Last Updated

08/30/2021

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Overview

Early care and education programs including child care, family child care, and Head Start programs offer a supportive learning environment for healthy child development as well as a foundation of services for young children and their families. The COVID-19 pandemic has highlighted the importance of these services, such as provision of healthy meals, referrals to community resources, and social connections for children and families. The sheltering imposed by the COVID-19 pandemic and the sudden loss of services can have a detrimental effect on children.

Decisions about implementing strategies for early care and education (eg, dismissals, event cancellations, other physical distancing measures) should be made locally in collaboration with local health officials, who can help determine the level of transmission in the community. Resources such as Child Care Health Consultants, Head Start Collaboration offices, or Childcare Aware of America can provide helpful local information and best practices in health and safety.

This guidance from the American Academy of Pediatrics (AAP) is based on what is currently known about the transmission and severity of COVID-19. Further guidance is available on the Centers for Disease Control and Prevention (CDC) website. Early care and education programs should also consult Caring for our Children as a resource for best practices.

The aim of the strategies provided within this guidance is to reduce risk of exposure and spread of infection to staff, children, and families involved with early care and education programs. The AAP encourages checking the CDC website regularly as guidance can change based on new research findings. This guidance explores primary prevention such as immunizations, well child care, and special considerations for children with special health care needs. Providers are encouraged to revise their program services and plans to keep everyone as safe as possible.

 

Well-Child Care, Routine Childhood Immunizations and Screenings

The AAP strongly supports the continued provision of health care and developmental screenings for children during the COVID-19 pandemic. The pandemic has highlighted the existing inequities and structural barriers to accessing health care and quality early education. The evidence has clearly shown that Black and Latinx adults and low-income families are disproportionately affected by COVID-19, face barriers to accessing care, and experience negative health outcomes. Child deaths related to COVID-19 have disproportionately affected historically disadvantaged racial and ethnic groups and youth with underlying medical conditions. Access to well-child care and vital health screenings helps to ensure the optimal development of young children.

Specifically, well-child care should be provided consistent with the recommendations in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents (4th Edition) and the corresponding Bright Futures/AAP Recommendations for Preventive Pediatric Health Care (Periodicity Schedule). Pediatricians have rapidly adapted to provide appropriate elements of well-child examinations through telehealth when clinically warranted. Primary care pediatricians are prepared to ensure that all newborns, infants, children, and adolescents are up to date on their comprehensive well-child care, inclusive of appropriate screenings, complete physical examinations, laboratory tests, fluoride varnish, and vaccines. 

Early care and education programs are often required to collect health data related to well-child care, such as immunization schedules, developmental screenings, oral health examinations, lead screening, hearing and vision screening, etc. Many regulatory organizations for early care and education relaxed these requirements during the pandemic. However, the AAP recognizes the vital role early care and education providers play in the support of families to access routine and appropriate health care. Since the onset of the pandemic, a significant drop in well-child visits has resulted in delays in vaccinations, delays in appropriate screenings and referrals, and delays in anticipatory guidance to ensure optimal health. Up-to-date immunizations are a cornerstone to protecting children from vaccine-preventable illnesses and are a crucial part of maintaining health, especially in group settings. COVID-19 is not the only devastating infection that can affect young children, and timely immunization can prevent the recurrence of previously epidemic diseases such as measles and polio.

Early care and education play an important role in the identification of developmental delays and referrals to appropriate services. Early intervention (EI) is essential to supporting optimal outcomes for children and families. EI services may need to adapt in order to provide care during the pandemic; however, if children qualify for services, they should still receive them. EI services have adapted to virtual and coaching models to support child care providers and families to implement strategies in the child’s natural environment including the early care program and home environment. The AAP recommends that early care and education providers continue to support EI services as safely as possible and support families in receiving needed care.

Further, many early care and education programs support the development and transition of Individualized Family Service Plans (IFSPs) and Individualized Education Programs (IEPs) in the program environment and during the transition to school settings. It is essential that evaluations to determine eligibility continue and that services are implemented to meet the related special education needs of that child. These evaluations and services may look different but should not be postponed. Early care and education programs can support the delivery of services as appropriate, inform families of their rights to receive services, and partner with the child’s pediatrician to adapt services during the pandemic.

