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Infant Meals - Memos

Food and Nutrition Service

Memorandums on Infant Meals

This document contains the following current memorandums related to Child Nutrition Programs requirements for serving meals to infants.

November 9, 2004

SUBJECT: Clarification on Acceptable Infant Formulas

TO: John Magnarelli, Director

Special Nutrition Programs

Northeast Regional Office

This memorandum is in response to questions raised by the Connecticut State agency:

1. Must a formula served (in the CACFP) be listed exactly as it says on the Child and Adult Care Food Program Approved List?

The answer is a qualified no. The current list of the Iron-Fortified Infant Formulas That Do Not Require a Medical Statement is NOT an inclusive list, because new infant formula products are continually being developed.

According to the Child and Adult Care Food Program (CACFP) regulation, 7 CFR 226.20(b)(2), “either breast milk or iron-fortified infant formula, or portions of both, must be served for the entire first year.” Any product labeled as an iron-fortified infant formula, legally must meet the Food and Drug Administration (FDA)’s definition, 21 CFR 107.10(b)(4) (i), 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.” The number of milligrams of iron per 100 kilocalories of formula can be found on the nutrition label of infant formulas.

2. Must a provider have a medical statement on file for an infant formula to be part of a reimbursable meal?

If a formula is not on the current list of the Iron-Fortified Infant Formulas That Do Not Require a Medical Statement, a child care provider or institution may use the following criteria to determine whether or not a formula is reimbursable under the CACFP without the need of a medical statement:

a) Ensure that the formula is not listed as 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 (21 CFR 107.3). Formulas classified as Exempt Infant Formulas by FDA require a medical statement in order to be served to infants under the CACFP as part of a reimbursable meal. A medical statement must be signed by a licensed physician if an infant is considered disabled according to USDA’s

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regulation, or a recognized medical authority specified by the State if an infant has a medical or other special dietary needs. To check whether or not an infant formula is an FDA Exempt Infant Formula, visit FDA's website at http://www.cfsan.fda.gov/~dms/infexmp.html .

b) Examine the nutrition label to make sure that the formula is iron-fortified. The statement "Infant Formula with Iron" or a similar statement must be on the label.

c) Be aware of the fact that all infant formulas marketed in the United States must meet the nutrient specifications listed in FDA Regulation, 21 CFR 107 http://www.cfsan.fda.gov/~lrd/cfr107.html#spD and in the Section 412 of the Food, Drug, and Cosmetic Act http://www.fda.gov/opacom/laws/fdcact/fdcact4.htm#sec412 . If a formula is purchased outside of the United States, it is likely that the formula is not regulated by FDA; therefore, it may not be creditable under the CACFP.

The nutritive values of each formula are listed on the product's nutrition label. Infant formula manufacturers may have their own proprietary formulations, but they must contain at least the minimum levels of all nutrients specified in FDA regulations without going over the maximum levels, when maximum levels are specified.

d) Also be aware of the fact that manufacturers of infant formula are required by FDA regulation to follow current Good Manufacturing Practices, including quality control procedures to assure that the infant formula provides nutrients in accordance with Section 412 of the Food, Drug, and Cosmetic Act, and to assure that the infant formula is manufactured in a manner designed to prevent adulteration.

A child care provider can serve a formula if the exact product is on the current list of the Iron-Fortified Infant Formulas without the need of obtaining a medical statement.

In the memorandum from Connecticut, the issue of whether the two specific brands of infant formulas are creditable was questioned. Similac Advance is an iron-fortified infant formula that is currently included in the list of Iron-Fortified Infant Formulas That Do Not Require a Medical Statement. Similac Alimentum Advanced, is an infant formula that is on the FDA Exempt Infant Formula list; therefore, it is not creditable unless supported by a statement from a licensed physician or a recognized medical authority specified by the State agency, as appropriate, that indicates the need for this special formula.

If a child care provider or institution is not sure of whether or not an infant formula is creditable under the CACFP, they should contact their State agency who can contact FNS for assistance, as needed

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3. Can you provide guidance about a formula supplied by the parent that is not iron-fortified? Would service of this product require a medical statement in order to be creditable for a reimbursable meal for an infant?

