at home and should be of ready-to-feed strength or liquid concentrate to be diluted using cold water from a source approved by the health department. Powdered infant formula, though it is the least expensive formula, requires special handling in mixing because it cannot be sterilized. The primary source for proper and safe handling and mixing is the manufacturer's instructions that appear on the can of powdered formula. Before opening the can, hands should be washed. The can and plastic lid should be thoroughly rinsed and dried. Caregivers/teachers should read and follow the manufacturer's directions. Caregivers/teachers should only use the scoop that comes with the can and not interchange the scoop from one product to another, since the volume of the scoop may vary from manufacturer to manufacturer and product to product. Also, a scoop can be contaminated with a potential allergen from another type of formula. If instructions are not readily available, caregivers/teachers should obtain information from their local WIC program or the World Health Organization's Safe Preparation, Storage and Handling of Powdered Infant Formula Guidelines at: http://www.who.int/foodsafety/publications/micro/pif_guidelines.pdf (1).

Formula mixed with cereal, fruit juice, or any other foods should not be served unless the child's primary care provider provides written documentation that the child has a medical reason for this type of feeding.

Iron-fortified formula should be refrigerated until immediately before feeding. For bottles containing formula, any contents remaining after a feeding should be discarded.

Bottles of formula prepared from powder or concentrate or ready-to-feed formula should be labeled with the child's full name and time and date of preparation. Any prepared formula must be discarded within one hour after serving to an infant. Prepared powdered formula that has not been given to an infant should be covered, labeled with date and time of preparation and child's full name, and may be stored in the refrigerator for up to twenty-four hours. An open container of ready-to-feed, concentrated formula, or formula prepared from concentrated formula, should be covered, refrigerated, labeled with date of opening and child's full name, and discarded at forty-eight hours if not used (2). The caregiver/teacher should always follow manufacturer's instructions for mixing and storing of any formula preparation. Some infants will require specialized formula because of allergy, inability to digest certain formulas, or need for extra calories. The appropriate formula should always be available and should be fed as directed. For those infants getting supplemental calories, the formula may be prepared in a different way from the directions on the container. In those circumstances, either the family should provide the prepared formula or the caregiver/teacher should receive special training, as noted in the infant's care plan, on how to prepare the formula. Formula should not be used beyond the stated shelf life period (3).

Parents/guardians should supply enough clean and sterilized bottles to be used throughout the day. The bottles must be sanitary, properly prepared and stored, and must be the same brand in the early care and education program and at home. Avoid bottles made of plastics containing bisphenol A (BPA) or phthalates (sometimes labeled with #3, #6, or #7). Use glass bottles with a silicone sleeve (a silicone bottle jacket to prevent breakage) or those made with safer plastics such as polypropylene or polyethylene (labeled BPA-free) or plastics with a recycling code of #1, #2, #4, or #5.

RATIONALE

Caregivers/teachers help in promoting the feeding of infant formula that is familiar to the infant and supports family feeding practice. By following this standard, the staff is able, when necessary, to prepare formula and feed an infant safely, thereby reducing the risk of inaccuracy or feeding the infant unsanitary or incorrect formula. Written guidance for both staff and parents/guardians must be available to determine when formula provided by parents/guardians will not be served. Formula cannot be served if it does not meet the requirements for sanitary and safe formula.

Staff preparing formula should thoroughly wash their hands prior to beginning preparation of infant feedings of any type. Water used for mixing infant formula must be from a safe water source as defined by the local or state health department. If the caregiver/teacher is concerned or uncertain about the safety of the tap water, s/he should "flush" the water system by running the tap on cold for 1-2 minutes or use bottled water (4). Warmed water should be tested in advance to make sure it is not too hot for the infant. To test the temperature, the caregiver/teacher should shake a few drops on the inside of her/his wrist. A bottle can be prepared by adding powdered formula and room temperature water from the tap just before feeding. Bottles made in this way from powdered formula can be ready for feeding as no additional refrigeration or warming would be required.

Adding too little water to formula puts a burden on an infant's kidneys and digestive system and may lead to dehydration (5). Adding too much water dilutes the formula. Diluted formula may interfere with an infant's growth and health because it provides inadequate calories and nutrients and can cause water intoxication. Water intoxication can occur in breastfed or formula-fed infants or children over one year of age who are fed an excessive amount of water. Water intoxication can be life-threatening to an infant or young child (6).If a child has a special health problem, such as reflux, or inability to take in nutrients because of delayed development of feeding skills, the child's primary care provider should provide a written plan for the staff to follow so that the child is fed appropriately. Some infants are allergic to milk and soy and need to be fed an elemental formula which does not contain allergens. Other infants need supplemental calories because of poor weight gain.

Infants should not be fed a formula different from the one the parents/guardians feed at home, as even minor differences in formula can cause gastrointestinal upsets and other problems (7).

Excessive shaking of formula may cause foaming that increases the likelihood of feeding air to the infant.

TYPE OF FACILITY

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

RELATED STANDARDS

4.3.1.1 General Plan for Feeding Infants
4.3.1.8 Techniques for Bottle Feeding
4.3.1.9 Warming Bottles and Infant Foods
5.2.9.9 Plastic Containers and Toys

REFERENCES

United States Department of Agriculture, Food and Nutrition Service. 2017. Feeding infants: A guide for use in the child nutrition programs. https://www.fns.usda.gov/tn/feeding-infants-guide-use-child-nutrition-programs.
Brown, J., Krasowski, M. D., & Hesse, M. 2015. Forced water intoxication: A deadly form of child abuse.The Journal of Law Enforcement.4(4).
Seattle Children's Hospital. 2014. Topics covered for formula feeding: Is this your child's symptoms? Seattle, WA. http://www.seattlechildrens.org/medical-conditions/symptom-index/bottle-feeding-formula-questions/.
Centers for Disease Control and Prevention. 2016. Water. https://www.cdc.gov/nceh/lead/tips/water.htm.
Seltzer, H. 2012. U.S Department of Health & Human Services. Keeping infant formula safe. https://www.foodsafety.gov/blog/infant_formula.html.
U.S. Department of Health & Human Services, U.S. Food & Drug Administration. 2016. Food safety for moms to be: Once baby arrives. College Park, MD. https://www.fda.gov/food/resourcesforyou/healtheducators/ucm089629.htm.
World Health Organization. 2007. Safe preparation, storage and handling of powdered infant formula: Guidelines. http://www.who.int/foodsafety/publications/powdered-infant-formula/en/.

NOTES

Content in the STANDARD was modified on 11/5/2013 and 8/25/2016.

Standard 4.3.1.9: Warming Bottles and Infant Foods

Frequently Asked Questions/CFOC Clarifications

Reference: 4.3.1.9

Date: 10/13/2011

Topic & Location:
Chapter 4
Nutrition and Food Service
Standard 4.3.1.9: Warming Bottles and Infant Foods

Question:
I have concerns about the standards recommending glass and ceramic containers due to concerns about using plastic. Once again, it is good in theory, but I don't feel it is safe. I had a center that had a glass bottle drop and shatter in their infant room.

Answer:
BPA-free plastic bottles, those labeled #1, #2, #4, or #5, can be used to avoid the use of glass.

For those child care and early education facilities that choose to use glass bottles, a relatively new option is to use a bottle sleeve with the glass bottle to reduce the risk of shattered glass. Efficacy on this product is still being proven. Overall, glass is safer than plastic with BPA.

Content in the STANDARD was modified on 11/5/2013, 8/25/2016 and 05/31/2018.

Bottles and infant foods do not have to be warmed; they can be served cold from the refrigerator. If a caregiver/teacher chooses to warm them, bottles or containers of infant foods should be warmed under running, warm tap water or by placing them in a container of water that is no warmer than 120°F (49°C). Bottles should not be left in a pot of water to warm for more than 5 minutes. Bottles and infant foods should never be warmed in a microwave oven because uneven hot spots in milk and/or food may burn the infant (1,2).

Infant foods should be stirred carefully to distribute the heat evenly. A caregiver/teacher should not hold an infant while removing a bottle or infant food from the container of warm water or while preparing a bottle or stirring infant food that has been warmed in some other way. Bottles used for infant feeding should be made of the following substances (3):

a. Bisphenol A (BPA)-free plastic; plastic labeled #1, #2, #4, or #5, or

b. Glass (a silicone sleeve/jacket covering a glass bottle to prevent breakage is permissible).

When a slow-cooking device, such as a crock-pot, is used for warming human milk, infant formula, or infant food, the device (and cord) should be out of children's reach. The device should contain water at a temperature that does not exceed 120°F (49°C), and be emptied, cleaned, sanitized, and refilled with fresh water daily. When a bottle warmer is used for warming human milk, infant formula, or infant food, it should be out of children's reach and used according to manufacturer's instructions.

RATIONALE

Bottles of human milk or infant formula that are warmed at room temperature or in warm water for an inappropriate period provide an ideal medium for bacteria to grow. Infants have received burns from hot water dripping from an infant bottle that was removed from a crock-pot or by pulling the crock-pot down on themselves by means of a dangling cord. Caution should be exercised to avoid raising the water temperature above a safe level for warming infant formula or infant food.

Additional Resource

Feeding Infants: A Guide for Use in the Child Nutrition Programs, US Department of Agriculture Food and Nutrition Service (https://www.fns.usda.gov/tn/feeding-infants-guide-use-child-nutrition-programs)

TYPE OF FACILITY

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

RELATED STANDARDS

4.3.1.8 Techniques for Bottle Feeding
4.3.1.12 Feeding Age-Appropriate Solid Foods to Infants
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.1.5 Preparing, Feeding, and Storing Infant Formula

REFERENCES

US Department of Health and Human Services, US Food and Drug Administration. Food safety for moms to be: once baby arrives. https://www.fda.gov/food/resourcesforyou/healtheducators/ucm089629.htm. Updated November 8, 2017. Accessed January 11, 2018
Cowan D, Ho B, Sykes KJ, Wei JL. Pediatric oral burns: a ten-year review of patient characteristics, etiologies and treatment outcomes. Int J Pediatr Otorhinolaryngol. 2013;77(8):1325–1328
Environmental Working Group. Guide to baby-safe bottles and formula. https://www.ewg.org/research/ewg%E2%80%99s-guide-baby-safe-bottles-and-formula#.WlfPqWeWzct. Updated October, 2015. Accessed January 11, 2018

NOTES

Content in the STANDARD was modified on 11/5/2013, 8/25/2016 and 05/31/2018.

Standard 4.5.0.3: Activities that Are Incompatible with Eating

Content in the STANDARD was modified on 8/25/2016.

Children should be seated when eating. Caregivers/teachers should ensure that children do not eat when standing, walking, running, playing, lying down, watching TV, playing on the computer, participating in arts and crafts projects that do not involve food, or riding in vehicles.

Anyone who has signs or symptoms of illness, including vomiting, diarrhea, and infectious skin sores that cannot be covered, or who potentially or actually is infected with bacteria, viruses or parasites that can be carried in food, should be excluded from food preparation and handling. Staff members may not contact exposed, ready-to-eat food with their bare hands and should use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. No one with open or infected skin eruptions should work in the food preparation area unless the injuries are covered with nonporous (such as latex or vinyl), single use gloves.

In centers and large family child care homes, staff members who are involved in the process of preparing or handling food should not change diapers. Staff members who work with diapered children should not prepare or serve food for older groups of children. When staff members who are caring for infants and toddlers are responsible for changing diapers, they should handle food only for the infants and toddlers in their groups and only after thoroughly washing their hands. Caregivers/teachers who prepare food should wash their hands carefully before handling any food, regardless of whether they change diapers. When caregivers/teachers must handle food, staffing assignments should be made to foster completion of the food handling activities by caregivers/teachers of older children, or by caregivers/teachers of infants and toddlers before the caregiver/teacher assumes other caregiving duties for that day. Aprons worn in the food service area must be clean and should be removed when diaper changing or when using the toilet.

RATIONALE

Food handlers who are ill can easily transmit their illness to others by contaminating the food they prepare with the infectious agents they are carrying. Frequent and proper handwashing before and after using plastic gloves reduces food contamination (1,2,4).

Caregivers/teachers who work with infants and toddlers are frequently exposed to feces and to children with infections of the intestines (often with diarrhea) or of the liver. Education of child care staff regarding handwashing and other cleaning procedures can reduce the occurrence of illness in the group of children with whom they work (1,2,4).

The possibility of involving a larger number of people in a foodborne outbreak is greater in child care than in most households. Cooking larger volumes of food requires special caution to avoid contamination of the food with even small amounts of infectious materials. With larger volumes of food, staff must exercise greater diligence to avoid contamination because larger quantities of food take longer to heat or to cool to safe temperatures. Larger volumes of food spend more time in the danger zone of temperatures (between 41°F and 135°F) where more rapid multiplication of microorganisms occurs (3).

TYPE OF FACILITY

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

RELATED STANDARDS

3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.2.2.3 Assisting Children with Hand Hygiene
3.2.2.4 Training and Monitoring for Hand Hygiene
3.2.2.5 Hand Sanitizers

REFERENCES

U.S. Department of Health and Human Services, U.S. Department of Agriculture. 2010. Dietary guidelines for Americans, 2010. 7th ed. Washington, DC: U.S. Government Printing Office. http://www.health.gov/dietaryguidelines/dga2010/DietaryGuidelines2010.pdf.
U.S. Department of Agriculture (USDA), Food Safety and Inspection Service. 2000. Keeping kids safe: A guide for safe handling and sanitation, for child care providers. Rev ed. Washington, DC: USDA. http://teamnutrition.usda.gov/resources/appendj.pdf.
Cowell, C., S. Schlosser. 1998. Food safety in infant and preschool day care. Top Clin Nutr 14:9-15.
U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration (FDA). 2009. 2009 Food code. College Park, MD: FDA. http://www.fda.gov/downloads/Food/FoodSafety/RetailFoodProtection/FoodCode/FoodCode2009/UCM189448.pdf.

Standard 4.9.0.3: Precautions for a Safe Food Supply

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

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

RATIONALE

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

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

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

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

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

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

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

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

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

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

COMMENTS

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

TYPE OF FACILITY

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

RELATED STANDARDS

4.3.1.7 Feeding Cow's Milk
4.8.0.6 Maintaining Safe Food Temperatures
Appendix U: Recommended Safe Minimum Internal Cooking Temperatures

REFERENCES

U.S. Department of Health and Human Services, U.S. Department of Agriculture. 2010. Dietary guidelines for Americans, 2010. 7th ed. Washington, DC: U.S. Government Printing Office. http://www.health.gov/dietaryguidelines/dga2010/DietaryGuidelines2010.pdf.
Food Marketing Institute (FMI), U.S. Department of Agriculture, Food Safety and Inspection Service. 1996. Facts about food and floods: A consumer guide to food quality and safe handling after a flood or power outage. Washington, DC: FMI.
Potter, M. E. 1984. Unpasteurized milk: The hazards of a health fetish. JAMA 252:2048-52.
Sacks, J. J. 1982. Toxoplasmosis infection associated with raw goat's milk. JAMA 246:1728-32.
Chicago Dietetic Association. 1996. Manual of clinical dietetics. 5th ed. Chicago, IL: American Dietetic Association.
Dietz, W.H., L. Stern, eds. 1998. Guide to your child's nutrition. Elk Grove Village, IL: American Academy of Pediatrics.
Enders, J. B. 1994. Food, nutrition and the young child. New York: Merrill.
U.S. Department of Agriculture (USDA). 2002. Making nutrition count for children - Nutrition guidance for child care homes. Washington, DC: USDA. http://www/gpo.gov/fdsys/pkg/ERIC-ED482991/pdf/ERIC-ED482991.pdf.
Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.
Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.
Daniels, S. R., F. R. Greer, Committee on Nutrition. 2008. Lipid screening and cardiovascular health in childhood. Pediatrics 122:198-208.
U.S. Department of Agriculture (USDA), Food Safety and Inspection Service. 2000. Keeping kids safe: A guide for safe handling and sanitation, for child care providers. Rev ed. Washington, DC: USDA. http://teamnutrition.usda.gov/resources/appendj.pdf.
Cowell, C., S. Schlosser. 1998. Food safety in infant and preschool day care. Top Clin Nutr 14:9-15.
U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration (FDA). 2009. 2009 Food code. College Park, MD: FDA. http://www.fda.gov/downloads/Food/FoodSafety/RetailFoodProtection/FoodCode/FoodCode2009/UCM189448.pdf.

Standard 5.2.9.9: Plastic Containers and Toys

The facility should use infant bottles, plastic containers, and toys that do not contain Polyvinyl chloride (PVC), Bisphenol A (BPA), or phthalates. When possible, caregivers/teachers should substitute materials such as paper, ceramic, glass, and stainless steel for plastics.

RATIONALE

Plastics can contain chemicals and metals, which are used as additives and stabilizers. Some of these additives and stabilizers can be toxic, such as lead (e.g., toys, vinyl lunchboxes). Plastics can release chemicals into food and drink; some types of plastics are more likely to do so than others (polycarbonate, PVC, polystyrene). Effects are not fully studied or understood, but in animal studies, some plastics have been tied to a wide range of negative health effects including endocrine (hormone) disruption and cancer (1,11).

PVC, also known as vinyl, is one of the most commonly used types of plastics today. PVC is present in many things used daily, from water bottles and containers, to wallpaper, wall paneling, credit cards, and children's toys. Some of the substances added to PVC are among the hormone-disrupting chemicals that may pose hazards to human health and child development. PVC products, including certain toys, may have chemicals such as lead, cadmium, and phthalates, which can flake, leach, or off-gas, causing the release of these chemicals into the surroundings (2).

Phthalates is a class of chemicals used to make plastics flexible (3,4,11). Phthalates are used in many products: vinyl flooring, plastic clothing (e.g., raincoats), detergents, adhesives, personal-care products (fragrances, nail polish, soap), and is commonly found in vinyl (PVC) plastic products (toys, plastic bags) (13). In a national study, some phthalates have been found in 97% (5) of the people tested with generally higher concentrations found in children (6). In animal studies, health effects range from developmental and reproductive toxicity to damage to the liver (7,8).

Bisphenol A (BPA) is used when making polycarbonate and other plastic products. BPA is widely used in consumer products (infant bottles, protective coating in food cans, toys, containers, and personal care products) (13). It can leach from these products and potentially cause harm to those in contact with them. It can also have estrogen (female hormone)-like effects, which may impact biological systems at very low doses. Children may be exposed via: ingestion (diet and sucking/mouthing plastics), inhalation (of dust), and dermal contact. A national study found BPA in the urine of over 90% of people tested; children were found to have higher levels than adults (9). BPA has been found in pregnant women, umbilical cord blood, and placentas at levels demonstrated in animals to alter development (10).

COMMENTS

The Consumer Product Safety Improvement Act (CPSIA) empowers the U.S. Consumer Product Safety Commission (CPSC) to set regulations protecting consumers of these products with testing and labeling. As of this writing new CPSC requirements are under development. Consumers of products for children should look for products that state "phthalate-free" or "BPA-free" or certification by Toy Safety Certification Program (TSCP) or American National Standards Institute (ANSI).

TYPE OF FACILITY

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

RELATED STANDARDS

5.3.1.2 Product Recall Monitoring

REFERENCES

Calafat, A. M., X. Ye, L. Wong, et al. 2008. Exposure of the U.S. population to bisphenol A and 4-tertiary-octylphenol: 2003-2004. Environ Health Perspectives 116:39-44.
U.S. Consumer Product Safety Commission. 2009. Prohibition on the sale of certain products containing specified phthalates. http://www.cpsc.gov/about/cpsia/108rfc.pdf.
California Childcare Health Program (CCHP). 2008. Banning chemicals called phthalates in childhood products. Berkeley, CA: CCHP.http://www.ucsfchildcarehealth.org/pdfs/factsheets/BannedChem_0308.pdf.
American Academy of Pediatrics. 2007. Technical report: Pediatric exposure and potential toxicity of phthalate plasticizers. Pediatrics 119:1031.
Ikezuki, Y., O. Tsutsumi, Y. Takai, Y. Kamei, Y. Taketani. 2002. Determination of bisphenol A concentrations in human biological fluids reveals significant early prenatal exposure. Human Reproduction 17:2839-41.
Blount, B. C., M. Silva, S. Caudill, et al. 2000. Levels of seven urinary phthalate metabolites in a human reference population. Environ Health Perspectives 108:979-82.
Centers for Disease Control and Prevention (CDC). 2009. Fourth national report on human exposure to environmental chemicals. Atlanta, GA: CDC. http://www.cdc.gov/exposurereport/pdf/FourthReport.pdf.
Kolarik, B., K. Naydenov, M. Larsson, et al. 2008. The association between phthalates in dust and allergic diseases among Bulgarian children. Environ Health Perspectives 116:98-103.
Silva, M. J., D. B. Barr, J. A. Reidy, et al. 2004. Urinary levels of seven phthalate metabolites in the U.S. population from the National Health and Nutrition Examination Survey (NHANES), 1999-2000. Environ Health Perspectives 112:331-38.
Kluwe, W. M. 1986. Carcinogenic potential of phthalic acid esters and related compounds: Structure-activity relationships. Environ Health Perspectives 65:271-78.
Huff, J. 1982. Di(2-ethylhexyl) adipate: Condensation of the carcinogenesis bioassay, technical report.Environ Health Perspectives 45:205-7.
BE SAFE. The dangers of polyvinyl chrloride (PVC). http://www.ussafety.com/media_vault/documents/1264894110.pdfhttp://www.ussafety.com/media_vault/documents/1264894110.pdf
Eco-Healthy Child Care. 2010. Plastics and plastic toys. Children's Environmental Health Network. http://www.cehn.org/files/Plastics_Plastic_Toys_Dec2010.pdf.

Health Promotion and Protection

Standard 3.1.2.1: Routine Health Supervision and Growth Monitoring

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

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

RATIONALE

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

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

COMMENTS

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

TYPE OF FACILITY

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

RELATED STANDARDS

4.2.0.2 Assessment and Planning of Nutrition for Individual Children

REFERENCES

Kleinman, R. E. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.
Hagan, J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Bright futures: Guidelines for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics.
Story, M., K. Holt, D. Sofka, eds. 2002. Bright futures in practice: Nutrition. 2nd ed. Arlington, VA: National Center for Education in Maternal and Child Health.
Centers for Disease Control and Prevention. 2011. About BMI for children and teens. http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.html.
Paige, D. M. 1988. Clinical nutrition. 2nd ed. St. Louis: Mosby.
Holt K, Wooldridge N, Story M, Sofka D. Growth/ In adolescence, in infancy. In: Bright Futures: Nutrition. Chicago, IL: American Academy of Pediatrics; 2011: 95-101, 21-26, 49

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

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

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

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

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

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

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

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

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

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

RATIONALE

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

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

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

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

COMMENTS

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

Moon R. Y., T. Calabrese, L. Aird. 2008. Reducing the risk of sudden infant death syndrome in child care and changing provider practices: Lessons learned from a demonstration project.Pediatrics 122:788-79.
Centers for Disease Control and Prevention. 2013. Sudden infant death syndrome (SIDS). http://www.cdc.gov/features/sidsawarenessmonth/.
UCSF California Childcare Health Program (CCHP). 2016. Safe sleep policy for infants in child care programs. UCSF School of Nursing California Childcare Health Program, San Francisco, CA: CCHP. http://cchp.ucsf.edu/Safe-Sleep-Policy.
Eunice Kennedy Shriver National Institute of Child Health and Human Development. Safe sleep ® campaign materials. 2014. https://www.nichd.nih.gov/sts/materials/Pages/default.aspx.
UCSF California Childcare Health Program (CCHP). 2016. Safe Sleep: Reducing the Risk of Sudden Infant Death Syndrome (SIDS). UCSF School of Nursing California Childcare Health Program, San Francisco, CA: CCHP. http://cchp.ucsf.edu/Safe-Sleep-FAM.
UCSF California Childcare Health Program (CCHP). 2016. Safe Sleep for Infants in Child Care Programs: Reducing the Risk of SIDS and SUID. UCSF School of Nursing California Childcare Health Program, San Francisco, CA: CCHP. http://cchp.ucsf.edu/SIDS-Note.
Healthy Child Care America. 2012. A child care provider's guide to safe sleep. Helping you to reduce the risk of SIDS. http://www.healthychildcare.org/PDF/SIDSchildcaresafesleep.pdf.
First Candle. 2016. SIDS and daycare: A fatal combination. http://www.firstcandle.org/sids-and-daycare-a-fatal-combination/.
U.S. Consumer Product Safety Commission (CPSC). 2012. Cribs. https://www.cpsc.gov/safety-education/safety-guides/kids-and-babies/cribs.
U.S. Centers for Disease Control and Prevention. 2016. About SUID and SIDS. http://www.cdc.gov/sids/aboutsuidandsids.htm.
American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: Updated 2016 recommendations for a safe infant sleeping environment.Pediatrics.2016;138(6):e20162938.
https://pediatrics.aappublications.org/content/138/5/e20162938.
Jenik, A. G., N. E. Vain, A. N. Gorestein, N. E. Jacobi, Pacifier and Breastfeeding Trial Group. 2009. Does the recommendation to use a pacifier influence the prevalence of breastfeeding?Pediatrics155:350-54.
Pease AS, Fleming PJ, Hauck FR, et al. 2016. Swaddling and the risk of sudden infant death syndrome: A Meta-analysis.Pediatrics;137(6):e20153275.

NOTES

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

Standard 3.1.4.2: Swaddling

Frequently Asked Questions/CFOC Clarifications

Reference: 3.1.4.2

Date: 4/5/2013

Topic & Location:
Chapter 3
Health Promotion
3.1.4.2: Swaddling

Question:
Does CFOC ban swaddling?

Answer:

CFOCStandard 3.1.4.2: Swaddling states: "In child care settings, swaddling is not recommended or necessary."

This specific language was carefully chosen and reviewed by national contributors and stakeholders, and then approved by the CFOC Steering Committee and each author organization (AAP, APHA, NRC). A child care setting is a group care setting, and therefore presents different health and safety concerns when compared to a private home. One of these concerns is inconsistency with caregivers/teachers. As noted in CFOCStandard 3.1.4.1: Safe Sleep Practices and SIDS/Suffocation Risk Reduction, "Infants who are cared for by adults other than their parent/guardian or primary caregiver/teacher are at increased risk for dying from SIDS" (Moon, 2005). To that end, implementing swaddling guidelines, training, and compliance across child care programs would be a significant challenge.

We recognize the many benefits of swaddling (when done correctly) by parents/guardians for newborns and young infants in hospital nurseries and in private homes. However, the primary target audience for the CFOCstandardsis caregivers/teachers in early education and child care settings.

The majority of standards in CFOC use the phrase "should" or "should not." The national contributors that developed Standard 3.1.4.2 made the conscious decision not to use this terminology in the standard language.Thus, CFOCdoes not ban or prohibit swaddling. Instead, it states that swaddling is not recommended or necessary.

CFOC does, however, account for programs that may choose to swaddle in this same standard (Standard 3.1.4.2). The last sentence of the Comments section states: "If swaddling is used, it should be used less and less over the course of the first few weeks and months of an infant's life."

Moreover, it is important to note that CFOCalso includes Standard 1.1.2.1: Minimum Age to Enter Child Care, which states that "Healthy full-term infants can be enrolled in child care settings as early as three months of age." The national contributors recognized that swaddling becomes less necessary for older infants, a time at which CFOCrecommends entering a child care setting.

Frequently Asked Questions/CFOC Clarifications

Reference: 3.1.4.2

Date: 4/5/2013

Topic & Location:
Chapter 3
Health Promotion
3.1.4.2: Swaddling

Question:
Does the AAP have a Policy Statement prohibiting Swaddling?

Answer:
The American Academy of Pediatrics (AAP) does not have a Policy Statement prohibiting swaddling. The AAP does have a Policy Statement on the Safe Sleep Environment, which does recommend against loose blankets in a safe sleeping environment. "Loose bedding, such as blankets and sheets, might be hazardous and should not be used in the infant's sleeping environment" (Task Force on Sudden Infant Death Syndrome, 2011).

The AAP Technical Report specifically addresses swaddling (page e1356) in expanded recommendations for a safe infant sleep environment. The Technical Report states that "there is insufficient evidence to recommend routine swaddling as a strategy for reducing the incident of SIDS" (Task Force on Sudden Infant Death Syndrome, 2011).
CFOC is co-authored by AAP, APHA, and NRC, and published by the AAP. It is consistent with AAP Policy, but is not "AAP Policy", nor "APHA Policy".

Citations:
Moon, R. e. (2005). Stable prevalence but changing risk factors for sudden infant death syndrome in child care settings in 2001. Pediatrics, 116(4):972-7.

Task Force on Sudden Infant Death Syndrome. (2011). Policy Statement: SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe infant Sleeping Environment. Pediatrics, 128:5 1030-1039.

Task Force on Sudden Infant Death Syndrome. (2011). Technical Report: SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe infant Sleeping Environment. Pediatrics, 128:5 e1341-e1367.

In child care settings, swaddling is not necessary or recommended.

RATIONALE

There is evidence that swaddling can increase the risk of serious health outcomes, especially in certain situations. The risk of sudden infant death is increased if an infant is swaddled and placed on his/her stomach to sleep (1,2) or if the infant can roll over from back to stomach. Loose blankets around the head can be a risk factor for sudden infant death syndrome (SIDS) (3). With swaddling, there is an increased risk of developmental dysplasia of the hip, a hip condition that can result in long-term disability (4,5). Hip dysplasia is felt to be more common with swaddling because infants' legs can be forcibly extended. With excessive swaddling, infants may overheat (i.e., hyperthermia) (6).

COMMENTS

Most infants in child care centers are at least six-weeks-old. Even with newborns, research does not provide conclusive data about whether swaddling should or should not be used. Benefits of swaddling may include decreased crying, increased sleep periods, and improved temperature control. However, temperature can be maintained with appropriate infant clothing and/or an infant sleeping bag. Although swaddling may decrease crying, there are other, more serious health concerns to consider, including SIDS and hip disease. If swaddling is used, it should be used less and less over the course of the first few weeks and months of an infant's life.

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

Pease AS, Fleming PJ, Hauck FR, et al. 2016. Swaddling and the risk of sudden infant death syndrome: A Meta-analysis. Pediatrics;137(6):e20153275.
Franco, P., N. Seret, J. N. Van Hees, S. Scaillet, J. Groswasser, A. Kahn. 2005. Influence of swaddling on sleep and arousal characteristics of healthy infants.Pediatrics 115:1307-11.
Mahan, S. T., Kasser J. R. 2008. Does swaddling influence developmental dysplasia of the Hip? Pediatrics 121:177-78.
Van Sleuwen, B. E., A. C. Engelberts, M. M. Boere-Boonekamp, W. Kuis, T. W. J. Schulpen, M. P. L'Hoir. 2007. Swaddling: A systematic review.Pediatrics 120:e1097-e1106.
Contemporary Pediatrics. 2004.Guide for parents: Swaddling 101. http://www.aap.org/sections/scan/practicingsafety/Toolkit_Resources/Module1/swadling.pdf.
Richardson, H. L., A. M. Walker, R. S. Horne. 2010. Influence of swaddling experience on spontaneous arousal patterns and autonomic control in sleeping infants.J Pediatrics157:85-91.

Standard 3.1.4.3: Pacifier Use

Content in the STANDARD was modified on 12/5/2011.

Facilities should be informed and follow current recommendations of the American Academy of Pediatrics (AAP) about pacifier use (1-3).

If pacifiers are allowed, facilities should have a written policy that indicates:

Rationale and protocols for use of pacifiers;
Written permission and any instructions or preferences from the child's parent/guardian;
If desired, parent/guardian should provide at least two new pacifiers (labeled with their child's name using a waterproof label or non-toxic permanent marker) on a regular basis for their child to use. The extra pacifier should be available in case a replacement is needed;
Staff should inspect each pacifier for tears or cracks (and to see if there is unknown fluid in the nipple) before each use;
Staff should clean each pacifier with soap and water before each use;
Pacifiers with attachments should not be allowed; pacifiers should not be clipped, pinned, or tied to an infant's clothing, and they should not be tied around an infant's neck, wrist, or other body part;
If an infant refuses the pacifier, s/he should not be forced to take it;
If the pacifier falls out of the infant's mouth, it does not need to be reinserted;
Pacifiers should not be coated in any sweet solution;
Pacifiers should be cleaned and stored open to air; separate from the diapering area, diapering items, or other children's personal items.

Infants should be directly observed by sight and sound at all times, including when they are going to sleep, are sleeping, or are in the process of waking up. The lighting in the room must allow the caregiver/teacher to see each infant's face, to view the color of the infant's skin, and to check on the infant's breathing and placement of the pacifier.

Pacifier use outside of a crib in rooms and programs where there are mobile infants or toddlers is not recommended.

Caregivers/teachers should work with parents/guardians to wean infants from pacifiers as the suck reflex diminishes between three and twelve months of age. Objects which provide comfort should be substituted for pacifiers (6).

RATIONALE

Mobile infants or toddlers may try to remove a pacifier from an infant's mouth, put it in their own mouth, or try to reinsert it in another child's mouth. These behaviors can increase risks for choking and/or transmission of infectious diseases.

Cleaning pacifiers before and after each use is recommended to ensure that each pacifier is clean before it is inserted into an infant's mouth (5). This protects against unknown contamination or sharing. Cleaning a pacifier before each use allows the caregiver/teacher to worry less about whether the pacifier was cleaned by another adult who may have cared for the infant before they did. This may be of concern when there are staffing changes or when parents/guardians take the pacifiers home with them and bring them back to the facility.

If a caregiver/teacher observes or suspects that a pacifier has been shared, the pacifier should be cleaned and sanitized. Caregivers/teachers should make sure the nipple is free of fluid after cleaning to ensure the infant does not ingest it. For this reason, submerging a pacifier is not recommended. If the pacifier nipple contains any unknown fluid, or if a caregiver/teacher questions the safety or ownership, the pacifier should be discarded (4).

While using pacifiers to reduce the risk of sudden infant death syndrome (SIDS) seems prudent (especially if the infant is already sleeping with a pacifier at home), pacifier use has been associated with an increased risk of ear infections and oral health issues (7).

COMMENTS

To keep current with the AAP's recommendations on the use of pacifiers, go to http://www.aap.org.

