CHILD CARE HEALTH AND SAFETY BULLETIN

NORTH CAROLINA CHILD CARE HEALTH AND SAFETY BULLETIN N O R T H C A RO L I N A C H I L D C A R E H E A LT H DECEMBER 2004/J ANUARY The NC Child Care...
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NORTH CAROLINA

CHILD CARE HEALTH AND SAFETY BULLETIN N O R T H C A RO L I N A C H I L D C A R E H E A LT H DECEMBER 2004/J

ANUARY

The NC Child Care Health and Safety Resource Center is a project of the Department of Maternal and Child Health, School of Public Health, The University of North Carolina at Chapel Hill. Funding for the Resource Center originates with the Maternal and Child Health Title V Block Grant of USDHHS’s Health Resources and Services Administration/Maternal and Child Health Bureau, awarded to the University under a contract from the Division of Public Health, NCDHHS. The development, translating, printing, web posting and mailing of the Health and Safety Bulletin are supported by funding from the Child Care and Development Fund Block Grant of the Child Care Bureau, Administration on Children and Families, USDHHS, through a contract between the Division of Child Development, NCDHHS, and the Department of Maternal and Child Health, School of Public Health, The University of North Carolina at Chapel Hill.

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Infectious Diseases

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Prevent the Spread of Infectious Diseases

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The Flu

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Daily Health Check

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Parent Page – Will Antibiotics Help?

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Munching & Moving

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Hands

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Ask the Resource Center

S A F E T Y R E S O U RC E C E N T E R

2005

About The Resource Center

In This Issue

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VOLUME 4, I SSUE 6

Infectious Diseases inter is here and with it comes that bite in the air that not only nips children’s noses, but their throats, chests and tummies too. Children are exposed to many illnesses in winter and most recover quickly. Some may develop serious complications from colds, influenza and other common diseases. In child care, children and adults work and play together in close quarters, sharing germs as freely as they share stories, songs and games. Children pick up germs from sick family members, friends and people in the community. Germs enter the facility on children’s hands and on items brought from home. Children can infect others before developing symptoms. In winter there is a higher concentration of germs inside because less fresh air circulates in the facility. Children and caregivers spend more time indoors, which increases their exposure to germs. Some children are at higher risk for becoming seriously ill from common infections: young infants; children with immune deficiencies, children with chronic lung disease, cardiac disease, or skin disease; children with disabilities such as cerebral palsy (CP); and children from developing nations. Young infants and children with immune deficiencies are less able to fight infections. Infants can be exposed to disease when they are held, diapered, fed, and cuddled. Infants have not yet developed enough antibodies to fight infection. A simple cold can develop into pneumonia; diarrhea can lead to dehydration. Drugs given to treat cancer and infections like HIV can weaken the immune system and make it difficult to fight disease.

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Children with chronic lung, cardiac or skin diseases may have severe reactions to common respiratory viruses like colds or the flu. Lack of mobility in children with physical disabilities increases their risk of ear infections and pneumonia. Children from developing nations may not have received all their immunizations. They may also have a history of poor nutrition. Both conditions make it harder for them to resist and overcome infectious diseases. Develop policies that explain how the facility intends to control the spread of illness. Implement procedures that explain how to achieve these goals. Hand washing is the single most effective way to decrease the spread of illness. Following recommended diapering and toileting procedures as well as cleaning rinsing and sanitizing toys and surfaces, will also reduce illness. Immunizations protect against diseases like whooping cough (pertussis) and measles. Children who are frequently ill miss opportunities to learn and develop new skills. Healthy children are more likely to meet developmental milestones, to be successful learners and to take pleasure in their daily experiences. References: Grossman, L. Infection Control in the Child Care Center and Preschool. Sixth edition. Philadelphia: LWW; 2003

Prevent the Spread of Infectious Diseases

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Caregivers may not see the disease-causing germs that make children sick, but they can certainly see how fast germs get around. One child comes in with a sniffle and pretty soon his classmates are making a beeline for the tissues. Many illnesses spread quickly in group settings. Following sanitation procedures and exclusion guidelines reduces illness by decreasing overall exposure to disease-causing germs. More information on infectious diseases is available in the Child Health Information Database at www.healthychildcare.org. NC administrative code Chapter 15, Subchapter 19A, Section .0100 lists the communicable diseases that must be reported to the local health department.

