Injury Prevention in Child Care: A Guide for Licensing Staff*
Jodi Jungman, MA
Introduction
Hi, my name is Eva. In this course we are going to discuss some of the most common
injuries that affect children in child care settings, as well as information about ways
providers can help prevent these types of injuries. One of your most important jobs as a
child care licensing staff member is to ensure that children are cared for in safe
environments. The information in this course is designed to clarify the rationale behind
information contained in minimum standards, and to give you suggestions for providing
guidance and technical assistance related to the prevention of common childhood injuries.
Learning Objectives
When you have completed this course, you will be able to:
 Describe injuries that commonly occur among young children, including falls, airway
obstructions and drownings, poisonings, burns, and vehicle-related injuries,
 Explain how certain licensing standards serve to keep children safe,
 Describe appropriate supervision practices, and
 Offer technical assistance to providers using practical strategies to improve children’s
safety.
Why Is Injury Prevention Important in Child Care?
Unintentional injuries, or injuries that result from unplanned or accidental events, are
among the leading causes of death for children in all age brackets. In fact, according to
the Centers for Disease Control, or CDC, unintentional injury is the number one cause of
death for children between 1 and 9 years old, and is the fifth most common cause of death
among infants less than 1 year old.
The risk of injury is particularly high among children 4 years old and younger. Children
in this age bracket account for 49 percent of the deaths among children of all ages. These
children are at a higher risk of injury for many reasons. Young children may not be aware
of the risks associated with certain behaviors, may have poorer impulse control than older
children, and are still mastering both gross and fine motor skills. Infants and toddlers, in
particular, learn by exploring their environments. One way they accomplish this is by
placing objects in their mouths to learn about textures, shapes, and tastes.
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The majority of injuries to children occur while the child is at home, but some injuries
still occur in the child care setting. The Consumer Product Safety Commission, or CPSC,
conducted a study that examined accidents that occurred while children were in out-ofhome care, and found that:
 2 percent of all injuries to children ages 2 and under occur in child care.
 54 percent of all injuries to children ages 2 to 4 occur in child care, and
 42 percent of all injuries to children ages 5 to 9 occur in child care.
Injuries in child care most commonly occur on playgrounds, but can also be the result of
unsafe furniture or toys, children’s actions, such as pushing, biting, or throwing, or unsafe
elements in the environment. Some examples of unsafe elements include exposed
radiators, glass doors, certain types of vegetation, and missing or unused gates and
fences. Another CPSC study found that more than two-thirds of child care environments
had one or more potential hazards such as these, which can lead to serious injury.
Experts believe that up to 90 percent of childhood injuries can be prevented if the right
measures are taken. At times, you may encounter caregivers who do not understand the
value of taking steps to improve safety. Let providers know that there are three main
reasons they should strive to prevent injuries:
1. It is ethically necessary, since parents place children in a provider’s care with the
expectation that their child will be well taken care of, and since children cannot
ensure their own safety without adult assistance;
2. Many provisions related to injury prevention are required by Texas Child Care
Licensing standards; and
3. Caregivers who choose not to engage in proactive injury prevention could find
themselves facing criminal or civil litigation and potentially losing their ability to
legally provide child care in the future.
Throughout the rest of this course, we will address some of the most common types of
injuries that occur in child care settings, and some strategies caregivers can adopt to help
prevent them, focusing, where appropriate, on special risks and best practices related to
the care of infants and toddlers, who are at a particularly high risk of injury. You should
keep in mind, however, that it is unrealistic to expect that providers will eliminate all risk
of childhood injuries. Accidents will happen. The goal of injury prevention should be to
minimize the risk and mitigate the impact of potential injuries in a given care setting.
Since injuries cannot be totally eliminated, child care staff should still maintain up-todate certifications in CPR and first aid, according to minimum standard requirements.
A Note on Supervision
One of the key factors in preventing all types of injuries is adequate supervision. The
National Program for Playground Safety estimates that more than 40 percent of all
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playground injuries result from inadequate adult supervision. Even sleeping children,
especially infants, should be carefully supervised. Supervision allows caregivers to
enforce guidelines for the safe use of materials, intervene in the case of unsafe behavior,
and quickly respond if an injury occurs.
Texas’ licensing standards for child care programs reinforce the importance of
supervision in several ways. First, standards require that caregivers who are responsible
for supervising children, meaning they are counted in required staff-to-child ratios,
should not be asked to perform other duties, such as janitorial or administrative tasks,
while children are present. These activities could distract caregivers from the important
job of supervision, which puts the children in care at a higher risk of injury. Standards
also require that child care environments be arranged such that providers can easily view
the entire play space at once, allowing for maximum supervision of all children. Finally,
staff-to-child ratios are specified for child care settings, determined in part by the ages of
the children in care. Having too many children to keep track of at one time detracts
greatly from a caregiver’s ability to provide adequate supervision.
So, what does adequate supervision looks like in practice? There are several principles
that define adequate supervision. Caregivers who are adequately supervising children in
care:
 Position themselves so that they can see all of the indoor or outdoor environment, and
all children in that environment, at once,
 Collaborate with other caregivers to ensure that the area is being supervised from
multiple vantage points, focusing slightly more on high-risk areas such as swings,
 Be alert and attentive at all times,
 Be aware of the age-appropriateness of equipment and materials,
 Constantly inspect and evaluate potential hazards,
 Consistently apply safety guidelines,
 Train children to use materials and equipment safely,
 Meet or exceed required staff-to-child ratios,
 Constantly count children to ensure that all children are accounted for,
 Intervene when unsafe or inappropriate behavior occurs, and
 Have a plan for responding to injuries and emergencies so that all children are still
well supervised.
In order to achieve adequate supervision, providers need to know their care
environments, assessing and addressing potential hazards multiple times a day. If a
caregiver is having difficulty identifying hazards, encourage her to think about the play
area from the perspective of a child in care. Especially for infant and toddler caregivers,
this might involve crawling through the environment to literally see the child’s point of
view. If there are multiple providers who care for a particular group, encourage each to
perform an independent assessment of the hazards in the environment. Having more eyes
searching for potential problems makes it more likely that dangers will be identified and
fixed before a child is injured.
