Feeding Infants and Meal Pattern Requirements in the Child and Adult Care Food Program; Questions and Answers (Revised September 2023)

The purpose of this memorandum is to provide updated guidance on feeding infants and the infant meal pattern requirements in the Child and Adult Care Food Program (CACFP). It also includes questions and answers in the Attachment. This revision incorporates updated breastmilk storage recommendations, infant formula food safety considerations, and information on crediting grains in ounce equivalents. This memorandum supersedes CACFP 02-2018: Feeding Infants and Meal Pattern Requirements in the Child and Adult Care Food Program; Questions and Answers, Oct. 19, 2017.

Background

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 of 2010.” This final rule amended CACFP regulations at 7 CFR 226.20 to update the meal pattern requirements. CACFP centers and day care homes had to comply with the updated meal pattern requirements by Oct. 1, 2017.

When developing the updated infant meal pattern, 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. At the time, the Dietary Guidelines for Americans (DGAs) did not provide recommendations for children under the age of 2. However, the most recent 2020-2025 DGAs include recommendations for children under 2 years of age.

This revised memorandum incorporates updated recommendations from the AAP and guidance from the 2020-2025 DGAs, while also incorporating new questions and answers related to infant feeding.

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)). An institution or facility must make reasonable modifications, including substitutions for meals and snacks, for infants with a disability and whose disability restricts their diet (7 CFR 226.20(g)(1)).

CACFP regulations define an enrolled child as “a child whose parent or guardian has submitted to an institution a signed document which indicates 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 CACFP center or day care home, not if the infant is enrolled in the CACFP.

Infants may get hungry at times outside of typical mealtimes. For this reason, it is recommended that infants be fed on demand, which means feeding them when they show signs of being hungry. Infant meals must not be disallowed due solely to the fact that they are not served within the center or day care home’s established mealtime periods. To learn more about hunger and satiety cues, see FNS’ Feeding Infants in the CACFP guide at TeamNutrition.USDA.gov.

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. This makes maintaining 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. The FDA has a webpage, Exempt Infant Formulas Marketed in the United States by Manufacturer and Category that provides more information and a list of FDA Exempt Infant Formulas.
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. Additional information on feeding the formula-fed infant can be found in Chapter 3 of the Feeding Infants in the CACFP guide.

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 (21 USC 321(z))¹ and meet the requirements for an infant formula under section 412 of the Federal Food, Drug, and Cosmetic Act (21 USC 350a)² and the regulations at 21 CFR parts 106 and 107³. 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 formula that is imported into the U.S. as a result of the 2022 FDA Infant Formula Enforcement Discretion Policy may be served in the CACFP as detailed in CACFP 01-2023. Infant formulas that are not regulated by the 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 by 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 in a secure location by the center or day care home. For more information on providing meal accommodations for participants with disabilities, see CACFP 14-2017, SFSP 10-2017 Modifications to Accommodate Disabilities in the Child and Adult Care Food Program and Summer Food Service Program.

State agencies should contact their FNS regional office when they are uncertain if an infant formula is creditable.

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 to the infant by the child care provider are eligible for reimbursement, including meals when an infant is only consuming breastmilk or infant formula. In recognition of the numerous benefits of breastfeeding, including the AAP and DGA recommendation to feed infants human milk (breastmilk) exclusively for approximately 6 months after birth, if possible, and continue to feed infants breastmilk, along with complementary foods through at least the first year of life, and longer if desired, centers and day care homes may claim reimbursement of meals when a parent directly breastfeeds their infant at the center or day care home. This includes meals when an infant is only consuming breastmilk. This added flexibility in the infant meal pattern is consistent with FNS efforts to support and encourage breastfeeding. Therefore, meals when a parent directly breastfeeds their infant on-site are eligible for reimbursement.

While centers and day care homes must maintain menus to show what foods an infant is served, there is no federal requirement to document the delivery method for breastmilk (e.g., if it was served in a bottle by the day care provider or if the parent breastfed on-site). A center or day care home may simply indicate on the menu that the infant was offered breastmilk. Additionally, centers and day care homes do not need to record the amount of breastmilk a parent directly breastfeeds their infant. Please see the questions and answers in the Attachment for more information and best practices for documenting infant meals.

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 for the meal to be reimbursable.

Expressed Breastmilk Storage

In the Pediatric Nutrition Handbook, 8th Edition, the AAP generally recommends storing expressed breastmilk in the refrigerator for up to four days. This recommendation may vary if the breastmilk is to be fed to an infant that is either preterm and/or ill. For general CACFP purposes, breastmilk may be stored at the center or day care home in a refrigerator for up to four (4) days from the date the breastmilk was expressed. The previously established standard was 72 hours (or three (3) days) from the time it was expressed. Bottles of expressed breastmilk must be stored in a refrigerator kept at 40^o Fahrenheit (4^o Celsius) or below. Previously frozen breastmilk that is thawed and stored in the refrigerator should be used within 24 hours and should never be refrozen. This is consistent with recommendations from the AAP and the Centers for Disease Control and Prevention. Centers and day care homes should continue to follow all other breastmilk handling and storage guidelines listed in the Feeding Infants in the CACFP guide. If your state or local authorities have stricter health and safety regulations for handling and storing food, including breastmilk or formula, then follow those regulations.