Reduce Infection! Follow recommended procedures for: ❏ Handwashing ❏ Diapering and toileting ❏ Sanitation of surfaces and objects ❏ Safe and sanitary food preparation ❏ Appropriate exclusion from child care ❏ Universal precautions and use of protective gloves ❏ Coughing/sneezing in elbow ❏ Laundering of linens and vacuuming of rugs ❏ Time outdoors to reduce overall exposure to germs

How do infections spread? FECAL-ORAL ROUTE Some germs live in the stool (bowel movement) of infected people. During diapering and toileting routines, hands become contaminated, spreading germs to objects and surfaces such as sinks, toilets, tabletops, drinking fountains, doorknobs and toys. Children become infected though hand to mouth contact. Exclusion guidelines ❏ Diarrhea: Exclude if onset is sudden, if number of stools is increased compared to child’s normal pattern, and if stools are loose, unformed and watery ❏ Hand Foot & Mouth: (Coxsackie’s virus): Do NOT exclude ❏ Hepatitis A: Exclude until one week after onset of illness ❏ Pinworms: Exclude until treated ❏ Vomiting: Exclude when 2 or more episodes occur within 12 hours

When to exclude? Guidelines on exclusion are designed to protect well children from exposure to infection and to ensure that sick children are able to get well in a comfortable environment. According to NC Child Care Rules .0804 and .1720, children should be excluded for fevers over 100º F under the arm, for sudden onset diarrhea or vomiting, and when they are too ill to comfortably participate in activities. Children with parasites and some bacterial infections should not attend child care until treated with effective medications. Exclusion is needed for some gastrointestinal illnesses, conjunctivitis, whooping cough (pertussis), TB (tuberculosis) and chicken pox. Hepatitis C and HIV infections do not require exclusion except for children who are acutely ill or break the skin of another person by biting or scratching.

Caring for mildly ill children Children who are mildly ill can often remain in care. Illnesses, such as colds, flu and RSV (respiratory syncytial virus), are most contagious before any symptoms appear. When sniffles and sneezes begin, children and adults have already been exposed. Base decisions about exclusion on NC Child Care Rules, the child’s ability to comfortably participate in activities and the amount of care the child needs. A quiet “sick bay” with low-key activities will accommodate some mildly ill children. Those who need substantial medical support or comforting will be difficult to care for without neglecting other children.

2 • HEALTH AND SAFETY BULLETIN • DECEMBER 2004/JANUARY 2005

DIRECT CONTACT ROUTE Germs and parasites can be found in body fluids, on body surfaces, and in linens, pillows and rugs. Children become infected when they touch or come in contact with an infected person or object. Parasites such as head lice can crawl from person to person. Exclusion guidelines ❏ Chicken Pox: Exclude until lesions crust over ❏ Conjunctivitis (bacterial): Exclude until 24 hours after beginning treatment ❏ Conjunctivitis (viral): Exclude until oozing has stopped ❏ Head Lice: Exclude until treated ❏ Herpes cold sores: Exclude until lesions are dry and crusted ❏ Impetigo: Exclude for 24 hours after beginning treatment ❏ Ringworm: Exclude only if lesion can’t be covered or until treated ❏ Scabies: Exclude until treated

RESPIRATORY ROUTE Sneezing and coughing sends germs into the air. People nearby become infected when they inhale the infected droplets. Germs land on toys and surfaces where they can live for many days. Children become infected when they put their fingers in their mouths after touching them or when people whose hands are contaminated touch children. Exclusion guidelines ❏ Chickenpox: Exclude until lesions crust over ❏ Colds, flu, ear infections and RSV: Exclude until fever is below 100º F under the arm, and child is well enough to participate. ❏ Strep throat: Exclude until 24 hours after beginning treatment. BLOODBORNE ROUTE Germs that live in blood or other body fluids enter the body through breaks in the skin or contact with mucus membranes in the mouth, nose, eyes, or digestive tract. Body fluids that can be infected include blood, stool, urine, vomit, saliva, breast milk and drainage from skin lesions or rashes. Use universal precautions when handling these fluids. Exclusion guidelines ❏ Hepatitis B: Exclude during acute illness. Exclude children who bite or scratch another person and break the skin ❏ Hepatitis C: Do NOT exclude ❏ HIV: Allow children with HIV to attend and participate. Children with weeping skin sores may need to be excluded. Children with HIV have weakened immune systems and are vulnerable to complications from common illnesses.Work closely with the child’s parents and health care provider to decide how best to protect the child during infectious outbreaks. Reference: Grossman L. Infection Control in the Child Care Center and Preschool, LWW; 2003

The Flu The flu, or influenza, is a contagious respiratory illness caused by a virus. Up to 20% of the US population get the flu each year. Flu season begins in the winter and peaks in February. Flu symptoms can be mild to severe. Most people completely recover. However, 200,000 people are hospitalized for flu complications and about 36,000 people die from flu each year.

