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Official source

Prod ID Product RFO Description Qualifying Conditions Staff Guidance Manufacturer/ Packaging 157 (CI) Peptamen Junior 1.5 (8.45 oz. RTF) 8.45 Hydrolyzed/Peptide Increased Calorie Supplement: 45 cal/oz, high calorie, lactose-free, gluten-free; peptide-based, 100% hydrolyzed whey protein, nutritionally complete; 60% of fat is MCT oil; enriched with EPA, DHA. 1.35 g fiber per 250 mL container.

Similar to PediaSure Peptide 1.5

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. Nestle 24 containers/case unflavored vanilla 156 (CI) Peptamen Junior with Fiber (8.45 oz. RTF) 8.45 Hydrolyzed/Peptide Increased Calorie Supplement: 30 cal/oz, lactose-free, gluten- free, peptide-based, 100% hydrolyzed whey protein, nutritionally complete, for oral or tube feeding; 60% of fat is MCT oil; 1.8 g fiber per 250 mL container.

Allergens by Nature: Milk and Soy Increased fiber needs/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. Nestle 24 containers/case vanilla 215 (CI) Pepticate (13.2 oz Powder) 86.00 Hydrolyzed/Peptide: 20cal/oz; hypoallergenic, extensively hydrolyzed whey protein; contains scGOS and lcFOS, prebiotics, lactose, DHA/ARA; 15% of fat as MCT Oil; lactose is primary source of carbohydrate.

Add 1 unpacked, level scoop (4.8 g) of powder to 1 fl oz of water.

Similar to Alimentum, Extensive HA, generic hypoallergenic, Nutramigen, Pregestimil.

Allergens by Nature: Coconut 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. Nutricia 4 cans/case 235 (CI) Periflex Advance (16 oz. Powder) 78.00 Special Medical Conditions - Metabolic: phenylalanine-free, nutritionally incomplete.

Dilution: add 29 g powder to 5 - 6 fl oz of cold water for a 10 g protein equivalent serving

Allergens by Nature: Coconut Phenylketonuria (PKU) or hyperphenylalaninemia Limitations: Can only issue to children 12 months to 5 years old and women.

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