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Objectives: Respiratory infections (RIs) are an important cause of morbidity and excessive antibiotic prescriptions in children attending day care centers (DCCs). We aimed to assess the effectiveness of an educational and hand hygiene program in DCCs and homes in reducing RI incidence and antibiotic prescriptions in children., Methods: A cluster, randomized, controlled, and open study of 911 children aged 0 to 3 years attending 24 DCCs in Almería (Spain) with an 8-month follow-up. Two intervention groups of DCC families performed educational and hand hygiene measures, 1 with soap and water (SWG; n = 274), another with hand sanitizer (HSG; n = 339), and the control group (CG; n = 298) followed usual hand-washing procedures. RI episode rates were compared through multilevel Poisson regression models. The percentage of days missed were compared with Poisson exact tests., Results: There were 5211 RI episodes registered. Children in the HSG had less risk of RI episodes (incidence rate ratio [IRR]: 0.77; 95% confidence interval [CI]: 0.68-0.88) and antibiotic prescriptions (IRR: 0.69; 95% CI: 0.57-0.84) compared with the those in the CG. Children in the SWG had a higher risk of RI episodes (IRR: 1.21; 95% CI: 1.06-1.39) and antibiotic prescriptions (IRR: 1.31; 95% CI: 1.08-1.56) than those in the HSG. Pupils missed 5186 DCC days because of RIs, and the percentage of days absent was significantly lower in the HSG compared with the CG ( P < .001) and the SWG ( P < .001)., Conclusions: Hand hygiene programs that include hand sanitizer and educational measures for DCC staff, children, and parents, reduce absent days, RIs, and antibiotic prescriptions for these infections in children at DCCs., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Objective: To determine if family childcare homes (FCCH) in Nebraska meet best practices for nutrition and screen time, and if focusing on nutrition and screen time policies and practices improves the FCCH environment., Design: A pre-post evaluation was conducted using the Go Nutrition and Physical Activity Self-Assessment for Childcare (Go NAP SACC)., Setting: FCCH in Nebraska, USA., Subjects: FCCH enrolled in the Child and Adult Care Food Program (CACFP; n 208) participated in a pre-post evaluation using Go NAP SACC., Results: At baseline, all FCCH met the minimum childcare standards for fifty-four of fifty-six practices in nutrition and screen time. After the intervention, FCCH demonstrated significant improvement in fourteen of the forty-four Child Nutrition items and eleven of the twelve Screen Time items. However, FCCH providers did not meet best practices at post-intervention. Lowest scores were found in serving meals family-style, promoting visible support for healthy eating, planned nutrition education and written policy on child nutrition. For screen time, lowest scores were reported on the availability of television, offering families education on screen time and having a written policy on screen time., Conclusions: FCCH in Nebraska were able to strengthen their policies and practices after utilizing Go NAP SACC. Continued professional development and participation in targeted interventions may assist programmes in sustaining improved practices and policies. Considering the varying standards and policies surrounding FCCH, future studies comparing the current findings with childcare centres and non-CACFP programmes are warranted.

Background: This article describes the process and intermediate outcomes from a program implemented in 65 Early Care and Education (ECE) centers serving low-income families throughout Georgia during the 2014-2017 school years., Methods: The HealthMPowers' Empowering Healthy Choices in Schools, Homes, and Communities ECE program was based on the organization's previously successful elementary school program and aligns with current early childhood nutrition and physical activity recommendations. Participating centers worked with HealthMPowers for up to 3 years. A team from each center led changes by conducting annual self-assessments, creating and implementing improvement plans, and implementing nutrition and physical activity programs using educational resources and environmental cues. A monitoring and evaluation plan provided ongoing feedback to HealthMPowers and centers. Family and staff surveys provided insights into behaviors of children, families, and staff. Process measures included specific benchmarks (e.g., center leadership team formation, improvement plan implementation). Annual self-assessment results served as intermediate outcome measures., Results: As of 2017, 65 centers had enrolled in the program. All centers formed a health team and completed the baseline self-assessment and most implemented an improvement plan (88%). At the 1-year follow-up self-assessment, centers reported improvements from baseline including never offering food incentives for good behavior (75%-86%), conducting taste testing at least once a month (61%-79%), and rarely/never serving sugar-sweetened beverages (93%-96%)., Conclusions: Initial process measures from a multicomponent health promotion program in ECE were promising. An integrated continuous improvement approach to working with child care settings is feasible and likely effective.

Background: More than 3.6 million children are served daily by the Child and Adult Care Food Program (CACFP)-participating child day care centers. This study provides a nationwide assessment of center-level responsibilities for menu, meal/snack preparation, meal preparer training, and food and beverage (F&B) purchasing., Methods: A nationally representative survey of 5483 CACFP child day care centers was conducted between August 22, 2017, and September 30, 2017. One thousand three hundred forty-three centers (25% response) in 47 states and the District of Columbia responded. Descriptive statistics describe center-level menu, meal, and purchasing practices and center characteristics. Multivariate logistic regressions examined characteristics associated with F&B purchasing sources., Results: Menus were primarily prepared by directors/assistant directors and on-site food manager/cooks, while site staff primarily prepared meals/snacks. Fifty-two percent of meal preparers held a food sanitation license, but only 5% had formal nutrition training (e.g., Registered Dietician). Most centers purchased F&B from food service providers (63%), local grocery stores (59%), warehouse stores (40%), or from 2+ sources (50%). Independent centers were more likely to purchase F&B from local grocery stores or 2+, while free or state-subsidized sites were more likely to purchase from a food service provider and less likely to purchase from other sources than were centers charging between $101 and $201.99 per week. Centers where an on-site cook/food manager prepared the menus were significantly more likely to purchase their F&B from local grocery and/or warehouse stores and/or from 2+ sources., Conclusions: Opportunities exist to target CACFP training to specific roles within and specific types of CACFP-participating child day care centers to facilitate compliance with the updated CACFP standards.

Background: State policies have the potential to improve early care and education (ECE) settings, but little is known about the extent to which states are updating their licensing and administrative regulations, especially in response to national calls to action. In 2013, we assessed state regulations promoting infant physical activity in ECE and compared them with national recommendations. To assess change over time, we conducted this review again in 2018., Methods: We reviewed regulations for all US states for child care centers (centers) and family child care homes (homes) and compared them with three national recommendations: (1) provide daily tummy time; (2) use cribs, car seats, and high chairs for their primary purpose; and (3) limit the use of restrictive equipment (e.g., strollers). We performed exact McNemar's tests to compare the number of states meeting recommendations from 2013 to 2018 to evaluate whether states had made changes over this period., Results: From 2013 to 2018, we observed significant improvement in one recommendation for homes-to use cribs, car seats, and high chairs for their primary purpose (odds ratio 11.0; 95% CI 1.6-47.3; p = 0.006). We did not observe any other significant difference between 2013 and 2018 regulations., Conclusions: Despite increased awareness of the importance of early-life physical activity, we observed only modest improvement in the number of states meeting infant physical activity recommendations over the past 5 years. In practice, ECE programs may be promoting infant physical activity, but may not be required to do so through state regulations.

