Transition from Breastfeeding and Complementary Feeding to Toddler Nutrition in Child Care Settings

Abstract

Child care has broad reach to young children. Yet, not all child care settings have nutrition standards for what and how foods and beverages should be served to infants as they transition to toddlerhood. The purpose of this paper is to describe the development of nutrition recommendations to guide feeding young children in licensed child care settings in the USA, a process that could be adapted in other countries. Nutrition standards were designed by nutrition and child care experts to address what and how to feed young children, also including the transition from infants to toddlers. Nutrition standards are important for health and can be feasibly implemented in child care settings. Feasibility considerations focused on family child care homes, which typically have fewer resources than child care centers or preschools. Infant standards include recommendations for vegetables, fruits, proteins, grains, and breast milk and other beverages. Also included are recommendations for supporting breastfeeding, introducing complementary foods, and promoting self-regulation in response to hunger and satiety. Toddler standards are expanded to address the frequency as well as types of food groups, and recommendations on beverages, sugar, sodium, and fat. Feeding practice recommendations include meal and snack frequency and style, as well as the promotion of self-regulation among older children. 

Importance of the Infant to Toddler Transition

Obesity among US children 2–5 years old has nearly tripled from 5% in 1976 to  14% in 2016 [1]. Dietary risk factors for obesity begin in infancy when energy intakes begin to exceed recommendations [2]. Although rates of breastfeeding have improved in recent years [3], most infants in the USA are bottle fed at some point in the first year of life, and 10–20% are introduced to complementary foods prior to the recommended 4–6 months of age [2–4]. As infants transition into toddlers, dietary patterns worsen and are characterized by inadequate intake of fruits, vegetables, and whole grains, and excessive consumption of sugar-sweetened foods and beverages [5]. For example, in a 2008 study, 16– 27% of infants 9–12 months old transitioning into toddlers up to 23 months of age did not consume any fruit on a given day. In contrast, intake of sweetened foods tends to increase rapidly as an infant transitions into toddlerhood resulting in as many or more children consuming a sweetened food than a fruit or
vegetable on a given day by the second year of life [2, 6]. By the end of toddlerhood, dietary intakes tend to be established, becoming habits that track into later life [2]. Despite the importance of early life for subsequent nutrition and health, the evidence-based recommendations for the nation, the Dietary Guidelines for Americans, do not currently include guidance for young children 0–2 years of age [7].

Role of Child Care in Infant and Toddler Nutrition

Given that over 1 in 5 US children are already overweight or obese before entering kindergarten [1], interventions in the youngest children are essential. Licensed early care and education settings (hereafter referred to as child care) are the largest institutional settings in the USA for improving nutrition among young children. Since the 1970s, the rate of employment by mothers of children under 3 years old has nearly doubled [8]. In 2018, among families with children 0–5 years old, both parents were employed in 58% of households of married couples, and 69% of mothers and 85% of fathers were employed in single-parent households [9]. Concurrent with rates of parent employment, use of child care has risen. Over one-third of all young children spend time in organized, licensed child care (as opposed to informal care with family, friends, or neighbors) [10]. Many young children attend child care for a long day that matches
their parent’s employment, where they consume much of their daily nutrition [11].

Studies have found mixed associations between attending child care and child obesity [12–14]. For example, in a systematic review of observational studies conducted in developed countries, 3 studies found center-based care associated with increased prevalence of child overweight or obesity, 8 studies found no association, and 2 studies found a protective relationship [12]. Enrollment in full-day child care at an early age (< 3 months) has been associated with less breastfeeding and early introduction of complementary foods [15]. Disparities in findings may be partially explained by the timing of exposure to child care. Studies suggest that more time spent in child care, especially during the transition from infancy to toddlerhood in the first and second years of life, is a risk factor for child obesity [13, 14].

