Fitness and Health · 2015-03-19 · of life, extracurricular activities, and family situations such as the separation or divorce of parents or adjusting to blended families. There

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Child Care Information Exchange 1/00 — 41

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Photograph by Bonnie Neugebauer

Relaxation: Every Child’s Right to Simply Be by Patrice Thomas and Wendy Shepherd

Infant Massage by Carolyn Oleson

Fitness and the Young Child by James M. Poole, MD, FAAP

Partners in Health: Helping Families Advoc ate for Their Children’s Health Careby Karen Sokal-Gutierrez, MD, MPH

Preventing Injuries to Children: Interventions That Really Work by Ann Zavitkovsky and Diane Thompson

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Child Care Information Exchange ¥ PO Box 3249, Redmond, WA 98073-3249 ¥ (800) 221-2864

Fitness and Health

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W e live in a world that is undergoing rapid anddramatic change, and our children are beingplaced under more and more stress Ñ at

home, in care settings, and at school. ChildrenÕs time isnow more and more directed by adults, and there is littletime for children to contemplate, reflect, or simply be.Without this balance of child-centred and teacher-directed play, childrenÕs health, well-being, and develop-ment are affected by the negative and damaging effectsof stress. Some of these include long hours in a range ofcare settings and spending time with a number of care-givers, overstimulation and noise, the general fast paceof life, extracurricular activities, and family situationssuch as the separation or divorce of parents or adjustingto blended families.

There is now limited time for play and motor develop-ment as a result of the frantic pace of life and the needfor children to be secure and supervised at all times.Hence, sedentary play is promoted at home and atschool. Media games, advertising, videos, and exposureto news programmes contribute to stress, and in somecases unresolved terror, for children (Levin, 1994, 1998).

Much research to date has focused on stress and stressmanagement strategies for adults in work and home set-tings. However, little research has been directed at howwe can incorporate holistic stress management ideas intoour curricula for young children. Adults readily admitthat they often transfer their stress reactions (no matterhow subtle) onto the children in their care but feelunequipped to incorporate relaxation into their dailyroutines. Young children, often mistakenly stereotypedas innocent and carefree (Dahlberg, Moss, & Pence,1999), do not have the words or the understandings toexpress their worries, fears, and anxieties and often as aresult are labeled ÓnaughtyÓ or Ódisruptive.Ó Relaxationtechniques are simple and easy to incorporate into early

childhood programmes and provide valuable life skillsfor the children in our care.

Dispelling the Myths

Introducing relaxation exercises into an early childhoodprogramme requires discussion, preparation, and plan-ning. Families and colleagues need your support in pro-viding them with relevant information before you beginto work with the children in your program. Families andcolleagues need to know why relaxation is beingincluded and how you will introduce it to the children.Following is a list of concerns that we have encounteredin our work with young children.


Relaxation: Every Child’s Right to Simply Be

by Patrice Thomas and Wendy Shepherd

Patrice Thomas is a part-timelecturer at the Institute of Early

Childhood in communicationand health and a stress

management consultant.She has worked as an elementary

school teacher in general andspecial education and teaches

Tai Chi and relaxation classes fromher studio in the Blue Mountains,

New South Wales.

Wendy Shepherd is the directorof Mia-Mia Child and Family Study

Centre and part-time lecturer withinthe Institute of Early Childhood in

the areas of managementand health. She has worked as a

teacher in elementary schooland as a director of a preschool

and a long day care centre.

Concern. Parents and colleagues may view relaxation asa Ònew ageÓ or religious concept.

Remedy. Inform parents and colleagues by providingwritten information or video programmes thatdescribe and demonstrate the techniques of Tai Chi,progressive relaxation, and visualization exercises.Reassure families and colleagues that relaxation exer-cises are not promoting any religious beliefs. Discussthe lifelong benefits for children and adults. (Displaya copy of this article!)

Concern. Eastern philosophy such as Tai Chi and therelaxation exercises are viewed as Òdifferent.Ó

Remedy. Embracing diversity is a valuable method ofimparting acceptance of differences in young chil-drenÕs lives.

Concern. Tai Chi exercises are only for adults.Remedy. Reassure families that Tai Chi exercises are safe,

non-invasive exercises for the very young to the veryold. There is a lot of information about Tai Chi forfamilies to read.

Concern. The staff do not know how to do Tai Chi or therelaxation exercises.

Remedy. No one needs specialized skills. Everyone cando it at their own level and pace. Just try! Hold ameeting to demonstrate the exercises to colleaguesand parents. Invite them to do the exercises; theywill enjoy them and feel refreshed.

Concern. Relaxation is adding yet another task to analready heavy work schedule.

Remedy. Consider replacing a less beneficial activity Ñfor example, the preparation for the rest period ofthe day may be replaced with the use of Tai Chi andrelaxation exercises. Some older children have grownout of the need of a midday nap. The relaxation pro-gramme is a perfect substitute for rest or nap timefor those children who do not either rest or sleep.The children are settled and focused after a relax-ation session. The visualization exercise is a wonder-ful opportunity for imaginative storytelling andcommunication with peers. Drawing and writing canbe added as an extension to the experience.

What Is Relaxation?

Relaxation helps children to slow down and to calm andquiet their bodies and their minds. Relaxation experi-ences are soothing and restorative for young children.We can teach children to handle stress through gentle

exercise and techniques that provide inner peace andsecurity. Fundamental to learning to relax is discerningthe difference between muscle tension and relaxation(Madders, 1987). We believe that before the mind canrelax, the body must learn to relax. Our approach is dif-ferent to that of most other practitioners as it involvesthe use of gentle exercise (Tai Chi movements) to relaxthe body, followed by progressive relaxation and visual-ization exercises to relax the mind, emotions, and spirit.The techniques we use are gentle and have been prac-ticed for many years in a range of health and educationsettings. Teachers do not need specialist knowledge toimplement these exercises as they are simple and easy tolearn.

Tai Chi or gentle exercise is an ancient form of slow,repetitive movements which bring the body back intobalance and harmony. Tai Chi simply defined is ÒmovingmeditationÓ and, as such, creates peace, harmony, calm,and quietness in children (Crook, 1988). Tai Chi also pro-motes good posture, muscle tone, flexibility, and supple-ness. We have practiced Tai Chi exercises with childrenfrom two years of age and have found that most childrenlove the repetition and flow of the movements.

