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Temporary exclusion is recommended when the child has any of the following conditions: a. The illness results in a need for care that is greater than the staff can provide without compromising the health and safety of other children; c. A severely ill appearance - this could include lethargy/ lack of responsiveness, irritability, persistent crying, difficult breathing, or having a quickly spreading rash; d. Diarrhea is defined by stools that are more frequent or less formed than usual for that child and not assocIated with changes in diet. Exclusion is required for all diapered children whose stool is not contained in the diaper and toilet-trained children if the diarrhea is causing "accidents". In addition, diapered children with diarrhea should be excluded if the stool frequency exceeds two stools above normal for that child during the time in the program day, because this may cause too much work for 143 Chapter 3: Health Promotion and Protection the caregivers/teachers, or those whose stool contains blood or mucus. Readmission after diarrhea can occur when diapered children have their stool contained by the diaper (even if the stools remain loose) and when toilettrained children are not having "accidents" and when stool frequency is no more than 2 stools above normal for that child during the time in the program day; Special circumstances that require specific exclusion criteria include the following (2): A health care provider must clear the child or staff member for readmission for all cases of diarrhea with blood or mucus. Children and staff members with Shigella should be excluded until diarrhea resolves and test results from at least 1 stool culture are negative (rules vary by state). Children and staff members with Salmonella serotype Typhi and Paratyphi are excluded until test results from 3 stool cultures are negative. State laws may govern exclusion for these conditions and should be followed by the health care provider who is clearing the child or staff member for readmission. Vomiting more than two times in the previous twentyfour hours, unless the vomiting is determined to be caused by a non-infectious condition and the child remains adequately hydrated; b. Abdominal pain that continues for more than two hours or intermittent pain associated with fever or other signs or symptoms of illness; c. Rash with fever or behavioral changes, until the primary care provider has determined that the illness is not an infectious disease; e. Impetigo, only if child has not been treated after notifying family at the end of the prior program day. Exclusion is not necessary before the end of the day as long as the lesions can be covered; g. Head lice, only if the child has not been treated after notifying the family at the end of the prior program day. Scabies, only if the child has not been treated after notifying the family at the end of the prior program day. Chickenpox (varicella), until all lesions have dried or crusted (usually six days after onset of rash and no new lesions have appeared for at least 24 hours); k. Any child determined by the local health department to be contributing to the transmission of illness during an outbreak. The child should be supervised by someone who knows the child well and who will continue to observe the child for new or worsening symptoms. Toys, equipment, and surfaces used by the ill child should be cleaned and disinfected after the child leaves; b. Discuss the signs and symptoms of illness with the parent/guardian who is assuming care. If necessary, provide the family with a written communication that may be given to the primary care provider. The communication should include onset time of symptoms, observations about the child, vital signs and times (e. The nature and severity of symptoms and or requirements of the local or state health department will determine the necessity of medical consultation. Telephone advice, electronic transmissions of instructions are acceptable without an office visit; c. If the child has been seen by their primary health provider, follow the advice of the provider for return to child care; 144 Caring for Our Children: National Health and Safety Performance Standards d. If the child seems well to the family and no longer meets criteria for exclusion, there is no need to ask for further information from the health professional when the child returns to care. Children who had been excluded from care do not necessarily need to have an in-person visit with a health care provider; e.

