Position of The American Dietetic Association:
Nutrition standards for child-care programs

It is the position of The American Dietetic Association (ADA) that all child care programs should achieve recommended standards for meeting children's nutrition and nutrition education needs in a safe, sanitary, supportive environment that promotes healthy growth and development. Over the past 3 decades there has been steady growth in the use of center-based child care arrangements. At the same time, trends in child health have shifted the emphasis in child nutrition programs from the prevention of dietary deficiencies to the promotion of healthful food practices for prevention of chronic diseases. Therefore, the implementation of high standards for nutrition and nutrition education in child care settings today will have major impact on the health of Americans in the future. This position provides guidance to health care practitioners, day-care providers, and parents regarding menu adequacy and planning, food preparation, foodservice, food safety, and nutrition education for children in day care centers. The provision of a safe and pleasant environment will promote the acquisition of healthful eating habits for children that will prevent disease and enable growth and development. JAm Diet Assoc. 1999;99:981-988.

Child care is no longer an experience for a few children. Every day 13 million preschoolers-including 6 million babies and toddlers-are in child care in the United States (1). This number is 60% of the nation's young children-that is, 3 of every 5 children aged 5 years and younger participate in some type of nonparental child care. In addition, millions of school-age children are in child-care programs after school and during school holidays (1). Mandatory work requirements in the Welfare Reform Act of 1996, together with an increase in the amount of federal dollars for child-care block grants to the states (2), can be expected to increase yet again the numbers of children who eat one or more of their daily meals at a childcare facility.

Over the past 3 decades there has been steady growth in the use of center-based child-care arrangements. In 1965, 26% of young children in nonparental care were in center-based programs. By 1995, more than 70% of young children in nonparental care were in center-based programs, 20% in family child-care homes, and 8% in other arrangements (eg, relatives or in-home caregivers) (3). This trend toward increasing reliance on center-based and other formal child-care settings provides expanded opportunities to ensure that young children are routinely offered nutritious foods that keep them free from hunger, promote their proper growth, and reinforce choices and habits that prevent disease and support good health.

Over the years, trends in child health in the United States have shifted the emphasis in child nutrition programs from a narrow focus on the prevention of dietary deficiencies toward the broader view of promoting healthful food practices for longterm benefits. During the past 3 decades, increased iron intake among infants has resulted in a decline in childhood iron-- deficiency anemia (4). Total energy intakes have increased or, in some cases, remained stable (5,6). The percent of energy intake from protein and carbohydrate has increased whereas the percent of energy intake from fat has decreased (7). These are positive trends. Opportunities abound, however, for further improvements in children's diets. Prevalence of overweight among preschool children has doubled in the past 20 years (8). Although intake of fat and saturated fat has declined, it still is consumed in amounts that exceed recommendations (7,9). In addition, children are not eating the recommended amounts of fruits and vegetables (7,9,10) or grain products (7,11). New research is providing clear evidence that food habits and patterns of nutrient intake acquired in early childhood "track" into later childhood and adulthood (12-14). It is reasonable to assume, therefore, that implementation of high standards for nutrition and nutrition education in child-care settings today will have major impact on the health of Americans well beyond the year 2010.

The importance of having a set of standards to ensure that meals and snacks in child care meet children's nutrition needs and provide them with excellent models of healthful dietary patterns is acknowledged by the frequency with which standards for nutrition are included in licensing and other forms of regulations established to ensure quality in child-care services (15-17). Such standards, which are science based and established by state and federal regulatory programs, are necessary to ensure that child-care foodservice is uniformly of high quality. The following statement updates the position of The American Dietetic Association (ADA) regarding standards for nutrition in child-care programs (18-20).

POSITION STATEMENT

It is the position of the American Dietetic Association that all child-care programs should achieve recommended standards for meeting children's nutrition and nutrition education needs in a safe, sanitary, supportive environment that promotes healthy growth and development.

STANDARDS

Meal Plans

Menus should be nutritionally adequate Every child should receive quantities and combinations of foods that provide nutrients in proportion to the amount of their day spent at a child-care facility. A child in a part-day program (4 to 7 hours), for example, should receive food that provides at least one third of the daily nutrition needs, whereas those in a full-day program (8 hours or more) should receive foods that meet at least one half to two thirds of the child's daily nutrition needs.

