Chapter Nine:

Division of Child Development Child Care Center Handbook

Chapter 9: NUTRITION

Purpose Of These Requirements

Proper nutrition plays a crucial role in the health and development of children. Nutritious foods

should be offered throughout the day to ensure children are getting the nourishment and energy

they need to learn, grow, and be healthy. Research shows that there are crucial relationships

between nutrition and health, and health and learning. This makes it especially important for

caregivers to show children what it means to eat for good health, including how important it is to

eat a variety of foods, and to provide proper nutrition through the meals and snacks served in

child care. The purpose of these requirements is to establish the minimum nutritional

requirements for children in child care.

In addition to eating nutritious foods, meal times are an opportunity for learning and developing

social and self-help skills. Offering a pleasant meal time environment gives children the

opportunity to enhance their social skills by letting them interact with each other. Self-help skills

develop when children are encouraged to set the table, clear their place, wash their hands before

and after meals, and use child-size utensils.

Definitions

Special diet: the usual eating habit of an individual is altered for a specific reason such as a

medical condition that requires food substitutions or modifications in meals to meet an

individual’s special dietary needs.

There are four different types of meals that can be served to children. These meals are:

Snack: consists of at least two components: milk, juice or fruit, bread or cereal, meat or meat

alternative

Breakfast: consists of at least three components: milk, juice or fruit, bread or cereal

Lunch and Dinner: consists of at least four components: milk, 2 or more fruits or vegetables,

meat or meat alternative, bread or bread alternative.

Nutrition

9.1

Division of Child Development Child Care Center Handbook

SECTION 1: MEALS AND SNACKS

NC GENERAL STATUTES 110-91(2) AND CHILD CARE RULE .0901

Requirement for Nutritious Foods

 Each child care center must ensure all children receive nutritious foods and beverages

appropriate to the developmental needs of all children at the center.

 Meals and snacks served must comply with the Meal Patterns for Children in Child Care

standards.

 The types of food, number and size of servings must be appropriate for the ages and

developmental levels of the children in care.

 The Meal Patterns for Children in Child Care is based on the

recommended nutrient intake judged by the National

Research Council to be adequate for maintaining good

nutrition.

 A copy of the Meal Patterns for Children in Child Care is

located in the resource section.

 The Child and Adult Care Food Program (CACFP) reimburse

licensed child care providers for meals and snacks served to

children. For more information on this program call 919-

707-5799 or visit www.nutritionnc.com/snp/cacfp.htm.

HH – Obesity in children has become one of the primary concerns

for parents and health care professionals. Caregivers are

responsible for the dietary decisions of children while in

child care. Good nutrition fosters children’s healthy growth

and development and reduces the risk that children will

become overweight or obese.

HH – Refer to the resource section for Issue Brief 1: Why Child

Care Matters for Obesity Prevention. It presents the case for

focusing on child care as an important part of strategic plans

to reduce childhood obesity.

 Additional resources on nutrition:

 USDA Center for Nutrition Policy and Promotion –

Information about healthy eating habits, dietary guidelines,

and healthy eating activities for children and adolescents.

http://www.cnpp.usda.gov/

Nutrition

9.2

Division of Child Development Child Care Center Handbook

 NC Action for Healthy Kids is a nationwide initiative

dedicated to improving the health and educational

performance of children through better nutrition and

physical activity in schools.

http://www.ncactionforhealthykids.org/AboutUs.html

 Be Active Kids is an innovative, interactive physical

activity, nutrition, and food safety curriculum for NC

preschoolers ages four and five.

http://beactivekids.org/bak/Front/Default.aspx

 Eat Smart, Move More North Carolina is a statewide

movement that promotes increased opportunities for

healthy eating and physical activity. Program tools have

been designed for preschool and child care programs.

www.eatsmartmovemorenc.com/Preschool.html

 Nutrition and Physical Activity Self-Assessment for

Child Care (NAP-SACC) is a statewide program aimed at

improving the eating and physical activity environments in

North Carolina child care centers. www.napsacc.org

CHILD CARE RULE .0901

Food From Home

 When children bring their own food for meals or snacks to the center, if the food does not

meet the nutritional requirements outlined in the Meal Patterns for Children in Child Care,

the center must provide additional food necessary to meet those requirements.

 If parents supply the meals and snacks on a regular basis, it is

advised to inform them of the nutritional standards the center

is required to meet, and even supply them with a copy of the

Meal Patterns for Children in Child Care form.

