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CaCrinhgiflodr Oruern National Health and Safety Performance Standards Guidelines for Early Care and Education Programs FOURTH EDITION

CaCrinhgiflodr Oruern National Health and Safety Performance Standards Guidelines for Early Care and Education Programs FOURTH EDITION A Joint Collaborative Project of American Academy of Pediatrics 345 Park Boulevard Itasca, IL 60143 American Public Health Association 800 I Street NW Washington, DC 20001-3710 National Resource Center for Health and Safety in Child Care and Early Education University of Colorado, College of Nursing 13120 19th Avenue Aurora, CO 80045 Support for this project was provided by the Maternal and Child Health Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services (Cooperative Agreement #U44MC30806).

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. Listing of resources does not imply an endorsement by the copyright holders. The copyright holders are not responsible for the content of external resources. Information was current at the time of publication. Brand names are furnished for identification purposes only. No endorsement of the manufacturers or products mentioned is implied. The publishers have made every effort to trace the copyright holders for borrowed material. If they have inadvertently overlooked any, they will be pleased to make the necessary arrangements at the first opportunity. Special discounts are available for bulk purchases of this publication. E-mail Special Sales at [email protected] for more information. © 2019 American Academy of Pediatrics, American Public Health Association, and National Resource Center for Health and Safety in Child Care and Early Education All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means—electronic, mechanical, photocopying, recording, or otherwise—without prior written permission from the publisher (locate title at http://ebooks.aappublications.org and click on © Get permissions; you may also fax the permissions editor at 847/434-8780 or e-mail [email protected]). The photographs in this publication were taken using funds from cooperative agreement #U44MC30806 for the US Department of Health and Human Services, Administration for Children and Families, Office of Head Start, Office of Child Care, and Health Resources and Services Administration, Maternal and Child Health Bureau, by the National Center on Early Childhood Health and Wellness. The photographs may be duplicated for noncommercial uses without permission. The photographs are in the public domain, and no copyright can be claimed by persons or organizations. Suggested Citation: American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education. Caring for Our Children: National Health and Safety Performance Standards; Guidelines for Early Care and Education Programs. 4th ed. Itasca, IL: American Academy of Pediatrics; 2019 Printed in the United States of America 1 2 3 4 5 6 7 8 9 10 MA0908 ISBN: 978-1-61002-297-2 eBook: 978-1-61002-298-9 Cover and publication design by Linda Diamond Library of Congress Control Number: 2018947984

iii Contents Acknowledgments............................................................................................................................................................ix Introduction.....................................................................................................................................................................xvii Guiding Principles................................................................................................................ xix Advice to the User..................................................................................................................xx History of Caring for Our Children Standard Language Changes Since the 3rd Edition (Through July 2018)......................................................................................................xxiii ➊Chapter Staffing...................................................................................................................................................... 1 1.1 Child:Staff Ratio, Group Size, and Minimum Age..................................................... 3 1.1.1 Child:Staff Ratio and Group Size....................................................................... 3 1.1.2 Minimum Age............................................................................................................... 7 1.2 Recruitment and Background Screening....................................................................9 1.3 Pre-service Qualifications................................................................................................. 11 1.3.1 Director’s Qualifications...................................................................................... 11 1.3.2 Caregiver’s/Teacher’s and Other Staff Qualifications..........................12 1.3.3 Family Child Care Home Caregiver/Teacher Qualifications..............19 1.4 Professional Development/Training...........................................................................21 1.4.1 Pre-service Training................................................................................................21 1.4.2 Orientation Training...............................................................................................23 1.4.3 First Aid and CPR Training.................................................................................. 26 1.4.4 Continuing Education/Professional Development............................... 28 1.4.5 Specialized Training/Education.......................................................................31 1.4.6 Educational Leave/Compensation.................................................................33 1.5 Substitutes............................................................................................................................... 34 1.6 Consultants.............................................................................................................................. 36 1.7 Staff Health.............................................................................................................................. 42 1.8 Human Resource Management...................................................................................... 46 1.8.1 Benefits........................................................................................................................ 46 1.8.2 Evaluation....................................................................................................................47 ➋Chapter Program Activities for Healthy Development................................................................... 49 2.1 Program of Developmental Activities.........................................................................51 2.1.1 General Program Activities.................................................................................51 2.1.2 Program Activities for Infants and Toddlers from Three Months to Less Than Thirty-Six Months....................................... 59 2.1.3 Program Activities for Three- to Five-Year-Olds.................................... 64 2.1.4 Program Activities for School-Age Children............................................. 66 2.2 Supervision and Discipline..............................................................................................68 2.3 Parent/Guardian Relationships....................................................................................80 2.3.1 General.........................................................................................................................80 2.3.2 Regular Communication...................................................................................... 82 2.3.3 Health Information Sharing..............................................................................84 2.4 Health Education................................................................................................................... 85 2.4.1 Health Education for Children......................................................................... 85 2.4.2 Health Education for Staff.................................................................................88 2.4.3 Health Education for Parents/Guardians..................................................90

iv Contents ➌Chapter Health Promotion and Protection........................................................................................... 93 3.1 Health Promotion in Child Care..................................................................................... 95 3.1.1 Daily Health Check................................................................................................. 95 3.1.2 Routine Health Supervision.............................................................................. 96 3.1.3 Physical Activity and Limiting Screen Time...............................................97 3.1.4 Safe Sleep.................................................................................................................102 3.1.5 Oral Health...............................................................................................................108 3.2 Hygiene......................................................................................................................................111 3.2.1 Diapering and Changing Soiled Clothing..................................................111 3.2.2 Hand Hygiene......................................................................................................... 118 3.2.3 Exposure to Body Fluids................................................................................... 122 3.3 Cleaning, Sanitizing, and Disinfecting..................................................................... 125 3.4 Health Protection in Child Care....................................................................................127 3.4.1 Tobacco and Drug Use.........................................................................................127 3.4.2 Animals.......................................................................................................................128 3.4.3 Emergency Procedures.......................................................................................131 3.4.4 Child Abuse and Neglect................................................................................... 132 3.4.5 Sun Safety and Insect Repellent.................................................................. 135 3.4.6 Strangulation..........................................................................................................138 3.5 Care Plans and Adaptations.......................................................................................... 139 3.6 Management of Illness..................................................................................................... 141 3.6.1 Inclusion/Exclusion Due to Illness.............................................................. 141 3.6.2 Caring for Children Who Are Ill...................................................................... 147 3.6.3 Medications............................................................................................................. 153 3.6.4 Reporting Illness and Death........................................................................... 155 Chapter Nutrition and Food Service.......................................................................................................159 4.1 Introduction............................................................................................................................161 4.2 General Requirements..................................................................................................... 162 4.3 Requirements for Special Groups or Ages of Children....................................174 4.3.1 Nutrition for Infants.............................................................................................174 4.3.2 Nutrition for Toddlers and Preschoolers.................................................184 4.3.3 Nutrition for School-Age Children...............................................................186 4.4 Staffing..................................................................................................................................... 187 4.5 Meal Service, Seating, and Supervision..................................................................188 4.6 Food Brought From Home............................................................................................... 193 4.7 Nutrition Learning Experiences for Children and Nutrition Education for Parents/Guardians.........................................................194 4.8 Kitchen and Equipment................................................................................................... 197 4.9 Food Safety............................................................................................................................ 200 4.10 Meals from Outside Vendors or Central Kitchens.............................................206 ➎Chapter Facilities, Supplies, Equipment, and Environmental Health...................................209 5.1 Overall Requirements........................................................................................................211 5.1.1 General Location, Layout, and Construction of the Facility...........................................................................................................211 5.1.2 Space per Child...................................................................................................... 215 5.1.3 Openings....................................................................................................................217 5.1.4 Exits.............................................................................................................................. 219 5.1.5 Steps and Stairs..................................................................................................... 221 5.1.6 Exterior Areas......................................................................................................... 222

v Contents 5.2 Quality of the Outdoor and Indoor Environment..............................................224 5.2.1 Ventilation, Heating, Cooling, and Hot Water........................................224 5.2.2 Lighting......................................................................................................................230 5.2.3 Noise............................................................................................................................ 232 5.2.4 Electrical Fixtures and Outlets...................................................................... 233 5.2.5 Fire Warning Systems.........................................................................................234 5.2.6 Water Supply and Plumbing...........................................................................235 5.2.7 Sewage and Garbage..........................................................................................239 5.2.8 Integrated Pest Management......................................................................... 241 5.2.9 Prevention and Management of Toxic Substances.............................243 5.3 General Furnishings and Equipment........................................................................253 5.3.1 General Furnishings and Equipment Requirements..........................253 5.3.2 Additional Equipment Requirements for Facilities Serving Children with Special Health Care Needs..............................260 5.4 Space and Equipment in Designated Areas.......................................................... 261 5.4.1 Toilet and Handwashing Areas...................................................................... 261 5.4.2 Diaper Changing Areas.......................................................................................265 5.4.3 Bathtubs and Showers....................................................................................... 267 5.4.4 Laundry Area...........................................................................................................268 5.4.5 Sleep and Rest Areas..........................................................................................268 5.4.6 Space for Children Who Are Ill, Injured, or Need Special Therapies............................................................................... 272 5.5 Storage Areas........................................................................................................................ 273 5.6 Supplies................................................................................................................................... 274 5.7 Maintenance...........................................................................................................................277 ➏Chapter Play Areas/Playgrounds and Transportation................................................................. 281 6.1 Play Area/Playground Size and Location..............................................................283 6.2 Play Area/Playground Equipment............................................................................. 287 6.2.1 General Requirements..................................................................................... 287 6.2.2 Use Zones and Clearance Requirements............................................... 291 6.2.3 Play Area and Playground Surfacing........................................................292 6.2.4 Specific Play Equipment.................................................................................293 6.2.5 Inspection of Play Areas/Playgrounds and Equipment................296 6.3 Water Play Areas (Pools, Etc.)....................................................................................... 297 6.3.1 Access to and Safety Around Bodies of Water.................................... 297 6.3.2 Pool Equipment.................................................................................................. 300 6.3.3 Pool Maintenance............................................................................................. 300 6.3.4 Water Quality of Pools.....................................................................................302 6.3.5 Other Water Play Areas...................................................................................302 6.4 Toys.............................................................................................................................................303 6.4.1 Selected Toys........................................................................................................303 6.4.2 Riding Toys and Helmets................................................................................305 6.5 Transportation......................................................................................................................307 6.5.1 Transportation Staff..........................................................................................307 6.5.2 Transportation Safety......................................................................................309 6.5.3 Vehicles.................................................................................................................... 313

vi Contents ➐Chapter Infectious Diseases....................................................................................................................... 315 7.1 How Infections Spread......................................................................................................317 7.2 Immunizations.......................................................................................................................317 7.3 Respiratory Tract Infections..........................................................................................320 7.3.1 Group A Streptococcal (GAS) Infections.................................................320 7.3.2 Haemophilus Influenzae Type B (Hib)..................................................... 321 7.3.3 Influenza................................................................................................................. 323 7.3.4 Mumps......................................................................................................................324 7.3.5 Neisseria Meningitidis (Meningococcus)...............................................325 7.3.6 Parvovirus B19......................................................................................................326 7.3.7 Pertussis..................................................................................................................326 7.3.8 Respiratory Syncytial Virus (RSV)...............................................................328 7.3.9 Streptococcus Pneumoniae...........................................................................329 7.3.10 Tuberculosis..........................................................................................................330 7.3.11 Unspecified Respiratory Tract Infection................................................. 331 7.4 Enteric (Diarrheal) Infections and Hepatitis A Virus (HAV)........................... 332 7.5 Skin and Mucous Membrane Infections..................................................................336 7.5.1 Conjunctivitis........................................................................................................336 7.5.2 Enteroviruses........................................................................................................ 337 7.5.3 Human Papillomaviruses (Warts)..............................................................338 7.5.4 Impetigo..................................................................................................................338 7.5.5 Lymphadenitis.....................................................................................................339 7.5.6 Measles................................................................................................................... 340 7.5.7 Molluscum Contagiosum............................................................................... 340 7.5.8 Pediculosis Capitis (Head Lice)................................................................... 341 7.5.9 Tinea Capitis and Tinea Cruris (Ringworm)..........................................342 7.5.10 Staphylococcus Aureus Skin Infections Including MRSA...............342 7.5.11 Scabies.....................................................................................................................343 7.5.12 Thrush......................................................................................................................344 7.6 Bloodborne Infections.....................................................................................................344 7.6.1 Hepatitis B Virus (HBV)....................................................................................344 7.6.2 Hepatitis C Virus (HCV)....................................................................................346 7.6.3 Human Immunodeficiency Virus (HIV).................................................... 347 7.7 Herpes Viruses.....................................................................................................................349 7.7.1 Cytomegalovirus (CMV)....................................................................................349 7.7.2 Herpes Simplex...................................................................................................350 7.7.3 Herpes Virus 6 and 7 (Roseola)................................................................... 351 7.7.4 Varicella-Zoster (Chickenpox) Virus......................................................... 351 7.8 Interaction with State or Local Health Departments......................................353 7.9 Note to Reader on Judicious Use of Antibiotics.................................................353

vii Contents ➑Chapter Children with Special Health Care Needs and Disabilities......................................355 8.1 Guiding Principles for This Chapter and Introduction................................... 357 8.2 Inclusion of Children with Special Needs in the Child Care Setting.......359 8.3 Process Prior to Enrolling at a Facility................................................................... 360 8.4 Developing a Service Plan for a Child with a Disability or a Child with Special Health Care Needs........................................................... 361 8.5 Coordination and Documentation.............................................................................365 8.6 Periodic Reevaluation......................................................................................................365 8.7 Assessment of Facilities for Children with Special Needs...........................366 8.8 Additional Standards for Providers Caring for Children with Special Health Care Needs................................................................................. 367 ➒Chapter Administration.................................................................................................................................369 9.1 Governance.............................................................................................................................371 9.2 Policies..................................................................................................................................... 372 9.2.1 Overview................................................................................................................. 372 9.2.2 Transitions...............................................................................................................377 9.2.3 Health Policies..................................................................................................... 379 9.2.4 Emergency/Security Policies and Plans.................................................393 9.2.5 Transportation Policies...................................................................................402 9.2.6 Play Area Policies.............................................................................................. 403 9.3 Human Resource Management.................................................................................. 405 9.4 Records....................................................................................................................................407 9.4.1 Facility Records/Reports................................................................................407 9.4.2 Child Records........................................................................................................418 9.4.3 Staff Records.........................................................................................................424 ➓Chapter Licensing and Community Action.......................................................................................... 427 10.1 Introduction.......................................................................................................................429 10.2 Regulatory Policy............................................................................................................429 10.3 Licensing Agency.............................................................................................................430 10.3.1 The Regulation Setting Process............................................................430 10.3.2 Advisory Groups............................................................................................. 431 10.3.3 Licensing Role with Staff Credentials, Child Abuse Prevention, and ADA Compliance..............................433 10.3.4 Technical Assistance from the Licensing Agency.........................435 10.3.5 Licensing Staff Training..............................................................................439 10.4 Facility Licensing............................................................................................................ 440 10.4.1 Initial Considerations for Licensing................................................... 440 10.4.2 Facility Inspections and Monitoring...................................................442 10.4.3 Procedures for Complaints, Reporting, and Data Collecting......................................................................................443 10.5 Health Department Responsibilities and Role............................................... 444 10.6 Caregiver/Teacher Support...................................................................................... 448 10.6.1 Caregiver/Teacher Training..................................................................... 448 10.6.2 Caregiver/Teacher Networking and Collaboration.................... 449 10.7 Public Policy Issues and Resource Development......................................... 450

viii Contents Appendixes....................................................................................................................................................................... 451 Appendix A: Signs and Symptoms Chart......................................................................................................453 Appendix B: Major Occupational Health Hazards................................................................................... 458 Appendix C: Nutrition Specialist, Registered Dietitian, Licensed Nutritionist, Consultant, and Food Service Staff Qualifications......................................................459 Appendix D: Gloving................................................................................................................................................ 460 Appendix E: Child Care Staff Health Assessment.................................................................................... 461 Appendix F: Enrollment/Attendance/Symptom Record......................................................................467 Appendix G: Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger............................................................................. 468 Appendix H: Recommended Immunization Schedule for Adults Aged 19 Years or Older................................................................................................................ 476 Appendix I: Recommendations for Preventive Pediatric Health Care........................................482 Appendix J: Selecting an Appropriate Sanitizer or Disinfectant .................................................. 484 Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting.................................491 Appendix L: Cleaning Up Body Fluids............................................................................................................493 Appendix M: Recognizing Child Abuse and Neglect: Signs and Symptoms............................... 494 Appendix N: Protective Factors Regarding Child Abuse and Neglect........................................... 498 Appendix O: Care Plan for Children With Special Health Needs..................................................... 500 Appendix P: Situations that Require Medical Attention Right Away............................................ 506 Appendix Q: Getting Started with MyPlate..................................................................................................507 Appendix R: Choose MyPlate: 10 Tips to a Great Plate........................................................................ 508 Appendix S: Physical Activity: How Much Is Needed?.......................................................................... 509 Appendix T: Helping Children in Foster Care Make Successful Transitions Into Child Care....................................................................................................... 510 Appendix U: Recommended Safe Minimum Internal Cooking Temperatures........................... 512 Appendix V: Food Storage Chart....................................................................................................................... 513 Appendix W: Sample Food Service Cleaning Schedule.......................................................................... 515 Appendix X: Adaptive Equipment for Children with Special Health Care Needs................... 516 Appendix Y: Even Plants Can Be Poisonous .............................................................................................. 518 Appendix Z: Depth Required for Shock-Absorbing Surfacing Materials for Use Under Play Equipment...............................................................................................520 Appendix AA: Medication Administration Packet.......................................................................................522 Appendix BB: Emergency Information Form for Children With Special Needs........................... 527 Appendix CC: Incident Report Form...................................................................................................................529 Appendix DD: Child Injury Report Form for Indoor and Outdoor Injuries.....................................530 Appendix EE: America’s Playgrounds Safety Report Card.....................................................................532 Appendix FF: Child Health Assessment...........................................................................................................535 Appendix GG: Licensing and Public Regulation of Early Childhood Programs...........................536 Appendix HH: Use Zones and Clearance Dimensions for Single- and Multi-Axis Swings......544 Appendix II: Bike and Multi-sport Helmets: Quick-Fit Check............................................................ 547 Appendix JJ: Our Child Care Center Supports Breastfeeding............................................................549 Appendix KK: Authorization for Emergency Medical/Dental Care....................................................550 Acronyms/Abbreviations.......................................................................................................................................... 551 Glossary............................................................................................................................................................................. 557 Index.................................................................................................................................................................................... 575

ix Acknowledgments The following individuals and organizations are acknowl- Dr. Susan Aronson, MD, FAAP; Dr. Albert Chang, MD, edged for their contributions as subject matter experts or MPH, FAAP; and Dr. George Sterne, MD, FAAP. field reviewers for Caring for Our Children, Third Edition. Some of those listed also served as subject matter experts for Their leadership and dedication in setting the bar high revised standards included in Caring for Our Children, for quality health and safety standards in early care and Fourth Edition, which did not undergo additional field education ensured that children experienced healthier and testing. safer lives and environments in child care and provided a The National Resource Center for Health and Safety in valuable and nationally recognized resource for all in the Child Care would like to acknowledge the outstanding field. We are pleased to build upon their foundational work contributions of all persons and organizations involved in in this Third Edition with new science and research. the revision of Caring for Our Children: National Health and Safety Performance Standards: Guidelines for Out-of-Home Technical Panel Chairs and Members Child Care Programs, Third Edition. The collaboration of the American Academy of Pediatrics, the American Public Child Abuse Health Association, and the Maternal and Child Health Bureau provided a wide scope of technical expertise from Anne B. Keith, DrPH, RN, C-PNP, Chair; their constituents in the creation of this project. The subject- New Gloucester, ME specific Technical Panels as listed provided the majority Melissa Brodowski, MSW, MPH; Washington, DC of the content and resources. Over 180 organizations and Gilbert Handal, MD, FAAP; El Paso, TX individuals were asked to review and validate the accuracy Carole Jenny, MD, MBA, FAAP; Providence, RI of the content and contribute additional expertise where Salwa Khan, MD, MHS; Baltimore, MD applicable. The individuals representing these organizations Ashley Lucas, MD, FAAP; Baton Rouge, LA are listed in Stakeholder Reviewers/Additional Contributors Hannah Pressler, MHS, PNP-BC; Portland, ME (see below). This broad collaboration and review from the Sara E. Schuh, MD, FAAP; Charleston, SC best minds in the field has led to a more comprehensive and useful tool. Child Development In a project of such scope, many individuals provide valuable input to the end product. We would like to acknowledge Angela Crowley, PhD, APRN, CS, PNP-BC, Chair; those individuals whose names may have been omitted. New Haven, CT George J. Cohen, MD, FAAP; Rockville, MD Steering Committee Christine Garvey, PhD, RN; Chicago, IL Danette Swanson Glassy, MD, FAAP Walter S. Gilliam, PhD; New Haven, CT Co-Chair, American Academy of Pediatrics; Peter A. Gorski, MD, MPA; Tampa, FL Mercer Island, WA Mary Louise Hemmeter, PhD; Nashville, TN Jonathan B. Kotch, MD, MPH, FAAP Michael Kaplan, MD; New Haven, CT Co-Chair, American Public Health Association; Cynthia Olson, MS; New Haven, CT Chapel Hill, NC Deborah F. Perry, PhD; Baltimore, MD Barbara U. Hamilton, MA June Solnit Sale, MSW; Los Angeles, CA Project Officer, U.S. Department of Health and Human Services, Health Resources and Services Administration, Children with Special Health Care Needs Maternal and Child Health Bureau; Rockville, MD Marilyn J. Krajicek, EdD, RN, FAAN Herbert J. Cohen, MD, FAAP, Chair; Bronx, NY Director, National Resource Center for Health and Elaine Donoghue, MD, FAAP; Neptune, NJ Safety in Child Care and Early Education; Aurora, CO Lillian Kornhaber, PT, MPH; Bronx, NY Phyllis Stubbs-Wynn, MD, MPH Jack M. Levine, MD, FAAP; New Hyde Park, NY Former Project Officer, U.S. Department of Health and Cordelia Robinson Rosenberg, PhD, RN; Aurora, CO Human Services, Health Resources and Services Sarah Schoen, PhD, OTR; Greenwood Village, CO Administration, Maternal and Child Health Bureau; Nancy Tarshis, MA, CCC/SP; Bronx, NY Rockville, MD Melanie Tyner-Wilson, MS; Lexington, KY The Caring for Our Children, 3rd Ed. Steering Committee would like to express special gratitude to Environmental Quality the Co-Chairs of the First and/or Second Editions: Steven B. Eng, MPH, CIPHI(C), Chair; Port Moody, BC Darlene Dinkins; Washington, DC Hester Dooley, MS; Portland, OR Bettina Fletcher; Washington, DC C. Eve J. Kimball, MD, FAAP; West Reading, PA Kathy Seikel, MBA; Washington, DC