Resources:
HealthyChildren.org articles:

Social media resources to promote well-child visits:

  • AAP #CallYourPediatrician campaign toolkit.

Daily Health Checks and Screening 

Programs should design a daily health check for staff and children before drop-off/check-in that expands the Caring for Our Children Standards: Standard 3.1.1 Daily Health Check to include at least a daily temperature check, other COVID-19 symptoms, and any history of contact with a confirmed case of COVID-19.

Temperature can be determined using any method: axillary (armpit), oral or other, and contactless. A fever is temperature ≥100.4°F. For additional information, please see the CDC Guidance for Operating Early Care and Education/ Childcare Programs During COVID19. This protocol relies on parent/caregiver access to a thermometer as well as knowledge and skills to use a thermometer, which can vary. It may be helpful to provide resources on how to obtain a thermometer as well as instructions on measuring the temperature accurately.

Not all children with fever have COVID-19, and not all children with COVID-19 have fever. Regardless, stopping a febrile child from entering a child care setting can help to prevent the disruptive series of consequences that would follow given the current circumstances.

COVIDchildcare_AAP_852x479 (003).jpgPrint and Post this Symptom Checklist

Resources:

The CDC offers testing guidance for staff members. Please be aware that testing does not determine whether someone is contagious. It is possible to receive a positive result for SARS-CoV-2 but not be currently contagious. A person can continue to test positive for up to 3 months. It is also possible to receive a negative result and be contagious. If a staff member tests positive for SARS-CoV-2 or has come into contact with a person with confirmed SARS-CoV-2 , that person should follow the CDC recommendations for self-isolation or quarantine. Consultation with your local health department is recommended when questions arise.

Exclusion Policy: When Someone Becomes Sick With COVID-19 or Has History of Contact With Someone With COVID-19

All programs should have a plan for what to do if a child becomes sick during the day. Caring for Our Children Standards provide guidance on caring for ill children (3.6.2) and exclusion policies. The CDC recommends keeping sick children separate from well children and staff, in an area that can be used to isolate a sick child with appropriate supervision until the child can return home. A staff member should stay with the isolated child to monitor symptoms and care for the child. Staff should continue wearing their masks, washing their hands routinely, and changing clothes, smocks, or gloves that become soiled. If possible, other personal protective equipment such as eye protection and a surgical mask should be worn. Surfaces should be cleaned and disinfected in the area used for isolation after the sick child leaves. A sufficient number of staff should be available to maintain the designated staff-to-child ratio.

Recommended exclusion criteria, as outlined by the CDC, should be used during this time. If a sick child does have a suspected or confirmed case of COVID-19, the child should be excluded from the in-program services according to existing program exclusion policies (Caring for Our Children 3.6.1.1).

Each program must keep current with CDC guidance on the duration of self-isolation (for suspected or confirmed cases) and quarantine (for people with a history of close contact to a confirmed case of COVID-19). If a child or staff member is a confirmed or suspected case of COVID-19 (because of signs and symptoms or because the person has been in close contact with a confirmed case), then the family should be encouraged to self-quarantine accordingly and instructed on when the child or staff member may return to the program. Notify local health officials immediately if a child or staff member has a confirmed case of COVID-19. These officials will help your program leadership determine an appropriate course of action. Work with your local health officials to determine appropriate next steps, whether closure is needed for a short duration (eg, for cleaning and disinfection) or to slow further spread of COVID-19.

Considerations for Closure

Notify local health officials immediately if a child (or household member) or staff member has a confirmed case of COVID-19. These officials will help your program leadership determine an appropriate course of action. If the child care program has maintained cohorts of children and staff, the child care may not need to close entirely. Instead, the exposed cohort would most likely need to remain home for the CDC’s recommended self-isolation period. This would allow child care services to continue for the remaining cohorts.

If health officials recommend closing your entire program, you may be closed for 2 to 5 days. This initial short-term closure allows time for local health officials to gain a better understanding of the COVID-19 situation affecting your program and allows you to plan to clean and disinfect the affected facilities. Work with your local health officials to determine appropriate next steps, including whether an extended duration is needed to stop or slow further spread of COVID-19 (COVID-19 Guidance for Operating Early Care and Education/Child Care Programs (cdc.gov)

 

Staff Vaccination

The AAP recommends that all eligible early care and education staff receive the COVID-19 vaccine. The pandemic has highlighted the important role these providers play in supporting families and enabling children to grow and learn. Getting vaccinated as soon as the opportunity is available can reduce the risk of staff becoming seriously ill from COVID-19 and from transmitting the infection to other staff and children. Review the CDC’s COVID-19 Vaccination Information or talk to your health care provider for more information.  

