Know

Healthy lifestyle attitudes begin early. You can help young children develop healthy lifelong habits. Children need you to offer healthy food choices and model a healthy lifestyle. Understanding what to eat and how much to eat are important skills for young children to develop. Understanding the importance of physical activity and how to achieve it is equally significant for young children. Establishing and maintaining healthy lifestyle attitudes ultimately affects young children’s learning and reinforces the significance and strength of the mind-body connection.

Family Style Dining

One of the best ways to model healthy eating is through family style dining. Family style dining is considered best practice when eating with children. It involves adults sitting at the same table with young children, with the children serving themselves when possible, and eating together while sharing pleasant conversation.

When you participate in family style dining with young children, you:

• Prevent behaviors that increase the possibility of safety hazards or arguments— children taking someone else’s food, stuffing their mouths with food, choking, and playing with food.
• Promote language and vocabulary development. Children learn the names of new foods, and adults can model complex language around the size, color, texture, taste, and smell of foods. Meals are also a natural time for conversations about children’s lives, interests and ideas.
• Model manners and how to use utensils.
• Establish warm relationships between children and their peers.
• Promote hand-eye coordination as children handle dishes and utensils.
• Promote decision-making and problem-solving as children decide what to eat, how much to eat, and how to express their wants and needs. When you serve your plate with all the foods you have prepared for mealtime, you encourage children to try new foods too. But never force a child to eat.
• Allow children to see adults making healthy choices. This is an excellent opportunity for modeling these important lifelong behaviors.

Family style dining has a special look and feel. It should allow you and children to relax, enjoy a meal, and enjoy each other’s company. However, family style dining does not happen without challenges. Young children might spill their drinks, drop their forks, fidget in their seats, and squabble with peers. In addition, children may also engage in a number of unsanitary behaviors such as eating off of serving spoons, putting their own utensils into serving bowls, sneezing or coughing directly into food while passing it, or sneezing, coughing, or wiping noses into hands during a communal dining experience. These behaviors are common in young children as they learn a greater sense of independence and mastery of their physical skills, as well as an understanding of sanitary eating practices. You can read more about family style dining in the Benefits and Steps for Family Style Dining resource located in the Learn Activities section below. Remember to be patient and well prepared. Make sure materials to clean up minor spills are easily accessible, and be ready to remove and replace any unsanitary utensils or bowls that have been contaminated with fingers, saliva, mucus, etc. For example, to help your family style dining process proceed smoothly, you might explain, “I’m replacing the serving spoon, because it was used as a personal spoon.”

Just as in other caregiving routines such as diapering, toileting, and napping, proper documentation of feeding is essential. Information should be shared daily between children’s homes and the program so families and providers will know when the child last ate and therefore know when they may be hungry again. Take time to consider how you will track what children eat during family style dining; talk with your trainer or coach about good strategies for recording and sharing this information with families. Some families may prefer to receive information digitally and others may prefer to receive information on paper; you need to determine which way is going to be most beneficial to you in your home that allows flexibility but is easily adaptable to your day-to-day schedule. The information you share with parents and guardians is valuable. When parents make an effort to improve or maintain their good health, those benefits are strongly related to their children's good health. (Murphey et al., 2018).

Take a moment to watch these examples of family style dining.

Family Style Dining

Meal Components and Patterns

Offering young children appropriate foods and beverages—and for infants this includes human milk or formula—is necessary for proper growth, development, and health.

Feeding children nutritious foods starting in infancy affects brain development, skeletal and muscle development, and tooth development, as well as a reduction in tooth decay. Nutritious foods give young children energy to play and learn. Unhealthy foods, such as those high in sugar and fat, can make them tired and sluggish, which can affect their emotional and social well-being.

For a comprehensive resource on feeding infants, see the U.S. Department of Agriculture (USDA) resource, Feeding Infants in the Child and Adult Care Food Program at https://www.fns.usda.gov/tn/feeding-infants-child-and-adult-care-food-program.

