Child Care Services (Article 47) - Improving supervision of children
Proposed Rules: Closed to Comments (View Public Comments Received:4)
Statement of Basis and Purpose
These amendments to the New York City Health Code (the Health Code) are promulgated pursuant to §§558 and 1043 of the New York City Charter (the Charter). Sections 558(b) and (c) of the Charter empower the Board of Health (the Board) to amend the Health Code and to include in the Health Code all matters to which the authority of the New York City Department of Health and Mental Hygiene (the Department) extends. Section 1043 grants the Department rule-making authority.
The Charter provides the Department with jurisdiction over all matters concerning health in the City of New York. The Department’s Division of Environmental Health includes the Bureau of Child Care, which issues permits to non-residential based child care services in accordance with Article 47 of the Health Code, and which regulates school based programs for children aged 3-5 in accordance with Article 43 of the Health Code. Child care providers who provide child care services in homes or apartments are regulated by the State Office of Children and Family Services, and are not subject to either Article 43 or Article 47.
The Department is proposing that the Board amend multiple provisions of Article 47 of the Health Code in order to improve supervision of children in child care services regulated by Article 47.
Promoting accountability for children’s whereabouts
The Department is proposing that the Board amend the Health Code to enhance child safety within child care services. The proposed amendments strengthen the requirements to account for a child’s whereabouts at all times while in care, when children are transported to and from the child care services or during off-site trips, and when children arrive and depart from the child care service. The Department has, on occasion, been notified by child care service permittees, the police, and parents that children have gone missing for a period of time during the child care day. These incidents may have occurred because a child exited the service unobserved by staff, was left on transportation vehicles, or was left in a playground or at another off-site trip location. Additionally, at least one child was discharged to an adult who did not have authority to take the child from the child care service. Though no child was harmed, these incidents are troubling and reflect a need for stronger procedures to monitor the whereabouts of children.
The Department has issued guidelines and provided training to assist child care services account for all of the children under their care at all times. When the Department learns that a child care service has been unable to account for a child for any period of time, the Department orders the service to cease operation. Only after the child care service demonstrates that it has determined why the incident happened and that it has instituted concrete measures to prevent it from happening again does the Department authorize it to reopen.
To help child care services implement systems designed to prevent these incidents, the Department is proposing to amend Article 47 of the Health Code. The amendments reflect best practices already in place at many child care services. They would be required at all establishments if approved.
- Written safety plan: Amend §47.11 to add procedural requirements that promote child safety in child care services, establish accountability so that child care services permittees know and can document where any child is at any given time, particularly when children arrive and leave the child care service, whether they are taken on trips offsite, on foot or by other means, or are leaving the service at the end of the day.
- Criminal justice and child abuse screening: Amend §47.19 to add screening with the State Registry for Child Abuse and Maltreatment (SCR) and for criminal history for personnel of child transportation services under contract to a child care service. The current provision requires screening for school bus drivers and all other staff employed by the permitted child care service, but not for personnel employed by transportation services operating under contract with a permittee. This provision would explicitly exclude from screening persons providing transportation arranged by parents.
- Health; daily requirements; communicable diseases: Amend §47.27(a), (c) and (d) to require that permittees maintain child attendance records and obtain earlier parental notifications of absences to promote greater accountability for children. This provision currently requires parents to contact permittees after their children are absent for three days in order to capture information about children who may have contracted certain communicable diseases. The Department is proposing that this be changed to require the parent to notify the child care service the same day when a child will not attend on a scheduled day to promote better accountability for children and more rapid investigation of children who fail to show up at the child care service and who may have been lost.
- Indoor physical facilities: Amend §47.41 to add new subdivisions (k) and (l) to require monitoring of entrances and exits and establishing other security measures. The Department has found that the majority of incidents demonstrating poor child accountability reported between 2008 to 2013 occurred when children wandered out of the child care service entrance door, alone or with another child and that child’s parent, or were left at an off-site location. In some cases, children left the child care service unaccompanied because they were able to open the front door by themselves, even though that door was closed. Locking a means of egress, however, is not permitted under the New York City Fire Code. In order to secure the door in a manner that prevents a child from exiting while also maintaining emergency access, the Department is proposing that the child care service be required to install a panic bar on all doors that lead to the outside. Panic bars allow adults to easily open a door but are too high or require too much force for young children. To allow time to comply this provision will become effective May 1, 2016.
