Caring for Our Childen (CFOC)

Chapter 3: Health Promotion and Protection

3.1 Health Promotion in Child Care

3.1.3 Physical Activity and Limiting Screen Time Active Opportunities for Physical Activity

Content in the STANDARD was modified on 05/29/2018.

The facility should promote all 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, to the extent of their abilities.

All children, birth to 6 years of age, should participate daily in:

     a. Two to 3 occasions of active play outdoors, weather permitting (see Standard Playing Outdoors for appropriate weather conditions)

     b. Two or more structured or caregiver/teacher/adult-led activities or games that promote movement over the course of the day—indoor or outdoor

     c. 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.

Outdoor play

     a. Infants (birth–12 months of age) should be taken outside 2 to 3 times per day, as tolerated. There is no recommended duration of infants’ outdoor play.

     b. Toddlers (12 – 35 months) and preschoolers (3–6 years) should be allowed 60 to 90 total minutes of outdoor play (1).

These outdoor times can be curtailed somewhat during adverse weather conditions in which children may still play safely outdoors for shorter periods, but the time of indoor activity should increase so the total amount of exercise remains the same.

Total time allotted for moderate to vigorous activities:

     a. Toddlers should be allowed 60 to 90 minutes per 8-hour day for moderate to vigorous physical activity, including running.

     b. Preschoolers should be allowed 90 to 120 minutes per 8-hour day for moderate to vigorous physical activity, including running (1,2).

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 his/her tummy for short periods (3–5 minutes), increasing the amount of time as the infant shows he/she enjoys the activity (3).

There are many ways to promote tummy time with infants:

     a. Place yourself or a toy just out of the infant’s reach during playtime to get him/her to reach for you or the toy.

     b. 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.

     c. 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 (3,4).

Structured activities have been shown to produce higher levels of physical activity in young children, therefore it is recommended that caregivers/teachers incorporate 2 or more short, structured activities or games daily that promote physical activity (5).

Opportunities to actively enjoy physical activity should be incorporated into part-time programs by prorating these recommendations accordingly (eg, 20 minutes of outdoor play for every 3 hours in the facility).

Active play should never be withheld from children who misbehave (eg, child is kept indoors to help another caregiver/teacher while the rest of the children go outside) (6). However, children with out-of-control behavior may need 5 minutes or fewer to calm themselves or settle down before resuming cooperative play or activities.

Infants should not be seated for more than 15 minutes at a time, except during meals or naps (5). Infant equipment, such as swings, stationary activity centers, infant seats (eg, bouncers), and molded seats, should only be used for short periods, if used at all. A least-restrictive environment should be encouraged at all times (7).

Children should have adequate space for indoor and outdoor play.


Time spent outdoors has been found to be a strong, consistent predictor of children’s physical activity (8). Children can accumulate opportunities for activity over the course of several shorter segments of at least 10 minutes each (9).  Free play, active play, and outdoor play are essential components of young children’s development (10). Children learn through play, developing gross motor, socioemotional, and cognitive skills. During outdoor play, children learn about their environment, science, and nature (10).

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 (11). 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 (12).

Toddlers and preschoolers generally accumulate moderate to vigorous physical activity over the course of the day in very short bursts (15–30 seconds) (5). Children may be able to learn better during or immediately after these types of short bursts of physical activity, due to improved attention and focus (13).
Tummy time prepares infants to 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 (3).

Childhood obesity prevalence, for children 2 to 5 years old, has steadily decreased from 13.9% in 2004 to 9.4% in 2014 (14). Incorporating government food programs, physical activities, and wellness education into child care centers has been associated with these decreases (15).

Establishing communication between caregivers/teachers and parents/guardians helps facilitate integration of classroom physical activities into the home, making it more likely that children will stay active outside of child care hours (16). Very young children and those not yet able to walk, are entirely dependent on their caregivers/teachers for opportunities to be active (17).

Especially for children in full-time care and for children who don’t have access to safe playgrounds, the early care and education facility may provide the child’s only daily opportunity for active play. 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 (18).


