Caring for Our Children: Chapter 4 - Nutrition and Food Service Chapter 4: Nutrition and Food Service 4.1 INTRODUCTION 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 physical 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 . 4.2 GENERAL REQUIREMENTS STANDARD 4.001 Written Nutrition Plan 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, STANDARD 4.069, for nutrition learning experiences with this plan. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 4.002 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 STANDARD 4.003 Meal Pattern 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 STANDARD 4.004 Categories of Foods 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 STANDARD 4.005 Juice 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 STANDARD 4.006 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 obesity. 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 STANDARD 4.007 Dietary Modifications 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 STANDARD 4.008 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 Appendix BB. For information on posting menus, see STANDARD 8.077. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 4.009 Feeding Plans 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 STANDARD 4.010; Nutrition for Infants, STANDARD 4.011 through STANDARD 4.021; Nutrition for Toddlers and Preschoolers, STANDARD 4.022 through STANDARD 4.024; and Nutrition for School-age Children, STANDARD 4.025, shall be applied. 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 STANDARD 4.010 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 NUTRITION FOR INFANTS STANDARD 4.011 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 STANDARD 4.012 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 STANDARD 4.013 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 STANDARD 4.014 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 STANDARD 4.015 Feeding Human Milk 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. See STANDARD 3.027 and STANDARD 6.035 for accidental feeding of human milk to another mother's child. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 4.016 Preparing Infant Formula 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, thereby reducing the risk of inaccuracy or feeding the infant unsanitary formula. Written guidance for both staff and parents must be available to determine when formula provided by parents will not be served as described in the standard above about unsanitary and unsafe formula. If a child has a special health problem, such as reflux, or inability to take in nutrients because of delayed development of feeding skills, the child's health professional should provide a written plan for the staff to follow so that the child is fed appropriately. COMMENTS: The intent of this standard is to protect a child's health by reducing the risk of unsanitary and unsafe conditions of transporting infant formula prepared at home and brought to the facility. To make infant formula bottles, the facility does not have to keep more than one container of the same brand and type of formula open at the same time. Parents can contribute their child's share of the formula or a share of the cost for a brand of formula the facility feeds to more than one infant. The bottles must be sanitary, properly prepared and stored, and must be the same brand in child care and at home. In many communities, the sanitation standard for community water is high enough that tap water could be used, but this may vary from time to time and from community to community. Unless local health authorities recommend otherwise, water should be brought to a rolling boil before being used to make formula from concentrate or powder. A safe source of water (usually tap water that is prepared fresh daily by being brought to a rolling boil) can be kept at room temperature. This water can be used by adding powdered formula to a bottle of water just before feeding (8, 18, 28). Bottles made in this way from powdered formula do not require refrigeration or warming and are promptly ready for feeding. The caregiver can make up whatever amount the infant seems to need at the time. Staff preparing formula shall thoroughly wash their hands prior to beginning preparation of infant feedings of any type. Powdered formula is the least expensive type of formula. Providers shall only use the scoop that comes with the can and not interchange the scoop from one product to another, since the volume of the scoop may vary from manufacturer to manufacturer and product to product. Although many infant formulas are made from powder, the liquid preparations are diluted with water at the factory. Concentrated infant formula, not ready-to feed, must be diluted with water. Sealed, ready-to-feed bottles are easy to use also, but they are the most expensive approach to feeding formula. Although some children have a medical indication for alternative feeding practices, feeding of solids and fruit beverages in the bottle to the child is often associated with premature feeding of these foods (when the infant is not developmentally ready for them) (8, 10, 16, 18, 25). TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 4.017 Preparation and Handling of Bottle Feeding Only cleaned and sanitized bottles, or their equi-valent, and nipples shall be used. All filled containers of human milk shall be of the ready-to-feed type, identified with a label which won't come off in water or handling, bearing the date of collection and child's full name. The filled, labeled containers of human milk shall be kept frozen or refrigerated, and iron-fortified formula shall be refrigerated until immediately before feeding. Any contents remaining after a feeding shall be discarded. Prepared bottles of formula from powder or concentrate or ready-to-feed formula shall be labeled with the child's name and date of preparation, kept refrigerated, and shall be discarded after 48 hours if not used. An open container of ready-to-feed or concentrated formula shall be covered, refrigerated, and discarded after 48 hours if not used. Unused expressed human milk shall be discarded after 48 hours if refrigerated, or by three months if frozen, and stored in a deep freezer at 0 degrees F. Unused frozen human milk which has been thawed in the refrigerator shall be used within 24 hours. Frozen human milk shall be thawed under running cold water or in the refrigerator. Human milk from a mother shall be used only with that mother's own child. A bottle that has been fed over a period that exceeds an hour from the beginning of the feeding or has been unrefrigerated an hour or more shall not be served to an infant. RATIONALE: Identification of the bottles prevents the potential for cross-infection when the facility is caring for more than one bottle-fed infant (2, 8). Placing human milk in ready-to-feed bottles (including single-use bags in a plastic holder) decreases the potential for exposure and spills. Infants should not be fed a formula different from the one the parents feed at home or human milk intended for another infant, as even minor differences in formula and the specific components of human milk can cause gastrointestinal upsets and other problems (54). Bottled formula that has been fed should not be reused because the formula will have been contaminated with saliva and bacteria, which could multiply to spoil the formula before the bottle is refed. This is especially true if the bottle is out of refrigeration for the first feeding for an hour or more and then reheated. Open containers of powdered formula are not safe to use beyond the stated shelf period (8). It is difficult to maintain 0 degrees F consistently in a freezer compartment of a refrigerator or freezer, so caregivers should carefully monitor temperature of freezers used to store human milk using an appropriate working thermometer. Human milk contains components that are damaged by excessive heating during or after thawing from the frozen state (54). Labels for containers of human milk should be resistant to loss of the name and date when washing and handling.This is especially important when the frozen bottle is thawed in running tap water. There may be several bottles from different mothers being thawed and warmed at the same time in the same place. Frozen milk should never be thawed in a microwave oven. COMMENTS: See STANDARD 4.018, regarding bottle warming and microwave ovens. STANDARD 3.027 regarding accidental feeding of human milk to another mother's child. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Hom e STANDARD 4.018 Warming Bottles and Infant Foods Bottles and infant foods shall be warmed under running warm tap water or by placing them in a container of water that is no warmer than 120 degrees F Bottles shall not be left in a pot of water to warm for more than 5 minutes. Bottles and infant foods shall not be warmed in a microwave oven. After warming, bottles shall be mixed gently and the temperature of the milk tested before feeding. Infant foods shall be stirred carefully to distribute the heat evenly. A caregiver shall not hold an infant while removing a bottle or infant food from the container of warm water or while preparing a bottle or stirring infant food that has been warmed in some other way. If a slow-cooking device, such as a crock pot, is used for warming infant formula, human milk, or infant food, this slow-cooking device shall be out of children's reach, shall contain water at a temperature that does not exceed 120 degrees F. and shall be emptied, sanitized, and refilled with fresh water daily. RATIONALE: Bottles of formula or human milk that are warmed at room temperature or in warm water for an extended time provide an ideal medium for bacteria to grow. Infants have received burns from hot water dripping from an infant bottle that was removed from a crock pot or by pulling the crock pot down on themselves by a dangling cord. Caution should be exercised to avoid raising the water above a safe level for warming infant formula or infant food. Studies have documented the dangers of using microwave ovens for heating human milk, formula, or food to be fed to infants (29, 55). Excessive shaking of human milk may damage some of the cellular components that are valuable to the infant, as may excessive heating. Excessive shaking of formula may cause foaming that increases the likelihood of feeding air to the infant. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Hom e STANDARD 4.019 Cleaning and Sanitizing Equipment Used for Bottle feeding Bottles, bottle caps, nipples and other equipment used for bottle feeding shall not be reused without first being cleaned and sanitized by washing in a dishwasher or by washing, rinsing and boiling for one minute. RATIONALE: Infant feeding bottles are contaminated by the child's saliva during feeding. Formula and milk promote growth of bacteria. To avoid contamination of subsequent feedings, bottles, bottle caps, and nipples that are reused should be washed and sanitized. COMMENTS: Excessive boiling of latex bottle nipples will damage them. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 4.020 Feeding Cow's Milk The facility shall not serve any cow's milk to infants from birth to 12 months of age and shall serve only whole, pasteurized milk to children between 12 and 24 months of age who are not on formula or human milk. The facility shall not serve skim milk, reconstituted nonfat dry milk, or milk containing 1% or 2% butterfat to any child between 12 and 24 months of age, except with the written direction of a parent and the child's health care provider. RATIONALE: Low-fat milk does not provide enough calories and nutrients for children from 1 to 2 years of age. If a child seems to be gaining weight excessively, he or she should be referred to the primary health care provider. The American Academy of Pediatrics recommends that whole cow's milk not be used during the first year of life (7, 8, 18, 28, 53). COMMENTS: This standard is consistent with the recommendation of the American Academy of Pedi-atrics for feeding children to 2 years of age, when brain development requires a certain amount of fat in the diet. Although obesity can be a problem, it can be controlled by volume of intake and balance with other desirable foods instead of reducing the fat content of milk in children younger than 2 years of age. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 4.021 Feeding Solid Foods To Infants Staff members shall serve commercially packaged baby food from a dish, not directly from a factory-sealed container. They shall serve solid food by spoon only. They shall discard uneaten food in dishes from which they have fed a child. The facility shall wash off all jars of baby food with soap and warm water before opening the jars, and examine the food carefully when removing it from the jar to make sure there are not glass pieces or foreign objects in the food. Food shall not be shared among children using the same dish or spoon. Unused portions in opened factory-sealed baby food containers or food brought in containers prepared at home shall be stored in the refrigerator and discarded if not consumed after 24 hours of storage. Solid food shall not be fed in a bottle or in an infant feeder unless the child has specific written instructions from a health professional to do so. RATIONALE: The external surface of a commercial container may be contaminated with disease-causing microorganisms during shipment or storage and may contaminate the food product during feeding. A dish should be cleaned and sanitized before use, thereby reducing the likelihood of surface contamination. Any food brought from home should not be served to other children. This will prevent cross-contamination and reinforce the policy that food sent to the facility is for the designated child only. Uneaten food should not be put back into its original container for storage because it may contain potentially harmful bacteria from the infant's saliva. Solid food should not be fed in a bottle or an infant feeder apparatus because of the potential for choking. In addition, this method teaches the infant to eat solid foods incorrectly. COMMENTS: For additional information on nutrition for infants, seeSTANDARD 8.036. See also STANDARD 4.038, on the size of food pieces to serve infants, and STANDARD 4.035 and STANDARD 4.036, on supervision of feeding. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home NUTRITION FOR TODDLERS AND PRESCHOOLERS STANDARD 4.022 Meal and Snack Patterns At a minimum, meals and snacks the facility provides for toddlers and preschoolers shall contain the meal and snack patterns shown for these age groups in Appendix Q. RATIONALE: During periods of slower growth, the children must eat nutritious foods. With limited appetites and selective eating of toddlers and preschoolers, less nutritious foods can easily displace more nutritious foods from the child's diet. COMMENTS: A nutritional analysis of the requirements in Appendix Q was conducted to ensure that a snack and lunch meet two-thirds of the Recommended Dietary Allowances (30). Children who are eating more than one snack and one meal may not want all the food offered at any one of these times. On the other hand, toddlers and preschoolers may eat only some meals or some snacks. The amount of food offered to them must be sufficient to meet their needs at that point. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 4.023 Portions for Toddlers and preschoolers The facility shall serve toddlers and preschoolers small-sized portions and shall permit them to have one or more additional servings as needed to meet the needs of the individual child. RATIONALE: Gradual extension of the diet begun in infancy should continue throughout the preschool period. A child will not eat the same amount each day because appetites vary and food "jags" are common (8, 10-12, 28). If normal variations in eating patterns are accepted without comment, feeding problems usually do not develop. Requiring that a child eat a specified food or amount of food may lead to eating problems. Eating habits established in infancy and early childhood possibly may contribute to problems later in life. Including nutritious snacks in the daily meal plan will help to ensure that the child's nutrient needs are met. The quality of snacks for young children is especially important, and small, frequent feedings are recommended to achieve the total desired daily intake. COMMENTS: Continuing to meet the child's needs for growth and activity is important. During the second and third years of life, the child grows much less rapidly than during the first year of life. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 4.024 Encouraging Self-Feeding By Toddlers Caregivers shall encourage toddlers to hold and drink from a cup, to use a spoon, and to use their fingers for self-feeding. RATIONALE: As children enter the second year of life, they are interested in doing things for themselves. Self-feeding appropriately separates the responsibilities of adults and children. The adult is responsible for providing nutritious food, and the child for deciding how much of it to eat (6, 8, 10, 28, 31). To allow for the proper development of motor skills and eating habits, children need to be allowed to practice learning to feed themselves. COMMENTS: Foods served should be appropriate to the toddler's developmental ability. For additional information on nutrition for toddlers and preschoolers, see STANDARD 4.014 through STANDARD 4.019, on bottle feeding, STANDARD 4.038, on the size of food pieces to serve toddlers and preschoolers, and STANDARD 4.035 and STANDARD 4.036, on supervision of feeding. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home NUTRITION FOR SCHOOL-AGE CHILDREN STANDARD 4.025 Meal and Snack Patterns for School-Age Children Meals and snacks the facility provides for school-age children, including those in school-age child care facilities, shall contain at a minimum the meal and snack patterns shown for this age group in Appendix Q. Children attending facilities for 2or more hours after school need at least one snack. RATIONALE: The principles of providing adequate, nourishing food for younger children apply to this group as well. This age is characterized by a rapid rate of growth that increases the need for energy and essential nutrients to support optimal growth. Food intake may vary considerably because this is a time when children express strong food likes and dislikes. The quantity and quality of food provided should contribute toward meeting nutritional needs for the day and should not dull the appetite (3, 4, 6, 10, 28). COMMENTS: A nutritional analysis was conducted of the requirements in Appendix Q, to ensure that a snack and lunch meet two thirds of the Recommended Dietary Allowances (31). TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home 4.4 STAFFING STANDARD 4.026 Food Service Staff by Type of Facility and Food Service Each center-based facility shall employ trained staff and provide ongoing supervision and consultation in accordance with individual site needs as determined by the Child Care Nutrition Specialist (see Appendix C). In centers, prior work experience in food service shall be required for the solitary worker responsible for food preparation without the continuous on-site supervision of a food service manager. For facilities operating 6 or more hours a day or preparing and serving food on the premises, the following food service staff requirements shall apply: SETTING FOOD SERVICE STAFF Small and large family child care homes Caregiver Centers serving up to 30 children Full-time child care Food Service Worker (cook) Centers serving up to 50 children Full-time child care Food Service Worker (cook) and part-time child care Food Service Aide Centers serving up to 125 children Full-time child care Food Service Manager or full-time child care Food Service Worker (cook) and full-time child care Food Service Aide Centers serving up to 200 children Full-time child care Food Service Manager and full-time child care Food Service Worker (cook) and one full-time plus one part-time child care Food Service Aide Vendor food service One assigned staff member or one part-time staff member, depending on amount of food service preparation needed after delivery RATIONALE: Trained personnel working in the food service component of facilities is essential to meet the nutrition standards required in these facilities (6, 10, 28, 31-33). Home cooking experience is not enough when large volumes of food must be served to children and adults. The type of food service, type of equipment, number of children to be fed, location of the facility, and food budget determine the staffing patterns. An adequate number of food service personnel is essential to meet the goals and objectives of the facility and ensure that children are fed according to the facility's daily schedule. If the facility serves only food brought from home, food service staff are needed to oversee the appropriate use of such food if the facility operates for 6 or more hours a day. COMMENTS: The food service staff may not necessarily consist of full-time or regular staff members but may include some workers hired on a consulting or contractual basis. Resources for food service staff include vocational high school food preparation programs, university and community college food preparation programs, and trade schools that train cooks and chefs. TYPE OF FACILITY: Center, Large Family