x Organization and Administration Acknowledgments Christopher A. Kus, MD, MPH, Chair; Albany, NY Christine Ross–Baze; Topeka, KS Richard Snaman, REHS/RS; Arlington, VA Brooke Janet Carter; Dover, DE Stebbins, BSN; Concord, NH Sally Clausen, ARNP, BSN; Des Moines, IA Nsedu Obot Witherspoon, MPH; Washington, DC Judy Collins; Norman, OK Pauline Koch; Newark, DE General Health Jackie Quirk; Raleigh, NC CAPT. Timothy R. Shope, MD, MPH, FAAP, Chair; Staff Health Portsmouth, VA Abbey Alkon, RN, PNP, PhD; San Francisco, CA Amy C. Cory, PhD, RN, CPNP, PCNS, BC, Chair; Paul Casamassimo, DDS, MS; Columbus, OH Valparaiso, IN Sandra Cianciolo, MPH, RN; Chapel Hill, NC Patricia S. Cole; Indianapolis, IN Beth A. DelConte, MD, FAAP; Broomall, PA Susan Eckelt, CDA; Tulsa, OK Karen Leamer, MD, FAAP; Denver, CO Bethany Geldmaker, PNP, PhD; Richmond, VA Judy Romano, MD, FAAP; Martins Ferry, OHLinda Stephanie Olmore, MA; Washington, DC Satkowiak, ND, RN, CNS; Denver, CO Barbara Sawyer; Arvada, CO Karen Sokal-Gutierrez, MD, MPH, FAAP; Berkeley, CA Lead Organizations’ Reviewers Infectious Diseases American Academy of Pediatrics Larry Pickering, MD, FAAP, Chair; Atlanta, GA Sandra G. Hassink, MD, MPH, FAAP Ralph L. Cordell, PhD; Atlanta, GA Jeanne VanOrsdal, MEd Dennis L. Murray, MD; Augusta, GA Thomas J. Sandora, MD, MPH; Boston, MA American Public Health Association Andi L. Shane, MD, MPH; Atlanta, GA Elizabeth L. M. Miller, BSN, RN, BC; Newtown Square, PA Barbara Schwartz, PhD; New York, NY Injury Prevention U.S. Department of Health and Human Services, Health Seth Scholer, MD, MPH, Chair; Resources and Services Administration, Maternal and Nashville, TN Child Health Bureau Laura Aird, MS; Elk Grove Village, IL R. Lorraine Brown, RN, BS, CPHP; Rockville, MD Sally Fogerty, BSN, Med; Newton, MA CAPT. Stephanie Bryn, MPH; Rockville, MD Paula Deaun Jackson, MSN, CRNP, LNC; Philadelphia, PA Denise Sofka, MPH, RD; Rockville, MD Rhonda Laird; Nashville, TN Sarah L. Myers, RN; Moorhead, MN National Resource Center for Health and Safety in Susan H. Pollack, MD, FAAP; Lexington, KY Child Care and Early Education Project Team Ellen R. Schmidt, MS, OTR; Washington, DC Marilyn J. Krajicek, EdD, RN, FAAN; Director Alexander W. (Sandy) Sinclair; Washington, DC Jean M. Cimino, MPH; Professional Research Assistant Donna Thompson, PhD; Cedar Falls, IA Betty Geer, MSN, RN, CPNP; Research Assistant Barbara U. Hamilton, MA; Former Assistant Director Nutrition Susan Paige Lehtola, BBA, BS; Research Assistant David Merten, BS; Former Research Assistant Catherine Cowell, PhD, Chair; New York, NY Garrett T. Risley, MBA-HA; Research Assistant Sara Benjamin Neelon, PhD, MPH, RD; Durham, NC Linda Satkowiak, ND, RN, CNS; Nurse Consultant Donna Blum-Kemelor, MS, RD, LD; Alexandria, VA Gerri Steinke, PhD; Evaluator Robin Brocato, MHS; Washington, DC Ginny Torrey, BA; Program Specialist Kristen Copeland, MD, FAAP; Cincinnati, OH Suzanne Haydu, MPH, RD; Sacramento, CA Janet Hill, MS, RD, IBCLC; Sacramento, CA Susan L. Johnson, PhD; Aurora, CO Ruby Natale, PhD, PsyD; Miami, FL Jeanette Panchula, BSW, RN, PHN, IBCLC Shana Patterson, RD; Denver, CO Barbara Polhamus, PhD, MPH, RD; Atlanta, GA Susan Schlosser, MS, RD; Chappaqua, NY Denise Sofka, MPH, RD; Rockville, MD Jamie Stang, PhD, MPH, RD; Minneapolis, MN

Stakeholder Reviewers/Additional Contributors xi Kenneth C. Akwuole, PhD U.S. Administration for Children and Families, Acknowledgments Office of Child Care, DC Duane Alexander, MD, FAAP Kathie Boe National Institute of Child Health and Human Knowledge Learning Corporation, OR Development, MD Kathie Boling Abbey Alkon, RN, PNP, MPH, PhD Zero to Three, DC American Academy of Pediatrics, Section on Early Suzanne Boulter, MD, FAAP Education and Child Care, IL American Academy of Pediatrics, Section on Pediatric University of California San Francisco, California Dentistry and Oral Health, IL Childcare Health Program, CA Laurel Branen, PhD, RD, LD Krista Allison, RN, BSN University of Idaho, School of Family and Consumer Parent, CO Sciences, ID Jamie Anderson, RNC, IBCLC Marsha R. Brookins New Jersey Department of Health and Senior Services, U.S. Administration for Children and Families, DC Division of Family Health Services, NJ Mary Jane Brown Kristie Applegren, MD Centers for Disease Control and Prevention, American Academy of Pediatrics, Council on Environment Division, GA Communication and Media, IL Oscar Brown, MD, FAAP Lois D. W. Arnold, PhD, MPH American Academy of Pediatrics, Committee on Practice National Commission on Donor Milk Banking, American in Ambulatory Medicine and Immunizations, IL Breastfeeding Institute, MA Heather Brumberg, MD, MPH, FAAP Susan Aronson, MD, FAAP American Academy of Pediatrics, Committee on Healthy Child Care America Pennsylvania, Pennsylvania Environmental Health, IL Chapter of the American Academy of Pediatrics, PA Barbara Cameron, MA, MSW Robert Baker, MD, PhD, FAAP University of North Carolina, Carolina Breastfeeding Gastroenterology, Hepatology, and Therapeutics, NY Institute, NC Polly T. Barey, RN, MS Charles Cappetta, MD, FAAP Connecticut Nurses Association, CT American Academy of Pediatrics, Council on Sports Molly Bauer, ARNP, CPNP, RN Medicine and Fitness, IL University of Iowa Health Care, IA Anne Carmody, BS Kristen Becker Wisconsin Department of Children and Families, Parent, WA Bureau of Early Care Regulation, WI Debbie Beirne Anna Carter Virginia Department of Social Services and Division of North Carolina Division of Child Development, NC Licensing, VA Susan Case Nancy P. Bernard, MPH Oklahoma Department of Human Services, OK Washington State Department of Health, Indoor Air Dimitri Christakis, MD, FAAP Quality/ School Environmental Health and Safety, WA American Academy of Pediatrics, Council on Wendy Bickford, MA Communication and Media, IL Buell Early Childhood Leadership Program, CO Tom Clark, MD, FAAP Julia D. Block, MD, MPH, FAAP Task Force of the Youth Futures Authority, GA American Academy of Pediatrics, NY Sally Clausen, ARNP, BSN Healthy Child Care America, IA Abby J. Cohen, JD National Child Care Information and Technical Assistance Center, CA

xii Jose Esquibel Colorado Department of Public Health and Acknowledgments Environment, CO Karen Farley, RD, IBCLC California WIC Association, CA Herbert J. Cohen, MD, FAAP Rick Fiene, PhD Council on Children with Disabilities, MD Penn State University, Capital Area Early Childhood Albert Einstein College of Medicine, Department Training Institute, PA of Pediatrics, NY Margaret Fisher, MD, FAAP Teresa Cooper, RN American Academy of Pediatrics, Disaster Preparedness Washington Early Childhood Comprehensive Systems, Advisory Council, IL State Department of Health, WA American Academy of Pediatrics, Section on Infectious Kristen A. Copeland, MD, FAAP Diseases, IL Cincinnati Children’s Hospital Medical Center, OH Thomas Fleisher, MD, FAAP Ron Coté, PE American Academy of Pediatrics, Section on Allergy and National Fire Protection Association, MA Immunology, IL William Cotton, MD, FAAP Janice Fletcher, EdD American Academy of Pediatrics, Council on University of Idaho, School of Family and Consumer Community Pediatrics, IL Sciences, ID Melissa Courts Carroll Forsch Ohio Early Childhood Comprehensive Systems, South Dakota Department of Social Services, Division of Healthy Child Care America, OH Child Care Services, SD Debby Cryer, PhD Daniel Frattarelli, MD, FAAP University of North Carolina-Chapel Hill, FPG American Academy of Pediatrics, Section on Clinical Child Development Institute, NC Pharmacology and Therapeutics/Committee on Drugs, IL Edward Curry, MD, FAAP Doris Fredericks, MEd, RD, FADA American Academy of Pediatrics, Committee on Practice Child Development, Inc., Choices for Children, CA in Ambulatory Medicine and Immunizations, IL Gilbert Fuld, MD, FAAP Nancy M. Curtis American Academy of Pediatrics, Council on Maryland Health and Human Services, Montgomery Communication and Media, IL County, MD Jill Fussell, MD, FAAP Cynthia Devore, MD, FAAP American Academy of Pediatrics, Committee on Early American Academy of Pediatrics, Council on Childhood, Adoption, and Dependent Care, Section School Health, IL on Developmental and Behavioral Pediatrics, IL Ann Ditty, MA Carol Gage National Association for Regulatory Administration, KY U.S. Administration for Children and Families, Steven M. Donn, MD, FAAP Office of Child Care, DC American Academy of Pediatrics, Committee on Medical Robert Gilchick, MD, MPH Liability and Risk Management, IL Los Angeles County Department of Public Health, Child Elaine Donoghue, MD, FAAP and Adolescent Health Program and Policy, CA American Academy of Pediatrics, Committee on Early Frances Page Glascoe, PhD Childhood, Adoption, and Dependent Care, IL American Academy of Pediatrics, Section on American Academy of Pediatrics, Section on Early Developmental and Behavioral Pediatrics, IL Education and Child Care, IL Mary P. Glode, MD, FAAP Adrienne Dorf, MPH, RD, CD American Academy of Pediatrics, Committee on Infectious Public Health - Seattle and King County, WA Diseases, IL Jacqueline Douge, MD, FAAP American Academy of Pediatrics, Council on Communication and Media, IL Benard Dreyer, MD, FAAP American Academy of Pediatrics, Council on Communication and Media, IL

Eloisa Gonzalez, MD, MPH xiii Los Angeles County Department of Public Health, Physical Activity and Cardiovascular Health Acknowledgments Program, CA Rosario Gonzalez, MD, FAAP Chanda Nicole Holsey, DrPH, MPH, AE-C American Academy of Pediatrics, Council on San Diego State University, Graduate School of Public Communication and Media, IL Health, CA David Gremse, MD, FAAP Sarah Hoover, MEd Gastroenterology, Hepatology, and Therapeutics, AL University of Colorado School of Medicine, Joseph Hagan, MD, FAAP JFK Partners, CO American Academy of Pediatrics, Bright Futures, IL Gail Houle, PhD Michelle Hahn, RN, PHN, BSN U.S. Department of Education, Early Childhood Healthy Child Care Minnesota, MN Programs Office of Special Education, DC Cheryl Hall, RN, BSN, CCHC Bob Howard Maryland State Department of Education, U.S. Division of Child Day Care Licensing and Regulatory Administration for Children and Families, Office Services, SC of Child Care, MD Julian Hsin-Cheng Wan, MD, FAAP Lawrence D. Hammer, MD, FAAP American Academy of Pediatrics, Section on Urology, IL American Academy of Pediatrics, Committee on Practice Moniquin Huggins in Ambulatory Medicine and Immunizations, IL U.S. Administration for Children and Families, Gil Handal, MD, FAAP Office of Child Care, DC American Academy of Pediatrics, Council on Anne Hulick, RN, MS, JD Community Pediatrics, IL Connecticut Nurses Association, CT Patty Hannah Tammy Hurley KinderCare Learning Centers, OH American Academy of Pediatrics, Section on Child Abuse Jodi Hardin, MPH and Neglect, IL Early Childhood Systems, CO Mary Anne Jackson, MD, FAAP Thelma Harms, PhD American Academy of Pediatrics, Committee on Infectious University of North Carolina-Chapel Hill, NC Diseases, IL Sandra Hassink, MD, FAAP Paula Deaun Jackson, MSN, CPNP, CCHC Pediatric Nurse American Academy of Pediatrics, Obesity Initiatives, IL Practitioner and Child Care Health Consultant, PA Leo Heitlinger, MD, FAAP Paula James Gastroenterology, Hepatology, and Therapeutics, PA Contra Costa Child Care Council, Child Health and James Henry Nutrition Program, CA U.S. Administration for Children and Families, Laura Jana, MD, FAAP Office of Child Care, DC American Academy of Pediatrics, Section on Early Mary Ann Heryer, MA Education and Child Care, IL University of Missouri at Kansas City, Institute of Human Renee Jarrett, MPH Development, MO American Academy of Pediatrics, Section on Early Karen Heying Education and Child Care, IL National Infant and Toddler Child Care Initiative, Zero to Paula Jaudes, MD, FAAP Three, DC American Academy of Pediatrics, Committee on Early Pam High, MD, MS, FAAP Childhood, Adoption, and Dependent Care, IL American Academy of Pediatrics, Committee on Early Lowest Jefferson, REHS/RS, MS, PHA Childhood Adoption and Dependent Care, IL Department of Health, WA Mark Jenkerson Missouri Department of Health and Senior Services, MO Lynn Jezyk U.S. Administration for Children and Families, Office of Child Care Licensing, DC

xiv Acknowledgments Veronnie Faye Jones, MD, FAAP Linda L. Lindeke, PhD, RN, CNP American Academy of Pediatrics, Committee on Early American Academy of Pediatrics, Medical Home Childhood, Adoption, and Dependent Care, IL Initiatives, IL Mark Kastenbaum Michelle Macias, MD, FAAP Department of Early Learning, WA American Academy of Pediatrics, Section on Harry L. Keyserling, MD, FAAP Developmental and Behavioral Pediatrics, IL American Academy of Pediatrics, Committee on Karin A. Mack, PhD Infectious Diseases, IL Centers for Disease Control and Prevention, GA Matthew Edward Knight, MD, FAAP Maxine M. Maloney American Academy of Pediatrics, Section on Clinical U.S. Administration for Children and Families, Pharmacology and Therapeutics/Committee on Drugs, IL Office of Child Care, DC Pauline Koch Barry Marx, MD, FAAP National Association for Regulatory Administration, DE U.S. Office of Head Start, DC Bonnie Kozial Bryce McClamroch American Academy of Pediatrics, Section/Committee on Massachusetts Early Childhood Comprehensive Systems, Injury, Violence, and Poison Prevention, IL State Department of Public Health, MA Steven Krug, MD, FAAP Janet R. McGinnis American Academy of Pediatrics, Disaster Preparedness North Carolina Department of Public Instruction, Advisory Council, IL Office of Early Learning, NC Mae Kyono, MD, FAAP Ellen McGuffey, CPNP American Academy of Pediatrics, Section on Early National Association of Pediatric Nurse Practitioners , NJ Education and Child Care, IL Kandi Mell Miriam Labbok, MD, MPH, FACPM, FABM, IBCLC Juvenile Products Manufacturers Association, NJ University of North Carolina, Carolina Breastfeeding Shelly Meyer, RN, BSN, PHN, CCHC Institute, NC Missoula City-County Health Department, Child Care Mary LaCasse, MS, EdD Resources, MT Department of Mental Health and Hygiene, MD Joan Younger Meek, MD, MS, RD, IBCLC James Laughlin, MD, FAAP Orlando Health, Arnold Palmer Hospital for Children, American Academy of Pediatrics, Committee on Practice Florida State University College of Medicine, FL in Ambulatory Medicine and Immunizations, IL Angela Mickalide, PhD, CHES Sharis LeMay Home Safety Council, DC Alabama Department of Public Health, Healthy Child Care Jonathan D. Midgett, PhD Alabama, AL U.S. Consumer Product Safety Commission, MD Vickie Leonard, RN, FNP, PhD Mark Minier, MD, FAAP University of California San Francisco, California American Academy of Pediatrics, Council on School Childcare Health Program, CA Health, IL Herschel Lessin, MD, FAAP Mary Beth Miotto, MD, FAAP American Academy of Pediatrics, Committee on Practice American Academy of Pediatrics, Council on in Ambulatory Medicine and Immunizations, IL Communication and Media, IL Michael Leu, MD, MS, MHS, FAAP Antoinette Montgomery, BA American Academy of Pediatrics, Council on Parent, VA Communication and Media, IL Rachel Moon, MD, FAAP Katy Levenhagen, MS, RD American Academy of Pediatrics, Task Force on Infant Snohomish Health District, WA Positioning and SIDS, IL

Len Morrissey xv ASTM International, PA Jane Morton, MD, FAAP Acknowledgments American Academy of Pediatrics, Section on Breastfeeding, IL Dawn Ramsburg, PhD Robert D. Murray, MD, FAAP U.S. Administration for Children and Families, Office of American Academy of Pediatrics, Council on School Child Care, DC Health, IL Chadwick Rodgers, MD, FAAP Scott Needle, MD, FAAP American Academy of Pediatrics, Committee on Practice American Academy of Pediatrics, Disaster Preparedness in Ambulatory Medicine and Immunizations, IL Advisory Council, IL Judy Romano, MD, FAAP Sara Benjamin Neelon, PhD, MPH, RD American Academy of Pediatrics, Section on Early Duke University Medical Center, Duke Global Health Education and Child Care, IL Institute, NC Kate Roper, EdM Jeffrey Okamoto, MD, FAAP, FAACPDM Massachusetts Early Childhood Comprehensive Systems, American Academy of Pediatrics, Council on School State Department of Public Health, MA Health, IL Bobbie Rose, RN Isaac Okehie University of California San Francisco, California U.S. Administration for Children and Families, Childcare Health Program, CA Office of Child Care, DC Lori Saltzman Stephanie Olmore U.S. Consumer Products Safety Commission, MD National Association for the Education of Teresa Sakraida, PhD, MS, MSEd, BSN Young Children, DC University of Colorado, College of Nursing, CO John Pascoe, MD, MPH, FAAP Kim Sandor, RN, MSN, FNP American Academy of Pediatrics, Committee on Connecticut Nurses Association, CT Psychosocial Aspects of Child and Family Health, IL Karen Savoie, RDH, BS Shana Patterson, RD Colorado Area Health Education Center System, Cavity Colorado Physical Activity and Nutrition Program, CO Free at Three, CO Jerome A. Paulson, MD, FAAP Barbara Sawyer American Academy of Pediatrics, Committee on National Association for Family Child Care, CO Environmental Health, IL Beverly Schmalzried Kathy Penfold, MSN, RN National Association of Child Care Resource and Referral Department of Health and Human Services, MO Agencies, VA Leatha Perez-Chun, MS David J. Schonfeld, MD, FAAP U.S. Administration for Children and Families, American Academy of Pediatrics, Disaster Preparedness Office of Child Care, DC Advisory Council, IL Christine Perreault, RN, MHA Gordon E. Schutze, MD, FAAP The Children’s Hospital, CO American Academy of Pediatrics, Committee on Infectious Lauren Pfeiffer Diseases, IL Juvenile Products Manufacturers Association, NJ Lynne Shulster, PhD Lisa Albers Prock, MD, MPH Centers for Disease Control and Prevention, GA American Academy of Pediatrics, Section on Adoption Steve Shuman and Foster Care, IL Consultant, CA Susan K. Purcell, BS, MA Benjamin S. Siegel, MD, FAAP Grandparent, CO American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health, IL Geoffrey Simon, MD, FAAP American Academy of Pediatrics, Committee on Practice in Ambulatory Medicine and Immunizations, IL

xvi Grace Whitney, PhD, MPA Connecticut Head Start Collaboration Office, CT Acknowledgments Karen Cachevki Williams, PhD University of Wyoming, Department of Family and Heather Smith Consumer Sciences, WY Parent, MO David Willis, MD, FAAP Linda J. Smith, BSE, FACCE, IBCLC, FILCA American Academy of Pediatrics, Section on Early Bright Future Lactation Resource Centre, OH Education and Child Care, IL Karen Sokal-Gutierrez, MD, MPH, FAAP UCB-UCSF Cindy Young, MPH, RD, CLE Joint Medical Program, CA County of Los Angeles Department of Public Health, CA Robin Stanton, MA, RD, LD Oregon Public Health Division, Adolescent Health Section, OR Brooke Stebbins Healthy Child Care New Hampshire, Department of Public Health Services, NH Kathleen M. Stiles, MA Colorado Office of Professional Development, CO Justine Strickland Georgia Department of Early Care and Learning, Child Care Policy, GA Jeanine Swenson, MD, FAAP American Academy of Pediatrics, Council on Communication and Media, IL Barbara Thompson U.S. Department of Defense, Office of Family Policy/ Children and Youth, VA Lynne E. Torpy, RD Colorado Department of Public Health and Environment, Colorado Child and Adult Care Food Program, CO Michael Trautman, MD, FAAP American Academy of Pediatrics, Section on Transport Medicine, IL Patricia A. Treadwell, MD, FAAP American Academy of Pediatrics, Section on Dermatology, IL Mari Uehara, MD University of Hawaii at Manoa, John A. Burns School of Medicine, Department of Pediatrics, HI Taara Vedvik Parent, CO Darlene Watford U.S. Environmental Protection Agency, Office of Pollution Prevention and Toxics, DC Holly E. Wells American Association of Poison Control Centers, VA Lani Wheeler, MD, FAAP American Academy of Pediatrics, Council on School Health, IL