TYPE OF FACILITY

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

RELATED STANDARDS

3.4.6.1 Strangulation Hazards
3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
3.1.5.3 Oral Health Education
3.3.0.3 Cleaning and Sanitizing Objects Intended for the Mouth

REFERENCES

American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: Updated 2016 recommendations for a safe infant sleeping environment.Pediatrics.2016;138(6):e20162938.
https://pediatrics.aappublications.org/content/138/5/e20162938.
Mayo Clinic. 2009. Infant and toddler health. Pacifiers: Are they good for your baby? http://www.mayoclinic.org/healthy-lifestyle/infant-and-toddler-health/in-depth/pacifiers/art-20048140.
American Academy of Pediatrics, Back to Sleep, Healthy Child Care America, First Candle. 2008.Reducing the risk of SIDS in child care. http://www.healthychildcare.org/pdf/SIDSfinal.pdf.
Cornelius, A. N., J. P. D'Auria, L. M. Wise. 2008. Pacifier use: A systematic review of selected parenting web sites.J Pediatric Health Care 22:159-65.
Reeves, D. L. 2006. Pacifier use in childcare settings.Healthy Child Care 9:12-13.
Mitchell, E. A., P. S. Blair, M. P. L'Hoir. 2006. Should pacifiers be recommended to prevent sudden infant death syndrome?Pediatrics 117:1755-58.
Hauck, F. R. 2006. Pacifiers and sudden infant death syndrome: What should we recommend?Pediatrics117:1811-12.

NOTES

Content in the STANDARD was modified on 12/5/2011.

Standard 3.1.5.1: Routine Oral Hygiene Activities

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

COVID-19 modification as of September 20, 2021

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

Caregivers/teachers should promote the habit of regular toothbrushing. All children with teeth should brush or have their teeth brushed with a soft toothbrush of age-appropriate size at least once during the hours the child is in child care. Children under three years of age should have only a small smear (grain of rice) of fluoride toothpaste on the brush when brushing. The caregiver/teacher should monitor the toothbrushing activity and thoroughly brush the child's teeth after the child has finished brushing, preferably for a total of two minutes. Those children ages three and older should use a pea-sized amount of fluoride toothpaste (1). An ideal time to brush is after eating. The caregiver/teacher should either brush the child's teeth or supervise as the child brushes his/her own teeth. The caregiver/teacher should teach the child the correct method of toothbrushing. Young children want to brush their own teeth, but they need help until about age 7 or 8. Disposable gloves should be worn by the caregiver/teacher if contact with a child's oral fluids is anticipated.

The cavity-causing effect of exposure to foods or drinks containing sugar (like juice) may be reduced by having children rinse with water after snacks and meals when toothbrushing is not possible. Local dental health professionals can offering education and training for the child care staff and providing oral health presentations for the children and parents/guardians.

Children whose teeth are properly brushed with fluoride toothpaste at home twice a day and are at low risk for dental caries may be exempt since additional brushing with fluoride toothpaste may expose a child to excess fluoride toothpaste.

COVID-19 modification as of September 20, 2021

In response to the Centers for Disease Control and Prevention's COVID-19 Guidance for Operating Early Care and Education/Child Care Programs , toothbrushing may resume if programs can implement strategies to reduce the possibility of transmitting the virus to others via salivary droplets during brushing. It is recommended that:

Program staff who brush infants' and children's teeth or help children brush should be fully vaccinated against COVID-19 and should wear a properly fitted mask covering their nose and mouth for additional protection.
For toothbrushing at the classroom table, seat children as far apart as possible, with staff supervising the brushing. After brushing, clean and disinfect the table. If toothbrushing at the classroom table is not possible, children can brush at the sink with staff supervising. The sink should be cleaned and sanitized after each child finishes brushing.
Encourage children to avoid placing toothbrushes directly on the classroom table or other surfaces.
Wash hands with soap and water for at least 20 seconds before and after brushing or helping infants and children brush their teeth. If soap and water are not available, staff can use hand sanitizer that contains at least 60% alcohol. After children brush, ensure that they wash their hands with soap and water for at least 20 seconds, or, for children over age 2, use hand sanitizer that contains at least 60% alcohol.
Encourage children to drink water throughout the day and after eating as water rinses a child's mouth with every sip.

Refer to CFOC Standard 3.1.5.2: Toothbrushes and Toothpaste for additional information. Additional Resources:
Early Childhood Learning and Knowledge Center. Centers for Disease Control and Prevention. Toothbrushing in Head Start Programs During the COVID-19 Pandemic

RATIONALE

Regular tooth brushing with fluoride toothpaste is encouraged to reinforce oral health habits and prevent gingivitis and tooth decay. There is currently no (strong) evidence that shows any benefit to wiping the gums of a baby who has no teeth. However, before the first tooth erupts, wiping a baby's gums with clean gauze or a soft wet washcloth as part of a daily routine may make the transition to tooth brushing easier. Good oral hygiene is as important for a six-month-old child with one tooth as it is for a six-year-old with many teeth (2). Tooth brushing with fluoride toothpaste at least once a day reduces build-up of decay-causing plaque (2,3). The development of tooth decay-producing plaque begins when an infant's first tooth appears in his/her mouth (4). Tooth decay cannot develop without this plaque which contains the acid-producing bacteria in a child's mouth. The ability to do a good job brushing the teeth is a learned skill, improved by practice and age. There is general consensus that children do not have the necessary hand eye coordination for independent brushing until around age seven or eight so either caregiver/teacher brushing or close supervision is necessary in the preschool child. Tooth brushing and activities at home may not suffice to develop this skill or accomplish the necessary plaque removal, especially when children eat most of their meals and snacks during a full day in child care.

COMMENTS

The caregiver/teacher should use a small smear (grain of rice) of fluoride toothpaste spread across the width of the toothbrush for children under three years of age and a pea-sized amount for children ages three years of age and older (1). Children should attempt to spit out excess toothpaste after brushing. Fluoride is the single most effective way to prevent tooth decay. Brushing teeth with fluoride toothpaste is the most efficient way to apply fluoride to the teeth. Young children may occasionally swallow a small amount of toothpaste and this is not a health risk. However, if children swallow more than recommended amounts of fluoride toothpaste on a consistent basis, they are at risk for fluorosis, a cosmetic condition (discoloration of the teeth) caused by over exposure to fluoride during the first eight years of life (5). Other products such as fluoride rinses can pose a poisoning hazard if ingested (6).

The children can rinse with water after a snack or a meal if their teeth have been brushed with fluoride toothpaste earlier. Rinsing with water helps to remove food particles from teeth and may help prevent tooth decay.

A sink is not necessary to accomplish tooth brushing in child care. Each child can use a cup of water for tooth brushing. The child should wet the brush in the cup, brush and then spit excess toothpaste into the cup.

Caregivers/teachers should encourage replacement of toothbrushes when the bristles become worn or frayed or approximately every three to four months (7,8).

Caregivers/teachers should encourage parents/guardians to establish a dental home for their child within six months after the first tooth erupts or by one year of age, whichever is earlier (4). The dental home is the ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated and family-centered way. Currently there are insufficient numbers of dentists who incorporate infants and toddlers into their practices so primary care providers may provide oral health screening during well child care in this population while promoting the establishment of a dental home (2).

Fluoride varnish applied to all children every 3-6 months at primary care visits or at their dental home reduces tooth decay rates, and can lead to significant cost savings in restorative dental care and associated hospital costs. Coupled with parent/guardian and caregiver/teacher education, fluoride varnish is an important tool to improve children's health (9-11).

TYPE OF FACILITY

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

RELATED STANDARDS

9.4.2.3 Contents of Admission Agreement Between Child Care Program and Parent/Guardian
3.1.5.2 Toothbrushes and Toothpaste
3.1.5.3 Oral Health Education
9.4.2.1 Contents of Child's Records
9.4.2.2 Pre-Admission Enrollment Information for Each Child
9.4.2.4 Contents of Child's Primary Care Provider's Assessment
9.4.2.5 Health History
9.4.2.6 Contents of Medication Record
9.4.2.7 Contents of Facility Health Log for Each Child
9.4.2.8 Release of Child's Records

REFERENCES

American Academy of Pediatric Dentistry. 2006. Talking points: AAPD perspective on physicians or other non-dental providers applying fluoride varnish. Dental Home Resource Center.http://www.aapd.org/dentalhome/1225.pdf.
Marinho, V.C., et al. 2002. Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database System Rev 3, no. CD002279. http://www.ncbi.nlm.nih.gov/pubmed/12137653
Centers for Disease Control and Prevention. 2013. Community water fluoridation. http://www.cdc.gov/fluoridation/faqs/http://www.cdc.gov/fluoridation/faqs/
American Academy of Pediatrics, Section on Pediatric Dentistry. 2009. Policy statement: Oral health risk assessment timing and establishment of the dental home.Pediatrics 124:845.
American Academy of Pediatric Dentistry, Clinical Affairs Committee, Council on Clinical Affairs. 2008-2009. Guideline on periodicity of examination, preventive dental services, anticipatory guidance/counseling, and oral treatment for infants, children, and adolescents. Pediatric Dentistry30:112-18.
American Academy of Pediatrics, Section on Pediatric Dentistry. 2008. Preventive oral health intervention for pediatricians.Pediatrics 122:1387-94.
American Academy of Pediatrics, Section on Oral Health. 2014. Maintaining and improving the oral health of young children. http://pediatrics.aappublications.org/content/134/6/1224
American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine.2016. Policy statement: 2016 Recommendations for preventive pediatric health care. http://pediatrics.aappublications.org/content/early/2015/12/07/peds.2015-3908
American Dental Association. ADA positions and statements. ADA statement on toothbrush care: Cleaning, storage, and replacement. Chicago: ADA. http://www.ada.org/1887.aspx.
American Academy of Pediatric Dentistry. Early childhood caries. Chicago: AAPD. http://www.aapd.org/assets/2/7/ECCstats.pdf.
Centers for Disease Control and Prevention, Fluoride Recommendations Work Group. 2001. Recommendations for using fluoride to prevent and control dental caries in the United States. MMWR50(RR14): 1-42.

NOTES

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

COVID-19 modification as of September 20, 2021

Standard 3.1.5.2: Toothbrushes and Toothpaste

Content in the STANDARD was modified on 2/6/2013, 04/22/2013, and 3/10/2016.

COVID-19 modification as of September 20, 2021

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

In facilities where tooth brushing is an activity, each child should have a personally labeled, soft toothbrush of age-appropriate size. No sharing or borrowing of toothbrushes should be allowed. After use, toothbrushes should be stored on a clean surface with the bristle end of the toothbrush up to air dry in such a way that the toothbrushes cannot contact or drip on each other and the bristles are not in contact with any surface (1). Racks and devices used to hold toothbrushes for storage should be labeled and disinfected as needed. The toothbrushes should be replaced at least every three to four months, or sooner if the bristles become frayed (2-5). When a toothbrush becomes contaminated through contact with another brush or use by more than one child, it should be discarded and replaced with a new one.

Each child should have his/her own labeled toothpaste tube. Or if toothpaste from a single tube is shared among the children, it should be dispensed onto a clean piece of paper or paper cup for each child rather than directly on the toothbrush (1,6). Children under three years of age should have only a small smear of fluoride toothpaste (grain of rice) on the brush when brushing. Those three years of age and older should use a pea-sized amount of fluoride toothpaste (7). Toothpaste should be stored out of children's reach.

Small smear of fluoride toothpaste Pea-sized amount of fluoride toothpaste

Photo Credit: National Center on Early Childhood Health and Wellness

When children require assistance with brushing, caregivers/teachers should wash their hands thoroughly between brushings for each child. Caregivers/teachers should wear gloves when assisting such children with brushing their teeth.

RATIONALE

Toothbrushes and oral fluids that collect in the mouth during tooth brushing are contaminated with infectious agents and must not be allowed to serve as a conduit of infection from one individual to another (1). Individually labeling the toothbrushes will prevent different children from sharing the same toothbrush. As an alternative to racks, children can have individualized, labeled cups and their brush can be stored bristle-up in their cup. Some bleeding may occur during tooth brushing in children who have inflammation of the gums. The Occupational Safety and Health Administration (OSHA) regulations apply where there is potential exposure to blood. Saliva is considered an infectious vehicle whether or not it contains blood, so caregivers/teachers should protect themselves from saliva by implementing standard precautions.

COMMENTS

Children can use an individually labeled or disposable cup of water to brush their teeth (1).

Toothpaste is not necessary if removal of food and plaque is the primary objective of tooth brushing. However, no anti-caries benefit is achieved from brushing without fluoride toothpaste.

Some risk of infection can occur when numerous children brush their teeth and spit into the sink that is not sanitized between uses.

Tooth brushing ability varies by age. Young children want to brush their own teeth, but they need help until about age seven or eight. Adults helping children brush their teeth not only help them learn how to brush, but also improve the removal of plaque and food debris from all teeth (5).

TYPE OF FACILITY

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

RELATED STANDARDS

3.1.5.1 Routine Oral Hygiene Activities
3.1.5.3 Oral Health Education
3.6.1.5 Sharing of Personal Articles Prohibited
5.5.0.1 Storage and Labeling of Personal Articles

REFERENCES

American Academy of Pediatrics, Section on Oral Health. 2014 Maintaining and improving the oral health of young children. http://pediatrics.aappublications.org/content/134/6/1224.
12345 First Smiles. 2006. Oral health considerations for children with special health care needs (CSHCN). http://www.first5oralhealth.org/page.asp?page_id=432.
Davies, R. M., G. M. Davies, R. P. Ellwood, E. J. Kay. 2003. Prevention. Part 4: Toothbrushing: What advice should be given to patients?Brit Dent Jour 195:135-41.
American Dental Hygienists' Association.Proper brushing. http://www.adha.org/oralhealth/brushing.htm.
American Academy of Pediatric Dentistry. 2004.Early childhood caries (ECC).http://www.aapd.org/assets/2/7/ECCstats.pdf.
American Dental Association, Council on Scientific Affairs. 2005. ADA statement on toothbrush care: Cleaning, storage, and replacement. http://www.ada.org/1887.aspx.
Centers for Disease Control and Prevention. 2005. Infection control in dental settings: The use and handling of toothbrushes. http://www.cdc.gov/OralHealth/InfectionControl/factsheets/toothbrushes.htm

NOTES

Content in the STANDARD was modified on 2/6/2013, 04/22/2013, and 3/10/2016.

COVID-19 modification as of September 20, 2021

Standard 3.2.1.1: Type of Diapers Worn

Frequently Asked Questions/CFOC Clarifications

Reference: 3.2.1.1

Date: 10/13/2011

Topic & Location:
Chapter 3
Health Promotion
Standard 3.2.1.1: Type of Diapers Worn

Question:
Does this standard allow for use of the newer cloth diapers (with either a removable or connected absorbent inner liner and waterproof Velcro closure cover)?

Answer:
Yes, (for children who require cloth diapers for a medical reason), but only if the cloth diaper and cover are removed simultaneously as one unit and not removed as two separate pieces (see page 105). Please review the Comments section of this Standard for more information.

Content in the STANDARD was modified on 8/9/2017.

Facilities should adhere to the procedures outlined in 3.2.1.2: Handling Cloth Diapers and 3.2.1.4: Diaper Changing Procedure to prevent and control infections caused by fecal contact:

Diapers worn by children should be able to contain urine and stool and minimize exposure to human waste in the child care setting. Children should use disposable diapers with absorbent material (e.g., polymers) or cloth diapers. Cloth diapers should have an absorbent inner layer that is completely covered with an outer waterproof layer that has a waist closure (i.e., not pull-on waterproof pants). The cloth diaper and waterproof later should be changed at the same time (1). Whichever diapering system is used in the facility, clothes should be worn over diapers while the child is in the facility.

No rinsing or dumping of the contents of cloth diapers should be performed at the child care facility. Soiled cloth diapers should be stored in a labeled container with a tight-fitting lid provided by an accredited commercial diaper service, or in a sealed plastic bag for removal from the facility by an individual child's family, stored in a location inaccessible to children, and given directly to the parent/guardian daily upon discharge of the child. Children of all ages who are incontinent of urine or stool should wear a barrier method, such as a disposable diaper or a cloth diaper that is completely covered with an outer waterproof layer and a waist closure.

While single unit reusable diaper systems, with an inner cloth lining attached to an outer waterproof covering, and reusable cloth diapers, worn with a front closure waterproof cover, meet the physical criteria of this standard (if used as described), they have not been evaluated for their ability to reduce fecal contamination, or for their association with diaper dermatitis (rash). Moreover, it has not been demonstrated that the waterproof covering materials remain waterproof with repeated cleaning and disinfecting. Therefore, single-use disposable diapers should be encouraged for use in child care facilities.

RATIONALE

Procedures that reduce fecal contamination help control the spread of disease. Fecal contamination has been associated with increased diarrheal rates in child care facilities (1). Gastrointestinal tract disease, or diarrhea (caused by bacteria, viruses, and parasites) and hepatitis A virus infection are spread from infected persons through fecal contamination of hands and objects. Protective procedures includes minimal handling of soiled diapers and clothing, thorough hand hygiene, and containment of fecal matter. Fecal contamination in child care settings may be reduced when single-use, disposable diapers are used compared to cloth diapers worn with pull-on waterproof pants (3). When clothes are worn over either disposable or cloth diapers with pull-on waterproof pants, there is a reduction in contamination of the environment (1, 3).

Diaper Rash

Diaper dermatitis (rash) occurs frequently in diapered children. Diapering practices that reduce the frequency and severity of diaper dermatitis will require less application of skin creams and ointments, thereby decreasing the likelihood for fecal contamination of caregivers/teachers' hands. Most common diaper dermatitis is caused by prolonged contact of the skin with urine, feces, or both (1). The action of fecal digestive enzymes on urinary urea and the resulting production of ammonia make the diapered area more alkaline, which has been shown to damage skin (1). Damaged skin is more susceptible to other biological, chemical, and physical insults that can cause or aggravate diaper dermatitis (1). Frequency and severity of diaper dermatitis are lower when diapers are changed more often, regardless of the diaper used (1). The use of disposable diapers with absorbent material has been associated with less frequent and less severe diaper dermatitis in some children than with the use of cloth diapers and pull-on pants made of a waterproof material (2, 3).

COMMENTS

Reusable cloth diapers worn either without a covering or with pull-on waterproof pants do not meet the physical requirements of the standard.

TYPE OF FACILITY

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

RELATED STANDARDS

5.4.1.10 Handwashing Sinks
3.2.1.2 Handling Cloth Diapers
3.2.1.4 Diaper Changing Procedure
3.2.1.5 Procedure for Changing Children's Soiled Underwear, Disposable Training Pants and Clothing
3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.2.2.3 Assisting Children with Hand Hygiene
3.2.2.4 Training and Monitoring for Hand Hygiene
3.2.2.5 Hand Sanitizers
5.2.7.4 Containment of Soiled Diapers

REFERENCES

American Academy of Pediatrics. Healthychildren.org. 2015. Diaper rash. https://www.healthychildren.org/English/ages-stages/baby/diapers-clothing/Pages/Diaper-Rash.aspx.
Counts, J.L., Helmes, C.T., Kenneally, D., Otts, D.R. Modern disposable diaper constructions: Innovations in performance help maintain healthy diapered skin. 2014. Clinical Pediatrics. 53(9S):10S-13S.
American Academy of Pediatrics. Infections Spread by the Fecal-Oral Route In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases . 31st Edition. Itasca, IL: American Academy of Pediatrics; 2018: 143

NOTES

Content in the STANDARD was modified on 8/9/2017.

Standard 3.2.1.2: Handling Cloth Diapers

If cloth diapers are used, soiled cloth diapers and/or soiled training pants should never be rinsed or carried through the child care area to place the fecal contents in a toilet. Reusable diapers should be laundered by a commercial diaper service. Soiled cloth diapers should be stored in a labeled container with a tight-fitting lid provided by an accredited commercial diaper service, or in a sealed plastic bag for removal from the facility by an individual child's family. The sealed plastic bag should be sent home with the child at the end of the day. The containers or sealed diaper bags of soiled cloth diapers should not be accessible to any child.¹

RATIONALE

Containing and minimizing the handling of soiled diapers so they do not contaminate other surfaces is essential to prevent the spread of infectious disease. Putting stool into a toilet in the child care facility increases the likelihood that other surfaces will be contaminated during the disposal.¹ There is no reason to use the toilet for stool if disposable diapers are being used. Commercial diaper laundries use a procedure that separates solid components from the diapers and does not require prior dumping of feces into the toilet.

TYPE OF FACILITY

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

RELATED STANDARDS

3.2.1.1 Type of Diapers Worn
3.2.1.5 Procedure for Changing Children's Soiled Underwear, Disposable Training Pants and Clothing

REFERENCES

American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 5th ed. Itasca, IL: American Academy of Pediatrics; 2020.25.

Standard 3.2.1.3: Checking For the Need to Change Diapers

Diapers should be checked for wetness and feces at least hourly, visually inspected at least every two hours, and whenever the child indicates discomfort or exhibits behavior that suggests a soiled or wet diaper. Diapers should be changed when they are found to be wet or soiled.

RATIONALE

Frequency and severity of diaper dermatitis is lower when diapers are changed more often, regardless of the type of diaper used (1). Diaper dermatitis occurs frequently in diapered children. Most common diaper dermatitis represents an irritant contact dermatitis; the source of irritation is prolonged contact of the skin with urine, feces, or both (2). The action of fecal digestive enzymes on urinary urea and the resulting production of ammonia make the diapered area more alkaline, which has been shown to damage skin (1,2). Damaged skin is more susceptible to other biological, chemical, and physical insults that can cause or aggravate diaper dermatitis (2).

Modern disposable diapers can be checked for wetness by feeling the diaper through the clothing and fecal contents can be assessed by odor. Nonetheless, since these methods of checking may be inaccurate, the diaper should be opened and checked visually at least every two hours. Even though modern disposable diapers can continue to absorb moisture for an extended period of time when they are wet, they should be changed after two hours of wearing if they are found to be wet. This prevents rubbing of wet surfaces against the skin, a major cause of diaper dermatitis.

TYPE OF FACILITY

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

RELATED STANDARDS

3.2.1.2 Handling Cloth Diapers
3.2.1.4 Diaper Changing Procedure
3.2.1.5 Procedure for Changing Children's Soiled Underwear, Disposable Training Pants and Clothing
3.2.2.1 Situations that Require Hand Hygiene

REFERENCES

Shelov, S. P., T. R. Altmann, eds. 2009. Caring for your baby and young child: Birth to age 5. 5th ed. Elk Grove Village, IL: American Academy of Pediatrics.
Healthy Children. 2010. Ages and stages: When diaper rash strikes. http://www.healthychildren.org/English/ages-stages/baby/diapers-clothing/Pages/When-Diaper-Rash-Strikes.aspx.

Standard 3.2.1.4: Diaper Changing Procedure

Frequently Asked Questions/CFOC Clarifications

Reference: 3.2.1.4

Date: 10/13/2011

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

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

Answer:

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

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

Frequently Asked Questions/CFOC Clarifications

Reference: 3.2.1.4

Date: 11/22/2011

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

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

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

Frequently Asked Questions/CFOC Clarifications

Reference: 3.2.1.4

Date: 7/21/2014

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

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

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

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

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

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

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

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

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

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

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

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

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

Step 3: Clean the child's diaper area.

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

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

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

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

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

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

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

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

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

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

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

RATIONALE

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

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

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

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

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

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

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

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

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

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

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

NOTES

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

Standard 3.2.1.5: Procedure for Changing Children's Soiled Underwear, Disposable Training Pants and Clothing

Frequently Asked Questions/CFOC Clarifications

Reference: 3.2.1.5

Date: 10/13/2011

Topic & Location:
Chapter 3
Health Promotion
Standard 3.2.1.5: Procedure for Changing Children's Soiled Underwear/Pull-Ups and Clothing

Question:
Should a distinction be made between "wet" and "soiled" pull-up, clothing, and underwear? Or are these terms interchangeable in the Standard and Rationale? More specifically, are the steps required for changing a pull-up with a bowel movement the same for changing a pull-up that is only wet?

Answer:
The same changing procedure should be used regardless of the contents.

Content in the STANDARD was modified on 1/2012, 7/13/2012, 1/5/2013, 8/23/2016 and 10/16/2018.

The following changing procedure for soiled disposable training pants, underwear and clothing should be posted in the changing area, followed for all changes, and used as part of staff evaluation of caregivers/teachers who change disposable training pants, underwear and clothing. The signage should be simple and in multiple languages if caregivers/teachers who speak multiple languages are involved in changing disposable training pants or underwear. All employees who will change disposable training pants, underwear and clothing should undergo training and periodic assessment of these practices.

Changing a child from the floor level or on a chair puts the adult in an awkward position and increases the risk of contamination of the environment. Using a toddler changing table helps establish a well-organized changing area for both the child and the caregiver/teacher. Changing tables with steps that allow the child to climb with the caregiver/teacher's help and supervision may also be used. Changing tables that are a comfortable height for caregivers help reduce the risk of back injury for the adults, which may occur from lifting the child onto the table (1).

Caregivers/teachers should never leave a child unattended on a table or countertop, even for an instant. A safety strap or harness should not be used on the changing surface. If an emergency arises, caregivers/teachers should bring any child on an elevated surface to the floor or take the child with them.

Use a fragrance-free bleach that is US Environmental Protection Agency (EPA) registered as a sanitizing or disinfecting solution. If other products are used for sanitizing or disinfecting, they should also be fragrance-free and EPA registered (2).

All cleaning and disinfecting solutions should be stored to be accessible to the caregiver/teacher but out of reach of any child. Please refer to Appendix J: Selecting an Appropriate Sanitizer or Disinfectant and Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting .

Step 1: Get organized and determine whether to change the child lying down or standing up. Before bringing the child to the changing area, perform hand hygiene if hands have been contaminated since the last time hand hygiene was performed(3), gather, and bring supplies to the changing area.

Nonabsorbent paper liner large enough to cover the changing surface
Unused disposable training pants, underwear, clean clothes (if you need them)
Readily available wipes, dampened cloths, or wet paper towels for cleaning the child's genitalia and buttocks
A plastic bag for any soiled clothes, including underwear, or disposable training pants
Disposable gloves, if you plan to use them (put gloves on before handling soiled clothing or disposable training pants; remove them before handling clean disposable training pants, underwear and clothing)

Step 2: Avoid contact with soiled items.

If the child is standing, it may cause the clothing, shoes, and socks to become soiled. The caregiver/teacher must remove these items before the change begins.
To avoid contaminating the child's clothes, have the child hold his or her shirt, sweater, etc., up above the waist during the change. This keeps the child's hands busy and the caregiver/teacher knows where the child's hands are during the changing process. Caregivers/teachers can also use plastic clothespins that can be washed and sanitized to keep the clothing out of the way.
If disposable training pants were used, pull the sides apart, rather than sliding the garment down the child's legs. If underwear is being changed, remove the soiled underwear and any soiled clothing, doing your best to avoid contamination of surfaces.
To avoid contamination of the environment and/or the increased risk of spreading germs to the other children in the room, do not rinse the soiled clothing in the toilet or elsewhere. Place all soiled garments in a plastic-lined, hands-free plastic bag to be cleaned at the child's home.
If the child's shoes are soiled, the caregiver/teacher must wash and sanitize them before putting them back on the child. It is a good idea for the child care facility to request a few extra pair of socks and shoes from the parent/caregiver to be kept at the facility in case these items become soiled (1).

Step 3: Clean the child's skin and check for spills.

Lift the child's legs as needed to use disposable wipes, a dampened cloth, or a wet paper towel to clean the skin on the child's genitalia and buttocks. Remove stool and urine from front to back and use a fresh wipe, dampened cloth, or wet paper towel each time you swipe. Put the soiled wipes, cloth, or paper towels into the soiled disposable training pants or directly into a plastic-lined, hands-free covered can. Reusable cloths should be stored in a washable, plastic-lined, tightly covered receptacle (within arm's reach of changing tables) until they can be laundered. The cover should not require touching with contaminated hands or objects.

Check for spills under the child. If there are any, use the corner of the paper that extends beyond or under the child's feet to fold over the soiled area so a fresh, unsoiled paper surface is now under the child.
If gloves were used, remove them using the proper technique (see Appendix D) and put them into a plastic-lined, hands-free covered can.
Whether or not gloves were used, use a fresh wipe to wipe the hands of the caregiver/teacher and another fresh wipe to wipe the child's hands. Put the wipes into the plastic-lined, hands-free covered can.

Step 4: Put on clean disposable training pants or clean underwear and clothing, if necessary.

Assist the child, as needed, in putting on clean disposable training pants or underwear, and then in re-dressing (1).

Note and plan to report any skin problems such as redness, cracks, or bleeding.
Put the child's socks and shoes back on if they were removed during the changing procedure (1).

Step 5: Wash the child's hands and return the child to a supervised area.

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

Step 6: Clean and disinfect the changing surface.

Dispose of the disposable paper liner used on the changing surface in a plastic-lined, hands-free covered can.

If clothing was soiled, securely tie the plastic bag used to store the clothing and send the bag home.

Remove any visible soil from the changing surface with a disposable paper towel saturated with water and detergent, and then rinse.

Wet the entire changing surface with a disinfectant that is appropriate for the surface material you are treating. Follow the manufacturer's instructions for use.

Put away the disinfectant. Some types of disinfectants may require rinsing the changing table surface with fresh water afterward.

Step 7: Perform hand hygiene according to the procedure in Standard 3.2.2.2 and record the change in the child's daily log.

In the daily log, record what was in the disposable training pants or underwear and any problems (e.g., a loose stool, an unusual odor, blood in the stool, any skin irritation) and report as necessary (4).

RATIONALE

Children who are learning to use the toilet may still wet/soil their disposable training pants, underwear and clothing. Changing these undergarments can lead to risk for spreading infection due to the contamination of surfaces from urine or feces (1). The procedure for changing a child's soiled undergarment and clothing is designed to reduce the contamination of surfaces that will later come in contact with uncontaminated surfaces such as hands, furnishings, and floors (5, 6). Posting the multistep procedure may help caregivers/teachers maintain the routine.

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

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

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

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

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

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

Changing areas should never be located in food preparation areas and should never be used for temporary placement of food, drinks, or eating utensils. Additionally, changing tables that are a comfortable height for caregivers help reduce the risk of back injury for the adults, which may occur from lifting the child onto the table (1).

COMMENTS

Children with disabilities may require diapering, and the method of diapering will vary according to their abilities. However, principles of hygiene should be consistent regardless of method. Toddlers and preschool-aged children without physical disabilities frequently have toileting issues as well. These soiling/wetting episodes can be due to rapid-onset gastroenteritis, distraction due to the intensity of their play, and emotional disruption secondary to new transition. These include new siblings, stress in the family, or anxiety about changing classrooms or programs, all of which are based on their inability to recognize and articulate their stress and to manage a variety of impulses.

Development is not a straight trajectory but, rather, a cycle of forward and backward steps as children gain mastery over their bodies in a wide variety of situations. It is typical and developmentally appropriate for children to revert to immature behaviors as they gain developmental milestones while simultaneously dealing with immediate struggles, which they are internalizing. Even for preschool- and kindergarten-aged children, these accidents happen, and these incidents are called "accidents" because of the frequency of these episodes among typically developing children. It is important for caregivers/teachers to recognize that the need to assist young children with toileting is a critical part of their work and that their attitude about the incident and their support of children as they work toward self-regulation of their bodies is a component of teaching young children.

TYPE OF FACILITY

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

RELATED STANDARDS

2.1.2.5 Toilet Learning/Training
3.2.1.1 Type of Diapers Worn
3.2.1.2 Handling Cloth Diapers
3.2.1.3 Checking For the Need to Change Diapers
3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.3.0.1 Routine Cleaning, Sanitizing, and Disinfecting
5.2.7.4 Containment of Soiled Diapers
5.4.4.2 Location of Laundry Equipment and Water Temperature for Laundering
Appendix D: Gloving
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting
Appendix J: Selecting an Appropriate Sanitizer or Disinfectant

REFERENCES

Early Childhood Education Linkage Systems, Healthy Child Care Pennsylvania. Changing soiled underwear. http://www.ecels-healthychildcarepa.org/publications/fact-sheets/item/116-changing-soiled-underwear?highlight=WyJzb2lsZWQiXQ . Published 2016. Accessed June 26, 2018
Children's Environmental Health Network. 2016. Household chemicals. https://sharemylesson.com/teaching-resource/household-chemicals-fact-sheet-298286 .
National Association for the Education of Young Children. Healthy Young Children: A Manual for Programs. Aronson SS, ed. 5th ed. Washington, DC: National Association for the Education of Young Children; 2012
American Academy of Pediatrics. Red Book: 2018–2021 Report of the Committee on Infectious Diseases. Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. 31st ed. Itasca, IL: American Academy of Pediatrics; 2018
University of California, San Francisco School of Nursing Institute for Health and Aging; University of California, Berkeley Center for Environmental Research and Children's Health; Informed Green Solutions. Green Cleaning, Sanitizing, and Disinfecting: A Checklist for Early Care and Education. https://www.epa.gov/sites/production/files/2013-08/documents/checklist_8.1.2013.pdf . Published 2013. Accessed June 26, 2018
Early Childhood Education Linkage System, Healthy Child Care Pennsylvania. Diapering poster. http://www.ecels-healthychildcarepa.org/tools/posters/item/279-diapering-poster . Reaffirmed April 2018. Accessed June 26, 2018
American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 5th ed. Itasca, IL: American Academy of Pediatrics; 2020.25.

NOTES

Content in the STANDARD was modified on 1/2012, 7/13/2012, 1/5/2013, 8/23/2016 and 10/16/2018.

Standard 3.2.2.1: Situations that Require Hand Hygiene

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

COVID-19 modification as of September 20, 2021

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

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

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

b. Before and after

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

c. After

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

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

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

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

RATIONALE

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

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

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

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

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

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

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

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

COMMENTS

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

NOTES

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

COVID-19 modification as of September 20, 2021

Standard 3.2.2.2: Handwashing Procedure

Frequently Asked Questions/CFOC Clarifications

Reference: 3.2.2.2

Date: 10/13/2011

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

RATIONALE

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

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

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

COMMENTS

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

NOTES

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

Standard 3.2.2.3: Assisting Children with Hand Hygiene

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

RATIONALE

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

For examples of handwashing posters, see:

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

Standard 3.2.2.5: Hand Sanitizers

Frequently Asked Questions/CFOC Clarifications

Reference: 3.2.2.5

Date: 10/13/2011

Topic & Location:
Chapter 3
Standard 3.2.2.5: Hand Sanitizers

Question:
Is there evidence to address the flammability risk of hand sanitizers and the recommended countermeasures with this product?

Answer:
Hand sanitizers are flammable as noted on product labels. Standard 5.5.0.5: Storage of Flammable Materials was updated in the CFOC Online Databaseto address that hand sanitizers in volume should be stored in a separate building, in a locked area, away from high temperatures and ignition sources, and inaccessible to children.

