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Prod ID Product RFO Description Qualifying Conditions Staff Guidance Manufacturer/ Packaging 139 (CI) PediaSure 1.5 (8 oz. RTF) 8.00 Increased Calorie Supplement: 45 cal/oz, lactose-free with DHA; nutritionally complete; 15% MCT oil; for oral or tube feeding.
Similar to Boost Kid Essentials 1.5.
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 138 (CI) PediaSure 1.5 w/Fiber (8 oz. RTF) 8.00 Increased Calorie Supplement: 45 cal/oz, lactose-free with DHA and prebiotic (scFOS); nutritionally complete; for oral or tube feeding; 15% MCT oil and 3 g fiber per 8 oz container.
Similar to Kid Essentials 1.5 with Fiber.
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 140 (CI) PediaSure Peptide 1.0 (8 oz. RTF) 8.00 Hydrolyzed/Peptide Increased Calorie Supplement: 30 cal/oz, lactose-free, nutritionally complete; hydrolyzed whey protein for oral or tube feeding for children 1 to 13 years; 50% of fat is MCT oil.
Similar to Peptamen Junior
Allergens by Nature: Milk and Soy Need for peptide formula 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. Condition that impairs digestion/absorption 8. Food Allergies (cow’s milk, soy, corn) *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 unflavored vanilla strawberry chocolate