4.2.0.1: Written Nutrition Plan

The facility should provide nourishing and appealing food for children according to a written plan developed by a qualified nutritionist/registered dietitian. Caregivers/teachers, directors, and food service personnel should share the responsibility for carrying out the plan. The director is responsible for implementing the plan but may delegate tasks to caregivers/teachers and food service personnel. Where infants and young children are involved, the feeding plan may include special attention to supporting mothers in maintaining their human milk supply. The nutrition plan should include steps to take when problems require rapid response by the staff, such as when a child chokes during mealtime or has an allergic reaction to a food. The completed plan should be on file, easily accessible to staff, and available to parents/guardians on request.

If the facility is large enough to justify employment of a full-time nutritionist/registered dietitian or child care food service manager, the facility should delegate to this person the responsibility for implementing the written plan.
Some children may have medical conditions that require special dietary modifications. A written care plan from the primary health care provider, clearly stating the food(s) to be avoided and food(s) to be substituted, should be on file. This information should be updated annually if the modification is not a lifetime special dietary need. Staff should be educated about a child’s dietary modification to ensure that no child in care ingests or has contact with foods he/she should avoid while at the facility. The proper modifications should be implemented whether the child brings his/her own food or whether it is prepared on site. The facility needs to inform all families and staff if certain foods, such as nut products (e.g., peanut butter, peanut oil), should not be brought from home because of a child’s life-threatening allergy. Staff should also know what procedure to follow if ingestion or contact occurs. In addition to knowing ahead of time what procedures to follow, staff must know their designated roles during an emergency. The emergency plan should be dated and updated biannually.

RATIONALE

Nourishing and appealing food is the cornerstone of children’s health, growth, and development, as well as developmentally appropriate learning experiences (1-3). Nutrition and feeding are fundamental and required in every facility. Because children grow and develop more rapidly during the first few years after birth than at any other time, a child’s home and the facility together must provide food that is adequate in amount and type to meet each child’s growth and nutritional needs. Children can learn healthy eating habits and be better equipped to maintain a healthy weight if they eat nourishing food while attending early care and education settings (4). Children can self-regulate their food intake and are able to determine an appropriate amount of food to eat in any one sitting when allowed to feed themselves. Excessive prompting, feeding in response to emotional distress, and using food as a reward have all been shown to lead to excessive weight gain in children (5,6). The obesity epidemic makes this an important lesson today.

Meals and snacks provide the caregiver/teacher an opportunity to model appropriate mealtime behavior and guide the conversation, which aids in children’s conceptual and sensory language development and eye/hand coordination. In larger facilities, professional nutrition staff must be involved to ensure compliance with nutrition and food service guidelines, including accommodation of children with special health care needs.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.2.0.2 Assessment and Planning of Nutrition for Individual Children
4.2.0.4 Categories of Foods
4.2.0.8 Feeding Plans and Dietary Modifications
4.3.1.2 Responsive Feeding of Infants by a Consistent Caregiver/Teacher
4.4.0.2 Use of Nutritionist/Registered Dietitian
4.5.0.11 Prohibited Uses of Food
4.7.0.1 Nutrition Learning Experiences for Children
Appendix C: Nutrition Specialist, Registered Dietitian, Licensed Nutritionist, Consultant, and Food Service Staff Qualifications

REFERENCES

1. US Department of Health and Human Services, Administration for Children and Families, Office of Head Start. Head Start Program Performance Standards. Rev ed. Washington, DC: US Government Printing Office; 2016. https://eclkc.ohs.acf.hhs.gov/policy/45-cfr-chap-xiii. Accessed September 7, 2017
2. Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017
3. Holt K, Wooldridge N, Story M, Sofka D. Nutrition Questionnaires/ For: adolescents, early childhood, infants. In: Bright Futures: Nutrition. Chicago, IL: American Academy of Pediatrics; 2011: 223-236
4. Kleinman RE, Greer FR, eds. Pediatric Nutrition. 7th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2014
5. Lally JR, Griffin A, Fenichel E, Segal M, Szanton E, Weissbourd B. Caring for Infants and Toddlers in Groups: Developmentally Appropriate Practice. 2nd ed. Arlington, VA: Zero to Three; 2008

NOTES

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

4.2.0.2: Assessment and Planning of Nutrition for Individual Children

As a part of routine health supervision by a primary health care provider, children should be evaluated for nutrition-related medical problems, such as failure to thrive, overweight, obesity, food allergy, reflux disease, and iron-deficiency anemia (1). The nutritional standards throughout this document are general recommendations that may not always be appropriate for some children with medically identified special nutrition needs. Caregivers/teachers should communicate with the child’s parent/guardian and pediatrician/other physician to adapt nutritional offerings to individual children as indicated and medically appropriate. Caregivers/teachers should work with the parent/guardian to implement individualized feeding plans developed by the child’s primary health care provider to meet a child’s unique nutritional needs. These plans could include, for instance, additional iron-rich foods for a child who has been diagnosed as having iron-deficiency anemia. For a child diagnosed as obese or overweight, the plan would focus on controlling portion sizes and creating a menu plan in which calorie-dense foods, like sugar-sweetened juices, nectars, and beverages, should not be served. Using these nutritional differences as educational moments will help children understand why they can or cannot eat certain food items. Some children require special feeding techniques, such as thickened foods or special positioning during meals. Other children will require dietary modifications based on food intolerances, such as lactose or wheat (gluten) intolerance. Some children will need dietary modifications based on cultural or religious preferences, such as vegan, vegetarian, or kosher diets, or halal foods.

RATIONALE

The early years are a critical time for children’s growth and development. Nutritional problems must be identified and treated during this period to prevent serious or long-term medical problems. Strong evidence shows a relationship between preschool-aged children being presented with larger sized portions and increased energy intake, prompting the importance of implementing proper portion sizing as soon as 2 years of age for children at risk of being overweight (2). The early care and education setting may be offering most of a child’s daily nutritional intake, especially for children in full-time care. It is important that the facility ensures that food offerings are congruent with nutritional interventions or dietary modifications recommended by the child’s pediatrician/other physician, in consultation with the nutritionist/registered dietitian, to make certain the intervention is child specific.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.2.0.8 Feeding Plans and Dietary Modifications
4.3.1.2 Responsive Feeding of Infants by a Consistent Caregiver/Teacher

REFERENCES

1. McAllister JW. Achieving a Shared Plan of Care with Children and Youth with Special Health Care Needs. Palo Alto, CA: Lucille Packard Foundation for Children’s Health; 2014. http://www.lpfch.org/sites/default/files/field/publications/achieving_a_shared_plan_of_care_full.pdf. Accessed September 7, 2017
   
2. McCrickerd K, Leong C, Forde CG. Preschool children's sensitivity to teacher-served portion size is linked to age related differences in leftovers. Appetite. 2017;114:320–328
   
3. ADDITIONAL RESOURCE
   US Department of Health and Human Services, US Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th ed. Washington, DC: US Department of Health and Human Services; 2015. https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_Guidelines.pdf. Accessed September 7, 2017 

NOTES

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

4.2.0.3: Use of US Department of Agriculture Child and Adult Care Food Program Guidelines

All meals and snacks and their preparation, service, and storage should meet the requirements for meals (7 CFR §226.20) of the child care component of the US Department of Agriculture Child and Adult Care Food Program (CACFP) (1-3).

RATIONALE

The CACFP regulations, policies, and guidance materials on meal requirements provide basic guidelines for sound nutrition and sanitation practices. The CACFP guidance for meals and snack patterns ensures that the nutritional needs of infants and children, including school-aged children through 12 years, are met based on the Dietary Guidelines for Americans (4,5) as well as other evidence-based recommendations (6,7). Programs not eligible for reimbursement under the regulations of CACFP should still use the CACFP food guidance.

COMMENTS

Staff should use information about the child’s growth and CACFP meal patterns to develop individual feeding plans (6).

ADDITIONAL RESOURCE

US Department of Agriculture. Child and Adult Care Food Program: best practices. US Department of Agriculture, Food and Nutrition Service Web site. https://www.fns.usda.gov/sites/default/files/cacfp/CACFP_factBP.pdf. Accessed September 7, 2017

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.2.0.4 Categories of Foods
4.2.0.5 Meal and Snack Patterns
4.3.1.2 Responsive Feeding of Infants by a Consistent Caregiver/Teacher
4.3.2.1 Meal and Snack Patterns for Toddlers and Preschoolers
4.3.3.1 Meal and Snack Patterns for School-Age Children

REFERENCES

1. US Department of Agriculture, Food and Nutrition Service. Requirements for meals. US Government Publishing Office Web site. https://www.ecfr.gov/cgi-bin/text-idx?SID=9c3a6681dbf6aada3632967c4bfeb030&mc=true&node=pt7.4.226&rgn=div5#se7.4.226_120. Accessed September 7, 2017
2. US Department of Agriculture, Food and Nutrition Service. Child and Adult Care Food Program (CACFP). Regulations. https://www.fns.usda.gov/cacfp/regulations. Updated September 7, 2017. Accessed September 7, 2017
3. Lally JR, Griffin A, Fenichel E, Segal M, Szanton E, Weissbourd B. Caring for Infants and Toddlers in Groups: Developmentally Appropriate Practice. 2nd ed. Arlington, VA: Zero to Three; 2008
4. US Department of Agriculture, Food and Nutrition Service. Independent Child Care Centers: A Child and Adult Care Food Program Handbook. Washington, DC: US Department of Agriculture; 2014. https://fns-prod.azureedge.net/sites/default/files/cacfp/Independent%20Child%20Care%20Centers%20Handbook.pdf. Accessed September 7, 2017
5. US Department of Health and Human Services, US Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th ed. Washington, DC: US Department of Health and Human Services; 2015. https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_Guidelines.pdf. Accessed September 7, 2017
6. US Department of Agriculture, Food and Nutrition Service. Child and Adult Food Program (CACFP). Nutrition standards for CACFP meals and snacks. https://www.fns.usda.gov/cacfp/meals-and-snacks. Updated March 27, 2017. Accessed September 7, 2017
7. US Department of Agriculture, Healthy Meals Resource System, Team Nutrition. CACFP wellness resources for child care providers. https://healthymeals.fns.usda.gov/cacfp-wellness-resources-child-care-providers. Accessed September 7, 2017

NOTES

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

4.2.0.4: Categories of Foods

The early care and education program should ensure the following food groups are being served to children in care. When incorporated into a child’s diet, these food groups make up foundational components of a healthy eating pattern.
 

Making Healthy Food Choicesa
Food Groups/Ingredients	USDAb	CFOC Guidelines for Young Children
Fruits	Whole Fruits Includes fresh, frozen, canned (packed in water or 100% fruit juice), and dried varieties that include good sources of potassium (e.g., bananas, dried plums) Fruit Juice 100% juice (i.e., without added sugars)	Eat a variety of whole fruits. Whole fruit, mashed or pureed, for infants. Do not serve juice to infants younger than 12 months. No more than 4 oz of juice per day for 1- to 3-year-olds. No more than 4–6 oz of juice per day for 4- to 6-year-olds. No more than 8 oz of juice per day for 7- to 12-year-olds.
Vegetables	Includes fresh, frozen, canned, and dried varieties Vegetable Subgroups Dark green Red and orange Beans and peas (legumes) Starchy vegetables Other vegetables	Include a variety of vegetables from the vegetable subgroups. Select low-sodium options when serving canned vegetables.
Grains	Whole Grains Contain the entire grain kernel (e.g., whole wheat flour, bulgur, oatmeal, brown rice) Refined Grains Enriched grains that have been milled, processed, and stripped of vital nutrients	Limit the amount of refined grains. Make half the grains served whole grains or whole-grain products.
Protein Foods (Meat and Meat Alternatives)	Includes food from animal and plant sources (e.g., seafood, lean meat, poultry, eggs, yogurt, cheese, soy products, nuts and seeds, cooked [mature] beans and peas)	Fish, poultry, lean meat, eggs. Unsalted nuts and seeds (if developmentally and age appropriate). Legumes (beans and peas) may also be considered a protein source. Limit processed meats and poultry. Avoid fried fish and poultry.
Dairy	Fat-free or low-fat (1%) milk or soy milk	Human milk and/or iron-fortified infant formula for infants 0–12 months of age. Unflavored whole milk for children 1–2 years of age. 2% (reduced-fat) milk for those children at risk for obesity or hypocholesteremia. Unflavored low-fat (1%) or fat-free milk for children 2 years and older. Nondairy milk substitutes that are nutritionally equivalent to milk. Yogurt must not contain more than 23 g of sugar per ounce.
Abbreviations: CFOC, Caring for Our Children: National Health and Safety Performance Standards; USDA, US Department of Agriculture. a All foods are assumed to be in nutrient-dense forms, lean or low-fat, and prepared without added fats, sugars, or salt. Solid fats and added sugars may be included up to the daily maximum limit identified in the 2015–2020 Dietary Guidelines for Americans. b The USDA recommends finding a balance between food and physical activity.

OTHER RECOMMENDATIONS

• Trans-fatty acids (trans fat) should be avoided.
• Avoid concentrated sweets (eg, candy, cake, cookies) and sugar-sweetened beverages (eg, sodas, sports and energy drinks, fruit nectars, flavored milk).¹ Offer foods and beverages that have little or no added sugars. Early care and education programs should establish water as the preferred safe and accessible beverage.²
• Limit salty foods such as chips and pretzels. When buying foods, choose no salt added, low-sodium, or reduced sodium versions, and prepare foods without adding salt. Use herbs or no-salt spice mixes instead of salt, soy sauce, ketchup, barbeque sauce, pickles, olives, salad dressings, butter, stick margarine, gravy, or cream sauce with seasonal vegetables and other dishes.
• Avoid caffeine.

ADDITIONAL RESOURCES

• American Academy of Pediatrics. American Academy of Pediatrics recommends no fruit juice for children under 1 year. https://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/American-Academy-of-Pediatrics-Recommends-No-Fruit-Juice-For-Children-Under-1-Year.aspx. Published May 22, 2017. Accessed August 21, 2019
• Holt K, Wooldridge N, Story M, Sofka D. Bright Futures: Nutrition. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2011
• US Department of Agriculture. ChooseMyPlate.gov. Children. http://www.choosemyplate.gov/children. Updated August 26, 2015. Accessed August 21, 2019
• US Department of Health and Human Services. Physical Activity Guidelines for Americans. 2nd ed. Washington, DC: US Department of Health and Human Services; 2018. https://health.gov/paguidelines/second-edition. Accessed August 21, 2019

RATIONALE

The 2015–2020 Dietary Guidelines for Americans and The Surgeon General’s Call to Action to Support Breastfeeding support patterns of healthy eating to promote a healthy weight and lifestyle that, in turn, prevent the onset of overweight and obesity in children.^3,4 Incorporating each of the food groups by providing children with appropriate meals and snacks helps set the stage for a lifetime of healthy eating behaviors. Research reinforces the following suggestions as being a practical approach to selecting foods high in essential nutrients and moderate in calories/energy:

• Meals and snacks planned based on the food groups in the Making Healthy Food Choices Table promote normal growth and development of children as well as reduce children’s risk of overweight, obesity, and related chronic diseases later in life. Age-specific guidance for meals and snacks is outlined in the US Department of Agriculture Child and Adult Care Food Program (CACFP) guidelines.⁵
• Early care and education settings provide the opportunity for children to learn about the food they eat, to develop and strengthen their fine and gross motor skills, and to engage in social interaction at mealtimes.
• “Energy” or sports beverages are typically high in added sugars and, therefore, not recommended for consumption. They contain many nonnutritive stimulants, such as caffeine, that have a history of harmful effects on a child’s developing heart, brain, and nervous system.⁶ 

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.⁴ For more information on portion sizes and types of food, see the CACFP guidelines.⁵

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.2.0.5 Meal and Snack Patterns
4.2.0.7 100% Fruit Juice
4.2.0.8 Feeding Plans and Dietary Modifications
4.3.1.2 Responsive Feeding of Infants by a Consistent Caregiver/Teacher
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.1.5 Preparing, Feeding, and Storing Infant Formula
4.3.1.7 Feeding Cow’s Milk
4.3.2.1 Meal and Snack Patterns for Toddlers and Preschoolers
4.3.3.1 Meal and Snack Patterns for School-Age Children
4.7.0.1 Nutrition Learning Experiences for Children
4.7.0.2 Nutrition Education for Parents/Guardians
Appendix Q: MyPlate: Make It Yours
Appendix R: Choose MyPlate: 10 Tips to a Great Plate

REFERENCES

1. Muth ND, Dietz WH, Magge SN, Johnson RK; American Academy of Pediatrics Section on Obesity and Committee on Nutrition; American Heart Association. Public policies to reduce sugary drink consumption in children and adolescents. Pediatrics. 2019;143(4):e20190282

2. Centers for Disease Control and Prevention. Increasing Access to Drinking Water and Other Healthier Beverages in Early Care and Education Settings. Atlanta, GA: US Department of Health and Human Services; 2014. https://www.cdc.gov/obesity/downloads/early-childhood-drinking-water-toolkit-final-508reduced.pdf. Accessed August 21, 2019

3. US Department of Health and Human Services, US Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th ed. https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_Guidelines.pdf. Published December 2015. Accessed August 21, 2019

4. Office of the Surgeon General, Centers for Disease Control and Prevention, Office on Women’s Health. The Surgeon General’s Call to Action to Support Breastfeeding. https://www.hhs.gov/surgeongeneral/reports-and-publications/breastfeeding/index.html. Reviewed May 14, 2019. Accessed August 21, 2019

5. US Department of Agriculture Food and Nutrition Service. Child and Adult Care Food Program. Ensuring children and adults have access to nutritious meals and snacks. https://www.fns.usda.gov/cacfp/child-and-adult-care-food-program. Accessed August 21, 2019

6. Centers for Disease Control and Prevention. CDC Healthy Schools. The buzz on energy drinks. https://www.cdc.gov/healthyschools/nutrition/energy.htm. Reviewed March 22, 2016. Accessed August 21, 2019

NOTES

Content in the STANDARD was modified on 2/2012, 11/16/2017 and 02/27/2020. 

