CFOC3 Content

 
Number of Standards Returned: 37
Content Current as of Sep 02, 2014


Special Collection

Oral Health 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


A Joint Collaborative Project of

American Academy of Pediatrics
141 Northwest Point Boulevard
Elk Grove Village, IL 60007-1019

American Public Health Association
800 I Street, NW
Washington, DC 20001-3710

National Resource Center for Health and Safety in Child Care and Early Education
University of Colorado, College of Nursing
13120 E 19th Avenue
Aurora, CO 80045

Support for this project was provided by the
Maternal and Child Health Bureau,
Health Resources and Services Administration,
U.S. Department of Health and Human Services
(Cooperative Agreement #U46MC09810)

 


Copyright © 2013
American Academy of Pediatrics
American Public Health Association
National Resource Center for Health and Safety in Child Care and Early Education

Oral Health in Child Care and Early Education may be reproduced without permisson 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. 2013. Oral health 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: Kent Hogue, Lorina Washington


 

Table of Contents

Introduction

Oral Health Practices

Standard 3.1.4.3: Pacifier Use
Standard 3.1.5.1: Routine Oral Hygiene Activities
Standard 3.1.5.2: Toothbrushes and Toothpaste
Standard 3.6.1.5: Sharing of Personal Articles Prohibited
Standard 5.5.0.1: Storage and Labeling of Personal Articles
Standard 2.1.1.1: Written Daily Activity Plan and Statement of Principles

Education and Training

Standard 2.4.1.1: Health and Safety Education Topics for Children
Standard 2.4.1.2: Staff Modeling of Healthy and Safe Behavior and Health and Safety Education Activities
Standard 2.4.2.1: Health and Safety Education Topics for Staff
Standard 2.4.3.2: Parent/Guardian Education Plan
Standard 3.1.5.3: Oral Health Education
Standard 1.4.3.2: Topics Covered in First Aid Training
Standard 1.4.4.1: Continuing Education for Directors and Caregivers/Teachers in Centers and Large Family Child Care Homes  
Standard 1.4.4.2: Continuing Education for Small Family Child Care Home Caregivers/Teachers
Standard 1.6.0.1: Child Care Health Consultants
Standard 1.3.2.7: Qualifications and Responsibilities for Health Advocates

Feeding and Nutrition

Standard 4.2.0.6: Availability of Drinking Water
Standard 4.2.0.7: 100% Fruit Juice
Standard 4.3.1.8: Techniques for Bottle Feeding
Standard 4.3.1.11: Introduction of Age-Appropriate Solid Foods to Infant

Oral Health-Related Infectious Disease

Standard 7.5.12.1: Thrush (Candidiasis)
Standard 7.6.1.1: Disease Recognition and Control of Hepatitis B Virus (HBV) Infection
Standard 7.6.1.3: Staff Education on Prevention of Bloodborne Diseases

Oral Health-Related Emergencies

Standard 9.4.1.9: Records of Injury
Appendix KK: Authorization for Emergency Medical/Dental Care

 

Oral Health Policies and Information

Standard 9.2.1.3: Enrollment Information to Parents/Guardians and Caregivers/Teachers
Standard 9.2.3.6: Identification of Child’s Medical Home and Parental Consent for Information Exchange
Standard 9.2.3.13: Plans for Evening and Nighttime Child Care
Standard 9.2.3.14: Oral Health Policy
Standard 9.2.4.1: Written Plan and Training for Handling Urgent Medical Care or Threatening Incidents
Standard 9.4.2.4: Contents of Child’s Primary Care Provider’s Assessment
Standard 9.4.2.5: Health History

Licensing and State Responsibilities

Standard 10.3.2.1: Child Care Licensing Advisory Board
Standard 10.3.4.1: Sources of Technical Assistance to Support Quality of Child Care
Standard 10.3.4.3: Support for Consultants to Provide Technical Assistance to Facilities
Standard 10.3.4.4: Development of List of Providers of Services to Facilities
Standard 10.6.1.1: Regulatory Agency Provision of Caregiver/Teacher and Consumer Training and Support Services

Related Issues

Standard 1.7.0.1: Pre-Employment and Ongoing Adult Health Appraisals, Including Immunization


 

INTRODUCTION

Why Oral Health Practices are Important

Early care and education caregivers/teachers touch the lives of young children and their families in many important ways. One of the most important roles that caregivers/teachers play is to model healthy behaviors and provide an environment that incorporates healthy practices into everyday activities. Providing health education and skills-building for children is an investment in a lifetime of good health practices and contributes to a healthier childhood and adult life. Oral (dental) health is a component of overall health and should be addressed as early as possible (1). The early care and education setting is an optimal place to teach, practice and nurture positive oral health skills and activities.

Early childhood caries (ECC), also known as cavities in children under the age of 6 years old, is a significant public health problem in the United States. Forty-four percent of 5 year-olds have experienced a cavity (2). Yet caries and other dental diseases are highly preventable (1). Routine oral health activities, such as regular tooth brushing and reducing the exposure to sweetened foods and drinks, can help prevent tooth decay and caries (3). Poor oral health in children has been associated with dental pain, missed school, and poor school performance (4). This suggests that reducing the risk of tooth decay in early childhood can have a positive impact on the child's school readiness and future school experience. 

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. Increasing health promotion in child care and early education settings has the potential to improve the oral health of millions of preschool-aged children (1).

Overview of Content

This document is a compilation of 37 nationally recognized health and safety standards and 1 Appendix from Caring for Our Children: National Health and Safety Performance Standards; Guidelines for Early Care and Education Programs, 3rd Edition, 2011 (CFOC3)* on oral health in child care and early education settings.

Standards are listed in order of relevance to the topic. For this reason, the 37 standards are not necessarily in numerical order as they are presented in CFOC3. Throughout the document there are references to other standards contained in the full edition of CFOC3. For example, in Standard 5.5.0.1: Storage and Labeling of Personal Articles, the Related Standards section refers to Standard 5.4.5.1: Sleeping Equipment and Supplies, which is not provided in this document, but can be found in the full edition at http://nrckids.org/CFOC3.

The intended audiences for this document are:

  • Child care and early education caregivers/ teachers who can implement these strategies, many of which are cost free, to provide healthy oral health practices and policies in child care and early education settings;
  • State regulators and policy makers who can promote the adoption of oral health practices within their state licensing standards, quality rating improvement systems and early learning standards;
  • Health consultants, trainers and other health professionals who can promote and teach these strategies to child care and early education caregivers/teachers; and
  • Parents/guardians who can advocate for the use of these strategies and practices in their child’s child care and early education setting.
As with all areas in health, new research regularly becomes available and we recommend that users continue to visit the following websites for the most up-to-date information on oral health practices and policies:
 
American Academy of Pediatrics
http://www.aap.org and http://www.healthychildcare.org
American Academy of Pediatric Dentistry
http://www.aapd.org/
Bright Futures in Practice: Oral Health
http://www.brightfutures.org/oralhealth/about.html
National Maternal & Child Oral Health Resource Center
http://www.mchoralhealth.org/

 

For questions or assistance on these standards or CFOC3, please contact:
National Resource Center for Health and Safety in Child Care and Early Education (NRC)
Toll-free Hotline: 1-800-598-KIDS (5437)
Email: info@nrckids.org
Website: http://www.nrckids.org

REFERENCES
1. American Academy of Pediatric Dentistry. Policy on Oral Health in Child Care Centers. http://www.aapd.org/media/Policies_Guidelines/P_OHCCareCenters.pdf.
2. Centers for Disease Control and Prevention. A Simulation Model for Designing Effective Interventions in Early Childhood Caries. http://www.cdc.gov/pcd/issues/2012/11_0219.htm.  
3. American Academy of Pediatric Dentistry. Early Childhood Caries (ECC).
http://www.aapd.org/assets/2/7/ECCstats.pdf.
4. Jackson, S.L., W.F. Vann, J.B. Kotch, B.T. Pahel, J.Y. Lee. 2011. Impact of poor oral health on children's school attendance and performance. Am J Public Health 101(10):1900-06.

ACKNOWLEDGEMENTS
Thanks to the CFOC3 Standards Review Council: Danette Swanson Glassy, MD, FAAP; Brian Johnston, MD, MPH; Barbara U. Hamilton, MA; and Marilyn Krajicek, Ed.D., RN, FAAN for reviewing this compilation of Oral Health in Child Care and Early Education standards. We would also like to thank all those individuals who contributed to CFOC3. A listing can be viewed at: http://nrckids.org/CFOC3/PDFVersion/ PDF_Color/CFOC3_acknowledgments.pdf.

Also, a special thanks to Paul S. Casamassimo, DDS, MS, of Nationwide Children’s Hospital and The Ohio State University, and to Jeanne VanOrsdal, M.Ed. and Cassie Bernardi, MPH of the American Academy of Pediatrics for reviewing the compilation of standards and the Introduction.

* The full edition is available on the National Resource Center for Health and Safety in Child Care and Early Education (NRC) web site at http://www.nrckids.org/CFOC3. Also, CFOC3 content can be searched via the NRC’s online database at http://cfoc.nrckids.org/.

 

 

Oral Health Practices

Standard 3.1.4.3: Pacifier Use

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:

  1. Rationale and protocols for use of pacifiers;
  2. Written permission and any instructions or preferences from the child’s parent/guardian;
  3. 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;
  4. Staff should inspect each pacifier for tears or cracks (and to see if there is unknown fluid in the nipple) before each use;
  5. Staff should clean each pacifier with soap and water before each use;
  6. 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;
  7. If an infant refuses the pacifier, s/he should not be forced to take it;
  8. If the pacifier falls out of the infant’s mouth, it does not need to be reinserted;
  9. Pacifiers should not be coated in any sweet solution;
  10. 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:

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

REFERENCES:

  1. American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome. 2009. Policy statement: The changing concept of SIDS: Diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk. Pediatrics 123:188.
  2. Hauck, F. R. 2006. Pacifiers and sudden infant death syndrome: What should we recommend? Pediatrics 117:1811-12.
  3. 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.
  4. Reeves, D. L. 2006. Pacifier use in childcare settings. Healthy Child Care 9:12-13.
  5. Cornelius, A. N., J. P. D’Auria, L. M. Wise. 2008. Pacifier use: A systematic review of selected parenting web sites. J Pediatric Health Care 22:159-65.
  6. 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.
  7. Mayo Clinic. 2009. Infant and toddler health. Pacifiers: Are they good for your baby? http://www.mayoclinic.com/health/pacifiers/PR00067/.

Standard 3.1.5.1: Routine Oral Hygiene Activities SS3 footprint

Caregivers/teachers should promote the habit of regular tooth brushing. All children with teeth should brush or have their teeth brushed at least once during the hours the child is in child care. Children under two years of age should have only a smear of fluoride toothpaste (rice grain) on the brush when brushing. Those over two years of age should use a pea-sized amount of fluoride toothpaste. 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. Disposable gloves should be worn by the caregiver/teacher if contact with a child’s oral fluids is anticipated. The younger the child, the more the caregiver/teacher needs to be involved. The caregiver/teacher should be able to evaluate each child’s motor activity and to teach the child the correct method of tooth brushing when the child is capable of doing this activity. The caregiver/teacher should monitor the tooth brushing activity and thoroughly brush the child’s teeth after the child has finished brushing, preferably for a total of two minutes. Children whose teeth are brushed at home twice a day may be exempted since additional brushing has little additive benefit and may expose a child to excess fluoride toothpaste.

The cavity-causing effect of frequent exposure to food or juice should be reduced by offering the children rinsing water after snacks and meals when tooth brushing is not possible. Local dental health professionals can facilitate compliance with these activities by offering education and training for the child care staff and providing oral health presentations for the children and parents/guardians.

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. 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 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 (1). 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 six 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 amount of fluoride toothpaste (a smear about the size of a rice grain spread across the width of the toothbrush for children under two years of age and a pea-sized amount for children two years of age and over). Children should attempt to spit out excess toothpaste after brushing. Fluoride is the single most effective way to prevent tooth decay. Brushing of teeth with fluoridated 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 condition caused by ingesting excessive levels of fluoride (6). Other products such as fluoride rinses can pose a poisoning hazard if ingested (7).

The children can also rinse with water and spit out after a snack or a meal if their teeth have already been brushed earlier. Rinsing with water helps to remove food particles from teeth, diluting sugars and may help prevent cavities.

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 (4,5).

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 (1). 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 are able to 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 at primary care visits reduce decay rates by one-third, and 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 (8,9).

TYPE OF FACILITY:

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

RELATED STANDARDS:

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

  1. 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.
  2. American Academy of Pediatrics, Section on Pediatric Dentistry. 2008. Preventive oral health intervention for pediatricians. Pediatrics 122:1387-94.
  3. American Academy of Pediatric Dentistry, Clinical Affairs Committee, 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 Dentistry 30:112-18.
  4. American Academy of Pediatric Dentistry. Early childhood caries. Chicago: AAPD. http://www.aapd.org/assets/2/7/ECCstats.pdf.
  5. American Dental Association. ADA positions and statements. ADA statement on toothbrush care: Cleaning, storage, and replacement. Chicago: ADA. http://www.ada.org/1887.aspx.
  6. 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. MMWR 50(RR14): 1-42.
  7. Centers for Disease Control and Prevention. 2009. Community water fluoridation. Other fluoride products. http://www.cdc.gov/fluoridation/other.htm.
  8. Marinho, V. C., et al. 2002. Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database System Rev 3, no. CD002279. http://www2.cochrane.org/reviews/en/ab002279.html.
  9. 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.

Standard 3.1.5.2: Toothbrushes and Toothpaste Notes

In facilities where tooth brushing is an activity, each child should have a personally labeled, age-appropriate toothbrush. No sharing or borrowing 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 (6). 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 (2-4,6). 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.

If toothpaste is used, each child should have his/her own labeled toothpaste tube. 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 two years of age should have only a smear of fluoride toothpaste (rice grain) on the brush when brushing. Those over two years of age should use a pea-sized amount of fluoride toothpaste. Toothpaste should be stored out of children’s reach.

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 (6). 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. In child care, saliva is considered an infectious vehicle if it contains blood, so caregivers/teachers should protect themselves from exposure to blood in such situations, as required by standard precautions. The Occupational Safety and Health Administration (OSHA) regulations apply where there is potential exposure to blood.

COMMENTS:

Children can use an individually labeled or disposable cup of water to brush their teeth (6).

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 is involved when numerous children brush their teeth into sinks that are not sanitized between uses.

