Colorado WIC Program Policies and Procedures Section 2: Nutrition Services

Revised: 04/01/2025

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Food Packages - Infants

Policy: WIC staff shall select infant’s food packages according to the infant’s age, breastfeeding status (Excl BF, Prim Excl/No F Pkg, Prim Excl/Comp, Part BF, No Longer BF, and Never BF), and nutritional needs.

Regulation: 7 CFR 246.10, Policy Memodandum #2025-3

Procedure/Additional Guidance: When certifying/recertifying a mother/infant pair, begin with entering infant data into Compass and then proceed with entering the mother’s data. WIC food packages can be promoted to incentivize and support clients to reach their breastfeeding goals. When appropriate, refer to local agency staff with advanced breastfeeding credentials to provide breastfeeding assessment and support.

Food Package Types/Categories for Infants:  Exclusively Breastfeed Infants: An infant who is breastfed and receives no WIC formula.  Fully Formula Fed or “Full Formula”: An infant who receives WIC formula and is not breastfed.  Partially (Mostly) Breasfeeding Infant: An infant who is breastfed and receiving WIC formula.  “Partial (Mostly) BF Within Range”: An amount of standard formula an infant can receive that allows mother to receive a partially breastfeeding food package for herself.  “Partial BF Out of Range”: An amount of standard formula greater than what is allowed for mother to receive a partially breastfeeding food package for herself.

Infant Food Packages There are three food package options:  Exclusively breastfed  No food package is needed for the infant until he/she is 6 months old. The mother should receive either a model or tailored food package appropriate for an exclusively breastfeeding woman.  Partially Breasfeeding Infant  If the mother reports that she is breastfeeding and offering or requesting formula, first ask open- ended questions to determine why formula is being used or requested and find out what the mother’s breastfeeding plan or goal is. Affirm the mother for breastfeeding. Depending on the situation, counseling may be done by the educator or can be passed on to a High Risk Counselor, WLS, or DBE. Discuss with the mother the alternatives to formula, such as breast milk collected by hand or breast pump. If, after counseling and education, the mother requests formula, verify that the infant’s breastfeeding description is “part BF” and provide only the minimum amount of formula needed to meet, but not exceed the nutritional needs of the infant. Reinforce the importance and benefits of any amount of breastfeeding. Remember that mothers have greater breastfeeding success when they continue to breastfeed and/or express breast milk regularly. The amount of formula the infant receives determines the mother’s food package. Explain that food packages with smaller amounts of formula may enable her to receive more food for herself.  Fully Formula Fed  A fully formula-fed infant receives a formula food package and the mother receives a food package for postpartum/non breastfeeding women until her infant is 6 months old. After her fully formula- fed infant reaches 6 months or age, the mother is no longer WIC-eligible.

Age of breastfed infant at first day of the month BF Within Range (standard formulas) BF Out of Range (standard formulas) 0 – 3 months 1 to 4 cans 5 to 9 cans 4 – 5 months 1 to 5 cans 6 to 10 cans 6 – 12 months 1 to 4 cans 5 to 7 cans

Colorado WIC Program Policies and Procedures Section 2: Nutrition Services

Revised: 04/01/2025

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Infants 11 month of age until their first birthday Issue an infant food package to all infants, including those between 11 and 12 months of age. If the recertification occurs during the month the child turns one year of age, recertify using the Infant Nutrition Interview, assign infant nutrition risk factors, and issue an infant food package for the full month. Issue a child (toddler) food package at the beginning of the month when the child has already turned one year of age.

Medical Indication for Formula Certain medical indications may pose a temporary or long term problem for breastfeeding and require supplementation of formula or banked human milk (although banked human milk is not a WIC-eligible food, as defined by 7 CFR 246.10). Staff must work with mothers to determine the amount of formula that the food package shall contain and the length of time the doctor recommended the supplement, particularly if the need is for a standard formula and there is no prescription. If the mother does not know, staff will recommend she contact her infant’s health care provider.  Maternal medical indications:  Breast anatomical challenges (e.g., tubular breasts or marked breast asymmetry, inverted nipples for which shields and pumping alone will not suffice).  Breast surgery (e.g., reduction, augmentation, abscesses, cancer).  Endocrine abnormality (e.g., diabetes, pituitary insufficiency – noted as a lack of noticeable breast changes during pregnancy, failure of lactogenesis stage 2 – milk did not noticeably come in) .  Polycystic ovary syndrome (PCOS). Mothers with PCOS are at greater risk for insufficient milk supply, however many mothers with PCOS do not experience breastfeeding challenges and produce ample milk.  Perinatal complications (e.g., hypertension, hemorrhage, retained placental fragments).  Contraindicated medication.  Infant medical indications:  Premature (<37 weeks/0 days gestation) or very low birth weight.  Excessive weight loss (not regained birth weight by 14 days of age or loss of more than 10% of birth weight).  Acute dehydration not responsive to routine breastfeeding.  Breastfeeding jaundice.  Hypoglycemia.  Inborn errors of metabolism (e.g., PKU).  Special formula needed.  Not feeding well at discharge and sent home pumping with a formula supplement (should be followed by a physician within 24-72 hours after discharge).