Even after child care providers and staff are vaccinated, there will be a need to continue prevention measures for the foreseeable future, including wearing masks, physical distancing, and other important prevention strategies outlined in this guidance document. 

Be prepared to answer or provide information to families and staff with questions or vaccine hesitancy. 

Resources:  

 

Redesigning the Learning Environment

Building Cohorts and Limiting Classroom Size

Physically distancing can be difficult among children in child care settings. The AAP recommends that classrooms use a cohort model of care and learning experiences. Children should be grouped according to developmental age as well as household as much as possible, grouping siblings or children from the same household in the same cohort. This cohort, including staff, should not mix with other children or staff during the program day. Cohorting guidance includes: 

  • Any in-person staff support for child care providers should be limited to staff assigned to the same cohort. Floaters should not be used as staff support, because their movement across cohorts may increase the risk of exposure to COVID-19.  
  • Children and staff in the same class cohort can learn, eat, play, and access facilities together but should not mix with children or staff in other class cohorts. 
  • Classroom toys and play equipment can be shared by children in the same cohort but should not be shared across cohorts.  

The CDC recommends removal of soft, difficult-to-clean toys from the classroom. Hard, smooth-surface toys should be cleaned at the end of the day (if half day or full day) or when a toy is soiled or put in a child’s mouth, etc. Supplies such as crayons, markers, and other material that can be difficult to clean can be individualized in a container labeled with each child’s name. The AAP recommends keeping these difficult-to-clean supplies and toys to a minimum.  

Classroom Size 

Follow guidance from your state and local health department as well as your state licensing entity. Head Start programs and child care centers should keep staff-to-child ratios as small as possible and children and staff from different classrooms in separate physical spaces.  

Allow opportunities to spread out children in the same cohort or classrooms so that they occupy a greater amount of space. Although young children do not practice physical distancing well, increasing the square footage of the communal space can reduce close contact that may otherwise occur when children are in smaller spaces. Before the COVID-19 pandemic, Caring for Our Children Standards and most licensing standards recommended approximately 45 square feet per child. During the pandemic, the 3-foot separation recommended for physical distancing would translate to 1.5 times as much space as is standard. This may not always be possible for some providers. Strategies for increasing space per child, including keeping class sizes small and using outdoor environments as much as possible, are encouraged.  

Relevant Caring for Our Children Standards: 

Drop-off and Pick-up 

It is important to reduce congestion and interaction of those not receiving or providing direct care. If possible, the AAP recommends that children in the same cohort arrive together and the staff in the same cohort welcome and screen them. This practice can reduce risk of possible exposure across classrooms. Early childhood programs including family child care should develop their own revised procedures for drop-off and pick-up. Considerations may include: 

  • Stagger arrival and drop-off times to facilitate keeping cohorts arriving at the same time. 
  • Plan arrival and drop-off outside the facility. 
  • Limit pen and paper sign-in by families. 
  • Provide hand sanitizer for sign-in/out. 
  • Limit direct contact with parents/guardians. 
  • Refrain from hugging and shaking hands. 
  • Limit caregivers who welcome and screen children at drop-off.  
  • All staff welcoming children should wear appropriate personal protective equipment (PPE).  

Families may need preparation to adjust to changes in policy and services. It is suggested that staff support families by providing detailed guidance and regular communication regarding these changes in procedures. It may also be helpful to provide strategies for families to talk about these changes with their child. Consider creating a small social story for children to assist with the transition. For example, send pictures of what the new process and program environment will look like. Include faces of those who will greet their child with masks on. Families can use these pictures to practice new procedures, wearing masks, and washing their hands. It is very important to have these materials available in different languages according to the particular needs of the child care center. 

Consultants and Staff 

Early child care programs aim to further the healthy development of our young children. Early intervention, speech therapy, mental health consultation, and other professionals provide valuable services to young children and staff. However, during the COVID-19 pandemic, if a consultative service does not need to be provided in the classroom, then consultants should find other methods for completing the service, such as videotaped observations or video or phone conferencing for consultation with staff. Support staff should be assigned to individual cohorts and classrooms and not float from one room to another. This measure would potentially decrease the exposure of staff and prevent possible spread.  

