174 Caring for Our Children: National Health and Safety Performance Standards 4.3 several objectives, including increasing the proportion of REQUIREMENTS FOR SPECIAL mothers who breastfeed their infants and increasing the GROUPS OR AGES OF CHILDREN duration of breastfeeding and exclusive breastfeeding (4). Incidences of common childhood illnesses, such as diarrhea, 4.3.1 respiratory disease, bacterial meningitis, botulism, urinary NUTRITION FOR INFANTS tract infections, sudden infant death syndrome, insulin- dependent diabetes, ulcerative colitis, and ear infections, 4.3.1.1 and overall risk for childhood obesity are significantly General Plan for Feeding Infants decreased in breastfed children (5,6). Similarly, breastfeed- ing, when paired with other healthy parenting behaviors, The facility should keep records detailing whether an infant has been directly related to increased cognitive development is breastfed or formula fed, along with the type of formula in infants (7). Breastfeeding also has added benefits to the being served. An infant feeding record of human (breast) mother: it decreases risk of diabetes, breast and ovarian milk and/or all formula given to the infant should be com- cancers, and heart disease (8). pleted daily. Infant meals and snacks should follow the Mothers who want to supplement their breast milk with meal and snack patterns of the Child and Adult Care Food formula may do so, as the infant will continue to receive Program. Food should be appropriate for the infant’s indi- breastfeeding benefits (4,5,7). Iron-fortified infant formula is vidual nutrition requirements and developmental stage an acceptable alternative to human milk as a food for infant as determined by written instructions obtained from the feeding even though it lacks any anti-infective or immuno- child’s parent/guardian or primary health care provider. logical components. Regardless of feeding preference, an The facility should encourage breastfeeding by providing adequately nourished infant is more likely to achieve healthy accommodations and continuous support to the breastfeed- physical and mental development, which will have long-term ing mother. Facilities should have a designated place set positive effects on health (9). aside for breastfeeding mothers who want to visit the class- room during the workday to breastfeed, as well as a private COMMENTS area (not a bathroom) with an outlet for mothers to pump The ways to help a mother breastfeed successfully in the their breast milk (1,2). The private area also should have early care and education facility are (2,6,8): access to water or hand hygiene. A place that parents/ a. If she wishes to breastfeed her infant or child when she guardians feel they are welcome to breastfeed, pump, or bottle-feed can create a positive and supportive environ- comes to the facility, offer or provide her a ment for the family. 1. Quiet, comfortable, and private place to breastfeed Infants may need a variety of special formulas, such as soy-based formula or elemental formulas, that are easier (This helps her milk to let down.) to digest and less allergenic. Elemental or special hypo- 2. Place to wash her and her infant’s hands before and allergenic formulas should be specified in the infant’s care plan. Age-appropriate solid foods other than human milk after breastfeeding or infant formula (ie, complementary foods) should be 3. Pillow to support her infant on her lap while nursing introduced no sooner than 6 months of age or as indicated 4. Nursing stool or step stool for her feet so she doesn’t by the individual child’s nutritional and developmental needs. Please refer to standards 4.3.1.11 and 4.3.1.12 for have to strain her back while nursing more information. 5. Glass of water or other liquid to help her stay RATIONALE Human milk, as an exclusive food, is best suited to meet hydrated the entire nutritional needs of an infant from birth until b. Encourage her to get the infant used to being fed her 6 months of age, with the exception of recommended vita- min D supplementation. In addition to nutrition, breast- expressed human milk by another person before the feeding supports optimal health and development. Human infant starts in early care and education, while continu- milk is also the best source of milk for infants for at least ing to breastfeed directly herself. the first 12 months of age and, thereafter, for as long as c. Discuss with her the infant’s usual feeding pattern and mutually desired by mother and child. Breastfeeding the benefits of feeding the infant based on the infant’s protects infants from many acute and chronic diseases hunger and satiety cues rather than on a schedule; ask and has advantages for the mother, as well (3). her if she wishes to time the infant’s last feeding so that Research overwhelmingly shows that exclusive breastfeed- the infant is hungry and ready to breastfeed when she ing for 6 months, and continued breastfeeding for at least a arrives; and ask her to leave her availability schedule with year or longer, dramatically improves health outcomes for the early care and education program as well as to call if children and their mothers. Healthy People 2020 outlines she is planning to miss a feeding or is going to be late. d. 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.
175 Chapter 4: Nutrition and Food Service e. Share with her information about other places or people 4. Healthy People 2020. Maternal, infant, and child health. HealthyPeople.gov in the community who can answer her questions and Web site. https://www.healthypeople.gov/2020/topics-objectives/topic/ concerns about breastfeeding, such as local lactation maternal-infant-and-child-health/objectives. Accessed January 11, 2018 consultants. 1. Provide culturally appropriate breastfeeding 5. Furman L. Breastfeeding: what do we know, and where do we go from here? materials, including community resources for Pediatrics. 2017;139(4):e20170150 parents/guardians that include appropriate lan- guage and pictures of multicultural families to 6. American Academy of Pediatrics Section on Breastfeeding. Breastfeeding assist families in identifying with them. and the use of human milk. Pediatrics. 2012;129(3):e827–e841 f. Ensure that all staff receive training in breastfeeding 7. Gibbs BG, Forste R. Breastfeeding, parenting, and early cognitive support and promotion. development. J Pediatr. 2014;164(3):487–493 g. Ensure that all staff are trained in the proper handling, storing, and feeding of each milk product, including 8. 8. Binns C, Lee M, Low WY. The long-term public health benefits of human milk or infant formula. breastfeeding. Asia Pac J Public Health. 2016;28(1):7–14 ADDITIONAL RESOURCES 9. 9. Danawi H, Estrada L, Hasbini T, Wilson DR. Health inequalities and breastfeeding in the United States of America. Int J Childbirth Educ. Breastfeeding, US Department of Health and Human Services Office on 2016;31(1) Women’s Health (https://www.womenshealth.gov/printables-and-shareables/ health-topic/breastfeeding) NOTES Content in the STANDARD was modified on 05/30/2018. Feeding Infants: A Guide for Use in the Child Nutrition Programs, US Department of Agriculture (USDA) Food and Nutrition Service (https://www. 4.3.1.2 fns.usda.gov/tn/feeding-infants-guide-use-child-nutrition-programs) Feeding Infants on Cue by a Consistent Caregiver/Teacher Infant Meal Pattern, USDA (https://fns-prod.azureedge.net/sites/default/files/ cacfp/CACFP_infantmealpattern.pdf) Caregivers/teachers should feed infants on cue unless Strategy 6, Support for Breastfeeding in Early Care and Education, Centers for the parent/guardian and the child’s primary health care Disease Control and Prevention (https://www.cdc.gov/breastfeeding/pdf/ provider give written instructions stating otherwise (1). strategy6-support-breastfeeding-early-care.pdf) Caregivers/teachers should be gentle, patient, sensitive, and reassuring when responding appropriately to the Updated Child and Adult Care Food Program Meal Patterns: Infant Meals, infant’s feeding cues (2). Responsive feeding is most suc- USDA (https://fns-prod.azureedge.net/sites/default/files/cacfp/CACFP_ cessful when caregivers/teachers learn how infants exter- InfantMealPattern_FactSheet_V2.pdf) nally communicate hunger and fullness. Crying alone is not a cue for hunger unless accompanied by other cues, TYPE OF FACILITY such as opening the mouth, making sucking sounds, Center, Large Family Child Care Home, Small Family rooting, fast breathing, clenched fingers/fists, and flexed Child Care Home arms/legs (1,2). Whenever possible, the same caregiver/ teacher should feed a specific infant for most of that infant’s RELATED STANDARDS feedings (3). Caregivers/teachers should not feed infants beyond satiety; just as hunger cues are important in initiat- 4.2.0.9 Written Menus and Introduction of New ing feedings, observing satiety cues can limit overfeeding. Foods An infant will communicate fullness by shaking the head or turning away from food (1,4,5). 4.3.1.3 Preparing, Feeding, and Storing Human Milk A pacifier should not be offered to an infant prior to being fed. 4.3.1.5 Preparing, Feeding, and Storing Infant RATIONALE Formula Responsive feeding meets the infant’s nutritional and emotional needs and provides an immediate response to 4.3.1.11 Introduction of Age-Appropriate Solid Foods the infant, which helps ensure trust and feelings of security to Infants (6). A caregiver/teacher is more likely to understand how a particular infant communicates hunger/satiety when con- 4.3.1.12 Feeding Age-Appropriate Solid Foods to sistent, reliable feedings and interactions are done regularly Infants over time. Early relationships between an infant and care- givers/teachers involving feeding set the stage for an infant Appendix JJ: Our Child Care Center Supports to develop eating patterns for life (1-5). Responsive feeding Breastfeeding may help prevent childhood obesity (5-7). TYPE OF FACILITY References Center, Large Family Child Care Home, Small Family Child Care Home 1. Centers for Disease Control and Prevention. Strategies to Prevent Obesity RELATED STANDARDS and Other Chronic Diseases: The CDC Guide to Strategies to Support 4.3.1.1 General Plan for Feeding Infants Breastfeeding Mothers and Babies. Atlanta, GA: US Department of Health 4.3.1.8 Techniques for Bottle Feeding 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
176 Caring for Our Children: National Health and Safety Performance Standards References filled, labeled containers of human milk should be kept refrigerated. Human milk containers with significant 1. Blaine RE, Davison KK, Hesketh K, Taveras EM, Gillman MW, Benjamin amount of contents remaining (greater than one ounce) Neelon SE. Child care provider adherence to infant and toddler feeding may be returned to the mother at the end of the day as recommendations: findings from the Baby Nutrition and Physical Activity long as the child has not fed directly from the bottle. Self-Assessment for Child Care (Baby NAP SACC) Study. Child Obes. Frozen human milk may be transported and stored in 2015;11(3):304–313 single use plastic bags and placed in a freezer (not a com- partment within a refrigerator but either a freezer with a 2. Pérez-Escamilla R, Segura-Pérez S, Lott M, on behalf of the Robert Wood separate door or a standalone freezer). Human milk should Johnson Foundation HER Expert Panel on Best Practices for Promoting be defrosted in the refrigerator if frozen, and then heated Healthy Nutrition, Feeding Patterns, and Weight Status for Infants and briefly in bottle warmers or under warm running water Toddlers From Birth to 24 Months. Feeding Guidelines for Infants and so that the temperature does not exceed 98.6°F. If there Young Toddlers: A Responsive Parenting Approach. Guidelines for is insufficient time to defrost the milk in the refrigerator Health Professionals. Durham, NC: Healthy Eating Research; 2017. before warming it, then it may be defrosted in a container http://healthyeatingresearch.org/wp-content/uploads/2017/02/ of running cool tap water, very gently swirling the bottle her_feeding_guidelines_brief_021416.pdf. Published February 2017. periodically to evenly distribute the temperature in the Accessed November 14, 2017 milk. Some infants will not take their mother’s milk unless it is warmed to body temperature, around 98.6°F. The care- 3. Zero to Three. How to care for infants and toddlers in groups. 4. Continuity giver/teacher should check for the infant’s full name and of care. https://www.zerotothree.org/resources/77-how-to-care-for-infants- the date on the bottle so that the oldest milk is used first. and-toddlers-in-groups#chapter-38. Published February 8, 2010. Accessed After warming, bottles should be mixed gently (not shaken) November 14, 2017 and the temperature of the milk tested before feeding. Expressed human milk that presents a threat to an infant, 4. US Department of Agriculture, Special Supplemental Nutrition Program such as human milk that is in an unsanitary bottle, is for Women, Infants, and Children. Infant hunger and satiety cues. curdled, smells rotten, and/or has not been stored follow- https://wicworks.fns.usda.gov/wicworks/WIC_Learning_Online/support/ ing the storage guidelines of the Academy of Breastfeeding job_aids/cues.pdf. Updated October 2016. Accessed November 14, 2017 Medicine as shown later in this standard, should be returned to the mother. 5. Buvinger E, Rosenblum K, Miller AL, Kaciroti NA, Lumeng JC. Observed Some children around six months to a year of age may be infant food cue responsivity: associations with maternal report of infant developmentally ready to feed themselves and may want eating behavior, breastfeeding, and infant to drink from a cup. The transition from bottle to cup can weightgain. Appetite. 2017;112:219–226 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 6. Early Head Start National Resource Center. Observation: The Heart of without cracks or chips and should help the child to lift Individualizing Responsive Care. Washington, DC: Early Head Start and tilt the cup to avoid spillage and leftover fluid. The National Resource Center; 2013. https://eclkc.ohs.acf.hhs.gov/sites/default/ caregiver/teacher and mother should work together on files/pdf/ehs-ta-paper-15-observation.pdf. Accessed November 14, 2017 cup feeding of human milk to ensure the child is receiving adequate nourishment and to avoid having a large amount 7. 7. Redsell SA, Edmonds B, Swift JA, et al. Systematic review of randomised of human milk remaining at the end of feeding. Two to controlled trials of interventions that aim to reduce the risk, either directly three ounces of human milk can be placed in a clean or indirectly, of overweight and obesity in infancy and early cup and additional milk can be offered as needed. Small childhood. Matern Child Nutr. 2016;12(1):24–38 amounts of human milk (about an ounce) can be discarded. Human milk can be stored using the following guidelines NOTES from the Academy of Breastfeeding Medicine: Content in the STANDARD was modified on 05/30/2018. RATIONALE 4.3.1.3 Labels for containers of human milk should be resistant Preparing, Feeding, and Storing Human Milk to loss of the name and date/time when washing and handling. This is especially important when the frozen Expressed human milk should be placed in a clean and bottle is thawed in running tap water. There may be sanitary bottle with a nipple that fits tightly or into an several bottles from different mothers being thawed equivalent clean and sanitary sealed container to prevent and warmed at the same time in the same place. spilling during transport to home or to the facility. Only By following this standard, the staff is able, when necessary, cleaned and sanitized bottles, or their equivalent, and to prepare human milk and feed an infant safely, thereby nipples should be used in feeding. The bottle or container reducing the risk of inaccuracy or feeding the infant un- should be properly labeled with the infant’s full name and sanitary or incorrect human milk (2,3). Written guidance the date and time the milk was expressed. The bottle or container should immediately be stored in the refrigerator on arrival. The mother’s own expressed milk should only be used for her own infant. Likewise, infant formula should not be used for a breastfed infant without the mother’s written permission. Avoid bottles made of plastics containing bisphenol A (BPA) or phthalates, sometimes labeled with #3, #6, or #7 (1). 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. Non-frozen human milk should be transported and stored in the containers to be used to feed the infant, identified with a label which will not come off in water or handling, bearing the date of collection and child’s full name. The
177 Chapter 4: Nutrition and Food Service Guidelines for Storage of Human Milk Location Temperature Duration Comments Countertop, table Room temperature 6-8 hours Containers should be covered and kept as cool as (up to 77°F or 25°C) possible; covering the container with a cool towel may keep milk cooler. Insulated cooler bag 5°F – 39°F or 24 hours Keep ice packs in contact with milk containers at all times, -15°C – 4°C limit opening cooler bag. Refrigerator 39°F or 4°C 5 days Store milk in the back of the main body of the refrigerator. Freezer compartment of a refrigerator 5°F or -15°C 2 weeks Store milk toward the back of the freezer, where Freezer compartment of refrigerator 0°F or -18°C 3-6 months temperature is most constant. Milk stored for longer with separate doors durations in the ranges listed is safe, but some of the Chest or upright deep freezer -4°F or -20°C 6-12 months lipids in the milk undergo degradation resulting in lower quality. Source: Academy of Breastfeeding Medicine Protocol Committee. 2010. Clinical protocol #8: Human milk storage information for home use for healthy full term infants, revised. Breastfeeding Med 5:127-30. http://www.bfmed.org/Media/Files/Protocols/Protocol%208%20-%20English%20revised%202010.pdf. From the Centers for Disease Control and Prevention Website: Proper handling and storage of human milk – Storage duration of fresh human milk for use with healthy full term infants. http://www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htm. for both staff and parents/guardians should be available to 4.3.1.8 Techniques for Bottle Feeding determine when milk provided by parents/guardians will 4.3.1.9 Warming Bottles and Infant Foods not be served. Human milk cannot be served if it does not 5.2.9.9 Plastic Containers and Toys meet the requirements for sanitary and safe milk. References Although human milk is a body fluid, it is not necessary to wear gloves when feeding or handling human milk. Unless 1. Harley, K.G., Gunier, R.B., Kogut, K., Johnson, C., et al. 2013. Prenatal and there is visible blood in the milk, the risk of exposure to early childhood bisphenol a concentrations and behavior in school-aged infectious organisms either during feeding or from milk children. Environ Res. 126: 43-50. that the infant regurgitates is not significant. 2. United States Cooperative Expansion System. 2015. Guidelines for child care Returning unused human milk to the mother informs providers to prepare and feed bottles to infants. 2015. http://articles. her of the quantity taken while in the early care and extension.org/pages/25404/guidelines-for-child-care-providers-to-prepare- education program. and-feed-bottles-to-infants. Excessive shaking of human milk may damage some of 3. Centers for Disease Control and Prevention. 2016. Proper handling and the cellular components that are valuable to the infant. It storage of human milk. Atlanta, GA. https://www.cdc.gov/breastfeeding/ is difficult to maintain 0°F consistently in a freezer com- recommendations/handling_breastmilk.htm. partment of a refrigerator or freezer, so caregivers/teachers should carefully monitor, with daily log sheets, temperature 4. La Leche League International. (2014). Storage guidelines: LLLI guidelines of freezers used to store human milk using an appropriate for storing breastmilk. http://www.llli.org/faq/milkstorage.html. working thermometer. Human milk contains components that are damaged by excessive heating during or after thaw- 5. Boué, G., Cummins, E., Guillou, S., Antignac, J., Bizec, B., & Membré, J. ing from the frozen state (4). Currently, there is nothing 2016. Public health risks and benefits associated with breast milk and infant in the research literature that states that feedings must be formula consumption. Critical Reviews in Food Science and Nutrition. Feb warmed at all prior to feeding. Frozen milk should never 6:1-20. be thawed in a microwave oven as 1) uneven hot spots in the milk may cause burns in the infant and 2) excessive 6. Binns, C. 2016. The long-term public health benefits of breastfeeding. heat may destroy beneficial components of the milk. Asia-Pacific Journal of Public Health. 28(1):7. By following safe preparation and storage techniques, NOTES nursing mothers and caregivers/teachers of breastfed Content in the STANDARD was modified on 8/23/2016. infants and children can maintain the high quality of expressed human milk and the health of the infant (5,6). 4.3.1.4 Feeding Human Milk to Another TYPE OF FACILITY Mother’s Child Center, Large Family Child Care Home Because parents/guardians may express concern about the RELATED STANDARDS likelihood of transmitting diseases through human milk, 4.3.1.1 General Plan for Feeding Infants this issue is addressed in detail to assure there is a very 4.3.1.4 Feeding Human Milk to Another Mother’s Child small risk of such transmission occurring. 4.3.1.7 Feeding Cow’s Milk If a child has been mistakenly fed another child’s bottle of expressed human milk, the possible exposure to infectious diseases should be treated just as if an unintentional expo- sure to other body fluids had occurred. The early care and education program should (1): a. Inform the mother who expressed the human milk about the mistake and when the bottle switch occurred, and ask:
178 Caring for Our Children: National Health and Safety Performance Standards 1. When the human milk was expressed and how it was References handled prior to being delivered to the caregiver/ teacher or facility; 1. U.S. Centers for Disease Control and Prevention. 2016. What to do if an infant or child is mistakenly fed another woman’s expressed breast milk. 2. Whether the mother has ever had a Human http://www.cdc.gov/breastfeeding/recommendations/ Immunodeficiency Virus (HIV) blood test and, if so, other_mothers_milk.htm. the date of the test and would she be willing to share the results with the parents/guardians of the child 2. U.S. Centers for Disease Control and Prevention. 2016. Hepatitis B FAQs who was fed her child’s milk; for the public. https://www.cdc.gov/hepatitis/hbv/bfaq.htm#bFAQ13. 3. If she does not know whether she has ever been 3. U.S. Centers for Disease Control and Prevention. 2016. Hepatitis C FAQs tested for HIV, ask her if would she be willing to for the public. https://www.cdc.gov/hepatitis/hcv/cfaq.htm#cFAQ37. contact her primary health care provider and find out if she has been tested; and 4. Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. Red Book: 2015 Report of the Committee on Infectious Diseases. 30th Ed. 4. If she has never been tested for HIV, would she be Elk Grove Village, IL: American Academy of Pediatrics. willing to be tested and share the results with the parents/guardians of the other child. NOTES Content in the STANDARD was modified on 8/24/2017. b. Discuss the mistake with the parents/guardians of the child who was fed the wrong bottle: 4.3.1.5 1. Inform them that their child was given another Preparing, Feeding, and Storing Infant Formula child’s bottle of expressed human milk and the date it was given; Formula provided by parents/guardians or by the facility 2. Inform them that the risk of transmission of HIV should come in a factory-sealed container. The formula is low; should be of the same brand that is served at home and 3. Encourage the parents/guardians to notify the should be of ready-to-feed strength or liquid concentrate child’s primary health care provider of the potential to be diluted using cold water from a source approved by exposure; and the health department. Powdered infant formula, though it 4. Provide the family with information including the is the least expensive formula, requires special handling in time at which the milk was expressed and how the mixing because it cannot be sterilized. The primary source milk was handled prior to its being delivered to the for proper and safe handling and mixing is the manufac- caregiver/teacher so that the parents/guardians may turer’s instructions that appear on the can of powdered inform the child’s primary health care provider. formula. Before opening the can, hands should be washed. The can and plastic lid should be thoroughly rinsed and c. Assess why the wrong milk was given and develop a dried. Caregivers/teachers should read and follow the manu- prevention plan to be shared with the parents/guardians facturer’s directions. Caregivers/teachers should only use the as well as the staff in the facility. scoop that comes with the can and not interchange the scoop from one product to another, since the volume of the scoop RATIONALE may vary from manufacturer to manufacturer and product Hepatitis B and C are not spread through breastfeeding to product. Also, a scoop can be contaminated with a poten- (2,3). tial allergen from another type of formula. If instructions are The risk of HIV transmission from expressed human not readily available, caregivers/teachers should obtain infor- milk consumed by another child is believed to be mation from their local WIC program or the World Health low because: Organization’s Safe Preparation, Storage and Handling of a. Transmission of HIV from a single human milk Powdered Infant Formula Guidelines at: http://www.who.int/ foodsafety/publications/micro/pif_guidelines.pdf (1). exposure has never been documented (1); Formula mixed with cereal, fruit juice, or any other foods b. Chemicals present in human milk stored in cold should not be served unless the child’s primary care provider provides written documentation that the child has a medical temperatures, act to destroy the HIV present in reason for this type of feeding. expressed human milk; and Iron-fortified formula should be refrigerated until immedi- c. In the United States, women who know they are HIV- ately before feeding. For bottles containing formula, any positive are advised NOT to breastfeed their infants and contents remaining after a feeding should be discarded. to refrain from breastfeeding if they are hepatitis C- Bottles of formula prepared from powder or concentrate positive or have cracked or bleeding nipples. [However, or ready-to-feed formula should be labeled with the child’s the transmission of hepatitis C by breastfeeding has not full name and time and date of preparation. Any prepared been documented (4). formula must be discarded within one hour after serving to an infant. Prepared powdered formula that has not been TYPE OF FACILITY given to an infant should be covered, labeled with date and Center, Large Family Child Care Home time of preparation and child’s full name, and may be stored in the refrigerator for up to twenty-four hours. An open RELATED STANDARD container of ready-to-feed, concentrated formula, or 4.3.1.3 Preparing, Feeding, and Storing Human Milk formula prepared from concentrated formula, should be covered, refrigerated, labeled with date of opening
