Standards and Guidelines for Health in Child Care Settings

Transcription

1 Standards and Guidelines for Health in Child Care Settings (2005) Government of Newfoundland and Labrador Department of Health and Community Services

2 INTRODUCTION The health and safety of children is of prime importance. In addition to ensuring that children are safe from injury and infection, child care providers must demonstrate, model, and promote sound health practices. Children learn by example and we, as adults and professionals who work with young children, have an obligation to help them develop in the healthiest way possible. Newfoundland and Labrador has made a commitment to improve the health status of all the people living in the province. The Strategic Heath Plan has outlined specific goals that help to fulfill this commitment. One of these goals is to improve the healthy growth and development of children and youth. This manual provides information which will assist child care providers* in helping to achieve this particular goal. The manual outlines standards and guidelines that child care providers must follow in order to meet their responsibility for providing the children in their care with a healthy and safe environment. Included is information related to health promotion, safety and injury prevention, preventing and controlling disease in child care settings, recognizing and reporting disease, caring for mildly ill children, child abuse and neglect, and good adult health. There is also a new Resources section in this manual. Space is provided for users of this manual to add resources that they have found useful. Users of this manual can consult with regional social workers or child care services consultants if they have any questions about how to obtain resources mentioned within the manual or if they have any questions about any the guidelines presented in this book. This manual is an updated version of the original Health in Child Care Settings (1995)**. One of the major additions to this version is the inclusion of information pertaining to infant care. Several sections are written specifically for infant care, however much other information is found throughout the document in the related sections. Providers caring for infants should use the entire document as a reference tool as many health issues apply to all ages of children. This manual recognizes that many health and safety issues are common to all children. Children attending child care settings have a variety of developmental needs and abilities. Issues specific to a particular special need or condition are

3 best addressed by the provider working with the parents and any professional team members that may be associated with the child and family. More information on a number of specific special needs and conditions will be provided in a separate document. This manual also includes a Feedback Form. Users of this manual can complete this form and return it to Child Care Services, Health and Community Services with their comments pertaining to the manual. If there are sections that are thought to be particularly helpful or areas that could be revised in future versions, this form can be used to supply this feedback. Errors or omissions can also be recorded on the feedback form and sent in to the address provided. Equipped with knowledge, information, and an enthusiasm for health promotion, child care providers can have a major impact on the quality of children s health in this province. Healthy attitudes and practices must be encouraged in all child care settings and the attitudes and practices learned by children during these early years will have life-long benefits. * This document is for use in both centre-based and family child care settings. The term provider or child care provider is used to refer to the adults working with children in child care settings. ** The 2005 manual contains information that has been revised since the 2004 version. Any page that contains revisions will indicate this at the bottom of the page. iii

4 ACKNOWLEDGEMENTS This document is a revision of HEALTH IN CHILD CARE SETTINGS GUIDELINES FOR CHILD CARE PROVIDERS AND EARLY CHILDHOOD EDUCATORS (February 1995) - Original Authors: Ann Manning and Lynn Vivian-Book The Department thanks Janet Murphy-Goodridge for reviewing the original manual and collecting and/or developing many of the revisions contained in this document. The Department would also like to acknowledge and thank the many other individuals who have assisted with the development of this document. Portions of this manual have been adapted with permission from Well Beings: A Guide to Promote the Physical Health, Safety, and Emotional Well-Being of Children in Child Care Centres and Family Day Care Homes. Canadian Paediatric Society, (1999) Ottawa, Ontario. iv

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6 TABLE OF CONTENTS INTRODUCTION... iii ACKNOWLEDGEMENTS... v IMMUNIZATION... 1 Policies for Immunization... 1 Immunization Schedule... 2 Common Reactions to Immunizations... 3 HANDWASHING... 5 For Proper Handwashing You Need... 5 The Correct Way to Wash Hands... 7 When to Wash Hands... 8 Alcohol Based Hand Rinses... 9 DIAPERING AND TOILETING Diaper Changing Toileting Routine PHYSICAL ENVIRONMENT Equipment, Supplies and Materials Sleeping Area and Arrangements SANITIZATION AND HOUSEKEEPING General Cleaning and Sanitizing Practices Materials for Cleaning Cleaning Routine Sanitizing Routine Items Which Should be Cleaned and/or Sanitized Infant and Toddler Toys In the Kitchen Food Safety Cleaning Dishes Garbage Composting Sleeping Areas Sand Boxes and Tables Water Tables Routine for Cleaning Body Fluid Spills NUTRITION Nutrition Guidelines for Child Care Settings Canada s Food Guide to Healthy Eating for Preschoolers... 35

7 A Word About Salt, Sugar And Fat Products Sweetened with Artificial Sweeteners Food Intolerance and Food Allergy Food Intolerance Food Allergy Common Food Allergies Avoidance Food Choking Hazards Keeping Parents Informed GUIDELINES FOR INFANT FEEDING Breastfeeding Storing and Handling Breastmilk Formula Feeding Storing and Handling of Formula Preparing Bottles for Bottle-feeding Feeding Basics How do you know a breastfed baby is getting lots of milk? Feeding and Sleeping Patterns Feeding in Child Care Settings What should the provider do if the breastfed baby seems hungry and the mother is due to arrive shortly? Water and Juice Introducing Complementary Foods Infant Readiness for Complementary foods Handling Conflicting Issues Parent Guidelines for Introducing Complementary Foods Commercial and Homemade Infant Foods Storing and Serving Infant Foods Feeding Time: A Time for Closeness ORAL HEALTH - CARING FOR MOUTH, TEETH AND GUMS Mouth Care for the Infant and Toddler Teething Early Childhood Tooth Decay - Baby Bottle Mouth Dental Safety Mouth Care for the Preschool/Kindergarten Child Food and Teeth - Those Hidden Sugars Labelling and Storing of Toothbrushes vii

