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The purpose of this study was to compare state and regional variation in infant feeding regulations for child care facilities and to compare these regulations to national standards.
We reviewed regulations for child care for all US states and Washington, DC, and examined patterns according to type of facility and geographic region. We compared state regulations with national standards for feeding infants in child care. The standards included were: (1) infants are fed according to a feeding plan from a parent or physician; (2) breastfeeding is supported by the child care facility; (3) no solid food is given before 6 months of age; (4) infants are fed on demand; (5) infants are fed by a consistent caregiver; (6) infants are held while feeding; (7) infants cannot carry or sleep with a bottle; (8) caregivers cannot feed >1 infant at a time; (9) no cow’s milk is given to children <12 months of age; (10) whole cow’s milk is required for children 12 to 24 months of age; and (11) no solid food is fed in a bottle.
The mean number of regulations for states was 2.8 (SD: 1.6) for centers and 2.0 (SD: 1.3) for family child care homes. No state had regulations for all 11 standards for centers; only Delaware had regulations for 10 of the 11 standards. For family child care homes, Ohio had regulations for 5 of the 11 standards, the most of any state. States in the South had the greatest mean number of regulations for centers (3.3) and family child care homes (2.2), and the West had the fewest (2.3 and 1.9, respectively).
Many states lacked infant feeding regulations. Encouraging states to meet best-practice national standards helps ensure that all child care facilities engage in appropriate and healthful infant feeding practices.
In recent decades, greater numbers of parents have turned to organized child care to help care for their infants. In the United States, nearly two thirds of infants are cared for routinely by someone other than a parent. About half of these infants attend child care centers, whereas the other half spend time in a variety of home-based settings including licensed family child care homes or the home of a family member, friend, or neighbor.1 Recent studies revealed that nonparental home-based child care may negatively affect children’s health. Kim and Peterson2 examined child care during the first 9 months of life and found that infants who were cared for by a relative were less likely to have been breastfed and more likely to be given solid foods too early compared with infants cared for by a parent. The authors also found that these infants gained more weight during that time period, which is a risk factor for obesity and increased blood pressure later in childhood3–5 and possibly for recurrent wheezing.6 A second study found that child care during the first 6 months of life was associated with higher weight-for-length z scores at 1 year of age and BMI z scores at 3 years of age.7 Child care in an outside home, such as a licensed family child care home or the home of a family member, friend, or neighbor, was the only type of care associated with the outcomes.7
Despite the large number of infants in nonparental care, only 1 resource provides recommendations for feeding infants in child care. Caring for Our Children—National Health and Safety Performance Standards: Guidelines for Out-of-Home Child Care Programs (CFOC), a collaborative effort between the American Academy of Pediatrics, the American Public Health Association, the US Department of Health and Human Services, and the National Resource Center for Health and Safety in Child Care, provides standards for the prevention and management of illness and injury as well as health promotion, including infant feeding, for children in child care.4 Child care providers may use CFOC standards as a guide to appropriate infant feeding in child care, but they are not required by law to adhere to these standards.
Child care providers are, however, required to comply with their state regulations. Regulation of child care facilities is the responsibility of each individual state and the District of Columbia, and each has an agency charged with creation and enforcement of their regulations.4 Regulations typically reflect the minimum health and safety standard of care considered acceptable by states. Conversely, CFOC represents uniform best-practice standards to ensure high-quality child care. Ideally, state regulations should mirror CFOC standards, which reflect best practices for caring for children in child care. Previous research has examined the relationship between state regulations and national standards or evidence-based recommendations. Although no study has examined state regulations for feeding infants in child care, previous studies have examined regulations related to obesity,8–10 sudden infant death syndrome,11,12 and menus in child care.13 The purpose of this study was to compare state and regional variations in infant feeding regulations for child care facilities according to type and to compare these regulations to standards found in CFOC.
