Childcare Services

Standards and Guidelines
for
Health
in
Child Care Settings
(2005)
Government of Newfoundland and Labrador
Department of Health and Community Services
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
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 childrens 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
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
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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Diaper Changing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Toileting Routine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
PHYSICAL ENVIRONMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Equipment, Supplies and Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Sleeping Area and Arrangements . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
SANITIZATION AND HOUSEKEEPING . . . . . . . . . . . . . . . . . . . . . . . 19
General Cleaning and Sanitizing Practices . . . . . . . . . . . . . . . . . . . . . 19
Materials for Cleaning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Cleaning Routine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Sanitizing Routine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Items Which Should be Cleaned and/or Sanitized . . . . . . . . . . . 21
Infant and Toddler Toys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
In the Kitchen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Food Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Cleaning Dishes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Garbage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Composting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Sleeping Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Sand Boxes and Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Water Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Routine for Cleaning Body Fluid Spills . . . . . . . . . . . . . . . . . . . . . . . . 31
NUTRITION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Nutrition Guidelines for Child Care Settings . . . . . . . . . . . . . . . . . . . 33
Canadas Food Guide to Healthy Eating for Preschoolers . . . . . . 35
A Word About Salt, Sugar And Fat . . . . . . . . . . . . . . . . . . . . . . . 38

Products Sweetened with Artificial Sweeteners . . . . . . . . . . . . . 39
Food Intolerance and Food Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Food Intolerance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Food Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Common Food Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Avoidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Food Choking Hazards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Keeping Parents Informed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
GUIDELINES FOR INFANT FEEDING . . . . . . . . . . . . . . . . . . . . . . . . 45
Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Storing and Handling Breastmilk . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Formula Feeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Storing and Handling of Formula . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Preparing Bottles for Bottle-feeding . . . . . . . . . . . . . . . . . . . . . . . . . 50
Feeding Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
How do you know a breastfed baby is getting lots of milk? . . . . 51
Feeding and Sleeping Patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Feeding in Child Care Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
What should the provider do if the breastfed baby seems hungry
and the mother is due to arrive shortly? . . . . . . . . . . . . . . . . 54
Water and Juice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Introducing Complementary Foods . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Infant Readiness for Complementary foods . . . . . . . . . . . . . . . . . 55
Handling Conflicting Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Parent Guidelines for Introducing Complementary Foods . . . . . . 56
Commercial and Homemade Infant Foods . . . . . . . . . . . . . . . . . . . . . 57
Storing and Serving Infant Foods . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Feeding Time: A Time for Closeness . . . . . . . . . . . . . . . . . . . . . . . . . . 58
ORAL HEALTH - CARING FOR MOUTH, TEETH AND GUMS . . . 59
Mouth Care for the Infant and Toddler . . . . . . . . . . . . . . . . . . . . . . 59
Teething . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Early Childhood Tooth Decay - Baby Bottle Mouth . . . . . . . . . . . . . . 60
Dental Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Mouth Care for the Preschool/Kindergarten Child . . . . . . . . . . . . . 61
Food and Teeth - Those Hidden Sugars . . . . . . . . . . . . . . . . . . . . . . . 62
Labelling and Storing of Toothbrushes . . . . . . . . . . . . . . . . . . . . . . . 62
vii
Dental Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Liquid Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The Newfoundland and Labrador Childrens 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 . . . . . . . . . .
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83
86
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91
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97
99
When a Childs 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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115
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135
137
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141
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156
157
158
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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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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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 As): . . . . . . . . . . . . .
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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Childs 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
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Childs 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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xiii
PROMOTING
HEALTH IN
CHILD CARE SETTINGS
Health in Child Care Settings
IMMUNIZATION
Immunization is the most effective way of preventing common childhood
infections.
These diseases can all be prevented if immunizations are up to date.
Pneumococcal Disease
Chicken Pox
Pertussis (Whooping Cough)
Measles
Tetanus
Mumps
Polio
Rubella (German Measles)
Haemophilus Influenzae b
Diphtheria
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 childs 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 childs 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
childs personal file, indicating any issues with the childs immunization status.
Page Revised 03/05
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 childs parent/guardian, dated, signed and kept in the
childs 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 20005
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.)
DaPTP (Diphtheria, Pertussis, Tetanus, Polio); Varicella (if Varicella has not
been given at 12 months, meaning two needles at this visit)
9 - 10 yrs.
(Gr. IV)
Hepatitis B (1 dose x 3 visits); Meningococcal (if not given at 12 months,

meaning two needles at this visit.)
14 - 16 yrs.
(Gr. IX)
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
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. Childrens 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 childs parent and seek medical attention immediately.
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
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.
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.
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 childs 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 childrens

footwear which may be
covered with salt, dirt and
slush
when hands are visibly dirty

or any other reason
Alcohol Based Hand Rinses
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.
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 manufacturers
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
http://www.health.gov.on.ca/english/public/pub/pubhealth/handwash_tech.pdf
http://www.health.gov.on.ca/english/public/pub/pubhealth/handwash.html
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.
12
<
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 childs
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 - 3 inches in height running 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:
<
<
<
<
<
<
<
<
<
<
<
<
<
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 childs bottom with a moist disposable wipe. Wipe front to
back using the wipe only once. Repeat with fresh wipes if necessary.
Dont 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 childs 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 childs 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 childs 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 childs 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.
14
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 childs
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.
<
<
<
<
<
<
<
<
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
childs 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.
16
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 childs use of the potty, any bowel movements, including
diarrhea, unusual odour, or those containing blood, and any skin
irritation. Report as necessary.
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 110-1150 F. (430C).
<
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 childs 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.
18
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 childs 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 childs 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.
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.
20
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.
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).
22
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
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 childs 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 childrens
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 childs mouth.
24
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 Everyones
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 4C

(40F). Hot foods need to be kept at or above 60C (140F).
Refrigerate leftovers right away.
Do not store any perishable foods in the danger zone between 4C and
60C, 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 4C (40F) and keep the freezer at
-18C (0F).
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
Temperature
Food Mixtures containing poultry,

eggs, meat, fish, or other
potentially hazardous foods.
74C (165F) for at least 10

minutes.
Pork, Lamb, Veal, Beef
70C (158F)
Poultry
85C (185F) for 15 seconds
Ground Meat
71C (160F)
Eggs
63C (145F) for 15 seconds
Fish
70C (158F)
26
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 60C to 65C (140 F to 150F). 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).
27
handle clean utensils only by their handles.

sanitize sinks, faucets, and taps after washing dishes.
When a domestic dishwasher or handwashing of dishes is utilized contact your

environmental health officer to ensure standards are being met.
Baby Bottles and Artificial Nipples:
cleaning method)
(see infant feeding section for
Pacifiers: If dropped, rinse under hot water before returning to child. Clean
and sanitize if dropped in dirty container.
Garbage
use separate containers in the diapering area, bathrooms, kitchen, eating

and play areas.
should be stored in waterproof, sealed containers and away from children.
use plastic liners or bags to line containers.
store plastic liners or plastic bags out of reach of children.
empty each container daily and insert a new plastic liner (bag).
garbage should be removed from the kitchen daily.
clean and sanitize containers once a week or more often if necessary.
outdoor garbage containers need to be sturdy, waterproof, rodent proof
and hard to tip over.
Composting
Many child care settings are trying to do their part to help protect the
environment. Composting is one way to help reduce the garbage that we
produce in our day to day life. Up to 30% of the garbage we discard each week
can go into a compost pile. Weeds, leaves, grass clippings, vegetable and fruit
scraps and peelings and a variety of other organic wastes can be turned into a
valuable product to enhance the soil. The lawn, plants and garden vegetables
benefit from the nutrient rich compost.
28
Here are some suggestions for composting:
Gloves are not required when handling compost.

Collect food scraps in a covered, tightly lidded plastic container; keep
in a location that is not accessible to the children.
An outdoor compost pile should be in a sheltered spot out of the hot
summer sun; avoid trees and shrubs as their roots may push up into the
pile.
A covered container or bin is recommended to keep the back yard
looking clean and neat and to keep out pets and rodents.
Bins can be purchased from garden supply shops or can be built from a
variety of materials, e.g., a bottomless wooden box with ventilation
spaces between wall boards and an easily removable face for ease of
turning.
A well constructed compost container should not give off unpleasant
odours. If there is a foul odour you may have too much green material
(ammonia smell) or too little air circulating (rotten-egg smell). See below
for Green and Brown materials.
For a successful compost there needs to be about half green materials
and half brown materials by weight.
Composting can continue in the winter months; you may need to increase
the amount of green materials to keep the temperature up.
Indoor composts should be stored in a place where children can not
access it such as a garage or basement.
Fruit flies or house flies can be a problem for indoor composting unless
preventative steps are taken. Here are a few ideas:
Always cover food scraps with a layer of brown material such as soil, old
compost, dead leaves or wood shavings.
In worm composting, food scraps should be buried in the bedding rather
than placed on the surface.
If fruit flies do become a problem a simple home-made trap can be
developed. Take a soda bottle and remove the lid. Cut the bottle in half,
and pour cider vinegar into the bottom half to a depth of about 2
centimetres. Invert the top half of the bottle into the bottom half,
forming a funnel leading into the bottle. Fruit flies will be attracted to
the vinegar and will be trapped or drown in the bottle.
29
Sample materials to use in a compost include:

Green: coffee grounds, tea leaves, eggshells, garden wastes fruits and
vegetables and their peelings, manure
Brown: autumn leaves, coffee filter and paper, tea bags, corn cobs, sawdust,
peat moss, wood ash
This is not an exhaustive list. In reality, anything that is organic can be
composted.
There are a few exceptions:
Pet wastes as they may contain very harmful bacteria.

Meat, fish fats and dairy products as they will smell as they rot and
attract rodents and other animals.
Diseased or insect- infested plants.
Any materials contaminated by herbicides or pesticides, including grass
clippings and leaves in areas where lawns are chemically treated.
Weeds that have a strong root system such as crabgrass, ground ivy or
daylilies.
Rhubarb and walnut leaves, as they contain toxic substances.
For more in-depth information about composting and ways to develop a

composting system visit the following web sites:
<http://www.gnb.ca/0009/0372/0003/0001-e.html> (Province of New
Brunswick)
<http://www.city.richmond.bc.ca/recycle/compost.htm> (City of Richmond, BC)
Sleeping Areas
Assign bedding to individual children.
Label bedding individually or use fresh bedding each day if the bedding is
removed from the individual cribs or cots each day.
Launder bedding once a week.
Clean and sanitize sleep equipment, such as cribs, cots and mats, before
assigning them to another child.
Clean and sanitize all equipment if it becomes soiled or wet.
30
Family (or household) beds are acceptable for use in family child care
settings as long as each child has individually marked, clean bedding that is
placed on top of the family bedding.
Sand Boxes and Tables
<
<
<
<
Cover sand when not in use.

Sweep up sand that falls onto the floor and throw it away.
Clean and sanitize sand toys daily.
Replace some or all of the sand if it becomes soiled or contaminated, e.g.,
child vomits.
Note: The Healthy Environment and Consumer Safety branch of Health

Canada strongly discourages the use of organic materials such as rice, beans,
peas and other grains as a substitute for sand in a sand box or sand table.
Most grains will absorb moisture which will promote the growth of bacteria and
molds and these food products can also attract insects and vermin. As well,
they cannot be cleaned, washed or heated to remove organic materials such as
mold and bacteria.
Water Tables
Infants and Toddlers: use individual plastic basins as they are more easily
sanitized between use, less likely to spread infections, and children can still
play collectively on a table or floor or outside.
Water tables trap germs. They need to be drained and sanitized on a daily
basis.
< Fill with fresh tap water daily.
< Empty or drain water tables daily and then sanitize.
< Leave empty until next use.
< Sanitize all water toys daily.
< Instruct children and providers to wash hands before playing in the
water.
< If a child vomits into the water, scoop out vomit and flush down toilet.
Drain and discard water and sanitize the table.
31
Routine for Cleaning Body Fluid Spills

Universal Precautions
The following steps are not necessary for general sanitization but should be
used for cleaning spills of blood or other body fluids containing visible blood,
e.g., blood tinged urine, stool or vomitus.
< Treat blood and bloody body fluids as infectious.
< Disposable gloves should be worn when there is blood or a body fluid
containing blood.
< Disposable gloves should be discarded in a lined, covered garbage can.
< Wipe up as much of the visible material as possible with disposable
towelling and place in a lined, covered garbage container.
< Immediately sanitize the spill area with a bleach solution consisting of 1
part bleach in 9 parts water (50 mL of bleach in 450 mL of water).
< Bleach solution should be left on the spill area for at least 10 minutes.
< Rinse and dry with a disposable towel.
< Hands must be washed afterwards - disposable gloves are not a
replacement for handwashing.
Specific ways that child care providers can prevent the spread of any blood
borne infection include:
< Seek information and advice from local Health and Community Services
office for additional resources or information.
< Reinforce good hand washing practices for children and providers.
< Follow good diapering practices.
< Clean up blood spills immediately; wear gloves for clean-ups unless the spill
is so small that the blood is maintained within the cloth used to clean-up.
Wash hands for at least 30 seconds after cleaning up spills.
< Ensure that children never share toothbrushes.
< Disinfect any surfaces on which blood or bodily fluids have been spilled
with bleach solution.
< Machine wash all blood stained laundry separately in hot soapy water.
< Place blood stained materials in sealed plastic bags and discard in a lined,
covered garbage container.
< Always cover open cuts and wounds of children and providers.
< If a child care provider has open sore or cuts on the hands, s/he should
wear gloves when cleaning up blood.
Please refer to the Canadian Child Care Federation resource package HIV/AIDS and Child
Care. There is a resource sheet that could easily be photocopied for providers and parents.
33
NUTRITION
Eating habits formed in the early years often remain throughout life. It is a
lot easier to develop good eating habits in young children than to try to change
poor habits in adults. As a child care provider you play an important role in
promoting healthy eating habits in child care settings. Your attitudes and
practices will serve as a model to the infants and children in your care.
The provision of a good nutrition program is one of the most important aspects
of a quality child care arrangement. Following are guidelines for nutrition
programs in child care settings. For more information on the general principles
of planning healthy meals and snacks, please refer to the relevant Program
Guide(s).
Nutrition Guidelines for Child Care Settings

For Breakfast:
Any centre that opens before 7:30 a.m. is required to provide breakfast. As
well, consideration must be given to those children who have either eaten their
breakfast an hour or so prior to arriving at the centre or those who have come
to the centre without having any breakfast. It may be quite difficult for these
children to wait until the scheduled mid-morning snack before eating. In these
situations, discussion with parents is required and arrangements can be made
to provide breakfast for those children who need it.
Breakfast should include at least one serving from at least 3 of the 4 food
groups of Canadas Food Guide to Healthy Eating.
34
For Lunch or Supper:
Provide at least one serving from each of the four food groups of Canadas Food
Guide to Healthy Eating at the midday meal. Offer child-sized portions and let
the childs appetite be a guide to the amount they need. Seconds should always
be available.
N.B.:
Generally, child sized portions for preschool children are about half of
suggested serving sizes listed in Canadas Food Guide to Healthy Eating.
Portion size depends on the age and appetite of the individual child.
When a child care service offers care beyond 5:30 p.m., supper, consisting of
all four food groups, must be provided unless the parents advise otherwise. In
all situations if the child is in care after 6:30 p.m., supper must be provided.
For Snacks:
Snacks should include a serving from at least two of the four food groups. If
one of the servings is not a beverage, then water should be offered. Additional
items, if served, should be chosen from Canadas Food Guide to Healthy Eating.
Snacks should be nutritious and be low in sugar so as not to promote tooth
decay. Serve the morning snack early enough to satisfy the needs of children
who wake up very early, and those who may need or want additional nourishment
for this active time of day.
A Word on Vitamin and Mineral Supplements
There is no substitute for healthy eating. If a child is eating a variety of foods
from Canadas Food Guide to Healthy Eating, vitamin-mineral supplements are
not necessary and cannot be given in child care settings, except under a
physicians prescription. (Please see Child Care Services Regulations)
Supplements cannot take the place of the more than 50 different nutrients
found in food.
35
Canadas Food Guide to Healthy Eating for Preschoolers

Single selections or combinations of foods from the four food groups listed
below will provide a variety of healthy choices for young children.
GRAIN PRODUCTS: 5-12 servings per day

Examples of one child-size serving:
- 1 slice bread
15 - 30 g cold cereal ( 125-250 mL flaked cereal, 250-500 mL puffed cereal,
30-75 mL granola-type cereal without nuts or seeds)
75-175 mL (1/3 - 3/4 cup) hot cereal
- bagel, pita or bun
- 1 muffin
50-125 mL ( - cup) pasta or rice
4-8 soda crackers
These foods provide B vitamins and iron. Foods made with whole grains also
provide fibre.
Tips
<
Whole grain products have more fibre than refined products. Try using
whole wheat flour in some of your baking. Choose whole grain breads and
cereals and brown rice more often.
<
Breakfast cereals served with milk make an excellent morning snack in

child care settings. Lower sugar varieties are best. Read labels to find out
whats in the cereal. Choose cereals with 6g or less of sugar per serving.
Encourage children to enjoy the natural taste of cereal without adding
extra sugar.
VEGETABLES AND FRUIT: 5-10 servings per day

-1 medium-size vegetable or fruit
50-125mL ( - cup) fresh, frozen or canned vegetables or fruit
36
125-250 mL ( - 1 cup) salad

50-125 mL (1/4 - cup) juice
Vegetables and fruit contain many vitamins and minerals which are important
for growth and health. At least 2 of the daily servings from this food group
should be vegetables. If no vegetables are offered to children in the child care
setting, they would have to consume 2 vegetable servings at supper which might
be difficult for some. Offer a variety of orange, green or green leafy
vegetables throughout the week. A variety of fruits and juices should also be
offered.
Tips
<
<
<
<
Children often prefer finger foods, crisp textures and bright colours.
Serve vegetables raw, (see section on Choking Hazards) or cooked but
still crisp.
Only 100% unsweetened fruit juices are to be served in child care
settings. Fruit flavoured drinks, crystals, and powders are high in sugar.
Even those that contain vitamin C are not a substitute for fruit juice.
They do not contain the many vitamins and minerals found naturally in fruit
juice.
A child who drinks too much juice (or milk) will not be very hungry at
mealtimes. It is recommended that preschoolers intake be limited to no
more than one cup of juice per day. Since children will likely be drinking
juice at home as well, and since preschoolers milk requirements are
substantial, a good practice is to offer juice at just one snack each day
and milk at the other snack plus at lunch.
Water must be available to children at all times.
MILK PRODUCTS
2-3 servings per day for children eating full size portions, e.g., 250
mL (1 cup) milk;
4-6 servings per day for children eating half-size portions, e.g., 125
mL ( cup) milk.
37

125-250 mL ( cup - 1 cup) milk
25-50 g cheese
75 - 175 g (1/3-3/4 cup) yogurt
These foods provide calcium, protein, vitamin A, and riboflavin needed for
healthy bones and teeth and for many other important body functions.
Tips
<
<
<
<
<
<
Whole milk is recommended for children up to age 2 years.

Milk, processed cheese slices and spreads, cheese, and yogurt contain more
calcium than cream cheese, cottage cheese and frozen milk products such as
ice cream.
If a child does not drink much milk, serve more foods made with milk, such
as cream soups, milk puddings, and hot cereals cooked in milk. Try adding
powdered milk to foods such as scrambled eggs and mashed potatoes.
Remember that yogurt and cheese are good substitutions for milk. For young
children, try using a fancy cup or letting the child drink through a straw.
Remember children love to imitate adults. Providers are encouraged to drink
milk along with the children at mealtimes.
Chocolate milk, chocolate drinks or other flavoured milks are higher in sugar
than plain white milk. They are not recommended for regular use in child care
settings.
A child needs milk every day, but not more than 750 mL (3 cups). Too much
milk may interfere with the childs hunger for other foods. If a child drinks
a lot of milk but has a poor appetite for other foods, check with the parent
about the childs overall eating pattern and see if milk needs to be limited.
MEAT AND ALTERNATIVES: 2-3 servings daily

Example of one child size serving:
25-50 g meat, fish or poultry
1 egg
50 -125 mL (1/4 -1/2 cup) beans
50-100 g (1/4 - 1/3 cup) tofu
38
15-30 mL (1-2 tbsp.) peanut butter

These foods provide the iron needed to make healthy blood and the protein
needed to build and maintain healthy tissues.
Tips
<
<
<
If a child finds meat hard to chew, it can be chopped very finely or

replaced by other foods such as eggs, ground lean beef (as in meatloaf),
fish, chicken, pea soup, baked beans, or peanut butter.
Preschoolers should not be given nuts because of the danger of accidental
choking on small pieces. Smooth-style peanut butter spread thinly on bread
or crackers is an acceptable alternative unless there is a peanut
restriction due to the presence of a child with a peanut allergy in the child
care setting.
Processed meats such as bologna, luncheon meats, wieners, potted meat,
sausages, bacon, salami and pepperoni are high in fat and salt. It is
recommended that these be served no more than once a week in a child
care setting.
A Word About Salt, Sugar And Fat
Children have a very keen sense of taste. What might seem bland to an adult
will be fine to a child. It is not necessary to add extra flavourings to food that
is prepared for children. Children should be encouraged to enjoy the taste of
foods without the addition of a lot of salt, sugar, and fat.
Salt
Diets that are high in salt have been linked to high blood pressure, especially
in people with a family history of hypertension. It is a good idea to limit the
intake of salt in our diets as foods that have natural sources of salt provide a
sufficient quantity to meet our needs. Providers are advised to practise
moderation in the use of salt by generally avoiding salty snack foods, and by
limiting the use of other salty foods such as processed meats, pickles, dry soup
mixes, and canned soups. Keep salt shakers off tables as there shouldnt be a
need to add salt at the table.
Page Revised 09/04
39
Sugar
Sugar causes tooth decay, particularly when sweet foods are consumed as snack
foods between meals. Honey, molasses, syrups, white sugar, and brown sugar
all promote tooth decay. There is also a risk of infant botulism with honey for
infants less than one year old. Encourage raw fruits with natural sugars as
snacks.
Fat
Encourage moderation in relation to fat content when selecting food choices in
child care settings. Parents and providers can encourage healthy fat intake by:
Using butter, margarine and salad dressings in moderation
Trimming visible fat from meats
Limiting processed meats such as wieners and luncheon meats
Promoting fruits and vegetables as healthy snacks
Limiting the amount of fried foods
Children do need some dietary fat for normal growth and development, and this
need can be met in the form of nutritious foods; for example, a nutritious
higher fat food such as cheese is an appropriate food for helping preschoolers
satisfy their nutrient and energy needs.
Products Sweetened with Artificial Sweeteners
Although aspartame, sucralose and acesulfame potassium, the artificial
sweeteners used in almost all sugar-free products, are considered safe, they
may be consumed by some individuals (primarily children) in quantities
exceeding acceptable levels. Healthy children do not need to use sugar
substitutes. Artificially-sweetened diet drinks, gelatin desserts, cereals,
chewing gum, puddings, or chocolate drinks are not recommended in child care
settings.
Children can be encouraged to develop a taste for less sweet foods and
naturally flavoured foods, rather than substituting artificial sweeteners.
Page Revised 09/04
40
Food Intolerance and Food Allergy

It is important to know the difference between a food intolerance and food
allergy. A child with a milk allergy must avoid all milk products and ingredients,
whereas a child with lactose intolerance can eat some cheese, such as cheddar
and mozzarella, and drink lactose-free milk. A child with a food intolerance may
also have to avoid certain ingredients in foods.
Food Intolerance
Food intolerance is a problem with food digestion that does not involve the
immune system. Symptoms of a food intolerance commonly include cramps, gas,
bloating, and loose bowel movements when a specific food is eaten. Examples of
food intolerance include lactose intolerance, in which people do not have enough
lactase (enzyme) to digest the sugar lactose in milk, or celiac disease, in which
people cannot digest gluten, which is found in many flours, including wheat.
Food Allergy
(see also Children with Special Needs and Long Term Conditions)
Food allergy is a reaction with the bodys immune system, when a particular food
protein is eaten or sometimes touched or inhaled. Our immune system helps to
keep us healthy, defending the body from viruses and germs, but during an
allergic reaction, the immune system mistakenly treats a food as if it were an
enemy. When this happens, the body produces antibodies that locate and
release chemicals to destroy the food particles. These chemicals also affect
other parts of the body and can cause one or more of the following symptoms:
< tingling in the mouth,
< hives and itching,
< swelling of eyes, lips, face, tongue, throat,
< tightness in throat, mouth and chest,
< difficulty breathing and swallowing,
< wheezing or coughing,
< choking,
< vomiting,
< loss of consciousness,
< death.
41
The symptoms of a food allergy can range from mild to very severe. The
symptoms can begin within moments of ingestion of the food or may be delayed.
The most severe symptom is an anaphylactic reaction, which involves a reaction
in two or more body systems, including the cardiovascular (heart) and
respiratory (breathing) systems. An anaphylactic reaction is life threatening
and can quickly lead to death.
If you have a child in your care who has potential for an anaphylactic reaction
to a food allergy, you must work with the parents and the health professionals
involved. You must also:
< know what food(s) to avoid, and advise all parents (and all children)
about foods that should not be brought to child care.
< read all food labels to ensure the food is safe.
< know the allergy symptoms.
< know the suggested medications, including Epi-Pen.
< know how to give the Epi-Pen.
< have an emergency plan following the Epi-Pen injection.
< complete the Allergy Awareness Posters (available through the
Newfoundland and Labrador Lung Association) and post them at strategic
places throughout the child care setting.
See also Tips for Providers in Children with Special Needs and Long Term
Conditions.
Common Food Allergies
Almost any food can cause a food allergy. The most common foods are:
Milk
Eggs
Soy
Peanuts
Nuts
Fish
Shellfish
Wheat
Kiwi
Strawberries
Seeds
42
Avoidance
Providers must ask parents for information about management of a childs food
allergies and intolerance. If the allergy is life-threatening, an emergency plan
is necessary to ensure the safety of a child. Additional information about food
allergies may be necessary to help ensure the safety of an allergic child.
Information on reading food labels to help identify uncommon words for
common food ingredients, such as milk - casein, whey, curds, or egg - albumin,
ovalbumin, yolk, will be necessary. Additional information can be obtained from
parents, dietitian and physician. Providers should watch all children carefully
and report any apparent distress from food to the childs parents.
Avoiding the trigger food(s) to which a child is allergic is the only way to
prevent an allergic reaction. It is important to read the labels to determine
if the trigger food is an ingredient in a food. Cross-contamination must be
avoided. It occurs when a non-trigger food comes in contact with the trigger
food. While you may not see traces of the trigger food, there may be enough
contamination in the non-trigger food to cause a reaction. Cross-contamination
often occurs when the same preparation and serving utensils are used for
different foods, or foods are placed next to each other. Occasionally a
reaction can occur if a child is simply in the same area as the trigger food. For
more information on cross-contamination, obtain a copy of Food Allergy Facts
(yellow sheet), available from the Newfoundland and Labrador Lung Association
(709) 726-4664 or by contacting the regional child care services consultant or
social worker. This sheet is part of an information package developed for
parents by the Airways/Allergies Parent Support Group.
Food Choking Hazards
(See also How to Prevent Choking in Safety and Injury Prevention)
Children up to the age of about 4 years are most at risk of choking and
suffocating on certain foods because they do not have the chewing capabilities
of older children and adults. Thus they are more likely to swallow a food
before it has been thoroughly chewed to a soft, small mass. Choking is the
second most common cause of deaths in the home for children under 5 years
of age. It is critical that parents and providers know how to reduce the risk
43
of choking and what to do if an infant or child is choking. Young children are

at risk of choking during meals when they bite off large chunks but then have
difficulty grinding the foods. Some foods are of a shape and size that can block
the airway of a young child if swallowed whole.
Choking can occur in children when they:
< Eat pieces too large.
< Eat too fast.
< Chew improperly.
< Cry, laugh or run with food in their mouth.
Supervise all children when eating. A child who is choking may not be able to
make noise or attract attention. Coughing is a sign that the child is removing
the object naturally.
The following foods may cause choking in young children:
<
<
<
<
<
<
Chips
Wieners
Round or Hard Candy
Cough drops
Raisins
Large Pieces of Fruit
<
<
<
<
<
<
Marshmallows
Corn
Raw Celery
Peanut Butter
Nuts and Seeds
Gum
<
<
<
<
<
Chunks of Meat
Cherries with Pits
Grapes
Raw Carrots
Popcorn
To reduce the risk of choking from any foods, follow these guidelines for children
under four years of age.
<
<
<
<
Avoid foods that are hard, or tough, and difficult to chew. Raw carrots and
hard fruit pieces can be cooked and mashed or grated for younger children.
Speak with parents of younger children to determine how these foods are
served at home.
If wieners, sausages, or grapes are served, they should be cut both lengthwise
and crosswise so they are no longer a plug shape.
Carefully remove all bones from meat, fish, and poultry.
Never serve peanut butter alone in a lump, as it may stick in the throat or to the
vocal cords; serve it thinly spread on bread or crackers.
44
<
<
<
Children should eat sitting upright, with an adult present; never alone or while
moving around.
Check floors for hazardous items that may have been dropped, (e.g., peanuts,
candy), especially if there are younger children in the child care setting.
toothpicks are also a choking hazard and should not be used in foods served in
child care settings.
Keeping Parents Informed
<
<
<
<
<
Ensure parents are familiar with your child care services policies regarding
nutrition.
Include articles in your newsletter about nutrition activities in your child care
setting. Parents might also appreciate recipes which are popular with the
children. They can make the same healthy fun foods at home. Your Child Care
Services Consultant or Nutritionist may be able to help with this.
Talk with parents about eating problems you notice, as they may wish to seek
advice from a health professional.
If a child really enjoys a particularly nutritious food, mention it to the
parents. They may wish to serve it at home.
Each week, the current menu must be easily available for parents viewing.
The entrance or coat and boot area is a good place. It is important that the
menu reflect what is actually served each day. Pencil in any daily changes
directly onto the menu form. When parents have the opportunity to read the
weekly menu, it helps them to plan the evening meals without repetition. They
might also note foods served at child care which their child refuses to eat at
home and this presents a perfect opening for discussion with providers. It
can also be a means of providing information to parents as to what makes up
healthy eating for children.
45
GUIDELINES FOR INFANT FEEDING

Providers will receive direction from the parents for the feeding plan of their
infants in child care settings. While the provider follows the directives of the
parents, it is important that all providers are aware of national recommendations
around infant and young child feeding and work closely with parents to ensure that
the infants and children receive optimal nutrition.
In situations where the
parents instructions deviate from recognized standards for feeding, the provider
should consult with the Regional Integrated Health Authority staff for guidance.
Use every opportunity to share current recommendations with parents, either
through fact sheets or a parents information board or at a general meeting.
Infant and young child feeding practices are strongly influenced by family and
socio-cultural patterns.
Breastfeeding
Breastfeeding is the optimal method for infant and child feeding. The World
Health Organization, UNICEF and Health Canada recommend that all infants be
exclusively breastfed for the first six months of life and continue breastfeeding
while adding complementary foods, until at least two years of age or beyond.
When a breastfeeding mother enrolls her child in child care, she may decide to
provide expressed breastmilk for the provider to give at the child care service or
she may visit the centre to feed her child during the day. She will likely continue
to breastfeed her child in the mornings, evenings and through the night at home.
This is a very important contribution to the infants and mothers health.
It is very possible for women to combine child care and breastfeeding. Here are
two examples:
Scenario I
Mary is an elementary school teacher. She returned to work when her baby was
one year of age. She continued to breastfeed her baby in the early morning
before work. The provider at Happy Days Child Care Centre gave her child a
bottle of breastmilk at noon. Mary collects her daughter at 4 p.m. and usually
nurses her on-site prior to taking her home. Mary continues to breastfeed her
daughter in the evening before bed time and once during the night. To maintain
46
her milk supply, Mary expressed her milk during her lunch break in the teachers
room at school and stored it in the refrigerator until the end of the day. She used
an insulated lunch bag to carry the milk back and forth between home, school and
the child care centre. On the weekends Mary went back to her normal feeding
pattern of breastfeeding.
Scenario II
Suzanne returned to school in September when her baby was 3 months of age. She
fortunately had a child care centre on- site at her high school. She maintained her
breastfeeding by feeding her baby at home. She came to the child care centre
during her breaks and lunch hour to breastfeed her young baby. Suzanne has built
up a supply of expressed breastmilk which she maintains in the freezer at the child
care centre for times when she is unable to be present for the feeding.
Some women decide to continue breastfeeding at home and provide formula for
their infants while they are in child care. If women feel that expressing breastmilk
is not an option for them they can still enjoy the many benefits of breastfeeding
by combining breastfeeding and formula feeding.
The benefits of breastfeeding are undisputed by researchers and health
professionals. Providers can support the breastfeeding mother and child by
demonstrating a positive attitude towards breastfeeding and encouraging the
mother in her efforts. The child care setting should reflect a breastfeeding
friendly environment. Posters and literature such as pamphlets and brochures that
recognize breastfeeding as the norm for infant and child feeding in the local
community should be evident.
Here are some tips for making your child care setting breastfeeding friendly:
<
<
<
<
<
<
<
Express positive and enthusiastic attitudes about breastfeeding.

Provide a comfortable space for breastfeeding women and their families, e.g.,
comfortable armchair and/or rocker.
Provide privacy for women who want it, and for milk expression.
Ensure educational and promotional materials, e.g., posters, pamphlets, reflect
positive breastfeeding images and messages.
Ensure formula industry samples and gifts, including free formula, are not
distributed to pregnant women and new mothers in your child care setting.
Support those, including providers, who wish to breastfeed in the workplace.
Be aware of breastfeeding support services in the community and know how
<
<
47
to access these resources.

Establish a well organized plan to support the mother to continue
breastfeeding (include specifics on plan for giving breastmilk and alternative
feeding methods used, e.g., bottle, cup, training cup, etc.).
Develop a plan for what the care provider should do for those times when
Mom might be late getting to the child care setting to breastfeed her child.
For more information about breastfeeding see Canadian Child Care Federation
Resource Sheet Supporting Breastfeeding in Child Care, Spring 2001.
Storing and Handling Breastmilk
Breastmilk may not look like formula or cows milk from the store. Breastmilk is
not homogenized and therefore it separates into layers of milk and cream. It is
normal for breastmilk to be bluish, yellowish or even brownish in colour. Frozen
milk often takes on a yellowish colour. Some women have noticed a slightly soapy
odour to their frozen breastmilk after it is thawed. This milk is not harmful to
the baby. The milk is not spoiled unless it smells sour or tastes bad.
Ensure that parents bring in new bottles of expressed milk on a daily basis. All
bottles or foods must be labelled correctly with the infants name, contents, and
date and then refrigerated appropriately. Keep a roll of masking tape and a pen
handy in case the parent forgets to label the infants food or milk. Give any
expressed breastmilk that remains at the end of the day back to parents or
discard it.
Storage
< It is recommended that breastmilk stored in a refrigerator be used within 48
hours.
< Freshly expressed breastmilk can be kept frozen inside the freezer section
of a refrigerator for 2 weeks.
< Freshly expressed breastmilk can be kept frozen in a deep freezer for 6
months.
< Previously frozen breastmilk should not be refrozen, but you can refrigerate
it and use it within 24 hours.
< Thawed breastmilk should be refrigerated.
< Throw out any breastmilk that has been left at room temperature since the
last feeding.
48
To thaw breastmilk:
< Loosen the lid of the bottle or container first. Place frozen milk under cool
running water until thawed, or thaw frozen milk in the refrigerator several
hours before it is needed. Use thawed breastmilk within 24 hours.
< Breastmilk separates into layers when stored. The cream in the breastmilk
rises to the top. Shake it gently before serving to mix in the cream.
< Warm breastmilk gently by putting it in a pan or bowl of warm water.
< Do not use a microwave to thaw or warm breastmilk as it is very easy to
overheat the milk and destroy its high quality. Microwaves heat the milk
unevenly, causing hot spots that can scald the babys mouth. Plastic bags may
break in the microwave.
Formula Feeding
Commercially prepared infant formulas are used for infants who are not exclusively
breastfed. They are generally used for the first 9-12 months. The most common
types of formula are:
<
<
<
Ready-to-serve types, where no water is added and there is no mixing.