8 Dental Emergencies Liquid Medications The Newfoundland and Labrador Children s Dental Plan SMOKING SAFETY AND INJURY PREVENTION The Importance of Preventing Injuries Most Common Times for Injuries General Safety Issues for Infants and Toddlers Outdoors Sun Safety Water Safety Insect Bites Winter Safety Safety for School Age Children Plants Pets Risks and Responsibility What Providers Can Teach Children about Pet Safety Reporting Injuries How to Prevent Choking Toys Balloons Eating Utensils Other Safety Checklists Indoors Outdoors Protective Surfacing Requirements Guidelines for Safe Play Transportation Safety Emergency Preparation First Aid Kits ACTIVE LIVING SEXUALITY IN CHILDHOOD Normal Sexual Development in Children: Major Landmarks Obstacles to Talking about Sex Guidelines for Communicating with Children about Sex viii

9 When a Child s Sexual Behaviour Is Not Appropriate CHILD ABUSE AND NEGLECT Recognizing Child Sexual Abuse ADULT HEALTH Reducing the Risk of Infectious Disease Immunization Handwashing Managing Illness for Child Care Providers Reducing Adult Injury in Child Care Settings Taking Care of Yourself Pregnancy and Working in a Child Care Setting INFECTIOUS DISEASE IN CHILD CARE SETTINGS Introduction Infectious Diseases - Why They Spread in Child Care Controlling Infectious Diseases MANAGING ILLNESS: WHAT TO DO IN CHILD CARE SETTINGS Managing the Mildly Ill Child in Child Care Outbreaks Common Complaints Fever Febrile Seizures Taking a Temperature Cleaning a Thermometer Vomiting Diarrhea Exclusion Dehydration E. Coli Infections Nosebleeds Constipation TABLE I GUIDELINES FOR MANAGING ILLNESS Facts about Chickenpox Facts About The Common Cold Facts About Ear Infections Facts about Fifth Disease Facts about Giardiasis ix

10 Facts about Hand, Foot and Mouth Disease Facts about Hepatitis A Facts about Impetigo Facts about Pink Eye Facts About Ringworm Facts about Strep Throat and Scarlet Fever Facts about Whooping Cough Facts about Measles Facts about German Measles (Rubella) Facts about Mumps Facts about HIB Disease Facts about Meningococcal Disease Facts about Head Lice Facts about Scabies COMMON HEALTH ISSUES WITH INFANTS Crying and the Fussy Baby Colic Shaken Baby Syndrome Thrush and Candida Diaper Rash Oral Thrush Diaper Rash Facts about Thrush and Candida Diaper Rash Cradle Cap Diaper Rash Tips For Preventing Diaper Rash Eczema Burping Hiccoughs Spitting up Gastroesophageal Reflux in Babies (Reflux) Respiratory Syncytial Virus (RSV) Sudden Infant Death Syndrome (SIDS) Sleeping Position Preventing Flat Heads in Babies Who Sleep on Their Backs MEDICATIONS General Guidelines Administering Medication x

11 Preparing the Child Preparing and Giving the Medication Recording the Medications Specific Medication Issues Ointments and Cream Tablets and Capsules Epi-Pen for Anaphylactic Reactions for Children CHILDREN WITH SPECIAL NEEDS AND LONG-TERM CONDITIONS Allergies Anaphylactic Reaction Prevention of Anaphylaxis (The Three A s): How to Care for Children with Allergies Tips for Providers Asthma Signs and Symptoms of an Asthma Attack Prevention Tips for Providers Administering Medication for Asthma Scented Products and Health Concerns Seizures Common Types of Seizures First Aid for Seizures Safety Issues Infants and Seizures Delegation of Health Related Procedures to Child Care Providers HEALTH RECORDS Child s Health Questionnaire Incident/Injury Reports Consent for Emergency Care and Transportation Medication Consent and Record Sheet Children with Special Needs or Long-term Conditions Notification of Illness Infant Daily Record Record of Illness, Absence and Early Departure RECORD FORMS xi

12 Child s Health Questionnaire Incident/Injury Report Consent For Emergency Care And Transportation Medication Consent And Record Sheet Asthma/Allergies History Form Special Needs/Long-term Condition History Form Notification of Illness Infant Daily Record Record of Illness, Absence and Early Departure Appendix A - Recommended Protective Surfacing FEEDBACK FORM BIBLIOGRAPHY RESOURCES xii

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14 PROMOTING HEALTH IN CHILD CARE SETTINGS

