S-4.1.1, r. 2 - Educational Childcare Regulation

Full text
SCHEDULE II
(s. 121 and 121.6)
PROTOCOLS
(1) PROTOCOL FOR ADMINISTERING ACETAMINOPHEN TO TREAT FEVER
Acetaminophen is the generic name of the medication that is commercially available under the following brand names: Atasol, Tempra, Tylenol and other house brand names. Acetaminophen has analgesic (pain-reducing) and antipyretic (fever-reducing) properties, but does not have anti-inflammatory properties. Although it is an over-the-counter medication, its use should not be taken lightly.
Under the Educational Childcare Regulation (chapter S-4.1.1, r. 2), acetaminophen may be administered without medical authorization to a child receiving childcare, provided it is administered in accordance with this Protocol and that a parent has given written consent. The parent must declare any known allergy to acetaminophen. If a child is allergic to it, acetaminophen must not be administered by the childcare service. The child’s weight must be stipulated in kilograms on the authorization form, and must be verified by the parents (a parent’s initials are required) at least every 3 months.
A parent is not required to consent to the application of this Protocol. However, if a parent does not sign the authorization form, the medication may not be administered to the child unless the parent and a member of the Collège des médecins du Québec give written authorization.
BASIC RULES
Under this Protocol, acetaminophen may be administered solely to reduce fever. It may not be administered:
— to children under 3 months of age (a child under 3 months of age who has a fever should be taken to see a physician);
— to relieve pain (a child who is in pain should be taken to see a physician);
— for more than 48 consecutive hours (2 days);
— to children who have received medication containing acetaminophen in the preceding 4 hours.
In those 4 cases, the Protocol does not apply and written authorizations from a physician and the parent are required to administer the medication.
Acetaminophen must never be administered before taking the child’s temperature using a thermometer.
Childcare providers may have their own acetaminophen container, in which case the brand name, the dosage form (e.g. liquid suspension) and the concentration (80 mg/ml, 80 mg/5 ml or 160 mg/5 ml) must be indicated on the authorization form.
Childcare providers who purchase acetaminophen at the pharmacy must be careful to buy products containing only acetaminophen. Products that combine acetaminophen with other medications (decongestants, cough-relieving agents, expectorants) are strictly prohibited. Childcare providers should not hesitate to ask the pharmacist for advice, so as to purchase a product with the correct concentration of acetaminophen and at the best price. House brand names of acetaminophen sold in pharmacies are all as effective as brandmarks and are often less expensive.
To minimize the risk of mistakes, childcare providers should keep only the liquid form of acetaminophen, at one concentration (80 mg/ml, 80 mg/5 ml or 160 mg/5 ml). If they provide care only for children under 18 months of age, it is recommended that they use a concentration of 80 mg/ml. If they provide care only for children over 18 months of age, it is recommended that they use a concentration of 80 mg/5 ml or of 160 mg/5 ml. Childcare providers who provide care for children of all ages should select and keep to hand only one of the three available concentrations (80 mg/ml, 80 mg/5 ml or 160 mg/5 ml).
Liquid acetaminophen should be used. With tablets, it is not possible to give an accurate dose, especially to children under 5 years of age. Tablets should therefore be avoided.
Childcare providers must ensure that all the acetaminophen in their possession has a valid expiry date. Acetaminophen that is outdated must be returned to the pharmacy, where it will be destroyed.
All forms of acetaminophen must be kept under lock and key, out of the reach of children.
It is strictly forbidden to use acetaminophen formulated for adults (500 mg and 325 mg tablets).
Any administration of acetaminophen must be recorded on the medication administration sheet. The parent must be informed of the number of daily administrations and times of administration.
WHAT YOU SHOULD KNOW
What is fever?
Fever is defined as a body temperature that is higher than normal. Normal temperature may vary somewhat depending on the child, the time of day, the outdoor temperature and the level of activity. The cause of the fever is more important than the temperature itself.
It is generally considered that there is fever if the temperature is above the normal temperature range when measured with a thermometer. Normal temperature varies depending on where the measurement is taken.
Levels above which fever is present, depending on the measurement method


Measurement method Level in degree Celsius
(°C) above which a child is
considered to have a fever



