STANDARD 4.2.0.4: Categories of Foods

Children in care should be offered items of food from the following categories:

Making Healthy Food Choices*
Food Groups	USDA†	CFOC Guidelines for Young Children
Fruits	All fresh, frozen, canned, dried fruits, and fruit juices	Eat a variety, especially whole fruits Whole fruit, mashed or pureed, for infants seven months up to one year of age No juice before twelve months of age 4 to 6 oz juice /day for one- to six-year-olds 8 to 12 oz juice/day for seven- to twelve-year-olds
Vegetables	Dark green, red, and orange; beans and peas (legumes); starchy vegetables; other vegetables	Dark green, red, orange, deep yellow vegetables Other vegetables, including starchy ones like potatoes Other root vegetables, such as viandas Dried peas and beans (legumes)
Grains	Whole grains and enriched grains	Whole and enriched grains, breads, cereals, crackers, pasta, and rice
Protein Foods	Seafood, meat, poultry, eggs, nuts, seeds, and soy products	Fish, chicken, lean meat, eggs Nuts and seeds (if appropriate) Avoid fried fish, meat, and chicken
Dairy	Milk	Human milk, infant formula for infants at least up to one year of age Whole milk for children ages on up to two years of age or reduced fat (2%) milk for those at risk for obesity or hypercholesterolemia 1% or skim milk for children two years of age and older Other milks such as soy when recommended Other milk equivalent products such as yogurt and cottage cheese (low-fat for children two years of age and older)
Oils	Oils, soft margarines, includes vegetable, nut, and fish oils and soft vegetable oil table spreads that have no trans fats	Choose monounsaturated and polyunsaturated fats (olive oil, safflower oil) Soft margarines Avoid trans fats, saturated fats and fried foods
Solid Fats and Added Sugar	Limit calories (% of calories) of these food groups	Avoid concentrated sweets such as candy, sodas, sweetened drinks, fruit nectars, and flavored milk Limit salty foods such as chips and pretzels
*All foods are assumed to be in nutrient-dense forms, lean or low-fat and prepared without added fats, sugars, or salt. Solid fats and added sugars may be included up to the daily maximum limit identified in the Dietary Guidelines for Americans, 2010. †Recommends: Find your balance between food and physical activity.

Additional Resources:

• U.S. Department of Health and Human Services (DHHS). 2010. The Surgeon General’s vision for a healthy and fit nation. Washington, DC: DHHS, Office of the Surgeon General. http://www.surgeongeneral.gov/library/obesityvision/obesityvision2010.pdf.
• U.S. Department of Health and Human Services, U.S. Department of Agriculture. 2011. Dietary guidelines for Americans, 2010. 7th ed. Washington, DC: U.S. Government Printing Office. http://www.health.gov/dietaryguidelines/dga2010/DietaryGuidelines2010.pdf.
• U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion (ODPHP). 2008. 2008 physical activity guidelines for Americans. Rockville, MD: ODPHP. http://www.health.gov/paguidelines/guidelines/default.aspx.
• Story, M., K. Holt, D. Sofka, eds. 2002. Bright futures in practice: Nutrition. 2nd ed. Arlington, VA: National Center for Education in Maternal and Child Health. http://www.brightfutures.org/nutrition/pdf/frnt_mttr.pdf.
• U.S. Department of Agriculture. 2011. MyPlate. http://www.choosemyplate.gov.

RATIONALE: The Dietary Guidelines for Americans, 2010 and “The Surgeon General’s Call to Action to Support Breast Feeding” support feeding nutritious foods and healthy lifestyles to prevent the onset of overweight and obesity and chronic diseases (1,2). From the very first feeding of an infant begins setting the stage for lifetime eating behavior. Using the food groups as a tool is a practical approach to select foods high in essential nutrients and moderate in calories/energy. Meals and snacks planned based on the five food groups promote normal growth and development of children as well as reduce their risk of overweight, obesity and related chronic diseases later in life. Age-specific guidance for meals and snacks is outlined in CACFP guidelines and accessible at http://www.fns.usda
.gov/cnd/care/ProgramBasics/Meals/Meal_Patterns.htm (3). Early care and education settings provide the opportunity for children to learn about the food they eat, to develop and strengthen their fine and gross motor skills, and to engage in social interaction at mealtimes (4).

COMMENTS: Early Care and education settings should encourage mothers to breastfeed their infants. Scientific evidence documents and supports the nutritional and health contributions of human milk (2). For more information on portion sizes and types of food, see CACFP Guidelines at http://www.fns.usda.gov/cnd/care/ProgramBasics/Meals/Meal_Patterns.htm.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Standard 4.2.0.5: Meal and Snack Patterns

Standard 4.2.0.7: 100% Fruit Juice

Standard 4.2.0.8: Feeding Plans and Dietary Modifications

Standard 4.3.1.3: Preparing, Feeding, and Storing Human Milk

Standard 4.3.1.5: Preparing, Feeding, and Storing Infant Formula

Standard 4.3.1.7: Feeding Cow’s Milk

Standard 4.3.2.1: Meal and Snack Patterns for Toddlers and Preschoolers

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

Standard 4.7.0.1: Nutritional Learning Experiences for Children

Standard 4.7.0.2: Nutrition Education for Parents/Guardians

Appendix Q: Getting Started with MyPlate

Appendix R: Choose MyPlate: 10 Tips to a Great Plate

REFERENCES:

1. U.S. Department of Health and Human Services, U.S. Department of Agriculture. 2011. Dietary guidelines for Americans, 2010. 7th ed. Washington, DC: U.S. Government Printing Office. http://www.health.gov/dietaryguidelines/dga2010/DietaryGuidelines2010.pdf.

2. U.S. Department of Health and Human Services (HHS). 2011. The Surgeon General’s call to action to support breastfeeding. Washington, DC: HHS, Office of the Surgeon General. http://www.surgeongeneral.gov/topics/breastfeeding/calltoactiontosupportbreastfeeding.pdf.

3. U.S. Department of Agriculture, Food and Nutrition Service. 2011. Child and adult care food program (CACFP). http://www.fns.usda.gov/cnd/care/.

4. Nemours Health and Prevention Services. 2008. Best practices for healthy eating: A guide to help children grow up healthy. Version 2. Newark, DE: Nemours Foundation. http://www.nemours.org/content/dam/nemours/www/filebox/service/preventive/nhps/heguide.pdf.

STANDARD 4.2.0.5: Meal and Snack Patterns

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

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

RATIONALE: Young children, under the age of six, need to be offered food every two to three hours. 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 (1-6). Snacks should be nutritious, as they often are a significant part of a child’s daily intake. Children in care for more than eight hours need additional food because this period represents a majority of a young child’s waking hours.

COMMENTS: Caloric needs vary greatly from one child to another. A child may require more food during growth spurts. Some states have regulations indicating suggested times for meals and snacks. By regulation, in the Child and Adult Care Food Program (CACFP), centers and family child care homes may be approved to claim up to two reimbursable meals (breakfast, lunch or supper) and one snack, or two snacks and one meal, for each eligible participant, each day. Many after-school programs provide before school care or full day care when elementary school is out of session. Many of these programs offer either a breakfast and/or a morning snack. After-school care programs may claim reimbursement for serving each child one snack, each day. In some states after-school programs also have the option of providing a supper. These are reimbursed by CACFP if they meet certain guidelines and timeframes. For more information on CACFP meal reimbursement see the CACFP Website at http://www.fns.usda.gov/cnd/care/CACFP/aboutcacfp.htm.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Standard 4.3.2.1: Meal and Snack Patterns for Toddlers and Preschoolers

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

REFERENCES:

1. U.S. Department of Health and Human Services, Administration for Children and Families, Office of Head Start. 2009. Head Start program performance standards. Rev. ed. Washington, DC: U.S. Government Printing Office. http://eclkc.ohs.acf.hhs.gov/hslc/Head Start Program/Program Design and Management/Head Start Requirements/Head Start Requirements/45 CFR Chapter XIII/45 CFR Chap XIII_ENG.pdf.

2. Benjamin, S. E., ed. 2007. Making food healthy and safe for children: How to meet the national health and safety performance standards – Guidelines for out of home child care programs. 2nd ed. Chapel Hill, NC: National Training Institute for Child Care Health Consultants. http://nti.unc.edu/course_files/curriculum/nutrition/making_food_healthy_and_safe.pdf.

3. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.

4. Butte, N., S. K. Cobb. 2004. The Start Healthy feeding guidelines for infants and children. J Am Diet Assoc 104:442-54.

5. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.

6. Plemas, C., B. M. Popkin. 2010. Trends in snacking among U.S. children. Health Affairs 29:399-404.

STANDARD 4.2.0.6: Availability of Drinking Water

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

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

RATIONALE: When children are thirsty between meals and snacks, water is the best choice. Encouraging children to learn to drink water in place of fruit drinks, soda, fruit nectars, or other sweetened drinks builds a beneficial habit. Drinking water during the day can reduce the extra caloric intake which is associated with overweight and obesity (1). Drinking water is good for a child’s hydration and reduces acid in the mouth that contributes to early childhood caries (1,3,4). Water needs vary among young children and increase during times in which dehydration is a risk (e.g., hot summer days, during exercise, and in dry days in winter) (2).

COMMENTS: Clean, small pitchers of water and single-use paper cups available in the classrooms and on the playgrounds allow children to serve themselves water when they are thirsty. Drinking fountains should be kept clean and sanitary and maintained to provide adequate drainage.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Standard 3.1.3.2: Playing Outdoors

Standard 4.3.1.3: Preparing, Feeding, and Storing Human Milk

Standard 4.3.1.5: Preparing, Feeding, and Storing Infant Formula

REFERENCES:

1. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.

2. Manz, F. 2007. Hydration in children. J Am Coll Nutr 26:562S-569S.

3. Casamassimo, P., K. Holt, eds. 2004. Bright futures in practice: Oral health–pocket guide. Washington, DC: National Maternal and Child Oral Health Resource Center. http://www.mchoralhealth.org/PDFs/BFOHPocketGuide.pdf.

4. Centers for Disease Control and Prevention. 2011. Community water fluoridation. http://www.cdc.gov/fluoridation/.

STANDARD 4.2.0.7: 100% Fruit Juice

The facility should serve only full-strength (100%) pasteurized fruit juice or full-strength fruit juice diluted with water from a cup to children twelve months of age or older. Juice should have no added sweeteners. The facility should offer juice at specific meals and snacks instead of continuously throughout the day. Juice consumption should be no more than a total of four to six ounces a day for children aged one to six years. This amount includes juice served at home. Children ages seven through twelve years of age should consume no more than a total of eight to twelve ounces of fruit juice per day. Caregivers/teachers should ask parents/guardians if they provide juice at home and how much. This information is important to know if and when to serve juice. Infants should not be given any fruit juice before twelve months of age. Whole fruit, mashed or pureed, is recommended for infants seven months up to one year of age.

RATIONALE: Whole fruit is more nutritious than fruit juice and provides dietary fiber. Fruit juice which is 100% offers no nutritional advantage over whole fruits.

Limiting the feeding of juice to 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 (1,2).

Drinks that are called fruit juice drinks, fruit punches, or fruit nectars contain less than 100% fruit juice and are of a lower nutritional value than 100% fruit juice. Liquids with high sugar content have no place in a healthy diet and should be avoided. 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 and overweight/obesity. Infants should not be given juice from bottles or easily transportable, covered cups (e.g., sippy cups) that allow them to consume juice throughout the day.

The American Academy of Pediatrics (AAP) recommends that children aged one to six years drink no more than four to six ounces of fruit juice a day (3). This amount is the total quantity for the whole day, including both time at early care and education and at home. Caregivers/teachers should not give the entire amount while a child is in their care. For breastfed infants, AAP recommends that gradual introduction of iron-fortified foods may occur no sooner than around four months, but preferably six months to complement the human milk. Infants should not be given juice before they reach twelve months of age.

Overconsumption of 100% fruit juice can contribute to overweight and obesity (3-6). One study found that two- to five-year-old children who drank twelve or more ounces of fruit juice a day were more likely to be obese than those who drank less juice (2). Excessive fruit juice consumption may be associated with malnutrition (over nutrition and under nutrition), diarrhea, flatulence, and abdominal distention (3). Unpasteurized fruit juice may contain pathogens that can cause serious illnesses (3). The U.S. Food and Drug Administration requires a warning on the dangers of harmful bacteria on all unpasteurized juice or products (7).

COMMENTS: Caregivers/teachers, as well as many parents/guardians, should strive to understand the relationship between the consumption of sweetened beverages and tooth decay. Drinks with high sugar content should be avoided because they can contribute to childhood obesity (2,5,6), tooth decay, and poor nutrition.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Standard 4.2.0.4: Categories of Food

REFERENCES:

1. Casamassimo, P., K. Holt, eds. 2004. Bright futures in practice: Oral health–pocket guide. Washington, DC: National Maternal and Child Oral Health Resource Center. http://www.mchoralhealth.org/PDFs/BFOHPocketGuide.pdf.

2. Dennison, B. A., H. L. Rockwell, S. L. Baker. 1997. Excess fruit juice consumption by preschool-aged children is associated with short stature and obesity. Pediatrics 99:15-22.

3. American Academy of Pediatrics, Committee on Nutrition. 2007. Policy statement: The use and misuse of fruit juice in pediatrics. Pediatrics 119:405.

4. Faith, M. S., B. A. Dennison, L. S. Edmunds, H. H. Stratton. 2006. Fruit juice intake predicts increased adiposity gain in children from low-income families: Weight status-by-environment interaction. Pediatrics 118:2066-75.

5. Dubois, L., A. Farmer, M. Girard, K. Peterson. 2007. Regular sugar-sweetened beverage consumption between meals increases risk of overweight among preschool-aged children. J Am Diet Assoc 107:924-34.

6. Dennison, B. A., H. L. Rockwell, M. J. Nichols, P. Jenkins. 1999. Children’s growth parameters vary by type of fruit juice consumed. J Am Coll Nutr 18:346-52.

7. U.S. Food and Drug Administration. Safe handling of raw produce and fresh-squeezed fruit and vegetable juices. New York: JMH Education. http://www.fda.gov/Food/ResourcesForYou/Consumers/ucm114299.htm.

STANDARD 4.2.0.8: Feeding Plans and Dietary Modifications

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

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

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

For a child identified with special health care needs for dietary modification or special feeding techniques, written instructions from the child’s parent/guardian and the child’s primary care provider should be provided in the child’s record and carried out accordingly. Dietary modifications should be recorded. These written instructions must identify:

1. The child’s full name and date of instructions;
2. The child’s special needs;
3. Any dietary restrictions based on the special needs;
4. Any special feeding or eating utensils;
5. Any foods to be omitted from the diet and any foods to be substituted;
6. Limitations of life activities;
7. Any other pertinent special needs information;
8. What, if anything, needs to be done if the child is exposed to restricted foods.

The written history of special nutrition or feeding needs should be used to develop individual feeding plans and, collectively, to develop facility menus. Disciplines related to special nutrition needs, including nutrition, nursing, speech, occupational therapy, and physical therapy, should participate when needed and/or when they are available to the facility. The nutritionist/registered dietitian should approve menus that accommodate needed dietary modifications.

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

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

Some children have difficulty with slow weight gain and need their caloric intake monitored and supplemented. Others with special needs, such as those with diabetes, may need to have their diet matched to their medication (insulin if they are on a fixed dose of insulin). Some children are unable to tolerate certain foods because of their allergy to the food or their inability to digest it. In children, foods are the most common cause of anaphylaxis. Nuts, seeds, eggs, soy, milk, and seafood are among the most common allergens for food-induced anaphylaxis in children (3). Staff members must know ahead of time what procedures to follow, as well as their designated roles during an emergency.

As a safety and health precaution, the staff should know in advance whether a child has food allergies, inborn errors of metabolism, diabetes, celiac disease, tongue thrust, or special health care needs related to feeding, such as requiring special feeding utensils or equipment, nasogastric or gastric tube feedings, or special positioning. These situations require individual planning prior to the child’s entry into early care and education and on an ongoing basis (3,4).

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

COMMENTS: Close collaboration between the home and the facility is necessary for children on special diets. Parents/guardians may have to provide food on a temporary or, even, a 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

RELATED STANDARDS:

Standard 4.2.0.2: Assessment and Planning of Nutrition for Individual Children

REFERENCES:

1. Samour, P. Q., K. King. 2005. Handbook of pediatric nutrition. 3rd ed. Lake Dallas, TX: Helm.

2. Dietz, W. H., L. Stern, eds. 1998. American Academy of Pediatrics guide to your child’s nutrition. New York: Villard.

3. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.

4. Lally, J. R., A. Griffin, E. Fenichel, M. Segal, E. Szanton, B. Weissbourd. 2003. Caring for infants and toddlers in groups: Developmentally appropriate practice. Arlington, VA: Zero to Three.

STANDARD 4.2.0.9: Written Menus and Introduction of New Foods

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

To avoid problems of food sensitivity in very young children under eighteen months of age, caregivers/teachers should obtain from the child’s parents/guardians 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 considered for serving, caregivers/teachers should share and discuss these foods with the parents/guardians prior to their introduction.