Additional Resources

Choosy Kids (

EatPlayGrow Early Childhood Health Curriculum, Children’s Museum of Manhattan (

Head Start Early Childhood Learning & Knowledge Center, US Department of Health and Human Services, Administration for Children & Families (

Healthy Kids, Healthy Future; The Nemours Foundation (

Nutrition and Physical Activity Self-Assessment for Child Care, Center for Health Promotion and Disease Prevention, University of North Carolina (

Online Physical Education Network (

Spark (

Center, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS Health, Nutrition, Physical Activity, and Safety Awareness Playing Outdoors Caregivers’/Teachers’ Encouragement of Physical Activity Restrictive Infant Equipment Requirements Policies and Practices that Promote Physical Activity
Appendix S: Physical Activity: How Much Is Needed?
  1. Henderson KE, Grode GM, O’Connell ML, Schwartz MB. Environmental factors associated with physical activity in childcare centers. Int J Behav Nutr Phys Act. 2015;12:43

  2. Vanderloo LM, Martyniuk OJ, Tucker P. Physical and sedentary activity levels among preschoolers in home-based childcare: a systematic review. J Phys Act Health. 2015;12(6):879–889

  3. American Academy of Pediatrics. Back to sleep, tummy to play. Web site. Updated January 20, 2017. Accessed January 11, 2018

  4. Zachry AH. Tummy time activities. American Academy of Pediatrics Web site. Updated November 21, 2015. Accessed January 11, 2018

  5. US Department of Agriculture, US Department of Health and Human Services. Provide opportunities for active play every day. Nutrition and wellness tips for young children: provider handbook for the Child and Adult Care Food Program. Published June 2013. Accessed January 11, 2018

  6. Centers for Disease Control and Prevention and SHAPE America-Society of Health and Physical Educators. Physical activity during school: Providing recess to all students. 2017. Accessed January 11, 2018

  7. Moir C, Meredith-Jones K, Taylor BJ, et al. Early intervention to encourage physical activity in infants and toddlers: a randomized controlled trial. Med Sci Sports Exerc. 2016;48(12):2446–2453

  8. Vanderloo LM, Martyniuk OJ, Tucker P. Physical and sedentary activity levels among preschoolers in home-based childcare: a systematic review. J Phys Act Health. 2015;12(6):879–889

  9. Hnatiuk JA, Salmon J, Hinkley T, Okely AD, Trost S. A review of preschool children’s physical activity and sedentary time using objective measures. Am J Prev Med. 2014;47(4):487–497

  10. Bento G, Dias G. The importance of outdoor play for young children’s healthy development. Porto Biomed J. 2017;2(5):157–160

  11. Jayasuriya A, Williams M, Edwards T, Tandon P. Parents’ perceptions of preschool activities: exploring outdoor play. Early Educ Dev. 2016;27(7):1004–1017

  12. Timmons BW, Leblanc AG, Carson V, et al. Systematic review of physical activity and health in the early years (aged 0-4 years). Appl Physiol Nutr Metab. 2012;37(4):773–792

  13. Donnelly JE, Hillman CH, Castelli D, et al. Physical activity, fitness, cognitive function, and academic achievement in children: a systematic review. Med Sci Sports Exerc. 2016;48(6):1197–1222

  14. Centers for Disease Control and Prevention. Overweight & obesity. Childhood obesity facts. Prevalence of childhood obesity in the United States, 2011-2014. Updated April 10, 2017. Accessed January 11, 2018

  15. Ogden CL, Carroll MD, Lawman HG, et al. Trends in obesity prevalence among children and adolescents in the United States, 1988-1994 through 2013-2014. JAMA. 2016;315(21):2292–2299

  16. Taverno Ross S, Dowda M, Saunders R, Pate R. Double dose: the cumulative effect of TV viewing at home and in preschool on children’s activity patterns and weight status. Pediatr Exerc Sci. 2013;25(2):262–272

  17. Society of Health and Physical Educators. Active Start: A Statement of Physical Activity Guidelines for Children From Birth to Age 5. 2nd ed. Reston, VA: SHAPE America; 2009. Accessed January 11, 2018

  18. Simmonds M, Llewellyn A, Owen CG, Woolacott N. Predicting adult obesity from childhood obesity: a systematic review and meta‚Äźanalysis. Obes Rev. 2016;17(2)95–107


Content in the STANDARD was modified on 05/29/2018. Playing Outdoors

Content in the STANDARD was modified on 8/8/2013 and 05/29/2018.