Tooth brushing ability varies by age. Preschool children most likely will require assistance. 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:

Small Family Child Care Home, Center, Large 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:

  1. 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.
  2. American Dental Association, Council on Scientific Affairs. 2005. ADA statement on toothbrush care: Cleaning, storage, and replacement. http://www.ada.org/1887.aspx.
  3. American Academy of Pediatric Dentistry. 2004. Early childhood caries (ECC). http://www.aapd.org/assets/2/7/ECCstats.pdf.
  4. American Dental Hygienists’ Association. Proper brushing. http://www.adha.org/oralhealth/brushing.htm.
  5. 12345 First Smiles. 2006. Oral health considerations for children with special health care needs (CSHCN). http://www
    .first5oralhealth.org/page.asp?page_id=432.
  6. 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 and 04/22/2013.

Standard 3.6.1.5: Sharing of Personal Articles Prohibited

Combs, hairbrushes, toothbrushes, personal clothing, bedding, and towels should not be shared and should be labeled with the name of the child who uses these objects.

RATIONALE:

Respiratory and gastrointestinal infections are common infectious diseases in child care. These diseases are transmitted by direct person-to-person contact or by sharing personal articles such as combs, brushes, towels, clothing, and bedding. Prohibiting the sharing of personal articles and providing space so that personal items may be stored separately helps prevent these diseases from spreading.

TYPE OF FACILITY:

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

RELATED STANDARDS:

5.5.0.1 Storage and Labeling of Personal Articles

Standard 5.5.0.1: Storage and Labeling of Personal Articles

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.

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:

  1. Individual cloth towels for bathing purposes;
  2. Toothbrushes;
  3. Washcloths;
  4. Combs and brushes.

Toothbrushes, towels, and washcloths should be allowed to dry when they are stored and not touching.

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:

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

RELATED STANDARDS:

3.6.1.5 Sharing of Personal Articles Prohibited
3.6.3.2 Labeling, Storage, and Disposal of Medications
5.4.5.1 Sleeping Equipment and Supplies

Standard 2.1.1.1: Written Daily Activity Plan and Statement of Principles

Facilities should have a written comprehensive and coordinated planned program of daily activities based on a statement of principles for the facility and each child’s individual development, as well as appropriate activities for groups of children at each stage of early childhood. The objective of the program of daily activities should be to foster incremental developmental progress in a healthy and safe environment and should be flexible to capture the interests of the children and the individual abilities of the children.

Centers, large and small family child care homes should develop a written statement of principles that set out the basic elements from which the daily indoor/outdoor program is to be built. These principles should include the following elements:

  1. Overall child health and safety;
  2. Physical development, which facilitates small and large motor skills;
  3. Family development, which acknowledges the role of the family, including culture and language;
  4. Social development, which leads to cooperative play with other children and the ability to make relationships with other children and adults and children of other backgrounds and ability levels;
  5. Emotional development, which facilitates self awareness and self confidence;
  6. Cognitive development, which includes an understanding of the world and environment in which they live and leads to understanding science, math, and literacy concepts, as well as increasing the use and understanding of language to express feelings and ideas.

The planned program should provide for the incorporation of specific health education topics on a daily basis throughout the year. Topics of health education should include health promotion and disease prevention topics, e.g., handwashing, oral health, nutrition, physical activity, etc.

Health and safety behaviors should be modeled by staff in order to insure that children and parents/guardians understand the need for a safe indoor and outdoor learning/play environment and feel comfortable.

Continuity and consistency by a caring staff is vital so that children and parents/guardians know what to expect. All of the principles should be developed with play being the foundation of the planned curriculum. Material such as blocks, clay, paints, books, puzzles, and/or other manipulatives should be available indoors and outdoors to the children to further the planned curriculum.

RATIONALE:

Reviews of children’s performance after attending out-of-home child care indicate that children attending facilities with well-developed curricula achieve appropriate levels of development (1,2).

Early childhood specialists agree on the:

  1. Inseparability and interdependence of cognitive, physical, emotional, communication and social development. Social-emotional capacities do not develop or function separately;
  2. Influence of the child’s health and safety on all these areas;
  3. Central importance of continuity and consistent relationships with affectionate care that is the formation of strong, nurturing relationships between caregivers/teachers and children;
  4. Relevance of the phase or stage concept;
  5. Importance of action (including play) as a mode of learning, and to express self (3).

Those who provide child care and early education must be able to articulate components of the curriculum they are implementing and the related values/principles on which the curriculum is based. In centers and large family child care homes, because more than two caregivers/teachers are involved in operating the facility, a written statement of principles helps achieve consensus about the basic elements from which all staff will plan the daily program (4).

A written description of the planned program of daily activities allows staff and parents/guardians to have a common understanding and gives them the ability to compare the program’s actual performance to the stated intent. Child care is a “delivery of service” involving a contractual relationship between the caregiver/teacher and the consumer. A written plan helps to define the service and contributes to specific and responsible operations that are conducive to sound child development and safety practices and to positive consumer relations (4). For infants and toddlers who learn through healthy and ongoing relationships with primary caregivers/teachers, a relationship-based plan should be shared with parents/guardians that include opportunities for parents/guardians to be an integral partner and member of this relationship system. Professional development is often required to enable staff to develop proficiency in the development and implementation of a curriculum that they use to carry out daily activities appropriately (6).

Planning ensures that some thought goes into indoor and outdoor programming for children. The plans are tools for monitoring and accountability. Also, a written plan is a tool for staff orientation.

COMMENTS:

The National Association for the Education of Young Children (NAEYC) Accreditation Criteria and Procedures, the National Association for Family Child Care (NAFCC) accreditation standards, and the National Child Care Association (NCCA) standards can serve as resources for planning program activities.

Parents/guardians and staff can experience mutual learning in an open, supportive setting. Suggestions for topics and methods of presentation are widely available. For example, the publication catalogs of the NAEYC and of the American Academy of Pediatrics (AAP) contain many materials for child, parent/guardian, and staff education on child development, the importance of attachment and temperament, and other health issues. A certified health education specialist (CHES) can also be a source of assistance. The American Association for Health Education (AAHE) at http://www
.aahperd.org/AAHE/, and the National Commission for Health Education Credentialing (NCHEC) at http://www
.nchec.org, provide information on this specialty.

TYPE OF FACILITY:

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

RELATED STANDARDS:

2.1.1.3 Coordinated Child Care Health Program Model
2.1.1.8 Diversity in Enrollment and Curriculum
2.1.2 Section 2.1.2: Program Activities for Infants and Toddlers from Three to Less Than Thirty-Six Months
2.1.3 Section 2.1.3: Program Activities for Three- to Five-Year-Olds
2.1.4 Section 2.1.4: Program Activities for School-Age Children
2.4 Section 2.4: Health Education

REFERENCES:

  1. Colker L. J., A. L. Dombro, D. T. Dodge. 1996. Curriculum for infants and toddlers: Who needs it? Child Care Info Exch 112:74-78.
  2. Smith A. B. 1996. Quality programs that care and educate. Child Education 72:330-36.
  3. Dimidjian, V. J., ed. 1992. Play’s place in public education for young children. National Education Association Early Childhood Education Series. Washington, DC: NEAECE.
  4. The Family Child Care Accreditation Project, Wheelock College and The National Association for Family Child Care. 2005. Quality standards for NAFCC accreditation. 4th ed. http://www.nafcc.org/documents/QualStd.pdf.
  5. National Child Care Information Center (NCCIC). NCCIC resources. U.S. Department of Health and Human Services, Administration for Children and Families. http://nccic.acf.hhs.gov/nccic-resources/.
  6. Nell, M. 2009. Using the integrative research approach to facilitate early childhood teacher planning. J Early Child Teach Edu 30:79-88.

Education and Training

Standard 2.4.1.1: Health and Safety Education Topics for Children

Health and safety education for children should include physical, oral, mental, emotional, nutritional, and social health and should be integrated daily into the program of activities, to include such topics as:

  1. Body awareness and use of appropriate terms for body parts;
  2. Families (including information that all families are different and have unique beliefs and cultural heritage);
  3. Personal social skills such as sharing, being kind, helping others, and communicating appropriately;
  4. Expression and identification of feelings;
  5. Self-esteem;
  6. Nutrition, healthy eating (preventing obesity);
  7. Outdoor learning/play;
  8. Fitness and age-appropriate physical activity;
  9. Personal and dental hygiene including wiping, flushing, handwashing, cough and sneezing etiquette and toothbrushing;
  10. Safety (such as home, vehicular car seats and safety belts, playground, bicycle, fire, and firearms, water safety, personal safety, what to do in an emergency, getting help and/or dialing 9-1-1 for emergencies);
  11. Conflict management, violence prevention, and bullying prevention;
  12. Age-appropriate first aid concepts;
  13. Healthy and safe behaviors;
  14. Poisoning prevention and poison safety;
  15. Awareness of routine preventive and special health care needs;
  16. Importance of rest and sleep;
  17. Health risks of secondhand smoke;
  18. Taking medications;
  19. Handling food safely; and
  20. Preventing choking and falls.

RATIONALE:

For young children, health and safety education are inseparable from one another. Children learn about health and safety by experiencing risk taking and risk control, fostered by adults who are involved with them. Whenever opportunities for learning arise; caregivers/teachers should integrate education to promote healthy and safe behaviors (1). Health and safety education does not have to be seen as a structured curriculum, but as a daily component of the planned program that is part of child development. Health and safety education supports and reinforces a healthy and safe lifestyle (1,2).

COMMENTS:

Teaching children the appropriate names for their body parts is a good way to increase self esteem and personal safety. Learning about routine health maintenance practices such as receiving vaccines, having vision screening, blood pressure screening, oral health examinations, and blood tests helps children understand these activities and appreciate their value rather than fearing them. Similarly, learning about the importance of fitness choices helps children make responsible healthful decisions when facing abundant temptation to do otherwise.

Certified health education specialists (CHES) are good resources for this instruction. The American Association for Health Education (AAHE), the National Commission for Health Education Credentialing. (NCHEC), and the State and Territorial Injury Prevention Directors’ Association (STIPDA) provide information on this specialty.

TYPE OF FACILITY:

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

REFERENCES:

  1. Gupta, R. S., S. Shuman, E. M. Taveras, M. Kulldorff, J. A. Finkelstein. 2005. Opportunities for health promotion education in child care. Pediatrics 116: e499-e505.
  2. Hemmeter, M. L., L. Fox, S. Jack, L. Broyles. 2007. A program-wide model of positive behavior support in early childhood settings. J Early Intervention 29:337-55.

Standard 2.4.1.2: Staff Modeling of Healthy and Safe Behavior and Health and Safety Education Activities

The program should strongly encourage all staff members to model healthy and safe behaviors and attitudes in their contact with children in the indoor and outdoor learning/play environment, including, eating nutritious foods, drinking water or nutritious beverages when with the children, sitting with children during mealtime, and eating some of the same foods as the children. Caregivers/teachers should engage in daily movement and physical activity, limiting sedentary behaviors when in the outdoor learning/play environment (e.g., not sitting in structured chairs), not watching TV, and should comply with tobacco and drug use policies and handwashing protocols.

Caregivers/teachers should talk about and model healthy and safe behaviors while they carry out routine daily activities. Activities should be accompanied by words of encouragement and praise for achievement.

Facilities should encourage and support staff who wish to breastfeed their own infants and those who engage in gardening to enhance interest in healthy food, science, inquiries and learning. Staff are consistently a model for children and should be cognizant of the environmental information and print messages they bring into the indoor and outdoor learning/play environment. The labels and print messages that are present in the indoor and outdoor learning/play environment or family child care home should be in line with the healthy and safe behaviors and attitudes they wish to impart to the children.

Facilities should use developmentally appropriate health and safety education materials in the children’s activities and should also share these with the families whenever possible.

All health and safety education activities should be geared to the child’s developmental age and should take into account individual personalities and interests.

RATIONALE:

Modeling is an effective way of confirming that a behavior is one to be imitated. Young children are particularly dependent on adults for their nutritional needs in both the home (1) and child care environment (2). Thus, modeling healthy and safe behaviors is an important way to demonstrate and reinforce healthy and safe behaviors of caregivers/teachers and children. Young children learn better through experiencing an activity and observing behavior than through didactic training (3,4). Learning and play have a reciprocal relationship; play experiences are closely related to learning (5).

Caregivers/teachers impact the nutrition habits of the children under their care, not only by making choices regarding the types of foods that are available but by influencing children’s attitudes and beliefs about that food as well as social interactions at mealtime. This provides a unique opportunity for programs to guide children’s choices by assigning parents/guardians and caregivers/teachers to the role of nutritional gatekeepers for the young children in their care. Such intervention is consistent with the USDA and U.S. Department of Health and Human Services (DHHS) recent release of 2010 Dietary Guidelines for Americans. The Dietary Guidelines focus on increased healthy eating and physical activity to reduce the current rate of overweight or obesity in American children (one in three in the nation) (6).

The effectiveness of health and safety education is enhanced when shared between the caregiver/teacher and the parents/guardians (7).

COMMENTS:

Caregivers/teachers are important in the lives of the young children in their care. They should be educated and supported to be able to interact optimally with the children in their care. Compliance should be documented by observation. Consultation can be sought from a child care health consultant or certified health education specialist. The American Association for Health Education (AAHE) and the National Commission for Health Education Credentialing (NCHEC) provide information on this specialty.

An extensive education program to make such experiential learning possible indoors and outdoors should be supported by strong community resources in the form of both consultation and materials from sources such as the health department, nutrition councils, and so forth. Suggestions for topics and methods of presentation are widely available (8). Examples include, but are not limited to, routine preventive care by health professionals, nutrition education and physical activity to prevent obesity, crossing streets safely, how to develop and use outdoor learning/play environments, car restraint safety, poison safety, latch key programs, health risks from secondhand smoke, personal hygiene, and oral health, including limiting sweets, rinsing the mouth with water after sweets, and regular tooth brushing. It can be helpful to place visual cues in the indoor and outdoor learning/play environments to serve as reminders (e.g., posters). “Risk Watch” is a prepared curriculum from the National Fire Protection Association (NFPA) offering comprehensive injury prevention strategies for children in preschool through eighth grade (9).

