USDA Child Nutrition Program and Breastfed Toddlers in Day-Care

By Laura Spitzfaden, LLLL, IBCLC

Under the USDA Child Nutrition Program guidelines, infants and children 1 year of age and older, who are in licensed day-care programs, must be offered fluid cow’s milk (or approved alternative milk) in order for their day-care providers to be reimbursed for their meals. This is in conflict with what is best for employed mothers of breastfed toddlers and their day-care providers, who have limited breastfeeding friendly options under these guidelines.

iStock_000016831831SmallMany employed mothers, knowing that their breastmilk provides excellent nutrition, antibodies, and a sense of security for their older babies, continue to breastfeed when they are with their babies, even if they no longer express milk while they are at work. A breastfed baby, who is 1 year of age or older and eating nutrient dense solids, needs approximately 15 ounces of breastmilk each day to meet child nutrition standards. If a mother and baby breastfeed at least 3–4 times daily, the baby will receive age-appropriate amounts of milk and will not need a milk-substitute when separated from the their mother.

In order to support the breastfeeding relationship, a day-care provider may choose not to be reimbursed for the meals the breastfed child consumes that do not include milk, however this option is economically punitive to the provider and may affect how much they charge for their services. In order to take the burden off the day-care provider, the mother may send food from home for the child to consume at day-care but this creates extra work and expense for the mother. Alternatively, the mother’s own expressed breastmilk may be served at meals. This satisfies the milk requirement under the USDA Child Nutrition Program, but continued breastmilk expression may be unnecessarily burdensome for the mother of an older baby who doesn’t need this extra milk.

Expressing breastmilk takes a great deal of dedication and time; pump-weaning can be a welcome relief for the employed breastfeeding mother of an older baby. No longer does she have to cart her pump to and from work or have to scramble to accommodate for the occasional misplaced or broken pump part. Break times become actual breaks and lunches can be enjoyed without the hassle of setting up a pump, expressing and storing milk, and cleaning pump parts.

If a breastfeeding mother allows cow’s milk or other alternative milks to be offered at her child’s meals, she may risk their breastfeeding relationship. One mother who had pump- weaned but whose toddler continued to breastfeed when they were together writes, “when I got to that point with [my daughter], she just stopped getting milk at daycare. She is getting enough mama milk straight from the source when we are together. She just drinks water at daycare. We didn’t originally do it that way—we gave her cow’s milk for a couple of days—then she drastically reduced nursing, so I took her off of cow’s milk. She went back to nursing like normal.”

The Healthy, Hunger-Free Kids Act of 2010 states “In the case of children who cannot consume fluid milk due to medical or other special dietary needs, other than a disability, the caregiver may serve non-dairy beverages in lieu of fluid milk….If a non-dairy milk substitute is served that does not meet the nutritional standards outlined in Title 7 CFR 210.10(m)(3), then the meal is not reimbursable.” According to Kelley Knapp, MS RD from the California Department of Education Nutrition Services Division, there is another option in USDA’s Child Nutrition Programs. The child’s physician can fill out a form, “…stating that the child cannot receive milk due to a disability.” In this case, the toddler may be offered a physician-determined alternative (e.g. water or juice) with meals and the meal may still be reimbursable.

These options do not address the unique needs of the breastfed toddler who does not have a disability or a medical condition, but just doesn’t need additional milk in their diet. It doesn’t address the concern that offering non-human milk to a breastfed toddler can reduce the amount of breastmilk that is consumed and replace it with an inferior substitute that is linked to allergy and obesity.

Employed mothers should not have to continue to express milk for their children past the age when it is needed and they should not have to jump through hoops for their children to continue to enjoy a health promoting breastfeeding relationship. Day-care providers should not have to take an economic hit in order to support their breastfeeding clients. It is imperative that this gap in the USDA food program be closed, so that we may continue to support breastfeeding mothers, their babies, and their care providers, whether their breastfeeding relationships are measured in terms of months or years.

