One of the basic responsibilities of every parent and caregiver is to provide nourishing food that is clean, safe and developmentally appropriate for children. Children need freely available, clean drinking water too. Feeding should occur in a relaxed and pleasant environment that fosters healthy digestion and pro social behavior. Food provides energy and nutrients needed by infants and children during a critical period when they grow and develop more rapidly than at any other time.
Human milk, the most natural and beneficial first food, sets the stage for an infant to establish a human relationship. These first feeding experiences foster attachment and bonding, while the infant is nurtured by the mother or primary caretaker. From the first feeding after birth, the process begins of the infant responding to and identifying with the mother during breastfeeding or with the primary caregiver when bottle fed. Each subsequent feeding reinforces human relationships and attitudes about food and eating by the child. The infant learns to associate the food offered with the parent or caregiver, which together forms a feeding/eating dynamic.
As new foods are introduced, children learn to self-feed concurrently with the attainment of phy-
sical growth, physiological readiness, and the development of motor coordination, cognitive and social skills. This period is an opportune time for children to learn more about the world around them by expressions of independence. Children pick and choose from different kinds and combinations of foods offered. Eating jags are to be expected as evidence of growth and self-feeding. Family homes and out-of-home care settings have many opportunities to guide and support sound eating habits and food learning experiences for children.
Early food and eating experiences are the foundation for the formation of attitudes about food, eating behavior, and consequently, food habits. Sound food habits build on eating and enjoying a variety of healthful foods. Including culturally acceptable family foods is a dietary goal for feeding infants and young children. Current research documents that a balanced diet combined with regular and routine age-appropriate physical activity can reduce the risks of chronic diseases later in life that are related to diet (
1). These two essentials - eating healthy foods and engaging in physical activity on a daily basis - promote a healthy beginning during the early years and throughout the life span.
Nutrition and Your Health: Dietary Guidelines for Americans is designed to support lifestyle behaviors that promote health, including a diet composed of a variety of healthy foods and physical activity (
1). See Appendix O,
Food Guide Pyramid.
The facility shall provide children nourishing and attractive food according to a written plan, developed by a qualified Child Care Nutrition Specialist. Caregivers, directors, and food service personnel shall share the responsibility for carrying out the plan. The administrator is responsible for implementing the plan but may delegate tasks to caregivers and food service personnel.
The nutrition plan (see
STANDARD 8.035) shall include steps to take when problems require rapid response by the staff such as when a child chokes during mealtime. The completed plan shall be on file and accessible to the staff.
If the facility is large enough to justify employment of a full-time Child Care Nutrition Specialist or Child Care Food Service Manager, the facility shall delegate to this person the responsibility for implementing the written plan.
RATIONALE: Nourishing and attractive food is the cornerstone for health, growth, and development as well as developmentally appropriate learning experiences(
2-
10). Nutrition and feeding are fundamental and required in every facility. Because children grow and develop more rapidly during the first few years of life than at any other time, the child's home and the facility together must provide food that is adequate in amount and type to meet each child's metabolic, growth, and energy needs.
Meals and snacks provide opportunities for observation and conversation, which aid in children's conceptual, sensory, and language development. Professional nutrition staff must be involved along with the rest of the child care staff to assure compliance with nutrition and food service guidelines in larger facilities, including accommodation of children with special health care needs.
The staff must know ahead of time what procedures to follow, as well as their designated roles during an emergency. The plan should be dated and updated when revised.
COMMENTS:
Making Food Healthy and Safe for child-ren contains practical tips for implementing the standards for culturally diverse groups of infants and children. This publication is cued to the standards in the first edition of
Caring for Our Children. Until
Making Food Healthy and Safe for Children is revised, readers should use Appendix CC Conversion Table from 1st Edition to 2nd Edition to link the numbering of its standards with the numbering of the second edition of
Caring for Our Children. The guidelines in
Making Food Healthy and Safe for Children are current. This publication is available from the National Maternal and Child Health Clearinghouse. Contact information is located in Appendix BB.