For an age-based chart on the recommended foods for meals and snacks designed to meet a child’s nutritional needs, visit the U.S. Department of Agriculture (USDA) Nutrition Standards for CACFP Meals and Snacks page: https://www.fns.usda.gov/cacfp/meals-and-snacks

Here are some general meal component tips:

• Provide a balance and variety of healthy foods so young children learn to like a variety of foods and make healthy choices.
• Do not use food as reward or punishment. This can cause negative emotional connections to food which can transfer into adulthood and result in unhealthy eating habits and emotional stress.
• Offer water between meals and snacks to quench thirst and establish the healthy habit of staying well-hydrated.
• Juice, even if 100 percent juice, is an option for snack, but it’s not recommended. Juice is high in calories and sugar, and it has little nutritional value. Increased consumption of fruit juice is associated with increased risk for obesity. Offer fruits and vegetables as snacks instead of juice.
• Serve milk at meal times.

Remember to tailor your meal schedules and routines to the specific children in your care. Each infant’s feeding schedule is likely unique; it’s important to follow individual schedules and look for hunger cues. Even for toddlers and preschoolers, it is important to look for hunger signs (e.g., irritability, chewing items or fingers). No child should be forced to wait when hungry. Work with children’s families to help provide a meal schedule that best fits the needs of the children in your care; it may be that children of different ages snack at slightly different times.

If families in your program provide their child’s meals, it’s important that you monitor and supplement these meals when needed. Once again, refer to the USDA Child and Adult Food Care Program guidelines to assure that children are receiving the kinds of foods and nutrients they need. Child-care programs can also look to the U.S. Department of Agriculture’s Child and Adult Care Food Program for nutritional information related to each meal. You will find the recommended daily servings of each food group for breakfast, snack, and lunch in the Child Care Meal Pattern resource below in the Learn Activities section.

Food Choking Hazards

If you work with infants and toddlers, remember that you are responsible for ensuring that all food these very young children come into contact with is not a choking hazard. Choking happens quickly and silently. The general rule is that foods that are safe to eat are not round, hard, small, thick, sticky, smooth, or slippery. For a list of choking hazards and tips to reduce choking incidents, see the Reducing Choking Risks resource located in the Apply Activities section below. Never leave an infant or toddler unattended while eating. You should always be within an arm’s reach and in sight of very young children who are eating. Certain foods are known choking hazards. For example, children under 4 years old should not be given:

• Hot dogs (whole or sliced into rounds)
• Whole grapes
• Raw peas and carrot rounds
• Hard candy
• Nuts, seeds
• Hard pretzels, chips, peanuts, or popcorn
• Rice cakes
• Marshmallows
• Spoonfuls of peanut butter
• Chunks of meat larger than what can be swallowed whole

Regardless of a child’s age, watch to make sure they take reasonably sized bites. Intervene if a child stuffs their mouth or takes an overly large bite. Cut foods into pieces no larger than 1/4-inch square for infants and 1/2-inch square for toddlers/twos, according to each child's chewing and swallowing capability. Never leave an infant or toddler unattended while eating. You should be within an arm’s reach and in sight of infants and toddlers at all times.

Portion Control

It is your responsibility to serve proper portions of a well-balanced diet for each child. Awareness of portion sizes and knowledge of children’s physical development is important when serving healthy food.

Portion-control recommendations:

• Consider that a child’s stomach is about the size of their fist.
• Use child-sized pitchers, serving dishes, plates, bowls and cups; this will help children serve themselves and limit themselves to healthy portions.
• Limit waste by only putting a portion of available food in the serving dishes; refill as needed.
• Remember that children’s appetites and tastes change over time; it is normal for some children to consume a lot one day and then eat considerably less the next day.
• Model adventurous eating; try each food item yourself even if you know you don’t like it.
• Allow second helpings of nutritious foods.
• Avoid the “clean-your-plate club.” This forces children to eat more than they may naturally want to.
• Encourage, but don’t force, the one-bite rule; ask each child is asked to try one bite of all the food offered. There is no need to enforce this recommendation if a child is not interested to try a bite.

