45 C.F.R. Subpart B—Early Childhood Development and Health Services
Title 45 - Public Welfare
(a) Determining child health status. (1) In collaboration with the parents and as quickly as possible, but no later than 90 calendar days (with the exception noted in paragraph (a)(2) of this section) from the child's entry into the program (for the purposes of 45 CFR 1304.20(a)(1), 45 CFR 1304.20(a)(2), and 45 CFR 1304.20(b)(1), “entry” means the first day that Early Head Start or Head Start services are provided to the child), grantee and delegate agencies must: (i) Make a determination as to whether or not each child has an ongoing source of continuous, accessible health care. If a child does not have a source of ongoing health care, grantee and delegate agencies must assist the parents in accessing a source of care; (ii) Obtain from a health care professional a determination as to whether the child is up-to-date on a schedule of age appropriate preventive and primary health care which includes medical, dental and mental health. Such a schedule must incorporate the requirements for a schedule of well child care utilized by the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program of the Medicaid agency of the State in which they operate, and the latest immunization recommendations issued by the Centers for Disease Control and Prevention, as well as any additional recommendations from the local Health Services Advisory Committee that are based on prevalent community health problems: (A) For children who are not up-to-date on an age-appropriate schedule of well child care, grantee and delegate agencies must assist parents in making the necessary arrangements to bring the child up-to-date; (B) For children who are up-to-date on an age-appropriate schedule of well child care, grantee and delegate agencies must ensure that they continue to follow the recommended schedule of well child care; and (C) Grantee and delegate agencies must establish procedures to track the provision of health care services. (iii) Obtain or arrange further diagnostic testing, examination, and treatment by an appropriate licensed or certified professional for each child with an observable, known or suspected health or developmental problem; and (iv) Develop and implement a follow-up plan for any condition identified in 45 CFR 1304.20(a)(1)(ii) and (iii) so that any needed treatment has begun. (2) Grantee and delegate agencies operating programs of shorter durations (90 days or less) must complete the above processes and those in 45 CFR 1304.20(b)(1) within 30 calendar days from the child's entry into the program. (b) Screening for developmental, sensory, and behavioral concerns. (1) In collaboration with each child's parent, and within 45 calendar days of the child's entry into the program, grantee and delegate agencies must perform or obtain linguistically and age appropriate screening procedures to identify concerns regarding a child's developmental, sensory (visual and auditory), behavioral, motor, language, social, cognitive, perceptual, and emotional skills (see 45 CFR 1308.6(b)(3) for additional information). To the greatest extent possible, these screening procedures must be sensitive to the child's cultural background. (2) Grantee and delegate agencies must obtain direct guidance from a mental health or child development professional on how to use the findings to address identified needs. (3) Grantee and delegate agencies must utilize multiple sources of information on all aspects of each child's development and behavior, including input from family members, teachers, and other relevant staff who are familiar with the child's typical behavior. (c) Extended follow-up and treatment. (1) Grantee and delegate agencies must establish a system of ongoing communication with the parents of children with identified health needs to facilitate the implementation of the follow-up plan. (2) Grantee and delegate agencies must provide assistance to the parents, as needed, to enable them to learn how to obtain any prescribed medications, aids or equipment for medical and dental conditions. (3) Dental follow-up and treatment must include: (i) Fluoride supplements and topical fluoride treatments as recommended by dental professionals in communities where a lack of adequate fluoride levels has been determined or for every child with moderate to severe tooth decay; and (ii) Other necessary preventive measures and further dental treatment as recommended by the dental professional. (4) Grantee and delegate agencies must assist with the provision of related services addressing health concerns in accordance with the Individualized Education Program (IEP) and the Individualized Family Service Plan (IFSP). (5) Early Head Start and Head Start funds may be used for professional medical and dental services when no other source of funding is available. When Early Head Start or Head Start funds are used for such services, grantee and delegate agencies must have written documentation of their