If a consultant does enter the program, that person should follow all of the same policies and procedures established for staff to mitigate the risk of exposure, including health screenings, wearing a mask, washing hands at entry and exit of the classroom, removing any soiled clothing, etc. When a consultant is observing in a classroom, it is advisable to maintain as much physical distance as possible. In addition to following program protocols, some specialists such as occupational, physical, or speech therapists may consider additional safety measures related to the services they provide. 

The National Association for Regulatory Administration offers a resource on remote inspections in child care settings. Directors and education staff can also reach out to the National Center on Early Childhood Development, Teaching, and Learning and the Center for Excellence for Infant and Early Childhood Mental Health Consultation. 

 

Supporting Breastfeeding Mothers

Programs should follow CDC recommendations as well as any local or state guidance for screening anyone entering the facility, including breastfeeding mothers. It is still recommended to limit adults including consultants and family members from entering the physical program environment. If programs continue to provide support services to breastfeeding mothers, they are encouraged to: 

  • Create lactation rooms or private spaces with a comfortable chair and pillow (with disposable or washable covers), flat surface for a breast pump, easy access to electrical outlets, and a sink with soap and disposable towels to wash hands and rinse pump parts.  
  • Ask the mother to properly label and leave her pumped milk in the private space. A staff member should transport the milk for proper refrigeration and storage. The milk should still be stored according to recommendations in Caring for Our Children. 
  • If a program decides to allow a mother to breastfeed her baby during program hours (in place of pumping and storing milk), a staff member from the classroom environment should bring the infant to the mother in this separate space to feed her child and carry the infant back to the classroom. 
  • The private lactation space should have adequate ventilation bringing fresh air in and indoor air outside.  
  • All furniture, equipment, surfaces, door knobs, light switches, faucets (and other high touch areas) in these rooms should be cleaned and disinfected after each use. Soft, porous items are not easily cleaned and should be limited to a chair and pillow.  

Resources: 

 

Food Service

Family-style meal service is an important part of early care and education. Family-style dining supports healthy habits, healthy development, and early learning. The CDC has advised that family-style meal service can be reinstated. Staff should consider how best to maintain infection control procedures in their program.  

  • As possible, maintain classroom or cohort groups rather than mixing classrooms of children. 
  • Consider eating meals and snacks outdoors, as weather permits, or in well-ventilated spaces.  
  • All staff and children should wash their hands before and after meal and snack times.  
  • To support children serving themselves, try smaller groups of children during meal time, even within classrooms.  

 

Oral Health and Toothbrushing

Oral health is a key component in the health of children. Early care providers play a vital role supporting oral health habits in their program and at home. Additionally, early care providers support families to access necessary dental care. The American Dental Association, Academy of General Dentistry, and the American Academy of Pediatric Dentistry all encourage parents to establish a dental home for their child no later than 12 months of age. However, the COVID-19 pandemic has caused many families to delay or postpone needed dental care. Early care providers can help families locate and access needed dental services, including pediatricians or dental hygienists  Additional resources: 

The CDC has advised toothbrushing service in early care and education can be reinstated during the COVID-19 pandemic. However, providers should consider how best to maintain infection control procedures in their program. The Early Childhood Learning and Knowledge Center offers detailed guidance by age group. In addition, program should consider: 

  • Staff responsible for supporting toothbrushing with children should be fully vaccinated against COVID-19.  
  • Classrooms or cohorts should be maintained while practicing toothbrushing. It is recommended that toothbrushing be conducted at the classroom table, if possible.  
  • Children should be seated as far away from each other as possible, ideally 3 feet, during toothbrushing. Staff may also consider rotating smaller groups of children at the table to brush their teeth to allow more space between children.  
  • A mask, face shield or goggles, and gloves should be worn by staff during toothbrushing. Gloves should be changed after helping each child brush their teeth.  
  • Children should be encouraged to avoid placing toothbrushes directly on the classroom table or other surfaces. Consider utilizing removable tablecloths or other nonpermeable barriers when children are brushing their teeth at the table.  
  • It is recommended to place the appropriate amount of toothpaste on an individual paper cup or napkin. Staff may then support the child to place the toothpaste on their toothbrush.