4.2.0.5: Meal and Snack Patterns

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

   a.  Children in care for 8 or fewer hours in 1 day should be offered at least 1 meal and 2 snacks or 2 meals and 1 snack (1).
   b.  A nutritious snack should be offered to all children in midmorning (if they are not offered a breakfast on-site that is provided within 3 hours of lunch) and in mid-afternoon.
   c.   Children should be offered food at intervals at least 2 hours apart but not more than 3 hours apart unless the child is asleep. Some very young infants may need to be fed at shorter intervals than every 2 hours to meet their nutritional needs, especially breastfed infants being fed expressed human milk. Lunch may need to be served to toddlers earlier than preschool-aged children because of their need for an earlier nap schedule. Children must be awake prior to being offered a meal/snack.
   d.  Children should be allowed time to eat their food and not be rushed during the meal or snack service. They should not be allowed to play during these times.
   e.  Caregivers/teachers should discuss breastfed infants’ feeding patterns with their parents/guardians because the frequency of breastfeeding at home can vary. For example, some infants may still be feeding frequently at night, while others may do the bulk of their feeding during the day. Knowledge about infants’ feeding patterns over 24 hours will help caregivers/teachers assess infants’ feeding schedules during their time together.

RATIONALE

Children younger than 6 years need to be offered food every 2 to 3 hours. Appetite and interest in food varies from one meal or snack to the next. Appropriate timing of meals and snacks prevents children from snacking throughout the day and ensures that children maintain healthy appetites during mealtimes (2,3). Snacks should be nutritious, as they often are a significant part of a child’s daily intake. Children in care for longer than 8 hours need additional food because this period represents most of a young child’s waking hours.

COMMENTS

Caloric needs vary greatly from one child to another. A child may require more food during growth spurts (4). Some states have regulations that indicate suggested times for meals and snacks. By regulation, under the US Department of Agriculture Child and Adult Care Food Program (CACFP), centers and family child care homes may be approved to claim up to 2 reimbursable meals (breakfast, lunch, or supper) and 1 snack, or 2 snacks and 1 meal, for each eligible participant, each day. Many after-school programs provide before-school care or full-day care when elementary school is out of session. Many of these programs offer breakfast and/or a morning snack. After-school care programs may claim reimbursement for serving each child one snack, each day. In some states after-school programs also have the option of providing supper. These are reimbursed by CACFP if they meet certain guidelines and time frames (5).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.3.1.2 Responsive Feeding of Infants by a Consistent Caregiver/Teacher
4.3.2.1 Meal and Snack Patterns for Toddlers and Preschoolers
4.3.3.1 Meal and Snack Patterns for School-Age Children

REFERENCES

1. US Department of Agriculture, Food and Nutrition Service. Independent Child Care Centers: A Child and Adult Care Food Program Handbook. Washington, DC: US Department of Agriculture; 2014. https://www.fns.usda.gov/sites/default/files/cacfp/Independent%20Child%20Care%20Centers%20Handbook.pdf. Published May 2014. Accessed September 19, 2017
   
2. Shield JE, Mullen M. When should my kids snack? Academy of Nutrition and Dietetics Web site. http://www.eatright.org/resource/food/nutrition/dietary-guidelines-and-myplate/when-should-my-kids-snack. Published February 13, 2014. Accessed September 19, 2017
   
3. Kleinman RE, Greer FR, eds. Pediatric Nutrition. 7th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2014
   
4. American Academy of Pediatrics Committee on Nutrition. Childhood nutrition. American Academy of Pediatrics HealthyChildren.org Web site. https://www.healthychildren.org/English/healthy-living/nutrition/Pages/Childhood-Nutrition.aspx. Updated March 3, 2016. Accessed September 19, 2017
   
5. US Department of Agriculture, Food and Nutrition Service. Child and Adult Care Food Program (CACFP). Why CACFP is important. https://www.fns.usda.gov/cacfp/why-cacfp-important. Published September 22, 2014. Accessed September 19, 2017
   

NOTES

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

4.2.0.6: Availability of Drinking Water

Clean, sanitary drinking water should be readily available and offered throughout the day in indoor and outdoor areas.^1,2 Water should not be a substitute for milk at meals or snacks at which milk is a required food component unless recommended by the child’s primary health care provider. 

On hot days, infants receiving human milk in a bottle can be given additional human milk in a bottle but should not be given water, especially in the first 6 months after birth.¹ Infants receiving formula and water can be given additional formula in a bottle. Toddlers and older children will need additional water as physical activity and/or hot temperatures cause their needs to increase. Toddlers should learn to drink water from a cup or drinking fountain without mouthing the fixture. They should not be allowed to have water continuously in hand in a sippy cup or bottle. Permitting toddlers to suck continuously on a bottle or sippy cup filled with water, to soothe themselves, may cause nutritional or, in rare instances, electrolyte imbalances. When toothbrushing is not done after a feeding, children should be offered water to drink to rinse food from their teeth.

Drinking fountains should be kept clean and sanitary and maintained to provide adequate drainage.

RATIONALE

When children are thirsty between meals and snacks, water is the best choice. Young children may not be able to request water on their own prompting the need for caregivers/teachers to offer water throughout the day.² Additionally, having clean, small pitchers of water and single-use paper cups available in classrooms and on playgrounds allows children to serve themselves water when they are thirsty. Drinking water during the day can keep children hydrated while reducing calorie intake if the water replaces high-caloric beverages, such as fruit drinks/nectars and sodas, which are associated with overweight and obesity.³ Personal and environmental factors, such as age, weight, gender, physical activity level, outside air temperature, heat, and humidity, can affect an individual child’s water needs.⁴ Fluoride has been added to the tap (faucet) water in many communities. Drinking fluoridated water and keeping teeth “bathed” in low levels of fluoride protect a child’s teeth by decreasing the likelihood of early childhood caries (cavities) when consumed throughout the day, especially between meals and snacks.^5–7

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.1.5 Preparing, Feeding, and Storing Infant Formula

REFERENCES

1. Centers for Disease Control and Prevention. Increasing Access to Drinking Water and Other Healthier Beverages in Early Care and Education Settings. Atlanta, GA: US Department of Health and Human Services; 2014. https://www.cdc.gov/obesity/downloads/early-childhood-drinking-water-toolkit-final-508reduced.pdf. Accessed January 11, 2018

2. US Department of Agriculture, Food and Nutrition Service. Child and Adult Care Food Program: meal pattern revisions related to the Healthy, Hunger-Free Kids Act of 2010. Final rule. Fed Regist. 2016;81(79):24347–24383

3. Muckelbauer R, Sarganas G, Grüneis A, Müller-Nordhorn J. Association between water consumption and body weight outcomes: a systematic review. Am J Clin Nutr. 2013;98(2):282–299

4. Wolfram T. Water: how much do kids need? Academy of Nutrition and Dietetics Eat Right website. http://www.eatright.org/resource/fitness/sports-and-performance/hydrate-right/water-go-with-the-flow. Published August 10, 2018. Accessed December 20, 2018

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

6. Casamassimo P, Holt K, eds. Bright Futures: Oral Health Pocket Guide. 3rd ed. Washington, DC: National Maternal and Child Oral Health Resource Center; 2016. https://www.mchoralhealth.org/PDFs/BFOHPocketGuide.pdf. Accessed September 19, 2017 
   

7. Early Childhood Learning and Knowledge Center, US Department of Health and Human Services Administration for Children and Families, Head Start. Encouraging your child to drink water. https://eclkc.ohs.acf.hhs.gov/publication/encouraging-your-child-drink-water. Updated September 11, 2018. Accessed December 20, 2018

NOTES

Content in the STANDARD was modified on 11/9/2017, 03/22/2019 and 05/21/2019.

4.2.0.7: 100% Fruit Juice

Fruit or vegetable juice may be served once per day during a scheduled meal or snack to children 12 months or older (1). All juices should be pasteurized and 100% juice without added sugars or sweeteners.

Age	Maximum Allowed (1)
0–12 mo	Do not offer juices to infants younger than 12 months.
1–3 y	Limit consumption to 4 oz/day (½ cup).
4–6 y	Limit consumption to 4–6 oz/day (½–¾ cup).
7–18 y	Limit consumption to 8 oz/day (1 cup).

RATIONALE

While 100% fruit juice can be included in a healthy eating pattern, whole fruit is more nutritious and provides many nutrients, including dietary fiber, not found in juices (4).

Limiting overall juice consumption and encouraging children to drink water in-between meals will reduce acids produced by bacteria in the mouth that cause tooth decay. The frequency of exposure and liquids being pooled in the mouth are important in determining the cause of tooth decay in children (5). Beverages labeled as “fruit punch,” “fruit nectar”, or “fruit cocktail” contain less than 100% fruit juice and may be higher in overall sugar content. Routine consumption of fruit juices does not provide adequate amounts of vitamin E, iron, calcium, and dietary fiber—all essential in the growth and development of young children (6). Continuous consumption of fruit juice may be associated with decreased appetite during mealtimes, which may lead to inadequate nutrition, feeding issues, and increases in a child’s body mass index—all of which are considered risk factors that may contribute to childhood obesity (7).

Serving pasteurized juice protects against the possible outbreak of foodborne illness because the process destroys any harmful bacteria that may have been present (8).

 Drinks high in sugar and caffeine should be avoided because they can contribute to childhood obesity, tooth decay, and poor nutrition (9).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.2.0.4 Categories of Foods
4.2.0.6 Availability of Drinking Water
4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants

REFERENCES

1. Heyman MB, Abrams SA; American Academy of Pediatrics Section on Gastroenterology, Hepatology, and Nutrition and Committee on Nutrition. Fruit juice in infants, children, and adolescents: current recommendations. Pediatrics. 2017;139(6):e20170967
   
2. American Academy of Pediatrics. Fruit juice and your child's diet. American Academy of Pediatrics HealthyChildren.org Web site. https://www.healthychildren.org/English/healthy-living/nutrition/Pages/Fruit-Juice-and-Your-Childs-Diet.aspx. Updated May 22, 2017. Accessed September 19, 2017
   
3. American Academy of Pediatrics. Starting solid foods. American Academy of Pediatrics HealthyChildren.org Web site. https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Switching-To-Solid-Foods.aspx. Updated April 7, 2017. Accessed September 19, 2017
   
4. US Department of Health and Human Services, US Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th ed. Washington, DC: US Department of Health and Human Services; 2015. https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_Guidelines.pdf. Accessed September 19, 2017
   
5. Casamassimo P, Holt K, eds. Bright Futures: Oral Health Pocket Guide. 3rd ed. Washington, DC: National Maternal and Child Oral Health Resource Center; 2016. https://www.mchoralhealth.org/PDFs/BFOHPocketGuide.pdf. Accessed September 19, 2017
   
6. Crowe-White K, O’Neil CE, Parrott JS, et al. Impact of 100% fruit juice consumption on diet and weight status of children: an evidence-based review. Crit Rev Food Sci Nutr. 2016;56(5):871–884
   
7. Shefferly A, Scharf RJ, DeBoer MD. Longitudinal evaluation of 100% fruit juice consumption on BMI status in 2–5?year?old children. Pediatr Obes. 2016;11(3):221–227
   
8. US Food and Drug Administration. Talking about juice safety: what you need to know. https://www.fda.gov/food/resourcesforyou/consumers/ucm110526.htm. Updated September 19, 2017. Accessed September 19, 2017
   
9. Centers for Disease Control and Prevention. Healthy schools. The buzz on energy drinks. https://www.cdc.gov/healthyschools/nutrition/energy.htm. Updated March 22, 2016. Accessed September 19, 2017.
   

NOTES

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

4.2.0.8: Feeding Plans and Dietary Modifications

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

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

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

For a child with special health care needs who requires dietary modifications or special feeding techniques, written instructions from the child’s parent/guardian and the child’s primary health care provider should be provided in the child’s record and carried out accordingly. Dietary modifications should be recorded. These written instructions must identify
 
a.  The child’s full name and date of instructions
b.  The child’s special health care needs
c.   Any dietary restrictions based on those special needs
d.  Any special feeding or eating utensils
e.  Any foods to be omitted from the diet and any foods to be substituted
f.    Any other pertinent information about the child’s special health care needs
g.  What, if anything, needs to be done if the child is exposed to restricted foods
 
The written history of special nutrition or feeding needs should be used to develop individual feeding plans and, collectively, to develop facility menus. Health care providers with experience in disciplines related to special nutrition needs, including nutrition, nursing, speech therapy, occupational therapy, and physical therapy, should participate when needed and/or when they are available to the facility. If available, the nutritionist/registered dietitian should approve menus that accommodate needed dietary modifications.

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

RATIONALE

Children with special health care needs may have individual requirements related to diet and swallowing, involving special feeding utensils and feeding needs that will necessitate the development of an individual plan prior to their entry into the facility (1). Many children with special health care needs have difficulty with feeding, including delayed attainment of basic chewing, swallowing, and independent feeding skills. Food, eating style, food utensils, and equipment, including furniture, may have to be adapted to meet the developmental and physical needs of individual children (2,3,).

Some children have difficulty with slow weight gain and need their caloric intake monitored and supplemented. Others, such as those with diabetes, may need to have their diet matched to their medication (e.g., insulin, if they are on a fixed dose of insulin). Some children are unable to tolerate certain foods because of their allergy to the food or their inability to digest it. The 8 most common foods to cause anaphylaxis in children are cow’s milk, eggs, soy, wheat, fish, shellfish, peanuts, and tree nuts (3). Staff members must know ahead of time what procedures to follow, as well as their designated roles, during an emergency.

As a safety and health precaution, staff should know in advance whether a child has food allergies, inborn errors of metabolism, diabetes, celiac disease, tongue thrust, or special health care needs related to feeding, such as requiring special feeding utensils or equipment, nasogastric or gastric tube feedings, or special positioning. These situations require individual planning prior to the child’s entry into an early care and education program and on an ongoing basis (2).

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

COMMENTS

Close collaboration between families and the facility is necessary for children on special diets. Parents/guardians may have to provide food on a temporary, or even permanent, basis, if the facility, after exploring all community resources, is unable to provide the special diet.