The specific nutrient needs of children aged 1 to 3 years, 4 to 8 years, and 9 to 13 years are listed in the Recommended Dietary Allowances (RDAs) (21) and the Dietary Reference Intakes (DRIs) (22). The DRIs provide quantitative estimates of intake of nutrients that can be used when planning and assessing diets of healthy people. The DRIs will eventually replace the RDAs as reference values for healthy people as a more precise and quantitative approach. The DRIs include the RDAs, the Adequate Intakes, Tolerable Upper Intake Levels (ie, an upper and lower bound), and an Estimated Average Requirement for healthy people in a group such as found in a child-care center. When evaluating menus planned for groups of children, dietetics professionals must also consider the amount of the child's day that is being spent at the child-care facility. Because full-day programs usually cover the period of time that includes half to two thirds of daily meals and snacks (eg, breakfast or morning snack, lunch, and afternoon snacks or afternoon snack, supper, and evening snack), it is recommended that child-care menus provide their "share" of the child's daily nutrient requirements.

Evaluations of menus and meals actually served in samples of child-care centers and family child-care homes show that the combinations and quantities of foods that are prepared for children often fail to supply the recommended share of energy, iron, zinc, and magnesium (23-27). The growing evidence that deficiencies of these nutrients are linked to behavior problems and to delays in children's cognitive development (28,29), provides further reinforcement for the recommendation that the nutrition needs of children in child care are met.

Parents should be involved in planning the menus and learning how family meals can complement food served in child-care settings Historically, parents have filled the role of primary gatekeeper on nutrient intake and teacher of healthful food choices for their children (30-33). Today, more and more parents are sharing that role with providers in child-care centers and family child-care homes. During 1997, 1.5 billion meals were provided to young children in centers and homes that participate in the Child and Adult Food Care Program (CACFP) (E Morawetz, US Department of Agriculture, Food and Nutrition Service, Child and Adult Care Food Program. Alexandria, Va, personal communication, 1998). This number of meals is approximately half again as many as in 1992 and 3 times as many as the 493 million meals served in 1982. A recent large-scale study of the CACFP shows that children typically consume 50% to 100% of their RDAs during their time at the child-care facility (34). Results of several small-scale studies suggest that parents may, in fact, be relying on the child-care program to meet most or all of their children's needs for nutrition and nutrition education (35,36). Other research suggests that parents are only occasionally involved in planning menus or participating in other aspects of the nutrition programs in child-care facilities (37). In fact, parents often do not know what foods were served during their child's day in care (36,38). This is of concer99, no. 8 (Aug 1999): p. 981-988n because the food behavior of young children is strongly influenced by parents (32,39,40). Children's eating habits are established early in life and are the result of interactions and encouragement by caregivers and parents (41). Children look to adults as models for the foods they prefer (42). It is important, therefore, for parents to be knowledgeable about and to participate in the child-care nutrition program.

Menus should be consistent with the Dietary Guidelines for Americans Every child should be presented with meals and snacks that enable them to learn about and to practice dietary habits that allow them to eat a variety of nutritious foods, maintain healthy weight, choose plenty of fruit and vegetables and grain products, avoid excessive fat and sodium, and use sugars only in moderation.

The Dietary Guidelines for Americans (43) and the Food Guide Pyramid (44) are meant to be applied together to plan a diet that promotes good health. By making a standard practice of having child-care menus consistent with the guidelines, caregivers can help to ensure that while children are in their early and formative years they have opportunities to eat nutritious foods that promote proper growth and health and help them to learn food preferences and dietary habits that prevent disease and support a lifetime of good health. The importance of this recommendation is underscored in the Healthy People 2000 objectives for the nation, which include goal 2.17, "increase to at least 90% the proportion of school lunch and breakfast services and child care food services with menus that are consistent with the nutrition principles in the Dietary Guidelines for Americans" (45, p 126)1.

Meals and snacks should follow recommended patterns with appropriate accommodations for ages of the children, number of hours in the child-care setting, and cultural or ethnic differences in food habits Children in care for a full day (8 hours or more of the active part of the child's day) should be offered at least one meal and 2 snacks. Food should be offered at intervals not more than 3 hours apart during the active part of the child's day. Components of meals and snacks should be planned so that they are appetizing and provide adequate servings from the milk, yogurt, and cheese group; meat, poultry, fish, dry beans, eggs, and nuts group; vegetable group; fruit group; and bread, cereal, rice and pasta group.

