Meal Modifications in the CACFP

Requests for Fluid Milk Substitutes

CACFP operators may offer a nondairy beverage (fluid milk substitute) to meet the fluid milk component for participants with a dietary need/preference that is not due to a disability and for participants with a disability that restricts their diet (without requiring the participant with a disability to submit a medical statement) if the two requirements listed below are met.

1. The nondairy beverage must meet the minimum nutrient requirements for fluid milk substitutes (refer to Table 1 below) for the CACFP operator to claim the meal for reimbursement. If a nondairy beverage does not meet the minimum nutrient requirements for fluid milk substitutes:
 
• Participants without a disability: The CACFP operator may not serve the nondairy beverage as part of reimbursable meals.
 
• Participants with a disability that restricts their diet: If the participant requires a fluid milk substitute for disability-related reasons, and the substitution does not meet minimum nutrient requirements for fluid milk substitutes, a medical statement is required to serve the nondairy beverage in order for the meal to be reimbursed. Please see the Modifications for Participants with a Disability That Restricts Their Diet section for detailed information on medical statements.
 
2. A child’s parent/guardian, an adult participant, a person on behalf of an adult participant, a state-licensed healthcare professional, or a registered dietitian (RD) must provide a written request for a fluid milk substitute, identifying the reason for the substitute.
   
   The written request may be incorporated into an existing form (e.g., enrollment record), or on a specific form (e.g., CACFP 49, Request for a Creditable Fluid Milk Substitute, accessible in the Download Forms section of the Child Nutrition Information and Payment System [CNIPS] website).

Notes:

• Expenses incurred when providing fluid milk substitutes that exceed the reimbursement rate are paid by the CACFP operator. The cost of fluid milk substitutes may be paid from the nonprofit food service account.
 
• All beverages served to children of any age in licensed child care centers and homes must be unflavored (no added sweeteners) to comply with the California Healthy Beverages in Child Care Act, as outlined in California Health and Safety Code, Section 1596.808.
 
• Fluid milk substitutes are not required to be low-fat or fat-free. For a nondairy 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 fortification/nutrient packet added.
 
• Lactose-free and lactose-reduced milks are creditable fluid milk options in the CACFP per 7 CFR 226.20(a)(1) and may be served to participants who are lactose-intolerant without needing to meet the two requirements listed above, if the lactose-free or lactose-reduced milk meets the fat content and flavor specifications for milk for each age group.

Table 1: Minimum Nutrient Requirements for Fluid Milk Substitutes per 1 cup (8 oz)

Nutrient	Amount
Calcium	276 mg
Protein	8 g
Vitamin A	150 mcg retinol activity equivalents (RAE)
Vitamin D	2.5mcg
Magnesium	24 mg
Phosphorus	222 mg
Potassium	349 mg
Riboflavin	0.44 mg
Vitamin B-12	1.1 mcg

Modifications for Participants without a Disability (Other than Fluid Milk Substitutes)

A parent, guardian, adult participant, or a person on behalf of an adult participant may request that CACFP operators make meal modifications (other than fluid milk substitutes) for participants with dietary preferences that are not related to a disability. For example, a parent/guardian or adult participant may request that another meat/meat alternate food (e.g., chicken) is substituted for pork for religious reasons or that a meat alternate product (e.g., beans) is substituted for meat because they follow a vegetarian diet.

Modifications are allowed to the planned meal if the substituted foods/beverages are creditable components in the CACFP. It is at the CACFP operator’s discretion to provide meal modifications if the request for the modification is not related to a disability; however, CACFP operators are strongly encouraged to accommodate the dietary needs of participants without a disability.

Expenses incurred when making meal modifications that exceed the reimbursement rate are paid by the CACFP operator. The cost of meal modifications may be paid from the nonprofit food service account.

Parent/Guardian-Provided Components

For the CACFP Operator to claim reimbursement of a meal for a participant without a disability, the parent or household member may only provide one creditable component per meal; the CACFP operator must provide all other components.

Documenting Requests for Modifications

For meal modifications (that meet the meal pattern requirements) other than nondairy beverages (addressed in the Requests for Fluid Milk Substitutes section), CACFP operators must document the modification on either an existing form (e.g., enrollment record), or on a specific form (e.g., CACFP 12, Parent/Guardian’s Form for Declining a Provider’s Infant Formula or Food or CACFP 84, Parent/Guardian’s Form for Declining a Provider’s Food for Older Children [and adults] per the California Department of Social Services (CDSS) Documentation Requirements for the CACFP Meal Patterns Bulletin. Both forms CACFP 12 and 84 are accessible in the Download Forms section of the CNIPS website.

Modifications for Participants with a Disability That Restricts Their Diet

CACFP operators must make meal modifications, at no extra charge, for participants with a disability that restricts their diet. According to the Americans with Disabilities Act, Section 504 of the Rehabilitation Act, and the applicable USDA regulations at 7 CFR Part 15b, a person with a disability is any person who has a physical or mental impairment which substantially limits one or more ‘major life activities,’ which includes, but is not limited to eating.

Most physical and mental impairments will constitute a disability and the focus for CACFP operators should be on ensuring equal opportunity to participate in the Program.

