1304.23

 

 

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1304.23

Child Nutrition

(a) Identification of Nutritional Needs

(b) Nutritional Services

(c) Meal Service

(d) Family Assistance with Nutrition

(e) Food Safety and Sanitation

INTRODUCTION TO 1304.23

The objective of 45 CFR 1304.23 is to promote child wellness by providing nutrition services that supplement and complement those of the home and community. Head Start’s child nutrition services assist families in meeting each child’s nutrition needs and in establishing good eating habits that nurture healthy development and promote life-long well-being.

This section includes standards in five areas: the identification of each child’s nutritional needs; the design and implementation of nutritional services programs; meal service in center-based programs; family assistance with nutrition; and food safety and nutrition.
Performance Standard

1304.23(a)

(a) Identification of nutritional needs.

Staff and families must work together to identify each child's nutritional needs, taking into account staff and family discussions concerning:

  

Rationale: A child’s healthy development is promoted through ongoing communication between staff and families concerning nutrition-related child assessment data, family eating patterns, the child’s feeding schedules and eating preferences, and community nutritional issues. This rationale serves 45 CFR 1304.23(a)(1)-(4).

Related Information: See 45 CFR 1304.23(a)(3) for information on feeding and elimination patterns.

Guidance: A variety of opportunities exist for staff and parents to discuss each child’s nutritional needs. Discussions may take place during enrollment, or at meetings called especially to discuss family partnership agreements (see 45 CFR 1304.40(a)(2)), initial home visits, and early staff-parent conferences. Staff members who may be involved in these discussions include: home visitors, teachers, qualified nutritionists or registered dietitians, kitchen staff, health care providers, including dentists and lactation consultants, and the Head Start staff persons in charge of nutrition, health, or disabilities services.

As the nutritional needs of young children change rapidly over a period of weeks or months, periodic reassessment is necessary. For infants and toddlers, it is especially important that parents provide and regularly update certain key nutritional information about their children’s needs, feeding, and elimination patterns. It also is important that parents share with appropriate personnel special nutritional and feeding requirements for children with disabilities.

One way to gather information on nutritional requirements and feeding patterns is to ask families to prepare a record of each child’s nutritional intake and feeding schedule over a period of time. Such a brief dietary history is useful as a basis for discussions with the family about a child’s nutritional requirements.
Performance Standard

1304.23(a)(1)

(1) Any relevant nutrition-related assessment data (height, weight, hemoglobin/hematocrit) obtained under 45 CFR 1304.20(a);

  

Guidance: The child’s current health or medical history record contains important information related to nutritional status. These data are particularly critical for identifying children who are over- or underweight, underheight, or anemic.

In assessing children’s nutritional status, it is important to recognize that healthy children have individual differences and patterns of growth. Thus, one should refrain from comparing one child’s development to another’s. Rather, it is important to involve a health professional or a nutrition specialist in the review of nutritional data, as well as in the development of treatment and follow-up plans. Other local resources, such as the Supplemental Nutrition Program for Women, Infants, and Children (WIC), also are helpful in providing assistance. Discussions with parents on nutritional needs and treatment strategies that can be followed during program hours and at home further support this process; and providing staff and parents with information on typical growth patterns is another method that is used to facilitate the identification of unusual, nutrition-related situations.
Performance Standard

1304.23(a)(2)

(2) Information about family eating patterns, including cultural preferences, special dietary requirements for each child with nutrition-related health problems, and the feeding requirements of infants and toddlers and each child with disabilities (see 45 CFR 1308.20);

  

Guidance: Family eating patterns vary according to many factors, including the availability of certain foods, family preferences, and family income. A registered dietitian or qualified nutritionist can provide staff with background information about how to conduct discussions related to nutritional needs and health, while taking proper dietary guidelines and family preferences and income into consideration. Topics that may be raised in discussions with parents include:

cultural, religious, ethical, or personal food preferences (such as vegetarianism), and medically prescribed diets that should be taken into account when planning menus,
nutrition-related health problems diagnosed by a health professional, such as obesity, iron deficiency, failure-to-thrive, food allergies and intolerances, such as milk allergies and lactose intolerance, that require special dietary considerations,
healthy eating on a family budget, and
any adaptations or accommodations needed for children with disabilities.
Performance Standard

1304.23(a)(3)

(3) For infants and toddlers, current feeding schedules and amounts and types of food provided, including whether breast milk or formula and baby food is used; meal patterns; new foods introduced; food intolerances and preferences; voiding patterns; and observations related to developmental changes in feeding and nutrition. This information must be shared with parents and updated regularly; and

  

Related Information: See 45 CFR 1304.40(e)(3) for additional suggestions about how to share information with parents on a daily basis. See 45 CFR 1304.40(c)(3) for information on the benefits of breast feeding.