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16 Health in Child Care Settings 1 IMMUNIZATION Immunization is the most effective way of preventing common childhood infections. These diseases can all be prevented if immunizations are up to date. Chicken Pox Pneumococcal Disease Measles Pertussis (Whooping Cough) Mumps Tetanus Rubella (German Measles) Polio Diphtheria Haemophilus Influenzae b Meningitis Policies for Immunization 1. A copy of the current immunization record for each child must be kept on file in the child care setting. 2. The record can consist of a photocopy of the child s immunization card and must have dates of the immunization and the signature of the nurse or physician. 3. If there is any doubt about the immunization status, consult your public/community health nurse. 4. All providers must have a current immunization record on file. Providers immunization records and indicators of immune status (such as rubella titre), if appropriate, should be available in case of outbreak or if specific concerns arise about exposure to an infection. See also Adult Health section for more information on adult immunization. If a child s immunization record differs significantly from the following schedule, providers should consult the local public/community health nurse, with the permission of the parents. The public/community health nurse can help the child care staff in assessing immunization status particularly when immunizations have been late or irregular. A note can then be attached to the child s personal file, indicating any issues with the child s immunization status. Page Revised 03/05

17 2 Health in Child Care Settings Note: Up-to-date immunization is strongly recommended but not required. If immunizations are out of date or not done, this information is to be provided in written form by the child s parent/guardian, dated, signed and kept in the child s file. Immunizations that are more than ten years old no longer provide protection and in such situations it is strongly recommended that the parent contact the public health nurse or family physician on the matter. Immunization Schedule- Newfoundland and Labrador, January Age Diseases 2 months DaPTP/Hib (Diphtheria, Pertussis, Tetanus, Polio and Haemophilus b. ) Pneumococcal 4 months DaPTP/Hib (Diphtheria, Pertussis, Tetanus, Polio and Haemophilus b.) Pneumococcal 6 months DaPTP/Hib (Diphtheria, Pertussis, Tetanus, Polio and Haemophilus b.) Pneumococcal 12 months MMR (Measles, Mumps and Rubella); Varicella; Meningococcal 18 months DaPTP/Hib and MMR (Diphtheria, Pertussis, Tetanus, Polio and Haemophilus b., ) (Measles, Mumps and Rubella); Pneumococcal 4-6 yrs. (Kdg.) 9-10 yrs. (Gr. IV) yrs. (Gr. IX) DaPTP (Diphtheria, Pertussis, Tetanus, Polio); Varicella (if Varicella has not been given at 12 months, meaning two needles at this visit) Hepatitis B (1 dose x 3 visits); Meningococcal (if not given at 12 months, meaning two needles at this visit.) dtap (Tetanus, Diphtheria and Pertussis) and Meningococcal (if not given in Grade 4, meaning two needles at this visit.) REMEMBER: Publicly funded immunizations are free, and, if up-to-date, give children protection against several serious infectious childhood diseases. Immunizations can be given by your public/community health nurse or family doctor. Report any case of vaccine preventable disease to your local Health and Community Services office. Page Revised - 03/05

18 Health in Child Care Settings 3 Common Reactions to Immunizations You may have a child in your care who has been immunized earlier that day or the previous day. Some side effects from the vaccine may occur. Parents and child care providers must work together to plan on the action that will be taken if a child exhibits a reaction to the immunization. Common reactions include: redness, tenderness, and swelling at the site of injection, a low grade fever (38/C -38.5/C) and fussiness or irritability. These may last for 1-2 days and can usually be controlled with fever reducing medication. (Remember: DO NOT GIVE ASPIRIN). The plan of action decided upon between the parent and the child care provider will indicate what the child care provider will do in case of a fever. Fever reducing medicine, such as acetaminophen, (e.g. Children s Tylenol or Tempra), if given, must be done in accordance with the Child Care Services Regulations. (See Medications Section, and Medication Consent and Record Sheet form, in this document.) For more information on what to do in the case of a fever, see under Common Complaints. Less frequently, more serious reactions may occur. Excessive crying or extreme drowsiness associated with a high fever may occur. Occasionally, seizures have also been noted. A child may also experience an allergic reaction with wheezing, swelling of the face, mouth, or throat, and /or hives. The high fever may not be able to be brought down. Should any of these occur, contact the child s parent and seek medical attention immediately.

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20 Health in Child Care Settings 5 HANDWASHING HANDWASHING IS THE SINGLE MOST IMPORTANT TOOL FOR CONTROLLING INFECTION IN CHILD CARE SETTINGS. When providers wash their hands, how they wash their hands and how often they wash their hands are as important as what they wash with. The best way to reduce infection in child care settings is to ensure providers and children follow recommended handwashing routines. Studies in both hospitals and child care settings have shown that education and regular monitoring of providers handwashing are necessary in order to ensure that the proper routine is followed. Providers should consider hanging a handwashing poster by each sink as a reminder to providers and children. Remember: Young children need supervision with handwashing. This is a good time to teach a good health habit which can last a lifetime. For Proper Handwashing You Need: 1. Running Water Use running water to remove germs from hands. Full sinks of water and basins should not be used. The water may be warm, not hot. Hot water can scald. Hot water for handwashing should be no more than 43/C (110/F-115/F.) Note: When handwashing is impossible, such as on some field trips, providers can use disposable wet wipes. These are not, however, as effective as washing with running water. Even cool running water and soap works well to remove germs if hands are rubbed vigorously. It is the friction of rubbing the hands together that helps remove germs. 2. Soap A plain, mild, liquid hand soap is best for handwashing. The use of germicidal (anti-bacterial) soap is not necessary and not recommended in a child care program, because germs can be effectively removed by rubbing hands with soap. An empty soap dispenser should either be replaced or cleaned before