TYPE OF FACILITY:

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

RELATED STANDARDS:

2.2.0.3 Limiting Screen Time – Media, Computer Time
2.4.1.1 Health and Safety Education Topics for Children
2.4.1.2 Staff Modeling of Healthy and Safe Behavior and Health and Safety Education Activities
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
3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.4.1.1 Use of Tobacco, Alcohol, and Illegal Drugs
4.2.0.1 Written Nutrition Plan
4.2.0.6 Availability of Drinking Water
4.3.1.1 General Plan for Feeding Infants
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.2.2 Serving Size for Toddlers and Preschoolers
4.3.3.1 Meal and Snack Patterns for School-Age Children
4.5.0.4 Socialization During Meals
4.5.0.7 Participation of Older Children and Staff in Mealtime Activities
4.6.0.2 Nutritional Quality of Food Brought From Home
4.7.0.1 Nutrition Learning Experiences for Children

REFERENCES:

  1. Lindsay, A. C., K. M. Sussner, J. Kim, S. Gortmaker. 2006. The role of parents in preventing childhood obesity. Future Child 16:169-86.
  2. McBean, L. D., G. D. Miller. 1999. Enhancing the nutrition of America’s youth. J Am College of Nutrition 18:563-71.
  3. 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.
  4. Hemmeter, M. L., L. Fox, S. Jack, L. Broyles. 2007. A program-wide model of positive behavior support in early childhood settings. J Early Intervention 29:337-55.
  5. Petersen, E. A. 1998. The amazing benefits of play. Child Fam 17:7-8.
  6. U.S. Department of Agriculture, “USDA and HHS Announce New Dietary Guidelines to Help Americans Make Healthier Food Choices and Confront Obesity Epidemic,” press release June 2, 2011.
  7. Holmes, M., et al. 1996. Promising partnerships: How to develop successful partnerships in your community. Alexandria, VA: National Head Start Association.
  8. Gupta, R. S., S. Shuman, E. M. Taveras, M. Kulldorff, J. A. Finkelstein. 2005. Opportunities for health promotion education in child care. Pediatrics 116: e499-505.
  9. Kendrick, D., L. Groom, J. Stewart, M. Watson, C. Mulvaney, R. Casterton. 2007. Risk Watch: Cluster randomized controlled trial evaluating an injury prevention program. Injury Prevention 13:93-99.

Standard 2.4.2.1: Health and Safety Education Topics for Staff

Health and safety education for staff should include physical, oral, mental, emotional, nutritional, physical activity, and social health of children. In addition to the health and safety topics for children in Standard 2.4.1.1, health education topics for staff should include:

  1. Promoting healthy mind and brain development through child care;
  2. Healthy indoor and outdoor learning/play environments;
  3. Behavior/discipline;
  4. Managing emergency situations;
  5. Monitoring developmental abilities, including indicators of potential delays;
  6. Nutrition (i.e., healthy eating to prevent obesity);
  7. Food safety;
  8. Water safety;
  9. Safety/injury prevention;
  10. Safe use, storage, and clean-up of chemicals;
  11. Hearing, vision, and language problems;
  12. Physical activity and outdoor play and learning;
  13. Appropriate antibiotic use;
  14. Immunizations;
  15. Gaining access to community resources;
  16. Maternal or parental/guardian depression;
  17. Exclusion policies;
  18. Tobacco use/smoking;
  19. Safe sleep environments and SIDS prevention;
  20. Breastfeeding support (1);
  21. Environmental health and reducing exposures to environmental toxins;
  22. Children with special needs;
  23. Shaken baby syndrome and abusive head trauma;
  24. Safe use, storage of firearms;
  25. Safe medication administration.

RATIONALE:

When child care staff are knowledgeable in health and safety practices, programs are more likely to be healthy and safe (2). Compliance with twenty hours per year of staff continuing education in the areas of health, safety, child development, and abuse identification was the most significant predictor for compliance with state child care health and safety regulations (3). Child care staff often receive their health and safety education from a child care health consultant. Data support the relationship between child care health consultation and the increased health and safety of a center (4,5).

COMMENTS:

Community resources can provide written health- and safety-related materials. Consultation or training can be sought from a child care health consultant (CCHC) or certified health education specialist (CHES).

Child care programs should consider offering “credit” for health education classes or encourage staff members to attend accredited education programs that can give education credits.

The American Association for Health Education (AAHE) and the National Commission for Health Education Credentialing (NCHEC) provide information on certified health education specialists.

TYPE OF FACILITY:

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

RELATED STANDARDS:

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 CPR Training for Staff
1.4.3.2 Topics Covered in First Aid Training
1.4.3.3 CPR 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
2.4.1.1 Health and Safety Education Topics for Children

REFERENCES:

  1. Gupta, R. S., S. Shuman, E. M. Taveras, M. Kulldorff, J. A. Finkelstein. 2005. Opportunities for health promotion education in child care. Pediatrics 116: e499-e505.
  2. 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.
  3. Crowley, A. A., M. S. Rosenthal. 2009. Ensuring the health and safety of Connecticut’s early care and education programs. Farmington, CT: The Child Health and Development Institute of Connecticut. http://www.chdi.org/admin/uploads/3074013304b154ef428c1a.pdf.
  4. Snohomish Health District: Child Care Health Program. Child care health consultation: Evidence based effectiveness. http://www
    .napnap.org/docs/CCS_SIG_Evidence_ Based_ CCHP.pdf.
  5. Rosenthal, M. S., A. A. Crowley, L. Curry. 2009. Promoting child development and behavioral health: Family child care providers’ perspectives. J Pediatric Health Care 23:289-97.

Standard 2.4.3.2: Parent/Guardian Education Plan

The content of a parent/guardian education plan should be individualized to meet each family’s needs and should be sensitive to cultural values and beliefs. Written material, at a minimum, should address the most important health and safety issues for all age groups served, should be in a language understood by families, and may include the topics listed in Standard 2.4.1.1, with special emphasis on the following:

  1. Safety (such as home, community, playground, firearm, seat belts, safe medication administration procedures, poison awareness, vehicular, or bicycle, and awareness of environmental toxins and healthy choices to reduce exposure);
  2. Value of developing healthy and safe lifestyle choices early in life and parental/guardian health (such as exercise and routine physical activity, nutrition, weight control, breastfeeding, avoidance of substance abuse and tobacco use, stress management, maternal depression, HIV/AIDS prevention);
  3. Importance of outdoor play and learning;
  4. Importance of role modeling;
  5. Importance of well-child care (such as immunizations, hearing/vision screening, monitoring growth and development);
  6. Child development and behavior including bonding and attachment;
  7. Domestic and relational violence;
  8. Conflict management and violence prevention;
  9. Oral health promotion and disease prevention;
  10. Effective toothbrushing, handwashing, diapering, and sanitation;
  11. Positive discipline, effective communication, and behavior management;
  12. Handling emergencies/first aid;
  13. Child advocacy skills;
  14. Special health care needs;
  15. Information on how to access services such as the supplemental food and nutrition program (i.e., The Women, Infants and Children [WIC] Supplemental Food Program), Food Stamps (SNAP), food pantries, as well as access to medical/health care and services for developmental disabilities for children;
  16. Handling loss, deployment, and divorce;
  17. The importance of routines and traditions (including reading and early literacy) with a child.

Health and safety education for parents/guardians should utilize principles of adult learning to maximize the potential for parents/guardians to learn about key concepts. Facilities should utilize opportunities for learning, such as the case of an illness present in the facility, to inform parents/guardians about illness and prevention strategies.

The staff should introduce seasonal topics when they are relevant to the health and safety of parents/guardians and children.

RATIONALE:

Adults learn best when they are motivated, comfortable, and respected; when they can immediately apply what they have learned; and when multiple learning strategies are used. Individualized content and approaches are needed for successful intervention. Parent/guardian attitudes, beliefs, fears, and educational and socioeconomic levels all should be given consideration in planning and conducting parent/guardian education (1,2). Parental/guardian behavior can be modified by education. Parents/guardians should be involved closely with the facility and be actively involved in planning parent/guardian education activities. If done well, adult learning activities can be effective for educating parents/guardians. If not done well, there is a danger of demeaning parents/guardians and making them feel less, rather than more, capable (1,2).

The concept of parent/guardian control and empowerment is key to successful parent/guardian education in the child care setting. Support and education for parents/guardians lead to better parenting skills and abilities.

Knowing the family will help the staff such as the health and safety advocate determine content of the parent/guardian education plan and method for delivery. Specific attention should be paid to the parents’/guardians’ need for support and consultation and help locating resources for their problems. If the facility suggests a referral or resource, this should be documented in the child’s record. Specifics of what the parent/guardian shared need not be recorded.

COMMENTS:

Community resources can provide written health- and safety-related materials. School-age child care facilities may incorporate child health education into their programs as they can be integrated into their regular activities, (e.g., handwashing before snack, making healthful snack choices, pointing out why screen time limits are in place to promote physical activity, safe playground behaviors, and where possible, making an attempt to coordinate with formal health education enrollees receive in school).

TYPE OF FACILITY:

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

RELATED STANDARDS:

1.3.2.7 Qualifications and Responsibilities for Health Advocates
2.4.1.1 Health and Safety Education Topics for Children

REFERENCES:

  1. Gonzalez-Mena, J. 1996. When values collide: Exploring a cross cultural issue. Child Care Infor Exch 108:30-32.
  2. Hendricks, C., M. Russell, C. J. Smith. 1997. Staying healthy: Strategies for helping parents ensure their children’s health and well being. Child Fam 16:10-17.

Standard 3.1.5.3: Oral Health Education

All children with teeth should have oral hygiene education as a part of their daily activity.

Children three years of age and older should have developmentally appropriate oral health education that includes:

  1. Information on what plaque is;
  2. The process of dental decay;
  3. Diet influences on teeth, including the contribution of sugar-sweetened beverages and foods to cavity development; and
  4. The importance of good oral hygiene behaviors.

School-age children should receive additional information including:

  1. The preventive use of fluoride;
  2. Dental sealants;
  3. Mouth guards for protection when playing sports;
  4. The importance of healthy eating behaviors; and
  5. Regularly scheduled dental visits.

Adolescent children should be informed about the effect of tobacco products on their oral health and additional reasons to avoid tobacco.

Caregivers/teachers and parents/guardians should be taught to not place a child’s pacifier in the adult’s mouth to clean or moisten it or share a toothbrush with a child due to the risk of promoting early colonization of the infant oral cavity with Streptococcus mutans (5).

Caregivers/teachers should limit juice consumption to no more than four to six ounces per day for children one through six years of age.

RATIONALE:

Studies have reported that the oral health of participants improved as a result of educational programs (1).

COMMENTS:

Caregivers/teachers are encouraged to advise parents/guardians on the following recommendations for preventive and early intervention dental services and education:

  1. Dental or primary care provider visits to evaluate the need for supplemental fluoride therapy (prescription pills or drops if tap water does not contain fluoride) starting at six months of age, and professionally applied topical fluoride treatments for high risk children (4);
  2. First dental visit within six months after the first tooth erupts or by one year of age, whichever is earlier and whenever there is a question of an oral health problem;
  3. Dental sealants generally at six or seven years of age for first permanent molars, and for primary molars if deep pits and grooves or other high risk factors are present (2,3).

Caregivers/teachers should provide education for parents/guardians on good oral hygiene practices and avoidance of behaviors that increase the risk of early childhood caries, such as inappropriate use of a bottle, frequent consumption of carbohydrate-rich foods, and sweetened beverages such as juices with added sweeteners, soda, sports drinks, fruit nectars, and flavored teas.

For more resources on oral health education, see:

Parent’s Checklist for Good Dental Health Practices in Child Care, a parent handout in English and Spanish, developed by the National Resource Center for Health and Safety in Child Care and Early Education at http://nrckids.org/
dentalchecklist.pdf;

Bright Futures for Oral Health at http://brightfutures.aap.org/practice_guides_and_other_resources.html;

California Childcare Health Program Health and Safety in the Child Care Setting: Promoting Children’s Oral Health A Curriculum for Health Professionals and Child Care Providers (in English and Spanish) at http://www.ucsfchildcarehealth.org and its 12345 first smiles program at http://first5oralhealth.org; and

National Training Institute for Child Care Health Consultant’s Healthy Smiles Through Child Care Health Consultation course at http://nti.unc.edu/healthy_smiles/.

TYPE OF FACILITY:

Center

RELATED STANDARDS:

2.4 Section 2.4: Health Education
3.1.4.3 Pacifier Use
3.1.5.1 Routine Oral Hygiene Activities
3.1.5.2 Toothbrushes and Toothpaste
4.2.0.7 100% Fruit Juice
9.2.3.14 Oral Health Policy

REFERENCES:

  1. Dye, B. A., J. D. Shenkin, C. L. Ogden, T. A. Marshould, S. M. Levy, M. J. Kanellis. 2004. The relationship between healthful eating practices and dental caries in children aged 2-5 years in the United States. J Am Dent Assoc 135:55-66.
  2. 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.
  3. American Academy of Pediatrics, Section on Pediatric Dentistry.2008. Preventive oral health intervention for pediatricians. Pediatrics 122:1387-94.
  4. 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 Dentistry 30:112-18.
  5. American Academy of Pediatrics, Oral Health Initiative. Protecting all children’s teeth (PACT): A pediatric oral health training program. Factors in development: Bacteria. http://www.aap.org/oralhealth/pact/ch4_sect2.cfm.

Standard 1.4.3.2: Topics Covered in First Aid Training SS3 footprint

First aid training should present an overview of Emergency Medical Services (EMS), accessing EMS, poison center services, accessing the poison center, safety at the scene, and isolation of body substances. First aid instruction should include, but not be limited to, recognition and first response of pediatric emergency management in a child care setting of the following situations:

  1. Management of a blocked airway and rescue breathing for infants and children with return demonstration by the learner (pediatric CPR);
  2. Abrasions and lacerations;
  3. Bleeding, including nosebleeds;
  4. Burns;
  5. Fainting;
  6. Poisoning, including swallowed, skin or eye contact, and inhaled;
  7. Puncture wounds, including splinters;
  8. Injuries, including insect, animal, and human bites;
  9. Poison control;
  10. Shock;
  11. Seizure care;
  12. Musculoskeletal injury (such as sprains, fractures);
  13. Dental and mouth injuries/trauma;
  14. Head injuries, including shaken baby syndrome/abusive head trauma;
  15. Allergic reactions, including information about when epinephrine might be required;
  16. Asthmatic reactions, including information about when rescue inhalers must be used;
  17. Eye injuries;
  18. Loss of consciousness;
  19. Electric shock;
  20. Drowning;
  21. Heat-related injuries, including heat exhaustion/heat stroke;
  22. Cold related injuries, including frostbite;
  23. Moving and positioning injured/ill persons;
  24. Illness-related emergencies (such as stiff neck, inexplicable confusion, sudden onset of blood-red or purple rash, severe pain, temperature above 101°F [38.3°C] orally, above 102°F [38.9°C] rectally, or 100°F [37.8°C] or higher taken axillary [armpit] or measured by an equivalent method, and looking/acting severely ill);
  25. Standard Precautions;
  26. Organizing and implementing a plan to meet an emergency for any child with a special health care need;
  27. Addressing the needs of the other children in the group while managing emergencies in a child care setting;
  28. Applying first aid to children with special health care needs.

RATIONALE:

First aid for children in the child care setting requires a more child-specific approach than standard adult-oriented first aid offers. To ensure the health and safety of children in a child care setting, someone who is qualified to respond to common injuries and life-threatening emergencies must be in attendance at all times. A staff trained in pediatric first aid, including pediatric CPR, coupled with a facility that has been designed or modified to ensure the safety of children, can reduce the potential for death and disability. Knowledge of pediatric first aid, including the ability to demonstrate pediatric CPR skills, and the confidence to use these skills, are critically important to the outcome of an emergency situation (1).