If the participant has a disability that affects their behavior, preferences, and/or sensitivity to food, beverages, or the meal service environment, CACFP operators must provide a reasonable modification for the participant. For example, some children with autism have sensory sensitivities and prefer food of a certain texture or color. They may require the same foods every day and need to maintain a regular routine.

CACFP operators must review each participant’s situation and meal modification requests on a case-by-case basis and should communicate with parents/guardians or the adult participant to determine how best to accommodate the participant’s needs.

Note: CACFP operators are not required to make modifications that would result in a fundamental alteration in the nature of the Program. For example, providing an expensive medical infant formula to accommodate an infant’s disability may be so financially burdensome for a small CACFP agency with one staff member that it would make operating the Program unfeasible and would fundamentally alter the nature of the Program. In this example, the CACFP operator would not be required to provide the requested medical infant formula.

CACFP operators facing a very expensive request should first engage in dialogue with the participant and/or the participant’s parents or guardian. CACFP operators should send questions by email to the CDSS CACFP Nutrition Team at CACFPMealPatterns@dss.ca.gov if concerned that a request for meal modifications may fundamentally alter the nature of the program.

Procedures for Requesting Meal Modifications

CACFP operators must provide households and participants with:

• Notice of the procedure for requesting meal modifications for disabilities, which should include providing a written final decision on each request.
 
• The process for procedural safeguards related to meal modifications for disabilities, which should ensure CACFP operator staff understand the procedures for handling requests for meal modification.

Additional information on procedural safeguards is available on page 9 of the USDA Policy Memo, CACFP 14-2017, Modifications to Accommodate Disabilities in the CACFP and SFSP.

Parent/Guardian-Provided Components

For the CACFP operator to claim reimbursement of a meal for a participant with a disability, the parent/guardian or adult participant may provide all but one creditable component per meal; the CACFP operator must provide a minimum of one component. Program operators may not require a parent, guardian, adult participant or person on behalf of an adult participant to provide any of the required components of a meal.

An exception to the requirement for the CACFP operator to provide a minimum of one component to claim reimbursement of a meal for a participant with a disability is if the participant only consumes one component. In this situation, the CACFP operator can claim meals without providing a minimum of one component. For example, if a participant can only consume gastric tube (G tube) feedings and the household provides and administers the G tube formula, the CACFP operator can claim meals for reimbursement because there are costs incurred by the CACFP operator to support the administration of the G tube feedings.

Modifications That Meet Meal Pattern Requirements

In many cases (including Requests for Fluid Milk Substitutes), dietary modifications to accommodate a disability can be managed within the meal pattern requirements. For example, there are many gluten-free foods (e.g., brown rice, quinoa, and corn tortillas) that meet the requirements for a creditable grain in the CACFP that may be served to participants with a gluten intolerance or allergy.

If the disability involves a request for foods or beverages that meet the meal pattern requirements (e.g., requests for gluten-free foods, pureed foods, or that another fruit be substituted when strawberries are on the menu due to an allergy), a medical statement signed by a state licensed healthcare professional or a registered dietitian (RD) is not required; however, CACFP operators must document the date they communicated with the parent/guardian or adult participant to determine a safe and appropriate menu modification and details about the modification per the CDSS Documentation Requirements for the CACFP Meal Patterns Bulletin. This can be done on a specific form developed by the CACFP operator to document the meal modifications made within the meal pattern or on an existing form (e.g., enrollment record). Such meals are reimbursable.

Modifications That Do Not Meet Meal Pattern Requirements

If the disability involves a request for foods or beverages that do not meet the meal pattern requirements, the CACFP operator must request and retain a signed written medical statement to claim those meals for reimbursement. Expenses incurred when making meal modifications that exceed the reimbursement rate are paid by the CACFP operator. The cost of meal modifications may be paid from the nonprofit food service account.

Medical Statements

CACFP operators may use Form ID CACFP 97, Medical Statement to Request Special Meals or Accommodations in the CACFP for Participants with a Disability, available in the Download Forms section of the CNIPS website, to obtain the level of documentation required to implement a sound nutrition plan for participants with dietary restrictions due to a disability. Medical statements are only required for CACFP operators to claim reimbursement for meals if the required meal modifications do not meet the meal pattern requirements. (Note: Although not required, program operators may choose to require a written medical statement for all disability meal modifications, including those that can be accommodated within the meal pattern requirements. Operators should consider the burden of requiring medical statements and must inform parents, guardians, and their children, if age appropriate, of the process for requesting meal modifications.)

Written medical statements must:

1. Provide sufficient information about the participant’s dietary restrictions, such as the following:
 
1. Briefly describe how the disability restricts the participant’s diet;
2. An explanation of how to accommodate the participant’s disability;
3. Identify foods to omit from a participant’s diet;
4. Recommend foods to substitute; and,
 
2. Be signed by a state-licensed healthcare professional¹ or an RD².

When operators believe the medical statement is unclear or lacks sufficient detail, they must obtain appropriate clarification.

