Enrolling a child in day care might raise a few concerns or unknowns about the steps the facilities take to protect the kids they serve from illness and injury.

It’s important for parents to know that the Texas Health and Human Services Commission (HHSC) sets rules that state-licensed day care operators, including in-home day cares, must follow. Those rules aim to minimize the risks for infants, toddlers and older children while playing, eating and sleeping at day care. The goal is to make the settings as sanitary and hazard-free as possible.

Across the state, there are about 8,300 licensed child care centers and in-home day cares with a combined capacity for more than 997,000 children. Sharon Evans, trauma injury prevention coordinator at Cook Children’s, advises parents to make sure the facility they choose is licensed and subject to the regulations.

“Day care regulations are in place to keep your child as safe as possible. However, Cook Children’s still sees broken bones and head injuries from day cares due to kids playing,” Evans said.  

The HHSC requirements are published in Minimum Standards for Child-Care Centers, which was revised in March 2023. You’ll find specifics on many topics – from food allergies and first aid to fever and fire drills – in the updated manual. Sections cover illness protocol, required immunizations, playground equipment and much more in 294 pages.

Here’s a shorter and simplified look at a few key requirements.

Parents will need to provide:

Medical information at admission: Name, address and phone number of the child’s physician; authorization for emergency medical care; an emergency plan for any severe allergic reactions; a statement of any special care needs.   

Health statement: Signed by a health care professional who has examined the child in the past year. It says the child can participate in the day care’s program.

Routine vaccinations: Immunize by 3 months old for diseases including polio, hepatitis B and diphtheria, tetanus and pertussis (DTaP). Booster shots are due for older children. The day care must keep a copy of every child’s up-to-date shot record on file.  Learn more here.

Licensed day cares are required to provide:

Caregiver training: Before they start the job, with 24 hours of additional training each year. Certification in pediatric first aid and pediatric cardiopulmonary resuscitation (CPR) is also required. “Ongoing training provides caregivers an opportunity to learn the newest techniques for addressing children’s behaviors, to discover the latest findings on what children need as they develop, and to refresh and re-energize their skills,” the manual says.

Communication for any injuries: The day care will let you know about minor scratches and cuts when you pick up your child. An Incident/Illness Report must be filled out for injuries.

Infant safe sleep practices: Infants are always placed on their backs, by themselves, in a crib that meets federal regulations. Bean bags, waterbeds and foam pads may not be used. No pillows, blankets or soft toys can be in the sleep space. If your infant falls asleep in their car seat on the way to day care, they’ll be moved out of the seat and into a crib.

Sanitization: Toys that have been in a child’s mouth; potty chairs; sleeping spaces; table tops; anything soiled or contaminated. 

Proper handwashing: For employees upon arrival for the day; before handling food or medication; before feeding a child; after a diaper change or assisting a child with toileting; after wiping a child’s nose, mouth or sores; after their own trips to the bathroom. The children also must wash their hands frequently throughout the day.  

Guidelines for illness: Don’t bring your child to day care with an oral temperature above 101 degrees or ear temperature above 100 degrees. Other exclusions include lethargy, abnormal breathing, uncontrolled diarrhea, vomiting twice or more in 24 hours, rash with fever, or mouth sores with drooling.  A child may return after being symptom-free for 24 hours.

Safeguards on the premises: Childproof covers on electrical outlets; televisions anchored so they can’t tip over; heaters out of children’s reach; no access to firearms. Smoke detectors, carbon monoxide detectors, fire extinguishers and sprinkler systems are required. No use of alcohol, drugs, tobacco products or e-cigarettes is permitted by anyone on the property. 

Medication: In the original container, labeled with your child’s name, and not past the expiration date. The employee who administers the medicine will record the date, time and dosage given.

Safe handling for food allergies: Employees who prepare and serve food will be made aware of the known food allergies. Foods listed on a child’s emergency plan will be posted wherever food is prepared and where the child spends time.

But many parents are still asking the question, 'Should I take my child to daycare?'

Of course, there's no one clear answer for all families. The bottom line is that everyone should consider carefully whether taking their child to daycare is the right decision for them.

The first consideration is whether you think your child’s daycare center is ready to open.

