Special Collection

Preventing Childhood Obesity in Early Care and Education Programs

The second edition of Preventing Childhood Obesity in Early Care and Education Programs is the new set of national standards describing evidence-based best practices in nutrition, physical activity, and screen time for early care and education programs. The standards are for ALL types of early care and education settings - centers and family child care homes. These updated standards are part of the new comprehensive Caring for Our Children: National Health and Safety Performance Standards; Guidelines for Early Care and Education Programs, Third Edition (CFOC, 3rd Ed.), which was released in June 2011.

Suggested Citation Format:

American Academy of Pediatrics, American Public Health Association, and National Resource Center for Health and Safety in Child Care and Early Education. 2012. Preventing Childhood Obesity in Early Care and Education: Selected Standards from Caring for Our Children: National Health and Safety Performance Standards; Guidelines for Early Care and Education Programs, 3rd Edition.

The second edition of Preventing Childhood Obesity in Early Care and Education Programs contains practical intervention strategies to prevent excessive weight gain in young children. The standards detail opportunities for providers to work with families beginning on day one of an infant's enrollment.

Areas of coverage:

The CFOC standards are developed through a public-private partnership with the American Public Health Association (APHA), the American Academy of Pediatrics(AAP), the National Resource Center for Health and Safety in Child Care and Early Education and the U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau (MCHB). Funding for the pre-released selected standards was provided by the Department of Health and Human Services, Administration for Children and Families, Office of Child Care.

Table of Contents

I. Nutrition Standards

A. General Requirements

4.2.0.1 Written Nutrition Plan
3.1.2.1 Routine Health Supervision and Growth Monitoring
4.2.0.2 Assessment and Planning of Nutrition for Individual Children
4.2.0.8 Feeding Plans and Dietary Modifications
4.2.0.3 Use of US Department of Agriculture Child and Adult Care Food Program Guidelines
4.2.0.4 Categories of Foods
4.2.0.5 Meal and Snack Patterns
4.2.0.6 Availability of Drinking Water
4.2.0.7 100% Fruit Juice
4.2.0.9 Written Menus and Introduction of New Foods
4.2.0.10 Care for Children with Food Allergies
4.2.0.11 Ingestion of Substances that Do Not Provide Nutrition
4.2.0.12 Vegetarian/Vegan Diets

B. Requirements for Infants

4.3.1.1 General Plan for Feeding Infants
4.3.1.2 Feeding Infants on Cue by a Consistent Caregiver/Teacher
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.1.4 Feeding Human Milk to Another Mother’s Child
4.3.1.5 Preparing, Feeding, and Storing Infant Formula
4.3.1.8 Techniques for Bottle Feeding
4.3.1.9 Warming Bottles and Infant Foods
4.3.1.10 Cleaning and Sanitizing Equipment Used for Bottle Feeding
4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants
4.3.1.12 Feeding Age-Appropriate Solid Foods to Infants
4.3.1.6 Use of Soy-Based Formula and Soy Milk

C. Requirements for Toddlers and Preschoolers

4.3.2.1 Meal and Snack Patterns for Toddlers and Preschoolers
4.3.2.2 Serving Size for Toddlers and Preschoolers
4.3.2.3 Encouraging Self-Feeding by Older Infants and Toddlers
4.3.1.7 Feeding Cow’s Milk

D. Requirements for School-Age Children

4.3.3.1 Meal and Snack Patterns for School-Age Children

E. Meal Service and Supervision

4.5.0.4 Socialization During Meals
4.5.0.5 Numbers of Children Fed Simultaneously by One Adult
4.5.0.6 Adult Supervision of Children Who Are Learning to Feed Themselves
4.5.0.7 Participation of Older Children and Staff in Mealtime Activities
4.5.0.8 Experience with Familiar and New Foods
4.5.0.3 Activities that Are Incompatible with Eating
4.5.0.11 Prohibited Uses of Food
4.4.0.2 Use of Nutritionist/Registered Dietitian

F. Food Brought From Home

4.6.0.2 Nutritional Quality of Food Brought From Home
4.6.0.1 Selection and Preparation of Food Brought From Home

G. Nutrition Education

4.7.0.1 Nutrition Learning Experiences for Children
2.1.1.2 Health, Nutrition, Physical Activity, and Safety Awareness
4.7.0.2 Nutrition Education for Parents/Guardians

H. Policies

9.2.3.11 Food and Nutrition Service Policies and Plans
9.2.3.12 Infant Feeding Policy

II. Physical Activity Standards

3.1.3.1 Active Opportunities for Physical Activity
3.1.3.2 Playing Outdoors
3.1.3.3 Protection from Air Pollution While Children Are Outside
3.1.3.4 Caregivers’/Teachers’ Encouragement of Physical Activity
9.2.3.1 Policies and Practices that Promote Physical Activity

III. Screen Time Standard

2.2.0.3 Screen Time/Digital Media Use

Appendices

Appendix C: Nutrition Specialist, Registered Dietitian, Licensed Nutritionist, Consultant, and Food Service Staff Qualifications
Appendix P: Situations that Require Medical Attention Right Away
Appendix Q: Getting Started with MyPlate
Appendix R: Choose MyPlate: 10 Tips to a Great Plate
Appendix S: Physical Activity: How Much Is Needed?
Appendix JJ: Our Child Care Center Supports Breastfeeding

I. Nutrition Standards

A. General Requirements

Standard 4.2.0.1: Written Nutrition Plan

Content in the STANDARD was modified on 11/9/2017.

 

The facility should provide nourishing and appealing food for children according to a written plan developed by a qualified nutritionist/registered dietitian. Caregivers/teachers, directors, and food service personnel should share the responsibility for carrying out the plan. The director is responsible for implementing the plan but may delegate tasks to caregivers/teachers and food service personnel. Where infants and young children are involved, the feeding plan may include special attention to supporting mothers in maintaining their human milk supply. The nutrition plan should include steps to take when problems require rapid response by the staff, such as when a child chokes during mealtime or has an allergic reaction to a food. The completed plan should be on file, easily accessible to staff, and available to parents/guardians on request.

If the facility is large enough to justify employment of a full-time nutritionist/registered dietitian or child care food service manager, the facility should delegate to this person the responsibility for implementing the written plan.
Some children may have medical conditions that require special dietary modifications. A written care plan from the primary health care provider, clearly stating the food(s) to be avoided and food(s) to be substituted, should be on file. This information should be updated annually if the modification is not a lifetime special dietary need. Staff should be educated about a child’s dietary modification to ensure that no child in care ingests or has contact with foods he/she should avoid while at the facility. The proper modifications should be implemented whether the child brings his/her own food or whether it is prepared on site. The facility needs to inform all families and staff if certain foods, such as nut products (e.g., peanut butter, peanut oil), should not be brought from home because of a child’s life-threatening allergy. Staff should also know what procedure to follow if ingestion or contact occurs. In addition to knowing ahead of time what procedures to follow, staff must know their designated roles during an emergency. The emergency plan should be dated and updated biannually.

RATIONALE
Nourishing and appealing food is the cornerstone of children’s health, growth, and development, as well as developmentally appropriate learning experiences (1-3). Nutrition and feeding are fundamental and required in every facility. Because children grow and develop more rapidly during the first few years after birth than at any other time, a child’s home and the facility together must provide food that is adequate in amount and type to meet each child’s growth and nutritional needs. Children can learn healthy eating habits and be better equipped to maintain a healthy weight if they eat nourishing food while attending early care and education settings (4). Children can self-regulate their food intake and are able to determine an appropriate amount of food to eat in any one sitting when allowed to feed themselves. Excessive prompting, feeding in response to emotional distress, and using food as a reward have all been shown to lead to excessive weight gain in children (5,6). The obesity epidemic makes this an important lesson today.

Meals and snacks provide the caregiver/teacher an opportunity to model appropriate mealtime behavior and guide the conversation, which aids in children’s conceptual and sensory language development and eye/hand coordination. In larger facilities, professional nutrition staff must be involved to ensure compliance with nutrition and food service guidelines, including accommodation of children with special health care needs.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.2.0.2 Assessment and Planning of Nutrition for Individual Children
4.2.0.4 Categories of Foods
4.2.0.8 Feeding Plans and Dietary Modifications
4.3.1.2 Feeding Infants on Cue by a Consistent Caregiver/Teacher
4.4.0.2 Use of Nutritionist/Registered Dietitian
4.5.0.11 Prohibited Uses of Food
4.7.0.1 Nutrition Learning Experiences for Children
9.2.3.11 Food and Nutrition Service Policies and Plans
9.2.4.3 Disaster Planning, Training, and Communication
Appendix C: Nutrition Specialist, Registered Dietitian, Licensed Nutritionist, Consultant, and Food Service Staff Qualifications
REFERENCES
  1. Kleinman RE, Greer FR, eds. Pediatric Nutrition. 7th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2014
  2. Holt K, Wooldridge N, Story M, Sofka D. Bright Futures: Nutrition. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2011
  3. Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017
  4. US Department of Health and Human Services, Administration for Children and Families, Office of Head Start. Head Start Program Performance Standards. Rev ed. Washington, DC: US Government Printing Office; 2016. https://eclkc.ohs.acf.hhs.gov/policy/45-cfr-chap-xiii. Accessed September 7, 2017
  5. Lally JR, Griffin A, Fenichel E, Segal M, Szanton E, Weissbourd B. Caring for Infants and Toddlers in Groups: Developmentally Appropriate Practice. 2nd ed. Arlington, VA: Zero to Three; 2008
NOTES

Content in the STANDARD was modified on 11/9/2017.

 

Standard 3.1.2.1: Routine Health Supervision and Growth Monitoring

The facility should require that each child has routine health supervision by the child’s primary care provider, according to the standards of the American Academy of Pediatrics (AAP) (3). For all children, health supervision includes routine screening tests, immunizations, and chronic or acute illness monitoring. For children younger than twenty-four months of age, health supervision includes documentation and plotting of sex-specific charts on child growth standards from the World Health Organization (WHO), available at http://www.who.int/childgrowth/standards/en/, and assessing diet and activity. For children twenty-four months of age and older, sex-specific height and weight graphs should be plotted by the primary care provider in addition to body mass index (BMI), according to the Centers for Disease Control and Prevention (CDC). BMI is classified as underweight (BMI less than 5%), healthy weight (BMI 5%-84%), overweight (BMI 85%-94%), and obese (BMI equal to or greater than 95%). Follow-up visits with the child’s primary care provider that include a full assessment and laboratory evaluations should be scheduled for children with weight for length greater than 95% and BMI greater than 85% (5).

School health services can meet this standard for school-age children in care if they meet the AAP’s standards for school-age children and if the results of each child’s examinations are shared with the caregiver/teacher as well as with the school health system. With parental/guardian consent, pertinent health information should be exchanged among the child’s routine source of health care and all participants in the child’s care, including any school health program involved in the care of the child.

RATIONALE
Provision of routine preventive health services for children ensures healthy growth and development and helps detect disease when it is most treatable. Immunization prevents or reduces diseases for which effective vaccines are available. When children are receiving care that involves the school health system, such care should be coordinated by the exchange of information, with parental/guardian permission, among the school health system, the child’s medical home, and the caregiver/teacher. Such exchange will ensure that all participants in the child’s care are aware of the child’s health status and follow a common care plan.

The plotting of height and weight measurements and plotting and classification of BMI by the primary care provider or school health personnel, on a reference growth chart, will show how children are growing over time and how they compare with other children of the same chronological age and sex (1,3,4). Growth charts are based on data from national probability samples, representative of children in the general population. Their use by the primary care provider may facilitate early recognition of growth concerns, leading to further evaluation, diagnosis, and the development of a plan of care. Such a plan of care, if communicated to the caregiver/teacher, can direct the caregiver’s/teacher’s attention to disease, poor nutrition, or inadequate physical activity that requires modification of feeding or other health practices in the early care and education setting (2).

COMMENTS
Periodic and accurate height and weight measurements that are obtained, plotted, and interpreted by a person who is competent in performing these tasks provide an important indicator of health status. If such measurements are made in the early care and education facility, the data from the measurements should be shared by the facility, subject to parental/guardian consent, with everyone involved in the child’s care, including parents/guardians, caregivers/teachers, and the child’s primary care provider. The child care health consultant can provide staff training on growth assessment. It is important to maintain strong linkage among the early care and education facility, school, parent/guardian, and the child’s primary care provider. Screening results (physical and behavioral) and laboratory assessments are only useful if a plan for care can be developed to initiate and maintain lifestyle changes that incorporate the child’s activities during their time at the early care and education program.

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) can also be a source for the BMI data with parental/guardian consent, as WIC tracks growth and development if the child is enrolled.

For BMI charts by sex and age, see http://www.cdc.gov/growthcharts/clinical_charts.htm.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.2.0.2 Assessment and Planning of Nutrition for Individual Children
REFERENCES
  1. Centers for Disease Control and Prevention. 2011. About BMI for children and teens. http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.html.
  2. Story, M., K. Holt, D. Sofka, eds. 2002. Bright futures in practice: Nutrition. 2nd ed. Arlington, VA: National Center for Education in Maternal and Child Health.
  3. Hagan, J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Bright futures: Guidelines for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics.
  4. Kleinman, R. E. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.
  5. Paige, D. M. 1988. Clinical nutrition. 2nd ed. St. Louis: Mosby.

Standard 4.2.0.2: Assessment and Planning of Nutrition for Individual Children

Content in the STANDARD was modified on 11/9/2017.

 

As a part of routine health supervision by a primary health care provider, children should be evaluated for nutrition-related medical problems, such as failure to thrive, overweight, obesity, food allergy, reflux disease, and iron-deficiency anemia (1). The nutritional standards throughout this document are general recommendations that may not always be appropriate for some children with medically identified special nutrition needs. Caregivers/teachers should communicate with the child’s parent/guardian and pediatrician/other physician to adapt nutritional offerings to individual children as indicated and medically appropriate. Caregivers/teachers should work with the parent/guardian to implement individualized feeding plans developed by the child’s primary health care provider to meet a child’s unique nutritional needs. These plans could include, for instance, additional iron-rich foods for a child who has been diagnosed as having iron-deficiency anemia. For a child diagnosed as obese or overweight, the plan would focus on controlling portion sizes and creating a menu plan in which calorie-dense foods, like sugar-sweetened juices, nectars, and beverages, should not be served. Using these nutritional differences as educational moments will help children understand why they can or cannot eat certain food items. Some children require special feeding techniques, such as thickened foods or special positioning during meals. Other children will require dietary modifications based on food intolerances, such as lactose or wheat (gluten) intolerance. Some children will need dietary modifications based on cultural or religious preferences, such as vegan, vegetarian, or kosher diets, or halal foods.

RATIONALE
The early years are a critical time for children’s growth and development. Nutritional problems must be identified and treated during this period to prevent serious or long-term medical problems. Strong evidence shows a relationship between preschool-aged children being presented with larger sized portions and increased energy intake, prompting the importance of implementing proper portion sizing as soon as 2 years of age for children at risk of being overweight (2). The early care and education setting may be offering most of a child’s daily nutritional intake, especially for children in full-time care. It is important that the facility ensures that food offerings are congruent with nutritional interventions or dietary modifications recommended by the child’s pediatrician/other physician, in consultation with the nutritionist/registered dietitian, to make certain the intervention is child specific.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.1.2.1 Routine Health Supervision and Growth Monitoring
4.2.0.8 Feeding Plans and Dietary Modifications
4.3.1.2 Feeding Infants on Cue by a Consistent Caregiver/Teacher
REFERENCES
  1. McAllister JW. Achieving a Shared Plan of Care with Children and Youth with Special Health Care Needs. Palo Alto, CA: Lucille Packard Foundation for Children’s Health; 2014. http://www.lpfch.org/sites/default/files/field/publications/achieving_a_shared_plan_of_care_full.pdf. Accessed September 7, 2017
  2. McCrickerd K, Leong C, Forde CG. Preschool children's sensitivity to teacher-served portion size is linked to age related differences in leftovers. Appetite. 2017;114:320–328
  3. ADDITIONAL RESOURCE
    US Department of Health and Human Services, US Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th ed. Washington, DC: US Department of Health and Human Services; 2015. https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_Guidelines.pdf. Accessed September 7, 2017 
NOTES

Content in the STANDARD was modified on 11/9/2017.

 

Standard 4.2.0.8: Feeding Plans and Dietary Modifications

Content in the STANDARD was modified on 11/9/2017. 

 

Before a child enters an early care and education facility, the facility should obtain a written history that contains any special nutrition or feeding needs for the child, including use of human milk or any special feeding utensils. The staff should review this history with the child’s parents/guardians, clarifying and discussing how the parents’/guardians’ home feeding routines may differ from the facility’s planned routine. The child’s primary health care provider should provide written information to the parent/guardian about any dietary modifications or special feeding techniques that are required at the early care and education program so they can be shared with and implemented by the program.

If dietary modifications are indicated, based on a child’s medical or special dietary needs, caregivers/teachers should modify or supplement the child’s diet to meet the individual child’s specific needs. Dietary modifications should be made in consultation with the parents/guardians and the child’s primary health care provider. Caregivers/teachers can consult with a nutritionist/registered dietitian.

A child’s diet may be modified because of food sensitivity, a food allergy, or many other reasons. Food sensitivity includes a range of conditions in which a child exhibits an adverse reaction to a food that, in some instances, can be life-threatening. Modification of a child’s diet may also be related to a food allergy, an inability to digest or to tolerate certain foods, a need for extra calories, a need for special positioning while eating, diabetes and the need to match food with insulin, food idiosyncrasies, and other identified feeding issues, including celiac disease, phenylketonuria, diabetes, and severe food allergy (anaphylaxis). In some cases, a child may become ill if he/she is unable to eat, so missing a meal could have a negative consequence, especially for children with diabetes.

For a child with special health care needs who requires dietary modifications or special feeding techniques, written instructions from the child’s parent/guardian and the child’s primary health care provider should be provided in the child’s record and carried out accordingly. Dietary modifications should be recorded. These written instructions must identify
 
a.  The child’s full name and date of instructions
b.  The child’s special health care needs
c.   Any dietary restrictions based on those special needs
d.  Any special feeding or eating utensils
e.  Any foods to be omitted from the diet and any foods to be substituted
f.    Any other pertinent information about the child’s special health care needs
g.  What, if anything, needs to be done if the child is exposed to restricted foods
 
The written history of special nutrition or feeding needs should be used to develop individual feeding plans and, collectively, to develop facility menus. Health care providers with experience in disciplines related to special nutrition needs, including nutrition, nursing, speech therapy, occupational therapy, and physical therapy, should participate when needed and/or when they are available to the facility. If available, the nutritionist/registered dietitian should approve menus that accommodate needed dietary modifications.

The feeding plan should include steps to take when a situation arises that requires rapid response by the staff, such as a child choking during mealtime or a child with a known history of food allergies demonstrating signs and symptoms of anaphylaxis (severe allergic reaction), such as difficulty breathing and severe redness and swelling of the face or mouth. The completed plan should be on file and accessible to staff and available to parents/guardians on request.

RATIONALE

Children with special health care needs may have individual requirements related to diet and swallowing, involving special feeding utensils and feeding needs that will necessitate the development of an individual plan prior to their entry into the facility (1). Many children with special health care needs have difficulty with feeding, including delayed attainment of basic chewing, swallowing, and independent feeding skills. Food, eating style, food utensils, and equipment, including furniture, may have to be adapted to meet the developmental and physical needs of individual children (2,3,).

Some children have difficulty with slow weight gain and need their caloric intake monitored and supplemented. Others, such as those with diabetes, may need to have their diet matched to their medication (e.g., insulin, if they are on a fixed dose of insulin). Some children are unable to tolerate certain foods because of their allergy to the food or their inability to digest it. The 8 most common foods to cause anaphylaxis in children are cow’s milk, eggs, soy, wheat, fish, shellfish, peanuts, and tree nuts (3). Staff members must know ahead of time what procedures to follow, as well as their designated roles, during an emergency.

As a safety and health precaution, staff should know in advance whether a child has food allergies, inborn errors of metabolism, diabetes, celiac disease, tongue thrust, or special health care needs related to feeding, such as requiring special feeding utensils or equipment, nasogastric or gastric tube feedings, or special positioning. These situations require individual planning prior to the child’s entry into an early care and education program and on an ongoing basis (2).

In some cases, dietary modifications are based on religious or cultural beliefs. Detailed information on each child’s special needs, whether stemming from dietary, feeding equipment, or cultural needs, is invaluable to the facility staff in meeting the nutritional needs of all the children in their care.

COMMENTS
Close collaboration between families and the facility is necessary for children on special diets. Parents/guardians may have to provide food on a temporary, or even permanent, basis, if the facility, after exploring all community resources, is unable to provide the special diet.

Programs may consider using the American Academy of Pediatrics (AAP) Allergy and Anaphylaxis Emergency Plan, which is included in the AAP clinical report, Guidance on Completing a Written Allergy and Anaphylaxis Emergency Plan (4).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.2.0.1 Written Nutrition Plan
4.2.0.2 Assessment and Planning of Nutrition for Individual Children
3.5.0.1 Care Plan for Children with Special Health Care Needs
4.2.0.12 Vegetarian/Vegan Diets
4.3.1.2 Feeding Infants on Cue by a Consistent Caregiver/Teacher
4.5.0.10 Foods that Are Choking Hazards
REFERENCES
  1. Wang J, Sicherer SH; American Academy of Pediatrics Section on Allergy and Immunology. Guidance on completing a written allergy and anaphylaxis emergency plan. Pediatrics. 2017;139(3):e20164005
  2. Kleinman RE, Greer FR, eds. Pediatric Nutrition. 7th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2014
  3. Kaczkowski CH, Caffrey C. Pediatric nutrition. In: Blanchfield DS, ed. The Gale Encyclopedia of Children's Health: Infancy Through Adolescence. Vol 3. 3rd ed. Farmington Hills, MI: Gale; 2016:2063–2066
  4. Samour PQ, King K. Pediatric Nutrition. 4th ed. Sunbury, MA: Jones and Bartlett Learning; 2010
NOTES

Content in the STANDARD was modified on 11/9/2017. 

 

Standard 4.2.0.3: Use of US Department of Agriculture Child and Adult Care Food Program Guidelines

Content in the STANDARD was modified on 11/9/2017.

 

All meals and snacks and their preparation, service, and storage should meet the requirements for meals (7 CFR §226.20) of the child care component of the US Department of Agriculture Child and Adult Care Food Program (CACFP) (1-3).

RATIONALE
The CACFP regulations, policies, and guidance materials on meal requirements provide basic guidelines for sound nutrition and sanitation practices. The CACFP guidance for meals and snack patterns ensures that the nutritional needs of infants and children, including school-aged children through 12 years, are met based on the Dietary Guidelines for Americans (4,5) as well as other evidence-based recommendations (6,7). Programs not eligible for reimbursement under the regulations of CACFP should still use the CACFP food guidance.

COMMENTS
Staff should use information about the child’s growth and CACFP meal patterns to develop individual feeding plans (6).

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.1.2.1 Routine Health Supervision and Growth Monitoring
4.2.0.4 Categories of Foods
4.2.0.5 Meal and Snack Patterns
4.3.1.2 Feeding Infants on Cue by a Consistent Caregiver/Teacher
4.3.2.1 Meal and Snack Patterns for Toddlers and Preschoolers
4.3.3.1 Meal and Snack Patterns for School-Age Children
REFERENCES
  1. Lally JR, Griffin A, Fenichel E, Segal M, Szanton E, Weissbourd B. Caring for Infants and Toddlers in Groups: Developmentally Appropriate Practice. 2nd ed. Arlington, VA: Zero to Three; 2008
  2. US Department of Agriculture, Food and Nutrition Service. Child and Adult Care Food Program (CACFP). Regulations. https://www.fns.usda.gov/cacfp/regulations. Updated September 7, 2017. Accessed September 7, 2017
  3. US Department of Agriculture, Food and Nutrition Service. Requirements for meals. US Government Publishing Office Web site. https://www.ecfr.gov/cgi-bin/text-idx?SID=9c3a6681dbf6aada3632967c4bfeb030&mc=true&node=pt7.4.226&rgn=div5#se7.4.226_120. Accessed September 7, 2017
  4. ADDITIONAL RESOURCE
    US Department of Agriculture. Child and Adult Care Food Program: best practices. US Department of Agriculture, Food and Nutrition Service Web site. https://www.fns.usda.gov/sites/default/files/cacfp/CACFP_factBP.pdf. Accessed September 7, 2017

  5. US Department of Agriculture, Healthy Meals Resource System, Team Nutrition. CACFP wellness resources for child care providers. https://healthymeals.fns.usda.gov/cacfp-wellness-resources-child-care-providers. Accessed September 7, 2017
  6. US Department of Agriculture, Food and Nutrition Service. Child and Adult Food Program (CACFP). Nutrition standards for CACFP meals and snacks. https://www.fns.usda.gov/cacfp/meals-and-snacks. Updated March 27, 2017. Accessed September 7, 2017
  7. US Department of Health and Human Services, US Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th ed. Washington, DC: US Department of Health and Human Services; 2015. https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_Guidelines.pdf. Accessed September 7, 2017
  8. US Department of Agriculture, Food and Nutrition Service. Independent Child Care Centers: A Child and Adult Care Food Program Handbook. Washington, DC: US Department of Agriculture; 2014. https://fns-prod.azureedge.net/sites/default/files/cacfp/Independent%20Child%20Care%20Centers%20Handbook.pdf. Accessed September 7, 2017
NOTES

Content in the STANDARD was modified on 11/9/2017.