For this cross-sectional study, we collected data on individual state regulations for child care centers and family child care homes from a public database of regulations for all 50 US states and the District of Columbia (“states”) maintained by the National Resource Center for Health and Safety in Child Care.14 Most states regulate 2 classes of child care facilities: child care centers and family child care homes. Child care centers care for greater numbers of children and typically have more staff members than family child care homes. Family child care homes are located in the residence of the owner and operator of the facility, who is often the only provider of care. States typically limit enrollment in family child care homes to ≤6 children. Some states regulate these types of child care facilities individually, with a unique set of regulations for each, whereas others provide 1 regulation that applies to both child care centers and family child care homes.
States also define “infant” differently. For example, Arizona considers infants to be children 12 months of age or younger, North Carolina <15 months of age, and California <24 months of age. CFOC standards, however, define infants as children 12 months of age or younger. For the purposes of this review, we considered infant to be whatever age the state used to define this category of infants.
We included all 11 CFOC infant feeding standards related to nutrition, which were: (1) infants are fed according to a feeding plan from a parent or physician; (2) breastfeeding is supported by the child care facility; (3) no solid food is given before 6 months of age; (4) infants are fed on demand; (5) infants are fed by a consistent caregiver; (6) infants are held while feeding; (7) infants cannot carry or sleep with a bottle; (8) caregivers cannot feed >1 infant at a time; (9) no cow’s milk is given to children <12 months of age; (10) whole cow’s milk is required for children 12 to 24 months of age; and (11) no solid food is fed in a bottle. We also report on regulations prohibiting bottle propping, because this practice is related to the standard requiring infants to be held while feeding. Standards 1, 6, 7, and 8 are included in Stepping Stones to Using Caring for Our Children, 2nd Edition,15 a supplement to CFOC to identify the most important standards for prevention of morbidity and mortality in child care.
We reviewed regulations for child care centers and family child care homes for all states in March 2008. We compared regulations with infant feeding standards found in CFOC. One researcher read each state’s regulations in their entirety and recorded regulations consistent with each CFOC standard. We considered regulations consistent with CFOC standards if the wording was clear and specific and matched unequivocally the spirit of each CFOC standard.
We computed the average number of regulations for each state and for each US census region. Census regions included Connecticut, Massachusetts, Maine, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont in the Northeast; Arkansas, Alabama, Washington, DC, Delaware, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia in the South; Iowa, Illinois, Indiana, Kansas, Michigan, Minnesota, Missouri, North Dakota, Nebraska, Ohio, South Dakota, and Wisconsin in the Midwest, and Arkansas, Arizona, California, Colorado, Hawaii, Idaho, Montana, New Mexico, Nevada, Oregon, Utah, Washington, and Wyoming in the West. A previous study examining menu regulations for child care found that states in the South and the West had more regulations for family child care homes than states in the Northeast and the Midwest.13
We also recorded the date of the most recent update of regulations for each state for both centers and family child care homes. We assigned a value of 0 to 22, representing the range of years (1985–2007) when states made their last update. In addition, we reviewed the frequency of compliance checks conducted by states for both centers and family child care homes from the National Association of Child Care Resource and Referral Agencies’ Web site.16
We computed frequencies for the total number of regulations for each state according to type of facility and census region for child care centers and family child care homes. We used Mantel-Haenszel trend tests to assess correlations between geographic region (Northeast, South, Midwest, and West) and number of regulations in each state. We conducted additional analyses to examine the relationship between year of last update and total number of regulations reflecting CFOC standards. We computed Spearman correlation coefficients to examine the relationship between year of last update and number of regulations in each state for each type of child care facility. We used Mantel-Haenszel trend tests to explore associations between the dichotomized year variable and number of regulations in each state. Tests of association were conducted at a significance level of α = .05, and analyses were conducted by using SAS 9.1 (SAS Institute, Inc, Cary, NC).