Oral (mouth) 38 °C and over


Rectal (rectum) 38.5 °C and over


Tympanic (ear) 38.5 °C and over


Axillary (underarm) 37.5 °C and over


How to take a child’s temperature
The only sure way to measure fever is to take the child’s temperature. A child’s temperature must be checked whenever the child’s general condition (frantic crying, loss of energy, change in general condition, loss of appetite, irritability, etc.) or physical symptoms (flushed cheeks, excessively warm skin, sweating) could be signs of fever. Rectal measurement is the most reliable method, and underarm measurement is the least reliable.
The following measures are recommended:
— take the rectal temperature of children under 2 years of age. At that age, to know if they have a fever, the axillary temperature may also be taken (underarm). If it is equal to or greater than 37.5 °C, a second reading should be taken rectally to confirm that the child does in fact have a fever;
— take the axillary (underarm) or tympanic (ear) temperature of children between 2 and 5 years of age;
— take the oral (mouth) temperature of children over 5 years of age only. The tympanic (ear) temperature may also be taken;
— use the appropriate thermometer. Glass and mercury thermometers should not be used because of the risk of accidental exposure to mercury if they break. Fever strips (strips placed on the forehead or cheeks) are not recommended because they do not give accurate readings. Digital thermometers are recommended;
— always use disposable plastic tips because they are more hygienic. In addition, always disinfect the thermometer properly between uses, in accordance with the manufacturer’s recommendations;
— apply a water-based lubricant jelly or petroleum jelly from a single-dose sachet to the disposable plastic tip before taking a child’s temperature rectally;
— if the child has just been physically active or has drunk a cold or hot liquid, wait for 20 minutes before taking his or her temperature;
— always comply with the time requirements for the thermometer being used, since it will vary from one thermometer to the next.
WHAT YOU SHOULD DO
Children under 3 months of age
If a child under 3 months of age has a fever, that is, if the rectal temperature is 38.5 °C or above:
— dress the child comfortably, in lightweight clothing;
— have the child drink at more frequent intervals;
— keep an eye on the child and take the child’s temperature again after 60 minutes, or sooner if the child’s condition seems to be worsening;
— notify the parent immediately, ask the parent to come and pick up the child and, in the meantime, apply the measures listed above;
— if the parent cannot come to pick up the child, call the persons designated by the parent as emergency contacts, and if they cannot be reached, take the child to a medical service, to the local community service centre or to a hospital emergency department; do not administer acetaminophen without a written medical authorization for the child.
Children 3 months of age or older
If a child 3 months of age or older has a fever, that is, if the rectal temperature is 38.5 °C or above or if the axillary temperature is 37.5 °C or above if a child is over 2 years of age:
— dress the child comfortably, in lightweight clothing;
— have the child drink at more frequent intervals;
— keep an eye on the child and take the child’s temperature again after 60 minutes, or sooner if the child’s condition seems to be worsening;
— inform the parent of the child’s condition;
— if the childcare provider considers it necessary, acetaminophen may be administered to relieve the child, according to the dosage guidelines in the table included in this Protocol, or the dosage instructions on the medication container, in accordance with the rules in this Protocol;
— one hour after administering acetaminophen, take the child’s temperature again; if the temperature has not fallen or if the child’s general condition has not improved, ask the parent to come and pick up the child. If the parent cannot be reached, call the persons designated by the parent as emergency contacts, and if they cannot be reached, take the child to a medical service, to the local community service centre or to a hospital emergency department.
Calculating and administering a dose of acetaminophen
It is not always necessary to administer medication to reduce fever if the child has no other symptoms.
When you administer acetaminophen:
— Check the child’s weight in the file. For the treatment to be effective, weight and not age should be used to determine the dose. If in doubt, contact the parent to check the child’s weight.
— Always use simple words, appropriate to the child’s age, to explain the relationship between his or her condition, the medication being taken and the expected results.
— Wash your hands before handling the medication.
— Always check:
— the name of the product on the container, to make sure it really is acetaminophen;
— the acetaminophen concentration (80 mg/ml, 80 mg/5 ml or 160 mg/5 ml) shown on the medication container, before deciding on the dose to be administered;
— the product’s expiry date;
— Use the table in this Protocol or follow the manufacturer’s instructions to decide the dose that will be administered.
— Never exceed the dose shown in the table in this Protocol or that shown on the medication container.
— When administering acetaminophen in liquid form, always measure the dose accurately, using an oral syringe or medicine dropper calibrated in milliliter; never use a kitchen spoon. An oral syringe graduated in milliliter is particularly recommended because it produces a more accurate measurement.
— If the acetaminophen is a liquid suspension, shake the container before removing the dose.
— Once the dose has been measured using the calibrated oral syringe or medicine dropper, pour the medication into a medicine spoon or goblet calibrated in milliliter, and administer it to the child; never put a medicine dropper or syringe directly into a child’s mouth, unless it is disposable. If the spoon or goblet is to be used again, it must be washed in very hot water after use.
— Wash your hands after administering the medication.
Acetaminophen doses based on the child’s weight


Child’s Volume of medication to be administered, by acetaminophen
weight concentration