Concentrated liquid, where formula is mixed with an equal amount of water
that has been boiled, then cooled.
Powdered, where following product directions, powder is mixed with water
that has been boiled, then cooled.
The instructions are very different for each type. In all cases, the manufacturers
instructions on the label should be followed exactly. Always check the label for
the type of infant formula you are using for the infant and check the expiry date.
Always measure formula and water accurately. Babies can become severely
dehydrated if too little water is added. If too much water is added the baby will
not get enough calories and other nutrients. Never add any extra formula,
water or cereal to the bottle.
Evaporated (canned) milk is not an infant formula. It is lacking iron and other
important nutrients. It is also high in protein, difficult to digest and the fat is
poorly absorbed. If parents choose to use it, it must be prepared according to the
instructions on the sheet Preparing Evaporated (Canned) Milk Formula, available
from your Regional Integrated Health Authority office.
49
In some situations a physician may have ordered a soy-based or specialized infant

formula for an infant or child with a special health problem. All formulas should
only be used for the specific infant for whom it is intended.
Storing and Handling of Formula
Note: For health and safety reasons, it is strongly recommended that parents
of formula-fed infants bring prepared bottles of formula to the child care
setting each day. Every bottle of formula must be clearly labelled with the
infants name, contents and date and then refrigerated appropriately.
While cold formula will not harm the infant, most babies prefer it warm. To warm
up the formula, take the bottle out of the refrigerator a few minutes before it is
to be used and stand it in a container of warm water. Test the temperature and
flow of the formula by turning the bottle upside down, letting a few drops fall on
the inside of your wrist. The formula should feel warm. Formula should flow
steadily from the nipple, about one drop per second. Do not microwave formula,
as microwaves can cause hot spots in the milk that burn the babys mouth and
throat. Also, plastic bags may break in the microwave.
Safety measures
< Prepared infant formula can be stored in the refrigerator for 24 hours.
< Do not leave the formula out of the refrigerator for longer than one hour.
< If the baby needs a little more formula, remove a bottle from the
refrigerator and pour some of it into one already in use.
< Continue to sterilize bottles and utensils until baby is four months old.
< Always boil water for 2-5 minutes and cool before preparing the formula.
Use water from the cold water tap for boiling.
< Always use a clean bottle for each feeding.
Cleanliness is the key
<
<
<
<
<
<
Wash hands before preparing formula and feeding the baby.

Keep cans of powder tightly closed and the cans of liquid covered and
refrigerated after opening.
Cool the made-up formula quickly by putting it in the refrigerator.
Keep the formula cold until the baby wants it.
Never put warm formula in a thermos or bottle warmer.
Throw away any formula the baby does not drink.
(Adapted from Postpartum Parent Support Program Handout)
50
Preparing Bottles for Bottle-feeding

Note: for both breast-fed and formula fed infants, it is preferable and
strongly recommended that providers do not prepare bottles; parents should
bring prepared bottles to the child care setting each day. However, in some
circumstances, child care providers may have to prepare a bottle for feeding.
The following information is applicable to these circumstances.
If a disposable nursing system is being used, the holder must be washed and rinsed
well. Place a sterile liner in the holder, making sure that you do not touch the
inside of the liner. The caps and nipples must be sterilized before each use (see
below). Rubber nipples deteriorate over time. Look for softening, tears, and
cracks in the nipples by pulling in the ends and stretching them when washing.
Also, it is recommended that pacifiers be replaced if they are older than two
months.
If glass bottles are used for feeding, they must be cleaned and sterilized
according to the following instructions:
Cleaning and sterilizing glass bottles, nipples, and equipment
Sterilize bottles, artificial nipples, and utensils until the baby is four months of
age. Bottles may be sterilized in a dishwasher if it has a sterilizer cycle.
Microwave ovens should not be used to sterilize bottles or to warm the
refrigerated bottled formula. Microwave ovens heat liquids unevenly, causing hot
spots in the milk that may burn the babys mouth and throat.
Equipment you will need:
<
<
<
<
<
<
Large pot, kettle or sterilizer

Bottle brush
Nipple brush
Tongs
Measuring cup (optional)
Funnel (optional)
Always wash and rinse equipment after use. Hold bottles up to the light to check
that all milk rings are removed (rinsing the bottle well immediately after a feeding
51
will usually prevent this problem). Squirt hot water through nipples to clear away
any clogged formula and ensure that the hole is clear. Wash the top of the
formula can before opening it.
Use a large pot with a tightly fitting lid for sterilizing and put a rack or folded
cloth on the bottom. Put the equipment and nipples in the pot, laying the bottles
on their sides. Fill pot with water, but not up to the top of jar. Water should
cover the bottles and other utensils completely. Cover pot and bring water to a
boil. Continue to boil rapidly for 2-5 minutes and allow to cool. Remove equipment
and nipples with sterilized tongs.
Feeding Basics
How do you know a breastfed baby is getting lots of milk?
One of the most common reasons why women give up breastfeeding early is their
concern about whether or not their baby is getting enough breastmilk. After the
first week of life a healthy breastfed baby should have at least 6 heavy, wet cloth
diapers each day or 4-5 disposable diapers. The urine should be pale in colour.
Sometimes it may be difficult to tell if a disposable diaper is wet. To know what
a wet disposable diaper feels like, pour 2-4 tablespoons of water in a dry diaper
and feel the weight of the wet diaper as compared to the dry diaper. A breastfed
baby usually has at least two yellow, seedy bowel movements, about the size of a
loonie each day. After the first month of life there may be fewer bowel
movements but they remain mustardy yellow in colour and fairly loose. Many people
who are not familiar with the normal breastmilk stool may wrongly assume that the
baby has diarrhea.
The bowel movements of the baby who is drinking formula tend to be firmer,
stronger smelling and brown in colour. Formula fed infants usually pass stool less
often than the breastfed baby.
A breastfed baby may have a bowel movement as often as after every feeding or
as little as once in 7-10 days. Both patterns are normal. A breastfed baby rarely
has problems with constipation. Many young infants appear to have difficulty
passing their stools. They grunt, groan, raise their legs, cry, turn red and push
hard, but nothing comes for a while. This does not mean that the baby is
52
constipated. If the stools are hard and dry, the infant is constipated. Once
complementary (solid and semi-solid) foods are introduced the appearance of the
stools change.
A healthy breastfed baby looks relaxed and content after a feeding.
Feeding and Sleeping Patterns
Daily feeding and sleeping patterns will vary from baby to baby. All babies are
unique and develop a pattern that is right for them. The infants individual pattern
and needs for food and sleep will determine the eating and sleeping routine that
is established for that child. The established routine must be flexible and
amended to accommodate the childs changing patterns and needs.
As the baby grows and develops the feeding pattern may change to meet the
babys needs. Babies do best when they have unrestricted feedings based on their
cues. Babies feed best on cue before they reach the crying state, and for as long
and as often as they are interested. Often, young babies cluster their feedings
closer together, for example every two hours, and then go for a little longer
stretch at another time in the day. Breastfed babies often feed frequently
throughout the evening.
The infant cues for beginning a feeding include: rapid eye movements, waking,
stretching, stirring, hand-to-mouth activity, and oral activities such as sucking,
licking and rooting (bob up and down) (Health Canada, 2000).
Sleeping patterns also change as the infant grows and develops. S/he must be
allowed to rest and sleep according to her/his own needs and in accordance with
the wishes of his or her parents, rather than on an artificially established routine.
A daily written record of the childs eating, sleeping and elimination patterns must
be provided to the parents of a child who is less than 24 months of age. (See
Infant Daily Record Form)
Feeding in Child Care Settings
It would be very difficult to predict accurately the exact amount of milk a baby
would take at each feeding. It is likely that the primary caregiver in a child care
setting will soon get to know the baby and have a better sense of what the baby
53
will typically take at each feeding. On average most breastfed babies take
between 60-120mL (2-4 ounces) about 8-12 times in 24 hours. It would be very
unusual for a breastfed baby to consume a 250 mL (8 ounce) bottle of milk at one
feeding. For formula-fed infants, allow her/him to feed until satiated, but do not
require her/him to finish the bottle.
For infants being fed from a cup, often they will take sips throughout the day as
opposed to a large cupful at one time.
There are some breastfed babies who never take a bottle. They learn to drink
from a cup instead and are quite adept at drinking in this way. Some mothers
choose to use a regular open cup while others use the sippy cups with the spouts
or straws. Some breastfed babies are reluctant to take a bottle. Try to be
patient and try these different ways to encourage the breastfed baby:
<
<
<
<
<
<
<
<
<
<
<
Encourage the mother to find someone else to try the bottle when she is not
around; it is unlikely that a breastfed baby will drink from a bottle if their
mother is nearby.
Try offering the bottle before the baby is too hungry; s/he may be more
cooperative.
Hold the baby lovingly in your arms while giving the bottle.
Encourage the mother to leave a piece of her clothing with the provider so
that the mothers smell is present; wrap around the baby.
Avoid pushing the bottle nipple in the babys mouth. Tickle her/his lips or lay
near the mouth so s/he can pull it in.
Run a little warm water over the nipple to bring it to body temperature.
Suggest that parents experiment with a variety of bottle nipples.
Ask the parent about different feeding positions; some babies will not take
the bottle easily in the nursing position but prefer sitting more upright
against the providers drawn up legs(like in an infant car seat); some babies
like to be held looking outwards rather than at the provider.
Try gently rocking, walking or swaying from side to side, as some babies will
accept bottle with movement.
Try to make the experience a pleasant one for the baby; never force the baby
to take a bottle.
If the baby refuses the bottle they can still be given the breastmilk by cup,
spoon or eyedropper. Talk to parents about alternate feeding method if using
a bottle does not work.
54
What should the provider do if the breastfed baby seems hungry and the
mother is due to arrive shortly?
Always discuss this possible situation with the mother when the baby is enrolled
in the child care setting. Perhaps the provider could satisfy the baby by giving
less than a full feeding with a small amount of milk until she gets there. The
mother may have full breasts and be anxious to feed her baby when she arrives at
the child care service.
Water and Juice
Healthy infants do not need extra water or juices in the first five - six months of
life. They only serve to limit the intake of breastmilk/formula by taking the place
of it in a babys diet. Certainly in the first year of life they should be kept to a
minimum. A daily maximum of 60 mL of juice is adequate for infants 5-12 months
old, 125 mL for those 12 -24 months old. Juice should not be given in a bottle.
Introducing Complementary Foods (solid and semi-solid)
At about six months of age, many but not all exclusively breastfed infants will
show a readiness and interest to be offered foods to complement their intake of
breastmilk. Solid foods help meet the babys increased need for iron, protein, and
energy (calories) as they grow. The World Health Organization now recommends
that babies be exclusively breastfed for six months before introducing any
complementary foods.
Introducing complementary foods to formula fed infants can begin at four to six
months of age. Infant cereal was traditionally, and continues to be, the first food
provided because of the concern for preventing iron deficiency in the formula fed
baby.
Not all babies are ready to start solid foods at the same time. It is important to
consider each baby as an individual and look for signs of readiness for solid foods.
The parents will make the decision when they feel it is best to begin solid foods,
but the provider has an important role to play in informing the parents of
behaviours that may or may not indicate a readiness for foods.
Page Revised 09/04
55
Infant Readiness for Complementary foods

Parents and providers will know the introduction of solid foods is appropriate when
the infant:
< Sits up, and holds head up without support
< Shows increased demand to feed that is not related to illness or teething pain
or change in routine
< Shows readiness to chew
< Does not automatically push the solid foods out with her tongue
< Shows interest in what others are eating
< Picks up food and puts it in his mouth
If the breastfed baby who is around six months of age continues to demand more
breastfeeding even after increasing the frequency after 4-5 days, it may be time
to offer solids.
Handling Conflicting Issues
Prior to enrolment, parents should be informed about current recommendations
regarding infant feeding as well as your child care services infant and child care
feeding policy. It is the parents ultimate decision on how best to feed their babies
and if they are made aware of the policies at a particular child care setting in
advance of enrolment then they can make an informed choice as to whether this
child care service would be a good match with them and their infant or child. If
providers are asked to give a specific food that is inappropriate for the age and
development of the baby (e.g., solid foods at three months of age or cereal added
to a bottle) it is best to reinforce current recommendations and your child care
services infant and child feeding policy with the parents. Talk to your regional
nutritionist for direction on specific issues that may arise from time to time.
Share Department of Health & Community Services booklets and pamphlets on this
issue.
56
Parent Guidelines for Introducing Complementary Foods (Solid and SemiSolid Foods)
New foods are not to be offered to infants at the child care service. Parents
have the responsibility to introduce new foods, as there may be an adverse
reaction.
The following is provided for information only - again, the
introduction of new foods is to be done by parents at home.
The time when complementary foods are introduced to the infant is an especially
vulnerable time because infants are just learning to eat and they need time and
patience from their provider. They need to be fed foods frequently. Care must
also be taken to avoid having the complementary foods replace the vital
breastmilk/formula. For breastfeeding mothers, it is important to note that
starting solid foods is not a sign to stop breastfeeding. Generally mothers are
encouraged to offer breastmilk first before offering solid foods.
There are many ways to introduce solid foods and feeding patterns vary from
family to family and culture to culture. It is best that parents and providers work
together when beginning the process of introducing first foods. If controversies
arise it is best to resolve these issues with a public health nutritionist.
Here are some tips for parents when introducing complementary foods:
<
<
<
<
<
<
<
<
<
<
<
Introduce new foods in a relaxed, unhurried time, early in the day.

Make sure baby is sitting up to avoid choking.
Offer breastmilk before solid food during the first year of life.
Offer new foods only one food at a time (no mixed foods like soup or stew or
a mixed grain cereal); if there is a reaction/sensitivity to a certain food it is
difficult to tell what may have caused it if combination foods are used.
Allow about a week between each new food (less critical if baby starts solids
after six months, as digestive system more mature).
Start with a small amount, about 5 mL ( one teaspoon) or less and increase the
amount gradually; feed with a small spoon.
A combination of foods can be offered as additional foods are introduced.
A baby who begins complementary foods at six months or older may not need
pureed foods. S/he may manage with mashed or finely chopped foods, which
can be moistened with water or breastmilk/formula.
An older baby e.g., 8 months of age, may prefer chunkier finger foods.
Try different textures to see what baby prefers.
Stay with the baby at all times while he is eating.
57
<
Keep mealtimes pleasant; allow the baby to stop eating when he is full and eat
only the foods he likes.
For more information refer to Babys First Year, available from Regional
Integrated Health Authority offices.
Commercial and Homemade Infant Foods
The decision on whether to use home prepared baby foods or commercial foods is
up to the parents of the infant. Both types of foods can provide the required
nutrients for the infant and young child. The smooth, uniform texture of the
commercial foods may, however, make the transition to family table foods more
difficult for some babies. Homemade foods allow parents to increase the texture
of foods as the infant improves her chewing and swallowing abilities.
Storing and Serving Infant Foods
Each child's food must be labeled with the child's name and date of opening, and
stored appropriately.
Before serving:
Remove from jar or container just the amount of food the baby will likely eat. Put
food into a feeding bowl. Don't feed from the jar/container. Food remaining in the
feeding bowl should be discarded, not put back in the jar/container.
If parents provide frozen home prepared food, thaw in the refrigerator, or as you
warm it (dish in hot water, egg poacher, or double boiler works well). (See Food
Safety)
If you warm infant foods, stir foods and test temperature before serving (food
should be just lukewarm).
Do not use a microwave to heat foods, as uneven heating may cause hot spots that
could burn a baby's mouth or throat.
58
Feeding Time: A Time for Closeness

Close physical contact during feeding is very important to the baby. It is best to
give the bottle while the baby is cradled in the providers arms. The baby should
be held in a semi-upright position during feeding. PROPPING THE BOTTLE IS
NOT PERMITTED IN CHILD CARE SERVICES. Propping a bottle or putting the
baby to bed with a bottle may cause the baby to choke. If the baby falls asleep
with the bottle in his mouth, it can cause tooth decay, and increase the chance of
ear infections. All infants should be fed individually, for health and safety reasons
and to ensure that each infant develops a warm and trusting bond with the primary
caregiver in the child care setting. Infants who require bottle feeding must be
fed by the same primary caregiver for at least three quarters (75%) of their
feedings during each day they are in attendance at the child care centre.
One to Two Years Old
Suggestions for snacks for infants and toddlers:
<
<
<
<
<
<
<
<
Grated raw vegetables and fruits, e.g., apple, pear, zucchini

Small pieces of soft fruit e.g., bananas, peaches
Unsweetened apple sauce
Plain or fruit yogurt
Cooked vegetable pieces
Small pieces of cheese
Toast pieces, rice cakes, whole grain crackers
Small muffins
For more on information on feeding 1 to 2-year-olds, refer to the booklet Feeding

Your Toddler, available from your Regional Integrated Health Authority office.
Page Revised 09/04
59
ORAL HEALTH - CARING FOR MOUTH, TEETH AND GUMS

A clean mouth and a nutritious diet can give a child a good start for a healthy life.
Child care providers can play a vital role in the promotion of good oral health habits
because they are both teachers and motivators.
With active support children and their parents can be helped to develop good
dental habits that will last a lifetime. Most dental disease is totally preventable.
Baby Teeth are Important
Baby teeth do start falling out around age 5 and finish about age 12, but they are
needed for proper eating, speaking and growth, and a nice smile. If a babys teeth
are badly decayed, pain and serious infection can result.
Mouth Care for the Infant and Toddler

Young children are NOT able to clean their own teeth. You must do it for them.
Around age two children want to copy you and should be encouraged to try, but an
adult must finish the job and make sure the teeth are thoroughly cleaned.
Most children have their first teeth by the age of six months, but cleaning a
childs mouth is recommended even BEFORE any teeth grow in.
THE INFANT
Start early. At the age of three months begin to wipe his or her gums gently.
The Steps Are:
< lie baby in a comfortable place
< make sure you can see into the babys mouth
< use a soft baby toothbrush or a clean damp wash cloth. Brush or wipe babys
teeth and gums.
< do not use toothpaste until the child has teeth
< use only a pea-sized piece of toothpaste on the toothbrush as young
children tend to swallow toothpaste. Swallowing fluoridated toothpaste
can lead to stains on the permanent teeth.
60
THE TODDLER
Toddlers will want to brush their teeth themselves and should be encouraged to
try, but an adult must finish the job and make sure teeth are thoroughly cleaned.
As children get older, they may not stay still while you are brushing their teeth.
To clean an older childs teeth, use only a pea-sized piece of toothpaste on the
toothbrush, stand behind the child, and gently cradle their head against your
stomach. This is comfortable for the child and allows you to see both upper and
lower teeth.
Use a child-size soft bristle toothbrush. Hold toothbrush at a 45 degree angle to
the childs teeth. Point the bristles to where the gums and teeth meet.
Use gentle circles. Do not scrub. Clean every surface of every tooth. For behind
the front teeth use the toe or front part of the brush.
Teething
Teething usually begins around age 6 months and is complete by age 3 years. If
the child is getting his or her teeth and seems to be in pain you can:
<
<
allow the child to chew on his or her own clean cool teething ring.
if the child is still unhappy the parent should consult with their dentist,
doctor or pharmacist.
Do not give teething biscuits as they contain sugar and can lead to tooth decay.
Early Childhood Tooth Decay - Baby Bottle Mouth
Early childhood tooth decay is very serious tooth decay in infants and young
children. This condition is caused by prolonged sucking on a bottle or frequent
intake of other liquids from other sources, e.g., a sipping cup, particularly at
naptime and bedtime in the absence of good tooth brushing.
The teeth most often affected are the top front or smile teeth. Drinks that can
cause cavities include milk, infant formula, juice and sugar water. The only safe
liquid is plain water. Sucking on a pacifier (soother) which has been dipped in a
61
sweetened liquid can also cause early childhood tooth decay.

If the baby tends to fall asleep while feeding clean the teeth before feeding,
especially at naptime or bedtime.
PREVENTION
< Avoid feeding excessive amounts of sugar
< Avoid filling the nursing bottle with sweetened liquids such as soft drinks,
syrup, fruit drinks
< Avoid sweet sticky foods during the day
< Do not allow a child to have a bottle or cup continuously
< Clean the childs teeth, especially at naptime and bedtime
Dental Safety
Here are some ways to protect the teeth and gums:
<
<
<
Always use properly installed child restraints in the car.

Babies will chew on almost anything. Keep hard objects that could damage
teeth away from babies.
Toddlers especially like to run. Do not allow small children to run or walk with
items such as toothbrushes or spoons in their mouths.
Mouth Care for the Preschool/Kindergarten Child

Preschoolers like to brush their own teeth and should be allowed to try in order
to learn the skill. A child who cannot tie his or her own shoelaces or has difficulty
cutting paper shapes with scissors will require help with tooth brushing. Let the
child start and have an adult check or finish up the job, depending on the childs
motor skills.
Tooth surfaces to check are the lingual (or tongue) side of the lower molar (jaw)
teeth, the cheek side of the upper molar (jaw) teeth and along the gum line of all
other teeth.
Note: red-looking gums can be a sign of poorly cleaned teeth. Persistent red or
swollen gums should be checked by a dentist.
62
Food and Teeth - Those Hidden Sugars

Good nutrition is the building block of healthy teeth in a healthy body. Any kind
of food that is high in sugar promotes tooth decay (cavities). Natural as well as
added sugar can cause tooth decay. Sugar causes problems because it feeds
germs (bacteria) in the mouth which then make a mild acid. The acid softens teeth
and eventually can make holes (cavities) in the teeth.
The damage depends on:
< how much sugar goes into the mouth
< how long it stays in the mouth - e.g., sweet sticky foods that get stuck on the
teeth, frequent sipping of juice between meals means the teeth are being
coated with sugar again and again.
< how clean the teeth are.
Tips to Help Reduce Sugar Damage
< Limit the number of times a day children eat or drink sweet foods. This
includes a range of items from sugary foods like jam to naturally sweet
nutritious foods like unsweetened fruit juice, and nutritious foods with added
sugar such as chocolate milk and pudding.
< Especially limit how often you serve sweet foods that may stick to the teeth
or stay in the mouth for a long time, such as raisins.
< If sweets are served, it is better to serve them at mealtimes (rather than
snack times) when there is more saliva in the mouth to help wash away sugars.
This is especially true for sticky sweet foods such as raisins or dates.
< Keep teeth clean, ensure the children brush after meals and snacks
Tooth decay occurs when sugar is present and teeth are NOT cleaned well enough.
REMEMBER CLEAN TEETH WILL NOT DECAY.
Labelling and Storing of Toothbrushes
<
<
<
each child must have his or her own toothbrush

toothbrushes should be child-size and have soft bristles
toothbrushes must be stored so they stay clean and open to the air. Bristles
must not come in contact with any other surfaces, especially with other
toothbrushes.
Page Revised 09/04
<
<
<
<
63
each toothbrush must be labelled with the childs name

use a toothpaste with fluoride for children 3 years of age and older
teeth should be brushed after each meal or snack
an adult should supervise tooth brushing and teach children the proper way
to brush teeth
Toothbrushes can be stored properly in a variety of ways, for example,

< on a rack or shelf that has individual slots and can be easily and effectively
sanitized.
< in containers used to hold test tubes labelled with the childs name. Once they
have air-dried, bristles of the toothbrush should be covered using toothbrush
covers that are well ventilated, allowing air to continue to circulate. Light
coloured, translucent or transparent toothbrush covers are best.
Note: Egg cartons or other cardboard containers should not be used to store toothbrushes. Using
egg cartons will introduce water and other nutrients to an impervious surface (the carton) which
can result in the survival and multiplication of bacteria, possibly disease causing bacteria. The
cartons cannot be cleaned adequately.
Each child should bring their own toothpaste to avoid cross-contamination.

Toothbrushes should be replaced every 3-4 months; when bristles become bent or
frayed they can no longer do a good job and may injure the gums.
Dental Emergencies
TOOTHACHE
<
<
<
If child is able to safely rinse without swallowing, have him/her rinse with
warm salt water or use dental floss to dislodge trapped food.
Apply cold compress to the childs face over the area that hurts.
Recommend parents take the child to a dentist as soon as possible.
BROKEN TOOTH
<
<
<
Rinse dirt from injured area with warm water.

Place cold compress on face in the area of the injury.
Call parents and recommend they take their child to the dentist. Bring piece
of tooth to the dentist.
64
TOOTH KNOCKED OUT - BABY TOOTH
<
<
<
Tooth CANNOT be put back in the socket

Find the tooth: If you cannot find the tooth, the child may have swallowed
it - recommend the parent take the child to see medical personnel.
If there is bleeding fold and place a clean gauze or cloth over the bleeding
area. Have the child bite on gauze with pressure for 15 minutes. This may be
repeated once; if bleeding persists recommend the parent take the child to
see a dentist.
BLEEDING AFTER BABY TOOTH FALLS OUT
<
fold and place a clean cloth or gauze over the bleeding area. Have the child
bite on the gauze with pressure for 15 minutes. This may be repeated once.
If bleeding persists recommend the parent take the child to see a dentist.
TOOTH KNOCKED OUT - PERMANENT TOOTH
<
<
<
<
Find tooth
Hold by top (not root), rinse under gently running water
Gently replace tooth in socket, have child bite on clean gauze to hold tooth
in place - call parent and recommend the parent take the child to see a
dentist IMMEDIATELY.
If you cannot replace the tooth, transport the tooth in a cup containing
milk. If possible place the cup of milk in a container of ice. Call parent
and recommend the parent take the child to see a dentist IMMEDIATELY.
Liquid Medications
Many liquid medications for children are sweetened with sugar. If a child must be
given medications while in the child care setting, care should be taken to clean the
mouth afterwards using a clean damp face cloth to wipe the gums of an infant and
brushing the teeth of toddlers and older children.
The Newfoundland and Labrador Childrens Dental Plan
Childrens Dental Plan provides subsidized dental care for children up to and
including age 12. This service is available at any dental office. For more
information suggest parents contact the family dentist.
Regular check-ups: Encourage parents to take the child to the dentist for the
first time after the teeth start to erupt and before age two.
SMOKING
Child care services, including in the outdoor play space and while children are
being transported, must be smoke-free. In addition, smoking in the presence
of children during off-site activities is not permitted. Smoking in family child
care is prohibited at times when the children are present. This includes
visitors to the home.
66
SAFETY AND INJURY PREVENTION

The Importance of Preventing Injuries
Injury is the leading cause of death and permanent disability among children in
Canada. Every year, one child in three is taken to a physician for treatment of
an injury.
Injuries do not occur because of fate, chance or bad luck. They are
predictable, and with an understanding of how they happen and some planning,
most injuries can be avoided. In this manual, therefore, the term accident will
not be used, because it suggests that harmful events are unplanned, unexpected
and random.
Falls are the leading cause of serious injuries in child care settings. Most
involve play equipment and sometimes stairs, windows and furniture.
Boys are usually involved in more active, physical play than girls, and thus, are
injured more often.
Providers face the challenge of creating a safe environment that also allows
children to learn by experimenting and testing their abilities. Minor bumps,
bruises and scrapes are part of a childs normal development. Providers need
to strike a balance between safety and the freedom to experiment. Knowing
when and where injuries may occur and then planning ahead to prevent injuries
is key. Use the following information to guide you in your planning.
Most Common Times for Injuries
<
<
<
<
<
<
<
if another child is sick or hurt and routine is disrupted, then other

children are likely to be hurt.
if providers are absent, busy or less watchful.
when providers underestimate a childs ability and forget to anticipate
the childs progress.
when children are tired and hungry (before lunch or at end of day).
when hazards are around.
during field trips.
when children or providers are new to a child care setting and not used
to surroundings.
67
The following major factors can contribute to injury prevention:
<
<
<
<
<
<
<
<
<
providers training in, and commitment to, injury prevention.

level of supervision.
the rules set for an activity.
the equipment used for an activity.
the childs cognitive and physical skills.
policies/ guidelines of the child care service.
safety culture in the child care setting (all providers recognize and accept
that safety is important).
the physical environment.
social interactions.
Implementing the following guidelines for prevention will reduce the number
and seriousness for all injuries:
<
<
<
<
<
<
<
<
<
<
<
safety education including:

< how to recognize hazards.
< how to reduce hazards.
< how to give first aid .
prevention involves anticipating possible injuries and learning from past
injury; the best prevention measures change the environment rather
than the actions of the child.
conduct regular safety checks.
assess new risks, e.g., new equipment, repairs, field trips.
provide adequate supervision.
establish rules for activities, use of equipment, etc, and be consistent.
The childs physical and cognitive abilities and the childs ability to follow
direction must be considered when establishing rules.
providers should be good role models for children.
ensure all equipment is in good repair or working order.
keep children away from other environmental hazards, e.g., traffic,
poisonous plants, water, toxic materials, etc.
teach children how to play safely and correctly.
acknowledge when children play safely.
68
General Safety Issues for Infants and Toddlers

Infants and toddlers have unique physical characteristics and needs that
require special attention and specific strategies. Skills and abilities are
changing rapidly at this stage (e.g., rolling over, climbing). From one day to the
next children can get into dangerous situations as they are now capable of an
action that they were seen as incapable of doing the day before. Never assume
that a child is too young to do something! Small children need to be watched
all of the time. Try to look at your child care setting from the eyes of an
infant or toddler. It is a good idea to get down on your hands and knees and
observe what children see. Note the potential hazards.
Infant furniture and equipment, including but not limited to, cribs, strollers,
high chairs, and car seats must meet specific safety criteria as outlined by
Health Canadas Product and Safety Branch. If you choose to use older
equipment, it is essential that it meets current standards. See also the Child
Care Services Policy Document for more information regarding appropriate
equipment.
Ground Fault Interrupters (GFI) or Ground Fault Circuit Interrupters (GFCI)
or alternate devices must be installed on all outlet circuits that are accessible
to children. Every effort should be taken to ensure that any alternate devices
used do not provide the potential for hazard, in particular, consideration should
be given to devices that can cause choking.
Specific issues to consider for infants and toddlers:
<
<
<
<
<
<
<
Infants and toddlers need lots of floor space to move about and explore;
ensure floors are free of cracks, splinters, and are not highly polished;
avoid area or scatter rugs.
Mobiles are not to be placed in cribs of infants who are able to pull up to
a sitting or standing position.
Use caution when changing diapers to prevent falls. Use safety belts, and
never leave a child unattended.
Avoid tables and furniture with sharp edges.
Secure furniture, as infants and toddlers will use it to pull themselves up.
Keep hallways clear.
Electrical cords and other cords should not be accessible; babies will chew
or bite cords causing severe burn or shock; cover outlets with sliding type
covers.
<
<
69
Supervise sleeping areas at all times.

Position cribs away from window blinds or window shade cords - cords must
be secured out of childrens reach.
Note: For information on Sudden Infant Death Syndrome and sleeping positions, see Infant
Section.
The licensee must have a policy with respect to childrens footwear to protect
them from slipping, injury, and to ensure safe evacuation in the event of an
emergency.
There shall be no drinking of hot beverages by adults in areas where children
are engaged in play activities.
Outdoors
Suitable clothing and appropriate protection must be available for children
during outside activities, for example, winter coat, boots, mittens, and hat in
winter, hat and sunscreen in summer. Each child should have her/his own
sunscreen for personal use. It is recommended that the centre have items
available for children in cases where a child may not have a particular item on
a given day, for example extra mittens, hat, scarf, sunscreen.
All appropriate safety gear (e.g., helmets for biking, elbow pads for roller
blading), is to be used for all activities where appropriate/necessary.
Sun Safety
The hot sun and warmer weather in the summer can be dangerous for children.
When children are protected from the sun during their childhood and teen
years their risk of developing skin cancer will be reduced. Extreme heat is
especially dangerous for infants and young children, as they are more likely
than adults to lose body fluids and become dehydrated. Children can be easily
burned in the sunlight or by touching hot surfaces, e.g., concrete, metal slides
and car doors.
Tips to protect the children in your care:
<
<
Limit time spent outdoors during the hottest part of the day(10am-2pm).
Ensure that outdoor play areas have shaded section; choose parks with lots
of shade; always set up outdoor play activities under a tree or in the
70
<
<
<
<
<
<
<
<
shaded area.
Use a sun block cream with a sun protection factor(SPF) of at least 30
applied to the childrens skin 30 minutes before they go outside; apply
enough so that the skin appears wet. Reapply every few hours because it
can rub off easily. Pay close attention to ears, nose and tops of feet.
Reapply sun block cream if children are playing in the water.
Note: Sun block cream is not recommended for babies under 6 months
of age as they can rub it in their eyes and mouth.
Encourage parents to provide broad spectrum sunglasses for the children,
as too much glare from the sun can damage childrens eyes.
Encourage children to wear wide brimmed hats and long-sleeved shirts at
all times, even when swimming.
Ensure water for drinking is available at all times - before, during and
after outdoor play.
Watch for signs of heat exhaustion - pale, clammy skin, heavy perspiration,
fatigue, weakness, dizziness, fainting, headache, muscle cramps, nausea
and/or vomiting. If any of these symptoms are observed you must move
the child to a cool, shady area, replace lost fluids by giving sips of water,
gradually cool the child by removing clothing and fanning constantly and
treat the child as you would for shock, which is, lay the child down, elevate
his or her legs about 20 cm. (8 in), comfort and reassure the child,
encourage regular full breaths and continuously check to see if the child
remains conscious.
Observe children in wheel chairs closely when they are in the sun, as the
vinyl and metal can become very hot; if they are wearing shorts their legs
can be burned easily.
Remember that cloudy days can produce serious sunburns.
Keep infants under one year of age out of direct sunlight. They should
wear a broad-brimmed hat and loose-fitting clothing covering arms and
legs.
For more information on sun safety go to:

www.cfc-efc.ca/docs/cccf/rs020_en.htm
71
Water Safety
Water, such as a sprinkler or wading pool is an ideal, fun way to keep cool
during the warm summer months. However constant supervision is required.
Never leave a child unattended in a wading pool, even for a moment. Always
empty childrens portable wading pools and turn upside down when not in use, as
when turned upright they can fill with rainwater. Store out of reach of
children.
A pool in the outside playspace of a child care service can be major safety
hazard and must meet safety requirements:
<
<
<
Adhere to local regulations and codes.

