Caring for Our Children National Health and Safety Standards Explained

The Caring for Our Children: National Health and Safety Performance Standards (CFOC) is the primary reference framework governing health and safety practice in licensed child care settings across the United States. Published jointly by the American Academy of Pediatrics (AAP) and the American Public Health Association (APHA), and funded through the Maternal and Child Health Bureau of the Health Resources and Services Administration (HRSA), CFOC establishes evidence-based benchmarks that states, licensing agencies, and providers use when developing and evaluating child care health policies. This page explains what CFOC standards are, how the framework is structured, the settings where its benchmarks apply, and where the standards function as regulatory floors versus aspirational targets.

Definition and scope

The Caring for Our Children standards document — now in its 4th edition — comprises more than 700 individual performance standards organized across health, safety, nutrition, staffing, and facility domains (American Academy of Pediatrics, CFOC). Each standard is accompanied by a rationale, a list of applicable setting types, and citations to research-based or agency literature that forms the evidentiary basis of the requirement.

CFOC applies across three primary setting categories:

1. Center-based care — licensed child care centers serving groups of children in a dedicated facility.
2. Family child care homes (large and small) — residential settings in which providers care for children in their own homes, often subject to different staff ratio and space requirements.
3. Out-of-school time programs — before- and after-school programs serving school-age children, which share some but not all standards with full-day infant/toddler care.

The scope of the document is national, but enforcement authority rests entirely with individual states. CFOC benchmarks inform — but do not automatically replace — state licensing codes. The National Resource Center for Health and Safety in Child Care and Early Education (NRC) maintains a living online version of CFOC that is updated between print editions as evidence evolves.

How it works

CFOC standards function as a three-tier reference system rather than a single regulatory mandate:

1. Standard text — a discrete, measurable practice requirement (e.g., staff-to-child ratios, diapering surface disinfection frequency, or required health record content).
2. Rationale — a cited explanation of why the standard reduces risk, drawn from sources such as the Centers for Disease Control and Prevention (CDC), the American Academy of Pediatrics Red Book, or research-based epidemiology.
3. Comments and type designations — clarifying notes and, in earlier editions, a classification of each standard as either a "Standard" (universally applicable) or an "Appendix" item.

State licensing agencies commonly adopt CFOC language verbatim, translate it into regulation, or use it as the baseline from which stricter state-specific rules are built. The Head Start Program Performance Standards (45 CFR Part 1302), administered by the Office of Head Start within the Administration for Children and Families (ACF), reference CFOC as a supplementary health and safety framework alongside their own federal code (45 CFR Part 1302).

Childcare health consultants play a specific operational role in the CFOC framework: Standard 1.6.0.1 and related standards define the minimum qualifications and functions of these professionals, who help facilities translate CFOC benchmarks into written policy and daily practice. Facilities that engage a qualified health consultant are more likely to meet documentation and training standards consistently.

Common scenarios

CFOC standards become operationally relevant across a predictable range of program decisions:

• Illness exclusion determinations — CFOC Chapter 3 provides condition-specific guidance on when children should be excluded from group care, which programs use to develop written illness exclusion policies. The standard distinguishes between conditions requiring immediate exclusion (e.g., fever above 101°F combined with behavior change) and conditions manageable within the program.
• Medication administration — CFOC Standard 3.6.3.1 requires written authorization, labeled containers, and a log for any medication given at a child care site. This framework directly informs written medication administration procedures at both center and home-based programs.
• Safe sleep — CFOC Chapter 3 contains specific standards for infant sleep positioning, crib specifications, and room-sharing configurations consistent with the AAP's Safe Sleep guidelines. These benchmarks underpin safe sleep practices required by most state licensing codes.
• Immunization verification — CFOC Standard 7.3.0.1 aligns with state immunization schedule requirements, obligating programs to collect and review documentation of child immunization status at enrollment and at defined intervals thereafter. The framework interfaces directly with immunization requirements enforced through state licensing.
• Emergency preparedness — CFOC Chapter 9 establishes requirements for written emergency plans, first-aid kit contents, and evacuation drills. Facilities link these standards to their emergency medical procedures documentation.

Decision boundaries

Understanding where CFOC standards are binding versus advisory is essential for accurate program compliance planning.

CFOC as mandatory floor: When a state's licensing regulation explicitly cites or incorporates CFOC language, that specific standard carries the legal weight of the licensing code. Violations can trigger corrective action, provisional licensing, or facility closure. Head Start grantees operating under 45 CFR Part 1302 face federal monitoring that cross-references CFOC as a supplementary health authority.

CFOC as aspirational benchmark: Where state regulations are silent on a topic addressed by CFOC, the standard functions as a best-practice reference rather than an enforceable rule. Facilities may adopt it voluntarily, and accreditation bodies such as the National Association for the Education of Young Children (NAEYC) incorporate CFOC-aligned indicators into their quality rating criteria.

CFOC versus state-specific code — conflict resolution: When a state rule is stricter than CFOC, state law governs. When CFOC is stricter than state law, compliance with state law is the minimum legal threshold, though adopting the CFOC standard may be required for accreditation or grant eligibility.

Family child care versus center distinction: Several CFOC chapters apply different numerical thresholds to the two settings. For example, minimum square footage per child, hand-washing sink requirements, and health record retention timelines may differ between a licensed center and a small family child care home. Programs must identify which setting-specific standards apply before drafting internal policy.

The CFOC framework is best understood alongside the broader landscape of federal health standards in child care, where multiple overlapping authorities — including HRSA, ACF, and individual state agencies — each carry different enforcement mechanisms and compliance timelines.

References

• American Academy of Pediatrics — Caring for Our Children, 4th Edition
• National Resource Center for Health and Safety in Child Care and Early Education (NRC) — CFOC Online
• American Public Health Association (APHA)
• Health Resources and Services Administration (HRSA) — Maternal and Child Health Bureau
• Office of Head Start — 45 CFR Part 1302 (Head Start Program Performance Standards)
• Administration for Children and Families (ACF)
• National Association for the Education of Young Children (NAEYC) — Accreditation Standards
• Centers for Disease Control and Prevention (CDC) — Child Care Health and Safety