Recommended patterns for planning well-balanced meals and snacks are available from a variety of sources, including the the US Department of Agriculture (USDA), US Department of Health and Human Services, American Public Health Association, and The American Dietetic Association (15-17,44,46-51). These guidance systems recommend meal patterns and child-- size portions as well as specifying amounts and schedules for meeting infants' and children's needs for fluids. Some of the systems include recommendations for assessing and accommodating nutrition requirements of children with special health care needs (eg, "A written history of any special nutrition or feeding needs of the child shall be obtained before the child enters the facility [and] shall be used to develop individual feeding plans" [47, p 38]). Guidance is also provided for offering food at times and in ways that encourage children to eat combinations and amounts of food that will help them grow and be healthy (eg, one set of recommendations includes the statement that "Infants shall be fed on demand unless the parent provides written instructions otherwise" [47, p 31]). The importance of planning menus that accommodate cultural preferences but are also consistent with the dietary guidelines is emphasized by the fact that minority populations are rapidly growing in number (52) and that Latino and black children have been shown to have less healthful diets than other subgroups (53,54). In addition, by learning about and trying foods from different cultures, children increase their knowledge of the world around them and increase the likelihood they will choose a more varied, better balanced diet in later life.

The addition of fat, sugar, and sources of sodium should be minimized in food preparation and foodservice The foods served to children aged 2 years or older should enable them to follow the recommended eating patterns for healthy Americans as suggested by the Dietary Guidelines for Americans. These recommendations include targets of no more than 30% of total daily energy from fat, less than 10% of total daily energy from saturated fat, less than 300 mg dietary cholesterol per day, and Limiting use of too much sugar and sodium. However, for children from 2 to 5 years old, the diet should gradually be adapted to contain no more than 30% of energy from fat.

Dietary excesses of sugar, fat, cholesterol, and sodium are common among today's children (7,9). These excesses can contribute to dental caries, obesity, and chronic diseases such as cancer and heart disease. The 1995 US Dietary Guidelines specify that healthy Americans should"choose a diet lowin fat" and "use sugars, salt, and sodium only in moderation." These guidelines were incorporated in the Healthy People 2000 nutrition-related health objectives for the nation. One of the objectives specifies that foods be prepared and served in ways that reduce dietary fat intake and decrease salt and sodium intake (45). Some experts are concerned, however, that restricting young children's fat intake may also restrict intake of other essential nutrients. Alternatively, the Canadian recommendations accommodate a transition period (early childhood and/or age 2 years to the end of linear growth) during which fat and cholesterol in the diet is gradually decreased (51,55).

Child-care personnel can facilitate the transition to a lower-- fat diet without imposing excessive restrictions by carefully monitoring the "seasonings" that are added to food. Cooks often justify the addition of margarine, butter, lard, salt pork, bacon, and meat drippings during food preparation by pointing out that it enhances flavor, thereby increasing the likelihood that the children will eat their food. Children, however, have taste buds in their cheeks and all over the surface of their tongues (56). They are, therefore, much more sensitive to salty and sweet tastes than are their older family members and caregivers, so it is not necessary to add salt to season children's food. Nor is it necessary to add sugar to their vegetables or cereal. Because studies have shown that eating sweets and other refined carbohydrates causes tooth decay (57,58), it is also recommended that special attention be given to avoiding snacks that have a high sugar content.

Plenty of fresh fruits, fresh or frozen vegetables, and whole-grain products should be used Each child should receive sufficient servings of fruits and vegetables to ensure that good sources of vitamin C are provided every day, and good sources of vitamin A are served at least 3 times a week. Whole-grain products should be included to ensure adequate daily intake of dietary fiber. Emphasis should be placed on use of raw, unprocessed foods when available.

