Feeding Infants and Meal Pattern Requirements in the Child and Adult Care Food Program: Questions and Answers

The purpose of this memorandum is to provide guidance on feeding infants and the infant meal pattern requirements in the Child and Adult Care Food Program (CACFP) and includes Questions and Answers. This memorandum supersedes CACFP 14-2015 (v.2) Infant Feeding in the CACFP- Revised.

Background

The Healthy, Hunger-Free Kids Act of 2010 (the Act), PL 111-296, amended section 17 of the Richard B. Russell National School Lunch Act (NSLA), 42 USC 1766(g), to require the U.S. Department of Agriculture (USDA) to update the CACFP meal pattern requirements to make them more consistent with (a) the most recent version of the Dietary Guidelines for Americans, (b) the most recent relevant nutrition science, and (c) appropriate authoritative scientific agency and organization recommendations. On April 25, 2016, USDA’s Food and Nutrition Service (FNS) published the final rule “Child and Adult Care Food Program: Meal Pattern Revisions Related to the Healthy, Hunger-Free Kids Act.” This final rule amended CACFP regulations at 7 CFR 226.20 to update the meal pattern requirements.

When developing the updated infant meal patterns, FNS relied on recommendations from the American Academy of Pediatrics (AAP), the leading authority for children’s developmental and nutritional needs from birth through 23 months, because the Dietary Guidelines do not currently provide recommendations for children under two years old. This memorandum outlines infant feeding requirements in the CACFP and explains the updated infant meal pattern requirements established in the final rule, including when solid foods must be served.

I. Offering Infant Meals

Infants enrolled for care at a participating CACFP center or day care home must be offered a meal that complies with the CACFP infant meal pattern requirements (7 CFR 226.20(b)). CACFP regulations define an enrolled child as “a child whose parent or guardian has submitted to an institution a signed document which indicated that the child is enrolled in child care” (7 CFR 226.2). A center or day care home may not avoid this obligation by stating that the infant is not “enrolled” in the CACFP, or by citing logistical or cost barriers to offering infant meals. Decisions on offering program meals must be based on whether the infant is enrolled for care in a participating center or day care home, not if the infant is enrolled in the CACFP.

Infants do not eat on a strict meal schedule. Instead, infants must be fed during a span of time that is consistent with the infant’s eating habits. To learn more about hunger and satiety cues, see the Feeding Infants: A Guide for Use in the Child Nutrition Programs available at https://www.fns.usda.gov/tn/feeding-infants-child-and-adult-care-food-program. This Feeding Infants Guide is being revised to reflect the updated CACFP infant meal patterns. Infant meals must not be disallowed due solely to the fact that they are not served within the established meal time periods.

Creditable Infant Formulas

As part of offering a meal that is compliant with the CACFP infant meal pattern requirements, centers and day care homes with infants in their care must offer at least one type of iron-fortified infant formula (7 CFR 226.20(b)(2)). The Food and Drug Administration (FDA) defines iron-fortified infant formula as a product “which contains 1 milligram or more of iron in a quantity of product that supplies 100 kilocalories when prepared in accordance with label directions for infant consumption” (21 CFR 107.10(b)(4)(i)). The number of milligrams (mg) of iron per 100 kilocalories (calories) of formula can be found on the Nutrition Facts Label of infant formulas. 

Previously, FNS provided a list of Iron-Fortified Infant Formulas That Do Not Require a Medical Statement. FNS no longer maintains such a list due to the continuous development of new or re-formulated infant formula products making an accurate, all-inclusive list impractical.  Instead, the following criteria may be used to determine whether a formula is eligible for reimbursement:

1. Ensure that the formula is not an FDA Exempt Infant Formula. An exempt infant formula is an infant formula labeled for use by infants who have inborn errors of metabolism or low birth weight, or who otherwise have unusual medical or dietary problems, as defined in 21 CFR 107.3. More information and a list of FDA Exempt Infant Formulas can be found at:  http://www.fda.gov/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformation/InfantFormula/ucm106456.htm.
2. Look for “Infant Formula with Iron” or a similar statement on the front of the formula package. All iron-fortified infant formulas must have this type of statement on the package. 
3. Use the nutrition facts label as a guide to ensure that the formula is iron-fortified. The nutritive values of each formula are listed on the product’s nutrition facts label. To be considered iron-fortified, an infant formula must have 1 mg of iron or more per 100 calories of formula when prepared in accordance with label directions.

