Amendment of Child Care Programs and Family Shelter-Based Drop-off Child Supervision Programs (Article 47 of the NYC Health Code)

Proposed Rules: Closed to Comments (View Public Comments Received:18)

Comment By: 
Wednesday, April 18, 2018
Download Copy of Proposed Rule (.pdf): 

Statement of Basis and Purpose


 Article 47 of the Health Code governs center-based child care. The Department proposes to clarify the Article’s requirements by simplifying terminology and reorganizing certain provisions, and to add requirements for tooth brushing, maintaining epinephrine auto-injectors on site, and for training of staff. The basis for the proposed changes is set forth below.

Clarifying Requirements    

The Department proposes several amendments to clarify requirements and facilitate compliance. For example, the proposed clarifying changes include adding definitions for “certified group teacher” and “corporal punishment,” and adding details to current definitions, including for “assistant teacher” and “education director.”

Currently, the Code requires that documentation be provided under certain provisions but not under others. The proposed changes create uniformity and enable the Department to effectively evaluate compliance with documentation requirements.

The Department is also proposing to add specificity to certain requirements, such as those regarding program capacity, supervision, and response to medical emergencies.  

Tooth Brushing

The Department is proposing to mandate that child care programs and family shelter-based child supervision programs assist children aged two or older with brushing their teeth at least once each day. Tooth decay (caries) is the most common chronic childhood disease. Consequences of early childhood caries include a higher risk of developing additional caries in both primary and permanent teeth,[1] difficulty eating and speaking,[2] increased hospitalizations and emergency room visits[3] and greater risk for delayed physical growth and development.[4] National data show that nearly one in four preschool-age children has had caries.[5] The Department’s 2014 Child Dental Health Survey (CDHS) found that at least 15 percent[6] of children in New York City child care programs had experienced caries and 45 percent of children consumed between-meal sugary snacks or sugary drinks four or more times a day, a major risk factor for caries. Caries prevalence increases as children get older, with 42 percent of third grade children having experiencing caries.[7]

Caries is a preventable disease. Relatively simple measures such as tooth brushing can significantly reduce risk. The American Dental Association recommends that tooth brushing twice per day begin at the eruption of a child’s first tooth. Despite the established benefits of tooth brushing, the oral hygiene practices of young children in New York City remain inadequate.  According to the CDHS[8], among those surveyed, 40 percent of children aged 0 to 6 years brushed their teeth only once a day or less frequently, and 45 percent of children ages 0 to 2 years did not use fluoride toothpaste. 

Requiring tooth brushing while in child care or child supervision programs will promote tooth brushing and help prevent caries. CDHS findings indicate that children with at least one tooth who are enrolled in Early Learn centers—which are required under the federal Head Start program to have a daily tooth brushing routine—are two and a half times as likely to brush their teeth the recommended two or more times per day than children in other programs. Including tooth brushing requirements in Article 47 will set children up for a lifetime of good oral hygiene practices.

Epinephrine Auto-Injectors

The Centers for Disease Control and Prevention estimates that four to six percent of children nationally have a food allergy; such food allergies include ones that are life-threatening. Rapid administration of an epinephrine auto-injector following a life-threatening allergen exposure is critical to preventing significant negative outcomes, including death. Having epinephrine auto-injectors on the premises at all times can save the lives of children with life-threatening food allergies who do not bring an epinephrine auto-injector with them to child care or shelter-base child supervision programs, and of children who have life-threatening food allergies identified for the first time while the child is in such programs.

In 2016, the New York State Public Health Law was amended[9] to allow certain entities, including child care providers, to obtain non-patient specific epinephrine auto-injectors and to administer them in an emergency. This new State law creates the opportunity for such programs to have this critical, lifesaving medication available. Accordingly, the Department is proposing to add a mandate that child care and child supervision programs maintain on site at least two unexpired epinephrine auto-injectors in each dosage appropriate for children who may be in the program, stored so they are easily accessible to staff and inaccessible to children. Programs would be required to have at least one staff person on site, whenever children are present, trained to recognize signs and symptoms of anaphylactic shock and to administer epinephrine as appropriate. The proposal also requires the program to monitor the auto-injectors’ expiration dates and call 911 after any administration, as required by the medication directions. Programs would be mandated to obtain parental consent at the time the child is enrolled in the program. All staff would be required to be trained in preventing and responding to emergencies related to food allergies.

Training requirements

The Department is proposing to expand staff training requirements to promote high quality learning environments, enhance child health and safety, and align with the health and safety training requirements in the federal Child Care Development Block Grant (CCDBG) Act of 2014, which apply to any program enrolling a child whose enrollment is paid for by CCDBG subsidies.

First, the Department is proposing to require that trainings currently required only for assistant teachers be mandated for all teaching staff. These core trainings address fundamental issues including preventing, recognizing signs and reporting injuries, infectious disease, lead poisoning and asthma; scheduling and conducting guided and structured physical activity; and childhood growth and development.

The Board’s authority to codify these proposed amendments is found in Sections, 556, 558, and 1043 of the New York City Charter (the “Charter”). Sections 558(b) and (c) of the Charter empower the Board to amend the Health Code and to include all matters to which the Department’s authority extends. Section 556 of the Charter provides the Department with jurisdiction to protect and promote the health of all persons in the City of New York. Section 1043 grants the Department rule-making authority.

[1] Al-Shalan TA, Erickson PR, Hardie NA. Primary incisor decay before age 4 as a risk factor for future dental caries. Pediatr Dent 1997;19(1):37-41.

[2] American Academy on Pediatric Dentistry; Policy on early childhood caries (ECC): classifications, consequences, and preventive strategies. Pediatr Dent. 2008-2009;30 (7 Suppl):40-3.

[3] Ladrillo TE, Hobdell MH, Caviness C. Increasing prevalence of emergency department visits for pediatric dental care 1997-2001. J Am Dent Assoc 2006;137(3):379-85.

[4] Acs G, Lodolini G, Kaminsky S, Cisneros GJ. Effect of nursing caries on body weight in a pediatric population. Pediatr Dent 1992;14(5):302-5.

[5] Dye BA, Thornton-Evans G, Li X, Iafolla TJ. Dental caries and sealant prevalence in children and adolescents in the United States, 2011–2012. NCHS data brief, no 191. Hyattsville, MD: National Center for Health Statistics. 2015.

[6] This is likely underreported as it is self-reported information and children may have had undiagnosed caries (of which parents were unaware) when parents responded to the survey.

[7] New York State Department of Health Third Grade Survey.

[8]DOHMH’s Oral Health Program conducted a survey to determine risk and protective behaviors for tooth decay among children in New York City group daycare centers. Over 1,800 parents and caregivers from 67 daycare centers reported risk and protective behaviors for tooth decay of their children and themselves.

[9] NYS Public Health §3000-C. Epinephrine Auto-injector devices. Effective March 28, 2017.

Public Hearing

Proposed Amendment to Child Care Programs and Family Shelter-Based Drop-off Child Supervision Programs (Article 47 of the NYC Health Code) to promote the health and safety of children under six years old attending child care programs or family shelter-based drop-off child supervision programs.

Public Hearing Date: 
Wednesday, April 18, 2018 - 10:00am

Svetlana Burdeynik, (347) 396-6078,

New York City Department of Health and Mental Hygiene, Gotham Center
42-09 28th Street, 3rd Floor, Room 3-32
Queens, NY 11101