Caring for Our Children: Chapter 3 - Health Promotion and Protection in Child Care Chapter 3: Health Promotion and Protection in Child Care 3.1 HEALTH PROMOTION IN CHILD CARE DAILY HEALTH CHECK STANDARD 3.001 Conduct of Daily Health Check Every day, a trained staff member shall conduct a health check of each child. This health check shall be conducted as soon as possible after the child enters the child care facility and whenever a change occurs while that child is in care. The health check shall address: a) Changes in behavior (such as lethargy or drowsiness) or appearance from behaviors observed during the previous day's attendance; b) Skin rashes, itchy skin, itchy scalp, or (during a lice outbreak) nits; c) If there is a change in the child's behavior or appearance, elevated body temperature, determined by taking the child's temperature; d) Complaints of pain or of not feeling well; e) Other signs or symptoms of illness (such as drainage from eyes, vomiting, diarrhea, and so on); f) Reported illness or injury in child or family members since last date of attendance. The facility shall gain information necessary to complete the daily health check by direct observation of the child, by querying the parent or legal guardian, and, where applicable, by conversation with the child. RATIONALE: Daily intake procedures to appraise each child's health and to ascertain recent illness or injury in the child and family reduce the transmission of communicable diseases in child care settings and enable the caregivers to plan for necessary care while the child is in care at the facility. COMMENTS: This assessment should be performed in a relaxed and comfortable manner that respects the family's culture as well as the child's body and feelings. The health consultant (see Health Consultants, STANDARD 1.040 through STANDARD 1.043) should train the caregiver(s) in conducting a health check, using a checklist. See Appendix F, for a sample symptom record. See Appendix G, for American Academy of Pediatrics' Recommended Childhood Immunization Schedule . Contact information is located in Appendix BB. Assessment by querying the parent should be at the time of transfer of care from the parent to the facility. If this happens outside the facility (when the child is put on a bus or in a car pool, for example), the facility should use some means of communication, such as written notes, checklists, conversations between bus drivers and parents, and daily log books. See STANDARD 3.068, regarding exclusion from child care. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.002 Documentation of the Daily Health Check The facility shall keep, for at least 3 months, a written record of concerns it identifies for each child during the daily health checks. RATIONALE: Although the vast majority of communicable diseases of concern in child care have incubation periods of less than 21 days, lags in reporting, non-apparent infections, and the slow-to-develop nature of some outbreaks suggest keeping data for 3 months. COMMENTS: For additional information on daily health assessment, see also Incidence Logs of Illness, Injury, and Other Problems, STANDARD 8.061 through STANDARD 8.064 and Child Records, STANDARD 8.046 through STANDARD 8.052. TYPE OF FACILITY: Center; Large Family Child Care Home PREVENTIVE HEALTH SERVICES STANDARD 3.003 Routine Health Supervision The facility shall require that the children have routine health supervision by the child's health provider, according to the standards of the American Academy of Pediatrics (AAP). Such health supervision includes routine screening tests, immunizations, and documentation and plotting on standard growth (if younger than 24 months of age) graphs of height and weight assessment and head circumference. School health services are acceptable to meet this standard if they meet the AAP's standards for school-age children and if the results of such examinations are shared with the child care provider as well as with the school health system. With parental consent, pertinent health information shall be exchanged among the child's routine source of health care and all participants in the child's care, including any school health program involved in the care of the child. RATIONALE: Provision of routine preventive health services helps detect disease when it is most treatable and through immunization, to prevent diseases for which effective vaccines are available. When children are receiving care that involves the school health system, such care should be coordinated by exchange of information with parental permission among the school health system, the child's usual source of health care, and the child care provider so that all participants in the child's care are aware of the child's health status and follow a common care plan. The plotting of height and weight measurements by health care providers or school health personnel on a reference growth chart will show how children are growing over time and how they compare with other children of the same chronological age and sex (1). Growth charts are based on data from national probability samples representative of children in the general population. Their use by health care providers will direct the child care provider's attention to unusual body size, which may be a result of disease or poor nutrition that requires modification of feeding practices in the child care setting (2). COMMENTS: Some infants and toddlers identified as showing signs of neglect and failure to thrive because of lack of food or inconsistent feeding