Additionally, to be creditable for reimbursement, infant formula must meet the definition of an infant formula in section 201(z) of the Federal Food, Drug, and Cosmetic Act (FFDCA) (21 USC 321(z)) and meet the requirements for an infant formula under section 412 of the Federal Food, Drug, and Cosmetic Act (FFDCA) (21 USC 350a) and the regulations at 21 CFR parts 106 and 107. Requiring an infant formula to be compliant with the FDA regulatory standards on infant formula is consistent with the Special Supplemental Nutrition Program for Women, Infants, and Children’s (WIC) infant formula requirements. It also ensures that all infant formulas served in the CACFP meet nutrient specifications and safety requirements. If a formula is purchased outside of the United States, it is likely that the formula is not regulated by the FDA. Infant formulas that are not regulated by FDA are not creditable in the CACFP.

Formulas classified as Exempt Infant Formulas by FDA may be served as a part of a reimbursable meal if the substitution is due to a disability and is supported with a medical statement signed by a licensed physician or a state recognized medical authority. A state recognized medical authority for this purpose is a state licensed health care professional who is authorized to write medical prescriptions under state law. The statement must be submitted and kept on file by the center or day care home. For more information on who may sign a medical statement for meal modifications due to a disability, see SP32 SFSP15 CACFP13-2015, Statements Supporting Accommodations for Children with Disabilities in the Child Nutrition Programs, available at http://www.fns.usda.gov/statements-supportingaccommodations-children-disabilities-cnp.

II. Parent or Guardian Provided Breastmilk or Formula

An infant’s parent or guardian may, at their discretion, decline the infant formula offered by the center or day care home and provide expressed breastmilk or a creditable infant formula instead. Meals containing parent or guardian provided expressed breastmilk or creditable infant formula that are served by the child care provider to the infant are eligible for reimbursement, including meals when an infant is only consuming breastmilk or infant formula. Additionally, in recognition of the numerous benefits of breastfeeding and that the AAP recommends breastmilk as the optimal source of nutrients through the first year of life, centers and day care homes may claim reimbursement of meals when a mother directly breastfeeds her infant at the center or day care home. This includes meals when an infant is only consuming breastmilk. This added flexibility in the updated infant meal patterns becomes effective Oct. 1, 2017 and is consistent with other FNS efforts, such as in WIC, to support and encourage breastfeeding. Therefore, starting Oct. 1, 2017, meals where a mother directly breastfeeds her infant on-site, are eligible for reimbursement.

State agencies have the discretion to begin allowing reimbursement of meals where a mother breastfeeds on-site prior to Oct. 1, 2017. Please see memorandum SP42 CACFP14-2016 Early Implementation of the Child and Adult Care Food Program Meal Patterns (http://www.fns.usda.gov/sites/default/files/cn/SP42_CACFP14_2016os.pdf) for more information. FNS strongly encourages state agencies to update existing forms to document when a mother breastfeeds on-site, rather than creating a new form for that purpose. This will help avoid adding unnecessary administrative burdens. Additionally, centers and day care homes do not need to quantify and record the amount of breastmilk a mother directly breastfeeds her infant.

When a parent or guardian chooses to provide breastmilk (expressed breastmilk or by directly breastfeeding on-site) or a creditable infant formula and the infant is consuming solid foods, the center or day care home must supply all the other required meal components in order for the meal to be reimbursable.