Small family child care home caregivers/teachers often work alone and are solely responsible for the health and safety of children in care. Such caregivers/teachers must have pediatric first aid competence.

COMMENTS:

Other children will have to be supervised while the injury is managed. Parental notification and communication with emergency medical services must be carefully planned. First aid information can be obtained from the American Academy of Pediatrics (AAP) at http://www.aap.org and the American Heart Association (AHA) at http://www.heart.org/HEARTORG/.

TYPE OF FACILITY:

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

RELATED STANDARDS:

1.4.3.1 First Aid and CPR Training for Staff
9.4.3.3 Training Record

REFERENCES:

  1. Aronson, S. S., ed. 2007. Pediatric first aid for caregivers and teachers. Rev. 1st ed. Elk Grove Village, IL: American Academy of Pediatrics; Sudbury, MA: Jones and Bartlett.

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

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

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

RATIONALE:

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

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

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

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

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

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

COMMENTS:

Tools for assessment of training needs are part of the accreditation self-study tools available from the NAEYC, the National Association for Family Child Care (NAFCC), National Early Childhood Professional Accreditation (NECPA), Association for Christian Education International (ACEI), National AfterSchool Association (NAA), and the National Child Care Association (NCCA). Successful completion of training can be measured by a performance test at the end of training and by ongoing evaluation of performance on the job.

Resources for training on health and safety issues include:

  1. State and local health departments (health education, environmental health and sanitation, nutrition, public health nursing departments, fire and EMS, etc.);
  2. Networks of child care health consultants;
  3. Graduates of the National Training Institute for Child Care Health Consultants (NTI);
  4. Child care resource and referral agencies;
  5. University Centers for Excellence on Disabilities;
  6. Local children’s hospitals;
  7. State and local chapters of:
    1. American Academy of Pediatrics (AAP), including AAP Chapter Child Care Contacts;
    2. American Academy of Family Physicians (AAFP);
    3. American Nurses’ Association (ANA);
    4. American Public Health Association (APHA);
    5. Visiting Nurse Association (VNA);
    6. National Association of Pediatric Nurse Practitioners (NAPNAP);
    7. National Association for the Education of Young Children (NAEYC);
    8. National Association for Family Child Care (NAFCC);
    9. National Association of School Nurses (NASN);
    10. Emergency Medical Services for Children (EMSC) National Resource Center;
    11. National Association for Sport and Physical Education (NASPE);
    12. American Dietetic Association (ADA);
    13. American Association of Poison Control Centers (AAPCC).

For nutrition training, facilities should check that the nutritionist/registered dietician (RD), who provides advice, has experience with, and knowledge of, child development, infant and early childhood nutrition, school-age child nutrition, prescribed nutrition therapies, food service and food safety issues in the child care setting. Most state Maternal and Child Health (MCH) programs, Child and Adult Care Food Programs (CACFP), and Special Supplemental Nutrition Programs for Women, Infants, and Children (WIC) have a nutrition specialist on staff or access to a local consultant. If this nutrition specialist has knowledge and experience in early childhood and child care, facilities might negotiate for this individual to serve or identify someone to serve as a consultant and trainer for the facility.

Many resources are available for nutritionists/RDs who provide training in food service and nutrition. Some resources to contact include:

  1. Local, county, and state health departments to locate MCH, CACFP, or WIC programs;
  2. State university and college nutrition departments;
  3. Home economists at utility companies;
  4. State affiliates of the American Dietetic Association;
  5. State and regional affiliates of the American Public Health Association;
  6. The American Association of Family and Consumer Services;
  7. National Resource Center for Health and Safety in Child Care and Early Education;
  8. Nutritionist/RD at a hospital;
  9. High school home economics teachers;
  10. The Dairy Council;
  11. The local American Heart Association affiliate;
  12. The local Cancer Society;
  13. The Society for Nutrition Education;
  14. The local Cooperative Extension office;
  15. Local community colleges and trade schools.

Nutrition education resources may be obtained from the Food and Nutrition Information Center at http://fnic.nal.usda.gov. The staff’s continuing education in nutrition may be supplemented by periodic newsletters and/or literature (frequently bilingual) or audiovisual materials prepared or recommended by the Nutrition Specialist.

Caregivers/teachers should have a basic knowledge of special health care needs, supplemented by specialized training for children with special health care needs. The type of special health care needs of the children in care should influence the selection of the training topics. The number of hours offered in any in-service training program should be determined by the experience and professional background of the staff, which is best achieved through a regular staff conference mechanism.

Financial support and accessibility to training programs requires attention to facilitate compliance with this standard. Many states are using federal funds from the Child Care and Development Block Grant to improve access, quality, and affordability of training for early care and education professionals. College courses, either online or face to face, and training workshops can be used to meet the training hours requirement. These training opportunities can also be conducted on site at the child care facility. Completion of training should be documented by a college transcript or a training certificate that includes title/content of training, contact hours, name and credentials of trainer or course instructor and date of training. Whenever possible the submission of documentation that shows how the learner implemented the concepts taught in the training in the child care program should be documented. Although on-site training can be costly, it may be a more effective approach than participation in training at a remote location.

Projects and Outreach: Early Childhood Research and Evaluation Projects, Midwest Child Care Research Consortium at http://ccfl.unl.edu/projects_outreach/projects/current/ecp/mwcrc.php, identifies the number of hours for education of staff and fourteen indicators of quality from a study conducted in four Midwestern states.

TYPE OF FACILITY:

Center, Large Family Child Care Home

RELATED STANDARDS:

1.8.2.2 Annual Staff Competency Evaluation
3.5.0.2 Caring for Children Who Require Medical Procedures
3.6.3.1 Medication Administration
9.4.3.3 Training Record
10.3.3.4 Licensing Agency Provision of Child Abuse Prevention Materials
10.3.4.6 Compensation for Participation in Multidisciplinary Assessments for Children with Special Health Care or Education Needs
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
Appendix C: Nutrition Specialist, Registered Dietitian, Licensed Nutritionist, Consultant, and Food Service Staff Qualifications

REFERENCES:

  1. National Association for the Education of Young Children (NAEYC). 2009. Standards for Early Childhood professional preparation programs. Washington, DC: NAEYC. http://www.naeyc
    .org/files/naeyc/file/positions/ProfPrepStandards09.pdf.
  2. Whitebook, M., C. Howes, D. Phillips. 1998. Worthy work, unlivable wages: The National child care staffing study, 1988-1997. Washington, DC: Center for the Child Care Workforce.
  3. Crowley, A. A. 1990. Health services in child care day care centers: A survey. J Pediatr Health Care 4:252-59.
  4. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/.
  5. Aronson, S. S., T. R. Shope, eds. 2009. Managing infectious diseases in child care and schools: A quick reference guide. 2nd ed. Elk Grove Village, IL: American Academy of Pediatrics.

Standard 1.4.4.2: Continuing Education for Small Family Child Care Home Caregivers/Teachers

Small family child care home caregivers/teachers should have at least thirty clock-hours per year (2) of continuing education in areas determined by self-assessment and, where possible, by a performance review of a skilled mentor or peer reviewer.

RATIONALE:

In addition to low child:staff ratio, group size, age mix of children, and continuity of caregiver/teacher, the training/education of caregivers/teachers is a specific indicator of child care quality (1). Most skilled roles require training related to the functions and responsibilities the role requires. Caregivers/teachers who engage in on-going training are more likely to decrease morbidity and mortality in their setting (3) and are better able to prevent, recognize, and correct health and safety problems.

Children may come to child care with identified special health care needs or may develop them while attending child care, so staff must be trained in recognizing health problems as well as in implementing care plans for previously identified needs.

Because of the nature of their caregiving/teaching tasks, caregivers/teachers must attain multifaceted knowledge and skills. Child health and employee health are integral to any education/training curriculum and program management plan. Planning and evaluation of training should be based on performance of the caregiver/teacher. Provision of workshops and courses on all facets of a small family child care business may be difficult to access and may lead to caregivers/teachers enrolling in training opportunities in curriculum related areas only. Too often, caregivers/teachers make training choices based on what they like to learn about (their “wants”) and not the areas in which their performance should be improved (their “needs”).

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 care. Peer review is part of the process for accreditation of family child care and can be valuable in assisting the caregiver/teacher in the identification of areas of need for training. Self-evaluation may not identify training needs or focus on areas in which the caregiver/teacher is particularly interested and may be skilled already.

COMMENTS:

The content of continuing education for small family child care home caregivers/teachers should include the following topics:

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

Small family child care home caregivers/teachers should maintain current contact lists of community pediatric primary care providers, specialists for health issues of individual children in their care and child care health consultants who could provide training when needed.

In-home training alternatives to group training for small family child care home caregivers/teachers are available, such as distance courses on the Internet, listening to audiotapes or viewing media (e.g., DVDs) with self-checklists. These training alternatives provide more flexibility for caregivers/teachers who are remote from central training locations or have difficulty arranging coverage for their child care duties to attend training. Nevertheless, gathering family child care home caregivers/teachers for training when possible provides a break from the isolation of their work and promotes networking and support. Satellite training via down links at local extension service sites, high schools, and community colleges scheduled at convenient evening or weekend times is another way to mix quality training with local availability and some networking.

TYPE OF FACILITY:

Small Family Child Care Home

RELATED STANDARDS:

1.4.4.1 Continuing Education for Directors and Caregivers/Teachers in Centers and Large Family Child Care Homes
1.7.0.4 Occupational Hazards
3.5.0.2 Caring for Children Who Require Medical Procedures
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
9.4.3.3 Training Record
Appendix B: Major Occupational Health Hazards

REFERENCES:

  1. Whitebook, M., C. Howes, D. Phillips. 1998. Worthy work, unlivable wages: The national child care staffing study, 1988-1997. Washington, DC: Center for the Child Care Workforce.
  2. The National Association of Family Child Care (NAFCC). 2005. Quality standards for NAFCC accreditation. 4th ed. Salt Lake City, UT: NAFCC. http://www.nafcc.org/documents/QualStd.pdf.
  3. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/.

Standard 1.6.0.1: Child Care Health Consultants SS3 footprint

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:

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

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

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

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

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

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

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

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

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).

Some states offer CCHC training with continuing education units, college credit, and/or a certificate of completion. Credentialing is an umbrella term referring to the various means employed to designate that individuals or organizations have met or exceeded established standards. These may include accreditation of programs or organizations and certification, registration, or licensure of individuals. Accreditation refers to a legitimate state or national organization verifying that an educational program or organization meets standards. Certification is the process by which a non-governmental agency or association grants recognition to an individual who has met predetermined qualifications specified by the agency or association. Certification is applied for by individuals on a voluntary basis and represents a professional status when achieved. Typical qualifications include 1) graduation from an accredited or approved program and 2) acceptable performance on a qualifying examination. While there is no national accreditation of CCHC training programs or individual CCHCs at this time, this is a future goal. 

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

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

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

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

TYPE OF FACILITY:

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

RELATED STANDARDS:

1.6.0.3 Early Childhood Mental Health Consultants
1.6.0.4 Early Childhood Education Consultants

REFERENCES:

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

Standard 1.3.2.7: Qualifications and Responsibilities for Health Advocates

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

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

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

The health advocate should have documented training in the following:

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

RATIONALE:

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

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

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

COMMENTS:

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

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

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

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

TYPE OF FACILITY:

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

RELATED STANDARDS:

1.3.1.1 General Qualifications of Directors
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 CPR Training for Staff
1.4.3.2 Topics Covered in First Aid Training
1.4.3.3 CPR 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
1.6.0.1 Child Care Health Consultants
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
7.2.0.1 Immunization Documentation
7.2.0.2 Unimmunized Children
8.7.0.3 Review of Plan for Serving Children with Disabilities or Children with Special Health Care Needs
Appendix G: Recommended Childhood Immunization Schedule
Appendix H: Recommended Adult Immunization Schedule

REFERENCES:

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

Feeding and Nutrition

Standard 4.2.0.6: Availability of Drinking Water SS3 footprint

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

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

RATIONALE:

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

COMMENTS:

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

TYPE OF FACILITY:

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

RELATED STANDARDS:

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:

  1. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.
  2. Manz, F. 2007. Hydration in children. J Am Coll Nutr 26:562S-569S.
  3. Casamassimo, P., K. Holt, eds. 2004. Bright futures in practice: Oral health–pocket guide. Washington, DC: National Maternal and Child Oral Health Resource Center. http://www.mchoralhealth.org/PDFs/BFOHPocketGuide.pdf.
  4. Centers for Disease Control and Prevention. 2011. Community water fluoridation. http://www.cdc.gov/fluoridation/.

Standard 4.2.0.7: 100% Fruit Juice

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

RATIONALE:

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

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

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

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

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

COMMENTS:

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

TYPE OF FACILITY:

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

RELATED STANDARDS:

4.2.0.4 Categories of Foods

REFERENCES:

  1. Casamassimo, P., K. Holt, eds. 2004. Bright futures in practice: Oral health–pocket guide. Washington, DC: National Maternal and Child Oral Health Resource Center. http://www.mchoralhealth.org/PDFs/BFOHPocketGuide.pdf.
  2. Dennison, B. A., H. L. Rockwell, S. L. Baker. 1997. Excess fruit juice consumption by preschool-aged children is associated with short stature and obesity. Pediatrics 99:15-22.
  3. American Academy of Pediatrics, Committee on Nutrition. 2007. Policy statement: The use and misuse of fruit juice in pediatrics. Pediatrics 119:405.
  4. Faith, M. S., B. A. Dennison, L. S. Edmunds, H. H. Stratton. 2006. Fruit juice intake predicts increased adiposity gain in children from low-income families: Weight status-by-environment interaction. Pediatrics 118:2066-75.
  5. Dubois, L., A. Farmer, M. Girard, K. Peterson. 2007. Regular sugar-sweetened beverage consumption between meals increases risk of overweight among preschool-aged children. J Am Diet Assoc 107:924-34.
  6. Dennison, B. A., H. L. Rockwell, M. J. Nichols, P. Jenkins. 1999. Children’s growth parameters vary by type of fruit juice consumed. J Am Coll Nutr 18:346-52.
  7. U.S. Food and Drug Administration. Safe handling of raw produce and fresh-squeezed fruit and vegetable juices. New York: JMH Education. http://www.fda.gov/Food/ResourcesForYou/Consumers/ucm114299.htm.

Standard 4.3.1.8: Techniques for Bottle Feeding FAQ

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:

  1. Initiate feeding when infant provides cues (rooting, sucking, etc.);
  2. Hold the infant during feedings and respond to vocalizations with eye contact and vocalizations;
  3. Alternate sides of caregiver’s/teacher’s lap;
  4. Allow breaks during the feeding for burping;
  5. 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, infant formula, or water 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 (22).

