Page 180

21

Prod ID Product RFO Description Qualifying Conditions Staff Guidance Manufacturer/ Packaging 240 (CI) PKU Sphere 20 (1.23 oz. Powder) 4.00 Special Medical Conditions - Metabolic: low phenylalanine formula; contains a blend of whey protein isolate (GMP), essential and non-essential amino acids, carbohydrate, fat (including DHA), vitamins and minerals; nutritionally incomplete.

Each 35 g (1.23oz) packet provides 20 g of protein equivalent and contains 30 mg of phenylalanine. Mix 1 packet with 4oz water.

Allergens by Nature: fish (tuna), Milk and Soy 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 Vitaflo 30 packets/case vanilla red berry chocolate banana lemon 241 (CI) PKU Trio (14.1 oz. Powder) 55.00 Special Medical Conditions - Metabolic: phenylalanine-free; nutritionally incomplete.

Add 2 level scoops (33 g) to 4.5 oz water to provide 10 g protein equivalent.

Allergens by Nature: Milk 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 Vitaflo 6 cans/case unflavored vanilla 109 Pregestimil (16 oz. powder) 112.00 Hydrolyzed/Peptide: 20 cal/oz, hypoallergenic, lactose, sucrose, and galactose-free, casein hydrolysate; nutritionally complete; 55% of fat is MCT oil; appropriate for infants with galactosemia.

Mixing Instructions: Add 1 PACKED level scoop (8.9 g) add 2 fl oz water

Similar to Alimentum, Extensive HA, generic hypoallergenic, Nutramigen, Pepticate. 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. Mead Johnson 6 cans/case 112 (CI) Pro- Phree (14.1 oz. Powder) 102.00 Modular: protein and lactose-free; nutritionally incomplete; provides 49% of energy as fat; supplemented with L-carnitine and taurine.

1 Tbsp = 8 g, 1 cup = 120 g

RFO is calculated based on mixing to 20cal/oz

Allergens by Nature: Coconut and Soy 1. Congenital heart disease 2. Congestive Heart Failure (CHF) 3. Bronchopulmonary dysplasia (BPD) 4. Other specified inborn errors of metabolism No limitations: Can issue to infants, children and women.

Requirements: Modular formulas must be approved by District Nutrition Director or State WIC Office Abbott 6 cans/case unflavored 20 (CI) Propimex-1 (14.1 oz. Powder) 96.00 Special Medical Conditions - Metabolic: methionine, valine and lactose-free; low in isoleucine and threonine; nutritionally incomplete.

1 Tbsp powder = 8 g; Preparation and dilution only as directed by a physician

RFO is calculated based on mixing to 20cal/oz

Allergens by Nature: Coconut and Soy Propionic or methylmalonic acidemia 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