Model_Childcare_Statute_FINAL_updated-20131122

Model Childcare Licensing Statute for Obesity Prevention The National Policy & Legal Analysis Network to Prevent Childhood Obesity (NPLAN), a project of ChangeLab Solutions, is a nonprofit organization that provides legal information on matters relating to public health The legal information in this document does not constitute legal advice or legal representation For legal advice, readers should consult a lawyer in their state Support for this document was provided by a grant from the Robert Wood Johnson Foundation August 2012 (updated November 2013) © 2013 ChangeLab Solutions changelabsolutions.org l nplan.org Obesity rates among U.S infants, toddlers, and preschool aged children approximately doubled over a roughly 20 year period, between 1976–1980 and 1999–2000.1 A 2007-2008 nationally representative survey found that about 10 percent of infants to two-year-olds and 22 percent of children age two to five were overweight.2 Of great concern, preschoolers who are overweight or obese are five times more likely to become overweight or obese adults than those preschoolers who are not obese.3 The good news is that a 2008-2011 study of low-income preschoolers found that obesity rates declined slightly in 19 of 43 states and territories studied.4 Most young children in the U.S spend time in a childcare setting About 12.5 million (61 percent) of U.S children under five years old are in some type of arranged childcare setting, including care by relatives or a babysitter at home, by small and large family childcare providers (nonrelatives who care for children in the provider’s home), and by childcare centers (including infant-toddler centers, preschools, and Head Start programs) Because childcare is a part of daily life for most U.S children and both nutrition and physical activity intervention efforts in childcare have shown promise, it is an important site for obesity prevention efforts.6 In the Healthy, Hunger-Free Kids Act of 2010 (HHFKA), Congress called on states to improve their childcare licensing standards to ensure that providers offer daily opportunities for age-appropriate physical activity, limit the use of electronic media and time spent in sedentary activity, and serve meals and snacks that are consistent with the requirements of the federal Child and Adult Care Food Program (CACFP).7 To assist states in strengthening obesity prevention in childcare licensing, NPLAN has developed this model statute Regulation of Childcare Childcare is primarily regulated at the state level State legislatures enact laws setting forth Model Childcare Licensing Statute for Obesity Prevention changelabsolutions.org general requirements for childcare providers and facilities to obtain a license or permission to operate Usually, the administering agency, such as the department of social services or similar office, enacts more detailed regulations implementing the statutes States tend to regulate childcare centers more heavily than family childcare homes, and some states differentiate between large and small family childcare homes, regulating small homes (usually limited to six children or fewer) more lightly than large ones Licensing laws and regulations address health and safety requirements, physical facility (including space per child and outdoor space), equipment standards, caregiver-per-child ratios, and caregiver qualifications, such as training certifications and criminal background clearances Depending upon state law, some cities and counties can enact childcare licensing standards for their local jurisdiction In Florida, for example, the state law and regulations act as minimum standards Individual counties may choose to enact their own standards, provided that they exceed the state minimums and the state’s Department of Children and Family Services approves the local standards.8 Similarly, New York City sets licensing standards for its childcare centers.9 State Licensing Laws Lack Sufficient Obesity Prevention Standards Despite the great need to prevent obesity in young children, most states lack adequate obesity prevention standards in their childcare licensing and administrative schemes While experts recommend that children ages two and older engage in at least 60 to 90 minutes of moderate- to vigorous-intensity physical activity throughout the day, 10 few states have adopted specific standards relating to the duration or scope of physical activity in childcare facilities A 2007 survey found that only three states—Alaska, Delaware, and Massachusetts —required a specified number of minutes of physical activity per day.11 A 2012 study found that the majority of states still fail to meet expert recommendations on active play as set forth in the most recent edition of the National Health and Safety Performance Standards: Guidelines for Out-of-Home Childcare (a collaborative project of the American Academy of