Standards for child and youth development programs

2020 Edition

Early Childhood Education (CYD-ECE) 4: Health

The program promotes and protects the health of children and staff.




Early Childhood Education facilitates appropriate child development and ensures the health and safety of children in care.

The research identifies health promotion as a key indicator of quality and a strong predictor of positive outcomes.

The program’s practices fully meet the standard, as indicated by full implementation of the practices outlined in the Practice Standards.
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards.
Practice requires significant improvement, as noted in the ratings for the Practice Standards.
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Procedures for reporting, responding to and recording health problems and injuries (CYD-ECE 4.03)
  • Procedures for tuberculosis testing, if applicable (CYD-ECE 4.14)
  • Health policy/procedures provided to parents (CYD-ECE 4.02)
  • Accident, injury, and illness reports
  • Sample menus for meals and snacks
  • Agreement with a health facility or qualified medical professional
  • Smoking policy (CYD-ECE 4.13)
  • Interview:
    1. Program director
    2. Relevant staff
  • Review teaching staff personnel records for documentation of health screening
  • Review childrens health records
  • Observe facility

Fundamental Practice

CYD-ECE 4.01

A health record is maintained for each child that includes:

  1. verification of up-to-date, preventative screenings;
  2. evidence of up-to-date immunizations as required by applicable law or regulation;
  3. emergency contact information that is kept current and updated at least once a year;
  4. written parental authorization for emergency care;
  5. information about and consent forms related to special needs, including medical needs, if applicable, updated at least annually; and
  6. an acknowledgment form, signed by the program director or a designee, which states that information has been received about the child’s health needs and allergies, and specifies the program’s role in carrying out any related care or treatment.
Related Standards:


Emergency contact information includes the names of the family physician, clinic, or hospital to be used in emergencies.  When a child has allergies or health issues, the acknowledgment form must include specific information regarding the allergy such as which foods or materials the child cannot eat or come in contact with, and any activities in which the child cannot participate.

Fundamental Practice

CYD-ECE 4.02

All parents receive a written health policy and procedures that address:

  1. the process for determining whether or not the program can handle a child’s specific health  needs;
  2. attendance guidelines for sick children, including separation from other children; and
  3. procedures for notifying parents that their child may have been exposed to an infectious disease.

Fundamental Practice

CYD-ECE 4.03

Child health problems and injuries, including changes in appearance or behavior, are promptly recorded and reported to parents and administration, and follow-up is conducted as needed.

Fundamental Practice

CYD-ECE 4.04

Procedures for regularly cleaning and sanitizing the classroom limit the spread of infection and include:

  1. daily cleaning of the facility;
  2. disinfecting bedding, beds, cots, cribs, and mats at least once a week and between use by different children; and
  3. disinfecting toys and other materials at least weekly and immediately after use if items are placed in the child’s mouth.

Fundamental Practice

CYD-ECE 4.05

To limit the spread of infection, diaper changing areas:

  1. are separate from food preparation areas;
  2. have a posted copy of diaper changing procedures;
  3. utilize changing tables made of non-porous material; and
  4. include covered, plastic-lined, hands-free cans for the disposal of used diapers.

Fundamental Practice

CYD-ECE 4.06

Diapering procedures meet nationally recognized guidelines for sanitary diapering practices, and include:

  1. that children are never to be left unattended on changing tables and that one hand must be on the child at all times;
  2. proper disposal of diapers and other contaminated items;
  3. proper use of gloves when they are offered to teaching staff;
  4. steps for gathering materials ahead of time;
  5. relevant hand-washing requirements; and
  6. steps for disinfecting the area after each use.

Note: Implementing element (a) of this standard also promotes safety, which is covered in CYD-ECE 5.

The 2nd Edition of Caring for Our Children, which is a joint partnership of the American Academy of Pediatrics, the American Public Health Association, and the National Resource Center for Health and Safety in Child Care, offers detailed diaper changing procedures that programs may find useful when developing their own diapering practices.

Fundamental Practice

CYD-ECE 4.07

Hand washing areas are designed to limit the spread of infection by:

  1. separating hand-washing sinks from food preparation sinks;
  2. making hand washing sinks easily accessible to all children; and
  3. having liquid soap and sanitary methods for drying off hands available.


Sanitary methods for drying off hands include disposable paper towels or electric dryers that turn on and off automatically.

Fundamental Practice

CYD-ECE 4.08

Hand washing procedures meet nationally recognized guidelines for hand washing and include:

  1. under what situations hands must be washed;
  2. requirements for water temperature, soap use, and time spent scrubbing and rinsing; and
  3. procedures for turning off water that reduce the risk of recontamination.