 Lunches and meals brought from home must be dated and

identified for the appropriate child at the child’s home and

must be returned to the child’s home or discarded at the end

of each day.

 Foods should be stored at an appropriate temperature until

eaten.

 The center must have additional food available to supplement

the meals and snacks brought from home that do not meet the

nutritional requirements.

Nutrition

9.3

Division of Child Development Child Care Center Handbook

HH - Child care programs are encouraged to develop policies

about food brought from home. Parents should be given a

copy of the policies when they enroll their child in the

program.

CHILD CARE RULE .0901

Non-Nutritional Foods

 Foods and beverages with little or no nutritional value served as a snack, such as sweets,

fruit drinks, soft drinks, etc., can only be available for special occasions.

 Snacks such as sweets, soft drinks, potato chips, candy,

cakes, cookies and fruit juices with less than 100% real fruit

juice are not considered to have any nutritional value.

 Special occasions are birthdays, holidays, and other activities

used to enhance learning, or other similar events.

HH – When celebrating special occasions encourage parents and

staff to offer more fruits, vegetables, and low-fat foods as

snacks.

SANITATION FOR CHILD CARE CENTERS RULE 15A NCAC .2804

Approved Sources for Foods Served in the Center

 Child care centers receiving prepared meals or snacks from outside sources must use meals

and snacks obtained from food handling establishments permitted by a local health

department, organizations that only serve prepared meals to child care centers, or another

child care center inspected by a local health department.

 When food is sent from a child's home and it will only be

served to that child, there are no restrictions on the source.

However, if food is prepared and sent from home to be

shared with other children, the food must be limited to non-

potentially hazardous baked goods. This allows parents to

bring in baked goods to celebrate birthdays but make sure

you are aware of the ingredients used if children are on a

special diet or have allergies.

HH – If you have questions or concerns about the type of baked

good a parent is requesting to bring in contact your local

health department.

Nutrition

9.4

Division of Child Development Child Care Center Handbook

 Public school programs that wish to serve meals and/or

snacks in the classroom should check with the local

Environmental Health Specialist to determine what types of

equipment and materials will be required.

 Many times public school programs will find it easier and

more cost effective to have the children eat all meals and

snacks in the school cafeteria since that space already meets

the Department of Environment and Natural Resources

requirements for preparing and serving food.

 Refer to Appendix C for complete rule text for NC Rules

Governing the Sanitation for Child Care Centers – 15A

NCAC 18A .2807-.2814.

CHILD CARE RULE .0903

Number of Meals and Snacks for Children 24 Months and Older

 The types of food and number and size of servings must be appropriate for the ages and

developmental levels of the children in care. A variety of different foods must be served.

 Meals and snacks must be planned according to the number of hours a child is in the center.

 A nutritious evening meal must be provided to each child who receives second shift care

(from approximately 3:00 p.m. to 11:00 p.m.) and who is present when the regularly

scheduled evening meal is served.

 No child may go more than four hours without a meal or a snack being provided.

 The number of meals and snacks for children in child care is

based on the number of hours the child is present at the center.

These rules apply in all situations except during sleeping hours

and nighttime care.

For preschool children in the

center at least 2 hours but less than

4 hours and for all school aged

children

One snack must be

provided unless the

child is present during

the time the center is

serving a meal, in

which case, a meal shall

be provided.

For children in the center for at

least 4 hours but less than 6 hours

One meal must be

provided equal to at

least one-third of the

child's daily food needs.

Nutrition

9.5

Division of Child Development Child Care Center Handbook

For children in the center for at

least 6 hours but less than 12

hours

Two meals and one

snack or two snacks and

one meal must be

provided equal to at

least one-half of the

child's daily food needs.

For children in the center for more

than 12 hours

Two snacks and two

meals must be provided

which are equal to at

least two-thirds of the

child's daily food needs.

CHILD CARE RULE .0902

Nutrition Requirements for Infants

 All infants must be fed in an appropriate manner.

 Each child must be held or placed in age-appropriate seating devices to be fed.

 Each infant must be held for bottle-feeding until able to hold his or her own bottle. Once a

child is able to hold his/her own bottle, it becomes a matter of choice whether the child is

held or placed in an appropriate feeding device.

 Bottles can never be propped.

 Infants must never be allowed to lie down in a crib with a bottle.

 Children should not be allowed to walk around or sit on the

floor while eating.

