Special CollectionA Joint Collaborative Project ofAmerican Academy of Pediatrics Show
American Public Health Association National Resource Center for Health and Safety in Child Care and Early Education Support for this project was provided by theMaternal and Child Health Bureau, Adapted from Caring for Our Children: National Health and Safety Performance Standards; Guidelines for Early Care and Education Programs, 3rd Edition. Copyright © 2012 All rights reserved. This publication is protected by copyright. No part of this publication may be reproduced in any form or by any means, including photocopying, or utilized by any information storage and retrieval system without prior written permission from the publisher. To request permission to reproduce materials from this publication, 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 (). Suggested Citation: Available at http://nrckids.org. The National Standards are for reference purposes only and shall not be used as a substitute for medical or legal consultation, nor be used to authorize actions beyond a person’s licensing, training, or ability. Design & Typesetting: Betty Geer, Diane Malk, Lorina Washington Table of ContentsSafe Sleep Practices3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction Safe Sleep Environment5.4.5.1 Sleeping Equipment and Supplies Education on Safe Sleep and Reducing the Risk of SIDSKnowledge Base1.3.1.1 General Qualifications of
Directors Orientation, Training and Continuing Education1.4.1.1 Pre-service Training Safe Sleep Policies and Information9.2.1.1 Content of Policies Related Issues4.3.1.1 General Plan for Feeding Infants AppendicesAppendix D: Gloving Safe Sleep PracticesStandard 3.1.4.1: Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk ReductionContent in the STANDARD was modified on 12/05/2011 and on 12/1/2016. Safe sleep practices help reduce the risk of sudden unexpected infant deaths (SUIDs). Facilities should develop a written policy describing the practices to be used to promote safe sleep for infants. The policy should explain that these practices aim to reduce the risk of SUIDs, including sudden infant death syndrome (SIDS), suffocation and other deaths that may occur when an infant is in a crib or asleep. About 3,500 SUIDs occurred in the U.S. in 2014 (1). All staff, parents/guardians, volunteers and others approved to enter rooms where infants are cared for should receive a copy of the Safe Sleep Policy and additional educational information and training on the importance of consistent use of safe sleep policies and practices before they are allowed to care for infants (i.e., first day as an employee/volunteer/subsitute). Documentation that training has occurred and that these individuals have received and reviewed the written policy before they care for children should be kept on file. Additional educational materials can be found at https://www.nichd.nih.gov/sts/materials/Pages/default.aspx. All staff, parents/guardians, volunteers and others who care for infants in the child care setting should follow these required safe sleep practices as recommended by the American Academy of Pediatrics (AAP) (2):
The lighting in the room must allow the caregiver/teacher to see each infant’s face, to view the color of the infant’s skin, and to check on the infant’s breathing and placement of the pacifier (if used). A caregiver/teacher trained in safe sleep practices and approved to care for infants should be present in each room at all times where there is an infant. This caregiver/teacher should remain alert and should actively supervise sleeping infants in an ongoing manner. Also, the caregiver/teacher should check to ensure that the infant’s head remains uncovered and re-adjust clothing as needed. The construction and use of sleeping rooms for infants separate from the infant group room is not recommended due to the need for direct supervision. In situations where there are existing facilities with separate sleeping rooms, facilities have a plan to modify room assignments and/or practices to eliminate placing infants to sleep in separate rooms. Facilities should follow the current recommendation of the AAP about pacifier use (2). If pacifiers are allowed, facilities should have a written policy that describes relevant procedures and guidelines. Pacifier use outside of a crib in rooms and programs where there are
mobile infants or toddlers is not recommended. RATIONALEDespite the decrease in deaths attributed to sleeping practices and the decreased frequency of prone (tummy) infant sleep positioning over the past two decades, some caregivers/teachers continue to place infants to sleep in positions or environments that are not safe. Most sleep-related deaths in child care facilities occur in the first day or first week that an infant starts attending a child care program (4). Many of these deaths appear to be associated with prone positioning, especially when the infant is unaccustomed to being placed in that position (2). Training that includes observations and addresses barriers to changing caregiver/teacher practices would be most effective. Use of safe sleep policies, continued education of parents/guardians, expanded training efforts for child care professionals, statewide regulations and mandates, and increased monitoring and observation of intants while they are sleeping are critical to reduce the risk of SUIDs in child care (2). Infants who are cared for by adults other than their parent/guardian or primary caregiver/teacher are at increased risk of SUID (4,5). Recent research and demonstration projects (6,7) have revealed that:
1) Facilities do not have or use written “safe sleep” policies or guidelines; COMMENTSBackground: Deaths of infants who are asleep in child care may be under-reported because of the lack of consistency in training and regulating death scene investigations and determining and reporting cause of death. Not all states require documentation that clarifies that an infant died while being cared for by someone other than their parents/guardians. TYPE OF FACILITYCenter, Early Head Start, Large Family Child Care Home, Small Family Child Care Home RELATED STANDARDS3.1.4.2 Swaddling REFERENCES
NOTESContent in the STANDARD was modified on 12/05/2011 and on 12/1/2016. Standard 3.1.4.2: SwaddlingFrequently Asked Questions/CFOC Clarifications Reference: 3.1.4.2 Date: 04/05/2013 Topic & Location: Question: Answer: CFOC Standard 3.1.4.2: Swaddling states: “In child care settings, swaddling is not recommended or necessary.” This specific language was carefully chosen and reviewed by national contributors and stakeholders, and then approved by the CFOC Steering Committee and each author organization (AAP, APHA, NRC). A child care setting is a group care setting, and therefore presents different health and safety concerns when compared to a private home. One of these concerns is inconsistency with caregivers/teachers. As noted in CFOC Standard 3.1.4.1: Safe Sleep Practices and SIDS/Suffocation Risk Reduction, “Infants who are cared for by adults other than their parent/guardian or primary caregiver/teacher are at increased risk for dying from SIDS” (Moon, 2005). To that end, implementing swaddling guidelines, training, and compliance across child care programs would be a significant challenge. We recognize the many benefits of swaddling (when done correctly) by parents/guardians for newborns and young infants in hospital nurseries and in private homes. However, the primary target audience for the CFOC standardsis caregivers/teachers in early education and child care settings. The majority of standards in CFOC use the phrase “should” or “should not.” The national contributors that developed Standard 3.1.4.2 made the conscious decision not to use this terminology in the standard language.Thus, CFOC does not ban or prohibit swaddling. Instead, it states that swaddling is not recommended or necessary. CFOC does, however, account for programs that may choose to swaddle in this same standard (Standard 3.1.4.2). The last sentence of the Comments section states: “If swaddling is used, it should be used less and less over the course of the first few weeks and months of an infant’s life.” Moreover, it is important to note that CFOC also includes Standard 1.1.2.1: Minimum Age to Enter Child Care, which states that “Healthy full-term infants can be enrolled in child care settings as early as three months of age.” The national contributors recognized that swaddling becomes less necessary for older infants,a time at which CFOC recommends entering a child care setting. Frequently Asked Questions/CFOC Clarifications Reference: 3.1.4.2 Date: 04/05/2013 Topic
& Location: Question: Answer: The AAP Technical Report specifically addresses swaddling (page e1356) in expanded recommendations for a safe infant sleep environment. The Technical Report states that “there is insufficient evidence to recommend routine swaddling as a strategy for
reducing the incident of SIDS” (Task Force on Sudden Infant Death Syndrome, 2011). Citations: Task Force on Sudden Infant Death Syndrome. (2011). Policy Statement: SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe infant Sleeping Environment. Pediatrics, 128:5 1030-1039. Task Force on Sudden Infant Death Syndrome. (2011). Technical Report: SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe infant Sleeping Environment. Pediatrics, 128:5 e1341-e1367. In child care settings, swaddling is not necessary or recommended. RATIONALEThere is evidence that swaddling can increase the risk of serious health outcomes, especially in certain situations. The risk of sudden infant death is increased if an infant is swaddled and placed on his/her stomach to sleep (1,2) or if the infant can roll over from back to stomach. Loose blankets around the head can be a risk factor for sudden infant death syndrome (SIDS) (3). With swaddling, there is an increased risk of developmental dysplasia of the hip, a hip condition that can result in long-term disability (4,5). Hip dysplasia is felt to be more common with swaddling because infants’ legs can be forcibly extended. With excessive swaddling, infants may overheat (i.e., hyperthermia) (6). COMMENTSMost infants in child care centers are at least six-weeks-old. Even with newborns, research does not provide conclusive data about whether swaddling should or should not be used. Benefits of swaddling may include decreased crying, increased sleep periods, and improved temperature control. However, temperature can be maintained with appropriate infant clothing and/or an infant sleeping bag. Although swaddling may decrease crying, there are other, more serious health concerns to consider, including SIDS and hip disease. If swaddling is used, it should be used less and less over the course of the first few weeks and months of an infant’s life. TYPE OF FACILITYCenter, Early Head Start, Large Family Child Care Home, Small Family Child Care Home RELATED STANDARDS3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction REFERENCES
Standard 3.1.4.3: Pacifier UseContent in the STANDARD was modified on 12/5/2011. Facilities should be informed and follow current recommendations of the American Academy of Pediatrics (AAP) about pacifier use (1-3). If pacifiers are allowed, facilities should have a written policy that indicates:
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). RATIONALEMobile 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). COMMENTSTo keep current with the AAP’s recommendations on the use of pacifiers, go to http://www.aap.org. TYPE OF FACILITYCenter, Early Head Start, Large Family Child Care Home, Small Family Child Care Home RELATED STANDARDS3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk
Reduction REFERENCES