Background: Child care settings provide opportunities for obesity prevention by implementing nutrition/physical activity best practices. This study examines how center policies, provider training, family education, and center demographics relate to best practices for nutrition/physical activity in Maryland's child care centers., Methods: A survey, including minor modifications to The Nutrition and Physical Activity Self-Assessment for Child Care (Go NAP SACC), was sent by e-mail to center directors statewide. Best practice sum scores (dependent variable) were calculated, including physical activity (17 items), feeding environment (18 items), and food served (19 items). Adjusted regression models analyzed the number of nutrition/physical activity policies, provider training topics, and family education opportunities related to best practice scores., Results: Response rate was 40% (n = 610/1506) with 69% independent centers (vs. organization sponsored), 19% with Child and Adult Care Food Program (CACFP enrolled), and 50.2% centers with majority (≥70%) Caucasian children and 16.8% centers with majority African American children. Centers reported 40.8% of physical activity best practices, 52.0% of feeding environment best practices, and 51.6% of food served best practices. Centers reported (mean) 7.9 of 16 nutrition/physical activity-relevant policies, 6.9 of 13 provider training topics, and 4.4 of 8 family education opportunities. Regression models yielded associations with best practices: policies and provider training with feeding environment (B = 0.26, p < 0.001; B = 0.26, p = 0.001, respectively); policies with foods served (B = 0.22, p = 0.002); and policies, provider training, and feeding environment with physical activity (B = 0.19, p = 0.001; B = 0.24, p = 0.010; B = 0.38, p < 0.001)., Conclusions: Nutrition/physical activity best practices in child care are supported by specific policies, provider training, and family education activities.

Background: The Child and Adult Care Food Program (CACFP) serves nutritious meals/snacks to >3.6 million children in early childhood education (ECE) centers. This study provides a nationwide assessment of nonhome-based CACFP-participating ECE centers' awareness of and reported readiness for implementing updated CACFP standards/best practices that took effect October 1, 2017., Methods: A national frame of 38,760 centers serving children ages 0-5 was developed. A web-based survey of 5483 sampled centers, stratified by census division, was conducted between August 22 and September 30, 2017. One thousand three hundred forty-three centers (25%) located in 47 states and the District of Columbia responded. Surveys were primarily completed by center directors/assistant directors (71%). Nonresponse adjusted multivariate regressions were conducted, controlling for center/zip code-level characteristics., Results: The majority of centers reported being "very" familiar with the updated standards and met specific standards/best practices. Centers that reported being "somewhat" (vs. "very") familiar with the standards were less prepared and likely to have begun implementation and more likely to need additional time, money, and staff. Centers that reported being "not"/"somewhat" familiar (vs. "very") with the updated standards were also less likely to meet specific standards/best practices. Center preparedness and standards/best practices varied by weekly rates/fees charged. Centers in the West (vs. South) were more likely to report meeting sugary cereal standards and fruits and vegetables as a snack component best practice., Conclusions: While most centers reported familiarity with and were prepared to implement the updated CACFP standards, readiness is not universal. Technical assistance and training should ensure that all centers are trained on the updated standards.

Background: Nationally, child care providers serve nutritious food to over 4.5 million children each day as part of the federal Child and Adult Care Food Program (CACFP). As implementation of the first major revisions to the CACFP standards occurs in 2017, understanding how to support compliance is critical., Methods: In 2016, surveys were sent to a randomly selected sample of 2400 licensed California child care centers and homes. Compliance with the new CACFP standards and best practices for infants under 1 year and children 1-5 years of age was assessed. Also, compliance was compared by CACFP participation, and between centers and homes. Interviews were conducted with 16 CACFP stakeholders to further understand barriers to and facilitators of compliance., Results: Analysis of 680 survey responses revealed that compliance with most individual CACFP standards and best practices examined was high (>60% of sites). However, compliance with all new standards was low (<23% of sites). Compliance was lowest for timing of introduction of solids to infants, not serving sweet grains, serving yogurt low in sugar, and serving appropriate milk types to children. When different, compliance was higher for sites participating in CACFP versus nonparticipants, and for centers versus homes. Although providers indicated few barriers, stakeholders identified the need for incremental and easily accessible trainings that provide practical tips on implementation., Conclusion: Training on a number of topics is needed to achieve full implementation of the new CACFP standards to ensure that young children in child care have access to healthier meals and snacks.

Background: The Child and Adult Care Food Program (CACFP) sets nutrition standards for foods served in participating settings. Licensing regulations in many states, including Connecticut (CT), extend these rules to nonparticipating facilities. This study evaluates the food environment for preschool-age children in CT child care centers and describes center-reported adherence to the CACFP nutrition regulations., Methods: We surveyed directors of licensed CACFP-participating and non-CACFP centers that served meals and/or snacks. Food served, caregiver feeding behavior, nutrition practices and policies, and CACFP knowledge were reported by 256 non-CACFP and 87 CACFP centers. We conducted bivariate analyses to describe adherence to the CACFP regulations as reported by CACFP and nonparticipating centers. Data were collected in 2015-2016 and analyzed in 2017., Results: CACFP centers reported more engagement in recommended feeding and nutrition practices than non-CACFP centers, including serving more fresh fruit and whole grains at snack time, serving low-fat milk for meals/snacks, and use of family style dining and positive caregiver behaviors. No center reported serving soda, only a few had fruit drinks, and the majority prohibited parents from sending in sugary drinks. Despite the licensing regulations about compliance with the CACFP nutrition standards, 52% of non-CACFP centers had never heard of CACFP and only 21% received information about following the CACFP standards and practices., Conclusions: CACFP participation is associated with better center-reported adherence to the CACFP nutrition standards and feeding practices. Poor awareness about CACFP among nonparticipating centers needs to be addressed to improve compliance with the CACFP nutrition standards.

Background: Sixty percent of US children 5 years old and under receive up to two-thirds of their daily nutrition in early care and education (ECE) settings. Although participation in the federal Child and Adult Care Food Program (CACFP) is shown to improve nutrition, little is known about the relationship between procurement practices (where and how child care programs purchase food) and nutrition in ECE settings or whether these practices differ depending on participation in CACFP., Methods: We assessed self-reported nutrition practices and procurement practices by CACFP participation using a 2013 cross-sectional survey of 690 Washington ECE centers ("Centers") and 1260 family homes (family home child care [FHCCs]) serving children aged 2-5 years old using validated survey tools. We examined the relationship between procurement variables (i.e., main store and main mode) and nutrition scores using multinomial logistic regression models that adjusted for sociodemographic and program characteristics., Results: In-person shopping was the primary mode of shopping for all programs, regardless of CACFP participation. Some Centers but very few FHCCs reported online shopping as their primary mode. Centers and non-CACFP FHCCs shopped primarily at megastores (Costco, Target, etc.). CACFP FHCCs used both megastores and grocery stores (Albertsons, QFC, etc.) at similar rates. Adjusted multinomial models found that shopping online or at two or more stores was associated with higher nutritional quality of foods served by programs., Conclusions: Understanding the procurement behaviors of ECE programs helps to illuminate and prioritize potential interventions that would support healthy food purchases.

Background: Child care settings have been a target for childhood obesity prevention efforts; changing licensing standards to require physical activity (PA)-related best practices is one strategy being used by states. The mechanisms used to support implementation by providers remain understudied, despite the potential for these efforts to significantly impact child-level outcomes. This qualitative study explored the mechanisms used and any outstanding challenges to implementation experienced by US states with one specific best practice PA licensing standard for toddlers (60-90 min of PA/day)., Methods: All states with the selected PA licensing standard were invited to participate (N = 9). Interviews were conducted with the licensing administrator and others in the state involved with implementation and referred by the Administrator (e.g., Licensing Inspectors). A total of 20 individuals from seven states were interviewed. All interviews were recorded, professionally transcribed, and analyzed to identify themes., Results: A range of strategies was reported, however the majority of interviewees reported that providers experienced few challenges with implementation. Steps taken during the rulemaking process and technical assistance provided by licensing staff, government and nonprofit partners were frequently mentioned as contributing to implementation success. Challenges faced by licensing staff included lack of resources and a need for specific, age-appropriate PA-promoting activities that providers could easily implement., Conclusions: Based on the experience of participating states, other jurisdictions may want to explore adding PA-related requirements to their licensing standards. The lessons learned from these seven states may be helpful during the rulemaking and implementation processes.