- Safety; general requirements: Amend §47.57 to establish requirements for adults escorting children out of the child care service and for enhanced off-site trip supervision, since such trips present a substantive risk of children being left behind. From 2008 to 2013, incidents of inadequate child supervision occurred when children left child care services with adults who were not authorized by parents to take them out of the child care service or when children were left at playgrounds, parks or on other offsite trips. The Department proposes that the Board amend subdivision (h) of this section to require that permittees maintain information on all adults authorized by parents to take children out of a child care service and add a new subdivision (j) to require that the permittee appoint a staff member as a trip coordinator who will be responsible for assessing supervision needs, developing guidelines and procedures for when additional staff or volunteers should accompany children on off-site trips, and incorporate those procedures in the written safety plan. Trip coordinators would also be required to accompany children on offsite trips to improve accountability and lower the risk of leaving children unsupervised.
- Transportation: Amend §47.65 to clarify parental consent requirements and add new procedures for verifying children’s attendance and identity during transportation. Several incidents of poor accountability have involved children who were left on a vehicle, dropped off at the wrong child care service or at a closed child care service, or simply left outside the child care service unsupervised.
Imminent or public health hazards
The Department is requesting that the Board amend the list of imminent or public health hazards in the definition in §47.01(k) to modify paragraph (10) to specify that use of a pillow by a child younger than two years of age is a public health hazard; and to delete paragraph (13), which addresses holding potentially hazardous foods out of temperature. Children can safely use pillows after age two. The amendment to §47.01(k)(10) is intended to update the current definition of a public health hazard to incorporate the prohibition of pillows in infants’ sleep environments as required by the safe sleep practices of the National Resource Center for Health and Safety in Child Care and Early Education Guidelines for Early Care and Education Programs.[i] Additionally, the Department is proposing that the Board amend §47.55(b)(4) and (7) to allow pillows to be used by children two years of age or older and to require that when pillows are used they be stored with each child’s other bedding. In addition, the Department is requesting that the Board delete paragraph (13) of §47.01(k), because requirements for holding food are addressed in more detail in Article 81, which is also applicable to child care services.
Health Code §47.25(d) requires that permittees maintain a cumulative, comprehensive medical record for each child. Section 47.33 requires that permittees also maintain staff physical examination certificates and vaccination records. The Department is requesting that the Board amend these provisions to clarify that comprehensive medical records of children and staff must be kept on the premises and made available to the Department upon request. Frequently, Department Early Childhood Educational Consultants who are conducting inspections are told that these records are not immediately available for review.
Currently, Health Code §47.59(a) only requires that exit signs at child care services be clear and legible “when required by Department of Buildings.” New York City Building Code §BC-1011 requires that all facilities housing child care services (occupancy use group E) have exit signs that are illuminated internally or externally. Accordingly, the Department is requesting that the Board amend this section to reflect current Building Code requirements.
Nutrition and physical activity updates
The Department proposes that the Board of Health amend §47.61(b) of the Health Code to update requirements limiting children’s juice consumption and §47.71(a) and (d) to further restrict sedentary time and television viewing.
Dietary and lifestyle habits and preferences developed at a very early age can often persist and may have a profound impact on an individual’s health later in life. Among preschoolers enrolled in the Women, Infants and Children program in NYC in 2011, 14.5% of 3 year olds and 16.9% of 4 year olds were obese.[ii] Obese children are more likely than normal-weight children to have risk factors for heart disease,[iii] type 2 diabetes,[iv]and many other disorders and conditions.[v] Obese children are more likely to become obese adults,[vi],[vii]and obesity in adulthood is associated with serious diseases and conditions, and with higher rates of death.[viii] Consequently, it is important to optimize the nutritional quality of the food and beverage offerings in early childhood settings and employ practices that serve to cultivate healthy lifestyle habits. The amendment is intended to update the current requirements for juice, sedentary time and screen time based on current expert recommendations and the best available evidence.