The use of a bottle or cup to modify or pacify a child’s behavior should not be allowed (1,16).

RATIONALE:

The manner in which food is given to infants is conducive to the development of sound eating habits for life. 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 (1-6). When infants and children are “cue fed”, 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 (7-18). Early childhood caries in primary teeth may hold significant short-term and long-term implications for the child’s health (7-18). 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.

COMMENTS:

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 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 (2). 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 (1-3,6-9). 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 (19-21). 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.

Infants should be burped after every feeding and preferably during the feeding as well.

TYPE OF FACILITY:

Small Family Child Care Home, Center, Large 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:

  1. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.
  2. Casamassimo, P., K. Holt, eds. 2004. Bright futures in practice: Oral health–pocket guide. Washington, DC: National Maternal and Child Oral Health Resource Center. http://www.mchoralhealth.org/PDFs/BFOHPocketGuide.pdf.
  3. Dietitians of Canada, American Dietetic Association. 2000. Manual of clinical dietetics. 6th ed. Chicago: ADA.
  4. Wang, Y. S., S. Y. Wu. 1996. The effect of exclusive breast feeding on development and incidence of infection in infants. J Hum Lactation 12:27-30.
  5. American Academy of Pediatric Dentistry. 1993. Recommendation for preventive pediatric dental care. Pediatr Dent 15:158-59.
  6. American Academy of Pediatric Dentistry. 1994. Reference manual, 1994-1995. Pediatr Dent 16:196.
  7. Schafer, T. E., S. M. Adair. 2000. Prevention of dental disease: The role of the pediatrician. Pediatr Clin North Am 47:1021-42.
  8. Ramos-Gomez, F. J. 2005. Clinical considerations for an infant oral health care program. Compend Contin Educ Dent 26:17-23.
  9. Ramos-Gomez, F. J., B. Jue, C. Y. Bonta. 2002. Implementing an infant oral care program. J Calif Dent Assoc 30:752-61.
  10. U.S. Department of Health and Human Services (DHHS). 2000. Oral health in America: A report of the surgeon general–Executive summary. Rockville, MD: DHHS, National Institute of Dental and Craniofacial Research, National Institutes of Health.
  11. Section on Pediatric Dentistry and Oral Health. 2008. Preventive oral health intervention for pediatricians. Pediatrics 122:1387-94.
  12. New York State Department of Health. 2006. Oral health care during pregnancy and early childhood: Practice guidelines. Albany, NY: New York State Department of Health. http://www.health.state.ny.us/publications/0824.pdf.
  13. American Dental Association. 2004. From baby bottle to cup: Choose training cups carefully, use them temporarily. J Am Dent Assoc 135:387.
  14. American Dental Association. ADA statement on early childhood caries. http://www.ada.org/2057.aspx.
  15. Tinanoff, N., C. Palmer. 2000. Dietary determinants of dental caries and dietary recommendations for preschool children. J Public Health Dent 60:197-206.
  16. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.
  17. Prolonged use of sippy cups under scrutiny. 2002. Dentistry Today 21:44.
  18. Behrendt, A., F. Szlegoleit, V. Muler-Lessmann, G. Ipek-Ozdemir, W. F. Wetzel. 2001. Nursing-bottle syndrome caused by prolonged drinking from vessels with bill-shaped extensions. ASDC J Dent Child 68:47-54.
  19. Satter, E. 2000. Child of mine: Feeding with love and good sense. 3rd ed. Boulder, CO: Bull Publishing.
  20. Watson Genna, C. 2008. Supporting sucking skills in breastfeeding infants. Sudbury, MA: Jones and Bartlett.

Standard 4.3.1.11: Introduction of Age-Appropriate Solid Foods to Infants SS3 footprint

A plan to introduce age-appropriate solid foods (complementary foods) to infants should be made in consultation with the child’s parent/guardian and primary care provider. Age-appropriate solid foods may be introduced no sooner than when the child has reached the age of four months, but preferably six months and as indicated by the individual child’s nutritional and developmental needs.

For breastfed infants, gradual introduction of iron-fortified foods may occur no sooner than around four months, but preferably six months and to complement the human milk. Modification of basic food patterns should be provided in writing by the child’s primary care provider.

Evidence for introducing complementary foods in a specific order or rate is not available. The current best practice is that the first solid foods should be single-ingredient foods and should be introduced one at a time at two- to seven-day intervals (1).

RATIONALE:

Early introduction of age-appropriate solid food and fruit juice interferes with the intake of human milk or iron-fortified formula that the infant needs for growth. Age-appropriate solid food given before an infant is developmentally ready may be associated with allergies and digestive problems (2,8). Around about six months of age, breastfed infants may require an additional source of iron. Vitamin drops with iron may be needed. Infants who are not exclusively fed human milk should consume iron-fortified formula as the substitute for human milk (9). In the United States, major non-milk sources of iron in the infant diet are iron-fortified cereal and meats (2). Zinc is important for healthy growth and proper immune function. Infant stores of zinc may subsidize the intake from human milk for several months. Age-appropriate solid foods such as meat (a good source of zinc) are needed beginning at six months (2). A full daily allowance of vitamin C is found in human milk (3). The American Academy of Pediatrics (AAP) recommends that all breastfed or partially breastfed infants receive a minimum daily intake of 400 IU of vitamin D supplementation beginning soon after birth until they consume sufficient vitamin D fortified milk (about one quart per day) to meet the 400 IU daily requirements (4). These supplements should be given at home by the parents/guardians to take the burden off the caregiver/teacher.

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

COMMENTS:

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

Many people believe that infants sleep better when they start to eat age-appropriate solid foods, however research shows that longer sleeping periods are developmentally and not nutritionally determined in mid-infancy (2,5).

An important goal of early childhood nutrition is to ensure children’s present and future health by fostering the development of healthy eating behaviors (2,9). Caregivers/teachers are responsible for providing a variety of nutritious foods, defining the structure and timing of meals and creating a mealtime environment that facilitates eating and social exchange (7). Children are responsible for participating in choices about food selection and should be allowed to take responsibility for determining how much is consumed at each eating occasion (2).

Good communication between the caregiver/teacher and the parents/guardians cannot be over-emphasized and is essential for successful feeding in general, including when and how to introduce age-appropriate solid foods. The decision to feed specific foods should be made in consultation with the parent/guardian. Caregivers/teachers should be given written instructions on the introduction and feeding of foods from the infant’s parent/guardian and primary care provider. Caregivers/teachers can use or develop a take-home sheet for parents/guardians in which the caregiver/teacher records the food consumed, how much, and other important notes on the infant, each day. Caregivers/teachers should continue to consult with each infant’s parents/guardians concerning which foods they have introduced and are feeding. This schedule of introducing new foods one at a time, followed by waiting two to seven days before introducing another new food, enables parents and caregivers/teachers to pinpoint any problems a child might have with any specific food (10). Following this schedule for introducing new foods, the caregiver/teacher can more easily identify an infant’s possible food allergy or intolerance. Consistency between home and the early care and education setting is essential during the period of rapid change when infants are learning to eat age-appropriate solid foods (6,8).

TYPE OF FACILITY:

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

RELATED STANDARDS:

4.2.0.7 100% Fruit Juice
4.2.0.9 Written Menus and Introduction of New Foods
4.2.0.10 Care for Children with Food Allergies
4.2.0.12 Vegetarian/Vegan Diets
4.5.0.8 Experience with Familiar and New Foods

REFERENCES:

  1. Hagan, Jr., J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Promoting healthy nutrition. In Bright futures: Guidelines for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics. http://brightfutures.aap.org/pdfs/Guidelines_PDF/6-Promoting_Healthy_Nutrition.pdf.
  2. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.
  3. Lawrence, R. A., R. Lawrence. 2005. Breast feeding: A guide for the medical profession. 6th ed. St. Louis: Mosby.
  4. Wagner, C. L., F. R. Greer, Section on Breastfeeding, Committee on Nutrition. 2008. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Pediatrics 122:1142–52.
  5. 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.
  6. U.S. Department of Agriculture, Food and Nutrition Service (FNS). 2002. Feeding infants: A guide for use in the child nutrition programs. Rev ed. Alexandria, VA: FNS. http://www.fns.usda.gov/tn/resources/feeding_infants.pdf.
  7. Branscomb, K. R., C. B. Goble. 2008. Infants and toddlers in group care: Feeding practices that foster emotional health. Young Children 63:28-33.
  8. Grummer-Strawn, L. M., K. S. Scanlon, S. B. Fein. 2008. Infant feeding and feeding transitions during the first year of life. Pediatrics 122: S36-S42.
  9. Griffiths, L. J., L. Smeeth, S. S. Hawkins, T. J. Cole, C. Dezateux. 2008. Effects of infant feeding practice on weight gain from birth to 3 years. Arch Dis Child (November): 1-17.
  10. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.

Oral Health-Related Infectious Disease

Standard 7.5.12.1: Thrush (Candidiasis)

Children with thrush do not need to be excluded from group settings. 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. 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. 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 (1).

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:

Small Family Child Care Home, Center, Large 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

REFERENCES:

  1. Pickering, L. K., C. J. Baker, D. W. Kimberlin, S. S. Long, eds. 2009. Candidiasis. In Red book: 2009 report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics.

Standard 7.6.1.1: Disease Recognition and Control of Hepatitis B Virus (HBV) Infection

Facilities should have written policies for inclusion and exclusion of children known to be infected with hepatitis B virus (HBV) and for immunization of all children with hepatitis B vaccine per the “Recommended Immunization Schedules” for children and adolescents. All infants should complete a three dose series of hepatitis B vaccine beginning at birth as recommended by the American Academy of Pediatrics (AAP) and Centers for Disease Control and Prevention (CDC) (1). When a child who is an HBV carrier is admitted to a facility, the facility director and primary caregivers/teachers should be informed.

Children who carry HBV chronically and who have no behavioral or medical risk factors, such as aggressive behavior (such as biting or frequent scratching), generalized dermatitis (weeping skin lesions), or bleeding problems, may be admitted to the facility without restrictions.

Testing of children for HBV should not be a prerequisite for admission to facilities.

With regard to infection control measures and handling of blood or blood-containing body fluids, every person should be assumed to be an HBV carrier with regard to blood exposure. All blood should be considered as potentially containing HBV. Child care personnel should adopt Standard Precautions, as outlined in Prevention of Exposure to Blood and Body Fluids, Standard 3.2.3.4.

Toys and objects that young children (infants and toddlers) mouth should be cleaned and sanitized, as stated in Standards 3.3.0.2-3.3.0.3.

Toothbrushes and pacifiers should be individually labeled so that the children do not share toothbrushes or pacifiers, as specified in Standard 3.1.5.2.

RATIONALE:

Prior to routine hepatitis B immunization of infants, transmission in child care facilities was reported (2,3). Currently the risk of transmitting the disease in child care is theoretically small because of the low risk of transmission, implementation of infection control measures, and high immunization rates. Immunization not only will reduce the potential for transmission but also will allay anxiety about transmission from children and staff in the child care setting who may be carriers of hepatitis B (1). However, children who are HBV carriers (particularly children born in countries highly endemic for HBV) could be enrolled in child care. Thus, transmission of HBV in the child care setting is of concern to public health authorities.

The risk of disease transmission from an HBV-carrier child or staff member with no behavioral risk factors and without generalized dermatitis or bleeding problems is considered rare. This extremely low risk does not justify exclusion of an HBV-carrier child from out-of-home care, nor does it justify the routine screening of children as possible HBV carriers prior to admission to child care.

HBV transmission in a child care setting is most likely to occur through direct exposure via bites or scratches that break the skin and introduce blood or body secretions from the HBV carrier into a susceptible person. Indirect transmission via blood or saliva through environmental contamination may be possible but has not been documented. Saliva contains much less virus (1/1000) than blood; therefore, the potential infection from saliva is much lower than that of blood.

No data are available to indicate the risk of transmission if a susceptible person bites an HBV carrier. When the HBV statuses of both the biting child and the victim are unknown, the risk of HBV transmission would be extremely low because of the expected low incidence of HBV carriage by children of preschool-age and the low efficiency of disease transmission by bite exposure. Because a bite in this situation is extremely unlikely to involve an HBV-carrier child, screening is not warranted, particularly in children who are immunized appropriately against HBV (1), but each situation should be evaluated individually. In the rare circumstance that an unimmunized child bites a known HBV carrier, the hepatitis B vaccine serries should be initiated (4).

COMMENTS:

Parents/guardians are not required to share information about their child’s HBV status, but they should be encouraged to do so. For additional information regarding HBV consult the current edition of the Red Book from the AAP.

TYPE OF FACILITY:

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

RELATED STANDARDS:

3.1.5.2 Toothbrushes and Toothpaste
3.2.3.4 Prevention of Exposure to Blood and Body Fluids
3.3.0.2 Cleaning and Sanitizing Toys
3.3.0.3 Cleaning and Sanitizing Objects Intended for the Mouth

REFERENCES:

  1. Centers for Disease Control and Prevention. 2005. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States. MMWR 54 (RR16). http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5416a1.htm.
  2. Deseda, D. D., C. N. Shapiro, K. Carroll. 1994. Hepatitis B virus transmission between a child and staff member at a day-care center. Pediatr Infect Dis J 13:828-30.
  3. Shapiro, C. N., L. F. McCaig, K. F. Genesheimer, et al. 1989. Hepatitis B virus transmission between children in day care. Pediatr Infect Dis J 8:870-75.
  4. Shane, A. L., L. K. Pickering. 2008. Infections associated with group child care. In Principles and practice of pediatric infectious diseases, eds. S. S. Long, L. K. Pickering, C. G. Prober. 3rd ed. Philadelphia: Churchill Livingstone.

Standard 7.6.1.3: Staff Education on Prevention of Bloodborne Diseases

All caregivers/teachers should receive training at employment and annually thereafter as required by the Occupational Safety and Health Administration (OSHA) on how to prevent transmission of bloodborne diseases, including hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV (1).

RATIONALE:

Efforts to reduce risk of transmitting diseases in child care through hygiene and environmental standards in general should focus primarily on blood precautions, limiting saliva contamination (no sharing of utensils, pacifiers, tooth brushes), and ensuring that children are appropriately immunized against HBV. People, including caregivers/teachers, who may be expected to come into contact with blood as a part of their employment, are required to be trained how to protect themselves from bloodborne diseases by their employers and be offered hepatitis B vaccine at no charge to them, within ten working days of initial assignment (1,2).