Traditional exercises and games can be beneficial formany children. However, there are those children whofind that too much competitive play and sport can beemotionally and physically damaging. Children whohave limited mobility or special needs can also partici-pate in some of the Tai Chi exercises. For example, children in wheelchairs can easily perform the upperbody movements alongside the rest of the children. Weassert that it is vital, therefore, to introduce children togentle, non-invasive exercise in order to develop ahealthy, balanced lifestyle instead of negative habits such as poor posture, diet, and exercise.

Progressive relaxation and visualization practices can beused successfully with young children as a follow up totheir Tai Chi practice. Progressive relaxation involvesfocusing the attention on the different parts of the bodyand using rhythmical breathing to help the musclesrelax. It is important that adults keep their terminologyand instructions short and simple here. Visualization orguided imagery involves the children engaging in anexperience led by a teacher which creates a relaxingstory or scene in their imaginations. These stories areoften related to scenes from nature, imaginary friends,animals, and pets. The scripts can be created by adults orchildren.


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It is important to create a quiet time for children each day,that doesnÕt have the stressful associations that sleep timecan often give. In quiet time, children learn to valuelearning to just ÓbeÓ and to experience stillness, reflec-tion, and calmness. These opportunities give childrentime away from busy routines and overstimulation fromnoise and activity during the day.

Creating a Special Place

Select an area that is out of the traffic zones within theplay room, a quiet corner. Weather permitting, a grassyspace under a tree is perfect.

Once this space has been decided on, organize the envi-ronment. A large carpet defines the space, providing aclear message that this is where the relaxation exerciseshappen.

Have a shelf or low table nearby to display somethingwondrous and special: a float bowl with a flower or twodrifting in a pool of water, a basket of beautiful leaves, apaperweight that has a hint of mystery about it, a piece ofpottery or a figurine, a length of shimmery fabric, a musicbox, an art book opened to a page with a painting thatwill intrigue and delight both adult and child, a mask, amusical instrument Ñ the possibilities are endless. Thetable or shelf could also store the tape deck or CD playerfor the relaxation music.

If possible, reduce the lighting in this area to a soft lamp-light, to make it a cozy space.

Cushions around the edge of the carpet are appealing,and if you decide to soften the space with small cushions,you need to be sure there are enough for each child tohave one.

Once this special place has been created, do not pack itaway. Maintain the space as it is so that the children cancome to the area with a minimum of fuss or wait time.You will be surprised to see how well children respond tolooking after this space once it has been arranged andmaintained.

Children often bring along a ÒgiftÓ for the special table Ña feather they have found on the playground or a shellcollected on holiday. Families enjoy looking at the specialobjects to be found on the table as well.

How to Structure Relaxation Sessions

In our work with young children we have found that thefollowing guidelines are useful. As you become morecomfortable and familiar with using relaxation in yourroom, you will begin to structure your sessions specifi-cally to the needs of your children.

To begin:

Spend a short time sitting in a circle and introduce whatthe children will be doing during relaxation time. Takinga few deep breaths with the eyes closed will ÒcentreÓ thegroup. It is interesting to note that for some children, sit-ting still with eyes closed and breathing rhythmically isdifficult. It is important to persevere with this processand support children with calming, gentle, encouragingwords.

Gentle exercises:

Have the children stand up and find their own space.Undertake a few warm-up exercises as you would for anyphysical activity (e.g., limbering, stretching) to preparethe children for their Tai Chi. Begin with one or two TaiChi exercises (we have provided some for you in this arti-cle) and build upon these as you learn more.

Progressive relaxation and visualization experiences:

Ask the children to lie on their backs with their arms andlegs relaxed and their eyes closed. (Closing eyes andkeeping still may be threatening for some children, soallow them to come to this in their own time.) Prepare aÒrelaxation scriptÓ and lead the children through an exercise where they focus on relaxing each part of theirbodies in turn. For young children, begin with the feet,ankles, knees, thighs through to tummy, chest, back,shoulders, arms, neck, and head. Encourage slow breath-ing throughout this.

Next, create a Òvisualization scriptÓ or a story where youlead the children on a journey in their imaginations.Always enter into the story slowly, as they visualizethemselves moving out of their classroom and to theirspecial destination. Likewise, do not end the visualizationprocess too abruptly. Lead the children back from theirjourney carefully as they slowly Òre-enterÓ the room andgive them time to ÒsenseÓ their bodies and recall whattheir room looks like before opening their eyes. Remem-ber, there is no need to rush relaxation time . . . you willdefeat its purpose.


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Closing circle:

After relaxation, have the children sit up and form a cir-cle where they will share their responses and reactions tothe relaxation sessions. Children usually love to tell oth-ers about the sights, sounds, and adventures they hadduring their visualization experiences. Likewise, childrenoften provide very insightful comments about how theirbodies feel after their Tai Chi exercises. Not all childrenwill want to talk about their experiences each time. It isimportant to respect those children who simply wish toÒbeÓ after their relaxation time. This part of the sessioncan be further followed up with drawing, painting, orother creative art experiences as a way of expressing thechildrenÕs ideas and imaginings. These materials andresources need to be organized beforehand and set upclose by the relaxation space.

Some Simple Exercises

Some easy and simple TaiChi exercises suitable foryoung children are as fol-lows:

Greeting Ñ Sun andMoon Bow. Have childrenstand with their feet apart,knees slightly bent, armsresting by their sides (thisis traditionally called theÒHorse Riding StanceÓ).Ask the children to form afist with their right hand Ñ this is their Òsun.Ó At thesame time, ask the children to form a semi-circle aroundtheir ÒsunÓ with their left hand Ñ this is their Òmoon.Ó(See photograph.) Bring the hands to the forehead and

make a bow. This is how we beginour Tai Chi.

Exercise 1Ñ Wu Chi.Begin withthe HorseRidingStance. As thechildrenbreathe in,they raisetheir armsin front of

them to shoulder height. As they lower their arms to theirsides, the children breathe out slowly. Repeat this exercisethree or four times. (See photograph.)