The CDSS encourages operators to take a team approach to providing modifications for participants with disabilities. The team should work with the child’s parent or guardian, participating adult, or a person acting on behalf of the adult participant to review the request and develop a solution as quickly as possible. The team should be advised that medical information obtained must be kept confidential.

Notes:

• Medical statements may be signed electronically, by hand, or with a stamp.
 
• Signed medical statements may not be altered by CACFP operators or parents/guardians to document additional or clarifying information about a participant’s disability or meal modification(s).  Additional or clarifying information must be documented separately (e.g., written clarification stapled to the medical statement).

Requests for Specific Modifications

CACFP operators are generally not required to provide a specific modification requested in the medical statement (e.g., brand name), as long as they offer a modification that accommodates the participant’s disability safely and effectively. CACFP operators should communicate with parents/guardians to identify whether the specific modification (e.g., brand name) is the only effective accommodation, or whether it would be safe and appropriate to provide an alternate modification.

Accommodating Disabilities Without a Medical Statement

CACFP operators are encouraged to work with families and adult participants to obtain medical statements and any needed clarification regarding requests for meal modifications. CACFP operators should not delay meal modifications while waiting for the family to submit a medical statement or if the CACFP operator needs additional clarification from the parent, guardian, licensed healthcare professional, or RD about the meal modification required. CACFP operators can claim meals with dietary modifications that do not meet the meal pattern requirements without a signed medical statement if they:

• Maintain documentation of the initial conversation with the family where they first learned of the need for an accommodation and requested the family obtain a signed written medical statement from a state-licensed healthcare professional or an RD;
 
• Document all follow up with the family if the CACFP operator does not receive the requested medical statement as anticipated, including what will be done to accommodate the child until a medical statement is received; and,
 
• Diligently continue to follow up with the family until a medical statement is obtained or the request is rescinded.

Note: CACFP operators should maintain a method of recordkeeping (e.g., written, electronic) for follow-up communications with parents/guardians to clarify meal modifications listed in a medical statement to justify meal modifications that do not meet the meal pattern requirements to the CDSS during a CACFP administrative review.

For additional guidance on accommodating meal modifications for participants with disabilities, access the U.S. Department of Agriculture Policy Memo CACFP 14-2017, SFSP 10-2017: Modifications to Accommodate Disabilities in the CACFP and Summer Food Service Program.

Modifications for Jewish CACFP Institutions and Facilities

Per 7 CFR, Section 226.20(h), the USDA FNS may approve variations in the meal components on an experimental or continuing basis in any institution or facility where there is evidence that such variations are nutritionally sound and are necessary to meet ethnic, religious, economic, or physical needs.

FNS clarified this allowance in FNS Instruction 783-13, Rev.3, Variations in Meal Requirements for Religious Reasons: Jewish Schools, Institutions, and Sponsors, to meet the needs of Jewish CACFP institutions and facilities as follows:

 

• During the religious observance of Passover only, grains are not required to be enriched or whole grain-rich. Unenriched matzo may be substituted for enriched or WGR grain products. CACFP operators are not required to notify the CDSS in advance to use the grains flexibility during the religious observance of Passover.
 
• On an ongoing basis (not limited to the religious observance of Passover), if the meal contains meat or poultry and Offer Versus Serve meal service (only allowed during meals for at-risk programs and adult day care centers) is not an option, CACFP operators may use one of the four milk flexibilities listed below.
 
1. Serve an equal amount of nondairy beverages that is nutritionally equivalent to fluid milk.
 
2. Serve an equal amount of full-strength juice in place of fluid milk with lunch or supper.
 
3. Serve fluid milk at an appropriate time before or after the meal service period, in accordance with applicable Jewish Dietary Law.
 
4. Serve the snack’s juice component at breakfast, lunch, or supper, and serve the corresponding meal’s fluid milk component as part of the snack.

Jewish CACFP institutions are required to notify the CDSS in advance to use the milk flexibility option(s) and maintain documentation of which option was chosen. To notify the CDSS, email the CDSS CACFP Nutrition Team at CACFPMealPatterns@dss.ca.gov with Jewish Institution Meal Pattern Flexibility in the Subject line, and include the following information: (1) CNIPS ID(s) of the institution and (2) milk flexibility option being used.

For additional details on allowable flexibilities for Jewish institutions and facilities, access FNS Instruction 783-13, Rev.3.

Resources and References

USDA Policy Memos

• USDA Policy Memo, CACFP 14-2017, Modifications to Accommodate Disabilities in the CACFP and SFSP
• USDA Policy Memo, CACFP 01-2025, Nutrition Requirements for Fluid Milk and Fluid Milk Substitutions in the CACFP, Questions and Answers
• USDA Policy Memo, CACFP 07-2025, Requirement to Accept Medical Statements from Registered Dietitians for Schools and Child and Adult Care Institutions and Facilities
• 7 CFR, §226.20(g) and 226.20(h)
• Institution of Child Nutrition (ICN) Mealtime Menu (September 2024): Lactose Intolerance and Milk Allergies

Autism Resources

• Parent’s Guide to Feeding Behavior in Children with Autism
• Overcoming Feeding Difficulties in Children with Autism Spectrum Disorder
• The Feeding Doctor web page