Content in the STANDARD was modified on 4/5/2017 and 8/9/2017.

The use of hand sanitizers by children and adults in child care programs is an appropriate alternative to the use of traditional handwashing if soap and water is not available and if hands are not visibly dirty (1,2).

Supervision of children is required to monitor effective use and to avoid potential ingestion or inadvertent contact of hand sanitizers with eyes and mucous membranes (3).
The technique for using hand sanitizers is:

For visibly dirty hands and soap is not available, rinsing under running water or wiping with a water-saturated towel should be used to remove as much dirt as possible before using a hand sanitizer.
Apply the product to the palm of one hand (read the label to learn the correct amount);
Rub hands together; and
Rub the product over all surfaces of the hands and fingers until hands are dry (4).

Hand sanitizers using an alcohol-based active ingredient must contain 60% to 95% alcohol to be effective in killing most germs including multi-drug resistant pathogens. Child care programs should follow the manufacturer's instructions for use, check instructions to determine how much product and how long the hand sanitizer needs to remain on the skin surface to be effective.

Where alcohol-based hand sanitizer dispensers are used:

The maximum individual dispenser fluid capacity should be as follows:
0.32 gal (1.2 L) for dispensers in individual rooms, corridors, and areas open to corridors;
0.53 gal (2.0 L) for dispensers in suites of rooms;
Where aerosol containers are used, the maximum capacity of the aerosol dispenser should be 18 oz. (0.51 kg) and should be limited to Level 1 aerosols as defined in NFPA 30B: Code for the Manufacture and Storage of Aerosol Products;
Wall mounted dispensers should be separated from each other by horizontal spacing of not less than 48 in. (1,220 mm);
Wall mounted dispensers should not be installed above or adjacent to ignition sources such as electrical outlets;
Wall mounted dispensers installed directly over carpeted floors should be permitted only in child care facilities protected by automatic sprinklers (5).

When alcohol based hand sanitizers are offered in a child care facility, the facility should encourage parents/guardians to teach their children about their use at home.

RATIONALE

Studies have demonstrated that using an alcohol-based hand sanitizer after washing hands with soap and water is effective in reducing illness transmission in the home, in child care centers and in health care settings (6-8).
Hand sanitizer products may be dangerous or toxic if ingested in amounts greater than the residue left on hands after cleaning. It is important for caregivers/teachers to monitor children's use of hand sanitizers to ensure the product is being used appropriately (5).

Alcohol-based hand sanitizers have the potential to be toxic due to the alcohol content if ingested in a significant amount (1,3,4).

COMMENTS

Even in health care settings, the Centers for Disease Control and Prevention (CDC) guidelines recommend washing hands that are visibly soiled or contaminated with organic material with soap and water as an adjunct to the use of alcohol-based sanitizers (6).

While alcohol-based hand sanitizers are helpful in reducing the spread of disease when used correctly, there are some common diarrhea-causing germs that are not killed (e.g. norovirus, spore-forming organisms) (1). These germs are common in child care settings, and children less than 2 years are at the greatest risk of spreading diarrheal disease due to frequent diaper changing. Even though alcohol-based hand sanitizers are not prohibited for children under the age of 2 years, hand washing with soap and water is always the preferred method for hand hygiene.

Some hand sanitizing products contain non-alcohol and "natural" ingredients. The efficacy of non-alcohol containing hand sanitizers is variable and therefore a non-alcohol-based product is not recommended for use.

TYPE OF FACILITY

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

RELATED STANDARDS

3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
5.5.0.5 Storage of Flammable Materials

REFERENCES

Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4^th Edition.Elk Grove Village, IL: American Academy of Pediatrics.
U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2016. Show me the science-When and how to use hand sanitizer. http://www.cdc.gov/handwashing/show-me-the-science-hand-sanitizer.html.
Centers for Disease Control and Prevention. When & how to wash your hands. 2015. https://www.cdc.gov/handwashing/when-how-handwashing.html.
Santos, C., Kieszak, S., Wang, A., Law, R., Schier, J., Wolkin, A.. Reported adverse health effects in children from ingestion of alcohol-based hand sanitizers — United States, 2011–2014. MMWR Morb Mortal Wkly Rep 2017;66:223–226. DOI: http://dx.doi.org/10.15585/mmwr.mm6608a5.
National Fire Protection Association (NFPA). 2009.NFPA 101: Life safety code. 2009 ed. Quincy, MA: NFPA.
Vessey, J. A., J. J. Sherwood, D. Warner, D. Clark. 2007. Comparing hand washing to hand sanitizers in reducing elementary school students' absenteeism.Pediatric Nurs 33:368-72.
U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2016. Handwashing: Clean hands save lives! http://www.cdc.gov/handwashing/.
ADDITIONAL REFERENCE:
American Association of Poison Control Centers. 2016. Hand sanitizer. http://www.aapcc.org/alerts/hand-sanitizer/.
American Academy of Pediatrics. Hand Hygiene In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases . 31st Edition. Itasca, IL: American Academy of Pediatrics; 2018: 148-149, 154, 164

NOTES

Content in the STANDARD was modified on 4/5/2017 and 8/9/2017.

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

Frequently Asked Questions/CFOC Clarifications

Reference: 3.4.1.1

Date: 11/7/2012

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

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

Answer:

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

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

U.S. FDA, 2013 article

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

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

RATIONALE

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

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

Alcohol use, illegal and legal drug use, and misuse of prescription or over-the-counter (OTC) drugs prevent caregivers/teachers from providing appropriate care to infants and children by impairing motor coordination, judgment, and response time. Safe child care necessitates alert, unimpaired caregivers/teachers.

The use of alcoholic beverages and legal drugs in family child care homes after children are not in care is not prohibited, but these items should be safely stored at all times.

COMMENTS

The age, defenselessness, and dependence upon the judgment of caregivers/teachers of the children under care make this prohibition an absolute requirement.

As more states move toward legalizing marijuana use for recreational and/or medicinal purposes, it is important for caregivers/teachers to be aware of the impact marijuana used medicinally and/or recreationally has on their ability to provide safe care. Staff modeling of healthy and safe behavior at all times is essential to the care and education of young children.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

5.2.9.1 Use and Storage of Toxic Substances
9.2.3.15 Policies Prohibiting Smoking, Tobacco, Alcohol, Illegal Drugs, and Toxic Substances

REFERENCES

ADDITIONAL REFERENCES:
Centers for Disease Control and Prevention. 2009. Facts: Preventing residential fire injuries. http://www.cdc.gov/injury/pdfs/Fires2009CDCFactSheet-FINAL-a.pdf.

American Lung Association. E-cigarettes and Lung Health. 2016. http://www.lung.org/stop-smoking/smoking-facts/e-cigarettes-and-lung-health.html?referrer=https://www.google.com/.

Children's Hospital Colorado. 2016. Acute marijuana intoxication. https://www.childrenscolorado.org/conditions-and-advice/conditions-and-symptoms/conditions/acute-marijuana-intoxication/.
Dale, L. 2014. What is thirdhand smoke, and why is it a concern? http://www.mayoclinic.org/healthy-lifestyle/adult-health/expert-answers/third-hand-smoke/faq-20057791
Winickoff, J. P., J. Friebely, S. E. Tanski, C. Sherrod, G. E. Matt, M. F. Hovell, R. C. McMillen. 2009. Beliefs about the health effects of "thirdhand" smoke and home smoking bans.Pediatrics 123: e74-e79.
U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Secondhand Smoke What It Means to You. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006. http://www.surgeongeneral.gov/library/reports/secondhand-smoke-consumer.pdf.
U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Secondhand Smoke What It Means to You. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006. http://www.surgeongeneral.gov/library/reports/secondhand-smoke-consumer.pdf.
Schwartz, J., K. L. Timonen, J. Pekkanen. 2000. Respiratory effects of environmental tobacco smoke in a panel study of asthmatic and symptomatic children.Am J Resp Crit Care Med161:802-6.
U.S. Department of Health and Human Services. 2007.Children and secondhand smoke exposure. Excerpts from the health consequences of involuntary exposure to tobacco smoke: A report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.
American Academy of Pediatrics. Healthychildren.org. 2015. The dangers of secondhand smoke. https://www.healthychildren.org/English/health-issues/conditions/tobacco/Pages/Dangers-of-Secondhand-Smoke.aspx.
Centers for Disease Control and Prevention. 2016. Health effects of secondhand smoke. http://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/health_effects/.
American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: Updated 2016 recommenations for a safe infant sleeping environment. Pediatrics. 2016;138(6):e20162938.
http://pediatrics.aappublications.org/content/early/2016/10/20/peds.2016-2938.

NOTES

Content in the STANDARD was modified on 1/12/2017.

Standard 3.4.5.1: Sun Safety Including Sunscreen

Frequently Asked Questions/CFOC Clarifications

Reference: 3.4.5.1

Date: 2/17/2012

Topic & Location:
Chapter 3
Health Promotion
3.4.5.1: Sun Safety Including Sunscreen

Question:
Why does this standard state that sunscreen should be applied thirty minutes before going outdoors, but the AAP reference listed on page 127 states that sunscreen should be applied 15-30 minutes before going outside?

Answer:
The recommendation of how many minutes prior to going outside sunscreen should be applied was revised from 30 minutes to 15-30 minutes on January 30, 2012, which was after the publication of CFOC, 3rd Edition.

Content in the STANDARD was modified on 8/8/2013.

Caregivers/teachers should implement the following procedures to ensure sun safety for themselves and the children under their supervision:

Keep infants younger than six months out of direct sunlight. Find shade under a tree, umbrella, or the stroller canopy;
Wear a hat or cap with a brim that faces forward to shield the face;
Limit sun exposure between 10 AM and 4 PM, when UV rays are strongest;
Wear child safe shatter resistant sunglasses with at least 99% UV protection;
Apply sunscreen (1).

Over-the-counter ointments and creams, such as sunscreen that are used for preventive purposes do not require a written authorization from a primary care provider with prescriptive authority. However, parent/guardian written permission is required, and all label instructions must be followed. If the skin is broken or an allergic reaction is observed, caregivers/teachers should discontinue use and notify the parent/guardian.

If parents/guardians give permission, sunscreen should be applied on all exposed areas, especially the face (avoiding the eye area), nose, ears, feet, and hands and rubbed in well especially from May through September. Sunscreen is needed on cloudy days and in the winter at high altitudes. Sun reflects off water, snow, sand, and concrete. "Broad spectrum" sunscreen will screen out both UVB and UVA rays. Use sunscreen with an SPF of 15 or higher, the higher the SPF the more UVB protection offered. UVA protection is designated by a star rating system, with four stars the highest allowed in an over-the-counter product.

Sunscreen should be applied thirty minutes before going outdoors as it needs time to absorb into the skin. If the children will be out for more than one hour, sunscreen will need to be reapplied every two hours as it can wear off. If children are playing in water, reapplication will be needed more frequently. Children should also be protected from the sun by using shade and sun protective clothing. Sun exposure should be limited between the hours of 10 AM and 4 PM when the sun's rays are the strongest.

Sunscreen should be applied to the child at least once by the parents/guardians and the child observed for a reaction to the sunscreen prior to its use in child care.

RATIONALE

Sun exposure from ultraviolet rays (UVA and UVB) causes visible and invisible damage to skin cells. Visible damage consists of freckles early in life. Invisible damage to skin cells adds up over time creating age spots, wrinkles, and even skin cancer (2,4).

Exposure to UV light is highest near the equator, at high altitudes, during midday (10 AM to 4 PM), and where light is reflected off water or snow (5).

COMMENTS

Protective clothing must be worn for infants younger than six months. For infants older than six months, apply sunscreen to all exposed areas of the body, but be careful to keep away from the eyes (3). If an infant rubs sunscreen into her/his eyes, wipe the eyes and hands clean with a damp cloth. Unscented sunblocks or sunscreen with titanium dioxide or zinc oxide are generally safer for children and less likely to cause irritation problems (6). If a rash develops, have parents/guardians talk with the child's primary care provider (1).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.2.2.1 Situations that Require Hand Hygiene
3.4.5.2 Insect Repellent and Protection from Vector-Borne Diseases
3.6.3.1 Medication Administration
6.1.0.7 Shading of Play Area

REFERENCES

Misra, M., D. Pacaud, A. Petryk, P. F. Collett-Solberg, M. Kappy. 2008. Vitamin D deficiency in children and its management: Review of current knowledge and recommendations. Pediatrics 122:398-417.
Norval, M., H. C. Wulf. 2009. Does chronic sunscreen use reduce vitamin D production to insufficient levels? British J Dermatology 161:732-36.
Yan, X. S., G. Riccardi, M. Meola, A. Tashjian, J. SaNogueira, T. Schultz. 2008. A tear-free, SPF50 sunscreen product. Cutan Ocul Toxicol 27:231-39.
Weinberg, N., M. Weinberg, S. Maloney. Traveling safely with infants and children. Medic8. http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-7-international-travel-infants-children/traveling-safely-with-infants-and-children.
Maguire-Eisen, M., K, Rothman, M. F. Demierre. 2005. The ABCs of sun protection for children. Dermatology Nurs 17:419-22,431-33.
Kenfield, S., A. Geller, E. Richter, S. Shuman, D. O'Riordan, H. Koh, G. Colditz. 2005. Sun protection policies and practices at child care centers in Massachusetts. J Comm Health 30:491-503.
American Academy of Dermatology. 2010. Skin, hair and nail care: Protecting skin from the sun. Kids Skin Health.http://www.kidsskinhealth.org/grownups/skin_habits_sun.html.
American Academy of Pediatrics. 2008. Sun safety. http://www.healthychildren.org/english/safety-prevention/at-play/pages/Sun-Safety.aspx.

NOTES

Content in the STANDARD was modified on 8/8/2013.

Standard 3.4.5.2: Insect Repellent and Protection from Vector-Borne Diseases

Content in the STANDARD was modified on 4/5/2017.

Most insects do not carry human disease and most insect bites only cause mild irritation. Insect repellents may be used with children older than 2 months in child care where there are specific disease outbreaks and alerts. As with all pesticides, care should be taken to limit children's exposure to insect repellents (1). Caregivers/teachers should consult with a child care health consultant, the primary care provider, or the local health department about the appropriate use of repellents based on the likelihood that local insects are carrying potentially dangerous diseases (e.g., local cases of meningitis from mosquito bites). This information should be shared with parents/guardians, and collective decisions made about use.
Insect repellent requires the written permission of parents/guardians and label instructions must be followed. It does not require written permission from a primary care provider.

Repellents containing DEET

Repellents with 10%-30% DEET offer the broadest protection against mosquitoes, ticks, flies, chiggers, and fleas. Caregivers/teachers should read product labels and confirm that the product is 1) safe for children and 2) contains no more than 30% DEET. Most product labels for registrations containing DEET recommend consultation with a physician if applying to a child less than six months of age.
The use of DEET should reflect how much time the child will be exposed to biting insects (2):

10% DEET is generally effective for two hours.
24% DEET is generally effective for five hours.
Products with more than 30% DEET should never be used on children.
Do not use products that combine insect repellent and sunscreen. This is because sunscreen may need to be re-applied more often and in larger amounts than repellent.
If sunscreen is also used, apply sunscreen FIRST. DEET may decrease the SPF of sunscreens by one-third. Sunscreens may increase absorption of DEET through the skin).

Other Types of Insect Repellents

Picaridin and IR3535 are other products registered at the Environmental Protection Agency (EPA) identified as providing repellent activity sufficient to help people avoid the bites of disease carrying mosquitoes (4). Para-menthane-diol (PMD) or pil of lemon eucalyptus products, according to their product labels, should NOT be used on children under three years of age (4,5).

General Guidelines for Use of Insect Repellents with Children

As noted above, insect repellents may be applied to children older than two months. In addition to consulting label instructions, teachers/caregivers may follow these guidelines:

a.    Apply insect repellent to the caregiver/teacher's hands first.
b.    When applying insect repellent on a child, use just enough to cover exposed skin.
c. Do not apply under clothing.
d.    Do not use on children's hands.
e.    Avoid applying to areas around the eyes and mouth.
f. Do not use over cuts or irritated skin.
g.    Do not use near food.
h.    After returning indoors, wash treated skin immediately with soap and water.
i. Caregivers/teachers should wash their hands after applying insect repellent to the children in the group.
j. If the child gets a rash or other skin reaction from an insect repellent, stop using the repellent, wash the repellent off with mild soap and water, and call a local poison center (1-800-222-1222) for further guidance (4). If repellent is used on broken skin or an allergic reaction is observed, discontinue use and notify the parent/guardian.

Protection from ticks

In places where ticks are likely to be found (6), caregivers/teachers should take the following steps to protect children in their care from ticks:

a.    Remove leaf litter and clear tall grasses and brush around homes and buildings and at the edges of lawns;
b.    Place wood chips or gravel between lawns and wooded areas to restrict tick migration to recreational areas;
c. Mow the lawn and clear brush and leaf litter frequently;
d.    Keep playground equipment, decks, and patios away from yard edges and trees;
e.    Ensure that children wear light colored clothing, long sleeves and pants, tuck pants into socks; and
f. Conduct tick checks of children when returning indoors (7).

How to Remove a Tick

(8):
It is important to remove the tick as soon as possible. Use the following steps:

a. If possible, clean the area with an antiseptic solution or soap and water. Take care not to scrub the tick too hard. Just clean the skin around it;
b. Use blunt, fine tipped tweezers or gloved fingers to grasp the tick as close to the skin as possible;
c. Pull slowly and steadily upwards to allow the tick to release;
d. If the tick's head breaks off in the skin, use tweezers to remove it like you would a splinter;
e. Wash the area around the bite with soap;
f. Following the removal of the tick, wash your hands, the tweezers, and the area thoroughly with soap and warm water.

Take care not to do the following:

a. Do not use sharp tweezers.
b. Do not crush, puncture, or squeeze the tick's body.
c. Do not use a twisting or jerking motion to remove the tick.
d. Do not handle the tick with bare hands.
e. Do not try to make the tick let go by holding a hot match or cigarette close to it.
f. Do not try to smother the tick by covering it with petroleum jelly or nail polish.

RATIONALE

Mosquitoes and ticks can carry pathogens that may cause serious diseases (i.e., vector-borne diseases such as West Nile virus and Lyme disease) (7).
Zika is a mosquito-borne virus that usually causes mild illness that lasts from several days to a week. The mosquito that spreads Zika virus is found everywhere in the world including the United States. Zika can be passed from a pregnant woman to her fetus. Infection during pregnancy can cause certain birth defects (9). Information and recommendations regarding Zika are rapidly evolving. Please visit the Centers for Disease Control and Prevention (CDC) Zika updates page for the most recent information: http://www.cdc.gov/zika/index.html (9).

COMMENTS

Insect repellents should be EPA-registered and labeled as approved for use in the child's age range.
Aerosol sprays are not recommended. Pump sprays are a better choice. Regardless of the type of spray used, caregivers/teachers should spray the insect repellent into her/his hand and then apply to the child. It is not recommended to directly spray the child with the insect repellent to prevent unintentional injury to eyes and mouth. Preschool children, toddlers, and infants should not apply insect repellent to themselves. School age children can apply insect repellent to themselves if they are supervised to make sure that they are applying it correctly.
Parents/guardians should be notified when insect repellent is applied to their child since it is recommended that treated skin is washed with soap and water.
If a product gets in the eyes, flush with water and consult the poison center at 1-800-222-1222.
Several resources are available on reducing exposure to ticks and mosquitoes based on habits, protective attire, and insect repellent use. The following resources offer detailed information on preventing exposure to ticks and mosquitoes in early care and education settings:

Preventing Tick Bites on People by the Centers for Disease Control and Prevention at http://www.cdc.gov/lyme/prev/on_people.html.
UCSF California Childcare Health Program's (CCHP) Health and Safety Note for child care centers:

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

5.2.8.1 Integrated Pest Management
3.2.2.1 Situations that Require Hand Hygiene
3.4.5.1 Sun Safety Including Sunscreen

REFERENCES

ADDITIONAL REFERENCE:
U.S. Environmental Protection Agency. 2016. Find the insect repellent that is right for you. https://www.epa.gov/insect-repellents/find-insect-repellent-right-you.
Centers for Disease Control and Prevention. 2016. About zika. https://www.cdc.gov/zika/about/index.html.
Centers for Disease Control and Prevention. 2015. Tick removal. https://www.cdc.gov/ticks/removing_a_tick.html.
Centers for Disease Control and Prevention. 2015. Geographic distribution of ticks that bite humans. https://www.cdc.gov/ticks/geographic_distribution.html.
Centers for Disease Control and Prevention. 2016. Avoid bug bites. https://wwwnc.cdc.gov/travel/page/avoid-bug-bites.
Centers for Disease Control and Prevention, Division of Vector-Borne Infectious Diseases. 2015. West nile virus: Insect repellent use and safety. http://www.cdc.gov/westnile/faq/repellent.html.
Center for Disease Control and Prevention. 2015. Chapter 2 - Protection against mosquitos, ticks, & other anthropods. https://wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-consultation/sun-exposure.
National Pesticide Information Center. 2015. Pesticides and children. http://npic.orst.edu/health/child.html.
Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4^th Edition. Elk Grove Village, IL: American Academy of Pediatrics.
Centers for Disease Control and Prevention, Division of Vector-Borne Infectious Diseases. 2010. Lyme disease: Protect yourself from tick bites.http://www.cdc.gov/ncidod/dvbid/lyme/Prevention/ld_Prevention_Avoid.htm.

NOTES

Content in the STANDARD was modified on 4/5/2017.

Standard 3.5.0.1: Care Plan for Children with Special Health Care Needs

Reader's Note: Children with special health care needs are defined as "...those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally" (1).

Any child who meets these criteria should have a Routine and Emergent Care Plan completed by their primary care provider in their medical home. In addition to the information specified in Standard 9.4.2.4 for the Health Report, there should be:

A list of the child's diagnosis/diagnoses;
Contact information for the primary care provider and any relevant sub-specialists (i.e., endocrinologists, oncologists, etc.);
Medications to be administered on a scheduled basis;
Medications to be administered on an emergent basis with clearly stated parameters, signs, and symptoms that warrant giving the medication written in lay language;
Procedures to be performed;
Allergies;
Dietary modifications required for the health of the child;
Activity modifications;
Environmental modifications;
Stimulus that initiates or precipitates a reaction or series of reactions (triggers) to avoid;
Symptoms for caregiver/teachers to observe;
Behavioral modifications;
Emergency response plans – both if the child has a medical emergency and special factors to consider in programmatic emergency, like a fire;
Suggested special skills training and education for staff.

A template for a Care Plan for children with special health care needs is provided in Appendix O.

The Care Plan should be updated after every hospitalization or significant change in health status of the child. The Care Plan is completed by the primary care provider in the medical home with input from parents/guardians, and it is implemented in the child care setting. The child care health consultant should be involved to assure adequate information, training, and monitoring is available for child care staff.

RATIONALE

Children with special health care needs could have a variety of different problems ranging from asthma, diabetes, cerebral palsy, bleeding disorders, metabolic problems, cystic fibrosis, sickle cell disease, seizure disorder, sensory disorders, autism, severe allergy, immune deficiencies, or many other conditions (2). Some of these conditions require daily treatments and some only require observation for signs of impending illness and ability to respond in a timely manner (3).

COMMENTS

A collaborative approach in which the primary care provider and the parent/guardian complete the Care Plan and the parent/guardian works with the child care staff to implement the plan is helpful. Although it is usually the primary care provider in the medical home completing the Care Plan, sometimes management is shared by specialists, nurse practitioners, and case managers, especially with conditions such as diabetes or sickle cell disease.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.6.3.1 Medication Administration
4.2.0.10 Care for Children with Food Allergies
9.4.2.4 Contents of Child's Primary Care Provider's Assessment
Appendix P: Situations that Require Medical Attention Right Away

REFERENCES

Donoghue, E. A., C. A. Kraft, eds. 2010. Managing chronic health needs in child care and schools: A quick reference guide. Elk Grove Village, IL: American Academy of Pediatrics.
American Association of Nurse Anesthetists. 2003. Creating a latex-safe school for latex-sensitive children. http://www
.anesthesiapatientsafety.com/patients/latex/school.asp.
U.S. Department of Health and Human Services, Health Resources and Services Administration. The national survey of children with special health care needs: Chartbook 2005-2006. http://mchb.hrsa.gov/cshcn05/.
McPherson, M., P. Arango, H. Fox, C. Lauver, M. McManus, P. Newacheck, J. Perrin, J. Shonkoff, B. Strickland. 1998. A new definition of children with special health care needs. Pediatrics 102:137-40.

Standard 3.5.0.2: Caring for Children Who Require Medical Procedures

Content in the STANDARD was modified on 02/27/2020.

Any child enrolled in an early care and education program who requires dietary, activity, environmental, or behavioral modifications or medication regularly or for emergencies should receive a written care plan from his or her primary health care provider or pediatric specialist. This is especially important for children with special health care needs who need procedures while in early care and education programs. Medical procedures requiring a written care plan can include, but are not limited to, instructions about¹

Blood sugar regulations
Postural drainage
Supplemental oxygen
Endotracheal suctioning
Catheterization (unless the child requiring catheterization can perform this function on his or her own)
Medication administration to control seizure activity
Tube feedings
Special medical procedures performed routinely or on an urgent basis

Early care and education staff should consider how the procedure aligns with the child's daily schedule.

The child's primary care provider, medical home (eg, pediatricians and other specialists), or pediatric specialist should provide all medical information, while parents/guardians are responsible for supplying the required equipment necessary to accommodate the child's needs. This care plan should address any special preparation to perform routine and/or urgent procedures (other than those that might be required in an emergency for any typical child, such as cardiopulmonary resuscitation). This care plan should also include instructions for performing the procedure, a description of common and uncommon complications of the procedure, and what to do and who to notify if complications occur.

Caregivers/teachers should not assume care for a child with special health care needs who requires a procedure unless they are comfortable with training they have received and approved for that role by the child care health consultant or consulting primary care provider. Appropriate and sufficient training, consultation, and monitoring of early care and education staff should be provided by a qualified health care professional in accordance with all state practice acts and local, state, and other applicable laws. Facilities should follow state laws where such laws require registered nurses, or licensed practical nurses under supervision of a registered nurse, to perform certain medical procedures. Updated, written medical orders are required for these procedures.

If possible, parents/guardians should be present and take part in any training required for accommodating needs of their child in the early care and education program. Parents/guardians know their child best and should be encouraged to establish a relationship with their child's caregivers/teachers and communicate information about the child's tolerance of the procedures, normal reactions, and complications/issues they have encountered.

Communication among parents/guardians, the early care and education program, and the primary care provider (medical home) requires the free exchange of protected medical information.^1(p30–31) Confidentiality should be maintained at each step in compliance with any laws or regulations that are pertinent to all parties, such as the Family Educational Rights and Privacy Act (commonly known as FERPA) and/or the Health Insurance Portability and Accountability Act (commonly known as HIPAA).^1(p23–24)

RATIONALE

Special health care needs that require specialized procedures are common among children, with their specific needs varying with age, abilities, and increasing independence.^1(p3) Children with special health care needs, and their families, require assistance to maintain health, well-being, and quality of life while in out-of-home care. Another goal of implementing these special health care procedures is to maximize the inclusion of children in all program- or school-related activities.

The specialized skills required to implement these procedures are not traditionally taught to early childhood caregivers/teachers or educational assistants as part of their academic or practical experience. Skilled nursing care may be necessary in some circumstances.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

1.6.0.1 Child Care Health Consultants
1.4.3.1 First Aid and Cardiopulmonary Resuscitation Training for Staff
3.5.0.1 Care Plan for Children with Special Health Care Needs
Appendix O: Care Plan for Children with Special Health Care Needs

REFERENCES

American Academy of Pediatrics. Managing Chronic Health Needs in Child Care and Schools. Donoghue EA, Kraft CA, eds. 2nd ed. Itasca, IL: American Academy of Pediatrics; 2019

NOTES

Content in the STANDARD was modified on 02/27/2020.

Standard 4.2.0.10: Care for Children with Food Allergies

Content in the STANDARD was modified on 11/9/2017.

When children with food allergies attend an early care and education facility, here is what should occur.
a. Each child with a food allergy should have a care plan prepared for the facility by the child's primary health care provider, to include
1. A written list of the food(s) to which the child is allergic and instructions for steps that need to be taken to avoid that food.
2. A detailed treatment plan to be implemented in the event of an allergic reaction, including the names, doses, and methods of administration of any medications that the child should receive in the event of a reaction. The plan should include specific symptoms that would indicate the need to administer one or more medications.

b. Based on the child's care plan, the child's caregivers/teachers should receive training, demonstrate competence in, and implement measures for
1. Preventing exposure to the specific food(s) to which the child is allergic
2. Recognizing the symptoms of an allergic reaction
3. Treating allergic reactions

c. Parents/guardians and staff should arrange for the facility to have the necessary medications, proper storage of such medications, and the equipment and training to manage the child's food allergy while the child is at the early care and education facility.

d. Caregivers/teachers should promptly and properly administer prescribed medications in the event of an allergic reaction according to the instructions in the care plan.

e. The facility should notify parents/guardians immediately of any suspected allergic reactions, the ingestion of the problem food, or contact with the problem food, even if a reaction did not occur.

f. The facility should recommend to the family that the child's primary health care provider be notified if the child has required treatment by the facility for a food allergic reaction.

g. The facility should contact the emergency medical services (EMS) system immediately if the child has any serious allergic reaction and/or whenever epinephrine (eg, EpiPen, EpiPen Jr) has been administered, even if the child appears to have recovered from the allergic reaction.

h. Parents/guardians of all children in the child's class should be advised to avoid any known allergens in class treats or special foods brought into the early care and education setting.

i. Individual child's food allergies should be posted prominently in the classroom where staff can view them and/or wherever food is served.

j. The written child care plan, a mobile phone, and a list of the proper medications for appropriate treatment if the child develops an acute allergic reaction should be routinely carried on field trips or transport out of the early care and education setting.

For all children with a history of anaphylaxis (severe allergic reaction), or for those with peanut and/or tree nut allergy (whether or not they have had anaphylaxis), epinephrine should be readily available. This will usually be provided as a premeasured dose in an auto-injector, such as EpiPen or EpiPen Jr. Specific indications for administration of epinephrine should be provided in the detailed care plan. Within the context of state laws, appropriate personnel should be prepared to administer epinephrine when needed.

Food sharing between children must be prevented by careful supervision and repeated instruction to children about this issue. Exposure may also occur through contact between children or by contact with contaminated surfaces, such as a table on which the food allergen remains after eating. Some children may have an allergic reaction just from being in proximity to the offending food, without actually ingesting it. Such contact should be minimized by washing children's hands and faces and all surfaces that were in contact with food. In addition, reactions may occur when a food is used as part of an art or craft project, such as the use of peanut butter to make a bird feeder or wheat to make modeling compound.

RATIONALE

Food allergy is common, occurring in between 2% and 8% of infants and children (1). Allergic reactions to food can range from mild skin or gastrointestinal symptoms to severe, life-threatening reactions with respiratory and/or cardiovascular compromise. Hospitalizations from food allergy are being reported in increasing numbers, especially among children with asthma who have one or more food sensitivities (2). A major factor in death from anaphylaxis has been a delay in the administration of lifesaving emergency medication, particularly epinephrine (3). Intensive efforts to avoid exposure to the offending food(s) are, therefore, warranted. The maintenance of detailed care plans and the ability to implement such plans for the treatment of reactions are essential for all children with food allergies (4).

COMMENTS

Successful food avoidance requires a cooperative effort that must include the parents/guardians, child, child's primary health care provider, and early care and education staff. In some cases, especially for a child with multiple food allergies, parents/guardians may need to take responsibility for providing all the child's food. In other cases, early care and education staff may be able to provide safe foods as long as they have been fully educated about effective food avoidance.
Effective food avoidance has several facets. Foods can be listed on an ingredient list under a variety of names; for example, milk could be listed as casein, caseinate, whey, and/or lactoglobulin.

Some children with a food allergy will have mild reactions and will only need to avoid the problem food(s). Others will need to have antihistamine or epinephrine available to be used in the event of a reaction.

For more information on food allergies, contact Food Allergy Research & Education (FARE) at www.foodallergy.org.
Some early care and education/school settings require that all foods brought into the classroom are store-bought and in their original packaging so that a list of ingredients is included, to prevent exposure to allergens. However, packaged foods may mistakenly include allergen-type ingredients. Alerts and ingredient recalls can be found on the FARE Web site (5).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.2.0.2 Assessment and Planning of Nutrition for Individual Children
4.2.0.8 Feeding Plans and Dietary Modifications
3.5.0.1 Care Plan for Children with Special Health Care Needs
Appendix P: Situations that Require Medical Attention Right Away

REFERENCES

Wang J, Sicherer SH; American Academy of Pediatrics Section on Allergy and Immunology. Guidance on completing a written allergy and anaphylaxis emergency plan. Pediatrics. 2017;139(3):e20164005
Tsuang A, Demain H, Patrick K, Pistiner M, Wang J. Epinephrine use and training in schools for food-induced anaphylaxis among non-nursing staff. J Allergy Clin Immunol Pract. 2017;5(5):1418–1420.e3
Caffarelli C, Garrubba M, Greco C, Mastrorilli C, Povesi Dascola C. Asthma and food allergy in children: is there a connection or interaction? Front Pediatr. 2016;4:34
Bugden EA, Martinez AK, Greene BZ, Eig K. Safe at School and Ready to Learn: A Comprehensive Policy Guide for Protecting Students with Life-threatening Food Allergies. 2nd ed. Alexandria, VA: National School Boards Association; 2012. http://www.nsba.org/sites/default/files/reports/Safe-at-School-and-Ready-to-Learn.pdf. Accessed September 20, 2017
ADDITIONAL RESOURCES
Centers for Disease Control and Prevention. Healthy schools. Food allergies in schools. https://www.cdc.gov/healthyschools/foodallergies/index.htm. Reviewed May 9, 2017. Accessed September 20, 2017
Centers for Disease Control and Prevention. Voluntary Guidelines for Managing Food Allergies in Schools and Early Care and Education Programs . Washington, DC: US Department of Health and Human Services; 2013. https://www.cdc.gov/healthyschools/foodallergies/pdf/13_243135_A_Food_Allergy_Web_508.pdf. Accessed September 20, 2017
Food Allergy Research & Education. Allergy alerts. https://www.foodallergy.org/alerts. Accessed September 20, 2017

NOTES

Content in the STANDARD was modified on 11/9/2017.