Colorado WIC Program Policies and Procedures Section 2: Nutrition Services

Revised: 04/01/2025

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No Medical Indication for Formula If there is no medical indication, promote any amount of breastfeeding, ask open-ended questions to understand the reason for the formula request, affirm the parent’s breastfeeding success so far (promote any amount of breastfeeding), and provide information and troubleshoot with the mother. Infant formula should only be provided to infants after evaluation and counseling by the High Risk Counselor, WLS, or DBE.

If, after counseling and education, the mother chooses to receive formula, tailor the food package to best meet, but not exceed, the nutritional needs of the infant. First, determine if the infant is already receiving formula, then change the infant’s breastfeeding description to “part BF” and provide only the minimum amount of formula needed.

Work with the mother to create food packages that best support her breastfeeding plan, explaining that smaller formula packages may enable her to receive more food for herself with a food package for partially breastfeeding women.

Infant Formulas Categories Infant formulas are classified into three categories:

1. Primary Contract Brand Infant Formula: Any (standard) infant formula manufactured by the company with whom Colorado WIC has a formula rebate contract. (See MPSF: WC-00-25-P). A prescription is not required for WIC to issue primary contract brand infant formula. a. All infants enrolled on the Colorado WIC Program receiving a standard infant formula should receive one of five primary contract brand infant formulas: Enfamil Infant, Enfamil ProSobee, Enfamil Gentlease, Enfamil Reguline or Enfamil AR. Mead Johnson Nutritionals contracts with Colorado WIC to provide rebate dollars for each container of Enfamil Infant, Enfamil ProSobee, Enfamil Gentlease, Enfamil Reguline or Enfamil AR issued to WIC participants. Rebate money is used to support additional caseload.

Contract for Infant Formula Rebate: Federal regulations require that state WIC Programs contract with a single infant formula manufacturer. Additionally, federal regulations require the use of Primary Contract Brand Infant Formulas, except when contraindicated by a specific medical condition. The Colorado WIC Program contracts with Mead Johnson Nutritionals to be the provider of standard milk and soy-based formulas. These formulas contain at least 10 mg iron per liter and 20 kilocalories per fluid ounce. Rebates for the contract formulas, which are used to enroll more children and women in WIC, support a significant percentage of the Colorado WIC caseload. There are no exceptions for the provision of standard formulas made by other manufacturers.

Colorado WIC receives rebate for the following formulas:  Enfamil Infant - A milk-based formula.  Enfamil ProSobee – A soy-based formula.  Enfamil Gentlease - A reduced-lactose milk-based formula that has partially hydrolyzed protein.  Enfamil Reguline – A milk-based formula with added prebiotics.  Enfamil AR – A milk-based formula with added rice starch.

2. Non-Contract Brand Infant Formula: Any infant formula or exempt infant formula that is not a contract formula. (See MPSF:WC-00-25-P)

3. Exempt Infant Formula. Any infant formula designed for infants with special medical conditions who require a modified infant formula. (See FDC Act 21 U.S.C. 350a). Exempt infant formulas are those that are represented and labeled for use by an infant who has an inborn error of metabolism, a low birth weight or who otherwise has an unusual medical or dietary problem. They are often used with infants who have medical problems that affect their nutritional needs and/or their ability to digest regular infant formulas. It is very important that a physician regularly reevaluate the need and acceptance by an infant receiving an exempt infant formula.

Colorado WIC Program Policies and Procedures Section 2: Nutrition Services

Revised: 04/01/2025

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Issuance of an exempt infant formula is only permitted with a properly completed Colorado WIC Program’s Physician Authorization Form or a physician’s prescription and High Risk Counselor approval of prescription prior to issuance. It is important that a physician regularly reevaluates the appropriateness of the type and amount of the formula or nutritional prescribed. For more information, see Prescription Required Formulas and Nutritionals policy in Section 2, Nutrition Services.

Formulas to Accommodate Religious Beliefs: In the event that one of Colorado WIC’s contract formulas does not meet a participant’s religious requirements, such as need for a kosher formula, a non-contract formula can be issued without a physician’s authorization. Documentation of the issuance of a non-contract formula to accommodate religious eating patterns must be included in the participant’s record.

Issuance of Ready-To-Feed Federal and State regulations require that infant formulas be issued in concentrated liquid or powder physical forms. Ready-to-feed (RTF) WIC formulas may be authorized when the CWA determines and documents that:  The family’s water supply is contaminated and / or is unsafe for consumption.  The caregiver has difficulty correctly diluting concentrate or powder formula.  For a medically fragile infant (i.e. premature).  The formula only comes in ready-to-feed form.