RATIONALE: Planning menus in advance helps to ensure that food will be on hand. Parents/guardians need to be informed about food served in the facility to know how to complement it with the food they serve at home. If a child has difficulty with any food served at the facility, parents/guardians can address this issue with appropriate staff members. Some regulatory agencies require menus as a part of the licensing and auditing process (2).

COMMENTS: Caregivers/teachers should be aware that new foods may need to be offered between eight to fifteen times before a food may be accepted (3,5). Posting menus in a prominent area and distributing them to parents/guardians helps to inform them 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 (CACFP).

Good communication between the caregiver/teacher and the parents/guardians is essential for successful feeding, in general, including when introducing age-appropriate solid foods (complementary foods). The decision to feed specific foods should be made in consultation with the parents/guardians. It is recommended that the caregiver/teacher be given written instructions on the introduction and feeding of foods from the parents/guardians and the infant’s primary care provider. Caregivers/teachers should use or develop a take-home sheet for parents/guardians on which the caregiver/teacher records the food consumed each day or, for breastfed infants, the number of breastfeedings, and other important notes on the infant. Caregivers/teachers should continue to consult with each infant’s parents/guardians concerning foods they have introduced and are feeding. In this way, the caregiver/teacher can follow a schedule of introducing new foods one at a time and more easily identify possible food allergies or intolerances. Caregivers/teachers should let parents/guardians know what and how much their infant eats each day. Consistency between home and the early care and education setting is essential during the period of rapid change when infants are learning to eat age-appropriate solid foods (1,4,6).

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Standard 4.3.1.1: General Plan for Feeding Infants

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

Standard 4.5.0.8: Experience with Familiar and New Foods

REFERENCES:

1. Benjamin, S. E., ed. 2007. Making food healthy and safe for children: How to meet the national health and safety performance standards – Guidelines for out-of-home child care programs. 2nd ed. Chapel Hill, NC: National Training Institute for Child Care Health Consultants. http://nti.unc.edu/course_files/curriculum/nutrition/making_food_healthy_and_safe.pdf.

2. Benjamin, S. E., K. A. Copeland, A. Cradock, E. Walker, M. M. Slining, B. Neelon, M. W. Gillman. 2009. Menus in child care: A comparison of state regulations to national standards. J Am Diet Assoc 109:109-15.

3. Sullivan, S. A., L. L. Birch. 1990. Pass the sugar, pass the salt: Experience dictates preference. Devel Psych 26:546-51.

4. U.S. Department of Agriculture, Food and Nutrition Service (FNS). 2001. Feeding infants: A guide for use in the child nutrition programs. Rev ed. Alexandria, VA: FNS. http://www.fns.usda.gov/tn/resources/feeding_infants.pdf.

5. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.

6. Grummer-Strawn, L. M., K. S. Scanlon, S. B. Fein. 2008. Infant feeding and feeding transitions during the first year of life. Pediatrics 122: S36-S42.

STANDARD 4.2.0.10: Care for Children with Food Allergies

When children with food allergies attend the early care and education facility, the following should occur:

1. Each child with a food allergy should have a care plan prepared for the facility by the child’s primary care provider, 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 should include specific symptoms that would indicate the need to administer one or more medications;
2. Based on the child’s care plan, the child’s caregivers/teachers should receive training, demonstrate competence in, and implement measures for:
   1. Preventing exposure to the specific food(s) to which the child is allergic;
   2. Recognizing the symptoms of an allergic reaction;
   3. Treating allergic reactions;
3. Parents/guardians and staff should 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 early care and education facility;
4. Caregivers/teachers should promptly and properly administer prescribed medications in the event of an allergic reaction according to the instructions in the care plan;
5. The facility should notify the parents/guardians immediately of any suspected allergic reactions, the ingestion of the problem food, or contact with the problem food, even if a reaction did not occur;
6. The facility should recommend to the family that the child’s primary care provider be notified if the child has required treatment by the facility for a food allergic reaction;
7. The facility should contact the emergency medical services system immediately whenever epinephrine has been administered;
8. Parents/guardians of all children in the child’s class should be advised to avoid any known allergens in class treats or special foods brought into the early care and education setting;
9. Individual child’s food allergies should be posted prominently in the classroom where staff can view and/or wherever food is served;
10. The written child care plan, a mobile phone, and the proper medications for appropriate treatment if the child develops an acute allergic reaction should be routinely carried on field trips or transport out of the early care and education setting.

RATIONALE: Food allergy is common, occurring in between 2% and 8% of infants and children (1). Food allergic reactions can range from mild skin or gastrointestinal symptoms to severe, life-threatening reactions with respiratory and/or cardiovascular compromise. Hospitalizations from food allergy are being reported in increasing numbers (5). A major factor in death from anaphylaxis has been a delay in the administration of life-saving emergency medication, particularly epinephrine (6). Intensive efforts to avoid exposure to the offending food(s) are therefore warranted. The maintenance of detailed care plans and the ability to implement such plans for the treatment of reactions are essential for all food-allergic children (2-4).

COMMENTS: Successful food avoidance requires a cooperative effort that must include the parents/guardians, the child, the child’s primary care provider, and the early care and education staff. The parents/guardians, with the help of the child’s primary 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/guardians may need to take responsibility for providing all of the child’s food. In other cases, the early care and education staff may be able to provide safe foods as long as they have been fully educated about effective food avoidance.

Effective food avoidance has several facets. Foods can be listed on an ingredient list under a variety of names, such as milk being listed as casein, caseinate, whey, and/or lactoglobulin. Food sharing between children must be prevented by careful supervision and repeated instruction to the child about this issue. Exposure may also occur through contact between children or by contact with contaminated surfaces, such as a table on which the food allergen remains after eating. Some children may have an allergic reaction just from being in proximity to the offending food, without actually ingesting it. Such contact should be minimized by washing children’s hands and faces and all surfaces that were in contact with food. In addition, reactions may occur when a food is used as part of an art or craft project, such as the use of peanut butter to make a bird feeder or wheat to make play dough.

Some children with a food allergy will have mild reactions and will only need to avoid the problem food(s). Others will need to have an antihistamine or epinephrine available to be used in the event of a reaction. For all children with a history of anaphylaxis (severe allergic reaction), or for those with peanut and/or tree nut allergy (whether or not they have had anaphylaxis), epinephrine should be readily available. This will usually be provided as a pre-measured dose in an auto-injector, such as the EpiPen or EpiPen Junior. Specific indications for administration of epinephrine should be provided in the detailed care plan. Within the context of state laws, appropriate personnel should be prepared to administer epinephrine when needed. 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. A single dose of epinephrine wears off in fifteen to twenty minutes and many experts will recommend that a second dose be available for administration.

For more information on food allergies, contact the Food Allergy and Anaphylaxis Network or visit their Website at http://www.foodallergy.org.

Some early care and education/school settings require that all foods brought into the classroom are store-bought in their original packaging so that a list of ingredients is included, in order to prevent exposure to allergens.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Standard 4.2.0.2: Assessment and Planning of Nutrition for Individual Children

Standard 4.2.0.8: Feeding Plans and Dietary Modifications

Appendix P: Situations that Require Medical Attention Right Away

REFERENCES:

1. Burks, A. W., J. S. Stanley. 1998. Food allergy. Curr Opin Pediatrics 10:588-93.

2. U.S. Department of Health and Human Services, Administration for Children and Families, Office of Head Start. 2009. Head Start program performance standards. Rev. ed. Washington, DC: U.S. Government Printing Office. http://eclkc.ohs.acf.hhs.gov/hslc/Head Start Program/Program Design and Management/Head Start Requirements/Head Start Requirements/45 CFR Chapter XIII/45 CFR Chap XIII_ENG.pdf.

3. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.

4. Samour, P. Q., K. King. 2005. Handbook of pediatric nutrition. 3rd ed. Lake Dallas, TX: Helm.

5. Branum, A. M., S. L. Lukacs. 2008. Food allergy among U.S. children: Trends in prevalence and hospitalizations. NCHS data brief, no. 10. Hyattsville, MD: National Center for Health Statistics.

6. Muraro, A., et al. 2010. The management of the allergic child at school: EAACI/GA2LEN Task Force on the allergic child at school. Allergy 65:681-89.

STANDARD 4.2.0.11: Ingestion of Substances that Do Not Provide Nutrition

All children should be monitored to prevent them from eating substances that do not provide nutrition (often referred to as Pica). The parents/guardians of children who repeatedly place non-nutritive substances in their mouths should be notified and informed of the importance of their child visiting their primary care provider.

RATIONALE: Children who ingest paint chips or contaminated soil can develop lead toxicity which can lead to developmental delays and neurodevelopmental disability. Children who regularly ingest non-nutritive substances can develop iron deficiency anemia. Eating soil or drinking contaminated water could result in an infection with a parasite.

In collaboration with the child’s parent/guardian, an assessment of the child’s eating behavior and dietary intake should occur along with any other health issues to begin an intervention strategy. Dietary intake plays an important role because certain nutrients such as a diet high in fat or lecithin increase the absorption of lead which can result in toxicity (1).

Currently there is consensus that repeated ingestion of some non-food items results in an increased lead burden of the body (1,2). Early detection and intervention in non-food ingestion can prevent nutritional deficiencies and growth/developmental disabilities.

The occasional ingestion of non-nutritive substances can be a part of everyday living and is not necessarily a concern. For example, ingestion of non-nutritive substances can occur from mouthing, placing dirty hands in the mouth, or eating dropped food. Pica involves the recurrent ingestion of substances that do not provide nutrition. Pica is most prevalent among children between the ages of one and three years (1). Among children with intellectual developmental disability and concurrent mental illness, the incidence exceeds 50% (1).

COMMENTS: Lead-based paint (old housing as well as lead water pipes), neighborhoods with heavy traffic (leaded fuel), and the storage of acidic foods in open cans or ceramic containers with a lead glaze are sources of lead and should be addressed concurrently with a nutritionally adequate diet as prevention strategies. Community water supply may be a source of lead and should be analyzed for its lead content and other metals. Once a child is identified with lead toxicity, it is important to control the child’s exposure to the source of lead and promote a healthy and balanced diet. This health problem can be addressed through collaboration among the child’s parents/guardians, primary care provider, local childhood lead poisoning prevention program, and the comprehensive child care team of health, education, and nutrition staff.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Ekvall, S. W., V. K. Ekvall, eds. 2005. Pediatric nutrition in chronic disease and developmental disorders: Prevention, assessment, and treatment. 2nd ed. New York: Oxford University Press.

2. Mitchell, M. K. 2002. Nutrition across the life span. 2nd ed. Philadelphia: W. R. Saunders Co.

STANDARD 4.2.0.12: Vegetarian/Vegan Diets

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

1. Written documentation from parents/guardians on the detailed and accurate dietary history about food choices - foods eaten, levels of limitations/restrictions to foods, and frequency of foods offered;
2. An up-to-date health record of the child available to the caregivers/teachers, including information about linear growth and rate of weight gain, or consistent poor appetite (these indicators can be warning signs of growth deficiencies);
3. Collaboration among early care and education staff, especially the sharing of updated information on the child’s health with the parents/guardians by the child care health consultant and the nutritionist/registered dietitian;
4. Sound health and nutrition information that is culturally relevant to the family to ensure that the child receives adequate calories and essential nutrients which promote adequate growth and development of the child.

RATIONALE: Infants and young children are at highest risk for nutritional deficiencies for energy levels and essential nutrients including protein, calcium, iron, zinc, vitamins B6, B12, and vitamin D (1-3). The younger the child the more critical it is to know about family food choices, limitations and restrictions because the child is dependent on family food (2). Also due to the rapid growth in the early years, it is imperative that a child’s diet should consist of a variety of nourishing food to support growth during this critical period. All vegetarian/vegan children should receive multivitamins, especially vitamin D (400 IU of vitamin D are recommended for infants six months to adulthood unless there is certainty of having the daily allowance met by foods); infants under six months who are exclusively or partially breastfed and who receive less than sixteen ounces of formula per day should receive 400 IU of vitamin D (4).

COMMENTS: For older children who have more choice about what they chose to eat and drink, effort should be made to provide accurate nutrition information so they make the wisest food choices for themselves. Both the early care and education program/school and the caregiver/teacher have an opportunity to inform, teach, and promote sound eating practices along with the consequences when poor food choices are made (1). Sensitivity to cultural factors including beliefs and practices of a child’s family should be maintained.

Changing lifestyles, convictions and beliefs about food and religion, what is eaten and what foods are restricted or never consumed, have some families with infants and children practicing several levels of vegetarian diets. Some parents/guardians indicate they are vegetarians, semi-vegetarian, or strict vegetarians because they do not or seldom eat meat. Others label themselves lacto-ovo vegetarians, eating or drinking foods such as eggs and dairy products. Still others describe themselves as vegans who restrict themselves strictly to ingesting only plant-based foods, avoiding all and any animal products.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Standard 3.1.2.1: Routine Health Supervision and Growth Monitoring

Standard 4.2.0.2: Assessment and Planning of Nutrition for Individual Children

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

REFERENCES:

1. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.

2. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.

3. Mitchell, M. K. 2002. Nutrition across the life span. 2nd ed. Philadelphia: W. R. Saunders Co.

4. Wagner, C. L., F. R. Greer. 2008. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Pediatrics 122:1142-52

4.3 Requirements for Special Groups or Ages of Children

4.3.1 Nutrition for Infants

STANDARD 4.3.1.1: General Plan for Feeding Infants

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

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

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

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

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

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

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

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

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

COMMENTS: Some ways to help a mother to breastfeed successfully in the early care and education facility (3):

1. If she wishes to breastfeed her infant or child when she comes to the facility, offer or provide her a:
   1. Quiet, comfortable, and private place to breastfeed (this helps her milk to letdown);
   2. Place to wash her hands;
   3. Pillow to support her infant on her lap while nursing if requested;
   4. Nursing stool or stepstool if requested for her feet so she doesn’t have to strain her back while nursing; and
   5. Glass of water or other liquid to help her stay hydrated;
2. Encourage her to get the infant used to being fed her expressed human milk by another person before the infant starts in early care and education, while continuing to breastfeed directly herself;
3. Discuss with her the infant’s usual feeding pattern and whether she wants the caregiver/teacher to feed the infant by cue or on a schedule, also ask her if she wishes to time the infant’s last feeding so that the infant is hungry and ready to breastfeed when she arrives, also, ask her to leave her availability schedule with the early care and education program and ask her to call if she is planning to miss a feeding or is going to be late;
4. Encourage her to provide a back-up supply of frozen or refrigerated expressed human milk with the infant’s full name on the bottle or other clean storage container in case the infant needs to eat more often than usual or the mother’s visit is delayed;
5. Share with her information about other places in the community that can answer her questions and concerns about breastfeeding, for example, local lactation consultants (14,16);
6. Ensure that all staff receive training in breastfeeding support and promotion;
7. Ensure that all staff are trained in the proper handling and feeding of each milk product, including human milk or infant formula;
8. Provide culturally appropriate breastfeeding materials including community resources for parents/guardians that include appropriate language and pictures of multicultural families to assist families to identify with them.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Standard 4.2.0.9: Written Menus and Introduction of New Foods

Standard 4.3.1.3: Preparing, Feeding, and Storing Human Milk

Standard 4.3.1.5: Preparing, Feeding, and Storing Infant Formula

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

Standard 4.3.1.12: Feeding Age-Appropriate Solid Foods to Infants

Appendix JJ: Our Child Care Center Supports Breastfeeding

REFERENCES:

1. U.S. Department of Health and Human Services. 2000. Healthy people 2010: Understanding and improving health. 2nd ed. Washington, DC: U.S. Government Printing Office.

2. Dietitians of Canada, American Dietetic Association. 2000. Manual of clinical dietetics. 6th ed. Chicago: ADA.

3. U.S. Department of Agriculture, Food and Nutrition Service (FNS). 1993. Breastfed babies welcome here! Alexandria, VA: FNS.

4. American Academy of Pediatrics, Section on Breastfeeding. 2005. Policy statement: Breastfeeding and the use of human milk. Pediatrics 115:496-506.

5. Uauy, R., I. DeAndroca. 1995. Human milk and breast feeding for optimal brain development. J Nutr 125:2278-80.

6. Wang, Y. S., S. Y. Wu. 1996. The effect of exclusive breast feeding on development and incidence of infection in infants. J Hum Lactation 12:27-30.

7. Quandt, S. 1998. Ecology of breast feeding in the US: An applied perspective. Am J Hum Biol 10:221-28.

8. Hammosh, M. 1996. Breast feeding and the working mother. Pediatrics 97:492-98.

9. Kramer M. S., L. Matush, I. Vanilovich, et al. 2007. Effects of prolonged and exclusive breastfeeding on child height, weight, adiposity, and blood pressure at age 6.5 y: Evidence from a large randomized trial. Am J Clin Nutr 86:1717–21.

10. Lawrence, R. A., R. Lawrence. 2005. Breast feeding: A guide for the medical profession. 6th ed. St. Louis: Mosby.

11. Birch, L., W. Dietz, eds. 2008. Eating behaviors of the young child: Prenatal and postnatal influences on healthy eating. Elk Grove Village, IL: American Academy of Pediatrics.

