resulted from suffocation in a toy chest; the other was caused by a REFERENCES

blow from a heavy swing. These deaths were clearly preventable;

I . Costley J, Genser A, Goodman I, Lombardi J, McGenser B, Morgan
providers must have access to sound and meaningful training op-
G. The State ofthe States Report. Boston: Wheelock College; 1992 (in draft)
portunities before or soon after they enter the field. With corporate
2. Whitebook M, Howes C, Phillips D. Who Cares? Child Care Teachers and
funding through the consulting firm, the materials were field tested,
produced, and distributed along with a workshop curriculum to tl,e Quality of Care in America: Final Report of the National Child Care

Child Care Resource and Referral agencies throughout the country. Staffing Study. Oakland, CA: Child Care Employee Project; 1989
Health departments and licensing agencies have been active in 3. Galinsky E. What really constitutes quality care? Child Care Info Lx-
supporting child-cane training. Some offer consultation, technical change. 1986;51 :41-47
assistance, and traimng some have written manuals and “tip sheets.” 4. Phillips C, McCartney K, Scarr S. Child care quality and children’s
Child-care resource and referral agencies must play a vital role in development. Dcv Psychol. 1987;23:537-543
promoting health and disseminating health training and resources. 5. Roupp R, Travers J, Glantz F, Coelen C. Children at the Center: Final
Preliminary recommendations to improve these problems from Report of the National Day Care Staffing Study. Cambridge, MA: Abt
the Center for Careen Development suggest systemic planning, Associates, Inc; 1989
regular public funding, a progressive role-related system, quality 6. Phillips DA, Howes C. Indicators of Quality Child Care: Revieu’ ofthe Research.
controls, and recognition and rewards. Quality in Child Care: What the Research Tell Us? Washington,
Does DC:
In summary, good, appropriate, respectful training can make
National Association for the Education of Young Children; 1987;1
an appreciable difference in the quality of health and safety poli-
7. Black RE, Dykes AC, Anderson KA, et al. Handwashing to prevent
cies and practice. The myriad of other excellent resources could
diarrhea in day-care centers. Am I Epist. 1981;1 134:446-451
not be described in this paper. I recommend a national repository
8. Aronson 55, Aiken SA. Compliance of child care programs with health
of training materials from which all training data, models, and
and safety standards: impact of program evaluation and advocate train-
curricula can be assessed and accessed.
ing. Pediatrics. 1990;652:318-325
Health-cane providers, child-care providers, and families must
form an integral partnership and communicate regularly to benefit 9. American Public Health
Association, American Academy of Pediatrics.
individual children. From a programmatic and policy perspective, Caring for Our Washington,
Children. DC: APHA/AAP; 1992
the child-cane community needs and desires the rich array of 10. Child Development Associate Assessment System and Competency Standards,

skills, talents, and resources that health providers have to offer. Preschool Caregivers. Washington, DC: Council for Early Childhood Pro-
However, health professionals must recognize the wealth of in- fessional Recognition; 1990
formation and discovery available to them in the child-care field; I I . Wolfe B. Presentation at The Early Childhood Profession Coming To-
one benefit from teaching is that health professionals can learn gether, from the First Annual Conference of NAEYC’s National Institute
from child-care experiences. I challenge health professionals to for Early Childhood Professional Development. June 4, 1992, Los An-
become partners with child-care professionals in training efforts. geles, CA
Together, we can train other trainers to disseminate our vital 12. Kendrick AS, Gravell J. Family Child Care Health and Safety Checklist.
child-care health messages throughout the world. 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 The APHA/AAP guidelines address the following technical
cane for children and a growing need for national guidance on content areas:
health and safety aspects of child cane, the American Public
. environmental quality;
Health Association (APHA) and the American Academy of
S prevention and control of infectious diseases;
Pediatrics (AAP) developed national health and safety guide-
S injury prevention and control;
lines for child-care programs. This collaborative effort culmi-
. general health;
nated in the publication, Caring for Our Children-National S nutrition;
Health and Safety Performance Standards: Guidelines for Out-of- . prevention and management of child abuse;
Home Child Care Programs.’ S staff health;
. children with special needs;
. health concerns related to social environment and child
development;
From the APHA/AAP Child Care Standards Implementation Project, . health and safety organization and administration.
American Public Health Association, Washington, DC; §Children’s Corn-
munity Bridge Project, Office of Family and Community Health, New While all of these content areas are important in terms of health
Hampshire Department of Health, Concord, NH; lDepartment of Pedi- and safety, some tend to receive more attention. Certain standards
atrics and Otolaryngology, School of Medicine, University of Minnesota, in each of the featured content areas are highlighted on the basis
Minneapolis, MN; IlCommunicable Disease Program, Whatcorn County of the perceived significance to care givers and health profession-
Health Department, Bellingharn, WA; **Department of Mental health, als; the reflection of new knowledge and state of the ant; possible
State of Connecticut, Hartford, CT; Yale Child Study Center, New controversy; on considerations for implementation.
Haven, CT.
‘See also “American Public Health Association/American Academy of
HEALTH CONCERNS RELATED TO SOCIAL
Pediatrics National Health and Safety Guidelines for Child-Care Pro-
grams: An Overview,” page 1 107, and “American Public Health Associ- ENVIRONMENT AND CHILD DEVELOPMENT
ation/American Academy of Pediatrics Injury Prevention Standards,” This technical area describes the standards on social environ-
page 1046. ment and child development in the service of promoting physical