States varied widely in their regulations related to infant feeding for both child care centers (Table 1) and family child care homes (Table 2). The mean number of regulations for states was 2.8 (SD: 1.6; range: 0–10) for centers and 2.0 (SD: 1.3; range: 0–5) for family child care homes. No states had regulations for all of the 11 infant feeding standards for child care centers; only Delaware had regulations for 10 of the 11 standards. Delaware recently updated its regulations for child care centers and is in the process of updating its regulations for family child care homes. Delaware regulations most closely reflect infant feeding standards found in CFOC. For centers, Michigan had regulations for 6 of the 11 standards, the second highest number of regulations consistent with CFOC standards. Illinois, Tennessee, Washington, and West Virginia had regulations for 5 of the 11 standards. Colorado, Idaho, and Kentucky did not have any of the 11 regulations for centers. For family child care homes, Ohio had regulations for 5 of the 11 infant feeding standards, and Alaska, Arkansas, the District of Columbia, Delaware, Mississippi, New Hampshire, South Carolina, and Tennessee had regulations consistent with 4 of the 11 standards, the most for any state for family child care homes. California, Florida, Idaho, Iowa, Kentucky, and Maryland did not have any of the 11 CFOC infant feeding standards for family child care homes.
States in the South had the greatest mean number of regulations for centers (3.3) and family child care homes (2.24), compared with the West, which had the fewest mean number of regulations for centers (2.3) and family child care homes (1.9). However, we did not find associations between geographic region and number of state regulations for centers (P = .83) or family child care homes (P = .91).
Thirty-four states (67%) for centers and 31 states (61%) for family child care homes had updated their regulations in the past 5 years. In contrast, 7 states (14%) for centers, and 6 states (12%) for family child care homes had regulations that had not been updated in the past 10 years. The number of regulations was not highly correlated with the year of last update examined as a continuous variable for centers (Spearman’s rho = 0.19; P = .21) or for family child care homes (Spearman’s rho = −0.14; P = .31).
To assess compliance with regulations, state regulatory agencies reported that they visit child care facilities to ensure that providers are adhering to state regulations. Twenty-nine states have inspectors visit centers at least 1 time per year, 16 visit every 2 years, and 6 visit every 3 or more years for routine inspections. For family child care homes, states monitor compliance less frequently, ranging from every 6 months to every 10 years, or only when a complaint is reported.
Thirty states(59%)required centers to obtain and follow a feeding plan from either a parent or a physician for each infant in care. Twenty states (39%) required this plan for family child care homes.
Only 11 states (22%) had regulations expressing support for breastfeeding for child care centers. In addition to its regulation supporting breastfeeding, Indiana also required parents to have a written breastfeeding agreement on file, to provide breast milk in single-serving sterilized bottles or bags labeled with the child’s name and the date and time collected, and to keep milk at 41 degrees or less during transport to the child care center. Five states (10%) mandated support to breastfeeding mothers for family child care homes.
Two states (4%), Washington and West Virginia, did not allow child care centers to give infants solid foods before 6 months of age. Two additional states, Illinois and Oregon, prohibited centers from giving solid foods to infants <4 months of age. No states included this standard in their regulations for family child care homes.
Eighteen states (35%) for child care centers and 12 states (24%) for family child care homes required providers to feed infants on demand, rather than on a fixed schedule or according to the time of day.
For child care centers, only Delaware required infants to be fed routinely by a consistent provider. No state had this regulation for family child care homes.
Requiring child care providers to hold infants while feeding them was the most common regulation. Forty-six states (90%) required child care providers to hold infants during feedings for child care centers, and 37 states (73%) included this regulation for family child care homes. The majority of these states required child care providers to hold infants while feeding them until they were either 6 months of age, able to sit up on their own, or able to hold their own bottles.
Nineteen states (37%) for child care centers and 14 states (27%) for family child care homes did not allow infants to sleep with or carry a bottle. For this standard, we included states that did not allow infants to carry a bottle or walk with a bottle, and also states that prohibited bottles in cribs.
Delaware prohibited providers from feeding >1 infant at a time for child care centers only; no states included this standard as a regulation for family child care homes.
Five states (10%) did not allow providers in centers and 6 states (12%) did not allow providers in family child care homes to give cow’s milk to infants <12 months of age.
Seven states (14%) for child care centers and 6 states (12%) for family child care homes required whole cow’s milk for infants 12 to 24 months of age. A handful of these states were included in the tally of states meeting this standard but were less specific in their wording. For centers, Illinois, Indiana, New Hampshire, and New Mexico, and for family child care homes, Delaware, New Hampshire, and New Mexico, stated that infants <24 months of age must be given whole milk rather than low-fat or fat-free milk.
