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resulted from suffocation in a toy chest; the other was caused by a blow from a heavy swing. These deaths were clearly preventable; providers must have access to sound and meaningful training op-portunities before or soon after they enter the field. With corporate funding through the consulting firm, the materials were field tested, produced, and distributed along with a workshop curriculum to Child Care Resource and Referral agencies throughout the country.
Health departments and licensing agencies have been active in supporting child-cane training. Some offer consultation, technical assistance, and traimng some have written manuals and “tip sheets.” Child-care resource and referral agencies must play a vital role in promoting health and disseminating health training and resources.
Preliminary recommendations to improve these problems from the Center for Careen Development suggest systemic planning, regular public funding, a progressive role-related system, quality controls, and recognition and rewards.
In summary, good, appropriate, respectful training can make an appreciable difference in the quality of health and safety poli-cies and practice. The myriad of other excellent resources could not be described in this paper. I recommend a national repository of training materials from which all training data, models, and curricula can be assessed and accessed.
Health-cane providers, child-care providers, and families must form an integral partnership and communicate regularly to benefit individual children. From a programmatic and policy perspective, the child-cane community needs and desires the rich array of skills, talents, and resources that health providers have to offer. However, health professionals must recognize the wealth of in-formation and discovery available to them in the child-care field; one benefit from teaching is that health professionals can learn from child-care experiences. I challenge health professionals to become partners with child-care professionals in training efforts. Together, we can train other trainers to disseminate our vital child-care health messages throughout the world.
REFERENCES
I. Costley J, Genser A, Goodman I, Lombardi J, McGenser B, Morgan
G. The State ofthe States Report. Boston: Wheelock College; 1992 (in draft)
2. Whitebook M, Howes C, Phillips D. Who Cares? Child Care Teachers and
tl,e Quality of Care in America: Final Report of the National Child Care Staffing Study. Oakland, CA: Child Care Employee Project; 1989
3. Galinsky E. What really constitutes quality care? Child Care Info Lx-change. 1986;51 :41-47
4. Phillips C, McCartney K, Scarr S. Child care quality and children’s development. Dcv Psychol. 1987;23:537-543
5. Roupp R, Travers J, Glantz F, Coelen C. Children at the Center: Final
Report of the National Day Care Staffing Study. Cambridge, MA: Abt
Associates, Inc; 1989
6. Phillips DA, Howes C.Indicators of Quality Child Care: Revieu’ ofthe Research. Quality in Child Care: What Does the Research Tell Us? Washington, DC:
National Association for the Education of Young Children; 1987;1 7. Black RE, Dykes AC, Anderson KA, et al. Handwashing to prevent
diarrhea in day-care centers. Am I Epist. 1981;1 134:446-451
8. Aronson 55, Aiken SA. Compliance of child care programs with health
and safety standards: impact of program evaluation and advocate
train-ing. Pediatrics. 1990;652:318-325
9. American Public Health Association, American Academy of Pediatrics.
Caring for Our Children. Washington, DC: APHA/AAP; 1992 10. Child Development Associate Assessment System and Competency Standards,
Preschool Caregivers. Washington, DC: Council for Early Childhood Pro-fessional Recognition; 1990
I I. Wolfe B. Presentation at The Early Childhood Profession Coming
To-gether, from the First Annual Conference of NAEYC’s National Institute for Early Childhood Professional Development. June 4, 1992, Los An-geles, CA
12. Kendrick AS, Gravell J. Family Child Care Health and Safety Checklist.
Massachusetts Department of Public Health. Boston: Redleaf Press; 1991
American
Public
Health
Association/American
Academy
of Pediatrics
National
Health
and
Safety
Guidelines
for
Child-Care
Programs:
Featured
Standards
and
Implementation*
Debra
Hawks,
MPH;
Joan
Ascheim,
MSN,
PNP;
C.
