Healthy Young Children: a Manual for Programs. INSTITUTION Administration for Children, Youth, and Families (DHHS), Washington, D.C.; Georgetown Univ

,DOCUMENT 'RESUME

PS 017 779

:AUTHOR Kendrick, Abby Shapiro, Ed.; And Others TITLE Healthy Young Children: A Manual for Programs. INSTITUTION Administration for Children, Youth, and Families (DHHS), Washington, D.C.; Georgetown Univ. Child Development Center, Washington, DC.; Health 'Resources and Services Administration (DHHS/PHS), Rockville, MD. Office for Maternal and Child Health Services.; Massachusetts State Dept. of Public Health, Boston.; National Association for the Education of Young Children, Washington, D.C. REPORT NO ISBN-0-935989-13-7 PUB DATE 88' NOTE 346p. AVAILABLE FROMNational Association for the Education of Young Children, 1834' Connecticut Avenue, N.W.,liashington, DC 20009-5786 (NAEYC Publication No. 704, $12.00. No shipping charges on pre-paid orders). PUB TYPE Guided = -Non-Classroom Use (055)

EDRS PRICE MFO1 Plud Postage. PC Not Available from EDRS. DESCRIPTORS- Child Abuse; Child Neglect; *Disease Control; Diseases; Early Childhood Education; Environmental Influences; FirstAid; Guidelines; *Health Education; Lead Poisoning; *Nutrition; Prevention; *Safety; *Sanitation; Special Education; Standards IDENTIFIERS *Child Health,

ABSTRACT This manual, which was developed as a reference and resource guide ,fOr program directors and teachers of young children, describes high standards for health policies. Also provided are information based on current research and recommendations from experts in health and early childhood education. The manual contains 7 sections and 19 chapters. Section A, which concerns the promotion of health in programs for young children, focuses on policies, providers, records, and health education in early childhood programs. Section B discusses the creation of a healthy environment, sanitation standards, diapering, and toilet learning. Section C deals with safety and first aid, and also covers transportation and emergencies. Preventive health care and dental health for children and adults are considered in section D. &lotion E deals with nutrition in programs for young children. Section F focuses- on special health issues, including children with special needs, child abuse and neglect, lead poisoning, and chronic health conditions. The concluding Section G ,provides guidance for managing illnesses, and discussion of infectious diseases and care of the mildly ill child. Appendices providelists of national resources for health and safety information and children's picture books about health, nutrition, and safety. (RH)

*********************************************************************** Reproductions supplied by EDRS are the best-that can be made from the original-document. *********************************************************************** -7- ,DOCUMENT RESUME

'ED 303'264 PS 017 779

AUTHOR Kendrick, Abby Shapiro, Ed.; And Others TITLE Healthy Young Children: A Manual for Programs. INSTITUTION Administration for Children, Youth, and Families (DHHS),-Washington, D.C.; Georgetown Univ. Child Development Center, Washington, DC.; Health Redources and Services Administration_ (DHHS/PHS), Rockville, 190. Office for-Maternal and Child Health Services.;, Massachusetts. State Dept. of Public Health, Boston.; National Association for the Education of Young Children, Washington, D.C. REPORT NO ISBN-0-935989-13-7 PUB DATE 88 NOTE 346p. AVAILABLE FROMNational Association for the,Education of Young Children, 1834Connecticut Avenue, N.W.,illashington, DC 20009-5786 (NAEYC Publication No. 704, $12.00. No shipping charges on pre-paid-orders). PUB TYPE Guided :=.11on-Clasdroom Use (055)

EDRS PRICE -MF01 Plug Postage. PC Not Available from EDRS. DESCRIPTORS -Child Abude; Child Neglect; Diseade Control; Diseases; Early Childhood-Education; Environmental Influences; First.Aid; Guidelines; *Health Education; Lead Poisoning; *Nutrition; Prevention; *Safety; *Sanitation;: "Special EduCatio4; Standards IDENTIFIERS *Child Health,

ABSTRACT This manual, which was defeloped as a reference and :resource guide fin' program directorb and teachers of young children, describes high standards for health policies. Also provided are information based On current research and.recommendations from experts in health and early childhood education. The manual contains 7 aeCtions-and 19 chapters. Section A, which concerns the promotion of health in programs for young children, focuses on policies,, providers, records, and health education in early childhood programs. Section.B discusses_ the creation of a healthy environment, sanitation standards, diapering,- and toilet learning. Section C deals with safety and first aid, and also covers transportation and emergencies. Preventive health care and dental health for children and adUlts are -considered in section D. SLIctioa E deals with nutrition in programs for young children. Section-F focuses on speCial health issues, including children with special needs, child abuse and neglect, lead Poisoning, and chronic health conditions.. The concluding Section G Trovide0 guidance for managing illnesses, and discuiSion of infectious diseases and care of the mildly ill child. ApOendices provide lists-of national resources for health and safety information and children's picture books about health, nutrition, and safety. (RH)

********************************************************************** Reproductions supplied by EDRS are the best that can 'be made from the original-document. *********************************************************************** Healthy Young 'Children A Manual for Programs

Editors Abby Shapiro Kendridc, Roxane Kaufmann, and 'Catherine P. Messenger

Consulting Editors Francine H. Jacobs and Serena Mailloux, M.D.

A cooperative effort of Administration fOr Children, Youth and Families Division of Maternal and Child Health, U.S. Department of Health and Human Servkes Georgetown liniversKy Child Development Center Massadmittts,Department-of Pubik Health National Association for the Education of Young Children

A 1987-88 Comprehensive Membership Benefit BEST COPYAVAILABLE National Association for the Education of YoungChildren Washington, D.C. 3 This manual Was funded through an intra - agency agreement between the Adminict Ation for Children, Youth and Families; the Division of Maternal and Child Health, U.S. Department of Health and Human Services; and the Massachusetts Depaitment of Public Health, through federal Maternal and Child Health Block Grant funds to Georgetown University Child Development Center, 3800 Reservoir Road, N.W., Washington, DC 20007.

Photographs - Hildegard Adler Cover I Nancy P. Alexander 21, 38, 46, 93, 116, 117, 144, 189 Dena Bawinkel 217 Robert J. Bennett 156 Marja Bergen 32 Jim Bradshaw Cover 1, 195 Cleo Freelance Photo 36, 118 Rose Engel 191 J. D. Images 59 Robert Koenig163, 169 Marietta Lynch 120, 254 Lois Main 145 Gunnar Mengers 162 Merrie L. `Murray 89 Katherine Nell 225 Marilyn L. Nolt 237 Wendy Press 52 Rick Reinhard 280 Paul M. Schrock 199 Michael Siluk 64 Steve & Mary Skjold Photographs 122 Michaelyn Straub85, 296 Subjects & Predicates173, 192, 233, 244, 281 'Dave Swan 53 James A. Tuck Cover 1 Francis Wardle 15

Production coordinator and designer Melanie Rose White

Published by the National Association for the Education of Young Children 1834 Connecticut Avenue, N.W. Washington, DC 20009-57,86

Library of Congress Catalog Card Number. 88-060739 ISBN Catalog Number: 0-935989-13-7' NAEY0#704

Printed in the United States of America Preface As program- directors and teachei, you must protect and promote the health and well-being of the young children, staff, and families in your care. This manual was-developed as a reference and resource guide to help you -meet your health and safety responsibilities. You can achieve Major health gainS by taking several simple steps. Washing hands, for example, is the single best thing peoplecan do to prevent the spread of disease. When you includeoothbrushing in the daily routine, children learn good habits for life. You may-preventa tragic injury by conducting frequent site afety checks. Your careful, regular observations of children may reveal heafth problems thatcan respond to early treatment. Specificinformation, procedures, and recommendations on each of these topics, as well as on many others, are provided here. The information included reflects the most current research and recommendations from experts in the fields of health and early childhoOd education. In such rapidly changing fields, however,new information and approaches are constantly emerging. Youare- encouraged.to gather such information and add it to the topics in this document. This manual has been extensively reviewed by both health and early childhood professionals and describes very high standards for health polieies. None of:the recommendations was made lightlyor without gotid evidence that it is important to protect the health of children and staff. You may find it impossible to meetsome of these standards in your program. Implementas many of these recommendations as you can, but don't expect to change everything overnight. Plan carefully and thoroughly before you make any changes. You may find that some of our recommendations differ from materials you have received from the Centers for Disease Control (CDC) or from your own health consultants. Because there isnot complete agreement within the medical community about specific procedures and treatments, you will have to make the best decision you can after hearing many points of view. Your state department of public health can serve as a valuable resource for information-and guidance. Healthy Young Children was designed as a reference document and contains a great deal of information. In order to use it effectively,you should read it through at least one time to become familiar with the contents and to complete information for your program. You.nray copy any part of the manual for staff, parents,your health consultant, or community agencies, but besure to acknowledge the source of the material when you reuse it: Acknowledgments Hundreds of people have been involved in the preparation of this document. The need for a comprehensive guide abotwhealth in programs for young children has been acute. The Preschool Health Program, Division of Family Health Services, Massachusetts Department of Public Health first tackled the enormous task of pulling together material for childcare workers in that state. At the same time, the Georgetown University Child Development 'Center and the National Association for the Education of Young Children were also seeking to publish materialon child care health. A grant from the Administration for Children, Youth and Families and the DivSion-of Maternal and Child Health of the U.S. Department of Health and Human Services was awarded to Georgetownto develop materials on the topic. Georgetown and NAEYCwere fortunate to learn of the work from Massachusetts and collaborated with Abby Shapiro Kendrick to adapt the original material, written especially for 'Massachusetts, for a national audience. In addition to the -Massachusetts edition, a limited edition was made available through Georgetown University Child Development Center. Since those volumes were released, the material has been revised further and updated by the National Association for the Education of Young Children. Any undertaking of this magnitude necessarily involvesmany people with expertise in different areas. Some wrote major sections of the book, others served as reviewers, and still otherswere consultantS. Several provided editorial and word processing services. The editors gratefully acknowledge the contributions of these and many other people and organizations whose untiring efforts made this ambitious volume a reality.

.71.111111,1 Contributing authoirs Susan S. Aronson, M.D: Michelle Miclette Mary JeamBrown Janice Mirabassi Elba Crespo Lynne.Mofenson,;M.D. Margaret Dyke Ruth Palombo Ellie Goldberg Barbara. Polhamus Jo-Ann S. Harris, M.D. Preschool Enrichment Team staff Marilyn Hoy- Youngblood Melissa Ann Renck Paul Hunter Cindy Rodgers -Francine Jacob: Mary Terrell 'Mary Renck Jalongo Patricia Wise Massachusetts Department of Social' Services

Reviewers SuSan S. Aronson, M.D., primary reviewer

American Academy of Pediatrics Susan Gallagher American Red Cross Ellie Goldberg Jenny Austin Mary Greene Phil Bairnas Bernard Guyer fran Barrett Dorothy Hall Helene Bednarsch Jo-Ann S. Harris, M.D. Connie Brown Cathy Hess Mary Jean Brown Patti Hills Linda Burbank Marilyn Hoy-Youngblood Nancy Carrey-Beaver Lily Hsu Peggy Casey Paul Hunter Centers for Disease Control Francine Jacobs Lisa Cole Mary Rend- Jalongo Gregory Connolly Karl Kastorf Pamela Coughlin Marie Keefe Elba Crespo Nancy Kloczko Donna Deardorff Beverly Larson Betty Donovan Mary Leary Joan Doyle Lihette Lieblirig Ma-rgaret Dyke Anne Long Beverly Edgehill Phyllis Magrab Bess Emanuel Marion Malinowski ,Martin Favero, M.D. Massachusetts Department of Social Services Gail Fenton Bernadine McQueeney Sally. Fogerty Michelle Miclette Karen Frederick Janice Mirabassi Beth Fredericks Lynne Mofenson, M.D. Donna Haig Friedman New England Association for the Education Gerri Norris Funke of Young Children 7 Revieviers continued

Jean Collins Norris Benjamin Siegel Mary O'Connor Barbara Silverstein Ruth Palombo Havi Standen Fran. Patch Mary Terrell Rea Pfeiffer Linda,Truitt Judith Pokorni Deborah Klein Walker Barbara Polhamus Deborah A. Waring Preschool Enrichment Team staff Michael Weitzman Elizabeth Pressman Howard Wensley Virginia Rail Jack Wertheimer Melissa Ann Renck Becky Wilson Robin- Roderiques Patricia Wise Cindy Rodgers Suzi Wojdyslawski Pamela Romanow Linda Yeomans Dennis Rosen Marian Zeitlin TanyaRyden. David Zuccolo ,Nancy Schirmer Ken Schulman Joyce Sebian Jack Shonkoff Contents Preface v `List of figures xv Section A. Promoting health in programs for young children Chapter 1. The basics: Policies, providers, and records 3 Health policies3 Staff responsibilities for health3 Communicating.with health providers14 Keeping health records16

Chapter 2. Health education in programs for young children19 Health curriculum for children19 Health education for staff and parents 20 Section. B. Healthful environment Chapter 3. Creating a healthy environment 25 Keeping clean with bleaCh25 Handwashing 25 Disposable gloves28 Space 28 (iir quality 28 Asbestos31, Food handling31 Handling contaminated items31 Turnover and health issues32 Risks from play materials and activities32 Chapter 4. Sanitation standards 35 Housekeeping 35 Handwashing 36 Kitchen facilities38 Storage and disposal of garbage39 Laundry 39 Toilet facilities39 ,Fluttbing40 Ventilation, light, and heat 40 Chapter, 5. Diapering and toilet learning 43 Diapering 43 Toilet learning 46 9 t Section C. Safety and first aid Chapter 6. Safety 51 Creating a safe facility51 Times when children get hurt51 Indoor safety51 -Safety bey6nd the classrooms 54 Special safety tips for infants and toddlers60' Safety education82 Chapter 7. Transportation safety 85 Child safety restraints85 Preparation for emergencies 87 Field trips/car pools89 Passenger safety education89 Chapter 8. Emergencies and first aid 93 Preparing for emergencies93 Getting help94 Emergency evacuation,plans 94 `First-aid procedures96 First aid for common situations97 First-aid education100. Section D. Preventive health care Chapter 9. Preventive health care for children109 Why preventivecare is impoiiant109 Health histories111 Observations116 Major health screenings117 Medical examinations120 Chapter 10. Adult health135 Ways to promote good adult health135 Your adult health plan135 Chapter 11. Dental health143 Healthy foods'for teeth143 Fluoride143 Brushing teeth143 Dental health education144 Dental ca' 144 Special denial problems146

10 Section E. Nutrition Chapter 12. Nutrition in programs for young children131 Feeding infants151 Feeding toddlers156 Basic nutrition facts157 Common nutritional concerns163 Special nutritional concerns165 Special nutritional problems165 Nutrition education168 Feeding children who have special needs169 Dietitry guidelines for all ages169 Weakling- 170 Nutrition education with young children170 Community nutrition resources172 Running a food service174 Section F. Special health issues Chapter 13. Children with special needs 189 Mainstreaming/ 190 Staff's feelings and attitudes toward special needs children191 Resources and support- 192 Modifying your program192 HandiCapping conditions197 -Chapter 14. Child abuse and neglect199 Identification of abused and neglected children199 Characteristics of child abusers 201 How early childhood educators can help abused children201 Reporting procedures 203 Preventing abuse and neglect in programs for young children 203 Chapter IS. Lead poisoning 209 Sources of lead209 Lead screening 209 ' Treatment and follow-up, 210 Environmental manageMent 210 Measures to protect children210 Chapter 16. Chronic health conditions 213 Allergy 213 Asthma 217 Heart problems 218 Epilepsy/seizure disorder '221 Sickle-cell anemia 223 Diabetes 223 Review of emergency planning considerations225 Section G. Managing illnesses Chapter 17. Infectious diseases 229 The five commandments of infectious diseases control229 Diseases spread through the intestinal tract233 Diseases spread through the respiratory tract242 Diseases spread through direct contact 254 Diseases spread through blood or other intimate body fluid contact267 Vaccine-preventable diseases271 Noncontagious infectious diseases274 Chapter 18. Care of the mildly ill child 279 Basic issues for decision making 279 Common minor illnesses283 How to give medication288 Chapter 19. Models for the care of sick children 293 General guidelines293 Care for sick children in group programs293 Care for sick,children in family day care programs 294 Sick care,;;ervices at home 294 Appendix 1. National resources for health and safety 297 Appendix 2. Children's picture books about health, nutrition, and safety 303 Compiled by Mary Renck Jalongo and Melissa Ann Renck Index 305 Information about NAEYC

12 List of figures

1-1.Topics to include in health policies4 2-1.Safilp le integrated health education objectives: Mental/family health21 3-1.,Bleach solution26 3-2.Handwashing poster27 3-3.Alternative to running water 29 4-1.Handwashing procedure 37 5-1.How to change a diaper 44 6-1.Poisonous plants55 6-2.How to choose art supplies56 6-3.Safe playground habits58 6-4.How to select safe infant furniture and equipment61 6-5.Safe toys for children younger than age 365 6-6.Site safetychecklist66 6-7.Playground safety checklist73 7-1.Ten rules for transportation safety86 7-2.How to use car safety seats and safety restraints88 8-1.Emergency procedures 101 8=2. First-aid kit contents102 8-3.Emergency transportation permission form103 8-4.Injury report form104 8-5.Phone emergency list105 9-1,. Recommendations for preventive pediatric health care 110 9-2.Potential health team members112 9-3.Developmental health history113 9-4.Developmental red flags for children ages 3 to 5 years122 9-5.Descriptions of four valid developmental screening instruments128 9-6.Physician's exam form 130 10-1.How to care for your back 136 11-1.Dental referral criteria for 3-year-old children146 12-1.Developmental sequence of feeding skills153 12-2.Infant feeding guide154 12-3.Preschool feeding guide158 12-4.Ideas for nutritious snacks160 12-5.Types of vegetarian diets164 12-6.Dietary sources of calcium166 12-7.Ideas for nutrition education171 12-8.Child Care Food Program: Meal pattern requirements 175 12-9.Sample weekly menus 176 12-10. Menu planning worksheet182

,. List of figures continued

13-1.National resources for children ivith special needs193 14-1. Considerations when examining materials on child sexual abuse/personal safety for young children205 14-2.National-resources for information on child abuse and neglect206 16-r.Program considerations for young children with health impairments 214 16-2.Chronic illness health record215 16-3.Asthma record219 17-1.Recommended immunization schedules230 17`-':Exclusion guidelines234 17-3.Letter to parents about diarrheal diseases239 17;4.Letter to parents about pinworms 241 17-5.Letter to parents about hepatitis A 243 17-6.Letter to parents about strep throat246 17 -7. Letter to parents about chicken pox 248 17-8.Letter to parents about meningococcal illnesses250 17-9.Letter to parents about Hib disease252 17-10. Lettei- to parents about impetigo256 17-11. Letter to parents about ringworm 258 17-12. Letter to parents about conjunctivitis259 17-13. Letter to parents about scabies261 17-14. Letter to parents about head-lice263 17-15. Symptoms/diagnosis/treatment of major sexually transmitted diseases268 18 -1. Symptom record282 18-2.'How to take a child's temperature 284 18-3.Parent permission to administer medication and log form 289

I4 ;lq Section A Promoting health in programs for young children

Major concepts The health,,program must be carefully planned and carried out through comprehensive health policies that integrate community resources. All-staff and parents must be aware of and fully Understand your program's health

The experiences of children and families in your program can lay the foundation for future health practices. Early childhood educators promote better child health by encouraging appropriate health care and offering some preventive health services.

5 1 The basics: Policies, providers, and records

Health policies so that they can be easily referenced. You may want to color code or index sections for fast access in an Health care policies are the blueprint for thinking emergency. about health issues and how they relate to other Be sure to give copies of your health care policies aspects of your program. They should bring to- to all staff, parents, and health consultants. Post a gether the recommendations of staff, parents, reference copy at each telephone in your center. health experts, and especially your health con- Make sure everyone is told about policy revisions. sultant. You should review and revise the policies each year in response to program experiences and new medical recommendations. Staff responsibilities for health

Tips on writing policies Health policies are an excellent means to protect Write specific and detailed policies. Keep in mind and promote children's health. Through them you the following questions. WHO (is responsible)? create a healthful and safe environment; practice WHAT? WHERE? WHEN? WHY? HOW? Be sure preventive measures such as washing hands and responsibilities are clearly defined. For example, monitoring the safety of the playground; and edu- policies about the first-aid kit might be cate staff, parents, and children about health issues. Daily observation of children during a long period The director will purchase all items for the first- of time plays a critical role in identifying potential aid kit and review its contents eve-month to health probiems. While staff members are not ex- be sure all supplies are available. The kit shall at pected to diagnose medical problems, they can add all times contain....The first-aid kit will be to the information used to make the diagnosis. stored out of children's reach on the top shelf in One of the services early childhood programs pro- thenitlathroom above the sink. Any teacher who vide is to act as a switchboard for health data ad isters first aid to a child must report the receiver, collector, and distributor of health infor- incident on the injury report on the day it oc- mation. The administrator should obtain a medical curs. The report shall be filed in the child's record and a detailed developmental health history folder and the center incident log. ParentS shall for each child in the program. Both the administra- receive a copy as well. tor and teaching staff should become familiar with Include parents, staff, and your health consultant this information. It is easy to assume a child who in a small committee to write or review /revise your appears very healthy has no outstanding health policies. Send the draft to staff, parents, and medi- needs. However, if you do not know he is allergic to cal experts for review. Be sure the policies are un- bee stings, you could be confronted with a shocking derstood and that all groups are willing to carry and life-threatening emergency if he is stung. Or, them out. knowing that a child has had an extended early hos- Figure 1-1 outlines topics to include when you pitalization may help you to understand her sep- write or revise your policies. You should develop aration difficulties or her reluctance to becOme at- policies that work well in your program and thq tached to staff. suit your needs. Organize the policies under topics Teachers must be trained in first aid and CPR

3 Figure 1-1. Topics to include in health policies 41.

What is the outcome Who is responsible? What is the process? When will it be done? Where/how and other (purpose)? Or, why (How will it be done?) information should it be done?

Children's health records

1. Contents of health record (include forms used) (a) enrollment form/developmental health history (b) physical examinations/immunization status/growth data (c) injury reports

(d) medicine log (e) screening/assessment results (I) parent permission slips

(g) problem list with information about chronic disease/special needs

2. Screenings 3. Review/update of health record 4. Communication system among health providers, staff, parents 5. Protection of confidentiality

7 Figure 1-1 cont. Topics to include in health policies

What is the outcome Who is responsible? What is the process? When will it be done? Where/how and other (purpose)? Or, why (How will it be done?) information should it be done? Staff health records

1. Requirements for pre- employment and periodic health exams (including who pays)

2. Contents of health record

(a) health history (b) Immunization status (c) results of initial and subsequent health exams (d) record of injuries at work

3. Staff exclusion policies

4. Plan for sick leave, breaks, and substitutes

Health consultant(s)

1. Tasks

2. Backup resources for special situations, e.g., . outbreak of infectious disease

3. Fee arrangements, if any

4. Lines of communication (Who can contact health consultant? To whom does health consultant give advice?) (ft Figure 1-1 cont. Topics V) include in-health policies

What is the outcome Who is responsible? What is the process? When will it be done? Where/how and other (purpose)? Or, why (How will it be done?) information should it be done?

Daily admission

1. Greet child/observe possible health problems

2. Communication system between staff and parents (e.g., nap, food, bowel movements, mood)

The environment

1. Method for checking and correcting safety hazards, lighting, heating, ventilation, and maintenance problems

2. Supervision required in classroom/playground

3. Safe storage of poisonous and hazardous materials

4. Location of activities in relation to handwashing facilities.

5. Disposal of contaminated items and trash

6. Changing of diapers/clothing

7. Arranging for soiled clothing/bedding to be properly laundered Figure 1-1 cont. Topics to include in health policies

What is the outcome Who is responsible? What is the process? When will it be done? Where/how and other (purpose)? Or, why (How will it be done?) information The environment should it be done? cont.

8. Cleaning the center, including bathrooms, kitchen, play areas, toys; schedule for cleaning; cleaning agents

9. Cleaning and storing individual rest equipment

10. Pufchase of safe equipment and cleaning, pest control, and art materials

Ill children

1. Evaluate symptoms

2. Contact parent(s) or emergency person

3. Reasons for including/ excluding ill children

4. Decide whether child can attend, will remain in or leave program

5. Get medical advice, if needed

6. Provide care for ill children who are waiting to be picked up or are included

7. Monitor status of ill children who are excluded

23 0 C7 Figure 1-1 cont. Topics to include in health policies 00

What is the outcome Who is responsible? What is the process? When will it be done? Where/how and other . (purpose)? Or, why (How will it be done?) information should it be done?

Medications

1. Determine whether program will accept responsibility for administering medications and which ones (i.e., oral, topical, eye, rectal, nasal, ear, injectable, inhalers)

2. Get written parent permission with doctor's orders.

3. Storage

4. Give medications

5. Record medicines given

6. Parent/staff communication (e.g., side effects, child's reactions)

Outbreaks of infectious diseases

1. Identify the illness

2. Communications with involved children's health providers

3. Specific measures to prevent spread

4. Notify other parents/local health department

r 2 L.) Figure 1-1 cont. Topics to include in health policies

What is the outcome Who is responsible? What is the process? When will it be done? Where/how and other Outbreaks of (purpose)? Or, why (How will it be done?) information infectious diseases should it be done? cont,

5. Program's treatment plan, when necessary (e.g., Rifampin for meningococcus)

6. Experts to consult

7. Maintain up-to-date list of diseases to be reported to state health department

Emergency preparedness

1. Post emergency plan near all telephones and exits

2. Keep emergenc- contact person file up-to -date

3. Evacuation procedures including special considerations for infants, toddlers, and non-walkers

4. Staff responsibilities

5. Scheduled and unannounced evacuation drills

6. Alternate facility to use -until parents can come for children if return to child care site is not possible.

27 2° Figure 1-1 cont. Topics to include in health policies 0 . What is the outcome Who is responsible? What is the process? When will it be done? Where/how and other (purpose)? Or; Why (How will it be done?) information should it be done?

Injuries

1. Identity of first alders

2. Assess injuries

3. Give first aid

4. First-aid procedures

5. Type, location, and maintenance of first-aid supplies

6. Notify parents

7. Emergency transportation

8. Write/file injury report

9. Special field trip procedures (e.g., portable first-aid supplies, sources of emergency help, copies of consents and emergency forms, safety precautions, additional adults)

10. Review injury reports to identify hazards

Transportation

1. Requirements for vehicle safety restraints for children and adults

2. Safety procedures for field trips

IL Dr "9 t Figure 1-1 cont. Topics to include in health policies

What is the outcome Who is responsible? What is the process? When will it be done? Where/how and other (purpose)? Or, why (How will it be done?) information should it be done? Transportation cont.

3. Procedures for safe arrival and departure, including escorting children to and from vehicles

4. Selection of drivers

5. Driver training

6. Late arrival/pickup

7. Maintenance of vehicles

8. Requirements for attendants in addition to the driver

Nutrition/food preparation and handling

1. Obtain and use information about child's usual feeding schedule, food habits, vitamin and mineral supplements, food allergies, cultural eating habits

2. Manage food services, including food orders, menu plans, food preparation, storage, inventory, and turnover of stock supplies

3. Transport/store perishable foods sent from home to program Figure 1-1 cont. Topics to include in health policies

What is the outcome Who is responsible? What is the process? When will it be done? Where/how and other (purpose)? Or, why . (HowwilVit,be done?) information should it be done? Nutrition/food handling .

4: Special food procedures for infants

Dental

1. Daily teeth/gums cleaning procedure

2. Store toothbrushes

3. Dental first-aid procedures,

4. Fluoridation program, if appropriate Children's health curriculum

1. Concepts/topics to be taught

2. Methods to integrate health into overall curriculum Staff/parent health education

1. Process to assess needs

2. Methods (e.g., workshops, newsletters)

3. Possibie topics to be covered 3 3- Oil Figure 1-1 cont. Topics to include in health policies

What is the outcome Who is responsible? What is the process? When will it be done? Where/how and other (purpose)? Or, why (How will it be done?) information should it be done? Child abuse/neglect

1. Recognizing signs of abuse/neglect

2.Documentation of observations

3. Procedures for filing reports of suspected abuse or neglect

4. Procedures for handling accusations of abuse/neglect by program staff

5. Procedures/resources for children who have been abused/neglected

Resource and referral

1. Procedure to refer for screening, diagnosis, treatment, or support services

2. Resources commonly used for training, curriculum development, screening, treatment, support services, medical consultation, financial assistance

ro. 14 Promoting health in programs

(cardiopulmonary resuscitation), and learn to rec- take appropriate action when children are injured ognize common childhood illnesses. In addition to or sick, including contacting parents when neces- obtaining health data for individual children, child sary care staff must learn how to deal with their specific maintain a working relationship with a health needs. For instance, asthma is very common in early consultant and community health resources childhood. If you have a child with asthma in your supervise caregivers to be sure they follow your program, review the history of treatment and cur- health policies rent medications. Use reference material to read assist families to arrange health care, as requested about asthma's triggers and signs of distress. Ask the coordinate health education for children, staff, parents how the child responds best during the at- and parents tack. Ask your health consultant or the child's health maintain a quality food service program provider to give you appropriate information. Know report suspected child abuse or neglect to the ap- what you need to do in the event of an attack. With propriate agency adequate information, you and the child will be able to manage the situation with confidence. Role of the teaching staff Each staff member must be sensitive, con- Staff who work directly with children must scientious, and systematic in addressing a child's maintain a clean, safe, hazard-free, and healthful health needs on a daily basis. Most teachers greet environment the cliild,in the morning and notice such things as a observe children for signs of illness or potential new haircut or outfit. Look at the child's appear- health problems and report any concerns to the ance. Is there any significant change? Through daily appropriate person observation, you learn a great deal about the child administer medications according to center pol- as an individual: typical coloring and appearance, icy and local health regulations moods and temperament, response to pain and assure appropriate care is given to mildly ill chil- sickness, activity level, and patterns of behavior. dren who remain in the program Each of these is a vital clue to health. provide health education to children, including While you are expected to be observant, you are daily health routines not expected to be an expert on health. Observe the supervise children to insure safety child, record relevant data, and then report anything report suspected child abuse or neglect to the ap- unusual to the appropriate person on your staff and propriate agency to the parents. You cannot and should not offer diagnoses or treatment plaiks. But health professionals will be able to make better judgments Communicating with health providers using the information you have provided. Health observation is an important first step before screen- Your health care consultant ing, diagnosis, or treatment. These topics are discussed in greater detail in Chapter 9. Qualifications and role. Your program's health care consultant should -bc a physician, nursc, or Role of the director or administrator nurse practitioner who has pediatric experience and regularly deals.-with children. It is very important The administrator is responsible for overseeing all that this individual be familiar with the specific health services, policies, and procedures in your medical and developmental needs of children from program: birth to 5 years. Look for a consultant who is aware develop and carry out health policies to protect of early childhood and parenting issues, has knowl- the health of children and staff edge of infectious diseases in group settings, and insure that staff have first-aid training (some can promote health among children and adults. states specify the type of first-aid training) Ideally, the consultant should be involved in the organize the center, equipment, and materials to local community and familiar with community re- prevent injuries_and the spread of disease sources for referral, support, and educational-mate- exchange health information with parents at chil- rials. The consultant should be able to develop posi- dren's enrollment tive relationships with children, families, staff, other collect and monitor information for individual health providers, and the community. health files, including permissions and releases be sure children receive immunizations and screenings on schedule 37 Policies, providers, and records 15

As a minimum, your health consultant should about individual cases, it is better to use her or his perform three major tasks: services for broad issues and policies that affect the approve and aid in developing health care policies group or program. approve the plan for first-aid training of staff Communicating with your consultant. Ideally, be available for consultations your consultant should be in regular contact with In addition, she or he should your program, not just for emergencies. Invite your provide information about specific medical issues consultant to visit often to learn more about the provide advice about group problems such as out- program and your children so as to make the most breaks of infectious disease or general health effective suggestions on such topics as safety issues, issues child interactions, or sanitation procedures. The re- explain and advocate for the program's health lationship with your consultant should be flexible so policies with parents and/or family health care that needs can be addressed as they arise. Be sure to provider share this manual with your health consultant. review the overall plan for staff and parent training on health issues and provide training when Where to find a consultant. It is not always an appropriate easy task to find a qualified health consultant. If you have access to other medical resources to assist in are looking for a consultant, this resource list may areas beyond her or his expertise be a good starting point: While it is temptingsto seek the consultant's advice neighborhood or community health centers local health clinics or hospital pediatric departments public health nurses -visiting nurse associations private health providers (e.g., pediatricians, pediatric nurse practitioners, family doctors, health maintenance organizations) regional pediatric societies or state chapter of the American Academy of Pediatrics (AAP) Remember to be clear from the beginning about your needs, expectations, and ability to pay for services.

Children's health care providers In providing health care for the child, each family's health care provider has learned about the child's medical status and personality as well as family strengths, This wealth of information shoo !Irl be shared with your program. Likewise, health care providers could learn more about the child's growth and development from your extensive observations. To encourage good communication about the children, set up a system to exchange information. One system might be to mail each child's periodic progress reports (with parental permission) to the family's health care provider to keep her or him up to date on the child's development from your perspective. You might also suggest that the health form provided to your program include developmental information or identify health issues. (See -In forniation-fach 'child's' :health care provider has Chapter 9, Preventive health care, for more infor- learned about the chiN's medical status, mation.) personality, and family: strengths should be shared_ The American Academy of Pediatrics (1984) has with your program. outlined these common topics for communication 16 Promoting health in programs between physicians and early childhood educators: child protective agencies current state of health and nutrition, including colleges and universities management of colds, diarrhea, bruises, chronic community health centers illness, handicapping conditions, and appetite community mental health centers/state depart- growth patterns and their significance ment of mental health hearing and vision (e.g., the child with frequent County Extension Service car infections or the child who needs glasses but department of public health/regional public doesn't wear them) health offices patterns of development, fine motor skills, com- department of social services munications, self-care, interaction with adults Food Stamp program and children, and types of play hospital and health clinics family involvement to maintain positive parent- local board of health or health department child relationships library child's initial and current adjustment to the pro- medical or dental society gram physicians and other health specialists poison control centers All communication with health care providers public schools concerning individual children must be done voluntary and service organizations only with parents' permission. Women, Infants and Children program (WIC) What if medical experts disagree? Some information about the: health of young chil- Keeping health records dren in groups is so, new that many health care providers.have not yei been trained- in current rec- gaintain a complete, up-to-date health record for ommendations. Some research is so new or limited each child enrolled in the program. Make this health that it remains controversial. Therefore, this man- record available to the child's parents in case the ual presents some recommendations that,Inay differ child leaves the program or the program closes. Es- from what you have been told-153,--your health con- tablish clear policies about confidentiality. No in- sultant. This may be confusing and frustrating. As formation may be released by the program without with all policy decisions, you will have to weigh the specific permission from the parent or guardian. facts and rationale and make the best decision for your setting at that time. If you receive conflicting Contents opinions, follow this advice: The health record should contain at least the fol- 1. Try to work out your policies with your health lowing information: consultant before difficult situations arise (e.g., how telephone numbers where parents and at least to handle Hib disease or diarrhea before an out- two emergency contacts can be reached at all break occurs). Share these policies with parents. times,.(Figum8-3) L. Whcndifficultquestions abouttlealth or infec- the name of the child's regular health care pro- tion arise, ask your health consultant for help. vider, address, and telephone number 3. If you have additional questions or conflicts, child's pre-admission medical examination form, (e.g., between your health consultant and a child's including immunization status pediatrician) contact your local board of health or developmental healtIthistory (Figure 9-3) your State department of public health. They have notations about allergies, special diet, chronic ill- the legal responsibility to make decisions about ness, or other special health concerns health issues for groups of people. emergency transportation permission slip (Figure 8-3) Other community resources all permission slips authorizing non-emergency It would be helpful to identify the agencies and health care and giving medications individuals in your area who can assist the children, results of all screenings and assessments staff, and families in your program. You may want reports of all injuries or illnesses that occur while to keep a resource file for handy reference when you child is present in program want additional information, training, and referral medication logs services. The following list will help you get your file reports of referrals and follow-up action started. 39 Policies, providers, and records 17

notes about any health communication with par- you in writing to release information or given .nts or health providers witnessed phone consent (by use of an extension written correspondence about the child's health line). health observations of staff Information collected by others and forwarded to The record should be reviewed periodically to be you with parcntal consent becomes part of your sure that it is up -to -date and that staff are familiar record and thus the responsibility of the program. with its contents. All releases of information should be properly logged. Confidentiality Parents have a right to sec all information in their child's file. Confidentiality of health records must be maintained to protect the child and family. Use the fol- Parents must be made aware of the nature and lowing guidelines when developing or reviewing type of all information collected and how it will be used. your confidentiality policy. Health records must be kept away from public Though parents may ask to speak to you in con- access and unauthorized review. fidence, you must receive this information in a Information may not be sent to anyone without responsible manner. This is particularly true in parental review and consent. relationship to child abuse. Your primary respon- Phone requests for information are not accept- sibility is to protect the child. able unless the parent has previously instructed

1. 18 Promoting health in programs

Bibliography American Academy of Pediatrics. Committee on Early Childhood, Adoption, and Dependent Care. (1984). The pediatrician's role in Promoting the health of a patient in day care. Pediatrics, 74(1), 157 -158. American Academy of Pediatrics. Committee on Early Childhood, Adoption and Dependent Care. (1987). Deitch, M.D., S.R. (Ea.). Health in day care: A manual for health professionals. Evanston, IL: Author. Aronson, S:S. (1983). Health policies and procedures. Child Care Information Exchange, (Sep.. tember 1983), 14-16. Reinisch, E.H., & Minear, R.E., Jr. (1978). Health of the preschool child. New York: Wiley. U.S. Office of Human Development Services. Ad- ministration for Children, Youth and Families. Head Start health services: Health coordination manual (DHHS Publication No. (OHDS] 84-31190. Washington, DC: U.S. Government Printing Office.

41 2 Health education inprograms for young children

During the early childhood years, children- form An occasional puppet show or filmstrip is not habits and attitudes -that can lasta lifetime. We enough. know-that health education can help establish good When you know what you want to teach,you can 'habits such as eating low sugar snacks, exercising capture the teachable moments when children are regularly, avoiding piiisons, and choosing other most likely to learn. For example, when a child is positiVe lifetime health behaviors. sitting in your lap with the sniffles, talk about taking Health education-works best in the framework of good care of your body when sick (rest, drink a healthy environment and healthy adult behavior. liquids). When a child is going into the hospital, that Your Program should follow healthy routines such is a perfect time to set up a hospital corner and to as frequent handwashing and toothbrushing. It read hospital books. Spring is a natural time to talk should be safe and organized so that children feel about growing foods and whichioods are gciod to secure and:carea children, eat=7-plant-a garden if:ott can. Talk about sticky and must respect other people and materials. Your sweet foods while you're brushing teeth. health education program will not makesense Learning always has more meaning when it otherwise. is concrete To-create a healthy environment, all staff should is geared toward the skills and interests of the be models of good behavior. If adults talk about how children We need to take care of our bodies, but sit in the fits- into the rest of the children's learning and kitchen smoking, drinking soda, and munching understanding candy, children, will recognize the contradiction. is presented in many different waysbooks, dis- Adult behavior, attitudes, and appearance all affect cussions, free play, group activities, field trips, children's learning. films Your program can promote good health bypro- is tied into all areas of the curriculumscience viding information and activities for children, staff, (growing food), cooking, dramatic play (hospital and parents, addressing the same topic with all play), art (making a collage of pictures ofways to three groups at the same time. The child healthcur- exercise) riculum will be more successful if adultsare in- is strengthened throughrbrInt;n. "Voiiedziii-thepro-Cers and can reinforce the ideas and practices being taught. In addition, adults What to include themselves will also gain valuable health and child development information. Health education should be interpreted in the broadest senseteaching children about well-being. Your 'health education program should focus not Health curriculumfor,children only on physical health and safety, but alsoon 'topics such as emotional- health, growing and How to include health learning changing, and the environment. You should provide children with an-opportunity to learn about-per- 'Health activities should fit into the naturalflow of sonal health, the health of those around them, and the program throughout theyear. Routines such as their world. Ideally, your health education plan brushing teeth, handwashing, careful food han- should draw upon the resources of teachers,par- dling, and good nutrition should happen everyday. ents, nutritionists, mental health specialists, special 42 19 20- Promoting health in prOgrams

needs staff, and others, including community agen- shops/guest speakers, newsletters, site visits (e.g., cies and resources. Many groups have materials and hospital emergency room), newspaper and maga- teaching ideas especially for young children. zine clippings, posters, pamphlets, and other These.are somerbroad topic areas that can be in- audio-visual materials. cluded in your health curriculum. growth and development Topics similarities-and differences How do you knw., what to plan for staff/parent families (including cultural heritage and pride) health training? Many state licensing agencies re- expression of feelings (verbal and physical) quire specific training in topics such as approved nutrition dentarhealth first-aid procedures, CPR, and treatment of convulsions and choking. Beyond that, decide what is personal' hygiene most important for your group this year. Here are safety some ideas to help you plan: _physical health Ask your administrator or health consultant to .awareness of disabilities observe the program, consider families' needs and 0- environmental health strengths, and suggest topics "foi-iirimediate and- long-term concern. Ask staff and parents about their needs and interests. It is usually helpful to present a list of sug- Health education for staff and parents gested topics. You might ask them to set priorities for their choices. Knowledge is power Find out the most convenient time to meet with Having good information is one of.the best ways parents. to feel Confident and in control. When you know Try to get a sense of the learning style of the ::hat fa4fig- .pareritS-and staff. Plan-someihing:for,every,on forming CPR, or keeping a child relaxed during an speakers, written materials, hands-on experience, asthma attackboth you and the child are going to films. benefit from your knowledge. You- can provide the Plan a yearly training schedule based on the pri- /necessary care, remain calm, and maintain control. ority topics. Revise and update your schedule Lack of information often leads to panic in emer- each year. Some suggested topics are gencies or to improper Care, such as spreading disorientation to your health policies ease by not washing hands when necessary. preventive health practices nutritional needs of children Keys to getting the message across safety/injury prevention, including transporta- Some basic ways for program administrators to tion safety teach staff, parents, and volunteers about health in- first aid clude management of minor illness Model good health behaviorspractice what you child growth and development preach! child abuse/neglect -f.--Establish-good health routines such as tooth- -- cultural view_ of health brushing, serving only healthy foods, hand- how to be a good consumer of health ser- washing. vices/health advocacy. Post routines and suggestions as reminders health education for young children emergency plans, handwashing techniques, dia- the meaning of health screenings pering instructions. chronic illness/special needs Teach children good habits and they will remind parentingdiscipline, talking with children Figure 2 -1 -will also help you identify objectives -to- Use a variety of media and training techniques integrate your health program for children, staff, such as .staff ,meeting discussions, work- and parents. Health education in programs 21

Figure 2-1. Sample integrated health education objectives: Mental/family health For children For staff

Know that it is healthy and normal to express Provide effective developmental assessment of feelings. children. Know that -feelings are to be expressed in ways Recognize and support importance of children's that are not dangerous or traumatic-to themselves secure home base. or. others. Recognize children's normal reactions to strange Know that everyone has feelings and everyone situation., needs to have opportunities to express them. Provide psychologically safe environment for Understand same and different (both physical children, staff, and parents. and role), and learn to function with all kinds of Model positivism and acceptance. people. Be aware of own attitudes concerning family, Learn they have abilities by experiencing success emotional expression, cultural differences, sexual in daily .activities and thereby develop self- curiosity of children. confidence. Develop partnership with parents, using re- Learn they are part of. a family and group. sources of home and community. Be aware of their bodies and respond appropriately. For parents

Develop skills ir- observing children's feelings and needs. Recognize importance of secure home base for

Develop stable relationship with children's program and community health care providers. Develop self-confidence through participation.

,Parents ,need to develop stable:relation:0.'1PS iwith -their child's prograntand'community health care providers; 44 22 Promoting health in programs Bibliography

Aronson, S.S. (1984). Health and safety training for Nelson, H.M., & Aronson, S.S. (1982). Health child care workers. Child Care Information Ex- power: A blueprint for improving the health of change, (October 1984), 25-28. children. New York: Westinghouse Health Sys- Brown, M. (1974). Stone soup. New York:-Scribner. tems. Miller, J. (1975). Web of life: Health education activ- U.S. Office of Human Development Services. Ad- ities for children. (Available from Pennsylvania ministration for Children, Youth and Families. Department of Education, Bureau of Curriculum (1984). Head Start health services: Health coor- and Instruction, 8th Floor, 333 Market Street, dination manual (DHHS Publication No. [OHDS] P.O. Box 911r Harrisburg, PA 17108) 84-31190). Washington, DC: U.S. Government National Highway Traffic Safety Administration. Printing Office. (1984). We Love YouBuckle Up! Washington, Whicker, P.H. (1983). Aim for health. Win- DC: Author. (Available from National Association stonSalem, NC: Kaplan Press. for the Education of Young Children, 1834 Con- necticut Avenue, N.W., Washington, DC 20009-5786)

40 Sedion B Healthful environment

Major concepts Good 'handwasiring and deaning of the materials and facility will helpto prevent the spread of disease. GoOd-air quality (proper temperature, ventilation, and humidity) andopen space help preVent Illness 'and injury. .SOine,playactivitiet and: materialscarry health risks that must be considered. Food: handling requires special sanftaticn.precautioris. Specific, sanitation procedures arenecessary during diapering and toileting to vi !coma.asm-ori valia = %IP Villliariroaaig. Monitor the environment regularly.

4 p Creating a healthy environment

Many programs for young children cannot totally Handwashing control their environments. Some spaces are rented and were not designed to meet children's needs in Handwashing is the first line of defense the first place. Even so, there are ways you can im- against infectious disease. Numerous studies have proVe your space. As you work toward ideal condi- shown that unwashed or improperly washed hands tions, you can establish policies that will control the are the primary carriers of infections. When you spread of infectious diseases and maintain a wash and how often you wash are more important healthier environment. than what you wash with. Alwayi wash your hands upon arrival for the day Keeping clean with bleach before eating or handling food before feeding a child Throughout this man the importance of clean7 after diapering;and toiletf.ng ,ing surfaces -and =objects with a _recommended after handling body fluids (mucus, vomitus) and bleach solution will-be mentioned (see Figure 3-1). after wiping noses, mouths, bottoms, sores The standard reconhaended bleach solution is a after cleaning 1/4 CO bleach to 1 gallon of water (1 tbs. per after giving medication quart). The five most important concepts to remember Use thiS solution to clean and sanitize items and about handwashing are Surfaces (diaper changing surfaces, table tops, toys, You must use running water that drainsnot a eating utensils). Stronger bleach solutions are un- stoppered sink or container. A common container necessary and may cause irritation to children or of water spreads germs! staff: (Hospitals and some other facilities use solu- You must use soap, preferably liquid. tions of bleach-1 part bleach to 10 parts waterto You must rub your hands together for approxi- disinfect heavily contaminated surfaces. This mately 15 seconds. This friction helps remove the strength is not required for routine use as long as germs. Rinse hands well under running water for heavy contamination [visible material] is removed 30 seconds. first.), You must turn off the faucet with a paper towel. Yoti need to make-fresh bleach solution each day Because you use your dirty hands to turn on the because bleach loses its strength by evaporation faucet, the faucet is considered dirty at all times. (and thus its effectiveness) when it is exposed to air. If you touch it with clean hands you will be recon- Bleach is quite inexpensive and readily available. taminated. Ideally, the paper towel should be However, acceptable commercial alternatives can thrown into a lined, covered trash container that be used by those who prefer other sanitizing agents. has a foot pedal. Tou,purchase commerciaLproducts, select those Hand lotion should be available for staff to pre- that: are EPA (Environmental Protection Agency) vent dry or cracked skin. 'chemical germicides registered as hospital disin- Post the handwashing poster (Figure 3-2) fettant.S. above every sink. Refer, also to Figure 4-1 for detailed procedures for handwashing.

47 25 26 Healthful environment

Figure 3-1. Bleach solution

Bleach solution Add.--a 1/4 cup bleach to 1 gallon of water (1 tbs. per quart).

Mix a fresh solution each day. Use it to clean and sanitize items and surfaces. Dispense froma spray bottle that you keep out of reach of children. Creating a healthy environment 27

Figure 3-2. Handwashing poster

Use soap and running water. Rub your hands vigorously. Wash all surfaces, including backs of hands Wrists between fingers under fingernails Rinse well. Dry hands with a paper towel. Turn off the water using a paper towel, not your clean hands.

Help children learn the proper way to wash their hands too. 28 Healthful environment

Ideally, sinks should be located near all diapering, Space toileting, and food areas. If you are renovating or building new space, consider installing a sink with a Infections pass more frequently from one -child to knee or elbow faucet handle to avoid the concerns of another when children are confined in small spaces. recontaminating hands. Even where new plumbing Children need lots of space to roam, for both devel- for sinks is not possible, you might develop some- opmental and health reasons. Open space and good creative alternatives. One interesting example using ventilation decrease the opportunity for germs to a portable water tank bubbler is described in Figure pass among children. 3 -3.. Portable. water alternatives such as -these are The best big space available is the outdoors! Chil- fine for handwashing as long as dren should play outside every day except in cases there is running waternot a common basin of extreme cold weather or rain. Outdoor play is the water temperature is not higher than 115° F. healthy on many levelsit provides open space to the container of contaminated water is out of the decrease spread of infections, a variety of oppor- children's reach tunities for gross motor development, and balance the system is safe for children (do not use a hot in the children's play and routine. Some children coffee urn for water) who have particularly high energy levels need lots of .soap is available outdoor play. Consider these suggestions for your use of space. When- handwashing is impossible, such as on a Do not concentrate toys and equipment in-small field trip, use disposable wet wipes with an alcohol areas. base. (These are-better tharrnothing, but are not as Place cots/cribs at least 3' from each other and effective as washing with running water.) alternating foot to head so that air circulates Disposable items such as paper towels, diapering freely and children do not breathe directly on covers,,and wet wipes are expensive. Consider buy- each other. ing in bulk from medical or paper supply compa- Take children outdoors as often as possible. nieS. Use centralized buying whenever possible; if If you group infants and toddlers with preschool- you are not part of a system -or large agency, ask ers, be sure to keep the group small to limit the other programs near you to join in bulk purchases. spread of infectious diseases. (Diseases are spread 'It is Vioi-th easily by children in diapers.)

Disposable gloves Air quality Gloves can provide a protective barrier against Adequate ventilation, humidity, and temperature germs that cause infections. All gloves should be disposable and made of latex. Gloves should be control increase our resistance to illness and ability to get well after sickness. In winter, dry, hot air takes changed after contact- with each child. Gloves moisture from skir, and mucous membranes. In should not be used as a substitute for handwashing. summer, hot arn,,mid air prevents children's Hands and other skin surfaces should be washed bodies from cooling off well, and they tend to over- immediately and thoroughly if contaminated with heat. Therefore, pay specific attention to the air blood and/or body fluids. Hands should be washed around you, and try to do the following. immediately after gloves are removed. Keep the air temperature between 65° and 72° F. Disposable latex gloves shouldbe considered in _ if at all possible. the following situations: Open the windows in every room every day to when changing the diaper of a child with diarrhea circulate fresh air, even in winter (except in cen- or a diagnosed gastrointestinal disease trally air conditioned or ventilated buildings). when contact with blood or blood-containing flu- Windows must be screened to prevent insects ids from a child is likely, particularly if the care- from entering and children from exiting. giver's hands have open cuts or sores (e.g., when Offer more liquids and sponge bathing in ex- using first aid for a child's cut or changing a dia- tremely hot weather to prevent overheating and per with bloody d'iarrhea) dehydration. Use sprinklers outside for toddlers when cleaning surfaces that have been con- and preschoolers. Young children, especially in- -tam inated -with blood or gross- contamination fants, become dehydrated more easily than with body fluids, such as large amounts of adults. vomitus or feces 50 Creating a healthy environment 29

Figure ,3-3. Alternative to running water

Use a portable water (bubbler) tank, a sink top, and a cabinet that can be locked to create a place for handwashing, even if plumbing is not available. The tank will be very heavy when filled with water.

Setup

Option 1 Option 2 (hot and cold water) (cold water only)

Water bubbler tank

Two spigots and plastic mixing tube OR One spigot and plastic drain tube

Cabinet with lockable door

Large bucket to catch drained water

Electric wire and plug (for water units that heat/cool water)

Caution: If your water bubbler has both hot and cold spigots, Note: If your water bubbler has only cold water, keep it you MUST use plastic tubing to mix the water before it unplugged so the water will remain at room temperature. reaches the sink. Hot water can cause severe burns.

51 30 Healthful environment

Figure 3-3 cont. Alternative to running water

Shop at a discount hardware store if possible to find the items needed to set up your bubbler unit. Selecta spigot that locks in the ON position (similar to that on a large coffee urn) so that hands can be washed tor,ether. If water flow control is important, use a screw-type facucet. Tubing should be either 3/8" or 1/2" in diameter. Connect the apparatus as shown in the diagram. Place a very large bucket inside the cabinet the drainpipe for the sink. Keep the cabinet door locked so children cannot reach the bucket.

Use Wash hands using running water from the spigot(s) and liquid soap. Check the waste-water bucket frequently, and empty it into a toilet as needed.

Refilling water/disinfecting If you replace the water bubbler tank, remember to sanitize the plastic tubing with bleach solution periodically. Rinse thoroughly before using. When you refill the water bubbler tank, be sure to sanitize both the tank and plastic tubing with bleach solution and rinse thoroughly before refilling.

52 Creating a healthy environment 31

Provide extra clothing during cold weather to cream cone, or put two spoons into the same serv- maintain body heat. Ask parents to leave extra ing). clothing or develop your own supply. (Shared Always keep food far away from a diapering area. clothing must be washed between uses by differ- Whenever possible, adults who change diapers ent children.) Hats should never be shared. should not prepare food on the same day. Use a humidifier or cool air vaporizer to add Keep food and food utensils separate from class- moisture to dry air. Do not use a steam vaporizer. room items. If you use an air conditioner, be sure that it is Provide drinking fountains that are the approved cleaned and serviced regularly. Air conditioners jet-angle type with a mouth guard above the rim. can build up molds and dust that are harmful allergens for some children and adults. Avoid strong odors. Some people, including chil- Handling contaminated items dren, have allergic responses to smoke, perfume, and room deodorizers. Contact with heavily contaminated materials such Do not allow cigarette smoking in spaces that as tissues, toilet paper, soiled diapers, bandages, children will use. An even better policy would Soiled clothing, and vomitus encourages the spread be to prohibit smoking in the child care facility of disease. Be sure that as few people as possible at any time. If you feel you must allow smoking, handle contaminated items and that clean-up it should be limited to areas such as an office or areas are completely separated from food han- staff/parent lounge that can be ventilated to the dling areas. outside to prevent smoke from entering child care Use disposable gloves to clean up blood and blood areas. spills. If possible, use them when cleaning up other types of potentially contaminated surfaces. Dispose of soiled items immediately into covered Asbestos containers., Wash hands immediately! Asbestos is the name given to material that sepa- Do not rinse or wash soiled cloth diapers Cr cloth- rates into fibers-If the fibers from these,products Place.4 Tlastic,kag,_ close -it:tight,.and Ofiitrig-disease. Keep it out of the reach of children. Ask the parent Asbestos is a common insulation material on to take the items home for laundering. Changes of heating pipes, boilers, and furnaces. If asbestos in- clothing should be kept handy. sulation is cracked, torn, or crumbling, it can Cover all diaper pails and line them with plastic release harmful asbestos fibers. In most cases, the bags. material can be repaired to prevent fiber release. Wash, rinse, and spray all mouthed toys with the However, when the material is beyond repair, it bleach solution between users. An easy way to do should be removed. Because the repair or removal this is to keep a dishpan marked "soiled" on a process can release very dangerous, fibers into the shelf into which you put toys when they have been air, repair and/or removal methods must be ap- mouthed and put down by a child. At naptime, or proved by your board of health. another convenient time, put dishwasher wash- If you are concerned that there may be exposed or able toys through the dishwasher and wash other crumbling, asbestos in your facility, contact your toys in soapy water. Rinse the toys with water and board of health. then with the bleach solution before letting them air dry. Anything not washable in a dishwasher, by hand; or in a laundry machine and- dryer Food handling should be considered limited for use to one person. Adequate numbers of toys should be avail- Improper food handling is one sure way to spread able to correspond with the washing frequency. infection! Specific information on sanitary food Wash and sanitize daily all frequently used sur- handling appears in Chapters 4 and 12. Please refer faces with the bleach solution. to them and remember these basic concepts for food Wash and sanitize the changing surface and any handling. potty chairs with bleach solution after each use. Always wash hands before handling food. Consider whether the time and risk of spread of Never_,_ allow 'children to share food unless indi- diseme involved-in,potty-chair-clean-up-males vidual portions are made (do not lick the same ice them undesirable in child care.

1 3. 32 Healthful environment

Label toothbrushes and personal items. Make restrict water table play to children withoutrunny sure they are used only by their owners. noses or sores on their hands unless individual Vacuum any carpeted areas on a daily basis, and basins are used shampoo or clean them often. wash and sanitize all water toys daily (Wash with soap and water and spray with bleach solution, or put in the dishwasher.) Turnover and health issues consider using individual basins within thewater table. The basins can be cleaned and sanitized Aside from the obvious emotional benefits of low more easily between use by children and the turnover of staff and children, there are health bene- water table catches the splashes so clean-up fits too. High turnover constantly introducesnew around the table is much easier. infections. New children and staff may not be immune to the infections already there and may be- Dress-up clothes come sick more often. Of course, turnover is a most difficult problem to solve. It is mentioned hereso Sharing clothing generates the risk of spreading you will be aware of the health risks involved. disease, particularly head lice and certain skin infec- Because of the number of comings and goings, tions. Any clothing soiled by stoolor other body large programs (with 50 or more children)open secretions should be removed immediately andnot more than 10 hours a day appear to be at greater returned until laundered. If there isan outbreak of risk for spreading infectious diseases. Such centers head lice or scabies you should- should be particularly careful about preventive take away all play clothing until the outbreak has health routines. stopped Do not admit new children into your program launder and clean all items according to direc- during an outbreak of a serious infectious disease tions listed in Chapter 17 or store in airtight plas- (for example, hepatitis A). With your healthcon- tic bags for 2 weeks sultant, decide upon an appropriate waiting period for each infectious disease. Consider limiting_ the mixing of children in dia -older-chticken when possible, although this also may inhibit developmental learningoppor- tunities. You must decide the balance between these two issues..

Risks from play materials and activities

Some materials and activities for young children can carry specific health risks. You should be aware of the potential risks and know how to handleThem. Try to create an environment that is both challenging and safe for children and staff.

Water play A container of water that is shared bymmy children carries the risks of spreadinggerms through the water and the toys. Germs grow in warm and wet environments. If you decide to keep a water table (and you are encouraged to do so), you should be sure the water table is cleaned and sanitized with the bleach solution and filled with fresh water at least daily All toys used by infants carry the risk of spreading have children wash their hands before playing at disease because the_ y are mouthed frequently..and. thelable passed Creating a healthy environment 33

Infant/toddler toys must be supervised by an adult at all times. The All toys, used by infants carry the risk of spreading adult should be directly beside the water. Super- disease because they are mouthed frequently and vision of a vading pool from a nearby area of the :passed,around. All-infant-toys.should,be.washable playgroundis mot_acceptable. Use These.guidelines- as well as safe. whenever young children are near water. Mouth toys (any that must be used in the mouth, Be sure your swimming or wading pool meets the such as bubble pipes, horns, tubing for water requirements of and is licensed by your board of tables, and toy thermometers) should not be al- health. Poftable wading pools, are acceptable only lowed unless you are prepared to supervise the if used as a bathtubfor one childthen use to I-sure that the toy is washed, rinsed; and dumped, rinsed, and filled with fresh water for sanitized with the bleach solution between users. another child. Toys with hard plastic, rubber, or other cleanable Supervise children at all times. surfaces should be washed and sanitized with the Be sure that a person competent in CPR for young bleach solution at least once daily. Some toys are children is in attendance when the pool 'is in use dishwasher safe. Do not use disposable diapers in pools with fil- Stuffed toys should be machine washable, indi- ters, since they can clog the filters. Use cloth dia- vidually assigned if mouthed, and should be pers and/or rubber pants. washed at least weekly or more often, if soiled. Fence and lock swimming pools in accordance Toys that cannot be washed according to these with accepted safety practice to prevent acciden- guidelines should not be used. See Chapter 6 regard- tal drownings or chance access by children or ing choking hazards also. others. Portable wading pools should be turned upside down when not in use. Pools (including wading pools) Post safety rules for the use- of pools in a con- spicuous location and be sure they are, reviewed Pools carry the double risk of spreading disease by the staff. and possible drowning, Because of these clear health risks, the use of wading pools for young children is not recommended. The use of sprinklers in- Sand stead-of pools on hot summer days is preferable. If your sand area is accessible to animals, be sure Any container of water (bathtub, wading pool, that it is covered when not in use. Animal feces can swimming pool) is considered a possible hazard and spread infectious diseases. 4 Sanitation standard:.

The sanitation standards presented in this chapter Use a standard sanitizing solution consisting of a will help you create a sanitary, healthful environ- 1/4 cup bleach to 1 gallon of water (1 tbs. of ment for children. Careful use of sanitary practices bleach to 1 quart of water). Dispense the solution, can limit the spread of infectious disease. These made up fresh daily, from a spray bottle. recommended standards are based on federal and Wash plastic mats, mouthed toys, and commonly typical state regulations dealing with sanitation, used surfaces at least once a day, spray with recommended standards from the American Acad- bleach solution, and sun or air dry. emy of Pediatrics, and Accreditation Criteria and Procedures of the National Academy of Early Child- Standard IIMaintain adequate housekeeping hood Programs (National Association for the Edu- and maintenance equipment and cleaning cation of Young Children, 1984). supplies. The equipment is kept clean, in good working condition, and stored safely. Provide adequate housekeeping equipment and Housekeeping cleaning supplies including wet and dry mops, mop pails, brooms, cleaning cloths, and at least Early childhood programs should have written one vacuum cleaner. policies and procedures for the routine cleaning and Store housekeeping equipment in a separate, maintenance of the facility. Such written policies locked space such as a closet or cabinet. Do not and procedures should specify the type of sanitizing store it in bathrooms, halls, or on stairs. and cleaning agents used, method for cleaning, and When possible, use a separate sink with hot and schedule for cleaning. They should also name the cold running water for cleaning purposes only. person responsible for supervising and monitoring Launder wet mops, dusting and cleaning cloths cleaning and other maintenance activities. and sponges daily and dry mops twice a week. Store sponges in bleach solution between uses. Standard I The facility is neat, clean, and free If potty chairs are used, use a separate sink to of rubbish. wash, rinse, and sanitize the potty chair bowl. Clean the facility in a way that avoids con-con- This sink should not be used for handwashing-or tamination of food and foodcontact surfaces. any other purpose. Keep soiled linens or aprons in laundry bags or other suitable containers. Standard IIIThere is a pest control program Wash all windows inside and outside at least for the facility. twice a year. Provide screens for exterior windows and doors. Do not use deodorizers to cover up odors caused Store pesticides away from child activity areas by unsanitary conditions or poor housekeeping. and in non-food service and storage areas. Lock Ventilate baOmells away. all storage areas. Keep storage areas, attics, and cellars free from Post instructions on the safe and proper use of refuse, furniture, old ,newspapers, and other these chemicals in a highly visible location. paper. goods. Be sure that pesticides for crawling insects are _.Keep -flammahle -cleaning:rags or solutions in applied- only by-a-certified pest control operator. closed metal containers in locked cabinets. Be sure a qualified staff member accompanies the

u1 56 33- 36 j-iealthful environment

All programs need a written policy specifying when handwashing is required for personnel and children.

pest control operator to bsure no chemical is animal likely to cause such problems (rabbits, applied to surfaces that children can touch. The guinea pigs, and other furry animals). insects are much less harmful than the pesticide. Be sure that animals are friendly and have an Do not use over-the-counter products for crawling appropriate temperament to be around children. insects such as roaches, ants, and spiders. You Clean animal areas frequently. Do not use food may use over-the-counter products for flying in- service facilities. Wash hands afterwards. Do not sects such as bees, wasps, and hornets. Read di- let children assist with pet cleaning and mainte- rections carefully, wash your hands after use, and nance to protect them from contamination. store the product safely out of the reach of chil- Be sure animals are healthy and appropriately dren. immunized and licensed. Check pet health and Be sure that bait for catching pests is kept out of care requirements with a veterinarian before children's reach and in tamper-proof boxes. bringing the pet into child care. Some pets need to -Do not-use_no-pest strips in food service or sleep- be protected from abuse by children. ing areas. Fly paper is acceptable if it is changed Be sure children and staff wash their hands after regularly. handling or feeding animals. Separate animal food and cleaning supplies from Standard IVAnimals housed as pets are food service supplies. adequately fed, sheltered, and clean. -0 Do not allow any animals in areas used for pre- Handwashing paring, eating, or storing food. Standard VThe program has a written policy Do not allow turtles, cats, or parrots, as they are that specifies when handwashing is required known to carry disease. for personnel and children, defines the Be sure that no child is allergic to the animals for handwashing procedure, and provides the program. Since it may be traumatic to remove continuing monitoring to assure that the an animal after an allergy is discovered, you handwashing procedure is carried out should think about whether you truly need an according to the criteria in Figure 4-1. Sanitation standards 37

Figure 4-1. Handwashing procedure

Adults Rinse well under running water for 30 seconds. Hold hands so that water flows from wrist to Wash hands upon arrival. fingertips. - Wash hands before preparing food, eating, or Dry hands with paper towel. feeding a child. Use paper towel to turn off faucet; then discard Wash hands after towel. toileting self or a child Use hand lotion, if desired. handling body secretions (e.g., changing diapers, cleaning up a child who has vomited or Spit up, wiping a child's nose, handling soiled Infants/toddlers clothing or other contaminated items) Post signs to -remind staff and children to wash Wipe hands with damp paper towel moistened their.hands in the toilet room, the kitchen, and with a liquid soap solution. the area where diapers are changed. Wipe hands with paper towel moistened with Be sure that the hot water supplied to fixtures clear water. accessible to children does not exceed a maxi- Dry hands with paper towel. mum temperature of 115° F. Turn off faucet with paper towel and discard. How to wash hands Turn on water to a comfortable temperature. Older children Check to be sure a paper towel is available. Moisten hands with water and apply heavy lather Squirt a drop of liquid soap on children's hands. of liquid soap. Wash and rinse their hands in running water, Wash well under running water for approximately directing flow from wrist to fingertips. 15 seconds. Dry hands with paper towel. Pay particular attention to areas between fingers, Turn off faucet with paper towel and discard. around nail beds, under fingernails, and backs of Teach older children to carry out the procedure hands. themselves. Supervise younger children in carrying out this handwashing procedure. 38 Healthful environment

(Also refer to Chapter 12 for further information about food preparation and service.) Require that staff who prepare food follow these hygiene procedures. --,Wear clean clothes, maintain a high standard of personal cleanliness, and carry out strict hygiene procedures during working hours. Wash hands according to prescribed handwashing procedure before preparing and serving food and as necessary to remove soil contamination. Keep hands clean while handling food contact surfaces, dishes, and utensils. Do not prepare and serve food while ill with a communicable disease. If possible, do not diaper children or assist with toileting on the same day as food preparation. Keep hair covered with hairnet or cap while preparing food. Provide easy-to-clean equipment and utensils. Use food contact surfaces and utensils that are easy to clean, nontoxic, corrosion-resistant,and non-absorbent. (No wood utensils or cutting boards.) Use disposable articles that are made of nontoxic materials. Do not reuse disposable articles. Install appliances so that they, and areas around them, can be cleaned easily. Staff ivho prepare food should carry" out strict Be sure food contact surfaces are free of cracks hygiene procedures to help create a sanitary, and crevices; pots and pans are free of pits and healthful environment for children. dents; and plates are free of chips and cracks. Cracks in any surface can harbor germs. Make sure that food contact surfaces and utensils Kitchen facilities are kept clean. Clean all eating and drinking utensils, table- Standard VIPrograms that provide meals and ware, kitchenware, and food contact surfaces snacks to children maintain a clean kitchen after use. with adeqUate equipment and space for food Do not use cloths used for wiping food contact preparation, serving, and storage. surfaces for anything else. Make sure food is handled and used properly by Wash a spoon or other utensil used to test food doing.thelollowing. before using again. Limit direct handling of food by using utensils Wash food contact surfaces with bleach solu- such as forks, knives, trays, spoons, and scoops. tion and sun or air dry. Wash raw fruits and vegetables before use. Clean kitchenware and food contact surfaces Cover foods that are stored in the refrigerator that have come in contact with spoiled food, and on shelves. sanitize them with the bleach solution, and let Throw away handled leftovers and food left in them air dry. serving bowls. Scrape and presoak dishes, pots and pans, and Pay close attention to expiration dates, espe- utensils, if necessary to remove food particles cially on foods that spoil easily (dairy products, before washing. mayOnnaise, etc.). Wash highchair trays, bottles, and nipples in a Do not use the kitchen area as a traffic way or dishwasher, if available. If th- trays do not fit in meeting room while food is being prepared. dishwasher, wash in detergent, rinse, spray with bleach solution, and air dry. 59 Sanitation standards 39

USe the proper concentration of suitable deter- laundry supplies. Wash laundry with detergent, gent for hand and machine dishwashing, ac- bleach, and hot water, and dry it in the sun or in corc,hg to package directions. an automatic dryer. Use this procedure for haiiiidiShiVashing-: If you do not have laundry facilities, develop a 1. Use a-three-compartmentsink-orthreebasins, written policy and,procedure fer_ handling emer, one each for dishwashing, rinsing, and sanitizing. gency situations and for doing routine washirit 2. Wash dishes in hot, soapy water (120° F.), then Do not launder clothing, sheets, or other items, rinse thoroughly. that have been soiled with mucus, feces, urine, 3. Dip dishes for 1 minute in bleach solution that blood, or vomitus. Place such items in double is at a temperature no lower than 75° F. plastic bags, seal them, and store away from chil- 4. Rinse dishes. dren. Attach the child's name to the bag, to be 5. Sun or air dry. (Do not use dish towels.) taken home by the child's pareres for laundering. Make -sure that the water used in your dishwasher is 170° F. Because this temperature is higher than that allowed for hot water heaters, you may have to adjust the dishwasher so that Toilet facilities the water will reach this temperature. Pick up. and touch clean spoons, -knives, and Standard IXThe toilet room is kept clean and forks onlybyliaidles, not by any part that will sanitized, and:the fixtures are in good working be in contact with food. condition. Handle clean cups, glasses, and bowls so that Provide sanitarily designed and easily cleaned fingers and thumbs do not touch the inside or toilet fixtures and potty chairs. After each use of a the lip contact surfaces. potty Note: If you donot have adequate facilities for Empty contents into the toilet. cleaning and sanitizing dishes and utensils, use only Rinse potty chair with water in a sink not used disposable items. for any other purpose and empty into toilet. Wash the chair with soap and water. Consider using paper towels or disposable mop. Empty Storage and disposal of garbage soapy water into toilet. Rinse again. .Empty intz., toilet. Standard VIIThe facility is kept free of Spray with bleach solution. accumulated garbage. Air dry. Store garbage in water- and rodent-proof con- Wash and sanitize sink. tainers with tight lids. Remove such containers Wash hands. from children's areas daily. Now that you know what is necessary to keep Put out garbage for pick up on the day of col- potties clean, you may want to reconsider whether lection. you really want to use them! Suggest that each child After the garbage is removed, clean the con- have her or his own potty chair sent from home if tainers, room, and areas. parents wish a child to use a potty rather than the Use plastic bags to line covered containers. These toilet, but you will still have to follow the procedure may be put out for collection unless prohibited by listed above. the Board` of' health. (Store plastic bags out of Provide toilet paper and holders, towels, and soap children's reach.) dispensers with liquid soap where they can be easily reached by all users. Label toothbrushes and make sure they are not Laundry shared. Store them brush up, away from contamination. Egg cartons and shoe-box lids are Standard VIIIMake arrangements to wash easily adapted, disposable toothbrush holders. crib sheets, cot covers, and other items Empty and sanitize trash containers regularly, belonging to the program. using the bleach solution. Equip any laundry area with a sink for soaking, Wash and sanitize bathroom fixtures with bleach an automatic washer and dryer, and locked cabi- solution at least daily or when contaminated by nets for the storage of soaps, bleaches, and other feces or vomitus. 6O 40 Healthful environment

Plumbing Standard XPlumbing is in compliance with the regulations and codes for your state and county, or city.

Ventilation, light, and heat Standard XIAll rooms are well-lighted, ventilated, and sufficiently heated. Be sure that adequate lightavailable in rooms, halls, and stairways. Supplement natural light with properly diffused and distributed artificial light. Maintain adequate ventilation by using windows that can be opened, air conditioning, or a venti- lating system. Sanitation standards 41*

Bibliography

.American Academy of Pediatrics. Committee on Early Childhood, Adoption and Dependent Care. (1987). Deitch, M.D., S.R. (Ed.). Health in day care: 14: "manual for -health professionals. Evan- ston, IL: Author. National Association for the Education of Young Children. (1984). Accreditation criteria and procedures of the National Academy of Early Child- hood Programs. Washington, DC: Author.

" :` 5 Diapering and toilet learning

-Diaper and toileting carry distinct health risks rolls of paper, or buy disposable squares from to children and adults. You need to handle both of discount medical supply companies. these activities with extremecare from both sani- Keep all creams, lotions, and cleaning items out tation and child development viewpoints. of the reach of children. Never give a childany of Toileting is one of the mowbasic physical needs these to play with while being diapered since she of young children. The Way thatyou handle the or he could be poisoned. process of toileting can haire major emotional ef- Provide a belt or strap to restrain the child. Adda fects as well. The entire process from diapering in- guard rail or recessed area as a good extra safety lants to teaching toddlers and preschoolers about measure. If you have no restraint, always keep a using the toilet should be a positive one. At dia- hand on the child. Even when you usea restraint, pering time you have a chance to engage in special never leave the child, even for a second. individual communication with a child. It isa time to show extra caring and support. Often the proeesS of toilet learning for toddlers How to change a diaper becomes an unnecessary struggle for control be- To correctly change a diaper, follow the steps in tween adults and'children. You can join forces with Figure 5-1. Please copy and post this information the part of the child that wants to learn andgrow. above your diapering area. You help a child gain her or his own control with your patience and understanding. This chapter will proVide ways to meet the physical and emotional Cloth versus paper diapers needs of young children. Disposable paper diapers are preferable because they can be thrown away, thus reducing the chance Diapering of spreading disease. When you use disposable diapers, be sure they are thrown away immediately into Diapering area a lined, covered pail. Some children, however, must wear cloth diapers Follow these very important rules about the dia- because their skin reacts to disposableones. Use pering area. extra precautions when diapering these children. Use the area only for diapering. Empty any stool fi pm a Soiled cloth diaper into the Set up the diapering area as far awayas possible toilet, put the diaper in a plastic bag, tie it, and from any food handling area. enclose it in a second plastic bag with aname label. Provide running water so handscan be washed (Plastic bags from fruit and vegetables or bread2.re immediately after a diaper is changed. a cheap and ready supply.) Put the diaper out of Construct a diapering surface that is flat, safe, reach for the parent to take home. Do not rinseor and preferAly 3' above the floor. launder cloth diapers even if you have a washing. Be sure this surface is clean, waterproof, and free machine. If a diaper service is used, handle the of cracks, tape, and crevices. Cover it witha dis- diapering in the same way, except bag the diapers posable cover. Use cheap materials suchas paper for the service. This is very expensive and therefore bags, used computer paper (on the backside), not feasible for most programs. 44' Healthful environment

Figure 5-1. How to change a diaper

Check to be sure Supplies you need are ready. Place paper or other disposable cover on diapering surface. Pick up the child. If the diaper is soiled, hold the child away from you.

