FD: 3 Guideline for Choosing Food Packages (New)

Effective Date: 10/09 Downloads: PDF Version    Revised Date: 11/16
   

Policy

Food packages will be prescribed by a competent professional authority (CPA). Each food package will be individually tailored and prescribed to the participant. Participants will only receive those foods allowed for their category, age, special dietary needs and food preparation/storage needs.

Procedure

Food Packages

There are seven food packages available under the WIC program which may be provided to participants. Each food package shown contains the maximum amounts and types of foods which can be prescribed for a single participant, as participants are to receive the maximum amount except when warranted by special circumstances. Every food package must be individually tailored to the participant to meet that participant’s specific nutritional needs based on the nutritional assessment performed by the CPA.

FD-3.1

 

Definitions

Pregnant – A woman that is pregnant with a singleton pregnancy.

Mostly Breastfeeding – A woman who breastfeeds or expresses milk at least one time in 24 hours, and receives supplemental formula from the WIC program.

  • This package is issued to breastfeeding participants whose infants are mostly breastfeeding and receiving WIC formula in amounts that do not exceed the maximum allowance for that infant category.

Non-Breastfeeding – A woman who is not breastfeeding her infant or a postpartum participant whose participating infant receives more than the maximum amount of WIC formula allowed for a mostly breastfed infant.

Exclusively Breastfeeding – A woman breastfeeding her infant or is expressing milk, who receives no supplemental formula from the WIC program.

  • This package is also issued to women pregnant with multiple fetuses, as well as women who are mostly breastfeeding multiple infants. Women that are fully breastfeeding multiples will receive 1.5 times the supplemental foods provided in this package.

 

FD-3.2

FD-3.3

     

  • Ready to Feed (RTF) WIC formulas may be issued when a CPA determines and documents the following:
    • The participant’s household has unsanitary or restricted water supply.
    • The participant’s household has poor or no refrigeration.
    • The participant or caregiver has a difficult time correctly diluting concentrated or powder forms of formula.
    • The WIC infant formula is only available in the ready to feed form.
    • The powdered or concentrated formulation contains a diagnosed allergen not in the RTF formulation.
  • Breastfed Infants: Infant formula will not be issued to fully breastfeeding infants in the first month after birth to support the successful establishment of breastfeeding.

A breastfeeding assessment must be completed whenever a breastfeeding mom requests formula, or requests an increase in the amount of formula she already receives from WIC. Refer to the “Breastfeeding Assessment Guidelines” (Appendix FD: J).

The maximum amount of formula issued to supplement infants being mostly breastfed is outlined above by age.

Formula supplementation is known to decrease the mother’s milk production; staff will discuss this with the participant prior to issuance of formula. Clinic staff will issue only the amount of formula that is indicated per federal regulation.

  • Infant Food: Participating infants that are fully formula fed or are mostly breastfed will receive 128 oz of jarred infant fruits and vegetables between the ages of 6 and 11 months of age.

Participating infants that are exclusively breastfed will receive 256 oz of jarred infant fruits and vegetables, as well as 31 – 2.5 oz jars of infant meats. 

 

FD-3.4 

FD-3.5aFD-3.5b

  • WIC regulations state that the maximum monthly allowance of formula authorized for women and children with qualifying conditions (refer to Medical Nutrition Products for exceptions) is 455 fluid ounces of liquid concentrate WIC Formula or eligible WIC medical food.
    • Medical food breakdowns for powdered and RTF formula /medical food issuance may be found in the Food Delivery Appendix FD: G.
  • WIC regulations prohibit exceeding the maximum amount of formula for infants. If an infant has increased needs or a physician is recommending additional formula, the CPA will refer the participant to Early Intervention Services and Medicaid.
  • Dietitian/Nutritionist’s may not approve the issuance of additional formula on an individual basis. Participants are to receive no more than the maximum allowable amounts of supplemental foods.

Exception:

Infants over 6 months of age whose medical condition prevents them from consuming supplemental infant foods, such as infant cereal, jarred fruits, vegetables, or meat may receive exempt infant formula or WIC eligible nutritionals at the same maximum monthly allowance as infants age 4-5 months of age in lieu of complementary infant foods.

  • The State of Nevada WIC Program has elected to use the rounding up option according to the specific rounding methodology per section 246.10(h)(l) of the Federal Rule to determine the maximum allowance of formula.
    • The maximum amount is determined by using the maximum monthly allowance of reconstituted fluid ounces of liquid concentrate to allow for the maximum for the full nutritional benefit.  The full nutritional benefit is determined over the timeframe (number of months) that the participant will receive the food package.
    • In any given month of the timeframe, the monthly issuance of reconstituted fluid ounces of infant formula may exceed the maximum monthly allowance or fall below the full nutritional benefit however; the cumulative average over the timeframe may not fall below the full nutritional benefit.

Refer to the Formula Maximum Quantity Table to determine the amount of formula to issue to reach the full nutritional benefit. The State Agency has used the required methodology to create the Formula Maximum Quantity Table.  If you cannot find your formula, please contact the State Office for assistance.