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and mental health. One of the most substantial achievements was children, care givers, environmental surfaces, and objects in the
to describe the qualifications, numbers, and availability of adults child-care setting.
caring for young children in out-of-home settings.’ The National Routine childhood vaccination is particularly important for
Research Council in its report, Who Cares for America’s Children? children in child care because preschool-age children have the
Child Care Policy for the 1990s,2 states that child:staff ratios and highest age-specific incidence rates of measles, rubella, Hae-
group size are two of the most critical areas needing to be ad- mophilus influenzae type b disease, and pertussis. The APHA/
dressed in national standards. AAP guidelines recommend that children entering child cane
Characteristically, social environment, child development, and should be fully vaccinated for age, and vaccination records
mental health in infancy and childhood most usefully emphasize should be updated frequently, especially during the first 2
qualitative more than quantitative factors. However, the APHA/ years of life.
AAP guidelines define the qualitative factors in physical health Other infectious disease standards in the APHA/AAP guide-
lines address food handling, environmental sanitation, the use
and safety measures that must be related to developmental and
of health consultants, group size and age separation, and staff
mental-health issues.
training.
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
GENERAL HEALTH
turnover; such a revolving door of care givers will be detrimental
for most of the children receiving care. The so-called resiliency of The APHA/AAP guidelines stress that every child-care facility
the child is designed to promote adaptation and progressive de- use a health consultant in developing policies, practices, and pro-
velopment-not to absorb the jarring loss of familiar, competent cedures; however, obtaining a health consultant is often difficult
care givers. The APHA/AAP guidelines emphasize continuity by for child-care facilities. The APHA/AAP guidelines suggest many
qualified care givers who are delegated to extend the healthiest possible resources including volunteer consultant services
aspects of the parents’ nurturing, guidance, protective and social- through professional health organizations, local or state public
izing influence, and expectations. health agencies, parents, and board members.
Parents and care givers need to have a sound, mutually The APHA/AAP guidelines require that a daily health assess-
respectful relationship so that the child feels the psychological ment be performed by a trained staff member and include pantic-
radius of the parents’ presence in the care, nurturing, safe- ular health observations to reduce the acquisition and transmis-
guarding, and healthy values that have been extended to the sion of communicable diseases. The facility’s health consultant can
care givers and administrators. The APHA/AAP guidelines conduct the training and assist in developing an observation
include specific standards on relationships between parents record.
and care givers. One of the most controversial General Health Standards
If social-environment and child-development factors are given states that all nonprescription or over-the-counter medications
a high priority in out-of-home child care through an emphasis on be “recommended by a health cane provider for a specific
staffing, the program of activities, and the relationship of the care child, with written permission of the parent or legal guardian
givers and parents, then the child’s sound development and men- referencing a written or telephone instruction received by the
tal health will be supported. This, in turn, will inherently extend facility from the health care provider” (pp. 88-89).’ There
the safeguarding and health promotion that is the main focus of should be clear reasons why care givers are requested to give
these APHA/AAP guidelines. 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
PREVENTION AND CONTROL OF education into the daily activities. In the child-care setting,
INFECTIOUS DISEASES there are many opportunities for promoting health to young
children and parents, which contributes to a healthy childhood
Infectious diseases occur among toddlers and preschool-age
and adult life.
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 STAFF HEALTH
Disease Standards of the APHA/AAP guidelines recognize these
facts and were developed to prevent and limit the spread of The guiding principles of the Staff Health standards define the
infectious diseases in the child care environment. relationship between the well-being of child-care providers and
The common infectious diseases of early childhood affect pri- the quality of care for children. For adults as well as for children,
manly the respiratory system (eg, the common cold, otitis media, the child-care setting provides opportunities to promote health as
pharyngitis, bronchitis, pneumonia), the gastrointestinal tract (eg, well as risks to health. For staff members, those risks include
vomiting and diarrheal illness), and the skin (eg, impetigo, para- communicable diseases (eg, hepatitis, measles, tetanus, giardia),
sitic infestation). A few affect multiple organs (eg, cytomegalovi- injury (eg, back, bites), stress, and exposure to toxic substances
rus). Respiratory infections predominate, accounting for 75% to such as cleaning supplies and art materials.
90% of infections occurring in child-care settings.4 Although the APHA/AAP guidelines largely address children
Mild illness is very common in young children. Most children enrolled in out-of-home child cane, a number of standards were
with common respiratory and gastrointestinal illnesses of mild developed to encourage practices promoting health and prevent-
severity need not be excluded from their usual source of care ing illness of adult care givers. For example, the standards recom-
unless certain conditions exist.’ There is no evidence that the mend a pre-employment staff health appraisal to assess vaccina-
incidence of acute respiratory disease can be reduced by excluding tion status and the staff member’s ability to perform typical duties
sick children from child care. including lifting and frequent hand washing and to move quickly.
The spread of enteric bacteria, viruses, and parasites is partic- Periodic, ongoing staff health appraisals as well as daily health
ularly common among children in child care because of close, checks for obvious signs of illness also are recommended to pro-
personal contact and poor hygiene of young children. The most tect the health of staff members and children.
important aspects of child care associated with these illnesses are Program policies are recommended, including measures to re-
hand washing and toileting practices, which are emphasized duce stress (eg, adequate wages; benefits, and educational, sick,
throughout the APHA/AAP guidelines. Child-care facilities that and vacation leave; adequate staff:child ratios; and sound-absorb-
provide care for infants and toddlers need to give special attention ing materials), to prevent injury and illness spread, and to prevent
to measures for infection control. exposure to toxic substances (eg, use of nontoxic alternatives for
Diapering practices contribute to fecal contamination of the cleaning and art).
child-care environment,5 and coliform contamination of the envi- A number of challenges to implementing the Staff Health stan-
ronment is related to the incidence of diarrheal illness.6 The diaper dands exist. Most state regulations and other standards do not
standard in the APHA/AAP guidelines-which generated the address the relationship between staff and quality care. The costs
most controversy in its review and development-specifies diaper of health appraisals and employee benefits will additionally bun-
properties that will help minimize fecal contamination of the den an inadequately funded system. Many of the standards re-