Currently Health Code §47.61(b) authorizes child care services to provide children over the age of eight months up to six fluid ounces of 100% juice per day. The proposed amendment will increase the age that 100% juice is permitted to 2 years of age, and reduce the amount of 100% juice that may be served to four ounces per day.
This amendment would make the Health Code provision consistent with current standards of the federal Child and Adult Care Food Program (CACFP), allowing four ounces of 100% juice per day for children ages 2 – 5 years old.[ix] Numerous health organizations including the United States Department of Agriculture (USDA)[x], the Institute of Medicine (IOM)[xi], the American Heart Association (AHA)[xii] and the American Academy of Pediatrics (AAP)[xiii] recommend limiting children’s intake of 100% juice. When consumed in moderation, 100% juice can be a healthy beverage; however, the USDA recommends that the majority of a child’s recommended fruit servings should come from whole fruit.[xiv] Despite this recommendation, current data suggest that 100% juice overconsumption by young children is commonplace. Daily per capita caloric intake from 100% fruit juice is increasing among children, including toddlers, and children who consume juice typically consume quantities that far exceed the cited recommendations.[xv],[xvi] A 2002 study of the sources of energy among over 3,000 infants and toddlers demonstrated that 100% fruit juice was the second largest source of energy among toddlers ages 12-24 months and the fourth largest source of energy among infants 4 to 5 months old.[xvii] Despite being offered 100% juice in small quantities, it is likely that children consume juice in multiple settings and at multiple occasions throughout the day, causing overall daily consumption to be above recommended levels. Water and low-fat milk are the healthiest beverages for children over 2 years of age.[xviii]
- Television viewing
Currently Health Code §47.71(d) prohibits screen time for children under 2 years of age and requires that screen time for children 2 years of age and older be restricted to 60 minutes per day of programming that is educational or actively engages children in movement. The proposed amendment would further limit the amount of screen time for children 2 years and older to no more than 30 minutes per week.
Research suggests that more than 80% of children ages 6 months to 6 years are exposed to some type of screen-based media on a typical day,[xix] and caregivers report that preschool age children spend 2 to 3 hours per day on screen time,[xx],[xxi],[xxii]which exceeds recommended levels of screen time exposure. [xxiii] Surveys reveal that child care centers vary widely in the average amount of screen time provided, from small amounts or none at all[xxiv],[xxv],[xxvi] to 1 or more hours per day.[xxvii],[xxviii]Studies have found that increased screen time exposure in early childhood is related to risk of obesity later in childhood[xxix],[xxx],[xxxi],[xxxii],[xxxiii] and even into adulthood.[xxxiv],[xxxv],[xxxvi] In recognition that children are exposed to screen time in various settings throughout the day, the AAP, American Public Health Association (APHA), and National Resource Center for Health and Safety in Child Care and Early Education Guidelines for Early Care and Education Programs, the First Lady’s Let’s Move initiative, and the USDA Provider Handbook for the Child and Adult Care Food Program recommend that early care settings limit screen time to 30 minutes per week.[xxxvii],[xxxviii],[xxxix]
- Sedentary time
Currently Health Code §47.71(a) requires that children not be allowed to remain sedentary or to sit passively for more than 60 minutes continuously, except during scheduled rest or naptime. The proposed amendment would reduce the amount of sedentary time to no more than 30 minutes continuously except during scheduled rest or naptime.
In an effort to combat early childhood obesity, the IOM recommends that child care providers and early childhood educators implement activities for toddlers and preschoolers that limit passively sitting or standing to no more than 30 minutes at a time.[xl] Limiting time spent on sedentary activities is important, as sedentary activities may take the place of time spent being physically active or otherwise actively engaged. Studies show that children spend a significant amount of time being sedentary in preschool and child care settings[xli],[xlii],[xliii] and that sedentary activities, such as television viewing, may be linked to increased BMI and adiposity in children.[xliv],[xlv]
[i] American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education. 2011. Caring for our children: National health and safety performance standards; Guidelines for early care and education programs. 3rd edition. Elk Grove Village, IL: American Academy of Pediatrics; Washington, DC: American Public Health Association. Also available at http://nrckids.org.