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Afferent nerves in the dorsal root ganglion synapse with neurons in the dorsal horn. These signals result in reflexes that control motor and secretory functions as they synapse with efferent paths in the prevertebral ganglia and spinal cord. Ultimately, stimulation of the brainstem brings sensation to a conscious level (Figure 6). Bidirectional signaling between the brainstem and the dorsal horn mediate sensation. The descending pathways are primarily adrenergic and serotonergic and affect incoming stimuli. End organ sensitivity, stimulus intensity changes or receptive field size of the dorsal horn neuron and limbic system modulation are the mechanisms involved in visceral hypersensitivity. Sensory pathway in Irritable Bowel Syndrome: an animated sequence (To view, click on the image above). Enteric inflammatory cells may also play an important role in the pathophysiology of Irritable Bowel Syndrome. In patients with rapid transit times, short or medium chain fatty acids can reach the right colon and cause diarrhea. In addition to pain and discomfort, altered bowel habits are common, including diarrhea, constipation, and diarrhea alternating with constipation. Patients also complain of bloating or abdominal distension, mucous in the stool, urgency, and a feeling of incomplete evacuation. Some patients describe frequent episodes, whereas others describe long symptom-free periods. Patients with irritable bowel frequently report symptoms of other functional gastrointestinal disorders as well, including chest pain, heartburn, nausea or dyspepsia, difficulty swallowing, or a sensation of a lump in the throat or closing of the throat (Figure 8). Some patients have diarrhea-predominant symptomatology, others constipation-predominant, and still others have a combination of the two. Symptoms may vary from barely noticeable to debilitating, at times within the same patient. In some patients, stress or life crises may be associated with the onset of symptoms, which may then disappear when the stress dissipates. The disorder is also recognized in children, generally appearing in early adolescence. These may include headache, sleep disturbances, post-traumatic stress disorder, temporomandibular joint disorder, sicca syndrome, back/pelvic pain, myalgias, back pain, and chronic pelvic pain (Figure 8). The ascending colon rises from the cecum along the right posterior wall of the abdomen, under the ribs to the undersurface of the liver. The transverse portion crosses the abdominal cavity toward the spleen, then goes high up into the chest under the ribs, and turns downward at the splenic flexure. Continuing along the left side of the abdominal wall to the rim of the pelvis, the descending colon turns medially and inferiorly to form the S-shaped sigmoid (sigma-like) colon. The rectum extends from the sigmoid colon to the pelvic floor muscles, where it continues as the anal canal terminating at the anus (Figure 9). Glands secrete large quantities of alkaline mucus into the large intestine, and the mucus lubricates intestinal contents and neutralizes acids formed by bacteria in the intestine. These bacteria aid in decomposition of undigested food residue, unabsorbed carbohydrates, amino acids, cell debris, and dead bacteria through the process of segmentation and putrefaction. Short-chain fatty acids, formed by bacteria from unabsorbed complex carbohydrates, provide an energy source for the cells of the left colon. The sympathetic and parasympathetic nervous systems innervate the gastrointestinal tract (Figure 10). Both carry sensory stimuli, though it appears that spinal affrent nerves in the dorsal horn of the spinal cord process pain. Sensory pathway in Irritable Bowel Syndrome, an animated sequence (To view, click on the image above). The most current research on the topic suggests a biopsychosocial model of the disorder, implicating physiological, emotional, behavioral and cognitive factors. It is thought that these psychiatric disturbances influence coping skills and illness-associated behaviors.

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If utility gloves are used, they should be cleaned after every use with soap and water and then dipped in disinfectant solution up to the wrist. The wearing of gloves does not prevent contamination of hands or of surfaces touched with contaminated gloved hands. Hand hygiene and sanitizing of contaminated surfaces is required when gloves are used. Ongoing exposures to latex may result in allergic reactions in both the individual wearing the latex glove and the individual who contacts the latex glove. Caregivers/teachers should take the following steps to protect themselves, children, volunteers, and visitors from latex exposure and allergy in the workplace (6): a. Use non-latex gloves for activities that are not likely to involve contact with infectious materials (food preparation, diapering, routine housekeeping, general maintenance, etc. Such gloves reduce exposures to latex protein and thus reduce the risk of latex allergy; 2. However, they may reduce reactions to chemical additives in the latex (allergic contact dermatitis); c. When wearing latex gloves, do not use oil-based hand creams or lotions (which can cause glove deterioration); e. Practice good housekeeping, frequently clean areas and equipment contaminated with latex-containing dust; g. Attend all latex allergy training provided by the facility and become familiar with procedures for preventing latex allergy; h. Learn to recognize the symptoms of latex allergy: skin rash; hives; flushing; itching; nasal, eye, or sinus symptoms; asthma; and (rarely) shock. Natural fingernails that are long or wearing artificial fingernails or extenders is not recommended. Child care facilities should develop an organizational policy on the wearing of non-natural nails by staff (2). Each term has a specific purpose and there are many methods that may be used to achieve such purpose. Task Clean Purpose To remove dirt and debris by scrubbing and washing with a detergent solution and rinsing with water. The friction of cleaning removes most germs and exposes any remaining germs to the effects of a sanitizer or disinfectant used later. To reduce germs on inanimate surfaces to levels considered safe by public health codes or regulations. Facilities should follow a routine schedule of cleaning, sanitizing, and disinfecting as outlined in Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting. Cleaning, sanitizing and disinfecting products should not be used in close proximity to children, and adequate ventilation should be maintained during any cleaning, sanitizing or disinfecting procedure to prevent children and caregivers/ teachers from inhaling potentially toxic fumes. Illnesses may be spread in a variety of ways, such as by coughing, sneezing, direct skin-to-skin contact, or touching a contaminated object or surface. Respiratory tract secretions that can contain viruses (including respiratory syncytial virus and rhinovirus) contaminate environmental surfaces and may present an opportunity for infection by contact (1-3). For example, if there is visible soil on a diaper changing or table surface, clean it with detergent and water before spraying the surface with a sanitizer or disinfectant. Using a sanitizer or disinfectant as this "first step" is not effective because the purpose of the solution is to either sanitize or disinfect. Disinfect To destroy or inactivate most germs on any inanimate object, but not bacterial spores. Note: the term "germs" refers to bacteria, viruses, fungi and molds that may cause infectious disease. Bacterial spores are dormant bacteria that have formed a protective shell, enabling them to survive extreme conditions for years. The spores reactivate after entry into a host (such as a person), where conditions are favorable for them to live and reproduce (5). In addition, some manufacturers of cleaning products have developed "green cleaning products". As new environmentally-friendly cleaning products appear in the market, check to see if they are 3rd party certified by Green Seal:.