efforts to access other available sources of funding. (d) Ongoing care. In addition to assuring children's participation in a schedule of well child care, as described in §1304.20(a) of this part, grantee and delegate agencies must implement ongoing procedures by which Early Head Start and Head Start staff can identify any new or recurring medical, dental, or developmental concerns so that they may quickly make appropriate referrals. These procedures must include: periodic observations and recordings, as appropriate, of individual children's developmental progress, changes in physical appearance (e.g., signs of injury or illness) and emotional and behavioral patterns. In addition, these procedures must include observations from parents and staff. (e) Involving parents. In conducting the process, as described in §§1304.20 (a), (b), and (c), and in making all possible efforts to ensure that each child is enrolled in and receiving appropriate health care services, grantee and delegate agencies must: (1) Consult with parents immediately when child health or developmental problems are suspected or identified; (2) Familiarize parents with the use of and rationale for all health and developmental procedures administered through the program or by contract or agreement, and obtain advance parent or guardian authorization for such procedures. Grantee and delegate agencies also must ensure that the results of diagnostic and treatment procedures and ongoing care are shared with and understood by the parents; (3) Talk with parents about how to familiarize their children in a developmentally appropriate way and in advance about all of the procedures they will receive while enrolled in the program; (4) Assist parents in accordance with 45 CFR 1304.40(f)(2) (i) and (ii) to enroll and participate in a system of ongoing family health care and encourage parents to be active partners in their children's health care process; and (5) If a parent or other legally responsible adult refuses to give authorization for health services, grantee and delegate agencies must maintain written documentation of the refusal. (f) Individualization of the program. (1) Grantee and delegate agencies must use the information from the screening for developmental, sensory, and behavioral concerns, the ongoing observations, medical and dental evaluations and treatments, and insights from the child's parents to help staff and parents determine how the program can best respond to each child's individual characteristics, strengths and needs. (2) To support individualization for children with disabilities in their programs, grantee and delegate agencies must assure that: (i) Services for infants and toddlers with disabilities and their families support the attainment of the expected outcomes contained in the Individualized Family Service Plan (IFSP) for children identified under the infants and toddlers with disabilities program (Part H) of the Individuals with Disabilities Education Act, as implemented by their State or Tribal government; (ii) Enrolled families with infants and toddlers suspected of having a disability are promptly referred to the local early intervention agency designated by the State Part H plan to coordinate any needed evaluations, determine eligibility for Part H services, and coordinate the development of an IFSP for children determined to be eligible under the guidelines of that State's program. Grantee and delegate agencies must support parent participation in the evaluation and IFSP development process for infants and toddlers enrolled in their program; (iii) They participate in and support efforts for a smooth and effective transition for children who, at age three, will need to be considered for services for preschool age children with disabilities; and (iv) They participate in the development and implementation of the Individualized Education Program (IEP) for preschool age children with disabilities, consistent with the requirements of 45 CFR 1308.19. [61 FR 57210, Nov. 5, 1996, as amended at 63 FR 2313, Jan. 15, 1998] (a) Child development and education approach for all children. (1) In order to help children gain the skills and confidence necessary to be prepared to succeed in their present environment and with later responsibilities in school and life, grantee and delegate agencies' approach to child development and education must: (i) Be developmentally and linguistically appropriate, recognizing that children have individual rates of development as well as individual interests, temperaments, languages, cultural backgrounds, and learning styles; (ii) Be inclusive of children with disabilities, consistent with their Individualized Family Service Plan (IFSP) or Individualized Education Program (IEP) (see 45 CFR 1308.19); (iii) Provide an environment of acceptance that supports and respects gender, culture, language, ethnicity and family composition; (iv) Provide a balanced daily program of child-initiated and adult-directed activities, including individual