[ii] Centers for Disease Control and Prevention. Obesity prevalence among low-income, preschool-aged children — New York City and Los Angeles County, 2003–2011. MMWR 2013;62(2):17-22.
[iii] Freedman DS, Mei Z, Srinivasan SR, Berenson GS, Dietz WH. Cardiovascular risk factors and excess adiposity among overweight children and adolescents: The Bogalusa Heart Study. J Pediatr. 2007;150:12-17.e2.
[iv] Hannon TS, Rao G, Arslanian SA. Childhood obesity and type 2 diabetes mellitus. Pediatrics. 2005;116:473-480.
[v] Han JC, Lawlor DA, Kimm SY. Childhood obesity. Lancet. 2010;375:1737-1748.
[vi] Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med. 1997;37:869-873.
[vii] Serdula MK, Ivery D, Coates RJ, Freedman DS. Williamson DF, Byers T. Do obese children become obese adults? A review of the literature. Prev Med. 1993;22:167-177.
[viii] National Institutes of Health. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: the Evidence Report. Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services; 1998.
[ix] New York State Department of Health, Child and Adult Care Food Program. Healthy Child Meal Pattern. March 2012. Available at: https://www.health.ny.gov/prevention/nutrition/cacfp/docs/cacfp-102.pdf. Accessed April 21, 2014.
[x] U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th Edition, Washington, DC: U.S. Government Printing Office, December 2010.
[xi] Institute of Medicine (IOM). 2011. Early childhood obesity prevention policies. Washington, DC: The National Academies Press.
[xii] Gidding SS, et al; AHA; AAP. Dietary recommendations for children and adolescents: a guide for practitioners: consensus statement from the AHA. Circulation. 2005 Sep 27;112(13):2061-75.
[xiii] Committee on Nutrition. American Academy of Pediatrics: The use and misuse of fruit juice in pediatrics. Pediatrics. 2001 May;107(5):1210-3. Reaffirmed August 2013.
[xiv] U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th Edition, Washington, DC: U.S. Government Printing Office, December 2010.
[xv] Wang YC, Bleich SN, Gortmaker SL. Increasing caloric contribution from sugar-sweetened beverages and 100% fruit juices among US children and adolescents, 1988-2004. Pediatrics 2008;121(6):e1604-e1614.
[xvi] Fulgoni VL, Quann EE. National trends in beverage consumption in children from birth to 5 years: analysis of NHANES across three decades. Nutr J 2012;11:92.
[xvii] Fox MK, Reidy K, Novak T, Ziegler P. Sources of energy and nutrients in the diets of infants. J Am Diet Assoc. 2006;106(1, suppl 1):S28-S42.
[xviii] Beverages Let’s Move Childcare. Available at: http://www.healthykidshealthyfuture.org/content/hkhf/home/nutrition/beve.... Accessed April 22, 2014.
[xix] Rideout V, Hamel E. The media family: electronic media in the lives of infants, toddlers, preschoolers and their parents. The Kaiser Family Foundation; May 2006.
[xx] Rideout V, Hamel E. The media family: electronic media in the lives of infants, toddlers, preschoolers and their parents. The Kaiser Family Foundation; May 2006.
[xxi] Common Sense Media. Zero to eight: children’s media use in America 2013. A Common Sense Media Research Study; Fall 2013.
[xxii] Christakis DA, Ebel BE, Rivara FP, Zimmerman FJ. Television, video, and computer game usage in children under 11 years of age. J Pediatr 2004;145(5):652-6.
[xxiii] American Academy of Pediatrics. Children, adolescents, and the media. Pediatrics 2013;132:958-961.
