ERIC ED372513: Preventing Preventable Harm to Babies: Promoting Health and Safety in Child Care. Better Care for the Babies Project.

38 Pages·1992·0.82 MB·English

by  ERIC

DOCUMENT RESUME
ED 372 513
EC 302 113
AUTHOR
Griffin, Abbey
TITLE
Preventing Preventable Harm to Babies: Promoting
Health and Safety in Child Care. Better Care for the
Babies Project.
INSTITUTION
Zero to Three/National Center for Clinical Infant
Programs, Arlington, VA.
SPONS AGENCY
Health Resources and Services Administration
(DHHS/PHS), Rockville, MD. Bureau of Maternal and
Child Health and Resources Development.
PUB DATE
[92]
CONTRACT
MCJ-513317
NOTE
38p.
PUB TYPE
Information Analyses (070)
Viewpoints
(Opinion/Position Papers, Essays, etc.) (120)
EDRS PRICE
MF01/PCO2 Plus Postage.
DESCRIPTORS
At Risk Persons; Child Caregivers; Child Health;
*Communicable Diseases; Day Care; *Day Care Centers;
*Disease Control; Emotional Development; *Health
Promotion; *Immunization Programs; Infants; Injuries;
Physical Health; Program Development; Quality
Control; Safety; State Programs; Toddlers; Training;
Well Being
ABSTRACT
This report covers the risks to health, safety, and
emotional well-being for infants and toddlers in child
care settings,
and examines opportunities for diminishing those risks and promoting
healthy development. Part 1 examines the risks of
poor caregiving
practices, including the spread of infectious disease, the incidence
of injury, and the risks to healthy emotional development. Part 2
proposes systematic approaches that states can use to diminish risks
and to provide for the healthy development of infants and toddlers in
child care, through the following four components of states'
child
care quality assurance systems: child care regulation, state planned
health and safety training, child care monitoring, and data
collection on the health and safety status of infants and
toddlers in
child care. The report calls for development of mechanisms
to ensure
that service systems operate in an integrated, coordinated
manner.
Appendices provide a recommended schedule for immunization;
a list of
conditions in children that call for immediate medical attention;
a
discussion of inclusion, exclusion, aLd dismissal of children
with
mild infectious diseases from child
care settings; and
recommendations for training of child caregivers. (Contains
approximately 55 references.)
(.JDD)
**I
******************************************************************
Reproductions supplied by EDRS are the best that
can be made
from the original document.
***********************************************************************
U.S. DEPARTMENT OP EDUCATION
(Mc* of Educaoonal Research and Improvement
EDUCATIONAL RESOURCES INFORMATION
CENTER (ERIC)
pus
document has been reproduced as
received from the person or organization
originating it
0 Minor changes have been made to improve
reproduction Qualify
Points of view or opinions stated in this docu-
ment do not neCeSSenly represent official
OERI position or policy
Foundation, the
With the support of the Carnegie Corporation of New York, the Ford
ZERO TO
Foundation for Child Development, and the Smith Richardson Foundation,
in 1993
THREE/National Center for Clinical Infant Programs is producing several policy papers
improving
describing and analyzinE selected financing, regulatory, and nonregulatory approaches to
infant child care. This paper was also supported in part by project #MCJ-513317 and the Maternal
and Child Health Bureau Program (Title V, Social Security Act), Health Resources and Services
Administration, Department of Health and Human Services.
ZERO TO THREE acknowledges with appreciation the support of the contributors to this
project. ZERO TO THREE, however, is solely responsible for the views and opinions expressed in
this paper.
The author would like to acknowledge the significant contributions of Peggy Daly Pizzo as well
Fiene, Gwen Morgan, Eleanor
as the insights and information contributed by Susan Aronson, Richard
Szanton, Helen Keith, Deane Argenta and Joan Delcoco in the development of this policy paper.
The long-standing support and guidance of the members of ZERO TO THREE's Board
Subcommittee on Child Carc in the States, Kathryn Barnard. J. Ronald Lally. Sally Provence, Lynn
Straus, Bernice Weissbourd, and Edward Zig ler, are essential to the development of these papers,
the goals of the Better Care for the Babies Project, and the continuing work of ZERO TO THREE
in the field of infant and toddler child care.
Preventing Preventable Harm to Babies:
Promoting Health and Safety in Child Care
Table of Contents
What Do We Know?
