4.3.1.1: General Plan for Feeding Infants

The facility should keep records detailing whether an infant is breastfed or formula fed, along with the type of formula being served. An infant feeding record of human (breast) milk and/or all formula given to the infant should be completed daily. Infant meals and snacks should follow the meal and snack patterns of the Child and Adult Care Food Program. Food should be appropriate for the infant’s individual nutrition requirements and developmental stage as determined by written instructions obtained from the child’s parent/guardian or primary health care provider.

The facility should encourage breastfeeding by providing accommodations and continuous support to the breastfeeding mother. Facilities should have a designated place set aside for breastfeeding mothers who want to visit the classroom during the workday to breastfeed, as well as a private area (not a bathroom) with an outlet for mothers to pump their breast milk (1,2). The private area also should have access to water or hand hygiene. A place that parents/guardians feel they are welcome to breastfeed, pump, or bottle-feed can create a positive and supportive environment for the family.

 

Infants may need a variety of special formulas, such as soy-based formula or elemental formulas, that are easier to digest and less allergenic. Elemental or special hypoallergenic formulas should be specified in the infant’s care plan. Age-appropriate solid foods other than human milk or infant formula (ie, complementary foods) should be introduced no sooner than 6 months of age or as indicated by the individual child’s nutritional and developmental needs. Please refer to standards 4.3.1.11 and 4.3.1.12 for more information.

RATIONALE

Human milk, as an exclusive food, is best suited to meet the entire nutritional needs of an infant from birth until 6 months of age, with the exception of recommended vitamin D supplementation. In addition to nutrition, breastfeeding supports optimal health and development. Human milk is also the best source of milk for infants for at least the first 12 months of age and, thereafter, for as long as mutually desired by mother and child. Breastfeeding protects infants from many acute and chronic diseases and has advantages for the mother, as well (3).

Research overwhelmingly shows that exclusive breastfeeding for 6 months, and continued breastfeeding for at least a year or longer, dramatically improves health outcomes for children and their mothers. Healthy People 2020 outlines several objectives, including increasing the proportion of mothers who breastfeed their infants and increasing the duration of breastfeeding and exclusive breastfeeding (4). 

Incidences of common childhood illnesses, such as diarrhea, respiratory disease, bacterial meningitis, botulism, urinary tract infections, sudden infant death syndrome, insulin-dependent diabetes, ulcerative colitis, and ear infections, and overall risk for childhood obesity are significantly decreased in breastfed children (5,6). Similarly, breastfeeding, when paired with other healthy parenting behaviors, has been directly related to increased cognitive development in infants (7). Breastfeeding also has added benefits to the mother: it decreases risk of diabetes, breast and ovarian cancers, and heart disease (8). 

Mothers who want to supplement their breast milk with formula may do so, as the infant will continue to receive breastfeeding benefits (4,5,7). Iron-fortified infant formula is an acceptable alternative to human milk as a food for infant feeding even though it lacks any anti-infective or immunological components. Regardless of feeding preference, an adequately nourished infant is more likely to achieve healthy physical and mental development, which will have long-term positive effects on health (9).

COMMENTS

The ways to help a mother breastfeed successfully in the early care and education facility are (2,6,8): 

1. If she wishes to breastfeed her infant or child when she comes to the facility, offer or provide her a
   1. Quiet, comfortable, and private place to breastfeed (This helps her milk to let down.)
   2. Place to wash her and her infant’s hands before and after breastfeeding
   3. Pillow to support her infant on her lap while nursing
   4. Nursing stool or step stool for her feet so she doesn’t have to strain her back while nursing
   5. Glass of water or other liquid to help her stay hydrated
      
      
2. Encourage her to get the infant used to being fed her expressed human milk by another person before the infant starts in early care and education, while continuing to breastfeed directly herself.
   
   
3. Discuss with her the infant’s usual feeding pattern and the benefits of feeding the infant based on the infant’s hunger and satiety cues rather than on a schedule; ask her if she wishes to time the infant’s last feeding so that the infant is hungry and ready to breastfeed when she arrives; and ask her to leave her availability schedule with the early care and education program as well as to call if she is planning to miss a feeding or is going to be late.
   
   
4. Encourage her to provide a backup supply of frozen or refrigerated expressed human milk; properly label the infant’s full name, date, and time on the bottle or other clean storage container in case the infant needs to eat more often than usual or the mother’s visit is delayed.
   
   
5. Share with her information about other places or people in the community who can answer her questions and concerns about breastfeeding, such as local lactation consultants.
   1. Provide culturally appropriate breastfeeding materials, including community resources for parents/guardians that include appropriate language and pictures of multicultural families to assist families in identifying with them.
6. Ensure that all staff receive training in breastfeeding support and promotion.
   
   
7. Ensure that all staff are trained in the proper handling, storing, and feeding of each milk product, including human milk or infant formula.

 

Additional Resources

• Breastfeeding, US Department of Health and Human Services Office on Women’s Health (https://www.womenshealth.gov/printables-and-shareables/health-topic/breastfeeding)
• Feeding Infants: A Guide for Use in the Child Nutrition Programs, US Department of Agriculture (USDA) Food and Nutrition Service (https://wicworks.fns.usda.gov/wicworks/Topics/FG/CompleteIFG.pdf)
• Infant Meal Pattern, USDA (https://fns-prod.azureedge.net/sites/default/files/cacfp/CACFP_infantmealpattern.pdf)
• Strategy 6, Support for Breastfeeding in Early Care and Education, Centers for Disease Control and Prevention (https://www.cdc.gov/breastfeeding/pdf/strategy6-support-breastfeeding-early-care.pdf)
• Updated Child and Adult Care Food Program Meal Patterns: Infant Meals, USDA (https://fns-prod.azureedge.net/sites/default/files/cacfp/CACFP_InfantMealPattern_FactSheet_V2.pdf)

TYPE OF FACILITY

Center, Early Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.2.0.9 Written Menus and Introduction of New Foods
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.1.5 Preparing, Feeding, and Storing Infant Formula
4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants
4.3.1.12 Feeding Age-Appropriate Solid Foods to Infants
Appendix JJ: Our Child Care Center Supports Breastfeeding

REFERENCES

1. Centers for Disease Control and Prevention. Strategies to Prevent Obesity and Other Chronic Diseases: The CDC Guide to Strategies to Support Breastfeeding Mothers and Babies. Atlanta, GA: US Department of Health and Human Services; 2013. http://www.cdc.gov/breastfeeding/pdf/BF-Guide-508.pdf. Accessed January 11, 2018

2. Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); US Department of Agriculture Food and Nutrition Service. Breastfeeding Policy and Guidance. https://www.fns.usda.gov/sites/default/files/wic/WIC-Breastfeeding-Policy-and-Guidance.pdf. Published July 2016. Accessed January 11, 2018

3. Darmawikarta D, Chen Y, Lebovic G, Birken CS, Parkin PC, Maguire JL. Total duration of breastfeeding, vitamin D supplementation, and serum levels of 25-hydroxyvitamin D. Am J Public Health. 2016;106(4):714–719

4. Healthy People 2020. Maternal, infant, and child health. HealthyPeople.gov Web site. https://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-child-health/objectives. Accessed January 11, 2018

5. Furman L. Breastfeeding: what do we know, and where do we go from here? Pediatrics. 2017;139(4):e20170150

6. American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827–e841

7. Gibbs BG, Forste R. Breastfeeding, parenting, and early cognitive development. J Pediatr. 2014;164(3):487–493

8. Binns C, Lee M, Low WY. The long-term public health benefits of breastfeeding. Asia Pac J Public Health. 2016;28(1):7–14

9. Danawi H, Estrada L, Hasbini T, Wilson DR. Health inequalities and breastfeeding in the United States of America. Int J Childbirth Educ. 2016;31(1)

NOTES

Content in the STANDARD was modified on 05/30/2018.