It is the position of the Academy of Nutrition and Dietetics that early care and education (ECE) programs should achieve recommended benchmarks to meet children's nutrition needs and promote children's optimal growth in safe and healthy environments. Children's dietary intake is influenced by a number of factors within ECE, including the nutritional quality of the foods and beverages served, the mealtime environments, and the interactions that take place between children and their care providers. Other important and related health behaviors that may influence the development of obesity include children's physical activity, sleep, and stress within child care. Recent efforts to promote healthy eating and improve other health behaviors in ECE include national, state, and local policy changes. In addition, a number of interventions have been developed in recent years to encourage healthy eating and help prevent obesity in young children in ECE. Members of the dietetics profession, including registered dietitian nutritionists and nutrition and dietetics technicians, registered, can work in partnership with ECE providers and parents to help promote healthy eating, increase physical activity, and address other important health behaviors of children in care. Providers and parents can serve as role models to support these healthy behaviors. This Position Paper presents current evidence and recommendations for nutrition in ECE and provides guidance for registered dietitian nutritionists; nutrition and dietetics technicians, registered; and other food and nutrition practitioners working with parents and child-care providers. This Position Paper targets children ages 2 to 5 years attending ECE programs and highlights opportunities to improve and enhance children's healthy eating while in care., (Copyright © 2018 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Day-care centers are the ideal place for conducting nutrition intervention to improve children&rsquo;s nutrition. The aim of this study is to evaluate the effectiveness of a multi-strategy childcare-base intervention in improving compliance with nutrition guidelines regarding beverages supply in preschools. The intervention included the staff training, audit, feedback, and ongoing support provided by trained educators. The emphasis was put on adequate nutrition, including recommended beverages, reducing sugar-sweetened beverages and increasing water availability. Enrolled were 478 full-board preschools from Poland (4.2% of all preschools in the country). The assortment of beverages served to children within ten consecutive days was assessed based on menus and inventory reports at the baseline, and three months after the intervention. Education increased significantly the percentage of preschools serving water to meals and between meals (67% vs. 83% and 93% vs. 99%, respectively), fruit/herbal tea (75% vs. 81%), and natural fruit juices (46% vs. 56%). The percentage of preschools offering fruit/soft drinks decreased from 23% to 15%. This study shows that education has a great potential in improving the assortment of beverages served in preschools. Future research is needed to determine barriers in better optimizing the assortment of beverages in preschool settings., Competing Interests: The authors declare no conflict of interest. The founding sponsors had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, and in the decision to publish the results.

Introduction: Childcare centers (CCCs) with good quality standards can be effective in reducing the risk of diseases being easily spread from person to person. The aim of the present study's program, adapted from a method used by the United Nations Development Program, was to increase the capacity of local administrators(s) and heads of CCCs to improve quality standards., Methods: This study was quasi-experimental, with a one group pretest-post-test design. In this study the authors describe the effects and impacts of the program in Chonburi Province in eastern Thailand. Six LAs and 48 CCC heads were trained regarding (1) knowledge of the Thai Department of Health quality standards, (2) implementation and assurance and (3) program evaluation. The program consisted of three sequential participatory workshops. Effects at the center level were increased overall knowledge of quality standards of CCCs (QCCC), and developed skills of improvement plans. The impact at the center level was CCCs achieving the QCCC. At the child level it was the reduction in the period prevalence of three diseases and two symptoms., Results: The significant (p<0.05) effects and impacts at the center level were increased overall knowledge of QCCC in LAs and CCC heads and increased overall managerial skills of CCC heads. At the child level, the period prevalence of chickenpox and diarrhea symptom were reduced., Conclusion: Participatory capacity building is an appropriate way to enhance the managerial skills of LAs and heads of CCCs for improving quality of CCCs to meet the local authority and the Ministry of Public Health quality standards.

Objectives Although infants increasingly spend time in community-based child care centers, little attention has been paid to their physical activity experiences while in group care. In particular, the use of devices to restrict infant mobility, such as bouncy seats, high chairs, cribs, and stationary activity centers, has received little attention in the physical activity literature. The current study examines the presence and use of these confinement devices in infant classrooms. Methods A secondary analysis of observational data in child care centers participating in Delaware's Quality Rating and Improvement System was conducted. Quality assessment observations were coded for the use of confinement devices and the actual amount of time the confinement device was employed per child. The sample consisted of 38 infant classrooms serving a total of 162 infants in the statewide system. Results Findings suggest a high level of utilization of confinement devices in infant child care classrooms with each classroom averaging three pieces of equipment used during the observations and 22% of observed children being confined 30 min or longer during the observation period. Conclusions for Practice The reliance on confinement devices in group child care is a potential concern in the quest to prevent childhood obesity by ensuring adequate physical activity and mobility for infants in group care settings. More research is needed to understand the implications of the use of confinement devices on physical activity in group care settings.

This article presents the first Danish study of the acceptance of children's nudity and sexuality at Danish childcare institutions. The study revealed an important cultural shift in the attitude toward children's nudity and sexual games, the so-called doctor games. Although these were quite accepted at Danish childcare institutions until the beginning of this century, the study showed that new, pervasive regulations had been established to control the child's body and its sexuality. A new discourse revealed that fear of child sexual abuse, in particular, had influenced views of children's sexual games and nudity and that, at times, the child itself was viewed as a potential threat to other children. This marks a new development in Denmark, internationally known for its broadmindedness, and this article discusses the background to this cultural shift in the institutions, and possible implications for the children.

Objective: We evaluated the extent to which providing training and technical assistance to early childcare centre (ECC) directors, faculty and staff in the implementation of evidence-based nutrition strategies improved the nutrition contexts, policies and practices of ECC serving racially and ethnically diverse, low-income children in Broward County, Florida, USA. The nutrition strategies targeted snack and beverage policies and practices, consistent with Caring for Our Children National Standards., Design: We used the nutrition observation and document review portions of the Environment and Policy Assessment and Observation (EPAO) instrument to observe ECC as part of a one-group pre-test/post-test evaluation design., Setting: ECC located within areas of high rates of poverty, diabetes, minority representation and unhealthy food index in Broward County, Florida, USA., Subjects: Eighteen ECC enrolled, mean 112·9 (sd 53·4) children aged 2-5 years; 12·3 (sd 7·2) staff members; and 10·2 (sd 4·6) children per staff member at each centre., Results: We found significant improvements in centres' overall nutrition contexts, as measured by total EPAO nutrition scores (P=0·01). ECC made specific significant gains within written nutrition policies (P=0·03) and nutrition training and education (P=0·01)., Conclusions: Our findings support training ECC directors, faculty and staff in evidence-based nutrition strategies to improve the nutrition policies and practices of ECC serving racially and ethnically diverse children from low-income families. The intervention resulted in improvements in some nutrition policies and practices, but not others. There remains a need to further develop the evaluation base involving the effectiveness of policy and practice interventions within ECC serving children in high-need areas.