 Children eating table food or feeding themselves should be

seated in high chairs or at child-size tables with steady chairs.

 Propping a bottle or laying a baby down in a crib with a

bottle may cause choking or ear infections.

HH - A child's feet should be firmly on the floor or on a footrest to

provide support for the upper body and their elbows should

be able to rest comfortably on the table.

Can you suggest some examples of appropriate feeding devices?

High chair feeding table child-size table and chairs

Nutrition

9.6

Division of Child Development Child Care Center Handbook

CHILD CARE RULE .0902

Feeding Schedules

 The parent or health care professional of each child under 15 months of age must provide

the center an individual written feeding schedule for the child. The schedule must be

followed at the center.

 The schedule must include the child’s name, be signed by the parent or health care

professional, and be dated when received by the center. It should also include the amounts

of food/formula the child should be served and state time intervals for feeding.

 Each infant’s schedule must be modified in consultation with the child’s parent and/or health

care professional, to reflect changes in the child’s needs as he or she develops.

 The feeding instructions for each infant must be posted for quick reference by the

caregivers.

 Each infant’s feeding schedule should be updated in

consultation with the child's parent and/or health care

professional, to reflect changes in the child’s needs as he or

she develops.

 Centers licensed for 3 to 12 children located in a residence

are not required to post the feeding schedule but must have it

available for review.

 If a parent makes a verbal request for a change to a child's

feeding schedule, the staff member can note the change on

the schedule and have the parent review and initial it at a

later time.

 Whenever there are questions about the type or quantity of

food listed on the feeding schedule, the caregivers should

check with the parent and/or with the center's medical

consultant.

HH - Breastfeeding is the recommended feeding practice for

infant’s birth to 12 months. Importance of breastfeeding:

 Breastfeeding supports optimal growth and development

of infants.

 It decreases the possibility that babies will get a variety

of infectious diseases, ear infections, diarrhea, and some

forms of cancer.

 Breastfed infants have a lower incidence of sudden

infant death syndrome.

 Breastfed infants have a lower risk of obesity in

childhood and in adolescence.

Nutrition

9.7

Division of Child Development Child Care Center Handbook

HH - Encourage mothers to continue breastfeeding and providing

breast milk for their baby while in child care.

HH -Support breastfeeding mothers and staff by providing a

comfortable and quiet place to breastfed or express milk.

Examples of designated spaces may include an area in the

classrooms for infants or in the center’s office. You may

want to provide a screen or blanket for the mother to use for

privacy. If the mother will be expressing milk, designate the

area near an electrical outlet.

HH -Seek training for staff on safe and proper storage and

handling of human milk and the importance of breastfeeding.

 The NC Child Care Health and Safety Resource Center

promotes safe and healthy environments in child care

settings. Look for resources, training opportunities, and a

directory of child care health consultants at

www.healthychildcarenc.org

or 1-800-367-2229.

 Visit the NC Nutrition Services Branch web site for

information on promoting and supporting breastfeeding.

http://www.nutritionnc.com/breastfeeding/breastfeeding-

home.htm

 Contact your local Breastfeeding Coordinator or Women,

Infants, and Children (WIC) coordinator at the local health

department to get up-to-date information on breastfeeding

practices, how you can support breastfeeding, and potential

grants supporting breastfeeding in child care programs.

 Two resources on breastfeeding are available in the resource

section, “How to Handle Pumped Milk” and “10 Ways

Child Care Programs Can Support Breastfeeding.”

 A sample Infant Feeding Schedule is located in the resource

section.

Nutrition

9.8

Division of Child Development Child Care Center Handbook

SECTION 2: MENUS

CHILD CARE RULE .0901

Menus

 All meals and snacks must be planned in advance on a written menu.

 A variety of foods must be included in meals and snacks.

 Any substitution must be of comparable food value and must be clearly identified on the

menu.

 The menu must include the following information:

 food and beverages to be served for each meal and snack for the current week

 food substitutions

 effective dates for the menu

 Menus for nutritious meals and snacks must be planned at

least one week in advance.

 When food is prepared or provided by the center, at least one

dated copy of the current week's menu must be posted where

it can be seen easily by parents and food preparation staff.

 Centers with a licensed capacity of 3 to 12 children located in

a residence do not have to post the menu.

 Refer to the Meal Patterns for Children in Child Care in

the resource section when planning the menu.