Lay the child on the diapering surface. Never leave the child unattended. If you use them, put on disposable gloves now, Remove soiled diaper and clothes. Fold disposable diapers inward and reseal with their tapes.

Put disposable diapers in a lined, covered step can. Put cloth diapers in a plastic bag securely tied, then put into a larger, labeled, plastic bag to go home. Do not put diapers in toilet. Bulky stool may be emptied into toilet. Put soiled clothes in double, labeled, plastic bags to be taken home.

Clean the child's bottom with a moist disposable wipe. Wipe front to back using towelette only once. Repeat with fresh wipes if necessary. Pay particular attention to skin fOlds, Pat dry with paper towel. Do not use any kind of powder, as inhaling it can be dangerous. Use a skin care product only on parent request. Dispose of the towelette or paper towel in a lined, covered step can. If you used disposable gloves, discard them now. Wipe your hands with a disposable wipe. Dispose of it in the lined, covered step can.

64 Diapering and toilet learning 45

Figure 5-1 cont. How to changea diaper

Diaper or dress the child. Now you can hold heror him close to you.

Wash the child's hands. Assist the child backto the group.

Remove disposable covering from the diapering surface. Wash and rinse the area with water (usesoap if necessary) and sanitize it with bleach solution made fresh daily.

Wash your own hands thoroughly. 46 Healthful environment

Toilet learning

When is a child ready? Children must be ready to participate willingly if the process of toilet learning isto,be a positive one. ..Qther_wise,_ toilet. "training" can be a, battle of the wills and endless disciplining and disappointments. The, purpose of toilet learning is to help children gain control of their body functions. If a child is ready, the process of toilet learning can become a sign of great success and achievement for the child's own sense of growing up. Look for these landmarks that indicate a child is ready for toilet learning. Muscle control. The child, must be able to work the bottom muscles at will. She or he must be able, to squeeze the sphincter (bottom) and stomach muscles at the same time. Usually most children do not have this control until around their second birthday. Some are not ready until age 3. They should also be able to undress enough to be able to sit on a toilet or potty without assistance and without fear of falling off. Communication. The child should be able to use words; lr consistent gestures to ask for help un- dressing or getting to the toilet. Remember to ask The best ''technique for toilet learning is to wait parents about their word preferences for toileting until the child is ready and to take the cues (i.e., pee or poo). Bowel movement and urine are directly from the child's own pattern. good words for children to learn since they are part Children should not be punished for lapses in of the child's needed vocabulary as a grown-up. using the,toilet. If you expect some backslide, you Desire. Starting before children want to learn will be more apt to accept a child's behavior. Chil- fj about the toilet is a waste of time and may set up a dren need your understanding and patience when they are having difficulty in toileting. Your support lasting power struggle. Children have a natural de- should actually shorten the time for children to re- sire to please those whom they love and trust. Chil- dren also love to imitate! Children will eventually gain their toileting patterns. Punishment will pro- become uncomfortable in diapers and may want to long the struggle. wear underwear instead. Never force children to sit on a potty or toilet. Equipment needs Parents and staff should decide together when the Some children need no special equipment except child is ready to begin toilet learning. Develop a plan a good supply of extra underpants and clothing. together that will be consistent and manageable in Training pants are extra thick and absorbent and both settings. Different approaches are confusing may be helpful, although not necessary, in the be- -and:inay-be upsetting. If possible, you should de- ginning. velop similar schedules and use similar equipment. Some children are insecure or frightened on an The process of toilet learning usually is neither adult-sized toilet and may need one or mu, - of the fast nor consistent. For some children, the process following: may take several years to complete. Commonly, Stool to step up to the toiletUse a nonslippery children have accidents when they are sick (espe- plastic stool, wooden block covered with a wash- cially with urine infections or diarrhea, tired, ex- able surface, or any inexpensive step so the chil- cited, very involved in play, or stressed (e.g., when a dren can reach the toilet easily. A step also acts as sibling is born or when there is an illness in the a firm footrest for pushing. A stool is recom- family). mended for all young children who use a toilet. 66 Diapering and toilet learning 47

Toilet seat adapterThis inexpensive adapter If a potty chair is used, follow the guidelines for fits over the regular seat to make the seat more cleaning in Chapter 4, Standard IX. child-sized and secure. Be sure it is washable Wash your hands. plastic. Potty chairPotty chair frames should be made Helpful hints of a smooth, non-porous material that is easily The best technique for toilet learning_ is_to wait. cleanable: Vocht-frarites are-hot- recommended: until the child is ready and to take the cues directly The waste container should be easily removable from the child's own pattern. Beyond that, these and fit securely into the chair. Many medical ex- suggestions may help: perts recommend potty chairs not be used in Choose clothing that is easy to remove in a hurry. .groups because of hygiene problems. If a, child A child must be able to act on an,urge to toilet truly needs a potty chair, ask the parents to pro- immediately. Avoid tight snaps, lots of buttons, vide it as a personal item to be used only by that etc. Velcro fasteners are especially easy. child. If you do use potty chairs, follow the guide- Use the equipment necessary to make the child lines for cleaning them in Standard DC in Chapter 4. feel secure. Always explain the equipment and your expectations for its use. In some cases, it may be best if you flush the toilet or remove the Hygiene when children are learning to use the waste after the child leaves the room; the noise or toilet disappearance of the waste may frighten some Place any soiled clothes in double, labeled, plastic children. Others may enjoy the sound and action. bags for parents to take home at the end of the Suggest regularly that the child use the toilet. day. Washing different children's soiled clothes Common toileting times are after meals, before together can spread disease. and after naptime, and before trips. Be sure that Help the child use the toilet. you do not expect a child to go only on your Help the child wash her or his hands. Tell chil- schedule. Especially in the beginning, children dren that washing their hands will stop germs often need/want to go to the toilet frequently. that might make them sick. When children use Ask the child to sit on the toilet for no more than 5 the toilet, make sure they wash their hands cor- minutes unless the child is upset or uncomfort- rectly. Show them how to wash their hands (see able. Never insist that the child sit there until "the Figure 4-1). Watch children wash their hands job is done." after they use the toilet, or ask children if they Always give the child lots of positive feedback and have washed their hands when they return from encouragement for success. Never punish the the bathroom. child for failures.

rr4, 48 Healthful environment

Bibliography Granger, R.H. (1977). Your child from one to six (DHEW Publication No. [OHDS] 77-30026). Washington, DC: U.S. Government Printing Of- fice. -Provence,S. (1967). Gaidefor the care of infants in groups. New York: Child WelfareLeague of America.

68 Section C Safety and first aid

Major concepts Most injuries can be prevented. Regular safety, checks of the indoor and outdoor environment should be made and improvements implemented immediately. Infants and toddlers require special safety precautions. Safety educatiowfor staff, children, and parents must be provided. Children and adults must be properly restrained while riding ina vehide, and specific safety rules must be followed. All staff must be trained in first aid and prepared to carry out the center's emergency procedures. 6 Safety

Injuries are the result of problems in the envi- ards. Parents and older children can help too. ronment, a mismatch between a child's abilities and Know what you're buying or what is being do- activities, and/or a lack of adult supervision. Some- nated to your program. Read labels and instruc- times there are hidden dangers that are seen only tions carefully. If you have any questions or coin- after a child or staff member is injured. Injuries can plaints about the safety of a product, call the often be prevented by Consumer Product Safety Commission (CPSC) at being aware of potential hazards its toll-free number: 800-638-CPSC. taking action to eliminate or reduce these hazards knowing what to do in an emergency Times when children get hurt Creating a safe facility During certain situations and times of day, children-are more likely to be injured. Injuries A safe facility is arranged so that children can play are more likely when freely without harming themselves or others. A safe another child becomes ill or injured and the rou- environment allows children to learn by taking risks tine is disrupted (other children become more at and challenging themselves and, at the same time, risk) protects them from injury. A sterile, risk-free envi- staff are absent or busy ronment and rules that do not let children play and children are not involved in the activity that was explore are not healthy. planned, and they are tired or hungry (for exam- Your program must follow certain safety stan- ple, immediately before lunch) dards and practices to be licensed. Local building, hazards are too attractive sanitary, and fire safety codes must also be ob- staff are not up-to-date on children's abilities served. You can also create a safe environment by during field trips, when there are new places to carefully' following these additional basic guide- explore and safety rules may be forgotten lines. Be alert-to,hazards both indoors and outdoors and eliminate or avoid them. Look at the world through the eyes of a young Indoor safety childit is colorful, mysterious, and has new places and objects to experiment with and ex- Traffic and play areas plore. Get down on your hands and knees to see Make sure there is enough space for all furniture what a child sees. You may be surprised at what and equipment and for traffic around them. you find! Bolt top-heavy furniture (e.g., cubbies) to the wall Conduct regular safety checks. Each room should or floor. be checked at least once per month. Use the two Experiment with different arrangements until checklists at the end of this chapter (Figures 6-6 you find one that, best suits the needs of the chil- and 6-7).. dren and your program. Encourage all staff to participate in conducting Place chairs and other furniture away from win- the checks and planning ways to deal with haz- dows, cabinets, and shelves to prevent children 70 52 Safety and first aid

from climbing or reaching hazards. cord underneath a carpet or rugit may become .1 Keep aisles,freeuCtoys, furniture, A nd other trip- worn or frayed and cause a fire. Never run cords ping hazards such-as spilled water. Break up long through doorways or walls. Do not nail extension aisles to discourage children from running. cords to the wall. Keep extension cords out of the Involve,,the children in setting rules to limit run- reach of infants and toddlers to prevent mouth ning, pushing, and other such behaviors. Enforce burns caused by biting. Store extension cords these rules consistently. when not in use.

kitchen and cooking facilities Choking hazards Make sure the kitchen is not accessible to chil- Young children may choke during meals or dur- dren, unless you can prciVide constant adult su- ing playtime because they use their mouths to ex- pervision. plore and experiment with unfamiliar objects. Place other cookiriglacilitiES:or equiptrieht Objects Sinaiiefiliait 11/2"-in diameter should not hot plates, toaster ovens) out of reach of children. be accessible to children who mouth items (Lego Make sure electrical cords and extension cords pieces, beads, coins, small wads of paper). are not dangling with'an children'S reach. Check toys and equipment regularly for small Turn handles in toward the back of the stove. Do parts that may break off,, such as eyes and noses not carry hot foods or liquids when children are on stuffed animals, buttons on doll- clothes, or near you. plastic hats or shoes on miniature people. Re- Prevent scalds by keeping tap water temperature move or securely attach these items. no higher,than 110° F. Do not give peanuts to children younger than 4 years old. Electrical wiring Do not give popcorn, hotdogs, and whole grapes Cover unused outlets with shock stops. Cover out- to children until -they are 3 years old. Hard can- lets in use with outlet covers, especially near sinks dies, gum, and cough drops also can be choking and where young children can reach them. hazards. Use extension cords only when absolutely neces- Learn proper techniques for helping a choking sary. Place extension cords so they run along the infant or child. wall, behind furniture, to, reduce the chance of Do not allow balloonsthey can be a choking tripping. Never run any appliance or extension hazard.

4,r t*Zata.,,

Teach children how to play correctly and to put toys away immediately after playing. Safety and first aid 53

Toys Most toys are not dangerous by themselves. The way they are used'or misused by-a child can cause injury.. Carefully examine toys for sharp, splintered, or jagged edges and small pieces that can be easily broken off. Tug at different parts to test for strength. Reject any with such hazards. Check toys frequently and do minor repairs whenever necessary. Cover hinges and joints to prevent fingers from being pinched or caught. Projectile toys, such as darts, are not appropriate for 'children younger than' age 8 years. Bend- plastic toys to test for brittleness. Cheap, hard plastic can break easily, leaving sharp edges. test toys for weight and for noise level. Look for the nontoxic label on all painted toys and play equipment. KeeP wooden toys smooth and- free from splin-

ters. U) 6 Pull on the heads and limbs of dolls,to make sure they won't come off and expose sharp wires. Look for the flame retardant label on cloth toys. Make sure your program s art materials are Check seams regularly for tearing and weak nontoxic. The safest materials have the AP or CP threads. labels. Teach children how to play correctly and safely and to put toys away immediately after playing. Comment on children's safe play behavior.

Gross motor equipment tion so that it will not slam shut from its own Be sure riding toys, such as tricycles, are stable weight. Make sure that the device to hold the lid and well balanced. open cannot pinch. You may want to remove the Provide double matting under indoor climbers. lid to avoid possible danger. Do not use trampolines. They cr ^ause very seri- Check for rough or sharp edges on all metalcom- ous injuries. ponents and for splinters and other rough areas Teach children how to use equipment correctly on wooden boxes. and safely. Try to buy toy chests with rounded and padded Compliment children on safe play behavior. edges and corners. Be sure the toy box or chest is well ventilated with Toy chests holes or with a lid that cannot close completely. Do not buy a toy chest with a lid that locks. Toy chests are not an appropriate way to display toys for groups of children. Use open shelves instead Poisons to limit toy breakage and increase children's ease of selection. Toy boxes also are very cluttered. If par- You probably think first of cleansers and med- ents wish to purchase a toy chest for home use, icines, but your program has many other things that suggest a laundry basket be used instead. If they could be harmful if eaten or sucked. Refer to Chap- insist on a toy chest, the-Consumer Product Safety ter 8, Emergencies and first aid, for ways to handle Commission offers the following advice: poison emergencies. When you buy a chest-with a hinged lid, be sure Art materials. Watch children closely during art that the lid-is lightweight, has a flat inner surface, projects for mouthing of paintbrushes, fingers, cra- and has a device to hold it open in a raised posi- yons, or other objects and materials. Some children 72 54 Safety and first aid are attracted to fruit-scented markers and may try to Cooking and kitchen utensils. Cooking and pre- eat them. paring foods are important for young children. Dur- Avoid using homemade dough clay that has large ing these activities, observe safety precautions and amounts or salt; it can be dangerous if inueli is make sure that children do not mouth or gnaw on eaten. cooking utensils. The handles on some utensils are Make sure your art materials have these labels. painted with lead-based paint. See More. Than Gra- Nontoxic. Item will not cause acute (immediate) ham Crackers (National Association for the Educa- poisoning. tion of Young Children, 1979) for other safety and AP: Approved Product. Item contains no mate- health suggestions for cooking activities. rials in sufficient quantities to be toxic or in- jurious, even if eaten or swallowed. Poisons in diaper-changing area. Staff should CP: Certified Product. Item meets same stan- be careful about giving items to children to "keep dards as AP, but also meets specific standards for them occupied" during diaper changing. Avoid giv- quality, color, etc. ing a bottle of lotion or a container of talcum powder. Many of these substances are dangerous if swal- The safest materials will have the AP or CP labels. lowed or inhaled, and a child mouthing a container Some tips on purchasing art supplies are given in might eat some of the contents. Talcum powder Figure 6-2. If you have any questions, call,the Art should not be used on .babies at all because some Hazards-Information Center at 212-227-6231. inevitably gets -into the air and can be inhaled and Plants. Plants are a leading cause of poisoning of damage the lungs. Also, keep the bleach solution :,,bung children. If -eaten, some plants cancause a used for cleaning well out of reach of children. skin rash or stomach upsetothers can even cause death. Some common household plants are posi- onolis (see Figure 6-1). Sothe indoor plants that are safe for growing around young children are Safety beyond the classrooms African violet prayer plant Aluminum plant 6 rubber plant Playgromids begonia sensitive plant Boston fern snake plant Playgrounds provide the space in which children coleus spider plant can challenge themselves physically. While it is im- dracaena portant for children to take risks and experiment, Swedish ivy they can also get hurt. Many common playrpund hen-and-chickens wandering Jew ./ jade plant wax plant facilities are not appropriate for younger children. peperomia weeping fig For suggestions on how to improve children's outdoor play spaces, see Frost (1986) and Esbensen Most plant poisonings can be prevented with (1987). some simple measures: Whether the playground you use is on your prop- Learn which plants are poisonous. For help, erty or down the street, you can reduce the chance check library books, garden and floral shops, ar- that a child will be injured by following these basic boretums, or ask your local Cooperative Exten- safety guidelines. These guidelines also-apply to sion Service. home play areas so you may wish to share them Remove poisonous plants. with parents. Many injuries are due to misuse of Supervise young children closely around plants. equipment. The safest equipment is designed to Eating too much of any plant can make a child prevent misuse, but there is no substitute for good sick. Label plants so if ingestion occurs accurate supervision. information can be given to the poison control Supervise children closely at all times to prevent center. misuse of the equipment such as swinging too Teach children not to put plants, fruits, or berries high, running close to moving swings, or playing in their mouth without asking a grown-up first. on equipment that is too advanced. If possible, assign extra staff to areas of high risk. Batteries. Small button batteries found in some Check play equipment and its surroundings once toys, cameras, and calculators present a choking a week; use the Playground Safety Checklist (Fig- hazard and can be extremely poisonous if swal- ure 6-7). lowed. When replacing a button battery, be sure that Look for sharp edges, rough surfaces, and loose or you discard the old one immediately, away from broken parts. Cover sharp or protruding parts children's areas. with heavy, waterproof tape. 73 Safety and first aid 55

Figure 64. Poisonous plants

Children are often attracted to the colorful ber- laurel rhododendron 114 flbwers, fruits, and leaves of plants, but more lily-of-the-valley rhubarb leaves than 700 typical plants in the United States and lupine rosary pea Canada have been identified as poisonous. Plants mistletoe rubber vine

tansy important for parents, grandparents, teachers, and mountain laurel thorn apple others to keep poisonous plants away from children. mushrooms tobacco If eaten, some plant parts can cause a skin rash or nightshade tung oil tree stomach upset; others can even cause death. Here is oleander water hemlock a partial list of plants that are very dangerous o philodendron white snakeroot CHILDREN HAVE DIED FROM EATING THESE poison hemlock yellow jessamine PLANTS. pokeweed yellow oleander yew autumn crocus delphinium privet azalea dieffenbachia baneberry (dumbcane) If you think a child may have swallowed any part belladonna duranta of a poisonous plant, first remove any remaining black cherry false hellebore pieces from the child's mouth. Then bring a piece of black locust foxglove the plant to the phone and call your poison control buckeye golden chain center. Be sure the telephone number of the poison caladium hyacinth control center nearest you is posted by each tele- caper spurge hydrangea phone. Keep an up-to-date container of syrup of castor bean jequirity bean ipecac available in case the poison_ control center tells you to use it to make the child vomit a poison- cherry jsamine ous substance. (See the section about first-aid kits in chinaberry jiesson weed daffodil lantana Chapter 8, p. 93.) daphne larkspur Phone number of local poison control center:

7/1 56 Safety and first aid

Figure 6-2. How to choose art supplies

AVOID powdered clay. It contains silica which is easily inhaledand harmful to the lungs. USE wet clay which cannot be inhaled. AVOID)glazes that contain lead. USE poster paints. AVOID paints that require solvents, suchas turpentine, to clean brushes. USE water-based paints.

AVOID cold-water or commercial dyes that contain chemicaladditives. USE natural dyes-such as vegetablesor onion skins. AVOID permanent markers that may contain toxic solvents. USE water-based markers. AVOID instant papier -mache whichmay contain lead or asbestos. USE newspaper (printed with black ink only) and librarypaste or liquid starch. AVOID epoxy, instant glues, or other solvent-based glues. USE water-based white glue or library paste. AVOID powdered tempera paints. USE liquid tempera paint or any nontoxic paint.

For more information contact Art Hazards Information Center,5 Beekman Street, New York, NY 10038. Phone 212-227-6231.

75 Safety and first aid 57

Cover the ground under equipment with 8" to 12" Keep the vehicles in good condition. Check regu- of a soft, loose, resilient material such as shred- larly for missing or damaged pedals and hand- ded tires, pea gravel, wood chips, or loose sand. grips, loose handlebars and seats, broken parts, "Reeeigniie that cement, asphalt, and hard-packed and other defects. or frozen soil or sand are dangerous play surfaces, Cover any sharp edges and protrusions with even when children are supervised. Rake sand heavy, waterproof tape. and other loose materials frequently to keep them Don't leave riding toys outdoors overnight. soft. Moisture can cause rust and weaken metal parts. Keep area clean from glass, litter, and large rocks. Teach children how to play safely. Involve them in making rules for playground behavior, and en- Pedestrian safety force these rules Consistently. Praise children Children learn by imitation and experience. Walks when they use the playground appropriately (see to the nearby playground are teachable moments Figure 6-3). that can be used to introduce and practice safe pe- Remove a misbehaving child from play and ex- destrian behavior. plain how her or his actions could hurt someone. Use a travel rope to keep younger children to- Make sure all play areas are protected from gether. Children can hold onto spaced knots in streets and traffic to minimize the chance of a the-rope. Make the walk fun, not confining, by child darting into the street. playing Follow the Leader or singing songs. Check the outdoor environment for poisonous Ask staff to explain rules for crossing the streets plants and remove them, if possible. safely, enforce the rules consistently, and follow Avoid poisonous wood preservatives. If possible, these rules themselves. use pressure-treated wood-instead. Talk about safety often. Encourage children to think and talk about the reason behind the ac- Riding toys tions. Have several sizes of tricycles or other riding toys During walks, ask children to point out traffic available for the-older toddlers and preschoolers. If warning signs (stoplights, signs, and crosswalks) a child is too large for the tricycle, it will be un- and to explain how they help pedestrians and traf- stable. If the child is too small, the tricycle may be fic. difficult to control properly. Use low-slung riding toys with seats close to the ground and a wide wheelbase. They are more Field trips stable. Pay extra attention to safety during field trips be- Avoid vehicles with sharp edges, particularly cause children may become excited about new and fenders. unfamiliar surroundings. Remember that safety Look for pedals and handgrips with non-skid sur- rules for indoors may not apply outdoors. Increase faces to prevent children's hands and feet from the safety of your field trips by doing the following: slipping. Recruit parents, volunteers from senior citizen Teach children safe riding iiabits and check on centers, or students from early childhood courses

their-performance frequently. to help supervise field trips. 24, Do not allow wheeled vehicles on sidewalks or Obtain a signed permission slip for eachexcur- near streets, because low tricycles cannot be seen sion, even neighborhood walks, so you are sure by cars or trucks. parents approve of the child leaving for that par- Do not allow children to ride double. Carrying a ticular trip. passenger makes the vehicle unstable. Be a positive role model. Wear safety belts when Teach children that riding down hills is danger- riding, and cross traffic areas correctly when ous. A tricycle can pick up so much speed that it walking. -becomes almost impossible to. stop. Involve children in making and enforcing rules. Teach children to aye .1 sharp turns, to make all Make sure children understand the rules before turns at low speed, and not to ride down steps or you !cave. over curbs. Identify children with a label that states the pro- Advise children to keep ha-tds and feet away from gram's name and telephone number. Do notuse moving spokes. the7 child's name. 58 Safety and first aid

Figure 6-3. Safe playground habits Swings Horizontal ladders and bars

Sit in the center of the swing. Never stand or Only people at a time. (Fill in your limit.) kneel. Everybody starts at the same end and goes in the Hold on with both hands. same direction. Stop the swing before getting off. Use the lock grip (fingers and thumbs). Stay faraway froth moving swings. Keep a big space between you and the person in Be sure Only one person is on a swing at a time. front. Don't swing empty swings or twist unoccupied Don't use when wet. rings. Diop down with knees bent. Try to land on both Keep head and feet out of the exercise rings. feet.

Slides Seesaws (older children only)

Wait your turn. Give the person ahead lots of Sit up straight and face each other. room. Hold on tight with both hands. Hold on with both hands climbing up. Keep feet out from underneath the board. Before sliding down, make sure no one is in front. Tell your partner when you want to get off. Get Slide down feet first, sitting up, one at a time. cff carefully, and hold your end so it rises slowly After sliding down, get away from the front of the until your partner's feet touch the ground. slide.

Climbing apparatus

Only people at a time. (Fill in your limit.) Use bothands, and use the lock grip (fingers and thumbs). Stay away from other climbers.

Adapted from U.S. Consumer Products Safety Commission (1981). "Play Happy, Play Safe."Washington, DC: U.S. Government Printing Office. Safety and first aid 59

Prepare for an emergency by bringing a small first-aid kit with yOu. Include change for a phone and a list of emergency phone numbers, a folder with copies of emergency forms, and the signed Permission.slips.. If you are traveling by car, be sure in advance that there are enough vehicles so that each child and adult has a safety seat and/or belt. Summer safety Heat and sun. Warm, sunny weather can pres-nt additional areas of concern for outdoor play. Chil- dren can easily be burned by the hot sun or by contact -with hot surfaces such as asphalt and playground equipment. Dehydration and heatstroke can also occur. Make sure children have access,to drinks befoie and after vigorous play, and at least every 2 hours during the day. If there is no natural shade on your playground, you may want to create some by using tents or canopies. (They add lots of new fun and adventure, too!) During the period when the hót, midday sun shines ti (10 a.m. to 2 p.m.) limit the amount of time you There must 6e constant adult supervision when spend outdoors. Ask parents to authorize the use of children-are near .water. Teach children basic sunscreeidotion or to send protective clothing such water safety rules. as hats or visors. Protect young children's skin, which is more sen- Preventing insect stings. Bugs like summer, too. sitive to the sun than the skin of adults. At the be- Stinging insects are often seen swarming around ginning of the season, provide gradual exposure, sugary containers and trash cans. In late summer, starting with 5 to 15 minutes the first day and in- insects are busy gathering sugar from ripe fruits. creasing 5 to 10 minutes each day. Although chil- Although most insects will not sting unless pro- dren with darker skin generally can spend more voked, during late summer and early fall it seems to time in the sun than those who have light skin, even take less to irritate them and their venom is more children who' have dark skin can burn. Suntans in potent. childhood and later years are responsible for skin To prevent stings, adults and children should cancer and wrinkles in adulthood. Please refer to the learn to avoid getting excited and moving around sunburn section in Chapter 18 for treatment. rapidly when they see stinging insects. Such activity Drowning. Drowning is still one of the leading is more likely to result in a sting. Prevention also causes of death among young children. There must includes keeping sugary foods away from children be constant adult supervision when children are and adults outside. Keep trash cans away from out- near water (such as swimming pools, wading pools, side play areas. During picnics, avoid sweet foods ponds, streams, or salt marshes). Children can such as fruits and fruit juices unless water is avail- drown in less than an inch of water. Teach children able to rinse off sticky areas aftc eating. Sponge off these basic water safety rules right from the start. children to keep them cool because perspiration and Swim or play in the water only when an adult has overheated skin also seem to attract stinging insects. agreed to watch you. See the section on first aid for information on Do not run, push, or dunk in or around water. how to handle insect and other bites (p. 98). Do not bring glass near the area. Do not swim with something in your mouth. Winter outdoor play Yell for help only when you need it. Children of all ages enjoy and benefit from play- Teach all adults and older children how to admin- ing outdoors in all except the most extreme ister mouth-to-mouth resuscitation, the technique weatherand that varies according to what you are to restore breathing accustomed to in, your climate. In winter, be sure 00- Safety-and first aid children are dressed warmly. If they are overdressed could not possibly turn over and fall off a changing and play actively, they will get sweaty and then table; the very next day the child can give a suc- chilled. Staff: and children alike will feel refreshed cessful push and end up on the floor! An infant's or when fresh air is fiarVof the daily, routine. toddler's natural curiosity can be encouraged in a Children should not be allowed to play outdoors _safe_environment, if you give-special consideration when etV WIa and frostbite. to equipment and indoor and outdoor play areas.

Equipment and toys Snow safety. Children should be encouraged to play in and with snow, so take advantage of this Keep safety in mind when you buy and use fur- wonderful natural resource for daily winter play niture and equipment for children younger than 3 .. ac- twittes.,Itemernber these snow safety precautions. years old. Injuries involving cribs, baby walkers, and Snowballs can be dangerous, especially when highchairs are fairly common. You can reduce the the snow is packed hard or when childrenput possibility of injury by selecting appropriate equip- rocks or other items in snowballs. Being hit in the ment (see Figure 6-4), properly maintaining it, and face or head with this type of snowballcan cause supervising its use. Infant walkers are no longer a serious injury. recommended because so many injuries are:associ- Be sure children do not throw snowballs into ated with them when children-fall over, pull objects parking lots, streets, or at moving cars. down on them, or go down steps in them. Some Encourage children-to play in the snow and authorities also are concerned that children who with the snowbut don't let them eat it. Al- spend a lot, of time in them may not develop the though eating snow is fun, it is riGt healthy. Par- proper sense of balance needed for walking. ticularfrin cities, snow can contain dirtor other A SPECIAL NOTE: If you buy or use old infant atmospheric substances. cribs, be sure they meet the criteria in Figure 6 -4.. 6 Keep a watchful eye on scarves and hoods. They Changing Surfaces. Even though the floor may can get caught on playground equipment and seem to be the safest place to change diapers, it is have caused strangulation and other serious in- not recommended for use in groups. Use a chang- juries. ing. surface -that is at least 3' above the floor to Keep children dry. Wet clothing allows rapid cool- help prevent the spread of infectious diseases. Keep ing and frostbite. diapering and play spaces separate. Always strap the baby in place if possible. Even so, there is no substitute for close supervision. Always keep at least one hand on the baby. Never leave the baby for a Special safety tips for infants and moment, even if a strap is used. Whenever possible, toddlers use a table with guard rails or a recessed top. These offer some additional protection against infant falls. Never assume that a child's motor abilities will Please refer to Chapter 5 for more information remain the same from day to day. One day a baby about diapering safety.

7 Safety and first aid 61

Figure 6-4. How to select safe infant furniture and equipment

Highchairs fabric seats with heavy-duty stitching or large, rugged snaps ;Hanown...1", e- protective covers over coil springs and hinges; no sharp points or exposed screws unstable chairs that tip easily trays that baby can push against and unlatch Supervision and use seat belts attached to tray instead of chair rough, sharp edges or points Remain with baby while she or he uses the parts that can pinch walker. Prevent the baby from limning or leaning too far. Safety features Help the,child maneuver over thresholds. Remove throw rugs and other obstacles. wide, stable base no sharp or rough edges or points Place guards at the top of all stairways and/or sturdy restraining straps that are attached se- keep stairway doors closed to prevent falls. curely to chair tray that locks securely Baby carrier seats Supervision and use Hazards Place highchairs out of the path of opening doors (such as range or refrigerator). narrow base, slippery bottom surface Be sure child is trapped in securely. Never use supporting devices on back that may collapse the tray as a restrainer without straps. If the high- no safety straps chair has no safety straps, purchase a set and attach thern,to the chair. Safety features Never allow a child to stand up in a highchair. sturdy materials and wide, stable base Put the highchair out of the way when not in use safety straps so it can't be knocked over easily. nonskid bottom surface Don't let older children hang onto highchair while supporting device that locks firmly in place a baby is in it. Make sure child's hands are out of the way when Supervision and use attaching or detaching the tray. Use the carrier only as intendedit is not a car safety seat. Always stay with baby. Walkers Place carrier on a low, non-slip surface. Always use safety straps. Hazards Attach rough-surfaced adhesive strips to carriers walkers that might tip over when baby leans, with slippery bases. runs, or reaches If you must use a carrier on high surfaces, make *.- children ean pull objects down on themselves or sure the child is within arm's teach and out of fall down stairs reach of dangerous objects. older x-frame walkers that could trap fingers Check supporting device to make sure it is firmly when walker partially collapses in place. may interfere with child's development of proper Don't leave the baby (even for a second) untended balance for walking in an infant carrier above floor level.

Safety features stabilitywheelbase wider and longer than frame of walker sturdy materials: unbreakable plastic or tough go 62 Safety and first aid

Figure 6-4 cont. How to select safe infant furniture and equipment Back carriers Safety features no more than 23/s" between slats 0111a7Ards- snug- fitting Mattressif you can fit two 'adult unpadded frames near baby's face and head fingers between mattress and sides, then mattress leg openings that are too large is too small joints that could accidentally close and pinch crib sides that lock at maximum height no rough edges or exposed bolts Safety features safe materials, such, as nonlead paint : particularly important with older or used equip- padded covering on frame near baby's face ment seat belts latching device that cannot be released easily leg openings small enough to prevent baby from no finials, cutouts, or decorative knobs slipping out endposts no more than 5/8" high leg openings big enough to avoid chafing baby's legs Supervision and use strong stitching and large, heavy-duty snaps to prevent accidental release Check latches to make sure they are secure. Check slats on all sides for closeness and install Supeivisioil,anik use bumper padsif too far apart. Do not use a crib if a slat has been broken, unless it has been replaced " Do not use back carriers until baby is 4 to 5 properly. months old and can hold her or his head up. Until you can replace a _mattress that does not fit Buy carrier to-match baby's size-and weight. snugly, roll large towels and place them between Always,use restraining straps. mattress and crib sides. 4i Be sure leg openings do not chafe the baby's legs. Check baby's standing height on mattress against 4 Avoid sharp points, edges, and rough surfaces. side rail. If height of rail is less than 3/4 of baby's ° Avoid joints tiler c=tri accidentally close and pinch height when the mattress is in the lowest position, or cut the baby. obtain a larger crib, or move the baby to a regular Bend from 'knees when leaning or stooping to bed. minimize chance of baby falling out. Remove large toys or any objects an older baby Walk gently to avoid jolting the baby's neck. may stack or use for climbing. Never hang any stringed object (including toys) on bedposta child could become caught in it Cribs Similarly, never put a loop of ribbon or cord around child's neck. Hazards Remove and destroy all plastic wrapping materi- removable plastic wrapping on mattress als on crib mattress. Never use plastic cleaner's mattress too small for cribbaby could get stuck bags or trash bags as mattress covers. between mattress and sides and suffocate -crib- slats -too far apartbaby could Wriggle through and/or strangle if head gets stuck Strollers and carriages crib so small baby could climb out large toys, objects, or bumper padsolder baby Hazards could climb on and fall out inadequate or faulty brakes dangling stringsbaby may get caught in them latches that do not hold securely and strangle sharp edges or exposed hardware, exposed hinges finials (decorative devices on cornerposts) and or dangerous scissors-like mechanisms cutoutsbaby's head may become caught children's fingers may be pinched or severed canopies that don't lock firmly in place Safety and first aid 63

Figure 6-4 cont. How to select :7-7fe infant furniture and equipment

Safety features protruding bolts or rough edges stability safeguards=stroller will, not, tip over hinges that do not lock tightly even if child is reclined as far back as possible larie toys left in playpenbaby could step on firm; vertical (or nearly vertical) backrestchild's them and climb out head should be supported slats that are loose or more than 23/8" apart firmly attached safety belt, waist strap, or harness weak floors; no padding on floor tightly locking,brakesa two-wheel brake provides-extra security Safety features wide base and wheels with large diameters mesh netting with weave smaller than tiny baby canopy thatiocks in fo.ward horizontal position buttons (less than 1/4" diameter) and rotates to downward position in rear slats iii.),rnare than 23/8" apart shopping basket that can be mounted in front of, firm floors with a foam pad or centered above, rear axle for stability hinges that lock tightly,-no sharp edges plastic coverings over exposed hinges vinyl covering on railings and padding thick enough to resist being chewed and bitten off by Supervision and use teething children Chcck brakes before taking baby for a ride; always use brakes when stroller is not in motion. Supervision and use Make sure baby is safely strapped in. Never leave a baby in a playpen with one side Check latch devices for security on collapsible down. models.. eBring playpen indoors after userain and sun. NEVER leave infant unattended. can damage it. Do not allow other children to pull or stand in or Remove any objects that could be stacked and on the shopping basket. used for climbing. Never hang any stringed object (including toys) Playpens on playpen; a child could become caught in it. Similarly, never put a loop of ribbon or cord Hazards around child's neck. playpens too small for growing children baby Keep an cyc on baby and be aware of what she or shouldn't be able to crawl over the side or cause he is doing. pen to tip over by leaning against it mesh playpcns with large open weaves child can use mesh for climbing or netting may catch buttons

Adapted from U.S. Consumer Products Safety Commission. (1977). "Nursery Furniture and Equipment Can Be Dangerous." Washington. DC: U.S. Government Printing Office.

82 64 Safety and first aid

Toys. General information about toy safety was presehted on p..53 in this chapter. Refer to Figure 6=5'for examples of safe toys for children younger than age 3. Follow these special guidelines for infant

and-toddler tOyS. Regularly check any toys that babies can find-and grab. Be sure-toys are.at least 11/2" in diameter so they can't be swallowed. Avoid toys that can be taken apart or use only with Constant adult supervision. Be 'Sure stuffed animals are not so la.te or heavy that they can suffocate children. Children can also use large tioys'to climb out. Use this CPSC rattle test to avoid choking haz- 'ards. Trace the oval here (13/8" by 2") on apiece of cardboard. Cut Out the ()Val. If a rattle can pass through this hole to a depth of I.3/16", discard the rattle. as CPSC rattle test

1.2 Teach older ehildien:towatch out for the younger children to help keep them safe it outdoor-play areas.

Toddlers must be well supervised especially near watertables and in bathroom's near toilets and deep sinks. All these are naturally of great interest to young children and, with the unsteady: gait of toddlers, present a potential drowning hazard. t. Sleeping arrangements Placement of cots and cribs is an important safety issue. Indoor play areas Leave a clear aisle between cribs. In an emer- Programs with infants and toddlers should' make gency, staff must have-quick access to each child. sure.thatenough floor space is available for crawl- Place cribs away from window =blinds or shade big' and toddlingiChildren. These floors should be cords. Olean, free of Splinters crad-ss, ,and,,not highly polished. Outdoor play areas -Separateinfant -and toddler play areas from the Because infants and toddlers spend Much more 'general play area for older children. This will en- time on the ground than older.children,- check the courage the youngerchildren to explore without the playground dailyfor items thatcari be hazardous. danger of the older children knocking them down. Be sure to provide close adult supervision when ProVicie acarpeted area 'for- quiet activities and be- toddlers and older children are outdoors together. ginning 'large motor movement by infants. Bolt Also, 'teach_ older children to watch out for the down top -heavy ktrniture sue i.as shelving,orcubb. yotingerschildren to help keep them ,afe in the out- les, to avoid=toPpling,, doorplay areas. Safety and first aid 65

Figure 6-5. Safe toys for children younger than age 3

The first year snap-together beads (large size) .sturdy rattles banging musical instruments (xylophone) shatterproof mirror toy telephones bright objects out of reach but hanging in view large-sized crayons or watercolor markers (mobiles, pictures) (nontoxic) washable dolls and stuffed animals (with plastic kitchenware (lightweight, without sharp riveted eyes) edges) bright cloth or rubber balls puzzles with knobs and a few large pieces soft stacking blocks steerable riding toy -,nesting toys ring stack sets 2-to 3 years old (in addition to above) squeaky toys (with unremovable squeakers) puzzles with more large pieces cloth, vinyl, or board books blocks (lightweight) musical instruments to shake (bells) size-shape matching toys and games books with short stories 1 to 2 year old (in addition to above) soft dough clay (nontoxic) pull toys (withtringsmo longer than 12") finger or tempera paint large, lightweight spinning top construction sets with large pieces books_ with cloth or cardbbard pages puppets blocks dress-up clothes wooden threading beads (large size)

`For details, see "Toys: Tools for Learning." (National Association for the Education of Young Children, 1985).

0CI A Figure 6-6. Site safety checklist

Date

-"elle-eke& bY

Item TrueFalseDate made correction Corrections/comment General environment

There is a floormat or other nonskid surface at each entrance to the facility.

Floors are smooth and have a nonskid surface.

,Pipes and radiators are ilnaccessible to children or are covered to prevent contact.

Hot tap *ater temperature for handwashing is115°F: or lower.

All pieces of equipment with an electrical motor or an electrical connection amgrounded.

Electrical cords are out of children's reach and are kept out of doorways and traffic paths.

Unused electrical outlet are covered by furniture, or outlet 'covers, or shock stops.

Medicines, cleansers, and aerosols are stored in their original containers and kept in a locked Place where children are unCile to see and reach them.

Matches and lighters are always kept out of sight and reach of children. Figure-6-6 cont. Site safety-checklist

Item TrueFalse:Date made correction Corrections/comments General environment 'cont. All windows have screens that stay in place when used. Expandable screens are not used.

Windows can be opened 6" or less from the bottom.

All storage units are stable and secured against sliding and collapsing.

Drawers are kept closed to prevent tripping or bumps.

Trash is covered at all times.

Walls and ceilings are free of peeling paint and cracked or falling plaster. Facility has been inspected for, and is free of, lead paint:

There are no diseasebearing animals such as turtles, parrots, or cats.

Children are always supervised.

There is no crumbly asbestos.

Equipment and toys

Desks and chairs are in good repair and are free of splinters and sharp edges.

'Toys and play equipment are checked often for sharp edges, small parts, apdsharp points. Figure 6-6 cont. Site safety checklist O's 00 Item TrueFalseDate made correction Correctionskonunents EqUipment and toy!,.cont. Leacqfee paint is used on all painted toys.

Tviys are put away when not in use. Open shelves are used -,ivhenever possible.

There are no toy boxes used at the facility.

Toys are appropriate for the age and abilities of the children who use them. ,

Art materials are nontoxic, and have either the AP or CP label.

Art materials are stored in their original containers in a locked place.

Audio-visual equipment (VCR, television, computer, film projector) is secured on stands in a way that will prevent tipping.

Teaching aids (e.g., projectors) are put away when not in use.

Curtains, pillows, blankets, and cloth toys arc made of flame- resistant materials. They are laundered regularly.

Hallways and stairs

Stairs and stairways are free of boxes, toys, and other clutter.

Stairw4s are lighted well. Figure 6-6 cont. Site safety checklist

Item TrueFalseDate made correction Corrections/comments -Hallways and stairs cont. The right-hand railing on the stairs is at child height and does not wobble when held. There is a railing orwall on both sides of stairways.

Stairway gates are in place when appropriate.

Doors to unsupervised or unsafe areas are always locked unless this prevents emergency evacuation.

Staff are able to monitor strangers -entering the-building.

Kitchen

Trash is kept away from areas where food is prepared or stored. 1 Trash is stored away from the furnace and hot water heater.

No-Pest Strips are NOT used. Pesticides for crawling insects arc applied by a certified pest control operator.

Cleansers and other poisonous products are stored in their Original containers away from fOod and out of children's reach.

Nonperishable food is stored in labeled, insect - resistant containers. Perishable food is stored in covered containers in the refrigerator.

92 Figure 6-6 cont. Site safety checklist

Item. TrueFalseDate made correction Corrections/comments Kitchen , cont. .. -Food preparation surfaces are . clean and free of ,cracks and chips. ,

Eating utensils are free of cracks aitd-Ctiiiii.

Electrical cords are placed where . people will not trip over them or them. Then sharp or hazardous cooking uteniits-Within children's reach-(e.g., knives, glass).

P6fhanclies are always turned toward tide back of the stove.

The fire extinguisher can be reached easily: .

All staff know how to use the fire extinguisher correctly.

Bathrooms

Stable step stools are available when needed.

Cleaning products, soap, and disinfectant are stored in a locked place, out of children's reach.

Floors are smooth and have a nonskid surface.

The trash :Container is emptied daily and kept clean.

Water for handwashing is no hotter than 1 15° F. Figure 6-6 cont. Site safety checklist

Item TrueFalseDate made correction Corrections/comments Emergency preparation All staff understand their roles and responsibilities in case of emergency.

At least one staff person is always present who is certified in first aid and CPR for infants and children.

The first-aid kit is checked at least monthly for supplies and is kept where itcan be reached easily by staff.

Smoke detectors and other alarms are checked regularly to make sure they work.

Each room and hallway has two -fire escape routes posted in clear view.

Emergency procedures, telephone numbers, and the address and directions to the facility are.posted in clear view near each phone. g, Children's emergency phone numbers are kept near the phone.

All exits are clearly marked and are free of clutter.

Doors open in the direction of exit . travel.

Cots are piaced so thai walkways are clear for evacuation in an emergency.

0 95' 9.6 Figure 6-6 cont.. Site safety checklist

Item TrueFalseDate made correction Corrections/comments Traffic and pedestrian safety There is a safe drop-off and pickup location for children arriving in motor vehicles.

There is a clearly posted, one-way traffic pattern in the loading zone.

School-bus parking is isolated fromthe flow of automobile traffic and parking.

School-bus drop-off and pick-up times are supervised by a staff member each morning and afternoon.

Signs are posted to warn motorists that they are approaching a school zone.

Adapted from Statewide Comprehensive Injury Prevention Program (SCIPP), Department of Public Health, 150 Tremont Street, Boston, MA 02111.

98 9t7 Figure 6-7. Playground safety checklist

Date

Checked by

Item TrueFalseDate made correction Corrections/comments All equipment

Nuts, bolts, and screws are recessed, covered, or sanded smooth and level.

Nuts and bolts are tight.

Metal equipment is free of rust and chipping paint.

Wooden equipment if free of splinters and rough surfaces.

Equipment is free of sharp edges.

Ropes, chains, and cables have not frayed or worn out.

Equipment has not shifted or become bent.

There are no "V" entrapment angles on any part of the equipment.

There are no open holes in the equipment forming finger traps (e.g., at the ends of tubes).

There is no corrosion at points where equipment comes into contact with ground surface.

All parts of the equipment are present.

99 100 Figure 6-7 cont. Playground safety checklist

Item TrueFalseDate made correction Corrections/comments All equipment cont.

Anchors for equipment are stable and buried below ground level.

Children who use equipment are of the age/developmental level for . which the equipment was designed.

Slide ladders have handrails on both sides, and flat steps.

There is a flat .urface at the bottom of the slide (if the slide is more than 4' high, the flat surface should be 16" in length).

The bottom of the sliding surface is no more than 15" above the ground.

There are no "tube" slides.

,There are no circular slides in the preschool area.

The sliding surface is not made of wood or fiberglass.

If the slide is made in several pieces, there are no gaps or rough edges in the sliding surface.

The sliding surface faces away from the sun or is located in the shade. 102 The steps or rungs on the slide are slip-resistant.

Steps and rungs are regularly spaced, 7" to 10" apart, from top to bottom. 0 Figure 6-7 cont. Playground safety checklist

Item TrueFalseDate made correction Correctious/comments All equipment cont.

Rungs are between 3/4" and 11/2" in diameter.

Climbing equipment

An adequate impact-absorbing surface under the structure extends 6' beyond the slides of the apparatus.

Handholds stay in place when grasped. .

Equipment height does not exceed 6' in height.

Climbers have regularly spaced footholds (7" to 10" apart) from top to bottom.

There is an easy, safe way out for children when they reach the top.

Rings are painted in bright or contrasting colors so children will see them.

Rungs, climbing bars, and handrails are between 3/4" and 1/2" in diameter.

There is a 28" to 32" (or higher) barrier around preschool . equipment that is more than 30" above the ground.

The space between slats of barriers does not exceed 4".

There is no head entrapment area on the apparatus.

.103 104 Figure 6-7 cont. Playground safety checklist

Item TrueFalse Date made correction Corrections/comments Ground surface

All elevated play equipment (slides, swings, bridges, seesaws, climbing apparatus) has 8" to 12" of impact-absorbing material underneath, such as sand, pea gravel, or wood chips. (Pea gravel and wood chips should be avoided in the 'nfanttioddler areas.)

SUrfazes are raked weekly to prevent them from becoming packed down and to remove hidden hazards (e.g., litter, sharp objects, animal feces).

Standing water is not found on the surface or inside equipment.

Spacing

Swings have adequate clearance in both directions (14' beyond the farthest extension of the swing: 8' of impact-absorbing surface, plus a 6' safety zone).

Swings are at least 18" from each other and 28" away from the frame.

Slides have 2 1/2 tc 3 yards of space at the bottom. There is at least 8' between all 106 equipment.

10 Boundaries between equipment are visible to children (for instance, painted lines or, low bushes). Figure 6-7 cont. Playground safety checklist

Item TrueFalseDate made correction Corrections/comments Spacing cont.

Play areas for active play (e.g., bike riding, running a games) are located away from areas for quiet activities (e.g., sandbox, outdoor tables).

Slides

An adequate impact-absorbing surface under structure extends 5' beyond the sides of the apparatus.

Slides are 6' in height or less.

Side rims are at least 21/2" high (F." for circular or wave slides).

Slides have a flat surface at the top (with safety barriers).

Swings

Swing seats with back supports and safety bars are available for toddlers and children with disabilities.

All swing seats arc made of canvas, rubber, or other pliable material. .

There are no "S" or open-ended hooks.

Hanging rings arc less :tan 5", or more than 10", in diameter (smaller or larger than child's head). Figure 6-7 cont. Playground safety checklist

Item TrueFalseDate made correction Corrections/comments Swings, cont.

The point ai which the chain/rope and the seat meet is designed to prevent entrapment.

Chain link-openings do not exceed 1/4' in diameter. When stationary, all seats are level.

There are no more than two swings on any one apparatus.

Preschool swing seats are at a maximum height of 18".

The swing seat cannot rise more than 6' above the surface.

For tire swings, there is at least a 19" safety zone between the support structure and the farthest extensions of the swing.

Tire swings have drainage openings.

Plar., swings (gliders) have stable handholds, footholds, and seats.

Seesaws

There is an adequate impact- absorbing surface under the structure and beyond the sides of

the apparatus. .

The seating does not reach more than 5' above the ground.

The fulcrum is enclosed or designed to prevent pinching. Figure 64 cont. Playground safety-cheCklist

1 Item TrueFalseDate made correction Corrections/comments Seesaws cont.

Handholds stay in place when grasped, without turning or wobbling.

A wooden block is on the underside of the seats or a rubber tire segment is buried in the surface under the seats.

Sandboxes

Sandboxes are located in a shaded spot.

The sand is raked at least every week to check for debris and to provide exposure to air and sun.

The box is covered at night to protect from moisture and.animal excrement.

The sandbox has proper drainage.

Rocking equipment

There is an adequate impact- absorbing surface under the structure and extending 6' beyond the sides of the apparatus.

Seating surfaces are less than 39" above the ground.

There are no parts that could cause a pinching cir crushing injury.

111 11.2 Figure 6-7 cont. Playground safety checklist

, . Item TrueFalseDate made correction Corrections/comments Rocking equipment cont. Handholds stay in place when grasped.

Footrests stay in place.

Tunnels

The internal diameter of the tunnel is at least 2' 6".

There are two exits from the tunnel.

The tunnel is designed to drain freely.

General environment

The playground can be reached safely by children (on foot or bicycle).

The playground is accessible to people with disabilities.

If needed, a suitable perimeter fence is provided (e.g., if the playground is near a road, pool, or pond). Seating (benches, outdoor tables) is in good condition.

Signs give information about where to seek help in case of an emergency restrictions on the use of playground (hours, pets) name and address of playground operator (to report hazards) Figure 6-7 cont. Playgroundsafety checklist

Item TrueFalseDate made correction Corrections/comments General environment cont. A road sign advises motorists that a playground is nearby.

Trash receptacles are provided and located away from the playareas.

Poisonous plants are removed from play area.

There is a source of clean drinking water available in the play area.

There is shade.

The entire play area can beseen easily for good supervision.

Adapted from Statewide Comprehensive Injury Prevention Program (SCIPP),Department of Public Health, 150 Tremont Street, Boston, MA02111.

116 11.5 82 Safety and first aid

Safety education In addition to your own ideas, you may wish to use safety curricula from a variety of resources. Se- Provide children with the skills to prevent injuries Ica the age-appropriate safety curriculum that best and to care for themselves and others incase of fits the needs and philosophy of yourprogram. _emergency. Keep in mind that your own attitudes Whatever you decide to do, remember that safety and behaviors toward safety are as importantas the education is more than just a one-time activity. physical set up of your facility. Use these different Safety concepts should be integrated into allyour ways to give safety messages to children and staff. activities. For example: Be a positive role model. Include poison prevention in nutrition education. Give clear statements when explaining the cor- Children can make a doll house from cardboard rect, safe way to do something. boxes or hollow blocks. Ask them touse real or Compliment children for doing things safely. paper dolls to act out home hazards such as hot Involve the children in making and enforcing surfaces, poisonous products, toys lefton stairs. rules. This will increase their safety awareness Include messages about clothing into discussions and help them feel involved. You may also want to on weather and appropriate dress. Suggest that involve children in making safety checks. children wear light colors at nightor on dark, Teach children what to do in an emergency and rainy days and dark colors on bright, snowy days. where to get help. Safety and first aid 83

Bibliography

This chapter was prepared in largepart by and re- Lovell, P., & Harms, T. (1985). viewed by the staff of Statewide Comprehensive How can play- In- grounds je improved? Young Children,40(3), jury Prevention Program (SCIPP) in Massachusetts. 3-8. It draws upon the extensive library of SCIPP's Injury National Association for the Education ofYoung Prevention Resource Center, as wellas some of Children. (1985). "Toys: tools forlearning." SCIPP's own research data. Readers wishingmore Washington, DC: Author. extensive or detailed references should contact the U.S. Consumer Products SafetyCommission. Play Resource Center at 617-727-1246. happy, play safe. Washington, DC: Author. Esbensen, S. (1987). The early childhoodplay- U.S. Consumer Products SafetyCommission. ground: An outdoor classroom. Ypsilanti,MI: (1977). Nursery furniture and equipmentcan be High/Scope. dangerous. Washington, DC: Author. Frost, J.L. (1986). Children's playgrounds: Research Wanamaker, N., Hearn, K., &'Richarz, S. (1979). and practice. In G. Fein, & M. Rivkin (Eds.).The More than graham crackers: Nutritioneducation young child at play: Reviews of research, Vol. 4 and food preparation withyoung children. Wash- (pp. 195-211). Washington, DC: NationalAssoci- ington, DC: Author. ation for the Education of Young-Children. 7

Transportation safety

Transportation is an important aspect of all early life. You can reduce the chances of injury to chil- childhood programs. Whether you drive the children and staff during transport by being alert to dren to and from their homes each day or have only potential dangers, eliminating or avoiding :hese an occasional field trip, the cars or buses that you dangers, and knowing what to do when an emer- use form part of your environment. Motor vehicle gency occurs. accidents represent the greatest 'threat to a child's This chapter offers some ideas for setting up and maintaining a safe transportation system. First, be aware of and follow all state laws and licensing regulations that pertain to your program's transportation. Next, develop a written policy that clearly states the rules, the responsibilities of staff and children, and the emergency procedures to be followed. Use the 10 rules in Figure 7-1 and the topics in this chapter as a guide to help you develop a policy that fits your program's particular needs. Finally, make ever:one including staff, drivers, parents, and children aware of the policies and procedures as well as the reasons for their existence. A written policy will help answer questions and encourage everyone to carry out her or his role.

Child safety restraints

Legal requirements Whenever motor vehicles are used to transport children, special safety measures are necessary. The driver of any vehicle must assume responsibility for the safety of the passengers and must have a valid license for the vehicle. All states require that children be fastened in a properly adjusted safety seat or seat belt while riding in a motor vehicle. Car acci- Allistates require that children be fastened in a dents are the number one killer of children, and properly adjusted safety seat or seat belt while proper child safety seats help prevent death and riding in a motor vehicle. injury.

119 85 86 Safe& and first aid

Figure 7-1. Ten rules for transportation safety

1. Make sure that all vehicles used to transport 6. Never transport children or adults in the children have the most recent federally approved cargo area of a station wagon or van. safety seats and/or safety belts. 7. Never leave children alone in a vehicle. 2. Secure each child and adult in her or his own safety seat or belt. Never put two or more children 8. Keep sharp or heavy cbjects in the trunk. in thjsame belt They can become deadly projectiles in a sudden stop or accident. 3. Every day check vehicles that are used. 9. Load and unload young children only when 4. Before each trip, require the driver to the vehicle is pulled up to the curb, side of the conduct a quick 5-minute check to ensure that the road, or in a driveway, releasing them only to an vehicle is working well and contains nothing that authorized adult. could harm the children. 10. Do not let children put their arms or heads 5.*Ask drivers to remain alert to changes in the out of the vehicle's windows. vehicle while driving. Unusual odors, sounds, or vibrations can be warning signals for breakdown.

120 Transportation safety 87

Selection of equipment Each year, remind parents about the center's Passenger safety seats manufactured after emergency procedures and collect accurate par- January-1981 must meet_the Federal Motor Vehicle ent contact information. Safety Standard Act 213. Select a scat made since If you use a bus, practice emergency evacuation that time that will fit securely and properly in your drills with the children so they will be familiar vehicle(s) and will be used correctly on each ride. with what they may be asked to do. Transportation emergency issues include Proper_ use of restraints how to evacuate the vehicle Refer to Figure 7-2 for information on using how to assess injuries and provide first aid safety restraints for young children. Report prob- how to explain the situation to the children and lems with safety, scats to the National Highway Traf- reassure them of their safety fic Safety Admihistration at 800-424-9393. what staff still in the building are to do Protection of child passengers involves more than when to call for emergency support (e.g., police) simply placing them in a safety scator scat belt. what to do in bad weather Child restraint devices can be highly effective in what to do when a child becomes ill or injured preventing death and injury to children IF theyare during transport properly used. Carefully read instructions for such Emergency situations need to be handled calmly, devices before you install and use them. Makean efficiently, and with constant attention to the chil- extra copy of the directions to keep on hand. dren's fears, concerns, and safety. Train all staff and parent volunteers who will be using safety seats in their proper use. Each person must be able to demonstrate how to properly install What to have in the vehicle and use the scat. The information and equipment listed here is Remember that metal buckles and plastic cover- helpful for both daily transportation activities and ings can get hot and cause serious burns. Cover special field trips. scats that arc not in use with a blanket or towel. Touch all metal pieces to test temperature before Information. Keep information about the chil- putting a child into a safety scat or safety belt. dren and the route in a three-ring notebook in the vehicle. Make sure the driver and other staff can find it easily. In this information notebook Preparation for emergencies include a map of the route with estimated mile- ages and travel times, and the names and ad- To be prepared for transportation emergencies, dresses of children on the route (1) know what to do (c.g., first aid or evacuation) include an information/emergency card for each and, (2) have the necessary equipment and infor- child that describes how to reach parents and mation immediately available. emergency contacts, and special medical or health information Emergency procedures provide information on children with special Always expect the unexpected, no matter how ef- needs so that their ride will be as safe andcom- ficient and safe your transportationsystem is. Pre- fortable as possible. Descriptions of the condi- pare by taking the following steps: tion, behavior patterns, and warning signs for Be sure that parents, children, driver(s), and medical attention can be helpful in cast of an other staff all know what to do in an emergency. emergency. list phone numbers of emergency services such as For each of the following issues, develop a pro- local police, fire station, hospital, and ambulance cedure, using suggestions from children, parents, service, and name and phone number of the pro- and staff. Usc discussion groups and/or handouts gram and a contact person there to inform everyone of these procedures. Train drivers in the specific steps to follow under Equipment various emergency conditions. First-aid kitUse the list of suggested items in Make sure that staff who remain at the program Figure 8-2 to assemble your first-aid kit. know what to do when they are notified of an Emergency toy chestProvide songs, books, emergency on the road (e.g., contact parentsOr and toys to help keep children occupied if stuck provide alternate transportation). somewhere. 121 ,,

88 Safety and first aid

Figure 7-2. How to use car safety seats and safety restraints

There are three essential points to remember Booster seats (20 lbs. to 65 lbs.) about restraining children: 1. The child must be buckled properly into the These scats arc an option to the saf:.ty belt for restraint. children who are shorter than 4'6'L(:ieight 2. The restraint must be facing in the requirements vary slightly with model), and who appropriate direction. have outgrown the height and weight 3. The restraint must be correctly attached to specifications for the toddler scat. the vehicle. Use only with support for the upper body shield, harness, or the vehicle's lap/shoulder belt leant safety seats (birth to 20 lbs.) Usc with vehicle lap/shoulder belt (instead of lap belt only) to improve effectiveness. Make sure infant safety scats face therear of Try to use boosters with a tethered upper body the car. harness. They are highly effective although Secure the straps that hold the infant in the more difficult to use. (They are no longer safety scat. commercially available, but many are still Attach the safety seat to the car with a safety available secondhand.) belt. Usc the safety scat in the semi-reclined position. Safety belts (more than 50 lbs.)

Toddler safety seats (20 lbs. to 50 lbs.) Use for children who are too tall or too heavy for safety scats. Use only for children who can sit up by Fasten the lap belt low and snugly across the themselves. child's hips. Place the safety seat facing forward anduse it Use the shoulder belt only if it does not cross only in the upright position. the child's face or neck. Secure the child in the safety seat by a harness, If the shoulder belt is not used, tuck it behind shield, or combination. the child, not under her or his arm. Attach the safety seat to the car witha safety If no safety seat is available, use safety belts for belt. any child able to sit up alone. If a top anchor strap is provided, USE IT!

122 Transportation safety 89

Travel ropeUse for children to holdonto for make sure that all passengers know in which ve- easy evacuation of the vehicle or for walks from hicle they are to ride for the return trip. the vehicle to a safe place. On field trips, make sure that no child enters the Fire extinguisher, extra water, and appropriate vehicle alone or plays on the vehicle while the tools for minor repairs in case of breakdown. others are visiting the site. Never leave children alone in the vehicle. Use a trip sheet to record destina tion, mileage, times of departure and return, and a list of passengers. For large field trips, the latter is par- Field trips/car pools ticularly important. Be sure that all members of the car pools under- A well-organiied transportation system is impor- stand and agree to follow the guidelines you have tant even if you, do not transport children regularly. established for the trip. Special trips mean special circumstances. First of Provide enough staff assistance to besure every all, drivers may be traveling an unfamiliar route,or child is buckled up, unbuckled, and removed transporting children who may not ordinarily ride from the vehicle. Parents who are in a hurry may ,irith them. Drivers may be sharing responsibility make unsafe, "just this time" decisions. with volunteers who are themselves in a new situation. Finally, the children may be overly excited or overly tired from a new or long trip, or may be Passenger safety education frightened because they are going to an unfamiliar place. These- suggestions can help staff transport For children children safely during special hips Preschoolers are old enough to learn simple con- When your destination is knowr in advance,re- cepts of auto safety. Consistent use of safe behaviors view the route mentally or with a map if the-dis- helps children continue to practice them in later tance is great. Practice the route ii you have time and the vehicle is available. Make sure you have an authorization for and a list of every child and adult who will be traveling. Each child should have a parent's or guardian's permission for each trip. Check your insurance coverage for car pools. Make sure both the driver and other adults riding the bus- know who is responsible for responding to disciplineissuesmith_the.children_(e.g,,parenr volunteers, staff, or bus driver). Make sure you tell children who is in charge, and what the rules are. Make sure that children and all adults are appropriately restrained and/or wearing safety belts when.riding in Ahe car. Never have more passengers than seat belts. Help the driver concentrate by providing soft books or toys, songs, and conversation for the children. Use travel time to talk about rules for safe riding or other important concepts. If children become unrulyor remove their safety g restraints, stop and pull off the road to calm them 2 down. Do not try to drive and discipline at the same,time. , Make. sure that all passengers know when and where they are supposed to return to the vehicle, Keexparents educationalacti Wiles, If more :than' one vehicle is involved in the trip, toincluding transportation safety. 90 Safety and first aid years. There are four major passenger messages to For parents emphasize with children (and parents!). Everyone in the car should buckle upincluding It is important to involve parents in educational drivers and passengers in the front and back activities; they can promote concepts you present in seatsno matter how short the trip. the classroom. Keep them informed of the topics Seat belts go across the hips, not the stomach. that you cover with letters, parent education meet- The back seat is the safest place for child passen- ings, and personal contacts. You can also send activ- gers. ities home that parents and children can workon Good passengers buckle up and ride quietly. together (e.g., counting the number of seat belts in the car). The curriculum "We Love YouBuckle Up!" Focus on three main issues when you work with (National Highway Traffic Safety Administration, parents: 1984) contains a variety of activities and materials The importance of always using child safety seats for use- with preschool children and parents. You and safety belts. Might make pretend cars with cardboard boxes, How to select a suitable child safety seat. chairs, or seats; and safety belts from fabric scraps. How to use child safety seats and seat belts cor- Play games such as Simon Says, using safety belts, rectly. and entering/leaving vehicles correctly. These games are also fun for role playing and dramatic play activ- The article "Child Safety SeatsThey Work!" ities. Invite the safety officer from your community (Scott, 1985) contains many'helpful ideas andan to come and talk about traffic safety. annotated bibliography of resources. Transportation safety 91

Bibliography

Scott, D.K. (1985). Child,.safety seatsThey work. Younithildren, 40(4), 13-17. National Highway Traffic Safety Administration. (1984). We Love You Buckle ,Up! Washington, DC: Author. (Available from National Association for the Education of Young Children, 1834 Con- necticut Avenue, N.W., Washington, DC 20009-5786)_

125 8 Emergencies and first aid

A child falls from the climber on your playground. CPR and renew this certification annually. Re- You suddenly lose your electrical power during a quire that at least one certified staff person be in winter storm. You smell gas in the kitchen. A child attendance at all times. starts to choke during snack time. Would you know Maintain a first-aid kit. Figure 8-2 lists the con- what to do? tents for first-aid kits. Pack your kit in any light- No matter how careful and safety-conscious you weight, convenient container (a lunch box, hand- are, there will be times when emergencies occur.If your center has a comprehensive, written emergency policy, you will be better prepared tohandle such situations. Your center's policy needs to answer questions such as Who will give first aid? Who will take the attendance list if the building needs to be evacuated? What will you do if some of the children panic? Your policy should clearly state the roles and responsibilities of the children and each staff member in an emergency. Parents, too, need to be informed of your emergency policy and their roles in it.

Preparing for emergencies

In the event of an emergency in your program, remember these three important things: KEEP CALMif you panic, the children are likely to panic, too. FOLLOW YOUR EMERGENCY PROCEDURES ACT QUICKLY Figure 8-1 outlines emergency procedures you can adapt to fit your program, based onits size, location, and children's ages. This and all other figures referred to in this chapter are located atthe end of the chapter. In addition to specifying emergency procedures, you should also take these steps to preparefor potential emergencies. Develop a standardized form for reporting all Train staff in first aid and CPR. Make sure staff injuries or illnesses that require first aid or receive training and certification in first aid and additional care.

1.2.6 93 94 Safety and first aid

bag, or shopping bag). Keep at least one first-aid Be sure you know the location of phones in parks, kit available at all times including neighborhood playgrounds, and other places you visit with the walks and trips. Locate it near high-risk areas children. such as the kitchen or playground. Have another Your phone list should include your program's kit available for field trips or walks. Store your address, description of the building, and directions first-aid kit out of the reach of children but to it from a major road since these may be hard to easily accessible in case of an emergency. Make remember in a crisis. sure that someone on the staff inspects the kit Find answers to these questions about your local each month and replaces supplies. Keep a list of emergency and medical services. contents for the kit, as well as a record of the Who answers the emergency phone? (Police, fire, monthly inspections. ambulance, dispatcher?) Keep information where you need it. Place a What steps does the dispatcher have to take be- list of emergency phone numbers (Figure 8-5) and fore sending the ambulance? (Call another dis- a copy of your emergency procedures near each patcher? Call Emergency Medical Technicians?) phone for quick reference. Keep an extra list with Who provides the ambulance service? (Police, you on field trips. fire, volunteer, private companies, another town?) HAVE IMPORTANT FORMS AVAILABLE How far do they have to travel to get to your Parental permission formsHospitals and program? Where is the station? .emergency rooms will not give emergency treatment How long will it usually take them to get to your to any minor child, except in a life-threatening situ- program? ation, without parental informed consent at the Where are the nearest emergency rooms? time of treatment. Ask parents to complete emer- Try to visit your local helpers before you need gency transportation permission forms (Figure 8-3) them in a crisis. Most ambulance services are happy before enrollment, and keep these on file. Take a to show groups of visitors around their office, and copy of all permission forms with you on field trips. some will even come visit you if you ask. Emergency Injury report formsYour program should de- rooms are harder to tour, but you can at least visit velop a standardized form for reporting all injuries the waiting area and become familiar with how to or illnesses that require first aid or additional care get checked in. Familiarity with helpers now will (Figure 8-4 presents a sample). Give one copy of the come in handy when you need them later. These report to the child's parents and keep another copy visits will also help reassure children. in the child's folder. Find out which incidents or injuries must be reported to state or local authorities. Maintain a master listing or injury log so that Emergency evacuation plans patterns of injury or other incidents can be moni- tored and safety in your, program improved. Pyarssatinn Saving lives is the first priority in the event of any Getting help emergency. Saving property should be considered only when all lives are safe. Mt-Ku-4,31s aggnme thnt we can use a telephone to Planning, preparation, and practice are the essen- call' for help. Usually we can, but it is important to tial ingredients of a successful evacuation plan. De- think about alternatives in case a telephone is not velop a written procedure that includes routes, as- available. Know the locations of nearby pay phones, signments for all staff, and location of nearest alarm fire alarm boxes, or places you could go for help. that alerts the fire department. Make sure that the phone in your program can be When your program has an emergency that re- reached easily. quires evacuation, follow these steps. Keep a phone emergency list posted by every tele- Sound alarmnotify everyone in building. phone (Figure 8-5). Usually you can reach emer- Evacuateuse exit routes or alternate routes pre- gency assistance by dialing 911. If 911 is not avail- viously marked and practiced in drills. able in your area, refer to your phone list for specific Eliminate draftsclose all doors and windows. numbers for police, fire, and ambulance. You can Take a head countmake sure everyone is safely also call the operator, but this is a slower way to get out of the building. help. 127 Emergencies and first aid 95

Call fire department after leaving the building Test fire and smoke alarms at least once each call from nearest alarm box or phone if building month to be sure they are working. Have fire ex- alarm is not connected to the fire department. tinguishers inspected annually. Prepare for emergencies in advance by taking Place fire e:_inguishers where they can be these important actions. reached easily. Post diagrams of exits and escape routes in each Keep up-to-date emergency information for chil- room. Mark exits clearly, and do not block them dren and staff. Make a specific person responsible with furniture or other objects. for having this information on hand in emergencies, on trips, and in the event of program site Practice leavinthe building with the children evacuation. Ask parents to update emergency once each month so that they know the sound of the alarm and where to go. contact information every 6 months, and verify it by phone or mail. Include fire and burn prevention in children's curriculum. Know where you are going to stay if the building has to be evacuated. Families must know where to Knowing when and when not to use a fire extin- look for their children. Prearrange an-emergency guisher is an important part of fire preparedness. shelter where you will stay and inform parents by Use your extinguisher only if letter. You are nearby when a fire starts or the fire is Record daily attendance of staff and children. discovered in its early stages. Designate a staff member to carry the list out of Other staff get all children out of the building the building so that complete evacuation is as- and call the fire department. sured. The fire is small (confined to its originin a Post emergency telephone numbers (police, fire, wastepaper basket, cushion, or small appliance). rescue or central emergency code, and poison You can fight it with your back to an exit. control) beside every phone. All individuals using Your extinguisher is in working order, and you the building should be familiar with these num- Stand back about 8'. bers and the procedures to be used in an emer- Aim at the base of the fire, not the flames or gency. smoke. Plan two exit routes from every area of the build- Squeeze or press the lever while sweeping from ing. Post emergency evacuation exit instructions the sides to middle. in every room where they can be seen easily. You can get out fast if your effort is failing. Have unannounced evacuation drills monthly. If the fire spreads beyond the spot where it started Evacuation should include use of alternative exit or if the fire could block your exit, don't try to fight routes in case of blockage. Time should vary to it. If you have the slightest doubt about whether include all activities (naptime too) and when the to fight or not to fightdon't. Get out and call the fewest adults are at the center. fire dPpnrtmPnt. Maintain logs of evacuation drills for on-site in- spection and review by the building inspector. Helping children during emergency or For most buildings, evacuation in less than 2 evacuation procedures minutes is possible. Fire-resistant exit routes in large buildings are usually required to provide To calm a group of panicked children. Remove enough time to exit safely. them from the scene (if a child has been injured), Contact the public education division at your and reassure them. Explain simply and carefully local police and fire departments and ask them to what has happened and what will happen. Answer arrange on-site visits to help staff make appropri- their questions truthfully. Then redirect their ate emergency plans. attentiona game or quiet activity. Most important: STAY CALM. If you panic, the children will panic, Fire preparedness procedures too. If you need to evacuate the building, and children are frightened, have them hold each other's Keep the phone number of the fire department hands. Human touch is very reassuring in scary and heating service company by your telephones situations. (see Figure 8-5). Post a- diagram showing the main shut-off To get non-ambulatory children out of the switches for electricity, gas, and water. building. Carry two or three infants at the same 1 28 96 Safety and first aid

time. Use a large wagon to quickly transport tod- Remember, never move a- victim- except to savea dlers or severely disabled children outdoors (ifyour life. Am I calm and reassuring to the children? Who building has ramps) or at least to the door where can help? someone else can take them. 2. Check for life-threatening problems. Is the To get a child who is too scared to move to child conscious? leave the building. Use your legs to press gentlyon If the child is not conscious, is the child breathing the back of the child's knees to push him forwardor (chest moving, air coming out of nose or mouth)? If hold his hands with one of your armsacross his not, lift only the jaw of child and give four quick back. Having everyone join handscan also help the breaths of mouth-to-mouth resuscitation. Is there a child feel less frightened. pulse in the neck? If not, start CPR. If the child is conscious and old enough, ask questions such as, "What's your name?" to help deter- First-aid procedures mine the child's condition. Keep checking breathing and pulse as you proceed. First aid is the immediate care for persons who Wash any wounds to reduce chances of infection. are injured or ill. All staff must be trained in first-aid 3. Call an ambulance if you have any doubt procedures and have access to a first-aid guidebook about the situation. Ask another adult to call the at all times. emergency number first and then the person legally responsible for the child. Emergency situations are always upsetting. Being upset makes it difficult to think clearly. In these 4. Check for injuries. Start at the head and work down unless the place of injury is obvious. situations, it is particularly important to 'followa system so you will be able to react quickly and cor- Eyes. Pull eyelids open and look at the pupils (dark circle in middle). Are they the same size? Are rectly. First aid is a way to manage an illnessor injury until further medical care can be obtained, if the child's eyes looking in the same direction? necessary. When giving first aid, there are two ways Ears. Look for blood or fluid (don't be fooled by tears). you can harm someone. The first is by not treating an injury, and the second is by further damaging the Scalp. Feel gently (without moving child's head) injury. for bumps, dents, bleeding, or anything unusual. Remember these two very important rules of first Nose and mouth. Look for bleeding or tooth in- aid: jury. Do no harm. Neck. Recheck pulse and breathing. Feel for Never move a hurt child except to save a life. bleeding, swelling, or stiffness. Chest. Feel gently for swelling, unusual position When you provide first aid, it is absolutely critical or motion of bones. that you remain calm and reassure the victim. A Back. Slide your hands under the child to check ,calm.attitude allow ynii tn-think cloarly and -art for-bleedingor pain. appropriately. At the time of an emergency injury or Abdomen. Check for bleeding, pain, or tight illness, ask other adults to remove the other children muscles. to an area away from the victim. This will clear the Arms. Start at the shoulder and feel carefully area so you can carry out the necessary first aid. It along both arms. Check for bleeding, swelling, pain, will also- create a calmer atmosphere for the other or any unusual shape or motion. Check pulse at the- children. Later, when the situation is takencare of, wrist (if it is not strong, check pulse at neck again). you and all others involved (including other chil- Feel hand bones. Check skin temperature. dren) will need the opportunity to work through Hips and legs. Are knees the sameAistance from your feelings about what happened. the hips? Are feet warm or cold? Keep the victim comfortable and warm with a Assess the injury clean blanket or clothing until help arrives. Provide Follow these steps whenever you are faced with detailed information to the emergency crew. an emergency situation. If more than one person is If you are handling the situation, administer the injured, start with the one who appears to be in appropriate first aid. greatest danger. 5. Regroup. Check the condition of any other 1. Find out what happened. What caused the injured children. Talk with all present in calm, re- injury? How? Who is hurt? Is there still danger? assuring tones about how you are taking care-of the injured child. Complete an injury-report form (Fig- 12.9 Emergencies and first aid 97 ure 8-4). Give one copy to the parents the day of the Cardiopulmonary resuscitation (CPR) incident, put one copy in the child's file. Note the To be used in situations such as drownings, elec- incident in the injury log. tdc shock, and smoke inhalation. Technique of pulmonary support Clear the throat (see section on choking in left First aid for common situations column) and wipe out any fluid, vomitus, mucus, or foreign body. Choking Place victim on back. If an infant younger than 1 year of age chokes and Straighten neck (unless neck injury suspected) is unable to'breathe, place the baby face down over and lift jaw. your arrrrwith the head lower than the trunk. Rest Give slow, steady breaths into infant's nose and your forearm on the infant's thigh. Deliver four mouth and into larger child's mouth with nostrils measured blows rapidly with the heel of your hand pinched closed. between the infant's shoulder blades (see illus- Breathe at 20 breaths per minute for infants and tration A). If breathing does not start, roll the infant 15 breaths per minute for children, using only over and - compress the chest four times rapidly as enough air to move chest up and down. for CPR (see CPR section in next column). If a child older than 1 year of age chokes, place the child on her or his back. Kneel down and place the heel of your hand on the child's abdomen in the midline between the navel and the rib cage. Apply a series of 6_to 10 abdominal thrusts (as with Heim- lich maneuverrapid inward and upward thrusts) until the foreign body is expelled (see illustration B). With an older child, you can apply the thrusts with two hands while the child is sitting, standing, or lying down (see illustration C). Technique of cardiac support (if no pulse or If the child does not start to breathe, open the heartbeat) mouth and place your thumb over the child's Place victim on firm surface. tongue, with your fingers wrapped around the lower In the infant, using two fingers depress breast- jaw. If you see a foreign body, remove it with a bone 1/2" to 1" at level of one finger's breadth finger sweep. below nipples. Compress at 100 times per minute. Rapid transport to a medical facility is urgent if In the child, depress lower V3 of breastbone with these emergency first-aid measures fail. heel of hand at 80 compressions per minute. There should be 5 compressions to one respiration. Learn and practice CPR.