NOTESContent in the STANDARD was modified on 12/5/2011. Standard 3.1.4.4: Scheduled Rest Periods and Sleep ArrangementsContent in the STANDARD was modified on 05/30/2018. The facility should provide an opportunity for, but should not require, sleep and rest. The facility should make available a regular rest period for all children and age appropriate sleep/nap environment (See Standard 5.4.5.1). For children who are unable to sleep, the facility should provide time and space for quiet play. A facility that includes preschool-aged and school-aged children should make books, board games, and other forms of quiet play available. Facilities that offer infant care should provide a safe sleep environment and use a written safe sleep policy that describes the practices they follow to reduce the risk of sudden infant death syndrome and other infant deaths. For example, when infants fall asleep, they must be put down to sleep on their back in a crib with a firm mattress and no blankets or soft objects. RATIONALEConditions conducive to sleep and rest for younger children include a consistent caregiver, a routine quiet place, regular times for rest, and use of routines and safe practices. Most preschool-aged children in all-day care benefit from scheduled periods of rest. This rest may take the form of actual napping, a quiet time, or a change of pace between activities. The times and duration of naps will affect behavior at home (1). Young children need to develop healthy sleep habits for optimal development. Yet, sleep problems, i.e. short sleep duration, behavioral sleep problems, and sleep-disordered breathing all peak during the preschool years. In 2016, the National Sleep Foundation issued recommended sleep durations for newborns (14–17 hours), infants (12–15 hours), toddlers (11–14 hours), and preschoolers (10–13 hours), which include both daytime and nighttime sleep (2,3).Getting sufficient sleep helps prevent pediatric obesity. In meta-analyses, short sleep duration before 5 years of age is associated with 30% to 90% increased odds of overweight/obesity at later ages (4,5). To prevent early childhood obesity, the Institute of Medicine recommends that child care providers be required to adopt practices that promote age-appropriate sleep duration and that staff be trained to counsel parents about recommended sleep durations (6). Behavioral sleep problems (i.e., difficulty getting to/falling asleep) at 18 months of age are associated with a 60% to 80% increased risk of emotional and behavioral problems at 5 years of age (7). Irregular bedtimes throughout early childhood are associated with reduced reading, math, and spatial ability scores (8). Sleep-disordered breathing (e.g., snoring, apnea) in early childhood is associated with a 60% to 80% increase in social and emotional difficulties at 7 years of age (9). COMMENTSIn the young infant, favorable conditions for sleep and rest include being dry, well fed, and comfortable. Infants may need 1 or 2 (or sometimes more) naps during the time they are in child care. As infants age, they typically transition to 1 nap per day, and having 1 nap per day is consistent with the schedule that most facilities follow. Different practices, such as rocking, holding a child while swaying, singing, reading, or patting an arm or back, could be used to calm the child. Lighting does not need to be turned off during nap time. TYPE OF FACILITYCenter, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home RELATED STANDARDS3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction REFERENCES
NOTESContent in the STANDARD was modified on 05/30/2018. Standard 2.2.0.1: Methods of Supervision of ChildrenContent in the STANDARD was modified on 10/09/2018. Caregivers/teachers should provide active and positive supervision of infants, toddlers, preschoolers, and school-aged children by sight and hearing at all times, including when children are resting or sleeping, eating, being diapered, or using the bathroom (as age appropriate) and when children are outdoors. Active supervision requires focused attention and intentional observation of children at all times. Caregivers/teachers position themselves so that they can observe all of the children: watching, counting, and listening at all times. During transitions, caregivers/teachers account for all children with name-to-face recognition by visually identifying each child. They also use their knowledge of each child’s development and abilities to anticipate what they will do, then get involved and redirect them when necessary. This constant vigilance helps children learn safely. All children in out-of-home care must be directly supervised at all times. The following strategies allow children to explore their environments safely. (1,2)
6. Engage and Redirect Caregivers/teachers use what they know about each child’s individual needs and development to offer support. They wait until children are unable to problem-solve on their own to get involved. They may offer different levels of assistance or redirection depending on each individual child’s needs. Caregivers/teachers should always be on the same floor and in the same room as the children. If toilets are not on the same floor as the child care area or within sight or hearing of a caregiver/teacher, an adult should accompany children younger than 5 years to and from the toilet area. Younger children who request privacy and have shown the capability to use toilet facilities properly should be given permission to use separate and private toilet facilities. School-aged children may use toilet facilities without direct visual observation but must remain within hearing range in case children need assistance and/or to prevent unsafe behavior. Program spaces should be designed with visibility that allows constant, unobtrusive adult supervision and allow for children to have alone time or quiet play in small groups. To protect children from maltreatment, including sexual abuse, the environment layout should limit situations in which an adult or older child can be alone with a child without another adult present (1,2). Children are going to be more active in the outdoor learning/play environment and need more supervision rather than less time outside. Playground supervisors need to be designated and trained to supervise children in all outdoor play areas. Staff supervision of the playground should incorporate strategic watching all the children within a specific territory and not engaging in prolonged dialog with any one child or group of children (or other staff). Other adults not designated to supervise may facilitate outdoor learning/play activities and engage in conversations with children about their exploration and discoveries. Caregivers/teachers should make an effort to maintain close proximity to children who are developing new motor skills and may need additional support to ensure the safety of the children. Caregivers/teachers should repeatedly count children, record the count, ensure accuracy, and be able to verbally state how many children are in care at all times. Caregivers/teachers should record the count on an attendance sheet or on a pocket card, along with notations of any children joining or leaving the group. An accurate count is required at all times. Caregivers/teachers should participate in a counting routine that encourages duplicate counts to verify the attendance record to ensure constant supervision and safety of all children in care. School-aged children should be permitted to participate in activities off the premises with appropriate adult supervision and with written approval by a parent/guardian. If parents/guardians give written permission for the school-aged child to participate in off-premises activities, the facility would no longer be responsible for the child during the off-premises activity. The facility would not need to provide staff for the off-premises activity. Developmentally appropriate child to staff ratios should be met during all hours of operation, including indoor and outdoor play and field trips. Additionally, all safety precautions for specific areas and equipment should be followed. No center-based facility or large family child care home should operate with fewer than 2 staff members if more than 6 children are in care, even if the group otherwise meets the child to staff ratio. Although centers often downsize the number of staff for early arrival and late departure times, another adult should be present to help in the event of an emergency. See Related Standards below for further information regarding ratios.
RATIONALESupervision is directly tied to safety and the prevention of injury and maintaining quality child care for infants, toddlers, preschoolers, and school-aged children. Parents/guardians depend on caregivers/teachers to supervise their children. To be available for supervision or rescue in an emergency, an adult must be able to hear and see the children. With proper supervision and in the event of an emergency, supervising adults can quickly and efficiently remove children from any potential harm. The importance of supervision is to protect children not only from physical injury (3) but also from harm that can occur from topics discussed by children or by teasing/bullying/inappropriate behavior. It is the responsibility of caregivers/teachers to monitor what children are talking about and intervene when necessary. Children like to test their skills and abilities, which is encouraged, as it is developmentally appropriate behavior. This is particularly noticeable around playground equipment. Playgrounds, when compared with indoor play areas, pose a higher risk when it comes to injuries in children (4). Even if the highest safety standards for playground layout, design, and surfacing are met, serious injuries can happen if children are left unsupervised. Adults who are involved and aware of children’s behavior are in the best position to safeguard their well-being. Regular counting (or use of active supervision) will reduce opportunities for a child to become separated from the group, especially during transitions between locations. These practices encourage responsive interactions and understanding each child’s strengths and challenges while providing active supervision in infant, toddler, preschool, and school-age environments. COMMENTSTYPE OF FACILITYCenter, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home RELATED STANDARDS1.1.1.1 Ratios for Small Family Child Care Homes REFERENCES
NOTESContent in the STANDARD was modified on 10/09/2018. Safe Sleep EnvironmentStandard 5.4.5.1: Sleeping Equipment and SuppliesContent in the STANDARD was modified on 3/31/2017. Facilities should have an individual crib, cot, sleeping bag, bed, mat, or pad for
each child who spends more than four hours a day at the facility. No child should simultaneously share a crib, bed, or bedding with another child. Facilities should ensure that furniture and surfaces for sleeping are in compliance with the current U.S. Consumer Product Safety Commission (CPSC) and ASTM safety standards and have not been recalled by the manufacturer (1). No child should sleep on a bare, uncovered surface. Seasonally appropriate covering, such as sheets, sleep garments, or blankets that are sufficient to maintain adequate warmth, should be available and should be used by each child below school-age. Pillows, blankets, and sleep positioners should not be used with infants (2). If pillows are used by toddlers and older children, pillows should have removable cases that can be laundered, be assigned to a child, and used by that child only while s/he is enrolled in the facility. (Pillows are not required for older children.) Each child’s pillow, blanket, sheet, and any special sleep item should be stored separately from those of other children. Pads and sleeping bags should not be placed directly on any floor that is cooler than 65°F when children are resting. Cribs, cots, sleeping bags, beds, mats, or pads in/on which children are sleeping should be placed at least three feet apart (3). If the room used for sleeping cannot accommodate three feet of spacing between children, it is recommended for caregivers/teachers to space children as far as possible from one another and/or alternate children head to feet. Screens used to separate sleeping children are not recommended because screens can affect supervision, interfere with immediate access to a child, and could potentially injure a child if pushed over on a child. If unoccupied sleep equipment is used to separate sleeping children, the arrangement of such equipment should permit the staff to observe and have immediate access to each child. The ends of cribs do not suffice as screens to separate sleeping children. The sleeping surfaces of one child’s rest equipment should not come in contact with the sleeping surfaces of another child’s rest equipment during storage. Caregivers/teachers should never use strings to hang any object, such as a mobile, or a toy or a diaper bag, on or near the crib where a child could become caught in it and strangle (2). Infant monitors and their cords and other electrical cords should never be placed in the crib or sleeping equipment. Crib mattresses should fit snugly and be made specifically for the size crib in which they are placed. Infants should not be placed on an inflatable mattress due to potential of entrapment or suffocation (2). RATIONALESeparate sleeping and resting, even for siblings, reduces the spread of disease from one child to another. Droplet transmission occurs when droplets containing microorganisms generated from an infected person, primarily during coughing, sneezing, or talking are propelled a short distance (three feet) and deposited on the eyes, nose, or mouth (3). Because respiratory infections are transmitted by large droplets of respiratory secretions, a minimum distance