 

Standard 4.2.0.4: Categories of Foods

Content in the STANDARD was modified on 2/2012 and 11/16/2017. 

The early care and education program should ensure the following food groups are being served to children in care. When incorporated into a child’s diet, these food groups make up foundational components of a healthy eating pattern.
 

Making Healthy Food Choicesa
Food Groups/Ingredients USDAb CFOC Guidelines for Young Children
Fruits Whole Fruits
Includes fresh, frozen, canned (packed in water or 100% fruit juice), and dried varieties that include good sources of potassium (eg, bananas, dried plums)

Fruit Juice
100% juice (ie, without added sugars)
  • Eat a variety of whole fruits.
  • Whole fruit, mashed or pureed, for infants.
  • Do not serve juice to infants younger than 12 months.
  • No more than 4 oz of juice per day for 1- to 3-year-olds.
  • No more than 4–6 oz of juice per day for 4- to 6-year-olds.
  • No more than 8 oz of juice per day for 7- to 12-year-olds.
Vegetables Includes fresh, frozen, canned, and dried varieties

Vegetable Subgroups
  • Dark green
  • Red and orange
  • Beans and peas (legumes)
  • Starchy vegetables
  • Other vegetables
  • Include a variety of vegetables from the vegetable subgroups.
  • Select low-sodium options when serving canned vegetables.
Grains Whole Grains
Contain the entire grain kernel (eg, whole wheat flour, bulgur, oatmeal, brown rice)

Refined Grains
Enriched grains that have been milled, processed, and stripped of vital nutrients
  • Limit the amount of refined grains.
  • Make half the grains served whole grains or whole-grain products.
Protein Foods
(Meat and Meat Alternatives)
Includes food from animal and plant sources (eg, seafood, lean meat, poultry, eggs, yogurt, cheese, soy products, nuts and seeds, cooked [mature] beans and peas)
  • Fish, poultry, lean meat, eggs.
  • Unsalted nuts and seeds (if developmentally and age appropriate).
  • Legumes (beans and peas) may also be considered a protein source.
  • Limit processed meats and poultry.
  • Avoid fried fish and poultry.
Dairy Fat-free or low-fat (1%) milk or soy milk
  • Human milk and/or iron-fortified infant formula for infants 0–12 months of age.
  • Unflavored whole milk for children 1–2 years of age.
  • 2% (reduced-fat) milk for those children at risk for obesity or hypocholesteremia.
  • Unflavored low-fat (1%) or fat-free milk for children 2 years and older.
  • Nondairy milk substitutes that are nutritionally equivalent to milk.
  • Yogurt must not contain more than 23 g of sugar per ounce.
Abbreviations: CFOC, Caring for Our Children: National Health and Safety Performance Standards; USDA, US Department of Agriculture.

a All foods are assumed to be in nutrient-dense forms, lean or low-fat, and prepared without added fats, sugars, or salt. Solid fats and added sugars may be included up to the daily maximum limit identified in the 2015–2020 Dietary Guidelines for Americans.

b The USDA recommends finding a balance between food and physical activity.

OTHER RECOMMENDATIONS ADDITIONAL RESOURCES

RATIONALE
The 2015–2020 Dietary Guidelines for Americans and The Surgeon General’s Call to Action to Support Breastfeeding support patterns of healthy eating to promote a healthy weight and lifestyle that, in turn, prevent the onset of overweight and obesity in children (1,2). Incorporating each of the food groups by providing children with appropriate meals and snacks helps set the stage for a lifetime of healthy eating behaviors. Research reinforces the following suggestions as being a practical approach to selecting foods high in essential nutrients and moderate in calories/energy:
COMMENTS
Early care and education settings should encourage mothers to breastfeed their infants. Scientific evidence documents and supports the nutritional and health contributions of human milk.2 For more information on portion sizes and types of food, see the CACFP guidelines.3
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.2.0.8 Feeding Plans and Dietary Modifications
4.2.0.5 Meal and Snack Patterns
4.2.0.7 100% Fruit Juice
4.3.1.2 Feeding Infants on Cue by a Consistent Caregiver/Teacher
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.1.5 Preparing, Feeding, and Storing Infant Formula
4.3.1.7 Feeding Cow’s Milk
4.3.2.1 Meal and Snack Patterns for Toddlers and Preschoolers
4.3.3.1 Meal and Snack Patterns for School-Age Children
4.7.0.1 Nutrition Learning Experiences for Children
4.7.0.2 Nutrition Education for Parents/Guardians
Appendix Q: Getting Started with MyPlate
Appendix R: Choose MyPlate: 10 Tips to a Great Plate
REFERENCES
  1. Centers for Disease Control and Prevention. Healthy schools. The buzz on energy drinks. https://www.cdc.gov/healthyschools/nutrition/energy.htm. Updated March 22, 2016. Accessed September 19, 2017 
  2. US Department of Agriculture, Food and Nutrition Service. Child and Adult Care Food Program (CACFP). https://www.fns.usda.gov/cacfp/child-and-adult-care-food-program. Published March 29, 2017. Accessed September 19, 2017 
  3. US Department of Health and Human Services. The Surgeon General’s Call to Action to Support Breastfeeding. Washington, DC: US Department of Health and Human Services, Office of the Surgeon General; 2011. https://www.cdc.gov/breastfeeding/promotion/calltoaction.htm. Updated April 12, 2017. Accessed September 19, 2017
  4. US Department of Health and Human Services, US Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th ed. Washington, DC: US Department of Health and Human Services; 2015. https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_Guidelines.pdf. Accessed September 19, 2017
NOTES

Content in the STANDARD was modified on 2/2012 and 11/16/2017. 

Standard 4.2.0.5: Meal and Snack Patterns

Content in the STANDARD was modified on 11/9/2017. 

 

The facility should ensure that the following meal and snack pattern occurs:

   a.  Children in care for 8 or fewer hours in 1 day should be offered at least 1 meal and 2 snacks or 2 meals and 1 snack (1).
   b.  A nutritious snack should be offered to all children in midmorning (if they are not offered a breakfast on-site that is provided within 3 hours of lunch) and in mid-afternoon.
   c.   Children should be offered food at intervals at least 2 hours apart but not more than 3 hours apart unless the child is asleep. Some very young infants may need to be fed at shorter intervals than every 2 hours to meet their nutritional needs, especially breastfed infants being fed expressed human milk. Lunch may need to be served to toddlers earlier than preschool-aged children because of their need for an earlier nap schedule. Children must be awake prior to being offered a meal/snack.
   d.  Children should be allowed time to eat their food and not be rushed during the meal or snack service. They should not be allowed to play during these times.
   e.  Caregivers/teachers should discuss breastfed infants’ feeding patterns with their parents/guardians because the frequency of breastfeeding at home can vary. For example, some infants may still be feeding frequently at night, while others may do the bulk of their feeding during the day. Knowledge about infants’ feeding patterns over 24 hours will help caregivers/teachers assess infants’ feeding schedules during their time together.

RATIONALE
Children younger than 6 years need to be offered food every 2 to 3 hours. Appetite and interest in food varies from one meal or snack to the next. Appropriate timing of meals and snacks prevents children from snacking throughout the day and ensures that children maintain healthy appetites during mealtimes (2,3). Snacks should be nutritious, as they often are a significant part of a child’s daily intake. Children in care for longer than 8 hours need additional food because this period represents most of a young child’s waking hours.
COMMENTS
Caloric needs vary greatly from one child to another. A child may require more food during growth spurts (4). Some states have regulations that indicate suggested times for meals and snacks. By regulation, under the US Department of Agriculture Child and Adult Care Food Program (CACFP), centers and family child care homes may be approved to claim up to 2 reimbursable meals (breakfast, lunch, or supper) and 1 snack, or 2 snacks and 1 meal, for each eligible participant, each day. Many after-school programs provide before-school care or full-day care when elementary school is out of session. Many of these programs offer breakfast and/or a morning snack. After-school care programs may claim reimbursement for serving each child one snack, each day. In some states after-school programs also have the option of providing supper. These are reimbursed by CACFP if they meet certain guidelines and time frames (5).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.3.1.2 Feeding Infants on Cue by a Consistent Caregiver/Teacher
4.3.2.1 Meal and Snack Patterns for Toddlers and Preschoolers
4.3.3.1 Meal and Snack Patterns for School-Age Children
REFERENCES
  1. Kleinman RE, Greer FR, eds. Pediatric Nutrition. 7th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2014
  2. US Department of Agriculture, Food and Nutrition Service. Child and Adult Care Food Program (CACFP). Why CACFP is important. https://www.fns.usda.gov/cacfp/why-cacfp-important. Published September 22, 2014. Accessed September 19, 2017
  3. American Academy of Pediatrics Committee on Nutrition. Childhood nutrition. American Academy of Pediatrics HealthyChildren.org Web site. https://www.healthychildren.org/English/healthy-living/nutrition/Pages/Childhood-Nutrition.aspx. Updated March 3, 2016. Accessed September 19, 2017
  4. Shield JE, Mullen M. When should my kids snack? Academy of Nutrition and Dietetics Web site. http://www.eatright.org/resource/food/nutrition/dietary-guidelines-and-myplate/when-should-my-kids-snack. Published February 13, 2014. Accessed September 19, 2017
  5. US Department of Agriculture, Food and Nutrition Service. Independent Child Care Centers: A Child and Adult Care Food Program Handbook. Washington, DC: US Department of Agriculture; 2014. https://www.fns.usda.gov/sites/default/files/cacfp/Independent%20Child%20Care%20Centers%20Handbook.pdf. Published May 2014. Accessed September 19, 2017
NOTES

Content in the STANDARD was modified on 11/9/2017. 

 

Standard 4.2.0.6: Availability of Drinking Water

Content in the STANDARD was modified on 11/9/2017.

 

Clean, sanitary drinking water should be readily available, in indoor and outdoor areas, throughout the day (1). Water should not be a substitute for milk at meals or snacks where milk is a required food component unless recommended by the child’s primary health care provider. 

On hot days, infants receiving human milk in a bottle can be given additional human milk in a bottle but should not be given water, especially in the first 6 months after birth (1). Infants receiving formula and water can be given additional formula in a bottle. Toddlers and older children will need additional water as physical activity and/or hot temperatures cause their needs to increase. Children should learn to drink water from a cup or drinking fountain without mouthing the fixture. They should not be allowed to have water continuously in hand in a sippy cup or bottle. Permitting toddlers to suck continuously on a bottle or sippy cup filled with water, to soothe themselves, may cause nutritional or, in rare instances, electrolyte imbalances. When toothbrushing is not done after a feeding, children should be offered water to drink to rinse food from their teeth.

 

RATIONALE
When children are thirsty between meals and snacks, water is the best choice. Drinking water during the day can reduce extra caloric intake if the water replaces high-caloric beverages, such as fruit drinks/nectars and sodas, which are associated with overweight and obesity (2). Drinking water helps maintain a child’s hydration and overall health. Water can also decrease the likelihood of early childhood caries if consumed throughout the day, especially between meals and snacks (3,4). Personal and environmental factors, such as age, weight, gender, physical activity level, outside air temperature, heat, and humidity, can affect individual water needs (5).
COMMENTS
Having clean, small pitchers of water and single-use paper cups available in classrooms and on playgrounds allows children to serve themselves water when they are thirsty. Drinking fountains should be kept clean and sanitary and maintained to provide adequate drainage.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.1.3.2 Playing Outdoors
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.1.5 Preparing, Feeding, and Storing Infant Formula
5.2.6.3 Testing for Lead and Copper Levels in Drinking Water
REFERENCES
  1. Kleinman RE, Greer FR, eds. Pediatric Nutrition. 7th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2014
  2. Muckelbauer R, Sarganas G, Grüneis A, Müller-Nordhorn J. Association between water consumption and body weight outcomes: a systematic review. Am J Clin Nutr. 2013;98(2):282–299
  3. Centers for Disease Control and Prevention. Increasing Access to Drinking Water and Other Healthier Beverages in Early Care and Education Settings. Atlanta, GA: US Department of Health and Human Services; 2014. https://www.cdc.gov/obesity/downloads/early-childhood-drinking-water-toolkit-final-508reduced.pdf. Accessed September 19, 2017
  4. Mullen M, Shield JE. Water: how much do kids need? Academy of Nutrition and Dietetics Web site. http://www.eatright.org/resource/fitness/sports-and-performance/hydrate-right/water-go-with-the-flow. Published May 2, 2017. Accessed September 19, 2017
  5. Casamassimo P, Holt K, eds. Bright Futures: Oral Health Pocket Guide. 3rd ed. Washington, DC: National Maternal and Child Oral Health Resource Center; 2016. https://www.mchoralhealth.org/PDFs/BFOHPocketGuide.pdf. Accessed September 19, 2017 
NOTES

Content in the STANDARD was modified on 11/9/2017.

 

Standard 4.2.0.7: 100% Fruit Juice

Content in the STANDARD was modified on 11/9/2017. 

 

Fruit or vegetable juice may be served once per day during a scheduled meal or snack to children 12 months or older (1). All juices should be pasteurized and 100% juice without added sugars or sweeteners.


Age

Maximum Allowed (1)
 
  0–12 mo  
Do not offer juices to infants younger than 12 months.
 
  1–3 y
Limit consumption to 4 oz/day (½ cup).
 
4–6 y
Limit consumption to 4–6 oz/day (½–¾ cup).
 
7–18 y
Limit consumption to 8 oz/day (1 cup).
 

100% juice should be offered in an age-appropriate cup instead of a bottle (2). These amounts include any juices consumed at home.  Caregivers/teachers should ask parents/guardians if any juice is provided at home when deciding if and when to serve fruit juice to children in care. Whole fruit, mashed or pureed, is recommended for infants beginning at 4 months of age or as developmentally ready (3).

 

RATIONALE
While 100% fruit juice can be included in a healthy eating pattern, whole fruit is more nutritious and provides many nutrients, including dietary fiber, not found in juices (4).

Limiting overall juice consumption and encouraging children to drink water in-between meals will reduce acids produced by bacteria in the mouth that cause tooth decay. The frequency of exposure and liquids being pooled in the mouth are important in determining the cause of tooth decay in children (5). Beverages labeled as “fruit punch,” “fruit nectar”, or “fruit cocktail” contain less than 100% fruit juice and may be higher in overall sugar content. Routine consumption of fruit juices does not provide adequate amounts of vitamin E, iron, calcium, and dietary fiber—all essential in the growth and development of young children (6). Continuous consumption of fruit juice may be associated with decreased appetite during mealtimes, which may lead to inadequate nutrition, feeding issues, and increases in a child’s body mass index—all of which are considered risk factors that may contribute to childhood obesity (7).

Serving pasteurized juice protects against the possible outbreak of foodborne illness because the process destroys any harmful bacteria that may have been present (8).

 Drinks high in sugar and caffeine should be avoided because they can contribute to childhood obesity, tooth decay, and poor nutrition (9).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.2.0.4 Categories of Foods
4.2.0.6 Availability of Drinking Water
3.1.5.1 Routine Oral Hygiene Activities
3.1.5.3 Oral Health Education
4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants
REFERENCES
  1. US Department of Health and Human Services, US Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th ed. Washington, DC: US Department of Health and Human Services; 2015. https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_Guidelines.pdf. Accessed September 19, 2017
  2. American Academy of Pediatrics. Starting solid foods. American Academy of Pediatrics HealthyChildren.org Web site. https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Switching-To-Solid-Foods.aspx. Updated April 7, 2017. Accessed September 19, 2017
  3. American Academy of Pediatrics. Fruit juice and your child's diet. American Academy of Pediatrics HealthyChildren.org Web site. https://www.healthychildren.org/English/healthy-living/nutrition/Pages/Fruit-Juice-and-Your-Childs-Diet.aspx. Updated May 22, 2017. Accessed September 19, 2017
  4. Heyman MB, Abrams SA; American Academy of Pediatrics Section on Gastroenterology, Hepatology, and Nutrition and Committee on Nutrition. Fruit juice in infants, children, and adolescents: current recommendations. Pediatrics. 2017;139(6):e20170967
  5. Centers for Disease Control and Prevention. Healthy schools. The buzz on energy drinks. https://www.cdc.gov/healthyschools/nutrition/energy.htm. Updated March 22, 2016. Accessed September 19, 2017.
  6. US Food and Drug Administration. Talking about juice safety: what you need to know. https://www.fda.gov/food/resourcesforyou/consumers/ucm110526.htm. Updated September 19, 2017. Accessed September 19, 2017
  7. Shefferly A, Scharf RJ, DeBoer MD. Longitudinal evaluation of 100% fruit juice consumption on BMI status in 2–5?year?old children. Pediatr Obes. 2016;11(3):221–227
  8. Crowe-White K, O’Neil CE, Parrott JS, et al. Impact of 100% fruit juice consumption on diet and weight status of children: an evidence-based review. Crit Rev Food Sci Nutr. 2016;56(5):871–884
  9. Casamassimo P, Holt K, eds. Bright Futures: Oral Health Pocket Guide. 3rd ed. Washington, DC: National Maternal and Child Oral Health Resource Center; 2016. https://www.mchoralhealth.org/PDFs/BFOHPocketGuide.pdf. Accessed September 19, 2017
NOTES

Content in the STANDARD was modified on 11/9/2017. 

 

Standard 4.2.0.9: Written Menus and Introduction of New Foods

Content in the STANDARD was modified on 11/9/2017. 

 

Facilities should develop, at least one month in advance, written menus that show all foods to be served during that month and should make the menus available to parents/guardians. The facility should date and retain these menus for 6 months, unless the state regulatory agency requires a longer retention time. The menus should be amended to reflect any and all changes in the food actually served. Any substitutions should be of equal nutrient value.

Caregivers/teachers should use or develop a take-home sheet for parents/guardians on which caregivers/teachers record the food consumed each day or, for breastfed infants, the number of times they are fed and other important notes. Caregivers/teachers should continue to consult with each infant’s parent/guardian about foods they have introduced and are feeding to the infant. In this way, caregivers/teachers can follow a schedule of introducing new foods one at a time and more easily identify possible food allergies or intolerances. Caregivers/teachers should let parents/guardians know what and how much their infants eat each day.

To avoid problems of food sensitivity in infants younger than 12 months, caregivers/teachers should obtain from infants’ parents/guardians a list of foods that have already been introduced (without any reaction) and serve those items when appropriate. As new foods are considered for serving, caregivers/teachers should share and discuss these foods with parents/guardians prior to their introduction.

RATIONALE
Planning menus in advance helps to ensure that food will be on hand. Posting menus in a prominent area and distributing them to parents/guardians helps to inform parents/guardians about proper nutrition Parents/guardians need to be informed about food served in the facility to know how to complement it with the food they serve at home. If a child has difficulty with any food served at the facility, parents/guardians can address this issue with appropriate staff members. Some regulatory agencies require menus as a part of the licensing and auditing process (1).

Consistency between home and the early care and education setting is essential during the period of rapid change when infants are learning to eat age-appropriate solid foods (1-3).
COMMENTS
Caregivers/teachers should be aware that new foods may need to be offered between 8 and 15 times before they may be accepted (2,4). Sample menus and menu planning templates are available from most state health departments and the US Department of Agriculture (5) and its Child and Adult Care Food Program (6).

Good communication between caregivers/teachers and parents/guardians is essential for successful feeding, in general, including when introducing age-appropriate solid foods (complementary foods). The decision to feed specific foods should be made in consultation with the parents/guardians. It is recommended that caregivers/teachers be given written instructions on the introduction and feeding of foods from the parents/guardians and the infants’ primary health care providers. 
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.3.1.1 General Plan for Feeding Infants
4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants
4.5.0.8 Experience with Familiar and New Foods
REFERENCES
  1. American Academy of Pediatrics Committee on Nutrition. Childhood nutrition. American Academy of Pediatrics HealthyChildren.org Web site. https://www.healthychildren.org/English/healthy-living/nutrition/Pages/Childhood-Nutrition.aspx. Updated March 3, 2016. Accessed September 20, 2017
  2. US Department of Agriculture, Food and Nutrition Service. Child and Adult Care Food Program (CACFP). https://www.fns.usda.gov/cacfp/child-and-adult-care-food-program. Published March 29, 2017. Accessed September 20, 2017
  3. US Department of Agriculture. Menu planning tools for child care providers. https://healthymeals.fns.usda.gov/menu-planning/menu-planning-tools/menu-planning-tools-child-care-providers. Accessed September 20, 2017
  4. Savage JS, Fisher JO, Birch LL. Parental influence on eating behavior: conception to adolescence. J Law Med Ethics. 2007;35(1):22–34
  5. Coulthard H, Sealy A. Play with your food! Sensory play is associated with tasting of fruits and vegetables in preschool children. Appetite. 2017;113:84–90
  6. Benjamin SE, Copeland KA, Cradock A, et al. Menus in child care: a comparison of state regulations with national standards. J Am Diet Assoc. 2009;109(1):109–115
NOTES

Content in the STANDARD was modified on 11/9/2017. 

 

Standard 4.2.0.10: Care for Children with Food Allergies

Content in the STANDARD was modified on 11/9/2017.

 

When children with food allergies attend an early care and education facility, here is what should occur.
a.  Each child with a food allergy should have a care plan prepared for the facility by the child’s primary health care provider, to include
     1.  A written list of the food(s) to which the child is allergic and instructions for steps that need to be taken to avoid that food.
     2.  A detailed treatment plan to be implemented in the event of an allergic reaction, including the names, doses, and methods of administration of any medications that the child should receive in the event of a reaction. The plan should include specific symptoms that would indicate the need to administer one or more medications.

b.  Based on the child’s care plan, the child’s caregivers/teachers should receive training, demonstrate competence in, and implement measures for
     1.  Preventing exposure to the specific food(s) to which the child is allergic
     2.  Recognizing the symptoms of an allergic reaction
     3.  Treating allergic reactions

c.   Parents/guardians and staff should arrange for the facility to have the necessary medications, proper storage of such medications, and the equipment and training to manage the child’s food allergy while the child is at the early care and education facility.

d.  Caregivers/teachers should promptly and properly administer prescribed medications in the event of an allergic reaction according to the instructions in the care plan.

e.  The facility should notify parents/guardians immediately of any suspected allergic reactions, the ingestion of the problem food, or contact with the problem food, even if a reaction did not occur.

f.    The facility should recommend to the family that the child’s primary health care provider be notified if the child has required treatment by the facility for a food allergic reaction.

g.  The facility should contact the emergency medical services (EMS) system immediately if the child has any serious allergic reaction and/or whenever epinephrine (eg, EpiPen, EpiPen Jr) has been administered, even if the child appears to have recovered from the allergic reaction.

h.  Parents/guardians of all children in the child’s class should be advised to avoid any known allergens in class treats or special foods brought into the early care and education setting.

i.    Individual child’s food allergies should be posted prominently in the classroom where staff can view them and/or wherever food is served.

j.    The written child care plan, a mobile phone, and a list of the proper medications for appropriate treatment if the child develops an acute allergic reaction should be routinely carried on field trips or transport out of the early care and education setting.

For all children with a history of anaphylaxis (severe allergic reaction), or for those with peanut and/or tree nut allergy (whether or not they have had anaphylaxis), epinephrine should be readily available. This will usually be provided as a premeasured dose in an auto-injector, such as EpiPen or EpiPen Jr. Specific indications for administration of epinephrine should be provided in the detailed care plan. Within the context of state laws, appropriate personnel should be prepared to administer epinephrine when needed.

Food sharing between children must be prevented by careful supervision and repeated instruction to children about this issue. Exposure may also occur through contact between children or by contact with contaminated surfaces, such as a table on which the food allergen remains after eating. Some children may have an allergic reaction just from being in proximity to the offending food, without actually ingesting it. Such contact should be minimized by washing children’s hands and faces and all surfaces that were in contact with food. In addition, reactions may occur when a food is used as part of an art or craft project, such as the use of peanut butter to make a bird feeder or wheat to make modeling compound.

RATIONALE
Food allergy is common, occurring in between 2% and 8% of infants and children (1). Allergic reactions to food can range from mild skin or gastrointestinal symptoms to severe, life-threatening reactions with respiratory and/or cardiovascular compromise. Hospitalizations from food allergy are being reported in increasing numbers, especially among children with asthma who have one or more food sensitivities (2). A major factor in death from anaphylaxis has been a delay in the administration of lifesaving emergency medication, particularly epinephrine (3). Intensive efforts to avoid exposure to the offending food(s) are, therefore, warranted. The maintenance of detailed care plans and the ability to implement such plans for the treatment of reactions are essential for all children with food allergies (4).
COMMENTS
Successful food avoidance requires a cooperative effort that must include the parents/guardians, child, child’s primary health care provider, and early care and education staff. In some cases, especially for a child with multiple food allergies, parents/guardians may need to take responsibility for providing all the child’s food. In other cases, early care and education staff may be able to provide safe foods as long as they have been fully educated about effective food avoidance.
Effective food avoidance has several facets. Foods can be listed on an ingredient list under a variety of names; for example, milk could be listed as casein, caseinate, whey, and/or lactoglobulin.