179 Chapter 4: Nutrition and Food Service and child’s full name, and discarded at forty-eight hours Diluted formula may interfere with an infant’s growth and if not used (2). The caregiver/teacher should always follow health because it provides inadequate calories and nutrients manufacturer’s instructions for mixing and storing of and can cause water intoxication. Water intoxication can any formula preparation. Some infants will require spe- occur in breastfed or formula-fed infants or children over cialized formula because of allergy, inability to digest one year of age who are fed an excessive amount of water. certain formulas, or need for extra calories. The appro- Water intoxication can be life-threatening to an infant or priate formula should always be available and should be young child (6).If a child has a special health problem, such fed as directed. For those infants getting supplemental as reflux, or inability to take in nutrients because of delayed calories, the formula may be prepared in a different way development of feeding skills, the child’s primary care pro- from the directions on the container. In those circum- vider should provide a written plan for the staff to follow so stances, either the family should provide the prepared that the child is fed appropriately. Some infants are allergic formula or the caregiver/teacher should receive special to milk and soy and need to be fed an elemental formula training, as noted in the infant’s care plan, on how to which does not contain allergens. Other infants need prepare the formula. Formula should not be used supplemental calories because of poor weight gain. beyond the stated shelf life period (3). Infants should not be fed a formula different from the one Parents/guardians should supply enough clean and steril- the parents/guardians feed at home, as even minor differ- ized bottles to be used throughout the day. The bottles must ences in formula can cause gastrointestinal upsets and be sanitary, properly prepared and stored, and must be the other problems (7). same brand in the early care and education program and at Excessive shaking of formula may cause foaming that home. Avoid bottles made of plastics containing bisphenol increases the likelihood of feeding air to the infant. A (BPA) or phthalates (sometimes labeled with #3, #6, or #7). Use glass bottles with a silicone sleeve (a silicone bottle TYPE OF FACILITY jacket to prevent breakage) or those made with safer plastics Center, Large Family Child Care Home such as polypropylene or polyethylene (labeled BPA-free) or plastics with a recycling code of #1, #2, #4, or #5. RELATED STANDARDS 4.3.1.1 General Plan for Feeding Infants RATIONALE 4.3.1.8 Techniques for Bottle Feeding Caregivers/teachers help in promoting the feeding of infant 4.3.1.9 Warming Bottles and Infant Foods formula that is familiar to the infant and supports family 5.2.9.9 Plastic Containers and Toys feeding practice. By following this standard, the staff is able, when necessary, to prepare formula and feed an infant References safely, thereby reducing the risk of inaccuracy or feeding the infant unsanitary or incorrect formula. Written guid- 1. World Health Organization. 2007. Safe preparation, storage and handling of ance for both staff and parents/guardians must be available powdered infant formula: Guidelines. http://www.who.int/foodsafety/ to determine when formula provided by parents/guardians publications/powdered-infant-formula/en/. will not be served. Formula cannot be served if it does not meet the requirements for sanitary and safe formula. 2. U.S. Department of Health & Human Services, U.S. Food & Drug Staff preparing formula should thoroughly wash their Administration. 2016. Food safety for moms to be: Once baby arrives. hands prior to beginning preparation of infant feedings College Park, MD. https://www.fda.gov/food/resourcesforyou/ of any type. Water used for mixing infant formula must healtheducators/ucm089629.htm. be from a safe water source as defined by the local or state health department. If the caregiver/teacher is concerned 3. Seltzer, H. 2012. U.S Department of Health & Human Services. Keeping or uncertain about the safety of the tap water, s/he should infant formula safe. https://www.foodsafety.gov/blog/infant_formula.html. “flush” the water system by running the tap on cold for 1-2 minutes or use bottled water (4). Warmed water should 4. Centers for Disease Control and Prevention. 2016. Water. https://www.cdc. be tested in advance to make sure it is not too hot for the gov/nceh/lead/tips/water.htm. infant. To test the temperature, the caregiver/teacher should shake a few drops on the inside of her/his wrist. A bottle 5. Seattle Children’s Hospital. 2014. Topics covered for formula feeding: Is this can be prepared by adding powdered formula and room your child’s symptoms? Seattle, WA. http://www.seattlechildrens.org/ temperature water from the tap just before feeding. Bottles medical-conditions/symptom-index/bottle-feeding-formula-questions/. made in this way from powdered formula can be ready for feeding as no additional refrigeration or warming would 6. Brown, J., Krasowski, M. D., & Hesse, M. 2015. Forced water intoxication: be required. A deadly form of child abuse. The Journal of Law Enforcement. 4(4). Adding too little water to formula puts a burden on an in- fant’s kidneys and digestive system and may lead to dehy- 7. United States Department of Agriculture, Food and Nutrition Service. 2017. dration (5). Adding too much water dilutes the formula. 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
180 Caring for Our Children: National Health and Safety Performance Standards from animals (ie, cow’s milk and other dairy products). Both NOTES soy-based formula and soy milk should be labeled with the Content in the STANDARD was modified on 05/30/2018. infant’s or child’s full name and date and stored properly. 4.3.1.7 Soy milk should be available for the children of parents/ Feeding Cow’s Milk guardians participating in the Special Supplemental Nutri- tion Program for Women, Infants, and Children (WIC); The facility should not serve cow’s milk to infants from Child and Adult Care Food Program; or Supplemental birth to 12 months of age, unless provided with a written Nutrition Assistance Program (SNAP). Caregivers/teachers exception and direction from the infant’s primary health should encourage parents/guardians of children with pri- care provider and parents/guardians. Children between mary health care provider–documented indications for soy 12 and 24 months of age can be served whole pasteurized formula, who are participating in WIC and/or SNAP, to milk (1). Children 2 years and older should be served low- learn how they can obtain soy-based infant formula or fat (1%) or nonfat (skim, fat-free) pasteurized milk (1). With soy milk products. proper documentation from a child’s primary health care provider, reduced fat (2%, 1%, nonfat) pasteurized milk RATIONALE may be served to those children who are at risk for high The American Academy of Pediatrics recommends use of cholesterol or obesity after 12 months of age (2). hypoallergenic or soy formula for infants who are allergic to cow’s milk proteins (1). Soy-based formula and soy milk RATIONALE are plant-based alternatives to cow’s milk, often chosen Milk provides many nutrients that are essential for the by parents/guardians due to dietary or religious reasons. growth and development of young children. The fat con- Soy-based formulas are appropriate for children with galac- tent in whole milk is critical for brain development as well tosemia or congenital lactose intolerance (2). Soy-based as satiety in children 12 to 24 months of age (3). For those formulas are made from soy protein isolate with added children whom overweight or obesity is a concern or who methionine, carbohydrates, and oils (soy or vegetable) have a family history of obesity, dyslipidemia, or early and are fortified with vitamins and minerals (3). In the cardiovascular disease, the primary health care provider United States, all soy-based formula is fortified with iron. may request low-fat or nonfat milk (2). Soy-based formula does not contain lactose, so it is used It is not recommended that children consume cow’s milk for feeding infants with documented congenital lactose in place of human (breast) milk or infant formula during intolerance. There are known differences between aller- the first year after birth (1,4). Some early care and educa- gies to cow’s milk proteins and intolerance to lactose. The tion programs have children between the ages of 18 months child’s specific health concerns (allergy versus intolerance) and 3 years in one classroom. To avoid errors in serving should be documented by the child’s primary health care inappropriate milk, programs can use individual milk pit- provider and not based on possible parental/guardian chers clearly labeled for each type of milk being served. misinterpretation of symptoms. Caregivers/teachers can explain to the children the mean- ing of the colored labels and identify which milk they TYPE OF FACILITY are drinking. Center, Large Family Child Care Home, Small Family Child Care Home TYPE OF FACILITY Center, Large Family Child Care Home RELATED STANDARDS 4.2.0.10 Care for Children with Food Allergies RELATED STANDARDS 4.2.0.12 Vegetarian/Vegan Diets 4.2.0.4 Categories of Foods 4.3.1.5 Preparing, Feeding, and Storing Infant Formula 4.2.0.10 Care for Children with Food Allergies 4.9.0.3 Precautions for a Safe Food Supply References References 1. Greer FR, Sicherer SH, Burks AW; American Academy of Pediatrics Committee on Nutrition and Section on Allergy and Immunology. Effects 1. Holt K, Wooldridge N, Story M, Sofka D. Bright Futures: Nutrition. 3rd ed. of early nutritional interventions on the development of atopic disease in Elk Grove Village, IL: American Academy of Pediatrics; 2011 infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. 2. Oldfield B, Misra S, Kwiterovich P. Prevention of cardiovascular disease in Pediatrics. 2008;121(1):183–191 pediatric populations. In: Wong ND, Amsterdam EA, Blumenthal RS, eds. ASPC Manual of Preventive Cardiology. New York, NY: Demos Medical 2. American Academy of Pediatrics. Where we stand: soy formulas. Publishing; 2015:184–194 HealthyChildren.org Web site. https://www.healthychildren.org/English/ ages-stages/baby/feeding-nutrition/Pages/Where-We-Stand-Soy-Formulas. 3. Singhal S, Baker RD, Baker SS. A comparison of the nutritional value of aspx. Updated November 21, 2015. Accessed November 14, 2017 cow’s milk and nondairy beverages. J Pediatr Gastroenterol Nutr. 2017;64(5):799–805 3. US Department of Agriculture. Infant feeding guide. WIC Works Web site. https://wicworks.fns.usda.gov/infants/infant-feeding-guide. Modified 4. American Academy of Pediatrics. Why formula instead of cow’s milk? October 31, 2017. Accessed November 14, 2017 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
181 Chapter 4: Nutrition and Food Service NOTES Children are at an increased risk for injury when they walk Content in the STANDARD was modified on 05/30/2018. around with bottle nipples in their mouths. Bottles should not be allowed in the crib or bed for safety and sanitary 4.3.1.8 reasons and for preventing dental caries. It is difficult for a Techniques for Bottle Feeding caregiver/teacher to be aware of and respond to infant feed- ing cues when the child is in a crib or bed and when feeding Infants should always be held for bottle feeding. Caregivers/ more than one infant at a time. Infants should be burped teachers should hold infants in the caregiver’s/teacher’s after every feeding and preferably during the feeding arms or sitting up on the caregiver’s/teacher’s lap. Bottles as well. should never be propped. The facility should not permit Caregivers/teachers should offer children fluids from a cup infants to have bottles in the crib. The facility should not as soon as they are developmentally ready. Some children permit an infant to carry a bottle while standing, walking, may be able to drink from a cup around six months of age, or running around. while for others it is later (6). Weaning a child to drink from Bottle feeding techniques should mimic approaches a cup is an individual process, which occurs over a wide to breastfeeding: range of time. The American Academy of Pediatric Den- a. Initiate feeding when infant provides cues (rooting, tistry (AAPD) recommends weaning from a bottle by the child’s first birthday (7). Instead of sippy cups, caregivers/ sucking, etc.); teachers should use smaller cups and fill halfway or less to b. Hold the infant during feedings and respond to vocal- 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. izations with eye contact and vocalizations; Some children around six months to a year of age may be c. Alternate sides of caregiver’s/teacher’s lap; developmentally ready to feed themselves and may want d. Allow breaks during the feeding for burping; to drink from a cup. The transition from bottle to cup can e. Allow infant to stop the feeding. come at a time when a child’s fine motor skills allow use of A caregiver/teacher should not bottle feed more than one a cup. The caregiver/teacher should use a clean small cup infant at a time. without cracks or chips and should help the child to lift and Bottles should be checked to ensure they are given to the tilt the cup to avoid spillage and leftover fluid. The caregiver/ appropriate child, have human milk, infant formula, or teacher and parent/guardian should work together on cup water in them. When using a bottle for a breastfed infant, feeding of human milk to ensure the child’s receiving ade- a nipple with a cylindrical teat and a wider base is usually quate nourishment and to avoid having a large amount of preferable. A shorter or softer nipple may be helpful for human milk remaining at the end of feeding. Two to three infants with a hypersensitive gag reflex, or those who ounces of human milk can be placed in a clean cup and cannot get their lips well back on the wide base of additional milk can be offered as needed. Small amounts the teat (1). of human milk (about an ounce) can be discarded. The use of a bottle or cup to modify or pacify a child’s behavior should not be allowed (2). TYPE OF FACILITY RATIONALE Center, Large Family Child Care Home The manner in which food is given to infants is con- ducive to the development of sound eating habits for life. RELATED STANDARDS Caregivers/teachers and parents/guardians need to under- 4.3.1.2 Feeding Infants on Cue by a Consistent stand the relationship between bottle feeding and emotional security. Caregivers/teachers should hold infants who are Caregiver/Teacher bottle feeding whenever possible, even if the children are 4.3.1.9 Warming Bottles and Infant Foods old enough to hold their own bottle. Caregivers/teachers should promote proper feeding practices and oral hygiene References including proper use of the bottle for all infants and tod- dlers. Bottle propping can cause choking and aspiration 1. Ben-Joseph, E. 2015. Formula feeding FAQs: Getting started. Nemours: and may contribute to long-term health issues, including KidsHealth. http://kidshealth.org/en/parents/formulafeed-starting.html# ear infections (otitis media), orthodontic problems, speech disorders, and psychological problems (3). When infants 2. Lerner, C., & Parlakian, R. 2016. Colic and crying. Zero to three. https:// and children are fed on cue, they are in control of frequency www.zerotothree.org/resources/197-colic-and-crying. and amount of feedings. This has been found to reduce the risk of childhood obesity. Any liquid except plain water can 3. American Academy of Pediatrics, Healthy Children. 2015. Practical bottle cause early childhood caries (4). Early childhood caries in feeding tips. https://www.healthychildren.org/English/ages-stages/baby/ primary teeth may hold significant short-term and long- feeding-nutrition/Pages/Practical-Bottle-Feeding-Tips.aspx. term implications for the child’s health (5). Frequently sipping any liquid besides plain water between feeds 4. American Academy of Pediatrics, Healthy Children. 2015. How to prevent encourages tooth decay. 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., N. Wooldridge, M. Story and D. Sofka. 2011. Bright futures nutrition. 3rd ed. Chicago: American Academy of Pediatrics. Print.
182 Caring for Our Children: National Health and Safety Performance Standards 4.3.1.9 References Warming Bottles and Infant Foods 1. US Department of Health and Human Services, US Food and Drug Bottles and infant foods do not have to be warmed; they can Administration. Food safety for moms to be: once baby arrives. https:// be served cold from the refrigerator. If a caregiver/teacher www.fda.gov/food/resourcesforyou/healtheducators/ucm089629.htm. chooses to warm them, bottles or containers of infant foods Updated November 8, 2017. Accessed January 11, 2018 should be warmed under running, warm tap water or by placing them in a container of water that is no warmer than 2. Cowan D, Ho B, Sykes KJ, Wei JL. Pediatric oral burns: a ten-year review of 120°F (49°C). Bottles should not be left in a pot of water patient characteristics, etiologies and treatment outcomes. Int J Pediatr to warm for more than 5 minutes. Bottles and infant foods Otorhinolaryngol. 2013;77(8):1325–1328 should never be warmed in a microwave oven because un- even hot spots in milk and/or food may burn the infant (1,2). 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- Infant foods should be stirred carefully to distribute the heat formula#.WlfPqWeWzct. Updated October, 2015. Accessed January 11, 2018 evenly. A caregiver/teacher should not hold an infant while removing a bottle or infant food from the container of warm NOTES water or while preparing a bottle or stirring infant food that Content in the STANDARD was modified on 11/5/2013, has been warmed in some other way. Bottles used for infant 8/25/2016 and 05/31/2018. feeding should be made of the following substances (3): 4.3.1.10 a. Bisphenol A (BPA)-free plastic; plastic labeled #1, #2, Cleaning and Sanitizing Equipment #4, or #5, or Used for Bottle Feeding b. Glass (a silicone sleeve/jacket covering a glass bottle to Caregivers/teachers should follow proper handwashing pro- prevent breakage is permissible). cedures prior to handling infant bottles. Bottles, bottle caps, nipples, and other equipment used for bottle-feeding should When a slow-cooking device, such as a crock-pot, is used be thoroughly cleaned after each use by washing in a dish- for warming human milk, infant formula, or infant food, washer or by washing with a bottlebrush, soap, and water (1). the device (and cord) should be out of children’s reach. The Nipples that are discolored, thinning, tacky, or ripped device should contain water at a temperature that does not should not be used. exceed 120°F (49°C), and be emptied, cleaned, sanitized, and refilled with fresh water daily. When a bottle warmer RATIONALE is used for warming human milk, infant formula, or infant Infant feeding bottles are contaminated by the infant’s saliva food, it should be out of children’s reach and used according during feeding. Formula and milk promote growth of bac- to manufacturer’s instructions. teria, yeast, and fungi (2). Bottles, bottle caps, and nipples that are reused should be washed and sanitized to avoid RATIONALE contamination from previous feedings. Excessive boiling Bottles of human milk or infant formula that are warmed of latex bottle nipples will damage them. at room temperature or in warm water for an inappro- priate period provide an ideal medium for bacteria to grow. ADDITIONAL RESOURCE Infants have received burns from hot water dripping from Feeding Infants: A Guide for Use in the Child Nutrition an infant bottle that was removed from a crock-pot or by Programs, US Department of Agriculture Food and pulling the crock-pot down on themselves by means of a Nutrition Service (https://www.fns.usda.gov/tn/ dangling cord. Caution should be exercised to avoid raising feeding-infants-guide-use-child-nutrition-programs) the water temperature above a safe level for warming infant formula or infant food. TYPE OF FACILITY Center, Large Family Child Care Home, Small Family ADDITIONAL RESOURCE Child Care Home Feeding Infants: A Guide for Use in the Child Nutrition Programs, US Department of Agriculture Food and RELATED STANDARDS Nutrition Service (https://www.fns.usda.gov/tn/ 4.3.1.1 General Plan for Feeding Infants feeding-infants-guide-use-child-nutrition-programs) 4.3.1.3 Preparing, Feeding, and Storing Human Milk 4.3.1.4 Feeding Human Milk to Another Mother’s Child TYPE OF FACILITY 4.3.1.5 Preparing, Feeding, and Storing Infant Formula Center, Large Family Child Care Home, Small Family 4.3.1.8 Techniques for Bottle Feeding Child Care Home References RELATED STANDARDS 4.3.1.3 Preparing, Feeding, and Storing Human Milk 1. Centers for Disease Control and Prevention. Water, sanitation & 4.3.1.5 Preparing, Feeding, and Storing Infant Formula environmentally- related hygiene. How to clean, sanitize, and store infant 4.3.1.8 Techniques for Bottle Feeding feeding items. https://www.cdc.gov/healthywater/hygiene/healthychildcare/ 4.3.1.12 Feeding Age-Appropriate Solid Foods to Infants 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.
183 Chapter 4: Nutrition and Food Service 4.3.1.11 developmentally ready may be associated with allergies Introduction of Age-Appropriate Solid Foods and digestive problems (5). Age-appropriate solid foods, to Infants such as meat and fortified cereals, are needed beginning at 6 months of age to make up for any potential losses in zinc A plan to introduce complementary, age-appropriate and iron during exclusive breastfeeding (3). Typically, low solid foods to infants should be made in consultation levels of vitamin D are transferred to infants via breast milk, with the child’s parent/guardian and primary health warranting the recommendation that breastfed or partially care provider. Complementary foods are foods other than breastfed infants receive a minimum daily intake of 400 IU human (breast) milk or infant formula (liquids, semisolids, of vitamin D supplementation beginning soon after birth and solids) introduced to an infant to provide nutrients(1). (6). These supplements are given at home by the parents/ Age-appropriate solid foods may be introduced at 6 months guardians, unless otherwise specified by the primary of age with the flexibility to introduce sooner or later based health care provider. on the child’s developmental status (2). However, recom- mendations on the introduction of complementary foods Many caregivers/teachers and parents/guardians believe that provided to caregivers of infants should take into account: infants sleep better when they start to eat age-appropriate • The infant’s developmental stage and nutritional status solid foods; however, research shows that longer sleeping • Coexisting medical conditions periods are developmentally (not nutritionally) determined • Social factors in mid-infancy and, therefore, shouldn’t be the sole reason • Cultural, ethnic, and religious food preferences of for deciding when to introduce solid foods to infants (7,8). Additionally, for infants who are exclusively formula fed or the family given a combination of formula and human milk, evidence • Financial considerations for introducing complementary foods in a specific order • Other pertinent factors discovered through the has not been established. nutrition assessment process (1) Good communication between the caregiver/teacher and For infants who are exclusively breastfed, the amount the parents/guardians cannot be overemphasized and is of certain nutrients in the body—such as iron and zinc— essential for successful feeding in general, including when begins to decrease after 6 months of age. Therefore, pureed and how to introduce age-appropriate solid foods. meats/meat substitutes and iron-fortified cereals should be gradually introduced first (3). Iron-fortified cereals, pureed ADDITIONAL RESOURCE meats, and pureed fruits/vegetables are all appropriate foods Feeding Infants: A Guide for Use in the Child Nutrition to introduce. The first food introduced should be a single- Programs, US Department of Agriculture Food and ingredient food that is served in a small portion for 2 to Nutrition Service (https://www.fns.usda.gov/tn/ 7 days (3). Gradually increase variety and portion of foods, feeding-infants-guide-use-child-nutrition-programs) one at a time, as tolerated by the infant (4). There are several signs that caregivers/teachers should use when determin- TYPE OF FACILITY ing when the infant is ready for solid foods. These include Center, Large Family Child Care Home, Small Family sitting up with minimal support, proper head control, ability Child Care Home to chew well, or grabbing food from the plate. Additionally, infants will lose the tongue-thrusting reflex and begin RELATED STANDARDS acting hungry after formula feeding or breastfeeding (3). 3.6.3.1 Medication Administration Caregivers/teachers should use or develop a take-home 4.2.0.7 100% Fruit Juice sheet for parents/guardians in which the caregiver/teacher 4.2.0.9 Written Menus and Introduction of New Foods records the food consumed, how much, and other impor- 4.2.0.10 Care for Children with Food Allergies tant notes on the infant, each day. Caregivers/teachers 4.2.0.12 Vegetarian/Vegan Diets should continue to consult with each infant’s parents/ 4.5.0.6 Adult Supervision of Children Who Are Learning guardians concerning which foods they have introduced and are feeding. When appropriate, modification of basic to Feed Themselves food patterns should be provided in writing by the infant’s 4.5.0.8 Experience with Familiar and New Foods primary health care provider. If nutritional supplements are to be given by caregivers/ References teachers, written orders from the prescribing health care provider should specify medical need, medication, dosage, 1. US Department of Agriculture, Food and Nutrition Service. Special and length of time to give medication. Supplemental Nutrition Program for Women, Infants, and Children (WIC). Chapter 5: Complementary foods. In: Infant Nutrition and Feeding. RATIONALE Washington, DC: US Department of Agriculture; 2009:101–128 https:// Early introduction of age-appropriate solid food and wicworks.fns.usda.gov/wicworks/Topics/FG/CompleteIFG.pdf. Accessed fruit juice interferes with the intake of human milk or January 11, 2018 iron-fortified formula that the infant needs for growth. Age-appropriate solid foods given before an infant is 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. American Academy of Pediatrics. Working together: breastfeeding and solid foods. HealthyChildren.org Web site. https://www.healthychildren.org/ English/ages-stages/baby/breastfeeding/Pages/Working-Together- Breastfeeding-and-Solid-Foods.aspx. Updated November 21, 2015. Accessed January 11, 2018
184 Caring for Our Children: National Health and Safety Performance Standards 4. World Health Organization. Infant and young child feeding. http://www. The external surface of a commercial container or jar may who.int/mediacentre/factsheets/fs342/en. Updated July 2017. Accessed be contaminated with disease-causing microorganisms January 11, 2018 during shipment or storage and may contaminate the food product during removal of food for placement in the child’s 5. Abrams EM, Becker AB. Introducing solid food: age of introduction and its serving dish. effect on risk of food allergy and other atopic diseases. Can Fam Physician. TYPE OF FACILITY 2013;59(7):721–722 Center, Large Family Child Care Home, Small Family Child Care Home 6. Thiele DK, Ralph J, El-Masri M, Anderson CM. Vitamin D3 supplemen- RELATED STANDARD tation during pregnancy and lactation improves vitamin D status of the 4.3.1.11 Introduction of Age-Appropriate Solid Foods mother-infant dyad. J Obstet Gynecol Neonatal Nurs. 2017;46(1):135–147 to Infants 7. Walsh A, Kearney L, Dennis N. Factors influencing first-time mothers’ References introduction of complementary foods: a qualitative exploration. BMC Public Health. 2015;15:939 1. Lester J. Nutrition 411: introducing solid foods. Promise powered by Nemours Children’s Health System Web site. https://blog.nemours.org/ 8. Robert Wood Johnson Foundation Healthy Eating Research. Feeding 2016/02/nutrition-411-introducing-solid-foods. Published February 22, Guidelines for Infants and Young Toddlers: A Responsive Parenting Approach. 2016. Accessed January 11, 2018 Guidelines for Health Professionals. http://healthyeatingresearch.org/ wp-content/uploads/2017/02/her_feeding_guidelines_brief_021416.pdf. 2. US Department of Agriculture. Food Safety and Inspection Service Web site. Published February 2017. Accessed January 11, 2018 https://www.fsis.usda.gov/wps/portal/fsis/home. Accessed January 11, 2018 NOTES 3. US Department of Health and Human Services. Baby food and infant Content in the STANDARD was modified on 05/31/2018. formula. Foodsafety.gov Web site. https://www.foodsafety.gov/keep/ types/babyfood/index.html. Accessed January 11, 2018 4.3.1.12 Feeding Age-Appropriate Solid Foods 4. US Department of Health and Human Services, US Food and Drug to Infants Administration. Food safety for moms to be: once baby arrives. https:// www.fda.gov/food/resourcesforyou/healtheducators/ucm089629.htm>. Caregivers/teachers should thoroughly wash hands prior Updated November 8, 2017. Accessed January 11, 2018 to serving any foods to infants/children. All jars of baby food should be washed with soap and warm water and 5. Robert Wood Johnson Foundation Healthy Eating Research. Feeding rinsed with clean, running warm water before opening. All Guidelines for Infants and Young Toddlers: A Responsive Parenting Approach. commercially packaged baby food should be served from a Guidelines for Health Professionals. http://healthyeatingresearch.org/ dish and spoon, not directly from a factory-sealed container wp-content/uploads/2017/02/her_feeding_guidelines_brief_021416.pdf. or jar (1). A dish should be cleaned and sanitized before use Published February 2017. Accessed January 11, 2018 to reduce the likelihood of surface contamination. Age-appropriate solid food should not be fed in a bottle 6. US Department of Agriculture Food and Nutrition Service. Feeding Infants: or an infant feeder unless doing so is written in the child’s A Guide for Use in the Child Nutrition Programs. Publication FNS-258. care plan by the child’s primary health care provider. Alexandria, VA: US Department of Agriculture; 2017. https://www.fns.usda. Caregivers/teachers should ensure that there are no food gov/tn/feeding-infants-guide-use-child-nutrition-programs. Accessed safety recalls (2), and examine the food carefully when January 11, 2018 removing it from the jar to make sure there are no glass pieces or foreign objects in the food. Caregivers/teachers NOTES should discard uneaten food left in dishes from which they Content in the STANDARD was modified on 05/31/2018. have fed a child because it may contain potentially harmful bacteria from the infant’s saliva (3). If left out, all food should 4.3.2 be discarded after 2 hours (4). The portion of the food that is NUTRITION FOR TODDLERS touched by a utensil should be consumed or discarded. Any food brought from home should not be served to AND PRESCHOOLERS other children. This will prevent cross contamination and reinforce the policy that food sent to the facility is for the 4.3.2.1 designated child only. Meal and Snack Patterns for Toddlers Food should not be shared among children using the and Preschoolers same dish or spoon. Unused portions in opened factory-sealed baby food Meals and snacks should contain the minimum amount containers or food brought in containers prepared at home of foods shown in the meal and snack patterns for toddlers should be stored in the refrigerator and discarded if not con- and preschoolers described in the Child and Adult Care sumed after 24 hours of storage. Prior to refrigeration, the Food Program (CACFP). opened container or jar should be labeled with the child’s full When incorporating CACFP, caregivers/teachers should (1): name and the date and time the food container was opened. • Provide a variety of fruits and vegetables. RATIONALE • Serve a fruit and/or vegetable during scheduled snacks. Feeding of age-appropriate solid foods in a bottle to a child • Provide one serving each of dark-green vegetables, is often associated with premature feeding (ie, when the infant is not developmentally ready for solid foods) (5,6). 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.