and small group activities; and (v) Allow and enable children to independently use toilet facilities when it is developmentally appropriate and when efforts to encourage toilet training are supported by the parents. (2) Parents must be: (i) Invited to become integrally involved in the development of the program's curriculum and approach to child development and education; (ii) Provided opportunities to increase their child observation skills and to share assessments with staff that will help plan the learning experiences; and (iii) Encouraged to participate in staff-parent conferences and home visits to discuss their child's development and education (see 45 CFR 1304.40(e)(4) and 45 CFR 1304.40(i)(2)). (3) Grantee and delegate agencies must support social and emotional development by: (i) Encouraging development which enhances each child's strengths by: (A) Building trust; (B) Fostering independence; (C) Encouraging self-control by setting clear, consistent limits, and having realistic expectations; (D) Encouraging respect for the feelings and rights of others; and (E) Supporting and respecting the home language, culture, and family composition of each child in ways that support the child's health and well-being; and (ii) Planning for routines and transitions so that they occur in a timely, predictable and unrushed manner according to each child's needs. (4) Grantee and delegate agencies must provide for the development of each child's cognitive and language skills by: (i) Supporting each child's learning, using various strategies including experimentation, inquiry, observation, play and exploration; (ii) Ensuring opportunities for creative self-expression through activities such as art, music, movement, and dialogue; (iii) Promoting interaction and language use among children and between children and adults; and (iv) Supporting emerging literacy and numeracy development through materials and activities according to the developmental level of each child. (5) In center-based settings, grantee and delegate agencies must promote each child's physical development by: (i) Providing sufficient time, indoor and outdoor space, equipment, materials and adult guidance for active play and movement that support the development of gross motor skills; (ii) Providing appropriate time, space, equipment, materials and adult guidance for the development of fine motor skills according to each child's developmental level; and (iii) Providing an appropriate environment and adult guidance for the participation of children with special needs. (6) In home-based settings, grantee and delegate agencies must encourage parents to appreciate the importance of physical development, provide opportunities for children's outdoor and indoor active play, and guide children in the safe use of equipment and materials. (b) Child development and education approach for infants and toddlers. (1) Grantee and delegate agencies' program of services for infants and toddlers must encourage (see 45 CFR 1304.3(a)(5) for a definition of curriculum): (i) The development of secure relationships in out-of-home care settings for infants and toddlers by having a limited number of consistent teachers over an extended period of time. Teachers must demonstrate an understanding of the child's family culture and, whenever possible, speak the child's language (see 45 CFR 1304.52(g)(2)); (ii) Trust and emotional security so that each child can explore the environment according to his or her developmental level; and (iii) Opportunities for each child to explore a variety of sensory and motor experiences with support and stimulation from teachers and family members. (2) Grantee and delegate agencies must support the social and emotional development of infants and toddlers by promoting an environment that: (i) Encourages the development of self-awareness, autonomy, and self-expression; and (ii) Supports the emerging communication skills of infants and toddlers by providing daily opportunities for each child to interact with others and to express himself or herself freely. (3) Grantee and delegate agencies must promote the physical development of infants and toddlers by: (i) Supporting the development of the physical skills of infants and toddlers including gross motor skills, such as grasping, pulling, pushing, crawling, walking, and climbing; and (ii) Creating opportunities for fine motor development that encourage the control and coordination of small, specialized motions, using the eyes, mouth, hands, and feet. (c) Child development and education approach for preschoolers. (1) Grantee and delegate agencies, in collaboration with the parents, must implement a curriculum (see 45 CFR 1304.3(a)(5)) that: (i) Supports each child's individual pattern of development and learning; (ii) Provides for the development of cognitive skills by encouraging each child to organize his or her experiences, to understand concepts, and to develop age appropriate literacy, numeracy, reasoning, problem solving and