Some children with a food allergy will have mild reactions and will only need to avoid the problem food(s). Others will need to have antihistamine or epinephrine available to be used in the event of a reaction.

For more information on food allergies, contact Food Allergy Research & Education (FARE) at www.foodallergy.org.
Some early care and education/school settings require that all foods brought into the classroom are store-bought and in their original packaging so that a list of ingredients is included, to prevent exposure to allergens. However, packaged foods may mistakenly include allergen-type ingredients. Alerts and ingredient recalls can be found on the FARE Web site (5).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.2.0.2 Assessment and Planning of Nutrition for Individual Children
4.2.0.8 Feeding Plans and Dietary Modifications
3.5.0.1 Care Plan for Children with Special Health Care Needs
Appendix P: Situations that Require Medical Attention Right Away
REFERENCES
  1. Wang J, Sicherer SH; American Academy of Pediatrics Section on Allergy and Immunology. Guidance on completing a written allergy and anaphylaxis emergency plan. Pediatrics. 2017;139(3):e20164005
  2. Tsuang A, Demain H, Patrick K, Pistiner M, Wang J. Epinephrine use and training in schools for food-induced anaphylaxis among non-nursing staff. J Allergy Clin Immunol Pract. 2017;5(5):1418–1420.e3
  3. Caffarelli C, Garrubba M, Greco C, Mastrorilli C, Povesi Dascola C. Asthma and food allergy in children: is there a connection or interaction? Front Pediatr. 2016;4:34
  4. Bugden EA, Martinez AK, Greene BZ, Eig K. Safe at School and Ready to Learn: A Comprehensive Policy Guide for Protecting Students with Life-threatening Food Allergies. 2nd ed. Alexandria, VA: National School Boards Association; 2012. http://www.nsba.org/sites/default/files/reports/Safe-at-School-and-Ready-to-Learn.pdf. Accessed September 20, 2017
  5. ADDITIONAL RESOURCES
    Centers for Disease Control and Prevention. Healthy schools. Food allergies in schools. https://www.cdc.gov/healthyschools/foodallergies/index.htm. Reviewed May 9, 2017. Accessed September 20, 2017

    Centers for Disease Control and Prevention. Voluntary Guidelines for Managing Food Allergies in Schools and Early Care and Education Programs. Washington, DC: US Department of Health and Human Services; 2013. https://www.cdc.gov/healthyschools/foodallergies/pdf/13_243135_A_Food_Allergy_Web_508.pdf. Accessed September 20, 2017
  6. Food Allergy Research & Education. Allergy alerts. https://www.foodallergy.org/alerts. Accessed September 20, 2017
NOTES

Content in the STANDARD was modified on 11/9/2017.

 

Standard 4.2.0.11: Ingestion of Substances that Do Not Provide Nutrition

Content in this standard was modified on August 23, 2016 and November 10, 2017.

All children should be monitored to prevent them from eating substances that do not provide nutrition (often referred to as pica) (1,2). The parents/guardians of children who repeatedly place nonnutritive substances in their mouths should be notified and informed of the importance of having their children visit their primary health care provider or a local health department. In collaboration with the child’s parent/guardian, an assessment of the child’s eating behavior and dietary intake, along with any other health issues, should occur to begin an intervention strategy.

RATIONALE
The occasional ingestion of nonnutritive substances can be a part of everyday living and is not necessarily a concern. For example, ingestion of nonnutritive substances can occur from mouthing, placing dirty hands in the mouth, or eating dropped food. However, because of this normal behavior it is that much more important to minimize harmful residues in the facility to reduce children’s exposure. Pica involves the recurrent ingestion of substances that do not provide nutrition. Pica is most prevalent among children between the ages of 1 and 3 years (3). Among children with intellectual developmental disability and concurrent mental illness, the incidence exceeds 25% (3).
Children who have iron deficiency anemia regularly ingest nonnutritive substances. Dietary intake plays an important role because certain nutrients, such as those ingested with a diet high in fat or lecithin, increase the absorption of lead, which can result in toxicity (3). Lead, when present in the gastrointestinal tract, is absorbed in place of calcium. Children will absorb more lead than an adult. Whereas an adult absorbs approximately 10% of ingested lead, a toddler absorbs approximately 30% to 50% of ingested lead. Children who ingest paint chips or contaminated soil can develop lead toxicity, which can lead to developmental delays and neurodevelopmental disability. Currently, there is consensus that repeated ingestion of some nonfood items results in an increased lead burden of the body (3,4). Early detection and intervention in nonfood ingestion can prevent nutritional deficiencies and growth/developmental disabilities. Eating soil or drinking contaminated water could result in an infection with a parasite.
COMMENTS
Common sources of lead include lead-based paint (in buildings constructed before 1978 or constructed on properties that were formerly the site of buildings constructed before 1978); contaminated drinking water (from public water systems, supply pipes, or plumbing fixtures); contaminated soil (from old exterior paint); the storage of acidic foods in open cans or ceramic containers/pottery with a lead glaze; certain types of art supplies; some imported toys and inexpensive play jewelry; and polyvinyl chloride (PVC) vinyl products (eg, beach balls, soft PVC-containing dolls, rubber ducks, chew toys, nap mats). These sources and others should be addressed concurrently with a nutritionally adequate diet as a prevention strategy. It is important to reduce exposure to possible lead sources, promote a healthy and balanced diet, and encourage blood lead level (BLL) testing of children. If a child’s BLL is 5 mcg/dL or greater, it is important to identify and remove the child’s source of lead exposure. 
RELATED STANDARDS
5.2.6.3 Testing for Lead and Copper Levels in Drinking Water
5.2.9.13 Testing for Lead
REFERENCES
  1. Moya J, Bearer CF, Etzel RA. Children’s behavior and physiology and how it affects exposure to environmental contaminants. Pediatrics. 2004;113(4 Suppl 3):996–1006
  2. McNaughten B, Bourke T, Thompson A. Fifteen-minute consultation: the child with pica. Arch Dis Child Educ Pract Ed. May 2017;edpract-2016-312121
  3. Miao D, Young SL, Golden CD. A meta?analysis of pica and micronutrient status. Am J Hum Biol. 2015;27(1):84–93
  4. Centers for Disease Control and Prevention. Gateway to health communication & social marketing practice. Pica behavior and contaminated soil. https://www.cdc.gov/healthcommunication/toolstemplates/entertainmented/tips/pica.html. Updated September 15, 2017. Accessed September 20, 2017
NOTES

Content in this standard was modified on August 23, 2016 and November 10, 2017.

Standard 4.2.0.12: Vegetarian/Vegan Diets

Content in this standard was modified on November 10, 2017. 

Infants and children, including school-aged children from families practicing a vegetarian diet, can be accommodated in an early care and education environment when there is:

  1. Written documentation from parents/guardians with a detailed and accurate dietary history of food choices—foods eaten, levels of limitations/restrictions to foods, and frequency of foods offered;
  2. A current health record of the child available to the caregivers/teachers, including information about height and rate of weight gain, or consistent poor appetite (warning signs of growth deficiencies);
  3. Sharing of updated information on the child’s health with the parents/guardians and the early care and education staff by the child care health consultant and the nutritionist/registered dietitian; and
  4. Sharing sound health and nutrition information that is culturally-relevant to the family to ensure that the child receives adequate calories and essential nutrients.

RATIONALE
Infants and young children are at highest risk for nutritional deficiencies for energy levels and essential nutrients, including protein, calcium, iron, zinc, vitamins B6 and B12, and vitamin D (1-3). The younger the child, the more critical it is to know about family food choices, limitations, and restrictions because the child is dependent on family food (2).

Also, it is important that a child’s diet consist of a variety of nourishing food to support the critical period of rapid growth in the early years after birth. All children who are vegetarian/vegan should receive multivitamins, especially vitamin D (400 IU of vitamin D is recommended from 6 months of age to adulthood unless there is certainty of having the daily allowance met by foods); infants younger than 6 months who are exclusively or partially breastfed and who receive less than 16 oz of formula per day should receive 400 IU of vitamin D (4). If the facility participates in the US Department of Agriculture Child and Adult Care Food Program, guidance for meals and snack patterns must be followed for any child consuming a vegetarian or vegan diet (5).
COMMENTS
For older children who have more choice about what they eat and drink, effort should be made to provide accurate nutrition information so they make the wisest food choices for themselves. Both the early care and education program/school and the caregiver/teacher have an opportunity to inform, teach, and promote sound eating practices, along with the consequences when poor food choices are made (1). Sensitivity to cultural factors, including beliefs and practices of a child’s family, should be maintained.

Changing lifestyles and convictions and beliefs about food and religion, including what is eaten and what foods are restricted or never consumed, have some families with infants and children practicing several levels of vegetarian diets. Some parents/guardians indicate they are vegetarians, semi-vegetarian, or strict vegetarians because they do not or seldom eat meat. Others label themselves lacto-ovo vegetarians, eating or drinking foods such as eggs and dairy products. Still others describe themselves as vegans who restrict themselves to ingesting only plant-based foods, avoiding all and any animal products.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.1.2.1 Routine Health Supervision and Growth Monitoring
4.2.0.2 Assessment and Planning of Nutrition for Individual Children
4.3.1.6 Use of Soy-Based Formula and Soy Milk
4.4.0.2 Use of Nutritionist/Registered Dietitian
REFERENCES
  1. ADDITIONAL RESOURCES

    US Department of Agriculture. 10 tips: healthy eating for vegetarians. ChooseMyPlate.gov Web site. https://www.choosemyplate.gov/ten-tips-healthy-eating-for-vegetarians. Updated July 25, 2017. Accessed September 20, 2017

    US Department of Agriculture, US Department of Health and Human Services. Meat and meat alternates: build a healthy plate with protein. In: Nutrition and Wellness Tips for Young Children: Provider Handbook for the Child and Adult Care Food Program. Alexandria, VA: US Department of Agriculture; 2012. https://www.fns.usda.gov/sites/default/files/protein.pdf. Accessed September 20, 2017
  2. US Department of Agriculture, Food and Nutrition Service. Independent Child Care Centers: A Child and Adult Care Food Program Handbook. Washington, DC: US Department of Agriculture; 2014. https://www.fns.usda.gov/sites/default/files/cacfp/Independent%20Child%20Care%20Centers%20Handbook.pdf. Accessed September 20, 2017
  3. Hollis BW, Wagner CL, Howard CR, et al. Maternal versus infant vitamin D supplementation during lactation: a randomized controlled trial. Pediatrics. 2015;136(4):625–634
  4. Mangels R, Driggers J. The youngest vegetarians. Vegetarian infants and toddlers. Infant Child Adolesc Nutr. 2012;4(1):8–20
  5. Hayes D. Feeding vegetarian and vegan infants and toddlers. Academy of Nutrition and Dietetics Web site. http://www.eatright.org/resource/food/nutrition/vegetarian-and-special-diets/feeding-vegetarian-and-vegan-infants-and-toddlers. Published May 4, 2015. Accessed September 20, 2017
  6. Kleinman RE, Greer FR, eds. Pediatric Nutrition. 7th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2014
NOTES

Content in this standard was modified on November 10, 2017. 

B. Requirements for Infants

Standard 4.3.1.1: General Plan for Feeding Infants

At a minimum, meals and snacks the facility provides for infants should contain the food in the meal and snack patterns of the Child and Adult Care Food Program (CACFP). Food should be appropriate for the infant’s individual nutrition requirements and developmental stages as determined by written instructions obtained from the child’s parent/guardian or primary care provider.

The facility should encourage, provide arrangements for, and support breastfeeding. The facility staff, with appropriate training, should be the mother’s cheerleader and enthusiastic supporter for the mother’s plan to provide her milk. Facilities should have a designated place set aside for breastfeeding mothers who want to come during work to breastfeed, as well as a private area with an outlet (not a bathroom) for mothers to pump their breast milk (2-8). A place that mothers feel they are welcome to breastfeed, pump, or bottle feed can create a positive environment when offered in a supportive way.

Infants may need a variety of special formulas such as soy-based formula or elemental formulas which are easier to digest and less allergenic. Elemental or special non-allergic formulas should be specified in the infant’s care plan.

Age-appropriate solid foods (complementary foods) may be introduced no sooner than when the child has reached the age of four months, but preferably six months and as indicated by the individual child’s nutritional and developmental needs. For breastfed infants, gradual introduction of iron-fortified foods may occur no sooner than around four months, but preferably six months to complement the human milk.

RATIONALE
Human milk, as an exclusive food, is best suited to meet the entire nutritional needs of an infant from birth until six months of age, with the exception of recommended vitamin D supplementation. In addition to nutrition, breastfeeding supports optimal health and development. Human milk is also the best source of milk for infants for at least the first twelve months of age and, thereafter, for as long as mutually desired by mother and child. Breastfeeding protects infants from many acute and chronic diseases and has advantages for the mother, as well (4).

Research overwhelmingly shows that exclusive breastfeeding for six months, and continued breastfeeding for at least a year or longer, dramatically improves health outcomes for children and their mothers. Healthy People 2010 Objective 16 includes increasing the proportion of mothers who breastfeed their infants, and increasing the duration of breastfeeding and of exclusively breastfeeding (1).

Importance of breastfeeding to the infant includes reduction of some of the risks that are greater for infants in group care. Many advantages of breastfeeding are documented by research, including reduction in the incidence of diarrhea, respiratory disease, otitis media, bacteremia, bacterial meningitis, botulism, urinary tract infections, necrotizing enterocolitis, SIDS, insulin-dependent diabetes, lymphoma, allergic disease, ulcerative colitis, ear infections, and other chronic digestive diseases (4,13,15).Evidence suggests that breastfeeding is associated with enhanced cognitive development (6,10). Additionally, some evidence suggests that breastfeeding reduces the risk of childhood obesity (9,11). Breastfeeding also lowers the mother’s risk of diabetes, breast cancer, and heart disease (17).

Except in the presence of rare medical conditions, the clear advantage of human milk over any formula should lead to vigorous efforts by caregivers/teachers to promote and sustain breastfeeding for mothers who are willing to nurse their infants whenever they can, and to pump and supply their milk to the early care and education facility when direct feeding from the breast is not possible. Even if infants receive formula during the child care day, some breastfeeding or expressed human milk from their mothers is beneficial (8).

Iron-fortified infant formula is an acceptable alternative to human milk as a food for infant feeding even though it lacks any anti-infective or immunological components. An adequately nourished infant is more likely to achieve normal physical and mental development, which will have long-term positive consequences on health (12,13).

COMMENTS
Some ways to help a mother to breastfeed successfully in the early care and education facility (3):
  1. If she wishes to breastfeed her infant or child when she comes to the facility, offer or provide her a:
    1. Quiet, comfortable, and private place to breastfeed (this helps her milk to letdown);
    2. Place to wash her hands;
    3. Pillow to support her infant on her lap while nursing if requested;
    4. Nursing stool or stepstool if requested for her feet so she doesn’t have to strain her back while nursing; and
    5. Glass of water or other liquid to help her stay hydrated;
  2. Encourage her to get the infant used to being fed her expressed human milk by another person before the infant starts in early care and education, while continuing to breastfeed directly herself;
  3. Discuss with her the infant’s usual feeding pattern and whether she wants the caregiver/teacher to feed the infant by cue or on a schedule, also ask her if she wishes to time the infant’s last feeding so that the infant is hungry and ready to breastfeed when she arrives, also, ask her to leave her availability schedule with the early care and education program and ask her to call if she is planning to miss a feeding or is going to be late;
  4. Encourage her to provide a back-up supply of frozen or refrigerated expressed human milk with the infant’s full name on the bottle or other clean storage container in case the infant needs to eat more often than usual or the mother’s visit is delayed;
  5. Share with her information about other places in the community that can answer her questions and concerns about breastfeeding, for example, local lactation consultants (14,16);
  6. Ensure that all staff receive training in breastfeeding support and promotion;
  7. Ensure that all staff are trained in the proper handling and feeding of each milk product, including human milk or infant formula;
  8. Provide culturally appropriate breastfeeding materials including community resources for parents/guardians that include appropriate language and pictures of multicultural families to assist families to identify with them.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.2.0.9 Written Menus and Introduction of New Foods
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.1.5 Preparing, Feeding, and Storing Infant Formula
4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants
4.3.1.12 Feeding Age-Appropriate Solid Foods to Infants
Appendix JJ: Our Child Care Center Supports Breastfeeding
REFERENCES
  1. Dietitians of Canada, American Dietetic Association. 2000. Manual of clinical dietetics. 6th ed. Chicago: ADA.
  2. U.S. Department of Agriculture, Food and Nutrition Service (FNS). 1993. Breastfed babies welcome here! Alexandria, VA: FNS.
  3. American Academy of Pediatrics, Section on Breastfeeding. 2005. Policy statement: Breastfeeding and the use of human milk. Pediatrics 115:496-506.
  4. Uauy, R., I. DeAndroca. 1995. Human milk and breast feeding for optimal brain development. J Nutr 125:2278-80.
  5. Wang, Y. S., S. Y. Wu. 1996. The effect of exclusive breast feeding on development and incidence of infection in infants. J Hum Lactation 12:27-30.
  6. Quandt, S. 1998. Ecology of breast feeding in the US: An applied perspective. Am J Hum Biol 10:221-28.
  7.  Hammosh, M. 1996. Breast feeding and the working mother. Pediatrics 97:492-98.
  8. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.
  9.  Kramer M. S., L. Matush, I. Vanilovich, et al. 2007. Effects of prolonged and exclusive breastfeeding on child height, weight, adiposity, and blood pressure at age 6.5 y: Evidence from a large randomized trial. Am J Clin Nutr 86:1717–21.
  10. Birch, L., W. Dietz, eds. 2008. Eating behaviors of the young child: Prenatal and postnatal influences on healthy eating. Elk Grove Village, IL: American Academy of Pediatrics.
  11. U.S. Department of Agriculture, Food and Nutrition Service (FNS). 2002. Feeding infants: A guide for use in the child nutrition programs. Rev ed. Alexandria, VA: FNS. http://www.fns.usda.gov/tn/resources/feeding_infants.pdf.
  12. Ip, S., M. Chung, G. Raman, P. Chew, N. Magula, D. DeVine, T. Trikalinos, J. Lau. 2007. Breastfeeding and maternal and infant health outcomes in developed countries. Rockville, MD: Agency for Healthcare Research and Quality.
  13. U.S. Department of Agriculture, Food and Nutrition Service. Benefits and services: Breastfeeding promotion and support in WIC. http://www.fns.usda.gov/wic/breastfeeding/mainpage.HTM.
  14. Stuebe, A. M., E. B. Schwarz. 2009. The risks and benefits of infant feeding practices for women and their children. J Perinatology (July 16).
  15. U.S. Department of Health and Human Services. 2000. Healthy people 2010: Understanding and improving health. 2nd ed. Washington, DC: U.S. Government Printing Office.
  16.  Lawrence, R. A., R. Lawrence. 2005. Breast feeding: A guide for the medical profession. 6th ed. St. Louis: Mosby.
  17. Dietz, W. H., L. Stern, eds. 1998. American Academy of Pediatrics guide to your child’s nutrition. New York: Villard.

Standard 4.3.1.2: Feeding Infants on Cue by a Consistent Caregiver/Teacher

Caregivers/teachers should feed infants on the infant’s cue unless the parent/guardian and the child’s primary care provider give written instructions otherwise (6). Whenever possible, the same caregiver/teacher should feed a specific infant for most of that infant’s feedings. Cues such as opening the mouth, making suckling sounds, and moving the hands at random all send information from an infant to a caregiver/teacher that the infant is ready to feed. Caregivers/teachers should not feed infants beyond satiety, just as hunger cues are important in initiating feedings, observing satiety cues can limit overfeeding.

RATIONALE
Cue feeding meets the infant’s nutritional and emotional needs and provides an immediate response to the infant, which helps ensure trust and feelings of security. Cues such as turning away from the nipple, increased attention to surroundings, keeping mouth closed, and saying no are all indications of satiation (1,2,6).

When the same caregiver/teacher regularly works with a particular child, that caregiver/teacher is more likely to understand that child’s cues and to respond appropriately. Feeding infants on cue rather than on a schedule may help prevent childhood obesity (3,6). Early relationships between an infant and caregivers/teachers involving feeding set the stage for an infant to develop eating patterns for life (1,4).

COMMENTS
Caregivers/teachers should be gentle, patient, sensitive, and reassuring by responding appropriately to the infant’s feeding cues (1). Waiting for an infant to cry to indicate hunger is not necessary or desirable. Crying may indicate that feeding cues have been missed and adequate attention has not been paid to the infant (5). Nevertheless, feeding children who are alert and interested in interpersonal interaction, but who are not showing signs of hunger, is not appropriate. Cues for hunger or interaction-seeking may vary widely in different infants. A pacifier should not be offered to a hungry infant, they need food first.

A series of trainings on infant cues can be found at NCAST-AVENUW, University of Washington at http://www.ncast.org/index.cfm?category=16.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.3.1.1 General Plan for Feeding Infants
4.3.1.8 Techniques for Bottle Feeding
REFERENCES
  1. Satter, E. 2000. Child of mine: Feeding with love and good sense. 3rd ed. Boulder, CO: Bull Publishing.
  2. Hagan, Jr., J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Bright futures: Guidelines for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics.
  3. Hodges, E. A., S. O. Hughes, J. Hopkinson, J. O. Fisher. 2008. Maternal decisions about the initiation and termination of infant feeding. Appetite 50:333-39.
  4. Branscomb, K. R., C. B. Goble. 2008. Infants and toddlers in group care: Feeding practices that foster emotional health. Young Children 63:28-33.
  5. Taveras, E. M., S. L. Rifas-Shiman, K. S. Scanlon, L. M. Grummer-Strawn, B. Sherry, M. W. Gillman. 2006. To what extent is the protective effect of breastfeeding on future overweight explained by decreased maternal feeding restriction? Pediatrics 118:2341-48.
  6. Trahms, C. M., P. L. Pipes, eds. 1997. Nutrition and infancy in childhood. 6th ed. New York: McGraw-Hill.

Standard 4.3.1.3: Preparing, Feeding, and Storing Human Milk

Frequently Asked Questions/CFOC3 Clarifications

Reference: 4.3.1.3

Date: 10/17/2011

Topic & Location:
Chapter 4
Nutrition and Food Service
Standard 4.3.1.3: Preparing, Feed-ing, and Storing Human Milk

Question:
I cannot find any information in the new CFOC as to how long a bottle of breast milk can be kept after it is fed to an infant.  It states that a bottle of formula should be discarded after one hour.  I would think that it should be the same, since saliva is introduced into the bottle regardless of its contents, but I want to make sure.
Can you offer some guidance?

Answer:
This Standard provides two references at the end of the “Guide-lines for Storage of Human Milk” chart on page 166. Both re-sources state that breast milk should be discarded after it is fed to an infant.

  1. The Academy of Breastfeeding Medicine Protocol Committee states: “Milk left in the feeding container after a feeding should be discarded and not used again.”
  2. The Centers for Disease Control (CDC) states: “Do not save milk from a used bottle for use at another feeding.”
A specific amount of time is not given (similar to the formula standard). The milk could be used again if it’s the same feeding (for example, if the infant takes a short break from eating), but if it is clearly a different feeding, it should be thrown away.

Content in the STANDARD was modified on 8/23/2016.

 

Expressed human milk should be placed in a clean and sanitary bottle with a nipple that fits tightly or into an equivalent clean and sanitary sealed container to prevent spilling during transport to home or to the facility. Only cleaned and sanitized bottles, or their equivalent, and nipples should be used in feeding. The bottle or container should be properly labeled with the infant’s full name and the date and time the milk was expressed. The bottle or container should immediately be stored in the refrigerator on arrival.

The mother’s own expressed milk should only be used for her own infant. Likewise, infant formula should not be used for a breastfed infant without the mother’s written permission.

Avoid bottles made of plastics containing bisphenol A (BPA) or phthalates, sometimes labeled with #3, #6, or #7 (1). Use glass bottles with a silicone sleeve (a silicone bottle jacket to prevent breakage) or those made with safer plastics such as polypropylene or polyethylene (labeled BPA-free) or plastics with a recycling code of #1, #2, #4, or #5.

Non-frozen human milk should be transported and stored in the containers to be used to feed the infant, identified with a label which will not come off in water or handling, bearing the date of collection and child’s full name. The filled, labeled containers of human milk should be kept refrigerated. Human milk containers with significant amount of contents remaining (greater than one ounce) may be returned to the mother at the end of the day as long as the child has not fed directly from the bottle.

Frozen human milk may be transported and stored in single use plastic bags and placed in a freezer (not a compartment within a refrigerator but either a freezer with a separate door or a standalone freezer). Human milk should be defrosted in the refrigerator if frozen, and then heated briefly in bottle warmers or under warm running water so that the temperature does not exceed 98.6°F. If there is insufficient time to defrost the milk in the refrigerator before warming it, then it may be defrosted in a container of running cool tap water, very gently swirling the bottle periodically to evenly distribute the temperature in the milk. Some infants will not take their mother’s milk unless it is warmed to body temperature, around 98.6°F. The caregiver/teacher should check for the infant’s full name and the date on the bottle so that the oldest milk is used first. After warming, bottles should be mixed gently (not shaken) and the temperature of the milk tested before feeding.