Bottle Preparation

Stringent preparation procedures for bottles, whether they contain breast milk or formula, exist to reduce improper preparation and contamination that can cause mild to severe illness.

Though preparation procedures are not difficult, they can be confusing because there are different procedures for different types of milk (human milk, brands and types of formulas).

Preparing Human Milk

The following are recommendations and tips for the feeding process with human milk:

1. It is important that the bottles are labeled with the infant's first and last name, date, and time the human milk was expressed. The labels and ink on the bottle need to be water-resistant so they are still readable if the bottle is thawed or warmed under running tap water. This is important since you may be thawing and warming bottles from different mothers at the same time in the same sink area.
2. Non-frozen human milk should be transported to your program in the containers you will be using for the feedings. When you receive the milk, you must place it in the refrigerator. Use refrigerated bottles of fresh breastmilk, kept at 40° Fahrenheit or below, within 48 hours from the time they were collected. Throw out unused breastmilk if not used within 48 hours.
3. Frozen human milk can be transported to your program and stored in labeled, single-use plastic bags and then placed in your program's freezer. Breastmilk can be stored in a freezer (with a separate door from the refrigerator), for up to 3 months from when it was collected. Freezer temperature should be 0° Fahrenheit or below. Once the breastmilk is removed from the freezer and thawed, refrigerate it at 40° Fahrenheit or below and use it within 24 hours; do not refreeze it.
4. Thaw a bottle of frozen breastmilk in the refrigerator or hold it under running lukewarm water. Thaw only as much frozen breastmilk as you think a baby will need for a feeding.

• Do not thaw frozen breastmilk at room temperature, by mixing with warm breastmilk, placing it in boiling water, or by heating on a stove or in a microwave. Liquid may become very hot when microwaved even though the bottle feels cool. The hot liquid could seriously burn babies. Also, heating damages important nutrients in breastmilk.
• If breastmilk has a bad odor after thawing, it may have spoiled and should be thrown out.

5. The feeding process should always begin with the caregivers’ hands being washed, followed by use of clean, sanitized bottles and nipples. Bottles that are made of plastics containing BPA should be avoided.
6. It is not necessary to wear gloves when handling or feeding human milk to an infant.
7. Gently swirl the bottle of breastmilk before feeding the baby as breastmilk often separates into two layers when it is stored. This separation is normal.
8. For those babies who prefer a warm bottle, hold the bottle under running warm (not hot) water immediately before feeding the baby. Warm only as much breastmilk as you think a baby will need for a feeding. Feed breastmilk immediately after warming. The temperature of the milk should not be greater than 98.6 F.
9. After a feeding, throw out any unused breastmilk left in a bottle and wash the bottle with soap and hot water immediately.
10. If there is a significant amount of human milk left in the container at the end of the day, you can return it to the family, as long as the child has not been fed directly from the container.

Feeding Human Milk to the Wrong Infant

When following proper bottle-preparation techniques, the chance of feeding breast milk to the wrong infant is small. In the case of an infant being fed another child’s human milk by mistake, there is a possibility of disease or infection transmission. If this mistake should ever happen in your program, you should immediately do the following:

1. Alert your trainer or coach so that you can either inform the family together or discuss the process of informing the family.
2. The two of you will need to inform the mother who expressed the human milk about the error and discuss with her how the milk was handled before it was delivered to your program. It will be important to ask if she is willing to discuss any important medical information with the family of the child who was mistakenly fed her milk.
3. Next, you will need to discuss the mistake with the family of the infant who was fed the wrong bottle. Let them know that the risk of transmission of infectious disease is low, but that it would be best to notify their child’s primary care provider of the mistake. Provide as much information as you can about the time and date the milk was expressed and how the milk was handled before coming to your program. Depending on the health history of the mother whose milk was given, the child who received the wrong bottle may need to have baseline blood tests for hepatitis B, hepatitis C, or HIV.
4. You, with the help of your trainer or coach, will need to assess how the wrong milk was given and to create a plan to prevent future mistakes from happening. This plan should be shared with families.

