Unit 8 video - click to launch

Unit 8 video - click to launch

Unit 8

healthy practices, part 2


Playing outdoors and eating snack or lunch: these are the highlights of many young children's day. What can you do to keep your young charges eating well, developing strongly, and sleeping soundly? In this unit, those are the things we'll talk about.

Remember that nutrition and fitness are necessary for children's optimal development.

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Keeping Clean

Goodness knows, child care can be a messy business! Small children need help with diapering or toileting and with wiping their noses, and their little hands seem to be perpetually grimy. If we're to keep children and ourselves healthier, we've got to do a great job of keeping clean. 

Let's see what best practices in keeping clean look like.

The History Of Hand Washing

Hand washing as a way to prevent disease is an idea barely more than 150 years old. In 1847 Hungarian-born physician Ignaz Semmelweis noticed that fatal childbed fever (also called  “puerperal fever”) occurred much more frequently in women who were assisted by medical students than in those assisted by midwives. The difference, Dr. Semmelweis figured out, was that midwives washed up before delivering a baby but the doctors did not. A few years later, Louis Pasteur proposed the "germ theory" - the idea that invisible microbes cause many illnesses - and the connection between hand washing and health was made. Even so, many doctors well into the 20th century refused to wash their hands and Semmelweis himself was drummed out of the medical profession for suggesting that doctors wash.

The fact that washing hands once was something extraordinary has some basis in the fact that washing up was much more difficult for most people before the development of indoor plumbing. Water was difficult to get and, of course, it was always cold - in the winter, very cold. Besides, contact with water was associated with water-borne diseases such as malaria and typhoid fever. In addition, soap was homemade, often harsh, and something to be preserved for important uses. One didn't waste it on cleaning hands.

Today we have easy access to volumes of warm water and lovely soaps. We know well the connection between germs and disease. We have no excuses not to wash.

Hand Washing In Practice

In 1910, Dr. Sara Josephine Baker started a program to teach hygiene to child care providers in New York City. Thirty physicians sent a petition to the mayor protesting that Baker's hand washing program "was ruining medical practice by...keeping babies well." That, of course, is the point. We want to keep babies well, not finance the bank accounts of doctors.

However, the authors of a recent study of infectious diseases in children states: "In spite of all the studies about the benefits of hand washing, improper or infrequent hand washing continues to be a major factor in the spread of disease in day-care." The fact of the matter is, babies and small children are pretty germy. Child care professionals are exposed minute-by-minute to urine, excrement, saliva, and mucus and their hands are right in the thick of it (often literally). Those hands are capable of spreading disease from one child to another, more so, even, than the children are themselves.  

Ninety-six percent of Americans say they wash their hands after using the bathroom but only 85% actually do (based on 2011 observations of public restrooms in Atlanta, Chicago, New York City and San Francisco). While 85% isn't wonderful, it's much better than the results of studies in past years, that found as recently as 2000 that only 67% of people washed their hands. But these studies were done in public restrooms, where the danger from germs seems greatest and where others might be watching and judging (like those researchers, for example!). People might be less inclined - I think it's safe to say people are less inclined - to wash when they're in familiar surroundings and when there's a lot to do and when they think maybe they're just going to get dirty again soon.

We can't be that complacent. We need to wash.

Washing How and When

Obviously, we all need to wash... frequently. Find out how in the video in the Additional Resources above.

Notice a couple things. First, soap doesn't kill germs. It loosens dirt (and germs) so they can be washed away with water. So washing long enough to get things loosened is important. 

Second, hand sanitizer doesn't deliver the same level of clean that washing does. But as long as your sanitizer contains at least 60% alcohol, it's effective against many germs when used correctly.  According to the Centers for Disease Control, the correct way to apply hand sanitizer is this:

Apply the product to the palm of one hand.Rub your hands together.Rub the product over all surfaces of your hands and fingers until your hands are dry.

Some sanitizers advertise that they're "alcohol-free." These might not be effective.