of three feet should be maintained between cots, cribs, sleeping bags, beds, mats, or pads used for resting or sleeping (3). A space of three feet between cribs, cots, sleeping bags, beds, mats, or pads will also provide access by the staff to a child in case of emergency. If the facility uses screens to separate the children, their use must not hinder observation of children by staff or access to children in an emergency. Scabies and ringworm are diseases transmitted by direct person-to-person contact. For example, ringworm is transmitted by the sharing of personal articles such as combs, brushes, towels, clothing, and bedding. Prohibiting the sharing of personal articles helps prevent the spread of diseases. From time to time, children drool, spit up, or spread other body fluids on their sleeping surfaces. Using cleanable, waterproof, nonabsorbent rest equipment enables the staff to wash and sanitize the sleeping surfaces. Plastic bags may not be used to cover rest and sleep surfaces/equipment because they contribute to suffocation if the material clings to the child’s face. Canvas cots are not recommended for infants and toddlers. The end caps require constant replacement and the cots are a cutting/pinching hazard when end caps are not in place. A variety of cots are made with washable sleeping surfaces that are designed to be safe for children. COMMENTSAlthough children freely interact and can contaminate each other while awake, reducing the transmission of infectious disease agents on large airborne droplets during sleep periods will reduce the dose of such agents to which the child is exposed overall. In small family child care homes, the caregiver/teacher should consider the home to be a business during child care hours and is expected to abide by regulatory expectations that may not apply outside of child care hours. Therefore, child siblings related to the caregiver/teacher sleeping in the same bed during the hours of operation is discouraged. TYPE OF FACILITYCenter, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home RELATED STANDARDS3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction REFERENCES
NOTESContent in the STANDARD was modified on 3/31/2017. Standard 5.4.5.2: CribsFacilities should check each crib before its purchase and use to ensure that it is in compliance with the current U.S. Consumer Product Safety Commission (CPSC) and ASTM safety standards. Recalled or “second-hand” cribs should not be used or stored in the facility. When it is determined that a crib is no longer safe for use in the facility, it should be dismantled and disposed of appropriately. Staff should only use cribs for sleep purposes and should ensure that each crib is a safe sleep environment. No child of any age should be placed in a crib for a time-out or for disciplinary reasons. When an infant becomes large enough or mobile enough to reach crib latches or potentially climb out of a crib, they should be transitioned to a different sleeping environment (such as a cot or sleeping mat). Each crib should be identified by brand, type, and/or product number and relevant product information should be kept on file (with the same identification information) as long as the crib is used or stored in the facility. Staff should inspect each crib before each use to ensure that hardware is tightened and that there are not any safety hazards. If a screw or bolt cannot be tightened securely, or there are missing or broken screws, bolts, or mattress support hangers, the crib should not be used. Safety standards document that cribs used in facilities should be made of wood, metal, or plastic. Crib slats should be spaced no more than two and three-eighths inches apart, with a firm mattress that is fitted so that no more than two fingers can fit between the mattress and the crib side in the lowest position. The minimum height from the top of the mattress to the top of the crib rail should be twenty inches in the highest position. Cribs with drop sides should not be used. The crib should not have corner post extensions (over one-sixteenth inch). The crib should have no cutout openings in the head board or footboard structure in which a child’s head could become entrapped. The mattress support system should not be easily dislodged from any point of the crib by an upward force from underneath the crib. All cribs should meet the ASTM F1169-10a Standard Consumer Safety Specification for Full-Size Baby Cribs, F406-10b Standard Consumer Safety Specification for Non-Full-Size Baby Cribs/Play Yards, or the CPSC 16 CFR 1219, 1220, and 1500 – Safety Standards for Full-Size Baby Cribs and Non-Full-Size Baby Cribs; Final Rule. Cribs should be placed away from window blinds or draperies. As soon as a child can stand up, the mattress should be adjusted to its lowest position. Once a child can climb out of his/her crib, the child should be moved to a bed. Children should never be kept in their crib by placing, tying, or wedging various fabric, mesh, or other strong coverings over the top of the crib. Cribs intended for evacuation purpose should be of a design and have wheels that are suitable for carrying up to five non-ambulatory children less than two years of age to a designated evacuation area. This crib should be used for evacuation in the event of fire or other emergency. The crib should be easily moveable and should be able to fit through the designated fire exit. RATIONALEStandards have been developed to define crib safety, and staff should make sure that cribs used in the facility meet these standards to protect children and prevent injuries or death (1-3). Significant changes to the ATSM and CPSC standards for cribs were published in December 2010. As of June 28, 2011 all cribs being manufactured, sold or leased must meet the new stringent requirements. Effective December 28, 2012 all cribs being used in early care and education facilities including family child care homes must also meet these standards. For the most current information about these new standards please go to http://www.cpsc.gov/info/cribs/index.html. More infants die every year in incidents involving cribs than with any other nursery product (4). Children have become trapped or have strangled because their head or neck became caught in a gap between slats that was too wide or between the mattress and crib side. An infant can suffocate if its head or body becomes wedged between the mattress and the crib sides (6). Corner posts present a potential for clothing entanglement and strangulation (5). Asphyxial crib deaths from wedging the head or neck in parts of the crib and hanging by a necklace or clothing over a corner post have been well-documented (6). Children who are thirty-five inches or taller in height have outgrown a crib and should not use a crib for sleeping (4). Turning a crib into a cage (covering over the crib) is not a safe solution for the problems caused by children climbing out. Children have died trying to escape their modified cribs by getting caught in the covering in various ways and firefighters trying to rescue children from burning homes have been slowed down by the crib covering (6). CPSC has received numerous reports of strangulation deaths on window blind cords over the years (7). COMMENTSFor more information on articles in cribs, see Standard 5.4.5.1: Sleeping Equipment and Supplies and Standard 6.4.1.3: Crib Toys. TYPE OF FACILITYCenter, Early Head Start, Large Family Child Care Home, Small Family Child Care Home RELATED STANDARDS3.1.4.1 Safe
Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction REFERENCES
Standard 5.4.5.3: Stackable CribsUse of stackable cribs (i.e., cribs that are built in a manner that there are two or three cribs above each other that do not touch the ground floor) in facilities is not advised. In older facilities, where these cribs are already built into the structure of the facility, staff should develop a plan for phasing out the use of these cribs. If stackable cribs are used, they must meet the current Consumer Product Safety Commission’s (CPSC) federal standard for non-full-size cribs, 16 CFR 1220. In addition they should be three feet apart and staff placing or removing a child from a crib that cannot reach from standing on the floor, should use a stable climbing device such as a permanent ladder rather than climbing on a stool or chair. Infants who are able to sit, pull themselves up, etc. should not be placed in stackable cribs. RATIONALEStackable cribs are designed to save space by having one crib built on top of another. Although they may be practical from the standpoint of saving space, infants on the top level of stackable cribs will be positioned at a height that will be several feet from the floor. Infants who fall from several feet or more can have an intracranial hemorrhage (i.e., serious bleed inside of the skull). While no injury reports have been filed, there is a potential for injury as a result of either latch malfunction or a caregiver/teacher who slips or falls while placing or removing a child from a crib. It is best practice to place an infant to sleep in a safe sleep environment (safety-approved crib with a firm mattress and a tight-fitting sheet) at a level that is close to the floor. A minimum distance of three feet between cribs is required because respiratory infections are transmitted by large droplets of respiratory secretions, which usually are limited to a range of less than three feet from the infected person (1,2). Young children placed to sleep in stackable cribs may have difficulties falling asleep because they may not be used to sleeping in this type of equipment. In addition, requiring staff to use stackable cribs may cause them concern and fear regarding their liability if an injury occurs. COMMENTSMany state child care licensing regulations prohibit the use of stackable cribs. If stackable cribs are not prohibited in the caregiver’s/teacher’s state and they are used, parents/guardians should be informed and extreme care should be taken to ensure that no infant falls from the higher level cribs due to the potential for injury. Any injury that is suspected to be related to the use of stackable cribs should be reported to the U.S. Consumer Product Safety Commission (CPSC) at 1-800-638-2772 or http://www.cpsc.gov. TYPE OF FACILITYCenter, Early Head Start, Large Family Child Care Home, Small Family Child Care Home RELATED STANDARDS5.4.5.1 Sleeping Equipment and Supplies REFERENCES
Standard 6.4.1.3: Crib ToysCrib gyms, crib toys, mobiles, mirrors, and all objects/toys are prohibited in or attached to an infant’s crib. Items or toys should not be hung from the ceiling over an infant’s crib. RATIONALEFalling objects could cause injury to an infant lying in a crib. The presence of crib gyms presents a potential strangulation hazard for infants who are able to lift their head above the crib surface. These children can fall across the crib gym and not be able to remove themselves from that position (1). The presence of mobiles, crib toys, mirrors, etc. present a potential hazard if the objects can be reached and/or pulled down by an infant (1). Some stuffed animals and other objects that dangle from strings can wrap around a child’s neck (2). Soft objects/toys can cause suffocation. COMMENTSOrnamental or small toys are often hung over an infant to provide stimulation; however, the crib should be used for sleep only. The crib is not recommended as a place to entertain an infant or to “contain” an infant. If an infant is not content in a crib, the infant should be removed. TYPE OF FACILITYCenter, Early Head Start, Large Family Child Care Home, Small Family Child Care Home RELATED STANDARDS3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction REFERENCES