4.3.1.2: Responsive Feeding of Infants by a Consistent Caregiver/Teacher

Responsive feeding is a give-and-take approach between a caregiver and an infant where the infant communicates hunger and fullness cues and the caregiver responds appropriately to these cues. Caregivers/teachers should feed infants on cue unless the parent/guardian and the child’s primary health care provider give written instructions stating differently.¹ Caregivers/teachers should be gentle, patient, sensitive, and reassuring when responding properly to the infant’s feeding cues. Responsive feeding is most successful when caregivers/teachers learn how infants verbally communicate hunger and fullness. Crying alone is not a cue for hunger unless the infant also shows other cues, such as opening the mouth, making sucking sounds, rooting, fast breathing, clenched fingers or fists, and flexed arms or legs.^1,2 Whenever possible, the same caregiver/teacher should feed a specific infant for most of that infant’s feedings.³ Caregivers/teachers should not feed infants beyond satiety or fullness; just as hunger cues are important in starting a feeding, watching for satiety or fullness cues can limit overfeeding. An infant may communicate fullness by shaking the head or turning away from food.^1,3,4 A pacifier should not be offered to an infant before a feeding.

RATIONALE

Responsive feeding is a successful way to meet the infant’s nutritional and emotional needs and to give the infant an immediate response, which helps to make sure the infant trusts the caregiver/teacher and feels secure.⁵ A caregiver/teacher is more likely to understand how a specific infant communicates hunger and satiety when they give consistent feedings and bond with the child regularly over time. When an infant forms an early relationship with caregivers/teachers for feeding, this helps an infant to develop healthy eating patterns for life.^1–4 Responsive feeding may help prevent childhood obesity.⁶

COMMENTS

ADDITIONAL RESOURCES:

American Academy of Pediatrics

Starting Solid Foods - https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Starting-Solid-Foods.aspx

TYPE OF FACILITY

Center, Early Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.3.1.1 General Plan for Feeding Infants
4.3.1.8 Techniques for Bottle Feeding

REFERENCES

1. Pérez-Escamilla R, Segura-Pérez S, Lott M. Feeding guidelines for infants and young toddlers: a responsive parenting approach. Nutrition Today. 2017;52(5), 223-231. doi: 10.1097/NT.0000000000000234. Published September 2017. Accessed November 10, 2022

2. Pérez-Escamilla R, Segura-Pérez S, Lott M, on behalf of the Robert Wood Johnson Foundation HER Expert Panel on Best Practices for Promoting Healthy Nutrition, Feeding Patterns, and Weight Status for Infants and Toddlers From Birth to 24 Months. Feeding Guidelines for Infants and Young Toddlers: A Responsive Parenting Approach. Guidelines for Health Professionals. Durham, NC: Healthy Eating Research; 2017. http://healthyeatingresearch.org/wp-content/uploads/2017/02/her_feeding_guidelines_brief_021416.pdf. Published February 2017. Accessed November 10, 2022

3. 4Cs of Alameda County. Providing care for infants and toddlers. 4calameda.org Web site. www.4c-alameda.org/downloads/rr/providers/PROVCaringforInfantsToddlers.pdf. Published July 2017. Accessed November 9, 2022

4. U.S. Department of Agriculture. WIC Works Resource System. Guidelines for feeding healthy infants. USDA.gov Web site. https://wicworks.fns.usda.gov/sites/default/files/media/document/Guidelines_for_Feeding_Healthy_Infants_Job_Aid.pdf. Updated September 2018. Accessed November 9, 2022

5. Head Start Early Childhood Learning & Knowledge Center. Child observation: the heart of individualizing responsive care for infants and toddlers. HHS.gov Web site.  https://eclkc.ohs.acf.hhs.gov/child-screening-assessment/child-observation-heart-individualizing-responsive-care-infants-toddlers/child-observation-heart-individualizing. Updated June 13, 2022. Accessed November 9, 2022

6. Vandyousefi S, Messito MJ, Katzow MW, Scott MA, Gross RS. Infant appetite traits, feeding practices and child obesity in low‐income Hispanic families. Pediatric Obesity, p.e12913. https://onlinelibrary.wiley.com/doi/full/10.1111/ijpo.12913. Published March 11, 2022. Accessed November 9, 2022

NOTES

Content in the STANDARD was modified on 5/30/2018 and 2/9/2023.

4.3.1.3: Preparing, Feeding, and Storing Human Milk

Expressed human milk should be transported and stored in clean and sanitary bottles with nipples that fit tightly or in equivalent clean and sanitary sealed containers to prevent spilling during transport to home or to the facility. Only cleaned and sanitized bottles, or their equivalent, and nipples should be used in feeding. The bottle or container should be properly labeled with the child’s full name and the date and time the milk was expressed.¹ The filled, labeled bottles or containers of human milk should immediately be stored in the refrigerator on arrival.

Frozen human milk may be transported and stored in single-use plastic bags and placed in a freezer with a separate door or a stand-alone freezer, and not in a compartment within a refrigerator. To prevent intermittent rewarming due to opening the freezer door regularly, frozen human milk should be stored in the back of the freezer and caregivers/teachers should carefully monitor, with daily log sheets, temperature of freezers used to store human milk using an appropriate working thermometer.

Expressed milk brought by a parent/guardian should only be used for that child. Likewise, infant formula should not be used for a breastfed child without the parent/guardian’s written permission. Labels for containers of human milk should be resistant to loss of the name and date/time when washing and handling. This is especially important when a frozen bottle is thawed in running tap water. There may be several bottles for different children being thawed and warmed at the same time in the same place.

The caregiver/teacher should check the child’s full name and the date on the bottle so that the oldest milk is used first. Human milk should be thawed in the refrigerator if frozen. If there is insufficient time to thaw the milk in the refrigerator before serving, it may be thawed in a container of warm water, gently swirling the bottle periodically to evenly distribute the temperature in the milk and mix the fat, which may have separated. Frozen milk should never be thawed in a microwave oven because uneven hot spots in the milk may cause burns in the child and excessive heat may destroy beneficial components of the milk.^1–3

Human milk containers with significant amount of contents remaining after a feeding (>1 oz) may be returned to the parent/guardian at the end of the day as long as the child has not fed directly from the bottle. Returning unused human milk to the parent/guardian informs the parent/guardian of the quantity taken while in the early care and education program.