Introduction xvii Every day millions of children attend early care and educa- Standards; Guidelines for Early Care and Education tion programs. It is critical that they have the opportunity to Programs. 4th ed. Itasca, IL: American Academy of grow and learn in healthy and safe environments with Pediatrics; 2019 caring and professional caregivers/teachers. Following health and safety best practices is an important way to History provide quality early care and education for young children. In 1992, the American Public Health Association (APHA) The American Academy of Pediatrics (AAP), the American and the American Academy of Pediatrics (AAP) jointly Public Health Association (APHA), and the National published Caring for Our Children: National Health and Resource Center for Health and Safety in Child Care and Safety Performance Standards; Guidelines for Out-of-Home Early Education (NRC) are pleased to release the fourth Child Care Programs (1). The publication was the product of edition of Caring for Our Children: National Health and a five year national project funded by the U.S. Department Safety Performance Standards; Guidelines for Early Care and of Health and Human Services, Health Resources and Education Programs. These national standards represent the Services Administration, Maternal and Child Health best evidence, expertise, and experience in the country on Bureau (MCHB). This comprehensive set of health and quality health and safety practices and policies that should safety standards was a response to many years of effort by be followed in today’s early care and education settings. advocates for quality child care. In 1976, Aronson and Pizzo recommended development and use of national Caring for Our Children is an innovative, continually health and safety standards as part of a report to Congress updated set of standards for early care and education in association with the Federal Interagency Day Care programs. The most up-to-date version of the standards Requirements (FIDCR) Appropriateness Study (2). In the may be accessed at www.nrckids.org/CFOC. years that followed, experts repeatedly reaffirmed the need for these standards. For example, while the work to prepare The third print edition, the 2011 publication, was the result Caring for Our Children was underway, the National of an extensive process that benefited from the contribu- Research Council’s report, Who Cares for America’s tions of 86 technical experts in the field of health and safety Children? Child Care Policy for the 1990s, called for uniform in early care and education. (The history of past revisions national child care standards (3). Subsequently a second appears in the following section.) Since the publication of edition of Caring for Our Children was published in 2002 the third edition, the standards are continually reviewed by addressing new knowledge generated by increasing research the AAP, APHA, and NRC, with new and updated stan- into health and safety in early care and education dards posted online as they become available, year-round. programs. The increased use of the standards both in prac- tical onsite applications and in research documents the Many users of the Caring for Our Children standards like to value of the standards and validates the importance of have a print reference on-hand, and because the third keeping the standards up-to-date (4). Caring for Our edition preceded the online updates, the AAP, APHA, and Children has been a yardstick for measuring what has been NRC are publishing new print editions that reflect updated done and what still needs to be done, as well as a technical standards. The fourth print edition of Caring for Our manual on how to do it. Children builds upon the foundation of the first three editions and includes online updates since 2011. Third Edition Review Process The Maternal and Child Health Bureau’s continuing fund- Important note about edition terminology: The online ing since 1995 of a National Resource Center for Health and version of Caring for Our Children no longer will be labeled Safety in Child Care and Early Education (NRC) at the with “edition” terminology. It is the latest version, updated University of Colorado, College of Nursing supported the as new or revised standards are posted. The suggested cita- work to coordinate the development of the second and tion for the online standards at www.nrckids.org/CFOC is third editions. as follows: The standards in the third edition of Caring for Our Children were revised by eighty-six technical experts. American Academy of Pediatrics, American Public Health Critical reviews and recommendations were then provided Association, National Resource Center for Health and by 184 stakeholder individuals - those representing Safety in Child Care and Early Education. Caring for Our consumers of the information and organizations represent- Children: National Health and Safety Performance ing major constituents of the early care and education Standards; Guidelines for Early Care and Education community. Caregivers/teachers, parents/guardians, fami- Programs. http://cfoc.nrckids.org. Updated <date>. lies, health care professionals, safety specialists, early child- Accessed <date> hood educators, early care and education advocates, regulators, and federal, military, and state agencies all Print publications will be labeled by edition numbers to brought their expertise and experience to the revision identify the latest print edition for readers, programs, book- process. A complete listing of the Steering Committee, Lead stores, and libraries. The suggested citation for this fourth Organizations’ reviewers, Technical Panel members, and print edition is as follows: Stakeholder contributors appears on the Acknowledgment pages. American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education. Caring for Our Children: National Health and Safety Performance

xviii Introduction The process of revising the standards and the consensus 2. The NRC proposes revisions to individual standards building was organized in stages: based on current research-based evidence. 1. Technical panel chairs recruited members to their 3. The NRC conducts the following steps to revise stan- panels and reviewed the standards from the second dards identified above: edition. Using the best evidence available (peer reviewed • Develops timeline for review scientific studies, published reports, and best practice • Identifies and invites potential subject matter experts information) they removed standards that were no (SMEs) based on content area to serve as reviewers of longer applicable or out-of-date, identified those that the proposed changes were still applicable (in their original or in a revised • A ssigns SMEs to revision subgroups based on form), and formulated many new standards that were specific area of expertise deemed appropriate and necessary. • F acilitates communication with the SMEs through- out the revision process 2. Telephone conference calls were convened among tech- • Assesses the quality of SME feedback based on nical panel chairs to bring consensus on standards that current research/best practice bridge several technical areas. • Submits final SME-approved revisions to the NRC Expert Advisory Group (EAG) 3. A draft of these revised standards was sent to a national • I ncorporates EAG feedback and prepares the revised and state constituency of stakeholders for their standards for copyediting by the AAP. comments and suggestions. • Sends the copyedited version of standards to the NCECHW Steering Committee for final review 4. This feedback was subsequently reviewed and consid- • I ncorporates final revisions into the searchable ered by the technical panels and a decision was made to CFOC database further revise or not to revise a standard. It should be • C ommunicates with the NCECHW and the AAP to noted that the national review called attention to many disseminate information on revised standards important points of view and new information for addi- tional discussion and debate. Requirements of Other Organizations We recognize that many organizations have requirements 5. The edited standards were then sent to review teams of and recommendations that apply to out-of home early care the AAP, the APHA and the MCHB. Final copy was and education. For example, the National Association for approved by the Steering Committee representing the the Education of Young Children (NAEYC) publishes four organizations (AAP, APHA, NRC and MCHB). requirements for developmentally appropriate practice and accreditation of child care centers; Head Start follows In projects of this scope and magnitude, the end product is Performance Standards; the AAP has many standards only as good as the persons who participate in the effort. It related to child health; the U.S. Department of Defense has is hard to enumerate in this introduction the countless standards for military child care; the Office of Child Care hours of dedication and effort from contributors and (OCC) produces health and safety standards for tribal child reviewers. The project owes each of them a huge debt of care; the National Fire Protection Association has stan- gratitude. Their reward will come when high-quality early dards for fire safety in child care settings. The Office of care and education services become available to all children Child Care administers the Child Care and Development and their families! Fund (CCDF) which provides funds to states, territories, and tribes to assist low-income families, families receiving CFOC Standard Revision Process temporary public assistance, and those transitioning from In collaboration with the National Center for Early public assistance in obtaining child care so that they can Childhood Health and Wellness (NCECHW), the NRC work or attend training/education. Caregivers/teachers updates CFOC Standards using the following process: serving children funded by CCDF must meet basic health and safety requirements set by states and tribes. All of these 1. The NRC continually monitors and prioritizes stan- are valuable resources, as are many excellent state publica- dards for revision based on the following criteria: tions. By addressing health and safety as an integrated • I mpact on child and/or staff morbidity/mortality component of early care and education, contributors to • P ublication of new/updated science-based evidence Caring for Our Children have made every effort to ensure or best practices that necessitate a standard change that these standards are consistent with and complement • A ssessment of new/updated publications, require- other child care requirements and recommendations. ments, or applicable policy statements that are related Continuing Improvement to CFOC standards (eg, the AAP Red Book, Standards are never static. Each year the knowledge base Managing Infectious Diseases in Child Care and increases, and new scientific findings become available. Schools, Child and Adult Care Food Programs) New areas of concern and interest arise. These standards • Analysis of relationship to the Child Care will assist individuals and organizations who are involved Development Block Grant health and safety priority in the continuing work of standards improvement at every areas level: in early care and education practice, in regulatory • Receipt and analysis of nominations from subject matter experts and other stakeholders • Contact from stakeholders via direct communication with the NRC or via the NCECHW Info line • Inclusion in CFOC Basics

xix Introduction administration, in research in early childhood systems together should be encouraged. Daily communication, building, in academic curricula, and in the professional combined with at least yearly conferences between performance of the relevant disciplines. families and the principal caregiver/teacher, should Each of these areas affects the others in the ongoing process occur. Communication with families should take of improving the way we meet the needs of children. place through a variety of means and ensure all Possibly the most important use of these standards will be families, regardless of language, literacy level, or to raise the level of understanding about what those needs special needs, receive all of the communication. are, and to contribute to a greater willingness to commit 5. The nurturing of a child’s development is based on more resources to achieve quality early care and education knowledge of the child’s general health, growth and where children can grow and develop in a healthy and safe development, learning style, and unique characteristics. environment. This nurturing enhances the enjoyment of both child and parent/guardian as maturation and adaptation take References place. As shown by studies of early brain development, trustworthy relationships with a small number of adults 1. American Public Health Association, American Academy of Pediatrics. and an environment conducive to bonding and learning 1992. Caring for our children. National health and safety performance are essential to the healthy development of children. standards: Guidelines for out-of-home child care programs. Washington, DC: Staff selection, training, and support should be directed APHA. to the following goals: a. Promoting continuity of affective relationships; 2. USDHEW, Office of the Assistant Secretary for Planning and Evaluation. b. Encouraging staff capacity for identification with 1977. Policy issues in day care: Summaries of 21 papers, 109-15. and empathy for the child; 3. National Research Council, National Academy of Sciences. 1990. Who c. Emphasizing an attitude of involvement as an adult Cares for America’s Children? Child Care Policy in the 1990s. Washington, DC: National Academy Press. in the children’s play without dominating the activity; 4. Crowley, A. A., J. Kulikowich. 2009. Impact of training on child care health d. Being sensitive to cultural differences; and consultant knowledge and practice. Ped Nurs 35:93- 100. e. Being sensitive to stressors in the home environment. Guiding Principles 6. Children with special health care needs encompass those who have or are at increased risk for a chronic The following are the guiding principles used in writing physical, developmental, behavioral, or emotional these standards: condition and who also require health and related 1. The health and safety of all children in early care and services of a type or amount beyond that generally required by children. This includes children who have education settings is essential. The child care setting intermittent and continuous needs in all aspects of offers many opportunities for incorporating health and health. No child with special health care needs should safety education and life skills into everyday activities. be denied access to child care because of his/her disabil- Health education for children is an investment in a ity(ies), unless one of the four reasons for denying care lifetime of good health practices and contributes to a exists: level of care required; physical limitations of the healthier childhood and adult life. Modeling of good site; limited resources in the community, or unavailabil- health habits, such as healthy eating and physical activ- ity of specialized, trained staff. Whenever possible, chil- ity, by all staff in indoor and outdoor learning/play envi- dren with special health care needs should be cared for ronments, is the most effective method of health and provided services in settings including children education for young children. without special health care needs. 2. Child care for infants, young children, and school-age 7. Developmental programs and care should be based on a children is anchored in a respect for the developmental child’s functional status, and the child’s needs should be needs, characteristics, and cultures of the children and described in behavioral or functional terms. Children their families; it recognizes the unique qualities of each with special needs should have a comprehensive inter- individual and the importance of early brain develop- disciplinary or multidisciplinary evaluation if deter- ment in young children and in particular children birth mined necessary. to three years of age. 8. Written policies and procedures should identify facility 3. To the extent possible, indoor and outdoor learning/play requirements and persons and/or entities responsible for activities should be geared to the needs of all children. implementing such requirements including clear guid- 4. The relationship between parent/guardian/family and ance as to when the policy does or does not apply. child is of utmost importance for the child’s current 9. Whenever possible, written information about facility and future development and should be supported by policies and procedures should be provided in the native caregivers/teachers. Those who care for children on a language of parents/guardians, in a form appropriate for daily basis have abundant, rich observational informa- parents/guardians who are visually impaired, and also tion to share, as well as offer instruction and best prac- in an appropriate literacy/readability level for parents/ tices to parents/guardians. Parents/guardians should share with caregivers/teachers the unique behavioral, medical and developmental aspects of their children. Ideally, parents/guardians can benefit from time spent in the child’s caregiving environment and time for the child, parent/guardian and caregiver/teacher to be

xx Introduction guardians who may have difficulty with reading. How- and information about physical and mental health ever, processes should never become more important problems in the children for whom the staff care. If than the care and education of children. staff turnover is high, training on health and safety 10. Confidentiality of records and shared verbal informa- related subjects should be repeated frequently. tion must be maintained to protect the child, family, 18. Maintaining a healthy, toxic-free physical environment and staff. The information obtained at early care and positively impacts the health and well-being of the chil- education programs should be used to plan for a child’s dren and staff served. Environmental responsibility is safe and appropriate participation. Parents/guardians an important concept to teach and practice daily. must be assured of the vigilance of the staff in protect- ing such information. When sharing information, such Advice to the User as referrals to services that would benefit the child, attainment of parental consent to share information The intended users of the standards include all who care for must be obtained in writing. It is also important to young children in early care and education settings and document key communication (verbal and written) who work toward the goal of ensuring that all children between staff and parents/guardians. from day one have the opportunity to grow and develop 11. The facility’s nutrition activities complement and sup- appropriately, to thrive in healthy and safe environments, plement those of home and community. Food provided and to develop healthy and safe behaviors that will last a in a child care setting should help to meet the child’s lifetime. daily nutritional needs while reflecting individual, All of the standards are attainable. Some may have al- ready cultural, religious, and philosophical differences and been attained in individual settings; others can be imple- providing an opportunity for learning. Facilities can mented over time. For example, any organization that contribute to overall child development goals by helping funds early care and education should, in our opinion, the child and family understand the relationship of adopt these standards as funding requirements and should nutrition to health, the importance of positive child set a payment rate that covers the cost of meeting them. feeding practices, the factors that influence food prac- Recommended Use tices, and the variety of ways to meet nutritional needs. • Caregivers/Teachers can use the standards to develop All children should engage in daily physical activity in a safe environment that promotes developmentally and implement sound practices, policies, and staff train- appropriate movement skills and a healthy lifestyle. ing to ensure that their program is healthy, safe, age- 12. The expression of, and exposure to, cultural and ethnic appropriate for all children in their care. diversity enriches the experience of all children, fami- • Early Childhood Systems can build integrated health and lies, and staff. Planning for cultural diversity through safety components into their systems that promote the provision of books, toys, activities and pictures and healthy lifestyles for all children. working with language differences should be • Families have sound information from the standards to encouraged. select quality programs and/or evaluate their child’s cur- 13. Community resources should be identified and infor- rent early care and education program. They can work in mation about their services, eligibility requirements, partnership with caregivers/teachers in promoting and hours of operation should be available to the fami- healthy and safe behavior and practice for their child and lies and utilized as much as possible to provide consulta- family. Families may also want to incorporate many of tion and related services as needed. these healthy and safe practices at home. 14. Programs should continuously strive for improvement • Health Care Professionals can assist families and consult in health and safety processes and policies for the with caregivers/teachers by using the standards as guid- improvement of the overall quality of care to children. ance on what makes a healthy and safe and age ap- 15. An emergency or disaster can happen at any time. propriate environment that encourages children’s Programs should be prepared for and equipped to development of healthy and safe habits. Consultants may respond to any type of emergency or disaster in order to use the standards to develop guidance materials to share ensure the safety and well-being of staff and children, with both caregivers/teachers and parents/guardians. and communicate effectively with parents/guardians. • Licensing Professionals/Regulators can use the 16. Young children should receive optimal medical care evidence-based rationale to develop or improve regula- in a family-centered medical home. Cooperation and tions that require a healthy and safe learning environment collaboration between the medical home and caregivers/ at a critical time in a child’s life and develop lifelong teachers lead to more successful outcomes. healthy behaviors in children. 17. Education is an ongoing, lifelong process and child care • National Private Organizations that will update stan- staff need continuous education about health and safety dards for accreditation or guidance purposes for a special related subject matter. Staff members who are current discipline can draw on the new work and rationales of the on health related topics are better able to prevent, recog- third edition just as Caring for Our Children’s expert nize, and correct health and safety problems. Subjects to contributors drew upon the expertise of these organiza- be covered include the rationale for health promotion tions in developing the new standards.

xxi Introduction • Policy-Makers are equipped with sound science to meet required to enter an early care and education program. The emerging challenges to children’s development of lifelong components of the regulation will vary by topic addressed healthy behaviors and lifestyles. as well as by area of jurisdiction (e.g., municipality or state). Because a regulation prescribes a practice that every agency • State Departments of Education (DOEs) and local or program must comply with, it usually is the minimum or school administrations can use the standards to guide the floor below which no agency or program should the writing of standards for school operated child care operate. and preschool facilities, and this guidance will help prin- cipals to implement good practice in early care and educa- Types of Facilities tion programs. Child care offers developmentally appropriate care and education for young children who receive care in out-of- • States and localities who fund subsidized care and home settings (not their own home). Several types of facili- services for income-eligible families can use the stan- ties are covered by the general definition of child care and dards to determine the level and quality of service to be education. Although there are generally understood defini- expected. tions for child care facilities, states vary greatly in their legal definitions, and some overlap and confusion of terms still • University/College Faculty of early childhood education exists in defining child care facilities. Although the needs of programs can instill healthy practices in their students to children do not differ from one setting to another, the model and use with young children upon entering the declared intent of different types of facilities may differ. early childhood workplace and transfer the latest research Facilities that operate part-day, in the evening, during the into their education. traditional work day and work week, or during a specific part of the year may call themselves by different names. Definitions These standards recognize that while children’s needs do We have defined many terms in the Glossary. Some of these not differ in any of these settings, the way children’s needs are so important to the user that we are emphasizing them are met may differ by whether the facility is in a residence here as well. or a non-residence and whether the child is expected to have a longer or only a very short-term arrangement for Types of Requirements care. A standard is a statement that defines a goal of practice. It differs from a recommendation or a guideline in that it A Small family child care home provides care and carries greater incentive for universal compliance. It differs education of one to six children, including the care- from a regulation in that compliance is not necessarily giver’s/teacher’s own children in the home of the care- required for legal operation. It usually is legitimized or vali- giver/teacher. Family members or other helpers may be dated based on scientific or epidemiological data, or when involved in assisting the caregiver/teacher, but often, this evidence is lacking, it represents the widely agreed there is only one caregiver/teacher present at any one upon, state-of-the-art, high-quality level of practice. time. The agency, program, or health practitioner that does not A Large family child care home provides care and meet the standard may incur disapproval or sanction from education of seven to twelve children, including the within or without the organization. Thus, a standard is the caregiver’s/teacher’s own children in the home of the strongest criterion for practice set by a health organization caregiver/teacher, with one or more qualified adult or association. For example, many manufacturers advertise assistants to meet child: staff ratio requirements. that their products meet ASTM standards as evidence to A Center is a facility that provides care and education the consumer of safety, while those products that cannot of any number of children in a nonresidentialsetting, meet the standards are sold without such labeling to undis- or thirteen or more children in any setting if the facil- cerning purchasers. ity is open on a regular basis. A guideline is a statement of advice or instruction pertain- For definitions of other special types of child care – ing to practice. It originates in an organization with drop-in, school-age, for the mildly ill – see Standard acknowledged professional standing. Although it may be 10.4.1.1: Uniform Categories and Definitions. unsolicited, a guideline often is developed in response to a The standards are to guide all the types of programs listed stated request or perceived need for such advice or instruc- above. tion. For example, the American Academy of Pediatrics (AAP) has a guideline for the elements necessary to make Age Groups the diagnosis of Attention-Deficit/Hyperactivity Disorder. Although we recognize that designated age groups and A regulation takes a previous standard or guideline and developmental levels must be used flexibly to meet the makes it a requirement for legal operation. A regulation needs of individual children, many of the standards are originates in an agency with either governmental or official applicable to specific age and developmental categories. The authority and has the power of law. Such authority is following categories are used in Caring for Our Children. usually accompanied by an enforcement activity. Examples of regulations are: State regulations pertaining to child:staff ratios in a licensed child care center, and immunizations