Expressed human milk that presents a threat to an infant, such as human milk that is in an unsanitary bottle, is curdled, smells rotten, and/or has not been stored following the storage guidelines of the Academy of Breastfeeding Medicine as shown later in this standard, should be returned to the mother.

Some children around six months to a year of age may be developmentally ready to feed themselves and may want to drink from a cup. The transition from bottle to cup can come at a time when a child’s fine motor skills allow use of a cup. The caregiver/teacher should use a clean small cup without cracks or chips and should help the child to lift and tilt the cup to avoid spillage and leftover fluid. The caregiver/teacher and mother should work together on cup feeding of human milk to ensure the child is receiving adequate nourishment and to avoid having a large amount of human milk remaining at the end of feeding. Two to three ounces of human milk can be placed in a clean cup and additional milk can be offered as needed. Small amounts of human milk (about an ounce) can be discarded.

Human milk can be stored using the following guidelines from the Academy of Breastfeeding Medicine:

 

Guidelines for Storage of Human Milk

Location

Temperature

Duration

Comments

Countertop, table

Room temperature (up to 77°F or 25°C)

6-8 hours

Containers should be covered and kept as cool as possible; covering the container with a cool towel may keep milk cooler.

Insulated cooler bag

5°F – 39°F or -15°C – 4°C

24 hours

Keep ice packs in contact with milk containers at all times, limit opening cooler bag.

Refrigerator

39°F or 4°C

5 days

Store milk in the back of the main body of the refrigerator.

Freezer compartment of a refrigerator

5°F or -15°C

2 weeks

Store milk toward the back of the freezer, where temperature is most constant. Milk stored for longer durations in the ranges listed is safe, but some of the lipids in the milk undergo degradation resulting in lower quality.

Freezer compartment of refrigerator with separate doors

0°F or -18°C

3-6 months

Chest or upright deep freezer

-4°F or -20°C

6-12 months

Source: Academy of Breastfeeding Medicine Protocol Committee. 2010. Clinical protocol #8: Human milk storage information for home use for healthy full term infants, revised. Breastfeeding Med 5:127-30. http://www.bfmed.org/Media/Files/Protocols/Protocol%208%20-%20English%20revised%202010.pdf.

From the Centers for Disease Control and Prevention Website: Proper handling and storage of human milk – Storage duration of fresh human milk for use with healthy full term infants. http://www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htm.


RATIONALE
Labels for containers of human milk should be resistant to loss of the name and date/time when washing and handling. This is especially important when the frozen bottle is thawed in running tap water. There may be several bottles from different mothers being thawed and warmed at the same time in the same place.

By following this standard, the staff is able, when necessary, to prepare human milk and feed an infant safely, thereby reducing the risk of inaccuracy or feeding the infant unsanitary or incorrect human milk (2,3). Written guidance for both staff and parents/guardians should be available to determine when milk provided by parents/guardians will not be served. Human milk cannot be served if it does not meet the requirements for sanitary and safe milk.

Although human milk is a body fluid, it is not necessary to wear gloves when feeding or handling human milk. Unless there is visible blood in the milk, the risk of exposure to infectious organisms either during feeding or from milk that the infant regurgitates is not significant.

Returning unused human milk to the mother informs her of the quantity taken while in the early care and education program.

Excessive shaking of human milk may damage some of the cellular components that are valuable to the infant.
It is difficult to maintain 0°F consistently in a freezer compartment of a refrigerator or freezer, so caregivers/teachers should carefully monitor, with daily log sheets, temperature of freezers used to store human milk using an appropriate working thermometer. Human milk contains components that are damaged by excessive heating during or after thawing from the frozen state (4). Currently, there is nothing in the research literature that states that feedings must be warmed at all prior to feeding. Frozen milk should never be thawed in a microwave oven as 1) uneven hot spots in the milk may cause burns in the infant and 2) excessive heat may destroy beneficial components of the milk.

By following safe preparation and storage techniques, nursing mothers and caregivers/teachers of breastfed infants and children can maintain the high quality of expressed human milk and the health of the infant (5,6).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.3.1.1 General Plan for Feeding Infants
4.3.1.4 Feeding Human Milk to Another Mother’s Child
4.3.1.7 Feeding Cow’s Milk
4.3.1.8 Techniques for Bottle Feeding
4.3.1.9 Warming Bottles and Infant Foods
5.2.9.9 Plastic Containers and Toys
REFERENCES
  1. Binns, C. 2016. The long-term public health benefits of breastfeeding. Asia-Pacific Journal of Public Health. 28(1):7.
  2. Boué, G., Cummins, E., Guillou, S., Antignac, J., Bizec, B., & Membré, J. 2016. Public health risks and benefits associated with breast milk and infant formula consumption. Critical Reviews in Food Science and Nutrition. Feb 6:1-20.
  3. La Leche League International. (2014). Storage guidelines: LLLI guidelines for storing breastmilk. http://www.llli.org/faq/milkstorage.html.
  4. Centers for Disease Control and Prevention. 2016. Proper handling and storage of human milk. Atlanta, GA. https://www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htm.
  5. United States Cooperative Expansion System. 2015. Guidelines for child care providers to prepare and feed bottles to infants. 2015. http://articles.extension.org/pages/25404/guidelines-for-child-care-providers-to-prepare-and-feed-bottles-to-infants.
  6. Harley, K.G., Gunier, R.B., Kogut, K., Johnson, C., et al. 2013. Prenatal and early childhood bisphenol a concentrations and behavior in school-aged children. Environ Res. 126: 43-50.
NOTES

Content in the STANDARD was modified on 8/23/2016.

 

Standard 4.3.1.4: Feeding Human Milk to Another Mother’s Child

Content in the STANDARD was modified on 8/24/2017.

 

Because parents/guardians may express concern about the likelihood of transmitting diseases through human milk, this issue is addressed in detail to assure there is a very small risk of such transmission occurring.
 
If a child has been mistakenly fed another child’s bottle of expressed human milk, the possible exposure to infectious diseases should be treated just as if an unintentional exposure to other body fluids had occurred.
 
The early care and education program should (1):
 
a.  Inform the mother who expressed the human milk about the mistake and when the bottle switch occurred, and ask:
 
1.  When the human milk was expressed and how it was handled prior to being delivered to the caregiver/teacher or facility;
2.  Whether the mother has ever had a Human Immunodeficiency Virus (HIV) blood test and, if so, the date of the test and would she be willing to share the results with the parents/guardians of the child who was fed her child’s milk;
3.  If she does not know whether she has ever been tested for HIV, ask her if would she be willing to contact her primary health care provider and find out if she has been tested; and
4.  If she has never been tested for HIV, would she be willing to be tested and share the results with the parents/guardians of the other child.
 
b.  Discuss the mistake with the parents/guardians of the child who was fed the wrong bottle:
 
1.  Inform them that their child was given another child’s bottle of expressed human milk and the date it was given;
2.  Inform them that the risk of transmission of HIV is low;
3.  Encourage the parents/guardians to notify the child’s primary health care provider of the potential exposure; and
4.  Provide the family with information including the time at which the milk was expressed and how the milk was handled prior to its being delivered to the caregiver/teacher so that the parents/guardians may inform the child’s primary health care provider.
 
c.   Assess why the wrong milk was given and develop a prevention plan to be shared with the parents/guardians as well as the staff in the facility.

RATIONALE
Hepatitis B and C are not spread through breastfeeding (2,3).
 
The risk of HIV transmission from expressed human milk consumed by another child is believed to be low because:
 
a.  Transmission of HIV from a single human milk exposure has never been documented (1);
b.  Chemicals present in human milk stored in cold temperatures, act to destroy the HIV present in expressed human milk; and
c. In the United States, women who know they are HIV-positive are advised NOT to breastfeed their infants and to refrain from breastfeeding if they are hepatitis C-positive or have cracked or bleeding nipples. [However, the transmission of hepatitis C by breastfeeding has not been documented (4).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.3.1.3 Preparing, Feeding, and Storing Human Milk
REFERENCES
  1. Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. Red Book: 2015 Report to the Committee of Infectious Diseases. 30th Ed. Elk Grove Village, IL: American Academy of Pediatrics. 
  2. U.S. Centers for Disease Control and Prevention. 2016. Hepatitis C FAQs for the public. https://www.cdc.gov/hepatitis/hcv/cfaq.htm#cFAQ37
  3. U.S. Centers for Disease Control and Prevention. 2016. Hepatitis B FAQs for the public. https://www.cdc.gov/hepatitis/hbv/bfaq.htm#bFAQ13.
  4. U.S. Centers for Disease Control and Prevention. 2016. What to do if an infant or child is mistakenly fed another woman’s expressed breast milk. http://www.cdc.gov/breastfeeding/recommendations/other_mothers_milk.htm.
NOTES

Content in the STANDARD was modified on 8/24/2017.

 

Standard 4.3.1.5: Preparing, Feeding, and Storing Infant Formula

Content in the STANDARD was modified on 11/5/2013 and 8/25/2016.

Formula provided by parents/guardians or by the facility should come in a factory-sealed container. The formula should be of the same brand that is served at home and should be of ready-to-feed strength or liquid concentrate to be diluted using cold water from a source approved by the health department. Powdered infant formula, though it is the least expensive formula, requires special handling in mixing because it cannot be sterilized. The primary source for proper and safe handling and mixing is the manufacturer’s instructions that appear on the can of powdered formula. Before opening the can, hands should be washed. The can and plastic lid should be thoroughly rinsed and dried. Caregivers/teachers should read and follow the manufacturer’s directions. Caregivers/teachers should only use the scoop that comes with the can and not interchange the scoop from one product to another, since the volume of the scoop may vary from manufacturer to manufacturer and product to product. Also, a scoop can be contaminated with a potential allergen from another type of formula. If instructions are not readily available, caregivers/teachers should obtain information from their local WIC program or the World Health Organization’s Safe Preparation, Storage and Handling of Powdered Infant Formula Guidelines at: http://www.who.int/foodsafety/publications/micro/pif_guidelines.pdf (1).

Formula mixed with cereal, fruit juice, or any other foods should not be served unless the child’s primary care provider provides written documentation that the child has a medical reason for this type of feeding.

Iron-fortified formula should be refrigerated until immediately before feeding. For bottles containing formula, any contents remaining after a feeding should be discarded.

Bottles of formula prepared from powder or concentrate or ready-to-feed formula should be labeled with the child’s full name and time and date of preparation. Any prepared formula must be discarded within one hour after serving to an infant. Prepared powdered formula that has not been given to an infant should be covered, labeled with date and time of preparation and child’s full name, and may be stored in the refrigerator for up to twenty-four hours. An open container of ready-to-feed, concentrated formula, or formula prepared from concentrated formula, should be covered, refrigerated, labeled with date of opening and child’s full name, and discarded at forty-eight hours if not used (2). The caregiver/teacher should always follow manufacturer’s instructions for mixing and storing of any formula preparation. Some infants will require specialized formula because of allergy, inability to digest certain formulas, or need for extra calories. The appropriate formula should always be available and should be fed as directed. For those infants getting supplemental calories, the formula may be prepared in a different way from the directions on the container. In those circumstances, either the family should provide the prepared formula or the caregiver/teacher should receive special training, as noted in the infant’s care plan, on how to prepare the formula. Formula should not be used beyond the stated shelf life period (3).

Parents/guardians should supply enough clean and sterilized bottles to be used throughout the day. The bottles must be sanitary, properly prepared and stored, and must be the same brand in the early care and education program and at home. Avoid bottles made of plastics containing bisphenol A (BPA) or phthalates (sometimes labeled with #3, #6, or #7). Use glass bottles with a silicone sleeve (a silicone bottle jacket to prevent breakage) or those made with safer plastics such as polypropylene or polyethylene (labeled BPA-free) or plastics with a recycling code of #1, #2, #4, or #5.

RATIONALE
Caregivers/teachers help in promoting the feeding of infant formula that is familiar to the infant and supports family feeding practice. By following this standard, the staff is able, when necessary, to prepare formula and feed an infant safely, thereby reducing the risk of inaccuracy or feeding the infant unsanitary or incorrect formula. Written guidance for both staff and parents/guardians must be available to determine when formula provided by parents/guardians will not be served. Formula cannot be served if it does not meet the requirements for sanitary and safe formula.

Staff preparing formula should thoroughly wash their hands prior to beginning preparation of infant feedings of any type. Water used for mixing infant formula must be from a safe water source as defined by the local or state health department. If the caregiver/teacher is concerned or uncertain about the safety of the tap water, s/he should "flush" the water system by running the tap on cold for 1-2 minutes or use bottled water (4). Warmed water should be tested in advance to make sure it is not too hot for the infant. To test the temperature, the caregiver/teacher should shake a few drops on the inside of her/his wrist. A bottle can be prepared by adding powdered formula and room temperature water from the tap just before feeding. Bottles made in this way from powdered formula can be ready for feeding as no additional refrigeration or warming would be required.

Adding too little water to formula puts a burden on an infant’s kidneys and digestive system and may lead to dehydration (5). Adding too much water dilutes the formula. Diluted formula may interfere with an infant’s growth and health because it provides inadequate calories and nutrients and can cause water intoxication. Water intoxication can occur in breastfed or formula-fed infants or children over one year of age who are fed an excessive amount of water. Water intoxication can be life-threatening to an infant or young child (6).If a child has a special health problem, such as reflux, or inability to take in nutrients because of delayed development of feeding skills, the child’s primary care provider should provide a written plan for the staff to follow so that the child is fed appropriately. Some infants are allergic to milk and soy and need to be fed an elemental formula which does not contain allergens. Other infants need supplemental calories because of poor weight gain.

Infants should not be fed a formula different from the one the parents/guardians feed at home, as even minor differences in formula can cause gastrointestinal upsets and other problems (7).

Excessive shaking of formula may cause foaming that increases the likelihood of feeding air to the infant.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.3.1.1 General Plan for Feeding Infants
4.3.1.8 Techniques for Bottle Feeding
4.3.1.9 Warming Bottles and Infant Foods
5.2.9.9 Plastic Containers and Toys
REFERENCES
  1. United States Department of Agriculture, Food and Nutrition Service. 2017. Feeding infants: A guide for use in the child nutrition programs. https://www.fns.usda.gov/tn/feeding-infants-guide-use-child-nutrition-programs.
  2. Brown, J., Krasowski, M. D., & Hesse, M. 2015. Forced water intoxication: A deadly form of child abuse. The Journal of Law Enforcement. 4(4).
  3. Seattle Children's Hospital. 2014. Topics covered for formula feeding: Is this your child's symptoms? Seattle, WA. http://www.seattlechildrens.org/medical-conditions/symptom-index/bottle-feeding-formula-questions/.
  4. Centers for Disease Control and Prevention. 2016. Water. https://www.cdc.gov/nceh/lead/tips/water.htm.
  5. Seltzer, H. 2012. U.S Department of Health & Human Services. Keeping infant formula safe. https://www.foodsafety.gov/blog/infant_formula.html.
  6. U.S. Department of Health & Human Services, U.S. Food & Drug Administration. 2016. Food safety for moms to be: Once baby arrives. College Park, MD. https://www.fda.gov/food/resourcesforyou/healtheducators/ucm089629.htm.
  7. World Health Organization. 2007. Safe preparation, storage and handling of powdered infant formula: Guidelines. http://www.who.int/foodsafety/publications/powdered-infant-formula/en/.
NOTES

Content in the STANDARD was modified on 11/5/2013 and 8/25/2016.

Standard 4.3.1.8: Techniques for Bottle Feeding

Frequently Asked Questions/CFOC3 Clarifications

Reference: 4.3.1.8

Date: 10/13/2011

Topic & Location:
Chapter 4
Nutrition and Food Service
Standard 4.3.1.8: Techniques for Bottle Feeding

Question:
Can infants who are able to sit and hold their own bottles feed themselves or should all infants through 12 months be held during feedings?

Answer:
Infants should always be held for bottle feeding. Caregivers/teachers and parents/guardians need to understand the relationship between bottle feeding and emotional security.

Infants should always be held for bottle feeding. Caregivers/teachers should hold infants in the caregiver’s/teacher’s arms or sitting up on the caregiver’s/teacher’s lap. Bottles should never be propped. The facility should not permit infants to have bottles in the crib. The facility should not permit an infant to carry a bottle while standing, walking, or running around.

Bottle feeding techniques should mimic approaches to breastfeeding:
a.    Initiate feeding when infant provides cues (rooting, sucking, etc.);
b.    Hold the infant during feedings and respond to vocalizations with eye contact and vocalizations;
c.     Alternate sides of caregiver’s/teacher’s lap;
d.    Allow breaks during the feeding for burping;
e.    Allow infant to stop the feeding.

A caregiver/teacher should not bottle feed more than one infant at a time.

Bottles should be checked to ensure they are given to the appropriate child, have human milk, infant formula, or water in them. When using a bottle for a breastfed infant, a nipple with a cylindrical teat and a wider base is usually preferable. A shorter or softer nipple may be helpful for infants with a hypersensitive gag reflex, or those who cannot get their lips well back on the wide base of the teat (1).

The use of a bottle or cup to modify or pacify a child’s behavior should not be allowed (2).

RATIONALE
The manner in which food is given to infants is conducive to the development of sound eating habits for life. Caregivers/teachers and parents/guardians need to understand the relationship between bottle feeding and emotional security. Caregivers/teachers should hold infants who are bottle feeding whenever possible, even if the children are old enough to hold their own bottle. Caregivers/teachers should promote proper feeding practices and oral hygiene including proper use of the bottle for all infants and toddlers. Bottle propping can cause choking and aspiration and may contribute to long-term health issues, including ear infections (otitis media), orthodontic problems, speech disorders, and psychological problems (3). When infants and children are fed on cue, they are in control of frequency and amount of feedings. This has been found to reduce the risk of childhood obesity. Any liquid except plain water can cause early childhood caries (4). Early childhood caries in primary teeth may hold significant short-term and long-term implications for the child’s health (5). Frequently sipping any liquid besides plain water between feeds encourages tooth decay.

Children are at an increased risk for injury when they walk around with bottle nipples in their mouths. Bottles should not be allowed in the crib or bed for safety and sanitary reasons and for preventing dental caries. It is difficult for a caregiver/teacher to be aware of and respond to infant feeding cues when the child is in a crib or bed and when feeding more than one infant at a time. Infants should be burped after every feeding and preferably during the feeding as well.

Caregivers/teachers should offer children fluids from a cup as soon as they are developmentally ready. Some children may be able to drink from a cup around six months of age, while for others it is later (6). Weaning a child to drink from a cup is an individual process, which occurs over a wide range of time. The American Academy of Pediatric Dentistry (AAPD) recommends weaning from a bottle by the child’s first birthday (7). Instead of sippy cups, caregivers/teachers should use smaller cups and fill halfway or less to prevent spills as children learn to use a cup (8). If sippy cups are used, it should only be for a very short transition period.

Some children around six months to a year of age may be developmentally ready to feed themselves and may want to drink from a cup. The transition from bottle to cup can come at a time when a child’s fine motor skills allow use of a cup. The caregiver/teacher should use a clean small cup without cracks or chips and should help the child to lift and tilt the cup to avoid spillage and leftover fluid. The caregiver/teacher and parent/guardian should work together on cup feeding of human milk to ensure the child’s receiving adequate nourishment and to avoid having a large amount of human milk remaining at the end of feeding. Two to three ounces of human milk can be placed in a clean cup and additional milk can be offered as needed. Small amounts of human milk (about an ounce) can be discarded.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.3.1.2 Feeding Infants on Cue by a Consistent Caregiver/Teacher
4.3.1.9 Warming Bottles and Infant Foods
REFERENCES
  1. Holt, K., N. Wooldridge, M. Story and D. Sofka. 2011. Bright futures nutrition. 3rd ed. Chicago: American Academy of Pediatrics. Print.
  2. Rupal, C. 2016. Stopping the Bottle. Nemours, KidsHealth. http://kidshealth.org/en/parents/no-bottles.html#.
  3. Hirsch, L. 2017. Feeding your 4- to 7-month old. Nemours, KidsHealth. http://kidshealth.org/en/parents/feed47m.html#
  4. Çolak, H., Dülgergil, Ç. T., Dalli, M., & Hamidi, M. M. 2013. Early childhood caries update: A review of causes, diagnoses, and treatments. Journal of natural science, biology, and medicine, 4(1), 29.
  5. American Academy of Pediatrics, Healthy Children. 2015. How to prevent tooth decay in your baby. https://www.healthychildren.org/English/ages-stages/baby/teething-tooth-care/Pages/How-to-Prevent-Tooth-Decay-in-Your-Baby.aspx.
  6. American Academy of Pediatrics, Healthy Children. 2015. Practical bottle feeding tips. https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Practical-Bottle-Feeding-Tips.aspx.
  7. Lerner, C., & Parlakian, R. 2016. Colic and crying. Zero to three. https://www.zerotothree.org/resources/197-colic-and-crying.
  8. Ben-Joseph, E. 2015. Formula feeding FAQs: Getting started. Nemours: KidsHealth. http://kidshealth.org/en/parents/formulafeed-starting.html#

Standard 4.3.1.9: Warming Bottles and Infant Foods

Frequently Asked Questions/CFOC3 Clarifications

Reference: 4.3.1.9

Date: 10/13/2011

Topic & Location:
Chapter 4
Nutrition and Food Service
Standard 4.3.1.9: Warming Bottles and Infant Foods

Question:
I have concerns about the standards recommending glass and ceramic containers due to concerns about using plastic.  Once again, it is good in theory, but I don’t feel it is safe. I had a center that had a glass bottle drop and shatter in their infant room. 

Answer:
BPA-free plastic bottles, those labeled #1, #2, #4, or #5, can be used to avoid the use of glass.

For those child care and early education facilities that choose to use glass bottles, a relatively new option is to use a bottle sleeve with the glass bottle to reduce the risk of shattered glass. Efficacy on this product is still being proven. Overall, glass is safer than plastic with BPA.

Content in the STANDARD was modified on 11/5/2013 and on 8/25/2016.

Bottles and infant foods can be served cold from the refrigerator and do not have to be warmed. If a caregiver/teacher chooses to warm them, bottles should be warmed under running, warm tap water or by placing them in a container of water that is no warmer than 120°F. Bottles should not be left in a pot of water to warm for more than five minutes. Bottles and infant foods should never be warmed in a microwave oven.

Infant foods should be stirred carefully to distribute the heat evenly. A caregiver/teacher should not hold an infant while removing a bottle or infant food from the container of warm water or while preparing a bottle or stirring infant food that has been warmed in some other way. Only BPA-free plastic, plastic labeled #1, #2, #4 or #5, or glass bottles should be used.

If a slow-cooking device, such as a crock pot, is used for warming infant formula, human milk, or infant food, this slow-cooking device (and cord) should be out of children’s reach; should contain water at a temperature that does not exceed 120°F; and should be emptied, cleaned, sanitized, and refilled with fresh water daily.

If a bottle warmer is used for warming infant formula, human milk, or infant food, it should be out of children’s reach and used according to manufacturer’s instructions. For both slow-cooking devices and bottle warmers, glass bottles with a silicone sleeve (a silicone bottle jacket to prevent breakage) or those made with safer plastics, such as polypropylene or polyethylene, should be used.  
 

RATIONALE
Bottles of human milk or infant formula that are warmed at room temperature or in warm water for an extended time provide an ideal medium for bacteria to grow. Infants have received burns from hot water dripping from an infant bottle that was removed from a crock pot or by pulling the crock pot down on themselves by a dangling cord. Caution should be exercised to avoid raising the water temperature above a safe level for warming infant formula or infant food. Human milk, formula, or food fed to infants should never be heated in a microwave oven as uneven hot spots in milk and/or food may burn the infant (1,2).

Avoid bottles made of plastics containing bisphenol A (BPA) (3) or phthalates (sometimes labeled with #3, #6, or #7). Use glass bottles with a silicone sleeve (a silicone bottle jacket to prevent breakage) or those made with safer plastics such as polypropylene or polyethylene  (labeled BPA-free) or plastics with a recycling code of #1, #2, #4, or #5.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.1.5 Preparing, Feeding, and Storing Infant Formula
4.3.1.8 Techniques for Bottle Feeding
4.3.1.12 Feeding Age-Appropriate Solid Foods to Infants
REFERENCES
  1. Dixon J. J., D. A. Burd, D. G. Roberts. 1997. Severe burns resulting from an exploding teat on a bottle of infant formula milk heated in a microwave oven. Burns 23:268-69.
  2. Nemethy, M., E. R. Clore. 1990. Microwave heating of infant formula and breast milk. J Pediatr Health Care 4:131-35.
  3. Harley, K.G., Gunier, R.B., Kogut, K., Johnson, C., et al. 2013. Prenatal and early childhood bisphenol a concentrations and behavior in school-aged children. Environ Res. 126: 43-50.
NOTES

Content in the STANDARD was modified on 11/5/2013 and on 8/25/2016.

Standard 4.3.1.10: Cleaning and Sanitizing Equipment Used for Bottle Feeding

Bottles, bottle caps, nipples and other equipment used for bottle feeding should not be reused without first being cleaned and sanitized by washing in a dishwasher or by washing, rinsing, and boiling them for one minute.