Kilograms (kg) 80 mg/ml 80 mg/5 ml 160 mg/5 ml


4.3 - 5.3 0.8 ml 4 ml 2.0 ml


5.4 - 6.3 1.0 ml 5 ml 2.5 ml


6.4 - 7.4 1.2 ml 6 ml 3.0 ml


7.5 - 8.5 1.4 ml 7 ml 3.5 ml


8.6 - 9.5 1.6 ml 8 ml 4.0 ml


9.6 - 10.6 1.8 ml 9 ml 4.5 ml


10.7 - 11.7 2.0 ml 10 ml 5.0 ml


11.8 - 12.7 2.2 ml 11 ml 5.5 ml


12.8 - 13.8 2.4 ml 12 ml 6.0 ml


13.9 - 14.9 2.6 ml 13 ml 6.5 ml


15.0 - 15.9 2.8 ml 14 ml 7.0 ml


16.0 - 17.0 3.0 ml 15 ml 7.5 ml


17.1 - 18.1 3.2 ml 16 ml 8.0 ml


18.2 - 19.1 3.4 ml 17 ml 8.5 ml


19.2 - 20.2 3.6 ml 18 ml 9.0 ml


20.3 - 21.3 3.8 ml 19 ml 9.5 ml


21.4 - 22.3 4.0 ml 20 ml 10.0 ml


22.4 - 23.4 4.2 ml 21 ml 10.5 ml


23.5 - 24.5 4.4 ml 22 ml 11.0 ml


24.6 - 25.5 4.6 ml 23 ml 11.5 ml


25.6 - 26.6 4.8 ml 24 ml 12.0 ml


26.7 - 27.7 5.0 ml 25 ml 12.5 ml


27.8 - 28.7 5.2 ml 26 ml 13.0 ml


28.8 - 29.8 5.4 ml 27 ml 13.5 ml


29.9 - 30.9 5.6 ml 28 ml 14.0 ml


31.0 - 31.9 5.8 ml 29 ml 14.5 ml


32.0 - 33.0 6.0 ml 30 ml 15.0 ml


33.1 - 34.1 6.2 ml 31 ml 15.5 ml


34.2 - 35.1 6.4 ml 32 ml 16.0 ml


— The dosages shown in the chart above are based on a maximum dose of 15 mg/kg.
— The dosage unit may be repeated every 4 to 6 hours.
— Do not exceed 5 doses in a 24-hour period.
Mistakes when administering doses
If, after administering the medication, you find that the dose was too high, it is important to react immediately by contacting the Centre antipoison du Québec (1 800 463-5060) and following the instructions given. The child’s parent must be informed.
WARNING
Ibuprofen (Advil, Motrin and other brands)
A clear distinction must be made between acetaminophen and ibuprofen. Ibuprofen must never be given to a child under 6 months of age.
Although both medications have fever-reducing properties, they must not be confused because they belong to different classes of medications and work differently. Ibuprofen must not, under any circumstances, be substituted for acetaminophen for the purposes of this Protocol. Care must be taken never to confuse ibuprofen and acetaminophen or substitute one for the other.
This Protocol may be applied as indicated, even if the child was given ibuprofen at home before being brought to the childcare service, regardless of the time that has elapsed. There is no reason why acetaminophen should not be given to a child to whom ibuprofen has been administered, since the 2 medications do not work in the same way.
OTHER MEDICATIONS:
Because of the availability of an increasing number of combination medications containing acetaminophen and another pharmaceutical product, greater care is needed when applying this Protocol. For example, a number of cough syrups contain acetaminophen.
Good communication between the parents and the person authorized to administer the medication is important. The person authorized to administer the medication must know what medication the child was given in the 4 hours before arriving at the childcare service and must ask the parent if it contained acetaminophen. At the same time, the parent must be informed of the doses of acetaminophen administered at the childcare centre, and the times of administration. There must be at least 4 hours between 2 doses of acetaminophen.
AUTHORIZATION FORM FOR THE ADMINISTRATION OF ACETAMINOPHEN
A parent is not required to consent to the application of this Protocol. However, if a parent does not sign the authorization form, acetaminophen many not be administered to the child unless the parent and a member of the Collège des médecins du Québec give written authorization. A parent may limit the period of validity of the authorization by indicating the duration of the authorization in the space provided.
I hereby authorize

(name of childcare centre, day care centre, person recognized as a home childcare provider, as the case may be, or person designated under section 81 of the Educational Childcare Regulation, where applicable) to administer to my child, in accordance with this Protocol, acetaminophen sold under the following brand name:


Child’s surname and given name

Child’s weight

Weight in kilos Date Parent’s initials







Authorization period.