xxii Introduction Functional Definition • Parents/guardians—for those adults legally responsible Age (By Developmental Level) for a child’s welfare; Infant Birth-12 Birth to ambulation • Primary care provider—for the licensed health profes- months sional, to name a few: pediatrician, pediatric nurse practitioner, family physician, who has responsibility Toddler 13-35 Ambulation to accomplishment of for the health supervision of an individual child; months self-care routines such as use of the toilet • Child abuse and neglectf­or all forms of child Pre-schooler 36-59 From achievement of self-care routines to maltreatment; months entry into regular school • Children with special health care needs—to encompass School-Age 5-12 Entry into regular school, including children with special needs, children with disabilities, Child years kindergarten through 6th grade children with chronic illnesses, etc. Format and Language Relationship of the Standards to Laws, Ordinances, Each standard unit has at least three components: the and Regulations Standard itself, the Rationale, and the applicable Type of The members of the technical panels could not annotate Facility. Most standards also have a Comment section, a the standards to address local laws, ordinances, and regula- Related Standards section and a References section. The tions. Many of these legal requirements have a different reader will find the scientific reference and/or epidemiolog- intent from that addressed by the standards. Users of this ical evidence for the standard in the rationale section of document should check legal requirements that may apply each standard. The Rationale explains the intent of and the to facilities in particular locales. need for the standard. Where no scientific evidence for a In general, child care is regulated by at least three different standard is available, the standard is based on the best legal entities or jurisdictions. The first is the building code available professional consensus. If such a professional jurisdiction. Building inspectors enforce building codes to consensus has been published, that reference is cited. The protect life and property in all buildings, not just child care Rationale both justifies the standard and serves as an facilities. Some of the standards should be written into state educational tool. The Comments section includes other or local building codes, rather than into the licensing explanatory information relevant to the standard, such as requirements. applicability of the standard and, in some cases, suggested The second major legal entity that regulates child care is the ways to measure compliance with the standard. Although health system. A number of different codes are intended to this document reflects the best information available at the prevent the spread of disease in restaurants, hospitals, and time of publication, as was the case with the first and other institutions where hazards and risky practices might second editions, this third edition will need updating from exist. Many of these health codes are not specific to child time to time to reflect changes in knowledge affecting early care; however, specific provisions for child care might be care and education. found in a health code. Some of the provisions in the Caring for Our Children standards and appendixes are standards might be appropriate for incorporation into a available at no cost online at http://nrckids.org. It is also health code. available in print format for a fee from the American The third legal jurisdiction applied to child care is child Academy of Pediatrics (AAP) and the American Public care licensing. Usually, before a child care operator receives Health Association(APHA). a license, the operator must obtain approvals from health Standards have been written to be measurable and enforce- and building safety authorities. Sometimes a standard is able. Measurability is important for performance standards not included as a child care licensing requirement because in a contractual relationship between a provider of service it is covered in another code. Sometimes, however, it is not and a funding source. Concrete and specific language helps covered in any code. Since children need full protection, caregivers/teachers and facilities put the standards into the issues addressed in this document should be addressed practice. Where a standard is difficult to measure, we have in some aspect of public policy, and consistently addressed provided guidance to make the requirement as specific as within a community. In an effective regulatory system, possible. Some standards required more technical terminol- different inspectors do not try to regulate the same thing. ogy (e.g., certain infectious diseases, plumbing and heating Advocates should decide which codes to review in making terminology). We encourage readers to seek interpretation sure that these standards are addressed appropriately in by appropriate specialists when needed. Where feasible, we their regulatory systems. Although the licensing require- have written the standards to be understood by readers ments are most usually affected, it may be more appropriate from a wide variety of backgrounds. to revise the health or building codes to include certain The Steering Committee agreed to consistent use of the standards, and it may be necessary to negotiate conflicts terms below to convey broader concepts instead of using among applicable codes. a multitude of different terms. The National Standards are for reference purposes only • Caregiver/teacher—for the early care and education/ and should not be used as a substitute for medical or legal consultation, nor be used to authorize actions beyond a child care professional that provides care and learning person’s licensing, training, or ability. opportunities to children—instead of child care provider, just caregiver or just teacher;

xxiii History of Caring for Our Children Standard Language Changes Since the 3rd Edition (Through July 2018) The Caring for Our Children (CFOC) standards listed in revisions, with the exception of those pending below, this document have had revisions made to the Standard appear in this fourth print edition. The pending standard language since the 2011 publication of the third print revisions and any future revisions may be found in the edition. Revisions are based on new or updated research/ CFOC online database (http://nrckids.org/CFOC) and are evidence, policy statements, and/or best practices. These designated by the Notes icon. Standard Number and Title (Listed Numerically) Date of Change 1.2.0.1 Staff Recruitment Pending at time of publication 1.2.0.2 Background Screening 5/2018 1.4.5.2 Child Abuse and Neglect Education 5/2018 1.5.0.2 Orientation of Substitutes 5/2018 1.6.0.2 Frequency of Child Care Health Consultant Visits 8/2013 2.1.1.1 Written Daily Activity Program and Statement of Principles 5/2018 2.1.1.2 Health, Nutrition, Physical Activity, and Safety Awareness 5/2018 2.1.2.1 Personal Caregiver/Teacher Relationships for Infants and Toddlers 5/2018 2.2.0.1 Methods of Supervision of Children Pending at time of publication 2.2.0.3 Screen Time/Digital Media Use 3/2012, 10/2017 2.2.0.9 Prohibited Caregiver/Teacher Behaviors 5/2018 2.3.1.2 Parent/Guardian Visits Pending at time of publication 2.4.1.1 Health and Safety Education Topics for Children 1/2017, 5/2018 2.4.1.2 Staff Modeling of Healthy and Safe Behavior and Health and Safety Education Activities 1/2017 2.4.2.1 Health and Safety Education Topics for Staff 1/2017 2.4.3.2 Parent/Guardian Education Plan 1/2017 3.1.3.1 Active Opportunities for Physical Activity 5/2018 3.1.3.2 Playing Outdoors 8/2013, 5/2018 3.1.3.3 Protection from Air Pollution While Children Are Outside 8/2016 3.1.3.4 Caregivers’/Teachers’Encouragement of Physical Activity 5/2018 3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction 12/2011, 12/2016 3.1.4.4 Scheduled Rest Periods and Sleep Arrangements 5/2018 3.1.5.1 Routine Oral Hygiene Activities 3/2016 3.1.5.2 Toothbrushes and Toothpaste 2/2013, 4/2013, 3/2016 3.2.1.1 Type of Diapers Worn 8/2017 3.2.1.4 Diaper Changing Procedure 1/2012, 7/2012, 5/2013, 8/2016 3.2.1.5 Procedure for Changing Children’s Soiled Underwear/Pull-Ups and Clothing 1/2012, 7/2012, 11/2013, 8/2016 3.2.2.1 Situations that Require Hand Hygiene 8/2016, 8/2017 3.2.2.2 Handwashing Procedure 8/2017 3.2.2.5 Hand Sanitizers 4/2016, 4/2017 3.4.1.1 Use of Tobacco, Electronic Cigarettes, Alcohol, and Drugs 1/2017 3.4.4.1 Recognizing and Reporting Suspected Child Abuse, Neglect and Exploitation 5/2018 3.4.4.2 Immunity for Reporters of Child Abuse and Neglect Pending at time of publication 3.4.4.3 Preventing and Identifying Shaken Baby Syndrome/Abusive Head Trauma 5/2018 3.4.4.4 Care of Children Who Have Been Abused/Neglected 3/2013; Pending at time of publication 3.4.4.5 Facility Layout to Reduce Risk of Child Abuse and Neglect Pending at time of publication 3.4.5.1 Sun Safety Including Sunscreen 8/2013 3.4.5.2 Insect Repellent and Protection from Vector-Borne Diseases 4/2017

xxiv History of Caring for Our Children Standard Language Changes Since the 3rd Edition (Through July 2018) Standard Number and Title (Listed Numerically) Date of Change 3.6.1.1 Inclusion/Exclusion/Dismissal of Children 4/2015, 8/2015, 4/2017 3.6.1.2 Staff Exclusion for Illness 4/2017 3.6.2.2 Space Requirements for Care of Children Who Are Ill 8/2017 3.6.2.10 Inclusion and Exclusion of Children from Facilities That Serve Children Who Are Ill 8/2017 4.2.0.1 Written Nutrition Plan 11/2017 4.2.0.2 Assessment and Planning of Nutrition for Individual Children 11/2017 4.2.0.3 Use of US Department of Agriculture Child and Adult Care Food Program Guidelines 11/2017 4.2.0.4 Categories of Foods 2/2012, 11/2017 4.2.0.5 Meal and Snack Patterns 11/2017 4.2.0.6 Availability of Drinking Water 11/2017 4.2.0.7 100% Fruit Juice 11/2017 4.2.0.8 Feeding Plans and Dietary Modifications 11/2017 4.2.0.9 Written Menus and Introduction of New Foods 11/2017 4.2.0.10 Care for Children with Food Allergies 11/2017 4.2.0.11 Ingestion of Substances that Do Not Provide Nutrition 8/2016, 11/2017 4.2.0.12 Vegetarian/Vegan Diets 11/2017 4.3.1.1 General Plan for Feeding Infants 5/2018 4.3.1.2 Feeding Infants on Cue by a Consistent Caregiver/Teacher 5/2018 4.3.1.3 Preparing, Feeding, and Storing Human Milk 8/2016 4.3.1.4 Feeding Human Milk to Another Mother’s Child 8/2017 4.3.1.5 Preparing, Feeding, and Storing Infant Formula 11/2013, 8/2016 4.3.1.6 Use of Soy-Based Formula and Soy Milk 5/2018 4.3.1.7 Feeding Cow’s Milk 5/2018 4.3.1.9 Warming Bottles and Infant Foods 11/2013, 8/2016, 5/2018 4.3.1.10 Cleaning and Sanitizing Equipment Used for Bottle Feeding 5/2018 4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants 5/2018 4.3.1.12 Feeding Age-Appropriate Solid Foods to Infants 5/2018 4.3.2.1 Meal and Snack Patterns for Toddlers and Preschoolers 5/2018 4.3.2.2 Serving Size for Toddlers and Preschoolers 5/2018 4.3.2.3 Encouraging Self-Feeding by Older Infants and Toddlers 5/2018 4.3.3.1 Meal and Snack Patterns for School-Age Children 5/2018 4.5.0.3 Activities that Are Incompatible with Eating 8/2016 4.7.0.2 Nutrition Education for Parents/Guardians 5/2018 4.9.0.13 Methods for Washing Dishes by Hand 8/2013 5.1.1.5 Environmental Audit of Site Location 8/2016 5.2.1.1 Ensuring Access to Fresh Air Indoors 8/2016 5.2.1.6 Ventilation to Control Odors 8/2016 5.2.6.1 Water Supply 5/2016 5.2.7.4 Containment of Soiled Diapers 8/2017 5.2.9.1 Use and Storage of Toxic Substances 1/2017 5.2.9.4 Radon Concentrations 5/2016 5.2.9.11 Chemicals Used to Control Odors 8/2016 5.2.9.12 Treatment of CCA Pressure-Treated Wood 8/2016 5.2.9.13 Testing for Lead 8/2015 5.2.9.15 Construction and Remodeling 5/2016 5.4.1.10 Handwashing Sinks 8/2017

xxv History of Caring for Our Children Standard Language Changes Since the 3rd Edition (Through July 2018) Standard Number and Title (Listed Numerically) Date of Change 5.4.5.1 Sleeping Equipment and Supplies 3/2017 5.5.0.5 Storage of Flammable Materials 8/2011 6.4.2.2 Helmets 3/2017 6.5.1.2 Qualifications for Drivers 1/2017 6.5.2.1 Drop-Off and Pick-Up 5/2016 7.3.1.1 Exclusion for Group A Streptococcal (GAS) Infections 8/2017 7.3.2.1 Immunization for Haemophilus Influenzae Type B (Hib) 8/2017 7.3.2.2 Informing Parents/Guardians of Haemophilus Influenzae Type B (Hib) Exposure 8/2017 7.3.11.1 Attendance of Children with Unspecified Respiratory Tract Infection 8/2017 7.4.0.1 Control of Enteric (Diarrheal) and Hepatitis A Virus (HAV) Infections 4/2017 7.4.0.2 Staff Education and Policies on Enteric (Diarrheal) and Hepatitis A Virus (HAV) Infections 4/2017 7.5.1.1 Conjunctivitis (Pinkeye) 3/2017 7.5.2.1 Enterovirus Infections 8/2017 7.5.8.1 Attendance of Children with Head Lice 8/2016 7.5.11.1 Attendance of Children with Scabies 8/2017 7.6.3.1 Attendance of Children with HIV 3/2017 7.7.1.1 Staff Education and Policies on Cytomegalovirus (CMV) 3/2017 9.2.3.1 Policies and Practices that Promote Physical Activity 8/2016, 5/2018 9.2.3.15 Policies Prohibiting Smoking, Tobacco, Alcohol, Illegal Drugs, and Toxic Substances 1/2017 9.4.1.11 Review and Accessibility of Injury and Illness Reports Pending at time of publication 10.3.3.2 Background Screening 5/2018 10.3.3.3 Licensing Agency Role in Communicating the Importance of Reporting Suspected Child Abuse Pending at time of publication 10.3.3.4 Licensing Agency Provision of Child Abuse Prevention Materials Pending at time of publication 10.3.5.3 Training of Licensing Agency Personnel about Child Abuse Pending at time of publication 10.4.3.3 Collection of Data on Illness or Harm to Children in Facilities Pending at time of publication Appendixes (Listed Alphabetically) Date of Change Appendix A: Signs and Symptoms Chart 1/2017 Appendix E: Child Care Staff Health Assessment 7/2018 Appendix G: Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger Updated Annually Last Update: 4/2018 Appendix H: Recommended Immunization Schedule for Adults Aged 19 Years or Older Updated Annually Last Update: 4/2018 Appendix I: Recommendations for Preventive Pediatric Health Care 7/2018 Appendix J: Selecting an Appropriate Sanitizer or Disinfectant 8/2011, 3/2013 Appendix II: Bike and Multi-sport Helmets: Quick-Fit Check 7/2018



1 CHAPTER Staffing



3 Chapter 1: Staffing 1.1 programs, this may be difficult in practice because the CHILD:STAFF RATIO, GROUP SIZE, caregiver/teacher is typically alone, and all of the children most likely will not sleep at the same time. In order to pro- AND MINIMUM AGE vide constant supervision during sleep, caregivers/teachers could consider discontinuing the practice of placing infant(s) 1.1.1 in a separate room for sleep, but instead placing the infant’s CHILD:STAFF RATIO AND GROUP SIZE crib in the area used by the other children so the caregiver/ teacher is able to supervise the sleeping infant(s) while caring 1.1.1.1 for the other children. Care must be taken so that placement Ratios for Small Family Child Care Homes of cribs in an area used by other children does not encroach upon the minimum usable floor space requirements. Infants The small family child care home caregiver/teacher do not require a dark and quiet place for sleep. Once they child:staff ratios should conform to the following table: become accustomed, infants are able to sleep without prob- lems in environments with light and noise. By placing infants If the small family child care home then the small family child care (as well as all children in care) on the main (ground) level of caregiver/teacher has no children home caregiver/teacher may the home for sleep and remaining on the same level as the under two years of age in care, have one to six children over children, the caregiver/teacher is more likely able to evacuate two years of age in care the children in less time; thus, increasing the odds of a suc- cessful evacuation in the event of a fire or another emergency. If the small family child care home then the small family child care Caregivers/teachers must also continually monitor other chil- caregiver/teacher has one child home caregiver/teacher may dren in this area so they are not climbing on or into the cribs. under two years of age in care, have one to three children over If the caregiver/teacher cannot remain in the same room as two years of age in care the infant(s) when the infant is sleeping, it is recommended that the caregiver/teacher should do visual checks every ten to If the small family child care home then the small family child care fifteen minutes to make sure the infant’s head is uncovered, caregiver/teacher has two children home caregiver/teacher may and assess the infant’s breathing, color, etc. Supervision is under two years of age in care, have no children over two years recommended for toddlers and preschoolers to ensure safety of age in care and prevent behaviors such as inappropriate touching or hurting other sleeping children from taking place. These The small family child care home caregiver’s/teacher’s own behaviors may go undetected if a caregiver/teacher is not children as well as any other children in the home tempo- present. If caregiver/teacher is not able to remain in the same rarily requiring supervision should be included in the room as the children, frequent visual checks are also recom- child:staff ratio. During nap time, at least one adult should mended for toddlers and preschoolers when they are sleeping. be physically present in the same room as the children. Each state has its own set of regulations that specify child: RATIONALE staff ratios. To view a particular state’s regulations, go to the Low child:staff ratios are most critical for infants and National Resource Center for Health and Safety in Child Care toddlers (birth to thirty-six months) (1). Infant and child and Early Education’s (NRC) Website: http://nrckids.org. development and caregiving quality improves when group Some states are setting limits on the number of school-age size and child:staff ratios are smaller (2). Improved verbal children that are allowed to be cared for in small family child interactions are correlated with lower child:staff ratios (3). care homes, e.g., two school-age children in addition to the Small ratios are very important for young children’s devel- maximum number allowed for infants/preschool children. opment (7). The recommended group size and child:staff No data are available to support using a different ratio where ratio allow three- to five-year-old children to have continu- school-age children are in family child care homes. Since ing adult support and guidance while encouraging inde- school-age children require focused caregiver/teacher time pendent, self-initiated play and other activities (4). and attention for supervision and adult-child interaction, this The National Fire Protection Association (NFPA) requires standard applies the same ratio to all children three-years-old in the NFPA 101: Life Safety Code that small family child and over. The family child care caregiver/teacher must be able care homes serve no more than two clients incapable of to have a positive relationship and provide guidance for each self-preservation (5). child in care. This standard is consistent with ratio require- Direct, warm social interaction between adults and chil- ments for toddlers in centers as described in Standard 1.1.1.2. dren is more common and more likely with lower child: staff ratios. Caregivers/teachers must be recognized as per- Unscheduled inspections encourage compliance with this forming a job for groups of children that parents/guardians standard. of twins, triplets, or quadruplets would rarely be left to han- dle alone. In child care, these children do not come from RELATED STANDARDS the same family and must learn a set of common rules that 1.1.1.3 Ratios for Facilities Serving Children with Special may differ from expectations in their own homes (6,8). Health Care Needs and Disabilities COMMENTS 1.1.2.1 Minimum Age to Enter Child Care It is best practice for the caregiver/teacher to remain in the same room as the infants when they are sleeping to provide constant supervision. However in small family child care

4 Caring for Our Children: National Health and Safety Performance Standards References During nap time for children ages thirty-one months and older, at least one adult should be physically present in the 1. Zero to Three. 2007. The infant-toddler set-aside of the Child Care and same room as the children and maximum group size must Development Block Grant: Improving quality child care for infants and be maintained. Children over thirty-one months of age can toddlers. Washington, DC: Zero to Three. http://main .zerotothree.org/site/ usually be organized to nap on a schedule, but infants and DocServer/Jan_07_Child_Care_Fact _Sheet.pdf. toddlers as individuals are more likely to nap on different schedules. In the event even one child is not sleeping the 2. National Institute of Child Health and Human Development (NICHD). child should be moved to another activity where appropriate 2006. The NICHD study of early child care and youth development: supervision is provided. Findings for children up to age 4 1/2 years. Rockville, MD: NICHD. If there is an emergency during nap time other adults should http://www.nichd.nih.gov/publications/pubs/upload/seccyd_051206.pdf. be on the same floor and should immediately assist the staff supervising sleeping children. The caregiver/teacher who 3. Goldstein, A., K. Hamm, R. Schumacher. Supporting growth and develop- is in the same room with the children should be able to ment of babies in child care: What does the research say? Washington, DC: summon these adults without leaving the children. Center for Law and Social Policy (CLASP); Zero to Three. http://main. When there are mixed age groups in the same room, the zerotothree.org/site/DocServer/ChildCareResearchBrief.pdf. child:staff ratio and group size should be consistent with the age of most of the children. When infants or toddlers are in 4. De Schipper, E. J., J. M. Riksen-Walraven, S. A. E. Geurts. 2006. Effects of the mixed age group, the child:staff ratio and group size for child-caregiver ratio on the interactions between caregivers and children in infants and toddlers should be maintained. In large family child-care centers: An experimental study. Child Devel. 77:861-74. child care homes with two or more caregivers/teachers car- ing for no more than twelve children, no more than three 5. National Fire Protection Association (NFPA). 2009. NFPA 101: Life safety children younger than two years of age should be in care. code. 2009 ed. Quincy, MA: NFPA. Children with special health care needs or who require more attention due to certain disabilities may require additional 6. Fiene, R. 2002. 13 indicators of quality child care: Research update. staff on-site, depending on their special needs and the Washington, DC: U.S. Department of Health and Human Services, Office extent of their disabilities (1). See Standard 1.1.1.3. of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/ At least one adult who has satisfactorily completed a course basic-report/13-indicators-qualitychild-care. in pediatric first aid, including CPR skills within the past three years, should be part of the ratio at all times. 7. Zigler, E., W. S. Gilliam, S. M. Jones. 2006. A vision for universal preschool education, 107-29. New York: Cambridge University Press. RATIONALE These child:staff ratios are within the range of recommen- 8. Stebbins, H. 2007. State policies to improve the odds for the healthy develop- dations for each age group that the National Association ment and school readiness of infants and toddlers. Washington, DC: Zero to for the Education of Young Children (NAEYC) uses in its Three. http://main.zerotothree.org/site/DocServer/NCCP_article_for_BM_ accreditation program (5). The NAEYC recommends a final.pdf. range that assumes the director and staff members are highly trained and, by virtue of the accreditation process, 1.1.1.2 have formed a staffing pattern that enables effective staff Ratios for Large Family Child Care functioning. The standard for child:staff ratios in this docu- Homes and Centers ment uses a single desired ratio, rather than a range, for each age group. These ratios are more likely than less stringent Child:staff ratios in large family child care homes and ratios to support quality experiences for young children. centers should be maintained as follows during all hours Low child:staff ratios for non-ambulatory children are essen- of operation, including in vehicles during transport. tial for fire safety. The National Fire Protection Association (NFPA), in its NFPA 101: Life Safety Code, recommends that Large Family Child Care Homes no more than three children younger than two years of age be cared for in large family child care homes where two staff Maximum Maximum members are caring for up to twelve children (6). Age Child:Staff Ratio Group Size Children benefit from social interactions with peers. How- ever, larger groups are generally associated with less positive ≤ 12 months 2:1 6 interactions and developmental outcomes. Group size and ratio of children to adults are limited to allow for one to one 13-23 months 2:1 8 interaction, intimate knowledge of individual children, and consistent caregiving (7). 24-35 months 3:1 12 Studies have found that children (particularly infants and toddlers) in groups that comply with the recommended 3-year-olds 7:1 12 4- to 5-year-olds 8:1 12 6- to 8-year-olds 10:1 12 9- to 12-year-olds 12:1 12 During nap time for children birth through thirty months of age, the child:staff ratio must be maintained at all times regardless of how many infants are sleeping. They must also be maintained even during the adult’s break time so that ratios are not relaxed. Child Care Centers Maximum Maximum Age Child:Staff Ratio Group Size ≤ 12 months 3:1 6 13-35 months 4:1 8 3-year-olds 7:1 14 4-year-olds 8:1 16 5-year-olds 8:1 16 6- to 8-year-olds 10:1 20 9- to 12-year-olds 12:1 24

