Section 6 - Infection Control
Purpose: The following recommendations are based on limited published materials concerning infection control information that is specifically applicable to hospital management of a large influx of children (and accompanying adults) affected by a biological disaster. While the principles of infection control are the same for adults and children, there are some unique issues in the population that will be highlighted. The following infection control guidance addresses the 3 populations of concern in a pediatric emergency:
- Exposed/symptomatic children
- Exposed/asymptomatic children
- Unexposed neonates and mothers
- General Guidelines
- Infection Control Measures for Exposed/Asymptomatic Children
- Infection Control Measures for Exposed/Symptomatic Children
- Cohorting of Children in a Hospital Setting
- Environmental Measures for Pediatric Units
- Additional Infection Control Measures for Unexposed Neonates
- Staff-to-Child Ratio and Group Size Indicator
- Appendices - Toy Cleaning Protocol
- For all children who are symptomatic due to a biological event, use applicable HICPAC Guidelines (currently 2007 Guidelines for Isolation Precautions in Hospitals);1 recommendations (such as duration of isolation) sometimes differ between adults and children.
- For asymptomatic infants, toddlers, and other children requiring diapering, feeding, toileting, and assistance with hand hygiene, use guidelines that are applicable to day care settings. (See the following Web sites: US Department of Health and Human Services, 13 Indicators of Quality Child Care: Research Update, 2002. Available at: http://www.aspe.hhs.gov/hsp/ccquality-ind02/2 and American Academy of Pediatrics, American Public Health Association, and National Resource Center (NRC) for Health and Safety in Child Care, 2002. Caring for Our Children (CFOC): National Health and Safety Performance Standards: Guidelines for Out-of-Home Child Care Programs, 2nd edition. Available at: http://nrckids.org/CFOC/index.html.3
General Infection Control Measures
Transmission of an infectious agent requires three elements: a source (or reservoir) of infectious agents, a susceptible host with a port of entry receptive to the agent, and a mode of transmission for the agent.1 Modes of transmission vary by type of organism and can be categorized into 3 major categories: contact (direct or indirect), droplet or airborne. Based on the specific characteristics of an infectious agent, a clinical case definition for exposed/symptomatic and exposed/asymptomatic children will need to be provided or developed.
- Promptly evaluate and separate unexposed and exposed/asymptomatic children as soon as possible from symptomatic children and symptomatic adults.
- While there is a known risk of transmission of infectious agents from infectious children to caregivers, the presence of caregivers (asymptomatic or symptomatic) may be in the best interest of the child (asymptomatic or symptomatic).
- Caregivers must be instructed in relevant isolation and care procedures as outlined in the hospital infection control manual on exposed/asymptomatic and exposed/symptomatic children.
- Signage should be posted in all relevant areas and fact sheets or parent education sheets handed out.
Infection Control Measures for Exposed/Asymptomatic Children:1
- Primary caregivers of exposed children should also be considered exposed and need to be screened for symptoms on a regular basis or when entering the facility.
- If it is in the best interest of a child that potentially infectious caregivers are allowed to visit, then they should use appropriate barrier precautions (e.g. mask) and remain in the patient's room.
- Similarly exposed/asymptomatic children may be cohorted. In very infectious situations, the whole facility may be cohorted.
- Day care approaches apply for the routine care of children and need to be communicated concisely and understandably to the caregivers who accompany the admitted child.2,3
- Hand hygiene is paramount. Children and caregivers need to be taught how to perform appropriate hand hygiene in a playful manner, such as singing "Happy Birthday" to ensure at least 20 seconds of hand washing with soap and water.
- Hand-washing by children and caregivers should be performed:
- Before and after eating and giving medication.
- After diapering, toileting, cleaning, and the handling of body fluids, even if gloves are used.
- As a priority: educate emergency caregivers (parents or others) about sanitary considerations and demonstrate specific isolation procedures to children in a playful manner.
Infection Control Measures for Exposed/Symptomatic Children:1
In addition to the points listed under infection control measures for exposed/asymptomatic children, the following points apply:
- HICPAC Isolation guidelines apply: appropriate to the nature of the illness/exposure.1
- Cohort as necessary (same exposure/same symptoms) based on space availability.
- Use of surgical facemasks as source containment (e.g. during transport) is inappropriate in infants. It may be possible to instruct toddlers in an age-appropriate manner to wear masks if constant supervision is possible. Children over 3 years must be instructed and their compliance evaluated.
- Respiratory hygiene/cough etiquette as an alternative to masking should be emphasized.4
Cohorting of Children in a Hospital Setting:
- Ideally cohort according to age group to accommodate sanitary needs of infants and young children (e.g., diapering, toileting, hand hygiene, feeding and cleaning).