Parent’s signature Date

This Protocol is an adaptation of a protocol prepared by the Ministère de la Famille, reviewed by the Association des pédiatres du Québec, reviewed by representatives of the Ministère de la Santé et des Services sociaux, in 2010 and in 2013 and approved by the Association des pédiatres du Québec in 2013. The information it contains reflects the state of knowledge on the subject in 2013.
(2) PROTOCOL FOR APPLYING INSECT REPELLENT
Under the Educational Childcare Regulation, insect repellent may be applied without medical authorization to a child receiving childcare, provided it is applied in accordance with this Protocol and that a parent has given written consent.
A parent is not required to consent to the application of this Protocol. However, if a parent does not sign the authorization form, the insect repellent may not be applied to a child unless the parent and a member of the Collège des médecins du Québec give written authorization.
BASIC RULES
The insect repellent used must contain DEET with a concentration of no more than 10% (N,N-diethyl-m-toluamide); read the product label carefully because the concentration of DEET varies significantly from product to product. Other insect repellents (e.g. citronella, lavender) are not recommended.
Childcare providers may have their own insect repellent container; the brand name, the form (lotion, cream, gel, liquid, non-aerosol or aerosol spray) and the concentration of the active ingredient DEET must be indicated on the authorization form. When purchasing an insect repellent, care is needed to avoid confusing the product required with insecticides designed to kill insects, which must not, under any circumstances, be applied to the body. Only personal insect repellents bearing a Pest Control Product registration number and labelled for human use by Health Canada should be used. Lastly, it is forbidden to use “2 in 1” products that act as both an insect repellent and a sunscreen. The reason for this is that sunscreen must be applied generously to all exposed skin and under clothing, to protect the child from the harmful effects of the sun, while an insect repellent should be applied in small amounts and never under clothing. It is for this reason that “2 in 1” products are not recommended.
To avoid confusion, it is recommended that childcare providers should keep only one type of insect repellent on hand. The product must be stored under lock and key, out of reach of the children. During outings, it is important to ensure that insect repellent is never within reach of the children.
Repeated or excessive applications of insect repellent are unnecessary for effectiveness; it is recommended that the repellent be applied sparingly to the skin or clothing. The product should not be used for extended periods of time.
Under no circumstances should insect repellent be applied:
— to the eyes or mucous membranes;
— to open wounds or broken skin;
— to irritated or sunburned skin;
— under clothing;
— to the hands;
— to the face; or
— in excessive amounts.
If a person gets insect repellent in his or her eyes, rinse immediately with plenty of water.
Insect repellents may not be used on children under 6 months of age without written authorization from a parent and a physician. Preventive measures must therefore be used to protect children of this age from mosquitoes (see the precautionary measures for children under 6 months of age).
It is recommended that insect repellent be applied only once a day to children between 6 months and 2 years of age, and a maximum of 3 times a day to children over 2 years of age.
Before the period of the year when mosquitoes appear (spring), it is recommended that the DEET-based products used by the childcare service should first be tested on the children to avoid undesirable reactions when they are brought into more general use. To do this, a small amount of insect repellent should be applied to a small area of the child’s skin (the size of a coin), preferably on the inside of the forearm, and left there for 24 hours. It is suggested that testing be done in the morning to see how well the children tolerate the product throughout the day, and then observe the results the following day. It is important to let parents know that the test will be done on that day. If a reaction occurs (e.g. rash, swelling), wash the treated skin immediately, inform the parent and suggest that the child be taken to see a physician. Make sure the parent has a list of the product’s ingredients for the physician. The results of the test should be written in the child’s file. Insect repellent should not be used on a child who reacts to the test, except with a written recommendation from a physician.
An insect repellent and sunscreen can both be used if they are not combined into one product. When a sunscreen and an insect repellent are used, it is recommended that the sunscreen should have a sun protection factor (SPF) of 30, and that the insect repellent be applied at least 20 minutes after the sunscreen. Sunscreens lose approximately 30% of their effectiveness when DEET is applied.
Insect repellent must be applied in well-ventilated areas away from food.
Any application of insect repellent must be recorded in the register of medications prescribed by the Regulation and the parent must be informed of the number of daily applications.
PRECAUTIONARY MEASURES
Insect repellent should be used only during periods when mosquitoes are abundant or if the area around the childcare service serves as a breeding ground for mosquitoes, and only after the precautionary measures below have been taken.
To avoid insect bites when outside, the children must
— wear a long-sleeved sweater and long pants that ideally fit tightly at the wrists and ankles;
— wear loose-fitting, light-coloured clothes made of a tightly-woven fabric;
— wear shoes and socks;
— avoid using perfumed products; and
— avoid going outside at times of the day when mosquitoes are most abundant, such as early morning or late afternoon.
To prevent mosquitoes from breeding in the area around the childcare service:
— eliminate any source of standing water, which is conducive to mosquito breeding;
— turn over any objects that are not stored indoors, such as boats, wading pools, gardening containers and children’s toys;
— cover outdoor garbage cans and any other container that may collect water;
— replace pool or wading pool water or make sure it is treated daily;
— use insect screens in the areas where younger children play; and
— repair damaged insect screens as quickly as possible.
Prevent children under 6 months of age from coming into contact with mosquitoes by using mosquito netting on strollers and by using screened-in verandas.
WHAT YOU SHOULD KNOW
DEET-based products remain the preferred and most effective insect repellents against a wide variety of insects; insect repellents with a DEET concentration of less than 10% provide 2 to 3 hours of protection.
Although the safety of these products has been proven, they may pose certain risks, especially to children, if they are misused. DEET is partially absorbed through the skin and may make its way into the bloodstream. It may also accumulate in the body fat, brain and heart. A few cases of poisoning have been cited in the literature. However, there is little risk to human health if insect repellents are used with discretion and only occasionally.
Applying insect repellent to clothing (except synthetics or plastic material) may be a way of decreasing the risk of poisoning. However it is important to ensure that the children do not put clothing treated with DEET in their mouths, or touch it and accidentally get repellent in their eyes. DEET-based products can cause severe eye irritation.
In choosing a product, the following benefits and inconveniences should be considered:
— Insect repellents in the form of a lotion, gel or cream are generally easy to apply, but heavy application should be avoided.
— Insect repellents in non-aerosol or aerosol spray form require additional caution. They should not be applied in closed or poorly-ventilated areas to avoid breathing in the harmful fumes, and care must be taken to avoid getting repellent on children’s faces or hands. In addition, it is preferable for the person applying the insect repellent to first spray it onto his or her own hands before applying the product to the child.
WHAT YOU SHOULD DO
Insect repellent must always be applied by a person authorized to do so. Under no circumstances should children be allowed to apply insect repellent themselves, regardless of their age.
When you go outdoors with the children, you must:
— apply the precautionary measures; and
— follow the steps below to apply the insect repellent:
— use simple words to explain to the child the relationship between the situation, the insect repellent being applied and the expected results;
— ask the children in a way that they understand not to touch with their hands the parts of their body or clothing on which insect repellent has been applied, not to put their fingers in their mouth or eyes, and not to chew clothing on which repellent has been applied;
— wash your hands before handling the product;
— read the product label carefully before applying, and make sure that the DEET concentration is less than 10% and that the product does not contain sunscreen;
— preferably, wear gloves to apply the product;
— put a small amount of the product in your hand, and apply it sparingly to exposed areas of skin or to clothing;
— make sure the children do not touch the areas to which the insect repellent has been applied. If they do so, they should wash their hands with soapy water;
— wash your hands after applying the insect repellent to all the children in the group, even if you wore gloves to apply it.
Wash the treated skin with soap and water when the children come inside or when protection is no longer needed. This is particularly important if insect repellent is applied several times in the same day or on several consecutive days. This recommendation should also be passed on to the parents.
AUTHORIZATION FORM FOR THE APPLICATION OF INSECT REPELLENT
A parent is not required to consent to the application of this Protocol. However, if a parent does not sign the authorization form, insect repellent may not be applied to a child unless the parent and a member of the Collège des médecins du Québec give written authorization. A parent may limit the period of validity of the authorization by indicating the duration of the authorization in the space provided.
I hereby authorize