COMMENTS:

If the employee initially declines hepatitis B vaccination but at a later date, while still covered under the acceptable timeline (ten working days), decides to accept the vaccination, the employer should make hepatitis B vaccination available at that time. The employer should require that employees who decline to accept the offer of hepatitis B vaccination sign the Occupational Safety and Health Administration’s (OSHA) “Hepatitis B Vaccine Declination” statement (1). The “Hepatitis B Vaccine Declination” statement can be found at http://www.ecels-healthychildcarepa
.org/content/Keeping Safe 07-27-10.pdf.

For additional information regarding HBV and HCV infections, consult the associated chapters in the current edition of the Red Book from the American Academy of Pediatrics (AAP).

TYPE OF FACILITY:

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

RELATED STANDARDS:

3.2.3.4 Prevention of Exposure to Blood and Body Fluids

REFERENCES:

  1. Occupational Safety and Health Administration. 2008. Bloodborne pathogens. Title 29, pt. 1910.1030. http://www.osha
    .gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051.
  2. Centers for Disease Control and Prevention. 2005. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States. MMWR 54 (RR16). http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5416a1.htm.

Oral Health-Related Emergencies

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:

  1. Name, sex, and age of the injured person;
  2. Date and time of injury;
  3. Location where injury took place;
  4. 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;
  5. Body part(s) involved;
  6. Description of any consumer product involved;
  7. Name and location of the staff member responsible for supervising the child at the time of the injury;
  8. 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;
  9. Recommendations of preventive strategies that could be taken to avoid future occurrences of this type of injury;
  10. Name of person who completed the report;
  11. Name, address, and phone number of the facility;
  12. 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);
  13. If parent/guardian of child was notified at time of injury;
  14. Documentation that written report was sent home the day of the injury, regardless of parental signature.

Examples of injuries that should be documented include:

  1. Child maltreatment (physical, sexual, emotional, and neglect abuse);
  2. Bites that are continuous in nature, break the skin, left a mark, and cause significant pain;
  3. Falls, burns, broken limbs, tooth loss, other injury;
  4. Motor vehicle injury;
  5. Aggressive/unusual behavior;
  6. Ingestion of non-food substances;
  7. Medication error;
  8. Blows to the head;
  9. 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.

Facilities should secure the parent’s/guardian’s signature on the form at the time it is presented to the parent/guardian.

TYPE OF FACILITY:

Small Family Child Care Home, Center, Large 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 CC: Incident Report Form
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

REFERENCES:

  1. 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.
  2. ChildCare.net. Incident reports. http://www.childcare.net/library/incidentreports.shtml.

Appendix KK: Authorization for Emergency Medical/Dental Care

(Reader's Note: Appendix KK resides at the end of the printed PDF version of this document.)

Oral Health Policies and Information

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:

  1. 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;
  2. 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);
  3. Hours and days of operation;
  4. 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;
  5. Payment of fees, deposits, and refunds;
  6. Methods and schedules for conferences or other methods of communication between parents/guardians and staff.

Policies on:

  1. Staffing, including caregivers/teachers, the use of volunteers, helpers, or substitute caregivers/teachers, and deployment of staff for different activities;
  2. Inclusion of children with special health care needs;
  3. Nondiscrimination;
  4. Termination and parent/guardian notification of termination;
  5. Supervision;
  6. Discipline;
  7. Care of children and caregivers/teachers who are ill;
  8. Temporary exclusion and alternative care for children who are ill;
  9. Health assessments and immunizations;
  10. Handling urgent medical care or threatening incidents;
  11. Medication administration;
  12. Use of child care health consultants, education and mental health consultants;
  13. 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.);
  14. Disasters, emergency plan and drills, evacuation plan, and alternative shelter arrangements;
  15. Security;
  16. Confidentiality of records;
  17. Transportation and field trips;
  18. Physical activity (both outdoors and when children are kept indoors), play areas, screen time, and outdoor play policy;
  19. Sleeping, safe sleep policy, areas used for sleeping/napping, sleep equipment, and bed linen;
  20. Sanitation and hygiene;
  21. Presence and care of any animals on the premises;
  22. Food and nutrition including food handling, human milk, feeding and food brought from home, as well as a daily schedule of meals and snacks;
  23. Evening and night care plan;
  24. Smoking, tobacco use, alcohol, prohibited substances, and firearms;
  25. Preventing and reporting child abuse and neglect;
  26. 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. Model Child Care Health Policies can be adapted to these smaller settings.

TYPE OF FACILITY:

Small Family Child Care Home, Center, Large 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
1.6.0.1 Child Care Health Consultants
2.1.1.1 Written Daily Activity Plan and Statement of Principles
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 Limiting Screen Time – Media, Computer Time
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
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 SIDS/Suffocation 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/Pull-Ups 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, Alcohol, and Illegal 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 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 USDA - CACFP 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
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
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
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

Standard 9.2.3.6: Identification of Child’s Medical Home and Parental Consent for Information Exchange

As part of the enrollment of a child, the caregiver/teacher should ask the family to identify the child’s primary care provider, his or her medical home, and other specialty health care professionals. The parent/guardian should provide written consent to enable the caregiver/teacher to establish communication with those providers. The family should always be informed prior to the use of the permission unless it is an emergency. The providers with whom the facility should exchange information (with parental consent) should include:

  1. Sources of regular medical and dental care (such as the child’s primary care provider, dentist, and medical facility);
  2. Special clinics the child may attend, including sessions with medical specialists and registered dietitians;
  3. Special therapists for the child (e.g., occupational, physical, speech, and nutritional), along with written documentation of the services rendered provided by the special therapist;
  4. Counselors, therapists, or mental health service providers for parents/guardians (e.g., social workers, psychologists, or psychiatrists);
  5. Pharmacists for children who take prescription medication on a regular basis or have emergency medications for specific conditions.

RATIONALE:

Primary care providers are involved not only in the medical care of the child but also involved in supporting the child’s emotional and developmental needs (1-3). A major barrier to productive working relationships between child care and health care professionals is inadequate communication (1,2).

Knowing who is treating the child and coordinating services with these sources of service is vital to the ability of the caregivers/teachers to offer appropriate care to the child. Every child should have a medical home and those with special health care needs may have additional specialists and therapists (4-7). The primary care provider and needed specialists will create the Care Plan which will be the blueprint for healthy and safe inclusion into child care for the child with special health care needs.

COMMENTS:

A source of health care may be a community or specialty clinic, a public health department, specialist, or a private primary care provider. Families should also know the location of the hospital emergency room departments nearest to their home and child care facility.

The California Childcare Health Program has developed a form to help facilitate the exchange of information between the health professionals and the parents/guardians and caregivers/teachers at http://ucsfchildcarehealth.org/pdfs/forms/CForm_ExchangeofInfo.pdf. They also release an information form at http://ucsfchildcarehealth.org/pdfs/forms/CF_ReferralRel.pdf. For more information on the medical home concept, see the American Academy of Pediatrics’ (AAP) Medical Home Website at http://www.medicalhome
info.org.

TYPE OF FACILITY:

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

RELATED STANDARDS:

2.3.3.1 Parents’/Guardians’ Provision of Information on Their Child’s Health and Behavior
3.5.0.1 Care Plan for Children with Special Health Care Needs
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
Appendix O: Care Plan for Children with Special Health Care Needs
Appendix AA: Medication Administration Packet
Appendix FF: Child Health Assessment

REFERENCES:

  1. American Academy of Pediatrics (AAP). 2001. The pediatrician’s role in promoting health and safety in child care. Elk Grove Village, IL: AAP.
  2. 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.
  3. 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.
  4. Starfield, B., L. Shi. 2004. The medical home, access to care, and insurance: A review of evidence. Pediatrics 113:1493-98.
  5. Homer, C. J., K. Klatka, D. Romm, K. Kuhlthau, S. Bloom, P. Newacheck, J. Van Cleave, J. M. Perrin. 2008. A review of the evidence for the medical home for children with special health care needs. Pediatrics 122:e922–37.
  6. Inkelas, M., M. Regolado, N. Halfon. 2005. Stategies for integrating developmental services and promoting medical homes. Los Angeles: National Center for Infant and Early Childhood Health Policy.
  7. Nowak, A. J., P. S. Casamassimo. 2002. The dental home: A primary care concept. JADA 133:93-98.

Standard 9.2.3.13: Plans for Evening and Nighttime Child Care

Facilities that provide evening and nighttime care should have plans for such care that include the supervision of sleeping children and the management and maintenance of sleep equipment including their sanitation and disinfection. Evacuation drills should occur during hours children are in care. Centers should have these plans in writing.

RATIONALE:

Evening child care routines are similar to those required for daytime child care with the exception of sleep routines. Evening and nighttime child care requires special attention to sleep routines, safe sleep environment, supervision of sleeping children, and personal care routines, including bathing and tooth brushing. Nighttime child care must meet the nutritional needs of the children and address morning personal care routines such as toileting/diapering, hygiene, and dressing for the day. Children and staff must be familiar with evacuation procedures in case a natural or human generated disaster occurs during evening child care and nighttime child care hours.

COMMENTS:

Sleeping time is a very sensitive time for infants and young children. Attention should be paid to individual needs, transitional objects, lighting preferences, and bedtime routines.

TYPE OF FACILITY:

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

RELATED STANDARDS:

2.2.0.1 Methods of Supervision of Children
3.3.0.4 Cleaning Individual Bedding
3.3.0.5 Cleaning Crib Surfaces
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
9.2.4.3 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

Standard 9.2.3.14: Oral Health Policy

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

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

RATIONALE:

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

TYPE OF FACILITY:

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

RELATED STANDARDS:

3.1.5.1 Routine Oral Hygiene Activities
3.1.5.2 Toothbrushes and Toothpaste
3.1.5.3 Oral Health Education
5.5.0.1 Storage and Labeling of Personal Articles

REFERENCES:

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

Standard 9.2.4.1: Written Plan and Training for Handling Urgent Medical Care or Threatening Incidents SS3 footprint

The facility should have a written plan for reporting and managing what they assess to be an incident or unusual occurrence that is threatening to the health, safety, or welfare of the children, staff, or volunteers. The facility should also include procedures of staff training on this plan.

The management, documentation, and reporting of the following types of incidents, at a minimum, that occur at the child care facility should be addressed in the plan:

  1. Lost or missing child;
  2. Suspected maltreatment of a child (also see state’s mandates for reporting);
  3. Suspected sexual, physical, or emotional abuse of staff, volunteers, or family members occurring while they are on the premises of the child care facility;
  4. Injuries to children requiring medical or dental care;
  5. Illness or injuries requiring hospitalization or emergency treatment;
  6. Mental health emergencies;
  7. Health and safety emergencies involving parents/guardians and visitors to the program;
  8. Death of a child or staff member, including a death that was the result of serious illness or injury that occurred on the premises of the child care facility, even if the death occurred outside of child care hours;
  9. The presence of a threatening individual who attempts or succeeds in gaining entrance to the facility.

The following procedures, at a minimum, should be addressed in the plan for urgent care:

  1. Provision for a caregiver/teacher to accompany a child to a source of urgent care and remain with the child until the parent/guardian assumes responsibility for the child;
  2. Provision for the caregiver/teacher to provide the medical care personnel with an authorization form signed by the parent/guardian for emergency medical care and a written informed consent form signed by the parent/guardian allowing the facility to share the child’s health records with other service providers;
  3. Provision for a backup caregiver/teacher or substitute for large and small family child care homes to make the arrangement for urgent care feasible (child:staff ratios must be maintained at the facility during the emergency);
  4. Notification of parent/guardian(s);
  5. Pre-planning for the source of urgent medical and dental care (such as a hospital emergency room, medical or dental clinic, or other constantly staffed facility known to caregivers/teachers and acceptable to parents/guardians);
  6. Completion of a written incident/injury report and the program’s response;
  7. Assurance that the first aid kits are resupplied following each first aid incident, and that required contents are maintained in a serviceable condition, by a monthly review of the contents;
  8. Policy for scheduled reviews of staff members’ ability to perform first aid for averting the need for emergency medical services;
  9. Policy for staff supervision following an incident when a child is lost, missing, or seriously injured.

RATIONALE:

Emergency situations are not conducive to calm and composed thinking. A written plan provides the opportunity to prepare and to prevent poor judgments made under the stress of an emergency.

Unannounced mock situations used as drills can help ease tension and build confidence in the staff’s ability to respond calmly in the event of a real incident. Discussion regarding performance and opportunities for improvement should follow the drill.

An organized, comprehensive approach to injury prevention and control is necessary to ensure that a safe environment is provided to children in child care. Such an approach requires written plans, policies, procedures, and record-keeping so that there is consistency over time and across staff and an understanding between parents/guardians and caregivers/teachers about concerns for, and attention to, the safety of children.

Routine restocking of first aid kits is necessary to ensure supplies are available at the time of an emergency. Staff should be trained in the use of standard precautions during the response to any situation in which exposure to bodily fluids could occur. Management within the first hour or so following a dental injury may save a tooth.

Intrusions by threatening individuals to child care facilities have occurred, some involved violence resulting in injury and death. These threats have come from strangers who gained access to the playground or an unsecured building, or impaired family members who had easy access to a secured building. Facilities must have a plan for what to do in such situations (1-3).

COMMENTS:

The American Academy of Pediatrics’ policy statement, “Medical Emergencies Occurring at School” contains information including a comprehensive list of resources that is relevant to child care facilities. The Emergency Medical Services for Children National Resource Center (http://www.childrensnational.org/emsc/) has downloadable print information for emergency medical training, particularly the brochure entitled “Emergency Guidelines for School” at http://ems.ohio.gov/EMSC web site_11_04/pdf_doc files/EMSCGuide.pdf. This site also lists internet links to emergency plans for specific health needs such as diabetes, asthma, seizures, and allergic reactions. Resources for emergency response to non-medical incidents can be found at http://www.chtc.org/dl/handouts/20061114/20061114-2.pdf and http://dcf.vermont.gov/sites/dcf/files/pdf/cdd/care/EmergencyResponse.pdf.

It is recommended that parents/guardians inform caregivers/teachers their preferred sources for medical and dental care in case of emergency. Parents/guardians should be notified, if at all possible, before dental services are rendered, but emergency care should not be delayed because the child’s own dentist is not immediately available.

Facilities should develop and institute measures to control access of a threatening individual to the facility and the means of alerting others in the facility as well as summoning the police if such an event occurs.

TYPE OF FACILITY:

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

RELATED STANDARDS:

1.5.0.1 Employment of Substitutes
1.5.0.2 Orientation of Substitutes
3.2.3.4 Prevention of Exposure to Blood and Body Fluids
3.6.4.5 Death
9.2.4.2 Review of Written Plan for Urgent Care
9.2.4.3 Disaster Planning, Training, and Communication
9.4.1.9 Records of Injury
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
9.4.2.1 Contents of Child’s Records

REFERENCES:

  1. AFP. 2009. Belgian charged over daycare killings. Nine News, Jan 24. http://news.ninemsn.com.au/world/.
  2. Haggerty, R. 2010. Man kills self after firing shots at day care. Journal Sentinel, Feb 17. http://www.jsonline.com/news/crime/.
  3. Guerra, C. 2010. Child care providers get lessons in Lee County on being prepared. News-Press, Apr 19. http://beta.news
    -press.com.