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Now let’s look at some of the most common types of childhood injuries: falls, airway
obstructions and drownings, poisonings, burns, and vehicle-related injuries. As we go
through each section, you can refer to the handout called Relevant Standards for the
specific location of licensing standards related to each type of injury.
Falls
Falls are the leading cause of non-fatal injury for children in all age groups. Falls are
particularly prevalent during outdoor play and among infants, both indoors and outdoors.
Nationwide statistics show that nearly 70 percent of all playground injuries are due to
falls. Some of these falls are more serious than others. The seriousness of a fall is
determined by two factors: the height from which the fall occurs, and the surface on
which the person lands. Licensing standards regulate the maximum height of playground
equipment, depending on the ages of the children for whom the equipment is intended.
Any raised equipment or surfaces should have guardrails and barriers in place to prevent
accidental falls. This is true of indoor play equipment as well.
Standards also include guidelines for measuring the area under raised pieces of
playground equipment where children are likely to land if they fall. These areas are called
“use zones” or “fall zones”, and they are the areas that require proper surfacing to absorb
some of the impact of a potential fall. Appropriate surfacing materials for most child care
playgrounds include loose-fill materials such as sand, pea gravel, or shredded rubber, or
unitary surfacing materials. For infant and toddler outdoor play areas, however, loose-fill
materials may cause choking and health hazards because infants and toddlers still explore
their environments through mouthing.
As we mentioned earlier, young children tend to be at a higher risk for all kinds of
injuries, in part because of their lack of awareness in hazardous situations. Infants and
toddlers may not be aware of the danger of falling in certain situations, so special
precautions should be taken by infant and toddler caregivers. You may find that some
caregivers need direction regarding how to get started preventing infant and toddler falls.
The rest of this section will give you some concrete suggestions to offer infant and
toddler providers who need guidance in this area.
Even before they are truly mobile, infants are exploring the use of their muscles to push,
pull, and move their bodies in new ways. For this reason, infants, even those who cannot
yet move on their own, should never be left unsupervised, especially while lying on a
raised surface like a changing table, bed, or sofa. Changing tables should have raised
barriers around all edges to prevent an infant or toddler from accidentally rolling off the
edge.
Equipment, such as infant swings, strollers, and high chairs, should have straps to keep
children in place while the equipment is being used. These straps should be utilized every
time a child is using the equipment. Cloth straps are not recommended for use on
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diapering tables, however, because they can absorb waste materials, which can lead to the
spread of infectious disease.
Infant walkers should never be used in child care. Walkers allow infants to access
hazards that would otherwise be inaccessible. This can lead to a fall if the walker tips
over or if a child reaches un-gated steps or stairs. If you encounter caregivers who are
still using baby walkers, inform them of these risks, and also let them know that research
has shown that walkers do not actually help children learn to walk faster. Circular activity
centers without wheels are commercially available, and are a safer choice for providing
important stimulation without exposing infants to the risks that come with greater
mobility.
Infants’ and toddlers’ motor skills are still developing. They tend to have relatively poor
balance and stability when standing. When children are learning to walk, falls are
inevitable. Coach providers to use gates to block children’s access to stairs, and to use
guardrails and barriers to prevent children from falling from balconies, decks, lofts, or
other raised platforms. Stairs that children will use need to have handrails.
As infants and toddlers explore the applications of their newfound mobility, some will
develop an enjoyment of climbing. Furniture in the child care environment needs to be
selected to minimize the appeal of climbing. To the greatest extent possible, furniture in
the child-care environment should be child-sized. Adult-sized furniture should be
arranged to discourage climbing. Tables and chairs should be positioned away from
countertops and windows. Preventing climbing requires strong supervision and consistent
redirection on the part of caregivers.
Airway Obstruction & Drowning
Airway obstruction is the term used to describe injuries that create a situation where air
cannot get into and out of a child’s lungs. It can be the result of a toy becoming lodged in
a child’s throat, something constricting a child’s neck, or something covering a child’s
nose and mouth. Deaths from events that cause airway obstruction, such as suffocation,
strangulation, or choking, are relatively common. It is the leading cause of death due to
unintentional injury among children less than 1 year old. In fact, some experts believe
that as many as 900 infant deaths diagnosed as Sudden Infant Death Syndrome, or SIDS,
each year may actually be the result of suffocation. Airway obstruction remains a very
high risk among children up to age 4.
A child who is experiencing airway obstruction might have difficulty speaking, wheeze
or have trouble breathing, be unable to cough, clutch at or gesture to his throat, have a
bluish tinge to his face, appear to be straining, uncomfortable, or agitated, or inexplicably
lose consciousness. The most devastating effect of airway obstruction is the possibility of
asphyxiation, which can cause permanent brain damage or even be fatal. Asphyxiation
occurs when a child’s lungs are unable to take in oxygen for an extended period of time.
Brain damage can occur after as little as four to six minutes of oxygen deprivation.
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There are four main categories of airway obstruction that affect young children. They are
suffocation, strangulation, choking, and drowning. In the next few sections, we will
define each of these categories, discuss objects or circumstances that put children at
greater risk for each, and examine some ways you can help providers decrease the
likelihood of airway obstruction injuries.
Suffocation
Suffocation occurs when something external causes the child not to be able to bring in air
through her nose or mouth. Usually, suffocation occurs when the nose and mouth are
covered, blocking air from entering the respiratory system, but it can also occur if a child
becomes enclosed in an airtight or poorly ventilated space, such as a refrigerator.
When you or a provider assesses potential risks in the child care environment, care
should be taken to identify objects that pose the threat of suffocation. Plastic wrappers
and bags, latex gloves and balloons, and other such objects are all capable of covering a
child’s mouth and nose with an airtight seal, leading to suffocation. If these items are
used in the child care setting, they should be kept inaccessible to children at all times.