Guidance: Infant nutritional needs change rapidly during the first year of life. Therefore, regular communication between parents and staff helps to ensure that nutritional needs are met, both at home and in the Head Start Program setting. Initial discussions with parents of infants may include topics such as:

how and when each child is fed,
whether the child consumes breast milk or formula,
the introduction of new foods and solid foods,
the child’s elimination patterns,
feeding preferences and problems, and
safe food preparation and handling.

Throughout the year, staff and parents also discuss nutritional changes and specific issues surrounding weaning, teething, the introduction of solid foods, the appropriateness of different foods at various developmental levels, infant reactions to new foods or to food changes, and strategies for dealing with adverse reactions to various foods.

Daily conversations with parents that address infant and toddler food intake, as well as eating and elimination patterns, are one method of sharing information. Therefore, time is set aside to discuss these issues, perhaps as parents come to pick up their children.
Performance Standard

1304.23(a)(4)

(4) Information about major community nutritional issues, as identified through the Community Assessment or by the Health Services Advisory Committee or the local health department.

  

Guidance: Information contained in the Community Assessment (see 45 CFR 1305.3) helps to identify children’s nutritional needs. This information includes topics such as:

the quality of the local food and water supply, such as availability of fluoridated water and fresh fruit and vegetables, and
nutrition-related, prevalent health conditions in the community, such as hunger, obesity, diabetes, hypertension, baby-bottle tooth decay (infant dental caries), and lead poisoning.

If this information is not available in the Community Assessment, the Health Services Advisory Committee, State and local health department nutritionists, or community health organizations may be helpful in obtaining it.
Performance Standard

1304.23(b)(1)

(b) Nutritional services.

(1) Grantee and delegate agencies must design and implement a nutrition program that meets the nutritional needs and feeding requirements of each child, including those with special dietary needs and children with disabilities. Also, the nutrition program must serve a variety of foods which consider cultural and ethnic preferences and which broaden the child’s food experience.

  

Rationale: One essential aspect of healthy growth and development is a nutrition program that meets each child’s nutritional needs, feeding requirements, and feeding schedules. A related aspect is proper dental hygiene, to prevent tooth decay and gum disease, which includes the teaching of habits that can preserve dental health through a child’s life. By involving parents and appropriate community agencies in all aspects of nutrition services, Head Start agencies ensure that menus and cooking styles take into account cultural and ethnic preferences, comply with Head Start and Departments of Agriculture and Health and Human Services (USDA/HHS) recommendations and requirements, and fully use community food resources. This rationale serves 45 CFR 1304.23(b)(1)-(4).

Related Information: See 45 CFR 1304.23(c)(1) for information on serving a variety of foods; 45 CFR 1304.23(b)(1)(i) regarding required documentation from health care providers for menu substitutions; 45 CFR 1304.23(b)(1)(iv) and (v) for information on feeding schedules; and 45 CFR 1308.20 on nutrition services for children with disabilities.

Guidance: Nutritional needs and requirements are met by serving a variety of healthy foods, including breads and other grain products, vegetables, fruits, meat and meat alternates (such as eggs, nuts, seeds, dry beans, peas, and cheese), and milk and milk products (yogurt and cheese). The USDA/HHS Food Guide Pyramid provides a basis for determining the kinds and amounts of the food groups to be eaten each day. Children are thus introduced to a broad variety within the food groups, while at the same time honoring, through careful menu planning, cultural, religious, ethical, and personal food preferences.

Staff and parents play an important role in the implementation of the nutrition program. Parents provide information on cultural and ethnic preferences and requirements, and that information is used to develop menus sensitive to the needs of families. In addition, the Health Services Advisory Committee provides input into the development of menus and information on other issues related to nutrition.

The nutrient needs of children with disabilities are the same as those of other children. However, due to difficulties in chewing or swallowing, or due to a lack of feeding abilities, the texture and consistency of foods may need to be modified. Modification of the menu for children with disabilities or for children with special medical or dietary needs are always undertaken in consultation with the child’s primary health care provider and with the assistance of a qualified nutritionist or registered dietitian. (See 45 CFR 1304.52(d)(3) on the qualifications of content area experts in nutrition.)
Performance Standard

1304.23(b)(1)(i)

(i) All Early Head Start and Head Start grantee and delegate agencies must use funds from USDA Food and Consumer Services Child Nutrition Programs as the primary source of payment for meal services. Early Head Start and Head Start funds may be used to cover those allowable costs not covered by the USDA.

  

Related Information: See 7 CFR Parts 210, 220 and 226 for information on USDA meal pattern requirements.

Guidance: The USDA Child and Adult Care Food Program (CACFP) is the primary source of reimbursement for meals for Head Start children. Therefore, agencies need to know about any changes in the CACFP program. Currently, agencies can claim reimbursement from CACFP for a daily maximum of two meals and one snack, or two snacks and one meal, for each enrolled child in attendance.