(name of childcare centre, day care centre, person recognized as a home childcare provider, as the case may be, or person designated under section 81 of the Educational Childcare Regulation, where applicable) to use on my child, in accordance with this Protocol, insect repellent sold under the following brand name:

Brand name, form (lotion, cream, gel, liquid, non-aerosol or aerosol spray) and concentration of the active ingredient DEET

Child’s surname and given name

Authorization period
Parent’s signature Date
This Protocol, originally prepared by the Ministère de la Famille, was reviewed by representatives of the Ministère de la Santé et des Services sociaux, in 2010 and in 2013 and approved by the Association des pédiatres du Québec in 2013. The information it contains reflects the state of knowledge on the subject in 2013.
O.C. 582-2006, Sch. II; O.C. 1314-2013, s. 69.
SCHEDULE II
(s. 116)
PROTOCOLS
(1) PROTOCOL FOR ADMINISTERING ACETAMINOPHEN
Acetaminophen is the generic name of the medication that is commercially available under the following brand names: Atasol, Tempra, Tylenol and other house brand names.
Under the Educational Childcare Regulation (chapter S-4.1.1, r. 2), acetaminophen may be administered without medical authorization to a child receiving childcare, provided it is administered in accordance with this Protocol and that a parent has given written consent.
A parent is not required to consent to the application of this Protocol. However, if a parent does not sign the authorization form, the medication may not be administered to the child unless the parent and a member of the Collège des médecins du Québec give written authorization.
BASIC RULES
Within the framework of this Protocol, acetaminophen may be administered solely to reduce fever. It may not be administered
— to children under 2 months of age;
— to relieve pain;
— for more than 48 consecutive hours (2 days); or
— to children who have received medication containing acetaminophen in the preceding 4 hours.
In those 4 cases, the Protocol does not apply and written authorizations from a physician and the parent are required to administer the medication.
Childcare providers may have their own acetaminophen container, in which case the brand name, the dosage form (drops, tablets, syrup) and the concentration must be indicated on the authorization form.
To avoid confusion, acetaminophen should be kept on hand in only one of its 2 liquid forms: drops or syrup. If children under 24 months of age are receiving childcare, it is recommended that drops be used instead of syrup. If the provider elects to use syrup for the other children, it is recommended only one concentration be used.
The dosage must not under any circumstances exceed the dosage guidelines below or the dosage prescribed on the medication container.

_________________________________________________________________________________
| |
| An adult tablet must never be cut up and administered to a child as it could |
| alter the dosage: an inadequate dose would not provide the expected expected |
| result, while an overdose could pose serious risks to the child. |
|_________________________________________________________________________________|
It is important to always check the concentration of acetaminophen and to follow the dosage instructions on the container since new products of greater or lesser strength may appear on the market. It is also recommended to use only one concentration if the brand name selected is available in more than one concentration.
Any administration of acetaminophen must be recorded in the register of medications prescribed by the Regulation and the parent must be informed.
WHAT YOU SHOULD KNOW
What is a normal temperature ?
The normal temperature range will vary depending on the measurement method, used as illustrated in the table below.
Measurement Method Normal Variation
in Temperature


Rectal 36.6°C to 38.0°C

Oral 35.5°C to 37.5°C

Axillary 34.7°C to 37.3°C
(underarm)