RATIONALE
Infant feeding bottles are contaminated by the child’s saliva during feeding. Formula and milk promote growth of bacteria, yeast, and fungi. Bottles, bottle caps, and nipples that are reused should be washed and sanitized to avoid contamination from previous feedings.
COMMENTS
Excessive boiling of latex bottle nipples will damage them. Nipples that are discolored, thinning, tacky, or ripped should not be used.
TYPE OF FACILITY
Center, Large Family Child Care Home

Standard 4.3.1.11: Introduction of Age-Appropriate Solid Foods to Infants

A plan to introduce age-appropriate solid foods (complementary foods) to infants should be made in consultation with the child’s parent/guardian and primary care provider. Age-appropriate solid foods may be introduced no sooner than when the child has reached the age of four months, but preferably six months and as indicated by the individual child’s nutritional and developmental needs.

For breastfed infants, gradual introduction of iron-fortified foods may occur no sooner than around four months, but preferably six months and to complement the human milk. Modification of basic food patterns should be provided in writing by the child’s primary care provider.

Evidence for introducing complementary foods in a specific order or rate is not available. The current best practice is that the first solid foods should be single-ingredient foods and should be introduced one at a time at two- to seven-day intervals (1).

RATIONALE
Early introduction of age-appropriate solid food and fruit juice interferes with the intake of human milk or iron-fortified formula that the infant needs for growth. Age-appropriate solid food given before an infant is developmentally ready may be associated with allergies and digestive problems (2,8). Around about six months of age, breastfed infants may require an additional source of iron. Vitamin drops with iron may be needed. Infants who are not exclusively fed human milk should consume iron-fortified formula as the substitute for human milk (9). In the United States, major non-milk sources of iron in the infant diet are iron-fortified cereal and meats (2). Zinc is important for healthy growth and proper immune function. Infant stores of zinc may subsidize the intake from human milk for several months. Age-appropriate solid foods such as meat (a good source of zinc) are needed beginning at six months (2). A full daily allowance of vitamin C is found in human milk (3). The American Academy of Pediatrics (AAP) recommends that all breastfed or partially breastfed infants receive a minimum daily intake of 400 IU of vitamin D supplementation beginning soon after birth until they consume sufficient vitamin D fortified milk (about one quart per day) to meet the 400 IU daily requirements (4). These supplements should be given at home by the parents/guardians to take the burden off the caregiver/teacher.

The transitional phase of feeding age-appropriate solid foods which occurs no sooner than four months and preferably six months of age is a critical time for development of gross, fine, and oral motor skills. When an infant is able to hold his/her head steady, open her/his mouth, lean forward in anticipation of food offered, close the lips around a spoon, and transfer from front of the tongue to the back and swallow, s/he is ready to eat semi-solid foods. The process of learning a more mature style of eating begins because of physical growth occurring concurrently with social, cultural, sociological, and physiological development.

COMMENTS
Many infants find fruit juices appealing and may be satisfied by the calories in age-appropriate solid foods so that they subsequently drink less human milk or formula. When fruit juice is introduced at one year of age, it should be by cup rather than a bottle or other container (such as a box) to decrease the occurrence of dental caries. Infants, birth up to one year of age, should not be served juice. Whole fruit, mashed or pureed, is appropriate for infants seven months up to one year of age. Children one year of age through age six should be limited to a total of four to six ounces of juice per day.

Many people believe that infants sleep better when they start to eat age-appropriate solid foods, however research shows that longer sleeping periods are developmentally and not nutritionally determined in mid-infancy (2,5).

An important goal of early childhood nutrition is to ensure children’s present and future health by fostering the development of healthy eating behaviors (2,9). Caregivers/teachers are responsible for providing a variety of nutritious foods, defining the structure and timing of meals and creating a mealtime environment that facilitates eating and social exchange (7). Children are responsible for participating in choices about food selection and should be allowed to take responsibility for determining how much is consumed at each eating occasion (2).

Good communication between the caregiver/teacher and the parents/guardians cannot be over-emphasized and is essential for successful feeding in general, including when and how to introduce age-appropriate solid foods. The decision to feed specific foods should be made in consultation with the parent/guardian. Caregivers/teachers should be given written instructions on the introduction and feeding of foods from the infant’s parent/guardian and primary care provider. Caregivers/teachers can use or develop a take-home sheet for parents/guardians in which the caregiver/teacher records the food consumed, how much, and other important notes on the infant, each day. Caregivers/teachers should continue to consult with each infant’s parents/guardians concerning which foods they have introduced and are feeding. This schedule of introducing new foods one at a time, followed by waiting two to seven days before introducing another new food, enables parents and caregivers/teachers to pinpoint any problems a child might have with any specific food (10). Following this schedule for introducing new foods, the caregiver/teacher can more easily identify an infant’s possible food allergy or intolerance. Consistency between home and the early care and education setting is essential during the period of rapid change when infants are learning to eat age-appropriate solid foods (6,8).

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.2.0.7 100% Fruit Juice
4.2.0.9 Written Menus and Introduction of New Foods
4.2.0.10 Care for Children with Food Allergies
4.2.0.12 Vegetarian/Vegan Diets
4.5.0.8 Experience with Familiar and New Foods
REFERENCES
  1. U.S. Department of Agriculture, Food and Nutrition Service (FNS). 2002. Feeding infants: A guide for use in the child nutrition programs. Rev ed. Alexandria, VA: FNS. http://www.fns.usda.gov/tn/resources/feeding_infants.pdf.
  2. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.
  3. Lally, J. R., A. Griffin, E. Fenichel, M. Segal, E. Szanton, B. Weissbourd. 2003. Caring for infants and toddlers in groups: Developmentally appropriate practice. Arlington, VA: Zero to Three.
  4. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.
  5. Lawrence, R. A., R. Lawrence. 2005. Breast feeding: A guide for the medical profession. 6th ed. St. Louis: Mosby.
  6. Branscomb, K. R., C. B. Goble. 2008. Infants and toddlers in group care: Feeding practices that foster emotional health. Young Children 63:28-33.
  7. Grummer-Strawn, L. M., K. S. Scanlon, S. B. Fein. 2008. Infant feeding and feeding transitions during the first year of life. Pediatrics 122: S36-S42.
  8. Griffiths, L. J., L. Smeeth, S. S. Hawkins, T. J. Cole, C. Dezateux. 2008. Effects of infant feeding practice on weight gain from birth to 3 years. Arch Dis Child (November): 1-17.
  9. Wagner, C. L., F. R. Greer, Section on Breastfeeding, Committee on Nutrition. 2008. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Pediatrics 122:1142–52.
  10. Hagan, Jr., J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Promoting healthy nutrition. In Bright futures: Guidelines for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics. http://brightfutures.aap.org/pdfs/Guidelines_PDF/6-Promoting_Healthy_Nutrition.pdf.

Standard 4.3.1.12: Feeding Age-Appropriate Solid Foods to Infants

Staff members should serve commercially packaged baby food from a dish, not directly from a factory-sealed container. They should serve age-appropriate solid food (complementary food) by spoon only. Age-appropriate solid food should not be fed in a bottle or an infant feeder unless written in the child’s care plan by the child’s primary care provider. Caregivers/teachers should discard uneaten food left in dishes from which they have fed a child. The facility should wash off all jars of baby food with soap and warm water before opening the jars, and examine the food carefully when removing it from the jar to make sure there are not glass pieces or foreign objects in the food.

Food should not be shared among children using the same dish or spoon. Unused portions in opened factory-sealed baby food containers or food brought in containers prepared at home should be stored in the refrigerator and discarded if not consumed after twenty-four hours of storage.

RATIONALE
Feeding of age-appropriate solid foods in a bottle to a child is often associated with premature feeding of age-appropriate solid foods (when the infant is not developmentally ready for them) (1-5).

The external surface of a commercial container may be contaminated with disease-causing microorganisms during shipment or storage and may contaminate the food product during feeding. The portion of the food that is touched by a utensil should be consumed or discarded. A dish should be cleaned and sanitized before use, thereby reducing the likelihood of surface contamination. Any food brought from home should not be served to other children. This will prevent cross-contamination and reinforce the policy that food sent to the facility is for the designated child only.

Uneaten food should not be put back into its original container for storage because it may contain potentially harmful bacteria from the infant’s saliva. Age-appropriate solid food should not be fed in a bottle or an infant feeder apparatus because of the potential for choking. Additionally, this feeding method teaches the infant to eat age-appropriate solid foods incorrectly.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants
REFERENCES
  1. Dietitians of Canada, American Dietetic Association (ADA). 2000. Manual of clinical dietetics. 6th ed. Chicago: ADA.
  2. Endres, J. B., R. E. Rockwell. 2003. Food, nutrition, and the young child. 4th ed. New York: Macmillan.
  3. Lawrence, R. A., R. Lawrence. 2005. Breast feeding: A guide for the medical profession. 6th ed. St. Louis: Mosby.
  4. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.
  5. Samour, P. Q., K. King. 2005. Handbook of pediatric nutrition. 3rd ed. Lake Dallas, TX: Helm.

Standard 4.3.1.6: Use of Soy-Based Formula and Soy Milk

Soy-based formula or soy milk should be provided to a child whose parents/guardians present a written request because of family dietary restrictions on foods produced from animals (i.e., cow’s milk and other dairy products). Both soy-based formula and soy milk should be labeled with the infant’s or child’s full name and date and stored properly.

The caregiver/teacher should collaborate with parents/guardians in exploring community resources to secure soy-based formula. Soy milk should be available for the children of parents/guardians participating in the Women, Infants, and Children (WIC) Supplemental Food Program, Child and Adult Care Food Program (CACFP), or Food Stamp Program.

RATIONALE
The American Academy of Pediatrics (AAP) recommends use of hypoallergenic formula (not soy-based formula) for infants who are allergic to cow’s milk proteins. Soy-based formulas are appropriate for children with galactosemia or congenital lactose intolerance (1). Because there is a lot of confusion in the public regarding cow’s milk proteins and lactose intolerance, these indications should be documented by the child’s primary care provider and not based on parental/guardian possible misinterpretation of symptoms. Soy-based formulas are made from soy meal (plant based) with added methionine, carbohydrates, and oils (soy or vegetable) and are fortified with vitamins and minerals (2). In the U.S., all soy-based formula is fortified with iron. Soy meal does not contain lactose, so it is used for feeding infants with primary care provider documented congenital lactose intolerance.
COMMENTS
The taste of soy milk is similar to cow’s milk. Because soy formula and soy milk are derived from a plant source, parents/guardians may choose these products for dietary (e.g., vegan) or religious reasons. In such cases, soy-based formula is used for infant feeding and unflavored soy milk is the choice for young children.

Caregivers/teachers should encourage parents/guardians of children with primary care provider documented indications for soy formula, participating in WIC and/or Food Stamp Programs, to learn how they can obtain soy-based infant formula or soy milk/products.

Infants may need a variety of special or elemental formulas which are easier to digest and less allergenic. Elemental or special non-allergic formulas should be specified in the infant’s care plan.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.2.0.12 Vegetarian/Vegan Diets
4.3.1.5 Preparing, Feeding, and Storing Infant Formula
REFERENCES
  1. Dietitians of Canada, American Dietetic Association (ADA). 2000. Manual of clinical dietetics. 6th ed. Chicago: ADA.
  2. Bhatia, J., F. Greer, Committee on Nutrition. 2008. Use of soy protein-based formulas for infant feeding. Pediatrics 121:1062-68.

C. Requirements for Toddlers and Preschoolers

Standard 4.3.2.1: Meal and Snack Patterns for Toddlers and Preschoolers

Meals and snacks should contain at least the minimum amount of foods shown in the meal and snack patterns for toddlers and preschoolers described in the Child and Adult Care Food Program (CACFP) guidelines at http://www.fns.usda.gov/cacfp/meals-and-snacks.

RATIONALE
Even during periods of slower growth, children must continue to eat nutritious foods. With limited appetites and selective eating by toddlers and preschoolers, less nutritious foods should not be served as they can displace more nutritious foods from the child’s diet.
COMMENTS
Children who are eating more than one snack and one meal may not want all the food offered at any one of these times. On the other hand, toddlers and preschoolers may eat only some meals or some snacks. The amount of food offered to them must be sufficient to meet their needs at that particular time but not too large to promote overeating.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.2.0.4 Categories of Foods
4.2.0.5 Meal and Snack Patterns

Standard 4.3.2.2: Serving Size for Toddlers and Preschoolers

The facility should serve toddlers and preschoolers small-sized, age-appropriate portions and should permit children to have one or more additional servings of the nutritious foods that are low in fat, sugar, and sodium as needed to meet the caloric needs of the individual child. Serving dishes should contain the appropriate amount of food based on serving sizes or portions recommended for each child and adult as described in the Child and Adult Care Food Program (CACFP) guidelines at http://www.fns.usda.gov/sites/default/files/Child_Meals.pdf. Young children should learn what appropriate portion size is by being served in plates, bowls, and cups that are developmentally appropriate to their nutritional needs.

Food service staff and/or a caregiver/teacher is responsible for preparing the amount of food based on the recommended age-appropriate amount of food per serving for each child to be fed. Usually a reasonable amount of additional food is prepared to respond to a child or children requesting a second serving of the nutritious foods that are low in fat, sugar, and sodium.

RATIONALE
Gradual extension of the diet begun in infancy should continue throughout the preschool period. A child will not eat the same amount each day because appetites vary and food sprees are common (1-5). If normal variations in eating patterns are accepted without comment, feeding problems usually do not develop. Requiring that a child eat a specified food or amount of food may be counterproductive. Eating habits established in infancy and early childhood may contribute to suboptimal eating patterns later in life. Including nutritious snacks in the daily meal plan will help to ensure that the child’s nutrient needs are met. The quality of snacks for young children and school-age children is especially important, and small, frequent feedings are recommended to achieve the total desired daily intake.

Strong evidence supports that larger plate, bowl, and cup sizes promote overeating in adults (6,7). It is likely that the same is true in children. Larger serving sizes and what is considered “normal” serving size (portion size distortion), at least in part is explained by increasing size of plates, bowls, and cups.

COMMENTS
Continuing to meet the child’s needs for growth and activity is important. During the second and third years of life, the child grows much less rapidly than during the first year of life.

Standardized recipes for cooking for young children are available and are a valuable resource. Periodic training is also available from resources such as regional Head Start agencies, State Child Care agencies, resource and referral agencies, local health departments, local colleges, and universities.

Size appropriate plates, bowls, and cups in early care and education settings should help children and caregivers/teachers recognize and understand appropriate portion sizes. They may also help decrease the risk of overeating.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.3.2.1 Meal and Snack Patterns for Toddlers and Preschoolers
4.3.2.3 Encouraging Self-Feeding by Older Infants and Toddlers
REFERENCES
  1. Wansink, B., J. E. Painter, J. North. 2005. Bottomless bowls: Why visual cues of portion size may influence intake. Obesity Research 13:93-100.
  2. Wansink, B. 2004. Environmental factors that increase the food intake and consumption volume of unknowing consumers. Annual Review of Nutrition 24:455-79.
  3. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.
  4. U.S. Department of Agriculture (USDA). Making nutrition count for children - Nutrition guidance for child care homes. http://www.gpo.gov/fdsys/pkg/ERIC-ED482991/pdf/ERIC-ED482991.pdf.
  5. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.
  6. U.S. Department of Agriculture, Food Service and Nutrition. 2010. Child and adult care food program. http://www.fns.usda.gov/CND/Care/CACFP/aboutcacfp.htm.
  7. Endres, J. B., R. E. Rockwell. 2003. Food, nutrition, and the young child. 4th ed. New York: Macmillan.

Standard 4.3.2.3: Encouraging Self-Feeding by Older Infants and Toddlers

Caregivers/teachers should encourage older infants and toddlers to hold and drink from an appropriate child-sized cup, to use a child-sized spoon (short handle with a shallow bowl like a soup spoon), a child-sized fork (short, blunt tines and broad handle similar to a salad fork), all of which are developmentally appropriate for young children to feed themselves, and to use their fingers for self-feeding.

RATIONALE
As children enter the second year of life, they are interested in doing things for themselves. Self-feeding appropriately separates the responsibilities of adults and children. The adult is responsible for providing nutritious food, and the child is responsible for deciding how much of it to eat (1-5). To allow for the proper development of motor skills and eating habits, children need to be allowed to practice learning to feed themselves (6-8). Children in group care should be provided with opportunities to serve and eat a variety of food for themselves. Children will continue to self-feed using their fingers even after mastering the use of a utensil.
COMMENTS
Foods served should be appropriate to the toddler’s developmental ability and cut small enough to avoid choking hazards.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.3.2.2 Serving Size for Toddlers and Preschoolers
4.5.0.5 Numbers of Children Fed Simultaneously by One Adult
4.5.0.6 Adult Supervision of Children Who Are Learning to Feed Themselves
REFERENCES
  1. Hagan, Jr., J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Bright futures: Guidelines for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics.
  2. Benjamin, S. E., ed. 2007. Making food healthy and safe for children: How to meet the national health and safety performance standards – Guidelines for out of home child care programs. 2nd ed. Chapel Hill, NC: National Training Institute for Child Care Health Consultants. http://nti.unc.edu/course_files/curriculum/nutrition/making_food_healthy_and_safe.pdf.
  3. University of Idaho, College of Agricultural and Life Sciences. Feeding young children in group settings. http://www.cals.uidaho
    .edu/feeding/.
  4. Branscomb, K. R., C. B. Goble. 2008. Infants and toddlers in group care: Feeding practices that foster emotional health. Young Children 63:28-33.
  5. Endres, J. B., R. E. Rockwell. 2003. Food, nutrition, and the young child. 4th ed. New York: Macmillan.
  6. Briley, M. E., C. Roberts-Gray. 1999. Position of the American Dietetic Association: Nutrition standards for child-care programs. J Am Diet Assoc 99:981-88.
  7. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.
  8. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.

Standard 4.3.1.7: Feeding Cow’s Milk

The facility should not serve cow’s milk to infants from birth to twelve months of age, unless provided with a written exception and direction from the child’s primary care provider and parents/guardians. Children between twelve and twenty-four months of age, who are not on human milk or prescribed formula, can be served whole pasteurized milk, or reduced fat (2%) pasteurized milk for those children who are at risk for hypercholesterolemia or obesity (1). Children two years of age and older should be served skim or 1% pasteurized milk.

RATIONALE
For children between twelve months and twenty-four months of age, for whom overweight or obesity is a concern or who have a family history of obesity, dyslipidemia, or early cardiovascular disease, the use of reduced fat (2%) milk is appropriate (1). The child’s primary care provider may also recommend reduced fat (2%) milk for some children this age. Studies show no compromise in growth, and no difference in height, weight, or percentage of body fat and neurological development in toddlers fed reduced fat (2%) milk compared with those fed whole milk (2,8,9). The American Academy of Pediatrics recommends that cow’s milk not be used during the first year of life (3-7).
COMMENTS
Sometimes early care and education programs have children ages eighteen months to three years of age in one classroom and staff report it is difficult to serve different types of milk (1% and 2%) to specific children. Programs can use a different color label for each type of milk on the container or pitcher. Caregivers/teachers can explain to the children the meaning of the color labels and identify which milk they are drinking.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.2.0.4 Categories of Foods
4.9.0.3 Precautions for a Safe Food Supply
REFERENCES
  1. Dietz, W. H., L. Stern, eds. 1998. American Academy of Pediatrics guide to your child’s nutrition. New York: Villard.
  2. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.
  3. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.
  4. Dietitians of Canada, American Dietetic Association. 2000. Manual of clinical dietetics. 6th ed. Chicago: ADA.
  5. Niinikoski, H. Lapinleimu, , J. Viikari, H. Lapinleimu, T. Rönnemaa, E. Jokinen, R. Seppänen, P. Terho, J. Tuominen, I. Välimäki, O. Simell. 1997. Growth until 3 years of age in a prospective, randomized trial of a diet with reduced saturated fat and cholesterol. Pediatrics 99:687-94.
  6. Rask-Nissila, L., E. Jokinen, P. Terho, A. Tammi, H. Lapinleimu, T. Ronnemaa, J. Viikari, R. Seppanen, T. Korhonen, J. Tuominen, I. Valimaki, O. Simell. 2000. Neurological development of 5-year-old children receiving a low-saturated fat, low-cholesterol diet since infancy: A randomized controlled trial. JAMA 284:993-1000.
  7. American Academy of Pediatrics, Committee on Nutrition. 1992. The use of whole cow’s milk in infancy. Pediatrics 89:1105-9.
  8. Wosje, K. S., B. L. Specker, J. Giddens. 2001. No differences in growth or body composition from age 12 to 24 months between toddlers consuming 2% milk and toddlers consuming whole milk. J Am Diet Assoc 101:53-56.
  9. Daniels, S. R., F. R. Greer, Committee on Nutrition. 2008. Lipid screening and cardiovascular health in childhood. Pediatrics 122:198-208.

D. Requirements for School-Age Children

Standard 4.3.3.1: Meal and Snack Patterns for School-Age Children

Meals and snacks should contain at a minimum the meal and snack patterns shown for school-age children in the Child and Adult Care Food Program (CACFP) guidelines found at http://www.fns.usda.gov/cacfp/meals-and-snacks

Children attending facilities for two or more hours after school need at least one snack.

Breakfast is recommended for all children enrolled in an early care and education facility or in school. Depending on age, in-between eating such as a snack should occur about two hours after a meal based on the total length of time a child is in care. Child care facilities enrolled in the CACFP must allow at least one and a half hours between the end of a snack and the beginning of another meal and they must allow three hours between the end of one meal to the beginning of the next meal. CACFP requirements differ from state to state; see CACFP’s Website for current recommendations.

RATIONALE
The principles of providing adequate, nourishing food for younger children apply to this group as well. This age is characterized by a rapid rate of growth that increases the need for energy and essential nutrients to support optimal growth. Food intake may vary considerably because this is a time when children express strong food likes and dislikes. The quantity and quality of food provided should contribute toward meeting nutritional needs for the day and should not dull the appetite (1-5).
COMMENTS
A nutrient analysis was conducted of the CACFP requirements, to ensure that a snack and lunch meet two-thirds of the Recommended Dietary Allowances (6).
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.
  2. Endres, J. B., R. E. Rockwell. 2003. Food, nutrition, and the young child. 4th ed. New York: Macmillan.
  3. Briley, M. E., C. Roberts-Gray. 1999. Position of the American Dietetic Association: Nutrition standards for child-care programs. J Am Diet Assoc 99:981-88.
  4. Hagan, Jr., J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Bright futures: Guidelines for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics.
  5. Story, M., K. Holt, D. Sofka, eds. 2002. Bright futures in practice: Nutrition. 2nd ed. Arlington, VA: National Center for Education in Maternal and Child Health. http://www.brightfutures.org/nutrition/pdf/frnt_mttr.pdf.
  6. Benjamin, S. E., ed. 2007. Making food healthy and safe for children: How to meet the national health and safety performance standards – Guidelines for out of home child care programs. 2nd ed. Chapel Hill, NC: National Training Institute for Child Care Health Consultants. http://nti.unc.edu/course_files/curriculum/nutrition/making_food_healthy_and_safe.pdf.

E. Meal Service and Supervision

Standard 4.5.0.4: Socialization During Meals

Caregivers/teachers and children should sit at the table and eat the meal or snack together. Family style meal service, with the serving platters, bowls, and pitchers on the table so all present can serve themselves, should be encouraged, except for infants and very young children who require an adult to feed them. A separate utensil should be used for serving. Children should not handle foods that they will not be consuming. The adults should encourage, but not force, the children to help themselves to all food components offered at the meal. When eating meals with children, the adult(s) should eat items that meet nutrition standards. The adult(s) should encourage social interaction and conversation, using vocabulary related to the concepts of color, shape, size, quantity, number, temperature of food, and events of the day. Extra assistance and time should be provided for slow eaters. Eating should be an enjoyable experience at the facility and at home.

Special accommodations should be made for children who cannot have the food that is being served. Children who need limited portion sizes should be taught and monitored.