Standard 9.4.1.9: Records of Injury

When an injury occurs in the facility that results in first aid or medical attention for a child or adult, the facility should complete a report form that provides the following information:

Name, sex, and age of the injured person;
Date and time of injury;
Location where injury took place;
Description of how the injury occurred, including who (name, address, and phone number) saw the incident and what they reported, as well as what was reported by the child;
Body part(s) involved;
Description of any consumer product involved;
Name and location of the staff member responsible for supervising the child at the time of the injury;
Actions taken by staff members on behalf of the injured following the injury as well as specifically whether emergency medical services and/or professional dental/medical care was required;
Recommendations of preventive strategies that could be taken to avoid future occurrences of this type of injury;
Name of person who completed the report;
Name, address, and phone number of the facility;
Signature of the parent/guardian of the child injured or signature of the adult injured and the date signature obtained (recommended that the signature be obtained the same day as the injury);
If parent/guardian of child was notified at time of injury;
Documentation that written report was sent home the day of the injury, regardless of parental signature.

Examples of injuries that should be documented include:

Child maltreatment (physical, sexual, emotional, and neglect abuse);
Bites that are continuous in nature, break the skin, left a mark, and cause significant pain;
Falls, burns, broken limbs, tooth loss, other injury;
Motor vehicle injury;
Aggressive/unusual behavior;
Ingestion of non-food substances;
Medication error;
Blows to the head;
Death.

Three copies of the injury report form should be completed. One copy should be given to the child's parent/guardian (or to the injured adult). The second copy should be kept in the child's (or adult's) folder at the facility. A third copy should be kept in a chronologically filed injury log that is analyzed periodically to determine any patterns regarding time of day, equipment, location or supervision issues. This last copy should be kept in the facility for the period required by the state's statute of limitations. If required by state regulations, a copy of an injury report for each injury that required medical attention should be sent to the state licensing agency.

Based on the logs, the facility should plan to take corrective action. Examples of corrective action include: adjusting schedules, removing or limiting the use of equipment, relocating equipment or furnishings, and/or increasing supervision.

RATIONALE

Injury patterns and child abuse and neglect can be discerned from such records and can be used to prevent future problems (1,2). Known data on typical injuries (scanning for hazards, providing direct supervision, etc.) can also how to prevent them. A report form is also necessary for providing information to the child's parents/guardians and primary care provider and other appropriate health or state agencies.

COMMENTS

Caregivers/teachers should report specific products that may have played a role in the injury to the U.S. Consumer Product Safety Commission (CPSC) via their toll-free consumer hotline: 800-638-2772 (TTY 800-638-8270) or online at http://www.cpsc.gov/talk.html. This data helps CPSC respond with needed recalls. Multi-copy forms can be used to make copies of an injury report simultaneously for the child's record, for the parent/guardian, for the folder that logs all injuries at the facility, and for the regulatory agency.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

9.2.4.1 Written Plan and Training for Handling Urgent Medical Care or Threatening Incidents
9.4.1.10 Documentation of Parent/Guardian Notification of Injury, Illness, or Death in Program
9.4.1.11 Review and Accessibility of Injury and Illness Reports
Appendix DD: Injury Report Form for Indoor and Outdoor Injuries
Appendix EE: America's Playgrounds Safety Report Card
Appendix KK: Authorization for Emergency Medical/Dental Care
Appendix CC: Incident Report Form

REFERENCES

ChildCare.net. Incident reports. http://www.childcare.net/library/incidentreports.shtml.
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.

C. Cleaning/Sanitizing/Disinfecting Practices

Standard 3.2.3.1: Procedure for Nasal Secretions and Use of Nasal Bulb Syringes

Staff members and children should blow or wipe their noses with disposable, single use tissues and then discard them in a plastic-lined, covered, hands-free trash container. After blowing the nose, they should practice hand hygiene, as specified in Standards 3.2.2.1 and 3.2.2.2.

Use of nasal bulb syringes is permitted. Nasal bulb syringes should be provided by the parents/guardians for individual use and should be labeled with the child's name.

If nasal bulb syringes are used, facilities should have a written policy that indicates:

Rationale and protocols for use of nasal bulb syringes;
Written permission and any instructions or preferences from the child's parent/guardian;
Staff should inspect each nasal bulb syringe for tears or cracks (and to see if there is unknown fluid in the nasal bulb syringe) before each use;
Nasal bulb syringes should be cleaned with warm soapy water and stored open to air.

RATIONALE

Hand hygiene is the most effective way to reduce the spread of infection (1,2).

TYPE OF FACILITY

Center, Early Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.2.2.3 Assisting Children with Hand Hygiene

REFERENCES

American Academy of Pediatrics. Out-of-home child care, infection control and prevention In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases . 31st Edition. Itasca, IL: American Academy of Pediatrics; 2018: 125-136, 122-125, 124t
American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 5th ed. Itasca, IL: American Academy of Pediatrics; 2020.20.

Standard 3.3.0.1: Routine Cleaning, Sanitizing, and Disinfecting

Keeping objects and surfaces in a child care setting as clean and free of pathogens as possible requires a combination of:

Frequent cleaning; and
When necessary, an application of a sanitizer or disinfectant.

Facilities should follow a routine schedule of cleaning, sanitizing, and disinfecting as outlined in Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting.

Cleaning, sanitizing and disinfecting products should not be used in close proximity to children, and adequate ventilation should be maintained during any cleaning, sanitizing or disinfecting procedure to prevent children and caregivers/teachers from inhaling potentially toxic fumes.

RATIONALE

Young children sneeze, cough, drool, use diapers and are just learning to use the toilet. They hug, kiss, and touch everything and put objects in their mouths. Illnesses may be spread in a variety of ways, such as by coughing, sneezing, direct skin-to-skin contact, or touching a contaminated object or surface. Respiratory tract secretions that can contain viruses (including respiratory syncytial virus and rhinovirus) contaminate environmental surfaces and may present an opportunity for infection by contact (1-3).

COMMENTS

The terms cleaning, sanitizing and disinfecting are sometimes used interchangeably which can lead to confusion and result in cleaning procedures that are not effective (4).

Task	Purpose
Clean	To remove dirt and debris by scrubbing and washing with a detergent solution and rinsing with water. The friction of cleaning removes most germs and exposes any remaining germs to the effects of a sanitizer or disinfectant used later.
Sanitize	To reduce germs on inanimate surfaces to levels considered safe by public health codes or regulations.
Disinfect	To destroy or inactivate most germs on any inanimate object, but not bacterial spores.

Note: The term "germs" refers to bacteria, viruses, fungi and molds that may cause infectious disease. Bacterial spores are dormant bacteria that have formed a protective shell, enabling them to survive extreme conditions for years. The spores reactivate after entry into a host (such as a person), where conditions are favorable for them to live and reproduce (5).

Only U.S. Environmental Protection Agency (EPA)-registered products that have an EPA registration number on the label can make public health claims that can be relied on for reducing or destroying germs. The EPA registration label will also describe the product as a cleaner, sanitizer, or disinfectant. In addition, some manufacturers of cleaningproducts have developed "green cleaning products". As new environmentally-friendly cleaning products appear in the market, check to see if they are 3rd party certified by Green Seal: http://www.greenseal.org, UL/EcoLogic: http://www.ecologo.org, and/or EPA's Safer Choice: http://www.epa.gov/saferchoice. Use fragrance-free bleach that is EPA-registered as a sanitizing or disinfecting solution (6). If other products are used for sanitizing or disinfecting, they should also be fragrance-free and EPA-registered (5). All products must be used according to manufacturer's instructions. The following resource may be useful: Green Cleaning, Sanitizing, and Disinfecting: A Toolkit for Early Care and Education.

Employers should provide staff with hazard information, including access to and review of the Safety Data Sheets (SDS) as required by the Occupational Safety and Health Administration (OSHA), about the presence of toxic substances such as, cleaning, sanitizing and disinfecting supplies in use in the facility. The SDS explain the risk of exposure to products so that appropriate precautions may be taken.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

5.2.1.6 Ventilation to Control Odors
3.3.0.2 Cleaning and Sanitizing Toys
3.3.0.3 Cleaning and Sanitizing Objects Intended for the Mouth
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting
Appendix J: Selecting an Appropriate Sanitizer or Disinfectant

REFERENCES

Butz, A. M., P. Fosarelli, D. Dick, et al. 1993. Prevalence of rotavirus on high-risk fomites in day-care facilities. Pediatrics 92:202-5.
Thompson, S. C. 1994. Infectious diarrhoea in children: Controlling transmission in the child care setting. J Paediatric Child Health 30:210-19.
Children's Environmental Health Network 2016. Household chemicals. http://cehn.org/wp-content/uploads/2015/12/Household_chemicals_1_16.pdf.
Children's Environmental Health Network Fragrances. Retrieved from: http://www.cehn.org/our-work/eco-healthy-child-care/ehcc-faqs/fragrances/.
U.S. Centers for Disease Control and Prevention. 2014. How to clean and disinfect schools to help slow the spread of flu. http://www.cdc.gov/flu/school/cleaning.htm Microbiology Procedure. Sporulation in bacteria. http://www.microbiologyprocedure.com/microorganisms/sporulation-in-bacteria.htm.
D. Leduc, eds. 2015.Well beings: A guide to health in child care. 3rd ed. (revised) Ottawa, Ontario: Canadian Paediatric Society.

Standard 3.3.0.2: Cleaning and Sanitizing Toys

Frequently Asked Questions/CFOC Clarifications

Reference: 3.3.0.2

Date: 11/7/2012

Topic & Location:
Chapter 3
Health Promotion
Standard 3.3.0.2: Cleaning and Sanitizing Toys

Question:
This standard states that plastic toys can be cleaned in a dishwasher but the Children's Environmental Health Network/Eco-Healthy Child Care generally discourages programs from exposing plastics to heat, including heated dishwashers, due to the potential risk of exposure to harmful chemicals in plastics, which could include toys that are frequently mouthed by children. What's your take on this issue considering that CFOCStandard 5.2.9.9: Plastic Containers and Toys also includes a standard on plastics, which states, "Do not place plastics in the dishwasher"?

Answer:

BPA, phthalates, and other additives may leach from a plastic toy while being exposed to the heat of a mechanical dishwasher. Hence, the reason standard 5.2.9.9 states that following the guideline of not placing plastics in the dishwasher "may reduce exposure to phthalates and BPA."

However, there is no evidence available to either support or refute the use of a mechanical dishwasher to clean, rinse, and sanitize toys. To best limit exposure to toxins, caregivers/teachers should follow the cleaning instructions provided by the toy's manufacturer, while also following their local regulations.

Toys that cannot be cleaned and sanitized should not be used. Toys that children have placed in their mouths or that are otherwise contaminated by body secretion or excretion should be set aside until they are cleaned by hand with water and detergent, rinsed, sanitized, and air-dried or in a mechanical dishwasher that meets the requirements of Standard 4.9.0.11 through Standard 4.9.0.13. Play with plastic or play foods, play dishes and utensils, should be closely supervised to prevent shared mouthing of these toys.

Machine washable cloth toys should be used by one individual at a time. These toys should be laundered before being used by another child.

Grenier, D., D. Leduc, eds. 2008. Preventing infections. In Well beings. 3rd ed. Ottawa, Ontario: Canadian Paediatric Society.

Standard 4.3.1.1: General Plan for Feeding Infants

Content in the STANDARD was modified on 05/30/2018.

RATIONALE

COMMENTS

The ways to help a mother breastfeed successfully in the early care and education facility are (2,6,8):

If she wishes to breastfeed her infant or child when she comes to the facility, offer or provide her a
1. Quiet, comfortable, and private place to breastfeed (This helps her milk to let down.)
2. Place to wash her and her infant's hands before and after breastfeeding
3. Pillow to support her infant on her lap while nursing
4. Nursing stool or step stool for her feet so she doesn't have to strain her back while nursing
5. Glass of water or other liquid to help her stay hydrated
Encourage her to get the infant used to being fed her expressed human milk by another person before the infant starts in early care and education, while continuing to breastfeed directly herself.
Discuss with her the infant's usual feeding pattern and the benefits of feeding the infant based on the infant's hunger and satiety cues rather than on a schedule; ask her if she wishes to time the infant's last feeding so that the infant is hungry and ready to breastfeed when she arrives; and ask her to leave her availability schedule with the early care and education program as well as to call if she is planning to miss a feeding or is going to be late.
Encourage her to provide a backup supply of frozen or refrigerated expressed human milk; properly label the infant's full name, date, and time on the bottle or other clean storage container in case the infant needs to eat more often than usual or the mother's visit is delayed.
Share with her information about other places or people in the community who can answer her questions and concerns about breastfeeding, such as local lactation consultants.
1. Provide culturally appropriate breastfeeding materials, including community resources for parents/guardians that include appropriate language and pictures of multicultural families to assist families in identifying with them.
Ensure that all staff receive training in breastfeeding support and promotion.
Ensure that all staff are trained in the proper handling, storing, and feeding of each milk product, including human milk or infant formula.

Additional Resources

Breastfeeding, US Department of Health and Human Services Office on Women's Health ( https://www.womenshealth.gov/printables-and-shareables/health-topic/breastfeeding)
Feeding Infants: A Guide for Use in the Child Nutrition Programs, US Department of Agriculture (USDA) Food and Nutrition Service (https://wicworks.fns.usda.gov/wicworks/Topics/FG/CompleteIFG.pdf)
Infant Meal Pattern, USDA ( https://fns-prod.azureedge.net/sites/default/files/cacfp/CACFP_infantmealpattern.pdf)
Strategy 6, Support for Breastfeeding in Early Care and Education, Centers for Disease Control and Prevention ( https://www.cdc.gov/breastfeeding/pdf/strategy6-support-breastfeeding-early-care.pdf)
Updated Child and Adult Care Food Program Meal Patterns: Infant Meals, USDA (https://fns-prod.azureedge.net/sites/default/files/cacfp/CACFP_InfantMealPattern_FactSheet_V2.pdf)

TYPE OF FACILITY

Center, Early Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

REFERENCES

Binns C, Lee M, Low WY. The long-term public health benefits of breastfeeding. Asia Pac J Public Health. 2016;28(1):7–14
Gibbs BG, Forste R. Breastfeeding, parenting, and early cognitive development. J Pediatr. 2014;164(3):487–493
American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827–e841
Furman L. Breastfeeding: what do we know, and where do we go from here? Pediatrics. 2017;139(4):e20170150
Healthy People 2020. Maternal, infant, and child health. HealthyPeople.gov Web site. https://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-child-health/objectives. Accessed January 11, 2018
Darmawikarta D, Chen Y, Lebovic G, Birken CS, Parkin PC, Maguire JL. Total duration of breastfeeding, vitamin D supplementation, and serum levels of 25-hydroxyvitamin D. Am J Public Health. 2016;106(4):714–719
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); US Department of Agriculture Food and Nutrition Service. Breastfeeding Policy and Guidance. https://www.fns.usda.gov/sites/default/files/wic/WIC-Breastfeeding-Policy-and-Guidance.pdf. Published July 2016. Accessed January 11, 2018
Centers for Disease Control and Prevention. Strategies to Prevent Obesity and Other Chronic Diseases: The CDC Guide to Strategies to Support Breastfeeding Mothers and Babies. Atlanta, GA: US Department of Health and Human Services; 2013. http://www.cdc.gov/breastfeeding/pdf/BF-Guide-508.pdf. Accessed January 11, 2018
Danawi H, Estrada L, Hasbini T, Wilson DR. Health inequalities and breastfeeding in the United States of America. Int J Childbirth Educ. 2016;31(1)

NOTES

Content in the STANDARD was modified on 05/30/2018.

Standard 5.4.2.6: Maintenance of Changing Tables

Changing tables should be nonporous, kept in good repair, and cleaned and disinfected after each use to remove visible soil and germs.

RATIONALE

Many infectious diseases can be prevented through appropriate cleaning and disinfection procedures. It is difficult, if not impossible, to disinfect porous surfaces, broken edges, and surfaces that cannot be completely cleaned. Bacterial cultures of environmental surfaces in child care facilities have shown fecal contamination, which has been used to gauge the adequacy of sanitation and hygiene measures practiced at the facility (1).

One study has demonstrated that "diapering, handwashing, and food preparation equipment that is specifically designed to reduce the spread of infectious agents significantly reduced diarrheal illness among the children and absence as a result of illness among staff in out-of-home child care centers" (2).

COMMENTS

Caregivers/teachers should be reminded that many disinfectants leave residues that can cause skin irritation or other symptoms. Caregivers/teachers should always follow the manufacturer's instructions for preparation and use.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting

REFERENCES

Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015.Red book: 2015 report to the committee of infectious diseases.30^th Ed. Elk Grove Village, IL: American Academy of Pediatrics.
Kotch, J. B., P. Isbell, D. J. Weber, V. Nguyen, E. Gunn, S. Fowlkes, J. Virk, J. Allen. 2007. Hand-washing and diapering equipment reduces disease among children in out-of-home child care centers.Pediatrics120: e29-e36.

Standard 9.2.3.10: Sanitation Policies and Procedures

The child care facility should have written sanitation policies and procedures for the following items:

Maintaining equipment used for hand hygiene, toilet use, and toilet learning/training in a sanitary condition;
Maintaining diaper changing areas and equipment in a sanitary condition;
Maintaining toys in a sanitary condition;
Managing animals in a safe and sanitary manner;
Practicing proper handwashing and diapering procedures (the facility should display proper handwashing instruction signs conspicuously);
Practicing proper personal hygiene of caregivers/teachers and children;
Practicing environmental sanitation policies and procedures, such as sanitary disposal of soiled diapers;
Maintaining sanitation for food preparation and food service.

RATIONALE

Many infectious diseases can be prevented through appropriate hygiene and sanitation practices. Bacterial cultures of environmental surfaces in facilities, which are used to gauge the adequacy of sanitation and hygiene practices, have demonstrated evidence of fecal contamination. Contamination of hands, toys, and other equipment in the room has appeared to play a role in the transmission of diseases in child care settings (1). Regular and thorough cleaning of toys, equipment, and rooms helps to prevent transmission of illness (1).

Animals can be a source of illness for people, and people may be a source of illness for animals (1).

The steps involved in effective handwashing (to reduce the amount of bacterial contamination) can be easily forgotten. Posted signs provide frequent reminders to staff and orientation for new staff. Education of caregivers/teachers regarding handwashing, cleaning, and other sanitation procedures can reduce the occurrence of illness in the group of children with whom they work (2).

Illnesses may be spread by way of:

Human waste (such as urine and feces);
Body fluids (such as saliva, nasal discharge, eye discharge, open skin sores, and blood);
Direct skin-to-skin contact;
Touching a contaminated object;
The air (by droplets that result from sneezes and coughs).

Since many infected people carry communicable diseases without symptoms, and many are contagious before they experience a symptom, caregivers/teachers need to protect themselves and the children they serve by carrying out, on a routine basis, standard precautions and sanitation procedures that approach every potential illness-spreading condition in the same way.

Handling food in a safe and careful manner prevents the spread of bacteria, viruses, and fungi. Outbreaks of foodborne illness have occurred in many settings, including child care facilities.

COMMENTS

State health department rules and regulations may also guide the child care provider.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

5.4.1.1 General Requirements for Toilet and Handwashing Areas
5.4.1.4 Preventing Entry to Toilet Rooms by Infants and Toddlers
5.4.1.6 Ratios of Toilets, Urinals, and Hand Sinks to Children
5.4.1.7 Toilet Learning/Training Equipment
5.4.2.1 Diaper Changing Tables
5.4.2.4 Use, Location, and Setup of Diaper Changing Areas
5.4.2.5 Changing Table Requirements
5.4.1.10 Handwashing Sinks
5.4.1.11 Prohibited Uses of Handwashing Sinks
5.4.2.2 Handwashing Sinks for Diaper Changing Areas in Centers
5.4.2.3 Handwashing Sinks for Diaper Changing Areas in Homes
4.8.0.1 Food Preparation Area
4.8.0.8 Microwave Ovens
4.8.0.4 Food Preparation Sinks
4.9.0.2 Staff Restricted from Food Preparation and Handling
4.9.0.3 Precautions for a Safe Food Supply
3.2.1.1 Type of Diapers Worn
3.2.1.2 Handling Cloth Diapers
3.2.1.3 Checking For the Need to Change Diapers
3.2.1.4 Diaper Changing Procedure
3.2.1.5 Procedure for Changing Children's Soiled Underwear, Disposable Training Pants and Clothing
3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.2.2.3 Assisting Children with Hand Hygiene
3.2.2.5 Hand Sanitizers
3.3.0.2 Cleaning and Sanitizing Toys
3.3.0.3 Cleaning and Sanitizing Objects Intended for the Mouth
5.4.2.6 Maintenance of Changing Tables
3.2.2.4 Training and Monitoring for Hand Hygiene
3.4.2.1 Animals that Might Have Contact with Children and Adults
3.4.2.2 Prohibited Animals
3.4.2.3 Care for Animals
4.8.0.2 Design of Food Service Equipment
4.8.0.3 Maintenance of Food Service Surfaces and Equipment
4.8.0.5 Handwashing Sink Separate from Food Zones
4.8.0.6 Maintaining Safe Food Temperatures
4.8.0.7 Ventilation Over Cooking Surfaces
4.9.0.1 Compliance with U.S. Food and Drug Administration Food Sanitation Standards, State and Local Rules
4.9.0.4 Leftovers
4.9.0.5 Preparation for and Storage of Food in the Refrigerator
4.9.0.6 Storage of Foods Not Requiring Refrigeration
4.9.0.7 Storage of Dry Bulk Foods
4.9.0.9 Cleaning Food Areas and Equipment
4.9.0.10 Cutting Boards
4.9.0.11 Dishwashing in Centers
4.9.0.12 Dishwashing in Small and Large Family Child Care Homes
4.9.0.13 Method for Washing Dishes by Hand
5.4.1.2 Location of Toilets and Privacy Issues
5.4.1.3 Ability to Open Toilet Room Doors
5.4.1.5 Chemical Toilets
5.4.1.8 Cleaning and Disinfecting Toileting Equipment
5.4.1.9 Waste Receptacles in the Child Care Facility and in Child Care Facility Toilet Room(s)
5.4.1.12 Mop Sinks
5.4.3.1 Ratio and Location of Bathtubs and Showers
5.4.3.2 Safety of Bathtubs and Showers
5.7.0.6 Storage Area Maintenance and Ventilation
5.7.0.7 Structure Maintenance
5.7.0.8 Electrical Fixtures and Outlets Maintenance
5.7.0.9 Plumbing and Gas Maintenance
5.7.0.10 Cleaning of Humidifiers and Related Equipment
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting

REFERENCES

Kotch, J., P. Isbell, D. J. Weber, et al. 2007. Hand-washing and diapering equipment reduces disease among children in out-of-home child care centers. Pediatrics 120:e29-36.
Chin, J., ed. 2000. Control of communicable diseases manual. Washington, DC: American Public Health Association.

Infection Control/Disease Prevention and Management

Standard 3.1.1.1: Conduct of Daily Health Check

Every day, a trained staff member should conduct a health check of each child. This health check should be conducted as soon as possible after the child enters the child care facility and whenever a change in the child's behavior or appearance is noted while that child is in care. The health check should address:

Reported or observed illness or injury affecting the child or family members since the last date of attendance;
Reported or observed changes in behavior of the child (such as lethargy or irritability) or in the appearance (e.g., sad) of the child from the previous day at home or the previous day's attendance at child care;
Skin rashes, impetigo, itching or scratching of the skin, itching or scratching of the scalp, or the presence of one or more live crawling lice;
A temperature check if the child appears ill (a daily screening temperature check is not recommended);
Other signs or symptoms of illness and injury (such as drainage from eyes, vomiting, diarrhea, cuts/lacerations, pain, or feeling ill).

The caregiver/teacher should gain information necessary to complete the daily health check by direct observation of the child, by querying the parent/guardian, and, where applicable, by conversation with the child.

RATIONALE

Daily health checks seek to identify potential concerns about a child's health including recent illness or injury in the child and the family. Health checks may serve to reduce the transmission of infectious diseases in child care settings by identifying children who should be excluded, and enable the caregivers/teachers to plan for necessary care while the child is in care at the facility.

COMMENTS

The daily health check should be performed in a relaxed and comfortable manner that respects the family's culture as well as the child's body and feelings. The child care health consultant should train the caregiver/teacher(s) in conducting a health check. The items in the standard can serve as a checklist to guide learning the procedure until it becomes routine.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

1.6.0.1 Child Care Health Consultants
3.6.1.1 Inclusion/Exclusion/Dismissal of Children
Appendix F: Enrollment/Attendance/Symptom Record

Standard 3.2.3.4: Prevention of Exposure to Blood and Body Fluids

Child care facilities should adopt the use of Standard Precautions developed for use in hospitals by The Centers for Disease Control and Prevention (CDC). Standard Precautions should be used to handle potential exposure to blood, including blood-containing body fluids and tissue discharges, and to handle other potentially infectious fluids.

In child care settings:

Use of disposable gloves is optional unless blood or blood containing body fluids may contact hands. Gloves are not required for feeding human milk, cleaning up of spills of human milk, or for diapering;
Gowns and masks are not required;
Barriers to prevent contact with body fluids include moisture-resistant disposable diaper table paper, disposable gloves, and eye protection.

Caregivers/teachers are required to be educated regarding Standard Precautions to prevent transmission of bloodborne pathogens before beginning to work in the facility and at least annually thereafter. Training must comply with requirements of the Occupational Safety and Health Administration (OSHA).

Procedures for Standard Precautions should include:

Surfaces that may come in contact with potentially infectious body fluids must be disposable or of a material that can be disinfected. Use of materials that can be sterilized is not required.
The staff should use barriers and techniques that:
1. Minimize potential contact of mucous membranes or openings in skin to blood or other potentially infectious body fluids and tissue discharges; and
2. Reduce the spread of infectious material within the child care facility. Such techniques include avoiding touching surfaces with potentially contaminated materials unless those surfaces are disinfected before further contact occurs with them by other objects or individuals.
When spills of body fluids, urine, feces, blood, saliva, nasal discharge, eye discharge, injury or tissue discharges occur, these spills should be cleaned up immediately, and further managed as follows:
1. For spills of vomit, urine, and feces, all floors, walls, bathrooms, tabletops, toys, furnishings and play equipment, kitchen counter tops, and diaper-changing tables in contact should be cleaned and disinfected as for the procedure for diaper changing tables in Standard 3.2.1.4, Step 7;
2. For spills of blood or other potentially infectious body fluids, including injury and tissue discharges, the area should be cleaned and disinfected. Care should be taken and eye protection used to avoid splashing any contaminated materials onto any mucus membrane (eyes, nose, mouth);
3. Blood-contaminated material and diapers should be disposed of in a plastic bag with a secure tie;
4. Floors, rugs, and carpeting that have been contaminated by body fluids should be cleaned by blotting to remove the fluid as quickly as possible, then disinfected by spot-cleaning with a detergent-disinfectant. Additional cleaning by shampooing or steam cleaning the contaminated surface may be necessary. Caregivers/teachers should consult with local health departments for additional guidance on cleaning contaminated floors, rugs, and carpeting.

Prior to using a disinfectant, clean the surface with a detergent and rinse well with water. Facilities should follow the manufacturer's instruction for preparation and use of disinfectant (3,4). For guidance on disinfectants, refer to Appendix J, Selecting an Appropriate Sanitizer or Disinfectant.

If blood or bodily fluids enter a mucous membrane (eyes, nose, mouth) the following procedure should occur. Flush the exposed area thoroughly with water. The goal of washing or flushing is to reduce the amount of the pathogen to which an exposed individual has contact. The optimal length of time for washing or flushing an exposed area is not known. Standard practice for managing mucous membrane(s) exposures to toxic substances is to flush the affected area for at least fifteen to twenty minutes. In the absence of data to support the effectiveness of shorter periods of flushing it seems prudent to use the same fifteen to twenty minute standard following exposure to bloodborne pathogens (5).

RATIONALE

Some children and adults may unknowingly be infected with HIV or other infectious agents, such as hepatitis B virus, as these agents may be present in blood or body fluids. Thus, the staff in all facilities should adopt Standard Precautions for all blood spills. Bacteria and viruses carried in the blood, such as hepatitis B, pose a small but specific risk in the child care setting (3). Blood and body fluids containing blood (such as watery discharges from injuries) pose a potential risk, because bloody body fluids contain the highest concentration of viruses. In addition, hepatitis B virus can survive in a dried state in the environment for at least a week and perhaps even longer. Some other body fluids such as saliva contaminated with blood or blood-associated fluids may contain live virus (such as hepatitis B virus) but at lower concentrations than are found in blood itself. Other body fluids, including urine and feces, do not pose a risk for bloodborne infections unless they are visibly contaminated with blood, although these fluids may pose a risk for transmission of other infectious diseases.

Touching a contaminated object or surface may spread illnesses. Many types of infectious germs may be contained in human waste (urine, feces) and body fluids (saliva, nasal discharge, tissue and injury discharges, eye discharges, blood, and vomit). Because many infected people carry infectious diseases without having symptoms, and many are contagious before they experience a symptom, staff members need to protect themselves and the children they serve by adhering to Standard Precautions for all activities.

Gloves have proven to be effective in preventing transmission of many infectious diseases to health care workers. Gloves are used mainly when people knowingly contact or suspect they may contact blood or blood-containing body fluids, including blood-containing tissue or injury discharges. These fluids may contain the viruses that transmit HIV, hepatitis B, and hepatitis C. While human milk can be contaminated with blood from a cracked nipple, the risk of transmission of infection to caregivers/teachers who are feeding expressed human milk is almost negligible and this represents a theoretical risk. Wearing of gloves to feed or clean up spills of expressed human milk is unnecessary, but caregivers/teachers should avoid getting expressed human milk on their hands, if they have any open skin or sores on their hands. If caregivers/teachers have open wounds they should be protected by waterproof bandages or disposable gloves.

Cleaning and disinfecting rugs and carpeting that have been contaminated by body fluids is challenging. Extracting as much of the contaminating material as possible before it penetrates the surface to lower layers helps to minimize this challenge. Cleaning and disinfecting the surface without damaging it requires use of special cleaning agents designed for use on rugs, or steam cleaning (3). Therefore, alternatives to the use of carpeting and rugs are favored in the child care environment.

COMMENTS

The sanctions for failing to comply with OSHA requirements can be costly, both in fines and in health consequences. Regional offices of OSHA are listed at http://www.epa.gov/aboutepa/index.html#regional/ and in the telephone directory with other federal offices.

Use non-latex gloves for activities that are not likely to involve contact with infectious materials (food preparation, diapering, routine housekeeping, general maintenance, etc.);
Use appropriate barrier protection when handling infectious materials. Avoid using latex gloves BUT if latex gloves are chosen, use powder-free gloves with reduced protein content;
1. Such gloves reduce exposures to latex protein and thus reduce the risk of latex allergy;
2. Hypoallergenic latex gloves do not reduce the risk of latex allergy. However, they may reduce reactions to chemical additives in the latex (allergic contact dermatitis);
Use appropriate work practices to reduce the chance of reactions to latex;
When wearing latex gloves, do not use oil-based hand creams or lotions (which can cause glove deterioration);
After removing latex gloves, wash hands with a mild soap and dry thoroughly;
Practice good housekeeping, frequently clean areas and equipment contaminated with latex-containing dust;
Attend all latex allergy training provided by the facility and become familiar with procedures for preventing latex allergy;
Learn to recognize the symptoms of latex allergy: skin rash; hives; flushing; itching; nasal, eye, or sinus symptoms; asthma; and (rarely) shock.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.2.1.4 Diaper Changing Procedure
7.6.1.3 Staff Education on Prevention of Bloodborne Diseases
Appendix D: Gloving
Appendix L: Cleaning Up Body Fluids

REFERENCES

Email communication from Amy V. Kindrick, MD, MPH, Senior Consultant, National Clinicians' Post-Exposure Prophylaxis Hotline (PEPline), UCSF School of Medicine at San Francisco General Hospital to Elisabeth L.M. Miller, BSN, RN, BC, PA Chapter American Academy of Pediatrics, Early Childhood Education Linkage System – Healthy Child Care Pennsylvania. November 11, 2009.
Rutala, W. A., D. J. Weber, HICPAC. 2008. Guideline for disinfection and sterilization in healthcare facilities. Center for Disease Control and Prevention. https://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf.
Kotch, J. B., P. Isbell, D. J. Weber, et al. 2007. Hand-washing and diapering equipment reduces disease among children in out-of-home child care centers. Pediatrics 120: e29-e36.
Siegel, J. D., E. Rhinehart, M. Jackson, L. Chiarello, Healthcare Infection Control Practices Advisory Committee. 2007. 2007 Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. http://www.cdc.gov/hicpac/pdf/Isolation/Isolation2007.pdf.
De Queiroz, M., S. Combet, J. Berard, A. Pouyau, H. Genest, P. Mouriquand, D. Chassard. 2009. Latex allergy in children: Modalities and prevention. Pediatric Anesthesia 19:313-19.
American Latex Allergy Association. Creating a safe school for latex-sensitive children. 1996-2016. http://latexallergyresources.org/articles/web-article-creating-safe-school-latex-sensitive-children.

Standard 3.6.1.1: Inclusion/Exclusion/Dismissal of Children

Content in the STANDARD was modified 04/16/2015, 8/2015, 4/4/2017 and 5/21/2019.

Adapted from American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. Elk Grove Village, IL: American Academy of Pediatrics; 2017:43–48.

Preparing for Managing Illness

Caregivers/teachers should

With a child care health consultant, develop protocols and procedures for handling children's illnesses, including care plans and an inclusion/exclusion policy.
Review with all families the inclusion/exclusion criteria. Clarify that the program staff (not the families) will make the final decision about whether children who are ill may attend. The decision will be based on the program's inclusion/exclusion criteria and the staff's ability to care for the child who is ill without compromising the care of other children in the program.
Encourage all families to have a backup plan for child care in the event of short- or long-term exclusion.
Consider 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.
Require, if necessary, a primary health care provider's note to readmit a child to determine whether the child is a health risk to others or if guidance is needed about any special care the child requires.

Daily health checks, as described in Standard 3.1.1.1 , should be performed on 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 health care provider visit before reentering care.