Formula Food Safety Considerations

The FDA strongly advises against homemade formula, stating that recipes are often not safe, do not meet infants’ nutritional needs, and in some cases, can be life threatening. Homemade infant formulas are not regulated by the FDA and are not creditable under any circumstances in the CACFP.

When preparing infant formula only use water from a safe source. If you are not sure if your tap water is safe to use for preparing infant formula, contact your local health department or use bottled water. Use the amount of water and number of powder scoops listed on the instructions of the infant formula label when preparing formula from powder. Be sure to use the scoop provided by the manufacturer. Always measure the water first and then add the powder. Using more or less water and powdered formula than instructed changes the amount of calories and nutrients in the bottle which can affect an infant’s growth and development. Formula that is not prepared correctly cannot credit towards a reimbursable meal or snack in the CACFP, unless a written medical statement from a state licensed healthcare professional is provided.

Use prepared infant formula within 2 hours of preparation. If the prepared infant formula is not being fed within 2 hours, refrigerate it right away in a refrigerator kept at 40^o Fahrenheit (4^o Celsius) or below, keep refrigerated until feeding, and use within 24 hours. Once you start feeding an infant, make sure the infant formula is consumed within 1 hour. Throw away any leftover formula that is in the bottle.

Do not buy or use infant formula if the container has dents, bulges, pinched tops or bottoms, puffed ends, leaks, rust spots, or has been opened. The formula in these containers may be unsafe. Check the infant formula “use by” date. The “use by” date is the date up to which the manufacturer guarantees the nutrient content and the quality of the formula. After this date, a package or container of infant formula should not be fed to infants. Store unopened containers of infant formula in a cool, dry, indoor place – not in a refrigerator or freezer, or in vehicles, garages, or outdoors.

Centers and day care homes should prepare, use, and store infant formula according to the product directions on the container or as directed by the infant’s health care provider. More information on formula handling and storage can be found in the Feeding Infants in the CACFP guide.

III. SOLID FOODS (COMPLEMENTARY FOODS)

The 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 infant age groups are consistent with the infant age groups in the WIC program. In addition, the 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 because most infants are typically not developmentally ready to consume solid foods until midway through the first year of life. The DGA states that human milk (breastmilk) can support an infant’s nutrient needs for about the first 6 months of life, except for Vitamin D and potentially iron. At about age 6 months, infants should be introduced to nutrient-dense, developmentally appropriate foods to complement breastmilk or iron-fortified infant formula. Some infants show developmental signs of readiness before age 6 months but introducing complementary foods before age 4 months is not recommended. 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).

Solid foods must be served to infants around 6 months of age, as it is developmentally appropriate for each individual 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 as solid foods are introduced gradually, new foods may be introduced one at a time over the course of a few days, and as 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 the infant. Meals should not be disallowed simply because one food was offered one day and not the next if that 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. Please see Question 2 under “III. SOLID FOODS” in the attached questions and answers for more information.

There is no single, direct signal to determine when an infant is developmentally ready to accept solid foods. An infant’s readiness depends on their rate of development and infants develop at different rates. Centers and day care homes should be in constant communication with infants’ parents or guardians about when and what solid foods to serve while the infant is in their care. As a best practice, FNS recommends that parents or guardians request in writing when a center or daycare 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 their mouth when food comes their way. The infant may watch others eat, reach for food, and seem eager to be fed;
• The infant can move food from a spoon into their throat; and
• The infant has doubled their birth 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.

Program operators are required to make substitutions to meals for participants when the substitution is due to a disability and when supported by 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 in a secure location by the center or day care home. For more information on providing meal accommodations for participants with disabilities, see CACFP 14-2017, SFSP 10-2017 Modifications to Accommodate Disabilities in the Child and Adult Care Food Program and Summer Food Service Program.

Program operators may receive reimbursement for a meal modification request without a medical statement when the accommodation can be made within the program meal pattern. For example, if an infant has an allergy to one fruit or vegetable, the program operator can substitute another fruit or vegetable. FNS encourages program operators to use flexibilities whenever possible. In situations where the program operator does not obtain a medical statement, FNS encourages program operators to make note of the actions taken in acknowledging children’s accommodations.

For more information and best practices on serving solid foods to infants including food safety considerations and for infants with special dietary needs, please see the Feeding Infants in the CACFP guide.