First-aid instructions from the AAP First Aid Chart, AAP Committee on Accident and Poison Prevention, revised 1988.

130 ...... , :ter '98 Safety and first aid

Bites and stings Marine stings (non-poisonous) Snake (non-poisonous) Flush with water, removeany clinging material. Treat as a puncture wound. Consult physician. Apply cold compress to relieve pain. Call physician or medical facility. If poisonous Put patient and injured part at rest. Keep quiet. Burns Do not apply ice. May use cool compress for pain. Immediate suction without incision may be ben- Protection against tetanus should be considered eficial. in all burns and whenever the skin is broken. Apply loose (allow two fingers under) constricting Burns of limited extent. If caused by heat band above the bite (not around fingersor toes) if Immerse extremity burns in cool wateror apply cannot get to medical help in 1 hour. cool (50° to 60° F.) compresses to burns of the Transport victim promptly to a medical facility. trunk or face for pain relief. Insects. Spiders, scorpions, or unusual reaction Do not break blisters. to other stinging insects such as bees, wasps, or Nonadhesive material such as household alu- hornets. minum foil makes an excellent emergencycover- Remove stinger if present with a scraping motion ing. of a plastic card or fingernail to reduce injection Burns of any size of the face, hands, feet,or ge- of more toxin. Do not pull out. nitalia should be seen immediately bya physi- Use cold compresses on bite area to relieve pain. cian. If victim stops breathing,use artifical respiration Extensive burns and have someone call rescue unit and physician Keep patient in a flat position. for further instructions. Remove non-adherent clothing from burnarea If any reactions such as hives; generalized rash; if not easily removed, leave alone. pallor; weakness; nausea; vomiting; "tightness" in Apply cool, wet compresses to injuredarea (not chest, nose, or throat; or collapseoccur; get more than 25% of the body at one time). patient to physician or emergency department Keep patient warm. immediately. Get patient to-hospital or physician atonce. For scorpion sting, get immediate medical advice. Do not use ointments, greases,or powders. For spider bites, obtain medical advice. (Save live specimen if safe and possible.) Electric burns Disconnect power source if possible,or pull vic- Ticks tim away from source using woodor cloth. Always thoroughly inspect child after time in Do not use bare hands. woods or brush. Ticks carry many serious dis- Electric burns may require CPR to be adminis- eases and must be completely. removed, Use twee- tered. zers or protected fingers placed close to the head All electric burns must be evaluated bya physi- to pull tick away from point of attachment. cian. If the tick's head breaks off, the child should be taken without delay for medical removal of the Sunburn. Children younger than 1year of age tick. may suffer serious injury and should be examined by a physician. Animal. Bat, raccoon, skunk, and fox bites,as well as unprovoked bites from cats and dogs (may Convulsions be from a rabid animal). Call physican or medical facility. Seek medical advice. Lay the patienton side, with head lower than hips. Put nothing in mouth. Wash wound gently but thoroughly withsoap and Sponge water for 15 minutes. with cool water if fever is present. Marine animals (poisonous). Stingray, lionfish, catfish, and stonefish stings. Put victim at rest and submerge stingarea in hot water. Call physician or medical facility. . 1 Q 1 Emergencies and first aid 99

Eye irritants Head injuries Hold lids open and flush out eye immediately Provide complete rest. Consult physician. Obtain with water. additional consultation if Remove contact lenses, if worn. there is a loss of consciousness at any time after Irrigate eye for 15 minutes with a gentle, con- injury tinuous stream of water from a pitcher. you are unable to arouse the child from sleep. Never rub the eye, or use eye drops. (You should allow the child to sleep after the in- Call physician, poison control center, or emer- jury but check frequently to see whether the child gency department for further advice. can be aroused. Check at least every 1 to 2 hours during the day, and 2 to 3 times during the night.) Eye pain there is persistent vomiting the child is unable to move a limb Do notapply pressure to eye or instill medications there is oozing of blood or watery fluid ft-al the without physician's advice. ears or nose Attempt removal of foreign body by gentle use of the child has a persistent headache lasting more it moist cotton swab. If not immediately successful, than 1 hour. The headache will be severe enough obtain medical assistance. Pain in eye from for- to interfere with activity and normal sleep. eign bodies, scrapes, scratches, cuts, etc., can be the child experiences persistent dizziness for 1 alleviated by bandaging the lids shut until aid hour after the injury from a physician can be obtained. the child's pupils are unequal For chemicals splashed in eyes, flush immediately the child is pale and does not regain normal color with plain water and continue for 15 minutes. Do in a short time not use drops or ointments. Call physician or poison control center. Poison emergencies If eye is perforated by a missile or sharp object, do not apply pressure to lids. Avoid straining. Con- We usually think of poisoning as swallowing a sult ophthalmologist immediately. toxic substance. However, chemicals in the eyes or If eye received blunt trauma, consult a physician on the skin and the breathing of toxic fumes are also if in doubt, especially if there is blurring "r considered po: in emergencies. Do not rely on anti- double vision, flashing lights, or floating specks. dote charts or first-aid information on product labels, They are sometimes incorrect or out of date Fainting and can cause additional damage. In all cases of poisoning, call your local poison Keep patient in a flat position. Loosen clothing control center. When you call, be sure to give spe- around neck. Turn head to one side. Keep patient nrsti,;,,gto" swallow. cific information about .warrn_and mouth Apar rnvo the product the child was exposed to (have con- Obtain medical aid. tainer with you when you call) the amount Fractures and sprains the time of exposure Any deformity of an injured part usually means a fracture has occurred: Do not move the person include syrup of ipecac in your first-aid kit. Swallowing ipecac is the most effective way to cause without splinting. A suspected neck or back injury vomiting. Do not use ipecac unless told to do so should only be moved with medical assistance to by the poison center or physician. Some poisons, avoid causing paralysis. such as drain cleaner or lye, can cause serious dam- Elevate sprains and apply only cold compresses. If age to the esophagus if vomited. marked pain or swelling is present, seek medical Phone number of local poison control center: advice.

132 100 Safety ana-first aid

Shock Children Speak reassuringly to the victim. Keep the victim Young children can begin to know how and from at a comfortable temperaturecover if the envi- whom to get help. Teach children these basic, help- ronment is cool; cool if the environment is warm. ful concepts. Follow all safety rules. Skin wounds Tell an adult right away if something is wrong Protection against tetanus should be considered (someone is hurt or sick).. in all burns and whenever the skin is broken. Some things are dangerous (e.g., poisons, matches, tiny objects in the mouth). Bruises. Rest injured part. Apply cold compress A person who is very hurt or sick may need to be for 30 minutes (no ice next to skin). If skin is broken, alone with a helper. treat as a cut. For wringer injuries and bicycle spoke injuries, always consult physician without delay. Older preschool children also can be taught about basic care concepts such as cuts need to be cleaned Scrapes. Use wet gauze or cotton to sponge off with soap and water, direct pressure helps stop gently with clean water and soap. Apply sterile bleeding, burns should be treated with cold water. dressing, preferably non-adhesive or "film" type This information may help children to be more co- (Telfapad). operative if they can understand why certain first- Cuts aid procedures are necessary. Small. Wash with clean water and soap. Hold under running water. Apply sterile gauze dressing. Parents Large. Apply dressing. Press firmly and elevate to Set up a program to help parents refresh their stop bleedinguse tourniquet only if necessary to first-aid skills. You may consider inviting parents to Control bleeding. Bandage. Secure medical care. Do your staff training or having a special meeting to not use iodine or other antiseptics without medical review home first-aid procedures. You might want advice. to put brief articles in your newsletter, if you have one. Keep parents informed when you hear about Puncture wounds. Consult physician. community education programs. First-aid resources Slivers. Wash with clean water and soap. Remove are a great addition to a parent lending library, too. with tweezers or forceps. Wash again. If not easily removed, consult physician.

First-aid education Staff All staff must be trained in basic first-aid procedures, including choking, seizures, and resusci- tatiou. This training, done by qualified instructors, .should be repeated at least yearly, or more often if necessary to train new staff. The first-aid training should include a developmental approach to young children and injury prevention as well as how to handle emergencies appropriately from both a med- fcal and psychological viewpoint. All staff must know your program's policies for emergencie.1 in addition to basic first aid.

133 Emergencies and first aid 101

Figure 8-1. Emergency procedures

1. Remain calm. Reassure the victim and others 6. Do not give aspirin or other medications at the scene. unless authorized by your local poison control center (for poisonings) or physician (for other 2. 'Stay atifhe scene and give help at least until illnesses). the person rissigned to handle emergencies arrives. 7. Notify parents) of the emergency and agree 3. Send word to the person who handles on a course of action with the parent(s). emergencies for your program. This person will take charge of the emergency, assess the situa,ion, 8. If parent_ cannot be reached, notify parent's and give any further first aid, as needed. emergency contact person and call the physician shown on the child's emergency_ transportation 4. Do_not move a severely injured or ill person permission. form. except to save a life. 9. Be sure that a responsible individual from 5. If necessary, phone for help. Give all the the program stays with the-child until parcnt(s) important information slowly and clearly. To take charge. make sure that you have given all the necessary information, wait for the other party to hang up 10. Fill out an injury report (Figure 8-4) within first. Arrange for transportation of the injured 24 hours. File in the child's folder. Give parent(s) person by ambulance or other such vehicle, if a copy, preferably that day. Note injury necessary. Do not drive unless accompanied by information in central injury log. another adult. Bring your emergency transportation permission form (Figure 8-3) with you.

134

1 102 Safety and first aid

Figure 8-2. First-aid kit contents

These items should be included ina basic first- 2 triangular muslin bandages aid kit. syrup of ipecac (at least 10 1-oz. bottles) a quick-reference first-aid manual (e.g., A.Sigh a large (1 to 2 quart) clean container for use in of ReliefThe First Aid Handbook for flushing eyes Childhood Emeigencies [Green, 1984]) plastic bags (for ice pack) index cards and pens rubber gloves thermometer tissues flashlight safety pins blunt-tip scissors in your field trip kitcoins forpay phones, tweezers soap for washing wounds, alcohol-based wipes, 10 2" x 2" gauze pads synthetic ice packs 10 4" x 4" gauze pads 1 roll 2" flexible gauze bandage Note: If a child has a special health need,you will 1 roll 4" flexible gauze bandage want to include additional supplies inyour kit; 25 1" and 25 assorted small bandages e.g., bee sting kit or antihistamine for a child with I roll 1" bandage tape a severe allergy, sugar or honey for a child with diabetes, or inhalator fora child with asthma.

?135 Emergencies and first aid 103

Figure 8-3. Emergency transportation permission form

Child's name I understand that no emergency treatment may be given without parental consent except ina life- threatening situation. Because informed consent must be given at the time of the incident, Iagree to leave numbers where I (or my spouse or a responsible adult designated by me)can be reached promptly if the numbers below do not apply for any given day. In case of a medical emergency while my child is attending (program name)

I understand that the following procedure will be followed:

1. The program will contact parent(s):

Mother can be telephoned at during (hours/days) during (hours/days) Father can be telephoned at during (hours/days) Father can be telephoned at during (hours/days) 2. If neither parent is available in an emergency, the program will contact these people:

Name can be reached at Relationship to child

tstamp ann rand-4%nel nt

Relationship to child

Name can be reached at Relationship to child

3. The program will arrange for emergency transportation to or the nearest emergency medical facility, if necessary. At no time will a staff member drive withmy child unless accompanied by another adult. My child will be transported byan ambulance or other such vehicle when necessary.

4. The program may contact my child's medical care provider who can be telephoned at

I hereby authorize the program to follow this procedure.

-Parenes,signature- 136 104 Safety and first aid

Figure 8-4. Injury report form SUBMIT WITHIN 24 HOURS OF INJURY

File in child's folder.

Give copy to parent.

Enter data into injury log.

Child's name Age Date Time of injury a m /p m Witnesses

Parent(s) notified by Time Location where injury occurred

Equipment/product (if any) involved

Description of injury (specify body park) and howit occurred

Tirst-,aid-given-at-the program

Other action taken by medical personnel(specify hospital, clinic,or physician)

Diagnosis/follow-up plan

Corrective action needed toprevent reoccurence

Signature of staff member Date

Signature.of parent Date Emergencies and first aid 105

Figure 8-5. Phone emergency list

This phone is located at

Phone number Area code

Program name Description of building

Directions for reaching this location from a major road

Emergency numbers

Ambulance Battered women's shelter

Poison control c ter Suicide prevention hotline

Pollee Gas company

Fire Water company

Health consultant Heating equipment service

Hospital Electric company

Nearest emergency facility Plumber

Local board of health Taxi

State dept. public health Parents Anonymous

Child abuse reporting Alcoholics Anonymous Rape crisis center

Always give this information in emergencies: Optional information: 1. Name 7. Help already given 2. Nature of emergency 8. Ways to make it easier to find you 3. Telephone number (e.g., standing in front of building, 4. Address waving red flag) 5. Easy directions 6. Exact location of injuredperson (e.g., backyard behind parking lot)

DO NOT HANG UP BEFORE THE OTHER PERSON HANGS UP!

ray 138 4 (4 106 Safety and first aid

Bibliography

Amdican Red Cross of Massachusetts Bay. (1986). Health and safety for infants and children. Bos- ton, MA: American Red Cross. Green, M. (1984). A sigh of reliefThe first aid handbook for childhood emergencies. (2nd ed.). New York:- Bantam. National Safety Council. (1985, JanuaryFebruary). Hoine fire extinguishers. Home Safety News- letter. Schutz, C.E., & Belda, M. (Eds.). (1987). Guidelines for good health in Illinois day care. Chicago: Il- linois Department of Public Health. Williams, K. (in collaboration with the Preschool Enrichment Team, Inc.). (1985). Childhood emergency sourcebook. Holyoke, MA: Preschool Enrichment. Team. Section D Preventive health care

Major -concepts Program-staff -are members of the preventive health team who aim to keep children

Regularly scheduled health visits including health screenings,are essential to maintain children's health. Health is assessed by, the health team basedon information from health histories, -health -observations, screening tests, and medical examinations. take:::_care;014eir_p_wnfitealtliltegdS-1fittOrttetnt-that-My diectithele job- perfOrmance. Dental health is an important part of general preventive healthcare.

140 9 Preventive health care for children

Why preventive care is important To identify children who may be at high risk for developing diseases due to hereditary factors, Health is defined by the World Health Organiza- family health habits, or environmental factors. tion as "... a stateof complete physical, mental, and To identify and follow signs in growth patterns, social well - being- and not merely the absence of behavior, or development that could mean future disease or infirmity." This total state of wellness is health problems. affected by the interrelationships between each area To evaluate the effectiveness of past or current of a person's development. For example, when chil- treatments, such as tubes in ears, antibiotics, or dren are ill, tired, hungry, or poorly fed, they cannot patching an eye. function well and may be cranky or inattentive. A The goals of routine checkups are child who has an undetected medical condition or to promote health through counseling, education, who is neglected may become depressed or with- and guidance for anticipated problems 4rawn. A child-witba physical problem may develop to take:specific preventive measures such_ -as int, emotional- or learning problems; likewise, a child munizations who has emotional upsets may develop physical to identify potential health problems through symptoms as a result of eating and/or sleeping dis- screenings such as measurements of growth, turbances. Children's health is constantly changing, vision, hearing, lead poisor ing, and tuberculin particularly during their early years. testing Adults' health also affects their state of well-being. to provide early detection and treatment of ill- Adults, like children, require good preventive health nesses with symptoms (e.g., strep throat) to pre- care to keep well and function at their best. vent complications to prevent disability from chronic diseases. Goals for preventive health care It is crucial that children be seen regularly by health Young children are at risk for developing a num- care providers to ensure that these goals are met. ber of health problems such as hearing or vision The majority of pediatricians in the United States difficulties, lead poisoning, developmental delays, are members of The American Academy of -Pedi- and injuries. The goal of preventive care is to keep atrics (AAP). The AAP sets the minimum guidelines children well, rather than to treat them after they for routine health care for children. These are up- become sick. A comprehensive preventive health dated from time to time as new information about care plan has these goals. valuable preventive health measures becomes avail- To detect medical conditions that may not be eas- able. The guidelines in use at the time this manual ily recognized that need medical attention (e.g., was printed are shown in Figure 9-1: Members of fluid in the ear, anemia, or "lazy eye "). Early iden- the AAP receive updated versions of the guidelines tification and treatment of such problems may when they are issued. Be sure a current version is completely resolve. them, while a delay in atten- being used by checking with an AAP member. Note tion ca_ n result in moreor permanent dam- that the guidelines are minimum requirements for age. healthy children who are receiving competent parenting and who have no significant health problems.

141 109 110 Preventive health care

Figure 9-1. Recommendations for preventive pediatric health care

RECOMMENDATIONS FOR PREVENTIVE PEDIATRIC HEALTH CARE Committee on Practice and Ambulatory Medicine Each child and family is unique; therefore these Recommendations Presidents. The Committee emphasizes the great importance of for Preventive Pediatric Health Cam are designed for the care continuity of cars In comprehensive health supervision and the of children who are receiving coi;ipetent parenting hive no need to avoid fragmentation of care. manifestations of any important health problems, and are griAving and developing- in satisfactory fashion. Additional visi%rmay A prenatal visit by the parents for anticipatory guidance and perti- beconie necessary if circumstances suggest varlatior4 item nor- nent medical history is strongly recommended. rnitInhese gUidelines represent a consensus by the Committee on Practice and Ambulatory Medicine in consultation with the member- Health supervision should begin with medical care of the newborn ship of the American Academy of Pediatrics through the Chapter in the hospital.

INFANCY EARLY CHILDHOOD LATE CHILDHOOD ADOLESCENCE' .7 s.,.4' i'pt^. \-111* Ely 1 2 4 6 9 12 15 18 24 3 4 5 6 8 10 .12 14 16 18 20+ AGE: mo ma.mos. moo.mos.mos. mos.mos. mos.yrs. yrs. yrs. yrs. VI 'Ir..1) yrs. yrs. yrs. yrs. yrs. yrs. yrs. ..++,.., HISTORY Initial/interval

MEASUREMENTS Height and Weight

Head Circumference

Blood Pressure

SENSORY SCREENING Vision S S-S S S S SS S S 0 000 S 0 0 S 0 0 Hearing 5 5 5 5 5 5 5 5 S 5 0 053 53 S3 0 S S 0 S DEVEL/BEHAV.4 ASSESSMENT o

PHYSICAL EXAMINATION5

PROCBDURESs- , Herecl./Metabolie Screening

Immunizations

Tuberculin Tests ...... ___. ______. Hematocrit or Hemoglobin" ..---- ____, Urinalysis" ____...... ___. ..._ .____.

ANTICIPATORY12 GUIDANCE

INITIAL DENTAL13 REFERRAL

1. Adolescent related issues (e.g., psychosocial, emotional, substance 9. For low risk groups, the Committee on Infectious Diseases rocom- usage, and reproductive health) may necessitate more frequent health mends the following options: Ono routine testing or Otesting at supervision. three timesinfancy, preschool, and adolescence. For high risk 2. If a child comes under care for the first time at any point on the groups, annual TB skin testing is recommended. 'schedule, or if any items are not accomplished at the suggested age; 10. Present medical evidence suggests the need for reevaluation of the the schedule should be brought up to date at the earliest possible frequency and timing of hemoglobin or hematocrit tests. Ow deter- time. mination is therefore suggested during each time period. Perfor- 3. At these points, history may suffice: if problem suggested, a standard Mance of additional teats is left to the individual practice experience. testing method should be employed. 11. Present medical evidence suggests the need for reevaluation of the 4. By history and appropriate physical examination: if suspicious, by frequency and timing of urinalyses. One determination Is therefore specific objective developmental testing. suggested during each time period. Performance of additional tests 5. At each visit, a complete physical examination is essential, with in- is left to the individual practice experience. fant totally unclothed, older child undressed and suitably draped. 12. Appropriate discussion and counselling should be an integral part B. These may be modified, depending upon entry point into schedule of each visit for care. and Individual need:: 13_ Subsequent examinations as prescribed by dentist. 7. Meiabolic screening thyroid, PKU, galactosemia) should be N.B.: Special chemical, immunologic, and endocrine testing are done according to state law. usually carried out upon specific indications. Testing other than newborn C. Schedule(s) per Report of Committee on infectious Disease, 1986 (e.g., inborn cares cf metabolism, sicide disease, lead) are discretionary Red Book. with the physician.

Key: -to be performed: S- subjective, by history: Owobjective, by a standard testing method. September 1987 Heal h supervision guidelines from Recoinmendations for Preventive Pediatric HealthCare, AAP Comm ttce ,on Practice and Amhulatoty-Medicine 4987' 142 Preventive health care for children 111

Some doctors and clinics do not follow the AAP guidelines. Some health programs do noay for Screening result Action needed preventive health care that meets these guidelines. apparently healthy none Despite these barriers, children should still receive (negative) the recommended services. possibly at risk repeat screening test Ideally, all preventive care and illnesscare should be provided by a single source of medicalcare, the at risk (positive) refer for further child's "medical home." Fragmentation of diagnosis and i0 care by inappropriate use of emergency rooms for minor possible treatment illnesses, and seeking care from a variety of different Diagnosis is a more detailed evaluation to find providers without careful maintenance of acom- prehensive medical record result inpoor health out if there is, in fact, a health problem and, if so, care. However, when the child's regular source of what it is. When making a diagnosis, the health care does not provide all the routine minimum ser- professional may use health histories, dietary in- vices as outlined in Figure 9-1, every effort should be formation, laboratory test results, family/teacher observations, X-rays, or physical and psycho- made to find community agencies to fill in thegaps (e.g., Society for Prevention of Blindness provides logical examinations. vision screening, lead detection programs do blood Treatment is designed to control, minimize, correct, or cure a disease or abnormality (e.g., eye- testing). Information obtained from specialscreen- glasses, fillings for dental caries, therapy). Treat- ing programs should always be forwarded (withpa- ment is the key to an effective program. Without rental consent) .to the child's usual source of health care to be considered with the rest of the child's it, screening and diagnosis arc meaningless. health data.

How health is assessed Health histories A child's health should he assessed by a variety of Health histories provide important information individuals who .have unique skills and experience about the child's prior health experiences and risks with- the child. This health team is usually infor- for future disease. The family health history may mally coordinated by the child's physicianor an- help predict what illnesses the child may inheritor other member of the health team as the child'sspe- develop. The physician will take a detailed health cial needs.suggest. The child's health team consists history including information about birth, illnesses, of the child's parents, teachers, and others whoreg- hospitalization, all treatments, immunization ularly observe and interact with the child in addi- status, and cerrent health concerns. tion to health professionals (see Figure 9-2). Each Programs for young children should also have a health team member has a special perspective to history form, but it needs to cover only major health offer about growth, development, and overall problems and developmental concerns. This infor- health. This information should be shared with the mation can help explain a child's current behavior health team coordinator so that a comprehensive and past experience. picture of the child can be created. The clear desig- Parents : now a great deal about their own child.. nation of the health team coordinator is especially However, unless there is a specific request for it, few important for children with multiple health and de- parents will review their child's nutritional, immu- velopmental problems. nization, health, and family history. Even the-most The assessment process is based on information alert parent may innocently overlook the health from a variety of sources: health histories, obser- needs of a rapidly changing and growing child be- vations by the health team, screening tests, and cause of other urgent demands. medical examinations. Health assessment and When your program requests a:child's health his- follow-up care are often separated into three catego- tory, you will help reinforce the parents' role in re- ries:screening, diagnosis, and treatment. taining important health information. You can as- Screening is the use of quick, inexpensive, and sist parents in reviewing the child's health record for simple procedures to identify children whomay general health strengths and weaknesses. A devel- have a problem in a specific area. Healthscreen- opmental health history form is presented in Figure ing tests typically produce one of these threepos- 9-3. Use it as a guide to develop one -that meets your sible results. needs. 112 Preventive health-care

Figure 9-2. Potential health team members

An allergist is a medical doctor with special interesi. and training in diseases of the immune system including allergies (certified by the American Board of Allergy). An audiologist is a specialist in hearing problems. A dentist is a specialist who cares for and treats the teeth and gums.

'A neurologist is a medical doctor with special interest and training in orain andnervous system disorders.

A nutritionist is a professional with interest and training (a masters degree) in nutrition, who evaluatesa pergon's food habits and nutritional status. This specialist can provide advice about normal and therapeutic nutrition,' feeding equipment, self-feeding techniques and food service. An occupational therapist evaluates and treats children who may have difficulty performing self-help, play, or other independent activities.

An ophthalmologist is a medical doctor who evaluates, diagnoses, and treats disease, injuries,or birth defects that limit vision. An optician advises in the selection of frames and fits the lenses prescribed by the optometristor ophthalmologist to the frames. An optician also fits contact lenses.

An ofitainetiist examines the eye and related structures to determine the presence of visual problems,eye disease, or other problems. An orthopedist is a medical doctor who evaluates, diagnoses, and treats diseases and injuries to muscles, joints, and bones.

An otorhinolaryngologist (E.N.T. doctor) is a medical doctor who screens, diagnoses, and treatsear, nose_ , and throat disorders. An otologist is a medical doctor who screens, diagnoses, and treats ear disorders. A pediatrician is a medical doctor who specializes in prevention and management of childhood diseases and problems. (Certified by the American Board of Pediatrics or the Osteopathic Board of Pediatricsor English or Canadian equivalents.) A physical therapist evaluate.. and plans physical therapy programs and equipment to promote self- sufficiency primarily related to gross-motor skills such as walking, sitting, and shifting position. A psychiatrist is a medical doctor who screens, diagnoses, and treats psychological, emotional, behavioral, and developmental or organic problems. Psychiatrists can prescribe medication. They generally donot administer tests.

A psychologist screens, diagnoses, and treats people with social, emotional, psychological, behavioral,or developthental problems.

A social worker provides services for individuals and families experiencing a variety of emotionalor social problems. These services include individual, family, or group counseling; advocacy; or consultation With programs, schools, clinics, or social agencies. A speech-language pathologist screens, diagnoSes, and treats children and adults with communication disorderS. This pettOn May alSo be called a speech clinician or speech therapist.

7 :' From Mainstreaming Preschoolers Series by U.S. Department of Healthand Human Services, 1978. Washington,. DC: U.S. Government Printing Office., A 1 A Preventive health care for children 113

Figure 9-3. Developmental health history

Child's name Birth date (last) (first)

Nickname

Physical health

What health problems has your child had in the past)

What health problems does your child have now?

Other than what you listed above , Does your child have any allergies?

If so, to what?

How severe?

Does your child take any medicine regularly? If so, what)

Has your child ever been hospitalized? If so, why and when

Does your child have any recurring chronic illness or health problem (such as asthma or frequent ear-

,aches)?

Does your child haw. a disability which has been diagnosed (such as cerebral palsy, seizure disorder,

developmental delay)

Do you have any other concerns about your child's health)

145 114 Preventive health care

Figure 9-3 cont. Developmental health history Development (compared to other children this age)

Does your child have any problems with talking or making sounds? Please explain

Does your child have any problems with walking, running, or moving? Please explain

Does your ch;ld have any problems seeing? Please explain.

Does your child have any problems hearing? Please explain

Does your child have any problems using her or his hands (such as with puzzles, drawing, small building

pieces)? Please explain

Daily living

What is your child's typical eating pattern)

Write N/A (non-applicable) if your child is too young for the following questions to apply.

What foods does your child like? Dislike)

How well does your child use table utensils (cup, fork,,spoon)?

How does your child indicate bathroom needs? Word for urination

Word for bowel movement Special words for body parts

What are your child's regular bowel and bladder patterns? Do you want us to follow a particular plan for

toileting) JI

146 Preventive health care for children 115

Figure 9-3 cont. Developmental health history

For toddlers, please describe use of diapers or toileting equipment (suchas potty, toilet seat adapter).

What arc your child'S regular sleeping patterns?

Awakes at Naps at Goes to bed at

What help does your child need to get dressed)

Social relationships/play

What ages are your child's most frequent playmates)

Is your child friendly? Aggressive? Shy? Withdrawn) Does ydur child play well alone)

What is your child's favorite toy?

Is your child frightened by animals? Rough children? Loud noises? The dark? Storms? Anything else?

Who does most of the disciplining)

What is the best way to discipline your child)

With what adults does your child have frequent contact)

How do you comfort your child)

Does your child use a special comforting item (such as blanket, stuffed animal, doll))

Parent's signature

Date

147 116 Preventive health care

Observations saying, "Jennifer has strep throat." State measurable facts whenever possible. A form to record symptoms Physical health of minor illness helps focus attention on significant observations (see Figure 18-1 on p. 282). Physical health observations may be organized Use all your senses (smell, hearing, seeing, into Signs and symptoms. touching) when making health. observations. Ob- -e-Signs-are-specific,observatiotzs (co,Ighing, vomit- serve clues such antic -texture of skin, bEeath odor, ing, orswelling). the appearance of a bruise, or the sound of a cough. Symptoms are internal and must be described in Sometimes it is difficult to judge what is significant. order to be known to others (nausea, headache, Observe the group in general and compare indi- or stomachache). vidual children. For example, do most of the chil- Signs and symptoms may occur together (vomit- dren need help zipping their coats? If so, the fact ing from nausea or pulling on an ear from ear pain). that Susan asks for help is not a concern. If a child Since young children often cannot express symp- differs significantly from others in the group, it is toms, your objective observations of signs usually worth noting. provide the best clues. Precise physical observations Each observer has a different perspectiVe in ob- are the most helpful. It is more-useful to say, "Jeffrey taining health information. Parents compare a child has a frequent dry cough, flushed cheeks, and a to her or his typical appearance or behavior or to runny nose with thick yellow mucus" than to say, siblings or friends. Teachers may have a similar "Jeffrey, looks sick." Report your specific obser- view but also, observe children in a group setting vations rather than drawing conclusions or making with many children of the same age. The physician a diagnosis. For instance, say, "Jennifer has a sore or health provider uses the knowledge and experi- throat and an oral temperature of 102 °" rather than ence from medical practice. Each view is valuable but limited; to have a total picture of the child, all observations from the health team must be shared and seen as a whole.

Development A child's physical health is only one aspect of her or his life. An equally important aspect is the development of language, gross and fine motor skills, -social-cmotional-competenceiand-cognition-(thinking). Problems in these areas often can be identified and worked out during the early years. Program staff are ideally suited to observe such problems and should develop capabilities in these areas. 1. Developmental milestones. Knowledge of general child development with in -depth information about the particular age of children in their group h,qp.,t. prrwirl fi-nri,...,r%rk,t, Hen- tify those whose abilities fall outside the normal range. These milestones must be viewed flexibly since a child's development is greatly influenced by childrearing styles, culture and ethnic norms, and by the child's own temperament. .A: Figure 9-4 at the end of this chapter contains a useful guide to observe children from ages 3 to 5 in = group settings. This guide will help you identify signs of potential trouble in areas of development. irnen-garkeling-observanons-aboura-chdd; Use it as a screening aid, not a developmental test or remember that each person has a different perspective in,obtaining health information. standard assessment tool, since it is neither of these.

148 Preventive health care for children 117

Figure 9-5 contains reviews of four developmental behaviors are appropriate for the family and culture screening instruments. These standardizedscreen- and which are not, and which behaviorsor traits arc ing tools are frequently used by health providersas a of particular concern to the parents. Often they have framework for reviewing the range of normal child- questions similar to yours, but may not have wanted hood behaviors and developmental skills for chil- to bother the staff or appear to be overly anxious. dren. Check with your local agencies tosee who Dealing with these concerns in a respectfulpartner- administers these instruments regularly inyour ship can be a great help and support. community. 4. Referral and consultation. Seek information 2. Observation and docu.fientation. Write on community resources for referral and con- down behaviors or moods -that mightsuggest prob- sultation. Many communities havea wide array of lems in a child's development. (Youcan keep file experts on every aspect of child development. Once cards in your pocket and noteon thenythe day, time, a problem has been identified and confirmed by activity, and behavior you'have observed.) Ask other parents and other staff members, you should be staff members to also observe and record the child's familiar enough with your community to be ableto behaviors. Then look for patterns in the child's be- make an appropriate referral to a competent and hayior. Is the behavior influenced by particular sympathetic diagnostician. A list of -local services children or adults who are presentor by times of the should be developed and kept at the centerso that day or days of the week? Youmay also need to look referrals can be made easily. for additional information in the child's environment. Perhaps there-is a new baby in the family or an undiagnosed medical condition. Determine the Major health screenings appropriate next steps to take, and plan a meeting to discuss your concerns with the child's parent(s). Value of screening for the apparently well child 3. Communication. Cultivate your ability to communicate concerns about unusualor delayed The AAP recommends a minimum number of development to parents ina supportive, non- screening tests for sound health care; Head Start threatening manner. Parentsarc experts on their requires its programs to perform a similar set. These children and ,should be involved in discussions tests try to identify conditions which, if undetected about 'develOpmental concerns early in thescreen- and untreated, may seriously handicapa child for ing process. Theirinput can help you identify which life. These conditions are important to discover,occur quite often, and generally respond to early

Screening involves short and simple procedures because it is intended for large numbers of apparently well children.

149 118 Preventive health care

treatment. Early treatment is often more effective the problem. Without screening, problems may go and less costly than later treatment and may also unnoticed or, if signs or symptoms are recognized, prevent the development of other problems. their significance may not be understood. For instance, children with undetected hearing Another reason-for screening the apparently well loss risk developing language, learning, and behav- child is that young children are in a period of rapid ior problems. Children with eyes that are not growth and development. There arc milestones that straight and Children- with a marked difference in the dhild-can be expected to reach within a certain visual acuity between eyes risk developing amblyo- range of time: Given the child's basic body structure, pia (loss of vision in one eye due to lack of normal growth should follow a predictable pattern. The use). If decreased vision in one eye is not treated child should be able to accomplish certain tasks by a during the early years, treatment in the school-age certain age. An abnormal screening test result is a years is slow and often unsuccessful. clue that something is wrong, that a further look is Screening generally involves short and simple needed. Abnormal screening results should be in- procedures because it is intended for large numbers terpreted by the child's usual source of health care of apparently well children. A good' screening may so appropriate further evaluation can be planned. identify. a,few.,children who-Aurn- out -not to have a Premature referral to,a specialist in one area may problem, but it should misszverylei.v-I.vho,,do have neglect the possibility that the abnormality is part of a multi-system problem. To be valuable, a screening program must include parent education about the screening parent involvement and consent use of a valid, reliable tool appropriate for the age practice by the ace= screening and rescreening all children who may have a problem before making referrals written information provided to the parents when further examination is suggested parental choice of the health professional to follow up information received from the health professional about examination results vision screening Developmental vision problems may be most effectively corrected during the preschool years. This is especially true in the areas of vision acuity (the ability of each eye to distinguish detail both near and far) and vision skills (the ability to use both eyes efficiently and effectively as a coordinated team). All 3- and 4-year-old children should have a full 0 eye examination that includes evaluation of general eye health, near and far vision acuity, and several 8 types of vision skills. This type of screening can be performed in a pediatrician's or family practitioner's office or by a vision specialist. Every child 8 should participate in a basic vision screening program. Many people believe that preschool children Normal vision acuity for young children follows a are too young to be tested. In fact, most can cooper- developmentally determined pattern. Early ate with a vision screening program. Any child who 1 detect:on-and treatment of is inure cannot perform weir liaMe s-ereetsiirig by effective and less expensive ;hat: later treatment. age 4 should be referred to a vision specialist. Two types of effective and efficient vision acuity screening can be done by program staff. Preventive health care for children 119

Informal screening is done by observing the hear well will not startle. at a sudden noise, will not child at play. The persistent symptoms listed in Fig- search with the eyes for the source of a noise, will ure 9-4 may indicate the need for a thorough eye not respond to a musical toy or a parent's voice exam. unless the parent is seen, and will be slow to imitate Formal screening is done with an age- sounds and respond to simple commands or the _appropriate, standardized.screening tool-designed sound of her onhis.name. Older children -with hear- to identify some of the most common problems ing problems may have smaller vocabularies, use found in-young children. Other problems may only shorter sentences, and seem to understand less than be found through further testing. other children the same age. These signs may indi- The Snellen E (Tumbling E)' and the Broken cate intermittent- hearing loss as a result of an ear Wheel tests are r ommended formal screening infection or middle ear fluid. tools for 3- to 5-year-old children. Seep. 302 in Hearing screening for infants can be easily per- Appendix 1 for-ordering information. Various pic- formed around 6 months of age using a set of toys titre identifiCation tests are generally considered less that make noise.at specific frequency. The test in- accurate. If you are interested in doing vision volves making the noise out of sight (about 3' away) Screening, it is iniportant that you receive training; from the child to see if the child turns to the direc- talk firstwith your health consultant. tion from which the noise came. This is called the Any screening program is valuable only if follow- Downs Hearing Screen (after Marion Downs who up occurs. Parents should choose specialists who developed the procedure). Some healthpro- have training, and experience with young children fessionals use this test routinely. Others relyon re- and who seem to enjoy working with thisage child. ports about how the child responds to sound from Normal vision acuity for young children followsa parents. developmentally determined pattern. At age 3,20/40 The pure tone audiometry is the typical hearing vision is normal (the child sees at 20' whata normal test and checks a child's ability to hear quiet sounds adult sees at 40'). Any difference in vision between at four different pitches or frequencies. It can be the child's two eyes requires further evaluation. done on 3- and 4-year-olds with ease, and can be Many 5- and 6-year-old children have (normal) used with some 2-year-olds. The test requires put- 20/30 vision. By 7 years, 20/20 vision in botheyes is ting a toy in a box or raising the hand when a sound expected. is heard through the earphones. Do not, assume that children will outgrow The following two tests may be appropriate pri- vision problems. Some problems getworse. Early marily for selected high-risk children. Tym- detection permits early treatment that willcorrect panometry measures the pressure required to move the problem more completely and that is lessexpen- the eardrum (middle ear) and the way the eardrum sive than.later treatment. moves. If fluid is present in, the middle ear, it may cause negative pressure and decrease the eardrum's Hearing screening ability to move. Fluid in the middleear can affect the child's ability to distinguish sounds clearly. This A child who does not hear clearly will have trouble test can be done on children age 3 and older. imitating sounds and developing language. Behav- Acoustic reflex screening measures thecon- ior -can also be affected. Learning to read and to traction of a muscle in the middle ear in response to write will be difficult. Finally, permanent hearing a loud sound. If the contraction (reflex) is absent, loss may occur. Hearing problems may be heredi- there may be fluid in the car or incomplete healing tary. or the result of certain illnesses during preg- from a recent infection. This test can he done_ nil nancy or early 'childhOOd. tornPorary or inter- very young children. mittent hearing loss may be caused by chronicear Because children are more comfortable andse- infection, a heavy buildup of wax in theear, or cure in familiar surroundings with familiar adults, chronic fluid in the middle ear. screening may be more successful if you bring the ;Hearing:14msmay be readily observed when the screeners to your program. Prepare the children for lossAs fairly severe. There are signs thatcan alert what to expect, and follow through on referrals. Be adults to milder loss also. An infant who does not sure to notify the child's usual source of health care about any screening results to avoid duplication and

151 -120. Preventive health care

A child's height and weight should be measured regularly and recorded on a chart that permits comparison with normal growth patterns. These measurements can integrate learning about mathematics, science, self, and health.

to prorifote-coordination of screening results with poisoning, see Chapter 15. The AAP recommends the rest of the child's health data. that the erythrocyte protoporphyrin (EP) test be used for screening children for lead toxicity. (This Measuring height and weight test also finds iron deficiency.) Ideally, all preschool Height and weight should be measured regularly children should be screened for lead, but highest and recorded on a chart that permits comparison priority should be given to children ages 1 to 3 years with normal growth patterns. These measurements who live in or are frequent visitors in older, dilapi- are-one of.the best ways to detect physical growth dated buildings. patterns that may indicate a serious problem. Head circumference .(measurement around the head) should also be measured for children from birth to 2 .years of age. Medical examinations Growth measurements will usually be done by the child's health care provider. You should receive this A medical examination is a comprehensive review information with the child's physical examination by a physician or nurse practitioner of all the health report. In some cases, you may also want to mea- information gathered from the health history, sure the children's height and weight as part of the health observations, and screening tests. 'i he exam- health curriculum. These measurements integrate ination includes an interview with the parent or learning about mathematics, science,. self, and guardian to get current health information and a health. record of immunizations, a complete physical examination l'i-.^r.t^ry tests as Lead screening blood or urine). A dentist or eye specialist may also be involved. Medical examinations should be done Lead is everywhereboth in nature and in manu- frequently during the first 3 years of life, and yearly factured products (see Chapter 15). Lead screening after age 3. The results of medical examinations is extremely important because even very low el- should be reported in detail on the child's health evations of lead can cause permanent problems in exam form (Figure 9-6). At a minimum, the form learning and behavior. Lead screening is performed should include by a simple finger-prick blood test. The Centers for a description of any health condition that may Disease Control recommend that children who live affect the child's participation in child care in high-risk areas should be tested eveiy6 months to history of significant illness and/or hospital- 1 year. For additional information about lead izations 152 Preventive health care for children 121

immunization status consultant, or parent should contact the health pro- reports of any screening or assessment vider for additional information. If any of the inany significant observations of the parents' or si- formation is unclear, you should ask questions. Ask blings' health the health provider to give you practical, concrete

notations about physical, mental, and social de- information. Yourprogram's health.policies_shoutd_ -velopment- require that these forms be on file prior to en- A complete and detailed health form should give rollment based on an examination dated as the most you an accurate picture of the child's unique devel- recent appropriate one according to the AAP guide- opment and health status. It should help you have lines for routine health care. The forms should be realistic expectations and to plan appropriate activi- updated each year for children older than 3 years of ties. If the form is incomplete, the director, health. age and at least every 6 months for Olinger children.

153 122 Preventive health care

Figure 9-4. Developmental red flags for children ages 3 to 5 Teachers and parents of young children fre- What are red flags? quently Wonder if particular behaviors are some- -thing:they-should= w-orry antint -There is- rib Way to Red flags are behaviors that should warn you to make these decisions simply or with total certainty. Observation and screening tools are always limited stop, look, and think. Having done so, you may decide there is nothing to worry about, or that a because they summarize enormous amounts of information. The Preschool. Enrichment Team, Inc., cluster of behaviors signals a possible problem. These guidelines will help you use red flags more has developed this material as a development obser- effectively. vationAool for children ages 3 to 5. The most useful tool in observing young children Behavior descriptions are sometimes repeated is a thorough- knowledge of normal growth and under different areas of development. It is diffi- development There is no substitute. The process cult to categorize children's behavior. Your job is of development Varies with- each individual child, to notice and describe what you see that concerns but normal development follows a predictable se- you. Do not try to decide into which category it quence of stages. Interruptions in the pattern and fits. sequence of stages should put an observer on the Look for patterns or clusters of red flags. One, or alert. a few in isolation, may not be significant. Variations in the timetable of a child's develop- Observe a child in a variety of situations in order ment are of much less concern. Each age and stage to watch for the behaviors that concern you. of development is affected by the personality of each Compare the child's behavior to the "norm," that child and represents- the-Skills the child has devel- should include children who are 6 months oped: motor, language, cognitive, r ersonal-social. younger or 6 months older as well as the same Children are continuously changing and emerging age. from yor nger stages into older stages- in all four Note how the child has grown during the past 3 to areas, thereby combining, characteristics of both 6 months. Be concerned if you feel the child has stages. not progressed.

Each child's developmer.. is affected by personality, temperament, family structure and dynamics, culture, experiences, physical characteristics, and the match of child and family to your program. -7/

Preventive health care for children 123

Figure 9-4 cont. Developmental red flags for children ages 3 to 5

Know normal growth and development. What Red flags. Be alert to a child who, compared with .rnayl3e..a red.flag_at_one age_can be ,a perfectly other children the same age or 6 months, older or normal behavior at another. younger, Keep in mind that each child's development is does not seem to recognize self as a separate per- affected by personality, temperament, family son, or does not refer'to self as "I" structure and dynamics, culture, experiences, has great difficulty separating from parent or sep- physical and the match of child arates too easily and family to your program. is.anxious, tense, restless, compulsive, cannot get Use a detailed skills list to develop a skills profile dirty or messy, has many fears,, engages in exces- for the child. sive self-stimulation seems preoccupied with- own inner world. Con- versations do not make sense. Consultation and referral shows little or no impulse control; hits or bites as first response; cannot follow a classroom routine None of us knows all there is to know about nor- expresses emotions inappropriately (laughs when mal growth and de-.- lopment. Use all of yourarea sad, denies feelings); facial expressions do not .resources to help yoti think about a child. match emotions Describe in detail what you see that concerns you. cannot focus on activities (short attention ,span, Do not try to conclude what it means or to label it. cannot complete anything, flits from toy to toy) It is much more helpful to parents, .consultants, relates only to adults. Cannot share adult atten- and to the child to have. descriptions, not con- tion, consistently sets up power ctritggle, or is clusions. physically abusive to adults Talk with the child's parent(s). consistently withdraws from people, prefers to be Wait and watch for a while if you have observed alone; no depth to relationships; does not seek or growth in the past 3 to 6 months. If no growth in accept affection or touching the area of concern can be described, then it is treats people as objects; has no empathy for other time to ask for help. children; cannot play on another child's terms Know that if you recommend further evaluation is consistently aggressive, frequently hurts others of a problem and your concerns are confirmed, deliberately; shows no remorse or is deceitful in you have helped a child and family begin to solve hurting others a problem. Also, be glad if further evaluation does not indi- How to screen cate that there is a problem at this time. 1. Observe child Note overall behavior. What does the child do all day? With whom? With what does child play? NOTE: These categories are intended to guide Note when, where, how frequently, and with your observation of children ages 3 to 5 only. whom problem behaviors occur. Describe behavior through clear observations. Do Major developmental areas not diagnose. 2. Note family history Social-emotional development, that includes Makeup of family. Who cares for child? Has there been a recent move, death, new sibling, relationships or long or traumatic separations? separations What support does family haveextended family, involvement friends? focusing affect 3. Note developmental history and child's tem- self-image perament since-infancy anxiety level activity level impulse control regularity of child's routinesleeping, eating transitions distractability 355 124 Preventive health care

Figure 9-4 cont. Developmental red flags for childrenages 3 to 5

intensity of child's responses produces extremely heavy coloring persistence/attention span leans over the table when concentratingon a -positive,ortegative-m. ood- fine motor project adaptability to changes in routine when doing wheelbarrows, keeps pulling the level of sensitivity to noise, light, touch knees and feet under the body,or thrusts rump up- Community resources in the air child's health care provider the child with extraneous and involuntarymove- -mental health-center ments, who farriily service organization while painting with one hand, holds the other child guidance center hand in the air or waves school system's early childhood special needsco- does chronic toe walking ordinator shows twirling or rocking movements birth-to-6 resource directory or regional offices, shakes hands or taps fingers Department of Education the child who involuntarily finds touchingun- early intervention programs comfortable and who integrated preschool programs and outreach and - flinches or tenses when touchedor hugged training teams avoids activities that require touchingor close regional offices of your department of public contact health may be uncomfortable lying down, particularly libraries on the back reacts as if attacked when unexpectedly Motor developmentFine motor, gross motor, bumped perceptual, that includes blinks, protects self from a ball even when trying to catch it quality of movement level of development the child who compulsively craves being touched sensory integration or hugged. Or, the older child who almost involuntarily has to feel things to understand them. Red flags. Pay extra attention to These children may the child who is particularly uncoordinated and cling to, or lightly brush, the teacher a lot who always sit close to or touch children ina circle has lots of accidents be strongly attracted to sensory experiences trips, bumps into things such as blankets, soft toys, water, dirt, sand, --is awkward getting down/up, climbing, jump- paste, hands in food ing, getting around toys and people the child who has a reasonable amount of experi- stands out from the group in structured motor ence with fine-motor tools but whose skill does taskswalking, climbing stairs, jumping, stand- not improve proportionately, such as ing on one foot an older child who can still only snip with scis- avoids the more physical games sors or whose cutting is extremely choppy the child who relies heavily on watchingown or a child who uses extremely heavy crayon pres- miner- peoples movements in order to do them sure and who an older child who still cannot color within the may frequently misjudge distances lines on a siinple project may become particularly uncoordinated or off an older child who frequently switches hands balance with eyes closed with crayon, scissors, paintbrush the child who, compared to peers, uses much an experienced child who tries but still gets more of her or his body to do the task than the paste, paint, sand, water everywhere task requires and who a child who is very awkward with, or chronic- --dives into the ball (as though tocover the fact ally avoids, small manipulative materials that she or he cannot coordinatea response) the child who has exceptional difficulty withnew uses tongue, feet, or other body parts exces- but simple puzzles, coloring, structured art proj- sively to help in coloring, cutting, tracing,or with ects, and drawing a person, and who, for example other concentration may Preventive health care for children 125

Figure 9-4 cont. Developmental red flags for children ages 3 to 5 take much longer to do the task, even when trying hard, and produce a final result that is still who has a history of ear infections or middle =notias,sophisticatcd compared to peers ear disorders show a lot of trial-and-error behavior when try- NOTE: Most children develop the following ing to do a puzzle sounds correctly by the ages shown (i.e., don't worry mix up top/bottom, left/right, front/back, on about a 3-year-old who mispronounces t). simple projects where a model is to be copied use blocks or- small cubes to repeatedly build 2 yearsall vowel sounds and crash tower structures and seem fascinated 3 yearsp, b, m, w, h and genuinely delighted with the novelty of the 4 yearst, d, n, k, h, ng crash (older child) 5 yearsf, j, sh still does a lot of scribbling (older child) 6 yearsch, v, r, 1 7 yearss, z, voiceless and voiced th How to screen 1. Note level and quality of development as col - dysfluency (stuttering). Note the child who, compared,with other children in the group. pared with others of the same age, shows excessive Community resources repetitions of sounds, words (m-m-m; I-I-I-I-) child's health care,provider prolongations of sounds (mmmmmmmmmmmmmmm) Registered Physical Therapist (RPT), Registered hesitations or long blocks during speech, usually accom- Occupational Therapist (OTR), preferably with panied by tension or struggle behavior pediatric experience putting in extra words (um, uh, well) school system's early childhood special needs co- shows two or more of these behaviors while speaking ordinator hand clenching rehabilitation center eye blinking regional office of Department of Public Health swaying of body ' hospital/physical or occupational therapy de- pill rolling with fingers partment no eye contact American Physical Therapy Association, local body tension or struggle breathing irregularity chapter tremors American Occcupational Therapy Association, pitch rise local chapter frustration avoidance of talking Speech and language development, that is labeled a stutterer by parents includes is aware of her or his dysfluencies articulation (pronouncing sounds) voice. Note the child whose dysfluency (excessive stutteringoccasional stut- rate of speech is extremely fast or slow tering may occur in the early years and is normal) voice is breathy or hoarse voice voice is very loud or soft language (ability to use and understand words) voice is very high or low voice sounds very nasal Red flags language (ability to use and understand words). articulation. Watch for the child Note the child who whose speech is difficult to understand, com- does not appear to understand when others pared with peers speak, even though hearing is normal who mispronounces sounds is unable to follow one or two-step directions whose mouth seems abnormal (excessive communicates by pointing, gesturing under., or overbite; swallowing difficulty; poorly makes no attempt to communicate with words lined-up teeth) has small vocabulary for age who has difficulty putting words and sounds in uses parrot-like speech (imitates what others proper sequence say) who cannot be encouraged to produce age- has difficulty putting words together in a sen- appropriate sound tence sr I:1 1 5 7 Oete 141 Preventive health care

Figure 9-4 cont. Developmental red flags for children ages 3 to 5 uses words inaccurately Red flags demonstrates difficulty with three or more of speech and language. Look for the child these, whose-speech is not easily understood-by:peo- making a word plural ple outside thejamily changing tenses of verb whose grammar is less accurate than other using pronouns using negatives children of the same age using possessives who does not use speech as much as other chil- naming common objects dren of the same age telling function of common objects who has unusual voice (hoarseness, stuffy qual- using prepositions ity, lack of inflection, or voice that is usually too NOTE: Two-year-olds use mostly nouns, few loud or soft) verbs. Three - year - olds -use nouns, verbs, some ad- social behavior (at home and in school). Look for Verbs, adjectives, prepositions. Four-year-olds use the child who all parts of speech. is shy or hesitant in answering questions or joining in conversation How to screen misunderstands questions or directions; fre- 1. Observe child. Note when, where, how frequently says "huh?" or "what?" in response to quently, and with whom problem occurs. questions 2. Check developmental historyboth heredity appears to ignore speech; hears "only what he and environment play an important part in speech wants to" development. is unusually attentive to speaker's face or un- 3. Look,at motor development, that is closely as- usually inattentive to speaker, turns one ear to sociated with speech. speaker 4. Look atsocial-emotional status, that can affect has difficulty with listening activities such as speech and language. storytime and following directions 5. Write down or record speech samples. has short attention span 6. Check hearing status. is distractible and restless; tends to shift quickly 7. Note number of speech sounds or uses of lan- from one activity to another guage. is generally lethargic or disinterested in most day-to-day activities Community resources is considered a behavior problemtoo active or child's health care provider aggressive, or too quiet and withdrawn school system's early childhood special needs co- medical indications Look for the child who ordinator has frequent or constant upper respiratory tract college or university, Communication Disorders infections, congestion that appears related to depaiiment allergies, or a cold for several weeks or months speech clinic has frequent earaches, ear infections, throat in- hospitals fections, or middle car problems medical schools has had draining cars on one or more occasions - -UP n -Stnrt-pr,,grrn is mouth breather and snorer speech practitioner is generally lethargic; has poor color early intervention program American Speech-Language-Hearing Association also see social-emotional resources How to screen 1. Conduct pure tone audiometry and acoustic Hearing reflex* tests for hearing, age 3 and older. Even a mild-or temporary hearing loss in a child 2. Conduct tympanometry* for middle ear func- Indy -interfere with speech, language, or social and tion, all ages academic progress. If more than one of these red 3. Note history (behavioral and medical). flag behaViors is observed, it is likely that a problem *The value of these tests is being reassessed. Check exists. with a specialist before using them. 158 Preventive health care for children 127

Figure 9-4 cont. Developmental red flags for children ages 3 to 5

Community rubs eyes excessively child's health care provider dizziness, headaches, nausea on close work college -COmniunication Disorders attempts-to brush away blur or Audiology department itchy, burning, scratchy eyes hearing or speech and hearing clinic contorts face or body when looking at distant school system objects, or thrusts head forward; squints or wid- audiologist ens eyes ear, nose, throat specialist (otorhinolaryn- blinks eyes excessively; holds book too close or gologist) too far; inattentive during visual tasks shuts or covers one eye; tilts head Vision, that includes eyes appear to cross or wander, especially when tired skills acuity (ability to see at a given distance) How to screen disease 1. Note child's medical history. Has child had an eye exam? If not, recommend one. Red flags 2. Screen using a screening tool appropriate for eyes young children such as the Snellen E chart or Bro- are watery ken Wheel cards.. have discharge Community resources lack coordination in directing gaze of both eyes for screening, contact service organizations such are red as women's club, Lion's club are sensitive to light to be trained to screen, contact Society for Pre- eyelids vention of Blindness or your department of public have crusts on lids or among lashes health. Your health consultant may be able to are red help. have recurring sties or swelling for eye examination, refer to an ophthalmologist behavior and complaints or optometrist

Adapted from material by Preschool Enrichment Team, Inc., 276 High Street, Holyoke, MA 01040. 128 Preventive health care

Figure 9-5. Descriptions of four valid developmentalscreening instruments

Denver DeVelopmental Screening Test, screening.based.nn observations of the child's inirtoPr ly17- functioning. Authois: W.F. Frankenburg, I. Dodds, A. Fandal, E. Kazuk, and M. Cohrs Early Screening Inventory (ESI) Age range covered: 2 weeks to 6 years, Authors: S.J. Meisels and M.S. Wiske Description: The DDST consists of 105 items Age range covered: 4 years to 6 years -from which a selection is made fora specific range. The items are grouped in four, areas: Description: The ESI is- composed-of 30 items personal/social, fine motor/adaptive, language, and that are related to three generalareas of gross motor. development: visud-motor/adaptive functioning, language and cognition, and gross motor/body Available in these languages (in additionto awareness. English): Spanish, Available in these languages (in additionto Total cost: $27.5b/100 children (includesmanual, English): Spanish and Korean -materials, and score sheets) Total cost: $39.95/30 children (includes manual, Order from Denver Developmental Materials, P.O. materials; and score sheets) Box 20037; Denver, CO 80220-0037. (Telephone: 303 - 355 -4729) Order from Teachers College Press, do Harper & Row, Keystone Industrial Park, Scranton, -PA Comments: The DDST is the best known and the 18512. (Telephone: 800-242-7737) most widely used developmental screening instrument available.. With its wide age range,a Comments: The ESI is an easily learned, brief child can be screened with the same testacross a screening instrument that samples developmental period of several years. The score sheet is abilities, rather than s chool achievement, and constructed ingeniously and providesa great deal focuses on performance, in a wide range of of normative information for the tester. developmental areas. The test yieldsa total score The test has been shown to be more accurate in that can be converted into an OK,rescreen, or predicting outcomes of infants ara-severely refer decision. Results from several reliability and impaired children than in predicting theoutcomes validity studies demonstrate that the ESI predicts of preschoolers or mildly handicapped children. school performance with moderate to excellent Very few children who are not at riskare accuracy through the end of second grade. incorrectly referred by the DDST. However,a The predictive sensitivity of the ESI is somewhat majority of the children who are at riskare higher than its specificity: It overrefers slightly overlooked by this test. The low sensitivity rates more than it underrefers. Furthermore, although indicate-that,although:the3DDST rarely tic,cri-c.-Stis the test does not appear to haveany inherent:bias, children, it seriously underrefers them. Because of and concurrent validity was basedon a stratified this problem, caution should be used when sample, the long-term validity of the instrument interpreting results from the DDST. (kindergarten to grade 4) was established witha group of low- to lower-middle SES urban, White Note: Some pediatricians are using a modified children. Nevertheless, the ESI makesa version of the DDST known as the Revised substantial contribution to the short-term and Parental Development Questionnaire (RPDQ). This longitudinal prediction of children at risk for tool allows parents and caregivers to perform learning problems or handicapping conditions.

Note: From Developmental Screening in Early Childhood:A Guide, Revised Edition (pages 32-39) by S.J. Meisels, 1985. Washington, DC: National Association for theEducation of Young Children. Copyright 1985 by National Association for. the Education of Young Children.

.160 Preventive health care for children 129

Figure 9-5 cont. Descriptions of four valid developmental screening instruments Tlie-VcCarthy-Screening Te StIMST) Minneapolis Preschool Screening Instrument (MPSI) Author: D. McCarthy Age range covered: 4 years to 6 1/2 years .Author: R. Lichtenstein Description: The MST consists of 6 of the 18 Age range covered: 3 years, 7 months to 5 years, subtests of the MSCA: Right-Left Orientation, 4 months Verbal Memory, Draw-a-Design, Numerical Mernory, Conceptual Grouping, and Leg Description: The test consists of 50 items that are -Coordination: divided among 11 subtests: building, copying shapes, providing information, matching shapes, Available in these languages (in addition to completing sentences, hopping and balancing, English): None naming colors, counting, using prepositions, 'Total cost: $47.50/30 children (includes manual, identifying body parts, and repeating sentences. materials, and score sheets) Available in these languages (in addition to Order from Order Service Center, Psychological English): None Corporation, P:O. Box 9954, San Antonio, TX 78204. (Telephone: 212-517-8184) Total cost: $35/30 children (includes manual, materials, and score sheets) Comments: The MST is a promising instrument. Because the MST is identical with six of the Order from Special School District #1, Planning & subtests of the MSCA, (that have an upper age Development Department, 807 NE Broadway, , rangeof 8 years), it may be more discriminating Minneapolis, MN 55413. (Telephone: for academically and developmentally more 612-627-2190) advanced children than other screening tests. However, it has been distributed prematurely. Comments: The MPSI is a well-developed test Reliability and data have not been that excludes items requiring extensive examiner independently collected for the MST but are judgment (e.g., expressive language and most extrapolated from the data obtained with the gross-motor items). It includes a higher proportion MSCA. Furthermore, studies of the factor of classroom readiness tasks than most structure of the MST indicate that the subtests all developmental screening tests. measure parts of the same attribute (cognitive and While the MPSI has been subjected to a wide sensorimotor functions) in varying degrees. range of tests by its author to establish its validity, Because no validity data were reported on the its predictive validity is based on comparisons MST during its development, and no cross - with a teacher report scale that lacks well- validation -with an independent criterion has been established validity or replication. Nevertheless, .attempted, the MST cannot he used. ithout some the MPSI appears to be a good predictor of caution concerning its predictions. learning problems for at least a 1-year period.

Note: From Developmental Screening in Early Childhood: A Guide, Revised Edition (pages 32-39) by S.J. Meisels, 1985. Washington, DC. National Association for the Education of Young Children. Copyright 1985 by National Association for the Education of Young Children.

, 161 130 Preventivehealth care

Figure 9-6. Physician's exam form

Child's name last first middle Address

-Sex M F

Birthdate

OVERALL STATEMENT OF HEALTH

I examined this child on date (NOTE: This date should correspond to the last date the childwas due for routine health care according to the current Guidelines for Health Supervision of the American Academyof Pediatrics.)

In my opinion thi' child is in excellent good poor health.

Notes on results of the physical exam

Weight Neck

(percentile) Chest

Height Lungs

(percentile) Heart

Blood pressure Extremities

Vision Abdomen

Audiogram Neurological

Ears/nose/throat Coordination

Eyes

Recommendations

Restrictions

162 Preventive health care for children 131

Figure 9-6 cont. Physician's exam form

Known allergies

Medications or supplements

Health history

-Prenatal,;perinatal; and postnatal development. Are there any significant findings that could-influence this child's a daptation to an early childhood program (e.g., physical handicap, sensory loss, developmental irregularities)?

Chronic illnesses. Does the child have any chronic illness that may require regular medication, special observation, or precautions in a group setting (e.g., recurrent car infections, seizure disorder, or allergies)?

Hospitalizations, surgery, or special tests

Pertinent family, social, or health characteristics

I 6 3

11 t 132 Preventive health care

Figure 9-6 cont. Physician'sexam form -Patti Mena

'Illness Date Illness Date Diphtheria Chicken pox

Pertussis Pneumonia

Measles Scarlet fever

Mumps Other

Rubella Other Yitecord of immunizations

Tyre of immunization Dates 1st 2nd 3rd 4th 5th Booster DTP

Oral Polio XXX XXXXXX MMR XXX XXX XXX XXX XXXXXX Hib XXX XXX XXX XXX Other

TB test type bate Result

Signature of examiner Date Printed name of examiner

Address

Phone

1s Preventive health care for children 133

Bibliography Haggerty, R.J. (1984). Section IIHealth pro- Preschool Enrichment Team. (1983). Preschool Moti On. In & R.J. Haggerty '(Eds.). vision screening: A reason to start young. Holy- Ambulatory Pediatrics III (pp. 27-37). New York: oke, MA: Preschool Enrichment Team. Saunders. Reinisch, E.H., & Minear, R.E., Jr. (1978). Health of Meisels, S.J. (1985). Developmental screening in the preschool child. New York: Wiley. early childhood: A guide. (Revised ed.). Washing- Souweine, J.; Crimmins, S.; & Mazel, C. (1981). ton, DC: National-Association for the Education Mainstreaming: Ideas for teaching young chil- of'Young Children. dren. Washington, DC: National Association for Nelson, 11.M., & ,Aronson, S.S. (1982). Health the Education of Young Children. power: A blueprint for improving the health of U.S. Department of Health and Human Services. children. New York: Westinghouse Health Sys- (1978). Mainstreaming preschoolers. Washing- tems. ton, DC: U.S. Government Printing Office. North, A.F., Jr. (1972). Day care 6: Health services. A guide for project directors and health personnel. (A Head Start paperbound book)

JLV 10 Adult health

Staff are the key ingredient in a good program for administrative, and curriculum work. Bring in young children. They are very concerned about po- adult-size folding chairs for staff meetings. Place tential health hazards of their work. In a 1979 study a phone book on a child-size chair to make it a of San Francisco child care workers, 67% stated that much more comfortable seat. their health was negatively affected by their jobs Set aside private adult space and provide ade- (Child Care Employee Project, 1982). Some hazards quate back-up to ensure genuine breaks to allevi- cited by the study are increased risk of getting ill- ate stress. nesses; presence of toxic substances in art supplies, Train staff in proper techniques for lifting and cleaning agents, and pesticides; back problems due bending to prevent leg and back strains (Figure to frequent heavy lifting and furniture and envi- 10-1). ronment designed for children; poor lighting; high Provide gloves to use with cleaning agents to help noise levels; clutter; and stress. prevent skin irritation. Another major health hazard is caused by the ten- Establish preventive health policies that can re- dency of staff to ignore their own health needs be- duce exposure to childhood illnesses, and prac- cause they lack health benefits and time off, and tice good preventive health procedures to help because they feel responsible for meeting children's keep adults and children healthy. needs first. Programs can alleviate some of these Include break and substitute plans in personnel- concerns by establishing an adult health plan; by policies. creating a positive, healthful environment; and by assisting adults to look after their own health needs. Your adult health plan

Ways to promote-good adult health Health examinations The foundation for an adult health plan is the Staff must care for themselves to be able to pro- requirement that all adults (staff and volunteers) vide the best care for children. To help the staff in who work or wish to work in your program have your program, take the time to look at your envi- periodic health exams. The results of such exams ronment and program demands. How can you make must be strictly confidential and can be given to the yorselves more comfortable? What policies need to employer only with the staff member's permission. be revised to meet adult needs? Are you encouraging Your adult health plan must specify the following good health? Can sick adults stay home without for each type of examination: -guilvand-loss-of pay?- content of the exam With staff and administration working together, it who can perform the exam is possible to adjust a facility 'and program to the how often it must occur needs of the adults as well as the children. Here are special examinations for special roles, if any examples of some simple solutions to adult health who receives the findings problems: where the examinations can be performed -0 Provide a high counter with stools, or an adult- who pays for the exam size table and chair, for staff who .do clerical, For examinations to be effective, the health pro-

166 135 136 Preventive health care

Figure 10-1. 11.1w to care for your back

Suggestimw_on, how to-protect your-back-. Lifting techniques Posture Everyone has a lifting technique thatseems most Having a firm, flattened abdomen and holding comfortable. But there are basic rules that applyto all. These rules will help control andprevent back your stomach in when you stand and sit provide pain. -needed support for the lower spine. Stv up close to your work area or-toa load. Sitting. When you sit, it's important to maintaina D'en't overreach to grasp or lift. normal spine curve. A sitting, position produces Get a firm footing. Keep your feet parted;one greater loads on the lower back than either stand- alongside, one behind the object. ing or walking. Select a chair wil:n a firm seat and Grip the object with the whole hand. Geta firm adequate lower back support. Keepingyour knees grip with the palms of your hands because the bent and resting youi' back against the chair will palms are stronger than the fingers alone. prevent back strain. Don't sit too long. Get up, Draw the object close to you, with arms and el- stretch, and walk around occasionally. bows tucked into the sides of your bodyto keep yourhody weight centered. Driving. When driving a car, move the seat forward to 'keep the knees bent and higher than the Bend knees, lift with your legslet your powerful hips. Often, a small pillow or towel rolled behind the leg muscles do the wDrk of lifting, notyour weaker back muscles. lower back will provide extra-support. Avoid lifting about the waist, but ifyou must, Standing. Standing can be hard on- your back. reposition your grip to keep the weight centered. Try not to work for long periods in .a bent-over posi- Arching your back during a lift makesnerve roots tion. Muscles and good posture- help to keepyour susceptible to pinching and cancause weak spine in the balanced, neutral position. Abdominal muscles to be strained. muscles pull up in front and buttock muscles pull down imback to maintain the natural Twisting during a lift is a common cause of back curve of the injury. If you have to turn with a load, change the spine. This allows you to hold a balanced standing position of your feet By simply turning the forward posture for-long periods of time without tiring. An- foot out and pointing it in the direction other technique is to stand withone foot elevated you intend to move, the greatest danger of injury by twisting is to a comfortable level. Switch feet every so often. avoided. Sleeping. Sleeping rests the back. Whenyou are Proper maintenance and preventive careare the lying down, your back doesn't haveto support your keys to a healthy back. Continue to learn howyour body weight. It is important touse a firm mattress. back works and what you can do to keep itstrong Sleet' on your side with knees bentor on your back and flexible. with knees elevated.

167 Adult health 137

fessional conducting the exam must know the after a severe or prolonged illness, to help identify nature and demands of the adult's job. For instance, continued disabilities, necessary modifications, a chronic lower back problem may not interfere and expected transition time to resume a full with--the job performance of a social- worker but work-role surely would affect the teacher of a toddler group. on return fr--n a jcb-related injury, when a writ- Pre-employment exams. Ideally, the results of a ten release protects the program from liability for health exam should be received before a job offer is allowing the adult back on the job made final and before contact with the children whenever a health condition seems to be affecting Isegins. It is hard to deal with health concerns-after job performance, no matter when the lastassess- ment was done an individual has begun to develop relationships, when a promotion or reassignment to another and an, exam that follows employment may reveal role could be affected by the adult's health status health problems to which other staff and the chil- whenever there are liability issues such as adults dren have already been exposed. with a history of back injuries, more than one Pre-employment exams should be concerned with heart attack, mental illness, or stress-related con- the prospective employee's ditions physical and emotional fitness for the job after certain infectious diseases to ensure the freedom from contagious diseases adult is no longer contagious immunization status and history of childhood infectious diseases such as chicken pox-and rubella For an example of a staff health appraisal form, if of childbearing age, immunity to cy- see Figure 10-2, on p. 138. tomegalovirus (CMV) disease(s) that might cause frequent absences from the job Infectious diseases condition(s) that might require emergency care Infectious diseases are common in groups of limitation(s) in common situations such as diffi- young children, but most are not serious and would culty being outdoors, skin conditions affected by probably spread at a similar rate from children to frequent handwashing, allergy to art materials adults in a large family. However, because staff care medication or special diet requirements that for a number of young children, many of whom might affect job performance cannot control their secretions and have not yet hotisehnld members and their status regarding learned pnnciples of hygiene, there is the potential infectious diseases (for family day care or group for spread of infections to the employee. Employees home care) may pass infection to other employees, children, vision and hearing acuity family members, and in the case of a pregnant em- Pre-employment exams for bus drivers must include ployee or parent, to the fetus. Therefore, it is impor- special tests, such as visual field, color and -lepth tant that the employee be familiar with- common perceptions, and an electrocardiogram infections and the measures to take to prevent them. Make sure that your pre-employment exams test Details on these infections and ways to reduce for poorly controlled health conditions that might their spread are contained in Chapter "17. affect the safety of the children (a poorly controlled seizurcdisorder-or obvious lack of stamina, for ex- Preventing infection. Two important barriers ample). If these conditions are identified after a per- that help prevent-the spread of infection are immu- son has been hired, you may wish to make adjust- nization and hygiene. ments to allow the person to continue working by ImmunizationSafe, effective vaccines against providing a change to part-time work, a change in many serious diseases including measles, mumps, role, or a temporary leave of absence. rubella, diphtheria, tetanus, and polio-are-available. These vaccines are strongly recommended Other periodic health exams. When you develop for employees. Vaccine for influenza virus (given your adult health plan, specify which of these ad- yearly) may be advisable. ditional exams are required. HandwashingCareful handwashing after con- prior to completion of a probationary period or if tact with potentially infectious secretions along health concerns have been raised with proper handling of contaminated items is

-$(..) .i.- 0u 138 Preventive health care

Figure 10-2. Staff health appraisal This section should be completed by the employee

Name and address of individual examined

Name of employer

Employer's address

Employer's telephone number

Purpose of ExaminationType of Activity in Child Care (Check all applicable) Initial employment Food preparation Driver of vehicle Re-examination Caring for children Desk work Facility maintenance Other This Section To Be Completed By Health Professional Who Does Health Appraising Part IAs "limn by physical examination, does the individual have Yes No 1. At least 20/40 combined vision, corrected by glasses, if needed? 2. Normal hearing? 3. Normal blood pressure? 4. Normal cardiovascular system? 5. Normal respiratory system?