F Symptoms of the flu • Fever (usually high) • Headache • Extreme tiredness • Dry cough

• Sore throat • Runny or stuffy nose • Muscle aches • Nausea, vomiting and diarrhea (in children)

Complications of the flu Older people, infants, those with weakened immune systems and conditions such as heart or lung disease, are all at risk for serious complications from the flu. • Bacterial pneumonia • Dehydration • Worsening of chronic medical conditions • Sinus or ear infections in children How flu spreads: The flu is spread when an infected person coughs or sneezes, releasing droplets into the air. Another person breathes in infected droplets. Infected adults can be contagious from one day prior to becoming sick to 3 to 7 days after first symptoms. Some children are contagious for over a week. Preventing the flu: Protect against the flu by getting a flu shot each fall. During flu vaccine shortages, shots are reserved for those at risk for complications. Avoid exposure to the flu and practice good hygiene. • WASH HANDS OFTEN • Stay away from people who are sick • When sick, stay home • Send children home from child care according to the facility’s exclusion policy • Cover the nose or mouth with tissue when coughing or sneezing • Avoid touching the face, particularly the mouth and nose

Treatment for the flu: Over the counter medications such as Tylenol, can be used to treat flu symptoms. NEVER give aspirin to anyone under the age of 19 to treat flu symptoms. Aspirin use following a virus such as flu or chicken pox has been associated with Reye’s Syndrome, a potentially deadly disease. Antiviral medications are sometimes prescribed to treat flu. Is it cold or flu? With the flu, symptoms appear suddenly, with fever, body aches, extreme tiredness and dry cough usually more severe than with the common cold. A runny, stuffy nose is common with colds. Reference: CDC Flu Homepage www.cdc.gov/flu/index.htm

DECEMBER 2004/JANUARY 2005 • HEALTH AND SAFETY BULLETIN • 3

1-800-367-2229 North Carolina Child Care Health & Safety Resource Center Providing Training, Consultation & Resources for North Carolina’s Child Care Community

Daily Health Check An effective way to reduce the spread of infectious diseases is for caregivers to do daily health checks when children arrive each day. A daily health check includes observing the child for signs of illness and talking with the parent about how the child is feeling. What to look for: • Changes in behavior such as lack of energy, sleepiness, crankiness • Itching of skin or scalp (nits!) • Skin rashes, bruises, unusual spots, oozing sores • Unusual odors • Signs of a fever: flushed face, warm forehead. Take a temperature if fever is suspected. • Unusually fussy infants or non-verbal children • Complaints of not feeling well or of having pain • Signs of an illness: coughing and sneezing, drainage from the eyes, ears or nose, diarrhea, or vomiting. What to ask about: • How the child has been feeling since last at the facility • Recent illness in the family Send children home if they are too sick to attend child care or they have evidence of a condition that requires exclusion such as a fever over 100ºF under the arm. When a concern is noted, keep a written record in the child’s file for three months. This helps identify possible child abuse or infectious diseases that spread in individual classrooms and throughout the facility.

Selecting Safe Toys Safe, developmentally appropriate toys can entertain children, teach them about the world, and help them develop new skills. Before buying a toy, read the label to make sure it meets safety standards and is developmentally appropriate. • Think LARGE when selecting toys for children under three. Balloons, marbles, and objects smaller than 1.75 inches are choking hazards. Look for toys that are well made with tightly secured pieces such as eyes, noses and wheels. • Avoid buying toys made with thin, brittle plastic that could break creating small pieces or jagged edges. • Look for non-toxic labels on art supplies. The designation D-4236 means a toxicologist has reviewed the material. • Protect children’s hearing by avoiding toys that make shrill or loud noises. • Be especially careful when purchasing crib toys. Long strings used to secure crib toys present a serious strangulation hazard. It is safest to keep toys, stuffed animals and fluffy blankets out of the crib when baby sleeps. For more information: Toy Safety Shopping Tips: http://www.cpsc.gov/cpscpub/pubs/grand/toy/toysafe.html Injury Facts: http://www.safekids.org/tier3_cd.cfm?content_item_id =1212&folder_id=540

2005 National Smart Start Conference January 23-27 • Koury Convention Center, Greensboro, NC

December

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Safe Toys and Gifts Month December 5-11 National Hand Washing Awareness Week December 1 AIDS Awareness Day December 3 International Day of Disabled Persons

Reference: American Adacemy of Pediatrics, American Public Health Association (2002). Caring for Our Children: National Health and Safety Performance Standards: Guidelines for Out-of-Home Child Care Programs, 2nd Ed.