Expressed Breastmilk Storage

The AAP recommends an optimal storage time of 72 hours for refrigerated expressed breastmilk.  Accordingly, to follow current scientific recommendations, breastmilk may be stored for no longer than 72 hours. The  previously established standard was 48 hours from the time it was collected. FNS made this change via policy guidance in 2015 to support breastfeeding practices and increase flexibility for centers and day care homes. Bottles of expressed breastmilk must be stored in a refrigerator kept at 39 degrees Fahrenheit (3.9 degrees Celsius) or below. Centers and day care homes should continue to follow all other breastmilk handling and storage guidelines listed in Feeding Infants: A Guide for Child Nutrition Programs (http://www.fns.usda.gov/tn/feedinginfants-guide-use-child-nutrition-programs).

III. Solid Foods (Complementary Foods)

The updated CACFP infant meal pattern includes two infant age groups: birth through the end of 5 months and the beginning of 6 months through the end of 11 months. These updated infant age groups are consistent with the infant age groups in the WIC program. In addition, the updated infant age groups will help delay the introduction of solid foods until around 6 months of age. It is important to delay the introduction of solid foods until around 6 months of age as most infants are typically not physiologically developed to consume solid foods until midway through the first year of life. According to the AAP, 6 to 8 months of age is often referred to as a critical window for initiating the introduction of solid foods to infants. In addition, by 7 to 8 months of age, infants should be consuming solid foods from all food groups (vegetables, fruits, grains, protein foods, and dairy). 

Starting Oct. 1, 2017, solid foods must be served to infants around 6 months of age, as it is  developmentally appropriate for the infant. Once an infant is developmentally ready to accept solid foods, the center or day care home is required to offer them to the infant. FNS recognizes, though, that solid foods are introduced gradually, new foods may be introduced one at a time over the course of a few days, and an infant’s eating patterns may change. For example, an infant may eat a cracker one week and not the next week. Centers and day care homes must follow the eating habits of infants. Meals should not be disallowed simply because one food was offered one day and not the next if it is consistent with the infant’s eating habits. In addition, solid foods served to infants must be of a texture and consistency that is appropriate for the age and development of the infant being fed.

There is no single, direct signal to determine when an infant is developmentally ready to accept solid foods. An infants’ readiness depends on his or her rate of development. Centers and day care homes should be in constant communication with infants’ parents or guardians about when and what solid foods should be served while the infant is in care. As a best practice, FNS recommends that parents or guardians request in writing when a center or day care home should start serving solid foods to their infant. When talking with parents or guardians about when to serve solid foods to infants in care, the following guidelines from the AAP can help determine if an infant is developmentally ready to begin eating solid foods:

• The infant is able to sit in a high chair, feeding seat, or infant seat with good head control;
• The infant opens his or her mouth when food comes his or her way. He or she may watch others eat, reach for food, and seem eager to be fed;
• The infant can move food from a spoon into his or her throat; and
• The infant has doubled his or her weight and weighs about 13 pounds or more.

Allowing solid foods to be served when the infant is developmentally ready (around 6 months of age) better accommodates infants’ varying rates of development and allows centers and day care homes to work together with the infant’s parents or guardians to determine when solid foods should be served. For more information and best practices on serving solid foods to infants, please see Feeding Infants: A Guide for Child Nutrition Programs (http://www.fns.usda.gov/tn/feeding-infants-guide-use-child-nutrition-programs). 

Vegetables and Fruits

The primary goal of updating the CACFP meal patterns was to help children establish healthy eating patterns at an early age. Offering a variety of nutrient dense foods, including vegetables and fruits (cooked, mashed, or pureed as needed to obtain the appropriate texture and consistency), can help promote good nutritional status in infants. Additionally, the AAP recommends infants consume more vegetables and fruit. Vegetables and fruits are already required at breakfast, lunch, and supper meals for infants that are developmentally ready to accept them (around 6 months of age). Therefore, starting Oct. 1, 2017, to further help increase infants exposure of and consumption of vegetables and fruits, the updated meal patterns requires vegetables and fruits to be served at snack for infants that are developmentally ready to accept them. In addition, juice cannot be served to infants of any age starting Oct. 1, 2017. 