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SUPPLEMENT 1111
quire changes in health behaviors, beliefs, and attitudes. More REFERENCES
research and training is needed in this area.
The APHA/AAP guidelines can enhance health and safety of 1. American Public Health Association and American Academy of Pedi-
children and their care givers. atnics. Caring for Our Children-National Health and Safety Performance
Standards: Guidelines for Out-of-Home Child Care Programs. Washington,
ACKNOWLEDGMENTS DC, and Elk Grove Village, IL: APHA/AAP; 1992
2. Hayes CD, Palmer JL, Zaslow MJ, eds. Who Cares for America’s Children?
The collaborative project of the American Public Health As-
Child Care Policy for the 1990s. Washington, DC: National Academy
sociation and the American Academy of Pediatrics was funded
Press; 1990
by the Maternal and Child Health Bureau, Department of
3. Don’t Shortchange America’s Future: The Full Cost of Quality Must Be Paid.
Health and Human Services (Grant MCJ 113001).
Washington, DC: National Association for the Education of Young
We acknowledge contributions to this article by Jean Ad-
nopoz, MPH, Yale Child Study Center; Angela Crowley, MA, Children; 1990

RN-C, PNP, Yale School of Nursing; Cynthia Farrar, PhD, New 4. Wald ER, Guerra N, Byers C. Upper respiratory tract infections in
Haven Foundation; Lola Nash, MA, Yale-New Haven Hospital; young children: Duration of and frequency of complications. Pediatrics.
Sally Provence, MD, Yale Child Study Center; and Kathryn 1991 ;87:129-133
Young, PhD, Smith Richardson Foundation. 5. Van R, Wun C-C, Morrow Al, et al. The effect of focal containment on
Copies of Caring for Our Children-National Health and Safety focal coliform contamination in the day care center environment. JAMA.
Performance Standards: Guidelines for Out-of-Home Child Care Pro- 1991;265:1840-1844
grams are available from the American Public Health Association, 6. Van R, Morrow AL, Reves RR, et al. Environmental contamination in
Publication Sales, Department 5037, Washington, DC 20061-5037 child day care centers. Am I Epidemiol. 1991;133:460-470
or from the American Academy of Pediatrics, 141 Northwest Point 7. Presser B. Place of child care and medicated respiratory illness among
Boulevard, P0 Box 927, Elk Grove Village, IL 60009-0927. young American children. I Marriage 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 To assess the quality of each prevention technique, information
in day-care settings for as much as 8 to 10 hours each day. is required on the efficacy, effectiveness, economic impact, and
Through hard work and good science, the US and other countries efficiency of each technique. First, we must be assured that an
have established rigorous health standards for day care, but we intervention works. Efficacy studies to demonstrate this are usu-
must do more. We must give others-the institutions and the ally conducted in carefully controlled research settings.
individuals who care for our children-the tools to foster a health- Once we have identified an intervention that works, we must
ful environment and promote healthy behaviors. The vision of the determine if it is safe and effective when applied in real-world
Centers for Disease Control and Prevention (CDC) is “healthy community settings. We can assess effectiveness using concepts of
people in a healthy world to achieve a quality life.” We must work prevented fraction, a measure which tells us how much morbidity
together to make that vision a reality for our children in day care. and mortality one could actually prevent with a particular inter-
Our paper addresses translating scientific knowledge into prac- vention. Next, we need to know about the resources required to
tice and making prevention a practical reality. We outline the achieve the benefits. This information comes from economic anal-
concepts underlying the assessment of the effectiveness of preven- yses, most commonly cost-effectiveness and cost-benefit analyses.
tion activities and illustrate its use in three case studies from child Once a prevention strategy is in place, our ongoing evaluations
day care. We close with a description of the prevention effective- allow us to improve the efficiency of our programs. Finally, we