Standard 2.2.0.2: Limiting Infant/Toddler Time in Crib, High Chair, Car Seat, Etc.Frequently Asked Questions/CFOC Clarifications Reference: 2.2.0.2 Date: 10/13/2011 Topic & Location: Question: Is part of the intent regarding this standard to educate parents about safe infant sleep practices or is it actually dangerous for infants to sleep sitting up, or both? Answer: Please see the Standard’s rationale and references for information on related injuries and SIDS. A child should not sit in a high chair or other equipment that constrains his/her movement (1,2) indoors or outdoors for longer than fifteen minutes, other than at meals or snack time. Children should never be left out of the view and attention of adult caregivers/teachers while in these types of equipment/furniture. A least restrictive environment should be encouraged at all times. Children should not be left to sleep in equipment, such as car seats, swings, or infant seats that does not meet ASTM International (ASTM) product safety standards for sleep equipment. RATIONALEChildren are continually developing their physical skills. They need opportunities to use and build on their physical abilities. This is especially true for infants and toddlers who are eagerly using their bodies to explore their environment. Extended periods of time in the crib, high chair, car seat, or other confined space limits their physical growth and also affects their social interactions. Injuries and Sudden Infant Death Syndrome (SIDS) have occurred when children have been left to sleep in car seats or infant seats when the straps have entrapped body parts, or the children have turned the seats over while in them. Sleeping in a seated position can restrict breathing and cause oxygen desaturation in young infants (3). Sleeping should occur in equipment manufactured for this activity. When children are awake, restricting them to a seat may limit social interactions. These social interactions are essential for children to gain language skills, develop self-esteem, and build relationships (4). TYPE OF FACILITYCenter, Early Head Start, Large Family Child Care Home, Small Family Child Care Home RELATED STANDARDS3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction REFERENCES
Standard 5.3.1.10: Restrictive Infant Equipment RequirementsRestrictive infant equipment such as swings, stationary activity centers (e.g., exersaucers), infant seats (e.g., bouncers), molded seats, etc., if used, should only be used for short periods of time (a maximum of fifteen minutes twice a day) (1). Infants should not be placed in equipment until they are developmentally ready. Infants should be supervised when using equipment. Safety straps should be used if provided by the manufacturer of the equipment. Equipment should not be placed on elevated surfaces, uneven surfaces, near the top of stairs, or within reach of safety hazards. Stationary activity centers should be used with the stabilizing legs down in a locked position. Infants should not be allowed to sleep in equipment that was not manufactured as infant rest/sleep equipment. The use of jumpers (attached to a door frame or ceiling) and infant walkers is prohibited. RATIONALEKeeping an infant confined in a piece of infant equipment prevents an infant from active movement. Infants need the opportunity to play on the floor in a safe open area to develop their gross motor skills. If infants are not given the opportunity for floor time, their development can be hindered or delayed (2). The shape of an infant’s head can be affected if pressure is applied often and for long periods of time. This molding of the skull is called plagiocephaly. Due to the recommendation for back sleeping, an infant’s skull already experiences a great amount of time with pressure on the back of the head. When an infant is kept in a piece of infant equipment such as an infant seat or a swing, the pressure again is applied to the back of an infant’s head; thus, increasing the likelihood of plagiocephaly. To prevent plagiocephaly and to promote normal development, infants should spend time on their tummies when awake and supervised (3). Infants are not well-protected in restrictive infant equipment and can be injured by animals or other children. Other children or animals can hang, climb, or jump on or into the equipment; therefore, supervision is required during use. Safety straps must be used to prevent injuries and deaths of infants; infants have fallen out of equipment or have been strangled when safety straps have not been used (10). Equipment must always be placed on the floor and away from the top of stairs to prevent falls; infants have been injured when equipment has been pushed or pulled off an elevated surface or the top of stairs. The surface or floor under the equipment needs to be level to prevent the risk of the equipment tipping over. It is imperative for equipment to be placed out of the reach of potential safety hazards such as furniture, dangling appliance cords, curtain pulls, blind cords, hot surfaces, etc., so infants cannot reach them. The guideline of twenty minutes twice a day was designated so that use could be clearly measured and monitored (1). Infants should not be placed in equipment, such as stationary activity centers, that require them to support their heads on their own unless they have mastered this skill. Allowing infants to sleep in infant equipment is not recommended due to the documented decrease in an infant’s oxygen saturation caused by the downward flexion of an infant’s head and neck due to an infant’s underdeveloped head and neck muscles (8,9). If an infant falls asleep in a piece of equipment, the infant should be promptly removed and placed flat on the infant’s back in a safety approved crib. If the stabilizing legs on stationary activity centers are not down and locked in place, this puts an infant at risk of tipping over in the equipment as well as creates an unstable piece of equipment for a mobile infant to use to pull himself up. Infant walkers are dangerous because they move children around too fast and to hazardous areas, such as stairs. The upright position also can cause children in walkers to “tip over” or can bring children close to objects that they can pull down onto themselves. In addition, walkers can run over or run into others, causing pain or injury. Many injuries, some fatal, have been associated with infant walkers (4-7). There have been several reports of spring/clamp breaking on various models of jumpers (jump-up seats) according to the CPSC (7). TYPE OF FACILITYCenter, Early Head Start, Large Family Child Care Home, Small Family Child Care Home RELATED STANDARDS3.1.3.4 Caregivers’/Teachers’ Encouragement of Physical Activity REFERENCES
Standard 5.3.1.1: Indoor and Outdoor Equipment, Materials, and FurnishingStandard was last updated on September 13, 2022. Early care and education programs should make sure that equipment,
materials, and furnishings, accessible to children both indoors and outdoors, are sturdy, in good condition, safe to use, and used only as intended by the manufacturer. The equipment, materials, and furnishings in the program should meet the safety recommendations of the U.S. Consumer Product Safety Commission and ASTM International. Program leadership and staff should:
RATIONALEYoung children in early care and education programs are at risk for unintentional injuries indoors and outdoors. Awareness of potential hazards and proper choice, use, and maintenance of equipment, materials, and furnishings can help prevent injuries. The CPSC collaborates with ASTM International, an international organization that develops and communicates technical standards, in determining safety and testing standards for many products for children.1 This standard
lists hazards often associated with injury and death by CPSC.2,3,4 Equipment and furnishings that are not sturdy, safe, or in good condition may cause falls, trap a child’s head or limbs, or contribute to other injuries.2,3,4 Regardless of their condition, some types of equipment are simply dangerous to use in early care and education programs (e.g., baby walkers, trampolines, inclined sleepers).5.6 Others are dangerous when used in ways
the manufacturer did not intend or when directions are not followed (e.g., not buckling safety belts, using infant bouncers or car seats for napping).7,8 Although emergency department visits due to tip-overs of televisions and furniture declined in recent years, tip-overs are still an important risk for injury of children younger than 6.9 Playground equipment and materials have many potential hazards.10 More than a third of emergency
visits for playground injuries involve pre-school children.11 Falls from climbing structures cause the most serious injuries in early care and education programs.11,12 However, knowing the surface temperature of outdoor playground equipment (metal and plastic) is also important to make sure children are playing safely. Staff should also pay attention to the temperature of other materials or furnishings (e.g., slides, steps, railings, metal picnic tables). Metal
and other surfaces exposed to sun can quickly reach high temperatures that can burn a child’s skin in seconds.3(See Burn Safety Awareness on Playgrounds, a CPSC factsheet about preventing thermal burns.13) Young children’s intake of lead dust and particles from artificial turf, playground surfaces, and lead-based paint on older playground equipment and furnishings is very hazardous to their health and development.14 (See Standard 5.2.9.13: Testing for and Remediating Lead Hazards.. Directors and program staff need to pay attention to the safety and condition of new and existing equipment, materials, and furnishings to remove or fix potential hazards. COMMENTSFor more information on specific requirements and safety considerations for many types of equipment, materials, and furnishings (e.g., infant equipment, playground surfaces, and inspections), see the Related Standards below. The CCHP Health and Safety Checklist,15 a CFOC-based resource from the California Childcare Health program, has sections on indoor and outdoor equipment and furnishings that may help programs assess hazards in this standard and related standards. Child care health consultants or other appropriately trained staff can help find resources to review the safety of equipment, materials, and furnishings in programs. The National Program for Playground Safety (NPPS) at the University of Northern Iowa offers the
Playground Safety Report Card.10 The tool is useful to assess the safety of playground equipment and what to correct or improve.10 For more information on lead hazards, visit the Environmental Protection Agency (EPA) Web page, Protect Your Family from Sources of Lead.16 Also see Standard 5.2.9.13: Testing for and Remediating Lead Hazards and Standard 5.2.9.15: Building Construction and Renovation Safety. Home-based early care and education programs may refer to The Lead-Safe Toolkit for Home-Based Child Care.17 TYPE OF FACILITYCenter, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home RELATED STANDARDS3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction REFERENCES
NOTESStandard was last updated on September 13, 2022. Standard 5.3.1.2: Product Recall MonitoringStaff should, on a monthly basis, seek information on recalls of juvenile products that may be in use at the facility. Of particular importance are recalls related to cribs, bassinets, and portable play yards that may be used for infant sleep. Additionally, caregivers/teachers should be aware of recalls of toys, playground equipment, strollers, and any other product routinely used by children in the child care facility. RATIONALEProduct recalls are often ineffective at removing hazardous products from use because the owners/users are not aware of the recall. Children have died in child care settings from injury related to sleep equipment that had been recalled. COMMENTSThe U.S. Consumer Product Safety Commission (CPSC) offers a free subscription email service for product recall notices at http://www.cpsc.gov/cpsclist.aspx. Subscribers can note that they only want to receive recalls related to juvenile products. TYPE OF FACILITYCenter, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home RELATED STANDARDS5.4.5.2 Cribs Standard 3.4.1.1: Use of Tobacco, Electronic Cigarettes, Alcohol, and DrugsFrequently Asked Questions/CFOC Clarifications Reference: 3.4.1.1 Date: 11/07/2012 Topic & Location: Question: Answer: Electronic cigarettes, also known as e-cigarettes, are a fairly new alternative to traditional smoking cigarettes. E-cigarettes are battery-operated products designed to deliver nicotine, flavor and other chemicals. They turn nicotine, which is highly addictive, and other chemicals into a vapor that is inhaled by the user (U.S. FDA, 2012). Currently, the research on the safety of this product is limited. However, the use of e-cigarettes would fall into the same category tobacco, alcohol, and illegal drugs products that are prohibited from being used on the premises of the program (both indoor and outdoor environments) and in any vehicles used by the program at all times. Additionally, children model adult behavior. Cigarette smoking in any form is not a healthy behavior. U.S. FDA, 2013 articleContent in the STANDARD was modified on 1/12/2017. The use of tobacco, electronic cigarettes (e-cigarettes), alcohol, and drugs should be prohibited on the premises of the program (both indoor and outdoor environments), during work hours including breaks, and in any vehicles used by the program at all times. Caregivers/teachers should be prohibited from wearing clothing that smells of smoke when working or volunteering. The use of legal drugs (e.g. marijuana, prescribed narcotics, etc.) that have side effects that diminish the ability to property supervise and care for children or safely drive