Child Care Home, Small Family Child Care Home STANDARD 4.027 Child Care Nutrition Specialist A local Child Care Nutrition Specialist (see Appendix C) or food service expert shall be employed to work with the architect or engineer on the design of the parts of the facility involved in food service, to develop and implement the facility's nutrition plan (see STANDARD 8.035) and to prepare the initial food service budget. The nutrition plan encompasses: a) Kitchen layout; b) Food procurement, preparation, and service; c) Staffing; d) Nutrition education. When contemplating alterations in the nutrition plan, such as installing a new dishwasher or expanding storage or dining areas, the procedure to be followed shall be the same as for new construction or renovation. The food service expert shall be involved in the decision-making and shall oversee carrying out completion of the plan. RATIONALE: Efficient and cost-effective food service in a facility begins with a plan and evaluation of the physical components of the facility. Planning for the food service unit includes consideration of location and adequacy of space for receiving, storing, preparing, and serving areas; cleaning up; dish washing; dining areas, plus space for desk, telephone, records, and employee facilities (such as handwashing sinks, toilets, and lockers). All facets must be considered for new or existing sites, including remodeling or renovation of the unit (10-12, 28). TYPE OF FACILITY: Cente r 4.5 MEAL SERVICE, SEATING, AND SUPERVISION STANDARD 4.028 Developmentally Appropriate Seating and Utensils for Meals The child care staff shall ensure that children who do not require highchairs are comfortably seated at tables that are between waist and mid-chest level and allow the child's feet to rest on a firm surface while seated for eating. All furniture and eating utensils that a child care agency/facility uses shall enable children to eat at their best skill level and to increase their eating skill. RATIONALE: Proper seating while eating reduces the risk of food aspiration and improves comfort in eating (32). Suitable furniture and utensils provide comfort, enable the children to perform eating tasks they have already mastered, and facilitate the development of skill and coordination in handling food and utensils (10-12, 28). COMMENTS: Eating utensils should be unbreakable, durable, attractive, and suitable in function, size, and shape for use by children. Dining areas should be clean and cheerful (2, 4, 6, 10, 28). Compliance is measured by observation of the fit of furniture for children. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 4.029 Tableware and Feeding Utensils Tableware and feeding utensils shall meet the following requirements: a) Dishes shall have smooth, hard, glazed surfaces and shall be free from cracks or chips. Sharp-edged plastic utensils intended for use in the mouth or dishes that have sharp or jagged edges shall not be used. b) Disposable tableware (such as plates, cups, utensils) made of heavy weight paper or food-grade medium weight plastic shall be permitted for single service if they are discarded after use. The facility shall not use Styrofoam tableware for children under 4 years of age. c) Single-service articles (such as napkins, paper placemats, paper tablecloths, and paper towels) shall be discarded after one use. d) Washable placemats, bibs, napkins, and tablecloths, if used, shall be laundered or washed, rinsed, and sanitized after each meal. Fabric articles shall be sanitized by being machine-washed and dried after each use. e) Highchair trays, plates, and all items used in food service that are not disposable shall be washed, rinsed, and sanitized. Tables and highchair trays that are used for eating shall be washed, rinsed, and sanitized just before and right after they are used for eating. Children who eat at tables shall have disposable or washed and sanitized plates for their food. f) Imported dishes and imported ceramic dishware or pottery shall be certified by the regulatory health authority to meet U.S. standards and to be safe from lead or other heavy metals before they can be used. g) All surfaces in contact with food shall be lead-free. RATIONALE: Clean food service utensils, napkins, bibs, and tablecloths prevent the spread of microorganisms that can cause disease. The surfaces that are in contact with food must be sanitary. Food should not be put directly on the table surface for two reasons. First, even washed and sanitized tables are more likely to be contaminated than disposable plates or washed and sanitized dishes. Second, learning to eat from plates reduces contamination of the table surface when children put down their partially eaten food while they are eating. Although highchair trays can be considered tables, they function as plates for seated children. The tray should be washed and sanitized in the same way as plates and other food service utensils (2, 6, 10). The use of disposable items eliminates the spread of contamination and disease and fosters safety and injury prevention. Single-service items are usually porous. Items intended for reuse must be capable of being washed, rinsed, and sanitized. Sharp-edged plastic spoons can cut soft oral tissues, especially when an adult is feeding a child and slides the spoon out of the child's closed mouth. Older children can cut their mouth tissues the same way. Styrofoam can break into pieces that could become choking hazards for young children. Imported dishware may be improperly fired and may release toxic levels of lead into food. U.S. government standards prevent the marketing of domestic dishes with lead in their glazes. There is no safe level of lead in dishware. COMMENTS: Ideally, food should not be placed directly on highchair trays, as studies have shown that highchair trays can be loaded with infectious microorganisms. If the highchair tray is made of plastic, is in good repair, and is free from cracks and crevices, it can be made safe if it is washed and sanitized before placing a child in the chair for feeding and if the tray is washed and sanitized after each child has been fed. Food must not be placed directly on highchair trays made of wood or metal, other than stainless steel, to prevent contamination by infectious microorganisms or toxicity from metals. If in doubt about whether tableware is safe and sanitary, consult the regulatory health authority or local health department. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 4.030 activities That Are Incompatible With Eating The child care staff shall ensure that children do not eat when walking, running, playing, lying down, or riding in vehicles. RATIONALE: Children should be seated when eating (6, 10, 28, 33). This reduces the risk of aspiration (6, 9, 10-12). TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Hom e STANDARD 4.031 Socialization During Meals Caregivers shall sit at the table and shall eat the meal or snack with the children. Family style meal service shall be encouraged, except for infants and very young children who require that an adult feeds them. The adult(s) shall encourage social interaction and conversation about the concepts of color, quantity, number, temperature of food, and events of the day. Extra assistance and time shall be provided for slow eaters. Eating should be an enjoyable experience at the facility and at home. RATIONALE: The presence of an adult or adults, who eat with the children, offers a role model and helps prevent behaviors that increase the possibility of fighting, feeding each other, stuffing food into the mouth, and other negative behaviors. Conversation at the table adds to the pleasant mealtime environment and provides opportunities for informal modeling of appropriate eating behaviors and communication of nutrition education (2, 6, 10, 28). The future development of children depends, to no small extent, on their command of language, and richness of language increases as adults and peers nurture it (28). Family style meals encourage children to serve themselves (10-12, 28). In addition to being nourished by food, eating experiences help infants and young children to establish warm human relationships. When children lack the developmental skills for self-feeding, they will be unable to serve food to themselves. As soon as a child learns to finger-feed, taking finger foods from a serving plate becomes possible and desirable. COMMENTS: Compliance is measured by structured observation. Use of small pitchers, a limited number of portions on service plates, and adult assistance to enable children to successfully serve themselves helps to make family style service possible without contamination or waste of food. See STANDARD 4.069 Plan For Food and Feeding Experience. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 4.032 Participation of Older Children and Staff in Mealtime activities Both older children and staff shall be actively involved in serving food and other mealtime activities, such as setting and cleaning the table, with provision for staff to supervise and assist children with appropriate handwashing procedures and sanitizing of eating surfaces and utensils to prevent cross contamination. RATIONALE: Children develop self-help and new motor skills as well as increase their dexterity through this type of involvement. Children require close supervision from staff and adults when they use knives and have contact with food surfaces and food that other children will use. COMMENTS: Compliance is measured by structured observation. TYPE OF FACILITY : Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 4.033 Experience with Familiar and New Foods In consultation with the family and child care nutrition specialist, caregivers shall offer children familiar foods that are typical of the child's culture and religious preferences, and shall also introduce a variety of healthful foods that may not be familiar, but meet a child's nutritional needs. RATIONALE: By learning about new food, children increase their knowledge of the world around them, and the likelihood that they will choose a more varied, better balanced diet in later life. Eating habits and attitudes about food formed in the early years often last a lifetime. TYPE OF FACILITY : Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 4.034 Hot Liquids and Foods Adults shall not consume hot liquids in child care areas. They shall keep hot liquids and hot foods out of the reach of infants, toddlers, and preschoolers. Adults shall not place hot liquids and foods at the edge of a counter or table, or on a tablecloth that could be yanked down, while the adult is holding or working with a child. Electrical cords from coffee pots shall not be allowed to hang within the reach of children. Food preparers shall position pot handles toward the back of the stove. RATIONALE: The most common burn in young children is scalding from hot liquids tipped over in the kitchen (34-36). TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 4.035 Numbers of Children Fed Simultaneously By One Adult One adult shall not feed more than one infant or three children who need adult assistance with feeding at the same time. RATIONALE: Cross-contamination among children whom one adult is feeding simultaneously poses significant risk. In addition, mealtime should be a socializing occasion. Feeding more than three children at the same time necessarily resembles an impersonal production line. It is difficult for the caregiver to be aware of and respond to infant feeding cues when feeding more than one infant at a time. Children with a special need for feeding assistance may need one-on-one supervision. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Hom e STANDARD 4.036 Location of The Adult Supervising Children Feeding Themselves Children in mid-infancy who are learning to feed themselves shall be supervised by an adult seated within arm's reach of them at all times while being fed. Children over 12 months of age who can feed themselves shall be supervised by an adult who is seated at the same table or within arm's reach of the child's highchair or feeding table. RATIONALE: A supervising adult should watch for several common problems that typically occur when children in mid-infancy begin to feed themselves. "Squirreling" of several pieces of food in the mouth increases the likelihood of choking. Supervised eating also promotes the child's safety by discouraging activities that can lead to choking. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 4.037 Food That Are Choking Hazards Caregivers shall not offer to children under 4 years of age foods that are implicated in choking incidents (round, hard, small, thick and sticky, smooth, or slippery). Examples of these foods are hot dogs (whole or sliced into rounds), raw carrot rounds, whole grapes, hard candy, nuts, seeds, raw peas, hard pretzels, chips, peanuts, popcorn, marshmallows, spoonfuls of peanut butter, and chunks of meat larger than can be swallowed whole. RATIONALE: These are high-risk foods, often implicated in choking incidents (37). Ninety percent of fatal chokings occur in children younger than 4 years of age (6-8, 10-12). Peanuts may block the lower airway. A chunk of hot dog or a whole grape may completely block the upper airway (6-8, 10-12, 38). COMMENTS: To reduce the risk of choking, menus should reflect the developmental abilities of the age of children served. Lists of high-risk foods should be made available. The presence of molars is a good indication of a healthy child's ability to chew hard foods (such as raw carrot rounds) that are likely to cause choking. Although dried fruits are sometimes mentioned as food hazards, a search of the literature does not identify a single instance when raisins were associated with a lethal choking incident. Because raisins are wrinkled, air likely gets around them, enabling the child's cough to remove them from the airway (37-39). TYPE OF FACILITY : Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 4.038 Progression of Experiences with Food Textures For infants, foods shall be fed which are age and developmentally appropriate. Foods shall progress from pureed to ground to finely mashed to finely chopped as an infant develops. When children are ready for chopped foods, these foods shall be cut into small pieces no larger than thin slices. For toddlers, foods shall be cut up in small pieces no larger than 1/2-inch cubes (11, 12, 37). RATIONALE: Often, infants and toddlers swallow pieces of food whole without chewing. TYPE OF FACILITY : Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 4.039 Prohibited Uses of Food Caregivers shall encourage, but not force, children to eat. Caregivers shall not use food as a reward or punishment. RATIONALE: Children who are forced to eat or for whom adults use food to modify behavior come to view eating as a tug-of-war and are more likely to develop lasting food dislikes and unhealthy eating behaviors. Offering food as a reward or punishment places undue importance on food and may have negative effects on the child by promoting "clean the plate" responses that may lead to obesity or poor eating behavior (2, 6, 8, 10, 28). TYPE OF FACILITY : Center; Large Family Child Care Home; Small Family Child Care Home 4.6 FOOD BROUGHT FROM HOME STANDARD 4.040 Selection and Preparation of Food Brought From Home The parent (or legal guardian) shall provide meals upon written agreement between the parent and the staff. Food brought into the facility shall have a label showing the child's name, the date, and the type of food. Lunches and snacks the parent provides for one child's eating shall not be shared with other children. When foods are brought to the facility from home or elsewhere, these foods shall, to the extent reasonable, be limited to whole fruits (like apples, oranges, or pears) and commercially packaged foods. When whole fruit is not reasonable (such as cantaloupe or watermelon), a written policy shall be in place regarding how the food must be prepared by the adult who is responsible for cutting the fruit for the child. Potentially hazardous and perishable foods shall be refrigerated, as specified in Food Safety, STANDARD 4.050 through STANDARD 4.060, and all foods shall be protected against contamination. RATIONALE: Foodborne illness and poisoning from food is a common occurrence when food has not been properly refrigerated and covered. Although many of these illnesses are limited to vomiting and diarrhea, sometimes they are life-threatening. Restricting food sent to the facility to the designated child reduces the risk of food poisoning from unknown procedures used in home preparation and transport. Food brought from home should be nourishing, clean, and safe for a child, and the other children should not be exposed to the unknown risk. The facility has an obligation to ensure that any food shared with other children complies with the food and nutrition guidelines for meals and snacks that the child care facility should observe. COMMENTS: Some local health and/or licensing jurisdictions prohibit foods being brought from home. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 4.041 Nutritional quality of Food Brought From Home The facility shall provide parents with written guidelines that the facility has established to meet the nutritional requirements of the children in the facility's care and suggested ways parents can assist the facility in meeting these guidelines. The facility shall have food available to supplement a child's food brought from home if the food brought from home is deficient in meeting the child's nutrient requirements. If the food the parent provides consistently does not meet the nutritional or food safety requirements, the facility shall provide the food and refer the parent for consultation to a Child Care Nutrition Specialist (see Appendix C), to the child's primary health care provider, or to community resources with trained nutritionists/dietitians (such as WIC, extension services, and health departments). RATIONALE: The caregiver/facility has a responsibility to follow feeding practices that promote optimum nutrition that supports growth and development in infants, toddlers, and children. Child care providers/facilities who fail to follow best feeding practices even when parents wish such counter practices to be followed negate their basic responsibility of protecting a child's health, social, and emotional well being. COMMENTS: See also nutrition requirements in General Requirements, STANDARD 4.001 through STANDARD 4.010, and Requirements for Special Groups of Children, STANDARD 4.011 through STANDARD 4.025. For additional information on food brought from home, see STANDARD 1.031, on training for food handlers. TYPE OF FACILITY : Center; Large Family Child Care Home; Small Family Child Care Hom e 4.7 KITCHEN AND EQUIPMENT STANDARD 4.042 Food Preparation Area The food preparation area of the kitchen shall be separate from eating, play, laundry, toilet, and bathroom areas and from areas where animals are permitted, and shall not be used as a passageway while food is being prepared. Food preparation areas shall be separated by a door, gate, counter, or room divider from areas the children use for activities unrelated to food, except in small family child care homes when separation may limit supervision of children. Infants and toddlers shall not have access to the kitchen in child care centers. Access by older children to the kitchen of centers shall be permitted only when supervised by staff members who have been certified by the Child Care Nutrition Specialist (see Appendix C) or the center director as qualified to follow the facility's sanitation and safety procedures. In all types of child care facilities, children shall never be in the kitchen unless they are directly supervised by a caregiver. Children of preschool-age and older shall be restricted from access to areas while hot food is being prepared. School-age children may engage in food preparation activities. Parents and other adults shall be permitted to use the kitchen only if they know and follow the food safety rules of the facility. The facility shall check with local health authorities about any additional regulations that apply. RATIONALE: The presence of children in the kitchen increases the risk of contamination of food as well as injury to children from burns and use of kitchen appliances and cooking techniques that require more skill than could be expected for their developmental level. The most common burn in young children is scalding from hot liquids tipped over in the kitchen (34-36). The kitchen should be used only by authorized individuals who have met the requirements of the local health authority and who know and follow the food safety rules of the facility so they do not contaminate food and food surfaces for subsequent food-related activities. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 4.043 Design of Food Service Equipment Food service equipment shall be designed, installed, operated, and maintained according to the manufacturer's instructions and in a way that meets the equivalent performance and health standards of the National Sanitation Foundation or applicable local or State public health authority, or the U. S. Department of Agriculture (USDA) food program and sanitation codes, as determined by the regulatory public health authority. RATIONALE: The design, installation, operation, and maintenance of food service equipment must follow the manufacturer's instructions and meet the standards for such equipment to ensure that the equipment protects the users from injury and the consumers of foods prepared with this equipment from foodborne disease (40). The manufacturer's warranty that equipment will meet recognized standards is valid only if the equipment is properly maintained. COMMENTS: Inspectors with appropriate training should periodically check food service equipment and provide technical assistance to facilities. The local public health department typically conducts such inspections. Manufacturers should attest to their compliance with equipment standards of the National Sanitation Foundation (NSF) and the Code of Federal Regulations, Part 200, Section 354.210 (revised January 1990), USDA Food Safety and Inspection Service. Testing labs such as Underwriters Laboratories (UL) also test food service equipment. Contact information for the NSF, the USDA, and the UL is located in Appendix BB. Before making a purchase, child care facilities should not only check the warranty but also the maintenance instructions provided by the equipment manufacturer to be sure the required maintenance is feasible, given the facility's resources. If the facility receives inspections from the public health department, the facility may want to consult with them before making a purchase. The facility director or food service staff should retain maintenance instructions and check to be sure that all users of the equipment follow the instructions. TYPE OF FACILITY : Center STANDARD 4.044 Maintenance of Food Service Surfaces and Equipment All surfaces that come into contact with food, including tables and countertops, as well as floors and shelving in the food preparation area shall be in good repair, free of cracks or crevices, and shall be made of smooth, nonporous material that is kept clean and sanitized. All kitchen equipment shall be clean and shall be maintained in operable condition according to the manufacturer's guidelines for maintenance and operation. The facility shall maintain an inventory of food service equipment that includes the date of purchase, the warranty date, and a history of repairs. RATIONALE: Cracked or porous materials must be replaced because they trap food and other organic materials in which microorganisms can grow. Harsh scrubbing on these areas tends to create even more areas where organic material can lodge and increase the risk of contamination. Repairs with duct tape, package tapes, and other commonly used materials add surfaces that trap organic materials. Cracked, chipped, or porous materials that can harbor organic material must be replaced. Food service equipment is designed by the manufacturer for specific types of use. The equipment must be maintained to meet those performance standards or food will become contaminated and spoil. An accurate and ongoing inventory of food service equipment tracks maintenance requirements and can provide important information when a breakdown occurs. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Hom e STANDARD 4.045 Food Preparation Sinks The sink used for food preparation shall not be used for handwashing or any other purpose. Handwashing sinks and sinks involved in diaper changing shall not be used for food preparation. All food service sinks shall be supplied with hot and cold running water under pressure. RATIONALE: Separation of sinks used for handwashing or other potentially contaminating activities from those used for food preparation prevents contamination of food. Hot and cold running water are essential for thorough cleaning and sanitizing of equipment and utensils and cleaning of the facility. COMMENTS: See STANDARD 4.065 for water temperature for cleaning and sanitizing dishes in the absence of a dishwasher and STANDARD 5.040, on hot water at sinks. TYPE OF FACILITY : Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 4.046 Handwashing Sink Separate From Food Zones Centers shall provide a separate handwashing sink in the facility. It shall have an 8-inch-high splash guard or have 18 inches of space between the handwashing sink and any open food zones (such as preparation tables and food sink). Where continuous water pressure is not available, handwashing sinks shall have at least 30 seconds of continuous flow of water to initiate and complete handwashing. RATIONALE: Separation of sinks used for handwashing or other potentially contaminating activities from those used for food preparation prevents contamination of food. Proper handwashing requires a continuous flow of water, no less than 60 degrees F and no more than 120 degrees F, to allow sufficient time for wetting and rinsing the hands. TYPE OF FACILITY : Center STANDARD 4.047 Maintaining Safe Food Temperatures The facility shall use refrigerators that maintain food temperatures of 40 degrees F or lower in all parts of the food storage areas, and freezers shall maintain temperatures of 0 degrees F or lower in food storage areas. Thermometers with markings in no more than 2-degree increments shall be provided in all refrigerators, freezers, ovens, and holding areas for hot and cold foods. Thermometers shall be clearly visible, easy to read, and accurate, and shall be kept in working condition and regularly checked. RATIONALE: Storage of food at proper temperatures minimizes bacterial growth (47). The use of accurate thermometers to monitor temperatures at which food is cooked and stored helps to ensure food safety. Hot foods must be checked to be sure they reach temperatures that kill microorganisms in that type of food. Cold foods must be checked to see that they are being maintained at temperatures that safely retard the growth of bacteria. Thermometers with larger than 2-degree increments are hard to read accurately. COMMENTS: Providing thermometers with a dual scale in Fahrenheit and Celsius will avoid making a child care provider convert between the two different temperature scales. TYPE OF FACILITY : Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 4.048 Ventilation over Cooking Surfaces In centers using commercial cooking equipment to prepare meals, ventilation shall be equipped with an exhaust system capable of providing a capture velocity of 50 feet per minute 6 inches above the outer edges of the cooking surfaces at the prescribed filter velocities (41). All gas ranges in centers shall be mechanically vented and fumes filtered prior to discharge to the outside. All vents and filters shall be maintained free of grease build-up and food spatters, and in good repair. RATIONALE: An exhaust system must properly collects fumes and grease-laden vapors at their source. Properly maintained vents and filters control odor, fire hazards, and fumes. COMMENTS: The center should refer to the owner's manual of the exhaust system for a description of capture velocity. Commercial cooking equipment refers to the type of equipment that is typically found in restaurants and other food service businesses. Proper construction of the exhaust system duct-work assures that grease and other build-up can be easily accessed and cleaned. If the odor of gas is present when the pilot lights are on, turn off gas and immediately call a qualified gas technician or commercial gas provider. Never use an open flame to locate a gas leak. TYPE OF FACILITY : Center STANDARD 4.049 Microwave Ovens Microwave ovens shall be inaccessible to preschool children. Any microwave oven in use in a child care facility shall be manufactured after October 1971 and shall be in good repair. RATIONALE: Young children can be burned when their faces come near the heat vent. The issues involved with the safe use of microwave ovens (such as no metal, the right plastic, and steam trapping) make use of this equipment by preschool-age children too risky. Older ovens made before the Federal standard went into effect in October 1971 can expose users or passers-by to microwave radiation. COMMENTS: If school-age children are allowed to use a microwave oven in the facility, this use should be closely supervised to avoid injury. See STANDARD 4.018 for prohibition of use of microwave ovens to warm infant feedings. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home 4.8 FOOD SAFETY STANDARD 4.050 Compliance with USDA Food Sanitation Standards, State and Local Rules The facility shall conform to the applicable portions of the U.S. Food and Drug Administration model food sanitation standards (42) and all applicable state and local food service rules and regulations for centers and small and large family child care homes regarding safe food protection and sanitation practices. If federal model standards and local regulations are in conflict, the health authority with jurisdiction shall determine which requirement the facility must meet. RATIONALE: Minimum standards for food safety are based on scientific data that demonstrate the conditions required to prevent contamination of food with infectious and toxic substances that cause foodborne illness. Many of these standards have been placed into statutes and therefore must be complied with by law. Federal, state, and local food safety codes, regulations, and standards may conflict. In these circumstances, the decision of the regulatory health authority should prevail. COMMENTS: The U. S. Food and Drug Administration's (FDA) Model Food Code is a good resource to have on hand. The Food Code is available on the Internet. Contact information is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 4.051 Staff Restricted From Food Handling No one who has signs or symptoms of illness, including vomiting, diarrhea, and infectious skin sores that cannot be covered, or who potentially or actually is infected with bacteria, viruses or parasites that can be carried in food, shall be responsible for food handling. Plastic gloves, which shall be kept clean and replaced when soiled, shall be used when food is served by hand (11, 12). No one with open or infected injuries shall work in the food preparation area unless the injuries are covered with nonporous (such as latex or vinyl) gloves. In centers and large family child care homes, staff members who are involved in the process of preparing or handling food shall not change diapers. Staff members who work with diapered children shall not prepare or serve food for older groups of children. When staff members who are caring for infants and toddlers are responsible for changing diapers, they shall handle food only for the infants and toddlers in their groups and only after thoroughly washing their hands. Caregivers who prepare food shall wash their hands carefully before handling food, regardless of whether they change diapers. Plastic gloves shall be used in addition to handwashing. When caregivers must handle food, staffing assignments shall be