Although these precautions are extremely important, note that the Centers for Disease Control and Prevention has never had a documented case of HIV or hepatitis C transmission in expressed breast milk (CDPHE, 2016).

Preparing Infant Formula

Recommendations and tips for feeding an infant in your program with infant formula:

1. The first step in preparing infant formula is always wash your hands.
2. Whether you use formula that is provided by families or by your program, it should come in a factory-sealed container.
3. If you are using infant formula that your family child care program provides, you should inform the parents what kind of formula is served in the program, and let the parents decide if they want the infant to have that formula or if they want to supply their own. Ideally it should be the same formula that your families use at home. Even small differences can cause stomach upset and other problems in infants.
4. The infant formula families or your program provides may be ready-to-feed strength, liquid concentrate, or powdered.
   1. The liquid concentrate will need to be diluted with water according to the directions on the can.
   2. Powdered formula requires special care since it cannot be sterilized. Follow the manufacturer’s directions on the can for safe handling. Before you open the can, wash your hands! The can and plastic lid should also be rinsed and dried. When scooping out the powder, it is important to only use the scoop that the manufacturer provides in the can. Other utensils may not measure accurately, and there is also the possibility of contamination from other utensils.
5. If the formula is iron-fortified, you need to refrigerate it until just before you are ready to feed the infant.
6. Just as with human milk, all bottles of infant formula should be labeled with the child’s first and last name and time and date of preparation.
7. All prepared formula should be discarded within one hour of serving to an infant.
8. Open containers of ready-to-feed or liquid concentrate formula need to be covered, refrigerated, and labeled with the date they were opened and the child’s full name. If this formula is not used within 48 hours, it should be discarded. Prepared powdered formula that has not been fed to an infant can be stored in the refrigerator for up to 24 hours and should be covered and labeled with the child’s name and date of opening.
9. Just as with human milk, you can warm the infant formula depending on the family and child’s preference by running it briefly under warm water, or, if used in your program, in a bottle warmer. Again, never use a microwave to warm the bottle of formula, and do not shake the bottle excessively. Too much shaking can cause the formula to foam, which can increase the likelihood of feeding air to an infant, which can lead to discomfort and pain.
10. The temperature of the formula should not be greater than 98.6 F. You can test the temperature of the prepared formula by sprinkling a few drops of it on the inside of your wrist before feeding.

Soy-Based Formula and Cow’s Milk

Some infants who are lactose intolerant or who have other health issues may drink soy-based formulas. These bottles should also be labeled with the infant’s name, date, and time of preparation.

Cow’s milk should not be served to infants younger than 12 months unless the family provides written directions from their primary health-care provider. Between 12 months and 24 months of age, children who are not drinking breast milk can be served whole milk. If there is a risk of obesity or other health concerns, these children can have reduced fat or 2% milk.

Special Concerns

Sometimes an infant cannot have infant formula or soy-based formula due to certain health conditions. The infant may be allergic to milk or soy or may need extra calories to thrive. When this is the case, the family should provide a written plan from their primary health-care provider. All infants, but especially those under 6 months, who are thirsty should be given additional formula or breastmilk, but shouldn’t be given water unless directed by their parent, guardian, or physician.

Nurturing Care and Bottle Feeding

Bottle feeding is a time to emotionally connect with an infant while satisfying the need for nourishment. It is a time for patience and comfort, a time to be alert for their feeding cues, to engage in eye contact, and to talk and respond to infants’ vocalizations.