In the USA, the federal Child and Adult Care Food Program (CACFP) provides
reimbursements to child care centers and homes for up to a total of 3 meals and snacks per day to provide specific types and amounts of food groups [16]. However, relatively few licensed child care facilities participate in this program. In California, for example, which accounts for one-seventh of the US population, only about one-third of young children in licensed child care were at facilities that participate in CACFP [17]. Further, CACFP standards do not regulate foods or beverages that are not claimed for reimbursement and do not specify how children should be fed (e.g., feeding practices). Outside of CACFP, there are no federal nutrition requirements and incomplete and inconsistent state-bystate nutrition requirements to which licensed child care facilities are subject [18]. Few states, for example, have comprehensive standards to support breastfeeding and other recommended early feeding practices in child care [19, 20].
In the USA, licensed facilities can vary from small, family child care homes with a single provider and a few children to large centers or preschools with a director, multiple teachers, and several hundred children. There is concern that nutrition standards may be difficult to afford or implement, particularly by child care homes [21]. Child care homes are independently operated businesses in the homes of providers who often are low-income women with limited resources and opportunities to obtain nutrition training [22]. Further, nutrition in family child care homes tends to be less optimal than in centers or preschools [23]. Developing nutrition standards that are both evidence-based and feasible for implementation in child care settings is an important early step towards laying the groundwork for improving the nutrition of young children. As such, the
purpose of this paper is to describe a process whereby evidence-based nutrition standards for young children in child care were developed and refined so that they would be actionable and achievable in most child care settings in the USA, including family child care homes. This process may be adapted to establish or refine nutrition standards for child care settings in other countries. 

Development of Child Care Nutrition Standards for Infants and Toddlers

Starting with current guidelines from authoritative bodies, in 2015 standards were refined by both nutrition experts and child care practice-based stakeholders. Science advisors (Table 1) from across the country were selected based on their scientific expertise in nutrition and obesity prevention for children and in child care. They were tasked with developing a comprehensive set of evidence based nutrition recommendations for: (1) infants from birth up to 1 year of age, and (2) children over 1 year. Science advisors were asked not to include practical considerations of child care settings in their deliberations but focus on standards optimal for child health.

Child care recommendations were first selected from authoritative bodies that had put forward nutrition recommendations for child care settings. These included the CACFP standards [16]; Academy of Nutrition and Dietetics [24]; Nutrition and Physical Activity Self-Assessment for Child Care Best Practices [25]; Institute of Medicine [26]; 2015 Dietary Guidelines for Americans [7]; American Academy of Pediatrics, American Public Health Association and National Resource Center for Health and Safety in Child Care and Early Education’s Caring for Our Children [27]; and Nemours [28]. Recommendations on what foods and beverages should be offered (dietary intake) as well as how the recommended foods and beverages should be offered (feeding practices) were compiled. The recommendations were tabulated from each expert body and organized by dietary intake of food group (e.g., fruit juice, other fruit, or vegetable) and feeding practices (e.g., breastfeeding or meal service). There were 25 infant nutrition recommendations and 173 child nutrition recommendations identified. To help expedite the process, the most comprehensive nutrition recommendations for each food group or feeding practice were selected prior to the expert convening. Using a Delphi process, group consensus was reached among the science advisors by discussing each highlighted standard and identifying additions, deletions, or revisions. After the completion of this group consensus process, each science advisor independently ranked the nutrition standards according to potential impact (high, medium, and low) on child nutrition, obesity, and health. The science advisor rankings were compiled, and the standards separated into 3 groups according to the following criteria:
• High impact: 70% or more of science advisors ranked as high impact and no science advisor ranked as low impact
• Medium impact: mixed responses from science advisors in between high and low
• Low impact: over 30% of science advisors ranked as low impact, and no science advisor ranked as high impact, or over 50% ranked as low impact.


