Chapter 4: Nutrition and Food Service
4.3 Requirements for Special Groups or Ages of Children
4.3.1 Nutrition for Infants
126.96.36.199: 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.
RATIONALECaregivers/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 FACILITYCenter, Large Family Child Care Home
RELATED STANDARDS188.8.131.52 General Plan for Feeding Infants
184.108.40.206 Techniques for Bottle Feeding
220.127.116.11 Warming Bottles and Infant Foods
18.104.22.168 Plastic Containers and Toys
World Health Organization. 2007. Safe preparation, storage and handling of powdered infant formula: Guidelines. http://www.who.int/foodsafety/publications/powdered-infant-formula/en/.
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.
Seltzer, H. 2012. U.S Department of Health & Human Services. Keeping infant formula safe. https://www.foodsafety.gov/blog/infant_formula.html.
Centers for Disease Control and Prevention. 2016. Water. https://www.cdc.gov/nceh/lead/tips/water.htm.
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/.
Brown, J., Krasowski, M. D., & Hesse, M. 2015. Forced water intoxication: A deadly form of child abuse. The Journal of Law Enforcement. 4(4).
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.
Content in the STANDARD was modified on 11/5/2013 and 8/25/2016.