Programs may consider using the American Academy of Pediatrics (AAP) Allergy and Anaphylaxis Emergency Plan, which is included in the AAP clinical report, Guidance on Completing a Written Allergy and Anaphylaxis Emergency Plan (4).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.2.0.1 Written Nutrition Plan
4.2.0.2 Assessment and Planning of Nutrition for Individual Children
4.2.0.12 Vegetarian/Vegan Diets
4.3.1.2 Responsive Feeding of Infants by a Consistent Caregiver/Teacher
4.5.0.10 Foods that Are Choking Hazards

REFERENCES

1. Samour PQ, King K. Pediatric Nutrition. 4th ed. Sunbury, MA: Jones and Bartlett Learning; 2010
   
2. Kleinman RE, Greer FR, eds. Pediatric Nutrition. 7th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2014
   
3. Kaczkowski CH, Caffrey C. Pediatric nutrition. In: Blanchfield DS, ed. The Gale Encyclopedia of Children's Health: Infancy Through Adolescence. Vol 3. 3rd ed. Farmington Hills, MI: Gale; 2016:2063–2066
   
4. Wang J, Sicherer SH; American Academy of Pediatrics Section on Allergy and Immunology. Guidance on completing a written allergy and anaphylaxis emergency plan. Pediatrics. 2017;139(3):e20164005
   

NOTES

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

4.2.0.9: Written Menus and Introduction of New Foods

Facilities should develop, at least one month in advance, written menus that show all foods to be served during that month and should make the menus available to parents/guardians. The facility should date and retain these menus for 6 months, unless the state regulatory agency requires a longer retention time. The menus should be amended to reflect any and all changes in the food actually served. Any substitutions should be of equal nutrient value.

Caregivers/teachers should use or develop a take-home sheet for parents/guardians on which caregivers/teachers record the food consumed each day or, for breastfed infants, the number of times they are fed and other important notes. Caregivers/teachers should continue to consult with each infant’s parent/guardian about foods they have introduced and are feeding to the infant. In this way, caregivers/teachers can follow a schedule of introducing new foods one at a time and more easily identify possible food allergies or intolerances. Caregivers/teachers should let parents/guardians know what and how much their infants eat each day.

To avoid problems of food sensitivity in infants younger than 12 months, caregivers/teachers should obtain from infants’ parents/guardians a list of foods that have already been introduced (without any reaction) and serve those items when appropriate. As new foods are considered for serving, caregivers/teachers should share and discuss these foods with parents/guardians prior to their introduction.

RATIONALE

Planning menus in advance helps to ensure that food will be on hand. Posting menus in a prominent area and distributing them to parents/guardians helps to inform parents/guardians about proper nutrition Parents/guardians need to be informed about food served in the facility to know how to complement it with the food they serve at home. If a child has difficulty with any food served at the facility, parents/guardians can address this issue with appropriate staff members. Some regulatory agencies require menus as a part of the licensing and auditing process (1).

Consistency between home and the early care and education setting is essential during the period of rapid change when infants are learning to eat age-appropriate solid foods (1-3).

COMMENTS

Caregivers/teachers should be aware that new foods may need to be offered between 8 and 15 times before they may be accepted (2,4). Sample menus and menu planning templates are available from most state health departments and the US Department of Agriculture (5) and its Child and Adult Care Food Program (6).

Good communication between caregivers/teachers and parents/guardians is essential for successful feeding, in general, including when introducing age-appropriate solid foods (complementary foods). The decision to feed specific foods should be made in consultation with the parents/guardians. It is recommended that caregivers/teachers be given written instructions on the introduction and feeding of foods from the parents/guardians and the infants’ primary health care providers. 

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.3.1.1 General Plan for Feeding Infants
4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants
4.5.0.8 Experience with Familiar and New Foods

REFERENCES

1. Benjamin SE, Copeland KA, Cradock A, et al. Menus in child care: a comparison of state regulations with national standards. J Am Diet Assoc. 2009;109(1):109–115
   
2. Coulthard H, Sealy A. Play with your food! Sensory play is associated with tasting of fruits and vegetables in preschool children. Appetite. 2017;113:84–90
   
3. Savage JS, Fisher JO, Birch LL. Parental influence on eating behavior: conception to adolescence. J Law Med Ethics. 2007;35(1):22–34
   
4. US Department of Agriculture. Menu planning tools for child care providers. https://healthymeals.fns.usda.gov/menu-planning/menu-planning-tools/menu-planning-tools-child-care-providers. Accessed September 20, 2017
   
5. US Department of Agriculture, Food and Nutrition Service. Child and Adult Care Food Program (CACFP). https://www.fns.usda.gov/cacfp/child-and-adult-care-food-program. Published March 29, 2017. Accessed September 20, 2017
   
6. American Academy of Pediatrics Committee on Nutrition. Childhood nutrition. American Academy of Pediatrics HealthyChildren.org Web site. https://www.healthychildren.org/English/healthy-living/nutrition/Pages/Childhood-Nutrition.aspx. Updated March 3, 2016. Accessed September 20, 2017
   

NOTES

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

4.2.0.10: Care for Children with Food Allergies

When children with food allergies attend an early care and education facility, here is what should occur.
a.  Each child with a food allergy should have a care plan prepared for the facility by the child’s primary health care provider, to include
     1.  A written list of the food(s) to which the child is allergic and instructions for steps that need to be taken to avoid that food.
     2.  A detailed treatment plan to be implemented in the event of an allergic reaction, including the names, doses, and methods of administration of any medications that the child should receive in the event of a reaction. The plan should include specific symptoms that would indicate the need to administer one or more medications.

b.  Based on the child’s care plan, the child’s caregivers/teachers should receive training, demonstrate competence in, and implement measures for
     1.  Preventing exposure to the specific food(s) to which the child is allergic
     2.  Recognizing the symptoms of an allergic reaction
     3.  Treating allergic reactions

c.   Parents/guardians and staff should arrange for the facility to have the necessary medications, proper storage of such medications, and the equipment and training to manage the child’s food allergy while the child is at the early care and education facility.

d.  Caregivers/teachers should promptly and properly administer prescribed medications in the event of an allergic reaction according to the instructions in the care plan.

e.  The facility should notify parents/guardians immediately of any suspected allergic reactions, the ingestion of the problem food, or contact with the problem food, even if a reaction did not occur.

f.    The facility should recommend to the family that the child’s primary health care provider be notified if the child has required treatment by the facility for a food allergic reaction.

g.  The facility should contact the emergency medical services (EMS) system immediately if the child has any serious allergic reaction and/or whenever epinephrine (eg, EpiPen, EpiPen Jr) has been administered, even if the child appears to have recovered from the allergic reaction.

h.  Parents/guardians of all children in the child’s class should be advised to avoid any known allergens in class treats or special foods brought into the early care and education setting.

i.    Individual child’s food allergies should be posted prominently in the classroom where staff can view them and/or wherever food is served.

j.    The written child care plan, a mobile phone, and a list of the proper medications for appropriate treatment if the child develops an acute allergic reaction should be routinely carried on field trips or transport out of the early care and education setting.

For all children with a history of anaphylaxis (severe allergic reaction), or for those with peanut and/or tree nut allergy (whether or not they have had anaphylaxis), epinephrine should be readily available. This will usually be provided as a premeasured dose in an auto-injector, such as EpiPen or EpiPen Jr. Specific indications for administration of epinephrine should be provided in the detailed care plan. Within the context of state laws, appropriate personnel should be prepared to administer epinephrine when needed.

Food sharing between children must be prevented by careful supervision and repeated instruction to children about this issue. Exposure may also occur through contact between children or by contact with contaminated surfaces, such as a table on which the food allergen remains after eating. Some children may have an allergic reaction just from being in proximity to the offending food, without actually ingesting it. Such contact should be minimized by washing children’s hands and faces and all surfaces that were in contact with food. In addition, reactions may occur when a food is used as part of an art or craft project, such as the use of peanut butter to make a bird feeder or wheat to make modeling compound.

RATIONALE

Food allergy is common, occurring in between 2% and 8% of infants and children (1). Allergic reactions to food can range from mild skin or gastrointestinal symptoms to severe, life-threatening reactions with respiratory and/or cardiovascular compromise. Hospitalizations from food allergy are being reported in increasing numbers, especially among children with asthma who have one or more food sensitivities (2). A major factor in death from anaphylaxis has been a delay in the administration of lifesaving emergency medication, particularly epinephrine (3). Intensive efforts to avoid exposure to the offending food(s) are, therefore, warranted. The maintenance of detailed care plans and the ability to implement such plans for the treatment of reactions are essential for all children with food allergies (4).

COMMENTS

Successful food avoidance requires a cooperative effort that must include the parents/guardians, child, child’s primary health care provider, and early care and education staff. In some cases, especially for a child with multiple food allergies, parents/guardians may need to take responsibility for providing all the child’s food. In other cases, early care and education staff may be able to provide safe foods as long as they have been fully educated about effective food avoidance.
Effective food avoidance has several facets. Foods can be listed on an ingredient list under a variety of names; for example, milk could be listed as casein, caseinate, whey, and/or lactoglobulin.

Some children with a food allergy will have mild reactions and will only need to avoid the problem food(s). Others will need to have antihistamine or epinephrine available to be used in the event of a reaction.

For more information on food allergies, contact Food Allergy Research & Education (FARE) at www.foodallergy.org.
Some early care and education/school settings require that all foods brought into the classroom are store-bought and in their original packaging so that a list of ingredients is included, to prevent exposure to allergens. However, packaged foods may mistakenly include allergen-type ingredients. Alerts and ingredient recalls can be found on the FARE Web site (5).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.2.0.2 Assessment and Planning of Nutrition for Individual Children
4.2.0.8 Feeding Plans and Dietary Modifications
Appendix P: Situations that Require Medical Attention Right Away

REFERENCES

1. Bugden EA, Martinez AK, Greene BZ, Eig K. Safe at School and Ready to Learn: A Comprehensive Policy Guide for Protecting Students with Life-threatening Food Allergies. 2nd ed. Alexandria, VA: National School Boards Association; 2012. http://www.nsba.org/sites/default/files/reports/Safe-at-School-and-Ready-to-Learn.pdf. Accessed September 20, 2017
   
2. Caffarelli C, Garrubba M, Greco C, Mastrorilli C, Povesi Dascola C. Asthma and food allergy in children: is there a connection or interaction? Front Pediatr. 2016;4:34
   
3. Tsuang A, Demain H, Patrick K, Pistiner M, Wang J. Epinephrine use and training in schools for food-induced anaphylaxis among non-nursing staff. J Allergy Clin Immunol Pract. 2017;5(5):1418–1420.e3
   
4. Wang J, Sicherer SH; American Academy of Pediatrics Section on Allergy and Immunology. Guidance on completing a written allergy and anaphylaxis emergency plan. Pediatrics. 2017;139(3):e20164005
   
5. Food Allergy Research & Education. Allergy alerts. https://www.foodallergy.org/alerts. Accessed September 20, 2017
   
6. ADDITIONAL RESOURCES
   Centers for Disease Control and Prevention. Healthy schools. Food allergies in schools. https://www.cdc.gov/healthyschools/foodallergies/index.htm. Reviewed May 9, 2017. Accessed September 20, 2017
   
   Centers for Disease Control and Prevention. Voluntary Guidelines for Managing Food Allergies in Schools and Early Care and Education Programs. Washington, DC: US Department of Health and Human Services; 2013. https://www.cdc.gov/healthyschools/foodallergies/pdf/13_243135_A_Food_Allergy_Web_508.pdf. Accessed September 20, 2017
   

NOTES

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

4.2.0.11: Ingestion of Substances that Do Not Provide Nutrition

All children should be monitored to prevent them from eating substances that do not provide nutrition (often referred to as pica) (1,2). The parents/guardians of children who repeatedly place nonnutritive substances in their mouths should be notified and informed of the importance of having their children visit their primary health care provider or a local health department. In collaboration with the child’s parent/guardian, an assessment of the child’s eating behavior and dietary intake, along with any other health issues, should occur to begin an intervention strategy.

RATIONALE

The occasional ingestion of nonnutritive substances can be a part of everyday living and is not necessarily a concern. For example, ingestion of nonnutritive substances can occur from mouthing, placing dirty hands in the mouth, or eating dropped food. However, because of this normal behavior it is that much more important to minimize harmful residues in the facility to reduce children’s exposure. Pica involves the recurrent ingestion of substances that do not provide nutrition. Pica is most prevalent among children between the ages of 1 and 3 years (3). Among children with intellectual developmental disability and concurrent mental illness, the incidence exceeds 25% (3).
Children who have iron deficiency anemia regularly ingest nonnutritive substances. Dietary intake plays an important role because certain nutrients, such as those ingested with a diet high in fat or lecithin, increase the absorption of lead, which can result in toxicity (3). Lead, when present in the gastrointestinal tract, is absorbed in place of calcium. Children will absorb more lead than an adult. Whereas an adult absorbs approximately 10% of ingested lead, a toddler absorbs approximately 30% to 50% of ingested lead. Children who ingest paint chips or contaminated soil can develop lead toxicity, which can lead to developmental delays and neurodevelopmental disability. Currently, there is consensus that repeated ingestion of some nonfood items results in an increased lead burden of the body (3,4). Early detection and intervention in nonfood ingestion can prevent nutritional deficiencies and growth/developmental disabilities. Eating soil or drinking contaminated water could result in an infection with a parasite.

COMMENTS

Common sources of lead include lead-based paint (in buildings constructed before 1978 or constructed on properties that were formerly the site of buildings constructed before 1978); contaminated drinking water (from public water systems, supply pipes, or plumbing fixtures); contaminated soil (from old exterior paint); the storage of acidic foods in open cans or ceramic containers/pottery with a lead glaze; certain types of art supplies; some imported toys and inexpensive play jewelry; and polyvinyl chloride (PVC) vinyl products (eg, beach balls, soft PVC-containing dolls, rubber ducks, chew toys, nap mats). These sources and others should be addressed concurrently with a nutritionally adequate diet as a prevention strategy. It is important to reduce exposure to possible lead sources, promote a healthy and balanced diet, and encourage blood lead level (BLL) testing of children. If a child’s BLL is 5 mcg/dL or greater, it is important to identify and remove the child’s source of lead exposure. 

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

1. Centers for Disease Control and Prevention. Gateway to health communication & social marketing practice. Pica behavior and contaminated soil. https://www.cdc.gov/healthcommunication/toolstemplates/entertainmented/tips/pica.html. Updated September 15, 2017. Accessed September 20, 2017
   
2. Miao D, Young SL, Golden CD. A meta?analysis of pica and micronutrient status. Am J Hum Biol. 2015;27(1):84–93
   
3. McNaughten B, Bourke T, Thompson A. Fifteen-minute consultation: the child with pica. Arch Dis Child Educ Pract Ed. May 2017;edpract-2016-312121
   
4. Moya J, Bearer CF, Etzel RA. Children’s behavior and physiology and how it affects exposure to environmental contaminants. Pediatrics. 2004;113(4 Suppl 3):996–1006
   

NOTES

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

4.2.0.12: Vegetarian/Vegan Diets

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

1. Written documentation from parents/guardians with a detailed and accurate dietary history of food choices—foods eaten, levels of limitations/restrictions to foods, and frequency of foods offered;
2. A current health record of the child available to the caregivers/teachers, including information about height and rate of weight gain, or consistent poor appetite (warning signs of growth deficiencies);
3. Sharing of updated information on the child’s health with the parents/guardians and the early care and education staff by the child care health consultant and the nutritionist/registered dietitian; and
4. Sharing sound health and nutrition information that is culturally-relevant to the family to ensure that the child receives adequate calories and essential nutrients.

RATIONALE

Infants and young children are at highest risk for nutritional deficiencies for energy levels and essential nutrients, including protein, calcium, iron, zinc, vitamins B₆ and B₁₂, and vitamin D (1-3). The younger the child, the more critical it is to know about family food choices, limitations, and restrictions because the child is dependent on family food (2).