 

Supporting Emotional and Behavioral Health of Young Children and Staff

Young children are often resilient and adaptable, as evident by the recent requirement of face masks. There is no evidence that use of face masks interferes with speech and language development, including social communication.t On the other hand, children may have limited ability to communicate their feelings of stress. The COVID-19 pandemic has created new and unfamiliar situations for everyone, and emotions and stress levels may be high for staff, families, and even young children. Young children often communicate feelings such as fear, stress, and anxiety through behavior. Early child care providers may witness increased moodiness, difficulty sleeping, clingy behaviors, focusing difficulties, behavioral outbursts, and aggression or self-aggression. It is important for providers to not take these behaviors personally and to avoid labeling a child for the behavior. Instead providers can seek to understand the behavior, remain calm, and offer comfort. Providers can also build resilience by keeping children engaged, emphasizing the program structure and schedule, encouraging children to be involved and active, scheduling stress-reducing activities such as sensory play, yoga, and music, and providing children with choices when possible to offer a sense of control. Use Child Care Resource and Referral Agencies to help identify early childhood mental health consultants who can help.  

Resources: 
PBS for Parents: 

Supporting Emotional Health of Staff 

Early child care programs should  support the health and wellness of their staff, especially during periods such as this pandemic. Staff with health concerns such as moderate to severe asthma, obesity, chronic obstructive pulmonary disease, and diabetes might be provided options to supporting children and families without increasing their risk of exposure, such as paperwork, virtual classrooms, and follow-up. Alternative tasks can include conducting virtual home visits, data entry, and preparing and serving food in center programs. Staff vaccination status can be factored into these decisions with input from medical professionals. It is important that program directors communicate procedural changes and measures to protect staff regularly. It may also be beneficial to consider engaging staff directly in revising and updating pandemic planning.  

Outdoor Play 

Outdoor play should be encouraged for young children.. Outdoor play equipment should be cleaned between each classroom’s use, and classrooms should practice handwashing before and after outdoor play. See Caring For Our Children 3.1.3.2 for further details. 

Infection Control 

Hand Hygiene  

The goal is to increase hand hygiene as much as possible during this pandemic. Caring for Our Children recommends use of soap and water when possible and when there is visible soiling and use of hand sanitizer is permissible if soap and water is not available. Antibacterial soaps have not been shown to be beneficial and do not prevent SARS-CoV-2 infection. Additionally, they expose children to chemicals that may be harmful. Alcohol-based hand sanitizer is toxic if ingested and must be kept out of reach of small children. Check your local licensing requirements to determine whether hand sanitizers are permissible in early care and education programs.  

Relevant Caring for Our Children Standard: Standard 3.2.2 Hand Sanitizers 

The US Food and Drug Administration is warning consumers and health care providers that the agency has seen a sharp increase in hand sanitizer products that are labeled to contain ethanol (also known as ethyl alcohol) but that have tested positive for methanol contamination. Methanol, or wood alcohol, is a substance that can be toxic when absorbed through the skin or ingested and can be life-threatening when ingested. Providers should check their hand sanitizer products to determine whether a product is on this list of hand sanitizers with potential methanol contamination.  

Resources: 

Cleaning and Disinfecting 

Early childhood programs should be using their existing cleaning and disinfecting procedures as recommended in Caring for Our Children. Staff should be training regularly in proper cleaning and disinfecting procedures. Cleaning can be conducted according to normal procedures at the end of each day or once a toy or equipment becomes soiled with dirt or bodily fluid including saliva. The AAP recommends removing soft, difficult-to-clean toys from the classroom at this time. Classrooms and family child care homes should clean hard, smooth surface toys at the end of the day (if half day or full day) or when a toy is soiled or put in a child’s mouth, etc. There is no need to clean toys every hour or after each play encounter of the same classroom group. Supplies such as crayons, markers, and other material that can be difficult to clean can be individualized in a container labeled with each child’s name. The AAP recommends keeping these difficult-to-clean supplies and toys to a minimum.  