Standard 9.4.2.4: Contents of Child’s Primary Care Provider’s Assessment

The file for each child should include an initial health assessment completed and signed by the child’s primary care provider. This should be on file preferably at enrollment and no later than within six weeks of admission. (Requirements may be waived to comply with the federal McKinney-Vento Homeless Assistance Act regarding health and health records.) It should include:

  1. Immunization Records;
  2. Growth Assessment – may include percentiles of weight, height, and head circumference (under age of two); recording body mass index (BMI) and percentile for age is especially helpful in those children age two years and older who are over or underweight;
  3. Health Assessment – includes descriptions of any current acute and/or chronic health issues and should also include any findings from an exam or screening that may need follow-up, e.g., vision, hearing, dental, obesity, or nutritional screens or tests for lead, anemia, or tuberculosis (these health concerns may require a care plan and possibly a medication plan [see h) below]);
  4. Developmental Issues – includes descriptions of concerns and the child’s special needs in a child care setting, (for example, a vision or hearing deficit, a developmental variation, prematurity, or an emotional or behavioral disturbance);
  5. Significant physical findings so that caregivers/teachers can note if there are changes from baseline and report those findings;
  6. Dates of Significant Illnesses and/or Injuries;
  7. Allergies;
  8. Medication(s) List – includes dosage, time and frequency of administration of any ongoing prescription or non-prescription (over-the-counter [OTC]) medication that the person with prescriptive authority recommends for the child. This list would also include information on recognizing side-effects and responding to them appropriately and it may also contain the same information for intermittent use of a fever reducer medication;
  9. Dietary modifications;
  10. Emergency plans;
  11. Other special instructions for the caregiver/teacher;
  12. Care Plan – (if the child has a special health need as indicated by c) or d) above) includes routine and emergency management plans that might be required by the child while in child care. This plan also includes specific instructions for caregiver/teacher observations, activities or services that differ from those required by typically developing children and should include specific instructions to caregivers/teachers on how to provide medications, procedures, or implement modifications required by children with asthma, severe allergic reactions, diabetes, medically-indicated special feedings, seizures, hearing impairments, vision problems, or any other condition that requires accommodation in child care;
  13. Parent’s/Guardian’s assessment and concerns (4).

For children up the age of three years, health care professional assessments should be at the recommended intervals indicated by the American Academy of Pediatrics (AAP) (3). For all other children, the Health Care Professional Assessment updates should be obtained annually. It should include any significant health status changes, any new medications, any hospitalizations, and any new immunizations given since the previous health assessment. This health report will be supplemented by the health history obtained from the parents/guardians by the child care provider at enrollment.

RATIONALE:

The requirement of a health report for each child reflecting completion of health assessments and immunizations is a valid way to ensure timely preventive care for children who might not otherwise receive it and can be used in decision-making at the time of admission and during ongoing care (2). This requirement encourages families to have a primary care provider (medical home) for each child where timely and periodic well-child evaluations are done. The objective of timely and periodic evaluations is to permit detection and treatment for improved oral, physical, mental, and emotional/social health (1,3). The reports of such evaluations provide a conduit for communication of information that helps the primary care provider and the caregiver/teacher determine appropriate services for the child. When the parent/guardian carries the request for the report to the primary care provider, concerns of the caregiver/teacher can be delivered by the parent/guardian to the child’s primary care provider and consent for communication is thereby given. The parent/guardian can give written consent for direct communication between the primary care provider and the caregiver/teacher so that the forms can be faxed or mailed.

Quality child care requires information about the child’s health status and need for accommodations in child care (2).

COMMENTS:

The purpose of a health care professional assessment is to:

  1. Give information about a child’s health history, special health care needs, and current health status to allow the caregiver/teacher to provide a safe setting and healthy experience for each child;
  2. Promote individual and collective health by fostering compliance with approved standards for health care assessments and immunizations;
  3. Document compliance with licensing standards;
  4. Serve as a means to ensure early detection of health problems and a guide to steps for remediation;
  5. Serve as a means to facilitate and encourage communication and learning about the child’s needs among caregivers/teachers, primary care providers, and parents/guardians.

This approach is usually the most efficient, effective and least costly since the primary care provider has the child, the family member, and the record in hand, to provide the information that the child care facility should have. When the data are requested separate from the visit to the primary care provider for the health assessment, the record must be pulled from the file and the information retrieved from the notes in the file. Some health care facilities charge families for the cost of the additional work to complete forms either at the time of a health care visit or later. Collaborating in reducing the burden of form completion by writing in as much information as is known before giving the forms to the primary care provider helps foster effective communication. Many primary care providers appreciate having identifying information filled in on the form about the child care facility, the child, the family and a note about any concerns to be addressed.

Caregivers/teachers may offer a four-week grace period during which the parent/guardian can arrange to get this assessment. The health history can serve as an interim health assessment during this grace period.

Health data should be presented in a form usable for caregivers/teachers to help identify any special needs for care. Local Early Periodic Screening and Diagnostic Treatment (EPSDT) program contractor, if available, should be called upon to help with liaison and education activities. In some situations, screenings may be performed at the facilities, but it is always preferable that the child have a medical home and primary care provider who screens the child and provides the information. When clinicians do not fill out forms completely enough to assist the caregiver/teacher in understanding the significance of health assessment findings or the unique characteristics of a child, the caregiver/teacher should obtain parental consent to contact the child’s primary care provider to explain why the information is needed and to request clarification.

Health assessments should be in a format easily usable by caregivers/teachers to identify any special needs for care.

A child’s primary care provider is a key resource to families when racial, ethnic, socioeconomic, or educational disparities create barriers to the child receiving regular dental care. He or she can perform an oral examination and conduct an oral health risk assessment and triage for infants and young children. Children with suspected oral problems should see a dentist immediately, regardless of age or interval.

The American Academy of Pediatrics (AAP) and Bright Futures recommend vision/hearing and dental screenings are:

  1. Vision/hearing at every well care visit (with objective measures of visual acuity by four years and audiometry measures of hearing by five years of age); and
  2. Dental exam at one year (or sooner if there are suspected oral problems) (3).

TYPE OF FACILITY:

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

RELATED STANDARDS:

9.4.2.1 Contents of Child’s Records
9.4.2.5 Health History
Appendix O: Care Plan for Children with Special Health Care Needs
Appendix FF: Child Health Assessment

REFERENCES:

  1. 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.
  2. 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.
  3. American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine, Bright Futures Steering Committee. 2007. Policy statement: Recommendations for preventive pediatric health care. Pediatrics 120:1376.
  4. Crowley A. A., G. C. Whitney. 2005. Connecticut’s new comprehensive and universal early childhood health assessment form. J School Health 75:281-85.

Standard 9.4.2.5: Health History

The file for each child should include a health history completed by the parent/guardian at admission, preferably with staff involvement. This history should include the following:

  1. Identification of the child’s medical home/primary care provider and dental home;
  2. Permission to contact these professionals in case of emergency;
  3. Chronic diseases/health issues currently under treatment;
  4. Developmental variations, sensory impairment, serious behavior problems or disabilities that may need consideration in the child care setting;
  5. Description of current physical, social, and language developmental levels;
  6. Current medications, medical treatments and other therapeutic interventions;
  7. Special concerns (such as allergies, chronic illness, pediatric first aid information needs);
  8. Specific diet restrictions, if the child is on a special diet;
  9. Individual characteristics or personality factors relevant to child care;
  10. Special family considerations;
  11. Dates of infectious diseases;
  12. Plans for medical emergencies;
  13. Any special equipment that might be needed;
  14. Special transportation adaptations.

RATIONALE:

A health history is the basis for meeting the child’s medical and psychosocial needs in the child care setting. This information must be obtained and reviewed at admission by the significant caregiver/teacher. This information may be the only health information on file for up to the first four weeks following enrollment.

COMMENTS:

This history will complement the child’s health history which is completed by the primary care provider.

TYPE OF FACILITY:

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

RELATED STANDARDS:

9.4.2.1 Contents of Child’s Records

Licensing and State Responsibilities

Standard 10.3.2.1: Child Care Licensing Advisory Board

States should have an official child care licensing advisory body for regulatory and related policy issues. A child care advisory board should:

  1. Review proposed rules and regulations prior to adoption;
  2. Recommend administrative policy;
  3. Recommend changes in legislation; and
  4. Guide enforcement, if granted this authority via the legislative process.

The advisory group should include representatives from the following agencies and groups:

  1. State agencies with regulatory responsibility or an interest in child care (human services, public health, fire marshal, emergency medical services, education, human resources, attorney general, safety council);
  2. Organizations with a child care emphasis;
  3. Operators, directors, owners, and caregivers/teachers reflecting various types of child care programs including for-profit and non-profit;
  4. Professionals with expertise related to the rules; may include pediatrics, physical activity, nutrition, mental health, oral health, injury prevention, resource and referral, early childhood education, and early childhood professional development;
  5. Parents/guardians who reflect the diversity of the families that are consumers of licensed child care programs.

This advisory board should be linked to the State Early Childhood Advisory Council (see Standard 10.3.2.2) as required by the Head Start Act of 2007 (1). 

RATIONALE:

The advisory group should actively seek citizen participation in the development of child care policy, including parents/guardians, child care administrators, and caregivers/teachers. The licensing advisory board should report directly to the agency having administrative authority over licensing.

RELATED STANDARDS:

10.3.2.2 State Early Childhood Advisory Council

REFERENCES:

  1. U.S. Congress. 2007. Head Start Act. 42 USC 9801. http://eclkc.ohs.acf.hhs.gov/hslc/Head Start Program/Program Design and Management/Head Start Requirements/Head Start Act/.

Standard 10.3.4.1: Sources of Technical Assistance to Support Quality of Child Care

Public authorities (such as licensing agencies) and private agencies (such as resource and referral agencies), should develop systems for technical assistance to states, localities, child care agencies, and caregivers/teachers that address the following:

  1. Meeting licensing requirements;
  2. Establishing programs that meet the developmental needs of children;
  3. Educating parents/guardians on specific health and safety issues through the production and distribution of related material.
 

RATIONALE:

The administrative practice of developing systems for technical assistance is designed to enhance the overall quality of child care that meets the social and developmental needs of children. The chief sources of technical assistance are:

  1. Licensing agencies (on ways to meet the regulations);
  2. Health departments (on health related matters);
  3. Resource and referral agencies (on ways to achieve quality, how to start a new facility, supply and demand data, how to get licensed, and what parents/guardians want);
  4. Child care health, education, mental health consultant networks; American Academy of Pediatrics (AAP) state chapters and child care contacts; and state Early Childhood Comprehensive Systems (ECCS) grants are examples of partners providing technical assistance on health and related child care matters.

The state agency has a continuing responsibility to assist an applicant in qualifying for a license and to help licensees improve and maintain the quality of their facility. Regulations should be available to parents/guardians and interested citizens upon request and should be translated if needed. Licensing inspectors throughout the state should be required to offer assistance and consultation as a regular part of their duties and to coordinate consultation with other technical assistance providers as this is an integral part of the licensing process.

The Maternal and Child Health Bureau (MCHB) of the Health Resources and Services Administration (HRSA) and the Office of Child Care (OCC) of the Administration for Children and Families (ACF) continue to develop initiatives that provide funding to support technical assistance to early care and education. States should check with their State Child Care Administrators, Maternal and Child Health Directors, and Head Start State Collaboration Directors, for more information.

Providing centers and networks of small or large family child care homes with guidelines and information on establishing a program of care is intended to promote appropriate programs of activities. Child care staff is rarely trained health professionals. Since staff and time are often limited, caregivers/teachers should have access to consultation on available resources in a variety of fields (such as physical and mental health care; nutrition; safety, including fire safety; oral health care; developmental disabilities; and cultural sensitivity) (1,2).

The public agencies can facilitate access to children and their families by providing useful materials to child care providers.

RELATED STANDARDS:

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
10.3.3.1 Credentialing of Individual Child Care Providers
10.4.1.3 Licensing Agency Procedures Prior to Issuing a License

REFERENCES:

  1. American Academy of Pediatrics. 2001. The pediatrician’s role in promoting health and safety in child care. Elk Grove Village, IL: AAP.
  2. Alkon, A., J. Bernzweig, K. To, M. Wolff, J. F. Mackie. 2009. Child care health consultation improves health and safety policies and practices. Acad Pediatr 9:366-70.

Standard 10.3.4.3: Support for Consultants to Provide Technical Assistance to Facilities

State agencies should encourage the arrangement and coordination of and the fiscal support for consultants from the local community to provide technical assistance for program development and maintenance. Consultants should have training and experience in early childhood education, early childhood growth and development, issues of health and safety in child care settings, business practices, ability to establish collegial relationships with child care providers, adult learning techniques, and ability to help establish links between facilities and community resources. There should be collaboration among all parts of the early care and education community to provide technical assistance and consultation to improve the quality of care. The licensing agency should be an integral part of the quality rating and improvement system (QRIS) in the state; all parts of the system must collaborate to assure the most effective and efficient use of resources to encourage quality improvement. See Glossary for definition of QRIS.

The state regulatory agency with the Title V or State Child Care Resource and Referral Agency should provide or arrange for other public agencies, private organizations or technical assistance agencies (such as a resource and referral agency) to make the following consultants available to the community of child care providers of all types:

  1. Program consultant, to provide technical assistance for program development and maintenance and business practices. Consultants should be chosen on the basis of training and experience in early childhood education and ability to help establish links between the facility and community resources;
  2. Child care health consultant (CCHC), who has knowledge and expertise in child health and child development, is knowledgeable about the special needs of children in out-of-home care settings, and knows the child care licensing requirements and available health resources. A regional plan to make consultants accessible to facilities for ongoing relationships should be developed;
  3. Nutritionist/registered dietitian, who also has the knowledge of infant and child development, food service, nutrition and nutrition education methods, to be responsible for the development of policies and procedures and for the implementation of nutrition standards to provide high quality meals, nutrition education programs and appropriately trained personnel, and to provide consultation to agency personnel, including collaborating with licensing inspectors;
  4. Early childhood education consultant, to assist centers, large family child care homes, and networks of small family child care homes in partnering with families in meeting the individual development and learning needs of children, including any special developmental and educational needs that a child may have. Early Childhood Education Consultants can assist providers n early detection and referral for identifying and addressing special learning needs, especially infants and toddlers;
  5. Early childhood mental health consultant (ECMHC), to assist centers, large family child care homes, and networks of small family child care homes in meeting the emotional needs of children and families. The state mental health agency should promote funding through community mental health agencies and child guidance clinics for these services. At the least, such consultants should be available when caregivers/teachers identify children whose behaviors are more difficult to manage than typically developing children;
  6. Dental health consultant, to assist centers, large family child care homes and networks small family child care homes in meeting the oral health needs of children. The dental health consultant should have knowledge of pediatric oral health and be able to help with policy and procedure development in this area;
  7. Physical activity consultant, who has knowledge in infant and child motor development (developmental biomechanics), locomotion, ballistic, and manipulative skills, sensory-perceptual development, social, psychosocial, and cultural constraints in motor development, and development of cardio-respiratory endurance, strength and flexibility, and body composition, to be responsible for the development of policies and procedures for the implementation of age and developmentally appropriate physical activity standards to provide children with the movement experiences needed for optimal growth and development, physical education/movement programs, and appropriately trained personnel, and to provide consultation to agency personnel, including collaborating with licensing inspectors.

