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Prod ID Product RFO Description Qualifying Conditions Staff Guidance Manufacturer/ Packaging 201 (CI) Neocate Syneo Infant (14.1 oz. Powder) 94.00 Elemental/Amino Acid: 20 cal/oz, lactose, sucrose, and soy-free; hypoallergenic; 100% free amino acids; 33% of fat is MCT oil; contains a blend of prebiotics and probiotics.
Mixing Instructions: Add 1 scoop of powder to 1 oz water.
Similar to Alfamino, Elecare, Neocate DHA/ARA, and Puramino 1. Cow’s milk protein allergy (CMPA) 2. Multiple food allergies 3. Eosinophilic GI disorders 4. Malabsorptive conditions 5. Short bowel syndrome (SBS) 6. Food protein-induced enterocolitis syndrome (FPIES) Limitations: Can only issue to infants and children through 23 months old.
Recommendations: A protein hydrolysate (Alimentum, generic hypoallergenic, Extensive HA, Nutramigen, Pepticate, or Pregestimil) is recommended before issuing unless medically contraindicated. Nutricia 4 cans/case 141 (PWD)
87 (CON)
88 (RTU) Nutramigen with Probiotic LGG (12.6 oz. Powder)
Nutramigen (13 oz. concentrate)
Nutramigen (32 oz. RTU) 87.00
26.00
32.00 Hydrolyzed/Peptide: 20 cal/oz, hypoallergenic casein hydrolysate, lactose, sucrose, and galactose-free; does not contain MCT oil. Powder contains probiotic Lactobacillus rhamnosus GG (LGG).
For powder, add 1 PACKED level scoop (9 g powder) with 2 fl oz. water
Similar to Alimentum, Extensive HA, generic hypoallergenic, Pepticate, Pregestimil.
Allergens by Nature: Coconut and Soy 1. Cow’s milk protein allergy and multiple food protein intolerance 2. Cow’s milk-induced FPIES 3. Soy protein sensitivity
Limitations: Can only issue to infants and children through 23 months old.
Staff may only issue Nutramigen RTU when it meets criteria outlined in Chapter 5 of the WIC Procedure Manual (5.3). Mead Johnson Powder: 6 cans/case
Concentrate: 12 cans/case
RTF: 6 bottles/case 50 PediaSure (8 oz. RTF) 8.00 Increased Calorie Supplement: 30 cal/oz, lactose-free; with DHA and prebiotic scFOS; nutritionally complete; 15% MCT oil; 1 g fiber and 18 g sugar/8 oz container.
Similar to Boost Kid Essentials.
Allergens by Nature: Milk and Soy 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 old. Abbott 24 containers/case vanilla chocolate strawberry smores 126 (CI) PediaSure w/Fiber (8 oz. RTF) 8.00 Increased Calorie Supplement: 30 cal/oz, lactose-free with fiber and DHA; nutritionally complete, 15% MCT oil; 3.2 g fiber and 18 g sugar/8 oz container.
Allergens by Nature: Milk and Soy Increased fiber needs AND 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 old.
Abbott 24 containers/case vanilla strawberry chocolate