Plastic trash bags can be tied or otherwise fastened in place, and latex balloons can be
replaced with Mylar.
Areas with poor ventilation can be involved in instances of suffocation as well. The risk
of suffocation because of poor ventilation is especially high in very young children 3
years old and younger, because they are not capable of escaping easily from confined
spaces. Coolers, plastic storage boxes, large plastic trash bags, refrigerators, freezers, and
similar spaces are all confined areas in which small children might become enclosed and
be at risk of suffocation. Coach providers to keep airtight containers closed and secured,
either by placing them out of reach of children or by locking or latching openings, to the
greatest extent possible.
For infants, crib safety is crucial to the prevention of injury or death related to lack of
oxygen flow. Providers should follow all regulations and recommendations related to the
prevention of SIDS and suffocation. Remind providers to:
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Always place babies on their backs to sleep,
Remove any soft bedding or other soft items, such as comforters, pillows, or crib
bumpers, from cribs,
Always place babies in cribs to sleep, never on sofas, pillows, bean bags, adult
beds, including water beds, or other soft surfaces, and
Check that crib mattresses fit snugly into each crib, such that an adult can fit no
more than two fingers between the edge of the mattress and the crib frame.
The following video explains in detail the procedures for safe sleep for infants. These are
the recommendations for SIDS and suffocation prevention.
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[VIDEO: Safe Crib]
Strangulation
Strangulation occurs when a child’s neck becomes constricted so tightly that the trachea,
or airway, inside becomes obstructed. This prevents air from traveling into and out of the
lungs.
Children, especially infants, can suffer strangulation if they become entrapped between
slats or other pieces on cribs, high chairs, strollers, furniture, playground structures, or
any other piece of equipment. Help caregivers check the distances between slats on
furniture and equipment meant for infants, particularly cribs. A good rule of thumb is to
try to insert an ordinary can of soda between the slats. If it fits, the opening is too wide,
and can put infants at risk of entrapment and strangulation. For other types of equipment,
especially playground equipment, advise providers to look for “upward facing vees” that
could catch children’s necks in the event of a slip or fall. Upward facing vees occur when
two beams or slats come together at a point, and then extend upward in different
directions.
Other common strangulation risks include cords or drawstrings on clothing, dangling
jewelry, and loosely fitting clothing. These items can easily catch on play equipment or
furniture, pulling tight against a child’s neck and causing strangulation. These risks are
particularly high when children are using playground equipment and engaging in active
play. Encourage caregivers to prohibit the types of clothing and jewelry that could lead to
strangulation.
Strings and cords in the environment can be strangulation hazards as well. Window
coverings and certain types of toys frequently have cords or strings. Check to see that the
cords attached to window coverings are not looped, and that all cords are equipped with
tension or tie-down devices to hold them tightly in place. Remind providers that window
coverings with cords made before 2001 need to be replaced, as they are likely to put
children in danger of strangulation.
Toys with strings or cords can be hazardous as well, if the strings are long enough to
allow a child to strangle. Cords, straps, and strings on toys and equipment should ideally
be less than 7 inches long, but never more than 10 inches long. Point out toys with strings
that are too long, and encourage providers to trim them to an appropriate length.
Choking
Choking occurs when something blocks a child’s internal airway, or trachea. This can
happen if an object becomes lodged in the trachea itself, and it can also happen if
something lodged in the esophagus, the tube leading from the mouth to the stomach,
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causes a bulge. Because the esophagus and the trachea share a very small passageway, a
bulge in the esophagus can press on and block the passage of air through the trachea.
Choking is a major concern in infant and toddler care for two main reasons. First, these
children’s airways are very small and therefore can be blocked easily. Second, very
young children have a tendency to put things in their mouths as a way of exploring their
environments. With these two circumstances combined, infants and toddlers tend to be at
a higher risk of choking than children in other age groups, and special precautions need to
be taken to protect them.
The trachea is a small, cylindrically shaped tube. This means that small, round food and
objects are particularly dangerous because they can easily block a child’s whole airway.
Objects that can put children at risk include just about anything that is small enough for a
child to swallow whole, including foods, toys, parts of toys, or broken pieces of
materials. Help caregivers recognize the importance of selecting food and materials
carefully in infant and toddler care to prevent potential choking incidents. Commercially
available choke tubes or empty paper towel rolls can be used to check whether an item is
appropriate for use with infants or toddlers. Any object that fits easily inside the tube is
too small for infants and toddlers to safely use.
When selecting foods for infant and toddler care, certain foods should be avoided
altogether. Any small, hard, circular food is probably a choking hazard. Hard candy,
gum, nuts, popcorn, spoonfuls of peanut butter, and carrots are all foods that can cause
choking, and should be left off the infant or toddler menu. Other foods, like grapes,
cherry tomatoes, and hot dogs can be modified to be safer. Grapes and cherry tomatoes
can be cut into quarters, and hot dogs can be sliced length-wise and then cut into sections.
Teach caregivers about the need to supervise children carefully during meals and snacks,
and to teach children not to talk, walk, run, play, or lie down while eating.
Non-food items can be responsible for many choking incidents in child care as well.
Some examples of dangerous materials include coins, small balls, beads, jewelry,
marbles, and balloons. Sometimes the danger occurs when small pieces of an object
break off and are swallowed. All items used in the care environment should be in good
repair and should be large and sturdy enough to prevent choking. Styrofoam products,
such as cups or plates, are not recommended for use by children under 4 years old. Young
children might bite off pieces of Styrofoam, which can put them in danger of choking.