Vegetables and Fruits

The primary goal of the CACFP meal pattern is to help children establish healthy eating patterns at an early age. Offering a variety of nutrient dense foods, including vegetables and fruits (cooked, mashed, pureed, or small diced, no larger than ½ inch, 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 fruits. Vegetables, fruits, or a combination of both are required at breakfast, lunch, and supper meals as well as snacks for infants that are developmentally ready to accept them (around 6 months of age). However, fruit juice, vegetable juice, or a combination of both juices cannot be served as part of a reimbursable meal for infants of any age under the infant meal pattern.

Grains

Grains are an important part of meals and snacks in the CACFP. To make sure infants get enough grains, required amounts of grain items are listed in the infant meal pattern as ounce equivalents (oz eq). Ounce equivalents approximate the amount of grain in a portion of food. Iron-fortified infant cereal is the only grain that may count towards a reimbursable breakfast, lunch, or supper in the CACFP infant meal pattern. Program operators may serve bread/bread-like items, crackers, iron-fortified infant cereal, or ready-to-eat cereal as part of a reimbursable snack to infants that are developmentally ready to accept them. The ounce equivalent requirements vary for the different grain items. For more information on crediting grains in ounce equivalents, please see the Feeding Infants Using Ounce Equivalents for Grains in the CACFP worksheet at TeamNutrition.USDA.gov.

As a reminder, all ready-to-eat cereals served to infants must meet the same sugar limit as breakfast cereals served to children and adults in the CACFP. This means, ready-to-eat cereals served to infants at snack must contain no more than 6 grams of sugar per dry ounce. Ready-to-eat cereals must also be whole grain-rich, enriched, or fortified in order to be creditable in the CACFP. For more information on the breakfast cereal sugar limit and creditable grains, please see memorandum CACFP 09-2018: Grain Requirements in the Child and Adult Care Food Program; Questions and Answers. Team Nutrition has a number of CACFP Training Tools, including training slides, training worksheets, and recorded webinars to assist CACFP operators in implementing the CACFP meal pattern requirements.

Meats and Meat Alternates

Meats and meat alternates are good sources of protein and provide essential nutrients, such as iron and zinc for growing infants. FNS acknowledges that yogurt is often served to infants as they are developmentally ready. In recognition of this, the infant meal pattern allows yogurt as a meat alternate for older infants who are developmentally ready to accept them. All yogurts served in the CACFP, including those served to infants, must contain no more than 23 grams of sugar per 6 ounces. Training worksheets are available from Team Nutrition to assist operators in choosing yogurts lower in sugar that meet the sugar limit. In addition, while cheese food and cheese spread are creditable for children one year and older, the infant meal pattern does not allow cheese food or cheese spread as creditable meat alternate. This is due to these products’ higher sodium content, and the AAP and DGA recommends caregivers choose products lower in sodium. Natural or processed cheese is creditable while cheese product is not creditable in the CACFP for infants or any other age group.

The infant meal pattern allows whole eggs (whites and yolk) 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 concluded that there is no convincing evidence to delay the introduction of foods that are considered major food allergens, such as eggs.

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.

Previously, serving any infant foods containing DHA was prohibited in the 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, FNS issued guidance in 2015 allowing infant foods containing DHA to be creditable in the CACFP infant meal pattern. Infant foods containing DHA may be served and claimed as part of a reimbursable meal, as long as they meet all other crediting requirements. Infants with a known DHA allergy should not be served foods containing DHA.

IV. COMPLIANCE

As currently required, centers and day care homes must demonstrate that they are serving meals that meet the meal pattern requirements, including the infant meal pattern requirements outlined in this memorandum. Centers and day care homes must keep records of menus (7 CFR 226.15(e)(10)). However, state agencies have the authority to determine other types of acceptable recordkeeping documents (7 CFR 226.15(e)). To the extent practicable, state agencies should not impose additional paperwork requirements to demonstrate compliance with the meal pattern requirements for infants. Rather, FNS encourages state agencies to maintain current recordkeeping requirements or update existing forms to avoid any additional burden. For additional information on documenting meals, please see CACFP 17-2017: Documenting Meals in the Child and Adult Care Food Program.

Please see the questions and answers in the Attachment for examples of best practices for demonstrating compliance with the infant meal pattern.

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 agency contact information is available on the USDA webpage. State agencies should direct questions to the appropriate FNS regional office.

J. Kevin Maskornick
Director
Community Meals Policy Division

Attachment

• Questions and Answers

¹ Section 201(z) of the Federal Food, Drug, and Cosmetic Act (21 USC 321(z)): https://www.govinfo.gov/content/pkg/USCODE-2010-title21/pdf/USCODE-2010title21-chap9-subchapII-sec321.pdf 
² Section 412 of the Federal Food, Drug, and Cosmetic Act (21 USC 350a): https://www.govinfo.gov/content/pkg/USCODE-2010-title21/pdf/USCODE-2010title21-chap9-subchapIV-sec350a.pdf
³ 21 CFR parts 106 and 107: https://www.ecfr.gov/current/title-21/chapter-I/subchapter-B