Infant Feeding Plan Form

*Application optimized for desktop use*

A written plan shall be maintained on file and available for the caregiver of any child less than 18 months of age.

Child's Information

NOTE: Breast milk shall be gently mixed but not be shaken. Refrigerated breast milk shall be used within 24 hours. Formula or breast milk that is served, but not completely consumed or refrigerated, shall be discarded. No milk, formula, or breast milk shall be warmed in a microwave oven.

Formula

Is your child fed formula?
Will formula be prepared (mixed) at home?
Will formula be prepared by the caregiver?

Breast Feeding/Breastmilk

Is your child breast fed?
I will nurse my child at the center at these times:
I will provide breast milk

Feedings

Does your child take a bottle? (Note: Bottles are required to be labeled with child’s name and the current date)
Are there any special instructions for bottle feeding your child?
Is your child using a sippy cup? (Note: Sippy cups must be labeled with the child’s name)
Does your child have any problems with feeding, such as choking or spitting up?
Can the child feed his or herself?
Is the bottle warmed?
Does your child hold their bottle?
Are there any special instructions concerning feeding your child?

Foods & Feeding Schedule

Liquids

(formula, breastmilk,
100% fruit juice in a cup)

Breast Feeding
Bottle Feeding
Cup Feeding

Semisolid Foods

(infant cereal, strained fruits
and/or vegetables)

Breast Feeding
Bottle Feeding
Cup Feeding

Modified Table Foods

(mashed, soft, diced fruit and /or
vegetables, strained meat or
poultry, pieces of soft bread)

Spoon Feeding

Finger Foods

(small pieces of soft/cooked table food, chopped food)

Spoon Feeding

Other

Does your child take a pacifier?

Note: Pacifiers with straps or other types of attachment devices are not permitted. Pacifiers must be removed when the child is crawling or walking

PAGE 1/2