6. Normal skin? . 7. Normal neuro musculoskeletal systems? 8. Normal endocrine system? Explain all "No" responseson reverse of form

Part II -1s the individual free from communicable tuberculosis as shown by No 9. Negative skin test results within the past 2 years? 10. Positive skin test followed by one negative x-ray and an asymptomatic history at this health_appraisal? Explain all "No" responses on reverse of form, giving plan for follow-up

169 Adult health 139 Figure 10-2 cont.Staff health appraisal Part IIIDoes _this individual have any of following medical problems: Yes No- 11. History of myocardial infarction, anginapectoris, coronary insufficiency? _ 12. History of epilepsy?

13. Diabetes?

14. Thyroid or other metabolic disorders?

15. Inadequate immune status (Td, measles,,mumps,rubella)? 16. Need for more frequent health visitson sick days than average for age? 17. Current dfug or alcohol dependency?

18. Disabling emotional disorder?

19. Other special medical problemor chronic diseae which requires restriction of activity, medication or which might affect hisor her work role? If so, specify on reverse of form. Explain all "Yes" responseson reverse of form, giving plan for follow-up ifany

20. Does this individual haveany special Medical problems which might interfere with the health of the children or that might prohibitthe individual from providing adequatecare for the i)hildren? If yes, explainon reverse of form.

Name and address of licensed physician

Telephone number

Signature of physician

Date of examination

170 -140 Preventive health care

the most -effective measure to prevent most with other contagious diseases (e.g., strep throat, spread of infectious diseases. Al" blood and lice, impetigo) may return after treatment is begun 'othe'r body fluids from all Childre., should be (see Chapter 17). Adults with herpetic cold sores hanped.asTotentially infectious. (See Chapter may work, but-must carefully practice_personahhy- 4,;Figure 4-1.) giene. Adults with diarrhea should not work until Special safeguards for pregnant women. well or until a physician has determined the diar- Women of childbearing age should be aware that rhea is not infectious. unborn children can acquire several infectious di- :seaseS..Such infections can cause,miscarriagei-birth Substitutes and breaks defects, or illness in the newborn. These infections Follow these suggestions for substitute and break inclUde rubella, measles, mumps, hepatitis B, cy- policies. tomegalovirus, herpes, and AIDS. Thelirst four diseases can be prevented by immu- Substitutes nization. Routine immunization (or other proof of Consider joining with other programs to hire a immunity) is strongly recommended for the first sub who rotates. This allows each program some three diseases: measles, mumps, and rubella. In ce-- guaranteed coverage and provides dependable tain settings, an increased risk of hepatitis B infec- employment for the sub. If nobody is absent on tion could exist. In those cases, vaccination is rec- the scheduled day, the sub can supervise- while ommended for persons who have daily close contact regular staff attend to parent conferences or With children who have or are at high risk of having planning, for example. hepatitis B. Strict attention to handwashing and Set a decent salary for substitutes. care with all children's blood and body fluids are the Regularly evaluate your substitute policy. Keep most effective safeguards for susceptible women the sub list active; call subs periodically to make against those infections for which there are no vac- sure they are still available. cines. Let parents know about the substitute procedure. When not to come to work Breaks. Because of the cost of hiring additional staff, most programs must work with remaining It is expected that children will catch colds and flu. Adults working daily with young children are personnel during staff breaks. Use the following suggestions to cope with limited staff. also likely to become ill. Yet, because of the diffi- Nonteaching staff can cover breaks on different culty of arranging for and keeping dependable sub- days of the week. stitutes, many programs have inadequate substitute policies. The result is that many staff keep working Assign parents students, and community mem- when they are ill, convincing themselves that they bers as "floaters." The key to making this plan really. are not that sick. Upgrading substitute cov- work is regular scheduling and dependable volun- erage is critical to a well-run program even teers! Be sure volunteers receive a thorough orientation to their duties and have the same health though creating a reliable substitute policy is a and skill monitoring as regular staff. difficult task. The best illness guideline to follow is this: In a well-staffed program, designate one staff member as a "floater" during break time' for a Ask adults -'who cannot comfortably entyl capably week at a time. This person can become farniliar perform their daily activities to remain at home. with each of the classrooms and also gain per- Personnel policies should be written to allow spective on the program. and encourage adults to stay at home when they Overlap staff shifts. Perhaps afternoon shifts can feel too sick to .work. begin during the last half hour of the-'morning Staff often come to work when they are sick be- shift. Although more expensive, this model covers cause of fear of lost pay or feelings of guilt due to breaks and also allows teachers time to com- inadequate substitute coverage. All staff must make municate. a choice that balances their personal concerns and Provide a relaxing space for staff. Even if space is those of the program. Clearly, adults with serious limited, a comfortable chair placed in front of a illness such as meningitis or chicken pox should not window can serve as a place to relax. If at all be at work in a program for young children. Adults possible, the budget should pay for refreshments for the staff. Adult health 141

Bibliography

Aronson, S:S. (1984). Why is adult healthan issue in day care? Child Care InformationExchange, (Maiali 1984). Child.Care Employee Project. Health and safetyre- sources for child care workers. (Various materials 'available from Child Care EmployeeProject, P.O. Box 5603, Berkeley, CA 94705) ,Child,Care,-EmploYee Troject: (1982). "ChildCare Employee Project: handout #9: Occupational health and safety for childcare staff." Berkeley, CA: Author.

172 Dental health

The type of hygiene and dental care children re- long time and cause serious decay called nursing ceive, along with diet and her-dity, will determine bottle mouth. their dental 'health throughout life. Your program Never reward good behavior with candy or can help prevent dental disease by serving well- other sweets. balanced, nutritious food and by limiting sugared Please refer to Chapter 12, Nutrition in programs and sticky foods. You can also promote dental for young children, for more information. health by providing fluoride tablets or drops (with ,parental permission), teaching children and staff about good dental care by having them all brush Fluoride their teeth during the day, and by looking for dental problems. Fluoridation of public water supplies is the single most effective method to prevent tooth decay. When children have fluoride in their drinking water, or Healthy foods for teeth fluoride supplements from birth, their tooth decay is reduced 50 to 70%! Find out if your community High-sugar foods are clearly linked to tooth decay. fluoridates its water. If not, consider using fluoride Avoid or limit sweet drinks, randy, jelly, jam, cake, drops or tablets if parents' permission has been re- cookies, sugared gelatin, and sweetened, canned ceived. After 2 years, 25 to 35% of the children's fruit. Low-sugar, fresh fruit makes a great snack or decay could be reduced. Contact your state or local dessert alternative. health department to locate resources for a pre- Here are some important facts about sugar and school fluoride program. teeth. Natural sugars (such as maple syrup and honey) are just as harmful to teeth as refined sugar. Brushing teeth Sticky sweets (such as caramel) are particularly harmful because they remain on the teeth longer Very young children can learn good habits that oilier sweets. will last into adulthood. Brushing teeth after lunch Eating a sweet all at once is better than eating one and/or snacks has the double benefit of cleaning for a long time (such as a lollipop), or often (such teeth and teaching a good habit. This routine, if it is as popping mints or hard candies every 20 min- organized well, will probably not take more- than -5- utes). minutes a day. Some points to remember are Sweet, sticky fruits, such as raisins and dates, Each child must have her or his own toothbrush, should be eaten with a meal. labeled by name, that must never be shared. Frequent snacking is not a good idea because the Toothbrushes must be stored so they stay clean teeth are attacked by the decay process through- and open to the air. The bristles should not touch out the day. any surface. One method is to use a Styrofoam Never put a baby to bed with a bottle of milk, egg carton. Clean it with alcohol, turn it upside formula, sweetened liquids, or fruit juices. The down, and punch a hole in the bottom of each egg sugars in all of these liquids stay on the teeth for a 143 170 144 Preventive health care

Guidelines for proper brushing are Direct the bristles at a 45° angle where the teeth and gums meet. Brush the outside and inside surfaces of the teeth. Place the bristles of the toothbrush where the teeth and gums come together. Move the brush in a short,,circular motion, back and forth; brushing the gums as well as the teeth. Scrub back and forth on the chewing surfaces. A systematic routine will help ensure that all areas get brushed each time. Begin with the top teeth in the back on the right side. Brush the outside surface. Follow the arch around to the left side. Follow this same pattern for the inside sur- 4 faces. Brush the chewing surfaces on-both sides. Brush the bottom teeth following the same rou- ,tine. Brush the tongue.

Dental health education

Children and parents must understand the importance of good dental health. Children can be taught effectively through an integration of dental educa- a, tion activities with their regular activities. Parent programs can be publicized through articles in your newsletter, parent handouts, posters, or films. Bro- chures that describe particular problems, condi- Teach children priiper brushing technique. Both tions, or resources are frequently available from children qnd parents must understand the importance of good dental health. state or local health departments. Also, some dentists or hygienists are willing to come to the classroom. A field trip to a dentist who enjoys working with young children can be a wonderful intro- compartment. Store the brushes bristle-side u_ p so duction to regular dental care. they-,do not touch each other. Most dentists and hygienists recommend a small toothbrush with soft, rounded, nylon bristles; a Dental care straight handle; an even brushing surface; and a head small enough to reach every tooth. When the Encourage parents to follow healthy dental rou- bristles become bent, the brush doesn't clean well tines and to get regular dental care. Your program and should be replaced. Brushes should be re- might provide the names of children's dentists (ped- placed-about every 3 months. odontists) or family dentists who work regularly Use a small amount (about the size of a pea) of with children. Some area resources may include toothpaste with fluoride and encourage children dental health clinics, dental school clinics, com- to spit it out.. Use this toothpaste only for children munity health centers, and for emergencies, hos- who will not swallow it because swallowed tooth- pital emergency rooms. paste can cause irregular doses of fluoride. To A child's first visit to the dentist should be at discourage children from eating toothpaste, do about 3 years of age, or when all 20 baby teeth are not use a highly flavored one. showing (see Figure 11-1). Since children usually Have an adult supervise toothbrushing. need little treatment at this stage, the dentist can TeaCh children proper brushing techniqtte. Use form a friendly and relaxed relationship with the the circular motion which is -6asy and effective. child. The dentist can also look for early signs of

1 74 Dental health 145

Figure 11-1. Dental, referral criteria for 3-year-old children

For most children younger than age 3, a visit to a Color dentist is purely an educational experience. How- Are the teeth milky white? Arc they all an even ever,,there are cases where consultation with a den- color? tist is recommended:Listed below are things to ob- Do any stains and colors come off easily with a: serve 3- year -old Children. If you answer "no" to toothbrush? any of the qUestionS, you should recommend that the child's parents consult a dentist. Oral hygiene Soft tissues (tongue, lips, cheeks, Are the teeth clean? gums) Does the mouth have a clean, sweet odor? Can the child stick the tongue tip completely out of the mouth? Can the. -child swallow 'with the teeth together (without the tongue pushing through)? Are-the_upper andlower lip the same size? Is there a clear distitittiblibetween lip and skin cf face? Is the color inside the cheeks even throughout? Are all gum tissues the same color? Are gums free of pimples and/or swelling?

Hard tissues (teeth)

Number Are there -20 teeth, 10 in each jaw? Are these the same number of teeth on either side of the middle of the jaw? Are teeth on either side the same shape?

Bite When the child closes the mouth, do the top teeth -bite over the. bottom tecth? Do tho back tA.A..th meet? .. Do all the teeth come in contact when the jaw is closed? A good first triptO the dentik will help mold' Are the teeth spaced out, not crowded? children's feelings for many years.

175 146 Preventive health care future. problems such as overcrowding or poor den- Toothache -tal-hygtene-(cleanliness). Ask the parent to call the dentist at once. The Try to make dental visits an important adventure. dentist will find the cause of the toothache and will Tell children that the dentist is afriendly doctor who reduce the pain as quickly as possible. If emergency will help keep their teeth and mouth healthy. Talk care is needed, there are temporary, emergency about the visit in a positive, matter-of-fact way as measures to use only when a child is in extreme -you ,would,any -new-experience..a-is -important to pain: If a cavity can-be seen' in the tooth-that aches, prevent fear. Avoid statements that suggest the visit flush out any food particles with warm water. Oil of may be unpleasant, such as, "It won't hurt." If you clove may be put directly into the aching tooth. As- are fearful about dental visits, try not to let the chil- pirin or acetominophen can be swallowed for tem- dren know.. A good first trip will help mold chil- porary relief of pain (use these-only-with parental dreri's feelings for many years. permission). Do not place aspirin directly onto the You can help promote children's dental health by tooth. Arrange a dentist appointment immediately. observing carefully. Suggest that the parent take the child to the dentist as soon as possible if any of these Thumbsucking problems occurs. redness, swelling, or bleeding of the gums Thumbsticking during the first several years swelling of the face should cause no concern. It gives thP baby a feeling coinplaints of pain of pleasure and security. However, if the child con- very dark a..discolored teeth or holes in teeth tinues tliumbsucking beyond the age of 5, it -can -complaints whcn thc child cats hard, hot, cold, or affect the position of the incoming permanent teeth sweet food and the shape of the jaws. The pressures of thumb- broken teeth sucking may push the teeth out and narrow the den- spaces from first teeth that fell out too early tal arches. Eventually orthodontic care may be constant bad breath needed. Work with the parents and their health care- provider to help the child find a caring way to eliminate this habit. Special dental problems Nursing bottle mouth Broken tooth Nursing bottle mouth is a condition that can de- Contact the parent and request that the child be stroy the teeth. The teeth most likely to be damaged taken to the dentist immediately. If a broken tooth is are the upper front teeth, but others may also be not cared for, it can be lost. affected. Nursing bottle mouth is caused by the frequent and lengthy exposure of a child's teeth to Knocked out tooth liquids containing sugars (milk, formula, fruit juice, and other sweetened liquids). Contact the parent and save the tooth! Some- Using frequent bottles of these liquids as a paci- times it can be replanted in the jaw. DO NOT clean fier is not a good idea. Allowing a child to fall asleep the tooth. Simply put it in a wet cloth or in a glass of with a bottle during naps or at night can do serious water or milk. Rush the child and the tooth to the harm to the child's teeth, since the liquids. pool dentist (within 30 to 90 minutes if possible). The around the teeth for long periods of time. If a child sooner the child sees the dentist, the better the falls asleep with a bottle, remove it and use a wet chance -of- saving the tooth. washcloth, paper towel, or napkin to wipe the liquid from all tooth surfaces.

176 Dental health 147 aibliogr.aphy-

American Dental Association. (1976). "Care of children's teeth." Chicago: Author. American Dental Association. (1983). "Nursing bottle mouth." Chicago: Author. Moss, S.J. (1977). Your children's teeth. New York: Brentano.

177 Section F Nutrition

majorconcepts Guidelines for nutritious meals and snacks for children Provide a variety of foods each day. One food cannot supply all the nutrientsa child needs. Establish regular times for meals and snacks. Offer portions appropriate to a child's age; discourage overeating. Offer nourishing snacks between meals to round out a well-balanced diet. Beaware that children often need more food than they are able to eat at a regular mealtime. Limit snacks that do not provide important nutrients. Encourage eating habits that are consistent with good dental health. Avoid serving foods with excess salt, fat, and sugar.

178 Nutrition in prOgrams foryoung children

Good nutrition is an essential ingredient of qual- Provide a _quiet, private place with &comfortable_ 'llychildcare.Sasty, Colorful, nutritious foods anda chair where ,mother can nurse before depar- pleaSant, relaxed eating éiiVi-tonirient contributooa ture; on arrii...q; or during-her work breaks. child's sense of well-being. A child develops lifelong Try iii-e-stahlish,&bottle,feeding schedule thaten- eatinghabits as a result of early eating experiences. sures the baby is eag...1' to,purse when the-mother, As a child care provider, you need to know the nutri- arrives (i.e., set the feeding. time for at least 2 1/2 tional requirements of children and howto provide hours before her arrival). a nutritious diet. Equally important is the atmos, Follow the guidelines for safe storage and han- phere you create at meal and snack time. dling of expressed breast milk (p. 183). Be informed about the basics of breast-feeding, and support the mother. Remember thata mother Fecling infants does not "lose 'her milk" when she bottle-feeds part-time. A full supply of 'breast milk can be During the first year of 'life, infants experience maintained, especially if the mother breast-feeds more changes in diet than at any other time in life. full-time while the baby is -with her. During this, time, they grow rapidly and develop motor skills. They quickly progress from sucking Introducing solid foods 'liquids through a nipple to feeding themselves table foods (see Figure 12-1). Although feeding skills Experts recommend starting solid food when in- are fants are between 4 and 6 months old. Until this developed in a systematic order, each childprog- resses through' this sequence at her or his own pace. time, the infant's digestive tract is not able tocom- C pletely break down the food; consequently, allergic During this period, interaction with adults hasa ,Strong influence on the infant's development of self- reactions or sensitivities to solid foods may bemore feeding skillS and acceptance of a variety of foods. likely. Also,,the infant's neuromuscular skills needed See Figure '12-2 for guidelines on feeding infants: for self-feeding and swallowing are not well developed. Therefore, it is best not to begin semisolid Breast milk is best foods (e.g., rice cereal) before 4 to 6 months. be- ,tween 6 and 8'months, add vegetables and fruits to Break milk is the recommended food for infant:. the diet. At about 8 or 9 months, offer food with because it is uniquely suited tosupport their lumps (including table food the babycan easily growth. Breast-fed infants should be,given vitamin chew or mash). By, the end of the firstyear, the baby D and fluoride suppleinen,ts.. Bottle -fed infants should be eating most table foods. shouldbegivenironLfortified fOrrnula.Until about 4 Use the following guidelines to help you introduce 0'6 Months of age, infants are not physically ready solid foods: to elf and digest any foOds except breast milk or Allow-time for the baby to get used to the feel and :formula. taste of solid foods. Your progfam, can help promote' breast-feeding Introduce a variety- of foods to help build. good es4 and support nursing mothers by following;some food habits throughout life, but take care to add siinOleguidelines. only one new food'at a time. Wait 5 days tosee that the new foodis well tolerated. 179 152 Nutrition.

Figure 12-1. Developmental sequence of feedingskills

Age Oral & -neuromuscular Feeding Skills Special notes (months), development implications Birth to 1 Rooting reflex Turns mouth toward nipple or object Breast-fed babies need that brushes cheek. Vitamin D and fluoride supplements. Formula-fed babies need no supplements except possibly fluoride.

Sucking reflex Begins when lips are touched.

Swallowing reflex Initially involves only the back of the tongue. By 9 to 12 weeks, the front will begin to become involved.

Extrusion reflex Pushes out any food placed on front of tongue.

Sucking reflex becomes voluntary

Holds head erect

Mouth poises for nipple Anticipates food/bottle on sight

4 to 6 Extrusion reflex diminishes, Begin introduction of solid foods as Start with rice cereal. giving way to chewing infant's need for calories and certain Prepare with 1 tbs. formula .motion nutrients increases that cannot be or breast milk. Gradually provided by breast milk or formula increase consistency as baby alone. gets used to it.

Begins to reach mouth with See Infant feeding guide hand (Figure 12-2).

Grasps objects voluntarily Uses tongue to move food in mouth. Texture of food may be increased. Moves jaw and tongue laterally Sits with support

6 to 8 Puts lips to rim of cup Begin to offer beverages from a cup. Plain yogurt may replace some milk.

Puts most objects into Encourage finger food. -mouth Grasps spoon, nipple, or Holds own bottle well. Removes food cup rim quickly from spoon with lips.

Sits without support for Increase texture to soft, mashed table Offer strained, mashed, or brief periods foods. bite-size pieces of cooked or soft, fresh, or canned fruits Begins voluntary biting and and vegetables. early chewing 1-2

Nutrition in programs 153

Figure 12-1 cont. Developmental sequence of feeding skills

8 to 10 Sits without support Feeds self cracker. Wheat products maybe started. Begin 'Meal and poultry (chopped or strained) and eggs.

10 to 12 Chews up and down Gradually increase texture: offer whole May try small amounts of fruits and vegetables. whole grain cereals.

Closes lips around rim of Drinki from cup or glass with help. cup Has neat pincer grasp Offer finger foods in small pieces.

Ceases drooling

Tries to use spoon.

12 to 18 Increased rotary motion of Tries to use spoon.. Give some thick Cheese or yogurt may jaw foods that will stick to spoon. replace some milk.

Can chew meats.

Growth rate slows considerably

Increases independence Appetite decreased, may refuse food. Provide small amounts. Uses spoon, may be upside down.

Mostly feeds self.

Holds glass/cup with two hands to drink.

Discards bottle.

From Guidelines for Feeding Infants and Young Children by Nutrition Services of Vermont Department of Health, Burlington, VT, 1979. Adapted with permission. Figure 12-2. Infant feeding guide Foods Birth to 4,months 4 to 6)months 6 to 8 months 8 to 10 months 10 to 12 months ,

op'Breast milkShort frequent feedings Short frequent feedings On demand 5 or morer da 5 or more feedings On demand On demand ho7; To32 oz A e. daY--- 24 to40 oz 24 to 32 oz. to 32 oz. 16 to 24 oz. 5 to 10 feedings per day 3 to 4 feedings 4 to 7 feedings per daY 3 to 4 feedings per day fortified -per day 3 to 4 feedingsper day formula Can wean now from the Whole milk can be offered bottle now - Offer 2 to 4 oz. in hot Water sow"1".^.0.011.01 ....me Offer water froma cup weather between m(zIs Offer water between meals Offer water between meals

1 ..- Most varieties of infant cereal 11.%-.A.4rk9 Rice, oatmi, or barley infant cereals, Cream of Hot or cold, unsweetened ' (spoon-fed) Avoid cereals that are pre- Wheat, or other plain, hot cereals none 06e, Mix 1 to 3 teaspoons with mixed with formula, fruit, cereals Bread formula or breast milk or honey Toast, bagel, or clackers Rice Cereals and bread 1 to 4 tablespoons, twice a good for teethi,-; Noodles or spaghetti ..,. day ilk Infant juice Infant juice . Adult apple juice, Vitamin Adult apple juice, Vitamin C-fortified C-fortified All 100% juices Fruit juices none la All 100% juices from a cup Avoid orange and tomato Offer diluted juice from a Orange and tomato juice WI juice now cup can be offered now 2 to 4 oz per day 4 oz. per day .

- Vegetables Strained or mashed vegetables: dark yellow or Cooked chopped or Cooked vegetable pieces none none orange (avoid corn); dark Cb green mashed, fresh or frozen May have some raw ...,V...: vegetables vegetables if child can 1/2 to 1 jar or 1/2 cup per 0 day chew them well

Fresh or cooked fruits: mashed bananas, Peeled, soft fruit wedges: All fresh fruits, peeled and Fruits . none none bananas, peaches, pears, seeded te. ir....,1 applesauce, strained fruits 1 jar or 1/2 cup per day oranges, apples Canned fruit, packed in water or its own juice

l'IcAll Lean meat, chicken, and fish (strained, chopped, or Small, tender pieces of Protein Try plain yogurt small, tender pieces) meat, fish, or chicken none none foods Can be mixed with soft, Egg yolk Whole egg v...---'*--t s.,I,;) fresh fruit or applesauce Yogurt Cheese Xogurt ,..kY'7.211-',. -J-:.,.. Mild cheese -,-- Cooked, dried beans 82 . Cooked, dried beans Figure 12-2 cont. Some thingsto remember. Every baby is different. Consult your doctor or nutritionist to make sureyour baby is getting what she or he needs.

Do not feel pressured to start- Use a baby-sized spoon to feed solid foods before4 months. .a. your baby small amounts at ,.. eN., ' -1.: el The baby'sAigestivesystem is .... firit. Make the fo-od thin and -f P4" not yet fully ,.....- developed to s ... smooth by mixing it with a digest solid foods. t' 43 N. little formula or breast milk. , e

Al.by's bottle is for water, forviinla, and diluted 100% juice only. Poor eating habits may result A.t.ld one new food ata time. Nursing bottle syndrome frcrit putting food in the Wait about 5 days beforeyou bade. Don't put your baby to >ed try another one. with a bottle bemuse This will give yourbaby Avoid soda (tonic) and fruit it can cause ear infections drinks:Kool-Aid, Hi-C, time to get used tothe new it can hurt their teeth by food. Hawaiian Punch, Zarex, and causing tooth decay If your baby has anallergic Tang. They are full of sugar (cavities) I. reaction, you will know and food coloring. it is a hard habit to break which food causedit.

You do not needto use baby Thebest foods foods. Fresh cookedfoods cost plainfruit plainmeats less and can bebetter for your ,,,,,..:(1: plainvegetables baby. I1 .;-.---. 1 Sugar, bunt:,and salt eggs should notbe added to your fruitjuices baby's food. 35 unsalted1 W% crackers rice Ask your doctor about what noodles,spaghetti type of foodto use for your whole-wheatbread When youstartto offer baby. Foods to avoid milk, hotor cold,unsweetened use wholemilk. mixed dinners If you use baby foods, buy cereals bacon, luncheonmeats, hot Skim or lowfatmilk should plain meats, vegetables, and plainyogurt dogs, h'm not be giventoany child fluits--you'll get more for cottagecheese creamedvegetables younger than --: 2-years-old your money. water fruit desserts because :., ... Combination dinners puddings it does nothave enough I 0- fat contain added water and cookies,candy, cakes for thebrain ci c':- 11 and nervesto starch fillers. sweeteneddrinks grow You can mix meats and (2salllibaie it may nothave enough :. These foodsare highin fat vegetables together if your caloriesforgrowth, Affiliff/%MrAcwww... and sugarand containfew baby prefers them that way. nutrients foryour money.

Adapted from Massachusetts WIC Program, Nutrition Education Task Force, WIC Form #51. Ut 184 Ut 185 least 10 months old. Before then, feedingeggs may promote development of egg allergies, Offer a variety of 100% frin'tjuices-(dilute,by- Mixing 1 part juice with 1 part water). Avoid juice drinks which are mostly water and sugar. Offer fluids from a cup at meals after 6 months. Offer plain water, especially during hot weather. Children need to learn to drinkun- flavored beverages. Beginning cow's milk Provide breast milkor formula, which are particularly nutritious and more digestible, to-infants until they-reach at least 6 months of age. Cow's milk can be introduced between 6. and 12 months, but many pediatricians prefer tozhave infants stay on formula until 12 months of age. Keep the following in mind: Do not serve lowfat or skim milk until 18 to 24 months, since these milk products have too few calories and too much protein for infants. Infants who are fed lowfat or skim milk may notconsume enough calories. Whole milk contains the fat, cho- Addlingerfood.s at-8 to 10 mOnths 'toencourage lesterol, and vitamin E babies need for brain and self-feeding. nerve development. Start feeding solids with a small spoon. Let the baby suck the food off the tip of thespoon. Never Avoiding nursing bottle mouth put solids in a bottlethe baby may consume too Do not allow infants or toddlers to go to bed with many calories and fail to learn to handle solid a bottle or to drink from a bottle lying down. For- foods differently from sucked liquids. mula, milk, juice, and sweetened drinks contain stig- Add finger foods (such as meat and cheese tid- ars,lhat can decay existing or erupting teeth, cre- bits, cooked or soft vegetable strips and fruitsec- atinga condition known as nursing bottle mouth. tion_ r) at 8 to 10 months to encourage self-feeding. This may lead to early loss of teeth, particularly the All foods should be easy for the baby togum. front upper and lower teeth. Asa result, the child Introduce table foods at about 9 months, to sup- may not be able to chew food properly and crowding plement the protein provided by breast milkor may occur in the adult teeth. If an infant wishes to formula: Astable foods are introduced to the intake a bottle to bed, fill it with plain water. Better fant, it is :important that an adult sit with the yet, try to have the child drink the bottle before lying child. down. Children who drink their bottles lying down Use coaled, lean hamburger, chicken,or fish are prone to ear infections. that has been strained, chopped, or cut into small pieces to make.chewing easier. Serve cooked, mashed dried beans or peas,-for Feeding toddlers additional protein. Avoid spoonfuls of peanut butter (spread it on bread or crackers and serve with A toddler's growth rate slows down during the moist food and beverages) and any nuts, carrot, period from 18 months to 3 years. Asa result, a hot clOgs; grapes, raisins, popcorn, corn, and large toddler eats less. Toddlers are demanding anden- 'chunks of any food due to'the pdiential for chok- ergetic by nature. As they,explore and gain control ing. over themselves and their environment, they feel .77Add wheat products,only:after 7 months, since successful and become more independent. They be- wheatis a common causeOf allergies. gin- to take more 'responsibility for what and how 7-Serve no more than two to three eggs:per week much they eat: For example, toddlersmay go on (soft - cooked or scrambled) after )childrenare at food jags where they eat onlY a few foods. SB, Nutrition in programs 157

You and the children's parents are responsible for Basic nutrition facts what children:are offered to eat, as well as where, ;When-, andliciWfand-ii Offered: The toddler is re- Food groups and major nutrients sponsible for how much food she or he eats. Your role-is to help-the child:establish positive attitudes Foods can be divided into groups according to the about eating, and to ensure a nutritionally adequate major nutrients they contain. See Figures 12-2 and diet. You can,help toddlers become independent by 12-3 for detail,; about the five major food groups and encouraging them to select from a variety of accept- the daily minimum servings from each f0,-,d group able foods.-Observe how energetic toddlers are, and needed by preschoolers for proper g 'rid de- -how they grow, play, and eat. Be reassured that velopment. most toddlers are well nourished if a variety of nutritious foods are available: How much is enough? / Snacks When too much food is put on a child's plate, the Snacks are an important part of a well-balanced child feels overwhelmed and may not even try to eat. diet. For preschoolers, snacks are especially impor- A good rule to follow is to offer a child-sized portion tant since their stomachs are small and they usually Consisting of 1/4' to- 1/2 of a usual adult portion, or 1 can't eat enough in three meals to meet energy tbs. per year of age, whichever seems more appro, needs or satisfy appetites. Within 3 hours after a priate. Give less than you think toddlers will eat and meal, young children will usually be hungry. Foods let them ask for seconds. Use the Preschool Feeding eaten at snack time can often provide nutrients Guide (Figure 12-3) to estimate appropriate portion missing from the rest of the day's food. The chal- sizes for toddlers. These are minimum amounts for lenge is to help preschoolers eat nutritious-snacks a nutritionally adequate diet and are not intended to and to do so at appropriate times during the day. limit the amount toddlers are allowed to eat. Good snacks are those that help provide children There will be daily variation in both types of foods with essential. nutrients they may be missing the rest and calories consumed by toddlers. Children 1 to 3 of the day. years of age consume approximately 1000 to 1300 Serve snacks that are nutritious and contain some Calories per day (some days less, some days more). protein, some fat, and some carbohydrate to be On a weekly average, a toddler should be eating satisfying and tasty. A list of nutritious snack ideas, a nutritionallyibalanced diet. is provided in Figure 12-4. Snack times often offeri good opportunities for children to try new foods. The eating environment Avoid such commercial snack- foods as chips, sweet cakes, candies, and fruit drinks. These all have lim- A pleasant, relaxed eating environment helps tod- ited nutritional' value for the calories they contain. dlers,clevelOp positive attitudes about food. Estab- lish regular meal and snack times. Make sure toddlers sit at a comfortable height in relation to the table surface with their feet touching the floor. Use plates and utensils appropriate to children's sizes Appetite ,and Skills. Offer silverware; but don't insist toddlers Preschool children are not growing as fast as they use it. If you allow toddlers to touch, -smell, and did in infancy so their appetites decrease. A small explore food, they are more likely to eat it. Helping appetite may also result if a-child is tired, excited, ill, toddlers develop positive-attitudes about eating is or in strange surroundings. Because no one food much more important than achieving fine-tuned contains all the nutrients our bodies need, serve a table manners. variety of foods such as fruits, vegetables, protein Encourage-toddlers to try new foods, and occa- foods, and unsweetened cereals. Preschoolers gen- sionally praise them for eating well. r on't praise erally enjoy eating the same foods as adults. children for eating large quantities -1:1ccause this in- Preschoolers often have unstable eating habits. terferes with their self-regulation. Serve small por- Childen may be less hungry because they a..e. in a tions,:and.encOurage toddlers to try one'bite. Prior slow growth stage or practicing newly discovered to a meal, ,try to help toddlers relax and settle down. independence. Be aware,,of any change in a child's If chilUren are tired or overstimulated from play, appetite that lasts longer than a few. days and talk to they rhay.not feel:like eating. parents or caregivers to try to find the reason. 181 Figure 12-3. Toddler and preschool feeding guide Major Food group Food sources Minimum number Serving sizes for children nutrients- of servings per day 1 to3years 3to5years

, 3/4 to 1 Cup Milk -Wilk- Whole, lowfat, skim, or Calciuni . and milk products evaporated milk mixed with 3 (20 to 24 oz.) 3/4 or 6 oz. of milk = I oz. of cheese = 3/4 cup Protein water, plain yogurt, cheese plain yogurt Note: Lowfat and skim milk should not be given before 2 years of age.

I oz. meat, fish, or I 1/2 oz. meat, fish, or poultry poultry Meat or meat i., .. Lean meat, fish, poultry, liver, eggs or or ..k..41 Protein alternative ' Dried peas or beans, peanut butter, tofu 2 1/2 cup peas, beans, or a...S. Iron 3/4 cup peas, beans, or tofu ...... a Nuts only for children age 4 years and older tofu or , or 3 tbs. peanut butter 2 tbs. peanut butter I egg = I serving

Carrots, sweet potatoes, greens, winter squash, Vitamin A broccoli, mango, cantaloupe (minimum I serving 2 to 4 tbs. (1/8 to 1/4 cup) per day)

. , ------Vegetables* Oranges, grapefruit, orange juice, grapefruit juice, tangerines, papaya, strawberries, green pepper, and fruits* Vitamin C 4 1/2 cup or I small piece brOccoli, Brussels sprouts (minimum I serving per day) ------L------:.------Potatoes, corn, green beans, peas, lettuce, cabbage, Other vitamins cucumbers, tomatoes, apples, bananas, grapes, 1/4 cup or 1/2 small piece and minerals plums, peaches

Carbohydrate Breads* "III 1/2 slice of bread I slice of bread B Vitamins Whole-wheat or enriched white bread; macaroni 1/4 cup rice, macaroni, l/2cup rice, macaroni, and cereals* 4 t a 4 Iron (if enriched or spaghetti; rice; cold or hot, unsweetened cereals or dry cereal or dry cereal -1111/11Mbt- .. or fortified) I to 2 tbs. hot cereal 3 to 5 tbs. hot cereal 414M11111e1

'Fats,

oils, Margarine, butter, vegetable oils, lard, . and sugar ,imm, Fat mayonnaise, salad dressing, bacon, sausage, salt To be used in limited amounts. These foods are high in calories, sugar, Sugar pork, candy, cookies, chips, Kool-Aid, soda (tonic), fat, arid/or salt. fruit punch

-----__"1"----"

4 (amounts from -WaterINIANA~NANAre- Water Most foods, water as a beverage 4 (amounts from 2 to 4 oz.) 2 to 4 oz.) *Note: Most fruits, vegetables, and whole giain foods are high in fiber.

.) Figure 12-3 cont. Some things to remember. . .

Build good eating habits Vegetables Juices Make sure your-child is Vegetables are important.and.can.be fun to _ Large amounts of sugarcan-decayteeth. sitting-in a comfortable eat. To encouragechildren to eat them Drinks such as Kool-Aid,HawaiianPunch, eatingplace. ..."'. - try themraw. Cut and clean themchildren Hi-C, soft drinks, Zarex,andfruit drinks are It is easier fora child to use can help.Eat them plain or dip them in mainly sugar and water.Somecontain vitamin a plastic cup filled only half yogurt,cottage cheese, or peanut butter. C but they shouldnot replace100% fruit juices way. elm c' 0 ....t.0ofit"it 004.),, Try themcooked. Put them in a stew-soup, that have many othervitaminsand minerals. A small bowl will help the spaghettisauce, or meatloaf. child16 get the food onto a ''',; SW spoon. 00 When shopping, lookfor"100% fruit juice Try one new food at a time. no sugar added" onthe label. Offer it at the beginning of a meal'when the child is -most-hungry; , Offer foods children can eat with fingers, such as pieces of ad, -411( vegetables, fruits, meat, cheese, crackers, or cereal. 4.. Ai Learning to eat takes practice. Be prepared for spills. a14 411)4 mil.rirevitt, _,mirte vaiikarrip tamp . vittr,%

...... ,...... Remember Keep teeth healthy Every child is different! Talk to your doctor Teach children to brush their teeth after ,..,...... or nutritionist to make sure your child is meals and snacks. When brushing is not getting what she or he needs. ., VZ ay, possible, have children rinse their mouths Children need the same good, nutritious 1:10,&-,'" with water. irill : foods as adults, only they don't need as :-.e.y....:404 tt it C'Avoid sticky food such as candy and raisins, / much. especially' between meals. Good eating begins at home. Remember Take children to the dentist between the what you buy is what you eat. 14, ages of 3 and 4 years. If a child has tooth 4011611+ 1,....Lzt 400 decay, GO IMMEDIATELY. i...4, Take children to the dentist every 6 months ='N IN for cleaning, a check-up, and if needed, a I. fluoride treatment. 111

Adapted from Massachusetts WIC Program, Nutrition Education Task Force, WIC Form #47.

190 191 .0 160 :Nutrition .

Figure 12-4. Ideas for nutritious snacks

-Fruits- and - vegetables ,Frozen strawberry-yogurt popsBlend,.1.cupof frozenstrawberries until smooth. Mix the straw- Keep them freshApples, oranges, grapes, cher- berries with 1 cup of plain, lowfat yogtirt and-3 to ries, strawberries, blueberries, bananas, grapes, 5 tbs. of honey. Pour into paper cupi with a Pop, cantaloupe, watermelons, grapefruit,etc. sick stick in the center and freeze 1 to 2 hours until firm. Remove cup-Irom frozen yogurt and Apple sandwichSlice an apple, spread peanut serve. Makes seven pops. butter onto slices, and make a sandwich. Or, add a slice of cheese between the My pop's better than yours - =Mix 2 cups of lowfat, plain yogurt; 1 cup of mashed banana; 1 tsp. Yogthi-stmdaeChildren-can-make-thcir own- ... just of 'Vanilla; and 1/2 cup of-Okopptd-Walriuts"(dp- supply'bowls, plain yogurt, cut up fruit, tional). Pour into six 4 -oil paper cups, insert,Pop- and toppings of chopped nuts, sunflower seeds, sidle sticks in the center, and 'freeze until firm. Wheat germ', or dry cereal. Remove cup from frozen pop and serve. Fruit kabobsSkewer cut up fresh fruit and low- Banana rocketsCoat peeled, ripe bananas With fat cheese cubes, pitted dates, 01 prunes on long orange juice or orange juice concentrate-(to pre:- straws or long toothpicks (for older children). vent discoloration), wrap in foil or plastic wrap, Servelcabobs with a dip made with plain, lowfat atidlreeie. Or, roll chilled, juice-coated bananas yogurt sprinkled with cinnamon or a few drops of in choPped nuts or granola, press firmly tcoat, vanilla flavoring, or well-stirred, mixed fruit yo- and i'reeze until firm. gurt. Fruit juice surprisesDiVide 1 -cup Of cut up Blender snacks fruit pieces (apple, banana, orange, strawberries) into four glasses. Add 3 cups of unsweetened fruit Blender basicsFor a shake, blend 1 cup of juice and chill. plain yogurt, 1 cup of chopped fruit (strawberries, Veggie kabobsSkewer (see notd above) cutup bananas, etc.), and1/2 cup of fruit juice (orange; Pieces of fresh vegetables -such as cherry tom- pineapple, grape). The shakes will be thicker if atoes, zucchini, carrots, cucumbers, green pep- fLo made with frozen fruit. perS, mushrooms, and lowfat cheese cubes. Serve Melon coolerIn blender, mix I -1 12'etiPs of ice with salad dressing or a,dip made with mashed cubes, 11/2 cups of cubed watermelon, honey- beans, yogurt, or cottage cheese and seasoned dew, or cantaloupe, and 1/2 tsp. of lemon juice with herbs. until smooth, Serve immediately. Makes 2 1/2 -Toss a salador invite children to a homemade cups. salad bar. Set out dishes of cut up veggies for Ambrosia shakeIn blender, mix four sliced, children to create their own salads. ripe bananas, 1/2 cup of orange juice, 1/4 tip. of -Celery stuff-itsFill celery with part-skim ri- vanilla, 4 cups of lowfat; or skim, or reconstituted cotta cheese mixed with unsweetened crushed nonfat, thy niilk. Makes six servings. pineapple. Or,,fill celery with peanut butter and Fruit soupIn blender, combine 1/4 cup of or-. add afew raisins (this is called "Ants on a Log"). ange juice, 1/2-of a small-banana, 1/2 of an apple, Lettuce StrollSpread tuna or chicken salad, 1 tsp. of lemon juice, 2 tbs. plain, lowfat Yogurt, peanut butter, or lowfat ricotta cheese on a let- 1/4 cup strawberries, a dash of cinnamon, and a -tuce'leaf, roll it up, and eat. dash of dried- mint. -Chill before serving. Makes three 1/2 cup servings. Freezer delights Homemade convenience snacks Frozen di/desFre-Cie one of-the following in a paper cup with a Popsicle stick: applesauce, Train mix ..-Combine dried fruits and dry cereal crashed pineapplerfruited yogurt (mixed well-or together, and divide into plastic bags or paper 'made With fruit juices). 192cups. Nutrition in programs 161

Figure 12-4 cont. Ideas for nutritious snacks

Cheese popcornMake popcorn and sprinkle NachosCut corn tortillas into six triangles and with grated Parmesan cheese. Add melted butter top v.ith grated mozzarella cheese. Place in oven or margarine if desired. (or toaster oven) at 3500 to crisp the tortillas and Going crackersCrackers and cheese, crackers melt cheese. Serve with salsa. and peanut butter (with or without jelly), crackers Natural soda popCombine half a glass of fruit and dip...just be sure to choose your crackers juice (orange, grape, apple, or pineapple) with carefully. Crackers that are lower in fat and so- half a glass of club soda or Seltzer. Add ice and dium include Melba toast, matzo, rice cakes, enjoy. Wasa, Rye Krisp, bread sticks, unsalted Saltines, Zwieback, and graham crackers. Yummo wrap-upsHave children make their own using flour tortillas spread with peanut butter, dried fruits, and raisinsideal for hikes. 0c, use part-skim ricotta cheese and cinnamon or jam.

Copyright ((' by Barbara Storper, M.S., R.D., Massachusetts Nutrition Resource Center, 150 Tremont Street, Boston, MA 02111. Reprinted with permission.

193 162 Nutrition

Help children develop good food habits by offering a wide variety Of foods. Encourage childrento eat foods from different food groups.

Varietyis essential Food as reward or punishment Adults can help children develop good food habits Sometimes you may be tempted touse food as a and cat the essential nutrients by offeringa wide reward, pacifier, or punishment. Howmany times variety of foods (both different foods and the same have you said, "No dessert untilyou cican your food prepared in different ways, e.g:,raw potato plate," thereby implying dessertsare a better part of sticks, baked potatoes, potato salad). Gradually in- the meal? Children do need positiveencourage- troduce a wide variety of foods to increase food ment, but using food as a reward places undueem- acceptance. Pay attention to what foods children cat phasis on certain foods. Praise,a smile, or a hug and encourage them to cat foods from different food serve just as well. Avoid using food for reasons other groups. than to,satisfy hunger. Make desserts nutritiousso that if only the dessert iseaten, the child will have Food habits are learned good food. Food habits and the ability toeat wisely arc learned! Children are great imitators and often Food safety mimic actions of people around them. New foods Follow these suggestions to avoid food-related will be accepted more readily ifyou follow these problems: guidelines. Do not serve nuts, popcorn, who;.grapes, or Introduce only one new food at a time. chunks of hot dog to children under theage of 4. Serve the new food with familiar foods. If a child chokes while eating, these foodscan be Serve only small amounts of the new food. easily breathed into the lungs. (Hot dogsmay be Introduce new foods only when childrenare served only if sliced lengthwise and thencut into hungry. bite-size pieces.) Talk about the new foodtaste, color,texture. Do not feed honey to infantsyounger than 1 year Let children see you eating and enjoying thenew of age. Honey can cause botulism in infancy. food! Check food and formula labelsto be sure that Ericourage children to taste the new food. If they honey has not been usedas a sweetener. reject it, accept the refusal and try again ina few Be sure that at least one staff member knows weeks. As foods becomemore familiar, they arc how to remove food caught ina child's throat more readily accepted. using a modified,Heimlich maneuver (see the Find out what is not liked about the rejected food. first-aid section, page 97). It -iscommon for Often the food will be accepted if it is prepared in children learning to eat finger foods to choke. a different way. 1 4 Immediate attention is required if the child Nutrition in programs

turns blue or is not making voice sounds. Salt. High-salt diets may lead to the development Be sure all staff arc aware of any children's fond of high blood pressure in.people with a family back- allergies. Be especially alert for foods that may ground of hypertension (high blood pressure). cause allergic reactions that are served atbirthday Salt intake can be reduced by not salting food at parties or other occasions when parents may not the table, decreasing the amount of salt used in be aware of the problem. Staff must also be aware cooking, and limiting salty foods (pickles, canned of emergency steps to be taken should the allergic soups, chips, salty crackers, and salted nuts). Don't child consume the problem food. overlook the hidden sources of salt found in hot dogs, bacon, sausages, condithents, and canned and Activity and physical exercise some frozen foods. Since preference for salty foods is learned, it can be changed. Activity has a lot to do with a child's appetite and nutritional status. Active children need more ca- Vegetariai_ diets. A well-planned vegetarian diet lories than inactive ones; this means that they have a can provide all the nutrients a child needs for better chance of getting all required nutrients. Ade- growth and activity. Vegetarian diets are often high quate physical exercise year around,,preferably on a in fiber and low in cholesterol and saturated fat, and ,daily basis, is important to a child's development they have many positive health benefits. However, because.it because of this there is also the possibility that the stimulates healthy appetites child will not get enough calories. Vegetarian diets uses calories and maintains muscle tissue may include different food restrictions. Figure 12-5 improves coordination describes vegetarian eating patterns. encourages children to express themselves and Vegetarian diets that include dairy products and develop social skills

Common nutritional concerns

Fats. There is growing concern about the role of fat in heart disease and controversy about the kind of fat and amount of cholesterol permissible in chil- dreii's diets. Polyunsaturated and saturated fats are important nutrients to include in the proper ratio. Polyunsaturated fats are the liquid vegetable oils thal contain essential fatty acids that the body cannot manufacture. Saturated fats are the solid fats found in beef, pork, lamb, chicken, and dairy products and are the ones to be limited. Some fat from both sources is necessary to maintain the proper balance of fatty acids in the body. Foods such as hot dogs, luncheon meats, and potato chips are high in saturated fat and salt and should be limited in a child's diet. Sugar. You can easily avoid serving foods high in sugar to children. There is really no reason to swee- ten food. Avoid honey, in any form, in the first year of life since it can cause botulism, a toxic condition for infants. Honey, molasses, raw sugar, and refined sugar all contain the same number of calories. Never add sweetener to vegetables, fruits, fruit juice, or cereal. Avoid serving empty calorie foods such as candy; sweetened beverages; and refined, sweetened baked goods that provide mainly calories and low levels of Early-experiences with food have a strong impel& essential nutrients. on a child's future eating habits and health. X3.5 164 Nutrition

Figure 12-5. Types of vegetarian diets

Foods consumed Beef Fish Milk Eggs Vegetables, fruits, and and and breads, cereals, pork poultry milk products and nuts Diet

Nonvegetarian X X X X X Semi-vegetarian. X X X X Lacto-ovo vegetarian X X X Ovo-vegetarian X X Lacto-vegetarian X X Vegan (total vegetarian) X

Adapted from Ivens & Weil (1984). Nutrition in programs 165 eggs readily provide all the needed nutrients for UnderweightSome children with handi- young children. Vegan or total vegetarian diets that capping conditions are underweight. Nutrition- omit all animal protein can be nutritionally inad- ists can be helpful in determining the causes of equate and may not provide enough protein, ca- underweight and in developing treatment plans. lcium, iron, zinc, vitamin D, and vitamin B'2. These When conventional foods do not meet a child's very strict vegetarian diets may alsa he low in ca- nutritional needs, special dietary supplements lories due to their high bulk and low fat content. In may be used. addition, problems of short stature, underweight, Behavioral problemsOccasionally, children and rickets have occurred in children, on very re- with handicapping conditions develop behavior strictive vegetarian diets. problems associated with eating. Discuss any Legumes, seeds, or nuts, when combined with problems with parents immediately and involve grains, provide a good protein source. But to get appropriate health care providers develop a enough protein, children on vegan or strict veg- workable treatment plan- etarian diets need to eat a larger volume of food Inborn errors of metabolismA child with than children who eat meat, fish, poultry, and phenylketonuria (PKU) or any other inborn error cheese. The number of servings from each food of metabolism needs to be on a carefully con- group will be different for a child eating a vegetarian trolle,1 diet in order to promote normal growth diet, particularly a vegan diet. Parents who wish to and development and ensure intake of adequatt. have their children_follow a vegan diet should be nutrients. For the most part, food for the child's referred to a dietitian or nutritionist to ensure that meals and snacks should be provided by the fam- intake of nutrients and calories is adequate for their ily. Other children should not share their food. child's growth. Other metabolic problemsConditions such as diabetes require only minor changes in the menu. Milk. If children drink too much milk, they may spoil their appetites for other foods and may de- Ask the child's parents or a nutritionist to give you a meal plan to be used as a guide. velop iron deficiency anemia. Offer water if a child is thirsty. If a child doesn't drink enough milk, try not to make an issue of it because this is probably just a Special nutritional problems phase. Left alone, the child will probably go back to drinking milk. A preschool child needs approxi- Early childhood programs must follow orders of mately 16 to 24 oz. (2 to 3 cups) of milk daily. Other parents or the physician in preparing and feeding a foods rich in calcium, such as hard cheese and yo- child's special diet. A nutritionist should be con- gurt, can be substituted for milk (see Figure 12-6). sulted for assistance in menu planning. Obesity Obesity is a complex problem with multiple Special nutritional concerns causes including overeating, poor food choices, inactivity, social or emotional factors, and genetics. ObesityObesity is a common nutritional prob- Obesity should be prevented. Many children who lem with many handicapping conditions. Pre- become obese will remain so throughout life. Ob- vention is especially important since obesity is esity can significantly affect a child psychologically difficult to reverse once it is present. Treatment and emotionally, and can result in low self-esteem. for obesity should include a calorie-controlled Many young children learn eating and at...ivity diet and physical activity. A nutritionist can help patterns that can lead to obesity later in life. Using you plan a reduced-calorie diet. By reinforcing food as a reward or pacifier, fora. feeding, providing appropriate eating behavior through nonfood re- cry large portions, and requiring clean plates may wards, you can help the child learn to control the contribute to obesity. Physical activity is essential to types and quantities of foods consumed. In- maintain a normal weight. Surprisingly, it is often creased physical activity can help use calories, inactivity rather than calbrie intake that causes ob- improve muscle tone, and relieve tension. Par- esity. ents, health care pi oviders, and the child all need The goal of weight management for children is to to be involved. See the next column for further discussion of this topic. 197 166 Nutrition

Figure 12-6. Dietary sources of calcium Excellent

Yogurt, lowfat or whole milk, plain or fruit flavored Skim milk Lowfat milk (1 or 2%) Buttermilk Whole milk Swiss cheese Sardines, canned with bones

Good

Cheeses: cheddar, Muenster, mozzarella, blue, Americanor Swiss pasteurized process cheese food Parmesan cheese, grated Tofu* Dry skim milk, instant Mackerel, canned, solids and liquids Salmon, pink, canned with bones Collard greens, cooked

Fair

Blackstrap molasses Vanilla, soft -serve, frozen dairy products Figs, dried Kale, cooked Mustard greens, cooked Ice cream, vanilla Corn muffins Chickpeas, cooked Broccoli, cooked Cottage cheese, creamed

*Calcium content of tofu differs according to th,.! processingmethod. Tofu contains calcium if it is processed with a calcium coagulant suchas sulfate. Look on the nutrition label or in the ingredient list. Nigari is a popular tofu coagulant that doesnot contain calcium.

198 Nutrition in programs 167 limit weight gain. Children will grow slim- How to manage anemia mer as they grow into their weight. Actual weight Encourage the child to consume a varied, well- loss is not generally recommended as children balanced diet that includes iron-rich foods. need adequate nutrients and calories for growth. Provide increased amounts of iron-rich foods at Lowfat, nutritious meals and snacks are essential to meals and snacks. Good sources of iron include good weight management. liver, dried beans and peas, lentils, beef, pork, lamb, whole wheat and enriched breads, and ce- How to manage/prevent obesity in young chil- real products. Raisins and peanut butter also con- dren tain a small amount of iron. Iron from animal Encourage children to be physically active. sources is absorbed better than iron from plant Limit high calorie foods (foods high in fat, sugar, sources. or both). Serve iron-rich foods with a source of vitamin C. Limit excessive drinking of sweetened beverages Vitamin C increases the body's ability to use iron. such as fruit drinks, powdered or syrup-based The amount of iron absorbed from plant sources drink mixes, and chocolate milk, that can add can be increased significantly when these foods many extra calories each day. A child's thirst can are combined with a food high in vitamin C. For be satisfied with water after the proper amount of example, serve spinach, broccoli, or tomato slices milk has been consumed. with chili; serve half an orange, cantaloupe cubes, Use lowfat or skim milk with children older than 2 or strawberries with split pea soup. These fruits years old. and vegetables provide fiber and vitamin C as well 'Help children learn to deal with emotions or as make the iron in the bean dishes more avail- stress without turning to food. able for use by the body. Remember that your food habits and attitudes Limit milk to 24 oz. per day and assure adequate will influence those of the children around you. intake of other foods, particularly iron-containing foods. Anemia Iron is needed to form hemoglobin, the substance in Failure-to-Thrive blood that carries oxygen from the lungs to the body Some children do not grow properly. They are cells. Without enough iron, our blood cannot carry small or thin for their age; their height may be short the oxygen our bodies need. Lack of iron results in for their age, or their weight may be low for their anemia. An anemic child is likely to appear tired, height. They may tire easily, be inattentive, disin- pale, and inattentive, and to be susceptible to infec- terested in eating, and be undernourished. This tion. complex syndrome known as Failure-to-Thrive Iron deficiency anemia is a common problem for (FTT), may be due to medical, nutritional, or psy- young children, particularly for children from low- chosocial factors. income families. Causes of iron deficiency anemia include How to manage FIT syndrome overconsumption of milk (more than 24 to 32 oz. Refer the child immediately for,a complete medi- per day) resulting in low intake of other foods, cal, nutritional, and social evaluation. particularly, iron-containing foods Consult a nutritionist who can plan a nutrition- too few foods containing iron in the diet ally appropriate diet and support the family, lack of high-iron, high-nutrient foods served for child, and early childhood program during the snacks critical period of weight gain. lead toxicity. Iron deficiency and lead poisoning Be available to assist the family with carrying out frequently occur together. Iron and lead compete the recommended treatment plan. with each other for the same binding sites in the Watch children who fail to thrive closely, even body. Iron deficiency may increase the absorption when the crisis is past. of lead from the intestine and make the toxic effects of lead worse. Therapeutic doses of iron are Food allergies ane. intolerances often required to correct the iron deficiency when Infants and young children sometimes have food accompanied by lead poisoning. allergies or are intolerant of certain foods. An allergic reaction occurs when a child becomes sensitive to a particular food' and the immune system pro- 199 168 Nutrition

duces increased amounts of antibodies. The allergic. crance may suffer from abdominal pain, bloating, reaction can be avoided only by avoiding the food. and diarrhea. Lactose intolerance is very common Foods -that commonly cause allergic reactions are in Africans, Black Americans, Orientals, Jews, nuts, peanuts, eggs, cow's milk protein, wheat, fish, Arabs, and Indians (North and South American). shellfish, and citrus fruits. Mood intolerance means that the child has some How to manage lactose intolerance. Tolerance of lactose varies. Many children can tolerate small metabolic factors (e.g., does not manufacturean enzyme or chemical needed to digest a certain food amounts of lactose (e.g., 8 oz. of milk) if intake of substance) that make it difficult or impossible to these foods is spaced throughout the day. En- digest or use that food. Sometimes, foods can be courage children to try cheese and other fermented modified so that the child can tolerate them. Intol- dairy products, such as yogurt, that have a lower erance to the sugar in cow's milk (lactose) is a com- lactose content and are better tolerated. Lactose- mon problem in infants and children. Soy formulas free, soy-based formulas are available as substitutes are frequently used alternatives to cow's milk or for regular infant formula or cow's milk. regular formula for children with either milk aller- Encourage parents to try hydrolyzed milk (milk in gies or lactose intolerance. which the lactose has been made more digestible by When the allergic child cats a food to which sheor the enzyme lactase). You can buy hydrolyzed milk he is sensitive, symptoms such as diarrhea, vomit- in many stores. Lact-aid, the commercial name for ing, abdominal pain, rash, irritability, breathing the lactase enzyme, is also available separately to be problems, and even death may occur. The relation- added to regular milk for the same effect. See Figure 12-6 for alternative calcium sources. ship between allergies and hyperactivity iscon- troversial. Reactions to food allergies may be im- The diet of a child with a milk allergy or intol- mediate or delayed; symptoms may be mild to erance should be evaluated regularly. Because ca- severe, depending on the type and amount of food lcium requirements are met primarily through eat- eaten and the age of the child. ing dairy products, these children may not get adequate calcium unless other adjustments are How to manage allergies made in their diet. Consult a nutritionist concerning diet planning for the allergic child. Hyperactivity Eliminate or decrease the problem food(s) from Additive-free diets for the treatment of hyper- the diet depending on the severity of the reaction. activity have not been found to be of value. Diets Read labels to identify hidden sources of the problem foods or substances. that eliminate artificial food colorings and sal- Work with parents to find acceptable substitutes icylates (aspirin-like compounds) are not harmful to for problem foods. children and may improve the nutritional value of Plan menus carefully to ensure adequate nutri- the child's diet. However, they have not been shown tion, particularly if a child has multiple food aller- to affect the hyperactivity itself. Any such diet, gies, or if the child is allergic to major food therefore, should be carefully planned along with groups. appropriate medical and psychological treatment. A nutritionist should be consulted to ensure nutri- Make sure the child gets critical nutrients from tional adequacy. other sources: calcium and vitamin D if child is allergic to milk; vitamin C if child is allergic to citrus fruits. Nutrition education Milk allergies Some children are allergic to the milk protein and Childhood is the best time to develop good food are unable to tolerate any milk products including habits, because early experiences with food have a dry milk solids added to margarine, for example. strong impact on a child's future eating habits and health. Poor diet has been associated with the de This allergy is often outgrown between theages of 2 to 5 years. velopment of many of the major chronic diseases in this country: heart disease, stroke, high blood pres- Other children arc unable to digest thesugar in sure, some forms of cancer, diabetes, and tooth de- milk, called lactose, due to a low leVel of theenzyme lactase in the intestine. Children with lactose intol- cay. Nutrition education can significantly enrich the 2 0 Nutrition in programs 169

8 Nutrition education teaches young children how to be selective about food so they can establish proper dietary habits.

lives of children and provide ameans for learning Whatever the disease or disorder, the child's about their life and culture. Children who under- growth and development to her or his full potential stand themselves and their environment developa must be promoted. Good nutrition always con- positive self-image, an essential ingredient for effec- tributes to optimal growth and development and tive learning of any kind. Nutrition education can decrease or prevent the debilitating effects of teaches young children how to be selective about many handicapping conditions. food and combats misinformation from television Use the services of a nutritionist or dietitian to advertising. ensure that families and staff have the knowledge, Dietary, habits are established early in life. The skills, and support to provide optimal nutritional habits children learn during their preschool care to the child with a handicapping condition. If years will significantly affect their future health. necessary, involve occupational and physical ther- apists, social workers, or other health providers to help solve any complex problems. Feeding children who have special Concentrate on creating a pleasant eating envi- needs ronment where all children can learn to eat in a manner appropriate to their developmental levels. It Children with special needs have thesame needs is essential to involve parents in meeting the special as all children for care and feeding. Often these nutritional needs of the child with a handicapping basic needs are overlooked in theconcern for the condition, since the major- part of the child's food child's disability or handicapping condition. Nutri- needs must be met at home. tional problems (such as poor food intake, inability to chew or swallow normally, inadequate weight gain, short stature, obesity, or iron deficiencyane- Dietary, guidelines for all ages mia) and behavioral problems associated witheat- ing frequently constitute a handicapping condi- The U.S. Department of Agriculture and the De- tion that causes a child to be at nutritional risk. partment of Health and Human Services have pub- Infants or children with handicapping conditions lished dietary guidelines intended to promote the may have feeding needs that require more patience, health of all Americans. They form the basis ofany time, and understanding than usual. Special adap- nutrition education activities you conduct for chil- tive equipment may be necessary also. dren, staff, or parents. These guidelines are

(11 170 Nutrition

e Eat a variety of foods. If you drink alcoholic. beverages, do so in mod- maintain desirable weight. eration. Avoid too much fat, saturated fat, and cholesterol. Choose lean meat, fish, poultry, and dried In addition to these guidelines, meet the special beans and peas as protein sources. nutritional needs of infants and toddlers. Use skim or lowfat milk and milk products Encourage breast-feeding unless there are spe- (preschool children and adults only). cial problems. Limit your intake of fat and oils, especially Delay introduction of solids until babiesare 4 to thoselligh in saturated. fat-such as butter, cream, 6 months old. lard, hydrogenated fats (some margarines), short- Do not add salt, fats, or sugar to-children's food. enings, and foods containing palm or coconut oil. Trim fat off meats. Broil, bake, or boil, rather than fry. Weaning Moderate your use of foods that contain fat, such as breaded and fried foods. Weaning is a process of replacing the bottleor Read labels carefully to determine both the breast with a cup. amount and type of fat present in foods. For ex- A cup can be introduced around 8 to 9 months of ample, choose margarines with liquid vegetable age. A cup without a spout top is recommended oils as the first ingredient. because this spout continues to promote sucking ' Eat foods with adequate starch and fiber. fluids. Choose foods that are good sources of fiber and A toddler can be completely weaned from the bot- starch, such as whole grain breads and cereals, tle or breast sometime during the first half of the fruits and vegetables, and dried beans and peas. second year (12 to 18 months of age). Use starchy foods rather than foods that have Weaning can be accomplished by gradually offer- large amounts of fats and sugars. ing more fluids in a cup at mealtimes and be- Avoid too much sugar. tween meals. Useless of all sugars and foods containing large Nap and bedtime bottles and nursings should amounts of sugars, including white sugar, brown gradually be replaced by reading stories, rocking, sugar, raw sugar, honey, and syrups. lullabies, and other soothing and relaxing actions. Read labels for clues of sugar content. If the word sugar, sucrose, glucose, maltose, dextrose, lactose, fructose, or syrup appears first, then there Nutrition education with children is a large amount of sugar. Select fresh fruit or fruit packed in water, its Teaching children to cat wisely and moderately is own juice, or with light rather than heavy syrup. an investment in the future. The foods children cat For good dental health, limit how often you eat influence their growth, development, capacityto sugar and sugar-containing foods. Avoid eating learn, and overall behavior. All children deservean sweets between meals. equal opportunity to learn about foods, to explore Avoid too much sodium (salt). different foods, and to learn why eatinga varied, Cook without salt or with only small amounts nutritionally adequate diet is necessary to reach of added salt. one's growth potential. Social, economic, cultural, Try flavoring foods with herbs, spices, and and psychological factors play an important role in lemon juice. determining what and how much we cat. Successful Add little or no salt to food at the table. nutrition education helps children develop flexible, Limit use of salty foods such as potato chips, enjoyable, healthy eating habits. pretzels, salted nuts and popcorn, condiments Figure 12-7 identifies ideas for nutrition educa- (soy sauce, steak sauce, garlic salt), pickled foods, tion activities that will foster the development of cured meats, some cheeses, and some canned positive eating practices and enhance a child'semo- vegetables and soups. tional and psychological growth. These learningex- Read food labels carefully to determine the periences can be easil; integrated int) dailyrou- amounts of sodium (salt). tines. For example, eating together at meal and Use lower sodium products, when available, to snack time or during special occasions isan oppor- replace those you use that have a higher sodium tunity for children to socialize. Visits to local farms, content. and farmers' markets will put children in touch with 202 Nutrition in programs 171

Figure 12-7. Ideas for nutrition education

Developmental areas Knowledge /skills used Activity Good self-image Develop skills to choose widely Have childen plan, prepare, and serve simple nutritional- snacks. For example, have children prepare, "Ants on a Log = celery stuffed IA ith peanut butter and topped with rasins. Appreciation of health Gain knowledge of how food Ask children to discuss what foods promotes growth and develop- help their teeth grow and stay ment healthy. Enjoyment of food through all the Experience various foods through Have children try to identify a ba- senses sight, sound, smell, feel, and taste nana using one sense (sound, smell, feel, touch) at a time and check their answers througirsight. Appreciation of ethnic back- Share cultural background Choose the cultural heritage of one ground or more children as a theme for a day's meals and snacks. Discuss at mealtimes how factors such as climate help shape food habits. Self-expression Foster creativity Have children try various whole grain breads by first baking the bread and then tasting it. En- courage children to shape the dough in different ways.

See Wanamaker, Hearn, & Richarz (1979) for many more ideas.

203 local surroundings and create an awareness of how grams, Food Stamps, WIC (Supplemental Food food is grown and sold in places other than a su- Program for Worsen, Infants and Clinch-en); and permarket. emergency feeding agencies. The cultural and ethnic customs of our society influence the food we eat. Cultural heritage often determines whether a particular food will be eaten, Community nutrition resources regardless of its nutritional value. A wide variety of cultures and food habits can make eating interesting A resource list of community nutrition programs, and fun. loe-nutritionists with whom you can consult, and emergency fond agencies will help you make appro- Involve parents priate referrals when necessary. Your program can't-be theonlyadvocate a good nutrition; parent involvement, is essential. The com- Child Care Food Program (CCFP) bination of foods eaten both places should provide The Child Care Food Program (CCFP) is a feder- all the necessary nutrients for a child. Parents and ally sponsored program that helps provide nutri- teachers need to educate themselves about the types tious meals to children enrolled in child care centers and amounts of food necessary for good nutrition. c.family child care r9grams throughout the coun- 'Suggestions to involve parents: try. It also introduc , young children to many dif- Ask parents to assist in planning menus. If par- ferent types of foods and helps teach them good ents are interested, provide an educational meet- eating,habits.itisfunded by the-U.S.-Department of ing on the princir,es of good nutrition involved in Agriculture and (in most states) is administered by menu planning for young children. the U.S. Department of Education as an adjunct to Include articles in your newsletter about your nu- the School Lunch Program. trition education activitics. Ask parents,for ideas for future programs, and invite parents to par- Who can participate?The program is limited to ticipate in classroom activities. Ask parents to public and private nonprofit organizations pro:. 0. contribute articles to the newsletter about nutri- iding licensed or approved nonresidential child tion activities with their children at home. care services. Private, for- prcAit programs may qual- Send menus home with children to show parents ify if they receive compensation under Title XX of what meals and snacks arc planned. Offer parents the Social Security Act for at least 25% of the chil- new ideas for providing nutritious foods at home. dren svho are receiving nonresidential care. Ask parents to Sham creative meal and snack Child care and after-school programs can operate ideas with each other. Have a contest for the best in the program either independently or through a idea. sponsoring organization that accepts final admini:- In9e parents to visit and participate with their tmtis e and financial responsibility for the program; children,at a pot luck dinner with a special ethnic Home-based child care programs must participate food unique to their culture. uncle; a sponsoring organization; they cannot enter Talk with parents about any eating or nutritional the CCFP directly. problems you notice. Make appropriate referrals Children 12 and younger are eligible to participate and provide regular progress reports. in the program. For children of migrant workers, Sponsor educational programs for parents on nu- the age limit is 15 years. Physically or mentally trition and consumer issues. Help parents under- -handicapped people are eligible regardless of age, if stand how they can encourage positive eating they receive care at a center or home where the habits at home. Use the dietary guidelines (p. 154 majority of he enrollees are 18 or younger. arid p. 158) as a starting point. Remind parents about ways to involve their child Eligibility requirements. Allprivate institutions with foodin the home, such as (except for-profit Title XX organizations) must have Allow yourchild to help prepare food. tax-exempt status under the Internal Revenue Code Let the child sharcin clean-up activities. of 1954, or must have applied to-the Internal Rev- --Encourage your child to talk with you about enue Service (IRS) for it at the-time they apply for food. the Child Care Food Program. If an institution takes Make available a list of 'community food and nu- part in other federal programs for which it needs trition services including school feeding pro- nonprofit status, it already meets this requirement. .2 0 4 Nutrition in programs 173

Home-based child care programs are not required the program. Separate administrative funds arc to be tax exempt but their sponsoring organizations provided to sponsoring organizations based on the must have tax-exempt status if they arc private. number of homes they administer. Local IRS offices can provide information on how to obtain tax-exempt status. All institutions, except Civil rights. The CCFP is available to all eligible sponsoring organizations, must have child care li- children regardless of race, color, national origin, censing or approval. sex, age, or handicap. If you believe you have been treated unfairly in receiving food services for any of Meal sek vice. All participating institutions must these reasons, write immediately to the Secretary of serve means that meet U.S. Department of Agricul- Agriculture, Washington, DC 20250. More infor- ture nutritional standards. Institutions may receive mation may be obtained from the Office of Equal payment for up to three meals per child per day; one Opportunity, U.S. Department of Agriculture, Wash- of these meals must be a snack. ington, DC 20250. Avail, ble assistance. Generally, payments to Additional information. To obtain information programs are limited to the number of meals served about CCFP in your area, write or call Director, to enrolled children multiplied by the appropriate Child Nutrition Division, Food and Nutrition Ser- rates for reimbursement. The rate of payment varies vices, U.S. Department of Agriculture, 3101 Park according to the family size and income of children Center Drive, Alexandria, VA 22302. 703-756-3590. participating in the program. Increased payment is provided for low-income children. Some state ad- Food Distribution Program ministering agencies may base payment on the max- Through the Food Distribution Program, the imum rates or actual costs, whichever is less. USDA purchases surplus foods from U.S. markets Meals served by home-based child care providers and distributes them to state agencies for use by under CCFP are paid for at different rates for each type of meal served that meets program require- eligible local agencies. The foods go to schools and institutions participating in the child nutrition pro- ments. The sponsoring organization must pass the grams (school lunch, school breakfast, summer full food service payment to the home, unless the feeding, and after-school programs), to nutrition sponsoring organization provides part of the home's programs for the elderly, to low-income families on food service. Providers receive payment for meals Indian reservations, and to hospitals and prisons. served to their own children only when (1) theft Licensed child care programs arc eligible to par- children meet the family size and income standards ticipate in the food distribution program. Programs for free and reduced-price meals, and are par- already enrolled in the CCFP automatically receive ticipating in the CCFP, and (2) other nonresident an application for the Food Distribution Program. If enrolled children are present and participating hi their applications are approved, they can elect to receive commodities or cash.

Operating a food service program for young children involves menu planning, food purchase and preparation, food service, and a number of issues related to environmental health, sanitation, and infectious disease control. 174 Nutrition

Food Stamp Program nutritionist visit homes to provide education on The Food Stamp Program helps low-income general and specific nutrition problems. The aides households purchase the foods they need for good teach food budgeting, purchasing, and preparation. health. Participating families get coupons, free of charge, that they exchange for food at authorized stores. People can apply for Food Stamps at their. Running a food service local Food stamp office. Operation of a food service program for young WIC children 'involves menu planning, food purchase and preparation, food service, and a number of The Special Supplemental Food Program for issues related to environmental health, sanitation, Women, Infants and Children is commonly known and infectious disease control. See Chapters 3, 4, as WIC. WIC is a federally funded food and nutrition and 17 for further information and guidelines. education program for pregnant, postpartum, and breast-feeding women; infants; and children Menu planning younger than age 5 who are low into= and at nutritional risk. WIC is operated by local health clinics Plan your menus,around the nutritional and de- and other authorized community agencies. velopmental needs of young children using the meal NutritiOnists counsel WIC participants concern- pattern developed by the USDA Child Care Food ing-specific dietary needs, eating ,patterns, and use Program (CCFP) as a minimum standard (see Fig- of WIC foods (milk, cheese, eggs, 100% fruit juice, ure 12-8). Figure 12-9 provides three sample weekly iron-fortified cereals, peanut butter, dried peas'and menus and shows -how the pattern translates into beans, infant formula, and infant cereal). WIC's goal meals and snacks. If you can not represent all the is to promote changes in eating, food preparation, food groups at one meal, serve the missing one at and shopping habits that will positively affect snack time. :health. Prepare written menus weekly and post them for WIC programs provide supplemental foods in one staff and parents. Provide nutritious snacks mid- of three ways: they obtain, foods from local firms morning or mid - afternoon for children who attend and distribute them directly; they arrange for home less than 4 hours. When children stay for 4 hours or delivery; or they give mothers vouchers to exchange longer, either the program or the parents must pro- for specified items at authorized grocery stores. vide meals in addition to snacks. Use a menu- planning worksheet to ensure consistency in each Nutrition Education and Training Program day's menu (Figure 12-10). (NETP) Provide children with nutritious foods they like and can eat easily. Fibrous foods arc difficult for Federal Nutrition Education and Training Pro- young children to eat. Preschoolers usually do not gram (NETP) funds are granted to states for the like food that is very hot or very cold. Cut foods into dissemination of nutrition information to children, bite-size pieces. Serve a variety of finger foods or and for in-service training of teachers and food ser- foods that can be easily picked up. In cooking, try to vice personnel. The program is for all children in preserve natural colors and textures so food looks public and private schools and in residential and appealing. nonresidential child care. Consider setting up a menu planning committee to Child care programs can apply to the NETP for involve interested people in developing your menu. small grants to start nutrition education programs. This committee might consist of a program director, Copies of previously funded nutrition projects arc a teacher or teacher's assistant, a cook, a parent(s), also available for loan. and a nutritionist. If you use cycle menus, you may only have to meet once a month or every 6 weeks. Expanded Food and Nutrition Education Here are some other factors to consider as you Program (EFNEP) plan menus: EFNEP serves loW-income families with (idren. InventoryKeep an inventory of the foods on It is regE.rded by many as the nutrition caucation hand to help you determine future menus and component of the'Food Stamp Program. Nutrition how much of a particular food you need to order aides under the direction of a registered dietitian or during a menu cycle.