Although human milk does not need to be warmed, some children prefer their milk warmed to body temperature, around 98.6°F (37°C). When warming human milk, it is important to keep the container sealed while warming to prevent contamination. Human milk can be warmed

• In a waterless warmer
• By placing the container of human milk into a separate container of warm water
• By placing the container of human milk under running warm (not hot) tap water for a few minutes

Human milk should never be warmed directly on the stove or in the microwave. After warming the milk, caregivers/teachers should test the temperature before feeding by putting a few drops on their wrist. It should feel warm, not hot.²

Avoid bottles made of plastics containing bisphenol A (BPA) or phthalates, sometimes labeled with recycling code 3, 6, or 7.⁴ Use glass bottles with a silicone sleeve or silicone bottle jacket to prevent breakage, or use those made with safer plastics, such as polypropylene or polyethylene (labeled BPA-free) or plastics with a recycling code of 1, 2, 4, or 5.

Expressed human milk that presents a threat to a child, such as human milk that is in an unsanitary bottle, is curdled, smells rotten, and/or has not been stored following the storage guidelines of the Academy of Breastfeeding Medicine (see Human Milk Storage Guidelines table), should be returned to the parent/guardian.² Written guidance for staff and parents/guardians should be available to determine when milk provided by parents/guardians will not be served. Human milk cannot be served if it does not meet the requirements for sanitary and safe milk.¹

Although human milk is a body fluid, it is not necessary to wear gloves when feeding or handling human milk.⁵ The risk of exposure to infectious organisms during feeding or from milk that the child regurgitates is not significant.²

Some infants around 6 months to 1 year of age may be developmentally ready to feed themselves and may want to drink from a cup. The transition from bottle to cup can come at a time when a child’s fine motor skills allow use of a cup. The caregiver/teacher should use a clean, small cup without cracks or chips and should help the child to lift and tilt the cup to avoid spillage and leftover fluid. The caregiver/teacher and family should work together on cup feeding of human milk to ensure the child is receiving adequate nourishment and to avoid having a large amount of human milk remaining at the end of the feeding.⁶ Two to 3 ounces of human milk can be placed in a clean cup and additional milk can be offered as needed. Small amounts of human milk (≤1 oz) can be discarded.

There are many different factors that can affect how long human milk can be stored in various locations, such as storage temperature, temperature fluctuations, and cleanliness while expressing and handling human milk. These factors make it difficult to recommend exact times for storing human milk in various locations, but the Human Milk Storage Guidelines table can be helpful.

 

Human Milk Storage Guidelines
Storage Locations and Temperatures
	Countertop   77°F (25°C) or colder (room temperature)	Refrigerator   40°F (4°C)	Freezer   0°F (-18°C) or colder
Freshly Expressed or Pumped Human Milk	Up to 4 hours	Up to 4 days	Within 6 months is best. Up to 12 months is acceptable.
Thawed, Previously Frozen Human Milk	1–2 hours	Up to 1 day (24 hours)	Never refreeze human milk after it has been thawed.
Leftover Human Milk From a Feeding (baby did not finish the bottle)	Use within 2 hours after the baby is finished feeding.
Sources Eglash A, Simon L; Academy of Breastfeeding Medicine. ABM clinical protocol #8: human milk storage information for home use for full-term infants, revised 2017. Breastfeed Med. 2017;12(7):390–395. https://abm.memberclicks.net/assets/DOCUMENTS/PROTOCOLS/8-human-milk-storage-protocol-english.pdf. Accessed October 24, 2019   Centers for Disease Control and Prevention. Proper storage and preparation of breast milk. https://www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htm. Reviewed August 6, 2019. Accessed October 24, 2019

RATIONALE

By following this standard, early care and education staff is able, when necessary, to prepare human milk and feed a child safely, thereby reducing the risk of inaccuracy or feeding the child unsanitary or incorrect human milk.^1,2 In addition, following safe preparation and storage techniques helps nursing mothers and caregivers/teachers of breastfed children maintain the high quality of expressed human milk and the health of the child.^7,8

TYPE OF FACILITY

Center, Early Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.3.1.1 General Plan for Feeding Infants
4.3.1.4 Feeding Human Milk to Another Mother’s Child
4.3.1.7 Feeding Cow’s Milk
4.3.1.8 Techniques for Bottle Feeding
4.3.1.9 Warming Bottles and Infant Foods
5.2.9.9 Plastic Containers and Toys

REFERENCES

1. Centers for Disease Control and Prevention. Proper storage and preparation of breast milk. https://www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htm. Reviewed August 6, 2019. Accessed October 24, 2019 
2. Eglash A, Simon L; Academy of Breastfeeding Medicine. ABM clinical protocol #8: human milk storage information for home use for full-term infants, revised 2017. Breastfeed Med. 2017;12(7):390–395. https://abm.memberclicks.net/assets/DOCUMENTS/PROTOCOLS/8-human-milk-storage-protocol-english.pdf. Accessed October 24, 2019
3. Extension Alliance for Better Child Care. Guidelines for child care providers to prepare and feed bottles to infants. https://articles.extension.org/pages/25404/guidelines-for-child-care-providers-to-prepare-and-feed-bottles-to-infants. Published August 15, 2019. Accessed October 24, 2019
4. Eco-Healthy Child Care. Plastics & plastic toys. Children’s Environmental Health Network website. https://cehn.org/wp-content/uploads/2017/07/Plastics_Plastic_Toys_6_16.pdf. Published June 2016. Accessed October 24, 2019
5. La Leche League International. Storing human milk. https://www.llli.org/breastfeeding-info/storingmilk. Accessed October 24, 2019
6. American Academy of Pediatrics. Working together: breastfeeding and solid foods. HealthyChildren.org website. https://www.healthychildren.org/English/ages-stages/baby/breastfeeding/Pages/Working-Together-Breastfeeding-and-Solid-Foods.aspx. Updated February 23, 2012. Accessed October 24, 2019
7. Boué G, Cummins E, Guillou S, Antignac JP, Le Bizec B, Membré JM. Public health risks and benefits associated with breast milk and infant formula consumption. Crit Rev Food Sci Nutr. 2018;58(1):126–145
8. Binns C, Lee M, Low WY. The long-term public health benefits of breastfeeding. Asia Pac J Public Health. 2016;28(1):7–14

NOTES

Content in the STANDARD was modified on 8/23/2016 and 06/10/2020.

4.3.1.4: Feeding Human Milk to Another Mother’s Child

Parents/guardians may express concern about the likelihood of disease transmission to their child if their child has been mistakenly fed another child’s bottle of expressed human milk. This issue is addressed in detail to reassure parents/guardians that the risk of transmission of infectious diseases via human milk is small.