See
STANDARD 4.026 and 4.027 and Appendix C (which includes level of responsibility and education and experience), on Child Care Nutrition Specialists and Child Care Food Service Managers. See
STANDARD 4.009 on written feeding plans. See also Nutrition Learning Experiences for Children,
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Use of USDA - CACFP Guidelines
All meals and snacks and their preparation, service, and storage shall meet the requirements for meals of the child care component of the U.S. Department of Agriculture (USDA), Child and Adult Care Food Program (CACFP), and the 7 Code of Federal Regulations (CFR) Part 226.20 (
9,
10).
RATIONALE: The CACFP regulations, policies, and guidance materials on meal requirements provide the basic guidelines for good nutrition and sanitation practices. Meals and snacks offered to young children should provide a variety of nourishing foods on a frequent basis to meet the nutritional needs of young children (
11,
12). Programs not eligible for reimbursement under the regulations of CACFP are encouraged to use the CACFP food guidance. The CACFP guidance for meals and snack patterns ensures that the nutritional needs of infants and children are met based on current scientific knowledge.
COMMENTS: For examples of diets for infants and children, see Appendices P and Q. The staff should use information on the child's growth in developing individual feeding plans. For information on growth data, see
STANDARD 3.003.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
The facility shall ensure the following:
a) Children in care for 8 and fewer hours shall be offered at least one meal and two snacks or two meals and one snack;
b) Children in care more than 8 hours shall be offered at least two meals and two snacks or three snacks and one meal;
c) A nutritious snack shall be offered to all children in midmorning and in midafternoon;
d) Children shall be offered food at intervals at least 2 hours apart and 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.
RATIONALE: Young children need to be fed often. Appetite and interest in food varies from one meal or snack to the next. To ensure that the child's daily nutritional needs are met, small feedings of nourishing food should be scheduled over the course of a day
(
2,
6,
10). Snacks should be nutritious, as they often are a significant part of a child's daily intake. Children in care for more than 8 hours need additional food, as this period represents a majority of a young child's waking hours.
COMMENTS: Caloric needs vary greatly from one child to another. They may require more food during growth spurts. Some states have regulations indicating suggested times for meals and snacks.
TYPE OF FACILITY
: Center; Large Family Child Care Home; Small Family Child Care Home
Children in care shall be offered 5 or more servings of a fruit, vegetable, or juice each day. At least one of these servings shall be high in Vitamin C. A fruit, vegetable, or juice high in Vitamin A shall be offered at least three times a week.
RATIONALE: Current dietary guidance recommends at least five servings of fruits and vegetables daily (
13). Juice is a means of fulfilling part of this requirement, but shall not be the exclusive offering. To serve fruits and vegetables without focusing on specific nutrients is not sufficient. The child's health, education, and food/nutrition learning experiences must be emphasized. Certain nutrients have been identified that may promote optimum health and may be protective against some disease processes.
COMMENTS: The staff should provide an example to children by eating the same foods and by discussing the food being eaten as part of nutrition education for the children.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
The facility shall serve only full-strength (100%) fruit juice from a cup. The facility shall offer juice at specific meals and snacks instead of continuously throughout the day.
RATIONALE: Feeding juice only at specific meals and snacks will reduce acids produced by bacteria in the mouth that cause tooth decay. The frequency of exposure, rather than the quantity of food, is important in determining whether foods cause tooth decay. Although sugar is not the only dietary factor likely to cause tooth decay, it is a major factor in the prevalence of tooth decay (
14,
15). Drinks that are called fruit juice drinks or fruit punches contain less than 100% fruit juice and are of a lower nutritional value than 100% fruit juice. Continuous consumption of juice during the day has been associated with a decrease in appetite for other nutritious foods which can result in feeding problems.
COMMENTS: Caregivers, as well as many parents, need to understand and accept the relationship between food eaten and tooth decay. Foods with high sugar content (such as candies or sweetened beverages) should be avoided because they contribute to tooth decay and poor nutrition.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Availability of Drinking Water
Clean, sanitary drinking water shall be readily available throughout the day.
RATIONALE: When children are thirsty between meals and snacks, clean water is the best choice. Offering drinking water is good for hydration and reduces the acid in the mouth, which contribute to early childhood caries. Drinking water during the day will reduce the intake of extra calories (from fruit juice) which are associated with overweight and
COMMENTS: For drinking water supply in case of emergency, see
STANDARD 4.058.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
If dietary modifications are indicated based on a child's medical or special dietary needs, the caregiver shall modify or supplement the child's diet on a case-by-case basis, in consultation with the parents and the Nutrition Specialist, a trained nutrition expert, or the child's usual health care source.