185 Chapter 4: Nutrition and Food Service Flavored milks contain higher amounts of added sugars 4.3.2.2 and should not be served. Facilities are encouraged to Serving Size for Toddlers and Preschoolers incorporate seasonal/locally produced foods into meals. Water should not be offered to children during mealtimes; The facility should serve toddlers and preschoolers small, instead, offer water throughout the day. age-appropriate portions. The facility should permit children With limited appetites and selective eating by toddlers and to have one or more additional servings of nutritious foods preschoolers, less nutritious foods should not be served that are low in fat, sugar, and sodium as required to meet the because they can displace more nutritious foods from the caloric needs of the individual child. Serving dishes should child’s diet. Early care and education settings should check contain, at minimum, the amount of food based on serving with state regulators about the timing between meals. State sizes or portions recommended for each child outlined in agencies may require any institution or facility to allow a the Child and Adult Care Food Program (CACFP). Young specific amount of time to elapse between meal services or children should learn what appropriate portion size is by require that meal services not exceed a specified duration (2). being served plates, bowls, and cups that are developmen- tally and age appropriate. RATIONALE Following CACFP guidelines ensures that all children Food service staff and/or a caregiver/teacher is responsible enrolled receive a greater variety of vegetables and fruits for preparing the amount of food based on the recommended and more whole grains and less added sugar and saturated age-appropriate amount of food per serving for each child fat during their meals while in care (3). Even during periods to be fed. Usually a reasonable amount of additional food is of slower growth, children must continue to eat nutritious prepared to respond to any spills or to children requesting foods. Picky or selective eating is common among toddlers. a second serving. They may decide to eat a meal/snack one day but not the next. Over time, with consistent exposure, toddlers are Children should continue to be exposed to new foods, more likely to accept new foods (4). textures, and tastes throughout infancy, toddlerhood, and preschool. Children should not be required or forced to eat ADDITIONAL RESOURCES any specific food items. Caregivers/teachers should create a supportive environment that promotes positive, sound US Department of Agriculture Food and Nutrition Service CACFP Nutrition eating behaviors (1). Standards for CACFP Meals and Snacks (www.fns.usda.gov/cacfp/meals-and- snacks) RATIONALE A child will not eat the same amount each day because US Department of Agriculture Healthy Tips for Picky Eaters (https://wicworks. appetites vary and food jags are common (2). Eating habits fns.usda.gov/wicworks/Topics/TipsPickyEaters.pdf) established in infancy and early childhood may contribute to optimal eating patterns later in life. These habits include TYPE OF FACILITY nutritious meals/snacks consumed in a pleasant, clean, sup- Center, Large Family Child Care Home, Small Family portive mealtime atmosphere with age-appropriate plates/ Child Care Home utensils (1). The quality of snacks for young and school-aged children is especially important, and small, frequent feedings RELATED STANDARDS are recommended to achieve the total desired daily intake. 4.2.0.3 Use of US Department of Agriculture Child and Strong evidence supports that larger plates, bowls, and cups, Adult Care Food Program Guidelines when paired with sustained long-term exposure of over- 4.2.0.4 Categories of Foods sized portions, promote overeating (3). Allowing children 4.2.0.5 Meal and Snack Patterns to decide how much to eat, through family-style dining, may also help promote self-regulation in children (3). References COMMENTS 1. US Department of Agriculture. Child and Adult Care Food Program: best The CACFP guidelines for meal and snack patterns can be practices. https://www.fns.usda.gov/sites/default/files/cacfp/CACFP_factBP. found at www.fns.usda.gov/cacfp/meals-and-snacks. pdf. Accessed January 11, 2018 TYPE OF FACILITY 2. US Department of Agriculture Food and Nutrition Service. Child and Adult Center, Large Family Child Care Home, Small Family Care Food Program: meal pattern revisions related to the Healthy, Hunger- Child Care Home 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. RELATED STANDARDS Accessed January 11, 2018 4.2.0.3 Use of US Department of Agriculture Child and 3. US Department of Agriculture Food and Nutrition Service. Independent Adult Care Food Program Guidelines Child Care Centers: A Child and Adult Care Food Program Handbook. 4.3.2.1 Meal and Snack Patterns for Toddlers and Washington, DC: US Department of Agriculture; 2014. https://fns-prod. azureedge.net/sites/default/files/cacfp/Independent%20Child%20Care%20 Preschoolers Centers%20Handbook.pdf. Accessed January 11, 2018 4.3.2.3 Encouraging Self-Feeding by Older Infants and 4. US Department of Agriculture. Updated Child and Adult Care Food Toddlers 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.
186 Caring for Our Children: National Health and Safety Performance Standards References 3. Williamson C, Beatty C. Weaning and childhood nutrition. InnovAiT. 2015;8(3):141–145 1. Mita SC, Gray SA, Goodell LS. An explanatory framework of teachers’ perceptions of a positive mealtime environment in a preschool setting. 4. Fewtrell M, Bronsky J, Campoy C, et al. Complementary feeding: a position Appetite. 2015;90:37–44 paper by the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) Committee on Nutrition. J PediatrGastroenterol 2. Green RJ, Samy G, Miqdady MS, et al. How to improve eating behavior dur- Nutr.2017;64(1):119–132 ing early childhood. Pediatric Gastroenterol Hepatol Nutr. 2015;18(1):1–9 NOTES 3. McCrickerd K, Leong C, Forde CG. Preschool children’s sensitivity to Content in the STANDARD was modified on 05/31/2018. teacher-served portion size is linked to age related differences in leftovers. Appetite. 2017;114:320–328 4.3.3 NUTRITION FOR SCHOOL-AGE CHILDREN NOTES Content in the STANDARD was modified on 05/31/2018. 4.3.3.1 Meal and Snack Patterns for School-Age 4.3.2.3 Children Encouraging Self-Feeding by Older Infants and Toddlers Meals and snacks should contain, at a minimum, the meal and snack patterns shown for school-aged children in the Caregivers/teachers should encourage older infants and Child and Adult Care Food Program (CACFP). Children toddlers to: attending facilities for 2 or more hours after school need • hold and drink from an appropriate child-sized cup, at least 1 snack. Breakfast, or a morning snack, is recom- • use a child-sized spoon (short handle with a shallow mended for all children enrolled in an early care and educa- tion facility or in school. Depending on age and length of bowl like a soup spoon), and time in care, snacks should occur 2 hours after a scheduled • use a child-sized fork (short, blunt tines and broad meal. Early care and education settings should check with state regulators about the timing between meals. State agen- handle, similar to a salad fork). cies may require any institution or facility to allow a specific All of which are developmentally appropriate for young amount of time to elapse between meal services or require children to feed themselves. Children can also use their that meal services not exceed a specified duration (1,2). The fingers for self-feeding. Children in group care should be quantity and quality of food provided should contribute provided with opportunities to serve and eat a variety of toward meeting children’s nutritional needs for the day food for themselves. Foods served should be appropriate to and should not lessen their appetites (3). the toddler’s developmental ability and cut small enough to RATIONALE avoid choking hazards. Early childhood is a time of rapid growth that increases the need for energy and essential nutrients to support optimal RATIONALE growth (2). Food intake may vary considerably because As children enter the second year after birth, they are this is a time when children express strong food likes and interested in doing things for themselves. Self-feeding dislikes. The CACFP requirements ensure that children in appropriately separates the responsibilities of adults and child care centers for longer than 8 hours (common in mili- children. The caregivers/teachers and parents/guardians tary child development centers, for example) are given the are responsible for providing nutritious food, and the child appropriate number of meals and snacks to meet individual is responsible for deciding how much of it to eat (1,2). To caloric and nutrient needs (1). allow for the proper development of motor skills and eat- COMMENTS ing habits, children need to be allowed to practice feeding The CACFP meal and snack pattern guidelines can be found themselves as early as 9 months of age (3,4). Children at www.fns.usda.gov/cacfp/meals-and-snacks. Programs ser- will continue to self-feed using their fingers even after ving children during the summer months can find the mastering the use of a utensil. recommendations of the Summer Food Service Program at https://www.fns.usda.gov/sfsp TYPE OF FACILITY summer-food-service-program. Center, Large Family Child Care Home, Small Family TYPE OF FACILITY Child Care Home Center, Large Family Child Care Home, Small Family Child Care Home RELATED STANDARDS References 4.3.2.2 Serving Size for Toddlers and Preschoolers 4.5.0.5 Numbers of Children Fed Simultaneously by 1. US Department of Agriculture Food and Nutrition Service. Child and Adult Care Food Program: meal pattern revisions related to the Healthy, Hunger- One Adult Free Kids Act of 2010. Final rule. Fed Regist. 2016;81(79):24347–24383. 4.5.0.6 Adult Supervision of Children Who Are Learning https://www.gpo.gov/fdsys/pkg/FR-2016-04-25/pdf/2016-09412.pdf. Accessed January 11, 2018 to Feed Themselves 4.5.0.10 Foods that Are Choking Hazards References 1. 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 2. 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
187 Chapter 4: Nutrition and Food Service 2. US Department of Agriculture Food and Nutrition Service. Independent day serves only food brought from home, food service staff Child Care Centers: A Child and Adult Care Food Program Handbook. is needed to oversee the appropriate use of such food. Washington, DC: US Department of Agriculture; 2014. https://fns-prod. COMMENTS azureedge.net/sites/default/files/cacfp/Independent%20Child%20Care%20 The food service staff may not necessarily consist of full-time Centers%20Handbook.pdf. Accessed January 11, 2018 or regular staff members but may include some workers hired on a consulting or contractual basis. Resources for 3. American Academy of Pediatrics Committee on Nutrition. Pediatric food service staff include vocational high school food prepa- Nutrition. Kleinman RE, Greer FR, eds. 7th ed. Elk Grove Village, IL: ration programs, university and community college food American Academy of Pediatrics; 2014 preparation programs, and trade schools that train cooks and chefs. NOTES TYPE OF FACILITY Content in the STANDARD was modified on 05/30/2018. Center, Large Family Child Care Home RELATED STANDARD 4.4 Appendix C: N utrition Specialist, Registered Dietitian, STAFFING Licensed Nutritionist, Consultant, and Food 4.4.0.1 Service Staff Qualifications Food Service Staff by Type of Facility and Food Service References Each center-based facility should employ trained staff 1. Benjamin, S. E., ed. 2007. Making food healthy and safe for children: How and provide ongoing supervision and consultation in to meet the national health and safety performance standards—Guidelines accordance with individual site needs as determined by for out of home child care programs. 2nd ed. Chapel Hill, NC: National the nutritionist/registered dietitian. In centers, prior work Training Institute for Child Care Health Consultants. http://nti.unc.edu/ experience in food service should be required for the soli- course_files/curriculum/nutrition/making_food_healthy_and_safe.pdf. tary worker responsible for food preparation without con- tinuous on-site supervision of a food service manager. For 2. Enders, J. B. 1994. Food, nutrition and the young child. New York: Merrill. facilities operating six or more hours a day or preparing 3. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. and serving food on the premises, the following food service staff requirements should apply: 6th ed. New York: McGraw-Hill. 4. Briley, M. E., C. Roberts-Gray. 1999. Position of the American Dietetic Setting Food Service Staff Association: Nutrition standards for child-care programs. J Am Diet Assoc Small and large family Caregiver/teacher and/or helper (note: some 99:981-88. child care homes large homes must have a helper) 5. U.S. Department of Agriculture (USDA), Food and Nutrition Service. 2009. USDA recipes for child care. http://teamnutrition.usda.gov/Resources/ Centers serving Full-time child care Food Service Worker childcare_recipes.html. up to 30 children (cook) 6. U.S. Department of Agriculture, Food and Nutrition Service. 2008. Food Buying Guide for Child Nutrition Programs. Rev ed. http://www.fns.usda. Centers serving Full-time child care Food Service Worker (cook) gov/tn/Resources/foodbuyingguide.html. up to 50 children and part-time child care Food Service Aide 4.4.0.2 Centers serving Full-time child care Food Service Manager or Use of Nutritionist/Registered Dietitian up to 125 children full-time child care Food Service Worker (cook) and full-time child care Food Service Aide A local nutritionist/registered dietitian, knowledgeable of the specific needs of infants and children, should work with Centers serving Full-time child care Food Service Manager and the on-site food service expert and the architect or engineer up to 200 children full-time child care Food Service Worker (cook) on the design of the parts of the facility involved in food and one full-time plus one part-time child care service. Additionally, the nutritionist/registered dietitian Food Service Aide should work with the food service expert and the early care and education staff to develop and to implement the facility’s Vendor food One assigned staff member or one part-time nutrition plan and to prepare the initial food service budget. service staff member, depending on amount of food The nutrition plan encompasses: service preparation needed after delivery a. Kitchen layout; b. Food budget and service; RATIONALE c. Food procurement and food storage; Trained personnel are essential workers in the food service d. Menu and meal planning (including periodic review of facilities to assure the maintenance of nutrition standards required in these facilities (1-6). Home cooking experience of menus); is not enough when large volumes of food must be served to e. Food preparation and service; children and adults. The type of food service, type of equip- f. Child feeding practices and policies; ment, number of children to be fed, location of the facility, g. Kitchen and mealtime staffing; and food budget determine the staffing patterns. An ade- h. Nutrition education for children, staff and parents/ quate number of food service personnel is essential to ensure that children are fed according to the facility’s daily guardians (including the prevention of childhood obesity schedule. If a facility that operates for six or more hours a and other chronic diseases, food learning experiences, and knowledge of choking hazards); i. Dietary modification plans.
188 Caring for Our Children: National Health and Safety Performance Standards RATIONALE 4.5 Efficient and cost-effective food service in a facility begins MEAL SERVICE, SEATING, with a plan and evaluation of the physical components of the facility. Planning for the food service unit includes consider- AND SUPERVISION ation of location and adequacy of space for receiving, stor- ing, preparing, and serving areas; cleaning up; dish washing; 4.5.0.1 dining areas, plus space for desk, telephone, records, and Developmentally Appropriate Seating employee facilities (such as handwashing sinks, toilets, and and Utensils for Meals lockers). All facets must be considered for new or existing sites, including remodeling or renovation of the unit (1-5). The child care staff should ensure that children who do not require highchairs are comfortably seated at tables that are COMMENTS between waist and mid-chest level and allow the seated Nutritionists/registered dietitians assist food service staff/ child’s feet to rest on a firm surface. caregivers/teachers in planning menus for meals/snacks All furniture and eating utensils that a child care facility consisting of healthy foods which meet CACFP guidelines; uses should make it possible for children to eat at their ensuring use of age-appropriate eating utensils and suitable best skill level and to increase their eating skill. furniture (tables, chairs) for children to sit comfortably RATIONALE while eating; addressing any dietary modification needed; Proper seating while eating reduces the risk of food providing training for staff and nutrition education for chil- aspiration and improves comfort in eating (7,9). dren and their parents/guardians; consulting on meeting Suitable furniture and utensils, in addition to providing local health department regulations and meeting local regu- comfort, enable the children to perform eating tasks lations when using an off-site food vendor. This standard is they have already mastered and facilitate the develop- primarily for Centers. ment of skill and coordination in handling food and utensils (4-6,8,9). TYPE OF FACILITY COMMENTS Center, Large Family Child Care Home Eating utensils should be unbreakable, durable, attractive, and suitable in function, size, and shape for use by chil- RELATED STANDARDS dren. Dining areas, whether in a classroom or in a separate area, should be clean and cheerful (1-6). 3.1.2.1 Routine Health Supervision and Growth Compliance can be measured by observing the fit of the Monitoring furniture for children. TYPE OF FACILITY 4.2.0.1 Written Nutrition Plan Center, Large Family Child Care Home RELATED STANDARD 4.2.0.2 Assessment and Planning of Nutrition for 4.5.0.2 Tableware and Feeding Utensils Individual Children References 4.2.0.8 Feeding Plans and Dietary Modifications 1. U.S. Department of Health and Human Services, Administration for Childrenand Families (ACF). 2006. Head Start Program Performance 9.2.3.11 Food and Nutrition Service Policies and Plans Standards and other Regulations. Rev ed. Washington, DC: ACF, Head Start Bureau. Appendix C: Nutrition Specialist, Registered Dietitian, Licensed Nutritionist, Consultant, and 2. Story, M., K. Holt, D. Sofka, eds. 2002. Bright futures in practice: Nutrition. Food Service Staff Qualifications 2nd ed. Arlington, VA: National Center for Education in Maternal and Child Health. http://www.brightfutures.org/nutrition/pdf/frnt_mttr.pdf. References 3. Benjamin, S. E., ed. 2007. Making food healthy and safe for children: How 1. Endres, J. B., R. E. Rockwell. 2003. Food, nutrition, and the young child. to meet the national health and safety performance standards – Guidelines 4th ed. New York: Macmillan. for out of home child care programs. 2nd ed. Chapel Hill, NC: National Training Institute for Child Care Health Consultants. http://nti.unc.edu/ 2. U.S. Department of Agriculture (USDA). 2002. Making nutrition count for course_files/curriculum/nutrition/making_food_healthy_and_safe.pdf. children - Nutrition guidance for child care homes. Washington, DC: USDA. http://www.gpo.gov/fdsys/pkg/ERIC-ED482991/pdf/ERIC-ED482991.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 3. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill. children - Nutrition guidance for child care homes. Washington, DC: USDA. http://www/gpo.gov/fdsys/pkg/ERIC-ED482991/pdf/ERIC- 4. Benjamin, S. E., K. A. Copeland, A. Cradock, E. Walker, M. M. Slining, B. ED482991.pdf. Neelon, M. W. Gillman. 2009. Menus in child care: A comparison of state 6. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. regulations to national standards. J Am Diet Assoc 109:109-15. 6th ed. New York: McGraw-Hill. 7. U.S. Department of Agriculture (USDA), Food and Nutrition Service. 5. Kaphingst, K. M., M. Story. 2009. Child care as an untapped setting for 2009. USDA recipes for child care. http://teamnutrition.usda.gov/ obesity prevention: State child care licensing regulations related to nutrition, Resources/childcare_recipes.html. physical activity, and media use for preschool-aged children in the United States. Prev Chronic Dis 6(1).
189 Chapter 4: Nutrition and Food Service 8. Hagan, Jr., J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Bright futures: disposable items eliminates the spread of contamination Guidelines for health supervision of infants, children, and adolescents. and disease and fosters safety and injury prevention. Single- 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics. service items are usually porous and should not be washed and reused. Items intended for reuse must be capable of 9. Fletcher, J., L. Branen, E. Price. 2005. Building mealtime environments and being washed, rinsed, and sanitized. relationships: An inventory for feeding young children in group settings. Medium-weight plastic should be chosen because lighter- Moscow, ID: University of Idaho. http://www.cals.uidaho.edu/feeding/pdfs/ weight plastic utensils are more likely to have sharp edges BMER.pdf. and break off small pieces easily. Sharp-edged plastic spoons can cut soft oral tissues, especially when an adult is feeding a 4.5.0.2 child and slides the spoon out of the child’s closed mouth. Tableware and Feeding Utensils Older children can cut their mouth tissues in the same way. Foam can break into pieces that can become choking Tableware and feeding utensils should meet the following hazards for young children. requirements: Imported dishware may be improperly fired and may a. Dishes should have smooth, hard, glazed surfaces and release toxic levels of lead into food. U.S. government stan- dards prevent the marketing of domestic dishes with lead should be free from cracks or chips. Sharp-edged plastic in their glazes. There is no safe level of lead in dishware. utensils (intended for use in the mouth) or dishes that have sharp or jagged edges should not be used; COMMENTS b. Imported dishes and imported ceramic dishware or Ideally, food should not be placed directly on highchair pottery should be certified by the regulatory health trays, as studies have shown that highchair trays can be authority to meet U.S. standards and to be safe from loaded with infectious microorganisms. If the highchair lead or other heavy metals before they can be used; tray is made of plastic, is in good repair, and is free from c. Disposable tableware (such as plates, cups, utensils made cracks and crevices, it can be made safe if it is washed and of heavy weight paper, food-grade medium- weight or sanitized before placing a child in the chair for feeding and BPA- or phthalates-free plastic) should be permitted for if the tray is washed and sanitized after each child has been single service if they are discarded after use. The facility fed. Food must not be placed directly on highchair trays should not use foam tableware for children under four made of wood or metal, other than stainless steel, to years of age (1,2); prevent contamination by infectious microorganisms d. Single-service articles (such as napkins, paper place- or toxicity from metals. mats, paper tablecloths, and paper towels) should be If there is a question about whether tableware is safe and discarded after one use; sanitary, consult the regulatory health authority or local e. Washable bibs, placemats, napkins, and tablecloths, if health department. used, should be laundered or washed, rinsed, and sani- tized after each meal. Fabric articles should be sanitized TYPE OF FACILITY by being machine-washed and dried after each use; Center, Large Family Child Care Home f. Highchair trays, plates, and all items used in food service that are not disposable should be washed, rinsed, RELATED STANDARDS and sanitized. Highchair trays that are used for eating 4.9.0.9 Cleaning Food Areas and Equipment should be washed, rinsed, and sanitized just before and 5.2.9.9 Plastic Containers and Toys immediately after they are used for eating. Children who eat at tables should have disposable or washed and References sanitized plates for their food; g. All surfaces in contact with food should be lead-free (3); 1. Eco-Healthy Child Care. 2016. Plastics & plastic toys. http://cehn.org/ h. Tableware and feeding utensils should be child-sized wpcontent/uploads/2015/12/Plastics_Plastic_Toys_6_16.pdf. and developmentally appropriate. RATIONALE 2. Safer Chemicals, Healthy Families. 2017. Styrene and styrofoam 101. Clean food service utensils, napkins, bibs, and tablecloths http://saferchemicals.org/2014/05/26/styrene-and-styrofoam-101-2/. prevent the spread of microorganisms that can cause disease. The surfaces that are in contact with food must 3. Center for Disease Control and Prevention. 2017. Lead. https://www.cdc. be sanitary. gov/nceh/lead/. Food should not be put directly on the table surface for two reasons. First, even washed and sanitized tables are more 4. Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. likely to be contaminated than disposable plates or washed Recommendations for care of children in special circumstances. In: and sanitized dishes. Second, eating from plates reduces Red Book: 2015 Report of the Committee on Infectious Diseases. 30th Ed. contamination of the table surface when children put Elk Grove Village, IL: American Academy of Pediatrics. 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
190 Caring for Our Children: National Health and Safety Performance Standards 4.5.0.3 7. Dennison, B. A., T. A. Erb, P. L. Jenkins. 2002. Television viewing and Activities that Are Incompatible with Eating television in bedroom associated with overweight risk among low-income preschool children. Pediatrics 109:1028-35. Children should be seated when eating. Caregivers/teachers should ensure that children do not eat when standing, 8. Mendoza, J. A., F. J. Zimmerman, D. A. Christakis. 2007. Television walking, running, playing, lying down, watching TV, viewing, computer use, obesity, and adiposity in US preschool children. playing on the computer, participating in arts and crafts Int J Behav Nutr Physical Activity 4, no. 44 (September 25).http://ijbnpa. projects that do not involve food, or riding in vehicles. org/content/4/1/44/. Children should not be allowed to continue to feed them- 9. Art and Creative Materials Institute. 2010. Safety - what you need to know. selves or continue to be assisted with feeding themselves if http://www.acminet.org/Safety.htm. they begin to fall asleep while eating. Caregivers/teachers should check that no food is left in a child’s mouth before 10. U.S. Consumer Product Safety Commission (CPSC). Art and craft safety laying a child down to sleep. guide. Bethesda, MD: CPSC. http://www.cpsc.gov/cpscpub/pubs/5015. pdf. RATIONALE Seating children, while they are eating, reduces the risk NOTES of aspiration (1-5). Eating while doing other activities Content in the STANDARD was modified on 8/25/2016. (including playing, walking around, or sitting at a com- puter) limits opportunities for socialization during meals 4.5.0.4 and snacks. Eating while watching television is associated Socialization During Meals with an increased risk of obesity (6-8). Continuing to eat while falling asleep puts the child at great risk for gagging Caregivers/teachers and children should sit at the table and or choking. eat the meal or snack together. Family style meal service, with the serving platters, bowls, and pitchers on the table COMMENTS so all present can serve themselves, should be encouraged, Staff can role model appropriate eating behaviors by sitting except for infants and very young children who require an down when they are eating and eating “family style” with adult to feed them. A separate utensil should be used for the children when possible. serving. Children should not handle foods that they will not be consuming. The adults should encourage, but not For additional information, see Building Mealtime force, the children to help themselves to all food compo- Environments and Relationships: An Inventory for Feeding nents offered at the meal. When eating meals with children, Young Children in Group Settings (http://www.cals.uidaho. the adult(s) should eat items that meet nutrition standards. edu/feeding/pdfs/BMER.pdf). The adult(s) should encourage social interaction and con- versation, using vocabulary related to the concepts of color, TYPE OF FACILITY shape, size, quantity, number, temperature of food, and Center, Large Family Child Care Home events of the day. Extra assistance and time should be provided for slow eaters. Eating should be an enjoyable RELATED STANDARDS experience at the facility and at home. 2.2.0.3 Screen Time/Digital Media Use Special accommodations should be made for children who 4.5.0.4 Socialization During Meals cannot have the food that is being served. Children who 4.5.0.10 Foods that Are Choking Hazards need limited portion sizes should be taught and monitored. 5.2.9.7 Proper Use of Art and Craft Materials RATIONALE “Family style” meal service promotes and supports social, References emotional, and gross and fine motor skill development. Caregivers/teachers sitting and eating with children is an 1. Benjamin, S. E., ed. 2007. Making food healthy and safe for children: opportunity to engage children in social interactions with How to meet the national health and safety performance standards— each other and for positive role-modeling by the adult care- Guidelines for out of home child care programs. 2nd ed. Chapel Hill, NC: giver/teacher. Conversation at the table adds to the pleasant National Training Institute for Child Care Health Consultants. http://nti. mealtime environment and provides opportunities for in- unc.edu/course_files/curriculum/nutrition/making_food_healthy_and_ formal modeling of appropriate eating behaviors, commu- safe.pdf. nication about eating, and imparting nutrition learning experiences (1-3,5-7). The presence of an adult or adults, 2. Lally, J. R., A. Griffin, E. Fenichel, M. Segal, E. Szanton, B. Weissbourd. who eat with the children, helps prevent behaviors that 2003. Caring for infants and toddlers in groups: Developmentally increase the possibility of fighting, feeding each other, appropriate practice. Arlington, VA: Zero to Three. stuffing food into the mouth and potential choking, and other negative behaviors. The future development of chil- 3. Endres, J. B., R. E. Rockwell. 2003. Food, nutrition, and the young child. dren depends, to no small extent, on their command of 4th ed. New York: Macmillan. language. Richness of language increases as adults and peers nurture it (5). Family style meals encourage children 4. U.S. Department of Agriculture (USDA). 2002. Making nutrition count to serve themselves which develops their eye-hand coordi- for children—Nutrition guidance for child care homes. Washington, DC: nation (3-5). In addition to being nourished by food, infants USDA. http://www.gpo.gov/fdsys/pkg/ERIC-ED482991/pdf/ERIC- and young children are encouraged to establish warm ED482991.pdf. human relationships by their eating experiences. When children lack the developmental skills for self-feeding, they 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.