RATIONALE
“Family style” meal service promotes and supports social, emotional, and gross and fine motor skill development. Caregivers/teachers sitting and eating with children is an opportunity to engage children in social interactions with each other and for positive role-modeling by the adult caregiver/teacher. Conversation at the table adds to the pleasant mealtime environment and provides opportunities for informal modeling of appropriate eating behaviors, communication about eating, and imparting nutrition learning experiences (1-3,5-7). The presence of an adult or adults, who eat with the children, helps prevent behaviors that increase the possibility of fighting, feeding each other, stuffing food into the mouth and potential choking, and other negative behaviors. The future development of children depends, to no small extent, on their command of language. Richness of language increases as adults and peers nurture it (5). Family style meals encourage children to serve themselves which develops their eye-hand coordination (3-5). In addition to being nourished by food, infants and young children are encouraged to establish warm human relationships by their eating experiences. When children lack the developmental skills for self-feeding, they will be unable to serve food to themselves. An adult seated at the table can assist and be supportive with self-feeding so the child can eat an adequate amount of food to promote growth and prevent hunger.
COMMENTS
Compliance is measured by structured observation. Use of small pitchers, a limited number of portions on service plates, and adult assistance to enable children to successfully serve themselves helps to make family style service possible without contamination or waste of food.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.3.2.2 Serving Size for Toddlers and Preschoolers
4.3.2.3 Encouraging Self-Feeding by Older Infants and Toddlers
4.7.0.1 Nutrition Learning Experiences for Children
REFERENCES
  1. Endres, J. B., R. E. Rockwell. 2003. Food, nutrition, and the young child. 4th ed. New York: Macmillan.
  2. U.S. Department of Health and Human Services, Administration for Children and Families, Office of Head Start. 2009. Head Start program performance standards. Rev. ed. Washington, DC: U.S. Government Printing Office. http://eclkc.ohs.acf.hhs.gov/hslc/Head Start Program/Program Design and Management/Head Start Requirements/Head Start Requirements/45 CFR Chapter XIII/45 CFR Chap XIII_ENG.pdf.
  3. Benjamin, S. E., ed. 2007. Making food healthy and safe for children: How to meet the national health and safety performance standards – Guidelines for out of home child care programs. 2nd ed. Chapel Hill, NC: National Training Institute for Child Care Health Consultants. http://nti.unc.edu/course_files/curriculum/nutrition/making_food_healthy_and_safe.pdf.
  4. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.
  5. U.S. Department of Agriculture (USDA). 2002. Making nutrition count for children - Nutrition guidance for child care homes. Washington, DC: USDA. http://www.gpo.gov/fdsys/pkg/ERIC-ED482991/pdf/ERIC-ED482991.pdf
  6. Sigman-Grant, M., E. Christiansen, L. Branen, J. Fletcher, S. L. Johnson. 2008. About feeding children: Mealtimes in child-care centers in four western states. J Am Diet Assoc 108:340-46.
  7. Branscomb, K. R., C. B. Goble 2008. Infants and toddlers in group care: Feeding practices that foster emotional health. Young Children 63:28-33.

Standard 4.5.0.5: Numbers of Children Fed Simultaneously by One Adult

One adult should not feed more than one infant or three children who need adult assistance with feeding at the same time.

RATIONALE
Cross-contamination among children whom one adult is feeding simultaneously poses significant risk. In addition, mealtime should be a socializing occasion. Feeding more than three children at the same time necessarily resembles an impersonal production line. It is difficult for the caregiver/teacher to be aware of and respond to infant feeding cues when feeding more than one infant at a time. A child may need one-on-one feeding based on age or degree of ability. Feeding more than three children also presents a potential risk of injury and/or choking.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.3.1.2 Feeding Infants on Cue by a Consistent Caregiver/Teacher
4.3.2.2 Serving Size for Toddlers and Preschoolers
4.3.2.3 Encouraging Self-Feeding by Older Infants and Toddlers
4.5.0.4 Socialization During Meals
4.5.0.6 Adult Supervision of Children Who Are Learning to Feed Themselves

Standard 4.5.0.6: Adult Supervision of Children Who Are Learning to Feed Themselves

Children in mid-infancy who are learning to feed themselves should be supervised by an adult seated within arm’s reach of them at all times while they are being fed. Children over twelve months of age who can feed themselves should be supervised by an adult who is seated at the same table or within arm’s reach of the child’s highchair or feeding table. When eating, children should be within sight of an adult at all times.

RATIONALE
A supervising adult should watch for several common problems that typically occur when children in mid-infancy begin to feed themselves. “Squirreling” of several pieces of food in the mouth increases the likelihood of choking. A choking child may not make any noise, so adults must keep their eyes on children who are eating. Active supervision is imperative. Supervised eating also promotes the child’s safety by discouraging activities that can lead to choking (1). For best practice, children of all ages should be supervised when eating. Adults can monitor age-appropriate portion size consumption.
COMMENTS
Adults can help children while they are learning, by modeling active chewing (i.e., eating a small piece of food, showing how to use their teeth to bite it) and making positive comments to encourage children while they are eating. Adults can demonstrate how to eat foods on the menu, how to serve food, and how to ask for more food as a way of helping children learn the names of foods (e.g., “please pass the bowl of noodles”).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.3.2.3 Encouraging Self-Feeding by Older Infants and Toddlers
4.5.0.4 Socialization During Meals
4.5.0.5 Numbers of Children Fed Simultaneously by One Adult
REFERENCES
  1. American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement: Prevention of choking among children. Pediatrics 125:601-7.

Standard 4.5.0.7: Participation of Older Children and Staff in Mealtime Activities

Both older children and staff should be actively involved in serving food and other mealtime activities, such as setting and cleaning the table. Staff should supervise and assist children with appropriate handwashing procedures before and after meals and sanitizing of eating surfaces and utensils to prevent cross contamination.

RATIONALE
Children develop social skills and new motor skills as well as increase their dexterity through this type of involvement. Children require close supervision by staff and other adults when they use knives and have contact with food surfaces and food that other children will use.
COMMENTS
Compliance is measured by structured observation.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.5.0.4 Socialization During Meals

Standard 4.5.0.8: Experience with Familiar and New Foods

In consultation with the family and the nutritionist/registered dietitian, caregivers/teachers should offer children familiar foods that are typical of the child’s culture and religious preferences and should also introduce a variety of healthful foods that may not be familiar, but meet a child’s nutritional needs. Experiences with new foods can include tasting and swallowing but also include engagement of all senses (seeing, smelling, speaking, etc.) to facilitate the introduction of these new foods.

RATIONALE
By learning about new food, children increase their knowledge of the world around them, and the likelihood that they will choose a more varied, better balanced diet in later life. Eating habits and attitudes about food formed in the early years often last a lifetime. New food acceptance may take eight to fifteen times of offering a food before it is eaten (1).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.2.0.9 Written Menus and Introduction of New Foods
4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants
REFERENCES
  1. Sullivan, S. A., L. L. Birch. 1990. Pass the sugar, pass the salt: Experience dictates preference. Developmental Psychology 26:546-51.

Standard 4.5.0.3: Activities that Are Incompatible with Eating

Content in the STANDARD was modified on 8/25/2016.

 

Children should be seated when eating. Caregivers/teachers should ensure that children do not eat when standing, walking, running, playing, lying down, watching TV, playing on the computer, participating in arts and crafts projects that do not involve food, or riding in vehicles.

Children should not be allowed to continue to feed themselves or continue to be assisted with feeding themselves if they begin to fall asleep while eating. Caregivers/teachers should check that no food is left in a child’s mouth before laying a child down to sleep.

RATIONALE
Seating children, while they are eating, reduces the risk of aspiration (1-5). Eating while doing other activities (including playing, walking around, or sitting at a computer) limits opportunities for socialization during meals and snacks. Eating while watching television is associated with an increased risk of obesity (6-8). Continuing to eat while falling asleep puts the child at great risk for gagging or choking.
COMMENTS
Staff can role model appropriate eating behaviors by sitting down when they are eating and eating “family style” with the children when possible.
For additional information, see Building Mealtime Environments and Relationships: An Inventory for Feeding Young Children in Group Settings
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.5.0.4 Socialization During Meals
4.5.0.10 Foods that Are Choking Hazards
5.2.9.7 Proper Use of Art and Craft Materials
2.2.0.3 Screen Time/Digital Media Use
REFERENCES
  1. U.S. Consumer Product Safety Commission (CPSC). Art and craft safety guide. Bethesda, MD: CPSC. http://www.cpsc.gov/cpscpub/pubs/5015.pdf.
  2. Art and Creative Materials Institute. 2010. Safety - what you need to know. http://www.acminet.org/Safety.htm.
  3. AAP Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement - Prevention of choking among children. http://pediatrics.aappublications.org/content/early/2010/02/22/peds.2009-2862
  4. U.S. Department of Agriculture (USDA). 2002. Making nutrition count for children - Nutrition guidance for child care homes. Washington, DC: USDA. http://www.gpo.gov/fdsys/pkg/ERIC-ED482991/pdf/ERIC-ED482991.pdf.
  5. Lally, J. R., A. Griffin, E. Fenichel, M. Segal, E. Szanton, B. Weissbourd. 2003. Caring for infants and toddlers in groups: Developmentally appropriate practice. Arlington, VA: Zero to Three.
  6. Benjamin, S. E., ed. 2007. Making food healthy and safe for children: How to meet the national health and safety performance standards – Guidelines for out of home child care programs. 2nd ed. Chapel Hill, NC: National Training Institute for Child Care Health Consultants.  http://nti.unc.edu/course_files/curriculum/nutrition/making_food_healthy_and_safe.pdf.
  7. Endres, J. B., R. E. Rockwell. 2003. Food, nutrition, and the young child. 4th ed. New York: Macmillan.
  8. Mendoza, J. A., F. J. Zimmerman, D. A. Christakis. 2007. Television viewing, computer use, obesity, and adiposity in US preschool children. Int J Behav Nutr Physical Activity 4, no. 44 (September 25).http://ijbnpa.org/content/4/1/44/.
  9. Dennison, B. A., T. A. Erb, P. L. Jenkins. 2002. Television viewing and television in bedroom associated with overweight risk among low-income preschool children. Pediatrics 109:1028-35.
  10. Briley, M., C. Roberts-Gray. 2005. Position of the American Dietetic Association: Benchmarks for nutrition programs in child care settings. J Am Dietetic Association 105:979–86.
NOTES

Content in the STANDARD was modified on 8/25/2016.

 

Standard 4.5.0.11: Prohibited Uses of Food

Caregivers/teachers should not force or bribe children to eat nor use food as a reward or punishment.

RATIONALE
Children who are forced to eat or, for whom adults use food to modify behavior, come to view eating as a tug-of-war and are more likely to develop lasting food dislikes and unhealthy eating behaviors. Offering food as a reward or punishment places undue importance on food and may have negative effects on the child by promoting “clean the plate” responses that may lead to obesity or poor eating behavior (1-5).
COMMENTS
All components of the meal should be offered at the same time, allowing children to select and enjoy all of the foods on the menu.
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Birch, L. L., J. O. Fisher, K. K. Davison. 2003. Learning to overeat: Maternal use of restrictive feeding practices promotes girls’ eating in the absence of hunger. Am J Clin Nutr 78:215-20.
  2. Murph, J. R., S. D. Palmer, D. Glassy, eds. 2005. Health in child care: A manual for health professionals. Elk Grove Village, IL: American Academy of Pediatrics.
  3. U.S. Department of Health and Human Services, Administration for Children and Families, Office of Head Start. 2009. Head Start program performance standards. Rev. ed. Washington, DC: U.S. Government Printing Office. http://eclkc.ohs.acf.hhs.gov/hslc/Head Start Program/Program Design and Management/Head Start Requirements/Head Start Requirements/45 CFR Chapter XIII/45 CFR Chap XIII_ENG.pdf.
  4. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.
  5. Benjamin, S. E., ed. 2007. Making food healthy and safe for children: How to meet the national health and safety performance standards – Guidelines for out of home child care programs. 2nd ed. Chapel Hill, NC: National Training Institute for Child Care Health Consultants. http://nti.unc.edu/course_files/curriculum/nutrition/making_food_healthy_and_safe.pdf.

Standard 4.4.0.2: Use of Nutritionist/Registered Dietitian

A local nutritionist/registered dietitian, knowledgeable of the specific needs of infants and children, should work with the on-site food service expert and the architect or engineer on the design of the parts of the facility involved in food service. Additionally the nutritionist/registered dietitian should work with the food service expert and the early care and education staff to develop and to implement the facility’s nutrition plan and to prepare the initial food service budget. The nutrition plan encompasses:

  1. Kitchen layout;
  2. Food budget and service;
  3. Food procurement and food storage;
  4. Menu and meal planning (including periodic review of menus);
  5. Food preparation and service;
  6. Child feeding practices and policies;
  7. Kitchen and mealtime staffing;
  8. Nutrition education for children, staff and parents/guardians (including the prevention of childhood obesity and other chronic diseases, food learning experiences, and knowledge of choking hazards);
  9. Dietary modification plans.

RATIONALE
Efficient and cost-effective food service in a facility begins with a plan and evaluation of the physical components of the facility. Planning for the food service unit includes consideration of location and adequacy of space for receiving, storing, preparing, and serving areas; cleaning up; dish washing; dining areas, plus space for desk, telephone, records, and employee facilities (such as handwashing sinks, toilets, and lockers). All facets must be considered for new or existing sites, including remodeling or renovation of the unit (1-5).
COMMENTS
Nutritionists/registered dietitians assist food service staff/caregivers/teachers in planning menus for meals/snacks consisting of healthy foods which meet CACFP guidelines; ensuring use of age-appropriate eating utensils and suitable furniture (tables, chairs) for children to sit comfortably while eating; addressing any dietary modification needed; providing training for staff and nutrition education for children and their parents/guardians; consulting on meeting local health department regulations and meeting local regulations when using an off-site food vendor. This standard is primarily for Centers.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.2.0.1 Written Nutrition Plan
3.1.2.1 Routine Health Supervision and Growth Monitoring
4.2.0.2 Assessment and Planning of Nutrition for Individual Children
4.2.0.8 Feeding Plans and Dietary Modifications
9.2.3.11 Food and Nutrition Service Policies and Plans
Appendix C: Nutrition Specialist, Registered Dietitian, Licensed Nutritionist, Consultant, and Food Service Staff Qualifications
REFERENCES
  1. Kaphingst, K. M., M. Story. 2009. Child care as an untapped setting for obesity prevention: State child care licensing regulations related to nutrition, physical activity, and media use for preschool-aged children in the United States. Prev Chronic Dis 6(1).
  2. Benjamin, S. E., K. A. Copeland, A. Cradock, E. Walker, M. M. Slining, B. Neelon, M. W. Gillman. 2009. Menus in child care: A comparison of state regulations to national standards. J Am Diet Assoc 109:109-15.
  3. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.
  4. U.S. Department of Agriculture (USDA). 2002. Making nutrition count for children - Nutrition guidance for child care homes. Washington, DC: USDA. http://www.gpo.gov/fdsys/pkg/ERIC-ED482991/pdf/ERIC-ED482991.pdf
  5. Endres, J. B., R. E. Rockwell. 2003. Food, nutrition, and the young child. 4th ed. New York: Macmillan.

F. Food Brought From Home

Standard 4.6.0.2: Nutritional Quality of Food Brought From Home

The facility should provide parents/guardians with written guidelines that the facility has established a comprehensive plan to meet the nutritional requirements of the children in the facility’s care and suggested ways parents/guardians can assist the facility in meeting these guidelines. The facility should develop policies for foods brought from home, with parent/guardian consultation, so that expectations are the same for all families (1,2). The facility should have food available to supplement a child’s food brought from home if the food brought from home is deficient in meeting the child’s nutrient requirements. If the food the parent/guardian provides consistently does not meet the nutritional or food safety requirements, the facility should provide the food and refer the parent/guardian for consultation to a nutritionist/registered dietitian, to the child’s primary care provider, or to community resources with trained nutritionists/registered dietitians (such as The Women, Infants and Children [WIC] Supplemental Food Program, extension services, and health departments).

RATIONALE
The caregiver/teacher/facility has a responsibility to follow feeding practices that promote optimum nutrition supporting growth and development in infants, toddlers, and children. Caregivers/teachers who fail to follow best feeding practices, even when parents/guardians wish such counter practices to be followed, negate their basic responsibility of protecting a child’s health, social, and emotional well-being.
COMMENTS
Some local health and/or licensing jurisdictions prohibit any foods being brought from home.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.2.0.1 Written Nutrition Plan
4.6.0.1 Selection and Preparation of Food Brought From Home
9.2.3.11 Food and Nutrition Service Policies and Plans
REFERENCES
  1. Contra Costa Child Care Council, Child Health and Nutrition Program. 2006. CHOICE: Creating healthy opportunities in child care environments. Concord, CA: Contra Costa Child Care Council, Child Health and Nutrition Program. http://w2.cocokids.org/_cs/downloadables/cc-healthnutrition-choicetoolkit.pdf.
  2. Sweitzer, S., M. E. Briley, C. Robert-Gray. 2009. Do sack lunches provided by parents meet the nutritional needs of young children who attend child care? J Am Diet Assn 109:141-44.

Standard 4.6.0.1: Selection and Preparation of Food Brought From Home

The parent/guardian may provide meals for the child upon written agreement between the parent/guardian and the staff. Food brought into the facility should have a clear label showing the child’s full name, the date, and the type of food. Lunches and snacks the parent/guardian provides for one individual child’s meals should not be shared with other children. When foods are brought to the facility from home or elsewhere, these foods should be limited to those listed in the facility’s written policy on nutritional quality of food brought from home. Potentially hazardous and perishable foods should be refrigerated and all foods should be protected against contamination.

RATIONALE
Food borne illness and poisoning from food is a common occurrence when food has not been properly refrigerated and covered. Although many such illnesses are limited to vomiting and diarrhea, sometimes they are life-threatening. Restricting food sent to the facility to be consumed by the individual child reduces the risk of food poisoning from unknown procedures used in home preparation, storage, and transport. Food brought from home should be nourishing, clean, and safe for an individual child. In this way, other children should not be exposed to unknown risk. Inadvertent sharing of food is a common occurrence in early care and education. The facility has an obligation to ensure that any food offered to children at the facility or shared with other children is wholesome and safe as well as complying with the food and nutrition guidelines for meals and snacks that the early care and education program should observe.
COMMENTS
The facility, in collaboration with parents/guardians and the food service staff/nutritionist/registered dietitian, should establish a policy on foods brought from home for celebrating a child’s birthday or any similar festive occasion. Programs should inform parents/guardians about healthy food alternatives like fresh fruit cups or fruit salad for such celebrations. Sweetened treats are highly discouraged, but if provided by the parent/guardian, then the portion size of the treat served should be small.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.6.0.2 Nutritional Quality of Food Brought From Home
9.2.3.11 Food and Nutrition Service Policies and Plans

G. Nutrition Education

Standard 4.7.0.1: Nutrition Learning Experiences for Children

The facility should have a nutrition plan that integrates the introduction of food and feeding experiences with facility activities and home feeding. The plan should include opportunities for children to develop the knowledge and skills necessary to make appropriate food choices.

For centers, this plan should be a written plan and should be the shared responsibility of the entire staff, including directors and food service personnel, together with parents/guardians. The nutrition plan should be developed with guidance from, and should be approved by, the nutritionist/registered dietitian or child care health consultant.

Caregivers/teachers should teach children about the taste, smell, texture of foods, and vocabulary and language skills related to food and eating. The children should have the opportunity to feel the textures and learn the different colors, sizes, and shapes of foods and the nutritional benefits of eating healthy foods. Children should also be taught about appropriate portion sizes. The teaching should be evident at mealtimes and during curricular activities, and emphasize the pleasure of eating. Caregivers/teachers need to be aware that children between the ages of two- and five-years-old are often resistant to trying new foods and that food acceptance may take eight to fifteen times of offering a food before it is eaten (14).

RATIONALE
Nourishing and attractive food is a foundation for developmentally appropriate learning experiences and contributes to health and well-being (1-13,15). Coordinating the learning experiences with the food service staff maximizes effectiveness of the education. In addition to the nutritive value of food, infants and young children are helped, through the act of feeding, to establish warm human relationships. Eating should be an enjoyable experience for children and staff in the facility and for children and parents/guardians at home. Enjoying and learning about food in childhood promotes good nutrition habits for a lifetime (17,18).
COMMENTS
Parents/guardians and caregivers/teachers should always be encouraged to sit at the table and eat the same food offered to young children as a way to strengthen family style eating which supports child’s serving and feeding him or herself (19). Family style eating requires special training for the food service and early care and education staff since they need to monitor food served in a group setting. Portions should be age-appropriate as specified in Child and Adult Care Food Program (CACFP) guidelines. The use of serving utensils should be encouraged to minimize food handling by children. Children should not eat directly out of serving dishes or storage containers. The presence of an adult at the table with children while they are eating is a way to encourage social interaction and conversation about the food such as its name, color, texture, taste, and concepts such as number, size, and shape; as well as sharing events of the day. These are some practical examples of age-appropriate information for young children to learn about the food they eat. The parent/guardian or adult can help the slow eater, prevent behaviors that might increase risk of fighting, of eating each others’ food, and of stuffing food in the mouth in such a way that it might cause choking.

Several community-based nutrition resources can help caregivers/teachers with the nutrition and food service component of their programs (16-18). The key to identifying a qualified nutrition professional is seeking a record of training in pediatric nutrition (normal nutrition, nutrition for children with special health care needs, dietary modifications) and experience and competency in basic food service systems.

Local resources for nutrition education include:

  1. Local and state nutritionists/RDs in health departments, in maternal and child health programs, and divisions of children with special health care needs;
  2. Nutritionists/RDs at hospitals;
  3. The Women, Infants, and Children (WIC) Supplemental Food Program and cooperative extension nutritionists/RDs;
  4. School food service personnel;
  5. State administrators of the Child and Adult Care Food Program;
  6. National School Food Service Management Institute;
  7. Healthy Meals Resource System of the Food and Nutrition Information System (National Agricultural Library, U.S. Department of Agriculture);
  8. Nutrition consultants with local affiliates of the following organizations:
    1. American Dietetic Association;
    2. American Public Health Association;
    3. Society for Nutrition Education;
    4. American Association of Family and Consumer Sciences;
    5. Dairy Council;
    6. American Heart Association;
    7. American Cancer Society;
    8. American Diabetes Association;
    9. Professional home economists like teachers and those with consumer organizations;
    10. Nutrition departments of local colleges and universities.

Compliance is measured by structured observation.

Following are select resources for caregivers/teachers in providing ongoing opportunities for children and their families to learn about food and healthy eating:

  1. Brieger, K. M. 1993. Cooking up the Pyramid: An early childhood nutrition curriculum. Pine Island, NY: Clinical Nutrition Services.
  2. Cunningham, M. 1995. Cooking with children: 15 lessons for children, age 7 and up, who really want to learn to cook. New York: Alfred A. Knopf.
  3. Goodwin, M. T., G. Pollen. 1980. Creative food experiences for children. Rev. ed. Washington, DC: Center for Science in the Public Interest.
  4. King, M. 1993. Healthy choices for kids: Nutrition and activity education program based on the US Dietary Guidelines. Levels 1-3 and 4-5. Wenatchee, WA: The Growers of Washington State Apples.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.2.0.1 Written Nutrition Plan
4.5.0.4 Socialization During Meals
4.5.0.7 Participation of Older Children and Staff in Mealtime Activities
4.5.0.8 Experience with Familiar and New Foods
4.7.0.2 Nutrition Education for Parents/Guardians
9.2.3.11 Food and Nutrition Service Policies and Plans
2.1.1.2 Health, Nutrition, Physical Activity, and Safety Awareness
Appendix C: Nutrition Specialist, Registered Dietitian, Licensed Nutritionist, Consultant, and Food Service Staff Qualifications
REFERENCES
  1. Hagan, Jr., J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Bright futures: Guidelines for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics.
  2. Tamborlane, W. V., J. Warshaw, eds. 1997. The Yale guide to children’s nutrition. New Haven, CT: Yale University Press.
  3. Benjamin, S. E., D. F. Tate, S. I. Bangdiwala, B. H. Neelon, A. S. Ammerman, J. M. Dodds, D. S. Ward. 2008. Preparing child care health consultants to address childhood overweight: A randomized controlled trial comparing web to in-person training. Maternal Child Health J 12:662-69.
  4. Ammerman, A. S., D. S. Ward, S. E. Benjamin, et al. 2007. An intervention to promote healthy weight: Nutrition and physical activity self-assessment for child care theory and design. Public Health Research, Practice, Policy 4:1-12.
  5. Story, M., K. M. Kaphingst, S. French. 2006. The role of child care settings in the prevention of obesity. The Future of Children 16:143-68
  6. Dietz, W., L. Birch. 2008. Eating behaviors of young child: Prenatal and postnatal influences on healthy eating. Elk Grove Village, IL: American Academy of Pediatrics.
  7. Murph, J. R., S. D. Palmer, D. Glassy, eds. 2005. Health in child care: A manual for health professionals. Elk Grove Village, IL: American Academy of Pediatrics.
  8. U.S. Department of Health and Human Services, Administration for Children and Families, Office of Head Start. 2009. Head Start program performance standards. Rev. ed. Washington, DC: U.S. Government Printing Office. http://eclkc.ohs.acf.hhs.gov/hslc/Head Start Program/Program Design and Management/Head Start Requirements/Head Start Requirements/45 CFR Chapter XIII/45 CFR Chap XIII_ENG.pdf.
  9. William, C. O., ed. 1998. Pediatric manual of clinical dietetics. Chicago: American Dietetic Association.
  10. Lally, J. R., A. Griffin, E. Fenichel, M. Segal, E. Szanton, B. Weissbourd. 2003. Caring for infants and toddlers in groups: Developmentally appropriate practice. Arlington, VA: Zero to Three.
  11. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.
  12. Sullivan, S. A., L. L. Birch. 1990. Pass the sugar, pass the salt: Experience dictates preference. Devel Psych 26:546-51.
  13. Endres, J. B., R. E. Rockwell. 2003. Food, nutrition, and the young child. 4th ed. New York: Macmillan.
  14. Wardle, F., N. Winegarner. 1992. Nutrition and Head Start. Child Today 21:57.
  15. Benjamin, S. E., ed. 2007. Making food healthy and safe for children: How to meet the national health and safety performance standards – Guidelines for out of home child care programs. 2nd ed. Chapel Hill, NC: National Training Institute for Child Care Health Consultants. http://nti.unc.edu/course_files/curriculum/nutrition/making_food_healthy_and_safe.pdf.
  16. Dietz, W. H., L. Stern, eds. 1998. American Academy of Pediatrics guide to your child’s nutrition. New York: Villard.
  17. Story, M., K. Holt, D. Sofka, eds. 2002. Bright futures in practice: Nutrition. 2nd ed. Arlington, VA: National Center for Education in Maternal and Child Health. http://www.brightfutures.org/nutrition/pdf/frnt_mttr.pdf.
  18. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.
  19. Stang, J., C. T. Bayerl, M. M. Flatt. 2006. Position of the American Dietetic Association: Child and adolescent food and nutrition programs. J American Dietetic Assoc 106:1467-75.