- Traumatized children may regress under duress and may require additional help with sanitary needs.
- Smaller group size is associated with a lower risk of infection in child care settings (See 13 Indicators of Quality Child Care, p.16).2
- Support infection control by aiming for recommended age-appropriate staff-to-child ratios. (See 13 Indicators of Quality Child Care, p.15: Staff:Child Ratio and Group Size Indicator).2
Environmental Measures for Pediatric Units:
- Establish hand hygiene procedures and ensure adequate supplies of soap, sinks, paper towels and alcohol-based hand sanitizers in patient rooms.
- For infants/young children: establish diapering protocols and distribute to caregivers. 2,3
- Hospitals without pediatric services have diapering protocols for adults, which should be easy to adapt for infants and children.
- For infants/young children: use the DHHS document2 (or similar) for guidance pertaining to setting up sanitary changing stations.
- For young children: toys should be easy to clean (hard plastic not fuzzy) and not be shared with other children. Toy cleaning protocol is attached as appendices.
- For young children: assign individual sleeping mats (if used).
- For infants/young children: adequate clean linens, disposable diapers, changes of clothing.
- Waste/soiled linen collection units should be child safe, adequate in number, constructed to permit hands free use.
- Have cleaning/disinfecting materials stored in a child safe manner.
- Have cleaning/disinfection procedures and schedules in place for toilets, bathrooms, changing stations, sleeping mats, toys, etc.
- Note any restrictions on disinfectant products used and do not use while in direct contact with children.
- Any reusable equipment or toys should be appropriately cleaned following hospital infection control procedures, or as recommended for the agent of concern.
- In addition to existing cleaning/disinfection procedures, schedules should also be in place for cleaning/disinfecting changing stations, sleeping mats, toys, and other items and equipment that may become contaminated and a source for passing on infection. A 2-minute contact with household bleach (1/4 cup per gallon tap water) or other Environmental Protection Agency-approved agent is recommended for sanitization.3
- Read labels carefully to ensure that cleaning products are nontoxic to children.
Additional Infection Control Measures for Unexposed Neonates
- Whenever possible, keep healthy mothers and their infants together. Cohort mothers and children together as a single unit. Behavioral, emotional and mental discomfort/disorders in the mother may be exacerbated by the emergency environment. When they cannot be kept together, ensure that there is good communication with the family, so that they are aware of where the patients are and what type of care they are receiving.
- Remember in selecting the location for cohorting that newborns require a dry, clean, warm environment to promote thermoregulation and minimize stress. A quiet environment would be best for promoting mother-infant bonding.
- Alternative sites for care of newborns and their mothers may need to be arranged in order to keep the neonate and new mother out of close proximity to infectious patients.
- Caregiver ratios need to be lower for newborns and infants than for older children. See the day care standards that follow as a guide to staff-to-child ratios.
Staff-to-Child Ratio and Group Size Indicator
There are two sources of guidance for staff-to-child ratios and group size. Caring for Our Children outlines national standards used for child care,3 however, there are specific state regulations regarding staff-to-child ratio and group size.5 The Caring for Our Children standard (ST 002)3 appears in the first chart. The New York State Day Care Center Regulations5 are cited in the second chart. Either of these may be used for guidance on group size and ratios.
|Caring for Our Children Standards2|
|Age of Children||Child-to-Staff Ratio||Maximum Group Size|
|3 years olds||7:1||14|
|4 year olds||8:1||16|
|5 year olds||8:1||16|
|6-8 year olds||10:1||20|
|9-12 year olds||12:1||24|
|NYS Day Care Licensing Standards5|
|Age of Children||Child-to-Staff Ratio||Maximum Group Size|
|Under 6 weeks||1:3||6|
|6 weeks-18 months||1:4||8|
|Thru 9 years||1:10||20|
According to Caring for Our Children, when there are mixed age groups in the same room, the child-to-staff ratio and group size shall be consistent with the age of the majority of the children when no infants or toddlers are in the mixed age group. When infants or toddlers are in the mixed age group, the child-to-staff ratio and group size for infants and toddlers shall be maintained.2,3
Similarly, NYS Day Care Regulations state that children under three years of age may not participate in mixed age groups except that for limited periods of time at the beginning and end of the child day care center's daily operation. Infants may never be placed in mixed age groups. When toddlers are cared for in mixed age groups, the staff-to-child ratio and maximum group size applicable to children, aged 18 months to 36 months, must be followed. When children 3 years of age or older are cared for in mixed age groups, follow the staff-to-child ratio and maximum group size applicable to the majority of the children in the group.