  • A food package containing formula for a woman or child >12 months old can only be issued to the participant with medical documentation.

 

  • Whole milk can only be issued to children 2-5 years old and women who have a documented qualifying medical condition that requires use of a WIC formula (infant formula, exempt infant formula or WIC-eligible nutritional) because use of conventional WIC-issued foods is precluded, restricted, or inadequate to address their special nutritional needs.
    • Whole milk, or any other WIC supplemental food added to the food prescription, in addition to the WIC formula, requires medical documentation indicating the whole milk, or deferring this decision to the WIC RD/Nutritionist. The participant can turn down the offer of the formula and choose whole milk exclusively – but the quantity will not be able to exceed Package III defined maximums).
  • WIC regulations allow 2% or whole milk as a substitute for low-fat or fat-free milk for children >24 months of age and women with medical documentation for qualifying conditions in Food Package III.

FD-3.6a FD-3.6b 

  • Reduced Fat (2%) Milk for 12 – 24 month old child can only be prescribed at this time by WIC RD /Nutritionist.
    • However, if a 12 – 24 month old participant presents a medical documentation form indicating either low-fat (1%) or fat-free for overweight, obesity or another valid medical reason (i.e. GERD), then issuance of 1% or fat-free milk can be authorized.

FD-3.7a FD-3.7b

  • Reduced Fat (2%) Milk for Women and 2 – 5 year old child can be prescribed at this time by WIC RD /Nutritionist for non-medically fragile high risk codes.
  • Infant/Child – 103
  • Women – 101, 131, 132, 133 

Fd-3.8aFD-3.8b 

  • Reduced Fat (2%) Milk for Women and 2 – 5 year old child can be prescribed at this time by WIC RD /Nutritionist for non-medically fragile high risk codes.
  • Infant/Child – 103
  • Women – 101, 131, 132, 133

 

FD3.4

Women Fully Breastfeeding Multiples

Federal regulation states that women that are fully breastfeeding multiples will receive Food Package VII in amounts that equal 1.5 times the maximum allowance of authorized supplemental foods. Realizing that some foods do not lend themselves easily to the provision of “halves,” for example bread, peanut butter, dry beans, and cheese; the State Agency has decided to issue this food package over a 2 month timeframe.

This means that in month one the participant would receive double the amounts of the maximum allowable foods in Food Package VII, while in month two the participant would receive only the maximum allowable amounts in Food Package VII. This rotation would continue throughout the participant’s eligible timeframe as a fully breastfeeding woman of multiples.

 FD-3.11

Women Mostly Breastfeeding Multiples and Women Pregnant with Multiple Fetuses 

Federal Regulation states that women who are mostly breastfeeding multiple infants or women who are pregnant with two or more fetuses will receive the maximum allowance of authorized foods in Food Package VII.

 Explanations of Food Substitutions

Milk:

  • Fresh Fluid MilkFederal regulations permit the substitution of dry and evaporated forms of milk for fresh fluid milks in the WIC food packages.
  • Dry Milk- is substituted at an equal reconstituted rate to fluid milk.
  • Evaporated Milk- is substituted at the rate of 16 fluid ounces of evaporated milk (as it comes in the can before water is added) for 32 fluid ounces of fresh fluid milk.
  • When a combination of different forms of milk is issued to a participant, then the full maximum monthly allowance for fluid milk must be provided.

***Federal regulation requires that children 12-23 months of age receive whole fat milk, while children over 24 months of age and women are to be issued only low-fat or fat-free fat milks.

However,

  • Fat-reduced milks to be issued to 1-yr-old children for whom overweight or obesity is a concern, based upon nutritionist determination through an individual nutritional assessment and consultation with the child’s health care provider if necessary.
  • 2% milk may be issued to participants under certain conditions during pregnancy and children per nutrition assessment
  • 2% milk may be issued to participants under 24 months per nutrition assessment

**Cheese:

A participant may select up to 1 pound of cheese as a substitution for milk, except a Fully Breastfeeding woman, who may substitute up to 6 quarts of milk for 2 pounds of cheese.

 For the purposes of cost containment and availability in cases where 1 pound of cheese is substituted for 3 quarts of milk the dangling quart of milk will be issued over a 2 month timeframe.  This means the participant will receive a ½ gallon of milk (equivalent to 2 quarts) OR 12 oz. can evaporated milk the first month while in month two the participant would receive 0 quarts of milk. This rotation would continue throughout the participant’s eligible timeframe when they choose to substitute 1 pound of cheese for 3 quarts of milk.

Soy Beverage and Tofu:

Soy Beverage and Tofu can be substituted for milk within Food Packages IV, V, VI, and VII. Please reference the specific food package for substitution rates, as they are dependent on participant category.