For individual children with special medical or dietary needs, substitutions can be made in meal patterns without approval from the USDA, if a supporting statement signed by a recognized medical authority is on file, and if that statement specifies how each child’s diet is restricted and which foods provided by the program or the parents must be substituted. The USDA requires agencies to make substitutions or modifications in the standard meal patterns for children who are unable to consume program meals due to mental or physical disabilities that limit one or more major life activities.

Children who arrive early, stay late, or simply are hungry may require an additional snack or meal. If the CACFP or other funding sources will not provide reimbursement, Head Start funds may be used. For example, a child who arrives at a migrant program at 4 a.m. may require and, therefore, is provided with a nutritious snack before breakfast. In such cases, Head Start funds may be used as the dollars of last resort.
Performance Standard

1304.23(b)(1)(ii)

(ii) Each child in a part-day center-based setting must receive meals and snacks that provide at least 1/3 of the child's daily nutritional needs. Each child in a center-based full-day program must receive meals and snacks that provide 1/2 to 2/3 of the child's daily nutritional needs, depending upon the length of the program day.

  

Related Information: See 45 CFR 1304.23(b)(1)(iv) for information on introducing new foods to children, and 7 CFR 226.20 for Child and Adult Care Food Program (CACFP) meal requirements and 45 CFR 1304.23(b)(2) and 1306.33 for requirements in the home-based program options.

Guidance: The Recommended Dietary Allowances (RDAs) of the National Research Council of the National Academy of Sciences are used to establish the nutritional needs of children. Analyses of nutrients in food served and Nutrition Facts Labels on most processed foods can be compared to the RDAs, as a cross-check to ensure that one-third of the nutritional needs of children in part-day programs, and one-half to two-thirds of the nutritional needs of children in full-day programs are met. Guidelines for the meal patterns of the Child and Adult Care Food Program (CACFP) provide a variety of options.

Use of cycle menus of three weeks or longer helps in formulating balanced and varied menus, as well as in planning purchase orders and work schedules. Before starting a new cycle of menus, children’s acceptance of food items on the menu can be checked, so that changes can be made. Posting menus in the food preparation and dining areas and sending menus home to parents helps to facilitate the integration of nutrition activities, especially if such menus are designed to cover an entire food cycle. To keep staff, parents, and children informed of changes, substitutions are indicated on all menus.
Performance Standard

1304.23(b)(1)(iii)

(iii) All children in morning center-based settings who have not received breakfast at the time they arrive at the Early Head Start or Head Start program must be served a nourishing breakfast.

  

Related Information: See additional guidance under 45 CFR 1304.23(b)(1)(vi) for information on suggested breakfast foods. See 7 CFR 226.20 for CACFP breakfast requirements.

Guidance: Breakfast is generally served to children upon their arrival. If only a small number of children arrive without breakfast, morning snacks for all children may be supplemented with additional foods, so that the CACFP breakfast pattern is met. However, if a majority of the children come without breakfast, it may be more efficient to serve a family style breakfast to all children. Children who have already had breakfast, or who do not wish to eat, may choose an alternate activity.

If group socialization activities begin in the morning, agencies may serve breakfast to participants — and, if such activities are scheduled through lunch, lunch, too, may be served.
Performance Standard

1304.23(b)(1)(iv)

(iv) Each infant and toddler in center-based settings must receive food appropriate to his or her nutritional needs, developmental readiness, and feeding skills, as recommended in the USDA meal pattern or nutrient standard menu planning requirements outlined in 7 CFR parts 210, 220, and 226.

  

Related Information: For information on CACFP requirements, see 7 CFR Part 226. Similarly, 7 CFR, Parts 210 and 220, contains information to assist centers serving meals in accordance with the School Meal Initiatives for Healthy Children. See 45 CFR 1304.40(c)(3) for further information on breast feeding.

Guidance: Agencies other than school systems follow the CACFP meal patterns. School systems may follow the nutrition standards set forth in the School Meal Initiatives for Healthy Children, which prescribe nutrition standards, appropriate nutrient and calorie levels, and quantities of menu items and foods for different age groups.

Breast milk is the optimal food for infants, as it gives them complete nutrition in the first four to six months of life, continues to be an important nutrient source for the first year, and helps to provide them with resistance to infection. According to the American Academy of Pediatrics (AAP), the introduction of cow’s milk, skim milk, 1 percent to 2 percent fat milk, and evaporated milk is not recommended in the first 12 months of life. The AAP recommends that children between age one and two receive whole cow’s milk, instead of skim or 1 percent to 2 percent fat milk, unless recommended otherwise by the child’s primary health care provider.

The introduction of solid foods is usually accomplished between four and seven months of age, depending upon each child’s nutritional and developmental needs, and only after consultation with the parents and the primary health care provider. Until a child has reached the above ages, he or she is not able to completely digest solid food, and the neuromuscular skills needed for eating and swallowing solid foods are not yet well-developed. New foods, therefore, are introduced one at a time, at least one week apart, to make it easier to identify food allergies or intolerances.