Tympanic 35.8°C to 38.0°C
(ear)
What is fever?
Fever is defined as a body temperature that is higher than normal. Normal temperature may vary somewhat depending on the child, the time of day, the outdoor temperature and the level of activity. The cause of the fever is more important than the temperature itself.
It is generally considered that there is fever if the temperature is above the normal temperature range where the rectal or tympanic temperature is above 38.0°C.
The only sure way to measure fever is to take the child’s temperature. A child’s temperature must be checked whenever the child’s general condition (frantic crying, loss of energy, change in general condition, loss of appetite, etc.) or physical symptoms (flushed cheeks, excessively warm skin, sweating) could be signs of fever. The following measures are recommended:
— take the rectal temperature of children under 2 years of age. At that age, to know if they have a fever, take the axillary temperature. If it is greater than 37.3°C, the rectal temperature should be taken;
— take the rectal or tympanic temperature of children between 2 and 5 years of age. If the axillary temperature is taken, it is important to note that it is less accurate;
— take the oral temperature of children over 5 years of age;
— use the appropriate thermometer. Glass and mercury thermometers are not recommended because of the risks of accidental exposure to that toxic substance if they break. Fever strips are not recommended because they do not give accurate readings;
— always use disposable plastic tips as they are more hygienic; otherwise, disinfect the thermometer properly before and after each use;
— if the child has just been physically active, wait approximately 15 minutes as the child’s body temperature may be higher than normal if it is taken immediately after an activity;
— always comply with the time requirements for the thermometer being used since the time required may vary with the thermometer. A digital thermometer, which requires less time to take the temperature, is recommended.
WHAT YOU SHOULD DO
If a child under 2 months of age has a fever, that is, if the rectal temperature is above 38.0°C,
— dress the child comfortably;
— have the child drink at more frequent intervals;
— keep an eye on the child and take the child’s temperature again after 60 minutes, or sooner if the child’s condition seems to be worsening;
— notify the parent immediately, ask the parent to come and pick up the child and, in the meantime, apply the measures listed above; and
— if the parent cannot come to pick up the child, call the persons designated by the parent as emergency contacts and if they cannot be reached, take the child to a medical service, to the local community service centre or to a hospital emergency department; do not administer acetaminophen without a written medical authorization for the child.
If a child 2 months of age or older has a fever, that is, if the rectal or tympanic temperature is above 38.0°C,
— apply the measures listed above for an increase in body temperature (dress the child comfortably, have the child drink and keep an eye on the child);
— inform the parent of the child’s condition;
— if the rectal temperature is above 38.5°C, acetaminophen may be administered to relieve the child, according to the dosage guidelines below or the dosage instructions on the medication container, in accordance with the rules in this Protocol. If necessary, acetaminophen may be given as soon as the temperature is 38.1°C or higher; and
— one hour after administering acetaminophen, take the child’s temperature again; if the temperature is still high, ask the parent to come and pick up the child. If the parent cannot be reached, call the persons designated by the parent as emergency contacts and if they cannot be reached, take the child to a medical service, to the local community service centre or to a hospital emergency department.
When you administer acetaminophen,
— always use simple words, appropriate to the child’s age, to explain to the child the relationship between his or her condition, the medication being taken and the expected results;
— wash your hands before handling the medication;
— check the concentration, dosage instructions and expiry date on the medication container;
—  pour the medication (drops or syrup) into a medicine spoon calibrated in ml, then administer it to the child; never put a medicine dropper directly into a child’s mouth, unless it is a disposable dropper. The spoon must be washed in very hot water after use;
OR
— if administering a tablet, put it in a goblet then have the child take it. If the child wants to, he or she may drink a little water after taking the tablet; and
— wash your hands after administering the medication.
ACETAMINOPHEN: DOSAGE
Concentration
Weight Drops Syrup Tablets
80 mg/ml 80 mg/5ml 160 mg/5ml 80 mg/tablet 160 mg/tablet


2.4 - 5.4 kg 0.5 ml 2.5 ml 1.25 ml - -
(40 mg) (40 mg) (40 mg)
5.5 - 7.9 kg 1.0 ml 5.0 ml 2.5 ml - -
(80 mg) (80 mg) (80 mg)
8.0 - 10.9 kg 1.5 ml 7.5 ml 3.75 ml - -
(120 mg) (120 mg) (120 mg)
11.0 - 15.9 kg 2.0 ml 10.0 ml 5.0 ml 2 tablets 1 tablet
(160 mg) (160 mg) (160 mg) (160 mg) (160 mg)
16.0 - 21.9 kg 3.0 ml 15.0 ml 7.5 ml 3 tablets 1.5 tablets
(240 mg) (240 mg) (240 mg) (240 mg) (240 mg)
22.0 - 26.9 kg 4.0 ml 20.0 ml 10.0 ml 4 tablets 2 tablets
(320 mg) (320 mg) (320 mg) (320 mg) (320 mg)
27.0 - 31.9 kg 5.0 ml 25.0 ml 12.5 ml 5 tablets 2.5 tablets
(400 mg) (400 mg) (400 mg) (400 mg) (400 mg)
32.0 - 43.9 kg 6.0 ml 30.0 ml 15.0 ml 6 tablets 3 tablets
(480 mg) (480 mg) (480 mg) (480 mg) (480 mg)
— The dosage unit may be repeated every 4 hours.
— Do not exceed 6 doses in a 24-hour period.
— The dosages shown in the chart above are based on a maximum dose of 10 to 15mg/kg.
____________________________________________________________________
| |
| WARNING |
| ACETAMINOPHEN IN RELATION TO IBUPROFEN AND OTHER MEDICATIONS |
|____________________________________________________________________|