Feeding allows you to physically connect with an infant by holding him or her in a pleasing manner. Allow the infant to hold your finger or stroke the fabric of your shirt. This helps the infant to feel comforted and secure; bottles should never be propped during feedings.

Bottle-Feeding Techniques

The procedures for bottle-feeding are similar to breastfeeding approaches:

• Begin feeding when infant provides cues (rooting, sucking, turning head, open mouth, irritability that is not explained by other factors, etc.).
• Wash your hands and the infant’s hands before feeding.
• Hold the infant during feedings; even if an infant can hold his or her own bottle. Create a calm, warm and pleasant atmosphere.
• Alternate sides of your lap.
• Allow breaks during the feeding for burping.
• Allow infant to stop the feeding when full.

When you are feeding an infant, arrange your body so you can properly supervise and engage with the rest of the children in your care. Consider how you will set up the environment to provide a comfortable space for feeding as well as a safe place for the other children to play. Before you go to wash your and the infant’s hands to begin the feeding procedure, arrange a safe activity or idea for the other children to engage in and remind them of the safe places or things they can do while you feed the infant. You can also invite older children in your care to help you.

Feeding Techniques to Avoid

• Bottles should never be propped.
• Do not bottle feed more than one infant at a time.
• Infants should not be permitted to have a bottle in the crib.
• Young children should not be permitted to carry a bottle while standing, walking, or running.
• Don’t force an infant to eat or to finish a bottle.
• Don’t display anger or frustration concerning an infant’s feeding.

Cue Feeding

Infants should be fed when they display feeding cues rather than on a schedule unless the family gives written instructions otherwise. Feeding by a cue meets the infant’s nutritional and emotional needs and provides the infant with an immediate response. This shows the infant that you are there to meet their physical needs, which helps them develop trust and feelings of security. As you consistently feed an infant, you better understand their cues and respond appropriately in a manner that is satisfying to them. Cues that an infant is hungry might include:

• opening their mouth
• turning their head
• rooting
• making sucking sounds
• moving hands at random.

Cue feeding also tells you when an infant is full and done eating. Cues that indicate a child is full include:

• Infant turning away from the bottle's nipple
• Increased atten­tion to surroundings
• Keeping mouth closed
• Shaking head or saying “no”
• Infant playing with, chewing, or mouthing the bottle's nipple without sucking

See

Feeding Infants Correctly

Physical Activity

Physical activity is a critical component of children’s development and overall well-being. Think of physical activity as one more way to model healthy habits for children. Physical activity promotes a healthy lifestyle and prevents obesity.

In family child care programs, there are two main ways to promote physical activity: offer daily opportunities for outdoor play and model or encourage movement or exercise indoors and outdoors. All children should have at least two or three chances to play outdoors each day, weather permitting (Caring for our Children, 2019). In addition, young children should have two or more structured, or caregiver-led games that promote movement throughout the day, either indoors or out, and many opportunities to practice age-appropriate motor skills and movement. Toddlers should have at least 60 to 90 minutes outdoors, weather permitting, and 60 to 90 minutes over the course of the program day for more vigorous activity (e.g., running, jumping, dancing).

It is also important to promote physical activity indoors. Music and movement is a great way to incorporate physical activity indoors and allow children opportunities to express themselves and have fun with their peers.

Infants should have some supervised tummy time every day. To avoid accidental suffocation, NEVER leave a child unattended during tummy time, even for a second. Caregivers can slowly increase the amount of time an infant is on his or her tummy as the individual infant shows increasing enjoyment of the activity. Tummy time helps develop strength for later motor movement. To support infant movement and caregiver interaction, infants should not be seated for more than 15 minutes at a time, except during meals or naps. You can find more information on tummy time in the Tummy Time for Infants resource below in the Learn Activities section. Much more on supporting young children’s physical development, including more information on tummy time, can be found in the Physical Development course.