4 • HEALTH AND SAFETY BULLETIN • DECEMBER 2004/JANUARY 2005

January

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National Birth Defects Prevention Month National Glaucoma Awareness Month Family Fit Lifestyle Month January 23-27 Healthy Weight Week January 29 Day for Day Care, Child Care Services, call (919) 967-3272

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We encourage you to copy page 5 and distribute it to parents.

Families often face colds, sore throats, and the flu during the year. Parents may bring their children to the doctor or health care provider for these illnesses. A doctor may or may not prescribe antibiotics, depending on the type of illness. Sometimes parents are surprised, maybe even angry, if they leave the doctor’s office empty-handed. They want their children to get well quickly and know that antibiotics work fast to make a child feel better. Over the years, however, doctors have become aware of the dangers of over-prescribing antibiotics. In certain circumstances not giving antibiotics to children may actually be better for them. There are two types of germs that can make children sick: bacteria and viruses. If an illness is caused by bacteria, such as strep throat, antibiotics can help fight it. However, if a child has a virus, such as the cold or flu, antibiotics will not work. Viruses do not respond to treatment with antibiotics. In addition to not working, if antibiotics are given for viral infections, they can cause a dangerous side effect over time. Super-strains of germs that are much harder to kill develop when a child takes antibiotics too often – and for the wrong reason. “Good” bacteria that live naturally in the body are accidentally wiped out along with the “bad.” This “bad” or harmful bacteria may survive and start overgrowing. Bacteria that was easily killed by antibiotics in the past have become increasingly stronger and harder to kill, making illnesses such as pneumonia, urinary tract infections, many middle ear infections, skin infections, and meningitis harder to treat. These super-strain bacteria are becoming

resistant to antibiotic treatment. The Centers for Disease Control considers this a widespread problem and calls it “one of the world’s most pressing public health problems.” When a child becomes ill the following tips are recommended: 1. Visit the doctor. Letting milder illnesses (especially viruses) run their course to avoid the development of drug-resistant bacteria may be a good decision and may help strengthen a child’s immune system. If the illness is caused by a bacteria, an antibiotic may be the recommended treatment. Work with the doctor to decide the best course of action with each illness. 2. Ask questions. Ask whether the child’s illness is bacterial or viral. Discuss the risks and benefits of using antibiotics. Doctors may recommend waiting a day or two to see if the child gets better on their own. 3. Use the medication properly. Antibiotics are most effective if taken for the full amount of time prescribed by the doctor. The child usually feels better after taking the first dose and will probably feel much better within a few days. Taking all the medication reduces the risk of super-strain bacteria developing. Caution: Never use antibiotics or other medicines that have been prescribed for someone else. Never take leftover antibiotics. Never take antibiotics that have expired. Reference: Rutherford, K. (Reviewer), “The Danger of Antibiotic Overuse”, (2001) Retrieved [4 November 2004] from URL: http://kidshealth.org/ PageManager.jsp?dn=KidsHealth&lic= 1&ps=107&cat_id= 128&article_set=27805.

1.800.367.2229

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Will Antibiotics Help?

DECEMBER 2004/JANUARY 2005 • HEALTH AND SAFETY BULLETIN • 5

Munching & Moving Nutrition & Physical Activity Corner

Three Bears’ Baked Porridge All wash hands. Clean, rinse and sanitize the cooking surface. The caregiver preheats the oven to 400ºF, gets out the ingredients and the equipment needed. Ingredients:

Build the Immune System! There’s a chill in the air and frost on the windows, but don’t let that keep children inside! Dress them in a second layer of clothes, warm mittens, wooly hats and extra socks. Take them outdoors in the fresh air where germs are less concentrated and get them moving. Exercise is a great way to boost a child’s immune system, the body’s way of fighting infections. It does this by increasing physical fitness, improving mood and reducing stress. Add fresh fruits, vegetables and whole grains to the diet to build healthy bodies that are better able to resist all those winter viruses.