References:

Child & Adult Care Food Program Reimbursable Meals and Snacks

Long-Term Breastfeeding: Nourishment or Nurturance? Kathleen M. Buckley, PhD, RN, IBCLC, J Hum Lact November 2001 17: 304-312

Breastfeeding Past Infancy Fact Sheet

Feeding Infants: A Guide for Use in the Child Nutrition Programs, Chapter 3

USDA FCS INSTRUCTION 783-7 Food and Nutrition Service REV. 1 Milk Requirement Child Nutrition Programs

The Healthy, Hunger-Free Kids Act of 2010, Public Law 111-296, Section 221.17(g); USDA Policy Memo CACFP 21-2011-REVISED; USDA Policy Memo CACFP 04-2010 Fluid Milk and Fluid Milk Substitutions (Revised)

Child Nutrition Programs PHYSICIAN STATEMENT FOR FOOD SUBSTITUTION

LauraLaura Spitzfaden is a private practice IBCLC in Charlotte, Michigan. She has been a La Leche League Leader since 1998 and an associate area professional liaison (AAPL) for La Leche League since 2012. She has three children whom she breastfed for a total of 10 years. Laura has a passion for helping moms to reach their own breastfeeding goals and has created an informational breastfeeding website dedicated to providing moms with accessible breastfeeding help and resources so they may solve some of their own breastfeeding difficulties. She has written many articles on breastfeeding topics including, bed-sharing, milk-sharing, tongue and lip-tie, birth practices and milk-supply and provides these articles freely, to support breastfeeding moms and their babies.

Laura has a special interest in early childhood development and has worked in preschools and her own child-care business, creating hands-on, science based curriculums for toddlers, preschoolers and young 5’s. She has also presented multiple science workshops for young children and for adults who work with young children and has worked in a children’s science museum in exhibit development. Additionally, Laura has a love of dance and has studied tap, jazz, lyrical, modern and ballet and performs each year with The Community Dance Project.

© 2013 Laura Spitzfaden, LLLL, IBCLC

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21 Responses to USDA Child Nutrition Program and Breastfed Toddlers in Day-Care

  1. Margot Mann says:

    Thank you! This is a wonderful wake up call.
    And I loved the description of your background. Where & when do you dance? I would love to attend.

  2. Hope Granger says:

    Bravo!! This issue has irritated me for while now. I completely agree and think you explained the issue very well. Thank you for resources too.

  3. Doraine Bailey, Lexington-Fayette Co. (KY) Health Dept., consultant to Child Care Health Consultant Program says:

    Firstly, please remember that the Child and Adult Food Program targets low-income children in the child care setting, so these rules may not be specifically applicable to all children. However, many centers will “require” all children to consume foods according to the CACFP meal plan for ease in food management. If a particular child is NOT a recipient of a meal paid for by CACFP funding, then there are no limitations/stipulations for what a parent can provide, unless there are other state-specific regulations on meals for children. Secondly, a specific medical need is not the ONLY WAY a mom can request special fluid beverages for her child. In the regulations (http://www.gpo.gov/fdsys/pkg/CFR-2012-title7-vol4/pdf/CFR-2012-title7-vol4-sec226-20.pdf), it states,”(h) Individual substitutions. Substitutions may be made in food listed in paragraphs (b) and (c) of this section if individual participants are unable, because of medical or other special dietary needs, to consume such foods. Substitutions because of medical needs shall be made only when supported by a statement from a recognized medical authority which includes recommended alternate foods.” If a mother says she does not want her child to receive cows milk or other milks, or any other particular foods for that matter, she should give that direction in writing to her provider.

    • Laura Spitzfaden, LLLL, IBCLC says:

      Hi Doraine, Thank-you for replying to my article.

      While the USDA Child Nutrition Program is critical for ensuring that low income children receive healthy meals, it also allows day-care providers to receive compensation for the foods they serve all their day-care children, not just those who are low income. Day-care providers are already underpaid and the compensation they receive through the Child Nutrition Program is important. I work regularly with moms of breastfed toddlers for whom this issue is extremely relevant to their breastfeeding relationships.

      In the article, I addressed your point about substitutions for medical or dietary needs. In fact, these substitutions no longer even need a “recognized medical authority” to support the statement, the parent can authorize the substitution. The problem for breastfed toddlers is that the substitution must meet certain nutritional criteria that results in one of three undesirabe situations, breastfed toddlers being served a fluid milk substitution they do not need (which can reduce the amount of breastmilk they consume when they are with mom), moms needlessly pumping breastmilk for the substitution, or day care providers not being reimbursed for the meal.