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Lead and copper rule: A quick reference guide for schools and child care facilities that are regulated under the safe Drinking Water Act. However, long-term storage of bottled water may result in aesthetic defects, such as off-odor and taste. Commercial bottled water containers should not be used for any purpose other than to hold drinking water. All drinking water containers must be thoroughly washed and sanitized prior to being refilled with drinking water. Early care and education programs should maintain photocopies of all watertesting results if the business is required to submit reports to the regulatory authority. State and local codes vary, but they generally protect against toxins or sewage entering the water supply. Backflow preventers, vacuum breakers, or strategic air gaps should be provided for all boiler units in which chemicals are used. Vacuum breakers should be installed on all threaded janitorial sink faucets and outdoor/indoor hose bibs; c. Non-submersible, antisiphon ballcocks should be provided on all flush tank-type toilets. Water must be protected from cross-connections with possible sources of contamination (1). The ends of a hose in a janitorial sink and a garden hose attached to an outside hose bibs are often found in a pool of potentially contaminated water. If the water faucet is not com- pletely closed, a loss of pressure in the water system could result in the contaminated water being drawn up the hose like dirt is drawn into a vacuum cleaner, thus contaminating the drinking water supply. Vacuum breakers may be installed as part of the plumbing fixture or are available to attach to the end of a faucet of hose bib. When plumbing is unavailable to provide a handwashing sink, the facility should provide a handwashing sink using a portable water supply and a sanitary catch system approved by a local public health department. A mechanism should be in place to prevent children from gaining access to soiled water or more than one child from washing in the same water. However, in emergency situations when a supply of running water or hand sanitizer may not be realistically available, sinks with a portable water supply can be used. Before purchasing, facilities should consult with their local health department on what types of portable sinks are allowed or approved for use. The pressure should be regulated so the water stream does not contact the orifice guard or splash on the floor, but should rise at least two inches above the orifice guard. Drinking fountains should be cleaned and disinfected at least daily and whenever visibly dirty. At least eighteen inches of space should be provided between a drinking fountain and any kind of towel dispenser. Space between a drinking fountain and sink or towel dispenser helps prevent contamination of the drinking fountain by organisms being splashed or deposited during use. Moist surfaces such as drinking fountains in child care centers can be sources of rotavirus contamination during an outbreak (1). The weight of children or the combined weight of children and playground equipment may cause the drainage field to become compacted, resulting in failure of the system. The legs of some equipment, such as swing sets, can puncture the surface of drainage fields. In areas where frequent rains are coupled with high water tables, poor drainage, and flooding, the surface of drainage fields often becomes contaminated with untreated sewage. Staff should consult with the local public health department regarding sewage storage and disposal. The national/ international organization representing on-site wastewater/ sewage interests is the National On-Site Wastewater Recycling Association, Inc. Where public sewers are not available, an on-site sewage system or other method approved by the local public health department should be installed. The wastewater or septic system drainage field should not be located within the outdoor play area of a child care program, unless the drainage field has been designed by a sanitation engineer with the presence of an outdoor play area in mind and meets the approval of the local health authority.