Reasons for modification of the child's diet may be related to allergies, food idiosyncrasies, and other identified feeding issues.
For a child identified with medical special needs for dietary modification or special feeding techniques, written instructions from the child's parent or legal guardian and the child's health care provider shall be provided in the child's record and carried out accordingly. Dietary modifications shall be recorded, as specified in
STANDARD 8.050.
These written instructions must identify:
a) The child's special needs;
b) Any dietary restrictions based on the special needs;
c) Any foods to be omitted from the diet and any foods to be substituted;
d) Limitations of life activities;
e) Any other pertinent special needs information.
The Nutrition Specialist shall approve menus that accommodate needed dietary modifications.
RATIONALE: Child care homes and facilities should have explicit and written procedures for dietary modifications or meal substitutes. Dietary modifications for any child, including those with special health care needs, developmental problems of chewing and swallowing food, and food allergies, should be carefully monitored by a trained health professional, coordinated with the rest of the child's health care, and documented in the child's record. Periodic monitoring of dietary modifications or substitutions should provide opportunities to reevaluate the plan to ensure that the child's nutritional needs are met as the child grows and develops.
As a safety and health precaution, the staff should know in advance whether a child has food allergies, tongue thrust, special medical needs related to feeding, or requires nasogastric or gastric tube feedings or special positioning. These situations require individual planning prior to the child's entry into child care and on an ongoing basis (
8,
9).
Detailed information on a child's special needs is invaluable to the facility staff in meeting the nutritional needs of that child.
COMMENTS: Close collaboration between the home and the facility is needed for children on special diets Parents may have to provide food on a temporary or permanent basis if the facility, after exploring all community resources, is unable to provide the special diet.
For additional information on the Nutrition Specialist, see
STANDARD 4.027.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Written Menus, Introduction of New Foods
Facilities shall develop, at least one month in advance, written menus showing all foods to be served during that month and shall make them available to parents. The facility shall date and retain these menus; amended to reflect any changes in the food actually served. Any substitutions shall be of equal nutrient value.
To avoid problems of food sensitivity in very young children, child care providers shall obtain from the child's parents, a list of foods that have already been introduced (without any reaction), and then serve some of these foods to the child. As new foods are introduced, child care providers shall share and discuss these foods with the parents prior to their introduction.
RATIONALE: Planning menus in advance helps to ensure that food will be on hand. Parents 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 can address this issue with appropriate staff members. Some regulatory agencies require menus as a part of the licensing and auditing process (
2,
6).
COMMENTS: Making the menus available to parents by posting them in a prominent area helps inform parents about proper nutrition. Sample menus and menu planning templates are available from most state health departments, the state extension service, and the Child and Adult Care Food Program. Contact information for the State Administrators of the Child and Adult Care Food Program is located in
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Before any child enters a child care facility, the facility shall obtain a written history of any special nutrition or feeding needs the child has. The staff shall review this history with the child's parents. If further information is required, along with the parents' written consent, the program may consult with the child's primary health care provider.
The written history of special nutrition or feeding needs shall be used to develop individual feeding plans and, collectively, to develop facility menus. Disciplines related to special nutrition needs, including nursing, speech, and occupational and physical therapy, shall participate when needed and/or when they are available to the facility. With the exception of children on special diets, the general nutrition guidelines for facilities in General Requirements,
STANDARD 4.001 through
The feeding plan shall include steps to take when a situation arises that requires rapid response by the staff (such as a child's choking during mealtime or a child with a known history of food allergies demonstrating signs and symptoms of anaphylaxis). The completed plan shall be on file and accessible to the staff.
RATIONALE: Children with special needs may have individual requirements relating to diet, swallowing, and similar feeding needs that require the development of an individual plan prior to their entry into the facility.
Many children with special needs have difficulty with feeding, including delayed attainment of basic chewing, swallowing, and independent feeding skills. Food, eating style, utensils, and equipment, including furniture, may have to be adapted to meet the developmental and physical needs of individual children (
16).
Staff members must know ahead of time what procedures to follow, as well as their designated roles during an emergency.