program vehicles should also be prohibited. RATIONALEScientific evidence has linked respiratory health risks to secondhand smoke. No children, especially those with respiratory problems, should be exposed to additional risk from the air they breathe. Infants and young children exposed to secondhand smoke are at risk of severe asthma; developing bronchitis, pneumonia, and middle ear infections when they experience common respiratory infections; and Sudden Infant Death Syndrome (SIDS) (1-6). Separation of smokers and nonsmokers within the same air space does not eliminate or minimize exposure of nonsmokers to secondhand smoke. Tobacco smoke contamination lingers after a cigarette is extinguished and children come in contact with the toxins (7). Thirdhand smoke exposure also presents hazards. Thirdhand smoke refers to gases and particles clinging to smokers’ hair and clothing, cushions and carpeting, and outdoor equipment, after tobacco smoke has dissipated (8). The residue includes heavy metals, carcinogens and radioactive materials that young children can get on their hands and ingest, especially if they’re crawling or playing on the floor. Residual toxins from smoking at times when the children are not using the space can trigger asthma and allergies when the children do use the space (2,3). Cigarettes and materials used to light them also present a risk of burn or fire. In fact, cigarettes used by adults are the leading cause of ignition of fatal house fires (9). Alcohol use, illegal and legal drug use, and misuse of prescription or over-the-counter (OTC) drugs prevent caregivers/teachers from providing appropriate care to infants and children by impairing motor coordination, judgment, and response time. Safe child care necessitates alert, unimpaired caregivers/teachers. The use of alcoholic beverages and legal drugs in family child care homes after children are not in care is not prohibited, but these items should be safely stored at all times. COMMENTSThe age, defenselessness, and dependence upon the judgment of caregivers/teachers of the children under care make this prohibition an absolute requirement. As more states move toward legalizing marijuana use for recreational and/or medicinal purposes, it is important for caregivers/teachers to be aware of the impact marijuana used medicinally and/or recreationally has on their ability to provide safe care. Staff modeling of healthy and safe behavior at all times is essential to the care and education of young children. TYPE OF FACILITYCenter, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home RELATED STANDARDS5.2.9.1 Use and Storage of Toxic Substances REFERENCES
NOTESContent in the STANDARD was modified on 1/12/2017. Education on Safe Sleep and Reducing the Risk of SIDSKnowledge BaseStandard 1.3.1.1: General Qualifications of DirectorsThe director of a center enrolling fewer than sixty children should be at least twenty-one-years-old and should have all the following qualifications:
Knowledge about parenting training/counseling and ability to communicate effectively with parents/guardians about developmental-behavioral issues, child progress, and in creating an intervention plan beginning with how the center will address challenges and how it will help if those efforts are not effective. The director of a center enrolling more than sixty children should have the above and at least three years experience as a teacher of children in the age group(s) enrolled in the center where the individual will act as the director, plus at least six months experience in administration. RATIONALEThe director of the facility is the team leader of a small business. Both administrative and child development skills are essential for this individual to manage the facility and set appropriate expectations. College-level coursework has been shown to have a measurable, positive effect on quality child care, whereas experience per se has not (1-3,5). The director of a center plays a pivotal role in ensuring the day-to-day smooth functioning of the facility within the framework of appropriate child development principles and knowledge of family relationships (6). The well-being of the children, the confidence of the parents/guardians of children in the facility’s care, and the high morale and consistent professional growth of the staff depend largely upon the knowledge, skills, and dependable presence of a director who is able to respond to long-range and immediate needs and able to engage staff in decision-making that affects their day-to-day practice (5,6). Management skills are important and should be viewed primarily as a means of support for the key role of educational leadership that a director provides (6). A skilled director should know how to use early care and education consultants, such as health, education, mental health, and community resources and to identify specialized personnel to enrich the staff’s understanding of health, development, behavior, and curriculum content. Past experience working in an early childhood setting is essential to running a facility. Life experience may include experience rearing one’s own children or previous personal experience acquired in any child care setting. Work as a hospital aide or at a camp for children with special health care needs would qualify, as would experience in school settings. This experience, however, must be supplemented by competency-based training to determine and provide whatever new skills are needed to care for children in child care settings. COMMENTSThe profession of early childhood education is being informed by research on the association of developmental outcomes with specific practices. The exact combination of college coursework and supervised experience is still being developed. For example, the National Association for the Education of Young Children (NAEYC) has published the (4). The National Child Care Association (NCCA) has developed a curriculum based on administrator competencies; more information on the NCCA is available at http://www.nccanet.org. TYPE OF FACILITYCenter, Early Head Start, Head Start, Large Family Child Care Home RELATED STANDARDS1.3.1.2 Mixed Director/Teacher Role REFERENCES
Standard 1.3.2.4: Additional Qualifications for Caregivers/Teachers Serving Children Birth to Thirty-Five Months of AgeCaregivers/teachers should be prepared to work with infants and toddlers and, when asked, should be knowledgeable and demonstrate competency in tasks associated with caring for infants and toddlers:
Caregivers/teachers should demonstrate knowledge of development of infants and toddlers as well as knowledge of indicators that a child is not developing typically; knowledge of the importance of attachment for infants and toddlers, the importance of communication and language development, and the importance of nurturing consistent relationships on fostering positive self-efficacy development. To help manage atypical or undesirable behaviors of children, caregivers/teachers, in collaboration with parents/guardians, should seek professional consultation from the child’s primary care provider, an early childhood mental health professional, or an early childhood mental health consultant. RATIONALEThe brain development of infants is particularly sensitive to the quality and consistency of interpersonal relationships. Much of the stimulation for brain development comes from the responsive interactions of caregivers/teachers and children during daily routines. Children need to be allowed to pursue their interests within safe limits and to be encouraged to reach for new skills (1-7). COMMENTSSince early childhood mental health professionals are not always available to help with the management of challenging behaviors in the early care and education setting early childhood mental health consultants may be able to
help. The consultant should be viewed as an important part of the program’s support staff and should collaborate with all regular classroom staff, consultants, and other staff. Qualified potential consultants may be identified by contacting mental health and behavioral providers in the local area, as well as accessing the National Mental Health Information Center (NMHIC) at http://store.samhsa.gov/ TYPE OF FACILITYCenter, Early Head Start, Large Family Child Care Home, Small Family Child Care Home RELATED STANDARDS3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction REFERENCES
Standard 1.3.3.1: General Qualifications of Family Child Care Caregivers/Teachers to Operate a Family Child Care HomeAll caregivers/teachers in large and small family child care homes should be at least twenty-one years of age, hold an official credential as granted by the authorized state agency, meet the general requirements specified in Standard 1.3.2.4 through Standard 1.3.2.6, based on ages of the children served, and those in Section 1.3.3, and should have the following education, experience, and skills:
Additionally, large family child care home caregivers/teachers should have at least one year of experience serving the ages and developmental abilities of the children in their large family child care home. Assistants, aides, and volunteers employed by a large family child care home should meet the qualifications specified in Standard 1.3.2.3. RATIONALEIn both large and small family child care homes, staff members must have the education and experience to meet the needs of the children in care (7). Small family child care home caregivers/teachers often work alone and are solely responsible for the health and safety of small numbers of children in their care. Most SIDS deaths in child care occur on the first day of care or within the first week; unaccustomed prone (tummy) sleeping increases the risk of SIDS eighteen times (3). Shaken baby syndrome/abusive head trauma is completely preventable. Pre-service training and frequent refresher training can prevent deaths (4). Caregivers/teachers are more likely to administer medications than to perform CPR. Seven thousand children per year require emergency department visits for problems related to cough and cold medications (5). Age eighteen is the earliest age of legal consent. Mature leadership is clearly preferable. Age twenty-one is more likely to be associated with the level of maturity necessary to independently care for a group of children who are not one’s own. The NAFCC has established an accreditation process to enhance the level of quality and professionalism in small and large family child care (2). COMMENTSA large family child care home caregiver/teacher, caring for more than six children and employing one or more assistants, functions as the primary caregiver as well as the facility director. An operator of a large family-child-care home should be offered training relevant to the management of a small child care center, including training on providing a quality work environment for employees. TYPE OF FACILITYEarly Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home RELATED STANDARDS3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction REFERENCES
Standard 1.3.2.7: Qualifications and Responsibilities for Health AdvocatesEach 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:
RATIONALEThe 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). COMMENTSThe director should assign the health advocate role to a staff member who seems to have an interest, aptitude, and training in this area. This person need not perform all the health and safety tasks in the facility but should serve as the person who raises health and safety concerns. This staff person has designated responsibility for seeing that plans are implemented to ensure a safe and healthful facility (1). TYPE OF FACILITYCenter, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home RELATED STANDARDS1.3.1.1 General Qualifications of
Directors REFERENCES
Standard 1.6.0.1: Child Care Health ConsultantsCOVID-19 modification as of May 21, 2021 *STANDARD UNDERGOING FULL REVISION* After reading the CFOC standard, see COVID-19 modification below (Also consult applicable state licensure and public health requirements). A facility should identify and engage/partner with a child care health consultant (CCHC) who is a licensed health professional with education and experience in child and community health and child care and preferably specialized training in child care health consultation. CCHCs have knowledge of resources and regulations and are comfortable linking health resources with child care facilities. The child care health consultant should be knowledgeable in the following areas:
The child care health consultant should be able to perform or arrange for performance of the following activities:
The role of the CCHC is to promote the health and development of children, families, and staff and to ensure a healthy and safe child care environment (11). The CCHC is not acting as a primary care provider at the facility but offers critical services to the program and families by sharing health and developmental expertise, assessments of child, staff, and family health needs and community resources. The CCHC assists families in care coordination with the medical home and other health and developmental specialists. In addition, the CCHC should collaborate with an interdisciplinary team of early childhood consultants, such as, early childhood education, mental health, and nutrition consultants. In order to provide effective consultation and support to programs, the CCHC should avoid conflict of interest related to other roles such as serving as a caregiver/teacher or regulator or a parent/guardian at the site to which child care health consultation is being provided. The CCHC should have regular contact with the facility’s administrative authority, the staff, and the parents/guardians in the facility. The administrative authority should review, and collaborate with the CCHC in implementing recommended changes in policies and practices. In the case of consulting about children with special health care needs, the CCHC should have contact with the child’s medical home with permission from the child’s parent/guardian. Programs with a significant number of non-English-speaking families should seek a CCHC who is culturally sensitive and knowledgeable about community health resources for the parents’/guardians’ native culture and languages. COVID-19 modification as of May 21, 2021 In response to the Centers for Disease Control and Prevention’s COVID-19 Guidance for Operating Early Care and Education/Child Care Programs, it is recommended that early childhood programs:
Use child care health consultants (CCHCs) during COVID for their knowledge and relationships with local pediatric and public health professionals to:
Address the many delays in children’s health care due to missed health and dental appointments during COVID-19 by working with the CCHC to:
Consider alternatives to CCHC onsite consultation and schedule other methods for delivering services:
Refer to the COVID-19 modifications in CFOC Standard 1.7.0.2: Daily Staff Health Check when on site visits are essential. Additional Resources: Centers for Disease Control and Prevention. COVID-19 Vaccine Toolkit for School Settings and Childcare ProgramsAmerican Academy of Pediatrics. Guidance Related to Childcare During COVID-19 Center for Health Care Strategies. COVID-19 and the Decline of Well-Child Care: Implications for Children, Families, and StatesChild Care Aware of America. Conducting Child Care Program Visits During COVID-19 (childcareaware.org) RATIONALECCHCs 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. COMMENTSThe U.S. Department of Health and Human Services Maternal and Child Health Bureau (MCHB) has supported the development of state systems of child care health consultants through HCCA and State Early Childhood Comprehensive Systems grants. Child care health consultants provide services to centers as well as family child care homes through on-site visits as well as phone or email consultation. Approximately twenty states are funding child care health consultant initiatives through a variety of funding sources, including Child Care Development Block Grants, TANF, and Title V. In some states a wide variety of health consultants, e.g., nutrition, kinesiology (physical activity), mental health, oral health, environmental health, may be available to programs and those consultants may operate through a team approach. Connecticut is an example of one state that has developed interdisciplinary training for early care and education consultants (health, education, mental health, social service, nutrition, and special education) in order to develop a multidisciplinary approach to consultation (8). TYPE OF FACILITYCenter, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home RELATED STANDARDS1.6.0.3 Infant and Early Childhood Mental Health Consultants
REFERENCES
NOTESCOVID-19 modification as of May 21, 2021 Orientation, Training and Continuing EducationStandard 1.4.1.1: Pre-service TrainingIn addition to the credentials listed in Standard 1.3.1.1, upon employment, a director or administrator of a center or the lead caregiver/teacher in a family child care home should provide documentation of at least thirty clock-hours of pre-service training. This training should cover health, psychosocial, and safety issues for out-of-home child care facilities. Small family child care home caregivers/teachers may have up to ninety days to secure training after opening except for training on basic health and safety procedures and regulatory requirements. All directors or program administrators and caregivers/teachers should document receipt of pre-service training prior to working with children that includes the following content on basic program operations:
RATIONALEThe director or program administrator of a center or large family child care home or the small family child care home caregiver/teacher is the person accountable for all policies. Basic entry-level knowledge of health and safety and social and emotional needs is essential to administer the facility. Caregivers/teachers should be knowledgeable about infectious disease and immunizations because properly implemented health policies can reduce the spread of disease, not only among the children but also among staff members, family members, and in the greater community (1). Knowledge of injury prevention measures in child care is essential to control known risks. Pediatric first aid training that includes CPR is important because the director or small family child care home caregiver/teacher is fully responsible for all aspects of the health of the children in care. Medication administration and knowledge about caring for children with special health care needs is essential to maintaining the health and safety of children with special health care needs. Most SIDS deaths in child care occur on the first day of child care or within the first week due to unaccustomed prone (on the stomach) sleeping; the risk of SIDS increases eighteen times when an infant who sleeps supine (on the back) at home is placed in the prone position in child care (2). Shaken baby syndrome/abusive head trauma is completely preventable. It is crucial for caregivers/teachers to be knowledgeable of both syndromes and how to prevent them before they care for infants. Early childhood expertise is necessary to guide the curriculum and opportunities for children in programs (3). The minimum of a Child Development Associate credential with a system of required contact hours, specific content areas, and a set renewal cycle in addition to an assessment requirement would add significantly to the level of care and education for children. The National Association for the Education of Young Children (NAEYC), a leading organization in child care and early childhood education, recommends annual training based on the needs of the program and the pre-service qualifications of staff (4). Training should address the following areas:
In the early childhood field there is often “crossover” regarding professional preparation (pre-service programs) and ongoing professional development (in-service programs). This field is one in which entry-level requirements differ across various sectors within the field (e.g., nursing, family support, and bookkeeping are also fields with varying entry-level requirements). In early childhood, the requirements differ across center, home, and school based settings. An individual could receive professional preparation (pre-service) to be a teaching staff member in a community-based organization and receive subsequent education and training as part of an ongoing professional development system (in-service). The same individual could also be pursuing a degree for a role as a teacher in a program for which licensure is required—this in-service program would be considered pre-service education for the certified teaching position. Therefore, the labels pre-service and in-service must be seen as related to a position in the field, and not based on the individual’s professional development program (5). COMMENTSTraining in infectious disease control and injury prevention may be obtained from a child care health consultant, pediatricians, or other qualified personnel of children’s and community hospitals, managed care companies, health agencies, public health departments, EMS and fire professionals, pediatric emergency room physicians, or other health and safety professionals in the community. TYPE OF FACILITYCenter, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home RELATED STANDARDS1.3.1.1 General Qualifications of
Directors REFERENCES
Standard 1.4.2.1: Initial Orientation of All StaffAll new full-time staff, part-time staff and substitutes should be oriented to the policies listed in Standard 9.2.1.1 and any other aspects of their role. The topics covered and the dates of orientation training should be documented. Caregivers/teachers should also receive continuing education each year, as specified in Continuing Education, Standard 1.4.4.1 through Standard 1.4.6.2. RATIONALEOrientation ensures that all staff members receive specific and basic training for the work they will be doing and are informed about their new responsibilities. Because of frequent staff turnover, directors should institute orientation programs on a regular basis (1). Orientation and ongoing training are especially important for aides and assistant teachers, for whom pre-service educational requirements are limited. Entry into the field at the level of aide or assistant teacher should be attractive and facilitated so that capable members of the families and cultural groups of the children in care can enter the field. Training ensures that staff members are challenged and stimulated, have access to current knowledge (2), and have access to education that will qualify them for new roles. Use of videos and other passive methods of training should be supplemented by interactive training approaches that help verify content of training has been learned (3). Health training for child care staff protects the children in care, staff, and the families of the children enrolled. Infectious disease control in child care helps prevent spread of infectious disease in the community. Outbreaks of infectious diseases and intestinal parasites in young children in child care have been shown to be associated with community outbreaks (4). Child care health consultants can be an excellent resource for providing health and safety orientation or referrals to resources for such training. COMMENTSMany states have pre-service education and experience qualifications for caregivers/teachers by role and function. Offering a career ladder and utilizing employee incentives such as Teacher Education and Compensation Helps (TEACH) will attract individuals into the child care field, where labor is in short supply. Colleges, accrediting bodies, and state licensing agencies should examine teacher preparation guidelines and substantially increase the health content of early childhood professional preparation. TYPE OF FACILITYCenter, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home RELATED STANDARDS1.6.0.1 Child Care Health Consultants REFERENCES
Standard 1.5.0.1: Employment of SubstitutesSubstitutes should be employed to ensure that child:staff ratios and requirements for direct supervision are maintained at all times. Substitutes and volunteers should be at least eighteen years of age and must meet the requirements specified throughout Standards 1.3.2.1-1.3.2.6. Those without licenses/certificates should work under direct supervision and should not be alone with a group of children. A substitute should complete the same background screening processes as the caregiver/teacher. Obtaining substitutes to provide medical care for children with special health care needs is particularly challenging. A substitute nurse should be experienced in delivering the expected medical services. Decisions should be made on whether a parent/guardian will be allowed to provide needed on-site medical services. Substitutes should be aware of the care plans (including emergency procedures) for children with special health care needs. RATIONALEThe risk to children from care by unqualified caregivers/teachers is the same whether the caregiver/teacher is a paid substitute or a volunteer (1). COMMENTSSubstitutes are difficult to find, especially at the last minute. Planning for a competent substitute pool is essential for child care operation. Requiring substitutes for small family child care homes to obtain first aid and CPR certification forces small family child care home caregivers/teachers to close when they cannot be covered by a competent substitute. Since closing a child care home has a negative impact on the families and children they serve, systems should be developed to provide qualified alternative homes or substitutes for family child care home caregivers/teachers. TYPE OF FACILITYCenter, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home RELATED STANDARDS1.3.2.4 Additional Qualifications for Caregivers/Teachers Serving Children Birth to Thirty-Five Months of Age REFERENCES