If a child has been mistakenly fed another child’s bottle of expressed human milk, steps should be taken to minimize fear and manage the situation in a timely manner. When a milk mix-up occurs, any decisions about medical management and diagnostic testing of the child who received another mother’s milk should be based on the details of the individual situation and determined collaboratively between the child’s primary care provider and parents/guardians.¹

The early care and education program should

1. Inform the mother who expressed the human milk about the mistake and when the bottle switch occurred, and ask her the following questions¹:
   • When was the human milk expressed and how was it handled prior to being delivered to the early care and education program?
   • Would she be willing to share information about her current medication use, recent infectious disease history, and presence of cracked or bleeding nipples during milk expression with the other family or the child’s primary care provider?
2. Discuss the event with the parents/guardians of the child who was given another mother’s milk.¹
   • Inform them that their child was given another mother’s expressed human milk.
   • Inform them that the risk of transmission of infectious diseases is small.
   • If possible, provide the family with information on when the milk was expressed and how the milk was handled prior to its being delivered to the early care and education program.
   • Encourage them to notify the child’s primary care provider of the situation and share any specific details known.
3. Assess why the wrong milk was given and develop policies and procedures to prevent future mistakes related to labeling, storing, preparing, and feeding human milk in the early care and education program. Share these policies and procedures with parents/guardians as well as the early care and education staff.

Few illnesses are transmitted via human milk, and in fact, the unique properties of human milk help protect children from colds and other typical childhood viruses. Nonetheless, both families need to be notified when there is a milk mix-up, and they should be informed that the risk of transmission of infectious diseases via human milk is small.¹

RATIONALE

Despite significant efforts to prevent mix-ups, expressed human milk is occasionally given to a child in error.¹ Common concerns about human milk mistakenly fed to an child include transmission of HIV and hepatitis B and C, as well as medication exposure.

The risk of HIV transmission from expressed human milk consumed by another child is believed to be low because¹

• Transmission of HIV from a single human milk exposure has never been documented.
• In the United States, women who know they are HIV positive are advised not to breastfeed their children. Thus, it is unlikely that a mother living with HIV would be providing expressed milk for her own child at an early care and education program center.

Hepatitis B and C cannot be spread from a woman to a child through breastfeeding unless there is exposure to blood.^2–4

The risk of hepatitis B and C transmission from expressed human milk consumed by another child is believed to be low because²

• Infants born to mothers with hepatitis B receive the hepatitis B vaccine at birth.

• While mothers with hepatitis B and C can breastfeed,^4,5 hepatitis B and C are spread by infected blood. If the nipples and/or surrounding areola of the mother with hepatitis B or C are cracked and bleeding, she should be advised to stop nursing or providing expressed milk to her child temporarily (until she is healed).²

Although many medications pass into human milk, most have little or no effect on a child’s well-being. Few medications are contraindicated while breastfeeding, and risk of adverse effects from a single exposure to a medication through human milk is very low.¹

TYPE OF FACILITY

Center, Early Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.3.1.3 Preparing, Feeding, and Storing Human Milk

REFERENCES

1. Centers for Disease Control and Prevention. What to do if an infant or child is mistakenly fed another woman’s expressed breast milk. http://www.cdc.gov/breastfeeding/recommendations/other_mothers_milk.htm. Reviewed January 24, 2018. Accessed October 24, 2019

2. Centers for Disease Control and Prevention. Hepatitis B or C infections. https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/maternal-or-infant-illnesses/hepatitis.html.Reviewed January 24, 2018. Accessed October 24, 2019

3. Centers for Disease Control and Prevention. Hepatitis B questions and answers for the public. https://www.cdc.gov/hepatitis/hbv/bfaq.htm#bFAQ13. Reviewed September 10, 2019. Accessed October 24, 2019

4. Centers for Disease Control and Prevention. Hepatitis C questions and answers for the public. https://www.cdc.gov/hepatitis/hcv/cfaq.htm#cFAQ37. Reviewed September 10, 2019. Accessed October 24, 2019

5. American Academy of Pediatrics. Human milk. In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018–2021 Report of the Committee on Infectious Diseases. 31st ed. Itasca, IL: American Academy of Pediatrics; 2018:113–122

NOTES

Content in the STANDARD was modified on 8/24/2017 and 06/10/2020.

4.3.1.5: Preparing, Feeding, and Storing Infant Formula

Formula provided by parents/guardians or by the facility should come in a factory-sealed container. The formula should be of the same brand that is served at home and should be of ready-to-feed strength or liquid concentrate to be diluted using cold water from a source approved by the health department. Powdered infant formula, though it is the least expensive formula, requires special handling in mixing because it cannot be sterilized. The primary source for proper and safe handling and mixing is the manufacturer’s instructions that appear on the can of powdered formula. Before opening the can, hands should be washed. The can and plastic lid should be thoroughly rinsed and dried. Caregivers/teachers should read and follow the manufacturer’s directions. Caregivers/teachers should only use the scoop that comes with the can and not interchange the scoop from one product to another, since the volume of the scoop may vary from manufacturer to manufacturer and product to product. Also, a scoop can be contaminated with a potential allergen from another type of formula. If instructions are not readily available, caregivers/teachers should obtain information from their local WIC program or the World Health Organization’s Safe Preparation, Storage and Handling of Powdered Infant Formula Guidelines at: http://www.who.int/foodsafety/publications/micro/pif_guidelines.pdf (1).

Formula mixed with cereal, fruit juice, or any other foods should not be served unless the child’s primary care provider provides written documentation that the child has a medical reason for this type of feeding.

Iron-fortified formula should be refrigerated until immediately before feeding. For bottles containing formula, any contents remaining after a feeding should be discarded.

Bottles of formula prepared from powder or concentrate or ready-to-feed formula should be labeled with the child’s full name and time and date of preparation. Any prepared formula must be discarded within one hour after serving to an infant. Prepared powdered formula that has not been given to an infant should be covered, labeled with date and time of preparation and child’s full name, and may be stored in the refrigerator for up to twenty-four hours. An open container of ready-to-feed, concentrated formula, or formula prepared from concentrated formula, should be covered, refrigerated, labeled with date of opening and child’s full name, and discarded at forty-eight hours if not used (2). The caregiver/teacher should always follow manufacturer’s instructions for mixing and storing of any formula preparation. Some infants will require specialized formula because of allergy, inability to digest certain formulas, or need for extra calories. The appropriate formula should always be available and should be fed as directed. For those infants getting supplemental calories, the formula may be prepared in a different way from the directions on the container. In those circumstances, either the family should provide the prepared formula or the caregiver/teacher should receive special training, as noted in the infant’s care plan, on how to prepare the formula. Formula should not be used beyond the stated shelf life period (3).

Parents/guardians should supply enough clean and sterilized bottles to be used throughout the day. The bottles must be sanitary, properly prepared and stored, and must be the same brand in the early care and education program and at home. Avoid bottles made of plastics containing bisphenol A (BPA) or phthalates (sometimes labeled with #3, #6, or #7). Use glass bottles with a silicone sleeve (a silicone bottle jacket to prevent breakage) or those made with safer plastics such as polypropylene or polyethylene (labeled BPA-free) or plastics with a recycling code of #1, #2, #4, or #5.

RATIONALE

Caregivers/teachers help in promoting the feeding of infant formula that is familiar to the infant and supports family feeding practice. By following this standard, the staff is able, when necessary, to prepare formula and feed an infant safely, thereby reducing the risk of inaccuracy or feeding the infant unsanitary or incorrect formula. Written guidance for both staff and parents/guardians must be available to determine when formula provided by parents/guardians will not be served. Formula cannot be served if it does not meet the requirements for sanitary and safe formula.