Anaphylaxis is a severe, rapid immune response in an allergic individual. This response manifests itself in a collection of symptoms affecting multiple organ systems in the body. The most dangerous symptoms include difficulty breathing and shock. Anaphylaxis is life-threatening and should be considered a medical emergency requiring immediate recognition and treatment (
7,
8,
16).
In children, foods are the most common cause of anaphylaxis. Nuts, eggs, milk, and seafood are the most common allergens for food-induced anaphylaxis in children.
COMMENTS: Close collaboration between the home and the facility is necessary for children on special diets. Parents may have to provide food on a temporary or permanent basis if the facility, after exploring all community resources, is unable to provide the special diet.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Care for Children With Food Allergies
When children with food allergies attend the child care facility, the following shall occur:
a) Each child with a food allergy shall have a special care plan prepared for the facility by the child's source of health care, to include:
1) Written instructions regarding the food(s) to which the child is allergic and 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 shall include specific symptoms that would indicate the need to administer one or more medications;
b) Based on the child's special care plan, the child's caregivers shall 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 and staff shall arrange for the facility to have 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 child care facility;
d) Caregivers shall promptly and properly administer prescribed medications in the event of an allergic reaction according to the instructions in the special care plan;
e) The facility shall notify the parents 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 shall notify the child's physician if the child has required treatment by the facility for a food allergic reaction;
g) The facility shall contact the emergency medical services system immediately whenever epinephrine has been administered;
h) Parents of all children in the child's class shall be advised to avoid any known allergies in class treats or special foods brought into the child care setting.
i) Individual child's food allergies shall be posted prominently in the classroom and/or wherever food is served.
j) On field trips or transport out of the child care setting, the written child care plan for the child with allergies shall be routinely carried.
RATIONALE: Food allergy is common, occurring in between two and eight percent of infants and children (
17). Food allergic reactions can range from mild skin or gastrointestinal symptoms to severe, life-threatening reactions with respiratory and/or cardiovascular compromise. Deaths from food allergy are being reported in increasing numbers. A major factor in these deaths has been a delay in the administration of life-saving emergency medication, particularly epinephrine. Intensive efforts to avoid exposure to the offending food(s) are therefore warranted. Detailed care plans and the ability to implement such plans for the treatment of reactions is essential for all food-allergic children (
2,
8,
16).
Successful food avoidance requires a cooperative effort that must include the parents, the child, the child's health care provider, and the child care staff. The parents, with the help of the child's health care provider, must provide detailed information on the specific foods to be avoided. In some cases, especially for children with multiple food allergies, the parents may need to take responsibility for providing all the child's food. In other cases, the child care 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, such as milk being listed as casein, caseinate, whey, and lactoglobulin. Food sharing between children must be prevented by careful supervision and repeated instruction to the child about this issue. Accidental 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 play dough.
Some children with food allergy will have mild reactions and will only need to avoid the problem food(s). Others will need to have an antihistamine or epinephrine available to be used in the event of a reaction. For all children with a history of anaphylaxis, 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 pre-measured dose in an auto-injector, such as the Epi-Pen or Epi-Pen Junior. Specific indications for administration of epinephrine should be provided in the detailed care plan. In virtually all cases, Emergency Medical Services (EMS) should be called immediately and children should be transported to the emergency room by ambulance after the administration of epinephrine (
8). A single dose of epinephrine wears off in 15 to 20 minutes.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
4.3 REQUIREMENTS FOR SPECIAL GROUPS OR AGES OF CHILDREN
General Plan For Feeding Infants
At a minimum, meals and snacks the facility provides for infants shall contain the food in the meal and snack patterns shown in Appendix P. Food shall be appropriate for infants' individual nutrition requirements and developmental stages as determined by written instructions obtained from the child's parent or health care provider.
The facility shall encourage and support breastfeeding. Facilities shall have a designated place set aside for breastfeeding mothers who want to come during work to breastfeed (
18-
24).
The facility shall offer solid foods and fruit juices to infants 6 months of age and younger only upon the recommendation of the parent and the child's health professional.