Diapering And Toileting

While colds are spread by coughing, sneezing, and snotty fingers, tummy upsets and diarrhea are spread by contact with poop - I mean "excrement." Practicing scrupulous hygiene during diapering, being alert to messy diapers and taking action quickly, and following careful practices in guiding children in toilet training... these are the ways you control nasty diseases in your classroom and center.

Here's what to do...

1.    Wash your hands.

2.    Gather all the necessary materials.

3.    Put disposable gloves on hands.

4.    Place the child gently on the changing table and remove his diaper.

5.    Dispose of the diaper in a hands-free garbage can with a lid.

6.    Clean the child’s diaper area from front to back, using a clean, damp wipe for each wipe.

7.    Apply topical cream or ointment only when a written consent is on file.

8.    Remove your gloves.

9.    Wash hands or use wet wipe (if there is no fecal matter on your hands).

10. Put a clean diaper on the child and dress him.

11. Wash the child’s hands with soap and running water or with a wet wipe and dry his hands with a paper towel.

12. Place the child in safe place.

13. Clean and disinfect the diapering area and any equipment you touched.

14. Wash your hands.

Whew! You can understand why each diaper changing area is required to have posted instructions on this procedure.

The same general level of care is repeated when you help children use the toilet. 

Cleanliness in the Kitchen

All the hand washing in the world won't keep illness away if the food children eat isn't fit to eat. The way food is stored, prepared and served all matters.

First of all, it's important to recognize that the center is not home, not even if the center is located in a home. Casual attitudes towards food and feeding, including eating at odd times and in odd places - attitudes that might be appropriate at home - are not suitable at the center. Folk notions about food, including the "five-second rule" about dropped food, have no place here.

The temperature at which foods are held is something to be aware of. Bacteria thrive in temperatures between 41o and 140o, so foods that are ordinarily served hot or cold should not be allowed to reach temperatures in this zone. Cooked foods must reach an internal temperature high enough to kill bacteria that the food in its raw state might contain.

Food that is served raw, like fruits and vegetables, should be washed to remove surface dirt, chemicals, coatings, and bacteria. Many episodes of food-borne illness arise from eating contaminated raw food. Understand that the sorts of beasties that cause food poisoning most often, like salmonella and e. coli, cannot be detected by off flavors or funky smells and cannot be seen with the naked eye.

If foods or food ingredients are stored in your classroom, make certain they are in airtight containers to avoid attracting insects and rodents. This includes any ingredients you might have on hand for cooking activities, for making play dough, or for using as part of craft projects. Not only do insects and rodents ruin the food or ingredients themselves but they also bring in germs that can cause disease. Clean up leftover food quickly.

Food service is a complicated business, as any restaurant-owner or caterer will tell you. Anyone at your center who prepares, handles or serves food should have a Food Handler's certification. 


Cleanliness continues in any food containers or serving dishes you or the children might use. Whether you wash dishes by hand or by machine, you must follow these steps:

The Three-Step Method for Washing Dishes by Hand

Dishes, utensils and equipment that touch food must be washed in the following method. This is the only way you can wash dishes by hand.

You must wash, rinse, and sanitize them in a three-sink unit. These are the steps for washing dishes by hand:

·         Scrape leftover food and grease from the dishes and throw it away.

·         In the first sink, wash the dishes with hot water and detergent.

·         In the second sink, rinse them with clean hot water.

·         In the third sink, submerge dishes in a bleach solution (1 tablespoon bleach per gallon of        cool water) for one minute.

·         Air dry the dishes and utensils.

Washing Dishes Using a Dishwasher That Sanitizes Using Heat or Chemicals

A dishwasher will wash, rinse, and sanitize dishes, equipment, and utensils. Make sure you:

·         Scrape leftover food and grease from the dishes and throw it away.

·         Load dishes into the machine and run the full cycle.

·         Air dry the dishes and utensils. Do not use a towel to dry them.

