Background
Purpose
Program Considerations
Summary

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Background

During the last ten years, local crisis nurseries have experienced the need to serve increasing numbers of children who are "medically fragile." Contributing factors include increased drug and alcohol usage, the cutback of funding sources for family medical care, and limited availability of foster homes for children. In addition, traditional placement resources and funding for children’s programs have also declined, or were simply inappropriate for children with more serious physical and emotional problems. Crisis nurseries traditionally have accepted referrals for children who have experienced or been at risk of physical and/or sexual abuse, neglect, or abandonment (which frequently included a medical condition). Children who have been at higher risk of abuse because of their medical condition have been added to the population served in crisis nurseries. In either case, this new classification of infants and children who are medically fragile has necessitated specialized forms of childcare, staffing, training, and medical services.

Purpose

The purpose of offering crisis nursery care for infants and children who are medically fragile is to provide a supportive, nurturing environment for children who have special medical problems which require 24-hour observation or treatment. Crisis nursery care for children who are medically fragile is medically supervised child care offered to families in collaboration with a medical facility. This usually occurs when health care needs are 1) beyond the normal care of other children in the same age group (which results in the child’s requiring a significant amount of individualized care apart from the group setting); or 2) so specialized that special health care plans directed by physicians and/or nurses are required to provide daily care for the child.

Examples of children who meet the criteria of being identified as medically fragile:

• Infants on an apnea monitor
• Infants born prenatally exposed to alcohol or drugs (e.g., infants with Fetal Alcohol Syndrome or Crack/Cocaine exposure)
• Children who are admitted directly from a hospital where they have received care for a significant injury or illness
• Children with special breathing problems requiring significant care or ongoing alteration in the daily routine due to the medical condition
• Children in Spica Casts (body casts from waist to feet)
• Children with specialized feeding problems (e.g., feeding tubes, cleft lip and palate)
• Children with infectious or contagious diseases (e.g., hepatitis, sexually transmitted diseases, HIV–related conditions)
• Children with chronic health problems such as diabetes, asthma, or seizure disorders

Program Considerations

Child Care

Routine child care functions for children who are medically fragile require the ability to develop individualized child care plans to accommodate the child’s specific physical problem. Types of medication (and their effects on the child’s waking and sleeping patterns), the child’s physical mobility, the age and size of the child, and specific medical issues, must be considered in organizing the child’s day. Child care plans must be discussed and understood by all child care staff. Toddlers or elementary age children may require shorter school schedules. Frequently, infants who are medically fragile will require extended feeding schedules because of their inability to retain food, or due to physical abnormalities such as a cleft palate or lack of sucking reflexes. A daily schedule should be developed, and case records should reflect the child’s progress toward the established child care plan.

Staffing

Infants who are medically fragile usually require a lower staff-child ratio. This depends on the level of care required. A one-to-three staff ratio is a rule of thumb, but infants or children who are medically fragile (in body casts, etc.) may need one-on-one care during key hours of the day. Nursing staff and the availability of medical consultation are a necessity. Medical care plans must be developed in conjunction with a physician and/or nurse, depending on the severity of the medical problem. Medical staff must supervise the implementation of the crisis nursery care.

Training

Key to the provision of services to children who are medically fragile is the training program for the child care staff. Training must adhere to state licensing requirements. The training program needs to be flexible and ongoing in order to incorporate special topics as well as to offer training in specific areas. It must include discussion of the types of physical problems to be encountered; the use of cardiopulmonary resuscitation; the use of specialized medical equipment, such as inhalers or apnea monitors, feeding tubes, etc.; the administration of medication; charting of medication and physical symptoms; and emergency procedures. When caring for children who are medically fragile, and, indeed, for all children in crisis care, some universal medical precautions should be observed. These precautions include training on the use of plastic gloves, proper handling of diapers, bedding, and of any blood stained clothing or items. Thorough training and education of staff, as well as practice in using various pieces of equipment and various procedures, will ensure a staff "comfort level" when caring for children who are medically fragile. However, no amount of training can take the place of selecting staff who have empathy, a willingness to acquire the needed skills, competent childcare practices, and the patience to work with children who have medical problems.

Medical Services

Collaboration with a medical service (e.g., hospital, clinic, private physicians) which has a basic program of medical care must be in place in order to serve children who are medically fragile. The medical program is developed by trained professionals (doctors, nurses, etc.). Components include the following:

• Initial medical exam and assessment
• Medical history and prescribed treatment from referring entity. Infants referred from hospitals are more likely to have this information available
• A weekly clinic where children who are medically fragile may be examined by a physician, treatment revised, and any staff concerns addressed
• The availability of emergency consultation with a physician during evening and weekend hours.
• Separate medical exam room where children may be seen by the nurse or physician, sick children may be monitored, medications stored in locked cabinets or locked refrigerator, and medical supplies and equipment stored. This room may also store special foods or formulas required by children
• Procedures for when, how, and where to refer children requiring urgent medical treatment
• Medical staff capability to teach older children aged six to eleven how to care for their own medical conditions

Summary

Crisis nurseries provide temporary child care, and access to support services, for families experiencing extreme stress. Crisis nursery care can be provided for infants and children who are medically fragile. It is critical when establishing services to this group of children that issues of adequate program, staffing, training, and medical protocol be addressed. Children who are medically fragile can be mainstreamed along with healthy children. The types of crisis nursery services, and populations served, may be specified according to the nursery’s capability and funding. In this way, valuable untapped placement opportunities can be realized for this very special group of children.

About the Author

Jeanne Landdeck-Sisco has been the Executive Director of Casa de los Niņos for the past five years, and has been an active child welfare advocate in the public and private sectors for 23 years.

ARCH Factsheet Number 3, March 1992

This fact sheet was produced by the ARCH National Resource Center for Respite and Crisis Care Services funded by the U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau—Cooperative Agreement No. 90-CN-0121 under contract with the North Carolina Department of Human Resources, Mental Health/Developmental Disabilities/Substance Abuse Services, Child and Family Services Branch of Mental Health Services, Raleigh, North Carolina. The contents of this publication do not necessarily reflect the views or policies of the funders, nor does mention of trade names, commercial products or organizations imply endorsement by the U.S. Department of Health and Human Services. This information is in the public domain. Readers are encouraged to copy and share it, but please credit the ARCH National Resource Center.