Background: The World Health Organization recommends that nations implement evidence-based nutritional guidelines and policies in settings such as schools and childcare services to improve public health nutrition. Understanding the causal mechanism by which implementation strategies exert their effects could enhance guideline implementation. The aim of this study was to assess the mechanisms by which implementation strategies improved schools and childcare services' adherence to nutrition guidelines., Methods: We conducted a mechanism evaluation of an aggregated dataset generated from three randomised controlled trials conducted in schools and childcare services in New South Wales, Australia. Each trial examined the impact of implementation strategies that targeted Theoretical Domains Framework constructs including knowledge, skills, professional role and identity, environmental context and resources. We pooled aggregated organisation level data from each trial, including quantitative assessments of the Theoretical Domains Framework constructs, as well as measures of school or childcare nutrition guideline compliance, the primary implementation outcome. We used causal mediation analysis to estimate the average indirect and direct effects of the implementation strategies and assessed the robustness of our findings to varying levels of unmeasured and unknown confounding., Results: We included 121 schools or childcare services in the pooled analysis: 79 allocated to receive guideline and policy implementation strategies and 42 to usual practice. Overall, the interventions improved compliance (odds ratio = 6.64; 95% CI [2.58 to 19.09]); however, the intervention effect was not mediated by any of the four targeted Theoretical Domains Framework constructs (average causal mediation effects through knowledge = - 0.00 [- 0.05 to 0.04], skills = 0.01 [- 0.02 to 0.07], professional role and identity = 0.00 [- 0.03 to 0.03] and environmental context and resources = 0.00 [- 0.02 to 0.06]). The intervention had no significant effect on the four targeted Theoretical Domains Framework constructs, and the constructs were not associated with school or childcare nutrition guideline compliance. Potentially, this lack of effect could be explained by imprecise measurement of the mediators. Alternatively, it is likely that that the interventions were operating via alternative mechanisms that were not captured by the four Theoretical Domains Framework constructs we explored., Conclusions: Even though public health implementation strategies led to meaningful improvements in school or childcare nutrition guideline compliance, these effects were not mediated by key targeted constructs of the Theoretical Domains Framework. Future research should explore the mechanistic role of other Theoretical Domains Framework constructs and evaluate system-level mechanisms informed by an ecological framework., Trial Registration: All trials were prospectively registered with the Australian New Zealand Clinical Trials Registry ( ACTRN12613000543785 . Registered 15/05/2013; ACTRN12614001148662 . Registered 30/10/2014; ACTRN12615001032549 . Registered 1/10/2015).

Background: Physical activity has many benefits for young children's health and overall development, but few studies have investigated how early care and education centers allot time for physical activity, along with measured individual physical activity levels for indoor/outdoor activities during a typical day., Methods: Fifty early care and education centers in central North Carolina participated in 4 full-day observations, and 559 children aged 3-5 years within centers wore accelerometers assessing physical activity during observation days. Observation and physical activity data were linked and analyzed for associations between child activity and type of classroom activity., Results: Children averaged 51 (13) minutes per day of moderate to vigorous physical activity and 99 (18) minutes per day of light physical activity while in child care. Children averaged 6 (10) and 10 (13) minutes per day of observed outdoor and indoor daily teacher-led physical activity, respectively. Outdoor time averaged 67 (49) minutes per day, and physical activity levels were higher during outdoor time than during common indoor activities (center time, circle time, and TV time)., Conclusions: Physical activity levels varied between indoor and outdoor class activities. Policy and program-related efforts to increase physical activity in preschoolers should consider these patterns to leverage opportunities to optimize physical activity within early care and education centers.

Objective: The aim of this study was to compare adherence to physical activity and sedentary behaviour recommendations within the 2011 Institute of Medicine Early Childhood Obesity Prevention Policies as well as screen time recommendations from the 2013 American Academy of Pediatrics for samples of infants in child care centres in Australia, Canada, and the United States (US)., Methods: This cross-sectional study used data from: the Australian 2013 Standing Preschools (N=9) and the 2014-2017 Early Start Baseline (N=22) studies; the 2011 Canadian Healthy Living Habits in Pre-School Children study (N=14); and the American 2008 (N=31) and 2013-2017 (N=31) Baby Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) trials. Data were compared on the above infant recommendations. Percentages were used to describe compliance to the recommendations and chi-square tests to determine whether compliance differed by country., Results: Child care centres were most compliant (74%-95%) with recommendations to: provide daily indoor opportunities for infants to move freely under adult supervision, daily tummy time for infants less than 6 months of age, indoor and outdoor recreation areas that encourage infants to be physically active, and discourage screen time. Centres were least compliant (38%-41%) with adhering to recommendations to: limit the use of equipment that restricts an infant's movement and provide education about physical activity to families. Compared with Canadian and US centres, Australian centres were less compliant (46%) with the recommendation to engage with infants on the ground each day, to optimize adult-infant interactions and to limit the use of equipment that restricts the infant's movement. Canadian centres were less compliant (39%) with the recommendation to provide training to staff and education to parents about children's physical activity. US centres were less compliant (25%-41%) with the recommendations to provide daily opportunities for infants to explore their outdoor environment, limit the use of equipment that restricts the infant's movement and provide education to families about children's physical activity., Conclusions: Assisting child care centres on limiting the use of equipment that restricts an infant's movement, and providing education about children's physical activity to families may be important targets for future interventions., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Childhood marks the highest risk for allergic sensitization to asthma triggers. Hispanic/Latino children are at higher risk for hospitalization for asthma than non-Hispanic White children. Childcare providers lack knowledge about reducing asthma triggers., Objectives: The purpose of this paper is to describe a community-based participatory research (CBPR) initiative aimed at developing and pilot testing a bilingual walk-through assessment tool for asthma-friendly childcare environments., Methods: Ten Latina mothers of children with asthma living in the Pacific Northwest collaborated with research partners to develop and pilot test a Childcare Environmental Health (CEH) assessment walk-through survey.Results and Lessons Learned: The women innovated the survey with photography and structural examinations of stress and provision of basic needs. The survey tool identified environmental threats to asthma in all three childcares surveyed., Conclusions: Parents are well-positioned to build trust with childcare providers, assess asthma triggers, and recommend practical mitigation strategies.

Toronto has the largest absolute number of food insecure households for any metropolitan census area in Canada: of its 2.1 million households, roughly 252 000 households (or 12%) experience some level of food insecurity. Community organizations (including social agencies, school programs, and child care centres) serve millions of meals per year to the city's most vulnerable citizens, but often face challenges accessing fresh produce at affordable prices. Therefore in 2015, Toronto Public Health, in collaboration with public- and private-sector partners, launched the FoodReach program to improve the efficiency of food procurement among community organizations by consolidating their purchasing power. Since being launched, FoodReach has been used by more than 50 community organizations to provide many of Toronto's most marginalised groups with regular access to healthy produce., Competing Interests: The authors had no conflicts of interest to report.

Most women in the US are not meeting the recommendation of exclusively breastfeeding their infants for the first 6months of life. The child care environment can be especially influential in a mother's ability to continue breastfeeding after returning to employment. For this study, we reviewed child care regulations related to breastfeeding for centers and homes in all 50 states and the District of Colombia in late 2016, and compared them to 5 national standards. We coded regulations as either not meeting, partially meeting, or fully meeting each standard. We assessed correlations between number of regulations consistent with standards and 1) geographic census region and 2) last year of update. This study provides an update to a previous review conducted in 2012. No state met all 5 of the included standards, and only 2 states for centers and 1 state for homes at least partially met 4 of the 5 standards. More states had regulations consistent with standards encouraging general support for breastfeeding and requiring a designated place for mothers to breastfeed onsite. Number of regulations consistent with standards was associated with geographic census region, but not last year of update. States in the South had a greater number of regulations consistent with standards and states in the West had the fewest number of regulations consistent with standards. Overall support for breastfeeding at the state child care regulation level continues to be insufficient. States should improve child care regulations to include greater support for breastfeeding in child care facilities., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: Social marketing is a promising planning approach for influencing voluntary lifestyle behaviours, but its application to nutrition and physical activity interventions in the early care and education setting remains unknown., Methods: PubMed, ISI Web of Science, PsycInfo and the Cumulative Index of Nursing and Allied Health were systematically searched to identify interventions targeting nutrition and/or physical activity behaviours of children enrolled in early care centres between 1994 and 2016. Content analysis methods were used to capture information reflecting eight social marketing benchmark criteria., Results: The review included 135 articles representing 77 interventions. Two interventions incorporated all eight benchmark criteria, but the majority included fewer than four. Each intervention included behaviour and methods mix criteria, and more than half identified audience segments. Only one-third of interventions incorporated customer orientation, theory, exchange and insight. Only six interventions addressed competing behaviours. We did not find statistical significance for the effectiveness of interventions on child-level diet, physical activity or anthropometric outcomes based on the number of benchmark criteria used., Conclusion: This review highlights opportunities to apply social marketing to obesity prevention interventions in early care centres. Social marketing could be an important strategy for early childhood obesity prevention efforts, and future research investigations into its effects are warranted., (© 2017 World Obesity Federation.)