decision-making skills which form a foundation for school readiness and later school success; (iii) Integrates all educational aspects of the health, nutrition, and mental health services into program activities; (iv) Ensures that the program environment helps children develop emotional security and facility in social relationships; (v) Enhances each child's understanding of self as an individual and as a member of a group; (vi) Provides each child with opportunities for success to help develop feelings of competence, self-esteem, and positive attitudes toward learning; and (vii) Provides individual and small group experiences both indoors and outdoors. (2) Staff must use a variety of strategies to promote and support children's learning and developmental progress based on the observations and ongoing assessment of each child (see 45 CFR 1304.20(b), 1304.20(d), and 1304.20(e)). [61 FR 57210, Nov. 5, 1996, as amended at 63 FR 2313, Jan. 15, 1998] (a) Health emergency procedures. Grantee and delegate agencies operating center-based programs must establish and implement policies and procedures to respond to medical and dental health emergencies with which all staff are familiar and trained. At a minimum, these policies and procedures must include: (1) Posted policies and plans of action for emergencies that require rapid response on the part of staff (e.g., a child choking) or immediate medical or dental attention; (2) Posted locations and telephone numbers of emergency response systems. Up-to-date family contact information and authorization for emergency care for each child must be readily available; (3) Posted emergency evacuation routes and other safety procedures for emergencies (e.g., fire or weather-related) which are practiced regularly (see 45 CFR 1304.53 for additional information); (4) Methods of notifying parents in the event of an emergency involving their child; and (5) Established methods for handling cases of suspected or known child abuse and neglect that are in compliance with applicable Federal, State, or Tribal laws. (b) Conditions of short-term exclusion and admittance. (1) Grantee and delegate agencies must temporarily exclude a child with a short-term injury or an acute or short-term contagious illness, that cannot be readily accommodated, from program participation in center-based activities or group experiences, but only for that generally short-term period when keeping the child in care poses a significant risk to the health or safety of the child or anyone in contact with the child. (2) Grantee and delegate agencies must not deny program admission to any child, nor exclude any enrolled child from program participation for a long-term period, solely on the basis of his or her health care needs or medication requirements unless keeping the child in care poses a significant risk to the health or safety of the child or anyone in contact with the child and the risk cannot be eliminated or reduced to an acceptable level through reasonable modifications in the grantee or delegate agency's policies, practices or procedures or by providing appropriate auxiliary aids which would enable the child to participate without fundamentally altering the nature of the program. (3) Grantee and delegate agencies must request that parents inform them of any health or safety needs of the child that the program may be required to address. Programs must share information, as necessary, with appropriate staff regarding accommodations needed in accordance with the program's confidentiality policy. (c) Medication administration. Grantee and delegate agencies must establish and maintain written procedures regarding the administration, handling, and storage of medication for every child. Grantee and delegate agencies may modify these procedures as necessary to satisfy State or Tribal laws, but only where such laws are consistent with Federal laws. The procedures must include: (1) Labeling and storing, under lock and key, and refrigerating, if necessary, all medications, including those required for staff and volunteers; (2) Designating a trained staff member(s) or school nurse to administer, handle and store child medications; (3) Obtaining physicians' instructions and written parent or guardian authorizations for all medications administered by staff; (4) Maintaining an individual record of all medications dispensed, and reviewing the record regularly with the child's parents; (5) Recording changes in a child's behavior that have implications for drug dosage or type, and assisting parents in communicating with their physician regarding the effect of the medication on the child; and (6) Ensuring that appropriate staff members can demonstrate proper techniques for administering, handling, and storing medication, including the use of any necessary equipment to administer medication. (d) Injury prevention. Grantee and delegate agencies must: (1) Ensure that staff and volunteers can demonstrate safety practices; and (2) Foster safety awareness among