Staff preparing formula should thoroughly wash their hands prior to beginning preparation of infant feedings of any type. Water used for mixing infant formula must be from a safe water source as defined by the local or state health department. If the caregiver/teacher is concerned or uncertain about the safety of the tap water, s/he should "flush" the water system by running the tap on cold for 1-2 minutes or use bottled water (4). Warmed water should be tested in advance to make sure it is not too hot for the infant. To test the temperature, the caregiver/teacher should shake a few drops on the inside of her/his wrist. A bottle can be prepared by adding powdered formula and room temperature water from the tap just before feeding. Bottles made in this way from powdered formula can be ready for feeding as no additional refrigeration or warming would be required.

Adding too little water to formula puts a burden on an infant’s kidneys and digestive system and may lead to dehydration (5). Adding too much water dilutes the formula. Diluted formula may interfere with an infant’s growth and health because it provides inadequate calories and nutrients and can cause water intoxication. Water intoxication can occur in breastfed or formula-fed infants or children over one year of age who are fed an excessive amount of water. Water intoxication can be life-threatening to an infant or young child (6).If a child has a special health problem, such as reflux, or inability to take in nutrients because of delayed development of feeding skills, the child’s primary care provider should provide a written plan for the staff to follow so that the child is fed appropriately. Some infants are allergic to milk and soy and need to be fed an elemental formula which does not contain allergens. Other infants need supplemental calories because of poor weight gain.

Infants should not be fed a formula different from the one the parents/guardians feed at home, as even minor differences in formula can cause gastrointestinal upsets and other problems (7).

Excessive shaking of formula may cause foaming that increases the likelihood of feeding air to the infant.

TYPE OF FACILITY

Center, Early Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.3.1.1 General Plan for Feeding Infants
4.3.1.8 Techniques for Bottle Feeding
4.3.1.9 Warming Bottles and Infant Foods
5.2.9.9 Plastic Containers and Toys

REFERENCES

1. World Health Organization. 2007. Safe preparation, storage and handling of powdered infant formula: Guidelines. http://www.who.int/foodsafety/publications/powdered-infant-formula/en/.
   
2. U.S. Department of Health & Human Services, U.S. Food & Drug Administration. 2016. Food safety for moms to be: Once baby arrives. College Park, MD. https://www.fda.gov/food/resourcesforyou/healtheducators/ucm089629.htm.
   
3. Seltzer, H. 2012. U.S Department of Health & Human Services. Keeping infant formula safe. https://www.foodsafety.gov/blog/infant_formula.html.
   
4. Centers for Disease Control and Prevention. 2016. Water. https://www.cdc.gov/nceh/lead/tips/water.htm.
   
5. Seattle Children's Hospital. 2014. Topics covered for formula feeding: Is this your child's symptoms? Seattle, WA. http://www.seattlechildrens.org/medical-conditions/symptom-index/bottle-feeding-formula-questions/.
   
6. Brown, J., Krasowski, M. D., & Hesse, M. 2015. Forced water intoxication: A deadly form of child abuse. The Journal of Law Enforcement. 4(4).
   
7. United States Department of Agriculture, Food and Nutrition Service. 2017. Feeding infants: A guide for use in the child nutrition programs. https://www.fns.usda.gov/tn/feeding-infants-guide-use-child-nutrition-programs.
   

NOTES

Content in the STANDARD was modified on 11/5/2013 and 8/25/2016.

4.3.1.6: Use of Soy-Based Formula and Soy Milk

Soy-based formula or soy milk should be provided to a child whose parents/guardians present a written request because of family or religious dietary restrictions on foods produced from animals (ie, cow’s milk and other dairy products). Both soy-based formula and soy milk should be labeled with the infant’s or child’s full name and date and stored properly.

Soy milk should be available for the children of parents/guardians participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); Child and Adult Care Food Program; or Supplemental Nutrition Assistance Program (SNAP). Caregivers/teachers should encourage parents/guardians of children with primary health care provider–documented indications for soy formula, who are participating in WIC and/or SNAP, to learn how they can obtain soy-based infant formula or soy milk products.

RATIONALE

The American Academy of Pediatrics recommends use of hypoallergenic or soy formula for infants who are allergic to cow’s milk proteins (1). Soy-based formula and soy milk are plant-based alternatives to cow’s milk, often chosen by parents/guardians due to dietary or religious reasons. Soy-based formulas are appropriate for children with galactosemia or congenital lactose intolerance (2). Soy-based formulas are made from soy protein isolate with added methionine, carbohydrates, and oils (soy or vegetable) and are fortified with vitamins and minerals (3). In the United States, all soy-based formula is fortified with iron. Soy-based formula does not contain lactose, so it is used for feeding infants with documented congenital lactose intolerance. There are known differences between allergies to cow’s milk proteins and intolerance to lactose. The child’s specific health concerns (allergy versus intolerance) should be documented by the child’s primary health care provider and not based on possible parental/guardian misinterpretation of symptoms.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.2.0.10 Care for Children with Food Allergies
4.2.0.12 Vegetarian/Vegan Diets
4.3.1.5 Preparing, Feeding, and Storing Infant Formula

REFERENCES

1. Greer FR, Sicherer SH, Burks AW; American Academy of Pediatrics Committee on Nutrition and Section on Allergy and Immunology. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. Pediatrics. 2008;121(1):183–191

2. American Academy of Pediatrics. Where we stand: soy formulas. HealthyChildren.org Web site. https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Where-We-Stand-Soy-Formulas.aspx. Updated November 21, 2015. Accessed November 14, 2017

3. US Department of Agriculture. Infant feeding guide. WIC Works Web site. https://wicworks.fns.usda.gov/infants/infant-feeding-guide. Modified October 31, 2017. Accessed November 14, 2017

NOTES

Content in the STANDARD was modified on 05/30/2018.

4.3.1.7: Feeding Cow’s Milk

The facility should not serve cow’s milk to infants from birth to 12 months of age, unless provided with a written exception and direction from the infant’s primary health care provider and parents/guardians. Children between 12 and 24 months of age can be served whole pasteurized milk (1). Children 2 years and older should be served low-fat (1%) or nonfat (skim, fat-free) pasteurized milk (1). With proper documentation from a child’s primary health care provider, reduced fat (2%, 1%, nonfat) pasteurized milk may be served to those children who are at risk for high cholesterol or obesity after 12 months of age (2).

RATIONALE

Milk provides many nutrients that are essential for the growth and development of young children. The fat content in whole milk is critical for brain development as well as satiety in children 12 to 24 months of age (3). For those children whom overweight or obesity is a concern or who have a family history of obesity, dyslipidemia, or early cardiovascular disease, the primary health care provider may request low-fat or nonfat milk (2).