Background: Maternal depression is a risk factor for adverse outcomes in the child, including emotional and behavioural difficulties. There is evidence that child care attendance during the preschool years may moderate associations between familial risk factors and child outcome. However, the possibility that high-quality child care provides protection for children exposed to maternal depression or that low-quality child care provides additional risk has not been investigated. We study whether child-care quality moderates the association between probable history of maternal depression (PMD) and child behavioural and emotional outcomes over the preschool period., Methods: Within a longitudinal study, we examined PMD (no depression; clinical PMD before the child's birth; subclinical PMD from 0 to 5 years; clinical PMD from 0 to 5 years), child-care quality and child emotional and behavioural difficulties at the ages of 2, 3 and 4 years. Child-care quality was evaluated in settings, and trajectories were calculated to reflect (a) global quality and (b) two quality subfactors: 'Teaching and interactions' and 'Provision for learning'. Data were analysed for 264 families., Results: Significant interactions emerged between clinical PMD and global quality of child care for children's externalising behaviour (b = -.185, p = .008), more specifically hyperactivity/inattention (b = -.237, p = .002). In the context of clinical PMD, children attending high-quality child care presented fewer difficulties than those attending a low-quality care. Child-care quality was not associated with outcomes for children whose mothers did not report a PMD or a PMD before their birth., Conclusions: In the context of PMD, high-quality child care was associated with fewer behavioural problems and may thus constitute a protective factor., (© 2017 Association for Child and Adolescent Mental Health.)

Introduction: Many families enroll their infants and toddlers in early education and child care programs. The Pennsylvania Chapter of the American Academy of Pediatrics recruited 32 child care centers that care for infants and toddlers to be linked with a child care health consultant (CCHC)., Method: Project staff assigned the centers alternately to an immediate intervention or a 1-year delayed intervention (contrast) group. At entry into the project, and then 1 and 2 years later, an evaluator assessed center compliance with 13 standards for infants and toddler care selected from Caring for Our Children: National Health and Safety Performance Standards (3rd ed.). Project staff linked the Immediate Intervention centers with a CCHC in Year 1. In Year 2, in a crossover comparison, project staff linked Contrast centers with a CCHC., Results: Working with a CCHC effectively improved compliance with some selected health and safety standards., (Copyright © 2017 National Association of Pediatric Nurse Practitioners. All rights reserved.)

The quality of indoor environment has received considerable attention owing to the declining outdoor human activities and the associated public health issues. The prolonged exposure of children in childcare facilities or the occupational exposure of adults to indoor environmental triggers can be a culprit of the pathophysiology of several commonly observed idiopathic syndromes. In this study, concentrations of potentially toxic plasticizers (phthalates as well as non-phthalates) were investigated in 28 dust samples collected from three different indoor environments across the USA. The mean concentrations of non-phthalate plasticizers [acetyl tri-n-butyl citrate (ATBC), di-(2-ethylhexyl) adipate (DEHA), and di-isobutyl adipate (DIBA)] were found at 0.51-880 μg/g for the first time in indoor dust samples from childcare facilities, homes, and salons across the USA. The observed concentrations of these replacement non-phthalate plasticizer were as high as di-(2-ethylhexyl) phthalate, the most frequently detected phthalate plasticizer at highest concentration worldwide, in most of indoor dust samples. The estimated daily intakes of total phthalates (n = 7) by children and toddlers through indoor dust in childcare facilities were 1.6 times higher than the non-phthalate plasticizers (n = 3), whereas estimated daily intake of total non-phthalates for all age groups at homes were 1.9 times higher than the phthalate plasticizers. This study reveals, for the first time, a more elevated (∼3 folds) occupational intake of phthalate and non-phthalate plasticizers through the indoor dust at salons (214 and 285 ng/kg-bw/day, respectively) than at homes in the USA., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Staff education is considered key to quality of early childhood education and care (ECEC) programs. However, findings about associations between staff education and children's outcomes have been inconsistent. We conducted a systematic review and meta-analysis of associations between ECEC staff education and child outcomes. Searches of Medline, PsycINFO, and ERIC, websites of large datasets and reference sections of all retrieved articles were conducted. Eligible studies provided a statistical link between staff education and child outcomes for preschool-aged children in ECEC programs. Titles, abstracts and paper reviews as well as all data extraction were conducted by two independent raters. Of the 823 studies reviewed for eligibility, 39 met our inclusion criteria. Research in this area is observational in nature and subject to the inherent biases of that research design. Results from our systematic review were hampered by heterogeneity in how staff education was defined, variability in whose education was measured and the child outcomes that were assessed. However, overall the qualitative summary indicates that associations between staff education and childhood outcomes are non-existent to very borderline positive. In our meta-analysis of more homogeneous studies we identified certain positive, albeit very weak, associations between staff education and children's language outcomes (specifically, vocabulary and letter word identification) and no significant association with a mathematics outcome (WJ Applied Problems). Thus, our findings suggest that within the range of education levels found in the existing literature, education is not a key driver of child outcomes. However, since we only explored levels of education that were reported in the literature, our findings cannot be used to argue for lowering education standards in ECEC settings.

Children, the most vulnerable urban population group, are exceptionally sensitive to polluted environments, particularly urban soils, which can lead to adverse health effects upon exposure. In this study, the total concentrations of Ag, As, Ba, Cd, Co, Cr, Cu, Fe, Hg, Mn, Mo, Ni, Pb, Ti, V, and Zn were determined in 111 topsoil samples collected from kindergartens in Yerevan. The objectives of this study were to evaluate heavy metal pollution levels of kindergarten's soils in Yerevan, compare with national legal and international requirements on heavy metal contents in kindergarten soil, and assess related child health risk. Multivariate geostatistical analyses suggested that the concentrations of Ag, As, Ba, Cd, Cu, Hg, Mo, Pb, and Zn observed in the kindergarten's topsoil may have originated from anthropogenic sources, while Co, Cr, Fe, Mn, Ni, Ti, and V mostly come from natural sources. According to the Summary pollution index (Zc), 102 kindergartens belong to the low pollution level, 7 to the moderate and only 2 to the high level of pollution. Summary concentration index (SCI) showed that 109 kindergartens were in the allowable level, while 2 featured in the low level of pollution. The health risk assessment showed that in all kindergartens except for seven, non-carcinogenic risk for children was detected (HI>1), while carcinogenic risk from arsenic belongs to the very low (allowable) level. Cr and multi-element carcinogenic risk (RI) exceeded the safety level (1.0E- 06) in all kindergartens and showed that the potential of developing cancer, albeit small, does exist. Therefore, city's kindergartens require necessary remedial actions to eliminate or reduce soil pollution and heavy metal-induced health risks., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: Hand, foot, and mouth disease continues to cause seasonal epidemics in the Asia-Pacific Region. Since the current Enterovirus 71 vaccines do not provide cross-protection for all Enterovirus species that cause hand, foot, and mouth disease, there is an urgent need to identify appropriate detection tools and best practice to prevent its transmission and to effectively control its outbreaks. This systematic review aimed to identify characteristics of outbreak and assess the impact and effectiveness of detection tools and public health preventive measures to interrupt transmission. The findings will be used to recommend policy on the most effective responses and interventions in Hong Kong to effectively minimise and contain the spread of the disease within childcare facilities., Methods: We searched the following databases for primary studies written in Chinese or English: MEDLINE, EMBASE, Global Health, WHO Western Pacific Region Index Medicus database, China National Knowledge Infrastructure Databases, and Chinese Scientific Journals Database. Studies conducted during or retrospective to outbreaks of hand, foot, and mouth disease caused by Enterovirus 71 from 1980 to 2012 within childcare facilities and with a study population of 0 to 6 years old were included., Results: Sixteen studies conducted on outbreaks in China showed that hand, foot, and mouth disease spread rapidly within the facility, with an outbreak length of 4 to 46 days, especially in those with delayed notification (after 24 hours) of clustered outbreak (with five or more cases discovered within the facility) to the local Center for Disease Control and Prevention and delayed implementation of a control response. The number of classes affected ranged from 1 to 13, and the attack rate for children ranged from 0.97% to 28.18%., Conclusions: Communication between key stakeholders about outbreak confirmation, risk assessment, and surveillance should be improved. Effective communication facilitates timely notification (within 24 hours) of clustered outbreaks to a local Center for Disease Control and Prevention. Timely implementation of a control response is effective in minimising incidence and length of an outbreak in childcare facilities. The government should provide incentives for childcare facilities to train infection control specialists who can serve as the first contact, knowledge, and communication points, as well as facilitate exchange of information and provision of support across stakeholders during a communicable disease epidemic.