12. Dietz, W. H., L. Stern, eds. 1998. American Academy of Pediatrics guide to your child’s nutrition. New York: Villard.

13. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.

14. U.S. Department of Agriculture, Food and Nutrition Service (FNS). 2002. Feeding infants: A guide for use in the child nutrition programs. Rev ed. Alexandria, VA: FNS. http://www.fns.usda.gov/tn/resources/feeding_infants.pdf.

15. Ip, S., M. Chung, G. Raman, P. Chew, N. Magula, D. DeVine, T. Trikalinos, J. Lau. 2007. Breastfeeding and maternal and infant health outcomes in developed countries. Rockville, MD: Agency for Healthcare Research and Quality.

16. U.S. Department of Agriculture, Food and Nutrition Service. Benefits and services: Breastfeeding promotion and support in WIC. http://www.fns.usda.gov/wic/breastfeeding/mainpage.HTM.

17. Stuebe, A. M., E. B. Schwarz. 2009. The risks and benefits of infant feeding practices for women and their children. J Perinatology (July 16).

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

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

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

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

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

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

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Standard 4.3.1.1: General Plan for Feeding Infants

Standard 4.3.1.8: Techniques for Bottle Feeding

REFERENCES:

1. Branscomb, K. R., C. B. Goble. 2008. Infants and toddlers in group care: Feeding practices that foster emotional health. Young Children 63:28-33.

2. Trahms, C. M., P. L. Pipes, eds. 1997. Nutrition and infancy in childhood. 6th ed. New York: McGraw-Hill.

3. Taveras, E. M., S. L. Rifas-Shiman, K. S. Scanlon, L. M. Grummer-Strawn, B. Sherry, M. W. Gillman. 2006. To what extent is the protective effect of breastfeeding on future overweight explained by decreased maternal feeding restriction? Pediatrics 118:2341-48.

4. Hodges, E. A., S. O. Hughes, J. Hopkinson, J. O. Fisher. 2008. Maternal decisions about the initiation and termination of infant feeding. Appetite 50:333-39.

5. Hagan, Jr., J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Bright futures: Guidelines for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics.

6. Satter, E. 2000. Child of mine: Feeding with love and good sense. 3rd ed. Boulder, CO: Bull Publishing.

STANDARD 4.3.1.3: Preparing, Feeding, and Storing Human Milk

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

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

Bottles made of plastics containing BPA or phthalates should be avoided (labeled with #3, #6, or #7). Glass bottles or plastic bottles labeled BPA-free or with #1, #2, #4, or #5 are acceptable.

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

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

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

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

Human milk can be stored using the following guidelines from the Academy of Breastfeeding Medicine: Guidelines for Storage of Human Milk
Location	Temperature	Duration	Comments
Countertop, table	Room temperature (up to 77°F or 25°C)	6-8 hours	Containers should be covered and kept as cool as possible; covering the container with a cool towel may keep milk cooler.
Insulated cooler bag	5°F – 39°F or -15°C – 4°C	24 hours	Keep ice packs in contact with milk containers at all times, limit opening cooler bag.
Refrigerator	39°F or 4°C	5 days	Store milk in the back of the main body of the refrigerator.
Freezer compartment of a refrigerator	5°F or -15°C	2 weeks	Store milk toward the back of the freezer, where temperature is most constant. Milk stored for longer durations in the ranges listed is safe, but some of the lipids in the milk undergo degradation resulting in lower quality.
Freezer compartment of refrigerator with separate doors	0°F or -18°C	3-6 months
Chest or upright deep freezer	-4°F or -20°C	6-12 months
Source: Academy of Breastfeeding Medicine Protocol Committee. 2010. Clinical protocol #8: Human milk storage information for home use for healthy full term infants, revised. Breastfeeding Med 5:127-30. http://www.bfmed.org/Resources/Download .aspx?filename=Protocol 8 - English.pdf. From the Centers for Disease Control and Prevention Website: Proper handling and storage of human milk – Storage duration of fresh human milk for use with healthy full term infants. http://www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htm.

Setting	Food Service Staff
Small and large family child care homes	Caregiver/teacher and/or helper (note: some large homes must have a helper)
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: Labels for containers of human milk should be resistant to loss of the name and date/time when washing and handling. This is especially important when the frozen bottle is thawed in running tap water. There may be several bottles from different mothers being thawed and warmed at the same time in the same place.

By following this standard, the staff is able, when necessary, to prepare human milk and feed an infant safely, thereby reducing the risk of inaccuracy or feeding the infant unsanitary or incorrect human milk (2,5). Written guidance for both staff and parents/guardians should be available to determine when milk provided by parents/guardians will not be served. Human milk cannot be served if it does not meet the requirements for sanitary and safe milk.

Excessive shaking of human milk may damage some of the cellular components that are valuable to the infant.

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

By following safe preparation and storage techniques, nursing mothers and caregivers/teachers of breastfed infants and children can maintain the high quality of expressed human milk and the health of the infant (3,4,6).

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

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

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Standard 4.3.1.1: General Plan for Feeding Infants

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

Standard 4.3.1.7: Feeding Cow’s Milk

Standard 4.3.1.8: Techniques for Bottle Feeding

Standard 4.3.1.9: Warming Bottles and Infant Foods

REFERENCES:

1. American Academy of Pediatrics, Section on Breastfeeding. 2005. Policy statement: Breastfeeding and the use of human milk. Pediatrics 115:496-506.

2. Clark, A., J. Anderson, E. Adams, S. Baker. 2008. Assessing the knowledge, attitudes, behaviors and training needs related to infant feeding, specifically breastfeeding, of child care providers. Matern Child Health J 12:128-35.

3. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.

4. Samour, P. Q., K. King. 2005. Handbook of pediatric nutrition. 3rd ed. Lake Dallas, TX: Helm.

5. Lawrence, R. A., R. Lawrence. 2005. Breast feeding: A guide for the medical profession. 6th ed. St. Louis: Mosby.

6. Endres, J. B., R. E. Rockwell. 2003. Food, nutrition, and the young child. 4th ed. New York: Macmillan.

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

If a child has been mistakenly fed another child’s bottle of expressed human milk, the possible exposure to hepatitis B, hepatitis C, or HIV should be treated as if an exposure to other body fluids had occurred. For possible exposure to hepatitis B, hepatitis C, or HIV, the caregiver/teacher should:

1. Inform the mother who expressed the human milk about the mistake and when the bottle switch occurred, and ask:
   1. When the human milk was expressed and how it was handled prior to being delivered to the caregiver/teacher or facility;
   2. Whether she has ever had a hepatitis B, hepatitis C, or HIV blood test and, if so, the date of the test and would she be willing to share the results with the parents/guardians of the child who was fed the incorrect milk;
   3. If she does not know whether she has ever been tested for hepatitis B, hepatitis C, or HIV, would she be willing to contact her primary care provider and find out if she has been tested;
   4. If she has never been tested for hepatitis B, hepatitis C, or HIV, would she be willing to be tested and share the results with the parents/guardians of the other child;
2. Discuss the mistake of giving the wrong milk with the parents/guardians of the child who was fed the wrong bottle:
   1. Inform them that their child was given another child’s bottle of expressed human milk and the date it was given;
   2. Inform them that the risk of transmission of hepatitis B, hepatitis C, or HIV and other infectious diseases is low;
   3. Encourage the parents/guardians to notify the child’s primary care provider of the exposure;
   4. Provide the family with information including the time at which the milk was expressed and how the milk was handled prior to its being delivered to the caregiver/teacher so that the parents/guardians may inform the child’s primary care provider;
   5. Inform the parents/guardians that, depending upon the results from the mother whose milk was given mistakenly (1), their child may soon need to undergo a baseline blood test for hepatitis B (also see below), hepatitis C, or HIV;
3. Assess why the wrong milk was given and develop a prevention plan to be shared with the parents/guardians as well as the staff in the facility.

If the human milk given mistakenly to a child is from a woman who does not know her hepatitis B status, the caregiver/teacher should determine if the child has received the complete hepatitis B vaccine series. If the child has not been vaccinated or is incompletely vaccinated, then the parent/guardian of the child who received the milk should seek vaccination of the child. The child should complete the recommended childhood hepatitis B vaccine series as soon as possible. If human milk from a hepatitis B-positive woman is given mistakenly to a an unimmunized child, the child may receive HBIG (Hepatitis B Immune Globulin) as soon as possible within seven days, but it is not necessary because of the low risk of transmission (3). The hepatitis B vaccine series should be initiated and completed as soon as possible.

RATIONALE: The risk of hepatitis B, hepatitis C, or HIV transmission from expressed human milk consumed by another child is believed to be low because:

1. In the United States, women who are HIV-positive and aware of that fact are advised NOT to breastfeed their infants and therefore the potential for exposure to milk from an HIV-positive woman is low;
2. In the United States, women with high hepatitis C antiviral loads or who have cracked or bleeding nipples might transmit the infection through breastfeeding. Therefore, they are advised to refrain from breastfeeding (3,4);
3. Chemicals present in human milk act, together with time and cold temperatures, to destroy the HIV present in expressed human milk;
4. Transmission of HIV from a single human milk exposure has never been documented (1).

Because parents/guardians may express concern about the likelihood of transmitting these diseases through human milk, this issue is addressed in detail to assure there is a very small risk of such transmission occurring.

Among known HIV-positive women in Africa (where HIV-positive women are still advised to breastfeed only if they are located in areas where the water supply is unreliable), a study found that the transmission rate among infants who were fed infected human milk exclusively for several months was found to be 4%; thirteen infants out of 324 (2).

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Standard 4.3.1.3: Preparing, Feeding, and Storing Human Milk

REFERENCES:

1. Centers for Disease Control and Prevention. What to do if an infant or child is mistakenly fed another woman’s expressed breast milk. http://www.cdc.gov/breastfeeding/recommendations/other_mothers_milk.htm.

2. Becquet, R., D. K. Ekouevi, H. Menan, C. Amani-Bosse, L. Bequet, I. Viho, F. Dabis, M. Timite-Konan, V. Leroy. 2008. Early mixed feeding and breastfeeding beyond 6 months increase the risk of postnatal HIV transmission. Prev Med 47:27-33.

3. Pickering, L. K., C. J. Baker, D. W. Kimberlin, S. J. Long, eds. 2009. Red book: 2009 report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics.

4. Philip Spradling, CDC, email message to the NRC, May 12, 2010.

STANDARD 4.3.1.5: Preparing, Feeding, and Storing Infant Formula

Formula provided by parents/guardians or by the facility should come in a factory-sealed container. The formula should be of the same brand that is served at home and should be of ready-to-feed strength or liquid concentrate to be diluted using water from a source approved by the health department. Powdered infant formula, though it is the least expensive formula, requires special handling in mixing because it cannot be sterilized. The primary source for proper and safe handling and mixing is the manufacturer’s instructions that appear on the can of powdered formula. Before opening the can, hands should be washed. The can and plastic lid should be thoroughly rinsed and dried. Caregivers/teachers should read and follow the manufacturer’s directions. If instructions are not readily available, caregivers/teachers should obtain information from the World Health Organization’s Safe Preparation, Storage and Handling of Powdered Infant Formula Guidelines at http://www.who.int/foodsafety/publications/micro/pif2007/en/index.html (8). The local WIC program can also provide instructions.

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

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

Bottles of formula prepared from powder or concentrate or ready-to-feed formula should be labeled with the child’s full name and time and date of preparation. Any prepared formula must be discarded within one hour after serving to an infant. Prepared powdered formula that has not been given to an infant should be covered, labeled with date and time of preparation and child’s full name, and may be stored in the refrigerator for up to twenty-four hours. An open container of ready-to-feed, concentrated formula, or formula prepared from concentrated formula, should be covered, refrigerated, labeled with date of opening and child’s full name, and discarded at forty-eight hours if not used (7,9). The caregiver/teacher should always follow manufacturer’s instructions for mixing and storing of any formula preparation.

Some infants will require specialized formula because of allergy, inability to digest certain formulas, or need for extra calories. The appropriate formula should always be available and should be fed as directed. For those infants getting supplemental calories, the formula may be prepared in a different way from the directions on the container. In those circumstances, either the family should provide the prepared formula or the caregiver/teacher should receive special training, as noted in the infant’s care plan, on how to prepare the formula.

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

If a child has a special health problem, such as reflux, or inability to take in nutrients because of delayed development of feeding skills, the child’s primary care provider should provide a written plan for the staff to follow so that the child is fed appropriately. Some infants are allergic to milk and soy and need to be fed an elemental formula which does not contain allergens. Other infants need supplemental calories because of poor weight gain.

Infants should not be fed a formula different from the one the parents/guardians feed at home, as even minor differences in formula can cause gastrointestinal upsets and other problems (6).

Excessive shaking of formula may cause foaming that increases the likelihood of feeding air to the infant.

Formula should not be used beyond the stated shelf life period (1).

COMMENTS: The intent of this standard is to protect a child’s health by ensuring safe and sanitary conditions for transporting and feeding infant formula prepared at home and brought to the facility, and by ensuring that all infants get the proper formula.

Parents/guardians should supply enough clean and sterilized bottles to be used throughout the day. The bottles must be sanitary, properly prepared and stored, and must be the same brand in the early care and education program and at home.

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

Caregivers/teachers should only use the scoop that comes with the can and not interchange the scoop from one product to another, since the volume of the scoop may vary from manufacturer to manufacturer and product to product. Also, a scoop can be contaminated with a potential allergen from another type of formula. 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, however they are the most expensive approach to feeding formula.

If concentrated liquid or powdered infant formulas are used, it is very important to prepare them properly, with accurate dilution, according to the directions on the container. Adding too little water to formula puts a burden on an infant’s kidneys and digestive system and may lead to dehydration (4). Adding too much water dilutes the formula. Diluted formula may interfere with an infant’s growth and health because it provides inadequate calories and nutrients and can cause water intoxication. Water intoxication can occur in breastfed or formula-fed infants or children over one year of age who are fed an excessive amount of water. Water intoxication can be life-threatening to an infant or young child (5).

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Standard 4.3.1.1: General Plan for Feeding Infants

Standard 4.3.1.8: Techniques for Bottle Feeding

Standard 4.3.1.9: Warming Bottles and Infant Foods

REFERENCES:

1. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.

2. Dietitians of Canada, American Dietetic Association. 2000. Manual of clinical dietetics. 6th ed. Chicago: ADA.

3. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.

4. Institute for Safe Medication Practices. Infant formula: Read and follow the label instructions! http://www.ismp.org/consumers/Formula.asp.

5. U.S. Department of Agriculture, Food and Nutrition Service (FNS). 2001. Feeding infants: A guide for use in the child nutrition programs. Rev ed. Alexandria, VA: FNS. http://www.fns.usda.gov/tn/resources/feeding_infants.pdf.

6. American Academy of Pediatrics, Section on Breastfeeding. 2005. Policy statement: Breastfeeding and the use of human milk. Pediatrics 115:496-506.

7. Fomon, S. J. 1993. Nutrition of normal infants. St. Louis: Mosby.

8. World Health Organization (WHO), Food and Agriculture Organization of the United Nations. 2007. Safe preparation, storage and handling of powdered infant formula: Guidelines. Geneva: WHO.

9. International Formula Council. Guidelines for traveling with infants: Keeping formula safe and sound. http://www.infantformula
.org/for-parents/traveling-infants/.

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

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

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

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

COMMENTS: The taste of soy milk is similar to cow’s milk. Because soy formula and soy milk are derived from a plant source, parents/guardians may choose these products for dietary (e.g., vegan) or religious reasons. In such cases, soy-based formula is used for infant feeding and unflavored soy milk is the choice for young children.

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

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

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Standard 4.2.0.12: Vegetarian/Vegan Diets

Standard 4.3.1.5: Preparing, Feeding, and Storing Infant Formula

REFERENCES:

1. Bhatia, J., F. Greer, Committee on Nutrition. 2008. Use of soy protein-based formulas for infant feeding. Pediatrics 121:1062-68.

2. Dietitians of Canada, American Dietetic Association (ADA). 2000. Manual of clinical dietetics. 6th ed. Chicago: ADA.

STANDARD 4.3.1.7: Feeding Cow’s Milk

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

RATIONALE: For children between twelve months and twenty-four months of age, for whom overweight or obesity is a concern or who have a family history of obesity, dyslipidemia, or early cardiovascular disease, the use of reduced fat (2%) milk is appropriate (1). The child’s primary care provider may also recommend reduced fat (2%) milk for some children this age. Studies show no compromise in growth, and no difference in height, weight, or percentage of body fat and neurological development in toddlers fed reduced fat (2%) milk compared with those fed whole milk (2,8,9). The American Academy of Pediatrics recommends that cow’s milk not be used during the first year of life (3-7).

COMMENTS: Sometimes early care and education programs have children ages eighteen months to three years of age in one classroom and staff report it is difficult to serve different types of milk (1% and 2%) to specific children. Programs can use a different color label for each type of milk on the container or pitcher. Caregivers/teachers can explain to the children the meaning of the color labels and identify which milk they are drinking.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Standard 4.2.0.4: Categories of Foods

Standard 4.9.0.3: Precautions for a Safe Food Supply

REFERENCES:

1. Daniels, S. R., F. R. Greer, Committee on Nutrition. 2008. Lipid screening and cardiovascular health in childhood. Pediatrics 122:198-208.