  4. Melissa says:

    Thank you for this article. For mother’s who do choose to continue to pump and provide breast milk after 13 months, the FPP requires you to provide a certain amount (8oz) with each meal. This was almost impossible for me to meet and I ended up watering down my breast milk to meet these requirements. The FPP also requires a doctor’s approval to provide breast milk past 12 months. I ultimately stopped pumping at 18 months because of these regulations.

    • Laura Spitzfaden, LLLL, IBCLC says:

      HI Melissa,
      You sure had to work hard to continue to breastfeed your toddler! I don’t know if things are different now than before or if your day-care provider had their own rules but currently, a 13 month-old only needs to have 4 ounces of fluid milk per meal for meeting the Child Nutrition Standards. (http://www.fns.usda.gov/sites/default/files/Child_Meals.pdf). This is still more than the average breastfeed of 2-4 ounces.

      The doctor’s approval is also no longer needed for using an approved fluid milk substitution (breastmilk is approved). Currently, the parent can authorize the substitution. (http://www.cde.ca.gov/ls/nu/cc/mbusdacacfp202011.asp)
      “In the case of children who cannot consume fluid milk due to medical or other special dietary needs, other than a disability, the caregiver may serve non-dairy beverages in lieu of fluid milk. Non-dairy beverages must be nutritionally equivalent to milk and meet the nutritional standards for fortification of calcium, protein, vitamin A, vitamin D, and other nutrients to levels found in cow’s milk, as outlined in the National School Lunch Program regulations per Title 7, Code of Federal Regulations, Section 210.10 (m)(3).

      Parents or guardians may now request non-dairy milk substitutions in writing, as described above, without providing a medical statement. As an example, if a parent has a child who follows a vegan diet, the parent can submit a written request to the child’s caregiver asking that soy beverage be served in lieu of cow’s milk.”

  5. This is a great article outlining the problems mothers of toddlers face. Fortunately, I didn’t run into this problem, since my children’s daycare provider does not receive reimbursement from the USDA, but I can clearly see that this stipulation is very unfair to mothers who are not ready for their toddlers to receive cow’s milk.
    What governing body can we contact to voice an opinion to hopefully set the wheels in motion to changing this?

    • Laura Spitzfaden, LLLL, IBCLC says:

      Hi Lauren,
      I sent this link to Kelley Knapp, MS RD from the California Department of Education Nutrition Services Division, who allowed for my quoting her in this article. She also directed me to the information supporting breastmilk substititions for toddler reimbursable meals. From what I have learned, it is not widely known that toddlers may be served breastmilk as a cow’s milk substitute in the nutrition program. Hopefully this article will outline the concerns and some changes can be made.

  6. I hear this very complaint EVERY DAY from the active duty mothers that I serve! This issue affects our Active Duty (AD) military mothers as many of the on base/post Child Development Centers (CDCs) require that breastfed toddlers receive cows milk only. Since the CDCs on base are government-run and rely on the money coming in to subsidize the lower cost child care, many of these AD mothers are weaning, prematurely for the reasons you outline above.

    This is particularly sad considering that many of these AD mothers fought tooth and nail with the day care providers to allow breastmilk in the first place for their newborns, dealt with wasted breastmilk due to lack of training on how to feed breastfed infants, and of course dealt with all the major separation issues and milk supply concerns that AD mothers face. When they finally make it to one year mark, they have yet another, unneeded hurdle to overcome!

    Thank you for your post! I have linked it to my Facebook Page for AD military mothers (Breastfeeding in Combat Boots), in the hopes that some of them might take your suggestions and use them at the CDCs so that their toddlers can continue to receive the breastmilk they rightfully deserve!

    • Laura Spitzfaden, LLLL, IBCLC says:

      Thank-you for the comment and for sharing the post!

      It seems like it must not be widely known that the USDA Child Nutrition Program does alow for the substitution of breastmilk, without a doctor’s note for reimbursable toddler meals. Maybe it is different in military day-care centers but you could try sharing this link.

      http://www.fns.usda.gov/tn/resources/feedinginfants-ch3.pdf

      From the link:
      “Use of Breastmilk for Babies Over 12 Months of Age.
      Some parents may request that the caregiver continue feeding
      their babies breastmilk after 12 months of age. Continue to
      serve babies their mother’s milk as long as the mother is able
      and wishes to provide it. Mothers who wish to continue provid-
      ing breastmilk for their babies older than 12 months of age can
      do so without having to submit a medical statement. Breastmilk
      is a substitute for cow’s milk in the meal pattern for children. “