In order to properly sanitize dishes using heat, the dishwasher must reach a temperature of 140° F. This will kill germs. If your dishwasher has a “sanicycle,” the final rinse water heats to this temperature. A maximum registering or “holding thermometer” is needed to check dishwashing equipment. Contact your local health specialist for assistance. 

At the end of the day, clean the dishwasher and check the spray holes and traps to remove bits of food.

Eat, Play, Sleep

Food, fun and some sleep. If you're a small child, what else is there? Let's find out how to make these perfect.

What To Serve and How

Nutrition is a zero-sum game: a person - especially a baby or small child - can only consume so much before feeling full. So what children eat should always be nutritionally-dense and not junk food. Whatever junk food a child eats replaces - doesn't just supplement but actually replaces - the good food she might have eaten instead. Junk food should be reserved for at-home snacking. It has no place in your classroom or center. 

Nutrient content. It's important to include of a balance of carbohydrates, proteins and fats in children's meals. Foods that are minimally processed are preferred over manufactured foods. Food writer Michael Pollan says that one should eat foods "your grandmother would recognize." 

Keeping in mind the zero-sum quality of nutrition, it's true that every single meal must contribute to a balanced diet. Soda and a doughnut for breakfast cannot be excused because lunch and dinner will be healthier. Studies have shown that children's preferences for different foods and ideas about what is appropriate to eat are developed in early childhood. You have an opportunity to shape good eating habits by paying attention to what you serve and by serving a variety of interesting and delicious things.

This means also that your meals and snacks could include foods of the different cultural and ethnic groups that are represented in your classroom. There's no reason why breakfast must be oatmeal, when the Korean children in your group are used to eating kimchee and the British kids eat baked beans in the morning at home. When you expand the possibilities within the basic nutritional framework, you expand the learning opportunities available to all.

Good dining habits. Feeding children is about more than food. It's a time to observe behavior, a time to have friendly conversation, a time to feel like a community, a family, a class. So when you serve a meal or snack, do sit down with the children and share the experience. You don't need to eat and you might not sit very long. But joining the children as they eat is good manners and promotes the development of social skills in ways no other part of the day can do.

Children are not naturally neat eaters. Make certain to focus on positives and promote a cheerful, pleasant interaction, not one filled with directives and corrections. Model sampling new foods. Model polite behavior. When you feed infants and toddlers, be certain to make eye contact and to talk to each child as you hold the bottle or spoon the cereal.

Mealtimes take time. Be as unhurried and relaxed as possible so that eating is a pleasant interlude during the day, not a time of stress.

Feeding Infants. Of course babies take formula or breast milk. But how infants are fed matters. Feeding time is time for one-to-one cuddling and eye contact. It should be a delightful, unhurried time of a baby's day. No baby should be fed with a propped bottle under any circumstances.

Of course, there can be problems. Many infants suffer from reflux and may vomit most of a feeding. Most babies grow out of this condition but many need medication to help keep food down. Infants may struggle with too little or too strong a flow of fluid through the nipple and may gag and choke or fight and fuss. It's important to understand that babies who experience difficulties are not being willful or demanding. They require all your powers of investigation and problem-solving to get the nourishment they need.

Special Issues

Children present feeding issues it pays to be aware of. Let's look at some of these.

Choking Hazards. Young children can be at risk for choking on just about any food. Infants and toddlers have limited control of their mouth muscles and lack the molars to grind up hard foods. Three- to four-year-olds lack chewing sophistication and they are easily distracted while eating. 

In addition, certain foods pose greater choking risks than others. Food that are especially difficult for children to handle include nuts, seeds, whole grapes, hot dogs, hard candy, whole corn, popcorn, chips, tough meats, and “sticky” foods such as peanut butter, processed cheese, marshmallows and fruit roll-ups.

But keep in mind that children can choke on any food and must be supervised while they are eating.

Make sure all children are seated to eat. Modify foods to be smaller or softer (dice melons into small pieces and steam broccoli and carrots). Discourage children from eating too fast, engaging in silly conversation, or having food contests.