2. Wosje, K. S., B. L. Specker, J. Giddens. 2001. No differences in growth or body composition from age 12 to 24 months between toddlers consuming 2% milk and toddlers consuming whole milk.
J Am Diet Assoc 101:53-56.

3. Dietz, W. H., L. Stern, eds. 1998. American Academy of Pediatrics guide to your child’s nutrition. New York: Villard.

4. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.

5. Dietitians of Canada, American Dietetic Association. 2000. Manual of clinical dietetics. 6th ed. Chicago: ADA.

6. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.

7. American Academy of Pediatrics, Committee on Nutrition. 1992. The use of whole cow’s milk in infancy. Pediatrics 89:1105-9.

8. Rask-Nissila, L., E. Jokinen, P. Terho, A. Tammi, H. Lapinleimu, T. Ronnemaa, J. Viikari, R. Seppanen, T. Korhonen, J. Tuominen, I. Valimaki, O. Simell. 2000. Neurological development of 5-year-old children receiving a low-saturated fat, low-cholesterol diet since infancy: A randomized controlled trial. JAMA 284:993-1000.

9. Niinikoski, H. Lapinleimu, , J. Viikari, H. Lapinleimu, T. Rönnemaa, E. Jokinen, R. Seppänen, P. Terho, J. Tuominen, I. Välimäki, O. Simell. 1997. Growth until 3 years of age in a prospective, randomized trial of a diet with reduced saturated fat and cholesterol. Pediatrics 99:687-94.

STANDARD 4.3.1.8: Techniques for Bottle Feeding

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

Bottle feeding techniques should mimic approaches to breastfeeding:

1. Initiate feeding when infant provides cues (rooting, sucking, etc.);
2. Hold the infant during feedings and respond to vocalizations with eye contact and vocalizations;
3. Alternate sides of caregiver’s/teacher’s lap;
4. Allow breaks during the feeding for burping;
5. Allow infant to stop the feeding.

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

Bottles should be checked to ensure they are given to the appropriate child, have human milk, infant formula, or water in them.

When using a bottle for a breastfed infant, a nipple with a cylindrical teat and a wider base is usually preferable. A shorter or softer nipple may be helpful for infants with a hypersensitive gag reflex, or those who cannot get their lips well back on the wide base of the teat (22).

The use of a bottle or cup to modify or pacify a child’s behavior should not be allowed (1,16).

RATIONALE: The manner in which food is given to infants is conducive to the development of sound eating habits for life. Caregivers/teachers should promote proper feeding practices and oral hygiene including proper use of the bottle for all infants and toddlers. Bottle propping can cause choking and aspiration and may contribute to long-term health issues, including ear infections (otitis media), orthodontic problems, speech disorders, and psychological problems (1-6). When infants and children are “cue fed”, they are in control of frequency and amount of feedings. This has been found to reduce the risk of childhood obesity.

Any liquid except plain water can cause early childhood caries (7-18). Early childhood caries in primary teeth may hold significant short-term and long-term implications for the child’s health (7-18). Frequently sipping any liquid besides plain water between feeds encourages tooth decay.

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

COMMENTS: Caregivers/teachers and parents/guardians need to understand the relationship between bottle feeding and emotional security. Caregivers/teachers should hold infants who are bottle feeding whenever possible, even if the children are old enough to hold their own bottle.

Caregivers/teachers should offer children fluids from a cup as soon as they are developmentally ready. Some children may be able to drink from a cup around six months of age, while for others it is later (2). Weaning a child to drink from a cup is an individual process, which occurs over a wide range of time. The American Academy of Pediatric Dentistry (AAPD) recommends weaning from a bottle by the child’s first birthday (1-3,6-9). Instead of sippy cups, caregivers/teachers should use smaller cups and fill halfway or less to prevent spills as children learn to use a cup (19-21). If sippy cups are used, it should only be for a very short transition period.

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

Infants should be burped after every feeding and preferably during the feeding as well.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

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

Standard 4.3.1.9: Warming Bottles and Infant Foods

REFERENCES:

1. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.

2. Casamassimo, P., K. Holt, eds. 2004. Bright futures in practice: Oral health–pocket guide. Washington, DC: National Maternal and Child Oral Health Resource Center. http://www.mchoralhealth.org/PDFs/BFOHPocketGuide.pdf.

3. Dietitians of Canada, American Dietetic Association. 2000. Manual of clinical dietetics. 6th ed. Chicago: ADA.

4. Wang, Y. S., S. Y. Wu. 1996. The effect of exclusive breast feeding on development and incidence of infection in infants. J Hum Lactation 12:27-30.

5. American Academy of Pediatric Dentistry. 1993. Recommendation for preventive pediatric dental care. Pediatr Dent 15:158-59.

6. American Academy of Pediatric Dentistry. 1994. Reference manual, 1994-1995. Pediatr Dent 16:196.

7. Schafer, T. E., S. M. Adair. 2000. Prevention of dental disease: The role of the pediatrician. Pediatr Clin North Am 47:1021-42.

8. Ramos-Gomez, F. J. 2005. Clinical considerations for an infant oral health care program. Compend Contin Educ Dent 26:17-23.

9. Ramos-Gomez, F. J., B. Jue, C. Y. Bonta. 2002. Implementing an infant oral care program. J Calif Dent Assoc 30:752-61.

10. U.S. Department of Health and Human Services (DHHS). 2000. Oral health in America: A report of the surgeon general–Executive summary. Rockville, MD: DHHS, National Institute of Dental and Craniofacial Research, National Institutes of Health.

11. Section on Pediatric Dentistry and Oral Health. 2008. Preventive oral health intervention for pediatricians. Pediatrics 122:1387-94.

12. New York State Department of Health. 2006. Oral health care during pregnancy and early childhood: Practice guidelines. Albany, NY: New York State Department of Health. http://www.health.state.ny.us/publications/0824.pdf.

13. American Dental Association. 2004. From baby bottle to cup: Choose training cups carefully, use them temporarily. J Am Dent Assoc 135:387.

14. American Dental Association. ADA statement on early childhood caries. http://www.ada.org/2057.aspx.

15. The American Academy of Pediatric Dentistry (AAPD). 2002. Policy on baby bottle tooth decay (BBTD)/early childhood caries (ECC). In Reference manual 2002-2003, 23. Chicago, IL: AAPD. http://www.aapd.org/members/referencemanual/pdfs/02-03/Baby Bottle Tooth Decay.pdf.

16. American Academy of Pediatrics. 2007. Brushing up on oral health: Never too early to start. Healthy Children (Winter): 14-15. http://www.healthychildren.org/english/healthy-living/oral-health/pages/Brushing-Up-on-Oral-Health-Never-Too-Early-to-Start.aspx.

17. Tinanoff, N., C. Palmer. 2000. Dietary determinants of dental caries and dietary recommendations for preschool children. J Public Health Dent 60:197-206.

18. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.

19. Prolonged use of sippy cups under scrutiny. 2002. Dentistry Today 21:44.

20. Behrendt, A., F. Szlegoleit, V. Muler-Lessmann, G. Ipek-Ozdemir, W. F. Wetzel. 2001. Nursing-bottle syndrome caused by prolonged drinking from vessels with bill-shaped extensions. ASDC J Dent Child 68:47-54.

21. Satter, E. 2000. Child of mine: Feeding with love and good sense. 3rd ed. Boulder, CO: Bull Publishing.

22. Watson Genna, C. 2008. Supporting sucking skills in breastfeeding infants. Sudbury, MA: Jones and Bartlett.

STANDARD 4.3.1.9: Warming Bottles and Infant Foods

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

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

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

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

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Standard 4.3.1.8: Techniques for Bottle Feeding

Standard 4.3.1.12: Feeding Age-Appropriate Solid Foods to Infants

REFERENCES:

1. Nemethy, M., E. R. Clore. 1990. Microwave heating of infant formula and breast milk. J Pediatr Health Care 4:131-35.

2. Dixon J. J., D. A. Burd, D. G. Roberts. 1997. Severe burns resulting from an exploding teat on a bottle of infant formula milk heated in a microwave oven. Burns 23:268-69.

STANDARD 4.3.1.10: Cleaning and Sanitizing Equipment Used for Bottle Feeding

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

RATIONALE: Infant feeding bottles are contaminated by the child’s saliva during feeding. Formula and milk promote growth of bacteria, yeast, and fungi. Bottles, bottle caps, and nipples that are reused should be washed and sanitized to avoid contamination from previous feedings.

COMMENTS: Excessive boiling of latex bottle nipples will damage them. Nipples that are discolored, thinning, tacky, or ripped should not be used.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

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

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

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

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

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

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

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

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

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

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

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Standard 4.2.0.7: 100% Fruit Juice

Standard 4.2.0.9: Written Menus and Introduction of New Foods

Standard 4.2.0.10: Care for Children with Food Allergies

Standard 4.3.1.12: Feeding Age-Appropriate Solid Foods to Infants

Standard 4.5.0.8: Experience with Familiar and New Foods

REFERENCES:

1. Hagan, Jr., J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Promoting healthy nutrition. In Bright futures: Guidelines for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics. http://brightfutures.aap.org/pdfs/Guidelines_PDF/6-Promoting_Healthy_Nutrition.pdf.

2. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.

3. Lawrence, R. A., R. Lawrence. 2005. Breast feeding: A guide for the medical profession. 6th ed. St. Louis: Mosby.

4. Wagner, C. L., F. R. Greer, Section on Breastfeeding, Committee on Nutrition. 2008. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Pediatrics 122:1142–52.

5. Lally, J. R., A. Griffin, E. Fenichel, M. Segal, E. Szanton, B. Weissbourd. 2003. Caring for infants and toddlers in groups: Developmentally appropriate practice. Arlington, VA: Zero to Three.

6. U.S. Department of Agriculture, Food and Nutrition Service (FNS). 2002. Feeding infants: A guide for use in the child nutrition programs. Rev ed. Alexandria, VA: FNS. http://www.fns.usda.gov/tn/resources/feeding_infants.pdf.

7. Branscomb, K. R., C. B. Goble. 2008. Infants and toddlers in group care: Feeding practices that foster emotional health. Young Children 63:28-33.

8. Grummer-Strawn, L. M., K. S. Scanlon, S. B. Fein. 2008. Infant feeding and feeding transitions during the first year of life. Pediatrics 122: S36-S42.

9. Griffiths, L. J., L. Smeeth, S. S. Hawkins, T. J. Cole, C. Dezateux. 2008. Effects of infant feeding practice on weight gain from birth to 3 years. Arch Dis Child (November): 1-17.

10. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.

STANDARD 4.3.1.12: Feeding Age-Appropriate Solid Foods to Infants

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

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

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

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

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

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

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

REFERENCES:

1. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.

2. Dietitians of Canada, American Dietetic Association (ADA). 2000. Manual of clinical dietetics. 6th ed. Chicago: ADA.

3. Endres, J. B., R. E. Rockwell. 2003. Food, nutrition, and the young child. 4th ed. New York: Macmillan.

4. Samour, P. Q., K. King. 2005. Handbook of pediatric nutrition. 3rd ed. Lake Dallas, TX: Helm.

5. Lawrence, R. A., R. Lawrence. 2005. Breast feeding: A guide for the medical profession. 6th ed. St. Louis: Mosby.

4.3.2 Nutrition for Toddlers and Preschoolers

STANDARD 4.3.2.1: Meal and Snack Patterns for Toddlers and Preschoolers

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

RATIONALE: Even during periods of slower growth, children must continue to eat nutritious foods. With limited appetites and selective eating by toddlers and preschoolers, less nutritious foods should not be served as they can displace more nutritious foods from the child’s diet.

COMMENTS: Children who are eating more than one snack and one meal may not want all the food offered at any one of these times. On the other hand, toddlers and preschoolers may eat only some meals or some snacks. The amount of food offered to them must be sufficient to meet their needs at that particular time but not too large to promote overeating.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Standard 4.2.0.4: Categories of Food

Standard 4.2.0.5: Meal and Snack Patterns

STANDARD 4.3.2.2: Serving Size for Toddlers and Preschoolers

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

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

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

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

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

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

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

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Standard 4.3.2.1: Meal and Snack Patterns for Toddlers and Preschoolers

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

REFERENCES:

1. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.

2. Endres, J. B., R. E. Rockwell. 2003. Food, nutrition, and the young child. 4th ed. New York: Macmillan.

3. U.S. Department of Agriculture, Food Service and Nutrition. 2010. Child and adult care food program. http://www.fns.usda.gov/CND/Care/CACFP/aboutcacfp.htm.

4. U.S. Department of Agriculture (USDA). 2002. Making nutrition count for children – Nutrition guidance for child care homes. Washington, DC: USDA. http://www.fns.usda.gov/tn/Resources/nutritioncount.html.

5. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.

6. Wansink, B. 2004. Environmental factors that increase the food intake and consumption volume of unknowing consumers. Annual Review of Nutrition 24:455-79.

7. Wansink, B., J. E. Painter, J. North. 2005. Bottomless bowls: Why visual cues of portion size may influence intake. Obesity Research 13:93-100.

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

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

RATIONALE: As children enter the second year of life, they are interested in doing things for themselves. Self-feeding appropriately separates the responsibilities of adults and children. The adult is responsible for providing nutritious food, and the child is responsible for deciding how much of it to eat (1-5). To allow for the proper development of motor skills and eating habits, children need to be allowed to practice learning to feed themselves (6-8). Children in group care should be provided with opportunities to serve and eat a variety of food for themselves. Children will continue to self-feed using their fingers even after mastering the use of a utensil.

COMMENTS: Foods served should be appropriate to the toddler’s developmental ability and cut small enough to avoid choking hazards.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Standard 4.3.2.2: Serving Size for Toddlers and Preschoolers

Standard 4.5.0.5: Numbers of Children Fed Simultaneously by One Adult

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

REFERENCES:

1. Benjamin, S. E., ed. 2007. Making food healthy and safe for children: How to meet the national health and safety performance standards – Guidelines for out of home child care programs. 2nd ed. Chapel Hill, NC: National Training Institute for Child Care Health Consultants. http://nti.unc.edu/course_files/curriculum/nutrition/making_food_healthy_and_safe.pdf.

2. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.

3. Endres, J. B., R. E. Rockwell. 2003. Food, nutrition, and the young child. 4th ed. New York: Macmillan.

4. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.

5. Briley, M. E., C. Roberts-Gray. 1999. Position of the American Dietetic Association: Nutrition standards for child-care programs. J Am Diet Assoc 99:981-88.

6. Branscomb, K. R., C. B. Goble. 2008. Infants and toddlers in group care: Feeding practices that foster emotional health. Young Children 63:28-33.

7. Hagan, Jr., J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Bright futures: Guidelines for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics.

8. University of Idaho, College of Agricultural and Life Sciences. Feeding young children in group settings. http://www.cals.uidaho
.edu/feeding/.

4.3.3 Nutrition for School-Age Children

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

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

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

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

RATIONALE: The principles of providing adequate, nourishing food for younger children apply to this group as well. This age is characterized by a rapid rate of growth that increases the need for energy and essential nutrients to support optimal growth. Food intake may vary considerably because this is a time when children express strong food likes and dislikes. The quantity and quality of food provided should contribute toward meeting nutritional needs for the day and should not dull the appetite (1-5).

COMMENTS: A nutrient analysis was conducted of the CACFP requirements, to ensure that a snack and lunch meet two-thirds of the Recommended Dietary Allowances (6).

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Hagan, Jr., J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Bright futures: Guidelines for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics.

2. Story, M., K. Holt, D. Sofka, eds. 2002. Bright futures in practice: Nutrition. 2nd ed. Arlington, VA: National Center for Education in Maternal and Child Health. http://www.brightfutures.org/nutrition/pdf/frnt_mttr.pdf.

3. Benjamin, S. E., ed. 2007. Making food healthy and safe for children: How to meet the national health and safety performance standards – Guidelines for out of home child care programs. 2nd ed. Chapel Hill, NC: National Training Institute for Child Care Health Consultants. http://nti.unc.edu/course_files/curriculum/nutrition/making_food_healthy_and_safe.pdf.

4. Endres, J. B., R. E. Rockwell. 2003. Food, nutrition, and the young child. 4th ed. New York: Macmillan.

5. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.

6. Briley, M. E., C. Roberts-Gray. 1999. Position of the American Dietetic Association: Nutrition standards for child-care programs. J Am Diet Assoc 99:981-88.

4.4 Staffing

STANDARD 4.4.0.1: Food Service Staff by Type of Facility and Food Service

Each center-based facility should employ trained staff and provide ongoing supervision and consultation in accordance with individual site needs as determined by the nutritionist/registered dietitian. In centers, prior work experience in food service should be required for the solitary worker responsible for food preparation without continuous on-site supervision of a food service manager. For facilities operating six or more hours a day or preparing and serving food on the premises, the following food service staff requirements should apply:

Setting	Food Service Staff
Small and large family child care homes	Caregiver/teacher and/or helper (note: some large homes must have a helper)
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 are essential workers in the food service of facilities to assure the maintenance of nutrition standards required in these facilities (1-6). 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 ensure that children are fed according to the facility’s daily schedule. If a facility that operates for six or more hours a day serves only food brought from home, food service staff is needed to oversee the appropriate use of such food.