Objectives To understand the process by which early childhood education (ECE) providers effectively used an existing intervention to facilitate the creation or strengthening of a written breastfeeding policy, understand the factors important to this process, and present a logic model to guide future intervention design and evaluation. Methods A purposive sample of interviewees who recently completed an ECE nutrition and physical activity intervention and reported positive pre-post scores for breastfeeding support were recruited to complete semi-structured interviews. Interviews were recorded, transcribed, and coded, following a Grounded Theory approach. Results The ECE programs (n = 23) had a written breastfeeding policy and were located across six states in the United States. The most common aspects of breastfeeding support covered in the policies were handling and storing of breastmilk, pieces of equipment to be provided (e.g., breast pump), and the creation of a space or room designated for breastfeeding and pumping. Many factors important to the policy creation process were identified such as motivation, education, technical assistance, perceptions of parental indifference, staff buy-in, and time and administrative constraints. Once motivated to create a policy, ECE providers described actions, such as gathering background information and model policies, discussing policy needs with stakeholders, utilizing technical assistance, and overcoming barriers. Conclusions for Practice From these findings, a logic model was created to guide future intervention design and evaluation, and several recommendations were made to help guide subsequent interventions in promoting the development and implementation of written breastfeeding policies at ECE programs.

Objectives: We sought to determine the extent to which child care centers in South Carolina improved physical activity practices after a new policy took effect., Methods: In 2012, South Carolina adopted new mandatory physical activity standards within its child care quality enhancement program. This quasi-experimental study used North Carolina, a state not making policy changes, as the comparison. Participants were 34 child care centers in South Carolina and 30 centers in North Carolina. Researchers used the Environment and Policy Assessment and Observation (EPAO) tool to conduct center observations before and after policy implementation and then conducted repeated-measures linear regression with interaction between state and time for the Physical Activity Environment Total Score and the 8 subscale scores., Results: Compared with centers in North Carolina, EPAO subscale scores in South Carolina centers increased significantly for the Fixed Play Environment (P < .001) and Physical Activity Training and Education (P = .015). The state-by-time interaction of Physical Activity Environment Total Score approached statistical significance (P = .06)., Conclusions: Adoption of new physical activity standards in South Carolina child care centers was associated with improvements in practices aimed at increasing children's physical activity.

The quality of staff/child interactions as measured by the Classroom Assessment Scoring System (CLASS) in Early Childhood Education and Care (ECEC) programs is thought to be important for children's outcomes. The CLASS is made of three domains that assess Emotional Support, Classroom Organization and Instructional Support. It is a relatively new measure that is being used increasingly for research, quality monitoring/accountability and other applied purposes. Our objective was to evaluate the association between the CLASS and child outcomes. Searches of Medline, PsycINFO, ERIC, websites of large datasets and reference sections of all retrieved articles were conducted up to July 3, 2015. Studies that measured association between the CLASS and child outcomes for preschool-aged children who attended ECEC programs were included after screening by two independent reviewers. Searches and data extraction were conducted by two independent reviewers. Thirty-five studies were systematically reviewed of which 19 provided data for meta-analyses. Most studies had moderate to high risk of bias. Of the 14 meta-analyses we conducted, associations between Classroom Organization and Pencil Tapping and between Instructional Support and SSRS Social Skills were significant with pooled correlations of .06 and .09 respectively. All associations were in the expected direction. In the systematic review, significant correlations were reported mainly from one large dataset. Substantial heterogeneity in use of the CLASS, its dimensions, child outcomes and statistical measures was identified. Greater consistency in study methodology is urgently needed. Given the multitude of factors that impact child development it is encouraging that our analyses revealed some, although small, associations between the CLASS and children's outcomes., Competing Interests: The authors have declared that no competing interests exist.

Insights into transmission dynamics of enteropathogens in children attending daycare are limited. Here we aimed at identifying daycare centre (DCC) characteristics associated with time-clustered occurrence of enteropathogens in DCC-attending children. For this purpose, we used the KIzSS network, which comprises 43 DCCs that participated in infectious disease surveillance in The Netherlands during February 2010-February 2013. Space-time scan statistics were used to identify clusters of rotavirus, norovirus, astrovirus, Giardia lamblia and Cryptosporidium spp. in a two-dimensional DCC characteristic space constructed using canonical correlation analysis. Logistic regression models were then used to further identify DCC characteristics associated with increased or decreased odds for clustering of enteropathogens. Factors associated with increased odds for enteropathogen clustering in DCCs were having indoor/outdoor paddling pools or sandpits, owning animals, high numbers of attending children, and reporting outbreaks to local health authorities. Factors associated with decreased odds for enteropathogen clustering in DCCs were cleaning child potties in designated waste disposal stations, cleaning vomit with chlorine-based products, daily cleaning of toys, extra cleaning of toys during a suspected outbreak, and excluding children with gastroenteritis. These factors provide targets for reducing the burden of gastrointestinal morbidity associated with time-clustered occurrence of major enteropathogens in DCC attendees.