That is, unless the difference in age between the youngest and oldest child in the group is more than two years. In that case, the staff-to-child ratio and maximum group size applicable to children 2 years older than the youngest child in the group shall apply.5
Smaller group size is associated with a lower risk of infection in childcare. The risk of illness in children between the ages of 1 and 3 years of age increases as the group size increases to 4 or more. Children in groups of 3 or fewer have no more risk of illness than children cared for at home.6,7 The risk of repeated ear infections increases in one- to six-year-old children who attend childcare in groups of more than 6 children.8
The risk of Haemophilus influenza infections increases for children 1 year of age or older in a childcare setting with 4 or more children. The risk of infection peaks in settings with 21 or more children. Smaller childcare centers, not just those with smaller class sizes, have lower rates of disease. Outbreaks of Hepatitis A occur at the rate of 3% in centers that enroll less than 20 children but 53% in those that enroll 51 or more children.9 Children in small child care centers in France had 2 to 3 times the risk of repeated infections (e.g., upper respiratory tract infections, otitis media, conjunctivitis) than children in family child care settings with no more than 3 children.10
Lower child-to-staff ratios reduce the transmission of disease. There is little research available that examines the relationship between particular child-to-staff ratios and children's health (a major gap that needs to be addressed). However, the research that is available suggests that fewer children per adult reduces the transmission of disease because caregivers are better able to monitor and promote healthy practices and behaviors.11,12
1. Siegel JD, Rhinehart E, Jackson M, Chiarello L, for the Healthcare Infection Control Practices Advisory Committee. The 2007 guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings [Centers for Disease Control and Prevention Web site]. Atlanta, GA: Public Health Service, US Department of Health and Human Services, Centers for Disease Control and Prevention; 2007. Available at:http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf. Accessed February 9, 2010.
2. Fiene R. 13 Indicators of Quality Child Care. National Resource Center for Health and Safety in Child Care, University of Colorado, collaborator [Assistant Secretary for Planning and Evaluation Web site]. Washington, DC: Office of the Assistant Secretary for Planning and Evaluation; Health Resources and Services Administration/Maternal and Child Health Bureau, United States Department of Health and Human Services; 2002. Available at:http://aspe.hhs.gov/hsp/ccquality-ind02/index.htm. Accessed February 9, 2010.
3. American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education. Caring for Our Children: National Health and Safety Performance Standards: Guidelines for Out-of-Home Child Care Programs. 2nd ed [National Resource Center for Health and Safety in Child Care and Early Education Web site]. Elk Grove Village, IL: American Academy of Pediatrics and Washington, DC: American Public Health Association; 2002. Available at: http://nrckids.org/CFOC/index.html. Accessed February 9, 2010.
4. Respiratory hygiene/cough etiquette in healthcare settings page. Centers for Disease Control and Prevention Web site. Available at:http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm. Accessed February 9, 2010.
5. Day care regulations page. New York State Office of Children & Family Services Web site. Available at:http://www.ocfs.state.ny.us/main/childcare/regs/418-1_CDCC_regs.asp. Accessed February 9, 2010.
6. Bartlett AV, Orton P, Turner M. Day care homes: the "silent majority" of child day care. Rev Infect Dis. 1986;8(4):663-668.
7. Bell DM, Gleiber DW, Mercer AA, Phifer R, Guinter RH, Cohen AJ, Epstein EU, Narayanan M. Illness associated with child day care: a study of incidence and cost. Am J Public Health. 1989;79(4):479-484.
8. Hardy AM, Fowler MG. Child care arrangements and repeated ear infections in young children. Am J Public Health. 1993;83(9):1321-1325.
9. Hadler SC, Erben JJ, Francis DP, Webster HM, Maynard JE. Risk factors for hepatitis A in day-care centers. J Infect Dis. 1982;145(2):255-261.
10. Collet JP, Burtin P, Kramer MS, Floret D, Bossard N, Ducruet T. Type of day-care setting and risk of repeated infections. Pediatrics. 1994;94(6 Pt 2):997-999.
11. Bredekamp S, ed. Developmentally appropriate practice in early childhood programs serving children from birth through age 8. Exp ed. Washington, DC: National Association for the Education of Young Children; 1990.
12. Panel on Child Care Policy, Committee on Child Development Research and Public Policy, Commission on Behavioral and Social Sciences and Education, National Research Council. Who Cares for America's Children? Child Care Policy for the 1990s. Hayes CD, Palmer JL, Zaslow MJ, eds. Washington, DC: National Academy Press; 1990.