RATIONALE: Human milk or iron-fortified formula is the infant's first food and supports rapid growth in both weight and length during the first year of life and beyond. Human milk, as an exclusive food, is best suited to meet the entire nutritional needs of an infant from birth until 6 months of age. Human milk is the best source of milk for infants for at least the first 12 months of age and, thereafter, for as long as mutually desired. Breastfeeding protects infants from many acute and chronic diseases and has advantages for the mother, as well.
Advantages for the infant include reduction of some of the risks that are greater for infants in group care. The advantages of breastfeeding documented by research include reduction in the incidence of diarrhea, lower respiratory disease, otitis media, bacteremia, bacterial meningitis, botulism, urinary tract infections, necrotizing enterocolitis, SIDS, insulin-dependent diabetes, lymphoma, allergic disease, ulcerative colitis, and other chronic digestive diseases (
20,
21). Some evidence suggests that breastfeeding is associated with enhanced cognitive development (
22,
25). Therefore, human milk is the ideal nutrient source for term and many preterm infants.
Except in the presence of rare genetic diseases, the clear advantage of human milk over any formula should lead to vigorous efforts by child care providers to promote and sustain breastfeeding for mothers who are willing to nurse their babies whenever they can and to pump and supply their milk to the child care 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 (
24).
Iron-fortified infant formula is the best next to human milk as a food for infant feeding. Supplementation with juice, cereal, and any other foods during the first 4 months of life is unnecessary and, for healthy infants, inappropriate. An adequately nourished infant is more likely to achieve normal physical and mental development, which will have long-term positive consequences on health (
7,
8).
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Introduction of Solid Foods to Infants
In consultation with the child's parent and health care provider, solid foods shall be introduced routinely at no sooner than 6 months of age, as indicated by an individual child's nutritional and developmental needs. Introduction of solids and fruit juices for breastfed infants shall be started at six months of age unless the parent or health provider specifically recommends otherwise. Modification of basic food patterns shall be provided in writing by the child's health care provider.
RATIONALE: Early introduction (prior to 6 months of age) of solid food interferes with the intake of human milk or iron-fortified formula that the infant needs for growth. Solid food given before an infant is developmentally ready may be associated with allergies and digestive problems. For breastfed infants, gradual introduction of iron-fortified foods should occur after 6 months, during which time these foods will complement the human milk. After 4 to 6 months of age, breastfed infants may require an additional source of iron in their diets. Infants who are not exclusively fed human milk should consume iron-fortified formula as the substitute for human milk. Infants on iron-fortified formula have an 8% risk for iron deficiency. Those exclusively breastfed have a 20% risk of iron deficiency by 9 to 12 months of age, and those consuming non fortified formula or whole cow's milk have the a 30% to 40% risk of iron deficiency by 9 to 12 months of age. In the United States, major non milk sources of iron in the infant diet are iron-fortified cereal and meats (
8).
The transitional phase of feeding which occurs around 6 months of age is a critical time of development of fine, gross, and oral motor skills. When an infant is able to 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, he/she 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 physiolo-gical development. Failure to introduce non-liquid food after 6 months of age may result in difficulties in introducing solid foods later. Variations in readiness for solid foods are common. While this standard states that the introduction of solids should start no sooner than 6 months of age for most infants, caregivers should be prepared to respond to a health care provider's recommendation for introduction of solids as early as 4 months of age for some infants.
Dental decay is transmissible. Bacteria which contri-bute to dental decay can be transmitted from caregivers to infants. Individuals with active tooth decay are more likely to transmit this bacteria to the children in their care.
COMMENTS: Early introduction of solids and fruit juices can interfere with breastfeeding or formula feeding. Many infants find juices appealing and may be satisfied by the calories in solids so they subsequently drink less human milk or formula (
15). When juice is introduced, it should be by cup rather than bottle to decrease the occurrence of dental caries. Infants do not need juice unless their stools become hard from under-hydration or introduction of solids.
Although many people believe that infants sleep better when they start to eat solids, research reported in 1998 shows that longer sleeping periods are developmentally and not nutritionally determined in mid-infancy (
8,
9).
A full daily allowance of Vitamin C is found in human milk (
25). Most breastfed infants do not require supplemental vitamins. The AAP recommends Vitamin D supplementation for selected groups of infants whose mothers may be Vitamin D deficient or those infants who are not exposed to adequate sunlight (
8, 18).