Healthy, growing children need a balanced diet that includes fruits, vegetables, whole grains, lean meats and/or legumes, and low-fat dairy products to achieve a dietary pattern that maintains appropriate blood cholesterol levels and optimal energy (44,51,59). Unfortunately, Americans generally do not eat enough fruits and vegetables and whole-grain cereals. On a per capita basis, fresh fruit and vegetable intake in the United States increased 17% between 1970 and 1990. However, overall intake remains less than the recommended 5 servings a day for a majority of people (7,60). Intake of high-fiber and wholegrain breads and cereals also remains low, with all age groups from age 2 years to adult averaging less than 3 occasions per day of eating grain products (7,11). To correct these problems and improve the diet and health of Americans, the Food and Nutrition Board of the National Academy of Sciences recommends that children aged 2 years and older should have carbohydrate intake that is 55% or more of total energy (44,59,61). Five or more servings of a combination of vegetables and fruits, especially green and yellow vegetables and citrus fruits, should be eaten every day. At least 6 servings should be consumed daily of a combination of breads, cereals, and legumes. Whole-grain products such as whole-wheat bread, brown rice, and oatmeal should be consumed whenever possible to ensure a good supply of dietary fiber (44). At least one expert suggests that in determining the minimum daily fiber intake for children older than 2 years, nutrition professionals should use the following formula: age +5 g fiber per day (62). These recommendations are represented graphically in the USDA's Food Guide Pyramid (44,59). The meal pattern guidelines in the Food Buying Guide for Child Nutrition Programs can be used as an aid in translating the daily recommendations into meals and snacks for children in child-care programs (15). Choosing fresh fruits and vegetables and serving them raw rather than cooking them for extended periods helps to increase the amount of dietary fiber, minimizes fat and sodium in the diet, and avoids the loss of nutrients such as vitamin C.

Foods should be provided in quantities that balance energy and nutrients with the children's small appetites Children typically grow taller by 2 or 3 inches and heavier by 5 lb or so each year from age 1 year to adolescence. The RDAs reflect corresponding increases in the amounts of energy and nutrients recommended. Total energy needs increase slightly with age, although energy needs per kilogram of body weight actually decline gradually during childhood. Energy requirements are also influenced by activity level. Growth and activity patterns vary widely among children. The complexity of these factors makes it especially challenging to plan their diets so as to accommodate children's small appetites, avoid excess fat and sugar, and still supply adequate amounts of energy and nutrients to keep children free from hunger and promote their proper growth and health. Food guidance systems that recommend minimum amounts and age-appropriate portion sizes are available to help caregivers plan menus to balance energy and nutrients with children's growth and activity patterns (15-- 17,41,46-50,59,63). By ensuring that children are provided with adequate amounts and combinations of food during their day in care, child-care programs can make substantial contributions to prevent hunger and increase nutrition security for the nation's young children. The CACFP, which reimburses eligible child-care programs for the costs of foodservice operations, has been identified as one of the feeding programs in the United States that address food insecurity and hunger (64).

Food Preparation and Foodservice

Food preparation and service should be consistent with best practices for food safety and sanitation All children in child-care settings should be served food that is stored, prepared, and presented in a safe and sanitary manner. Cooking and serving food for a large group of children is different from preparing food for one's family. It is important that good institutional food management practices be implemented to protect the health and safety of children. The foodservice staff of child-care facilities need to assess the safety and quality of their total foodservice operation daily using the recommendations of Hazard Analysis and Critical Control Point (HACCP) for handling, cooking, serving, and storing food and equipment (65). Careful monitoring of temperatures, storage conditions, hazards such as cuts on hands of food handlers, as well as persistent sanitation of classrooms and restrooms can result in less illness for staff and children. Caregiver's and staff's behavior should provide good role models to help children learn safe sanitary practices (66,67).

Materials for training personnel to avoid the risks of foodborne illness and cross-contamination are abundant and easily accessible for child-care directors (67,68). The Guidelines for Outof-Home Child Care include more than a dozen standards related to sanitation in food storage, preparation, and service. Chief among these are the requirements that children and staff wash their hands, that children's food be served on plates or other disinfected holders and not placed on a bare table, that foods be properly refrigerated, that kitchen equipment be appropriately designed and maintained, and that single-service articles such as paper napkins be discarded after each use (16). Viruses transmitted from person to person are shed by infectious persons for 2 weeks before onset of symptoms although infected children under 6 years usually do not have symptoms and may shed the virus for longer periods of time. Further complicating the complexity of food safety is concern that some foodborne viruses are quite hardy and can survive refrigeration and freezing temperatures. Therefore, providing sanitary facilities for foodservice staff and enforcing sanitary practices, including thorough hand washing, is one of the most effective disease prevention strategies (69,70).