children and parents by incorporating it into child and parent activities. (e) Hygiene. (1) Staff, volunteers, and children must wash their hands with soap and running water at least at the following times: (i) After diapering or toilet use; (ii) Before food preparation, handling, consumption, or any other food-related activity (e.g., setting the table); (iii) Whenever hands are contaminated with blood or other bodily fluids; and (iv) After handling pets or other animals. (2) Staff and volunteers must also wash their hands with soap and running water: (i) Before and after giving medications; (ii) Before and after treating or bandaging a wound (nonporous gloves should be worn if there is contact with blood or blood-containing body fluids); and (iii) After assisting a child with toilet use. (3) Nonporous (e.g., latex) gloves must be worn by staff when they are in contact with spills of blood or other visibly bloody bodily fluids. (4) Spills of bodily fluids (e.g., urine, feces, blood, saliva, nasal discharge, eye discharge or any fluid discharge) must be cleaned and disinfected immediately in keeping with professionally established guidelines (e.g., standards of the Occupational Safety Health Administration, U.S. Department of Labor). Any tools and equipment used to clean spills of bodily fluids must be cleaned and disinfected immediately. Other blood-contaminated materials must be disposed of in a plastic bag with a secure tie. (5) Grantee and delegate agencies must adopt sanitation and hygiene procedures for diapering that adequately protect the health and safety of children served by the program and staff. Grantee and delegate agencies must ensure that staff properly conduct these procedures. (6) Potties that are utilized in a center-based program must be emptied into the toilet and cleaned and disinfected after each use in a utility sink used for this purpose. (7) Grantee and delegate agencies operating programs for infants and toddlers must space cribs and cots at least three feet apart to avoid spreading contagious illness and to allow for easy access to each child. (f) First aid kits. (1) Readily available, well-supplied first aid kits appropriate for the ages served and the program size must be maintained at each facility and available on outings away from the site. Each kit must be accessible to staff members at all times, but must be kept out of the reach of children. (2) First aid kits must be restocked after use, and an inventory must be conducted at regular intervals. [61 FR 57210, Nov. 5, 1996, as amended at 63 FR 2313, Jan. 15, 1998] (a) Identification of nutritional needs. Staff and families must work together to identify each child's nutritional needs, taking into account staff and family discussions concerning: (1) Any relevant nutrition-related assessment data (height, weight, hemoglobin/hematocrit) obtained under 45 CFR 1304.20(a); (2) Information about family eating patterns, including cultural preferences, special dietary requirements for each child with nutrition-related health problems, and the feeding requirements of infants and toddlers and each child with disabilities (see 45 CFR 1308.20); (3) For infants and toddlers, current feeding schedules and amounts and types of food provided, including whether breast milk or formula and baby food is used; meal patterns; new foods introduced; food intolerances and preferences; voiding patterns; and observations related to developmental changes in feeding and nutrition. This information must be shared with parents and updated regularly; and (4) Information about major community nutritional issues, as identified through the Community Assessment or by the Health Services Advisory Committee or the local health department. (b) Nutritional services. (1) Grantee and delegate agencies must design and implement a nutrition program that meets the nutritional needs and feeding requirements of each child, including those with special dietary needs and children with disabilities. Also, the nutrition program must serve a variety of foods which consider cultural and ethnic preferences and which broaden the child's food experience. (i) All Early Head Start and Head Start grantee and delegate agencies must use funds from USDA Food and Consumer Services Child Nutrition Programs as the primary source of payment for meal services. Early Head Start and Head Start funds may be used to cover those allowable costs not covered by the USDA. (ii) Each child in a part-day center-based setting must receive meals and snacks that provide at least (iii) All children in morning center-based settings who have not received breakfast at the time they arrive at the Early Head Start or Head Start program must be served a nourishing breakfast. (iv) Each infant and toddler in center-based settings must receive food appropriate to his or her nutritional needs, developmental readiness, and feeding skills, as recommended in the USDA meal pattern or nutrient standard menu planning requirements outlined in 7 CFR parts 