Scott
Giebink,
MD9J;
Stacey
Graville,
RN,
MNII;
and
Albert
J.
Solnit,
MD**
In response to the potential for illness and injury in group cane for children and a growing need for national guidance on health and safety aspects of child cane, the American Public Health Association (APHA) and the American Academy of Pediatrics (AAP) developed national health and safety guide-lines for child-care programs. This collaborative effort culmi-nated in the publication, Caring for Our Children-National
Health and Safety Performance Standards: Guidelines for
Out-of-Home Child Care Programs.’
From the APHA/AAP Child Care Standards Implementation Project, American Public Health Association, Washington, DC; §Children’s Corn-munity Bridge Project, Office of Family and Community Health, New Hampshire Department of Health, Concord, NH; lDepartment of Pedi-atrics and Otolaryngology, School of Medicine, University of Minnesota,
Minneapolis, MN; IlCommunicable Disease Program, Whatcorn County
Health Department, Bellingharn, WA; **Department of Mental health, State of Connecticut, Hartford, CT; Yale Child Study Center, New Haven, CT.
‘See also “American Public Health Association/American Academy of Pediatrics National Health and Safety Guidelines for Child-Care Pro-grams: An Overview,” page 1 107, and “American Public Health Associ-ation/American Academy of Pediatrics Injury Prevention Standards,” page 1046.
The APHA/AAP guidelines address the following technical content areas:
. environmental quality;
S prevention and control of infectious diseases; S injury prevention and control;
. general health; S nutrition;
. prevention and management of child abuse; S staff health;
. children with special needs;
. health concerns related to social environment and child development;
. health and safety organization and administration.
While all of these content areas are important in terms of health and safety, some tend to receive more attention. Certain standards in each of the featured content areas are highlighted on the basis of the perceived significance to care givers and health profession-als; the reflection of new knowledge and state of the ant; possible controversy; on considerations for implementation.
HEALTH CONCERNS RELATED TO SOCIAL
ENVIRONMENT AND CHILD DEVELOPMENT
This technical area describes the standards on social environ-ment and child development in the service of promoting physical
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SUPPLEMENT 1111
and mental health. One of the most substantial achievements was to describe the qualifications, numbers, and availability of adults caring for young children in out-of-home settings.’ The National Research Council in its report, Who Cares for America’s Children?
Child Care Policy for the 1990s,2 states that child:staff ratios and
group size are two of the most critical areas needing to be ad-dressed in national standards.
Characteristically, social environment, child development, and mental health in infancy and childhood most usefully emphasize qualitative more than quantitative factors. However, the APHA/ AAP guidelines define the qualitative factors in physical health and safety measures that must be related to developmental and mental-health issues.
The APHA/AAP guidelines call for quality-of-life consider-ations for care givers. Given that four out of 10 child-care workers leave their jobs each year,3 it is important to end this rate of turnover; such a revolving door of care givers will be detrimental for most of the children receiving care. The so-called resiliency of the child is designed to promote adaptation and progressive de-velopment-not to absorb the jarring loss of familiar, competent care givers. The APHA/AAP guidelines emphasize continuity by qualified care givers who are delegated to extend the healthiest aspects of the parents’ nurturing, guidance, protective and social-izing influence, and expectations.
Parents and care givers need to have a sound, mutually respectful relationship so that the child feels the psychological radius of the parents’ presence in the care, nurturing, safe-guarding, and healthy values that have been extended to the care givers and administrators. The APHA/AAP guidelines include specific standards on relationships between parents and care givers.
If social-environment and child-development factors are given a high priority in out-of-home child care through an emphasis on staffing, the program of activities, and the relationship of the care givers and parents, then the child’s sound development and men-tal health will be supported. This, in turn, will inherently extend the safeguarding and health promotion that is the main focus of these APHA/AAP guidelines.