Ensure that private pools are surrounded by a fence that is at least 1.5
metres (5 ft) in height with a self-closing, self-locking, child proof gate,
accessible only by an adult; the fence slats should be less than 10 cm(4 in)
in width.
Ensure that pool coverings do not collect rain water.
Insect Bites
Insects can present a safety and health hazard for children. Some insects,
such as bees and wasps can cause serious allergic reactions in some children.
Bites or stings can be extremely painful to the child.
Tips for preventing insect bites in the child care setting:
<
<
<
<
Keep garbage well away from play areas as it can attract insects, especially
wasps.
Avoid serving sweet foods, such as fruits and juices, outside as they
attract stinging insects.
Encourage children to clean up quickly after serving snacks or picnics
outside.
Remind children that getting too excited and thrashing about will increase
the chances of being stung by insects. Tell children to stay calm and be
still if they come close to a stinging insect.
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Guidelines for the Application of Personal Insect Repellent:
'
'
'
'
'
Check with parents about the type of insect repellent they would like you
to use with their child.
Do not use products with more than 10% concentration of DEET on
children under 12 years of age.
Do not apply insect repellent containing DEET more than three times per
day.
Do not use insect repellents containing DEET on infants under 6 months.
If insect repellent is to be applied on children aged 6 months to 2 years:
the least concentrated product should be used (less than 10%
concentration of DEET)
apply the product sparingly and do not apply to the childs face or hands.
apply the product only once per day and only when necessary.
For more information on the safe use of personal insect repellents, see the
brochure entitled Safety Tips on Using Personal Insect Repellents available
from Health Canada. Their website address is www.hc-sc.gc.ca.
Winter Safety
Canadian winters can be long and cold. It is important that children are given
every opportunity to play outside safely and comfortably. The key to being
comfortable is ensuring that children are dressed appropriately for the
weather. If children are too warmly dressed they will sweat and become
chilled, increasing the risk of frostbite.
Tips for preparing children for outside play in the winter:
Dress children in layers, e.g., socks or legwarmers over tights; a hat under
a hood, fleece shirt with cotton turtleneck underneath.
Make sure heads are well covered, as most of our body heat is lost through
the head.
On days when the snow is very wet, a splash suit over a snowsuit keeps the
children drier.
A sun block cream may be needed on sunny days in the winter; sunlight
reflects off of snow.
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Make sure scarves are tucked inside coats or snowsuits and hoods are
tied snugly around faces; tuck drawstrings inside. A child can choke
easily if a scarf or string gets caught on play equipment.
Teach children not to lick metal objects in cold weather, as the tongue or
lips will freeze to the metal.
Keep a close eye on the wind chill factor regardless of the natural
temperature as wind chills can be very dangerous. Exposed skin can freeze
in minutes. It is too cold for children to play outside when the wind chill
factor is greater than -28C (-15F) and/or if the temperature is below 25/C, regardless of wind chill factor.
Safety for School Age Children

Many school age children spend a lot of time outdoors in active play. They want
and need independence and responsibility. Here are a few ways to help protect
them from some of the risks of the street:
Bicycle injuries are very common and mostly due to not wearing a helmet.
Make sure that the provider knows the skill level of the child and insist
that they wear a Canadian Standards Association (CSA) approved bike
helmet. Make a rule that children must be at least 9 years of age to ride
their bicycle on the street. If children will be riding bicycles then the
child care provider must have parental permission, in writing, stating that
it is permissible for this to happen.
Skateboards and in-line skating are other hobbies that result in injuries.
Be sure children are over 5 years old and that they wear CSA approved
bike helmet, elbow, wrist and knee pads. If children will be using
skateboards or in-line skating while at the child care setting then the child
care provider must have parental permission, in writing, stating that it is
permissible for this to happen.
Encourage children to use only playgrounds and paths built for

skateboarders, not streets and sidewalks.
Ensure that you talk to the parents about the kind of supervision required
for their child after school. See the related Child Care Services
regulation and policy for more information on the types of supervision
required for school age children.
School bus accidents getting on or off the bus are another potential risk
for school age children. Ideally children should be taken to and from bus
stops.
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Plants
Plants are one of the leading causes of poisoning in children. Several of the
most common house plants, such as caladium, dieffenbachia, elephants ear,
philodendrum, poinsettia, and Jerusalem cherry are poisonous. Common garden
plants such as daffodils, lily of the valley, holly and oak chestnut are also
poisonous to some extent. When deciding on what type of plant to include,
check out the list of plants known to be toxic (poisonous or possibly dangerous
to humans). Often a large quantity of the plant would have to be ingested to
cause toxicity, however a variety of symptoms, such as stomachache, skin rash
and more serious swelling of the mouth and throat can develop even with
minimal exposure.
It may be a challenge to eliminate all poisonous plants in a child care setting,
especially in a home, however child care providers can take steps to prevent
exposure:
Always supervise infants and young children closely especially in outdoor

gardens or parks.
Keep poisonous houseplants out of reach of infants and young children.
Store bulbs and seeds out of sight and reach.
Keep children away from all plants and ensure that they do not put parts
of plants such as leaves, stems, bark, seeds, nuts or berries in their
mouths.
Do not assume that plants are not poisonous if animals or birds are eating
them.
Teach children not to touch plants or place their mouths near plants or
other bushes.
If it is necessary to take a child to the emergency department, bring along
a sample of the plant.
For immediate information on poison emergencies call:

The Poison Information Centre at the Janeway Child Health Centre, St.
Johns 722-1110
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Pets
Children gain much from interactions with animals, however, having pets in a
child care setting requires that precautions are taken. You must also consider
that many children and providers can be allergic to animal fur, hair, saliva, or
dander. Even if no one has a reaction when a pet is first brought into the area,
a child already in the group may develop an allergy after continued exposure.
Pets in a child care centre should be kept in a locked cage in order to

prevent unsupervised contact with children.
The following list of animals are never appropriate for child care settings
and are therefore known as restricted animals: Turtles, newts, rabbits,
snakes, monkeys, parrots and wild animals.
If animals are living on the premises, providers must follow these procedures:
Inform parents before their child is enrolled if an animal is present at the

child care service, or if an animal is obtained after the childs enrollment.
If you have a restricted animal on your premises (see list above), it must
be kept in a room that the children do not have access to.
Children must always be closely supervised with pets and should never be
left alone with animals.
Ensure only adults clean and maintain the animals living quarters in order
to protect children from contamination.
Ensure all pets are healthy and have current vaccinations and/or health
records. Regular contact with a veterinarian is important.
Do not allow pets to sleep with children.
Ensure children and adults wash their hands after feeding and handling
animals.
Keep animal food, dishes and cat litter boxes out of childrens reach.
If the animal stays outside throughout the day it must be kept in an area
inaccessible from the childrens outdoor playspace.
If livestock is present, children should not have easy access to barns and
corrals.
Tick and flea collars should not be used in homes with very young children.
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Risks and Responsibility

Providers who are contemplating having a pet in the child care setting should
consider the following risks and responsibilities:
Small children may intentionally or unintentionally abuse animals.

Animals, even those normally very gentle, may bite if harassed. Animal
bites may lead to infection.
The presence of a pet represents extra responsibility. Litter boxes and
cages must be changed and cleaned on a regular basis, or they will cause
contamination. If the animal escapes, it can soil the play area.
If at a child care centre, care of the animal will be required on weekends
and holidays.
If an animal becomes ill, the illness may be infectious to humans.
It is reasonable to expect that a pet in family home care will not be confined
to one room of the house for the entire time that children are present in the
home (unless it is a restricted animal as listed above). Pets may be in contact
with the children throughout the day. It is especially important for providers
to follow the above recommendations carefully in these situations.
What Providers Can Teach Children about Pet Safety
Never approach a strange animal unless an adult is present and says it is

safe.
Use caution around a sick, hurt, sleeping, eating or agitated animal.
Keep your face away from an animals mouth, beak or claws.
Let animal make first move.
If a strange hostile animal comes across your path, keep still; avoid looking
directly at the animal; drop any food and move away slowly.
Never try to stop animals who are fighting.
Reporting Injuries
Note: See Incident/Injury Report
Along with the other required information, the provider must include in the
incident/ injury report factors that might have played a role in the event, such
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as:
the childs behaviour.

the level of supervision.
the surrounding conditions.
the condition of the equipment or toys.
the time of day.
the location.
a change in the routine.
This information can be provided in the areas of the report that ask for a
description of what happened. For more information on how to fill out an
incident/injury report see this report in the Records section.
The completed incident/injury report is to be submitted to the operator of the
child care setting to be kept on file, with copies being given to the parent and
the Regional Child Care Services Staff.
Once providers determine the factors involved in an injury, steps can be taken
to prevent future injuries. These steps might involve all or several of the
following:
changing the level of supervision.

setting precise limits for a particular child.
re-evaluating the rules for an activity.
repairing, replacing or eliminating equipment.
redesigning the physical space.
adding safety features to the equipment, for example, additional energy
absorbing material at the base of the slide.
using play equipment in another playground.
additional training for providers.
establishing policies/ guidelines.
How to Prevent Choking

Here are some ways child care providers can prevent choking:
(Note: See also Food and Choking in Nutrition Section)
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Toys
Purchase toys and materials that are appropriate for the childs age and
level of development.
Inspect toys and equipment regularly for small parts that may break off,
such as eyes on stuffed animals, buttons on doll clothes or plastic
accessories on small figures. Remove either the faulty toys or loose parts
if you find them.
Balloons
Latex balloons are not permitted in a child care service. They are a serious
choking hazard and a potential allergen. Children under four years of age can
inhale a balloon while attempting to blow it up. When they burst, they can
break into many small pieces, which children may then put in their mouths or
even their noses, inhaling them.
Foil balloons (the type that are filled with helium) are safe for all ages. Once
foil balloons are deflated, providers need to discard them properly, as they
pose a suffocation hazard, just like plastic bags.
Eating Utensils
The safer utensils are made of either metal or hard plastic. Foam cups and
plastic utensils, which are usually used for picnics or take-out foods must not
be used. They are easily broken and children can choke on the pieces.
Food or treats on a wooden or plastic stick, i.e., frozen treats, lollipops, pogo
sticks also present a potential choking hazard.
Other
Keep coins, buttons, batteries, jewellery and other small objects out of reach
of small children.
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Safety Checklists
Government Services Centre inspectors conduct Fire and Life Safety
inspections on a regular basis. Child Care Services staff and/or Home Visitors
also conduct inspections of child care services regularly, including for health
and safety issues.
These checklists are provided to assist in checking the child care environment
for safety. They are not all inclusive, but are intended to provide information
regarding a number of the areas that must be checked on a regular basis.
Indoors
GENERAL ENVIRONMENT
Floors are smooth and skid proof.
Area and scatter rugs are not recommended. They can cause a person to
trip or slide. Tape any loose rugs in a home to floor.
Pipes and radiators are not in childrens reach or are covered to prevent
contact.
Keep floor area free of spills, clothing, toys, etc.
Hot tap water temperature for handwashing is (43C) (110-115F) or less.
Three-pronged plugs have not had ground plug removed.
Electrical cords are out of childrens reach and out of the line of traffic.
Watch cords hanging over counters or tables.
Unused extension cords are unplugged and out of reach.
Unused electrical outlets are covered by outlet covers.
Medicines, cleaners, and aerosol sprays are kept in a locked place where
children are unable to see or reach them.
Purses or other carry-alls, diaper bags, knap sacks and tote bags should be
kept out of reach of children.
All windows have screens that stay in place. Move furniture away from
windows.
Window blinds or window shade cords should be tied and secured with
safety hooks; children have been strangled on these cords.
Windows can be opened up 10 cm or 4" or less from the bottom and should
be securely fastened when raised. A window screen alone will not stop a
child from falling out.
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Furniture and shelves should be free of sharp edges and splinters and in
good repair; ensure that they are firmly anchored if there are infants and
toddlers who will try to pull themselves up.
Drawers should be kept closed to prevent tripping or bumps.
Keep chairs and other easily climbed items away from windows, cabinets
and shelves.
Walls and ceilings are free of peeling paint, and cracked or falling plaster;
centre has been inspected for lead paint.
Locks on doors can be easily opened by adults but not by children.
Providers should remove or firmly attach items which the child can pull
down e.g., heavy furniture, televisions, lamps, bookcases.
All clear glass panels in traffic areas should be made of safety glass and
have colourful decals to make them more noticeable to children.
Avoid falls on wet floors by keeping water play areas and entrances dry.
Fire extinguishers are securely fastened but easy for adults to access.
Family child care providers should walk through the house and look at it
from a childs point of view; crawl on the floor and see what hazards are
present for children, include the basement, garage and storage area.
Look for any sources of water in outdoor spaces that may create hazards
e.g., pails of water, ponds, ditches, rivers, hot tubs.
Ensure that dangerous products are stored in a safe place e.g., cleaning
products, insecticides, children and adult medications, vitamins, perfumes,
liquor and tobacco.
Close off or contain fireplaces or wood stoves.
Do not allow younger children into washroom and laundry rooms.
Guns such as BB and air rifles should not be allowed on premises of child
care settings; in a family home never leave guns loaded, keep ammunition
in locked cupboards, trigger lock, remove firing pins on souvenir collector
guns.
Avoid table cloths and hanging plants that are accessible to young children.
EQUIPMENT AND TOYS
Toys are age appropriate and suited to the abilities of the child.
Toys and play equipment are checked often for sharp edges, small parts,
sharp points and parts that are not well attached e.g., stuffed animals or
dolls limbs.
Toy parts should have diameters greater than 4 cm (1 in) to avoid risk
of choking.
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No toy accessible to young children should have strings or cords longer

than 15cm. or 6 inches.
Cover hinges and joints to prevent fingers from being pinched or caught.
All toys are painted with non-toxic paint.
Toys are put away when not in use.
Toy chests have lightweight lids or no lids.
Art materials are non-toxic.
Art materials are stored in their original labelled containers in a locked
place.
Check labels on toys and equipment for age recommendation and any
warnings or safety advice.
Promptly repair or discard broken toys.
Inspect toys regularly and carefully, and if in doubt about their safety,
throw the toy out or send an unsafe toy to Health Canada.
Check wooden toys carefully to ensure free of splinters.
Large or heavy stuffed animals may suffocate a child under three or allow
the child to crawl out of a crib.
Avoid hard plastic toys that break easily.
Do not provide propellant toys such as rockets or dart guns.
Equipment such as VCRs, and computers are put away when not in use.
Curtains, pillows, blankets, and cloth toys are made of fire resistant
material.
Encourage and teach children how to play safely with toys.
Teethers and Toys with Polyvinyl chloride (PVC)

Polyvinyl chloride (PVC) is a type of plastic which is often used in the production
of childrens toys such as bath toys, squeeze toys and teething rings. It is a
naturally hard substance. Harmful chemicals are added to the PVC to change
its characteristics. Phythlates are added to make the toys more soft and
squishy. Lead and other heavy metals are added to make the toys more durable.
These harmful substances can leach out of the PVC plastic exposing infants and
young children to serious health risks. Health Canada has decided to remove
additives in vinyl teethers, teething rings and rattles. However, the majority
of plastic toys sold in Canada are exported from Asia where PVC is still widely
used. It is difficult to identify toys with PVC. It is best to choose fabric
teethers, wooden toys with non-toxic paint and hard plastic toys. Visit Health
Canadas web site for a list of safe teething toys.
http://www.hc-sc.gc.ca/english/protection/warnings/1998/list.html
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( PVC is also found in mini-blinds. Lead is added to stabilize the plastic in the
blinds. As the blind ages with exposure to sunlight and heat, the lead dust can
form on the surface of the blind. Lead exposure is a serious health issue.
Exposure to lead can cause neurological damage in young children. Health
Canada has advised that these blinds be removed in child care settings or
homes with pregnant women and young children. Lead-free mini-blinds are
available.)
HALLWAYS AND STAIRS
Supervise children in halls and stairways.

Stairs and stairways are well-lit and free of boxes, toys and other clutter.
Providers are able to watch for strangers entering the building.
Closed doorways to unsupervised or unsafe areas are always locked unless
this prevents emergency evacuation.
KITCHEN
If children are in the food preparation area of the kitchen they must be
constantly supervised.
Garbage is stored away from areas where food is prepared and stored.
Garbage is not stored near the furnace or hot water heater.
Pest strips are not used; if pests are noticed, contact public health
inspector.
Non-perishable food is stored in labelled, insect resistant containers such
as metal or plastic. Perishable food is stored in covered containers in the
refrigerator.
Electrical cords are placed where people will not trip over them or pull
them, e.g., over counter edges; unplug cords when not in use.
There are no sharp or hazardous cooking utensils within childrens reach
(e.g., knives, glass).
Cooking equipment and appliances are out of reach of children.
Cleaners and other poisonous products are stored in their original
containers away from food and out of childrens reach.
Food preparation surface and eating utensils are clean and free of cracks
and chips.
Pot handles are always turned in towards the back of the stove.
Dishes should be in good condition and not cracked or chipped.
Do not carry hot foods or liquids when children are near.
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Store unopened glass pop bottles in a locked cupboard as they can break
easily and explode.
Use special latches, locks or safety devices to make storage areas
inaccessible to children.
Plastic bags should be stored in a secure drawer or cupboard as they pose
a suffocation hazard.
Be sure fire extinguishers are checked routinely and are located close to
exit doors.
Fire extinguishers should be easy to reach.
All providers know how to use the fire extinguisher correctly.
Watch for spills and drips.
WASHROOMS
Young children should always be supervised in washrooms; they should

never be left alone near water. Infants and toddlers have poor balance
and have drowned in less than 4cm (1 in) of water in 5 minutes.
Stable step stools are available when needed.
Electrical outlets are covered with outlet covers.
Electrical outlets in washroom, kitchen and outdoors should be protected
by Ground Fault Interrupter Circuitry(decreases chance of electric
shock).
Cleaning products, soap, and disinfectant are stored in a locked place in
original containers, out of childrens reach.
Floors are smooth and are skid proof.
Watch for spills and drips - wet floors.
The trash container is emptied daily and kept clean.
Hot water for handwashing is no more than 43 C( 110-115F.)
Washroom doors that can be locked by children should be designed to
permit adults to enter easily.
Outdoors
Children love playing on swing sets, jungle gyms, ride-on toys, playhouses,
climbers and the like. However, if not properly assembled, installed or
maintained, they can cause injuries; and, of course, even the best-designed and
maintained structures can be hazardous if children are not supervised or taught
some basic rules about their proper use. Please read the following checklists
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and make sure that play structures are safe for children in your care.
Children are naturally inquisitive. They love to explore their physical
surroundings, test limits and see how far they can get. Exploring the outside
environment is important to their healthy development. Adult supervision is the
key aspect of any safety program. Develop a safe environment where children
can live and play comfortably and safely.
ASSEMBLY IS CRUCIAL
Assemble and install equipment in strict accordance with the

manufacturers instructions. If the instructions are not clear, contact the
manufacturer or dealer. If it isnt put together properly, it could break
and cause injury.
Keep your instruction sheets. You may need them to make repairs or order
parts.
Making changes to the equipment without the manufacturers approval
could make the structure unsafe.
Make sure that all nuts and bolts are tight.
Remove or cover any sharp points or edges. Any bolt that extends beyond
the nut should be replaced with a shorter bolt, or covered with an acorn
nut or plastic cap.
See that all tent pegs, stabilizer bars, etc, are level with ground or easy
to see so children dont trip.
Adjust the height of swing sets so that children can get on and off safely.
Be sure to leave enough space from the ground, and in front and behind to
allow safe movement of a childs legs and feet while swinging.
Swings should have no open-ended or S-shaped hooks. Closed hooks are
necessary.
Ensure that swing sets, slides and climbing equipment are securely
anchored.
Make sure that no part of a play structure could trap a childs head or
limbs.
Seesaws should have wooden blocks or rubber tires placed on the
underside of the seats to prevent feet from getting caught.
Garbage containers should be anchored and away from equipment and play
areas.
Boundaries of play areas should be clear to both adults and children.
Play areas for active play (e.g., bike riding, running games) are separate
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from areas for other activities (e.g., sandbox, outdoor tables).

Swing sets should be located a safe distance from fences, trees, houses,
electrical wires or other obstacles. They should also be placed a safe
distance from other play equipment so children dont collide.
Remember that slides can become too hot for safe use. Place them in the
shade or facing away from the sun.
Sandboxes should be located in a shaded spot; should have proper drainage
and should be covered at night to protect from moisture and animal feces.
If animal feces is found in the outdoor sand area, the feces is to be
removed and properly disposed of as well as the sand from a 12" radius
from the area where the feces was found. If the animal stool is loosely
formed, then the entire amount of sand in the sand box is to be removed
and replaced with clean sand. Sand should be raked at least every two
weeks to check for debris and provide exposure to the air and sun.
Fences are essential in back gardens or outdoor play spaces. Fences
should be 1.2 metres (4 ft.) high and have gate locks on the outside so that
children can not reach them.
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Protective Surfacing Requirements

All equipment should be located on a surface which will lessen the impact of a
fall - for example, coarse sand, pea gravel, CSA approved manufactured
surfaces. The area should be kept free from broken glass or other sharp
objects, garbage, animal feces or other debris. Rake surfaces weekly to
prevent them from becoming compacted and hard. A child only needs to fall
three feet to a hard surface to suffer a fatal head injury. The following table
details the required depth of protective surfacing material found under
playground equipment.
Table 1
Critical Heights of Tested Materials*
Uncompressed Depth**
Compressed
Depth**
Material
150 mm (6
in.)
225 mm (9
in.)
300 mm (12
in.)
225 mm (9
in.)
Wood Chips
2.1 m (7 ft)
3 m (10 ft.)
3.3 m (11 ft.)
3 m (10 ft.)
Double
Shredded
bark mulch
1.8 m (6 ft.)
3 m (10 ft.)
3.3 m (11 ft.)
2.1 m (7 ft.)
Engineered
wood fibres
1.8 m (6 ft.)
2.1 m (7 ft.)
3.6 m (12 ft.)
1.8 m (6 ft. )
Fine sand
1.5 m (5 ft.)
1.5 m (5 ft.)
2.7 m (9 ft. )
1.5 m (5 ft.)
Coarse sand
1.5 m (5 ft.)
1.5 m (5 ft.)
1.8 m (6 ft.)
1.2 m (4 ft.)
Fine gravel
1.8 m (6 ft.)
2.1 m (7 ft.)
3 m (10 ft.)
1.8 m (6 ft.)
Medium
gravel
1.5 m (5 ft.)
1.5 m (5 ft.)
1.8 m (6 ft.)
1.5 m (5 ft.)
Shredded
Tires
3.6 m (12 ft.)
N/A
N/A
N/A
*With the permission of Canadian Standards Association, material is reproduced from CSA
Standard CAN/CSA-Z614-98, Childrens Playspaces and Equipment which is copyrighted by
Canadian Standards Association, 178 Rexdale BLVD., Toronto, Ontario, M9W 1R3. While use of
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this material has been authorized, CSA shall not be responsible for the manner in which the
information is presented, nor for any interpretations thereof.
** Results of tests conducted by the United States Consumer Product Safety Commission
(CPSC), according to ASTM F 355 test method.
Note: Maintenance is integral to the reliability of surfacing materials.

For points to consider when deciding on which type of protective surfacing
material to use, please refer to Appendix A - Recommended Protective
Surfacing.
MAINTENANCE IS A MUST
<
<
<
<
<
<
Plastic parts take an additional beating in the summers sun and winters
cold. Check all plastic parts carefully and frequently - especially those
parts designed to support a childs weight. You can often buy replacement
parts such as swing seats, slide tops, ladder rungs, bolt caps, tube endcovers, etc. from local dealers or from the manufacturer.
Chains for swings, trapezes, rings, and hand holds, etc. should be checked
frequently for smooth functioning and for signs of wear, weakness or rust.
Replace them when necessary. You can purchase plastic protective covers
for chains. This will prevent fingers from becoming caught in the loops.
Use non-toxic paints when repainting any childrens product. Take care of
rusted parts as soon as possible.
Check all nuts and bolts regularly to make sure that they are tight.
The surface of slides should be smooth and show no wear and there should
be no gaps, pinch points, or rough edges in the sliding surface.
Maintenance of protective surfacing materials is essential. If the
required depth of surfacing materials is not maintained then these
surfaces are not considered safe.
ADULT SUPERVISION IS ESSENTIAL

Providers should be familiar with the most current edition of Canadian
Standards for Childrens Playspaces and Equipment (CAN/CSA Z614). This
standard provides requirements for playspaces and equipment intended for use
by children aged 18 months to 12 years. It is generally accepted that children
younger than 18 months and children aged 13 years and older do not usually use
the equipment covered in this standard. This standard does not apply to
homemade or child-constructed equipment and play equipment intended for
private backyard use.
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In supervising playgrounds, the number of providers assigned will depend on the

risk associated with a particular activity. For example, extra providers may be
required to supervise swings, slides and other similar equipment.
In addition to watching the children allowed on the equipment, children too
young to use the apparatus should be kept off and out of danger. It is
recommended that providers have a first aid kit available at the playground,
and record all playground injuries requiring first aid. The key to an everimproving injury control strategy is to carefully review how injuries happened.
<
<
<
<
Remember that loose clothing, hats with chin straps, draw strings, bike
helmets, ponchos, scarves, and jewellery can get caught on equipment.
Make sure that children in your care are dressed appropriately.
Preschoolers need constant supervision and should never be left alone on
play structures. Older children often try to make equipment more
challenging and use it in unexpected and unintended ways. They also take
risks as they develop their physical skills. As this kind of misuse results
in a large number of injuries, play rules are very important.
Swing sets with back supports and safety bars should be used for young
children or children with disabilities.
A source of clean drinking water should be provided in the play area.
Teach Children How to Use Playground Equipment With These
Guidelines for Safe Play
Remind children that they are to:

< Avoid walking in front of, between or directly behind moving parts.
< Keep fingers away from moving parts.
< Use feet first when sliding. Never run up and down slide beds or slide down
head first.
< Remember that equipment is slippery when wet! Slick surfaces can cause
serious injuries. Wait until structure and clothing are dry.
< Always hold onto handgrips or rails.
< Sit on swings - never stand on swings or jump off them while they are
moving.
89
Providers must remember that:

< Children sometimes have difficulty judging distance and what can be
considered a safe height. When helping a child judge what can be
considered a safe jumping height, factors such as the landing surface, and
the childs age and ability must be taken into account.
< They are not to lift younger children to unsafe heights.
< They must ensure that riding toys are stable and well balanced
< Children riding bicycles, tricycles, and similar wheeled toys must always
wear a CSA approved bicycle helmet.
< Play equipment is designed for a specific number of children at any one
time. Make sure that children do not exceed this number.
< Riding downhill is dangerous. A tricycle can pick up so much speed that it
becomes almost impossible for a child to stop.
< Riding toys are to stay off sidewalks and streets.
< Children should not be lifted on and off equipment. They should be able
to get on and off themselves. If they are not able to do this then the
equipment is probably not developmentally appropriate for that particular
child.
Transportation Safety
Children require appropriate car restraints to protect them when being
transported to and from the child care setting. Motor vehicle crashes are the
number one cause of death and injury of young children. Children tend to fly
into things head first in a collision or sudden stop. Make sure that the
restraint system is appropriate for the child and used correctly.
All requirements of the Highway Traffic Act must be adhered to when
transporting children. See the relevant Child Care Services Policy document,
which outlines the transportation requirements in child care.
Emergency Preparation
<
<
<
All providers should understand their roles and responsibilities in case of

emergency.
All providers must be certified in First Aid.
First Aid Kits (see below) are checked regularly for supplies and kept
where they can be reached easily by providers when needed.
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<
<
<
<
<
<
<
<
<
<
<
<
<
Easy access to phones in case of emergency; a cordless phone is ideal

especially when caring for infants and toddlers. A cellular phone is ideal
for field trips.
Childrens emergency phone numbers must be readily accessible at the
child care setting and during field trips.
Include address and phone number of child care setting on a label near
phone.
Family child care providers and centres with one staff person must have
name and contact number for the emergency replacement in the case of
an emergency.
Smoke detectors and other alarms are checked at least once a month to
make sure they are working. Batteries should be changed yearly.
Each room and hallway has a fire escape route posted in clear view.
Fire drills are carried out monthly.
The required number of functioning fire extinguishers is accessible and all
are fully pressurized.
All exits are clearly marked and free of clutter.
Emergency procedures are practised.
Have policies for notifying parents of emergency situations and for
reporting injuries.
Develop plans for specific emergency situations which include:
- providers responsibility
- evacuation routes
- emergency accommodation
- hospital to be used
- emergency transportation
S alternate location if the home or centre cannot be re-entered.
Ask parents to sign Consent for Emergency Care and Transportation form
and familiarize themselves with child care services emergency policies and
procedures.
91
First Aid Kits

The Child Care Services Regulations require first aid kits meet the
Occupational Health and Safety First Aid Regulations under the Occupational
Health and Safety Act (O.C. 96-478)
All child care services must have a Pocket First Aid Kit containing:
1 - 15 ml container of sterile eyewash
1 - 50 ml bottle Dettol, merthiolate or other approved antiseptic
1 - 5 cm by 5 m roller bandage
1 - 5 cm compressed bandage
2 - 5 cm by 5 cm sterile gauze pads
12 - 2.5 cm x 7.5 cm adhesive dressings
1 roll 1.25 cm by 2.3 m adhesive plaster
6 safety pins
1 metal or plastic box container
In addition,
Child Care Centres must have a First Aid Kit as outlined in Schedule C:
#2 First Aid Kit
EQUIPMENT
1 emergency first aid safety oriented manual
1 first aid record book
12 safety pins
1 splinter tweezers, blunt nose
1 pair scissors, 10 cm
DRESSINGS (Each item to be individually wrapped to maintain sterility.)
2 sterile bandage compresses, 10 cm x 10 cm
16 sterile pads, 7.5 cm x 7.5 cm
16 sterile adhesive dressings, 2.5 cm x 7.5 cm
6 - triangular bandages, 95 cm x 95 cm
ADHESIVE TAPE - 1 roll - 2.5 cm x 5 m
ANTISEPTIC - 100 mL bottle peroxide
92
Family Child Care Homes must have a First Aid Kit as outlined in Schedule B:
#1 First Aid Kit

EQUIPMENT
1 emergency first aid safety oriented manual
1 first aid record book
12 safety pins
1 splinter tweezers, blunt nose
1 pair scissors - 10 cm
DRESSINGS (Each item to be individually wrapped to maintain sterility.)
2 sterile bandage compresses, 10 cm x 10 cm
12 sterile adhesive dressings, 2.5 cm x 7.5 cm
12 sterile pads, 7.5 cm x 7.5 cm
4 - triangular bandages, 95 cm x 95 cm
ANTISEPTIC - 100 mL bottle peroxide
ADHESIVE TAPE - 1 roll - 1.25 cm x 2.3 m
The kit requirements as outlined above are as per the Occupational Health and
Safety First Aid Regulations. A service may wish to add the following:
two pairs of disposable gloves

two coins (25) for telephone
note cards and a pen
a flashlight
1 splint
1 roll 3" kling bandage
index card with telephone number

and address of child care service
1 elastic tenser bandage - 3"
bandages (assorted sizes)
1 package sterile hand wipes
2 eye pads and eye cup for

bathing
In addition, if a child has a long-term illness, you may need to include other
supplies in your kit. A child with severe allergy or asthma may require
medication. For the child known to have life threatening allergies, adrenalin
must be available at all times (Epi-pen). Children with other long-term care
conditions, such as Diabetes, may require other supplies or treatments.
Providers are responsible for having necessary food or drinks available for the
specific child.
Check and refill the contents of the First Aid Kit monthly and before each
field trip. All kits must be labelled and kept out of reach of children. Suitable
containers for first aid supplies are light weight and waterproof.
93
ACTIVE LIVING
Active living is an important component in the lives of all children and adults.
Childhood is the perfect time to acquire active living skills and to develop the
enjoyment that active living brings. It has been demonstrated that children
who are more active have better attitudes toward health, more positive health
benefits, and are more fit. For more information on active living and for ideas
on how to encourage active living in a child care setting, please see the relevant
Child Care Services Program Guide(s).
95
SEXUALITY IN CHILDHOOD
Children are sexual persons. Their experience of sexuality and their sexual
behaviours change as they grow. Children need information about sexuality
throughout childhood. As they get older children learn by the many influences
surrounding them. Some may have difficulty trying to sort out the many
confusing messages they receive throughout their childhood years. Parents and
providers can help children learn about their sexuality by encouraging open
communication from early on in their life.
Children start asking questions as young as 2 years of age. They tend to ask
the same questions at 3, 4, and 5 years of age and so on. As they are able to
use concepts and generalize information, parents and providers must:
1.
2.
3.
4.
5.
Know where to obtain accurate information.

Know about normal sexual development in young children.
Determine what level or kind of information the child can understand
at his or her age.
Be prepared to give answers in simple language that can be easily
understood by children.
Give information gradually and build on knowledge.
Normal Sexual Development in Children: Major Landmarks

The following general landmarks are useful in determining what types of sexual
behaviour to expect at different ages.
Birth Through Two Years of Age
< Child begins to discover and explore genitals and other body parts .
< Family and other significant adults convey attitudes toward body parts
(in particular, genitals) and gender appropriate behaviour and activities.
< Child experiences awareness of genital pleasure (from birth, boys
experience erections and girls lubricate vaginally).
< Family either builds or discourages the development of trust.
< Family either builds or discourages the development of self-esteem in
the child.
< Child is completely dependent upon parents/providers.
< Child experiences pleasure when urinating or defecating.
96
<
<
Child is aware of physical differences between boys and girls.

Child begins to be aware of gender role behaviours-that is doing things
that boys do or that girls do.
Three and Four Years of Age

< Family continues to reinforce a gender identity by the way in which boys
and girls are treated, dressed, and the type of toys they are given.
< Childs gender identity is stable and they can easily label themselves as
either a boy or girl and know differences between men and women.
< Child may wish for special relationship with opposite sex parent and
compete with parent of same sex.
< Child becomes more independent - sees himself/herself as a separate
person.
< Child shows interest in own body and bodies of others.
< Child may masturbate, sometimes to orgasm.
< Child may participate in doctor or house games.
Five Through Seven Years of Age
< Child becomes aware of the relationship, sexual and otherwise, between
his/her parents.
< Childs gender identity is fixed.
< Child usually gives up wish for special relationship with opposite-sex
parent and seeks a stronger relationship with same-sex parent.
< Child may continue to participate in doctor or house games.
< Child may begin to daydream or fantasize about sex.
< Child may have confusing , even hostile, feelings towards children of the
opposite sex.
Eight Through Twelve Years of Age
< Peer group has increased influence on childs self-image.
< Child begins to separate from parents and spends more time with
friends.
< Child begins to experience body changes during puberty.
< Some girls begin to menstruate (9-10 years).
< Child may feel modest or shy about their body.
< Child may masturbate, sometimes to orgasm.
< Child hides sex play with same-sex peer, as well as with self, from
parents.
Source: Alter, J.S. et al. Teaching Parents to be the Primary Sexuality
Educator of Their Children (1982). Bethesda, MD: Mathtech, Inc.
97
Obstacles to Talking about Sex for Parents and Providers

It may be difficult for some parents and providers to talk about sex with
children or deal with childrens sexual behaviour because:
1.
Many adults did not talk about sexual issues with their parents. Thus, they
do not have any past experiences to rely on when attempting to talk to
children. Also, parents may remember being scolded or punished for
behaviour, such masturbation, which they observe in their children.
2.
Many adults are afraid that they will not be able to answer a childs
question so that the child will understand the explanation.
3.
Many adults feel uncomfortable and embarrassed talking about sexual

issues with other adults, let alone children.
4.
Some adults are afraid that giving sexual information to children may give
them the message that they are encouraging them to behave in certain
ways.
5.
Because there is not a common sexual language, adults use different words
to describe the same behaviour, e.g., masturbation, playing with yourself,
jerking off. They avoid naming the private parts of the body when
playing, show me games with children. The reproduction organs may be
given cute names, e.g., the penis is called birdie.
6.
Because of personal experience, inadequate sexuality education or personal

values, some sexual issues stir up strong feeling in parents and adults.
They find these topics particularly difficult to discuss with children.
98
Be Prepared
Providers can prepare themselves for dealing with childrens questions about
sex and childrens sexual behaviour by being aware of normal sexual
development in young children. There are good sources of information about
teaching children about sexuality. Talk to your local public/community health
nurse or child care services staff for information about appropriate books or
pamphlets that will help you get started.
In addition:
1.
2.
3.
4.
Providers are exposed to a lot of information and ideas about sexuality. It

is important to listen to and consider any new information or ideas. Talk to
others. Read books that are recommended by recognized specialists in this
area.
Think about what you have heard or read. Become clear in your own mind
how you feel about it.
Once you are clear about how you feel about something, you can accept or
reject a particular idea and take the appropriate action. However, it is
important not to impose your own views or values on the children in your
care.
If a provider has had a damaging sexual experience in the past which is
affecting her/his ability to deal with a childs sexual issues, s/he should
seek appropriate professional help.
REMEMBER: Parents are the primary sexuality educators of their children.