 Do not serve these foods to children under the age of 4 years:

• Spoonsful of peanut butter

• Fresh broccoli

• Marshmallows

• Large chunks of meat

• Nuts, seeds, and peanuts

• Raw carrots

• Fish with bones

• Dried fruit

• Hot dogs (whole or sliced in rounds)

• Hard candy

• Popcorn

• Raw peas

• Whole grapes

• Ice cubes

• Raisins

• Chips

• Pretzels

• Whole corn

• Tough meats

• Sticky foods

• Processed cheese

• Fruit roll-ups

Other Issues

Allergies. Children younger than 12 months should not eat foods known to trigger allergic reactions, since these often cause problems in infants but not in slightly older children. Wait to offer citrus fruits, strawberries, wheat cereal, and nut products like peanut butter.

If a child in your class has a known allergy, understand the severity of her sensitivity and the extent to which you must limit exposure. Because allergic reactions tend to increase with repeated exposure to the target substance, be alert to the possibility of a more severe reaction even when past exposures produced mild reactions.

Sensory issues.  Children who are just learning to eat solid foods are especially picky about food textures. Babies find some food textures easier to move around in the mouth and swallow. Older children may reject foods that are crunchy, slippery, tacky, or nubbly. Gradually introduce different textures and let children warm up to them at their own pace.

Children with acute sensory awareness in other areas (who dislike clothing tags or who are repulsed by fuzzy things, for example) may have difficulty with different foods. Cutting foods up into small dice, pureeing foods, and offering food alternatives are ways to manage the hyper-sensitive eater. While your goal is to dampen sensitivity over time, so children can enjoy ordinary foods, it's also important to help children find pleasure in what they eat.

Cultural issues. What is "comfort food" in one culture might be exotic in another. If yours is a culturally diverse classroom, stay open-minded with regards to what foods families eat and what flavors, spices, and condiments are deemed essential.

In addition, be aware of dietary restrictions that may be part of cultural tradition, religious observance or family preference. You may have children in your class who do not eat meat, who avoid certain food combinations, or who avoid some foods altogether. Work with parents to arrive a food choices for all children that include and respect food traditions.

Food preferences. Young children notoriously go on food "streaks," seemingly subsisting on only a few dishes for long periods of time. It's as if the little person has settled on flavors and textures he can trust and sees no reason to risk eating something he doesn't like by trying something new. Even former favorite foods can be rejected when a child is on a streak.

Generally, in the child care center classroom where all children are eating the same things, kids eat what others are eating even if they maintain their food streak at home. But even if they don't - if they reject your food completely - remember that they will not starve. If they are hungry, they will eat. In the meantime, let them eat what they want of the served meal and don't fuss about what's been left on the plate. If you don't make a big deal of things and don't cater to children's food whims, eventually they will eat more adventurously. 

Mealtimes, for all the hassle and rules, should be a pleasant part of the day. Eating is nice. Enjoy it with your children.

Physical Development

Children are built for play and activity. Your role is to provide opportunities for developmentally appropriate, challenging, fun and safe choices for physical activities. Do this both indoors and out.

Infants need plenty of floor time, especially on their tummies. Babies like to hang out together on the floor and they enjoy reaching for things and, eventually, rolling over. Many babies, though, do not like being on their tummies and will need encouragement to gradually extend the time they will tolerate tummy time.

Older babies and toddlers need floor time too, with safe places to sit up, to crawl, and to pull themselves to stand. Pay attention to fine muscle development as well as large muscles, by providing babies and toddlers with lots of toys to handle.

Walkers and preschoolers love to push the limits by running, climbing, jumping, and dancing. Make it possible for children to do all these things without constantly being told to "slow down" or "be careful." Make the space adapt to the children, instead of the children needing to adapt to the space.

Keep in mind that small children are bodies in motion. They should not be expected to sit still for more than a few minutes at a time, gradually extending this time to about 15 minutes at age four. 