Also, it is important that a child’s diet consist of a variety of nourishing food to support the critical period of rapid growth in the early years after birth. All children who are vegetarian/vegan should receive multivitamins, especially vitamin D (400 IU of vitamin D is recommended from 6 months of age to adulthood unless there is certainty of having the daily allowance met by foods); infants younger than 6 months who are exclusively or partially breastfed and who receive less than 16 oz of formula per day should receive 400 IU of vitamin D (4). If the facility participates in the US Department of Agriculture Child and Adult Care Food Program, guidance for meals and snack patterns must be followed for any child consuming a vegetarian or vegan diet (5).

COMMENTS

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

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

ADDITIONAL RESOURCES

US Department of Agriculture. 10 tips: healthy eating for vegetarians. ChooseMyPlate.gov Web site. https://www.choosemyplate.gov/ten-tips-healthy-eating-for-vegetarians. Updated July 25, 2017. Accessed September 20, 2017

US Department of Agriculture, US Department of Health and Human Services. Meat and meat alternates: build a healthy plate with protein. In: Nutrition and Wellness Tips for Young Children: Provider Handbook for the Child and Adult Care Food Program. Alexandria, VA: US Department of Agriculture; 2012. https://www.fns.usda.gov/sites/default/files/protein.pdf. Accessed September 20, 2017

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.2.0.2 Assessment and Planning of Nutrition for Individual Children
4.3.1.6 Use of Soy-Based Formula and Soy Milk
4.4.0.2 Use of Nutritionist/Registered Dietitian

REFERENCES

1. Kleinman RE, Greer FR, eds. Pediatric Nutrition. 7th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2014
   
2. Hayes D. Feeding vegetarian and vegan infants and toddlers. Academy of Nutrition and Dietetics Web site. http://www.eatright.org/resource/food/nutrition/vegetarian-and-special-diets/feeding-vegetarian-and-vegan-infants-and-toddlers. Published May 4, 2015. Accessed September 20, 2017
   
3. Mangels R, Driggers J. The youngest vegetarians. Vegetarian infants and toddlers. Infant Child Adolesc Nutr. 2012;4(1):8–20
   
4. Hollis BW, Wagner CL, Howard CR, et al. Maternal versus infant vitamin D supplementation during lactation: a randomized controlled trial. Pediatrics. 2015;136(4):625–634
   
5. US Department of Agriculture, Food and Nutrition Service. Independent Child Care Centers: A Child and Adult Care Food Program Handbook. Washington, DC: US Department of Agriculture; 2014. https://www.fns.usda.gov/sites/default/files/cacfp/Independent%20Child%20Care%20Centers%20Handbook.pdf. Accessed September 20, 2017
   

NOTES

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

4.3.1.1: General Plan for Feeding Infants

The facility should keep records detailing whether an infant is breastfed or formula fed, along with the type of formula being served. An infant feeding record of human (breast) milk and/or all formula given to the infant should be completed daily. Infant meals and snacks should follow the meal and snack patterns of the Child and Adult Care Food Program. Food should be appropriate for the infant’s individual nutrition requirements and developmental stage as determined by written instructions obtained from the child’s parent/guardian or primary health care provider.

The facility should encourage breastfeeding by providing accommodations and continuous support to the breastfeeding mother. Facilities should have a designated place set aside for breastfeeding mothers who want to visit the classroom during the workday to breastfeed, as well as a private area (not a bathroom) with an outlet for mothers to pump their breast milk (1,2). The private area also should have access to water or hand hygiene. A place that parents/guardians feel they are welcome to breastfeed, pump, or bottle-feed can create a positive and supportive environment for the family.

 

Infants may need a variety of special formulas, such as soy-based formula or elemental formulas, that are easier to digest and less allergenic. Elemental or special hypoallergenic formulas should be specified in the infant’s care plan. Age-appropriate solid foods other than human milk or infant formula (ie, complementary foods) should be introduced no sooner than 6 months of age or as indicated by the individual child’s nutritional and developmental needs. Please refer to standards 4.3.1.11 and 4.3.1.12 for more information.

RATIONALE

Human milk, as an exclusive food, is best suited to meet the entire nutritional needs of an infant from birth until 6 months of age, 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 12 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 (3).

Research overwhelmingly shows that exclusive breastfeeding for 6 months, and continued breastfeeding for at least a year or longer, dramatically improves health outcomes for children and their mothers. Healthy People 2020 outlines several objectives, including increasing the proportion of mothers who breastfeed their infants and increasing the duration of breastfeeding and exclusive breastfeeding (4). 

Incidences of common childhood illnesses, such as diarrhea, respiratory disease, bacterial meningitis, botulism, urinary tract infections, sudden infant death syndrome, insulin-dependent diabetes, ulcerative colitis, and ear infections, and overall risk for childhood obesity are significantly decreased in breastfed children (5,6). Similarly, breastfeeding, when paired with other healthy parenting behaviors, has been directly related to increased cognitive development in infants (7). Breastfeeding also has added benefits to the mother: it decreases risk of diabetes, breast and ovarian cancers, and heart disease (8). 

Mothers who want to supplement their breast milk with formula may do so, as the infant will continue to receive breastfeeding benefits (4,5,7). 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. Regardless of feeding preference, an adequately nourished infant is more likely to achieve healthy physical and mental development, which will have long-term positive effects on health (9).

COMMENTS

The ways to help a mother breastfeed successfully in the early care and education facility are (2,6,8): 

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 let down.)
   2. Place to wash her and her infant’s hands before and after breastfeeding
   3. Pillow to support her infant on her lap while nursing
   4. Nursing stool or step stool for her feet so she doesn’t have to strain her back while nursing
   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 the benefits of feeding the infant based on the infant’s hunger and satiety cues rather than on a schedule; 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; and ask her to leave her availability schedule with the early care and education program as well as to call if she is planning to miss a feeding or is going to be late.
   
   
4. Encourage her to provide a backup supply of frozen or refrigerated expressed human milk; properly label the infant’s full name, date, and time 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 or people in the community who can answer her questions and concerns about breastfeeding, such as local lactation consultants.
   1. Provide culturally appropriate breastfeeding materials, including community resources for parents/guardians that include appropriate language and pictures of multicultural families to assist families in identifying with them.
6. Ensure that all staff receive training in breastfeeding support and promotion.
   
   
7. Ensure that all staff are trained in the proper handling, storing, and feeding of each milk product, including human milk or infant formula.

 

Additional Resources

• Breastfeeding, US Department of Health and Human Services Office on Women’s Health (https://www.womenshealth.gov/printables-and-shareables/health-topic/breastfeeding)
• Feeding Infants: A Guide for Use in the Child Nutrition Programs, US Department of Agriculture (USDA) Food and Nutrition Service (https://wicworks.fns.usda.gov/wicworks/Topics/FG/CompleteIFG.pdf)
• Infant Meal Pattern, USDA (https://fns-prod.azureedge.net/sites/default/files/cacfp/CACFP_infantmealpattern.pdf)
• Strategy 6, Support for Breastfeeding in Early Care and Education, Centers for Disease Control and Prevention (https://www.cdc.gov/breastfeeding/pdf/strategy6-support-breastfeeding-early-care.pdf)
• Updated Child and Adult Care Food Program Meal Patterns: Infant Meals, USDA (https://fns-prod.azureedge.net/sites/default/files/cacfp/CACFP_InfantMealPattern_FactSheet_V2.pdf)

TYPE OF FACILITY

Center, Early Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.2.0.9 Written Menus and Introduction of New Foods
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.1.5 Preparing, Feeding, and Storing Infant Formula
4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants
4.3.1.12 Feeding Age-Appropriate Solid Foods to Infants
Appendix JJ: Our Child Care Center Supports Breastfeeding

REFERENCES

1. Centers for Disease Control and Prevention. Strategies to Prevent Obesity and Other Chronic Diseases: The CDC Guide to Strategies to Support Breastfeeding Mothers and Babies. Atlanta, GA: US Department of Health and Human Services; 2013. http://www.cdc.gov/breastfeeding/pdf/BF-Guide-508.pdf. Accessed January 11, 2018

2. Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); US Department of Agriculture Food and Nutrition Service. Breastfeeding Policy and Guidance. https://www.fns.usda.gov/sites/default/files/wic/WIC-Breastfeeding-Policy-and-Guidance.pdf. Published July 2016. Accessed January 11, 2018

3. Darmawikarta D, Chen Y, Lebovic G, Birken CS, Parkin PC, Maguire JL. Total duration of breastfeeding, vitamin D supplementation, and serum levels of 25-hydroxyvitamin D. Am J Public Health. 2016;106(4):714–719

4. Healthy People 2020. Maternal, infant, and child health. HealthyPeople.gov Web site. https://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-child-health/objectives. Accessed January 11, 2018

5. Furman L. Breastfeeding: what do we know, and where do we go from here? Pediatrics. 2017;139(4):e20170150

6. American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827–e841

7. Gibbs BG, Forste R. Breastfeeding, parenting, and early cognitive development. J Pediatr. 2014;164(3):487–493

8. Binns C, Lee M, Low WY. The long-term public health benefits of breastfeeding. Asia Pac J Public Health. 2016;28(1):7–14

9. Danawi H, Estrada L, Hasbini T, Wilson DR. Health inequalities and breastfeeding in the United States of America. Int J Childbirth Educ. 2016;31(1)

NOTES

Content in the STANDARD was modified on 05/30/2018.

4.3.1.2: Responsive Feeding of Infants by a Consistent Caregiver/Teacher

Responsive feeding is a give-and-take approach between a caregiver and an infant where the infant communicates hunger and fullness cues and the caregiver responds appropriately to these cues. Caregivers/teachers should feed infants on cue unless the parent/guardian and the child’s primary health care provider give written instructions stating differently.¹ Caregivers/teachers should be gentle, patient, sensitive, and reassuring when responding properly to the infant’s feeding cues. Responsive feeding is most successful when caregivers/teachers learn how infants verbally communicate hunger and fullness. Crying alone is not a cue for hunger unless the infant also shows other cues, such as opening the mouth, making sucking sounds, rooting, fast breathing, clenched fingers or fists, and flexed arms or legs.^1,2 Whenever possible, the same caregiver/teacher should feed a specific infant for most of that infant’s feedings.³ Caregivers/teachers should not feed infants beyond satiety or fullness; just as hunger cues are important in starting a feeding, watching for satiety or fullness cues can limit overfeeding. An infant may communicate fullness by shaking the head or turning away from food.^1,3,4 A pacifier should not be offered to an infant before a feeding.

RATIONALE

Responsive feeding is a successful way to meet the infant’s nutritional and emotional needs and to give the infant an immediate response, which helps to make sure the infant trusts the caregiver/teacher and feels secure.⁵ A caregiver/teacher is more likely to understand how a specific infant communicates hunger and satiety when they give consistent feedings and bond with the child regularly over time. When an infant forms an early relationship with caregivers/teachers for feeding, this helps an infant to develop healthy eating patterns for life.^1–4 Responsive feeding may help prevent childhood obesity.⁶

COMMENTS

ADDITIONAL RESOURCES:

American Academy of Pediatrics

Starting Solid Foods - https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Starting-Solid-Foods.aspx

TYPE OF FACILITY

Center, Early Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.3.1.1 General Plan for Feeding Infants
4.3.1.8 Techniques for Bottle Feeding

REFERENCES

1. Pérez-Escamilla R, Segura-Pérez S, Lott M. Feeding guidelines for infants and young toddlers: a responsive parenting approach. Nutrition Today. 2017;52(5), 223-231. doi: 10.1097/NT.0000000000000234. Published September 2017. Accessed November 10, 2022

2. Pérez-Escamilla R, Segura-Pérez S, Lott M, on behalf of the Robert Wood Johnson Foundation HER Expert Panel on Best Practices for Promoting Healthy Nutrition, Feeding Patterns, and Weight Status for Infants and Toddlers From Birth to 24 Months. Feeding Guidelines for Infants and Young Toddlers: A Responsive Parenting Approach. Guidelines for Health Professionals. Durham, NC: Healthy Eating Research; 2017. http://healthyeatingresearch.org/wp-content/uploads/2017/02/her_feeding_guidelines_brief_021416.pdf. Published February 2017. Accessed November 10, 2022

3. 4Cs of Alameda County. Providing care for infants and toddlers. 4calameda.org Web site. www.4c-alameda.org/downloads/rr/providers/PROVCaringforInfantsToddlers.pdf. Published July 2017. Accessed November 9, 2022

4. U.S. Department of Agriculture. WIC Works Resource System. Guidelines for feeding healthy infants. USDA.gov Web site. https://wicworks.fns.usda.gov/sites/default/files/media/document/Guidelines_for_Feeding_Healthy_Infants_Job_Aid.pdf. Updated September 2018. Accessed November 9, 2022

5. Head Start Early Childhood Learning & Knowledge Center. Child observation: the heart of individualizing responsive care for infants and toddlers. HHS.gov Web site.  https://eclkc.ohs.acf.hhs.gov/child-screening-assessment/child-observation-heart-individualizing-responsive-care-infants-toddlers/child-observation-heart-individualizing. Updated June 13, 2022. Accessed November 9, 2022

6. Vandyousefi S, Messito MJ, Katzow MW, Scott MA, Gross RS. Infant appetite traits, feeding practices and child obesity in low‐income Hispanic families. Pediatric Obesity, p.e12913. https://onlinelibrary.wiley.com/doi/full/10.1111/ijpo.12913. Published March 11, 2022. Accessed November 9, 2022

NOTES

Content in the STANDARD was modified on 5/30/2018 and 2/9/2023.

4.3.1.3: Preparing, Feeding, and Storing Human Milk

Expressed human milk should be transported and stored in clean and sanitary bottles with nipples that fit tightly or in equivalent clean and sanitary sealed containers 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 child’s full name and the date and time the milk was expressed.¹ The filled, labeled bottles or containers of human milk should immediately be stored in the refrigerator on arrival.

Frozen human milk may be transported and stored in single-use plastic bags and placed in a freezer with a separate door or a stand-alone freezer, and not in a compartment within a refrigerator. To prevent intermittent rewarming due to opening the freezer door regularly, frozen human milk should be stored in the back of the freezer and caregivers/teachers should carefully monitor, with daily log sheets, temperature of freezers used to store human milk using an appropriate working thermometer.

Expressed milk brought by a parent/guardian should only be used for that child. Likewise, infant formula should not be used for a breastfed child without the parent/guardian’s written permission. 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 a frozen bottle is thawed in running tap water. There may be several bottles for different children being thawed and warmed at the same time in the same place.

The caregiver/teacher should check the child’s full name and the date on the bottle so that the oldest milk is used first. Human milk should be thawed in the refrigerator if frozen. If there is insufficient time to thaw the milk in the refrigerator before serving, it may be thawed in a container of warm water, gently swirling the bottle periodically to evenly distribute the temperature in the milk and mix the fat, which may have separated. Frozen milk should never be thawed in a microwave oven because uneven hot spots in the milk may cause burns in the child and excessive heat may destroy beneficial components of the milk.^1–3

Human milk containers with significant amount of contents remaining after a feeding (>1 oz) may be returned to the parent/guardian at the end of the day as long as the child has not fed directly from the bottle. Returning unused human milk to the parent/guardian informs the parent/guardian of the quantity taken while in the early care and education program.

Although human milk does not need to be warmed, some children prefer their milk warmed to body temperature, around 98.6°F (37°C). When warming human milk, it is important to keep the container sealed while warming to prevent contamination. Human milk can be warmed

• In a waterless warmer
• By placing the container of human milk into a separate container of warm water
• By placing the container of human milk under running warm (not hot) tap water for a few minutes

Human milk should never be warmed directly on the stove or in the microwave. After warming the milk, caregivers/teachers should test the temperature before feeding by putting a few drops on their wrist. It should feel warm, not hot.²

Avoid bottles made of plastics containing bisphenol A (BPA) or phthalates, sometimes labeled with recycling code 3, 6, or 7.⁴ Use glass bottles with a silicone sleeve or silicone bottle jacket to prevent breakage, or use those made with safer plastics, such as polypropylene or polyethylene (labeled BPA-free) or plastics with a recycling code of 1, 2, 4, or 5.

