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Prod ID Product RFO Description Qualifying Conditions Staff Guidance Manufacturer/ Packaging 167
Ensure (8 oz. RTF) 8.00 Increased Calorie Supplement: 31 cal/oz, lactose-free with prebiotic (scFOS) short- chain fructooligosaccharides; Nutritionally complete; 3 g fiber, 9 g protein, and 220 calories per 8 oz container.
Similar to Boost.
Allergens by Nature: Milk and Soy Women: Increased calorie needs with one or more of the following diagnoses: 1. Pregnancy with underweight BMI pre- pregnancy 2. Fetal growth restriction 3. Multi-fetal pregnancy 4. Underweight BMI during breastfeeding
Children: 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 2 years old to 5 years old and women. Abbott 8 containers/case vanilla chocolate coffee latte strawberry butter pecan banana nut 189 Ensure Plus (8 oz. RTF) 8.00 Increased Calorie Supplement: 45 cal/oz; Nutritionally complete, high calorie, lactose- free; with prebiotic short-chain fructooligosaccharides (scFOS); 3 g fiber/8 oz container. 16g protein and 350 calories per container
Similar to Boost Plus.
Allergens by Nature: Milk and Soy Increased calorie needs with one or more of the following diagnoses: 1. Pregnancy with underweight BMI pre- pregnancy 2. Fetal growth restriction 3. Multi-fetal pregnancy 4. Underweight BMI while breastfeeding Limitations: Can only issue to women. Abbott 24 containers/case vanilla chocolate strawberry butter pecan 225 (CI) Essential Amino Acid Mix (7 oz. Powder) 135.00 Modular: powdered mixture of essential amino acids, including cystine and histidine; nutritionally incomplete; does not contain carbohydrates or fat.
Recommended feeding concentration is 5% weight per volume (e.g. 5 g powder to 100 mL of water).
Allergens by Nature: N/A 1. Dietary management of urea cycle disorders 2. Disorders of protein metabolism 3. Conditions in which a nutritionally complete feed is not suitable, or a modular approach is required Limitations: Can only issue to children 12 months to 5 years old and women.
Requirements: Modular formulas must be approved by District Nutrition Director or State WIC Office Nutricia 6 cans/case 213 Extensive HA (14.1 oz. Powder) 96.00 Hydrolysate/Peptide: 20 cal/oz; hypoallergenic 100% extensively hydrolyzed whey protein; 49% of fat is MCT oil; contains the probiotic Bifidobacterium lactis and DHA/ARA.
Mixing Instructions: 1 scoop to 1 oz. water
Similar to Alimentum, generic hypoallergenic, Nutramigen, Pepticate, Pregestimil.
Allergens by Nature: N/A 1. Cow’s milk protein allergy and multiple food protein intolerance 2. Cow’s milk induced FPIES 3. Soy protein sensitivity 4. Fat malabsorption Limitations: Can only issue to infants and children through 23 months old. Nestle 6 cans/case