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

RELATED STANDARDS:

Appendix C: Nutrition Specialist, Registered Dietitian, Licensed Nutritionist, Consultant, and Food Service Staff Qualifications

REFERENCES:

1. Benjamin, S. E., ed. 2007. Making food healthy and safe for children: How to meet the National health and safety performance standards – Guidelines for out of home child care programs. 2nd ed. Chapel Hill, NC: National Training Institute for Child Care Health Consultants. http://nti.unc.edu/course_files/curriculum/nutrition/making_food_healthy_and_safe.pdf.

2. Enders, J. B. 1994. Food, nutrition and the young child. New York: Merrill.

3. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.

4. Briley, M. E., C. Roberts-Gray. 1999. Position of the American Dietetic Association: Nutrition standards for child-care programs. J Am Diet Assoc 99:981-88.

5. U.S. Department of Agriculture (USDA), Food and Nutrition Service. 2009. USDA recipes for child care. http://teamnutrition
.usda.gov/Resources/childcare_recipes.html.

6. U.S. Department of Agriculture, Food and Nutrition Service. 2008. Food Buying Guide for Child Nutrition Programs. Rev ed. http://www.fns.usda.gov/tn/Resources/foodbuyingguide.html.

STANDARD 4.4.0.2: Use of Nutritionist/Registered Dietitian

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

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

RATIONALE: Efficient and cost-effective food service in a facility begins with a plan and evaluation of the physical components of the facility. Planning for the food service unit includes consideration of location and adequacy of space for receiving, storing, preparing, and serving areas; cleaning up; dish washing; dining areas, plus space for desk, telephone, records, and employee facilities (such as handwashing sinks, toilets, and lockers). All facets must be considered for new or existing sites, including remodeling or renovation of the unit (1-5).

COMMENTS: Nutritionists/registered dietitians assist food service staff/caregivers/teachers in planning menus for meals/snacks consisting of healthy foods which meet CACFP guidelines; ensuring use of age-appropriate eating utensils and suitable furniture (tables, chairs) for children to sit comfortably while eating; addressing any dietary modification needed; providing training for staff and nutrition education for children and their parents/guardians; consulting on meeting local health department regulations and meeting local regulations when using an off-site food vendor. This standard is primarily for Centers.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Standard 3.1.2.1: Routine Health Supervision and Growth Monitoring

Standard 4.2.0.1: Written Nutrition Plan

Standard 4.2.0.2: Assessment and Planning of Nutrition for Individual Children

Standard 4.2.0.8: Feeding Plans and Dietary Modifications

Standard 9.2.3.11: Food and Nutrition Service Policies and Plans

Appendix C: Nutrition Specialist, Registered Dietitian, Licensed Nutritionist, Consultant, and Food Service Staff Qualifications

REFERENCES:

1. Endres, J. B., R. E. Rockwell. 2003. Food, nutrition, and the young child. 4th ed. New York: Macmillan.

2. U.S. Department of Agriculture (USDA). 2002. Making nutrition count for children - Nutrition guidance for child care homes. Washington, DC: USDA. http://www.fns.usda.gov/tn/Resources/nutritioncount.html.

3. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.

4. Benjamin, S. E., K. A. Copeland, A. Cradock, E. Walker, M. M. Slining, B. Neelon, M. W. Gillman. 2009. Menus in child care: A comparison of state regulations to national standards. J Am Diet Assoc 109:109-15.

5. Kaphingst, K. M., M. Story. 2009. Child care as an untapped setting for obesity prevention: State child care licensing regulations related to nutrition, physical activity, and media use for preschool-aged children in the United States. Prev Chronic Dis 6(1).

4.5 Meal Service, Seating, and Supervision

STANDARD 4.5.0.1: Developmentally Appropriate Seating and Utensils for Meals

The child care staff should ensure that children who do not require highchairs are comfortably seated at tables that are between waist and mid-chest level and allow the seated child’s feet to rest on a firm surface.

All furniture and eating utensils that a child care facility uses should make it possible for 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 (7,9).

Suitable furniture and utensils, in addition to providing 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 (4-6,8,9).

COMMENTS: Eating utensils should be unbreakable, durable, attractive, and suitable in function, size, and shape for use by children. Dining areas, whether in a classroom or in a separate area, should be clean and cheerful (1-6).

Compliance can be measured by observing the fit of the furniture for children.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Standard 4.5.0.2: Tableware and Feeding Utensils

REFERENCES:

1. U.S. Department of Health and Human Services, Administration for Children and Families (ACF). 2006. Head Start Program Performance Standards and other Regulations. Rev ed. Washington, DC: ACF, Head Start Bureau.

2. Story, M., K. Holt, D. Sofka, eds. 2002. Bright futures in practice: Nutrition. 2nd ed. Arlington, VA: National Center for Education in Maternal and Child Health. http://www.brightfutures.org/nutrition/pdf/frnt_mttr.pdf.

3. Benjamin, S. E., ed. 2007. Making food healthy and safe for children: How to meet the National health and safety performance standards – Guidelines for out of home child care programs. 2nd ed. Chapel Hill, NC: National Training Institute for Child Care Health Consultants. http://nti.unc.edu/course_files/curriculum/nutrition/making_food_healthy_and_safe.pdf.

4. Enders, J. B. 1994. Food, nutrition and the young child. New York: Merrill.

5. U.S. Department of Agriculture (USDA). 2002. Making nutrition count for children - Nutrition guidance for child care homes. Washington, DC: USDA. http://www.fns.usda.gov/tn/Resources/nutritioncount.html.

6. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.

7. U.S. Department of Agriculture (USDA), Food and Nutrition Service. 2009. USDA recipes for child care. http://teamnutrition
.usda.gov/Resources/childcare_recipes.html.

8. Hagan, Jr., J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Bright futures: Guidelines for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics.

9. Fletcher, J., L. Branen, E. Price. 2005. Building mealtime environments and relationships: An inventory for feeding young children in group settings. Moscow, ID: University of Idaho. http://www.cals.uidaho.edu/feeding/pdfs/BMER.pdf.

STANDARD 4.5.0.2: Tableware and Feeding Utensils

Tableware and feeding utensils should meet the following requirements:

1. Dishes should have smooth, hard, glazed surfaces and should be free from cracks or chips. Sharp-edged plastic utensils (intended for use in the mouth) or dishes that have sharp or jagged edges should not be used;
2. Imported dishes and imported ceramic dishware or pottery should 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;
3. Disposable tableware (such as plates, cups, utensils made of heavy weight paper, food-grade medium- weight or BPA- or phthalates-free plastic) should be permitted for single service if they are discarded after use. The facility should not use foam tableware for children under four years of age;
4. Single-service articles (such as napkins, paper placemats, paper tablecloths, and paper towels) should be discarded after one use;
5. Washable bibs, placemats, napkins, and tablecloths, if used, should be laundered or washed, rinsed, and sanitized after each meal. Fabric articles should be sanitized by being machine-washed and dried after each use;
6. Highchair trays, plates, and all items used in food service that are not disposable should be washed, rinsed, and sanitized. Highchair trays that are used for eating should be washed, rinsed, and sanitized just before and immediately after they are used for eating. Children who eat at tables should have disposable or washed and sanitized plates for their food;
7. All surfaces in contact with food should be lead-free;
8. Tableware and feeding utensils should be child-sized and developmentally appropriate.

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, eating 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 before and after use (1-3). The use of disposable items eliminates the spread of contamination and disease and fosters safety and injury prevention. Single-service items are usually porous and should not be washed and reused. Items intended for reuse must be capable of being washed, rinsed, and sanitized.

Medium-weight plastic should be chosen because lighter-weight plastic utensils are more likely to have sharp edges and break off small pieces easily. 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 in the same way.

Foam can break into pieces that can 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 there is a question 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

RELATED STANDARDS:

Standard 4.9.0.9: Cleaning of Food Areas and Equipment

Standard 5.2.9.9: Plastic Containers and Toys

REFERENCES:

1. U.S. Department of Health and Human Services, Administration for Children and Families (ACF). 2006. Head Start Program Performance Standards and other Regulations. Rev ed. Washington, DC: ACF, Head Start Bureau.

2. Benjamin, S. E., ed. 2007. Making food healthy and safe for children: How to meet the National health and safety performance standards – Guidelines for out of home child care programs. 2nd ed. Chapel Hill, NC: National Training Institute for Child Care Health Consultants. http://nti.unc.edu/course_files/curriculum/nutrition/making_food_healthy_and_safe.pdf.

3. Enders, J. B. 1994. Food, nutrition and the young child. New York: Merrill.

STANDARD 4.5.0.3: Activities that Are Incompatible with Eating

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

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

RATIONALE: Seating children, while they are eating, reduces the risk of aspiration (1-4). Eating while doing other activities (including playing, walking around, or sitting at a computer) limits opportunities for socialization during meals and snacks. Eating while watching television is associated with an increased risk of obesity (5-8). Continuing to eat while falling asleep puts the child at great risk for gagging or choking.

COMMENTS: Staff can role model appropriate eating behaviors by sitting down when they are eating and eating “family style” with the children when possible.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Standard 4.5.0.4: Socialization During Meals

REFERENCES:

1. Benjamin, S. E., ed. 2007. Making food healthy and safe for children: How to meet the national health and safety performance standards – Guidelines for out of home child care programs. 2nd ed. Chapel Hill, NC: National Training Institute for Child Care Health Consultants. http://nti.unc.edu/course_files/curriculum/nutrition/making_food_healthy_and_safe.pdf.

2. Lally, J. R., A. Griffin, E. Fenichel, M. Segal, E. Szanton, B. Weissbourd. 2003. Caring for infants and toddlers in groups: Developmentally appropriate practice. Arlington, VA: Zero to Three.

3. Endres, J. B., R. E. Rockwell. 2003. Food, nutrition, and the young child. 4th ed. New York: Macmillan.

4. U.S. Department of Agriculture (USDA). 2002. Making nutrition count for children - Nutrition guidance for child care homes. Washington, DC: USDA. http://www.fns.usda.gov/tn/Resources/nutritioncount.html.

5. Briley, M., C. Roberts-Gray. 2005. Position of the American Dietetic Association: Benchmarks for nutrition programs in child care settings. J Am Dietetic Association 105:979–86.

6. Andersen, R. E., C. J. Crespo, S. J. Bartlett, L. J. Cheskin, M. Pratt. 1998. Relationship of physical activity and television watching with body weight and level of fatness among children. J Am Med Assoc 279:938-42.

7. Dennison, B. A., T. A. Erb, P. L. Jenkins. 2002. Television viewing and television in bedroom associated with overweight risk among low-income preschool children. Pediatrics 109:1028-35.

8. Mendoza, J. A., F. J. Zimmerman, D. A. Christakis. 2007. Television viewing, computer use, obesity, and adiposity in US preschool children. Int J Behav Nutr Physical Activity 4, no. 44 (September 25). http://ijbnpa.org/content/4/1/44/.

STANDARD 4.5.0.4: Socialization During Meals

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

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

RATIONALE: “Family style” meal service promotes and supports social, emotional, and gross and fine motor skill development. Caregivers/teachers sitting and eating with children is an opportunity to engage children in social interactions with each other and for positive role-modeling by the adult caregiver/teacher. Conversation at the table adds to the pleasant mealtime environment and provides opportunities for informal modeling of appropriate eating behaviors, communication about eating, and imparting nutrition learning experiences (1-3,5-7). The presence of an adult or adults, who eat with the children, helps prevent behaviors that increase the possibility of fighting, feeding each other, stuffing food into the mouth and potential choking, and other negative behaviors. The future development of children depends, to no small extent, on their command of language. Richness of language increases as adults and peers nurture it (5). Family style meals encourage children to serve themselves which develops their eye-hand coordination (3-5). In addition to being nourished by food, infants and young children are encouraged to establish warm human relationships by their eating experiences. When children lack the developmental skills for self-feeding, they will be unable to serve food to themselves. An adult seated at the table can assist and be supportive with self-feeding so the child can eat an adequate amount of food to promote growth and prevent hunger.

COMMENTS: Compliance is measured by structured observation. Use of small pitchers, a limited number of portions on service plates, and adult assistance to enable children to successfully serve themselves helps to make family style service possible without contamination or waste of food.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Standard 4.3.2.2: Serving Size for Toddlers and Preschoolers

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

Standard 4.7.0.1: Nutrition Learning Experiences for Children

REFERENCES:

1. U.S. Department of Health and Human Services, Administration for Children and Families, Office of Head Start. 2009. Head Start program performance standards. Rev. ed. Washington, DC: U.S. Government Printing Office. http://eclkc.ohs.acf.hhs.gov/hslc/Head Start Program/Program Design and Management/Head Start Requirements/Head Start Requirements/45 CFR Chapter XIII/45 CFR Chap XIII_ENG.pdf.

2. Benjamin, S. E., ed. 2007. Making food healthy and safe for children: How to meet the national health and safety performance standards – Guidelines for out of home child care programs. 2nd ed. Chapel Hill, NC: National Training Institute for Child Care Health Consultants. http://nti.unc.edu/course_files/curriculum/nutrition/making_food_healthy_and_safe.pdf.

3. Endres, J. B., R. E. Rockwell. 2003. Food, nutrition, and the young child. 4th ed. New York: Macmillan.

4. U.S. Department of Agriculture (USDA). 2002. Making nutrition count for children - Nutrition guidance for child care homes. Washington, DC: USDA. http://www.fns.usda.gov/tn/Resources/nutritioncount.html.

5. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.

6. Branscomb, K. R., C. B. Goble 2008. Infants and toddlers in group care: Feeding practices that foster emotional health. Young Children 63:28-33.

7. Sigman-Grant, M., E. Christiansen, L. Branen, J. Fletcher, S. L. Johnson. 2008. About feeding children: Mealtimes in child-care centers in four western states. J Am Diet Assoc 108:340-46.

STANDARD 4.5.0.5: Numbers of Children Fed Simultaneously by One Adult

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

RATIONALE: Cross-contamination among children whom one adult is feeding simultaneously poses significant risk. In addition, mealtime should be a socializing occasion. Feeding more than three children at the same time necessarily resembles an impersonal production line. It is difficult for the caregiver/teacher to be aware of and respond to infant feeding cues when feeding more than one infant at a time. A child may need one-on-one feeding based on age or degree of ability. Feeding more than three children also presents a potential risk of injury and/or choking.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

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

Standard 4.3.2.2: Serving Size for Toddlers and Preschoolers

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

Standard 4.5.0.4: Socialization During Meals

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

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

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

RATIONALE: A supervising adult should watch for several common problems that typically occur when children in mid-infancy begin to feed themselves. “Squirreling” of several pieces of food in the mouth increases the likelihood of choking. A choking child may not make any noise, so adults must keep their eyes on children who are eating. Active supervision is imperative. Supervised eating also promotes the child’s safety by discouraging activities that can lead to choking (1). For best practice, children of all ages should be supervised when eating. Adults can monitor age-appropriate portion size consumption.

COMMENTS: Adults can help children while they are learning, by modeling active chewing (i.e., eating a small piece of food, showing how to use their teeth to bite it) and making positive comments to encourage children while they are eating. Adults can demonstrate how to eat foods on the menu, how to serve food, and how to ask for more food as a way of helping children learn the names of foods (e.g., “please pass the bowl of noodles”).

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

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

Standard 4.5.0.4: Socialization During Meals

Standard 4.5.0.5: Numbers of Children Fed Simultaneously by One Adult

REFERENCES:

1. American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement: Prevention of choking among children. Pediatrics 125:601-7.

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

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

RATIONALE: Children develop social skills and new motor skills as well as increase their dexterity through this type of involvement. Children require close supervision by staff and other adults when they use knives and have contact with food surfaces and food that other children will use.

COMMENTS: Compliance is measured by structured observation.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Standard 4.5.0.4: Socialization During Meals

STANDARD 4.5.0.8: Experience with Familiar and New Foods

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

RATIONALE: By learning about new food, children increase their knowledge of the world around them, and the likelihood that they will choose a more varied, better balanced diet in later life. Eating habits and attitudes about food formed in the early years often last a lifetime. New food acceptance may take eight to fifteen times of offering a food before it is eaten (1).

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Standard 4.2.0.9: Written Menus and Introduction of New Foods

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

REFERENCES:

1. Sullivan, S. A., L. L. Birch. 1990. Pass the sugar, pass the salt: Experience dictates preference. Developmental Psychology 26:546-51.

STANDARD 4.5.0.9: Hot Liquids and Foods

Adults should not consume hot liquids above 120°F in child care areas (3). Hot liquids and hot foods should be kept out of the reach of infants, toddlers, and preschoolers. Hot liquids and foods should not be placed on a surface at a child's level, at the edge of a table or counter, or on a tablecloth that could be yanked down. Appliances containing hot liquids, such as coffee pots and crock pots, should be kept out of the reach of children. Electrical cords from any appliance, including coffee pots, should not be allowed to hang within the reach of children. Food preparers should position pot handles toward the back of the stove and use only back burners when possible.