Pediatrics, the American Public Health Association, and the National Resource Center for Health and Safety in Childcare).12 State regulations also fall short in limiting the amount of time young children in childcare facilities spend watching television, video, or other visual recordings, or viewing computers (collectively referred to as “screen time”) The 2012 study found that only 15 states addressed screen time limitations, although none met all of the expert standards 13 Similarly, many states need improved nutrition standards The 2012 childcare study found that only 31 states required some types of childcare providers to comply with the nutrition Model Childcare Licensing Statute for Obesity Prevention changelabsolutions.org standards required by the Child and Adult Care Food Program (CACFP) and only and 20 states required all childcare providers to comply.14 The Child and Adult Care Food Program (CACFP) The CACFP is a federal program administered by the U.S Department of Agriculture (USDA) that subsidizes meals and snacks for low-income children and adults receiving care outside their homes.15 More than 3.2 million children receive meals and snacks each day through CACFP 16 The USDA’s Food and Nutrition Service administers CACFP through grants to states In most states, the state educational agency administers the program Independent childcare centers and “sponsoring organizations” enter into agreements with their administering state agency to assume administrative and financial responsibility for CACFP operations A family childcare home must sign an agreement with a sponsoring organization to participate in CACFP and must be licensed or approved to provide day-care services.17 The childcare centers and sponsoring organizations (on behalf of family childcare homes) receive cash reimbursement for serving meals and snacks that meet the federal nutritional guidelines The CACFP meal pattern varies according to the age of the child and types of meal served 18 Under the HHFKA, the USDA must review and update the requirements for meals at least every ten years to ensure that they are consistent with the goals of the most recent U.S Dietary Guidelines.19 The USDA is currently reviewing the Institute of Medicine’s report on CACFP meal patterns and anticipates issuing its proposed rule with new meal patterns in 2013 20 NPLAN’s Model Childcare Licensing Statute for Obesity Prevention NPLAN’s model statute is based on recommendations issued in the 2011 edition of the National Health and Safety Performance Standards: Guidelines for Out-of-Home Childcare (a collaborative project of the American Academy of Pediatrics, the American Public Health Association, and the National Resource Center for Health and Safety in Childcare), the Institute of Medicine’s Early Childhood Obesity Prevention Policies (2011), and the National Association for Sport and Physical Education’s Physical Activity Guidelines for Children from Birth to Age Five (2009); it is modeled in part on the New York City Department of Health and Mental Hygiene Board of Health Day Care Regulations.21 While designed as a statute, the model can be adapted for other uses, including as state administrative regulations (provided that the administrative agency has the enacting authority) or part of a state’s childcare quality rating system In addition, local jurisdictions that have the authority to so can adopt the standards by ordinance or regulation Cities and counties without authority to regulate childcare could pass a resolution urging providers to adopt these standards State and local governments and private funders could require implementation of these standards as a condition for funding Finally, childcare providers could adopt the standards voluntarily Model Childcare Licensing Statute for Obesity Prevention changelabsolutions.org NPLAN’s model standards are designed for full-day childcare programs but can be modified for partial-day programs States can enact these standards for childcare centers and family childcare providers alike The model standards provide comments explaining the provisions and options for implementation Language written in italics provides different options or explains the type of information that needs to be inserted in the blank spaces in the regulations Finally, to implement these standards effectively, providers will need training to serve more nutritious meals and lead developmentally appropriate physical activities for young children.22 Many childcare providers will face an added financial burden because of enhanced nutrition standards and physical activity training and implementation; government or private subsidies may help Children with Disabilities The Americans with Disabilities Act (ADA), a federal law that prohibits discrimination against people with disabilities,23 applies to most childcare facilities—both those run by government agencies, such as Head Start, as well