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Milk Substitutes Minor Updates: Units of Measurement and Medical Statements

October 28, 2024

Fluid Milk and Substitutions_4x3

USDA released a memorandum that details the nutrition requirements for fluid milk and fluid milk substitutes in the CACFP and includes a series of frequently asked questions and answers. This memorandum supersedes CACFP 17-2016, Nutrition Requirements for Fluid Milk and Fluid Milk Substitutions in the Child and Adult Care Food Program, Questions and Answers, July 14, 2016.

In addition to the information included in previous memoranda, this memorandum specifically:

  • Clarifies who may sign medical statements;
  • Provides technical updates on units of measurement for vitamins A and D in fluid milk substitutes;
  • Includes a table of the nutrition requirements for fluid milk substitutes; and
  • Provides information related to temporary and ongoing unavailability of fluid milk.

Why It Matters

The final rule, Child Nutrition Programs: Meal Patterns Consistent with the 2020-2025 Dietary Guidelines for Americans updated the Vitamin A and Vitamin D units of measurement for fluid milk substitutes from International Units (IUs) to micrograms (mcg). The amount of Vitamin A and Vitamin D required in fluid milk substitutes did not change, only the unit of measurement changed to conform to U.S. Food and Drug Administration (FDA) labeling requirements. The final rule also clarified that both State licensed healthcare professionals and registered dietitians may write medical statements to request meal modifications on behalf of participants with disabilities. Prior to this final rule, only State licensed healthcare professionals were able to make meal modification requests.

No action is needed by CACFP operators, these changes will not impact day-to-day operations

Fluid Milk

Fluid milk is a required component for reimbursable meals in the CACFP. Institutions and facilities have the option to serve fluid milk as one of the two components of a snack served in the CACFP; however, the other required meal component must not also be a beverage when fluid milk is served at snack. Fluid milk must be served as a beverage or on cereal, or a combination of both.

Fluid milk must be pasteurized and meet State and local standards. Fluid milk refers to the following varieties of pasteurized or Ultra High Temperature (UHT) milk:

  • fat-free (skim) milk;
  • low-fat (1%) milk;
  • reduced-fat (2%) milk;
  • whole milk;
  • lactose-free milk;
  • lactose-reduced milk;
  • cultured milk, such as cultured buttermilk, cultured kefir milk, and cultured acidophilus milk; and
  • acidified milk, such as acidified kefir milk and acidified acidophilus milk.

Goat’s milk may be served in place of cow’s milk, provided it meets State and local standards for fluid milk. Age-specific requirements for percent fat content and flavored vs. unflavored apply regardless of type of fluid milk serve

One Year Old Children

One-year-old children must be served unflavored whole milk (7 CFR 226.20(a)(1)(i)). This is consistent with recommendations from the National Academy of Medicine and the Dietary Guidelines for Americans, 2020-2025. There may be some cases when a one-year-old child’s physician recommends low-fat (1%) milk if the child’s growth and weight gain is appropriate, or for other medical reasons. If it is medically and nutritionally appropriate for a one-year-old child to consume low-fat (1%) milk, or any type of milk other than whole milk, a meal modification may be made by following the requirements for modifications for disability reasons outlined in 7 CFR 226.20(g)(1). Additionally, breastmilk is considered an allowable fluid milk substitute for children of any age if a parent chooses to breastfeed their child past 1 year of age.

Reimbursable milk for one-year-old children includes breastmilk, whole milk, whole lactose reduced milk, whole lactose-free milk, whole cultured milk, or whole acidified milk (7 CFR 226.20(a)(1)).

FNS recognizes that switching immediately from breastmilk or iron-fortified formula to whole milk when a child turns one year old may be challenging. Therefore, iron-fortified formula may be served to children between the ages of 12 months and 13 months to help with the transition to whole milk. Breastmilk may be served to a child of any age.

Children Two Years Old and Older and Adults

Fluid milk served to children two–years old and older and adult participants must be low-fat (1%) milk or fat-free (skim) milk. Whole milk and reduced-fat (2%) milk may not be served to participants two years of age and older or adult participants except in the case of a modification for disability reasons as outlined in 7 CFR 226.20(g)(1).

