Licensing regulations in States and Territories provide health and safety standards that help promote children’s health and ensure safe environments for infants and toddler in child care centers and family child care (FCC) homes. These regulations establish the minimum requirements that must be met to legally operate a licensed child care center or home. Some States and Territories allow selected programs to be legally exempt from licensing (Office of Child Care, 2014). Children in those programs are not protected by licensing standards. The Child Care and Development Block Grant (CCDBG) of 2014 and the Final Rule require health and safety monitoring for all programs and homes receiving Child Care and Development Fund (CCDF) subsidies, including license-exempt facilities (45 C.F.R. § 98.42(b)(2), 2016), with the option to exclude relative child care providers from these requirements (45 C.F.R. § 98.42(c), 2016).

Caring for infants and toddlers, including children who are not mobile nor verbal, requires additional and intentional planning on the part of early childhood programs. These children may be physically or developmentally unable to protect themselves. Young children, especially infants and toddlers, rely on their caregivers to provide a safe, healthy environment and to meet their individual needs.

In an effort to develop health and safety standards that meet the updated CCDF requirements, States and Territories can begin with assessments of their current infant and toddler standards in licensing regulations, quality rating and improvement systems (QRIS), and other quality improvement initiatives. This process provides an opportunity to identify gaps and create a plan for improvements. States and Territories may also refer to health and safety resources to compare their current standards with established recommendations.

QRIS are designed by States and Territories to build on licensing regulations and assess quality beyond the minimum health and safety standards (Office of Child Care, 2014). In addition to addressing health and safety, the QRIS structure also evaluates multiple quality indicators of child care programs and communicates the findings in an understandable way (Office of Child Care, n.d.). As of February 2017, 39 States reported using a statewide model for QRIS, and almost all of the remaining States and Territories are piloting or planning a QRIS model or operating QRIS at the county or regional level (QRIS National Learning Network, n.d.). Of these 39 States, 31 report having infant and toddler standards within their QRIS.

Caring for Our Children Basics: Health and Safety Foundations for Early Care and Education (CFOCB), by the Administration for Children and Families (ACF), addresses the minimum health and safety standards for when children are cared for outside of their homes (ACF, 2011). CFOCB includes health and safety standards that are voluntary for States and Territories. These standards focus on ways to prevent harm and do not include standards that promote optimal environments, relationships, and practices that support children’s learning and development. States and Territories can compare their licensing regulations with the standards outlined in CFOCB to improve health and safety standards in licensing. One resource to support States’ and Territories’ use of CFOCB is Caring for Our Children Basics Health and Safety Standards Alignment Tool for Child Care Centers and Family Child Care Homes. This tool was developed by the National Center on Early Childhood Quality Assurance. It provides a simple format for comparing CFOCB standards for health and safety with States’ and Territories’ current licensing standards. This helps States and Territories determine if their standards are full aligned, partially aligned, or not aligned with each CFOCB standard (National Center on Early Childhood Quality Assurance, 2016a). In addition to capturing alignment, readers can use the notes section to capture information for implementation plans, stakeholder comments, and ideas for future rules and standards development (National Center on Early Childhood Quality Assurance, 2016).

Although CFOCB addresses the health and safety needs of all children in child care, there are some standards that provide guidance specific to the needs of infants and toddlers, such as the following examples (National Center on Early Childhood Quality Assurance, 2016):

• Staffing ratios;
• Staff training;
• Practices for safe sleep and reducing the risk of sudden infant death syndrome/sudden unexplained infant death;
• Developmental and behavioral screening for infants and toddlers;
• Program philosophies to support relationship-based practices, such as continuity of care;
• Supervision by sight and sound at all times;
• The use of outlet covers, hand washing, and regular cleaning;
• Practices and procedures to promote social-emotional health and prevent expulsions and suspensions;
• Procedures for diaper changing;
• Procedures and policies to prevent and identify abusive head trauma and shaken baby syndrome;
• Sun safety for infants and toddlers;
• Guidelines for warming infants’ food and bottles; and
• Health and immunization records.

States and Territories can assess their licensing regulations against these best practices to identify where standards can be strengthened. A 2014 study shows the number of States that include safe sleep practices within their licensing standards. A majority of States now require that infants be placed on their backs to sleep, however, additional regulations could be put into place to strengthen safe sleep practices for infants (National Center on Early Childhood Quality Assurance, 2016b).

The following table is from the Reducing the risk of sudden infant death syndrome and using safe sleeping practices brief (2016), by the National Center on Early Childhood Quality Assurance.

N = The number of States that regulate the type of facility.

Once States and Territories have assessed the strength of their licensing regulations to protect infants and toddlers, an assessment of their QRIS standards and quality improvement initiatives will help to identify if there are stronger standards in place. However, participation in a QRIS is often voluntary and child care programs that are not participating in the QRIS or the quality improvement initiatives would not receive monitoring or support that address these higher health and safety standards.

Since States and Territories include licensing standards related to children’s health and safety, there tend to be fewer of those standards in a State’s or Territory’s QRIS. The standards in a QRIS are designed to identify and measure progress that begins with and moves beyond basic licensing requirements (Office of Child Care, 2014). There is variance across States and Territories as to the quantity and content of their health and safety licensing standards and the degree to which these standards are monitored for compliance (Early Childhood Development, n.d.). Although States and Territories are relying on licensing to monitor the health and safety aspects of care, the standards may not be strong enough or monitored consistently enough to assure a level of health and safety that adequately serves as a foundation for a QRIS or other quality initiative. Examples of how States are integrating health and safety standards in QRIS should be noted. These examples support essential elements of quality infant and toddler care, including individualized, responsive care in a safe and healthy environment that supports inclusion of children with disabilities or other special needs.