as privately run centers and home-based providers 24 The ADA prohibits childcare providers from discriminating against children with disabilities It requires providers to include children with disabilities in their programs and give them an equal opportunity to participate in the facility’s programs and services Childcare providers must make reasonable accommodations to their policies, procedures, and practices to integrate children with disabilities into their programs, unless doing so would constitute a fundamental alteration of the program.25 Another federal law, the Individuals with Disabilities Education Act (IDEA), mandates that children with disabilities have access to a free appropriate education in the “least restrictive environment.”26 Under the IDEA, a child with disabilities is eligible from birth for early intervention services—specialized health, education, and therapeutic services—at home or in the community 27 Children with disabilities may be entitled to services, including therapeutic physical activity, at the childcare facility The ADA would require a childcare provider to modify any of the obesity prevention standards to care for a child with disabilities who may need an accommodation that is not consistent with the standards For ease of administration, a state could consider including language in its licensing standards reflecting the ADA’s requirements More information on the ADA and its application to childcare centers and providers is available from the U.S Department of Justice, responsible for enforcement of the ADA (www.ada.gov), or the Childcare Law Center (www.childcarelaw.org) Model Childcare Licensing Statute for Obesity Prevention changelabsolutions.org MODEL CHILDCARE LICENSING STATUTE FOR OBESITY PREVENTION COMMENT: This statute is drafted for application to both childcare centers (including infanttoddler centers and preschools) and large and small family day cares (non-relative childcare providers who care for children in the provider’s home) A jurisdiction may modify it as they wish and adapt provisions as useful A jurisdiction that adopts some or all of its provisions must consider where they would best fit into its existing code and amend it accordingly The model can be adapted as state administrative regulations or, in those local jurisdictions with the authority to regulate childcare, as a local ordinance or regulation The model standards provide comments explaining the provisions and options for implementation Language written in italics provides different options or explains the type of information that needs to be inserted in the blank spaces in the regulations This model statute focuses on practices (or programmatic activities) that prevent childhood obesity Facility standards, such as requiring facilities to contain sufficient space to allow physical activity, particularly in locations where air quality or weather conditions limit outdoor playtime, are also important States could also consider amending facility standards, as well as childcare practices AN ACT TO ESTABLISH LICENSING STANDARDS FOR OBESITY PREVENTION IN CHILDCARE SETTINGS BY SETTING PHYSICAL ACTIVITY REQUIREMENTS, LIMITING SCREEN TIME, AND SETTING NUTRITION REQUIREMENTS BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF [ _]: Section One Findings (a) Obesity rates among U.S infants, toddlers, and preschool aged children approximately doubled over a roughly 20 year period, between 1976–1980 and 1999– 2000.28 A 2007-2008 nationally representative survey found that about 10 percent of infants to two-year-olds and 22 percent of children age two to five were overweight.29 In [insert name of state], [insert state’s obese population percentage here] of our State’s adult residents were considered obese in [insert the year of the most recently available information] (b) Obese children are at least twice as likely as non-obese children to become obese adults.30 (c) Overweight children and adults are at greater risk for numerous adverse health consequences, including type diabetes, heart disease, stroke, high blood pressure, high cholesterol, certain cancers, asthma, low self-esteem, depression, and other debilitating diseases.31 Model Childcare Licensing Statute for Obesity Prevention changelabsolutions.org (d) Obesity-related health conditions cost the nation billions of dollars in health care costs and lost productivity; overweight and obesity account for $147 billion in health care costs nationally, or percent of all medical spending, per year.32 Obesity-related annual medical expenditures in the State of [ ] are estimated at [insert State’s cost of obesity here] million.33 (e) About 61 percent of children up to age five spend time in some form of childcare setting.34 [Insert number of children in childcare in the State, if information is available.] (h) Ensuring that children ages zero to five in childcare engage in the recommended amounts of