PREVENTION
AND
CONTROL
OF
INFECTIOUS
DISEASES
Infectious diseases occur among toddlers and preschool-age children, and most of these diseases do not severely limit a child’s activity. These illnesses are contagious, however, and may pose a health threat for other children in group care. The Infectious Disease Standards of the APHA/AAP guidelines recognize these facts and were developed to prevent and limit the spread of infectious diseases in the child care environment.
The common infectious diseases of early childhood affect pri-manly the respiratory system (eg, the common cold, otitis media, pharyngitis, bronchitis, pneumonia), the gastrointestinal tract (eg, vomiting and diarrheal illness), and the skin (eg, impetigo, para-sitic infestation). A few affect multiple organs (eg, cytomegalovi-rus). Respiratory infections predominate, accounting for 75% to 90% of infections occurring in child-care settings.4
Mild illness is very common in young children. Most children with common respiratory and gastrointestinal illnesses of mild severity need not be excluded from their usual source of care unless certain conditions exist.’ There is no evidence that the incidence of acute respiratory disease can be reduced by excluding sick children from child care.
The spread of enteric bacteria, viruses, and parasites is partic-ularly common among children in child care because of close, personal contact and poor hygiene of young children. The most important aspects of child care associated with these illnesses are hand washing and toileting practices, which are emphasized throughout the APHA/AAP guidelines. Child-care facilities that provide care for infants and toddlers need to give special attention to measures for infection control.
Diapering practices contribute to fecal contamination of the child-care environment,5 and coliform contamination of the envi-ronment is related to the incidence of diarrheal illness.6 The diaper standard in the APHA/AAP guidelines-which generated the most controversy in its review and development-specifies diaper properties that will help minimize fecal contamination of the
children, care givers, environmental surfaces, and objects in the child-care setting.
Routine childhood vaccination is particularly important for children in child care because preschool-age children have the highest age-specific incidence rates of measles, rubella,
Hae-mophilus influenzae type b disease, and pertussis. The APHA/
AAP guidelines recommend that children entering child cane should be fully vaccinated for age, and vaccination records should be updated frequently, especially during the first 2 years of life.
Other infectious disease standards in the APHA/AAP guide-lines address food handling, environmental sanitation, the use of health consultants, group size and age separation, and staff training.
GENERAL HEALTH
The APHA/AAP guidelines stress that every child-care facility use a health consultant in developing policies, practices, and pro-cedures; however, obtaining a health consultant is often difficult for child-care facilities. The APHA/AAP guidelines suggest many possible resources including volunteer consultant services through professional health organizations, local or state public health agencies, parents, and board members.
The APHA/AAP guidelines require that a daily health assess-ment be performed by a trained staff member and include pantic-ular health observations to reduce the acquisition and transmis-sion of communicable diseases. The facility’s health consultant can conduct the training and assist in developing an observation record.
One of the most controversial General Health Standards states that all nonprescription or over-the-counter medications be “recommended by a health cane provider for a specific child, with written permission of the parent or legal guardian referencing a written or telephone instruction received by the facility from the health care provider” (pp. 88-89).’ There should be clear reasons why care givers are requested to give children medication, not just on the basis of a parent’s desire. A national study reported excessive use of nonprescription med-ications for respiratory illness.7
The APHA/AAP guidelines recommend integrating health education into the daily activities. In the child-care setting, there are many opportunities for promoting health to young children and parents, which contributes to a healthy childhood and adult life.
STAFF HEALTH
The guiding principles of the Staff Health standards define the relationship between the well-being of child-care providers and the quality of care for children. For adults as well as for children, the child-care setting provides opportunities to promote health as well as risks to health. For staff members, those risks include communicable diseases (eg, hepatitis, measles, tetanus, giardia), injury (eg, back, bites), stress, and exposure to toxic substances such as cleaning supplies and art materials.