Banked Human Milk Banked human milk is not a WIC-eligible supplemental food and WIC federal funds cannot be used for the purposes of collecting, storing, purchasing, or disseminating banked human milk.

Colorado WIC Program Policies and Procedures Section 2: Nutrition Services

Revised: 04/01/2025

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Infant Food Package

Age Exclusively Breastfeeding (breastfed- no WIC formula) Partially Breastfeeding – in range (breastfed and receiving WIC formula) Partially Breastfeeding – out of range (an infant who is breastfed and receiving WIC formula) Fully Formula-Fed (infant who receives WIC formula and is not breastfed) Birth through 3 mo.a None 435 oz powder or 364 oz concentrate c or 384 oz RTF 436 - 870 oz powder or 365 - 806 oz concentrate c or 385 – 832 oz RTF 870 oz powder or 806 oz concentrate c or 832 oz RTF 4 mo. through 5 mo.a None 522 oz powder or 442 oz concentrate c or 474 oz RTF 523 - 960 oz - powder Or 443 - 884 oz concentrate c or 475- 913 oz RTF 960 oz - powder or 884 oz concentrate c or 913 oz RTF 6 mo. through 11 mo.a,b

(16) 2.5-oz jars baby food meat (2) 8-oz boxes baby cereal

32) 4-oz jars baby food F/V Or (16) 4 oz jars baby food F/V + $11 CVB Or (0)4 oz jars baby food F/V +$22 CVB 384 oz powder or 312 oz concentrate c or 338 oz RTF

(1) 8-oz boxes baby cereal (32) 4-oz jars baby food F/V Or (16) 4 oz jars baby food F/V + $11 CVB Or (0)4 oz jars baby food F/V +$22 CVB 385 - 696 oz powder or 313 - 624 oz concentrate c or 339 - 643 oz RTF

(1) 8-oz boxes baby cereal

(32) 4-oz jars baby food F/V Or (16) 4 oz jars baby food F/V + $11 CVB Or (0)4 oz jars baby food F/V +$22 CVB 696 oz powder or 624 oz concentrate c or 643 oz RTF

(1) 8-oz boxes baby cereal

(32) 4-oz jars baby food F/V Or (16) 4 oz jars baby food F/V + $11 CVB Or (0) 4 oz jars baby food F/V +$22 CVB

a All formula amounts are considered “up to” amounts. b When individually tailoring infant food packages to provide the CVB substitution, nutrition assessment and appropriate nutrition education must be provided addressing developmental readiness, safe food preparation, storage techniques, and feeding practices to make certain participants are meeting their nutritional needs in a safe and effective manner. c Colorado WIC uses the Full Nutrition Benefit (FNB) for concentrate formulas, and the Maximum Monthly Allowances (MMA) for powder and RTF formulas.

Colorado WIC Program Policies and Procedures Section 2: Nutrition Services

Revised: 04/01/2025

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Guidelines for Providing Supplemental Formula To Non-Exclusively Breastfed Infants: Staff carefully determine with mothers the amount of formula the food package shall contain for the non-exclusively breastfed infant. When possible staff should provide the minimum amount of formula needed and issue powder (not concentrate) formula.

Number of cans powdered formula

Breastfed Infant's Average Daily Formula Intake Enfamil EnfaCare Nutramigen with Enflora LGG Similac Alimentum Similac NeoSure EleCare Infant Enfamil Infant Gentlease Infant Prosobee Enfamil AR Enfamil Reguline EleCare Infant Neocate Infant PurAmino Similac PM 60/40 Pregestimil Comforts Hypoallergenic Parent’s Choice Hypoallergenic Alfamino Infant Gerber Extensive HA Neocate Syneo Infant 1-3 ounces 1 1 1 1 2 1 1 4 ounces 2 2 2 1 2 2 2 5-6 ounces 2 2 2 2 3 2 2 7 ounces 3 2 2 2 3 3 3 8 ounces 3 3 3 2 3 3 3 9 ounces 3 3 3 3 * # 4 3 3 10 ounces 4 # 3 3 3 4 * # 4 4 11-12 ounces 4 4 * # 4 * # 3 5 4 * # 4 * # 13 ounces 5 * 4 4 4 + 5 5 5 14-15 ounces 5 5 + 5 + 4 6 + 5 + 5 + 16-17 ounces 6 + 5 5 5 6 6 6 18-19 ounces 6 6 6 5 7 6 6 20 ounces 7 6 6 6 7 7 7 21 ounces 7 7 6 6 8 7 7 22 ounces 8 7 7 6 8 8 7 23 ounces 8 8 7 7 8 8 8 24 ounces 9 8 7 7 9 8 8 25-26 ounces 9 9 8 7 9 9 9 27 ounces 10 9 8 8 9 9 9 28 ounces + 11 10 9 8 9 9 9 * Maximum “in range” formula for 0-3 month olds + Maximum “in range” formula for 4-5 month olds # Maximum “in range” formula for 6-11 month olds