191 Chapter 4: Nutrition and Food Service will be unable to serve food to themselves. An adult seated TYPE OF FACILITY at the table can assist and be supportive with self-feeding so Center, Large Family Child Care Home the child can eat an adequate amount of food to promote growth and prevent hunger. RELATED STANDARDS 4.3.1.2 Feeding Infants on Cue by a Consistent COMMENTS Compliance is measured by structured observation. Use of Caregiver/Teacher small pitchers, a limited number of portions on service 4.3.2.2 Serving Size for Toddlers and Preschoolers plates, and adult assistance to enable children to success- 4.3.2.3 Encouraging Self-Feeding by Older Infants fully serve themselves helps to make family style service possible without contamination or waste of food. and Toddlers 4.5.0.4 Socialization During Meals TYPE OF FACILITY 4.5.0.6 Adult Supervision of Children Who Are Learning Center, Large Family Child Care Home to Feed Themselves RELATED STANDARDS 4.3.2.2 Serving Size for Toddlers and Preschoolers 4.5.0.6 4.3.2.3 Encouraging Self-Feeding by Older Infants Adult Supervision of Children Who Are Learning to Feed Themselves and Toddlers 4.7.0.1 Nutrition Learning Experiences for Children Children in mid-infancy who are learning to feed them- selves should be supervised by an adult seated within arm’s References reach of them at all times while they are being fed. Children over twelve months of age who can feed themselves should 1. U.S. Department of Health and Human Services, Administration for be supervised by an adult who is seated at the same table or Children and Families, Office of Head Start. 2009. Head Start program within arm’s reach of the child’s highchair or feeding table. performance standards. Rev. ed. Washington, DC: U.S. Government When eating, children should be within sight of an adult Printing Office. http://eclkc.ohs.acf.hhs.gov/hslc/HeadStartProgram/ at all times. ProgramDesignandManagement/Head Start Requirements/Head Start Requirements/45 CFR Chapter XIII/45 CFR Chap XIII_ENG.pdf. RATIONALE A supervising adult should watch for several common 2. Benjamin, S. E., ed. 2007. Making food healthy and safe for children: How problems that typically occur when children in mid-in- to meet the national health and safety performance standards—Guidelines fancy begin to feed themselves. “Squirreling” of several for out of home child care programs. 2nd ed. Chapel Hill, NC: National pieces of food in the mouth increases the likelihood of Training Institute for Child Care Health Consultants. http://nti.unc.edu/ choking. A choking child may not make any noise, so course_files/curriculum/nutrition/making_food_healthy_and_safe.pdf. adults must keep their eyes on children who are eating. Active supervision is imperative. Supervised eating also 3. Endres, J. B., R. E. Rockwell. 2003. Food, nutrition, and the young child. promotes the child’s safety by discouraging activities that 4th ed. New York: Macmillan. can lead to choking (1). For best practice, children of all ages should be supervised when eating. Adults can monitor 4. U.S. Department of Agriculture (USDA). 2002. Making nutrition count for age-appropriate portion size consumption. children - Nutrition guidance for child care homes. Washington, DC: USDA. http://www.gpo.gov/fdsys/pkg/ERIC-ED482991/pdf/ERIC-ED482991.pdf COMMENTS Adults can help children while they are learning, by model- 5. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. ing active chewing (i.e., eating a small piece of food, show- 6th ed. New York: McGraw-Hill. ing how to use their teeth to bite it) and making positive comments to encourage children while they are eating. 6. Branscomb, K. R., C. B. Goble 2008. Infants and toddlers in group care: Adults can demonstrate how to eat foods on the menu, Feeding practices that foster emotional health. Young Children 63:28-33. 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 7. Sigman-Grant, M., E. Christiansen, L. Branen, J. Fletcher, S. L. Johnson. pass the bowl of noodles”). 2008. About feeding children: Mealtimes in child-care centers in four western states. J Am Diet Assoc 108:340-46. TYPE OF FACILITY Center, Large Family Child Care Home 4.5.0.5 Numbers of Children Fed Simultaneously RELATED STANDARDS by One Adult 4.3.2.3 Encouraging Self-Feeding by Older Infants One adult should not feed more than one infant or three and Toddlers children who need adult assistance with feeding at the 4.5.0.4 Socialization During Meals same time. 4.5.0.5 Numbers of Children Fed Simultaneously by RATIONALE One Adult 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 care- giver/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.
192 Caring for Our Children: National Health and Safety Performance Standards Reference 4.5.0.9 Hot Liquids and Foods 1. American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement: Prevention of choking among Adults should not consume hot liquids above 120°F in child children. Pediatrics 125:601-7. care areas (3). Hot liquids and hot foods should be kept out of the reach of infants, toddlers, and preschoolers. Hot 4.5.0.7 liquids and foods should not be placed on a surface at a Participation of Older Children and Staff child’s level, at the edge of a table or counter, or on a table- in Mealtime Activities cloth that could be yanked down. Appliances containing hot liquids, such as coffee pots and crock pots, should be Both older children and staff should be actively involved kept out of the reach of children. Electrical cords from any in serving food and other mealtime activities, such as appliance, including coffee pots, should not be allowed to setting and cleaning the table. Staff should supervise and hang within the reach of children. Food preparers should assist children with appropriate handwashing procedures position pot handles toward the back of the stove and use before and after meals and sanitizing of eating surfaces only back burners when possible. and utensils to prevent cross contamination. RATIONALE RATIONALE The most common burn suffered by young children is Children develop social skills and new motor skills as well scalding from hot liquids tipped over in the kitchen (1). The as increase their dexterity through this type of involvement. skin of young children is much thinner than that of adults Children require close supervision by staff and other adults and can burn at temperatures that adults find comfortable when they use knives and have contact with food surfaces (2). In a recent study, 90.4% of scald injuries to children and food that other children will use. under age five were related to hot cooking or drinking COMMENTS liquids (4). Compliance is measured by structured observation. COMMENTS TYPE OF FACILITY Hot liquids can cause burns to young children at the follow- Center, Large Family Child Care Home ing rates of contact: one second at 156°F, two seconds at RELATED STANDARDS 149°F, five seconds at 140°F, fifteen seconds at 133°F, 4.5.0.4 Socialization During Meals five minutes at 120°F (2). TYPE OF FACILITY 4.5.0.8 Center, Large Family Child Care Home Experience with Familiar and New Foods References In consultation with the family and the nutritionist/ 1. Ring, L. M. 2007. Kids and hot liquids-A burning reality. J of Pediatric registered dietitian, caregivers/teachers should offer chil- Health Care 21:192-94. dren familiar foods that are typical of the child’s culture and religious preferences and should also introduce a 2. Children’s Safety Association of Canada. Safety fact sheet: Scald burns. variety of healthful foods that may not be familiar, but http://www.safekid.org/scald.htm. meet a child’s nutritional needs. Experiences with new foods can include tasting and swallowing but also include 3. Turner, C., A. Spinks, R. J. McClure, J. Nixon. 2004. Community-based engagement of all senses (seeing, smelling, speaking, etc.) interventions for the prevention of burns and scalds in children. Cochrane to facilitate the introduction of these new foods. Database Systematic Rev (2). RATIONALE By learning about new food, children increase their knowl- 4. Lowell, G., K. Quinlan, L. J. Gottlieb. 2008. Pediatrics 122:799-804. edge of the world around them, and the likelihood that they will choose a more varied, better balanced diet in later life. 4.5.0.10 Eating habits and attitudes about food formed in the early Foods that Are Choking Hazards years often last a lifetime. New food acceptance may take eight to fifteen times of offering a food before it is eaten (1). Caregivers/teachers should not offer to children under four TYPE OF FACILITY years of age foods that are associated with young children’s Center, Large Family Child Care Home choking incidents (round, hard, small, thick and sticky, RELATED STANDARDS smooth, compressible or dense, or slippery). Examples of 4.2.0.9 Written Menus and Introduction of New Foods these foods are hot dogs and other meat sticks (whole or 4.3.1.11 Introduction of Age-Appropriate Solid Foods sliced into rounds), raw carrot rounds, whole grapes, hard candy, nuts, seeds, raw peas, hard pretzels, chips, peanuts, to Infants popcorn, rice cakes, marshmallows, spoonfuls of peanut Reference butter, and chunks of meat larger than can be swallowed whole. Food for infants should be cut into pieces one- 1. Sullivan, S. A., L. L. Birch. 1990. Pass the sugar, pass the salt: Experience quarter inch or smaller, food for toddlers should be cut dictates preference. Developmental Psychology 26:546-51. 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).
193 Chapter 4: Nutrition and Food Service RATIONALE RATIONALE High-risk foods are those often implicated in choking inci- Children who are forced to eat or, for whom adults use dents (1,9,10). Almost 90% of fatal choking occurs in chil- food to modify behavior, come to view eating as a tug-of- dren younger than four years of age (2-7). Peanuts may war and are more likely to develop lasting food dislikes and block the lower airway. A chunk of hot dog or a whole seed- unhealthy eating behaviors. Offering food as a reward or less grape may completely block the upper airway (2-8,10). punishment places undue importance on food and may The compressibility or density of a food item is what allows have negative effects on the child by promoting “clean the the food to conform to and completely block the airway. plate” responses that may lead to obesity or poor eating Hot dogs are the foods most commonly associated with behavior (1-5). fatal choking in children. COMMENTS COMMENTS All components of the meal should be offered at the same To reduce the risk of choking, menus should reflect the devel- time, allowing children to select and enjoy all of the foods opmental abilities of the age of children served. Because it is on the menu. normal for children to get their first teeth at a widely variable TYPE OF FACILITY age, menus must take into account not only the ages of chil- Center, Large Family Child Care Home dren but also their teeth, or lack thereof. This becomes References particularly important with those whose teeth come in late. Foods considered otherwise appropriate for one year-olds 1. U.S. Department of Health and Human Services, Administration for with a full complement of teeth may need to be reevaluated Children and Families, Office of Head Start. 2009. Head Start program for the child whose first tooth has just emerged. Lists of high- performance standards. Rev. ed. Washington, DC: U.S. Government risk foods should be made available. The presence of molars Printing Office. http://eclkc.ohs.acf.hhs.gov/hslc/HeadStartProgram/ is a good indication of a healthy child’s ability to chew hard Program Design and Management/Head Start Requirements/ foods that are likely to cause choking (such as raw carrot HeadStartRequirements/45 CFR Chapter XIII/45 CFR Chap XIII_ENG.pdf. rounds). To date, raisins appear to be safe, but, as when eating all foods, children should be seated and supervised. 2. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove TYPE OF FACILITY Village, IL: American Academy of Pediatrics. Center, Large Family Child Care Home References 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 1. Rimell, F. L., A. Thome Jr., S. Stool, et al. 1995. Characteristics of objects of Pediatrics. that cause choking in children. JAMA 274:1763-66. 4. Benjamin, S. E., ed. 2007. Making food healthy and safe for children: How to 2. Benjamin, S. E., ed. 2007. Making food healthy and safe for children: meet the national health and safety performance standards – Guidelines for How to meet the national health and safety performance standards— out of home child care programs. 2nd ed. Chapel Hill, NC: National Guidelines for out of home child care programs. 2nd ed. Chapel Hill, NC: Training Institute for Child Care Health Consultants. http://nti.unc.edu/ National Training Institute for Child Care Health Consultants. http://nti. course_files/curriculum/nutrition/making_food_healthy_and_safe.pdf. 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 3. Dietz, W.H., L. Stern, eds. 1998. Guide to your child’s nutrition. Elk Grove hunger. Am J Clin Nutr 78:215-20. Village, IL: American Academy of Pediatrics. 4.6 4. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk FOOD BROUGHT FROM HOME Grove Village, IL: American Academy of Pediatrics. 4.6.0.1 5. Enders, J. B. 1994. Food, nutrition and the young child. New York: Merrill. Selection and Preparation of Food Brought 6. U.S. Department of Agriculture (USDA). 2002. Making nutrition count From Home for children—Nutrition guidance for child care homes. Washington, DC: The parent/guardian may provide meals for the child upon USDA. http://www/gpo.gov/fdsys/pkg/ERIC-ED482991/pdf/ERIC- written agreement between the parent/guardian and the ED482991.pdf. staff. Food brought into the facility should have a clear label 7. U.S. Department of Agriculture (USDA), Child and Adult Care Food showing the child’s full name, the date, and the type of Program (CACFP). 2002. Menu magic for children: A menu planning food. Lunches and snacks the parent/guardian provides guide for child care. Washington, DC: USDA. http://www.fns.usda.gov/ for one individual child’s meals should not be shared with tn/resources/menu_magic.pdf. other children. When foods are brought to the facility from 8. Baker, S. B., R. S. Fisher. 1980. Childhood asphyxiation by choking or home or elsewhere, these foods should be limited to those suffocation. JAMA 244:1343-46. listed in the facility’s written policy on nutritional quality 9. Morley, R. E., J. P. Ludemann, J. P. Moxham, F. K. Kozak, K. H. Riding. of food brought from home. Potentially hazardous and 2004. Foreign body aspiration in infants and toddlers: Recent trends in perishable foods should be refrigerated and all foods British Columbia. J Otolaryngology 33:37-41. should be protected against contamination. 10. American Academy of Pediatrics, Committee on Injury, Violence, and RATIONALE Poison Prevention. 2010. Policy statement: Prevention of choking among Food borne illness and poisoning from food is a common children. Pediatrics 125:601-7. occurrence when food has not been properly refrigerated and covered. Although many such illnesses are limited to 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.
194 Caring for Our Children: National Health and Safety Performance Standards vomiting and diarrhea, sometimes they are life-threatening. and children. Caregivers/teachers who fail to follow best Restricting food sent to the facility to be consumed by the feeding practices, even when parents/guardians wish such individual child reduces the risk of food poisoning from counter practices to be followed, negate their basic respon- unknown procedures used in home preparation, storage, and sibility of protecting a child’s health, social, and emotional transport. Food brought from home should be nourishing, well-being. clean, and safe for an individual child. In this way, other COMMENTS children should not be exposed to unknown risk.Inadvertent Some local health and/or licensing jurisdictions prohibit sharing of food is a common occurrence in early care and any foods being brought from home. education. The facility has an obligation to ensure that any TYPE OF FACILITY food offered to children at the facility or shared with other Center, Large Family Child Care Home children is wholesome and safe as well as complying with the RELATED STANDARDS food and nutrition guidelines for meals and snacks 4.2.0.1 Written Nutrition Plan that the early care and education program should observe. 4.6.0.1 Selection and Preparation of Food Brought COMMENTS From Home The facility, in collaboration with parents/guardians and the 9.2.3.11 Food and Nutrition Service Policies and Plans food service staff/nutritionist/registered dietitian, should References establish a policy on foods brought from home for celebrat- ing a child’s birthday or any similar festive occasion. Pro- 1. Sweitzer, S., M. E. Briley, C. Robert-Gray. 2009. Do sack lunches provided by grams should inform parents/guardians about healthy food parents meet the nutritional needs of young children who attend child care? alternatives like fresh fruit cups or fruit salad for such cele- J Am Diet Assn 109:141-44. brations. Sweetened treats are highly discouraged, but if provided by the parent/guardian, then the portion size of 2. Contra Costa Child Care Council, Child Health and Nutrition Program. the treat served should be small. 2006. CHOICE: Creating healthy opportunities in child care environments. Concord, CA: Contra Costa Child Care Council, Child Health and TYPE OF FACILITY Nutrition Program. http://w2.cocokids.org/_cs/downloadables/cc- Center, Large Family Child Care Home healthnutrition-choicetoolkit.pdf. RELATED STANDARDS 4.7 4.6.0.2 Nutritional Quality of Food Brought From Home NUTRITION LEARNING EXPERIENCES 9.2.3.11 Food and Nutrition Service Policies and Plans FOR CHILDREN AND 4.6.0.2 NUTRITION EDUCATION Nutritional Quality of Food Brought From FOR PARENTS/GUARDIANS Home 4.7.0.1 The facility should provide parents/guardians with written Nutrition Learning Experiences for Children guidelines that the facility has established a comprehensive plan to meet the nutritional requirements of the children in The facility should have a nutrition plan that integrates the the facility’s care and suggested ways parents/guardians can introduction of food and feeding experiences with facility assist the facility in meeting these guidelines. The facility activities and home feeding. The plan should include should develop policies for foods brought from home, with opportunities for children to develop the knowledge parent/guardian consultation, so that expectations are the and skills necessary to make appropriate food choices. same for all families (1,2). The facility should have food For centers, this plan should be a written plan and should available to supplement a child’s food brought from home be the shared responsibility of the entire staff, including if the food brought from home is deficient in meeting directors and food service personnel, together with parents/ the child’s nutrient requirements. If the food the parent/ guardians. The nutrition plan should be developed with guardian provides consistently does not meet the nutri- guidance from, and should be approved by, the nutritionist/ tional or food safety requirements, the facility should registered dietitian or child care health consultant. provide the food and refer the parent/guardian for con- Caregivers/teachers should teach children about the sultation to a nutritionist/registered dietitian, to the child’s taste, smell, texture of foods, and vocabulary and language primary care provider, or to community resources with skills related to food and eating. The children should have trained nutritionists/registered dietitians (such as The the opportunity to feel the textures and learn the different Women, Infants and Children [WIC] Supplemental Food colors, sizes, and shapes of foods and the nutritional bene- Program, extension services, and health departments). fits of eating healthy foods. Children should also be taught about appropriate portion sizes. The teaching should be RATIONALE evident at mealtimes and during curricular activities, and The caregiver/teacher/facility has a responsibility to emphasize the pleasure of eating. Caregivers/teachers need follow feeding practices that promote optimum nutrition supporting growth and development in infants, toddlers,
195 Chapter 4: Nutrition and Food Service to be aware that children between the ages of two- and five- c. The Women, Infants, and Children (WIC) Supple- years-old are often resistant to trying new foods and that mental Food Program and cooperative extension food acceptance may take eight to fifteen times of offering nutritionists/RDs; a food before it is eaten (14). d. School food service personnel; RATIONALE e. State administrators of the Child and Adult Care Nourishing and attractive food is a foundation for develop- mentally appropriate learning experiences and contributes Food Program; to health and well-being (1-13,15). Coordinating the learn- f. National School Food Service Management Institute; ing experiences with the food service staff maximizes effec- g. Healthy Meals Resource System of the Food and Nutri- tiveness of the education. In addition to the nutritive value of food, infants and young children are helped, through tion Information System (National Agricultural Library, the act of feeding, to establish warm human U.S. Department of Agriculture); relationships. Eating should be an enjoyable experience h. Nutrition consultants with local affiliates of the for children and staff in the facility and for children and following organizations: parents/guardians at home. Enjoying and learning about 1. American Dietetic Association; food in childhood promotes good nutrition habits for 2. American Public Health Association; a lifetime (17,18). 3. Society for Nutrition Education; 4. American Association of Family and Consumer COMMENTS Parents/guardians and caregivers/teachers should always be Sciences; encouraged to sit at the table and eat the same food offered 5. Dairy Council; to young children as a way to strengthen family style eating 6. American Heart Association; which supports child’s serving and feeding him or herself 7. American Cancer Society; (19). Family style eating requires special training for the 8. American Diabetes Association; food service and early care and education staff since they 9. Professional home economists like teachers need to monitor food served in a group setting. Portions should be age-appropriate as specified in Child and Adult and those with consumer organizations; Care Food Program (CACFP) guidelines. The use of ser- 10. Nutrition departments of local colleges and ving utensils should be encouraged to minimize food handling by children. Children should not eat directly universities. out of serving dishes or storage containers. The presence of an adult at the table with children while they are eating Compliance is measured by structured observation. is a way to encourage social interaction and conversation about the food such as its name, color, texture, taste, and Following are select resources for caregivers/teachers in concepts such as number, size, and shape; as well as sharing providing ongoing opportunities for children and their events of the day. These are some practical examples of age- families to learn about food and healthy eating: appropriate information for young children to learn about the food they eat. The parent/guardian or adult can help a. Brieger, K. M. 1993. Cooking up the Pyramid: An early the slow eater, prevent behaviors that might increase risk childhood nutrition curriculum. Pine Island, NY: of fighting, of eating each other’s food, and of stuffing food Clinical Nutrition Services. in the mouth in such a way that it might cause choking. Several community-based nutrition resources can help b. Cunningham, M. 1995. Cooking with children: caregivers/teachers with the nutrition and food service 15 lessons for children, age 7 and up, who really want component of their programs (16-18). The key to identify- to learn to cook. New York: Alfred A. Knopf. ing a qualified nutrition professional is seeking a record of training in pediatric nutrition (normal nutrition, nutrition c. Goodwin, M. T., G. Pollen. 1980. Creative food for children with special health care needs, dietary modifi- experiences for children. Rev. ed. Washington, DC: cations) and experience and competency in basic food Center for Science in the Public Interest. service systems. Local resources for nutrition education include: d. King, M. 1993. Healthy choices for kids: Nutrition and a. Local and state nutritionists/RDs in health departments, activity education program based on the US Dietary Guidelines. Levels 1-3 and 4-5. Wenatchee, WA: The in maternal and child health programs, and divisions of Growers of Washington State Apples. children with special health care needs; b. Nutritionists/RDs at hospitals; TYPE OF FACILITY Center, Large Family Child Care Home RELATED STANDARDS 2.1.1.2 Health, Nutrition, Physical Activity, and Safety Awareness 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 9.2.3.11 Food and Nutrition Service Policies and Plans
196 Caring for Our Children: National Health and Safety Performance Standards Appendix C: Nutrition Specialist, Registered Dietitian, into obesity prevention programming. Informal programs Licensed Nutritionist, Consultant, and should be implemented during teachable moments Food Service Staff Qualifications throughout the year. References RATIONALE One goal of a facility is to provide a positive environment for 1. U.S. Department of Health and Human Services, Administration for the entire family. Informing parents/guardians about nutri- Children and Families, Office of Head Start. 2009. Head Start program tion, food, food preparation, and mealtime enhances nutri- performance standards. Rev. ed. Washington, DC: U.S. Government tion and mealtime interactions in the home, which helps to Printing Office. http://eclkc.ohs.acf.hhs.gov/hslc/HeadStart Program/ mold a child’s food habits and eating behavior (1-3). Because Program Design and Management/Head Start Requirements/Head Start of the current epidemic of childhood obesity, prevention of Requirements/45 CFR Chapter XIII/45 CFR Chap XIII_ENG.pdf. childhood obesity through nutrition and physical activity is an appropriate topic for parents/guardians. Periodically 2. Hagan, Jr., J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Bright futures: providing families records of the food eaten and progress in Guidelines for health supervision of infants, children, and adolescents. physical activities by their children will help families coordi- 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics. nate home food preparation, nutrition, and physical activity with what is provided at the early care and education facility. 3. Story, M., K. Holt, D. Sofka, eds. 2002. Bright futures in practice: Nutrition. Nutrition education directed at parents/guardians comple- 2nd ed. Arlington, VA: National Center for Education in Maternal and ments and enhances the nutrition learning experiences pro- Child Health. http://www.brightfutures.org/nutrition/pdf/frnt_mttr.pdf. vided to their children. Similarly, bedtime routines are an important facet of a child’s physical, social, and emotional 4. Wardle, F., N. Winegarner. 1992. Nutrition and Head Start. Child Today health and development. Interestingly, sleep time has a 21:57. bigger effect on children’s weight than awake time (4). 5. Benjamin, S. E., ed. 2007. Making food healthy and safe for children: COMMENTS How to meet the national health and safety performance standards – One method of nutrition education for parents/guardians Guidelines for out of home child care programs. 2nd ed. Chapel Hill, NC: is providing healthy recipes that are quick and inexpensive National Training Institute for Child Care Health Consultants. http://nti. to prepare. Another is sharing information about access to unc.edu/course_files/curriculum/nutrition/making_food_healthy_and_ local sources of healthy foods (eg, farmers’ markets, grocery safe.pdf. stores, healthier prepared foods and restaurant options). Also, caregivers/teachers can provide parents/guardians 6. Dietz, W., L. Birch. 2008. Eating behaviors of young child: Prenatal and ideas for healthy and inexpensive snacks, including foods postnatal influences on healthy eating. Elk Grove Village, IL: American available and served at parents’/guardians’ meetings. Educa- Academy of Pediatrics. tion should be helpful and culturally relevant and incorpo- rate the use of locally produced food. Educate parents/ 7. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. guardians that an early bedtime is defined as 8:00 pm or Elk Grove Village, IL: American Academy of Pediatrics. earlier and is associated with fewer parent/guardian- and teacher-reported incidences and attention-deficient issues 8. Lally, J. R., A. Griffin, E. Fenichel, M. Segal, E. Szanton, B. Weissbourd. (4,5). Decreased sleep duration with accompanying sleep- 2003. Caring for infants and toddlers in groups: Developmentally related issues is associated with impaired social-emotional appropriate practice. Arlington, VA: Zero to Three. and cognitive function that can increase risk of childhood/ adolescent obesity (6). Nutrition education programs may 9. Endres, J. B., R. E. Rockwell. 2003. Food, nutrition, and the young child. be supplemented by periodic distribution of newsletters 4th ed. New York: Macmillan. and sharing Web sites and/or materials. 10. Stang, J., C. T. Bayerl, M. M. Flatt. 2006. Position of the American TYPE OF FACILITY Dietetic Association: Child and adolescent food and nutrition programs. Center, Large Family Child Care Home, Small Family J American Dietetic Assoc 106:1467-75. Child Care Home 11. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. RELATED STANDARDS 6th ed. New York: McGraw-Hill. 2.4.1.1 Health and Safety Education Topics for Children 4.7.0.1 Nutrition Learning Experiences for Children 12. William, C. O., ed. 1998. Pediatric manual of clinical dietetics. Chicago: American Dietetic Association. References 13. Tamborlane, W. V., J. Warshaw, eds. 1997. The Yale guide to children’s 1. US Department of Health and Human Services, Administration for Children nutrition. New Haven, CT: Yale University Press. and Families, Head Start Early Childhood Learning and Knowledge Center. Head Start policy & regulations. Subchapter B—the administration for 14. Sullivan, S. A., L. L. Birch. 1990. Pass the sugar, pass the salt: Experience children and families, Head Start program. https://eclkc.ohs.acf.hhs.gov/ dictates preference. Devel Psych 26:546-51. policy/45-cfr-chap-xiii. Accessed November 14, 2017 15. Murph, J. R., S. D. Palmer, D. Glassy, eds. 2005. Health in child care: 2. Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health A manual for health professionals. Elk Grove Village, IL: American Supervision of Infants, Children, and Adolescents. 4th ed. Elk Grove Village, Academy of Pediatrics. IL: American Academy of Pediatrics; 2017 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 informa- tion and education as perceived by families and staff. The importance of healthy sleep habits should be incorporated