Although the APHA/AAP guidelines largely address children enrolled in out-of-home child cane, a number of standards were developed to encourage practices promoting health and prevent-ing illness of adult care givers. For example, the standards recom-mend a pre-employment staff health appraisal to assess vaccina-tion status and the staff member’s ability to perform typical duties including lifting and frequent hand washing and to move quickly. Periodic, ongoing staff health appraisals as well as daily health checks for obvious signs of illness also are recommended to pro-tect the health of staff members and children.
Program policies are recommended, including measures to re-duce stress (eg, adequate wages; benefits, and educational, sick, and vacation leave; adequate staff:child ratios; and sound-absorb-ing materials), to prevent injury and illness spread, and to prevent exposure to toxic substances (eg, use of nontoxic alternatives for cleaning and art).
A number of challenges to implementing the Staff Health stan-dands exist. Most state regulations and other standards do not address the relationship between staff and quality care. The costs of health appraisals and employee benefits will additionally bun-den an inadequately funded system. Many of the standards
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1112 SUPPLEMENT
quire changes in health behaviors, beliefs, and attitudes. More research and training is needed in this area.
The APHA/AAP guidelines can enhance health and safety of children and their care givers.
ACKNOWLEDGMENTS
The collaborative project of the American Public Health As-sociation and the American Academy of Pediatrics was funded by the Maternal and Child Health Bureau, Department of Health and Human Services (Grant MCJ 113001).
We acknowledge contributions to this article by Jean Ad-nopoz, MPH, Yale Child Study Center; Angela Crowley, MA, RN-C, PNP, Yale School of Nursing; Cynthia Farrar, PhD, New Haven Foundation; Lola Nash, MA, Yale-New Haven Hospital; Sally Provence, MD, Yale Child Study Center; and Kathryn Young, PhD, Smith Richardson Foundation.
Copies of Caring for Our Children-National Health and Safety
Performance Standards: Guidelines for Out-of-Home Child Care Pro-grams are available from the American Public Health Association, Publication Sales, Department 5037, Washington, DC 20061-5037 or from the American Academy of Pediatrics, 141 Northwest Point Boulevard, P0 Box 927, Elk Grove Village, IL 60009-0927.
REFERENCES
1. American Public Health Association and American Academy of Pedi-atnics. Caring for Our Children-National Health and Safety Performance Standards: Guidelines for Out-of-Home Child Care Programs. Washington, DC, and Elk Grove Village, IL: APHA/AAP; 1992
2. Hayes CD, Palmer JL, Zaslow MJ, eds. Who Cares for America’s Children?
Child Care Policy for the 1990s. Washington, DC: National Academy
Press; 1990
3. Don’t Shortchange America’s Future: The Full Cost of Quality Must Be Paid.
Washington, DC: National Association for the Education of Young Children; 1990
4. Wald ER, Guerra N, Byers C. Upper respiratory tract infections in young children: Duration of and frequency of complications. Pediatrics.
1991 ;87:129-133
5. Van R, Wun C-C, Morrow Al, et al. The effect of focal containment on focal coliform contamination in the day care center environment. JAMA.
1991;265:1840-1844
6. Van R, Morrow AL, Reves RR, et al. Environmental contamination in child day care centers. Am I Epidemiol. 1991;133:460-470
7. Presser B. Place of child care and medicated respiratory illness among young American children. IMarriage Family. 198850:995-1005
VIII.
SUMMARY
SECTION
Translating
Science
Into
Practice
in Child
Day-Care
Settings
William
L. Roper,
MD;
Stephen
B. Thacker,
MD;
and
Steven
M.
Teutsch,
MD
We trust our children, indeed our world’s future, to care givers in day-care settings for as much as 8 to 10 hours each day. Through hard work and good science, the US and other countries have established rigorous health standards for day care, but we must do more. We must give others-the institutions and the individuals who care for our children-the tools to foster a health-ful environment and promote healthy behaviors. The vision of the Centers for Disease Control and Prevention (CDC) is “healthy people in a healthy world to achieve a quality life.” We must work together to make that vision a reality for our children in day care.