Parents should ensure that children have the correct information about sex
and sexuality issues; they should reinforce a healthy attitude towards a childs
sexuality, help influence their set of values, and foster open communication
from a very early age through to their adult years. Parents should always be
involved and kept informed if sexuality issues are discussed in the child care
settings.
99
General Guidelines for Communicating with Children about Sex

1.
Children learn by observing others. Often times, values and attitudes are
conveyed by adults behaviour rather than their spoken words. As they
grow older, children learn to recognize the contradictions between what
adults/parents do and what they say children should do. Childrens
attitudes towards sex are formed very early in life by watching their
parents and other adults and providers around them. If sex is a taboo
subject it gives children the impression that sex is bad and should not be
talked about openly. Foster a healthy body image in young children by
always talking in positive terms. Never respond with anger or scolding;
talk to children gently about what is appropriate behaviour.
2.
Anticipate typical age related questions that might arise relating to sex.
Try to answer questions as they come up. It is important not to laugh at
childrens questions even when you think the question is cute. Children may
feel ashamed for their questions and curiosity.
3.
Keep your answers short, simple, clear and age appropriate. Use proper
names for all body parts. Toilet learning provides a good opportunity to
convey positive attitudes about body parts and functions.
4.
When children ask a question, try to find out what they already know.
Clear up any misunderstandings. Give only enough information to answer
the question. Check with the child to see if s/he wants or needs more
information. For example, Does that answer your question? may be an
appropriate way to discern if the child has had his question addressed
adequately.
5.
If you do not know the answer, say so. Make sure you have the facts. Find
the answer and get back to the child with a suitable picture, answer, video,
etc.
6.
Sexual learning continues throughout a persons life. A child may continue

to ask the same questions. You may answer differently or give more details
as the child gets older. You may have to repeat your answers.
100
7. If a child asks a question, do not worry about whether or not the child is
too young to know the answer. Children understand what they are ready to
understand. However, try to answer at the childs level of understanding.
Listen carefully to childrens responses and reactions and keep parents
informed.
8.
Become familiar with a childs environment - TV programs, Internet, music,

playmates. This will help you teach children about human sexuality.
9.
Be honest in your discussion. Avoid fairy-tale explanations. Babies are not

found in cabbage patches, nor are they delivered by storks. Children who
are told such stories become distrustful of adults when they eventually
learn the truth about the birth process. They may then turn to their
friends or other sources such as television or the Internet for answers to
their questions.
10. Respect a childs privacy (within the limits of his/her personal safety) and
have him/her respect the privacy of others. Children need to be taught
from an early age that they are in charge of their own bodies.
When a Childs Sexual Behaviour Is Not Appropriate
If you are not certain whether a specific sexual behaviour is appropriate or
normal in terms of the childs growth and development, ask for help. Contact
an appropriate, knowledgeable person, e.g., Child Care Services Consultant or
Social Worker, Public/Community Health Nurse.
101
CHILD ABUSE AND NEGLECT

Child abuse and neglect is a serious problem. Children under the age of
three are usually more vulnerable to physical abuse and make up 70% of
all cases. If you suspect a child is being abused or neglected, you MUST,
by law, report this suspicion. Procedures for reporting are mandated
under the Child, Youth and Family Services Act (1998) (See policy
document Appendix for information on Duty to Report).
The provider is responsible for identifying, documenting and reporting
suspected cases of child abuse. S/he is not responsible for, and MUST
NOT investigate the abuse or identify the abuser. Clear policies and
procedures for documenting and reporting suspected abuse must be in
place in all child care services.
If in doubt about abuse or neglect, make a referral to the Regional
Integrated Health Authority in your area. You do not need direct
evidence of abuse or neglect to make a referral. Remember, your
referral may be saving a child from further abuse/neglect. There are
many indicators for physical, emotional, and sexual abuse of children.
Lists of indicators or signals are available from Child Youth and
Family Services staff at the Regional Integrated Health Authority
office.
If you suspect physical, sexual, or emotional child abuse or neglect:
< Any incident of suspected abuse or neglect MUST BE REPORTED.
< If a child has unusual or frequent injuries, e.g., bruises, cuts,
burns, bleeding or markings, ask for assistance from a child
protection worker.
< Listen to children who report harsh punishment, especially when
there is physical evidence of injury; or who disclose sexual abuse.
< Children should be believed; they rarely lie about abuse.
< Avoid blaming the child or reinforcing a childs belief that the
abuse was his/her fault.
102
<
Providers should listen and support the child, however, they should
NOT ask leading questions which may interfere with the
investigation process.
If a child tells you s/he has been abused, the following suggestions may
be helpful:
< Remain calm.
< Do not show shock or revulsion in front of the child.
< Provide a quiet, private place to speak to the child.
< Tell the child you know it must be hard to talk about it, but
that you will listen and would like to help.
Recognizing Child Sexual Abuse
Sexual abuse of a child occurs when a child is exposed to or subjected to
sexual contact, activity or behaviour. The sexual behaviour is for the
benefit of the offender. The sexual activity may be with a child of the
same or opposite sex. Sexual abuse crosses all races, cultures and socioeconomic backgrounds. In about 90% of the cases, the offenders are
male.
Some of the behavioural indicators of the sexually abused child
include:
<
<
<
<
<
<
<
<
<
<
<
Developmental regression e.g., Children who were able to use the

toilet are now wetting or soiling pants.
Nightmares or night terrors, sleep disturbances.
Seeking attention and affection from both boys and girls.
Clinging.
Overly cooperative.
Overly aggressive.
Destructive or anti-social behaviour.
General feeling of sadness most of the time.
Difficulty developing relationships with other children.
Poor self-confidence.
Frequent lying without cause.
<
<
<
<
<
103
Self-destructive behaviour e.g., biting, pulling out hair.

Distrust or fear of adults or specific adults.
Unusual fears e.g., of going home.
Unusual, secretive relationship with an older person.
Unusual sexual knowledge and frequent inappropriate sexual play for
age and developmental stage.
NOTE:
Many of these indicators would be observed in any child
under stress, not only in sexual abuse situations. The provider has a
responsibility to report what she observes
to the appropriate
responsible professional. It is not the providers responsibility to
investigate the concern.
Some of the physical signs of sexual abuse in children include:
<
<
<
<
<
<
pain, itching or discomfort in genitals or throat.

trouble having a bowel movement, urinating or swallowing.
frequent complaints of headaches and stomach aches.
eating disorders.
torn or stained or bloody underwear or diaper.
trauma to breasts, buttocks, lower abdomen, thighs, genitals or
anal/rectal area.
Actions that providers can take if sexual abuse is suspected:
<
<
<
<
<
<
<
Seek immediate medical attention if injury or child complains of pain.

Encourage parents to see their family physician if the child complains
of frequent genital discomfort.
Listen and support child if s/he wants to talk about sexual abuse.
Give the child lots of reassurance that you believe him or her.
Avoid showing emotion that may lead the child to believe that she is
responsible for the sexual abuse.
Give emotional support to the child throughout the experience.
Report any findings or indicators of sexual abuse.
104
Note: If you are unsure about what you have observed or been told,
contact Child Youth and Family Services staff at the Regional Integrated
Health Authority office in your area for further information. The Child
Youth and Family Services staff are responsible for screening all
reported cases of suspected child abuse or neglect and following up if
necessary. The staff can also be available for consultation on these
matters. Callers may remain anonymous if they so choose.
105
ADULT HEALTH
Child care providers need to take care of their own health needs as well as
those of children in their care.
Providers, as well as children, may be exposed to infections which can pose risks
to their health. Infectious diseases in adults may be more or less severe than
in children, depending upon the disease. In addition, childcare providers, during
their care of children, are often required to lift, bend and carry children and
equipment. This can result in injury if adequate measures are not taken to
reduce risk. If a child care provider is pregnant, special precautions may be
necessary regarding her health and well being. Child care providers who are
pregnant should consult with their family doctor or public/community health
nurse for further information.
Reducing the Risk of Infectious Disease
Immunization
Immunization programs are a safe and effective method for preventing many
infectious diseases, and prevention of infection by immunization is a lifelong
process. All adults should receive adequate doses of all recommended vaccines.
Regular influenza shots are also recommended for people who work with young
children. All child care providers must have a current immunization record.
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 individual, dated, signed and kept in the individuals file.
Immunizations that are more than ten years old no longer provide protection
and in such situations it is strongly recommended that the individual contact
her/his physician on the matter.
Documentation is to include information regarding immunization for tetanus and
diphtheria. Immunity should be maintained with combined tetanus and
diphtheria (Td) immunizations every ten years.
Child care providers must also have written documentation of immunity to
measles, mumps and rubella, as noted below:
106
Measles: Either a record of immunization or laboratory evidence of immunity

is sufficient documentation. Adults born before 1970 are likely to be immune
to measles.
Mumps: A record of immunization or a history of mumps is sufficient
documentation. Adults born before 1970 are likely to be immune to mumps.
Rubella (German measles): Either a record of rubella immunization or
laboratory evidence of rubella immunity is sufficient documentation.
If providers immunization is incomplete or needs updating, your local Health
and Community Services office can provide assistance. It is important to note
that some vaccines should not be given to pregnant women or to a woman who
may become pregnant within one month after receiving a vaccine, e.g., rubella.
Handwashing
The single most important infection control practice is handwashing.
Always follow the guidelines for when and how to wash hands ( Handwashing
section for these guidelines.) Handwashing can significantly reduce the risk of
transmission of infections.
The best way to reduce infection in a child care setting is to ensure providers
and children follow recommended handwashing routines. Studies in both
hospitals and child care settings have shown that providers education and
regular monitoring of providers handwashing are necessary in order to ensure
that the proper routine is followed. Providers might consider hanging a
handwashing poster by each sink as a reminder to providers and children.
Managing Illness for Child Care Providers
It is important to follow the Guidelines for Managing Illness in Table I of this
manual. Know how to recognize infection, how it spreads, when it is contagious,
what to do at home, and what to do at the child care setting.
107
Reducing Adult Injury in Child Care Settings

Child care providers may be at increased risk for physical injury, e.g., back
injury, in the workplace.
Use of proper lifting and transferring techniques can significantly reduce the
risk of injury. Providers education in this area is essential.
All suspected injuries should be medically evaluated as soon as possible and an
injury report completed.
Providers should be aware of other occupational risks within their settings,
such as chemical hazards. Providers may be at an occupational risk from
particular arts and supplies and cleaning products.
Providers and children should not eat or drink in an area where arts and craft
supplies are used. Tables used for both purposes should be cleaned and
sanitized after each use to prevent exposure during eating.
Some general guidelines can be applied, including:
<
<
<
<
<
<
<
<
reading labels carefully before purchasing and using cleaners and/or arts
and craft supplies.
minimizing exposure to chemical products; wear protective gloves and
safety glasses when necessary; avoid breathing vapour mist or dust
using products in a well-ventilated area.
using liquid tempra paint instead of powdered tempra paint - the dust
particles from the powdered paint can irritate the respiratory system.
avoid mixing chemicals unless specific directions are available.
ensuring product labels remain properly attached to containers.
disposing of containers and their contents according to hazardous waste
guidelines.
knowing first aid; have emergency and poison control numbers available.
108
Taking Care of Yourself
Caring for infants and young children is physically and emotionally demanding
work. The work environment can be especially stressful for providers who work
alone. Caring for yourself is of utmost importance if you are expected to have
the energy, enthusiasm, positive attitude and patience to care for children.
Many parents and providers may be sleep deprived as they cope with the normal
routines of family life and work environments. Fatigue results in less energy and
enthusiasm for daily activities and irritability at the smallest of issues.
Providers should actively participate in development and implementation of
providers education related to health issues in child care settings. Regular
updates on infection control and prevention of back injuries should be provided.
Regular checks should be carried out to assess and reduce potential workplace
hazards.
Providers who are ill should report illnesses and follow Guidelines for Managing
Illness (Table I). Providers do have the right to confidentiality related to
health issues. Unless the provider is at risk to the public, to co-workers or to
children, it is not necessary that specific health information be given to the
employer.
Child care providers need to take care of their own health needs, as well as
those of the children in their care.
Here are some strategies for supporting the child care providers health needs:
<
<
<
<
<
Ensure that you receive adequate rest and relaxation.

Maintain a healthy nutrition status by snacking well with nutritious foods
such as cheese, bran muffins.
Make time for yourself for physical activity at least three times a week.
Exercise will not only enhance your physical well being it does wonders for
your emotional well being. You will also feel more energetic and eat
healthier food choices.
Look for ways that you can streamline the many activities in your daily
family and work life.
Think of more effective ways to cope with stress in your life by finding
some time for yourself each day. For providers in family child care,
developing a supportive network of fellow providers as a support group is
<
<
<
109
useful.
Advocate for yourself and for other child care providers by ensuring that
your work environment is supportive of your needs (e.g., adequate
providers available for breaks, adequate breaks in an adult space away
from children).
Have adult-size furniture as well as child size. Chairs and desks used by
adults should be comfortable for adults.
Providers should also work at providing support for one another and work
together to establish further community supports if necessary.
Pregnancy and Working in a Child Care Setting

Child care providers who are pregnant, or who are intending to become pregnant
or who are in their child-bearing years have some special considerations to keep
in mind when working in a child care setting. Of course all pregnant women can
be exposed to people with viral infections at anytime, but child care providers
are considered a high-risk group for coming into contact with infectious viral
diseases. Here are some things to keep in mind:
All women of child-bearing age who work in a child care setting should be
aware of their immunity to the following communicable diseases:
<
<
<
<
Rubella (German Measles)

Hepatitis B
Chicken Pox
Cytomegalovirus (CMV)
When determining immunity, most women will be able to easily remember if

they ever had chicken pox or if they are up-to-date with their Rubella
immunizations. If they are unable to remember, they can be tested for
immunity. Cytomegalovirus (CMV) doesnt cause any symptoms so a provider
probably doesnt know if she is immune. It is a common infection, however, and
it is one that can be easily passed from mother to baby. According to the
Canadian Paediatric Society, ....the most important ways (for pregnant women)
to avoid acquiring CMV infection while working in a child care setting include
handwashing and avoiding direct exposure to potentially contaminated blood and
body fluids (especially urine and saliva). Susceptibility to CMV infection can be
determined by a blood test. Although routine screening for CMV is not
recommended, it may be prudent for child care workers who are, or intend
110
to become, pregnant.
(CPS, 2003) Child care workers who fall into this

category should speak with their doctor about being screened for immunity to
CMV.
A provider who is pregnant and working in a child care setting should speak
with her doctor about:
<
<
toxoplasmosis
Fifth disease (parvovirus B19)
Toxoplasmosis is an infection that can threaten the health of a developing

fetus. It is caused by a parasite that is found in cat feces and in raw or
undercooked beef. Women who are most at risk for getting Toxoplasmosis are
those with a new or outdoor cat at home and those who eat raw or undercooked
meat. At the child care setting it is sometimes possible for cats to use outdoor
sandboxes as litter boxes so it is important that pregnant providers ask
someone else to inspect and clean the outdoor sandboxes if they are soiled with
cat feces. It is vital that pregnant child care providers wash their hands
thoroughly after handling raw meat, soil, sands, or cats. They should also avoid
eating raw or undercooked meat or poultry and unwashed fruit or vegetables
(because of possible contamination of the soil).
Fifth disease (parvovirus B19) - Most pregnant women are not at risk for
parvovirus B19 infection because it is a common infection and most people have
developed immunity (Canadian Paediatric Society, 2003) . However, pregnant
women should talk with their doctors if they are exposed to an outbreak of
fifth disease so that their immunity can be checked. Fifth disease does not
cause birth defects but it can cause anaemia in pregnant women. Anaemia can
have very serious effects on a pregnancy so it is important that pregnant
women consult with their doctor if they are exposed to fifth disease. Exclusion
of either the child who has fifth disease or the pregnant child care provider
may not be necessary, as the disease is infectious well before the rash becomes
apparent.
Good hygiene practices, especially good handwashing is always important. It
becomes doubly important for child care providers who are pregnant. The best
advice for a pregnant child care provider is Wash Your Hands! (For more
information see Handwashing Section)
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Here are some good websites that provide a lot of information that may be
helpful for child care providers who are pregnant or who are thinking about
becoming pregnant:
www.marchofdimes.com
www.sogc.org (Society of Obstetricians and Gynaecologists of Canada)
www.cps.ca (Canadian Paediatric Society)
www.familydoctor.org (American Academy of Family Physicians)
For more information of a variety of communicable diseases, see Table I
Guidelines for Managing Illness.
MANAGING ILLNESS
AND SPECIAL HEALTH CARE NEEDS IN
CHILD CARE SETTINGS
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INFECTIOUS DISEASE IN CHILD CARE SETTINGS

Introduction
A communicable disease, sometimes called an infectious disease or a contagious
disease, is one that can be passed from one person to another. An infectious
disease is like a chain; there are four links that must be present in the chain
before the disease can pass from one person to another.
The four links in the chain of infection are:
1. The
2. The
3. The
4. The
germ that causes the infection (the agent),

person who has the infection (the host),
way that the germ is spread (in the air, on objects, and so on),
person who catches the infections (the new host).
The germs that cause infections are very small, and they cannot be seen
without a microscope. The most common germs include bacteria and viruses.
They can live in a persons body, on the skin, or sometimes in the environment,
such as in the air, on counter tops, or on toys. Germs outside the body can be
destroyed by handwashing and thorough cleaning, and some germs can be
destroyed by specific medications in the body.
A person who has an infection (a host) can carry the germ and infect other
people. Such a person is called a carrier. A carrier may feel very sick or may
never feel sick, depending on the kind of germ that is being spread. Some
illnesses, such as chickenpox, are spread very easily from one person to
another. The virus that causes chickenpox can be spread before a person
knows that they have chickenpox, as well as during the time that they have the
spots. With other diseases, a person may be infectious and not know it, but the
disease may be much harder to catch.
Very often, a person will have been infected with a germ for some time before
becoming ill. This time period, between when a person gets infected to when
that person gets sick, is called an incubation period. For example, a child who
has chickenpox will have the virus in the body for 2 to 3 weeks before any
spots appear. From 2 days before the rash appears until 5 days after the child
can spread the virus to other children. This is why chickenpox is so contagious,
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and why so many children in a child care setting will get the disease if one
person has it. Some infectious diseases, such as a cold, have a very short
incubation period of several days. Other diseases, such as Hepatitis B, have a
very long incubation period, of several months.
Different germs are spread in different ways. Generally, germs are spread by
direct contact or by indirect contact, and some germs can go either way. Take,
for example, three children at Sunny Days Child Care: David, Dawn and Sarah.
David has a cold, and while crayoning with Dawn, he sneezes on her. Dawn
breathes in the particles from Davids sneeze, and several days later, she has
a cold. This is an example of direct contact.
Dawn, who still has her cold, does not have any tissues, and wipes her nose
several times on the sleeve of her painting smock. Ten minutes later, Sarah
puts on the smock, and while wiping paint off her nose, rubs the same sleeve
against her nose. Sarah comes down with a cold over the weekend. This is an
example of indirect contact.
Some diseases are spread to many people at once, like some germs that cause
diarrheal illness. For example: Mrs. Hurry, who works at Slapdash Child Care,
has just finished diapering Justin and is about to fix some sandwiches for the
childrens snack time. She carefully washes her hands, with soap and hot water,
and goes towards the kitchen area to prepare the snacks. Adam interrupts her,
saying he has to go to the bathroom, NOW. Mrs. Hurry helps Adam, who has
had several bowel movements already that day, hastily washes her hands, and
makes the snack. The next day, several children in the centre experience
frequent loose bowel movements. This type of indirect contact, through food
that has been contaminated with germs, can happen if a person preparing food
has not properly washed her hands after toileting or diapering.
As the examples show, germs can enter the body a number of ways: through the
mouth and nose, from fingers or food going into the mouth, or even through
breaks in the skin. However, germs that enter the body dont always cause
disease. Some germs cannot cause illness because the person has been
immunized. For example, if a person has been immunized against measles, then
the germ that causes the illness is not likely to make that person as sick as
those immunized. This is because immunization helps the body to fight off the
germ. For some diseases, a person needs several immunizations to make sure
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the body can stay protected.

There are many different types of germs, spread in different ways. Some of
them can be prevented with immunization, and some cannot. Table I, Guidelines
for Managing Illness, provides further information.
Infectious Diseases - Why They Spread in Child Care
All sorts of infections, including colds and diarrhea, are common in young
children. This is true for all young children, whether they are in a child care
setting or at home, because young children have usually not been exposed
before to the germs that cause infectious diseases.
However, children in child care settings get colds, respiratory infections and
diarrhea 2 to 3 times more often than children who are cared for in their own
home. This is because:
1.
There are children from different families together in one place every
day, so there is more of a chance of exposure to germs.
2.
Children have a lot of close contact with each other. They share things
like food, clothing and toys, and will cough and sneeze at very close range.
This kind of contact allows germs to pass easily from one child to another.
3.
Young children put many things in their mouths. A child with a cold or a
runny nose may mouth toys, wipe their nose and face on toys, and then
other children will use the toys in the same way, allowing germs to pass
from one child to another.
4.
Children may have contact with feces (bowel movements) from diapers,
going to the toilet, or accidents in toileting. They may not be very good at
handwashing, and can pass germs along to each other. Providers who are
caring for many children can pass germs this way as well.
5.
Food is prepared and eaten every day in child care. If the food handler
has not practised good personal hygiene, or has to diaper and toilet
children in addition to preparing food, then the food can become
contaminated and cause illness.
Some children and providers may not be fully immunized, allowing some vaccine-
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preventable diseases to spread among them.

6.
Children enroll in, take part in, and leave child care services at various
times during a year. This can lead to some infections, like chickenpox,
going around as children enter and leave the service.
7.
With many infectious diseases infection is present and can be spread

before any signs and symptoms are noticed.
Controlling Infectious Diseases

There are steps that can be taken to ensure that infectious diseases are
controlled in child care settings. Refer to the following ten points for
information on how best to prevent or control infectious disease.
1.
Handwashing
Proper handwashing is essential in child care services, and everywhere.

Providers and children must have the facilities and the ability to wash hands as
often as needed. Younger children will need help with handwashing. When to
wash hands is as important as how to wash hands. Children need to be reminded
about handwashing.
How?
With soap and warm running water. Hands must be soaped under warm running
water for at least 20 seconds, using plenty of friction (rubbing). Hands must
be rinsed in warm running water, then dried with a personal towel or a single use
disposable towel. If nails need cleaning, they must be done with a disposable
manicure stick, not a nail brush. (Refer to guidelines for handwashing.)
When?
BEFORE: preparing or eating food, feeding a child, or giving first aid (applying
bandages, cleaning cuts and scrapes).
AFTER: Diapering/toileting, caring for an ill child, wiping noses, giving first aid,
cleaning a spill of any body fluid, disinfecting or sanitizing an area, handling
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chemicals, handling animals and/or cages, removing boots, shoes and so on.
See also Handwashing Section.
2.
Written Policies
All providers and parents must be aware of and be given clear directions on how
to deal with infectious diseases in child care. Child care services must have
policies that address:
<
<
<
<
<
<
<
<
Health records, including documentation of immunization.

Reporting of some diseases to public/community health nurse.
Exclusion of ill children.
Notification of illness or absence of children (by Parents or Guardians).
Caring for mildly ill children in child care settings.
Medications to be given in child care settings.
Food preparation procedures.
Sanitation and hygiene procedures.
Written policies allow for all parties concerned to be aware of their role in
preventing the spread of infectious disease. Written policies need to be
reviewed and updated periodically.
3.
Immunization of Children and Providers
Records of up-to-date immunization must be on hand at the child care setting,

for both children and providers. Children and providers who are not fully
immunized can develop and spread some serious infectious diseases. The
public/community health nurse can provide information and assess the
immunization records of children in your child care service.
4.
Daily Observation of Children
When children arrive at child care, providers must make note of the childs
health and appearance, and check throughout the day for changes in behaviour
or symptoms that might signal illness. If a child must depart early due to
illness then this must be recorded by the provider. See Record of Illness,
Absence or Early Departure.
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5.
Communication With Parents
Parents must alert providers to any possible problems that might be brewing.
If a child is to be absent from the centre, policies must be in place that require
the parent to inform the centre of this absence. (See Record of Illness,
Absence and Early Departure). This is important for health reasons - so that
patterns of illness among the children at the setting can be noticed and also for
safety reasons, (for example if a child is usually transported to the child care
setting by someone other than the parent then the lines of communication are
vital between the child care setting and the parent).
Providers also have an important communication role to play. The provider
should inform the parent at the end of a day if the child seems to be ill or not
quite up to par. Similarly, parents must be informed if a case of an infectious
disease occurs in the child care setting, and parents need to let the providers
know if their child has been exposed to an infectious disease. Care must be
taken in this instance to maintain confidentiality.
6.
Toileting and Diapering
Infants and young children in child care services need to be diapered, or need
help with toileting, and may have accidents from time to time. Providers have
to handle a number of children every day, and this situation promotes the
transmission of germs unless the proper precautions are taken.
Handwashing is essential, and correct sanitation and placement of diapering
areas is just as important. Diapers have to be disposed of or held in covered,
plastic lined containers, away from childrens reach. Diapering and toileting
areas must be separate from food preparation and serving areas. Wherever
possible, providers who are involved with toileting and diapering should not be
involved with food preparation or service on the same day. (See also Diapering
and Toileting)
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7. Sanitation and Housekeeping

Some germs are very stable in the environment (on counter tops, fridge door
handle, tables, toys), so all surfaces must be thoroughly cleaned each day. (See
General Cleaning and Sanitizing Practices)
8.
Food Safety
Germs can easily contaminate food, and children are especially likely to get ill
if they eat contaminated food. Foodstuffs must be stored, prepared and
served in a safe and careful manner. (See Food Storage Safety)
9.
Animals in Child Care
Having any pets in a child care service requires careful monitoring. Any pet in
a child care setting must be healthy and vaccinated (if applicable). If you
already have pet(s) in your child care service, or are considering obtaining a pet,
ensure that parents are informed prior to enrolling their child. It is important
that parents let providers know how they expect their child to respond to a
pet.
10. Policies and Facilities to Deal with Sick Children
Although some illnesses do not require exclusion from the child care setting,
there must be a quiet, restful area for any child who becomes ill while
participating in the program. Policies must include the procedures providers will
follow for caring for an ill child and the other children at the service, and when
parents will be called to pick up their child.
Providers must be able to supervise ill children appropriately as well as the
other children at the service. Also, providers must be able to reach emergency
facilities quickly if the need arises.
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MANAGING ILLNESS:
WHAT TO DO IN CHILD CARE SETTINGS
Some infectious diseases are bound to occur when children spend a lot of time
in close contact with each other. Providers can control diseases and prevent
further spread by properly managing ill children. This does not mean that
providers are expected to diagnose or treat illness.
Every child shall be observed daily by staff for symptoms of communicable
disease, injury and illness.
A child suffering from a communicable disease or acute illness shall not be
permitted to attend the child care service during any period as outlined herein
or as prescribed by the physician for non-attendance.
There are three essential steps to managing illness in the child care setting:
1.Identify the sick child
Communication with the child, the parents and other providers, as well as
routine observation of the child, can identify when a child is not feeling well,
or is brewing something. Familiarity with the signs and symptoms of common
childhood illnesses can help a child care provider identify children who are ill.
See Table I, Guidelines for Managing Illness, for more information.
2.Ensure that the proper steps are taken to care for a sick child.
A quiet, restful place away from other children is needed when caring for a
child who is sick. Whether the child is ill and is waiting to go home, or is ill but
well enough to attend the program, direct supervision in a quiet area is needed.
Providers must know and have ready access to contact numbers for parents
where they can be reached at any time. In addition, providers must be aware
of the policies and procedures for dealing with emergency situations. (See
Emergency Preparation)
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3.Make sure that other children and providers in the child care
setting are protected.
Immunization records shall be current and up-to-date, to ensure that the
information is readily available. In some cases of disease outbreak, it may be
necessary to check this in a very short period of time. If a child is not
immunized, the parent or guardian shall be made aware, in writing, that is there
is an outbreak of the particular illness that the child has not been immunized
against, the public health/community health nurse may exclude him/her from
the child care centre for the duration of the outbreak.
Depending upon the nature of the infectious or communicable disease, it may
be necessary to report the occurrence to the Regional Integrated Health
Authority office so that rapid and appropriate action can be taken to prevent
the infection from spreading to other children or providers, e.g., measles, food
poisoning.
For many infectious diseases, even if they are not reportable, parents need to
be informed of a case occurring in the child care setting. This way, parents can
be alert for the signs and symptoms of the disease in their child. In the case
of children who are very susceptible to disease, this type of information is very
valuable. Fact sheets on a number of these diseases are provided in this
manual. As well, the public/community health nurse can provide assistance.
It may be necessary to isolate a child who appears to have an infectious disease
until such time as s/he can be picked up by a parent and taken for medical
attention. A quiet area away from other children, with a place for the child to
rest quietly under the direct care of a provider, is very important in controlling
the spread of infectious diseases.
For many infectious diseases, the threat of spread to other children can be
quickly stopped if the child receives prompt attention and the correct
treatment. It is vital that providers communicate to the parents if their child
shows any symptoms of illness. Infectious diseases that are promptly and
properly treated can usually be controlled before they spread to many other
children.
The Notification of Illness form and FACTS ABOUT sheets provided with this
manual are to be used to provide parents with information on various infectious
125
diseases. The FACTS ABOUT sheets were adapted with permission from Well
Beings: A Guide to Promote the Physical Health, Safety and Emotional WellBeing of Children in Child Care Centres and Family Day Care Homes, Canadian
Paediatric Society, 1999.
Table I, Guidelines for Managing Illness, provides information on when and when
not to allow ill children to attend child care. Other infectious diseases which
do not require exclusion may occur from time to time. Call the Regional
Integrated Health Authority office for assistance if the diagnosis you are
dealing with does not appear on the list.
Managing the Mildly Ill Child in Child Care
Children who are mildly ill can sometimes attend a child care program, under
certain conditions. Most importantly, the child must be well enough to cope
with some level of activity, and not require complete bedrest. In order for a
mildly ill child to attend child care, the following conditions must exist:
<
<
<
the illness is mild enough to allow the child to participate in activities,

the illness does not require a level of care by providers that would
compromise the care of other children, and
the illness is not infectious*.
Note: See also Common Health Concerns with Infants

* Not all infectious diseases require that the child be excluded from a child
care setting. For example, Hepatitis B & HIV infection do not require exclusion
because they are not highly infectious diseases; other children will not get ill
because they are in the same child care setting.
For some infectious diseases, children who have been treated can attend the
child care service, even if the infection has not completely cleared up. For
example, a child with Giardiasis may attend as long as the child does not still
have diarrhea and providers follow good infection control practices.
Other infectious diseases, such as colds or Fifth disease, do not require
exclusion because this would not prevent the spread of disease. The child is
infectious before getting any symptoms, and the disease is mild enough not to
cause the child to feel ill. In these situations, if the child is well enough to
126
participate, then the child can attend the child care service. For more
information on fifth disease and pregnant providers, see Adult Health.
Outbreaks
When several children and/or providers become ill on the same day, notify the
Regional Integrated Health Authority office immediately. The
public/community health staff will assist your child care service in bringing
outbreaks under control and in communicating with parents. The
public/community health staff can help you answer the following questions
about outbreaks:
<
<
<
Should exposed children and providers receive medications or

immunization?
What other measures should be taken to protect children and providers?
What information (written and verbal) should parents receive?
The most common outbreaks involve diarrhea. If two or more children in your
program develop diarrhea within 48 hours and if this diarrhea is not associated
with a preexisting condition, e.g. medication-related, notify Public/Community
Health officials immediately. Depending on what the protocol is in your region,
either the Public Health Nurse, the Parent/Child Health Coordinator, the
Environmental Health Officer or Communicable Disease Control (CDC) Nurse
will be the person who will investigate the outbreak. Check with your public
health nurse regarding the protocol in your area. Other gastrointestinal
problems, e.g. vomiting, can also signify the outbreak of an infectious disease.
If two or more children in the program are showing signs of gastrointestinal
illness within 48 hours of each other, then the Regional Integrated Health
Authority office must be notified. To keep track of illness in the child care
setting, providers can use the Record of Illness, Absence and Early Departure,
found in Records Section.
If there is a child in your program with childhood cancer, leukemia or other
disorders affecting their immune system, notify the parents if infectious
rashes and other contagious diseases occur.
127
Common Complaints
Some of the more common complaints that providers must cope with in child
care settings include fever, diarrhea, and vomiting. These symptoms may or
may not be related to a developing illness. Refer to the following for some
guidelines on coping with these, and other common childhood symptoms.
Fever
Colds, tonsillitis, croup, pneumonia, pharyngitis (sore throat), and ear infections
are some of the more common infections causing fever in young children. A
fever may also accompany the flu. Occasionally babies develop a fever after
routine immunizations.
A fever by itself is not an illness. It is a warning sign that the body is trying to
fight off an infection. Normal body temperature is 37/C. The body
temperature changes from child to child, the time of day, type of clothing,
amount of activity and kinds of food and drinks taken. Young infants tend to
have higher temperatures than older children and everyones temperature is
highest in the late afternoon and early evening and lowest between midnight
and early morning. Children feel uncomfortable with a fever because of the
increased need for fluids and their increased heart rate and breathing rate.
When you observe a child s/he may have the following symptoms: dry hot skin,
excess sweating, flushed complexion, unusual breathing, cold symptoms, poor
appetite, ear pain, vomiting, or diarrhea.
Managing fever in the child care setting
A high fever does not necessarily mean a serious infection. A mild viral
infection can cause a temperature of 40/C, while a very seriously ill child could
have a temperature of 38.2/C.
The most important thing to consider when a child has a fever is the childs
behaviour. If the child has any of the following symptoms in addition to the
fever, medical attention may be necessary. In any case, parents are to be
notified if the child has any of the following symptoms.
128
Infants
< excessive listlessness, drowsiness, sleepiness or lack of interest in
activities or surroundings.
< irritability, fussiness, crankiness.
< screaming cry.
< poor skin colour, or very pale.
< very rapid breathing (more than 40 breaths per minute).
< difficulty breathing.
< a rash of any kind.
< excessive drooling.
< does not suck well on breast or bottle.
Toddlers and Older Children
< excessive listlessness, drowsiness, sleepiness or lack of interest in
activities or surroundings.
< irritability.
< poor skin colour, or very pale.
< very rapid breathing (more than 40 breaths per minute).
< difficulty breathing.
< a rash of any kind.
If you suspect a fever, separate the child from the group and take his or her
temperature. Observe the child for any other signs of illness, such as rash,
cough, vomiting or diarrhea.
Contact the parents and advise them of their childs condition and need for pick
up as soon as possible. The child may return to the child care setting when
s/he is well or when a physician makes a diagnosis no longer requiring exclusion.
Take the temperature again in 30 minutes or sooner if child appears to be
worse. Make sure the child is comfortable and offer plenty of fluids. Remove
extra blankets and clothing so heat can leave the childs body. Do not remove
all of the childs clothes because the child may become too cold and start
shivering, which produces more heat.
A fever in an infant under six months of age should be evaluated by
medical personnel. Parents must be contacted immediately if an infant
under six months of age has a fever.
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Febrile Seizures
Some children may be prone to the development of seizures when they have a
fever. Approximately 3 % of normal children will have at least one febrile
seizure between the ages of six months to six years. There is a tendency for
febrile seizures to run in families. They usually last less than 15 minutes and do
not cause brain damage or epilepsy. The seizure could mean that there is a more
serious infection present. Any child with a fever and seizure should be
immediately taken to medical personnel or emergency department for
assessment. Parents must be contacted immediately.
Taking a Temperature
An oral, ear or axillary (under the armpit) temperature of 38/C or higher
indicates a fever. A digital thermometer provides a fast, accurate, safe, easy
reading. Do not use a glass or mercury thermometer in your child care setting.
Always read the instructions first before taking the temperature.
Axillary (armpit) method
1. Lift the childs arm and place the tip of the thermometer in the centre
of the bare armpit.
2. Hold the childs arm snugly against the childs body for 1 minute, or until
the thermometer beeps.
Providers can take a childs temperature orally if the child is 4 years of age or
older and in a cooperative mood. Ensure that the child has not had anything to
eat or drink at least 10 minutes before taking the temperature this way.
Oral method
1. Place the bulb under the childs tongue and wait for the digital
thermometers signal.
2. Make sure that the childs lips are closed and that s/he does not talk
while taking it.
130
There are many different types of thermometers. Choose a method appropriate

to the age of the child. If the thermometer is used properly, according to the
instructions provided, it should be reliable. A fever strip or sensitive tape is
not recommended because it does not give an accurate temperature reading.
The pacifier type of thermometers for babies three months of age through to
two years may be rejected by an infant who doesnt use a pacifier regularly. It
must be in place for at least 3 minutes or until the pacifier beeps. It is
necessary to add 0.5 degrees to the reading.
The ear thermometer for children 3 years and up requires proper technique and
is difficult to master. Gently pull the upper part of the childs ear up and out
and gently place the probe at the entrance to the ear canal. Aim at the ear
drum which is warmer than the ear canal. Change the thermometer shield for
each child.
Child care providers in child care settings must never take rectal
temperatures.
Acetaminophen is the best medication for reducing a fever. Providers can give
the dose recommended on the package only as per Child Care Services
Regulation and Policy. Parents must be notified immediately, especially if the
temperature is higher than 38/C.
Cleaning a Thermometer
Thermometers must be cleaned after each use. Refer to manufacturers
instructions when cleaning a digital thermometer. To properly clean a
thermometer follow these steps:
1. Wash the thermometer with soap and cool water. Rinse and disinfect with
a sanitizing solution. Do not rinse with hot water.
2. Store the clean thermometer in a clean container until its next use.
3. If the digital thermometer has a disposable plastic cover, after taking a
temperature, throw out the cover and use a new cover to take the next
temperature.
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Vomiting
Children vomit more readily and easily than adults do, with less discomfort, but
the experience can be frightening and embarrassing, especially to an older
child.
A single episode of vomiting might be due to non-infectious illness, or it may be
due to the general effects of an infection. Young children sometimes vomit
because of fever, especially if it is high. Viruses and intestinal infections can
also lead to vomiting. If the child also has episodes of diarrhea, you may
suspect an infectious cause. If a child has more than two episodes of vomiting
over a 24 hour period then s/he should be excluded from child care until the
vomiting has stopped and the child is well enough to participate in activities or
it is determined that the vomiting is caused by a non-infectious condition.
Parents should be advised to seek medical advice.
A child who vomits should be separated from the group for rest and
observation. If diarrhea and more vomiting occurs, inform the parents
immediately so the child can be picked up and cared for promptly. If the child
complains of pain in the abdomen ask the parents to pick the child up
immediately and seek medical attention. Always clean and sanitize the areas
where the child vomited as soon as possible. Wash hands thoroughly.
Vomiting can cause dehydration very quickly in an infant or toddler. (For
more information on dehydration, see Dehydration)
Diarrhea
Each childs pattern of bowel movements is different. Diarrhea occurs when
the bowel is stimulated or irritated in an unusual way.
Diarrhea means that there is a change in the normal pattern of bowel
movements, so that there is a noticeable increase in the number of stools, and
a change in the consistency, so that they are watery or unformed.
Diarrhea is a common symptom in childhood and usually is mild and brief.
Dehydration (too much water lost from the body) can occur if the amount of
water lost in the diarrhea is larger than the amount of fluid the child drinks.
132
If diarrhea persists, a child can become dehydrated. Young infants are

particularly at risk for dehydration when they have diarrhea, as they can
become severely dehydrated in less than 24 hours. See also section on
Dehydration below. Most diarrhea gets better by itself, provided that the
child is given adequate fluids and nutrition.
Germs which cause diarrhea are easily spread from person to person,
especially from child to child.
Diarrhea can be caused by infectious disease. Viruses are the most common
cause of infectious diarrhea in children. It can also come from some types of
medication, from allergies, or from excessive juice intake.
Diarrhea germs may survive on contaminated areas for long periods of time
(e.g., toys, table tops, diaper change areas). Only a few germs are needed to
cause diarrhea in another child. Diarrhea is spread more quickly among children
who have not yet learned to use the toilet. The spread of diarrhea can be
reduced by careful handwashing.
If a child in your child care setting has diarrhea:
<
<
<
Ensure that all staff who are working directly with the child are
notified if a child has one unformed or watery bowel movement and who
is otherwise well ( i.e., without fever, vomiting, or blood in the bowel
movement). Providers should be extra careful to wash their hands after
caring for this child in any way.
Notify the parents if their child has two or more episodes of diarrhea,
or diarrhea with fever, vomiting, or blood in the bowel movement; the
child must be seen by medical personnel as soon as possible.
Ensure that parents notify the child care setting if the child is absent
due to diarrhea so that this may be recorded using the Record of
Illness, Absence and Early Departure.
133
If two or more children in your child care setting have diarrhea:

< If two or more cases of diarrhea occur within a 48 hour period (2 days)
and if this diarrhea is unrelated to a preexisting condition, e.g., allergy
or medication-related, then this must be reported to the Regional
Integrated Health Authority office.
< Record any absence due to illness on the Record of Illness, Absence and
Early Departure form. This information will be very useful to officials
at the Regional Integrated Health Authority office as they determine
whether there is an outbreak of an infectious disease.
< If the situation continues or worsens, e.g. more children develop illness
involving diarrhea, then the Regional Integrated Health Authority office
needs to be contacted again.
Exclusion
Most children with diarrhea should be excluded from the child care setting
until the diarrhea has stopped. In certain circumstances, children with chronic
non-infectious diarrhea (e.g., from allergy, medication or long-term disease)
may continue to attend. If doubt exists about the cause of the diarrhea
exclude the child and consult with your Regional Integrated Health Authority
Health and Community Services office.
Dehydration
Dehydration means that there is a loss of water from the body, impairing the
circulation of blood. The risk of dehydration is greater if a child is suffering
from vomiting or diarrhea. Unfortunately, it is not possible to give an exact
number of the episodes of vomiting or diarrhea that will lead to dehydration.
Infants are at greatest risk for dehydration. It can become serious enough
to require hospitalization if it is not handled carefully. The usual causes of
dehydration in a young infant are:
<
<
<
<
fever.
overheating.
vomiting.
diarrhea.
134
In rare situations, an infant's dehydration may be a result of inadequate

feeding at the breast or bottle.
The signs of dehydration include:
<
<
<
<
<
<
<
fewer than 6-8 wet cloth diapers or 4-5 disposables in 24 hours.

dark yellow urine that does not change.
dry sticky mouth, tongue and lips.
sleepy and listless.
less energy or less playful than usual.
sunken fontanel(soft spot on top of head in children under 18 months)
(this may be difficult to determine).
not shedding tears while crying.
More serious signs of dehydration include:
<
<
<
sunken eyes.
hands and feet that are cold and splotchy.
lethargy (no energy, very inactive).
If a child in your care appears to have any of these signs or symptoms they
need to see medical personnel immediately.
In a young infant under a year of age, other signs that a baby may be very ill
and dehydrated include:
<
<
<
decrease in ability and desire to suck at breast or bottle.

very lethargic.
sleeping through too many feedings.
If the baby is breastfed, continue to offer expressed breastmilk at least every

two hours while waiting for parents. For babies and toddlers drinking formula
or milk, do not give formula, cow's milk or fruit juices. Oral rehydration
solution can be given every hour or so, from bottle or cup.
135
E. Coli Infections
Diarrhea can be caused by many different types of bacteria. E. coli bacteria
are found in the digestive systems of most healthy humans and many animals.
These infections are usually harmless. However, not all E. Coli infections are
alike and some strains of the bacteria can cause more serious illness through
contaminated water systems or from eating undercooked ground beef.
Some people infected with this more serious strain may have very mild illness
while others develop severe bloody diarrhea and abdominal cramps. Children
under five years of age, the elderly and people whose general health status is
already weakened are at risk for developing a more serious E. Coli infection.
When E. Coli is found in the drinking water there is a strong likelihood of
recent sewage or animal waste contamination. During rainfalls and snow melts,
E. Coli can be washed into rivers, streams, ponds, lakes or ground water. When
these water sources are used for drinking water and the water is not treated
properly, people may be drinking E. Coli contaminated water without their
knowledge.
Symptoms of E. Coli contamination usually appear within 2-4 days but can take
up to eight days. Most people improve without antibiotics or other treatment.
Medical personnel should be consulted if it is suspected that children or
providers attending the child care service have contracted an E. Coli infection.
Determining whether an E. Coli Infection is the cause of illness would be
difficult and inappropriate for providers to determine, therefore, any outbreak
of diarrhea or gastrointestinal illness among children and providers must be
reported to the Regional Integrated Health Authority office. The Record of
Illness, Absence and Early Departure will provide valuable information to
health/medical personnel regarding possible outbreaks of E. Coli infection.
Using this record will also make it easier for providers to keep track and record
any pattern of illness. For more information on this topic see Diarrhea and
Outbreaks.
Safety of the drinking water - If your child care service gets water from a
public water system, then you should be notified if there are concerns about
the safety of the drinking water. A list of boil water advisories for public
water supplies is maintained at the following website:
136
http://www.gov.nl.ca/env/env/waterres/CWWS/Microbiological/summary.pdf
Chemical water quality for public water supplies can be viewed at
http://www.gov.nf.ca/env/env/waterres/Surfacewater/drinking/DrinkingWa
ter.asp
For information or questions regarding drinking water quality, child care
services can contact an Environmental Health Officer at their nearest
Government Services Centre location. If there is a boil water advisory in your
area, all drinking water must be brought to a rigorous rolling boil for one (1)
minute. This will kill any disease-causing organisms in the water. Pamphlets
about this issue are available through your Regional Integrated Health
Authority office. If you have a private well, you should have your water tested
regularly.
Here are some tips for preventing E. Coli infection in your child care
setting:
(See also Food Storage Safety)
< Practice good hygiene and careful handwashing practices.
< Cook all ground beef and hamburger thoroughly(well done).
< Avoid unpasteurized milk and unpasteurized fruit juices and cider.
< Avoid spreading harmful bacteria in your kitchen. Keep raw meat
separate from ready- to- eat foods. Wash hands, counters and utensils
with hot soapy water after they have been in contact with raw meat. Do
not put cooked hamburgers or meat on a plate that held raw patties.
< Wash all fruits and vegetables thoroughly, especially those that will not
be cooked.
< Exclude any children with diarrhea (except as outlined above), especially
those in diapers, from your child care setting until diarrhea has
resolved.
< If your community has a boil water advisory:
< ensure that all providers and parents are aware of the boil order.
< follow strict guidelines for boiling water for consumption.
137
Nosebleeds
Most children are likely to have at least one nosebleed, and likely more, during
their early years. There are some preschool age children who have up to
several nosebleeds in a week. It may be very frightening for the child and
provider. For the most part it is not abnormal or dangerous.
The most common causes of nosebleeds are:
<
<
<
<
<
<
<
Colds and allergies causing swelling and irritation.

Trauma such as picking the nose, inserting an object in the nose or hitting
the nose.
Dry climate or exposure to toxic fumes causing the lining of the nose to
dry out and become more fragile and prone to bleeding.
Structural problems inside the nose can lead to crusting and bleeding.
Abnormal tissue growing in the nose.
Blood clotting problems.
Long-term medical conditions.
TIPS for handling nosebleeds in your child care setting

< Encourage the child to sit up and lean forward.
< Loosen any tight clothing around the neck.
< Pinch the lower end of the nose to close the nostrils.
Constipation
Constipation is a condition in which children have bowel movements that are
hard and dry, difficult to pass, and less frequent than usual. A child may also
have cramps. It usually temporary in nature. It should not cause parents or
providers cause for concern.
The common causes of constipation in children are:
< Excessive milk intake.
< Less intake of fibre foods.
< Less intake of fluid.
138
<
<
Ignoring urge to defecate due to fear, embarrassment or lack of

confidence when parent not present, preoccupied with other activities, or
fear of using a public washroom.
Pain from ulcer or crack near anus.
Occasionally a medication or illness can cause constipation. Since a constipated

stool is often hard to pass the child may try to avoid having a bowel movement
by clenching their buttocks, rocking up and down on their toes and turning red
in the face.
TIPS which may be helpful in preventing constipation
< Encourage more fibre rich foods, e.g., fruits, vegetables and whole-grain
cereals and breads. The infant over 6 months of age could have more
vegetables and fruits gradually introduced. The child over 3 years might
be able to have bran cereals, whole wheat or bran bread, oatmeal cookies,
muffins, beans and lentils added to their foods.
< Follow recommendations for milk intake to avoid over consumption and less
desire for other foods.
< Encourage toddlers, preschoolers and school age children to drink lots of
fluids, especially water in between meals.
< Encourage a relaxed attitude about using the toilet or potty.
< If there are cracks around the anus check with parents about how they
have been advised to treat this by their physician.
Child care services can help prevent problems with constipation in young
children by providing meals and snacks from a variety of nutritious food
sources. It is also important to have a relaxed attitude about toilet learning
so that children are not pressured before they are ready. In situations where
the constipation does not seem to be improving, encourage the parents to seek
advice from their physician or public/community health nurse.
GUIDELINES
FOR
MANAGING ILLNESS
141
TABLE I GUIDELINES FOR MANAGING ILLNESS (Revised 05/04)

(for information about communicable diseases that are not included in this chart, please contact your public/community health nurse)
Disease/
Incubation Period
How to Recognize
How It Spreads
When It Is
Contagious
What To Do At Home
What To Do At Child Care

Setting
Chickenpox
Incubation Period:
2-3 weeks Usually
13-17 days
Reportable
Highly Contagious
Sudden onset of slight

fever, tiredness, and loss
of appetite, followed by
the appearance of small
pink spots that change to
blisters and persist for 34 days before scabs form.
New blisters can appear
during this time. These
spots usually appear on the
body, less so on the arms
and legs.
Contact with infected

person, (discharge
from nose or throat)
or contact with items
of linen and clothing
which have been
contaminated with
fluid from the
blisters.
Most contagious
2 days before
the first rash
appears and
continues to be
contagious until
5 days after
rash has
appeared
- Careful disposal of used

tissues.
- Hot water washing of
contaminated articles.
- Keep fingernails short to
prevent scratching and
scarring.
- Use Calamine lotion or baking
soda baths to relieve itching.
- If necessary, give
acetaminophen (e.g.,, Tempra,
Tylenol) for fever. Do not
give Aspirin
- Frequent hand washing.
- Child can attend as long as (s)he is

feeling well enough to take part in
activities. Chickenpox is dangerous
for children who are
immunosuppressed, such as those
taking steroid drugs or any child
who has been treated with anti
cancer drugs. Parents of these
children and pregnant women who
have not had Chicken Pox should
contact their family doctor
immediately.
- Notify Public /Community Health
Unit
Common Cold
Incubation Period:
12-72 hrs. Usually
48 hrs.
Not Reportable
Caused by a virus.
Symptoms include runny
nose, headache, sore
throat, chills, and fever

person (through
coughing and
sneezing) or by
articles freshly soiled
with discharge from
nose and throat, such
as tissues or toys
that have been in the
childs mouth.
1 day before to
5 days after
the onset of
symptoms.
- Rest, increase fluids.

tissues.
- Encourage child to cover
mouth and nose when coughing
and sneezing.
acetaminophen, (e.g., Tempra,
give Aspirin.
- Child can attend as long as s/he

is feeling well enough to take
part in activities.
142
Disease/
Incubation Period

How to Recognize
How It Spreads
When It Is
Contagious
What To Do At Home

Setting
Ear Infection
Not Reportable
Child may have flu-like

symptoms (including fever)
for a few days. May pull at
ears, and complain of
earache. May have
temporary hearing loss.
Not spread from

person to person.
Not contagious
- Take child to family doctor.

- Take full antibiotic
treatment, if ordered by
family physician.
- Child may attend as long as

s/he is feeling well enough to
take part in activities.
Fifth Disease
(Erythema
Infectiousum)
Incubation Period:
4-20 days
Reportable
Highly Contagious
A viral illness, starting

with reddened cheeks
(slapped face appearance)
followed within 1-4 days by
a rosy rash on the trunk,
legs and arms. Rash fades,
but can return for a few
weeks if child is exposed
to sunlight or heat. Very
mild illness unless child has
immuno-suppression or
blood disease.
Indirect contact with

a sick child (coughing
and sneezing) or
direct contact with
the saliva (kissing,
sharing drinks) of a
sick child.
Up to a week
before the rash
appears. Once
the rash
appears, the
disease is not
contagious.
Highly
contagious in
infected
children who
have aplastic
anaemia or are
immuno
suppressed.
- Take the child to the doctor

(to make sure the rash is not
German Measles).
- There is no need to exclude a

child with fifth disease,
providing the child is well enough
to take part in activities.
- Pregnant providers should
contact their physician if they
have been in contact with fifth
disease.
- Parents of children who have
aplastic anaemia or are immunosuppressed should contact their
family doctor immediately.

Disease/
Incubation Period
How to Recognize
How It Spreads
143
When It Is
Contagious
What To Do At Home

Setting
Food Poisoning
Reportable
Sudden onset of nausea,

vomiting, and/or diarrhea.
By eating food
products which
contains the organism
which causes food
poisoning.
Not contagious
- No need to isolate child from

other family members.
- Stress good personal
hygiene including hand washing.
- Give clear liquids as tolerated
by the child.
- Have child examined by
family doctor.
- Specimens of stool and
vomitus should be collected.
- It is important to note what
your child has been eating in
the past day or two.
- Contact parents immediately if

symptoms occur at child care
- Notify Public/Community
Health immediately, as an
investigation may be necessary.
- Child should not attend until
symptoms are gone
- Ensure good personal hygiene,
especially after toileting, and
before preparing/eating food.
German Measles
(Rubella)
Incubation Period:
1-4 weeks (Usually
2 weeks)
Reportable
Highly Contagious
Mild cold symptoms,

swelling of glands in neck
followed 5-10 days later by
a red rash
Contact with
discharge from the
nose and throat of an
infected person.
Directly from person
to person or
indirectly by handling
From 1 week
before to at
least 4 days
after onset of
rash.

tissues.
- Avoid contact with pregnant
women. (Rubella can be
dangerous to unborn babies).
- If necessary use
give Aspirin
- Call a Public/Community
Health Nurse.
- Child must not attend until at

least four days after rash
appears.
- Any providers who are
pregnant should check with
doctor or Public/Community
Health Nurse to determine
whether they have immunity to
this disease.
Health, as unimmunized children
will need to be offered
immunization.
144
Disease/
Incubation Period

How to Recognize
How It Spreads
When It Is
Contagious
What To Do At Home

Setting
Giardiasis
Incubation Period:
1-4 weeks (Usually
2 weeks)
Reportable
Soft mushy foul-smelling

bowel movement or
diarrhea, (mild to severe)
nausea, loss of appetite,
bloating and gas.
Sometimes no symptoms.
Caused by infection with
giardia cysts that grow in
the intestine.
From water that has

been contaminated
with giardia cysts, or
person to person from
infected stool to
hands to mouth.
As long as
symptoms last,
usually from 3 to
10 days.
- Take child to doctor.

Giardiasis can be treated with
medication.
- Stress good personal hygiene
including washing of hands
after toileting and before
preparing/eating food.
- Child must not attend until

diarrhea is gone.
- Ensure good personal hygiene,
especially after toileting and
before preparing/eating food.
- If more than one case occurs,
inform
Public
Health
Unit/Community Health Agency
immediately.
Hand, Foot and

Mouth Disease
(CoxsackieA)
Incubation Period
3-5 days
Not Reportable
Fever, headache, sore

throat, loss of appetite and
a rash: red blister-topped
spots on the palms,
fingers, feet. Small painful
mouth ulcers can occur as
well. The blisters contain
the virus.
Contact with
discharge from the
infected person.
Contact with soiled
articles such as
clothing or diapers.
Two weeks or
more after the
onset of the
illness.
- See family doctor to rule out

other illness.
tissue.
- Careful hand washing after
changing diapers, toileting, and
before preparing and eating
food.
- Encourage good hygiene,

especially hand washing habits.
- Clean change table area
thoroughly.
-
No
isolation
required.
Exclusion of the child will not

prevent additional cases since
the virus may be excreted for
weeks after the symptoms have
disappeared. Some children who
have the virus may have no
symptoms. There may be some
benefit in excluding children who
have blisters in their mouths and
who drool or who have weeping
lesions on their hands.

Disease/Incubation
Period
How to Recognize
145
How it Spreads
When It Is
Contagious
What To Do At Home

Setting
Haemophilias
Influenza type b
disease (HIB
disease)
Incubation Period:
2-4 days
Reportable
HIB disease includes HIB

Meningitis, a bacterial
infection of the lining of
the brain. Symptoms
include headache, fever,
irritability, tiredness and
vomiting. Stiff neck and
back are additional
symptoms seen in older
children.
Contact with the nose

and throat secretions
(coughs and sneezes),
or direct contact with
saliva (kissing or
sharing drinks) of a
sick child who has not
been treated.
As long as the
organisms are
present in the
untreated child
until 48 hours
after starting
the
proper
treatment with
antibiotics.
- Have the child seen

immediately by a doctor.
- Notify the child care service
and parents of other children
who have been in contact with
the child.
- N o t i f y P u b l i c H e a lt h
immediately, as unimmunized
children will need to be offered
immunization.
- Treatment with antibiotics may
be necessary for other children
in the child care setting.
- A sick child must be excluded
until 48 hours after treatment is
started.
- Advise parents.
Hepatitis A
Incubation Period:
15-50 days
incubation Usually
28-30 days
Reportable
Highly Contagious
An illness that is caused by

the Hepatitis A virus
infecting the liver.
Symptoms of disease
include fever, tiredness,
loss of appetite, nausea
and abdominal pain,
followed by jaundice
(yellowing of the skin).
From person to
person. The virus is
found in the stool of
an infected person
who can pass it
directly to another
person, especially if
people do not wash
their hands and the
childrens hands after
changing diapers and
after having a bowel
movement. The virus
may also be present in
food and water. If a
person eats or drinks
contaminated water,
they can become
infected.
As long as the
virus is present
- from about 15
days before
symptoms
appear until
about a week
after jaundice
starts.
- A child or provider who might

have been exposed to the virus
should see a physician.
- If disease develops, then the
child should be kept at home
until a week after jaundice has
appeared. The child can then
return to the child care setting
providing s/he feels well enough
to attend.
- Ensure good hygiene,

especially hand washing habits.
- Inform parents that a case
has occurred in the child care
setting and be alert for
symptoms in other children.
- Notify Public Health
that a case has occurred.
- Child should not return to
setting until one week after
jaundice (yellow skin) first
appears.
146
Disease/
Incubation Period
How to Recognize
How It Spreads
Hepatitis B
Incubation Period:
45 - 180 days
Usually 60 - 90
days
Reportable
Contagious
Hepatitis B is a virus that

infects the liver.
Symptoms of disease
develop gradually: loss of
appetite, abdominal
discomfort, nausea and
vomiting, pain, mild fever,
rash and jaundice
(yellowing of the skin).
Disease may be unapparent
(no symptoms), mild or very
serious (resulting in
permanent liver damage or
death). Young children
with Hepatitis B usually
have very mild symptoms
or none at all.
It can be spread in
several ways (1)
through sexual
contact with an
infected person, (2)
through exchange of
infected blood (such
as shared needles in
injection drug use),
and (3) from an
infected mother to
her baby before or
during birth. In some
cases spread within
families can occur,
particularly with
young children.
When It Is
Contagious
As long as the
person has the
infective virus
in the blood.
There must be
exchange of
blood or other
body fluids in
order to pass
the virus from
one person to
another.
What To Do At Home

Setting
- A child who may be infected

should be seen by a physician.
- Discourage sharing of
personal items such as
toothbrushes.
- As with any other infection,
use universal precautions when
handling blood, stool or urine.
- Contact your Public Health
Unit /Community Health
Agency for information about
vaccination for household
contacts.
- A person with Hepatitis B

disease should not be excluded
from child care. However, any
person who may have Hepatitis
B disease should see a physician.
- Discourage sharing of
personal items such as
toothbrushes.
- As with any other infection,
use universal precautions when
handling blood, stool or urine.
147
Disease/
Incubation Period
How to Recognize
How It Spreads
When It Is
Contagious
What To Do At Home
HIV Infection
and HIV/AIDS
Reportable
The Human Immunodeficiency virus (HIV)

attacks the immune system
and causes Acquired
Immune Deficiency
Syndrome (AIDS). A child
may be infected with HIV
for many years. Symptoms
of HIV/AIDS in children
include weight loss or
failure to gain weight
normally, tiredness, fever,
and diarrhea. These
symptoms are common and
general; children often
have one or more of these
symptoms. Children with
HIV/AIDS get very ill with
any infection, and may have
unusual infections as well.
There is a blood test that
can be done to test for
HIV infection.
From person to
person by exchange
of blood and other
body fluids. It can be
spread in several
ways:
(1) through sexual
contact with an
infected person,
(2) through exchange
of infected blood
(such as shared
needles in injection
drug use), and
(3) from an infected
mother to her baby
before or during
birth, or by
breastfeeding.
From the time

of infection.
There must be
exchange of
blood or body
fluids in order
to pass the
virus from one
person to
another. Saliva,
tears, urine,
feces or
vomitus are not
considered to
be infected
unless they
contain blood.
This virus is not spread through

everyday contact in the home or
at child care. A child with HIV
infection can attend child care.
However, the child with HIV
infection or the child who has
developed HIV/AIDS can
become very ill if exposed to
common childhood infections
such as chickenpox. This must
be considered when deciding
whether or not the child should
attend child care.
- A child or provider who has HIV

infection need not be excluded
from child care. A child or
provider who has HIV/AIDS and
is well enough may attend.
- The infection is not spread by
casual contact.
- In addition, the parents of any
child with immune systems
problems, including HIV infection
and HIV/AIDS, must be
informed if other children in the
centre have infections of any
sort.
- As with any other infection, use
good hygiene practices when
handling blood, stool or urine
148
Disease/Incubation
Period
How to Recognize
How It Spreads
When It Is
Contagious
Impetigo
Incubation Period:
4-10 days
Not Reportable
Highly Contagious
Small, clustered, pus-filled

sores with little drainage.
Often on face, diaper area,
arms and lower part of leg.
Caused by a bacterial
infection.
Contact with the fluid

from sores. Often
spread from one area
of the body to
another by hand.
While there is
pus in the sore.
- See family doctor.

- Use antibiotic treatment as
directed.
- Child must not attend until 24

hours after treatment with
antibiotics begins.
- Stress personal hygiene.
Infectious
Mononucleosis
Incubation Period:
4-6 weeks
Reportable
A viral infection.
Symptoms include fever,
sore throat, swollen glands,
tiredness and loss of
appetite.
Person to person by
mouth, (e.g. kissing),
or through children
mouthing toys, and
other objects that
have been
contaminated with
infectious saliva.
Mildly
contagious

- Rest as required.
- Stress good hygiene.
- No restrictions provided child

feels well enough to attend.
Head Lice
Incubation Period
of eggs: 1 week
Not Reportable
Scratching the head,

presence of lice or nits
(eggs) in hair.
Direct contact or
indirect through
sharing head clothing,
brushes, and clips,
etc.
As long as lice
or eggs remain
alive on the
person.
- Examine all family members.

- Launder clothing and linen in
hot (55C or 131F) water for
20 minutes, or dry in hot dryer
or dry clean.
- Use medicated shampoo as
directed and remove all nits.
- Some medication should not
be used on children less than 2
years of age or pregnant
women.
-Do not use conditioner or
shampoo/conditioner before or
after the treatment

treatment with medicated
shampoo and all nits are
removed.
What To Do At Home

Setting

Disease/
Incubation Period
How to Recognize
149
How It Spreads
When It Is
Contagious
What To Do At Home

Setting
Measles
Incubation Period:
7-18 days Usually
10 days
Reportable
Highly Contagious
Caused by a virus.
Symptoms include fever,
tiredness, cough, runny
eyes, red rash over face,
neck, behind ears. Eyes
sensitive to light.
Contact with
discharge from the
infected person.
to person or by
indirect handling of
2 days before
onset of fever
(3-5 days
before onset of
rash) until 4
days after
onset of rash

tissue.
give Aspirin
- See public/community health
nurse if there are other people
in the home not immunized.
Health, as unimmunized
children will need to be offered
immunization.
- Child must not attend until at
least four days after rash
appears. Identify unimmunized
children and adults.
Meningococcal
Disease
Incubation Period:
2-10 days Usually
3-4 days
Reportable
A bacterial infection that

can affect the lining of
the brain (meningitis).
Symptoms include sudden
severe headache, vomiting
and stiff neck. High fever
and irritability are seen in
younger children. Can also
affect the blood
(meningococcaemia).
Symptoms include severe
headache, vomiting and
high fever in young
children. There may also
be a purplish bruise-like
rash on the body.

(coughs and sneezes),
or direct contact with
the saliva (e.g., kissing
or sharing drinks) of a
sick child who has not
been treated or a well
child who is carrying
the bacteria.
until 24-48
hours after
starting the
proper
treatment with
antibiotics.
- Have the child seen

immediately by a doctor.
- Notify the child care setting
and parents of other children
who have been in contact with
the child.
-Notify Public Health

Unit/Community Health
immediately.
- Treatment with antibiotics
may be necessary for adults
and other children at the
setting.
- Advise parents of all children
if there is a case at the child
care setting.
- Any child who is sick should be
seen by family doctor.
- Provide public /community
health nurse with a list of
names, parents names,
addresses, phone numbers and
family doctors for all children
attending the setting.
150
Disease/Incubation
Period

How To Recognize
How It Spreads
When It Is
Contagious
What To Do At Home
What To Do At School
Mumps
Incubation Period:
12-25 days
Usually 18 days
Reportable
Highly Contagious
Fever with swelling and

tenderness on one or both
sides of face.
Contact (coughing,
sneezing) with
infected person or
articles soiled with
saliva.
From 7 days
before swelling
to 9 days after.
Most contagious
in the 2 days
before swelling
starts.
- Do not give Aspirin.

acetaminophen (e.g.,, Tylenol,
Tempra)
- Disinfect articles soiled by
saliva by hot water washing.
tissue.
- See public/community health
nurse or family doctor.

Unit/Community Health Agency,
as unimmunized children will
need to be offered
immunization.
- Child should not attend until 9
days after swelling appears.
- Identify unimmunized children
and adults.
Pink Eye
Conjunctivitis
Incubation Period:
24-72 hours
Not Reportable
Highly Contagious
A bacterial or viral infection

that starts with watery,
itchy eyes progressing to
yellowish drainage from
eyes. Usually infects both
eyes. Sensitivity to light,
swollen lids and pink
colouration of eye. Most
often affects children
under 5 years of age .
Direct contact or
indirect contact with
discharge from the
eye, such as on
clothing, tissues, etc.
While there is
drainage from
the eye.
- See family doctor and use

treatment as directed.
- Discourage rubbing or
touching eyes.
If the child has drainage from

the eyes, she or he should be
kept home for at least 24 hours
after medication is started.
151
Disease/
Incubation Period
How to Recognize
How It Spreads
When It Is
Contagious
What To Do At Home
Pinworm Disease
Incubation Period:
2-6 weeks
Not Reportable
Anal itching, disturbed

sleep, irritability. Skin
may become infected
because of frequent
scratching.
From person to
person, directly by
transfer of eggs by
hand from rectum to
mouth. Indirectly
through clothing,
bedding, food, or
other articles
contaminated with
eggs.
If untreated,
about 2 weeks
- See family doctor for

treatment.
- Daily shower or sponge bath
(not tub bath).
- Change bed linen and
underwear daily during
treatment.
- Launder clothing and linen in
hot (55C or 131F) water.
- Clean/vacuum sleeping and
living areas daily for several
days after treatment.
- Examine all members of
family for infection.
- Encourage good personal

hygiene habits.
- Proper hand washing and food
handling techniques are
essential. - No isolation
required.
- Clean/vacuum child care
service daily for several days
after treatment.
Ringworm
a) Scalp
Incubation Period:
10-14 days Not
Reportable
Scaly, grey mildly itchy

ring on scalp. Hair breaks
off, leaving bald spots.
Direct skin-to-skin
contact with infected
areas, or indirect
through shared
combs, hats, hair
bands and clips. May
be passed from animal
to human.
As long as rings
are present.
- See family doctor and obtain

medication.
- Daily washing of hair. Hot
water (55C or 131F) washing
of contaminated articles.
- Treat infected animals
- Examine family members.
- No isolation required.
- Stress good personal hygiene.
-Examine child care contacts.
-Child should not return until
treatment has started and
should avoid activities which
could lead to another exposure
of others until cure is
completed.
152
Disease/
Incubation Period
How to Recognize
How It Spreads
When It Is
Contagious
What To Do At Home
Ringworm
b) Body
Incubation Period
4-10 days Not
Reportable
Flat, spreading ring-shaped

spots, moist or scaly.
Reddish brown edge with
white scales, clear at
centre as rings spread.
Contaminated articles
of clothing, floors,
shower stalls,
benches, direct skin
to skin contact with
sores and indirectly
through clothing. May
be passed from animal
to human.
As long as rings
are present
- See family doctor and obtain

medication.
- Bathe daily with mild soap
and water.
- Hot water (55C or 131F)
washing of contaminated
articles.
- Treat infected animals.
- Examine family members.
-No isolation required

- Stress good personal hygiene
- Examine child care contacts.
-Children should not return to
school until treatment has
started and should avoid
activities which could lead to
exposure of others until cure is
completed.
Scabies Itch
Incubation Period:
2-6 weeks before
itching
Not Reportable
Small sores around finger

webs, back of wrists,
elbows, skin folds, armpits,
lower portion of buttocks,
beltline. Itching - more
intense at night.
Usually direct skinto-skin contact.

Through clothing or
toys only if worn or
handled by the
infected person
immediately
beforehand.
Until mites are

destroyed
(usually one
treatment).
- All family members should be

treated. Launder all clothing
and linen used by the infected
person in hot water (55C or
131F) and dry in dryer or dry
clean.
- Use a medication lotion such
as Kwellada as directed.
- Some medicated lotions
should not be used on children
less than 2 years of age or
pregnant or breastfeeding
women Consult your physician.

the day after treatment.
Scarlet Fever
Incubation Period:
1-3 days
Reportable
Fever, headache, sore

throat, vomiting, fine red
rash that feels like
sandpaper on neck, chest,
arms, and legs. Flushing of
cheeks, whitened area
around mouth, very red
tongue.
Contact with
discharge from the
infected person.
to person.
Until 24 hours
after starting
antibiotic
treatment.
- See family doctor

-Careful disposal of used tissue
- Take full antibiotic treatment.
-If necessary, give acetaminophen
(e.g. Tempra, Tylenol). Do not give
Aspirin

hours after treatment is
started.
Health.
153
Disease/
Incubation Period
How to Recognize
How It Spreads
When It Is
Contagious
What To Do At Home
Stomach Flu
Gastroenteritis
Incubation Period:
Approximately 48
hours
Highly Contagious
May complain of abdominal

pain, accompanied by
vomiting and/or diarrhea.

person or soiled
articles such as
clothing and diapers.
For duration of
illness
- Clear fluids for 24 hours

- Careful hand washing after
changing diapers, toileting, and
before preparing and eating
food.
- See family doctor if
symptoms persist.

vomiting and diarrhea have
stopped.
- Proper hand washing and food
handling techniques are
essential. - Advise parents of all
children if there is an outbreak
at the child care setting.
Strep Throat
Incubation Period:
1-3 days
Not Reportable
Contagious
A bacterial infection that

leads to fever, sore throat
and mouth. Redness and
white spots on mouth and
throat.
Contact with
discharge from the
infected person.
to person.
Until 24-48
hours after
starting
antibiotic
treatment.

-Take full antibiotic
treatment.
give aspirin.

hours after antibiotic
treatment is started.
Whooping Cough
Incubation Period:
7-14 days Usually
7-10 days
Reportable
Highly Contagious
Begins with cold-like

symptoms and a cough that
gradually gets worse
leading to coughing attacks
that end with a sharp
pitched whooping sound.
During a coughing attack a
child may become blue in
the face, and may vomit
when the attack is over.

