Child Care Health Consultation Improves Infant and Toddler Care

Rosemary Johnston, RN, BSN, MSN; Beth A. DelConte, MD, FAAP; Libby Ungvary, Med; Richard Fiene, PhD; Susan S. Aronson, MD, FAAP


J Pediatr Health Care. 2017;31(6):684-694. 

In This Article

Abstract and Introduction


Introduction Many families enroll their infants and toddlers in early education and child care programs. The Pennsylvania Chapter of the American Academy of Pediatrics recruited 32 child care centers that care for infants and toddlers to be linked with a child care health consultant (CCHC).

Method Project staff assigned the centers alternately to an immediate intervention or a 1-year delayed intervention (contrast) group. At entry into the project, and then 1 and 2 years later, an evaluator assessed center compliance with 13 standards for infants and toddler care selected from Caring for Our Children: National Health and Safety Performance Standards (3rd ed.). Project staff linked the Immediate Intervention centers with a CCHC in Year 1. In Year 2, in a crossover comparison, project staff linked Contrast centers with a CCHC.

Results Working with a CCHC effectively improved compliance with some selected health and safety standards.


Nationally, about 48% of children younger than 3 years of age are enrolled in organized child care facilities (Laughlin, 2013). Early educators (child care staff) care for these children for many hours and many days. The quality of their care has lifelong impact on their physical, developmental, and social–emotional well-being (Garcia, Heckman, Leaf, & Padros, 2016).

In 2013, the Early Childhood Education Linkage System (ECELS), a program of the Pennsylvania (PA) Chapter of the American Academy of Pediatrics (AAP) received a 3-year grant from the Maternal and Child Health Bureau (MCHB). The purpose of the grant was to "improve state infant/toddler [I/T] child care quality initiatives (Quality Rating and Improvement Systems [QRIS] and professional development)…" MCHB's grant required selection and promotion of 10 or more standards from a list provided by MCHB from Caring for Our Children: National Health and Safety Performance Standards; Guidelines for Early Care and Education Programs, 3rd ed. (CFOC3; AAP, American Public Health Association, & National Resource Center for Health and Safety in Child Care and Early Education, 2011).

Child care programs in PA's QRIS, called Keystone STARS, are ranked from the entry level at STAR 1 to STAR 4. To earn a rating, programs must comply with state regulations and meet the requirements listed for the designated STAR level on the PA Key Web site ( For a STAR 4 rating, a center that serves infants and toddlers must have scores at or above 5 (good) on the seven subscales of the Infant and Toddler Environment Rating Scale–Revised Edition (ITERS-R; Harms, Cryer, & Clifford, 2006). The Personal Care Routines subscale of the ITERS-R has some health and safety items. Scores in this subscale and on health and safety items in some of the other subscales are among the lowest scoring ITERS-R items in PA and elsewhere. This finding is reported by the PA Key Program Quality Assessment Team (2016) and by the authors of the ITERS-R (Harms and Cryer, personal communication, 2014).

Child care health consultants (CCHCs) use observation, education, collaborative decision making, coaching, and mentoring to achieve quality improvement in the QRIS (Zaslow, Tout, & Halle, 2012). CCHCs base their work on needs and feasible implementation. For more than a decade, published research has confirmed that child care health consultation is an effective approach to improving health and safety compliance with national child care standards (Alkon and Bernzweig, 2008, Alkon et al., 2008, Alkon et al., 2009, Alkon et al., 2014, Alkon et al, nd, Alkon et al., 2002, Banghart and Kraeder, 2012, Carabin et al., 1999, Crowley, 2006, Isbell et al., 2013, Moon and Oden, 2005, Organizational Research Services and Geo Education & Research, 2007, Pacific Research and Evaluation, 2008, Pacific Research and Evaluation, 2007, Ramler et al., 2006, Roberts et al., 2000a, Roberts et al., 2000b) Most of these studies did not specifically target care for infants and toddlers.

Published studies document the following specific improvements associated with involvement of a CCHC. Sanitation and hygiene reduced respiratory and gastrointestinal illness and days absent for illness among young children in group care (Carabin et al., 1999, Kotch et al., 2007, Roberts et al., 2000a, Roberts et al., 2000b). Nationally recommended practices related to active play, nutrition, and food handling were adopted (Alkon et al., 2014). Policies and procedures accompanied by staff training reduced hazards and injuries (Kotch, 2002, Organizational Research Services and Geo Education & Research, 2007). Training about safe infant sleep positioning and the infant sleep environment reduced risk of sudden infant death syndrome (Moon & Oden, 2005). Better monitoring and tracking of immunization data in child care programs was associated with more children having up-to-date vaccine documentation (Alkon & Bernzweig, 2008).

The PA AAP established ECELS in 1989. ECELS maintains a CCHC Registry and regularly communicates with registered CCHCs to provide professional development, technical assistance, and tools to enable their implementation of the CCHC role. PA's CCHCs include private and public health service providers and health professionals who teach in academic settings. Funding for CCHC work is unpredictable, making recruitment, education, and retention of CCHCs challenging.

PA's child care regulations require that child care providers have documents showing that enrolled children are up to date with preventive health services recommended by the AAP, including "a review of the child's immunized status according to recommendations of the ACIP [Advisory Committee on Immunization Practices]" (PA Department of Human Services, 2008). This regulation is not enforced. Few providers use any reliable way to ensure that enrolled children are up to date. ECELS encourages child care centers to use a well-tested and routinely updated online software application called WellCareTracker™ (Weinburg, 2002) to check child health records for up-to-date routine preventive health services. It is described, demonstrated, and offered for subscription at Using WellCareTracker™ eases the burden for child care providers to comply with the regulation and remind families to obtain these services in a timely manner.