Food Package Tailoring

A participant’s food package must be tailored according to his/her individual nutritional needs. This entails making changes to food types (e.g. milk vs. cheese), to food forms (e.g. fluid milk vs. evaporated milk), and to quantities of WIC foods. Food package tailoring is to be done solely for the following reasons and on an individual basis, to better meet the needs of the participant. The automatic tailoring of a whole category’s food package is not allowed (i.e.: mostly breastfeeding woman).

Examples of Individual Tailoring of Food Packages 

  • To accommodate participant preferences (e.g. participant is given peanut butter instead of beans or quantities are reduced, participant does not eat eggs).
  • To accommodate household conditions (e.g. a homeless or migrant person).
  • To accommodate a participants food intolerance or restrictions (e.g. lactose reduced milk, more cheese) 

Maximum Monthly Allowances 

  • The full maximum monthly allowances of all supplemental foods in all food packages must be made available to participants if medically or nutritionally necessary.
  • Maximum monthly allowances may only be decreased if: 
    • Medically or nutritionally warranted. For example, to eliminate a food due to allergy.
      • “I can’t eat wheat.” 
    • A participant refuses or cannot use the maximum monthly allowance
      • “I can’t stand eggs.”
      • “I have so much peanut butter” 
  • The quantities necessary to supplement another program’s contribution to fill a medical prescription would be less than the maximum monthly allowances.

 

Increased Nutritional Needs 

Participants that have appropriate medical documentation for a qualifying condition may receive Food Package III, where supplemental foods as well as medical foods are offered.

 

Breastfeeding Status and Food Package Tailoring Documentation Standards:

Tailoring of the food package needs to be clearly, consistently documented on in the participant Health Questionnaire or Nutrition Education documentation form.

Example:

“Declined eggs in food package” on Health Questionnaire

Initial assignment of and updates in breastfeeding status will be clearly documented in the Participant Health Questionnaire or associated contact on the Nutrition Education documentation form. (Refer to Appendix FD: E: WIC Food package Guide and FD: K – Breastfeeding Assessment Guidelines)

Example 1:

For a postpartum women fully breastfeeding her infant. In MIS: 1) documented “Full BF, no infant formula” clearly on the Infant’s Health Questionnaire, and 2) Check Fully Breastfed status in MIS

Example 2:

A post-partum women reports she is no longer fully breastfeeding, but still breastfeeds or expresses milk at least once in 24 hours. She is now requesting a special formula or food package.

  1. A breastfeeding assessment is performed to assess need for supplementation and,
  2. quantity of formula need (Appendix FD_E and FD: K – Breastfeeding Assessment Guidelines),
  3. change infant’s BF status in MIS to reflect updated BF rate,
  4. document change on Nutrition Education Form: “now PBF, consuming 10 oz. reconstituted formula/day. Issued 3 cans Similac Advance/month”
  5. in mothers MIS record, document change in BF status, adjustment in Food package or WIC eligibility status when applicable.

 

Food package tailoring documentation will be assessed during LA Program Reviews, and should be clear and consistent between staff throughout the LA.

 

Issuance of Food Packages for Homeless & Those Lacking Adequate Facilities

To meet the needs of participants who are homeless or lack adequate facilities for proper preparation and storage of WIC foods, CPA’s are instructed to (1) issue a specially altered food package and (2) provide food storage and sanitation information.

If a participant indicates that they are homeless or lack adequate facilities, question to determine the level of storage, cooking, and sanitary conditions. Use the following chart to make necessary changes to the standard food package:

 

If Then
Infant Women/Child
No Refrigeration
  • Issue powdered formula
  • Issue evaporated, powdered, or UHT milk
  • Issue convenient pack  juice
  • Substitute 2nd jar of peanut butter for 2 doz eggs
  • 64 oz. canned beans for one dozen eggs
  • 15oz of fish for a dozen eggs
Ice Chest Only
  • If room in the ice chest, issue concentrated or RTF, otherwise issue powdered formula
  • Issue only amounts of fluid milk & cheese that can be stored, or issue evaporated, powdered or UHT milk.
  • Issue large containers of juice if room in ice chest, otherwise issue convenient pack juice
No stove or cooking facilities
  • Issue RTF formula
  • Recommend cold cereals only
  • Do not issue beans
  • Do not issue eggs
Microwave oven only
  • Instruct the participant to heat water only in the microwave, then cool
  • Recommend canned beans
Unsafe or lack of water
  • Issue RTF infant formula
  • Issue fluid milk only
  • Issue canned juices(no frozen)
  • Issue peanut butter(no beans)

 

When issuing food benefits to homeless participants discuss spreading out the redemption of the food benefits over the 4-week period, and offer food storage and sanitation information when applicable.

 

Food Safety Guidelines

Counsel the participant/parent/guardian on the following food safety guidelines;

  • Refrigerate fluid milk, cheese and eggs as soon as possible after purchasing.
  • Do not eat cracked or broken eggs.
  • Cover and refrigerate unused portions of juices, concentrated and RTF formulas immediately. Use formulas within 2 days.
  • When mixing powdered milk or formulas, make only amount to be used.