The 2nd Edition of Caring for Our Children, which is a joint partnership of the American Academy of Pediatrics, the American Public Health Association, and the National Resource Center for Health and Safety in Child Care, has hand washing procedures that programs may find useful when developing their own hand washing practices.


CYD-ECE 4.09

Teaching staff promote good health habits by:

  1. modeling and providing developmentally-appropriate instruction on health and hygiene practices;
  2. serving nutritious meals and snacks; and
  3. providing opportunities for active play.


Examples of health and hygiene practices include, but are not limited to:

  1. washing hands before and after eating;
  2. washing hands after using the bathroom; 
  3. covering the nose and mouth when sneezing or coughing; and
  4. regular tooth brushing. 


Active play for infants may include “tummy time,” allowing infants to develop the muscles of their back and neck.

Research has shown that healthy eating habits and active lifestyles are established in infancy.

Fundamental Practice

CYD-ECE 4.10

Children are protected from injuries, accidents, and illnesses through practices that ensure teaching staff:

  1. follow universal precautions as well as diapering, hand washing, and sanitation procedures;
  2. notify parents in case of emergencies or when safety issues arise;
  3. identify and report suspected child abuse and neglect to prescribed authorities;
  4. have access to poison control information and first aid supplies and manuals both on- and off-site;
  5. are informed about children in their care with special medical needs or allergies; and
  6. are healthy and capable of performing the essential functions of the job with reasonable accommodation.


Regarding element (a), the program should ensure that it complies with any applicable legal and regulatory requirements regarding risk of exposure to contagious and infectious disease.  COA recommends that programs consult with local health authorities or a qualified professional about how to minimize the risk of contagious and infectious diseases to program personnel and participants, which may include voluntary adherence to CDC guidelines.

Regarding element (f), while an annual physical examination is preferred, teaching staff may receive a general health screening performed by a qualified medical practitioner, provided the screening addresses communicable diseases, including tuberculosis when required by relevant health authorities.  See CYD-ECE 4.14 for more information regarding the applicability of tuberculosis testing.

Note: See CYD-ECE 5.06 for additional information regarding practices designed to promote emergency response preparedness.

Fundamental Practice

CYD-ECE 4.11

Bottles of breast milk and formula are:

  1. labeled with the child’s full name and the date that it was brought in;
  2. brought in daily and stored in a refrigerator upon arrival;
  3. discarded if the bottle is not finished in one feeding; and
  4. warmed in water and never in a microwave oven.


Breast milk or formula should not stored overnight by the child care center.  Bottles that are unused at the end of the day should be sent home with the parent.

Fundamental Practice

CYD-ECE 4.12

The facility provides an optimal care and learning environment that is:

  1. clean;
  2. welcoming;
  3. well lit, with natural light where possible;
  4. maintained at a safe, comfortable temperature and noise level;
  5. odor free; and
  6. adequately ventilated.

Fundamental Practice

CYD-ECE 4.13

Smoking is prohibited anywhere on the premises, including outside entrances, outdoor play areas and program vehicles.

Fundamental Practice

CYD-ECE 4.14

The program implements a targeted tuberculosis testing program for personnel who are in direct contact with children, as appropriate given the identified service population and as required by law or regulation.


Local and state public health authorities should be a program’s primary source of information when determining if there is a need to implement a targeted testing program among its staff.  Local public health authorities have access to epidemiological data analysis, guidance from national authorities, and local rates of TB infection, which will help programs assess the risk for TB.  Programs should consult annually with their local health department for any new information or changes in the local population that might affect the risk of TB.

NA The program does not serve high risk groups and is not required by law to conduct TB testing.

The Centers for Disease Control and Prevention discourages TB testing among individuals with a low risk for developing tuberculosis because it utilizes resources that should be maintained for populations at greater risk of infection and increases the prevalence of false positives.  Mandated skin-testing programs should be avoided unless a large percentage of the program population is defined as “high risk” by local authorities.


CYD-ECE 4.15

A health facility or qualified medical professional is available to provide:

  1. medical consultation to the program and parents;
  2. a review of children’s health needs; and
  3. a review of the program’s health and safety practices.


The intent of this standard is not to require that programs pay for this service, but to ensure they have access to medical professionals as needed.  Some programs, particularly those that serve a higher risk population, might have medical professionals on staff; others will develop formal or informal relationships with medical professionals outside the program to receive assistance when special health needs arise.  Some programs may also find it beneficial to consult with health professionals when developing procedures for minimizing the risk of contagious and infectious diseases, or responding to situations such as accidents and medical emergencies, in order to ensure that their procedures are sufficient and appropriate.

Note: Implementing element (c) of this standard also promotes safety, which is covered in CYD-ECE 5.

The literature identifies physical health as one predictor of future academic success.  As such, programs should consider each child’s physical health and well-being when making program decisions.