IBUPROFEN:
— A warning is needed since a clear distinction must be made between acetaminophen and ibuprofen.
— Although both medications have antipyretic (fever-reducing) properties, they must not be confused because they belong to different classes of medications and work differently. Ibuprofen must not, under any circumstances, be substituted for acetaminophen for the following reasons:
— acetaminophen and ibuprofen belong to different classes of medications;
— ibuprofen is a non-steroidal anti-inflammatory drug (NSAID);
— the dosage and frequency of administration are different for the 2 medications;
— it has been established that all NSAIDs may affect respiratory functions; that is why ibuprofen is contra-indicated in persons who have or have had asthma; and;
— a cross-sensitivity has been observed between salicylates and ibuprofen (allergic reaction).
— When applying this Protocol, care must be taken to never confuse ibuprofen and acetaminophen or substitute one for the other.
— This Protocol may be applied as indicated even if a child has received ibuprofen at home before arriving at the childcare service, regardless of the time elapsed. There is no contra-indication to or danger in giving acetaminophen to a child who received ibuprofen earlier since the 2 medications do not work in the same way.
OTHER MEDICATIONS:
— The availability of an increasing number of combination medications containing acetaminophen and another pharmaceutical product on the market calls for greater care in applying this Protocol. A number of cough syrups, for example, contain acetaminophen.
— Good communication between the parents and the person authorized to administer the medication is important. The person authorized to administer the medication must know what medication the child received in the 4 hours before arriving at the childcare service so the Protocol may be applied safely, for the health and well-being of the child.
— If an educator or a person recognized as a home childcare provider notices fever in a child within 4 hours of the child’s arrival and has been made aware that the child took syrup or other medication earlier, the educator or provider may contact a pharmacist to obtain the necessary information concerning the medication and apply the Protocol accordingly.
______________________________________________________________
| |
| AUTHORIZATION FORM FOR THE ADMINISTRATION OF ACETAMINOPHEN |
|______________________________________________________________|
A parent is not required to consent to the application of this Protocol. However, if a parent does not sign the authorization form, acetaminophen may not be administered to the child unless the parent and a member of the Collège des médecins du Québec give written authorization. A parent may limit the period of validity of the authorization by indicating the duration of the authorization in the space provided.
I hereby authorize __________________________________________________________________________ (name of childcare centre, day care centre, person recognized as a home childcare provider or person who assists the provider, as the case may be, or person designated under the second paragraph of section 81 of the Educational Childcare Regulation) to administer to my child, in accordance with this Protocol, acetaminophen sold under the following brand name:

Brand name, form (drops, syrup or tablets) and concentration of the active ingredient DEET

Child’ surname and given name

Authorization period
______________________________________________________________ _________/_________/________
Parent’s signature Date
_________________________________________________________________________________
| |
| This Protocol, prepared by the Ministère de la Famille et de l’Enfance, was |
| initially approved by a working group composed of representatives from the |
| health and social services network and childcare services. The Protocol was |
| reviewed by the Comité de prévention des infections dans les services de garde |
| garde à l’enfance du Québec. The information it contains reflects the state |
| of knowledge on the subject in 2006. |
|_________________________________________________________________________________|