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Feeding Infants on Demand with Feeding by a Consistent Caregiver
Caregivers shall feed infants on demand unless the parent and the child's health care provider gives written instructions otherwise. Whenever possible, the same caregiver shall feed a specific infant for most of that infant's feedings.
RATIONALE: Demand 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.
When the same caregiver regularly works with a particular child, that caregiver is more likely to understand that child's cues and to respond appropriately.
COMMENTS: Caregivers should be gentle, patient, sensitive, and reassuring by responding appropriately to the infant's feeding cues. Cues such as opening the mouth, making suckling sounds, and moving the hands at random all send information from an infant to a caregiver. Early relationships between an infant and caregivers involving feeding set the stage for an infant to develop eating patterns for life.
Waiting for an infant to cry to indicate hunger is not necessary or desirable. 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.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Techniques for Bottle Feeding
When bottle feeding, caregivers shall either hold infants or feed them sitting up. Infants who are unable to sit shall always be held for bottle feeding.
The facility shall not permit infants to have bottles in the crib or to carry bottles with them either during the day or at night.
A caregiver shall not bottle feed more than one infant at a time.
RATIONALE: The manner in which food is given to infants is conducive to the development of sound eating habits for life. Caregivers should promote proper oral hygiene and feeding practices 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 (
8,
14,
18,
22,
26,
27).
Any liquid except plain water can cause early childhood dental caries (
8,
14,
18,
22,
26,
27). Early childhood dental caries in primary teeth may hold significant short-term and long-term implications for the child's health (
8,
14,
18,
22,
26,
27).
Children are at an increased risk for injury when they walk around with bottle nipples in their mouths. Glass bottles create a safety hazard if the bottle is dropped and broken. Bacteria introduced by saliva makes milk consumed over a period of more than an hour unsuitable and unsafe for consumption. For safety and sanitary reasons, bottles should not be allowed in the crib or bed, whether propped or not.
It is difficult for a caregiver to be aware of and respond to infant feeding cues when feeding more than one infant at a time.
COMMENTS: Caregivers and parents need to understand the relationship between dental caries and the milk or juice in a bottle used as a pacifier.
Caregivers should offer children fluids from a cup as soon as they are developmentally ready. Children may be able to drink from a sippy cup as early as 5 months of age while for others it is later. 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 by the child's first birthday.
Use of a bottle or cup in an effort to modify a child's behavior should not be allowed (
8,
28).
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Expressed human milk shall be placed in a clean and sanitary bottle and nipple that fits tightly to prevent spilling during transport to home or facility. The bottle shall be properly labeled with the infant's name. The bottle shall immediately be stored in the refrigerator on arrival. Expressed human milk shall be discarded if it presents a threat to a baby such as:
· Human milk is in an unsanitary bottle;
· Human milk that has been unrefrigerated for an hour or more;
· A bottle of human milk that has been fed over a period that exceeds an hour from the beginning of the feeding.
RATIONALE: This standard promotes the family's choice and practice of feeding human milk which is familiar to the infant. Child care providers should support and encourage this method of infant feeding because it is best for the infant.
Though human milk has antibacterial components, the bacterial load and the antibacterial component in any individual sample of human milk is unknown. When the infant feeds, the milk is inoculated by the infant's saliva and the bacteria in the infant's mouth. If the infant eats expressed milk from a bottle for periods in excess of an hour, bacteria could overwhelm the antibacterial components in the milk.
COMMENTS: The intent of this standard is to promote, support, and advocate feeding human milk by a mother because of the overwhelming benefits of human milk for infants. Using caution, providers can safely and properly store expressed human milk transported to the child care facility.
Chilled or frozen human milk may be transported from home to the child care facility in a cooler bag as long as the ambient temperature is below 86 degrees F and the out-of-refrigerator time is less than 2 hours.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Formula provided by parents or by the facility shall come in a factory-sealed container. The formula shall be of the same brand that is served at home and shall be of ready-to-feed strength or prepared according to the manufacturer's instructions, using water from a source approved by the health department.
Formula mixed with cereal, fruit juice, or any other foods shall not be served unless the child's source of health care provides written documentation that the child has a medical reason for this type of feeding.
RATIONALE: This standard promotes the feeding of a formula 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, there