[xxiv] Christakis DA, Garrison MM, Zimmerman FJ. Television viewing in child care programs: a national survey. Communication Reports 2006;19(2):111-120.
[xxv] Christakis DA, Garrison MM. Preschool-aged children's television viewing in child care settings. Pediatrics 2009;124(6):1627-32.
[xxvi] Tandon PS, Zhou C, Lozano P, Christakis DA. Preschoolers' total daily screen time at home and by type of child care. J Pediatr 2011;158(2):297-300.
[xxvii] Christakis DA, Garrison MM, Zimmerman FJ. Television viewing in child care programs: a national survey. Communication Reports 2006;19(2):111-120.
[xxviii] Christakis DA, Garrison MM. Preschool-aged children's television viewing in child care settings. Pediatrics 2009;124(6):1627-32.
[xxix] Viner RM, Cole TJ. Television viewing in early childhood predicts adult body mass index. J Pediatr 2005;147(4):429-35.
[xxx] Reilly JJ, Armstrong J, Dorosty AR, et al. Early life risk factors for obesity in childhood: cohort study. BMJ 2005;330(7504):1357.
[xxxi] Proctor MH, Moore LL, Gao D, et al. Television viewing and change in body fat from preschool to early adolescence: The Framingham Children's Study. Int J Obes Relat Metab Disord 2003;27(7):827-33.
[xxxii] Danner FW. A national longitudinal study of the association between hours of TV viewing and the trajectory of BMI growth among US children. J Pediatr Psychol 2008;33(10):1100-7.
[xxxiii] Pagani LS, Fitzpatrick C, Barnett TA, Dubow E. Prospective associations between early childhood television exposure and academic, psychosocial, and physical well-being by middle childhood. Arch Pediatr Adolesc Med 2010;164(5):425-31.
[xxxiv] Landhuis C, Poulton R, Welch D, Hancox RJ. Programming obesity and poor fitness: the long-term impact of childhood television. Obesity 2008;16(6):1457-9.
[xxxv] Viner RM, Cole TJ. Television viewing in early childhood predicts adult body mass index. J Pediatr 2005;147(4):429-35.
[xxxvi] Hancox RJ, Milne BJ, Poulton R. Association between child and adolescent television viewing and adult health: a longitudinal birth cohort study. Lancet 2004;364:257-261
[xxxvii] American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education. 2011. Caring for our children: National health and safety performance standards; Guidelines for early care and education programs, 3rd edition. Elk Grove Village, IL: American Academy of Pediatrics; Washington, DC: American Public Health Association.
[xxxviii] Screen Time. Let’s Move Child Care. Available at: http://www.healthykidshealthyfuture.org/home/activities/screentimes.html. Accessed March 21, 2014
[xxxix] U.S. Department of Agriculture and U.S. Department of Health and Human Services. Nutrition and Wellness Tips for Young Children: Provider Handbook for the Child and Adult Care Food Program. Alexandria, VA: 2012.
[xl] Institute of Medicine (IOM). 2011. Early childhood obesity prevention policies. Washington, DC: The National Academies Press.
[xli] Pate RR, McIver K, Dowda M, Brown WH, Addy C. Directly observed physical activity levels in preschool children. J Sch Health 2008;78(8):438-44.
[xlii] Bower JK, Hales DP, Tate DF, Rubin DA, Benjamin SE, Ward DS. The childcare environment and children's physical activity. Am J Prev Med 2008;34(1):23-9.
[xliii] Pate RR, Pfeiffer KA, Trost SG, Ziegler P, Dowda M. Physical activity among children attending preschools. Pediatrics 2004;114(5):1258-63.
[xliv] Proctor MH, Moore LL, Gao D, et al. Television viewing and change in body fat from preschool to early adolescence: The Framingham Children's Study. Int J Obes Relat Metab Disord. 2003;27(7):827-33.
[xlv] Janz KF, Burns TL, Levy SM. Tracking of activity and sedentary behaviors in childhood: the Iowa Bone Development Study. Am J Prev Med 2005;29(3):171-8.