5 Chapter 1: Staffing ratio receive more sensitive and appropriate caregiving and COMMENTS score higher on developmental assessments, particularly The child:staff ratio indicates the maximum number of chil- vocabulary (1,9). dren permitted per caregiver/teacher (8). These ratios assume As is true in small family child care homes, Standard 1.1.1.1, that caregivers/teachers do not have time-consuming book- child:staff ratios alone do not predict the quality of care. keeping and housekeeping duties, so they are free to provide Direct, warm social interaction between adults and chil- direct care for children. The ratios do not include other dren is more common and more likely with lower child:staff personnel (such as bus drivers) necessary for specialized ratios. Caregivers/teachers must be recognized as perform- functions (such as driving a vehicle). ing a job for groups of children that parents/guardians of twins, triplets, or quadruplets would rarely be left to handle Group size is the number of children assigned to a caregiver/ alone. In child care, these children do not come from the teacher or team of caregivers/teachers occupying an individ- same family and must learn a set of common rules that ual classroom or well-defined space within a larger room (8). may differ from expectations in their own homes (10). The “group” in child care represents the “home room” for school- Similarly, low child:staff ratios are most critical for infants age children. It is the psychological base with which the and young toddlers (birth to twenty-four months) (1). Infant school-aged child identifies and from which the child gains development and caregiving quality improves when group continual guidance and support in various activities. This size and child:staff ratios are smaller (2). Improved verbal standard does not prohibit larger numbers of school-aged interactions are correlated with lower ratios (3). For three- children from joining in occasional collective activities as and four-year-old children, the size of the group is even long as child:staff ratios and the concept of “home room” more important than ratios. The recommended group size are maintained. and child:staff ratio allow three- to five-year-old children to have continuing adult support and guidance while encour- Unscheduled inspections encourage compliance with aging independent, self-initiated play and other activities (4). this standard. In addition, the children’s physical safety and sanitation routines require a staff that is not fragmented by excessive These standards are based on what children need for quality demands. Child:staff ratios in child care settings should be nurturing care. Those who question whether these ratios are sufficiently low to keep staff stress below levels that might affordable must consider that efforts to limit costs can result result in anger with children. Caring for too many young in overlooking the basic needs of children and creating a children, in particular, increases the possibility of stress highly stressful work environment for caregivers/teachers. to the caregiver/teacher, and may result in loss of the Community resources, in addition to parent/guardian fees caregiver’s/teacher’s self-control (11). and a greater public investment in child care, can make criti- Although observation of sleeping children does not require cal contributions to the achievement of the child:staff ratios the physical presence of more than one caregiver/teacher and group sizes specified in this standard. Each state has its for sleeping children thirty-one months and older, the staff own set of regulations that specify child: staff ratios. To view needed for an emergency response or evacuation of the a particular state’s regulations, go to the National Resource children must remain available on site for this purpose. Center for Health and Safety in Child Care and Early Ratios are required to be maintained for children thirty Education’s (NRC) Website: http://nrckids.org. months and younger during nap time due to the need for closer observation and the frequent need to interact with TYPE OF FACILITY younger children during periods while they are resting. Center, Large Family Child Care Home Close proximity of staff to these younger groups enables more rapid response to situations where young children RELATED STANDARDS require more assistance than older children, e.g., for evacu- 1.1.1.3 Ratios for Facilities Serving Children with Special ation. The requirement that a caregiver/teacher should remain in the sleeping area of children thirty-one months Health Care Needs and Disabilities and older is not only to ensure safety, but also to prevent 1.1.1.4 Ratios and Supervision During Transportation inappropriate behavior from taking place that may go un- 1.1.1.5 Ratios and Supervision for Swimming, Wading, detected if a caregiver/teacher is not present. While nap time may be the best option for regular staff conferences, and Water Play staff lunch breaks, and staff training, one staff person should 1.4.3.1 First Aid and CPR Training for Staff stay in the nap room, and the above staff activities should 1.4.3.2 Topics Covered in First Aid Training take place in an area next to the nap room so other staff can 1.4.3.3 CPR Training for Swimming and Water Play assist if emergency evacuation becomes necessary. If a child with a potentially life- threatening special health care need References is present, a staffmember trained in CPR and pediatric first aid and one trained in administration of any potentially 1. Zero to Three. 2007. The infant-toddler set-aside of the Child Care and required medication should be available at all times. Development Block Grant: Improving quality child care for infants and toddlers. Washington, DC: Zero to Three. http://main .zerotothree.org/site/ DocServer/Jan_07_Child_Care_Fact _Sheet.pdf. 2. National Institute of Child Health and Human Development (NICHD). 2006. The NICHD study of early child care and youth development: Findings for children up to age 4 1/2 years. Rockville, MD: NICHD. http://www.nichd.nih. gov/ publications/pubs/upload/seccyd_051206.pdf. 3. Goldstein, A., K. Hamm, R. Schumacher. Supporting growth and develop- ment of babies in child care: What does the research say? Washington, DC: Center for Law and Social Policy (CLASP); Zero to Three. http://main. zerotothree.org/site/DocServer/ChildCareResearchBrief.pdf.

6 Caring for Our Children: National Health and Safety Performance Standards 4. De Schipper, E. J., J. M. Riksen-Walraven, S. A. E. Geurts. 2006. Effects of Reference child-caregiver ratio on the interactions between caregivers and children in child-care centers: An experimental study. Child Devel 77:861-74. 1. University of North Carolina at Chapel Hill, FPG Child Development Institute. The national early childhood technical assistance center. http:// 5. National Association for the Education of Young Children (NAEYC). www.nectac.org 2007. Early childhood program standards and accreditation criteria. Washington, DC: NAEYC. 1.1.1.4 Ratios and Supervision During Transportation 6. National Fire Protection Association (NFPA). 2009. NFPA 101: Life safety code. 2009 ed. Quincy, MA: NFPA. Child:staff ratios established for out-of-home child care should be maintained on all transportation the facility 7. Bradley, R. H., D. L. Vandell. 2007. Child care and the well-being of provides or arranges. Drivers should not be included in the children. Arch Ped Adolescent Med 161:669-76. ratio. No child of any age should be left unattended in or around a vehicle, when children are in a car, or when they 8. Murph, J. R., S. D. Palmer, D. Glassy, eds. 2005. Health in child care: A are in a car seat. A face-to-name count of children should be manual for health professionals. 4th ed. Elk Grove Village, IL: American conducted prior to leaving for a destination, when the desti- Academy of Pediatrics. nation is reached, before departing for return to the facility and upon return. Caregivers/teachers should also remember 9. Vandell, D. L., B. Wolfe. 2000. Child care quality: Does it matter and to take into account in this head count if any children were does it need to be improved? Washington, DC: U.S. Department of picked up or dropped off while being transported away Health and Human Services. http://aspe.hhs.gov/hsp/ccquality00/. from the facility. 10. Fiene, R. 2002. 13 indicators of quality child care: Research update. RATIONALE Washington, DC: U.S. Department of Health and Human Services, Children must receive direct supervision when they are being Office of the Assistant Secretary for Planning and Evaluation. http:// transported, in loading zones, and when they get in and out aspe.hhs.gov/basic-report/13-indicators-quality-child-care. of vehicles. Drivers must be able to focus entirely on driving tasks, leaving the supervision of children to other adults. This 11. Wrigley, J., J. Derby. 2005. Fatalities and the organization of child care in is especially important with young children who will be sit- the United States. Am Socio Rev 70:729-57. ting in close proximity to one another in the vehicle and may need care during the trip. In any vehicle making multiple 1.1.1.3 stops to pick up or drop off children, this also permits one Ratios for Facilities Serving Children with adult to get one child out and take that child to a home, while Special Health Care Needs and Disabilities the other adult supervises the children remaining in the vehicle, who would otherwise be unattended for that time (1). Facilities enrolling children with special health care needs Children require supervision at all times, even when buckled and disabilities should determine, by an individual assess- in seat restraints. A head count is essential to ensure that ment of each child’s needs, whether the facility requires no child is inadvertently left behind in or out of the vehicle. a lower child:staff ratio. Child deaths in child care have occurred when children were mistakenly left in vehicles, thinking the vehicle was empty. RATIONALE The child:staff ratio must allow the needs of the children TYPE OF FACILITY enrolled to be met. The facility should have sufficient direct Center, Large Family Child Care Home care professional staff to provide the required programs and services. Integrated facilities with fewer resources may be RELATED STANDARD able to serve children who need fewer services, and the staff- 5.6.0.1 First Aid and Emergency Supplies ing levels may vary accordingly. Adjustment of the ratio allows for the flexibility needed to meet each child’s type Reference and degree of special need and encourage each child to participate comfortably in program activities. Adjustment of 1. Aird, L. D. 2007. Moving kids safely in child care: A refresher course. Child the ratio produces flexibility without resulting in a need for Care Exchange (January/February): 25-28. http://www.childcareexchange. care that is greater than the staff can provide without com/library/5017325.pdf. compromising the health and safety of other children. The facility should seek consultation with parents/guardians, a 1.1.1.5 child care health consultant (CCHC), and other profession- Ratios and Supervision for Swimming, als, regarding the appropriate child:staff ratio. The facility Wading, and Water Play may wish to increase the number of staff members if the child requires significant special assistance (1). The following child:staff ratios should apply while children are swimming, wading, or engaged in water play: COMMENTS These ratios do not include personnel who have other Developmental Levels Child:Staff Ratio duties that might preclude their involvement in needed Infants 1:1 supervision while they are performing those duties, such Toddlers 1:1 as therapists, cooks, maintenance workers, or bus drivers. 4:1 Preschoolers 6:1 TYPE OF FACILITY School-age Children Center, Large Family Child Care Home RELATED STANDARDS 1.1.1.1 Ratios for Small Family Child Care Homes 1.1.1.2 Ratios for Large Family Child Care Homes and Centers

7 Chapter 1: Staffing Constant and active supervision should be maintained 6.3.1.4 Safety Covers for Swimming Pools when any child is in or around water (4). During any swim- 6.3.1.7 Pool Safety Rules ming/wading/water play activities where either an infant 6.3.2.1 Lifesaving Equipment or a toddler is present, the ratio should always be one adult 6.3.2.2 Lifeline in Pool to one infant/toddler. The required ratio of adults to older 6.3.5.2 Water in Containers children should be met without including the adults who 6.3.5.3 Portable Wading Pools are required for supervision of infants and/or toddlers. References An adult should remain in direct physical contact with an infant at all times during swimming or water play (4). 1. U.S. Consumer Product Safety Commission (CPSC). Pool and spa safety: Whenever children thirteen months and up to five years of The Virginia Graeme Baker pool and spa safety act. http://www.poolsafely. age are in or around water, the supervising adult should be gov/wp-content/uploads/VGBA.pdf. within an arm’s length providing “touch supervision” (6). The attention of an adult who is supervising children of any 2. Consumer Product Safety Commission. Steps for safety around the pool: age should be focused on the child, and the adult should The pool and spa safety act. Pool Safely. http://www.poolsafely.gov/ never be engaged in other distracting activities (4), such as wp-content/uploads/360.pdf. talking on the telephone, socializing, or tending to chores. 3. Gipson, K. 2008. Pool and spa submersion: Estimated injuries and reported A lifeguard should not be counted in the child:staff ratio. fatalities, 2008 report. Bethesda, MD: U.S. Consumer Product Safety Commission. http://www.cpsc.gov/LIBRARY/poolsub2008.pdf. RATIONALE The circumstances surrounding drownings and water- 4. Gipson, K. 2009. Submersions related to non-pool and non-spa products, related injuries of young children suggest that staffing 2008 report. Washington, DC: CPSC. http://www.cpsc.gov/library/FOIA/ requirements and environmental modifications may reduce FOIA09/OS/nonpoolsub2008.pdf. the risk of this type of injury. Essential elements are close continuous supervision (1,4), four-sided fencing and self- 5. U.S. Consumer Product Safety Commission (CPSC). 2009. CPSC warns of locking gates around all swimming pools, hot tubs, and in-home drowning dangers with bathtubs, bath seats, buckets. Release spas, and special safety covers on pools when they are not in #10-008. http://www.cpsc.gov/cpscpub/prerel/prhtml10/10008.html. use (2,7). Five-gallon buckets should not be used for water play (4). Water play using small (one quart) plastic pitchers 6. American Academy of Pediatrics Committee on Injury, Violence, and and plastic containers for pouring water and plastic dish pans Poison Prevention, J. Weiss. 2010. Technical report: Prevention of drowning. or bowls allow children to practice pouring skills. Between Pediatrics 126: e253-62. 2003 and 2005, a study of drowning deaths of children younger than five years of age attributed the highest percent- 7. American Academy of Pediatrics Committee on Injury, Violence, and age of drowning reports to an adult losing contact or knowl- Poison Prevention, J. Weiss. 2010. Technical report: Prevention of drowning. edge of the whereabouts of the child (5). During the time of Pediatrics 126: e253-62. lost contact, the child managed to gain access to the pool (3). 1.1.2 COMMENTS MINIMUM AGE Water play includes wading. Touch supervision means keeping swimming children within arm’s reach and in sight 1.1.2.1 at all times. Drowning is a “silent killer” and children may Minimum Age to Enter Child Care slip into the water silently without any splashing or scream- ing. Ratios for supervision of swimming, wading and water Reader’s Note: This standard reflects a desirable goal when play do not include personnel who have other duties that sufficient resources are available; it is understood that for might preclude their involvement in supervision during some families, waiting until three months of age to enter swimming/wading/water play activities while they are their infant in child care may not be possible. performing those duties. This ratio excludes cooks, main- Healthy full-term infants can be enrolled in child care set- tenance workers, or lifeguards from being counted in the tings as early as three months of age. Premature infants or child:staff ratio if they are involved in specialized duties at those with chronic health conditions should be evaluated the same time. Proper ratios during swimming activities by their primary care providers and developmental special- with infants are important. Infant swimming programs ists to make an individual determination concerning the have led to water intoxication and seizures because infants appropriate age for child care enrollment. may swallow excessive water when they are engaged in any RATIONALE submersion activities (1). Brain anatomy, chemistry, and physiology undergo rapid development over the first ten to twelve weeks of life (1-6). TYPE OF FACILITY Concurrently, and as a direct consequence of these shifts Center, Large Family Child Care Home in central nervous system structure and function, infants demonstrate significant growth, irregularity, and eventu- RELATED STANDARDS ally, organization of their behavior, physiology, and social 2.2.0.4 Supervision Near Bodies of Water responsiveness (1-3,5). Arousal responses to stimulation 6.3.1.3 Sensors or Remote Monitors mature before the ability to self-regulate and control such responses in the first six to eight weeks of life causing infants to demonstrate an expanding range and fluctuation of behavioral state changes from quiet to alert to irritable (1-3,6). Infant behavior is most disorganized, most difficult to read and most frustrating to support at the six to eight week period (2,3). At approximately eight to twelve weeks after birth, full term infants typically undergo changes in

8 Caring for Our Children: National Health and Safety Performance Standards brain function and behavior that helps caregivers/teachers leave, established for the first time job protected maternity understand and respond effectively to infants’ increasingly leave for qualifying employees (16,20). Despite the impor- stable sleep-wake states, attention, self-calming efforts, tance of FMLA, only about 60% of the women in the work- feeding patterns and patterns of social engagement. Over force are eligible for job protected maternity leave. FMLA the course of the third month, infants demonstrate an does not provide paid leave, which may force many women emerging capacity to sustain states of sleep and alert atten- to return to work sooner than preferred (18). FMLA is not tion. Infants, birth to three months of age, can become transferable between parents/guardians. However, five seriously ill very quickly without obvious signs (7). This U.S. states support five to six weeks of paid maternity leave increased risk to infants, birth to three months makes it and a few companies allow generous paid leaves for select important to minimize their exposure to children and employees (21). adults outside their family, including exposures in child In a nationally representative sample, 84% of women and care (8). In addition, infants of mothers who return to work, 74% of men supported expansion of the FMLA; furthermore, particularly full-time, before twelve weeks of age, and are 90% of women and 72% of men reported that employers and placed in group care may be at even greater risk for devel- government should do more to support families (21). oping serious infectious diseases. These infants are less Substantial evidence exists to strengthen social policies, likely to receive recommended well-child care and specifically job protected paid leave for all families, for at immunizations and to be breastfed or are likely to least the first twelve weeks of life, in order to promote the have a shorter duration of breastfeeding (16,22). health and development of children and families (22). Researchers report that breastfeeding duration was signifi- Investing in families during an important life transition, cantly higher in women with longer maternity leaves as the birth or adoption of a child, reflects a society’s values compared to those with less than nine to twelve weeks leave and may in fact contribute to a healthier and more (9,22). A leave of less than six weeks was associated with a productive work force. much higher likelihood of stopping breastfeeding (10,22). Continuing breastfeeding after returning to work may be TYPE OF FACILITY particularly difficult for lower income women who may Center, Large Family Child Care Home have fewer support systems (11). It takes women who have given birth about six weeks to RELATED STANDARD return to the physical health they had prior to pregnancy 2.1.1.5 Helping Families Cope with Separation (12). A significant portion of women reported child birth related symptoms five weeks after delivery (17). In contrast, References women’s general mental health, vitality, and role function were improved with maternity leaves at twelve weeks or 1. Staehelin, K., P. C. Bertea, E. Z. Stutz. 2007. Length of maternity leave longer (13). and health of mother and child–a review. Int J Public Health 52:202-9. Birth of a child or adoption of a newborn, especially the first, requires significant transition in the family. First time 2. Guendelman, S., J. L. Kosc, M. Pearl, S. Graham, J. Goodman, M. Kharrazi. parents/guardians are learning a new role and even with 2009. Juggling work and breastfeeding: Effects of maternity leave and subsequent children, integration of the new family member occupational characteristics. Pediatrics 123: e38-e46. requires several weeks of adaptation. Families need time to adjust physically and emotionally to the intense needs of a 3. McGovern P., B. Dowd, D. Gjerdingen, I. Moscovice, L. Kochevar, W. newborn (14,15). Lohman. 1997. Time off work and the postpartum health of employed women. Medical Care 35:507-21. COMMENTS In an analysis of twenty-one wealthy countries including 4. Cunningham, F. G., F. F. Gont, K. J. Leveno, L. C. Gilstrap, J. C. Australia, New Zealand, Canada, United States, Japan, Hauth, K. D. Wenstrom. 2005. Williams obstretrics. 21st ed. and several European countries, the U.S. ranked twentieth New York: McGraw Hill. in terms of unpaid and paid parental leave available to two-parent families with the birth of their child (18,21). 5. Kimbro, R. T. 2006. On-the-job moms: Work and breastfeeding Although Switzerland ranked twenty-first with fourteen initiation and duration for a sample of low-income women. Maternal Child versus twenty-four weeks as compared to the U.S. for Health J 10:19-26. both parents/guardians, eleven weeks of leave are paid in Switzerland. In this study of twenty-one countries, only 6. Carter, B., M. McGoldrick, eds. 2005. The expanded family life cycle: Australia and the U.S. do not provide for paid leave after Individual, family, and social perspectives. 3rd ed. New York: Allyn the birth of a child (18). and Bacon Classics. Major social policies in the U.S. were established with the Social Security Act in 1935 at a time when the majority of 7. Ishimine, P. 2006. Fever without source in children 0-36 months. women were not employed (19,20). The Family and Medical Pediatric Clinics North Am 53:167. Leave Act (FMLA) of 1993, which allows twelve weeks of 8. Harper, M. 2004. Update on the management of the febrile infant. Clin Pediatric Emerg Med 5:5-12. 9. Carey, W. B., A. C. Crocker, E. R. Elias, H. M. Feldman, W. L. Coleman. 2009. Developmental-behavioral pediatrics. 4th ed. Philadelphia: W. B. Saunders. 10. Parmelee, A. H. Jr, W. Weiner, H. Schultz. 1964. Infant sleep patterns: From birth to 16 weeks of age. J Pediatrics 65:576-82. 11. Brazelton, T. B. 1962. Crying in infancy. Pediatrics 29:579-88. 12. Huttenlocher, P. R., C. de Courten. 1987. The development of synapses in striate cortex of man. Human Neurobiology 6:1-9. 13. Anders, T. F. 1992. Sleeping through the night: A developmental perspective. Pediatrics 90:554-60. 14. Edelstein, S., J. Sharlin, S. Edelstein. 2008. Life cycle nutrition: An evidence-based approach. Boston: Jones and Bartlett. 15. Robertson, S. S. 1987. Human cyclic motility: Fetal-newborn continuities and newborn state differences. Devel Psychobiology 20:425-42. 16. Berger, L. M., J. Hill, J. Waldfogel. 2005. Maternity leave, early maternal employment and child health and development in the US. Economic J 115: F29-F47.