RATIONALE: The most common burn suffered by young children is scalding from hot liquids tipped over in the kitchen (1). The skin of young children is much thinner than that of adults and can burn at temperatures that adults find comfortable (2). In a recent study, 90.4% of scald injuries to children under age five were related to hot cooking or drinking liquids (4).

COMMENTS: Hot liquids can cause burns to young children at the following rates of contact: one second at 156°F, two seconds at 149°F, five seconds at 140°F, fifteen seconds at 133°F, five minutes at 120°F (2).

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Ring, L. M. 2007. Kids and hot liquids-A burning reality. J of Pediatric Health Care 21:192-94.

2. Children’s Safety Association of Canada. Safety fact sheet: Scald burns. http://www.safekid.org/scald.htm.

3. Turner, C., A. Spinks, R. J. McClure, J. Nixon. 2004. Community-based interventions for the prevention of burns and scalds in children. Cochrane Database Systematic Rev (2).

4. Lowell, G., K. Quinlan, L. J. Gottlieb. 2008. Pediatrics 122:799-804.

STANDARD 4.5.0.10: Foods that Are Choking Hazards

Caregivers/teachers should not offer to children under four years of age foods that are associated with young children’s choking incidents (round, hard, small, thick and sticky, smooth, compressible or dense, or slippery). Examples of these foods are hot dogs and other meat sticks (whole or sliced into rounds), raw carrot rounds, whole grapes, hard candy, nuts, seeds, raw peas, hard pretzels, chips, peanuts, popcorn, rice cakes, marshmallows, spoonfuls of peanut butter, and chunks of meat larger than can be swallowed whole. Food for infants should be cut into pieces one-quarter inch or smaller, food for toddlers should be cut into pieces one-half inch or smaller to prevent choking. In addition to the food monitoring, children should always be seated when eating to reduce choking hazards. Children should be supervised while eating, to monitor the size of food and that they are eating appropriately (for example, not stuffing their mouths full).

RATIONALE: High-risk foods are those often implicated in choking incidents (1,9,10). Almost 90% of fatal choking occurs in children younger than four years of age (2-7). Peanuts may block the lower airway. A chunk of hot dog or a whole seedless grape may completely block the upper airway (2-8,10). The compressibility or density of a food item is what allows the food to conform to and completely block the airway. Hot dogs are the foods most commonly associated with fatal choking in children.

COMMENTS: To reduce the risk of choking, menus should reflect the developmental abilities of the age of children served. Because it is normal for children to get their first teeth at a widely variable age, menus must take into account not only the ages of children but also their teeth, or lack thereof. This becomes particularly important with those whose teeth come in late. Foods considered otherwise appropriate for one year-olds with a full complement of teeth may need to be reevaluated for the child whose first tooth has just emerged. 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 that are likely to cause choking (such as raw carrot rounds). To date, raisins appear to be safe, but, as when eating all foods, children should be seated and supervised.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Rimell, F. L., A. Thome Jr., S. Stool, et al. 1995. Characteristics of objects that cause choking in children. JAMA 274:1763-66.

2. Benjamin, S. E., ed. 2007. Making food healthy and safe for children: How to meet the National health and safety performance standards – Guidelines for out of home child care programs. 2nd ed. Chapel Hill, NC: National Training Institute for Child Care Health Consultants. http://nti.unc.edu/course_files/curriculum/nutrition/making_food_healthy_and_safe.pdf.

3. Dietz, W.H., L. Stern, eds. 1998. Guide to your child’s nutrition. Elk Grove Village, IL: American Academy of Pediatrics.

4. Kleinman, R. E., ed. 2009. Pediatric Nutrition Handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.

5. Enders, J. B. 1994. Food, nutrition and the young child. New York: Merrill.

6. U.S. Department of Agriculture (USDA). 2002. Making nutrition count for children - Nutrition guidance for child care homes. Washington, DC: USDA. http://www.fns.usda.gov/tn/Resources/nutritioncount.html.

7. U.S. Department of Agriculture (USDA), Child and Adult Care Food Program (CACFP). 2002. Menu magic for children: A menu planning guide for child care. Washington, DC: USDA. http://www
.fns.usda.gov/tn/resources/menu_magic.pdf.

8. Baker, S. B., R. S. Fisher. 1980. Childhood asphyxiation by choking or suffocation. JAMA 244:1343-46.

9. Morley, R. E., J. P. Ludemann, J. P. Moxham, F. K. Kozak, K. H. Riding. 2004. Foreign body aspiration in infants and toddlers: Recent trends in British Columbia. J Otolaryngology 33:37-41.

10. American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement: Prevention of choking among children. Pediatrics 125:601-7.

STANDARD 4.5.0.11: Prohibited Uses of Food

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

RATIONALE: Children who are forced to eat or, for whom adults use food to modify behavior, come to view eating as a tug-of-war and are more likely to develop lasting food dislikes and unhealthy eating behaviors. Offering food as a reward or punishment places undue importance on food and may have negative effects on the child by promoting “clean the plate” responses that may lead to obesity or poor eating behavior (1-5).

COMMENTS: All components of the meal should be offered at the same time, allowing children to select and enjoy all of the foods on the menu.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. U.S. Department of Health and Human Services, Administration for Children and Families, Office of Head Start. 2009. Head Start program performance standards. Rev. ed. Washington, DC: U.S. Government Printing Office. http://eclkc.ohs.acf.hhs.gov/hslc/Head Start Program/Program Design and Management/Head Start Requirements/Head Start Requirements/45 CFR Chapter XIII/45 CFR Chap XIII_ENG.pdf.

2. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.

3. Murph, J. R., S. D. Palmer, D. Glassy, eds. 2005. Health in child care: A manual for health professionals. Elk Grove Village, IL: American Academy of Pediatrics.

4. Benjamin, S. E., ed. 2007. Making food healthy and safe for children: How to meet the national health and safety performance standards – Guidelines for out of home child care programs. 2nd ed. Chapel Hill, NC: National Training Institute for Child Care Health Consultants. http://nti.unc.edu/course_files/curriculum/nutrition/making_food_healthy_and_safe.pdf.

5. Birch, L. L., J. O. Fisher, K. K. Davison. 2003. Learning to overeat: Maternal use of restrictive feeding practices promotes girls’ eating in the absence of hunger. Am J Clin Nutr 78:215-20.

4.6 Food Brought From Home

STANDARD 4.6.0.1: Selection and Preparation of Food Brought From Home

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

RATIONALE: Food borne illness and poisoning from food is a common occurrence when food has not been properly refrigerated and covered. Although many such illnesses are limited to vomiting and diarrhea, sometimes they are life-threatening. Restricting food sent to the facility to be consumed by the individual child reduces the risk of food poisoning from unknown procedures used in home preparation, storage, and transport. Food brought from home should be nourishing, clean, and safe for an individual child. In this way, other children should not be exposed to unknown risk. Inadvertent sharing of food is a common occurrence in early care and education. The facility has an obligation to ensure that any food offered to children at the facility or shared with other children is wholesome and safe as well as complying with the food and nutrition guidelines for meals and snacks that the early care and education program should observe.

COMMENTS: The facility, in collaboration with parents/guardians and the food service staff/nutritionist/registered dietitian, should establish a policy on foods brought from home for celebrating a child’s birthday or any similar festive occasion. Programs should inform parents/guardians about healthy food alternatives like fresh fruit cups or fruit salad for such celebrations. Sweetened treats are highly discouraged, but if provided by the parent/guardian, then the portion size of the treat served should be small.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Standard 4.6.0.2: Nutritional Quality of Food Brought from Home

Standard 9.2.3.11: Food and Nutrition Service Policies and Plans

STANDARD 4.6.0.2: Nutritional Quality of Food Brought From Home

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

RATIONALE: The caregiver/teacher/facility has a responsibility to follow feeding practices that promote optimum nutrition supporting growth and development in infants, toddlers, and children. Caregivers/teachers who fail to follow best feeding practices, even when parents/guardians wish such counter practices to be followed, negate their basic responsibility of protecting a child’s health, social, and emotional well-being.

COMMENTS: Some local health and/or licensing jurisdictions prohibit any foods being brought from home.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Standard 4.2.0.1: Written Nutrition Plan

Standard 4.6.0.1: Selection and Preparation of Food Brought from Home

Standard 9.2.3.11: Food and Nutrition Service Policies and Plans

REFERENCES:

1. Sweitzer, S., M. E. Briley, C. Robert-Gray. 2009. Do sack lunches provided by parents meet the nutritional needs of young children who attend child care? J Am Diet Assn 109:141-44.

2. Contra Costa Child Care Council, Child Health and Nutrition Program. 2006. CHOICE: Creating healthy opportunities in child care environments. Concord, CA: Contra Costa Child Care Council, Child Health and Nutrition Program. http://w2.cocokids.org/_cs/downloadables/cc-healthnutrition-choicetoolkit.pdf.

4.7 Nutrition Learning Experiences for Children and Nutrition Education for Parents/Guardians

STANDARD 4.7.0.1: Nutrition Learning Experiences for Children

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

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

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

RATIONALE: Nourishing and attractive food is a foundation for developmentally appropriate learning experiences and contributes to health and well-being (1-13,15). Coordinating the learning experiences with the food service staff maximizes effectiveness of the education. In addition to the nutritive value of food, infants and young children are helped, through the act of feeding, to establish warm human relationships. Eating should be an enjoyable experience for children and staff in the facility and for children and parents/guardians at home. Enjoying and learning about food in childhood promotes good nutrition habits for a lifetime (17,18).

COMMENTS: Parents/guardians and caregivers/teachers should always be encouraged to sit at the table and eat the same food offered to young children as a way to strengthen family style eating which supports child’s serving and feeding him or herself (19). Family style eating requires special training for the food service and early care and education staff since they need to monitor food served in a group setting. Portions should be age-appropriate as specified in Child and Adult Care Food Program (CACFP) guidelines. The use of serving utensils should be encouraged to minimize food handling by children. Children should not eat directly out of serving dishes or storage containers. The presence of an adult at the table with children while they are eating is a way to encourage social interaction and conversation about the food such as its name, color, texture, taste, and concepts such as number, size, and shape; as well as sharing events of the day. These are some practical examples of age-appropriate information for young children to learn about the food they eat. The parent/guardian or adult can help the slow eater, prevent behaviors that might increase risk of fighting, of eating each others’ food, and of stuffing food in the mouth in such a way that it might cause choking.

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

Local resources for nutrition education include:

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

Compliance is measured by structured observation.

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

1. Brieger, K. M. 1993. Cooking up the Pyramid: An early childhood nutrition curriculum. Pine Island, NY: Clinical Nutrition Services.
2. Cunningham, M. 1995. Cooking with children: 15 lessons for children, age 7 and up, who really want to learn to cook. New York: Alfred A. Knopf.
3. Goodwin, M. T., G. Pollen. 1980. Creative food experiences for children. Rev. ed. Washington, DC: Center for Science in the Public Interest.
4. King, M. 1993. Healthy choices for kids: Nutrition and activity education program based on the US Dietary Guidelines. Levels 1-3 and 4-5. Wenatchee, WA: The Growers of Washington State Apples.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

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

Standard 4.2.0.1: Written Nutrition Plan

Standard 4.5.0.4: Socialization During Meals

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

Standard 4.5.0.8: Experience with Familiar and New Foods

Standard 4.7.0.2: Nutrition Education for Parents/Guardians

Standard 9.2.3.11: Food and Nutrition Service Policies and Plans

Appendix C: Nutrition Specialist, Registered Dietitian, Licensed Nutritionist, Consultant, and Food Service Staff Qualifications

REFERENCES:

1. U.S. Department of Health and Human Services, Administration for Children and Families, Office of Head Start. 2009. Head Start program performance standards. Rev. ed. Washington, DC: U.S. Government Printing Office. http://eclkc.ohs.acf.hhs.gov/hslc/Head Start Program/Program Design and Management/Head Start Requirements/Head Start Requirements/45 CFR Chapter XIII/45 CFR Chap XIII_ENG.pdf.

2. Hagan, Jr., J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Bright futures: Guidelines for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics.

3. Story, M., K. Holt, D. Sofka, eds. 2002. Bright futures in practice: Nutrition. 2nd ed. Arlington, VA: National Center for Education in Maternal and Child Health. http://www.brightfutures.org/nutrition/pdf/frnt_mttr.pdf.

4. Wardle, F., N. Winegarner. 1992. Nutrition and Head Start. Child Today 21:57.

5. Benjamin, S. E., ed. 2007. Making food healthy and safe for children: How to meet the national health and safety performance standards – Guidelines for out of home child care programs. 2nd ed. Chapel Hill, NC: National Training Institute for Child Care Health Consultants. http://nti.unc.edu/course_files/curriculum/nutrition/making_food_healthy_and_safe.pdf.

6. Dietz, W. H., L. Stern, eds. 1998. American Academy of Pediatrics guide to your child’s nutrition. New York: Villard.

7. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.

8. Lally, J. R., A. Griffin, E. Fenichel, M. Segal, E. Szanton, B. Weissbourd. 2003. Caring for infants and toddlers in groups: Developmentally appropriate practice. Arlington, VA: Zero to Three.

9. Endres, J. B., R. E. Rockwell. 2003. Food, nutrition, and the young child. 4th ed. New York: Macmillan.

10. Stang, J., C. T. Bayerl, M. M. Flatt. 2006. Position of the American Dietetic Association: Child and adolescent food and nutrition programs. J American Dietetic Assoc 106:1467-75.

11. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.

12. William, C. O., ed. 1998. Pediatric manual of clinical dietetics. Chicago: American Dietetic Association.

13. Tamborlane, W. V., J. Warshaw, eds. 1997. The Yale guide to children’s nutrition. New Haven, CT: Yale University Press.

14. Sullivan, S. A., L. L. Birch. 1990. Pass the sugar, pass the salt: Experience dictates preference. Devel Psych 26:546-51.

15. Murph, J. R., S. D. Palmer, D. Glassy, eds. 2005. Health in child care: A manual for health professionals. Elk Grove Village, IL: American Academy of Pediatrics.

16. Benjamin, S. E., D. F. Tate, S. I. Bangdiwala, B. H. Neelon, A. S. Ammerman, J. M. Dodds, D. S. Ward. 2008. Preparing child care health consultants to address childhood overweight: A randomized controlled trial comparing web to in-person training. Maternal Child Health J 12:662-69.

17. Ammerman, A. S., D. S. Ward, S. E. Benjamin, et al. 2007. An intervention to promote healthy weight: Nutrition and physical activity self-assessment for child care theory and design. Public Health Research, Practice, Policy 4:1-12.

18. Story, M., K. M. Kaphingst, S. French. 2006. The role of child care settings in the prevention of obesity. The Future of Children 16:143-68

19. Dietz, W., L. Birch. 2008. Eating behaviors of young child: Prenatal and postnatal influences on healthy eating. Elk Grove Village, IL: American Academy of Pediatrics.

STANDARD 4.7.0.2: Nutrition Education for Parents/Guardians

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

RATIONALE: One goal of a facility is to provide a positive environment for the entire family. Informing parents/guardians about nutrition, food, food preparation, and mealtime enhances nutrition and mealtime interactions in the home, which helps to mold a child’s food habits and eating behavior (1-9). Because of the current epidemic of childhood obesity, prevention of childhood obesity through nutrition and physical activity is an appropriate topic for parents/guardians. Periodically providing families records of the food eaten and progress in physical activities by their children will help families coordinate home food preparation, nutrition, and physical activity with what is provided at the early care and education facility. Nutrition education directed at parents/guardians complements and enhances the nutrition learning experiences provided to their children.

COMMENTS: One method of nutrition education for parents/guardians is providing healthy recipes that are quick and inexpensive to prepare and sharing information regarding access to local sources of healthy foods (farmers’ markets, grocery stores, healthier prepared foods and restaurant options). Also caregivers/teachers can provide parents/guardians ideas for healthy and inexpensive snacks including foods available and served at parents’/guardians’ meetings. Education should be helpful, culturally relevant and incorporate the use of locally produced food. The educational programs may be supplemented by periodic distribution of newsletters and/or literature.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Standard 4.7.0.1: Nutrition Learning Experiences for Children (contains resources for nutrition expertise)

REFERENCES:

1. U.S. Department of Health and Human Services, Administration for Children and Families, Office of Head Start. 2009. Head Start program performance standards. Rev. ed. Washington, DC: U.S. Government Printing Office. http://eclkc.ohs.acf.hhs.gov/hslc/Head Start Program/Program Design and Management/Head Start Requirements/Head Start Requirements/45 CFR Chapter XIII/45 CFR Chap XIII_ENG.pdf.

2. Hagan, Jr., J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Bright futures: Guidelines for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics.

3. Benjamin, S. E., ed. 2007. Making food healthy and safe for children: How to meet the national health and safety performance standards – Guidelines for out of home child care programs. 2nd ed. Chapel Hill, NC: National Training Institute for Child Care Health Consultants. http://nti.unc.edu/course_files/curriculum/nutrition/making_food_healthy_and_safe.pdf.