Expressed human milk that presents a threat to a child, 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 (see Human Milk Storage Guidelines table), should be returned to the parent/guardian.² Written guidance for 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.¹

Although human milk is a body fluid, it is not necessary to wear gloves when feeding or handling human milk.⁵ The risk of exposure to infectious organisms during feeding or from milk that the child regurgitates is not significant.²

Some infants around 6 months to 1 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 family 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 the feeding.⁶ Two to 3 ounces of human milk can be placed in a clean cup and additional milk can be offered as needed. Small amounts of human milk (≤1 oz) can be discarded.

There are many different factors that can affect how long human milk can be stored in various locations, such as storage temperature, temperature fluctuations, and cleanliness while expressing and handling human milk. These factors make it difficult to recommend exact times for storing human milk in various locations, but the Human Milk Storage Guidelines table can be helpful.

 

Human Milk Storage Guidelines
Storage Locations and Temperatures
	Countertop   77°F (25°C) or colder (room temperature)	Refrigerator   40°F (4°C)	Freezer   0°F (-18°C) or colder
Freshly Expressed or Pumped Human Milk	Up to 4 hours	Up to 4 days	Within 6 months is best. Up to 12 months is acceptable.
Thawed, Previously Frozen Human Milk	1–2 hours	Up to 1 day (24 hours)	Never refreeze human milk after it has been thawed.
Leftover Human Milk From a Feeding (baby did not finish the bottle)	Use within 2 hours after the baby is finished feeding.
Sources Eglash A, Simon L; Academy of Breastfeeding Medicine. ABM clinical protocol #8: human milk storage information for home use for full-term infants, revised 2017. Breastfeed Med. 2017;12(7):390–395. https://abm.memberclicks.net/assets/DOCUMENTS/PROTOCOLS/8-human-milk-storage-protocol-english.pdf. Accessed October 24, 2019   Centers for Disease Control and Prevention. Proper storage and preparation of breast milk. https://www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htm. Reviewed August 6, 2019. Accessed October 24, 2019

RATIONALE

By following this standard, early care and education staff is able, when necessary, to prepare human milk and feed a child safely, thereby reducing the risk of inaccuracy or feeding the child unsanitary or incorrect human milk.^1,2 In addition, following safe preparation and storage techniques helps nursing mothers and caregivers/teachers of breastfed children maintain the high quality of expressed human milk and the health of the child.^7,8

TYPE OF FACILITY

Center, Early Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.3.1.1 General Plan for Feeding Infants
4.3.1.4 Feeding Human Milk to Another Mother’s Child
4.3.1.7 Feeding Cow’s Milk
4.3.1.8 Techniques for Bottle Feeding
4.3.1.9 Warming Bottles and Infant Foods

REFERENCES

1. Centers for Disease Control and Prevention. Proper storage and preparation of breast milk. https://www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htm. Reviewed August 6, 2019. Accessed October 24, 2019 
2. Eglash A, Simon L; Academy of Breastfeeding Medicine. ABM clinical protocol #8: human milk storage information for home use for full-term infants, revised 2017. Breastfeed Med. 2017;12(7):390–395. https://abm.memberclicks.net/assets/DOCUMENTS/PROTOCOLS/8-human-milk-storage-protocol-english.pdf. Accessed October 24, 2019
3. Extension Alliance for Better Child Care. Guidelines for child care providers to prepare and feed bottles to infants. https://articles.extension.org/pages/25404/guidelines-for-child-care-providers-to-prepare-and-feed-bottles-to-infants. Published August 15, 2019. Accessed October 24, 2019
4. Eco-Healthy Child Care. Plastics & plastic toys. Children’s Environmental Health Network website. https://cehn.org/wp-content/uploads/2017/07/Plastics_Plastic_Toys_6_16.pdf. Published June 2016. Accessed October 24, 2019
5. La Leche League International. Storing human milk. https://www.llli.org/breastfeeding-info/storingmilk. Accessed October 24, 2019
6. American Academy of Pediatrics. Working together: breastfeeding and solid foods. HealthyChildren.org website. https://www.healthychildren.org/English/ages-stages/baby/breastfeeding/Pages/Working-Together-Breastfeeding-and-Solid-Foods.aspx. Updated February 23, 2012. Accessed October 24, 2019
7. Boué G, Cummins E, Guillou S, Antignac JP, Le Bizec B, Membré JM. Public health risks and benefits associated with breast milk and infant formula consumption. Crit Rev Food Sci Nutr. 2018;58(1):126–145
8. Binns C, Lee M, Low WY. The long-term public health benefits of breastfeeding. Asia Pac J Public Health. 2016;28(1):7–14

NOTES

Content in the STANDARD was modified on 8/23/2016 and 06/10/2020.

4.3.1.4: Feeding Human Milk to Another Mother’s Child

Parents/guardians may express concern about the likelihood of disease transmission to their child if their child has been mistakenly fed another child’s bottle of expressed human milk. This issue is addressed in detail to reassure parents/guardians that the risk of transmission of infectious diseases via human milk is small.

If a child has been mistakenly fed another child’s bottle of expressed human milk, steps should be taken to minimize fear and manage the situation in a timely manner. When a milk mix-up occurs, any decisions about medical management and diagnostic testing of the child who received another mother’s milk should be based on the details of the individual situation and determined collaboratively between the child’s primary care provider and parents/guardians.¹

The early care and education program should

1. Inform the mother who expressed the human milk about the mistake and when the bottle switch occurred, and ask her the following questions¹:
   • When was the human milk expressed and how was it handled prior to being delivered to the early care and education program?
   • Would she be willing to share information about her current medication use, recent infectious disease history, and presence of cracked or bleeding nipples during milk expression with the other family or the child’s primary care provider?
2. Discuss the event with the parents/guardians of the child who was given another mother’s milk.¹
   • Inform them that their child was given another mother’s expressed human milk.
   • Inform them that the risk of transmission of infectious diseases is small.
   • If possible, provide the family with information on when the milk was expressed and how the milk was handled prior to its being delivered to the early care and education program.
   • Encourage them to notify the child’s primary care provider of the situation and share any specific details known.
3. Assess why the wrong milk was given and develop policies and procedures to prevent future mistakes related to labeling, storing, preparing, and feeding human milk in the early care and education program. Share these policies and procedures with parents/guardians as well as the early care and education staff.

Few illnesses are transmitted via human milk, and in fact, the unique properties of human milk help protect children from colds and other typical childhood viruses. Nonetheless, both families need to be notified when there is a milk mix-up, and they should be informed that the risk of transmission of infectious diseases via human milk is small.¹

RATIONALE

Despite significant efforts to prevent mix-ups, expressed human milk is occasionally given to a child in error.¹ Common concerns about human milk mistakenly fed to an child include transmission of HIV and hepatitis B and C, as well as medication exposure.

The risk of HIV transmission from expressed human milk consumed by another child is believed to be low because¹

• Transmission of HIV from a single human milk exposure has never been documented.
• In the United States, women who know they are HIV positive are advised not to breastfeed their children. Thus, it is unlikely that a mother living with HIV would be providing expressed milk for her own child at an early care and education program center.

Hepatitis B and C cannot be spread from a woman to a child through breastfeeding unless there is exposure to blood.^2–4

The risk of hepatitis B and C transmission from expressed human milk consumed by another child is believed to be low because²

• Infants born to mothers with hepatitis B receive the hepatitis B vaccine at birth.

• While mothers with hepatitis B and C can breastfeed,^4,5 hepatitis B and C are spread by infected blood. If the nipples and/or surrounding areola of the mother with hepatitis B or C are cracked and bleeding, she should be advised to stop nursing or providing expressed milk to her child temporarily (until she is healed).²

Although many medications pass into human milk, most have little or no effect on a child’s well-being. Few medications are contraindicated while breastfeeding, and risk of adverse effects from a single exposure to a medication through human milk is very low.¹

TYPE OF FACILITY

Center, Early Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

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. Reviewed January 24, 2018. Accessed October 24, 2019

2. Centers for Disease Control and Prevention. Hepatitis B or C infections. https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/maternal-or-infant-illnesses/hepatitis.html.Reviewed January 24, 2018. Accessed October 24, 2019

3. Centers for Disease Control and Prevention. Hepatitis B questions and answers for the public. https://www.cdc.gov/hepatitis/hbv/bfaq.htm#bFAQ13. Reviewed September 10, 2019. Accessed October 24, 2019

4. Centers for Disease Control and Prevention. Hepatitis C questions and answers for the public. https://www.cdc.gov/hepatitis/hcv/cfaq.htm#cFAQ37. Reviewed September 10, 2019. Accessed October 24, 2019

5. American Academy of Pediatrics. Human milk. In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018–2021 Report of the Committee on Infectious Diseases. 31st ed. Itasca, IL: American Academy of Pediatrics; 2018:113–122

NOTES

Content in the STANDARD was modified on 8/24/2017 and 06/10/2020.

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 cold 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. 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. If instructions are not readily available, caregivers/teachers should obtain information from their local WIC program or the World Health Organization’s Safe Preparation, Storage and Handling of Powdered Infant Formula Guidelines at: http://www.who.int/foodsafety/publications/micro/pif_guidelines.pdf (1).

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 (2). 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. Formula should not be used beyond the stated shelf life period (3).

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. Avoid bottles made of plastics containing bisphenol A (BPA) or phthalates (sometimes labeled with #3, #6, or #7). Use glass bottles with a silicone sleeve (a silicone bottle jacket to prevent breakage) or those made with safer plastics such as polypropylene or polyethylene (labeled BPA-free) or plastics with a recycling code of #1, #2, #4, or #5.

RATIONALE

Caregivers/teachers help in promoting 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.

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 should "flush" the water system by running the tap on cold for 1-2 minutes or use bottled water (4). 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.

Adding too little water to formula puts a burden on an infant’s kidneys and digestive system and may lead to dehydration (5). 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 (6).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 (7).

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

TYPE OF FACILITY

Center, Early Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.3.1.1 General Plan for Feeding Infants
4.3.1.8 Techniques for Bottle Feeding
4.3.1.9 Warming Bottles and Infant Foods

REFERENCES

1. World Health Organization. 2007. Safe preparation, storage and handling of powdered infant formula: Guidelines. http://www.who.int/foodsafety/publications/powdered-infant-formula/en/.
   
2. U.S. Department of Health & Human Services, U.S. Food & Drug Administration. 2016. Food safety for moms to be: Once baby arrives. College Park, MD. https://www.fda.gov/food/resourcesforyou/healtheducators/ucm089629.htm.
   
3. Seltzer, H. 2012. U.S Department of Health & Human Services. Keeping infant formula safe. https://www.foodsafety.gov/blog/infant_formula.html.
   
4. Centers for Disease Control and Prevention. 2016. Water. https://www.cdc.gov/nceh/lead/tips/water.htm.
   
5. Seattle Children's Hospital. 2014. Topics covered for formula feeding: Is this your child's symptoms? Seattle, WA. http://www.seattlechildrens.org/medical-conditions/symptom-index/bottle-feeding-formula-questions/.
   
6. Brown, J., Krasowski, M. D., & Hesse, M. 2015. Forced water intoxication: A deadly form of child abuse. The Journal of Law Enforcement. 4(4).
   
7. United States Department of Agriculture, Food and Nutrition Service. 2017. Feeding infants: A guide for use in the child nutrition programs. https://www.fns.usda.gov/tn/feeding-infants-guide-use-child-nutrition-programs.
   

NOTES

Content in the STANDARD was modified on 11/5/2013 and 8/25/2016.

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 or religious dietary restrictions on foods produced from animals (ie, 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.

Soy milk should be available for the children of parents/guardians participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); Child and Adult Care Food Program; or Supplemental Nutrition Assistance Program (SNAP). Caregivers/teachers should encourage parents/guardians of children with primary health care provider–documented indications for soy formula, who are participating in WIC and/or SNAP, to learn how they can obtain soy-based infant formula or soy milk products.

RATIONALE

The American Academy of Pediatrics recommends use of hypoallergenic or soy formula for infants who are allergic to cow’s milk proteins (1). Soy-based formula and soy milk are plant-based alternatives to cow’s milk, often chosen by parents/guardians due to dietary or religious reasons. Soy-based formulas are appropriate for children with galactosemia or congenital lactose intolerance (2). Soy-based formulas are made from soy protein isolate with added methionine, carbohydrates, and oils (soy or vegetable) and are fortified with vitamins and minerals (3). In the United States, all soy-based formula is fortified with iron. Soy-based formula does not contain lactose, so it is used for feeding infants with documented congenital lactose intolerance. There are known differences between allergies to cow’s milk proteins and intolerance to lactose. The child’s specific health concerns (allergy versus intolerance) should be documented by the child’s primary health care provider and not based on possible parental/guardian misinterpretation of symptoms.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.2.0.10 Care for Children with Food Allergies
4.2.0.12 Vegetarian/Vegan Diets
4.3.1.5 Preparing, Feeding, and Storing Infant Formula

REFERENCES

1. Greer FR, Sicherer SH, Burks AW; American Academy of Pediatrics Committee on Nutrition and Section on Allergy and Immunology. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. Pediatrics. 2008;121(1):183–191

2. American Academy of Pediatrics. Where we stand: soy formulas. HealthyChildren.org Web site. https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Where-We-Stand-Soy-Formulas.aspx. Updated November 21, 2015. Accessed November 14, 2017

3. US Department of Agriculture. Infant feeding guide. WIC Works Web site. https://wicworks.fns.usda.gov/infants/infant-feeding-guide. Modified October 31, 2017. Accessed November 14, 2017

NOTES

Content in the STANDARD was modified on 05/30/2018.

4.3.1.7: Feeding Cow’s Milk

The facility should not serve cow’s milk to infants from birth to 12 months of age, unless provided with a written exception and direction from the infant’s primary health care provider and parents/guardians. Children between 12 and 24 months of age can be served whole pasteurized milk (1). Children 2 years and older should be served low-fat (1%) or nonfat (skim, fat-free) pasteurized milk (1). With proper documentation from a child’s primary health care provider, reduced fat (2%, 1%, nonfat) pasteurized milk may be served to those children who are at risk for high cholesterol or obesity after 12 months of age (2).

RATIONALE

Milk provides many nutrients that are essential for the growth and development of young children. The fat content in whole milk is critical for brain development as well as satiety in children 12 to 24 months of age (3). For those children whom overweight or obesity is a concern or who have a family history of obesity, dyslipidemia, or early cardiovascular disease, the primary health care provider may request low-fat or nonfat milk (2).

It is not recommended that children consume cow’s milk in place of human (breast) milk or infant formula during the first year after birth (1,4). Some early care and education programs have children between the ages of 18 months and 3 years in one classroom. To avoid errors in serving inappropriate milk, programs can use individual milk pitchers clearly labeled for each type of milk being served. Caregivers/teachers can explain to the children the meaning of the colored labels and identify which milk they are drinking.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.2.0.4 Categories of Foods
4.2.0.10 Care for Children with Food Allergies
4.9.0.3 Precautions for a Safe Food Supply

REFERENCES

1. Holt K, Wooldridge N, Story M, Sofka D. Cow's Milk / Children's need for. In: Bright Futures: Nutrition. Chicago, IL: American Academy of Pediatrics; 2011: 69

2. Oldfield B, Misra S, Kwiterovich P. Prevention of cardiovascular disease in pediatric populations. In: Wong ND, Amsterdam EA, Blumenthal RS, eds. ASPC Manual of Preventive Cardiology. New York, NY: Demos Medical Publishing; 2015:184–194

3. Singhal S, Baker RD, Baker SS. A comparison of the nutritional value of cow’s milk and nondairy beverages. J Pediatr Gastroenterol Nutr. 2017;64(5):799–805

4. American Academy of Pediatrics. Why formula instead of cow’s milk? HealthyChildren.org Web site. https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Why-Formula-Instead-of-Cows-Milk.aspx. Updated November 21, 2015. Accessed January 11, 2018

NOTES

Content in the STANDARD was modified on 05/30/2018.

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:
a.    Initiate feeding when infant provides cues (rooting, sucking, etc.);
b.    Hold the infant during feedings and respond to vocalizations with eye contact and vocalizations;
c.     Alternate sides of caregiver’s/teacher’s lap;
d.    Allow breaks during the feeding for burping;
e.    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 or infant formula 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 (1).