Introduction: Interventions to improve child diet are recommended as dietary patterns developed in childhood track into adulthood and influence the risk of chronic disease. For child health, childcare services are required to provide foods to children consistent with nutrition guidelines. Research suggests that foods and beverages provided by services to children are often inconsistent with nutrition guidelines. The primary aim of this study is to assess, relative to a usual care control group, the effectiveness of a multistrategy childcare-based intervention in improving compliance with nutrition guidelines in long day care services., Methods and Analysis: The study will employ a parallel group randomised controlled trial design. A sample of 58 long day care services that provide all meals (typically includes 1 main and 2 mid-meals) to children while they are in care, in the Hunter New England region of New South Wales, Australia, will be randomly allocated to a 6-month intervention to support implementation of nutrition guidelines or a usual care control group in a 1:1 ratio. The intervention was designed to overcome barriers to the implementation of nutrition guidelines assessed using the theoretical domains framework. Intervention strategies will include the provision of staff training and resources, audit and feedback, ongoing support and securing executive support. The primary outcome of the trial will be the change in the proportion of long day care services that have a 2-week menu compliant with childcare nutrition guidelines, measured by comprehensive menu assessments. As a secondary outcome, child dietary intake while in care will also be assessed. To assess the effectiveness of the intervention, the measures will be undertaken at baseline and ∼6 months postbaseline., Ethics and Dissemination: The study was approved by the Hunter New England Human Research Ethics Committee. Study findings will be disseminated widely through peer-reviewed publications., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: Policies to promote healthy eating in young children appear promising, but are largely untested. Recently, South Carolina implemented mandatory nutrition standards governing child-care centers serving low-income children., Objective: This study evaluated consistency with the standards before and after the policy took effect., Design: This study evaluated consistency with the nutrition standards in South Carolina, using North Carolina-a state not making policy changes-as the comparison. The research team conducted assessments in a longitudinal sample of centers and a cross-sectional sample of children before and approximately 9 months after the standards took effect., Participants/setting: Trained observers recorded foods and beverages served to 102 children from 34 centers in South Carolina and 90 children from 30 centers in North Carolina at baseline. At follow-up, the research team observed 99 children from 33 centers in South Carolina and 78 children from 26 centers in North Carolina., Intervention: The policy was implemented in April 2012 and included 13 standards governing the nutritional quality of foods and beverages served to children, and staff behaviors related to feeding children in care., Main Outcome Measures: The outcome was consistency with each standard at follow-up in South Carolina compared with North Carolina, controlling for baseline consistency and other covariates., Statistical Analyses Performed: Logistic regressions were conducted to evaluate consistency with each standard, adjusting for baseline and potential confounders., Results: Compared with North Carolina, centers in South Carolina were more likely to be consistent with the standard prohibiting the use of food as a reward or punishment (odds ratio=1.22; 95% CI 1.11 to 1.61; P=0.03). Two centers in South Carolina met all 13 standards at follow-up compared with none in North Carolina. No other differences were observed., Conclusions: New standards modestly improved nutrition practices in South Carolina child-care centers, but additional support is needed to bring all centers into compliance with the current policies., (Copyright © 2016 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Objectives: To determine frequency of non-compliance with child care regulations among family day care homes (FDCH) and identify the role of income in compliance., Methods: We analyzed non-compliance in 746 routine, unannounced inspection and re-inspection reports of FDCH collected by the Connecticut Department of Public Health licensing specialists in 2007-2008 and linked results to median income of zip code data. We grouped the 83 state regulations into 12 regulation categories, analyzed 11 categories, and used latent class analysis to classify each FDCH as high or low compliance for each category. We used logistic regression analysis to estimate the odds ratios of low compliance., Results: Among the 746 FDCH inspections (594 first inspections and 152 re-inspections), we found high rates of non-compliance in inspection regulations in immunizations (32.9 %), water temperature (35.6 %) and hazards (30.0 %). Among the 11 regulation categories, 4 categories (indoor safety, emergency preparedness, child/family/staff documentation, and qualifications of provider) had regulations with high non-compliance. Median household income of FDCH zip code was lower for re-inspection sites than for inspection sites ($34,715 vs. $57,118, p < 0.0001) and FDCH in the lowest quartile of income had greater odds of low compliance in indoor safety (OR 1.86, 95 % CI 1.04, 3.35, p < 0.05)., Conclusions: The majority of FDCH were in compliance with the majority of regulations, yet there are glaring non-compliance issues in inspections and re-inspections and there are income-based inequities that place children at higher risk who are already at high risk for suboptimal health outcomes.

Background: Studies have established that growth of children usually falters during the preschool age when the child is usually left in the hands of other care givers; as parents go to work. Feeding of the preschool children is sometimes solely under the care of Day Care Staff (DCS) whoselevel of knowledge and practice of nutritional care is unknown. Knowledge and practices of nutritional care among DCS in selected preschools were investigated., Method: A descriptive cross-sectional study design was used and 400 DCS were randomly selected for interview. A validated questionnaire with 50-point knowledge scale was used to collect information from the target population and this was complemented with observational checklist to assess the level of practice of nutritional care and environmental hygiene. Data obtained were analysed using both univariate and bivariate analyses including Chi-square test at p=0.05 level of significance., Results: Most of the DCS were female (97.5%) and 47.5% specialised in child education. Few (28.8% and 25.0%) of the DCS had ever received training on child nutritional care during pre-service and in- service training, respectively. Only 20.0% of DCS had good knowledge of nutritional care, which reflected in the activities observed. Age was significantly associated with knowledge of preschool nutritional care.., Conclusion: Knowledge of day care staff on nutritional care of preschool children was found to be poorer as the age of staff increases. This may also contribute to the poor practices observed. Training on nutritional care among day care staff, especially the older ones is suggested.

The aim of these guidelines is to assist staff in school and childcare settings to plan and implement appropriate risk minimisation strategies, taking into consideration the needs of the allergic child, the likely effectiveness of measures and the practicality of implementation. Although these guidelines include risk minimisation strategies for allergic reactions to insect stings or bites, latex and medication, the major focus relates to food allergy. This is due to the higher relative prevalence of food allergy in childhood (compared with other allergic triggers) and the higher likelihood of accidental exposure in these settings. Care of the allergic child in the school, pre-school or childcare settings requires accurate information obtained from parents and carers, staff training in the recognition and management of acute allergic reactions, planning for unexpected reactions (including in those not previously identified as being at risk), age appropriate education of children with severe allergies and their peers, and implementation of practical strategies to reduce the risk of accidental exposure to known allergic triggers. Strategy development also needs to take into account local or regional established legislative or procedural guidelines and the possibility that the first episode of anaphylaxis may occur outside the home. Food bans are not recommended as the primary risk minimisation strategy due to difficulties in implementation and lack of proven effectiveness., (© 2015 The Authors. Journal of Paediatrics and Child Health © 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians).)

Background: The federal Child and Adult Care Food Program (CACFP) assists child care centers serving low-income preschoolers and regulates the quality and quantity of food served. The aim of this study was to assess the nutritional quality of lunches served at 38 child care centers and examine how current practices compare to proposed meal pattern recommendations., Methods: Preschool-aged children (n = 204) were observed eating lunch in 38 CACFP-participating preschools. All foods served and consumed were measured and compared to the 2011 Institute of Medicine (IOM) recommendations to improve CACFP and the 2015 Proposed Rule issued by the USDA., Results: All centers provided access to all required lunch components, but not all components were served (i.e., placed on the child's plate). Vegetables were significantly less likely to be served than meat or grains. Compared with CACFP recommended portion sizes, servings of meat and grain were high, whereas milk was low. Compared with IOM recommendations, average calorie consumption was appropriate, but saturated fat, protein, and sodium intake were high and dietary fiber was low. Meals that offered children both a fruit and a vegetable led to significantly higher produce consumption than meals that offered only one fruit or one vegetable., Conclusions: Child care centers generally comply with current CACFP regulations, but do not provide lunches consistent with the 2011 IOM recommendations for saturated fat, protein, fiber, and sodium. Decreased use of beef and cheese and increased provision of whole grains, fruits, and vegetables are recommended.

Background: Although some researchers have examined nutrition and physical activity policies within urban child care centers, little is known about the potentially unique needs of rural communities., Methods: Child care centers serving preschool children located within low-income rural communities (n = 29) from seven states (Indiana, Kansas, Michigan, North Dakota, Ohio, South Dakota, and Wisconsin) were assessed to determine current nutrition and physical activity (PA) practices and policies. As part of a large-scale childhood obesity prevention project, the Community Healthy Living Index's previously validated Early Childhood Program Assessment Tool was used to collect data. Descriptive statistical analysis was conducted to identify high-priority areas. Healthy People 2020 and the Academy of Nutrition and Dietetics' recommendations for nutrition and PA policies in child care centers were used as benchmarks., Results: Reports of not fully implementing (<80% of the time) recommended nutrition-related policies or practices within rural early child care centers were identified. Centers not consistently serving a variety of fruits (48%), vegetables (45%), whole grains (41%), limiting saturated fat intake (31%), implementing healthy celebration guidelines (41%), involving children in mealtime (62%), and referring families to nutrition assistance programs (24%) were identified. More than one third of centers also had limited structured PA opportunities. Although eligible, only 48% of the centers participated in the Child and Adult Care Food Program., Conclusions: Overall, centers lacked parental outreach, staff training, and funding/resources to support nutrition and PA. These results provide insight into where child care centers within low-income, rural communities may need assistance to help prevent childhood obesity.