2 cups cooked oatmeal 1 1/2 cup diced apple 1/2 cup raisins 1/4 cup molasses 1/2 tsp. Cinnamon butter for greasing pan

Equipment: Mixing bowl Plastic knives 2 plastic serving spoons Measuring cups Baking dish

Know each child’s abilities before assigning cooking tasks. Follow these general guidelines while making porridge. Toddlers wash apples and grease the baking dish. The caregiver chops the apples into large pieces. Young preschoolers chop apples into smaller pieces with plastic knives and put the apples into the mixing bowl. Older preschoolers measure remaining ingredients and pour them over the apples. Children mix the ingredients together and spoon the porridge into the baking dish. The caregiver bakes the porridge for 20 minutes. Read Goldilocks and the Three Bears, by James Marshall, while the porridge is getting “just right”!

January is Oatmeal Month! Oats are one of the oldest cereals cultivated by humans. 7,000 years ago people in China knew about them. The ancient Greeks were the first to make oats into porridge. They continue to be a favorite food and for good reasons. Oats are a whole grain food, high in fiber and low in fat. They have zero cholesterol and are rich in disease fighting antioxidants, zinc, B vitamins and iron. Eating oats increases immunity, reduces heart disease, helps control weight, reduces blood pressure, improves diabetes and may increase cognitive function. And they are good in cookies and bread. Goldilocks ate them in porridge when it was “just right”! References: North American Miller’s Association. Fun Facts. www.namamillers.org/ci_products_oats_fun.html Wellhousen, K. Outdoor Play Everyday. Albany: Thompson Delmar; 2002.

Photocopy and paste these activities on index cards.

Physical Activity Take children outdoors, even on a chilly day, for creative movement fun. Sing or play music at different tempos and rhythms. Give children a prop, such as a scarf, to incorporate into their movement. Infants can join in with a rattle to shake. Caregivers and infants can dance to the music. Toddlers and preschoolers can become The wind Frogs hopping from leaf to leaf Feathers A lion charging across the plain Leaves twirling in the breeze A tree swaying slowly, back and forth When it is time to go inside they can become birds “flying” back to their nest. Resources of interest: Creating the Environment for Movement www.journal.naeyc.org/btj/200403/PhysicalActivityFitness.pdf Oats, Peas, Beans and Barley Grow www.agclassroom.org/teacher/pdf/prairie/prek_1/song.pdf Team Nutrition Iowa Go for the Good Stuff www.iptv.org/rtl/downloads/SlidesFood1.pdf (Nutrition activities and books for young children)

6 • HEALTH AND SAFETY BULLETIN • DECEMBER 2004/JANUARY 2005

Did You Know This About Your Hands?

“Hands” My hands upon my head I’ll place, Upon my shoulders, on my face, At my waist and by my side, Then behind me they will hide. Then I’ll raise them way up high, And let my fingers fly, fly, fly, Then clap, clap, clap them – One - Two - Three! Now see how quiet they can be.

Plan activities around the theme of hands. Encourage children to learn more about their own bodies and promote handwashing to reduce the spread of germs! • Infants and young toddlers enjoy playing games such as “pat-a-cake”, which develop hand-eye coordination. Additional fingerplays: The Itsy Bitsy Spider, Clap Your Hands, Open- Shut Them, Where is Thumbkin? • Toddlers can fingerpaint on a table top, large tray or cookie sheet. Beginning artists may need help in scribbling with their fingertips or moving their hands and arms in big circular motions. • Older toddlers and young preschoolers take pleasure in flattening play dough with a rolling pin. They can cut out hand shapes using cookie cutters or by making a hand print in the play dough and cutting around it with a plastic play knife. • Preschoolers can illustrate their stories with fingerprint people, animals, flowers and vehicles by using an inkpad and their fingers and thumbs. The thumb or fingerprint can be a face, a wheel or a petal. A row of prints makes a tree trunk. Add color at will. Handwashing-for-Health Activities • Dust preschoolers’ hands with flour. Have them touch people, toys, books, etc., and see where the “germs” have spread in the room. Then go wash the germs off. (American Red Cross, 1994). • Let children spray water on a piece of dark-colored paper. Explain that sneezes and coughs spray germs the same way water sprays on paper and that is why people should cough and sneeze in their elbow or a tissue. Did you know that the material spread by sneezing travels 6-10 feet, at a speed of around 93 miles per hour? It is a very efficient way of spreading germs. • Have the children brainstorm ways to prevent getting sick. Encourage ideas such as wearing warm clothes, exercise, good nutrition, covering sneezes/coughs and handwashing.