The use of a bottle or cup to modify or pacify a child’s behavior should not be allowed (2).

RATIONALE

The manner in which food is given to infants is conducive to the development of sound eating habits for life. 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 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 (3). When infants and children are fed on cue, 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 (4). Early childhood caries in primary teeth may hold significant short-term and long-term implications for the child’s health (5). 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. Infants should be burped after every feeding and preferably during the feeding as well.

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 (6). 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 (7). 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 (8). 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.

TYPE OF FACILITY

Center, Early Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.3.1.2 Responsive Feeding of Infants by a Consistent Caregiver/Teacher
4.3.1.9 Warming Bottles and Infant Foods

REFERENCES

1. Ben-Joseph, E. 2015. Formula feeding FAQs: Getting started. Nemours: KidsHealth. http://kidshealth.org/en/parents/formulafeed-starting.html#
   
2. Lerner, C., & Parlakian, R. 2016. Colic and crying. Zero to three. https://www.zerotothree.org/resources/197-colic-and-crying.
   
3. American Academy of Pediatrics, Healthy Children. 2015. Practical bottle feeding tips. https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Practical-Bottle-Feeding-Tips.aspx.
   
4. American Academy of Pediatrics, Healthy Children. 2015. How to prevent tooth decay in your baby. https://www.healthychildren.org/English/ages-stages/baby/teething-tooth-care/Pages/How-to-Prevent-Tooth-Decay-in-Your-Baby.aspx.
   
5. Çolak, H., Dülgergil, Ç. T., Dalli, M., & Hamidi, M. M. 2013. Early childhood caries update: A review of causes, diagnoses, and treatments. Journal of natural science, biology, and medicine, 4(1), 29.
   
6. Hirsch, L. 2017. Feeding your 4- to 7-month old. Nemours, KidsHealth. http://kidshealth.org/en/parents/feed47m.html#
   
7. Rupal, C. 2016. Stopping the Bottle. Nemours, KidsHealth. http://kidshealth.org/en/parents/no-bottles.html#.
   
8. Holt K, Wooldridge N, Story M, Sofka D. Breast Milk/ microwaving, storage of, advantages of. In: Bright Futures: Nutrition. Chicago, IL: American Academy of Pediatrics; 2011: 27, 118, 120
   

4.3.1.9: Warming Bottles and Infant Foods

Bottles and infant foods do not have to be warmed; they can be served cold from the refrigerator. If a caregiver/teacher chooses to warm them, bottles or containers of infant foods should be warmed under running, warm tap water or by placing them in a container of water that is no warmer than 120°F (49°C). Bottles should not be left in a pot of water to warm for more than 5 minutes. Bottles and infant foods should never be warmed in a microwave oven because uneven hot spots in milk and/or food may burn the infant (1,2).

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. Bottles used for infant feeding should be made of the following substances (3):

     a. Bisphenol A (BPA)-free plastic; plastic labeled #1, #2, #4, or #5, or 

     b. Glass (a silicone sleeve/jacket covering a glass bottle to prevent breakage is permissible).

When a slow-cooking device, such as a crock-pot, is used for warming human milk, infant formula, or infant food, the device (and cord) should be out of children’s reach. The device should contain water at a temperature that does not exceed 120°F (49°C), and be emptied, cleaned, sanitized, and refilled with fresh water daily. When a bottle warmer is used for warming human milk, infant formula, or infant food, it should be out of children’s reach and used according to manufacturer’s instructions.

RATIONALE

Bottles of human milk or infant formula that are warmed at room temperature or in warm water for an inappropriate period 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 means of a dangling cord. Caution should be exercised to avoid raising the water temperature above a safe level for warming infant formula or infant food.

Additional Resource

Feeding Infants: A Guide for Use in the Child Nutrition Programs, US Department of Agriculture Food and Nutrition Service (https://www.fns.usda.gov/tn/feeding-infants-guide-use-child-nutrition-programs)

TYPE OF FACILITY

Center, Early Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.1.5 Preparing, Feeding, and Storing Infant Formula
4.3.1.8 Techniques for Bottle Feeding
4.3.1.12 Feeding Age-Appropriate Solid Foods to Infants

REFERENCES

1. US Department of Health and Human Services, US Food and Drug Administration. Food safety for moms to be: once baby arrives. https://www.fda.gov/food/resourcesforyou/healtheducators/ucm089629.htm. Updated November 8, 2017. Accessed January 11, 2018

2. Cowan D, Ho B, Sykes KJ, Wei JL. Pediatric oral burns: a ten-year review of patient characteristics, etiologies and treatment outcomes. Int J Pediatr Otorhinolaryngol. 2013;77(8):1325–1328

3. Environmental Working Group. Guide to baby-safe bottles and formula. https://www.ewg.org/research/ewg%E2%80%99s-guide-baby-safe-bottles-and-formula#.WlfPqWeWzct. Updated October, 2015. Accessed January 11, 2018

NOTES

Content in the STANDARD was modified on 11/5/2013, 8/25/2016 and 05/31/2018.

4.3.1.10: Cleaning and Sanitizing Equipment Used for Bottle Feeding

Caregivers/teachers should follow proper handwashing procedures prior to handling infant bottles. Bottles, bottle caps, nipples, and other equipment used for bottle-feeding should be thoroughly cleaned after each use by washing in a dishwasher or by washing with a bottlebrush, soap, and water (1).

Nipples that are discolored, thinning, tacky, or ripped should not be used.

RATIONALE

Infant feeding bottles are contaminated by the infant’s saliva during feeding. Formula and milk promote growth of bacteria, yeast, and fungi (2). Bottles, bottle caps, and nipples that are reused should be washed and sanitized to avoid contamination from previous feedings. Excessive boiling of latex bottle nipples will damage them.

Additional Resource
Feeding Infants: A Guide for Use in the Child Nutrition Programs, US Department of Agriculture Food and Nutrition Service (https://www.fns.usda.gov/tn/feeding-infants-guide-use-child-nutrition-programs)

TYPE OF FACILITY

Center, Early Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.3.1.1 General Plan for Feeding Infants
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.1.4 Feeding Human Milk to Another Mother’s Child
4.3.1.5 Preparing, Feeding, and Storing Infant Formula
4.3.1.8 Techniques for Bottle Feeding

REFERENCES

1. Centers for Disease Control and Prevention. Water, sanitation & environmentally-related hygiene. How to clean, sanitize, and store infant feeding items. https://www.cdc.gov/healthywater/hygiene/healthychildcare/infantfeeding/cleansanitize.html. Updated April 11, 2017. Accessed January 11, 2018

2. Wolfram T. How to safely clean baby bottles. Academy of Nutrition and Dietetics Eat Right Web site. http://www.eatright.org/resource/homefoodsafety/four-steps/wash/how-to-safely-clean-baby-bottles. Published February 16, 2017. Accessed January 11, 2018

NOTES

Content in the STANDARD was modified on 05/31/2018.

4.3.1.11: Introduction of Age-Appropriate Solid Foods to Infants

A plan to introduce complementary, age-appropriate solid foods to infants should be made in consultation with the child’s parent/guardian and primary health care provider. Complementary foods are nutritious foods and beverages other than human breast milk or infant formula.⁶ Age-appropriate solid foods may be introduced by 6 months, or sooner or later based on the child’s developmental level.^1,5-6 Caregivers/teachers should watch for signs to decide when the infant is ready for solid foods. These signs include sitting up with only a little support, proper head control, the ability to chew well, or grabbing food from the plate. Also, infants will lose the tongue-thrusting reflex and begin acting hungry after formula feeding or breastfeeding.^4,6 Recommendations on the introduction of complementary should take into account:⁶

• The infant’s developmental level
• Nutritional needs
• Coexisting medical conditions
• Social factors
• Cultural, ethnic, and religious food preferences of the family
• Financial considerations
• Other related factors found through the nutrition assessment

For infants who are exclusively breastfed, the amount of certain nutrients in the body ¾ such as iron and zinc ¾ begins to get lower after the age of 6 months. So, gradually introduce puréed meats or meat substitutes and iron-fortified cereals.^5-6 Iron-fortified cereals, puréed meats, and puréed fruits and vegetables are all appropriate foods to introduce. The first food introduced should have just one ingredient that is served in a small portion for 3 to 5 days before introducing another food.⁶ Watch the infant closely for potential reactions to the foods being introduced. Gradually increase the variety and portion, one at a time, depending on how the infant reacts .⁸ 

Caregivers/teachers should 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 also continue to talk with each infant’s parents/guardians about which foods they have introduced and are feeding. When appropriate, changes to basic food patterns should be given in writing by the infant’s primary health care provider.

If caregivers/teachers will give nutritional supplements/medications, written orders from the prescribing health care provider should specify the medical need; medication or supplement; dosage; and how long to give the medication or supplement.

RATIONALE

The ideal time to introduce complementary foods to infants may vary because infants develop at different rates. 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. Solid foods given before an infant is developmentally ready may be related to extra weight gain, a higher risk of choking, and consuming less than the right amount of breast milk or formula.^1,4,6 Age-appropriate solid foods, such as meat and fortified cereals, are needed beginning at 6 months to make up for any losses in zinc and iron from breastfeeding exclusively.^5-6 Typically, low levels of vitamin D are transferred to infants via breast milk, so it is recommended that breastfed or partially breastfed infants receive at least 400 IU of vitamin D supplements every day beginning soon after birth.^2,3,6 Parents/guardians give these supplements at home, unless the primary health care provider has different instructions.

Many caregivers/teachers and parents/guardians believe that infants sleep better when they start to eat age-appropriate solid foods, but research shows that longer sleeping periods are developmental -not nutritionally- determined in mid-infancy, and so this shouldn’t be the only reason for deciding when to introduce solid foods.^4,6 Also, for infants who are exclusively formula fed or fed a combination of formula and human milk, evidence for introducing complementary foods in a specific order has not been proven.

Good communication between the caregiver/teacher and the parents/guardians cannot be overemphasized and is needed for successful feeding in general, including when and how to introduce age-appropriate solid foods.

COMMENTS

ADDITIONAL RESOURCES:

American Academy of Pediatrics

Starting Solid Foods - https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Starting-Solid-Foods.aspx

TYPE OF FACILITY

Center, Early Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.2.0.7 100% Fruit Juice
4.2.0.9 Written Menus and Introduction of New Foods
4.2.0.10 Care for Children with Food Allergies
4.2.0.12 Vegetarian/Vegan Diets
4.5.0.6 Adult Supervision of Children Who Are Learning to Feed Themselves
4.5.0.8 Experience with Familiar and New Foods

REFERENCES

1. American Academy of Pediatrics. Infant food and feeding. AAP.org Web site. https://www.aap.org/en/patient-care/healthy-active-living-for-families/infant-food-and-feeding/. Published July 6, 2021. Accessed November 20, 2022

2. American Academy of Pediatrics. Where we stand: vitamin D & iron supplements for babies. Updated May 24, 2022. Healthy Children.org Web site. https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Vitamin-Iron-Supplements.aspx. Accessed November 20, 2022

3. Centers for Disease Control and Prevention. Vitamin D supplementation CDC (Centers for Disease Control and Prevention). CDC.gov Web site. http://www.cdc.gov/breastfeeding/recommendations/vitamin_D.htm. Last Reviewed July 2, 2021. Accessed November 20, 2022

4. U.S Department of Agriculture. Food and Nutrition Service. Feeding infants in the Child and Adult Care Food Program. USDA.gov Web site. https://www.fns.usda.gov/tn/infant-and-toddler-nutrition. Published July 2021. Accessed November 20, 2022

5. U.S Department of Agriculture. Food and Nutrition Service. Q&As: Feeding infants and meal pattern requirements in the Child and Adult Care Food Program. https://fns-prod.azureedge.us/sites/default/files/cacfp/CACFP06-2017os.pdf. Published January 17, 2017. Accessed November 20, 2022

6. U.S Department of Agriculture. WIC Works Resource System. WIC infant nutrition and feeding guide. Chapter 5: Complementary foods. USDA.gov Web site. https://wicworks.fns.usda.gov/resources/infant-nutrition-and-feeding-guide. Published April 2019. Accessed November 20, 2022

7. Vadiveloo M, Tovar A, Østbye T, Benjamin-Neelon SE. Associations between timing and quality of solid food introduction with infant weight-for-length z-scores at 12 months: findings from the Nurture cohort. Appetite, 141, p.104299. https://www.sciencedirect.com/science/article/pii/S0195666318317860?casa_token=AI_mEyEGr4IAAAAA:sWFkOzAZjvFMH_TAGxxymoYTKr0XlLodeP4MT_unvd3fyUB0CqGmqP6K7G5QCdmQwSk2iwjQvis. Published October 1, 2019. Accessed November 20, 2022

8. World Health Organization. Infant and young child feeding: key facts. WHO.int Web site. https://www.who.int/news-room/fact-sheets/detail/infant-and-young-child-feeding. Published June 9, 2021. Accessed November 20, 2022

NOTES

Content in the STANDARD was modified on 5/31/2018 and 2/9/2023.

4.3.1.12: Feeding Age-Appropriate Solid Foods to Infants

Caregivers/teachers should thoroughly wash hands prior to serving any foods to infants/children. All jars of baby food should be washed with soap and warm water and rinsed with clean, running warm water before opening. All commercially packaged baby food should be served from a dish and spoon, not directly from a factory-sealed container or jar (1). A dish should be cleaned and sanitized before use to reduce the likelihood of surface contamination.

Age-appropriate solid food should not be fed in a bottle or an infant feeder unless doing so is written in the child’s care plan by the child’s primary health care provider. Caregivers/teachers should ensure that there are no food safety recalls (2), and examine the food carefully when removing it from the jar to make sure there are no glass pieces or foreign objects in the food. Caregivers/teachers should discard uneaten food left in dishes from which they have fed a child because it may contain potentially harmful bacteria from the infant’s saliva (3). If left out, all food should be discarded after 2 hours (4). The portion of the food that is touched by a utensil should be consumed or discarded.

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.

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 24 hours of storage. Prior to refrigeration, the opened container or jar should be labeled with the child’s full name and the date and time the food container was opened.

 

RATIONALE

Feeding of age-appropriate solid foods in a bottle to a child is often associated with premature feeding (ie, when the infant is not developmentally ready for solid foods) (5,6).

The external surface of a commercial container or jar may be contaminated with disease-causing microorganisms during shipment or storage and may contaminate the food product during removal of food for placement in the child’s serving dish.

 

TYPE OF FACILITY

Center, Early Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants

REFERENCES

1. Lester J. Nutrition 411: introducing solid foods. Promise powered by Nemours Children’s Health System Web site. https://blog.nemours.org/2016/02/nutrition-411-introducing-solid-foods. Published February 22, 2016. Accessed January 11, 2018

2. US Department of Agriculture. Food Safety and Inspection Service Web site. https://www.fsis.usda.gov/wps/portal/fsis/home. Accessed January 11, 2018

3. US Department of Health and Human Services. Baby food and infant formula. Foodsafety.gov Web site. https://www.foodsafety.gov/keep/types/babyfood/index.html. Accessed January 11, 2018

4. US Department of Health and Human Services, US Food and Drug Administration. Food safety for moms to be: once baby arrives. https://www.fda.gov/food/resourcesforyou/healtheducators/ucm089629.htm>. Updated November 8, 2017. Accessed January 11, 2018

5. Robert Wood Johnson Foundation Healthy Eating Research. Feeding Guidelines for Infants and Young Toddlers: A Responsive Parenting Approach. Guidelines for Health Professionals. http://healthyeatingresearch.org/wp-content/uploads/2017/02/her_feeding_guidelines_brief_021416.pdf. Published February 2017. Accessed January 11, 2018

6. US Department of Agriculture Food and Nutrition Service. Feeding Infants: A Guide for Use in the Child Nutrition Programs. Publication FNS-258. Alexandria, VA: US Department of Agriculture; 2017. https://www.fns.usda.gov/tn/feeding-infants-guide-use-child-nutrition-programs. Accessed January 11, 2018

NOTES

Content in the STANDARD was modified on 05/31/2018.

4.3.2.1: Meal and Snack Patterns for Toddlers and Preschoolers

Meals and snacks should contain 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).  