1
Part 1: Preventable Health, Mental Health and Safety Risks
Associated with Child Care
3
Vaccine-Preventable Diseases
4
Higher Incidence of Common Childhood Diseases
6
Injury
7
Emotional Well-Being
9
Part 2: Strengthening State Approaches to Quality Assurance
In Infant Child Care
11
Improving State Child Care Regulations
11
Increasing State Planned Training for Infant/Toddler Caregivers
13
Increasing the Efficiency and Effectiveness of
Child Care Monitoring
15
Increasing States Data Collection Capacity
17
Conclusion: Reaching Health and Safety Objectives in Child Care
18
References
Attachments
It Is No Coincidence...Immunizations Save Lives.
1.
2. What Vaccines Should A Child Have?
3. APHA/AAP Seventeen Conditions That Call for
Immediate Medical Attention.
4. APHA/AAP Child Inclusion/Exclusion/Dismissal.
5. APHA/AAP Training Recommendations.
4
Preventing Preventable Harm to Babies:
Promoting Health and Safety in Child Care
In 1990, the Secretary of Health and
to diminish risks and to provide the
healthy
Human Services issued the nation's Year 2000
development of infants and toddlers in child
Health Promotion and Disease Prevention
care through the following four components
They are a call for action to
objectives.
of states' child care quality assurance system:
improve the lives of young children many of
(1) child care regulation; (2) state planned
whom suffer disease, disability, and death due
(affordable and accessible) health and safety
to inadequate immunization, injury, exposure
training; (3) child care monitoring; and (4)
to environmental toxins, poor nutrition, and
data collection on the health and safety status
other preventable threats to health and safety
of infants and toddlers in child care.
(U.S. Department of Health and Human
Services, 1990).
What do we know?
This paper covers the risks to health,
There
ample
that
evidence
the
is
safety and emotional well-being as well
as the
foundations of strong, healthy development are
opportunities for diminishing those risks and
built in the first three years of life (beginning
promoting the healthy development of infants
with good prenatal care). This is a time when
and toddleN in the child care setting. It
is
children are most vulnerable to disease, injury,
intended
to
state
assist
policymakers,
and emotional harm that can have life-long
researchers and practitioners in improving the
effects. This is also the optimal period for
lives of children and families. The policy
identifying developmental problems. (Lally,
changes recommended and the policy-making
Szanton & Weissbourd,
Provence,
1988;
process outline will help to move us closer to
Szanton, 1992). Yet it is the birth to 3
year-
both the goals of quality irant/toddler child
old children who receive the least attention
care and child care that is an integral part of
from
Heart,Start:
policymakers.
The
a comprehensive network of family support
Emotional Foundations of School Readiness
services.
(ZERO TO THREE, 1992) which represents
the collective views of experts from
many
Part 1 examines the risks of poor care
-
disciplines On the Board of ZERO TO
practices
giving
the
including
spread
of
THREE, argues for a national commitment to
infectious disease, the incidence of injury, and
policies that address the basic needs (the
thc less visible (but equally threatening) risks
foundation) of their very young children.
to healthy emotional development.
Part 2
Infant child care is of special concern. Why?
proposes systematic approaches states can use
Fifty-one percent of mothers with children under 3 years of
age are currently working (U.S. Department
of Labor, Bureau of Labor Statistics, 1990). The
reasons include: (1) lack of job-protected family leave;
(2) increasing numbers of single parent families; (3) shrinking family
income and the desire of many
mothers to contribute financially; and (4) growing numbers of
teenage parents and low-income families
participating in welfare-to-work programs under thc Family Support Act of 1988
(Young & Zigler, 1988).
One in five children lives in a family with earnings that fall below the federal
poverty level. Many more
families hover just above the poverty line (U.S. Department of Health
and Human Services, 1990;
National Commission on Children, 1991).
5
Low-income employed parents and those affected by the Family Support Act are less likely to have a
consistent source of preventive and primary health care for their children -- 30% use hospital emergency
rooms as a primary health service (Adams, 1990; U.S. Department of Health and Human Services, 1990;
National Center for Children in Poverty, 1990).
The quality of infa2t/toddler child care has been found to be poor (Willer, Hofferth, Kisker, Divine-
Hawkins, Farquhar, Glantz, 1992; Whitebook, Howes, & Phillips, 1989; ZERO TO THREE, 1988).
Infants and toddlers of poor or low income employed families are more likely to experience child care
of substandard quality due to (1) lack of child care options, (2) high cost of quality care and (3) Lek of
quality standards required of infant child care in all settings, particularly child care funded under the
Family Support Act (Sorentein & Wolf, 1988).
Increased health, mental health and safety risks have been associated with group care of infants and
toddlers (Belsky, 1988; Centers for Disease Control [CDC], 1990; Osterholm, 1990; Osterholm, Klein,
Aronson, & Pickering, 1986).