Children should play outdoors when the conditions do not pose any concerns health and safety such as a significant risk of frostbite or 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. Weather that poses a significant health risk includes wind chill factor below -15°F (-26°C) and heat index at or above 90°F (32°C), as identified by the National Weather Service (NWS) (1). Child Care Center Directors as well as caregivers/teachers directors should monitor weather-related conditions through several media outlets, including local e-mail and text messaging weather alerts.

Caregivers/teachers should also monitor the air quality for safety. Please reference Standard for more information.


Sunny weather

  1. Children should be protected from the sun between the hours of 10:00 am and 4:00 pm. Protective measures include using shade; sun-protective clothing such as hats and sunglasses; and sunscreen with UV-B and UV-A ray sun protection factor 15 or higher. Parental/guardian permission is required for the use of sunscreen.

Warm weather

  1. Children should have access to clean, sanitary water at all times, including prolonged periods of physical activity, and be encouraged to drink water during periods of prolonged physical activity (2).
  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 6 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 rain or snow is present.
  2. Children should wear a hat, coat, and gloves/mittens kept snug at the wrist. There should be no  hood and neck strings..
  3. Caregivers/teachers should check children’s extremities for normal color and warmth at least every 15 minutes.

Caregivers/teachers should be aware of environmental hazards such as unsafe drinking 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 fully enclosed and away from heavy traffic areas. In addition, outdoor play for infants may include riding in a carriage or stroller. Infants should be offered opportunities for gross motor play outdoors.


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 (3) and better nighttime sleep (4). Short exposure of the skin to sunlight promotes the production of vitamin D that growing children require.

Open spaces in outdoor areas, even those located on 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. Heat-induced illness and cold injury are preventable. Weather alert services are beneficial to child care centers because they send out weather warnings, watches, and hurricane information. Alerts are sent to subscribers in the warned areas via text messages and e-mail. It is best practice to use these services but do not rely solely on this system. Weather radio or local news affiliates should also be monitored for weather warnings and advisories. Heat and humidity can pose a significant risk of heat-related illnesses, as defined by the NWS (5). Children have a 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 (6).

Wind chill conditions can pose a risk of frostbite. 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, earlobes, and 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 rewarmed by immersing frozen areas in warm water (around 104°F [40°C]) or applying warm compresses for 30 minutes. If warm water is not available, wrap gently in warm blankets (7). 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 (7,8). Call 911 or your local emergency number if a child has these symptoms. Both hypothermia and frostbite can be prevented by properly dressing a child. Dressing in several layers will trap air between layers and provide better insulation than a single thick layer of clothing.

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


Additional Resources

  • The National Weather Service (NWS) provides up-to-date weather information on all advisories and warnings. It also provides safety tips for caregivers/teachers to use as a tool in determining when weather conditions are comfortable for outdoor play (
  • The National Oceanic and Atmospheric Administration (NOAA) Weather Radio All Hazards (NWR) broadcasts continuous weather information 24 hours a day, 7 days a week, directly from the nearest NWR office. As an all-hazards radio network, it is 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 (eg, earthquakes, avalanches), environmental (eg, chemical releases, oil spills), and public safety (eg, AMBER alerts, 911 telephone outages). A special radio receiver or scanner capable of picking up the signal is required to receive NWR. Such radios/receivers can usually be found in most electronic store chains across the country; you can also purchase NOAA weather radios online at
  • To access the latest local weather information and warnings, visit the NWS at; for local air quality conditions, visit
Center, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS Active Opportunities for Physical Activity Protection from Air Pollution While Children Are Outside Caregivers’/Teachers’ Encouragement of Physical Activity Sun Safety Including Sunscreen Inclusion in All Activities
Appendix S: Physical Activity: How Much Is Needed?
  1. National Weather Service, National Oceanic and Atmospheric Administration. Wind chill safety. Accessed January 11, 2018

  2. 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. Accessed January 11, 2018

  3. Cleland V, Crawford D, Baur LA, Hume C, Timperio A, Salmon J. A prospective examination of children’s time spent outdoors, objectively measured physical activity and overweight. Int J Obes (Lond). 2008;32(11):1685–1693