Given the risk of choking and the spread of contagious illnesses, some providers might be
tempted to prohibit infants and toddlers from mouthing objects at all. While this tactic
may appear to be based on sound logic, it is actually in counter to the best interests of
infants’ and toddlers’ learning. Infants and toddlers learn through exploration, including
mouthing. A better technique for protecting them from danger is for caregivers to
intentionally select materials that are well-made, age-appropriate, and easy to clean and
sanitize. These choices, along with sanitizing mouthed toys before they are circulated to
other children, can help keep infants and toddlers safe and healthy, while allowing them
the best opportunity to learn and grow.
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Even with supervision and selection of materials, choking emergencies are still can still
occur. Remind caregivers of the importance of maintaining current CPR and First Aid
training that includes information about appropriate Heimlich techniques and blocked
airway management for use with small children. Review the handout called Responding
to Choking Emergencies, and use it as a starting point to talk to providers about key
“Do’s and Don’ts” in a choking emergency. For example, if the child is able to cough,
adults should let her cough without interfering, and see if she is able to dislodge the
object without assistance. If the child stops coughing before the object is dislodged,
intervention may be necessary. On the other hand, neither patting a child on the back, nor
trying to remove the object by reaching fingers into the child’s throat to retrieve the
object are good responses to choking. These actions can push the object further into the
child’s throat, making the problem worse rather than better. Consider sharing copies of
the handout with the providers you work with.
Drowning
Drowning happens when a person’s nose and mouth remain submerged in water too long,
causing her to be unable to breathe. Very little water is required for drowning if the
circumstances are right. A small child can drown in less than 2 inches of water.
Supervision is the key to preventing drowning, as it is with most other injuries. Bathtubs,
sinks, toilets, buckets, puddles, spas, wading or swimming pools, and water play tubs can
be lethal to an unsupervised child. Advise caregivers that even toilet-trained toddlers and
preschoolers need to be supervised in restroom areas.
Water play is a popular activity in infant, toddler, and preschool care. Coach caregivers to
keep children safe by emptying water play containers immediately after use, and to have
an adult nearby at all times when children are engaged in water play activities.
Buckets and pails containing water or other liquids are dangerous as well. Toddlers are
top-heavy, and have limited dexterity and problem-solving capability. This makes them
more likely than other children to fall into a bucket and less likely to be able to get out.
No container of water, however big or small, should ever be left in children’s reach
unless the proper precautions are taken and the children are well supervised.
Wading and swimming pools are involved in many of the drowning incidents that involve
children. Wading pools should be emptied as soon as children are finished using them,
and should not be left where they can collect water from rain or other sources. Swimming
pools must be fenced on all four sides, and gates must remain closed at all times when
children are present. Most drowning accidents occur when a child falls into an improperly
fenced swimming pool. Even a child who knows how to swim can drown if he falls
unexpectedly into a swimming pool. Emphasize to providers that teaching children to
swim is not an adequate substitute for fencing and supervision.
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Poisoning
Poisoning is another common source of injury among children. Most incidents of
accidental poisoning occur in the home environment, but children in child care are still at
risk if dangerous substances are left within their reach. The most common substances
involved in accidental poisonings include normal household items such as cleaners,
pesticides, and medications. Animal bites and stings can also be considered instances of
poisoning in some cases.
Young children are at a particularly high risk for poisoning injuries or deaths. According
to the National Safety Council, more than half of accidental poisonings may involve
children under the age of 6. Unintentional poisoning kills more than 40 children ages 4
and under each year. The risk of poisoning is high among young children for several
reasons. As we have mentioned, these children may explore by putting things into their
mouths. They may not recognize the difference between substances that should and
should not be ingested. They spend much of their time at the floor-level, where hazardous
substances are likely to be located. Their bodies are very small, so small amounts of
hazardous substances can be toxic, and this effect is compounded by the fact that their
bodies might take longer to excrete harmful substances than the bodies of older children
and adults. Last but not least, young children tend to imitate things they see adults doing,
including using cosmetics, taking medications, or using other products that might be
poisonous.
Now we will take a few minutes to look at how poisoning is likely to happen and what
technical assistance you can provide to child care programs in order to prevent it.
Mechanisms of Poisoning
Poisons can enter the body through several mechanisms, including injection, ingestion,
inhalation, or contact with the skin or eyes. Let’s take a moment and look at how each of
these mechanisms can lead to poisoning.
Injections involve harmful substances coming in contact with the bloodstream through
openings in the skin. Sometimes this occurs when an existing wound allows a toxin
immediate access to the bloodstream. Other times it occurs because the event leading to a
puncture wound forces bacteria or other harmful substances into the wound. Tetanus is a
good example of this kind of injection poisoning. Tetanus is a condition caused by the
toxins released by a certain type of bacteria, and it is usually associated with puncture
wounds. Injection poisonings can also include animal bites or stings. The toxins injected
into the body through some bites or stings, such as a bee sting, can cause allergic
reactions in some children. Other bites or stings, such as a snake bite or scorpion sting,
can inject toxins directly into the bloodstream.
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Ingestion poisoning occurs when a harmful substance, such as a cleaning chemical or
lead-based paint, is consumed and enters the digestive tract. Poisons that are ingested can
enter the bloodstream through the same systems used to transfer nutrients from food from
the digestive tract into the blood. Ingestion poisonings are among the most frequent
instances of poisoning, particularly when considering instances involving young children.
Depending on the toxin, ingestion poisoning can occur after just one exposure to a
substance, or it can be a cumulative process over the course of many exposures. For
example, consuming antifreeze just once is likely to cause injury, but the danger of
exposure to lead-based paint takes time to accumulate.
If a child inhales a toxin, it enters the lungs are a part of the normal respiratory process,
and can then be transferred to the bloodstream along with oxygen. Harmful substances
can be inhaled if they are in vapor-form or dust-form. Carbon monoxide, ammonia,
chloride, and lead paint dust are all harmful substances that can be inhaled as either
vapors or dust. Proper ventilation can be a factor in preventing inhalation poisonings.
Poisoning can also occur when dangerous substances come in contact with the skin or
eyes and are absorbed into the body, where they reach the bloodstream. This can occur
when children come into contact with potentially toxic fluids or residues, such as residue
from chemicals used to treat an area for pests.