  • Before cleaning and disinfecting, make sure that the area is well ventilated to decrease the risk of exposure to the fumes of the chemicals contained in these products. Chemical fumes may trigger symptoms in people with asthma and allergies.  
  • First, clean surfaces and objects using soap and water to remove dirt and impurities from the surface. If the surface is not cleaned first, the disinfectant is less likely to be effective.  
  • Then, clean the surface (remove dirt and impurities from the surface) before disinfecting to kill the germs.  
    • Most common Environmental Protection Agency (EPA)-registered household disinfectants should be effective for disinfecting program spaces. Refer to List N on the EPA website.  
    • Consider liquids instead of sprays and allow sufficient time after application before exposure to children as methods for keeping these children safe.  
    • Please note, disinfectants may trigger respiratory symptoms in children with reactive airways.  
    • Follow the instructions on the label to ensure safe and effective use of the product.  

Check the label to see if your bleach is intended for disinfection and has a sodium hypochlorite concentration of 5% to 6%. Follow manufacturer’s instructions for application and proper ventilation. Check to ensure the product is not past its expiration date, as the concentration will degrade over time. Never mix household bleach with ammonia or any other cleanser. Some disinfectants also require the extra step of rinsing if the item can/will be “mouthed” or “licked.” Remember that infants/toddlers explore with their mouths. 

It is important to note the contact time needed to disinfect a surface for COVID-19.  

The AAP does not recommend special cleaning services or products. The coronavirus is killed easily with EPA-registered disinfectants and normal disinfecting routines aligned to the standards outlined in Caring for Our Children.  

Read more detailed information on cleaning surfaces safely, properly disinfecting to kill germs, and how to make safer, effective disinfection choices.  

Relevant Caring for Our Children Standards 

 

Masks for Staff and Children

Staff can protect children and each other by being vaccinated, wearing masks, and encouraging children age 2 years and older to wear masks. Programs should ensure staff have access to multiple smocks, masks, gloves, face shields, and other resources throughout the day. Staff should follow normal infectious disease risk protocols including for diapering and washing hands often. It is highly recommended all early care and education providers are fully vaccinated against SARS-CoV-2. It is also recommended that staff continue to wear masks while caring for children. See AAP Face Mask guidance. 

Nearly all children 2 years and older can successfully use masks that securely cover the nose and mouth. The mask must fit appropriately, covering the nose and mouth. There are few valid medical exceptions in which adaptations and alternatives may need to be made on the basis of the needs of the individuals and their diagnosis. For specific examples, please see the CDC website. Practicing, modeling, and using resources like social stories and picture schedules will increase success. 

Children should be encouraged to wear their masks but should not be reprimanded or punished. Early care providers, in partnership with parents, can be a helpful resource to teach children how to wear their masks as well as following other guidelines such as handwashing and physical distancing.  

Because the AAP recommends children younger than the age of 2 years do not wear masks, it may be helpful to reinforce lessons for covering coughs and sneezes. Remind children to “catch their coughs and sneezes in their elbows.” Be prepared to answer children’s questions in a calm, reassuring, developmentally appropriate way. Early care providers can use visual supports such as pictures, create social stories during class time, and use books. There are several games and early learning supports to build this habit.  

The AAP recommends programs keep extra masks in each classroom for staff and children. Masks should be replaced if they become soiled or wet. Children’s masks should be removed for nap time. Masks should be washed at the end of each program day or if they become soiled. The number of washings should not compromise the integrity of the masks. Programs will also need to plan how to store individual masks, such as in a paper bag, separately during nap, meal, and snack times.  

Helpful resources: 

Child care providers can protect themselves by wearing a smock or large button-down, long sleeved shirt and by wearing long hair up off the collar in a ponytail or other updo. 

Cleaning staff should wear disposable gloves and gowns for all tasks in the cleaning process, including handling trash. Gloves and gowns should be compatible with the disinfectant products being used. Gloves and gowns should be removed carefully to avoid contamination of the wearer and the surrounding area. If gowns are not available, coveralls, aprons, or work uniforms can be worn during cleaning and disinfecting. Reusable (washable) clothing should be laundered afterward. Hands should be washed after handling dirty laundry. Gloves should be removed after cleaning a room or area occupied by ill people. Clean hands immediately after gloves are removed. 