Exercise 2 Ñ The Bird. Begin with the Horse Riding Stance. As the children breathe in,they bring their palms up tochest height, crossing theirhands as the wrists. As theybreathe out, the children raisetheir arms out to the sides,palm down, at shoulderheight. Repeat this exercisethree or four times. (Seephotograph.)

Closing Ñ Embrace Tiger andReturn to the Mountain.Begin with the Horse RidingStance. Ask the children tohold their right hand undertheir left hand (palms up) just

below navel height. The chil-dren move their hands uptowards chest height andturn them over (palmsdown). Now hands arelowered to their sides and


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feet are in the starting position. Repeat three or fourtimes. (See photograph.)

Terminology

Young children relate well to the symbolic and lyrical language of Tai Chi exercises. For example, closing withÒEmbrace Tiger and Return to MountainÓ becomes anenchanting ritual experience for them.

Some Simple Visualization Ideas

We have been using progressive relaxation and visualiza-tion techniques with children for over ten years. We havewritten some enjoyable visualization stories (or ÒscriptsÓfor adults to read to children aloud) based on the follow-ing ideas:

■ A Walk in the Rainforest■ A Magic Carpet Ride■ My Teddy Bear Friend■ The Fairy Party■ Walking Along a Beach■ My Symbol of Peace■ The Wise Old Tree■ My Peaceful Garden■ A Ride on a Cloud■ A Flight with a Magical Bird

As you develop confidence and familiarity in using thesetechniques with your children, it wonÕt be long beforeyou will be creating many varied and interesting storiestogether.

Incorporating Relaxation intoYour Daily Routine

We have established why it is important to teach relax-ation to children at an early age and we have discussedhow beneficial some simple relaxation exercises can befor young children. However, the main comment wereceive from many early childhood teachers and care-givers is that they donÕt have enough time in their busydays to practice relaxation Ñ that there are simply toomany other things to fit into the curriculum. Herein lies

the problem that we discussed at the beginning ofthis article. We all need to reflect upon our currentroutines and practices and ask ourselves thequestion:

Am I adding to the stress of the children in my care withthe routine tasks of the day and the expectations ofparticipation in all aspects of the programme?

We believe that many practices in care and educa-tion settings do indeed create more stress forchildren and staff alike. However, like any newidea, we need to develop slowly and gently untileveryone becomes comfortable with the concept of a daily relaxation time.


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Reflection (above)Circle Ñ at the end of the

visualization process (right)

Ñ Black and white photographs by Kylie Duffy

Using relaxation with children involves much more thanlearning and trying out a few exercises and scripts. Welike to refer to our commitment to the health and well-being of children as Òdeveloping an ecology of relax-ation.Ó This involves questioning our current timetablesand looking at our own stress reactions and verbal andnon-verbal behaviours. It also means creating aestheti-cally beautiful and peaceful spaces for relaxation times Ñplaces where children and adults want to be. This ecologyof relaxation also involves exploring our attitudes andvalues towards health and well-being and the importancewe place on quiet, reflective time for children and adultseach day.

Fundamental to the success of any programme with children is the way we incorporate parents and col-leagues into the planning, design, and implementation.At Mia-Mia, we shared our ideas for setting up a relax-ation programme with our parents and asked for theircontributions and questions. We communicated theprogress of our sessions at evening group meetings byvideotaping meetings and sessions with the children andloaning these tapes out to parents, and through newslet-ters, interviews, and surveys. In this way, the parentswere in tune with the relaxation programme and sup-ported it by practicing the techniques and discussingthem withthe children at home.

Conclusion

We believe that every child has a right to quiet, reflectivetime each day Ñ what we call Òspirit and soulÓ time.Relaxation activities uplift the spirit and soothe the soul.Early childhood settings are unique in that they have thepotential to embrace relaxation settings each day as partof their programmes. In this way, children and adultsalike can share the benefits of exercise, relaxation, andimaginative time. At Mia-Mia, we have developed theconcept of relaxation as a Òway of beingÓ Ñ which is fun-damental to the underlying philosophy and practices ofthe whole centre. We continue to include relaxation as anintegral part of our preschool programme because wehave observed our children enjoying Tai Chi exercisesand soaring creatively and imaginatively through visual-ization experiences.

It is our hope that many other early childhood practition-ers discover the health and learning benefits of usingrelaxation with children. Small beginnings lead to a senseof peacefulness, calmness, wonder, and enchantment forall those who tread the path of relaxation Ñ a path wehope will be more traveled in the future.

Useful References

Crook, R. (1988). Relaxation for children. Katoomba,Australia: Second Back Row Publishing.

Dahlberg, G., Moss, P., & Pence, A. (1999). Beyondquality in early childhood education and care: Postmod-ern perspectives. London: Falmer Press.

Garth, M. (1991). Starbright. Sydney: Collins Dove.

Garth, M. (1997). Earthlight. Sydney: Collins Dove.

Khor, G. (1993). Tai Chi qi gong for stress control andrelaxation. Sydney: Simon and Schuster.

Levin, D. (1994). Teaching young children in violenttimes: building a peaceable classroom. Cambridge, MA:Educators for Social Responsibility.

Levin, D. (1998). Remote control childhood: combatingthe hazards of media culture. Washington, DC:National Association for the Education of YoungChildren.

Madders, J. (1987). Relax and be happy. Sydney: Allenand Unwin.

Rickard, J. (1994). Relaxation for children. Canberra:Australian Council for Education Research.

Roe, D. (1996). Young children and stress: how can wehelp? Canberra: Australian Early Childhood Associ-ation Resource Booklet (3), 4.

Rozman, D. (1994). Meditating with children. BoulderCreek, CA: Planetary Publications.

Thomas, P. (in press). The magic of relaxation: A guidefor teachers, parents and carers. Sydney: PademelonPress.

Special Thanks in Shaping ThisBeginnings Workshop to:

Cecelia Alvarado ¥ Susan Aronson ¥ Celia Boykin Leah Curry-Rood ¥ Roslyn Duffy ¥ Peter A. Gorski

Joan Lombardi ¥ Peter Michael Miller ¥ Rich ScofieldKaren Stephens ¥ Ann Zavitkovsky


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Infant Massageby Carolyn Oleson

Best stated, infant massage is a wellness program for children. When else would it be better to implement andinstill wellness into people than in childhood? Optimizing our well-being is generally an ongoing goal for all, andinfant massage is a great avenue for reaching toward that goal.