made to foster completion of the food handling activities by caregivers of older children, or by caregivers of infants and toddlers before the caregiver assumes other caregiving duties for that day. RATIONALE: Food handlers who are ill can easily communicate their illness to others by contaminating the food they prepare with the infectious agents they are carrying. Frequent and proper handwashing before and after using plastic gloves reduces food contamination (43, 44). Caregivers who work with infants and toddlers frequently are exposed to feces and to children with infections of the intestines (often with diarrhea) or liver. Education of child care staff regarding handwashing and other cleaning procedures can reduce the occurrence of illness in the group of children with whom they work (43, 44). The possibility of involving a larger number of people in a foodborne outbreak is greater in child care than in most households. Cooking larger volumes of food requires special caution to avoid contamination of the food with even small amounts of infectious materials. With larger volumes of food, staff must exercise greater diligence to avoid contamination because larger quantities of food take longer to heat or to cool to safe temperatures. Larger volumes of food spend more time in the danger zone of temperatures (between 40 degrees F and 140 degrees F) where more rapid multiplication of microorganisms occurs. Whenever possible, cooks should not be assigned child care or janitorial duties, so as to reduce the cook's exposure to infectious materials. The cook who is exposed to infectious materials may subsequently infect the food served in the facility. If a caregiver must cook, letting that caregiver complete the food preparation before assuming caregiver duties (such as wiping noses, diaper changing, or toilet supervision) for that day can minimize the risk. COMMENTS: Facilities can minimize the need for final preparation in the caregiving areas by careful planning, advance preparation, and serving of foods at safe temperatures. For additional information on handwashing, see STANDARD 3.021 through STANDARD 3.023. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 4.052 Precautions for a Safe Food Supply All foods stored, prepared, or served shall be safe for human consumption by observation and smell (10-12). The following precautions shall be observed for a safe food supply: a) Home-canned food, food from dented, rusted, bulging, or leaking cans, and food from cans without labels shall not be used; b) Foods shall be inspected daily for spoilage or signs of mold, and foods that are spoiled or moldy shall be discarded; c) Meat shall be from government-inspected sources or otherwise approved by the governing health authority (44); d) All dairy products shall be pasteurized and Grade A where applicable; e) Raw, unpasteurized milk, milk products; unpasteurized fruit juices; and raw or undercooked eggs shall not be used. Freshly squeezed fruit or vegetable juice prepared in the child care facility prepared just prior to serving is permissible; f) Unless a child's health provider documents a different milk product, children from 12 months to 2 years of age shall be served only whole milk. Children older than 2 years of age shall be served whole, skim, 1%, or 2% milk. If allowed by funding resources, dry milk and milk products may be reconstituted in the facility for cooking purposes only, provided that they are prepared, refrigerated, and stored in a sanitary manner, labeled with the date of preparation, and used or discarded within 24 hours of preparation; g) Meat, fish, poultry, milk, and egg products shall be refrigerated or frozen until immediately before use (47); h) Frozen foods shall be defrosted in the refrigerator, under cold running water, as part of the cooking process, or by using the defrost setting of a microwave oven (47); i) All fruits and vegetables shall be washed thoroughly with water prior to use (47); j) Frozen foods shall never be defrosted by leaving them at room temperature or standing in water that is not kept at refrigerator temperature (47). k) Food shall be served promptly after preparation or cooking or maintained at temperatures of not less than 140 degrees F for hot foods and not more than 40 degrees F for cold foods. l) All opened moist foods that have not been served shall be dated, covered, and maintained at a temperature of 40 degrees F or lower in the refrigerator or 0 degrees F or lower in the freezer, verified by a working thermometer kept in the refrigerator or freezer. m) Fully cooked and ready-to-serve hot foods shall be held for no longer than 30 minutes before being served, or covered and refrigerated. RATIONALE: For children, a small dose of infectious or toxic material can lead to serious illness. Some molds produce toxins that may cause illness or even death (such as aflatoxin or ergot). Keeping frozen food at 0 degrees F or below, cold food below 40 degrees F and hot food above 140 degrees F prevents bacterial growth (9, 10). Food intended for human consumption can become contaminated if left at room temperature. Foodborne illnesses from Salmonella and E. coli 0157:H7 have been associated with consumption of contaminated, raw, or undercooked egg products, meat, poultry, and seafood. Children tend to be more susceptible to E. coli 0157:H7 infections from consumption of undercooked meats, and such infections can lead to kidney failure and death. Home-canned food and food from dented, rusted, bulging, or leaking cans has an increased risk of containing microorganisms or toxins. Users of unlabeled food cans cannot be sure what is in the can and how long the can has been stored. Excessive heating of foods results in loss of nutritional content and causes foods to lose appeal by altering color, consistency, texture, and taste. Caregivers should discourage parents from bringing home-baked items for the children to share as it is difficult to determine the cleanliness of the environment in which the items are baked and transported. Several states allow the sale of raw milk or milk products. These products have been implicated in outbreaks of salmonellosis, listeriosis, toxoplasmosis, and campylobacteriosis and should never be served in child care facilities (45, 46). Only pasteurized milk and fruit juices should be served. Foods made with uncooked eggs have been involved in a number of outbreaks of Salmonella infections. Eggs should be well cooked before being eaten, and only pasteurized eggs or egg substitutes should be used in foods requiring raw eggs. The American Academy of Pediatrics (AAP) recommends that children from 12 months to 2 years of age receive whole milk or formula. Children 2 years of age and older can drink skim, 1%, or 2% milk (7, 8, 10-12, 18, 28). Soil particles and contaminants that adhere to fruits and vegetables can cause illness. Therefore, all fruits or vegetables used to make fresh juice at the facility should be washed first. Thawing frozen foods under conditions that expose any of the food's surfaces to temperatures between 40 and 140 degrees F promotes the growth of bacteria that may cause illness if ingested. Storing perishable foods at safe temperatures in the refrigerator or freezer reduces the rate at which microorganisms in these foods multiply. COMMENTS: Caregivers should consult with the health department regarding proper cooking temperatures. The general rule is "keep hot foods hot and cold foods cold-out of the temperature danger zone between 40 degrees F and 140 degrees F." The FDA 1999 Food Code specifies that potentially hazardous foods be refrigerated at 41 degrees F or less. It is easier for caregivers to remember the 40 to 140 degree range than it is to remember a 41 to 140 degree range. Therefore, for practical reasons and since 40 degrees F is within the FDA 1999 Food Code refrigeration temperature range, 40 degrees F is used in this standard. (42, 56) The use of dairy products fortified with vitamins A and D is recommended (51A). TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 4.053 Leftovers Food returned from individual plates and family style serving bowls and platters and unrefrigerated foods into which microorganisms are likely to have been introduced during food preparation or service, shall be discarded. Unserved food shall be covered promptly for protection from contamination, shall be refrigerated immediately, and shall be used within 24 hours. Hot foods shall be cooled first before they are fully covered in the refrigerator. Prepared perishable foods that have not been maintained at safe temperatures for 2 hours or more shall be discarded. RATIONALE: Served foods have a high probability of contamination during serving. Bacterial multiplication proceeds rapidly in perishable foods out of refrigeration, as much as doubling the numbers of bacteria every 15 to 20 minutes. The potential is high for perishable foods (such as those that could have been exposed to bacterial contamination during preparation) that have been out of the refrigerator for more than 2 hours to have substantial loads of bacteria. When such food is stored and served again, it may cause foodborne illness. COMMENTS: All food, once served or handled outside the food preparation area, should be discarded. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 4.054 Preparation for and Storage of Food in the Refrigerator All food stored in the refrigerator shall be tightly covered, wrapped, or otherwise protected from direct contact with other food. Hot foods to be refrigerated and stored shall be transferred to shallow containers in food layers less than 3 inches deep and refrigerated immediately. These foods shall be covered when cool. Any pre-prepared or leftover foods that are not likely to be served the following day shall be labeled with the date of preparation before being placed in the refrigerator. The basic rule for serving food shall be, "first food in, first food out" (6, 10-12). In the refrigerator, raw meat, poultry and fish shall be stored below cooked or ready to eat foods. RATIONALE: Covering food protects it from contamination and keeps other food particles from falling into it. Hot food cools more quickly in a shallow container, thereby decreasing the time when the food would be susceptible to contamination. Foods should be covered only after they have cooled. Leaving hot food uncovered allows it to cool more quickly, thereby decreasing the time when bacteria may be produced. Labeling of foods will inform the staff about the duration of storage, which foods to use first, and which foods to discard because the period of safe storage has passed. Storing raw meat, poultry and fish below ready-to-eat foods reduces the possibility that spills or drips from raw animal foods might contaminate ready-to-eat food. COMMENTS: See Appendix R, for a Food Storage Chart. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 4.055 Maintenance of Clean Refrigerators and Freezers Refrigerators and freezers shall be free of visible spills. The interior surfaces shall be cleaned and sanitized as often as necessary to assure that these appliances are maintained in a clean and sanitary condition. RATIONALE: During routine use, refrigerators and freezers become soiled by foods stored in them and by handling food and containers as they are being placed in or taken out of them. Without routine cleaning and sanitizing, this soil builds up and creates a place for bacterial growth, with subsequent contamination of stored foods. TYPE OF FACILITY : Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 4.056 Storage of Foods Not Requiring Refrigeration Foods not requiring refrigeration shall be stored at least 6 inches above the floor in clean, dry, well-ventilated storerooms or other approved areas (47). Food products shall be stored in such a way (such as in nonporous containers off the floor) as to prevent insects and rodents from entering the products. RATIONALE: Storage of food off the floor in a safe and sanitary manner helps prevent food contamination and keeps insects and rodents from entering the products. This practice also facilitates cleaning. COMMENTS: Storing food 6 inches or higher above the floor enables easier cleaning of the floor under the food. Storing food in nonporous containers prevents contamination of the food by insects, cleaning chemicals, and spills of other foods. TYPE OF FACILITY : Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 4.057 Storage of Dry Bulk Foods Dry, bulk foods that are not in their original, unopened containers shall be stored off the floor in clean metal, glass, or food-grade plastic containers with tight-fitting covers. All bulk food containers shall be labeled and dated, and placed out of children's reach. Children shall be permitted to handle household-size food containers during supervised food preparation and cooking activities and when the container holds a single serving of food intended for that child's consumption. RATIONALE: Food-grade nonporous containers prevent insect infestations and contamination from other foods and cleaning chemicals. By labeling and dating food, the food service staff can rotate the oldest foods to be used next and discard foods that have gone beyond safe storage times. Keeping bulk food containers out of the children's reach prevents contamination and misuse. Young children cannot be expected to have learned safe food handling practices well enough to risk the food supply of others. TYPE OF FACILITY : Center STANDARD 4.058 Supply of Food and water For Disasters In areas where natural disasters (such as earthquakes) occur, a 48 hour supply of food and water shall be kept in stock for each child and staff member (47). RATIONALE: It may take as long as 48 hours for help to arrive in some areas after a natural disaster of great magnitude. COMMENTS: A child care facility should consult with their local health authority or local emergency preparedness agency for more information on disaster preparedness. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 4.059 Storage of Garbage Garbage shall be placed in containers inaccessible to children and shall be removed from the kitchen daily. The containers shall be labeled and covered with tight fitting lids between deposits. RATIONALE: This practice minimizes odors, controls insects and rodents, and protects children and premises from contamination. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 4.060 Storage of Cleaning Agents Separate From Food Cleaning agents that must be stored in the same room with food shall be clearly labeled and kept separate from food items in locked cabinets. Cleaning agents shall not be stored on shelves above those holding food items. Cleaning agents and food items shall not be stored on the same shelf. Any storage room or cabinet that contains cleaning agents shall be locked. Poisonous or toxic materials shall remain in their original labeled containers. RATIONALE: Food products should be stored away from cleaning products to prevent accidental poisoning, potential leakage, and contamination. COMMENTS: Store cleaning agents below any food items. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home 4.9 MAINTENANCE STANDARD 4.061 Cleaning of Food Areas and Equipment Areas and equipment used for storage, preparation, and service of food shall be kept clean. All of the food preparation, food service, and dining areas shall be cleaned and sanitized before and after use. Food preparation equipment shall be cleaned and sanitized after each use and stored in a clean and sanitary manner, and protected from contamination. Sponges shall not be used for cleaning and sanitizing. Disposable paper towels or washable cloths that are only used once shall be used. Used cloths shall be stored in a covered container and washed daily. RATIONALE: Outbreaks of foodborne illness have occurred in child care settings. Many of these communicable diseases can be prevented through appropriate hygiene and sanitation methods. Keeping hands clean reduces soiling of kitchen equipment and supplies. Education of child care staff regarding routine cleaning procedures can reduce the occurrence of illness in the group of children with whom they work (43). Sponges harbor bacteria and are difficult to completely clean and sanitize between cleaning surface areas. COMMENTS: "Clean" means free of visible soil. Routine cleaning of kitchen areas should comply with the cleaning schedule provided in Appendix S or local health authority regulations. TYPE OF FACILITY : Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 4.062 Cutting Boards Cutting boards shall be made of nonporous material and shall be scrubbed with hot water and detergent and sanitized between uses for different foods or placed in a dishwasher for cleaning and sanitizing. The facility shall not use wooden cutting boards, boards made with wood components, and boards with crevices and cuts. RATIONALE: Wood boards and boards with cracks and crevices harbor food or organic material that can promote bacterial growth and contaminate the next food cut on the surface. COMMENTS: Heavy duty plastic and Plexiglas cutting boards can be placed in dishwashers. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 4.063 Dishwashing in Centers Centers shall provide a three-compartment dishwashing area with dual integral drain boards or an approved dishwasher capable of sanitizing multi-use utensils. If a dishwasher is installed, there shall be at least a two-compartment sink with a spray unit. If a dishwasher or a combination of dish pans and sink compartments that yield the equivalent of a three-compartment sink is not used, paper cups and plates and plastic utensils shall be used and shall be disposed of after every use. RATIONALE: These are minimum requirements for proper cleaning and sanitizing of dishes and utensils (11, 12). A three-compartment sink is ideal. If only a single- or double-compartment sink is available, three freestanding dish pans or two sinks and one dish pan may be used as the compartments needed to wash, rinse, and sanitize dishes. An approved dishwasher is a dishwasher that meets the approval of the regulatory health authority. Dishwashers should be carefully chosen. Depending on the size of the child care center and the food prepared, a household dishwasher may be adequate. Because of the time required to complete a full wash, rinse, and dry cycle, household domestic dishwashers are recommended for centers that do only one load of dishes after a snack or meal. Commercial dishwashers are recommended for centers that have a lot of children. The length of time to wash dishes in commercial dishwashers is 3 to 4 minutes. Commercial dishwashers that operate at low water temperatures (140 to 150 degrees Fahrenheit) are recommended because they are more energy-efficient. These would be equipped with automatic detergent and sanitizer injectors. When choosing a dishwasher, caregivers can consult with the local health authority to ensure that they meet local health regulations. COMMENTS: Household dishwashing machines can effectively wash and sanitize dishes and utensils provided that certain conditions are met (52). The three types of household dishwashers are: Those that lack or operate without sanitizing wash or rinse cycles; Those that have sanitizing wash or rinse cycles and a thermostat that senses a temperature of 150 degrees F or higher before the machine advances to the next step in its cycle; Those that have a sanitizing cycle and a thermostat as in (b) but advance to the next step in its cycle after 15 minutes, if the temperature required to operate the thermostat is not reached. All three types of household dishwashers are capable of producing the cumulative heat factor to meet the National Sanitation Foundation time-temperature standard for commercial, spray-type dishwashing machines. Dishwasher types (a) and (c) are capable of doing so only if the temperature of their inlet water is 155 degrees F or higher. The temperature of a hot water supply necessary for operating a dishwasher conflicts with what is considered a safe temperature to prevent scalding. Installing a separate small hot water tank for a dishwasher is one option to consider. See STANDARD 5.040, for additional information on water temperature. TYPE OF FACILITY : Center STANDARD 4.064 Dishwashing in Small and Large Family Child Care Homes Small and large family child care homes shall provide a three-compartment dishwashing arrangement or a dishwasher. At least a two-compartment sink or a combination of dish pans and sink compartments shall be installed to be used in conjunction with a dishwasher to wash, rinse, and sanitize dishes. The dishwashing machine must incorporate a chemical or heat sanitizing process. If a dishwasher or a three-compartment dishwashing arrangement is not used, paper cups and plates and plastic utensils shall be used and shall be disposed of after every use. RATIONALE: These are minimum requirements for proper cleaning and sanitizing of dishes and utensils (5, 10). The purpose is to remove food particles and other soil, and to control bacteria. TYPE OF FACILITY: Large Family Child Care Home; Small Family Child Care Home STANDARD 4.065 Method For Washing Dishes By Hand If the facility does not use a dishwasher, reusable food service equipment and eating utensils shall be scraped to remove any leftover food, washed thoroughly in hot water containing a detergent solution, rinsed, and then sanitized by one of the following methods: a) Immersion for at least 2 minutes in a lukewarm (not less than 75 degrees F) chemical sanitizing solution (bleach solution of a least 100 parts per million by mixing 1 1/2 teaspoons of domestic bleach per gallon of water). The sanitized items shall be air-dried; or b) Or, complete immersion in hot water and maintenance at a temperature of 170 degrees F for not less than 30 seconds. The items shall be air-dried (48, 53, 57). c) Or, other methods if approved by the health department. RATIONALE: These procedures provide for proper sanitizing and control of bacteria (6, 10-12). COMMENTS: To manually sanitize dishes and utensils in hot water at 170 degrees F, a special hot water booster is usually required. To avoid burning the skin while immersing dishes and utensils in this hot water bath, special racks are required. Therefore, if dishes and utensils are being washed by hand, the chemical sanitizer method using household bleach will be a safer choice. Often, sponges are used in private homes when washing dishes. The structure of natural and artificial sponges provides an environment in which microorganisms thrive. This may contribute to the microbial load in the wash water. Nevertheless, the rinsing and sanitizing process should eliminate any pathogens contributed by a sponge. When possible, a cloth that can be laundered should be used instead of a sponge. The concentration of bleach used for sanitizing dishes is much more diluted than the concentration recommended for sanitizing surfaces elsewhere in the facility. After washing and rinsing the dishes, the amount of infectious material on the dishes should be small enough so that the 2 minutes of immersion in the bleach solution combined with air-drying will reduce the number of microorganisms to safe levels. The stronger sanitizing solution used for other surfaces in the facility is made by diluting uid chlorine bleach in 1 gallon of water to achieve 500-800 parts per million. Using this 1:64 dilution is acceptable, but stronger than needed to sanitize detergent-cleaned and thoroughly rinsed dishes. Air-drying of surfaces that have been sanitized using bleach leaves no residue, since chlorine evaporates when the solution dries. However, other sanitizers may need to be rinsed off to remove retained chemical from surfaces. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home 4.10 MEALS FROM OUTSIDE VENDORS OR CENTRAL KITCHENS STANDARD 4.066 Approved Off-Site Food Services Food provided by a central kitchen or vendor to off-site locations shall be obtained from sources approved and inspected by the local health authority. RATIONALE: This standard ensures that the child care facility receives safe food. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 4.067 Food Safety During Transport After preparation, food shall be transported promptly in clean, covered, and temperature-controlled containers. Hot foods shall be maintained at temperatures not lower than 140 degrees F, and cold foods shall be maintained at temperatures of 40 degrees F or lower. Hot foods may be allowed to cool before serving to young children as long as the food is cooked to appropriate temperatures and the time at room temperature does not exceed 2 hours. The temperature of foods shall be checked with a working food-grade, metal probe thermometer. RATIONALE: Served foods have a high probability of becoming contaminated during serving. Bacteria multiply rapidly in perishable foods out of refrigeration, as much as doubling every 15 to 20 minutes. Foods at 140 degrees are too hot for children's mouths. A working food-grade, metal probe thermometer will accurately determine when foods are safe for consumption. COMMENTS: If the temperature of hot foods is well below 140 degrees F when it arrives, the caregiver should review delivery and storage practices and make any changes necessary to maintain proper food temperatures during storage and delivery. The caregiver shall record food temperatures in a log book to document the pattern of temperature control and spot shifts toward unsafe levels. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 4.068 Holding of Food Prepared at Off-Site Food Service Facilities Centers receiving food from an off-site food service facility shall have provisions for the proper holding and serving of food and washing of utensils to meet the requirements of the Food and Drug Administration's Model Food Code and the standards approved by the State or local health authority (42). RATIONALE: Served foods have a high probability of becoming contaminated during serving. Bacteria multiply rapidly in perishable foods out of refrigeration, as much as doubling every 15 to 20 minutes. COMMENTS: Contact information for the Food and Drug Administration's Food Code is located in Appendix BB. TYPE OF FACILITY: Center 4.11 NUTRITION LEARNING EXPERIENCES AND EDUCATION STANDARD 4.069 Nutrition Learning Experiences For Children The facility shall have a nutrition plan (see STANDARD 4.001 and STANDARD 8.035) that integrates the introduction of food and feeding experiences with facility activities and home feeding. The plan shall include opportunities for children to develop the knowledge and skills necessary to make appropriate food choices. For centers, this plan shall be a written plan and shall be the shared responsibility of the entire staff, including directors, food service personnel, and parents. The nutrition plan shall be developed with guidance from, and shall be approved by, the Child Care Nutrition Specialist (see Appendix C). Caregivers shall teach children about the taste and smell of foods. The children shall feel the textures and learn the different colors and shapes of foods. The teaching shall be evident at mealtimes and during curricular activities, without interfering with the pleasure of eating. RATIONALE: Nourishing and attractive food is a foundation for developmentally appropriate learning experiences and contributes to health and well-being (2-10, 18, 28, 50, 51). Coordinating the learning experiences with the food service staff maximizes effectiveness of the education. In addition to the nutritive value of food, infants and young children are helped, through the act of feeding, to establish warm human relationships. Eating should be an enjoyable experience in the facility and at home. Nutrition is a vital component of good health. Enjoying and learning about food in childhood promotes good nutrition habits for a lifetime. COMMENTS: Parents and caregivers should always be encouraged to sit at the table and eat the same food offered to young children as a way to strengthen family style eating which supports child's serving and feeding him or herself. Family style eating requires special training for the food service and child care staff since they need to monitor food served in a group setting. The use of serving utensils shall be encouraged to minimize food handling by children. The presence of an adult at the table with children while they are eating is a way to encourage social interaction and conversation about the food such as its name, color, texture, taste, and concepts such as number, size, and shape; as well as sharing events of the day. The parent or adult can help the slow eater, prevent behaviors that might increase risk of fighting, eating each others food and stuffing food in mouth which might cause choking. Several community based nutrition resources can help child care providers with the nutrition and food service component of their programs. The key to identifying a qualified nutrition professional is training in pediatric nutrition (normal nutrition, nutrition for children with special needs, dietary modifications) and experience and competency in basic food service systems. Local resources for nutrition education include: Local and state nutritionists in health department in maternal and child health programs and divisions of children with special health care needs; Registered dietitians/nutritionists at hospitals; WIC and cooperative extension nutritionists; School food service personnel; State administrators of Child and Adult Care Food Program; National School Food Service Management Institute; Child Care Nutrition Resource System of the Food and Nutrition Information System (National Agricultural Library, USDA); Nutrition consultants with local affiliates of the following organizations: American Dietetic Association; American Public Health Association; Society for Nutrition Education; American Association of Family and Consumer Sciences; Dairy Council; American Heart Association; American Cancer Society; American Diabetes Association; Professional home economists like teachers and those with consumer organizations; Nutrition departments of local colleges and universities. Contact information for the national organizations is located in Appendix BB. Compliance is measured by structured observation. For additional information on nutrition learning experiences for children, see also STANDARD 4.031 through 4.033, on mealtime activities. TYPE OF FACILITY : Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 4.070 NUTRITION EDUCATION FOR PARENTS Parents shall be informed of the scope of nutrition learning activities provided in the facility. Nutrition information and education programs shall be conducted at least twice a year under the guidance of the Child Care Nutrition Specialist (see Appendix C), based on a needs assessment for nutrition information and education as perceived by families and staff. RATIONALE: One goal of a facility is to provide a positive environment for the entire family. Informing parents about nutrition, food, food preparation, and mealtime enhances nutrition and mealtime interactions in the home, which helps to mold a child's food habits and eating behavior (2, 3, 6, 7, 10-12, 28, 51, 52). Nutrition education directed at parents complements and enhances the nutrition education provided to their children. COMMENTS: The educational programs may be supplemented by periodic newsletters and/or literature. Several community based nutrition resources can help child care providers with the nutrition and food service component of their programs. The key to identifying a qualified nutrition professional is training in pediatric nutrition (normal nutrition, nutrition for children with special needs, dietary modifications) and experience and competency in basic food service systems. Local resources for nutrition education include: Local and state nutritionists in health department in maternal and child health programs and divisions of children with special health care needs; Registered dietitians/nutritionists at hospitals; WIC and cooperative extension nutritionists; School food service personnel; State administrators of Child and Adult Care Food Program;