The next step involved convening an independent group of child care community advisors to review the final set of nutrition standards compiled by the science advisors. The child care community advisors included representation from child care advocates, CACFP sponsoring agencies (who provide training and technical assistance to child care centers and homes participating in CACFP), and family child care provider representatives (unions, resources, and referral networks) (Table 2). The primary goal of this group was to come to a consensus about which of the nutrition standards could be applied without jeopardizing the solvency and operation of licensed child care facilities, namely family child care homes. The group deliberated collectively and then independently rated each standard for ease of implementation (easy, medium, or difficult) taking into account the typical needs and resources of child care settings. The child care community advisor rankings were grouped as follows:
• difficult: 70% or more of the child care community advisors ranked as difficult and no child care community advisors ranked as easy;
• medium: mixed responses from child care community advisors in between high and low; and
• easy: over 30% of child care community advisors ranked as easy and no child care community advisors ranked as difficult, or over 50% ranked as easy. The nutrition standards were then grouped into tiers based on both impact and feasibility of implementation: tier 1 (easy/high, easy/medium, or medium/ high); tier 2 (all other rankings). The tiers were included to provide implementation options to be evaluated by researchers as well as for those that implement programs for child care providers and for policy makers.

The final development step was to pilot test the nutrition standards in 2017 with a sample of 30 licensed family child care providers in the USA (specifically in the state of California) over a 3-month period to assess adherence and challenges in implementation. Providers were given a 2-h in-person training and written information on the standards, and they were asked to select a minimum of 3–5 standards to meet over the next 3 months. Adherence to each standard was assessed by survey and observation at baseline and the 3-month follow-up, and compared over time using paired t tests. Among the 12 family child care providers caring for infants, adherence increased from 41 to 59% (p < 0.01) for tier 1 infant standards and from 32 to 42% (p < 0.05) for infant feeding practice standards (both tiers combined). Changes in tier 2 (32 vs. 29%), food and beverage (49 vs. 63%), and all combined (36 vs. 44%) infant standards were not significant.

Among the 30 family child care providers caring for toddlers, adherence increased from 58 to 69% (p < 0.001) for tier 2 standards, from 62 to 74% (p < 0.001) for food and beverage standards, from 51 to 60% (p < 0.001) for feeding practice standards, and from 59 to 68% (p < 0.001) for all child standards 




combined. Change in tier 1 child standards (60 vs. 67%) was not significant.
Slightly over one-third (39%) of providers rated tier 1 infant standards as difficult
to implement; 19% of providers rated the tier 1 child standards as difficult
to implement. Results of the pilot test suggested that nutrition standards are well
accepted and can be feasibly implemented by child care providers. The final nutrition standards include not only what foods and beverages to serve but also how to feed infants (Table 3) and toddlers (Table 4). Because few differences were detected in implementation in the pilot intervention between the tiers, it was also concluded that tiers were not necessary. Infant standards include recommendations for vegetables, fruits, proteins, grains, and breast milk and other beverages. Also included are recommendations for bottle feeding, introducing complementary foods, and promoting self-regulation in response to hunger and satiety. Toddler standards are expanded to address the frequency as well as types of food groups and beverages, and include guidance on sugar, sodium, and fat. Feeding practices for toddlers include meal and snack frequency, feeding style, and how to promote self-regulation of intake.

Implications for Research and Practice

Past studies have shown that child care-based interventions, while having mixed results, have shown promising impacts on child dietary intakes [29, 30]. Given the multifactorial etiology of child obesity, it is unlikely that changing child care nutrition alone will be sufficient to improve young children’s nutrition and weight status. However, the growing number of children in child care for long periods of the day warrants the adoption of optimal nutrition standards by licensed child care facilities.



The infant and toddler nutrition standards developed through review of authoritative
standards and ranking by research and practice-experienced specialists have the potential to influence children in licensed family child care homes and centers in the USA. In addition, the process used to develop the standards may be adapted to establish or refine nutrition standards for child care settings in other countries. These standards should next be tested in a randomized controlled intervention trial in the USA to assess both the feasibility for providers and the impact on child nutrition and weight. A number of communities that are focused on improving early childhood nutrition may welcome the opportunity to implement the standards voluntarily. The recommended standards may also inspire quality indicator-focused child care leaders to incorporate the science- and practice-based nutrition standards into their own efforts. Further, the
standards could be used to inform the establishment of state-based policy tied to child care licensing or through training and technical assistance for providers. Given the large and growing number of young children in child care, improving nutrition of infants and toddlers in child care settings has the potential to reduce child obesity and improve child health.

Conflict of Interest Statement
The authors declare that there are no conflicts of interest.

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