Grains

To provide greater flexibility to the menu planner, the updated infant meal pattern allows ready-to-eat cereals to be served at snack for infants that are developmentally ready to accept them. All ready-to-eat cereals served to infants are subject to the same sugar limit as breakfast cereals served to children and adults in the CACFP that begins Oct. 1, 2017. This means, ready-to-eat cereals served to infants at snack must contain no more than 6 grams of sugar per dry ounce.

This flexibility to serve ready-to-eat cereals at infant snacks goes into effect Oct. 1, 2017.  However, state agencies have the discretion to begin allowing reimbursement of infant snacks with ready-to-eat cereals prior to Oct. 1, 2017. Please see memorandum SP42 CACFP14-2016 Early Implementation of the Child and Adult Care Food Program Meal Patterns (http://www.fns.usda.gov/sites/default/files/cn/SP42_CACFP14_2016os.pdf) for more information.

Meat and Meat Alternates

Meat and meat alternates are good sources of protein and provide essential nutrients for growing infants, such as iron and zinc. FNS acknowledges that yogurt is often served to infants as they are developmentally ready. In recognition of this and to be consistent with the WIC food packages for infants, the updated infant meal pattern allows yogurt as a meat alternate for older infants that are developmentally ready to accept them. In addition, the updated infant meal pattern no longer allows cheese food or cheese spread as reimbursable meat alternates. This is due to their higher sodium content, and the AAP recommends caregivers choose products lower in sodium.

The updated infant meal patterns allow whole eggs as meat alternates. Previously, only egg yolks were creditable in the infant meal pattern because there were concerns with developing food allergies when infants are exposed to the protein in the egg white. However, the AAP recently concluded that there is no convincing evidence to delay the introduction of foods that are considered major food allergens, such as eggs. 

Crediting yogurt and whole eggs as meal alternates and the disallowance of cheese food and cheese spread in the infant meal patterns goes into effect Oct. 1, 2017. State agencies, though, have the option to reimburse infant meals with yogurt and whole egg prior to Oct. 1, 2017. Please see memorandum SP42 CACFP14-2016 Early Implementation of the Child and Adult Care Food Program Meal Patterns (http://www.fns.usda.gov/sites/default/files/cn/SP42_CACFP14_2016os.pdf) for more information.

DHA Enriched Infant Foods

Docosahexaenoic acid, known as DHA, is an omega-3 fatty acid that may be added to infant formulas and infant foods. While more research on the benefits of DHA and ARA (arachidonic acid, an omega-6 fatty acid) is needed, some studies suggest they may have positive effects on visual function and neural development. For these reasons, manufacturers and consumers are interested in adding DHA and ARA to infant formula and food products.

Previously, the service of any infant foods containing DHA was prohibited in CACFP due to the concern that the source of DHA in infant foods, such as egg yolk, and other ingredients, additives, or extenders in those foods may result in a food sensitivity or a food allergy (CACFP memorandum Baby Foods and Vegetables with DHA, Dec. 19, 2002). However, as stated in the section above, there is no current convincing evidence to warrant delaying the introduction of foods considered to be major food allergens. Therefore, FNS issued guidance in 2015 allowing single-ingredient infant foods containing DHA to be creditable in the CACFP infant meal pattern. Infant foods containing DHA may be served and claimed for reimbursement, as long as they meet all other crediting requirements. 

Please see memorandum SP42 CACFP14-2016 Early Implementation of the Child and Adult Care Food Program Meal Patterns (http://www.fns.usda.gov/sites/default/files/cn/SP42_CACFP14_2016os.pdf) for information on implementing the updated meal pattern requirements prior to Oct. 1, 2017. FNS supports implementing the updated meal patterns, including allowing reimbursement of meals when a mother directly breastfeeds on-site, as soon as possible because it will greatly benefit participating infants, children and adults.

State agencies are reminded to distribute this information to program operators immediately. Program operators should direct any questions regarding this memorandum to the appropriate state agency. State agencies should direct questions to the appropriate FNS regional office.

Angela Kline
Director
Policy and Program Development Division
Child Nutrition Programs