(2) PROTOCOL FOR APPLYING INSECT REPELLENT
Under the Educational Childcare Regulation, insect repellent may be applied without medical authorization to a child receiving childcare, provided it is applied in accordance with this Protocol and that a parent has given written consent.
A parent is not required to consent to the application of this Protocol. However, if a parent does not sign the authorization form, the insect repellent may not be applied to a child unless the parent and a member of the Collège des médecins du Québec give written authorization.
BASIC RULES
The insect repellent used must contain a concentration of less than 10% DEET (N,N-diethyl-m-toluamide); read the product label carefully because the concentration of DEET varies significantly from product to product.
Childcare providers may have their own insect repellent container; the brand name, the form (lotion, cream, gel, liquid, non-aerosol or aerosol spray) and the concentration of the active ingredient DEET must be indicated on the authorization form. To avoid confusion, only one form of insect repellent should be kept on hand.
Repeated or excessive applications of insect repellent are unnecessary for effectiveness; it is recommended the repellent be applied to the skin sparingly. The product should not be used for extended periods of time
Under no circumstances should insect repellent be applied
— to the eyes or mucous membranes;
— to open wounds or broken skin;
— to irritated or sunburned skin;
— under clothing;
— to the hands; or
— in excessive amounts.
Insect repellent may not be used on children under 2 years of age without written authorization from a parent and a physician. This Protocol therefore does not apply to children under 2 years of age.
It is recommended insect repellent be applied only once a day to children between 6 months and 2 years of age, and a maximum of 3 times a day to children over 2 years of age.
Insecticides and pesticides are made for use on land or in houses, and should never be used on the body.
DEET-based products should first be tested by applying a small amount to a small area of the child’s skin, preferably on the inside of the forearm, then waiting 8 to 12 hours. It is suggested that testing be done in the morning to see how well the children tolerate the product through the day; it is important to let parents know that the test will be done on that day. The test should be done in early spring, well before the Protocol is applied. If a reaction occurs, wash the treated skin immediately and consult a physician; make sure to give the physician a list of the product’s ingredients.
Never combine insect repellent and sunscreen. Avoid all “2-in-1” products that act as both an insect repellent and a sunscreen. To adequately protect the children from the harmful effects of the sun, apply sunscreen generously to exposed skin and under clothing; apply insect repellent, in contrast, in small amounts and never under clothing. If suntan lotion is applied after insect repellent, both products become less effective. Sunscreens also lose approximately 20% of their effectiveness when DEET is applied. When a sunscreen and an insect repellent are used, it is recommended a cream with a sun protection factor (SPF) of 30 be used and the insect repellent be applied 30 to 45 minutes after the sunscreen.
Insect repellent must be used in well-ventilated areas away from food.
Any application of insect repellent must be recorded in the register of medications prescribed by the Regulation and the parent must be informed of the number of daily applications.
PRECAUTIONARY MEASURES
Insect repellent should be used only during periods when mosquitoes are abundant or if the area around the childcare service provides a breeding ground for mosquitoes, and only after the precautionary measures below have been taken.
To avoid insect bites when outside, the children should
— wear a long-sleeved sweater and long pants that ideally fit tightly at the wrists and ankles;
— wear loose-fitting, light-coloured clothes made of a tightly woven fabric;
— wear shoes and socks;
— avoid using perfumed products; and;
— avoid going outside at times of the day when mosquitoes are most abundant, such as early morning or late afternoon.
To prevent mosquitoes from multiplying in the area around the childcare service,
— eliminate any source of standing water, which is conducive to mosquito breeding;
— turn over any objects that are not stored indoors, such as boats, wading pools, gardening containers and children’s toys;
— cover outdoor garbage cans and any other container that may collect water;
— replace pool or wading pool water or make sure it is treated daily;
— use insect screens in the areas where younger children play; and
— repair damaged insect screens as quickly as possible.
Protect children under 6 months of age from coming into contact with mosquitoes by using mosquito netting on strollers and by using screened-in verandas.
WHAT YOU SHOULD KNOW
DEET-based products remain the preferred and most effective insect repellents against a wide variety of insects; insect repellents with a DEET concentration of less than 10% provide 2 to 3 hours of protection.
Although the safety of these products has been proven, they may pose certain risks, especially to children, if they are misused. DEET is partially absorbed through the skin and may make its way into the bloodstream. It may also accumulate in the body fat, brain and heart. A few cases of poisoning have been cited in the literature. However, there is little risk to human health if insect repellents are used with discretion and only occasionally.
Applying insect repellent to clothing (except synthetics or plastic material) may be a way of decreasing the risk of poisoning in children over 2 years of age, but it is important to watch that children do not put the saturated clothing in their mouths, or touch it and accidentally get repellent in their eyes. DEET-based products can cause severe eye irritation.
In choosing a product, the following benefits and inconveniences should be considered:
— products in the form of a lotion, gel or cream are generally easy to apply but heavy application should be avoided;
— insect repellents in non-aerosol or aerosol spray form require additional caution; they should not be applied in closed or poorly-ventilated areas to avoid breathing in the harmful fumes, and care must be taken to avoid getting repellent on children’s faces or hands.
WHAT YOU SHOULD DO
Insect repellent must always be applied by a person authorized to do so. Under no circumstances should children be allowed to apply insect repellent themselves, regardless of their age.
When you go outdoors with the children, you must
— apply the precautionary measures; and
— follow the steps below to apply the insect repellent:
— use simple words to explain to the child the relationship between the situation, the insect repellent being applied and the expected results;
— wash your hands before handling the product;
— read the product label carefully before applying, and make sure that the DEET concentration is less than 10% and that the product does not contain sunscreen;
— it is preferable to wear gloves to apply the product;
— use single-use gloves and change gloves if a child has broken skin, such as insect bites (which often lead to a secondary infection), to eliminate the risk of transmitting a skin infection to another child;
— put a small amount of the product in your hand, apply it sparingly to exposed areas only or to clothing, only at the nape of the neck and ankles, as far as possible;
— make sure the children do not touch the areas to which the insect repellent has been applied. If they do touch those areas, they should wash their hands with soapy water; and
— wash your hands after applying the insect repellent to all the children in the group, even if you wore gloves to apply it.
Wash the treated skin with soap and water when the children come inside or when protection is no longer needed. This is particularly important if insect repellent is applied several times in the same day or on several consecutive days.
________________________________________________________________________________
| |
| AUTHORIZATION FORM FOR THE APPLICATION OF INSECT REPELLENT |
|________________________________________________________________________________|

_______________________________________________________________________________
| |
| A parent is not required to consent to the application of this Protocol. |
| However, if a parent does not sign the authorization form, insect repellent |
| may not be applied to a child unless the parent and a member of the Collège |
| des médecins du Québec give written authorization. A parent may limit the |
| period of validity of the authorization by indicating the duration of the |
| authorization in the space provided. |
|_______________________________________________________________________________|
I hereby authorize __________________________________________________________________________ (name of the childcare centre, day care centre, person recognized as home childcare provider or person who assists the provider, as the case may be, or person designated under the second paragraph of section 81 of the Educational Childcare Regulation, where applicable) to use on my child, in accordance with this Protocol, insect repellent sold under the following brand name:

Brand name, form (drops, syrup or tablets) and concentration of the active ingredient DEET

Child’ surname and given name

Authorization period
______________________________________________________________ _________/_________/________
Parent’s signature Date
_________________________________________________________________________________
| |
| This Protocol was prepared by the Ministère de la Famille et de l’Enfance and |
| approved by a working group composed of representatives from the health and |
| social services network and childcare services. The information it contains |
| reflects the state of knowledge on the subject in 2006. |
|_________________________________________________________________________________|
O.C. 582-2006, Sch. II.