A plan should be in place that supports the interdisciplinary collaboration of consultant support to programs to ensure coordinated support, avoid duplication and stress on programs and families, and promote efficient use of consultant resources.

Additionally, a plan should be in place that outlines how the state identifies, trains, and supports consultants who, in turn, support programs. Minimum qualifications required of consultants may be specified in state regulations. There are resources for training consultants that can be integrated into state plans for supporting health and other early childhood consultants. States will ideally take advantage of opportunities to partner with Head Start, child welfare, Part C and Part B, and others to maintain an ongoing system of supporting consultants and fostering partnerships that support children, families and programs and help improve the overall quality of services provided in the community.

RATIONALE:

Securing expertise is acceptable by whatever method is most workable at the state or local level (for example, consultation could be provided from a resource and referral agency). Providers, not the regulatory agency, are responsible for securing the type of consultation that is required by their individual facilities. Ongoing relationships with CCHCs, nutritionists/registered dietitians, and ECMHCs are effective in promoting healthy and safe environments (3-5).

COMMENTS:

Several states now have mental health consultants specifically serving the child care community. There are different models of mental health consultation. Some models are programmatic and only include the staff, others work with individual children with behavioral and emotional problems and the third model integrates both approaches. MHCs are usually social workers or professionals with a child development or psychology background who are trained to work in child care settings (2). There is no formal or standardized training for ECMHCs nationally. Developmental and behavioral pediatricians, child and adolescent psychiatrists, and child psychologists are resources for the behavioral and mental health needs of young children (1). Some, but not all, adolescent and child psychiatrists and psychologists, social workers and child counselors have the necessary skills to work with behavior problems of this youngest age group. To find such specialists, contact the Department of Pediatrics at academic centers or the State Department of Mental Health. The faculty at such centers can usually refer child care facilities to individuals with the necessary skills in their area.

The administrative practice of developing systems for technical assistance is designed to enhance the overall quality of child care that meets the social and developmental needs of children. The chief sources of technical assistance are:

  1. AAP Chapter Child Care Contact (contact information can be found at http://www.healthychildcare.org);
  2. Licensing agencies (on ways to meet the regulations and make quality improvements);
  3. Health departments (on health related matters);
  4. Resource and referral agencies (on ways to achieve quality, how to start a new facility, supply and demand data, how to get licensed, and what parents/guardians want);
  5. Community action programs or non-profit organizations (on health related matters including physical education, for health education and/or quality improvement issues);
  6. Local university kinesiology departments (on early childhood motor development and physical activity issues);
  7. Small business administration (on financial issues related to program operations);
  8. Subsidy agencies may fund a variety of consultants to programs through the Child Care and Development Fund (CCDF) quality dollars;
  9. Education departments often administer the food program dollars and may have technical assistance related to the Individuals with Disabilities Education Act (IDEA).

REFERENCES:

  1. American Academy of Pediatrics (AAP). 2001. The pediatrician’s role in promoting health and safety in child care. Elk Grove Village, IL: AAP.
  2. Healthy Child Care America. 2006. The influence of child care health consultants in promoting children’s health and well-being: A status report. Rockville, MD: Maternal and Child Health Bureau.
  3. Crowley, A. A., J. M. Kulikowich. Impact of training on child care health consultant knowledge and practice. Ped Nurs 35:93-100.
  4. 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.
  5. Alkon, A., J. Bernzweig, K. To, M. Wolff, J. F. Mackie. 2009. Child care health consultation improves health and safety policies and practices. Acad Pediatr 9:366-70.

Standard 10.3.4.4: Development of List of Providers of Services to Facilities

The local regulatory agency or resource and referral agency should assist centers and small and large family child care homes to formulate and maintain a list of community professionals and agencies available to provide needed health, dental, and social services to families.

RATIONALE:

Families depend on their child care facilities to provide information about obtaining health and dental care and other community services. A number of communities have Family Resource Centers, which are central points for information. It is important that regulatory agencies and resource and referral agencies have knowledge of family resource centers or can provide a directory of community services to child care facilities.

Partnerships among health care professionals and community agencies are necessary to provide a medical home for all children. The American Academy of Pediatrics (AAP) defines the medical home as care that is accessible, family-centered, continuous, comprehensive, coordinated, compassionate, and culturally competent. The medical home is not a building, house, or hospital, but an approach to providing health care services in a high-quality and cost-effective manner (1,2). Health care professionals and other community service agencies are beginning to recognize that child care facilities are a logical opportunity to provide information or referral of children to a medical home. Child care programs also provide opportunities for education in health promotion and disease prevention for children and families (3).

REFERENCES:

  1. Kempe, A., B. Beaty, B. P. Englund, R. J. Roark, N. Hester, J. F. Steiner. 2000. Quality of care and use of the medical home in a state-funded capitated primary care plan for low-income children. Pediatrics 105:1020-28.
  2. American Academy of Pediatrics. 2008. Policy statement: The medical home. Pediatrics 122:450.
  3. Gupta, R. S., S. Shuman, E. M. Taveras, M. Kulldorff, J. A. Finkelstein. 2005. Opportunities for health promotion education in child care. Pediatrics 116: e499-e505.

Standard 10.6.1.1: Regulatory Agency Provision of Caregiver/Teacher and Consumer Training and Support Services

The licensing agency should promote participation in a variety of caregiver/teacher and consumer training and support services as an integral component of its mission to reduce risks to children in out-of-home child care. Such training should emphasize the importance of conducting regular safety checks and providing direct supervision of children at all times. Training plans should include mechanisms for training of prospective child care staff prior to their assuming responsibility for the care of children and for ongoing/continuing education. The higher education institutions providing early education degree programs should be coordinated with training provided at the community level to encourage continuing education and availability of appropriate content in the coursework provide by these institutions of higher education.

Persons wanting to enter the child care field should be able to learn from the regulatory agency about training opportunities offered by public and private agencies. Discussions of these trainings can emphasize critical child care health and safety messages. Some training can be provided online to reinforce classroom education.

Training programs should address the following:

  1. Child growth and development including social-emotional, cognitive, language, and physical development;
  2. Child care programming and activities;
  3. Discipline and behavior management;
  4. Mandated child abuse and neglect reporting;
  5. Health and safety practices including injury prevention, basic first aid and CPR, reporting, preventing and controlling infectious diseases, children’s environmental health and health promotion, and reducing the risk of SIDS and use of safe sleep practices;
  6. Cultural diversity;
  7. Nutrition and eating habits including the importance of breastfeeding and the prevention of obesity and related chronic diseases;
  8. Parent/guardian education;
  9. Design, use and safe cleaning of physical space;
  10. Care and education of children with special health care needs;
  11. Oral health care;
  12. Reporting requirements for infectious disease outbreaks;
  13. Caregiver/teacher health;
  14. Age-appropriate physical activity.

RATIONALE:

Training enhances staff competence (1,2,4). In addition to low child:staff ratio, group size, age mix of children, and continuity of caregiver/teacher, the training/education of caregivers/teachers is a specific indicator of child care quality (1,2). Most states require limited training for child care staff depending on their functions and responsibilities. Some states do not require completion of a high school degree or GED for various levels of teacher positions (5). Staff members who are better trained are more able to prevent, recognize, and correct health and safety problems. Decisions about management of illness are facilitated by the caregiver’s/teacher’s increased skill in assessing a child’s behavior that suggests illness (2,3). Training should promote increased opportunity in the field and openings to advance through further degree-credentialed education.

RELATED STANDARDS:

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
10.6.2.1 Development of Child Care Provider Organizations and Networks

REFERENCES:

  1. U.S. General Accounting Office (USGAO); Health, Education, and Human Services Division. 1994. Child care: Promoting quality in family child care. Report to the chairman, subcommittee on regulation, business opportunities, and technology, committee on small business, House of Representatives. Publication no. GAO-HEHS-95-36. Washington, DC: USGAO.
  2. Galinsky, E., C. Howes, S. Kontos, M. Shinn. 1994. The study of children in family child care and relative care. New York: Families and Work Institute.
  3. Aronson, S. S., L. S. Aiken. 1980. Compliance of child care programs with health and safety standards: Impact of program evaluation and advocate training. Pediatrics 65:318-25.
  4. Kendrick, A. S. 1994. Training to ensure healthy child day-care programs. Pediatrics 94:1108-10.
  5. Moon, R. Y., R. P. Oden. 2003. Back to sleep: Can we influence child care providers? Pediatrics 112:878-82.
  6. National Child Care Information and Technical Assistance Center, National Association for Regulatory Administration (NARA). 2010. The 2008 child care licensing study: Final report. Lexington, KY: NARA. http://www.naralicensing.org/associations/4734/files/1005_2008_Child Care Licensing Study_Full_Report.pdf.

Related Issues

Standard 1.7.0.1: Pre-Employment and Ongoing Adult Health Appraisals, Including Immunization FAQ

All paid and volunteer staff members should have a health appraisal before their first involvement in child care work. The appraisal should identify any accommodations required of the facility for the staff person to function in his or her assigned position.

Health appraisals for paid and volunteer staff members should include:

  1. Physical exam;
  2. Dental exam;
  3. Vision and hearing screening;
  4. The results and appropriate follow up of a tuberculosis (TB) screening, using the Tuberculin Skin Test (TST) or IGRA (interferon gamma release assay), once upon entering into the child care field with subsequent TB screening as determined by history of high risk for TB thereafter;
  5. A review and certification of up-to-date immune status per the current Recommended Adult Immunization Schedule found in Appendix H, including annual influenza vaccination and up to date Tdap;
  6. A review of occupational health concerns based on the performance of the essential functions of the job.

All adults who reside in a family child care home who are considered to be at high risk for TB, should have completed TB screening (1) as specified in Standard 7.3.10.1. Adults who are considered at high risk for TB include those who are foreign-born, have a history of homelessness, are HIV-infected, have contact with a prison population, or have contact with someone who has active TB.

Testing for TB of staff members with previously negative skin tests should not be repeated on a regular basis unless required by the local or state health department. A record of test results and appropriate follow-up evaluation should be on file in the facility.

RATIONALE:

Caregivers/teachers need to be physically and emotionally healthy to perform the tasks of providing care to children. Performing their work while ill can spread infectious disease and illness to other staff and the children in their care (2). Under the Americans with Disabilities Act (ADA), employers are expected to make reasonable accommodations for persons with disabilities. Under ADA, accommodations are based on an individual case by case situation. Undue hardship is defined also on a case by case basis. Accommodation requires knowledge of conditions that must be accommodated to ensure competent function of staff and the well-being of children in care (3).

Since detection of tuberculosis using screening of healthy individuals has a low yield compared with screening of contacts of known cases of tuberculosis, public health authorities have determined that routine repeated screening of healthy individuals with previously negative skin tests is not a reasonable use of resources. Since local circumstances and risks of exposure may vary, this recommendation should be subject to modification by local or state health authorities.

COMMENTS:

Child care facilities should provide the job description or list of activities that the staff person is expected to perform. Unless the job description defines the duties of the role specifically, under federal law the facility may be required to adjust the activities of that person. For example, child care facilities typically require the following activities of caregivers:

  1. Moving quickly to supervise and assist young children;
  2. Lifting children, equipment, and supplies;
  3. Sitting on the floor and on child-sized furniture;
  4. Washing hands frequently;
  5. Responding quickly in case of an emergency;
  6. Eating the same food as is served to the children (unless the staff member has dietary restrictions);
  7. Hearing and seeing at a distance required for playground supervision or driving;
  8. Being absent from work for illness no more often than the typical adult, to provide continuity of caregiving relationships for children in child care.

Healthy Young Children: A Manual for Programs, from the National Association for the Education of Young Children (NAEYC), provides a model form for an assessment by a health professional. See also Model Child Care Health Policies, from NAEYC and from the American Academy of Pediatrics (AAP).

Concern about the cost of health exams (particularly when many caregivers/teachers do not receive health benefits and earn minimum wage) is a barrier to meeting this standard. When staff members need hepatitis B immunization to meet Occupational Safety and Health Administration (OSHA) requirements (4), the cost of this immunization may or may not be covered under a managed care contract. If not, the cost of health supervision (such as immunizations, dental and health exams) must be covered as part of the employee’s preparation for work in the child care setting by the prospective employee or the employer. Child care workers are among those for whom annual influenza vaccination is strongly recommended.

Facilities should consult with ADA experts through the U.S. Department of Education funded Disability and Business Technical Assistance Centers (DBTAC) throughout the country. These centers can be reached by calling 1-800-949-4232 (callers are routed to the appropriate region) or by accessing regional center’s contacts directly at http://adata
.org/Static/Home.aspx.

TYPE OF FACILITY:

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

RELATED STANDARDS:

1.7.0.3 Health Limitations of Staff
1.7.0.4 Occupational Hazards
7.2.0.1 Immunization Documentation
7.2.0.2 Unimmunized Children
7.2.0.3 Immunization of Caregivers/Teachers
7.3.10.1 Measures for Detection, Control, and Reporting of Tuberculosis
7.3.10.2 Attendance of Children with Latent Tuberculosis Infection or Active Tuberculosis Disease
Appendix B: Major Occupational Health Hazards
Appendix E: Child Care Staff Health Assessment
Appendix H: Recommended Adult Immunization Schedule

REFERENCES:

  1. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2011. Recommended adult immunization schedule – United States, 2011. http://www.cdc.gov/vaccines/recs/schedules/.
  2. Baldwin, D., S. Gaines, J. L. Wold, A. Williams. 2007. The health of female child care providers: Implications for quality of care. J Comm Health Nurs 24:1-7.
  3. Keyes, C. R. 2008. Adults with disabilities in early childhood settings. Child Care Info Exchange 179:82-85.
  4. Occupational Safety and Health Administration. 2008. Bloodborne pathogens. Title 29, pt. 1910.1030. http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=standards&p _id=10051.