physical activity, including outdoor play; spend limited time using electronic media; and are served meals and snacks that are consistent with the requirements of the federal Child and Adult Care Food Program will help to prevent children from becoming overweight or obese (i) It is the intent of the Legislature, by adopting this legislation, to improve the health and well-being of children ages zero to five COMMENT: While state practices vary, in many states new legislation includes findings of fact that support the purposes of the legislation The findings section is part of the statute and legislative record, but it usually does not become codified in the state codes The findings contain factual information supporting the need for the law—in this case, documenting the need for and benefits of the childcare licensing standards States may select findings from this list to include in their legislation, along with additional findings addressing the specific conditions in the particular state Model Childcare Licensing Statute for Obesity Prevention changelabsolutions.org Section Two [State Code] is hereby amended by adding thereto a new chapter [or amending chapter _] to read as follows: Section -1 Application The following licensing standards for physical activity, screen time, and nutrition shall apply to [all licensed childcare facilities and family childcare providers] COMMENT: States regulate both childcare centers (including infant-toddler centers, preschools, and other childcare centers) and small and large family childcare providers (non-relative childcare providers who care for children in the provider’s home), often imposing more rigorous standards on centers Ideally, the obesity-prevention standards should be applied to all forms of childcare arrangements Because these new standards require changes in childcare practices, they may require additional costs and training States may consider phasing in the changes over time for all providers or imposing the new standards on childcare centers first, and then family childcare providers Section -2 Physical Activity Standards (a) Standards for children up to [12] months old (1) Caregivers shall place children under one year old in safe settings that facilitate physical activity and not restrict movement for prolonged periods of time, promote the development of movement skills, and allow infants to perform small and large muscle activities (2) Caregivers shall limit the time children under one year are placed in infant equipment such as swings, stationary activity centers, exersaucers, bouncers, and molded seats to short periods of no more than [15] minutes at a time (3) Infants shall play outdoors daily when weather and air-quality conditions not pose a significant health risk Infants shall be dressed appropriately for the weather and protected from the sun Outdoor play for infants may include riding in a carriage or stroller; however, infants shall be permitted daily opportunities for independent gross motor play outdoors (b) Standards for children ages one and older (1) Caregivers shall promote children’s active play every day Children should participate daily in no fewer than two occasions of active play outdoors, weather and air quality permitting Children shall be dressed appropriately for the weather and protected from the sun Children shall have ample opportunity to engage in vigorous activities such as running, climbing, dancing, skipping, and jumping and to develop gross-motor and fine- Model Childcare Licensing Statute for Obesity Prevention changelabsolutions.org motor skills (A) Children ages to shall engage in no less than [60–120] minutes of moderate to vigorous physical activity per day of childcare, including no fewer than two structured or caregiver/teacher/adult-led activities or games that promote movement (B) Children ages to shall engage in no less than [90–120] minutes of moderate to vigorous physical activity per day of childcare, including no fewer than two structured or caregiver/teacher/adult-led activities or games that promote movement (C) Standards are based on an eight-hour day in childcare and shall be implemented on a proportional basis for children attending less than full-day programs (2) Children ages to shall not engage in a sedentary activity for more than 60 minutes at a time, except when sleeping (3) Caregivers may not withhold active play from children who misbehave, although caregivers may separate children from others for short periods of time, not to exceed [five minutes], to calm themselves or settle down before resuming cooperative play or activities COMMENTS: Age standards Most states set childcare regulations according to age The standards for children younger than one year old could be adjusted by applying them to children who are not yet walking or, for ease of administration, to reflect existing age categories in the state’s licensing regulations Outdoor