• States’ and Territories’ QRIS models are increasingly including standards that address conducting health and developmental screenings, which is particularly important for infants and toddlers (Office of Child Care, 2014).
• More than one-third of States using QRIS address developing activity plans or accommodating existing plans that are specific to children with disabilities in their QRIS assessments. Less than half of States’ licensing standards require that programs develop or accommodate these plans. Very few States require programs to provide services or ensure accessibility for children with disabilities beyond the requirement to develop or accommodate activity plans. (Office of Child Care, 2014). 

Additional QRIS examples:

• New Jersey’s Quality Rating System includes a requirement for infant/toddler programs to have a breastfeeding policy and documentation of staff orientation to the breastfeeding policy at Level 3 or higher. (Grow New Jersey’s Kids, retrieved August 2017)
• New York’s Quality Rating System includes physical activity requirements for infants and toddlers in child care centers as well as  a requirement for screen-time policies. (Quality Stars New York, retrieved August 2017)

The care of infants and toddlers can be improved by viewing licensing regulations and QRIS requirements as a continuum of increasingly stronger standards. Using existing tools, such as the CFOCB health and safety standards alignment tool to assess infant and toddler health and safety standards, will help States and Territories identify gaps and opportunities for improvement.

References

Administration for Children and Families, U.S. Department of Health and Human Services. (2015). Caring for our children basics: Health and safety foundations for early care and education. Retrieved from https://childcareta.acf.hhs.gov/sites/default/files/cfocb_alignment_tool.pdf

Child Care and Development Fund (CCDF) Program, 81 Fed. Reg. 67438 (September 30, 2016) (codified at 45 C.F.R. Part 98). Retrieved from https://www.gpo.gov/fdsys/pkg/FR-2016-09-30/pdf/2016-22986.pdf

Child Care State Capacity Building Center, Office of Child Care, Administration for Children and Families, U.S. Department of Health and Human Services. (2017). State and territory approaches to improving the supply and quality of child care programs and services for infants and toddlers. Retrieved from https://childcareta.acf.hhs.gov/sites/default/files/itrg/itrg_improving_childcare.pdf

Early Childhood Development, Administration for Children and Families, U.S. Department of Health and Human Services. (n.d.). Caring for our children basics: Health and safety foundations for early care and education [Web page]. Retrieved January 15, 2017, from https://www.acf.hhs.gov/ecd/caring-for-our-children-basics

National Center on Early Childhood Quality Assurance, Office of Child Care, Administration for Children and Families, U.S. Department of Health and Human Services. (2016). Caring for our children basics health and safety standards alignment tool for child care centers and family child care homes. Retrieved from https://childcareta.acf.hhs.gov/resource/caring-our-children-basics-health-and-safety-standards-alignment-tool-child-care-centers

National Center on Early Childhood Quality Assurance, Office of Child Care, Administration for Children and Families, U.S. Department of Health and Human Services. (2016). Reducing the risk of sudden infant death syndrome and using safe sleeping practices. Retrieved from https://childcareta.acf.hhs.gov/sites/default/files/healthsafety_sids_brief.pdf

New Jersey Center for Quality Ratings, William Patterson University. (2017). Star rating readiness checklist: All programs. Retrieved from http://www.wpunj.edu/coe/NJCQR/FINAL%20Star%20Rating%20Readiness%20Checklist%20-%20All%20Programs%205-17%20FE.pdf

Office of Child Care, Administration for Children and Families, U.S. Department of Health and Human Services. (n.d.). About QRIS [Web page]. Retrieved January 15, 2017, from https://qrisguide.acf.hhs.gov/about-qris 

Office of Child Care, Administration for Children and Families, U.S. Department of Health and Human Services. (2014). Comparison of state licensing and QRIS standards for infants and toddlers in child care centers: Health services, nutrition, and disabilities. Retrieved from https://childcareta.acf.hhs.gov/sites/default/files/health_disabilities_standards.pdf

Professional Development/Technical Assistance Group, New York State Early Childhood Advisory Council Work Group. (n.d.). QUALITYstarsNY resource guide: Guide to the center-based standards. Retrieved August 11, 2017, from http://qualitystarsny.org/standardsguide/std_list.php?pop=722

QRIS National Learning Network. (n.d.). QRIS state contacts and map [Web page]. Retrieved January 15, 2017, from https://ecquality.acf.hhs.gov/states

Additional Resources

The Office of Child Care’s Early Childhood Training and Technical Assistance System offers a variety of resources on health and safety on its website. This site allows viewers to filter the content of health and safety resources by topics such as licensing administration and monitoring and enforcement. 

The Office of Head Start’s Early Learning & Knowledge Center (ECLKC) also has many health and safety resources, some of which address the CCDF health and safety requirements. Visit https://eclkc.ohs.acf.hhs.gov/hslc/tta-system/health. 

The Office of Head Start has developed a Health and Safety Screener that help programs to identify where they need to make changes and build capacity in order to ensure children are healthy and safe while in their care. https://eclkc.ohs.acf.hhs.gov/sites/default/files/pdf/chs-certification-fillableform.pdf

The California Childcare Health Program has developed a Health and Safety Checklist for Early Care and Education Programs that is evidence based and aligned with Caring for our Children, 3^rd Edition. http://cchp.ucsf.edu/content/forms