practices are enrolled in facilities for both promotional and preventive health services. Periodic and accurate height and weight measurements that are plotted and interpreted by a person who is competent in performing these tasks provide an easily obtainable indicator of health status. If such measurements are made in the child care facility, the data from the measurements should be shared by the facility with everyone involved in the child's care, including parents, caregivers, and the child's health care provider. The health consultant can provide staff training on growth assessment. See Health Consultants, STANDARD 1.040 through STANDARD 1.043. See Appendix H, for Recommendations for Preventive Pediatric Health Care . See STANDARD 3.004, on follow-up for nutrition and growth problems and nutrition assessment data; and STANDARD 8.047 through STANDARD 8.052, on files to be kept for each child in care. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.004 Assessment and Planning of Nutrition for Individual Children Nutrition assessment data (such as growth and anemia screening) shall be an integral part of the routine health supervision documented in the health record. Communication shall occur with a health care provider on how to meet the nutritional needs of children found to be at risk for nutritional problems. RATIONALE: Children who need special nutrition intervention or dietary modification of child care feeding routines because of growth problems must be identified so that preventive health/nutrition care can be provided at a critical time during growth and development. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home IMMUNIZATIONS STANDARD 3.005 Immunization Documentation The facility shall require that all children enrolling in child care provide written documentation of immunizations appropriate for the child's age. Infants, toddlers, older children, and adolescents shall be immunized as specified in the Recommended Childhood Immunization Schedule developed by the American Academy of Pediatrics (AAP), the Advisory Committee on Immunization Practice of the Centers for Disease Control and Prevention (CDC), and the American Academy of Family Practice (AAFP) (AA). See Appendix G. Children whose immunizations are late or not given according to the schedule shall be immunized as recommended by the American Academy of Pediatrics (3) Because of frequent changes, an updated schedule is published by the AAP every January and shall be consulted for current information (4). RATIONALE: Routine immunization at the appropriate age is the best means of preventing vaccine-preventable diseases. Laws requiring the age-appropriate immunization of children attending licensed facilities exist in almost all states. Parents of children who attend unlicensed child care should be encouraged to comply with the Recommended Childhood Immunization Schedule for infants and children. See Appendix G. Immunization is particularly important for children in child care because preschool-aged children currently have the highest age-specific incidence of many vaccine-preventable diseases (specifically, measles, pertussis, rubella, varicella, and Haemophilus influenzae type b disease). COMMENTS: In addition to publication in print, as shown in Appendix G, the current Recommended Childhood Immunization Schedule is posted on the web site of the American Academy of Pediatrics: www.aap.org/ ; and the web site of the Centers for Disease Control and Prevention: www.cdc.gov/ . TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.006 Under-immunized Children If immunizations are not to be administered because of a medical condition, a statement from the child's health care provider documenting the reason why the child is exempt from the immunization requirement shall be on file. If immunizations are not given because of parents' religious beliefs, a waiver signed by the parent shall be on file. If a child who is not immunized is in care, the parents must be notified of the risk of the spread of preventable diseases. Children who have not received their age-appropriate immunizations prior to enrollment and do not have documented religious or medical exemptions from routine childhood immunizations shall show evidence of an appointment for immunizations. The immunization series shall be initiated within one month and completed according to the Recommended Childhood Immunization Schedule from the American Academy of Pediatrics (AAP). See Appendix G. If a vaccine-preventable disease to which children are susceptible occurs in the facility, unimmunized children shall be excluded for the duration of possible exposure or until the age-appropriate immunizations have been completed (whichever comes first). RATIONALE: Routine immunization at the appropriate age is the best means of preventing vaccine-preventable diseases. Laws requiring the age-appropriate immunization of children attending licensed facilities exist in all states (73). Parents of children who attend unlicensed child care should be encouraged to comply with the Recommended Childhood Immunization Schedule from the American Academy of Pediatrics (AAP) for infants and children. See Appendix G. The exclusion of an unimmunized child from the facility in the event of an outbreak of a vaccine-preventable disease protects the health of that unimmunized child. COMMENTS: A sample statement excluding a child from immunizations is: "This is to inform you that [NAME] should not be immunized with [VACCINE] because of [CONDITION, such as immunosuppression]. [SIGNED], [PHYSICIAN] [DATE]" See Appendix G, for the Recommended Childhood Immunization Schedule from the AAP. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.007 Immunization of Child Care Providers Child care providers shall be current for all immunizations routinely recommended for adults by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC). All child care providers shall have: a) Completed a primary series for tetanus and diphtheria, and shall receive boosters every 10 years; b) Been immunized or certified immune by a health care provider against measles, mumps, rubella, poliomyelitis, varicella (chickenpox), and hepatitis B following guidelines of the ACIP (2, 4). Additionally, influenza immunization is recommended for people 50 years of age and older and pneumococcal polysaccharide vaccine is recommended for people 65 years of age or older. If a staff member is not appropriately immunized for medical or religious reasons, the child care facility shall require documentation of the reason, in writing. RATIONALE: Vaccine-preventable infections of adults represent a continuing cause of morbidity and mortality and source of transmission of infectious organisms. Vaccines, which are safe and effective in preventing these diseases, need to be used in adults to minimize disease and to eliminate potential sources of transmission (4, 5) COMMENTS: For additional information on adult immunization, contact the Centers for Disease Control and Prevention (CDC) or visit the CDC website at www.cdc.gov/. Contact information is located in Appendix BB. For additional information on vaccine-preventable diseases, see Health Plan for Child Health Services, STANDARD 8.013 through STANDARD 8.017; for additional immunization standards, Pre-employment Staff Health Appraisal, STANDARD 1.045. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home SLEEP STANDARD 3.008 Scheduled Rest Periods and Sleep Arrangements The facility shall provide an opportunity for, but shall not require, sleep and rest. The facility shall make available a regular rest period for school-aged children, if the child desires. For children who are unable to sleep, the facility shall provide time and space for quiet play. Unless the child has a note from a physician specifying otherwise, infants shall be placed in a supine (back) position for sleeping to lower the risks of Sudden Infant Death Syndrome (SIDS). Soft surfaces and gas-trapping objects such as pillows, quilts, sheepskins, soft bumpers or waterbeds shall not be placed under or with an infant for sleeping. When infants can easily turn over from the supine to the prone position, they shall be put down to sleep on their back, but allowed to adopt whatever position they prefer for sleep. Unless a doctor specifies the need for a positioning device that restricts movement within the child's bed, such devices shall not be used. RATIONALE: Conditions conducive to sleep and rest for younger children include a consistent caregiver, a routine quiet place, and a regular time for rest (6). Most preschool children in all-day care benefit from scheduled periods of rest. This rest may take the form of actual napping, a quiet time, or a change of pace between activities. The times of naps will affect behavior at home (8). The supine (back) position presents the least risk of SIDS (7, 8). Once infants develop the motor skills to move from their back to their side or stomach it is safe to put them to sleep on their backs and allow them to adapt to whatever position makes them comfortable. Repositioning sleeping infants onto their backs is not recommended once the child has learned to turn over easily from supine (back) to prone (front). If a child has an illness or a disability that predisposes the child to airway obstruction in the back sleeping position, parents should give the child care provider a physician's note specifying the need for prone sleeping and any other special arrangements required for that child. COMMENTS: In the young infant, favorable conditions for sleep and rest include being dry, well-fed, and comfortable. A school-age child care facility should make available board games and other forms of quiet play. The 1996 update to the statement prepared by the AAP Task Force on Infant Positioning and SIDS details the rationale for preferential back-positioning when caregivers put children down to sleep. Infants who are back-sleepers at home, but are put to sleep in the prone position in child care settings, have a higher risk of SIDS (7). A certain amount of "tummy time" while the child is awake and observed helps muscle development and reduces the tendency for back positioning to flatten the back of the head (8). Additional resources are available from the National SIDS Resource Center and the Back to Sleep Campaign or from the local or state health department. Contact information is located in Appendix BB. See STANDARD 5.146, for additional information on appropriate bedding to reduce the risk of SIDS. See STANDARD 1.023 and STANDARD 1.038, regarding child care provider training on SIDS. See also STANDARD 3.089, regarding dealing with SIDS deaths. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.009 Unscheduled Access to Rest Areas All children shall have access to rest or nap areas whenever the child desires to rest. These rest or nap areas shall be set up to reduce distraction or disturbance from other activities. All facilities shall provide for rest areas for children who need to rest off schedule, including children who become ill, at least until the child leaves the facility for care elsewhere. RATIONALE: Any child, especially children who are ill, may need more opportunity for rest or quiet activities. COMMENTS: See also STANDARD 3.008, on additional sleep requirements. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home ORAL HEALTH STANDARD 3.010 Routine Oral Hygiene activities Caregivers shall promote the habit of regular tooth brushing. All children with teeth shall brush or have their teeth brushed at least once during the hours the child is in child care. Using a size-appropriate brush and a small amount of fluoride toothpaste, the caregiver shall either brush the child's teeth or supervise as the child brushes his/her own teeth. The younger the child the more the caregiver needs to be involved. After feeding, an infant's teeth and gums shall be wiped with a moist cloth to remove any remaining liquid that coats the teeth and gums and which turns to plaque causing tooth decay. Very few preschool-age children have the hand-eye coordination or the fine motor skills necessary to complete the complex process of tooth brushing. The caregiver shall be able to evaluate each child's motor activity and to teach the child the correct method of tooth brushing when the child is capable of doing this activity. The caregiver shall monitor the tooth brushing activity and thoroughly brush the child's teeth after the child has finished brushing. The cavity-causing effect of frequent exposure to food shall be reduced by offering the children rinsing water after snacks when brushing is not possible. RATIONALE: Regular tooth brushing with fluoride toothpaste and flossing is encouraged to reinforce oral health habits and prevent gingivitis and tooth decay. Good oral hygiene is as important for a six-month-old child with one tooth as it is for a six-year-old with many teeth. Tooth brushing at least once a day reduces build-up of decay-causing plaque. The development of tooth decay-producing plaque begins when an infant's first tooth appears in his/her mouth. Tooth decay cannot form without this plaque or the acid-producing bacteria in a child's mouth. The ability to do a good job brushing the teeth is a learned skill, improved by practice. Tooth brushing and flossing activities at home may not suffice to learn this skill or accomplish the necessary plaque removal, especially when children eat most of their meals and snacks during a full day in child care. COMMENTS: The caregiver should use a layer of fluoride toothpaste (about children under three years of age and a pea-sized amount for children over three years of age) and rinse well. Fluoride is the single most effective way to prevent tooth decay. Brushing of teeth with fluoridated toothpaste is the most efficient way to apply fluoride to the teeth. Children under 3 years of age may swallow toothpaste that contains fluoride. If children swallow more than recommended amounts of fluoride toothpaste, they are at risk for fluorosis, a condition caused by excessive levels of fluoride intake. The children can also rinse and spit out after a snack if their teeth have already been brushed after a meal. Rinsing with water helps to remove food particles from teeth and may prevent cavities. A sink is not necessary to accomplish tooth brushing in child care. Each child can use a cup of water for tooth brushing. The child should wet the brush in the cup, take a rinsing drink, and then spit into the cup. For information on toothbrush storage, see STANDARD 5.095 and STANDARD 5.151. For additional information on oral health, see also STANDARD 3.011; and STANDARD 8.046 through STANDARD 8.052, on child records. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.011 Oral Health Education All children with teeth shall have oral hygiene as a part of their daily activity. Those two years and older shall have developmentally appropriate oral health education that includes information on what plaque is, the process of dental caries development, and the importance of good oral hygiene behaviors. School-age children shall receive additional information including the preventive use of fluoride, dental sealants, mouth guards, and the importance of healthy eating behaviors and regularly scheduled dental visits. Older children shall be informed about the effect of tobacco products on their oral health and additional reasons for avoidance. RATIONALE: Studies have reported that the oral health of participants improved as a result of educational programs (9, 10). COMMENTS: Child care providers are encouraged to advise parents that the following ages for preventive and early intervention dental services and education are suggested: Dental visits, evaluation for systemic fluoride therapy at six months of age, and professionally applied topical fluoride treatments for high risk children; First dental visit whenever there is a question of an oral health problem, but no later than 3 years of age; Dental sealants generally at 6 or 7 years of age for first permanent molars, and for primary molars if deep pits and grooves or other high risk factors are present. When possible, child care providers should provide education for parents on good oral hygiene practices and avoidance of behaviors that increase the risk of early childhood caries, such as inappropriate use of a bottle and frequent consumption of carbohydrate-rich foods. Local dental health professionals can facilitate compliance with these activities by offering education and training for the child care staff and providing oral health presentations for the children and parents. See