Other items of special note in standards for safety specify that foods be stored and served at appropriate temperatures to minimize bacterial growth, that foods be stored in areas separate from storage areas for cleaning products and pesticides, and that foam cups and plates not be used because swallowed pieces may cause choking (16). Other areas of concern noted in a survey of child-care centers were appropriate pest control, leaky pipes dripping onto pots and pans that are used only infrequently, thawing foods at room temperature or leaving food standing for extended periods of time at room temperature (71). The unique challenges to prevent foodborne disease at child-care facilities must focus on eliminating microorganisms with techniques such as cooking raw products thoroughly before consumption and implementing HACCP as a means to effectively and systematically reduce risk of infections (72).

Nutrition Consultation and Guidance

Child-care programs should obtain consultation and guidance from a dietetics professional on a regularly scheduled basis Planning menus and foodservice for children of different ages, preferences, activity levels, cultural backgrounds, and special needs is a complex and challenging task. The difficulty of achieving nutrition standards for childcare programs is indicated in research documenting problems in child-care foodservice (24,35,66,73,74). These studies verify that standards are not enough. Other research suggests that child-care programs with access to dietetics professionals produce higher-quality meals (75). Dietetics professionals should be accessible to child-care programs to assist with menu planning and evaluation and to provide nutrition information and education for caregivers. Tools have been developed to help dietetics professionals evaluate the implementation of standards and provide appropriate guidance to care givers (66). Other important tasks a dietetics professional can perform to ensure high-quality nutrition in child-care settings include screening and assessment, information and education activities, and counseling that takes into account physical as well as psychosocial constraints of the child-care program.

Nutrition education should be a component of the child-- care program Every child should have opportunities to learn about food, food sources, nutrition, and the link between nutrition and health. Child-care foodservice should be integrated with nutrition learning activities. To the extent possible, parents should be engaged in helping to plan and implement the nutrition education component of the child-care program.

The menu at a child-care facility can be used as a centerpiece of nutrition education programs that reinforce healthful food habits at the child-care facility and at home. Food experiences are vital in helping children to recognize and accept a wide variety of foods. Research demonstrates that even very young children are ready to learn more about food, nutrition, and health than previously thought (76,77). Learning how to choose and enjoy many different nutritious foods in early childhood provides the foundation for a lifetime of wise food choices (19,78-80)

Nutrition education activities should be offered at appropriate developmental levels for learning and muscular activity, be based on meanings familiar to the families and the children, and teach lifetime skills for problem solving and making decisions and taking responsibility (81). Examples of exciting nutrition education activities include teaching children food safety and good nutrition with "cup cooking" or "baggie cooking" as they make their own snacks of apple salad in a cup or vegetable salad in a bag; learning about size, smell, shape, color, and growth as children "explore a potato"; visits to the local grocery store to see the produce or to a farm to see the animals and crops; visits to other stores, such as a fish farm or fish market, a bakery, or a cheese factory; section fruits, count the parts, and discuss the concepts of "whole" and "part"; learn about size by lining up fruits from smallest to largest; make geometric shapes out of frozen dough and bake for snack time; identify the parts of a melon (ie, skin, rind, meat, and seeds); present lessons on "I can make my own breakfast," "I can name foods," or "Microwave magic" (ie, how to microwave safely). Parental involvement regarding foodservice and nutrition learning activities at a child-care facility is extremely important for the health of young children. Posting menus is an inexpensive way to keep families informed about meal patterns and nutrition learning experiences. Although research demonstrates the powerful role that parents play in the development of children's food preferences (34,77), actual involvement of parents in child-care nutrition programs may be much less than is desirable (36,37). It is important, therefore, that special efforts be made to get parents involved so they can make informed decisions about what foods and nutrition learning experiences to offer during the child's hours away from the child-care facility.

The National Dairy Council, American Heart Association affiliates, local branches of the American Cancer Society, state coordinators of the USDA's Nutrition Education and Training Program, and state administrators of CACFP are several of the many resources that child-care program personnel can call on to help them implement an effective nutrition education plan. Other local resources for nutrition education include the Special Supplemental Nutrition Program for Women, Infants, and Children, the nutrition department at local health clinics or hospitals, the Agricultural Extension Service, and the local dietetic association. Caregivers should receive appropriate nutrition and foodservice training Those engaged in direct care giving should be informed about the basic principles of infant and child nutrition, strategies for creating a positive environment that promotes the development of good eating habits, and the importance of their role as a model for the children to follow in acquiring healthful behaviors. Foodservice personnel should have appropriate training in how to plan, prepare, and serve nutritious, safe, and appealing meals and snacks that are consistent with the dietary guidelines.