210, 220, and 226. (v) For 3- to 5-year-olds in center-based settings, the quantities and kinds of food served must conform to recommended serving sizes and minimum standards for meal patterns recommended in the USDA meal pattern or nutrient standard menu planning requirements outlined in 7 CFR parts 210, 220, and 226. (vi) For 3- to 5-year-olds in center-based settings or other Head Start group experiences, foods served must be high in nutrients and low in fat, sugar, and salt. (vii) Meal and snack periods in center-based settings must be appropriately scheduled and adjusted, where necessary, to ensure that individual needs are met. Infants and young toddlers who need it must be fed “on demand” to the extent possible or at appropriate intervals. (2) Grantee and delegate agencies operating home-based program options must provide appropriate snacks and meals to each child during group socialization activities (see 45 CFR 1306.33 for information regarding home-based group socialization). (3) Staff must promote effective dental hygiene among children in conjunction with meals. (4) Parents and appropriate community agencies must be involved in planning, implementing, and evaluating the agencies' nutritional services. (c) Meal service. Grantee and delegate agencies must ensure that nutritional services in center-based settings contribute to the development and socialization of enrolled children by providing that: (1) A variety of food is served which broadens each child's food experiences; (2) Food is not used as punishment or reward, and that each child is encouraged, but not forced, to eat or taste his or her food; (3) Sufficient time is allowed for each child to eat; (4) All toddlers and preschool children and assigned classroom staff, including volunteers, eat together family style and share the same menu to the extent possible; (5) Infants are held while being fed and are not laid down to sleep with a bottle; (6) Medically-based diets or other dietary requirements are accommodated; and (7) As developmentally appropriate, opportunity is provided for the involvement of children in food-related activities. (d) Family assistance with nutrition. Parent education activities must include opportunities to assist individual families with food preparation and nutritional skills. (e) Food safety and sanitation. (1) Grantee and delegate agencies must post evidence of compliance with all applicable Federal, State, Tribal, and local food safety and sanitation laws, including those related to the storage, preparation and service of food and the health of food handlers. In addition, agencies must contract only with food service vendors that are licensed in accordance with State, Tribal or local laws. (2) For programs serving infants and toddlers, facilities must be available for the proper storage and handling of breast milk and formula. [61 FR 57210, Nov. 5, 1996, as amended at 63 FR 2313, Jan. 15, 1998] (a) Mental health services. (1) Grantee and delegate agencies must work collaboratively with parents (see 45 CFR 1304.40(f) for issues related to parent education) by: (i) Soliciting parental information, observations, and concerns about their child's mental health; (ii) Sharing staff observations of their child and discussing and anticipating with parents their child's behavior and development, including separation and attachment issues; (iii) Discussing and identifying with parents appropriate responses to their child's behaviors; (iv) Discussing how to strengthen nurturing, supportive environments and relationships in the home and at the program; (v) Helping parents to better understand mental health issues; and (vi) Supporting parents' participation in any needed mental health interventions. (2) Grantee and delegate agencies must secure the services of mental health professionals on a schedule of sufficient frequency to enable the timely and effective identification of and intervention in family and staff concerns about a child's mental health; and (3) Mental health program services must include a regular schedule of on-site mental health consultation involving the mental health professional, program staff, and parents on how to: (i) Design and implement program practices responsive to the identified behavioral and mental health concerns of an individual child or group of children; (ii) Promote children's mental wellness by providing group and individual staff and parent education on mental health issues; (iii) Assist in providing special help for children with atypical behavior or development; and (iv) Utilize other community mental health resources, as needed.
Title 45: Public Welfare
PART 1304—PROGRAM PERFORMANCE STANDARDS FOR THE OPERATION OF HEAD START PROGRAMS BY GRANTEE AND DELEGATE AGENCIES
Subpart B—Early Childhood Development and Health Services
§ 1304.20 Child health and developmental services.
§ 1304.21 Education and early childhood development.
§ 1304.22 Child health and safety.
§ 1304.23 Child nutrition.
§ 1304.24 Child mental health.