21 6 Health in Child Care Settings adding fresh soap. It is important not to mix fresh soap with the old soap already in the dispenser. The use of bar soup is discouraged because germs can grow on the soap and the water surrounding the soap. 3. Towels There are two options for towels; single-use towels or towels that are assigned to each individual. The choice to use one or both types of towels rests with individual child care settings. It will depend on storage space, laundry facilities, available space to hang towels to dry, laundry hampers, cost, and effect on the environment. The use of single-use towels, either cloth or paper, should not influence the effectiveness of handwashing in infection control. Single-Use < Use a clean towel each time. < Use to turn off taps. < Dispose of towel in garbage or laundry. Individual Towels < Assign each child and provider an individual towel to be used for the day < Clearly identify the name of the person on the towel. (You must use a separate towel for food preparation and after toileting.) < Hang the towels to dry so they are not touching. < Replace the towels with clean ones daily. < Supervise children closely during handwashing to ensure children use their own towels. < Do not use these towels to turn off the taps. The taps are dirty and will contaminate the towel, which is used all day. One suggestion is to have a provider use a single-use towel to turn off the taps for the child. Another is to use taps or water that is controlled with foot pedals. 4. Sinks Sinks should be stocked with an adequate supply of liquid soap and towels and located next to each diapering and toileting area. Step-up stools should be provided where child height sinks are not available. These sinks should not be used for rinsing contaminated clothing or for cleaning potties. Another sink or a utility sink should be used for cleaning contaminated objects.

22 Health in Child Care Settings 7 The Correct Way to Wash Hands 1. Wet hands with running water before putting soap on them. By doing this, less soap gets stuck in the pores and there will be less chance of irritation. 2. Vigorously rub hands for 20 seconds (count to 20) when washing them; this friction helps remove germs. 3. Wash all surfaces, including the backs of hands, wrists and between fingers. 4. Rinse hands well under running water for 10 seconds. 5. Dry hands well with towel. 6. Turn taps off with a single-use towel. 7. Throw the disposable towel into a lined, covered garbage container or place single-use cloth towels in the laundry hamper or hang individual cloth towels to dry. 8. Providers may use hand lotion after washing. Skin cracks and irritations are not only uncomfortable, they also trap germs that can be passed on to others. 9. When cleaning under your fingernails, use a disposable manicure stick, not a nailbrush. NOTE: If children are too young to wash their hands themselves, the child care provider should do it for them. For older children, tell them how to do it, show them and let them know that hand washing will help keep them healthy.

23 8 Health in Child Care Settings When to Wash Hands Adults should wash their hands at the start of the work day after changing a diaper after using the toilet or taking a child to the toilet before preparing food or eating after handling raw meat or vegetables after caring for an ill child after direct contact with nasal secretions (that is, after wiping a child s nose or sneezing or coughing yourself) before and after applying a bandage or other first aid after cleaning up any body fluids (blood, mucus, vomitus, stool, urine) before giving medication or applying an ointment after handling chemicals after removing disposable or household rubber gloves after handling pets or animals, and cleaning pets cages after removing children s footwear which may be covered with salt, dirt and slush when hands are visibly dirty or any other reason Children should wash their hands after using the toilet or the potty after diaper changes (during the diaper change, the child may touch the genital area, the soiled diaper or the contaminated changing surface, and the child can then spread the germs to others or to objects) before handling food in nutritional activities after eating snacks or meals, or drinking after blowing nose or vomiting after using play materials, such as finger paint and sand (Often, providers have children use a communal pail or sink of water to rinse off paint or clay from their hands. It will still be necessary for the children to wash their hands before they eat.) after handling pets and other animals after removing their own footwear - if covered with salt, dirt and/or slush after playing outside and when hands are visibly dirty for any other reason. Alcohol Based Hand Rinses

24 Health in Child Care Settings 9 It is ideal to have adequate hand washing facilities available in all child care settings. However there may be times when hand washing facilities are not available, e.g., during some field trips or in the playground area. For these specific situations, alcohol based hand rinses (e.g., Purell which has a 62% alcohol content) are an acceptable interim measure. The product should contain a minimum of 60%-70% alcohol content in order to effectively kill germs. Because these products contain alcohol, they must be kept out of reach of children and used with supervision. These products are essentially antiseptic hand rinses and are safe for use on skin, however they are only effective if hands are not visibly soiled. If hands are soiled then a moistened hand wipe/towelette should be used first, hands must be dried using a paper towel and then the sanitizer can be applied. Sanitizers cannot be used on wet hands as the water dilutes the alcohol, making the product less effective. These products dry very quickly and should not be rinsed off after the application. These alcohol hand rinses should not be used in place of regular hand washing. Hands should be washed using soap and running water as soon as facilities are available. Consult the manufacturer s information for specific instructions on the use of these products. The same principle applies here as with hand washing; a quantity of the product is dispensed into the palm of one hand and worked into both hands with friction. The product must dry before moving on to the next task. These products are available in various formats (small personal size bottles, pump style dispensers, etc.) These products are not a substitution for hand washing with soap and running water. They can also be harsh on skin as they remove natural oils. For more information on the use of alcohol based sanitizers, see the following websites Page Revised - 05/04

