November 20, 2002
September 4, 2015
Clinical Nutrition Services
To establish procedures for ordering and supplying infant formula for inpatients and
1. The Nutrition Committee, appointed by the Medical Board, periodically reviews
the type and variety of infant formulas carried onsite for infants and children
treated as inpatients and outpatients. Formulas typically stocked include: cow
milk-based, soy, protein hydrolysate, free amino acid or elemental, preterm and
preterm discharge, as well as metabolic formulas (for patients with inborn errors
2. The Culinary Service Department orders, stores, and delivers ready-to-use, liquid
concentrate, and powdered infant formulas to the pediatric patient care
units. Quantity stocked is based on formulary with established par levels based
on typical usage. Issues are monitored to meet patient needs. Non-formulary
products will be ordered as needed following review by the Clinical Nutritionist
and Director of Clinical Nutrition Services. Non-formulary orders may take 3-5
working days to obtain.
3. Ready-to-feed formulas are preferred and used whenever possible. Formulas
that need to be mixed are prepared per established policy and procedures using
aseptic technique. Sterile water is used to reconstitute powdered infant
III. FORMS USED
Health Link Electronic Medical Record – Physician Orders
Health Link Diet Lists and CBORD Worksheets
Infant Formula Labels
Infant Formula Mixing Instruction
Infant Formula Formulary
1. Determination of Infant Formula Formulary
1. Infant formulas routinely carried at UWHC are determined by the Clinical
Nutrition Staff with input from the Nutrition Committee and other
appropriate medical and nursing staff. Categories and generic
specifications are developed and used by purchasing to obtain
competitive bids per Purchasing Policy and Procedures.
2. Types of Infant Formula
1. Human milk or iron fortified infant formula is recommended for the first
12 months of age.
2. A number of infant formulas are on the market. The major classes
include: cow milk-based, soy, protein hydrolysate, free amino acid or
elemental, preterm and preterm discharge formulas, and metabolic
formulas. The levels of nutrients required in infant formulas, based
largely on recommendations of the Committee on Nutrition of the
American Academy of Pediatrics, are dictated by the Infant Formula Act
of 1980 and regulated by the FDA.
3. Infant formulas are available in ready-to-feed, liquid concentrate, and
powdered forms. Ready-to-feed formula and the standard mixing
instructions for concentrate and powder provide 19 to 22 kcal per ounce.
4. If infant formula needs to be mixed greater than 19 to 22 kcal per ounce,
the Clinical Nutritionist will calculate the appropriate recipe and enter it
as a “Feeding Recipe” in Health Link in accordance with physician order
5. Sterile water is used to reconstitute powdered infant formulas.
3. Purchasing Infant Formulas
1. Culinary Services will order product established by the Infant
Formulary. Physical inventory is taken three times per week and orders
placed based on par stock and projected patient consumption/occupancy
rate. Clinical Nutritionists, Registered Dietitians and Nutrition
Technicians will notify Culinary Service when need increases or unique
specialty products are required.
2. Infant formula and sterile water is stocked in the Milk Lab on P8/AFCH. A
smaller par level is also stocked on each unit within AFCH.
3. Special order products will be obtained on a case-by-case basis by
Culinary Services. Availability depends on distributor and/or
manufacturer terms and conditions. (Allow 3-5 weekdays for receipt).
Families must supply 1 unopened can of formula for the nutrition
technicians to use in mixing until the special order arrives.
4. If a formula not normally in stock is needed by an inpatient on the
weekend, the clinical nutritionist on-call for the weekend will obtain the
formula according to established purchasing procedures. Product(s) may
be borrowed from Waisman Center, Meriter Hospital or St. Mary's
Hospital to meet immediate needs. Borrowed products will be purchased
and replaced with the next order/delivery schedule.
4. Preparation of Infant Formulas
1. Clinical Nutrition Service staff will mix infant formulas following food
safety requirements and procedures according to nutritional adequacy,
prescription, and recipe instructions.
2. Nursing will mix infant formula as needed for new admits and/or infant
feedings ordered after normal Milk Lab operation hours.
Pediatric Nutrition Care Manual, Academy of Nutrition and Dietetics
Infant Feedings: Guidelines for Preparation of Human Milk and Formula in Health Care
Facilities, Second Edition; Pediatric Nutrition Practice Group
Normal Food Intake for Infants and Children from Birth to Two Years
Calculation of Calorie Requirements of Pediatric Patients
Composition of Infant Formulas
4.2 Infant Formula Preparation, UWHC Clinical Nutrition Services Inpatient Nutrition
Policy and Procedure
2.6 Metabolic Formula Preparation for Patients with Inborn Errors of Metabolism,
UWHC Nursing Patient Care Policy & Procedure
Accreditation Manual for Hospitals, The Joint Commission
Senior Management Sponsor: Chief Nursing Officer and Senior VP Patient Care Services
Author: Clinical Nutrition Services
Review/Approval Committee(s): Clinical Nutrition Services, Food Service
Director, Culinary and Clinical Nutrition Services
Associate Chief Nursing Officer and VP Development, Nursing & Patient Care Services