It may not always be easy, or even necessary, to identify the mechanism by which poison
has entered a child’s body. In fact, in some cases poison may actually enter the body
using multiple mechanisms at once. For example, a child might ingest a dangerous
chemical while simultaneously inhaling the chemical’s toxic fumes. Still, if providers are
aware of the ways poison can enter a child’s bloodstream, they can be more cognizant of
potentially hazardous situations. When necessary, take the time to talk to caregivers about
the different mechanisms associated with poisoning, and about the importance of
eliminating potentially dangerous circumstances from the care environment.
Common Toxic Substances
It is also important to share information with child care providers about the types of
materials that can be toxic. The handout called “Toxic Materials Frequently Associated
with Poisoning” gives a list of substances that should be kept out of reach of children
and, whenever possible, out of the child care environment altogether. Consider taking this
list with you during your next inspection and using it as a tool to help you assess the risk
of potential poisoning. Now let’s take a moment and explore the different toxic
substances children might encounter.
Medications are a common source of poisoning. Special care should be taken when
medications are being administered to children in care. Medicines, including vitamins
and supplements such as iron pills, may look like candy to some young children. In fact,
some adults may be tempted to refer to medication as “candy” in an attempt to entice a
young child to take prescribed medication without a fuss. Alert caregivers to the danger
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of this practice, and encourage them to be honest with children about their medications,
and to teach children that medicine is a useful tool, but it can be dangerous if used
incorrectly. Whenever possible, medications should be stored in child-resistant
packaging, and they should always be stored in a locked cabinet out of children’s reach.
Coach caregivers to put medication back in the cabinet and secure it as soon as they are
finished administering it. A child should never be left alone with medication, even if it is
in child-resistant packaging.
Certain household chemicals are also involved in many instances of poisoning. Furniture
polish, lighter fluid, antifreeze, windshield washer fluid, drain cleaner, toilet bowl
cleaner, oven cleaner, rust remover, paint thinner, turpentine, and many others can be
deadly if proper precautions are not taken. It is recommended that these products not be
in use while children are in care, and it is required that they be stored in a locked area out
of children’s reach.
Chemical pesticides are a particular concern when it comes to poisoning. This includes
things like rat poison, weed killers, ant poison, roach spray, and many others. Pesticides
are, in fact, designed to kill. Encourage caregivers to select non-toxic products before
attempting to treat with chemicals. If toxic chemicals will be used, children should not be
present. Even if children are not present when chemical pesticides are applied to the child
care environment, the fumes and residues from these products can still be lethal. Children
should be kept out of the environment until it is clear that the fumes and residues are
completely gone.
It may come as a surprise to some providers, but toiletry items, including nail polish
remover, hair spray, and some cosmetics, can be toxic as well. Let caregivers know that
personal care items, even those that seem harmless, can be dangerous, and should be kept
out of children’s reach. Even items that appear benign, like toothpaste, mouthwash, or
soap, can be harmful if they are ingested in enough quantity. Remind providers to store
their own personal items, such as purses, backpacks, briefcases, and jackets in a locked
area that is inaccessible to children. Adults’ personal belongings often contain toiletry
items, prescription and over-the-counter medications, and supplements that could be
harmful to children.
Alcohol poisoning is another potential threat to children’s health and safety. Rubbing
alcohol, alcoholic beverages, and even alcohol-based hand-sanitizers can lead to alcohol
poisoning if they are ingested by children. Products containing alcohol should be treated
like any other dangerous chemical, and stored where children cannot access them.
Licensing staff can offer technical assistance to alert providers to the dangers of alcoholbased products, including hand-sanitizers. Remind them that hand-sanitizers are not an
effective substitute for hand-washing and that these products are flammable and can be
toxic if ingested.
Carbon monoxide poisoning is a very real risk in child care environments. Standards
require that child care programs have carbon monoxide detection systems installed and in
good working order. Carbon monoxide can enter the environment when it is released
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from ordinary appliances, including many types of heating devices. Advise caregivers
that appliances that operate using natural gas or gasoline should be regularly maintained
to prevent carbon monoxide leaks from occurring.
Plants, both indoors and outdoors, can often be poisonous if ingested. Licensing staff can
provide technical assistance about the dangers and help providers understand the benefit
of taking time to teach children not to ingest plant parts, including seeds and fruits, unless
an adult who is certain the plant is safe gives them permission. Toxic houseplants should
be replaced with harmless substitutes. Wild mushrooms, while not actually a plant, may
also contain toxins. Talk to caregivers about the importance of teaching children not to
eat anything they find outside unless a trusted adult tells them it is safe.
The last group of toxic substances we are going to discuss consists of certain art materials
sometimes used by children. Regulations for art materials are discussed in licensing
standards, because some common art supplies can be poisonous if ingested or inhaled.
Some examples of potentially dangerous art supplies include powdered clay or tempera
paint, ceramic glazes or copper enamels, solvents like turpentine or rubber cement,
aerosol sprays, commercial dyes, permanent felt-tip markers, epoxy or powdered glues,
pastels, chalks, or dry markers that create dust, and instant paper mache. Instruct
providers to look for a label that says “Conforms to ASTM D-4236” to identify art
supplies that are safe for use with children. This designation comes from the Consumer
Product Safety Commission. Art supplies used in child care settings should be
intentionally selected to be non-toxic.
General Precautions to Prevent Poisoning
Even though poisoning can occur by many different mechanisms and as a result of
exposure to many different substances, there are some general precautions that providers
can take to prevent many possible poisoning scenarios. These strategies are fairly simple
to implement, but some programs may need you to provide technical assistance related to
the importance of taking precautions, and the types of steps they can take to protect
children from poisoning.
As we have already discussed, you should see that any harmful material is kept out of
reach of children and in a locked storage area. Also, check to see that chemicals are
stored in their original containers and are clearly labeled.