Health Education, STANDARD 2.060 through STANDARD 2.064. TYPE OF FACILITY: Center 3.2 HYGIENE TOILETING AND DIAPERING STANDARD 3.012 Type of Diapers Diapers worn by children shall be able to contain urine and stool and minimize fecal contamination of the children, caregivers, environmental surfaces, and objects in the child care setting. Only disposable diapers with absorbent gelling material or carboxymethyl cellulose may be used unless the child has a medical reason that does not permit the use of disposable diapers (such as allergic reactions). When children cannot use disposable diapers for a medical reason, the reason shall be documented by the child's health care provider. When cloth diapers are used, the diaper shall have an absorbent inner lining completely contained within an outer covering made of waterproof material that prevents the escape of feces and urine. The outer covering and inner lining shall be changed together at the same time as a unit and shall not be reused unless both are cleaned and disinfected, washed, and either chemically disinfected or heat dried at 165 degrees F or more. No rinsing or dumping of the contents of the diaper shall be performed at the child care facility. RATIONALE: Gastrointestinal tract disease caused by bacteria, viruses, parasites, and hepatitis A virus infection of the liver are spread from infected persons through fecal contamination of objects in the environment and hands of caregivers and children. Procedures that reduce fecal contamination, such as minimal handling of soiled diapers and clothing, handwashing, proper personal hygiene, and fecal containment in diapered children control the spread of these diseases. Diapering practices that require increased manipulation of the diaper and waterproof covering, particularly reuse of the covering before it is cleaned and disinfected, present increased opportunities for fecal contamination of the caregivers' hands, the child, and consequently, objects and surfaces in the environment. Environmental contamination has been associated with increased diarrheal rates in child care facilities (11). Fecal contamination in the center environment may be less when paper diapers are used than when cloth diapers worn with pull-on waterproof pants are used (14). When clothes are worn over either paper or cloth diapers with pull-on waterproof pants, there is a reduction in contamination (11, 14). Diaper dermatitis occurs frequently in diapered children. Diapering practices that reduce the frequency and severity of diaper dermatitis will require less application of skin creams, ointments, and drug treatments, thereby decreasing the likelihood for fecal contamination of caregivers' hands. Most common diaper dermatitis represents an irritant contact dermatitis; the source of irritation is prolonged contact of the skin with urine, feces, or both (11). The action of fecal digestive enzymes on urinary urea and the resulting production of ammonia make the diapered area more alkaline, which has been shown to damage skin (11, 12). Damaged skin is more susceptible to other biological, chemical, and physical insults that can cause or aggravate diaper dermatitis (11). Frequency and severity of diaper dermatitis are lower when diapers are changed more often, regardless of the diaper used (11). The use of modern disposable diapers with absorbent gelling material or carboxymethyl cellulose has been associated with less frequent and severe diaper dermatitis in some children than with the use of cloth diapers and pull-on pants made of a waterproof material (14). COMMENTS: Several types of diapers or diapering systems are currently available: disposable paper diapers, reusable cloth diapers worn with pull-on waterproof pants, reusable cloth diapers worn with a modern front closure waterproof cover, and single unit reusable diaper systems with an inner cotton lining attached to an outer waterproof covering. Two types of diapers meet the physical requirements of the standard: modern disposable paper diapers, with absorbent gelling material or carboxymethyl cellulose, and single unit reusable diaper systems, with an inner cotton lining attached to an outer waterproof covering. A third type, reusable cloth diapers worn with a modern front closure waterproof cover, meet the standard only: If the cloth diaper and cover are removed simultaneously as a unit and are not removed as two separate pieces, and; If the cloth diaper and outer cover are not reused until both are cleaned and disinfected. Reusable cloth diapers worn either without a covering or with pull-on pants made of waterproof material do not meet the physical requirements of the standard and are not recommended in facilities. Whichever diapering system is used in the facility, clothes should be worn over diapers while the child is in the facility. Rigorous protocols should be implemented for diaper handling and changing, personal hygiene, and environmental decontamination. While single unit reusable diaper systems, with an inner cloth lining attached to an outer waterproof covering, and reusable cloth diapers, worn with a modern front closure waterproof cover, meet the physical criteria of this standard (if used as described), they have not been evaluated for their ability to reduce fecal contamination, or for their association with diaper dermatitis. Moreover, it has not been demonstrated that the waterproof covering materials remain waterproof with repeated cleaning and disinfecting. If these reusable diaper products are used in child care, the user should determine the waterproof characteristics of the covering material at frequent intervals. For additional information on decreasing contamination when diapering, see also STANDARD 3.014; Handwashing, STANDARD 3.020 through STANDARD 3.024; and Sanitation, Disinfection, and Maintenance of Handwashing Sinks, STANDARD 3.029. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.013 Checking For The Need To Change Diapers Diapers shall be checked for wetness and feces at least hourly, visually inspected at least every two hours, and whenever the child indicates discomfort or exhibits behavior that suggests a soiled or wet diaper. Diapers shall be changed when they are found to be wet or soiled. RATIONALE: Frequency and severity of diaper dermatitis are lower when diapers are changed more often, regardless of the type of diaper used (11). Diaper dermatitis occurs frequently in diapered children. Most common diaper dermatitis represents an irritant contact dermatitis; the source of irritation is prolonged contact of the skin with urine, feces, or both (12). The action of fecal digestive enzymes on urinary urea and the resulting production of ammonia make the diapered area more alkaline, which has been shown to damage skin (11, 12). Damaged skin is more susceptible to other biological, chemical, and physical insults that can cause or aggravate diaper dermatitis (12). Modern disposable diapers can be checked for wetness by feeling the diaper through the clothing and fecal contents can be assessed by smell. Nonetheless, since these methods of checking may be inaccurate, the diaper should be opened and checked visually at least every two hours. Even though modern disposable diapers can continue to absorb moisture for an extended period of time when they are wet, they should be changed after two hours of wearing if they are found to be wet. This prevents rubbing of wet surfaces against the skin, a major cause of diaper dermatitis. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.014 Diaper Change Procedure The following diaper changing procedure shall be posted in the changing area, shall be followed for all diaper changes, and shall be used as part of staff evaluation of caregivers who do diaper changing. Child caregivers shall never leave a child alone on a table or countertop, even for an instant. A safety strap or harness shall not be used on the diaper changing table. If an emergency arises, caregivers shall put the child on the floor or take the child with them. Step 1: Get organized. Before you bring the child to the diaper changing area, wash your hands, gather and bring what you need to the diaper changing table: · Non-absorbent paper liner large enough to cover the changing surface from the child's shoulders to beyond the child's feet; · Fresh diaper, clean clothes (if you need them); · Wipes for cleaning the child's genitalia and buttocks removed from the container or dispensed so the container will not be touched during diaper changing; · A plastic bag for any soiled clothes; · Disposable gloves, if you plan to use them (put gloves on before handling soiled clothing or diapers); · A thick application of any diaper cream (when appropriate) removed from the container to a piece of disposable material such as facial or toilet tissue. Step 2: Carry the child to the changing table, keeping soiled clothing away from you and any surfaces you cannot easily clean and sanitize after the change. · Always keep a hand on the child; · If the child's feet cannot be kept out of the diaper or from contact with soiled skin during the changing process, remove the child's shoes and socks so the child does not contaminate these surfaces with stool or urine during the diaper changing; · Put soiled clothes in a plastic bag and securely tie the plastic bag to send the soiled clothes home. Step 3: Clean the child's diaper area. · Place the child on the diaper change surface and unfasten the diaper but leave the soiled diaper under the child. · If safety pins are used, close each pin immediately once it is removed and keep pins out of the child's reach. Never hold pins in your mouth. · Lift the child's legs as needed to use disposable wipes to clean the skin on the child's genitalia and buttocks. Remove stool and urine from front to back and use a fresh wipe each time. Put the soiled wipes into the soiled diaper or directly into a plastic-lined, hands-free covered can. Step 4: Remove the soiled diaper without contaminating any surface not already in contact with stool or urine. · Fold the soiled surface of the diaper inward. · Put soiled disposable diapers in a covered, plastic-lined, hands-free covered can. If reusable cloth diapers are used, put the soiled cloth diaper and its contents (without emptying or rinsing) in a plastic bag or into a plastic-lined, hands-free covered can to give to parents or laundry service. · If gloves were used, remove them using the proper technique (see Appendix D) and put them into a plastic-lined, hands-free covered can. · Whether or not gloves were used, use a disposable wipe to clean the surfaces of the caregiver's hands and another to clean the child's hands, and put the wipes into the plastic-lined, hands-free covered can. · Check for spills under the child. If there are any, use the paper that extends under the child's feet to fold over the disposable paper so a fresh, unsoiled paper surface is now under the child's buttocks. Step 5: Put on a clean diaper and dress the child. · Slide a fresh diaper under the child. · Use a facial or toilet tissue to apply any necessary diape