9 Chapter 1: Staffing 17. McGovern, P., B. Dowd, D. Gjerdingen, C. R. Gross, S. Kenney, L. COMMENTS Ukestad, D. McCaffrey, U. Lundberg. 2006. Postpartum health of In staff recruiting, the hiring pool should extend beyond the employed mothers 5 weeks after childbirth. Annals Fam Med 4:159-67. immediate neighborhood of the child’s residence or location of the facility, to reflect the diversity of the people with whom 18. Ray, R., J. C. Gornick, J. Schmitt. 2009. Parental leave policies in 21 the child can be expected to have contact as a part of life ex- countries: Assessing generosity and gender equality. Rev. ed. perience. Reasons to deny employment include the following: Washington, DC: Center for Economic and Policy Research. a. The applicant or employee is not qualified or is unable 19. Social Security Act. 1935. 42 USC 7. to perform the essential functions of the job with or 20. Family and Medical Leave Act. 1993. 29 USC 2601. without reasonable accommodations; 21. Lovell, V., E. O’Neill, S. Olsen. 2007. Maternity leave in the United b. Accommodation is unreasonable or will result in undue hardship to the program; States: Paid parental leave is still not standard, even among the best U.S. c. The applicant’s or employee’s condition will pose a sig- employers. Washington, DC: Institute for Women’s Policy Research. nificant threat to the health or safety of that individual http://iwpr.org/pdf/parentalleaveA131.pdf. or of other staff members or children. 22. Human Rights Watch. 2011. Failing its families: Lack of paid leave d. Accommodations and undue hardship are based on and work-family supports in the U.S. http://www.hrw.org/en/ each individual situation. reports/2011/02/23/failing-its-families-0/. The U.S. Equal Employment Opportunity Commission (EEOC) does not enforce the protections that prohibit dis- 1.2 crimination and harassment based on sexual orientation, RECRUITMENT AND BACKGROUND status as a parent, marital status, or political affiliation. However, other federal agencies and many states and SCREENING municipalities do. For assistance in locating your state or local agency’s rules go to http://www.eeoc.gov/field/ (3). 1.2.0.1 Caregivers/teachers can obtain copies of the EEOA and the Staff Recruitment ADA from their local public library. Facilities should consult with ADA experts through the U.S. Department of Education Staff recruitment should be based on a policy of non- funded Disability and Business Technical Assistance Cen- discrimination with regard to gender, race, ethnicity, disa- ters (DBTAC) throughout the country. These centers can be bility, or religion, as required by the Equal Employment reached by calling 1-800-949-4232 (callers will be routed to Opportunity Act (EEOA). Centers should have a plan of the appropriate region), or by visiting http://www.adata .org/ action for recruiting and hiring a diverse staff that is repre- Static/Home.aspx. sentative of the children in the facility’s care and people TYPE OF FACILITY in the community with whom the child is likely to have Center, Large Family Child Care Home contact as a part of life experience. Staff recruitment poli- References cies should adhere to requirements of the Americans with Disabilities Act (ADA) as it applies to employment. The 1. Chang, H. 2006. Developing a skilled, ethnically and linguistically diverse job description for each position should be clearly written, early childhood workforce. Adapted from Getting ready for quality: The and the suitability of an applicant should be measured critical importance of developing and supporting a skilled, ethnically and with regard to the applicant’s qualifications and abilities linguistically diverse early childhood workforce. to perform the tasks required in the role. http://www.buildinitiative.org/files/DiverseWorkforce.pdf. RATIONALE Child care businesses must adhere to federal law. In 2. U.S. Department of Justice, Civil Rights Division, Disability Rights Section. addition, child care businesses should model diversity 1997. Commonly asked questions about child care centers and the Americans and non-discrimination in their employment practices with Disabilities Act. http://www.ada.gov/childq%26a.htm. to enhance the quality of the program by supporting diversity and tolerance for individuals on the staff who 3. U.S. Equal Employment Opportunity Commission. Discrimination based on are competent caregivers/teachers with different back- sexual orientation, status as a parent, marital status and ground and orientation in their private lives. Children political affiliation. http://www.eeoc.gov/federal/otherprotections.cfm. need to see successful role models from their own ethnic and cultural groups and be able to develop the ability to 1.2.0.2 relate to people who are different from themselves (1). Background Screening The goal of the ADA in employment is to reasonably accommodate applicants and employees with disabilities, To ensure their safety and physical and mental health, chil- to provide them equal employment opportunity and to dren should be protected from any risk of abuse or neglect. integrate them into the program’s staff to the extent feasi- Directors of centers and large family child care homes and ble, given the individual’s limitations. Under the ADA, caregivers/teachers in small family child care homes should employers are expected to make reasonable accommoda- conduct a complete background screening before employing tions for persons with disabilities. Some disabilities may any staff member, including substitutes, cooks, clerical staff, be accommodated, whereas others may not allow the transportation staff, bus drivers, or custodians who will be person to do essential tasks. The fairest way to address on the premises or in vehicles when children are present. this evaluation is to define the tasks and measure the abilities of applicants to perform them (2).

10 Caring for Our Children: National Health and Safety Performance Standards The background screening should include (1-4). Performing diligent background screenings also protects a. Name and address verification the child care facility against future legal challenges (2,3). b. Social Security number verification c. Education verification COMMENTS d. Employment history The following resources can help the director screen e. Alias search individual applicants: f. Driving history through state Department of Motor • If fingerprinting is required, it can be secured at Vehicles records local law enforcement offices or the State Bureau of g. Background screening of Investigation. • Court records are public information and can be 1. State, tribal, and federal criminal history records, obtained from county court offices; some states including fingerprint checks have statewide online court records. • Driving records are available from the state Department 2. Child abuse and neglect registries of Motor Vehicles. 3. Licensing history with any other state agencies • A Social Security number trace is a report, derived from credit bureau records, that will return all current and (eg, foster care, mental health, nursing homes) reported addresses for the last 7 to 10 years on a specific 4. Sex offender registries individual based on his or her Social Security number. e. Court records (misdemeanors and felonies) If there are alternate names (aliases), these are also f. Reference checks; These should come from a variety reported on the Social Security record. of employment or volunteer sources and should not • State child abuse registries can be accessed at https://www. be limited to an applicant’s family and/or friends (5). adoptuskids.org/for-professionals/interstate-adoptions/ g. In-person interview; Open-ended questions about state-child-abuse-registries. Sex offender registries can establishing appropriate and inappropriate boundaries be accessed at https://www.nsopw.gov. with young children should be asked to all job applicants • Companies also offer background check services. during the in-person interview; for example, “How would The National Association of Professional Background you handle a situation in which a child asked you to keep Screeners (https://www.napbs.com) provides a directory a secret?” (6).  of its membership. Directors should contact their state child care licensing For more information on state licensing requirements agency for the appropriate background screening docu- regarding criminal background screenings, see the current mentation required by their state’s licensing regulations.  National Association for Regulatory Administration All family members older than 10 years living in large and Licensing Study at www.naralicensing.org/resources. small family child care homes should also have background screenings. Drug tests/screens may be incorporated into TYPE OF FACILITY the background screening. Written permission to obtain Center, Large Family Child Care Home, Small Family the background screening (with or without a drug screen) Child Care Home should be obtained from the prospective employee. Con- sent to the background investigation should be required for References employment consideration. Prospective employers should verbally ask applicants about previous convictions and 1. Child Care and Development Block Grant Act, 42 USC §9857 arrests, in- vestigation findings, or court cases with child 2. Social Security Act, 42 USC §618 abuse/neglect or child sexual abuse. Failure of the prospec- 3. Child Care and Development Fund, 42 USC §9858f(c)(1)(D), 42 USC tive employee to disclose previous history of child abuse/ neglect or child sexual abuse is grounds for immediate §9858f(h)(1) dismissal. Persons should not be hired or allowed to work 4. Head Start Early Childhood Learning & Knowledge Center. 1302.90 or volunteer in the child care facility if they acknowledge being sexually attracted to children or having physically personnel policies. https://eclkc.ohs.acf.hhs.gov/policy/45-cfr-chap-xiii/ or sexually abused children, or if they are known to have 1302-90-personnel-policies. Accessed January 11, 2018 committed such acts. 5. Alliance of Schools for Cooperative Insurance Programs. Best Practices for Background screenings should be repeated periodically, Child Abuse Prevention. Cerritos, CA: Alliance of Schools for Cooperative mirroring state laws and/or requirements. If there are Insurance Programs; 2015. http://ascip.org/wp-content/uploads/2014/05/ concerns about an employee’s performance or behavior, Child-Abuse-Best-Practices.pdf. Published April 15, 2015. Accessed January background screenings should be conducted as needed. 11, 2018 6. Berkower F. Preventing child sexual abuse in your organization. Denver’s RATIONALE Early Childhood Council Web site. https://denverearlychildhood.org/ Properly executed reference checks, as well as in-person preventing-child-sexual-abuse-organization. Published April 23, 2016. interviews, help seek out and prevent possible child abuse Accessed January 11, 2018 from occurring in child care centers. The use of open-ended questions and request for verbal references require personal NOTES conversations and, in turn, can uncover a lot of warranted Content in the STANDARD was modified on 5/22/2018. information about the applicant.

11 Chapter 1: Staffing 1.3 skills are essential for this individual to manage the facility PRE-SERVICE QUALIFICATIONS and set appropriate expectations. College-level coursework has been shown to have a measurable, positive effect on 1.3.1 quality child care, whereas experience per se has not (1-3,5). DIRECTOR’S QUALIFICATIONS The director of a center plays a pivotal role in ensuring the day-to-day smooth functioning of the facility within the 1.3.1.1 framework of appropriate child development principles General Qualifications of Directors and knowledge of family relationships (6). The director of a center enrolling fewer than sixty children The well-being of the children, the confidence of the should be at least twenty-one-years-old and should have all parents/guardians of children in the facility’s care, and the the following qualifications: high morale and consistent professional growth of the staff a. Have a minimum of a Baccalaureate degree with at least depend largely upon the knowledge, skills, and dependable presence of a director who is able to respond to long-range nine credit-bearing hours of specialized college-level and immediate needs and able to engage staff in decision- course work in administration, leadership, or manage- making that affects their day-to-day practice (5,6). Manage- ment, and at least twenty-four credit-bearing hours of ment skills are important and should be viewed primarily specialized college-level course work in early childhood as a means of support for the key role of educational leader- education, child development, elementary education, ship that a director provides (6). A skilled director should or early childhood special education that addresses know how to use early care and education consultants, child development, learning from birth through kin- such as health, education, mental health, and community dergarten, health and safety, and collaboration with resources and to identify specialized personnel to enrich consultants OR documents meeting an appropriate the staff’s understanding of health, development, behavior, combination of relevant education and work and curriculum content. Past experience working in an experiences (6); early childhood setting is essential to running a facility. b. A valid certificate of successful completion of pediatric first aid that includes CPR; Life experience may include experience rearing one’s own c. Knowledge of health and safety resources and access to children or previous personal experience acquired in any education, health, and mental health consultants; child care setting. Work as a hospital aide or at a camp for d. Knowledge of community resources available to chil- children with special health care needs would qualify, as dren with special health care needs and the ability to use would experience in school settings. This experience, how- these resources to make referrals or achieve interagency ever, must be supplemented by competency-based training coordination; to determine and provide whatever new skills are needed e. Administrative and management skills in facility to care for children in child care settings. operations; f. Capability in curriculum design and implementation, COMMENTS ensuring that an effective curriculum is in place; The profession of early childhood education is being g. Oral and written communication skills; informed by research on the association of developmental h. Certificate of satisfactory completion of instruction in outcomes with specific practices. The exact combination medication administration; of collegecoursework and supervised experience is still i. Demonstrated life experience skills in working with being developed. For example, the National Association for children in more than one setting; the Education of Young Children (NAEYC) has published j. Interpersonal skills; the Standards for Early Childhood Professional Preparation k. Clean background screening. Programs (4). The National Child Care Association (NCCA) Knowledge about parenting training/counseling and ability has developed a curriculum based on administrator com- to communicate effectively with parents/guardians about petencies; more information on the NCCA is available at developmental-behavioral issues, child progress, and in http://www.nccanet.org. creating an intervention plan beginning with how the center will address challenges and how it will help if those TYPE OF FACILITY efforts are not effective. Center The director of a center enrolling more than sixty children should have the above and at least three years experience RELATED STANDARDS as a teacher of children in the age group(s) enrolled in the 1.3.1.2 Mixed Director/Teacher Role center where the individual will act as the director, plus 1.3.2.1 Differentiated Roles at least six months experience in administration. 1.3.2.2 Qualifications of Lead Teachers and Teachers RATIONALE 1.3.2.3 Qualifications for Assistant Teachers, Teacher The director of the facility is the team leader of a small business. Both administrative and child development Aides, and Volunteers 1.4.2.1 Initial Orientation of All Staff 1.4.2.2 Orientation for Care of Children with Special Health Care Needs

12 Caring for Our Children: National Health and Safety Performance Standards 1.4.2.3 Orientation Topics 1.3.2 1.4.3.1 First Aid and CPR Training for Staff CAREGIVER’S/TEACHER’S AND 1.4.3.2 Topics Covered in First Aid Training OTHER STAFF QUALIFICATIONS 1.4.3.3 CPR Training for Swimming and Water Play 1.4.4.1 Continuing Education for Directors and 1.3.2.1 Differentiated Roles Caregivers/Teachers in Centers and Large Family Child Care Homes Centers should employ a caregiving/teaching staff for direct 1.4.4.2 Continuing Education for Small Family Child work with children in a progression of roles, as listed in Care Home Caregivers/Teachers descending order of responsibility: 1.4.5.1 Training of Staff Who Handle Food a. Program administrator or training/curriculum 1.4.5.2 Child Abuse and Neglect Education 1.4.5.3 Training on Occupational Risk Related to specialists; Handling Body Fluids b. Lead teachers; 1.4.5.4 Education of Center Staff c. Teachers; 1.4.6.1 Training Time and Professional Development d. Assistant teachers or teacher aides. Leave Each role with increased responsibility should require 1.4.6.2 Payment for Continuing Education increased educational qualifications and experience, as well as increased salary. References RATIONALE 1. Roupp, R., J. Travers, F. M., Glantz, C. Coelen. 1979. Children at the A progression of roles enables centers to offer career ladders center: Summary findings and their implications. Vol. 1 of Final report rather than dead-end jobs. It promotes a mix of college- of the National day care study. Cambridge, MA: Abt Associates. trained staff with other members of a child’s own commu- nity who might have entered at the aide level and moved 2. Howes, C. 1997. Children’s experiences in center-based child care as a into higher roles through college or on-the-job training. function of teacher background and adult:child ratio. Merrill-Palmer Professional education and pre-professional in-service Q43:404-24. training programs provide an opportunity for career pro- gression and can lead to job and pay upgrades and fewer 3. Helburn, S., ed. 1995. Cost, quality and child outcomes in child care turnovers. Turn-over rates in child care positions in 1997 centers. Denver, CO: University of Colorado at Denver. averaged 30% (3). 4. National Association for the Education of Young Children (NAEYC). COMMENTS 2009. Standards for early childhood professional preparation programs. Early childhood professional knowledge must be required Washington, DC: NAEYC. http://www.naeyc .org/files/naeyc/file/ whether programs are in private centers, public schools, or positions/ProfPrepStandards09.pdf. other settings. The National Association for the Education of Young Children’s (NAEYC) Academy of Early Child- 5. Fiene, R. 2002. 13 indicators of quality child care: Research update. hood Programs recommends a multi-level training program Washington, DC: U.S. Department of Health and Human Services, that addresses pre-employment educational requirements Office of the Assistant Secretary for Planning and Evaluation. http:// and continuing education requirements for entry-level aspe.hhs.gov/basic-report/13-indicators-quality-child-care. assistants, caregivers/teachers, and administrators. It also establishes a table of qualifications for accredited programs 6. National Association for the Education of Young Children (NAEYC). (1). The NAEYC requirements include development of an 2007. Early childhood program standards and accreditation criteria. employee compensation plan to increase salaries and bene- Washington, DC: NAEYC. fits toensure recruitment and retention of qualified staff and continuity of relationships (2). The NAEYC’s recom- 1.3.1.2 mendations should be consulted in conjunction with the Mixed Director/Teacher Role standards in this document. Centers enrolling thirty or more children should employ TYPE OF FACILITY a non-teaching director. Centers with fewer than thirty Center children may employ a director who teaches as well. References RATIONALE The duties of a director of a facility with more than thirty 1. National Association for the Education of Young Children (NAEYC). 2005. children do not allow the director to be involved in the Accreditation and criteria procedures of the National Academy of Early classroom in a meaningful way. Childhood Programs. Washington, DC: NAEYC. COMMENTS 2. National Association for the Education of Young Children (NAEYC). 2009. This standard does not prohibit the director from occasional Standards for early childhood professional preparation programs. substitute teaching, as long as the substitute teaching is not Washington, DC: NAEYC. http://www.naeyc .org/files/naeyc/file/positions/ a regular and significant duty. Occasional substitute teach- ProfPrepStandards09.pdf. ing may keep the director in touch with the caregivers’/ teachers’ issues. 3. Whitebook, M., C. Howes, D. Phillips. 1998. Worthy work, unlivable wages: The National child care staffing study, 1988-1997. Washington, DC: Center TYPE OF FACILITY for the Child Care Workforce. Center

13 Chapter 1: Staffing 1.3.2.2 care staff, refer to the Standards for Early Childhood Qualifications of Lead Teachers and Teachers Professional Preparation Programs from the National Association for the Education of Young Children (NAEYC) Lead teachers and teachers should be at least twenty-one (4). Additional information on the early childhood educa- years of age and should have at least the following education, tion profession is available from the Center for the Child experience, and skills: Care Workforce (CCW). a. A Bachelor’s degree in early childhood education, TYPE OF FACILITY school-age care, child development, social work, Center nursing, or other child-related field, or an associate’s degree in early childhood education and currently RELATED STANDARDS working towards a bachelor’s degree; 1.4.3.1 First Aid and CPR Training for Staff b. A minimum of one year on-the-job training in pro- 1.4.3.2 Topics Covered in First Aid Training viding a nurturing indoor and outdoor environment 1.4.3.3 CPR Training for Swimming and Water Play and meeting the child’s out-of-home needs; c. One or more years of experience, under qualified References supervision, working as a teacher serving the ages and developmental abilities of the children in care; 1. National Institute of Child Health and Human Development (NICHD) d. A valid certificate in pediatric first aid, including CPR; Early Child Care Research Network. 1996. Characteristics of infant child e. Thorough knowledge of normal child development care: Factors contributing to positive caregiving. Early Child Res Q and early childhood education, as well as knowledge 11:269-306. of indicators that a child is not developing typically; f. The ability to respond appropriately to children’s needs; 2. Bredekamp, S., C. Copple, eds. 1997. Developmentally appropriate practice g. The ability to recognize signs of illness and safety/injury in early childhood programs. Rev ed. Washington, DC: National hazards and respond with prevention interventions; Association for the Education of Young Children. h. Oral and written communication skills; i. Medication administration training (8). 3. U.S. Department of Justice. 2011. Americans with Disabilities Act. Every center, regardless of setting, should have at least one http://www.ada.gov. licensed/certified lead teacher (or mentor teacher) who meets the above requirements working in the child care 4. National Association for the Education of Young Children (NAEYC). 2009. facility at all times when children are in care. Standards for early childhood professional preparation programs. Additionally, facilities serving children with special health Washington, DC: NAEYC. http://www.naeyc .org/files/naeyc/file/positions/ care needs associated with developmental delay should ProfPrepStandards09.pdf. employ an individual who has had a minimum of eight hours of training in inclusion of children with special 5. Committee on Integrating the Science of Early Childhood Development, health care needs. Board on Children, Youth, and Families. 2000. From neurons to neighborhoods. Ed. J. P. Shonkoff, D. A. Phillips. Washington, DC: RATIONALE National Academy Press. Child care that promotes healthy development is based on the developmental needs of infants, toddlers, and pre- 6. Kagan, S. L., K. Tarrent, K. Kauerz. 2008. The early care and education school children. Caregivers/teachers are chosen for their teaching workforce at the fulcrum, 44-47, 90-91. New York: Teachers knowledge of, and ability to respond appropriately to, the College Press. needs of children of this age generally, and the unique characteristics of individual children (1-4). Both early 7. U.S. Department of Health and Human Services. 2008. CDC study childhood and special educational experience are useful estimates 7,000 pediatric emergency departments visits linked to cough in a center.Caregivers/teachers that have received formal and cold medication: Unsupervised ingestion accounts for 66 percent of education from an accredited college or university have incidents. Centers for Disease Control and Prevention (CDC). shown to have better quality of care and outcomes of pro- http://www.cdc.gov/media/pressrel/2008/r080128.htm. grams. Those teachers with a four-year college degree exhibit optimal teacher behavior and positive effects on 8. American Academy of Pediatrics, Council on School Health. 2009. Policy children (6). Caregivers/teachers are more likely to admin- statement: Guidance for the administration of medication in school. ister medications than to perform CPR. Seven thousand Pediatrics 124:1244-51. children per year require emergency department visits for problems related to cough and cold medication (7). 1.3.2.3 Qualifications for Assistant Teachers, COMMENTS Teacher Aides, and Volunteers The profession of early childhood education is being informed by the research on early childhood brain develop- Assistant teachers and teacher aides should be at least ment, child development practices related to child outcomes eighteen years of age, have a high school diploma or GED, (5). For additional information on qualifications for child and participate in on-the-job training, including a struc- tured orientation to the developmental needs of young children and access to consultation, with periodic review, by a supervisory staff member. At least 50% of all assistant teachers and teacher aides must have or be working on either a Child Development Associate (CDA) credential or equivalent, or an associate’s or higher degree in early childhood education/child development or equivalent (9). Volunteers should be at least sixteen years of age and should participate in on-the-job training, including a structured orientation to the developmental needs of young children. Assistant teachers, teacher aides, and volunteers should work only under the continual supervision of lead teacher or teacher. Assistant teachers, teacher aides, and volunteers should never be left alone with children. Volunteers should not be counted in the child:staff ratio.