Caregivers help toddlers become independent at meal times by encouraging them to select from a variety of acceptable foods, including those that represent cultural preferences. It also is helpful to cut their food into small pieces, as toddlers often swallow pieces of food whole. Head Start staff and the toddler’s parents, in some cases with consultation and advice from a qualified nutritionist, registered dietitician, or health care provider, are responsible for what the toddler is offered, as well as where, when, and how food is served. The toddler, on the other hand, is responsible, within reason, for how much food she or he eats. Young children have a tendency to display daily variation in the kind and quantity of food consumed due to varying energy levels, differing stages of growth, and an emerging sense of independence. Therefore, meals do not need to be completely balanced each day. Rather, dietary intake should be balanced over a period of several days, or a week, to provide adequate nutrition. For that reason, documenting children’s food consumption is an important part of staff members’ ongoing observation of each child.

Although infants and toddlers may eat many different kinds of food, some foods pose a high risk of choking. Therefore, agencies avoid serving such foods, examples of which are:

hot dogs or sausage rounds,
whole grapes, hard raw vegetables and fruits, and uncooked dried fruit, including raisins,
candy,
whole nuts, beans, seeds or grain kernels,
pretzels, chips, peanuts, and popcorn,
marshmallows, chewing gum, and spoonfuls of peanut butter, and
chunks of meat.

Some other foods also may pose health risks to children less than a year old, including honey, since it may contain a kind of botulism that is harmful to infants, and foods that can be highly allergenic, such as eggs and cow’s milk.

Home visitors and other staff discuss with families the feeding stages of infants and toddlers and how families meet the special nutritional and feeding requirements of the youngest children. The CACFP infant and toddler meal patterns are discussed and used as a guide for parents to serve appropriate quantities and varieties of food at home.
Performance Standard

1304.23(b)(1)(v)

(v) For 3- to 5-year-olds in center-based settings, the quantities and kinds of food served must conform to recommended serving sizes and minimum standards for meal patterns recommended in the USDA meal pattern or nutrient standard menu planning requirements outlined in 7 CFR parts 210, 220, and 226.

 Related Information: For information related to the Child and Adult Care Food Program and the School Meal Initiatives nutrition standards and patterns, see the guidance under 45 CFR 1304.23(b)(1)(i) and (ii).

Guidance: Home visitors and other staff discuss with families the USDA/HHS Dietary Guidelines for Americans and the USDA Food Guide Pyramid, as well as means of ensuring that meals and snacks conform to those recommendations (such as reviewing the Nutrition Facts Labels on most processed foods). In developing menus that follow the USDA/HHS guidelines, staff include foods traditional to the culture of the families served, to demonstrate how to incorporate the guidelines into everyday meal planning and preparation. Snacks also are an important source of nutrition for young children, and are used to supplement nutritional needs that may not be met through regular meals.
Performance Standard

1304.23(b)(1)(vi)

(vi) For 3- to 5-year-olds in center-based settings or other Head Start group experiences, foods served must be high in nutrients and low in fat, sugar, and salt.

  

Guidance: Some foods, such as cheese and other milk products, are actually considered protective for teeth, and are offered frequently to children as part of meals and snacks. However, sweet and sticky foods are used in moderation, especially those high in refined sugars. Studies have shown that eating sweets and other refined carbohydrates causes tooth decay, because such foods continue to produce harmful acid over a long period of time. It is important to remember that the frequency, rather than the amount, of the food eaten is an important factor in whether or not tooth decay will occur. If foods high in sugar are served, they are offered at the end of meals, when experts say the acid environment in the mouth is lower, in order to help reduce the risk of tooth decay.

Suggestions for moderating the amount of fat, sugar, and salt in everyday meals include:

Providing low-fat milk and cheese for children older than two years of age;
Reducing salt in cooking;
Avoiding adding sugar to cereals by sweetening them with fresh fruit, substituting applesauce for maple syrup on pancakes, and eliminating the use of fatty breakfast meats; increasing the use of low-fat, whole grain muffins and bagels, fruit pancakes, and fruit shakes;
Serving full-strength, (100 percent) fruit juice, rather than drinks called fruit juice drinks, as the latter have added sugar and are less than 100 percent juice; and
Avoiding the placement of additional sugar, salt, butter, or margarine on tables.

The use of foods high in fats, especially saturated fats (which raise cholesterol levels), should be gradually reduced, although some fat in the diet is essential for good health, especially in young children. The USDA/HHS Dietary Guidelines for Americans recommends the gradual reduction of fat to no more than 30 percent of calories for children between 2 and 5 years of age. As children begin to consume fewer calories from fat, those calories are replaced with more grain products, fruits, vegetables, and low-fat milk products or other calcium-rich foods, as well as with beans, lean meat, poultry, fish, or other protein-rich foods.
Performance Standard

1304.23(b)(1)(vii)

(vii) Meal and snack periods in center-based settings must be appropriately scheduled and adjusted, where necessary, to ensure that individual needs are met. Infants and young toddlers who need it must be fed "on demand" to the extent possible or at appropriate intervals.