Conditions/Symptoms That Do Not Require Exclusion

Common colds, runny noses (regardless of color or consistency of nasal discharge).
A cough not associated with fever, rapid or difficult breathing, wheezing, or cyanosis (blueness of skin or mucous membranes).
Pinkeye (bacterial conjunctivitis) indicated by pink or red conjunctiva with white or yellow eye mucous drainage and matted eyelids after sleep. This may be thought of as a cold in the eye. Exclusion is no longer required for this condition. Health care professionals may vary on whether or not to treat pinkeye with antibiotic drops. The role of antibiotics in treatment and preventing spread of conjunctivitis is unclear. Most children with pinkeye get better after 5 or 6 days without antibiotics. Parents/guardians should discuss care of this condition with their child's primary health care provider and follow the primary health care provider's advice. Some primary health 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 no treatment is provided, the child should be allowed to remain in care. If the child's eye is painful, a health care professional should examine the child. If 2 or more children in a group develop pinkeye in the same period, the program should seek advice from the program's health consultant or a public health agency.
Watery, yellow or white discharge or crusting eye discharge without fever, eye pain, or eyelid redness.
Yellow or white eye drainage that is not associated with pink or red conjunctiva (ie, the whites of the eyes).
Fever without any signs or symptoms of illness in infants and children who are older than 4 months regardless of whether acetaminophen or ibuprofen was given. For this purpose, fever is defined as temperature above 101°F (38.3°C) by any method. These temperature readings do not require adjustment for the location where they are made. They are simply reported with the temperature and the location, as in "101°F in the armpit/axilla."

Fever 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, the child should be monitored but does not need to be excluded for fever alone. For example, an infant with a fever after an immunization who is behaving normally does not require exclusion.

Rash without fever and behavioral changes. Exception: Call EMS (911) for rapidly spreading bruising or small blood spots under the skin.
Impetigo lesions should be covered, but treatment may be delayed until the end of the day. As long as treatment is started before return the next day, no exclusion is needed.
Lice or nits treatment may be delayed until the end of the day. As long as treatment is started before returning the next day, no exclusion is needed.
Ringworm treatment may be delayed until the end of the day. As long as treatment is started before returning the next day, no exclusion is needed.
Scabies treatment may be delayed until the end of the day. As long as treatment is started before returning the next day, no exclusion is needed.
Molluscum contagiosum (does not require covering of lesions).
Thrush (ie, white spots or patches in the mouth or on the cheeks or gums).
Fifth disease (slapped cheek disease, parvovirus B19) once the rash has appeared.
Methicillin-resistant Staphylococcus aureus (MRSA) without an infection or illness that would otherwise require exclusion. Known MRSA carriers or colonized individuals should not be excluded.
Cytomegalovirus infection.
Chronic hepatitis B infection.
HIV infection.
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.
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.

Written notes should not be required for return to ECE for common respiratory illnesses that are not specifically listed in the excludable condition list.

Key Criteria for Exclusion of Children Who Are Ill

When a child becomes ill but does not require immediate medical help, a determination should be made regarding whether the child should be sent home (ie, should be temporarily excluded from child care). Most illnesses do not require exclusion. The caregiver/teacher should determine if the illness

Prevents the child from participating comfortably in activities
Results in a need for care that is greater than the staff can provide without compromising the health and safety of other children
Poses a risk of spread of harmful diseases to others

If any of these criteria are met, the child should be excluded, regardless of the type of illness. Decisions about providing care that is comfortable for the child while awaiting parent/guardian pickup should be made on a case-by-case basis, considering factors such as the child's age, surroundings, potential risk to others, and type and severity of symptoms the child is exhibiting. The child should be supervised by someone who knows the child well and who will continue to observe the child for new or worsening symptoms. If symptoms allow the child to remain in his or her usual care setting while awaiting pickup, the child should be separated from other children by at least 3 feet until the child leaves to help minimize exposure of staff and children who were not previously in close contact with the child. All who have been in contact with the ill child should wash their hands. Toys, equipment, and surfaces used by the ill child should be cleaned and disinfected after the child leaves.

Temporary exclusion is recommended when the child has any of the following conditions:

The illness prevents the child from participating comfortably in activities.
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.
A severely ill appearance—this could include lethargy/lack of responsiveness, irritability, persistent crying, difficult breathing, or having a quickly spreading rash.
Fever (temperature >101°F [38.3°C] by any method) with a behavior change in infants older than 2 months. For infants younger than 2 months, a fever (temperature >100.4°F [38°C] by any method) with or without a behavior change or other signs and symptoms (eg, sore throat, rash, vomiting, diarrhea) requires exclusion and immediate medical attention. When taking temperatures remember that:
- The amount of temperature elevation varies at different body sites.
- The height of the temperature does not indicate a more- or less-severe illness. The child's activity level and sense of well-being are far more important that the temperature reading.
- If a child has been in a very hot environment and heatstroke is suspected, a higher temperature is more serious.
- 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.
- Oral temperatures are difficult to take for children younger than 4 years.
Diarrhea is defined by stools that are more frequent or less formed than usual for that child and not associated with changes in 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 "accidents." In addition, diapered children with diarrhea should be excluded if stool frequency exceeds 2 stools more than typical for that child during the time in the program day, because this may cause too much work for the caregivers/teachers, or if stools contain blood or mucus. 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 not having "accidents," and when stool frequency is no more than 2 stools more than typical for that child during the time in the program day.

Special circumstances that require specific exclusion criteria include the following¹:

A health care professional should clear the child or staff member for readmission for all cases of diarrhea with blood or mucus. Readmission can occur following the requirements of the local health department authorities, which may include testing for a diarrhea outbreak in which the stool culture result is positive for Shigella, Salmonella serotype Typhi and Paratyphi, or Shiga toxin–producing Escherichia coli (STEC). Children and staff members with Shigella should be excluded until diarrhea resolves and test results from at least 1 stool culture are negative (rules vary by state). Children and staff members with STEC should be excluded until test results from 2 stool cultures are negative at least 48 hours after antibiotic treatment is complete (if prescribed). Children and staff members with Salmonella serotype Typhi and Paratyphi are excluded until test results from 3 stool cultures are negative. Stool should be collected at least 48 hours after antibiotics have stopped. State laws may govern exclusion for these conditions and should be followed by the health care professional who is clearing the child or staff member for readmission.
Vomiting more than 2 times in the previous 24 hours, unless the vomiting is determined to be caused by a noninfectious condition and the child remains adequately hydrated.
Abdominal pain that continues for longer than 2 hours or intermittent pain associated with fever or other signs or symptoms of illness.
Mouth sores with drooling that the child cannot control unless the child's primary health care provider or local health department authority states that the child is noninfectious.
Rash with fever or behavioral changes, until the primary health care provider has determined that the illness is not an infectious disease.
Active tuberculosis, until the child's primary health care provider or local health department states child is on appropriate treatment and can return.
Impetigo, only if the child has not been treated after notifying family at the end of the prior program day. Exclusion is not necessary before the end of the day as long as the lesions can be covered.
Streptococcal pharyngitis (ie, strep throat) until at least 12 hours after treatment has been started.^1,2
Head lice, only if the child has not been treated after notifying the family at the end of the prior program day. Note: Exclusion is not necessary before the end of the program day.
Scabies, only if the child has not been treated after notifying the family at the end of the prior program day. Note: Exclusion is not necessary before the end of the program day.
Chickenpox (varicella), until all lesions have dried or crusted (usually 6 days after onset of rash and no new lesions have appeared for at least 24 hours).
Rubella, until 7 days after the rash appears.
Pertussis, until 5 days of appropriate antibiotic treatment.
Mumps, until 5 days after onset of parotid gland swelling.
Measles, until 4 days after onset of rash.
Hepatitis A virus infection, until 1 week after onset of illness or jaundice if the child's symptoms are mild or as directed by the health department. Note: Protection of the others in the group should be checked to be sure everyone who was exposed has received the vaccine or receives the vaccine immediately.
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

Make decisions about providing care that is comfortable for the child while awaiting parent/guardian pickup on a case-by-case basis, considering factors such as the child's age, surroundings, potential risk to others, and type and severity of symptoms the child is exhibiting. The child should be supervised by someone who knows the child well and who will continue to observe the child for new or worsening symptoms. If symptoms allow the child to remain in his or her usual care setting while awaiting pickup, the child should be separated from other children by at least 3 feet until the child leaves to help minimize exposure of staff and children who were not previously in close contact with the child. All who have been in contact with the ill child should wash their hands. Toys, equipment, and surfaces used by the ill child should be cleaned and disinfected after the child leaves.
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 health care provider. The communication should include onset time of symptoms, observations about the child, vital signs and times (eg, temperature of 101.5°F at 10:30 am), and any actions taken and the time actions were taken (eg, ½ tsp children's acetaminophen given orally at 11:00 am). The nature and severity of symptoms and requirements of the local or state health department will determine the necessity of medical consultation. Telephone advice and electronic transmissions of instructions are acceptable without an office visit.
If the child has been seen by his or her primary health care provider, follow the advice of the primary care provider for return to child care.
If the child seems well to the family and no longer meets criteria for exclusion, there is no need to ask for further information from the primary health care provider when the child returns to care. Children who had been excluded from care do not necessarily need to have an in-person visit with a health care professional.
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.
Document actions in the child's file with date, time, symptoms, and actions taken (and by whom); sign and date the document.
In collaboration with the local health department, notify parents/guardians of contacts to the child or staff member with presumed or confirmed reportable infectious disease.

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 are listed at https://wwwn.cdc.gov/nndss/conditions/notifiable/2019/infectious-diseases .

The caregiver/teacher should contact the local health department

When a child or staff member who is in contact with others has a reportable disease.
If a reportable illness occurs among the staff, children, or families involved with the program.
For assistance in managing a suspected outbreak. Generally, an outbreak is considered to be 2 or more unrelated children (ie, not siblings) with the same diagnosis or symptoms in the same group within 1 week. Clusters of mild respiratory illness, ear infections, and certain dermatologic 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.

RATIONALE

Most infections are spread by children who do not have symptoms. Excluding children with mild illnesses is unlikely to reduce the spread of most infectious agents (germs) caused by bacteria, viruses, parasites, and fungi. Exposure to frequent mild infections helps the child's immune system develop in a healthy way. As a child gets older, she/he develops immunity to common infectious agents and will become ill less often.³ Because exclusion is unlikely to reduce the spread of disease, the most important reason for exclusion is the inability of the child to participate in activities and the staff to care for the child. Some communicable diseases have other criteria for a child's return to school or child care. For example, children with a diagnosed case of strep throat or strep skin infection should not return to school or child care until at least 12 hours after beginning an appropriate antibiotic and they are able to participate.¹

COMMENTS

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 or pose a threat to their contacts. Hand and personal hygiene are paramount in preventing transmission of these organisms.

ADDITIONAL RESOURCES

For specific conditions,Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide,4th Edition, has educational handouts that can be copied and distributed to parents/guardians, health care professionals, and caregivers/teachers. This publication is available from the American Academy of Pediatrics at https://shop.aap.org/managing-infectious-diseases-in-child-care-and-schools-4th-edition-paperback .

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 Managing Infectious Diseases in Child Care and Schools . Usually, the criteria in these 2 sources are more detailed than the state regulations, so they can be incorporated into local written policies without conflicting with state law.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.1.1.1 Conduct of Daily Health Check
3.6.1.2 Staff Exclusion for Illness
3.6.1.3 Thermometers for Taking Human Temperatures
3.6.1.4 Infectious Disease Outbreak Control
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting
Appendix A: Signs and Symptoms Chart
Appendix J: Selecting an Appropriate Sanitizer or Disinfectant

REFERENCES

American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017
American Academy of Pediatrics. School health. In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018–2021 Report of the Committee on Infectious Diseases. 31st ed. Itasca, IL: American Academy of Pediatrics; 2018:136–138
American Academy of Pediatrics. Children in out-of-home child care. In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018–2021 Report of the Committee on Infectious Diseases. 31st ed. Itasca, IL: American Academy of Pediatrics; 2018:122

NOTES

Content in the STANDARD was modified 04/16/2015, 8/2015, 4/4/2017 and 5/21/2019.

Standard 3.6.1.2: Staff Exclusion for Illness

Content in the STANDARD was modified on 4/5/2017.
COVID-19 modification as of July 13, 2021

After reading the CFOC standard, see COVID-19 modification below (Also consult applicable state licensure and public health requirements).

Please note that if a staff member has no contact with the children, or with anything with which the children has come into contact, this standard does not apply to that staff member.

A facility should not deny admission to or send home a staff member or substitute with illness unless one or more of the following conditions exists:

Influenza, until fever free for 24 hours. (Health care providers can use a test to determine whether an ill person has influenza rather than other symptoms. However, it is not practical to test all ill staff members to determine whether they have common cold viruses or influenza infection. Therefore, exclusion decisions are based on the symptoms of the staff member);
Chickenpox, until all lesions have dried and crusted, which usually occurs by six days;
Shingles, only if the lesions cannot be covered by clothing or a dressing until the lesions have crusted;
Rash with fever or joint pain, until diagnosed not to be measles or rubella;
Measles, until four days after onset of the rash (if the staff member or substitute has the capacity to develop an immune response following exposure);
Rubella, until six days after onset of rash;
Diarrheal illness, stool frequency exceeds two or more stools above normal for that individual or blood in stools, until diarrhea resolves, or until a primary care provider determines that the diarrhea is not caused by a germ that can be spread to others in the facility; For all cases of bloody diarrhea and diarrhea caused by Shiga toxin–producing Escherichia coli (STEC), Shigella, or Salmonella serotype Typhi I, exclusion must continue until the person is cleared to return by the primary health care provider. Exclusion is warranted for STEC, until results of 2 stool cultures are negative (at least 48 hours after antibiotic treatment is complete (if prescribed)); for Shigella species, until at least 1 stool culture is negative (varies by state); and for Salmonella serotype Typhi, until 3 stool cultures are negative. Stool samples need to be collected at least 48 hours after antibiotic treatment is complete. Other types of Salmonella do not require negative test results from stool cultures. Vomiting illness, two or more episodes of vomiting during the previous twenty-four hours, until vomiting resolves or is determined to result from non-infectious conditions;
Hepatitis A virus, until one week after symptom onset or as directed by the health department;
Pertussis, until after five days of appropriate antibiotic therapy or until 21 days after the onset of cough if the person is not treated with antibiotics;
Skin infection (such as impetigo), until treatment has been initiated; exclusion should continue if lesion is draining AND cannot be covered;
Tuberculosis, until noninfectious and cleared by a health department official or a primary care provider;
Strep throat or other streptococcal infection, until twenty-four hours after initial antibiotic treatment and end of fever;
Head lice, from the end of the day of discovery until after the first treatment;
Scabies, until after treatment has been completed;
Haemophilus influenzae type b (Hib), prophylaxis, until cleared by the primary health care provider;
Meningococcal infection, until cleared by the primary health care provider;
Other respiratory illness, if the illness limits the staff member's ability to provide an acceptable level of child care and compromises the health and safety of the children. This includes a respiratory illness in which the staff member is unable to consistently manage respiratory secretions using proper cough and sneeze etiquette.

Caregivers/teachers who have herpes cold sores should not be excluded from the child care facility, but should:

1. Cover and not touch their lesions;
2. Carefully observe hand hygiene policies; and

3. Not kiss any children.

COVID-19 modification as of July 13, 2021
In response to the Centers for Disease Control and Prevention'sGuidance for Operating Child Care Programs during COVID-19 , it is recommended that early childhood programsimplement daily screening procedures for staff, or other support services, to self-screen with temperature checks at home or when they arrive to the program.Refer to COVID-19 modifications of CFOCStandard 1.7.0.2: Daily Staff Health Check.

Staff who are experiencing any of the symptoms/exposures/testing listed below should not enter the program:

COVID-19 symptoms

Fever (100.4^oF/38^oC or higher); feeling feverish (chills, sweating)
New cough
Fatigue
New loss of taste or smell
Sore throat
Headache
Runny or stuffy nose
Muscle pain or body aches
Nausea, vomiting or diarrhea

Have had close contact (within 6 feet for at least 15 minutes) with someone who is COVID-19 positive
Are waiting for results of a COVID-19 test
Have been recently diagnosed with COVID-19 and not yet cleared to return to work.

If staff develop symptoms upon arrival or become sick during the day:

Immediately separate sick staff from others.
Use an isolation room or area with access to a separate restroom not used by others.
Send staff member home and encourage them to follow CDC guidance for caring for oneself and others who are sick .
Encourage sick staff to consult with their health care provider.
- Sick individuals should consider getting COVID-19 tested.
Staff in contact with the sick individual should be appropriately protected with proper personal protective equipment (PPE) such as a well fitted facemask, eye protection, disposable gloves, and a gown.
Clean and disinfect the work area and any shared common areas (including restrooms) and any supplies, tools, or equipment handled by the sick staff member. Prior to cleaning, if possible, increase ventilation in the work area and any shared common areas.
Document who has been in close contact with the sick staff member to assist with future contact tracing efforts.

If the staff member is confirmed to have COVID-19:

Follow the Guidance for Cleaning and Disinfecting Public Spaces, Workplaces, Businesses, Schools, and Homes | CDC
Contact local public health authorities about contact tracing.
Maintain sick staff member's confidentiality, as required by the Americans with Disabilities Act (ADA) and other applicable federal and state laws.
Work with local health officials to identify exposed and potentially exposed individuals, such as coworkers or enrolled children.
Refer to state and local agencies for guidance on when it is safe to discontinue self-isolation or end quarantine for staff or children who test positive or had close contact with an individual who tested positive for COVID-19.
Sick staff members should not return to work until they have met the CDC's criteria to discontinue isolation.

Staff who have been close contacts (within 6 feet for a cumulative total of 15 minutes or more over a period of 24 hours) of an individual who tested positive for COVID-19 should not return to in-person work until they have completed their quarantine.

Programs may need to implement short term closure procedures if an infected person has been at the program and has had contact with others. Work with your local public health authorities to determine next steps.

Facilities are encouraged to develop policies that encourage sick employees to stay home without fear of negative consequences.

Additional Resources:

Centers for Disease Control and Prevention

Symptoms of COVID-19
COVID-19: Quarantine vs. Isolation
Use of Masks to Help Slow the Spread of COVID-19
Interim Public Health Recommendations for Fully Vaccinated People | CDC

RATIONALE

Most infections are spread by children who do not have symptoms.
The terms contagious, infectious and communicable have similar meanings. A fully immunized child with a contagious, infectious or communicable condition will likely not have an illness that is harmful to the child or others. Children attending child care frequently carry contagious organisms that do not limit their activity nor pose a threat to their contacts.
Adults are as capable of spreading infectious disease as children (1,2). Hand and personal hygiene is paramount in preventing transmission of these organisms.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.6.1.1 Inclusion/Exclusion/Dismissal of Children
3.2.3.2 Cough and Sneeze Etiquette
3.6.1.4 Infectious Disease Outbreak Control

REFERENCES

Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4^th Edition. Elk Grove Village, IL: American Academy of Pediatrics.
American Academy of Pediatrics. School Health In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases . 31st Edition. Itasca, IL: American Academy of Pediatrics; 2018: 138-146

NOTES

Content in the STANDARD was modified on 4/5/2017.
COVID-19 modification as of July 13, 2021

Standard 3.6.1.3: Thermometers for Taking Human Temperatures

COVID-19 modification as of Ma y 21, 2021

*STANDARD UNDERGOING FULL REVISION*

After reading the CFOC standard, see COVID-19 modification below (Also consult applicable state licensure and public health requirements).

Digital thermometers should be used with infants and young children when there is a concern for fever. Tympanic (ear) thermometers may be used with children four months and older. However, while a tympanic thermometer gives quick results, it needs to be placed correctly in the child's ear to be accurate.

Glass or mercury thermometers should not be used. Mercury containing thermometers and any waste created from the cleanup of a broken thermometer should be disposed of at a household hazardous waste collection facility.

Oral (under the tongue) temperatures can be used for children over age four. Individual plastic covers should be used on oral thermometers with each use or thermometers should be cleaned and sanitized after each use according to the manufacturer's instructions.

RATIONALE

When using tympanic thermometers, too much earwax can cause the reading to be incorrect. Tympanic thermometers may fail to detect a fever that is actually present (1). Therefore, tympanic thermometers should not be used in children under four months of age, where fever detection is most important.

Mercury thermometers can break and result in mercury toxicity that can lead to neurologic injury. To prevent mercury toxicity, the American Academy of Pediatrics (AAP) encourages the removal of mercury thermometers from homes. This includes all child care settings as well (1).

Although not a hazard, temporal thermometers are not as accurate as digital thermometers (2).

COMMENTS

The site where a child's temperature is taken (rectal, oral, axillary, or tympanic) should be documented along with the temperature reading and the time the temperature was taken, because different sites give different results and affect interpretation of temperature.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

Dodd, S. R., G. A. Lancaster, J. V. Craig, R. L. Smyth, P. R. Williamson. 2006. In a systematic review, infrared ear thermometry for fever diagnosis in children finds poor sensitivity. J Clin Epidemiol 59:354-57.
Healthy Children. 2010. Health issues: How to take a child's temperature. American Academy of Pediatrics. http://www.healthychildren.org/English/health-issues/conditions/fever/pages/How-to-Take-a-Childs-Temperature.aspx.

NOTES

COVID-19 modification as of Ma y 21, 2021

Standard 3.6.4.1: Procedure for Parent/Guardian Notification About Exposure of Children to Infectious Disease

Caregivers/teachers should work collaboratively with local and state health authorities to notify parents/guardians about potential or confirmed exposures of their child to a infectious disease. Notification should include the following information:

The names, both the common and the medical name, of the diagnosed disease to which the child was exposed, whether there is one case or an outbreak, and the nature of the exposure (such as a child or staff member in a shared room or facility);
Signs and symptoms of the disease for which the parent/guardian should observe;
Mode of transmission of the disease;
Period of communicability and how long to watch for signs and symptoms of the disease;
Disease-prevention measures recommended by the health department (if appropriate);
Control measures implemented at the facility;
Pictures of skin lesions or skin condition may be helpful to parents/guardians (i.e., chicken pox, spots on tonsils, etc.)

The notice should not identify the child who has the infectious disease.

RATIONALE

Effective control and prevention of infectious diseases in child care depends on affirmative relationships between parents/guardians, caregivers/teachers, public health authorities, and primary care providers.

COMMENTS

The child care health consultant can locate appropriate photographs of conditions for parent/guardian information use. Resources for fact sheets and photographs include the current edition of (1) and the Centers for Disease Control and Prevention Website on conditions and diseases. For a sample letter to parents notifying them of illness of their child or other enrolled children, see Healthy Young Children, available from the National Association for the Education of Young Children (NAEYC) at http://www.naeyc.org.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.6.1.4 Infectious Disease Outbreak Control

REFERENCES

Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4^th Edition. Elk Grove Village, IL: American Academy of Pediatrics.

Standard 3.6.4.2: Infectious Diseases That Require Parent/Guardian Notification

In cooperation with the child care regulatory authority and health department, the facility or the health department should inform parents/guardians if their child may have been exposed to the following diseases or conditions while attending the child care program, while retaining the confidentiality of the child who has the infectious disease:

Neisseria meningitidis (meningitis);
Pertussis;
Invasive infections;
Varicella-zoster (Chickenpox) virus;
Skin infections or infestations (head lice, scabies, and ringworm);
Infections of the gastrointestinal tract (often with diarrhea) and hepatitis A virus (HAV);
Haemophilus influenzae type B (Hib);
Parvovirus B19 (fifth disease);
Measles;
Tuberculosis;
Two or more affected unrelated persons affiliated with the facility with a vaccine-preventable or infectious disease.

RATIONALE

Early identification and treatment of infectious diseases are important in minimizing associated morbidity and mortality as well as further reducing transmission (1). Notification of parents/guardians will permit them to discuss with their child's primary care provider the implications of the exposure and to closely observe their child for early signs and symptoms of illness.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.6.1.4 Infectious Disease Outbreak Control

REFERENCES

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.

Standard 3.6.4.4: List of Excludable and Reportable Conditions for Parents/Guardians

The facility should give to each parent/guardian a written list of conditions for which exclusion and dismissal may be indicated (1).

For the following symptoms, the caregiver/teacher should ask parents/guardians to have the child evaluated by a primary care provider. The advice of the primary care provider should be documented for the caregiver/teacher in the following situations:

The child has any of the following conditions: fever, lethargy, irritability, persistent crying, difficult breathing, or other manifestations of possible severe illness;
The child has a rash with fever and behavioral change;
The child has tuberculosis that has not been evaluated;
The child has scabies;
The child has a persistent cough with inability to practice respiratory etiquette.

The facility should have a list of reportable diseases provided by the health department and should provide a copy to each parent/guardian.

RATIONALE

Vomiting with symptoms such as lethargy and/or dry skin or mucous membranes or reduced urine output may indicate dehydration, and the child should be medically evaluated. Diarrhea with fever or other symptoms usually indicates infection. Blood and/or mucus may indicate shigellosis or infection with E. coli 0157:H7, which should be evaluated. Effective control and prevention of infectious diseases in child care depend on affirmative relationships between parents/guardians, caregivers, health departments, and primary care providers (2).

COMMENTS

If there is more than one case of vomiting in the facility, it may indicate either contagious illness or food poisoning.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.6.1.1 Inclusion/Exclusion/Dismissal of Children
Appendix P: Situations that Require Medical Attention Right Away

REFERENCES

Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4^th Edition. Elk Grove Village, IL: American Academy of Pediatrics.
American Academy of Pediatrics. Out-of-home child care In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases . 31st Edition. Itasca, IL: American Academy of Pediatrics; 2018: 122-123
American Academy of Pediatrics. School Health In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases . 31st Edition. Itasca, IL: American Academy of Pediatrics; 2018: 140-141

Standard 5.2.7.4: Containment of Soiled Diapers

Content in the STANDARD was modified on 8/9/2017.

Soiled diapers (disposable and cloth), and training pants should be stored inside the facility in containers separate from other waste. A secure, hands-free, plastic-lined container with firmly fitting and tightly covered lid, that does not require touching with contaminated hands or objects, should be provided, within arm's reach of diaper changing tables, to store soiled diapers (1,2). The container for soiled diapers should be designed to prevent the user from contaminating any exterior surfaces of the container or the user when inserting the soiled diaper (1,2). Soiled disposable diapers do not have to be individually bagged before placing them in the container for soiled diapers. Soiled cloth diapers and soiled clothing that are to be sent home with a parent/guardian, however, should be individually bagged (2).

The following types of diaper containers should not be used;
a.    Those that require the user's hand to push the diaper through a narrow opening;
b.    Those with exterior surfaces that must be touched with the hand;
c.     Those with exterior surfaces that are likely to be touched with the soiled diaper while the user is discarding the soiled diaper;
d.    Those that have lids with handles.

Separate containers should be used for disposable diapers, cloth diapers (if used), and soiled clothes and linens. All containers should be inaccessible to children and should be tall enough to prevent children reaching into the receptacle or from falling headfirst into containers (1,2). The containers should be placed in an area that children cannot enter without close adult supervision (1,2).

RATIONALE

Separate, plastic-lined waste receptacles that do not require touching with contaminated hands or objects and that children cannot access enclose odors within, and prevent children from coming into contact with body fluids. Anything that increases handling increases potential for contamination (1,2). Step cans or other hands-free cans with tightly fitted lids provide protection against odor and hand contamination.

COMMENTS

Fecal material and urine should not be mixed with regular trash and garbage. Where possible, soiled disposable diapers should be disposed of as biological waste rather than in the local landfill. In some areas, recycling depots for disposable diapers may be available. The facility should not use the short, poorly made domestic step cans that require caregivers/teachers to use their hands to open the lids because the foot pedals don't work. Caregivers/teachers will find it worthwhile to invest in commercial-grade step cans of sufficient size to hold the number of soiled diapers the facility collects before someone can remove the contents to an outside trash receptacle. These are the types used by doctor's offices, hospitals, and restaurants. A variety of sizes and types are available from restaurant and medical wholesale suppliers. Other types of hands-free containers can be used as long as the user can place the soiled diaper into the receptacle without increasing contact of the user's hands and the exterior of the container with the soiled diaper.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

REFERENCES

American Academy of Pediatrics. Managing infectious diseases in child care and schools: A quick reference guide. Aronson SS, Shope TR, eds. 4^th ed. Elk Grove Village, IL; 2017.
American Academy of Pediatrics. Infections Spread by the Fecal-Oral Route In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases . 31st Edition. Itasca, IL: American Academy of Pediatrics; 2018: 143

NOTES

Content in the STANDARD was modified on 8/9/2017.

Standard 5.2.7.5: Labeling, Cleaning, and Disposal of Waste and Diaper Containers

Each waste and diaper container should be labeled to show its intended contents. These containers should be cleaned daily to keep them free from build-up of soil and odor. Wastewater from these cleaning operations should be disposed of by pouring it down a toilet or floor drain. Wastewater should not be poured onto the ground, into handwashing sinks, laundry sinks, kitchen sinks, or bathtubs.

RATIONALE

This standard prevents noxious odors and spread of disease.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

Standard 5.5.0.1: Storage and Labeling of Personal Articles

COVID-19 modification as of September 20, 2021

After reading the CFOC standard, see COVID-19 modification below (Also consult applicable state licensure and public health requirements).

The facility should provide separate storage areas for each child's and staff member's personal articles and clothing. Personal effects and clothing should be labeled with the child's name. Bedding should be labeled with the child's full name, stored separately for each child, and not touching other children's personal items (1,2).

If children use the following items at the child care facility, those items should be stored in separate, clean containers and should be labeled with the child's full name:

Individual cloth towels for bathing purposes;
Toothbrushes;
Washcloths; and
Combs and brushes (1).

Toothbrushes, towels, and washcloths should be allowed to dry when they are stored and not touching (1).

RATIONALE

This standard prevents the spread of organisms that cause disease and promotes organization of a child's personal possessions. Lice infestation, scabies, and ringworm are common infectious diseases in child care. Providing space so personal items may be stored separately helps to prevent the spread of these diseases.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

5.4.5.1 Sleeping Equipment and Supplies
3.6.1.5 Sharing of Personal Articles Prohibited
3.6.3.2 Labeling, Storage, and Disposal of Medications

REFERENCES

Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, pp. 43-48. 4^th Edition. Elk Grove Village, IL: American Academy of Pediatrics.
American Academy of Pediatrics. School Health In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases . 31st Edition. Itasca, IL: American Academy of Pediatrics; 2018: 138-146

NOTES

COVID-19 modification as of September 20, 2021

Standard 7.2.0.1: Immunization Documentation

Child care facilities should require that all parents/guardians of children enrolled in child care provide written documentation of receipt of immunizations appropriate for each child's age. Infants, children, and adolescents should be immunized as specified in the "Recommended Immunization Schedules for Persons Aged 0 Through 18 Years – United States" developed by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP). Children whose immunizations are not up-to-date or have not been administered according to the recommended schedule should receive the required immunizations, unless contraindicated or for legal exemptions (1,2).

An updated immunization schedule is published annually in the AAP's Pediatrics and in the CDC's MMWR and should be consulted for current information. In addition to print versions of the recommended immunization schedules, the current child, adolescent, and catch-up schedules are posted on the Websites of the CDC at http://www.cdc.gov/vaccines/ and the AAP at http://www.aap.org/
immunization/.

RATIONALE

Routine immunizations at the appropriate age are the best means of protecting children against vaccine-preventable diseases. Legal requirements for age-appropriate immunizations of children attending licensed facilities exist in almost all states (see http://www.immunize.org/laws/). Parents/guardians of children who attend unregulated child care facilities should be encouraged to comply with the most recent "Recommended Immunization Schedules" (2).

Immunization is particularly important for children in child care because preschool-aged children have the highest age-specific incidence or are at high risk of complications from many vaccine-preventable diseases (specifically, measles, pertussis, rubella, influenza, varicella [chickenpox], rotavirus, and diseases due to Haemophilus influenzae type b (Hib) and pneumococcus) (3).

COMMENTS

Early education and child care settings present unique challenges for infection control due to the highly vulnerable population, close interpersonal contact, shared toys and other objects, and limited ability of young children to understand or practice good respiratory etiquette and hand hygiene. Parents/guardians, early childhood caregivers/teachers, and public health officials should be aware that, even under the best of circumstances, transmission of infectious diseases cannot be completely prevented in early childhood or other settings. No policy can keep everyone who is potentially infectious out of these settings (4).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

1.7.0.1 Pre-Employment and Ongoing Adult Health Appraisals, Including Immunization
9.2.3.5 Documentation of Exemptions and Exclusion of Children Who Lack Immunizations

REFERENCES

Centers for Disease Control and Prevention. 2015. Recommended immunization schedules for persons aged 0-18 years – United States, 2015. http://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html
Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.
Centers for Disease Control and Prevention (CDC). 2009. CDC guidance on helping child care and early childhood programs respond to influenza during the 2009–2010 influenza season . Atlanta: CDC. http://www.cdc.gov/h1n1flu/childcare/pdf/guidance.pdf.
American Academy of Pediatrics, Committee on Infectious Diseases. 2011. Policy statement: Recommended childhood and adolescent immunization schedules – United States, 2011. Pediatrics 127:387-88.

Standard 7.2.0.2: Unimmunized Children

If immunizations have not been or are not to be administered because of a medical condition (contraindication), a statement from the child's primary care provider documenting the reason why the child is temporarily or permanently medically exempt from the immunization requirements should be on file. If immunizations are not to be administered because of the parents/guardians' religious or philosophical beliefs, a legal exemption with notarization, waiver or other state-specific required documentation signed by the parent/guardian should be on file (1,2).

The parent/guardian of a child who has not received the age-appropriate immunizations prior to enrollment and who does not have documented medical, religious, or philosophical exemptions from routine childhood immunizations should provide documentation of a scheduled appointment or arrangement to receive immunizations. This could be a scheduled appointment with the primary care provider or an upcoming immunization clinic sponsored by a local health department or health care organization. An immunization plan and catch-up immunizations should be initiated upon enrollment and completed as soon as possible according to the current "Recommended Immunization Schedules for Persons Aged 0 Through 18 Years – United States" from the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP). Parents/guardians of children who attend an unlicensed child care facility should be encouraged to comply with the "Recommended Immunization Schedules" (6).

If a vaccine-preventable disease to which children are susceptible occurs in the facility and potentially exposes the unimmunized children who are susceptible to that disease, the health department should be consulted to determine whether these children should be excluded for the duration of possible exposure or until the appropriate immunizations have been completed. The local or state health department will be able to provide guidelines for exclusion requirements.

RATIONALE

Routine immunization at the appropriate age is the best means of protecting children against vaccine-preventable diseases. Mandates requiring age-appropriate immunization of children attending licensed facilities exist in all states (1).

Exclusion of an unimmunized (susceptible) or underimmunized child from the child care facility in the event of a risk of exposure to an outbreak of a vaccine-preventable disease protects the health of the unimmunized or underimmunized child and minimizes potential for further spread of that disease to other children, staff, family, and community members (2).

