Special Health Care for Child Care Settings:

by Trudy Norton

Special health care refers to health care beyond that typically provided in child care settings -- health care for which care providers require additional information, training and support.

In recent years, the survival rate of babies and children with special health needs has increased dramatically. Advances in medical science and technology are not only saving lives, but also providing mobility to children previously confined to home or hospital. Today, children with a variety of special health care needs are attending child care programs. Their inclusion reflects a commitment to mainstreaming and to providing the opportunity for all children to enjoy typical childhood experiences.

It is estimated that one in 10 children has some type of cognitive, physical, communicative or emotional special need. Of these children, approximately 10 per cent require special health care intervention for a chronic illness or allergy, injury trauma, disability or serious infectious disease. Conditions and symptoms within each of these categories range from mild to severe and may be long- or short-term. It is always important to consider the unique circumstances and individuality of each child.

Meet the Children

The following excerpts are taken from parent stories collected for the Special Health Care Project in 1992.¹ Written by mothers, they are examples of special health care needs which children attending child care programs may have. As well, they provide a family perspective on positive inclusive experiences. In each case, child care staff were trained by health professionals to provide the necessary health care.

Carly

Carly and her twin sister, Angela, were born at 25 weeks gestation. Carly required life support intervention for four months and did not join Angela at home until she was a year and a half old. She continued to require oxygen therapy 24 hours a day and her nutritional needs were met with gastrostomy feeding. Both of the children have cerebral palsy, although Carly is more severely affected than Angela.

When Angela began to attend preschool, it was clear that Carly was aware that she was missing out on new activities. We were hesitant to enrol Carly because of her health condition, but we also believed that there would be many benefits to having her participate.

Her oxygen therapy was the first concern, but she also required other care, such as chest physiotherapy for her chronic lung condition and physio "stretches" to maintain her range of motion. The physiotherapist came in and demonstrated the technique, the staff demonstrated back and then the physio "signed them off." The health nurse wrote up a health care plan and trained the staff to feed Carly.

It was a smooth transition once everything was in place.

-- April Plasteras

Kevin

Kevin was 14 months old when I gave him peanut butter for the first time. Within seconds, his neck, face and eyes were swollen. His face was bright red and completely covered with hives. That was his first allergic reaction. Since then, there have been other milder reactions and the potential for a severe reaction -- anaphalactic shock -- is very real.

Without medical intervention, the airways to the lungs become blocked, blood pressure drops, the victim loses consciousness and may die. An allergic reaction can occur within minutes of exposure, but sometimes it is several hours before the life-threatening symptoms appear.

Kevin attended child care and is now in kindergarten. A great deal of care and attention went into preparing for his inclusion in both settings. The environment had to be nut-free and Kevin was required to follow strict eating guidelines. Training care providers and teachers in preventative procedures and emergency responses was essential to ensuring a safe environment for Kevin. The health nurse taught all staff members to recognize warning signs of an emergency and the correct procedure for administering Epi-Pen.

At home and away from home, everyone is very careful and diligent about Kevin's needs and we have avoided another life-threatening emergency.

-- Colleen Sipila

Stephanie

Stephanie has spina bifida and hydrocephalia. Because of the spina bifida, Stephanie is catheterized. Two of the staff at the centre were trained in the procedure by a nurse. I demonstrated and then the nurse provided additional information that she felt was necessary for the staff to know.

Stephanie uses crutches now. Being with the able-bodied children was a big incentive. Lots of play activity is up, over, into or under things. She still uses her walker outside, but inside she wants to be as unrestricted as possible. The other children help her when she needs it. For instance, if she crawls somewhere, they will run over with her crutches. But they don't baby her. Sometimes she will try to tell them, "I can't." They reply, "I think you can do it Stephanie. Come on!"

Although she has always been a strong little personality, she is becoming increasingly capable and has gained confidence. Interestingly, it is often the children whom you would least expect to respond to Stephanie who do so.

-- Tracey McDougall

Jake

Jake was born with only 10 per cent of his short intestine. A few years ago he would not have survived. He spent his first two years in the hospital fighting for his life. When preparations began for Jake to leave the hospital, I was totally overwhelmed. He required gastrostomy feeding 24 hours a day. How would I manage all day with this active, busy little boy tethered to a gastric feeding pump on a stationary intravenous pole? Then someone heard about a pumping machine that only weighed two pounds. We tried having Jake wear one in a little back pack so that he could be mobile. It worked, and my son became a pioneer. Gradually, Jake was able to eat more more food orally and his gastrostomy feedings were primarily done at night.