Only 8 states (16%) for child care centers and 4 states (8%) for family child care homes did not allow child care providers to add solid food, namely infant cereal, to a bottle.
In this review of state regulations for child care facilities, we found that states had few regulations related to infant feeding for child care centers and even fewer for family child care homes. For family child care homes, only 1 state had regulations for 5 of the 11 infant feeding standards, the most of any state. Six states did not have any regulations related to infant feeding for family child care homes. This lack of regulation related to infant feeding is alarming given recent evidence suggesting that infants cared for in family child care homes and other nonparental homes may be at greater risk for obesity.2,7
We did not find associations between the number of regulations and geographic region. We also did not see a relationship between the number of regulations and year of last update. Although state regulations typically reflect minimum standards of performance in child care, states that do revise their regulations could use CFOC standards as a guide for improvement. These CFOC standards represent best practices, and states could benefit from following high-quality national recommendations. Reviewing regulations on a regular basis and revising regulations on the basis of best-practice standards in CFOC helps ensure that regulations reflect current recommendations for infant feeding. In this review, we found that 8 states had regulations dating back to the 1990s. As additional evidence becomes available, states should revise regulations for both child care centers and family child care homes to reflect new information. In addition, revision to CFOC standards is currently underway to incorporate new evidence related to infant feeding and other health and safety issues in child care. This revision is due out in late 2010. A recent study showed that child care center directors and infant care providers wanted up-to-date recommendations for feeding infants, and both reported low knowledge of appropriate infant feeding practices, so this revision is well-timed.17
In this review, we compared state regulations related to infant feeding to standards found in CFOC. Although CFOC standards represent best practice, some standards lack support from the scientific literature. Bottle propping and putting solid food in bottles, for example, are generally considered by health professionals to be inappropriate feeding practices, but few studies have examined the relationship between these practices and child health outcomes.18,19 There is some evidence that introducing solid foods before 4 months of age is linked to obesity in infancy, although the data are inconclusive.20–22 The benefits of breastfeeding, on the other hand, are numerous and supported by the research literature. Evidence suggests that longer duration of breastfeeding may protect against development of later obesity23,24 possibly by promoting maternal responsiveness to infants’ signals for frequency and volume of feedings.14 Requiring child care providers to feed infants on demand may help facilitate this responsiveness to infant hunger and satiety cues.
A limitation of this review is the evolving nature of state regulations. States may revise their regulations at any time, and, consequently, this review may become outdated soon. Frequent revision also provides an opportunity to revise and improve regulations, and public health professionals have the opportunity to influence their state regulations through education and advocacy. Delaware is in the process of updating their regulations for family child care homes. In addition, Rhode Island is in the early stages of revising their regulations related to nutrition, and new regulations for Massachusetts child care centers are scheduled to take effect in 2009.
In this review we report on the presence or absence of a regulation and did not consider actual practice of child care facilities. Enforcement is one way to help ensure that child care providers comply with state regulations. However, given the relative infrequency of compliance checks by states, regulation may not be the most effective way to improve infant feeding practices in child care. States can improve infant feeding practices through child care provider training and professional development, technical assistance and consultation by health professionals, or perhaps compensation to providers and child care facilities to encourage appropriate infant feeding practices. Previous research highlights the need for provider training. Clark et al17 found that providers need not only information on best practice but also training on how and why to comply with the standard.
Future studies should explore not only the presence of infant feeding regulations but also training and consultation for providers to support the regulations. In addition, researchers should examine compliance and enforcement of the regulations within each state, as well as the overall effect on infant and child health outcomes. Strong, evidence-based regulations may help improve the health of children in child care, especially if these regulations reflect the best-practice standards outlined in CFOC.
Dr Benjamin is supported by National Institutes of Health grant DK80618; Dr Taveras is supported in part by the Physician Faculty Scholars Program of the Robert Wood Johnson Foundation; and Dr Cradock is supported in part by Centers for Disease Control and Prevention, Prevention Research Center grant U48-CC115807.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.