ness program recently initiated at CDC. must constantly remind ourselves to be alert to the social, legal,
political, and distributional aspects of our prevention strategies.
PREVENTION EFFECTIVENESS
It is important to assess the effectiveness of prevention practices CASE STUDIES
to ensure that public health programs are built on scientifically
Immunization
sound strategies for improving the quality of life and reducing
unnecessary morbidity and premature mortality.’ There are three Measles vaccination is an example of a clinical prevention
basic approaches to prevention: clinical, behavioral, and environ- strategy that has been proven effective, safe, and efficient in de-
mental. Clinical prevention strategies rely on the one-on-one, pro- creasing morbidity and mortality in children. In the early 20th
vider-to-patient interaction, which underlie immunization and century, thousands of deaths due to measles were recorded annu-
screening programs. These interactions usually occur within our ally in the US, peaking at more than 10 000 deaths in 1923.2 In
regular health-care delivery system. 1966, a measles immunization program was launched in the US.3
Behavioral techniques use a broad array of strategies to encour- The subsequent quarter-century has seen a dramatic decrease in
age lifestyle changes, such as exercise and healthful diets. Behav- the incidence of both measles and measles-associated illnesses
ioral change remains a difficult yet crucial method for improving such as otitis media, pneumonia, subacute sclerosing panencepha-
quality of life, both the individual and the community. litis, and measles-associated mental retardation.4
The environmental prevention strategies involve such ap- Studies on the efficacy and efficiency of the single-dose measles
proaches as fluoridation of water and lead abatement. These far- immunization programs have demonstrated benefit-to-cost ratios
ranging interventions usually require a significant societal com- upward from 5 to 1, depending on the techniques and assump-
mitment but once accepted and implemented, they require little tions used.56 More recently, the benefit-cost ratio determined for
effort on the part of the beneficiary and can have far-reaching measles vaccine combined with the mumps and rubella vaccine
effects. All three approaches will be required to improve the showed benefits to be 14 times greater than costs.7
health of our children. 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.
From the Centers for Disease Control and Prevention, Atlanta, GA. In recent years, an increase in the incidence of measles in this

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American Public Health Association/American Academy of Pediatrics National Health
and Safety Guidelines for Child-Care Programs: Featured Standards and
Implementation
Debra Hawks, Joan Ascheim, G. Scott Giebink, Stacey Graville and Albert J. Solnit
Pediatrics 1994;94;1110
Updated Information & including high resolution figures, can be found at:
Services /content/94/6/1110
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or in its entirety can be found online at:
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007.
Copyright © 1994 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005.
Online ISSN: 1098-4275.

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American Public Health Association/American Academy of Pediatrics National Health
and Safety Guidelines for Child-Care Programs: Featured Standards and
Implementation
Debra Hawks, Joan Ascheim, G. Scott Giebink, Stacey Graville and Albert J. Solnit
Pediatrics 1994;94;1110

The online version of this article, along with updated information and services, is located on
the World Wide Web at:
/content/94/6/1110

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication,
it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked
by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village,
Illinois, 60007. Copyright © 1994 by the American Academy of Pediatrics. All rights reserved. Print
ISSN: 0031-4005. Online ISSN: 1098-4275.

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