play Outdoor play, even in rooftop play areas in urban spaces, allows for physical activity to support the maintenance of healthy weight and to develop gross motor skills 35 Time spent outdoors has been found to be a strong predictor of children’s physical activity, and evidence suggests that physical activity habits learned early in life may track into adolescence and adulthood.36 In addition, for children in full-time care who live in unsafe areas, childcare may provide the only opportunity for active outdoor play Depending upon local weather and environmental conditions, state regulations often include more specific requirements regarding weather conditions, appropriate attire, and air quality appropriate for outdoor play Total minutes per day spent in play Experts agree that caregivers need to increase young children’s physical activity but differ slightly in their total time recommendations The National Health and Safety Performance Standards recommend that children ages one to three engage in 60 to 90 minutes of Model Childcare Licensing Statute for Obesity Prevention changelabsolutions.org moderate to vigorous playtime while children three and older engage in 90 to 120 minutes.37 The IOM guidelines recommend providing opportunities for light, moderate, and vigorous physical activity for at least 15 minutes per hour while children are in childcare 38 NPLAN’s model statute sets a minimum amount of accumulated time per day (covering the range of recommendations) devoted to physical activity Many states may find that setting a total measurement per day may be easier for caregivers to implement than an hourly requirement, but other states may choose to set a time-per-hour recommendation Structured playtime Experts differ in the amount of structured playtime recommended for toddlers and preschool-age children, although all agree that some structured playtime is necessary Evidence suggests that structured activities produce higher levels of physical activity in young children.39 The National Association for Sport and Physical Education (NASPE) recommends that children three and older should accumulate at least 60 minutes of structured physical activity each day to help develop gross-motor and fine-motor skills 40 The National Health and Safety Performance Standards recommend that caregivers incorporate two or more short structured activities (five to ten minutes) or games daily that promote physical activity.41 The model statute does not give a total amount of structured activity time, but states could choose to so The standards in the model are based on a full day in childcare States may choose to set standards based on half-day or per hour in care Section -3 Screen Time Standards (a) Children under two years old shall not watch television, video, or other visual recordings, or view computers (b) Children two years or older may not watch television, video, or other visual recordings for more than [30/60] minutes per [day/week] of childcare The video, television, or other visual programming may consist only of educational programs or programs that actively engage children’s movement (c) Computer use for children two years or older shall be limited to increments of no more than 15 minutes at a time for no more than [30/60] minutes per day [States that wish to permit more computer usage should adjust time limits on viewing television, video, or other visual recordings to ensure that total time exposed to media viewing does not exceed one hour per day.] COMMENT: Young children are increasingly exposed to media, including television, video recordings, computers, and cell phones Preschool-age children watch between one and three hours of television daily.42 Substantial exposure to television (including any advertising) is associated with greater risk of overweight and later obesity, inactivity, Model Childcare Licensing Statute for Obesity Prevention changelabsolutions.org 10 decreased metabolic rate, and increased snacking.43 Experts agree that young children’s total daily exposure to media and other forms of screen time should be limited Limiting exposure in childcare helps limit total daily exposure, along with setting healthy habits for life Both the National Health and Safety Performance Standards and the IOM guidelines recommend that children under two years should not watch television or video recordings or view computers in childcare.44 NPLAN’s model statute is consistent with that limitation Expert recommendations for children two years and older differ.45 The National Health and Safety Performance Standards recommend that total media exposure in childcare be limited to no more than 30 minutes once a week of educational or physical activity–oriented content It also recommends that computer exposure be limited to increments of no more than 15 minutes at a time.46 The IOM guidelines recommend that childcare providers limit screen time (including