Colorado WIC Program Policies and Procedures Section 2: Nutrition Services

Revised: 04/01/2026

Page 1 of 3 High and Low Risk Protocols

Policy: WIC staff must follow the Colorado WIC protocols in the identification and follow-up of high and low risk participants. Participants classified as high risk must be scheduled for a high risk nutrition education visit with the High Risk Counselor within the required time frames. All participants must receive nutrition education counseling at their initial visit and at all recertification, mid-certification and follow-up visits.

Regulation: USDA WIC Nutrition Risk Criteria, Colorado WIC Policy

Procedure/Additional Guidance Assigned nutrition risk factors (NRFs) determine whether a participant is classified as high or low risk.

For participants classified as high risk, schedule a high risk appointment within the required timeframe. At least one HR appointment with the High Risk Counselor is required per certification period, and this appointment must be documented in the participant’s WIC record. If the participant misses their high risk appointment, staff may offer to reschedule. However, scheduling another high risk appointment is not required. A chart review does not meet the requirement for addressing a high risk NRF.

If another (different) high risk NRF is identified after the initial high risk counseling visit, another High Risk Appointment is required to address the new high risk NRF. The High Risk Counselor will determine whether subsequent visits will be with the High Risk Counselor or the Educator. Participants must not be denied supplemental foods for failure to attend an educational activity or for lack of willingness, readiness, or ability to participate in the activity. For additional guidance, refer to Section 2: Nutrition Education Policy. . High Risk Counseling Timeframe Requirements ● Within 30 Days: In most cases, the High Risk Counselor must counsel the high risk participant within 30 days from the date the high risk factor was identified.

● Exceptions to the 30-day rule are: o Within 24 Hours of NRF Assignment: For the nutrition risk factors listed below, the High Risk Counselor must counsel the high risk participant within 24 hours from the time of the high risk NRF assignment. When a contact between the endorser/participant and the High Risk Counselor is not possible within 24 hours, the Educator may issue 1 month of food benefits. The High Risk Counselor must contact the participant by telephone/video call within 7 days, document the high risk contact, and determine if a clinic visit is needed before the next date of food benefit issuance. For example, a participant is consuming alcohol while pregnant, and the High Risk Counselor is not available but calls the participant 1 day later by phone. After talking with the participant, she decides to stop drinking. Using professional judgment, the High Risk Counselor decides to schedule a return clinic visit in 3 months.

✔ NRF 201b Severely Low Hemoglobin/Hematocrit (Child, pregnant woman, breastfeeding woman and non-breastfeeding woman): When a participant’s blood value falls within a range specified in the Standards for Severely Low Hemoglobin-NRF201b-High Risk Condition table and permission: ⮚ Has been granted for WIC to contact the health care provider: Print two Abnormal Blood Work Notices. Give one copy of the Notice to the endorser/participant. On the second Notice, write in the High Risk Counselor's name and contact information and fax or email that Notice to the health care provider within 24 hours. Schedule an appointment with the High Risk Counselor within the next 30 days. ⮚ Has not been granted for WIC to contact the health care provider: Print one Abnormal Blood Work Notice. Give the Notice to the endorser/participant and urge that it be shared with the participant's health care provider. Also, WIC staff must notify the High Risk Counselor of this abnormal blood value within 24 hours.

✔ NRF 135 - Slowed/Faltering Growth Pattern

Colorado WIC Program Policies and Procedures Section 2: Nutrition Services

Revised: 04/01/2026

Page 2 of 3 Infant birth up to 2 weeks of age: Current weight – Excessive weight loss after birth, defined as ≤7% birth weight.

✔ NRF 372A – Alcohol Use Pregnant: Any current alcohol use.

Breastfeeding: ⮚ High Risk Drinking: Routine consumption of ≥8 drinks per week or ≥4 drinks on any day. ⮚ Binge Drinking: Routine consumption of ≥4 drinks within 2 hours.

Note: For non-breastfeeding women, 372A is a low risk NRF.

✔ NRF 372B – Substance Use Pregnant & Breastfeeding: ⮚ Any illegal substance use and/or abuse of prescription medications. ⮚ Any marijuana use in any form.

Non-Breastfeeding Postpartum: ⮚ Any illegal substance use and/or abuse of prescription medications.

Note: 372B is not assignable to non-breastfeeding women who use marijuana.

✔ NRF 602 – Breastfeeding Complications or Potential Complications Breastfeeding woman with any of the following: ⮚ Severe breast engorgement ⮚ Recurrent plugged ducts ⮚ Mastitis ⮚ Flat or inverted nipples ⮚ Cracked, bleeding or severely sore nipples ⮚ Failure of milk to come in by 4 days postpartum ⮚ Tandem nursing ⮚ Age 40 years or older*

*The 24-hour high risk counseling rule applies to all complications or potential complications that comprise NRF 602 except for “age 40 years and older.” This is low risk and does not require a referral to the High Risk Counselor.

✔ NRF 603 – Breastfeeding Complication or Potential Complications: Breastfed infant with any of the following: ⮚ Jaundice ⮚ Weak or ineffective suck ⮚ Difficulty latching onto mother’s breast ⮚ Inadequate stooling (for age, as determined by a physician or other health care professional) or less than 6 wet diapers per day.

Initial (24-hour high risk) counseling for NRFs 602 and 603 can be conducted via phone or in-person, as determined by the clinical judgment of the High Risk Counselor, Designated Breastfeeding Expert (DBE), Educator Advanced Lactation Credentials (CLC, CLE, or IBCLE), or Educator WIC Lactation Specialist (WLS).

If initial (24-hour high risk) counseling is provided by:

High Risk Counselor, DBE, or Educator Advanced Lactation Credentials: ⮚ Document ‘High Risk Follow-up Appointment’ on the Nutrition Education panel and complete the participant’s care plan. ⮚ Provide a phone follow up within two weeks (as best practice). ⮚ Refer a participant to a health care provider when warranted.

Colorado WIC Program Policies and Procedures Section 2: Nutrition Services

Revised: 04/01/2026

Page 3 of 3

Educator WLS: ⮚ Document as individual counseling in the participant’s care plan. ⮚ Schedule a high risk follow-up appointment with High Risk Counselor, DBE, or Educator Advanced Lactation Credentials within two weeks of risk assignment. Can be conducted via phone or in- person, as determined by the clinical judgment of the High Risk Counselor, DBE, or Educator Advanced Lactation Credentials. ⮚ Refer participant to a health care provider when warranted.

● Within 90 Days from date of NRF assignment o NRF 113 – Obese Child 2-5 years of age

High Risk Resolved Clicking the High Risk Resolved check box on the Risk panel changes the participant’s risk status from high to low risk. The High Risk Resolved check box may only be selected when a user incorrectly assigns a high risk nutrition risk factor (NRF) to a participant who, in actuality, is low risk. If two or more high risk NRFs have been assigned and one high risk NRF is assigned in error, do not select this check box as the participant’s risk status must remain as high. Only the High Risk Counselor has the authority to check the High Risk Resolved check box.