They should not only protect the child, but
There are immediate and essential steps
that can be taken to improve the health,
should also promote the achievement of his or
her fullest potential in both physical and
mental health, and safety of infants and
toddlers in child care. There is evidence of a
psychological health" (American Public Health
of
Academy
American
growing consensus among state policymakers,
Association
&
researchers, and practitioners around the need
Pediatrics, 1992, p.xviii).
for linking health, mental health and child care
The authors of HeartlIStart also emphasize
services (Griffin & Fiene, 1992; Kagan, 1991;
that physical and psychological health are
Pizzo, 1990). Moving towards interagency and
inseparable for infants and toddlers.
The
interdisciplinary service planning that includes
foundation for healthy physical and emotional
child care is essential to realizing the potential
built on four
basic and
of quality child care (i.e., a comprehensive
development
is
has been the
interrelated needs that must be met at home
family-centered model that
strength of Head Start). Furthermore, recent
as well as in the child care setting if each child
major national reports offer explicit guidance
is to reach his/her full pot:..-ntial:
based on the pooled expertise of professionals
1. Good
early
(including
from many fields for improving the quality of
health
physical
identification and treatment of congenitd
infant and toddler child care.
problems or developmental problems related to
environmental risk).
With support from the U.S. Department
of Health and Human Services' Bureau of
2. Unhurried
primary
time
caregivers
with
Maternal and Child Health, the American
develop
to
time
"caring
(specif.cally,
a
Public Health Association (APHA) and the
relationship" with primary caregiver/s in the
American Academy of
(AAP)
Pediatrics
family and a primary caregiver in the child care
undertook a joint 4 year effort to identify and
setting).
publish comprehensive
health
safety
and
performance standards and guidelines for child
3. Responsive caregiving (specifically, care by
Caring for Our Children: National
care.
primary caregivers who (a) understand how
Health and Safety Performance Standards:
children develop; understand and adapt to the
unique temperament, rate of development, and
Guidelines for Out-of-Home Child Care offers
communication style of each child and know
an appropriately broad view of performance
how to
emotional,
healthy
foster
social,
In the introduction,
standards for child care.
cognitive, and physical growth; and (b) who
Dr. Albert Chang states: "Facilities must also
respect and involve the child's parent/fa mily).
provide a setting for nurturing and affection.
6
2
A
and
safe
supportive
environment
greater of
two-to-three
times
4.
risk
a
(specifically, protection from known causes of
infection by Haemophilus influenzae type b
injury and space that is arranged to encourage
-- leads to meningitis in 12,000 children
safe exploration and testing of developing
under 5 years of age per year; 1 in 4 suffer
skills).
in 20 die
permanent brain damage;
1
(Granoff and Cates, 1985);
While the relevance of "good physical
and
safe
health"
supportive
and
"a
a four-to-nine fold increased risk of measles
environment"
to
health
and
safety
in
for minority children living in urban areas --
infant/toddler child care is obvious, the field
highly contagious; can lead to severe ear
too frequently fails to address the essential
infection, pneumonia, encephalitis;
in
1
contribution of the emotional well-being of the
1,000 suffet mental retardation; 3 in 1,000
is one of the strengths of the
It
baby.
die (Centers for Disease Control, 1990);
APHA/AAP health and safety guidelines that
deal
they
with
of
aspccts
early
all
much diarrheal
three-to-four
times
as
development.
disease -- can cause dehydration (CDC,
Bartlett, & Woodward
1990; Pickering,
Part 1: Preventable Health, Mental
1986; U.S Department of Health Human
Health, and Safety Risks Associated
Services, 1990); and
with Child Care
higher incidence of colds and respiratory
recurrent
ear
cause
diseases
can
--
Infants
and
toddlers
are
the
most
infections, hearing loss in some children;
infection-susceptible age groups due to their
can lead to pneumonia (Presser,
1988;
lack of prior exposure to most infectious
Wald, Dashefsky, Byers, Guerra, Taylor,
pathogens
(Donowitz,
Research
1991).
1987).
documents an increased burden for young
children in child care or group carc settings of
preventable
mostly
minor
serious
and
infections, including:
What proportion of the 40%-50% under-immunized children are in unregulated child care?
How many of these children contracted vaccine-preventable disease from other children
or
adults in their child care?
Of these very young children, how many did not have
a primary care physician -- how many
were seen only when sick enough for thc:;r parents to take them to an emergency care facility?
What was the cost to tax payers of the delayed treatment, hospital treatment, long term illness,
physical or mental impairment?
What is the cost to the child and family of early and traumatic illness?