206 Nutrition in 0 grams 175

Figure 12-8. Child Care Food Program: Mealpattern requirements

Children Breakfast Children Children 6 through 1 and 2 years 3 through 5 years 12 years

Milk, fluid 1/2 cup 3/4 cup 1 cup Juice or fruit or 1/4 cup 1/2 cup 1/2 cup vegetable

Bread (enriched or whole 1/2 slice 1/2 slice 1 slice grain) and/or cereal: cold, dry or 1/4 cup 1/3 cup 3/4 cup*" hot, cooked 1/4 cup 1/4 cup 1/2 cup

Midmorning or midafternoon snack (supplement) (select 2 of these 4 components)

Milk, fluid 1/2 cup 1/2 cup 1 cup Meat or meat alternate 1/2 oz. 1/2 oz. 1 oz. Juice or fruit or vegetable 1/2 cup 1/2 cup 3/4 cup Bread, (enriched or whole 1/2 slice 1/2 slice 1 slice grain) and/or cereal: cold, dry or 1/4 cup* 1/3 cup** 3/4- cup*** hot, cooked 1/4 cup 1/4 cup 1/2 cup

Lunch or supper

Milk, fluid 1/2 cup 3/4 cup 1 cup Meat or meat alternate I oz. 1 1/2 oz. 2 oz. Meat, poultry, or fish, cooked (lean meat without bone) Cheese 1 oz. 1 1/2 oz. 2 oz. 1 Egg 1 1 Cooked, dried beans or peas 1/4 cup 3/8 cup 1/2 cup Peanut butter 2 tbs. 3 tbs. 4 tbs. Vegetable and/or fruit 1/4 cup 1/2 cup 3/4 cup (2 or more)

Bread or bread alternate, 1/2 slice 1/2 slice 1 slice enriched or whole grain

*1/4 rup (volume) or 1/3oz. (weight) whichever is less "1/3 cup (volume) or 1/2 oz. (weight) whichever is less ***3/4 cup (volume) or 1 oz. (weight) whichever is less 207 Figure 12-9. Sample weekly menus

Week one

Pattern 1st day 2nd day 3rd day 4th day 5th day Breakfast

Juice or fruit or Orange juice-1/2 cup 1/2 banana sliced Apricot halves-1/2 cupFruit cup-1/2 cup Grapefruit sections vegetable 1/2 cup

Cereal, bread, or breadBiscuit ! Cornflakes-1/3 cup Blueberry muffin Toast-1/2 slice Rolled oats-1/4 cup alternate 1/2 muffin

Milk Milk-3/4 cup Milk-3/4 cup Milk-3/4 cup Milk-3/4 cup Milk-3/4 cup

Other foods Baked, scrambled Hard-cooked egg egg-2 tbs. 1/2 egg

Morning snack (Select two of these four components)

Milk Milk I /2 cup Milk-1/2 cup

Meat ormeat alternate Cheese wedge-1/2 oz. Peanut butter Fruit, vegetable,or juice Fruit or vegetable Orange juice-1/2 cup Grape juice-1/2 cup juice-1/2 cup Bread or bread Toast-1/2 slice Dry cereal-1/3 cup Toasted raisin breadEnriched soda alternate sprinkled with 1/2 slice crackers-2 (including cereal) cinnamon

tip,k.,4-, Figure 12-9 cont. Sample weeklymenus

Pattern 1st day 2nd day 3rd day 4th day 5th day Lunch or supper

Meat or meat alternate Meat loaf-1 slice Baked chicken Chicken vegetable Spaghetti and meat Fish sticks-3 (1 1/2 oz. meat) (I 1/2 oz. meat) soup-1/2 cup sauce-1/2 cup (1 1/2 oz. fish) (I oz. meat, (1 1/2 oz. meat) 1/4 cup vegetable)

Vegetables and fruits Green beans-1/4 cup Mashed potatoes Green pepper stick Peas-1/4 cup Green beans I /4 cup (two or more) 1/4 cup Pineapple cubes Sliced peaches Green salad-1/4 cup Fresh pear half- 1/4 cup Peas-1/4 cup 1/4 cup 1/4 cup Carrot stick

Bread or bread Bread-1/2 slice Rollsmall Peanut butter and French bread-1/2 sliceCorn bread-1 square alternate jelly sandv.ich-1/4 (I tbs. peanut butter)

Milk Milk-3/4 cup Milk-3/4 cup Milk-3/4 cup Milk-3/4 cup Milk-3/4 cup

Afternoon snack (Select two of these four components)

Milk Milk-1/2 cup Milk-1/2 cup

Meat or meat alternate Cottage cheese dip-1/4 cup with zucchini sticks Fruit, vegetable, or Mixed fruit juice I/2 Apple juice I /2 cup Turnip stick juice cup Celery sticks with peanut butter- 1 tbs.

Bread or bread Oatmeal cookie-1 Soft pretzel-1 Peanut butter cookie Melba toast-3 alternate (including cereal)

210 21.1 Figure 12-9 cont. Sample weekly menus

Week two

Pattern 1st day 2nd day 3rd day 4th day 5th day

Breakfast

Juice, fruit, or Small bananaI/2 Apple juice (fortified Orange juiceI/2 cup Tangerine sections-3 Orange juiceI/2 cup vegetable with vitamin C)I/2 (remove seeds) cup

Cereal, bread, or Unsweetened iron- ToastI/2 slice with Corn muffinI/2 to I Raisin toastI/2 to I French toast with bread alternate fortified cerealI/2 margarine-1 tsp., jelly muffin slice cinnamonI/2 to I cup slice

Milk Milk -3/4 cup Milk-3/4 cup Milk-3/4 cup Milk-3/4 cup Milk-3/4 cup

Other foods Scrambled eggI MargarineI tsp. Cottage cheeseI/4 cupMargarineI tsp. MargarineI tsp. Maple syrupI tsp.

Morning snack (Select two of these four components)

Milk MilkI/2 cup Milk--I/2 cup MilkI/2 cup MilkI/2 cup MilkI/2 cup

Meat or meat alternate Peanut butter-2 tsp. Peanut butter-2 tsp. Cheese slices-2

Fruit, vegetable, Small bananaI/2 or juice

Bread or bread Graham crackers-2 Unsweetened iron- Rye wafers-2 or 3 Wheat crackers-2 Cereal, iron- alternate (including fortified cerealI/3 fortifiedI/3 to 1/2 to 1/2 cup cup cereal)

21.3 212 Figure 12-9 cont. Sample weekly menus

Pattern 1st day 2nd day 3rd day 4th day 5th day Lunch or supper

Meat or meat alternate Tuna sandwich (1/2 cupMacaroni and American chop Meatball subI 1/2 ox. Homemade turkey .tt.na with 'Asp. cir:ex-113 to 1/2 cup sueyI/2 cup with cheeseI/8 cup soupI/2 cup mayonnaise, 1/2 to 1 slice bread)

Vegetables and fruits 2 fruit slices (pear, Tomato Wedges-2 to 3Vegetable sticksI/4 Tossed saladI/4 cup (two or more) apple, or orange) cup RaisinsI tbs. Fruit cupI/4 cup Sliced peachesI/4 cup Bread or bread Pumpernickel alternate breadI/2 slice

Milk Milk-3/4 cup Milk-3/4 cup Milk-3/4 cup Milk-3/4 cup Milk-314 cup

Other foods Apple crisp with cheeseI/2 cup Afternoon snack (Select two of these four components)

Milk MilkI/2 cup Milk-1/2 cup MilkI/2 cup

Meat or meat alternatePlain yogurtI/2 cup Peanut butter and Vanilla yogurt-1/2 cup mixed with small banana sandwich bananaI/2 mashed

Fruit, vegetable, or Orange juiceI/3 to 1/2 Small bananaI/2 Grape juiceI/4 to 1/2 juice cup sliced cup

Bread or bread Unsweetened iron- Bran toastie l/2 Small oatmeal alternate (including fortified cereal I/:2 cookies-2 cereal) to 1/2 cup

214 21.5 Figure 12-9 cont. Sample weeklymenus

Week three

Pattern 1st day 2nd day 3rd day 4th day 5th day Breakfast Juice, fruit, or Pineapple juiceI/2 Citrus fruit cupI/2 FruitI/2 cup Orange sectionsI/2 Fresh berries (in vegetable cup cup cup season)I/4 cup

Cereal, bread, or Oatmeal with English muffinI/2 Bran muffinI/2 to I Unsweetened, iron- bread alternate raisinsI/2 cup to 1 fortified cerealI/2 cup Milk Milk-3/4 cup Milk-3/4 cup Milk-3/4 cop Milk-3/4 cup Milk-3/4 cup

Other foods Poached eggI Cheest: cubesI oz. Peanut butter-1 tsp,

Morning snack (Select two of these four components)

Milk Milk-1/2 cup MilkI/2 cup MilkI/2 cup

Meat or meat alternate Plain yogurt-1/2 cup, with 1/4 cup CheeseI slice applesauce Fruit, vegetable, or Fruit juice-1/2 cup juice

Bread or bread Bagel-1/2 with peanut Crackers-2 to 4 Oatmeal cookieI alternate (including butterI tbs. BreadI/2 slice cereal) Margarine-1 tsp.

21.6 217 Figure 12-9 cont. Sample weekly menus

Pattern 1st day 2nd day 3rd day 4th day 5th day Lunch or supper

Meat or meat alternate Chili con carne-1/4 toChicken rice soupI/2Tuna noodle Beef stewI/2 cup Turkey sandwich (I oz. 1/2 cup cup casserole -1/2 cup turkey, 1 tsp. mayonnaise, 1/2 to 1 slice bread)

Vegetables and fruits Assorted vegetable Green beans -1/4 cup Fresh garden Sweet red or green slices-1/2 cup vegetable-1/2 cup (two or more) Carrot sticks-1/4 cup pepper slices-2 Orange wedges -1/4 cup Fruit cup -1/4 cup

Bread or bread Bread-1/2 to I slice Whole-wheat Graham crackers-2 alternate bread -1/2 slice

Milk Milk-3/4 cup Milk-3/4 cup Milk-314 cup Milk-3/4 cup Milk-3/4 cup

Other foods Pudding -1/2 cup Cheese sandwich-1/2 Ice cream-1/4 cup Margarine-1 tsp.

Afternoon snack (Select two of these four components)

Milk Milk-1/2 cup

Meat or meat alternate Cheese toast (melt on 1/2 slice bread)

,Fruit, vegetable. or Orange juice-1/2 cup Fresh fruit-1/2 Chilled juice-1/2 cup Orange juice-1/2 cup juice.juice

Bread or bread Buttered raisin Banana bread-1 slice Crackers and cheese-2Rice pudding-1/3 cup alternate (including breadI/2 slice to 4 cereal) 218 219 00 Figure 12-10. Menu planning worksheet tJ USDA Child Care Food Program Monday Tuesday Wednesday Thursday Friday snack and meal pattern Breakfast- Milk Fruit and/or vegetable Bread or cereal

= Morning snack (serve any two of the following foods) Milk Fruit and/or vegetable Bread or bread alternate Meat or meat alternate

Lunch or supper (serve one) Meat or meat alternate Vegetable and/or fruits (serve two or more) Bread or bread alternate Milk Other foods

Afternoon snack (serve any two of the following foods) g m. Fruit and/or vegetable Bread or bread alternate Meat or meat alternate Ad 4. 220 Nutrition in programs 183

BudgetRecognize that the budget is an impor- and refrigerator walls. This will help maintain tant factor in planning a menu. If your program is proper food temperatures. not being reimbursed by the Child Care Food Always examine food when it arrives to makesure Program for meals served, your food costs will be it is not spoiled, dirty, or infested with insects. a-large pan of yourimulget. Consider shopping at Store unrefrigerated foods in clean, rodent- and food cooperatives or food banks. insect-proof, covered metal, glass, or hard plastic EquipmentConiider the availability andcapac- containers. (Large shortening cans available from ity of equipment when planning menus. Ask the bakeries are ideal for storing flour and other following questions: Is the oven large enough to commodities.) accommodate the amount of food to be baked? Is Store containers of food above the floor (about there enough room in the refrigerator to store 6") on racks or other clean slotted surfaces that foods? permit air circulation. Storage spaceCheck the availability of storage Keep storerooms dry and free from leaky plumb- space before you plan the menu. Is there enough ing or drainage problems. Repair all holes and dry storage space for the number of cases of dry cracks in storerooms to prevent insect and rodent goods you'll need to order? infestation. Cultural diversityServe foods that represent dif- Keep storerooms cool (about 60° F.) to increase feient cultural food patterns and are familiar to the food's shelf life. children as .a natural- way to establish rapport Store all food items separately from non-food with the children and then' families. This practice items. will also educate children about various cultures Use an inventory system: The first food stored is and their food preferences. the first food used. This will ensure that stored SeasonSome foods, particularly fruits and vege- food is rotated. tables, are more available during various times of the year. Plan your menus to include the fruits Preparing and handling infant formula and and vegetables that are in season. They aremore foods sent from home. Always washyour hands economical and taste better. and utensils before handling breast milk, infant formulas, and foods. Be sure to follow directionson Guide for food preparation and service the packages regarding shelf life and preparation. Breast milkAny breast milk sent from home These procedures for food preparation and ser- should be in the infant's bottle with the child's vice can be used by cooks and others involved with name and the date. Do not store defrosted breast food service. milk for longer than 24 hours. Do not refreeze FOod purchasing previously frozen breast milk. Be sure that Suppliers of food and beveragesmeet Coi-mxiiiraied infant "formuiaThis-shouicrbe local, state, and federal codes. sent from the child's home in its original, factory- 'Be sure that the meats and poultryyou purchase sealed container and reconstituted according to package directions. Refrigerate unused portions have been. inspected and passed for whole- someness by federal or state inspectors. immediaf 'v. Never reuse a bottle of milk that has Use only pasteurized milk and milk products. If been warmed-and/or used to feed an infant. you use dry milk, prepare it in a sanitized con- Ready-to-feed infant formulaThis can be served tainer and refrigerate or use it immediately. as is, unless parents proviee instructions for spe- Do not use home-canned foods. cial formula preparation. Accept only factory- sealed containers. Food storage Powdered formulaReconstitute as directedon ..Store all perishable foods at temperatures that the container. will prevent spoilage (refrigerator temperature, Junior foodsServe commercially prepared jun- 45° F. or lower; freezer temperature, 0° F.or ior foods from a serving dish, not the food jar. lower). Cover, date, and refrigerate open jars of junior Place thermometers in the warmest part of the foods and use the contents within 48 hours. refrigerator and freezer (near the door) and check them daily. Food preparation and handling Set up refrigerators so that there is enough shelf Wash a1 raw fruits and vegetables before-use. space to allow for air ,circulation around shelves Wash tops of cans before opening. 222 184 Nutrition

Thaw frozen foods in the refrigerator or put Storage of non-food 'upplies quick-thaw foods in plastic bags under cold run- Store all cleaning st., plies (including dish sani- ning water for immediate preparation. DO NOT tizers) and other po )nous materials in locked thaw frozen foods by allowing them to stand at compartments or inJmpartments well above the ,roomdemperature. reach of_children and separate from food, dishes, Use a thermometer to check internal tempera- and utensils. tures of, the following foods to be sure they have Store poisonous and toxic materials, other than been cooked evenly: those needed for kitchen sanitation, in locked Poultryheat to a minimum temperature of compartments outside the kitchen area. 165° F. Store insect and rodent poisons in locked com- Stuffingheat to a minimum temperature of partments in an area apart from other cleaning 165° F. in a separate pan. (Do not cook stuffing materials to avoid contamination or mistaken us- inside poultry.) age. Pork and pork productsminimum of 160° F. Bait put into food storage areas should be boxed Prepare these potentially hazardous foods as and separated to prevent a possible con- quickly as possible from chilled products, serve tamination of food supplies. immediately, and refrigerate leftovers immedi- Clearly label all containers of poisonous material ately. as poison and include information on appropriate meat salads, poultry salads, egg salads, seafood antidotes. salads, and potato salads cream-filled pastries Cleaning and care of equipment other prepared foods containing milk, meat, Cracked or chipped dishes or utensils may harbor poultry, fish, and/or eggs bacteria. Throw them away. Avoid utensils with Prevent the growth of bacteria by maintaining all chipped or painted handles. potentially hazardous foods at temperatures Wash dishes using an approved method (see lower than 45° F. or higher than 140° F. during Chapter 4, p. 38 to 39). transportation and while holding until service. Wash equipment frequently Bacteria multiply most rapidly between 45° and Clean range tops during food preparation as 140° F. needed and on a daily basis. Cover or completely wrap foods during trans- Clean ovens and overhead hoods at least portation. weekly. Never reuse a spoon that has been used even once Wash the inside and outside of refrigerators for tasting. weekly with the bleach solution; defrost when ice Make sure that each serving bowl has a spoon or is 1/4" thick. -pthPr ePrt.ling-frInd. Wash tables with the bleach solution before and Reserve food for second serving times at safe after each meal. -temperatures in the kitchen. Set up a cleaning schedule to prevent con- , Leftover food from serving bowls on the table tamination of food as follows: must be thrown away with these possible excep- Wet mop floors daily; scrub as needed. -dons Wash and sanitize food preparation surfaces raw fruits and vegetables that can be thor- between preparation of different food items (e.g., oughly washed meat and salad) and between different meats packaged foods that do not spoil (e.g., pork and chicken). Place foods to be stored for reuse in shallow pans Wash and thoroughly sanitize cutting boards and refrigerate or freeze immediately to rapidly after cutting any single meat, fish, or poultry item. bring-temperature to 45° F. or lower. (Use only hard, nontoxic, non-wood boards that Leftovers or prepared casseroles held in the re- are free of cracks, crevices, and open seams.) frigerator must be discarded after 2 days. Wash and sanitize can openers daily. Leftover foods should not be sent home with chil- Clean and sanitize utensils between use on dif- dren or adults because of the hazards of bacterial ferent food items. growth during transport. Special notes Keep lunches brought from home in the refrigera- Air dry all food contact surfaces after clean- tor until lunch time. sing and sanitizing. Do not use wiping cloths.

n 11 et 4,4"; Nutrition in programs 185

Make sure no food contact surfaces are made of labels. Do not allow insecticides to come in con- cadmium, lead, zinc, granite enamelware, or tact with raw ,or cooked food, utensils, or equip- other toxic materials. ment used in food preparation and serving, or Do not use cyanide to polish or clean silver. with any other food contact surface. Do not use Be sure there are sufficient: garbage- cans to insect strips that hangfrom the ceiling. hold all garbage. These cans should have tight- Insecticides for crawling insects should -be ap- fitting lids and be leakproof. Line garbage cans plied only by certified insect control personnel. A with plastic linets; empty and clean the cans fre- staff member should monitor where the insec- quently. Keep the garbage area clean at all times. ticides are applied to be certain that food prepara- Insect and rodent control tion surfaces or child contact areas are not con- For flying insects, use only approved pyrethrin- taminated. based insecticides or a fly swatter in the food Be sure all doors and windows have screens in preparation areas. Use products in accordance good condition. Keep screens closed at all times. with directions and cautions appearing on their Close all openings to the outside to prevent ro- dents and insects from entering.

224 186 Nutrition

Bibliography

0 Goodwin, M.T., & Pollen, G. (1980). Creative food Service. (1985). A planning guide for food service experiences for children. Washington, DC; Center in child care centers. (FHS Publication No. 64). for Science-in the Public Interest. Washington, DC: U.S. Government Printing Of- .Howard,,R.B.,, & Herbold, N.H. (1982). Nutrition in fice. clinical care. (2nd ed.): New York: McGrawHill. U.S. Department of Agriculture, & 11.5. Department Howard, R.B., & Winter, H.S. (1984). Nutrition and of Health and Human Services. (1985). Nutrition feeding of infants and toddlers. Boston: Little, and your health: Dietary guidelines for Ameri- Brown. cans. (2nd ed.). (Home and Garden Bulletin No. Ivens, B.J., & Weil, W.B. (1984). Teddy bears and 232). Washington, DC: U.S. Government Printing bean, sproutsThe infant and vegetarian nutri- Office. tion. Fremont, MI: Gerber Products. Vermont Department of Health, Nutrition Services. Satter, F. (1983). Child of mineFeeding with love (1979). Guidelines for feeding infants andyoung and good sense. Palo Alto, CA: Bull Publishing. children. Burlington, VT: Author. State of Washington,. Department of Social and Wanamaker, N., Hear., K, & Richarz, S. (1979). Health Services, Nutrition Education Training More than graham crackers: Nutrition education Program. (1981). Food for the preschooler. Vol- and food preparation with yciung children. Wash- umes I, II, III. Olympia, WA: Author. ington, DC: National Association for the Educa- U.S. Department of Agriculture, Food and Nutrition tion of Young Children. Section F Special health issues

Major concepts

rChildren with special health conditions do best when their needsare met by health and mental health professionals and specialists,program staff, and parents working together as aleam. Most children with mild and moderate special health needscan be served in mainstreamed group programs whenproper prior planning has been done by the team. Staff; along, with other members of the team induding parents, needto observe these,.children carefully for signs and symptoms of special healthneeds. A wide-variety-otcommunity.res.ources at.the.state,..regional,and.local levels -are available to assistprograms and faMilies. Some- conditions, such as lead priisoning and abuse and neglect,are preventable. Other conditions, such as chrolik health problemsor physical disabilities, are not Preventable. All these special health issues require appropriate intervention,regular -monitoring_ t-and daily care. Whenever possible, children with special health needs should not be exdudedfrom activities. Rather, give these children extra help, changeyour expectations, or modify "the materialsor activity. 13 Children with special needs

Children with a wide range of problems or family, the other children and families in the pro- disabilitiesthose with speech and language prob- gram, and staff members; and they must be flexible lems, problems getting along with other children, in planning activities. ,Each program also needs to chronic illnesses, family difficulties, abusive or ne- be realistic about which children it can safely and glectful parents, or developmental delays or physi- appropriately serve and which it cannot; children cal impairmentscan benefit from being in group should be, zonsidered on a case-by-case basis. situations with non-handicapped children. The lives Several other chapters in this manual may also of other children and staff can also be greatly en- provide helpful information. For example, Chapter riched by including special needs children in main- 6 presents safety issues to consider with a particular streamed early childhood programs. special needs child in mind. Chapter ,8 offers Some children with special needs will require ex- emergency-related advice that may have special im- tensive individual prograni planning and extra ser- portance for a program with a handicapped LI:M. vices. Others will need staff to help them for limited Chapter 14 presents information on abused or ne- times or in minor ways. Whatever the special need, glected children, and Chapter 16 describes chronic staff must remain attentive to reactions of the child, health co ditions that you may encounter.

Mainstreaming gives all children the opportunity to learn and grow by experiencing the strengths and weaknesses of their friends. ,Children with special needs learn self-reliance and master new

189 190 Special health issues

Mainstreaming and play with other children, handicapped children are encouraged to strive for greater achievements. What does mainstreaming mean? Working toward greater achievements helps them develop a healthy and positive self-concept. Mainstreaming, means helping people with handi- Mainstreaming can be an especially valuable caps live, learn, and work in typical settings where method for discovering undiagnosed handicaps. they will have the greatest opportunity to become as Some handicaps don't become evident until after independent as possible. In early childhood pro- children enter elementary school, and by_ then much grams, Inainstreaming---carr,be---defined-as--thc- intc- important learning tirne-has been lost. Teachers of gratio n of handicapped children and non- young children have the opportunity to observe and handicapped children in the same classroom. It compare many children of the same age, that makes gives handicapped children the chance to join in the it easier to spot problems that may signal a handi- mainstream of life by including them in a regular cap. See Chapter 9 for additional information on preschool experience, and it gives all children the developmental milestones and screening instru- opportunity to learn and grow by experiencing the ments. strengths and weaknesses of their friends. Mainstreaming, however, does not simply involve Mainstreaming helps able-bodied children. enrolling handicapped children in a program with Mainstreaming can help n .1-handicapped children, non-handicapped children. Definite steps must be too. They can learn to accept and be comfortable taken to ensure that handicapped children par- with individual differences. Some studies show that ticipate actively and fully in classroom activities. children's attitudes toward handicapped children You are responsible for taking the steps outlined in become more positive when they have the oppor- the "Modifying your program" section of this chap- tunity to play together regularly. They learn that ter. handicapped children share their ability to do some things better than others. In a mainstreamed class- Benefits of mainstreaming room, non-handicapped children have the oppor- -Research on children has shown repeatedly that tunity to make friends with many different indi- the early years of life are critical for learning and viduals. growth. It is during this time that children's cogni- Mainstreaming helps parents. Mainstreaming tive, speech and language, physical, social, and emo- can also be helpful for the parents of children with tional development can be most influenced. If their special needs. These parents may feel less isolated, special needs are recognized and met during these when you, the other members of the staff, and spe- years, handicapped children will have a much better cialists s;,are the responsibility for teaching their chance of becoming competent and independent child. They can learn new ways to help their own adults. Handkapped children, who are given the op- child. As they watch their child progress and inter- portunity to play and learn with other children in act with non-handicapped children, parents can be- the classroom learn more about themselves and gin to think about the child more realistically. They how to cope with the give-and-take of everyday life. will sCe -that -s^:n- of the behaviors that conccrn, This is one of the first steps they can make toward them are probably typical of all young children, not developing independence. When children with spe- just children with handicaps. cial needs participate in regular early childhood settings that provide for their special needs and have Mainstreaming helps teachers. Mainstreaming teacher_ s who know how to adapt teaching tech, can also, have.advantagesior you. You.will have.the niques and activities, they will have a head start chance to make a significant impact on a handi- toward achieving their fullest potential. capped child. The techniques you developlar working with a child with special needs will be just as Mainstreaming helps handicapped children. useful with non-handicapped children who have When children with special needs participate in a minor weaknesses in the same areas. In fact, many mainstreamed classroom as a welcome member of of the most effective teaching techniques known. the class, they learn self-reliance and master new were first developed for handicapped children. Fi- skills. For some, it may the first time in their lives nally, working with handicapped children is a that they are expected to do for themselves the chance to broaden both your teaching and personal things they are capable of doing. When they work experience.

2 2 8 Children with special needs 191

How is mainstreaming carried out? schools. The identification of team members and Mainstreaming can be carried out in a variety of development and coordination of their efforts is ways. Your decisions about the best ways to main- both a challenge and a critical requirement for stream a particular handicapped child will depend meeting the needs of a handicapped child. upon the child's strengths, weaknesses, and needs. Every child is an individual with different needs and abilities. This is just as true for a handicapped child Staff's feelings and attitudes toward -who-displays- a 'broad'rante Of behavior and abili- speciallieedi children ties. Your decisions will also be influenced by the parents, the staff, and the resources within your Each staff member will probably experience dif- community. ferent feelings, both positive and negative, towarda Some handicapped children may thrive in a full- handicapped child. Different handicaps may evoke day program with non-handicapped children. different emotions and responses. You may feel Others will do best in a mainstreamed environment sympathy, pity, frustration, repulsion, caring, anger, for only part of the time, attending special classesor fear, and/or acceptance. Each of these feelings may other programs for the rest of the day. For still affect how you respond to a child with a handi- others, mainstreaming may not be the most helpful capping condition. approach. Follow the principle Place handicapped Feeling sorry for the child may lead to an overly children in the least restrictive environment. This protective attitude; you,may try to shelter the child means that the early learning experiences of handi- from experiences that non- handicapped- children capped children should be as much like those of have on a daily basis. Pity may prevent you from non-handicapped children as possible, while still seeing the child's strengths and expecting the most meeting the special needs created by their handi- from a child. Your anger may flare up when you caps. The least restrictive environment should be realize the extra responsibility or work required as individually determined for a particular child ata you deal with a handicapped child. You may experi- particular time, and reassessed regularly. ence fear and insecurity if you do not have adequate Mainstreaming involves the efforts of many peo- information about the handicapping conditionor ple working as a team. This team includes teachers, feel that you are not capable of meeting the child's the child's parents, other specialists providingcon- needs. Your feelings of acceptance and caring may sultant services on a full- or part-time basis, agen- happen immediately or may develop as you get to cies serving handicapped children, and the public know the child and view her or him as an individual.

WWW

Take steps to learn about specific handicapping conditions so that you can see children as children first. 192 Special health issues

Resources and support

You arc not expected to be an expert in special education; however, there are many ways you can prepare yourself to work with a handicapped child. You can read about a particular disability; you may find that the child's parents have a wealth of information to share: You cat; visit- othcr,classrooms where children- with similar handicaps are being taught. Specialists, particularly those who have worked with or evaluated the child, may have valuable suggestions. Seek permission from the parent to contact the child's physician and others who arc working with the child so child care goals, activities, and evaluations for the child can be coordinated among all the members of the child's "team." Train- ing sessions, conferences, or workshops can provide excellent background material. Your local hospital, college, clinic or other community agencies may be able to provide you with information and assistance. Your state or local school system may be responsible for providing services to preschool handicapped children under Pub- lic Law 94-142, the Education for All Handicapped Children Act and for younger children under Public Law 99-457. National associations may be able to send you specific information on a handicap and may serve as an important resource for parents. A list of national associations is provided in Figure 13-1.

(/) Th&primmy goal of mainstreaming is to enable handiCapped children to participate actively in ,;:lassroom activities and to operate as Modifying your program independently as. possible. When children with handicaps are enrolled, Regardless (Aydin' tcclings, it is best to first adMit w adaptatiGns tcag--tech, and acknowledge them to yourself. Then, share niques, equipment, and routine may be needed to these feelings with other staff who are supportive facilitate these children's active participation in and who may help you deal with your feelings in a your program. The primary goal of mainstreaming healthy way. Most of you did not choose special handicapped children is to enable them to par- education as a career and may feel unprepared to ticipate actively in ciaiSrOom activities and,to allow work with various handicapping conditions. Often them to operate as independently as possible. For teachers have found that working on a daily basis this reason, a program that enrolls handicapped with children who have handicaps has helped to children should meet these objectives: ease their anxiety and fear. These teachers have adapt the program to ensure successful participa- taken steps to learn about the specific handicapping tion conditions and have learned to sec the children as develop handicapped children's feelings of com- children first. They have learned to place emphasis petence on the whole child rather than on the child's handi- promote peer acceptance cap or limitations. Learning to sec beyond a par- avoid overprotection Saiiilicappiii-6---Londitionis you.- can cirenthenthoteamwork _between parents, teach- develop. ers, andother specialists 230 Children with special needs 193

Figure 13-1. National resources for children with special needs

Alexander Graham Bell Association for the Responds to inquiries on a wide range of topics, Deaf, 3417 Volta Place, N.W., Washington, DC especially on federal funding for programs serving 20007. 202-337-5220. the disabled, federal legislation affecting the Provides information on home training and handicapped, and federal programs benefiting amplification. handicapped people. "The Pocket Guide to Federal Help for the Disabled Person" is free upon request. Ainericari keitdeiliY-eif Pediatrics, P.O. Box 927, 141 Northwest Point Blvd., Elk Grove Closer Look, 1201 16th Street, N.W., Washington, Village, IL 60009. DC 20036. 202-639-4404. National information center for parents, American Diabetes Association, National Service professionals, students, and disabled adults Center, P.O. Box 25757, 1660 Duke Street, seeking assistance in dealing with problems and Alexandria, VA 22313. 703-549-1500. needs of the mentally, physically, or emotionally American Heart Association, 7320 Greenville disabled. When writing for information, be as Avenue, Dallas, TX 75231. 214-750-5300. specific as possible; for example, include facts about the person's known or suspected American Lung Association, 1740 Broadway, handicapping condition, her or his age, and the New York, NY 10019. 212-315-8700. kind of help being sought. You will receive a packet of material including pamphlets and American Speech-Language-Hearing reading lists; the semi-annual newsletter, Report Association, 10801 Rockvilk Pike, Rockville, from Closer Look; addresses of parent MD 20852. 301-897-5700. organizations and local groups; and selected Education and'professional organization for information about additional resources. speech, language, and audiology. Provides clinical services. Free public information Council for Exceptional Children, 1920 literature is available on request. Association Drive, Reston, VA 22901. 703-620-3660. Association for Children and Adults with Provides information on handicapped and gifted Learning Disabilities (ACALD), 4156 Library children. Maintains a library and data base on Road, Pittsburgh, PA,15234. 412-341-1515. professional literature in the field of special Provides information on advocacy, education. Prepares books, monographs, digests, publications, and new developments related to media, search reprints, journals, and the ERIC children with learning disabilities. microfiche collection. Association for Retarded Citizens, 2501 Epilepsy Foundation of Anierica, 4351 Garden Avenue E East, P.O. Box 6109, Arlington, TX City Drive, Landover, MD 20785. 301-459-3700 or 76011. 817-649-7718. 800-332-1000. Serves PrOleSsionais-and pafffnis, and Provides tree Information on epilepsy and addresses issues of retarded persons of all age educational materirAls dealing with seizure levels. Disseminates information on retardation, disorders; provides referral services; monitors parent needs, and many ether topics. A catalog related legislative activity; is a strong advocate to and brochure arc free upon request. help obtain needed services and rights for persons Association for the Severely Handicapped, with epilepsy and their families. Affiliates have job 7010 Roosevelt Way, N.E., Seattle, WA 98115. placement programs and support groups. 206-523-8446. Head Start, P.O. Box 1182, Washington, DC Publishes a monthly newsletter for parents and 20013. 202-744-7782. professionals concerned with children having Handicapped children eligible for Head Start are great need for special assistance. preschoolers defined by the Omnibus Budget Clearinghouse on the Handicapped, U.S. Reconciliation Act of 1981 (P.L. 97-35) as Department of Education, 400 Maryland Avenue, "mentally retarded, hard of hearing, deaf, speech- S.W., Room 3132, Switzer Building, Washington, impaired, or other health-impaired children who -DC zuctu.-2319: 202432-1250; hy-reaspu.thereofrequire_special educationand. 231 194 Special health issues

Figure 13-1 cont. National resources for children with special needs related services."Ilead S-tart is primarily for those Washington, DC 20013. 703-522-3332 (Voice or who meet poverty-level requirements, but there TDD). are exceptions. To locate a Head Start program in Free information service to ensure that all your area, check the telephone directory or children and youth-with-disabilities have a better contact the national office. opportunity to reach their fullest potential. Services include personal response to questions, March of Dimes Birth Defects Foundation, 1275 referral to other organizations, information 'Mamaroneck Avenue, White Plains, NY 10605. packets, special education and referral services 914-428-7100. (career recruitment materials), state-of-the-art National Association for the Visually publications, and technical-assistance to parent Handicapped, 305 E..24th Street, New York, NY and/or professional groups. 10010. 212 - 889 -3141. National Mental Health Association, 1021 Provides,freelearning materials-for-parents-to Prince Street, Alexandria, VA 22314. 703-684-7722: help their children, including large print books Provides referral services for the general public. and-a monthly newsletter, and to keep families Makes available a large collection of free informed on the new techniques used with the literature. For further information, call the visually handicapped. number here or refer to your local Yellow Pages National Audiovisual Center, National Archives listings for "Mental Health." and Record' Services, 8700 Edgeworth Drive, Office of Special Education Programs, U.S. Capitol Heights, MD 20743 -3701. 301-763-1896. Department of Education, 400 Maryland Avenue, Catalogs are available for audio-visual materials S.W., Room 3090, Switzer Building, Washington, by subject area, for example, special education. DC 20202-3511. 202-732-1007. National Easter Seal Society for Crippled Administers Public Law 94-142, the Education Children and Adults, 2023 W. Ogden Avenue, for All Handicapped Children Act, that guarantees Chicago, IL 60612. 312-243-8400. appropriate free public education for children Provides rehabilitation services to people with with handicapping conditions. The Washington, physical handicaps. D.C. office.nd regional offices in the United States receive complaints of violations of the law National HemophiliaFoundation, SOHO and act on these complaints, if necessary. Building, 110 Greene Street, New York, NY 10012. 212-219-8180 ext. 406. The Self-Help Center, 1600 Dodge Avenue, Suite Provides free literature on hemophilia and S -122, .Evanston; IL 60204. 312-328-0470. -handicapping conditions-that can result from it; Research and information clearinghouse_that provides referral services. offers free information to those seeking self-help group locations, contact persons, and telephone National Information Center for Educational numbers. Incemaz(NICEM); c, TnrP.O. Box 40130, Albuquerque, NM 87196. Sickle Cell Disease Foundation of Greater New 800-421:-8711. York, 209 W. 125th Street, Room 208, New York, Indexes non-book media materials in all subjects NY 10027. 212-865-1201. atrall grade levels. Many of these groups have local chapters who National Information Center for Handicapped may be able to provide services and information. Children:and Youth (NICHCY), P.O. Box 1492, Check your telephone directory. Children with special needs 195

Adapt the program use more visuals to accompany classroom discussions The selection and adaptation of materials for use a wedge, standing table, bolster, or other spe- children with handicaps requires problem solving cial equipment and a little creativity. For some handicaps special materials are required and may need to be pur- Adaptations to the environment may depend on Chasod. Examples of such materials are the type and severity of a child's handicap. Forex- eating utensils with special grips or edges affiple,if a classroom, is to accommodate a Child in a puzzles with -large pieces and/or knobs for chil- wheelchair, the staff can do the following: rr -dren-With fine-motor problems measure traffic lanes between areas to ensure that. books with large pictures for children with visual the child can maneuver:from one area to the next handicaps check the height of tables to ensure that the arms a magnifying glass of the wheelchair fit under them, or find an alternate seating arrangement Staff can also adapt materials already available. add blocks under a table to slightly increase the For example, they can height apply, masking tape to brush:handles and crayons -L- explore- the-use of a-scooter-board -instead of a so-children can get a firmer grip wheelchair, if appropriate, for mobility around slit a rubber ball and; slide the paint brush or the classroom crayon through it so 6hildrcd can grab it better confirm ready access to and from the building cut out fabric to paste on a storybook to make it add ramps instead of,-or in addition to, stepS More tactile position a water tray or a table so the child can lower an easel reach it

When children are provided an opportunity to watch adults relating cosufortably.to children -With handicaps, they take the first step toward learning peer acceptance. 196 Special health issues

'Developing feelings ofcompetency Focus on the similarities as wellas the differences All children need to feel a sense, ofcompetence. among people. For some children with handicaps, learning andre- lating -take-rnore time and--effort. Toensure suc- Avoid overprotection cessful experiences for children, staffcan Overprotection limits a child's opportunities to observe children closely to see what interests grow to full potential. Pity and fear may limit a them teacher's ability to allow a child with a handicap'to talk With children about themselves, their- fa"m- take risks, to respond to limits, to engage in conflict, ilies,. experiences and to experience real success and failure. Staffcan -break tasks into a sequence avoid overprotection by remembering the following 'allow sufficient time to use new skills beforemov- concepts: ing on to something new- Limits need to be set for all children (a child with offer a-variety of materials and activities suitedto a handicap must also wait for a turn on the slide). different levels of ability It is important to provide many options and activ- -0-provide an emotionally safe c_ lassroom byrespect7 ities in the.classroomso.thatchildren do not-being-children- come overly dependent on adult direction. s focus on the process of learning rather than the All children should be encouraged to trynew ac- end- result tivities they wouldn't naturally choose. accept different-answers from different children Your attitude and feelings will be conveyed to the set clear and realistic goals for each child children, who see you as an important role model. If you avoid overprotection, the children will fol- Promote peer acceptance low. Children must be provided with positive role You should keep an eye on the behavior of the models so that they learn to interact with others ina children. Do not allow handicapped children to kind, accepting.way. When theyare given an oppor- become the baby. tunity to watch you and other adults relatingcom- fortably to children with handicaps, they take the Strengthen teamwork first step toward learning peeracceptance. Children For a child with a handicapping condition, the should be given factual information about handi- necessity for teamwork becomes even greater. To caps to dispel misunderstandings and diminish fear. ensure that the special needs of a child and family Staff can encourage the acceptance ofa handi- are met, parents, teachers, and-administrators-must cap-lied-Child in The- following ways: communicate closely and regularly. Collaboration Always answer children's questions accurately, on the following tasks is especially important: using language that is easily understood. identify the,special-needs,of a child ReaKaife -Children that handicapsare not "catch- cap(s) ing" (contagious). plan and implement a classroomprogram re- ProVide simulation activities so that childrencan sponsive to the child's needs have some idea about what it is like to be handi- pinpoint any changes in a child's condition capped. For example, whisperor put cotton in talk or meet with other specialists who provide ears-so-that-children know-What a hearing loss therapeutic Services sounds like. Lead children on a blindfold walkso share information, obsermtions, concerns, and that they experience the loss of vision. the progress of a handicapped child Plan activities that allow the other childrento see obtain special materials, information, andre- the child with a special need ina successful role. sources to help work with a handicapped child Have materials routinely available that depict When team members focus on providinga child and handicapped people. For eiample,_ include books family with, a supportive, caring -environment; the abdirtdisabled'eliildren in the readingcorner, and personal feelings of role pwsessiveness, inferiority, include dolls or puppets with handicaps (corn- or superiority can often be eliminated. Focusing, mercially_availableirom Mattel). helps- a team see each member's contributionas Invite adults with disabilities into the classroom essential to achieving the goals for the child. and have them participate.

234 Children with special needs 197

Handicapping conditions

States, local. school systems, organizations, and pertinent legislation may all have different definitions for conditions that are considered handicaps. A list of handicapping conditions with basic descriptions is provided here. You may want to check with your local school system for the definitions applicable toyour. own community.

Handicapping condition A person with this condition is Mentally retarded One who shows significant, belmweverage intellectual functioning combined with impairment in adaptive behavior and who will have difficulty both in schoolwork and in everyday living. Deaf One whose hearing is extremely defective. Hearing impaired One who has slightly to severely defective hearing Or a specific hearing loss. Blind One who is sightless or has very limited vision and must depend on hearing and touch as the chief means of learning. Visually impaired One who is considered .legally blind by the state, or one who has very limited vision even with corrective lenses. Serious emotional disturbance One who is identified' by a psychologist or psychiatrist as requiring special services because of dangerous aggressiveness, severe withdrawal, severe anxiety or depression, or other socioemotional difficulty. Physical (orthopedic) handicap One who has a condition that impairs normal development of muscle activities (forexample, one who has spina bifida, cerebral palsy, or loss of limbs). -Specific learning disability One who has a disorder in understanding or using spoken or- written language (such as perceptual handicaps, brain injury, dyslexia). Speech and/or Language impaired One Wtho'se speech is ifriliaired-by receptive and/or expressive language impairment, stuttering, or serious articulation problems. Other health impairment One who has a chronic health condition (such as severe actlirna opilopcy hornrph;lia ar rorirlition, diabetes). Multi-handicapped One who has, in addition to the most severe handicapping condition, one or more other conditions.

Within each handicapping condition there may be a wide range of functioning. It is important, therefore,to understand both the characteristics of a disability as well as the particular special needs of individual children. These terns should never be used to label children.

235 198 Special health issues

Bibliography :Froschl; M:;. Colon, L.; Rubin, E.; & Sprung, B. (1984). Including all of us: An early childhood curriculum about disability. Educational Equity Concepts. Souweine, J., Crimmins, S., & Mazel, C. (1981). Mainstreaming: Ideas for teaching young chil- dred.-WaOingion, DC: -National AssoCiation for the Education of Young Children. U.S. Department of Health and Human Services. (1978). Mainstreaming preschoolers. Washing- ton, DC: U:S. Government Printing Office. White, B.P., & Phan-, M.A. (1986). "It'll be a challenge!" %Managing, emotional stress in-teaching disabled children. Young Children, 41(2), 44-47.

236. 14 Child abuse and neglect

Many factors contribute to the maltreatment of accidental injury or pattern of injuries to a child children, making the identification, treatment, and for which there is no 'reasonable' explanation." - prevention of child,abuse - and - ,neglect complex. Child abuse includes There are several types of child abuse and neglect non - accidental injury and, each leavesa permanent mark on the victim. negleCt No standard definition is used by all professionals sexual molestation who deal with child abuse and neglect. Every state emotional abuse has one. 7-'r- more legal definitions that are used to establish official reporting procedures. Various It is, impossible to identify how many children are agencieS also develop their own definitions for re- abusedeach year, since the definitions of abuse and porting and accepting cases of abuse and neglect. neglect, as well as reporting- practices, vary from However, most definitions have common elements. state to state. It is estimated,itowever, that u least The National Committee for Prevention of Child 1,000,000 children are abused each year, and that Abuse (NCPCA) defines child abuse as a "non- between 2,000 and 5,000 die each year as a direct result of child abuse. All communitiesurban, sub- urban, and ruralexperience child abuse that occurs regardless of ethnicity, race, religion, or income level.

Identification of abused and neglected children

Educators :are,required to yeport all, suspected cases of abuse and neglect. As an educator, you are probably willing to comply with your professional responsibility but may feel that you lack the information required for accurate identification of those cases. The following indicators are provided to help you identify suspected cases of abuse and neglect in children. Many of these indicators are signals that the child is possibly being abused; however, some could also be caused by other physical, environmental, or emotional problems.

Physical-abuse ,A physically: abused child is one who has received injuries from shaking, beating, striking, burning, or All communities ilthn;,:sulnii.ii4n,..and,itinil--, other similar acts. You should suspect physical _o f abuse has occurred when any of these conditions ethnicity, race, .iiligion,,orincorne level. exist.

3'7. Olt 200 Special health issues

repeated or unexplained injuries (burns, frac- frequent lateness or absenteeism; parents arrive tures, bruises, bites, eye or head injuries, bilateral too early or leave child after closing clustered. injuries) beyond the usual bumps and unusual fear of adults, especially parents -bruises 4:tfactive_ ch ildren malnourished or dehydrated appearance The lolloWing are often seen in cases of abuse or avoidance of-logical explanations for injuties neglect. They should be considered in light of ex- withdrawn, anxious, or uncommunicative behav- planations provided, medical history (especially if ior, outspoken or disruptive behavior incorisistent),4nd the developmental abilities of the lack of seeking and/or giving affection child' to -engage in 'the activities said to cause the evidence that the child was given inappropriate injury. food; beverage, or drugs Bruises and welts Emotional abuse -bruises on any infant, especially bruises on the An emotionally or psychologically abused child is face, one who has been verbally abused by her or his -bruises on the backside of a child's body parent(s) or who has had excessive or inappropriate : bruises in unusual patterns that might be made by demands placed on her or his emotional, social, or an,instrument-(e.g., belt buckle or strap) or hu- physiological capabilities. You should suspect emo- -Manbite---marks- clustered, bruises that might indicate repeated tional-abilie iia-s occurred when-any-of these,indi- contact with a hand or object cators areipresent. is generally unhappy and seldom smiles or laughs ,..bruises_in various stages of healing is aggressive_ and disruptive or unusually shy and .Burns withdrawn immersion burns indicating dunking in a hot reacts without emotion to unpleasant statements -liquid ("sock" or "glove" -burns on-the arms or legs and actions or "doughnut" sriaped -burns of the buttocks or displays behaviors that are unusually ad' 'tor genitalia) childlike - cigarette burns exhibits delayed growth and/or delayed emotional - rope burns and intellectual development dry burns indicating that .1 child has been forced has low self-esteem to sit upon a hot surface has had a hot instru- receives belittling or degrading comments from ment applied to the skin her or his parents Cuts, tears, ok:scrapes fears adults -.cuIsmf thelip,_eye, or any portion of an infant's face Sexual abuse any cut or scrape on external genitalia A sexually abused child is one who has been ex- ploited for any sexual gratification such as rape, --Head Juiuries. ;,,cest fondling of-the_genitals, exhibitionism, and/ absence of hair or bleeding beneath the scalp due or i...iyeurism. Yon, should suspect sexual abuse liar to hair pulling . black eyes, occurred when a child exhibits any of these indicators. bruised, bloody, swollen eyes swollen mouth or jaw Physical indicators loosened or missing teeth difficulty in walking or sitting torn, stained, or bloody underclothing If injuries look more serious, children probably complaints of pain, itching, or swelling in genital should be taken to a physician or hospital. area Other conditions that may indicate physical abuse pain when urinating include bruises or bleeding in external genitalia, vaginal complaints of pain or anal areas, mouth, or throat wearing clothing to hide injuries, wearing vaginal discharge inappippriate for weather conditions reports,4harsh treatment venereal disease or vaginal infections Child abuse and neglect 201

tehavioral'indicators lacks adequate shelter ` unwilling- to hav(- clothes changed or to be as- structurally unsafe housing or exposed wiring siSted: with toileting inadequate heating holds-self, -wants to be changed although not wet unsanitary housing conditions unwilling,to participate in physical activities extreme changes-in behavior such as loss of appe- In identifying neglect, be sensitive to tite- different cultural expectations and values withdrawn or infantile behaviors; may go back to different childrearing-practices earlier behaviors (such as bed-wetting, thumb Neglect is not necessarily related to poverty; it sucking) reflects a bre..kdown in household management,as extremely aggressive or disruptive behavior well as a breakdown of concern for and caretaking -4-,tinusuannterestin or knowledge of sexualmat- of the'child. ters (normally, 3-year-olds may masturbate frequently and show great interest in -body parts, Characteristics of child abusers -especially the genitalia); expressing _affection in ways inappropriate for a child of that age All adults have the capacity to strike out in anger, poor peer relationships fear, pain, or frustration, and this capability makes fear of a person or a strong dislike of being left it possible for all of us to be potential child abusers. somewhere or with someone Yet most people have the ability to control these - ilerePOrt-S7'Sexti al: as s aul t -violent impulses, Child abuse -can- happen, when, adults Physical and emotional neglect are under stress A child who is a victim of physicalor emotional are isolated, without support neglect is one Whohas not received sufficientphysi- have unfulfilled needs for nurturance and Cal; emotional, intellectual, or social ,support from pendence her or his caretaker(s). The level ofneglect may feel that their failures outnumber their successes range from beginning stages to truly gross pro- were abused themselves and lack nurturing child- portions. You should suspect physical neglect rearing experiences when a child keep their frustrations inside until they finally lacksisupervision boil over very young children left unattended Many of the causes of child abuse can also be traced children left in the care of Other children-too to societal or personal problems such as marital young to protect them difficulties, economic problems, unemployment, children inadequately supervised for long the loss of a supportive, community- feeling inour periods of time or when engaged in dangerous neighborhoods, and the acceptance of violenrp asa activities. way of dealing with problems. lacks adequate clothing and'good hygiene children dressed inadeq0tely for the weather persistent skin disorders resulting from im- How early childhood educators can proper hygiene 'map -a1J11bV11.1 %;111.11.11.1V11 - children chronically dirty and unbathed lacks medical or dental care Early childhood programs are the only places =children whose needs for medical or dentalcare where young children are seen on a daily basis for or-medication and-health aids are not met an extended time by,professionals trained to observe lacks adequate education their appearance, behavior, and development. You children who are chroniCally absent may be the first person to suspect (and to report) lacks adequate nutrition abuse and neglect. When you suspect that somechildren lacking sufficient quantityor quality of thing is amiss, you should try to gather some more food data,to substantiate your suspicions. children consistently complaining of hungeror Children who are abused or neglected will not be xumniaging,for food- able to learn or participate to their maximum poten- -children suffering severe developmental lags tial. These children may catty emotionalat-atfUl 239 202 Special health issues

life. Depending on the kind and/or severity of abuse may be reluctant to become Involved again. Perhaps and neglect, long, term physical effects can include you felt that a social worker discouraged you from motor impairment, loss of hearing or vision, mental reporting, or was unresponsive, or that a case was retardation; and/or learning- and emotional prob- not adequately handled. Perhaps you have heard.of leins. Thus,;it is essential that you take action ,to cases where nothing was done and that abuse con- interrupt the cycle of abuse and neglect by helping tinued or escalated. These concerns are often valid. children and parents receive needed treatment. But a previous bad experience does' not mean that Your trusting relationship with children is a major next time things will not be handled better. You factor in helping children and farriilieS cope with must file a -report regardless of previous- experi- and resolve such difficult situations. ences. The law requires it, with no exemptions. Abused and neglected children cannot be protected ,Legal and ethical issues unless they are first identified and reported. You may worry about endangering your relation- All states have mandatory reporting laws for child ship with the child's parents by reporting your sus- abuse. Most states require (and no state forbids) the picion. Although the identity of the reporter of child reporting of suspected child abuse and neglect by abuse is supposed to remain anonymous, parents educators. Many states provide penalties for those will suspect who reported them by the nature of the who are mandated to report suspected child abuse information contained in the report. Many abusive but who fail to do,so. On the other hand, every state parents are grateful for the identificationa guilty provides immunity from civil or criminal liability. z. secret for them. This is especially true if supportive services result -from making- the report. Each-case Problems you may encounter requires individual handling, but in general, it is You may have mixed feelings about reporting best to advise the parent that a child abuse/neglect suspected abuse. You may not want to become in- report is being filed as required by law, that the volved or you may feel that parents have the right to person filing the report is seeking help for the fam- discipline Their Child in-their own way: You may also ily. Even .1f-the-parent,adamantly denies.any abuse be reluctant to face the fact that someone you know or neglect, filing of suspected abuse or neglect is May be a possible abuser. This is a natural feeling, rt. --Iuired so concerns about the problem can be but must be overcome. Once you are aware that aired and put to rest. your involvement is required and that child abuse You should get a copy of your state's child and neglect differ from acceptable childrearing abuse reporting statute. This can be obtained from practices, much of this rekaance should disappear. a local department of social services, law en- At times it will be difficult to decide whether or forcement agency, district attorney's office, or the not to tell a parent beforehand that you are going to DHHS regional office of child development. Check make a report. Of course, if you feel that a child is in how the report will be handled once filed so you can imminent danger and you believe the parent may explain the procedure to parents when you inform disappeF.r with the child, call the appropriate agency them about_ our responsibility to report their child. immediately and do not tell the parent. Most fre- Every program has a responsibility to inform staff of quently, however, you will be faced with a situation appropriate federal, state, local, and program reg7 where_you know and care about theyarent, and the ulations_regarding,child abuse and neglect. Eliiki is not in imminent danger. You may worry Your program should have a written policy on that telling the parent will evoke hostility and anger, child abuse and neglect. At minimum this policy that may spur the parent to remove the child from should include your program. However, if you fail to inform par- requirements for reporting suspected child abuse ents, they may feel betrayed or deceived. As a gen- and neglect eral rule, it is probably better to inform the parent of a code of conduct for staff relating to their behav- your decision to make a report. You might start by ior with children explaining that, as an educator, you are required to procedures for investigating staff or job appli- report all instances of known or suspected child cants for child abuse and neglect abuse. Although they may be -very angry, they will decision-making guidelines for hiring staff previ- see that you had no choice in the matter. ously accused, indicted, and/or found guilty of You-inay also have had previous experiences with child abuse and neglect -rel:i6rtifiesuspected Child abuse.-and, negied and 240 Child abuse and neglect 203

Reporting procedures If you know or suspect that a staff member has abused or neglected a child you should contact the What and when to report appropriate agency immediately. You must consult your state statutes to determine Injury just what is considered child abuse and neglect. No state requires that the, reporter have proof that If a child arrives with an injury requiring immo.di- abuse or neglect has occurred before reporting. ate medical attention, you should take the child to a The law may specify reporting of suspected inci- doctor or to_an emergency room for treatment. -If dents or include the phrase reason to believe. Inci- you notice bruises, cuts, burns, or other injuries on dents must lieseported as soon as they areno- a child, you should ask the parent how the injury ,fleeksince waiting for proof may involve grave risk occurred; what treatment' has been prciVided, and: to the child. what care or precautions must be taken. As a routine practice, you should keep careful Where to report records for every child, noting all injuries received while in your program and any other injuries that Each state specifies one or more agencies tore- come to your attention. In your record include a ceive reports of suspected child abuse and neglect. description of the injury, date, time, and how it was Usually this agencrisahe department of socialser- received, if known; any statements by parent or vices, human resources, or public welfare. It is im- child; and.treatment given. Always notify parents liortant.lo, know who receives reports ofsus- immediately -if any injury or illness occurs. 'Sec pected- Child" abuse sand negleCt inyour Chapter 8 for further information. jurisdiction. Some states maintain a 24-hour hot line just for reports of suspected child abuseor ne- Sudden Infant Death Syndrome glect. One of the most difficult situations to deal with is How-to report the death of a child, and one of the most frightening types of death is that of a sleeping, apparently State-statutes vary with regard to the foam and healthy infant who dies for no apparent reason. contents of ,reports of suspected' child abuse and Sudden Infant Death Syndrome (SIDS), also known neglect. All states:- require that an oralor written as crib death, is a well-recognized event in the report (or both) be made to the specified agency. health care field and is the major cause of death in Usually the information included in the report should contain infants after the first month of life (up to two deaths per 1,000 live births). We do not yet fully understand the name, age, and address of the child the causes of SIDS, but we do know that it is NOT the name(s) and address(es) of the parent(s) predictable or preventable; that it is not caused by the name and location of the reporter (sometimes suffocation, aspiration, or regurgitation; and that not required, but extremely helpful) the infant does. not struggle or make any noises_to alert a caretaker. As far as w there is nothing we can do to prevent the tragedy of SIDS. Preventing abuse and neglect in Because of the obvious, trauma that an. uncx7_ programs-for young children pected death of a healthy baby can cause, however, child care providers have been accused of abuse or Discipline neglect in such circumstances. In the very unlikely Your prograth should have a philosophy and pol- event that an apparent SIDS death occurs in your icy_ that provide guidelines for disciplining children. program, you should be aware that an autopsy can Corporal punishment should not be used, and verify that there was no identifiable cause of death children should not be punished inany way that (disease, suffocation). If the needarises,,contact interferes with their daily functions of living suchas your state public health department and state chap- eating, sleeping, or toileting. Expectations should be ter of the national SIDS support program for help developmentally appropriate for children, and for the family, the staff, and other families in the 'limits should be realistid. Chn;ti-en should be taught program who will understandably be very upset by positive and appropriate words, ac Ions, andways knowing about: a SIDS case in a family in the proof relating to other children and adults. Adults gram. should model positive patterns of interaction. 241 204 Special health-issues

ACcusations of abuse in the program ensure that there is adequate daily supervision of all staff and that children can not be taken to any area If a complaint of child abuse is filed against your of the child care program where they can not be program or staff, it will be investigated. Your pro- easily viewed by other adults. gram should have a policy specifying the internal steps that will be followed during the investigation. Working with families and children It is possible that a teacher may be removed from the classroom and given a job that doesn't require As a sensitive, perceptive teacher or director, you -interaction with-.children. Staff may be suspended may note the early warning signs of a potentially or given leave with or without pay during the inves- abusive or neglectful situation. This is, of course, tigative period. Parents of other children in the pro- the best time to act. You should become aware of, gram -may -be contacted: Staff members' past em- and-let -parents know about, community-- agencies- ployment records may be checked. Do not panic, but that provide needed support services such as respite it may be wise to contact an attorney. care, counseling, temporary shelter, drug treatment, or Food Stamps. Share your knowledge of child de- ScreeRing potential staff velopment and childrearing techniques with parents. Let them know if you recognize signs of stress During the hiring process, you should find out if in their children. Share your concerns with parents the applicant has been convicted of any violent and/ and help them share their concerns with you. or sex-related crimes or of driving under the in- Your early attention and intervention could-save a fluence -of _alcohol- or. drugs. Ways -you-can learn child :froth, harin_and: rnaintain_a family's integrity. abdut an individual include Make it a part of your job to get to know parents so an-interview with the candidate you can build a trusting, sharing relationship with a reference check them. observation of the candidate in the job for which Another part of prevention is educating young she or he is applying, if possible children about their right to say no. Particularly in '4-a-search-for information- from -those who know the area of child sexual abuse, children can learn to the candidate, including past co-workers and par- try, to stop the abuse and how to tell a trusted adult ents a check of public records related to child abuse about the experience. The concept of teaching children about "good touches" and "bad touches" is con- and neglect convictions troversial. Care must be taken not to teach children A probationary (trial) period for new employees is that genital touching or fondling is "bad" since such strongly recommended. During this time, you will touching is a normal and "good" part of mature have the chance to monitor new staff members by sexual practice, and masturbation is commonplace observing and discussing their performance. Par- among preschoolers. Children can be taught that ents may be encouraged to drop in and visit the new doctors must check "private parts," but that other- employees as well. Each new employee must receive wise, private parts should not be shown to anyone a copy of your program's written pOlicies on staff without checking with a parent. There are many conduct and on reporting procedures for suspected excellent materials for young children on-this topic. child abuse. Figure 14-1 presents a guide for evaluating, these. The InOst important step program directors can materialS. take to guard against child abuse and neglect is to

242 Child abuse and neglect 205

Figure 144.. Considerations when examining,materials on child sexual abuse/ personal safety foryoung children

Content Is the material compatible with classroom/ school philosophy? Does the material teach assertiveness, build self-esteem, and help children develop problem-solving skills? Curriculum package

Is it appropriate for the age group Is there meacher's guide? Does it recommended? Is it easy to understand? recognize that a teacher may be uncomfortable teaching about child sexual Does it portray a range of touches thatare abuse and may not be well informedon good, as well as touches thatarc bad the subject? without implying that genital touching itself is bad? Does the curriculum provide supplemental materials for parents and teachers and Does it describe verbal as well as physical explain how the materialsarc to be used? abuse? Are the curriculum and guide complete? Is Does it encourage children to trust their everything contained in the packageor own feelings and instincts? does it specify all the materialsyou need? Can you get the materials? Does it teach children whom to tell if there is abuse? Does it identify therange of What is thecost of the curriculum and people who make up a child's support other materials? Is the package cost- system? Will the child understand that effective? there are others to tell if one person doesn't believe heror him? Is it flexible? Does it allow the teacherto combine activities or to choose froma Do the pictures, examples, and/or music variety of activities? avoid frightening a child? Does it help the teacher to deal with Is the material free from bias? Does it disclosure once a child has confided? include a variety of male and' female, racial and ethnic, urban-and-rural situations? Are any audiovisuals short enough to keep Does it avoid stereotypes? a child's attention?

Ic-the_rnaterial cpncitiyetn the needs of Does it suggest ways to involve,parents? handicapped children? Is the material pretested? Whatarc the Does the material teach caution with expected outcomes of using the strangers without making children fearful curriculum? Are the stated purpose and of helpfuLstrangers, suchas police outcome compatible? officers? Arc children madeaware that most adults arc trustworthy?

Does it discuss family abuse inan 'appropriate way?

Adapted from the Head Start, RegionIII, Task Force on Child Abuse and Neglect.

A411. 206= Special health issues

figure 14-2. National resources for information on child abuse and neglect These-organizations provide -information, -National Committee for Prevention of Child resource lists, and/or training on various aspects Abuse, 332 S. Michigan Avenue, Suite 950, of child abuse and neglect. You should also check Chicago, IL 60604. 312-663-3520. with your local public health and mental health agencies for state and local resources. National Legal Resource Center for Child Advocacy and Protection, do American Bar Children's Defense Fund, 122 C Strett, N.W., Association, 1800 M Street, N.W., Washington, DC Washington, DC 20001. 20Z- 628 -8787. 20036. 202-331-2250. For Rids.gike, inc., 753 Lambert Road, Brea, CA Parents Anonymous, National Office, 22330 92621. 144-529-8358. Hawthorne Boulevard, Suite 208, Torrance, CA National "Center on Child Abuse and Neglect, 90505. 213-371-3501 or 800-421-0353. (California P.O. Box 1182, Washington, DC 20013. only-800-352-0386). 202-245-2840. Parents United, Inc, National Program for the IStatipi--;a:=:Child-Abuse Hotline (a referral service). Prevention of Child Sexual Abuse, P.O. Box 952, .800422-4453. San Jose, CA 95102. 408-280=5055.

2 4 4 Child abuse and neglect 207

Bibliography 'oblinsky, S., & Behana, N. (1984). Child sexual abuse: The educator's role in prevention, detec- "-----tien, and intervention. Young Children, 39(6), 3-15. Meddin, B.J., & Rosen, A.L. (1986). Child abuse and neglect: Prevention and reporting. Young Chil- dren, 41(4), 26-30,

245 Lead poisoning

Lead poisoning is the damage caused by too much accumulate in soil from the residue of auto exhaust' lead in the body. Even small -amounts of leadcan from gasoline containing lead. Children playing interfere with a Child's learning and behavior. Large outdoors who get dirt on their hands and then put amounts- may-cause,-serious- damage :to- the :brain, -their:hnnds in,their mouths ,can,become kidneys, nervous system, and red blood cells. Young poisoned. Lead is most highly concentrated in house children are at greatest risk for lead poisoning be- dust and in soil within 3' of a building Or in areas cause of their natural curiosity and hand-to-mouth close to busy streets, parking lots, and driveways. activity. They are exposed to many sources of lead in Dust and fumes created by renovation and sand- their normal. environment and absorba high pro- blasting- are also important lead sources. Adults portion of the lead to which they are exposed,espe- working in lead- related jobs or crafts can also con- cially if their diets lack adequate ironor calcium. tribute to a child's exposure by bringing home lead ICnowledge of lead poisoning should bean essen- dust on their clothes, hands, and hair. Another tial aspect of training for all early childhood educa- source of lead is lead solder used with water pipes in tors. Educate parents about the dangers of lead new construction, or in older plumbing, lead pipes. -Poisoning and encourage them to have their children screened even if the state does not require it. Each child's medical history should contain lead Lead screening screening results. Most children who are lead poisoned showno symptoms. Early symptoms such as headache and Sources of lead stomachache, tiredness, fussiness, and poorappe- tite are vague and can be easily mistaken for a viral Most lead poisoning happens when lead paint infection, teething, or stress. A blood testis the best chips or leaded dust is swallowed. While most way to find out if a child is lead poisoned: paints sold since the mid-I970s have not contained The blood screening test is a simple finger stick to lead many older homes and public buildings still collect a small amount of blood. Ideally, children have layers of lead based paint. Children become between the ages of 9 months and 6years should lead,poisened-from eating, chewing, or suckingon - b this test yearly, but children- between 9- lead-painted surfaces or items coated with lead months and 3 years who live in high-riskareas dust. Typical sources include railings, window wells should be tested every 6 months. In low-riskareas and sills, door sills, toys, furniture, and jewelry. (with mostly newer housing) lead screeningmay not Children are easily lead poisoned if theyare around be done because it is not cost-effective. old buildings that are being renovatedor redeco- Because lead levels tend to rise in the summer,a rated. Children touching things with sticky fingers screening test should be done during the months of are likely to pick up the contaminated dustor mate- May through October. Most doctors will screen rial. children for lead. Many boards of health alsopro- Soil is often overlooked as a source of lead. Soil vide screening tests, usually at no cost. Ifan elevated can be contaminated by paint that has weathered or blood-lead level is found, children will be referred to been scraped or sanded off buildings. Leadcan also their health care providers for follow-up.

246 209 210 Special health issues

Treatment and follow-up Deleading is very hazardous. Specific safety precautions must be taken to prevent poisoning work- If the initial lead screening test is elevated, the ers as well as the occupants. Steps must also be ChikrifiriSfhaVel venous -lead-test -since lingenstick taken-toprevent- contaminating;otherzparts7cf:the: blood screening tests can be contaminated by lead building, ChiIdientS-play areas, and soil. No children on the hands of the child or the person drawing the or pregnant women should be present during de- blood. A venous blood test (usually drawn from the leading, renovation, or sandblasting. Check with vein inside the elbow) is the only way to determine your department of public health for specific infor- the child's actual lead level. mation. Be sure your child care program facility is The child's health care provider will d .de on lead-free. treatment based on the venous load test. For moderate levels-of lead poisoning, the medical treatment - may =be- limited to removing the source of lead and Measures to protect children testing the child's 'blobCI frequently -to ensure that She or he -.is no longer being exposed. Sometimes Early childhood programs and parents must ac- iron is prescribed, since the lead present in the tively work to protect children by taking the fol- -blood:.interferestwith:tle:body!s,ability,tc:rnanufae, lowing_steps:. ture healthy red blood cells. Comply fully and promptly with all applicable Children with higher levels of lead poisoning may state and local regulations regarding lead testing be treated with a chelating agent. Chelation removes and removal. lead from the body and causes it to be passed Have soil tested. Contact your nearest agricultural through the kidneys. This treatment, consisting of extension service for information. daily injections either into a muscle or vein, can be Never let a child dig in contaminated soil. done in a hospital or through a clinic. Most often the Remove or cover contaminated soil (pave, sod, or treatment lasts for 5 days. Children who have very add mulch, gravel, or new topsoil). high lead levels.may require more than one course Plant bushes close to buildings to discourage play of 'treatment. there. Following the diagnosis and treatment of lead Plan gardens and play areas away from painted poisoning, children must continue to have frequent structures and busy roads. blood-lead tests to determine if additional treatment Install a fence or bushes as a barrier between busy is necessary or to detect evidence of re-exposure. streets and play areas and gardens. Lead-poisoned children should have careful devel- Provide a diet rich in iron and calcium, low in opmental testing to identify learning or behavioral fats. ;problems. Although the medical treatment for lead Use the same measures recommended to control poisoning cannot reverse brain damage, an enriched the spread of germs to help prevent lead dust environment may help children overcome or com- buildup on hands and surfaces. pensate for their disabilities. Clean your own and children's hands frequently, especially before preparing food or "ating, after touching pets or shoes, gardening, playing in soil, Environmental management or crawling. Wet-mop floors, window wells, and sills fre- When a child is identified as lead poisoned, her or quently with a trisodium phosphate (TSP) to ab- his dwelling should be inspected by a state or local sorb lead. This is available over the counter. health inspector. All deteriorating paint and all ac- Provide clean teething toys to discourage chewing cessible, chewable lead paint must be removed from on railings, painted items, or paper products. interior surfaces, common- areas, and exterior sur- Teach children to throw away any food that falls faces. Each-case must be followed until the delead- on the floor. ing is completed and the child's lead level is normal. Keep indoor toys inside and outdoor toys outside.

24` Lead poisoning 211 Bibliography

American Academy of Pediatrics.(March 1987). Lead poisoning. Pediatrics.

248

4 16 Chronic health conditions

Almost every early childhood program includes child has another.. Allergies develop whena person several children with chronic health problemSor is repeatedly exposed to a substance and the,body's medical- conditions: =For :example; =more-than-of immune system, normally protective against foreign every 10 preschool children has some type of aller- substances, overreacts to the substance, causing gy. Other less common conditions are asthma, heart symptoms. problems, and epilepsy. Children with chronic health conditions already What triggers an allergic reaction? in programs generally have mild forms of the problems and, most of the time, are able to participate in The foreign substances that cause an allergicper- the-normal routines. Even children with more se- son's body to react are called allergens. These aller- vere forms of these conditions, or with less common gens may be swallowed, inhaled, or touched. Com- chronic illnesses, can be involved in programs with mon allergens include sound planning (see Figure 16-1). indoor and outdoor dust General information about each chronic condi- pollen from trees and weeds mold from plants, dead grass, and leaves tion,can usually be obtained by contacting a volun- animal fur and feathers tary agency associated with the disease (see Figure 13-1). It is important that you get detailed infor- insect venom (bee or other insect stings) mation from parents about their children's health foods such as eggs, nuts, chocolate, shellfish, problems. When doing this, you need to ask specific cow's milk, and wheat (the last two are especially questions. The child's health record should include common allergens for infants) an additional section that describes the child's chronic illness (see Figure 16-2). What are the symptoms of an allergic attack? Allergic children do not have symptoms-all the time. Rather, they have a tendency to react under Allergy certain conditions. For example, a child withan allergy to chocolate may be in perfectly good health Whatis it? unless -she eats chocolate, in whichcase She May develop hives Or abdominal pains. An allergic reaction is a special type of inflam- Sythptoms of. an allergic reaction depend on matory (swelling) response in various parts of the which part of the body is especially sensitive to the body to a substance in the environment thatmost allergen. people tolerate without any problem. Hay fever, Allergens that are inhaled can cause asthma, eczema, hives, and sinusitisare common asthma attacks allergic reactions. sneezing itchy eyes How do people get allergiCs? coughing a is thought that-the tendency to develop allergies Allergens that are ingested (eaten) can cause largely is inherited from a parentor parents, al- itchy throat though the parent may have had allergies onlyas a child or may:have-had one_type_of allergy while the nausea/vomiting 249 213 Figure 16-1. Program considerations for young children with health impairments

Consideration. Mild Mild to moderate Moderate Severe 4"-thechild No Possibly Yes Yes H. does the health im- Health impairment does Health impairment doesHealth impairment eitherHealth impairment is so sum= use cams s"110 "'filet WIC 'W1111 day -lo- -Vvat...-.1-arn- ars...it:cm-crises 7fillictionbigt d ay 'fu ctioning ands thefelS-a passi.of so-limits the child's op;-cal= attention -is regularly I learning. bility of unusual episodesportunity to participate inneeded. The child's op- or crises. activities that it interferesportunity for activity is so with learning. limited that she or he may not be able to participate in a regular classroom. 'Mitat theprogram be No No change in programActivities will have to beExtensive staff and pro- Modified? planning is necessary.modified to allow agram changes are neces- Watch for unusual occur-health-impaired child -tosary to accept child into rences and report them toparticipate. Staff mustprogram. Home- or parents. Know any first-know proper first-aidhospital-based programs aid procedures that mightprocedures-and be pre-may be more appropriate. be required. pared to deal with chil-Classroom support from dren's questions aboutmedical services will be 1`..; crises. necessary if child is in 7 classroom. ,Adapted from Healy, McAvearey, Von Huppel, cid. Jones, 1978.

250 Chronic health conditions 215

Figure 16-2. Chronic illness health record

-Name- of -child

1. Which health problems (chronic illnesses) does 3. What procedures would the staff follow to the child have? a. prevent these crises? allergies to

anemia

asthma

diabetes

epilepsy

heart trouble b. deal with them when they occur? kidney trouble

sickle-cell disease

other

2: What happens to the child when she or he has a crisis related to the condition(s)?

4. Does the staff need to be trained in any particular emergency procedures (e.g., CPR)? If so, which one(s)?

251 216 Special' health issues

Figure 16-2 cont. Chronic illness health record

5. What medication(s) does,the child take? d. Length of activities. Describe:

e Naptime routine. Explain:

a. Are there any side effects (including behavioral)? From which medicines? f. Toileting. Explain:

g. Other. Explain:

b. Does the child need to have medication during,program hours? On what schedule?