I know what you're thinking: kids stay still for hours with Mom's iPhone or tablet. True. And that's part of the problem. Children need to move even if the mesmerizing effects of technology capture them. All the more reason to make certain children in your care are active, don't sit too long, and grow in physical strength and coordination.

Both you and the children will be happier - and the children will be better coordinated and stronger - when you give them safe spaces and time for active play.


Children need lots of sleep. Infants may sleep up to 17 hours in a 24 hour period; toddlers and very young children need 12 to 14 hours of sleep; and older preschoolers and kindergarteners need 10 to 12 hours of sleep every day. Many children do not get enough sleep.

In the child care setting, children aged five and younger must be given a rest time if they are in your care for more than six hours or anytime they show signs of needing a nap. Babies and toddlers younger than 29 months need to follow individual sleep schedules; toddlers need about 2 hours of naptime during the day.  Even if a child is not able to fall to sleep while in your care, she must be provided with alternative quiet activities. 

Sleep is important for brain development and learning. During sleep, the brain is actually just as active as it is while the sleeper is awake. It's as if the brain needs to have nothing conscious going on so it can do the work of reorganizing things and cleaning out what's no longer needed. Children who get adequate amounts of sleep are smarter and more pleasant to be with.

Sometimes parents will ask you to "keep a child awake" so he falls asleep quickly at night. Remember that you're responsibility is to the child and to the child's health and well-being. No matter what, do what is best for the child.

Back to sleep

About one in five sudden death syndrome (SIDS) deaths occur while an infant is in the care of someone other than a parent, often within the first few days of care outside the home. Pediatricians agree that putting a baby to sleep on her back is safest. 

When babies who are used to sleeping on their backs are placed to sleep on their tummies by their child care provider, they are 18 times more likely to die from SIDS. This is called “unaccustomed tummy sleeping.” 

You can reduce a baby’s risk of dying from SIDS by always placing babies in your care one their back during naps. Make sure there is nothing in the crib that a child can get tangled in or that is soft enough to smother her. Never leave a baby sleeping alone.

Sickness & Injury

Being sick is a fact of any small child's life. For some children, the early years are one long list of sniffles, vomiting, fevers, ear aches, and tummy troubles. Naturally, some of this will happen on your watch. What then?

When is Ill Too Ill for Child Care?

Part of your daily routine involves checking for symptoms of illness. Each day, as children arrive, you will give them a quick look, paying attention to running noses, faces that are unusually pale or rosy, dark circles under the eyes, and a general listlessness that signals trouble. As the day goes on, you will be alert to inexplicable changes in mood or activity. It's your job to know when a child is too sick for school.

Ask yourself these questions:

  • Does the child behave or look different than normal?

  • Does the child complain of not feeling well?

  • Does the child have skin rashes, discoloration of the skin, itchy skin, or scalp?

  • Does the child appear to have a fever? If so, is his/her temperature above 38 degrees C (100 degrees F)?

  • Does the child refuse to eat or drink as much as usual (especially when offered favorite foods)?

  • Does the child vomit?

  • Does the child have an abnormal stool (white bowel movement, gray bowel movement, blood in the stool, or diarrhea)?

  • Does the child seem less active than usual?

  • Does the child seem irritable or easily angered (even after comforting)?

  • Does the child have severe coughing?

  • Does the child fail to urinate?

  • Does the child appear to have less energy, or is the child sleepier, than usual?

Children with common colds do not need to stay home. Usually a child has already exposed others before presenting symptoms.  And excluding or isolating children with non-contagious, mild illnesses  - like an ear infection - can be a hardship on the family and child. 

At the same time, the center sometimes must exclude an ill child from care. Some infections such as chickenpox, hepatitis, and meningitis require the child to stay home for a lengthy recovery period. Your Parent Handbook should spell things out for parents but it's your job to enforce these policies. Naturally, parents may be reluctant to have a child stay home, since it likely means they will miss a day of work. You can be sympathetic but you must be firm.