 A sample Menu Planning Form is located in the resource

section.

HH – Making the transition from playing to eating can be hard for

some children. If children are over-stimulated from play,

they may not feel like eating. Try to plan an activity that will

relax the children and help them settle down before

mealtime.

HH – Have the meal ready to serve before calling children to the

table or placing them in high chairs. When children are

required to wait they often become restless and bored.

Encourage staff to plan ahead to minimize wait time.

HH – Mealtime is important to a child’s development. The food

they eat gives them the vitamins and nutrients needed to

grow and stay healthy.

Nutrition

9.9

Division of Child Development Child Care Center Handbook

HH – There are many benefits when caregivers eat with children.

It helps shape children’s eating habits (sets a good example).

Caregivers may influence a child’s food choices by what the

caregivers says and does. Caregivers are able to model

expectations and appropriate behaviors.

HH – Good nutrition fosters children’s healthy growth and

development and reduces the risk that children will become

overweight or obese. Encourage children to eat healthy by

providing nutritious foods.

 The NC Nutrition Services Branch provides activities that

promote sound nutrition habits among infants, children and

women in their child-bearing years. Visit

www.nutritionnc.com for more details.

 MyPyramid is your access point for the U.S. Department of

Agriculture food guidance system. This website contains the

latest news, background information, and resources about the

food guidance system. http://www.mypyramid.gov/

CHILD CARE RULE .0901

Requirements for Drinking Water

 Drinking water must be freely available to children of all ages and offered at frequent

intervals.

 Approved drinking fountains or individual drinking utensils must be provided.

 When a private water supply is used, it must be tested by and meet the requirements of the

Department of Environment and Natural Resources.

 Water must be easily accessible for children who can drink

by themselves. Children who cannot drink without help must

be offered water regularly throughout the day.

 Water should be offered to all children more frequently in hot

weather and after and during vigorous play.

 Make sure water is available indoors and outdoors.

Nutrition

9.10

Division of Child Development Child Care Center Handbook

SECTION 3: SPECIAL DIETS AND ALLERGIES

CHILD CARE RULE .0901

Children with Special Diets or Food Allergies

 Children's special diets or food allergies must be posted in the food preparation area and in

the child’s eating area.

 The food required by special diets may be provided by the center or may be brought to the

center by the parents.

 If the diet is prescribed by a health care professional, a statement signed by the health care

professional shall be on file at the center and written instructions shall be provided by the

child's parent, health care professional, or a registered dietitian.

 If the diet is not prescribed by a health care professional, written instructions must be

provided by the child’s parent and be on file at the center.

 Get as much information as possible from the child’s parent

regarding the child’s food allergies and/or special diet.

 Special diet would include dietary requirements due to

allergies or other medical issues, or could be for religious

reasons. It does not include parental preferences.

 Staff members should also know what to look for if a child

has an allergic reaction and what measures should be taken in

case of accidental exposure.

HH - Ask parents to provide a written emergency treatment plan to

be followed in the event a child has an allergic reaction. The

plan should include a list of all allergens, signs of an allergy

reaction, and types and doses of medications to be used.

Identify a protocol for an emergency and include contact

information for the child’s doctor.

 Refer to Chapter 12 – Medical Care for information on

permission to administer medications. Make sure all staff is

aware of any special diets or allergies of children enrolled in

the program.

 Staff should be particularly aware and on alert during special

events such as birthday parties and seasonal celebrations.

 A Food Allergy Action Plan is located in the resource

section.

Nutrition

9.11

Division of Child Development Child Care Center Handbook

Nutrition 9.12

HH – Encourage staff to receive training from a child care health

consultant to prevent and manage allergic reactions, even if

no food allergic child is enrolled. A first reaction can happen

at child care, and it can be severe.

 The NC Child Care Health and Safety Resource Center

promotes safe and healthy environments in child care

settings. Look for resources, training opportunities, and a

directory of child care health consultants at

www.healthychildcarenc.org or 1-800-367-2229.

Division of Child Development Child Care Handbook

Resource Section

Chapter 9:

NUTRITION

The following pages contain resource materials discussed in or

related to the preceding chapter.

Some of the resources are forms created by the Division of Child Development and

must be used by licensed child care centers. Other materials are provided as a

resource only for child care centers and can be used at the discretion of the center.

Center operators may also wish to use this section to add any additional resource

materials they have that are related to the chapter or information that is specific to

their child care center.