Background: Higher quality childcare in the years before school may help narrow developmental gaps between the richest and poorest children in our societies, but specific evidence is limited and inconsistent. We address this issue by examining whether higher quality childcare is associated with better developmental outcomes at school entry for children from lower than higher income families., Methods: The sample from the Longitudinal Study of Australian Children included children attending childcare from 2 to 3 years (n=980-1187, depending on outcome). Childcare quality was measured using carers assessment of their relationship with the child. Children's receptive vocabulary was directly assessed in the child's home, and behavioural difficulties were measured by teachers and parents at 4-5 years. We assessed additive and multiplicative income-related effect measure modification of the quality of carer-child relationship on developmental outcomes., Results: After adjusting for confounding, there was some evidence of effect measure modification on the additive and multiplicative scales of childcare quality by income. Children experiencing higher quality relationships and lower income had almost the same risk of poorer receptive vocabulary as children in higher quality relationships and higher incomes (relative excess risk due to interaction=0.18; 95% CI -0.20 to 0.52), ratio of relative risks=1.11 (1.04 to 1.17)). These patterns were similar for teacher-reported and parent-reported behavioural difficulties., Conclusions: The effects of higher quality childcare, in terms of quality relationships with carers, on children's cognitive and behavioural development at school entry were stronger among children from lower income families. This provides some evidence that higher quality relationships in childcare may be especially important in helping reduce developmental gaps for children from lower income families., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Introduction: Day care center attendance is a risk factor for acquiring respiratory tract infections. There are preventive measures which should be applied., Objectives: To describe the availability of adequate supplies or building facilities, staff habits, behaviors and training, and the existence and enforcement of official guidelines or institutional standards regarding the prevention of respiratory tract infections in day care centers for infants in the city of Buenos Aires., Methods: Exploratory and cross sectional study carried out at systematically selected private day care centers for infants. The person responsible of the day care center was interviewed and a 3-hour observation session was held in a room of each of the day care centers. Information was collected on hand washing practices, clearance of nasal secretions, school exclusion guidance, immunization control, breastfeeding promotion and the existence of guidelines, standards and training on the prevention of respiratory tract infections., Results: Twelve day care centers were included. Though 8 of the 12 centers had the necessary infrastructure and items, hand washing was uncommon and the technique used was incorrect. Clearance of nasal secretions was not followed by hand washing. At 11 of the 12 day care centers, children's immunization is monitored; at 9 of 12, school exclusion guidelines are not followed; none of the centers have breastfeeding promotion material. In 1 of 12, teachers were trained in the subject the year before and, 1 out of 12 had its own guidelines for infection prevention., Conclusion: Despite the availability of resources, preventive measures were not regularly and systematically implemented in the day care centers visited.

In 2008, the Alberta government released the Alberta Nutrition Guidelines for Children and Youth (ANGCY) as a resource for child care facilities to translate nutrition recommendations into practical food choices. Using a multiple case study method, early adoption of the guidelines was examined in two child care centres in Alberta, Canada. Key constructs from the Diffusion of Innovations framework were used to develop an interview protocol based on the perceived characteristics of the guidelines (relative advantage, compatibility, complexity, trialability and observability) by child care providers. Analysis of the ANGCY was conducted by a trained qualitative researcher and validated by an external qualitative researcher. This entailed reviewing guideline content, layout, organisation, presentation, format, comprehensiveness and dissemination to understand whether characteristics of the guidelines affect the adoption process. Data were collected through direct observation, key informant interviews and documentation of field notes. Qualitative data were analysed using content analysis. Overall, the guidelines were perceived positively by child care providers. Child care providers found the guidelines to have a high relative advantage, be compatible with current practice, have a low level of complexity, easy to try and easy to observe changes. It is valuable to understand how child care providers perceive characteristics of guidelines as this is the first step in identifying the needs of child care providers with respect to early adoption and identifying potential educational strategies important for dissemination., (© 2012 Blackwell Publishing Ltd.)

Despite the well-known benefits of youths engaging in 60 or more minutes of daily physical activity, physical inactivity remains a significant public health concern. The 2008 Physical Activity Guidelines for Americans (PAG) provides recommendations on the amount of physical activity needed for overall health; the PAG Midcourse Report (2013) describes effective strategies to help youths meet these recommendations. Public health professionals can be dynamic change agents where youths live, learn, and play by changing environments and policies to empower youths to develop regular physical activity habits to maintain throughout life. We have summarized key findings from the PAG Midcourse Report and outlined actions that public health professionals can take to ensure that all youths regularly engage in health-enhancing physical activity.

More than half of all children in the United States aged 3 to 6 years are enrolled in child care centers. Maine received funds from the U.S. Department of Health and Human Services' Communities Putting Prevention to Work to promote the adoption of Nutrition and Physical Activity Self-Assessment for Child Care (NAPSACC), an evidence-based program for the child care setting. We evaluated the rollout and adoption of NAP SACC in Maine using multiple methods. Our findings suggest that the NAP SACC program has been successfully adopted in Maine. Nutrition and physical activity policies and offerings have improved, especially with regard to purchasing healthier options in the child care setting., (© The Author(s) 2014.)

Recent national guidelines call for improved nutrition within early years settings. The aim of this cross-sectional study was to describe foods and beverages served in nurseries, assess provider behaviors related to feeding, and compare these practices to national guidelines. We administered a mailed survey to a random sample of nurseries across England, stratifying by tertile of deprivation. A total of 851 nurseries returned the survey (54.3% response rate). We fitted separate multivariate logistic regression models to estimate the association of deprivation with each of the 13 food and beverage guidelines and the seven provider behavior guidelines. We also conducted a joint F-test for any deprivation effect, to evaluate the effect of the guidelines combined. After adjusting for confounders, we observed differences in the frequency of nurseries that reported serving healthier foods across the tertiles of deprivation (p = 0.02 for joint F test). These adjusted results were driven mainly by nurseries in more deprived areas serving more whole grains (OR 1.57 (95% CI 1.00, 2.46)) and legumes, pulses, and lentils (1.40 (1.01, 2.14)). We also observed differences in the frequency of nurseries reporting more provider behaviors consistent with national guidelines across the tertiles of deprivation (p = 0.01 for joint F test). Nurseries in more deprived areas were more likely to dilute juice with water (2.35 (1.48, 3.73)), allow children to select their own portions (1.09 (1.06, 1.58)), and sit with children during meals (1.84 (1.07, 3.15)). While nurseries in the most deprived areas reported serving more healthy foods, a large percentage were still not meeting national guidelines. Policy and intervention efforts may increase compliance with national guidelines in nurseries in more deprived areas, and across England., (Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: The rising number of children in daycare nurseries increases opportunities for the transmission of infectious diseases. Pathogens may be transmitted directly from child to child via sneezing, coughing and touching, or indirectly via the environment. Toys are among the fomites with the highest pathogen load, but their role in disease transmission is unknown., Aim: To determine if washing and disinfection of toys can reduce sickness absence and microbial pathogen load in the nursery environment., Methods: Twelve nurseries (caring for 587 children) were randomized to intervention and control groups. The intervention consisted of washing and disinfection of toys and linen every two weeks for three months by a commercial cleaning company. The extent and causes of sickness absence among the children were recorded in both groups before and after introduction of the intervention. Ten sampling points in each nursery were examined for bacteria and respiratory viruses., Results: The presence of respiratory virus DNA/RNA was widespread, but very few pathogenic bacteria were found in the environment. The intervention reduced the presence of adenovirus [odds ratio (OR) 2.4, 95% confidence interval (CI) 1.1-5.0], rhinovirus (OR 5.3, 95% CI 2.3-12.4) and respiratory syncytial virus (OR 4.1, 95% CI 1.5-11.2) compared with the control group, but the intervention had no effect on sickness absence or disease patterns in the nurseries., Conclusion: Although cleaning and disinfection of toys every two weeks can decrease the microbial load in nurseries, it does not appear to reduce sickness absence among nursery children., (Copyright © 2014 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)