Remind providers that toxic materials, including medications, should be stored separately
from food. If food and toxic materials must be stored in the same room, they should be
kept in separate areas, with the poisonous substances clearly labeled and in locked
storage.
If the opportunity presents itself, you can suggest that caregivers seek out non-toxic
replacements for poisonous substances whenever alternatives are practically available.
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This can include cleaning supplies, plants, art materials, and toiletries, even if they are
not used while children are present.
Advise providers to be prepared for a poisoning emergency, should one arise. Part of this
preparation includes knowing who to call if a child is exposed to a toxin. If the child has
severe symptoms, such as a loss of consciousness, convulsions, or seizures, tell providers
they should call 911 immediately. If the child shows mild symptoms, or even no
symptoms at all, but it is suspected that he has been exposed to a toxic substance, an adult
should call the National Poison Control Center at 1-800-222-1222. Remind providers that
they must have the phone number for poison control posted near every phone used by the
child care program. Provide technical assistance to providers about having the following
information on hand when calling poison control: the child’s age and weight, the bottle or
container the poison came from, if possible), the time of the exposure, and the address
where the incident occurred.
Strongly advise child caregivers that inducing vomiting is not recommended in a
poisoning emergency. Products like syrup of ipecac are not effective in reducing the
effects of poisoning, and should not be used in child care. In addition to calling for help,
caregivers should try to identify and remove the source of the poison. This may involve
washing eyes or areas of skin that came in contact with the substance, or, in the case of
inhalation, moving the child into fresh air.
Burns
Burns occur more frequently at home than in child care, but it is still important for child
care providers to understand the risk and take intentional steps to prevent burns. Burns
can happen in many different ways. Scalding is the most common type of burn among
young children. Scalding occurs when hot liquid, such as water, coffee, tea, or soup,
comes in contact with the skin. Other causes of burns include:
 Contact with flames, such as candles or open fireplaces,
 Contact with hot surfaces or objects, such as stoves or curling irons,
 Contact with chemicals, which can occur through spills or by the child ingesting an
object, such as a watch battery, containing harmful chemicals,
 Electrical shock, which can occur from contact with electrical outlets or from chewing
on cords, and
 Overexposure to the sun.
Many licensing standards are intended to help prevent the various types of burns.
Preventing burns means protecting children from flames, hot surfaces and materials,
chemicals, electrical outlets and cords, and the sun.
To prevent scalding, water heater thermostats should be set no higher than 120 degrees
Fahrenheit. Licensing staff may find it beneficial to provide technical assistance to
minimize the risk of scalding by turning the cold water on first and off last. As children
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learn to wash their hands independently, it could be beneficial if they were taught to
follow this pattern as well.
Food and beverages are also common causes of scalding. You can remind child care staff
about the importance of checking the temperature of food before serving it to children.
This includes bottles for feeding infants. Placemats and tablecloths can create a
hazardous situation while young children are eating hot food. Children are likely to pull
on the placemat or tablecloth, which can cause hot food to fall on them. Providers need to
know that it is not safe to eat or drink hot items while holding a child in their arms or
laps. Remind infant caregivers that bottles should never be heated in the microwave,
because microwaves heat food unevenly and can cause dangerous “hot spots” in the
liquid. Instead of microwaving, encourage providers to place the bottle into a container of
warm water, or to hold the bottle under a stream of warm, running tap water.
Child care programs are required to have working smoke detectors, well-maintained fire
extinguishing systems, and regular fire drills to practice evacuation plans. All of these
requirements are in place to protect children from the dangerous consequences of coming
in contact with open flames and smoke. Additional protections you can recommend to
caregivers include keeping other sources of open flame, such as candles, matches,
lighters, and fireplaces inaccessible to children. To the greatest extent possible, the use of
these items should be avoided while children are in care. If necessary, remind providers
that smoking is not allowed in the child care environment.
Preventing contact with hot surfaces is also a matter of making sure providers understand
and takes steps to keep certain objects out of children’s reach. Kitchen appliances, space
heaters, heating vents, and metal grating around fireplaces can all get very hot. These
surfaces and objects should be made inaccessible to children. Another set of surfaces that
can heat up to dangerous temperatures can be found on the playground. The temperature
of playground equipment should be checked regularly to prevent burns from contact with
these potentially hot surfaces. If possible, outdoor place structures can be built or
relocated in the shade so they remain cool throughout the day. When outside, infant seats
and strollers should be left in the shade while not in use, never in the sun. If a caregiver
absolutely must leave a stroller in the sun, it should be covered with a sheet or towel to
keep it from becoming too hot.
Batteries and other chemicals should be labeled and locked up. Preventing chemical
burns requires following the same precautions we discussed in relation to preventing
poisoning.
Electrical burns can be prevented by covering unused electrical outlets, avoiding
plugging multiple devices into the same socket, and keeping electrical cords in good
repair and, to the greatest possible extent, where children cannot reach them. Remind
providers about the importance of regularly examining electrical cords. Cords that are
frayed, damaged, or have a coating that is peeling away should be discarded or replaced
immediately.
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Sunburns are dangerous in both the short-term and the long-term. In the short-term,
sunburns can be very painful and can cause blistering and peeling of the skin. In the longterm, repeated exposure to the sun may eventually lead to certain types of skin cancer. To
protect children, child care providers need to be aware of these risks and of the program’s
policies related to sun protection. Talk to program staff and administrators to find out
about their procedures for sun protection. These should include considerations related to
shaded areas, protective clothing, and sunscreen use.
Vehicle-Related Injuries
Vehicle-related injuries include injuries that occur both inside and outside of vehicles.
The common factor is that a motorized or non-motorized vehicle is involved in the
incident in some way. Injuries involving vehicles are the leading cause of death among
children 6 months old and older. In this section, we will discuss strategies providers need
to know to prevent injury while children are being transported, while children are in
vehicles that are not moving, while children are near vehicles, and while children are
using non-motorized vehicles. Most of the concepts we will be talking about are
precautions providers should have in place already. If you come across a program that
does not utilize these procedures, help them understand the risk and emphasize to
providers that vehicle safety is of the utmost importance, and offer suggestions to help
them begin to reform their safety measures.