Infant massage, also called nurturing touch, is health promoting in a number of ways. One of the most signifi-cant results is the enhancement of immune function. Research findings show lower levels of stress hormones inchildren who are massaged. Knowing that stress hormones sabotage our immune systems and negatively impacthealth and learning makes using this anti-stress routine a powerful tool for parents.

Another compelling reason to practice nurturing touch for children is the building of neuronal connections. Brainresearchers along with child development experts have identified touch as one of the Ò10 Things Every ChildNeedsÓ (McCormick Foundation Project) to grow the brain and enable children to more fully reach their potential.

Massage also can bring about many positive effects that will help parents get through the day in a more lovingway. Such effects include helping the child to sleep deeper and longer, and providing relief from gas, colic, constipation, teething pain, and congestion. Massage is also known to improve muscle tone, digestive tone, andcirculation, and to deepen respiration. Best of all, it strengthens the relationship and enhances bonding andcommunication between parent or teacher and child.

Unlike other massage approaches, infant massage is unique in that it is meant to be provided by a parent or otherprimary caretaker. The International Association of Infant Massage trains providers to instruct parents on how tomassage their child with emphasis on individualizing for each child. The trick is to get the parent to let go ofexpectations and allow for joyful interaction. It is when parents let go and give unconditional love to their childthrough touch that remarkable effects are brought about.

Children with special needs ranging from developmental delays to complex medical problems can benefitdramatically from touch. It is possible that this dramatic effect is related to the empowerment that parents feelfrom providing nurturing touch to their children. When struggling with physical or medical problems, thisempowerment goes a long way.

Small group classes of up to four sessions are taught to parents of well babies through various health outreachprograms such as hospitals, spas, or health clubs. Instruction is also done for children with special needs on aprivate basis because of the need to individualize for that child. Instructors certified by the InternationalAssociation of Infant Massage (IAIM) are available in most areas of the United States.

Infant massage is fairly new to this country, starting in the Midwest in the mid Õ80s. It has been part of other cultures in different countries for centuries. Americans are catching on. The IAIMÕs goal for the future is to haveinfant massage passed down from generation to generation. Then it will be an important element of child rearingin American culture too.

For more information on infant massage, contact the International Association of Infant Massage at (805) 644-8524.

Carolyn Oleson is a pediatric nurse of 13 years. She is certified by the International Association ofInfant Massage to teach massage to parents of infants and young children. She has also completed an intensity course in touch for kids with special needs. Carolyn became interested in infant massagewhen her daughter Lauryn, now two, was born. Lauryn receives this nurturing touch daily, and Carolynis committed and dedicated to sharing this development-promoting wellness tool with others.


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T he fitness craze is upon us; people are runningalong the streets, joining health clubs, and spend-ing millions of dollars on nutrition and diet sup-

plements. It is well proven that there is a relationshipbetween an inactive lifestyle and the development ofcoronary artery disease, high blood pressure, diabetes,and being overweight. Magazine and television modelspromote the in shape look. Unfortunately, with all thissurrounding our everyday life, over 50% of Americanmen and women are overweight, and many of them areobese. Just as we are working at getting in shape andbeing fit, our society is running in the other direction.Something is happening to our own behavior that allowsus to be okay with being overweight. The victims in allthis could be our preschool children, as the promotion ofeating habits, activities, and sedentary lifestyles aretaught in childhood.

Preschool children are active by their very nature. Theytend to have an inherent drive for motor activity. In look-ing at the behavior of young children, notice how theyexplore their environment, go to all corners of the roomor playground, achieve physical closeness, and enjoycommunicating with others. These are all essential forproper cognitive, emotional, and physical development.When we allow children to run, play, and explore in asafe environment they will naturally get all the largemotor activity that they need.

Television and computers obviously decrease the amountof time children are up and playing, either indoors oroutdoors, and increase the likelihood of eating calorie-rich snack foods. There is a definite genetic link or predis-position to obesity. The recently discovered obese genemakes it imperative that families having problems withweight look at their diet, activity level, and exercise levelto control obesity. Overweight children are more likely toexperience depression, low self-esteem, and medicalproblems. Child care teachers can encourage healty eat-ing habits at the center and at home. Limit the amount ofjuice (two servings per day), fatty foods, and sugar givento the children and encourage children to drink water.

Water still remains a wonderful source of liquid. Workwith any child at risk for being overweight and help allchildren to develop healthy lifestyles.

Physical development is most important in the earlyyears of exploring, experimentation, and activity. Throw-ing balls, jumping, dancing, and jogging are all excellentexercises, as children learn to use their bodies and movethrough space in a coordinated fashion. Children are nat-urally active, and we must encourage the inactive child.

Children tend to follow a set sequence of learning andacquiring motor skills. The rate is not the same for allchildren, as children tend to develop and grow differ-ently. There is no evidence that physical training duringthe preschool years accelerates or enhances a childÕsfuture sports performance. However, the preschool yearsare very important for motor development. The acts ofrunning, throwing, catching, kicking, hopping, jumping,and climbing are all tasks learned through a childÕs nat-ural activity. As they mature, learn by trial and error,perform tasks repeatedly, do not compete or comparethemselves with their peers, and have supportive adults,children will naturally learn to accomplish and perform.

Parents, caregivers, and now some child care centers arepushing children into participating in organized sportsand structured exercise sessions. The Academy of Pedi-atrics has identified three important factors for a childÕsreadiness: (1) neurodevelopmental level (ability to havemotor skills to accomplish the activity); (2) social devel-opment (ability to interact with the coaches and team-mates); and (3) cognitive level (ability to understand theinstructions or the rules of the game). All of this comesunder the title of Sports Readiness, which is determined bythe childÕs excitement and desire to participate (not theparentÕs).


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by James M. Poole, MD, FAAP

James M. Poole, MD, FAAP, is a member of the Academy of PediatricsEarly Childhood, Adoption, Dependent Care Committee and liaison toHealthy Childcare America. He is a member of the North Carolina SportsMedicine Committee. Dr. Poole is in private pediatric practice and is theowner of The Growing Child Physician Childcare Centers.