14 Caring for Our Children: National Health and Safety Performance Standards All assistant teachers, teacher aides, and volunteers should have personal characteristics, experience, and skills in work- possess: ing with parents, guardians and children, and the potential a. The ability to carry out assigned tasks competently for development on the job or in a training program. States may have different age requirements for volunteers. under the supervision of another staff member; b. An understanding of and the ability to respond TYPE OF FACILITY Center, Large Family Child Care Home appropriately to children’s needs; c. Sound judgment; RELATED STANDARD d. Emotional maturity; and 6.5.1.2 Qualifications for Drivers e. Clearly discernible affection for and commitment to References the well-being of children. 1. National Institute of Child Health and Human Development (NICHD) RATIONALE Early Child Care Research Network. 1996. Characteristics of infant child While volunteers and students can be as young as sixteen, care: Factors contributing to positive caregiving. Early Child Res Q age eighteen is the earliest age of legal consent. Mature lead- 11:269-306. ership is clearly preferable. Age twenty-one allows for the maturity necessary to meet the responsibilities of managing 2. National Association for the Education of Young Children (NAEYC). a center or independently caring for a group of children 2005. Accreditation and criteria procedures of the National Academy of who are not one’s own. Early Childhood Programs. Washington, DC: NAEYC. Child care that promotes healthy development is based on the developmental needs of infants, toddlers, preschool, and 3. National Association for the Education of Young Children (NAEYC). school-age children. Caregivers/teachers should be chosen 2009. Developmentally appropriate practice in early childhood programs for their knowledge of, and ability to respond appropriately serving children from birth through age 8. Washington, DC: NAEYC. to, the general needs of children of this age and the unique http://www.naeyc.org/files/naeyc/file/positions/position statement Web.pdf. characteristics of individual children (1,3-5). Staff training in child development and/or early childhood 4. U.S. Department of Justice. 2011. Americans with Disabilities Act. education is related to positive outcomes for children. This http://www.ada.gov. training enables the staff to provide children with a variety of learning and social experiences appropriate to the age 5. National Association for the Education of Young Children (NAEYC). of the child. Everyone providing service to, or interacting 2009. Standards for Early Childhood professional preparation programs. with, children in a center contributes to the child’s total Washington, DC: NAEYC. http://www.naeyc .org/files/naeyc/file/ experience (8). positions/ProfPrepStandards09.pdf. Adequate compensation for skilled workers will not be given priority until the skills required are recognized and 6. National Child Care Association (NCCA). NCCA official Website. valued. Teaching and caregiving requires skills to promote http://www.nccanet.org. development and learning by children whose needs and abilities change at a rapid rate. 7. National Association for Family Child Care (NAFCC). NAFCC official Website. http://nafcc.net. COMMENTS Experience and qualifications used by the Child Develop- 8. Da Ros-Voseles, D., S. Fowler-Haughey. 2007. Why children’s dispositions ment Associate (CDA) program and the National Child Care should matter to all teachers. Young Children (September): 1-7. Association (NCCA) credentialing program, and included http://www.naeyc.org/files/yc/file/200709/ DaRos-Voseles.pdf. in degree programs with field placement are valued (10). Early childhood professional knowledge must be required 9. National Association for the Education of Young Children (NAEYC). whether programs are in private homes, centers, public Candidacy requirements. http://www.naeyc.org/academy/pursuing/ schools, or other settings. Go to http://www .cdacouncil. candreq/. org/the-cda-credential/how-to-earn-a-cda/ to view appro- priate training and qualification information on the 10. Council for Professional Recognition. 2011. How to obtain a CDA. CDA Credential. http://www.cdacouncil.org/the-cda-credential/ how-to-earn-a-cda/. The National Association for the Education of Young Chil- dren’s (NAEYC) National Academy for Early Childhood 1.3.2.4 Program Accreditation, the National Early Childhood Additional Qualifications for Caregivers/ Program Accreditation (NECPA) and the National Asso- Teachers Serving Children Three to ciation of Family Child Care (NAFCC) have established Thirty-Five Months of Age criteria for staff qualifications (2,6,7). Caregivers/teachers who lack educational qualifications may Caregivers/teachers should be prepared to work with be employed as continuously supervised personnel while infants and toddlers and, when asked, should be knowl- they acquire the necessary educational qualifications if they edgeable and demonstrate competency in tasks associated with caring for infants and toddlers: a. Diapering and toileting; b. Bathing; c. Feeding, including support for continuation of breastfeeding; d. Holding; e. Comforting; f. Practicing safe sleep practices to reduce the risk of Sudden Infant Death Syndrome (SIDS) (3); g. Providing warm, consistent, responsive caregiving and opportunities for child-initiated activities; h. Stimulating communication and language development and pre-literacy skills through play, shared reading, song, rhyme, and lots of talking; i. Promoting cognitive, physical, and social emotional development;

15 Chapter 1: Staffing j. Preventing shaken baby syndrome/abusive head trauma; 1.4.2.3 Orientation Topics k. Promoting infant mental health; 1.4.3.1 First Aid and CPR Training for Staff l. Promoting positive behaviors; 1.4.3.2 Topics Covered in First Aid Training m. Setting age-appropriate limits with respect to safety, 1.4.3.3 CPR Training for Swimming and Water Play 1.4.4.1 Continuing Education for Directors and health, and mutual respect; n. Using routines to teach children what to expect from Caregivers/Teachers in Centers and Large Family Child Care Homes caregivers/teachers and what caregivers/teachers expect 1.4.4.2 Continuing Education for Small Family Child Care from them. Home Caregivers/Teachers 1.4.5.1 Training of Staff Who Handle Food Caregivers/teachers should demonstrate knowledge of 1.4.5.2 Child Abuse and Neglect Education development of infants and toddlers as well as knowledge 1.4.5.3 Training on Occupational Risk Related to Handling of indicators that a child is not developing typically; Body Fluids knowledge of the importance of attachment for infants 1.4.5.4 Education of Center Staff and toddlers, the importance of communication and 1.4.6.1 Training Time and Professional Development Leave language development, and the importance of nurturing 1.4.6.2 Payment for Continuing Education consistent relationships on fostering positive self-efficacy 1.6.0.3 Early Childhood Mental Health Consultants development. 3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction To help manage atypical or undesirable behaviors of chil- 4.3.1.1 General Plan for Feeding Infants dren, caregivers/teachers, in collaboration with parents/ 4.3.1.2 Feeding Infants on Cue by a Consistent guardians, should seek professional consultation from Caregiver/Teacher the child’s primary care provider, an early childhood 4.3.1.3 Preparing, Feeding, and Storing Human Milk mental health professional, or an early childhood mental 4.3.1.4 Feeding Human Milk to Another Mother’s Child health consultant. 4.3.1.5 Preparing, Feeding, and Storing Infant Formula 4.3.1.6 Use of Soy-Based Formula and Soy Milk RATIONALE 4.3.1.7 Feeding Cow’s Milk The brain development of infants is particularly sensitive to 4.3.1.8 Techniques for Bottle Feeding the quality and consistency of interpersonal relationships. 4.3.1.9 Warming Bottles and Infant Foods Much of the stimulation for brain development comes from 4.3.1.10 Cleaning and Sanitizing Equipment Used for the responsive interactions of caregivers/teachers and chil- Bottle Feeding dren during daily routines. Children need to be allowed 4.3.1.11 Introduction of Age-Appropriate Solid Foods to pursue their interests within safe limits and to be to Infants encouraged to reach for new skills (1-7). 4.3.1.12 Feeding Age-Appropriate Solid Foods to Infants COMMENTS References Since early childhood mental health professionals are not always available to help with the management of challenging 1. Shore, R. 1997. Rethinking the brain: New insights into early development. behaviors in the early care and education setting early child- New York: Families and Work Inst. hood mental health consultants may be able to help. The consultant should be viewed as an important part of the 2. National Forum on Early Childhood Policy and Programs, National Scien- program’s support staff and should collaborate with all tific Council on the Developing Child. 2007. A science-based framework for regular classroom staff, consultants, and other staff. Quali- early childhood policy: Using evidence to improve outcomes in learning, fied potential consultants may be identified by contacting behavior, and health for vulnerable children. http://developingchild.harvard. mental health and behavioral providers in the local area, as edu/index.php/library/reports_and_working_papers/policy_framework/. well as accessing the National Mental Health Information Center (NMHIC) at http://store.samhsa.gov/mhlocator/ 3. Moon, R. Y., T. Calabrese, L. Aird. 2008. Reducing the risk of sudden infant and Healthy Child Care America (HCCA) at http://www. death syndrome in child care and changing provider practices: Lessons healthychildcare.org/Contacts.html. learned from a demonstration project. Pediatrics 122:788-98. TYPE OF FACILITY 4. Fiene, R. 2002. 13 indicators of quality child care: Research update. Center, Large Family Child Care Home Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/ RELATED STANDARDS basic-report/13-indicators-quality-child-care. 1.3.1.1 General Qualifications of Directors 1.3.1.2 Mixed Director/Teacher Role 5. Centers for Disease Control and Prevention. Learn the signs. Act early. 1.3.2.2 Qualifications of Lead Teachers and Teachers http://www.cdc.gov/ncbddd/actearly/. 1.3.2.3 Qualifications for Assistant Teachers, Teacher 6. Shonkoff, J. P., D. A. Phillips, eds. 2000. From neurons to neighborhoods: Aides, and Volunteers The science of early childhood development. Washington, DC: National 1.4.2.1 Initial Orientation of All Staff Academy Press. 1.4.2.2 Orientation for Care of Children with Special 7. Cohen, J., N. Onunaku, S. Clothier, J. Poppe. 2005. Helping young children Health Care Needs succeed: Strategies to promote early childhood social and emotional development. Washington, DC: National Conference of State Legislatures; Zero to Three. http://main.zerotothree.org/site/DocServer/help_yng_child_ succeed.pdf.

16 Caring for Our Children: National Health and Safety Performance Standards 1.3.2.5 1.4.3.2 Topics Covered in First Aid Training Additional Qualifications for Caregivers/ 1.4.3.3 CPR Training for Swimming and Water Play Teachers Serving Children Three to 1.4.4.1 Continuing Education for Directors and Five Years of Age Caregivers/Teachers in Centers and Large Caregivers/teachers should demonstrate the ability to apply Family Child Care Homes their knowledge and understanding of the following to chil- 1.4.4.2 Continuing Education for Small Family Child dren three to five years of age within the program setting: Care Home Caregivers/Teachers 1.4.5.1 Training of Staff Who Handle Food a. Typical and atypical development of three- to ive-year- 1.4.5.2 Child Abuse and Neglect Education old children; 1.4.5.3 Training on Occupational Risk Related to Handling Body Fluids b. Social and emotional development of children, including 1.4.5.4 Education of Center Staff children’s development of independence, their ability to 1.4.6.1 Training Time and Professional Development Leave adapt to their environment and cope with stress, prob- 1.4.6.2 Payment for Continuing Education lem solve and engage in conflict resolution, and success- fully establish friendships; References c. Cognitive, language, early literacy, scientific inquiry, 1. National Institute of Child Health and Human Development (NICHD) and mathematics development of children; Early Child Care Research Network. 1999. Child outcomes when child center classes meet recommended standards for quality. Am J Public d. Cultural backgrounds of the children in the facility’s care; Health 89:1072-77. e. Talking to parents/guardians about observations and 2. Shore, R. 1997. Rethinking the brain: New insights into early development. concerns and referrals to parents/guardians; New York: Families and Work Inst. f. Changing needs of populations served, e.g., culture, 3. Fiene, R. 2002. 13 indicators of quality child care: Research update. income, etc. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/ To help manage atypical or undesirable behaviors of children basic-report/13-indicators-qualitychild-care. three to five years of age, caregivers/teachers serving this age group should seek professional consultation, in collabora- 1.3.2.6 tion with parents/guardians, from the child’s primary care Additional Qualifications for Caregivers/ provider, a mental health professional, a child care health Teachers Serving School-Age Children consultant, or an early childhood mental health consultant. Caregivers/teachers should demonstrate knowledge about RATIONALE and competence with the social and emotional needs and Three- and four-year-old children continue to depend developmental tasks of five- to twelve-year old children, be on the affection, physical care, intellectual guidance, and able to recognize and appropriately manage difficult behav- emotional support of their caregivers/teachers (1,2). A sup- iors, and know how to implement a socially and cognitively portive, nurturing setting that supports a demonstration enriching program that has been developed with input from of feelings and accepts regression as part of development parents/guardians. Issues that are significant within school- continues to be vital for preschool children. Preschool chil- age programs include having a sense of community, bullying, dren need help building a positive self-image, a sense of self sexuality, electronic media, and social networking. as a person of value from a family and a culture of which they are proud. Children should be enabled to view them- With this age group as well, caregivers/teachers, in collabora- selves as coping, problem-solving, competent, passionate, tion with parents/guardians, should seek professional con- expressive, and socially connected to peers and staff (3). sultation from the child’s primary care provider, a mental health professional, a child care health consultant, or an early TYPE OF FACILITY childhood mental health consultant to help manage atypical Center, Large Family Child Care Home or undesirable behaviors. RELATED STANDARDS RATIONALE 1.3.1.1 General Qualifications of Directors A school-age child develops a strong, secure sense of identity 1.3.1.2 Mixed Director/Teacher Role through positive experiences with adults and peers (1,2). 1.3.2.1 Differentiated Roles An informal, enriching environment that encourages self- 1.3.2.2 Qualifications of Lead Teachers and Teachers paced cultivation of interests and relationships promotes 1.3.2.3 Qualifications for Assistant Teachers, Teacher the self-worth of school-age children (1). Balancing free exploration with organized activities including homework Aides, and Volunteers assistance and tutoring among a group of children also 1.4.2.1 Initial Orientation of All Staff supports healthy emotional and social development (1,3). 1.4.2.2 Orientation for Care of Children with Special When children display behaviors that are unusual or Health Care Needs difficult to manage, caregivers/teachers should work with 1.4.2.3 Orientation Topics parents/guardians to seek a remedy that allows the child 1.4.3.1 First Aid and CPR Training for Staff to succeed in the child care setting, if possible (4).

17 Chapter 1: Staffing COMMENTS 1.4.6.2 Payment for Continuing Education The first resource for addressing behavior problems is the 2.2.0.8 Preventing Expulsions, Suspensions, and Other child’s primary care provider. School personnel, including professional serving school-based health clinics may also be Limitations in Services able to provide valuable insights. Support from a mental health professional may be needed. If the child’s primary References care provider cannot help or obtain help from a mental health professional, the caregiver/teacher and the family 1. Fiene, R. 2002. 13 indicators of quality child care: Research update. may need an early childhood mental health consultant to Washington, DC: U.S. Department of Health and Human Services, Office advise about appropriate management of the child. Local of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/ mental health agencies or pediatric departments of medical basic-report/13-indicators-quality-child-care. schools may offer help from child psychiatrists, psycholo- gists, other mental health professionals skilled in the issues 2. Deschenes, S. N., A. Arbreton, P. M. Little, C. Herrera, J. B. Grossman, of early childhood, and pediatricians who have a subspe- H. B. Weiss, D. Lee. 2010. Engaging older youth: Program and city-level cialty in developmental and behavioral pediatrics. Local strategies to support sustained participation in out-of-school time. http:// or area education agencies serving children with special www.hfrp.org/out-of-schooltime/publications-resources/engaging-older- health or developmental needs may be useful. State Title V youth-program-and-city -level-strategies-to-support-sustained-participation- (Children with Special Health Care Needs) may be con- in-out-of -school-time/. tacted. All state Maternal Child Health (MCH) programs are required to have a toll-free number to link consumers 3. New York State Department of Social Services, Cornell Cooperative to appropriate programs for children with special health Extension. 2004. A parent’s guide to child care for school-age children. care needs. The toll-free number listing is located at https:// National Network for Child Care. http://www .nncc.org/choose.quality.care/ perfdata.hrsa.gov/MCHB/MCHReports/search/program/ parents.sac.html#anchor68421/. references prgsch16.asp. Dis- missal from the program should be the last resort and only after consultation with the parent/ 4. Harvard Family Research Project. 2010. Family engagement as a systemic, guardian(s). sustained, and integrated strategy to promote student achievement. http:// www.hfrp.org/publications-resources/browse -our-publications/family- TYPE OF FACILITY engagement-as-a-systemic-sustained -and-integrated-strategy-to-promote- Center, Large Family Child Care Home student-achievement/. RELATED STANDARDS 1.3.2.7 1.3.1.1 General Qualifications of Directors Qualifications and Responsibilities 1.3.1.2 Mixed Director/Teacher Role for Health Advocates 1.3.2.1 Differentiated Roles 1.3.2.2 Qualifications of Lead Teachers and Teachers Each facility should designate at least one administrator 1.3.2.3 Qualifications for Assistant Teachers, Teacher Aides, or staff person as the health advocate to be responsible for policies and day-to-day issues related to health, develop- and Volunteers ment, and safety of individual children, children as a group, 1.4.2.1 Initial Orientation of All Staff staff, and parents/guardians. In large centers it may be 1.4.2.2 Orientation for Care of Children with Special important to designate health advocates at both the center and classroom level. The health advocate should be the Health Care Needs primary con- tact for parents/guardians when they have 1.4.2.3 Orientation Topics health concerns, including health-related parent/guardian/ 1.4.3.1 First Aid and CPR Training for Staff staff observations, health-related information, and the 1.4.3.2 Topics Covered in First Aid Training provision of resources. The health advocate ensures that 1.4.3.3 CPR Training for Swimming and Water Play health and safety is addressed, even when this person does 1.4.4.1 Continuing Education for Directors and not directly perform all necessary health and safety tasks. Caregivers/Teachers in Centers and Large Family Child Care Homes The health advocate should also identify children who have 1.4.4.2 Continuing Education for Small Family Child Care no regular source of health care, health insurance, or posi- Home Caregivers/Teachers tive screening tests with no referral documented in the 1.4.5.1 Training of Staff Who Handle Food child’s health record. The health advocate should assist 1.4.5.2 Child Abuse and Neglect Education the child’s parent/guardian in locating a Medical Home 1.4.5.3 Training on Occupational Risk Related to Handling by referring them to a primary care provider who offers Body Fluids routine child health services. 1.4.5.4 Education of Center Staff 1.4.6.1 Training Time and Professional Development Leave 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: a. Control of infectious diseases, including Standard Precautions, hand hygiene, cough and sneeze etiquette, and reporting requirements; b. Childhood immunization requirements, record-keeping, and at least quarterly review and follow-up for children who need to have updated immunizations;

18 Caring for Our Children: National Health and Safety Performance Standards c. Child health assessment form review and follow-up enroll, but they sometimes miss scheduled immunizations of children who need further medical assessment or thereafter. Because the risk of vaccine-preventable disease updating of their information; increases in group settings, assuring appropriate immuniza- tions is an essential responsibility in child care. Caregivers/ d. How to plan for, recognize, and handle an emergency; teachers should contact their child care health consultant e. Poison awareness and poison safety; or the health department if they have a question regarding f. Recognition of safety, hazards, and injury prevention immunization updates/ schedules. They can also provide information to share with parents/guardians about the interventions; importance of vaccines. g. Safe sleep practices and the reduction of the risk of Child health records are intended to provide information that indicates that the child has received preventive health Sudden Infant Death Syndrome (SIDS); services to stay well, and to identify conditions that might h. How to help parents/guardians, caregivers/teachers, interfere with learning or require special care. Review of the information on these records should be performed by and children cope with death, severe injury, and someone who can use the information to plan for the care of natural or man-made catastrophes; the child, and recognize when updating of the information i. Recognition of child abuse, neglect/child maltreatment, by the child’s primary care provider is needed.Children must shaken baby syndrome/abusive head trauma (for facilities be healthy to be ready to learn. Those who need accommo- caring for infants), and knowledge of when to report dation for health problems or are susceptible to vaccine- and to whom suspected abuse/neglect; preventable diseases will suffer if the staff of the child care j. Facilitate collaboration with families, primary care program is unable to use information provided in child providers, and other health service providers to create health records to ensure that the child’s needs are met (5,6). a health, developmental, or behavioral care plan; k. Implementing care plans; COMMENTS l. Recognition and handling of acute health related The director should assign the health advocate role to a situations such as seizures, respiratory distress, allergic staff member who seems to have an interest, aptitude, and reactions, as well as other conditions as dictated by the training in this area. This person need not perform all the special health care needs of children; health and safety tasks in the facility but should serve as m. Medication administration; the person who raises health and safety concerns. This staff n. Recognizing and understanding the needs of children person has designated responsibility for seeing that plans with serious behavior and mental health problems; are implemented to ensure a safe and healthful facility (1). o. Maintaining confidentiality; A health advocate is a regular member of the staff of a center p. Healthy nutritional choices; or large or small family child care home, and is not the same q. The promotion of developmentally appropriate types as the child care health consultant recommended in Child and amounts of physical activity; Care Health Consultants, Standard 1.6.0.1. The health r. How to work collaboratively with parents/guardians advocate works with a child care health consultant on and family members; health and safety issues that arise in daily interactions (4). s. How to effectively seek, consult, utilize, and collaborate For small family child care homes, the health advocate will with child care health consultants, and in partnership usually be the caregiver/teacher. If the health advocate is with a child care health consultant, how to obtain infor- not the child’s caregiver/teacher, the health advocate should mation and support from other education, mental work with the child’s caregiver/teacher. The person who is health, nutrition, physical activity, oral health, and most familiar with the child and the child’s family will social service consultants and resources; recognize atypical behavior in the child and support t. Knowledge of community resources to refer children effective communication with parents/guardians. and families who need health services including access A plan for personal contact with parents/guardians should to State Children’s Health Insurance (SCHIP), impor- be developed, even though this contact will not be possible tance of a primary care provider and medical home, daily. A plan for personal contact and documentation of a and provision of immunizations and Early Periodic designated caregiver/teacher as health advocate will ensure Screening, Diagnosis, and Treatment (EPSDT). specific attempts to have the health advocate communicate directly with caregivers/teachers and families on health- RATIONALE related matters. The effectiveness of an intentionally designated health advo- The immunization record/compliance review may be accom- cate in improving the quality of performance in a facility plished by manual review of child health records or by use has been demonstrated in all types of early childhood of software programs that use algorithms with the currently settings (1). A designated caregiver/teacher with health recommended vaccine schedules and service intervals to test training is effective in developing an ongoing relationship the dates when a child received recommended services and with the parents/guardians and a personal interest in the the child’s date of birth to identify any gaps for which refer- child (2,3). Caregivers/ teachers who are better trained are rals should be made. On the Website of the Centers for more able to prevent, recog- nize, 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