As stated above, according to 7 CFR 226.20(b)(2), “either breast milk or iron-fortified formula, or portions of both, must be served for the entire first year.” In addition, Page 24 of Feeding Infants: A Guide for Use in the Child Nutrition Programs, Paragraph 2, states that low-iron formulas do not meet the meal pattern and may be served as a dietary substitution only if an infant is unable to consume iron-fortified infant formula because of medical or other special dietary needs. The substitution can only be made when supported by a statement from a licensed physician or a recognized medical authority that indicates the recommended infant formula. These rules apply to formula provided by the CACFP facility and to formula provided by the parent.

While our responses to these questions pertain to meals served to infants in the CACFP, it should be noted that they also apply to meals containing infant formula under the National School Lunch Program or the School Breakfast Program. If you have additional questions about infant formula in any of the child nutrition programs, please contact Clare Miller or Yibo Wood.

Sincerely,

STANLEY C. GARNETT

Director

Child Nutrition Division

cc: FNS Regional SNP Directors

Cheryl Fogerty, NERO

MWCN: CC 2

May 13, 2003

FY 03 School and Community Nutrition Programs Policy Memorandum # 03-16

FY 03 Child and Adult Care Food Program Policy Memorandum # 03-13

Reimbursement of Infant Meals in the Child Nutrition Programs

State Directors

Child Nutrition Programs

Midwest Region

The child nutrition programs reimburse child care centers, family day care homes, emergency shelters, schools, and residential child care institutions for the costs of serving nutritious meals-- including the costs of preparation and clean up of meals--to infants. We are revising program policy to recognize the non-food related cost of serving infants by allowing reimbursement for meals containing only infant formula, whether supplied by the caregiver or by the parent.

Please advise your agencies that reimbursable meals for infants may contain either breastmilk or iron-fortified infant formula, or both, supplied by the caregiver or by the parent. However, to receive reimbursement, the caregiver must always offer the infant a complete, developmentally appropriate meal. Because we are recognizing the labor involved in serving meals to infants, the meal must be served and fed to the infant by the caregiver.

If you have additional questions about the reimbursement of infant meals, please contact our office.

THERESA E. BOWMAN

Regional Director

Special Nutrition Programs

December 19, 2002

SUBJECT: Baby Fruits or Vegetables with DHA

TO: Regional Directors

Child Nutrition Programs

All Regions

In response to a number of inquiries, we wish to clarify that certain baby food products containing DHA cannot be served to infants as part of a reimbursable meal in the child nutrition programs. DHA is an omega-3 fatty acid known as docosahexaenoic that may be added to commercially prepared fruits or vegetables.

The source of DHA in some lines of baby food products, such as Beech-Nut First Advantage Sweet Potato Souffle or Tropical Blend, is egg yolk. These DHA-added products combine fruits or vegetables with dried egg yolk, heavy cream, rice flour, vanilla extract, and other ingredients. They are not labeled or marketed as desserts, but they contain similar ingredients that may not be appropriate for an infant younger than 8 months of age. Introducing these “dessert-like” ingredients into an infant’s diet at an earlier age could result in a food sensitivity or a food allergy.

Although DHA-added products cannot contribute to the infant meal pattern, they may be served as additional foods to infants 8 months of age or older. Since they contain several ingredients, additives, or extenders that could cause allergic reactions, we recommend that the center, the provider, or the school check with the infant’s parent or guardian, before serving them.

STANLEY C. GARNETT

Director

Child Nutrition Division

cc: Blum-Kemelor, OANE

May 17, 2002

SUBJECT: Obligations of Child Care Centers and Day Care Homes to Offer Infant Meals in the Child and Adult Care Food Program (CACFP)

TO: Regional Directors

Child Nutrition Programs

All Regions

This memorandum clarifies that child care centers and family day care homes participating in CACFP must offer program meals to all eligible children who are enrolled for care in their facilities. We are providing this explanation to ensure that all children, including infants, who are enrolled for child care have access to CACFP meals.

A facility may not avoid this obligation by stating that the infants are not “enrolled” in CACFP, or by citing some logistical or cost barrier to offering an infant meal. Decisions on offering program meals must be based on whether the child is enrolled for care, not whether the child is enrolled for CACFP. Section 226.2 of the CACFP regulations defines 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 for child care.”

