Page 164

5

Prod ID Product RFO Description Qualifying Conditions Staff Guidance Manufacturer/ Packaging 160 (CI) Compleat Pediatric Standard 1.0 (8.45 oz. RTF) 8.45 Increased Calorie Supplement: 29.5 cal/oz; nutritionally complete, contains pea protein with soluble and insoluble fiber, plant- based, milk-free, lactose-free, gluten-free, non-GMO, and Kosher; no added artificial flavors, colors, or sweeteners; primarily used for tube feeding.

Allergens by Nature: N/A Weight/length or BMI <10% and/or downward crossing of 2 major percentiles along with one or more of the following diagnoses: 1. Faltering weight or inadequate weight gain 2. Failure to Thrive (FTT) or malnutrition 3. Increased calorie needs 4. Tube feeding* 5. Oral motor feeding issues/aversions* 6. Developmental delays (sensory & motor)* 7. Prematurity (<37 weeks)/LBW *Authorization is not dependent on growth meeting parameters outlined above when diagnosis is present. See Note on page 24 for additional information. Limitations: Can only issue to children 12 months to 5 years. Nestle 24 containers/case vanilla 223 (CI) Compleat Pediatric Standard 1.4 (8.45 oz. RTF) 8.45 Increased Calorie Supplement: 41 cal/oz, nutritionally complete, contains pea protein with soluble and insoluble fiber, plant-based, milk-free, lactose-free, gluten-free, non- GMO, and Kosher; no added artificial flavors, colors, or sweeteners, primarily used for tube feeding.

Allergens by Nature: N/A Weight/length or BMI <10% and/or downward crossing of 2 major percentiles along with one or more of the following diagnoses: 1. Faltering weight or inadequate weight gain 2. Failure to Thrive (FTT) or malnutrition 3. Increased calorie needs 4. Tube feeding* 5. Oral motor feeding issues/aversions* 6. Developmental delays (sensory & motor)* 7. Prematurity (<37 weeks)/LBW *Authorization is not dependent on growth meeting parameters outlined above when diagnosis is present. See Note on page 24 for additional information. Limitations: Can only issue to children 12 months to 5 years.

Nestle 24 containers/case vanilla 224 (CI) Complex Essential MSD (16 oz. Powder) 80.00 Special Medical Conditions - Metabolic: Isoleucine, leucine, and valine-free (BCAA free), nutritionally incomplete; 380 kcal, 3.9 g fiber, and 25 g protein equivalent per 100 g powder; with DHA and EPA.

Add 40 g (approx. 1/4 cup, level and unpacked) to approx. 7 fl oz (210 mL) of cold water.

Allergens by Nature: Soy Maple syrup urine disease (MSUD) Limitations: Can only issue to children 12 months to 5 years and women.

Requirements: Metabolic formulas must be approved by District Nutrition Director or State WIC Office Nutricia 6 cans/case vanilla 63 (CI) Cyclinex- 1 (14.1 oz. Powder) 102.00 Special Medical Conditions - Metabolic: Non-essential amino acid free with added L- carnitine and taurine; vitamins and mineral content to compensate for nutrient losses due to nitrogen-scavenger medications and a low protein diet; nutritionally incomplete; not intended as a sole source of nutrition. 1 Tbsp = 8 g

RFO is calculated based on mixing to 20cal/oz

Allergens by Nature: Soy 1. HHH Syndrome (ornithine translocase deficiency- hyperornithinemia, hyperammonemia, homocitrullinemia) 2. Defects in urea cycle enzyme 3. Gyrate atrophy of the choroid and retina Limitations: Can only issue to infants and children.

Requirements: Metabolic formulas must be approved by District Nutrition Director or State WIC Office Abbott 6 cans/case unflavored