Caring for Our Childen, 3rd Edition (CFOC3)

Chapter 4: Nutrition and Food Service

4.2 General Requirements

4.2.0

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. 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
  2. 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
  3. Holt K, Wooldridge N, Story M, Sofka D. Bright Futures: Nutrition. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2011
  4. Kleinman RE, Greer FR, eds. Pediatric Nutrition. 7th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2014
  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.

 

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.

 

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. 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
  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. 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
  4. 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
  5. 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
  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 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
  8. 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

NOTES

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

 

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
  • Trans-fatty acids (trans fat) should be avoided.
  • Avoid concentrated sweets such as candy, sodas, sweetened caffeinated drinks, fruit nectars, and flavored milks. Offer foods that have little or no added sugars.
  • Limit salty foods such as chips and pretzels. When buying foods, choose no salt added, low-sodium, or reduced sodium versions, and prepare foods without adding salt. Use herbs or no-salt spice mixes instead of salt, soy sauce, ketchup, barbeque sauce, pickles, olives, salad dressings, butter, stick margarine, gravy, or cream sauce with seasonal vegetables and other dishes.
  • Avoid caffeine.
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:
  • Meals and snacks planned based on the food groups in the Making Healthy Food Choices Table promote normal growth and development of children as well as reduce children’s risk of overweight, obesity, and related chronic diseases later in life. Age-specific guidance for meals and snacks is outlined in the US Department of Agriculture Child and Adult Care Food Program (CACFP) guidelines (3).
  • Early care and education settings provide the opportunity for children to learn about the food they eat, to develop and strengthen their fine and gross motor skills, and to engage in social interaction at mealtimes.
  • "Energy” or sports beverages are typically high in added sugars and, therefore, not recommended for consumption. They contain many nonnutritive stimulants, such as caffeine, that have a history of harmful effects on a child’s developing heart, brain, and nervous system (4). 
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
4.2.0.5 Meal and Snack Patterns
4.2.0.7 100% Fruit Juice
4.2.0.8 Feeding Plans and Dietary Modifications
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. 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. 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
  3. 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 
  4. 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 
NOTES

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

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. 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
  2. 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
  3. Kleinman RE, Greer FR, eds. Pediatric Nutrition. 7th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2014
  4. 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
  5. 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
NOTES

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

 

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. 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
  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. Kleinman RE, Greer FR, eds. Pediatric Nutrition. 7th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2014
  4. 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 
  5. 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
NOTES

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

 

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
3.1.5.1 Routine Oral Hygiene Activities
3.1.5.3 Oral Health Education
4.2.0.4 Categories of Foods
4.2.0.6 Availability of Drinking Water
4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants
REFERENCES
  1. 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
  2. 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
  3. 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
  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
  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
  6. 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
  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. 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
  9. 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.
NOTES

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

 

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
3.5.0.1 Care Plan for Children with Special Health Care Needs
4.2.0.1 Written Nutrition Plan
4.2.0.2 Assessment and Planning of Nutrition for Individual Children
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. Samour PQ, King K. Pediatric Nutrition. 4th ed. Sunbury, MA: Jones and Bartlett Learning; 2010
  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. 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
NOTES

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

 

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. 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
  2. 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
  3. Savage JS, Fisher JO, Birch LL. Parental influence on eating behavior: conception to adolescence. J Law Med Ethics. 2007;35(1):22–34
  4. 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
  5. 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
  6. 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
NOTES

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

 

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
3.5.0.1 Care Plan for Children with Special Health Care Needs
4.2.0.2 Assessment and Planning of Nutrition for Individual Children
4.2.0.8 Feeding Plans and Dietary Modifications
Appendix P: Situations that Require Medical Attention Right Away
REFERENCES
  1. 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
  2. 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
  3. 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
  4. 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
  5. Food Allergy Research & Education. Allergy alerts. https://www.foodallergy.org/alerts. Accessed September 20, 2017
  6. 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
NOTES

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

 

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. 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
  2. Miao D, Young SL, Golden CD. A meta?analysis of pica and micronutrient status. Am J Hum Biol. 2015;27(1):84–93
  3. McNaughten B, Bourke T, Thompson A. Fifteen-minute consultation: the child with pica. Arch Dis Child Educ Pract Ed. May 2017;edpract-2016-312121
  4. 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
NOTES

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

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. Kleinman RE, Greer FR, eds. Pediatric Nutrition. 7th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2014
  2. 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
  3. Mangels R, Driggers J. The youngest vegetarians. Vegetarian infants and toddlers. Infant Child Adolesc Nutr. 2012;4(1):8–20
  4. 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
  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. Accessed September 20, 2017
  6. 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
NOTES

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