The Center for Disease Control (CDC) has issued some guidance for child care opening. Before I sent my child back, I would ensure that they are at a minimum following their recommendations that daycare centers should only open when:

• They can be compliant with local and state orders, are ready to protect high risk children and employees, and can screen children and employees on arrival.
• The following health and safety actions are in place: promote hygiene practice such as handwashing with employees wearing masks, intensified cleaning, encouraged social distancing when feasible, adjust activities to limit sharing of toys/supplies and training all employees.
• Ongoing monitoring is in place. Children and employees should have a process for checking for signs and symptoms upon arrival, sick employees should be allowed to stay home and a plan should be in place should employees or children get sick.

Once daycare center readiness has been determined, each family will still need to make a determination for when their child should go back. Here are some factors to consider:

1. Child’s medical history - This may seem obvious but children with chronic conditions are who are immunosuppressed would be at higher risk with returning to day care.
2. Child’s age - Children 2 and older will likely be asked to wear a mask but the younger kids are, the harder it will be. It might be easier for children who aren’t mobile to be separated. Toddlers will be the trickiest as they are mobile and can’t wear masks.
3. Family medical history - At risk family or household members will be at risk for contracting disease from asymptomatic children who bring infection home.
4. Family work situation - As offices open up, many parents will not have a choice. Even parents who work from home may face increasing pressure to be more productive as the economy begins to open up. Parents need to be able to provide for their family and maintain insurance coverage in a time where work insecurity is a real issue.

While each parent will have a choice to make in regards to taking their kids back to daycare, hopefully these considerations will help you make the best decision for you and your children.

You don’t expect tragedy and you certainly don’t expect that tragedy to occur as a result of negligence by your child care provider.

Unfortunately, for Katie Mulkey of Reynoldsburg, Ohio, this is exactly what happened. On May 13, she dropped her son Haddix off at the babysitter’s house where his unlicensed childcare provider allegedly gave him two tablets (an adult dose) of Benadryl to help him sleep because he was fussy. When the babysitter went to the back room to check on him later, he wasn’t breathing.

Of course, the family is devastated but they have taken the opportunity to educate and advocate against the use of medications to help babies sleep.

Here are the lessons to learn:

1. Medications have indications for use and they should be used for those reasons and those reasons only. Benadryl works fine for allergies and even for itching. Benadryl is not a baby sedative, period. The promotion of its use for sleep in babies is irresponsible and dangerous.
2. Medications have dosing for children. The difference between the effective dose and the fatally toxic dose is not always as big as you think. Kids are harmed and die from overdoses of just about every over the counter medicine you can imagine. Know the dose and use the appropriate one.
3. Medications come with a dosing cup. Use the cup or syringe to measure out your child’s medications. Using a teaspoon from home doesn’t work because they will likely under or overdose your child.

Use of medications is a huge responsibility.

Giving medicine to your child should only be done by you or by your explicit instruction. They should be given for the right reasons at the right doses.

Jamye Coffman, M.D., a child abuse pediatrician and medical director for Cook Children’s Advocacy Resource and Evaluation (CARE) Team, advises parents to monitor their nanny or babysitter at all times.

“I would set up cameras in my home,” Dr. Coffman said “We’ve had nanny cam videos brought to us and we’ve seen what can happen when the nanny or babysitter gets frustrated. They many not leave physical injuries or bruises, but we’ve seen some awful and abusive behavior that would not have been discovered without the cameras.”

The nanny, who has pleaded not guilty, is charged with trying to smother a baby boy in her care. Police say they have video from a hidden nanny cam of Moriah Gonzales, 20 years old, pressing her hands against the 3 month old untl he went limp. She has been charged with felony child abuse likely to cause great bodily harm.

So how do you avoid this kind of thing happening to you? Dr. Coffman says parents should start with research.

The Texas Department of Family and Protective Services provides a list of licensed child care centers and licensed or registered child care homes.Learn more about reporting abuse by clicking here. The Texas Abuse Hotline number is 1-800-252-5400.

Once you’ve selected the child care for you, Dr. Coffman says go visit it yourself. Also, make sure two adults are in the room with the children at all times. Ask about the visitation policy. If parents are discouraged to check in, find another place for your child’s care.

And most importantly, Dr. Coffman says to trust your gut.