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26 Health in Child Care Settings 11 DIAPERING AND TOILETING Research studies indicate some infections in child care settings are associated with the presence of young children in diapers. Children promote the transmission of infection through their behaviour, for example, children are constantly putting things in their mouths, and are touching each other frequently, and they have not learned how to wash their hands after toileting. Using the following diaper-changing and toileting routines will help providers and parents reduce the spread of germs. It will make it easier for providers and parents to remember the routines if they are posted in the diaper changing and toileting areas. Whenever possible, providers responsible for changing diapers should not prepare any food on the same day. This practice is very important for preventing the spread of infections. Several points are important to consider when caring for children in diapers: < proper handwashing routine by both adult and child < proper diaper changing practices < children should always wear clothing over their diapers throughout the day < good cleaning and sanitizing routines Where children in diapers are in attendance, appropriate diapering provisions shall be included with the materials taken on field trips/outings. Diaper Changing < Never leave a child unattended. Make sure that you have everything you need ready before you begin. < Gloves are not recommended for diaper changing. Regular exposure to latex gloves can cause latex allergies or sensitivity in some children. Proper handwashing provides sufficient protection for adults and children.

27 12 Health in Child Care Settings < The diaper changing area must be physically separated from the food preparation area and must never be used for any other purpose. This will prevent stool from contaminating food. < Changing the diaper of a child who is standing on the floor or diaperchanging area surface results in a less thorough cleaning of the child s diaper area and is therefore not recommended. < Older children not changed on a change table must not be changed on a bare or carpeted floor. A nonporous, washable pad must be used at all times. < Infants require frequent diaper changes during the day. When the child urinates, the moisture, lack of air and heat provide ideal conditions for the growth of bacteria and yeast and contribute to skin irritations. Diaper Changing Area You need: 1. a diaper changing area which is separated from play, sleep, eating, and food preparation areas. 2. a firm, smooth, moisture resistant, nonporous, easily cleanable surface. If a change table is used it must meet the following criteria: height approximately 1 metre(3 feet) from the floor; ensure that it has a safety ledge at least 2 ½- 3 inches in height running ¾ of the table length. 3. handwashing facilities close by. 4. a special waste container, with plastic levers, and with lids operated by foot pedal. Note: If the size or behaviour of a child does not permit safe use of a changing centre, there shall be an area where a child can have diapers or clothing changed that provides for privacy and easy cleaning of the child. This area is to be kept in a sanitary condition and adjacent to a source of potable (suitable for drinking) water. Changing the Diaper:

28 Health in Child Care Settings 13 < Check to be sure supplies you need are ready and near the diapering area. < Wash your hands. < Lay the child on the diapering surface. Never leave the child unattended. If an emergency arises, put the child on the floor or take the child with you. < Remove soiled diaper by folding it inward; put aside. < If safety pins are used, close each pin immediately. Keep pins away from child. Never hold pins in your mouth. < Put disposable diapers in a lined, covered step can. Do not put diapers in toilet; bulky stool may be emptied into toilet (remove this formed stool from the diaper with a tissue). < For cloth diapers provided by parents, place the dirty diaper in a plastic bag to return to parents. NOTE: Do not rinse diapers. Toilet paper should be used to remove formed stool from any type of diaper and then flushed in the toilet. < Clean the child s bottom with a moist disposable wipe. Wipe front to back using the wipe only once. Repeat with fresh wipes if necessary. Don t overlook skin creases. Pat dry. Use warm water and soft cloth and mild soap if there is stool present. < Dispose of the wipe in a lined covered waste container with pedal. < Wipe your hands with moist disposable wipe. Dispose of it in the lined, covered step can. < Diaper or dress the child. < Wash the child s hands and your own hands. Assist the child back to the group. < For infants, record the information on the daily record. Note: Ointments and creams are not usually necessary when a child s skin is healthy and diapers are being changed whenever soiled. Skin preparations can trap germs, urine and stool between the ointments and skin, causing skin irritation or infections. These ointments must be completely removed with each diaper change to clean the urine and stool from the child s skin. The products should not be used routinely unless the skin is irritated and the parents especially request them. These products must only be used for the designated child and must be labelled with the child s name. Products in squeeze application containers as opposed to tubs and jars are recommended. Baby powder, talc, and cornstarch are dangerous and should not be used; they always get in the air and the child may inhale the powder.

29 14 Health in Child Care Settings Sanitizing the Diaper Changing Surface: < Remove any visible urine or stool with toilet paper and discard or flush in the toilet. < Spray the sanitizing solution onto the entire changing surface, and let it sit for 30 seconds while you put skin care products back and wash your hands. Always assume that the outside of the spray bottle and skin care products are contaminated. Sanitizing solutions should be made up fresh daily. < Wash your hands. < Dry the changing surface with a single-use towel. Dispose of the towel appropriately. < Wash your hands thoroughly. You have contaminated them while wiping off the sanitizing solution. < Report abnormal skin or bowel movements to the parents, e.g., rash, unusually hard or soft bowel movement, unusual colour, unusual or foul odour, frequency. Toileting Routine Providers may also play an active role in assessing and reinforcing a child s progress in toilet learning. Most children are ready to begin toilet learning between the ages of 2 and 4 years. Each child is unique and providers should follow their individual cues throughout the process. Providers must coordinate with parents so that their toilet learning methods are consistent. A child is usually ready to begin toilet learning when the child: < Knows s/he is wetting or having a bowel movement. < Can let you know that s/he is needs to go. < Can stay dry in diapers for several hours or wakes up with a dry diaper. < Can stand up and sit down by himself/herself. < Can understand simple instructions. < Knows how to pull down loose pants. < Show signs of wanting to be independent in toileting. Ways to encourage toilet learning in the child that appears ready: < Talk to parents about what they are doing at home to ensure consistency.