COMMENTS

A sample statement excluding a child from immunizations is: "This is to inform you that [NAME] should not be immunized with [VACCINE] because of [CONDITION, such as immunosuppression]. I expect this condition to persist for _______. [SIGNED], [PRIMARY CARE PROVIDER] [DATE]"

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

9.2.3.5 Documentation of Exemptions and Exclusion of Children Who Lack Immunizations

REFERENCES

Institute of Medicine Immunization Safety Review Committee. Immunization safety review. http://iom.edu/Activities/PublicHealth/ImmunizationSafety.aspx.
Centers for Disease Control and Prevention. 2008. Update: Measles – United States, January-July 2008. MMWR 57 (33): 893-96. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5733a1.htm.
Centers for Disease Control and Prevention. 2009. Invasive Haemophilus influenzae type B disease in five young children – Minnesota, 2008. MMWR 58 (03): 58-60. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5803a4.htm.
Omer, S. B., D. A. Salmon, W. A. Orenstein, M. P. deHart, N. Halsey. 2009. Vaccine refusal, mandatory immunization, and the risks of vaccine-preventable diseases. New Eng J Med 360:1981-88.
Immunization Action Commission. State mandates on immunization and vaccine-preventable diseases. http://www
.immunize.org/laws/.
National Network for Immunization Information. NNii. http://www.immunizationinfo.org.
Centers for Disease Control and Prevention. Vaccines and immunizations. http://www.cdc.gov/vaccines/.
American Academy of Pediatrics. Immunization. Childhood Immunization Support Program (CISP).http://www2.aap.org/immunization/about/programfacts.html

Standard 7.2.0.3: Immunization of Caregivers/Teachers

Caregivers/teachers should be current with all immunizations routinely recommended for adults by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) as shown in the "Recommended Adult Immunization Schedule" at http://www.cdc.gov/vaccines/schedules/index.html. This schedule is updated annually at the beginning of the calendar year and can be found in Appendix H.

Caregivers/teachers should have received the recommended vaccines in the following categories: (1,2)

Vaccines recommended for all adults who meet the age requirements and who lack evidence of immunity (i.e., lack documentation of vaccination or have no evidence of prior infection):
1. Tdap/Td;
2. Varicella-zoster;
3. MMR (measles, mumps, and rubella);
4. Seasonal influenza;
5. Human papillomaviruses (HPV) (eleven through twenty-six years of age);
6. Others as determined by the ACIP and state and local public health authorities.
Recommended if a specific risk factor is present:
1. Pneumococcal;
2. Hepatitis A;
3. Hepatitis B;
4. Meningococcal;
5. Others as determined by the ACIP and state and local public health authorities.
If a staff member is not appropriately immunized for medical, religious or philosophical reasons, the child care facility should require written documentation of the reason.
If a vaccine-preventable disease to which adults are susceptible occurs in the facility and potentially exposes the unimmunized adults who are susceptible to that disease, the health department should be consulted to determine whether these adults should be excluded for the duration of possible exposure or until the appropriate immunizations have been completed. The local or state health department will be able to provide guidelines for exclusion requirements.

RATIONALE

Routine immunization of adults is the best means of preventing vaccine-preventable diseases. Vaccine-preventable diseases of adults represent a continuing cause of morbidity and mortality and a source of transmission of infectious organisms. Vaccines, which are safe and effective in preventing these diseases, need to be used in adults to minimize disease and to eliminate potential sources of transmission (1-3).

COMMENTS

Several of the vaccines recommended routinely for adults will prevent diseases that can be transmitted to children in the child care setting, including pertussis, varicella, measles, mumps, rubella and influenza. One dose of Tdap is a new recommendation for all adults and is especially important for those in close contact with infants. Adults often spread pertussis (whooping cough) to vulnerable infants and young children. Yearly influenza vaccination of adults in contact with children is also an especially important way to protect young infants. Hepatitis A vaccine is not recommended for routine administration to caregivers/teachers; however, hepatitis A vaccine can be administered to any person seeking protection from hepatitis A virus (HAV). Hepatitis A is an illness that often spreads to caregivers/teachers in early education and child care settings. Caregivers/teachers should be aware of the availability of hepatitis A vaccine. As of the printing of this edition, hepatitis A and B, pneumococcal and meningococcal vaccines are only recommended for adults with high risk conditions or in high risk settings unless requested.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

1.7.0.1 Pre-Employment and Ongoing Adult Health Appraisals, Including Immunization

REFERENCES

Centers for Disease Control and Prevention. 2015. Recommended adult immunization schedule – United States, 2015. http://www.cdc.gov/vaccines/schedules/easy-to-read/adult.html.
Centers for Disease Control and Prevention. 2011. General recommendations on immunization: Recommendations of the Advisory Committee on Immunization Practices. MMWR 60 (RR02). http://www.cdc.gov/mmwr/pdf/rr/rr6002.pdf.
Advisory Committee on Immunization Practices. 2011. Recommended adult immunization schedule – United States, 2011. Ann Intern Med 154:168-73.

Standard 7.3.2.1: Immunization for Haemophilus Influenzae Type B (HIB)

Content in the STANDARD was modified on 8/9/2017.

All children in a child care facility should have received age-appropriate immunizations with a Haemophilus influenzae type b (Hib) conjugate containing vaccine (1). Staff and children in child care who are not immunized or not age-appropriately immunized (those under the age of 4 years) against invasive Hib disease do not need to be excluded from the child care setting unless there is another reason for exclusion (2). Please reference Standard 3.6.1.1: Inclusion/Exclusion/Dismissal of Children for a comprehensive list of exclusion criteria.

RATIONALE

Appropriate immunization of children with a Hib conjugate-containing vaccine prevents the occurrence of disease and decreases the rate of spread of this organism, thereby decreasing the risk of transmission to others (3).

COMMENTS

Transmission of Hib may occur among unimmunized young children in group child care, especially children younger than twenty-four months of age. Hib causes pneumonia, meningitis, joint and bone infection, heart infection, and epiglottitis. In an outbreak of invasive Hib disease in child care, rifampin prophylaxis may be indicated for all non-pregnant contacts, especially when unimmunized or incompletely immunized children attend the child care facility (3).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.6.1.1 Inclusion/Exclusion/Dismissal of Children
7.2.0.1 Immunization Documentation
7.2.0.2 Unimmunized Children
7.2.0.3 Immunization of Caregivers/Teachers
7.3.2.2 Informing Parents/Guardians of Haemophilus Influenzae Type B (HIB) Exposure

REFERENCES

Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4^th Edition. Elk Grove Village, IL: American Academy of Pediatrics.
Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices. 2016. Immunization schedules. https://www.cdc.gov/vaccines/schedules/hcp/index.html.
American Academy of Pediatrics. Haemophilus Influenzae Type B (HIB) In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases . 31st Edition. Itasca, IL: American Academy of Pediatrics; 2018: 367

NOTES

Content in the STANDARD was modified on 8/9/2017.

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.

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, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

7.3.3.2 Influenza Control
7.3.3.3 Influenza Prevention Education

REFERENCES

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.
American Academy of Pediatrics, Committee on Infectious Disease. 2010. Recommendations for prevention and control of influenza in children, 2010-2011. Pediatrics 126:816-28.

Standard 7.3.5.1: Recommended Control Measures for Invasive Meningococcal Infection in Child Care

Identification of an individual with invasive meningococcal infection in the child care setting should result in the following:

Immediate notification of the local or state health department;
Notification of parents/guardians about child care contacts to the person with invasive meningococcal infection;
Assistance with provision of antibiotic prophylaxis and vaccine receipt, as advised by the local or state health department, to child care contacts;
Frequent updates and communication with parents/guardians, health care professionals, and local health authorities.

RATIONALE

Due to the increased transmissibility of meningococcal infections following close personal contact with oral and respiratory tract secretions of a person with infection, institution of antibiotic prophylaxis within twenty-four hours of diagnosis of the index case is advised. Younger age and close contact with an infected person increases the attack rate of meningococcal disease among child care attendees to several hundred fold greater than the general population. As outbreaks may occur in child care settings, chemoprophylaxis with oral rifampin is the prophylaxis of choice for exposed child contacts. In some cases, intramuscular ceftriaxone may be used as an alternative if a contraindication to oral rifampin exists in the contact (1,2). In contacts over eighteen years of age, oral rifampin, ciprofloxacin, or intramuscular ceftriaxone, are effective (2,3). Rifampin is not recommended for pregnant women.

In addition to chemoprophylaxis with an oral antimicrobial agent, immunoprophylaxis with a meningococcal vaccination of age-eligible contacts in an outbreak setting, if the infection is due to a serogroup contained in the vaccine, may be recommended by the local or state health department (1,2).

COMMENTS

For facilities that care for older school-age children, meningococcal vaccine is recommended at eleven or twelve years of age with a second dose administered at sixteen years of age.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.6.1.1 Inclusion/Exclusion/Dismissal of Children

REFERENCES

American Academy of Pediatrics. Meningococcus In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL: American Academy of Pediatrics; 2018: 107-108
American Academy of Pediatrics, Committee on Infectious Diseases. 2009. Prevention and control of meningococcal disease: Recommendations for use of meningococcal vaccines in pediatric patients. Pediatrics 123:1421-22.
Centers for Disease Control and Prevention. 2007. Revised recommendations of the Advisory Committee on Immunization Practices to vaccinate all persons aged 11-18 years with meningococcal conjugate vaccine. MMWR 56:749-95.http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5631a3.htm.

Standard 7.3.7.3: Exclusion for Pertussis

Children and staff members with characteristic symptoms of pertussis (whooping cough) should be excluded from child care pending evaluation by a primary care provider. A symptomatic child or staff member with pertussis or suspected pertussis may not return to the facility until:

Five days after initiation of a course of any of the following antibiotics: azithromycin (full course of treatment is five days), erythromycin (full course of treatment is fourteen days), or clarithromycin (full course of treatment is seven days) antimicrobial therapy;
The medical condition allows;
The child's need for care does not compromise the
caregiver's/teacher's ability to provide for the health and safety of the other children in the group.

Untreated adults should be excluded until twenty-one days after onset of cough.

RATIONALE

Even if outbreaks of pertussis in child care facilities have not been reported, children and staff who attend out-of-home child care occasionally contract pertussis. The spread of infection to contacts who are incompletely immunized can be reduced by treating the primary case and susceptible contacts with prophylactic antibiotics (1-4).

COMMENTS

For additional information regarding pertussis, consult the current edition of the from the American Academy of Pediatrics (AAP).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.6.1.1 Inclusion/Exclusion/Dismissal of Children
3.6.1.2 Staff Exclusion for Illness
3.6.1.3 Thermometers for Taking Human Temperatures
3.6.1.4 Infectious Disease Outbreak Control
3.6.2.1 Exclusion and Alternative Care for Children Who Are Ill

REFERENCES

Centers for Disease Control and Prevention. 2005. Recommended antimicrobial agents for treatment and postexposure prophylaxis of pertussis: 2005 CDC Guidelines. MMWR 54 (RR14). http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5414a1.htm.
Centers for Disease Control and Prevention. 2006. Preventing tetanus, diphtheria, and pertussis among adolescents: Use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccines. MMWR 55 (RR03). http://www.cdc.gov/mmwr/pdf/rr/rr5503.pdf.
Centers for Disease Control and Prevention. 2006. Preventing tetanus, diphtheria, and pertussis among adults: Use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine. MMWR 55 (RR17). http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5517a1.htm.
Centers for Disease Control and Prevention. 2010. Vaccines and preventable diseases: Pretussis (whooping cough) vaccination. http://www.cdc.gov/vaccines/vpd-vac/pertussis/.

Standard 7.3.8.1: Attendance of Children with Respiratory Syncytial Virus (RSV) Respiratory Tract Infection

Respiratory syncytial virus (RSV) is a common cause of respiratory tract infection in infants and young children, although infection in all ages may occur. Children with known RSV infection may return to child care once symptoms have resolved, temperature has returned to normal, the child can participate in child care activities and the child's care does not result in more care than the staff can provide without compromising the health and safety of other children.

Parents/guardians and staff need to be aware that the period of RSV shedding is usually three to eight days but shedding may last longer, especially in young infants from whom virus can be shed in nasal secretions and saliva for three to four weeks following infection.

RATIONALE

RSV is a well-known cause of respiratory tract illness in children. Almost all children are infected at least once with RSV by two years of age and reinfection is common. In contrast to older children and adults who develop upper respiratory tract infections, RSV is one of the most frequent causes of lower respiratory tract infections including bronchiolitis (fever, cough, wheezing, and increased respiratory rate) or pneumonia in infants and young children less than two years of age.

RSV is responsible for greater than one hundred twenty-five thousand hospitalizations, mostly in infants and young children each year. Some 1% to 2% of previously healthy infants require hospitalization for bronchiolitis and up to 5% of these infants may require mechanical ventilation. Infants and children with weakened immune systems, specific types of heart problems, and those born prematurely have even greater difficulty with this infection (1,2).

Because RSV circulation is most common in the U.S. during a defined time period (generally November to March), and increased levels of RSV-specific antibody have been shown to decrease disease severity and/or prevent lower respiratory tract involvement, some infants and young children who meet specific criteria as outlined by the American Academy of Pediatrics (AAP) may benefit from receiving monthly injections (prophylaxis to prevent disease) of a monoclonal antibody (palivizumab) (2). Palivizumab does not treat someone already infected with RSV. For most patients infected with RSV, the disease is self-limited; no anti-viral therapy is available.

During an outbreak of RSV in a child care setting, most children and staff will be exposed before the occurrence of specific symptoms. Most viral respiratory tract illnesses, including RSV infections, are self-limited and go undiagnosed.

Transmission of virus occurs through close contact with respiratory tract secretions (2). Infants with chronic heart and lung problems and immunocompromised children may be at high risk for complications. Parents/guardians of such children should be alerted that a child with RSV has been diagnosed in their group.

Limiting the spread of RSV by using good hand hygiene practices, prohibiting sharing of food; bottles; toothbrushes; or toys, and disinfecting surfaces will be important to reducing the risk of RSV transmission in such situations.

COMMENTS

RSV is a major viral illness in children, especially children two years of age and younger. A critical aspect of RSV prevention among high risk infants is education of parents/guardians and other care providers about the importance of decreasing exposure to and transmission of RSV. Preventive measures may include limiting, where feasible, exposure to contagious settings, hand hygiene and avoidance of contact with people with respiratory tract infections.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.6.1.1 Inclusion/Exclusion/Dismissal of Children

REFERENCES

American Academy of Pediatrics, Committee on Infectious Diseases. 2009. Policy statement: Modified recommendations for use of palivizumab for prevention of respiratory syncytial virus infections. Pediatrics 124:1694-1701.
Peters, T. R., J. E. Crowe, Jr. 2008. Respiratory syncytial virus. In Principles and practice of pediatric infectious diseases, eds. S. S. Long, L. K. Pickering, C. G. Prober, 1112-16. 3rd ed. Philadelphia: Churchill Livingstone.

Standard 7.3.11.1: Attendance of Children with Unspecified Respiratory Tract Infection

Content in the STANDARD was modified on 8/9/2017.

Children without fever who have mild symptoms associated with the common cold, sore throat, croup, bronchitis, rhinitis, runny nose (rhinorrhea), or ear infection (otitis media) should not be denied admission to child care, sent home from child care, or separated from other children in the facility unless their illness is characterized by one or more of the following conditions:

1.    The illness has a specified cause that requires exclusion, as determined by other specific performance
standards in Child and Staff Inclusion/Exclusion/Dismissal, Standards 3.6.1.1-3.6.1.4;
2.    The illness limits the child's comfortable participation in child care activities;
3.    The illness results in a need for more care than the staff can provide without compromising the health and
safety of other children (1).

Treatment with antibiotics should not be required or otherwise encouraged as a condition for attendance of children with mild respiratory tract infections unless directed by the primary health care provider and/or local health officials.

RATIONALE

The incidence of acute diseases of the respiratory tract, including the common cold, croup, bronchitis, pneumonia, and ear infections (otitis media), is common in infants and young children, whether they are cared for at home or attend out-of-home facilities. However, children in child care experience more frequent respiratory tract infections when compared to children cared for at home (2). Infants and young children may have more upper respiratory infections when they first enter out-of-home group child care (1,2).

Routine hand hygiene and cough etiquette may reduce the incidence of most acute upper respiratory tract infections among children in child care. Frequently, infected children shed viruses before they are symptomatic, and some infected children never become overtly ill. Therefore, exclusion criteria based on symptoms will not reduce transmission of upper respiratory tract infections among child care attendees.

Parents/guardians may pressure their primary care provider to prescribe antibiotics because they believe that antibiotics will shorten the duration of exclusion from child care. Primary health care providers and caregivers/teachers should reinforce an understanding of the ineffectiveness of antibiotics on duration of viral upper respiratory tract infection and should attempt to ensure children remain in child care unless they meet exclusion criteria. Please reference Standard 3.6.1.1: Inclusion/Exclusion/Dismissal of Children for a comprehensive list of exclusion criteria.

COMMENTS

Uncontrolled coughing, difficult or rapid breathing, and wheezing (if associated with difficult breathing) may represent severe illness requiring medical evaluation before readmission to the facility.

For additional information regarding unspecified respiratory tract infections, consult a child care health consultant, primary health care provider, and/or the local health department. For additional information, consult the current edition of the Red Book from the American Academy of Pediatrics (AAP) and Managing Infectious Diseases in Child Care and Schools (AAP).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.6.1.1 Inclusion/Exclusion/Dismissal of Children
3.6.1.2 Staff Exclusion for Illness
3.6.1.3 Thermometers for Taking Human Temperatures
3.6.1.4 Infectious Disease Outbreak Control

REFERENCES

Dowell, S. M. Marcy, S. F., B. Schwartz, W. R. Phillips, et al. 1998. Principles of judicious use of antimicrobial agents for pediatric upper respiratory tract infections. Pediatrics 101:163-65.
Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4^th Edition. Elk Grove Village, IL: American Academy of Pediatrics.
American Academy of Pediatrics. Out-of-home child care In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases . 31st Edition. Itasca, IL: American Academy of Pediatrics; 2018: 122-123
American Academy of Pediatrics. School Health In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases . 31st Edition. Itasca, IL: American Academy of Pediatrics; 2018: 140-141

NOTES

Content in the STANDARD was modified on 8/9/2017.

Standard 7.4.0.1: Control of Enteric (Diarrheal) and Hepatitis A Virus (HAV) Infections

Content in the STANDARD was modified on 4/5/2017.

Facilities should employ the following procedures, in addition to those stated in Child and Staff Inclusion/Exclusion/Dismissal, Standards 3.6.1.1-3.6.1.4, to prevent and control infections of the gastrointestinal tract (including diarrhea) or hepatitis A (1,2):
Exclusion:

a. Toilet trained children who develop diarrhea should be removed from the facility by their parent/guardian. Diarrhea is defined as stools that are more frequent or less formed than usual for that child and not associated with changes in diet.

b. Diapered children should be excluded if stool is not contained in the diaper, stool frequency exceeds two or more stools above normal for that child during the program day, blood or mucus in the stool, abnormal color of stool, no urine output in eight hours, jaundice (when skin and white parts of the eye are yellow, a symptom of hepatitis A), fever with behavior change, or looks or acts ill.

c. Decisions about caring for the child while awaiting parent/guardian pick-up should be made on a case-by-case basis providing care that is comfortable for the child considering factors such as the child's age, the surroundings, potential risk to others and the type and severity of symptoms the child is exhibiting. The child should be supervised by someone who knows the child well and who will continue to observe the child for new or worsening symptoms. If symptoms allow the child to remain in their usual care setting while awaiting pick-up, the child should be separated from other children by at least 3 feet until the child leaves to help minimize exposure of staff and children not previously in close contact with the child. All who have been in contact with the ill child must wash their hands. Toys, equipment, and surfaces used by the ill child should be cleaned and disinfected after the child leaves.
d. Caregivers/teachers with diarrhea as defined in Standard 3.6.1.2 should be excluded. Separation and exclusion of children or caregivers/teachers should not be deferred pending health assessment or laboratory testing to identify an enteric pathogen.
e. Exclusion for diarrhea should continue until diapered children have their stool contained by the diaper (even if the stools remain loose), when toilet-trained children are not having "accidents", and when stool frequency is no more than 2 stools above normal for that child during the time in the program day.
f. Exclusion for hepatitis A virus (HAV) should continue for one week after onset of illness and after all contacts have received vaccine or immune globulin as recommended.
g. Alternate care for children with diarrhea or hepatitis A should be provided in facilities for children who are ill that can provide separate care for children with infections of the gastrointestinal tract (including diarrhea) or hepatitis A.

Informing parents/guardians and public health:

a. The local health department should be informed immediately of the occurrence of HAV infection or an increased frequency of diarrheal illness in children or staff in a child care facility.
b. If there has been an exposure to a person with hepatitis A or diarrhea in the child care facility, caregivers/teachers should inform parents/guardians, in cooperation with the health department, that their children may have been exposed to children with HAV infection or to another person with a diarrheal illness.
c. If a child or staff member is confirmed to have hepatitis A disease (HAV), all other children and staff in the group should be checked to be sure everyone who was exposed has received the hepatitis A vaccine or immune globulin within 2 weeks of exposure.

Return to Care:

a. Children can be readmitted when they are able to fully participate in program activities without the caregivers/teachers having to compromise their ability to care for the health and safety of other children in the group.
b. Children and caregivers/teachers who excrete intestinal pathogens but no longer have diarrhea generally may be allowed to return to child care once the diarrhea resolves, except for the case of infections with Shigella, Shiga toxin-producing Escherichia. coli (STEC),or Salmonella enterica serotype Typhi. ForShigella and STEC, resolution of symptoms and two negative stool cultures are required for readmission, unless state requirements differ. ForSalmonella serotype Typhi, resolution of symptoms and three negative stool cultures are required for return to child care. For Salmonella species other than serotype Typhi, documentation of negative stool cultures are not required from asymptomatic people for readmission to child care.

RATIONALE

Intestinal organisms, including HAV, cause disease in children, caregivers/teachers, and close family members (1,2). Disease has occurred in outbreaks within centers and as sporadic episodes. Although many intestinal agents can cause diarrhea in children in child care, rotavirus, other enteric viruses,Giardia intestinalis,Shigella, and Cryptosporidium have been the main organisms implicated in outbreaks
Caregivers/teachers should always observe children for signs of disease to permit early detection and implementation of control measures. Facilities should consult the local health department to determine whether the increased frequency of diarrheal illness requires public health intervention.
The most important characteristic of child care facilities associated with increased frequencies of diarrhea or hepatitis A is the presence of young children who are not toilet trained. Contamination of hands, communal toys, and other classroom objects is common and plays a role in transmission of enteric pathogens in child care facilities.
Studies frequently find that fecal contamination of the environment is common in centers and is highest in infant and toddler areas, where diarrhea or hepatitis A are known to occur most often. Studies indicate that the risk of diarrhea is significantly higher for children in centers than for age-matched children cared for at home or in small family child care homes. The spread of infection from children who are not toilet trained to other children in child care facilities, or to their household contacts is common, particularly whenShigella, rotavirus, Giardia intestinalis, Cryptosporidium, or HAV are the causal agents (1,2).
With recommendations for administration of rotavirus vaccine between two and six months of age and 2 doses of hepatitis A vaccine given at least 6 months apart between 12 and 23 months, rates of disease due to rotavirus and hepatitis A have decreased.
To decrease diarrheal disease in child care due to all pathogens, staff and parents/guardians must be educated about modes of transmission as well as practical methods of prevention and control. Staff training in hand hygiene, combined with close monitoring of compliance, is associated with a significant decrease in infant and toddler diarrhea (1,2). Staff training on a single occasion, without close monitoring, does not result in a decrease in diarrhea rates; this finding emphasizes the importance of monitoring as well as education. Therefore, appropriate hygienic practices, hygiene monitoring, and education are important in limiting diarrheal infections and hepatitis. Asymptomatic children can still easily transmit infection to susceptible adults who often develop signs and symptoms of disease and may become seriously ill.

COMMENTS

Sample letters of notification to parents/guardians that their child may have been exposed to an infectious disease are contained in the current publication of the American Academy of Pediatrics (AAP), Managing Infectious Diseases in Child Care and Schools. For additional information regarding enteric (diarrheal) and HAV infections, consult the current edition of the Red Book, also from the AAP.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

9.4.2.3 Contents of Admission Agreement Between Child Care Program and Parent/Guardian
2.1.2.5 Toilet Learning/Training
9.2.3.11 Food and Nutrition Service Policies and Plans
9.2.3.12 Infant Feeding Policy
4.9.0.2 Staff Restricted from Food Preparation and Handling
4.9.0.3 Precautions for a Safe Food Supply
3.2.1.1 Type of Diapers Worn
3.2.1.2 Handling Cloth Diapers
3.2.1.3 Checking For the Need to Change Diapers
3.2.1.4 Diaper Changing Procedure
3.2.1.5 Procedure for Changing Children's Soiled Underwear, Disposable Training Pants and Clothing
3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.2.2.3 Assisting Children with Hand Hygiene
3.2.2.5 Hand Sanitizers
3.3.0.1 Routine Cleaning, Sanitizing, and Disinfecting
3.3.0.2 Cleaning and Sanitizing Toys
3.3.0.3 Cleaning and Sanitizing Objects Intended for the Mouth
3.3.0.4 Cleaning Individual Bedding
3.3.0.5 Cleaning Crib Surfaces
3.6.1.1 Inclusion/Exclusion/Dismissal of Children
3.6.1.2 Staff Exclusion for Illness
3.6.1.3 Thermometers for Taking Human Temperatures
3.2.2.4 Training and Monitoring for Hand Hygiene
3.4.2.1 Animals that Might Have Contact with Children and Adults
3.4.2.2 Prohibited Animals
3.4.2.3 Care for Animals
3.6.1.4 Infectious Disease Outbreak Control
3.6.2.2 Space Requirements for Care of Children Who Are Ill
3.6.2.3 Qualifications of Directors of Facilities That Care for Children Who Are Ill
3.6.2.4 Program Requirements for Facilities That Care for Children Who Are Ill
3.6.2.5 Caregiver/Teacher Qualifications for Facilities That Care for Children Who Are Ill
3.6.2.6 Child-Staff Ratios for Facilities That Care for Children Who Are Ill
3.6.2.7 Child Care Health Consultants for Facilities That Care for Children Who Are Ill
3.6.2.8 Licensing of Facilities That Care for Children Who Are Ill
3.6.2.9 Information Required for Children Who Are Ill
3.6.2.10 Inclusion and Exclusion of Children from Facilities That Serve Children Who Are Ill
4.9.0.1 Compliance with U.S. Food and Drug Administration Food Sanitation Standards, State and Local Rules
4.9.0.4 Leftovers
4.9.0.5 Preparation for and Storage of Food in the Refrigerator
4.9.0.6 Storage of Foods Not Requiring Refrigeration
4.9.0.7 Storage of Dry Bulk Foods
4.9.0.8 Supply of Food and Water for Disasters
4.9.0.9 Cleaning Food Areas and Equipment
9.4.2.1 Contents of Child's Records
9.4.2.2 Pre-Admission Enrollment Information for Each Child
9.4.2.4 Contents of Child's Primary Care Provider's Assessment
9.4.2.5 Health History
9.4.2.6 Contents of Medication Record
9.4.2.7 Contents of Facility Health Log for Each Child
9.4.2.8 Release of Child's Records
Appendix A: Signs and Symptoms Chart
Appendix G: Recommended Childhood Immunization Schedule

REFERENCES

American Academy of Pediatrics. School Health In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases . 31st Edition. Itasca, IL: American Academy of Pediatrics; 2018: 138-146
Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4^th Edition. Elk Grove Village, IL: American Academy of Pediatrics.
American Academy of Pediatrics. Hepatitis A Virus (HAV) In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases . 31st Edition. Itasca, IL: American Academy of Pediatrics; 2018: 392-400

NOTES

Content in the STANDARD was modified on 4/5/2017.

Standard 7.5.1.1: Conjunctivitis (Pinkeye)

Content in the STANDARD was modified on 3/31/17.

Conjunctivitis (pinkeye), defined as redness and swelling of the covering of the white part of the eye (1), may result from a number of causes. Bacteria, viruses, allergies, chemical reactions, and immunological conditions may manifest as redness and discharge from one or both eyes. Management of pinkeye should involve frequent hand hygiene to prevent the spread (1). Children and staff with conjunctivitis (pinkeye) should not be excluded from child care unless:

They are unable to participate in activities;
Care for other children would be compromised because of the care required by the child with conjunctivitis;
The person with conjunctivitis meets any of the following exclusion criteria outlined in Standard 3.6.1.1; or
A health care professional or health department recommends exclusion of the person with conjunctivitis.

Children and staff in close contact with a person with conjunctivitis should be observed for symptoms and referred for evaluation, if necessary. If two or more children in a group care setting develop conjunctivitis in the same period, seek advice from the program's child care health consultant or public health authority about how to prevent further spread (1). Children who have severe prolonged symptoms should be evaluated by their primary care provider (1)

RATIONALE

Hand contact with eye, nose, and oral secretions is the most common way that organisms causing conjunctivitis are spread from person to person. Careful hand hygiene and sanitizing of surfaces and objects exposed to infectious secretions are the best ways to prevent spread.
Conjunctivitis may be caused by both infectious and non-infectious conditions. The length of time that a person is considered contagious due to a bacterial or viral conjunctivitis depends on the organism. Antibiotic eye drops and oral medications may decrease the time that a person is considered to be contagious from a bacterial conjunctivitis. For viral conjunctivitis, the contagious period continues while the signs and symptoms are present (1).

COMMENTS

Occasionally, conjunctivitis might occur in several children at the same time or within a few days of each other. Some children with conjunctivitis may have other symptoms including fever, nasal congestion, respiratory, and gastrointestinal tract symptoms.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.6.1.1 Inclusion/Exclusion/Dismissal of Children

REFERENCES

Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4^th Edition. Elk Grove Village, IL: American Academy of Pediatrics.

NOTES

Content in the STANDARD was modified on 3/31/17.

Standard 7.5.10.1: Staphylococcus Aureus Skin Infections Including MRSA

The following should be implemented when children or staff with lesions suspicious for Staphylococcus aureus infections are identified:

Lesions should be covered with a dressing;
Report the lesions to the parent/guardian with a recommendation for evaluation by a primary care provider; and
Exclusion is not warranted unless the individual meets any of the following criteria:
1. Care for other children would be compromised by care required for the person with the S. aureus infection;
2. The individual with the S. aureus infection has fever or a change in behavior;
3. The lesion(s) cannot be adequately covered by a bandage or the bandage needs frequent changing; and
4. A health care professional or health department official recommends exclusion of the person with S. aureus infection (1).

Meticulous hand hygiene following contact with lesions should be practiced (1). Careful hand hygiene and sanitization of surfaces and objects potentially exposed to infectious material are the best ways to prevent spread. Children and staff in close contact with an infected person should be observed for symptoms of S. aureus infection and referred for evaluation, if indicated.

A child may return to group child care when staff members are able to care for the child without compromising their ability to care for others, the child is able to participate in activities, appropriate therapy is being given, and the lesions can be covered (1).

S. aureus skin infections initially may appear as red raised areas that may become pus-filled abscesses or "boils," surrounded by areas of redness and tenderness. Fever and other symptoms including decreased activity, bone and joint pain, and difficulty breathing may occur when the infection occurs in other body systems. If any of these signs or
symptoms occur, the child should be evaluated by his/her primary care provider.

RATIONALE

S. aureus (also known as "Staph") is a bacterium that commonly causes superficial skin infections (cellulitis and abscesses). It also may cause muscle, bone, lung, and blood (invasive) infections. One type of S. aureus, called methicillin-resistant S. aureus or "MRSA," is resistant to one or more classes of antibiotics. S. aureus and MRSA have been the source of attention due to increasing rates of infections from these bacteria associated with health care associated (HCA) infections and in healthy children and adults in the community. Transmissibility and infectivity is comparable to infections with S. aureus without methicillin resistance. Therefore signs and symptoms, incubation and contagion periods, control of spread, and exclusion guidelines are identical for all S. aureus infections, including infections with methicillin resistance or MRSA (1,2).

Most people with skin infections due to S. aureus do not develop invasive infections; they may experience recurrent skin infections. Infants and children who are diapered and pre-adolescents and adolescents who participate in team sports may have an increased risk for developing S. aureus skin infections. This is likely due to frequent breaks of skin and the sharing of towels. The incubation period for S. aureus skin infections is unknown. Some people may carry MRSA without having symptoms of active infection. These people are considered to be "colonized" with S. aureus; however, they are not considered to be infectious when they do not have active infection.

S. aureus skin infections may occur at sites of skin trauma. Pus and other material draining from skin lesions should be considered to be infectious. Treatment of S. aureus skin infections may be accomplished with an oral or an intravenous antibiotic or a combination of both. In some cases, incision and drainage of the lesion(s) alone may be required. In other instances, incision and drainage of smaller lesions with the use of a topical antibiotic may result in a cure. Skin lesions are considered to be infectious until they have healed; therefore, they should be kept covered and dry. Frequent hand hygiene to prevent spread of S. aureus should be practiced at home and in child care (1). Evaluation by a primary care provider in people with severe or prolonged symptoms may be indicated.

COMMENTS

skin infections are common, especially among infants wearing diapers and adolescent members of sports teams. Infections may be more common among children where other family members have or have had skin lesions and during the warmer months when skin exposure to trauma may be increased. Shedding of bacteria from skin lesions may occur until the lesion has healed. Occasionally infections may occur in several children at the same time or within a few of days of each other. Consultation with a health care professional and the local health department may be sought when several people have these symptoms.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.6.1.1 Inclusion/Exclusion/Dismissal of Children
Appendix A: Signs and Symptoms Chart

REFERENCES

American Academy of Pediatrics. Staphylococcus Aureus In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases . 31st Edition. Itasca, IL: American Academy of Pediatrics; 2018: 350, 477, 735, 746
Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, pp. 43-48. 4^th Edition. Elk Grove Village, IL: American Academy of Pediatrics.

Standard 7.5.12.1: Thrush (Candidiasis)

Children with thrush do not need to be excluded from group settings (1). Careful hand hygiene and sanitization of surfaces and objects potentially exposed to oral secretions including pacifiers and toothbrushes is the best way to prevent spread (1). Toothbrushes and pacifiers should be labeled individually so that children do not share toothbrushes or pacifiers, as specified in Standard 3.1.5.2. The presence of children with thrush should be noted by caregivers/teachers, and parents/guardians of the children should be notified to seek care, if indicated.