      • Laurel says:

        I had to get a Doctor’s note at the two on post daycares I used after my son turned one. I also pulled that exact quote out of the Nutrition Program book and was given a lazy, “well we have our own additional policies”. I had nothing but hassle with breastfeeding my son and using military daycares. Much wasted milk, much “you need to bring more”. But I’m also a Nurse Practitioner who read a lot of research, had a great Lactation Consultant and called the public health department who was overseeing the nutrition portion of the on post daycare. I think at one point I was so furious I looked up the contact information on that USDA Nutrition Program and made a request that they put in more up to date information on breastmilk. I pumped and brought milk for him until he was two, but it wasn’t easy. I felt like I needed to educate a little so at least those coming behind me wouldn’t have to.

      • Laura Spitzfaden, LLLL, IBCLC says:

        Laurel, that sounds so frustrating! It is fortunate that you had the knowledge and resources to keep providing your milk for your child. I imagine that many moms in your situation just give up. Thank-you for helping to pave the way for other moms and babies!

  7. Anne Marie says:

    I was very confused about this & checked with my daycare provider, who is very supportive of breastfeeding. They provided me this link, which leads me to believe that things may differ state-to-state? Any guidance?
    https://www.educateiowa.gov/faq/infant-over-1-year-still-consuming-breast-milk-according-cacfp-meal-pattern-children-1-12-breast

    • Laura Spitzfaden, LLLL, IBCLC says:

      Hi Anne Marie,

      I read the information at the link you provided and it is very confusing! In the question there is the statement that “breast milk is not an option for fluid milk” but in the answer there is the statement that “USDA recognizes the many benefits of breast-feeding and promotes it by allowing reimbursement for these meals until the child reaches two years of age.”

      This is very contradictory. I checked into the Iowa Department of Education Website and I found this.
      http://www.childcareinfo.com/KnowledgeCenter/Government/State/IowaCACFP.aspx
      In this document, breastmilk is listed as an acceptable replacement for milk until 2 years of age so I am thinking that the statement in the link you posted is possibly worded incorrectly. Hopefully this information clears up your daycare provider’s confusion.

      • Anne Marie Gruber says:

        It’s a lot to sort out. It shouldn’t be so complicated to just feed our babies. In any case, my provider is awesome & the director told me today that it’s cheaper for them if parents provide breastmilk. Plus they like getting to know the moms like me who go there to nurse over lunch. :)

      • Laura Spitzfaden, LLLL, IBCLC says:

        Anne Marie, That is great that you have such an understanding child-care provider.

        It looks like it isn’t possible to link directly to the information about creditable foods I tried to link to above. If you want to find the PDF I referenced, you you may have to follow these instructions. First go to this link…

        http://www.childcareinfo.com/KnowledgeCenter/Government/State/IowaCACFP

        then click on the drop down menu for PK-12. Click on Child and Adult Care Food Program, then Child Care Center, then Resources, then click on Handy Guide to Creditable Foods. This will lead to a PDF that shows that breastmilk is an acceptable fluid milk substitute in Iowa, until the child is 2 years old.

        I agree with you that it shouldn’t have to be this difficult!

      • We are having a hard time appropriately attaching the document to these comments. If you’d like to see the document Laura references, please email lactationmatters@gmail.com.

  8. While one would generally agree with the benefits of breastfeeding children and other observations made in the write up, the challenge is how to make arrangements that this Godly fluid is available to maximum number of children. Those who agree with the approach here should help overcome systemic infirmities and any prejudices in realization of this objective. In India, the system of day care exists in most metropolitan cities and informal arrangements exist in smaller towns to fulfill the needs of working mothers with growing urbanization and industrialization. But the coverage and quality of protection available to the children leaves much to be desired. In conservative families, the mothers sometimes enter into informal cross-nursing arrangements, but other alternatives must also be explored. In this respect initiatives of women’s’ organizations and those of individual mothers also matter a lot and need to be encouraged with pooling of new ideas.

  9. Laura Spitzfaden, LLLL, IBCLC says:

    http://www.fns.usda.gov/sites/default/files/feedinginfants-ch3.pdf

    Above is a new link to replace dead link below.

    Feeding Infants: A Guide for Use in the Child Nutrition Programs, Chapter 3

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