4. Dietz, W. H., L. Stern, eds. 1998. American Academy of Pediatrics guide to your child’s nutrition. New York: Villard.

5. Endres, J. B., R. E. Rockwell. 2003. Food, nutrition, and the young child. 4th ed. New York: Macmillan.

6. U.S. Department of Agriculture. 2002. Making nutrition count for children - Nutrition guidance for child care homes. Washington, DC: USDA. http://www.fns.usda.gov/tn/Resources/nutritioncount.html.

7. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.

8. Tamborlane, W. V., ed. 1997. The Yale guide to children’s nutrition. New Haven, CT: Yale University Press.

9. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.

4.8 Kitchen and Equipment

STANDARD 4.8.0.1: Food Preparation Area

The food preparation area of the kitchen should be separate from eating, play, laundry, toilet, and bathroom areas and from areas where animals are permitted. The food preparation area should not be used as a passageway while food is being prepared. Food preparation areas should 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 should not have access to the kitchen in child care centers. Access by older children to the kitchen of centers should be permitted only when supervised by staff members who have been certified by the nutritionist/registered dietitian or the center director as qualified to follow the facility’s sanitation and safety procedures.

In all types of child care facilities, children should never be in the kitchen unless they are directly supervised by a caregiver/teacher. Children of preschool-age and older should be restricted from access to areas where hot food is being prepared. School-age children may engage in food preparation activities with adult supervision in the kitchen or the classroom. Parents/guardians and other adults should be permitted to use the kitchen only if they know and follow the food safety rules of the facility. The facility should 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 and the risk of injury to children from burns. Use of kitchen appliances and cooking techniques may require more skill than can be expected for children’s developmental level. The most common burn in young children is scalding from hot liquids tipped over in the kitchen (1).

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 food-related activities. Under adult supervision, school-age children may be encouraged to help with developmentally appropriate food preparation, which increases the likelihood that they will eat new foods.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Appendix C: Nutrition Specialist, Registered Dietitian, Licensed Nutritionist, Consultant, and Food Service Staff Qualifications

REFERENCES:

1. Ring, L. M. 2007. Kids and hot liquids–A burning reality. J Pediatric Health Care 21:192-94.

STANDARD 4.8.0.2: Design of Food Service Equipment

Food service equipment should be designed, installed, operated, and maintained according to the manufacturer’s instructions and in a way that meets the performance, health, and safety standards of the National Sanitation Foundation (1) or applicable State or local public health authority, or the U.S. Department of Agriculture (USDA) food program and sanitation codes (3), 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 (1,2). The manufacturer’s warranty that equipment will meet recognized standards is valid only if the equipment is properly maintained.

COMMENTS: Inspectors from state and local agencies with appropriate training should 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). Testing labs such as Underwriters Laboratories (UL) also test food service equipment. Before making a purchase, child care facilities should check not only 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

REFERENCES:

1. National Sanitation Foundation. 2007. Commercial cooking, rethermalization and powered hot food holding, and transport equipment, ANSI/NSF 4. Ann Harbor, MI: National Sanitation Foundation.

2. National Restaurant Association. 2008. ServSafe essentials. 5th ed. Upper Saddle River, NJ: Prentice Hall.

3. U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration (FDA). 2009. 2009 Food code. College Park, MD: FDA. http://www.fda.gov/downloads/Food/FoodSafety/RetailFoodProtection/FoodCode/FoodCode2009/UCM189448.pdf.

STANDARD 4.8.0.3: 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 should be in good repair, free of cracks or crevices, and should be made of smooth, nonporous material that is kept clean and sanitized. All kitchen equipment should be clean and should be maintained in operable condition according to the manufacturer’s guidelines for maintenance and operation. The facility should 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 should be replaced because they trap food and other organic materials in which microorganisms can grow (1). Harsh scrubbing of 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.

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 (1). 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 Home

REFERENCES:

1. National Restaurant Association. 2008. ServSafe essentials. 5th ed. Upper Saddle River, NJ: Prentice Hall.

STANDARD 4.8.0.4: Food Preparation Sinks

The sink used for food preparation should not be used for handwashing or any other purpose. Handwashing sinks and sinks involved in diaper changing should not be used for food preparation. All food service sinks should 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.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Standard 4.9.0.13: Method for Washing Dishes by Hand

Standard 5.2.1.14: Water Heating Devices and Temperatures Allowed

STANDARD 4.8.0.5: Handwashing Sink Separate from Food Zones

Centers should provide a separate handwashing sink in the food preparation area of the facility. It should have an eight-inch-high splash guard or have eighteen inches of space between the handwashing sink and any open food zones (such as preparation tables and food sink).

Where continuous warm water pressure is not available, handwashing sinks should have at least thirty seconds of continuous flow of warm 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 100°F and no more than 120°F, for at least thirty seconds to allow sufficient time for wetting and rinsing the hands (1).

TYPE OF FACILITY: Center

RELATED STANDARDS:

Standard 3.2.2.2: Handwashing Procedure

REFERENCES:

1. U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration (FDA). 2009. 2009 Food code. College Park, MD: FDA. http://www.fda.gov/downloads/Food/FoodSafety/RetailFoodProtection/FoodCode/FoodCode2009/UCM189448.pdf.

STANDARD 4.8.0.6: Maintaining Safe Food Temperatures

The facility should use refrigerators that maintain food temperatures of 41°F or lower in all parts of the food storage areas, and freezers should maintain temperatures of 0°F or lower in food storage areas.

Thermometers with markings in no more than 2° increments should be provided in all refrigerators, freezers, ovens, and holding areas for hot and cold foods. Thermometers should be clearly visible, easy to read, and accurate, and should be kept in working condition and regularly checked. Thermo-
meters should be mercury free.

RATIONALE: Storage of food at proper temperatures minimizes bacterial growth (1).

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° increments, are hard to read accurately.

COMMENTS: Refrigerator and freezer thermometers are widely available in stores and over the Internet. They are available in both digital and analog forms. Providing thermometers with a dual scale in Fahrenheit and Celsius will avoid the necessity for a child care provider to convert temperature scales.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Appendix U: Recommended Safe Minimum Internal Cooking Temperatures

REFERENCES:

1. Food Marketing Institute, U.S. Department of Agriculture, Food Safety and Inspection Service. 1996. Facts about food and floods: A consumer guide to food quality and safe handling after a flood or power outage. Washington, DC: Food Marketing Institute.

STANDARD 4.8.0.7: Ventilation Over Cooking Surfaces

In centers using commercial cooking equipment to prepare meals, ventilation should be equipped with an exhaust system in compliance with the applicable building, mechanical, and fire codes. These codes may vary slightly with each locale, and centers are responsible to ensure their facilities meet the requirements of these codes (1-2).

All gas ranges in centers should be mechanically vented and fumes filtered prior to discharge to the outside. All vents and filters should be maintained free of grease build-up and food spatters, and in good repair.

RATIONALE: Properly maintained vents and filters control odor, fire hazards, and fumes.

An exhaust system must collect fumes and grease-laden vapors properly at their source.

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, commercial gas provider, or local gas, electric or utility provider. Never use an open flame to locate a gas leak.

TYPE OF FACILITY: Center

REFERENCES:

1. American Society of Heating, Refrigeration and Air Conditioning Engineers. 2007. ASHRAE handbook: HVAC applications. Atlanta, GA: ASHRAE.

2. Clark, J. 2003. Commercial kitchen ventilation design: What you need to know. http://www.esmagazine.com/Articles/Feature_Article/229549b01fca8010VgnVCM100000f932a8c0.

STANDARD 4.8.0.8: Microwave Ovens

Microwave ovens should be inaccessible to all children, with the exception of school-age children under close adult supervision. Any microwave oven in use in a child care facility should be manufactured after October 1971 and should be in good condition. While the microwave is being used, it should not be left unattended.

If foods need to be heated in a microwave:

1. Avoid heating foods in plastic containers;
2. Avoid transferring hot foods/drinks into plastic containers;
3. Do not use plastic wrap or aluminum foil in the microwave;
4. Avoid plastics for food and beverages labeled “3” (PVC), “6” (PS), and “7” (polycarbonate);
5. Stir food before serving to prevent burns from hot spots.

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 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. If adults or school-age children use a microwave, it is recommended that they do not heat food in plastic containers, plastic wrap or aluminum foil due to concerns of releasing toxic substances even if the container is specified for use in a microwave (1).

COMMENTS: If school-age children are allowed to use a microwave oven in the facility, this use should be closely supervised by an adult to avoid injury. See Standard 4.3.1.9 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

RELATED STANDARDS:

Standard 4.3.1.9: Warming Bottles and Infant Foods

Standard 5.2.9.9: Plastic Containers and Toys

REFERENCES:

1. Institute for Agriculture and Trade Policy (IATP), Food and Health Program. 2005. Smart plastics guide: Healthier food uses of plastics for parents and children. Minneapolis, MN: IATP.

4.9 Food Safety

STANDARD 4.9.0.1: Compliance with U.S. Food and Drug Administration Food Sanitation Standards, State and Local Rules

The facility should conform to the applicable portions of the U.S. Food and Drug Administration model food sanitation standards (1) and all applicable state and local food service rules and regulations for centers and large and small 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 should determine which requirement the facility must meet.

RATIONALE: Minimum standards for food safety are based on current 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 in statutes and must be complied with by law.

Federal, state, and local food safety codes, regulations, and standards may be in 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 current Food Code is available at http://www.fda
.gov/downloads/Food/FoodSafety/RetailFoodProtection/FoodCode/FoodCode2009/UCM189448.pdf.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration (FDA). 2009. 2009 Food code. College Park, MD: FDA. http://www.fda.gov/downloads/Food/FoodSafety/RetailFoodProtection/FoodCode/FoodCode2009/UCM189448.pdf.

STANDARD 4.9.0.2: Staff Restricted from Food Preparation and Handling

Anyone 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, should be excluded from food preparation and handling. Staff members may not contact exposed, ready-to-eat food with their bare hands and should use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. No one with open or infected skin eruptions should work in the food preparation area unless the injuries are covered with nonporous (such as latex or vinyl), single use gloves.

In centers and large family child care homes, staff members who are involved in the process of preparing or handling food should not change diapers. Staff members who work with diapered children should 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 should handle food only for the infants and toddlers in their groups and only after thoroughly washing their hands. Caregivers/teachers who prepare food should wash their hands carefully before handling any food, regardless of whether they change diapers. When caregivers/teachers must handle food, staffing assignments should be made to foster completion of the food handling activities by caregivers/teachers of older children, or by caregivers/teachers of infants and toddlers before the caregiver/teacher assumes other caregiving duties for that day. Aprons worn in the food service area must be clean and should be removed when diaper changing or when using the toilet.

RATIONALE: Food handlers who are ill can easily transmit 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 (1,2,4).

Caregivers/teachers who work with infants and toddlers are frequently exposed to feces and to children with infections of the intestines (often with diarrhea) or of the 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 (1,2,4).

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 41°F and 135°F) where more rapid multiplication of microorganisms occurs (3).

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Standards 3.2.2.1-3.2.2.5: Handwashing

REFERENCES:

1. Cowell, C., S. Schlosser. 1998. Food safety in infant and preschool day care. Top Clin Nutr 14:9-15.

2. U.S. Department of Agriculture (USDA), Food Safety and Inspection Service. 2000. Keeping kids safe: A guide for safe handling and sanitation, for child care providers. Rev ed. Washington, DC: USDA. http://teamnutrition.usda.gov/resources/appendj.pdf.

3. U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration (FDA). 2009. 2009 Food code. College Park, MD: FDA. http://www.fda.gov/downloads/Food/FoodSafety/RetailFoodProtection/FoodCode/FoodCode2009/UCM189448.pdf.

4. U.S. Department of Health and Human Services, U.S. Department of Agriculture. 2010. Dietary guidelines for Americans, 2010. 7th ed. Washington, DC: U.S. Government Printing Office. http://www.health.gov/dietaryguidelines/dga2010/DietaryGuidelines2010.pdf.

STANDARD 4.9.0.3: Precautions for a Safe Food Supply

All foods stored, prepared, or served should be safe for human consumption by observation and smell (1-2). The following precautions should be observed for a safe food supply:

1. Home-canned food; food from dented, rusted, bulging, or leaking cans, and food from cans without labels should not be used;
2. Foods should be inspected daily for spoilage or signs of mold, and foods that are spoiled or moldy should be promptly and appropriately discarded;
3. Meat should be from government-inspected sources or otherwise approved by the governing health authority (3);
4. All dairy products should be pasteurized and Grade A where applicable;
5. Raw, unpasteurized milk, milk products; unpasteurized fruit juices; and raw or undercooked eggs should not be used. Freshly squeezed fruit or vegetable juice prepared just prior to serving in the child care facility is permissible;
6. Unless a child’s health care professional documents a different milk product, children from twelve months to two years of age should be served only human milk, formula, whole milk or 2% milk (6). Note: For children between twelve months and two years of age for whom overweight or obesity is a concern or who have a family history of obesity, dyslipidemia, or CVD, the use of reduced-fat milk is appropriate only with written documentation from the child’s primary health care professional (4). Children two years of age and older should be served skim or 1% milk. If cost-saving is required to accommodate a tight budget, 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 twenty-four hours of preparation;
7. Meat, fish, poultry, milk, and egg products should be refrigerated or frozen until immediately before use (5);
8. Frozen foods should be defrosted in one of four ways: In the refrigerator; under cold running water; as part of the cooking process, or by removing food from packaging and using the defrost setting of a microwave oven (5). Note: Frozen human milk should not be defrosted in the microwave;
9. Frozen foods should never be defrosted by leaving them at room temperature or standing in water that is not kept at refrigerator temperature (5);
10. All fruits and vegetables should be washed thoroughly with water prior to use (5);
11. Food should be served promptly after preparation or cooking or should be maintained at temperatures of not less than 135°F for hot foods and not more than 41°F for cold foods (12);
12. All opened moist foods that have not been served should be covered, dated, and maintained at a temperature of 41°F or lower in the refrigerator or frozen in the freezer, verified by a working thermometer kept in the refrigerator or freezer (12);
13. Fully cooked and ready-to-serve hot foods should be held for no longer than thirty minutes before being served, or promptly covered and refrigerated;
14. Pasteurized eggs or egg products should be substituted for raw eggs in the preparation of foods such as Caesar salad, mayonnaise, meringue, eggnog, and ice cream. Pasteurized eggs or egg products should be substituted for recipes in which more than one egg is broken and the eggs are combined, unless the eggs are cooked for an individual child at a single meal and served immediately, such as in omelets or scrambled eggs; or the raw eggs are combined as an ingredient immediately before baking and the eggs are fully cooked to a ready-to-eat form, such as a cake, muffin or bread;
15. Raw animal foods should be fully cooked to heat all parts of the food to a temperature and for a time of; 145°F or above for fifteen seconds for fish and meat; 160°F for fifteen seconds for chopped or ground fish, chopped or ground meat or raw eggs; or 165°F or above for fifteen seconds for poultry or stuffed fish, stuffed meat, stuffed pasta, stuffed poultry or stuffing containing fish, meat or poultry.

RATIONALE: Safe handling of all food is a basic principle to prevent and reduce foodborne illnesses (14). For children, a small dose of infectious or toxic material can lead to serious illness (13). Some molds produce toxins that may cause illness or even death (such as aflatoxin or ergot).

Keeping cold food below 41°F and hot food above 135°F prevents bacterial growth (1,6,12). 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, food from dented, rusted, bulging or leaking cans, or leaking packages/bags of frozen foods, have 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. Positive learning activities for children, using their senses of seeing and smelling, help them to learn about the food they eat. These sensory experiences are counterproductive when food is overcooked. Children are not only shortchanged of nutrients, but are denied the chance to use their senses fully to learn about foods.

Caregivers/teachers should discourage parents/guardians from bringing home-baked items for the children to share as it is difficult to determine the quality of the ingredients used and the cleanliness of the environment in which the items are baked and transported. Parents/guardians should be informed why home baked items like birthday cake and cupcakes are not the healthiest choice and the facility should provide ideas for healthier alternatives such as fruit cups or fruit salad to celebrate birthdays and other festive events.

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 (7,8). 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 twelve months to two years of age receive human milk, formula, whole milk, or 2% milk. For children between twelve months and two years of age for whom overweight or obesity is a concern or who have a family history of obesity, dyslipidemia, or CVD, the use of reduced-fat milk is appropriate only with written documentation from the child’s primary health care professional (4). Children two years of age and older can drink skim, or 1%, milk (6,9-11).

Soil particles and contaminants that adhere to fruits and vegetables can cause illness. Therefore, all fruits or vegetables to be eaten and used to make fresh juice at the facility should be thoroughly washed first.

Thawing frozen foods under conditions that expose any of the food’s surfaces to temperatures between 41°F and 135°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 (12).

COMMENTS: The use of dairy products fortified with vitamins A and D is recommended (4).

The FDA provides the following Website for caregivers/teachers to check status of foods and food products that have been recalled, see http://www.fda.gov.