Daily Programs

When counseling teenagers on attention problems, I com-pare them to four year olds who by nature are fast mov-ing, have short attention spans of five to ten minutes, arevery active, easily distracted, playful, explore the environ-ment (not the game at hand), and have difficulty follow-ing directions. Keep all that in mind and tailor theactivity to fit childrenÕs natural responses: easy directions,short periods of structured activity (15 to 20 minutesmaximum), followed with periods of free, unstructuredplay. When teaching, place all the children in a group orsmall groups with minimal distractions. Keep your fieldsshort, equipment adapted to the size of the child, andgames that do not require a score. Use soft balls, smallergroups, and balls like the Nerf tennis ball that do notbounce so high. Remember: To keep an active mindactive, you must change the game or the position of theplayers often.

Classrooms should have open areas for large musclemovement. For example, a slide or climber for the two tothree year olds, or crawl spaces and tunnels and obstaclecourses set up within the room (a mesh tunnel can bepurchased for little money). Four year olds are veryactive and will hide, so care must be taken in setting uptheir inside movement area due to the increase in acci-dents and running that takes place at this age.

Music and movement time is essential and is a wonderfulactive time. It teaches music to the children while they arelearning how to gain control of themselves and movetheir muscles in some sort of pattern.

Transition times are another opportunity for physicalactivity. Singing and playing games as the children movefrom one activity to the next is a great way to accomplishthe task. Having a small group of children do a particularexercise, such as touching their toes prior to washinghands, gets them moving and exercising without risk.

Proper clothing is very important for outside play Ñwarm- and cold-weather clothes, no drawstrings, andproper shoes. Tennis shoes or shoes with some rubbersoles are safest and best for the feet of the active child.

Playgrounds are interactive learning centers for staff andchildren. This is the perfect place for the learning ofsharing, playing games together, support, and for doingyour best without worry of comparison or winning. Freetime as well as structured playground time is essential forchildren of all ages. Climbing equipment, though nice, isnot necessary for the developing child. Safety, however, is

very important. Field trips to parks and playgrounds maysound exciting, but providers must look at safety issuessuch as fall zones, cushioning material, fencing, sharpobjects, hot metal, and visualization to name just a fewproblems at public and private playgrounds.

Families and child care providers can be roadblocks orthey can be springboards for making children excitedabout learning and accomplishing new tasks for andbelieving in themselves. Support, fun, success, variety ofactivities, freedom from the worry of failure and embar-rassment, and the love of playing are what keep childrenof all ages (two to 92 years) enjoying games, learning,being active, and leading happier, healthier lives.


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The American Academy of Pediatrics recommends:

■ All preschool children should participate regularly in physical activity appropriate for their developmental level and physical health status.

■ Emphasis should be placed on the promotion of physical activity as healthy living, not to maximize subsequent sports ability.

■ Free play is preferred over structured play as it allows the children to develop at their own rate.

■ Readiness to participate in organized sports must come from the childÕs eagerness and not the parentÕs desire.

■ In structured sports programs, goals of partici-pation and enjoyment should be emphasized rather than those of competition and winning.

■ Physical activity is vitally important in the over-all development of children and the development of healthy lifestyles. Parents and caregivers should closely monitor the amount of passive time children spend in front of the tele-vision or computer.

■ Parents, family members, and caregivers should be role models for children by participating with children in physical activities.

■ The playground for preschool children is a dynamic place of active learning, requiring the ability for free play, some structured learning activities, and the ability to explore in a safe and healthy environment.

ÒI Õm really concerned about Robbie, a three yearold in my child care program. HeÕs often sickand misses a lot of child care. RobbieÕs parents

give him medicine they have around the house or theytake him to the emergency room. One doctor said Robbiehad asthma, but heÕs never gotten a full evaluation orregular treatment. Robbie doesnÕt have a regular doctorand his parents say they canÕt afford health insurance.What can we do to help Robbie stay healthier?Ó Ñ Lena, child care director

How common is the lack of adequate health care?

Currently, about 44 million Americans, including 12 mil-lion children like Robbie, lack health insurance. Mostuninsured children come from families in which at leastone parent is working but cannot afford health insurance.Ethnic minority children are more likely to lack healthinsurance including 30% of Latino children, 20% ofAfrican Americans, and 17% of Asians, compared with11% of Caucasians (U.S. Census, 1998). Immigrant chil-dren are most at risk: 43% of non-citizen children lackhealth insurance (Brown, Wyn, & Ojeda, 1999).

How does inadequate health care affectchildren’s health and child care?

Children without health insurance are less likely to getpreventive care such as immunizations and dental care,as well as treatment for illnesses such as ear infectionsand asthma. As a result, they are more likely to sufferfrom health problems and absences from school and childcare (Monheit & Cunningham, 1992; U.S. GeneralAccounting Office, 1997).

As a child care program director, Lena is rightfully con-cerned about RobbieÕs health. After experiencing a life-

threatening episode, she realized she had to take a moreactive role in promoting RobbieÕs health. She explained:ÒOne day Robbie was coughing and having troublebreathing. We gave him the medicine his mom left but it didnÕt help and he started turning blue. So we called911. Luckily, the ambulance came quickly and he gottreatment at the hospital. He was able to return to childcare a week later.Ó But Lena wonders: ÒWhat if RobbieÕsfamily could get health insurance and a regular doctorfor Robbie? What if he could get a full evaluation, diagnosis, and the right medicine? What if I could work with his family and his doctor Ñ wouldnÕt Robbie be healthier day to day, and couldnÕt we prevent emergencies?Ó

How can staff work with families and health care providers topromote children’s health?

1Talk with parents about the importance of aÒmedical homeÓ for every child. Every childshould have a Òmedical home,Ó a health care


Partners in Health:Helping Families

Advocate for TheirChildren’s Health Care

by Karen Sokal-Gutierrez, MD, MPH

Karen Sokal-Gutierrez is a physicianwith training in pediatrics, preven-

tive medicine, and public health.She provides health consultation toearly childhood programs, developseducational materials, and conducts

training on health and safety inchild care for early childhood and

health care professionals. She livesin the San Francisco Bay area.

Photograph by Subjects & Predicates

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provider who coordinates the childÕs preventive care(e.g., immunizations, hearing and vision screening) aswell as care for illnesses, injuries, and developmental/behavioral concerns. The medical home encourages regu-lar visits over time which help promote the childÕs healthand treat health problems early in order to prevent com-plications. For example, appropriate diagnosis and treat-ment of RobbieÕs asthma could help keep him healthier,improve his participation in child care, and help preventemergencies.