197 Chapter 4: Nutrition and Food Service 3. American Academy of Pediatrics Committee on Nutrition. Pediatric dren may be encouraged to help with developmentally Nutrition. Kleinman RE, Greer FR, eds. 7th ed. Elk Grove Village, IL: appropriate food preparation, which increases the American Academy of Pediatrics; 2014 likelihood that they will eat new foods. TYPE OF FACILITY 4. Anderson SE, Andridge R, Whitaker RC. Bedtime in preschool-aged children Center, Large Family Child Care Home and risk for adolescent obesity. J Pediatr. 2016;176:17–22 RELATED STANDARD Appendix C: Nutrition Specialist, Registered Dietitian, 5. Kobayashi K, Yorifuji T, Yamakawa M, et al. Poor toddler-age sleep schedules predict school-age behavioral disorders in a longitudinal Licensed Nutritionist, Consultant, and survey. Brain Dev. 2015;37(6):572–578 Food Service Staff Qualifications Reference 6. Bonuck KA, Schwartz B, Schechter C. Sleep health literacy in Head Start families and staff: exploratory study of knowledge, motivation, and 1. Ring, L. M. 2007. Kids and hot liquids–A burning reality. J Pediatric Health competencies to promote healthy sleep. Sleep Health. 2016;2(1):19–24 Care 21:192-94. NOTES 4.8.0.2 Content in the STANDARD was modified on 05/30/2018. Design of Food Service Equipment 4.8 Food service equipment should be designed, installed, KITCHEN AND EQUIPMENT operated, and maintained according to the manufacturer’s instructions and in a way that meets the performance, 4.8.0.1 health, and safety standards of the National Sanitation Food Preparation Area Foundation (1) or applicable State or local public health authority, or the U.S. Department of Agriculture (USDA) The food preparation area of the kitchen should be separate food program and sanitation codes (3), as determined by from eating, play, laundry, toilet, and bathroom areas and the regulatory public health authority. from areas where animals are permitted. The food prepara- RATIONALE tion area should not be used as a passageway while food is The design, installation, operation, and maintenance of being prepared. Food preparation areas should be separated food service equipment must follow the manufacturer’s by a door, gate, counter, or room divider from areas the instructions and meet the standards for such equipment to children use for activities unrelated to food, except in ensure that the equipment protects the users from injury small family child care homes when separation may and the consumers of foods prepared with this equipment limit supervision of children. from foodborne disease (1,2). The manufacturer’s warranty Infants and toddlers should not have access to the kitchen that equipment will meet recognized standards is valid in child care centers. Access by older children to the kitchen only if the equipment is properly maintained. of centers should be permitted only when supervised by COMMENTS staff members who have been certified by the nutritionist/ Inspectors from state and local agencies with appropriate registered dietitian or the center director as qualified to training should check food service equipment and provide follow the facility’s sanitation and safety procedures. technical assistance to facilities. The local public health In all types of child care facilities, children should never department typically conducts such inspections. Manufac- be in the kitchen unless they are directly supervised by a turers should attest to their compliance with equipment caregiver/teacher. Children of preschool-age and older should standards of the National Sanitation Foundation (NSF) be restricted from access to areas where hot food is being pre- and the Code of Federal Regulations, Part 200, Section pared. School-age children may engage in food preparation 354.210 (revised January 1990). Testing labs such as Under- activities with adult supervision in the kitchen or the class- writers Laboratories (UL) also test food service equipment. room. Parents/guardians and other adults should be permit- Before making a purchase, child care facilities should check ted to use the kitchen only if they know and follow the food not only the warranty but also the maintenance instruc- safety rules of the facility. The facility should check with local tions provided by the equipment manufacturer to be sure health authorities about any additional regulations that apply. the required maintenance is feasible, given the facility’sre- RATIONALE sources. If the facility receives inspections from the public The presence of children in the kitchen increases the risk of health department, the facility may want to consult with contamination of food and the risk of injury to children from them before making a pur- chase. The facility director or burns. Use of kitchen appliances and cooking techniques may food service staff should retain maintenance instructions require more skill than can be expected for children’s devel- and check to be sure that all users of the equipment follow opmental level. The most common burn in young children the instructions. 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 chil-
198 Caring for Our Children: National Health and Safety Performance Standards TYPE OF FACILITY RATIONALE Center Separation of sinks used for handwashing or other poten- References tially contaminating activities from those used for food preparation prevents contamination of food. Hot and cold 1. National Sanitation Foundation. 2007. Commercial cooking, rethermali- running water are essential for thorough cleaning and zation and powered hot food holding, and transport equipment, ANSI/NSF sanitizing of equipment and utensils and cleaning of 4. Ann Harbor, MI: National Sanitation Foundation. the facility. TYPE OF FACILITY 2. National Restaurant Association. 2008. ServSafe essentials. 5th ed. Upper Center, Large Family Child Care Home Saddle River, NJ: Prentice Hall. RELATED STANDARDS 4.9.0.13 Methods for Washing Dishes by Hand 3. U.S. Department of Health and Human Services, Public Health Service, 5.2.1.14 Water Heating Devices and Temperatures Allowed Food and Drug Administration (FDA). 2009. 2009 Food code. College Park, MD: FDA. http://www.fda.gov/downloads/Food/FoodSafety/ 4.8.0.5 RetailFoodProtection/FoodCode/FoodCode2009/UCM189448.pdf. Handwashing Sink Separate from Food Zones 4.8.0.3 Centers should provide a separate handwashing sink in Maintenance of Food Service Surfaces the food preparation area of the facility. It should have an and Equipment eight-inch-high splash guard or have eighteen inches of space between the handwashing sink and any open food All surfaces that come into contact with food, including zones (such as preparation tables and food sink). tables and countertops, as well as floors and shelving in Where continuous warm water pressure is not available, the food preparation area should be in good repair, free of handwashing sinks should have at least thirty seconds of cracks or crevices, and should be made of smooth, nonpo- continuous flow of warm water to initiate and complete rous material that is kept clean and sanitized. All kitchen handwashing. equipment should be clean and should be maintained in RATIONALE operable condition according to the manufacturer’s guide- Separation of sinks used for handwashing or other lines for maintenance and operation. The facility should potentially contaminating activities from those used for maintain an inventory of food service equipment that food preparation prevents contamination of food. includes the date of purchase, the warranty date, and a Proper handwashing requires a continuous flow of water, history of repairs. no less than 100°F and no more than 120°F, for at least RATIONALE thirty seconds to allow sufficient time for wetting and Cracked or porous materials should be replaced because rinsing the hands (1). they trap food and other organic materials in which micro- TYPE OF FACILITY organisms can grow (1). Harsh scrubbing of these areas Center tends to create even more areas where organic material RELATED STANDARD can lodge and increase the risk of contamination. Repairs 3.2.2.2 Handwashing Procedure with duct tape, package tapes, and other commonly used Reference materials add surfaces that trap organic materials. Food service equipment is designed by the manufacturer for 1. U.S. Department of Health and Human Services, Public Health Service, specific types of use. The equipment must be maintained Food and Drug Administration (FDA). 2009. 2009 Food code. College to meet those performance standards or food will become Park, MD: FDA. http://www.fda.gov/downloads/Food/FoodSafety/ contaminated and spoil (1). An accurate and ongoing RetailFoodProtection/FoodCode/FoodCode2009/UCM189448.pdf. inventory of food service equipment tracks maintenance requirements and can provide important information 4.8.0.6 when a breakdown occurs. Maintaining Safe Food Temperatures TYPE OF FACILITY Center, Large Family Child Care Home The facility should use refrigerators that maintain food Reference temperatures of 41°F or lower in all parts of the food stor- age areas, and freezers should maintain temperatures 1. National Restaurant Association. 2008. ServSafe essentials. 5th ed. of 0°F or lower in food storage areas. Upper Saddle River, NJ: Prentice Hall. Thermometers with markings in no more than 2° incre- ments should be provided in all refrigerators, freezers, 4.8.0.4 ovens, and holding areas for hot and cold foods. Food Preparation Sinks Thermometers should be clearly visible, easy to read, and accurate, and should be kept in working condition and The sink used for food preparation should not be used for regularly checked. Thermometers should be mercury free. 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 sup- plied with hot and cold running water under pressure.
199 Chapter 4: Nutrition and Food Service RATIONALE If the odor of gas is present when the pilot lights are on, Storage of food at proper temperatures minimizes bacterial turn off gas and immediately call a qualified gas technician, growth (1). commercial gas provider, or local gas, electric or utility The use of accurate thermometers to monitor temperatures provider. Never use an open flame to locate a gas leak. at which food is cooked and stored helps to ensure food TYPE OF FACILITY safety. Hot foods must be checked to be sure they reach Center temperatures that kill microorganisms in that type of food. Cold foods must be checked to see that they are References being maintained at temperatures that safely retard the growth of bacteria. Thermometers with larger than 2° 1. American Society of Heating, Refrigeration and Air Conditioning increments, are hard to read accurately. Engineers. 2007. ASHRAE handbook: HVAC applications. Atlanta, GA: ASHRAE. COMMENTS Refrigerator and freezer thermometers are widely available 2. Clark, J. 2003. Commercial kitchen ventilation design: What you need to in stores and over the Internet. They are available in both know. http://www.esmagazine.com/Articles/Feature_ digital and analog forms. Providing thermometers with a Article/229549b01fca8010VgnVCM100000f932a8c0. dual scale in Fahrenheit and Celsius will avoid the necessity for a child care provider to convert temperature scales. 4.8.0.8 Microwave Ovens TYPE OF FACILITY Center, Large Family Child Care Home Microwave ovens should be inaccessible to all children, with the exception of school-age children under close adult RELATED STANDARD supervision. Any microwave oven in use in a child care Appendix U: Recommended Safe Minimum Internal facility should be manufactured after October 1971 and should be in good condition. While the microwave is Cooking Temperatures being used, it should not be left unattended. If foods need to be heated in a microwave: Reference a. Avoid heating foods in plastic containers; b. Avoid transferring hot foods/drinks into plastic 1. Food Marketing Institute, U.S. Department of Agriculture, Food Safety and Inspection Service. 1996. Facts about food and floods: A consumer guide to containers; food quality and safe handling after a flood or power outage. Washington, c. Do not use plastic wrap or aluminum foil in the DC: Food Marketing Institute. microwave; 4.8.0.7 d. Avoid plastics for food and beverages labeled “3” (PVC), Ventilation Over Cooking Surfaces “6” (PS), and “7” (polycarbonate); In centers using commercial cooking equipment to e. Stir food before serving to prevent burns from hot spots. prepare meals, ventilation should be equipped with an RATIONALE exhaust system in compliance with the applicable building, Young children can be burned when their faces come mechanical, and fire codes. These codes may vary slightly near the heat vent. The issues involved with the safe use with each locale, and centers are responsible to ensure their of microwave ovens (such as no metal and steam trapping) facilities meet the requirements of these codes (1-2). make use of this equipment by preschool-age children too All gas ranges in centers should be mechanically vented risky. Older ovens made before the Federal standard went and fumes filtered prior to discharge to the outside. All into effect in October 1971 can expose users or passers-by vents and filters should be maintained free of grease to microwave radiation. If adults or school-age children use build-up and food spatters, and in good repair. a microwave, it is recommended that they do not heat food in plastic containers, plastic wrap or aluminum foil due to RATIONALE concerns of releasing toxic substances even if the container Properly maintained vents and filters control odor, fire is specified for use in a microwave (1). hazards, and fumes. COMMENTS An exhaust system must collect fumes and grease-laden If school-age children are allowed to use a microwave oven vapors properly at their source. in the facility, this use should be closely supervised by an adult to avoid injury. See Standard 4.3.1.9 for prohibition COMMENTS of use of microwave ovens to warm infant feedings. The center should refer to the owner’s manual of the TYPE OF FACILITY exhaust system for a description of capture velocity. Com- Center, Large Family Child Care Home mercial cooking equipment refers to the type of equipment RELATED STANDARDS that is typically found in restaurants and other food service 4.3.1.9 Warming Bottles and Infant Foods businesses. 5.2.9.9 Plastic Containers and Toys Proper construction of the exhaust system duct-work assures that grease and other build-up can be easily accessed and cleaned.
200 Caring for Our Children: National Health and Safety Performance Standards Reference Staff members may not contact exposed, ready-to-eat food with their bare hands and should use suitable utensils such 1. Institute for Agriculture and Trade Policy (IATP), Food and Health as deli tissue, spatulas, tongs, single-use gloves, or dispens- Program. 2005. Smart plastics guide: Healthier food uses of plastics for ing equipment. No one with open or infected skin erup- parents and children. Minneapolis, MN: IATP. tions should work in the food preparation area unless the injuries are covered with nonporous (such as latex or vinyl), 4.9 single use gloves. FOOD SAFETY In centers and large family child care homes, staff members 4.9.0.1 who are involved in the process of preparing or handling Compliance with U.S. Food and Drug food should not change diapers. Staff members who work Administration Food Sanitation Standards, with diapered children should not prepare or serve food State and Local Rules for older groups of children. When staff members who are caring for infants and toddlers are responsible for The facility should conform to the applicable portions of changing diapers, they should handle food only for the the U.S. Food and Drug Administration model food sani- infants and toddlers in their groups and only after thor- tation standards (1) and all applicable state and local food oughly washing their hands. Caregivers/teachers who service rules and regulations for centers and large and small prepare food should wash their hands carefully before family child care homes regarding safe food protection and handling any food, regardless of whether they change sanitation practices. If federal model standards and local diapers. When caregivers/teachers must handle food, regulations are in conflict, the health authority with juris- staffing assignments should be made to foster completion diction should determine which requirement the facility of the food handling activities by caregivers/teachers of must meet. older children, or by caregivers/teachers of infants and RATIONALE toddlers before the caregiver/teacher assumes other care- Minimum standards for food safety are based on current giving duties for that day. Aprons worn in the food service scientific data that demonstrate the conditions required to area must be clean and should be removed when diaper prevent contamination of food with infectious and toxic changing or when using the toilet. substances that cause foodborne illness. Many of these standards have been placed in statutes and must be RATIONALE complied with by law. Food handlers who are ill can easily transmit their illness Federal, state, and local food safety codes, regulations, and to others by contaminating the food they prepare with the standards may be in conflict. In these circumstances, the infectious agents they are carrying. Frequent and proper decision of the regulatory health authority should prevail. handwashing before and after using plastic gloves reduces COMMENTS food contamination (1,2,4). Caregivers/teachers who work The U.S. Food and Drug Administration’s (FDA) Model with infants and toddlers are frequently exposed to feces Food Code is a good resource to have on hand. The current and to children with infections of the intestines (often Food Code is available at http://www.fda.gov/downloads/ with diarrhea) or of the liver. Education of child care staff Food/FoodSafety/RetailFoodProtection/FoodCode/ regarding handwashing and other cleaning procedures can FoodCode2009/UCM189448.pdf. reduce the occurrence of illness in the group of children TYPE OF FACILITY with whom they work (1,2,4). Center, Large Family Child Care Home Reference The possibility of involving a larger number of people in a foodborne outbreak is greater in child care than in most 1. U.S. Department of Health and Human Services, Public Health Service, households. Cooking larger volumes of food requires spe- Food and Drug Administration (FDA). 2009. 2009 Food code. College Park, cial caution to avoid contamination of the food with even MD: FDA. http://www.fda.gov/downloads/Food/FoodSafety/ small amounts of infectious materials. With larger volumes RetailFoodProtection/FoodCode/FoodCode2009/UCM189448.pdf. of food, staff must exercise greater diligence to avoid con- tamination because larger quantities of food take longer 4.9.0.2 to heat or to cool to safe temperatures. Larger volumes of Staff Restricted from Food Preparation food spend more time in the danger zone of temperatures and Handling (between 41°F and 135°F) where more rapid multiplication of microorganisms occurs (3). Anyone who has signs or symptoms of illness, including vomiting, diarrhea, and infectious skin sores that cannot be TYPE OF FACILITY covered, or who potentially or actually is infected with Center, Large Family Child Care Home bacteria, viruses or parasites that can be carried in food, should be excluded from food preparation and handling. RELATED STANDARDS 3.2.2.1 Situations that Require Hand Hygiene 3.2.2.2 Handwashing Procedure 3.2.2.3 Assisting Children with Hand Hygiene
201 Chapter 4: Nutrition and Food Service 3.2.2.4 Training and Monitoring for Hand Hygiene and using the defrost setting of a microwave oven (5). 3.2.2.5 Hand Sanitizers Note: Frozen human milk should not be defrosted in References the microwave; i. Frozen foods should never be defrosted by leaving them 1. Cowell, C., S. Schlosser. 1998. Food safety in infant and preschool day care. at room temperature or standing in water that is not Top Clin Nutr 14:9-15. kept at refrigerator temperature (5); j. All fruits and vegetables should be washed thoroughly 2. U.S. Department of Agriculture (USDA), Food Safety and Inspection Service. with water prior to use (5); 2000. Keeping kids safe: A guide for safe handling and sanitation, for child k. Food should be served promptly after preparation or care providers. Rev ed. Washington, DC: USDA. http://teamnutrition.usda. cooking or should be maintained at temperatures of not gov/resources/appendj.pdf. less than 135°F for hot foods and not more than 41°F for cold foods (12); 3. U.S. Department of Health and Human Services, Public Health Service, l. All opened moist foods that have not been served should Food and Drug Administration (FDA). 2009. 2009 Food code. College be covered, dated, and maintained at a temperature of Park, MD: FDA. http://www.fda.gov/downloads/Food/FoodSafety/ 41°F or lower in the refrigerator or frozen in the freezer, RetailFoodProtection/FoodCode/FoodCode2009/UCM189448.pdf. verified by a working thermometer kept in the refrigera- tor or freezer (12); 4. U.S. Department of Health and Human Services, U.S. Department of m. Fully cooked and ready-to-serve hot foods should be Agriculture. 2010. Dietary guidelines for Americans, 2010. 7th ed. held for no longer than thirty minutes before being Washington, DC: U.S. Government Printing Office. http://www.health.gov/ served, or promptly covered and refrigerated; dietaryguidelines/dga2010/DietaryGuidelines2010.pdf. n. Pasteurized eggs or egg products should be substituted for raw eggs in the preparation of foods such as Caesar 4.9.0.3 salad, mayonnaise, meringue, eggnog, and ice cream. Precautions for a Safe Food Supply Pasteurized eggs or egg products should be substituted for recipes in which more than one egg is broken and All foods stored, prepared, or served should be safe for the eggs are combined, unless the eggs are cooked for human consumption by observation and smell (1-2). an individual child at a single meal and served immedi- The following precautions should be observed for a safe ately, such as in omelets or scrambled eggs; or the raw food supply: eggs are combined as an ingredient immediately before a. Home-canned food; food from dented, rusted, bulging, baking and the eggs are fully cooked to a ready-to-eat form, such as a cake, muffin or bread; or leaking cans, and food from cans without labels o. Raw animal foods should be fully cooked to heat all should not be used; parts of the food to a temperature and for a time of; b. Foods should be inspected daily for spoilage or signs of 145°F or above for fifteen seconds for fish and meat; mold, and foods that are spoiled or moldy should be 160°F for fifteen seconds for chopped or ground fish, promptly and appropriately discarded; chopped or ground meat or raw eggs; or 165°F or above c. Meat should be from government-inspected sources or for fifteen seconds for poultry or stuffed fish, stuffed otherwise approved by the governing health authority (3); meat, stuffed pasta, stuffed poultry or stuffing contain- d. All dairy products should be pasteurized and Grade A ing fish, meat or poultry. where applicable; e. Raw, unpasteurized milk, milk products; unpasteurized RATIONALE fruit juices; and raw or undercooked eggs should not be Safe handling of all food is a basic principle to prevent and used. Freshly squeezed fruit or vegetable juice prepared reduce foodborne illnesses (14). For children, a small dose just prior to serving in the child care facility is permissible; of infectious or toxic material can lead to serious illness f. Unless a child’s health care professional documents a (13). Some molds produce toxins that may cause illness or different milk product, children from twelve months even death (such as aflatoxin or ergot). to two years of age should be served only human milk, Keeping cold food below 41°F and hot food above 135°F formula, whole milk or 2% milk (6). Note: For children prevents bacterial growth (1,6,12). Food intended for between twelve months and two years of age for whom human consumption can become contaminated if left overweight or obesity is a concern or who have a family at room temperature. history of obesity, dyslipidemia, or CVD, the use of Foodborne illnesses from Salmonella and E. coli 0157:H7 reduced-fat milk is appropriate only with written docu- have been associated with consumption of contaminated, mentation from the child’s primary health care profes- raw, or undercooked egg products, meat, poultry, and sea- sional (4). Children two years of age and older should food. Children tend to be more susceptible to E. coli 0157:H7 be served skim or 1% milk. If cost-saving is required to infections from consumption of undercooked meats, and accommodate a tight budget, dry milk and milk products such infections can lead to kidney failure and death. may be reconstituted in the facility for cooking purposes Home-canned food, food from dented, rusted, bulging or only, provided that they are prepared, refrigerated, and leaking cans, or leaking packages/bags of frozen foods, have stored in a sanitary manner, labeled with the date of preparation, and used or discarded within twenty-four hours of preparation; g. Meat, fish, poultry, milk, and egg products should be refrigerated or frozen until immediately before use (5); h. 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
202 Caring for Our Children: National Health and Safety Performance Standards an increased risk of containing microorganisms or toxins. The FDA provides the following Website for caregivers/ Users of unlabeled food cans cannot be sure what is in the teachers to check status of foods and food products that have can and how long the can has been stored. been recalled, see http://www.fda.gov. Excessive heating of foods results in loss of nutritional Temperatures come from the FDA 2009 Food Code (12). content and causes foods to lose appeal by altering color, Local or state regulations may differ. Caregivers/teachers consistency, texture, and taste. Positive learning activities should consult with the health department concerning ques- for children, using their senses of seeing and smelling, tions on proper cooking temperatures for specific foods. help them to learn about the food they eat. These sensory TYPE OF FACILITY experiences are counterproductive when food is over- Center, Large Family Child Care Home cooked. Children are not only shortchanged of nutrients, RELATED STANDARDS but are denied the chance to use their senses fully to learn 4.3.1.7 Feeding Cow’s Milk about foods. 4.8.0.6 Maintaining Safe Food Temperatures Caregivers/teachers should discourage parents/guardians Appendix U: Recommended Safe Minimum Internal from bringing home-baked items for the children to share as it is difficult to determine the quality of the ingredients Cooking Temperatures used and the cleanliness of the environment in which the References items are baked and transported. Parents/guardians should be informed why home baked items like birthday cake and 1. U.S. Department of Agriculture (USDA). 2002. Making nutrition count cupcakes are not the healthiest choice and the facility for children - Nutrition guidance for child care homes. Washington, DC: should provide ideas for healthier alternatives such as USDA. http://www/gpo.gov/fdsys/pkg/ERIC-ED482991/pdf/ERIC- fruit cups or fruit salad to celebrate birthdays and other ED482991.pdf. festive events. Several states allow the sale of raw milk or milk products. 2. Enders, J. B. 1994. Food, nutrition and the young child. New York: Merrill. These products have been implicated in outbreaks of salmo- 3. Potter, M. E. 1984. Unpasteurized milk: The hazards of a health fetish. nellosis, listeriosis, toxoplasmosis, and campylobacteriosis and should never be served in child care facilities (7,8). JAMA 252:2048-52. Only pasteurized milk and fruit juices should be served. 4. Sacks, J. J. 1982. Toxoplasmosis infection associated with raw goat’s milk. Foods made with uncooked eggs have been involved in a number of outbreaks of Salmonella infections. Eggs should JAMA 246:1728-32. be well-cooked before being eaten, and only pasteurized 5. Cowell, C., S. Schlosser. 1998. Food safety in infant and preschool day care. eggs or egg substitutes should be used in foods requiring raw eggs. Top Clin Nutr 14:9-15. The American Academy of Pediatrics (AAP) recommends 6. Dietz, W.H., L. Stern, eds. 1998. Guide to your child’s nutrition. Elk Grove that children from twelve months to two years of age receive human milk, formula, whole milk, or 2% milk. For Village, IL: American Academy of Pediatrics. children between twelve months and two years of age for 7. U.S. Department of Agriculture (USDA), Food Safety and Inspection whom overweight or obesity is a concern or who have a family history of obesity, dyslipidemia, or CVD, the use of Service. 2000. Keeping kids safe: A guide for safe handling and sanitation, reduced-fat milk is appropriate only with written documen- for child care providers. Rev ed. Washington, DC: USDA. http:// tation from the child’s primary health care professional (4). teamnutrition.usda.gov/resources/appendj.pdf. Children two years of age and older can drink skim, or 1%, 8. Daniels, S. R., F. R. Greer, Committee on Nutrition. 2008. Lipid screening milk (6,9-11). and cardiovascular health in childhood. Pediatrics 122:198-208. Soil particles and contaminants that adhere to fruits and 9. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove vegetables can cause illness. Therefore, all fruits or vegeta- Village, IL: American Academy of Pediatrics. bles to be eaten and used to make fresh juice at the facility 10. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. should be thoroughly washed first. 6th ed. New York: McGraw-Hill. Thawing frozen foods under conditions that expose any of 11. Chicago Dietetic Association. 1996. Manual of clinical dietetics. 5th ed. the food’s surfaces to temperatures between 41°F and 135°F Chicago, IL: American Dietetic Association. promotes the growth of bacteria that may cause illness if 12. U.S. Department of Health and Human Services, U.S. Department of ingested. Storing perishable foods at safe temperatures in Agriculture. 2010. Dietary guidelines for Americans, 2010. 7th ed. the refrigerator or freezer reduces the rate at which micro- Washington, DC: U.S. Government Printing Office. http://www.health. organisms in these foods multiply (12). gov/dietaryguidelines/dga2010/DietaryGuidelines2010.pdf. 13. Food Marketing Institute (FMI), U.S. Department of Agriculture, Food COMMENTS Safety and Inspection Service. 1996. Facts about food and floods: A The use of dairy products fortified with vitamins A and D is consumer guide to food quality and safe handling after a flood or power recommended (4). 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 intro- duced 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.