The importance of making nutrition information and training accessible to child-care personnel is underscored in research that demonstrates limitation in knowledge about food and nutrition. Research in child-care centers and family childcare homes suggests that only about half of caregivers know the main food sources for selected nutrients and/or appropriate serving size for vegetables for preschool-aged children (24,25). This lack of information is not, of course, limited to child-care personnel-a nationwide survey, for example, showed that the majority of adult men believe 1 serving of fruits and vegetables each day is adequate to maintain good health. But limited nutrition knowledge of caregivers can put children at risk. The complexity of the kinds of knowledge required to plan and serve well-balanced meals and snacks is illustrated by the amounts of juice in young children's diets. Although milk and fruit juice are nutritious foods, frequent substitution of juice, water, or other fluids for milk or formula may put a child at risk for inadequate calcium and vitamin D to promote healthy bone development (82). Some investigators have reported excessive intake of fruit juice (ie, more than 12 oz per day) to be associated with short stature and obesity (83). Other research has failed to confirm this relationship and warns against limitations on children's intake of 100% fruit juice (84). The evolving nature of research in this area illustrates why caregivers need to remain informed regarding the most current "best practices" for planning and serving meals and snacks that meet children's needs. Caregivers should regularly receive information and training from credible sources.

The USDA requires that sponsors of child-care centers and family day-care homes that participate in its CACFP provide annual training for child-care providers regarding child nutrition and the CACFP requirements. The American Public Health Association and the American Academy of Pediatrics recommend prescribed programs of nutrition-related education and experience tailored to the level of involvement that staff have with child-care foodservice (eg, to fill the position of child-care foodservice manager staff should have coursework in menu planning, basic foods, and introduction to child feeding programs). The USDA's Nutrition Education and Training Program and its Extension Services are resources that can be called on to help with staff training. In addition, community colleges and universities can provide low-cost training for child-care personnel and/or their graduate students or dietetic interns may be available to volunteer their services. The National Association for the Education of Young Children and the National Association for Family Child Care each include nutrition criteria in their self-study guides for accreditation (85,86). Taking advantage of these resources can help child-care programs achieve recommended standards for nutrition in child care.

Physical and Emotional Environment

Furniture and eating utensils should be age appropriate and developmentally suitable to encourage children to accept and enjoy mealtime Chairs, tables, and eating utensils should be comfortable, attractive, and suitable in size and shape for children. Appropriate accommodations should be made for children with developmental disabilities. Dining areas should be clean, cheerful, and supportive of healthful eating habits.

There are 2 reasons why it is important that special consideration be given to the physical environment at mealtime. First, it is important that the environment not imperil the children's health and safety. Chairs and tables should be of a size that enable the children to rest their feet on the floor so that they are comfortable and not in danger of falling. Eating utensils should be appropriate in size and weight to match the children's motor skills and protect the children from choking (16,87). The second reason for giving special consideration to the physical environment is that it should encourage healthful eating. Dishes should be attractive and free from nicks and cracks. The eating area should be cheerfully decorated and spacious enough for comfort. Posters and decorations that communicate nutrition messages can help to make the area cheerful and reinforce nutrition concepts that are taught by the children's teachers and modeled in the meals and snacks served at the child-care center.

Staff should encourage positive experiences with food and eating Family-style meal service is encouraged. The caregiver should be a role model, sitting at the table to eat with the children. Mealtime should be unhurried. Social interaction and conversation, especially conversation about food and eating behavior, should be encouraged.

A pleasant social and emotional environment encourages children to accept and enjoy food. Companionship at mealtime, a positive atmosphere, and appropriate food-related behavior by the caregiver has been shown to be related to dietary quality of preschool-aged children (40,78,87). Food should not be used as a reward or punishment, and conflict during meals should be avoided. Children learn about food and nutrition from messages conveyed by their caregivers (77,88). These messages can be conveyed through direct instruction, in conversation, in guided practice, and through modeling (88). Suggested caregiver mealtime behaviors also include encouraging, but not forcing, children to taste the food offered, and not requiring children to eat all foods offered before any additional servings of any food are given (66). Because the most effective role models are people who are admired or people with whom the child identifies, it is essential that caregivers participate with the children in making mealtime a pleasant opportunity for learning about and practicing healthful eating habits.