3
Vaccine-Preventable Diseases Little is known about immunization coverage
for young children in unregulated child care (e.g.,
care by relatives, by babysitters, and many family
Age appropriate immunizations for all
child care homes) including license-exempt centers
infants and toddlers in out-of-home group care
(e.g., church-based, school-based).1 The paucity of
will prevent the spread of the most harmful
data on unregulated child care makes it difficult to
diseases. These include diphtheria, tetanus,
estimate the number of infants and toddlers in
measles, mumps, rubella,
pertussis,
polio,
each of these forms of care. For example:
Haemophilus influenzae type b (Hib), and
For children under 36 months, recent studies
hepatitis B (See immunization brochure and
vary in their estimates of the type of child care
schedule in Attachment 1).
used, from 16% relative and 14% nonrelative-
out-of-home care (Hofferth, et al., 1990) to
High rates of immunization are recorded
21% relative and 22% family child care
for licensed child care centers. The Centers
(National Center for Children in Poverty,
for Disease Control (CDC) report that in
1990).
1988-89, 94% of children in licensed child care
centers had their basic immunization series by
A 1990 survey estimated that 2.6 million or
age 2. The rate is 98% for children in Head
83% of all children are in license-exempt or
Start programs, including infants and toddlers
unregulated child care (Children's Defense
Migrant Head Start and Parent-Child
in
Fund, 1991).
Centers (Centers for Disease Control, 1990).
The CDC's surveys of the general population of
children indicate coverage by age 2 for between
There is less data on the immunization of
70% to 80% for specific diseases. Complete
infants and toddlers in family child care, in
coverage with the full basic immunization series is,
which an adult (usually a woman) cares for 2
however, estimated at between 50% to 60%
or more (in some states up to 12) children in
(Centers for Disease Control, 1990). The Healthy
home. Family
her
care
child
usually
is
People 2000 objectives provide an even more
administered under a separate set of state
dismal picture: 93% of newborns have at least one
These can
licensing and
rules.
include
well-baby exam but less than 50% have received
monitoring, mandatory registration with few
the required three doses of diphtheria-pertussis-
requirements and infrequent to no monitoring,
tetanus (DPT) vaccine by
18 months (U.S.
or voluntary registration. For example:
Department of Health and Human Services, 1990).
The. report indicates that children living in large
A 1988 survey of regulated care (including
urban areas, the majority of whom are African or
registered family child care) indicates that 12 Hispanic Americans, are "as much as 20% behind
did not require immunizations in
immunization rates for children living in other
states
areas" (U.S. Department of Health and Human
regulated family child care and 2 states have
no regulations for family child care (Morgan,
Services, 1990, p. 34).
in press).
I Individual state's laws differ in their definitions of what child
care is and in dcciding what size and types of child carc scttings must be
regulated (i.e. meeting certain standards in order to have a license, certification, registration, approval to operate). Very few states require
that all people and organizations who provide child care must meet regulatory rules. Often states exempt people offering carc to a small
number of children in the providers home and/or they exempt services offered undcr the auspices of churches and/or schools. The laws
usually authorizc the state to develop rules (that have the force of law) in the kcy areas of health, safety, staff/child ratios, group sizes and
program act ivit ies.
The degree to which services arc monitored along with the sanctions or penalties for not complying with rules arc outlined in cach state's
laws and/or regulations. Typically there arc lower levels of requirements in family day care settings, with some states only requiring self
certification and some having no monitoring. Depending on thc definitions and exemptions in each state law, very high numbers of children
arc being cared for in child care settings that have no public oversight and have no standards for health and safety to meet.
4
It
of
symptomatic
the
of
Hepatitis B contracted
lack
is
bodily
fluids.
in
collaboration between state child care and
childhood or adulthood can lead to chronic
health
that
agencies
state
care
child
liver disease, long-term chronic illness and a
regulations can lag far behind the medical field
rare form of cancer in adults.
Hepatitis B
in requiring the most current immunization
immunizations are generally not found in state
schedules (U.S. Department of Health and
child care regulations (Aronson, 1992).
Human Services, 1990). A significant gap has
been the omission of vaccination requirements
Measles and rubella are diseases that are
against Haemophilus influenzae type b (Hib).
easily transmitted to unvaccinated adults. The
Hib disease
particularly dangerous for
is
recent measles epidemic provides a dramatic
children under 3 in group care because it can
example of our failure to protect children and
lead to meningitis and other invasive bacterial
adults with a vaccine that has been available
diseases. Over 95% of all reported
cases of
since 1963.
From 1990 to 1991, more than
Hib disease
that
meningitis were
to
led
cases,
deaths,
55,000
150
11,260
children under 5 years of age and 67% of
hospitalizations, and 44,169 hospital days have
those cases were infants
15 months and
been reported to the Centers for Disease
younger.