203 Chapter 4: Nutrition and Food Service “Perishable foods” include those foods that are subject to day should be labeled with the date of preparation before decay, spoilage or bacteria unless it is properly refrigerated being placed in the refrigerator. The basic rule for serving or frozen (1). food should be, “first food in, first food out” (1-3). Hot food can be placed directly in the refrigerator or it In the refrigerator, raw meat, poultry and fish should be can be rapidly chilled in an ice or cold water bath before stored below cooked or ready to eat foods. refrigerating. Hot foods should be promptly cooled first before they are fully covered in the refrigerator. Prepared RATIONALE perishable foods that have not been maintained at safe Covering food protects it from contamination and keeps temperatures for two hours or more should be discarded other food particles from falling into it. Hot food cools more immediately. If the air or room temperature is above 90°F, quickly in a shallow container, thereby decreasing the time this time is reduced to one hour after which the food should when the food would be susceptible to contamination. Foods be discarded (2). “Safe temperatures” mean keeping foods should be covered only after they have cooled. Leaving hot cold (below 41°F) or hot (above 135°F) (4). food uncovered allows it to cool more quickly, thereby RATIONALE decreasing the time when bacteria may be produced. Served foods have a high probability of contamination Labeling of foods will inform the staff about the duration of during serving. Bacterial multiplication proceeds rapidly in storage, which foods to use first, and which foods to discard perishable foods out of refrigeration, as much as doubling because the period of safe storage has passed. the numbers of bacteria every fifteen to twenty minutes. Storing raw meat, poultry and fish on a dish or in a pan The potential is high for perishable foods (food that is below ready-to-eat foods reduces the possibility that spills subject to decay, spoilage, or bacteria unless it is properly or drips from raw animal foods might contaminate ready- refrigerated or frozen) that have been out of the refrigerator to-eat food. for more than two hours to have substantial loads of bacte- ria. This time can be as short as one hour if the air tempera- TYPE OF FACILITY ture is above 90°F. When such food is stored and served Center, Large Family Child Care Home again, it may cause foodborne illness. COMMENTS RELATED STANDARDS All food, once served or handled outside the food prepara- 4.8.0.6 Maintaining Safe Food Temperatures tion area, should be discarded. 4.9.0.3 Precautions for a Safe Food Supply TYPE OF FACILITY Appendix V: Food Storage Chart Center, Large Family Child Care Home RELATED STANDARD References 4.8.0.6 Maintaining Safe Food Temperatures 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 1. U.S. Department of Agriculture, Food Safety and Inspection Service. out of home child care programs. 2nd ed. Chapel Hill, NC: National Training Glossary:Perishable. http://www.fda.gov/downloads/Food/ Institute for Child Care Health Consultants. http://nti.unc.edu/course_files/ FoodScienceResearch/ToolsMaterials/UCM430363.pdf. curriculum/nutrition/making_food_healthy_and_safe.pdf. 2. U.S. Department of Agriculture, Food Safety and Inspection Service. 2006. 2. Enders, J. B. 1994. Food, nutrition and the young child. New York: Merrill. Safe food handling, basics for handling food safely. http://www.fsis.usda.gov/ 3. U.S. Department of Agriculture (USDA). 2002. Making nutrition count for PDF/Basics_for_Safe_Food_Handling.pdf. children - Nutrition guidance for child care homes. Washington, DC: USDA. 3. U.S. Department of Agriculture, Food Safety and Inspection Service. 2006. http://www/gpo.gov/fdsys/pkg/ERIC-ED482991/pdf/ERIC-ED482991.pdf. Safe food handling, how temperatures affect food. http://www.fsis.usda.gov/ pdf/How_Temperatures_Affect_Food.pdf 4.9.0.6 Storage of Foods Not Requiring Refrigeration 4. U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration (FDA). 2009. 2009 Food code. College Park, Foods not requiring refrigeration should be stored at least MD: FDA.http://www.fda.gov/downloads/Food/FoodSafety/ six inches above the floor in clean, dry, well-ventilated store- RetailFoodProtection/FoodCode/FoodCode2009/UCM189448.pdf. rooms or other approved areas (1,2). Food products should be stored in such a way (such as in nonporous containers 4.9.0.5 off the floor) as to prevent insects and rodents from entering Preparation for and Storage of Food the products. in the Refrigerator RATIONALE All food stored in the refrigerator should be tightly covered, Storage of food off the floor in a safe and sanitary manner wrapped, or otherwise protected from direct contact with helps prevent food contamination from cleaning chemicals other food. Hot foods to be refrigerated and stored should or spills of other foods and keeps insects and rodents from be transferred to shallow containers in food layers less than entering the products. three inches deep and refrigerated immediately. These foods should be covered when cool. Any pre-prepared or COMMENTS leftover foods that are not likely to be served the following Storing food six inches or higher above the floor enables easier cleaning of the floor under the food. TYPE OF FACILITY Center, Large Family Child Care Home
204 Caring for Our Children: National Health and Safety Performance Standards RELATED STANDARD COMMENTS 5.2.8.1 Integrated Pest Management Child care providers should periodically use and replace References the food and water supplies from the emergency supplies to ensure usage before expiration dates. A child care facility 1. Food Marketing Institutes (FMI). 1996. Facts about food and floods: A should consult with their local health authority or local consumer guide to food quality and safe handling after a flood or power emergency preparedness agency to integrate disaster outage. Washington, DC: FMI. planning within the community. 2. U.S. Department of Health and Human Services, Public Health Service, TYPE OF FACILITY Food and Drug Administration (FDA). 2009. 2009 Food code. College Park, Center, Large Family Child Care Home MD: FDA. http://www.fda.gov/downloads/Food/FoodSafety/ RetailFoodProtection/FoodCode/FoodCode2009/UCM189448.pdf. RELATED STANDARD 9.2.4.3 Disaster Planning, Training, and Communication 4.9.0.7 Storage of Dry Bulk Foods Reference Dry, bulk foods that are not in their original, unopened 1. American Public Health Association. Get ready. http://www.getreadyforflu. containers should be stored off the floor in clean metal, org/newsite.htm. glass, or food-grade plastic containers with tight-fitting covers. All bulk food containers should be labeled and 4.9.0.9 dated, and placed out of children’s reach. Children should Cleaning Food Areas and Equipment be permitted to handle household-size food containers during adult-supervised food preparation and cooking Areas and equipment used for storage, preparation, and activities and when the container holds a single serving service of food should be kept clean. All of the food prepa- of food intended for that child’s consumption. ration, food service, and dining areas should be cleaned and RATIONALE sanitized before and after use. Food preparation equipment Food-grade nonporous containers prevent insect infesta- should be cleaned and sanitized after each use and stored in tions and contamination from other foods and cleaning a clean and sanitary manner, and protected from chemicals. By labeling and dating food, the food service contamination. staff can rotate the oldest foods to be used next and discard Sponges should not be used for cleaning and sanitizing. foods that have gone beyond safe storage times. Keeping Disposable paper towels should be used. If washable cloths bulk food containers out of the children’s reach prevents are used, they should be used once, then stored in a covered contamination and misuse. Young children cannot be container and thoroughly washed daily. Microfiber cloths expected to have learned safe food handling practices well are preferable to cotton or paper towels for cleaning tasks enough to prevent contaminating the food supply of others. because of microfiber’s numerous advantages, including TYPE OF FACILITY its long-lasting durability, ability to remove microbes, Center ergonomic benefits, superior cleaning capability and RELATED STANDARDS reduction in the amount of chemical needed. 5.2.8.1 Integrated Pest Management RATIONALE 4.9.0.8 Outbreaks of foodborne illness have occurred in child care Supply of Food and Water for Disasters settings. Many of these infectious diseases can be prevented through appropriate hygiene and sanitation methods. Keep- In areas where natural disasters (such as earthquakes, bliz- ing hands clean reduces soiling of kitchen equipment and zards, tornadoes, hurricanes, floods) occur, a seventy-two supplies. Education of child care staff regarding routine hour supply of food and water should be kept in stock for cleaning procedures can reduce the occurrence of illness each child and staff member (1). For some areas, an addi- in the group of children with whom they work (1). tional thirty-six hour supply may be needed, for example Sponges harbor bacteria and are difficult to clean and those areas at risk during hurricane season. The supply of sanitize between cleaning surface areas. food and water should be dated to know by which time it should be used to avoid its expiration date. COMMENTS RATIONALE “Clean” means removing all visible soil. Routine cleaning It may take seventy-two hours or longer for help to arrive in of kitchen areas should comply with the cleaning schedule some areas after a natural disaster of great magnitude. The provided in Appendix K or local health authority direct path of a hurricane or other natural disaster cannot regulations. always be anticipated and it is not possible for supplies to “Sanitize” means using a product to reduce germs on be brought into some disaster locations until: a) efforts to inanimate surfaces to levels considered safe by public rescue/save lives are completed and b) needs of communi- health codes or regulations. ties/populations are assessed. TYPE OF FACILITY Center, Large Family Child Care Home
205 Chapter 4: Nutrition and Food Service RELATED STANDARD household domestic dishwashers are recommended for Appendix K: Routine Schedule for Cleaning, Sanitizing, centers that do only one load of dishes after a snack or meal. Commercial dishwashers are required for some sizes of and Disinfecting centers in some locales. Centers are responsible to comply Reference with the requirements of the local regulatory health agency. The length of time to wash dishes in commercial dishwash- 1. Cowell, C., S. Schlosser. 1998. Food safety in infant and preschool day care. ers is three to four minutes. Commercial dishwashers that Top Clin Nutr 14:9-15. operate at low water temperatures (140°F to 150°F) are recommended because they are more energy-efficient. These 4.9.0.10 would be equipped with automatic detergent and sanitizer Cutting Boards injectors. When choosing a dishwasher, caregivers/teachers can consult with the local health authority or state/local Cutting boards should be made of nonporous material nutritionist/registered dietitian to ensure that they meet and should be scrubbed with hot water and detergent and local health regulations. sanitized between uses for different foods or placed in a COMMENTS dishwasher for cleaning and sanitizing. The facility should Household dishwashing machines can effectively wash and not use porous wooden cutting boards, boards made with sanitize dishes and utensils provided that certain conditions wood components, and boards with crevices and cuts. Only are met. The three types of household dishwashers are: hard maple or an equivalently hard, close-grained wood a. Those that lack or operate without sanitizing wash or (e.g. oak) may be used for cutting boards. RATIONALE rinse cycles; Some wood boards and boards with cracks and crevices b. Those that have sanitizing wash or rinse cycles and a harbor food or organic material that can promote bacterial growth and contaminate the next food cut on the surface. thermostat that senses a temperature of 150°F or higher COMMENTS before the machine advances to the next step in its cycle; Heavy duty plastic and Plexiglas cutting boards can be c. Those that have a sanitizing cycle and a thermostat as in placed in dishwashers. Programs should check with their (b) but advance to the next step in its cycle after fifteen local health department with questions regarding the minutes, if the temperature required to operate the proper hard wood for an allowable wood cutting board thermostat is not reached. in child care facilities. All three types of household dishwashers are capable of TYPE OF FACILITY producing the cumulative heat factor to meet the National Center, Large Family Child Care Home Sanitation Foundation time-temperature standard for commercial, spray-type dishwashing machines. Dish- 4.9.0.11 washer types (a) and (c) are capable of doing so only if Dishwashing in Centers the temperature of their inlet water is 155°F or higher. The temperature of a hot water supply necessary for operat- Centers should provide a three-compartment dishwash- ing a dishwasher conflicts with what is considered a safe ing area with dual integral drain boards or an approved temperature to prevent scalding (no higher than 120°F). dishwasher capable of sanitizing multi-use utensils. If a Installing a separate small hot water heater exclusively for dishwasher is installed, there should be at least a two- dishwasher type (a) or (c) is a way to meet this requirement. compartment sink with a spray unit. If a dishwasher or TYPE OF FACILITY a combination of dish pans and sink compartments that Center yield the equivalent of a three-compartment sink is not RELATED STANDARD used, paper cups, paper plates and plastic utensils should 5.2.1.14 Water Heating Devices and Temperatures Allowed be used and should be disposed of after every use. RATIONALE Reference These are minimum requirements for proper cleaning and sanitizing of dishes and utensils (1). 1. U.S. Department of Agriculture (USDA). 2002. Making nutrition count for A three-compartment sink is ideal. If only a single- or children - Nutrition guidance for child care homes. Washington, DC: USDA. double-compartment sink is available, three freestanding http://www/gpo.gov/fdsys/pkg/ERIC-ED482991/pdf/ERIC-ED482991.pdf. dish pans or two sinks and one dish pan may be used as the compartments needed to wash, rinse, and sanitize dishes. 4.9.0.12 An approved dishwasher is a dishwasher that meets the Dishwashing in Small and Large Family approval of the regulatory health authority. Dishwashers Child Care Homes should be carefully chosen. Depending on the size of the child care center and the quantity of food prepared, a Small and large family child care homes should provide a household dishwasher may be adequate. Because of the three-compartment dishwashing arrangement or a dish- time required to complete a full wash, rinse, and dry cycle, washer. At least a two-compartment sink or a combination
206 Caring for Our Children: National Health and Safety Performance Standards of dish pans and sink compartments should be installed to Nevertheless, the rinsing and sanitizing process should be used in conjunction with a dishwasher to wash, rinse, and eliminate any pathogens contributed by a sponge. When sanitize dishes. The dishwashing machine must incorporate possible, a cloth that can be laundered should be used a chemical or heat sanitizing process. If a dishwasher or a instead of a sponge. three-compartment dishwashing arrangement is not used, The concentration of bleach used for sanitizing dishes is paper cups, paper plates and plastic utensils should be used much more diluted than the concentration recommended and should be disposed of after every use. for disinfecting surfaces elsewhere in the facility. After washing and rinsing the dishes, the amount of infectious RATIONALE material on the dishes should be small enough so that the These are minimum requirements for proper cleaning two minutes of immersion in the bleach solution (or treat- and sanitizing of dishes and utensils (1). The purpose is to ment with an EPA-registered sanitizer) combined with remove food particles and other soil, and to control bacteria. air-drying will reduce the number of microorganisms to safe levels. TYPE OF FACILITY Air-drying of surfaces that have been sanitized using bleach Center, Large Family Child Care Home leaves no residue, since chlorine evaporates when the solu- tion dries. However, other sanitizers may need to be rinsed RELATED STANDARD off to remove retained chemical from surfaces. 4.9.0.11 Dishwashing in Centers TYPE OF FACILITY Appendix K: Routine Schedule for Cleaning, Sanitizing, Center, Large Family Child Care Home RELATED STANDARD and Disinfecting 4.9.0.12 Dishwashing in Small and Large Family Child Reference Care Homes References 1. U.S. Department of Agriculture (USDA). 2002. Making nutrition count for children - Nutrition guidance for child care homes. Washington, DC: 1. Bryan, F. L., G. H. DeHart. 1975. Evaluation of household dishwashing USDA. http://www/gpo.gov/fdsys/pkg/ERIC-ED482991/pdf/ machines, for use in small institutions. J Milk Food Tech 38:509-15. ERIC-ED482991.pdf. 2. Benjamin, S. E., ed. 2007. Making food healthy and safe for children: How to 4.9.0.13 meet the national health and safety performance standards – Guidelines for Methods for Washing Dishes by Hand out of home child care programs. 2nd ed. Chapel Hill, NC: National Training Institute for Child Care Health Consultants. http://nti.unc.edu/ If the facility does not use a dishwasher, reusable food ser- course_files/curriculum/nutrition/making_food_healthy_and_safe.pdf. vice equipment and eating utensils should be first scraped to remove any leftover food, washed thoroughly in hot water 3. Enders, J. B. 1994. Food, nutrition and the young child. New York: Merrill. containing a detergent solution, rinsed, and then sanitized 4. U.S. Department of Agriculture (USDA). 2002. Making nutrition count for by one of the following methods: a. Immersion for at least two minutes in a lukewarm (not children - Nutrition guidance for child care homes. Washington, DC: USDA. http://www/gpo.gov/fdsys/pkg/ERIC-ED482991/pdf/ERIC- less than 75°F) chemical sanitizing solution. Bleach may ED482991.pdf. be used as a sanitizing solution when diluted according to manufacturer’s instructions. The sanitized items NOTES should be air-dried; or Content in the STANDARD was modified on 8/6/2013. b. Immersed in an EPA-registered sanitizer following the manufacturer’s instructions for preparation and use; or 4.10 c. Complete immersion in hot water and maintenance at a MEALS FROM OUTSIDE VENDORS temperature of 170 °F for not less than thirty seconds. The items should be air-dried (1); OR CENTRAL KITCHENS d. Or, other methods if approved by the health department. 4.10.0.1 RATIONALE Approved Off-Site Food Services These procedures provide for proper sanitizing and control of bacteria (2-4). Food provided by a central kitchen or vendor to off-site locations should be obtained from sources approved and COMMENTS inspected by the local health authority. To manually sanitize dishes and utensils in hot water at RATIONALE 170°F, a special hot water booster is usually required. To This standard ensures that the child care facility receives avoid burning the skin while immersing dishes and utensils safe food. in this hot water bath, special racks are required. Therefore, TYPE OF FACILITY if dishes and utensils are being washed by hand, the chemi- Center, Large Family Child Care Home cal 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.
207 Chapter 4: Nutrition and Food Service 4.10.0.2 4.10.0.3 Food Safety During Transport Holding of Food Prepared at Off-Site Food Service Facilities After preparation, food should be transported promptly in clean, covered, and temperature-controlled containers. Facilities receiving food from an off-site food service facility Hot foods should be maintained at temperatures not lower should have provisions for the proper holding and serving than 135°F, and cold foods should be maintained at tempera- of food and washing of utensils to meet the requirements tures of 41°F or lower (1). Hot foods may be allowed to cool of the Food and Drug Administration’s Model Food Code to 110°F or lower before serving to young children as long and the standards approved by the State or local health as the food is cooked to appropriate temperatures and the authority (1). time at room temperature does not exceed two hours (or if room temperature is above 90°F then the time does not RATIONALE exceed one hour) (2). The temperature of foods should be Served foods have a high probability of becoming contami- checked with a working food-grade, metal probe nated during serving. Bacteria multiply rapidly in perish- thermometer. able foods out of refrigeration, as much as doubling every fifteen to twenty minutes (2). RATIONALE Served foods have a high probability of becoming contami- TYPE OF FACILITY nated during serving. Bacteria multiply rapidly in perish- Center, Large Family Child Care Home able foods out of refrigeration, as much as doubling every fifteen to twenty minutes (2). References Foods at more than 110°F are too hot for children’s mouths. A working food-grade, metal probe thermometer will 1. U.S. Department of Health and Human Services, Public Health Service, determine accurately when foods are safe for consumption. Food and Drug Administration (FDA). 2009. 2009 Food code. College Park, MD: FDA. http://www.fda.gov/downloads/Food/FoodSafety/ COMMENTS RetailFoodProtection/FoodCode/FoodCode2009/UCM189448.pdf. If the temperature of hot foods is well below 135°F when it arrives, the caregiver/teacher should review delivery and 2. U.S. Department of Agriculture, Food Safety and Inspection Service. 2006. storage practices and make any changes necessary to main- Safe food handling, how temperatures affect food. http://www.fsis.usda.gov/ tain proper food temperatures during storage and delivery. PDF/How_Temperatures_Affect_Food.pdf. TYPE OF FACILITY Center, Large Family Child Care Home RELATED STANDARD 4.8.0.6 Maintaining Safe Food Temperatures References 1. U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration (FDA). 2009. 2009 Food code. College Park, MD: FDA. http://www.fda.gov/downloads/Food/FoodSafety/ RetailFoodProtection/FoodCode/FoodCode2009/UCM189448.pdf. 2. U.S. Department of Agriculture, Food Safety and Inspection Service. 2006. Safe food handling, how temperatures affect food. http://www.fsis.usda.gov/ PDF/How_Temperatures_Affect_Food.pdf.