“Even if you do all the research sometimes an incident hasn’t been reported and may have occurred,” Dr. Coffman said. “If you think something is off about where your child is being cared for, you don’t want to risk sending him or her back until something does happen. If you have that gut instinct, look for another day care.”

If you take your child to an in-home day care provider or you have a nanny at your home, similar rules apply. Dr. Coffman says she always prefers two sets of adult eyes on the child, but if that’s not possible, make frequent drop in visits. Any day care operator should welcome the opportunity for you to check in on your own child.

Click the following link for more information: Did you know only 7 percent of licensed child programs in Tarrant County considered quality? Click to read more.

Hepatitis A is an infection of the liver. It can be passed easily from contaminated food, water or close contact with an infected person.

"Hepatitis A can cause outbreaks in day care which infect many children and last for several months,” Mary Suzanne Whitworth, M.D., medical director of Infectious Diseases. “Good hand washing techniques can prevent outbreaks and decrease the spread of the disease, but the best protection for your child is to have them vaccinated.”

Hepatitis A usually goes away on its own within two months. There are no lasting effects in most once the infection passes. Symptoms include:

• Tiredness
• Loss of appetite
• Fever
• Nausea and vomiting
• Abdominal pain or discomfort
• Yellowing of the eyes and skin—jaundice
• Darker colored urine
• Light or chalky colored stools
• Rash

Medical treatments that may help prevent infection include:

• Immune (Gamma) Globulin—temporary protection from hepatitis A. It can last about 3-6 months. It must be given before exposure to the virus or within 2 weeks after exposure.
• Hepatitis A vaccine—highly effective in preventing infection. It provides full protection 4 weeks after the first injection. A second injection provides long-term protection. The vaccine should be considered for:

• All children aged 12-23 months.
• Children aged 24 months or older who are at high risk and have not been previously vaccinated.
• People traveling to areas where hepatitis A is prevalent (The Centers for Disease Control and Prevention's http://wwwnc.cdc.gov/travel/ shows which areas have a high prevalence of hepatitis A).
• People with chronic liver disease.
• People with blood-clotting disorders, such as hemophilia. 
• People who desire immunity to hepatitis A.

About the source

Mary Suzanne Whitworth, M.D. is the medical director of Infectious Diseases at Cook Children’s, which offers care for children and teens with diseases caused by bacteria, parasites, fungi or viruses. Our team provides a broad range of services including diagnosis, inpatient and outpatient consultations, immune deficiency evaluations and treatment of recurring infections.

What if you then found out that you had been lied to about that day care’s license?

In fact, they didn’t have a license at all.

Fortunately cases like this are rare.

But what about a more common case where your child is bitten once or a few times at day care? What if your child is the one who is biting?

I reviewed the Texas Department of Family and Protective Services Minimum Standards for Child-Care Centers. Here is what I found:

• Parents should be notified about minor injuries when the child is picked up from day care (biting is included in this category).
• Relevant ongoing education is required for employees (and specifically mentions biting).
• Decisions about child/caregiver ratio must take into account situations where there are tricky situations. For biting, it suggests that a caregiver be assigned with training in redirection or that an extra caregiver be assigned.
• Biting is specifically prohibited as a means of discipline for a child (day care workers cannot use the old “just bite them back” techniques for biting).

What can you do?

Three tips if your child is being bit:

1. If it’s a one-time thing, try your best to let it go. I know this is hard but biting does happen and can happen in the blink of an eye even in very closely supervised environments.
2. If you start to notice bites over time, mention your concerns and assess what the day care is doing to prevent the issue.
3. If the bites are severe or very frequent, I would feel very confident suggesting that your child’s day care follow the steps as outlined in the Child Care Guidelines. This might mean that the day care needs a specialized or extra caregiver for the “problem” room.

Three tips if your child is the biter:

1. Do not feel guilty. Sometimes the day care will make it seem like your parenting is the problem. The reality is that you cannot do anything at home to teach a toddler to not bite at day care. Discipline in the toddler age does not work that way.
2. Discuss your child’s triggers with the day care. Biting usually occurs in predictable situations for children. You might be able to help them prevent biting in the first place.
3. Learn what works to distract your child. Children need to be distracted when they are biting. It’s clear from studies that direct punishment does not work well with toddlers. Teach the day care what strategies they can use.