  4. Söderström M, Boldemann C, Sahlin U, Mårtensson F, Raustorp A, Blennow M. The quality of the outdoor environment influences children’s health—a cross-sectional study of preschoolers. Acta Paediatr. 2013;102(1):83–91

  5. KidsHealth from Nemours. Heat illness. Reviewed February 2014. Accessed January 11, 2018

  6. American Academy of Pediatrics. Children & disasters. Extreme temperatures: heat and cold. Accessed January 11, 2018

  7. American Academy of Pediatrics. Winter safety tips from the American Academy of Pediatrics. Published January 2018. Accessed January 11, 2018

  8. American Academy of Pediatrics. Extreme temperature exposure. Web site. Updated November 21, 2015. Accessed January 11, 2018


Content in the STANDARD was modified on 8/8/2013 and 05/29/2018. 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.
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).
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

The AQI (available at 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.
Center, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS Playing Outdoors Ensuring Access to Fresh Air Indoors
  1. 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.
  2. Lerodiakonou, D. (2016). Ambient air pollution, lung function, and airway responsiveness in asthmatic children. The Journal of Allergy and Clinical Immunology. 137(2), 390.

Content in the STANDARD was modified on 8/25/2016. Caregivers’/Teachers’ Encouragement of Physical Activity

Content in the STANDARD was modified on 05/29/2018.

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

     a. Lead structured activities to promote children’s activities 2 or more times per day.

     b. Wear clothing and footwear that permits easy and safe movement (1). 

     c. Provide prompts for children to be active (2,3). (eg, “Good throw!”).

     d. Encourage children’s physical activities that are appropriate and safe in the setting (eg, do not prohibit running on the playground when it is safe to run).

     e.Have orientation and annual training opportunities to learn about age-appropriate gross motor activities and games that promote children’s physical activity (2,4).

     f. Not sit during active play.

     g. Limit screen time and other digital media as outlined in Standard

Caregivers/teachers should consider incorporating structured activities into the curriculum indoors or after children have been on the playground for 10 to 15 minutes. Caregivers/teachers should communicate with parents/guards about their use of screen time/digital media in the home.


Children learn from the adult modeling of healthy and safe behavior. Caregivers/teachers may not be comfortable promoting active play, perhaps due to inhibitions about their own physical activity skills or lack of training. Caregivers/teachers may also assume 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 (4).

Children exposed to less screen time/digital media in early care and education settings engage in more moderate-to-vigorous physical activity compared with children who are exposed to more screen time (5).  This gives caregivers/teachers the opportunity to model the limitation of screen time/digital media use and to educate parents/guardians about alternative activities that families can do with their children (2). 

Additional Resource:

American Academy of Pediatrics Council on Communications and Media. Media and young minds. Pediatrics. 2016;138(5):e20162591

Center, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS Screen Time/Digital Media Use Active Opportunities for Physical Activity Playing Outdoors Policies and Practices that Promote Physical Activity
Appendix S: Physical Activity: How Much Is Needed?
  1. Henderson KE, Grode GM, O’Connell ML, Schwartz MB. Environmental factors associated with physical activity in childcare centers. Int J Behav Nutr Phys Act. 2015;12:43

  2. Tandon PS, Saelens BE, Copeland KA. A comparison of parent and childcare provider's attitudes and perceptions about preschoolers' physical activity and outdoor time. Child Care Health Dev. 2017;43(5):679–686

  3. Tandon PS, Walters KM, Igoe BM, Payne EC, Johnson DB. Physical activity practices, policies and environments in Washington state child care settings: results of a statewide survey. Matern Child Health J. 2017;21(3):571–582

  4. Copeland KA, Khoury JC, Kalkwarf HJ. Child care center characteristics associated with preschoolers’ physical activity. Am J Prev Med. 2016;50(4):470–479

  5. Taverno Ross S, Dowda M, Saunders R, Pate R. Double dose: the cumulative effect of TV viewing at home and in preschool on children’s activity patterns and weight status. Pediatr Exerc Sci. 2013;25(2):262–272


Content in the STANDARD was modified on 05/29/2018.