As long as the infant is in care during the meal service period, the facility must offer the infant a meal that complies with program requirements. As with all children in CACFP facilities, an infant’s parent or guardian may decline what is offered, and supply the infant’s meals instead. The key factor is that the infant must be provided access to CACFP meals.

We are aware that there are States that are not currently following this policy. Please advise State agencies to ensure that their CACFP institutions and facilities come into compliance within a reasonable amount of time. If you have additional questions about this issue, please contact Melissa Rothstein or Susan Ponemon.

STANLEY C. GARNETT

Director

Child Nutrition Division

MWCN 202: CC2

May 9, 2000

FY00 Child and Adult Care Food Program Policy Memorandum #11

Issues Related to Feeding Infants in the Child and Adult Care Food Program (CACFP)

State Directors

Child Nutrition Programs

We know that dietary needs during an infant’s first year of life are individually prescribed and more complicated than those for toddlers and older children. Recent changes in the requirements for infant meal service have raised questions regarding reimbursable meals and snacks for infants in CACFP.

The interim rule, Amendments to the Infant Meal Pattern, published in the Federal Register on November 15, 1999 (64 FR 61770), announced important changes in meal services to infants in CACFP. The rule eliminates whole cow’s milk from the infant meal pattern by requiring that all meals and snacks served to infants, up to one year of age, include breast milk or iron fortified infant formula. The rule also allows reimbursement for meals served to infants, from birth through seven months, that exclusively contain breast milk.

Since publication of the interim rule, we have received a number of questions related to feeding infants in the CACFP. Some questions were addressed in the January 13, 2000, memorandum, Effective Date for Implementation of Interim Regulation Amending the Infant Meal Patterns for the National School Lunch Program, School Breakfast Program and Child and Adult Care Food Program (#4-00). Attached are additional questions and answers issued by the National office that we hope you will find helpful.

For purposes of this memorandum, the term “infant” will refer to babies under 12 months of age, and the term “child” or “children” will refer to those over 12 months of age. Also included in this memorandum are some technical corrections to the infant meal pattern in the CACFP final rule, Overclaim Authority, published on December 27, 1999 (64 FR 72257).

If you have any questions regarding this memorandum, please contact Julie Mikkelson at 312-886-5514.

THERESA E. BOWMAN

Regional Director

Special Nutrition Programs

Attachment

(1) When an infant receives both breast milk and formula, is the meal eligible for reimbursement?

Yes, a meal served to an infant under 12 months of age and under which contains some amount of breast milk (and some amount of formula ) is reimbursable as long as the total number of ounces offered to the infant meets, or exceeds, the minimum amount for the milk component as specified in the CACFP infant meal pattern.

(2) Are meals served to children, 12 months and older, reimbursable if they contain infant formula?

Yes, for a period of one month, when a child is weaning from infant formula to whole cow’s milk (i.e., transitioning), meals that contain infant formula may be reimbursable. When a child is weaned from formula (or breast milk) to cow's milk, it is a common practice to provide the infant with both foods at the same meal service, to gradually ease the infant to accept some of the new food. However, unlike breast milk, infant formula is not an alternative type of milk which can be substituted to meet the fluid milk requirement for the CACFP meal pattern for children over the age of one year. (See FNS Instruction 783-7, rev. 1, Milk Requirement—Child Nutrition Programs.) Thus, for a child 13 months of age and older who is not in this transitional stage, a statement from a recognized medical authority is needed for a meal containing infant formula to be eligible for reimbursement (See FNS Instruction 783-2, rev 2, Meal Substitutions for Medical or Other Special Dietary Reasons).

(3) If a physician prescribes whole cow’s milk as a substitute for breast milk for an infant under 12 months of age, is the meal reimbursable?

Yes, a meal or snack containing whole fluid cow's milk and served to an infant under 12 months of age is eligible for reimbursement if the substitution is authorized, in writing, by a recognized medical authority. Similarly, if a recognized medical authority prescribes a formula such as low-iron fortified formula, which is not currently listed as a creditable formula for CACFP, the meal is eligible for reimbursement.

We have always recognized the unique dietary needs of infants and that decisions concerning diet, during this first year of life, are for the infant's health care provider and parents or guardians to make together. Therefore, to support the request, a medical statement which explains the food substitution or modification is needed. The statement must be submitted and kept on file by the facility or institution.