2Inform parents about opportunities to get healthinsurance. Having health insurance helps ensurethat children get the health care they need. The

patchwork of public and private health insurance pro-grams, however, can be confusing for families. Caregiverscan help inform parents about health insurance programsfor which they may be eligible.

About half of uninsured children are eligible for govern-ment-subsidized health insurance. Many families wholost welfare benefits donÕt know that their children maystill be eligible for health care benefits (Free & Low-CostHealth Insurance, 1998). And many immigrant familiesmay not know that a new federal ruling allows them toreceive non-cash government services, including healthcare, without compromising their application for resi-dency or citizenship (Federal Register, 1999).

In every state, two free or low-cost government-subsi-dized insurance programs are available: Medicaid andChildrenÕs Health Insurance Program (CHIP). Medicaidcovers comprehensive health care services for childrenwhose family income is below the poverty level. Since1997, the CHIP program provides health insurance forchildren whose family income is above the poverty levelbut who still cannot afford private health insurance. Inmore than half of the states, CHIP serves families earningat or above 200% of poverty level.

Parents can contact their local department of publichealth, 877-KIDS-NOW, or www.insurekidsnow.gov forinformation about these and other programs.

3Give parents tips on navigating the health caresystem and advocating for their childrenÕs healthcare. The Òalphabet soupÓ of terms for health care

services can be particularly confusing. Staff can helpfamilies understand some of the options.

Some key types of health insurance and health caresystems include:

■ Fee for service: Patients can choose health care pro-viders for their health needs. Health insurance usuallyreimburses a percentage of the cost and patients pay therest.

■ Health maintenance organizations (HMOs) andmanaged care: Patients have a primary health careprovider who cares for their general health needs andmust coordinate referrals to specialists, if needed. Healthinsurance usually covers most of the cost and patientspay a co-payment.

■ Preferred provider organizations (PPOs): Patients canchoose to use the ÒpreferredÓ health care providers on theinsurance plan and pay the usual co-payments or useother health care providers and pay higher co-payments.

Currently, over half of Americans are insured by man-aged care plans, either through private or government-subsidized health insurance. In theory, managed carehelps promote high-quality, ongoing care with a primarycare provider who coordinates the health care. In reality,however, the quality, continuity, and coordination of carevaries widely. Many families experience excellent carewhile many other families bounce from one medical pro-vider to another when they change jobs, their employerchanges insurance plans, or their providers stop accept-ing their insurance plan.

In 1998, a review of the U.S. health care system identifiedmany problems including the underuse of preventive services, overuse of treatment services, and disparitiesin the quality of care. Health care advocates are trying to address the problems through quality assurance sys-tems and state and federal legislation to regulate healthcare. In addition, ÒThe Consumer Bill of Rights andResponsibilitiesÓ (1998) recommended that patientsbecome more involved in decisions about their ownhealth care.

Caregivers should encourage parents to advocate strong-ly for their childrenÕs health care. Tracy and Jeff, parentsof a 15 month old, received a letter from their pediatricianexplaining that she could no longer accept their healthinsurance and they would need to find a new pediatri-cian. They were very upset because they had relied on theexcellent relationship with their pediatrician throughouttheir sonÕs infancy and health problems. After they andseveral other families appealed to the doctorÕs office andtheir employers appealed to the insurance company, thecontract was reinstated and they were able to continuewith their pediatrician.


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Tips for Working with the System

■ Be persistent. It can be difficult to find the rightperson to talk to, or even to talk to a ÒrealÓ person on the phone. Expect that it might take several calls to get an appointment or information.

■ Be informed and prepared. Try to find out what youneed to know and do in advance. For example, if youneed medical forms completed for child care, be sure totake them to the medical visit.

■ Get help. If medical issues make you nervous, bring afriend or family member for support. If language or read-ing is a problem, bring someone who can help or ask forassistance from the health office.

■ Write it down. If you have questions, write themdown as you think of them, and take them to theappointment. If your health provider tells you importantinformation, such as how to give a medication, write itdown or ask for it in writing. ItÕs best not to rely on yourmemory alone.

■ Go to the top. If you feel youÕre being treated unfairlyor given incorrect information, get the personÕs name andpolitely ask to speak to a supervisor. The supervisor hasmore authority and may be more helpful.

[Above tips adapted from Caring for Children With ChronicConditions, 1998.]

4Be an active partner in childrenÕs health Ñ estab-lish communication and collaboration amongstaff, families, and health care providers. Chil-

dren in child care stay healthiest when thereÕs an effectivepartnership among the family, staff, and health careprovider. Communication must flow in all directions soeveryone has the information they need to best care forthe child.

During enrollment, parents should share the childÕsmedical history, results of the medical exam and healthscreening, diagnoses, treatment, and immunizationrecord. Phyllis, a family child care provider adds, ÒI askparents for written consent to talk directly with the doctor when I need more information. And every fewmonths I remind parents to update me on changes inmedications and doses.Ó

Staff should also share with parents and health care pro-viders their own observations or concerns about chil-drenÕs health. For example, Lena noticed that RobbieÕscough worsened when he ran around the play yard oncold mornings, and he became irritable after taking a

particular medicine. Lena felt it was important to shareher observations with RobbieÕs parents and health careprovider to improve his care and treatment.

5Advocate for your own health care. Lena workedhard to help RobbieÕs family get health insurance, a medical home, and proper care for his asthma.

At the same time, however, Lena lacked adequate healthinsurance and health care for herself and her own family.Lack of adequate health care is also a common problemfor caregivers. A recent survey found that 21% of familychild care providers and 16% of center providers lackedhealth insurance. Even among insured providers, overhalf lacked coverage for preventive health screening,dental, and vision care (Bassoff & Willis, 1998). Unin-sured adults, like children, are more likely to experienceproblems with their health and with access to health care.

Remember, you canÕt sell what you donÕt have. In orderto promote childrenÕs health, caregivers must take care oftheir own health. Caregivers should try to secure healthinsurance and advocate for high quality health care forthemselves and their families. By promoting health carefor everyone in child care Ñ children, families, and staffÑ child care programs can keep everyone healthier.