❏ Half of your bones are in your hands and feet – 27 in each hand. ❏ Bend your fingers. How many bones do you see and feel? (three). How many bones are in your thumb? (two). ❏ The longer your finger is the faster that fingernail grows. Which of your fingernails do you think grows the fastest? It works the same way with your toenails. Will toenails or fingernails grow faster? ❏ Humans are the only primates that don’t have pigment (skin color) in the palms of their hands. ❏ One of the most common ways people catch colds is by rubbing their nose or their eyes after their hands have been contaminated with the cold virus. To keep from getting sick, wash your hands!

Children’s Books on Hands • Clap Hands by Helen Oxenbury 1999 (i/t – preschool) • Germs Make Me Sick by Melvin Berger 1995 (i/t – preschool) • Hand, Hand, Fingers, Thumb by Al Perkins 1998 (i/t – preschool) • Here Are My Hands by Bill Martin & John Archambault 1998 (i/t – preschool) • Wash Your Hands by Tony Ross 2000 (preschool – school-age)

DECEMBER 2004/JANUARY 2005 • HEALTH AND SAFETY BULLETIN • 7

Ask the Resource Center

HEALTH BULLETIN EDITOR:

Q: I’ve just started working in a classroom of 2-year olds. With the flu season coming I’d like to know more about taking a child’s temperature.

A:

A child’s temperature is taken to tell if the child has a fever (higher than normal body temperature). The type of thermometer to use in child care should be chosen for its safety, accuracy, ease of use and cost. Glass thermometers are not recommended. If they break an injury can result from the broken glass or the release of mercury, an environmental toxin. Forehead and pacifier thermometers are unreliable. Electronic ear thermometers are accurate, easy to use, costly, require training for proper use, and should not be used with infants under 3 months of age. Digital thermometers are quick, easy to use, accurate, relatively inexpensive and can have disposal plastic covers to reduce the risk of spreading infections. Temperatures can be taken in the armpit (axillary) or by mouth (orally) with a digital thermometer. Taking a temperature in the armpit by a digital thermometer is the most frequent method used in child care settings. Taking rectal temperatures is not recommended for safety reasons. Become familiar with the thermometer in your facility before using it. Follow these easy steps to take a temperature: 1. Get the thermometer. Wash it with warm soapy water, dry it and then sanitize it with rubbing alcohol. Put on the plastic cover if it is available. 2. Lift the child’s shirt and place the tip of the thermometer in the child’s armpit. Be certain the tip is touching the skin only and not clothing. 3. Fold the child’s arm across his/her chest to hold the thermometer in place. Holding young children is a comforting way to assist keeping the thermometer in place. 4. Amuse the child with a story or song. Wait for the beep(s) that signals the temperature is finished and ready to be read. Never leave a child unattended while taking a temperature. 5. Carefully remove the thermometer and record in the child’s record: the temperature; if taken in the armpit, or by mouth; and time and day taken. Sign your name. 6. Wash the thermometer with warm soapy water, dry it and then sanitize it with rubbing alcohol. Return to its usual storage place. Ask the parents to pick up their child if the child • Is an infant under 4 months of age and has a fever • Has a fever over 100º F taken in • Has a fever and cannot participate in activities. the armpit NC Child Care Rules .0804 and .1720(b) cover when to exclude children from child care.

References: Fever and Taking Your Child’s Temperature, Retrieved from www.kidshealth.org on 10/28/04. Fever: What You Need to Know, Retrieved from http://www.ucsfchildcarehealth.org/webpages/ pdftext/healthsafety/feveren081803.pdf on 10/28/04.

VOL. 4 ISSUE 6

Jacqueline Quirk

CONTRIBUTORS: Lucretia Dickson, Jeannie Reardon, Judy Sowerby, Jonathan Kotch

DOWNLOAD: You may download a copy of this publication from our website at:

www.healthychildcarenc.org

REPRINTING: Articles may be reprinted without permission if credit is given to the bulletin and the material is not reproduced for commercial purposes. This publication is produced by the North Carolina Child Care Health and Safety Resource Center and distributed to licensed child care facilities, CCR&R agencies, DCD child care licensing consultants, and child care health consultants throughout North Carolina.

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8 • HEALTH AND SAFETY BULLETIN • DECEMBER 2004/JANUARY 2005

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