During Transportation
Child care providers may need to transport children for many reasons, including field
trips, as part of pick-up and drop-off services for parents, and during emergency
situations. Transportation may take place in vans, buses, or cars. You can assess the
safety of children during transport by talking with directors and staff members of a given
program about their transportation practices.
One of the most important factors that determine how safe children are during transport is
the driver. Minimum standards require that anyone who drives children as a part of a
program of care must have a valid driver’s license. If a program is experiencing issues or
concerns with drivers, they can consider choosing drivers who have exemplary driving
records.
In order for the driver to do his job effectively, he must be able to focus on the task of
driving at all times. For this reason, it is crucial that providers maintain proper staff-tochild ratios during transportation. If at all possible, best practice is that the driver should
not be the only adult in the vehicle and should not be counted in the ratio, because the
staff who are included in the ratio are responsible for supervising children, and
supervisory responsibilities would detract from the driver’s ability to focus on driving.
However, for smaller operations, including licensed child care homes these best practice
suggestions may not be practical.
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The vehicle itself also contributes to the safety of child passengers. Vehicles should be
well-maintained and regularly inspected by an automotive professional. Issues with
program vehicles should be addressed promptly, and children should not be allowed to
ride in a vehicle with known problems. Just like any area where children are present,
daily inspections of program vehicles can help providers identify and rectify potential
hazards. Let caregivers know that this is not a requirement, but a best practice suggestion
in safely transporting children.
Vehicle safety features are ineffective if used improperly. This is true of features like
airbags, antilock brakes, and windshield wipers, as well as personal safety restraints.
Encourage providers to use power window locks and child locks on vehicle doors to
prevent children from operating doors and windows without adult assistance. A child can
break or severe a finger or even strangle in a power window.
Everyone in the vehicle should be using proper safety restraints at all times. This includes
the driver and all other adults who are riding with the children. For young children,
proper safety restraints include child safety seats and booster seats. Children should not
ride in the front seat of a vehicle. This is especially true for infants and toddlers in rearfacing child seats if the vehicle has a passenger air bar. Each safety restraint should be
used by only one person at a time. If necessary, tell providers that they absolutely may
not place more than one person in a single safety belt, seat, or booster at the same time.
Encourage caregivers to maintain up-to-date knowledge of legal requirements and best
practice recommendations for child passenger safety.
Minimum standards require that programs have a plan in place for responding to
emergencies while transporting children. If a vehicle breaks down or has an accident,
staff should know exactly what to do in regard to evacuating and supervising children.
Take the time to talk to any program employees and volunteers who participate in
transportation procedures. This conversation should include questions about the
emergency response procedures while children are in transport.
When you speak to staff responsible for transporting children, they should be able to tell
you about the items required in program vehicles while children are present. Each vehicle
that is transporting children should contain, at minimum:
 Emergency information, including contact phone numbers and medical treatment
authorizations, for each child being transported,
 A clearly visible posting of the name and phone number of the child care program,
either inside or outside the vehicle, and
 First aid kits and fire extinguishers in good working order.
In the event of an accident, emergency medical personnel may need to contact children’s
families and the child care program. Having all appropriate contact information on hand
and easy to locate will make this task easier if for some reason the adult passengers are
unable to show them where it is.
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First aid kits and fire extinguishers are useless if staff do not know where they are and
how to properly use them to respond to emergencies. Specialized training and vehicle
emergency drills conducted without children present can help providers stay alert when
transporting children. It is strongly recommend that transport vehicles carry a charged
cell phone for emergency purposes, in addition to the required materials. Remind
providers, though, that they are still responsible for supervising children during
transportation, so cell phones should only be used for emergency response.
In Parked Vehicles
Injury can occur when children are left unsupervised in a vehicle, whether or not the
vehicle is running. The rule caregivers need to be aware of is this: No child should ever
be left in a vehicle. This is true even if the vehicle is parked and the windows are left
open.
Standards require that caregivers ensure that all children are out of the vehicle before
leaving the vehicle unattended. Talk with providers about steps they can take to ensure
children are not accidentally left in a vehicle. For example, providers can make a habit of
looking in the front and the back of the vehicle every time they exit. They can also take
the time to verify each child’s presence by name and sight. They can have two adults
independently check the vehicle. There are even commercially available devices that
make a sound when the vehicle is turned off, and continue to make that sound until
someone pushes a button at the back of the vehicle.
Just like caregivers, parents are at risk for accidentally leaving a child in an unattended
vehicle. To minimize this risk, you may choose discuss, with the provider, the benefits of
developing a policy that requires parents to be contacted if a child is not present in care.
If the child was accidentally left in a vehicle, this contact may bring a life-threatening
situation to the parent’s attention before it is too late.
Securing parked vehicles is another important way caregivers can protect children.
Encourage staff to lock vehicles every time they exit, and to store keys in a location that
is inaccessible to children. Also, encourage providers to use the parking brake every time
they park a vehicle. These precautions are important even if program vehicles are parked
in a garage or gated area. Talk to program directors and staff about the importance of
teaching children about the dangers of playing in unattended vehicles.
Near Vehicles
Vehicle-related injuries can also occur when children are near vehicles, but not in them.
Such situation can arise when children are being dropped off and picked up, during
outdoor play time, or while caregivers are taking children for walks.
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Let caregivers know that supervision and vigilance can drastically reduce the likelihood a
child will experience a vehicle-related injury while outside the vehicle. Children should
always be supervised when getting into, getting out of, or walking near vehicles. Parents
should be informed of the program’s parking procedures and alerted to the danger of
letting children in and out of vehicles unsupervised. If there is a particular parking lot that
is concerning, you can discuss the benefits of stationing staff members near parking areas
to help watch for potentially dangerous situations.