Do

To encourage and model healthy feeding, eating, and physical activity habits, always do the following:

• Feed infants on cue.
• Build secure relationships between you and the children, which will help you recognize their feeding patterns.
• Listen for crying that may indicate missed feeding cues.
• Do not feed an infant who does not show signs of hunger.
• Know that cues vary among infants; become familiar with each infant’s mannerisms and cues.
• Observe the children in your care and talk with their families to understand what feeding schedule best fits each child.
• When caring for more than one infant, build your family child care program schedule on your knowledge of each child’s feeding schedule, so that you can individually bottle feed each child.
• Prepare materials and the environment ahead of time so that when you bottle-feed an infant, the other children in your care are appropriately engaged, allowing you to easily monitor all the children while also provide nurturance to the child being fed.
• Do not use pacifiers when infants are hungry. Instead, work to quickly offer a bottle or food and use soothing words to describe the child’s feelings as you work to remedy their hunger.
• Practice family style dining.
• Provide appropriately sized foods.
• Encourage children to try new foods.
• Respect when children show signs of fullness.
• Document daily what and when young children, especially infants and toddlers, eat, and share this information with families at pick up time.
• Eat healthy foods and drinks. Do you drink soda, eat fast food, chips, or sweets in front of the children? Because they look up to you, the children in your care will want to consume food and drinks similar to what you consume.
• Share a weekly menu so families know about the foods you plan to serve and can provide substitutes as necessary.
• If families provide their own meals and snacks, ensure these are nutritious, and supplement when necessary.
• Sit down to eat and drink for snacks and meals. Teach children that they must sit while eating and drinking. Model this habit by doing so yourself.
• Be physically active during indoor and outdoor gross-motor time. Do you supervise infants and toddlers while up, moving, and playing or while sitting? Children will imitate the behaviors you model.
• Provide a variety of healthy foods. For ideas, see the “Grow It, Try It, Like It!” materials provided by the U.S. Department of Agriculture to integrate activities about where food comes from into your curriculum. Designed expressly for family child care providers, these resources provide practical steps for you to deliver garden-based nutrition education to the children in your care. Sections are available about farmer’s markets, mixed-age activities, and aids to help you implement planting, growing, harvesting, and eating foods grown right at or near your family child care home. Visit https://www.fns.usda.gov/tn/grow-it-homes to access the resources.

Promoting Oral Health

Good oral health begins early in life. Take a moment to review the information at the following link to learn about practices for starting and sustaining good oral health for young children: https://www.health.ny.gov/prevention/dental/birth_oral_health.htm. Share these practices with children’s families. To help get parents thinking about building good oral hygiene habits early, you may want to display the 5 Ways to Prevent Kids’ Tooth Decay poster from the American Dental Association at https://www.mouthhealthy.org/-/media/project/ada-organization/ada/mouthhealthy/files/ada_mh_5ways.pdf.

After meals, it is important to encourage children to brush their teeth. Good oral health is associated with improved overall health. Make sure each child has his or her own toothbrush. Store toothbrushes so they do not touch each other and can air dry. When you apply toothpaste, make sure the toothpaste container does not touch children’s brushes. Each child should have their own tube of toothpaste, or try using a cup or plate to dispense the toothpaste onto and place carefully on each child’s brush so as to decrease the spread of germs. Only use a small smear of toothpaste for children under 2 and a pea size amount for children over 2. Teach children proper brushing techniques.

Supporting Physical Activity Outdoors

To make sure children stay safe and healthy outdoors, follow these precautions:

• Make sure each child is dressed for the weather. Encourage parents to dress children in layers that can be easily removed if needed.
• Have extra clean mittens, jackets, and hats available if a child does not have appropriate gear.
• Make sure all clothing a child wears is dry.
• Offer shaded and sheltered areas outdoors.
• Use sun protection on sunny days, as appropriate for the child’s age and the family’s preferences.
• Make sure water is available or that additional formula or breastmilk is available for infants.