  

Related Information: For specific information on the proper method of storing and handling breast milk and formula, see 45 CFR 1304.23(e)(2).

Guidance: Feeding on demand is the best way to meet an infant’s nutritional and emotional needs. In addition, feeding on demand helps infants to develop trust and a feeling of security. However, feeding on demand does not mean offering food every time an infant shows signs of discomfort. A crying infant may want attention and interaction or sleep, and not food.

When the individual needs of a particular child vary from expected eating patterns, eating too much or too little, for example, staff should consult with the child’s parents, and a qualified nutritionist, registered dietitian, or other health professional before establishing a new feeding pattern. Children should never be forced to eat at home or in the program setting. However, since individual children’s food preferences and eating patterns may vary dramatically, both staff and parents can benefit from information and training about ways to encourage good eating habits in all children.

Nutritious snacks often provide an important part of a child’s daily food intake. For older children, agencies may wish to keep snacks, such as fruit, peanut butter, vegetable sticks, and whole grain products, available at all times, so that hungry children can select nutritious food for snacks. Snacks also may be provided to children on field trips, group socializations, health clinic visits, or during other, off-site experiences.
Performance Standard

1304.23(b)(2)

(2) Grantee and delegate agencies operating home-based program options must provide appropriate snacks and meals to each child during group socialization activities (see 45 CFR 1306.33 for information regarding home-based group socialization).

  

Guidance: Home visitors and parents plan and conduct food preparation and nutrition education experiences during group socializations on a regular basis. Such times also may be used to discuss nutrition issues with parents, such as ways to:

Plan menus;
Budget meals;
Recognize hunger in infants and young children;
Encourage healthy eating patterns in children;
Broaden children’s tastes in good food, as well as their food preferences;
Balance good nutrition with physical activity;
Limit fat, sugars, and salt in children’s diets, when appropriate; and
Honor and respect cultural, religious, ethical, and personal food preferences.
Performance Standard

1304.23(b)(3)

(3) Staff must promote effective dental hygiene among children in conjunction with meals.

  

Related Information: For further guidance on baby bottle tooth decay (infant dental caries), see 45 CFR 1304.23(c)(5).

Guidance: Effective dental hygiene practices differ according to the age and developmental level of the child. Guidelines for toothbrushing and good dental hygiene follow:

Infant teeth are cleaned, beginning with the eruption of the first tooth at about five or six months of age. Use a gauze pad for infants less than one, and switch to a toothbrush at one year of age. Use only water to clean teeth (not toothpaste), since an infant will likely swallow the toothpaste. When a toddler is able to spit toothpaste out without swallowing it, an adult begins brushing the child’s teeth twice a day with a small amount of fluoridated toothpaste;
Staff and parents are educated about proper ways to prevent baby-bottle tooth decay and other early childhood cavities;
Proper care of teething toys is considered part of dental hygiene, as toys need to be kept clean and never shared;
Each preschool child is taught to brush his or her own teeth with a "pea-size" amount of fluoridated toothpaste. Staff supervise toothbrushing after each meal, ensuring that
Each child has his or her own toothbrush, labeled by name, so that toothbrushes are never shared;
Toothbrushes are stored so they stay clean and open to circulating air, and so that the bristles do not touch any surface, including another toothbrush. Agencies follow Health Services Advisory Committee recommendations regarding the proper storage and disposal of toothbrushes;
Toothbrushes are replaced when the bristles become bent, and at least every three months. They are never decontaminated. Rather, contaminated toothbrushes are always discarded to control the spread of infection or illness; and
Children are taught proper toothbrushing techniques, and children with disabilities are supported with any needed adaptations.
When brushing after meals is not possible (e.g., on a field trip), children may be offered drinking water, as rinsing with water helps to remove particles from teeth and prevent cavities; and
Staff serve as role models by brushing their own teeth after meals.

Staff encourage and assist parents in scheduling dental appointments, as a part of the schedule of well child care described in 45 CFR 1304.20(a)(1)(ii). Dental appointments also provide an opportunity for parents to discuss with their dental health professional such issues as the use of fluorides and dental sealants.
Performance Standard

1304.23(b)(4)

(4) Parents and appropriate community agencies must be involved in planning, implementing, and evaluating the agencies’ nutritional services.

  

Guidance: Involving parents in the nutrition program and related activities is accomplished in a variety of ways. For example, parents are encouraged to participate in program nutrition activities by:

Planning menus;
Assisting with classroom nutrition activities;
Assisting with dental hygiene activities;
Serving as volunteers or staff for food service activities; and
Reviewing the nutrition program on an ongoing basis.

Staff send menus home with children (in the parents’ preferred language, whenever possible), so that parents are aware of the meals and snacks planned for their children.