Treatment of thrush may consist of a topical or an oral medication. Most people are able to control thrush without treatment. Evaluation by a primary care provider of people with severe or prolonged symptoms may be indicated.

RATIONALE

Thrush is a common infection, especially among infants (1). Thrush is caused by yeast, a type of fungus called Candida. This fungus thrives in warm, moist areas (skin, skin under a diaper, and on mucous membranes). Thrush appears as white patches on the mucous membranes, commonly on the inner cheeks, gums, and tongue, and may cause diaper rash. The yeast that causes thrush lives on skin and mucous membranes of healthy people and is present on surfaces throughout the environment. An imbalance in the normal bacteria and fungi on the skin may cause the yeast to begin growing on the mucous membranes, appearing as white plaques that are adherent. Intermittent thrush may be normal in infants and young children. People with exposure to moisture, those receiving antibiotics, or those with an illness may develop thrush (2).

COMMENTS

Occasionally, thrush might occur in several individuals at the same time or within a couple of days of each other. Consultation with a health care professional and the local health department may be sought when several individuals have these symptoms.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.1.5.2 Toothbrushes and Toothpaste
3.3.0.2 Cleaning and Sanitizing Toys
3.3.0.3 Cleaning and Sanitizing Objects Intended for the Mouth
3.6.1.1 Inclusion/Exclusion/Dismissal of Children

REFERENCES

American Academy of Pediatrics. Thrush (Candidiasis) In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL: American Academy of Pediatrics; 2018: 264
Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4^th Edition. Elk Grove Village, IL: American Academy of Pediatrics.

Standard 7.7.2.1: Disease Recognition and Control of Herpes Simplex Virus

Children with herpetic gingivostomatitis, an infection of the mouth caused by the herpes simplex virus, who do not have control of oral secretions, should be excluded from child care. In selected situations, children with mild disease who are in control of their oral secretions may not need to be excluded. The facility's child care health consultant or health department officials should be consulted.

Caregivers/teachers with herpetic gingivostomatitis, cold sores, or herpes labialis should do the following:

Refrain from kissing and nuzzling children;
Refrain from sharing food and drinks with children and other caregivers;
Avoid touching the lesions;
Wash their hands frequently;
Cover any skin lesion with a bandage, clothing, or an appropriate dressing if practical.

Caregivers/teachers should be instructed in the importance of and technique for hand hygiene and other measures aimed at limiting transfer of infected material, such as saliva, tissue fluid, or fluid from a skin sore.

Caregivers/teachers who work in a child care program with young infants should avoid caring for infants including neonates when the caregiver has an active "fever blister" on their lips.

RATIONALE

Initial herpes simplex virus disease in children often produces a sudden illness of short duration characterized by fever and sores around and within the mouth. Illness and viral excretion may persist for a week or more. Multiple, painful sores in the mouth and throat may prevent oral intake and necessitate hospitalization for hydration (1). Recurrent oral herpes is manifested as small, fluid-filled blisters on the lips and entails a much shorter period of virus shedding from sores. Adults and children also can shed the virus in oral secretions in the absence of identifiable sores.

Although the risk of transmission of herpes simplex virus in the child care setting has not been documented, spread of infection within families has been reported and is thought to require direct contact with infected secretions (1). Transmission of herpes simplex in child care is uncommon (2). However, neonates are at the highest risk for disseminated disease.

For additional information regarding herpes simplex, consult the herpes simplex chapter in the current edition of the Red Book from the American Academy of Pediatrics (AAP).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.2.1.1 Type of Diapers Worn
3.2.1.2 Handling Cloth Diapers
3.2.1.4 Diaper Changing Procedure
3.2.1.5 Procedure for Changing Children's Soiled Underwear, Disposable Training Pants and Clothing
3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.2.2.3 Assisting Children with Hand Hygiene
3.2.2.5 Hand Sanitizers
3.2.3.1 Procedure for Nasal Secretions and Use of Nasal Bulb Syringes
3.2.3.4 Prevention of Exposure to Blood and Body Fluids
3.6.1.1 Inclusion/Exclusion/Dismissal of Children
3.6.1.2 Staff Exclusion for Illness
3.6.1.3 Thermometers for Taking Human Temperatures
3.2.2.4 Training and Monitoring for Hand Hygiene
3.2.3.2 Cough and Sneeze Etiquette
3.2.3.3 Cuts and Scrapes
3.6.1.4 Infectious Disease Outbreak Control

REFERENCES

Schmitt, D. L., D. W. Johnson, F. W. Henderson. 1991. Herpes simplex type I infections in group care. Pediatr Infect Dis J 10:729-34.
Prober, C. G. 2008. Herpes simplex virus. In Principles and practice of pediatric infectious diseases, eds. S. S. Long, L. K. Pickering, C. G. Prober. 3rd ed. Philadelphia: Churchill Livingstone.

Medication Administration

Standard 3.6.3.1: Medication Administration

The administration of medicines at the facility should be limited to:

Prescription or non-prescription medication (over-the-counter [OTC]) ordered by the prescribing health professional for a specific child with written permission of the parent/guardian. Written orders from the prescribing health professional should specify medical need, medication, dosage, and length of time to give medication;
Labeled medications brought to the child care facility by the parent/guardian in the original container (with a label that includes the child's name, date filled, prescribing clinician's name, pharmacy name and phone number, dosage/instructions, and relevant warnings).

Facilities should not administer folk or homemade remedy medications or treatment. Facilities should not administer a medication that is prescribed for one child in the family to another child in the family.

No prescription or non-prescription medication (OTC) should be given to any child without written orders from a prescribing health professional and written permission from a parent/guardian. Exception: Non-prescription sunscreen and insect repellent always require parental consent but do not require instructions from each child's prescribing health professional.

Documentation that the medicine/agent is administered to the child as prescribed is required.

"Standing orders" guidance should include directions for facilities to be equipped, staffed, and monitored by the primary care provider capable of having the special health care plan modified as needed. Standing orders for medication should only be allowed for individual children with a documented medical need if a special care plan is provided by the child's primary care provider in conjunction with the standing order or for OTC medications for which a primary care provider has provided specific instructions that define the children, conditions and methods for administration of the medication. Signatures from the primary care provider and one of the child's parents/guardians must be obtained on the special care plan. Care plans should be updated as needed, but at least yearly.

RATIONALE

Medicines can be crucial to the health and wellness of children. They can also be very dangerous if the wrong type or wrong amount is given to the wrong person or at the wrong time. Prevention is the key to prevent poisonings by making sure medications are inaccessible to children.

All medicines require clear, accurate instruction and medical confirmation of the need for the medication to be given while the child is in the facility. Prescription medications can often be timed to be given at home and this should be encouraged. Because of the potential for errors in medication administration in child care facilities, it may be safer for a parent/guardian to administer their child's medicine at home.

Over the counter medications, such as acetaminophen and ibuprofen, can be just as dangerous as prescription medications and can result in illness or even death when these products are misused or unintentional poisoning occurs. Many children's over the counter medications contain a combination of ingredients. It is important to make sure the child isn't receiving the same medications in two different products which may result in an overdose. Facilities should not stock OTC medications (1).

Cough and cold medications are widely used for children to treat upper respiratory infections and allergy symptoms. Recently, concern has been raised that there is no proven benefit and some of these products may be dangerous (2,3,5). Leading organizations such as the Consumer Healthcare Products Association (CHPA) and the American Academy of Pediatrics (AAP) have recommended restrictions on these products for children under age six (4-7).

If a medication mistake or unintentional poisoning does occur, call your local poison center immediately at 1-800-222-1222.

Parents/guardians should always be notified in every instance when medication is used. Telephone instructions from a primary care provider are acceptable if the caregiver/teacher fully documents them and if the parent/guardian initiates the request for primary care provider or child care health consultant instruction. In the event medication for a child becomes necessary during the day or in the event of an emergency, administration instructions from a parent/ guardian and the child's prescribing health professional are required before a caregiver/teacher may administer medication.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.4.5.1 Sun Safety Including Sunscreen
3.4.5.2 Insect Repellent and Protection from Vector-Borne Diseases
3.6.2.9 Information Required for Children Who Are Ill
3.6.3.2 Labeling, Storage, and Disposal of Medications

REFERENCES

Schaefer, M. K., N. Shehab, A. Cohen, D. S. Budnitz. 2008. Adverse events from cough and cold medications in children. Pediatrics 121:783-87.
American Academy of Pediatrics, Committee on Drugs. 2009. Policy statement: Acetaminophen toxicity in children. Pediatrics 123:1421-22.
Consumer Healthcare Products Association. Makers of OTC cough and cold medicines announce voluntary withdrawal of oral infant medicines. http://www.chpa-info.org/10_11_07_OralInfantMedicines.aspx.
Centers for Disease Control and Prevention. 2007. Infant deaths associated with cough and cold medications: Two states. MMWR 56:1-4.
American Academy of Pediatrics. 2008. AAP Urges caution in use of over-the-counter cough and cold medicines. http://www.generaterecords.net/PicGallery/AAP_CC.pdf
Vernacchio, L., J. Kelly, D. Kaufman, A. Mitchell. 2008. Cough and cold medication use by U.S. children, 1999-2006: Results from the Slone Survey.Pediatrics 122: e323-29.
U.S. Department of Health and Human Services, Food and Drug Administration. 2008. Public Health advisory: FDA recomends that over-the-counter (OTC) cough and cold products not be used for infants and children under 2 years of age. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2008/ucm051137.htm

Standard 3.6.3.2: Labeling, Storage, and Disposal of Medications

Any prescription medication should be dated and kept in the original container. The container should be labeled by a pharmacist with:

The child's first and last names;
The date the prescription was filled;
The name of the prescribing health professional who wrote the prescription, the medication's expiration date;
The manufacturer's instructions or prescription label with specific, legible instructions for administration, storage, and disposal;
The name and strength of the medication.

Over-the-counter medications should be kept in the original container as sold by the manufacturer, labeled by the parent/guardian, with the child's name and specific instructions given by the child's prescribing health professional for administration.

All medications, refrigerated or unrefrigerated, should:

Have child-resistant caps;
Be kept in an organized fashion;
Be stored away from food;
Be stored at the proper temperature;
Be completely inaccessible to children.

Medication should not be used beyond the date of expiration. Unused medications should be returned to the parent/guardian for disposal. In the event medication cannot be returned to the parent or guardian, it should be disposed of according to the recommendations of the US Food and Drug Administration (FDA) (1). Documentation should be kept with the child care facility of all disposed medications. The current guidelines are as follows:

If a medication lists any specific instructions on how to dispose of it, follow those directions.
If there are community drug take back programs, participate in those.
Remove medications from their original containers and put them in a sealable bag. Mix medications with an undesirable substance such as used coffee grounds or kitty litter. Throw the mixture into the regular trash. Make sure children do not have access to the trash (1).

RATIONALE

Child-resistant safety packaging has been shown to significantly decrease poison exposure incidents in young children (1).

Proper disposal of medications is important to help ensure a healthy environment for children in our communities. There is growing evidence that throwing out or flushing medications into our sewer systems may have harmful effects on the environment (1-3).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.6.3.1 Medication Administration
3.6.3.3 Training of Caregivers/Teachers to Administer Medication

REFERENCES

Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.
U.S. Environmental Protection Agency. 2009. Pharmaceuticals and personal care products as pollutants (PPCPs). http://www.epa
.gov/ppcp/.
U.S. Food and Drug Administration. 2010. Disposal by flushing of certain unused medicines: What you should know. http://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/
EnsuringSafeUseofMedicine/SafeDisposalofMedicines/
ucm186187.htm.

Standard 3.6.3.3: Training of Caregivers/Teachers to Administer Medication

Any caregiver/teacher who administers medication should complete a standardized training course that includes skill and competency assessment in medication administration. The trainer in medication administration should be a licensed health professional. The course should be repeated according to state and/or local regulation. At a minimum, skill and competency should be monitored annually or whenever medication administration error occurs. In facilities with large numbers of children with special health care needs involving daily medication, best practice would indicate strong consideration to the hiring of a licensed health care professional. Lacking that, caregivers/teachers should be trained to:

Check that the name of the child on the medication and the child receiving the medication are the same;
Check that the name of the medication is the same as the name of the medication on the instructions to give the medication if the instructions are not on the medication container that is labeled with the child's name;
Read and understand the label/prescription directions or the separate written instructions in relation to the measured dose, frequency, route of administration (ex. by mouth, ear canal, eye, etc.) and other special instructions relative to the medication;
Observe and report any side effects from medications;
Document the administration of each dose by the time and the amount given;
Document the person giving the administration and any side effects noted;
Handle and store all medications according to label instructions and regulations.

The trainer in medication administration should be a licensed health professional: Registered Nurse, Advanced Practice Registered Nurse (APRN), MD, Physician's Assistant, or Pharmacist.

RATIONALE

Administration of medicines is unavoidable as increasing numbers of children entering child care take medications. National data indicate that at any one time, a significant portion of the pediatric population is taking medication, mostly vitamins, but between 16% and 40% are taking antipyretics/analgesics (5). Safe medication administration in child care is extremely important and training of caregivers/teachers is essential (1).

Caregivers/teachers need to know what medication the child is receiving, who prescribed the medicine and when, for what purpose the medicine has been prescribed and what the known reactions or side effects may be if a child has a negative reaction to the medicine (2,3). A child's reaction to medication can be occasionally extreme enough to initiate the protocol developed for emergencies. The medication record is especially important if medications are frequently prescribed or if long-term medications are being used (4).

COMMENTS

Caregivers/teachers need to know the state laws and regulations on training requirements for the administration of medications in out-of-home child care settings. These laws may include requirements for delegation of medication administration from a primary care provider. Training on medication administration for caregivers/teachers is available in several states. from Healthy Child Care Pennsylvania is available at http://www.ecels-healthychildcarepa.org/publications/manuals-pamphlets-policies/item/248-model-child-care-health-policies and contains sample polices and forms related to medication administration.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.6.3.1 Medication Administration
3.6.3.2 Labeling, Storage, and Disposal of Medications
9.2.3.9 Written Policy on Use of Medications
Appendix AA: Medication Administration Packet
Appendix O: Care Plan for Children with Special Health Care Needs

REFERENCES

Vernacchio, L., J. P. Kelly, D. W. Kaufman, A. A. Mitchell. 2009. Medication use among children <12 years of age in the United States: Results from the Slone Survey. Pediatrics 124:446-54.
Calder, J. 2004. Medication administration in child care programs. Health and Safety Notes. Berkeley, CA: California Childcare Health Program. http://www.ucsfchildcarehealth.org/pdfs/healthandsafety/medadminEN102004_adr.pdf.
Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.
Qualistar Early Learning. 2008. Colorado Medication Administration Curriculum. 5th ed. http://www.qualistar.org/medication-administration.html.
Heschel, R. T., A. A. Crowley, S. S. Cohen. 2005. State policies regarding nursing delegation and administration in child care settings: A case study. Policy, Politics, and Nursing Practice 6:86-98.

Standard 9.4.2.6: Contents of Medication Record

The file for each child should include a medication record maintained on an ongoing basis by designated staff for all prescription and non-prescription (over-the-counter [OTC]) medications. State requirements should be checked and followed. The medication record for prescription and non-prescription medications should include the following:

A separate consent signed by the parent/guardian for each medication the caregiver/teacher has permission to administer to the child; each consent should include the child's name, medication, time, dose, how to give the medication, and start and end dates when it should be given;
Authorization from the prescribing health professional for each prescription and non-prescription medication; this authorization should also include potential side effects and other warnings about the medication (exception: non-prescription sunscreen and insect repellent always require parental/guardian consent but do not require instructions from each child's individual medical provider);
Administration log which includes the child's name, the medication that was given, the dose, the route of administration, the time and date, and the signature or initials of the person administering the medication. For medications given "as needed," record the reason the medication was given. Space should be available for notations of any side-effects noted after the medication was given or if the dose was not retained because of the child vomiting or spitting out the medication. Documentation should also be made of attempts to give medications that were refused by the child;
Information about prescription medication brought to the facility by the parents/guardians in the original, labeled container with a label that includes the child's name, date filled, prescribing clinician's name, pharmacy name and phone number, dosage/instructions, and relevant warnings. Potential side effects and other warnings about the medication should be listed on the authorization form;
Non prescription medications should be brought to the facility in the original container, labeled with the child's complete name and administered according to the authorization completed by the person with prescriptive authority;
For medications that are to be given or available to be given for the entire year, a Care Plan should also be in place (for instance, inhalers for asthma or epinephrine for possible allergy);
Side effects.

RATIONALE

Before assuming responsibility for administration of prescription or non-prescription medicine, facilities must have written confirmation of orders from the prescribing health professional that includes clear, accurate instructions and medical confirmation of the child's need for medication while in the facility. Caregivers/teachers should not administer medication based solely on a parent's/guardian's request. Proper labeling of medications is crucial for safety (1). Both the child's name and the name and dose of the medication should be clear. Medications should never be removed from their original container. All containers should have child resistant packaging. Potential side-effects are usually included on prescription and OTC medications if the packaging is left intact (2).

Medications may have side-effects, and parents/guardians might not be aware that their child is experiencing those symptoms unless they are recorded and reported. Serious medication side-effects might require emergency care. Adjustments or additional medications might help those symptoms if the prescribing health professional is made aware of them. Children who do not tolerate medications may vomit or spit up the medication. Notation should be made if any of the medication was retained in those cases. Children may also vigorously refuse medications, and plans to deal with this should be made (1,2).

The Medication Log is a legal document and should be kept in the child's file for as long as required by state licensing requires.

COMMENTS

A curriculum for child care providers on safe administration of medications in child care is available from the American Academy of Pediatrics at: http://www.healthychildcare.org/HealthyFutures.html.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.6.3.1 Medication Administration
3.6.3.2 Labeling, Storage, and Disposal of Medications
3.6.3.3 Training of Caregivers/Teachers to Administer Medication
9.2.3.9 Written Policy on Use of Medications
9.4.2.1 Contents of Child's Records
Appendix AA: Medication Administration Packet

REFERENCES

Healthy Child Care America. 2010. Healthy futures: Medication administration in early education and child care settings. American Academy of Pediatrics. http://www.healthychildcare.org/HealthyFutures.html.
American Academy of Pediatrics, Council on School Health. 2009. Policy statement: Guidance for the administration of medication in school. Pediatrics 124:1244-51.

Abuse/Neglect

Standard 3.4.4.1: Recognizing and Reporting Suspected Child Abuse, Neglect, and Exploitation

Content in the STANDARD was modified on 05/29/2018.

Caregivers/teachers should receive initial and ongoing training to assist them in preventing child abuse and neglect and in recognizing signs of child abuse and neglect. Programs are encouraged to partner with primary health care providers, child care health consultants, and/or child protection advocates to provide training and to be available for consultation. Caregivers/teachers are mandated reporters of child abuse and neglect. Each facility should have a written policy for reporting child abuse and neglect.

The facility should report any instance in which there is reasonable cause to believe that child abuse and/or neglect has occurred to the child abuse reporting hotline, department of social services, child protective services, or police as required by state and local laws. Every staff member should be oriented to what and how to report. Phone numbers and reporting system, as required by state or local agencies, should be clearly posted in a location accessible to caregivers/teachers.

Employees and volunteers in centers and large family child care homes should receive an instruction sheet about child abuse and neglect reporting that contains a summary of the state child abuse reporting statute and a statement that they will not be discharged or disciplined because they have made a child abuse and neglect report. Some states have specific forms that are required to be completed when abuse and neglect is reported. Some states have forms that are not required but assist mandated reporters in documenting accurate and thorough reports. In those states, facilities should have such forms on hand and all staff should be trained in the appropriate use of those forms.

Parents/guardians should be notified on enrollment of the facility's child abuse and neglect reporting requirement and procedures.

RATIONALE

While caregivers/teachers are not expected to diagnose or investigate child abuse and neglect, it is important that they be aware of common physical and emotional signs and symptoms of child maltreatment (see Appendix M, Recognizing Child Abuse and Neglect) (1,2).

All states have laws mandating the reporting of child abuse and neglect to child protection agencies and/or police. Laws about when and to whom to report vary by state (3). Failure to report abuse and neglect is a crime in all states and may lead to legal penalties.

COMMENTS

Child abuse includes physical, sexual, psychological, and emotional abuse. Other components of abuse include shaken baby syndrome/acute head trauma and repeated exposure to violence, including domestic violence. Neglect occurs when the parent/guardian/caregiver does not meet the child's basic needs and includes physical, medical, educational, and emotional neglect (4). Caregivers/teachers and health professionals may contact individual state hotlines where available. While almost all states have hotlines, they may not operate 24 hours a day, and some toll-free numbers may only be accessible within that particular state. Childhelp provides a national hotline: 1-800-4-A-CHILD (800/422-4453).

Many health departments will be willing to provide contact for experts in child abuse and neglect prevention and recognition. The American Academy of Pediatrics ( www.aap.org ) can also assist in recruiting and identifying physicians who are skilled in this work.

Caregivers/teachers are still liable for reporting even when their supervisor indicates they don't need to or says that someone else will report it. Caregivers/teachers who report in good faith may do so confidentially and are protected by law.

For more information about specific state laws on mandated reporting, go to the Child Welfare Information Gateway Mandated Reporting Web site, https://www.childwelfare.gov/topics/responding/reporting/mandated .

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

1.6.0.1 Child Care Health Consultants
9.4.1.9 Records of Injury
1.7.0.5 Stress
3.4.4.2 Immunity for Reporters of Child Abuse and Neglect
3.4.4.3 Preventing and Identifying Shaken Baby Syndrome/Abusive Head Trauma
3.4.4.4 Care for Children Who Have Experienced Abuse/Neglect
Appendix M: Recognizing Child Abuse and Neglect
Appendix N: Protective Factors Regarding Child Abuse and Neglect

REFERENCES

Rheingold AA, Zajac K, Chapman JE, et al. Child sexual abuse prevention training for childcare professionals: an independent multi-site randomized controlled trial of Stewards of Children. Prev Sci. 2015;16(3):374–385
Smith M, Robinson L, Segal J. Child abuse and neglect: how to spot the signs and make a difference. Helpguide.org Web site. https://www.helpguide.org/articles/abuse/child-abuse-and-neglect.htm. Updated October 2017. Accessed January 11, 2018
Darkness to Light. Reporting child sexual abuse. https://www.d2l.org/get-help/reporting. Accessed January 11, 2018
Child Welfare Information Gateway. What Is Child Abuse and Neglect? Recognizing the Signs and Symptoms. Washington, DC: Child Welfare Information Gateway; 2013. https://www.childwelfare.gov/pubpdfs/whatiscan.pdf. Accessed January 11, 2018

NOTES

Content in the STANDARD was modified on 05/29/2018.

Standard 3.4.4.3: Preventing and Identifying Shaken Baby Syndrome/Abusive Head Trauma

Content in the STANDARD was modified on 05/30/2018.

All childcare facilities should have a policy and procedure to identify and prevent shaken baby syndrome/abusive head trauma. All caregivers/teachers who are in direct contact with children, including substitute caregivers/teachers and volunteers, should receive training on preventing shaken baby syndrome/abusive head trauma; recognizing potential signs and symptoms of shaken baby syndrome/abusive head trauma; creating strategies for coping with a crying, fussing, or distraught child; and understanding the development and vulnerabilities of the brain in infancy and early childhood.

RATIONALE

Shaken baby syndrome/abusive head trauma is the occurrence of brain injury in newborns, infants, and children younger than 3 years caused by shaking a child. Even mild shaking can result in serious, permanent brain damage or death. The brain of the young child may bounce inside of the skull, resulting in brain damage, hemorrhaging, blindness, or other serious injuries or death. There have been several reported incidents in child care (1).

Caregivers/teachers care for young children who may be fussy or constantly crying. It is important for caregivers/teachers to be educated about the risks of shaking and provided with strategies to cope if they are frustrated (2). Many states have passed legislation requiring education and training for caregivers/teachers. Caregivers/teachers should check their individual state's specific requirements (3). Staff should be knowledgeable about and be able to recognize the signs and symptoms of shaken baby syndrome/abusive head trauma in children in their care.

COMMENTS

Victims of shaken baby syndrome/abusive head trauma may exhibit one or more of the following symptoms (4):

Irritability
Trouble staying awake
Trouble breathing
Vomiting
Unable to be woken up

For more information and resources on shaken baby syndrome/abusive head trauma, contact the National Center on Shaken Baby Syndrome at www.dontshake.org .

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.4.4.1 Recognizing and Reporting Suspected Child Abuse, Neglect, and Exploitation

REFERENCES

Araki T, Yokota H, Morita A. Pediatric traumatic brain injury: characteristic features, diagnosis, and management. Neurol Med Chir (Tokyo). 2017;57(2):82–93
Fortson BL, Klevens J, Merrick MT, Gilbert LK, Alexander SP. Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2016. https://www.cdc.gov/violenceprevention/pdf/CAN-Prevention-Technical-Package.pdf. Accessed January 11, 2018
Child Care Aware. Health and safety training. http://childcareaware.org/providers/training-essentials/health-and-safety-training . Accessed January 11, 2018
American Academy of Pediatrics. Abusive head trauma: how to protect your baby. HeathyChildren.org Web site. https://www.healthychildren.org/English/safety-prevention/at-home/Pages/Abusive-Head-Trauma-Shaken-Baby-Syndrome.aspx. Updated November 21, 2015. Accessed January 11, 2018

NOTES

Content in the STANDARD was modified on 05/30/2018.

Standard 3.4.4.5: Facility Layout to Reduce Risk of Child Abuse and Neglect

Content in the STANDARD was modified on 08/28/2018

All caregivers/teachers have a responsibility to supervise children at all times. The physical layout of child care facilities should be arranged to allow for a high level of visibility in all areas used by children, including diaper changing stations and toileting areas, while upholding children's right to privacy. All areas should be within view by at least 1 adult in addition to the primary caregiver/teacher at all times.

For center-based programs, rooms should be designed so that there are windows to the hallways to keep classroom activities visible, or it should be ensured that inside doors to activity areas remain open during hours of operation. Home-based programs should ensure that activities are conducted in 1 or 2 primary rooms that are dedicated to child care programming. These arrangements reduce the risk of child abuse and neglect and the likelihood of extended periods in isolation for individual caregivers/teachers with children, especially in areas where children may be partially undressed or in the nude. For small family child care home caregivers/teachers, a plan should be intentionally made for how to ensure the most active supervision possible.

Caregivers/teachers should be educated and trained in child abuse prevention and remain aware of potential risks of abuse and neglect of a child when in care. Other facility staff should periodically walk into child care rooms to monitor/prevent potential instances of child abuse and neglect. Family home caregivers/teachers should not allow other adults in the household to be alone with children at any time.

RATIONALE

Despite the fact that most child abuse and neglect occur inside the home, children may also experience abuse by caregivers/teachers while in out-of-home care (1). While upholding a child's right to privacy, centers can take action to prevent child abuse and neglect from occurring. For instance, the presence of multiple caregivers greatly reduces the risk of serious abusive injury. Child maltreatment tends to occur in privacy and isolation, especially in toileting areas and during diaper changing (2).

COMMENTS

Small family child care homes will need to be creative to ensure active supervision at all times, even when the children are toileting. This may include group potty time for toddlers or creating a very small play area in the hall outside the bathroom to which all the small children can be moved when each one in is the bathroom.

Additional information on preventing child abuse in out-of-home care can be found at:

United States Department of Agriculture, National Institute of Food and Agriculture. Cooperative Extension. What child care providers need to know about preventing abuse and neglect. http://articles.extension.org/pages/25590/what-child-care-providers-need-to-know-about-preventing-abuse-and-neglect. Published September 4, 2015. Accessed June 26, 2018
Karageorge K, Kendall R. The Role of Professional Child Care Providers in Preventing and Responding to Child Abuse and Neglect. Washington, DC: US Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families Children's Bureau, Office on Child Abuse and Neglect; 2008. https://www.childwelfare.gov/pubPDFs/childcare.pdf. Accessed June 26, 2018
Office of Head Start, Early Childhood Learning & Knowledge Center. Active supervision toolkit. https://eclkc.ohs.acf.hhs.gov/publication/active-supervision-toolkit. Updated January 12, 2018. Accessed June 26, 2018
Virtual Lab School. Child abuse prevention, identification, and reporting. https://www.virtuallabschool.org/preschool/safe-environments/lesson-7?module=426. Accessed June 26, 2018

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

2.2.0.1 Methods of Supervision of Children
5.4.1.1 General Requirements for Toilet and Handwashing Areas
5.4.1.4 Preventing Entry to Toilet Rooms by Infants and Toddlers
5.4.1.6 Ratios of Toilets, Urinals, and Hand Sinks to Children
5.4.1.7 Toilet Learning/Training Equipment
2.1.2.5 Toilet Learning/Training
3.2.1.4 Diaper Changing Procedure
3.2.1.5 Procedure for Changing Children's Soiled Underwear, Disposable Training Pants and Clothing
3.2.2.1 Situations that Require Hand Hygiene
5.4.1.2 Location of Toilets and Privacy Issues
5.4.1.3 Ability to Open Toilet Room Doors
5.4.1.5 Chemical Toilets
5.4.1.8 Cleaning and Disinfecting Toileting Equipment
5.4.1.9 Waste Receptacles in the Child Care Facility and in Child Care Facility Toilet Room(s)

REFERENCES

American Academy of Pediatrics. Child abuse and neglect. HealthyChildren.org Web site. https://www.healthychildren.org/English/safety-prevention/at-home/Pages/What-to-Know-about-Child-Abuse.aspx. Updated April 13, 2018. Accessed June 26, 2018
United States Department of Agriculture, National Institute of Food and Agriculture. Cooperative Extension. Creating safe and appropriate diapering, toileting, and hand washing areas in child care. http://articles.extension.org/pages/63292/creating-safe-and-appropriate-diapering-toileting-and-hand-washing-areas-in-child-care. Published October 2, 2015. Accessed June 26, 2018

NOTES

Content in the STANDARD was modified on 08/28/2018

Standard 3.6.4.5: Death

Content in the STANDARD was modified on 05/17/2016 and 8/25/2020.

Early care and education (ECE) programs should have a plan in place for responding to any death relevant to children enrolled in the program and their families. The plan should describe protocols the program will follow and resources available to children, families, and staff.¹

If an ECE program experiences the death of a child or adult, the following should be done, and these actions can take place simultaneously²:

When a child dies or collapses unexpectedly, ECE staff should notify emergency medical services/personnel promptly on discovering the child and begin to administer appropriate first aid and/or cardiopulmonary resuscitation as directed.²
Caregivers/teachers responsible for any children who may have observed or were in the same room where the collapse or death occurred should take the children to a different room.
Immediately notify the child's parents/guardians or adult's emergency contact; this can include information on what hospital the child/adult is being taken to.³
Notify law enforcement immediately and follow all law enforcement protocols regarding the scene of the death.³

Do not disturb the scene.
Do not show the scene to others.
Reserve conversation about the event until having consulted with and completed all interviews with law enforcement.

Notify the licensing agency the same day the death occurs.
ECE programs should only release specific information about the circumstances of the child's or adult's death that the authorities and the deceased member's family agree that the program may share.
Supportive and reassuring comments should be provided to children directly affected. Provide age-appropriate information for children, parents/guardians, and staff.

Depending on the cause of death (including sudden unexpected infant deaths [SUIDs], sudden infant death syndrome [SIDS], suffocation, injury, maltreatment, etc), there may be a need for updated education on the subject for caregivers/teachers and/or children as well as implementation of improved health and safety practices.

Caregivers/teachers should be knowledgeable about safe sleep practices and implement them so that sleep-related deaths are not treated as possible maltreatment cases, resulting in false, inappropriate criminal and protective services investigations of the ECE program.⁵

If a child or adult known to the children enrolled in the ECE program dies while not at the ECE facility^1,3

Provide age-appropriate information for children, parents/guardians, and staff.
Make resources for support available to staff, parents, and children.

If a death outside the ECE program might be due to suspected child maltreatment or neglect, the caregiver/teacher is mandated to report this to child protective services. Failing to consider or follow up on a suspected child abuse/neglect case can put other children (eg, siblings, children in the extended family, those enrolled in the program) at risk.⁴

RATIONALE

Proper management of unexpected deaths of children or adults by ECE staff allows families and staff who are affected the opportunity to react, grieve, assess, and communicate their needs.⁵A parent's experience following the death of a child varies enormously, and the way staff respond to and support families can make a considerable difference.²

COMMENTS

ADDITIONAL RESOURCES

The following resources can offer support and counseling to caregivers/teachers and families experiencing tragedy:

National Action Partnership to Promote Safe Sleep

http://nappss.org

First Candle

www.firstcandle.org

National Center for School Crisis and Bereavement
https://www.schoolcrisiscenter.org

"Supporting the Grieving Child and Family"

https://pediatrics.aappublications.org/content/138/3/e20162147

National Center for Education in Maternal and Child Health SUID/SIDS Gateway

https://www.ncemch.org/suid-sids

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

1.4.1.1 Pre-service Training
3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
3.4.4.1 Recognizing and Reporting Suspected Child Abuse, Neglect, and Exploitation
3.4.4.3 Preventing and Identifying Shaken Baby Syndrome/Abusive Head Trauma
3.4.4.5 Facility Layout to Reduce Risk of Child Abuse and Neglect
3.4.4.2 Immunity for Reporters of Child Abuse and Neglect
3.4.4.4 Care for Children Who Have Experienced Abuse/Neglect
9.2.4.3 Disaster Planning, Training, and Communication

REFERENCES

Sidebotham P, Marshall D, Garstang J. Responding to unexpected child deaths. In: Duncan JR, Byard RW, eds. SIDS: Sudden Infant and Early Childhood Death; The Past, the Present and the Future. Adelaide, South Australia, Australia: University of Adelaide Press; 2018. https://www.ncbi.nlm.nih.gov/books/NBK513395 . Accessed May 18, 2020
Association of SIDS and Infant Mortality Programs. The unexpected death of an infant or child: standards for services to families. http://www.stonybrookmedicine.edu/sites/default/files/asip_standards.pdf . Reviewed March 2001. Accessed May 18, 2020
National SIDS/Infant Death Resource Center. Responding to a Sudden, Unexpected Infant Death: The Professional's Role. Vienna, VA: National SIDS/Infant Death Resource Center; 2004. https://www.ncemch.org/suid-sids/documents/SIDRC/ProfessionalRole.pdf . Accessed May 18, 2020
Palusci VJ, American Academy of Pediatrics Council on Child Abuse and Neglect, Kay AJ, et al. Identifying child abuse fatalities during infancy. Pediatrics. 2019;144(3):e20192076 PMID: 31451610 https://doi.org/10.1542/peds.2019-2076
Palusci VJ. Pediatricians have critical role in identifying child abuse fatalities during infancy. AAP News. ttps://www.aappublications.org/news/2019/08/26/childabuse082619 . Published August 26, 2019. Accessed May 18, 2020

NOTES

Content in the STANDARD was modified on 05/17/2016 and 8/25/2020.