When incorporating CACFP, caregivers/teachers should (1):

     -Provide a variety of fruits and vegetables.

     -Serve a fruit and/or vegetable during scheduled snacks.

     -Provide one serving each of dark-green vegetables, red and orange vegetables, beans and peas, starchy vegetables, and other vegetables weekly.

     -Serve whole grains and whole-grain products.

     -Limit yogurt to no more than 23 grams of sugar per 6 ounces.

     -Limit processed foods to once per week.

Flavored milks contain higher amounts of added sugars and should not be served. Facilities are encouraged to incorporate seasonal/locally produced foods into meals. Water should not be offered to children during mealtimes; instead, offer water throughout the day.

With limited appetites and selective eating by toddlers and preschoolers, less nutritious foods should not be served because they can displace more nutritious foods from the child’s diet.
Early care and education settings should check with state regulators about the timing between meals. State agencies may require any institution or facility to allow a specific amount of time to elapse between meal services or require that meal services not exceed a specified duration (2).

RATIONALE

Following CACFP guidelines ensures that all children enrolled receive a greater variety of vegetables and fruits and more whole grains and less added sugar and saturated fat during their meals while in care (3). Even during periods of slower growth, children must continue to eat nutritious foods. Picky or selective eating is common among toddlers. They may decide to eat a meal/snack one day but not the next. Over time, with consistent exposure, toddlers are more likely to accept new foods (4).

Additional Resource

US Department of Agriculture Food and Nutrition Service CACFP Nutrition Standards for CACFP Meals and Snacks (www.fns.usda.gov/cacfp/meals-and-snacks)

US Department of Agriculture Healthy Tips for Picky Eaters (https://wicworks.fns.usda.gov/wicworks/Topics/TipsPickyEaters.pdf)

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.2.0.3 Use of US Department of Agriculture Child and Adult Care Food Program Guidelines
4.2.0.4 Categories of Foods
4.2.0.5 Meal and Snack Patterns

REFERENCES

1. US Department of Agriculture. Child and Adult Care Food Program: best practices. https://www.fns.usda.gov/sites/default/files/cacfp/CACFP_factBP.pdf. Accessed January 11, 2018

2. US Department of Agriculture Food and Nutrition Service. Child and Adult Care Food Program: meal pattern revisions related to the Healthy, Hunger-Free Kids Act of 2010. Final rule. Fed Regist. 2016;81(79):24347–24383. https://www.gpo.gov/fdsys/pkg/FR-2016-04-25/pdf/2016-09412.pdf. Accessed January 11, 2018

3. US Department of Agriculture Food and Nutrition Service. Independent Child Care Centers: A Child and Adult Care Food Program Handbook. Washington, DC: US Department of Agriculture; 2014. https://fns-prod.azureedge.net/sites/default/files/cacfp/Independent%20Child%20Care%20Centers%20Handbook.pdf. Accessed January 11, 2018

4. US Department of Agriculture. Updated Child and Adult Care Food Program meal patterns: child and adult meals. https://www.fns.usda.gov/sites/default/files/cacfp/CACFP_MealBP.pdf. Accessed January 11, 2018

NOTES

Content in the STANDARD was modified on 05/31/2018.

4.3.2.2: Serving Size for Toddlers and Preschoolers

The facility should serve toddlers and preschoolers small, age-appropriate portions. The facility should permit children to have one or more additional servings of nutritious foods that are low in fat, sugar, and sodium as required to meet the caloric needs of the individual child. Serving dishes should contain, at minimum, the amount of food based on serving sizes or portions recommended for each child outlined in the Child and Adult Care Food Program (CACFP). Young children should learn what appropriate portion size is by being served plates, bowls, and cups that are developmentally and age appropriate.

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 any spills or to children requesting a second serving.

Children should continue to be exposed to new foods, textures, and tastes throughout infancy, toddlerhood, and preschool. Children should not be required or forced to eat any specific food items. Caregivers/teachers should create a supportive environment that promotes positive, sound eating behaviors (1).

RATIONALE

A child will not eat the same amount each day because appetites vary and food jags are common (2). Eating habits established in infancy and early childhood may contribute to optimal eating patterns later in life. These habits include nutritious meals/snacks consumed in a pleasant, clean, supportive mealtime atmosphere with age-appropriate plates/utensils (1). The quality of snacks for young and school-aged children is especially important, and small, frequent feedings are recommended to achieve the total desired daily intake.

Strong evidence supports that larger plates, bowls, and cups, when paired with sustained long-term exposure of oversized portions, promote overeating (3). Allowing children to decide how much to eat, through family-style dining, may also help promote self-regulation in children (3).

COMMENTS

The CACFP guidelines for meal and snack patterns can be found at www.fns.usda.gov/cacfp/meals-and-snacks.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.2.0.3 Use of US Department of Agriculture Child and Adult Care Food Program Guidelines
4.3.2.1 Meal and Snack Patterns for Toddlers and Preschoolers
4.3.2.3 Encouraging Self-Feeding by Older Infants and Toddlers

REFERENCES

1. Mita SC, Gray SA, Goodell LS. An explanatory framework of teachers' perceptions of a positive mealtime environment in a preschool setting. Appetite. 2015;90:37–44

2. Green RJ, Samy G, Miqdady MS, et al. How to improve eating behavior during early childhood. Pediatric Gastroenterol Hepatol Nutr. 2015;18(1):1–9

3. McCrickerd K, Leong C, Forde CG. Preschool children's sensitivity to teacher-served portion size is linked to age related differences in leftovers. Appetite. 2017;114:320–328

NOTES

Content in the STANDARD was modified on 05/31/2018.

4.3.2.3: Encouraging Self-Feeding by Older Infants and Toddlers

Caregivers/teachers should encourage older infants and toddlers to:¹

• Hold and drink from an appropriate child-sized cup.
• Use a child-sized spoon (short handle with a shallow bowl like a soup spoon).
• Use a child-sized fork (short, blunt tines and broad handle, similar to a salad fork).

All of these are developmentally appropriate for young children to feed themselves. Children can also use their fingers for self-feeding. Children in group care should have opportunities to serve and eat a variety of food for themselves. Foods should be appropriate for the toddler’s developmental ability and cut small enough to avoid choking.

RATIONALE

As children enter the second year after birth, they are interested in doing things for themselves. Self-feeding appropriately separates the responsibilities of adults and children. The caregivers/teachers and parents/guardians are responsible for offering nutritious food, and the child is responsible for deciding how much of it to eat.^1,2 To allow for the proper development of motor skills and eating habits, children need to be allowed to practice feeding themselves as early as 9 months old.^1,3 Children will continue to self-feed using their fingers even after learning how to use a utensil.

COMMENTS

ADDITIONAL RESOURCES

American Academy of Pediatrics

Starting Solid Foods - https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Starting-Solid-Foods.aspx

TYPE OF FACILITY

Center, Early Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.3.2.2 Serving Size for Toddlers and Preschoolers
4.5.0.5 Numbers of Children Fed Simultaneously by One Adult
4.5.0.6 Adult Supervision of Children Who Are Learning to Feed Themselves
4.5.0.10 Foods that Are Choking Hazards

REFERENCES

1. U.S Department of Agriculture. WIC Works Resource System. WIC infant nutrition and feeding guide. Chapter 5: Complementary foods. USDA.gov Web site. https://wicworks.fns.usda.gov/resources/infant-nutrition-and-feeding-guide. Published April 2019. Accessed November 20, 2022

2. American Academy of Pediatrics. Infant food and feeding. AAP.org Web site. https://www.aap.org/en/patient-care/healthy-active-living-for-families/infant-food-and-feeding/. Published July 06, 2021. Accessed November 20, 2022

3. U.S Department of Agriculture. Food and Nutrition Service. Feeding infants in the Child and Adult Care Food Program. USDA.gov Web site. https://fns-prod.azureedge.us/sites/default/files/resource-files/FI_FullGuide_2021.pdf. Published July 2021. Accessed November 20, 2022

NOTES

Content in the STANDARD was modified on 5/31/2018 and 2/9/2023.

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-aged children in the Child and Adult Care Food Program (CACFP). Children attending facilities for 2 or more hours after school need at least 1 snack. Breakfast, or a morning snack, is recommended for all children enrolled in an early care and education facility or in school. Depending on age and length of time in care, snacks should occur 2 hours after a scheduled meal. Early care and education settings should check with state regulators about the timing between meals. State agencies may require any institution or facility to allow a specific amount of time to elapse between meal services or require that meal services not exceed a specified duration (1,2). The quantity and quality of food provided should contribute toward meeting children’s nutritional needs for the day and should not lessen their appetites (3).

RATIONALE

Early childhood is a time of rapid growth that increases the need for energy and essential nutrients to support optimal growth (2). Food intake may vary considerably because this is a time when children express strong food likes and dislikes. The CACFP requirements ensure that children in child care centers for longer than 8 hours (common in military child development centers, for example) are given the appropriate number of meals and snacks to meet individual caloric and nutrient needs (1).

COMMENTS

The CACFP meal and snack pattern guidelines can be found at www.fns.usda.gov/cacfp/meals-and-snacks. Programs serving children during the summer months can find the recommendations of the Summer Food Service Program at https://www.fns.usda.gov/sfsp/summer-food-service-program.

TYPE OF FACILITY

Center, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

1. US Department of Agriculture Food and Nutrition Service. Child and Adult Care Food Program: meal pattern revisions related to the Healthy, Hunger-Free Kids Act of 2010. Final rule. Fed Regist. 2016;81(79):24347–24383. https://www.gpo.gov/fdsys/pkg/FR-2016-04-25/pdf/2016-09412.pdf. Accessed January 11, 2018

2. US Department of Agriculture Food and Nutrition Service. Independent Child Care Centers: A Child and Adult Care Food Program Handbook. Washington, DC: US Department of Agriculture; 2014. https://fns-prod.azureedge.net/sites/default/files/cacfp/Independent%20Child%20Care%20Centers%20Handbook.pdf. Accessed January 11, 2018

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

NOTES

Content in the STANDARD was modified on 05/30/2018. 

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, Early Head Start, Head Start, 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.

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, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.2.0.1 Written Nutrition Plan
4.2.0.2 Assessment and Planning of Nutrition for Individual Children
4.2.0.8 Feeding Plans and Dietary Modifications
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.gpo.gov/fdsys/pkg/ERIC-ED482991/pdf/ERIC-ED482991.pdf
   
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).
   

4.5.0.1: 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, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

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. Holt K, Wooldridge N, Story M, Sofka D. Nutrition Education/ curriculum for, aspects of. In: Bright Futures: Nutrition. Chicago, IL: American Academy of Pediatrics; 2011: 10, 55
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/gpo.gov/fdsys/pkg/ERIC-ED482991/pdf/ERIC-ED482991.pdf.
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.

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 (1,2);
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 (3);
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 (4). 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, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.9.0.9 Cleaning Food Areas and Equipment

REFERENCES

1. Eco-Healthy Child Care. 2016. Plastics & plastic toys. http://cehn.org/wpcontent/uploads/2015/12/Plastics_Plastic_Toys_6_16.pdf.
   
2. Safer Chemicals, Healthy Families. 2017. Styrene and styrofoam 101. 
   http://saferchemicals.org/2014/05/26/styrene-and-styrofoam-101-2/. 
   
3. Center for Disease Control and Prevention. 2017. Lead. https://www.cdc.gov/nceh/lead/.
   
4. Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. Recommendations for care of children in special circumstances. In: Red Book: 2015 Report to the Committee of Infectious Diseases. 30^th Ed. Elk Grove Village, IL: American Academy of Pediatrics.
   

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, participating in arts and crafts projects that do not involve food, 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 (1-5). 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 (6-8). 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.
For additional information, see Building Mealtime Environments and Relationships: An Inventory for Feeding Young Children in Group Settings. 

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.5.0.4 Socialization During Meals
4.5.0.10 Foods that Are Choking Hazards

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.gpo.gov/fdsys/pkg/ERIC-ED482991/pdf/ERIC-ED482991.pdf.
   
5. AAP Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement - Prevention of choking among children. http://pediatrics.aappublications.org/content/early/2010/02/22/peds.2009-2862. 
   
6. 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.
   
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/.
   
9. Art and Creative Materials Institute. 2010. Safety - what you need to know. http://www.acminet.org/Safety.htm.
   
10. U.S. Consumer Product Safety Commission (CPSC). Art and craft safety guide. Bethesda, MD: CPSC. http://www.cpsc.gov/cpscpub/pubs/5015.pdf.
    

NOTES

Content in the STANDARD was modified on 8/25/2016.

4.5.0.4: Socialization During Meals

After reading the CFOC standard, see COVID-19 modification below (Also consult applicable state licensure and public health requirements).

 

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. 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.

 

COVID-19 modification as of October 10, 2022:  During times of moderate-to-high COVID-19 community transmission, programs may temporarily stop serving meals family-style and increase the use of masks. When community transmission levels are low, programs may resume family-style meals if the following implement strategies are followed: Children (2 years and older) and staff are recommended to wear a face covering until eating. Provide as much fresh air as possible. When possible, have children eat outdoors or in well-ventilated spaces. Wash hands prior to and immediately after eating. Clean and sanitize food surfaces before and after meals. Programs should continue to: Serve meal components in serving sizes as specified in the Child and Adult Care Food Program (CACFP) Hold conversations at the table with children to guide their decisions about how much they want to eat. Inform families of changes to mealtime practices and communicate how their children respond. Additional Resources: Early Childhood Learning & Knowledge Center. Family Style Meals USDA. FNS responses to COVID

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, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.2.0.8 Feeding Plans and Dietary Modifications
4.3.2.2 Serving Size for Toddlers and Preschoolers
4.3.2.3 Encouraging Self-Feeding by Older Infants and Toddlers
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.gpo.gov/fdsys/pkg/ERIC-ED482991/pdf/ERIC-ED482991.pdf
   
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.
   

NOTES

COVID-19 modification as of October 10, 2022. 

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, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.3.1.2 Responsive Feeding of Infants by a Consistent Caregiver/Teacher
4.3.2.2 Serving Size for Toddlers and Preschoolers
4.3.2.3 Encouraging Self-Feeding by Older Infants and Toddlers
4.5.0.4 Socialization During Meals
4.5.0.6 Adult Supervision of Children Who Are Learning to Feed Themselves

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, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.3.2.3 Encouraging Self-Feeding by Older Infants and Toddlers
4.5.0.4 Socialization During Meals
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.

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, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.5.0.4 Socialization During Meals

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, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.2.0.9 Written Menus and Introduction of New Foods
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.

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, Early Head Start, Head Start, 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.

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, Early Head Start, Head Start, 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/gpo.gov/fdsys/pkg/ERIC-ED482991/pdf/ERIC-ED482991.pdf.
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.

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, Early Head Start, Head Start, 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.

4.6.0.1: 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, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.6.0.2 Nutritional Quality of Food Brought From Home

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, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.2.0.1 Written Nutrition Plan
4.6.0.1 Selection and Preparation of Food Brought From Home

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.

4.7.0.1: 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, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.2.0.1 Written Nutrition Plan
4.5.0.4 Socialization During Meals
4.5.0.7 Participation of Older Children and Staff in Mealtime Activities
4.5.0.8 Experience with Familiar and New Foods
4.7.0.2 Nutrition Education for Parents/Guardians
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. Holt K, Wooldridge N, Story M, Sofka D. Nutrition Education/ curriculum for, aspects of. In: Bright Futures: Nutrition. Chicago, IL: American Academy of Pediatrics; 2011: 10, 55
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., L. Birch. 2008. Eating behaviors of young child: Prenatal and postnatal influences on healthy eating. Elk Grove Village, IL: American Academy of Pediatrics.
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. H., L. Stern, eds. 1998. American Academy of Pediatrics guide to your child’s nutrition. New York: Villard.

4.7.0.2: Nutrition Education for Parents/Guardians

Parents/guardians should be informed of the range of nutrition learning activities for children in care provided in the facility. Formal nutrition information and education programs for parents/guardians 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. The importance of healthy sleep habits should be incorporated into obesity prevention programming. Informal programs should be implemented during 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 (1-3). 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. Similarly, bedtime routines are an important facet of a child’s physical, social, and emotional health and development. Interestingly, sleep time has a bigger effect on children’s weight than awake time (4).