Ventilation 

Efficient ventilation taking indoor air outside and bringing fresh air in helps reduce the risk of infection when accompanied with other strategies such as wearing masks and practicing hand hygiene, physical distancing, screening, and cleaning and disinfecting. Programs may contact licensed heating, ventilation, and air conditioning (HVAC) experts to inspect and assess their current systems and advise on how to ensure that ventilation systems operate most effectively. 

Extend the indoor environment to outdoors, bringing the class (or part of a class) outside, weather and air quality permitting. If weather allows, open windows and screen doors. Do not open windows and doors if this creates a safety, supervision, or health risk; for example, creating a fall risk or if there is poor outdoor air quality. 

Although access to fresh air is optimal, there are many other practices recommended for efficient and effective ventilation in the Caring for Our Children Online Standards Database. For additional information on how to prevent environmental exposures in the child care setting, contact the AAP regional Pediatric Environmental Health Specialty Unit (PEHSU).  

Resources: 

 

Special Populations

Caring for Children With Special Health Care Needs (CSHCN)

Supporting Individual Health, Developmental, and Behavioral Needs

Early care and education providers need to communicate regularly with parents about any special health care needs. Families know their children best and can give providers guidance on keeping their children safe, happy, and healthy. Providers can ask families how their child is coping to support any behavioral and emotional needs – if child care providers know what children are struggling most with, they can respond to the child’s behavior with an understanding, nurturing approach and can prevent additional behavior problems. Providers and families will need to be flexible and creative to meet needs, and it is important to empower parents as essential partners who will help the plan succeed and also to be forgiving when things do not work out exactly as planned. 

Individualized health plans should be updated to reflect current COVID-19 pandemic guidance. Early care and education programs must still be prepared to meet dietary needs within the current meal and snack recommendations for group care settings.  

The National Child Traumatic Stress Network STRYDD Center (Supporting Trauma Recovery for Youth with Developmental Disabilities) Long Island Jewish Medical Center, Northwell Health, has created resources to help parents support their child with special needs during this COVID-19 pandemic. Many resources address all children, and some were developed specifically for children with intellectual or developmental disabilities and/or autism spectrum disorder. Resources include: 

  • An Overview Guide 
  • Expert Advice and General Resources 
  • Tools for Helping Children Cope 
  • Access to Internet, Health, Education and Other Special Needs Services  
  • Tools for Maintaining Skills and Behavior 
  • Activities for Learning and Fun 

The set of resources is available at COVID-19 Resources for Parents of Children with Intellectual or Other Developmental Disabilities 

Resources: 

The CDC guidance notes that children with medical complexity, with genetic, neurologic, or metabolic conditions, or with congenital heart disease might be at increased risk for severe illness from COVID-19. Similar to adults, children with obesity, diabetes, moderate to severe asthma and chronic lung disease, sickle cell disease, or immunosuppression might also be at increased risk for severe illness from COVID-19. Early education providers should be in regular communication with the child’s family and pediatrician to determine individual risk and infection protection controls as vaccination rates increase. Decisions about whether CSHCN should attend child care are complex and multifaceted and should be addressed through shared decision making with the child’s parents/caregivers and health care providers. Many CSHCN might be more vulnerable to COVID-19, but there are still many unknowns.  

Mobility Limitations 

Some children with special health care needs require more hands-on contact because of their condition. Depending on a child’s specific needs, more hands-on care may be required for tasks of daily living such as feeding, safe mobility, redirection, and/or learning tasks. Early child care providers should continue to provide appropriate care that children with special needs require.  

Enhanced hand washing should be performed. The same risk mitigation strategies for staff should also be followed, including diligent hand washing, face masks, and cleaning procedures. A face shield in addition to a face mask may also add to staff protection. Coordinate with providers ahead of time when appropriate (early intervention providers, speech therapists, occupational therapists, behavior therapists).  

Special Considerations for Drop-off/Pick-up  

Early care programs should plan for any special needs at drop-off/pick-up such as special equipment (for example, walkers, wheelchairs), communication devices, and extra supervision for children who might elope. Engaging with families at drop-off/pick-up might be more challenging because of distancing requirements. 

Programs should consider the following: 

  • Developing a written plan for substitute caregivers from home and school.  
  • Developing a daily communication plan with families of children with special needs, especially for children with communication skill impairment. 
  • Creating a social story about new processes, including daily health screening can be especially helpful.  