7. Name of person(s) other than yourself (selves) to contact for questions about this child's condition if you are unavailable

Person:

Relationship to child- 6. Check all of the program areas that require any -changes. Tell us-what changes or special Phone- arrangeMents need to be made. a. ___ Diet. What? Person-

Relationship to child-

Phone- b. Order of activities. Describe: 8. Any other information you feel we should have:

c Types of activities. Describe:

Person completing form (please print) Date Chronic health conditions 217

diarrhea child is having allergic symptoms. Desensitization hives/skin rash may be used with some children who have severe allergies and/or asthma. Allergens that are touched can cause itchy/blotchy skin What should staff do during an allergic attack? skin rash/hives Use-comir on.sense,If_staff can identify the aller- In extremely rare instances, a child will develop gen, either remove the child from the allergic en= an overall allergic response that causes the voice box vironment or take the irritant out of the child's to swell and Makes breathing difficult. This reaction space. If the allergen cannot be easily identified, should be treated immediately by a physician, since and the child's symptoms do not decrease, the staff it can be fatal: Some people have this kind of reac- member should try to keep the child calm, quiet, tion to bee stings and need to have available a bee and comfortable while she or he contacts the sting kit that contains an injection to treat the reac- parent or physician. Severe reactions must be tion. treated immediately according to the procedures the parents have specified. 'What is the treatment for allergies? Parents should be required to leave detailed in- The most effective approach to treat allergies for structions on what to do if any reaction occurs. most children- with mild problems is to figure out what specific allergens cause-,the reaction and then How should programs integrate children with avoid exposing the children to them. Sortie allergens allergies? are treated by medications, either taken regularly Most children with allergies require no special (everyday or during certain seasons) or when the planning at all; common sense is the key to handling these children successfully. For example, if a child develops uncomfortable itchy eyes one spring day on the playground, she or he should be brought inside. Or, a child with a food allergy should-not be given that food, and all the parents in the group with the-allergic child could be asked not to bring birthday treats containing the food. Some of the main problems for allergic children in group programs are the following: keeping pets such as rabbits, guinea pigs, and other furry animals damp/moldy basements or bathrooms field trips to farms or zoos; hikes in the woods or playing in leaf piles Modifications in your program or physical space may be required to avoid allergic reactions.

Asthma

What is it? Asthma is a respiratory problem in which breathing is difficult and often accompanied by a wheezing or whistling sound. Wheezing is caused by this combination of events in the lungs: the muscles surrounding the air tubes in the. lungs tighten, the tis-

=c sues lining the air tubes swell, and an extra amount ,Keepmg.pets such-as rabbits; sritnea.pigs, and of mucus is produced. The airways are narrowed other" fUrrk-aniinals in group programs can cause ncause of these events, and air passing through problems for children with allergies. makes a wheezing sound. Most children with -i'41C t; 4/a 218 Special health issues

asthma have attacks only occasionally. At other asthma medications only during particular seasons times, they are fine. or.when they have colds. How-do people get asthma? What should staff do during an asthma attack? Asthma can be caused by allergic and nonallergic Yottsifould have detailed instructions about what triggers. Children with allergic asthma probably in- to do during an asthma attack, including a descrip- lierited the tendency, from one or both parents. It is tion of which symptoms are particularly worrisome. -not yet clearly understood how children develop An asthma record for each child- must be at- nonallergic asthma. tached to the child's general medical forin (see Figure 16-3). General guidelines include the fol- What triggers an asthma attack? lowing: Because children's lungs are especially sensitive if Remove the child from the allergen, if it is known. they have asthma, a-variety of factors can trigger an Try to.keep the child calm and relaxed. attack including Keep the child sitting upright. allergens, such as dust pollens, molds, feathers . Encourage the child to drink fluids (but nothing weather conditions, such as cold- air, weather ice cold). changes, windy or rainy days Administer medications as indicated by-parents smoke, both cigarette and other types and doctors. odors, such as'paint fumes, aerosol sprays, cleaning materials, chemicals, perfumes How should a program plan to accommodate infections, especially viral respiratory tract infec- children with asthma? tions Most children with asthma can participate in the exercise, especially strenuous exercise in cold or usual early childhood program's activities. Adults in damp weather contact with theSe children should know emergency sleeping with head not raised, especially when the procedures and what allergens to avoid in the class- child has a cold room environment: and in foods served. If a child tends to get asthma during exercise, staff should What are the symptoms of an asthma attack? keep- close watch during strenuous activity. If an asthma attack begins, the child should be kept quiet During an attack, a child has discomfort or tight- and encouraged to relax; after the attack, the child ness in the chest and has difficulty breathing. This is may be able to continue playing. Be sure to let par- usually accompanied by the wheezing sound, espe- ents know of the attack at the end of the day so that cially when breathing out (exhaling). Sometimes they can monitor the child's condition. coughing and'spitting up mucus are part of the ep- Parents of children with asthma know their isode. Asthma attacks can frighten children, or they may appear tired and listless. children's limitations and should be consulted frequently so your program does notun- What is the treatment for asthma? necessarily limit the child's activity. Depepding on the frequency of attacks and severity af-the asthma; a range of treatments is available. Often, asthma attacks are mild-and will calm down with, est or treatment within a short time. Keeping the Child away from the irritants that are known to Heart problems -cause-wheezing-is-the first step. Some children take regular medications to relax airways, making it eas- What are they? ier to breathe; prevent exercise-induced asthma; de- The heart is a muscle that pumps blood through crease inflammation; and relieve nasal/sinus con- the body. It is divided into four hollow parts called gestion, itching eyes, and sneezing. chambers. The blood goes from the heart to the Special equipment called nebulizers convert the lungs to pick up oxygen. The blood then returns to medicine into a fine mist that can be inhaled. Some the heart so it can pump the blood out to the body. children- with asthma use nebulizers on a regular As the oxygen is used up, the blood returns to the basis or to treat an attack. Other children need heart and the process begins again. 9 -Ad c t-1 Chronic health conditions 219

Figure 16-3. Asthma record

Child's name Parents' names and phone numbers

(work) (home)

(work) (home) Physician's name and phone number

,1; Describe the child's asthma symptoms, including when they generally occur. What triggers an attack?

2. How are mild episodes (attacks) treated?

3. How are serious episodes treated?

4. Is this child on daily medication?. If so, give details here:

0: 5. Are there any side effects of the medicationphysical and/or behavioral? If so, please explain. 220 Special health issues

Figure 16-3cont. Asthma record

6. Does strenuous activity seem to trigger episodes? If so, under which conditions should this child not participate in sports?

7. Do weather conditions affect the asthma') If so, how?

8. Does the child understand asthma')

If yes, does the child participate in the management of this condition') How?

Additional comments

D4e 406 Chronic health conditions 221

Heart problems occur when one or more of these shorter active play periods are not working properly: additional rest periods, longer naps the pumping Chambers more frequent smaller meals the valves that separate the pumping chambers administration of regular medications and keep the blood flowing in the proper direction It is important to obtain.detailed information from the blood vessels Lading to or from the heart parents and doctors describing the types and amounts of -activities =in -wilieli'these-childreti tam participate. Activity restrictions -are unusual be- How do children develop heart problems? cause children will generally pace themselves.If you Most heart problems in children are congenital are uncertain if a child should take part in a particular event (e.g., dance or movement), get advice (present at birth). These congenital- defects begin-in from the doctor and/or parent. Make sure to explain the early part of pregnancy when the heart is form- to the other children the reasons for the child's lim- ing. Heart disease also may occur in children who ited activity and provide opportunities to excel in have had rhetimatic fever, an unusual complication non-physical areas. Do not restrict the child be- of strep throat. They are left with s_ carred valves that -yond,whatissequested by, doctors or parents. do not properly control the flow of-blood' between It is important that children with a history of pumping chambers. rheumatic fever not contract strep. throat. If'there, are cases of strep throat in your program and you have a child who has had_rheuthatic fever, What- is-the treatment for children with heart inform her or his parents immediately. problems? Many congenital heart defects are mild and.do not require therapy. The most severe congenital heart defects and sc:Ae heart disease from rheumatic fever can be corrected or vastly improved with sur- Epilepsy/seizure disorder gery. Other heart defects can be treated with drugs or mechanical' aids such as pace-makers. What is it? Often children who-have had rheumatic fever will The brain serves as a master control center for take daily antibiotics to prevent them from catching almost all functions of the body including move- another strep throat that could possibly causc fur- ment, thinking, feeling, and talking. It sends electri- ther damage to their heart valves. cal charges along nerves to body parts and also receives and interprets these electrical signals. Epilepsy is a disorder of the brain in which the What are the symptoms of heart disease? brain sometimes becomes overloaded with electri- Congenital heart problems care be identified in cal charges and produces a set of uncontrollable movements called seizures or convulsions. The loss infants who have a bluish color, difficulty breathing, or abnormal growth and weight gain. These chil- of control is temporary, and the brain usually func- dren, as well as those with rheumatic heart disease, tions normally between seizures. Epilepsy is fairly may tire easily and feel weak. In most cases, heart rare compared to allergies; it is estimated that be- problems are already known to parents before a tween 1 and 2% of all children have some form of child is enrolled. However, in case they are not, it is seizure disorder. Among preschoolers, it is thought important to alert parents to any such symptoms as to be less than 1 child per 100. they may indicate heart disease. The two most common types of seizures are grand mal and petit mal (absence) seizures. Grand mal seizures are the most dramatic sei- How can programs accommodate children with zures and affect the whole body. Grand mal sei- heart problems? zures usually last only a few minutes. During this Children with heart problems not fully corrected time the person becomes unconscious and may bysurgery or children recovering from surgery may shake violently; drool at the mouth;' and/or bite require modifications in the daily program because lips, cheeks, or tongue. The individual may also their stamina and endurance may not match that of have no control over bladder and bowel move- other children. These modifications include rAents. A deep sleep may follow the seizure. In ow tit 222 Special health issues

suaie-....,...,-:th..,seizure is preceded by a-cperial What should staff do during a grand mal seizure? feeling that differs from person toperson. This warning sign is called an aura and enables the Although a grand mal seizure appears frightening;, it is not dangerous to the child and generally will person to get ready by lying on the floor to pre- pass without complications. These steps should be ; vent a fall. taken by staff members during a grand mal seizure. ,-"etit-mall.absencg)_seiztire.s.are..very_short_and. Remain calm. usually very frequent. The child mayseem to stare Remember that-there "is no way to stopa seizure" blankly, blink, or experience slight twitching, and once it has begun, except by methods available to then return to an activity. Though this behavior is a physician. often mistaken for daydreaming,a child ex- If the child is on the floor, leave heror him there; periencing an absence seizure cannot be roused if the child is elsewhere, place her or him,on out of the seizure, as one can do with a day- either side, on the floor. dreaming child. Petit- mal seizuresarc most Clear the area of hard, hot, sharp, or pointed ob- common in youngChildren. Children with petit jects. mal often have hundreds of brief (absence) sei- Place a soft pillow or clothing under child's head. zures each- day. Loosen tight clothing. Turn the heicitoihe Side so the child canbreathe- and-saliVa-cannOt colleet-in-the throat. Do not place any sticks or other objects in the How-do children get epilepsy? mouth:during a-seizure! There are many different knowncauses of sei- Do not try to interfere with or stop the seizure zures in children, including movements (except to prevent serious injury from high, rapidly rising fever knocking against something). infection, such as viral encephalitis Stay with the child until the seizure ends (usually metabolic or body chemistry imbalance 2 to 3 minutes) and help her or him to a comfort- head injury/trauma (complication at birthor able place to rest for a while. afterward) Have a treatment plan prepared for seizures that poisoning, such as lead poisoning last more than 15 minutes (status epilecticus). Heredity may also be a factor. Formany children Emergency contacts and transportation to a hos- with epilepsy, however, there is no knownex- pital should be arranged immediately. planation for the brain's malfunctioning. Reorient the child to activities. It is critical that the child not be made to feel awkward after a seizure. The teacher should discuss What triggers an epileptic seizure? seizures with the child's group in advance so the other children will be prepared. Some children's seizures have known triggers including fatigue, blinking lights, scaryamusement What should a program do to integratea child rides such as roller coasters, certain soundsor with epilepsy? odors, or rapidly rising fever. For other children there are-no known triggers. Most children with epilepsy take medication -to- control their condition and therefore no special planning is needed for them. It is important, how- What is the treatment for epilepsy? ever, to train staff in emergency procedures and get complete medical information from parents and At-present, there is no-cure for epilepsy. However, physicians. in the case of children who-haveocca- almost half of all people with epilepsy have their sional seizures, the staff should know which activi- seizures completely controlled by medications and ties might be dangerous and should prepare the other treatments. An additional 30% of people with other children to be helpful if they seea grand mal epilepsy have their seizures substantially, although seizure. not totally, controlled. As with other conditions, the child with ep- Most children with epilepsy will be taking daily ilepsy should not be restricted from par- medication. Information on the medication,pos- ticipating in the full program, unless specific sible side effects, and seizure triggers should be ob- limitations are imposed by parents or physi- tained from parents and physicians. cians.

1...... :-,.. ad Chronic health conditions 223

What are Sebrile seizures? What triggers a sickle-cell crisis? 'Febrile seizures are seizures iii children younger A sickle-cell crisis can be set off by an infection, than 4 years that usually occur as the child's tern- fatigue, unusual stress, or overexertion. At times, a ,perature is rising. They last less than 15 minutes and crisis occurs without any identifiable trigger. cause no permanent-harm. Once a child has been evaluated and found to have febrile seizures, no What is the treatment for sickle-cell anemia? __._treatment is- needed other than cooling the child off during illness with fever. Sickle-cell anemia-isnot-ciirable,-Ithough-it-ran- sometimes be controlled by -medication. Its complications can often be treated. Children with sickle- cell anemia should avoid overexertion and infections. Some children with sickle-cell anemia require Sickle-cell anemia hospitalization to deal with painful crises and infections.

What is it? How should a program prepare to integrate a Aneinia is a general --tern for a blood disorder child with sickle-cell diseaie? Caused by too tow red blood cells or too little Because a child with sickle-cell disease is par- hemoglobinthe pigment that gives the red blood ticularly vulnerable to infection, the decision to theincolor-These red blood cells are important place such a child in a group setting is a delicate one to the breathing process and they feed the body 'S that should be reached jointly by parents,,pliysi-, other cells; therefore, people with anemia often cians, and staff. A child with a mild case may be able seem to be tired or to lack energy. to participate fully and should be encouraged to do With sickle-cell anemia, the normal round red so. You should have detailed information on the cells take on a sickle shape, and they do not contain child's ability to engage in physical activities, begin- the correct amount of oxygen. They have difficulty ning symptoms of illness or infection, and proce- moving through the smaller blood vessels and be- dures to handle a sickle-cell crisis should it occur. cornc,,damaged or destroyed. Sickle-cell anemia is Discuss the child's illness with other children in the mast commonly found in Black children and young group in a sensitive way. -adults. Detailed emergency procedures must be available as well as several possible contact persons who know about the condition. How do people get sickle-cell anemia? Diabetes Sickleycell anemia is a disease that children in- herit from their parents. Parents may be unknowing What is it? carriers and pass the defective gene on to their chil- ,dre.n.,Both-parents-must pass on a defective gene to Diabetes is a condition in which the pancreas, a produce a child with sickle-cell anemia, but either gland located behind the stomach, doe, not produce parent can pass on a defective gene to produce a enough of a natural chemical called insulin. Insulin -child-who carries.the.sickle-cell trait. is a very important substance that helps the body store and use (metabolize) sugar (glucose). All cells in the body need glucose to work properly, since it is their main fuel or food for energy. Without insulin, What.happens during .a sickle -cell crisis? these cells cannot use -the glucose already in the Sickle-cell anemia affects children differently. A blood and do not get enough nourishment. small percentage, are able to participate in all activi- There are two forms of diabetes: ties, but a far greater number have intermittent insulin-dependent diabetes (also called Type I or periods of fatigue and pain. When a large number of juvenile-onset diabetes) .sickled cells stick together in a blood vessel, the non-insulin-dependent diabetes (also called Type blockage is called a crisis. It usually causes extreme II or maturity-onset diabetes) pain in the place where it occurs. Common locations Almost all children have the insulin-dependent are the hands, feet, legs, and abdomen. form, which means they must add insulin to their

; 259 224 Special health issues

`bodies daily 'tlifoitgh injections, usually two each headache and dizziness day...Imaddition-to,the ,each child needs to abdominal pain or nausea follow a special diet. Insulin and diet must be bal- blurred vision anced with exercise. Food makes the-ghicose (blood- drowsiness/fatigue sugar) level rise; exercise and insulin make it fall. If an insulin reaction is not treated immecli- Problems-can result from an imbalance among ately, unconsciousness and convulsions may oc- ..thes-e.ifactors.. The. most ,corrimbn. reaction,. when cur. blobd=s-ugar1evel is too low, is called an insulin reaction or hypoglycethia. Much rarer is a blood-sugar level that is too high; this results from not enough What should a staff member do during an insulin to allow sugar to be used. Acids and fruity- insulin reaction? smelling ketones build up. The person starts to Follow the procedures, approved in advance, by breathe differently and can become unconscious if the parents and physicians. the Situation is not corrected. This condition is Provide sugar immediately in the form of orange called ketoacidosis and" Can lead to a diabetic coma. juice, other sugar-containing juice, or granulated This does not come on suddenly and is generally not Sugar. a concern for child care program personnel-. Reassure the child. Call parents or physician if there is no improve- How do children get diabetes? ment within 10 to 15 minutes. When the child is feeling better, provide a small The causes of diabetes are not yet known. How- snack. ever, it is generally thought that a child inherits Invite the child to resume activities. diabetes, and many diabetic children have a family history of the disease. How should a program prepare for a child with diabetes? What is the treatment for diabetes? Collect 'basic information about the child's dia- Most insulin-dependent diabetic children must betes prior to enrollment using the chronic illness have insulin injections twice daily. They must stay health record (Figure 16-2). Note additional in- on a diet that is specifically planned for their normal formation on emergencies that may occur as well. activity level and temperament. Exercise is neces- Make sure you get information on signs and sary to control diabetes. Finally, using a simple pro- symptoms the child usually exhibits before an in- cedure several times each day, the blood or urine sulin reaction; when insulin reaction is most should be tested to determine their blood-sugar likely to occur; and the most effective treatment level. Although diabetes.is not curable, in most cases and amount. it can be controlled so that children may lead full Acquaint all staff with the signs of an insulin reac- lives. tion and how to treat it. Post general procedures in each classroom. What triggers an insulin reaction? Make sure every staff member has quick access to An insulin reaction occurs when the glucose level sugar or the sugar-containing foods suggested by is too low; either because of too much exercise or the child's physician. too little food. An insulin reaction is usually sudden. Prepare meals in accordance with the child's special requirements. Work out meal plans with the parents and/or consulting dietitian. What are the symptoms of an insulin reaction? Give meals anr: snacks on time. There are warning signs that an insulin reaction is Have the child eat an extra bit of food before going, to.occur. Often a child will feel these symp- strenuous exercise, if prescribed. toms coming on and alert a staff member. Assist in monitoring the child's blood-sugar level staggering/poor coordination if requested. Review this or any other special re- irritability/unusual behavior quirement with the parent and physician. pale color/sweating Explain insulin reactions to the other children so confusion/disorientation they can inform an adult if a reaction occurs. excessive hunger Children with diabetes should not be unduly trembling/crying restricted from involvement in all activities. 20.0 Chronic health conditions 225

Know what behaviors a child is likely to have during and after a crisis and how long it usually a lasts.

Review of emergency planning considerations

These summary points, adapted from Main- Ask the parent/doctor to describe, demonstrate, streaming Preschoolers, apply to all programs serv- or train you in what you are to do during al- d ing children with chronic conditions. following the crisis. Can you do it alone or should Prepare for emergency situations by talking to you get help? parents or the child's doctor. Prepare a list of typical classroom activities. Ask Be aware of what may cause a crisis and how the child's doctor to check off activities that must often it may occur. be avoided and to describe modifications so the Be aware of how the child may behave before a child can participate. crisis. - Prepare other children for possible health crises Know what behaviors the child is likely to have by giving them a simple explanation when dis- during and after a crisis, and how long it usually cussing other emergencies. Assure ..hi!dren that lasts. the staff will be able to handle all such situations.

261 226 Special health issues

Bibliography

Paniphlets, 'booldetS, and information sheets from City of Boston. Mayor's Commission on the Handi- agencies such as those listed in Figure 13-1 (p. capped/Boston Public Schools, Department of 00). Student Support Services. (1982). Chronic health Black, E., & Nagel, D. ,(Eds.). (1982). Physically problems: The special needs booklet series.. Bos, 'handicapped' Children: A. Medical atlas for teach- ton: City of Boston. ers (2nd ed.). New York: Grune & Stratton. Freudenberg, N., Feldman, C., Clark, N.,, Millman, Booth, A., Donsbad, P., & Maykut, P. (1981). Main- E.J., Valle, I., & Wasilewsld, Y. (1980). The im- streaming children= with a handicap in day care pact of bronchial asthma on school attendance and preschool: A manual .of training activities. and performance. Journal of School Health, 50, Madison, WI: Wisconsin Council on Develop- 522-526. mental Disabilities. Healy, A., McAvearey, P., Von Huppel, C.S., & Boston Children's MedicaluCenter, & Feinbloom, R. Jones, S.H. (1978).. Mainstreaming preschoolers: (1985). Child health encyclopedia: The complete Children with health impairments. (DHHS Publi- guide for parents. New ,;York: Delacorte Press= cation No. [OHDS] 80-31111. Washington, DC: /Seymour Lawrence. U.S. Government Printing Office.

0 n 0 (*) Section G Managing illnesses

Major concepts

Your program must establish detailed policies about preventing and-handlingillness, including policies about attendance by sick children and staff. You can help to-prevent the spread-of disease by following appropriate precautions. Always consider all body-secretions from children, adults, and animals to be POSSIBLY INFECTIOUS. These indude stool, urine, blood, and secretions fromthe 'eyes, nose, throat, and skin. It is essential that you handle secretions carefully and dean up after them, even when this.process is complicated. Despite your best efforts, children and adults will get sick. It isan expected part of life. Become familiar with signs and symptoms of illness. Encourage the parents of sick children to consult their health care provider for diagnosis, guidance, andcare. Recognize that many illnesses DO NOT require exdusion. Most mildly ill childrencan safely attend if they feel *NI enoughto come. Discuss options available for sac Chili care with parents at the time of enrollment. 'roe juiiritOikieSauuur non. Take active steps to educate staff, parents, and children about infectious illnesses, techniques to prevent their spread, and proper care of ill children.

263 17

Allow sufficient space between cots, cribs, and Infectious diseases other Furniture. Infectious diseases are illnesses caused by infec- Clean and sanitize areas for diapering, toileting, tion with specific microorganismsviruses, bac- and eating as well as toys and furniture. teria, fungi, or parasites. Contagious or communicable diseases are infectious diseases that can To clean the environment, wash with soap and spread from one person to another. water and then use the bleach solution (see Figure Contagious diseases are one of the major prob- 3-1 on p. 26). lems Ahat,prograrrxs-for-young children must face. e -Remember than an,ounce of_prevention-is worth. They cause discomfort, suffering, and absences for a ton of cure. both children and staff. Occasionally, outbreaks of Refer to Chapters 3 and 4 for detailed information serious diseases may occur. If precautions are not on these topics. taken, these serious diseases can spread quickly. Infectious illnesses are often spread by people The organisms that cause infections and contagious who do not look or feel sick. Body secretions from diseases are spread in four main ways: these people get into the air, food, or onto surfaces through the intestinal tract (via the stool) where they are breathed, eaten, or touched by through the respiratory tract (via secretions or others. To control the spread of illness: fluids from the eyes, nose, mouth, and lungs) through direct contact or touching teach children and staff how to catch a sneeze/ through blood contact cough correctly and how to dispose of tissues. This chapter will give you information about some Sneeze and cough toward the floor and awa:, of the contagious diseases that occur in early child- from other people. If you sneeze or cough into your hands or into a tissue, you will have to wash hood,programs. It will also discuss some common your hands! infectious diseases that are not contagious. use running water, liquid soap, and individual paper towels for handwashing The five commandments or infectious disease control do not allow sharing of personal items

1. Prevent illness from spreading 2. Require certain immunizations The viruses and bacteria that cause infectious ill- All children in your program must be immunized nesses thrive in warm, wet, and stuffy environ- against the diseases of diphtheria, tetanus, per- ments. Conversely, these infectious agents have dif- tussis, poliomyelitis, measles, mumps, rubella. and ficulty growing in clean, dry environments where Haemophilus influenzae (Hib) at appropriate ages there is lots of fresh air. To prevent the spread of unless they are exempted by your state laws for re- illness, take these steps. ligious or medical reasons. You must exclude chil- Require correct handwashing procedures for dren who are not properly immunized. adults and children (see Figure 4-1). Figure 17-1 shows childhood immunization schedules typically recommended by state public _ Air out the rooms daily, and take the children health departments. Ideally, these schedules would outside often. not be interrupted, and most children would com-

26 4 229 230 Managing illnesses

Figure 17-1. Recommended schedule for active immunization of noniial infants and children

RecommendedImmunization(s)t Comments Age

2 mo. DTP OPT Can-be-initiated as early as age 2 wk in areas of high endemicity or during epidemics 4 mo. DTP OPV 2-mo. interval desired for OPV to--arid interference from previous dose 6 mo. DIP A third dose 'of OPV Is not indicated In the U.S. but Is dosirable,in geographic areas where polio Is endemic 15 ma. Measles, MMR preferred to individual mumps, vaccines; tuberculin testing rubella. .erfa9.-iie,dbee_ at-the -same (MMR) visit (see ibberculosis, page 431) 18 mo. DTRt§ See-footnotes OPV,II PRP-D 4-6 yr DTP,1 OPV At or before school entry 14-16 yr Td Repeat every 10 yr throughout life

'For all products used, consult-manufacturer's package insert for Instructions for storage, handling, dosage, and administration. Bio- logics prepared by different manufacturers may vary, and package Inserts of the same manufacturer may change from time to time. Therefore, the physician should be aware of the contents of the current package Insert. tDTP =diphtheria and tetanus toxoids with pertussis vaccine; OPV =oral poliovirus vaccine containing attenuated poliovirus types 1, 2, and 3; MMR=live measles, mumps, and rubella-viruses in-A combined vaccine (see text for. discussion of single vaccines versus combination); PRP-D =Haemophilus b diphtheria toxoid conjugate vaccine; Td=adult tetanus toxoid (full dose) and diphtheria toxoid (reduced dose) for adult use. *Should be given 6 tow 12 months after the third dose. §Mayliehien-simuitac=iy,.Avith-P4MR.staae-t 15 months. liMay be given simultaneously with MMR at'15-"Months of age or at any time between 12 and 24 months df age. 1Up to the seventh birthday.

Figure 17-1 is reprinted with the permission of the American Academy of Pediatrics, Elk Grove Village, IL. The immunization schedules are from the 1988 Report of the Committee on Infectious Diseases, ed. 21, AAP Committee on Infectious Diseases, 1988.

0t).r%r- 4ir'' Infectious diseases 231

Figure 17-1 cont. Recommended immunization schedules for children not immunized in first year of life

Recommended Time Immunization(s) Comments Less than7years old

-First-visit DTP,-OPV,- MMFLit chkid_15 mo. old; MMR tuberculin testing may be done at same visit (see Tuberculosis, page 431) Interifil-after PRP-D For children aged18-60 mo.; can first visit: given concurrently with DTP 1 mo. (at seParate)sites) and other vaccines* 2 mo. 4 mo. A third dose of OPV is not indicated in the U.S. but is desirable in geographic areas where polio is endemic 10-16 mo. OPV is not given if third dose was given earlier 4.6 yr. (at-or OFV DTP4s.rietificessary if the before fourth dose was given after the school fciiirth birthday; OPV Is not entry) necessary if recommended OPV dose at 1016 mo. following first visit was given after the fourth birthday 10 yr later Repeat every 10 yr throughout life

7 wars Old and Older

First visit Td, OPV, MMR Interval after first visit 2 mo. Td, OPV 8-14 mo. Td, OPV 10 yr later Td Repeat every 10 yr throughout life

The initial three doses'of DTP can be given at 1- to 2.month intervals; so, for the OMin whom immunization is initiated at age_24 months or older, one visit could be eliminated t rij giving -DTP, OPV,Ind-MMR-atrttiii-fir3t and- PRP-D at the second visit (1 month later); and DTP and OPV at the third visit (2 months after the flit visit). Subsequent DTP and OPV 10 to 16 months'after the first visit are still indicated. PRP-D, MMR, DTP and OPV can be given simultaneously at separate sites if return of vaccine recipient for future immunizations is doubtful.

Figure 17-1 is reprint ed with the permission of the American Academy of Pediatrics, Elk Grove Village,IL. The immunization schedules are from the 1988 Report of the Committee on Infectious Diseases, ed. 21, A A.PCommittee on Infectious Diseases, 1988.

266

Wes. 232 Managing illnesses

plete their basic series of immunizations before the who diagnose these diseases are generally the manage of 2 years. Imreality, however, appointments are dated reporters. missed and immunization schedules are disrupted. .PartiaLininiuniiations,do complete 4. Exclude some children protection against disease. For this reason, children with delayed or disrupted schedUleS fiiiiSt re- Contrary-to popular belief and practice, ordya ceive makeup immunizations according to the few illnesses require exclusion of sick children to schedule for children not immunized in the first ensure protection of other children and staff. Figure 11,7 -lists seven_ of -thpci..illrsPccPc_ anri_giuPS, To:determine-if.a,child is, eligible to, enter your exclusion guidelines for each. program With- most other illnesses; .children have:either ask the parents to obtain a completed Certificate already exposed others before becoming obviouSly of Immunization (or a Physician's exam form, ill (e.g., colds) or are not contagious at some point Figure 9-6) from their health care provider after beginning treatment (e.g., strep throat, con- determine the child's age junctivitis, impetigo, tuberculosis, ringworm, para- compare the immunization record with the rec- sites, head lice, and scabies). The waiting periods ommended schedule in Figure 17-1 to see if all required after the onset of treatment vary with the immunizations are up-to-date disease (see specific disease descriptions later in this Additional information on vaccine-preventable dis- chapter). eases is provided later in this chapter. In some cases, children may attend ONLY IF SPECIAL PRECAUTIONS ARE TAKEN (see spe- 3. Report some illnesses cific disease descriptions). Children who are carriers of viral illnesses such as- CMV (cy,, titery state has laws that require early childhood tomegalovirus) and herpes can and should be programs to report the occurrence of certain infec- admitted. tious diseases to- the state department of public When your program allows mildly ill children to health. Because reportable diseases vary from state attend, consider these steps to better meet their to state, you need to contact your local board of needs. health for the Current list. Be sure to incrude this list Maintain a small room or area where they can and a reportihg procedure in your health policy. The spend a quiet day. purpose of reporting certain diseases is to enable If the child's illness might worsen with outdoor your board of health and/or state department of play, assign one staff person to remain with this public health to conduct investigations and take ap- child when others go outside. propriate measures to prevent further spread of Refer to Chapters 18 and 19 for additional infor- contagious diseases. mation. For some diseases, an individual occurrence must be reported (e.g., hepatitis and meningitis). Other diseases must be reported when an outbreak (in- 5. Be prepared! volvingthree or inure children or sta.1) occurs. Gen- Don't wait until an epidemic hits! Do some ad- _erplly, an epidemic (a large number of cases in a vance planning and take these steps. short period of time) should be reported, even if the Insist that staff learn and follow handwashing, disease is not listed (flu, mononucleosis, con- cleaning, and ventilation guidelines. tir pneumonia). Choose a health consultant. who knows about in- Special reporting requirements usually exist for fectious disease in early childhood settings. illnesses caused b3 consumption of contaminatea Have the phone numbers of your local board of food. If a number of your staff and children experi- health and the state department of public health ence stomach cramps, vomiting, diarrhea, and/or posted and readily available. dizziness, suspect food contamination and report Make sure children's immunizations are up to the situation. date before you admit them. Check immunization Finally, there are a number of diseases, such as status for a!! -:hildren at least once a year, Acquired Immune Deficiency Syndinme (AIDS) and Make sure parents recognize their responsibilities sexually transmitted diseases (STDs), that must be for taking their sick child to the health care pro- .reparted :toyour state public health department. vider and for reporting a contagious illness to Physicians, health care providers, and laboratories you. Do not expect parents will read all the mate- 267 Infectious diseases 233

rial you give them. Review health procedures teria, or parasites) that multiply in the intestines orally at enrollment and send a letter annually to and are passed out of the body in the stool. Anyone all parents. 'Describe each of your he, nth policies can catch these diseases, and they can be caught and_ask _them to repeatedly ,(except. .for .hepatitis A). Programs that --eat or ''/../ite When their child is ill and tell'you care for children in diapers are especially at risk, the .problem: -because staff- and children may get- stool on their =call or write if a health care provider makes a hands frequently. When stool containing these specific diagnosis-(such as strep throat)' germs gets On hands or objects, it can inadvertently ---4elLyou immediately' if Hilo or meningococcal be swallowed. Swallowing as few as 10 Shigella or diiease is diagnosed Giardia germs can cause an intestinal tract illness. keep theft- child home if she or he has an ex- Salmonella and Campylobacter germs must be swat efildable illiieSS lowed in'larger quantities-to cause illnesss. Children call and discuss with you whether or not their or staff with disease-causing germs in their stool child should attend when she or he has mild diar- may not actor feel sick or have diarrhea. Laboratory rhea or an infectious disease that has been treated tests are the only way to tell- if a particular stool has inform you of any changes in emergency num- these germs in it. These tests are sometimes done as bers-where they can be reached each day part of an effort to control an outbreak of disease. Be watchfullIcarn to look for signs of infectious If cases of infectious diarrhea, pinworms, or hep- disease.. Call or-send a note home if you suspect a atitis A occur, notify. parents, staff, and your health problem. consultant. Also, report both infectious diarrhea . -Inform staff and parents of contagious diseases and hepatitis A to your local, board of health. that occur in your program. How to stop spread of intestinal tract diseases Diseases spread through the intestinal Because children and staff who have intestinal tractInfectious diarrheal diseases, tract diseases don't always feel sick or have diar- pinworms, hepatitis A rhea, the best method for pt=eventing spreadthese diseases is to have a constant prevention 1-Togram in These diseases are caused by germs (viruses, bac- place. Take these special precautions.

Children and staff sometimes .have an infectious disease without feeling sick. The best way to prevent the spread of disease is to have a constant prevention program in place. 234 Managing illnesses

Figure 17-2. Exclusion guidelines

Staff must exclude children with these illnesses or symptoms. Exclude until 11iteiiirigOeocCal-disease (Neisseria well and also completed 2-day course of -meningitides) Rifampin Hib disease-_(Haemophilus influenzae) Well and also completed 4-day course of Rifampin a diarrhea and illness (such as fever and/or Diarrhea gone (or clearance from health vomiting) consultant) diarrhea (if the program cannot assure special diarrhea gone (or clearance from health precautions) consultant) chicken pox 1 week from onset, or skin lesions (blisters) scabbed over. Children with chicken pox who were in contact with their group in the few days before developing the chicken pox rash need not be excluded if they are well enough to fully participate. Chicken pox is so contagious that exclusion after exposure occurs is useless. hepatitis A 1 week after illness started AND fever gone AIDS (or HIV infection) 4 years old. Children from birth through age 3 years, who have clinical AIDS, should not attend a group setting because of their increased susceptibility to infection. Children ages .4 and 5 years zind the developmentally disabled who have clinical AIDS or evidence of infection with HIV may attend a group setting UNLESS they have skin eruptions or weeping lesions that cannot be covered, or are likely to be bitten by the other children. (In either of these cases, the child's physician and the program should collaborate to decide about the appropriateness of the child's attendance. Siblings of children with clinical AIDS or evidence of infection with HIV virus may attend group programs without any restrictions. Other diseases may have waiting periods after treatment beginsor may require special precautions.

2 6 Infectious diseases 235

Insist on frequent, thorough handwashing for tive stool cultures) but haveno diarrhea or illness both staff and children (see Figure4-1). symptoms.. . take special precautions but do Insist on general cleanliness. (See Chapters 3 not exclude them. (Also makesure they receive and 5 for detailed informatiorton cleaning, sani- appropriate management.) tizing; arid diapering:) When staff who normallyprepare food or feed Separate children into three.groups.whenever .children-have-positive possiblei infants, diapered children, and .-DONOT toilet- ALLOW THEM TO PREPARE FOODOR FEED trained children. Try to have-a staff memberwork CHILDREN until they have with only one group to avoid carrying two negative stool germs from cultures taken 48 hoursapart. (Cultures should group to group. (Note: Because this type ofgroup- not be taken until 48 hours after medication ing may not meet administrative is or child devel- completed if antibioticsare used). -opment...needs; directors-will, have-to- conSider a variety of factors when grouping childrenand as- Special precautions signing staff. If mixing staff andchild groups must Occur, minimize the numbers of people strictly -enforce all handwashing, diapering; in- toileting, and cleaning procedures; and volved and emphasize careful handwashingfor all concerned.) set up a separate room or area where added staff attention is provided Return guidelines. Excluded children and staff Infectious diarrheal diseasesGiardia, may come back after treatment and whensevere Shigella, Salmonella, and Campylobacter diarrhea is gone. Continue to takespecial pre- , cautions until all those with positivestool cultures People have diarrhea when they have more stools have had two negative stool culturesafter treat- than normal- for-them andthe stools are loose, ment. watery, and unformed. (Exception:Breast-fed ba- Alies may have stools thatare normally unformed.) Infectious diarrhea is caused byviruses, para- How to stop spread of infectious diarrheal sites, or bacteria andcan spread quickly from per- diseases son to person. Non-infectious diarrheacan be caused by toxins (e.g., food poisoning), Follow handwashing and cleanliness procedures. chronic dis- Keep track of the number ofcases of diarrhea and eases (e.g., cystic fibrosis), or antibiotics(e.g., am- take these steps: picillin) and does not spread from person to person. If one person has diarrhea,use special pre- This section gives detailedinformation on infec- cautions or exclude her tious diarrhea caused by Giardia, or him. Shigella, Salmon- If two or three people havediarrhea, use spe- ella, and Campylobacter. Otherinfectious diarrheal cial precautions agents including parasites (e.g., or exclude them. Ask parents to crypotosporidiosis, have stool samples cultured and examined amoeba), other bacteria (e.g., for ova Yersina), and other (eggs) and parasites by healthcare providers. In- viruses (e.g., Rotavirus)are not discussed in detail, but the general stop-spread form staff and parents (seeFigure 17-3). Talk to instructions in thissec- your health consultant. tion apply to all of.these diseases. If more than threepeople have diarrhea, do all of the above AND callyour local board of health for help. Exclusion guidellines When children or staff have diarrheaand fever or Giardia lamblia diairhea that cannot be contained bydiapers or What is it? Giardia lamblia is routine toileting procedures, an intestinal para- or vomiting (or have site in the small bowel thatmay cause chronic diar- severe or bloody diarrhea).. . exclude until rhea, abdominal cramping, bloating,pale and foul- treated and fever and diarrheaare gone. smelling stools, weight loss, andfatigue. Although When children or staff have mild diarrheabut are not sick many people who have Giardia donot experience .. . take special precautions or ex- these symptoms, theyare still passing Giardia cysts clude. (Also makesure they receive appropriate in their stools and are infectious ifuntreated. management with fluids and diet.) Who gets it and how ? Giardia is When children or staff very common are found to have infec- between 3 and 20% of all people haveit. It spreads tious diarrheal disease agents in their stool (posh quickly in programs foryoung children, especially 270 236 Managing illnesses when children in diapers are present. The mi- How is it treated? Children and adults who have croscopic Giardia cysts are spread by contact with Shigella in their stool should receive antibiotic stool, drinking untreated water, and sometimes by medication that shortens both duration of the ill- drinking water in areas where the water supplies are ness and length of time that bacteria are passed with the stools. How is it diagnosed? Stool must be examined un- When should" people with Shigella be excluded der a microscope to identify Giardia cysts. Because apd allowed to return? Sze infectious diarrhea ex- Giardia is present in stools only intermittently, sev- clusion and return guidelines. ,eral examinations. must be made. Where to report it? Notify parents and staff if a How is..it treated? -Most health- providers agree child ,or, staff member is diagnosed with Shigella that persons with Giardia who are ill and/or have (see Figure 17-3). Also notify your Health consultant diarrhea should receive medication. Your local and your local board of health. Family and house- board of health and health consultant will help the hold members in contact with a person with Shi- program decide if a person wh has no symptoms gella diarrhea should be made aware of -their pos- should be treated. sible exposure to the bacteria, especially -if they are involved in food handling or preparation. If they When should people with Giardia be excluded and develop diarrhea, they should immediately see their allowed to return? See infectious diarrhea exclusion health care provider and get a stool culture. and returksuidelines. Where to report it? Notify parents and staff if a child or staff member is diagnosed with Giardia (see Figure 17-3). Also notify your health consultant and Siiiiieltlearlxiard of health. Make family-and-house- Salmonella hold-members in contact with a person with Giardia What is it? Salmonella is a family of bacteria tl.at diarrhea aware of their posSible exposure to this causes diarrhea accompanied by stomach cramps, parasite, especially if theare involved in food han- pain, and fever. These symptoms usually develop 1 dling or preparation. If they develop diarrhea, they or 2 days after bacteria are swallowed and may dis- should immediately see their` health care provider appear untreated in 2 to 5 days. Bacteria may be and"get stool tests. present in the stool for several weeks after the diarrhea is gone. Very rarely, Salmonella causes- a Shigella bloodstream infection or infects a part of the body What is it? 'Shigella is a family of bacteria that (such as a joint). People who do not have diarrhea causes symptoms ranging from mild diarrhea to di- but are passing Salmonella bacteria in their stools arrhea.with blood and mucus. In severe cases, it can are called carriers. cause dehydration, fever, severe cramps, vomiting, headache, and even convulsions (in young children). Who gets it and how? Children younger than 5 Illness generally begins 1 to 4 days after swallow- and adults older than 70 get it most often. Salmonel- ing the bacteria. Although symptoms usually disap- la can-cause severe infections in these people as well pear without treatment after 4 to 7 days, bacteria as those with underlying diseases, such as sickle-cell may still bc-passed out in the stool for several more anemia or cancer. In group programs for children, weeks. Salmonella is usually spread from stool to- mouth. Children pass it easily when stool goes from one Who gets it and how? Shigella is most common in child's hand to an object or directly to anoint-1- children younger than 5 and can be a significant child's hands. A very large number of Salmonella problem in groups. It is spread when diarrhea! :teria must be swallowed to cause an illness. stools get on hands or objects and then onto other children's hands and mouths. It can also be spread Salmonella can also be spread by contaminated through stool-contaminated food, drink, or water. food or drink and is sometimes found on eggshells and in uncooked meat or poultry. Therefore thoroughly As few as 10 swallowed bacteria can cause a Shigella cook all foods, especially beef and poultry products, infection. and refrigerate any leftovers. Do not use unpasteu- How is it diagnosed? A test called a stool culture rized (raw) milk or raw eggs because they are 'fre- must be performed. Up to 72 hours may be required quently contaminated with Salmonella bacteria. to grow the bacteria from a stool sample. Pct turtlts can be carriers of Salmonella. 271 Infectious diseases- 237

Campylobacter, a family of bacteria, sometimes spread through puppies and kittens. The bacteria can also be spread 4hrough,pporly cooked poultry, unpasteurized milk, and contaminated water.

How is it diagnosed? A stool culture must beper- stool to mouth. A person must swallow a largenum- formed. Up to 72 hours may be required togrow ber of these bacteria to become ill,so Ca- bacteria from a stool sample. mpylobacter is not as easy to catchas Giardia or How is it treated? Medication is not usually given for Salmonella. In fact, medicationcan actually The bacteria can also be spread-Lhrough food lengthen the time the germ is found in the stool. (especially poorly cooked poultry products),=- pasteurized milk, and contaminated water. When should people with Salmonella be excluded When puppies and kittens have this germ in their and allowed to return? See infectious diarrheaex- stools, they may infect people. clusion and return guidelines. How is it diagnosed? A stool culture must beper- Where to report it? Notify parents and staff ifa formed. Up to 72 hours may be required togrow child or staff member is diagnosed with Salmonella bacteria from a stool sample. (see Figure 17-3). Notify your health consultant and your local board of health. Make family and house- How is it treated? No treatment is necessary for hold members in contact witha person with mild diarrhea. If the illness is severe, antibiotic therapy will help. Therefore, adults and children Salmonella diarrhea aware of their possibleexposure to the bacteria, especially if the people arc with Campylobacter in their stools should receive involved in food handlingor preparation. If they medication. This will reduce the chance of spread to develop diarrhea, they should immediatelysee their others. :health care- provider and get a stool culture. When should people with Campylobacter beexcluded and allowed to return? See infectious diar- r, arnpyints shpt.:kr rhea exclusion and return guidelines. `What is it? Campylobacter is a family of bacteria that can cause diarrhea with fever, stomachcramps, Where to report it? You must reportcases of Cam- and vomiting in adults and children. The diarrhea pylobacter to parents and staff (see Figure 17-3). may be severe and bloody. Campylobacter infec- Also notify your health consultant and your local tions occur 2 to 10 days after the bacteriaare swal- board of health. Family and household members in lowed. Usually symptoms disappear withouttreat- contact with a person with Campylobacter diarrhea ment in 1 to 10 days, but there may still be bacteria should be made aware of their possibleexposure to in the stools for several weeks if treatment isnot the bacteria, especially if the people are involved in received. food handling or preparation. If they develop diarrhea, they should immediately sec their healthcare Who gets it and how? Campylobacterarc spread provider and get a stool culture. .41 272 238 Managing illnesses

Figure 17-3. Letter to parer' diarrheal diseases

Dear parent or guardian:

A child in our_program,hasa_diarrivai iisca c; .1 Your child may have a diarrhea! disease.

Please take the following precautions: 1. Watch your child and member: of your family to see if they develop diarrhea, stomach cramps, gas, ,and/onnausea.. 2. If your child develops severe diarrhea, diarrhea with fever or vomiting, or diarrhea with blood cz mucus, do not send your child to the program. 3. If-your child develops mild diarrhea, please callus to discuss whether attendance is recommended. Irreithcpcase,,we,mapasLyour.bealth care,provider to do the tests for bacteria and parasites in the stool. We-way ask you to obtain tests for your child andlor other family members who develop diarrhea. 5. Be sure to remind your health provider that your child is in a child care program so the implications for the child's management and the needs of the other children can be considered. If your child's test is positive, keep your child home until any serious diarrhea or illness is over and our program's health nsultanvcietermines,-whether any-speciai-pretatitiOns arc required for your child to return. .6. Keep usinformed about how your child isdoina and about any positive tests or treatment.

Information about diarrheal diseases What are they? Diarrheal diseases arc caused by germs (bacteria, parasites, or viruses) that multiply in the intestines and are passed out of the body in the stool. Anyone can get diarrheal diseases and they can be caught repeatedly. People with these germs in their stool may not actually have diarrhea or feel sick. Laboratory tests are the only way to tell if a particular stool contains germs. Five diarrheal diseases commonly found in early childhood programs are listed on the next page, along with the symptoms they typically cause.

117 0 Infectious diseases 239

Figure 17-3 cont. Letter to parents about diarrhealdiseases

,INTamc Caused-by Syinptoms Rotavirus A virus Most cases of winter diarrhea in children younger than 2years, usually preceded or accompanied by vomiting and low grade fever.May also have runny nose and cough. Giardia lamblls' A microscopic parasite Mild' diarrhea, bad-smelling diarrhea, gas, stomachcramps, nausea, lad( ofappetite, and/or possible weight loss Shigella Microscopic bacteria J diarrhea, fever, stomach pain, and/or diarrhea with bloodor mucus, Salmonella Microscopic bacteria Mild to severe diarrhea; fever, and/or painful stomachcramps Campylobacter Microscopic bacteria Mild to severe or bloody diarrhea, fever, stomach cramps, and/or. vomiting

How do you catch diarrheal diseases? Whenpeo- How can you stop the spread of diarrheal diseases ple do not wash their hands well after goingto the in your household? bathroom, changing diapers,or helping a c'd go to Be sure .everyone thoroughly washes their the bathroom, microscopic diarrhealgeniis stay on hands after using the bathroomor helping a their hands and the children'S-hands. Thegerms can- baby or Child with diapers then spread to -food or drink 'or toileting and be- or to objects and; fore preparing or eating food. Babies andchil- eventually, to other people's hands and mouths.The dren need to have their hands washed,too, at germs are then swallowed by the other people, mul- these times. Ask us if youare unsure of the steps tiply in their intestines, and causean infection. required`for. proper handwashing. Obviously diarrheal diseasescan spread easily If someone in your family develops diarrhea, among -young childrer, who ask normally get their your health care provider to consider doinga test hands into everything and-imay nct waMh their hands for germs in the stool. This is critical forfamily well. or household members who handle or prepare How do you know if you havea diarrhea! disease? food as a job. Some of these diseases can be diagnosed.by exam- Medication may be recommended for children ining the stool under a microscope,some by grow- and adults whc have diarrheal diseases.Your ing- the -gerins-in-the-labomtoiy;- othefi byspecial :health -care- provider will decide abouttreatment Chemical tests. Since thegerms are usually passed for your child and/or other family members: in the-I-idols off andon, stool samples taken on several days may need to be examined. 240 Managing illnesses

Pinworms Special stop-spread information What are they? Pinworms are tiny worms, that. In addition_ to_following% handwaShing-and-xlean- infect people (but not animals) and live in the lower liness procedures, staff should be sure' each child intestine. The female worms, (resembling short, has her or his own crib or mat with its own sheets. white threads-less than 1/2" long) come out through_ Each child's clothing should be stored seprately in the anus at -night and lay their microscopic eggs plastic bags and sent home for laundering. around the opening. In some people, this causes intense itching; in others, nothing. Pinworms do not cause teeth 'gtinding or bed-wetting and are not dangerous, just irritating. Hepatitis A -Who gets them and how? It is estimated that 5 to :15% _of:people- in the Un ited =States= have pinWorms What is it ?Hepatitis A is an infection of the-liver (the rate is higher-in other countries). Children fre- caused:by the hepatitis A virus. Although the virus -quently have pinworms, and members of an infected causes a totabbody illness, it is spread through the `hotisehold' can be infected and reinfect a intestines and stools. The illness often occurs from 2 treatedchild. When children or, adults scratch their to 8-weeks after the virusswallowed. Adults who itchy bottoms,_ the microscopic eggs can come -off have hepatitis-A often suffer from tiredness, loss of onto-the fingers or under the fingernails. These peo- :appetite, nausea,, fever; and jaundice (yellowing of ple may put their fingers into Someone's mouth or the skin and whites of the eyes as well as dark brown food, and -eggs. may be swallowed that will hatch urine). These symptoms usually last from 1 to 2 into worms- n the intestines. People can also keep Weeks, although some adults may be sick for several reinfecting- themselves by swallowing eggs that are months. Most young children who catch the virus on their-own hands. PinWatins can also beindireCtly have only a mild flu-like illness without jaundice, or spread through contact with clothing Or bedding no symptoms at all. -that-has been containinated with eggs. Who gets it and how? 'Anyone can get this infec7 How are, they diagnosed? The 'worms crawl out-at Lion, that spreads quicklyin groups of children who night to lay their eggs while the child lies still and do not yet use the toilet and who cannot wash their Sleeps. The easiest way to find them is to-inspect a 1" own hands well. Because Most young children with circular area around,the child's anus about 1 hour hepatitis A do not become ill, often the first sign of afterthe ch'14 has gone to sleet, .By .spreading _the the infection is a jaundiced parent or staff member. buttocks and looking with a-flashlight, a parent can HepatitiA, virus is passed out of the body in the see the worms crawling toward the-opening-of the stool and is spread by the -stool to mouth method: bowel. A health care provider can make the diagno- Contact with stool-contaminated food, drink, dr en- sis J:)3, asking the parent-to appiythe sticky side of vironmental surfaces can also spread the infection. transparent tape around the: anal area so any eggs The virus is not found in urine, saliva, or other body on the skin will stick to it. This is best done first fluids, and is found only briefly in the blood. A thing in the morning Before bathing. The tape is person is most contagious during the 2 weeks before then placed sticky side down -on-,a slide And exam- the illness begins, when there are the most virus -ined under-a microscope to see if there areany eggs. particles in the stool. Usually, within a-Week after the illness starts, the Virus disappears from the stool. How are they treated? Several medicines are available for treatment of this infection. Often the How is it diagnosed? Hepatitis A is diagnosed by a health, care provider will treat the whole family if blood test that indicates if a person has ever had the bile person:in thehomeAs infected'and may repeat infection, regardless of the presence of symptoms. treatment 2 weeksiater. How is it treated? There .s no treatment that Wheit should people with -pinworms be excluded cures hepatitis A. However, because- the incubation ,andiallowed,,to return? ,Children and adults do not period is so long, the illness can be Prevented by need to be,ejicluded: giving persons a protective shot of immunoglobulin within 2 weeks of their exposure to the virus. Where' to report it'Notify, _parent§ and -staff so They May watch 'for,Symptorns in themselves and/or When should people with hepatitis A be excluded .their children (see Figure 17-4). and allowed to return? Exclude these people: I

Infectious diseases 241

Figure 17-4. Letter to parents About pinworms

Dear parent or guardian: A child in our program has pinworms. Your child may have pinworms.

Please take these precautions: 1. Check your child for pinworms, using the information given below. 2. If you think your child may have pinworms, call your health care provider for instructions. 3. If your child does have pinworms,_ please tell us. 4. Remember to wash your hands and your child's hands carefully after going to the bathroom and BEFORE eating or preparing food. This will help prevent spread of pinworms to family members.

Information about pinwennS What are they,:'' Pinworms are small, white, threadlike worms that live in the large intestine and only infect people. The female worms crawl .cut-through the anus at night and lay eggs on the skin around the opening. This can cause intense itching in,this area. It does not cause teeth grinding or bed-wetting. It is not a dangerous, disease, just a very irritating one. Who gets them and how? It is estimated that 5 to 15% of people in the United States have pinworms. Children frequently have pinworms, and members of an infected child's family can be infected and then il reinfect a treated child. When children scratch their bottoms, the microscopic eggs can come off onto their fingers or under their fingernails. If they put their fingers into someone's mouth or food, the eggs may be swallowed, ; then hatch into worms in their intestines. Pinworms can also be spread through contact with clothing or bedding that has Leen contaminated with eggs. What do you do atm- ut pinworms? Your health care provider will ask you to place sticky tape on your child's bottom first thing in the morning and will then look at the tape under the microscope. If there are pinworm eggs on the tape, she or he will give your child a medication to cure the infection. Your whole family may be treated, too, because other people in households are often infected as well but are not aware of it.

76 242 Managing illnesses

those who are jaundiced DiseaseS spread through The those exposed to hepatitiS A virus in the past 2 respiratory Watt weeks, unless they receive immunoglobulin. If they do not receive immunoglobulin, exclude Respiratory tract diseases are all spread through them for 6 weeks after-the last case occurs. microscopic droplets of infectious nose, eye, or People who are sick with hepatitis A can return to throat secretions most of which are shared via hand the program 1 week after the illness started AND contact with infected secretions and subsequent when their fever is gone. contact with surfaces that uninfected people touch to pickup the germs. Whether ornot true airborne Where to report it? Notify parents and staff (see transmission accounts for much if any disease ,Figure 17-5). Also notify your health consultant and spread is unclear. Respiratory tractdiseases may be your local board of health. mild (viral Col& and strop throat) or life threatening- (bacterial meningitis). Some of these diseases are common in children (Hib-Haemophilus irifluenzae type b) whereas others like the viral cold affect all Special stop-spread information ages fairly equally. When an infected person talks, coughs, sneezes, Strictly enforce handwashing and cleanliness or blows the nose, infectious droplets get on objects rules. such as hands, toys, or food, and can be touched; Make sure all parents and staff notify the pro- mouthed;, or eaten by others. When the germs in gram if any person in theirhousehold is diag- these infected droplets come in contact with the nosed with hepatitis A. nose, eyes, or mouth of an uninfected person, they If a household member comes down with hep- can multiply in the nose and throat and cause infec- atitis A, the child or staff member living there tion. Young children often fail to wash their hands should get a-pod test to see V she or he has the after touching their noses or eyes and are in con- 111rieSS-as If-the lest is . negative, she or he stant physical /oral; contact with objects around should receive a shot of immunoglobulin. If the them. Adults- and r.hildren--oftemputAheir :hands test is positive for hepatitis A, exclude as de- around their eyes, mouth, and nose. As a result; scribed above. respiratory tract diseases spread easily, in a group You may have an outbreak if, in the course of 1 setting. month one child in the program OR one staff person develops hepatitis A (diagnosed by blood test or Stop-spread methods for respiratory tract illness) diseases or Handwashing and cleanliness are essential to stop people with hepatitis A are found in two or the spread of all respiratory tract diseases. more households with children in group pro- Ensure that staff and children thoroughly wash grams or staff their hands after wiping or blowing noses; after At this point, call your local board of health. They contact with any nose, throat, or eye secretions; will help you investigate the possible outbreak and before preparing or eating food. and will also request that exposed children and Dr not allow food to be shared. adults be given the immunoglobulin shot by their ash and sanitize any mouthed' toys and fre- own health care providers. quently used surfaces (such as table0 at least When a case of hepatitis A occurs in a program once daily. that has childrenin diapers, all children and staff Wash eating utensils ca-efully in hot, soapy should get the immunoglobulin shot. If there are water; then sanitize andair dry. Use a dishwasher no children in diapers, only staff and children in whenever possible. the infected person's class need to get the shot. Use disposable cups whenever possible; when re- If an outbreak of hepatitis -9 occurs in a Program, usable cups must be used, wash them in hot, all children enrolled or staff-hired during the 6 soapy water then rinse them in a Sanitizing,solu- week.sfollowing the last case of hepatitis A should tion and allow them to air dry after each use. receive immunoglobulin before coming to the Label each child's cup. prograM to prevent ftirther spread of the disease. Air out the rooms daily, even in winter. 277 Infectious diseases 243

Figure 17-5. Letter to parents about hepatitis A

Dear parent or guardian: A child or staff member in our program has been diagnosed witha viral infection called, hepatitis A, and your child may .have been exposed.

_Information about hepatitis A What is it? ,Hepatitis A is an infection of the liver caused bya virus. It can cause tiredness, fever, lack of appetite, nausea, and jaundice' (yelloWing of the skin and whites of theeyes, with darkening of the urine). The illness usually lasts 1 to 2 weeks. Young children donot usually become jaundiced, however, and may have onlyallu-like illness, or nothing at all. HOW do:you get it? The virus lives in the intestines and is passedout of the body, in the Stool. The virus is microscopic, so yob cannot see it. If people do not wash their hands well after toiletinga child or themselves, or do not wash the child's hands, the virus can be spread-to other people, food,drink, or other .things. The germs can then be swallowed by anotherperson, multiply in the intestines, and_cause illness 2 to 8 -weeks later. If a person may Ilve swallowed some germs, the illnesSmay be prevented by a shot of immunoglobulin. Wow is it diagnosed? Hepatitis A is diagnosed bya blood test. What should you do about hepatitis A? t------t 'Be sureall,Membersof your household thoroughly wash their hands after goingto the toilet, helping a child go to the toilet, or changing a diaper. They must wash the children's,hands,,too.These are:the most, '.----liiiixiitaileihing-s-riti do!-Hands ShoUld also be washed before touching food,eating, or feeding. 2. If anyone in your household develops signs of hepatitis A, askyour health care provider to do a blood test. Tell us if it is positive. 3. Do any of the checked items:

-Ask your.health care provider to give your childa shot of'immunoglobulin. The immunoglobulin may be available free of charge to your physician from your state or local health department. Ask your health cafe provider to give immunoglobulin shotsto the other people in your household.

278'

.:, 244 Managing illnesses

,t%' Teach children and staff to cough or sneeze more if they have young siblings or attend a group toward the floor or to one side. If they sneeze or program. The virus concentration in respiratory -coughintd=a-hand:-..or-tissue,_ they must properly secretions is usually highest 2 to 3 days before a diSpose of the tissue and wash their hands. person develops -symptoms. of illness.- Viruses Wipe runny noses and eyes promptly, and wash continue to be present in respiratory secretions for 2 hands;afterwards. to 3 days after symptoms begin. As a result,-infected AiSe,disposable towels and tissues. children and staff have already spread viruses be- Dispose- of towels or tissues contaminated with fore they begin to feel ill. In fact, children and adults nose, throat, or eye secretions in a step can with a often have mild colds that may go undetected but plastic liner. Keep them away from food and ma- still cause them to be con.agious. terials. How are they diagnosed? These viral illnesses are usually diagnosed by- their symptoms. The viruses tommen-respiratoiy-tract illnesses-- can be grown in spedial cultures in laboratories, but Respiratory viral illnesses (colds,- influenza, this prOCesS is -time consuming, expensive, and and roseola) usually unnecessary. What are they? Colds are mild infections of the How are they treated? No medicines or treat- nose and throat that are caused' by many different ments can cure these viral illnesses. Health care viruses. The -most common of these is a rhinovirus providers usually suggest rest and plenty of fluids:- (nose virus): Cold symptoms include stuffy or runny Sometimes a viral infection can be Cornplicatediby nose, sore throat, coughing or sneezing, watery secondary bacterial infection (e.g., ear or sinus in- -eyes, fluid. in- the ears, fever, and general. fatigue. fection, pneumonia). A person with high fever, per- Irifluenia is also caused-by viruses (Influenza A or sistent cough, or earache should be evaluated by a B) and has symptoms of high izver, chills, con- health care provider to see if there is a bacterial gestion, coughing, and muscle aches. Most people infection that requires antibiotic treatment. Aspirin who get'influenza feel too ill to attend a grotip pro- (or products containing salicylate) shwld NOT be gram:- -Roseolai §,another viral =infection that-StaftS used-for. fever Chicken pox is with-a-high fever (103°F. or above) and lasts 3 to 4 suspect( id because of the rare association between days. Satan after the fever ends,the infectedperson Reye's syndrome (vomiting, liver problems, and/or develops a late-like rash over the whole body, but coma) and influenza and chicken pox. begins to feel well again. When should people with viral illnesses he ex- Who gets inem and how? YoUng children usually eluded? There is no need to exclude these children catch many colds each- year, and will' catch even and staff, as long as they feel well enough to attend.

Many illnesses do not require

.exclusion from group programs. It! Most mildly ill children can safely attend if they feel well enough to come. Infectious diseases 245

Stop-spread methods for common respiratory They continue to be infectious until they have re- tract illnesses ceived treatment for a day or so. Follow the stop-spread methods for respiratory t'low are strep infections diagnosed? Throat cul- tract diseases. tures (that take 24 to 48 hours to complete) are the best,method,to.diagnose, strep-infectionsSeveral, COmmotirespiratory-tract illnessesGroup A recently developed tests can take less time, but their 'Streptococcal infections (Strep throat, scarlet accuracy is still being evaluated: lever,, and imPetigo) How are they treated? Strep infections are usually What. are they? A variety of infections, including treated with an oral antibiotic for 10 days, starting strep.throat, Scarlet fever, and impetigo, are caused either at the onset of symptoms or after throat cul- by Group-A-Streptotocci bacteria (seep. 255 for a ture results are received. A single, long-lasting in- -diScussion-of impetigo). jection may also be used to treat strep. -Strep throat infections are characterised by a When should people be excluded and allowedto Very_red, painful throat often accompanied by fever, return? tender-arid swollen lymph nodes "(called glands by People who are only mildly ill Can continue to -many peOple), headache, and _stomachache. Some- attend while awaiting the results ofa strep cul- times,a strep throar-will_ be accompanied by cough- ture, IF the doctor has not begun antibiotic ing or1ess often arunny nese:The vast majority of treatment. ,(If the culture proves -to be positive, sore throats in children -andadults are caused by send them home.) Cold viruses, not strep bacteria. People who have a positive strep culture should Scarlet fever-is a type of Streptococcal infection stay home until after they have had at least 24 -characterized by a skin rash. The rash usually con- hours of antibiotic medicine. Make sure that sists of fine, red -bumps that feel sandpapery and eiery dose of the antibiotic is taken for the next 10 usually appear-Orr the heck, Chest; grciinand/or in- dayS. ner surface of the knees, thighs, and elbows. It may laSt only a few hours. Other scarlet fever symptoms Where to repOrt strep infections? Notify allpar- include flushed cheeks, paleness around the mouth, ents if a child has astrep infection (see Figure 1776). and a red tongueithat resembles the surface ofa strawberry. "Scarlet fever is no more serious than Special stop-spread information for strep strep-throat. Infedions Rhetimatic fever ,(abnormalities of the heart Follow the stop-spread Methods for respiratory valves and inflammation of the joints)can develop 5 tract diseases. to 6 weeks after the occurrence of any type of strep If there is a case of strep in the program, send infection that goes untreated. -In rare instances, children or staff with sore throats to their health kidney disease can also follow an untreated strep care providers for throat cultures. infection. Therefore, it is very important that all Be alert to an outbreak. If there are three or more cases of suspected strep infections be referred to cases and/or any associated rheumatic fever or health care providers for treatmentPeople with kidney disease, talk to your health consultant persistent sore throats without a runny nose deserve about having all children and staff cultured. a throat culture. Who gets them and how? -Strep throats,occur Common respiratory tract illneiseichicken most frequently in, childreri older than 3 (and in pax and shingles adults); during the colder months; and in crowded What are they?--CLIcken p is a very contagious situations. New, information suggests that spread disease Caused by the vati:.ella-zoster virus. It :may oceilr-4,mong younger children in child care as usually 'begins with a mild 'fever, symptoms ofa in Older children in schools. If one person-ina fam- !,:old, and an itchy rash. The rash appears with small; ilygets-strep throat, other-fan-lily memberSmay also red 1.3r.mps on the stomach or back and spreads to set it. The Group .A StreptocOcci are transmitted the face and limbs. These bumps rapidly become from one perSon -to .another through microscopic blistered and Oozy, then crust over. Peoplemay have reSpiratOrY,SeeretiOn The incubation period lasts 2 only a few bumps or maybe totally covered., to5 days. People witlystrep.throat are generally-not Once a person, has been infected with -the "infectious, however, until -their symptoms.appear. varicella-zoster virus and gets chicken pox, the 246 Managing illnesses

Figure 17-6. Letter to parents about strep throat Dear parent or guardian: A child in the program has strep throat. Your_child_may have strep throat.

Please take these precautions: 1. Watch your child for signs of a sore throat and other signs of strep(headache, fever, stomachache, swollen and tender neck.glands). 2. If your child develops a sore throat and any of these other signs, pleasesee yourhealth care provider, tell her or him that another child in the program has strep, and ask to have your child testedfor strep throat. In into 2 days,you will have the results of the culture. If strep is found, your childwill receive

treatment. _

Information about strep Throat What is strep throat? Strep throat is a sore throat caused by-streptococcus bacteria that arepassed around through nose and mouth secretions. It is very common in children. Most sore throats,however, are ,caused by viruses and-are not treated withantibiotics. Why is it important, that your child receive treatment? There are three main reasons. .1. Treatment reduces spread. If not treated or not treated long enough, yourchild may continue to spread the infection to other members of your family or to other children. 2.. Treatment with antibiotics can usually prevent rheumatic fever. Rarely, somechildren with strep throat.later develop rheumatic feverabnormalities of the heart valves and inflammationof the joints. 3. Treatment will also prevent other rare, but possibly dangerous,complications. When can your child come back to the program? Your child can return after taking medicinefor at lest 24 hours. What should you do to prevent the spread of strep throat? 1. Thoroughly wash your hands and your child's hands after wiping nosesand before eating or preparing food. 2: Wash dishes carefully in hot, soapy water or a dishwasher. 3. Do not allow children 'to share cups, spoons, or toys that are put intothe mouth. 4. -DO Or, allow sharing of-food. Infectious diseases 247

virus remains (without symptoms) in the body's allowed-to attend. Most child care programs have nerve cells. In.some people the virus becomes ac- a policy that children and staff with chicken pox tive again: at a later time and is called shinglesor should be excluded for 1 week after the rash first zoSter. With shingles a red; painful, itchy, blister), appears (or until all blisters are crusted over and rash appears, usually in. a line along one- side of dry). the body. There is no fever. The virus .shed_in_the ,Children-and_ staff -with- shingles shed-A-he-3.411s- TtiliitTrii- or& rash can cause chickenpox in a that causes chicken pox and could cause an out- person who hasnothad it,, ifthat person has direct break of chicken -pox. Therefore, unless the shin- .contact with the infected shingles blisters. gles rash can be 'Completely cc it is advis- Who gets them and how? Anyone whois -ex- able that people with shingles ie until the posedAo.the.varicella-zcister virus and .has,-not had rash is crusted over and dry. 1.h with shin- chieken pox before will,almost certainly get it. If gles must be very careful about pc .al hygiene. you had chicken pox once, you cannot get it Where to report it? Notify parents and staff about again. Chicken pox is Most common in school-age the occurrences of chickenpox (see Figure 17-7). children whereas shingles is most .common in Also notify your health consultant and your local adults. Chicken pox is generally not consideredto board of health. You -do not need to report cases of be a serious:disease in otherwise healthy _people. shingles. However,..adirlts and people on medicines that -Suppress 'the system (immunosuppreSSor Special stop - spread information for chicken medicines) (e.g., _persons with. canter) tendto ex- pox and shingles perience,a More severe disease- from this virus. People with chicken pox are contagious from 2 The best way to prevent spread of these- very days before-the rash appears- until-the-last blister contagious diseases is to keep -infected people has developed' crusts. The -disease is spread by away from the program. Whether prevention of close Contact (sharing breathingspace or--direct chicken pox infectionS is desirable for otherwise touching) with infected secretions from-lhenose, healthy children is debatable. The severity of the -throat, or rash. Itakes about 10to 21 days from the infection tends to increase with increasing age. 'time of exposure until a person develops thesymp- Develop a system for immediate notification if a toms of chicken pox. child or staff member develops chicken pok or shingles. How is it diagnosed? Chicken pox and shingles Keep a person with chicken pox (or shingles with 'are usually diagnoSed by the typical _appearance of the rash. a rash that cannot be completely covered) at home until the rash is completely dry and crus- 1) ;How is -it treated? There is no specific treatment ted. for chicken pox. The symptoms may be treated, Watch closely for early symptoms in others for 3 however, with anti- itching medicine and lotions, weeks following the most recent case. If a child-Or-- medicine forfever control, fluids and rest. Aspirin staff Member develops a suspicious,raSti, the per- (or products containing salicylate) should NOT be son's-health care provider should be, contacted to used for fever control because ,rarely Reye's syn- discuss what- co db. drorhe (vomiting, liver problems, and/or coma) can result. Scratching- should be -avoidedhecause Serious respiratory tract -it can increase scarring. A vaccine to prevent Meningococcal illnesses- chicken pok is currently under development. What are they? Bacteria called Neisseriamen- When should people with chic.1:enpox and shin- ingitidis cause meningococcal illnesses, that are gles be excluded and allowed- to return? Some serious and sometimes fatal. The most common of infectious disease 'Experts (e.g., F. Denny) believe these illnesses is meningitis, an inflammation of that exclusionof,a child with chickenpox who has the covering of the brain. People with thisqype- of ,mild disease is unnecessary since by thetime the Meningitis mug be hospitalized' immediately and diagnosis is made, -everyone, contact with the receive intravenous antibiotics. The disease child has 'h 'en thoroughly 'exposed'. Few 'child usually starts Suddenly with fever, chills, lethargy, ',care programs Can 'handle thiS approach,par- and a rash of fine red freckleS or purple splotches. tiatilarlysWhen Parents' ot'children whoare well do Young children with meningitis show symptomS of not underStand'why children with chiclenpox ,are unusual irritability, poor-feeding, vomiting, fever, 282 248 Managing illnesses

Figure 17-7. Letter to parents about chicken pox

Dear Parent or guardian: A child or staff member in our program has chicken pox. Child may haVe chicken

Iriformation-about chicken pox What is it? Chicken pox is a very contagious infection caused by a virus. It usually begins with-a mild fever and an itchy rash. The rash starts as small, red bumps that become blistery, oozy, and then crust over. How is it spread? It is spread through exposure to infected fluids from the nose, throat, or skin rash of someone with chicken pox. This can occur either by sharing that person's breathing space or by directly touching the infected fluids from 'the skin. Chicken pox is contagious from 2 days,before.the rash starts until all the rash is dried and crusted. After exposure, it takes 10 days to 3 weeks before the rash appears. How is it treated? Chicken pox is generally not a serious disease and there is no specific treatment for it. The symptoms can be treated with plenty of fluids, rest, anti-itching medicines and lotions, and medieine fors fever;control. ASPIRIN- (SALICYLATE) CONTAINING PRODUCTS SHOULD NOT BE USED FOR FEVER CONTROL IN CHILDREN WITH CHICKEN PDX. There is apossible,association between the use of aspirin and a rare but very serious disease called Reye's syndrome (vomiting associated with liver problems and coma). What should ybu do about-chicken pox? 1. Watch your child for the next 10 days to 3 weeks to see if the chicken pox rash develops. fief send your child to our program with a suspicious rash. Ask your health care provider to -diagnose the illnesS and to give you' anti-itching medicine or lotions for your child if the itching is disturbing the-Chi-Id. S. If your child develops chicken pox, you can return her or him to the program 1 week after the rash began or when all;the.blisters are dried up and crusted over. 4. Be aware that.if one of your children develops chicken pox, other people in the family who have not willprobably get-it; too,'bedatiSe ChiCken pok is very easily spread.