FNS recognizes that switching immediately from whole milk to low-fat (1%) milk or fat-free (skim) milk when a child turns two years old may be challenging. Therefore, unflavored whole milk and reduced-fat (2%) milk may be served to children between the ages of 24 months to 25 months to help with the transition to fat-free (skim) milk or low-fat (1%) milk. Meals served to children 24 months to 25 months old may be reimbursable when they contain breastmilk, whole milk, reduced-fat (2%) milk, low-fat (1%) milk, fat-free (skim) milk, or a combination of these milk types.

Reimbursable milk for children two years old and older and adult participants includes low fat (1%) milk or fat-free (skim) milk, low-fat or fat-free lactose reduced milk, low-fat or fat-free lactose free milk, low-fat or fat-free buttermilk, or low-fat or fat-free acidified milk (7 CFR 226.20(a)(1)). Breastmilk is considered an allowable fluid milk substitute for children of any age when provided by the parent or guardian.

Fluid Milk Flexibilities for Adult Participants

Institutions and facilities may use the following meal pattern flexibilities as they relate to fluid milk to meet the needs and preferences of their adult day care participants. Flexibilities are optional, not required. For CACFP adult day care participants only:

  • A serving of fluid milk is optional for suppers served to adult participants. USDA encourages institutions and facilities to serve water as a beverage for adult participants when fluid milk is not served at supper.
  • Once per day, 6 ounces by weight or ¾ cup by volume of yogurt may be served in place of an 8 fluid ounce serving of milk for adult participants only. Yogurt must not be served as a meat alternate in the same meal (7 CFR 226.20(a)(1)(iv)). Yogurt must contain no more than 12 grams of added sugars per 6 ounces. Allowing yogurt to substitute for fluid milk once per day for adults offers greater flexibility to the menu planner and will help encourage consumption of a calcium-rich food among adult participants.

Flavored Milk

Flavored milk contains all the nutrients found in unflavored milk. Flavored milk (which includes both commercially prepared flavored milk and plain milk that is flavored with syrup, powders, straws, or other flavorings) typically contains added sugars, and the Dietary Guidelines recommends that all Americans reduce their consumption of added sugars. To align with the Dietary Guidelines’ recommendation and help children develop healthy eating practices early, flavored milk may only be served to participants 6 years old and older:

  • Children 1 through 5 years old: Flavored fluid milk and flavored non-dairy beverages served to children 1 through 5 years old cannot be claimed for reimbursement.
  • Children 6 years old and older and adults: If flavored milk is served to children 6 years old and older or adult participants, it must be low-fat (1%) milk or fat-free (skim) milk. The CACFP does not have an added sugars limit for flavored milk. USDA encourages CACFP institutions and facilities to consider choosing milks that are lower in added sugars.

Fluid Milk Substitutes for Non-Disability Reasons

Non-Dairy Beverages (Fluid Milk Substitutes)

For participants who do not consume fluid milk due to non-disability reasons that include, but are not limited to cultural, ethical, Tribal and religious preferences, fluid milk substitutes may be served in place of fluid milk in order to better meet the dietary preferences of participants. Program operators are encouraged but not obligated to meet requests that are not related to a participant’s disability.

Program regulations encourage Program operators to meet and consider participants’ dietary preferences when planning and preparing meals and snacks; however, variations must be consistent with the meal pattern requirements outlined at 7 CFR 226.20. Fluid milk substitutes 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. Requiring fluid milk substitutes to be nutritionally equivalent to cow’s milk ensures participants receive vital nutrients needed for growth and development. The nutrient standards for non-dairy beverages are outlined in the CACFP regulations at 7 CFR 226.20(g)(3)(ii) and are detailed in the table below. The nutrition requirements for fluid milk substitutes apply only in non-disability situations.

Nutrition Requirements for Fluid Milk Substitutes

CACFP State agencies have the discretion to identify appropriate substitutions that meet these requirements. FNS encourages CACFP State agencies to coordinate with the State agency operating the National School Lunch Program to ensure that the identified locally available substitutions are consistent among the Child Nutrition Programs.