It is not recommended that children consume cow’s milk in place of human (breast) milk or infant formula during the first year after birth (1,4). Some early care and education programs have children between the ages of 18 months and 3 years in one classroom. To avoid errors in serving inappropriate milk, programs can use individual milk pitchers clearly labeled for each type of milk being served. Caregivers/teachers can explain to the children the meaning of the colored labels and identify which milk they are drinking.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.2.0.4 Categories of Foods
4.2.0.10 Care for Children with Food Allergies
4.9.0.3 Precautions for a Safe Food Supply

REFERENCES

1. Holt K, Wooldridge N, Story M, Sofka D. Cow's Milk / Children's need for. In: Bright Futures: Nutrition. Chicago, IL: American Academy of Pediatrics; 2011: 69

2. Oldfield B, Misra S, Kwiterovich P. Prevention of cardiovascular disease in pediatric populations. In: Wong ND, Amsterdam EA, Blumenthal RS, eds. ASPC Manual of Preventive Cardiology. New York, NY: Demos Medical Publishing; 2015:184–194

3. Singhal S, Baker RD, Baker SS. A comparison of the nutritional value of cow’s milk and nondairy beverages. J Pediatr Gastroenterol Nutr. 2017;64(5):799–805

4. American Academy of Pediatrics. Why formula instead of cow’s milk? HealthyChildren.org Web site. https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Why-Formula-Instead-of-Cows-Milk.aspx. Updated November 21, 2015. Accessed January 11, 2018

NOTES

Content in the STANDARD was modified on 05/30/2018.

4.3.1.8: Techniques for Bottle Feeding

Infants should always be held for bottle feeding. Caregivers/teachers should hold infants in the caregiver’s/teacher’s arms or sitting up on the caregiver’s/teacher’s lap. Bottles should never be propped. The facility should not permit infants to have bottles in the crib. The facility should not permit an infant to carry a bottle while standing, walking, or running around.

Bottle feeding techniques should mimic approaches to breastfeeding:
a.    Initiate feeding when infant provides cues (rooting, sucking, etc.);
b.    Hold the infant during feedings and respond to vocalizations with eye contact and vocalizations;
c.     Alternate sides of caregiver’s/teacher’s lap;
d.    Allow breaks during the feeding for burping;
e.    Allow infant to stop the feeding.

A caregiver/teacher should not bottle feed more than one infant at a time.

Bottles should be checked to ensure they are given to the appropriate child, have human milk or infant formula in them. When using a bottle for a breastfed infant, a nipple with a cylindrical teat and a wider base is usually preferable. A shorter or softer nipple may be helpful for infants with a hypersensitive gag reflex, or those who cannot get their lips well back on the wide base of the teat (1).

The use of a bottle or cup to modify or pacify a child’s behavior should not be allowed (2).

RATIONALE

The manner in which food is given to infants is conducive to the development of sound eating habits for life. Caregivers/teachers and parents/guardians need to understand the relationship between bottle feeding and emotional security. Caregivers/teachers should hold infants who are bottle feeding whenever possible, even if the children are old enough to hold their own bottle. Caregivers/teachers should promote proper feeding practices and oral hygiene including proper use of the bottle for all infants and toddlers. Bottle propping can cause choking and aspiration and may contribute to long-term health issues, including ear infections (otitis media), orthodontic problems, speech disorders, and psychological problems (3). When infants and children are fed on cue, they are in control of frequency and amount of feedings. This has been found to reduce the risk of childhood obesity. Any liquid except plain water can cause early childhood caries (4). Early childhood caries in primary teeth may hold significant short-term and long-term implications for the child’s health (5). Frequently sipping any liquid besides plain water between feeds encourages tooth decay.

Children are at an increased risk for injury when they walk around with bottle nipples in their mouths. Bottles should not be allowed in the crib or bed for safety and sanitary reasons and for preventing dental caries. It is difficult for a caregiver/teacher to be aware of and respond to infant feeding cues when the child is in a crib or bed and when feeding more than one infant at a time. Infants should be burped after every feeding and preferably during the feeding as well.

Caregivers/teachers should offer children fluids from a cup as soon as they are developmentally ready. Some children may be able to drink from a cup around six months of age, while for others it is later (6). Weaning a child to drink from a cup is an individual process, which occurs over a wide range of time. The American Academy of Pediatric Dentistry (AAPD) recommends weaning from a bottle by the child’s first birthday (7). Instead of sippy cups, caregivers/teachers should use smaller cups and fill halfway or less to prevent spills as children learn to use a cup (8). If sippy cups are used, it should only be for a very short transition period.

Some children around six months to a year of age may be developmentally ready to feed themselves and may want to drink from a cup. The transition from bottle to cup can come at a time when a child’s fine motor skills allow use of a cup. The caregiver/teacher should use a clean small cup without cracks or chips and should help the child to lift and tilt the cup to avoid spillage and leftover fluid. The caregiver/teacher and parent/guardian should work together on cup feeding of human milk to ensure the child’s receiving adequate nourishment and to avoid having a large amount of human milk remaining at the end of feeding. Two to three ounces of human milk can be placed in a clean cup and additional milk can be offered as needed. Small amounts of human milk (about an ounce) can be discarded.

TYPE OF FACILITY

Center, Early Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.3.1.2 Responsive Feeding of Infants by a Consistent Caregiver/Teacher
4.3.1.9 Warming Bottles and Infant Foods

REFERENCES

1. Ben-Joseph, E. 2015. Formula feeding FAQs: Getting started. Nemours: KidsHealth. http://kidshealth.org/en/parents/formulafeed-starting.html#
   
2. Lerner, C., & Parlakian, R. 2016. Colic and crying. Zero to three. https://www.zerotothree.org/resources/197-colic-and-crying.
   
3. American Academy of Pediatrics, Healthy Children. 2015. Practical bottle feeding tips. https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Practical-Bottle-Feeding-Tips.aspx.
   
4. American Academy of Pediatrics, Healthy Children. 2015. How to prevent tooth decay in your baby. https://www.healthychildren.org/English/ages-stages/baby/teething-tooth-care/Pages/How-to-Prevent-Tooth-Decay-in-Your-Baby.aspx.
   
5. Çolak, H., Dülgergil, Ç. T., Dalli, M., & Hamidi, M. M. 2013. Early childhood caries update: A review of causes, diagnoses, and treatments. Journal of natural science, biology, and medicine, 4(1), 29.
   
6. Hirsch, L. 2017. Feeding your 4- to 7-month old. Nemours, KidsHealth. http://kidshealth.org/en/parents/feed47m.html#
   
7. Rupal, C. 2016. Stopping the Bottle. Nemours, KidsHealth. http://kidshealth.org/en/parents/no-bottles.html#.
   
8. Holt K, Wooldridge N, Story M, Sofka D. Breast Milk/ microwaving, storage of, advantages of. In: Bright Futures: Nutrition. Chicago, IL: American Academy of Pediatrics; 2011: 27, 118, 120
   

4.3.1.9: Warming Bottles and Infant Foods

Bottles and infant foods do not have to be warmed; they can be served cold from the refrigerator. If a caregiver/teacher chooses to warm them, bottles or containers of infant foods should be warmed under running, warm tap water or by placing them in a container of water that is no warmer than 120°F (49°C). Bottles should not be left in a pot of water to warm for more than 5 minutes. Bottles and infant foods should never be warmed in a microwave oven because uneven hot spots in milk and/or food may burn the infant (1,2).