(4) A mother would like her 5-month old infant to receive breast milk which she provides and solid foods, which are listed as options in the meal pattern. Because the infant is developmentally ready for solid foods, whose responsibility is it to provide them?

If an infant is developmentally ready for one or more solid food items and the parent or guardian requests that the infant be served solid foods, the center or provider is responsible for purchasing and serving them to the infant.

The CACFP infant meal pattern takes into consideration that infants develop at different paces. Some food items such as fruit and cereal are listed as options in the infant meal pattern to account for an infant’s “readiness” to accept these foods (i.e., some infants are developmentally ready for solid foods earlier than others). This occurs in the breakfast and lunch/supper meal service for infants 4-7 months of age, and for the snack meal service for infants 8-11 months of age. A child care center or provider must serve a complete meal to every infant or child enrolled in the meal service. Therefore, if a child is developmentally ready for these solid foods, and the parent or guardian requests that the infant is served solid foods, the components are no longer considered as options and should be served to the infant to provide her with the optimal nutrition she needs to develop and grow.

(5) Is a meal reimbursable if the parent or guardian provides the majority of the meal components for infants older than three months?

In addition to medical or special dietary needs, parents may choose to provide one or several of the meal components under the CACFP infant meal pattern for infants older than three months, as long as this is in compliance with local health codes. Because we recognize that parents or guardians are often most in touch with their child’s individual dietary preferences, we believe the CACFP infant meal pattern can accommodate these preferences. In such a case, the center or provider would still be required to provide at least one of the components in at least the minimum quantities specified in the meal pattern in order for the meal to be reimbursable. Centers and sponsoring organizations also need to ensure that the parent or guardian is truly choosing to provide the preferred component(s), and that the center or provider has not solicited (requested or required) the parent or guardian to provide the components in order to complete the meal and reduce cost to the center or provider.

(6) If a mother comes to the day care home or center to nurse her infant, is the meal reimbursable?

No. Although we strongly support all efforts for mothers to breastfeed their infants, we believe that the caregiver must provide some type of service in order to be reimbursed for a meal. CACFP reimburses child care facilities for the cost of preparing and serving nutritious meals and snacks to infants and children receiving day care. In the case of breastfed infants, CACFP reimburses the facility for the cost of preparing the bottle and feeding the infant. When a parent nurses her own child, the services for which the center or the provider would receive reimbursement are not being performed.

However, the meal would be reimbursable for infants over 3 months of age who are developmentally ready for solid foods, if at least one other component is furnished by the center or provider. For example, if a mother comes to the day care home for lunch meal service to breastfeed her 5 month old infant and the provider supplies a serving of vegetables (listed as an option in the infant meal pattern for lunch for infants aged 4-7 months), the meal is reimbursable.

(7) If a day care home provider breastfeeds her own infant, is the meal eligible for reimbursement?

Yes, a day care provider who nurses her own infant may claim reimbursement for the meal as long as she is eligible to claim reimbursement for meals and snacks served to her own child. In this case, the meal is reimbursable because the mother (provider) is actively engaged with the child. Thus, unlike a mother who comes into a center or home to breastfeed an infant, the provider is being reimbursed for her services—the time and effort she expends breastfeeding her own infant.

As with any other claim for meals served to the provider’s own child, the infant must be eligible for free and reduced price meals, enrolled in the day care program, and participating in the program during the time of the meal service. At least one other nonresident child must also be enrolled in the day care program and be present during the meal service.

(8) Cottage cheese is a meat alternate in the lunch and supper meal pattern for infants aged 8 through 11 months. How much cottage cheese must be offered to fulfill the meat/meat alternate meal pattern requirement?

Cottage cheese, cheese food, and cheese spread are acceptable meat alternates in the CACFP infant meal pattern. An error in the meal pattern tables in sections 210.10(m)(2)(iii)(C), 210.10a(h)(3), and 226.20(b)(4) incorrectly measures the amount of cheese in tablespoons. The correct amount which may be offered as a meat alternate to infants, aged 8 through 11 months, is 1 to 4 ounces.

(9) Is yogurt an allowable meat alternate in the infant meal pattern?

The Office of Analysis, Nutrition and Evaluation plans to issue a memorandum on the use of yogurt in the CACFP infant meal pattern in the future.

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