Many agencies are resources for additional funding, equipment, food, or professional guidance and resources that support a high quality nutrition program. Such agencies will be identified in the Community Assessment, and include some of the following organizations:

USDA child nutrition programs, such as the Child and Adult Care Food Program (CACFP) and the Supplemental Nutrition Program for Women, Infants, and Children (WIC);
State Nutrition Education and Training Program (NET) Coordinators in State health or education departments or the (State) Cooperative Extension Service; and
Professional and trade organizations, such as the American Dietetic Association, American Home Economics Association, American Academy of Pediatrics, American Dental Association, and Society for Nutrition Education.

Representatives from these groups are invited to speak with parents and staff, serve on the Health Services Advisory Committee, and help in accessing resources. Head Start staff work closely with parents and community agencies who provide food (where licensing agencies permit it) to make certain that donated foods are healthy and are compatible with the Head Start nutrition philosophy.
Performance Standard

1304.23(c)

(c) Meal service.

Grantee and delegate agencies must ensure that nutritional services in center-based settings contribute to the development and socialization of enrolled children by providing that:

  

Rationale: Food-related activities and leisurely meal times provide opportunities for the development of positive attitudes toward healthy foods; for decision-making, sharing, communicating with others; and for the development of muscle control and eye-hand coordination. Children also learn appropriate eating patterns and meal time behavior when they observe adult behavior at family style meals. Children who are forced to eat, or for whom food is used to modify behavior, may develop unpleasant or undesirable food associations. This rationale serves 45 CFR 1304.23(c)-(c)(4).

Related Information: See 45 CFR 1304.53(b)(1)(iii) for information on child-sized furniture and equipment. See 45 CFR 1304.23(c)(4) and (c)(5) for information on the important role of nutritional services in supporting the development and socialization of infants and toddlers.

Guidance: Meal times provide a range of opportunities that support the development and socialization of children. Suggestions for making the most of such opportunities include:

Serving meals in a pleasant, well-lit, and ventilated area that encourages socialization;
Considering how food-related activities can support and enhance each child’s social, emotional, cognitive, and physical skills and abilities. For example, agencies provide child-sized furniture and utensils, wherever possible; and
Involving families in food preparation and meal time activities at the program, and discussing ways to use such activities as learning opportunities in the home.
Performance Standard

1304.23(c)(1)

(1) A variety of food is served which broadens each child's food experiences;

  

Related Information: See 45 CFR 1304.23(b)(1)(iv) for information on introducing foods to infants and toddlers.

Guidance: Suggested ways to broaden food experiences include:

A small amount of one new food is offered along with a meal of familiar foods;
Children are prepared for the new food through activities in the program setting or through a home visit, such as reading stories about the food, shopping for the food, helping in its preparation, and perhaps, actually growing food or seeing it grow in a garden;
Snack time is used to introduce a new food; and
Agencies explore various ways a food item is prepared and served in different cultures. For example, different people prepare bread in many different ways (tortillas, biscuits, pita, bagels, fry bread, oven bread, and soda bread).

Home visitors and other staff support these efforts by discussing with families ideas for new meals and foods the family could try. Home visitors also can plan food preparation activities with parents to conduct with children in the home on a regular basis. Agencies may be able to obtain food supplies from local food banks for such activities.
Performance Standard

1304.23(c)(2)

(2) Food is not used as punishment or reward, and that each child is encouraged, but not forced, to eat or taste his or her food;

  

Guidance: Understanding and accepting that a child may not eat the same amount every day, or be hungry at the same time every day, helps to prevent feeding problems. If a child refuses food, staff and parents are encouraged to offer such food again at some future time. Children may require a number of exposures to a new food before they will accept it. Older children may accept a wider variety of foods. When introducing new foods, parents and staff should note that "pestering" the child is not an effective strategy. "Clean-plate clubs," "eating stars," and other gimmicks are not appropriate ways to encourage children to eat.
Performance Standard

1304.23(c)(3)

(3) Sufficient time is allowed for each child to eat;

  

Guidance: Relaxing meal times provide children many opportunities to learn. Although children can begin to serve themselves, family style, as soon as they come to the table, a leisurely meal pace is encouraged. Conversation at the table between children and adults helps set an appropriate pace for the meal, while at the same time establishing a pleasant environment. Slow eaters are allowed sufficient time to finish their food; and children who become restless before the meal is over may be allowed to get up and move around. For example, when finished, children take their plates to a cleaning area away from the table, and then are directed toward an alternative activity.
Performance Standard

1304.23(c)(4)

(4) All toddlers and preschool children and assigned classroom staff, including volunteers, eat together family style and share the same menu to the extent possible;

  

Related Information: See 45 CFR 1304.23(c)(5) for information on holding and interacting with infants during feeding. See 45 CFR 1304.53(b)(1)(iii) for information on child-sized furniture and utensils.

Guidance: Family style meals are implemented in a variety of ways. For example, children and adults may prepare for the meal by clearing the table and setting places, sharing conversation during the meal, and cleaning up afterwards. In some cases, children and adults serve and pass food among themselves. In the event that classroom staff are unable to have their meals at the same time as the children, other designated staff members may eat and converse with the children at meal times. In all cases, children are seated when eating and each child makes his or her own food choices based on individual appetites and preferences.