Parents, guardians, adult participants, or a person on behalf of the adult participant, must provide a written request for the fluid milk substitute that is nutritionally equivalent to milk. A medical statement is not required. For example, if a child follows a vegan diet, the parent or guardian must submit a written request to the child’s center or day care home asking that a fluid milk substitute be served in place of cow’s milk. An institution or facility choosing to offer fluid milk substitutes for a non-disability reason is not required to offer the specific fluid milk substitute(s) requested but may offer an allowable fluid milk substitute(s) of its choice. Additionally, the parent, guardian, adult participant, or a person on behalf of an adult participant may choose to supply one meal component, including a fluid milk substitute that is nutritionally equivalent to cow’s milk; the institution or facility must provide all remaining meal components in order for the meal or snack to be reimbursable.

Fluid Milk Modifications for Disability Reasons

Program operators are required to provide fluid milk substitutions requested due to a disability. To receive reimbursement when a modified meal related to a disability does not meet the meal pattern requirements, a written medical statement signed by a State licensed healthcare professional or registered dietitian must be on file. Therefore, a medical statement is required if the milk substitute requested does not meet the nutritional standards of cow’s milk as described above. The medical statement must provide information about the participant’s dietary restrictions, such as foods or beverages to be omitted and recommended alternatives, if appropriate. Regulations at 7 CFR 226.20(g)(1)(iv) allow a parent, guardian, adult participant, or a person on behalf of an adult participant to supply one or more components of the reimbursable meal for a participant with a disability, as long as the Program operator provides at least one required meal component. However, Program operators may not require a parent, guardian, adult participant, or a person on behalf of an adult participant to provide any of the required components of a meal.

Unavailability of Fluid Milk

Temporary Unavailability

State agencies may allow institutions and facilities experiencing milk supply shortages to serve meals during an emergency period with an alternate form of fluid milk or without fluid milk as detailed at 7 CFR 226.20(e)(1). Institutions and facilities are expected to meet the fluid milk requirements to the greatest extent possible. Supply chain disruptions, including disruptions that limit milk variety or affect serving size, would be considered a temporary emergency condition for purposes of this flexibility. Because this is an existing regulatory flexibility, a waiver is not required for State agencies to exercise this authority. Additionally, State agencies are reminded that monitoring reviews should accurately account for any waivers or flexibilities that have been provided to Program operators.

Continuing Unavailability

When an institution or facility is unable to obtain a supply of fluid milk on a continuing basis, the State agency may approve service of meals without milk, as long as an equivalent amount of canned dry, whole dry, or fat-free dry milk is used in the preparation of the components of the meal (7 CFR 226.20(e)(2)). These flexibilities are not allowable for crediting fluid milk under normal circumstances. Institutions and facilities should work with their State agency when requesting use of this flexibility.

Compliance

In order to ensure compliance with the fluid milk requirements outlined in 7 CFR 226.20(a)(1) and this memorandum, institutions and facilities must document the type of milk served on their menus. Documentation includes listing the fat content (e.g., whole, reduced-fat (2%), low-fat (1%), and fat-free (skim)) and whether the milk is flavored or unflavored. It is the responsibility of the State agency or sponsor, as applicable, to further ensure that the correct type of milk is being served when conducting reviews.

Questions and Answers

Flavored Milk

  1. May a center or day care home add chocolate or strawberry syrup to unflavored milk and serve it to children 1 through 5 years old?

No. Adding syrup, or other forms of flavoring, to unflavored milk adds sugar to the unflavored milk and turns the beverage into flavored milk. Flavored milk is not allowed as part of a CACFP reimbursable meal for children 1 through 5 years old.

Fluid Milk Substitutes

  1. Is an institution or facility required to provide a fluid milk substitute for a participant if it is not related to a disability?

No. For non-disability reasons, institutions or facilities may decide whether or not to provide a fluid milk substitute. However, FNS strongly encourages institutions and facilities to provide options to meet participants’ dietary preferences.