Children With Asthma 

Asthma action plans should also be updated at this time. As before the pandemic, controlling asthma triggers is vital to maintaining health. Inhaled medications should be provided through use of an inhaler rather than a nebulizer to minimize aerosolization, and the asthma action plan should be updated accordingly. Programs should obtain proper medication and spacers from the family before the child returns to care. Metered dose inhalers (MDIs) with a spacer are recommended as the safest means to deliver acute medications such as albuterol. MDIs have been shown to deliver medication as effectively as nebulizer treatments in children of all ages. Experts continue to review emerging data as to whether aerosols generated by nebulizer treatments are potentially infectious. During the COVID-19 pandemic, use of nebulizer machines is discouraged.  

If the child develops asthma symptoms while in child care: 

  • Use an MDI with a spacer and mask or mouthpiece as recommended in the child’s Individualized Health Plan. 
  • Call 911/emergency medical services if the child is having difficulty breathing. Give a treatment with an MDI after calling 911. 
  • Call parent/caregivers to pick up the child if the medical condition is stable. 

Make sure families are prepared with needed medications and medical supplies and encourage them to contact their health care provider and/or pharmacy for help if concerns with supplies arise.  

Decisions about balancing the benefits of outdoor play with considerations of air quality might need to be made. Cleaning products should be as hypoallergenic as possible. 

Resources: 

Caring for Infants and Young Toddlers

Appropriate care for infants and young toddlers requires more direct contact to maintain safe, stable, and nurturing relationships. Staff caring for infants should continue to provide developmentally appropriate care for infants. Infants should still be held while fed, comforted, and cleaned appropriately.

Staff can protect infants and toddlers by getting vaccinated, wearing masks and encouraging children over the age of 2 to wear masks, as well as changing smocks or clothes when they become soiled with bodily fluid. Programs should ensure staff have access to multiple smocks, face masks, and other resources throughout the day.

Staff should follow normal infectious disease risk protocols including for diapering and washing hands often. Staff caring for infants may also consider face shields in addition to face masks. Droplets from spit or drool may enter the eye to contribute to infection, and although less common than inhalation, it can still occur, so face shields can offer additional protections. Face shields should not replace masks, because shields are open at the bottom, allowing droplets to enter and exit.

Extended Hours and After-School Care

Child care providers might be engaged to provide extended hours and after-school care as part of their regular services. It is important to keep possible exposure to other children and staff to a minimum. The AAP recommends creating a cohort of after-school children similar to classrooms of younger children. Do not mix children from schools with younger children served during the day. Consider creating cohorts of children who need extended hours rather than bringing these children together from different classrooms. The same precautions related to masks, cleaning and disinfecting, and health screenings should be followed. Consultation with school nurses, if available, can be helpful especially for children with special health care needs.

 

Special Considerations for Family Child Care

Family child care has served an important role during the COVID-19 pandemic as many families looked to providers who could care for their children in smaller home settings. However, family child care providers often provide care and services differently than center-based programs. A few special considerations for the family child care provider include: 

  • Keeping or limiting other family members from interacting within the dedicated space for care: family child care providers care for children within their home environment, so this may increase exposure if family members and other adults interact within the home care environment. The AAP recommends keeping this space separate from the remaining household. The family child care provider can clean and disinfect the early child care space at the end of each day and restrict access to other family members to reduce possible exposure.  
  • Preparing and serving meals: In center-based programs, food preparation should not be performed by the same staff who diaper children. However, this is rarely possible in family child care. Family child care providers should remember their existing meal preparation guidelines to: 
    • Wash hands before preparing food and after helping children to eat. 
    • Sanitize food surfaces before eating. 
    • Help children wash hands prior to and after eating meals. 
    • Wear gloves when serving food 

 

Additional Information 

A professional, trained child care workforce is vital for supporting healthy child development and learning. It is encouraged for child care providers to seek training and technical assistance through the National Center on Health, Behavioral Health, and Safety. 

The AAP offers Pedialink courses for early care and education providers:  


Interim Guidance Disclaimer: The COVID-19 clinical interim guidance provided here has been updated based on current evidence and information available at the time of publishing. Guidance will be regularly reviewed with regards to the evolving nature of the pandemic and emerging evidence. All interim guidance will be presumed to expire on June 30, 2023 unless otherwise specified.

Last Updated

08/30/2021

Source

American Academy of Pediatrics