During meal times, adults encourage interesting and pleasant table conversation across a variety of topics, not only subjects related to food and nutrition. Some methods for facilitating meal time discussions include:

Asking open-ended questions, modeling good listening skills, and encouraging turn-taking in conversation; and
Encouraging children to compare, contrast, and classify food attributes, such as taste, texture, shape, size, and color.

Staff set good examples by demonstrating a positive attitude toward all foods served. If a staff member or child is on a special diet, this can be explained and used as a positive learning experience. Staff also are sensitive to family customs that do not encourage children to participate in meal conversations.

Classroom staff may invite other staff (e.g., cooks), parents, and other volunteers to join the children at meal times. (See 45 CFR 1304.23(b)(1)(i) for a discussion of allowable costs for food services.)

When high chairs are used for older infants and toddlers, staff securely strap in the children, rather than rely upon high-chair trays for restraint. Whenever possible, children in high chairs are pulled up to the table, to include them in family style meals.
Performance Standard

1304.23(c)(5)

(5) Infants are held while being fed and are not laid down to sleep with a bottle;

  

Rationale: It is important to hold infants and to establish eye contact while feeding them, in order to enhance bonding and to establish a sense of security. The practice of giving infants a bottle when lying down to rest is dangerous, as it may lead to choking, ear infections, or dental problems such as baby bottle tooth decay (infant dental caries).

Related Information: See 45 CFR 1304.21(b)(1)(ii) for information on trust and emotional security.

Guidance: The growth and development of children during their first year of life requires many changes and adaptations with regard to feeding. Staff and parents help infants have a positive experience by feeding them in a relaxed setting and at a leisurely pace. If possible, breast feeding mothers are encouraged to come to the program setting to feed their children.

Staff and parents use the following techniques for feeding infants:

Wash hands with soap and water before feeding;
Find a comfortable place for feeding;
Hold the infant in their arms or on their lap during feeding, with the infant in a semi-sitting position, with the head tilted slightly forward and slightly higher than the rest of the body, and supported by the person feeding the infant;
Communicate and interact with the infant in a calm, relaxed, and loving manner, by cuddling and talking gently;
Hold the bottle still, and at an angle, so that at all times the end of the bottle near the nipple is filled with liquid and not air;
Ensure that the liquid flows from the bottle properly by checking that the nipple hole is of an appropriate size; and
Burp the infant at any natural break during, and at the end of, a feeding.

Infant cereal is served with a spoon, unless there is a medical reason for some other approach.

As children grow older, they may prefer to hold their own bottles, and may do so while in an adult’s arms or lap, or while sitting in a high chair or similar chair.

Dental problems, such as tooth decay, may result from children using bottles as pacifiers. For this reason, children are not allowed to carry bottles with them for long periods during the day. Parents and staff are taught that breast feeding also may cause baby bottle tooth decay (infant dental caries).

Older infants do not need to be held when eating solid foods. Instead, they may sit in a high chair or other chair scaled to size. It is important, however, to maintain eye contact with a child who is being fed, and to closely supervise all feeding activities in order to minimize the risk of choking.
Performance Standard

1304.23(c)(6)

(6) Medically-based diets or other dietary requirements are accommodated; and

  

Rationale: Accommodating special diets or dietary requirements ensures that a child’s health will not be jeopardized and that individual needs are met.

Guidance: Discussions between other staff and parents provide many opportunities to review any special diets or dietary requirements identified through regular assessments or other medical testing. Staff and parents work together to develop ways to incorporate special dietary needs into the regular menu. They also consult with others, such as a child nutrition specialist or a registered dietitian, to help plan meals for children with special diets. In addition, staff and parents explore ways to make children with special diets feel comfortable, and, to the highest degree possible, included in all meal time activities.

In Head Start programs providing meal services, staff modify or supplement individual children’s diets only at the written direction of both the child’s parents and the health care providers. All staff are trained in agency procedures for feeding children with food allergies or other special dietary concerns, as well as in emergency procedures.
Performance Standard

1304.23(c)(7)

(7) As developmentally appropriate, opportunity is provided for the involvement of children in food-related activities.

  

Rationale: Involvement in age-appropriate, food-related nutrition education activities fosters thinking skills, the development of large and small motor skills, a positive attitude toward food, and positive attitudes toward achievement and cooperation.

Related Information: See 45 CFR 1304.21(c)(1)(iii) on integrating educational aspects of nutrition services into program activities.

Guidance: There are many ways to involve children of all ages in the preparation of food and other food-related activities. Children are encouraged, for example, to select activities in which they would like to be involved, such as shopping for food, setting the table, serving food to others and to one’s self, cleaning up, and making place mats and table centerpieces. Food-related activities also are coordinated with nutrition education to reinforce ideas about how food contributes to good health. These coordinated lessons and activities can be conducted through the joint involvement of teachers, home visitors, food service staff, and parents.