Standard 1.5.0.2: Orientation of SubstitutesContent in the STANDARD was modified on 5/22/2018 The director of any center or large family child care home and the small family child care home caregiver/teacher should provide orientation training to newly hired substitutes, including a review of all the program’s policies and procedures (see sample that follows). This training should include the opportunity for an evaluation and a repeat demonstration of the training lesson. Orientation should be documented in all child care settings. Substitutes should have background screenings. All substitutes should be oriented to, and demonstrate competence in, the tasks for which they will be responsible. On the first day a substitute caregiver/teacher should be oriented on the following topics:
During the first week of employment, all substitute caregivers/teachers should be oriented to, and should demonstrate competence in, at least the following items:
1. Hand hygiene techniques, including indications for hand hygiene 2. Diapering technique, if care is provided to children in diapers, including appropriate diaper disposal and diaper changing techniques and use and wearing of gloves 3. Preventing shaken baby syndrome/abusive head trauma 4. Strategies for coping with crying, fussing, or distraught infants and children 5. Early brain development and its vulnerabilities 6. Other injury prevention and safety, including the role of a mandatory child abuse reporter to report any suspected abuse/neglect 7. Correct food preparation and storage techniques, if employee prepares food 8. Proper handling and storage of human (breast) milk, when applicable, and formula preparation, if formula is handled 9. Bottle preparation, including guidelines for human milk and formula, if care is provided to infants or children with bottles 10. Proper use of gloves in compliance with Occupational Safety and Health Administration blood-borne pathogen regulations h. Emergency plans and practices On employment, substitutes should be able to carry out the duties assigned to them. RATIONALEBecause facilities and the children enrolled in them vary, orientation programs for new substitutes can be most productive. Because of frequent staff turnover, comprehensive orientation programs are critical to protecting the health and safety of children and new staff (1,2). Most SIDS deaths in child care occur on the first day of care or within the first week due to unaccustomed prone (on stomach) sleeping. Unaccustomed prone sleeping increases the risk of SIDS 18 times (3). TYPE OF FACILITYCenter, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home RELATED STANDARDS3.1.4.4 Scheduled Rest Periods and Sleep Arrangements REFERENCES
NOTESContent in the STANDARD was modified on 5/22/2018 Standard 1.4.4.1: Continuing Education for Directors and Caregivers/Teachers in Centers and Large Family Child Care HomesAll 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. RATIONALEBecause 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:
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. COMMENTSTools 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. TYPE OF FACILITYCenter, Early Head Start, Head Start, Large Family Child Care Home RELATED STANDARDS1.8.2.2 Annual Staff Competency Evaluation REFERENCES
Standard 1.4.4.2: Continuing Education for Small Family Child Care Home Caregivers/TeachersSmall 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. RATIONALEIn 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. COMMENTSThe content of continuing education for small family child care home caregivers/teachers should include the following topics: TYPE OF FACILITYEarly Head Start, Head Start, Small Family Child Care Home RELATED STANDARDS1.4.4.1 Continuing Education for Directors and Caregivers/Teachers in Centers and Large Family Child Care Homes REFERENCES
Standard 2.4.2.1: Health and Safety Education Topics for StaffContent in the STANDARD was modified on 1/10/2017 and 02/25/2022. The program activities on health and safety education should prepare early care and education staff in physical health; infection control; oral health; mental, and social and emotional health; nutrition; physical activity; environmental health; and safe environments for children and staff. Staff should be able to demonstrate knowledge or implement best practices of the following health education topics: Physical Health
Infection Control
Oral Health
Mental, and Social and Emotional Health
Nutrition
Physical Activity
Environmental Health and Safe Environments
RATIONALEEarly care and education staff members who are up to date on health and safety practices are more likely to provide a safe and healthy environment for children.1 The most significant predictor of compliance with state child care health and safety regulations is staff continuing education in the areas of health, safety, child development, and abuse identification.2 More health and safety topics that staff needs to be knowledgeable about to teach children are listed in Standard 2.4.1.1. COMMENTSChild care staff often learn about health and safety from a child care health consultant (CCHC).3 Data support the relationship between child care health consultation and the increased quality of the health of the children and safety of the child care center environment.3,4 Community
resources can provide written materials about health and safety. Examples of materials can be found at https://eclkc.ohs.acf.hhs.gov/ and http://www.childhealthonline.org/. State and local public health departments and child care state licensing agencies often conduct trainings or offer resources on the health and safety education topics listed above. Early care and education 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. For more information on e-cigarettes and marijuana use, please visit: American Lung Association. E-Cigarettes. 2020. https://www.lung.org/quit-smoking/e-cigarettes-vaping/lung-health American Lung Association. Marijuana and Lung Health. 2020. https://www.lung.org/quit-smoking/smoking-facts/health-effects/marijuana-and-lung-health National Institute on Drug Abuse. Marijuana DrugFacts. 2019. https://www.drugabuse.gov/publications/drugfacts/marijuana TYPE OF FACILITYCenter, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home RELATED STANDARDS3.3.0.1 Routine Cleaning, Sanitizing, and Disinfecting REFERENCES
NOTESContent in the STANDARD was modified on 1/10/2017 and 02/25/2022. Standard 9.4.3.3: Training RecordThe director of a center or a large or small family child care home should provide and maintain documentation or participate in the state’s training/professional development registry of training/professional development received by, or provided for, staff. For centers, the date of the training, the number of hours, the names of staff participants, the name(s) and qualification(s) of the trainer(s), and the content of the training (both orientation and continuing education) should be recorded in each staff person’s file or in a separate training file. If the state has a training/professional development registry, the director should provide training documentation to the registry. Small family child care home caregivers/teachers should keep a written record of training acquired and certificates containing the same information as the documentation recommended for centers and large homes. RATIONALEThe training record should be used to assess each employee’s need for additional training and to provide regulators with a tool to monitor compliance. Continuing education with course credit should be recorded and the records made available to staff members to document their applications for licenses/certificates or for license upgrading. All accrediting bodies for child care facilities, homes and centers, require documentation of training. In many states, small family child care home caregivers/teachers are required to keep records of training. COMMENTSColleges issue transcripts, workshops can issue certificates, and facility administrators can maintain individual training logs. TYPE OF FACILITYCenter, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home RELATED STANDARDS9.4.3.1 Maintenance and Content of Staff and Volunteer Records Standard 10.6.1.1: Regulatory Agency Provision of Caregiver/Teacher and Consumer Training and Support ServicesThe 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:
RATIONALETraining 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 STANDARDS1.4.2.1 Initial Orientation of All Staff REFERENCES
Standard 10.6.1.2: Provision of Training to Facilities by Health AgenciesPublic health departments, other state departments charged with professional development for out of home child care providers, and Emergency Medical Services (EMS) agencies should provide training, written information, consultation in at least the following subject areas or referral to other community resources (e.g., child care health consultants, licensing personnel, health care professionals, including school nurses) who can provide such training in:
RATIONALETraining of child care staff has improved the quality of their health related behaviors and practices. Training should be available to all parties involved, including caregivers/teachers, public health workers, health care providers, parents/guardians, and children. Good quality training, with imaginative and accessible methods of presentation supported by well-designed materials, will facilitate learning. RELATED STANDARDS1.4.4.1 Continuing Education for Directors and Caregivers/Teachers in Centers and Large Family Child Care Homes Safe Sleep Policies and InformationStandard 9.2.1.1: Content of PoliciesThe facility should have policies to specify how the caregiver/teacher addresses the developmental functioning and individual or special health care needs of children of different ages and abilities who can be served by the facility, as well as other services and procedures. These policies should include, but not be limited to, the following:
The facility should have specific strategies for implementing each policy. For centers, all of these items should be written. Facility policies should vary according to the ages and abilities of the children enrolled to accommodate individual or special health care needs. Program planning should precede, not follow the enrollment and care of children at different developmental levels and abilities and with different health care needs. Policies, plans, and procedures should generally be reviewed annually or when any changes are made. A child care health consultant can be very helpful in developing and implementing model policies. RATIONALENeither
plans nor policies affect quality unless the program has devised a way to implement the plan or policy. Children develop special health care needs and have developmental differences recognized while they are enrolled in child care (2). Effort should be made to facilitate accommodation as quickly as possible to minimize delay or interruption of care (1). For examples of policies see Model Child Care Health Policies at http://www.ecels-healthy COMMENTSReader’s note: Chapter 9 includes many standards containing additional information on specific policies noted above. TYPE OF FACILITYCenter, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home RELATED STANDARDS1.8.2.1 Staff Familiarity with Facility Policies, Plans and Procedures REFERENCES
Standard 1.8.2.1: Staff Familiarity with Facility Policies, Plans and ProceduresAll caregivers/teachers should be familiar with the provisions of the facility’s policies, plans, and procedures, as described in Chapter 9: Administration. The compliance with these policies, plans, and procedures should be used in staff performance evaluations and documented in the personnel file. RATIONALEWritten policies, plans and procedures provide a means of staff orientation and evaluation essential to the operation of any organization (1). TYPE OF FACILITYCenter, Early Head Start, Head Start, Large Family Child Care Home REFERENCES
Standard 9.2.1.3: Enrollment Information to Parents/Guardians and Caregivers/TeachersAt 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:
Policies on:
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. RATIONALEModel 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. COMMENTSFor large and small family child care homes, a written statement of services, policies, and procedures is strongly recommended and should be added to the “Parent Handbook.” Conflict over policies can lead to termination of services and inconsistency in the child’s care arrangements. If the statement is provided orally, parents/guardians should sign a statement attesting to their acceptance of the statement of services, policies and procedures presented to them. can be adapted to these smaller settings. TYPE OF FACILITYCenter, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home RELATED STANDARDS3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction Standard 9.4.2.3: Contents of Admission Agreement Between Child Care Program and Parent/GuardianThe file for each child should include an admission agreement signed by the parent/guardian at enrollment. The admission agreement should contain the following topics and documentation of consent:
RATIONALEThese records and reports are necessary to protect the health and safety of children in care. These consents are needed by the person delivering the medical care. Advance consent for emergency medical or surgical service is not legally valid, since the nature and extent of injury, proposed medical treatment, risks, and benefits cannot be known until after the injury occurs, but it does allow the parent/guardian to guide the caregiver/teacher in emergency situations when the parent/guardian cannot be reached (1). See Appendix KK: Authorization for Emergency Medical/Dental Care for an example. The parent/guardian/child care partnership is vital. TYPE OF FACILITYCenter, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home RELATED STANDARDS9.2.1.3 Enrollment Information to Parents/Guardians and
Caregivers/Teachers REFERENCES
Standard 9.2.3.13: Plans for Evening and Nighttime Child CareFacilities 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. RATIONALEEvening 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. COMMENTSSleeping 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 FACILITYCenter, Large Family Child Care Home, Small Family Child Care Home RELATED STANDARDS2.2.0.1 Methods of Supervision of Children Standard 9.2.3.15: Policies Prohibiting Smoking, Tobacco, Alcohol, Illegal Drugs, and Toxic SubstancesContent in the STANDARD was modified on 1/12/2017. Facilities should have written policies addressing the use and possession of tobacco and electronic cigarette (e-cigarette) products, alcohol, illegal drugs, legal drugs (e.g. medicinal/recreational marijuana, prescribed narcotics, etc.) that have side effects that diminish the ability to properly supervise and care for children or safely drive program vehicles, and other potentially toxic substances. Policies should include that all of these substances are prohibited inside the facility, on facility grounds, and in any vehicles that transport children at all times. Policies should specify that smoking and vaping is prohibited at all times and in all areas (indoor and outdoor) of the program. This includes any vehicles that are used to transport children. Policies must also specify that use and possession of all substances referred to above are prohibited during all times when caregivers/teachers are responsible for the supervision of children, including times when children are transported, when playing in outdoor play areas not attached to the facility, and during field trips and staff breaks. Child care centers and large family child care homes should provide information to employees about available drug, alcohol, and tobacco counseling and rehabilitation, and any available employee assistance programs. RATIONALEThe age, defenselessness, and lack of discretion of the child under care make this prohibition an absolute requirement. The hazards of second-hand and third-hand smoke exposure warrant the prohibition of smoking in proximity of child care areas at any time (1-10). Third-hand smoke refers to gases and particles clinging to smokers’ hair and clothing, cushions, carpeting and outdoor equipment after visible tobacco smoke has dissipated (9). The residue includes heavy metals, carcinogens, and even radioactive materials that young children can get on their hands and ingest, especially if they’re crawling or playing on the floor. Residual toxins from smoking at times when the children are not using the space can trigger asthma and allergies when the children do use the space (10). Safe child care necessitates sober caregivers/teachers. Alcohol and drug use, including the misuse of prescription, over-the-counter (OTC), or recreational drugs, prevent caregivers/teachers from providing appropriate care to infants and children by impairing motor coordination, judgment, and response time. Off-site use prior to or during work, of alcohol and illegal drugs is prohibited. OTC medications or prescription medications that have not been prescribed for the user or that could impair motor coordination, judgment, and response time is prohibited. The use of alcoholic beverages and legal drugs in family child care homes when children are not in care is not prohibited, but these items should be stored safely at all times. COMMENTSThe policies related to smoking and use of prohibited substances should be discussed with staff and parents/guardians. Educational material such as handouts could include information on the health risks and dangers of these prohibited substances and referrals to services for counseling or rehabilitation programs. TYPE OF FACILITYCenter, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home RELATED STANDARDS3.4.1.1 Use of Tobacco, Electronic Cigarettes, Alcohol, and
Drugs REFERENCES
NOTESContent in the STANDARD was modified on 1/12/2017. Related IssuesStandard 4.3.1.1: General Plan for Feeding InfantsContent in the STANDARD was modified on 05/30/2018. The facility should keep records detailing whether an infant is breastfed or formula fed, along with the type of formula being served. An infant feeding record of human (breast) milk and/or all formula given to the infant should be completed daily. Infant meals and snacks should follow the meal and snack patterns of the Child and Adult Care Food Program. Food should be appropriate for the infant’s individual nutrition requirements and developmental stage as determined by written instructions obtained from the child’s parent/guardian or primary health care provider. The facility should encourage breastfeeding by providing accommodations and continuous support to the breastfeeding mother. Facilities should have a designated place set aside for breastfeeding mothers who want to visit the classroom during the workday to breastfeed, as well as a private area (not a bathroom) with an outlet for mothers to pump their breast milk (1,2). The private area also should have access to water or hand hygiene. A place that parents/guardians feel they are welcome to breastfeed, pump, or bottle-feed can create a positive and supportive environment for the family. Infants may need a variety of special formulas, such as soy-based formula or elemental formulas, that are easier to digest and less allergenic. Elemental or special hypoallergenic formulas should be specified in the infant’s care plan. Age-appropriate solid foods other than human milk or infant formula (ie, complementary foods) should be introduced no sooner than 6 months of age or as indicated by the individual child’s nutritional and developmental needs. Please refer to standards 4.3.1.11 and 4.3.1.12 for more information. RATIONALEHuman milk, as an exclusive food, is best suited to meet the entire nutritional needs of an infant from birth until 6 months of age, with the exception of recommended vitamin D supplementation. In addition to nutrition, breastfeeding supports optimal health and development. Human milk is also the best source of milk for infants for at least the first 12 months of age and, thereafter, for as long as mutually desired by mother and child.
Breastfeeding protects infants from many acute and chronic diseases and has advantages for the mother, as well (3). Research overwhelmingly shows that exclusive breastfeeding for 6 months, and continued breastfeeding for at least a year or longer, dramatically improves health outcomes for children and their mothers. Healthy People 2020 outlines several objectives, including increasing the proportion of mothers who breastfeed their infants and increasing the duration
of breastfeeding and exclusive breastfeeding (4). Incidences of common childhood illnesses, such as diarrhea, respiratory disease, bacterial meningitis, botulism, urinary tract infections, sudden infant death syndrome, insulin-dependent diabetes, ulcerative colitis, and ear infections, and overall risk for childhood obesity are significantly decreased in breastfed children (5,6). Similarly, breastfeeding, when paired with other healthy parenting behaviors, has
been directly related to increased cognitive development in infants (7). Breastfeeding also has added benefits to the mother: it decreases risk of diabetes, breast and ovarian cancers, and heart disease (8). Mothers who want to supplement their breast milk with formula may do so, as the infant will continue to receive breastfeeding benefits (4,5,7). Iron-fortified infant formula is an acceptable alternative to human milk as a food for infant feeding even though it lacks any anti-infective or immunological components. Regardless of feeding preference, an adequately nourished infant is more likely to achieve healthy physical and mental development, which will have long-term positive effects on health (9). COMMENTSThe ways to help a mother breastfeed successfully in the early care and education facility are (2,6,8):
Additional Resources
TYPE OF FACILITYCenter, Early Head Start, Large Family Child Care Home, Small Family Child Care Home RELATED STANDARDS4.2.0.9
Written Menus and Introduction of New Foods REFERENCES
NOTESContent in the STANDARD was modified on 05/30/2018. Standard 3.6.4.5: DeathContent in the STANDARD was modified on 05/17/2016 and 8/25/2020. Early care and education (ECE) programs should have a plan in place for responding to any death relevant to children enrolled in the program and their families. The plan should describe protocols the program will follow and resources available to children, families, and staff.1 If an ECE program experiences the death of a child or adult, the following should be done, and these actions can take place simultaneously 2:
Depending on the cause of death (including sudden unexpected infant deaths [SUIDs], sudden infant death syndrome [SIDS], suffocation, injury, maltreatment, etc), there may be a need for updated education on the subject for caregivers/teachers and/or children as well as implementation of improved health and safety practices. Caregivers/teachers should be knowledgeable about safe sleep practices and implement them so that sleep-related deaths are not treated as possible maltreatment cases, resulting in false, inappropriate criminal and protective services investigations of the ECE program.5 If a child or adult known to the children enrolled in the ECE program dies while not at the ECE facility 1,3
If a death outside the ECE program might be due to suspected child maltreatment or neglect, the caregiver/teacher is mandated to report this to child protective services. Failing to consider or follow up on a suspected child abuse/neglect case can put other children (eg, siblings, children in the extended family, those enrolled in the program) at risk.4 RATIONALEProper management of unexpected deaths of children or adults by ECE staff allows families and staff who are affected the opportunity to react, grieve, assess, and communicate their needs.5 A parent’s experience following the death of a child varies enormously, and the way staff respond to and support families can make a considerable difference.2 COMMENTSADDITIONAL RESOURCES The following resources can offer support and counseling to caregivers/teachers and families experiencing tragedy: National Action Partnership to Promote Safe Sleep http://nappss.org
www.firstcandle.org National Center for School Crisis and Bereavement “Supporting the Grieving Child and Family” https://pediatrics.aappublications.org/content/138/3/e20162147 National Center for Education in Maternal and Child Health SUID/SIDS Gateway https://www.ncemch.org/suid-sids TYPE OF FACILITYCenter, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home RELATED STANDARDS3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction REFERENCES
NOTESContent in the STANDARD was modified on 05/17/2016 and 8/25/2020. |
Which safety education would the nurse provide to the parent of a 3-month-old infant?
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