Finding a day care was a confusing and challenging time for me, but the one I chose felt like home to me from the moment I walked in. Day care is very important to me. Before Jake started attending, I focused my energy on his special needs. Day care taught me to treat him as a child first. I saw him playing and laughing, growing and learning, just like the other children.

-- Nancy Sweedler

Team Approach to Planning

A team coordinating supports for the inclusion of children with special health care needs may include parents, health care professionals, program staff and community consultants. While the composition will vary with the child's condition and with local resources and delivery systems, a multidisciplinary approach is important in order to ensure full and accurate information is shared.

Specific tasks of team members include assessing the child's health, developing an Individual Health Care Plan (IHCP), training and establishing emergency procedures. Program planning considers any adaptions which may be necessary in order to best meet the needs of the child and other children attending the program.

A health professional assesses the child's health to determine the stability of the child's condition and to decide if the health care procedures involved can be safely and appropriately delegated to a non-health professional. In cases where clinical judgement is required, a health professional must be responsible for the child's health care. For example, if a child requires adjustments of oxygen flow in response to changes in his or her condition while at a child care program, a nurse attends to the child. If, as in Carly's case, the flow is set before arrival and remains constant, a non-health professional may administer the therapy.

An IHCP is written by a health professional in collaboration with parents. It provides specific information about the child's health history and current health status. It documents the special heath care that the child requires while at the centre. The "how to" of care procedures, the warning signs and symptoms of an emergency and emergency procedures are detailed. An IHCP is a legal document; it must be approved and signed by the health professional and parent.

Training of child care staff looks at four areas: background information about special health care; condition-specific information; child-specific information; and skill development in delegated nursing tasks. Questions about knowledge and skills to be taught, who will provide the training and who will participate in training are answered with the safety of the child as well as the safety and protection of the care provider in mind. Arrangements are confirmed for ongoing monitoring of the skills of care providers and retraining as necessary.

Child Care Programs

Planning within a child care program for the enrolment of a child with special health care needs will likely include administrative preparations. There are inherent risks involved because the centre is an educational and child care facility, not a health care facility. Therefore, insurance coverage and liability concerns require careful attention.

Parents must fully understand and acknowledge the potential risks. As with any medical intervention or procedure for children, it is imperative that parents give their informed consent to the provision of special health care.

Insurance coverage and liability are determined by assessing risk. For this reason, insurance underwriters must be assured that decisions regarding the safe and appropriate delegation of nursing tasks, training to provide special health care and monitoring of the procedures have been made by a health professional. Insurance companies must know that inherent risks have been identified and addressed.

The risk of liability has posed one barrier to mainstreaming children with special health care needs in early childhood programs. With this risk minimized, child care providers can focus on creating supportive environments and quality programs for all children.

Trudy Norton is Co-director of an inclusive child care facility serving families of children aged three to 12 in four licensed programs. She is Past President of the Early Childhood Educators of British Columbia and was Principal Researcher of the Special Health Care Project.

Recommended Resources

Canadian Paediatric Society (1992). Well Beings: A Guide to Promote the Physical Health, Safety and Emotional Well Being of Children in Child Care Centres and Family Day Care Homes Volumes I & II. Toronto, Ontario: Creative Premises, Ltd.

In Their Own Special Way [video] (1993). Vancouver, B.C.: MediaVision.

Infection Control in Child Care Settings [video]. Lawrence, Kansas: Learner Management Designs, Inc.

Taking Off Lids (1990) [video]. Ottawa, Ontario: Cerebral Palsy Association.

Urbano, M.T. (1994). Preschool Children with Special Health Care Needs. Washington, D.C.: NAEYC.

Wolery, M. (1994). Including Children with Special Needs in Early Childhood Programs. Washington, D.C.: NAEYC.

1. The Special Health Care Project was funded by the Child Care Initiatives Fund between 1990 and 1994 to research the issues involved when children with special health care needs are enroled in child care settings and to develop resources for the child care field. Special Health Care: Recommended Practices for the Early Childhood Education Field consists of a user's guide, a facilitator's manual and a video. Limited copies of the manual ($20) and the video ($30) are available from SpeciaLink, P.O. Box 775, Sydney, Nova Scotia, B1P 6G9 (1-800-840-5465). ECEBC is hoping to revise and reprint this resource soon.

For related articles on special needs, go to the Main Menu.

This article appeared in Interaction (Winter 1997), published by the Canadian Child Care Federation.

Posted by the Canadian Child Care Federation, July 1997.

---

This site was initiated by the Canadian Child Care Federation and produced under contract to Industry Canada.

Ce site a été développé par la Fédération canadienne des services de garde à l'enfance et produit avec l'aide de Industrie Canada.

---