Infant foods should be stirred carefully to distribute the heat evenly. A caregiver/teacher should not hold an infant while removing a bottle or infant food from the container of warm water or while preparing a bottle or stirring infant food that has been warmed in some other way. Bottles used for infant feeding should be made of the following substances (3):

     a. Bisphenol A (BPA)-free plastic; plastic labeled #1, #2, #4, or #5, or 

     b. Glass (a silicone sleeve/jacket covering a glass bottle to prevent breakage is permissible).

When a slow-cooking device, such as a crock-pot, is used for warming human milk, infant formula, or infant food, the device (and cord) should be out of children’s reach. The device should contain water at a temperature that does not exceed 120°F (49°C), and be emptied, cleaned, sanitized, and refilled with fresh water daily. When a bottle warmer is used for warming human milk, infant formula, or infant food, it should be out of children’s reach and used according to manufacturer’s instructions.

RATIONALE

Bottles of human milk or infant formula that are warmed at room temperature or in warm water for an inappropriate period provide an ideal medium for bacteria to grow. Infants have received burns from hot water dripping from an infant bottle that was removed from a crock-pot or by pulling the crock-pot down on themselves by means of a dangling cord. Caution should be exercised to avoid raising the water temperature above a safe level for warming infant formula or infant food.

Additional Resource

Feeding Infants: A Guide for Use in the Child Nutrition Programs, US Department of Agriculture Food and Nutrition Service (https://www.fns.usda.gov/tn/feeding-infants-guide-use-child-nutrition-programs)

TYPE OF FACILITY

Center, Early Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.1.5 Preparing, Feeding, and Storing Infant Formula
4.3.1.8 Techniques for Bottle Feeding
4.3.1.12 Feeding Age-Appropriate Solid Foods to Infants

REFERENCES

1. US Department of Health and Human Services, US Food and Drug Administration. Food safety for moms to be: once baby arrives. https://www.fda.gov/food/resourcesforyou/healtheducators/ucm089629.htm. Updated November 8, 2017. Accessed January 11, 2018

2. Cowan D, Ho B, Sykes KJ, Wei JL. Pediatric oral burns: a ten-year review of patient characteristics, etiologies and treatment outcomes. Int J Pediatr Otorhinolaryngol. 2013;77(8):1325–1328

3. Environmental Working Group. Guide to baby-safe bottles and formula. https://www.ewg.org/research/ewg%E2%80%99s-guide-baby-safe-bottles-and-formula#.WlfPqWeWzct. Updated October, 2015. Accessed January 11, 2018

NOTES

Content in the STANDARD was modified on 11/5/2013, 8/25/2016 and 05/31/2018.

4.3.1.10: Cleaning and Sanitizing Equipment Used for Bottle Feeding

Caregivers/teachers should follow proper handwashing procedures prior to handling infant bottles. Bottles, bottle caps, nipples, and other equipment used for bottle-feeding should be thoroughly cleaned after each use by washing in a dishwasher or by washing with a bottlebrush, soap, and water (1).

Nipples that are discolored, thinning, tacky, or ripped should not be used.

RATIONALE

Infant feeding bottles are contaminated by the infant’s saliva during feeding. Formula and milk promote growth of bacteria, yeast, and fungi (2). Bottles, bottle caps, and nipples that are reused should be washed and sanitized to avoid contamination from previous feedings. Excessive boiling of latex bottle nipples will damage them.

Additional Resource
Feeding Infants: A Guide for Use in the Child Nutrition Programs, US Department of Agriculture Food and Nutrition Service (https://www.fns.usda.gov/tn/feeding-infants-guide-use-child-nutrition-programs)

TYPE OF FACILITY

Center, Early Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.3.1.1 General Plan for Feeding Infants
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.1.4 Feeding Human Milk to Another Mother’s Child
4.3.1.5 Preparing, Feeding, and Storing Infant Formula
4.3.1.8 Techniques for Bottle Feeding

REFERENCES

1. Centers for Disease Control and Prevention. Water, sanitation & environmentally-related hygiene. How to clean, sanitize, and store infant feeding items. https://www.cdc.gov/healthywater/hygiene/healthychildcare/infantfeeding/cleansanitize.html. Updated April 11, 2017. Accessed January 11, 2018

2. Wolfram T. How to safely clean baby bottles. Academy of Nutrition and Dietetics Eat Right Web site. http://www.eatright.org/resource/homefoodsafety/four-steps/wash/how-to-safely-clean-baby-bottles. Published February 16, 2017. Accessed January 11, 2018

NOTES

Content in the STANDARD was modified on 05/31/2018.

4.3.1.11: Introduction of Age-Appropriate Solid Foods to Infants

A plan to introduce complementary, age-appropriate solid foods to infants should be made in consultation with the child’s parent/guardian and primary health care provider. Complementary foods are nutritious foods and beverages other than human breast milk or infant formula.⁶ Age-appropriate solid foods may be introduced by 6 months, or sooner or later based on the child’s developmental level.^1,5-6 Caregivers/teachers should watch for signs to decide when the infant is ready for solid foods. These signs include sitting up with only a little support, proper head control, the ability to chew well, or grabbing food from the plate. Also, infants will lose the tongue-thrusting reflex and begin acting hungry after formula feeding or breastfeeding.^4,6 Recommendations on the introduction of complementary should take into account:⁶

• The infant’s developmental level
• Nutritional needs
• Coexisting medical conditions
• Social factors
• Cultural, ethnic, and religious food preferences of the family
• Financial considerations
• Other related factors found through the nutrition assessment

For infants who are exclusively breastfed, the amount of certain nutrients in the body ¾ such as iron and zinc ¾ begins to get lower after the age of 6 months. So, gradually introduce puréed meats or meat substitutes and iron-fortified cereals.^5-6 Iron-fortified cereals, puréed meats, and puréed fruits and vegetables are all appropriate foods to introduce. The first food introduced should have just one ingredient that is served in a small portion for 3 to 5 days before introducing another food.⁶ Watch the infant closely for potential reactions to the foods being introduced. Gradually increase the variety and portion, one at a time, depending on how the infant reacts .⁸ 

Caregivers/teachers should use or develop a take-home sheet for parents/guardians in which the caregiver/teacher records the food consumed, how much, and other important notes on the infant, each day. Caregivers/teachers should also continue to talk with each infant’s parents/guardians about which foods they have introduced and are feeding. When appropriate, changes to basic food patterns should be given in writing by the infant’s primary health care provider.

If caregivers/teachers will give nutritional supplements/medications, written orders from the prescribing health care provider should specify the medical need; medication or supplement; dosage; and how long to give the medication or supplement.

RATIONALE

The ideal time to introduce complementary foods to infants may vary because infants develop at different rates. Early introduction of age-appropriate solid food and fruit juice interferes with the intake of human milk or iron-fortified formula that the infant needs for growth. Solid foods given before an infant is developmentally ready may be related to extra weight gain, a higher risk of choking, and consuming less than the right amount of breast milk or formula.^1,4,6 Age-appropriate solid foods, such as meat and fortified cereals, are needed beginning at 6 months to make up for any losses in zinc and iron from breastfeeding exclusively.^5-6 Typically, low levels of vitamin D are transferred to infants via breast milk, so it is recommended that breastfed or partially breastfed infants receive at least 400 IU of vitamin D supplements every day beginning soon after birth.^2,3,6 Parents/guardians give these supplements at home, unless the primary health care provider has different instructions.