References

Bassoff, B., Turner, L., & Willis, B. (1998). The California childcare provider health insurance study. San Diego: San DiegoState University.

Brown, Wyn, Ojeda. (1999). Noncitizen childrenÕs rising unin-sured rates threaten access to health care. Los Angeles: UCLACenter for Health Policy Research.

Caring for children with chronic conditions: Training guides forthe Head Start learning community. (1998). Washington, DC:U.S. Department of Health and Human Services, Govern-ment Printing Office.

The consumer bill of rights and responsibilities. (1998). Presi-dentÕs Advisory Commission on Consumer Protection andQuality in the Health Care Industry.

Free & low-cost health insurance: Children you know are missingout. (1998). Washington, DC: Center on Budget and PolicyPriorities.

Inadmissibility and Deportation on Public Charge Grounds.Federal Register, May 26, 1999.

Monheit, A., & Cunningham, P. (1992). Children withouthealth insurance. The Future of Children, 2.

U.S. General Accounting Office. (1997). Health insurance:coverage leads to increased health care access for children.Washington, DC: Government Printing Office.


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A nn tells a story: One winterÕs day a couple yearsago, I noticed my three-year-old friend Jamieemphatically shaking her head ÓNo!Ó and mak-

ing a slicing motion across her throat with her hand as Itried to tie the drawstrings of her hood. I later discov-ered she had learned in preschool that drawstrings werea potential choking hazard. Not having the vocabulary toconvey this important fact, she had tried, through panto-mime, to tell me to stop. Though I have worked withchildren many years and thought I knew all about injuryprevention, it took a three year old to show me I still hada lot to learn, and that children really take to heart whattheir teachers, parents, and other adults show and tellthem about injury prevention.

Review of injury studies: Two years ago at the Har-borview Injury Prevention Center in Seattle, Washington,we completed a review of more than 1,169 studies ofinterventions to prevent or reduce injuries to children.Our review was spurred by the many needlessly injuredchildren seen in the emergency room and hospital, andour research question was simple and straightforward:which interventions really work?

The following interventions were found, in properlyevaluated studies, to prevent or reduce injury to childrenfrom motor vehicles, bicycles, drowning, falls, choking,and burns. Important common sense interventions suchas supervision, stair gates, cabinet locks, balloon bans,traffic safety training, and posted emergency numbershave not been included because we did not find ade-quate evaluations. This in no way implies they should beignored. Instead, it means always include the interven-tions below on your injury prevention list.

Injury Interventions That Really Work

■ Motor Vehicle InjuryTrue or false: 1. ■■ Motor vehicles are the single most important

cause of child injury. 2. ■■ Seat restraint requirements change as a childÕs

weight and height change. 3. ■■ A back seat ride, properly restrained, is no safer

than a front seat ride, properly restrained.

Motor vehicles are the single most important cause ofchild injury. Children are injured as passengers in


Preventing Injuriesto Children:

Interventions That Really Work

by Ann Zavitkovsky and Diane Thompson

Ann Zavitkovsky, MPH, is theformer director of PATCH, a child

care referral agency in Hawaii,and Family to Family, a family

day care training program inAtlanta, Georgia. Ann moved to

Seattle in 1991 and latercoordinated the literature searchfor Harborview Injury Prevention

Center’s review of child injury.Ann currently works at the

Immunization Studies Programat Group Health Cooperative of Puget Sound, and is a

co-author of Activities for School-Age Child Care,published by NAEYC.

Diane Thompson, MS, is an epidemiologist at Harborview InjuryPrevention Center in Seattle, Washington. For the past 11 years,Diane has conducted research to determine effective ways of preventing childhood injuries andwas a principle reviewer for the studydescribed in this article. Well knownwith her colleagues Fred Rivara andRobert Thompson for bicycle helmetresearch and helmet promotion cam-

paigns, Diane has published two recent reviews in the Cochrane Collabora-tion: “Pool Fencing for Preventing Drowning Children” and “Helmets forPreventing Head and Facial Injuries in Bicyclists.”

crashes and as bicyclists and pedestrians hit by cars. Seatposition and seat restraints decrease risk by reducing impact with the carÕs interior structures and preventingejection from the vehicle. As a childÕs weight and heightchange, seat restraint requirements change also: rear-facinginfant seats for children birth to 20 pounds; forward-facingconvertible/toddler seats for children 20 to 40 pounds;booster seats for children 40 to 70 pounds; and safety beltsfor children too tall or heavy for safety seats. Childrenproperly restrained in the back seat are safer than childrenproperly restrained in the front seat.

■ Bicycle InjuryTrue or false: 4. ■■ Broken arms and legs are the greatest risk posed

to child bicyclists. 5. ■■ A properly fitted helmet has a taut chin strap and

sits in a level position on the head.6. ■■ Children wear helmets more if their riding

partners also wear them.

Each year, approximately 1,000 people die from injuriesdue to bicycle crashes, and 40% of these deaths are chil-dren. Head injury is by far the greatest risk posed to bicy-clists. Properly fitted helmets decrease the risk of head andbrain injury by up to 88%, but it is estimated that only 25%of U.S. children wear them. A properly fitted helmet is thecorrect size, has a taut (not loose) chin strap, and sitssquarely on the head (not tilted forward or backward toexpose the forehead). Community interventions using acombination of parent involvement, media announce-ments, bike rodeos, and helmet discounts have increasedhelmet use. Studies also have shown that children aremore likely to wear helmets if their riding partners do.

■ DrowningTrue or false: 7. ■■ A drowning child makes a lot of noise and calls

for help.8. ■■ Adults standing near children playing in water

prevent drowning.

9. ■■ ItÕs safe for older children to supervise youngerchildren in the bathtub.

Drowning ranks only behind motor vehicles and fires as acause of unintentional injury death to children. Bathtubspose the greatest hazard to infants, and pools pose thegreatest hazard to toddlers, preschoolers, and youngschool-age children. Contrary to popular belief, drowningis often fast and silent, and a drowning child usually doesnot thrash around in the water and make a lot of noisecalling for help. Therefore, supervising water activitiesmeans constant adult attention rather than just beingnearby. (Sadly, infants have drowned in the tub whilebeing ÒwatchedÓ by other children.)