Temperatures come from the FDA 2009 Food Code (12). Local or state regulations may differ. Caregivers/teachers should consult with the health department concerning questions on proper cooking temperatures for specific foods.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Standard 4.3.1.7: Feeding Cow’s Milk

Standard 4.8.0.6: Maintaining Safe Food Temperatures

Appendix U: Recommended Safe Minimum Internal Cooking Temperatures

REFERENCES:

1. Enders, J. B. 1994. Food, nutrition and the young child. New York: Merrill.

2. U.S. Department of Agriculture (USDA). 2002. Making nutrition count for children - Nutrition guidance for child care homes. Washington, DC: USDA. http://www.fns.usda.gov/tn/Resources/nutritioncount.html.

3. U.S. Department of Agriculture (USDA), Food Safety and Inspection Service. 2000. Keeping kids safe: A guide for safe handling and sanitation, for child care providers. Rev ed. Washington, DC: USDA. http://teamnutrition.usda.gov/Resources/appendj.pdf.

4. Daniels, S. R., F. R. Greer, Committee on Nutrition. 2008. Lipid screening and cardiovascular health in childhood. Pediatrics 122:198-208.

5. Food Marketing Institute (FMI), U.S. Department of Agriculture, Food Safety and Inspection Service. 1996. Facts about food and floods: A consumer guide to food quality and safe handling after a flood or power outage. Washington, DC: FMI.

6. Kleinman, R. E., ed. 2009. Pediatric Nutrition Handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.

7. Potter, M. E. 1984. Unpasteurized milk: The hazards of a health fetish. JAMA 252:2048-52.

8. Sacks, J. J. 1982. Toxoplasmosis infection associated with raw goat’s milk. JAMA 246:1728-32.

9. Dietz, W.H., L. Stern, eds. 1998. Guide to your child’s nutrition. Elk Grove Village, IL: American Academy of Pediatrics.

10. Chicago Dietetic Association. 1996. Manual of clinical dietetics. 5th ed. Chicago, IL: American Dietetic Association.

11. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.

12. U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration (FDA). 2009. 2009 Food code. College Park, MD: FDA. http://www.fda.gov/downloads/Food/FoodSafety/RetailFoodProtection/FoodCode/FoodCode2009/UCM189448.pdf.

13. Cowell, C., S. Schlosser. 1998. Food safety in infant and preschool day care. Top Clin Nutr 14:9-15.

14. U.S. Department of Health and Human Services, U.S. Department of Agriculture. 2010. Dietary guidelines for Americans, 2010. 7th ed. Washington, DC: U.S. Government Printing Office. http://www.health.gov/dietaryguidelines/dga2010/DietaryGuidelines2010.pdf.

STANDARD 4.9.0.4: Leftovers

Food returned from individual plates and family style serving bowls, platters, pitchers, and unrefrigerated foods into which microorganisms are likely to have been introduced during food preparation or service, should be immediately discarded.

Unserved perishable food should be covered promptly for protection from contamination, should be refrigerated immediately, and should be used within twenty-four hours. “Perishable foods” include those foods that are subject to decay, spoilage or bacteria unless it is properly refrigerated or frozen (1).

Hot food can be placed directly in the refrigerator or it can be rapidly chilled in an ice or cold water bath before refrigerating. Hot foods should be promptly cooled first before they are fully covered in the refrigerator. Prepared perishable foods that have not been maintained at safe temperatures for two hours or more should be discarded immediately. If the air or room temperature is above 90°F, this time is reduced to one hour after which the food should be discarded (2). “Safe temperatures” mean keeping foods cold (below 41°F) or hot (above 135°F) (4).

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 fifteen to twenty minutes.

The potential is high for perishable foods (food that is subject to decay, spoilage, or bacteria unless it is properly refrigerated or frozen) that have been out of the refrigerator for more than two hours to have substantial loads of bacteria. This time can be as short as one hour if the air temperature is above 90°F. 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

RELATED STANDARDS:

Standard 4.8.0.6: Maintaining Safe Food Temperatures

REFERENCES:

1. U.S. Department of Agriculture, Food Safety and Inspection Service. Glossary: Perishable. http://www.fsis.usda.gov/Help/glossary-P/index.asp.

2. U.S. Department of Agriculture, Food Safety and Inspection Service. 2006. Safe food handling, basics for handling food safely. http://www.fsis.usda.gov/PDF/Basics_for_Safe_Food_Handling.pdf.

3. U.S. Department of Agriculture, Food Safety and Inspection Service. 2006. Safe food handling, how temperatures affect food.

http://www.fsis.usda.gov/PDF/How_Temperatures_Affect_Food.pdf.

4. U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration (FDA). 2009. 2009 Food code. College Park, MD: FDA. http://www.fda.gov/downloads/Food/FoodSafety/RetailFoodProtection/FoodCode/FoodCode2009/UCM189448.pdf.

STANDARD 4.9.0.5: Preparation for and Storage of Food in the Refrigerator

All food stored in the refrigerator should be tightly covered, wrapped, or otherwise protected from direct contact with other food. Hot foods to be refrigerated and stored should be transferred to shallow containers in food layers less than three inches deep and refrigerated immediately. These foods should be covered when cool. Any pre-prepared or leftover foods that are not likely to be served the following day should be labeled with the date of preparation before being placed in the refrigerator. The basic rule for serving food should be, “first food in, first food out” (1-3).

In the refrigerator, raw meat, poultry and fish should 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 on a dish or in a pan below ready-to-eat foods reduces the possibility that spills or drips from raw animal foods might contaminate ready-to-eat food.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Standard 4.8.0.6: Maintaining Safe Food Temperatures

Standard 4.9.0.3: Precautions for a Safe Food Supply

Appendix V: Food Storage Chart

REFERENCES:

1. Benjamin, S. E., ed. 2007. Making food healthy and safe for children: How to meet the National health and safety performance standards – Guidelines for out of home child care programs. 2nd ed. Chapel Hill, NC: National Training Institute for Child Care Health Consultants. http://nti.unc.edu/course_files/curriculum/nutrition/making_food_healthy_and_safe.pdf.

2. Enders, J. B. 1994. Food, nutrition and the young child. New York: Merrill.

3. U.S. Department of Agriculture (USDA). 2002. Making nutrition count for children - Nutrition guidance for child care homes. Washington, DC: USDA. http://www.fns.usda.gov/tn/Resources/nutritioncount.html.

STANDARD 4.9.0.6: Storage of Foods Not Requiring Refrigeration

Foods not requiring refrigeration should be stored at least six inches above the floor in clean, dry, well-ventilated storerooms or other approved areas (1,2). Food products should 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 from cleaning chemicals or spills of other foods and keeps insects and rodents from entering the products.

COMMENTS: Storing food six inches or higher above the floor enables easier cleaning of the floor under the food.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Standard 5.2.8.1: Integrated Pest Management

REFERENCES:

1. Food Marketing Institutes (FMI). 1996. Facts about food and floods: A consumer guide to food quality and safe handling after a flood or power outage. Washington, DC: FMI.

2 U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration (FDA). 2009. 2009 Food code. College Park, MD: FDA. http://www.fda.gov/downloads/Food/FoodSafety/RetailFoodProtection/FoodCode/FoodCode2009/UCM189448.pdf.

STANDARD 4.9.0.7: Storage of Dry Bulk Foods

Dry, bulk foods that are not in their original, unopened containers should be stored off the floor in clean metal, glass, or food-grade plastic containers with tight-fitting covers. All bulk food containers should be labeled and dated, and placed out of children’s reach. Children should be permitted to handle household-size food containers during adult-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 prevent contaminating the food supply of others.

TYPE OF FACILITY: Center

RELATED STANDARDS:

Standard 5.2.8.1: Integrated Pest Management

STANDARD 4.9.0.8: Supply of Food and Water for Disasters

In areas where natural disasters (such as earthquakes, blizzards, tornadoes, hurricanes, floods) occur, a seventy-two hour supply of food and water should be kept in stock for each child and staff member (1). For some areas, an additional thirty-six hour supply may be needed, for example those areas at risk during hurricane season. The supply of food and water should be dated to know by which time it should be used to avoid its expiration date.

RATIONALE: It may take seventy-two hours or longer for help to arrive in some areas after a natural disaster of great magnitude. The direct path of a hurricane or other natural disaster cannot always be anticipated and it is not possible for supplies to be brought into some disaster locations until: a) efforts to rescue/save lives are completed and b) needs of communities/populations are assessed.

COMMENTS: Child care providers should periodically use and replace the food and water supplies from the emergency supplies to ensure usage before expiration dates. A child care facility should consult with their local health authority or local emergency preparedness agency to integrate disaster planning within the community.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Standard 9.2.4.3: Disaster Planning, Training, and Communication

REFERENCES:

1. American Public Health Association. Get ready. http://www
.getreadyforflu.org/newsite.htm.

STANDARD 4.9.0.9: Cleaning Food Areas and Equipment

Areas and equipment used for storage, preparation, and service of food should be kept clean. All of the food preparation, food service, and dining areas should be cleaned and sanitized before and after use. Food preparation equipment should be cleaned and sanitized after each use and stored in a clean and sanitary manner, and protected from contamination.

Sponges should not be used for cleaning and sanitizing. Disposable paper towels should be used. If washable cloths are used, they should be used once, then stored in a covered container and thoroughly washed daily. Microfiber cloths are preferable to cotton or paper towels for cleaning tasks because of microfiber’s numerous advantages, including its long-lasting durability, ability to remove microbes, ergonomic benefits, superior cleaning capability and reduction in the amount of chemical needed.

RATIONALE: Outbreaks of foodborne illness have occurred in child care settings. Many of these infectious 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 (1).

Sponges harbor bacteria and are difficult to clean and sanitize between cleaning surface areas.

COMMENTS: “Clean” means removing all visible soil. Routine cleaning of kitchen areas should comply with the cleaning schedule provided in Appendix K or local health authority regulations.

“Sanitize” means using a product to reduce germs on inanimate surfaces to levels considered safe by public health codes or regulations.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

RELATED STANDARDS:

Appendix J: Selecting an Appropriate Sanitizer or Disinfectant

Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting

REFERENCES:

1. Cowell, C., S. Schlosser. 1998. Food safety in infant and preschool day care. Top Clin Nutr 14:9-15.

STANDARD 4.9.0.10: Cutting Boards

Cutting boards should be made of nonporous material and should 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 should not use porous wooden cutting boards, boards made with wood components, and boards with crevices and cuts. Only hard maple or an equivalently hard, close-grained wood (e.g. oak) may be used for cutting boards.

RATIONALE: Some 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. Programs should check with their local health department with questions regarding the proper hard wood for an allowable wood cutting board in child care facilities.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

STANDARD 4.9.0.11: Dishwashing in Centers

Centers should 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 should 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, paper plates and plastic utensils should be used and should be disposed of after every use.

RATIONALE: These are minimum requirements for proper cleaning and sanitizing of dishes and utensils (1).

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 quantity of 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 required for some sizes of centers in some locales. Centers are responsible to comply with the requirements of the local regulatory health agency.

The length of time to wash dishes in commercial dishwashers is three to four minutes. Commercial dishwashers that operate at low water temperatures (140°F to 150°F) are recommended because they are more energy-efficient. These would be equipped with automatic detergent and sanitizer injectors. When choosing a dishwasher, caregivers/teachers can consult with the local health authority or state/local nutritionist/registered dietitian 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. The three types of household dishwashers are:

1. Those that lack or operate without sanitizing wash or rinse cycles;
2. Those that have sanitizing wash or rinse cycles and a thermostat that senses a temperature of 150°F or higher before the machine advances to the next step in its cycle;
3. Those that have a sanitizing cycle and a thermostat as in (b) but advance to the next step in its cycle after fifteen 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°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 (no higher than 120°F). Installing a separate small hot water heater exclusively for dishwasher type (a) or (c) is a way to meet this requirement.

TYPE OF FACILITY: Center

RELATED STANDARDS:

Standard 5.2.1.14: Water Heating Devices and Temperatures Allowed

REFERENCES:

1. U.S. Department of Agriculture (USDA). 2002. Making nutrition count for children - Nutrition guidance for child care homes. Washington, DC: USDA. http://www.fns.usda.gov/tn/Resources/nutritioncount.html.

STANDARD 4.9.0.12: Dishwashing in Small and Large Family Child Care Homes

Small and large family child care homes should provide a three-compartment dishwashing arrangement or a dishwasher. At least a two-compartment sink or a combination of dish pans and sink compartments should 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, paper plates and plastic utensils should be used and should be disposed of after every use.

RATIONALE: These are minimum requirements for proper cleaning and sanitizing of dishes and utensils (1). 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

RELATED STANDARDS:

Standard 4.9.0.11: Dishwashing in Centers

Appendix J: Selecting an Appropriate Sanitizer or Disinfectant

Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting

REFERENCES:

1. U.S. Department of Agriculture (USDA). 2002. Making nutrition count for children - Nutrition guidance for child care homes. Washington, DC: USDA. http://www.fns.usda.gov/tn/Resources/nutritioncount.html.

STANDARD 4.9.0.13: Method for Washing Dishes by Hand

If the facility does not use a dishwasher, reusable food service equipment and eating utensils should be first 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:

1. Immersion for at least two minutes in a lukewarm (not less than 75°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 should be air-dried; or
2. Immersed in an EPA-registered sanitizer following the manufacturer’s instructions for preparation and use; or
3. Complete immersion in hot water and maintenance at a temperature of 170 °F for not less than thirty seconds. The items should be air-dried (1);
4. Or, other methods if approved by the health department.

RATIONALE: These procedures provide for proper sanitizing and control of bacteria (2-4).

COMMENTS: To manually sanitize dishes and utensils in hot water at 170°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 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 disinfecting 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 two minutes of immersion in the bleach solution (or treatment with an EPA-registered sanitizer) combined with air-drying will reduce the number of microorganisms to safe levels.

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

RELATED STANDARDS:

Standard 4.9.0.12: Dishwashing in Small and Large Family Child Care Homes

Appendix J: Selecting an Appropriate Sanitizer or Disinfectant

REFERENCES:

1. Bryan, F. L., G. H. DeHart. 1975. Evaluation of household dishwashing machines, for use in small institutions. J Milk Food Tech 38:509-15.

2. Benjamin, S. E., ed. 2007. Making food healthy and safe for children: How to meet the National health and safety performance standards – Guidelines for out of home child care programs. 2nd ed. Chapel Hill, NC: National Training Institute for Child Care Health Consultants. http://nti.unc.edu/course_files/curriculum/nutrition/making_food_healthy_and_safe.pdf.

3. Enders, J. B. 1994. Food, nutrition and the young child. New York: Merrill.

4. U.S. Department of Agriculture (USDA). 2002. Making nutrition count for children - Nutrition guidance for child care homes. Washington, DC: USDA. http://www.fns.usda.gov/tn/Resources/nutritioncount.html.

4.10 Meals from Outside Vendors or Central Kitchens

STANDARD 4.10.0.1: Approved Off-Site Food Services

Food provided by a central kitchen or vendor to off-site locations should 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 4.10.0.2: Food Safety During Transport

After preparation, food should be transported promptly in clean, covered, and temperature-controlled containers. Hot foods should be maintained at temperatures not lower than 135°F, and cold foods should be maintained at temperatures of 41°F or lower (1). Hot foods may be allowed to cool to 110°F or lower before serving to young children as long as the food is cooked to appropriate temperatures and the time at room temperature does not exceed two hours (or if room temperature is above 90°F then the time does not exceed one hour) (2). The temperature of foods should 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 fifteen to twenty minutes (2).

Foods at more than 110°F are too hot for children’s mouths.

A working food-grade, metal probe thermometer will determine accurately when foods are safe for consumption.

COMMENTS: If the temperature of hot foods is well below 135°F when it arrives, the caregiver/teacher should review delivery and storage practices and make any changes necessary to maintain proper food temperatures during storage and delivery.

The caregiver/teacher should 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

RELATED STANDARDS:

Standard 4.8.0.6: Maintaining Safe Food Temperatures

REFERENCES:

1. U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration (FDA). 2009. 2009 Food code. College Park, MD: FDA. http://www.fda.gov/downloads/Food/FoodSafety/RetailFoodProtection/FoodCode/FoodCode2009/UCM189448.pdf.

2. U.S. Department of Agriculture, Food Safety and Inspection Service. 2006. Safe food handling, how temperatures affect food. http://www.fsis.usda.gov/PDF/How_Temperatures_Affect_Food.pdf.

STANDARD 4.10.0.3: Holding of Food Prepared At Off-Site Food Service Facilities

Facilities receiving food from an off-site food service facility should 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 (1).

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 fifteen to twenty minutes (2).

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration (FDA). 2009. 2009 Food code. College Park, MD: FDA. http://www.fda.gov/downloads/Food/FoodSafety/RetailFoodProtection/FoodCode/FoodCode2009/UCM189448.pdf.

2. U.S. Department of Agriculture, Food Safety and Inspection Service. 2006. Safe food handling, how temperatures affect food.

http://www.fsis.usda.gov/PDF/How_Temperatures_Affect_Food.pdf.