Drivers of program vehicles can minimize risk by having a routine that involves checking
all around and under the vehicle for children, pets, toys, or other possible hazards before
starting the engine.
In accordance with minimum standards, play areas should be separate from areas for use
by vehicles, such as streets or parking lots. Any time children are walking near traffic or
parked cars, they should be instructed to walk, not run, and to use sidewalks and
crosswalks whenever possible. Promote the importance of teaching traffic safety to
children in child care, and recommend that caregivers teach children never to cross the
street without holding the hand of an adult.
Non-Motorized Vehicles
The last category of vehicle-related injuries concerns injuries involving non-motorized
vehicles. Non-motorized vehicles include tricycles, scooters, bicycles, and skateboards.
To prevent these types of injuries, caregivers must understand the importance of selecting
age- and size-appropriate equipment. Let them know that equipment that is too large or
too small is likely to be misused and can often lead to injuries. If it would beneficial,
licensing staff can discuss the potential benefits of creating a pathway for scooters and
tricycles, and to teach children to ride in one direction only. This helps prevent collisions
and other accidents.
A Note on Toy Safety
Toys are an important part of the exploration and learning process for young children.
Since toys are so critical to children’s development, they should be selected to
intentionally promote healthy development and prevent possible injury. Most toys are
safe. The U.S. government has tough regulations regarding toy safety, and generally
speaking, toys live up to the high expectation. However, even a safe toy can be hazardous
if used in the wrong way or by the wrong children.
The most common serious injuries related to toy use occur when children place small
toys or parts of toys in their mouths, noses, or ears, when toys are flammable, and when
toys have sharp edges. Let providers know that the best way to prevent toy-related
injuries is to choose age-appropriate toys. Safety labels on toys generally designate the
age range that can safely use the product.
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Advise caregivers that all toys should be well-constructed and well-maintained. To keep
toys well-maintained, they will have to be inspected regularly for broken or loose parts,
sharp edges, and exposed wires, nails, pins, or splinters. Damaged toys need to be
removed from use by children immediately. Remind them to check that all toys and parts
are non-toxic, washable, and do not have hinges or edges that could pinch or poke a
child. Soft toys, such as dolls or stuffed animals, need to be flame retardant, not flame
resistant.
For infants and toddlers, toys need to be selected to minimize the risk of choking. As we
mentioned earlier, these children will inevitably mouth objects, so toys should be large
enough that they do not constitute a choking hazard. Remind caregivers to check for parts
that might come loose during play and become choking hazards. A good example is the
noisemaker inside certain squeaking toys. Dolls and stuffed animals need to be securely
sewn together, and their facial features need to be molded or embroidered, not made of
buttons or other hard embellishments.
Even in infancy and toddlerhood, children need to start learning to put away toys that are
not being used. Until they are old enough to do this independently, caregivers should take
the initiative to keep unused toys off the floor and out of areas where someone might trip
over them. Toys that are left out can end up damaged and will then need to be replaced. If
children of different ages use the same play environment, remind caregivers that they
need to store toys for older children separately from toys for younger children.
Encourage providers to regularly check the Consumer Product Safety Commission’s
website, www.cpsc.gov, for information about product recalls, and to post this
information in plain view. Even if the child care program is free of recalled items, it is
beneficial for parents to view the list as well. Let providers know that they can receive
product recall information directly from the manufacturer if they take the time to fill out
warranty and product registration cards that come with new toys.
Bringing It All Together
In this course we have discussed some of the most common ways children can be injured
while in child care, and offered several practical suggestions you can pass along to
caregivers to help keep children safe. Unintentional injuries can have lasting implications
for children, and can even be fatal. Teaching child care providers how to keep children
safe is one of you most important responsibilities. Here are the major messages we’d like
you to keep in mind during your next inspection:
 Adequate supervision is the key to preventing all kinds of injuries in child care. You
should see caregivers who are aware of potential dangers, constantly alert to what is
happening in the care environment, and ready to respond if necessary,
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 Falls are the most common source of non-lethal injury to children. You can coach
providers to prevent falls by using guardrails, barriers, and hand rails, and to mitigate
the seriousness of falls by selecting appropriate equipment and surfacing, particularly
for outdoor play areas,
 There are many types of airway obstruction, and most are highly preventable. You can
coach a program to make airway obstruction injuries less likely by being conscientious
about the materials it allows in the care environment – including equipment, toys,
window coverings, clothing, and storage containers – and by keeping dangerous areas,
such as swimming pools, off limits to children,
 Poisoning injuries can be the result of many different mechanisms and many different
substances, and can be instantaneous or require repeated exposure. You can coach
caregivers to limit the risk of poisoning by removing dangerous materials from the care
environment to the greatest extent possible, either replacing toxic substances with nontoxic alternatives or removing the items altogether, and by storing harmful items in
locked areas out of children’s reach,
 There are several types of burns. You can coach child care providers to help prevent
burns by keeping children away from sources of open flame and hot surfaces, covering
unused electrical outlets, keeping electrical cords in good condition and away from
children, and having proper procedures in place to protect children from the sun,
 Vehicle-related injuries can occur whether children are inside or outside of vehicles,
whether vehicles are in motion or parked, and whether the engine is running or not.
You can coach child care programs to select competent drivers and allow them to focus
exclusively on driving, to have systems in place to prevent a child being left in an
unattended vehicle, to be prepared for emergencies while transporting children, and to
teach children and parents about the dangers in and around vehicles, and
 Toy safety is important because toys are such a critical part of the learning process for
young children. You can coach caregivers to select age-appropriate, well-constructed
toys and to regularly inspect and maintain them.
Thank you for your attention, and for your commitment to ensuring that our most
vulnerable children receive the best possible care.
* This course was developed and produced by the Texas AgriLife Extension Service
of the Texas A&M University System in cooperation with the Texas Department of
Family and Protective Services, Child Care Licensing Division, and using funds
provided under the American Recovery and Reinvestment Act of 2009.
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