Standard 5.6.0.1: First Aid and Emergency Supplies

Content in the STANDARD was modified on 01/23/2020.

Early care and education programs should maintain fully equipped first aid kits in each classroom in case of an injury. The first aid kit should be kept in a container, cabinet, or drawer that is labeled and stored in a location that is known and accessible to staff at all times and out of reach of children. First aid kits in vehicles and classroom kits taken out for recess or a walk should be stored safely in a place that is out of reach of children. When children leave the facility for recess or a walk or to be transported, a designated staff member should bring a first aid kit in a portable device (eg, backpack) or otherwise ensure that a first aid kit is readily available.

Early care and education staff should inventory or check first aid supplies once a month and replace any used or expired items.¹ An itemized list of supplies and a written log should be kept that documents

The date that each inventory was conducted
Verification that expiration dates of supplies were checked
Location of supplies (eg, in the facility supply, transportable first aid kit[s])
The legal name/signature of the staff member who completed the inventory

Early care and education program directors should have plans/methods for verifying that these steps are taken as planned.

First Aid Items

The following first aid supplies should be in all classroom first aid kits ^{1(p463-464)-4:}

Adhesive bandages (assorted sizes) and tape
Antiseptic solution (hydrogen peroxide) or antiseptic wipes
Cold pack
Cotton-tipped swabs
Disposable powder-free, latex-free gloves
Eye patch
Fever-reducing medications (eg, acetaminophen/ibuprofen) to be used ONLY for children with an order from a primary health care provider and signed parental consent
Flexible roller gauze
Liquid hand soap and/or handwashing gels
Mouthpiece for giving cardiopulmonary resuscitation (CPR) (available from your local Red Cross)
Pen/pencil and note pad
Plastic bags (for disposing of blood and other body fluids)
Safety pins
Sanitary pads, individually wrapped (to contain bleeding of injuries)
Small scissors
Sterile eyewash
Sterile gauze pads (various sizes)
Thermometer—digital or tympanic (ear)—should not contain glass/mercury
Triangular bandages
Tweezers
Water (2 L of sterile water for cleaning wounds or eyes)

When children are on a walk or are transported to another location, the transportable first aid kit should include ALL items listed previously AND the following emergency information/items:

A roster of all children present
Contact information and list of approved family/guardians authorized for pickup
List of emergency phone numbers (eg, poison control, hospital/emergency facilities)
Special health care plans/emergency medications for both children and caregivers
Special health care documents
Signed emergency release forms for each child
First aid/choking/CPR chart (American Academy of Pediatrics or equivalent)
Up-to-date first aid manual
Written transportation policy and contingency plan (up-to-date and easily accessible)
Maps
Cell phone
Radio
Whistle
Flashlight

RATIONALE

Facilities must place emphasis on safeguarding each child and ensuring that staff members are prepared and able to handle emergencies.³ Well-stocked first aid and disaster/emergency supplies help ensure staff are prepared and able to handle possible emergencies and injuries.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

1.4.3.1 First Aid and Cardiopulmonary Resuscitation Training for Staff
3.2.2.5 Hand Sanitizers
3.6.1.3 Thermometers for Taking Human Temperatures
1.4.3.2 Topics Covered in Pediatric First Aid Training
3.4.3.1 Medical Emergency Procedures
4.9.0.8 Supply of Food and Water for Disasters
9.2.4.1 Written Plan and Training for Handling Urgent Medical Care or Threatening Incidents
9.2.5.1 Transportation Policy for Centers and Large Family Homes
Appendix NN: First Aid and Emergency Supply Lists

REFERENCES

American Academy of Pediatrics. PedFACTs: Pediatric First Aid for Caregivers and Teachers. 2nd ed. Burlington, MA: Jones & Bartlett Learning; 2014
KidsHealth. First-aid kit. https://kidshealth.org/en/parents/firstaid-kit.html . Reviewed August 2018. Accessed August 20, 2019
eXtension. First aid in child care. https://articles.extension.org/pages/25746/first-aid-in-child-care . Published September 14, 2015. Accessed August 20, 2019
Federal Emergency Management Agency. Emergency supply list. https://www.fema.gov/media-library-data/1390846764394-dc08e309debe561d866b05ac84daf1ee/checklist_2014.pdf . Accessed August 20, 2019

NOTES

Content in the STANDARD was modified on 01/23/2020.

Standard 9.2.4.3: Disaster Planning, Training, and Communication

Content in the STANDARD was modified on 02/27/2020.

Early care and education programs should develop written action plans to prepare for and respond to emergency or natural disaster situations. These written action plans should include preparation/response practices and procedures for hazards/disasters that could occur in any location, including acts of violence, biological or chemical terrorism, exposure to hazardous agents, facility damage, fire, missing child, power outage, and other situations that may require evacuation, relocation, lockdown, lockout, or shelter in place. All early care and education programs should have procedures in place to address natural disasters relevant to their location (eg, earthquakes, tornados, tsunamis, floods/flash floods, storms, volcanoes).

If a facility is unsure of what to do, the first point of contact in any situation should be the local public health authority.¹ The local public 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.

Certain emergency/disaster situations may result in exceptions being made regarding state or local regulations (either in existing facilities or in temporary facilities). In these situations, facilities should make every effort to meet or exceed the temporary requirements.

Written Emergency/Disaster Action Plan

Facilities should develop and implement a written plan that describes the practices and procedures they will use to prepare for and respond to emergency or disaster situations. This emergency/disaster plan should include

Information on disasters likely to occur in or near the facility, county, state, or region that require advance preparation and/or contingency planning
Plans (and a timeline) to conduct regularly scheduled practice drills within the facility and in collaboration with community or other exercises
Mechanisms for notifying and communicating with parents/guardians in various situations (eg, website postings; use of social media platforms; email notifications; recorded message on central telephone number, telephone calls, use of telephone tree, or cellular phone texts; posting of flyers at the facility and other community locations)
Mechanisms for notifying and communicating with emergency management and public health officials (advance connections with these officials will be helpful to identify times when it would be important to notify others)
Information on crisis management (decision-making and practices) related to sheltering in place; lockdown; relocating to another facility; evacuation procedures, including how nonmobile 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; and responding to an intruder or threatening individual
Identification of primary and secondary meeting places and plans for reunification of parents/guardians with their children in the event of an evacuation
Details on collaborative planning with other groups and representatives (eg, other early care and education facilities; schools; state child care licensing personnel; law enforcement and fire officials; emergency management personnel and first responders; pediatricians and other health professionals; public health agencies; clinics; hospitals; volunteer agencies, including Red Cross and other known groups likely to provide shelter and related services)
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
Contingency plans for various situations that address

Emergency contact information and related procedures to maintain in contact with staff, families, community contacts, vendors, etc
How the facility will care for children and account for them, until the parent/guardian or other authorized adult has been appropriately identified and has accepted responsibility for their care
Acquiring, stockpiling, storing, and cycling provisions to keep updated emergency food/water and supplies that might be needed to care for children and staff for a minimum of 3 days and up to 7 days if sheltering in place is required or when removal to an alternate location is required
Administering medicine and implementing other instructions as described in individual special care plans
Procedures that might be implemented in the event of an infectious disease outbreak, epidemic, or other infectious disease emergency (eg, reviewing relevant immunization records, conducting daily health checks, 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)
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
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)
Actions to be followed when no authorized person arrives to pick up a child

Specific Written Emergency/Disaster Action Plans

The following are emergency/disaster action plans currently used in early care and education programs. Caregivers/teachers should be aware of the differences between each action plan and when to implement the appropriate actions.

Evacuation
An evacuation is carried out to move students and staff out of the building. These drills often accompany fire drills and require students and staff to leave and move to a nearby, predetermined location.²

An evacuation plan should include all the following components³:

Information, diagrams, and/or maps on classroom and building locations, including locations of all exits, doors, and stairways
Maps of evacuation routes in each classroom, including
1. Primary and secondary evacuation routes
2. Locations of the primary and secondary assembly areas
3. Locations of fire alarm manual pull stations, fire extinguishers, smoke detectors, sprinkler heads, and sprinkler control valves
Directions for how staff will be notified and what they will do when they need to immediately evacuate the building and proceed to assembly areas (staff and children should be advised to evacuate as quickly and as safely as possible and should not attempt to secure or collect personal items during an evacuation, if it would compromise their safety or the safety of the children they care for)
Recommendation that (when feasible) each classroom should take their portable first aid kit with emergency information, medications, and other documents
Description of how staff will monitor/track children, including a requirement that attendance should be taken immediately before evacuating and once at the assembly area
Steps to notify parents in an emergency

Shelter in Place

A shelter in place is carried out during severe weather and other environmental hazard/threat situations with the goal of keeping people safe while remaining indoors.^2,4 Early care and education programs should have students, staff, and visitors take shelter in predetermined rooms with access to a telephone, stored disaster supplies, and, ideally, a bathroom. Facility and classroom doors should all remain shut and locked, depending on the situation.

A shelter-in-place plan should include all the following components⁵:

Details on how to notify staff and children that a shelter-in-place drill (or another code word) is occurring, such as verbally announce "shelter-in-place" or other communication term.
Recommendations for staff as to whether they should bring children inside or relocate to another nearby facility.
Instructions to bring children and staff to the predetermined area(s) within the building/home.
1. Depending on the nature of the emergency, when outside air quality is compromised, select interior room(s) without windows or vents that has adequate space to accommodate all children and staff.
2. Close and lock all windows and doors.
3. If necessary, staff should shut off the building's heating systems, gas, air conditioners, and exhaust fans and switch valves to the closed position.
4. If necessary, seal all cracks around the doors and any vents into the room with duct tape or plastic sheeting.
Attendance should be taken to ensure everyone is present and accounted for in the area.
No outside access is permitted, but early care and education programs may allow activities within the predetermined area to continue.
Early care and education staff should follow established procedures for assisting children and/or staff with special health care needs. Bring medications, special health care plans, and assistive devices for communication and mobility.
Early care and education staff should follow established procedures for addressing children's (especially infants and toddlers) nutrition and hygiene needs.
Provide developmentally appropriate activities (a list of ideas can be determined in advance and included in the written plan).
Continue the shelter-in-place drill until the early care and education program director or designee announces the end of the drill.

Lockdown

A lockdown is used when there is a perceived threat/danger inside the building.² A lockdown is carried out to secure all children and staff within their classrooms by locking the doors, directing people to hide or stay away from windows and doors, and sometimes asking people to remain calm and quiet. No children or staff members should be in the hallways during a lockdown. The plan should include protocols on when to unlock/open doors and should be developed in collaboration with local law enforcement officials.

A lockdown plan should include all the following components⁶:

Notify children that a lockdown is occurring by verbally announce "lockdown" or other communication term.
If children are outside, bring them inside.
Instruct people to go to the nearest room or the designated location away from danger and bring first aid/disaster and emergency supply kits.
Lock the classroom doors and windows, cover the windows, and turn off lights and audio equipment. Use tables, cabinets, or other heavy furniture to block doors/windows, if needed.
Children should be asked to remain seated on the floor, away from doors and windows.
Attendance should be taken to ensure all children are accounted for and remain inside the room.
If relevant, instruct staff and children that everyone will ignore any fire alarm activation.
Set cell phones to silent or vibrate.
Activate the emergency communication/notification plan, contact outside staff and families, inform them of the situation, and explain that they cannot enter the building right now and if they are nearby, they may need to find a safe location.
Staff should follow established procedures to remain calm and help children stay quiet. Examples include holding hands, gently rocking back and forth, using modified hand gestures that relate to a song without singing (eg, heads, shoulders, knees, and toes; eensy-weensy spider), making eye contact with each child, or offering pacifiers to infants.
Staff should follow established procedures for assisting children and/or staff with special health care needs. Bring medications, care plans, and assistive devices for communication and mobility into the area where people are located.
Staff should follow established procedures for addressing children's (especially infants and toddlers) nutrition and hygiene needs.
Remain in the room until the early care and education program director or designee announces the end of the lockdown.

Details in the emergency/disaster plans should be reviewed and updated biannually and immediately after any relevant event to incorporate any best practices or lessons learned into the document.

Facilities should identify which agency or agencies would be the primary contact for early care and education regulations, evacuation instructions, and other directives that might be communicated in various emergency or disaster situations.

Staff Support/Training

Staff should receive training on emergency/disaster planning and response. Training can be provided by individual groups or people such as emergency management agencies, educators, child care health consultants (CCHCs), health professionals, hospital or health care coalition personnel, law enforcement or fire officials, or emergency personnel qualified and experienced in disaster preparedness and response. Training could also be developed with a community team identified to assist the program with these efforts. The training should address

Why it is important for early care and education programs to prepare for disasters and to have an emergency/disaster plan
Different types of emergency and disaster situations and when and how they may occur

Natural disasters
Exposure to agents (ie, biological, chemical, radiological, nuclear, or explosive) that may be intentional (terrorism) or accidental
Outbreaks, epidemics, or other infectious disease emergencies

The special and unique needs of children at various ages and developmental stages and appropriate responses to children's physical and emotional needs during and after the disaster, including information on consulting with pediatric disaster experts
How to obtain support for staff members in coping/adjusting after a disaster/emergency
Providing first aid and medications and accessing emergency health care in situations in which there are not enough available resources
Contingency planning, including the ability to be flexible, to improvise, and to adapt to ever-changing situations
Developing personal and family preparedness plans
Strategies for supporting and communicating with families
Floor plan/layout and appropriate safety considerations
Location of emergency documents, supplies, medications, and equipment needed by children and staff with special health care needs
Typical community, county, and state emergency procedures (including information on state disaster and pandemic influenza plans, emergency operation centers, and the incident command structure)
Community resources for post-event support, such as agencies with mental health consultants, counselors, and safety consultants
Which individuals or agency representatives have the authority to close early care and education programs and schools and when and why this might occur
Insurance and liability issues
New advances in technology, communication efforts, and disaster preparedness strategies customized to meet children's needs

Facilities should determine how often they will conduct drills/tests, or "practice use" of an evacuation, shelter in place, or lockdown, as well as the communication options/planning mechanisms that are selected. These drills/tests should be held at least annually, but some could also be held on a biannual or quarterly basis. After an event or practice drill, the staff should meet to review what happened and identify any needed changes to the written plan or protocols.

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

Portions of the emergency/disaster plan relevant to parents/guardians or the public
Procedures and instructions for what parents/guardians can expect if something happens at the facility
Description of how parents/guardians will receive information and updates during or after a potential emergency or disaster situation
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

Recovery After a Disaster

In the recovery time frame after a disaster, early childhood professionals, early care and education health and safety experts, CCHCs, health care professionals, and researchers with expertise in child development or early care and education may be asked to support the development of or help to implement emergency, temporary, or respite child care. These individuals may also be asked to assist with caring for children in shelters or other temporary housing situations. Disaster recovery can take months or even years, so it is wise to plan for how the program will address any ongoing support needs of the children, families, and staff in these situations. Refer to Standard 5.1.1.5: Environmental Audit of Site Location for more information on assessing building safety following a disaster.

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 (and testing/practicing these), 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, on a daily basis as well as during a disaster or emergency, 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 while a situation is evolving and 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.

Ignoring fire alarm activation during a lockdown or lockdown drill is used to protect children from an intruder either in or outside of the building, as the fire alarm could trigger everyone to leave the building, which would perhaps put them in the path of the intruder. Explaining this up front will help adults and children comply with this approach in an emergency.

Identifying and connecting with the appropriate key contact(s) 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 early care and education programs. In addition, representatives within the local school system (especially school administrators and school nurses) may have effective and more direct connections to the state emergency management or disaster preparedness and response system. If early care and education programs do not typically communicate with the schools in their area on a regular basis, staff can consider establishing a direct link to and partnership with school representatives already involved in disaster planning and response efforts.

Early care and education programs, as well as pediatricians, are rarely considered or included in disaster planning or preparedness efforts; unfortunately, the needs of children are, therefore, often overlooked. Children have important physical, physiological, developmental, and psychological differences from adults that can and must be anticipated in disaster planning, response, and recovery processes. Including considerations for children in state plans is a requirement beginning to be implemented in 2019. Caregivers/teachers, pediatricians, health care professionals, and child advocates can prepare to assume a primary mission of advocating for children before, during, and after a disaster.⁷

COMMENTS

Disaster planning and response protocols are unique and 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 US 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 Planning Frameworks ( https://www.fema.gov/national-planning-frameworks ). 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 an early care and education program 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.

ADDITIONAL RESOURCES

Ready.gov. Plan ahead for disasters. www.ready.gov . Accessed August 21, 2019

US Office of Human Services, Emergency Preparedness and Response. https://www.acf.hhs.gov/ohsepr . Accessed August 21, 2019

Centers for Disease Control and Prevention, Center for Preparedness and Response. Ready Wrigley. https://www.cdc.gov/cpr/readywrigley/ . Reviewed October 15, 2018. Accessed August 21, 2019

TYPE OF FACILITY

Center, Early Head Start, Early Head Start, Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

5.1.1.5 Assessment of the Environment at the Site Location
3.6.4.5 Death
5.6.0.1 First Aid and Emergency Supplies
3.4.3.1 Medical Emergency Procedures
3.4.3.2 Use of Fire Extinguishers
3.4.3.3 Response to Fire and Burns
4.9.0.8 Supply of Food and Water for Disasters
9.2.4.4 Written Plan for Seasonal and Pandemic Influenza
9.2.4.9 Policy on Actions to Be Followed When No Authorized Person Arrives to Pick Up a Child
Appendix NN: First Aid and Emergency Supply Lists

REFERENCES

American Academy of Pediatrics. PedFACTs: Pediatric First Aid for Caregivers and Teachers. 2nd ed. Burlington, MA: Jones & Bartlett Learning; 2014
American Academy of Pediatrics. School safety during emergencies: what parents need to know. HealthyChildren.org website. https://www.healthychildren.org/English/safety-prevention/all-around/Pages/Actions-Schools-Are-Taking-to-Make-Themselves-Safer.aspx . Updated June 7, 2015. Accessed August 21, 2019
US General Services Administration. Sample child care evacuation plan. https://www.gsa.gov/resources-for/citizens-consumers/child-care/child-care-services/for-professionals-providers/emergency-management/sample-child-care-evacuation-plan . Reviewed October 11, 2018. Accessed August 21, 2019
National Center on Early Childhood Health and Wellness, US Department of Health and Human Services Administration for Children and Families Office of Head Start. Emergency Preparedness Manual for Early Childhood Programs. https://eclkc.ohs.acf.hhs.gov/sites/default/files/pdf/emergency-preparedness-manual-early-childhood-programs.pdf . Accessed August 21, 2019
University of California San Francisco California Childcare Health Program. Sample announced shelter-in-place drill. https://cchp.ucsf.edu/sites/cchp.ucsf.edu/files/Sample-Drill-Shelter-in-Place.pdf . Published 2016. Accessed August 21, 2019
University of California San Francisco California Childcare Health Program. Sample announced lockdown drill. https://cchp.ucsf.edu/sites/cchp.ucsf.edu/files/Sample-Drill-Lockdown.pdf . Published 2016. Accessed August 21, 2019
Quinn M, Gillooly D, Kelly S, Kolassa J, Davis E, Jankowski S. Evaluation of identified stressors in children and adolescents after Super Storm Sandy. Pediatr Nurs. 2016;42(5):235–241

NOTES

Content in the STANDARD was modified on 02/27/2020.

Standard 9.2.4.4: Written Plan for Seasonal and Pandemic Influenza

The facility should have a written plan for seasonal and pandemic influenza (flu) to limit and contain influenza-related health hazards to the staff, children, their families and the general public. The plan should include information on:

Planning and coordination:
1. Forming a committee of staff members, parents/guardians, and the child care health consultant to produce/review a plan for dealing with the flu each year including specific plans if there is a flu pandemic;
2. Reviewing the seasonal flu plan during and after flu season so that key staff could discuss how the program would plan for a more serious outbreak or pandemic;
3. Assigning one person to identify reliable sources of information regarding the seasonal flu strain or pandemic flu outbreak considering local, state and national resources, monitor public health department announcements and other guidance, and forward key information to staff and parents/guardians as needed (the child care health consultant can be especially helpful with this);
4. Including the infection control policy and procedure (see below) and a communication plan (see below) in the seasonal flu plan;
5. Including a communication plan (see below), the infection control policy and procedure (see below), and the child learning and program operations plan (see below) in the pandemic flu plan. In addition the pandemic flu plan should include:
6. Identification of who in the program's community has legal authority to close child care programs if there is a public health emergency or pandemic;
7. A list of key contacts such as representatives at the local/state health departments and agencies that regulate child care and their plans to combat or address seasonal or pandemic influenza (programs can extend an invitation for consultation from these departments when formulating the plan).
8. Development of a plan of action for addressing key business continuity and programmatic issues relevant to pandemic flu;
9. Communication to parents/guardians encouraging them to have a back-up plan for care for their children if the program must be closed;
10. Collaboration with those in charge of the community's planning to find other sources of meals for low-income children who receive subsidized meals in child care in case of a closure;
11. Knowledge of services in the community that can help staff, children, and their families deal with stress and other problems caused by a flu pandemic;
12. Communicate with other child care programs in the area to share information and possibly share expertise and resources.
Communications plan:
1. Developing a plan for keeping in touch during the flu and/or pandemic with staff members and children's families;
2. Ensuring staff and families have read and understand the flu and/or pandemic plan and understand why it's needed;
3. Communicating reliable information to staff and children's families on the issues listed below in their languages and at their reading levels:
4. How to help control the spread of flu by handwashing/cleansing and covering the mouth when coughing or sneezing (see http://www.cdc.gov/flu/school/);
5. How to recognize a person that may have the flu, and what to do if they think they have the flu (see http://www.pandemicflu.gov);
6. How to care for family members who are ill (see https://www.cdc.gov/flu/pdf/freeresources/general/influenza_flu_homecare_guide.pdf);
7. How to develop a family plan for dealing with a flu pandemic (see https://www.cdc.gov/flu/pandemic-resources/index.htm).
Infection control policy and procedures:
1. Developing a plan for keeping children who become ill at the child care facility away from other children until the family arrives, such as a fixed place for holding children who are ill in an area of their usual caregiving room or in a separate room where interactions with unexposed children and staff will be limited;
2. Establishing and enforcing guidelines for excluding children with infectious diseases from attending the child care facility (1);
3. Teaching staff, children, and their parents/guardians how to limit the spread of infection (see http://www.cdc.gov/flu/school);
4. Maintaining adequate supplies of items to control the spread of infection;
5. Educating families about the influenza vaccine, including that experts recommend yearly influenza vaccine (and an influenza-specific vaccine, for example H1N1, if necessary) for everyone, however, if there is a vaccine shortage, priority should be given to children and adolescents six months through eighteen years of age, caregivers/teachers of all children younger than five years of age, and health care professionals (see http://www.cdc.gov/flu/);
6. Staff caring for all children should receive annual vaccination against influenza (and an influenza-specific vaccine such as what was used during the 2009 H1N1 pandemic, if necessary) each year, preferably before the start of the influenza season (as early as August or September) and as long as influenza is circulating in the community, immunization should continue through March or April;
7. Maintaining accurate records when children or staff are ill with details regarding their symptoms and/or the kind of illness (especially when influenza was verified through testing);
8. Practicing daily health checks of children and adults each day for illness;
9. Determining guidelines to support staff members to remain home if they think they might be ill and a mechanism to provide paid sick leave so they can stay home until completely well without losing wages.
Child learning and program operations:
1. Plan how to deal with program closings and staff absences;
2. Support families in continuing their child's learning if the child care program or preschool is closed;
3. Plan ways to continue basic functions (meeting payroll, maintaining communication with staff, children, and families) if modifications to program planning are necessary or the program is closed.

The facility should also include procedures for staff and parent/guardian training on this plan.

Some of the above plan components may be beyond the scope of ability in a small family child care home. In this case, the caregiver/teacher should work closely with a child care health consultant to determine what specific procedures can be implemented and/or adapted to best meet the needs of the caregiver/teacher and the families s/he serves.

RATIONALE

Yearly or seasonal influenza is a serious illness that requires specific management to keep children healthy. A pandemic flu is a flu virus that spreads rapidly across the globe because most of the population lacks immunity (1,2). The goals of planning for an influenza pandemic are to save lives and to reduce adverse personal, social, and economic consequences of a pandemic. Pandemics, while rare, are not new. In the twentieth century, three flu pandemics were responsible for more than fifty million deaths worldwide, including more than 20 million deaths in the United States (2).
The 2009 influenza A (H1N1) pandemic was the first in the 21^st century that resulted in between 151,700 and 575,400 deaths worldwide (2). As it is not possible to predict with certainty when the next flu pandemic will occur or how severe it will be, seasonal flu management and preparation is essential to minimize the potentially devastating effects (1-4).

COMMENTS

The Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) recommend annual influenza vaccination for children and caregivers/teachers in child care settings (1,2,5,6). Vaccination is the best method for preventing flu and its potentially severe complications in children (1,2,5,6). The CDC and AAP recommend children and adolescents six months through eighteen years of age, for all adults including household contacts, caregivers/teachers of all children younger than five years of age, and health care professionals get the flu vaccine. Certain groups of children are at increased risk for flu complications. Child care health consultants are very helpful with finding and coordinating the local resources for this planning. In addition most state and/or local health departments have resources for pandemic flu planning.

For additional resources, see:

Centers for Disease Control and Prevention Influenza (Flu): https://www.cdc.gov/flu/
Children, the Flu and the Flu Vaccine: http://www.cdc.gov/flu/protect/children.htm
Protecting Against Influenza (Flu): Advice for Caregivers of Young Children: http://www.cdc.gov/flu/protect/infantcare.htm

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.2.2.2 Handwashing Procedure
3.1.1.1 Conduct of Daily Health Check
3.6.1.1 Inclusion/Exclusion/Dismissal of Children
3.6.1.2 Staff Exclusion for Illness
7.3.3.1 Influenza Immunizations for Children and Caregivers/Teachers
9.2.4.3 Disaster Planning, Training, and Communication
3.2.3.2 Cough and Sneeze Etiquette
3.6.1.4 Infectious Disease Outbreak Control
3.6.2.1 Exclusion and Alternative Care for Children Who Are Ill
9.4.1.2 Maintenance of Records
Appendix A: Signs and Symptoms Chart
Appendix G: Recommended Childhood Immunization Schedule
Appendix H: Recommended Adult Immunization Schedule

REFERENCES

Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, pp. 43-48. 4^th Edition. Elk Grove Village, IL: American Academy of Pediatrics.
Centers for Disease Control and Prevention. 2016. Preventing the flu: Good habits can help stop germs. https://www.cdc.gov/flu/protect/habits.htm.
American Academy of Pediatrics. 2017. Influenza/pandemics. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Children-and-Disasters/Pages/Influenza-Pandemics.aspx.
Centers for Disease Control and Prevention. 2016. Children, the flu, and the flu vaccine. https://www.aap.org/en-us/Documents/disasters_dpac_InfluenzaHandout.pdf.
American Academy of Pediatrics. 2015. Influenza prevention and control. Strategies for early education and child care programs. https://www.aap.org/en-us/Documents/disasters_dpac_InfluenzaHandout.pdf.
American Academy of Pediatrics. Influenza In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases . 31st Edition. Itasca, IL: American Academy of Pediatrics; 2018: 476-477

Standard 9.2.4.5: Emergency and Evacuation Drills/Exercises Policy

Content in the STANDARD was modified on 05/21/2019.

Early care and education programs should have a written policy documenting that emergency drills or exercises are regularly practiced for geographically appropriate emergencies, natural disasters and violent/hostile intruder events.

a. Evacuation emergencies (eg, fires, floods, gas leaks, chemical spills)

b. Shelter-in-place emergencies (eg, tornados, earthquakes, threatening person outside)

c. Lockdown emergencies (eg, violent/hostile intruders, threatening/dangerous animals)

Early care and education programs should check their state licensing and regulations for specific drill requirements, including timing and frequency details. Staff members, children, and parents should be notified prior to a drill practice.¹

All drills/exercises should be recorded. More information on evacuation and shelter-in-place drill records can be found in Standard 9.4.1.16. Depending on the type of disaster, shelter-in-place and lockdown drills may take place within the early care and education program. Examples include earthquakes or tornadoes, where the drill might involve moving to a certain location within the building (eg, basements, away from windows). Evacuation drills/exercises should be practiced at various times of the day, including nap time; during varied activities; and from all exits. Early care and education programs should keep a roster of all children during the drill (Standard 9.2.4.6 Use of Daily Roster During Evacuation Drills). Children with special health care needs and disabilities should be included in all drills to determine if additional attention or accommodations may be needed.²

Caregivers/teachers are encouraged to invite first responders to become part of their emergency planning, training, and drills.²Early care and education programs should time evacuation procedures. Staff should aim to evacuate all persons in the specific number of minutes recommended by local fire officials (for fire evacuation), law enforcement officials, or emergency response personnel. A fire evacuation procedure should be approved and certified in writing by a fire inspector (for centers) or by a local fire department representative (for large and small family child care homes) during an annual on-site visit or other times at which an evacuation drill is observed and the facility is inspected for fire safety hazards.

During evacuation drills or when moving children from areas of potential danger, designated evacuation cribs can be used to evacuate infants and/or children with special health care needs or disabilities, if rolling is possible on the evacuation/exit route(s).³

In family child care homes, it is possible that infant rooms or napping areas are located on levels other than the main level, making written approval of the program's evacuation plan by the fire inspector or representative from the local fire department especially important.

RATIONALE

Regular emergency and evacuation drills/exercises constitute an important safety practice in areas where natural disasters and/or violent/hostile intruder events might occur. The routine practice of such drills fosters a calm, competent response to a natural or human-generated disaster when it occurs.⁴ Unannounced live drills with no prior notification to staff members, children, or parents/guardians may cause unnecessary and significant emotional distress.¹ The extensive turnover of both staff and children, in addition to the changing developmental abilities of the children who participate in evacuation procedures in early care and education programs, necessitate frequent practice of the exercises. Representatives and first responders from local fire and police departments can contribute their expertise when observing evacuation plans and drills and gain familiarity with the facility and the facility's plans in the event they are called on to respond in an emergency.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

5.4.5.2 Cribs
9.2.4.3 Disaster Planning, Training, and Communication
9.2.4.6 Use of Daily Roster During Evacuation Drills
9.4.1.16 Evacuation and Shelter-In-Place Drill Record

REFERENCES

Schonfeld DJ, Rossen E, Woodard D. Deception in schools—when crisis preparedness efforts go too far. JAMA Pediatr. 2017;171(11):1033–1034
State Capacity Building Center, Office of Child Care, US Department of Health and Human Services Administration for Children and Families. Emergency preparedness, response, and recovery: hostile intruders. How do states and territories plan for and respond to hostile intruder incidents? https://childcareta.acf.hhs.gov/sites/default/files/public/hostile_intruder_0.pdf. Published September 2017 . Accessed December 20, 2018
National Center on Early Childhood Health and Wellness, US Department of Health and Human Services Administration for Children and Families Office of Head Start. Emergency Preparedness Manual for Early Childhood Programs. https://eclkc.ohs.acf.hhs.gov/sites/default/files/pdf/emergency-preparedness-manual-early-childhood-programs.pdf. Accessed December 20, 2018
US General Services Administration. Sample child care evacuation plan. https://www.gsa.gov/resources-for/citizens-consumers/child-care/child-care-services/for-professionals-providers/emergency-management/sample-child-care-evacuation-plan . Reviewed October 11, 2018. Accessed December 20, 2018

NOTES

Content in the STANDARD was modified on 05/21/2019.

A Plant Where Plastic 2-liter Bottles Are Manufactured Probably Uses a ________ Layout.

Source: https://nrckids.org/CFOC/Infant_Toddlers

A Plant Where Plastic 2-liter Bottles Are Manufactured Probably Uses a ________ Layout.

Special Collection

Caring for Infants and Toddlers in Early Care and Education (I/T)

Table of Contents

I. Enrollment and Admission

Staffing, Consultants, and Supervision

Staff Qualifications and Training

Consultants

Supervision

Environment and Equipment

Building and Environment: Inside and Outside

Equipment, Materials, and Toys

Facility

Food Preparation and Feeding Area

Play Areas

Program Activities for Healthy Development

Developmentally Appropriate Practice

Positive Behavior Management

Healthy Weight Promotion

Physical Activity

B. Nutrition

Safe and Healthy Practices and Procedures

Safe Food Practices

Health Promotion and Protection

C. Cleaning/Sanitizing/Disinfecting Practices

Infection Control/Disease Prevention and Management

Medication Administration

Abuse/Neglect

Appendices

I. Enrollment and Admission

Standard 1.1.2.1: Minimum Age to Enter Child Care

RATIONALE

COMMENTS

TYPE OF FACILITY

RELATED STANDARDS

REFERENCES

Standard 9.2.1.3: Enrollment Information to Parents/Guardians and Caregivers/Teachers

RATIONALE

COMMENTS

TYPE OF FACILITY

RELATED STANDARDS

Standard 9.4.2.3: Contents of Admission Agreement Between Child Care Program and Parent/Guardian

RATIONALE

TYPE OF FACILITY

RELATED STANDARDS

REFERENCES

Staffing, Consultants, and Supervision

Standard 1.6.0.1: Child Care Health Consultants

RATIONALE

COMMENTS

TYPE OF FACILITY

RELATED STANDARDS

REFERENCES

NOTES

Standard 1.6.0.2: Frequency of Child Care Health Consultation Visits

RATIONALE

COMMENTS

TYPE OF FACILITY

RELATED STANDARDS

REFERENCES

NOTES

Standard 1.6.0.3: Infant and Early Childhood Mental Health Consultants

RATIONALE

COMMENTS

TYPE OF FACILITY

RELATED STANDARDS

REFERENCES

NOTES

Standard 1.6.0.4: Early Childhood Education Consultants

RATIONALE

TYPE OF FACILITY

RELATED STANDARDS

REFERENCES

Standard 1.1.1.1: Ratios for Small Family Child Care Homes

RATIONALE

COMMENTS

TYPE OF FACILITY

RELATED STANDARDS

REFERENCES

NOTES