  1. Must fluid milk substitutes served to children 1 through 5 be unflavored?

Yes. Fluid milk and fluid milk substitutes that are served to children 1 through 5 years of age must be unflavored.

  1. Must fluid milk substitutes meet the fat content requirements of fluid milk?

No. Fluid milk substitutes are not required to be low-fat or fat-free when served to children 2 years old and older and adults. In order for a non-dairy beverage to meet the nutrient requirements for fluid milk substitutes, they must be fortified, and some fat is often needed to help mask the flavor of the nutrient packet added. To ensure that institutions and facilities have access to a variety of fluid milk substitutes that are nutritionally equivalent to cow’s milk, and thus special dietary needs of participants are more likely to be met, there is not a fat standard for fluid milk substitutes.

  1. Will institutions or facilities receive additional meal reimbursements if they provide a fluid milk substitute?

No. Modifications and variations of meals, including meals with fluid milk substitutes, regardless of reason, are reimbursed at the same rate as regular meals. As detailed at 7 CFR 226.20(g)(1)(iii) and 7 CFR 226.20(g)(2)(ii), institutions or facilities cannot require a parent or guardian to pay the difference between the fluid milk and the fluid milk substitute if the fluid milk substitute costs more than the fluid milk.

  1. If a parent provides a creditable fluid milk substitute, may the institution or facility serve it and still receive reimbursement?

Yes. If a parent provides a fluid milk substitute that meets the nutritional standards outlined in 7 CFR 226.20(g)(3)(ii), the institution or facility may serve the fluid milk substitute and claim reimbursement for the meal. When a parent or guardian chooses to provide one meal component such as a fluid milk substitute for a non-disability reason, the institution or facility must supply all other required meal components in order for the meal to be reimbursable.

  1. May a parent of a child aged two years or older request for their child (or an adult participant request for themselves) to be served whole or reduced-fat (2%) milk?

No. Milk served to children two years old and older and adult participants must be low fat or fat-free (skim) milk in order to be reimbursable (7 CFR 226.20(a)(1)). Any request for higher fat milk must be made through a medical statement, related to a disability, and signed by a State licensed healthcare professional or registered dietitian in order to be reimbursable.

  1. If a parent agrees to provide the fluid milk substitute but brings in one that does not meet the USDA’s nutritional standards, may the institution or facility serve it and still receive reimbursement?

No. Institutions and facilities should inform parents, guardians, and adult participants about the types of creditable fluid milk substitutes. If a fluid milk substitute is served that does not meet the nutritional standards outlined in 7 CFR 226.20(g)(3)(ii), then the meal is not reimbursable.

Compliance

  1. When submitting menus for review, do institutions and facilities need to document the type of milk that they serve?

Yes. Institutions and facilities must document the type of milk served on their menus. The menu must indicate the fat content of the milk and whether it is flavored. In addition, it is the responsibility of the State agency or sponsor, as applicable, to further ensure that the correct type of milk is being served when conducting reviews.

  1. If one-year-old and two-year-old children sit together for the same meal, must they be served different types of milk?

Yes. Children two-years-old and older must be served unflavored low-fat (1%) milk or unflavored fat-free (skim) milk and children one year of age must be served unflavored whole milk. The fluid milk requirements are based on age to ensure that children are receiving the nutrients they need for growth and development. Institutions and facilities must ensure that children of various ages seated together receive the appropriate type of milk.

  1. May an institution or facility serve unflavored reduced-fat (2%) milk or whole milk to children two-years-old and older when there is a milk supply shortage preventing the institution or facility from obtaining unflavored low-fat (1%) milk or fat-free (skim) milk and claim that meal for reimbursement?

Yes. Program operators are expected to meet the fluid milk requirements to the greatest extent possible; however, State agencies may allow institutions or facilities experiencing milk supply shortages to serve reimbursable meals during an emergency period with an alternate form of fluid milk or without fluid milk.

 

Read the full Nutrition Requirements for Fluid Milk and Fluid Milk Substitutions  in the Child and Adult Care Food Program, Questions and Answers  (CACFP 01-2025).