television, cell phones, or digital media) for children two years and older to less than 30 minutes per day for children in half-day programs or less than one hour per day for those in full-day programs.47 The NPLAN model statute provides a range in its recommendations to allow states to make the final decision Limiting screen time exposure may require a significant change in practice for many childcare providers, particularly home care providers States could consider phasing in this limitation by requiring a more gradual reduction of screen time Section -4 Nutrition Standards (a) Caregivers shall offer to and make available to children, as nutritionally appropriate, potable water as an acceptable fluid for consumption throughout the day (b) Caregivers shall encourage mothers to breastfeed their infants and shall safely store and serve breast milk provided by the parent (c) Caregivers shall serve meals and snacks that, at a minimum, comply with the requirements of the Child and Adult Care Food Program (d) Caregivers shall not withhold food for punishment or use food as a reward Model Childcare Licensing Statute for Obesity Prevention changelabsolutions.org 11 Thanks to our reviewers: Sara Benjamin Neelon, Ph.D., M.P.H., R.D., Assistant Professor, Community and Family Medicine and Global Health, Duke University Medical Center and Duke Global Health Institute Melissa Rodgers, J.D., Directing Attorney, Childcare Law Center Mary Story, Ph.D., R.D., Professor in the Division of Epidemiology and Community Health, and Senior Associate Dean of Academic and Student Affairs in the School of Public Health, University of Minnesota and an Adjunct Professor in the Department of Pediatrics School of Medicine Model Childcare Licensing Statute for Obesity Prevention changelabsolutions.org 12 Ogden CL, Flegal, KM, Carroll, MD, et al “Prevalence and Trends in Overweight Among US Children and Adolescents, 1999-2000.” Journal of the American Medical Association, 288(14): 1728-1732, 2002 Available at: http://jama.jamanetwork.com/article.aspx?articleid=195387 Ogden CL, Carroll MD, Curtin LR, et al “Prevalence of High Body Mass Index in US Children and Adolescents, 2007–2008.” Journal of the American Medical Association, 303(3): 242–249, 2010 Available at: www.jama.amaassn.org/content/303/3/242.full Centers for Disease Control and Prevention (2013, August 9) Vital Signs: Obesity Among Low-Income, PreschoolAged Children United States, 2008-2011 MMWR, Morbidity and Mortality Weekly Report; Vol 62, No 31, p 629634, August 9, 2013 Id at 629 Laughlin, Lynda 2013 “Who’s Minding the Kids? Childcare Arrangements: Spring 2011.” Current Population Reports, P70-135 U.S Census Bureau, Washington, DC., p Accessed November 2013 Available at: www.census.gov/prod/2013pubs/p70-135.pdf Healthy Eating Research and Active Living Research Preventing Obesity Among Preschool Children: How Can Childcare Settings Promote Healthy Eating and Physical Activity? Research Synthesis October 2011 Available at: www.healthyeatingresearch.org/publications-mainmenu-111/research-briefs-and-syntheses-mainmenu114 Healthy, Hunger-Free Kids Act of 2010, P.L 111-296, Dec 13, 2010, 124 Stat 3183 § 222 Fl Stat § § 402.301, 402.306, 402.307 New York City, N.Y Health Code §§ 47.01, 47.35-47.37 10 While the federal government has issued physical activity standards, they not address children under six years old Health and Human Services (HHS) 2008 Physical Activity Guidelines for Americans Available at: www.health.gov/paguidelines/guidelines/default.aspx#toc The World Health Organization’s guidelines, Recommended Amount of Physical Activity, similarly not address children under age five www.who.int/dietphysicalactivity/factsheet_recommendations/en/ The American Academy of Pediatrics, American Public Health Association, and National Resource Center for Health and Safety in Childcare have developed recommendations for physical activity in childcare American Academy of Pediatrics, et.al Caring for Our Children: National Health and Safety Performance Standards; Guidelines for Early Care and Education Programs, 3rd ed Elk Grove Village, IL: American Academy of Pediatrics, 2013, Standard 3.1.3.1 (hereafter “Caring for Our Children”) Available at: http://nrckids.org/CFOC3/CFOC3_color.pdf 11 The study apparently looked at state administrative regulations, but it is not clear if it reviewed licensing statutes Benjamin S, Cradock A, Walker E, et al “Obesity Prevention in Childcare: A Review of U.S State Regulations.” BMC Public Health, 8: 188, 2008 12 National Resource Center for Health and Safety in Childcare and Early Education, Achieving a State of Healthy Weight: 2012 Update, p 19 June 2013, p 24 Available at: http://nrckids.org/index.cfm/products/achieving-a-stateof-healthy-weight1/ 13 Id at p 19 14 Id at p 50 15 42 U.S.C 1766, CRF Part 226 16 USDA Food and Nutrition Service, Children and Adult Care Food Program Available at: www.fns.usda.gov/cacfp/child-and-adult-care-food-program 17 Id 18 Id 19 Healthy, Hunger-Free Kids Act of 2010, § 221 20 21 USDA Implementation Plan: Healthy, Hunger-Free Kids Act of 2010 Available at: www.fns.usda.gov/cnd/Governance/legislation/implementation_actions.pdf Caring for Our Children, supra note 10; Institute of Medicine (IOM) Early Childhood Obesity Prevention Policies Washington, DC: The National Academies Press, 2011 (hereafter “IOM Guidelines”); National Association for Sport and Physical Education (NASPE) Active Start: A Statement of Physical Activity Guidelines for Children Birth to Five Years, 2nd ed 2009 (hereafter “NASPE Guidelines”) Accessed January 2012 Available at: wwww.aahperd.org/naspe/standards/nationalGuidelines/ActiveStart.cfm ; New York City Health Code §§ 47.01, 47.35–47.37 22 Information on developmentally appropriate physical activity for young children is available from the National Association for the Education of Young Children (www.naeyc.org), NASPE (www.aahperd.org), and PE Central (www.pecentral.org) 23 42 U.S.C § 12101 et seq The U.S Department of Justice, responsible for enforcement of the ADA, has a website containing the statute, regulations, and many helpful technical assistance documents (www.ada.gov) Especially helpful is “Commonly Asked Questions About Childcare Centers and the Americans with Disabilities Act” (hereafter “Commonly Asked Questions”) Available at: www.ada.gov/childq&a.htm 24 Childcare centers operated by religious entities are not subject to the ADA “Commonly Asked Questions,” supra note 23 25 Id More information on accommodating children with disabilities is available from the National Association for the Education of Young Children (www.naeyc.org) and the National Early Childhood Technical Assistance Center (www.nectac.org) 26 20 U.S.C § 1400 et seq 27 More information about early intervention services is available from the National Dissemination Center for Children with Disabilities (www.nichcy.org) 28 Ogden CL, Flegal, KM, Carroll, MD, et al “Prevalence and Trends in Overweight Among US Children and Adolescents, 1999-2000.” Journal of the American Medical Association, 288(14): 1728-1732, 2002 Available at: http://jama.jamanetwork.com/article.aspx?articleid=195387 29 Ogden CL, Carroll MD, Curtin LR, et al “Prevalence of High Body Mass Index in US Children and Adolescents, 2007–2008.” Journal of the American Medical Association, 303(3): 242–249, 2010 Available at: www.jama.amaassn.org/content/303/3/242.full 30 Serdula MK, Ivery D, Coates RJ, et al “Do Obese Children Become Obese Adults? A Review of the Literature.” Preventive Medicine, 22(2): 167–177, 1993 31 U.S Department of Health and Human Services, Office of the Surgeon General The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity Rockville, MD: U.S Department of Health and Human Services, Public Health Service, Office of the Surgeon General, 2007 Available at: www.surgeongeneral.gov/library/calls/obesity/fact_adolescents.html 32 Finkelstein EA, Trogdon JG, Cohen JW, et al 2009 “Annual Medical Spending Attributable to Obesity: Payer- and Service-Specific Estimates.” Health Affairs 5: w822–w831, http://content.healthaffairs.org/content/28/5/w822.long 33 For state-specific health care spending data, see: Finkelstein EA, Fiebelkorn IC, and Wang G “State-Level Estimates of Annual Medical Expenditures Attributable to Obesity.” Obesity Research, 12(1): 18–24, 2004 These state-level data are for 2003 State health agencies may have more recent spending data 34 Laughlin, Lynda 2013 “Who’s Minding the Kids? Childcare Arrangements: Spring 2011.” Current Population Reports, P70-135 U.S Census Bureau, Washington, DC., p Accessed November 2013 Available at: www.census.gov/prod/2013pubs/p70-135.pdf 35 Caring for Our Children, supra note 10, Standard 3.1.3.2, pp 93–94 36 Caring for Our Children, supra note 10, Standard 3.1.3.1., pp 90–93 37 Id 38 IOM Guidelines, supra note 21, at p 61 39 Id 40 NASPE Guidelines, supra note 21, Guideline One for Preschoolers 41 Caring for Our Children, supra note 10, Standard 3.1.3.1, pp 90–93 42 IOM Guidelines, supra note 21, at p 119 43 Id 44 Caring for Our Children, supra note 10, Standard 2.2.0.3, pp 66–68; IOM Guidelines, supra note 21, p 120 45 In 2012, NAEYC issued a position statement, “Technology and Interactive Media as Tools in Early Childhood Programs Serving Children from Birth through Age 8” that stated, “Technology and interactive media are tools that can promote effective learning and development when they are used intentionally by early childhood educators, within the framework of developmentally appropriate practice, to support learning goals established for individual children.” P More information is available from NAEYC at: www.naeyc.org/content/technology-and-youngchildren 46 Caring for Our Children, supra note 10, Standard 2.2.0.3, pp 66–68 47 IOM Guidelines, supra note 21, Recommendation 5.1, p 121