30 Health in Child Care Settings 15 < Decide what words the child is using to refer to body fluids and body parts. < Use a comfortable potty chair or toilet seat adapter making sure that child s feet are either flat on the floor or on a stool. Ensure that potty chairs are made of smooth, non- absorbent, easy to clean material and have a removable waste container. < Keep potty chairs in the bathroom, not in hallways or home rooms. Ensure that children know where the potty chairs are located. < Help the child get familiar with the potty by having her/him sit on it even if fully dressed at specific times in day. < Take the child to the potty when s/he tells you s/he has to go. < Watch for signs that the child needs to use the potty. < Expect accidents to happen and never scold a child when this happens. Always remain positive! < If child is not making any progress after a couple of weeks, stop and try again a few weeks later. Note: If at all possible, providers helping children on the potty and toilet should not prepare any food on the same day. Studies have shown that this practice is important for preventing the spread of infection. The following steps for providers outline the proper toileting routine for toddlers: Toileting < Remove the soiled diaper, clean the child as outlined in the diaper changing routine. Place the child on the toilet or potty. < Stay with the child for about five minutes. If the child is ready to urinate or have a bowel movement, the child will be successful within a few minutes. < Wipe the child from front to back, and teach the child to do the same. This wiping method is preferred, especially for girls, since it reduces contamination of the vagina and urinary tract. < Flush the toilet or let the child flush it. If the potty was used, empty its contents into the toilet and flush. Be sensitive to the fact that someone young children may be scared or upset by the flushing. In those cases, flush the toilet after the child has left the bathroom. < Diaper, as necessary, and assist the child in dressing. < Assist the child in handwashing; wash your own hands and return the child to a supervised area.

31 16 Health in Child Care Settings Rinsing and Sanitizing Rinse out the potty and flush the water down the toilet. Wear household rubber gloves if stool is present and is not easily removed, and wipe off all remaining stool with toilet paper. Spray the sanitizing solution on to the potty and the diaper changing surface (if used). Allow the solution to sit on the surface for 30 seconds while you put away all diapering supplies and wash your hands. This will give the sanitizer time to work. Ideally, a utility sink should be available to rinse potties. < Wash your hands. < Dry the potty with a single-use towel and dispose of the towel appropriately. Use different towels to dry the potty and the diaperchanging surface. < Return the potty to the storage area. < Wash your hands thoroughly. You will have contaminated them while wiping off the sanitizing solution. < Record the child s use of the potty, any bowel movements, including diarrhea, unusual odour, or those containing blood, and any skin irritation. Report as necessary.

32 Health in Child Care Settings 17 PHYSICAL ENVIRONMENT An important component of child care is the physical environment in which children spend their time. < The licensee must ensure that the premises, its furnishings and its play materials are kept in a safe, clean, and sanitary condition; < free of dust, insects, pests and rodents; < adequately lighted, vented and heated; and < kept in a good state of repair. < Carpet, either wall-to-wall or pieces, are difficult to keep clean and are therefore not permitted in infant playrooms. Floors should be covered with washable flooring. Washable mats with, or on top of, non-skid material are permitted. < Water temperature should be no hotter than F. (43 0 C). < In infant rooms, staff and visitors must have footwear for indoor use only. Equipment, Supplies and Materials Individual cubicles or other individual arrangements, such as hooks, are to be available, arranged in such a manner that each child s clothing and other belongings can be kept separate and within easy reach of the child. For each child who is in attendance for full days, there is to be available an individual comb, toothbrush & toothpaste, and a sanitary supply of individual washcloths, towels, and drinking cups. Washcloths, towels, and drinking cups may be disposable, however Styrofoam is not permitted in child care where children 4 years of age and under are present. Any or all of these items may be provided by the parents/guardians. For more information on how to store toothbrushes, see section on Oral Hygiene.

33 18 Health in Child Care Settings Sleeping Area and Arrangements Moisture-resistant or washable covers should be used for mats, resting pads, and cribs. There shall be sufficient blankets, individually marked, and sufficient clean linens and bed coverings, to allow for regular change and for change as they become soiled. These may be provided by the parent/guardian. For infants younger than 24 months of age, there should be a separate sleep room accessible to the home room. Infants are to be allowed naps determined by their individual needs. Supervision of sleeping infants is essential, and, at the same time, ratios must be maintained. The sleeping room must contain a separate crib or cot for each child, clearly marked with the child s name, with at least 12" between any two cots/cribs for health reasons and, on the side of the crib that provides access to the infant, there must be a minimum of 18" space to allow staff easy and immediate access to each child in case of an emergency. For more information on sleeping positions for infants, please see Infants Section. There shall be a separate cot or mat for each child older than 24 months of age who is in full day attendance and who requires sleep during the day. The cot or mat shall be clearly marked with the child s name, and the child shall have exclusive use of that cot or mat during that day. The cot or mat must be covered by moisture-resistant material in the case of mattresses or resting pads and washable covers for canvas cots. Bedding must be kept clean and dry at all times. A sufficient, sanitary supply of linens and bed coverings (individually marked) shall be available. These may be supplied by the parent/ guardian. There shall be a minimum of 2.3 square metres of space dividing each child in the sleeping area. Where there are children 6 to 12 years attending for more than 4 hours per day, a quiet area, suitably equipped for resting and relaxation, shall be available. In all cases where there are children in full day attendance, an area for rest and relaxation shall be available at all times.