Compliance with Local and State Regulations Child-care programs must comply with local and state regulations related to wholesomeness of food, food preparation facilities, food safety, and sanitation Compliance with regulations that help to establish and maintain a safe, sanitary, wholesome environment in which children can learn about and practice good eating habits should be a priority in every child-care program. State and local governing agencies establish regulations to protect the health and safety of children and staff in child-care programs. These regulations may stipulate minimum child-to-staff ratios during foodservice or meal times, particular staff training and experience requirements, and/or requirements for ensuring cleanliness and safety of the facilities and food during storage, preparation, and service. State child-care licensing agencies and state and local public health offices can provide information about state and local regulations governing child-care programs.

DIRECTIONS FOR DIETETICS PROFESSIONALS

* Be accessible to child-care programs to assist with menu planning and evaluation and to provide nutrition information and education for caregivers.

* Encourage parents to become knowledgeable about child nutrition and to participate in planning menus, conducting nutrition education, and otherwise supporting the nutrition program at the child-care facility.

* Monitor food guidance systems and nutrition education resources to ensure that they are accessible and useful to caregivers.

* Work in partnership with national initiatives to encourage child-care facilities to participate in food assistance programs (eg, CACFP) and to link low-income families with high-quality child-care programs.

* Participate in research and in dissemination of research findings regarding best practices in child-care nutrition.

* Provide education for child caregivers regarding availability of programs that increase food security for young children.

* Help child caregivers in the delivery of nutrition services for culturally diverse children. * Provide training for child caregivers about the nutrition needs of children with special needs.

* Educate caregivers and families about best practices for food safety and sanitation.

* Participate in policy development and implementation to promote and support high quality child care.

* Work in partnership with food industries and federal nutrition programs to ensure that high-quality food is available to support child-care nutrition.

* Work in partnership with governing agencies to ensure high levels of compliance with regulations to protect the health and safe of children and staff in child-care programs.

SUMMARY

ADA supports achievement of comprehensive nutrition standards in child-care programs. The standards presented in this position paper focus on meeting the child's nutrition needs and providing a safe and pleasant environment that promotes acquisition of eating habits that prevent disease and enable healthy growth and development. Dietetics professionals can play a powerful role in advocating and assisting the acceptance of child-care nutrition standards by parents, caregivers, foodservice personnel, and directors and policy makers for child-care programs.

Footnote:

Health objectives for the year 2010 are being developed during 1999 and will be available in 2000. The draft objectives for Healthy People 2010, which were reviewed during the development of this position, indicate that the final document should include recommendations for nutrition standards for child-care settings that are similar to those in the Healthy People 2000 document. For up to date information about the Healthy People 2010 Objectives see the following government Web site: http://www.health.gov/healthypeople/2010fctsht.html.

Reference:

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* ADA Position adopted by the House of Delegates on October 26, 1986, and reaffirmed on September 11, 1993, and September 12, 1997. This position will be in effect until December 31, 2003. ADA authorizes republication of the position, in its entirety, provided full and proper credit is given. Requests to use portions of this position must be directed to ADA Headquarters at 800/877-1600, ext 4896, or hod@eatright.org.

* Recognition is given to the following for their contributions: Authors:

Reference:

Margaret E. Briley, PhD, RD (The University of Texas at Austin) and Cindy Roberts-Gray, PhD (The resource Network, Austin, Tex).

Reference:

ADA Government Relations Team (Tracy Fox, MS, RD); Cynthia Taft Bayerl, MS, RD (Massachusetts Department of Public Health, Boston); Edward M. Cooney (Special Nutrition Programs, Food and Nutrition Services, US Department of Agriculture, Alexandria, Va); Debra L. Moore, MPH, RD (Places and Programs for Children, Inc, Portsmouth, Va); Donna H. Mueller, PhD, RD, FADA (Drexel University, Philadelphia, Pa); Pediatric Nutrition dietetic practice group (Doris Fredericks, MEd, RD); Margaret J. Tate, MS, RD (Arizona Department of Health Services, Phoenix).

Members of the ADA Association Positions Committee work group:

Robert Earl, MPH, RD; Myrtle Hogbin, RD; and Jodie Shield, MEd, RD.