460nr),-) Infectious diseases 249 and excessive, high-pitched crying. Older children has occurred so that Rifampin medication can be- and adults may experience severe. headache, gin. neck .pain, and stiffness. Develop a system for immediate notification if a Who gets them and how? Although older chil- child or staff member comes down with,a men- dren and adults can get meningococcal illnesses,. ingococcal illness. they occur niOat frequently in children younger -0- ASk all siarf andpaitriti to Contact their health than 5 years of age (and especially in babies. 6 to care providers immediately. 12 :months of age): The bacteria are passed be- Notify your local board of health. tween ,people who are in close contact through Require that all close contacts of the ill person coughing, sneezing, nasal discharge, saliva, and including people in the household and in the touching of infected secretions. These bacteria classroom.take Rifampin for 2 dayS. Classmates cannot live on environmental surfaces. People and staff in the ill,person's class need to take the Called carriers. -have these -bacteria in their noses, Medicine as soon as possible. Children and staff throats, or mouths ;but do nothave symptoms of the in separate classes may not need Rifampin. illness. Both sick people and carriers pass these Speak with ycur health consultant and/or local germs to others. Usually illness occurs 1 to 4 days -board of health,if you have questions about- who after -a. person has been expOsed, although incu- is a close contact. _Usually, the best way to as- bation can take up to 10 days. .If one infection sure that everyone who needs it gets-ki-fampin is occurs at your center, there are more than the to have a doctor (e.g., health departinent con- usual number of carriers, and the risk of disease sultant) prescribe the medication to-be,given to spread increases greatly. all the contacts in the child care program. Corn- .pliance. is not usually achieved by asking each How are they diagnosed? These infections are person to get a prescription from hcr or his own: diagnosed by culturing a sick person's bloodor doctor. spinal fluid. It may take up to 72'hours to grovrand Make parents and staff aware that Rifampin does identify the bacteria. Sometimes a doctor can NOT give.absolute protection against disease. Make an- earlier diagnosis by looking at a person's 'therefore, any child or adult who develops spinal fluid under a-microscope. syMptoms such as fever or headache, requires How are these infections, tre( ted? People sick prompt evaluation by a health Care provider. with 'theSe infections require hospitalization for -Monitor the situation closely for 2, to 3 weeks. Special care and a closely supervised program of Make sure all ill children are seen by their doctors alitibiotics. Sick people and those in contact with and that you arenotified if another person devel- them- should also-take an- oral medicine called ops meningococcal disease. Rifampin to lower the risk,of the spread of the disease to others. (NOTE: Pregnant women and peo- Serious respiratory tract,illnesses ple with liver disease should not take Rifampin Haeniophilus influenzae type,b illness (Hib disease)' When should people With ineningococcal dis- Maris it?IlaenioPhilus influenzae type B (Hib) eases be excluded and allowed to return? People is the bacteria that cause serious, sometimes with meningococcal diseaSe are too ill to attend. illnesses, most often in piling children. Some of the They may,retum when-they are well (after hospital diseases the bacteria can cause are treatment) and after_ they,have taken. Rifampin ,for 2 days. Exclude all. people who have been in close epiglottitisinfection of the upper throat and en- contact with a person who has meningococcal trance to the windpipe- cellulitisinfection of the deep skin, especially-of disease until their ,treatnient with Iiifampin the face and neck started. - meningitisinfection/inflammation of the cover- Where to report them? Notify all parents and ings of. the brain staff immediately (see Figure 17-8). Also notify your arthritiinfection and swelling* the joints health Consultant and your local board of health. pneumonia--Arifeetion of the lung bloodstream infections Special stop - spread information Who gets them and how? These illnesses occur The best way to Prevent spread:of ,this very con- primarily in- children younger than 5 -y ears of age, tagious disease is to warn everyone that a. case; Most of them in children younger than 2. Ep- x-

250 Managing illnesses

Figure 17-8. Letter to parents about meningococcal illnesses

Dear parent or guardian: A child or staff member in our program has a serious infectious illness caused by bacteria named

`14eiSseria., bacteria can spread betWeen persons who share breathing space or are in close- physical contact. ;I'llere is a medicine called Rifampin that can be taken to reduce the risk of infection in . people in close contact with the illperson. Your child has beenin close contact (Fame classroom or shared activities) with this child or staff member.

Your child has not been in close contact with, the ill person.

Please take these steps: 1. Call your health care provider. Tell her or him that your child is in a group program where another child or staff member has come down with a menigococcal illpess. Indicate whether or not your child has. been in close contact with the ill person. 2. If your'child has had close contact, our health consultant may recommend that your child take a medication called Rifampin (unless there is some reason why your child could not take this drug). Rifampin can help eliininate th?Igerm from someone else who has been exposed. We will help your child receive Rifampin if it is recommended by our health consultant. Be sure to let your child's doctor know whether or not your Child received Rifampin. 3. If your child has had close contact, do not return her or him to the program until the Rifampin treatment has been started. 4.. Watch your-Child for signs of illness or a fever for the next 3 weeks. if your child becomes ill, take her or him to a doctor immediately, whether or not Rifampin was given. The medicine is not always 100% effective.,Neisseria meningitidis usually causes meningitis, an infection of the coverings of the brain, that is often fatal if not treated with antibiotics. 5. Remember that our program will be very watchful during the next 3 weeks. We will notify you if anyone else becomes ill. Infectious diseases 251

iglottitis is an uncommon problem found most often one who has already' been exposed or in preventing in children 2 to 4 years old, while the other diseases the immediate spread of Hib. Children may be at are mostcommon in children younger than 2 years. slightly increased risk of coming down with Hib ,Children in group settings may be at greater risk of .disease during the week following the shot. catching these illnesses: Older children and adults rarely develop these illnesses. When should people with Hib disease be excluded As-With inenitigOOOCCahillneSSei, Hib disease-re- and;allowed to return? Exclude children and staff quires relatively close-contact in order to, spread who are ill with Hib disease while they afeill airdif between people, Spread is morelikely arriong chil- your health consultant recommends it, until they dren younger than 4, with the higheSt risk in chil- have taken Rifampin,for 4 dayi. Exclude

Figure 17-9. Letter to parents about Hib disease

Dear parentor guardian: A child in otir program has a serious infectious illness caused by bacteria named Haemophilus influenzae 'type b. (A short way of the name is Hib.) Hib can spread between people who are in close physical ,contactand:share_breathing spaco._Hib_is not,potall.related,to thcregular flu. Your child has been in close contact (same classroom or shared activities) with this child or staff member. Your child has not been_i.-close contact with the Unperson. Hib can cause very serious illnesses such as meningitis (infection of the coverings of the brain), pneumonia, arthritis, epiglottitis (infection of the upper throat), blood infections, and skin infections. All of these illnesses require hospital treatment and intravenous antibiotics. Because the bacteria can spread from child,to child and because they can cause serious illness, we want to make you aware of the fact that ,our child rnay=have been exposed. [Insert a statement of your recommendations and policy regarding the use of Rifampin to reduce the risk/9f spread.]

,Please take these steps: I. Call your health care provider. Tell her or him that your child is in a program where another child has come down with an illness caused by Haemophilus influenzae type b (Hib). Indicate whether or not your child has.been_in close contact with the ill person. Describe our program's policy on Hib and Rifampin. 2. Watch your child `for signs of illness or a fever. If your child becomes-ill, take her or him to your health:Ccre provider. Watch your childespecially carefully in the next week, and continue Watching for a month. 3. Remember that our program Will also be very watchful over the next month. We will notify you if another Child comes dowrr with thiS illness.

(.`

k 28 Infectious diseases 253 tense exposure to cause infection. Most persons who How is it diagnosed? Infection with the TB germ inhale TB bacteria are protected from infection by is diagnosed by a tuberculin skin test (a tine, Slavo, their immune systems that wall up the bacteria in or Mantoux test). A test is called positive when there tiny, hard capsules (tubercules). Bacteria in tu- is a significant amount of swelling at the skin test bercules do not usually cause illness. site 48 to 72 hours after the test is placed. After a People who have been infected with the TB germ person first breathes TB bacteria, it may take 2 to 3 who do not have -the disease can be identified by months for the skin test to become positive. A posi- positive tuberculin skin tests (such as tine, Slavo, or tive skin test indicates exposure to the TB germ at Mantoux tests). People with positive skin tests are some time in the past, causing the body to develop a not contagious and do not feel ill. However, if their response of th, zefense system to contain the germ. defense systems become weakened due to other A positive test does not indicate if a person has TB health problems, the walled up germs could begin to disease. Further evaluation by chest X-ray and med- multiply, break out of the capsules, and cause dis- ical examination is used to determine if infection ease. Mast cases of TB in the United States are has been contained by the person's defense system caused by suc-i. reactivation of old TB infection. A or has progressed-to active disease. If a person has a special anti-TB medicine can 3e taken to pr=event an positive skin test AND symptoms (such as cough infected person from breaking down with TB. This and fever), additional studies such as TB sputum medicine is taken once daily for a year. cultures may also be done. The TB germ grows very People who have active TB disease have symp- slowly, and it can take up to 3 months before a toms of coughing, infected sputum, fever, weight culture shows growth of the germ. loss, and abnormal chest X-rays. More rarely, TB How is it treated? TB is readily treated with sev- germs can cause disease in other body organs. Per- sons with TB disease in areas other than the lung eral medications, taken for 9 to 18 months. These are usually not contagious to others, because the TB medications usually make the person non- germ must be in the air and inhaled in order to contagious within a few weeks. TB infection without cause infection in another person. disease (that is, a positive skin test only) can be prevented from .progressing to disease by taking a Who gets it and how? Anyone who shares breath- single medication daily for a year. ing space with an adult with active TB lung disease, usually over a -long period of time, can develop TB When should people tvith TB be excluded and infection. Only a few of those infected, however, allowed to return? Anyone who has been diagnosed will develop TB disease. Infants, young children, with active TB disease must be excluded from attending or working in programs for young children. and people with problems of the imraune system are Children who have only a positive TB skin test (with more likely to develop serious TB disease if infected. When people with active lung disease cough, a normal chest X-ray and no symptoms of disease) sneeze, or spit they spread bacteria into the air in can attend. (They usually take medicine to prevent microscopic droplets. froni the nose, mouth, and the rare possibility of developing active disease.) lung. These,germs can be breathed by someone who Children and staff with -TB- disease may return after shares close breathing space with an infected person they have begun treatment and their health care over a prolonged period of time. TB is not spread by provider states that they are not contagious. brief contact in large, spacious areas or by handling Where to report it? You must report TB disease a diseased person's bed sheets, books, furniture, or to your local board of health. (TB infec- eating utensils. tionpositive skin test without symptoms and with The TB germ is spread only from a person with a normal chest X-ray does not need to be reported.) active TB disease, usually in the lungs, to another No'ify all staff, parents, and your health care con- person. Not all cases of TB disease are, equally consultant if a case of active TB disease occurs in your tagious. Advanced TB of the lung with extensive program. Your local board of health can help you to lung damage (as shown on a chest X-ray) is more notify parents and -can conduct an evaluation of often accompanied by a wet cough and is thus much exposed people, including free TB skin testing. more contagious than lung disease with few X-ray findings and little cough. Infants and children with TB disease are usually not contagious. This is be- Special stop-spread information cause the TB germs are scattered in the lungs, and ALL adult staff (paid or volunteer) should receive children are less likely to cough up and spit out either a tine, Slavo, or Mantoux test before they phlegm from their lungs. start to work. If the test is positive and an X-ray is 288 254 Managing illnesses

recommended, it should be done before the per- How to stop spread of superficial/skin son comes to work also. Any adult with TB lung infections disease, particularly if associated with extensive 1. Follow these handwashing and cleanliness guide- lung damage on chest X-ray and wet cough, can lines: present a significant risk to children and other Make sure staff and children thoroughly wash adults. People with positive skin tests should re- their hands after contact with any possible infec- ceive an appropriate evaluation and medical tious secretions. clearance frt:m their health care provider before Use free-flowing water for handwashing. beginning work. Use liquid soap dispenserswhenever.possible. You may wish to require a TB skin test for newly Always use disposable tissues or towels for wiping entering children as part of their entrai: 2 physi- and washing. cal examination, partiarlarly ifIrou are located in Never use the same tissue or towel for more than an area where the rate of disease is higher one child. than average. Your local board of health can give Dispose of uses. tissues and paper towels in a you information about the TB rate in your area. lined, covered container that is kept away from Ask your local board of health to conduct an 'food and materials. evaluation of exposed- people if a child or staff member is diagnosed with active TB. This evaluation should include TB skin testing of program children and staff, and medical evaluation of anyone with-a positive skin test. (The skin test needs to be repeated 2 to 3 months later because it may take several months to turn positive after the person is first exposed to the TB germ.)

Diseases spread through direct contact Superficial infections and skin infections Impetigo, ringworm, conjunctivitis, scabies, and pediculosis These diseases are caused by superficial bacterial or viral infections, or parasitic infestations. They are common and are not serious. They are spread by direct contact with infected secretions, infected skin areas, or infested articles. Because young children are constantly touching their surroundings and the people around them, these infections are easily spread among children and their teachers. The direct contact method of disease spread is illustrated in these examples: A child has oozy sores on his arm. While playing with another child, he rubs his arm against hers. Some ooze gets on her arm and then into a cut or scratch on her skin. A child with head lice takes off his hat that has a louse on it. A second child puts on the hat and the louse climbs onto his head. A child has runny eyes. She rubs them with her hand, then puts her hand on a toy. Another child Because young children are constantly touching touches the toy, gets eye discharge on his hand, their surroundings and the people around them, rubs his eyes, and puts eye discharge from the diseases spread through direct contact are first cbild into his own eyes. common among children and their teachers. 239 Infectious diseases 255

Wash and sanitize toys at least daily. Wash or How is it treated? Usually some combination of a vacuum frequently used surfaces (tables, count- special soap, an antibiotic ointment, and sometimes ers, furniture, floors) daily. an oral antibiotic is given. 2. Make sure that each child has her or his own crib When should people with impetigo be excluded or mat and does not switch. Sheets and mats should and allowed to return? Children and staff do not be kept clean and stored, so that the sleeping sur- need to be sent home in the middle of the day if a faces do not touch each other. suspected impetigo rash is noticed. Wash a child's 3. Do not allow children to share personal items rash area with soap and water and cover it. Wash such as combs, brushes, blankets, pillows, hats, or your hands and the child's afterwards. Notify the clothing. parents when they come to pick up the child and tell 4. Store each child's dirty clothing separately in them to check with,the child's health care provider. plastic bags and send it home for laundering. Children and staff can come back after using med- 5. Wash and cover sores, cuts, and scrapes icine for 24 hours. The sores should be kept lightly promptly and wipe eyes dry. covered until they have dried up. 6. Report rashes, sores, running eyes, and severe itching to the parents so they can contact their Where to report it? Notify parents and staff (see health care provider. Figure 17-10).

Impetigo Special stop-spread instructions for impetigo What is it? Impetigo is a very common skin infec- When children hurt themselves and cause a break tion caused by Streptococcal or Staphylococcal bac- in the skin, wash the area thoroughly with soap teria. It may start as oozing at an injured spot on the and water and dry carefuliy. skin (such as an insect bite, cut, or burn) and can If you think a child may have impetigo, wash the easily be spread by the person's hands to other areas rash with soap and water and cover it loosely with of the skin. Children often have impetigo on their gauze, a bandage, or clothing. Be sure those.who faces. The rash looks oozy, red, and round; may touch the rash wash their hands well. Dispose of have a flat, honey-colored crust; and may be itchy. any soiled tissues or bandages carefully; keep any In impetigo caused by either strep or staph bacteria, dirty clothing in a plastic bag; and ask the parents sometimes there are blisters that break easily leav- to have the child seen by their health care pro- ing raw, red, oozy skin exposed. In impetigo caused vider. by strep bacteria, kidney disease can develop under very rare circumstances. Impetigo is most com- Ringworm (tinea) monly seen during warm, summer months. What is it? Ringworm (or tinea) is a mild infection Who gets it and how? Ordinarily the skin protects of the skin or nails caused by several different fungi. the body from bacteria. When the skin is broken Ringworm infections are not serious and are easily (cut, scraped, bitten, scratched), bacteria can get treated. On the skin, ringworm appears as a flat, under the surface, multiply, and cause an infection. growing, ring-shaped rash. The -edges of the circle Children often have multiple cuts and scrapes on are usually reddish and may be raised, scaly, and their bodies that make them more vulnerable to im- itchy; the center of the circle is often clear. Another petigo than adults. Most children have impetigo at type of ringworm fungus can cause the skin to be- least a few times during their growing-up years. Im- come lighter in flat patches, especially on the trunk petigo bacteria are found all over infected skin, on and face. On the scalp, infection begins as a small the crusts, and in the ooze. They can be spread to bump and spreads outward, leaving scaly patches of another person who directly touches the skin or a temporary hair loss. Scales, cracks, and blisters may surface contaminated by the ooze or crusts. Bac- be seen on the skin between the toes. A chronic teria that get under the top protective skin layer of infection of the nails can cause thickening, discolor- the second person multiply and cause infection. ation, and brittleness. How is it diagnosed? Impetigo 'can be diagnosed Who gets it and how? Ringworm is spread when by the way it looks. Bacterial cultures are not infected skin touches healthy skin or when infected usually needed. Strep and staph impetigo may look broken nails or skin flakes fall onto the floor, get the same, although staph tends to cause blisters onto hair scissors or clothes, and are touched later more often. by other people. 290 256 Managing illne ;ses

Figure 17-10. Letter to parents about impetigo

Dear parent or guardian: A child in our program has impetigo. Your child may have impetigo.

Please take these precautions: 1. Check your child's skin for an impetigo rash. 2. Take your child to your health care provider if you suspect your child hasan impetigo rash so that medicine may be prescribed. 3. Tell us if your child is treated for impetigo. 4. If your child has impetigo, return her or him to the program the day after treatment is begun. Information about impetigo What is it? Impetigo is a skin infection common in young children. It isseen mostly on the face and around the mouth, but can occur any place on the skin. In impetigo infections, the skin becomesred and may ooze. There may be small bumps clustered together or larger red areas. These areas may have honey- colored crusts or blisters. Impetigo spreads quickly and is often itchy. Childrenmay scratch the crusts off and cause a little bleeding. What causes it? Impetigo is caused by common skin germs (suchas strep and staph). These germs usually cause infection only when the skin gets injured (scraped, cut,or scratched). Impetigo can spread ong young children who touch everything. How is : tietigo diagnosed and treated? Your health care providercan tell you if your child has impetigo. Usually t, treated with some combination of a special soap, an antibiotic ointment, andsometimes an oral antibiotic.

What should you do about impetigo? The most important thing is to keep the impetigo rash cleanand dry. You may want to cover it lightly so the ooze and crusts cannot be spreadto other people. People who touch the rash should wash their hands very well.

281 Infectious disrpses 257

How is it diagnosed? These infections can often How is it diagnosed and treated? Symptoms of be diagnosed by their typical appearance. Some- conjunctivitis are obvious; however, it is often diffi- times a special lamp is used to examine for ring- cult to tell if the cause is bacterial or viral. Occa- worm. OcCraSionally, scrapings- of suspicious- skin sionally the doctor will examine the discharge under may be examined under a microscope or cultured to a microscope of culture it Often -an-antibiotic eye see if a ringworm fungus is present. medicine will be given because treatment of bacterial conjunctivitis shortens the length of symptoms How is it treated? An antifungal ointment is and decreases infectiousness. There is no treatment usually applied to the skin for several weeks. Occa- for viral conjunctivitis that will go away by itself but sionally, antifungal medicine is taken by mouth, may last a week or more. It is recommended that particularly if the diagnosis is ringworm of the children who have conjunctivitis be treated by rins- scalp. ing out the eye and by sometimes using an antibiotic When should people with ringworm be excluded eye medicine to prevent spread of the infection. and allowed to return? There is no need to exclude When should people with conjunctivitis be ex- children or staff with these common, mild infec- cluded and allowed to return? Children with con- tions, once treatment has been started. Refer people junctivitis do not need to be sent home in the middle with a suspicious rash to their health c Are providers of the day. Let parents know that the symptoms for appropriate diagnosis and treatment, and allow were noticed, and allow infected children to return them to return as soon as treatment has begun. the day after treatment has begun. The parents Where to report it? Notify parents and staff if should notify the program if the health care pro- more than one person in the program develops vider decides not to prescribe a medicine. ringworm (see Figure 17-11). Where to report it? Notify parents and staff (see Figure 17-12).

Speciaistop-spread information for ringworm Special stop-spread information for Keep the environment as clean, dry, and cool as conjunctivitis possible, since ringworm fungi grow easily on moist, warm surfaces. Keep children's eyes wiped free of discharge, and always wash your hands after wiping a child's Conjunctivitis (pinkeye) eyes. What is it? Conjunctivitis (or pinkeye) is an infec- Teach children to wash their hands after wiping tion of the eyes most often caused by a virus but also their eyes. caused by bacteria. With this infection, the white Be sure articles that may touch children's eyes parts of the eyes become pink and the eyes produce (such as prisms, toy binoculars, and toy cameras) lots of tears and discharge. In the morning, the dis- are washed well with soap and water at least once charge may make the eyelids stick together. (Some daily. children and adults have allergies that can cause everything listed here except pus.) Conjunctivitis is Scabies a mild illness. Viral conjunctivitis will go away by What is it? Scabies, a common skin infection, is itself in 1 to 3 weeks. caused by a microscopic parasite called a mite that infects only people. The female mite burrows under Who gets it and how? Children have conjunctivitis the skin to lay her eggs that hatch and start the most often and spread it to people taking care of infestation cycle again. An infected person usually them or to other children when some pinkeye pus has only 10 to 12 mites. gets into an uninfected person's eyes. Children often Symptoms of scabies do not appear until 2 to 6 pass the infection by rubbing their eyes, getting dis- weeks after initial exposure. On re-exposure, symp- charge on their hands, and touching someone or toms can start-within days. Scabies symptoms in- something. Conjunctivitis can also be spread when clude an intensely itchy rash (with red bumps and staff wash, dry, or wipe a child's face and then use burrowsshort, wavy, dirty-looking lines in the the same washcloth, towel, paper towel, or tissue on skin). An infected person's scratch marks may cover another child's face. Staff could also get eye dis- up the typical appearance of the rash. The rash charge on their hands when wiping a child's eyes usually appears on the sides of the fingers and and then pass it along as outlined above. finger-webs, wrists, elbows, underarms, and belt 292 258 Managing illnesses

Figure 17-11. Letter to parents about ringworm Dear parent or guardian: A child in the program has ringworm. Younchild_ma; have ringworm.

Please take these precautions: 1. Check your child for ringworm, using the information given below. 2. Take your child to your health care provider if you think she or he has ringworm. 3. Tell us if your child has ringworm.

Information about ringworm What is it? Ringworm is a rash caused by a fungus. On the body you may see red rings that are slightly raised, itchy, and scaly. On the scalp you may see circles of hair loss. On the feet you may see cracking and peeling between the toes. Another kind of ringworm causes whitish patches on the face or body. All of these forms of ringworm spread easily. Ringworm is not dangerous and can be treated easily. How do people catch ringworm? Ringworm is spread by touching the rash on another person or touching the scales or broken hairs that have fallen off the rash. How is ringworm diagnosed? Your health care provider can usually identify ringworm by looking at the rash. Sometimes other tests are needed. When can your child come back? She or he can return to the program the same day treatment (usually an ointment, sometimes a medicine by mouth) is started. Infectious diseases 259

Figure 17-12. Letter to parents about conjunctivitis

Dear parent or guardian: A child-in our program has conjunctivitis (also called pinkeye). Your child may have conjunctivitis.

Please take these precautions: 1. Watch your child and members of your family for signs of pinkeye. 2. See your health care provider if your child develops pinkeye. Your child may need to be given an eye medication. 3. Do not send your child to the program until the day after you start giving II -! medicine. If your health care provider decides not to prescribe an eye medicine, ask for a note to send hith your child. 4. Tell us if your child is being treated for pinkeye.

Information about conjunctivitis What is it? Pinkeye is an infection of the eyes. It is most often caused by a virus but can also be caused by bacteria. The white parts of the eyes become pink or red; the eye; may hurt, feel itchy or scratchy; and the eyes may produce lots of tears and discharge. In the mornings, the discharge (pus) may- make the eyelids stick together. (Some children and adults have allergies that con cause everything listed here except pus.) Conjunctivitis is a mild illness and is NOT dangerous. Doctors usually prescribe an antibiotic eye medication just in case it is due to bacteria. How do you catch conjunctivitis? The pus is infectious. If children rub their eyes, they get it on their hands. They can then touch someone's eyes or hands or touch an object (toy or table). If other children get discharge on their hands and then touch their own eyes, they can catch it. It can spread easily among young children who touch their eyes and everything else and who do not know how (or forget) to wash their hands. What should you do if your child has conjunctivitis? 1. Keep your child's eyes wiped free of discharge. Use paper tissues and throw them away promptly. 2. Always thoroughly wash your hands after wiping your child's eyes. 3. Teach your children to wash their hands after wiping their eyes. 4. Ask your health care provider if your child needs to receive eye medication. 5. Be sure to wash carefully anything that touches your child's eyes (such as washcloths, towels, toy binoculars, and toy cameras).

294 260 ,Managing illnesses lines. In infants, the head,neck, palms, soles, and- the individual hairs near the scalp and cannot be buttocks may also be involved. easily moved up or down the hair (as could specks of Who gets it and how? Anyone who has contact dandruff). Nits may be found throughout the hair with the mite can become infested with scabies by but are most often located at the back of the scalp, skin-to-skin contact or by skin contact with clothes behind the ears, and at the top of the head. The eggs or bedding, for example: The mites can survive only hatch in about 10 days, with new lice reaching 3 days off the body and cannot jump or fly. They adulthood in about 2 weeks. The female louse is require direct contact with skin to be spread. about the size of a sesame seed, can live for 20 to 30 days, and can lay about six eggs a day. The lice live How is it diagnosed? Scabies can be diagnosed by by biting and sucking blood from the scalp. Lice can the typical appearance of the rash and accompany- survive up to 8 hours between feedings and can do ing symptoms and by examining skin scrapings un- so off the body. der a microscope to see the mite or its eggs. The major symptom of head lice is itching caused How is it treated? Scabies can be treated with one by the bite of the louse. Persistent scratching of the of several prescription mite-killing creams or lo- head and back of the neck should be viewed with tions. These are applied once to the skin and then suspicion. Often red bite marks and scratch marks washed off after a specified period of time. Medicine can be seen on the scalp and neck, and a secondary to relieve the itching is often necessary. Even after bacterial infection can occur causing oozing or effective therapy, itching can persist for as long as 4 crusting. Swollen neck glands can also occur. weeks. Some doctors may treat all household mem- Who gets them and how? Head lice are not a sign bers (even those without symptoms) once, due to of unclean people or homes. They can occur at any the high likelihood of spread within a household. age and afflict either sex. Anyone who has close When should people with scabies be excluded and contact with an infested person or shares personal allowed to return? Children or staff do not need to items can become infested. Lice are spread only by be sent home in the middle of the day if a rash that crawling from person to person directly or onto appears to be scabies is noticed. Ask parents to take shared personal items, such as combs, brushes, infested children to their health care provider for head coverings, clothing, bedding, and towels. treatment. An infested person can return the day How are they diagnosed? Diagnosis is usually after treatment is started. made by finding nitstiny, pearl gray, oval-shaped specks attached to the hair near the scalp. Use a Whereto report it? Notify parents and staff (see magnifying glass and natun t light when you search Figure17-13). for them on the hair at the back of the neck, behind Special stop-spread information fcr scabies the ears, and at the top of the head. Wash and dry on the hot cycle all washable items How are they treated? Treatment consists of get- that came into contact with the child's skin dur- ting rid of the lice from both the infested person and ing the 72 hours prior to treatment. the surroundings and personal items. All household Store difficult-to-wash items (such as stuffed toys members and people with close physical contact and pillows) in tightly closed plastic bags for 4 should be examined for lice and treated if infested. days before using again. Some health care providers may simultaneously Thoroughly vacuum any carpet or upholstered treat all members of a household once. furniture. To treat an infested person: Talk with your health consultant if you think you Use a medicine such as Nix or Prioderm Lotion have a major problem with scabies, because it (available by prescription on10. These brand may be necessary to treat all children and adults names are mentioned for identification purposes in the group once. only (not an endorsement). Other similar prod- Do not use pesticide sprays because they can be ucts may be used. harmful to people and animals. Use these products very carefully and consult a physician before treating infants, pregnant Pediculosis (head lice) or nursing women, or people with extensive What are they?. Head lice are tiny insects that live cuts or scratches on the head or neck. only on people's scalps and hair. They hatch from After shampooing the hair with medicine, remove small eggs, called nits, that are firmly attached to all the nits or eggs. This is a difficult and time-

DI Infectious diseases 261

Figure 17-13. Letter to parents about scabies

Dear parent or guardian: A child in our program has scabies. Your child may have scabies.

Please take these precautions: 1. During the next 6 weeks, watch for signs ofan itchy rash that usually appears in lines. 2. If a rash develops, see your health care provider. 3. Tell us if your child has scabies.

Information about scabies What is it? Scabies is a common skin rash caused by microscopicanimals called mites that are found only on people. The mite digs under the skin and layseggs that hatch. The new mites dig more paths and -lay,moitts eggs. The rash appears as red bumps and short,wavy lines in the skin (where the mites have dug). It is especially common between fingers and toes and at the wrists andankles, but can occur anywhere. The rash is intensely itchy. Scabies is not dangerous, but it isvery annoying. Anyone can get scabies from another person who has it or from clothesor bedding used by a person with scabies. The mites cannot jump or fly, but they can crawl. They can live for 3 days off the body. What to do if your child has scabies 1. See your health care provider to_get medicine to treat the scabies. 2. Wash all items such as clothes, hats, sheets, pillowcases, blankets,and towels, that your child has used, in HOT WATER. Dry these items on the hottest settingon the dryer. 3. Put things that you do not want to wash (pillows, blankets,toys, stuffed animals) away in tightly closed plastic bags for 4 days. 4. Thoroughly vacuum all carpets and upholstered furniture. Donot use pesticide spraysthey can be harmful to people and animals.

When can your child come back? Returnyour child to th .7.! program on the day after treatment was given. Sometimes your doctor may want to treat the whole family because scabiescan spread so easily.

286 262 Managing illnesses

consuming-proLess;because the nits have such a lice. Because almost all programs will have out- firm grip on, the hair. A solution of vinegar and breaks of head lice periodically, and because the water may help loosen the nits so you can remove hysteria produced by head lice is far greater than them more easily with a special, fine- toothed, nit- their threat to health, this is a prime area for removal comb. preventive, anticipatory parent information. A Check for nits daily for the next 10 days. If new well-organized-and prompt response to the first nits or newly hatched lice appear, the treatment few cases,:an prevent a widespread problem. may need to be repeated. Treatment should be If a cast is identified, your program should follow repeated in 10 days to kill newly hatched lice treatment procedures outlined above. unless an ovacidal preparation such as Nix is used. General infections and total body infections Cytomegalovirus, herpes simplex, and sexually To treat personal items and surroundings: transmitted diseases Machine wash all washable and possibly infested items in HOT water. Dry them in a HOT dryer. These generalized infections are caused 1;rdirect Put non - washable items (furry'toys, pillows) in a contact and can be more serious than the skin infec- hot dryer for 20 minutes or dry -clean them. tions previously described. People with these infec- Seal items that cannot be washed or dried in a tions can experience symptoms ranging from no plastic bag for 30 days (the life cycle of a louse). illness or mild illness (such as cold sores) to a total Boil combs and brushes for 10 minutes, or soak body illness. Some infections (such as syphilis) are them for 1 hour in the bleach-solution. treatable, but others (such as cytomcgalovirus) are Thoroughly vacuum rugs, upholstered furniture, not. What they have in common is the way they are and mattresses. spread from person to person. Anyone can get these Do not use insecticide sprays because they can be infections and can carry the germs in their body :,armful to people and animals. secretions for months or even years, even Though these carriers may not experience symptoms. The When should people whiz pediculosis be excluded germs that cause these infections are spread when and allowed to return? A child found to have an the secretions they are in (such as saliva) penetrate active case of head lice should be kept separate from the skin or mucous membrane of another person. other children. Notify the parent that the child may The germs then enter the other person's body and not return until treated. Other close contacts should multiply. This process can occur when germs get on be checked to determine if there are othcr casts. If skin that is broken, cut, or scraped, or on mucosal your program is having a problem with head lice, surfaces such as the inside linings of the mouth, you should conduct morning head checks before the eyes, nose, rectum, or sex organs. These infections children mingle together. There is some disagree- may also be transmitted from an infected mother to ment among authorities about whether to require her newborn infant. complete nit removal after trcatmcnt before allowing a child to return. Removal of nits is difficult, and How to stop spread of generalized or total body the majority of nits will be killed by trcatmcnt. infections. You should assume that every body se- However, rcinfcstation is possible if some nits sur- cretion is potentially contagious, and take these pre- vive and hatch into adult lice. If the nits are not ventive actions: removed, you will not be able to tell whether re- Insist that staff and children wash their hands infestation has occurred or there are only old nits. well after any contact with blood, saliva, urine, Program staff and the health consultant should de- stool, skin sorts, or genital secretions. cide on the bcst pulicy for both you and the parents. Make sure that staff and children place dis- Regardless of the policy, to ensure successful treat- posable items that are stained with body secre ment the children need to be checked for new nits tions (diapers, tissues, bandages, paper towels) in for 10 to 14 days after therapy. a lined, covered step can that is kept away from food and materials. Where to report them? Notify parents and staff if Store clothing and other personal items that be- a case of head lice occurs (see Figure 17-14). come stained with body secretions separately, in plastic bags,. and send them home for separate Special stop-spread :nstructions for pediculosis laundering and bleaching. Learn to recognize nits, and regularly check chil- Wash and sanitize 'surface areas and toys that dren's hair when there is a known case of head become stained with body secretions or blood 28 Infectious diseases 263

Figure 17-14. Letter to parents about headlice Dear parent or guardian: A child in our program has head lice. Your child has head lice.

Please do not be alarmed, as this is acommon occurrence in group prop..., ms. Head liceare not a sign of unclean people or homes.

Please take these precautions: 1. Check your child's hair for eggs (also called nits). 2. If you suspect your child has head licc, askyour health care provider to diagnose the problcm and recommend appropriate treatment. 3. Tell us if your child is diagnosed as having head lice. 4. If head lice are diagnosed, do not returnyour child to the program until she or he has been treated.

Information about head lice What are they? Head lice arc tiny insects that live onlyon people's scalp and hair. They hatch from small eggs (nits), that are firmly attached to the individual hairsnear the scalp and cannot be easily moved up or down the hair (as can specks of dandruff). They looklike grains of sand. Nits may be found throughoutthe hair but are most often located at the back of the scalp,behind the cars, and at the top of the head. The eggs hatch.in about 10 days, with new lice reaching adulthood in about 2 weeks.The female louse is about the size of a sesame seed, can live for 20 to 30 days, andcan lay about six eggs a day. The lice live by biting and sucking blood from the scalp. Licecan survive up to 8 hours between feedings and can doso off the body.

How should you check for head lice? Usually,you probably will not see the lice, only the eggs. Theseare tiny, pearl gray, oval-shaped specks attached to the hairnear the scalp. Look carefully, using a magnifying glass and natural light. Search for nits at the back of theneck, behind the cars, and at thetop of the head. How does a person get head lice? Anyone who has closecontact with an infested person or shares personal items can become infested. Liceare spread only by crawling from person to person directlyor onto shared personal items, such as combs, brushes, head coverings, clothing,bedding, or towels. What should you do about head lice?

1. If your child does have head lice, your healthcare provider may want to treat everyone in your family. Everyone should be checked, and anyone with nits should definitelybe treated. 2. To get rid of head lice

Use a medicine such as Nix or Prioderm Lotion (available byprescription only). Brand names are mentioned for identification purposes only (not endorsement).Other similar products may be used. Use any of these products very carefully, and consult a physician beforetreating infants, pregnantor nursing women, or people with extensive cutsor scratches on the head or neck.

7 298 264 Managing illnesses

Figure 17-4 cont. Letter to parents about head lice

Remove all nits after shampooing the hair with medicine. This is a diffic _lt and time-consuming process because the nits have such a firm grip on the hair. Using a solution of vinegar and water may help loosen nits so you can remove them with a special, fine-toothed, nit-removal comb. Check for nits daily for the next 10 to 14 days. Then repeat treatment to kill any newly hatched lice. Clean personal items and Surrcundings Machine wash all washable and possibly infested itta.:s in HOT water. Dry them in a HOT dryer. Put non-washable (furry toys or pillows) in a HOT dryer for 2u minutes or dry clean them. Seal items that cannot be washed or dried in a'plastic bag for 30 days (the life cycle of a louse). Boircombs and brushes foi 10 minutes, or soak them for 1 hour in a bleach solution of 1 tbs. of bleach mixed with 1 quart of water. Thoroughly vacuum rugs, upholstered furniture, and mattresses. Do not use insecticide sprays bccausc they can be harmful to people and animals. When can your child re:urn? Your child may come back as soon as the.ampoo has been used, you have removed as many nits as possible from your child's hair, and you have cleaned or stored personal items. Remember that you must keep checking your child's hair for new nits for at least 2 weeks. Infectious diseases 265

using the 'bleach solution. Clean or dispose of to be excluded, because= the program probably has aning,iterns,(mops;ragsiJandltowelsjrproperly. -other children-who have CMV. -bp. not 'permit aggiessfve behavior (biting, scratching). Where to report it? There is no need to report Do not allow sharing of personal items that may CMV infection, as it is common and frequently oc- have been contaminated with blood or other body curs unrecognized and undiagnosed in the com- fluids (toothbrushes, washcloths, teething rings). munity. Cytcmegalovirus (CMV) infection Spacial stop-spread information for CMV What is it? cytomegalovirds is a very common Make sure that adults (especially pregnant infection found espeCially, in young children. In women or women trying to become pregnant) almost cases, CMV causes mo symptoms. Occasion- wayswash their hands after contact with children's ally, children or adults with CMV will experience urine, saliva, or blood. Women- who work in child mononucleosis -like symptoms (fever, swollen care programs who might become pregnant should glands, fatigue). PerSons infected with CMV often consider finding out from their doctor if they have have the virus in their bodies for as long as several already had CMV or if they are at risk because they years. During thiS time, they continue to shed virus- have never had it. es into such body secretions as saliva, urine, genital Secretions, and (rarely) blood. Once people are infected with CMV, they develop substances called Herpes simplex infections antibodies that prevent them from getting new CMV What are they? Herpes simplex viral (HSV) infec- infections. tions are characterized by skin blisters or sores that CMV concerns early childhood programs pri- can be very painful. Once a person-is infected these marily hecause-itcan,cause-,problems.for pregnant viruses remain in nerve cells, and HSV tends to re- women. If a pregnant woman who has never had cur at the same places on the body again and again. CMV becomes infected, especially during the first There are two types of herpes virusHSV type 1 trimester, the fetus may also become infected. If this (usually found in the mouth) and HSV type 2 happens, in rare cases the fetus may suffer mental (usually found onAhe genitals). retardation, hearing loss, or other sensoric prob- HSV type 1 is extremely comrrion. Usually the lems. The mother may not realize she is sick' or may first infection occurs in childhood, is mild, and of- have only a mild, flu-like illness. ten unnoticed. It may come in the form of gin- Who gets it and how? CMV is usually caught by givostomatitisfever accompanied by widespread children from the ages of 1 to 2 years. The virus can painful ulcerations (sores) in the mouth. HSV also spread to:people who have regular, close physi- usually recurs as cold soressingle or blis- cal contact with children's secretions. At any given ters around the lip. Rarely, HSV can be spread by time, ,20% or more of the children in a group may direct touching to cause infection on a finger (her- have CMV but show no signs of illness. Spread of petic whitlowpainful recurrent blisters of a the virus requires direct contact with infected se- finger) or eye (herpetic keratitisrecurrent ulcer- cretions, that are then transferred to a mucosal sur- ations of the cornea). face (inside the mouth, genital tract, or lining of the HSV type 2 is the cause of most cases of genital eye) or into a person's bloodstream (through a break herpes that occur primarily in adults and is sexually in the skin, needle stick, or blood transfusion). transmitted. The first infection is frequently un- Spread between children can possibly occur by sha- noticed and without symptoms. However, it can a!so ring mouthed objects or toys that have infected sal- cause painful genital blisters and ulcers accom- iva on them. The virus can survive several hours on panied by fever and can last 2 weeks. Recurrence is surfaces outside the body. common and usually comes in the form of localized, less painful ulcers that go away in days and are not How is it diagnosed? Most people with CMV are accompanied by fever. Recurrence nwy also be as- not diagnosed because they show no symptoms. Di- ymptomatic. ,agnosis of the CMV virus can be made from cu;tures of infected fluids or by blood tests for the CMV Herpes of the newborn is most often caused by antibodies. HSV type 2, and occurs when a newborn infant passes through an infected birth canal. The result- Wheri should people with CMV be excluded? ing illnesses range in severity from skin blisters to Children who are known to have CMV do not need total body disease with death or severe brain dam- 300 266 Managing illnesses age. An infant who survives may have recurrent skin Allow returns as follows: blisters due to HSV. Children with oozing mouth -blisters can re- Herpes infections in children are generally caused turn when blisters are crusted over. by HSV type 1 and, while uncomfortable, are rarely Children or staff with skin blisters that cannot serious. People who have severe eczema or immune be covered can return when the blisters are crust- system problems may have more severe infections ed over. with herpes. Children or staff with herpetic whitlow can Who gets them and how? HSV type 1 is most return when blisters are completely crusted over. common in, young children, whereas HSV type 2 Where to report them? There is no need to report (due to its sexual transmission) is more common in HSV infections (either type 1 or type 2) unless they adults. HSV type 2 may be seen in children in un- occur in newborn babies. usual circumstances or as a result of sexual abuse. HSV is shed into the secretions of the blisters and ulcers. Spread of both HSV 1 and 2 requires direct Special stop-spread information for HSV contact of virus-containing secretions with a mu- infections cous membrane (inside the mouth, lining of the Make sure that staff who may touch blisters on eyes, rectum, or genitals) or with broken skin (such children wear gloves during diapering or changing as a cut). of a dressing. Because herpes viruses can survive as long as 4 hours on surfaces, mouthed objects contaminated by virus-containing saliva can transmit infections of Sexually transmitted diseases the mouth. It would be extremely unlikely, however, What are they? Sexually transmitted diseases (infor an object such as a toilet seat to transmit the cluding gonorrhea, syphilis, chlamydia, and genital virus, since transmission requires contact with in- herpes simplex, hepatitis B, and AIDS) are infec- ternal rectal or genital mucosa. It would also be tions caused by bacteria, viruses, or parasites, that unlikely for HSV from a child's mouth, skin, or geni- are transmitted by intimate sexual contact with in- tal lesion to cause genital ,herpes in another person, fected secretions. CMV, hepatitis B, and AIDS, three as transmission would require direct contact with viral infections discussed elsewhere in this chapter, the other person's genital area. can also be transmitted sexually because the viruses How are they diagnosed? Diagnosis is usually are present in genital secretions. made basedon the distinctive appearance of the Who gets them and how? These diseases are pri- blisters or sores. A doctor may also examine mate- marily seen in sexually active adolescents and adults rial under a microscope or do a special viral culture. and are transmitted through intimate sexual con- How are they treated? Antiviral therapy for HSV tact. They are NOT spread through the air, by con- infections has recently become available. Generally tact with objects such as toilet seats, or by casual speaking, this therapy is useful only for serious HSV contact. They are spread when infectious secretions infections (such as in the newborn, for infections of come in direct contact with a mucosal surface (such the brain or eye, or for certain cases of genital her- as genitals). Some infections can be passed from pes). There is no evidence that these medicines are mother to newborn during pregnancy or as the in- of any benefit to the common HSV infections in the fant passes through an infected birth canal. These mouth. include gonococcal or chlamydial eye infections (ophthalmia neonatorum), herpes simplex of the When should people with HSV infections be ex- newborn, congenital syphilis, CMV, hepatitis B, and cluded and allowed to return? AIDS. Exclude children or staff with open, oozing sores Except in cases of newborn infants infected dur- that cannot be covered. Exclude all cases of her- ing pregnancy or the birth process, the presence of petic whitlow if the sores are not crusted. Do not one of these infections in a child should raise the allow staff with oral (mouth) blisters' rare for possibility of sexual abuse. (Refer to Chapter 14 for children (since close physical contact might information about sexual abuse indicators and re- spread HSV). Assign them to administrative tasks, porting requirements.) In children, CMV and hep- instead. Do not exclude children or staff with atitis B are almost always transmitted by other skin blisters (in locations other than the mouth or mechanisms and should NOT be considered pos- finger) that can be covered or with genital herpes. sible indicators of sexual abuse. 301 Infectious diseases 267-

How are they diagnosed? Sexually transmitted these illnesses can be spread when blood containing diseases can be diagnosed by a variety of tests. Fig- the virus enters the bloodstream of another person. ure 17-15 reviews the symptoms, diagnosis, and Spread can occur when infected blood comes in treatment of the major sexually transmitted dis- contact with a broken surface of the mucosa (such eases. as the inside lining of the mouth, eyes, nose, rectum, When should people with sexually transmitted or sex organs). This can also happen when the skin diseases be excluded? Do not exclude children who is accidentally or intentionally punctured by a con- have sexually transmitted diseases. Make sure, how- taminated needle. An infected mother can also ever, that these children receive treatments appro- transmit these infections to her newborn infant. priate to their infections and that investigations for Once these viruses enter a person's'body, they may possible sexual abuse are carried out. stay for months or years. This person may appear to Do not exclude staff members who have sexually be healthy but can spread the viruses. -transmitted diseases. Ask these adults to get appropriate treatment and counseling. How to stop spread of diseases spread through blood contact Where to report them? The following sexually 'transmitted diseases must usually be reported by Even though these diseases spread through blood the diagnosing health care provider directly to your contact are more difficult to catch or transmit to State departnient of public health: another person than other diseases described in this gonorrhea chapter, you should treat all blood and mucosal syphiliS secretions as if they were contagious. Makesure chlamydial genital infection that you clean up all blood spills promptly and then it pelvic inflammatory disease sanitize all, blood-contaminated surfaces with the granuloma inguinale bleach solution (Figure 3-1). If a person with hep- lymphogranuloma venereum atitis B or AIDS/HIV infection attends your pro- chancroid gram,. use the bleach solution for all sanitizing and ophthalmia neonatorum cleaning tasks. See additional specific instructions neonatal herpes under each of these diseases. 'hepatitis. B AIDS Hepatitis B What is it? Hepatitis B is a viral infection of the If you suspect that occurrence of any of these liver. Symptoms of infection include fever, loss of diseases in a child was caused by sexual abuse, you appetite, nausea, jaundice (yellowing of the skin and must report these cases to the appropriate social whites of the eyes), and occasionally pain of the service department. joints and a hivelike skin rash. Illness can range from infection without symptoms to the very rare Special stop-spread information for sexually event of rapid liver failure and death. As with hep- transmitted diseases atitis A infection, young children are less likely to be jaundiced or show symptoms of illness. Unlike hep- - Watch for signs of sexual abuse when changing or atitis A infection, hepatitis B can cause chronic in- toileting children. fection with persistent shedding of the virus into Insist that staff and children wash hands after any body secretions and blood in up to 10% of those contact with genital areas. infected. People with such chronic infections are called Virus carriers. These people can develop chronic liver disease, cirrhosis with liver failure, and liver cancer, years after infection. An infected Diseases spread through blood or other mother can transmit the infection to her newborn intimate body fluid contactHepatitis infant. Although .these infants often show no ob- B -and AIDS/HIV infection vious symptoms of hepatitis B, they have a high likelihood of becoming carriers. Hepatitis B and AIDS (Acquired Immune Defi- Who gets it and how? Hepatitis B is transmitted ciency Syndrome)/HIV infection are two serious vi- when blood or body fluids containing the virus get ral infections spread by contact withinfected blood onto skin or mucosal surfaces (inside the mouth, or other intimate body fluids. The viruses that cause eyes, rectum, or genital tract). Hepatitis B infections 302 268 Managing illnesses

Figure 17-15. Symptoms/diagnosis/treatment of major sexually transmitted diseases Gonorrhea Symptoms Painless, hard ulcer usually on genitals, with swol- Cause len groin glands Bacteria (Neisseria gonorrhoeae) Body rash (symmetrical, brownish) with flu symptoms Symptoms Shallow ulcerations on mucosal surfaces (mouth) Moist, gray genital warts Vaginal/rectal pus discharge or redness Syndrome of congenital syphilis* Pain or pus during urination Sore throat Pus and eye discharge in newborn younger than 1 Diagnosis week old* Blood test Diagnosis Treatment Culture of appropriate area Antibiotics Treatment Antibiotics Herpes simplex type 2

Chlamydia Cause Virus (Herpes simplex type 2) Cause Bacteria-like germ (Chlamydia trachomatis) Symptoms Symptoms Recurrent, painful, tiny blisters or ulcers, usually on the genitals Vaginal/rectal pus discharge or redness Swollen groin lymph nodes Pain or pus during urination Severe generalized disease of skin, brain, liver* Pus and eye discharge in newborn younger than 1 one month* Certain pneumonia syndromes in infants younger Diagnosis than 3 months* Viral culture or scraping of infected area viewed under a microscope Diagnosis Culture or rapid test of scraping of infected area Treatment Treatment First (primary) infection: an antiviral ointment or oral medicine may be given Antibiotics Recurrent infection: usually no treatment, occasionally oral antiviral medicine Syphilis

Cause Spirochete bacteria (Treponema pallidum)

*Mother-to-newborn transmission 0 tro Infectious diseajes 269

are more difficult to transmit than hepatitis A infec- When should people with hepatitis B be excluded tions (which are spread via infected stool). Hepatitis and allowed to return? A staff person ill with hep- B infections occur most frequently in people who atitis B should stay home until she or he feels well have contact with other people's blood (suchas and fever and jaundice are gone. A staffperson with laboratory technicians or health care providers who chronic hepatitis B infection who has open, oozing may accidentally puncture their skin with blood- sores that cannot be covered should not attend until contaminated needles; or intravenous drug abusers, the skin sores are healed. Who may share needles). People who have hepatitis You do not have to exclude children whoare B can spread the infection to their sexual contacts carriers of the hepatitis B virus. However,a more via infected genital tract secretions. Mothers with restrictive environment may be desired for these hepatitis B are at high risk for infecting their new- children, because they may lack control- of their born babies. Transmission of infection in house- body secretions, share items contaminated withse- holds occurs only rarely, insituations where there is cretions, and/or display behavior (e.g., being bitten) continuous sharing of personal items (such as tooth- that May raise the risk of virus transmission. brushes or razors) that may be contaminated with Your decision to allow a child with acute hepatitis infected blood. B or a child who is a carrier of the virus to attend Although hepatitis B viruses have been found in your program depends on several factors, including almost all body fluids, only blood, genital fluids, and the age of the child. (Children younger than 3 salivashave been found infectious (or able to spread years are more likely to engage in behaviors, such the disease). Since spread of the infection requires as biting and chewing on objects, that would pre- contact with infected fluid through the skin or a sent some risk if the infected child were to be broken mucosal surface, it c?--ot transmitted by bitten, fer example; children between 4 and 5 casual `social contact (hugging or handshaking)or years are less likely to do so; school-age children via food or water. Transmission in groupprograms would be viewed as similar to an adult unless for young children is unusual. If an infectedperson high-risk behaviors were noted.) has behavioral or medical problems suchas oozing the developmental level of the child skin sores, the risk is higher. the behavioral patterns of the child how is it diagnosed? Hepatitis B infection is di- the ability of the staff to closely supervise the agnosed by a blood test. child to avoid sharing of chewed objects with others How is it treated? There is no specific treatment Your health consultant, the local board of health, for hepatitis B infection. Most often, the body's de- and the state department of public health can help fense system successfully fights off the infection, you make such decisions. If you decide to allow a and the person becomes immune. However, medical child with hepatitis B to attend, follow all stop- follow-up is important to prevent complications. spread precautions carefully. Recently a new vaccine for the prevention of hepatitis B has been licensed. This vaccine is highly Where to report it? Notify parents and staff about effective and considered very safe, but is relatively acute hepatitis B infections and report these cases expensive and must be given in three doses over 6 to your health consultant and local board of health. months. It is recommended for people who have If your program has one or more known carriers never had hepatitis B (screening for prior infection of hepatitis B, inform all staff of this fact andcare- by blood test is often recommended) and who havea fully train them about measures to prevent spread. high risk of exposure, such as healthcare workers, Inform them of the availability of the vaccine. laboratory technicians, sexual contacts with people Strongly consider telling parents of other children with acute hepatitis B, 1.nd infants born to infected in the same class an offer them information about mothers. People in programs for young children hepatitis B, its prevention, and the availability of the would not ordinarily be viewed as high risk. vaccine. Your health consultant, your local board of If a person is exposed to hepatitis B througha health, and the state department of public health needle stick, sexual contact with an acutely infected can help you in this process. person, or a deep bite that has drawn blood, she or It is vital that you respect the confidentiality of he should receive an injection of a special immu- the medical records of the hepatitis B carrier(s) noglobulin as soon as possible to prevent infection. and not stigmatize the individual carrier(s). Do The vaccine series following the immunoglobulin not release the names of specific children to other injection is also recommended. parents, and in the affected classroom(s) use any 304 270 Managing illnesses . precautions or procedures for ALL children and developments about these diseases. You should con- staff. tact the AIDS coordinator at your state and local departments of public health for current infor- Special stop-spread instructions for hepatitis B mation and guidance. Also, be aware of AIDS- Make sure that all staff and children follow the related changes to laws or regulations that affect the general procedures for thorough handwashing operation of your program. If a child with known and cleanliness. HIV infection or AIDS applies to your program, ask AlwayS treat blood as a potentially dangerous your state and/or public health department and the fluid and follow the stop-spread sanitizing guide- child's physician to help you decide if the child lines at the beginning of this section. If you know should attend, and if so, what procedures you that a- hepatitis B carrier attends your program, should' follow. always take careful blood precautions. What are AIDSIHIV infections and how are they Do not allow sharing of personal items that may transmitted? AIDS is a disease that leaves an indi- become contaminated with infectious blood or vidual vulnerable to illnesses that a healthy immune body fluids, such as 'toothbrushes, food, or any system might otherwise overcome. It is caused by a object that may be mouthed. virus, human immunodeficiency virus (HIV). Epi- Place disposable items contaminated with blood demiologic studies show that AIDS is transmitted or body fluid in plastic bags in covered con- primarily via intimate sexual contact, blood-to- tainers. blood contact, or from an infected mother to her. Store clothing or other personal items stained baby. There is no evidence of casual transmission by with blood and/or secretions separately in a plas- sitting near, living in the same household with, or tic bag to be sent home with the child for appro- playing with an individual with clinical AIDS or evi- priate cleaning. Ask parents to wash and then dence of infection with HIV. bleach these articles. The Centers for Disease Control (1985) have re- Clean surfaces or toys contaminated with blood ported that none of the identified cases of HIV infec- or body fluids with the bleach solution (Figure tion in the United States is known to have been 3-1) as soon as possible after they are con- transmitted in school, child care, or foster care set- taminated. You can also sanitize these articles by tings or through casual person-to-person contact. boiling them for 10 minutes. Further, studies of the transmission of HIV among Discourage aggressive behavior (biting, scratch- family members of patients infected with the virus ing). have failed to demonstrate transmission outside of Use gloves when you clean up blood spills, espe- sexual contact or in utero exposure. cially if they are from a known hepatitis B carrier. However, the risk of transmission of HIV among Wash your hands well afterward. preschool children and the developmentally dis- If a person receives a specific infectious exposure abled in a group setting raises special theoretical to a person with hepatitis B (such as a bite that considerations that are not relevant in older chil- causes bleeding), contact your local board of dren or with adults. Because children in the birth health and the exposed person's health care pro- through 3 years age group and the developmentally vider for advice. The exposed person may need to disabled may lack control of their bodily secretions receive a preventive immunoglobulin injection or may display behavior such as biting, it may be and the vaccine series. necessary to require a more restrictive environment If you enroll several children with hepatitis B, for these children until more is known about trans- strongly consider having a vaccination program mission of AIDS/HIV in these group settings. for non-immune employees and children, and discuss this action with your health consultant. Recommendations about attendance by preschool children and developmentally disabled people who AIDS/HIV infections have AIDS or evidence of HIV infections HIV (human immunodeficiency virus) infections Children from birth through age 3 years, who which include AIDS (Acquired Immune Deficiency have clinical AIDS should not attend a group Syndrome) and ARC (AIDS-related complex) are setting because of their increased susceptibility very serious viral infections. Because new infor- to infection. mation about HIV and AIDS is constantly beim, Children ages 4 and 5 years and the development- generated, it is important for you not only to read ally disabled who have clinical AIDS or evidence what is in this manual but also to keep up with new of infection with HIV may attend a group set- Infectious diseases 271

ting UNLESS they have skin eruptions or weep- are especially at risk because the children may be ing lesions that cannot be covered, or are likely to too young to be fully immunized and because the be bitten by the other children. (In either of these close contact that occurs in the group allows, easy cases, the child's physician and the program spread of any disease. In addition, programs that should collaborate to decide about the appropri- have a relatively young staff (born after the late ateness of the child's attendance.) 1950s and early 1960s) are at particular risk because Siblings of children with clinical AIDS or evi- this age group is too young to have gotten natural dence of infection with HIV virus may attend immunity from exposure. group programs without any restrictions. How to stop spread of vaccine-preventable Other recommendations for programs enrolling diseases children with AIDS /HIV infections Protect all children and staff by strictly following Make sure that all children are immunized as special procedures for cleaning and for handling completely as possible for their age (see Figure blood and body fluids. 17-1). Protect children with HIV infection or AIDS from Make sure that all adults working in your pro- infections by communicable diseases (e.g., gram (including volunteers) have immunity to chicken pox or measles) by excluding them if diphtheria, tetanus, measles, mumps, rubella, and there is an outbreak (until they are properly polio. (Adult vaccination against pertussis is not treated with hyper immune gamma globulin recommended). Acceptable evidence of immunity and/or until the outbreak no longer presents a in adults can be provided in several ways, that threat). vary by the age of the adult and the specific dis- Protect the right to privacy of these children by ease, as listed here. maintaining confidential records and by giving Diphtheria/tetanus medical information only to people with an abso- documentation of completion of a primary lute need to know. series (three doses) within the past 10 years, or Provide in-service education for appropriate documentation of a primary series in childhood school personnel to ensure accurate information and regular boosters every 10 years-since about AIDS. Help children with clinical AIDS or evidence of Measles/mumps infection with HIV to lead as normal a life as born before 1957 possible. documentation of vaccination with live measles vaccine on or after the first birthday documentation of physician-diagnosed measles Vaccine-preventable diseasesMeasles, laboratory evidence of immunity mumps, rubella, polio, pertussis, (Vaccination for mumps is recommended for diphtheria, and tetanus adults older than 20 years who are not sure they are immune.) Prior to the implementation of immunization Rubella programs, these seven diseases were a major cause documentation of vaccination with rubella vac- of widespread illness, often with permanent medical cine on or after the first birthday, or complications and even death. The diseases were a laboratory evidence of immunity problem especially for children, although adults (A history of rubella, or even documentation of were also affected. (Haemophilus influenzae type b physician-diagnosed rubella, without laboratory infections and hepatitis B are now also preventable confirmation, is not acceptable. Vaccination during through recently licensed vaccines. These diseases pregnancy is generally not advised. Vaccination and the vaccines are discussed in detail in previous should be given after delivery.) sections.) Some people believe that these diseases are no Polio longer a problem in the United States or that chil- born before 1964 dren can't get them anymore. However, cases of documentation of vaccination with a primary these diseases do occur still, particularly in non- series (three or more doses) of polio vaccine immunized or inadequately immunized children Notify your local board of health if a documented and adults. Children and staff in group programs case of measles, mumps, rubella, polio, diph- 306 272 Managing illnesses

theria, tetanus, or pertussis occurs in yor pro- a woman becomes infectedduring the first trimester gram. They will assist you in starting any neces- of pregnancy. sary identification and vaccinationof susceptible Who gets it and how? Most adults older than 25 children and adults. They will also instruct you on have been infected naturally and are probably im- procedures for closely watching for any ad- mune. Mumps may occur innon-immunized chil- ditional cases and for notifying other parents. dren, or adolescents and young adults whograd- Measles uated from school prior to laws requiring mumps What is it? Measles is a very communicable viral immunization. The mumps virus is found mostof- direct contact or by illness and is the most serious of the common child- ten in saliva. It is transmitted by hood diseases. Usually it causes a brownish-red, droplet spread of the virus in the air through snee- blotchy rash, that begins on the face and spreads zes or coughs. The virus mayalso be found in urine. down the body for 3 days, accompanied by high Mumps is most infectious 48 hours prior tothe fever, cough, runny nose, and watery eyes. The ill- onset of symptoms. ness lasts 1 to 2 weeks and canbe complicated by When should people with mumps be excluded and ear infections, pneumonia, andencephalitis (in- allowed to return? Exclude anyone with mumps un- flammation of the brain). It can also cause mis- til 9 days after the onset of swelling or untilthe carriages or premature delivery in pregnant women. swelling has subsided (whichever is sooner). Who gets it and how? Measles cases are generally Where to report it? Notify parents and staff as limited to three groups. well as your local board of health and health con- children younger than 15 months old (who are too sultant. young to have been immunized) those refusing vaccination Rubella adolescents and young adults who may have re- What is it? Rubella (also called German measles) ceived an earlier ineffective measles vaccine prior is a mild viral illness that causes a slightfever and to 1968 or who graduated from school prior tothe (in about 50% of infections) a flat, red rashthat mandatory measles vaccination law. (Adults born begins on the face. The rash spreads to the rest of prior to 1957 are generally considered immune.) the body over the next 24 hours. The illness causes Measles is spread by large infected droplets or swelling of the neck glandsparticularly those at direct contact with the nasal or throat secretions of the back of the neck. Adult women with rubella may infected persons. It can also be spread by inhaling experience swelling or aching of the joints thatlasts air that has tiny infectious droplets from sneezes or about a week. Rarely, encephalitis (brain inflam- coughs. It is one of the most readily transmissible mation) or a temporary bleeding disorder(purpura) communicable diseases. The communicable period may occur, usually inadults. is greatest prior to and just after rasn onset. The most serious problem with rubella is that if a When should people with measles be excluded pregnant woman becomes infected,her developing and allowed to return? Exclude anyone with mea- infant also can become infected. Stillbirth, mis- defects, sles until at least 4 days after the appearance of the carriage, or serious birth defects (e.g., heart deafness, blindness, and mental retardation) can rash. occur in the infant. Where to report it? Notify parents and staff as often seen well as your local board of health and your health Who gets it and how? Rubella is most in non-immunized children and in asusceptible consultant. group of adolescents and youngadults who grad- Mumps uated prior to school rubella vaccination laws. The What is it? Mumps is a viral infection that causes virus is spread by large droplets in the air(through fever, headache, and swelling and tenderness of the sneezes or coughs) or bydirect contact with infected salivary glands, particularly the gland at theangle of nasal or saliva secretions. Direct contact withblood, the jaw. This causes the cheeks to swell.Possible urine, and stool during the infectiousperiod can complications include meningitis (inflammation of also spread infection. the coverings of the brain and spinalcord), encephalitis (inflammation of the brain),deafness, When should people with rubella beexcluded and and in adolescent or adult males, inflammationof allowed to return? Exclude anyone with rubella un- the testicles. The virus may produce a miscarriageif til 5 days after the onset of the rash. °J07 Infectious diseases 273

Where to report it? Notify parents and staffas should be taken at least 24 hoursapart after treat- well as your local board of health andyour health ment is completed. consultant. Where to repw-t it? Notify parents and staffas Polio well as your local board of health andyour health What is it? Polio is caused bya virus and causes consultant. an illness that ranges in severity from a mild,unnoticed feverish illness to meningitis (inflammation Tetanus of the covering of the brain and 'spinalcord), to -What is it? The tetanus bacteria (that live insoil) paralysis and even death. can enter the body through a cut or wound and produce a poisonous substance thatcauses the Who gets it and how? Polio Casesoccur mainly muscles to go into spasms. Paralysis andeven death among non-immunized young children or members can result. Tetanus has also been called lockjaw. of groups that refuse immunization. Thevirus is spread by direct contact with infected stool Who gets it and how? Tetanusoccurs almost ex- and clusively in non-immunized throat secretions (phlegm, mucus). Peopleare most or inadequately immu- infectious during the first few days before andafter nized people. People need booster doses oftetanus the onset of syniptoms. toxoid every 10 years after finishing thechildhood primary immunization to maintain protection.Un- When should people with polio be excludedand like the other vaccine-preventable diseases,tetanus allowed to return? Exclude people whohave polio is NOT spread from person toperson. It occurs forweek from the onset of the diseaseor until when the bacteria in suil or dustare introduced into after the fever is gone, whichever is longer. the body through a wound. Where to report it? Notify parents and staffas When should people with tetanus be excluded and well as your local board of health andyour health allowed to return? Tetanus patientsmay attend consultant. when they feel well enough to return. Diphtheria Where to report it? Notifyyour local board of What is it and how is it treated? Diphtheriais a health and health consultant. very serious bacterial infection of thenose and throat. It causes a sore throat, swollen tonsilswith a Special stop-spread information fortetanus grayish covering, and swollen neck glands.It can Make sure that you clean all cuts,scrapes, and lead to severe throat swelling thatcan block breath- puncture wounds well with soap and water. ing. The bacteria also producea toxin (a type of poisonous substance) thatcan cause severe and Pertussis (whooping cough) permanent damage to the nervous system and heart. What is it? Pertussis is a very contagious bacterial Diphtheria is treated primarily withan antitoxin, infection of the respiratory tract. The disease begins along with antibiotics. Antibioticsare also given the with cold symptoms, and during 1 to 2 weeksdevel- carriers of the diphtheria bacteria. ops into repeated attacks of severe coughing that can last 1 to 2 months. The whoop sound (that gets Who gets it and how? Diphtheria occurs primarily its name from the sound a child makes whentrying among non-immunized or inadequately immunized to draw a breath after a coughing spell)may not people. People need booster doses of diphtheriatox- occur, especially in young infants or adults. During oid every 10 years after finishing the childhoodpri- the severe coughing stage, seizuresor even death mary immunization series to maintain protection. can occur, particularly in a young infant, due toa The bacteria are spread by directcontact with dis- lack of oxygen. Antibiotic treatment will reducethe charge from the nose, throat, skin,eyes, or other infectiousness of an ill person butmay not improve sores of infected people. Articles or food con- symptoms once a person has developeda severe taminated with dischargecan also spread infection. cough. When should people with diphtheria be excluded Who gets. it and how? Cases generallyoccur in and allowed to return? Exclude all diphtheria non-immunized or inadequately immunized chil- patients and carriers of the diphtheria bacteria. dren. Cases can also occur in adolescents andadults They should receive appropriatetreatment and not because immunity decreases withage and the vac- return until two cultures from nose, throat,or skin cine does not always provide lifetimeprotection. sores are negative for the bacteria. These cultures These adults, who may havevery mild symptoms, '3.0 8 274 Managing illneises

canspread the infection into a susceptible group of long as 6 months after an infection is gore. This is young children. Therefore. immunization of young called serous otitis media. children is important- because the most serious ef- Who-gets it and how? Middle ear infections are fects of the disease are most common among common in children between the ages of 1 month children. The bacteria are spread by direct contact and 6 years, and most common before age 3. Some with discharge from the nose orothroat of an infec- children develop ear infections a few-, days after a ted persoh, or by breathing infected droplets in the cold starts. Some children-have one infection after air where, an infected person coughs. The periodcof another, whereas others never have any. The ten- greatest risk of spread is the -early stage when it dency to have infections runs in families. The bac- appears to be a cold. teria and viruses that cause otitis media start out in When should people with pertussis be excluded the throat. About half of the cases of otitis are bac- and allowed to return? Exclude a person with per- terial and about half viral. It is impossible to tell tussis until 3 weeks after the onset of cough, or 7 which germ is causing the infection without in- days' after the initiation of appropriate antibiotic serting a sterile needle through the eardrum, pulling therapy. People with direct contact with a case of out some of the pus or fluid, and culturing it. This is 'pertussis should receive antibiotic treatment to pre- somewhat difficult and done only for special rea- vent the development or spread of the disease. sons. In general, all middle ear infections are treated with antibiotics asif they were bacterial. Where to report it? Notify parents and staff as well as your local board of health and your health When should people with ear infections be ex- consultant. cluded and allowed to return? Because ear infections themselves are not contagious, there is no reason to exclude a child with one. Noncontagious infectious diseases Special care notes for children who have frequent Otitis media, monilial infections, and ear infections tick-borne diseases Never use cG:ton swabs and never put anything smaller than your finger into a child's ear. Do not Some infectious diseases caused by bacteria, viru- allow the child to do so, either. ses, fungi, or parasites are not easily spread from Do not feed or bottle feed infants lying on their person to person. Two c f these noncontagious backsit is easier for the food or milk (with infectionsotitis media (middle ear infection) and mouth germs) to run down into the Eustachian Candida (yeast infection)occur frequently in tube into the middle ear in that position. young children. Tick-borne infections can also oc- Be especially alert :for any sign of hearing or cur inyoung children. speech problems. Refer the child to the family's Otitis media (middle ear infection) health care provider or other community re- What is it? Otitis media is an infection of the part sources (see Chapter 9). of the ear behind the eardrum. There is a small Special care notes for children who have ear tubes passageway (the Eustachian tube) from inside the An ear tube creates a hole in the eardrum so fluid throat to this middle ear. Bacteria and/or viruses and pus may drain out,and fluid will not build up. can travel from the throat area through the Eu- It usually stays in for 3 to 6 months. stachian tube to the middle ear and cause an infec- Since pus can drain out, water from the outside tion. When infection occurs, pus develops, pushes (that has germs in it) can also run into the middle on the eardrum, and causes pain and often fever. ear easily. Therefore, you must be very careful Sometimes the pressure is so great that the eardrum that children with tubes do not get water in their bursts, and the pus drains out into the ear canal. ears. This usually means no swimming unless Although this can frighten a parent, the child feels there are special earplugs and doctor's per- better, and the hole in the eardrum will heal over. mission. Untreated ear infections can spread to the mas- Watch for any sign of any hearing or speech prob- toid bone just behind the middle ear arid"Cause mas- lems. toiditis. Before antibiotics were available for treatment, mastoiditis was a serious problem. Today, the Monilial (Candida) infections biggest problem from otitis media is the potential What are they? Mcnilial infections are caused by a for hearing loss. Fluid may remain in an ear for as yeast (Candida albicans) and are very common in 0 (n 00 Infectious diseases 275 , children in diapers. In the mouths of infected inform of the disease and have repeated episodes of fants you will see white patches (called thrush)lhat painful swelling in the joints. Inrare cases, Lyme look like milk curds, but cannot be wiped off. Babies ,Disease sufferers may develop facial paralysisor rarely develop thrush after 3 to 4 months ofage. heart problems. Early diagnosis is important. If Diaper rashes caused by monilial infections look patients are treated early with appropriate anti- different and start as very red, raised, round spots. biotics, this disease can be a mild illness and later Often there will be a larger spots with surrounding complications can be avoided. smaller ones. Sometimes the spots allrun together, Rocky Mountain Spotted Fever is carried by and what you see are large areas of beefy red, raised a large and more readily, seen tick called the dog tick. skin that are very sore and may:eferv.bleed. Occa- Symptoms usually begin with a rash appearirzg first sionally, bacteria will invade this raw skin and set on the wrists and ankles and spreading to, other up a secondary infection with of ie or pustules. parts of the body. Other symptoms include a high Who can get them and how? The le infectionsare fever, chills, and severe headache, and usuallyap- particularly common in diapered children, but pear 3 to 10 days after a tick bite. The disease can be adults can get thrush in their mouths ora monilial effectively treated with antibiotics. rash in their groin or other moistareas. They are Who gets them and how?Anyone who is bitten by very mild infections in healthy people and almost an infected tick can,get them. Ticks are most com- everyone getS exposed. Yeast organisms that cause monly found in brushy, wooded, or tallgrassy areas. monilial infections are everywhere. Although they They are not found on open sandy beaches. The can be spread from one,person to another, usually deer tick is very small, no larger than the size of people catch it from themselvesthe organisms a are period on a printed page. During the tick's life cycle, already on their body, waiting for the right condi- it may feed on an infected animal, usuallya mouse. tions. When skin is wet and a little raw (suchas in In later stages of the cycle, it clings to.vegetation and diaper and groin areas), the yeast can invade the is spread by direct contact to the skin ofa passing skin and start spreading. Yeast infectionscan also animal or person. The bite of the lick occur after treatment with antibiotics.. can then spread the bacteria to thenew host. The greatest How are they treated? The child's health carepro- chance of being infected is while walking barelegged vider will prescribe medication (drops for mouth, through brush or tall grass, May through August. It cream for the diaper area). is important to remember that not all tickscarry Lyme Disease or Rocky Mountain Spotted Fever. When should children with monilial infectionsbe Thus, a tick bite does not necessarily excluded and allowed to return?If children have mean that disease will follow, and prompt removal ofa tick diaper rashes that last more than 1 to 2 days, ask will lessen any chance of disease transmission. their parents to see health care providers for diagnosis and treatment. You do not r eed to exdude How are they diagnosed? Diagnosis of Lyme Dis- children with these infections. ease is based primcrily )11 recognition of the typical symptoms of LD such' as the characteristic skin Tick-borne diseases rash. Atypical cases, or cases presenting with only What are they? These are several diseases, includ- later stage complications of.LD,are difficult to di- ing Lyme Disease and Rocky Mountain Spotted Fe- agnose. In these people, a blood test looking for ver, that are spread to people by the bite of an infec- antibody to the bacteria is often helpful. The diag- ted tick. nosis of Rocky Mountain Spotted Fever is basedon Lyme Disease (LD) is.caused by a form of bac- typical symptOms and can also be confirmed witha teria and is spread to people by a tiny deer tick. In blood test. Lyme Disease cases, symptoms can begin witha How are they treated? Oral antibiotic treatment is skin rash characterized by large, red, doughnut- helpful early in the illness and often prevents late shaped welts. Other symptomsare similar to those complications. of flu and can include headache, fever, chills, muscle aches, and stiff neck. Symptoms generally When should people with tick-borne diseases be appear from 1 to 3 weeks following a tick bite. Soine excluded and allowed to return? There isno need to patients, even if untreated, will recover from Lyme exclude a child or adult. Disease without complications. However, approxi- Where to report it?Report a diagnosis of LD, mately half of all LD patients' developa chronic Rocky Mountain Spotted Fever, or other tick-borne 276 Managingillnesses' illness to your local board of health. Notify all par- ier to sec against a light background.) ents and staff of a case-of tick-borne illness so that Conduct daily tick checks. Ticks are most often parents will watch for ticks as well. found on the thigh, flank, arms, underarms, and If any child is bitten by a tick during the day, -legs, and arc very small. Look for new "freckles." notify the parents of that child so they can inform If you find a tick, remove it immediately. Deer their health care provider: Tell them what the tick ticks are very small and hard, about the size of a looked like. If_the child develops the symptoms de- pinhead. They are orange-red or black depending scribed, particularly the skin rash and/or flu-like upon their stage of growth, and prefer to attach symptoms, ask the parents to see a health care pro- themselves to a human host under the hair. Dog vider profriptly for evaluation and treatment. ticks are larger, ranging from 1/10 to 1/4" in How toprevent tick-borne diseases.You should length. They are brown and also prefer to attach take these precautions during and after spending themselves under the hair or on protected parts of time in brushy, wooded, or tall grassy areas. the body. To remove a tick, use tweezers to grip Wear long-sleeved shirts and long pants. Keep the tick body firmly and pull it straight out. If shirt tails tucked securely into pants and pant legs using fingers, place a protective covering between tucked tightly into socks. Wear sneakers or hiking your fingers and the tick, and wash your hands boots instead of open sandals. Wear light-colored afterward. Wash the bitten area with soap and clothing. (Ticks are dark in color and will be eas- water. Infectious diseases 277

Bibliography

The Child Infectious Diseases Study Group. Centers Meinking, T. (1986). Comparative efficacy oftreat- for Disease Control. (1985). Considerationsof in- ment for pediculosis capitis infestation. Archives fectious_ diseases in daycare centers. Pediatric of Dermatology, 122, 267-271. Infectious Diseases, 4(2). National Association for the Education ofYoung Centers for Disease Control. (1985; August 30). Children. (1987). Lice aren't nice. Young Chil- Morbidity and Mortality Weekly Report.Atlanta: dren, 42(3), 46. U.S. Department of Health and HumanServices. Osterholm, M.T., Klein, J.0., Aronson, S.S., & Pick- Goodman, R., Osterholm, M., Granoff, D.,& Pick- ering, L.K. (Eds.). (1986). Infectious diseases in ering, L. (1984). Infectious diseases and child day child day care: Management and prevention.Re- care. Pediatrics, 74(1), 134-139. views of Infectious Diseases, 8(4). Haskins, R., & Kotch, J. (1986). Daycare and illness: Ross Laboratories. (1985). Daycare: Report of the Evidence, costs, and public policy. Pediatrics, Sixteenth Ross Roundtable. Columbus, OH: Au- 77(6), (Supplement, Part 2). thor.

312 18 Care of the mildly ill child

The care of ill children in group programs gener- members becoming ill with gastrointestinal or ates controversy. This issue can be viewed from skin infections or who develop temperatures many perspectives,, including the child's-needs, the greater than 101° F. should be excused froin parent's need to work, the staffs ability to cope and child care as quickly as possible. Sick leave to give the necessary attention, and the cost of serv- policy should be as liberal as possible to pre- ir,g ill children. vent personnel from exposing children to in- According to the American Academy of Pediatrics, fection. (1987, pp. 65-66) as stated in Health in Day Care, This AAP standard provides a starting point for The center should have a written policy con- looking at the issue of group care of ill children. cerning the management of sick children. It should be conveyed in writing at the time a child is registered. This policy, arrived at after consultation with health care providers, Basic issues for decision making should take into consideration the physical facilities and-the number and qualifications of Set a flexible policy the center's personnel. The decisions involved in developing policies are extremely difficult. It Many health policies concerning the care of ill must.be recognized that children do become ill children have been based upon common mis- at unpredictable times. Working parents often understandings about contagion, risks to ill chil- are not. given leave for children's illnesses. Cen- dren, and risks to other children and staff. Current ters many not have sufficient space or per- research clearly shows that certain ill children do sonnel to care for sick children properly. Home not pose a health threat. Also, the research shows care for sick children is expensive. that keeping certain mildly ill children at home or isolated at5-te program will not prevent other chil- If an infant or child becomes ill during the dren from -ecorning ill. Mt.lny children shed viruses hours she or he is in child care, the parent(s) before they are obviously sick and, for gastro- should be notified. To keep the infant or child intestinal infections, even after they seem perfectly in the child care program even temporarily, well. For both respiratory and gastrointestinal infec- there must be adequate quiet space separate tions, they can spread the illness before they develop from the rest of the children where the sick symptoms. Children receiving antibiotics for a spe- child can be watched and given appropriate cific bacterial infection usually are not contagious care. Staffing levels must be adequate to care after a day's treatment. for the sick child. Personnel must have suf- Obviously, seriously ill children should not be in a ficient training to recognize the child who regroup. However, based on the above facts, there is quires prompt medical attention. Most states no medical reason to exclude children who are have laws requiring reporting of specific com- mildly ill or who are being treated; Except in special municable diseases when they occur in ,a pub- erograms, children with active diarrhea should be lic facility. Child care personnel should be fa- cared for at home. Unless children are uncomfort- miliar with these requirements and promptly able, medical experts do not recommend exclusion report the designated diseases. Child care staff of children with chicken pox either, because they

279 313 280 Managing illnesses

have already exposed everyone before their symp- propriate care without interfering-with the -care of toms appear. -the other children? One child who has a fever and Appropriate reasons to exclude mildly ill children cough may still have a high energy level, good appe- are tite, and good mood. Another child may be droopy, the child's disease is highly communicable and whiny, uninterested in any activity, and very un- previously unexposed, susceptible children might happy. Every case is different and should be de- be exposed cided individually by staff and parents together the child does not feel weal enough to participate, using guidelines and procedures developed in and/or consultation with health prcifeSsionals. The focus the staff is not able to adequately care for sick and of policies for all children should be on what condi- well children tions and symptoms the program can include and manage. All other conditions and symptoms should Decisions must be made on a case -by -case basis. be excluded. There is no medical justification for a policy that sets arbitrary cutoffs such as, "Any child with a temperature higher than 100° F. may not remain at the Issues for programs to consider center." When you need to decide whether to keep a mildly The basic question is, Can the child participate ill child at your facility, ask these questions: with reasonable comfort and receive adequate, ap- Are there sufficient staff (including volunteers) to change the the program for a child who needs some modifications, such as quiet activities, staying inside, or extra liquids? Are staff willing and able to care for a sick child (wiping a runny nose, checking a fever, providing extra loving care) without neglecting the care of other children in the group? Is there a space where the mildly ill child can rest? Is there a space that might be used as a get well room so that several children could be cared for at once? Is the child familiar with the staff? Are parents able or willing to pay extra for sick care if other resources are not available, s_ o, that you-t.an -hire-extra staff as needed?

Issues for parents to consider When parents need to decide whether or not to send a child-to the group program, they must weigh many facts, such as how the child feels (physically and emotionally), the program's ability to serve the needs of the mildly ill child, and income/work lost by staying home. Lost work in many cases means lost income, but it may also mean the loss of a job. For low-income families, this is a particularly difficult problem. Although parents may honestly try to consider all the facts and to decide what is best for the child, this is hard to do when the facts are fuzzy. A child may awaken cranky but show no signs of illness. Or the Every case_ of caring for a mildly,achild is child may have vomited after dinner the night be- differentand.shOidtberdecided individually by fore but slept well and awakened cheerful. Or the staff and,pgrents.together using guidelineS and child may have an unexPlained-fever but seem abso- prOCedures developed in consultation with health lutely fine. In these situations parents need to use professionals. their best judgment very early in the morning. Un-

-1") 4 jk. 4 Care of the mildly ill child 281

derstandably, they make mistakes sometimes; but valuable.to the family and to the doctor whomay be having standard rules will not necessarily solve the called for advice later in the evening. Writtenre- problem. ports about a child's illness from childcare staff help to overcome the parent's natural tendencyto Keep the communication linesopen miss some of the details when pickingup the child A child's parents should always talk with staff in at the end of the day (see Figure 18-1. Symptom the morning about any mild illness that occurred record). the night before. This process should include face- to-face contact when the child is dropped off. If Conduct a daily health check there is no opportunity for personalcontact, the parent should Write a note or complete the symptom When you greet the children in the morning (pref- record (see Figure 18-1). When the child leaves, staff erably before parents have left), give each child,a must let the family know what happened during that quick health checkup. This does not haveto be a big daypreferably in written form. Simple infor- deal! Just as you would noticea new haircut or a mation about activity level, appetite and foodin- new pair of sneakers, you can be attuned to take, nap time, and bowel movementscan be inactivity level (sluggish, sleepy, or whatever) breathing difficulties skin color severe coughing rashes swelling or bruises discharge from nose, ears, oreyes sores general mood (happy, sad, cranky) If you have concerns about howa particular child looks or feels, discuss them with theparent right then. Perhaps the parent needsto take the child home. Perhaps you feel strongly that the child should leave. If you decide that the child willre- main, be sure to discuss how you willmanage the child and at what point you will call the parent. Note

NW' that it is the oroeram's decision, net the narrow, whether the program will accept responsibility for the ill child from the parent. If the childstays all day, make sure you let the parent know what happened during the day (see Figure 18-1).

Know what to do when a child appears ill When you discover a seriously ill or injured child, use your emergency procedures. If a child appears mildly ill, take the child aside, encourage rest, and assess the situation. Remem- ber that you are not expected to diagnose illness. Report the symptoms you have observed to the proper person(s)the parent(s), the director, the health staff person (if any)or health consultant, and/o-the citildS health piovidet. 'Whenyou lepoli the symptoms, followyour program's procedures and be as specific as possible. Note the following: to. .- symptom(s) WitemyoU:greet.Chrnirerl,in,theanorning when it began/how-long it has lasted (preferably-before-parents have left), give each how much child a quick health check-up. how often

3 -.1 5 282- Managing illnesses

Figure 18-1. Symptom record

Name of child Date

Symptom

When did it begins

-How long-has it lasted?

How muchl

How often1

Behavior change

Temperature

How much fluid and food intake in the past 12 hours?

Now much urine, bowel movement, vomiting in the past 12 hour0

Associated symptomsrunny nose, sore throat, cough, vomiting,diarrhea, rash, stiff neck, trouble voiding, pain, itching, etc.)

,PxprIcure_snmew foods. soaps, insects, animals, medications

Anyone else sick with whom child has been in contact? If so,who and what is sicknessl

Complicating illnessasthma, sickle-cell anemia, diabetes, allergy, emotional trauma

What has been done so fare

Name of-person-completing form

31 Care of the mildly ill child 283

behavior change Fever is often the child's body's response to infec- temperature tion. Fever may even be helpful, and there is a grow- o Other ing trend to treat it less aggressively. It is a symp- (See Figure 18-I on p. 282.) tom, not a disease, and is not itself dangerous below 106° F. Many children with temperatures of 104° F. Please see Chapter 9 for more information about or even 105° F. have infections that are basically not health observations. dangerous. Keep in mind that infants and young Take these general steps when a child becomes ill: children tend to run higher fevers than adults. keep the child comfortable Whether or not the temperature can be brought observe the child and report and document the down-with fever reducing mcdicine does norrelate symptoms to the severity of the illness. Some serious illnesses call the parent (or emergency contact) are associated with fevers that come down and some decide if the program can care for the child mild illnesses with high fevers that won't budge. Each child's family should identify at least two Figure 18-2 provides instructions for taking chil- emergency contact people who are usually available dren's temperatures. These were prepared for use to take the child home when the parent cannot be with a standard thermometer and include cleaning reached or is not available. Be sure these two con- techniques. You may wish to use disposable ther- tacts are in the child's record, and test their phone mometer covers to make good sanitation easier or numbers occasionally to be sure they are current. digital thermometers that provide fast, accurate Testing phone numbers is most easily incorporated readings and are unbreakable, inexpensive, and into the office routine if you divide the number of readily available. children in the program by the number of working When a child has a fever days in 6 months (approximately 120) and test that Offer small amounts of liquid often, but avoid number of phone contacts every day. citrus juice or milk, that may upset the stomach. Clear' liquids such as water flat soda, gelatin, broth, and apple or grape juice are best. (Clear liquids are those you can see through when you Common minor illnesses hold them up to a light.) When the fever is 100° to 103° F., take off layers of Most programs will need to provide at least tem- clothing. porary care of ill children even if their general pol- When the fever is higher than 103° F., strip the icy is to send sick children home. If children become child down to underwear or diaper. ill during the day, use the following guidelines to When the fever is 104° F. or higher, give the child help you manage their illnesses and keep them com- a ivpies warm spunge-ciuwn. (Water -should fortable. be warm enough to be comfortable and avoid shivering. As long as the water is cooler than the Guidelines for fevers 'body, the heat of the child's body will go from the hot skin, taking body heat with it into the Fever is a common symptom for yoUng children, water, lowering the temperature.) Do NOT use Many parents (and the public in general, including alcohol wipes or rubs. teachers) have unrealistic fears about fevers. In fact, Give acetaminophen (e.g., Tylenol, Tempra, fevers are rarely harmful, and treatment is not al- Panadol) only if you have a parent's author- ways necessary. An above-average body tempera- ization and a physician's order. This can be a ture can be caused by many things including stren- standing order, written into your health policies uous exercise, timt of day (temperature rises in late with a consent form signed by the parent at en- afternoon), infection, environment (a hot room,a rollment. hot day, or being bundled up), or individual -vari- Call (or have parents call) a doctor for fever in ations. an infant 6 Months of age or younger. This call Fever lc generally-defined as -a temperature of is critical for any child younger Ihan 2-months. 100° or more whether taken orally, rectally, or in the Keep in mind that children who DO have serious armpit (axillary). A fever of 105° F. is considered infections act sick and may present oneor more high, although in general, the height of the fever of these symptoms does not correlate to the seriousness of the illness. unusual drowsiness or excessive sleep How sick a child acts is what counts. loss of alertness 31,7 284 Managing illnesses

Figure 18-2. How to take a child's temperature

Preparation Taking oral temperatures Shake the thermometer until the mercury line is Be sure the child did not recently drink a very below 95° F. To avoid breakage, shake it above cold or warm drink. something soft. Place the thermometer tip under the right side of the tongue. Have the child hold the thermometer in place Where-to-take the temperature with-the-lips-and -fingers -(not the teeth). Have the child breathe through the nose with the In children younger than 4 to 5 years: axillary mouth closed. (armpit) temperature for screening; if axillary Leave the thermometer inside the mouth for 3 temperature is higher than 99° F., check with a minutes. rectal temperature. If the child can't keep the mouth closed because In children older than 5 years: oral (by mouth) the nose is blocked, take an axillary tempera- temperature. ture. Taking axillary (armpit) temperatures Place the tip of the thermometer in a dry armpit. Reading the thermometer Close the armpit by holding the elbow against the chest for 5 minutes. Determine where the mercury line ends by turn- If you're uncertain about the result, recheck it ing the thermometer slightly until the line appears. with a rectal temperature. After the newborn If this is difficult for you, practice. period, axillary temperatures are not reliable. Use this method for screening purposes only. Cleaning the thermometer Taking rectal temperatures Have the child lie stomach down on your lap. Wash the thermometer with cold water and Lubricate the end of the thermometer and the soap. (Hot water will crack the glass or break the child's anal opening with petroleum jelly. thermometer.) A cracked thermometer should Carefully insert the thermometer about 1" but be thrown away. -never,f^ree -P;nse the:therm^rneter water. Hold the child still while the thermometer is in Dry and wipe it with rubbing alcohol or immerse and press the buttocks together. it in the bleach solution. Then let it air dry. Leave the thermometer inside the rectum for 2 to Shake down the thermometer and put it back in 3 minutes. its case.

Adapted from Schmidt, 1984. Care of the mildly ill child 285

fast or different breathing Assist the child by helping to blow/wipe nose. very sick appearance Wash your hands afterward refusal to eat or drink Remove mucus from babies' noses before they irritability eat. Use a soft, rubber bulb with a soft, narrow tip refusal to play to suck out (aspirate), mucus for children who complaints about pain cannot blow their noses. Ask parents to send an excessive crying individual aspirator, and use it only fog the ap- The most significant sign of serious illness isa propriate baby. (A 3 oz. ear syringe works very child who looks and acts very ill. well for tlis purpose.) Let the child rest. She or he may need less strenu- Febrile seizures. Approximately 4% of children ous activities or more sleep. who experience fevers will have a febrile (associated Don't force the child to eat. with fever) seizure. Because these seizures are rarely harmful, and they are generally not preventable, Guidelines for vomiting and nausea they should not be cause for undue worry. Most Stop solid food. febrile seizures occur as the temperature is rising, Offer clear liquidswater, flat colaor ginger ale before you even realize the child has a fever. Febrile (shake bottle or stir in glass to remove the bub- seizures are usually brief (less than 15 minutes) and bles), gelatin, broth. Do not force child to drink, stop by themselves. Children who are likely to have but offer liquids often. such seizures are those who have had one before the Offer liquids in very small amounts: 1 to 2 age of 3 years. oz. (or 2 to 4 tbs.) every 5 to 15 minutes. If If a child has a history of febrile seizures and a tbs. of fluid is vomited, reduce the amount given each timeto develops a fever, you should try to bring down the a tsp. fever quickly by doing the following: Offer frozen juice or ice chips to help soothe the Remove the child's clothing. child. Apply cool, thin cloths (such as dish towels or Advise parents to give only clear liquids for cloth diapers) to the face and neck. OR, sponge 24 hours and to go slowly on solids for thenext day the body with warm water, cooler than the body or until the child is completely recovered. temperature, in a tub. Give plain, low-salt crackers; dry, plain cookies If the child is awake and can swallow medicine, or toast; or rice cereal if the child asks for food. give the appropriate dose of acetaminophen if Call the parent. you have a standing order from the child's Ask the parent to call the doctor whena baby physician and parental permission. younger than 6 months is vomiting. -Fel-rile-seizures are ,Inusual and rardy have. permanent effects. If a child has a seizure of any kind, it probably is a febrile seizure. you should follow your Guidelines for diarrhea emergency procedures for seizures. All children who One loose stool does not mean that a child has have a seizure for the first time should beseen by a diarrhea. Some children get diarrhea when they take antibiotics. Others may have loose stools fora long time after recovering from an infectious gastro- Guidelines for colds intestinal disease. However, you should carefully watch a child with even one loose stool and take Try to keep room temperature at or lower than precautions. 70° F. Diarrhea is Use a cool mist humidifier to keep the air moist an increase in the number of stools over what is during winter. Do not add anything to it. Do not normal for that person use steam vaporizers. The new ultrasonic humidi- and fiers are better than previous types. stools that are unformedloose/watery; take the -.he ,mattress- or cot under the head and shape of the e^ntainer thpy in- chest for sleeping. Do not use pillows because Breast-fed babies have stools that are normally they tend to flex the head on the chest, making loose.) breathing more difficult. Put something under the Children with diarrhea that is easily contained in mattress -instead. the diaper but no other symptoms do not need to Offer lots of clear liquids. be sent home or excluded if you can take appro- ai9 286 Managing illnesses priate precautions. A child with large, loose stools or courage the child to eat bran cereals; celery and both diarrhea and fever or another symptom of dis- carrots (because they have fiber that holds fluid in ease should be sent home (see section on infectious the intestine to keep stools soft), and leafy, green diarrhea' diseases in Chapter 17 for details). vegetables such as lettuce, spinach, greens, and If the child with diarrhea stays, or if the child is green and yellow beans that provide roughage. waiting to be picked up by parents, the following Limit binding foods such as bananas, apples, and guidelines for care should be followed. high-fat dairy products. If these measures do not Offer clear, dilute liquids (see vomiting section). work, consult a doctor. Liquids high in sugar (colas, apple juice, grape juice) should be diluted. For infants: 1 to 2 oz. at a time, every 15 min- Rashes utes or so. For preschool children: 2 to 4 oz. at a time, Although rashes are usually not symptoms of se- every 15 minutes or so. rious illness, people tend to worry about them be- Avoid any milk except breast milk. (The sugar in cause unusual skin conditions are so easily seen. full strength juice and milk can make diarrhea While you will not diagnose or decide on treatment worse.) for rashes, you should supply parents with detailed If the child acts hungr , offer a binding, bland diet information for them to report to their physician, (e.g., rice, noodles, oatmeal, dry cereal, crackers, who will want to know the following: low-sugar gelatin, mashed banana, applesauce, Is the rash red (blood colored) or pink? peanut butter, hard cheese, yogurt). Is the skin warm to the touch? If the baby is younger than 6 months, ask the Is the rash raised or flat? Pinprick size or blotchy? parent to call the doctor. Dry or blistery? Although vomiting and diarrhea are generally Where on the body was the rash first noted? How considered mild illnesses, they can sometimes lead has it changed since then? to dehydration, a more serious condition. Dehydra- Has the child had a recent injury or exposure to tion is an excessive loss of water and nutrients from infection, drugs, or chemicals? the body. Watch for these symptoms. Does the child look or act sick in any other way? decreased frequency and amount of urinating Has the child had this rash before? few or no tears Has the child been in contact with someone who a sticky or dry mouth, and/or has this rash? thirst Solid red, warm areas that are spreading may be caused by infection. Many infections that affect the whole body_are associated with rashes. (Please refer Guidelines for constipation to Chapter 17 for details.) Constipation is present when a child has exces- Many rashes look alike; sometimes even the doc- sively hard bowel movements that cause pain or are tor cannot make a definite diagnosis. The best clues accompanied by mucus or blood. A child who has are provided by any other symptoms accompanying infrequent bowel inuveinents is not constipated if the rash and by, knowing what's going around. the stool appears normal when it is passed. Normal Although most rashes are more troublesome than bowel patterns may vary from twice a day to once or dangerous, there is a group of rashes associated twice a week. When the stool is hard it usually with severe and 'life-threatening illness. These means the child is not drinking enough fluid to keep rashes look like little blood spots or bruises under up with the lxdy's needs or does not have enough the skin. Children may develop little blood spots roughage (fiber) in the diet. If a child is constipated around their faces and necks from crying hard or be sure that you discuss the problem with the par- vomiting; but when this type of rash appears else- ents so that together you can decide what to do. where on the body, without being explained by To help reduce the hardness of stools, begin by trauma, a health professional should be called im- increasing fluid intake, especially juices. Have the mediately. The rashes from spontaneous bleeding child drink at least 32 oz. ((our medium glasses) of into the skin signal serious disturbances 'in thc fluid each day, divided into frequent, small body's bleeding control systems. Spontaneous amounts. Try to have the child eat fruits such as blood-red spots or bruises without trauma should apricots, pears, peaches, and prunesfresh, dried, be addressed as a medical emergency. Fortunately, or canned in their own juicetwice a day. En- these illnesses occur infrequently. tiU Care of the mildly ill child 287

Take these steps to promote good skin health. contain broken down bile that is like a detergent Rinse the skin with water to remove food and and is irritating. Change the child rightaway and urine. wash child's bottom well with a little soap and Soap should be used only when you need to re- lukewarm water. For a small infant, this rinsing move stubborn sticky or greasy material; follow can be done easily over the sink. Do not run water with a thorough rinsing with plain water. from the tap directly onto an infant's skin because Avoid prolonged exposure to wetnessor stool. a sudden surge of hot water from the tap can Wear the least amount of clothing needed to keep scald the child. You must wash and sanitize the warm. sink after this type of use. In general, you should avoid special skin products Avoid talcum or baby powder. Itcan be in- unless they have been requested by a health pro- haled into the lungs. fessional. Many products are heavily perfumed and, Heat rash. Heat rash is also known as prickly in fact, may create skin problems (e.g., dry skinor heat. Small red bumps usually occuron the neck, diaper rash). Some creams are very difficult to wipe upper chest, and back of the head. To help manage off. Even the chemicals in premoistened, disposable heat rash wipes can cause trouble. The less you do to the skin, Do not overdress child. the better. Wash and dry the child's skin, especially between skin creases. Diaper rash. Diaper rash is the result of a com- Sponge and dry the area with cool tap water of- bination of irritation from rubbing of moist surfaces ten. on the skin, chemical action of stool and urine on Do not use baby powder. the skin, and wetness for prolonged periods. The ammonia odor in the diaper area comes when bac- Guidelines for teething teria on the skin break down urine. To care for diaper rash, you should take the following steps: Teething may be painful and cause children to be Treat the irritated skin. When a rash is present cranky. Take these steps to comfort the child. Let the baby sleep without a diaper and plastic Provide something hard and/or cold to biteon (a pants during naps. very cold, large carrot; a bagel; a teething biscuit; Provide a cool sitz bath (at least 15 minutes to or a safe, teething-ring toy). give time for deep cooling and contraction of Rub the child's gums with a clean finger or an ice blood vessels). cube. (Wash your hands before and after doing Neutralize the ammonia, and make it hard for the this.) bacteria on the skin to grow: Put vinegar (2 to 3 tbs.) in a sinkful of water for Guidelines for sunburn sitz_baths. 1/2 cup _in the bathtub. Vinegar isa Young children are more likely to get sunburned mild acid that works against the ammonia and than adults but everyone should avoid prolonged prevents bacterial growth. Bathing also cuts down skin exposure to sun. Sun causes aging and changes the need for rubbing the child's sore bottom to that can lead to skin cancer in later life. Certain clean off stool and urine. areas such as the face, shoulders, and back of knees Make the urine more acid by having the child are more likely to burn than other areas. For chil- drink acidic fruit juicecranberry is good (citrus dren who are susceptible to burn, protect these less effective). areas with one of the many sunblocks available. Ask Increase child's intake of liquid because bac- the parents to provide the sunblock and written teria do not grow well in diluted urine. consent for its use. The number on the sunblock Suggest to parents that if a diaper is used at indicates how many times the normal exposure time night, they should do the following to keep the the block will provide protection. Use sunblocks urine away from the skin: with number 15 or more. Do not apply suntan or Use a zinc oxide ointment (such as Desitin)or sunscreen lotions to broken skin. petroleum jelly as a barrier between the skin and Because it takes several hours for a sunburn to stool and/or urine. Make sure the child is clean show, watching for reddening of the skin is not a and dry'before applying. dependable way to tell when a child has been in the Use a "diaper doubler" insert inside a regular sun too long. By the time you notice any change, diaper or an extra-absorbent diaper at night. it is too late. The sun's rays are most intense from Keep stools away from the child's skin since stools 11 a.m. to 2 p.m. Reflections of the sun's rays from 321 288 Managing illnesses water and sand increase sunburn dangers. Cloudy How to give medication days can fool you; clouds won't stop the sun from burning. It is a good idea on most summer days to Almost all children, at one time or another, need plan for playtime in the shade, frequent fluid medication. It is reasonable to expect that parents intake, and skin cooling. will ask you to give medications either for a chronic When a child has a sunburn, medications should problem, for a mild illness, or as needed for a tem- not be applied to the skin without a doctor's rec- porary discomfort. ommendation. There is no cure for sunburn, but the Early childhood professionals are not required to pain and itching that accompany a burn can be give medication to children. If you do not want to be treated with a cool bath or cold compresses applied responsible for giving medication, you can help par- three or four times a day for 10 to 15 minutes at a ents to set up a schedule for giving medications only time. Severe burns may be accompanied by intense at home. Parents should consult with their doctor; pain, blistering of the skin, nausea, chills, and fever. sometimes medicines can be given in different If a child has these symptoms, ask the parents to forms (liquid, pill, capsule) and/or a varying number consult their physician. of times a day (e.g., morning and bedtime versus three times a day). If a parent works near your fa- Guidelines for heat exhaustion and cility, you may ask the parent to come during the dehydration day to give the medication, if necessary. After prolonged exposure to high temperatures If your program accepts responsibility for giving and high humidity, children may have one or more medications, make certain that you follow all appli- of these symptoms of heat exhaustion: cable regulations. Typical regulations for adminis- pale and clammy skin tration of medication are heavy sweating Prescription or nonprescription medications will fatigue not be administered to a child without the written weakness order of a physician that indicates the medication dizziness is for that specific child. ;headache No medication, whether prescription or non- nausea prescription, will be admini..7-__,1 to a child with- muscle cramps out written parental authorization (Figure 18-3). vomiting Written records of the administration of pre- fainting scribed medication to children will be kept and Avoid heat exhaustion and dehydration by en- will include the time and date of each administra- couraging children to drink liquids and cool off fre- tion, the name of the staff member administering quently. Provide small amounts of clear liquids at the medication, and the name of the child. least every 2 hours to help restore fluids that the All medicine will be stored in child-resistive safety body has lost through evaporation. Achieve quick containers, labeled with the child's name, the and sanitary cooling by having children play under a name of the drug, and the directions for its ad- sprinkler or by using cool water on paper towels to ministration. Any unused medication will be dis- remove the perspiration and oil from their skin. posed of or returned to the parent(s). Note: All Thirst is not a good indicator of dehydration, be- prescribed medications must, by law, be dis- cause a child can become dehydrated before be- pensed in child-resistive packaging unless the coming thirsty. Check a child's frequency of uri- purchaser specifically requests otherwise. Those nation and urine color (concentration) to determine who work with children should monitor com- fluid needs. Normally, the urine of a child should be pliance at the pharmacy so all medications in pale yellow or colorless, and urination should occur their possession are safely packaged. every 2 or 3 hours. Dark yellow (concentrated) urine is a sign the body is not well enough hydrated to be Some additional practical guidelines for giving able to make dilute (light colored) urine. medications are When a child (or adult) has symptoms of heat Train all staff who are responsible for giving exhaustion, the first thing to do is to move the per- medications. Have a physician or nurse describe son to a cool and shaded area. Then contact the the specific procedures to be used. parent and ask that the child's health care provider Have parents ask the pharmacist who fills the be called immediately. prescription to give them a small, extra labeled bottle to bring to your program.

ti'744. Care of the mildly ill child 289

Figure 18-3. Parent permission to administer medication and log form

Name of child Date Name of medication Date prescribed Date last dose due

For parent to complete I, (parent or guardian) give permission to (name of authorized child care staff) to administer (dose) of (name of medication) to my child, (name of child) at approximately (time[s] dose due) on (dates and days) for (reason for medication). Possible side effects to watch for with this medication include

The name and phone number of the prescribing physician.

For staff to complete Is the permission form (above) completed) Is the medication in a safety-cap container) Is the original prescription label on the medication container) Is the name of the child given above on the container) Is the date on prescription current? (Within the month for antibiotics and within theexpiration date for medications which are so labeled; within the year otherwise))

3 290 Managing illnesses

Figure 18-3 cont. Parent permission to administer medication and log form Medication Administration Record Day Date Dose Staff Signature Care of the mildly ill child 291

Keep a medicine log sheet posted at the spot ALWAYS READ THE LABEL CAREFULLY where you give medication to the child (e.g.,on BEFORE YOU GIVE ANY MEDICINE;BOT- refrigerator) so yonwon't forget to write down the TLES OFTEN LOOK THE SAME. Besure that exact time and date. Put this log sheet in the the child's name is on that bottle, because often child's folder after the course of medication ends. several children may be taking thesame med- 1Be sure you receive very specific instructions icine. As an extra precaution, put medicationin a about how the medicine should be given (e.g., bag labeled with'the child'sname in large letters. before or after meals, with a full glass ofwater Keep medicines in a locked cabinetor out of after the medication, tilting head). Mostpre- reach of children. Find a way tosecure medicines scription labels do not have this information. that are' kept in the refrigerator. Learn the possible side effects of the medication Be sure that you do not leave medicineout unless, and inform the parent immediately ifyou observe adult supervision is available. Whenyou answer any. Do not give more medication without the the telephone or leave theroom, put the medi- approval of the parentor child's physician. cation away first, or take it withyou. A child can take an overdose in seconds. Always read what the labelsays about storage; Never refer to medicineas candy or something some drugs need to be refrigerated. Avoid storing else children like. They may try toget more of it medication in warm, wet,or lighted places. when unsupervised.

325 ay

292 Managing illnesses

Bibliography

American Academy of Pediatrics. Committee on In- Aronson, S.S. (1985). Medication administration in fant and Preschool Child. (1973). Recommenda- child care. Child Care Information Exchange, tions for day care centers for infants and chil- (January 1985), 26-29. dren. EVanston, IL: Author. Boston Children's Medical Center, & Feinbloom, American Acdemy of Pediatrics. (1971). Standards R.I. (1985). Child health encyclopedia: Thecom- for day care for infants and children under three plete guide for parents. New York: Delacorte years of age. Evanston, IL: Author. Press/Seymour Lawrence. Aronson, S.S. (1981). Management of minor illness Nelson, H.M., & Aronson, S.S. (1982). Health and injury. power: A blueprint for improving the health of Aronson, S.S. (1984). Summer safety. Child Care children. New York: Westinghouse Health Sys- Information Exchange, (August 1984), 13-15. tems. Aronson, S.S. (1984). What to do about rashes. Preschool Perspectives. (1984). Rx for administeLmg Child Care Information Exchange, (May 1985), medication. Preschool Perspectives, 1 (1), 7-8. 26-28. Schmidt, B.B. (1984). Fever in childhood. Pedi- atrics, 74 (Supplement), 929-936. 19 Models for thecare of sick children

When young children become ill they need ade- Care for sick children in group quate rest, appropriate diet, medications as programs ordered, and appropriate physical and emotional support. The issue of sick child care is an- emotionally Because every child is bound to become sick at charged one. It challenges some very basicno- times, it is crucial that options for sick childcare be discussed at the time a child is first enrolled in tions about caring for children and the fine line a between parent responsibilities versus staff regroup program. Many parents have not thought sponsibilities. While it may be difficult to handle ahead about what they will do if the child be- even mildly ill children, you should consider some comes ill and cannot attend the group. of these models as a way to meet thisvery real In seine cases, employers will have personnel need for children and families. policies that allow a parent to providecare for a sick child at home. Paid time, within limits,can be Care at the,child's own program given to the parent to support this option. Employ- ers should be encouraged to develop flexible The advantage of both of the following options is policies that consider the fact that family illness is that ill children can be cared for in their familiar unavoidable. However, when care by the parent is environment by adults they already know and not possible, there are a variety of substitute sick trust. child care models. Get well area of the classroom. This model requires use of a small area of the classroom where a child can rest or play qu;i:tly. It may be as simple General guidelines as a cot in a quiet area. The area needs to be in. view of an adult for supervision and frequent con- There are some practices of care that relate to tact. The child may choose to participate in some all models of programs for the care of sick chil- group activities, while using the get well area as a dren. Consider these basic needs: home base. Ideally, a volunteer or floating adult training for providers in first aid, sick care, infec- will look after the child as needed, stay indoors tious diseases, child development, and CPR when the others are outside, and provide ad- suitable environment, including sink and bath- ditional physical and emotional support. room nearby appropriate storage for medications Get well room. This model could be considered careful hygiene of the sick care area when a small separate space is available. At least emergency procedures established one adult needs to be present at all times; an ideal plans for contacting parents ratio is one adult to no more than two or three sick medical backup children. The room should be equipped witha use of disposable-towels and tissues comfortable resting place; quiet activities (e.g., materials for quiet activities for the child reading, playing records, and table toys); and a cool air (preferably ultrasonic) vaporizer, for easy means for providing food, liquid, and medi- winter cation. You may want to havc a renular vnliniteer a method for laundcring items such as bedding o? extra staff person on call. Thisperson may be

2 293 294 Managing illnesses someone who also substitutes for staff and should Care by satellite homes linked to a group be-teacher-qualified if she or he is alone with chil- program or agency dren. In this model, the program or agency (such as a hospital) is-responsible for placement of children, Care in.programs for sick children training of providers, and payroll. The providers This model requires a separate facility specif- can be used as substitutes in the spbnsoring ically designed foi ill children. The facility may be agency when they are not giving sick care. Be- independent, or in some cases, sponsored by a cause of this linkage, children can become famil- regular program. Because the program for sick in with the providers before being cared for in the children is separate, the children may not be fa- home environment. Because all of the children miliar with the staff, the environment, or other chil- come from the same program, all- the ill children dren. It, is important, therefore, to have children come from the same germ pool; therefore, new visit before they become ill and intermittently so illnesses are rarely passed around. :thaveack=child:-cairhave-a-positive-introduction -to the-staff and-faculty. Sick care services at home This type of medical infirmary for ill and recovering children may serve the physical needs of Care by known adults children very well, but it is least likely to support Children may be cared for in their own homes by children emotionally, because both the environ- adults such as a family member, friend, or family ment and the staff are unfamiliar. The program baby sitter. This situation is probably one of the may also be far from home, which could mean a most comfortable options for the child, both emo- long, uncomfortable ride for the sick child. tionally and physically. The adult should be informed about the nature of the illness and given complete instructions for care. Care for sick children in family day care programs Informal network of caregivers Some programs keep a list of all available adults Care in the child's regular family day care who wish to care for ill children at the child's program home. Especially good resources are students (in early childhood or health fields), substitute staff Home-based childcare is often more flexible persons, and older or retired persons. These care- and informal than larger group programs. A mildly givers should be given detailed instructions for ill child may be included if the provider is willing care. .and!able, tn-handie-rninor jlInesses. Home health agencies/baby-sitting services Care by an independent program for ill children Hcme health agencies may have workers who care for ill children. This service tends to be quite Some home-based child care is designed spe- expensive but has the advantage of providing reli- cifically to care for ill children. This home could be able and trained staff. Some communities have separate from any agency. While this setup could developed specific child care programs for sick work very well, it is likely that no regulations or young children with the help of public funding or administrative support exists to monitor the care. employer support to help pay the high fees.

J8 Models for the care of sick children 295

Bibliography

Fredericks, B.; Hardman, B.; Morgan,G.; & Rogers, E (1986). A little bit under the Weather.Water- town, MA: Work/Family Directions. ,Mohlabane, N. -(1984). Infants- in day-carecenters: In sickness and in health. Oakland,CA: BANANAS Child Care Information Referral and Pafent Support. Parents in the Workplace. (1983). Sick childcare: A problem for working parents andemployers. Minneapolis, MN: Greater MinneapolisDay Care Association. Rodgers, F.S., Morgan, G., & Fredericks,B.C. .(1985). Caring fortheill childin daycare. Journal of School Health, 56, 131-133. Worlc/Family Directions. (1985). Sick childcare. (Unpublished working paper). Boston: Wheelock College. -"; ,* le; t 'r. A 4 .4 , Penbt 1 National resources for health and safety information

See also Figure 13-1 (p. 194) for a list of resources American Optometric Association, Department for children with special needs. of Public Information, 243 N. Lindbergh Blvd., Si.-rotii§",-mo American Public Health Association, 1015 15th Street, N.W., Washington, DC 20005. American Red Cross, 17th and D Streets N.W., Washington, DC 20006 (contact local chapter first). National organizations Association for the Care of Children's Health, 3615 Wisconsin Avenue, N.W., Washington, DC American Academy of Pediatrics, P.O. Box 927, 20016. 141 Northwest Point Blvd., Elk Grove Village, Centers for Disease Control, 1600 Clifton Road, IL 60009 (also state chapters). N.E., Atlanta, GA 30333. American Association for Health, Physical Child Care Employee Project, P.O. Box 5603, Education and Recreation, 1201 16th Street, Berkeley, CA 94705. N.W., Washington, DC 20006. Child Care Health Project, 8374 Fresno Avenue, American Association for Maternal and Child La Mesa, CA 92041. Health, 116 S. Michigan Avenue, Chicago, IL Council for Exceptional Children, Information 60603. Services, 1920 Association Drive, Reston, VA Ainerican Automobile Association, 1712 F 22091. Street, N.W., Washington, DC 20006 (highway Child Care Law Center, 625 Market Street, Suite and pedestrian safety). 815, San Francisco, CA 94105. AmeriCan Cancer SoCiety, Inc., 219 E. 42nd Children's Defenge Fund, 122 C Street, N.W., Street, New York, NY 10017. Washington, DC 20001. American'Dental Association, Bureau of Dental Clearinghouse on the Handicapped, Room Health Education, 211 E. Chicago Avenue, 338-D, Hubert H. Humphrey Building, 200 Chicago, IL 60611. Independence Avenue, S.W., Washington, DC American Dietetic Association, 430 N. Michigan 20201. Avenue, Chicago, IL 60611. Environmental Protection Agency (EPA), 401 M American Fire Insurance Companies, Street, S.W., ,Washington, DC 20406. Engineering pepartment, 80 Maiden Lane, New ERIC/EECE, Educational Resources York, NY 1007. Information Center, Elementary and Early American HeintiAssociation, 7320 Greenville Childhood Education, University of Illinois, Avenue, Dallas, TX 75231. (Has materials, 805 W. Pennsylvania Avenue, Urbana, IL 61801. resources, and training related to heart health, Health Insurance Council, 488 Madison Avenue, including nutrition, exercise, and CPR New York, NY 10022. certification). Heart Disease Control Program, Division of American Medical Association, Department of Special Health Services, United States Public Community Health and Health Education, 535 Health Service, Department of Health and N. Dearborn Street, Chicago, IL 60610. Human Services, Washington, DC 20025.

297 298 Appendix 1

Johnson & Johnson Health Care Division, New Nutrition Foundation, Inc., 888 17th Street, Brunswick, NJ 08903 (first aid and dental N.W., Washington, DC 20036. health). Office of Child Development, U.S. Department of Metropolitan Life Insurance Company, School Health-and Human Services, P.O. Box 1182, Health Bureau, Health and Welfare Division, 1 Washington, DC 20013. Madison Avenue, New York, NY 10010 (health, Public Health Service (PHS), Public Inquiries safety, and first aid). Brandh, U.S: Department of Health and'HUman NMional Academy of Sciences (NAS), National Services, Washington, DC 20201 (health and Research Council, 2101 Constittition Avenue, poison prevention). N.W., Washington; DC 20418 (food and School Health Education Study, 1507 M Street, nutrition). N.W., Room 800, WashingtonDC 20005. National Association for the Education of Sex Information:and Education. Council of the Young Children, 1834 Connecticut Avenue, United States, 1855 Broadway, New York, NY N.W., Washington, DC 20009-5786. 10023. National.Board.of Fire Underwriters American SocietyforNutritiowEducationt. 1736 Franklin Insurance Company, -85 John Street; New York, Street,-Oakland, CA 94612. . NY 10038 (fire prevention education). State Farm Insurance Companies, Public National Center for Education in Maternal and Relations Department, One State Farm Plaza, Child Health, 3520 Prospect Street, N.W., Bloomington, IL 61701 (first aid and safety). -Washington, DC 20057. United States Consumer Product Safety National Commission on Safety Education, Commission (CPSC), Room 336-B, 5401 National Education Association, 1201 16th Westbard Avenue, Bethesda, MD 20207. Street, N.W., Washington, DC 20036. United States Department of Agriculture, National Congress of Parents and Teachers, 700 Agricultural Research Administration, Bureau N. Rush Street, Chicago, IL 60611 (child health of Human Nutrition and Home Economics, and safety). Washington, DC 20250. National Dairy Council, 6300 N. River Road, United States Department of Health and Rosemont, IL 60018-4233. Human Services (DIMS), P.O. Box 1182, National Health Council, 1790 Broadway, New Washington, DC 20013. York, NY 10019. United. States Department of Labor, Occupational Safety and Health Administration, National Health Inforniation Clearinghouse, (OSHA), Washington,. DC 20013. P.O. Box 1133, Washington, DC 20013-1133. United States Department of Transportation, National Institutes of.Health (NIH), U.S. Public 400 7th Street, S.W., Washington, DC 20590. Health Service, Department of Health and Human Services, Bethesda, MD-20892. Allergy and Infectious Diseases (NIAID) Health in child care Arthritis, Diabetes, Digestive and Kidney Diseases (NIADDK) American Academy of Pediatrics. Committee on Citricer (NCI) Early Childhood, Adoption and Dependent Care. Child-Health and - Human Development (1987),.Deitch,.M.D., S.R. (Ed.). Health in day (NICHHD) care: A manual for healthprofesSionals. Dental Research (NIDR) Evanston, IL: Author. Eyes/Blindness (NEI) Child Care Employee Project. (1984). Health and Heart, Lung and Blood (NHLBI) safety resources for child care workers. Neurological and Communicable Disorders and Berkeley, CA: Author. (Available from Child Stroke (NINCDS) Care Employee Project, P.O. Box 5603, National Institute of Mental Health (NIMH), Berkeley, CA 94705) 5600 Fishers Lane, Rockville, MD 20857. Child Care Resource and Referral, Inc. (1984). National Passenger Safety Association, 1050 Health and safetyA first aid, safety, and 17th Street, N.W., Suite 770, Washington, DC medical information guide. Rochester, NY: 20036., Author: (Mailable from Child Care Resource National Safety Council, 444 N. Michigan and Referral, Inc., 903 W. Center Street, Suite Avenue, Chicago, IL 60611. 200, Rochester, NY 55902) r) National resources 299

Greater Minneapolis "Day Care Association. (1983). diseases Child health guidelines: Health, nutrition, infants, and toddlers: Minneapolis, MN: Author. (Available from Greater Minneapolis Day Care American Academy of Pediatrics. Committee on Association, 1006 West Lake, Minneapolis,,MN Early Childhood, Adoption and Dependent Care. 55408) (1987). Deitch, M.D., S.R. (Ed.). Health in day Gurizenhauser, & Caldwell, B. (Eds.). (1986). care: A manual for health professionals. Group care for young children: Considerations Evanston, IL: Author. for child care workers and health professionals, American Academy of Pediatrics Committee on public policy makers, and parents. Johnson & Infectious Diseases. (1988). Report of the Johnson Baby Products Company, Pediatric Commjttee on Infectious Diseases (AAP: "Red Roundtable Series: 12. New Brunswick, NJ: Book").(21st ed.). Elk Grove Village, IL: Author. Johnson & Johnson. Bananas Child Care Information and Referral and Schloesser, P. (Ed.). (1986). Health of children in Parent Support. (1980). Sick child care guide day care: Public health profiles. Topeka, KS: for parents and child care providers. Oakland,, Kaii§a..§12te-fraftriferit of-Health and- CA :-Author. -(Available -from Bananas; Inc., 6501 Environment. Telegraph Avenue, Oakland, CA 94609) King County-Department of Health-Day Care Centers for Disease Control. (1984). What you can Health Program. (1985). Child day care health do to stop disease in the child day care center handbook. Seattle, WA: Author. (Available from (Stock4 017-023-00172-8). Washington, DC: king County Department of Health-Day Care U.S. Government Printing Office. Health Program, Room 1406, Public Safety Fredericks, B., Hardman, R., Morgan, G., & Building, Third and James, Seattle, WA 98104) Rodgers, F. (1986). A little bit under the National Association for the Education of Young weather. Boston, MA: Work/Family Lirections. Children. (1984). Accreditation criteria and (Available from Work/Family Directions, Inc., 9 procedures of the National Academy of Early Galen Street, Suite 230, Watertown, MA 02172) Childhood Programs. Washington, DC: Author. Haskins, R., & Kotch, J. (1986). Day care and (Available from National Association for the illness: Evidence, costs, and public policy. Education of Young Children, 1834 Connecticut Pediatrics, 77. Avenue, N.W., Washington, DC 20009-5786) Osterholm, M., Klein, J., Aronson, S., & Pickering, Resources for Child Caring, Inc. (1980). Health, L. (1986). Infectious diseases in child day care: safety, and first. aid: A guide for training child Management and prevention. Reviews of care workers. St. Paul, MN: Toys 'n Things Infectious Diseases, 8(4). (Available in book Press. (Available from Resources for Child form from University of Chicago Press, Journal Caring, Inc., 906 North Dale, St. Paul, MN Division, P.O. Box 37005, Chicago, IL 60637) 55103) Resources for ChildCaring, -Inc./0980). Health, Ross Laboratories. (1985). Day care. Report of the safety, and first A guide for training child Sixteenth Ross Roundtable. Columbus, OH: care workers. St. Paul, MN: Toys 'n Things Author. Press. (Available from Re_ sourc.;s for Child U.S. Department of Health and Human Services. Caring, 906 North Dale, St. Paul, MN 55103) ; (1972). Health services: A guide for project Sleator, E. (1986). Infectious diseases in day care. directors -and health-personnel (DHEW Urbana, IL: ERIC Clearinghouse. (Available Publication No. OHDS 78-31060). Washington, from ERIC Clearinghouse, Ukwersity of Illinois, DC: U.S. Goverment Printing Office. 805 W. Pennsylvania Avenue, Urbana, IL 61801)

333 a 1...` 300 Appendix I

Child health Miller, J. (1975). Web of life: Health education activities for children. (Available from American Academy of Pediatrics. (1988). Pcnnsyivania Department of Education, Bureau Guidelines for health supervision (2nd ed.). Elk of Curriculum and Instruction, tith Moot, 333 Grove Village, IL: Author. (Available from Market Street, P.O. Box 911, Harrisburg, P_ A American Academy of Pediatrics, Publications 17108) Departriient, P.O. Box 927, Elk Grove Village, IL National Dairy Council. (1979). Chef Combo. 60009) Rosemont, IL: Author. (Available from National Boston Children's Medical Center, & Feinbloom, Dairy Council, 6300 N. River Road, Rosemont, R.I. (1985). Child health encyclopedia: The IL 60018-4233) complete guide for parents. New York: Nutrition curriculum kit that includes puppets, Delacorte Press/Seymour Lawrence. games, and other activities. Marotz, L., Rush, J., & Cross; M. (1985). Health, National Highway Traffic Safety Administration. safety, and nutrition for the young child. (1984). We Love You Buckle Up! Washington, Albany, NY: Delmar. (Available from the DC: Author. (Available from National Department-of Human Development and Family Associationfor the Education of Young Life, University of Kansas, Delmar Publishers, Children, 1834 Connecticut Avenue, N.W., Inc., 2 Computer Drive, W., Box 15-015, Albany, Washington, DC 20009-5786) NY 12212. A curriculum packet that contains a teacher's Pantell, R.H., Fries, J.F., & Vikery, D.M. (1984). guide, a book for children, handouts tocopy for Taking care of your children. Reading, MA: parents, a poster, 36 stickers, and other Addison-Wesley. information about child passenger safety. Reinish, E.H., & Minear, R.E., Jr. (1978). Health Peterson, P. (1984). Ready... Set ... Grow!!: A of the preschool child. New York: Wiley. comprehensive health education curriculum for 3-5 year olds. St. Paul, MN: Peterson. (Available from Peterson Publishing, P.O. Box 75991, St. Paul, MN 55175) U.S. Department of Health and Human Services. (1985). Head Start dental health curriculum (DHHS Publication No. OHDS 86-31535). Washington, DC: U.S. Government Printing Office. Child health curriculum Whicker, P. (1983). Aim for health. Winston- Salem, NC: Kaplan. Brevis Corporation, 3310 S. 2700 East, Salt Lake City,UT 84105. Very clever and' appealing materials on handwashing for children and adults. Children with special needs Harrison, D. D. (1974). Health and safety for young children: Child involvement in personal Black, E., & Nagel, D. (Eds.). (1982). Physically health. New York: Macmillan. (Available from handicapped children: A medical atlas for Threshold Division, Macmillan Publishing teachers (2nd ed.). New York: Grune & Company, Inc., 866 Third Avenue, New York, Stratton. NY 10022) Brooth, A., Donebad, P., & Maykut, P. (1981). Hendricks, C., & Smith, C.J. (1982). Hale and Mainstreaming children with a handicap in day hardy helpful health hints: A comprehensive care and preschool: A manual of training health education curriculum for Head Start activities. Madison, WI: Wisconsin Council on prograMs. Bowling Green, KY: Barren River Developmental Disabilities. District Health Department. Froschl, M., Colon, L., Rubin, E., & Sprung, B. Kerr, A. (1985). Health, safety, and nutrition early (1984). Including all of us: An early childhood childhood curriculum. Carson, CA: Lakeshore curriculum about disability. Mt. Rainier, MD: Curriculum. (Available from Lakeshore Educational Equity Concepts. ,(Available from Curriculum Materials Company, 295 E. Gryphon House, Inc., P.O. Box 275, Mt. Rainier, Dominguez Street, Carson CA 90749) MD 02712) 0 0/-1 4, National resources 301

U.S. Department of Health, Education and Pediatrics for Parents, 176 Mt. Hope Avenue, Welfare. (1972). Day Care Series # 8: Serving Bangor, ME 04401. 207-942-6212. children with special needs (Stock # 1791-0176). Excellent monthly newsletter with practical Washington, DC: U.S. Government Printing health information in an easy-to-read format. .-Office. Includes summaries of research and helpful

US.-Department of Health and Human Services. hintg dealing with children. Appropriate for- (1978). Mainstreaming preschoolers. parents and staff. Washington, DC: U.S. Government Printing Please I. fer to the list of organizationsnearly all Office. of them have publications. Contact your local Children with orthopedic handicaps (Stock Child Care Resource & Referral Agency for # 017-092-00034-1). other resources. Children with visual handicaps (Stock # 01-7-092-00030-8) Children with mental retardation (Stock # 017-092-00029-4) Children-with health impairments (Stock # 017-092-00031-6) Children with hearing impairment (Stock # 017-092-00032-4) Children with emotional disturbance (Stock # 017-092-00036-7) First-aid resources Children with speech and language impairments (Stock # 017-092-00033-2) American Red Cross. (1979). Standard first aid Children with.learning disabilities (Stock and personal safety (2nd ed.). New York: # 017-092-00035-9) Doubleday. Good basic text with an emphasis on safety. Not very useful as a quick reference. American Red Cross. (1979). Advanced first aid and emergency care (2nd ed.). New York: Doubleday. Emphasis on first aid and transportation. Aronson, S. (1988). First aid in child care settings. Washington, DC:-American Red Cross. Periodicals Freeman, L. What would you do if...A kid's guide to first aid. (1983). Seattle, WA: Parenting Child Care Information Exchange, P.O. Box 2890, Press. (Available from Parenting Press, 7750 Redmond, WA 98073. 31st Avenue, N.E., Seattle, WA 98115) Monthly magazine for directors with regular Emphasizes discussion of prevention and first- health update column written by Susan S. aid information for children. Aronson, M.D. Articles address important child Green, M. (1984). A sigh of reliefThe first aid care issues and are extremely informative and handbook for childhood emergencies (2nd ed.). well-written. NY: Bantam. Child Care News, Child Care Resources Center, Rovertson, A.A. Health, safety & first aid: A guide 552 Massachusetts Avenue, Cambridge, MA for training child care workers. (1980). White 02139. 617-547-1063. Bear Lake, MN: Toys 'n Things Press. (Available Ten newsletters per year with excellent coverage from Toys 'n Things Press, Minnesota of childcare issues, including alternating Curriculum Services Center, 3554 White Bear column on health. Massachusetts oriented. Avenue, White Bear Lake, MN 56110) Child Health Alert, P.O. Box 338, Newton Lots of good information for teachers. Highlands, MA 02161. Upjohn Company. (1981). First things firstYour A monthly newsletter with summaries and first book about first aid. New York: Author. comments on recent health research and issues. (Available from Upjohn, 3rd Floor, 99 Park Written in aclear and understandable format. A Avenue, New York, NY 10016.) good resource. For children. 35 302 Appendix 1

Nutrition resources Wanamaker, N., Hearn, K., & PJcharz, S. (1979). More than graham crackers: Nutrition Bershad, C., & Bernick, D. (1981). Bodyworks: The education & food preparation withyoung kid's guide to food and physical fitness. New children. Washington, DC: National Association York:-Random House. for the Education of Young Children. Brody, J. (1981). Jane Brody's nutrition book. New Winick, M. (1981). Growing up healthy: A parent's York: W.W. Norton. guide to good. nutrition.-New York: William G oodwinr MT.,- &Pollen, ,G...(1980). Creative food Morrow. experiences for children. Washington, DC: Zeitlin, M., Connell, D., Schlossman, N., Rall, V., Center for Service in the Public Interest. & Ryden, T. (1986). Breastfed babies: Massachusetts Department of Public Health. Guidelines for the day care provider. Weston, (1984). Infant feeding policy. Boston, MA: MA: Lactation Associates. Author. Natow, A., & Heslin, J.A. (1984). No-nonsense nutrition for kids. New York: McGraw-Hill. Satter,,F..(1983),,Child.of rnine-Feeding with love and good sense. Palo Alto, CA: Bull. Resources for health screening U.S. Department of Agriculture, Food and Nutrition Service. (1985). A planning guide for Vision food service in child care centers (FHS Broken Wheel Test. (Available from Burnell Publication No. 64). Washington, DC: U.S. Corporation, 750 Lincolnway East, P.O. Box Government Printing Office. 4637, South Bend, IN 46634) U.S. Department of Agriculture, & U.S. Preschool Vision Screening Package. (Available Department of Health and Human Services. from The Preschool Enrichment Team, Inc., 276 (1985). Nutrition and your health: Dietary High Street, Holyoke, MA 01040) guidelines for Americans (2nd ed.). (Home and Includes pamphlets and a screening manual, Garden Bulletin No. 232). Washington, DC: U.S. plus the Broken Wheel test. Government Printing Office. Snellen E (Tumbling E). (Available from National Vonde, D., & Beck, J. (1980). Food adventures for Society for the Prevention of Blindness, 79 children. Redondo Beach, CA: Plycon Press. Madison Avenue, New York, NY 10016) Appendix 2 Children's Oldure books about health, nutrition, and safety Mary Rand la longo and Melissa Ann Rencic-Compilers

Health care Okenbilly, H. (1986). I see. New York: Random House. Oxenbuty, H. (1986). I touch. New York: Random Aliki. (1962). My five senses. New York: Harper & House. Row. Peterson, J. (1977). I have a sister, my sister is Berger, M. (1983). Why I cough, sneeze, shiver, deaf. New York: Harper & Row. hiccup and yawn. New York: Crowel. Rabe, B. (1981). The balancing girl. New York: Berger, AC (1985). Germs make me sick! New Dutton. York: Crowell/Hai-per &-Row. Reit, S. (1985). Some busy hospital! New York: Brandefiberg, F. (1978). I wish I was sick, too! Golden Books. New York: Puffin Rockwell, A., & Rockwell, H. (1982). Sick in bed. Brown, M. (1979). Arthur's eyes. Boston: Little, New York: Macmillan. Brown. Rockwell, A., & Rockwell, H. (1985). The Brown, T. (1984). Someone special, just like you. emergency room. New York: Macmillan. New York: Ho lt, Rhinehart & Winston. Rockwell, H. (1973). My doctor. New York: Brenner, B. (1973). Bodies. New York; E.P. Dutton. Macmillan. -Cole,-J.,(1984). How you were born. -New- York: Rockwell, H. (1975). My dentist. New York: Morrow. Greenwillow. Cole, J. (1985). Cuts, breaks, bruises and burns: Showers, P. (1975). Her -,ur heart. New York: How yottr-body. heals. New York: Harper .& Row. Harper/Crowell. Showiri, P. (1980). No measles, no mumps for Cole, J. (1987). The magic schoolbus at the me. New York: Crowell/Harper & Row. waterworks. New York: Scholastic. Silverstein, A. (1978). Itch, sniffle and sneeze: All DeSantis, K. (1985). A doctor's tools. New York: about asthma, hay fever and other allergies. Dodd. New York: Four Winds. Howe, J. (1981). The hospital book. New York: Steedman, J. (1974). Emergency room: An ABC Crown. tour. McLean, VA: Windy Hill Press. Isadora, R. (1985). I hear. New York: Greenwillow. Stein, S.B. (1974). A hospital story: An open family Isadora, R. (1985). I see. New York: Greenwillow. book for parents and children together. New Krementz, J. (1986). Taryn goes to the dentist. York: Walker. New York: Crown. Trier, C.S. (1982). Exercise: What it is, what it .Marino, B.P. (1979). Eric needs stitches. Reading, does. New York: Greenwillow. MA: Addison-Wesley. Wolf, B. (1980). Michael and the dentist. New York: Oxenbuty, H. (1983). The checkup. New York: Dial. Four Winds. Oxenbuty, H. (1986)..1 hear. New York: Random Zim, H.S. (1952). What's inside me? New York: House. Morrow. 304 Appendix 2

Foods and.nutiition Seixas, J.S. (1986). Vitamins: What theyare, what they do. New Yt-±k: Greenwillow. Aliki. (1976). Corn is maize: The gift of the Sharmat, M. (1980). Gregory the terrible eater. Indians. New York: Crowell/Harper & Row. New York: Four Winds. Carle, .E.,(1969)_The very-hungry caterpillar. New Showers, P. (1985). What happens toa hamburger.

York: Philomel Books. . New York: Harper/Crowell. Ca_ uley, L.B. (1977). Pease porridge hot: A Mother Smaridge, N. (1982). What's on your plate? Gobse cookbook. New York: Putnam. Nashville, TN: Abingdon. ,.;ooper, J. (1977). Love at first bite: Snacks and Spier, P. (1981). The food market. New York: mealtime treats the easy way. New York: Knopf. Doubleday. Degan, Jamberry. New York: Harper & Row. de Paola, T. (1978): The popcorn book. New York: Holiday House. Ehlert_L.41987). -Growing vegetable soup. New Safety York: Harcourt Brace Jovanovich. Gibbons,-G. (1985). The milk makers. New York: Brown, M., & Krensky, L. (1982). Dinosaurs -Macmillan.. beware' ksafety guide. Boston: Little; Brown. Hoban, R. (1964). Bread and jam for Frances. New Gibbons, G. (1984). Fire! Fire! New York: York: Harper. Crowell/Harper & Row. Lynn, S. (1986). Food. New York: Girard, L.W. (1984). My body is private. Niles, IL: Macmillan/Aladdin. Whitman. Pluckrose, H. (1986). Think about tasting. New McLeod, E.W. (1975). The bear's bicycle. Boston: York: Watts. Little, Brown. Rockwell, A., & Rockwell, H. (1982). How my Schick, E. (1980). Home alone. New York: Dial garden grew. New York: Macmillan. Press. Rylant, C. (1984). This year's garden. New York: Smaridge, N. (1965). Watch out! New York: Bradbury. Abingdon. Seixas, J.S. (1984). Junk food. New York: Wachter, 0. (1983). No more secrets for me. Greenwillow. Boston: Little, Brown. Index

Acoustic reflex (hearing screening)119, 126 Sudden Infant Death Syndrome (SIDS)203 Adult health135-141 Child Care Food Program (CCFP)172-173, 174, environment135 175, 182, 183 infectious diseases137, 140 meal patterns174, 175 medical exams137, 138-139 Child care workers. See Staff TB screening 253-254 Child development AIDS/HIV infections267, 270-271 developmental health history form113-115 =attendance recommendations 234, 271 deVeliiPmental red'flags116-117, 122-127 Air quality28, 31 milestones116 Allergy167-168, 213, 217 observing and recording observations111, Anemia167, 223 116-117 Animals, care of 36 screening and assessment117-120 Art and crafts materials, risks of53-54, 56 Choking 97 Asbestos31 Chronic health conditions213-226 Asthma 217-218, 219-220 allergy213, 217 asthma 217-218, 219-220 Bee stings98, 217 diabetes 223-224 Bleach solution25, 26, 30, 31, 32, 33, 35, 39, 45, emergency planning 225 229, 265, 267, 270 epilepsy/seizure disorders221-223 Blood contact infections267, 269-271 heart problems218,-421 control and prevention267 sample health record213, 215-216 reporting 269 sicklecell anemia 223 types See als,) Emergencies; Special needs, children with AIDS/HIV 270-271 C_ leaning 35-36, 38-39'See Sanitation rtT hepatitis B 267, 269-270 food contact surfaces and utensils38-39, 183-185 Broken Wheel vision test119, 302 infectious diseases229, 235 Brushing teeth143-144 CMV 262, 265, 266 Colds242,'244, 285 Campylobacter 233, 235, 237, 239 Community resources16, 20, 192 Candida infections274-275 nutrition172-174 Carriages62-63 special needs192 Car seats and restraints85-90 See also Health care consultants laws and standards85, 89 Confidentiality17, 269-270 Chicken pox234, 245, 247, 248 Conjunctivitis (pinkeye)257, 259 Child abuse and neglect199-207 Constipation 286 complaints202-204 Consultants. See Health care consultants defined199 Contaminated items31-32, See also Food indicators199-201 preparation and handling law 202-203 Cribs60, 62 mandated reporter 202-203 Curriculum parents202, 203, 204 dental health19, 144 prevention and screening203, 204 mental/social health21 reporting 201-203 . Cytomegalovirus (CMV) infection262, 265, 266 3 3 9 305 Dehydration 286 sample emergency transportation permission Dental health143-146 form101, 103 brushing -teeth143-144 sample phone list94, 105 education144 transportation87 referral criteria and special problems145, 146 See also Chronic health conditions Dentist144-146 Ear infections274 Denver Developmental Screening Test Early Screening Instrument (ESI)128 (DDST)128 Education. See Health education Development. See Chad development Electrical wiring52 ,Diabetes223-224 Environmental concerns 25-33 Diapering 43-45 air quality28, 31 changing surfaces43, 44, 45, 60 allergy213, 217 infectious diseases229, 235, 239 contaminated items31-32 poisons54 eating and food handling31,157 procedure 43, 44-45 handwashing 25, 27, 28 See, also Sanitation; Toileting. infectious diseases229,232,233 Diaper rash 275, 287 lead209-210 Diarrhea233-239, 285-286 See individual play materials and activities32-33 ,intestinal diseases staff health135 Diet use of space28, 40 allergies and intolerances167-168, 213, See also Safety; Sanitation 215-216, 217 Epilepsy/seizure disorders221-223 calcium165, 166 Equipment and supplies fats, sugar, and salt155, 158, 163 fire emergency 95-96 guidelines154-155, 158-159 first aid93-94, 102 vegetarian163-165 housekeeping35 Diphtheria230-231, 271-272, 273-274 nursery 60-65 Direct contact diseases storage183-185 generalized infections262, 265-267 toileting39, 46-47 control and prevention262, 265 transportation87-89 sexually transmitted266-267 Evacuation plans94-96 types Expanded Food and Nutrition Education Program Cytomegalovirus (CMV) 262, 265, 266 (EFNEP)174 Herpes simplex262, 265-267 skin and superficial infections254-262 Failure-to-Thrive167 -control and-prevention254-255 Febrile seizures285 types Feeding infants and toddlers151-159 conjunctivitis254, 257, 259 bottle feeding151, 156, 183 impetigo254- 256 cow's milk156 pediculosis (head lice)254, 260, 262, food consumption157 263-264 new foods162 ringworm254; 255, 2c7, 258 nutritional problems165, 167-168 scabies254, 257, 260, 261 safety162-163 Dishwashing 38-39, 184-185 snacks157, 160-161 Drowning 59 solid foods151, 156 See also Nutrition Emergencies 93-105 Fevers283-285 assistance94, 105 Field trip and car pool safety57-59, 89-90 evacuation 94-96 Fire emergency 94-96 first aid93-94, 97-100 First aid 96-104 group management 95-96 education100 injury report94, 97, 104 injury assessment 96-97 poisons 99 kit93-94, 102 procedures 93-96, 101 Fluoride143

306 '140 Food allergies and intolerances167-168 sample medication form 289-290 Food Distribution Program173 Health screening109, 111, 117-120, 122-129 Food groups157 height and weight120 Food preparation and handling31, 174, 183-185 lead levels120, 209-210 breast milk and formula183 hearing119-120 dealing 184-185 vision118-119, 127, 302 infectious diseases229, 232, 236-237, 239 tests and instruments116-117, 119, 120, 126, menu planning174-183 128-129 procedures38-39, 183-185 Hearing screening119-120, 126 purchasing and storage183-185 Heart problems218, 221 See also Kitchen facilities; Nutrition Heat exhaustion and dehydration59, 288 Food Stamp Program174 Hepatitis A 233, 234, 240, 242, 243 Hepatitis B 267, 269-270 Garbage disposal 39 Herpes simplex viral (HSV) infection262, Giardia lamblia235-236, 2,39 265-266 Gloves, disposable28, 31, 44, 270 Hib disease230-231, 234, 242, 249, 25L 252 Grodp management Highchairs60, 61 emergency 94-96 Housekeeping 35-36 infectious diseases32, 235 Hygiene. See Sanitation -HaerriophiluS influenzae type B (Hib Hyperactivity168 disease)230-231, 234, 242, 249, 251, 252 Immunization137, 140, 229-232 Handwashing 25-28, 36-37 Hepatitis B 269 infectious diseases137, 140, 229, 235, 239, Hib disease229, 230, 231, 251 240, 242, 243, 244, 246, 254, 257, 259, 262, 270 See also Vaccine-preventable diseases Head lice (pedictilosis)254, 260, 262, 263-264 Head Start117, 193-194 Impetigo 254, 255, 256 Health assessment111, 116-117 Infant Feeding Guide154-155 See also Health observation; Health screening Infants and toddlers Health care consultants14-16, 112 changing surfaces43, 44-45, 60 dentist112, 144-146 feeding151-157 pediatrician15-16, 112 furniture and equipment60-65 See also Community resources nutritional problems165, 167-168, 169 Health curriculum, preschool19-21 play areas60, 64 safety90 safety60-82 Health education19-21 toys and play materials60, -64, 65 auto safety89-90 Infectious diseases137, 140, 229-276 dental- 144 control and prevention229, 232-233; See first aid100 individual diseases integrated19-21 exclusion fro_ m center 232, 234; See individual_ -ntiffitiOn'170-172 diseases preschool19-20, 21 immunization229-.232 safety82 reporting232; See individual diseases staff /parent20-21, 90 types Health hi

4? Playground safety54, 57, 58, 64, 73-81 Ringworm (Tinea)232, 254, 255, 257, 258 Playpens 63 Rocky Mountain Spotted Fever. See Tick-borne Play,risks32-33 diseases art:supplies, -53754;-56 Ilbseola 244 gross motor equipment53, 57, 58 Rubella (German measles)230-231, 271-272, infantS and toddlers' _33, 60, 64, 65 273 playgrounds 54, 57, 58, 64, 73-81 seasonal 5960, 287 -288 Safety32-33, 51-82, 85-90 Plumbing28, 29-30, 39,-40- art supplies53-54, 56 Poison control center 55, 100 choking52, 54, 62, 162-163 Poisons education82 -art and Craft materials53-54, 56 electrical wiring52 batteries54 field trips57, 59 -cooking-an dlitchen utensils54 infants-and toddlers 60-65 diapering54 kitchen facilities52 emergency 99 outdoors54, 57, 58, 59, 60, 64, 73-81 lead120, 167, 209 -210 pedestrian. 57 plants54; 55 play areas51-52 Polio230-231, 271-272, 273 playgrounds54, 57, 58, 64, 73-81 Pools33, 59 poisonous plants54, 55 Potty chairs39, 47- seasonal59-60, 287-288 Pregnancy and CMV 265 toys and play materials53, 57, 60, 64, 65 Preschool Enrichment Team (P.E.T.) 122 transportation85-90 Preschool Feeding Guide158-159 tricycleS53, 57 Preschool health curriculum. See Health water 33, 59 curriculum, preschool See also Environmentalconcerns Preventive child health care109-132 Salmonella233, 235, 236-237, 239 health histories111, 113-115 Sand 33 health observation111, 1137117 Sanitation25, 26, 31, 35-40 medical examinations120-121, 130-132 garbage disposal39, 185 primary services 111 handwashing25, 27, 28, 36, 37 screening111, 112, 116-120, 123-124, 125, housekeeping 35-36 126, 127, 128-129 kitchen facilities38-39, 184-185 See also Adult health; Dental health; Nutrition; laundry 39 Safety personal items255 toilet facilities and plumbing 39-40, 45 Rashes 286-287 See also Environmentalconcerns; Toileting See also Direct contact diseases Seizures98, 221-223 Records. See Health records Scabies254, 257, 260, 261 Reporting child abuse199, 202-203 Scarlet fever 245 Reporting.diseases232, 233, 249, 269 Screening. See Health screening See alsb individual diseases Sexual abuse. See Child abuse and neglect Respiratory diseases242, 244-254 Sexually transmitted diseases262, 265-271 control and prevention242, 244 AIDS/HIV 234, 267, 270-271 sample letters to parents, see Lettersto parents hepatitis B 267, 269-270 types Shigella233, 235, 236, 239 chicken pox and shingles245, 247, 248 Shingles245, 247 Hib disease242, 249, 251, 252 Sick child care- 279-291, 293-294 meningococcal242, 247, 249, 250 family day care294 streptococcal242, 245, 246 "get well" room 293-294 tuberculosis251, 253-254 medication 288-291 viral (colds, flu)242, 244-245, 285 policy279-281 Reye's Syndrome 247, 248 separate facility294 Rheumatic fever '221, 245, 246 types of minor illness and symptoms

X43 309 colds285 Toilet learning 46-47 constipation 286 Tooth fevers283, 285 ache146 .heatexhaustion 2_88 broken .146 rashes 286-287 knocked out146 Sunburn 287 Toys and play materials teething 287 risks32-33, 53, 57 vomiting and nausea 285 infants and toddlers33, 60, 64, 65 Sickle- cell-anemia 223 Training, staff/parent20-21 Skin and superficial infections254-267 Transportation safety85-90 See Direct contact diseases car seats and restraints85, 86, 87, 88 Skin products287 emergencies87, 89 Snellen E (Tumbling E) Test (vision equipment and information87, 89 screening)119, 127, 302 field trips and car_pools89 Space 28 policy85 Safety51-52 Tricycles, safety53; 57 Special needs, children with189-197 Tuberculosis (TB)251, 253-254 community resources 192 Turnover, siaff/children32 programming considerations192, 195-196 Tympanometry (hearing screening)119, 126 See also Child abuse and neglect; Chronic health conditions; Lead poisoning Underweight children165 Special Supplemental Food Program for Women, USDA Infants & Children (WIC)174 Child Care Food Program (CCFP)172-173 Staff Food Distribution Program173 health135-140 Vaccination. See Immunization health education20-21 Vaccine-preventable diseases230-231, 271-274 personnel policy135, 140 immunization 230-231, 271-272 relations with parents111 types responsibilities3, 14 diphtheria230-231, 271-272, 273 screening (for hiring)137, 204 measles230-231, 271-272 turnover 32 mumps 230-231, 271-272 Statewide Comprehensive Injury Prevention pertussis (whooping cough)230-231, Program (SCIPP)81, 83 271-272, 273-274 Strep throat221, 242, 245, 246 polio230-231, 271-272, 273 Streptococcal-infections (Group A)245-247 rubella (German-measles)230-231, 271-272, Strollers62-63 272-273 Sudden Infant Death Syndrome (SIDS) 203 tetanus230-231, 271-272, 273 Sunburn59; 287-288 See also Immunization Viral illnesses244-245, 246, 247, 248 Teething 287 Vision screening118-119, 127, 302 Temperatures, how to take284 Vomiting and nausea 285 Tetanus271, 273 Throat culture245, 246 Walkers60, 61 Tick-borne diseases274, 276-277 Water safety33, 59 Tinea (ringworm)232, 254, 255, 257, 258 Water table32 Toilet facilities and plumbing 29-30, 39-40, Whooping cough (pertussis)230-231, 271-272, 46-47 273-274 Toileting43-47 hygiene37, 39, 47 Yeast infections (Candida)274-275 See also Sanitation

310 Information about NAEYC

N A E Y C is. . .

. . . amembership- supported organization of people committed to fostering the growth and development of children from birth through age 8. Membership is open to all who share a desire to serve and act on behalf of the needs and rights of young children.

NAEYC provides. . .

...educational services and resources to adults who work with and for children, including Young Children, the journal for early childhodd educators Books, posters, brochures, and videos to expand professional knowledge and'commitment to young children, with topics including infants, curriculum, research, discipline, teacher education, and parent involvement AnAnnual Conference that brings people from all over the country to share their expertise and advocate on behalf of children and families Week of the Young Child celebrations sponsored by NAEYC Affiliate-Groups across the nation to call public attention to the needs and rights.of children and families Insurance plans for individuals and programs Public policy information for knowledgeable advocacy efforts at all,levels-of government The Information Service, a-computerized, central source of information sharing, distribution, i.nd collaboration The National Academy of Early Childhood Programs, a VOlUiffai-y acereditafiori system for high qualityprograms for children For free information about membership, publications, or other NAEYC services, call NAEYC at 202-232-8777 or 800-424-2460. Or write to NAEYC,,1834-Connecticut Avenue, N.W., Washington, DC 20009-5786. . )UflChikfrefl

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