When developmentally ready, children are allowed and encouraged to help with certain kinds of food preparation. Activities, such as making cream into butter, provide a multitude of language experiences, and develop thinking skills, as teachers encourage children to guess, observe, and draw conclusions about what they experience. Food preparation activities are always safe and are conducted in accordance with State, Tribal, or local regulations.
Performance Standard

1304.23(d)

(d) Family assistance with nutrition.

Parent education activities must include opportunities to assist individual families with food preparation and nutritional skills.

  

Rationale: Parent education opportunities can offer parents new skills and ideas for providing nutritious meals at home.

Related Information: See 45 CFR 1304.40(f)(3) for further guidance on providing a nutrition education program for parents.

Guidance: On a regular basis, home visitors and other staff assist parents in developing food preparation techniques and in increasing their knowledge about nutrition-related skills by:

Taking into account the child’s nutritional needs and the parents’ understanding of nutritional issues;
Providing parents with information regarding the selection and preparation of foods and menus;
Guiding parents in home and money management and smart consumer techniques;
Sharing information about the USDA/HHS Dietary Guidelines for Americans, the USDA Food Guide Pyramid, and Nutrition Facts Labels on commercially prepared foods;
Encouraging parents to discuss nutritional issues with one another; and
Serving nutritious food at parent functions.
Performance Standard

1304.23(e)(1)

(e) Food safety and sanitation.

(1) Grantee and delegate agencies must post evidence of compliance with all applicable Federal, State, Tribal, and local food safety and sanitation laws, including those related to the storage, preparation and service of food and the health of food handlers. In addition, agencies must contract only with food service vendors that are licensed in accordance with State, Tribal, or local laws.

  

Rationale: Compliance with food safety and sanitation measures protects the health and safety of everyone.

Guidance: Local or State sanitation departments in health agencies are helpful in providing ideas on ways to meet sanitation standards. However, some States do not send inspectors to Head Start facilities to check compliance with local and State standards. In such situations, designated program personnel with a knowledge of sanitation laws and regulations can check compliance on a quarterly basis, and be responsible for the correction of any existing violations. American Indian grantees may request the Indian Health Service’s Office of Environmental Health Services or Tribal sanitation departments to inspect all Head Start facilities on a quarterly basis. Written evidence of State, Tribal, and self-inspections should be kept on file.

In order to assure the maintenance of food sanitation standards, agencies conduct self-inspections on a quarterly basis. The resulting self-inspection reports address the following areas:

the cleanliness and safety of food before, during, and after preparation, including maintenance of correct food temperature;
food handling practices;
the dish washing procedures and equipment;
insect and rodent control (see 45 CFR 1304.53(a)(10)(viii));
the cleanliness and maintenance of food preparation, service, storage, and delivery areas and equipment (see 45 CFR 1304.53(a)(10)(viii));
the water supply (see 45 CFR 1304.53(a)(10)(xiii));
garbage disposal methods (see 45 CFR 1304.53(a)(10)(xvi)); and
health of food service personnel (see 45 CFR 1304.52(j)(1)).

If an outside vendor provides food, agencies receive regular reports on safety and sanitation related to food handling. Such reports indicate whether or not food service contractors have met certain required codes, that vehicles used for transporting and holding food are insulated, and that food transportation equipment is sanitized.

Performance Standard

1304.23(e)(2)

(2) For programs serving infants and toddlers, facilities must be available for the proper storage and handling of breast milk and formula.

  

Rationale: Proper storage and handling of breast milk and infant formula is necessary to prevent spoilage, to minimize bacterial growth, and to ensure that each infant receives his or her own mother’s milk or the correct brand of formula.

Related Information: See 45 CFR 1304.40(c)(3) on the benefits of breast feeding and agency support of nursing mothers.

Guidance: All bottles of breast milk and formula are refrigerated until immediately before feeding, and any contents remaining after a feeding are discarded immediately.

Staff and parents work together to ensure that all containers of breast milk and formula are dated, clearly labeled with the child’s name, and used only for the intended child. Unused breast milk and formula are discarded after 48 hours, if refrigerated, or after 3 months, if frozen. Frozen breast milk and formula is thawed in running, warm water, or in the refrigerator. Once frozen breast milk thaws, it is used within 24 hours, and is never refrozen.

If breast milk or formula is to be warmed, bottles may be placed in a pan of hot, not boiling water for five minutes, after which the bottle is shaken well and the milk temperature tested on the preparer’s wrist before feeding. Bottles of formula or breast milk are never warmed in a microwave oven, since microwaves heat unevenly and may cause severe burning. To avoid spoilage, avoid warming bottles of formula or breast milk at room temperature, or in warm water, for extended periods.

Home visitors and other staff work with parents to find safe methods for storing and handling breast milk and infant formula in both home and program environments, and for transporting breast milk, as needed.

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