Managing Medications

Even with all the care you and parents can muster, kids will still get sick. Sometimes they'll be able to be in school but will need to take medicine during the day. How you manage medication is another way you will keep all children in your care safe.

Keep in mind that except for medications required by a child with a disability who is protected under the Americans With Disabilities Act (ADA), your center is under no requirement to administer medications at all. However, whatever policy your center decides with regard to medication must be center-wide (not specific to particular cases or particular classrooms), must be consistently applied (the same for everyone all the time), and must be clearly explained in your parent handbook and staff policy manual.

Remember that prescription medication are those that must be authorized by a health-care provider and cannot be shared with others. Over-the-counter medications are those that parents can select themselves. Because of the danger of overdose, even of "ordinary" medicines like pain-relievers and teething gel, it's important that a record be kept of what medication was administered when to which child and by whom.

There must be a start and stop date for each medication. You can only give the medication for the duration of the illness.  Medications cannot be given “as needed,” except for epipens and asthma inhalers (consult licensing guidelines for details).

Medications should be in the original packaging (including the manufacturers' printed directions). Prescriptions must be labeled for the child in your care, not "left-over" from or shared with another family member.

In any case, all medications - including diaper ointment and sunscreen - must be accompanied by written instructions from the child's parent and all medications must be labeled for each child individually. Children may not share medications, even over-the-counter lotions.

Unless the directions from a parent specifically indicate you should, do not mix medications with children's formula or food. 

Again, keep careful records, with signatures, dates, times, and dosage given for each and every medication you or your staff administer. 

Medical Emergencies

When a child becomes ill or is injured while in your care, take immediate action. Children who become ill while in your care should be isolated from the rest of the group. Have them lie down in a quiet space away from the other children, but within view of the staff. Staff must supervise ill children at all times. Contact the parents to come pick up their child.

It goes without saying - but I'll say it anyway: you must call an ambulance any time a child seems to have broken a bone, suffered a concussion, has a very high fever, has a seizure, or stops breathing. Perform emergency first aid after dialing 911.

Your other responsibilities include the following:

  • Keep a confidential, individualized, written record in the child’s file that includes the date of an illness or injury, treatment provided and names of staff providing the treatment.

  • If you suspect the child has a communicable disease, remember to sanitize all equipment that the ill child used.

  • If an injury or illness results in a visit to the child’s doctor and includes casting, stitches, or hospitalization, you are required to notify your child care licensor.

  • Notify all parents in writing when their children have been exposed to infectious diseases or parasites. The notification may be either a letter to families or posting for all in a visible location.

One common problem is difficulty in reaching parents when an illness or injury happens at child care. Make certain that you have on file an Emergency Contact card for each child in your care, with phone numbers and a designated emergency contact. In addition, require families to sign a Medical Emergency Authorization form upon enrollment so medical personnel can help a child without parents' specific consent. Do not permit any child to stay in your center for even an hour without this form on file.

Non-medical Emergencies

No matter where your center is located, disaster can strike. It can come in the form of a tornado or earthquake, a flood or snowstorm, a fire, a police lockdown, or any of a host of other unforeseen events. You must be prepared for anything.

Your center should have an emergency response plan in place. This plan should spell out 

  • What you will do if families are not able to get to their children for two or three days

  • Who is designated to be responsible for each part of the plan

  • Procedures for accounting for all children and staff during and after the emergency, including location of daily attendance lists.

  • Plans for evacuation of children, including evacuation of babies and others who are unable to walk on their own.

  • Plans for meeting after the emergency

  • Accommodations for children with special needs

  • Plans for contacting parents, transporting and providing for children, including a quickly accessible file with parents' contact information.

Your center should stage quarterly disaster drills for children and staff. Written documentation of these drills should be on file.

Your good imagination and your ability to easily imagine the worst when it comes to children, is helpful in planning for emergencies. Know what you will do. Mentally rehearse things often. 

Be prepared.