19 Chapter 1: Staffing Disease Control and Prevention (CDC), individual vaccine 3. Murph, J. R., S. D. Palmer, D. Glassy, eds. 2005. Health in child care: A recommendations for children six years of age and younger manual for health professionals. 4th ed. Elk Grove Village, IL: American can be checked at http://www.cdc.gov/vaccines/recs/ Academy of Pediatrics. scheduler/catchup.htm. 4. Alkon, A., J. Bernzweig, K. To, J. K. Mackie, M. Wolff, J. Elman. 2008. TYPE OF FACILITY Child care health consultation programs in California: Models, services, and facilitators. Public Health Nurs 25:126-39. Center, Large Family Child Care Home 5. Centers for Disease Control and Prevention (CDC). 2011. Immunization RELATED STANDARDS schedules. http://www.cdc.gov/vaccines/recs/schedules/. 1.3.1.1 General Qualifications of Directors 6. Hagan, J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Bright futures: Guidelines 1.3.1.2 Mixed Director/Teacher Role for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove 1.3.2.1 Differentiated Roles Village, IL: American Academy of Pediatrics. 1.3.2.2 Qualifications of Lead Teachers and Teachers 1.3.2.3 Qualifications for Assistant Teachers, Teacher 1.3.3 FAMILY CHILD CARE HOME Aides, and Volunteers CAREGIVER/TEACHER QUALIFICATIONS 1.4.2.1 Initial Orientation of All Staff 1.3.3.1 1.4.2.2 Orientation for Care of Children with Special General Qualifications of Family Child Care Caregivers/Teachers to Operate a Family Health Care Needs Child Care Home 1.4.2.3 Orientation Topics 1.4.3.1 First Aid and CPR Training for Staff All caregivers/teachers in large and small family child care 1.4.3.2 Topics Covered in First Aid Training homes should be at least twenty-one years of age, hold an 1.4.3.3 CPR Training for Swimming and Water Play official credential as granted by the authorized state agency, 1.4.4.1 Continuing Education for Directors and meet the general requirements specified in Standard 1.3.2.4 through Standard 1.3.2.6, based on ages of the children Caregivers/Teachers in Centers and Large served, and those in Section 1.3.3, and should have the Family Child Care Homes following education, experience, and skills: 1.4.4.2 Continuing Education for Small Family Child a. Current accreditation by the National Association for Care Home Caregivers/Teachers 1.4.5.1 Training of Staff Who Handle Food Family Child Care (NAFCC) (including entry-level quali- 1.4.5.2 Child Abuse and Neglect Education fications and participation in required training) and a 1.4.5.3 Training on Occupational Risk Related to college certificate representing a minimum of three credit Handling Body Fluids hours of early childhood education leadership or master 1.4.5.4 Education of Center Staff caregiver/teacher training or hold an Associate’s degree 1.4.6.1 Training Time and Professional Development in early childhood education or child development; Leave b. A provider who has been in the field less than twelve 1.4.6.2 Payment for Continuing Education months should be in the self-study phase of NAFCC 1.6.0.1 Child Care Health Consultants accreditation; 3.1.2.1 Routine Health Supervision and Growth c. A valid certificate in pediatric first aid, including CPR; Monitoring d. Pre-service training in health management in child care, 3.1.3.1 Active Opportunities for Physical Activity including the ability to recognize signs of illness, knowl- 3.1.3.2 Playing Outdoors edge of infectious disease prevention and safety injury 3.1.3.3 Protection from Air Pollution While Children hazards; Are Outside e. If caring for infants, knowledge on safe sleep practices 3.1.3.4 Caregivers’/Teachers’ Encouragement of including reducing the risk of sudden infant death syn- Physical Activity drome (SIDS) and prevention of shaken baby syndrome/ 7.2.0.1 Immunization Documentation abusive head trauma (including how to cope with a 7.2.0.2 Unimmunized Children crying infant); 8.7.0.3 Review of Plan for Serving Children with f. Knowledge of normal child development, as well as Disabilities or Children with Special Health knowledge of indicators that a child is not developing Care Needs typically; g. The ability to respond appropriately to children’s needs; References h. Good oral and written communication skills; i. Willingness to receive ongoing mentoring from other 1. Ulione, M. S. 1997. Health promotion and injury prevention in a child teachers; development center. J Pediatr Nurs 12:148-54. j. Pre-service training in business practices; k. Knowledge of the importance of nurturing adult-child 2. Kendrick, A. S., R. Kaufmann, K. P. Messenger, eds. 1991. Healthy young relationships on self-efficacy development; children: A manual for programs. Washington, DC: National Association l. Medication administration training (6). for the Education of Young Children.

20 Caring for Our Children: National Health and Safety Performance Standards Additionally, large family child care home caregivers/ 1.3.2.4 Additional Qualifications for Caregivers/Teachers teachers should have at least one year of experience serving Serving Children Three to Thirty-Five Months the ages and developmental abilities of the children in their of Age large family child care home. 1.3.2.5 Additional Qualifications for Caregivers/Teachers Assistants, aides, and volunteers employed by a large family Serving Children Three to Five Years of Age child care home should meet the qualifications specified in Standard 1.3.2.3. 1.3.2.6 Additional Qualifications for Caregivers/Teachers Serving School-Age Children RATIONALE In both large and small family child care homes, staff mem- 1.4.3.1 First Aid and CPR Training for Staff bers must have the education and experience to meet the 1.4.3.2 Topics Covered in First Aid Training needs of the children in care (7). Small family child care 1.4.3.3 CPR Training for Swimming and Water Play home caregivers/teachers often work alone and are solely 3.1.4.1 Safe Sleep Practices and Sudden Unexpected responsible for the health and safety of small numbers of children in their care. Infant Death (SUID)/SIDS Risk Reduction Most SIDS deaths in child care occur on the first day of References care or within the first week; unaccustomed prone (tummy) sleeping increases the risk of SIDS eighteen times (3). Shaken 1. Center for Child Care Workforce. 1999. Creating better family child care baby syndrome/abusive head trauma is completely prevent- jobs: Model work standards. Washington, DC: Center for Child Care able. Pre-service training and frequent refresher training Workforce. can prevent deaths (4). 2. National Association for Family Child Care. NAFCC official Website. Caregivers/teachers are more likely to administer medica- http://nafcc.net. tions than to perform CPR. Seven thousand children per year require emergency department visits for problems 3. Moon, R. Y., T. Calabrese, L. Aird. 2008. Reducing the risk of sudden infant related to cough and cold medications (5). death syndrome in child care and changing provider practices: Lessons learned from a demonstration project. Pediatrics 122:788-98. Age eighteen is the earliest age of legal consent. Mature leadership is clearly preferable. Age twenty-one is more likely 4. Centers for Disease Control and Prevention. Learn the signs. Act early. to be associated with the level of maturity necessary to inde- http://www.cdc.gov/ncbddd/actearly/. pendently care for a group of children who are not one’s own. 5. U.S. Department of Health and Human Services. 2008. CDC study The NAFCC has established an accreditation process to estimates 7,000 pediatric emergency departments visits linked to cough and enhance the level of quality and professionalism in small cold medication: Unsupervised ingestion accounts for 66 percent of and large family child care (2). incidents. Centers for Disease Control and Prevention (CDC). http://www. cdc.gov/media/pressrel/2008/r080128.htm. COMMENTS A large family child care home caregiver/teacher, caring 6. American Academy of Pediatrics, Council on School Health. 2009. Policy for more than six children and employing one or more statement: Guidance for the administration of medication in school. assistants, functions as the primary caregiver as well as the Pediatrics 124:1244-51. facility director. An operator of a large family-child-care home should be offered training relevant to the manage- 7. National Association for Family Child Care (NAFCC). 2005. Quality ment of a small child care center, including training on standards for NAFCC accreditation. 4th ed. Salt Lake City, UT: NAFCC. providing a quality work environment for employees. For more information on assessing the work environment of 1.3.3.2 family child care employees, see Creating Better Family Support Networks for Family Child Care Child Care Jobs: Model Work Standards, a publication by the Center for the Child Care Workforce (CCW) (1). Large and small family child care home caregivers/teachers should have active membership in a national, and/or state TYPE OF FACILITY and local early care and education organization(s). National Large Family Child Care Home organizations addressing concerns of family child care home caregivers/teachers include the American Academy RELATED STANDARDS of Pediatrics (AAP), the National Association for Family 1.3.1.1 General Qualifications of Directors Child Care (NAFCC), and the National Association for 1.3.1.2 Mixed Director/Teacher Role the Educa-tion of Young Children (NAEYC). In addition, 1.3.2.1 Differentiated Roles belonging to a local network of family child care home 1.3.2.2 Qualifications of Lead Teachers and Teachers caregivers/teachers that offers education, training and 1.3.2.3 Qualifications for Assistant Teachers, Teacher networking opportunities provides the opportunity to focus on local needs. Child care resource and referral Aides, and Volunteers agencies may provide additional support networks for caregivers/teachers that include professional development opportunities and information about electronic networking. RATIONALE Membership in peer professional organizations shows a commitment to quality child care and also provides a conduit for information to otherwise isolated caregivers/ teachers. Membership in a family child care association and attendance at meetings indicate the desire to gain new knowledge about how to work with children (1).

21 Chapter 1: Staffing COMMENTS pre-service training. This training should cover health, For more information about family child care associations, psychosocial, and safety issues for out-of-home child care contact the NAFCC at http://nafcc.net and/or the NAEYC at facilities. Small family child care home caregivers/teachers http://www.naeyc.org. Also, caregivers/teachers should check may have up to ninety days to secure training after opening to see if their state has specific accreditation standards. except for training on basic health and safety procedures and regulatory requirements. TYPE OF FACILITY All directors or program administrators and caregivers/ Large Family Child Care Home teachers should document receipt of pre-service training prior to working with children that includes the following RELATED STANDARDS content on basic program operations: 1.3.1.1 General Qualifications of Directors a. Typical and atypical child development and appropriate 1.3.1.2 Mixed Director/Teacher Role 1.3.2.2 Qualifications of Lead Teachers and Teachers best practice for a range of developmental and mental 1.3.2.3 Qualifications for Assistant Teachers, Teacher health needs including knowledge about the developmen- tal stages for the ages of children enrolled in the facility; Aides, and Volunteers b. Positive ways to support language, cognitive, social, and 1.4.2.1 Initial Orientation of All Staff emotional development including appropriate guidance 1.4.2.2 Orientation for Care of Children with Special and discipline; c. Developing and maintaining relationships with Health Care Needs families of children enrolled, including the resources 1.4.2.3 Orientation Topics to obtain supportive services for children’s unique 1.4.3.1 First Aid and CPR Training for Staff developmental needs; 1.4.3.2 Topics Covered in First Aid Training d. Procedures for preventing the spread of infectious 1.4.3.3 CPR Training for Swimming and Water Play disease, including hand hygiene, cough and sneeze 1.4.4.1 Continuing Education for Directors and etiquette, cleaning and disinfection of toys and equip- ment, diaper changing, food handling, health depart- Caregivers/Teachers in Centers and ment notification of reportable diseases, and health Large Family Child Care Homes issues related to having animals in the facility; 1.4.4.2 Continuing Education for Small Family Child e. Teaching child care staff and children about infection Care Home Caregivers/Teachers control and injury prevention through role modeling; 1.4.5.1 Training of Staff Who Handle Food f. Safe sleep practices including reducing the risk of 1.4.5.2 Child Abuse and Neglect Education Sudden Infant Death Syndrome (SIDS) (infant sleep 1.4.5.3 Training on Occupational Risk Related to Handling position and crib safety); Body Fluids g. Shaken baby syndrome/abusive head trauma preven- 1.4.5.4 Education of Center Staff tion and identification, including how to cope with a 1.4.6.1 Training Time and Professional Development Leave crying/fussy infant; 1.4.6.2 Payment for Continuing Education h. Poison prevention and poison safety; 10.6.2.1 Development of Child Care Provider Organizations i. Immunization requirements for children and staff; and Networks j. Common childhood illnesses and their management, including child care exclusion policies and recognizing Reference signs and symptoms of serious illness; k. Reduction of injury and illness through environmental 1. Fiene, R. 2002. 13 indicators of quality child care: Research update. design and maintenance; Washington, DC: U.S. Department of Health and Human Services, Office of l. Knowledge of U.S. Consumer Product Safety the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/ Commis-sion (CPSC) product recall reports; basic-report/13-indicators-quality-child-care. m. Staff occupational health and safety practices, such as proper procedures, in accordance with Occupational 1.4 Safety and Health Administration (OSHA) bloodborne PROFESSIONAL pathogens regulations; DEVELOPMENT/TRAINING n. Emergency procedures and preparedness for disasters, emergencies, other threatening situations (including 1.4.1 weather-related, natural disasters), and injury to infants PRE-SERVICE TRAINING and children in care; o. Promotion of health and safety in the child care setting, 1.4.1.1 including staff health and pregnant workers; Pre-service Training p. First aid including CPR for infants and children; q. Recognition and reporting of child abuse and neglect in In addition to the credentials listed in Standard 1.3.1.1, upon compliance with state laws and knowledge of protective employment, a director or administrator of a center or the factors to prevent child maltreatment; lead caregiver/teacher in a family child care home should provide documentation of at least thirty clock-hours of

22 Caring for Our Children: National Health and Safety Performance Standards r. Nutrition and age-appropriate child-feeding including recommends annual training based on the needs of the food preparation, choking prevention, menu planning, program and the pre-service qualifications of staff (4). and breastfeeding supportive practices; Training should address the following areas: a. Health and safety (specifically reducing the risk of SIDS, s. Physical activity, including age-appropriate activities and limiting sedentary behaviors; infant safe sleep practices, shaken baby syndrome/abusive head trauma), and poison prevention and poison safety; t. Prevention of childhood obesity and related chronic b. Child growth and development, including motor diseases; development and appropriate physical activity; c. Nutrition and feeding of children; u. Knowledge of environmental health issues for both d. Planning learning activities for all children; children and staff; e. Guidance and discipline techniques; f. Linkages with community services; v. Knowledge of medication administration policies and g. Communication and relations with families; practices; h. Detection and reporting of child abuse and neglect; i. Advocacy for early childhood programs; w. Caring for children with special health care needs, j. Professional issues (5). mental health needs, and developmental disabilities In the early childhood field there is often “crossover” in compliance with the Americans with Disabilities regarding professional preparation (pre-service programs) Act (ADA); and ongoing professional development (in-service programs). This field is one in which entry-level requirements differ x. Strategies for implementing care plans for children with across various sectors within the field (e.g., nursing, family special health care needs and inclusion of all children support, and bookkeeping are also fields with varying entry- in activities; level requirements). In early childhood, the requirements differ across center, home, and school based settings. An in- y. Positive approaches to support diversity; dividual could receive professional preparation (pre-service) z. Positive ways to promote physical and intellectual to be a teaching staff member in a community-based organi- zation and receive subsequent education and training as part development. of an ongoing professional development system (in-service). The same individual could also be pursuing a degree for a RATIONALE role as a teacher in a program for which licensure is required— The director or program administrator of a center or this in-service program would be considered pre-service large family child care home or the small family child care education for the certified teaching position. Therefore, the home caregiver/teacher is the person accountable for all labels pre-service and in-service must be seen as related to policies. Basic entry-level knowledge of health and safety a position in the field, and not based on the individual’s and social and emotional needs is essential to administer professional development program (5). the facility. Caregivers/teachers should be knowledgeable about infectious disease and immunizations because pro- COMMENTS perly implemented health policies can reduce the spread of Training in infectious disease control and injury preven- disease, not only among the children but also among staff tion may be obtained from a child care health consultant, members, family members, and in the greater community pediatricians, or other qualified personnel of children’s (1). Knowledge of injury prevention measures in child care and community hospitals, managed care companies, health is essential to control known risks. Pediatric first aid train- agencies, public health departments, EMS and fire pro- ing that includes CPR is important because the director fessionals, pediatric emergency room physicians, or other or small family child care home caregiver/teacher is fully health and safety professionals in the community. responsible for all aspects of the health of the children in For more information about training opportunities, contact care. Medication administration and knowledge about the local Child Care Resource and Referral Agency (CCRRA), caring for children with special health care needs is essen- the local chapter of the American Academy of Pediatrics tial to maintaining the health and safety of children with (AAP) (AAP provides online SIDS and medication adminis- special health care needs. Most SIDS deaths in child care tration training), the Healthy Child Care America Project, or occur on the first day of child care or within the first week the National Resource Center for Health and Safety in Child due to unaccustomed prone (on the stomach) sleeping; the Care and Early Education (NRC). California Child-care risk of SIDS increases eighteen times when an infant who Health Program (CCHP) has free curricula for health and sleeps supine (on the back) at home is placed in the prone safety for caregivers/teachers to become child care health position in child care (2). Shaken baby syndrome/abusive advocates. The curriculum (English and Spanish) is free to head trauma is completely preventable. It is crucial for download on the Web at http://www.ucsfchildcarehealth.org/ caregivers/teachers to be knowledgeable of both syndromes html/pandr/trainingcurrmain.htm, and is based on the and how to prevent them before they care for infants. Early National Training Institute for Child Care Health Consul- childhood expertise is necessary to guide the curriculum tants (NTI) curriculum for child care health consultants. and opportunities for children in programs (3). The mini- mum 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,

23 Chapter 1: Staffing Online training for caregivers/teachers is also available children in care can enter the field. Training ensures that through some state agencies. staff members are challenged and stimulated, have access For more information on social-emotional training, contact to current knowledge (2), and have access to education the Center on the Social and Emotional Foundations for that will qualify them for new roles. Early Learning (CSEFEL) at http://csefel.vanderbilt.edu. TYPE OF FACILITY Use of videos and other passive methods of training should Center, Large Family Child Care Home be supplemented by interactive training approaches that RELATED STANDARDS help verify content of training has been learned (3). 1.3.1.1 General Qualifications of Directors 1.4.3.1 First Aid and CPR Training for Staff Health training for child care staff protects the children in 1.7.0.1 Pre-Employment and Ongoing Adult Health care, staff, and the families of the children enrolled. Infec- tious disease control in child care helps prevent spread of Appraisals, Including Immunization infectious disease in the community. Outbreaks of infec- 9.2.4.5 Emergency and Evacuation Drills/Exercises Policy tious diseases and intestinal parasites in young children 9.4.3.3 Training Record in child care have been shown to be associated with 10.6.1.1 Regulatory Agency Provision of Caregiver/Teacher community outbreaks (4). and Consumer Training and Support Services Child care health consultants can be an excellent resource 10.6.1.2 Provision of Training to Facilities by Health for providing health and safety orientation or referrals to resources for such training. Agencies References COMMENTS Many states have pre-service education and experience 1. Fiene, R. 2002. 13 indicators of quality child care: Research update. qualifications for caregivers/teachers by role and function. Washington, DC: U.S. Department of Health and Human Services, Office Offering a career ladder and utilizing employee incentives of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/ such as Teacher Education and Compensation Helps basic-report/13-indicators-quality-child-care. (TEACH) will attract individuals into the child care field, where labor is in short supply. Colleges, accrediting bodies, 2. Hayney M. S., J. C. Bartell. 2005. An immunization education program for and state licensing agencies should examine teacher prepara- childcare providers. J of School Health 75:147-49. tion guidelines and substantially increase the health con- tent of early childhood professional preparation. Child care 3. Moon R. Y., R. P. Oden. 2003. Back to sleep: Can we influence child care staff members are important figures in the lives of the young providers? Pediatrics 112:878-82. children in their care and in the well-being of families and the community. Child care staff training should include 4. Ritchie, S., B. Willer. 2008. Teachers: A guide to the NAEYC early childhood new developments in children’s health. For example; a new program standard and related accreditation criteria. Washington, DC: training program could discuss up-to-date information on National Association for the Education of Young Children (NAEYC). the prevention of obesity and its impact on early onset of chronic diseases. 5. National Association for the Education of Young Children. 2010. Definition of early childhood professional development, 12. Eds. M. S. Donovan, J. D. TYPE OF FACILITY Bransford, J. W. Pellegrino. Washington, DC: National Academy Press. Center, Large Family Child Care Home 1.4.2 RELATED STANDARDS ORIENTATION TRAINING 1.4.4.1 Continuing Education for Directors and 1.4.2.1 Caregivers/Teachers in Centers and Large Initial Orientation of All Staff Family Child Care Homes 1.4.4.2 Continuing Education for Small Family Child All new full-time staff, part-time staff and substitutes Care Home Caregivers/Teachers should be oriented to the policies listed in Standard 9.2.1.1 1.4.5.1 Training of Staff Who Handle Food and any other aspects of their role. The topics covered and 1.4.5.2 Child Abuse and Neglect Education the dates of orientation training should be documented. 1.4.5.3 Training on Occupational Risk Related to Handling Caregivers/teachers should also receive continuing educa- Body Fluids tion each year, as specified in Continuing Education, 1.4.5.4 Education of Center Staff Standard 1.4.4.1 through Standard 1.4.6.2. 1.4.6.1 Training Time and Professional Development Leave RATIONALE 1.4.6.2 Payment for Continuing Education Orientation ensures that all staff members receive specific 1.6.0.1 Child Care Health Consultants and basic training for the work they will be doing and are 9.2.1.1 Content of Policies informed about their new responsibilities. Because of fre- 9.4.3.3 Training Record quent 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 assis- tant teacher should be attractive and facilitated so that capable members of the families and cultural groups of the