Our paper addresses translating scientific knowledge into prac-tice and making prevention a practical reality. We outline the concepts underlying the assessment of the effectiveness of preven-tion activities and illustrate its use in three case studies from child day care. We close with a description of the prevention effective-ness program recently initiated at CDC.
PREVENTION
EFFECTIVENESS
It is important to assess the effectiveness of prevention practices to ensure that public health programs are built on scientifically sound strategies for improving the quality of life and reducing unnecessary morbidity and premature mortality.’ There are three basic approaches to prevention: clinical, behavioral, and environ-mental. Clinical prevention strategies rely on the one-on-one, pro-vider-to-patient interaction, which underlie immunization and screening programs. These interactions usually occur within our regular health-care delivery system.
Behavioral techniques use a broad array of strategies to encour-age lifestyle changes, such as exercise and healthful diets. Behav-ioral change remains a difficult yet crucial method for improving quality of life, both the individual and the community.
The environmental prevention strategies involve such ap-proaches as fluoridation of water and lead abatement. These far-ranging interventions usually require a significant societal com-mitment but once accepted and implemented, they require little effort on the part of the beneficiary and can have far-reaching effects. All three approaches will be required to improve the health of our children.
From the Centers for Disease Control and Prevention, Atlanta, GA.
To assess the quality of each prevention technique, information is required on the efficacy, effectiveness, economic impact, and efficiency of each technique. First, we must be assured that an intervention works. Efficacy studies to demonstrate this are usu-ally conducted in carefully controlled research settings.
Once we have identified an intervention that works, we must determine if it is safe and effective when applied in real-world community settings. We can assess effectiveness using concepts of prevented fraction, a measure which tells us how much morbidity and mortality one could actually prevent with a particular inter-vention. Next, we need to know about the resources required to achieve the benefits. This information comes from economic anal-yses, most commonly cost-effectiveness and cost-benefit analyses.
Once a prevention strategy is in place, our ongoing evaluations allow us to improve the efficiency of our programs. Finally, we must constantly remind ourselves to be alert to the social, legal, political, and distributional aspects of our prevention strategies.
Immunization
CASE STUDIES
Measles vaccination is an example of a clinical prevention strategy that has been proven effective, safe, and efficient in de-creasing morbidity and mortality in children. In the early 20th century, thousands of deaths due to measles were recorded annu-ally in the US, peaking at more than 10 000 deaths in 1923.2 In 1966, a measles immunization program was launched in the US.3 The subsequent quarter-century has seen a dramatic decrease in the incidence of both measles and measles-associated illnesses such as otitis media, pneumonia, subacute sclerosing panencepha-litis, and measles-associated mental retardation.4
Studies on the efficacy and efficiency of the single-dose measles immunization programs have demonstrated benefit-to-cost ratios upward from 5 to 1, depending on the techniques and assump-tions used.56 More recently, the benefit-cost ratio determined for measles vaccine combined with the mumps and rubella vaccine showed benefits to be 14 times greater than costs.7
Measles vaccination is an example of a very effective technol-ogy that has had a dramatic impact on the incidence of disease but has fallen short of its anticipated goal-the elimination of measles. In recent years, an increase in the incidence of measles in this
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1994;94;1110
Pediatrics
Debra Hawks, Joan Ascheim, G. Scott Giebink, Stacey Graville and Albert J. Solnit
Implementation
and Safety Guidelines for Child-Care Programs: Featured Standards and
American Public Health Association/American Academy of Pediatrics National Health
Services
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1994;94;1110
Pediatrics
Debra Hawks, Joan Ascheim, G. Scott Giebink, Stacey Graville and Albert J. Solnit
Implementation
and Safety Guidelines for Child-Care Programs: Featured Standards and
American Public Health Association/American Academy of Pediatrics National Health
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the World Wide Web at:
The online version of this article, along with updated information and services, is located on
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