34 Health in Child Care Settings 19 SANITIZATION AND HOUSEKEEPING Many of the germs that are spread from person to person are very stable and will stay on surfaces in the child care setting for hours, days and even weeks. This means the germ can still infect someone even after it has been on a surface for some time. Even a very small number of germs on a surface can cause someone to get an infection. For these reasons, it is vital for providers to consistently follow recommended sanitization and housekeeping policies and procedures. Ensure that your child care setting has adequate space and good ventilation to minimize spread of airborne germs. General Cleaning and Sanitizing Practices Housekeeping routines involve cleaning and sanitizing surfaces, toys, and objects. Cleaning and sanitizing have different purposes. As will be discussed in the following section, some surfaces require only one step, and others require two. Here are components of a good housekeeping routine: < materials for cleaning < a cleaning routine < a sanitizing routine < a routine for cleaning body fluid spills, blood and bloody body fluids Materials for Cleaning Most household detergents and bleach are satisfactory for cleaning and sanitizing. Single-use towels may be used for cleaning and sanitizing practices such as general cleaning, diaper-changing tables, potties, toilets, etc. Cloth towels must be laundered between use, and not used for handwashing.

35 20 Health in Child Care Settings Cleaning Routine The rubbing action of the towel on the surface creates friction. Friction is needed to remove any dirt on the surface and any germs that may be under the dirt. Although cleaning removes germs, it may not remove all of them. Sanitizing is designed to greatly reduce the number of germs and is often necessary after the dirt is removed from the surface. To clean surfaces, wash with household cleaners. Rinse well and dry. Sanitizing Routine Sanitizing greatly reduces the number of germs on a surface or object. Urine, stool, mucus, and vomitus contain germs. After these spills are wiped up and the area cleaned, sanitize the surface. Always use a freshly prepared bleach solution. A household bleach is recommended. It is effective, economical, convenient and readily available; however, it should be used with caution on metal. If bleach is found to be corrosive, a different sanitizer may be required. Ideally, cleaning is always done before sanitizing. Sanitizing Solution: Prepare the household bleach solution in the following way: < The dilution should be 1 to 100, or mix 40 ml of bleach in 4L of water (1/4 cup bleach in 16 cups of water). < For a smaller quantity, mix 5 ml of bleach in 500 ml of water (1 tsp. bleach in 2 cups water). < Mix a fresh bleach solution every day to ensure maximum effectiveness. < Label spray bottles and containers with the name of the solution and the dilution,(e.g., Label should read: Bleach solution: 5 mls of bleach in 500 mls of water; Mix fresh each morning; Keep out of reach of children). < Keep out of reach of children. < Wear household rubber gloves when sanitizing to prevent dry and irritated hands. Hands should be washed afterwards. The use of gloves is not a replacement for handwashing.

36 Health in Child Care Settings 21 How to Sanitize: There are various methods for applying sanitizing solutions: < spray bottle: for diaper-changing surfaces and potties. < cloths rinsed in sanitizing solution: for food preparation areas, or large toys, books, puzzles and activity centres. < dipping the object into a container filled with the sanitizing solution, e.g., for smaller toys. < Apply the sanitizing solution to the surface. It should be left on for at least 30 seconds in order to work. < When sanitization is complete, all surface areas can be air-dried, with the exception of diaper-changing surfaces and potties. These surfaces should be wiped dry with single-use towels. Items Which Should be Cleaned and/or Sanitized After each use diaper changing surfaces potty chairs table tops and highchair trays food preparation areas any clothing which is in a clothing pool, e.g., mitts, hats, blenders and food processors plastic bibs Daily toys which children put in their mouths (these may be cleaned in dish washer if dishwasher safe) bathroom fixtures and toilets sinks and countertops and when obviously soiled water table (& fill with fresh water). dusting and cleaning cloths (wash daily).

37 22 Health in Child Care Settings kitchen appliances (stove tops and can openers) floor areas (sweep and vacuum) clean floors with household cleaner daily and when soiled Weekly stuffed toys (by machine) (can use a dryer to dry) sponge mops should be rinsed in a bleach solution and hung upside down to air dry once a week microwaves launder dress-up clothes large toys, activity centres and toy storage shelves mats vacuum sofas and chairs launder pillow and cushion covers used in activity areas Other carpets should be vacuumed daily and shampooed every 3 months windows should be washed inside and out at least twice a year clean ovens and refrigerators monthly clean freezers every 6 months Drapes and air-vents: Vacuum monthly or bi-monthly and clean drapes yearly Mirrors and glass: Clean daily if they are frequently handled, and as required Surfaces that are out of reach of children: Clean as necessary; that is maintain a clean dust-free appearance Walls: Clean when visibly soiled, especially hand-contact areas. Wash ceilings and walls yearly Handles and light switches: Clean when necessary Door ledges and shelving: Damp-wipe monthly or bi-monthly