Control (Addiss & Sacks, in progress).
Tn
1990, the DHHS reported that one-third of
A highly effective vaccine has been
white children and one-half of nonwhite
available since 1985 and is currently available
children 1 to 4 years of age had not been
for children at 2 months of age. Yet
a CDC
properly immunized against measles (U.S.
survey taken in the 1991-1992 school year
Department of Health and Human Services,
indicated that only 31 out of the 50 states
1990).
required the Hib vaccine for children attending
licensed or regulated child care. An intensive
Lack of clear guidance on report;.:ig cases
informational campaign by the CDC, APHA,
of
infectious
diseases
and
of
lack
and AAP has resulted in the inclusion of the
communication among child care programs and
Hib vaccine in child care regulations for
health services contribute to underreporting.
licensed child care in most states in the last
Underreporting of cases of infectious disease
year.
may be contributing to spread of vaccine-
preventable diseases such as measles. (Again,
Failure to include specific standards for
this underlines the need for collaboration
a
on
pre-employment caregiver physical is also
health and child data collection regarding the
a
grave problem. For example, a highly reliable
health status of infants and toddlers in child
vaccine is available for the hepatitis B virus.
A national
care).
conducted by
study
(The AAP recommends vaccination for infants
researchers
the
Center
from
for
Injury
at birth, 2 months and, again, between 6 and
Prevention and Center for Infectious Disease
18 months). Occupational Safety and Health
of the CDC surveyed licensing staff, monitors,
Administration (OSHA) rules of 1991, revised
and directors of 20 child care centers in each
in July 1992, require that employers
are
state. Preliminary findings indicate that while
responsible for assuring that all adults be
94% of the child care center directors said
protected by the three part vaccination series.
their center had written health policies, only
Hepatitis B is not highly contagious. It is
most
66% of the directors sampled said they had
frequently transmitted by contact with blood
reported a case of measles to a health official
but can also be carried by
mucous and other
or health agency (Addiss & Sacks, in progress).
9
5
If child care providers are to report to
families, and health officials, state and local
An infant, who often spiked high
health and child care agencies (i.e. regulatory
fevers usually related to ear infections,
agencies or resource and referral programs
came to the center healthy in the
state contract), they must have the
under
morning but at lunch was acting sluggish
following information in language they can
and despondent. His fever went from
easily understand and communicate to the
normal at noon to 1030 at 1 P.M. The
families they serve:
parent was called and the child was
picked up. By Sunday morning the baby
What diseases must be reported, to whom
was hospitalized, went into a coma, and
should the caregiver report, and how should
when revived was completely deaf and
she/he prepare a formal medical report to
mentally retarded. The director spent
health officials?
time at the hospital, tried repeatedly to
the attending
get information from
For specific diseases, what are the risks of
physician and the city health department
infection, period of contagion, symptoms, and
It was
about what had happened.
precautions to be taken to eliminate further
Haemophilus
caused
meningitis
by
spread of infectious diseases?
The material and
influenzae type b.
verbal information she could collect
What is the child care providers liability risk if
they do not report, and, conversely, are they
were in medical terminology. She had
exposed to liability if they do report?
no health consultant and none of the
health personnel contacted offered to
In turn, state and local health providers
help in translating the information into
should reach out to child care providers,
parents staff
could
and
language
understand the particular risks of group care
obtain
nor
she
understand
could
and have personnel available to respond to
guidance on how to prevent other cases
questions. Some states have established a toll
of the
from occurring
(experience
free health information number (California
author, 1980).
health
excellent
have
and
Pennsylvania
In too many cases,
consultation models).
however, the system is run by the state's public
or
without consultation
agency
health
coordination with state child care agencies.
Are these directors irresponsible?
Not
Not all states require written
The result is that questions specific to child
necessarily.
health policies. Those that do are rarely
care are not answered and child care providers
are not informed that this is a service they
regarding reporting procedures to
explicit
health officials nor are they accompanied by
can/should access.
guidelines for how to inform families and staff.
Higher Incidence of
In a recent court case, a licensed child
Common Childhood Diseases
care center was assessed $300,000 in damages
for not informing a family when they enrolled
other
and
sanitation
Proper
hygiene,
their infant that there had been two cases of
prevention strategies can greatly reduce the
meningitis. The new baby died of meningitis.
incidence of gastrointestinal diseases including
There is no excuse for not informing new
those caused by viruses, parasites, or bacteria;
parents. Informing new families of known risks
as strep -
acute respiratory diseases such
But state and
is a matter of good practice.
local health officials must share in the blame.
i 0
6