Standard 2.1.1.2: Health, Nutrition, Physical Activity, and Safety Awareness

Early care and education programs should have and implement written program plans addressing the health, nutrition, physical activity, and safety aspects of each formally structured activity documented in the written curriculum. These plans should include daily opportunities to learn health habits that prevent infection and significant injuries, and health habits that support healthful eating, nutrition education, and physical motor activity. Awareness of healthy and safe behaviors, including good nutrition and physical activity, should be an integral part of the overall program.

RATIONALE
Young children learn better through experiencing an activity and observing behavior than through didactic methods (1). There may be a reciprocal relationship between learning and play so that play experiences are closely related to learning (2,3). Children can live by rules about health and safety when their personal experience helps them to understand why these rules were created. National guidelines for children birth to age five encourage their engagement in daily physical activity that promotes movement, motor skills and the foundations of health-related fitness (4). Physical activity is important to overall health and to overweight and obesity prevention (5).
COMMENTS
Resources for activities can be found at:
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.5.0.4 Socialization During Meals
4.7.0.1 Nutrition Learning Experiences for Children
3.1.3.1 Active Opportunities for Physical Activity
4.9.0.8 Supply of Food and Water for Disasters
2.1.1.3 Coordinated Child Care Health Program Model
Appendix S: Physical Activity: How Much Is Needed?
REFERENCES
  1. Evaldsson, A., W. A. Corsaro. 1998. Play and games in the peer cultures of preschool and preadolescent children: An interpretative approach. Childhood 5:377-402.
  2. Fleer, M., ed. 1996. Play through profiles: Profiles through play. Watson, Australia: Australian Early Childhood Association.
  3. U.S. Department of Health and Human Services, U.S. Department of Agriculture. 2010. Dietary guidelines for Americans. 7th ed. Washington, DC: Government Printing Office. http://www
    .cnpp.usda.gov/Publications/DietaryGuidelines/2010/PolicyDoc/PolicyDoc.pdf.
  4. National Association for Sport and Physical Education (NASPE). 2009. Active start: A statement of physical activity guidelines for children birth to five years. 2nd ed. Reston, VA: NASPE.
  5. Petersen, E. A. 1998. The amazing benefits of play. Children and Families 17:7-8, 10.

Standard 4.7.0.2: Nutrition Education for Parents/Guardians

Parents/guardians should be informed of the range of nutrition learning activities provided in the facility. Formal nutrition information and education programs should be conducted at least twice a year under the guidance of the nutritionist/registered dietitian based on a needs assessment for nutrition information and education as perceived by families and staff. Informal programs should be implemented during the “teachable moments” throughout the year.

RATIONALE
One goal of a facility is to provide a positive environment for the entire family. Informing parents/guardians about nutrition, food, food preparation, and mealtime enhances nutrition and mealtime interactions in the home, which helps to mold a child’s food habits and eating behavior (1-9). Because of the current epidemic of childhood obesity, prevention of childhood obesity through nutrition and physical activity is an appropriate topic for parents/guardians. Periodically providing families records of the food eaten and progress in physical activities by their children will help families coordinate home food preparation, nutrition, and physical activity with what is provided at the early care and education facility. Nutrition education directed at parents/guardians complements and enhances the nutrition learning experiences provided to their children.
COMMENTS
One method of nutrition education for parents/guardians is providing healthy recipes that are quick and inexpensive to prepare and sharing information regarding access to local sources of healthy foods (farmers’ markets, grocery stores, healthier prepared foods and restaurant options). Also caregivers/teachers can provide parents/guardians ideas for healthy and inexpensive snacks including foods available and served at parents’/guardians’ meetings. Education should be helpful, culturally relevant and incorporate the use of locally produced food. The educational programs may be supplemented by periodic distribution of newsletters and/or literature.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.7.0.1 Nutrition Learning Experiences for Children
REFERENCES
  1. Tamborlane, W. V., ed. 1997. The Yale guide to children’s nutrition. New Haven, CT: Yale University Press.
  2. U.S. Department of Agriculture. 2002. Making nutrition count for children - Nutrition guidance for child care homes. Washington, DC: USDA. http://www/gpo.gov/fdsys/pkg/ERIC-ED482991/pdf/ERIC-ED482991.pdf.
  3. U.S. Department of Health and Human Services, Administration for Children and Families, Office of Head Start. 2009. Head Start program performance standards. Rev. ed. Washington, DC: U.S. Government Printing Office. http://eclkc.ohs.acf.hhs.gov/hslc/Head Start Program/Program Design and Management/Head Start Requirements/Head Start Requirements/45 CFR Chapter XIII/45 CFR Chap XIII_ENG.pdf.
  4. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.
  5. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.
  6. Endres, J. B., R. E. Rockwell. 2003. Food, nutrition, and the young child. 4th ed. New York: Macmillan.
  7. Benjamin, S. E., ed. 2007. Making food healthy and safe for children: How to meet the national health and safety performance standards – Guidelines for out of home child care programs. 2nd ed. Chapel Hill, NC: National Training Institute for Child Care Health Consultants. http://nti.unc.edu/course_files/curriculum/nutrition/making_food_healthy_and_safe.pdf.
  8. Dietz, W. H., L. Stern, eds. 1998. American Academy of Pediatrics guide to your child’s nutrition. New York: Villard.
  9. Hagan, Jr., J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Bright futures: Guidelines for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics.

H. Policies

Standard 9.2.3.11: Food and Nutrition Service Policies and Plans

The facility should have food handling, feeding, and nutrition policies and plans under the direction of the administration that address the following items and assigns responsibility for each:

  1. Kitchen layout;
  2. Food budget;
  3. Food procurement and storage;
  4. Menu and meal planning;
  5. Food preparation and service;
  6. Kitchen and meal service staffing;
  7. Nutrition education for children, staff, and parents/guardians;
  8. Emergency preparedness for nutrition services;
  9. Food brought from home including food brought for celebrations;
  10. Age-appropriate portion sizes of food to meet nutritional needs;
  11. Age-appropriate eating utensils and tableware;
  12. Promotion of breastfeeding and provision of community resources to support mothers.

A nutritionist/registered dietitian and a food service expert should provide input for and facilitate the development and implementation of a written nutrition plan for the early care and education facility.

RATIONALE
Having a plan that clearly assigns responsibility and that encompasses the pertinent nutrition elements will promote the optimal health of children and staff in early care and education settings.

For sample policies see the Nemours Health and Prevention Services guide on best practices for healthy eating at http://www.nemours.org/content/dam/nemours/www/filebox/service/preventive/nhps/heguide.pdf.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.2.0.1 Written Nutrition Plan
4.2.0.9 Written Menus and Introduction of New Foods
4.3.1.1 General Plan for Feeding Infants
4.3.1.2 Feeding Infants on Cue by a Consistent Caregiver/Teacher
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.2.2 Serving Size for Toddlers and Preschoolers
4.4.0.2 Use of Nutritionist/Registered Dietitian
4.6.0.2 Nutritional Quality of Food Brought From Home
4.6.0.1 Selection and Preparation of Food Brought From Home
4.7.0.1 Nutrition Learning Experiences for Children
4.7.0.2 Nutrition Education for Parents/Guardians
Appendix C: Nutrition Specialist, Registered Dietitian, Licensed Nutritionist, Consultant, and Food Service Staff Qualifications
Appendix JJ: Our Child Care Center Supports Breastfeeding

Standard 9.2.3.12: Infant Feeding Policy

A policy about infant feeding should be developed with the input and approval from the nutritionist/registered dietitian and should include the following:

  1. Storage and handling of expressed human milk;
  2. Determination of the kind and amount of commercially prepared formula to be prepared for infants as appropriate;
  3. Preparation, storage, and handling of infant formula;
  4. Proper handwashing of the caregiver/teacher and the children;
  5. Use and proper sanitizing of feeding chairs and of mechanical food preparation and feeding devices, including blenders, feeding bottles, and food warmers;
  6. Whether expressed human milk, formula, or infant food should be provided from home, and if so, how much food preparation and use of feeding devices, including blenders, feeding bottles, and food warmers, should be the responsibility of the caregiver/teacher;
  7. Holding infants during bottle-feeding or feeding them sitting up;
  8. Prohibiting bottle propping during feeding or prolonging feeding;
  9. Responding to infants’ need for food in a flexible fashion to allow cue feedings in a manner that is consistent with the developmental abilities of the child (policy acknowledges that feeding infants on cue rather than on a schedule may help prevent obesity) (1,2);
  10. Introduction and feeding of age-appropriate solid foods (complementary foods);
  11. Specification of the number of children who can be fed by one adult at one time;
  12. Handling of food intolerance or allergies (e.g., cow’s milk, peanuts, orange juice, eggs, wheat).

Individual written infant feeding plans regarding feeding needs and feeding schedule should be developed for each infant in consultation with the infant’s primary care provider and parents/guardians.

RATIONALE
Growth and development during infancy require that nourishing, wholesome, and developmentally appropriate food be provided, using safe approaches to feeding. Because individual needs must be accommodated and improper practices can have dire consequences for the child’s health and safety, the policy for infant feeding should be developed with professional nutritionists/registered dietitians. The infant feeding plans should be developed with each infant’s parents/guardians and, when appropriate, in collaboration with the child’s primary care provider.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.3.1.1 General Plan for Feeding Infants
4.3.1.2 Feeding Infants on Cue by a Consistent Caregiver/Teacher
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.1.4 Feeding Human Milk to Another Mother’s Child
4.3.1.5 Preparing, Feeding, and Storing Infant Formula
4.3.1.8 Techniques for Bottle Feeding
4.3.1.9 Warming Bottles and Infant Foods
4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants
4.3.1.12 Feeding Age-Appropriate Solid Foods to Infants
4.8.0.8 Microwave Ovens
Appendix JJ: Our Child Care Center Supports Breastfeeding
REFERENCES
  1. Taveras, E. M., S. L. Rifas-Shiman, K. S. Scanlon, L. M. Grummer-Strawn, B. Sherry, M. W. Gillman. 2006. To what extent is the protective effect of breastfeeding on future overweight explained by decreased maternal feeding restriction? Pediatrics 118:2341-48.
  2. Birch, L., W. Dietz. 2008. Eating behaviors of young child: Prenatal and postnatal influences on healthy eating, 59-93. Elk Grove Village, IL: American Academy of Pediatrics.

II. Physical Activity Standards

Standard 3.1.3.1: Active Opportunities for Physical Activity

The facility should promote children’s active play every day. Children should have ample opportunity to do moderate to vigorous activities such as running, climbing, dancing, skipping, and jumping. All children, birth to six years, should participate daily in:

  1. Two to three occasions of active play outdoors, weather permitting (see Standard 3.1.3.2: Playing Outdoors for appropriate weather conditions);
  2. Two or more structured or caregiver/teacher/adult-led activities or games that promote movement over the course of the day—indoor or outdoor;
  3. Continuous opportunities to develop and practice age-appropriate gross motor and movement skills.

The total time allotted for outdoor play and moderate to vigorous indoor or outdoor physical activity can be adjusted for the age group and weather conditions.

  1. Outdoor play:
    1. Infants (birth to twelve months of age) should be taken outside two to three times per day, as tolerated. There is no recommended duration of infants’ outdoor play;
    2. Toddlers (twelve months to three years) and preschoolers (three to six years) should be allowed sixty to ninety total minutes of outdoor play. These outdoor times can be curtailed somewhat during adverse weather conditions in which children may still play safely outdoors for shorter periods, but should increase the time of indoor activity, so the total amount of exercise should remain the same;
  2. Total time allotted for moderate to vigorous activities:
    1. Toddlers should be allowed sixty to ninety minutes per eight-hour day for moderate to vigorous physical activity, including running;
    2. Preschoolers should be allowed ninety to one hundred and twenty minutes per eight-hour day (4).

Infants should have supervised tummy time every day when they are awake. Beginning on the first day at the early care and education program, caregivers/teachers should interact with an awake infant on their tummy for short periods of time (three to five minutes), increasing the amount of time as the infant shows s/he enjoys the activity (27).

Time spent outdoors has been found to be a strong, consistent predictor of children’s physical activity (1-3). Children can accumulate opportunities for activity over the course of several shorter segments of at least ten minutes each. Because structured activities have been shown to produce higher levels of physical activity in young children, it is recommended that caregivers/teachers incorporate two or more short structured activities (five to ten minutes) or games daily that promote physical activity.

Opportunities to be actively enjoying physical activity should be incorporated into part-time programs by prorating these recommendations accordingly, i.e., twenty minutes of outdoor play for every three hours in the facility.

Active play should never be withheld from children who misbehave (e.g., child is kept indoors to help another caregiver/teacher while the rest of the children go outside) (5). However, children with out-of-control behavior may need five minutes or less to calm themselves or settle down before resuming cooperative play or activities.

Infants should not be seated for more than fifteen minutes at a time, except during meals or naps. Infant equipment such as swings, stationary activity centers (ex. exersaucers), infant seats (ex. bouncers), molded seats, etc. if used should only be used for short periods of time. A least restrictive environment should be encouraged at all times (5,6,26).

Children should have adequate space for both inside and outside play.

RATIONALE
Free play, active play and outdoor play are essential components of young children’s development (2). Children learn through play, developing gross motor, socio-emotional, and cognitive skills. In outdoor play, children learn about their environment, science, and nature.

Infants’ and young children’s participation in physical activity is critical to their overall health, development of motor skills, social skills, and maintenance of healthy weight (7). Daily physical activity promotes young children’s gross motor development and provides numerous health benefits including improved fitness and cardiovascular health, healthy bone development, improved sleep, and improved mood and sense of well-being. Tummy time prepares infants for the time when they will be able to slide on their bellies and crawl. As infants grow older and stronger they will need more time on their tummies to build their own strength (27).

Daily physical activity is an important part of preventing excessive weight gain and childhood obesity. Some evidence also suggests that children may be able to learn better during or immediately after bursts of physical activity, due to improved attention and focus (8,9).

Numerous reports suggest that children are not meeting daily recommendations for physical activity, and that children spend 70% (10) to 87% (11) of their time in early care and education being sedentary, (i.e., sitting or lying down). Excluding nap time, children are sedentary 83% of the time (11). Children may only spend about 2% to 3% of time being moderately or vigorously active (11).

Very young children are entirely dependent on their caregivers/teachers for opportunities to be active (12-15). Especially for children in full-time care and for children who live in unsafe neighborhoods, the early care and education facility may provide the child’s only daily opportunity for active play. Evidence suggests that physical activity habits learned early in life may track into adolescence and adulthood supporting the importance for children to learn lifelong healthy physical activity habits while in the early care and education program (13,16-25).

COMMENTS
There are many ways to promote tummy time with infants:
  1. Place yourself or a toy just out of the infant’s reach during playtime to get him to reach for you or the toy;
  2. Place toys in a circle around the infant. Reaching to different points in the circle will allow him/her to develop the appropriate muscles to roll over, scoot on his/her belly, and crawl;
  3. Lie on your back and place the infant on your chest. The infant will lift his/her head and use his/her arms to try to see your face (27).

There are a multitude of short, structured activities that are appropriate for toddlers and preschoolers. Structured activities could include popular children’s games such as Simon Says, Mother May I, Red Rover, Get the Wiggles Out, Musical Chairs, or a simple walk through the neighborhood. For training materials and more ideas of effective and age-appropriate games for young children, consider the following resources:

  1. “Nutrition and Physical Activity Self Assessment for Child Care - NAP SACC Program” – http://www
    .napsacc.org;
  2. “Color Me Healthy Preschoolers Moving and Eating” – http://www.colormehealthy.com;
  3. “Let’s Move, Learn, and Have Fun” physical activity curriculum from Kansas State University;
  4. “I am Moving I am Learning: Intervention in Head Start” – http://eclkc.ohs.acf.hhs.gov/hslc/tta-system/health/Health/Nutrition/Nutrition Program Staff/
    IamMovingIam.htm;
  5. “Moving and Learning: The Physical Activity Specialists for Birth through Age 8” – http://www
    .movingandlearning.com;
  6. “How to Lower Your Risk for Type 2 Diabetes: National Diabetes Education Program” – http://ndep.nih
    .gov/media/kids-tips-lower-risk.pdf;
  7. “Motion Moments” – http://nrckids.org/Motion
    _Moments/.

Experts disagree about the appropriate amount of physical activity for toddlers and preschoolers, what proportion of children’s physical activity should be structured, and to what extent structured activities are effective in producing children’s physical activity. Researchers do agree that toddlers and preschoolers generally accumulate moderate to vigorous physical activity over the course of the day in very short bursts (fifteen to thirty seconds) (23). For additional recommendations by other national groups and experts, see:

  1. The National Association for Sport and Physical Education’s Active Start: A Statement of Physical Activity Guidelines for Children From Birth to Age 5, 2nd Edition at http://www.aahperd.org/naspe/standards/
    nationalGuidelines/ActiveStart.cfm and Physical Activity for Children: A Statement of Guidelines for Children 5 - 12, 2nd Edition at http://www.aahperd
    .org/naspe/standards/nationalGuidelines/PA
    -Children-5-12.cfm;
  2. U.S. Department of Health and Human Services’ 2008 Physical Activity Guidelines for Americans at http://www.health.gov/PAGuidelines/Report/pdf/CommitteeReport.pdf;
  3. U.S. Department of Health and Human Services and the U.S. Department of Agriculture’s Dietary Guidelines for Americans, 2010 at http://www.cnpp.usda
    .gov/DGAs2010-DGACReport.htm.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
2.1.1.2 Health, Nutrition, Physical Activity, and Safety Awareness
3.1.3.2 Playing Outdoors
3.1.3.4 Caregivers’/Teachers’ Encouragement of Physical Activity
5.3.1.10 Restrictive Infant Equipment Requirements
9.2.3.1 Policies and Practices that Promote Physical Activity
Appendix S: Physical Activity: How Much Is Needed?
REFERENCES
  1. American Academy of Pediatrics (AAP). 2008. Back to sleep, tummy to play. Elk Grove Village, IL: AAP. http://www.healthychildcare.org/pdf/SIDStummytime.pdf.
  2. Burdette, H. L., R. C. Whitaker, S. R. Daniels. 2004. Parental report of outdoor playtime as a measure of physical activity in preschool-aged children. Arch Pediatr Adolesc Med 158:353-57.
  3. Bower, J. K., D. P. Hales, D. F. Tate, D. A. Rubin, S. E. Benjamin, D. S. Ward. 2008. The childcare environment and children’s physical activity. Am J Prev Med 34:23-29.
  4. Benjamin, S. E., A. Ammerman, J. Sommers, J. Dodds, B. Neelon, D. S. Ward. 2007. The nutrition and physical activity self-assessment for child care (NAP SACC). Rev ed. Raleigh and Chapel Hill, NC: UNC Center for Health Promotion and Disease Prevention, Center of Excellence for Training and Research Translation. http://www.center-trt.org/downloads/obesity_prevention/interventions/napsacc/NAPSACC_Template.pdf.
  5. National Association for Sport and Physical Education (NASPE). 2002. Active start: A statement of physical activity guidelines for children birth to five years. Washington, DC: NASPE.
  6. Patrick, K., B. Spear, K. Holt, D. Sofka, eds. 2001. Bright futures in practice: Physical activity. Arlington, VA: National Center for Education in Maternal and Child Health. http://www.brightfutures
    .org/physicalactivity/pdf/index.html.
  7. Pellegrini, A., C. Bohn. 2005. The role of recess in children’s cognitive performance and school adjustment. Educ Res 34:13-19.
  8. Mahar, M. T., S. K. Murphy, D. A. Rowe, J. Golden, A. T. Shields, T. D. Raedeke. 2006. Effects of a classroom-based program on physical activity and on-task behavior. Med Sci Sports Exerc 38:2086-94.
  9. Pate, R. R., K. A. Pfeiffer, S. G. Trost, P. Ziegler, M. Dowda. 2004. Physical activity among children attending preschools. Pediatrics 114:1258-63.
  10.  Pate, R. R., K. McIver, M. Dowda, W. H. Brown, A. Cheryl. 2008. Directly observed physical activity levels in preschool children. J Sch Health 78:438-44.
  11. McKenzie, T. L., J. F. Sallis, J. P. Elder, C. C. Berry, P. L. Hoy, P. R. Nader, M. M. Zive, S. L. Broyles. 1997. Physical activity levels and prompts in young children at recess: A two-year study of a bi-ethnic sample. Res Q Exerc Sport 68:195-202.
  12. Sallis, J. F., T. L. McKenzie, J. P. Elder, S. L. Broyles, P. R. Nader. 1997. Factors parents use in selecting play spaces for young children. Arch Pediatr Adolesc Med 151:414-17.
  13. Sallis, J. F., P. R. Nader, S. L. Broyles, J. P. Elder, T. L. McKenzie, J. A. Nelson. 1993. Correlates of physical activity at home in Mexican-American and Anglo-American preschool children. Health Psychol 12:390-98.
  14. Davis, K., K. K. Christoffel. 1994. Obesity in preschool and school-age children: Treatment early and often may be best. Arch Pediatr Adolesc Med 148:1257-61.
  15. Sallis, J. F., C. C. Berry, S. L. Broyles, T. L. McKenzie, P. R. Nader. 1995. Variability and tracking of physical activity over 2 yr in young children. Med Sci Sports Exerc 27:1042-49.
  16. Pate, R. R., T. Baranowski, S. G. Trost. 1996. Tracking of physical activity in young children. Med Sci Sports Exerc 28:92-96.
  17. Birch, L. L., J. O. Fisher. 1998. Development of eating behaviors among children and adolescents. Pediatrics 101:539-49.
  18. Sallis, J. F., J. J. Prochaska, W. C. Taylor. 2000. A review of correlates of physical activity of children and adolescents. Med Sci Sports Exerc 32:963-75.
  19. Skinner, J. D., B. R. Carruth, W. Bounds, P. Ziegler, K. Reidy. 2002. Do food-related experiences in the first 2 years of life predict dietary variety in school-aged children? J Nutr Educ Behav 34:310-15.
  20. Skinner, J. D., B. R. Carruth, B. Wendy, P. J. Ziegler. 2002. Children’s food: A longitudinal analysis. J Am Diet Assoc 102:1638-47.
  21. Oliver, M., G. M. Schofield, G. S. Kolt. 2007. Physical activity in preschoolers: Understanding prevalence and measurement issues. Sports Med 37:1045-70.
  22. American Academy of Pediatrics, Council on Sports Medicine and Fitness, and Council on School Health. 2006. Active healthy living: Prevention of childhood obesity through increased physical activity. Pediatrics 117:1834-42.
  23. Physical Activity Guidelines Advisory Committee. 2008. Physical activity guidelines advisory committee report, 2008. Washington, DC: U.S. Department of Health and Human Services. http://www.health.gov/PAGuidelines/Report/pdf/CommitteeReport.pdf.
  24. American Physical Therapy Association. 2008. Lack of time on tummy shown to hinder achievement of developmental milestones, say physical therapists. News Release.
  25. Burdette, H. L., R. C. Whitaker. 2005. Resurrecting free play in young children: Looking beyond fitness and fatness to attention, affiliation, and affect. Arch Pediatr Adolesc Med 159:46-50.
  26. Brown, W. H., K. A. Pfeiffer, K. L. Mclver, M. Dowda, C. L. Addy, R. R. Pate. 2009. Social and environmental factors associated with preschoolers’ nonsedentary physical activity. Child Devel 80:45-58

Standard 3.1.3.2: Playing Outdoors

Content in the STANDARD was modified on 8/8/2013.

Children should play outdoors when the conditions do not pose a safety risk, individual child health risk, or significant health risk of frostbite or of heat related illness. Caregivers/teachers must protect children from harm caused by adverse weather, ensuring that children wear appropriate clothing and/or appropriate shelter is provided for the weather conditions. Outdoor play for infants may include riding in a carriage or stroller; however, infants should be offered opportunities for gross motor play outdoors, as well.

Weather that poses a significant health risk should include wind chill factor at or below minus 15°F and heat index at or above 90°F, as identified by the National Weather Service (NWS).

Sunny weather:

  1. Children should be protected from the sun by using shade, sun-protective clothing, and sunscreen with UVB-ray and UVA-ray protection of SPF 15 or higher, with permission from parents/guardians;
  2. Children should wear sun-protective clothing, such as hats, when playing outdoors between the hours of 10 AM and 4 PM.