Preventing children from reaching water unaccompaniedby an adult is the key to preventing drowning death andinjury. Keep in mind that a four year old can climb a fivefoot fence in 17 seconds if the interbar spacing is right, anda toddler tipped over in a bucket of liquid cannot righthimself. Swimming lessons improve swimming ability andpool deck behavior of children 24 months or older buthave not been shown to reduce drowning.

■ FallsTrue or false:10. ■■ Screens do not prevent children from falling out

of windows.11. ■■ Grass is a good surface under climbing equip-

ment.

Falls are the most common cause of emergency depart-ment visits for children under five and the most commonsource of injury in child care settings. Common falls lead-ing to serious injury are falls from one level to another,such as from playground equipment, beds, tables, chairs,baby walkers, and shopping carts (infants belted in shop-ping carts have been injured when siblings tipped over the whole cart). Window falls cause the highest number ofdeaths and are not prevented by window screens.

The most critical factors in fall injury are the height of thefall and the impact-absorbing qualities of the surface fallen onto. Lab tests demonstrate significant differences in the energy absorbing qualities of playground surfacingmaterials. For example, a five foot fall into nine inches ofloosely compressed sand is equal to a seven foot fall into


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Interventions that reduce motor vehicle injury

✔ Correctly sized and installed safety seats orsafety restraints

✔ Back seat rides, properly restrained, for all children

Interventions that reduce bicycle injury

✔ Properly fitted bicycle helmets, worn by all riders(including adults!)

Interventions that prevent drowning

✔ Isolation pool fencing (fencing that encloses onlythe pool), at least five feet high, with no morethan four inches in interbar spacing

✔ Pool gates with self-closing latches

nine inches of loosely compressed wood chips. However,if loose fill surfaces like sand and wood chips are notraked or maintained, they become hard and lose much oftheir energy absorbing qualities. Grass looks soft but thedirt under it is not absorptive.

■ ChokingTrue or false:12. ■■ Most objects that cause choking are regulated by

the Consumer Products Safety Commission.13. ■■ Balloons, swallowed and inhaled, are a choking

hazard mainly for children under four years old.

Airway obstruction (choking, strangulation, suffocation, or entrapment) results in about 700 deaths each year tochildren and adolescents, half in the first year of life andthree quarters in children younger than five years old. It is the leading cause of unintentional injury death in thefirst year of life and is exceeded only by motor vehicles,fires, and drowning as a cause of unintentional injurydeath to preschoolers. Fatal choking in young childrentypically involves small, roundish food products that perfectly block the windpipe (for example, grapes, hotdogs, hard candy, nuts), and non-food products such assmall toys and coins. Balloons, swallowed and inhaled, are a major cause of choking death in children under eight years old. Drapery cords, drawstrings with togglesthat snag on equipment, and crib gyms/decorations arerisk factors for strangulation.

Death rates have declined since enactment of legislationregulating refrigerator door locks, crib slat spacing (mustbe less than 23Ú8 inches), rattles, and small toy size (must be 11Ú4 inches in diameter and at least 21Ú4 inches in length).However, as described above, children can choke onobjects larger than this standard.

■ Fires and BurnsTrue or false: 14. ■■ Smoke detectors decrease the risk of being

injured in a house fire by over 70%.15. ■■ Flame-retardant fabric is required for all

childrenÕs clothing.16. ■■ Tap water scald burns can be prevented by

setting the hot water thermostat to 120 degrees.

Fires and burns cause more than 1,000 deaths each year in children. Though the majority of all fire and burndeaths are due to house fires, scald burns also cause seri-ous injury to young children. Smoke detectors are earlywarning devices, alerting residents to vacate the premisesand call the fire department. They may seem a nuisance to select, install, and maintain, but they decrease the riskof fire injury by 71%. Flame-retardant childrenÕs sleep-wear, required by the Flammable Fabrics Act, has reducedburn injuries, but not all childrenÕs clothing or costumesare covered by Flammable Fabrics legislation. Tap waterscalds to children occur most frequently in the bathtub or shower but can also occur in the kitchen or bathroom sink. Setting the hot water heater thermostat to 120degrees significantly reduces the risk of tap water scalds.

Diane tells a story: One hot summer day, my five-year-old twin grandchildren, Emily and Andrew, asked if theycould ride their bicycles in the sprinklers at the local highschool track. When their father said yes, they took off alltheir clothes, EXCEPT their bicycle helmets, and peddledinto the spray. Their parents, who make a practice ofpointing out helmeted riders as Òpeople who have made a good choice,Ó immediately phoned to tell us this story.Emily and Andrew may not know exactly what ÒinjuryinterventionÓ means, but they do know that helmets pre-vent injury and that helmets and bike riding always gotogether. They learned this automatic, preventive behav-ior from the adults around them . . . adults just like you.


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pInterventions that prevent injuries from falls

✔ Window bars, not just screens

✔ Sand or wood chip playground surfaces, rakedoften and carefully maintained

Interventions that prevent choking and airway obstruction

✔ Product safety laws for refrigerators, cribs, andplastic bags

✔ Product safety standards for small parts on toysand products intended for children younger thanthree years old (remember, though, that thesestandards may not be strict enough)

Interventions that prevent burns

✔ Smoke detectors, located and installed accordingto manufacturer instructions, with fresh batteries

✔ Flame retardant childrenÕs sleepwear

✔ Hot water thermostat set to 120 degrees

Quiz Answers: 1. T; 2. T; 3. F; a back seat ride is safer; 4. F; head and braininjuries are the greatest risk, thatÕs why helmets are so important; 5. T; 6. T;7. F; drowning is often silent; 8. F; since drowning is fast and silent, adultsmust be actively supervising as well as standing nearby; 9. F; adults, notchildren, should supervise the bathtub; 10. T; 11. F; grass looks soft but doesnot absorb the energy of a fall; wood chips or sand are safer surfaces; 12. F;children choke on food, coins, and many other unregulated items; 13. F; balloons are a major choking hazard for children of all ages; 14. T; 15. F; besure to look at labels and fabrics carefully when choosing clothes and cos-tumes; 16. T.

Fitness and Health · 2015-03-19 · of life, extracurricular activities, and family situations such as the separation or divorce of parents or adjusting to blended families. There

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