Many caregivers/teachers and parents/guardians believe that infants sleep better when they start to eat age-appropriate solid foods, but research shows that longer sleeping periods are developmental -not nutritionally- determined in mid-infancy, and so this shouldn’t be the only reason for deciding when to introduce solid foods.^4,6 Also, for infants who are exclusively formula fed or fed a combination of formula and human milk, evidence for introducing complementary foods in a specific order has not been proven.

Good communication between the caregiver/teacher and the parents/guardians cannot be overemphasized and is needed for successful feeding in general, including when and how to introduce age-appropriate solid foods.

COMMENTS

ADDITIONAL RESOURCES:

American Academy of Pediatrics

Starting Solid Foods - https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Starting-Solid-Foods.aspx

TYPE OF FACILITY

Center, Early Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.6.3.1 Medication Administration
4.2.0.7 100% Fruit Juice
4.2.0.9 Written Menus and Introduction of New Foods
4.2.0.10 Care for Children with Food Allergies
4.2.0.12 Vegetarian/Vegan Diets
4.5.0.6 Adult Supervision of Children Who Are Learning to Feed Themselves
4.5.0.8 Experience with Familiar and New Foods

REFERENCES

1. American Academy of Pediatrics. Infant food and feeding. AAP.org Web site. https://www.aap.org/en/patient-care/healthy-active-living-for-families/infant-food-and-feeding/. Published July 6, 2021. Accessed November 20, 2022

2. American Academy of Pediatrics. Where we stand: vitamin D & iron supplements for babies. Updated May 24, 2022. Healthy Children.org Web site. https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Vitamin-Iron-Supplements.aspx. Accessed November 20, 2022

3. Centers for Disease Control and Prevention. Vitamin D supplementation CDC (Centers for Disease Control and Prevention). CDC.gov Web site. http://www.cdc.gov/breastfeeding/recommendations/vitamin_D.htm. Last Reviewed July 2, 2021. Accessed November 20, 2022

4. U.S Department of Agriculture. Food and Nutrition Service. Feeding infants in the Child and Adult Care Food Program. USDA.gov Web site. https://www.fns.usda.gov/tn/infant-and-toddler-nutrition. Published July 2021. Accessed November 20, 2022

5. U.S Department of Agriculture. Food and Nutrition Service. Q&As: Feeding infants and meal pattern requirements in the Child and Adult Care Food Program. https://fns-prod.azureedge.us/sites/default/files/cacfp/CACFP06-2017os.pdf. Published January 17, 2017. Accessed November 20, 2022

6. U.S Department of Agriculture. WIC Works Resource System. WIC infant nutrition and feeding guide. Chapter 5: Complementary foods. USDA.gov Web site. https://wicworks.fns.usda.gov/resources/infant-nutrition-and-feeding-guide. Published April 2019. Accessed November 20, 2022

7. Vadiveloo M, Tovar A, Østbye T, Benjamin-Neelon SE. Associations between timing and quality of solid food introduction with infant weight-for-length z-scores at 12 months: findings from the Nurture cohort. Appetite, 141, p.104299. https://www.sciencedirect.com/science/article/pii/S0195666318317860?casa_token=AI_mEyEGr4IAAAAA:sWFkOzAZjvFMH_TAGxxymoYTKr0XlLodeP4MT_unvd3fyUB0CqGmqP6K7G5QCdmQwSk2iwjQvis. Published October 1, 2019. Accessed November 20, 2022

8. World Health Organization. Infant and young child feeding: key facts. WHO.int Web site. https://www.who.int/news-room/fact-sheets/detail/infant-and-young-child-feeding. Published June 9, 2021. Accessed November 20, 2022

NOTES

Content in the STANDARD was modified on 5/31/2018 and 2/9/2023.

4.3.1.12: Feeding Age-Appropriate Solid Foods to Infants

Caregivers/teachers should thoroughly wash hands prior to serving any foods to infants/children. All jars of baby food should be washed with soap and warm water and rinsed with clean, running warm water before opening. All commercially packaged baby food should be served from a dish and spoon, not directly from a factory-sealed container or jar (1). A dish should be cleaned and sanitized before use to reduce the likelihood of surface contamination.

Age-appropriate solid food should not be fed in a bottle or an infant feeder unless doing so is written in the child’s care plan by the child’s primary health care provider. Caregivers/teachers should ensure that there are no food safety recalls (2), and examine the food carefully when removing it from the jar to make sure there are no glass pieces or foreign objects in the food. Caregivers/teachers should discard uneaten food left in dishes from which they have fed a child because it may contain potentially harmful bacteria from the infant’s saliva (3). If left out, all food should be discarded after 2 hours (4). The portion of the food that is touched by a utensil should be consumed or discarded.

Any food brought from home should not be served to other children. This will prevent cross contamination and reinforce the policy that food sent to the facility is for the designated child only.

Food should not be shared among children using the same dish or spoon.

Unused portions in opened factory-sealed baby food containers or food brought in containers prepared at home should be stored in the refrigerator and discarded if not consumed after 24 hours of storage. Prior to refrigeration, the opened container or jar should be labeled with the child’s full name and the date and time the food container was opened.

 

RATIONALE

Feeding of age-appropriate solid foods in a bottle to a child is often associated with premature feeding (ie, when the infant is not developmentally ready for solid foods) (5,6).

The external surface of a commercial container or jar may be contaminated with disease-causing microorganisms during shipment or storage and may contaminate the food product during removal of food for placement in the child’s serving dish.

 

TYPE OF FACILITY

Center, Early Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants

REFERENCES

1. Lester J. Nutrition 411: introducing solid foods. Promise powered by Nemours Children’s Health System Web site. https://blog.nemours.org/2016/02/nutrition-411-introducing-solid-foods. Published February 22, 2016. Accessed January 11, 2018

2. US Department of Agriculture. Food Safety and Inspection Service Web site. https://www.fsis.usda.gov/wps/portal/fsis/home. Accessed January 11, 2018

3. US Department of Health and Human Services. Baby food and infant formula. Foodsafety.gov Web site. https://www.foodsafety.gov/keep/types/babyfood/index.html. Accessed January 11, 2018

4. US Department of Health and Human Services, US Food and Drug Administration. Food safety for moms to be: once baby arrives. https://www.fda.gov/food/resourcesforyou/healtheducators/ucm089629.htm>. Updated November 8, 2017. Accessed January 11, 2018

5. Robert Wood Johnson Foundation Healthy Eating Research. Feeding Guidelines for Infants and Young Toddlers: A Responsive Parenting Approach. Guidelines for Health Professionals. http://healthyeatingresearch.org/wp-content/uploads/2017/02/her_feeding_guidelines_brief_021416.pdf. Published February 2017. Accessed January 11, 2018

6. US Department of Agriculture Food and Nutrition Service. Feeding Infants: A Guide for Use in the Child Nutrition Programs. Publication FNS-258. Alexandria, VA: US Department of Agriculture; 2017. https://www.fns.usda.gov/tn/feeding-infants-guide-use-child-nutrition-programs. Accessed January 11, 2018

NOTES

Content in the STANDARD was modified on 05/31/2018.