38 Health in Child Care Settings 23 Infant and Toddler Toys Have a good supply of infant and toddler toys on hand < Clean and sanitize any toys that may have been put in child s mouth. < Minimize the sharing of mouthing toys to reduce the spread of germs; remove toy after child has played with it and put aside until there is time for cleaning and ensure that there is an adequate supply of toys. < Sanitize all frequently touched toys (for example, board books, puzzles) at least twice a week and when necessary. Wipe, rather than soak, these toys with the sanitizing solution. These toys only need to be cleaned before sanitizing if they are visibly soiled. < Keep an empty basin for storing heavily soiled toys. Keep out of children s reach. When time permits, wash and sanitize toys. < Machine-wash soft, washable toys, e.g., stuffed animals or cuddly dolls, every week and as necessary. < Clean all larger toys, activity centres and toy- storage shelves on a weekly basis. Toys for Older children Mouth toys (e.g., musical instruments, blowpipes, toy thermometers) must be cleaned and sanitized before going into another child s mouth.

39 24 Health in Child Care Settings In the Kitchen < wash your hands before handling food. < use utensils to handle food - NOT YOUR HANDS. < wash raw fruit and vegetables before use. < be sure all food which is stored is covered. < throw away unused portions of food. < check expiratory or best before dates. < never use bulged or dented cans. < food handlers should wear a hair net or cap. < never used cracked or chipped dishes. < use serving spoons. < do not allow children or providers to share glasses or eating utensils. < ABSOLUTELY NO SMOKING. < USE PROPER HANDWASHING PROCEDURES (see Handwashing ). Food Safety The following information is from the pamphlet Food Safety is Everyone s Responsibility published by the Government of Newfoundland and Labrador and available from the environmental health officer. Handle Perishable Foods Safely: Perishable foods must be stored at controlled temperatures. In addition, foods must be protected from contamination. Please follow these recommendations: Avoid the danger zone. Cold foods need to be stored at or below 4 C (40 F). Hot foods need to be kept at or above 60 C (140 F). Refrigerate leftovers right away. Do not store any perishable foods in the danger zone between 4 C and 60 C, where bacteria can grow. Keep raw meats and poultry away from other foods during storage and preparation. Keep separate cutting boards and utensils for raw meats and vegetables to avoid cross-contamination. Keep foods covered. Make sure the refrigerator is set at 4 C (40 F) and keep the freezer at -18 C (0 F). Page Revised - 09/04

40 Health in Child Care Settings 25 Serve foods right away so they do not linger at room temperatures where bacteria can grow. Keep cooked and ready-to-eat foods separate from raw foods and surfaces that raw meats have contacted. This will prevent the bacteria that live on raw meats from contaminating food which will not be cooked again. Thaw Frozen Food Safely Frozen foods can be safely thawed in the following ways: in a refrigerator. under cold running water. in cold water that is changed often enough to keep it cold. in a microwave oven. DO NOT THAW FOOD AT ROOM TEMPERATURE You must always thoroughly cook food. Cooking food thoroughly is necessary to kill harmful bacteria that may be present in or on the food. This is very important for poultry and ground beef. Food should be thawed before cooking to ensure that it is cooked throughout. Do not refreeze previously thawed food. Internal Temperature Needs: Cook foods to the following internal temperatures to kill bacteria (check it with a meat thermometer) Food Type Food Mixtures containing poultry, eggs, meat, fish, or other potentially hazardous foods. Pork, Lamb, Veal, Beef Poultry Ground Meat Eggs Fish Temperature 74 C (165 F) for at least 10 minutes. 70 C (158 F) 85 C (185 F) for 15 seconds 71 C (160 F) 63 C (145 F) for 15 seconds 70 C (158 F) Page Revised - 09/04

41 26 Health in Child Care Settings More Food Safety Tips: Sanitize countertops, cutting boards and utensils with a mild bleach and water solution. Remember: Clean first, then Sanitize! Wash all produce thoroughly before cooking or eating. Cook poultry dressing separately, never inside the bird. Cook poultry or roasts all at once, never cook partially on one day to finish cooking the next day. Use a thermometer to find out the internal temperature of cooked items. Place a hot food item in several shallow or smaller pans in a refrigerator for quick chilling. Avoid the use of home canned or preserved food items when serving large numbers of people (e.g. young children in a child care setting.) Obtain food from licensed food premises. Use two utensils to taste test. One is used to obtain the food. The food is then transferred to a second utensil which is used for tasting. Cover open cuts/sores with a water resistant dressing and gloves when handling food. Do not wear jewelry when preparing food. It collects dirt and is difficult to keep clean. Do not prepare food if you are suffering from a disease which may be transmitted through food. Cleaning Dishes dishwashers are recommended for settings that have large numbers of children. Commercial dishwashers are recommended, however, if domestic dishwashers are to be used they should be able to provide water temperature of 60 C to 65 C (140 F to 150 F). This temperature is higher than water from a hot water tap. clean all utensils, tableware, and kitchenware after each use. do not use cloths used for wiping food preparation surfaces for anything else. when handwashing dishes. wear household rubber gloves. in centres, use a 3 compartment sink. wash dishes in hot soapy water. germs are removed by friction (scrubbing) and sanitizing. rinse in second sink in hot water. sanitize in bleach solution for 1 minute (1 capful of bleach). sun or air dry (do not use dishtowels).