Warm weather:

  1. Children should be well hydrated before engaging in prolonged periods of physical activity and encouraged to drink water during periods of prolonged physical activity;
  2. Caregivers/teachers should encourage parents/guardians to have children dress in clothing that is light-colored, lightweight, and limited to one layer of absorbent material that will maximize the evaporation of sweat;
  3. On hot days, infants receiving human milk in a bottle can be given additional human milk in a bottle but should not be given water, especially in the first six months of life. Infants receiving formula and water can be given additional formula in a bottle.

Cold weather:

    1. Children should wear layers of loose-fitting, lightweight clothing. Outer garments such as coats should be tightly woven, and be at least water repellent when precipitation is present, such as rain or snow;
    2. Children should wear a hat, coat, and gloves/mittens kept snug at the wrist;
    3. Caregivers/teachers should check children’s extremities for maintenance of normal color and warmth at least every fifteen minutes.

Caregivers/teachers should also be aware of environmental hazards such as contaminated water, loud noises, and lead in soil when selecting an area to play outdoors. Children should be observed closely when playing in dirt/soil, so that no soil is ingested. Play areas should be secure and away from heavy traffic areas.

RATIONALE
Outdoor play is not only an opportunity for learning in a different environment; it also provides many health benefits. Outdoor play allows for physical activity that supports maintenance of a healthy weight (2). Short exposure of the skin to sunlight promotes the production of vitamin D that growing children require.

Open spaces in outdoor areas, even those confined to screened rooftops in urban play spaces, encourage children to develop gross motor skills and fine motor play in ways that are difficult to duplicate indoors. Nevertheless, some weather conditions make outdoor play hazardous.

Children need protection from adverse weather and its effects. Wind chill conditions that pose a risk of frostbite as well as heat and humidity that pose a significant risk of heat-related illness are defined by the NWS and are announced routinely.

Heat-induced illness and cold injury are preventable. Children have greater surface area-to-body mass ratio than adults. Therefore, children do not adapt to extremes of temperature as effectively as adults when exposed to a high climatic heat stress or to cold. Children produce more metabolic heat per mass unit than adults when walking or running. They also have a lower sweating capacity and cannot dissipate body heat by evaporation as effectively (1).

Generally, infectious disease organisms are less concentrated in outdoor air than indoor air.

COMMENTS
Wind chill temperature is the temperature it “feels like” outside and is based on the rate of heat loss from exposed skin caused by the effects of wind and cold. As the wind increases, the body is cooled at a faster rate causing the skin temperature to drop. Many layers of clothing traps air between the layers and provides better insulation than one thick layer of clothing.

The NWS provides up to date weather information and warnings. The NWS Website will inform the public when wind chill conditions reach critical thresholds. A Wind Chill Warning is issued when wind chill temperatures are life threatening. A Wind Chill Advisory is issued when wind chill temperatures are potentially hazardous.

The NWS provides convenient color-coded guides for caregivers/teachers to use to determine which weather conditions are comfortable for outdoor play, which require caution, and which are dangerous. These guides are available on the NWS Website at http://www.nws.noaa.gov/om/windchill/index.shtml for wind chill and http://www.nws
.noaa.gov/om/heat/index.shtml for heat index.

The National Oceanic and Atmospheric Administration (NOAA) Weather Radio All Hazards (NWR) broadcasts continuous weather information twenty-four hours a day, seven days a week, directly from the nearest NWR office. NWR is an “All Hazards” radio network, making it a single source for comprehensive weather and emergency information. In conjunction with Federal, State, and Local Emergency Managers and other public officials, NWR also broadcasts warning and post-event information for all types of hazards – including natural (such as earthquakes or avalanches), environmental (such as chemical releases or oil spills), and public safety (such as AMBER alerts or 9-1-1 telephone outages). NWR requires a special radio receiver or scanner capable of picking up the signal. NWR radios/receivers can usually be found in most electronic store chains across the country or you can also purchase NOAA weather radios online at http://www.noaaweatherradios.com.

Email and Text Message Weather Alerts: These weather alert services send out weather warnings, watches, and hurricane information. Alerts are sent to subscribers in the warned areas via text messages and email. Select a service that sends warnings based on county, state, or national advisories. Some alerts may be delayed or missed because of problems on the Internet or the cell-phone network. Thus, do not rely solely on this system. Weather radio or local news affiliates should also be monitored for weather warnings.

Some flexibility is needed depending on the location of the program. For example, in some climates where children do not have warm winter clothing even 20°F could be too cold. In some southern climates it is always above 90°F, but older children are acclimated and can play in shaded areas.

To access the latest local weather information and warnings, contact the National Weather Service at http://www.weather.gov.

Frostbite is an injury to the body caused by freezing body tissue. The most susceptible parts of the body are the extremities such as fingers, toes, ear lobes, or the tip of the nose. Symptoms include a loss of feeling in the extremity and a white or pale appearance. Medical attention is needed immediately for frostbite. The affected area should be SLOWLY re-warmed by immersing frozen areas in warm water (around 100° Fahrenheit) or apply warm compresses for thirty minutes. If warm water is not available, wrap gently in warm blankets (4).

Hypothermia is a medical emergency that occurs when the body loses heat faster than it can produce heat, causing a dangerously low body temperature. An infant with hypothermia may have bright red, cold skin and very low energy. A child‘s symptoms may include shivering, clumsiness, slurred speech, stumbling, confusion, poor decision making, drowsiness or low energy, apathy, weak pulse, or shallow breathing (3). Call 9-1-1 if a child has these symptoms.

Winter can be problematic for children with asthma for two reasons. Indoor allergens such as dust and dust mites are common triggers for asthma symptoms and levels of these allergens can become elevated during the winter, when doors and windows are kept shut to keep out cold air. Cold temperatures also may, in some cases, serve as a trigger to asthma symptoms for children with asthma. Children for whom cold weather is an asthma trigger may be helped by wearing a scarf during periods of cold weather. All children with asthma can safely play outdoors as long as their asthma is well controlled, and the parents/guardians of children with asthma should be encouraged to work with their child’s primary care provider to develop a plan the child can self-manage that incorporates opportunities for outdoor play.

The thought is often expressed that children are more likely to become sick if exposed to cold air, however upper respiratory infections and flu are caused by viruses, not exposure to cold air. These viruses spread easily during the winter when children are kept indoors in close proximity. The best protection against the spread of illness is regular and proper hand hygiene for children and caregivers/teachers, as well as proper sanitation procedures during mealtimes, and when there is any contact with bodily fluids.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.1.3.1 Active Opportunities for Physical Activity
3.1.3.3 Protection from Air Pollution While Children Are Outside
3.1.3.4 Caregivers’/Teachers’ Encouragement of Physical Activity
3.4.5.1 Sun Safety Including Sunscreen
8.2.0.1 Inclusion in All Activities
Appendix S: Physical Activity: How Much Is Needed?
REFERENCES
  1. Kids Health. 2008. Frostbite. Nemours. http://kidshealth.org/parent/firstaid_safe/emergencies/frostbite.html.
  2. Mayo Clinic. 2009. Hypothermia: Symptoms. http://www.mayoclinic.com/health/hypothermia/DS00333/.
  3. Hagan, J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Promoting physical activity. In Bright futures: Guidelines for health supervision of infants, children, and adolescents, 147-54. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics.
  4. American Academy of Pediatrics, Committee on Sports Medicine and Fitness. 2007. Policy statement: Climatic heat stress and the exercising child and adolescent. Pediatrics 120:683-84.
NOTES

Content in the STANDARD was modified on 8/8/2013.

Standard 3.1.3.3: Protection from Air Pollution While Children Are Outside

Content in the STANDARD was modified on 8/25/2016.

 

Supervising adults should check the air quality index (AQI) each day and use the information to determine whether it is safe for children to play outdoors.

RATIONALE
Children need protection from air pollution. Air pollution can contribute to acute asthma attacks in sensitive children and, over multiple years of exposure, can contribute to permanent decreased lung size and function (1,2).
COMMENTS
The federal Clean Air Act requires that the Environmental Protection Agency (EPA) establish ambient air quality health standards. Most local health departments monitor weather and air quality in their jurisdiction and make appropriate announcements. AQI is usually reported with local weather reports on media outlets or individuals can sign up for email or text message alerts at http://www
.enviroflash.info.

The AQI (available at http://www.airnow.gov) is a cumulative indicator of potential health hazards associated with local or regional air pollution. The AQI is divided into six categories; each category corresponds to a different level of health concern. The six levels of health concern and what they mean are:

  1. “Good” AQI is 0 - 50. Air quality is considered satisfactory, and air pollution poses little or no risk.
  2. “Moderate” AQI is 51 - 100. Air quality is acceptable, however, for some pollutants there may be a moderate health concern for a very small number of people. For example, people who are unusually sensitive to ozone may experience respiratory symptoms.
  3. “Unhealthy for Sensitive Groups” AQI is 101 - 150. Although general public is not likely to be affected at this AQI range, people with heart and lung disease, older adults, and children are at a greater risk from exposure to ozone and the presence of particles in the air.
  4. “Unhealthy” AQI is 151 - 200. Everyone may begin to experience some adverse health effects, and members of the sensitive groups may experience more serious effects.
  5. “Very Unhealthy” AQI is 201 - 300. This would trigger a health alert signifying that everyone may experience more serious health effects.
  6. “Hazardous” AQI greater than 300. This would trigger a health warning of emergency conditions. The entire population is more likely to be affected.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.1.3.2 Playing Outdoors
5.2.1.1 Ensuring Access to Fresh Air Indoors
REFERENCES
  1. Lerodiakonou, D. (2016). Ambient air pollution, lung function, and airway responsiveness in asthmatic children. The Journal of Allergy and Clinical Immunology. 137(2), 390.
  2. Gehring, U., Gruzieva, O., Agius, R., Beelen, R., Custovic, A., Cyrys, J.,Von Berg. (2013). Air pollution exposure and lung function in children: The ESCAPE project. Environmental Health Perspectives: EHP. 121(11-12), 1357-1364.
NOTES

Content in the STANDARD was modified on 8/25/2016.

 

Standard 3.1.3.4: Caregivers’/Teachers’ Encouragement of Physical Activity

Caregivers/teachers should promote children’s active play, and participate in children’s active games at times when they can safely do so. Caregivers/teachers should:

  1. Lead structured activities to promote children’s activities two or more times per day;
  2. Wear clothing and footwear that permits easy and safe movement (2);
  3. Not sit during active play;
  4. Provide prompts for children to be active (3,4), e.g., “good throw”;
  5. Encourage children’s physical activities that are appropriate and safe in the setting, e.g., do not prohibit running on the playground when it is safe to run;
  6. Have orientation and annual training opportunities to learn about age-appropriate gross motor activities and games that promote children’s physical activity (1,3);
  7. Limit screen time (TV, DVD, computer, etc.), except for 1) school-age children completing homework assignments and 2) children with special health care needs who require and consistently use assistive and adaptive computer technology.

RATIONALE
Children learn from the modeling of healthy and safe behavior.
COMMENTS
Caregivers/teachers may not feel comfortable promoting active play, perhaps due to inhibitions about their own physical activity skills, or due to lack of training. Caregivers/teachers may feel that their sole role on the playground is to supervise and keep children safe, rather than to promote physical activity. Continuing education activities are useful in disseminating knowledge about effective games to promote physical activity in early care and education while keeping children safe (1). Caregivers/teachers should consider incorporating structured activities into the curriculum indoors, or after children have been on playground for ten to fifteen minutes, as children tend to be less active after the first ten to fifteen minutes on the playground. Caregivers/teachers, if they are facilitating physical activity with a small group, must ensure that there is adequate supervision of all children on the playground.

Caregivers/teachers should be aware that there is often a high level of TV and computer exposure in the home. Early care and education settings offer caregivers/teachers the opportunity to model the limitation of media and computer time and to educate parents/guardians about alternative activities that families can do with their children (3).

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.1.3.1 Active Opportunities for Physical Activity
3.1.3.2 Playing Outdoors
9.2.3.1 Policies and Practices that Promote Physical Activity
2.2.0.3 Screen Time/Digital Media Use
Appendix S: Physical Activity: How Much Is Needed?
REFERENCES
  1. Brown, W. H., K. A. Pfeiffer, K. L. McIver, M. Dowda, C. L. Addy, R. R. Pate. 2009. Social and environmental factors associated with preschoolers’ nonsedentary physical activity. Child Devel 80:45-58.
  2. Trost, S. G., D. S. Ward, M. Senso. 2010. Effects of child care policy and environment on physical activity. Med Sci Sports Exercise 42:520-25.
  3. Copeland, K. A., S. N. Sherman, C. A. Kendeigh, B. E. Saelens, H. J. Kalkwarf. 2009. Flip-flops, dress clothes and no coat: Clothing barriers to children’s physical activity in child-care centers. Int J Behav Nutr Activ 74(6).
  4. Ward, D. S., A. Vaughn, C. McWilliams, D. Hales. 2010. Interventions for increasing physical activity at child care. Med Sci Sports Exercise 42:526-34.

Standard 9.2.3.1: Policies and Practices that Promote Physical Activity

Content in the STANDARD was modified on 8/25/2016.

 

The facility should have written policies on the promotion of physical activity and the removal of potential barriers to physical activity participation. Policies should cover the following:

  1. Benefits: benefits of physical activity and outdoor play;
  2. Duration: children will spend sixty to one hundred and twenty minutes each day outdoors depending on their age, weather permitting. Policies will describe what will be done to ensure physical activity and provisions for gross motor activities indoors on days with more extreme conditions (i.e., very wet, very hot, or very cold);
  3. Setting: provision of covered areas for shade and shelter on playgrounds, if feasible (2);
  4. Clothing: clothing should protect children from sun exposure and permit easy movement (not too loose and not too tight) that enables children to participate fully in active play; footwear should provide support for running and climbing. Hats should be worn to protect children from sun exposure. 

Examples of appropriate clothing/footwear include:

  1. Gym shoes or sturdy gym-shoe-equivalent;
  2. Clothes for the weather, including heavy coat, hat, and mittens in the winter/snow; raincoat and boots for the rain; and layered clothes for climates in which the temperature can vary dramatically on a daily basis. Light-weight breathable clothing should be worn when temperatures are hot to protect children from sun exposure. 

Examples of inappropriate clothing/footwear include:

  1. Footwear that can come off while running or that provide insufficient support for climbing (3);
  2. Clothing that can catch on playground equipment (e.g., those with drawstrings or loops).

If children wear “dress clothes” or special outfits that cannot be easily laundered, caregivers/teachers should talk with the children’s parents/guardians about the program’s goals in providing physical activity during the program day and encourage them to provide a set of clothes that can be used during physical activities.

Facilities should discuss the importance of this policy with parents/guardians upon enrollment and periodically thereafter.

In addition to outdoor play, the facility is encouraged to incorporate movement activities or games into the standard indoor curriculum.

RATIONALE
If appropriately dressed, children can safely play outdoors in most weather conditions. Children can learn math, science, and language concepts through games involving movement (1).
COMMENTS
Lack of coat, mittens/gloves, and/or hat has been cited as a barrier to children’s physical activity in early care and education (3). Caregivers/teachers can mitigate this issue by having extra clean clothing on hand. Only when weather-related health alerts are issued should restrictions be placed on outdoor activity. Children can play in the rain, snow, and in low temperatures, when wearing clothing that keeps them dry and warm. When it is very warm, children can play outdoors if they play in shady areas, wear sun-protective clothing, have water available to mist or sprinkle, and have plenty of water available for drinking.

Having a policy on outdoor physical activity that will take place on days when weather is moderately (but not severely) inclement informs all caregivers/teachers and families about the facility’s expectations. The policy can make clear that outdoor activity may require special clothing in colder weather, or arrangements for cooling off when it is warm. By having such a policy, the facility encourages caregivers/teachers and families to anticipate and prepare for outdoor activity when cold, hot, or wet weather prevail. The policy also identifies when alternate large muscle activity should be held indoors so that weather conditions do not dictate lack of physical activity.

For examples of policies, see the Nemours Health and Prevention Services guide on best practices for physical activity at: http://www.nemours.org/content/dam/nemours/www/filebox/service/preventive/nhps/heguide.pdf.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.1.3.1 Active Opportunities for Physical Activity
3.1.3.2 Playing Outdoors
3.1.3.4 Caregivers’/Teachers’ Encouragement of Physical Activity
3.4.5.1 Sun Safety Including Sunscreen
3.4.5.2 Insect Repellent and Protection from Vector-Borne Diseases
Appendix S: Physical Activity: How Much Is Needed?
REFERENCES
  1. American Academy of Pediatrics. 2012. Choosing an Insect Repellent for your Child. https://www.healthychildren.org/English/safety-prevention/at-play/Pages/Insect-Repellents.aspx.
  2. American Academy of Pediatrics. 2015. Sun Safety. https://www.healthychildren.org/English/safety-prevention/at-play/Pages/Sun-Safety.aspx\.
  3. Copeland, K. A., S. N. Sherman, C. A. Kendeigh, B. E. Saelens, H. J. Kalkwarf. 2009. Flip flops, dress clothes, and no coat: Clothing barriers to children’s physical activity in child-care centers identified from a qualitative study. Int J Behav Nutr and Physical Activity 6, no. 74 (November 6). http://ijbnpa.org/content/6/1/74.
  4. McWilliams, C., S. G. Ball, S. E. Benjamin, D. Hales, A. Vaughn, D. S. Ward. 2009. Best-practice guidelines for physical activity at child care. Pediatrics 124:1650-59.
  5. Trost, S. G., B. Fees, D. Dzewaltowski. 2008. Feasibility and efficacy of a “move and learn” physical activity curriculum in preschool children. J Phys Act Health 5:88-103.
NOTES

Content in the STANDARD was modified on 8/25/2016.

 

III. Screen Time Standard

Standard 2.2.0.3: Screen Time/Digital Media Use

Frequently Asked Questions/CFOC3 Clarifications

Reference: 2.2.0.3

Date: 3/8/2012

Topic & Location:
Chapter 2
Program Activities
Standard 2.2.0.3: Limiting Screen Time - Media, Computer Time

Question:
This standard states that children two years and older in early care and education settings should not be exposed to more than thirty minutes per week of screen time and that computer use should be limited to no more than fifteen minute increments.

Is the fifteen minute increment for computer use included in the total screen time of thirty minutes per week?

Answer:
Yes.

Content in the STANDARD was modified on 10/12/2017.

Please note: For the purposes of this standard “screen time/digital media” refers to media content viewed on cell/mobile phone, tablet, computer, television (TV), video, film, and DVD. It does not include video-chatting with family.
 
Screen time/digital media should not be used with children ages 2 and younger in early care and education settings. For children ages 2 to 5 years, total exposure (in early care and education and at home combined) to digital media should be limited to 1 hour per day of high-quality programming [1], and viewed with an adult who can help them apply what they are learning to the world around them (1).
 
Children ages 5 and older may need to use digital media in early care and education to complete homework. However, caregivers/teachers should ensure that entertainment media time does not displace healthy activities such as exercise, refreshing sleep, and family time, including meals.
 
For children of all ages, digital media and devices should not be used during meal or snack time, or during nap/rest times and in bed. Devices should be turned off at least one hour before bedtime. When offered, digital media should be free of advertising and brand placement, violence, and sounds that tempt children to overuse the product. 
 
Caregivers/teachers should communicate with parents/guardians about their guidelines for home media use. Caregivers/teachers should take this information into consideration when planning the amount of media use at the child care program to help in meeting daily recommendations (1).
 
Programs should prioritize physical activity and increased personal social interactions and engagement during the program day. It is important for young children to have active social interactions with adults and children. Media use can distract children (and adults), limit conversations and play, and reduce healthy physical activity, increasing the risk for overweight and obesity. Media should be turned off when not in use since background media can be distracting, and reduce social engagement and learning. Overuse of media can also be associated with problems with behavior, limit-setting, and emotional and behavioral self-regulation; therefore, caregivers/teachers should avoid using media to calm a child down (1).
 
Note: The guidance above should not limit digital media use for children with special health care needs who require and consistently use assistive and adaptive computer technology (2). However, the same guidelines apply for entertainment media use. Consultation with an expert in assistive communication may be necessary. 
 


[1] designed with child psychologists and educators to meet specific educational goals

RATIONALE
The first two years of life are critical periods of growth and development for children’s brains and bodies, and rapid brain development continues through the early childhood years. To best develop their cognitive, language, motor, and social-emotional skills, infants and toddlers need hands-on exploration and social interaction with trusted caregivers (1). Digital media viewing do not promote such skills development as well as “real life”.
 
Excessive media use has been associated with lags in achievement of knowledge and skills, as well as negative impacts on sleep, weight, and social/emotional health. (1). For example, among 2-year-olds, research has shown that body mass index (BMI) increases for every hour per week of media consumed (3).
 
COMMENTS

Digital media is not without benefits, including learning from high-quality content, creative engagement, and social interactions. However, especially in young children, real-life social interactions promote greater learning and retention of knowledge and skills.  When limited digital media are used, co-viewing and co-teaching with an engaged adult promotes more effective learning and development. 

Because children may use digital media before and after attending early care and education settings, limiting digital media use in early care and education settings and substituting developmentally appropriate play and other hands-on activities can better promote learning and skills development. Such an activity is reading. Caregivers/teachers should begin reading to children at infancy (4) and facilities should make age-appropriate books available for each cognitive stage of development that can be co-read and discussed with an adult. See the American Academy of Pediatrics’ “Books Build Connections Toolkit” at https://littoolkit.aap.org/forprofessionals/Pages/home.aspx for more information.
The American Academy of Pediatrics has developed a Family Media Use Plan tool, available at https://www.healthychildren.org/English/media/Pages/default.aspx, which can help parents/guardians, caregivers, and families identify healthy activities for each child, and prioritize them ahead of limited digital media use (5). 

Caregivers/teachers serve as role models for children in early care and education settings by not using or being distracted by digital media during care hours. In addition, if adults view media such as news in the presence of children, children may be exposed to inappropriate language or violent or frightening images that can cause emotional upset or increase aggressive thoughts and behavior. Caregivers/teachers should be discouraged from using digital media for personal use while actively engaging with and supervising the children in their care. Instead, opportunities for collaborative activities are preferred.

It is important to safeguard privacy for children on the internet and digital media.  Pictures and videos of children should never be posted on social media without parent/guardian consent. Caregivers/teachers should know and follow their program’s policy for taking, sharing, or posting pictures and videos. 

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.1.3.1 Active Opportunities for Physical Activity
2.1.2.1 Personal Caregiver/Teacher Relationships for Infants and Toddlers
2.1.3.1 Personal Caregiver/Teacher Relationships for Three- to Five-Year-Olds
2.1.4.3 Developing Relationships for School-Age Children
2.2.0.1 Methods of Supervision of Children
Appendix S: Physical Activity: How Much Is Needed?
REFERENCES
  1. ADDITIONAL REFERENCES:
     
    American Academy of Pediatrics Council on Communications and Media. Children and adolescents and digital media. Pediatrics. 2016;138(5): e20162593. http://pediatrics.aappublications.org/content/pediatrics/early/2016/10/19/peds.2016-2593.full.pdf.
     
    American Academy of Pediatrics. Media and children communication toolkit. Aap.org Web site. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/pages/media-and-children.aspx. Accessed October 12, 2017. 
     
    Campaign for a Commercial-Free Childhood. Screenfree.org Web site. http://www.screenfree.org/. Accessed October 12, 2017. 
     
    Common Sense Education. Commonsense.org Web site.  https://www.commonsense.org/education/toolkit/audience/device-free-dinner-educator-resources. Accessed October 12, 2017. 
     
    Fred Rogers Center for Early Learning and Children’s Media at Saint Vincent College. How am I doing? A checklist for identifying exemplary uses of technology and interactive media for early learning. Fredrogerscenter.org Web site. http://www.fredrogerscenter.org/2014/02/25/how-am-i-doing-checklist-exemplary-uses-of-technology-early-learning/. Updated February 25, 2014. Accessed October 12, 2017. 
     
    National Association for the Education of Young Children. Technology and interactive media as tools in early childhood programs serving children from birth through age 8. Position Statement. NAEYC.org Web site. http://www.naeyc.org/files/naeyc/PS_technology_WEB.pdf. January 2012. Accessed October 12, 2017.  
  2. American Academy of Pediatrics Council on Communications and Media. Media use in school-aged children and adolescents. Pediatrics. 2016;138(5):e20162592. http://pediatrics.aappublications.org/content/138/5/e20162592
  3. American Academy of Pediatrics. Council on Early Childhood. Literacy promotion: an essential component of primary care pediatric practice. Pediatrics. 2014;134(2):1-6. http://pediatrics.aappublications.org/content/early/2014/06/19/peds.2014-1384
  4. Wen LM, Baur LA, Rissel C, Xu H, Simpson, JM. Correlates of body mass index and overweight and obesity of children aged 2 years: finding from the healthy beginnings trial. Obesity. 2014;22(7):1723-1730.
  5. Reid CY, Radesky J, Christakis D, et al., American Academy of Pediatrics Council on Communications and Media. Children and adolescents and digital media. Pediatrics. 2016;138(5):e2016593. 
    http://pediatrics.aappublications.org/content/early/2016/10/19/peds.2016-2593
  6. American Academy of Pediatrics Council on Communications and Media. Media and young minds. Pediatrics. 2016;138(5):e20162591. http://pediatrics.aappublications.org/content/pediatrics/138/5/e20162591.full.pdf 
NOTES

Content in the STANDARD was modified on 10/12/2017.