5 CHAPTER Facilities, Supplies, Equipment, and Environmental Health
211 Chapter 5: Facilities, Supplies, Equipment, and Environmental Health 5.1 building and fire codes. A thorough review of former uses of OVERALL REQUIREMENTS the building(s) should be completed to determine if there may be lingering hazardous exposures from past contamina- 5.1.1 tion that might require mitigation. The indoor, air, water, GENERAL LOCATION, LAYOUT, AND paint, building materials and/or other furnishings in the CONSTRUCTION OF THE FACILITY buildings need to be assessed for contaminant levels prior to siting. Collecting a sample of indoor air, water, paint, and 5.1.1.1 building materials may also be necessary. A review of envi- Location of Center ronmental health hazards by county or city public health environmental offices can help to meet safety requirements. A center should not be located in a private residence unless that portion of the residence is used exclusively for the care TYPE OF FACILITY of children during the hours of operation. Center RATIONALE Centers in these standards are generally defined as “pro- RELATED STANDARDS viding care and education for any number of children in a 5.1.1.3 Compliance with Fire Prevention Code non-residential setting or thirteen or more children in any 5.1.1.5 Environmental Audit of Site Location setting.” When there are a large number of children in care 5.2.1.1 Ensuring Access to Fresh Air Indoors who may span the age groups of infants, toddlers, preschool, 5.2.6.1 Water Supply and school-age children, special sanitation and design are 5.2.6.7 Cross-Connections needed to protect children from injury and prevent trans- 5.2.9.6 Preventing Exposure to Asbestos or Other mission of disease. Undivided attention must be given to these purposes during child care operations. Friable Materials COMMENTS 5.2.9.13 Testing for Lead The portion of a private residence used as a child care facil- 5.2.9.15 Construction and Remodeling ity is variable and unique to each specific situation. If other people will be using the private residence during the child References care facility’s hours of operation, then the caregiver/teacher must arrange the residence so that the activities of these 1. Somers, T.S., Harvey, M.L., Rusnak, S.M. 2011. Making child care centers people do not occur in the area designated for child care. SAFER: A non-regulatory approach to improving child care center siting. TYPE OF FACILITY Public Health Reports 126(Suppl 1): 34–40. Accessible at: http://www.ncbi. Center nlm.nih.gov/pmc/articles/PMC3072901/. RELATED STANDARD 5.1.1.9 Unrelated Business in a Child Care Area 2. Centers for Disease Control and Prevention (CDC). 2012. Announcement: Response to the advisory committee on childhood lead poisoning preven- 5.1.1.2 tion report, low level lead exposure harms children: A renewed call for Inspection of Buildings primary prevention. MMWR. Atlanta, GA: CDC.http://www.cdc.gov/ mmwr/preview/mmwrhtml/mm6120a6.htm?s_cid=mm6120a6_e. Newly constructed, renovated, remodeled, or altered build- ings should be inspected by a public inspector to assure 5.1.1.3 compliance with applicable building and fire codes before Compliance with Fire Prevention Code the building can be made accessible to children (1). RATIONALE Every twelve months, the child care facility should obtain Building codes are designed to ensure that a building is safe written documentation to submit to the regulatory licensing for occupants. Environmental health recommendations authority that the facility complies with a state-approved or are designed to ensure the building and property are free of nationally recognized Fire Prevention Code. If available, this health hazards for children and workers. Existing buildings documentation should be obtained from a fire prevention may contain potentially toxic or hazardous construction official with jurisdiction where the facility is located. Where materials (e.g., lead paint, asbestos) that may be released fire safety inspections or a Fire Prevention Code applicable during renovation work. Assessing the presence of such to child care centers is not available from local authorities, materials enables the management of potential exposures the facility should arrange for a fire safety inspection by an through removal, containment, or by other means (2). inspector who is qualified to conduct such inspections using COMMENTS the National Fire Protection Association’s NFPA 101: Life Any building not used for child care for a period of time Safety Code. should be inspected for compliance with applicable RATIONALE Regular fire safety checks by trained officials will ensure that a child care facility continues to meet all applicable fire safety codes. NFPA 101: Life Safety Code addresses child care facilities in two chapters devoted exclusively to this occupancy – chapter 16, “New Day-Care Occupancies” and chapter 17, “Existing Day-Care Occupancies” (1). TYPE OF FACILITY Center
212 Caring for Our Children: National Health and Safety Performance Standards 5.1.1.4 e. Potential noise hazards in the community surrounding Accessibility of Facility the site. The facility should be accessible for children and adults with A written environmental audit report that includes any re- disabilities, in accordance with Section 504 of the Rehabili- medial action taken should be kept on file, along with tation Act of 1973 and the Americans with Disabilities Act appropriate follow-up assessment measures of noise, air, (ADA). Accessibility includes access to buildings, toilets, water and soil quality, and post-remediation to show sinks, drinking fountains, outdoor play areas, meal and compliance with local and federal environmental health snack areas, and all classroom and therapy areas. standards. RATIONALE RATIONALE Accessibility has been detailed in full, in Section 504 of Evaluation of potential health and safety risks associated the Rehabilitation Act of 1973. It is also a key component with the physical site location of a child care facility will of the ADA, barring discrimination against anyone with identify any remedial action required or whether the site a disability. should be avoided if children’s health could be compromised. COMMENTS Children have higher exposures to some harmful Any facility accepting children with motor disabilities substances than adults due to their unique behavior, such must be accessible to all children served. Small family home as crawling and hand-to-mouth activity. They also eat, caregivers/teachers may be limited in their ability to serve drink, and breathe more than adults do relative to their such children, but are not precluded from doing so if there body size. In addition, children are much more vulnerable is a reasonable degree of compliance with this standard. to harm from exposures to contaminated materials than Accommodation of adaptive equipment for all children adults because their bodies and organ systems are still should be made to ensure access to all activities of the care developing. Disrup-tion of this development could result in setting. Access to public and most private facilities is a key permanent damage with life-long health and developmen- to the implementation of the ADA. If toilet learning/train- tal consequences (4). ing is a relevant activity, the facility may be required to Awareness of remedial action required or sites to avoid will provide adapted toilet equipment. reduce exposure to conditions that cause injury or For more information on requirements regarding accessibil- adversely affect health and development. ity, consult the Americans with Disabilities Act Accessibility Epidemiological studies indicate a relationship between Guidelines for Buildings and Facilities (ADAAG), available outdoor air pollution and adverse respiratory effects on at http://www.access-board.gov/adaag/html/adaag.htm, and children (5). Air pollution sources can be stationary, such the U.S. Access Board’s play area accessibility guidelines at as nearby dry cleaning or nail salon business, gas stations, http://www.access-board.gov/play/guide/intro.htm. or industrial facilities. Proximity to high traffic roadways is an important factor to avoid in siting a child care facility. TYPE OF FACILITY The previous uses of sites may also have contaminated the Center, Large Family Child Care Home air if environmental hazards were not properly remedied. The soil in play areas should not contain hazardous levels RELATED STANDARDS of any toxic chemical or substance. Soil contaminated with 5.4.1.7 Toilet Learning/Training Equipment toxic materials can poison children. For example, ensuring 5.4.6.2 Space for Therapy Services that soil in play areas is free of dangerous levels of lead 6.2.1.2 Play Equipment and Surfaces Meet ADA helps prevent lead poisoning (6-8). Research indicates that children exposed to chronic noise Requirements pollution experience increased difficulties with learning and cognitive performance, resulting in impaired academic 5.1.1.5 achievement (9). Environmental Audit of Site Location COMMENTS An environmental audit should be conducted before con- Potential safety hazards in the community surrounding struction of a new building; renovation or occupation of the site location of a child care facility may include: an older building; or after a natural disaster, to properly a. Proximity to hazardous industrial air emissions; evaluate and, where necessary, remediate or avoid sites b. Proximity to toxic or hazardous substances in adjacent where children’s health could be compromised (1,2,3). The environmental audit should include assessments of: or nearby property; a. Previous uses of the site or nearby sites; c. Proximity to agricultural plots where industrial b. Potential air, soil, and water contamination on child pesticides are sprayed; care facility sites and outdoor play spaces; d. Proximity to transportation hazards (e.g., local auto- c. Potential toxic or hazardous materials in building mobile traffic, major roadways, airports, railroads); construction; d. Potential environmental and safety hazards in the community surrounding the site; and
213 Chapter 5: Facilities, Supplies, Equipment, and Environmental Health e. Proximity to utilities (e.g., drinking water reservoirs or 5.1.1.6 storage tanks, electrical sub-stations, high-voltage power Structurally Sound Facility transmission lines, pressurized gas transmission lines); Every exterior wall, roof, and foundation should be struc- f. Proximity to explosive or flammable products (e.g., turally sound, weather-tight, and water-tight to ensure propane tanks). protection from weather and natural disasters. Possible options for reducing exposure to potential safety Every interior floor, wall, and ceiling should be structurally hazards in the community may include: sound and should be finished in accordance with local building codes to control exposure of the occupants to a. Locating the site of a child care facility at a safe distance levels of toxic fumes, dust, and mold. from the hazard; and/or RATIONALE b. Providing a physical barrier to prevent children from Both the design of structures and the lack of maintenance being exposed to the safety hazards (e.g., fencing). can lead to exposure of children to physical injury, mold, dust, pests, and toxic materials (1). TYPE OF FACILITY Center, Large Family Child Care Home COMMENTS Child care operations sometimes use older buildings or RELATED STANDARDS buildings designed for purposes other than child care. 5.1.1.2 Inspection of Buildings 5.2.1.1 Ensuring Access to Fresh Air Indoors TYPE OF FACILITY 5.2.3.1 Noise Levels Center, Large Family Child Care Home 5.2.6.1 Water Supply 5.2.6.2 Testing of Drinking Water Not From Public System RELATED STANDARDS 5.2.6.3 Testing for Lead and Copper Levels in 5.1.1.2 Inspection of Buildings 5.1.1.5 Environmental Audit of Site Location Drinking Water 5.7.0.7 Structure Maintenance 5.2.6.4 Water Test Results 5.2.6.6 Water Handling and Treatment Equipment 5.1.1.7 5.2.9.6 Preventing Exposure to Asbestos or Other Use of Basements and Below Grade Areas Friable Materials Finished basements or areas that are partially below grade 5.2.9.13 Testing for Lead may be used for children who independently ambulate and who are two years of age or older, if the space is in compli- References ance with applicable building and fire codes. Environ- mental health factors may be reviewed with county 1. Etzel, R. A., S. J. Balk, eds. 2011. Pediatric environmental health. 3rd ed. or city public health departments. Elk Grove Village, IL: American Academy of Pediatrics Council on Environmental Health. RATIONALE Basement and partially below grade areas can be quite 2. Somers, T.S., Harvey, M.L., Rusnak, S.M. 2011. Making child care centers habitable and should be usable as long as building, fire SAFER: A non-regulatory approach to improving child care center siting. safety (1), and environmental quality is satisfactory. Public Health Reports 126(Suppl 1): 34–40. Accessible at: http://www.ncbi. nlm.nih.gov/pmc/articles/PMC3072901/. COMMENTS To “independently ambulate” means that children are 3. U.S. Environmental Protection Agency. 2014. Siting of school facilities. able to walk from place to place with or without the use https://www.epa.gov/schools/school-siting-guidelines. of assistive devices. 4. U.S. Environmental Protection Agency. Human health risk assessment. TYPE OF FACILITY http://www.epa.gov/risk/health-risk.htm. Center, Large Family Child Care Home 5. American Academy of Pediatrics, Committee on Environmental Health. RELATED STANDARDS 2004. Policy statement: Ambient air pollution: Health hazards to children. 5.1.1.8 Buildings of Wood Frame Construction Pediatrics 114:1699-1707. 5.1.2.1 Space Required per Child 5.1.2.2 Floor Space Beneath Low Ceiling Heights 6. U.S. Environmental Protection Agency. 2010. The lead-safe certified guide to 5.1.4.1 Alternate Exits and Emergency Shelter renovate right. http://www.epa.gov/lead/pubs/renovaterightbrochure.pdf. 5.1.4.2 Evacuation of Children with Special Health Care 7. Burke, P., J. Ryan. 2001. Providing solutions for a better tomorrow: Needs and Children with Disabilities Reducing the risks associated with lead in soil. Washington, DC: U.S. 5.2.1.1 Ensuring Access to Fresh Air Indoors Environmental Protection Agency. http://www.epa.gov/nrmrl/ 5.2.2.1 Levels of Illumination pubs/600f01014/600f01014.pdf. 8. Stansfeld, S., Clark, C. 2015. Health effects of noise exposure in children. Curr Envir Health Rpt. 2: 171. http://link.springer.com/article/10.1007/ s40572-015-0044-1. 9. Boothe V. L., D. G. Shendell. 2008. Potential health effects associated with residential proximity to freeways and primary roads: Review of scientific literature, 1999-2006. J Environmental Health 70:33-41, 55-56. 10. Zhou Y., J. I. Levy. 2007. Factors influencing the spatial extent of mobile source air pollution impacts: A meta-analysis. BMC Public Health 7:89. http://www.biomedcentral.com/content/pdf/1471-2458-7-89.pdf. 11. Zhua Y., W. C. Hinds, S. Kim, S. Shen, C. Sioutas. 2002. Study of ultrafine particles near a major highway with heavy-duty diesel traffic. Atmospheric Environment 36:4323–35. NOTES Content in the STANDARD was modified on 8/25/2016.
214 Caring for Our Children: National Health and Safety Performance Standards 5.2.9.4 Radon Concentrations RATIONALE 5.2.9.5 Carbon Monoxide Detectors Some activities that leave a harmful residue are smoking, 5.2.9.6 Preventing Exposure to Asbestos or Other ammunition reloading, soldering, woodworking, and weld- ing (1). Examples of materials or equipment that could be Friable Materials harmful are small screws, nails, and electric tools with sharp Reference blades. Child care requires child-oriented, child-safe areas where the child’s needs are primary. 1. National Fire Protection Association (NFPA). 2009. NFPA 101: Life Safety Code. 2009 ed. Quincy, MA: NFPA. COMMENTS Employers should inform caregivers/teachers about 5.1.1.8 harmful residues or equipment that may potentially Buildings of Wood Frame Construction remain from unrelated business activity so that such residues or equipment can be removed. Infants and toddlers should be housed and cared for only on the ground floor in buildings of wood frame construc- TYPE OF FACILITY tion. Preschool-age and school-age children should be able Center, Large Family Child Care Home to use floors other than the ground floor in a building of wood construction if the building has required exits and RELATED STANDARDS care is provided in: 5.1.1.11 Separation of Operations from Child Care Areas a. A daylight-lit basement with exits that are no more than 5.2.1.5 Ventilation of Recently Carpeted or Paneled Areas 5.2.9.1 Use and Storage of Toxic Substances a half flight high; 5.2.9.3 Informing Staff Regarding Presence of Toxic b. A tri-level facility with half flights of stairs; c. A facility that is protected throughout by an automatic Substances 5.2.9.10 Prohibition of Poisonous Plants sprinkler system, which has its exit stairs enclosed by 5.2.9.15 Construction and Remodeling minimum one- hour fire barriers with openings in 5.7.0.2 Removal of Hazards From Outdoor Areas those barriers protected by minimum one-hour 5.7.0.4 Inaccessibility of Hazardous Equipment fire doors; d. Any door encountered along the egress route should be Reference easy for caregivers/teachers and older preschool-age children to open. 1. U.S. Environmental Protection Agency, U.S. Consumer Product Safety RATIONALE Commission. 2010. The inside story: A guide to indoor air quality. Fire and building safety experts recommend that children http://www.epa.gov/iaq/pubs/insidest.html. be permitted above ground level only in buildings of wood construction with certain exceptions (1). 5.1.1.10 COMMENTS Office Space Infants and toddlers should always be on the main floor with access directly to the outdoors. Doors along the egress Office space separate from child care areas should be provided route need to be easy to open. Consult local or state fire for administration and staff in centers. Children should not safety codes and child care licensing laws for restrictions have access to this area unless they are supervised by staff. on floor occupancy by age groups. TYPE OF FACILITY RATIONALE Center, Large Family Child Care Home For the efficient and effective operation of a center, office RELATED STANDARD areas where activities incompatible with the care of young 5.1.1.7 Use of Basements and Below Grade Areas children are conducted should be separate from child care areas. These office areas can be expected to contain sup- Reference plies, equipment and records/documents that should not be accessible to children. Office staff should be free from 1. National Fire Protection Association (NFPA). 2009. NFPA 101: Life Safety the distractions of child care (1,2). Code. 2009 ed. Quincy, MA: NFPA. COMMENTS 5.1.1.9 Child care staff should have access to an area that is separate Unrelated Business in a Child Care Area from the child care areas where they can meet personal needs such as a break room, adult bathroom, resource library, etc. Child care areas should not be used for any business or purpose unrelated to providing child care when children TYPE OF FACILITY are present in these areas. Center If unrelated business is conducted in child care areas when the child care facility is not in operation, activities associ- References ated with such business should not leave any residue in the air or on the surfaces, or leave behind materials or equip- 1. National Association for the Education of Young Children (NAEYC). 1977. ment, that could be harmful to children. Planning environments for young children. Washington, DC: NAEYC. 2. Murph, J. R., S. D. Palmer, D. Glassy, eds. 2005. Health in child care: A manual for health professionals. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics.
215 Chapter 5: Facilities, Supplies, Equipment, and Environmental Health 5.1.1.11 5.1.1.12 Separation of Operations from Multiple Use of Rooms Child Care Areas Playing, eating, and napping may occur in the same area Rooms or spaces that are used for the following activities or (exclusive of diaper changing areas, toilet rooms, kitchens, operations should be separated from the child care areas hallways, and closets), provided that: and the egress route should not pass through such spaces: a. The room is of sufficient size to have a defined area a. Commercial-type kitchen; b. Boiler, maintenance shop; for each of the activities allowed there at the time the c. Janitor closet and storage areas for cleaning products, activity is under way; b. The room meets other building requirements; pesticides, and other chemicals; c. Programming is such that use of the room for one d. Laundry and laundering supplies; purpose does not interfere with use of the room for e. Woodworking shop; other purposes. f. Flammable or combustible storage; RATIONALE g. Painting operation; Except for toilet and diaper changing areas, which must have h. Rooms that are used for any purpose involving the no other use, the use of common space for different activities for children facilitates close supervision of a group of chil- presence of toxic substances; dren, some of whom may be involved simultaneously in i. Area for medication storage. more than one of the activities listed in the standard (1). Areas that have combustibles should be protected by fire- COMMENTS resistant barriers. The egress route and the fire-resistant Compliance is measured by direct observation. separation should be approved by the appropriate regula- TYPE OF FACILITY tory agencies responsible for building and fire inspections. Center, Large Family Child Care Home In small and large family child care homes, a fire-resistant Reference separation should not be required where the food prepara- tion kitchen contains only a domestic cooking range and 1. Olds, A. 2001. Zoning a group room. In Child care design guide, 137-65. the preparation of food does not result in smoke or grease- New York: McGraw-Hill. laden vapors escaping into indoor areas. Where separation is provided between the egress route and the hazardous 5.1.2 area, it should be safe to use such route, but egress should SPACE PER CHILD not require passage through the hazardous area. 5.1.2.1 RATIONALE Space Required per Child Hazards and toxic substances must be kept separate in a locked closet or room from space used for child care to In general, the designated area for children’s activities prevent children’s and staff members’ exposure to injury (1). should contain a minimum of forty-two square feet of Cleaning agents must be inaccessible to children (out of usable floor space per child. A usable floor space of fifty reach and behind locked doors). Food preparation surfaces square feet per child is preferred. must be separate from diaper changing areas including This excludes floor area that is used for: sinks for handwashing. Children must be restricted from a. Circulation (e.g., walkways around the activity area); access to the stove when cooking surfaces are hot. b. Classroom support (e.g., staff work areas and activity COMMENTS equipment storage that may be adjacent to the In small family child care homes, mixed use of rooms is activity area); common (2). Some combined use of space for food prepara- c. Furniture (e.g., bookcases, sofas, lofts, block corners, tion, storage of cleaning equipment and household tools, tables and chairs); laundry, and diaper changing requires that each space d. Center support (e.g., administrative office, washrooms, etc.) within a room be defined according to its purpose and Usable, indoor floor space for the children’s activity area that exposure of children to hazards be controlled. Food depends on the design and layout of the child care facility, preparation should be separate from all exposure to and whether there is an opportunity and space for outdoor possible cross-contamination. activities. RATIONALE TYPE OF FACILITY Numerous studies have explored child care space require- Center, Large Family Child Care Home ments that are necessary to: a. Provide an environment that is highly functional for References program delivery and to encourage strong, positive staff-to-child relationships; 1. National Fire Protection Association (NFPA). 2009. NFPA 101: Life Safety Code. 2009 ed. Quincy, MA: NFPA. 2. Olds, A. R. 2001. Child care design guide. New York: McGraw-Hill.
216 Caring for Our Children: National Health and Safety Performance Standards b. Accommodate the recommended group size and Square footage estimates should only be intended as guide- staff-to-child ratio; and lines. Especially in child care facilities with fewer than fifty children, “plugging in” the square footage into a formula to c. Efficiently use space and incorporates ease of calculate space required usually does not work (1). supervision. It is important to keep in mind that state licensing regula- tions specify minimum space requirements and that they d. Recommendations from research studies range between must be legally adhered to. Such requirements vary from forty-two to fifty-four square feet per child (1). state to state (3). For Federal child care centers, the U.S. General Services Administration’s (GSA) child care design Studies have shown that the quality of the physical designed standards require a minimum of forty-eight and one-half environment of early child care centers is related to chil- square feet per child in the classroom (4). dren’s cognitive, social, and emotional development (e.g., Although providing adequate space for implementing a pro- size, density, privacy, well-defined activity settings, modi- gram of activities that meets the developmental needs of fied open-plan space, a variety of technical design features children is important in providing quality child care, how and the quality of outdoor play spaces). In addition to that space is actually used is likely more critical (8). It has meeting the needs of children, caregivers/teachers require been observed that child care facilities operating in older space to implement programs and facilitate interactions buildings with less than ideal space can still deliver quality with children. child care programs to meet the needs of children. Never- A review of the literature indicates that in the past ten theless, the amount of activity space required per child years, there has been growing research and study into how should take the known research into consideration. the physical design of child care settings affects child devel- opment. Historically, a standard of thirty-five square feet TYPE OF FACILITY was used. Recommendations from research studies range Center, Large Family Child Care Home between forty-two to fifty-four square feet per child. Com- ments from researchers indicate that other factors must RELATED STANDARDS also be considered when assessing the context of usable 1.1.1.1 Ratios for Small Family Child Care Homes floor space for child care activities (1,5-8). 1.1.1.2 Ratios for Large Family Child Care Homes and Although each child’s development is unique to that child, age groups are often used to categorize developmental Centers needs. To meet these needs, the use of activity space for 1.1.1.3 Ratios for Facilities Serving Children with Special each age group will be inherently different. Child behavior tends to be more constructive when suf- Health Care Needs and Disabilities ficient space is organized to promote developmentally 2.1.2.3 Space and Activity to Support Learning of Infants appropriate skills. Crowding has been shown to be associ- ated with increased risk of developing upper respiratory and Toddlers infections (2). Also, having sufficient space will reduce 2.1.4.2 Space for School-Age Activity the risk of injury from simultaneous activities. Children with special health care needs may require more References space than typically developing children (1). 1. Olds, A. R. 2001. Child care design guide. New York: McGraw-Hill. COMMENTS 2. Fleming, D. W., S. L. Cochi, A. W. Hightower, et al. 1987. Childhood upper The usable floor space for children’s activities in this stan- dard refers to indoor space that is used as the primary play respiratory tract infections: To what degree is incidence affected by daycare space. Consideration should also be given to the presence attendance? Pediatrics 79:55-60. or absence of secondary indoor play space that might be 3. National Child Care Information and Technical Assistance Center and the shared between programs as well as to outdoor play space. National Association for Regulatory Administration. 2009. The 2007 Staff-child ratios (i.e., the number of staff required per num- licensing child care study. http://www.naralicensing.org/associations/4734/ ber of children) should also be taken into account since staff files/2007 Licensing Study_full_report.pdf. consumes floor area space as well as children. Group size 4. U.S. General Services Administration (GSA). 2003. Child care center design for various age groups should also be considered. Since guide. New York: GSA Public Buildings Service, Office of Child Care. http:// groups of infants are smaller than groups of preschoolers, www.gsa.gov/graphics/pbs/designguidesmall.pdf. “infant and toddler rooms tend to be small, while preschool 5. Beach J., M. Friendly. 2005. Child care centre physical environments. and school-age rooms are a bit generous at full capacity” (1). Working Documents, Child Care Resource and Research Unit. http://www. Infant and toddler rooms often dedicate a considerable childcarequality.ca/wdocs/QbD_PhysicalEnvironments.pdf. amount of inflexible space to cribs and diaper changing 6. Moore, G. T., T. Sugiyama, L. O’Donnell. 2003. Children’s physical areas. Sufficient space to accommodate these activities, environments rating scale. Paper presented at the Australian Early space for adult seating to care for infants, and space for safe Childhood Education 2003 Conference, Hobart, Australia. http://sydney. mobility of infants and toddlers requires that the per child edu.au/architecture/documents/ebs/AECA_2003_paper.pdf. square foot requirements are applied for their areas also. 7. White, R., V. Stoecklin. 2003. The great 35 square foot myth. http://www. whitehutchinson.com/children/articles/35footmyth.shtml. 8. The Family Child Care Accreditation Project, Wheelock College. 2005. Quality standards for NAFCC accreditation. 4th ed. Salt Lake City, UT: National Association for Family Child Care. http://www.nafcc.org/ documents/QualStd.pdf. 5.1.2.2 Floor Space Beneath Low Ceiling Heights In a room where the entire ceiling height is less than seven and a half feet above the floor, the floor area should not be
217 Chapter 5: Facilities, Supplies, Equipment, and Environmental Health counted in determining compliance with the space require- 5.1.3 ments specified in Standard 5.1.2.1. OPENINGS In a room where the ceiling is at different levels at least two- thirds of the usable floor area should have a ceiling height 5.1.3.1 of at least seven and one-half feet and one-third of the Weather-Tightness and Water-Tightness usable floor area should have a ceiling height of greater of Openings than six feet eight inches. Floor areas beneath ceiling heights less than six-feet eight-inches tall should not be Each window, exterior door, and basement or cellar hatch- considered (1). way should be weather-tight and water-tight when closed. RATIONALE RATIONALE Children’s environments must be protected from exposure Ceiling height must be adequate for caregivers/teachers to to moisture, dust, and temperature extremes. supervise and reach children who require assistance. TYPE OF FACILITY Center, Large Family Child Care Home TYPE OF FACILITY Center, Large Family Child Care Home 5.1.3.2 Possibility of Exit from Windows RELATED STANDARD 5.1.2.1 Space Required per Child All windows in areas used by children under five years of age should be constructed, adapted, or adjusted to limit the Reference exit opening accessible to children to less than four inches, or be otherwise protected with guards that prevent exit 1. National Fire Protection Association (NFPA). 2009. NFPA 101: Life Safety by a child, but that do not block outdoor light. Where such Code. 2009 ed. Quincy, MA: NFPA. windows are required by building or fire codes to provide for emergency rescue and evacuation, the windows and 5.1.2.3 guards, if provided, should be equipped to enable staff Areas for School-Age Children to release the guard and open the window fully when evacuation or rescue is required. Opportunities should be When school-age children are in care for periods that provided for staff to practice opening these windows, and exceed two hours before or after school, a separate area such releaseshould not require the use of tools or keys. away from areas for younger children should be available Children should be given information about these win- for school-age children to do homework. Areas used for dows, relevant safety rules, as well as what will happen this purpose should, in addition to meeting the other if the windows need to be opened for an evacuation. facility standards have: RATIONALE a. Table space; To prevent children from falling out of windows, stan- b. Chairs; dards from the U.S. Consumer Product Safety Commission c. Adequate ventilation; (CPSC) and the ASTM International (ASTM) require the d. Lighting of 40 to 50 foot-candles in the room; opening size to be four inches to prevent the child from get- e. Lighting of 50 to 100 foot-candles on the surface used ting through or the head from being entrapped (1,2). Some children may be able to pass their body through a slightly as a desk (1). larger opening but then get stuck and hang from the win- dow opening with their head trapped inside. Caregivers/ RATIONALE teachers must not depend on screens to keep children from School-age children need a quiet space for reading and falling out of windows. Windows to be used as fire exits to do homework so they are not forced to work against must be immediately accessible. Staff should supervise chil- the demands for attention that younger children pose. In dren when they are near these windows, and incorporate family child care homes such an area might be within the safety information and relevant emergency procedures and same room and separated by a room dividing arrangement drills into their day-to-day curriculum so that children will of furniture. better understand the safety issues and what will happen if they need to leave the building through the windows. TYPE OF FACILITY COMMENTS Center, Large Family Child Care Home “Screens” are intended to prevent flying insects from coming into the facility whereas window “guards” are the type of RELATED STANDARDS devices commonly used to provide building security and 5.1.2.1 Space Required per Child prevent intruders. 5.2.1.1 Ensuring Access to Fresh Air Indoors 5.2.1.2 Indoor Temperature and Humidity 5.2.2.1 Levels of Illumination Reference 1. American Society of Heating, Refrigeration and Air-conditioning Engineers (ASHRAE), American Institute of Architects, Illuminating Engineering Society of North America, U.S. Green Building Council, U.S. Department of Energy. 2008. Advanced energy design guide for K-12 school buildings, 148. Atlanta, GA: ASHRAE.