(coughs & sneezes) of
infected people.
From the early

stage before
coughing starts
until 5 days
after beginning
treatment with
antibiotics.
Without
antibiotics, it is
contagious for
up to three
weeks after
coughing starts.
give Aspirin
tissues.
-Hot water washing of
- Frequent hand washing
- See family doctor as some
members may need antibiotics
or immunization
- Child should not attend until 5

days after antibiotic treatment
has begun.
- Be alert for similar coughs in
other children.
Unit/Community Health Agency,
as children at the setting may
need to be offered
immunization and/or antibiotics.
155
Facts about Chickenpox

Chickenpox is a common infectious disease of childhood. It is caused by a virus,
and is spread through the air by cough or sneeze or by contact with the fluid
in a chickenpox blister.
HOW TO RECOGNIZE CHICKENPOX
Chickenpox starts with a fever, followed several days later by a red, spotty,
itchy rash. The spots turn into fluid filled blisters that crust over. More
blisters can appear while the first ones are still crusting over.
Children who have chickenpox can be infectious from several days before the
spots appear until five days after they appear.
WHAT PARENTS CAN DO
Look for signs and symptoms if there has been a case reported at the child
care service.
Inform the child care service if your child gets chickenpox.
Do not try to isolate your child from other household members, because it is
almost impossible to stop chickenpox from spreading to people in the house who
have not had chickenpox. If someone else catches the infection, it will appear
2-3 weeks after the family member got it.
Check with the family doctor if your child or a member of your household has
cancer, immune system problems, or is taking any anti-cancer drugs.
Chickenpox can be very serious for these people.
If you have not had chickenpox and you are pregnant, check with your family
doctor.
Give acetaminophen, not aspirin, for fever. Taking aspirin or aspirin products
increases the risk of Reyes syndrome, which can cause damage to the liver and
brain. It is, however, safe to use acetaminophen products (e.g., Tylenol,
Tempra).
156
Facts About The Common Cold

Colds are caused by viruses and so cannot be treated with antibiotics. Colds are
easily spread directly from sneezing or coughing or by contacting the saliva /
runny nose of another child. They can also spread indirectly from toys or other
objects.
How to Recognize the Common Cold

Colds are very common and most children have several a year. Sometimes a child
seems very sick with high fever, lack of energy and loss of appetite. Usually a
cold results in coughing, sneezing and runny nose.
What Parents Can Do

Make sure you wash your hands frequently and your childs especially after nose
wiping or before preparing food or eating.
Encourage your child to get lots of rest and drink lots of fluids.
Antibiotics do not help the common cold.
Often, a more serious illness can begin as a cold. Contact your doctor if your
child shows any of the following signs:
<
<
<
<
<
<
<
Earache.
Fever higher than 39C(102F).
Sleepier than usual.
More cranky and fussy.
Skin rash.
Persistent coughing.
Rapid breathing or difficulty breathing.
Your child may continue to attend child care if feeling well enough to
participate in activities. Your child may participate in outside activities even in
winter.
157
Facts About Ear Infections

Ear infections can be caused by bacteria or a virus so they can sometimes be
treated with antibiotics. Older children complain of ear ache. Young children
and infants may be more irritable and fussy.
HOW TO RECOGNIZE EAR INFECTIONS
Ear infections are very common in children. The infection often follows a cold
and has similar symptoms. Your child may seem very sick with high fever, lack
of energy and loss of appetite. The child may complain of having an earache
and/or may tug at his or her ears.
What Parents Can Do

If you think your child may have an ear infection, you should see a doctor who
will look inside your childs ears. If your child has been prescribed an antibiotic
medication, ensure that she or he takes all of the medication that is prescribed
even if the ear ache has improved. Your doctor may also recommend a painkiller
(e.g. acetaminophen) to relieve discomfort.
Sometimes complications can develop with ear infections. Contact your doctor
if your child shows any of the following signs:
<
<
<
<
<
<
<
Earache becomes worse even with treatment.

High fever over 39 C(102F) or a fever that lasts more than three days.
Child is more sleepy than usual.
Child is more cranky or fussy.
Skin rash.
Rapid or difficulty breathing.
Hearing loss.
Your child may continue to attend child care if feeling well enough to
participate in activities.
158
Facts about Fifth Disease

Fifth disease is a respiratory infection that is caused by a virus. It spreads
like a cold does, directly from sneezes or coughs, and indirectly by the hands
or objects (such as toys).
HOW TO RECOGNIZE FIFTH DISEASE
Fifth disease begins with a red rash on the face, in a slapped face pattern.
About 1 to 4 days later, a lacy red rash appears on the arms, spreading slowly
to the trunk. The rash can last for up to three weeks, and fever may be
present as well. The rash tends to look much worse when the child is warm:
just after a bath, for example. Generally, fifth disease is very mild, and a child
will not feel especially sick with it.
Fifth disease is infectious up to a week before the rash appears, and once the
rash appears on the body, it is no longer infectious.
There is no medication available to treat fifth disease, and it is very common
in school aged children.
WHAT PARENTS CAN DO
Watch for the signs of Fifth disease in your child if a case has occurred in the
child care service.
Contact your doctor if you are pregnant and your child has Fifth disease.
Keep your child out of child care only if he or she feels unwell.
159
Facts about Giardiasis

Giardiasis is a parasite or a tiny bug that can live in the human intestine and
cause diarrhea. It can be very common in child care settings. It is usually
spread from contaminated water to a person drinking the water, or from the
hands of a person who has changed a diaper or used a toilet without washing his
or her hands. Proper handwashing afer diapering or toileting and before
handling food can prevent the spread of giardiasis.
HOW TO RECOGNIZE GIARDIASIS
There may be no symptoms at all, or there may be diarrhea, foul smelling mushy
bowel movements, gas, loss of appetite and weight loss.
A person will be infectious for as long as the symptoms last, usually 3 to 10
days. There is medication available to kill the giardiasis bug.
WHAT PARENTS CAN DO
Look for signs of Giardiasis in your child if there has been a case at the child
care service.
Take your child to your doctor if you think he or she has Giardiasis.
Tell the child care service if your child as Giardiasis. If your child does have
Giardiasis, he or she should not go back to child care until the diarrhea has
cleared up.
Encourage good handwashing habits; before eating and after going to the toilet
or diaper changes.
If your water is supplied by a private well, it should be tested.
160
Facts about Hand, Foot and Mouth Disease

Hand, Foot and Mouth disease is an infection caused by a virus. The infection
can occur at any age, but it is most likely to affect young children. It usually
occurs in the summer and fall.
HOW TO RECOGNIZE HAND, FOOT and MOUTH DISEASE
Hand, foot and mouth disease is usually not a severe illness. It may cause:
< fever
< headache
< sore throat
< loss of appetite
< lack of energy
< small, painful ulcers in the mouth
< skin rash; red spots, often topped by small blisters. It usually appears
on the hands and feet, but can affect other parts of the body as well.
The virus that causes the infection is found in saliva and spreads from person
to person through the air or by touch, as do cold viruses. It is not related to
the virus that causes diseases in animals. There is no treatment for the
infection.
WHAT PARENTS CAN DO
Watch your child for symptoms of hand, foot and mouth disease if another
child at the child care service has it. If symptoms appear, contact your
physician immediately. The physician can determine if the rash is due to hand,
foot and mouth disease. If your child has a more severe infection, it is
important for the physician to diagnose it as soon as possible.
Make sure you wash your hands after wiping the childs nose, changing a diaper,
and using the toilet, and before preparing food.
Your child may continue attending the child care service if feeling well enough
to take part in the activities. There is the possibility that the child may be
excluded from the child care setting if he or she has blisters in the mouth and
is likely to drool or if he or she has weeping lesions or blisters on hands.
161
Facts about Hepatitis A

Hepatitis A is a liver infection caused by a virus. It can be spread to people
through water or food that has been contaminated with feces (bowel
movement) of a person with the illness. This can happen if a person preparing
food is not careful about handwashing after using a toilet, or after diapering
a child.
HOW TO RECOGNIZE HEPATITIS A
Hepatitis A will make a person feel generally unwell. Symptoms include: fever,
loss of appetite, nausea, jaundice (a yellow colour in the whites of the eyes and
the skin).
Young children sometimes have no symptoms at all, and will not feel sick with
Hepatitis A.
Children or adults with Hepatitis A can be infectious for weeks before showing
any signs. They are no longer infectious one week after symptoms of jaundice
begin. There is no treatment for Hepatitis A, as it will clear up by itself. You
can help prevent the disease if your child has been exposed, with an injection
that the family doctor can give. This injection must be given within two weeks
after the child has been exposed.
WHAT PARENTS CAN DO
Contact your family doctor if your child attends a child care service where a
case of Hepatitis A has occurred, and watch for any signs of disease in your
child.
Notify the child care service if your child develops Hepatitis A.
If your child does develop disease, he or she should not attend the child care
service until a week after symptoms of jaundice appear.
Encourage good handwashing habits in all family members.
162
Facts about Impetigo

Impetigo is a skin infection caused by bacteria, and is very common in children,
especially during the summer months. Bacteria enter the skin through
scratching of fly bites or cuts. The bacteria can spread by touch from one
child to another. Impetigo usually occurs on the face.
HOW TO RECOGNIZE
Symptoms include: clusters of tiny red blisters or bumps, usually around the
mouth or nose, or areas of skin not generally covered by clothing.
Blisters are covered with pus, or a honey coloured crusting.
Impetigo can be treated with antibiotics, prescribed by a doctor. The sores
are infectious as long as there is pus or fluid in them. The sores are no longer
infectious after 24 hrs. of antibiotic treatment.
WHAT PARENTS CAN DO
Watch for signs of Impetigo if another child in the child care service, or a
playmate of your child, has it.
Take your child to the doctor if you think he or she has Impetigo.
If medication is prescribed, use as directed for the full time, even if the
infection seems to be cleared up (otherwise it may recur)
If someone in the family has Impetigo, make sure he or she uses separate face
cloths and towels until the infection clears up.
If your child does have Impetigo, keep him or her at home for a day after
medication is started.
163
Facts about Pink Eye

Pink eye is an infection of the covering of the eye, caused by viruses or
bacteria. It can be spread by touch from the infected eye to the fingers to
the eye of another child, or by the same face cloth being used to wipe the eyes
of an infected child and another child.
HOW TO RECOGNIZE
Symptoms include:
< scratchy, itchy feeling or pain in the eye
< teary eyes
< drainage from the eye that can dry and form a crust at night, making
the lid stick together
Bacterial pink eye can be treated with antibiotics prescribed by a doctor.
WHAT PARENTS CAN DO
Watch for signs of pink eye if another child in the child care service, or a
playmate of your child, has it.
Take your child to the doctor if you think he or she has pink eye.
If medication is prescribed, use as directed for the full time, even if the
infection seems to be cleared up (otherwise it may recur).
If someone in the family has pink eye, make sure he or she uses separate
facecloths and towels until the infection clears up.
Avoid rubbing or touching the infected eye.
If you child does have drainage from the eyes, keep him or her at home for at
least 24 hours after medication is started.
164
Facts About Ringworm

Ringworm is a skin infection caused by a fungus. It spreads from person to
person by touch. When someone with ringworm touches or scratches the rash,
the fungus sticks to the fingers or gets under the fingernails. It is then spread
when that person touches someone else. It can also spread from contaminated
articles of clothing, floors, shower stalls and benches.
HOW TO RECOGNIZE RINGWORM
The rash may have a ring-shape with a raised reddish, brown edge. It is usually
quite itchy and flaky. If the scalp is infected there is an area of baldness.
Fungal infections of the feet are itchy and cause cracking between the toes.
Ringworm can be cured with a special anti-fungal medication either by mouth
or as creams or ointments spread on the infected area.
What Parents Can Do

Check your childs scalp and skin for signs of ringworm if another child has it.
Contact your doctor if you think your child has ringworm.
Bathe your child daily with mild soap and water.
Make sure you wash your hands and your childs hands after touching the
infected area.
If your child has ringworm of the scalp, make sure there is no sharing of childs
comb, hairbrush, face cloths and towels.
Hot water wash 55C (131 F) of contaminated articles.
Your child should not return to child care until after treatment has started.
165
Facts about Strep Throat and Scarlet Fever

Strep throat is a bacterial infection that can be spread by infected throat and
nose secretions. Coughing and sneezing at close range can spread infection.
HOW TO RECOGNIZE STREP THROAT
Symptoms include:
< headache
< sore throat
< stomach ache
< swollen glands
< sores around the nose
Sometimes strep throat can become scarlet fever, with a red sandpapery rash
covering the body.
Strep throat and scarlet fever are infectious until 24 hrs. after antibiotic
treatment starts. Antibiotics will make a person with strep throat feel better
very quickly, but it is important to take all medication as prescribed.
WHAT PARENTS CAN DO
Look for signs of strep throat in your child if another child at the child care
service has it.
Take your child to the doctor if you think he or she has strep throat or scarlet
fever. Take all medications as prescribed. If all medication isnt taken, the
infection may come back.
Make sure your child knows how to cover the mouth when coughing or sneezing,
and to wash hands after. Use disposable tissues for wiping noses.
If your child has strep throat and scarlet fever keep him or her at home until
24 hrs. after treatment has started.
166
Facts about Whooping Cough

Whooping cough or Pertussis is a serious bacterial infection. It affects
children, especially those under a year of age. It is spread through secretions
from the nose and mouth, and can spread very easily through the air or by
touch.
HOW TO RECOGNIZE WHOOPING COUGH (PERTUSSIS)
The following symptoms develop over time, starting mildly but becoming more
serious:
< runny nose
< cough that becomes more and more severe, leading to coughing attacks
that may cause the child to turn blue, to vomit, and will end with a loud
Whoop noise as breath is taken in
Whooping cough can be spread up to 2 weeks before any symptoms are noticed,
and up to three weeks after, if it is not treated. Medication must be taken for
14 days in order to prevent spreading. WHOOPING COUGH CAN BE
PREVENTED. Immunization can help to prevent whooping cough. All children
should be immunized against this disease.
WHAT PARENTS CAN DO
Make sure that your child is fully immunized against pertussis.
See your doctor if you think your child has pertussis.
If a case occurs in the child care service, your child may have to take
medication for 14 days as a protective measure. Make sure that all medication
is taken.
If your child has whooping cough, he or she must not return until five days
after treatment has started.
Even after treatment, coughing attacks may occur for up to one or two months.
167
Facts about Measles

Measles is viral infection that spreads very easily. The virus travels through
the air, in the droplets from the nose and throat of an infected person, or
indirectly by handling tissues or handkerchiefs of a person who is infected.
HOW TO RECOGNIZE MEASLES
Symptoms include:
< fever
< tiredness
< cough
< runny nose
< flat red rash over face, neck and behind ears that gradually spreads to
the rest of the body
< sore eyes that are sensitive to light
< spots (blue/white centres) in the mouth
A person with Measles is infectious one day before the onset of fever, 4 days
before a rash appears, and until 4 days after the rash appears. A child with
Measles must not attend a child care service until at least four days after the
rash appears.
MEASLES CAN BE PREVENTED. Immunization with MMR vaccine will prevent
measles from occurring. All children and adults in a child care service should
be protected from measles. Immunization on, or shortly after, the first
birthday and again at 18 months is the best way to protect your child from this
very infectious disease. Vaccine is given as a combined product: Measles,
Mumps, and Rubella (MMR).
WHAT PARENTS CAN DO
Make sure your child has been immunized, to protect against measles.
If your child has not been immunized, or is too young (less than a year old), see
your family doctor right away if the child has been exposed to a case.
If a case has occurred at child care, watch your child for symptoms.
168
Facts about German Measles (Rubella)

German Measles (Rubella) is a viral infection that spreads very easily. The virus
travels through the air, in the droplets from the nose and throat of an infected
person, or indirectly by handling tissues or handkerchiefs of a persons who is
infected.
HOW TO RECOGNIZE GERMAN MEASLES (RUBELLA)
Symptoms include:
< cold-like symptoms
< 1-5 days with a low grade fever
< swollen glands in neck, followed about 5-10 days later by a red rash on
the body
A person with German Measles is infectious for one week before rash appears,
and until at least 4 days after.
GERMAN MEASLES CAN BE PREVENTED. Immunization will prevent German
Measles from occurring. All children and adults in a child care service must be
protected from German Measles, and immunization on or shortly after the first
birthday and at 18 months is the best way to protect your child from this very
infectious disease. Vaccine is given as a combined product: Measles, Mumps,
and Rubella (MMR).
WHAT PARENTS CAN DO
Make sure your child has been immunized, to protect against German Measles.
your family doctor right away, if the child has been exposed to a case.
If you are pregnant, and your child or a family member has been exposed to
German measles, see your doctor right away, as German Measles can affect an
unborn baby.
169
Facts about Mumps

Mumps is a viral infection that spreads very easily. The virus travels through
the air, in the saliva of an infected person, or indirectly by handling tissues or
handkerchiefs of a person who is infected, or sharing food and drinks.
HOW TO RECOGNIZE MUMPS
Symptoms include:
< fever
< swelling of one or both sides of the face
A person with mumps is infectious for one week before any symptoms appear
and up to 9 days after swelling appears.
MUMPS CAN BE PREVENTED. Immunization will prevent mumps from
occurring. All children in a child care service should be protected from Mumps,
and immunization on or shortly after the first birthday is the best way to
protect your child from this very infectious disease. Vaccine is given as a
combined product: Measles, Mumps, and Rubella (MMR).
WHAT PARENTS CAN DO
Make sure your child has been immunized to protect against Mumps.
your family doctor right away if the child has been exposed to a case.
170
Facts about HIB Disease

HIB Disease is caused by infection with Haemophilus influenzae type b
bacteria. It can lead to HIB meningitis, an infection of the covering of the
brain. HIB disease is spread by direct contact with the nose and throat
secretions (coughs and sneezes) or by direct contact with the saliva (kissing,
sharing drinks) of a sick child who has not been treated.
HOW TO RECOGNIZE HIB MENINGITIS
Symptoms include:
< headache
< fever
< irritability
< tiredness
< vomiting
< stiff neck and stiff back (older children)
HIB meningitis is very serious and life threatening disease, needing immediate
medical attention. It can be spread as long as bacteria are in an untreated
child until 2 days after starting antibiotics. HIB MENINGITIS CAN BE
PREVENTED. Immunization can protect children from the disease. All children
at a child care service should be fully immunized against HIB disease by the
time that they are 19 months old.
WHAT PARENTS CAN DO
Make sure that your child is immunized and protected against HIB disease.
your family doctor right away if the child has been exposed to a case. Be alert
for symptoms in your child.
If your child develops HIB Meningitis or other HIB disease, get immediate
medical attention
Inform the child care service right away if your child does develop HIB
Meningitis or other HIB disease.
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Facts about Meningococcal Disease

Meningococcal disease is caused by bacteria that infects the lining of the brain
(meningococcal meningitis) or the blood (meningococcemia). It is spread by
direct contact with the nose and throat secretions (coughs and sneezes) or by
direct contact with the saliva (kissing, sharing drinks) of a sick child who has
not been treated.
HOW TO RECOGNIZE MENINGOCOCCAL DISEASE
Symptoms of Meningococcal meningitis include:
< sudden severe headache
< vomiting
< stiff neck
< high fever and irritability (younger children)
Symptoms of Meningococcemia include:
< severe headache
< vomiting and high fever (younger children)
< purplish, bruise-like rash (this is a late sign)
Meningococcal disease is a very serious and life threatening disease, needing
immediate medical attention. The infection can be spread until 2 days after
treatment until antibiotics are started.
WHAT PARENTS CAN DO
Observe your child for any signs or symptoms if a case has occurred at the
child care service.
If a child at the service does have meningococcal disease, your child may have
to take some medication for 2 days as an extra measure of protection. Make
sure all the medication is taken as directed.
If you think your child may have meningococcal disease, get immediate medical
attention.
Inform the child care service right away if your child does develop
meningococcal disease.
172
Facts about Head Lice

Head lice are tiny wingless, greyish insects that live on the scalp. They lay
eggs, called nits, which stick to the shaft of the hair very close to the scalp.
Nits may look like dandruff but they cannot be flicked off.
Head lice are very common in child care settings and are spread from person
to person by direct contact among children or on items such as hats, combs,
hair brushes and hairbands. Children need to be reminded not to borrow these
items. Head lice can be easily spread as long as lice or eggs remain alive on the
person.
HOW TO RECOGNIZE HEAD LICE
One of the first signs is itching and scratching the head. Look close to the
scalp, behind the ears, the back of the neck and the top of the head.
Head lice will hide from light, so they are not easy to see.
Look for nits by parting hair in small sections going from one side of the head
to the other. Check carefully, looking close to the scalp.
Spend a few minutes every week checking your childs head.
WHAT PARENTS CAN DO
If another child has head lice check your childs hair for nits immediately, after
one week, and then again after two weeks.
All family members (adults and children) must be checked if one member has
head lice and treat anyone with lice or nits with a treatment for head lice.
Head lice can be treated with a special medicated shampoo or cream rinse
which can be purchased over the counter at your drug store.
The medication does not always kill 100% of the nits.
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Close attention must be paid to manually remove the nits from the hair. If the
nits are not destroyed, they will hatch in seven days, and the head lice will
reinfest the scalp.
A child who had head lice may return to the child care service as soon as
treatment is completed.
Follow the directions on the product. Do not leave the shampoo or rinse in hair
longer than directed. Rinse hair well after treatment. Hair must be dried
naturally. Do not use a hair dryer. Do not use medication more than once in
seven days.
Do not use conditioner or shampoo/conditioner before or after treatment.
Wash combs, brushes and hair accessories with soap, and boil in water for 10
minutes.
Wash exposed clothing, linens and towels in hot water and dry in a hot cycle for
at least 20 minutes, or iron all washed items. Articles may be hung outdoors.
Note: Children under 2 years of age should only be treated under physician
supervision.
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Facts about Scabies

Scabies, a condition caused by tiny insects called mites, is common in children.
Some people think children get Scabies because they have not been washed
properly. However, Scabies has nothing to do with cleanliness.
HOW TO RECOGNIZE SCABIES
The initial sign of Scabies is itching. It becomes more persistent and intense at
night due to increased heat of bedding. It is also common to have bleeding
caused by scratching.
The mites that cause Scabies burrow into the skin and cause a very itchy rash.
The rash looks like curvy white threads, tiny red bumps, or scratches, and it can
appear anywhere on the body. It usually appears between fingers or around
wrists or elbows. On an infant, it can appear on the head, face, neck and body.
Scabies is spread by close, direct contact with infested skin, clothing or other
personal items of someone else who has had it. Transfer from undergarments
and bedclothes only occurs if these have been contaminated by an infested
person immediately beforehand. Washing the clothes in hot water and then
putting them in a hot dryer gets rid of the mites.
WHAT PARENTS CAN DO
Watch your child closely for signs of scabies if another child has it.
Contact your family doctor if you think your child has scabies. If the doctor
determines that your child has scabies, every member of your household will
probably have to be treated with an over-the-counter medication. Be sure to
follow the instructions on the bottle.
A child may still be itchy for a few weeks after the treatment has gotten rid of
the mites. This means that the child is reacting to the mites, not that the
treatment has failed to get rid of them.
If your child has Scabies, wash the childs bed linen, towels, and clothes in hot
water and dry in a clothes dryer at the hottest setting.
If you child has Scabies, inform the child care service. S/he should not return
to child care until the day after treatment has been given.
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COMMON HEALTH ISSUES WITH INFANTS

Note: For information on Fever and Febrile Seizures in Infants see Managing
the Mildly Ill Child in Child Care.
Crying and the Fussy Baby
Crying is a normal way for babies to express themselves. It helps babies
inform their parents and providers that they are uncomfortable, bored, hungry
or in pain. Many babies have regular, wakeful, fussy periods throughout the day
when they seem hard to settle or console. There may be many reasons for the
babys crying and fussiness. Perhaps the baby is hungry, tired, wants to suck,
is overstimulated, uncomfortable, bored with their surroundings or going
through a growth spurt. Most parents and providers get to know the different
types of crying and fussy behaviour over time and learn how to respond most
effectively to meet the unique needs of the baby. As babies grow older, their
needs change and the way they respond to consoling techniques then may also
change.
The best way to manage a fussy, crying baby is to respond promptly by
comforting and trying different consoling techniques. A baby who is lovingly and
quickly responded to by his parents and providers will not be spoiled but will
grow up feeling more secure. There are a variety of ways to console a crying
baby. Check with the babys parents to see what they have found works best
in their home environment.
Always try to meet the more obvious needs first by feeding, changing and
warming the baby. If the baby is warm, dry, and well fed try some of the
following strategies:
<
<
<
<
<
Try to anticipate the normal fussy times by having extra support at this
time whenever possible
Avoid overhandling if you think the baby is overstimulated; choose a quiet
setting with minimal distractions
Try rocking, either in a rocking chair or in your arms swaying back and
forth
Gently sing, hum or talk lovingly
Play soft background music
176
<
<
<
<
<
<
Walk the baby in your arms, stroller or carriage

Car rides work well but less realistic in child care!
Swaddle snugly, some very young babies settle better
Gentle massage
Rhythmic noise or vibration
Avoid strong scents on your skin or clothing as this may bother some
babies.
Helping Parents and Providers Cope With The Fussy Baby

An inconsolable baby is very stressful for parents and providers. The more
relaxed a provider is, the easier it will be to settle the baby. It is important
to not take a babys behaviour personally. They are not crying because they do
not like their parents or child care provider! All babies cry often, some for up
to several hours in a day. Make sure that you as the provider get plenty of rest
and help when faced with more challenging situations. It is amazing how short
this period is in a childs lifetime and they do improve after the first 3-4
months.
Colic
Colic is a term used to describe a baby who cries for long periods of time. The
continuous crying may cause tremendous distress for the parents and providers.
It is sometimes overused as a label for many infants who are simply showing
normal crying behaviours. Most babies have a period of time in the day when
they are fussier and seem to cry more often and for longer periods. This time
is often in the early evening when parents have many other stresses. Some
babies are fussier in the early morning. In the majority of situations the
babies are healthy and developing normally.
Both formula-fed and breastfed babies can have colic. Colicky babies are not
ill but are in pain. A very small number of infants cry inconsolably for hours on
end. They cry, get red in the face and pull their knees up to their chest. Their
abdomens become rigid and they pass lots of gas. These attacks can last for
as long as four hours and may continue for several weeks. Parents and
providers try numerous ways to find the source of their crying by feeding,
changing, rocking and cuddling, often to no avail. The cause of colic is unknown.
It may be due to swallowing excessive air, a reaction to a food, or simply a
177
babys general adjustment. However, it can create tremendous stress for

providers and parents. Often parents feel frustrated and helpless. Positive
words of encouragement that the behaviour usually does not last beyond four
months and that their child is healthy can be reassuring to parents. Talking to
parents who have experienced similar concerns can also be helpful.
Here are a few tips for caring for an infant with colic:
<
<
<
<
<
<
<
<
Support mothers who are breastfeeding to continue, as giving up

breastfeeding will not solve the problem
Offer lots of general support to the parents
Talk to parents about comforting techniques that have worked well at
home
Establish a regular routine in the child care setting
Avoid overstimulating the baby; play soothing music and talk to the baby
in a soothing, calm voice
Place the baby on his or her abdomen, or gently massage the abdomen adult supervision is necessary at all times when an infant is placed on her
abdomen.
Carry the baby and gently rock
Try steady, smooth vibrations such as rocking, stroller or car ride if
possible
Shaken Baby Syndrome

Shaking a baby, even once, can cause a lifetime of damage. Shaken Baby
Syndrome occurs when a young baby or childs head is shaken or quickly jerked
back and forth. A babys head is large and heavy compared with the rest of the
body and the neck muscles are very weak. This is the reason for supporting a
young babys head until the neck muscles become stronger and they are better
able to support themselves. Violent shaking causes the babys head to whip
back and forth, hitting the brain against the skull. This leads to bruising,
bleeding and brain damage. Shaking a baby can lead to seizures, coma and
death in severe cases. In less severe cases, the children may have long-term
learning difficulties in school, behaviour problems, vision and hearing problems
and other mental difficulties. While young babies under a year can be easily
injured by shaking, an older child is also at risk for serious injury when they are
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tossed in the air or swung in the air without supporting the head.
Shaken Baby Syndrome usually occurs in children who are under one year of
age. A child who constantly cries and is fussy often triggers a reaction in the
provider.
To protect infants and children in the child care setting:
<
<
<
<
<
<
Develop ways to cope with a babys crying and fussy behaviour

Talk to someone who can be a support and help when needed
Always support the young babys head when carrying or holding the baby.
Avoid games or activities that involve tossing a baby or young child in the
air.
Talk to other providers about this issue
Encourage parents to share information about prevention of Shaken Baby
Syndrome with anyone who is caring for young babies and children,
including friends and older siblings.
For more information about this issue contact your public/community health
nurse Or www.caringforkids.cps.ca
Thrush and Candida Diaper Rash
Thrush is a very common infection in infants and young children. The cause of
the infection is a fungus called Candida. A rash in the diaper area or the mouth
could develop if large numbers of Candida are present on the skin.
Breastfeeding mothers are also at risk for Candida infection of the nipples. All
three areas, the mouth, the diaper area and the mothers nipples are warm
moist areas that encourage the growth of the fungus. Breastfeeding should
continue in the presence of a Candida infection.
The Candida fungus is present in the bowels of many people without causing an
infection. A Candida infection of the mouth and skin is usually caused by the
germs in the bowel. A vaginal Candida infection in a provider does not present
a risk for infants and children.
Candida infections are often seen in the early weeks after birth in the
breastfeeding mother and baby. It may also occur in young children if they
179
have recently taken antibiotics for some other infection. Antibiotics destroy
the normal bacterial flora, resulting in an over growth of the fungus.
Oral Thrush
Oral thrush appears as white patches on the inside of the baby's mouth,
cheeks, or tongue. Sometimes it appears as if the white patches are milk, but
they can not be rubbed off. Strong efforts to remove the residue could result
in a bleeding raw area. Thrush infections do not appear to be painful for
infants. Only in very severe cases do babies find it difficult to suck.
Occasionally a baby may show signs of being gassy or fussy and repeatedly pull
off and on a nipple during feeding.
Diaper Rash
The Candida skin rash usually occurs in the diaper area in the deepest areas of
the creases of the groin and buttocks. The diaper area provides a warm, moist
environment that encourages the growth of the fungus. The rash looks fiery,
bright red with well defined edges and small red spots nearby. It can cause
discomfort for the baby.
A Candida infection is spread from person to person by direct contact. Paying
close attention to hand washing is important in preventing the transmission of
the fungus.
If an infant or child has oral thrush or a diaper rash caused by the Candida
fungus take the following steps:
<
<
<
<
If you notice a rash in the diaper area that does not seem to be improving
with routine diaper care, inform the parents so they can contact their
public/community health nurse or physician for diagnosis and treatment
If the infant or child is prescribed a treatment, such as oral drops for the
mouth or ointment for the diaper area, it is important that directions are
followed carefully, as the Candida fungus reproduces very quickly
For oral thrush, sanitize any items that the baby puts in her mouth, e.g.,
bottles, artificial nipples, soothers, medicine dropper and spoons, by boiling
for ten minutes
For a diaper rash, cleanse the diaper area with mild soap and warm water,
180
<
<
<
rinse and dry well, apply prescribed ointment according to directions

Wash your hands and the childs hands well after application of treatment.
Ensure that the treatment is continued for the recommended time, even
if the signs and symptoms have improved.
Let baby go without a diaper for short periods when possible to let the air
dry the skin (especially for non-mobile infants!) Ensure the area where the
baby is laying is well protected and can be easily and thoroughly sanitized,
protecting the other children from contamination.
There is no need to exclude a child with a Candida diaper rash or oral thrush
from the child care setting. Supply parents with a Fact Sheet.
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Facts about Thrush and Candida Diaper Rash

Candida is a fungus that causes an infection of the skin or mouth. The candida
fungus is present in the intestines of many people without causing any illness.
Thrush is a common infection in infants and young children in diapers. It may
occur after treatment with antibiotics for some other infection. Young infants
and children may develop a rash in the mouth (white mouth) or on the skin if
large numbers of Candida are present or if the skin is damaged. Most infants
do not appear to have any pain or complications with oral thrush. The thrush
infection can also affect breastfeeding mothers.
The fungus that causes thrush grows well in a warm, moist place, such as the
babys mouth, in the mothers milk ducts or on her nipples. Mothers develop
sore red nipples, a burning feeling around the nipple and areola during a feeding,
cracked nipples that do not heal, pain in the breasts during feedings and
possibly between feedings, and sore nipples that do not respond to improved
position and latching-on technique.
HOW TO RECOGNIZE ORAL THRUSH
< Whitish-grey coating on the tongue and on the insides of the cheeks and
gums. The coating is not easy to wipe off with a cotton swab.
< Vigorous attempts to wipe it off may leave a bleeding raw surface.
< In severe cases, the mouth may be so sore that the infant appears to find
it painful to suck.
HOW TO RECOGNIZE CANDIDA DIAPER RASH
< in the deepest part of the creases in the groin and buttock;
< very fiery red with a clearly-defined edge and small red spots close to the
large patches.
Candida infections can be cured with medication prescribed by a physician.
Candida diaper rash is treated with an ointment applied to the skin.
Thrush in the babys mouth can be treated in a number of ways, usually involving
putting a medicine in the babys mouth for at least two weeks until all signs of
the thrush are gone. It is very important for the breastfeeding mother to
treat her nipples at the same time as the baby is being treated. There are
other ways to treat thrush in the mouth and on the nipples. Mothers should
talk to their local public/community health nurse and/or physician for guidance.
182
WHAT PARENTS CAN DO

Pay close attention to personal cleanliness by ensuring that hands are washed
well, especially after changing your babys diaper.
If you suspect you or your child has a Candida infection(thrush), contact your
public/community health nurse or physician in order to have the diagnosis
confirmed. Follow exactly the specific recommendations for treatment.
Sanitize any items that come in contact with your babys mouth by boiling in
water for 10 minutes, e.g., bottles, artificial nipples or soothers, medicine
droppers, spoons.
Candida Diaper Rash:
<
<
<
<
<
Wash the childs diaper area with mild soap and warm water each time the
diaper is changed. Rinse well with warm water and pat dry.
Apply the prescribed ointment to the diaper area especially in areas where
the rash is located.
Baby powder is not recommended as it can get into babys lungs;
cornstarch can make a yeast infection worse.
Wash your own and the childs hands after the diaper change.
Let baby go without a diaper for short periods when possible to let the air
dry the skin (especially for non-mobile infants!)
Oral Thrush:
<
<
<
Ensure that you give providers detailed written instructions for applying
oral thrush medication in babys mouth.
The fungus that causes this infection reproduces very quickly so it is
important to follow the exact times for administration and to complete the
full treatment.
Breastfeeding mothers: Continue to breastfeed your baby.
Even if you have no signs or symptoms of a Candida infection of the
nipples, you should still be treated at the same time as the baby.
183
Cradle Cap
This is a common problem seen in young infants. The delightful two month
old baby in your care has developed a thick, greasy or flaky material that
looks like scales on his scalp. When this type of rash is seen on the scalp
alone it is called cradle cap. It can also be found in other areas such as the
creases of the neck, armpits, behind the ears and over the face and diaper
area. It occurs in these areas due to the large number of oil-producing
sweat glands. When it goes beyond the scalp it is referred to as seborrheic
dermatitis. It is rarely uncomfortable for the baby as it is not itchy like
excema.
The exact cause of the condition is unknown but it is probably related to the
normal changes in the babys skin and likely influenced by the hormonal
changes in pregnancy which stimulate the oil glands. It is not due to poor
cleaning of the babys hair and scalp by the parents.
Some children with cradle cap may be more prone to general skin rashes.
When the condition is very mild, parents may choose to remove the scales
with a small amount of mineral oil on a cotton ball. Parents should not rub
the scalp vigorously to remove the scales as this could cause an irritation of
the skin on the scalp. Parents should shampoo the babys hair regularly with
a mild baby shampoo and soft brush used to help remove the scales. In
severe cases, the physician may suggest to the parents that they use a
special shampoo or ointment to help treat the scales and the redness. Cradle
cap is not a serious infection and the problem invariably improves as they get
a little older.
Diaper Rash
Diaper rash usually causes the babys diaper area (where the diaper touches
the skin) to have mild redness and scaling. In very severe cases of diaper
rash, pimples, blisters and other sores can develop. The rash may be
infected if it is bright red with swollen skin. Small red patches or spots may
spread beyond the main area of the rash or even beyond the diaper area.
The most common reasons for infant and young children to develop a diaper
rash include:
184
<
<
<
Skin irritation from urine and stool

Skin irritation from diarrhea
Fungal infection (thrush)
Irritation can also be caused by diapers that rub against the skin, fit too
snugly or are left on for long periods. Occasionally the babys skin can be
irritated by the soap used to wash cloth diapers, by the brand of disposable
diaper or baby wipes.
Tips For Preventing Diaper Rash
The key to preventing and treating diaper rash is to keep the babys
skin in this area clean, cool and dry.
<
<
<
<
<
<
<
<
<
Check the babys diaper often (about every hour) and change it as soon as
it is wet or soiled.
Let baby go without a diaper for short periods when possible to let the
air dry the skin (especially for non-mobile infants!)
Carefully clean babys buttocks with plain warm (not hot) water with or
without a very mild soap
Dry completely before putting on another diaper
Use products such as petroleum jelly, e.g., Vaseline, to protect babys skin
from moisture.
Avoid using a lot of diaper creams and ointments as they trap germs,
urine and stool, and are hard to wash off
Baby powder is not recommended as it can get into babys lungs;
cornstarch can make a yeast infection worse
Check with parents about what they are using on babys skin if a rash has
developed. If special cream or ointment is recommended, apply very
thinly.
If the diaper rash persists, encourage the parents to seek advice from
their physician or public/community health nurse. They may also consider
changing the type of diapers, wipes, soap or detergent if using cloth
diapers.
N.B. When babies have diarrhea, their skin is more susceptible to

diaper rash as the acid in the stool burns the skin. A special
barrier cream may be suggested by parents to help prevent this
problem.
185
Eczema
Eczema is a general term that is used to describe a number of different skin
conditions. It can be one of the most bothersome of rashes for infants and
young children because of its nature to recur. For infants, eczema usually
appears on the face, body and skin creases. In older children the rash is
located in the bends of the elbows, behind the knees and on the backs of
the wrists and ankles. It usually appears as reddened skin that becomes
moist and oozing. When the rash continues for a long time the skin thickens,
dries out and becomes scaly. The eczema rash is very itchy.
Eczema often occurs in infants and children who have allergies or a family
history of allergy or eczema. In some situations, the eczema is a direct
reaction to the cows milk protein in formula, or to other foods such as
citrus fruits and eggs. Eczema can also develop when the infant or child
comes into contact with an irritating substance, such as bubble baths, strong
soaps, or medicines. One of the most common irritants is the childs own
saliva. This is a particular problem with drooling in young infants.
Eczema is not a serious problem unless the rash becomes badly infected.
Some infants with eczema may go on to develop other allergic conditions
such as asthma.
There is no cure for eczema, however, it can be controlled and often will
ease for several months or years. The most important aspect of care for
infants and children with eczema is to prevent the skin from becoming
dry and itchy.
TIPS for caring for an infant or child with Eczema
<
<
<
<
<
Discuss with parents about what they are doing at home to manage it.
Avoid prolonged exposure to hot water, e.g, bathing.
Use very mild soaps to wash the infant and young child.
Apply specific anti-inflammatory ointments or creams to control
inflammation and itching as prescribed by the physician.
Avoid using anything that may irritate the skin directly or encourage
sweating, avoid overdressing the infant, avoid harsh or irritating
clothing, e.g., woolen or rough-weave fabrics and nylon because they do
not allow the skin to breathe.
186
Burping
It is normal for infants to swallow air during their feedings making them
more fussy and cranky. It is more common in the bottle- fed baby. It is
best to stop the feeding, as the continued crying and fussiness will only lead
to the baby taking in more air and increasing the babys discomfort. Some
babies tend to take in more air than others and they may need to be burped
more frequently. Talk to the parents about their babys feeding pattern and
behaviours. Find out what has worked well for them at home. Often the
baby will bring up air simply by placing her/him in an upright burping position.
It is not necessary to vigorously pat the baby on the back to expel the air.
The bottle-fed baby may need to be burped after approximately 60-90 mL
(2-3 ounces) of milk.
Hiccoughs
Almost all babies hiccough from time to time. It usually bothers the parents
and providers more than the child. It is a harmless problem. If it occurs
during the feeding it may be helpful to wait until the hiccoughs are over to
resume the feeding. If the baby gets hiccoughs frequently, it is best to
feed her when she is calm and before she is overly hungry.
Spitting up
Spitting up is another very common situation with healthy infants. Only on
rare occasions is it related to a serious illness. Spitting up is a result of
excessive relaxation of the band of muscle located where the
esophagus(food tube) and the stomach meet. When the muscle is a little
slack, the breastmilk or formula escapes with air, especially when the baby
burps. Some babies constantly bring up small to moderate amounts of
breastmilk or formula. Some babies spit up more than others but most
babies usually grow out of this phase by the time they are sitting up. Some
of the heavy spitters continue throughout the first year of life.
Sometimes when babies spit up it is because the baby has eaten more than
the stomach can hold. (A newborns stomach is about the size of a golf ball!).
Spitting up is a little messy for the baby and provider. Occasionally the
spit up can have a sour odour. None of these minor irritations create a
187
problem for the baby. Keep a burp cloth handy.

Only in rare situations will the baby spit up enough milk to create a concern
about their healthy growth and development. Parents and providers may
worry that they will not be able to tell the difference between normal
spitting up and vomiting. Vomiting may be more upsetting to the infant as it
is forceful and causes more discomfort and distress. Most babies don't
notice the spitting up. Spitting up does not mean that the baby has an
allergy or food intolerance.
Gastroesophageal Reflux in Babies (Reflux)
One of the most common causes of colic or fussiness in a newborn baby is a
condition known as gastro-esophageal reflux(GER). GER is caused by a
problem with the valve like muscle between the stomach and the
esophagus(food tube). Normally this band of muscle keeps milk, food and
stomach acids from backing up into the esophagus when the stomach
contracts. When this muscle is not working properly it causes these
substances to move into the esophagus causing a type of heartburn and
colicky, fussy behaviour in the infants. The problem usually improves by six
months to a year of age, as the muscle matures and prevents the
regurgitation.
The signs of GER include:
<
<
<
<
<
<
Bouts of severe crying as if in pain

Frequent spitting up
Fussiness, especially after feeding
Arching or moving about as if in pain
Sour breath
Appears to be more comfortable in an upright position or when lying on
stomach
Usually the parents have already discussed this problem with their
public/community health nurse and or physician and have been given ideas to
help cope with the situation. In some severe cases the physician may
prescribe a medicine that lowers the amount of stomach acid. Child care
providers should discuss with parents what has worked well in easing their
188
babys discomfort. The physician may recommend a different, safe sleeping

position. Make sure the parents have written directions from the
physician if young babies are not positioned on their back for sleep.
TIPS which may help reflux
<
<
<
<
Keep baby in an upright position for at least 30 minutes after

feeding.
Offer smaller, more frequent feedings
Try to keep baby calm after feedings
Support mothers who are breastfeeding to continue, as GER is
seen less often in breastfed babies. Breastmilk is digested very
quickly from the stomach and breastfed babies tend to eat
smaller meals.
Respiratory Syncytial Virus (RSV)

RSV is the most common respiratory virus in infants and young children.
Almost all infants are infected by the age of two years. The symptoms of
RSV resemble a cold in most healthy, full-term babies. The infection usually
only lasts for a few days. However, there are certain infants who are at
greater risk for more serious illness when they are infected with RSV.
These include premature infants and infants with chronic lung disease.
Other factors that may place infants at greater risk include: infants in child
care settings, crowded households, exposure to environmental smoke, not
breastfeeding, older school age siblings, and children of multiple births, e.g.,
twin or triplet.
RSV is a very contagious and each year up to 50% of infants are infected.
Transmission of the virus occurs by touching an infected person and then
rubbing your own eyes, nose or mouth. The infection is also spread through
the air by coughing or sneezing. The virus survives for 4-7 hours on
surfaces such as cribs or countertops. The most effective way to prevent
transmission of the infection is to follow strict hand washing routine and
general infection control practices.
RSV season is generally from the Fall through to the Spring. This is usually
the time when more outbreaks occur. When high risk infants have RSV they
often need to be hospitalized. They can be in life threatening situations.
189
Parents and child care providers of high risk infants should follow these
steps to help prevent RSV:
<
<
<
<
<
Encourage all people who come in contact with the baby to wash their
hands with warm water and soap before handling her or him.
Try to find an alternate provider if you have a cold or fever
Try to keep other children away from the baby if they have colds, runny
noses, or fever.
Avoid taking the baby to crowded, confined areas, e.g., shopping
centres.
Never smoke in the babys presence (Smoking is prohibited in child care
services).
Sudden Infant Death Syndrome (SIDS)

This condition is also known as crib or cot death and refers to the sudden
and unexpected death of an apparently healthy infant, usually under one year
of age, during sleep. There is no obvious cause of death. Approximately 1 of
every 1,000 babies die of SIDS every year. Although researchers do not
know exactly what causes SIDS, there are things parents and providers can
do to make babies safer.
Sleeping Position
SIDS is less common in babies who are put to sleep on their backs. Always
put babies to sleep on their back on a firm, flat surface. Babies who sleep
on their backs are not more likely to choke as was once commonly thought.
The parents will inform you if there are special medical reasons for a baby
to sleep in another position (e.g., reflux). As babies become a little older,
they become capable of rolling over from their back to their tummy. Never
force a child to sleep on their back when they choose to turn over to their
tummy.
Fluffy pillows, stuffed toys, and comforters are not permitted in a crib in
child care services, with the exception of a comfort item (small stuffed toy,
security blanket) for infants 9 months of age or older. Bumper pads must
not be used as they can affect the proper circulation of air around the
babys face. Any plastics wrappings around the mattress should also be
190
removed to encourage good air circulation. Avoid overdressing babies when

they are sleeping. They should be kept warm, but not too hot. Place your
hand on the back of the babys neck to make sure the baby is not sweating.
Encourage some tummy time for babies when they are awake and being
watched. This is important for normal development and to prevent
temporary flat spots from developing on the babies heads from lying in one
position on their back.
A smoke free environment also helps decrease the babys risk for SIDS.
Breastfeeding may also provide protection against SIDS. For more
information about this topic contact SIDS Canada 1-800-END-SIDS(3637437).
Preventing Flat Heads in Babies Who Sleep on Their Backs

Some babies develop flat spots on their head from lying in one position.
Their skulls are very soft and the bones can be affected by constant
pressure. Also babys neck muscles are weak so they tend to turn their
heads to one side when they lie on their backs. When babies always turn to
the same side their skulls may flatten on that side. This does not affect the
babys brain or development. An easy way to prevent flat head is to change
the position of the babys head each day. Babies like to watch whats
happening around them so its best to avoid having them looking at a wall.
Try these position changes:
<
<
<
<
<
One day, place baby with head at the top of the crib
The next day, place baby with head at bottom of crib
Each day change the babys orientation in the crib
Always ensure that baby is looking out into the room
Give babies lots of tummy time when they are awake throughout the
day.
MEDICATION
193
MEDICATIONS
Healthy children do not routinely require medication. Children with temporary
illnesses may require medication for a short time. For this reason,
providers do not have to administer medication very often.
Some children with medical conditions may take medication on a long-term
basis. It may be necessary for providers to administer one or more doses
each day to these children on a regular basis. Some children may require
a medication under special circumstances (e.g., Epi-Pen for anaphylactic
reaction). Your child care settings medication policy must be used in this
event.
Always notify parent and physician if there is an error in the medication
given. See Preparing and Giving the Medication section for further
detail.
(Note: See Child Care Services Regulations for legislated requirements
relating to the administration of medication.)
General Guidelines
<
Encourage parents to ask the childs physician to put the child on a

schedule that does not require medication to be administered while the
child is in child care.
<
When parents have a prescription filled, have them ask the pharmacist
to give them an extra labelled bottle to bring to the child care setting.
<
Generally, for the first 24 hours, a new prescription or over-the-counter

medication should be given to the child at home by the parents. The
parents can then observe how the child reacts to the medication - that
is, if there are any medication allergies - and tell their physician. Even
if the child has taken this medication in the past s/he could still
have an allergic reaction, so the medication should be given for the
first 24 hours at home by the parents.
194
<
Remind parents who are giving their child vitamins or herbal supplements
that they are to be given at home.
<
Ask parents to tell providers when the child is taking a medication at

home and any side effects that may occur while the child is in child care
(such as drowsiness).
<
Only
medication,
either
prescription
or
over-the-counter,
prescribed/authorized by a physician, dentist or nurse practitioner is
permitted to be given in child care settings, except in the case of fever
reducing medication in an emergency.
This requirement for a
prescription or authorization includes any herbal remedies or alternate
therapies.
<
Do not administer any prescription or over-the-counter medication

(including herbal remedies, ointments, etc.) unless the childs parents
have given written consent in addition to having the required prescription
or authorization.
<
The individual who administers medication in a child care setting must:
<
<
<
<
be a permanent staff member (centre-based) or the provider

(Family Child Care)
be directly involved with the child
be someone the child trusts
have had some basic training in giving medications
<
To avoid the child missing a dose of medication or being given a double

dose, one person must be responsible for giving the medication to all the
children that day, or one person must be responsible for giving
medication to a particular child.
<
Keep medication in a locked cabinet or out of reach of children. (Dont

forget medication in the refrigerator, it must also be in a locked
container.)
<
Refrigerate medication if required, but do not freeze.
195
<
Never leave medication out without adult supervision, e.g., when you
answer the telephone or leave the room. Put the medication away first,
or take it with you. A child can take an overdose in seconds.
<
A record must be kept indicating that the medication has been given, at
what time, and by whom. (See Medication Consent and Record Sheet)
Administering Medication
<
No medication, whether prescription or non-prescription, can be

administered to a child without written consent.
<
Have parents complete a parental consent form for each medication.
<
If the medication is one that the child is taking on a long-term basis, ask
parents to renew their written permission to administer medication at
least every six months and whenever the prescription is changed.
<
All prescription medication must have a pharmacists label with the childs
name, the name of the drug, the dosage, the date the prescription was
filled, and the direction for storing and giving the medication.
<
All over-the counter medication (written authorization required) must be

in its original container, clearly labelled with the childs name, ensuring
that the name of the product, and all dosage, administration (e.g., taken
with water, food), side effects, storage, and expiry date information is
clearly visible
<
Always read what the label says about storage; some drugs need to be
refrigerated.
<
Be sure you have very specific instructions about how the medication
should be given (e.g., before or after meals; with a full glass of water
after the medication; tilting head, etc.)
<
Any unused medication and medication bottles must be returned to the

parent(s). It must not be disposed of in the garbage in the child care
service.
196
Preparing the Child
<
Parents should tell their child when s/he will be given medication at the
child care setting.
<
Parents know the best way to give their child the medication. Ask for any
suggestions they may have to make giving the medication easier.
<
Hold infants and toddlers in your arms in an upright position.
<
Give the child a few minutes notice before medication time. Allow the
child time to complete an activity or prepare to leave it for a few
moments.
<
Give the child his/her medication in a quiet area separate from other
children whenever possible.
<
Tell the child exactly what you are going to do.
<
Be truthful and matter-of-fact with the child about how the medication
will taste or feel.
<
Never refer to medicine as candy or something else children like. They

may try to get more of it later.
<
Let the child have some control over the situation wherever possible. For
example, allow the child to help hold the medication cup, encourage and
praise the child for taking the medication.
<
Verify or double check if the child says that s/he doesnt need the
medication anymore or that it was already received.
197
Preparing and Giving the Medication
<
Always check parental consent and medication record to make sure that
medication was not already given.
<
Prior to giving medication, wash hands and prepare all supplies (e.g.,
container, drink, tissues)
<
When measuring liquids, use a proper measuring spoon, syringe, dropper or

cup. Do not use household teaspoons because they can vary in size and are
inaccurate for precise measuring.
<
Read the instructions on the bottle or label. For example, a label might
specify that you shake well, or not mix the medication with certain foods,
or fluids; or not give within a certain time before or after a meal.
<
Always read the label carefully Three (3) times before you give any
medication; containers often look the same. Be sure to check all the
information on the label including the name of the child; the name of the
medication; the amount required; the time it is to be given; and the way it
should be given. Check the medication label when removed from storage
area, before it is poured and after it is poured.
<
If an error is made
< Call Poison Control to determine if possible actions are required.
< Follow the policies as outlined by the child care setting.
< Record the information and observe for any side effects.
< Complete an Incident/Injury report as soon as is feasible.
< Advise parent immediately as outlined in your child care policies.
N.B.
<
The child is not to be left unattended at any time, and must be

closely observed as these processes are being carried out.
Learn the possible side effects of the medication and inform the parent
immediately if you observe any effects. Do not give further medication
without the approval of the parent and the childs physician.
198
Recording the Medications
<
The medication consent and record sheet must include the name of the
child; name of medication to be given; the parents signature; the time and
date of each administration; and the name of the provider giving the
medication. In child care settings where there is more than 1 provider on
staff, a second provider must confirm the medication was administered.
<
Keep the medication consent and record sheet handy so you wont forget
to record the medication.
<
Record the date and time, and sign your initials in the appropriate space
on the medication record sheet.
<
Sign your initials and signature at the bottom of the sheet if you are giving
this medication for the first time.
<
Continue on another sheet if the child is still taking the medication and
there is no more space on the form. Be sure to complete the childs name
and date of birth on the second form.
<
If things dont go smoothly when administering the medication, e.g., child

refuses, try again in 15 minutes. If child refuses again, do not force.
Record that the medication was refused and inform parents.
<
Record any spillage of medication
<
Indicate the last date medication was administered by writing Stop.
<
Put the form in the childs health record when the medication is no longer
given.
199
Specific Medication Issues

Ointments and Cream
<
<
<
<
<
Keep container as clean as possible

Use a facial tissue to remove ointment or cream
Squeeze onto the tissue and avoid touching end of tube
Use tissue to apply cream or ointment
Avoid the eyes and mouth
Tablets and Capsules
<
<
<
<
Try to avoid touching tablets or capsules with your hands

Shake out the required number into a lid
Transfer to a cup to give to the child
Give the child a drink
Epi-Pen for Anaphylactic Reactions for Children

For children who may require an emergency injection, e.g., adrenalin for an
allergic reaction, this medication (e.g., Epi-pen) should be provided by parents
and never be locked away. It should be located in the room in which the child
is present. Ideally, the provider(s) caring for that child could carry the
medication in a waist/fanny pack so that the medication is on- site at all times
when the child is present. This medication should always be available for the
child, for example, in the playground or on field trips. All providers should be
trained in giving the medication by the local public/community health nurse. If
providers have any questions or concerns about a medication, always consult
parents, physician or a pharmacist.
201
CHILDREN WITH SPECIAL NEEDS AND

LONG-TERM CONDITIONS
Some children in child care settings have special needs or long-term conditions.
These health problems may interfere with a childs usual daily activities and
must be monitored on an ongoing basis. Most children who are in child care
usually are able to participate in normal program activities and routines.
Providers responsible for a child with a special health need must understand
the care which that child requires.
Some children may be challenged by physical, cognitive, emotional,
psychological, environmental or social factors and require specific additional
assistance. These children may face barriers to normal development and
activities of daily living. They may be more vulnerable to everyday stresses. It
may be necessary in some cases to modify the childs program or environment
in order for the child to participate in activities.
In some cases providers are aware of a childs special need before the child
enters the child care setting, for example, a child with Spina Bifida or Down
Syndrome. Also, providers play an important role in identification of children
with possible developmental, physical, sensory or other special medical care
needs. You may be the first person to notice that a child in your child care
setting has special needs. While providers cannot and should not diagnose,
they can make observations, share information with parents and when necessary
make suggestions for referral. However, it is the parents decision to seek
help.
Where children with special needs are integrated into child care settings,
sharing information is very important. Communication with parents of a child
who has a special need is essential. Providers and parents of children with
special needs may need to communicate with each other in a variety of ways to
ensure the specific needs of the child are met. The Canadian Child Care
Federation resource sheet Early Identification for Children with Special
Needs outlines ten steps to ensure that the childs needs are handled in an
adequate manner in a child care setting.(CCCF, 2001 <http://www.cfcefc.ca/docs/cccf/rs056_en.htm>). If you require information and advice about
a concern that you have regarding one of the children in your care, contact the
202
child care services staff in your region.

Following are special forms which may assist in information sharing:
<
<
Asthma/Allergies History Form.

Special Needs/Long-term Condition History Form
(See Health Records section of this manual).

*This section has been adapted 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 Pediatric Society, 1992.
Allergies
One in five children has some form of allergy. Allergies are caused by exposure
to particular triggers (or allergens) in the environment such as inhalants (dust
and pollen), foods (especially nuts, eggs, fish, milk, wheat, peanuts, soybeans,
sesame seeds, sulphate, kiwi), stinging insect venom, latex, and medications.
Allergic reactions differ from child to child but may include wheezing, coughing,
shortness of breath, swelling, redness, itching and vomiting. It may take more
than one exposure to build up a reaction to a particular substance. For example,
the first time a child eats peanut butter, s/he may not show signs of an allergic
reaction. But if s/he develops an allergy to nuts, the next exposure to peanut
butter may trigger hives, breathing difficulties or even anaphylactic shock
Allergic reactions may develop extremely quickly and can be fatal.
203
Anaphylactic Reaction
(See also Food Allergy)
An anaphylactic reaction is a severe allergic reaction that can occur within
seconds of exposure, or several hours after the exposure to the allergen. The
signs and symptoms of anaphylaxis include:
< hives
< itching
< tingling in mouth
< severe swelling in lips, tongue, throat
< coughing
< wheezing
< choking
< loss of consciousness
The symptoms can often develop in minutes, often less than 10. Death may
result if the person is not given adrenalin (epinephrine) and taken to the
hospital immediately. Some individuals have mild symptoms initially and then
progress to a much more severe, life threatening reaction. If someone is
experiencing an anaphylactic reaction it is time for ACTION:
Epinephrine(adrenalin) must be administered immediately. If you are in doubt,
give the epinephrine. The parents of the child with a history of anaphylaxis will
have an Epi-pen that must be carried by the provider for that specific child.
It can be carried in a fanny pack. It should not be kept in a locked cupboard
(see Medication section for more information)
The following food items can cause anaphylaxis:
<
<
<
<
<
<
Foods containing peanut and nut residue

Nuts
Fish, Shellfish
Milk
Eggs
Soy
The following non-food items can also cause anaphylaxis:
<
Bees, wasps, hornets and yellow-jacket stings.
204
<
<
Medications such as antibiotics, muscle relaxants and anti-convulsants

Latex - latex is found in such items as latex gloves, balloons, soft rubber
balls, and stretchy rubber items such as pink erasers and rubber bands.
Prevention of Anaphylaxis (The Three As):
<
<
AWARENESS
AVOIDANCE
<
ACTION
Know causes, Know emergency plan

Avoid contact with allergen; Check ingredients; Do not
share drinking cups, straws, utensils; Avoid bulk foods;
be aware of cross contamination; If unsure ,DO NOT
EAT IT.
Administer Epinephrine(Adrenaline); Call for Ambulance
and transport immediately to nearest emergency
facility.
If a child immediately reacts to a substance in food,
remove the food from the area and rinse the mouth
with water to remove any food particles/protein
remaining in the mouth.
(adapted from Allergy Asthma Information Association Anaphylaxis reference

Kit).
How to Care for Children with Allergies
Prior to enrolment, ask parents if their child has any allergies and the kind of
reaction the child usually has to the triggering substance. Have parents
complete the Asthma/Allergy History Form with the childs physician. For
Anaphylaxis (Life Threatening) Allergies complete the Anaphylaxis Alert Form
which is available from the public/community health nurse. Parents and
providers should then discuss this information in order to develop an individual
plan to meet the specific needs of the child.
All allergic reactions or suspected reactions, regardless of how mild, must be
documented in the childs file, and parents must be advised. It is important to
remember that the first reaction may be mild and subsequent reactions can be
severe.
205
Tips for Providers
<
<
<
<
<
<
<
Obtain Food Allergy Facts Yellow sheet, Allergy Awareness Posters and
Anaphylaxis Alert Forms from public/community health nurse and post at
strategic locations in the child care setting to alert everyone regarding
the specific allergens
Post an allergy list in the kitchen and eating area including each childs
name, photo and his/her particular triggers.
Review weekly menus with parents and plan for alternate food choices if
necessary.
Read food labels to avoid giving trigger substances to a child with allergies.
In some rare cases, it may be necessary for the meals and snacks to be
prepared and provided by the childs parents.
Watch for allergic food during special events, such as field trips or eating
in restaurants.
Food triggers do not have to be eaten in order to cause a reaction. Some
children who are highly allergic to peanuts may develop a severe reaction
if food is exposed to peanuts or cooked in peanut oil; if they touch a
peanut or peanut butter or even sit near a child who has peanuts.
Always be careful when kissing, cuddling, burping or holding close to mouth
any infants and young children with food allergies if provider has eaten
food to which child is allergic.
If an allergy trigger can be identified, it should be avoided. Treatment for

allergies differs from child to child. Some children may require injections, oral
medications or medicated sprays or inhalers. It is important that parents and
providers communicate information regarding a childs triggers and treatment
and that a child specific plan of action be developed, written down and kept in
the childs file. Have an emergency plan in place in case of a reaction.
206
Asthma
Asthma is a chronic breathing disorder characterized by recurring attacks of
wheezing, coughing and shortness of breath. Asthma affects 1 in 10 children
and affects children differently. Most children with asthma lead a normal life
and can participate fully in exercise and activity.
The symptoms of an asthma attack are caused by a narrowing of the air
passages in the lungs, swelling, inflammation of the air passages and a
thickening mucus secretions from the lungs. The child then must work harder
to move air into and out of the lungs.
A childs asthma attack can be triggered by:
<
<
<
<
<
<
<
a common cold virus

allergies, e.g., animals, dust, pollen
weather conditions (cold air, windy or rainy days)
smoking
irritants /odours (paint fumes, cleaning materials, perfumes)
exercise, especially strenuous exercise in cold or damp weather
emotional excitement/upsets
Signs and Symptoms of an Asthma Attack
Symptoms of asthma include cough, difficulty breathing, rapid breathing,

shortness of breath and may be accompanied by a wheezing or whistling sound.
Some people complain of a tightness in the chest. They may also feel restless
or tired. Symptoms may occur quickly after exposure to an allergen, or slowly,
over days, such as occurs with a cold.
Some children require medication to prevent or reduce asthma symptoms,
others may require medication only when an attack occurs, and still others only
in emergency situations.
Asthma medications may come in the form of liquids, pills, inhalers, powders, or
compressors. Asthma medications come in the form of Preventer Medicines
and Reliever Medicines. Reliever Medicines such as bronchodilators open up the
207
bronchial tubes or small airways by relaxing the muscles. Preventer Medicines

such as anti-inflammatory medications which include steroids are usually given
to prevent inflammation.
Prevention
Prior to enrolment, ask parents if their child has asthma. Ask about the childs
triggers and his / her asthma symptoms. Have parents complete the Asthma
/ Allergy History Form with the childs physician. Parents and providers should
then discuss the information so that providers can meet the specific needs of
the child.
Tips for Providers
<
<
<
<
<
<
<
<
<
<
<
Obtain Asthma Facts Information Sheet from public/community health

nurse.
Ensure those providing child care are aware of the emergency
procedures and phone numbers for the child with asthma
Avoid triggers that can cause asthma attacks such as dogs, cats, dust,
scented products, plush carpets, feather pillows, and duvets.
Stop exercise if the child begins to have breathing difficulties or
starts to wheeze; this may happen more often when the weather is cold
or damp. It is important to remember that most children with asthma
can tolerate exercise when their asthma is under control.
Ensure the child care setting is vacuumed daily and wet dusted regularly
to help reduce the number of substances that can trigger a reaction in
a child.
Painting and regular maintenance should not be carried out while
children are present or immediately before children arrive.
Paints and finishes must be non-toxic.
Ensure providers know which children have asthma, what triggers their
attacks, and what to do in case of an attack.
Record in the childs file any problems the child had during the day, and
inform the parents.
Use unscented personal care products, e.g., no perfumes, scented
hairspray or scented deodorant.
Ensure that providers are aware that cigarette smoke can trigger an
attack and cigarette smoke sticks to clean hair and clothes.
208
Administering Medication for Asthma

If a child requires medication, follow the childs plan of care (action plan) as
outlined by the parents and physician. Consult the childs parents or the
assigned nurse from Health and Community Services if instructions are
required to give special medication, such as an inhaler or emergency medication,
If a child appears to have trouble breathing:
< stop the childs activity and remove the trigger if possible
< calm the child
< check if medication should be given
< give medication if indicated
< contact the parents
< if the child does not improve with the medication before the parent
arrives, call an ambulance and transport the child to an emergency facility.
< record the asthma attack in the childs file.
Scented Products and Health Concerns
There may be some children and adults participating in your program who have
a sensitivity to specific scented products including: shampoos, hairsprays,
lotions, deodorants, colognes, after shaves, household or industrial chemicals,
soaps, cosmetics, candles and incense. There are organizations which have
taken steps to avoid scent -related illnesses by making their workplace scentfree. When scented products have been reported to cause problems, the
symptoms include: headaches, dizziness, nausea, fatigue and upper respiratory
symptoms. Individuals with existing allergic or asthmatic conditions may be
more vulnerable as certain odours can trigger an acute attack. The severity of
the response varies. Infants and young children who are carried in the arms
of adults may be affected by scented products. Child care settings may
choose to implement a scent-free policy or they may recommend that providers
and visitors choose low scent or lighter scented products if health concerns
have not been reported.
For more information on developing a scent-free policy for the workplace, visit
the following web site:
<http://www.ccohs.ca/oshanswers/hsprograms/scent_free.html>
(Canadian Centre for Occupational Health and Safety)
209
For more information on allergies, anaphylaxis and asthma, contact your

public/community health nurse. The public/community health nurse can provide
the following:
< General Allergy and Asthma Information
< Anaphylaxis Alert Forms
< Food Allergy Facts
< Asthma Facts
Seizures
A seizure occurs when there is abnormal functioning between cells within the
brain. During a seizure a child may experience unusual motor movements, level
of consciousness may be impaired, unusual behaviour may occur (e.g., confusion,
picking at clothing), or the senses may be affected (e.g., unusual smell, visual
hallucinations etc.).
Seizures may occur as a result of a high fever or illness. This is called Febrile
Seizures or Convulsions. It is very common in children age 1 to 5 years. For
more information on febrile seizures, see Managing Illness section.
Seizures also occur in children who have Epilepsy. This is a common neurological
disorder, in which children have seizures for no apparent reason. Often, the
cause of Epilepsy is unknown.
Common Types of Seizures
Generalized Tonic Clonic - This is a convulsive seizure with two parts.

First, in the tonic phase, there is a loud cry, the child loses consciousness
and falls, and the body becomes rigid. In the second phase, the clonic
phase, the childs muscles jerk and twitch. Sometimes, the whole body is
involved, at other times just the face or arms. Shallow breathing, bluish
skin or lips, excessive drooling and loss of bladder or bowel control may
occur. The seizure usually lasts 1 to 4 minutes. Afterwards consciousness
returns slowly. The child may be confused, drowsy and will want to sleep.
210
Absence Seizures - In this seizure the child appears to be daydreaming

or staring blankly. The eyelids may flicker or there may be some twitching
of the mouth, head or limb. The child is unresponsive to surroundings. The
seizure is very brief, 10 to 15 seconds.
Complex Partial Seizures - This seizure may appear in many different

ways; awareness is altered. The child may be dazed and confused and
seem to be in a dream or trance. S/he is unable to respond to directions
and may repeat simple actions over and over, e.g., head turning, mumbling,
picking at clothing, smacking lips, may appear frightened, run aimlessly,
may struggle if restrained etc. The seizure usually lasts 1 to 2 minutes.
Following the seizure the child will feel tired and will have no memory of
what happened.
Simple Partial Seizure - Again, this type of seizure may appear in many
different ways; awareness is not affected, the child is aware of what is
happening but cannot control it. With this type of seizure the child may
experience unusual sensations changing the way things look, sound, taste,
or smell. The seizure may be jerking of one part of the body, inability to
speak, sudden sense of fear or sadness or stomach discomfort.
Status Epilepticus - Status Epilepticus is a seizure lasting longer than 30

minutes or repeated seizures with no recovery between them. Status
Epilepticus is a medical emergency. It is recommended if a seizure is
lasting longer than 5 minutes, an ambulance be called and the child
transported to an emergency department. In some instances medication
is prescribed which can be administered either inside the childs cheek or
rectally in the event of a seizure lasting longer than 5 minutes. In cases
such as these, a written Action Plan should be developed. Included in this
Action Plan would be a requirement for providers to receive appropriate
education and training by a public/community health nurse.
211
First Aid for Seizures

Generalized Tonic Clonic Seizures
Remain calm; reassure the child and others.

Position the child on the floor on his/her side so saliva can drain from
the mouth, place something soft under the childs head to prevent injury.
Remove any sharp or dangerous objects that are in the way; remove
things such as eyeglasses. Loosen tight collars and clothing. Wipe saliva
from around the mouth.
Do not push objects between the childs teeth. This may injure teeth
or gums, s/he may bite the object and inhale broken pieces, or you may
push the tongue in a position that may obstruct the airway. It is
physically impossible for a child to swallow his/her tongue during a
seizure. If blood appears around the mouth, do not be alarmed, the child
may have bitten his/her tongue, lip or cheek.
Do not restrain the childs movements.
The child may appear not to be breathing; lips and skin may turn blue.
This is a natural part of the seizure. Do not attempt artificial
respiration.
Do not give medications or other substances by mouth. The child is
unconscious and will not be able to swallow.
Get emergency assistance if seizure lasts longer than 5 minutes, if a
second seizure follows immediately, or if the child injured his/her head.
As consciousness returns reassure the child. Let him/her rest. During
a seizure it is not unusual for a child to urinate or have a bowel
movement. Depending on the childs age this can be very embarrassing
and should be handled discreetly when the child awakens. It would be
helpful to keep a change of clothes at the child care setting.
Witnessing a seizure may be frightening for children and providers. Children

will need reassurance that the child who had the seizure is OK. They also need
to be reassured that their friend will not die and that they will not catch
seizures.
212
Safety Issues
Children who have seizures should participate in all activities. However, when
there are water activities, the child should be monitored closely in the event
of a seizure occurring in the water. Also it is recommended that the child not
climb heights higher than him/herself.
Infants and Seizures
Seizures in the first year of life are unusual and often represent an underlying,
acute illness (e.g., Meningitis) or a neurological disorder.
Seizures in infants are different than in older children and may be difficult to
recognize as abnormal behaviour. The seizures usually involve some type of
repetitive, almost mechanical behaviour. The following behaviours may indicate
an infant is having seizures:
Staring spells that cannot be interrupted by moving something in front of

the babys eyes
Unusual rhythmic movements of the eyes
Rhythmic movements of one or both arms or legs similar to bicycling

movements that continue even in the baby is moved or the limb is held
Sudden loss of body muscle tone
Sudden jerky movements
Unusual sucking or mouthing movements
Any behaviour that cannot be stopped by holding, touching or repositioning

the baby
If seizures are suspected parents should be notified and the child evaluated
by a physician. If the child is then diagnosed with seizures then have the
parents complete the Special Needs/Long-term Conditions History Form with
the childs physician. The following information should be included on this form.
the childs typical seizure
the frequency of seizures
any known triggers, such as camera flashes
special safety consideration
information about medication, including any side effects
213
Providers can then discuss this information with the parents to develop a plan
that meets the specific needs of the child.
Delegation of Health Related Procedures to Child Care Providers

A situation may arise in the child care setting that a child with a special need
may require a health related procedure during the time s/he is attending the
program. Procedures such as catheterization, insulin injection, or gastrostomy
feeding are some examples of procedures that may need to be performed by
the child care provider. In these rare situations, Health and Community
Services staff would determine whether or not it is safe and appropriate to
delegate the procedure by ensuring that specific criteria are met. An
education program of related theory and supervised practice would be
implemented in accordance with Health and Community Services policy.
RECORDS
217
HEALTH RECORDS
Information about the childs physical health, daily routines, emotional needs,
and growth and development can better help child care providers meet the
childs needs. Please note: It is essential that information on children and
families be kept confidential, accessible only to those who work directly with
the child.
A child health record must be kept on each child at the child care setting. The
record or file must always include (if applicable):
The Childs Health Questionnaire
a current record of Immunization
Medication Consent and Record Sheets
All Incident/Injury Report forms
Consent for Emergency Care and Transportation
Infant Daily Record
Special Needs / Conditions History Form
Asthma / Allergies History Form
Anaphylaxis Alert Form
Any other health related information
(Some of these forms 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 1992.)
The next few pages provides information on each of the forms found in the
next section entitled Record Forms. You will notice that in the Record
Forms section, the forms are not page numbered. The page numbering and the
page headings were intentionally omitted so that it would be easier to
photocopy the forms for use in a child care setting.
The Childs Health Questionnaire
Information provided by parents about their childs health can help providers
understand a child and develop a program that addresses the childs needs. The
questions on the Childs Health Questionnaire provide the providers with
218
important information about the childs:

physical health
emotional needs
family dynamics
daily routines
growth and development
Some parents may need help completing the questionnaire.

Incident/Injury Reports
At the time of enrollment providers should discuss with parents the policies
and procedures for handling injuries to children which occur in the child care
setting.
When a child is injured in a child care setting, the injury - no matter how minor
it may seem-should be recorded in an injury report(see When to report: below).
Written Incident/Injury Reports shall be maintained at the child care centre
and be available for inspection at all times. The child's name, the time and
place of the incident/injury, and a brief description of incident/injury together
with action taken is to be recorded. Each entry is to be signed by a minimum
of one provider, and in the case of child care services where two or more
providers are on site, two shall sign. A copy of the report is to be given to the
parent/guardian and regional Child Care Services staff.
When to report:
Incidents are defined as minor physical occurrences requiring minimal first aid,
or any concerns of health and safety. Precisely which incidents/injuries need
to be recorded and reported is to some extent a judgement call on the part of
the provider/operator, as the degree of seriousness is always an element.
However, when in doubt, the report is to be completed. The following is a guide
to determine when an incident/injury should be recorded:
where there may be a negative effect on a child being provided with
care (for example, a blow to the childs head)
where a parent/guardian may be likely to have a concern about the
incident/injury (for example, a bite from another child)
219
where a question regarding the incident/injury may be raised in the

future (for example, bruising that occurs more often than normal for
the developmental stage of the child)
In addition the incident/injury should be reported immediately to the regional
Director of Child Care Services where:
there is an injury to a child that requires treatment other than simple
first aid (for example, a suspected broken bone)
a child becomes seriously ill (for example, a convulsion)
there is an incident that put a child at risk (for example: a child leaving
the centre unobserved, discovery that drinking water is not safe)
there is an incident of communicable disease
In the case of a communicable disease, the public/community health nurse is
also to be informed immediately.
Child Abuse - All persons have a duty to report known or suspected abuse of
a child. Section 15 of the Child, Youth and Family Services Act outlines the
duty to report.
The injury report is a written report detailing the childs injury, how it
occurred and what first aid, if any, was administered. The report is to be
completed as soon after the injury as possible by the provider who witnessed
the injury. The report can serve as a legal record of the injury and must be
kept in the childs file and a copy given to the parents.
Consent for Emergency Care and Transportation
This form gives providers permission to act for the child on the parents behalf
in case of an emergency, e.g., very high fever/seizure. It gives parents and the
child care service the opportunity to be prepared, to discuss what might happen
in an emergency involving their child, and help to ensure that appropriate action
will be taken.
220
Medication Consent and Record Sheet

Medication cannot be given to a child without parental consent. If it is
necessary to administer medication, it is essential that proper procedures for
administering and recording are followed, as improper administration can be of
considerable risk to a child.
Children with Special Needs or Long-term Conditions
Providers and parents of children with special needs may need to communicate
with each other in a variety of ways to ensure the specific needs of the child
are met. For example, parents and providers may keep a journal that parents
can bring each day to record a childs daily routines.
Forms for Special Needs/Conditions
Some children have special medical conditions requiring providers to obtain
more information in order to provide appropriate care. Where children with
special needs are integrated into child care settings, sharing information is
especially important. Two forms have been included:
asthma / allergies history form
special needs / conditions history form
Notification of Illness
If a child or children have an illness outlined in Table I, a notification letter
must be provided to parents giving the relevant information and a Facts sheet
(if applicable).
Infant Daily Record
Open communication between the infants primary caregiver and the parents is
essential. This can only be achieved when there is trust between the two
parties. Having the required information in order that the needs of the infant
are met depends on sharing information on a daily basis. The parent needs to
know:
221
when the infant slept during the day and for how long
what the infant ate/drank during the day
when and how often the infant urinated and had a bowel movement during
the day.
It is very useful to have a chart that is divided into two sections. The first
half is completed by the parent at drop-off time and the second part is
completed by the primary caregiver throughout the day to provide daily
information to the parent. If the parent does not drop off or pick up the
infant the chart can be sent home in the diaper bag to the parent. The parent
completes their part of the chart and sends it in with the infants belongings
the next day. For more information on the use of the Infant Daily Record,
please see the Centre-Based Infant Care Program Guide, published by the
Department of Health and Community Services.
Record of Illness, Absence and Early Departure
This record is intended to keep track of any patterns of communicable illness
that may be occurring at the child care setting. By recording reasons for
health related absences, child care providers are more likely to determine
whether there is pattern of illness emerging that may be of concern. As
mentioned in the outbreak section of this manual (see Infectious Disease),
the Regional Integrated Health Authority office must be contacted if several
children or providers become ill on the same day, or if two or more children in
your program develop diarrhea or show signs of gastrointestinal illness, e.g.,
vomiting, within 48 hours. Each regional office will have its own protocol
regarding the reporting of outbreaks of infectious disease so child care
providers should check with officials at the Regional Integrated Health
Authority office to determine who the first contact should be in any suspected
outbreak. The Record of Illness, Absence and Early Departure will assist the
provider in keeping track of who was sick and when they were absent. This will
be valuable information for the Community Health officials when they try to
determine severity of outbreaks of infectious disease.
Each child care setting must have policies in place informing parents that they
are to notify the provider or child care setting if their child is to be absent.
222
This information is essential for health reasons, as outlined in the above

paragraph but for safety reasons as well.
Communication between parents and providers, especially if the parent relies
on someone else to transport the child to the child care setting, is vital to
ensure a childs safety in travelling to and from a child care setting.
RECORD FORMS
Childs Health Questionnaire

(To be completed by parents)
Name of Child:
Date of Birth:
MCP Number:
(yy/mm/dd)
Parents Names:
Tel: (w)
(h)
Tel: (w)
(h)
In Case of Emergency (Adult to contact if you cannot be reached)

Name:
Telephone (work):
Relationship:
(home:)
Physician and/or clinic: Name:

Address:
Telephone:
Dentist and/or clinic: Name:
Address:
Telephone:
Immunization Record: Please attach copy of current immunization record
Health and Developmental History

1.
Describe your childs general health, e.g., recurrent colds, ear

infections, stomach aches, etc:
2.
Does your child have any illnesses, conditions, or special needs which
I/we should know about, e.g., asthma, diabetes?
3.
Is your child taking any medication?
Yes
No 9
If yes, which medication and what is it for?
4.
Has your child ever been to a dentist?
Describe any dental problems:
Yes
No
5.
How would you describe your childs emotional, physical and social
growth and development?
6.
Does your child have any food allergies?
Yes 9 No 9
If Yes, please describe:
Does your child have any other allergies?
Yes 9 No 9
7.
Is your child on any special diet?
Yes 9 No 9
8.
Describe any particular concerns you have about your childs diet and/or
eating habits:
For infants/young children being breast or bottle fed

Describe your infant/child's breastfeeding or bottle-feeding patterns:
How will your infant/child be fed in the child care setting, e.g., expressed
breast milk in bottle or cup, formula?
9.
Describe specific techniques used to settle or calm your child, e.g.,

rocking, pacifier, singing (for infants and toddlers), quiet time with an
adult (for preschoolers) time to themselves (for school-age children).
10. Describe your childs sleeping habits and routine:
11.
How far has your child progressed in toilet learning? (if applicable)
12. Describe any particular fears your child has shown, e.g., to animals, loud
noises, strangers:
13. Describe how your child reacts to stressful situations, e.g., cries,
withdraws, acts out, nightmares:
14. How does your child usually react to new situations?
15. We would appreciate your views on guiding your childs behaviour and
setting limits:
16. Is there anything else that you would like to tell me/us about your child
to help me/us provide good care?
Parents signature
Date
Incident/Injury Report
Name of Child Care Service:
Name of Child:
Date of Birth:
(yy/mm/dd)
Date of Injury:
Time:
a.m.
p.m.
(yy/mm/dd)
Parent(s) notified:
Time:
a.m.
(yy/mm/dd)
Name of attending Provider:

Describe the incident/injury:
Describe how and where the incident/injury occurred:
Was first aid administered? Yes
No 9 (If yes, specify):
Who administered first aid?
Over
p.m.
Was any further action taken (e.g., child sent to hospital, to physician, taken
home):
If the child remained at the child care service, what was the childs level of
participation?
Other comments:
Name(s) of adult(s) who witnessed the injury:
Reporting Providers signature
Date
Reporting Providers name

(Please Print)
N.B. Copies to be provided to the parent and regional Child Care Services
staff
Consent For Emergency Care And Transportation

Name of Child:
Date of Birth:
(yy/mm/dd)
If, due to such circumstances as injury or sudden illness, medical treatment is

necessary, I authorize the child care service provider to take whatever
emergency measures s/he deems necessary for the protection of this child
while in her/his care.
I understand that this may involve calling a physician, interpreting and carrying
out his or her instructions, and transporting my child to a hospital, including the
possible use of an ambulance.
This could also include emergency transportation required as a result of fire or
other environmental emergencies.
I understand that this may be done prior to contacting me, and that any
expense incurred for such treatment, including ambulance fees, is my
responsibility.
Parents signature
Parents name (Please Print)
Operators/Providers Signature
Date
Medication Consent And Record Sheet

Name of Child:
Date of Birth:
(yy/mm/dd)
Part I: Information (to be completed by the parents)

Date medication prescribed:
for how long:
Name of prescribing physician:

Physicians telephone:
Reason for medication:
Name of medication:
Dose:
How is it given?
Time(s) to give medication:
The child received
(number) of doses at home.
Did the child have any reaction to the medication? Yes

describe:
No
If Yes,
Special consideration for this medication, e.g., taken with meals, taken 1 hr.
before meals:
I,
(parent) give permission for my child

(childs name) to be given
(medication) according to the instructions stated
above. I have explained when and how to give this medication and understand
that I will be contacted if my child shows any unusual symptoms.
Parents signature
Date
Part II: Medication Record

Write the date and time the medication was administered, and sign your initials
in the appropriate boxes below
Date
(yy/mm/dd)
Time
Initials
st
1
provider
Initials
2nd
provider
Date
(yy/mm/dd)
Time
Initials
1st
provider
Initials
2nd
provider
Note: Each provider who administers or witnesses this medication must verify her/his initials
with the signature, once, below.
Initials:
Initials:
Initials:
Initials:
Signature:
Signature:
Signature:
Signature:
Providers comments: (this could include ways the child prefers to take the
medication, or if refused)
Side effects:
Describe:
Action taken:
Yes
No 9
Asthma/Allergies History Form

(To be completed by physician)
Name of Child:
Allergies/Triggers
Date of Birth:
Type *
Reactions/Symptoms
* food, drug, environmental

Medication:
Name of medication:
(yy/mm/dd)
Prevention and/or
Treatment
Dose:
Frequency (e.g., daily; as needed):

What to do if a severe reaction occurs:
Adrenalin kit required:
Yes
No
Other information:
Physician signature:
Telephone:
Physician name:
(Please Print)
Review Date:
Special Needs/Long-term Condition History Form

(To be completed by the appropriate health professional)
Name of Child:
Date of Birth:
Name of/Information on condition(s):
Agencies/Programs the Child is Involved With:

1. Name of Agency/Program:
Address:
Telephone:
Contact:
Address:
Telephone:
Contact:
Address:
Telephone:
Contact:
Other Professionals involved:
Name
Physician
Nurse
Psychologist
Speech & language
pathologist
Telephone
(yy/mm/dd)
Occupational
therapist
Physiotherapist
Social worker
Vision/hearing
specialist
Other
Treatments:
Medication:
Other treatments:
What constitutes an emergency?
Daily Care: (please specify, e.g., catheterization)
Symptoms/Problems to watch for e.g., Action required e.g., skin care, child
needs to be out of wheelchair each day
red marks, problems with seating,
seizures, insulin reaction
Special child care programming requirements (e.g., limitation in activity,

special diet):
Additional Comments:
Health Professionals signature
Date
Telephone
Parents signature
Date
Review date:
(The operator/family child care provider and the childs parents are advised to
review this information every six months)
Notification of Illness
Dear Parent or Guardian:
Your child may have

A child in the child care service has
We have noticed the following symptoms of this illness:
Please take the following precautions:

1.
Check your child for the above symptoms.
2.
Take your child to the appropriate health professional if you think s/he
has
3.
Tell the child care service if your child has
Your child may participate in the program even with

Your child must be cared for at home for
until
Thank you
days or
Infant Daily Record

Name of Child:
Name of Primary Caregiver:
Arrival Time:
Date:
Departure Time:
Part 1: To be completed by parent

Time of last diaper
change - wet or b.m.
Time of last feeding
Times infant slept

last night
Information the primary caregiver needs to provide care to your infant

today:
Parent/Guardians Signature
Over
242
Part 2: This section to be completed by primary caregiver

Diaper Changes
Time
Wet
(T)
B.M.
(T)
Feeding
Time
Bottle
(T)
Sleeping
Food*
(T)
From
* Indicate what foods the infant ate today in table below:

What S/He Ate Today:
Morning
Lunch
General comments on her/his day:
_______________________________
Signature of Primary Caregiver
Afternoon
To
Record of Illness, Absence and Early Departure

Name of Child
Date of
Absence
Reason for Absence
Providers Signature
Note to Providers: This form is to be used to track possible patterns of illness. If a pattern is noted, e.g., two or more children
develop similar symptoms such as diarrhea or vomiting within a 48 hour period, then officials from the Regional Integrated Health
Authority office are to be notified. Parents/Guardians must notify providers regarding reasons for early departure or absence.
Reasons for absence or early departure (health related) must be indicated on this form.
Appendix A - Recommended Protective Surfacing*

*With the permission of Canadian Standards Association, this material is reproduced from CSA
Standard CAN/CSA-Z614-03, Childrens Playspaces and Equipment which is copyrighted by
Canadian Standards Association, 178 Rexdale Blvd., Toronto, Ontario, M9W 1R3. While use of
this material has been authorized, CSA shall not be responsible for the manner in which the
information is presented, nor any interpretations thereof.
1. General
All playground protective surfacing systems must be considered according to
their merits. At each stage of selection, specification, acquisition, installation,
maintenance, and repair, there are costs that must be balanced with the
advantages and disadvantages of the surface system or combination of systems.
When loosefill material is used, a minimum depth of 300mm is recommended.
2.
Wood Chips/Bark Mulch
2.1
Bark Mulch generally results from pruning and disposing of trees as part of
urban tree management and landscape maintenance programs or the debarking
of trees in the forest or mill. It can contain twigs and leaves from the trees
and shrubbery that have been processed. Wood chips are generally uniformly
crushed shreds or chips that contain no bark or leaves. The wood must be
separated prior to chipping or processing to ensure that no woods containing
toxic substances or allergens are included in the final product.
2.2
The
a)
b)
c)
d)
e)
f)
g)
h)
advantages of using this material include the following:

the initial cost is low;
it is easy to install;
it allows for good drainage;
it is less abrasive than sand;
it is readily available;
it is less attractive than sand to cats and dogs;
the mildly acidic composition of some woods retards insect infestation and
fungal growth; and
users of the playground will generally not use the wood chips for other
purposes or play with it.
2.3
The disadvantages of this material include the following:
a) rainy weather, high humidity, or freezing temperatures can cause it to
compact;
b)
245
h)
i)
with normal use over time, it combines with dirt and other foreign
materials;
over time, it decomposes, is pulverized, and compacts. The greater the
quantity of leaves or moisture, the faster the rate of decomposition;
its depth can be reduced by displacement due to childrens activity or by
materials being blown by the wind;
it can be blown or thrown into childrens eyes;
it is subject to microbial growth when wet;
it can conceal animal excrement and trash (e.g., broken glass, nails, pencils,
and other sharp objects that can cause cuts or puncture wounds);
it spreads easily outside the containment area; and
it can be flammable.
3.
Engineered Wood Fibre
c)
d)
e)
f)
g)
3.1
Engineered wood fibre generally results from grinding virgin or new wood, which
has been debarked and contains no leaves, to specific dimensions and
performance criteria. The wood must be separated prior to chipping or
processing to ensure that no woods containing toxic substances or allergens are
included in the final product.
3.2
The
a)
b)
c)
d)
e)
f)
g)
h)
i)
advantages of this material include the following;

it allows for good drainage;
it is less abrasive than sand;
it is less attractive than sand to cats and dogs;
the mildly acidic composition of some woods retards insect infestation and
fungal growth;
users of the playground will generally not use the material for other
purposes or play with it;
it is free of bark and leaves; and
it is less likely than other loosefill material to conceal animal excrement
and trash (e.g., broken glass, nails, pencils, and other sharp objects that
can cause cuts or puncture wounds).
3.3
246
a)
h)
i)
rainy weather, high humidity, and freezing temperatures reduce its

effectiveness;
with normal use over time it combines dirt and other foreign materials;
over time, it decomposes, is pulverized, and compacts. The greater the
level of moisture, the faster the rate of decomposition;
its depth can be reduced by displacement due to childrens activity or by
it can be blown or thrown into childrens eyes;
it is subject to microbial growth when wet;
it can be flammable.
4.
Sand
b)
c)
d)
e)
f)
g)
4.1
Sand is a naturally occurring material that will vary in texture and composition
depending on the source and geographic location from which it is mined. Once
mined, the raw sand is processed or manufactured through washing, screening,
and other actions, to provide specific grades and classifications.
4.2
The
a)
b)
c)
d)
e)
f)
advantages of this material include the following:

it does not easily support microbial growth;
it is non-flammable; and
it is not susceptible to vandalism except by contamination.
4.3
a) rainy weather, high humidity, and freezing temperatures reduces its
effectiveness;
b) with normal use over time, it combines with dirt and other foreign
materials;
c) its depth can be reduced by displacement due to childrens activity or by
d) it can be blown or thrown into childrens eyes;
e)
f)
247
j)
it can be swallowed;
it can conceal animal excrement and trash (e.g., broken glass, nails, pencils
and other sharp objects that can cause cuts or puncture wounds.)
it spreads easily outside the containment area;
small particles bind together and become less cushioning when wet; when
thoroughly wet, sand reacts as a rigid material;
it can be tracked onto other surfaces; when installed in conjunction with
a unitary surface, the fine particles can reduce the shock-absorbing
properties of porous unitary material. The abrasive characteristic of sand
can damage most other surfaces, including non-porous unitary materials
and surfaces outside the playground; and
it adheres to clothing.
5.
Gravel
g)
h)
i)
5.1
Gravel is a naturally occurring material that will vary in texture and composition
depending on the source and geographic location from which it is mined. Once
mined, the raw gravel is processed on manufactured through washing, screening,
and other actions, to provide specific grades and classifications. Crushed or
broken gravel is unacceptable, as this material does not allow for the
displacement of the particles.
5.2
The
a)
b
c)
d)
e)
f)
g)

it is non-flammable;
it is not susceptible to vandalism except by contamination; and
it is less attractive than sand to animals.
5.3
The disadvantages of this material include the following;
a) rainy weather, high humidity, and freezing temperatures reduce its
effectiveness;
b) with normal use over time, it combines with dirt and other foreign
materials;
c) its depth can be reduced by displacement due to childrens activity;
248
d)
e)
f)
g)
k)
it can be thrown into childrens eyes;

it can be swallowed;
it can be lodged in bodily openings such as the nose and ears;
it conceals animal excrement and trash (e.g. broken glass, nails, pencils and
other sharp objects that can cause cuts and puncture wounds);
it spreads very easily outside the containment area;
small particles bind together, become less cushioning, and form hard pan;
it can be tracked onto other surfaces. When on other hard surfaces, the
rolling nature of the gravel can contribute to slip-fall injuries; and
it is difficult to walk on.
6.
Shredded Tires
h)
i)
j)
6.1
Shredded tire materials are the result of grinding, buffing, or crushing a whole
tire or any part of the tire. The tire particle must not contain any metals or
foreign contaminants. Some processing techniques provide for the pigmenting
of the outside of the black rubber; this must be non-toxic and contain no
allergens such as latex.
6.2
The
a)
b)
c)
d)
e)
advantages of this material include the following;

it is not abrasive;
it is not susceptible to vandalism except by contamination; and
it is less attractive than sand to animals.
6.3
a) it can contain wires or other metal components;
b) its depth can be reduced by displacement due to childrens activity or by
c) it can be blown or thrown into childrens eyes;
d) it can be swallowed;
e) it can contain lead and other toxins;
f) small or dust-sized particles can enter and remain in the lungs;
g) when wet, small particles will stick to clothing and skin;
h) it can become lodged in bodily openings such as the nose and ears;
i)
249
j)
k)
it is difficult to walk on.
7.
Mats or Tiles
7.1
Mats or tiles are generally the result of the combination of a chemical binder
and rubber filler product. The mats or tiles can be manufactured using a
combination of heat, pressure or ambient application of a mixture within a form
or mould. The mats or tiles can appear to be monolithic in a single- or multiplelayer system or can have a support or leg structure combined with a firm top.
Mats or tiles can be porous or non-porous to water. Pigmentation of the
surface can be provided through the pigmentation of the binder holding the
rubber particles or through utilizing coloured rubber particles or chips. Mats
or tiles are manufactured in various thicknesses, lengths, and widths, depending
on the properties desired by the manufacturer.
7.2
The
a)
b)
c)
d)
e)
f)
g)
h)
i)
7.3
The
a)
b)
c)
d)
e)
f)

it requires low maintenance;
it is easy to clean;
it provides consistent shock absorbency;
it is not displaced by children during play activities;
life-cycle costs are generally low;
good footing can be provided (depending on the surface texture);
it can harbour few foreign objects;
generally, no retaining edges are required; and
it makes the playspace accessible to people with disabilities.
disadvantages of this material include the following:

the initial cost is relatively high;
the base materials can be critical for thinner materials;
it often must be used on almost smooth uniform surfaces without deviation
in slope;
it can be flammable;
it is subject to vandalism (e.g. ignited, defaced, cut);
it can curl up and cause tripping;
250
g)
h)
i)
j)
k)
8.
it can shrink and cause an accumulation of dirt and debris that does not
absorb impact;
it can become hard over time as a result of environmental degradation.
This would necessitate a total removal and replacement and would incur
added costs unless the damage were to be covered by warranty or
insurance;
some designs are susceptible to frost damage;
the locations of seams, anchors, and other fasteners cannot attenuate
impact to the same degree as the balance of the mat or tile; and
mechanical fasteners or anchors can become dislodged and present a
hazard to the user.
Poured-in-Place
8.1
A poured-in-place surface is generally the result of a combination of a chemical
binder and rubber filler product. It can be manufactured using single or
multiple layers of materials and binders, and generally is monolithic. Poured-inplace surfaces are generally porous; however, they can be non-porous to water
through the application of a non-porous material. Pigmentation of the surface
can be provided through the pigmentation of the binder holding the rubber
particles or through utilizing coloured rubber particles or chips. Poured-inplace surfaces are manufactured in various thicknesses, depending on the
properties desired by the manufacturer.
8.2
The
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)

it requires low maintenance;
it is easy to clean;
it provides consistent shock absorbency;
it is not displaced by children during play activities;
life cycle costs are generally low;
it does not require smooth uniform surfaces without deviation in slope;
good footing can be provided (depending on surface texture);
it can harbour few foreign objects;
generally, no retaining edges are required; and
it makes the playspace accessible to people with disabilities.
8.3
a)
b)
c)
d)
e)
f)
g)
251
the initial cost is relatively high;

the base materials can be critical for thinner materials;
it can be flammable;
it is subject to vandalism (e.g., ignited, defaced, cut);
it can shrink and cause an accumulation of dirt and debris that does not
absorb impact at the edges;
it can become hard over time as a result of environmental degradation.
This would necessitate a total removal and replacement and would incur
added costs unless the damage were to be covered by warranty or
insurance; and
some designs are susceptible to frost damage.
252
NOTES
254
FEEDBACK FORM
Use this form to provide your feedback on the Standards and Guidelines for
Health in Child Care Settings.
Type of setting in which you work:
Age group with whom you work:
Comments:
Send this Feedback Form to:

Child Care Services Consultant
Dept. of Health and Community Services
st
1 Floor, West Block, Confederation Building
P.O. Box 8700
St. Johns, NL A1B 4J6
Or
Fax: (709) 729-6382
256
BIBLIOGRAPHY
Allergy /Asthma Information Association (1999). AAIA Anaphylaxis Reference
Kit . Allergy/Asthma Information Association Anaphylaxis Committee
American Academy of Family Physicians, (1999) Toxoplasmosis in Pregnancy,
from AAFP website http://familydoctor.org/handouts/180.html
American Academy of Paediatrics (1987). Health in Day Care: A Manual for
Health Professionals. Elk Grove Village,IL
Chin, J. (2000). Control of Communicable Diseases Manual. 17th Ed Washington:
American Public Health Association.
Canadian Child Care Federation (1995). HIV/AIDS and Child Care. Ottawa,
Ontario.
Canadian Child Care Federation (2002). Resource sheets for parents and child
care providers Web site
http://www.cccf-fcsge.ca/publications/publications_en.html
Canadian Paediatric Society
www.caringforkids.cps.ca
(2002).
Caring
for
Kids
Web
site:
Canadian Paediatric Society (2002) Erythema infectiosum and parvovirus B19

infection in pregnancy. Canadian Paediatric Society website,
http://www.cps.ca/english/statements/ID/id88-03.htm
Canadian Paediatric Society (2003). Risk of acquiring cytomegalovirus infection
while working in out-of-home child care centres, CPS website,
http://www.cps.ca/english/statements/ID/id92-08.htm
Canadian Paediatric Society (1999). 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. Ottawa, Ontario
Canadian Paediatric Society (1994). Little Well Beings: A Handbook on Health
in Family Day Care. Ottawa, Ontario
Canadian Standards Association (1998). Guidelines on Childrens Playspaces and
Equipment. Ottawa, Ontario
257
Dunster, L. (1994). Home Child Care: A Caregivers Guide. Ottawa: Child Care
Providers Association.
Fitness Canada and the Canadian Institute of Child Health (1990). Moving and
Growing Exercises and Activities for Twos, Threes, and Fours. Ottawa, Ontario
Georgetown University Child Development Centre (1986). Health in Day Care:
A Manual for Day Care Providers. Washington, D.C.
Government of Newfoundland and Labrador (2002). Centre-Based Infant Care:
Guide to Program Standards. St. Johns, NL: Department of Health and
Community Services.
Government of Newfoundland and Labrador (2001) Individually Licensed Family
Child Care Policy Document. St. Johns, NL: Department of Health and
Community Services.
Government of Newfoundland and Labrador (1999). Breastfeeding Handbook.
St. Johns, NL: Department of Health and Community Services.
Government of Newfoundland and Labrador(1997). Early Childhood Program
Guide. St. Johns, NL: Department of Human Resources and Employment.
Government of Newfoundland and Labrador (1994). Active Living for Infants,
Toddlers and Preschoolers: Information Folder. St. Johns, NL: Departments
of Tourism, Culture and Recreation, Department of Health, and Child Care
Initiatives Fund of Human Resources Development Canada.
Government of Newfoundland and Labrador (1999) Child Care Services Act,
(Chapter C-11.1) Regulations, and Related Policies. St. Johns, NL: Department
of Health and Community Services, NL.
Government of Newfoundland and Labrador, (2003) Healthier Together: A

Strategic Health Plan for Newfoundland and Labrador, St. Johns, NL,
Department of Health and Community Services.
Health and Community Services: St. Johns Region (2001). Preventing Shaken
Baby Syndrome (resource kit). Prepared with assistance from the Child
Protection Committee, Janeway Child Health Centre, St. Johns, NL.
Health and Welfare Canada (1989). Facilities and Equipment for Day Care
Centres. Ottawa, Ontario.
258
Health Canada (2002). Canadian Immunization Guide. 6th Ed. Ottawa: Minister
of Public Works and Government Services. http://www.hc-sc.gc.ca/pphbdgspsp/publicat/cig-gci/pdf/cdn_immuniz_guide-2002-6.pdf
Health Canada (2002). Canadas Physical Activity Guide for Youth and Canadas
Physical Activity Guide for Children. Ottawa: Minister of Public Works and
Government Services Canada. www.healthcanada.ca/paguide
Health Canada (2002). A Practical Workbook to Protect, Promote, and Support
Breastfeeding in Community Based Projects. Canada Prenatal Nutrition Program,
Ottawa: Minister of Supply and Services.
Health Canada (2001). Postpartum Parent Support Program: Handouts. Ottawa:
Minister of Supply and Services, Canada Communication Group Publishing.
Health Canada (2000). Family-Centred Maternity and Newborn Care: National
Guidelines. Ottawa: Minister of Public Works and Government Services.
Health Canada (1995). Canadas Food Guide to Healthy Eating: Focus on
Preschoolers: Background for Educators and Communicators. Ottawa: Minister
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Lambton Health Unit (2000). Safe Healthy Children: A Health and Safety
Manual for Childcare Providers. Point Edward. ON
McKay, S.C. (1988). The New Child Safety Handbook. Toronto: McMillan Canada.
Mohrbacher, N., & Stock, J. (1997). The Breastfeeding Answer Book.
Schaumburg: La Leche League International.
Ontario Association of Public Health Dentistry (2003)., Position Statement on
Infant Feeding and Oral Health, Ontario,
Ontario Physical and Health Education Association, Ontario Ministry of Tourism
and Recreation (1993). Toronto: Author.
Society of Obstetricians and Gynaecologists of Canada (SOGC), (2000). Healthy
Beginnings: Guidelines for Care During Pregnancy and Childbirth, Toronto,
Ontario.
United Referral and Intake System, Manitoba Family Services and Housing,
Manitoba Education and Youth, Manitoba Health. (2002) Caring for Children
with Anaphylaxis: A Resource Manual for Child Care Personnel who Provide Care
to Children in Community Programs. Government of Manitoba
259
260
RESOURCES
Canadian Child Care Federation
This organization works to improve the quality of child care services for
Canadian families. Web site includes excellent resource sheets on a variety of
topics.
Web site: www.cfc-efc.ca/ccf
Phone: 1 800-858-1412 or 613-729-3159
Email: cccf@cfc-efc.ca
Caring for Kids - Canadian Paediatric Society
This web site gives parents and caregivers information on caring for newborns,
immunizations, healthy eating, common childhood illnesses, behaviour, and
growth development.
Web site: www.caringforkids.cps.ca
Canadian Institute of Child Health( CICH )
CICH is a national, non-profit organization dedicated to improving the overall
health and well-being of children and youth in Canada. CICH produces many
publications and resources for parents and health professionals.
Web site: www.cich.ca
Phone: 613-230-8838
Email: cich@cich.ca
Child and Family Canada
Child and Family Canada is a group of 50 non-profit organizations which works
to give parents and caregivers quality information on children and families on
a web site that is easy to navigate. The web site includes a wealth of
information on child care and parenting, including finding child care
organizations and information on family life and work.
Web site: www.cfc-efc.ca
Growing Healthy Kids: A Guide to Positive Child Development
This web site has a vast array of information on healthy child development,
such as information about a childs first year of life and transition to school.
The web site emphasizes the importance of families, schools, communities,
workplaces and government to childrens healthy development.
Web site: www.growinghealthykids.com
Health Canada
Health Canada is the federal governments department that is responsible
for providing information to Canadians on health issues and concerns and
ways to promote and support a healthy lifestyle. The web site includes
261
information about a variety of topics including: nutrition, breastfeeding,

health protection, immunization, diseases and conditions, product recalls,
health and safety warnings, exercise and active living and children and
parenting.
Web site: www.hc-sc.gc.ca
Phone: 613-957-2991
Email: info@hc-sc.gc.ca
Specific Government of Canada sites of interest:
Canadas Physical Activity Guide web site: www.paguide.com
Sudden Infant Death Syndrome (SIDS) web site: www.sidscanada.org
Canadian Food Inspection Agency: Index of Food Recalls and Allergy Alerts:
http:/ / www.inspection.gc.ca/english/corpaffr/recarapp/recaltoce.shtm
Safe Kids Canada
Safe Kids Canada is the national injury prevention program of Torontos
hospital for Sick Children. Injuries are the number one cause of death and
disability among Canadian children. The program works to help keep children
safe by providing information on how to prevent injuries. The web site
includes excellent fact sheets on safety prevention tips for infants and
young children under the age of five years.
Web site: www.safekidscanada.ca
Phone: 1 888-SAFE TIPS (723-3847) or 416-813-6766
Email: safekids.web@sickkids.ca
La Leche League Canada
La Leche League (LLL) Canada is a non-profit organization that works to help
support mothers to breastfeed successfully through mother-to-mother
support groups and individual counseling from LLL Leaders who are
experienced breastfeeding mothers.
Breastfeeding Referral Service 1-800-665-4324
Web site: www.lalecheleaguecanada.ca
Invest in Kids
The mission of this organization is to enhance the capacity of all Canadians
to positively influence the emotional, social, and cognitive development of our
youngest children. Invest in Kids Foundation works through research, public
education and awareness, and training, to provide the skills Canadians need
to make a difference. The Years before 5 Campaign, a multimedia campaign
to raise the publics awareness and understanding of the importance of the
262
early yearsand the profound impact we all have on young children was a
project of this organization. Invest in Kids was the lead in a collaborative
program Get Set for Life, a public media campaign on CBC television to
educate parents and caregivers about the importance of early child
development.
Phone: 1-877-583-KIDS(5437)
Web site: www.investinkids.ca
Email: mail@investinkids.ca
Canadian Red Cross
The Canadian Red Cross offers first aid programs for children and adults of
varying levels of skills and interest. The ChildSafe course helps parents and
caregivers learn first aid basic and safety knowledge such as creating a safe
environment for children, preventing injuries, and knowing what to do in an
emergency.
Phone: 1 888-890-1997
Web site: www.redcross.ca
Email: firstaid@redcross.ca
Kids in Safe Seats (KISS) Inc.
Kids in Safe Seats is a volunteer organization dedicated to promoting, and
educating Newfoundlanders about, the safe and correct use of car seats.
Among families who have attended their Car Seat Checkup Clinics, only 1 in
20 have had the seats and children set up exactly right-mistakes are easy to
make, with possibly disastrous consequences. We hope, through this website
and our other educational projects, to help parents and caregivers keep
their little ones as safe as they can be. KISS includes on their web site the
pamphlets on specific car seats and on buying and borrowing a used car seat.
Web site: www.kidsinsafeseats.ca
Email: kiss@kidinsafeseats.ca
Transport Canadas Public Notices of Recalls
Childrens Restraint Systems available at the following web site:
http:/ / www.tc.gc.ca/roadsafety/childsafe/notiavis/en/chart_e.htm
The space following is provided for you to add your own Resources:
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Standards and Guidelines

Government of Newfoundland and Labrador

Department of Health and Community Services

A Word About Salt, Sugar And Fat . . . . . . . . . . . . . . . . . . . . . . . 38

When a Childs Sexual Behaviour Is Not Appropriate . . . . . . . . . . .

Facts about Hand, Foot and Mouth Disease . . . . . . . . . . . . . . . .

Preparing the Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Childs Health Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Health in Child Care Settings

If there is any doubt about the immunization status, consult your

All providers must have a current immunization record on file. Providers

If a childs immunization record differs significantly from the following

Page Revised 03/05

Health in Child Care Settings

Note: Up-to-date immunization is strongly recommended but not required. If

DaPTP/Hib (Diphtheria, Pertussis, Tetanus, Polio and Haemophilus b. )

DaPTP/Hib (Diphtheria, Pertussis, Tetanus, Polio and Haemophilus b.)

DaPTP/Hib (Diphtheria, Pertussis, Tetanus, Polio and Haemophilus b.)

MMR (Measles, Mumps and Rubella); Varicella; Meningococcal

DaPTP/Hib and MMR (Diphtheria, Pertussis, Tetanus, Polio and Haemophilus

Hepatitis B (1 dose x 3 visits); Meningococcal (if not given at 12 months,

REMEMBER: Publicly funded immunizations are free, and, if up-to-date, give

Page Revised - 03/05

Health in Child Care Settings

Common Reactions to Immunizations

Health in Child Care Settings

Health in Child Care Settings

Health in Child Care Settings

The Correct Way to Wash Hands

Health in Child Care Settings

When to Wash Hands

at the start of the work day

after changing a diaper

after using the toilet or

before preparing food or

after handling raw meat or

after caring for an ill child

after direct contact with

before and after applying a

after cleaning up any body

before giving medication or

after handling chemicals

after removing disposable or

after handling pets or animals,

after removing childrens

when hands are visibly dirty

Alcohol Based Hand Rinses

Children should wash their hands

after using the toilet or the

after diaper changes (during

before handling food in

after eating snacks or meals,

after blowing nose or vomiting

after using play materials,

after handling pets and other

after removing their own

after playing outside and when

Health in Child Care Settings

Page Revised - 05/04

Health in Child Care Settings

DIAPERING AND TOILETING

proper handwashing routine by both adult and child

Where children in diapers are in attendance, appropriate diapering provisions

Gloves are not recommended for diaper changing. Regular exposure to