COMMENTS

One method of nutrition education for parents/guardians is providing healthy recipes that are quick and inexpensive to prepare. Another is sharing information about access to local sources of healthy foods (eg, 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 and culturally relevant and incorporate the use of locally produced food. Educate parents/guardians that an early bedtime is defined as 8:00 pm or earlier and is associated with fewer parent/guardian- and teacher-reported incidences and attention-deficient issues (4,5). Decreased sleep duration with accompanying sleep-related issues is associated with impaired social-emotional and cognitive function that can increase risk of childhood/adolescent obesity (6). Nutrition education programs may be supplemented by periodic distribution of newsletters and sharing Web sites and/or materials.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.7.0.1 Nutrition Learning Experiences for Children

REFERENCES

1. US Department of Health and Human Services, Administration for Children and Families, Head Start Early Childhood Learning and Knowledge Center. Head Start policy & regulations. Subchapter B—the administration for children and families, Head Start program. https://eclkc.ohs.acf.hhs.gov/policy/45-cfr-chap-xiii. Accessed November 14, 2017

2. Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017

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

4. Anderson SE, Andridge R, Whitaker RC. Bedtime in preschool-aged children and risk for adolescent obesity. J Pediatr. 2016;176:17–22

5. Kobayashi K, Yorifuji T, Yamakawa M, et al. Poor toddler-age sleep schedules predict school-age behavioral disorders in a longitudinal survey. Brain Dev. 2015;37(6):572–578

6. Bonuck KA, Schwartz B, Schechter C. Sleep health literacy in Head Start families and staff: exploratory study of knowledge, motivation, and competencies to promote healthy sleep. Sleep Health. 2016;2(1):19–24

NOTES

Content in the STANDARD was modified on 05/30/2018.

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, Early Head Start, Head Start, 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.

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, Early Head Start, Head Start

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.

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, Early Head Start, Head Start, 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.

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, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.9.0.13 Method for Washing Dishes by Hand

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, Early Head Start, Head Start

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.

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, Early Head Start, Head Start, 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.

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, Early Head Start, Head Start

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.

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, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.3.1.9 Warming Bottles and Infant Foods

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.

4.9.0.1: 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, Early Head Start, Head Start, 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.

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, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

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.

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, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.3.1.7 Feeding Cow’s Milk
4.8.0.6 Maintaining Safe Food Temperatures
Appendix U: Recommended Safe Minimum Internal Cooking Temperatures

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/gpo.gov/fdsys/pkg/ERIC-ED482991/pdf/ERIC-ED482991.pdf.
2. Enders, J. B. 1994. Food, nutrition and the young child. New York: Merrill.
3. Potter, M. E. 1984. Unpasteurized milk: The hazards of a health fetish. JAMA 252:2048-52.
4. Sacks, J. J. 1982. Toxoplasmosis infection associated with raw goat’s milk. JAMA 246:1728-32.
5. Cowell, C., S. Schlosser. 1998. Food safety in infant and preschool day care. Top Clin Nutr 14:9-15.
6. Dietz, W.H., L. Stern, eds. 1998. Guide to your child’s nutrition. Elk Grove Village, IL: American Academy of Pediatrics.
7. 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.
8. Daniels, S. R., F. R. Greer, Committee on Nutrition. 2008. Lipid screening and cardiovascular health in childhood. Pediatrics 122:198-208.
9. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.
10. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.
11. Chicago Dietetic Association. 1996. Manual of clinical dietetics. 5th ed. Chicago, IL: American Dietetic Association.
12. 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.
13. 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.
14. 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.

4.9.0.4: 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, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.8.0.6 Maintaining Safe Food Temperatures

REFERENCES

1. U.S. Department of Agriculture, Food Safety and Inspection Service. Glossary:Perishable. http://www.fda.gov/downloads/Food/FoodScienceResearch/ToolsMaterials/UCM430363.pdf.
   
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.
   

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, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.8.0.6 Maintaining Safe Food Temperatures
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/gpo.gov/fdsys/pkg/ERIC-ED482991/pdf/ERIC-ED482991.pdf.

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, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

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.

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, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

4.9.0.8: Supply of Food and Water for Disasters

Disaster Preparedness
A minimum 3-day supply of nonperishable food and 1 gallon of water per person per day for 3 days should be kept in stock for each child and staff member.^1,2 For programs with 100 children, this would mean 300 gallons of water and approximately 1,000 meals. Programs should consider appropriate and accessible storage for a large quantity of supplies.

For early care and education programs in areas at risk for hurricanes and other severe disasters, an additional 2-day supply (ie, supply for 5 days total) of nonperishable food and water may be needed. A written log detailing the expiration dates, as well as the amount and type of food, should be kept by early care and education staff and reviewed on a quarterly basis. Caregivers/teachers should review log/expiration dates on a quarterly basis; food and water supplies should be consumed and/or replaced from the emergency supplies to ensure usage before expiration.

Early care and education programs should accommodate children with special health care needs who require specialized diets. Appropriate, nonperishable food items should be kept and made available for these children in the event of a disaster.³

Disaster Response and Recovery

Early care and education programs should assess the emergency food supply and food preparation areas/equipment annually and after a disaster.

Early care and education staff should avoid serving food and beverages under the following circumstances^4,5:

• Food or beverages that have been exposed to floodwater or chemical agents. If unsure, throw them away.
• Dispose of wooden cutting boards, bottle nipples, and pacifiers if they have been contaminated with floodwater, as they are difficult to properly clean.
• Dispose of perishable foods, such as meat and eggs, that have been stored in temperatures above 40°F for longer than 2 hours. Foods stored at 40°F or below can be refrozen or cooked.
• Food that is packed in plastic, paper, cardboard, cloth, or similar containers that have been water damaged.
• Food that is stored in containers that cannot be disinfected. This would include foods in containers with screw caps, snap lids, crimped caps (soda bottles), twist caps, or flip tops, as well as home canned foods.

Water Safety

If there is any chance that tap water has been contaminated during a disaster, don’t use it. Listen to updates from emergency officials on the state of your community’s water supply and for instructions to boil tap water before use (to stay abreast of such updates, make sure your stockpile includes a battery-operated radio). Do not attempt to drink water you believe has been contaminated with fuel or toxic chemicals, as boiling and other disinfectants will not work to purify it.⁵

 

If bottled water is not available, boiling water is the best way to purify drinking supplies and kill disease-carrying bacteria, viruses, and parasites.⁵ If the water is cloudy, first filter it through a clean paper towel, cloth, or coffee filter before boiling. ⁶ Bring your water to a boil and allow it to boil for at least 1 minute.⁷ Store your boiled water in clean containers with tight lids.

If boiling your water is not an option, you can also use unscented household chlorine bleach, iodine, or chlorine dioxide tablets. Keep in mind that while such methods are effective at killing harmful bacteria and viruses, only chlorine dioxide tablets and boiling will kill disease-carrying parasites. To purify your water using unscented household chlorine bleach, add one-eighth of a teaspoon for every gallon of clear water and one-fourth of a teaspoon for every gallon of cloudy water. Stir the water and let it sit for 30 minutes before using it. To use iodine or chlorine dioxide tablets, follow the manufacturer’s instructions.

Early care and education staff should remove the labels of undamaged, commercially prepared foods in all-metal cans or retort pouches and thoroughly wash, rinse, and disinfect the cans. Lastly, relabel containers that had the labels removed, including the expiration date, with a permanent marker.³

RATIONALE

It may take 3 days or longer for nutrition assistance and food packages to arrive after a disaster strikes. Due to possible widespread damage, transportation disruptions, and supply shortages, it may not be possible for supplies to be brought into disaster locations until the following conditions are met:

     a) Efforts to rescue/save lives are completed.

     b) Needs of communities/populations are assessed.

Preparing for disasters by keeping an emergency supply of food and water can prolong the health of children and staff in disaster-impacted areas.⁸

COMMENTS

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.2.0.1 Written Nutrition Plan
4.2.0.10 Care for Children with Food Allergies

REFERENCES

1. Federal Emergency Management Agency, US Department of Homeland Security. Emergency supply list. https://www.fema.gov/media-library-data/1390846764394-dc08e309debe561d866b05ac84daf1ee/checklist_2014.pdf. Accessed December 20, 2018

2. Federal Emergency Management Agency, US Department of Homeland Security. Water. Ready website. https://www.ready.gov/water. Accessed December 20, 2018

3. Singh SN. Nutrition in emergencies: issues involved in ensuring proper nutrition in post-chemical, biological, radiological, and nuclear disaster. J Pharm Bioallied Sci. 2010;2(3):248–252

4. Wolfram T. Food safety in the home after a hurricane and flooding. Academy of Nutrition and Dietetics Eat Right website. https://www.eatright.org/homefoodsafety/safety-tips/food-poisoning/food-safety-in-the-home-after-a-hurricane-and-flooding. Published September 10, 2018. Accessed December 20, 2018

5. American Public Health Association. Keeping food and water safe in an emergency. http://aphagetready.org/foodwatersafety.htm. Accessed December 20, 2018

6. Federal Emergency Management Agency, US Department of Homeland Security. Fact sheet: How to make your water safe to drink. https://www.fema.gov/news-release/2017/10/08/fact-sheet-how-make-your-water-safe-drink. Accessed May 2, 2019

7. Centers for Disease Control and Prevention. Making water safe in an emergency. https://www.cdc.gov/healthywater/emergency/drinking/making-water-safe.html. Updated September 21, 2017. Accessed May 2, 2019

8. Pradhan PM, Dhital R, Subhani H. Nutrition interventions for children aged less than 5 years following natural disasters: a systematic review. BMJ Open. 2016;6(9):e011238

NOTES

 Content in the STANDARD was modified on 05/21/2019.

4.9.0.9: Cleaning Food Areas and Equipment

Areas and equipment for storing, preparing, and serving food should be kept clean. All areas for food preparation, food service, and dining 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. Use a microfiber cloth or disposable paper towels. Do not use sponges for cleaning and sanitizing. If regular cotton cloths are used, they should be used once, then stored in a covered container and thoroughly washed daily.

Detailed definitions of Clean, Sanitize, Disinfect, and Germ[s] (microbes such as bacteria, viruses, fungi) that can cause disease are in the CFOC Online Glossary.

RATIONALE

Early childhood settings have had outbreaks of foodborne illnesses. Many of these infectious diseases can be prevented by having clearly written policies and steps about how to clean surfaces and prepare food correctly.^1,2 Keeping hands clean reduces the soiling of kitchen equipment and supplies. Training staff to properly clean, and to clean on a regular schedule, can reduce illnesses.

Cotton cloths have fewer fibers than microfiber cloths and clean less well. Studies show that microfiber cloths reduce the transfer of germs from surface to surface better than cotton cloths.³ Sponges are not recommended for use in early care and education programs because they miss dirt, leave detergent and water on surfaces being cleaned, can become contaminated with bacteria, and are difficult to clean.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

Appendix J: Selection and Use of a Cleaning, Sanitizing or Disinfecting Product
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting

REFERENCES

1. Li Y, Jaykus L-A, Cates S, Wohlgenant K, Chen X, Fraser AM. Hygienic conditions in child-care facilities in North Carolina and South Carolina: an integrated microbial and observational study. Am J Infect Control. 2014;42:781-786. https://www.sciencedirect.com/science/article/abs/pii/S0196655314001825.Published July 2014. Accessed November 20, 2022

2. Gallo M, Ferrara L, Calogero A, Montesano D, Naviglio D. Relationships between food and diseases: what to know to ensure food safety. Food Research International. 2020;137:109414. https://www.sciencedirect.com/science/article/abs/pii/S0963996920304397?casa_token=htMkkTL1_4MAAAAA:6PLYNmLU0oiQ6GLaWl07uYlAynrmWlVTroJObpnobGkIh7PueBNdkPpQesMRkGtW9pAX6v761tg. Published November 2020. Accessed November 20, 2022

3. Trajtman AN, Manickam K, Alfa MJ. Microfiber cloths reduce the transfer of Clostridium difficile spores to environmental surfaces compared with cotton cloths. Am J Infect Control. 2015;43(7):686-689. doi: 10.1016/j.ajic.2015.03.002. https://pubmed.ncbi.nlm.nih.gov/25907782/. Published April 20, 2015. Accessed November 20, 2022

NOTES

Content in the STANDARD was modified on 3/30/2023.

4.9.0.10: Cutting Boards

Cutting boards should be made of nonporous material (does not allow liquid or air to pass through). Programs should choose plastic, marble, glass, or pyroceramic cutting boards. Cutting boards should be scrubbed with hot water and soap, sanitized each time it is used for a different food, or can be cleaned and sanitized in a dishwasher.¹

Programs should not use porous wooden cutting boards, boards made with wood pieces, and boards with grooves and cuts. Small and large family child care homes may choose to use bamboo cutting boards instead of plastic. Bamboo cutting boards should be cleaned with hot soapy water, sanitized, and rubbed with mineral oil monthly.¹

RATIONALE

Inadequate cleaning and sanitizing of cutting boards can cause food poisoning outbreaks and infections.^2,3 Cutting boards can hold high amounts of bacteria, so they should be regularly sanitized.⁴

Some wooden boards and boards with cuts, cracks and/or grooves hold on to food or other materials. This can cause bacteria grow on the surface and contaminate the next food that is placed on it (cross-contamination). Surfaces, such as cutting boards, that come into contact with food are common sources of cross-contamination in the kitchen.² Wooden boards are harder to wash and sanitize than plastic and glass boards, because of their porous surfaces.⁴ Bamboo absorbs very little moisture and resists damage from knives, so bamboo boards have less bacteria than other woods.¹ Bamboo cutting boards need to be maintained with mineral oil to protect from cracks and provide moisture protection.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

1. Food and Safety and Inspection Service. Cutting Boards. USDA.gov Web site. https://www.fsis.usda.gov/food-safety/safe-food-handling-and-preparation/food-safety-basics/cutting-boards. Updated August 2, 2017. Accessed November 20, 2022

2. Mahyudin NA, Sahil SM, Radu S, Mahmud NK, Rashid A. Multiple drug resistance among Staphylococcus aureus strains isolated from cutting boards of commercial food premises: a threat to food and public health safety. Journal of Biochemistry, Microbiology and Biotechnology. 2019;7(1):48-51. Published July 31, 2019. Accessed November 20, 2022 https://journal.hibiscuspublisher.com/index.php/JOBIMB/article/view/454

3. Malcolm TTH, San Chang W, Loo YY, et al. Simulation of improper food hygiene practices: a quantitative assessment of Vibrio parahaemolyticus distribution. International Journal of Food Microbiology. 2018;284:112-119. https://www.sciencedirect.com/science/article/pii/S0168160518305208?casa_token=9jHJkVuvsDoAAAAA:QZKN6QaUKqw2PPLm9feMWMfx-QN9iZ0lmQtX9MvtfPZ0WeENIE5hG8AkHoJlZQjvquFlfDog6hA.Published November 2, 2018. Accessed November 20, 2022

4. Dantas ST, Rossi BF, Bonsaglia EC, et al. Cross-contamination and biofilm formation by Salmonella enterica serovar Enteritidis on various cutting boards. Foodborne Pathogens and Disease. 2017;15(2):81-85. Published October 2017. Accessed November 20, 2022

NOTES

Content in the STANDARD was modified on 3/30/2023.

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, Early Head Start, Head Start

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/gpo.gov/fdsys/pkg/ERIC-ED482991/pdf/ERIC-ED482991.pdf.

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

Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.9.0.11 Dishwashing in Centers
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/gpo.gov/fdsys/pkg/ERIC-ED482991/pdf/ERIC-ED482991.pdf.

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 may be used as a sanitizing solution when diluted according to manufacturer's instructions. 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, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.9.0.12 Dishwashing in Small and Large Family Child Care Homes

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/gpo.gov/fdsys/pkg/ERIC-ED482991/pdf/ERIC-ED482991.pdf.

NOTES

Content in the STANDARD was modified on 8/6/2013.

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, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

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.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

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.

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, Early Head Start, Head Start, 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.