218 Caring for Our Children: National Health and Safety Performance Standards TYPE OF FACILITY c. Adjustable door closing devices that slow the rate of Center, Large Family Child Care Home door closing. Slowing the door closing rate helps prevent References finger pinching in the latch area of the door or abrupt closing of the door against a small child. 1. U.S. Consumer Product Safety Commission (CPSC). New standards for window guards to help protect children from fails. Release #00-126. RATIONALE Washington, DC: CPSC. http://www.cpsc.gov/en/Newsroom/News- Finger-pinch injuries in doors are a significant cause of Releases/2000/New-Standards-for- Window-Guards-To-Help-Protect- injury among claims against liability insurance in child Children-From-Falls-/. care. Closing doors and gates create significant exposure to children for bruised, cut, or smashed fingers, torn or 2. ASTM International. ASTM F2090-08 Standard specification for window cracked fingernails, broken bones, and even amputations. fall prevention devices with emergency escape (egress) release mechanisms. Finger-pinch injuries happen very quickly, often before West Conshohocken, PA: ASTM. staff can react. Finger-pinch protection devices ensure that this type of injury does not occur. 5.1.3.3 COMMENTS Screens for Ventilation Openings A child doesn’t have to pass through a door or gate to acquire a finger-trapping injury. A child can be on the out- All openings used for ventilation should be screened side of one of these doors and still get their fingers trapped against insect entry. while it is being closed. Young children are vulnerable to RATIONALE injury when they fall against the rear hinge-side of doors Screens prevent the entry of insects, which may bite, sting, and gates, striking the projecting hinges. The installation or carry disease. of rear finger-pinch protection devices will eliminate this TYPE OF FACILITY problem, too (1). Piano hinges are not recommended to alle- Center, Large Family Child Care Home viate this problem as they tend to sag over time with heavy RELATED STANDARD use. Costs of these devices vary significantly, as do method 5.1.3.2 Possibility of Exit from Windows and extent of protection, product durability and warranty; the different products may not provide equally suitable 5.1.3.4 protection. Whatever hardware is selected should prevent Safety Guards for Glass Windows/Doors (not just discourage) the entry of a finger into the danger zone from both sides of the door or gate and should protect Glass windows and glass door panels within thirty-six the door or gate through the full extent of its swing (i.e., it inches of the floor should have safety guards (such as rails should be capable of protecting doors and gates that open or mesh) or be of safety-grade glass or polymer and 180 degrees). Attachment should use screws rather than equipped with a vision strip. glue for a stronger, more durable connection. RATIONALE TYPE OF FACILITY Glass panels can be invisible to an active child or adult (1). Center, Large Family Child Care Home When a child collides with a glass panel, serious injury can result from the collision impact or the broken glass. Reference COMMENTS In areas where glass windows are repeatedly broken, 1. Moseley, G. 2008. Closing the door on finger injuries. Doors and Hardware installation of polymer material should be considered. 72:38-41. TYPE OF FACILITY Center, Large Family Child Care Home 5.1.3.6 RELATED STANDARD Directional Swing of Indoor Doors 5.1.3.2 Possibility of Exit from Windows Reference Doors, other than exit stair enclosure doors, from a building area with fewer than fifty persons should swing in the direc- 1. International Code Council (ICC). 2009. 2009 international building code. tion of most frequent travel. Doors from a building area Washington, DC: ICC. with more than fifty persons and exit stair enclosure doors should swing in the direction of egress travel (the path for 5.1.3.5 going out). An exception is that boiler room doors should Finger-Pinch Protection Devices swing into the room. RATIONALE Finger-pinch protection devices should be installed Proper door swings provide easy, quick passage and pre- wherever doors, cupboards/cabinets, and gates are vent injuries. Boiler room doors should swing inward to accessible to children. These devices include: help contain explosions. a. Flexible plastic and rubber devices that cover the gap The NFPA 101: Life Safety Code from the National Fire Protection Association (NFPA), and the model building created at the front and rear hinge-sides of a door or codes in wide use throughout the United States, require that gate when it is opened; b. Other types of flexible coverings for these gaps;
219 Chapter 5: Facilities, Supplies, Equipment, and Environmental Health doors serving an area with fifty or more persons swing in local parks as the playground site. Access to these parks the direction of egress travel (1). This is important because may require crossing a street at an intersection with a cross- large numbers of persons might push against each other walk. This would normally be considered safe, especially in leaving those up against a door without the ability to step areas of low traffic; however, when sirens go off, a route that back and allow the door to swing back into the room. otherwise may be considered safe becomes chaotic and COMMENTS dangerous. During evacuation or an emergency, children, Doors in homes usually open inward. The requirement for as well as staff, become excited and may run into the street door swing may be addressed in local building codes. when the playground is not fenced or immediately adjacent TYPE OF FACILITY to the center (1). Center In the event of a fire, staff members and children should be Reference able to get at least fifty feet away from the building or struc- ture. If the children cannot return to their usual building, a 1. National Fire Protection Association (NFPA). 2009. NFPA 101: Life Safety suitable shelter containing all items necessary for child care Code. 2009 ed. Quincy, MA: NFPA. must be available where the children can safely remain until their parents/guardians come for them. An evacuation 5.1.4 plan should take into consideration all available open EXITS areas to which staff and children can safely retreat in an emergency (1). 5.1.4.1 For information about the NFPA 101: Life Safety Code, Alternate Exits and Emergency Shelter contact the NFPA. TYPE OF FACILITY Each building or structure, new or old, should be provided Center, Large Family Child Care Home with a minimum of two exits, at different sides of the build- RELATED STANDARDS ing or home, leading to an open space at ground level. If the 5.1.4.6 Labeled Emergency Exits basement in a small family child care home is being used, 5.1.4.7 Access to Exits one exit must lead directly to the outside. Exits should be unobstructed, allowing occupants to escape to an outside Reference door or exit stair enclosure in case of fire or other emer- gency. Each floor above or below ground level used for 1. National Fire Protection Association (NFPA). 2009. NFPA 101: Life Safety child care should have at least two unobstructed exits that Code. 2009 ed. Quincy, MA: NFPA. lead to an open area at ground level and thereafter to an area that meets safety requirements for a child care indoor 5.1.4.2 or outdoor area. Children should remain there until their Evacuation of Children with Special Health parents/guardians can pick them up, if reentry into the Care Needs and Children with Disabilities facility is not possible. Entrance and exit routes should be reviewed and approved In facilities that include children who have physical disabil- by the applicable fire inspector. Exiting should meet all the ities or other developmental disabilities, all exits and steps requirements of the current edition of the NFPA 101: Life necessary for evacuation should have ramps approved by Safety Code from the National Fire Protection Association the local building inspector and be clearly marked or iden- (NFPA). tified. Children who have ambulatory difficulty, mobility RATIONALE limitations or impairments, use wheelchairs or other equip- Unobstructed exit routes are essential for prompt evacua- ment that must be transported with the child (such as an tion. The purpose of having two ways to exit when child oxygen ventilator) should be located on the ground floor of care is provided on a floor above or below ground level is the facility or provisions should be made for efficient emer- to ensure an alternative exit if fire blocks one exit (1). gency evacuation to a safe sheltered area. Children who COMMENTS have special medical or dietary needs should have their Using an outdoor playground as a safe place to exit to medical equipment brought along during an evacuation. may not always be possible. Where the playground is fully RATIONALE surrounded by fencing, it is important that a gate that staff The facility must meet building code standards for the is trained, authorized, and equipped to open, be provided community and also the requirements under the to permit travel away from the building should fire expose Americans with Disabilities Act (ADA) and their access children and staff to radiant heat and smoke. Some authori- guidelines (1). ties will permit a fenced area with sufficient accumulation All children must be able to exit the building quickly in space at least fifty feet from the building to serve in lieu of a case of emergency. Locating children in wheelchairs or gated opening. Some child care facilities do not have a play- those with special equipment on the ground floor may elim- ground located adjacent to the child care building and use inate the need for transporting these children down the stairs during an emergency evacuation. In buildings where the ground floor cannot be used for such children,
220 Caring for Our Children: National Health and Safety Performance Standards arrangements must be made to move children to a safe loca- TYPE OF FACILITY tion, such as a fire tower stairwell, during an emergency Center, Large Family Child Care Home exit. Children with diabetes, asthma, or special medical References diets may need medication or special foods brought along during an evacuation. 1. National Fire Protection Association (NFPA). 2009. NFPA 101: Life Safety COMMENTS Code. 2009 ed. Quincy, MA: NFPA. Assuring physical access to a facility also requires that a means of evacuation meeting safety standards for exit 2. U.S. Architectural and Transportation Barriers Compliance Board (Access accommodates any children with special health care needs Board). 2002. Americans with disabilities act accessibility guidelines for in care. buildings and facilities (ADAAG). http://www.access-board.gov/adaag/ TYPE OF FACILITY ADAAG.pdf. Center, Large Family Child Care Home RELATED STANDARDS 5.1.4.4 1.1.1.3 Ratios for Facilities Serving Children with Special Locks Health Care Needs and Disabilities In centers, no door should have a lock or fastening device that 5.1.1.4 Accessibility of Facility prevents free egress from the interior. Free egress means that 5.1.1.8 Buildings of Wood Frame Construction building occupants, without the use of a tool, key or special knowledge are able to operate the door, under all lighting Reference conditions, using not more than one releasing operation. In all child care facilities, all door hardware in areas that school- 1. U.S. Architectural and Transportation Barriers Compliance Board (Access age children use should be within the reach of the children. Board). 2002. Americans with disabilities act accessibility guidelines for In centers, doors serving areas with more than 100 occupants build- ings and facilities (ADAAG). http://www.access-board.gov/adaag/ should be permitted to be latched only if provided with panic ADAAG.pdf. hardware (latch release hardware that can be opened by pressure in the direction of travel). 5.1.4.3 In large or small family child day care homes, a double- Path of Egress cylinder deadbolt lock which requires a key to unlock the door from the inside should not be permitted on any door The minimum width of any path of egress should be thirty- along the escape path from any child care except the exterior six inches. An exception is that doors should provide a door, and then only if the key required to unlock the door is minimum clear width of thirty-two inches. The width of kept hanging at the door. doors should accommodate wheelchairs and the needs of If emergency exits lead to potentially unsafe areas for children individuals with physical disabilities. (such as a busy street), alarms or other signaling devices should Where exits are not immediately accessible from an open be installed on these exit doors to alert the staff in case a child floor area, safe and continuous passageways, aisles, or corri- attempts to leave. An alarm or signaling system should also dors leading to every exit should be maintained and should be in place in the case of a child with special behavior support be arranged to provide access for each occupant to at least needs who poses a risk for running out of a room or building. two exits by separate ways of travel. Doorways, exit access RATIONALE paths, passageways, corridors and exits should be kept free Children, as well as staff members, must be able to evacuate of materials, furniture, equipment and debris to allow a building in the event of a fire or other emergency. Never- unobstructed egress travel from inside the child care facil- theless, the caregiver/teacher must assure security from in- ity to the outside. truders and from unsupervised use of the exit by children. RATIONALE COMMENTS Unobstructed access to exits is essential to prompt evacua- Double-cylinder deadbolt locks that require a key to unlock tion (1). The hallways and door openings must be wide the door from the inside are often installed in private homes enough for added security. In such situations, these dead bolt locks to permit easy exit in an emergency. The actual exit is the should be present only on exterior doors and should be left enclosed stair or the actual door to the outside; doors in the unlocked position during the hours of child care opera- from most rooms and the travel along a corridor are tion. Locks that prevent opening from the outside, but can considered be opened without a key from the inside should be used for exit access or the path of egress. The NFPA 101: Life Safety security during hours of child care operation. Double cylinder Code from the National Fire Protection Association deadbolt locks should not be used on interior doors, such as (NFPA) per- mits the usual thirty-six inches minimum to closets, bathrooms, storage rooms, and bedrooms (1). be reduced TYPE OF FACILITY to a clear opening of thirty-two inches for doors (1). This Center, Large Family Child Care Home is consistent with Americans with Disabilities Act Reference Accessibility Guidelines for Buildings and Facilities (ADAAG) as it affords enough width for a person in a 1. National Fire Protection Association (NFPA). 2009. NFPA 101: Life Safety wheelchair to maneuver through the door opening (2). Code. 2009 ed. Quincy, MA: NFPA.
221 Chapter 5: Facilities, Supplies, Equipment, and Environmental Health 5.1.4.5 TYPE OF FACILITY Closet Door Latches Center, Large Family Child Care Home Reference Closet doors accessible to children should have an internal release for any latch so a child inside the closet can open 1. National Fire Protection Association (NFPA). 2009. NFPA 101: Life Safety the door. Code. 2009 ed. Quincy, MA: NFPA. RATIONALE Closet doors that can be opened from the inside prevent 5.1.5 entrapment (1). STEPS AND STAIRS TYPE OF FACILITY Center, Large Family Child Care Home 5.1.5.1 Reference Balusters 1. National Fire Protection Association (NFPA). 2009. NFPA 101: Life Safety Protective handrails and guardrails should have balusters/ Code. 2009 ed. Quincy, MA: NFPA. spindles at intervals of less than three and a half inches or have sufficient protective material to prevent a three and a 5.1.4.6 half inch sphere from passing through if caring for children Labeled Emergency Exits two years and over. If caring for children under the age of two years, balusters/spindles should be spaced at intervals In centers, required exits should be clearly identified and less than two and three-eighths inches or have sufficient visible at all times during operation of the child care facil- protective material to prevent a sphere with a diameter of ity. The exits for egress should be arranged or marked so the two and three-eighths inches from passing through. path to safety outside is unmistakable. RATIONALE RATIONALE A child’s head may be small enough to be entrapped in a As soon as children can learn to recognize exit signs and space more than three and a half inches wide (1). Infants and pathway markings, they will benefit from having these young toddlers may crawl or play close to railings around paths of egress clearly marked. Adults who come into the stairs. Because they may have access to railings, it is recom- building as visitors need these markings to direct them as mended to follow the same recommendation for the spacing well (1). of balusters/spindles for stair railings as the slats TYPE OF FACILITY on a crib. Center COMMENTS Reference Building codes vary from state to state and many regulations for balusters/spindles do not meet the recommendations for 1. National Fire Protection Association (NFPA). 2009. NFPA 101: Life Safety intervals less than three and a half inches. Some building Code. 2009 ed. Quincy, MA: NFPA. codes are for intervals of four inches or greater. Because of this discrepancy and the expense of adding balusters/ 5.1.4.7 spindles, using a protective material may be the only option. Access to Exits Recommendations as stated above should be considered for remodeling or new construction. Each room of a child care facility should be provided with TYPE OF FACILITY direct access to: Center, Large Family Child Care Home a. An exit to the outside; or Reference b. A corridor or hallway providing direct access to an exit 1. U.S. Consumer Product Safety Commission (CPSC). 2008. Public to the outside. playground safety handbook. Bethesda, MD: CPSC. http://www.cpsc.gov/ Where it is necessary to pass through an adjacent room for cpscpub/pubs/325.pdf. access to a corridor or exit, any doors providing passage to and through such room should not be latched or locked, or 5.1.5.2 otherwise barricaded, to prevent access. Handrails No obstructions should be placed in the corridors or passageways leading to the exits. Handrails should be provided on both sides of stairways, be RATIONALE securely attached to the walls or stairs, and at a maximum A room that requires exit through another room to get to height of thirty-eight inches. an exit path can entrap its occupants when there is a fire The outside diameter of handrails should be between one or emergency condition if passage can be impeded by a and one-quarter inches and two inches. barrier or door that is latched (1). When railings are installed on the side of stairs open to a An obstruction in the path of exit can lead to entrapment, stairwell, access to the stairwell should be prevented by a especially in an emergency situation where groups of barrier so a child cannot use the railings as a ladder to people may be exiting together. jump or fall into the stairwell.
222 Caring for Our Children: National Health and Safety Performance Standards RATIONALE be provided at the top and bottom of each open stairway Model codes, including the National Fire Protection Asso- in facilities where infants and toddlers are in care. Gates ciation’s NFPA 101: Life Safety Code, require handrails to should have latching devices that adults (but not children) be mounted in the height range of thirty-four to thirty-eight can open easily in an emergency. “Pressure gates” or accor- inches (1). Such handrails are equally usable by children. dion gates should not be used. Gate design should not aid in The stair researcher, Jake Pauls, has filmed small children climbing. Gates at the top of stairways should be hardware effectively using handrails mounted as high as thirty-eight mounted (e.g., to the wall) for stability. Basement stairways inches. This comes naturally to the children because they should be shut off from the main floor level by a full door. are used to reaching up to take an adult’s hand while This door should be self-closing and should be kept locked walking. There is no justification for forcing the center to entry when the basement is not in use. No door should be or home to incur the added expense of installing a locked to prohibit exit at any time. second set of handrails closer to the floor. RATIONALE Railings on both sides ensure a readily available handhold Falls down stairs and escape upstairs can injure infants and (whether right handed or left handed) in the event of a fall toddlers. A gate with a difficult opening device can cause down the stairs. When handrails are installed to allow chil- entrapment in an emergency (1). dren a handhold, the stairwell should be designed so the TYPE OF FACILITY railing does not provide the child with a ladder to climb. Center, Large Family Child Care Home COMMENTS RELATED STANDARD Open stairwells can be enclosed with rigid vertical materi- 5.1.6.6 Guardrails and Protective Barriers als to prevent children from climbing and falling over the Reference rail. Handrails are for purposes of providing a graspable rail for help in arresting falls on stairs. Guards are for 1. U.S. Consumer Product Safety Commission (CPSC). Old accordion style purposes of preventing falls over an open side where baby gates are dangerous. http://www.cpsc.gov/CPSCPUB/PUBS/5085.pdf. there is more than thirty inches vertical distance to fall. TYPE OF FACILITY 5.1.6 Center, Large Family Child Care Home EXTERIOR AREAS RELATED STANDARD 5.1.6.6 Guardrails and Protective Barriers Note to Reader: See Chapter 6 for Outdoor Play Area Reference Requirements. 1. National Fire Protection Association (NFPA). 2009. NFPA 101: Life Safety 5.1.6.1 Code. 2009 ed. Quincy, MA: NFPA. Designated Walkways, Bike Routes, and Drop-Off and Pick-Up Points 5.1.5.3 Landings Safe pedestrian crosswalks, drop-off and pick-up points, and bike routes in the vicinity of the facility should be Landings should be provided beyond each interior and identified, written in the facility’s procedures exterior door that opens onto a stairway. Landing width RATIONALE should not be less than the width of stairway it serves and In 2008, one-fifth (20%) of all children between the ages of must be at least the width of stairway in direction of travel, five and nine who were killed in traffic crashes were pedes- but need not be more than forty- eight inches. When fully trians (1). Identification and communication of safe routes open, the door should not project more than seven inches practices may reduce the potential of injuries resulting into the landing. Dimensions (length and width) of the from children darting into traffic (2). Providing bike route landing are equal to or greater than the width of the door. information may encourage the use of this health- RATIONALE promoting, economical, and environmentally friendly mode Landings are necessary to accommodate the swing of the of transportation. door without pushing the person on the stairway into a TYPE OF FACILITY precarious position while trying to leave the stairway (1). Center, Large Family Child Care Home TYPE OF FACILITY RELATED STANDARD Center, Large Family Child Care Home 6.5.2.1 Drop-Off and Pick-Up Reference References 1. International Code Council (ICC). 2009. 2009 international building code. 1. U.S. Department of Transportation, National Highway Traffic Safety Washington, DC: ICC. Administration (NHTSA). 2008. Traffic Safety Facts 2008: Pedestrians. Washington, DC: NHTSA. http://www-nrd.nhtsa.dot.gov/Pubs/811163.PDF. 5.1.5.4 Guards at Stairway Access Openings 2. U.S. General Services Administration (GSA). 2003. Child care center design guide. New York: GSA Public Buildings Service, Office of Child Care. http:// Securely installed, effective guards (such as gates) should www.gsa.gov/graphics/pbs/designguidesmall.pdf.
223 Chapter 5: Facilities, Supplies, Equipment, and Environmental Health 5.1.6.2 5.1.6.5 Construction and Maintenance of Walkways Areas Used by Children for Wheeled Vehicles Inside and outside stairs, ramps, porches, and other walk- The area used by children for wheeled vehicles should have a ways to the structure should be constructed for safe use as flat, smooth, non-slippery surface. A physical barrier should required by the local building code and should be kept in separate this area from the following: sound condition, well-lighted, and in good repair (1). a. Traffic; Walkways must be cleared and maintained during b. Streets; inclement weather to prevent falls. c. Parking; RATIONALE d. Delivery areas; Prevention of slipping and tripping hazards is key to e. Driveways; preventing injuries from falls. f. Stairs; TYPE OF FACILITY g. Hallways used as fire exits; Center, Large Family Child Care Home h. Balconies; RELATED STANDARDS i. Pools and other areas containing water. 5.1.6.3 Drainage of Paved Surfaces RATIONALE 5.1.6.4 Walking Surfaces Uneven or slippery riding surfaces can lead to injury (1). Physical separation from environmental obstacles is 5.1.6.3 necessary to prevent potential collision, injuries, falls, Drainage of Paved Surfaces and drowning. TYPE OF FACILITY All paved surfaces should be well-drained to avoid Center accumulation of water and ice. RELATED STANDARDS RATIONALE 5.1.6.2 Construction and Maintenance of Walkways Well-drained paved surfaces help prevent injury and 5.1.6.3 Drainage of Paved Surfaces deterioration of the surface by discouraging the 5.1.6.4 Walking Surfaces accumulation of water and ice (1). TYPE OF FACILITY Reference Center, Large Family Child Care Home Reference 1. U.S. General Services Administration (GSA). 2003. Child care center design guide. New York: GSA Public Buildings Service, Office of Child Care. 1. Whole Building Design Guide Secure/Safe Committee. 2010. Ensure http://www.gsa.gov/graphics/pbs/designguidesmall.pdf. occupant safety and health. National Institute of Building Sciences. http://www.wbdg.org/design/ensure_health.php. 5.1.6.6 Guardrails and Protective Barriers 5.1.6.4 Walking Surfaces Guardrails, a minimum of thirty-six inches in height, should be provided at open sides of stairs, ramps, and other All walking surfaces, such as walkways, ramps, and decks, walking surfaces (e.g., landings, balconies, porches) from should have a non-slip finish and be free of loose material which there is more than a thirty-inch vertical distance to (e.g., gravel, sand), water, and ice. Sand may be used on fall. Spaces below the thirty-six inches height guardrail walkways during ice and snow conditions. should be further divided with intermediate rails or All walking surfaces and other play surfaces should be free balusters as detailed in the next paragraph. of holes and abrupt irregularities in the surface. For preschoolers, bottom guardrails greater than nine RATIONALE inches but less or equal to twenty-three inches above the Slippery and uneven walking surfaces can lead to injury floor should be provided for all porches, landings, balconies, even during activities of children and adults that do not and similar structures. For school age children, bottom involve play (1). guardrails should be greater than nine inches but less or COMMENTS equal to twenty inches above the floor, as specified above. An example of a non-slip finish is asphalt or asphalt with a For infants and toddlers, protective barriers should be less covering of sand for icy walkways. than three and one-half inches above the floor, as specified TYPE OF FACILITY above. All spaces in guardrails should be less than three and Center, Large Family Child Care Home a half inches. All spaces in protective barriers should be less Reference than three and one- half inches. If spaces do not meet the specifications as listed above, a protective material sufficient 1. Whole Building Design Guide Secure/Safe Committee. 2010. Ensure to prevent the passing of a three and one-half inch diameter occupant safety and health. National Institute of Building Sciences. sphere should be provided. http://www.wbdg.org/design/ensure_health.php.
Search
Read the Text Version
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 23
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- 31
- 32
- 33
- 34
- 35
- 36
- 37
- 38
- 39
- 40
- 41
- 42
- 43
- 44
- 45
- 46
- 47
- 48
- 49
- 50
- 51
- 52
- 53
- 54
- 55
- 56
- 57
- 58
- 59
- 60
- 61
- 62
- 63
- 64
- 65
- 66
- 67
- 68
- 69
- 70
- 71
- 72
- 73
- 74
- 75
- 76
- 77
- 78
- 79
- 80
- 81
- 82
- 83
- 84
- 85
- 86
- 87
- 88
- 89
- 90
- 91
- 92
- 93
- 94
- 95
- 96
- 97
- 98
- 99
- 100
- 101
- 102
- 103
- 104
- 105
- 106
- 107
- 108
- 109
- 110
- 111
- 112
- 113
- 114
- 115
- 116
- 117
- 118
- 119
- 120
- 121
- 122
- 123
- 124
- 125
- 126
- 127
- 128
- 129
- 130
- 131
- 132
- 133
- 134
- 135
- 136
- 137
- 138
- 139
- 140
- 141
- 142
- 143
- 144
- 145
- 146
- 147
- 148
- 149
- 150
- 151
- 152
- 153
- 154
- 155
- 156
- 157
- 158
- 159
- 160
- 161
- 162
- 163
- 164
- 165
- 166
- 167
- 168
- 169
- 170
- 171
- 172
- 173
- 174
- 175
- 176
- 177
- 178
- 179
- 180
- 181
- 182
- 183
- 184
- 185
- 186
- 187
- 188
- 189
- 190
- 191
- 192
- 193
- 194
- 195
- 196
- 197
- 198
- 199
- 200
- 201
- 202
- 203
- 204
- 205
- 206
- 207
- 208
- 209
- 210
- 211
- 212
- 213
- 214
- 215
- 216
- 217
- 218
- 219
- 220
- 221
- 222
- 223
- 224
- 225
- 226
- 227
- 228
- 229
- 230
- 231
- 232
- 233
- 234
- 235
- 236
- 237
- 238
- 239
- 240
- 241
- 242
- 243
- 244
- 245
- 246
- 247
- 248
- 249
- 250
- 251
- 252
- 253
- 254
- 255
- 256
- 257
- 258
- 259
- 260
- 261
- 262
- 263
- 264
- 265
- 266
- 267
- 268
- 269
- 270
- 271
- 272
- 273
- 274
- 275
- 276
- 277
- 278
- 279
- 280
- 281
- 282
- 283
- 284
- 285
- 286
- 287
- 288
- 289
- 290
- 291
- 292
- 293
- 294
- 295
- 296
- 297
- 298
- 299
- 300
- 301
- 302
- 303
- 304
- 305
- 306
- 307
- 308
- 309
- 310
- 311
- 312
- 313
- 314
- 315
- 316
- 317
- 318
- 319
- 320
- 321
- 322
- 323
- 324
- 325
- 326
- 327
- 328
- 329
- 330
- 331
- 332
- 333
- 334
- 335
- 336
- 337
- 338
- 339
- 340
- 341
- 342
- 343
- 344
- 345
- 346
- 347
- 348
- 349
- 350
- 351
- 352
- 353
- 354
- 355
- 356
- 357
- 358
- 359
- 360
- 361
- 362
- 363
- 364
- 365
- 366
- 367
- 368
- 369
- 370
- 371
- 372
- 373
- 374
- 375
- 376
- 377
- 378
- 379
- 380
- 381
- 382
- 383
- 384
- 385
- 386
- 387
- 388
- 389
- 390
- 391
- 392
- 393
- 394
- 395
- 396
- 397
- 398
- 399
- 400
- 401
- 402
- 403
- 404
- 405
- 406
- 407
- 408
- 409
- 410
- 411
- 412
- 413
- 414
- 415
- 416
- 417
- 418
- 419
- 420
- 421
- 422
- 423
- 424
- 425
- 426
- 427
- 428
- 429
- 430
- 431
- 432
- 433
- 434
- 435
- 436
- 437
- 438
- 439
- 440
- 441
- 442
- 443
- 444
- 445
- 446
- 447
- 448
- 449
- 450
- 451
- 452
- 453
- 454
- 455
- 456
- 457
- 458
- 459
- 460
- 461
- 462
- 463
- 464
- 465
- 466
- 467
- 468
- 469
- 470
- 471
- 472
- 473
- 474
- 475
- 476
- 477
- 478
- 479
- 480
- 481
- 482
- 483
- 484
- 485
- 486
- 487
- 488
- 489
- 490
- 491
- 492
- 493
- 494
- 495
- 496
- 497
- 498
- 499
- 500
- 501
- 502
- 503
- 504
- 505
- 506
- 507
- 508
- 509
- 510
- 511
- 512
- 513
- 514
- 515
- 516
- 517
- 518
- 519
- 520
- 521
- 522
- 523
- 524
- 525
- 526
- 527
- 528
- 529
- 530
- 531
- 532
- 533
- 534
- 535
- 536
- 537
- 538
- 539
- 540
- 541
- 542
- 543
- 544
- 545
- 546
- 547
- 548
- 549
- 550
- 551
- 552
- 553
- 554
- 555
- 556
- 557
- 558
- 559
- 560
- 561
- 562
- 563
- 564
- 565
- 566
- 567
- 568
- 569
- 570
- 571
- 572
- 573
- 574
- 575
- 576
- 577
- 578
- 579
- 580
- 581
- 582
- 583
- 584
- 585
- 586
- 587
- 588
- 589
- 590
- 591
- 592
- 593
- 594
- 595
- 596
- 597
- 598
- 599
- 600
- 601
- 602
- 603
- 604
- 605
- 606
- 607
- 608
- 609
- 610
- 611
- 612
- 613
- 614
- 615
- 616
- 617
- 618
- 619
- 620
- 621
- 622
- 623
- 624
- 625
- 626
- 627
- 628
- 629
- 630
- 631
- 632
- 633
- 634
- 635
- 636
- 637
- 638
- 639
- 640
- 641
- 642
- 643
- 644
- 645
- 646
- 647
- 648
- 1 - 50
- 51 - 100
- 101 - 150
- 151 - 200
- 201 - 250
- 251 - 300
- 301 - 350
- 351 - 400
- 401 - 450
- 451 - 500
- 501 - 550
- 551 - 600
- 601 - 648
Pages:
