(ii) if the applicant uses a "day shelter" (a shelter for the homeless which is open only during the day), can that shelter's address be used;

(iii) if the applicant can use the address of a relative or a friend; or

(iv) if no address is available, can the address of the local WIC clinic be used.

b. Homeless applicants who reside in homeless shelters which do not meet the conditions in B.5 are not eligible for WIC food benefits.

c. Income eligibility requirements as outlined in Policy & Procedure 2.05.

Consideration shall be given to a homeless individual who cannot provide proof of income. If a homeless applicant does not have the facilities to store written documentation for income verification, the local agency shall accept a self-declaration of income from the applicant. A homeless applicant who has no source of income or support is clearly income eligible.

d. Nutritional risk as outlined in Policy and Procedure 2.31.

3. To provide the benefit of supplemental foods necessary to accommodate the homeless individual, food packages can be tailored to meet the needs of the homeless individual who may not have the facilities to store or utilize the usual WIC supplemental foods.

4. To provide the benefit of nutrition education which is relevant to the homeless individual, specific education concerning the use and the storage of foods should be offered in addition to other topics.

5. Local agencies should ensure that homeless facilities meet certain conditions:

a. The homeless facility does not accrue financial or in-kind benefit

Policy and Procedure 2.21

Page 3 of 4 from a person's participation in the Program, e.g. by reducing its expenditures for food service because its residents are receiving WIC foods;

b. Foods provided by the WIC Program are not subsumed into a communal food service, but are available exclusively to the WIC participant for whom they were issued; and

c. The homeless facility places no constraints on the ability of the participant to partake of the supplemental foods and nutrition education available under the Program.

6. The local agency shall:

a. Contact the homeless facility at least once every six months to ensure continued compliance with conditions described in B.5; and

b. Request that the homeless facility notify the local agency if it ceases to meet any of these conditions.

7. In those cases where the local agency has not determined if a homeless facility meets the conditions of B.5, the local agency shall:

a. Contact the homeless facility to make this determination;

b. Inform applicants that the local agency will contact the homeless facility to determine if the facility meets certain conditions required by federal regulations for applicants to be eligible for WIC; and

c. Inform applicants that they will be notified by mail or telephone within the regulatory timeframe (refer to Policy and Procedure 2.09) of their eligibility status.

8. Homeless applicants and participants must be referred to appropriate health and human service agencies, such as:

a. Local welfare/TCA client assistance services

b. Homeless shelters

c. Food pantries/meal programs

d. Supplemental Nutrition Assistance Program

e. Medical Assistance

Policy and Procedure 2.21

Page 4 of 4

If necessary, a referral phone call should be made on behalf of the homeless applicant to food and shelter resources in the local area.

Attachment(s):

References: 1. 7 CFR Part 246.2, 246.7(m), 246.10(b)(1)(ii) and (b)(2)(ii)(D)

Revisions:

04/1999 Revised definition to include “which cannot exceed 365 days” and changed AFDC to TCA 01/2009 Changed Food Stamps to read Food Supplement Program in B. 8.d. 10/2011 Clarified B.2.b and citation 246.7(m) 12/2019 Moved Confirmation of Residency attachment to 2.04A 01/2026 3. Added that food packages can be tailored; 8 added mandatory referrals to SNAP and MA; clarified references

This attachment has been moved to 2.04A

Policy and Procedure 2.22

Page 1 of 3 MARYLAND DEPARTMENT OF HEALTH WIC PROGRAM POLICY AND PROCEDURE MANUAL

Policy and Procedure Number: 2.22 Effective Date: October 1, 1993 Revised Date: October 1, 2012 SECTION: ELIGIBILITY AND CERTIFICATION SUBJECT: Appointment Waiting List

A. Policy

Once a person's certification period is over, the participant must reapply for WIC benefits and compete for WIC appointments with other persons within their priority levels. It is generally easier for current participants to obtain WIC appointments because they are already in the system and more difficult for new applicants to obtain access to the system. Therefore, special efforts must be made to ensure that high-priority new applicants are able to gain access to WIC appointments in a timely manner.

An Appointment Waiting List shall be implemented and maintained if, due to staff or space limitations, the local agency cannot schedule and process the applicant who requests an appointment for certification or recertification by telephone within the regulatory timeframes. The names of applicants who request in person, at a WIC site, to participate in the Program cannot be placed on an appointment waiting list. These applicants must be interviewed and notified of their eligibility or ineligibility according to the processing standards described in Policy and Procedure 2.09. An appointment waiting list should be implemented as a short- term solution. When a local agency decides to implement an appointment waiting list, the local coordinator shall notify the State WIC Director in writing, regarding:

a. The date an appointment waiting list has been implemented;

b. The priorities that will be given appointments;

c. The anticipated length of time that the appointment waiting list will be maintained; and

d. The measures that will be pursued to resolve the problems of lack of resources and/or space.

B. Procedure

1. Establishing an appointment waiting list.

Policy and Procedure 2.22

Page 2 of 3

a. The local agency should determine the priorities that can be served in a timely fashion and should provide appointments to those applicants who will most likely fall into those priorities.

b. Recertification:

As a WIC participant's certification period draws to an end, local agency staff must determine whether a recertification appointment should be scheduled. This decision is based on the individual's potential new priority status when assessed. Persons likely to remain in Priority I must be given highest priority for appointments, followed by those who would be Priority II, III, IV, etc. Recertification appointments should be given consistent with procedures for giving new appointments.

c. New Certification:

Applicants who telephone the WIC Program to request an appointment should be scheduled according to priority. However, local agency staff may not have enough information to determine which priorities these applicants will be. The following guidelines shall apply:

i. Pregnant and breastfeeding women will be given highest priority;

ii. Infants will be given second priority; and

iii. Children and postpartum women who are believed to have a nutritionally significant medical condition or other risk factor which would place them in Priority III will be given third priority.

d. Local agencies should make every effort to schedule pregnant women within 10 days of the request, whether the request is made in person or by telephone.

e. Any infant who appears to have a condition qualifying as a Priority I risk must be given an appointment within 10 days of the request, whether in person or by telephone.

2. The local agency shall establish an appointment waiting list, which contains the following information:

a. Name, address and contact telephone number of the individual for whom the appointment is requested or if the individual is an infant or child, the parent or guardian of the infant or child;

Policy and Procedure 2.22

Page 3 of 3

b. Name of individual for whom the appointment is requested;

c. Date the appointment was requested; and

d. Category of the individual for whom the appointment is requested, i.e.:

i. Pregnant woman;

ii. Infant;

iii. Breastfeeding woman;

iv. Child; or

v. Postpartum women.

3. Implementing an appointment waiting list.

When an appointment becomes available, the local agency shall contact the individual, or the parent or guardian of an infant or child, from the appointment waiting list according to the:

a. Highest priority according to category, which is:

i. Pregnant woman;

ii. Infant;

iii. Breastfeeding woman;

iv. Child; and

v. Postpartum woman; and

b. Earliest calendar date appointment was requested; and

c. The highest priority applicants (e.g. pregnant woman) must all be given appointments before the second highest priority can be given appointments

Attachments:

References:

Revisions:

10/2012 Corrected spacing issues

Policy and Procedure 2.23

Page 1 of 3

MARYLAND DEPARTMENT OF HEALTH WIC PROGRAM POLICY AND PROCEDURE MANUAL

Policy and Procedure Number: 2.23 Effective Date: October 1, 1992 Revised Date: September 24, 2019 SECTION: ELIGIBILITY AND CERTIFICATION SUBJECT: Establishment of Applicant Identity

A. POLICY:

To be certified as eligible for the WIC Program, applicants shall meet criteria for eligibility in accordance with policies established by the State Agency. In determining eligibility, all applicants must provide proof of identity. Identification must also be confirmed at subsequent appointments, prior to issuing benefits, and when a participant requests to make a change to their account.

B. PROCEDURE:

Local agencies shall require that all applicants provide proof of identity and document the type of proof presented in the management information system. Identification provided electronically may be used at the discretion of the local agency.

1. At initial certification one of the following documents shall be an acceptable proof of an applicant's identity:

a. Birth registration or birth certificate: official copy bearing State or Municipal seal; or seal of foreign government or province;

b. Hospital birth record: usually bears child's footprints, date of birth and signature of physician or registered nurse;

c. Crib card bearing child's name and date of birth;

d. Immunization record;

e. Baptismal record: official copy bearing the seal of the issuing church;

f. Confirmation record: official copy bearing the seal of the issuing church;

g. School identification card;

h. Military records: this may include a military identification card or discharge papers;

Policy and Procedure 2.23

Page 2 of 3

i. Marriage certificate/marriage license;

j. Driver's license;

k. Age of Majority identification card;

l. Passport, Visa or Foster Care Health Passport;

m. Immigration or Naturalization record;

n. Social Security Card;

o. Medical Assistance card; or

p. Any other documentation that establishes the applicant's identity except a WIC Verification of Certification, which may not be used for proof of identification.

2. At subsequent recertification appointments documents from B.1. may be provided for proof of identification. Additionally, one of the following documents shall be an acceptable proof of identity:

a. Scanned photo identification for the applicant on file in the Maryland WIC management information system;

b. Validated Maryland WIC Identification Folder; or

c. Visual personal recognition.

3. Applicants that are unable to provide proof of identity may use the Proof of Identity Affidavit form 2.23A. Criteria to use this form include, but are not limited to, a homeless applicant, victims of fire or theft, illegal aliens, or teenagers who were put out of their homes. Staff should request that the participant bring proof of identity to their next appointment, if possible.

4. If an applicant does not provide any of the documentation listed in B.1 – 3 above, the local agency shall enter “No Proof” in the Proof of Identity field in the management information system. Local agencies shall allow the applicant up to 30 days after the certification to provide documentation of identity. If documentation is not provided by the end of the 30 day certification, then the participant shall be terminated by the management information system. Participants may have their certification end date restored to the full certification period if documentation is provided before the 30 days has expired. Under no circumstances may a second, subsequent 30 day certification period be used if the applicant fails to

Policy and Procedure 2.23

Page 3 of 3

provide the required documentation of identity.

5. At all other appointment types or contacts, documents from B.1. and B.2. are preferred for proof of identification, but verbal verification of identification may be used. Local agencies that elect to use verbal verification shall request a minimum of two identifiers from the participant record, such as date of birth, and mailing address.

Attachments: 2.23A Proof of Identity Affidavit

References: 1. CFR 246.7 (c)(2)(i) 2. SFP 99-078 Strengthening Integrity in the WIC Certification Process

Revisions:

July 2002 Added check pick up appointments to C April 2008 Added at authorized stores to C. October 2010 Changed reference from 7 CFR 246.7(k)(2) to 7 CFR 246.7( c)(2)(i) October 2014 added language about short certs 06/07/2017 Removed VOC as a valid form of ID and added Maryland WIC ID folder to the list rather than written in a paragraph. 09/24/2019 Added clarification regarding scanned identification, verbal verification of ID, and edited attachment A.

Attachment 2.23A Attachment 2.23A

Page 1 of 1 Maryland WIC Program Proof of Identity Affidavit

I am unable to provide proof of my/my child’s identity because:

.

Name of applicant present for Certification

Applicant’s Date of Birth

Head of Household’s (HOH) Full Name

HOH’s Date of Birth

Physical Address: Street Address

Phone Number

Physical Address: City, State, Zip Code

By signing this affidavit, I am certifying that the above information is correct to the best of my knowledge. I have not made a false or misleading statement or intentionally withheld facts to obtain WIC benefits.

Head of Household or Designee Signature

Date of Signature

Policy and Procedure 2.24

Page 1 of 3 MARYLAND DEPARTMENT OF HEALTH WIC PROGRAM POLICY AND PROCEDURE MANUAL

Policy and Procedure Number: 2.24 Effective Date: April 1, 1993 Revised Date: October 7, 2024

SECTION: ELIGIBILITY AND CERTIFICATION SUBJECT: Establishment of Participant Category

A. Policy

To be certified as eligible for the WIC Program, applicants shall meet categorical criteria for eligibility. The category of applicants shall be established according to the following definitions:

Pregnant woman (PG) means a woman determined to have one or more embryos or fetuses in utero.

Postpartum woman (WPP) means a woman up to six months after termination of pregnancy.

Breastfeeding woman means a woman up to one year postpartum who provides their breastmilk to their infant (who is certified on WIC) on average of at least once per day. A non-birth parent who is providing breastmilk to an infant they are legally responsible for, may be certified as a breastfeeding parent. Two participants cannot be certified as breastfeeding parents for the same infant (see Policy and Procedure 5.09). There are two subcategories of breastfeeding women. They are:

Exclusively breastfeeding woman (BE) means a woman who has at least one infant who receives breastmilk on average of at least once per day and no formula from the Program.

Partially breastfeeding woman (BP) means a woman who has at least one infant who receives breastmilk on average of at least once per day and formula from the Program. The categories of partially breastfeeding- mostly and partially breastfeeding-some will be applied in conjunction with the amount of formula allotted to the breastfeeding infant.

Infant means a person under one year of age.

Exclusively breastfeeding infant (IBE) means an infant whose main source of nutrition is breastmilk and receives no formula from the

Policy and Procedure 2.24

Page 2 of 3 Program.

Partially breastfeeding infant (IBP) means an infant who receives breastmilk on the average of at least once per day and formula from the Program. An infant partially breastfeeding-mostly receives ≤ 14 ounces per day of reconstituted formula from the Program. An infant partially breastfeeding-some receives >14 ounces per day of reconstituted formula from the Program.

Formula fed infant (IFF) means an infant whose main source of nutrition is infant formula and does not receive breast milk on average of at least once per day.

Child (C1, C2, C3, C4) means a person who has had a first birthday but has not yet attained a fifth birthday.

B. Procedure

The management information system determines participant categories by using the birth date and pregnancy or breastfeeding status entered. Local agency staff shall change a participant’s pregnancy or breastfeeding category according to established management information system procedures.

Although it is desirable that the pregnant applicant presents documented proof of pregnancy, federal Program regulations do not require documentation as a condition of eligibility; and WIC benefits cannot be denied to a pregnant applicant who does not provide documented proof of pregnancy. Local agencies shall allow pregnant participants up to 60 days after certification to provide documentation.

The local agency may ask the applicant to provide proof of pregnancy as long as the applicant does not incur a cost to verify pregnancy. If available, local agencies shall refer the pregnant applicant to a clinic where a pregnancy test can be performed without cost to the applicant.

If documentation of pregnancy is not provided in 60 days, the participant shall be reassessed for: (1) a second 60 day period if the pregnancy is not obvious (e.g. the woman does not look pregnant) with a request that proof of pregnancy be provided; or (2) a reinstatement of the existing certification period if pregnancy is obvious.

With each successful contact with a breastfeeding infant’s parent or designee, the Breastfeeding Intake grid shall be updated to assure breastfeeding categories are accurate. If the amount of breastfeeding remains the same as previously documented, staff shall document with today’s date to indicate the current status.

Policy and Procedure 2.24

Page 3 of 3 References:

1. CFR 246.2 Definitions

2. CFR 246.7 (c)(2)ii Eligibility Criteria and Basic Certification Procedures

Revisions 10/2003 WICWINS References 10/2012 Changed 60 days to 30 days for short cert 10/2015 Changed 30 days to 60 days and clarified referral for free pregnancy testing if available 9/2020 Removed WOW verbiage; updated references; clarified definition of breastfeeding and added definitions of partial breastfeeding for both women and infants 10/2024 Edited breastmilk to be one word rather than two. Added information that non-birth parents who breastfeed an infant can be certified as breastfeeding participants. Added paragraph in policy section documenting requirement to update breastfeeding intake grid with each successful participant contact.

Policy and Procedure 2.25

Page 1 of 4

MARYLAND DEPARTMENT OF HEALTH WIC PROGRAM POLICY AND PROCEDURE MANUAL

Policy and Procedure Number 2.25 Effective Date: October 1, 1995 Revised Date: October 1, 2013 SECTION: ELIGIBILITY AND CERTIFICATION SUBJECT: Voter Registration

A. POLICY.

The intent of the National Voter Registration Act of 1993 is to increase the number of citizens registered to vote and to establish safeguards that ensure a citizen’s right to register to vote. The Act is designed to increase the number of Americans registered to vote by requiring many public agencies, including local agency WIC certification clinics, to provide registration opportunities to their clients or anyone else requesting to be registered to vote.

Local agencies shall provide all individuals applying for WIC Program benefits or the parent/caregiver/designee of individuals applying for WIC Program benefits an opportunity to register to vote at each certification and recertification visit.

Local agencies shall also provide assistance to other individuals who express an interest in registering to vote at any time.

B. PROCEDURE.

The local agency shall:

1. Inform each applicant or the applicant’s parent/caregiver at the initial certification:

a. “As part of the services of the WIC Program we are offering you the opportunity to register to vote.”

b. “Applying to register to vote, declining to register to vote, or refusing to complete the Voter Registration Agency Certification section of the Applicants Right and Responsibility form will not affect your participation in the WIC Program.”

c. “If you are not registered to vote where you now live, would you like to apply to register to vote?”

Policy and Procedure 2.25

Page 2 of 4

2. Ask the applicant or the applicant’s parent/caregiver at the initial

certification to:

a. Read or have read to them the Voter Registration Certification form (Attachment 2.25B);

b Provide a response to question number 1 on the Voter Registration

Agency Certification form and enter the response in the

management information system; and

c. Sign on the electronic signature device as instructed by the local agency staff.

3. For those WIC applicants or parents/caregivers/designees who want to register to vote and other individuals who express an interest:

a. Give the individual the voter registration application (Attachment 2.25A);

b. Ask the individual if he/she would like help in completing the voter registration application;

c. Provide assistance to those individuals who would like help in completing the registration application; and

d. Ask the individual if he/she would like the WIC Office to mail the completed voter registration application to the local election board.

e. Individuals who accompany the applicant or the parent/caretaker of an infant or child applicant who express an interest in registering to vote do not need to complete the Voter Registration Agency Certification section of the Applicant’s Rights and Responsibilities form.

4. Local agency staff shall document in the management information system,

the applicant or the applicant’s parent/caregiver/designee response to

the voter registration questions.

5. Advise the applicant or the applicant’s parent/caregiver/designee that the voter registration applications can be transmitted to the local Board of Elections in one of two ways:

a. Directly by the applicant; or

b. By the local agency office.

An applicant or the applicant’s parent/caregiver may, if he or she chooses, mail the voter registration application directly to the appropriate State

Policy and Procedure 2.25

Page 3 of 4

election official rather than returning it to the local agency office for transmittal. The local agency office providing voter registration services is prohibited from requiring registrant to mail the form.

If the local agency mails the completed voter registration application, the local agency shall date stamp each completed card in the two sections the applicant filled in and forward the card within 5 days to the appropriate registration official as listed on the form (Attachment 2.25A). The local agency must provide regular, visible means for collecting voter registration applications.

6. When a clinic serves a significant proportion of non-English speaking applicants or applicants with limited English and many applicants speak the same language, the local agency shall ensure:

a. That required voter registration information is provided to such persons in the appropriate language orally and in writing; and

b. That bilingual staff or interpreters are available to assist in completing the voter registration application.

C. ADMINISTRATION.

1. The local agency shall administer the voter registration program by:

a. Appointing a person to be in charge of, and responsible for, voter registration activities;

b. Training all employees involved with registration activities; and

c. Ensuring the accountability of voter registration forms.

2. Local agency staff working on voter assistance activities shall not:

a. Directly or indirectly seek to influence an applicant’s political preference or party or answer any question regarding party other than he must be enrolled in a party in order to vote in a primary election;

b. Make any statement to an applicant or take any action the purpose or effect of which is to discourage the applicant from registering to vote; or

c. Make any such statement to an applicant or take any action the purpose or effect of which is to lead the applicant to believe that a

Policy and Procedure 2.25

Page 4 of 4

decision to register or not to register has any bearing on the availability of WIC Program services or benefits.

Attachments: 2.25A Voter Registration Application

2.25B Voter Registration Certification form

References: National Voter Registration Act of 1993

State of Maryland House Bill 650

Revisions

October 1999

October 2003 WICWINS References October 2008 Changed “clinic” to read “certification and recertification in B.1 and B.4 Changed the term “declination form” to “Applicant’s Rights and Responsibilities form” and entered table in B.5 January 2009 Changed “clinic” to read “certification and recertification in B.1 that failed to be corrected in 10-08 October 2012 Corrected typo in C.2.c October 2013 Revised wording to include the revised Participant Rights and Responsibilities form procedures.

l l l l l l l l l l l l l l l l l l l l l

Attachment 2.25B

Attachment 2.25B

Page 1 of 1

MARYLAND WIC PROGRAM

VOTER REGISTRATION AGENCY CERTIFICATION

1. If you are not registered to vote where you live now, would you like to apply to register to vote here today?

YES _____ NO _____

ALREADY REGISTERED _____

2. IF YOU DO NOT CHECK ANY, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME.

3. Applying to register or declining to register to vote will not affect the assistance that you will be provided by this agency.

4. If you would like help filling out the voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application in private.

5. If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether or register or in applying to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with:

Maryland State Board of Elections PO Box 6486 Annapolis, MD 21401-0486 800-222-8683

6. If you decline to register to vote, your decision will remain confidential and be used only for voter registration purposes.

7. If you decide to register to vote, information regarding the office to which the application was submitted will remain confidential, again to be used only for voter registration purposes.

Applicant’s Signature:

Date:

Applicant Name:

PROGRAMA WIC DE MARYLAND

CERTIFICADO DE LA AGENCIA DE REGISTRO DE VOTANTES

1. ¿Si no está registrado en el lugar donde vive para votar, quisiera registrarse para votar aquí el día de hoy?

SÍ _____

NO _____

ESTOY REGISTRADO _____

2. SI NO ELIGE NINGUNA OPCIÓN, SE CONSIDERARÁ QUE HA TOMADO LA DECISIÓN DE NO REGISTRARSE AHORA PARA VOTAR.

3. Registrarse o no registrase para votar, no afectará la ayuda que le proporcionará esta agencia.

4. Si necesita ayuda para completar el formulario de solicitud de registro del votante, le brindaremos nuestra asistencia. La decisión acerca de buscar o aceptar ayuda es suya. Puede completar la solicitud en privado.

5. Si considera que alguien interfirió con su derecho de solicitar o declinar el registro para votar, su derecho a la privacidad para decidir si registrarse o solicitar el registro, o su derecho de elegir su propio partido político u otra preferencia política, puede enviar un reclamo a:

Maryland State Board of Elections PO Box 6486 Annapolis, MD 21401-0486 800-222-8683

6. Si decide no registrarse para votar, su decisión será confidencial y se usará solo para fines de registro del votante.

7. Si decide registrarse para votar, la información de la oficina a la cual se envió la solicitud será confidencial, y una vez más se usará solo para fines de registro del votante.

Firma del interesado:

Fecha:

Nombre del interesado:

Policy and Procedure 2.26

Page 1 of 1

Policy and Procedure 2.26 was changed to Policy and Procedure 2.34.

Policy and Procedure 2.27

Page 1 of 3 MARYLAND DEPARTMENT OF HEALTH WIC PROGRAM POLICY AND PROCEDURE MANUAL

Policy and Procedure Number: 2.27 Effective Date: May 24, 2003 Revised Date: July 28, 2020 SECTION: ELIGIBILITY AND CERTIFICATION SUBJECT: Immunization Record Screening (DTaP)

A. Policy

Low income children are more likely than higher income children to be delayed in receiving standard immunizations, placing them at high risk for potentially serious diseases including diphtheria, pertussis, measles, mumps, and rubella. As an adjunct to programs that provide immunizations, local agencies shall perform immunization screening, determine a child’s need for immunizations, provide immunization information and referrals with caregivers, including where to get a child immunized, and share information with local immunization offices.

B. Procedure:

1. The local agency staff person making the applicant’s certification appointment shall:

a. request that a documented record of immunization for all infant or child applicants under 2 years of age be brought to the appointment;

b. inform the caregiver that appropriate immunization status and provision or release of immunization information is not a requirement for application or participation in the WIC Program.

2. At each certification local agencies shall:

a. Enter into the management information system whether a documented immunization record was received. A documented record includes a caregiver’s hand-held immunization record from the health care provider, an immunization registry, an automated data system or a client chart.

b. Enter into the management information system the actual dates DTaP immunization(s) were received. The current recommended immunization schedule can be found on the Center for Disease Control’s website.

Policy and Procedure 2.27

Page 2 of 3

c. Ask the caregiver to request that the health care provider clarify the dates if the document is difficult to read. If the documented immunization record is difficult to read, select “illegible” from the dropdown under the “special” column on the immunizations screen.

d. Inform the caregiver of the apparent status of the immunizations based on the information provided on the immunization screen in the management information system. The message will either be that the immunizations are on schedule (Good or OK), or that the child needs to be referred to their health care provider (Due or Refer). If the child appears to be on schedule, congratulate the caregiver and encourage them to continue to follow through with timely immunizations. Those infants and children whose status is due, refer, or whose record was illegible or not provided to the local agency, shall be referred to their health care provider or local immunization program for immunization services. This referral shall be documented in the participant’s record.

e. Have information available in clinic regarding the recommended immunization schedule and provide this information to the caregiver if needed.

f. Advise the caregiver that the Participant Immunization Report, which can be printed from the immunization screen at the local agency's discretion, cannot be used as a documented immunization record for the child.

3. Local agencies may at their discretion, and in accordance with policy and procedure 7.70, contact the health care provider or local immunization program to receive actual immunization dates for those clients who did not provide a documented record. Local agency staff choosing this option may accept the information verbally and should request a copy of the record (electronic or physical) from the health care provider or immunization program.

4. Local agencies shall provide aggregate or cumulative immunization information to the local health department's immunization program on a monthly basis.

References:

SFP 01-111 Immunization Screening and Referral in WIC SFPD #01-7

Revisions:

10/01/08 Section B. 3. Changed WOW User’s Manual to read WOW clinic help screen

Policy and Procedure 2.27

Page 3 of 3 10/2010 Section B. 4. Clarified role of designee 10/2012 Deleted references to WOW 1/2017 Updates in procedure due to changes in the management information system. Clarified appropriate educational material resource of CDC or Maryland Immunization Program handouts. 7/28/2020 Clarified that a written document is preferred but actual dates of immunization can be received verbally from the health care provider or local immunization program using the Immunet data registry and removed procedure from the policy section.

Policy and Procedure 2.28

Page 1 of 3 MARYLAND DEPARTMENT OF HEALTH WIC PROGRAM POLICY AND PROCEDURE MANUAL

Policy and Procedure Number: 2.28 Effective Date: October 1, 2003 Revised Date: November 9, 2023 SECTION: ELIGIBILITY AND CERTIFICATION SUBJECT: Blood Lead Screening Requirement

A. Policy

When completing the medical assessment of an applicant, local agency staff shall ask the participant/parent or caregiver if the applicant has had a blood lead test to screen for lead poisoning. If it cannot be determined that the test has been performed, the local agency staff shall refer the participant/parent or caregiver to a program where the test can be obtained and offer information regarding the dangers of lead poisoning.

The Maryland Healthy Kids Program Schedule of Preventive Care requires that health care providers complete a verbal lead assessment starting at 6 months of age and repeated at each visit through 5 years of age. A blood lead test is required at the ages of 12 and 24 months.

B. Procedure

1. Staff shall ask the participant/parent or caregiver if the applicant has had a blood lead test. If the response is “no” or “don’t know,” staff shall:

For women applicants: ● Offer education such as the Lead Poisoning: Lead Risk Screening Questionnaire for Pregnant or Breastfeeding Women and Children and direct her to discuss any positive responses with her health care provider. ● Document the referral and education in the management information system.

For children applicants: ● Explain why children may need a blood test for lead; ● Offer education such as the Lead Poisoning: Lead Risk Screening Questionnaire for Pregnant or Breastfeeding Women and Children or the age appropriate Help Me Be Healthy and direct the parent or caregiver to discuss any positive responses with the child’s health care provider; ● Recommend that the caregiver inquire about the blood lead test at the child’s next scheduled health care appointment;

Policy and Procedure 2.28

Page 2 of 3 ● Provide information about medical assistance if the child has no source of health care; ● Provide supplemental information about childhood lead poisoning; and ● Document the referral and nutrition education in the management information system.

For infant applicants: ● Infants do not routinely receive blood lead tests. If the caregiver indicates that the infant has been tested for suspected elevated blood lead staff shall: i. Document the blood lead level in the management information system, if known ii. Offer education such as the Lead Poisoning: Lead Risk Screening Questionnaire for Pregnant or Breastfeeding Women and Children iii. Refer the family to the health care provider or the health department if not already being followed and; iv. Document the referral and nutrition education in the management information system.

2. Staff may provide information about the importance of the blood test and the dangers of lead poisoning by:

● Highlighting the message about the need for a blood lead test in the Help Me Be Healthy pamphlets for children aged 12 and 24 months to remind caregivers to discuss the issue with their child’s health care provider.

● Both the Lead Poisoning: Lead Risk Screening Questionnaire for Pregnant or Breastfeeding Women and Children and the Help Me Be Healthy pamphlets are available through the Maryland WIC Distribution Center.

3. If the woman or child has had a blood test for lead and the test result is known, staff shall enter the blood test result in the Medical Screen of the participant.

Attachments : 2.28 A Lead Risk Screening Questionnaire for Pregnant or Breastfeeding Women and Children

Reference: WIC Final Policy Memo 2001-1

SFP 93-113 WIC’s Role in Screening for Childhood Lead Poisoning

Revisions:

10/2011 Updated MDE website

10/2012 Updated MDE website

01/2018 Removed MDE website; Updated procedure to include

Policy and Procedure 2.28

Page 3 of 3 screening of women applicants and added attachment A 10/2023 Clarified instructions of infants vs children

Attachment 2.28A Attachment 2.28A 11/08/17 Page 1 of 2

Maryland WIC Lead Risk Screening Questionnaire for Pregnant or Breastfeeding Women and Children

Attachment 2.28A Attachment 2.28A 11/08/17 Page 2 of 2

October 2008

Policy and Procedure 2.29 has been removed.

October 2008

Policy and Procedure 2.30 has been removed.

Policy and Procedure 2.31

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MARYLAND DEPARTMENT OF HEALTH WIC PROGRAM POLICY AND PROCEDURE MANUAL

Policy and Procedure Number: 2.31 Effective Date: October 1, 1990 Revised Date: 1/7/2026 SECTION: ELIGIBILITY AND CERTIFICATION SUBJECT: Assessment of Nutritional Risk

A. Policy

To be certified as eligible for the WIC Program, an applicant who meets the categorical, residency, and income eligibility requirements shall also be assessed for nutritional risk. Nutritional risk assessment shall include the collection and evaluation of relevant information to determine the presence of federally defined risk factors and to provide the most appropriate nutrition services.

B. Procedure

1. To perform a nutritional risk assessment of applicants/participants, the local agency shall:

a. Obtain and evaluate relevant information that includes:

• Height (or length) and weight measurements, as described in Policy and Procedure 2.32; • Hemoglobin or hematocrit test results, as described in Policy and Procedure 2.33; and • Nutrition and health information, as described in Policy and Procedure 2.34.

b. Enter the data obtained from 1.a. into the applicant’s management information system (MIS) record to document and generate nutrition risk factors.

c. Review all MIS-generated risk factors to ensure that they are correct based on accurate data entry.

d. Document each risk factor in the applicant’s MIS record.

e. Use the results of the nutritional risk determination to provide the most appropriate nutrition education messages and to make referrals.

Policy and Procedure 2.31

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Attachments: 2.31A

Nutritional Risk Criteria: Guidelines for Interpretation 2.31B CHART: Nutrition Risk Criteria

References: 1. 7 CFR 246.7 (e) 2. COMAR 10.54.01.06 C (2) 3. WIC Policy Memorandum 2011-5 WIC Nutrition Risk Criteria 4. WIC Nutrition Services Standards, Standard 7 5. SFP 06-05 Value Enhanced Nutrition Assessment (VENA) – WIC Nutrition Assessment Policy 6. SFP 09-057 WIC Policy Memorandum 98-9, Revision 10: Nutrition Risk Criteria

Revisions: 10/10 Renumbered Attachment 2.31 B as 2.31A

Revised new Attachment 2.31A as follows:

Women: Deleted Table WP. Changed Table WN to Table N. Revised definitions of Gestational Diabetes, Diabetes, and Fetal Growth Restriction. Added new risks: History of Preeclampsia, Hypertension/Prehypertension, Post Bariatric Surgery, and Pre-Diabetes. .

Renumbered attachment 2.31C as 2.31B

Revised new Attachment 2.31Bas follows:

Women: Changes were made to Underweight, Overweight, Low Maternal Weight Gain, High Maternal Weight Gain, Hx Gestational Diabetes, Multi-fetal Gestation, Gestational Diabetes, Diabetes Mellitus, GI Disorders, and in Nutrition Practices, the amount of iron was reduced.

Women: Risk codes were added for new conditions including History of Preeclampsia; Hypertension/Prehypertension; Pre-Diabetes; in GI Disorders, Post Bariatric Surgery, and in Nutrition Practices, requiring an iodine supplement.

Infants and Children: changes were made to diabetes mellitus, GI disorders, and Hypertension/Prehypertension. In Nutrition Practices, the following risks were added: Eating unapproved local fish, not giving appropriate fluoride and/or vitamin D supplements.

Deleted Table WP: Weight Status of Pregnant Women

Changed Table WN: Weight Status of Breastfeeding and Postpartum Women to Table W: Weight Status of Pregnant, Breastfeeding and Postpartum Women.

Revised Table H: High Maternal Weight Gain to meet new weight guidelines.

Changed reference from 7 CRF 246.7(d) to 7 CFR 246.7(e)

01/12 Combined Attachments A and B

Revised Attachment A as follows:

Women: Added two thyroid conditions. Added contact information for metabolic

Policy and Procedure 2.31

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dietitians to Inborn Errors of Metabolism.

Infants and Children: changed cut off values for Underweight/At Risk of Underweight, Obese, Overweight/At Risk of Overweight, Short Stature/At Risk of Short Stature, Low Head Circumference. Added new risk: High Weight for Length. Changed risk names to reflect cut off values. Added two thyroid risks. Added contact information for metabolic dietitians for Inborn Errors of Metabolism.

10/13 Attachment 2.31A: Provided more background information on the following risks: Lactose Intolerance, Food Allergies, Celiac Disease, and Failure to Meet Dietary Guidelines. Added Recipient of Abuse.

10/14 Attachment 2.31A, made the following Procedure changes.

Risk condition Breastfeeding Mother of Infant at Nutritional Risk: Changed “If the infant is certified before the breastfeeding mother, this risk criterion may be assigned to the woman” to “This risk criterion shall be assigned to a breastfeeding mother of an infant at nutritional risk” and “Refer participants whose infants have been identified with any risk criteria below to the breastfeeding specialist” to “Refer participants….to the breastfeeding specialist and to the CPA for Nutrition Care counseling.”

Risk condition Breastfeeding Infant of Mother at Nutritional Risk: Changed “If the breastfeeding mother is certified before the infant, this risk criterion may be assigned to the infant” to “This risk criterion shall be assigned to the breastfeeding infant of a mother at nutritional risk.”

05/16 Attachment 2.31A updated Nutrition Risk Criteria related to clarify medical conditions and risk criteria definitions.

10/16 Changed the high risk blood lead level to 5 micrograms/dl for both women and children. Added Breastfeeding Complications or Potential Complications to pregnant woman high risk list and Breastfeeding Mother of Infant at Nutritional Risk to both pregnant woman and breastfeeding high risk lists. Removed Inadequate Growth risk from both infants and children.

11/17 Revised Attachment 2.31A Nutritional Risk Criteria to clarify medical conditions and risk criteria definitions and background information.

11/19 Updated Justification and Implications for WIC Nutrition Services in Attachment 2.31A for Low Maternal Weight Gain, Hyperemesis Gravidarum, Nutrient Deficiency or Disease, Alcohol or Substance Use, Possibility of Regression, Transfer of Certification, Woman Primary Caregiver with Limited Ability, Drug Nutrient Interaction, History of Preeclampsia, Pregnant Woman Currently Breastfeeding, Hypertension and Prehypertension, and Fetal Alcohol Disorder. Removed Maternal Weight Loss risk and incorporated into Low Maternal Weight

Policy and Procedure 2.31

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Gain risk. 08/21 Updated risk criteria as follows: Failure to Thrive - added additional background and counseling information. Pregnancy at a Young Age - revised from 18 years old to <20 years old and added additional background and counseling information. High Parity & Young Age - discontinued risk as it is now covered by Pregnancy at a Young Age. Nicotine and Tobacco Use - changed risk name from Maternal Smoking to Nicotine and Tobacco Use. Definition/Cut off value now includes any product which contains nicotine and/or tobacco to include but not limited to cigarettes, pipes, cigars, electronic nicotine delivery systems (ENDS) (e.g., e-cigarettes, vaping devices), hookahs, smokeless tobacco (e.g., chewing tobacco, snuff, dissolvables), or nicotine replacement therapies (e.g., gums, patches); added additional background and counseling information. Environmental Tobacco Smoke Exposure - included information in Nicotine and Tobacco Use risk section.

06/22 Updated upper lead level cut-off for children to < 3.5ug/dL in Attachment 2.31A.

02/23 Updated 2.31A by replacing breast milk with breastmilk (one word).

10/23 Updated background, justification, and implications for WIC Nutrition Services in Attachment 2.31A for Low Hematocrit/Low Hemoglobin, Elevated Blood Lead Levels, Eating Disorders, Mental Illnesses, and Recipient of Abuse.

Pending Updated HIV/AIDS with new breastfeeding information. Updated CHART: Nutrition Risk Criteria to match updated 10/23 risks. Removed CHART from 2.31A and renamed it 2.31B Nutrition Risk Criteria. Updated Table of Contents.

1/26 Updated background, justification, and implications for WIC Nutrition services in Attachment 2.31A for Low Birth Weight, Food Allergies, and Inappropriate Nutrition Practices for Women. Updated Breastfeeding Complications-Woman and -Infant, Breastfeeding Infant and Woman with Nutritional Risk, and Pregnant Woman Breastfeeding to separate Breastfeeding Risks between high and low risks. As needed, included “consider contacting participant’s specialist RD”. Removed History of Low Birth Weight which is no longer a risk. Deleted Lists 1, 2, 3, 4, and 5 from Charts and Lists. Adjusted 2.31B Risks CHART to reflect changes to 2.31A.

Attachment 2.31A 1/7/2026

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Nutritional Risk Criteria: Guidelines for Interpretation

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Nutritional Risk Criteria: Guidelines for Interpretation contains all of the allowed nutritional risk criteria that may be applied when determining nutritional risk eligibility of women, infants, or children who apply for WIC Program benefits. No additional risk criteria may be used.

Each risk criterion is listed with its definition or cut-off value, justification, WOW code number, and participant category or categories to which it applies. Risk criteria that require nutrition care counseling or referral to a breastfeeding specialist are identified. Guidance is included for the evaluation of each risk criterion and participant focused counseling goals are included. If additional guidance is needed regarding the applicability of a risk criterion, State Agency Nutrition or Breastfeeding Services staff should be consulted.

Tables include information and procedures used to evaluate specific risk criteria. Frequently Asked Questions address common questions to assist certifiers in assigning specific risk criteria appropriately.

Nutritional risk documentation is required by Federal WIC regulations. Each participant record must document the specific nutritional risk condition(s) for which the applicant was found eligible to receive Program benefits. Appropriate documentation must be included in the record to substantiate the condition(s) and to validate conformance with the definition of the condition(s). Some nutritional risk criteria permit the applicant or caregiver to self-report that the applicant has a condition diagnosed by a physician. A self-reported diagnosis should prompt the CPA or CPPA to validate the presence of the condition by asking more pointed questions related to the diagnosis.

Definitions In order to ensure consistency in determining nutritional risk eligibility across the State, the following definitions should be applied during the applicant’s evaluation: Date of Conception: Occurs on the 14th day following the onset of the last menstrual period (LMP). Trimester: ● First trimester = conception through completed week 13 of gestation. ● Second trimester = week 14 through completed week 26 of gestation. ● Third trimester = week 27 through completed week 40 of gestation. Week of gestation: The last completed week of gestation as estimated by use of a State WIC issued gestation wheel. Routine: A feeding, dietary, or lifestyle practice that currently occurs on more than one occasion.

Priority Levels

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To be considered at nutritional risk, an applicant must exhibit at least one of the nutritional risk criteria listed in this attachment. Risk criteria fall into one of six priority levels: Priority I A pregnant or breastfeeding woman or an infant at nutritional risk because of: a. Detrimental or abnormal nutritional conditions detected by biological or anthropometric measurements; b. Other documented nutritionally related medical conditions; or c. Conditions that directly affect the nutritional health of an individual, including depression, smoking, alcoholism or drug use. Priority II Except for an infant who qualifies for Priority I, Priority II is: a. An infant younger than 6 months old born to a woman who was a Program participant during her pregnancy; b. An infant younger than 6 months old born to a woman who was not a Program participant during pregnancy but whose medical records document that the woman was at nutritional risk during the pregnancy due to nutrition conditions detectable by biochemical or anthropometric measurements or other documented, nutritionally related medical conditions that demonstrated the individual’s need for supplemental foods; or c. A breastfeeding mother of a breastfed infant who has been certified in the Program as Priority II. Priority III A child or postpartum, non-breastfeeding woman at nutritional risk because of: a. Detrimental or abnormal nutrition conditions detected by biochemical or anthropometric measurements; b. Other documented nutritionally related medical conditions; or c. Conditions that directly affect the nutritional status of an individual, including depression, smoking, alcoholism or drug use. Priority IV A pregnant or breastfeeding woman or an infant at nutritional risk because of: a. Dietary deficiencies that impair or endanger health; or b. Conditions that predispose the individual to inadequate nutritional patterns, including homelessness or migrancy; and c. Breastfeeding woman or infant at nutritional risk because of possibility of regression of nutritional status.

Priority V

A child at nutritional risk because of:

Attachment 2.31A 1/7/2026

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a. Dietary deficiencies that impair of endanger health; b. Conditions that predispose the child to inadequate nutritional patterns including homelessness or migrancy; or c. Possibility of regression of nutritional status. Priority VI A postpartum non-breastfeeding woman at nutritional risk because of: a. Dietary deficiencies that impair of endanger health; b. Conditions that predispose the individual to inadequate nutritional patterns including homelessness or migrancy; or c. Possibility of regression of nutritional status.

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Maryland WIC Program Scope of Practice – based on USDA WIC Nutrition Services Standards, August 2013. Definitions Scope of Practice - Encompasses a staff position’s range of unique roles and activities in the provision of information, counseling and support to WIC participants. Each staff position’s scope of practice is defined by the required qualifications and job-specific responsibilities for that position. High Risk – A designation of a participant based on the nutrition risk condition(s). Criteria for a participant being designated “high risk” are based on State agency policy. The nutrition services associated with “high risk” includes an individual care plan, more frequent nutrition education contacts and the provision of nutrition services by a registered dietitian (or other professional). Nutrition Services Staff Standard 3 Staff Qualifications, Roles and Responsibilities Section G. The local agency ensures that the Competent Professional Authority (CPA) has all of the following qualifications: 1. Is a physician or nutritionist (Master’s or Bachelor’s degree in Nutritional Sciences, Community Nutrition, Clinical Nutrition, Dietetics, Public Health Nutrition or Home Economics with emphasis in Nutrition), dietitian, registered nurse, physician’s assistant certified by the National Committee on Certification of Physician’s Assistants or certified by the State medical certifying authority, or a State or local medically trained health official. 2. Has successfully completed a competency-based training program on performing the duties of a CPA. 3. Has literacy and language skills appropriate to address the needs of diverse participants. Section H. The local agency ensures that the CPA performs the following roles and responsibilities within a participant-centered framework to meet participant needs: 1. Assesses and documents a participant’s risk(s). 2. Prescribes food packages. 3. Provides nutrition education, including breastfeeding promotion and support that is responsive to the identified needs/interests of each participant. 4. Identifies the need for individual care plans. 5. Refers participants to other health and social services and provides appropriate follow-up to referrals. 6. Implements individual care plans for low-low risk participants. 7. When the CPA is a qualified nutritionist, implements individual care plans for high-risk participants, otherwise, identifies and refers high-risk participants to a qualified nutritionist. 8. Documents nutrition services provided, including referrals and follow-up to referrals.

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9. Ensures that screening and referrals for lead testing and immunizations using a documented immunization record is performed. Section M. The local agency has access to a qualified nutritionist to provide nutrition services to high-risk participants. The nutritionist has the following qualifications: 1. Has successfully completed a training program approved by the State agency on the provision of WIC nutrition services to high-risk participants AND 2. (Preferably) has credentials of a Registered Dietitian (R.D.) or eligible for registration with the Academy of Nutrition and Dietetics’ Commission on Dietetic Registration; if applicable, has State license or certified as a nutritionist/dietitian OR 3. Holds a Bachelor’s degree in the field of nutrition from an accredited college or university OR 4. Holds a Master’s or Doctoral degree in nutrition from an accredited college or university.

Table of Contents Alcohol and Substance Use 11 Breastfeeding Complications or Potential Complications - Woman 15 Breastfeeding Complications or Potential Complications – Infant 17 Breastfeeding Infant of Mother at Nutritional Risk 19 Breastfeeding Mother of Infant at Nutritional Risk 20 Complementary Feeding Process 22 Depression 23 Drug Nutrient Interaction 25 Eating Disorders 28 Elevated Blood Lead 33 Failure to Thrive 40 Fetal Alcohol Spectrum Disorders (FASDs) 44 Fetal Growth Restriction (FGR) 49 Food Allergies 50

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Foster Care 57 Gestational Diabetes 58 High Maternal Weight Gain 59 High Weight-for-Length (Infants/Children < 24 Months of Age) 61 History of Birth of a Large for Gestational Age (LGA) Infant 62 History of Birth with Nutrition-Related Congenital or Birth Defect 63 History of Gestational Diabetes 64 History of Preeclampsia 65 History of Preterm or Early Term Delivery 68 History of Spontaneous Abortion, Fetal Death, Neonatal Loss 70 HIV/AIDS 71 Hepatitis 76 Homelessness 79 Hyperemesis Gravidarum 80 Hypertension and Prehypertension 82 Late to Prenatal Care 90 Large for Gestational Age (LGA) 91 Limited Ability of Caregiver to Make Feeding Decisions 92 Listeriosis 94 Low Birth Weight or Very Low Birth Weight 95 Low Head Circumference 100 Low Hemoglobin/Hematocrit 101

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Low Maternal Weight Gain 107 May Not Meet Dietary Guidelines 110 Medical Condition, Nutrition Related 111 Asthma, moderate persistent or severe persistent 112 Bronchitis 112 Cancer 112 Cardiorespiratory diseases 112 Celiac disease 113 Cerebral palsy 113 Cleft lip or palate 113 Congenital Hyperthyroidism 113 Congenital Hypothyroidism 113 Crohn’s disease 113 Cystic fibrosis 113 Developmental, Sensory, or Mental Disability 114 Diabetes Mellitus 114 Down Syndrome 114 Epilepsy 114 Gall Bladder Disease 114 Gastrointestinal anomalies 114 Gastroesophageal Reflux Disease (GERD 114 Hyperthyroidism 115 Hypothyroidism 115 Inborn Errors of Metabolism 115 Juvenile Idiopathic Arthritis 115 Lactose intolerance 115 Multiple sclerosis 117 Muscular dystrophy 117 Neural tube defects 117 Pancreatitis 117 Parasitic infections 117 Parkinson’s Disease 117 Peptic Ulcer 117 Pneumonia 117 Post Bariatric Surgery 118

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Postpartum thyroiditis 118 Pre-diabetes 118 Renal disease 118 Short bowel syndrome 118 Sickle cell anemia 118 Thalassemia 119 Tuberculosis 119 Ulcerative colitis 119 Meningitis 120 Mental Illnesses 122 Migrant Farm Worker; Migrant Farm Worker Status 133 Mother in WIC or WIC-Eligible While Pregnant 134 Multi-fetal Gestation 135 Neonatal Abstinence Syndrome 136 Nicotine and Tobacco Use 139 Nutrient Deficiency or Disease 143 Nutrition Practice – Child 146 Nutrition Practice – Infant 149 Nutrition Practice – Woman 153 Consuming dietary supplements with potentially harmful consequences. 155 Consuming a diet very low in calories and/or essential nutrients 158 Inadequate vitamin/mineral supplementation recognized as essential by national public health policy. 160 Pregnant woman ingesting foods that could be contaminated with pathogenic microorganisms. 162 Obese (Child) 165 Oral Health Conditions 167

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Overweight (Woman) 169 Overweight/At Risk of Overweight (Infant, Child) 171 Pica Practice 173 Possibility of Regression 175 Pregnancy at a Young Age 177 Pregnant Woman Currently Breastfeeding 181 Preterm or Early Term Delivery 182 Recent Major Surgery, Physical Trauma, Burns 186 Recipient of Abuse 188 Short Interpregnancy Interval 194 Short Stature/At Risk of Short Stature 196 Slowed/Faltering Growth Pattern 198 Small for Gestational Age (SGA) 201 Transfer 202 Underweight (Woman) 203 Underweight/At Risk of Underweight (Child) 205 Tables and Lists 207 Table A Low Hemoglobin/Hematocrit Cut-off Values for Women 208 Table W Weight Status of Pregnant, Breastfeeding and Postpartum Women 209 Table I-P Low Maternal Weight Gain 212 Table BMI.1: 2154 Abbreviated Body Mass Index (BMI) Table (Self-reported by mother or father) * 215 Table GAA: Calculation of Gestation-Adjusted Age for Infants Born at 37 Weeks or Earlier 216

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Alcohol and Substance Use (3721) Categories: PG, BE/BP, WPP Defined as: Pregnant Woman: ● Any alcohol use ● Any illegal substance use and/or abuse of prescription medications. ● Any marijuana use in any form.

Breastfeeding or Non-Breastfeeding Postpartum Woman: ● Alcohol Use: • 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. ● Any illegal substance use and/or abuse of prescription medications. ● Any marijuana use in any form (breastfeeding women only).

A woman identified with alcohol or marijuana use, any illegal substance use, or abuse of prescription medications should have Nutrition Care counseling. Best Practice: provide Nutrition Care follow-up in 3-6 months.

Breastfeeding is contraindicated for women identified with ongoing binge drinking, marijuana use, illegal drug use, or prescription drug abuse. See Neonatal Abstinence Syndrome (and below) for recommendations for Breastfeeding while taking Methadone or other supervised withdrawal medications. A woman compliant with methadone or other maintenance treatment may be certified using the Drug Nutrient Interaction risk by checking Supervised Drug Maintenance Program in the medical conditions drop down list.

Justification: Maternal substance use during and after pregnancy can have a long-term impact on both the mother and her child:

● Nutrition Issues: Vitamin and mineral deficiencies and malnutrition, damage to vital organs and nervous system, and decreased immunity.

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● Obstetrical and Prenatal Complications - Substance use (and withdrawal from them) during pregnancy may cause constriction of uterine blood vessels leading to insufficient blood flow to the placenta, separation of the placenta from the uterus, maternal hypertension, maternal hemorrhage, and/or premature labor. These complications may in turn increase risk of fetal loss, premature birth and still birth. ● Personal Health and Safety – Substance use is associated with increased likelihood of death by illness, accident or suicide; intimate partner violence; sexually transmitted diseases, unintended pregnancy, poor parenting practices, child neglect and abuse, physical and mental impairments, frequent arrests and incarceration, and estrangement for primary family and related support. ● Societal Impacts - Substance use is associated with an unstable family structure, separation and divorce, and potential for involvement of Child Protective Services (CPS). The Child Abuse Prevention and Treatment Act [42 U.S.C. § 5106a(b)] requires States to have policies and procedures in place to notify CPS agencies of substance-exposed newborns and to establish a plan of safe care for newborns identified as being affected by illegal substance abuse or having withdrawal symptoms resulting from prenatal drug exposure. For more information about State-specific requirements please see: https://www.childwelfare.gov/topics/systemwide/laws-policies/state/. Impact on Children - Children who are exposed to alcohol and other substances prior to birth can experience long-term cognitive, behavioral, social and emotional developmental consequences. The WIC Program has a mandate to provide information about the dangers of substance abuse to all newly certified participants or their caregivers and to provide referral information regarding substance abuse counseling and treatment to all pregnant, breastfeeding, or postpartum women. A woman who is pregnant may be receptive to supportive counseling that encourages her to avoid substances that can harm her fetus. The substance-abusing woman should be encouraged to seek treatment and be given information about substance abuse programs in her community. Alcohol can disrupt body functions by causing nutrient deficiencies of vitamins and minerals. Alcohol inhibits fat absorption and thereby impairs absorption of vitamins A, E, and D which are normally absorbed along with dietary fats. Deficiencies of minerals such as calcium, magnesium, iron, and zinc are common in people who misuse alcohol.

There is no safe consumption of alcohol during pregnancy. Exposure to alcohol in utero can damage the developing fetus at any stage and is the leading preventable cause of birth defects and intellectual and neurodevelopmental disabilities. Alcohol itself can also restrict nutrient flow to the fetus and can result in the infant being born with a Fetal Alcohol Spectrum Disorder (FASD). Fetal Alcohol Syndrome (FAS) is the most severe type of FASD, and can include abnormal facial features, growth and central nervous system problems as well as problems with learning, memory, attention span, communication, vision, or hearing. (See risk Fetal Alcohol Spectrum Disorder for more information.)

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Marijuana is the illicit drug used most frequently by women of child-bearing age. There is no known safe amount of marijuana use during pregnancy. When inhaled, the smoke goes into the lungs and immediately passes through the membranes and enters the bloodstream. THC can pass from the mother to the unborn child through the placenta if marijuana is ingested or inhaled during pregnancy. Children who are exposed to THC prior to birth can experience decreased academic ability, cognitive function and ability to remain attentive. Although some states have legalized marijuana for a variety of medical conditions upon a doctor’s recommendation, as well as for recreational use, marijuana has been shown to have negative effects on brain development. Therefore, it is recommended that pregnant and breastfeeding women not use marijuana. Opiates and synthetic narcotics (e.g., heroin, oxycodone, Vicodin, Narco, Percocet, morphine, dilaudid) have serious health risks associated with their use including endocarditis; coma or sudden death from overdose; risk of HIV; and, if injected, viral hepatitis and other infections. Substance use during pregnancy can lead to neonatal abstinence syndrome (NAS), withdrawal symptoms by an infant after birth. Prenatal opioid exposure increases the risk of low birth weight, stillbirth and sudden infant death syndrome (see Neonatal Abstinence Syndrome).

Alcohol and Substance Use during Breastfeeding The American Academy of Pediatrics (AAP) recommends that alcoholic beverages be minimized and limited to occasional intake for breastfeeding women as follows: ● Consult with a health care provider before consuming alcohol. ● Do so only if breastfeeding is well established, consistent and predictable. ● Minimize alcoholic beverages to occasional intake. ● Limit to a single alcoholic drink (not more than one unit of alcohol) and wait at least 1 ½ - 2 hours before breastfeeding or expressing milk that will be fed to the baby, to ensure the alcohol is not likely to be present in the milk. ● Breastfeed the infant or express human milk before consuming alcohol.

Due to the lipophilic nature of THC found in marijuana, it is tremendously fat-soluble and therefore is readily transferred to human milk. Marijuana can impact the neurobehavioral development of the infant, and the AAP considers it to be a contraindication to breastfeeding. The maternal use of illegal substances and the misuse of prescription medicine is a contraindication to breastfeeding. However, according to the AAP, appropriate maternal use of prescribed medication, other than marijuana, is not a categorical contraindication to breastfeeding. For situations in which the mother is undergoing pharmacologic therapy, the benefits of breastfeeding must outweigh the potential risk of substance exposure to the infant. For example, research has shown that adequately nourished narcotic-dependent mothers should be encouraged to breastfeed if they are enrolled and compliant in a supervised medication-assisted treatment program and have negative toxicology screens for HIV and illicit drugs. (See Neonatal Abstinence Syndrome.)

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For more information, please see the Substance Use and Prevention Manual: Screening, Education and Referral Resource Guide for Local WIC Agencies: https://wicworks.fns.usda.gov/resources/wic-substance-use-prevention-guide Implications for WIC Nutrition Services WIC staff are required to refer participants known or suspected of substance use, to existing assessment agencies for professional evaluation and treatment, as appropriate. In addition to providing referrals and coordinating/facilitating services, WIC’s role is to educate women participants, parents, and caretakers of participating infants and children about substance use–related problems with the intended effects of increasing participants’ access to information about the dangers of substance use and abuse during pregnancy and breastfeeding as well as postpartum. WIC also provides supplemental foods that are rich in the nutrients lost from alcohol and substance misuse. WIC staff can:

● Provide referrals (and follow-up on the referral) for professional assessment and treatment. Do not advise a woman who uses narcotics to stop using on her own. This step should be taken only under the supervision of a physician or treatment specialist. ● Encourage women to improve their lifestyle and health habits during pregnancy and postpartum, since the concern for fetal health and/or the desire to be a good role model can be a powerful motivator to reduce or stop substance use. ● Emphasize the importance of substance abuse treatment during the postpartum period to safeguard the health of the mother and reduce the risk in subsequent pregnancies ● Recommend the Dietary Guidelines for Americans to address nutrition deficiencies associated with substance use. ● Provide breastfeeding promotion and support to women enrolled in and compliant with supervised medication-assisted treatment programs. ● Recommend that the ingestion of beverages containing alcohol be minimized and limited to occasional intake for breastfeeding women. Provide instruction to wait at least 1 ½ - 2 hours after consuming up to one standard size alcoholic drink before breastfeeding or expressing milk that is fed to the baby. (If less than the appropriate amount of time has elapsed, the woman should be advised to express her milk and discard it.) ● Refer to community resources for alcohol and substance use support groups.

Procedure: Assess alcohol intake and substance use: * One serving or standard size drink is: ● 1 can beer (12 fluid ounces); ● 5 ounces wine; or ● 1/2 fluid ounces liquor (1 jigger gin, rum, vodka, whiskey (80 proof), vermouth, cordials, or liqueurs).

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Breastfeeding Complications or Potential Complications - Woman

(6021) Categories: BE/BP, PG Defined as: A breastfeeding woman with any of the complications or potential complications for breastfeeding below. Refer a woman identified with breastfeeding complications or potential complications to the CPA or IBCLC/DBE as indicated below. Best Practice: see participant immediately; if not possible, within five days.

Justification: Breastfeeding complications or potential complications can result in inadequate intake and/or Failure to Thrive in the infant. Complications can also cause the mother to produce a lower milk supply. Severe engorgement, often caused by shallow latch, infrequent or ineffective nursing, can result in inadequate milk transfer, pain and diminished milk supply. If not resolved, this can lead to additional complications, such as plugged/clogged ducts, mastitis, and abscess. A plugged/clogged duct results from obstruction of a milk duct. Failure of milk to come in by 4 days postpartum could result from maternal illness or perinatal complications. Persistent nipple pain, cracks, and bleeding are symptomatic of a shallow latch and may promote infection. Impaired milk flow can lead to a diminished milk supply and inadequate intake by the infant. Latch-on by the infant can be difficult when nipples are flat or inverted but can be improved by appropriate interventions. Mastitis is a breast infection causing a flu-like illness that can threaten the health of the mother as well as the success of breastfeeding. Medical treatment is necessary. The woman over 40 years of age may be at risk of a reduced milk supply as a result of hormones and breast changes. Tandem nursing may increase the nutritional requirements of the mother. Care must be taken to ensure adequacy of breastmilk.

Procedure: Determine if the woman has any of these complications or potential complications: The following risks can be handled by a CPA or IBCLC/DBE:

● engorgement in first week—review positioning and latch. Provide comfort techniques, as needed. ● flat or inverted nipples--review positioning and latch. Babies latch onto the breast, not the nipple. ● age 40 years or older--review signs of getting enough milk and provide suggestions for increasing milk supply. If milk supply seems inadequate with appropriate stimulation, refer to IBCLC/DBE. ● tandem nursing (breastfeeding siblings who are not twins) – Review signs of getting enough milk. Check adequacy of weight gain for both children. Review feeding routine and discuss feeding the infant first, if older sibling is taking more milk supply.

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The following risks shall be handled by an IBCLC/DBE:

 Severe breast engorgement or engorgement after first week – review positioning, engorgement, and breast soreness. Teach lymphatic drainage. Provide comfort techniques, as needed.  Plugged ducts or recurrent plugged ducts – teach lymphatic drainage. Assess what might promote plugged ducts and discuss avoiding those things.  Cracked, bleeding, severely sore nipples – review positioning and latch. Consider breast shells, purified lanolin, nursing pads, and use of expressed breastmilk to heal, as appropriate.  Mastitis – advise mother to continue nursing and seek medical advice from her healthcare provider; Remind mother that infection is in the breast tissue, not in her milk. Encourage completing prescription provided by HCP. Teach lymphatic drainage; Assess what may have contributed to development of mastitis and discuss ways to avoid such.

Refer to the Maryland WIC Breastfeeding Kardex and Breastfeeding Protocols for information about the complications above.

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Breastfeeding Complications or Potential Complications – Infant (6031) Categories: IBE/IBP Defined as: A breastfed infant with any of the complications or potential complications for breastfeeding. An infant with breastfeeding complications or potential complications should be referred to the CPA or IBCLC/DBE as indicated below. Best Practice: see participant immediately; if not possible, within 5 days. Justification: ● Breastfeeding complications or potential complications can result in inadequate intake and/or Failure to Thrive in the infant. Complications can also cause the mother to produce a lower milk supply. ● A weak or ineffective suck may be due to prematurity, sleepiness, or a medical or physical problem and can result in inadequate breastmilk intake and a diminished milk supply in the mother. ● Difficulty with latch on may be due to maternal nipple conditions or positioning. ● Inadequate urination or stooling may be an indicator of an inadequate intake of breastmilk. The infant is at risk of Failure to Thrive and the mother, of a diminished milk supply. ● Jaundice occurs when bilirubin accumulates in the blood and the skin or whites of the eyes take on a yellowish color. Jaundice can be caused by a variety of reasons, which range from normal physiologic processes to true medical problems. Sometimes early jaundice is caused by inadequate breastmilk feeding and can be overcome by frequent breastmilk feedings. It is best to refer individuals with jaundice to their health care professionals who can determine the cause and recommend treatment.

Procedure: Using collected information, determine if the breastfed infant has any of these complications or potential complications for breastfeeding: The following risks can be handled by the CPA or IBCLC/DBE ● less than 6 wet diapers per day – babies who are less than 6 days old should have at least one wet diaper per day of life (1 on day one, 2 on day two, etc.). Babies who are 6 days old, or older should have at least 6 wet diapers per day. ● inadequate stooling (for age as determined by a physician or other health care professional) – baby should have at least 3 stools/day from day 6 to day 30. After that, stooling is varied by baby. Some have daily stools while others may stool once every other day and others may have as little as one bowel movement per week.

The following risks shall be handled by the IBCLC/DBE:  Weak or ineffective suck – review positioning and latch. Provide special latch techniques, as appropriate, and suggest waking a sleepy baby, if needed. Provide information for suck training, if appropriate.  Difficulty latching on to the breast – review various positions and latch. Provide suggestions for pillow placement under the baby and /or mother’s arm(s), as needed.

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 Jaundice – Refer to infant healthcare provider, if not already seen for this condition. Provide recommendations for frequent feeding and waking baby for feeds at least every three hours, if appropriate based on the type of jaundice.

Refer to the Maryland WIC Breastfeeding Kardex and Breastfeeding Protocols for information about the complications above.

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Breastfeeding Infant of Mother at Nutritional Risk (7021) Categories: IBE/IBP Defined as: Breastfeeding infant of mother at nutritional risk. Justification: A breastfed infant is dependent upon the mother’s milk as the primary source of nutrition. Special attention should, therefore, be given to the health and nutritional status of the mother. Procedure: This risk criterion shall be assigned to the breastfeeding infant of a mother at nutritional risk. The priority level of the risk criterion is based upon the mother’s priority, I or IV. Refer breastfeeding mothers with any of the risk criteria below to the CPA for Nutrition Care counseling: ▪ Underweight ▪ Low Hemoglobin/Hematocrit ▪ Elevated Blood Lead ▪ Breastfeeding Complications/Potential Complications – follow procedures for Breastfeeding Complications risk factor ▪ Pregnant Woman Currently Breastfeeding ▪ Alcohol or Illegal Drug Use ▪ Maternal Smoking ▪ Medical Condition, Nutrition-Related Review collected information before providing counseling. Refer to the Maryland WIC Breastfeeding Kardex and Breastfeeding Protocols. Participant Focused Counseling: ● The mother of a breastfed infant can: o State the eating, feeding, and lifestyle practices she can follow to promote optimal health, growth, and development. o State strategies to follow as her infant grows and circumstances change, to ensure breastfeeding success.

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Breastfeeding Mother of Infant at Nutritional Risk

(6011) Categories: BE/BP, PG Defined as: A breastfeeding woman whose breastfed infant has been determined to be at nutritional risk. Mother must be at the same priority as at-risk infant. Justification: A breastfed infant is dependent upon the mother’s milk as the primary source of nutrition. Special attention should be given to the health and nutritional status of the mother. The interconceptional period is an opportune time to assist the woman in adopting healthful dietary and lifestyle practices. Procedure: This risk criterion shall be assigned to a breastfeeding mother of an infant at nutritional risk. The priority level of the risk criterion is based upon the infant’s priority, I, II, or IV. Refer participants whose infants have been identified with any risk criteria below to the CPA or IBCLC/DBE as indicated for Nutrition Care counseling and breastfeeding support: The following risks can be handled by a CPA:  Low Hemoglobin/Hematocrit  Elevated Blood Lead  Medical Condition, Nutrition Related – work with IBCLC/DBE if participant has accompanying Breastfeeding complications

The following risks shall be handled by the IBCLC/DBE: ● Underweight – assess for milk transfer and provide suggestions, as needed. Check position and latch. Consider test weights and/or periodic weight checks. ● Inadequate Growth – assess for milk transfer and provide suggestions as needed. Check position and latch. Consider test weights and/or periodic weight checks. ● Failure to Thrive – assess for milk transfer and provide suggestions as needed. Check position and latch. Consider test weights and/or periodic weight checks. ● Breastfeeding Complications/Potential Complications- follow procedure for Breastfeeding Complications risk factor ● Low Birth Weight – assess for milk transfer, adequate intake/feedings, and provide suggestions as needed. Check position and latch. Consider test weights and/or periodic weight checks. ● Prematurity – assess for milk transfer, adequate intake/feeding, and provide suggestions as needed. Check position and

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latch. Consider test weights and/or periodic weight checks. ● Small for Gestational Age – assess for milk transfer, adequate intake/feeding. Check position and latch. Consider test weights and/or periodic weight checks. ●

Review dietary and lifestyle practices. Refer to the Maryland WIC Breastfeeding Kardex and Breastfeeding Protocols. Participant Focused Counseling: The breastfeeding mother can state the food and lifestyle choices she can make to promote optimal health for herself and her breastfed infant.

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Complementary Feeding Process (4281) Categories: IBE, IBP, IFF, C-1 Defined as: An infant or child who has begun to or is expected to begin to 1) consume complementary foods and beverages, 2) eat independently, 3) be weaned from only consuming breastmilk or infant formula, or 4) transition from a diet based on infant/toddler foods to one based on the Dietary Guidelines for Americans is at risk of inappropriate complementary feeding. Justification: Complementary feeding is the gradual addition of foods and beverages to the diet of an infant and young child. The process of adding complementary foods should reflect the physical, intellectual, and behavioral changes as well as the nutrient needs of the infant or child. Caregivers may not recognize signs of developmental readiness and may offer foods and beverages that are inappropriate in type, amount, consistency, and/or texture. To manage the process of complementary feeding successfully, caregivers must make decisions about what, when, where, and how to offer foods according to the child’s: ● Energy and nutrient requirements ● Fine, gross, and oral motor skills ● Emerging independence and desire to learn to self-feed ● Need to learn healthy eating habits through exposure to a variety of nutritious foods.

Procedure:

This risk factor may be assigned only to infants and children from 4 through 23 months and for whom a complete nutrition assessment has been performed and for whom no other risk is identified. Participant Focused Counseling: Anticipatory guidance is the focus of the session. The caregiver can state the stage-appropriate feeding practices she can follow that promote optimal health, growth, and development of her child.

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Depression (3611) Categories: PG, BE/BP, WPP Defined as: Presence of clinical depression, including postpartum depression, diagnosed, documented, or reported by a physician, clinical psychologist, or someone working under a physician’s orders, or as self-reported by applicant/participant/caregiver. A participant identified with depression should have Nutrition Care counseling. Best Practice: Provide Nutrition Care follow-up in 3-6 months. Justification: Depression is common during pregnancy, especially in the last trimester. Women who experience depression during pregnancy are less likely to seek prenatal care. They may also suffer from episodes of nausea/vomiting or initiate/increase the use of drugs, alcohol and nicotine. They are at risk for preeclampsia, preterm delivery or delivery of low birth weight infants, and have higher perinatal mortality rates.

Depression among pregnant adolescents is almost twice as high as among their adult counterparts and non-pregnant adolescents, because the physiologic and psychological changes of pregnancy are superimposed on the normal developmental changes of adolescence. Teens who are under stress, lack social and/or family support, experience significant loss, or have attention, learning, or conduct disorders are at greater risk for developing clinical depression. Depression in young people often occurs with mental disorders, substance abuse disorders, or physical illnesses, such as diabetes. They are more likely to delay or refuse prenatal care and have subsequent short-interval pregnancies (within 24 months) and poor pregnancy outcomes.

Postpartum depression is related to the influence of reproductive hormones on stress hormones, immune markers, or sleep quality, and lasts longer than “baby blues” which peak four to five days after delivery and resolve by the 10th postnatal day.

Breastfeeding is protective of maternal mood. Breastfeeding reduces the stress responses commonly found in the post-partum period. The hormones associated with lactation, oxytocin and prolactin have both antidepressant and anxiolytic (anti-anxiety) effects. (However, breastfeeding problems like nipple pain can increase the risk of depression and should be addressed promptly.)

Breastfeeding mothers may experience more restful sleep. It is well documented that new mothers experience sleep disturbances, independent of their feeding choices. This lack of sleep can lead directly to an increase in inflammation and increase in maternal stress, which can lead to depression in the early postpartum period. Several small studies showed that breastfeeding mothers actually get more sleep than their bottle/formula-feeding counterparts.

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Procedure:

During the nutrition assessment, be sensitive to questions related to depression. If the woman responds affirmatively about feelings that have lasted more than two weeks, encourage follow-up with her health care provider, other resources available in the local area, and/or reliable resources online (see below).

Participant Focused Counseling:

Awareness of a mother’s mental health status can assist the WIC nutrition professional in providing individualized breastfeeding support. Depressed mothers should be encouraged to continue breastfeeding as it can protect infants from the harmful effects of maternal depression. Additionally, if breastfeeding is going well, it may assist in a mother’s recovery from depression.

Nutrition issues that should be discussed: ● Eating a healthy diet. Research has identified likely links between nutrient deficiency and mood for folate, vitamin B-12, vitamin D, calcium, iron, selenium, zinc, and Omega-3 fatty acids ● Including fish as recommended in the Dietary Guidelines for Americans, available from:https://www.myplate.gov/life- stages/pregnancy-and-breastfeeding ● Asking her health care provider about omega-3 fatty acid supplements ● Being physically active. Exercise is anti-inflammatory and boosts mood. Routine exercise helps individuals with depression lower inflammation over time and is a positive coping strategy for stress. Exercise can help boost mood in the short term, but it is the cumulative impact of regular exercise that can stave off depression significantly. ● Getting enough sleep ● Referrals for counseling care. The following are web-based resources for State and local agencies to locate reliable services: • The Substance Abuse and Mental Health Services Administration (SAMHSA) Mental Health Treatment Locator is found at http://www.samhsa.gov/ and provides comprehensive information on mental health resources and/or facilities. This website provides informational materials about different mental health conditions. The SAMHSA's National Helpline is also available 24- hour-a-day, 365-day-a-year to provide referrals to local support networks and resources for individuals dealing with mental health issues or substance abuse problems at 1-800-662-HELP (4357). • MentalHealth.gov provides one-stop access to U.S. government mental health information and resources from the Centers for Disease Control and Prevention, FindYouthInfo.gov, MedlinePlus and National Institutes of Health, National Institute of Mental Health (NIMH) and SAMHSA. Resources are available for the general public, health and emergency preparedness professionals, policy makers, government and business leaders, school systems and local communities. • Mental Health America's website can be used to help individuals locate mental health treatment services, including affordable treatment for those without insurance, in their community. This website also includes links to other sites that provide specialized treatment referrals for specific illnesses and information about the specific illness.

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Drug Nutrient Interaction (3571) Categories: ALL Use of prescription or over-the-counter drugs or medications that have been shown to interfere with nutrient intake, absorption, distribution, metabolism, or excretion, to an extent that nutritional status is compromised. A participant identified with this risk criteria should have Nutrition Care counseling. Best Practice: Consider contacting the participant’s Specialist RD before counseling and assigning food package. Justification: The focus of this risk is on the impact that medications may have on an individual’s nutritional status, which can be physical, chemical, physiologic, and/or pathophysiologic. Over-the-counter and prescription medications may impact nutritional status directly or indirectly. Direct impacts of medications on nutritional status include changes to: • The absorption and the distribution of the nutrient • The metabolism of the nutrient • The rate at which the nutrient is excreted.

Direct impacts of medications may be severe enough to lead to nutrient deficiency and/or nutrient toxicity, which can then impact bodily systems such as bone formation, immune system function, and energy metabolism.

Indirect impacts of medications on nutritional status include: • Changes to appetite • Changes to taste and smell • A dry or sore mouth • Epigastric distress, nausea, vomiting, diarrhea, and/or constipation.

Indirect medication side-effects can impact the amount and/or variety of foods eaten and may lead to weight changes and/or the development of nutrient deficiency diseases. Some medications that are known to cause the indirect side-effects listed above include pain medications, such as oxycodone and hydrocodone, and medications to treat cancer. Research on the overall incidence and prevalence of nutrient and drug interactions remains limited. The following table provides a summary of medications that are commonly used and their associated potential impacts on nutritional status. For a comprehensive list of food and medication interactions, WIC programs should reference resources such as the Physician’s Desk Reference or the most current Food Medication Interactions guide. Additional information on medications can also be found online at: https://medlineplus.gov/druginformation.html.

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Breastfeeding and Medication Use Medication use in the postpartum period can sometimes pose challenges to breastfeeding. While many medications are safe to use while breastfeeding, some are not compatible with breastfeeding or should be used with caution. If breastfeeding women require medication, then medications should be chosen that are not contraindicated with breastfeeding, if possible. It is thus very important for the mother to discuss her breastfeeding status and goals with her health care provider to determine the best infant feeding and medication plan. Information and recommendations on the use of specific medications while breastfeeding can be found at the National Institutes of Health’s LactMed Drugs and Lactation Database (https://www.ncbi.nlm.nih.gov/books/NBK501922/ ) and in the most recent version of Hale’s Medication and Mothers’ Milk. Note that while these resources provide useful information, WIC staff need to refer women to their health care provider to discuss the safety of taking specific medications while breastfeeding. For additional guidance on breastfeeding and medication use, please refer to the Food and Nutrition Service’s WIC Breastfeeding Policy and Guidance, specifically section 1.4, “When Mothers Should Avoid Breastfeeding" (https://wicworks.fns.usda.gov/sites/default/files/media/document/WIC-Breastfeeding-Policy-and-Guidance_1.pdf ). Implications for WIC Nutrition Services For participants who are currently taking a medication with known nutrient interactions, WIC staff can: ● Refer the participant/caregiver to their health care provider or pharmacist to discuss the potential nutrient related side-effects and weight fluctuation of medications they take. ● Encourage improved intake of whole grains, legumes, dairy, lean protein, fruits, and vegetables, as appropriate. ● Inform the participant/caregiver of foods or beverages that provide nutrients that may be impacted by the medication. ● Provide education on nutrient-dense foods (when appropriate), meal frequency, portion sizes, and fluid intake when medications induce poor appetite, nausea, or vomiting. ● Provide education on fiber and fluid intake and physical activity to manage constipation related side-effects. ● Provide education on fluid intake, moist foods, and dental care when medications cause a dry mouth. ● Refer women who are either breastfeeding or planning on breastfeeding to their health care provider to determine the best infant feeding and medication plan.

Additional Resources for WIC Staff: • For information on food and medication interactions: o Physician’s Desk Reference (most recent edition) o Food Medication Interactions (most recent edition)

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o National Institute of Health’s Medline Plus Database on Drugs, Herbs and Supplements (https://medlineplus.gov/druginformation.html)

For information and recommendations on the use of medications while breastfeeding: o Food and Nutrition Service’s WIC Breastfeeding Policy and Guidance, specifically section 1.4 “When Mothers Should Avoid Breastfeeding" (https://wicworks.fns.usda.gov/sites/default/files/media/document/WIC-Breastfeeding-Policy-and-Guidance_1.pdf ) o National Institutes of Health’s LactMed Drugs and Lactation Database (https://www.ncbi.nlm.nih.gov/books/NBK501922/ ) o Hale’s Medication and Mothers’ Milk (most recent edition) Medication Medication Purpose Impact on Nutritional Status Amiloride (Midamor) Diuretic Loss of appetite, nausea, diarrhea, vomiting. May reduce magnesium excretion Calcium Carbonate (Tums) Antacid Vomiting, constipation, loss of appetite; decrease absorption of iron, zinc, magnesium, fluoride Chlorthalidone (Hygroton) Diuretic Upset stomach, vomiting, diarrhea, loss of appetite; increased zinc excretion Ciprofloxacin Antibiotic Nausea, vomiting, stomach pain, diarrhea; decreased zinc absorption Furosemide (Lasix) Diuretic Constipation, diarrhea; increased magnesium excretion w/chronic use Lansoprazole (Prevacid) & Omeprazole (Prilosec) Proton pump inhibitors Constipation, nausea, diarrhea; reduced iron absorption, poor iron repletion w/supplements Levothyroxine (Synthroid, Levothoid, Levoxly) Thyroid hormone Diarrhea, vomiting; decreased appetite and weight loss Metformin Antihyperglycemic Diarrhea, indigestion, constipation; decreased appetite; decreased absorption of folate and vitamin B12 Methadone Analgesic (Opioid) Weight gain; dry mouth, nausea, vomiting, constipation Ondansetron (Zofran) Antiemetic, antinauseant Constipation; rarely, decreased potassium levels Phenobarbital Antiepileptic Nausea, vomiting; decreased vitamin D & K; decreased calcium absorption; decreased folate levels Prednisone Corticosteroid Calcium depletion/osteoporosis; Calcium & vitamin D supplement recommended with long- term use. Rantidine (Zantac) Antiulcer, AntiGERD, Antisecretory Constipation, diarrhea, nausea, vomiting; decreased iron and vitamin B12 absorption Sertraline (Zoloft) Antidepressant Nausea, diarrhea, constipation, vomiting; anorexia and weight loss Sulfasalazine Ulcerative Colitis Diarrhea, appetite loss, vomiting; decreased folate absorption

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Eating Disorders (3580) Categories: PG, BE/BP, WPP Defined as: severe disturbances in a person’s eating behaviors and related thoughts and emotions. Eating disorders include but are not limited to: Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Binge Eating Disorder (BED). The presence of an eating disorder diagnosed, documented, or reported by a physician or someone working under a physician’s orders, or as self-reported by applicant/participant/caregiver.

A participant identified with an eating disorder should have Nutrition Care counseling. Consider contacting the participant’s Specialist RD before assigning food package. Best Practice: Provide Nutrition Care follow-up in 3-6 months. Justification: Eating disorders are caused by a complex interaction of genetic, biological, behavioral, psychological, and social factors. They are extremely prevalent in the United States and associated with the highest morbidity and mortality of any mental illness. Comorbidities that commonly occur with eating disorders include anxiety, bipolar disorder, depressive disorders, and substance use disorders. If left untreated, eating disorders can be serious and even fatal. Eating disorders are associated with an increased risk of premature death, including from electrolyte disturbances, dehydration, suicide, and alcoholism, among other causes. Total annual mortality attributable to eating disorders amounts to 10,200 deaths per year, equating to 1 death every 52 minutes. The three most common eating disorders are: • Anorexia Nervosa (AN) (3582) – involves a severe restriction of calories; there may be a fear of weight gain and strict “rules” about eating. AN is a syndrome of self-starvation involving significant weight loss of 15 percent or more of ideal body weight. • Bulimia Nervosa (BN) (3581)– involves recurrent episodes of binge eating followed by compensatory behaviors collectively referred to as purging and can include exercise as such a behavior. This could include vomiting or using laxatives or exercising excessively. Patients with BN are, by definition, at normal weight or above. • Binge-Eating Disorder (BED) (3583)– involves recurrent episodes of binge eating which are characterized by eating an amount of food that is larger than what most people would eat in a similar period of time under similar circumstances and a sense of lack of control over-eating during the episode. Unlike BN, periods of binge-eating are not followed by purging or

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excessive exercise. As a result, people with binge-eating disorder often are overweight or obese. In the U.S., BED is the most common type of eating disorder. Other less common types of eating disorders include Avoidant/Restrictive Food Intake Disorder (ARFID) and Rumination Disorder. Eating disorders are typically associated with thin, white, affluent females. However, there is very little research among low- income communities, so there is limited ability to assess this pathology among other groups.

Complications of Eating Disorders during Pregnancy and Postpartum Research suggests that about 7% of pregnant women are affected by an eating disorder. Eating disorders have been linked to poor health outcomes for pregnant and postpartum women including depressive symptoms during pregnancy*, postnatal depression*, and poor infant attachment or maternal bonding. Pregnant women with eating disorders may have specific maternal macro- and micronutrient deficiencies. When energy and nutrient stores are low and not sufficiently restored through healthy eating, as in AN, the mother can become severely malnourished which can lead to depression, exhaustion, and many other serious health complications. Women with BN who continue to purge during pregnancy are at increased risk of dehydration, chemical imbalances, or even cardiac irregularities. Some women experience an exacerbation of eating disorder symptoms during pregnancy including body image disturbances and abnormal stress from normal pregnancy weight gain whereas other women with eating disorders may experience relief from their symptoms during pregnancy. However, even when an eating disorder improves during pregnancy, eating disorder symptoms frequently relapse to their highest level almost immediately after delivery.

For women with eating disorders, pregnancies are often unplanned and eating disorder pathology is associated with delayed development, prematurity, hypotrophy, stillbirth, difficult delivery, and postnatal depression. The following table summarizes the health outcomes for both the woman and infant that may result from an eating disorder.

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Possible Health Outcomes for Women and Infants by Eating Disorder

Anorexia Nervosa Bulimia Nervosa Binge-Eating Disorder* Health Outcomes for Woman • Higher risk of cesarean delivery • Hyperemesis • Higher risk of anemia • Antepartum hemorrhage† • Hypertension • Stillbirth • Miscarriage • Malnutrition • Electrolyte imbalance • Fluid imbalance • Bone loss • Changes in brain function Higher risk of cesarean delivery • Hyperemesis • Stillbirth • Miscarriage • Malnutrition • Electrolyte imbalance • Fluid imbalance • Postpartum depression • Wearing down of tooth enamel • Heart problems Higher risk of cesarean delivery • Gestational hypertension • Gestational diabetes • Bone loss • Heart attack • Stroke • Arthritis • High cholesterol • Miscarriage • Delivery complications • Postpartum depression Health Outcomes for Infant • Underweight • Low birthweight • Small-for-gestational- age • Slow fetal growth • Intrauterine growth restriction • Preterm birth • Microcephaly • Perinatal death • Dehydration • Chemical imbalance • Cardiac irregularities • Microcephaly • Preterm birth • Low birthweight • Large-for-gestational-age *Added as a diagnosis to the DSM-5 in 2013, there is limited research on the health outcomes of BED for both the woman and infant. † Bleeding from the genital tract in the second half of pregnancy (34)

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Complications of Eating Disorders While Breastfeeding Research is inconclusive as to whether eating disorders affect breastfeeding rates. Some research shows that women with a history of eating disorders may be slightly less likely to initiate breastfeeding, whereas other research shows no difference in initiation and cessation of breastfeeding between mothers with and without eating disorders. Although there is limited research on the impact of eating disorders on breastfeeding rates, returning to eating disorder behaviors in the postpartum period may result in a shorter duration of breastfeeding and may impact the interaction a mother has with her infant as well as her relationship with her partner.

Diagnosis and Treatment The American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-5) outlines the diagnostic criteria that must be met to diagnose an eating disorder. A person with an eating disorder may display one symptom or many, and a person’s appearance may not always display the amount of physical or emotional danger they are experiencing. Someone that appears to be a “healthy weight” can have an eating disorder and need treatment. Although there are formal guidelines that professionals use to diagnose eating disorders, as specified in the DSM-5, unhealthy eating behaviors exist on a continuum and the severity of individual criteria are considered in making a diagnosis. There is no standardized screening for eating disorders during pregnancy and it is uncommon for a medical practitioner to screen pregnant patients for disordered eating symptoms. Women are often reluctant to inform medical staff of their struggle with eating disorders, likely the result of anxiety and guilt about harming the fetus. Lack of screening and diagnosis has the potential to increase adverse health outcomes for women who do not receive treatment or assistance to address the eating behavior symptoms and/or pathology. Treatment of eating disorders depends on the disorder and symptoms displayed, but typically involves psychotherapy. Depending on the severity of eating disorder symptoms, admission to a specialized residential or hospital-based treatment program can be lifesaving. Treatment plans are tailored to the individual’s needs, should involve a multidisciplinary team such as a therapist, dietitian, and physician, and may include one or more of the following: • Individual, group, and/or family psychotherapy • Medical care and monitoring • Nutritional counseling • Medications Additionally, obtaining adequate health insurance coverage for inpatient treatment for eating disorders remains a challenge due to the apparent gap between research on variables associated with outcomes and the formulas used for reimbursement.

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Implications for WIC Nutrition Services The role of WIC is not to diagnose or treat an eating disorder but to reinforce and support the medical nutrition therapy that the WIC participant is receiving. Discussing eating disorders, body weight, weight loss, or weight gain can trigger behaviors associated with eating disorders. Therefore, it is important for WIC staff to be sensitive when discussing eating disorders. For individuals affected by an eating disorder, staff can: • If available, refer the participant to a health care provider (HCP) with expertise in eating disorders. The participant can work with the provider to create a plan for healthy eating and weight gain. • Reinforce nutrition counseling/advice that is provided by the eating disorder treatment team/plan. • Encourage the participant to be honest with their HCP and WIC staff regarding past or present struggles with an eating disorder or disordered eating. • Encourage the participant to seek or refer the participant to individual counseling and/or support groups during and after pregnancy to help them cope with their concerns and fears regarding food, weight gain, body image, and the new role of parenting. • Encourage the participant to attend other classes on pregnancy, childbirth, child development, and parenting skills. • Educate participants that it is important for their prenatal HCP to weigh them as this information is essential to tracking the health of the baby . • Encourage the participant to discuss with their HCP about blind weighing: standing on the scale backwards, and not sharing the number with them. • When possible, the CPA should coordinate with the participant’s HCP to obtain referral data such as height, weight gain, etc. • Encourage the participant to talk to their HCP before attending a prenatal exercise class to make sure it fits with their recovery plan. • Modify conversation with the participant to avoid topics that are likely to provoke eating disordered behaviors (e.g., topics related to body weight, body shape, and calories). Participant Centered Counseling When a participant reveals an eating disorder, it is appropriate to affirm them for being aware of the eating disorder, sharing

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the information with the WIC certifier, and trusting the certifier with the information. During the Nutrition Care counseling, the CPA can: • Invite the participant to share the recommendations of her HCP. • Ask permission to contact the HCP, so that the CPA can support the HCPs recommendation, and, where possible, help create a food package that supports those recommendations. • Engage the participant in sharing the steps already taken and progress made and plans for next steps. • The CPA can ask permission to offer ideas for incorporating foods that interest the participant. • The CPA can offer to discuss any issues the participant is having with foods in the WIC food package and offer options for the participant to consider.

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Elevated Blood Lead (2111) Categories: All Defined as: Children: Blood lead level (BLL) of ≥ 3.5 μg/deciliter within the past 12 months* *Current Centers for Disease Control and Prevention reference value. Women and Infants: Blood lead level (BLL) of ≥ 5 μg/deciliter within the past 12 months* *Current Centers for Disease Control and Prevention reference value. A child participant who has a venous blood lead level of ≥ 3.5 ug/dl or higher should have Nutrition Care counseling. A woman or infant participant who has a venous blood lead level of ≥ 5 ug/dl or higher should have Nutrition Care counseling. Best Practice: see participant immediately; if not possible, within five days. Provide Nutrition Care follow up in one month. Each who answers No or Don’t Know to the question, Have you had a Blood Lead test? should be offered the Lead Screening Tool and directed to discuss any positive responses with their health care provider. Justification: The toxic effects of lead have been observed in every organ system and there is no known safe level of exposure. Even low levels of lead exposure can have harmful and irreversible neurological, renal, cardiovascular, hematological, immunological, reproductive, and developmental effects. Evidence also suggests that lead exposure can have detrimental respiratory, hepatic, endocrine, gastrointestinal, musculoskeletal, and ocular effects, and increase risk of all cancers. Lead exposure during pregnancy or postpartum can affect the mother, the developing fetus, and breastfeeding infant during critical stages of development. Lead readily crosses the placenta, and lead exposure during pregnancy is associated with increased risk of miscarriage, preterm birth, and decreased birth size (weight, length, and head circumference); fetal brain, kidney, and nervous system damage; and lifelong learning and behavior problems. Lead can also transfer from maternal blood to breastmilk, and ultimately to the breastfeeding infant, although the amount of blood lead transfer appears to be small with little impact on the infant. Lead exposure is most common in young children because they have greater contact with lead sources and higher

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gastrointestinal absorption. Children’s developing nervous systems are more vulnerable to lead exposure. Elevated BLL in children has been associated with adverse neurological and behavioral outcomes including learning and memory, attention, hyperactivity, impulsivity, irritability, delinquency, and altered visual-motor integration, dexterity, postural sway, and changes in hearing and vision.

Prevalence of Lead Exposure Over the four decades from 1976 to 2016, federal regulations on use of lead in gasoline, plumbing and other consumer products helped reduce population BLLs significantly among children ages 1 to 5 years from 15.2 to 0.83 ng/dL, and among women of childbearing age (15 to 49 years) from 10.37 to 0.61ng/dL in the U.S.

Despite this progress, sociodemographic disparities have persisted. Low-income and certain racial/ethnic minority populations continue to be disproportionately affected by lead exposure because these groups more commonly live in communities and housing with greater lead contamination.

Disparities Among Women Lead exposure is more prevalent among certain subpopulations, including women with low-income, of older age, born outside the U.S., of “other” race/ethnicity (i.e., other than black, white, Hispanic, or Mexican American), previous pregnancies, and a higher number of live births. In particular, recent immigrants, migrants, and refugee women are at increased risk of lead exposure since they have commonly lived in areas where ambient lead exposure is relatively high. These groups may also be more likely to consume products contaminated with lead such as traditional remedies, herbal supplements, spices, candies, cosmetics, and jewelries or amulets.

Disparities Among Children Between 2011 to 2016, an estimated 262,235 children ages 1 to 5 years had BLLs >5 µg/dL (note: the studies summarized here were conducted prior to October 2021, when the BLRV was >5 μg/dL). Subpopulations with greater prevalence of lead exposure include children 1 to 2 years old, non-Hispanic Black race/ethnicity, low- income (including children participating in WIC), and children born in Mexico, living in older housing, and living in the Northeast or Midwest regions of the U.S. compared to West and South regions.

Between 1999 and 2016, population mean BLL was greatest for non-Hispanic Black children at all ages under 5 years compared to other racial/ethnic groups (non-Hispanic White, Hispanic, and Other) as was the proportion of non-Hispanic Black children ages 1 to 5 with BLL ≥5 μg/dL. Further, greater proportions of non-Hispanic Black children had higher BLLs,

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with Black children accounting for all children with BLL ≥40 μg/dL. Lead exposure is also more common among refugee children in the U.S., particularly among children from certain countries of origin and country of last residence (e.g., India, Afghanistan, Burma, and Nepal). Children, as well as adults, may also be at risk for elevated BLL after arrival due to continued use of lead- contaminated spices, candies, traditional cosmetics, and cookware.

Sources of Lead Exposure The most common sources of lead exposure in the U.S. are lead-based paint chips and dust, lead-contaminated soil, and lead in drinking water, usually from living in public or private housing, or attending schools with lead plumbing built before 1978, before lead paint was banned, or with lead pipes or plumbing. Living near a highway, airport, powerplant, smelter, or hazardous waste site may also cause lead exposure through contaminated soil or air.

Other sources of lead exposure: ● Working in manufacturing, construction, services, and mining that involve working with lead-based products. ● Hobbies or activities that involve working with lead-based products such as casting, stained glass, pottery, painting, glassblowing, and screen printing. ● Smoking cigarettes or e-cigarettes, chewing tobacco, and exposure to second-hand smoke. ● A variety of consumer products such as storage batteries, solders, tire weights, pottery glazes, leaded crystal glassware, cosmetics, hair dyes, jewelry, antiques, gunshot and ammunition, relic fishing sinkers, and imported children’s toys. ● Imported foods, candies, and spices, including: o Candy with ingredients such as chili powder and tamarind (lead can get into the candy when drying, storing, and grinding the ingredients are done improperly). Ink from plastic or paper candy wrappers may also contain lead that leaches or seeps into the imported candy. o Certain commonly used spices, particularly those purchased abroad in Georgia, Bangladesh, Pakistan, Nepal, and Morocco. ● Cultural and traditional medicines, including: o Ba-baw-san: a Chinese herbal remedy used to treat colic pain or to pacify young children.

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o Daw Tway: a digestive aid used in Thailand and Myanmar (Burma). ● Greta and Azarcon (also known as alarcon, coral, luiga, maria luisa, or rueda): Hispanic traditional medicines used for an upset stomach, constipation, diarrhea, and vomiting. They are also used on teething babies. ● For additional examples, refer to the CDC’s table of Examples of regional or culture-specific exposures associated with elevated blood lead levels in children

Among pregnant and lactating women, the most common sources of lead exposure include: • Working in certain occupations. • Practicing pica (ingesting non-nutritive substances such as soil or paint chips). • Using herbal or traditional remedies or imported cosmetics. • Using traditional lead-glazed ceramic pottery for cooking and storing food. • Living in an older home during a renovation. • History of lead exposure since bone lead stores persist for decades and are mobilized into the blood during periods of increased bone turnover including pregnancy and lactation.

Key Recommendations for Initiation of Breastfeeding: • Mothers with BLLs < 40 μg/dL should breastfeed. • Mothers with confirmed BLLs ≥40 μg/dL should begin breastfeeding when their blood lead levels drop below 40 μg/dL. Until then, they should pump and discard their breastmilk.

Key Recommendations for Continuation of Breastfeeding (2): • Breastfeeding should continue for all infants with BLLs below 5 μg/dL. • Infants born to mothers with BLL ≥ 5 μg/dL and <40 μg/dL can continue to breastfeed unless there are indications that the breastmilk is contributing to elevating BLLs.

Lead Screening and Testing Lead exposure prevention and reduction are primary prevention strategies for preventing long-term damage from even low-level lead exposure. CDC recommends that public health and clinical professionals focus screening efforts on neighborhoods and children at high risk based on age of housing and sociodemographic risk factors and work together to develop screening plans

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responsive to local conditions using local data. CDC supports these efforts through cooperative agreements with state and local health departments that fund lead exposure prevention activities including blood lead testing. Where state or local screening plans do not exist, CDC recommends universal BLL testing.

Pregnant women identified with blood lead levels ≥5 μg/dL should be tested at the time of birth to establish a baseline to guide postnatal care for the mother and infant. Lactating women with BLL ≥5 μg/dL should be referred for follow-up testing at an interval according to the BLL.

All Medicaid-enrolled children are required to be tested at ages 12 and 24 months, or at age 24–72 months if they have not previously been screened.

For infants, the American Academy of Pediatrics recommends a risk assessment at 6 and 9 months, and if positive, appropriate follow up action. Risk assessment questions appropriate to local lead hazards should be developed by local health care professionals in collaboration with state, county, or local health authorities.

CDC’s specific screening guidelines for newly arrived refugees recommend that all refugee infants and children <16 years old and pregnant and breastfeeding women be screened for lead exposure with a blood test. Refugee adolescents > 16 years of age should be screened if there is a high index of suspicion, or clinical signs/symptoms of lead exposure. Follow up screening should occur 3 to 6 months later for all children under 6 years old, children and adolescents 7 to 16 years of age who had BLLs ≥3.5 μg/dL or who has a risk factor, and pregnant or lactating adolescents (<18 years of age) who had BLLs at or ≥3.5 μg/dL at initial screening. In addition, all newly arrived pregnant or breastfeeding women should be prescribed a prenatal or multivitamin with adequate iron and calcium.

Nutrition and Lead Exposure Adequate consumption of both calcium and iron, which compete with lead for intestinal absorption, have been found to decrease lead absorption. During pregnancy, adequate calcium intake may reduce maternal bone resorption and thereby reduce the mobilization of lead stored in the bone into the blood. Iron deficiency can be an indicator of lead poisoning as they often co-occur (see risk #201 for more information about iron deficiency anemia). Participants with elevated BLL should be provided with nutritional advice emphasizing adequate calcium and iron intake and pregnant participants should be encouraged to take a prenatal vitamin as prescribed by their healthcare provider.

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Procedure: When a participant has been diagnosed with lead poisoning: ● Evaluate iron status, as iron deficiency anemia and elevated blood lead frequently occur together. ● Evaluate calcium intake: Inadequate dietary calcium intake generally affects lead absorption. Results from some studies indicate that dietary calcium (when consumed at Adequate Intake levels) competitively inhibits lead absorption. ● Evaluate vitamin C intake: The antioxidant, vitamin C, has been shown to have natural chelating properties, enhancing the urinary elimination of lead from the body. ● Review lifestyle/dietary habits that explain or contribute to lead exposure, including: o Eating dirt, clay, or other non-foods (pica) o Review eating habits for protective nutrients: regular mealtimes, foods rich in iron, calcium, and vitamin C

Nutrition Education: ● Adequate intake of calories and nutrients such as calcium and iron help protect against lead uptake. ● Certain housekeeping practices can minimize the risk of exposure to lead.

Participant Focused Counseling: ● Offer lead brochure to any participant who answers No or Don’t Know to the lead test question, Have you had a blood lead test? ● Offer to discuss using WIC foods high in calcium, iron, and vitamin C to protect against lead absorption, especially those in their WIC food packages ● Suggest a woman, infant, or child who eats dirt, clay, or other non-foods discuss this habit with physician. ● Recommend all pregnant and breastfeeding women and caregivers of children review the Lead Screening Tool, and discuss any items answered Yes or Don’t Know with her health care provider.

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Failure to Thrive (1341) Categories: IBE, IBP, IFF, C-1, C2-4 Defined as: Diagnosis of Failure to Thrive (FTT) by a health care professional as self reported by applicant/participant/caregiver; or as reported or documented by a physician or someone working under physician’s orders. An infant or child identified with FTT should have Nutrition Care counseling. Best Practice: see participant immediately; if not possible, within 5 days, with a Nutrition Care follow-up in 1-3 months

Justification:

Failure to Thrive (FTT) is a serious growth problem with an often complex etiology. It may be a mild form of protein-energy malnutrition (PEM) that is manifested by a reduction in the rate of growth. Regardless of the etiology of FTT, there is inadequate nutrition to support weight gain. Education, referrals, and service coordination can aid the mother/caregiver in developing skills, knowledge, and or assistance to care for an infant or child with Failure to Thrive.

The following table includes factors that can contribute to undernutrition and increase the risk for FTT in infants and children:

Medical/Nutritional/Developmental Behavioral/Feeding Practices Environmental/Psychosocial General conditions: • Prematurity, low birth weight, and small for gestational age • Exposure to substances in utero • Any chronic medical condition • Infrequent feeding or not appropriately responding to hunger cues

• Poor caregiver-infant/child interactions, especially when feeding

• Inappropriate feeding based on infant/child’s stage of development

• Improper breastfeeding positioning or technique

• Poverty, food insecurity, and homelessness

• Caregiver’s lack of knowledge about appropriate nutrition and feeding

• Caregiver with limited ability to make appropriate feeding decisions/prepare food, including those with a mental health disorder, intellectual disability, or substance use disorder • Family stressors such as unemployment, separation, or incarceration Inadequate intake, which can be caused by: • Neurological disorders • Developmental delays, including autism spectrum disorders • Dental problems including cleft lip, cleft palate, and dental caries • Enlarged tonsils or adenoids

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• Feeding problems including insufficient or ineffective breastmilk transfer, weak suck, swallowing problems, and poor appetite • Gastrointestinal problems, including gastroesophageal reflux, frequent vomiting, and constipation • Chronic or frequent infections (These can lead to reduced intake, which can further compromise the immune system, thus contributing to additional infections and FTT.) • Lead poisoning (This can lead to anorexia, constipation, and abdominal pain. Reduced intake can then lead to calcium and iron deficiencies, further exacerbating the lead poisoning and FTT.)

• Incorrect preparation of infant formula

• Excessive fluids other than breastmilk/formula for infants

• Once foods are started, not providing appropriate support (such as a high chair) while eating

• For children, inconsistent timing of feeding or allowing to graze on food/beverages throughout day

• Restrictive diet, including vegan, low-fat, or food allergy-related

• Feeding in a chaotic household with multiple caregivers

• Neglect or abuse

• Inadequate access to appropriate foods, including culturally preferred foods

Inadequate absorption, which can be caused by: • Food allergies and lactose intolerance • Celiac disease • Gastrointestinal problems, including chronic diarrhea or vomiting and malformations • Protein-losing enteropathy • Pancreatic conditions, including cystic fibrosis • Inborn errors of metabolism

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Failure to thrive in infants/children, especially when severe or prolonged, can have several harmful effects, including the following: ● Dehydration and nutrient deficiencies ● Compromised immune system and increased risk of infections ● Increased susceptibility to lead poisoning (when calcium and iron deficiencies are present) Long-term impaired cognitive development, including learning difficulties ● Long-term problems with socioemotional development ● Long-term lower than average weight and/or height Treatment The goal of FTT treatment is to achieve optimal growth while also addressing whatever factors may be contributing to the FTT. Catch-up growth (growth at a faster rate than normal for age) is usually necessary; according to the American Academy of Pediatrics, a typical catch-up rate is 2-3 times the average weight gain for age. As treatment progresses, the rate of catch-up growth is continually adjusted as needed until growth is deemed appropriate.

Thus, growth must be measured frequently and assessed over time. It is also important to watch for relapse, as a history of FTT is associated with reoccurrence of FTT in the future.

During treatment, close follow-up by the health care provider and other health professionals is crucial. A multidisciplinary approach is often used, including collaboration among the family, pediatrician, dietitian, developmental therapist, and others.

Nutrition therapy is a core component of treatment, starting with nutrition assessment. A comprehensive assessment should take the following into account: feeding history, current intake, breastfeeding/formula feeding, the caregiver-infant/child feeding relationship, feeding timing/environment, and nutrition knowledge/beliefs. Nutrition and breastfeeding counseling are individualized to the infant/child and typically focus on increasing consumption of calories, protein, and micronutrients. The health care provider may also suggest providing a multivitamin that includes the Recommended Dietary Allowance for all vitamins, iron, and zinc during the period of rapid growth, as well as additional iron or vitamin D if there are deficiencies.

If behavioral interventions are not effective, treatment providers may recommend nutritional/caloric supplements be given for a limited time to achieve catch-up growth. These include supplemental formula for breastfed infants, high calorie/concentrated formulas for infants, and high calorie beverage supplements for children. If treatment is not effective, hospitalization may be needed, though this is rare. This may occur if the infant/child has a severe safety or health risk, including having a serious infection, medical condition, malnourishment, or dehydration.

Implications for WIC Nutrition Services WIC staff can provide the following nutrition services to infants and children with failure to thrive: • Learn about and reinforce the health care team’s plan of care for treating the participant’s FTT. Encourage caregivers to keep all health care appointments.

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• Offer breastfeeding support to breastfeeding dyads. Refer to the WIC Designated Breastfeeding Expert, if available, or other professional breastfeeding support when needed. • Offer participant-centered nutrition counseling based on a thorough assessment and on caregiver’s concerns and interests. Suggestions to caregivers may include the following, based on the situation: ● Increasing children’s intake of calorically-dense food ● Correctly preparing infant formula ● Reducing volume of fluids consumed, if excessive, to appropriate amounts (other than breastmilk or formula for infants) ● Allowing children to choose how much and which foods to eat (from what is offered) ● Feeding children at consistent times and not allowing child to graze on foods and beverages throughout the day ● Feeding in a supportive setting (such as a table or highchair) and in a distraction-free environment

• Provide individualized food packages, tailored to meet the increased nutritional needs of the infant/child. • Reinforce the importance of following recommended vaccination schedules, as FTT is sometimes associated with a compromised immune system. • Offer individualized referrals based on the household’s needs and interests, including referrals to financial assistance, food assistance, cooking classes, housing, transportation, childcare, adult education/career services, and substance use services. Consider referrals that promote a nurturing, responsive caregiver-infant/child relationship, including those to local home visiting programs, parenting programs, and early intervention services.

Procedure: Determine if the infant or child has a diagnosis of Failure to Thrive. Review collected information about feeding practices, medical conditions, and caregiver lifestyles that could lead to a poor rate of growth.

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Fetal Alcohol Spectrum Disorders (FASDs)

(3821) Categories: ALL Defined as: Presence of condition diagnosed by a physician or someone working under a physician’s orders, or as self-reported by applicant/participant/caregiver. Fetal alcohol spectrum disorders (FASDs) are a group of conditions that can occur in a person whose mother consumed alcohol during pregnancy. FASDs is an overarching phrase that encompasses a range of possible diagnoses, including fetal alcohol syndrome (FAS), partial fetal alcohol syndrome (pFAS), alcohol-related birth defects (ARBD), alcohol-related neurodevelopmental disorder (ARND), and neurobehavioral disorder associated with prenatal alcohol exposure (ND-PAE)

A participant identified with FASDs should have Nutrition Care counseling. Best Practice: see participant immediately; if not possible, within 5 days. Provide Nutrition Care follow-up in 3-6 months.

Justification: FASD is the leading preventable cause of birth defects and intellectual and neurodevelopmental disabilities. FASD is an umbrella term describing the range of effects that can occur in an individual whose mother consumed alcohol during pregnancy. These effects include physical, mental, behavioral, and/or learning disabilities with possible lifelong implications. Often, a person with FASD has a mix of these conditions. These conditions can affect each person in different ways and can range from mild to severe. A person with FASD might have any or a combination of the following conditions:

● Facial abnormalities, such as a smooth ridge between the nose and upper lip (this ridge is called the philtrum). ● Small head size, short stature, low body weight. ● Sleep and sucking problems as an infant. ● Hyperactive behavior, difficulty with attention, poor memory, difficulty in school (especially with math), learning disabilities, poor reasoning and judgment skills. ● Poor coordination, speech and language delays, intellectual disability or low IQ. ● Problems with the heart, kidneys, bones, vision, or hearing.

The severity of alcohol’s effects on a fetus primarily depends on the following: Quantity – the amount of alcohol consumed by a pregnant woman per occasion. Frequency – the rate at which alcohol is consumed or is repeatedly consumed by the pregnant woman. Timing – the specific gestational age of the fetus when alcohol is consumed by the pregnant woman. Fetal Alcohol Spectrum Disorders Diagnoses Different terms are used to describe FASDs, depending on the type of symptoms.

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Fetal Alcohol Syndrome (FAS) was the first form of FASD discovered. It represents the most involved end of the FASD spectrum. A diagnosis of FAS requires evidence of prenatal alcohol exposure; evidence of central nervous system (CNS) abnormalities (structural or functional); a specific pattern of the following three facial abnormalities: narrow eye openings, a smooth area between the lip and the nose (vs. the normal ridge), and a thin upper lip; and growth deficits either prenatally, after birth, or both.

A child with FAS may have problems with learning, memory, attention span, communication, vision, and/or hearing. Also, people with FAS often have a hard time in school and trouble getting along with others. FAS is the only part of the spectrum with guidelines for diagnosis. Diagnosing FAS can be challenging because other medical disorders have similar symptoms, and there are no standard medical tests for diagnosis. Alcohol-Related Neurodevelopmental Disorder (ARND) requires evidence of both prenatal alcohol exposure and CNS abnormalities, which may be structural or functional (a complex pattern of cognitive or behavioral problems not consistent with developmental level that can only be explained by prenatal alcohol exposure). Other symptoms of FAS may or may not be present. Alcohol-Related Birth Defects (ARBD) include problems with the heart, kidneys, bones, or hearing. People with ARBDs might have a combination of these. ARBD is rarely seen alone but rather as a secondary disorder accompanying other FASD conditions (e.g., FAS and ARBD). Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (ND-PAE) requires evidence of both prenatal alcohol exposure and CNS involvement (cognition, self-regulation, and adaptive functioning impairment). A child or youth with ND-PAE will have problems with 1) thinking and memory, where the child may have trouble planning or may forget material he or she has already learned; 2) behavior problems, (severe tantrums, mood issues, and difficulty shifting attention from one task to another), and 3) trouble with day-to-day living, (bathing, dressing for the weather, playing with other children). In addition, the mother must have consumed more than 13 alcoholic drinks per month of pregnancy or more than 2 alcoholic drinks in one sitting. Prenatal Alcohol Exposure (PAE) may be associated with altered acquisition and distribution of body mass with increasing age. A study by Werts and colleagues suggested that children with PAE may be at risk for nutritional deficiencies, inappropriate food preferences, disordered eating patterns, medication use, and the stressful dynamics surrounding food preparation and mealtime. PAE may be associated with female obesity, constant snacking, lack of satiety, constipation, and low vitamin D status.

Growth and Development of Children with FASD The estimated prevalence of FASD in populations of first-grade schoolchildren (~6.5-7.8 years old) is as high as 20-50 per 1,000 in the United States and some Western European countries. In a study conducted by Spohr and others, it was found that although the characteristic craniofacial malformations of FAS/FAE diminished over time, microcephaly, a poorly developed philtrum, a thin upper lip, and, to a lesser degree, short stature and

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underweight (in boys) persisted. In females, adult body weight increased. Although some catch-up growth occurred, a large proportion of the subjects had growth deficiency. Retrospective research demonstrated that children may be more affected by prenatal alcohol exposure based on the following variables regarding the mother:

• Poor pre-pregnancy or prenatal nutrition • Multiple pregnancies and births • Lower-than-average pre-pregnancy or prenatal weight, height, and body mass index (BMI) • Maternal smoking • Maternal age (effect on child increases with mother’s age) • Has family members or peers who drink heavily

One study indicated that, anecdotally, children with FASD are often “picky eaters”, some have autistic-like taste and texture sensitivities, and many have behavioral challenges such as rigidity and oppositionality. Children with FASD had lower intakes of saturated fats, vitamin D, and calcium. They may not meet the recommended intakes for several nutrients and have a dietary pattern that could benefit from improving intakes of dairy products, green leafy vegetables, vegetable oils, nuts, eggs, and fish. Most (>50%) did not meet the Adequate Intake for fiber, n-3 fatty acids, vitamin K, or choline, or the Recommended Dietary Allowance for vitamin D, vitamin E, or calcium.

Another study indicated that children with FASD were more likely to have a past diagnosis of underweight. Mean BMI was significantly reduced for males but not females. Abnormal eating patterns are common in children with FASD and may contribute to their delayed growth and nutritional inadequacies. Children with FASD were significantly more likely to experience delayed acquisition of age-appropriate eating skills, compared with controls. The median age for solid foods introduction was significantly older for children with FASD as was their age at self-feeding.

Breastfeeding may prevent or improve neurodevelopmental disorders for children with FASDs and has been shown to improve IQ. Infants with facial abnormalities may have breastfeeding challenges such as difficulty with latch, sucking, or swallowing; and individualized breastfeeding support will likely be needed. (See Alcohol or Substance Use for more information regarding breastfeeding and alcohol use.)

There is no cure for FASDs, but research shows that early intervention treatment services can improve a child’s development. There are many types of treatment options, including medication to help with some symptoms, behavior and education therapy, parent training, and other alternative approaches. Certain protective factors can help reduce the effects of FASD and help people with these

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conditions reach their full potential. Protective factors include diagnosis before 6 years of age; loving, nurturing, and stable home environment during the school years; absence of violence; and involvement in special education and social services. Adults with FASD FASDs last a lifetime. Research indicates that adults with FASDs have increased behavioral problems; are perhaps less efficient and more distractible; have more difficulty with paying attention, learning, memory, planning, and analyzing social situations; and feel less confident that they have sufficient resources to cope with their environment. Adults with FASDs have a high rate of psychiatric and personality disorders, problems with drugs and alcohol, and difficulties with the law. They are also less likely to obtain a degree, have stable employment, and live independently. Young adults with PAE have increased risks for mental health problems and secondary disabilities, which impacts their ability to live independently. Implications for WIC Nutrition Services When speaking with a biological mother of a child with an FASD, the American Academy of Pediatrics recommends the following: • Build rapport with the mother and allow her to express her emotions and concerns related to her child’s health and the demands of parenting a child with an FASD. • Reaffirm the parent as a key part of the child’s care team. • Keep all lines of communication and advocacy open as the child’s care is coordinated through the medical home.

WIC staff can help parents/caregivers of infants and children with FASD choose steps to improve health by: • Offering regular monitoring to address underweight/overweight, delayed growth, and nutritional inadequacies. • Tailoring food packages to meet the needs and preferences of participants. • Encouraging food choices to improve intake of dairy products, green leafy vegetables, vegetable oils, nuts, eggs and fish. • Guiding participants in choosing healthy snacks to achieve satiety. • Helping participants understand and improve age-appropriate feeding skills and behavioral and developmental issues associated with feeding. • Encouraging physical activity to improve glucose tolerance, muscle and nerve development, and motor coordination. • Referring to their health care provider to discuss nutritional supplements and any growth and development concerns. • Providing referrals to early intervention services, infant/child feeding skills, home visiting programs, and parenting programs. • Referring to their health care provider and WIC breastfeeding specialist for breastfeeding support. These infants may need frequent growth monitoring and re-evaluation of their feeding capacity, so feeding plans will need to be adjusted accordingly.

WIC staff can assist adult participants with FASD as follows (also see Woman or Infant/Child of Primary Caregiver with Limited Ability to Make Appropriate Feeding Decisions and/or Prepare Food):

• Provide individualized nutrition education appropriate for the learning level of the participant/caregiver. Be sensitive to the unique learning needs and style of the participant/caregiver, which may mean using food models, posters, and handouts.

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• Provide referrals to promote parenting and infant/child feeding skills, including referrals to local home visiting programs, parenting programs, and early intervention services. • Encourage participants/caregivers to follow the health care provider’s plan of care. Coordinate with health care providers as needed. • Provide individualized food packages tailored to meet the needs of participants. • Some adults with FASD may be unable to prepare powder or concentrated infant formula. Thus, for the safety of the infant, State WIC Agencies may allow ready-to-feed (RTF) WIC formulas. • Refer to their health care provider to discuss nutritional supplements for pregnant women. WIC staff can increase their own knowledge by reading Substance Use and Prevention Manual: Screening, Education and Referral Resource Guide for Local WIC agencies. Available from: https://wicworks.fns.usda.gov/resources/wic-substance-use-prevention- guide.

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Fetal Growth Restriction (FGR)

(3361) Category: PG Defined as: Diagnosed condition by a physician as self reported by applicant/participant/caregiver or as reported or documented by a physician or someone working under physician’s orders. A woman identified with fetal growth restriction should have Nutrition Care counseling. Justification: Fetal growth restriction (FGR) is usually defined as a fetal weight < 10th percentile for gestational age. It may be diagnosed by a physician using serial measurements of fundal height and abdominal girth and can be confirmed using ultrasonography. FGR usually leads to birth of an infant that is small for gestational age (SGA). The severely growth restricted infant is at increased risk of fetal and neonatal death as well as polycythemia, and long-term neurocognitive complications. FGR is also associated with increased risk of chronic diseases such as cardiovascular disease in adulthood. FGR may be caused by congenital anomalies or infections in the fetus or may be associated with maternal height, pre-pregnancy weight, birth interval, and maternal smoking. Procedure: Determine if the woman has been diagnosed with Fetal Growth Restriction. Apply to a pregnant woman only. Participant Focused Counseling: A pregnant woman diagnosed with FGR can benefit from nutrition counseling to promote optimal nutrient intake, appropriate weight gain, and avoidance of tobacco, alcohol, and drugs.

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Food Allergies (3531) Categories: ALL Defined as: Food allergies are adverse health effects arising from a specific immune response that occurs reproducibly on exposure to a given food, when diagnosed, documented, or reported by a physician or someone working under a physician’s orders, or as self- reported by participant or caregiver. Note: This risk only applies to food allergies and should not be assigned to those who have non-immunologic adverse reactions to food. A participant identified with Food Allergies should have Nutrition Care counseling. Consider contacting the participant’s Specialist RD for participant with multiple complex food allergies before counseling or assigning food package. Justification: Food allergies are a significant health concern as they can cause serious illness and life-threatening reactions. Prompt identification and proper treatment of food allergies improves quality of life and nutritional well-being. Studies of large, nationally representative samples suggest that 5.8% of children (ages 0-17) and 6.2% of adults have a food allergy based on a clinician’s diagnosis and/or the severity of reported symptoms. These estimates do not include food intolerances or other non-immunologic reactions to food. Perceived food allergy prevalence in these studies was 19% among adults and 11.4% among children, suggesting that more access to testing and counseling is needed. Common Food Allergens

Although reactions can occur from the ingestion of any food, a small number of foods are responsible for most food-induced allergic reactions. The foods that most often cause allergic reactions are listed below with their prevalence among all U.S. children and adults: Children Adults Any food allergy 7.6% 10.8% Peanuts 2.2% 1.8% Cow’s Milk 1.9% 1.9% Shellfish 1.3% 2.9%

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Tree Nuts 1.2% 1.2% Eggs 0.9% 0.8% Fish 0.6% 0.9% Wheat 0.5% 0.8% Soy 0.5% 0.6% Sesame* 0.2% 0.2% *As of Jan.1, 2023, sesame officially recognized as the 9th major food allergen in the US and required to be identified on food label

Many food allergies appear within the first two years of life. The majority of allergies to cow’s milk, eggs, wheat and soy resolve in early childhood. In contrast, allergies to peanuts and tree nuts typically persist into adulthood. Adults may have food allergies from childhood or developing later and continuing through life. People with an allergy to one food tend to be allergic to similar foods within a food group. For example, all shellfish are closely related; if a person is allergic to one shellfish, there is a strong chance that person is also allergic to other shellfish. The same holds true for tree nuts, such as almonds, cashews, and walnuts. Food Allergies vs. Non-Immunologic Adverse Reactions to Food Food allergy reactions occur when the body’s immune system responds to a food as if it were a threat. However, not all adverse reactions to food are caused by food allergies. Some are caused by “non-immunologic adverse reactions to food,” which includes a wide range of disorders related to the consumption of foods (often referred to as food intolerances, but this term is not preferred). Non-immunologic adverse reactions to food are often misdiagnosed as food allergies because the symptoms can be similar. However, unlike food allergies that trigger an immune response that may result from exposure to even small traces of a food allergen, non-immunologic adverse reactions to food do not involve the immune system and are typically dose-dependent. The National Institute of Allergy and Infectious Disease (NIAID) separates non-immunologic adverse reactions to food into four categories, including Metabolic, Pharmacologic, Toxic, and Idiopathic / Undefined, as follows:

1. Metabolic - A reaction is caused by an inability to metabolize a food component. The most common non-immunologic adverse reaction to food is lactose intolerance, caused by a deficiency in the enzyme lactase, which is necessary in the metabolism of lactose, a type of sugar found in dairy products. (For more information see nutrition risk criterion #355, Lactose Intolerance.)

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2. Pharmacologic - A reaction caused by the consumption of a food or food additive that results in drug-like pharmacologic effects. For example, overconsumption of caffeine can cause undesirable symptoms for some individuals such as nervousness, insomnia, headaches, nausea, and diarrhea. 3. Toxic - A reaction caused by a toxin found in a food. For example, consumption of fish in the Scombridae family (e.g., tuna, mackerel, bonito, etc.) can cause scombroid fish poisoning or histamine fish poisoning if the fish contains high levels of histamine. 4. Idiopathic / Undefined - There are some reactions for which there has yet to be a defined mechanism for the resulting symptoms. For example, many individuals claim to have a hypersensitivity to monosodium glutamate (MSG), and report a myriad of symptoms including headaches, numbness, dizziness, heart palpitations, chest pain and back pain. However, decades of research have yet to prove a definitive link between these symptoms and the consumption of MSG. Some research suggests that those diagnosed with Irritable Bowel Syndrome (IBS) may have some of their symptoms associated with undefined non-immunologic adverse reactions to food including wheat (e.g., non-celiac wheat sensitivity (NCWS)) and foods high in fermentable oligo-, di-, and mono-saccharides and polyols (FODMAPs). IgE vs Non-IgE Mediated Allergic Reactions to Foods There are several types of immune responses to foods, including immunoglobulin E (IgE)-mediated, non-immunoglobulin E (non- IgE)-mediated or mixed. The most common types of food allergies involve IgE-mediated responses. In an IgE-mediated response, the immune system produces allergen-specific IgE antibodies (sIgE) when a food allergen first enters the body. Upon re-exposure to the food allergen, the sIgE identifies it and quickly initiates the release of chemicals, such as histamine. These chemicals cause various symptoms based on the area of the body in which they were released. These reactions typically occur within minutes up to a couple of hours after ingestion and include symptoms such as urticaria (hives), angioedema (swelling), wheezing, cough, nausea, vomiting, hypotension (low blood pressure) and anaphylaxis. Food-induced anaphylaxis is the most severe form of IgE-mediated food allergies. It often occurs rapidly, within seconds to a few hours after exposure, and is potentially fatal without proper treatment (often including the use of epinephrine). Food-induced anaphylaxis often affects multiple organ systems and produces many symptoms, including difficulty breathing, swelling and reduced blood pressure. Tree nuts, peanuts, milk, egg, fish, and shellfish are the leading causes of food-induced anaphylaxis. Prompt diagnosis and avoidance of allergens is essential to prevent life-threatening reactions. Non-IgE-mediated allergic reactions to foods are generally delayed in onset, occurring more than 2 hours after ingestion, are more chronic in nature, and primarily affect the skin and/or gastrointestinal system. Celiac Disease (Risk 3541) is one example of a non-

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IgE mediated allergic reaction to food. Other less common examples, which fall under Risk 353: Food Allergies, are found in the table below. Examples of Non-IgE mediated allergic reactions to foods: Condition Brief Description Food Protein-Induced Enterocolitis Syndrome (FPIES) FPIES is a gastrointestinal food hypersensitivity that manifests as episodes of severe vomiting and diarrhea. It can lead to acute dehydration, changes in blood pressure and body temperature, pallor, and lethargy. If chronic and undiagnosed, it can cause weight loss or failure to thrive (Risk 1341). FPIES is commonly misdiagnosed initially as a severe stomach illness because the symptoms are so similar. Though any food can trigger FPIES, the most common triggers are cow’s milk, soy, rice, and oats. Management involves strict avoidance of the triggering food. Most cases resolve by age 5. Food Protein-Induced Allergic Proctocolitis (FPIAP) FPIAP is a food allergy that manifests as bloody stools, typically within the first few weeks of life. The most common food that triggers FPIAP is cow’s milk. Symptoms typically resolve with elimination of cow’s milk and soy protein. Cases often resolve around 12 months of age Food Protein-Induced Enteropathy (FPE) FPE (sometimes referred to as cow’s milk-sensitive enteropathy) involves injury to the small intestine when cow’s milk is present in the diet. Symptoms typically present as protracted diarrhea within weeks of introducing cow’s milk protein and resolve when cow’s milk is avoided. Other food proteins, such as soybean, wheat, and egg, can also cause FPE. More than half of infants with FPE also have vomiting and failure to thrive, and some may have malabsorption, abdominal distension and early satiety. Bloody stools are usually absent.

Prevention Theories In terms of food allergy prevention: There is no evidence that pregnant or breastfeeding women should restrict any foods to prevent the development of allergies in their offspring. The American Academy of Pediatrics (AAP) recommends that all infants, including those with a family history of food allergies, be exclusively breastfed until 6 months of age, unless contraindicated for medical reasons, and continue breastfeeding as long as mutually desired by mother and child for two years or more. There is also no evidence to suggest that exclusive breastfeeding is associated with the prevention of any specific food allergies among breastfed infants.

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However, exclusive breastfeeding for the first 3-4 months has been shown to decrease the risk of eczema in the first 2 years of life, a condition which has been associated with the development of food allergies. Eczema, also referred to as atopic dermatitis (AD), is a common inflammatory skin disorder characterized by recurrent lesions and intense itch. Eczema affects up to 20% of children and 10% of adults. While it can occur at any age, the typical age of onset is between 3 – 6 months. Exclusion diets should not be advised in the treatment of children with eczema unless there is a clinical history of IgE-mediated allergic reactions. Unjustified elimination of a specific food can be harmful and lead to loss of tolerance to the food, with high rates of anaphylaxis when reintroduced. There are currently no published trials that compare the timing of the introduction of allergenic foods on the development of food allergy in exclusively formula-fed versus exclusively breastfed infants. For infants who cannot be exclusively breastfed, there is not currently a specific formula that is recommended to prevent food allergy. Past recommendations to feed hydrolyzed formulas or soy formulas to prevent food allergies in high-risk infants who cannot be exclusively breastfed are not supported by current research. Previous research suggested a benefit of the delayed introduction of highly allergenic foods to high-risk infants and children. However, this advice was modified in 2008 when new research failed to find any benefit regarding the delayed introduction of allergenic foods to at-risk infants and children. Introducing Allergenic Foods Additional research has suggested that the early introduction of allergenic foods may help to prevent the development of allergies to the foods offered among both the general population as well as high-risk populations. Currently, the strongest evidence for these recommendations comes from research on peanuts and eggs. As a result, the American Academy of Allergy, Asthma, & Immunology (AAAAI) recommends the introduction of peanut-containing products and egg or egg-containing products to all infants, irrespective of their relative risk of developing peanut allergy, starting around 6 months of life, and not deliberately delaying the introduction of other potentially allergenic foods (cow’s milk, soy, wheat, tree nuts, sesame, fish, shellfish) once the introduction of solid foods has begun. Do the following two paragraphs contradict each other?--Colleen

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Introduction to potentially allergenic foods can occur at home when the infant is developmentally ready for complementary food introduction, in accordance with the family’s cultural practice, but not before the infant demonstrates developmental readiness with eating a few other common starter foods. While the AAAAI indicates that in-office allergy screening (such as sIgE and skin prick testing) by healthcare professionals is not required prior to offering potentially allergenic foods, irrespective of relative risk, this remains an option to consider for families that prefer to not introduce allergenic foods at home. Once potentially allergenic foods have been introduced, they should continue to be offered. WIC staff should encourage WIC families to speak with their healthcare providers (HCP) to discuss their plans for the introduction of potentially allergenic foods, especially those considered to be at risk of developing food allergies. According to a consensus report from the AAAAI and the Canadian Society for Allergy and Clinical Immunology (CSACI), infants should be considered “at increased risk” for developing a food allergy (or an additional food allergy) if they have mild or moderate eczema, a family history of atopy (a genetic tendency to develop allergic diseases such as asthma, allergic rhinitis, and eczema) in either parents, or who have already been diagnosed with at least one food allergy. Infants should be considered “at the highest risk” for developing a food allergy if they have severe eczema. Management The only way to manage a food allergy is avoidance. Food allergies produce anxiety and affect quality of life; however, management strategies can help mitigate these negative outcomes. HCPs should work closely with families to provide education on food allergen avoidance and emergency management plans that are culturally and age appropriate. This includes education on reading food labels and ingredient lists, communicating allergens with people providing food, and the avoidance of any cross-reactive foods, i.e., similar foods within a food. Emergency management plans are essential for individuals with severe food allergic reactions, such as anaphylaxis. Nutrition counseling and weight and/or growth monitoring is recommended for all individuals with food allergies to ensure a nutritionally adequate diet. Formula fed infants with a documented allergy to cow’s milk protein should be provided with an extensively hydrolyzed protein formula. According to the AAP, soy formulas should not be considered first for infants with a documented allergy to cow’s milk protein since approximately 10 to 14% of infants with a cow’s milk protein allergy also have a soy protein allergy (43). Infants who are partially breastfed or formula fed, with certain non-IgE mediated allergies, such as FPIES and FPIP, may require extensively hydrolyzed casein or amino acid-based formula. WIC nutritionists should refer infants to their HCP if there is a concern of allergy to a formula and follow recommendations made.

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Implications for WIC Nutrition Services Through participant-centered counseling, WIC staff can assist participants with food allergies in making changes that improve quality of life and promote nutritional well-being while avoiding allergenic foods. Based on the needs and interests of the participant, WIC staff can (as appropriate):  Refer participants diagnosed with severe asthma, eczema, eosinophilic esophagitis (EoE) and exercise-induced anaphylaxis to an HCP for food allergy evaluation, since food allergies often coexist with these conditions.  Facilitate and encourage the participant’s ongoing follow-up with their HCP for optimal management of the food allergy.  Promote exclusive breastfeeding until six months of age and continuing as long as mutually desired by mother and child for 2 years or beyond.  Provide hypoallergenic formula for participants with appropriate medical documentation, as needed.  Individually tailor food packages to substitute or remove allergenic foods.  Educate participants on maintaining adequate nutritional intake while avoiding allergenic foods. Surveys suggest that many individuals with food allergies are allergic to multiple foods. Multiple food allergies increase the level of effort required to avoid the triggering foods, as well as the risk of malnutrition. Consider contacting specialist RD for participant with multiple food allergies.  Monitor weight status and growth patterns of participants.  Educate participants with food allergies on reading food labels and identifying allergenic foods and ingredients. See resources below: o https://www.fda.gov/consumers/consumer-updates/have-food-allergies-read-label Accessed 6/9/25 o https://www.foodallergy.org/resources/how-read-food-label. Accessed 6/9/25 o Educate participants with food allergies on planning meals and snacks for outside the home. o Refer participants with suspected sensitivity to foods to their HCP for an oral food challenge of allergenic foods, as appropriate. o Establish/maintain communication with the participant’s HCP.

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Foster Care (9031) Categories: IBE, IBP, IFF, C-1, C 2-4 Defined as: entering the foster care system during the previous 6 months or moving from one foster care home to another foster care home during the previous 6 months. Note: This risk factor must be manually assigned in WOW and a note must be written to document it. Justification: Research findings have shown that foster children have a higher frequency of mental and physical problems, often the result of abuse and neglect suffered prior to entry into the foster care system. When compared to other Medicaid-eligible children, foster care children have higher rates of chronic conditions such as asthma, diabetes, and seizure disorders. Because the foster care system often lacks a comprehensive health component, the social and medical histories of foster children in transition are frequently unknown to the foster care providers applying for WIC benefits for the children. The nutrition education, referrals, and service coordination provided by WIC will support the foster parent in developing the knowledge and skills to ensure that the foster child receives appropriate nutrition and health care. Procedure: Determine that the child has entered into or transferred within foster care during the previous 6 months. Staff using this risk criterion should also evaluate and document other nutritional risks as well as problems that may require follow up or referral to other health care programs. This risk criterion should be used as the sole risk criterion only if careful assessment of the applicant’s nutritional status indicates that no other risk criteria based on anthropometric, biochemical, medical, or dietary risk criteria can be identified. This nutritional risk cannot be used for consecutive certifications while the child remains in the same foster home.

Participant Focused Counseling: The foster care provider can state the feeding practices she can follow to promote optimal growth and development of the child.

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Gestational Diabetes (3021) Category: PG Defined as: Diagnosed by a physician and self-reported by applicant/participant/caregiver. Gestational Diabetes is any degree of glucose/carbohydrate intolerance with onset or first recognition during pregnancy. A pregnant woman identified with Gestational Diabetes should have Nutrition Care counseling. Best Practice: see participant immediately; if not possible, within 5 days. Provide additional Nutrition Care follow-up in 3 months.

Justification: Uncontrolled Gestational Diabetes can result in stillbirth, polycythemia, or respiratory distress syndrome. Although rarely seen in GDM, congenital anomalies, neural tube defects, and/or cardiac abnormalities may occur if a woman has GDM in the early first trimester. Women with Gestational Diabetes are at increased risk for pregnancy complications and for Type II diabetes later in life. Diet and physical activity are the cornerstones of treatment. A woman with Gestational Diabetes should be monitored for compliance with diet and to ensure that blood sugar levels are maintained within the acceptable range. Close monitoring by the health care professional is essential. Procedure: Determine if the woman has been diagnosed with Gestational Diabetes. Review collected information about dietary and lifestyle practices.

Participant Focused Counseling: A woman with Gestational Diabetes can benefit from nutrition counseling that enables her to understand and follow the carbohydrate- controlled meal plan prescribed by her health care professional. Breastfeeding should be strongly encouraged as it is associated with maternal weight loss and reduced insulin resistance for both mother and offspring.

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High Maternal Weight Gain (1331) Categories: PG, BE/BP, WPP Defined as: Pregnant Women, including adolescents*

● A high rate of weight gain, such that in the 2nd and 3rd trimesters, for singleton pregnancies, a participant gains more weight per week than recommended based on her prepregnancy weight:

Pregnancy Weight Classification BMI Total Weight Gain (pounds) per week Underweight < 18.5 >1.3 Normal Weight 18.5 to 24.9 >1 Overweight 25 to 29.9 >0.7 Obese ≥ 30 >0.6 Multi-fetal Pregnancies See Justification for more information

OR ● High weight gain at any point in pregnancy, such that using an IOM-based weight gain grid, a pregnant woman’s weight plots at any point above the top line of the appropriate weight gain range for her weight gain category.

Breastfeeding or Non-Breastfeeding Women, including adolescents* (most recent pregnancy only): a total gestational weight gain exceeding the upper limit of IOM’s recommended range based on BMI for singleton pregnancies

Pregnancy Weight Classification BMI Total Weight Gain (pounds) Underweight < 18.5 >40 Normal Weight 18.5 to 24.9 >35 Overweight 25 to 29.9 >25 Obese ≥ 30 >20 Multi-fetal Pregnancies See Justification for more information

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Justification: Women with high maternal weight gain are at increased risk for cesarean delivery and delivering large for gestational age infants that can lead to complications during labor and delivery. There is a strong association between higher maternal weight gain and both postpartum weight retention and subsequent maternal obesity. High maternal weight gain may be associated with glucose abnormalities and gestational hypertension disorders. Childhood obesity is one of the most important long‐term health outcomes related to high maternal weight gain. The IOM prenatal weight gain recommendations based on prepregnancy weight status categories are associated with improved maternal and child health outcomes. For twin gestations, the 2009 IOM recommendations provide provisional guidelines: normal weight women should gain 37‐54 pounds; overweight women, 31‐50 pounds; and obese women, 25‐42 pounds. For underweight women with multiple fetuses, a consistent rate of weight gain is advisable. A gain of 1.5 pounds per week during the second and third trimesters has been associated with a reduced risk of preterm and low‐birth weight delivery in twin pregnancy. In triplet pregnancies the overall gain should be around 50 pounds with a steady rate of gain of approximately 1.5 pounds per week throughout the pregnancy. Education by the WIC nutritionist should address a steady rate of weight gain that is higher than for singleton pregnancies. Procedure: Pregnant Woman: Determine if the pregnant woman has had a weight gain of 7 pounds or more over a one-month period. Use self- reported information or information from the health care professional. Probing may be required to determine the amount of weight gained if a self-report is used. Breastfeeding or Postpartum Woman: Using data self-reported or from the health care professional, determine if the total weight gain for the most recent pregnancy exceeds the IOM recommended maximum number of pounds, based upon pre-pregnancy weight status. Participant Focused Counseling: The supplemental foods, nutrition education, and counseling related to the weight gain guidelines provided by the WIC Program may improve maternal weight status and infant outcomes. In addition, WIC nutritionists can play an important role, through nutrition education and physical activity promotion, in assisting postpartum women to achieve and maintain a healthy weight.

* Based on 2009 IOM Guidelines, the BMI weight categories used for adult women will be used for pregnant adolescent women as well.

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High Weight-for-Length (Infants/Children < 24 Months of Age) (1151) Categories: IBE, IBP, IFF, C-1 Defined as: ≥ 97.9 percentile weight-for-length as plotted on the CDC/WHO Birth to 24 months gender specific growth charts. Justification: CDC, WHO, and WIC use a cut-off value of ≥ 97.9 percentile weight for length in an infant 0 to ≤24 months. The WIC Program plays an important role in public health efforts to reduce the prevalence of obesity by actively identifying and enrolling infants and young children who may be at risk of overweight/obesity in later childhood or adolescence. Procedure:

● Obtain current length measured to the nearest 1/8 inch. Record measurement in the participant’s record. ● Determine the exact age of the infant or child. ● For an infant or child < 24 months of age who was born at 37 weeks or earlier, adjust the age before plotting, following the procedure in Table GAA. ● Plot Weight for Length on the CDC/WHO Birth to < 24 months growth chart. If the plotted point lies at or above the 97.9 percentile, assign the risk criterion. ● Review collected information for possible causes of high weight for length.

Participant Focused Counseling: When identifying this risk, it is important to communicate with parents/caregivers in a way that is supportive and non-judgmental, and with a careful choice of words that convey an empathetic attitude and minimize embarrassment or harm to a child’s self-esteem. The American Medical Association recommends more neutral terms like weight disproportionate to height, excess weight, and high weight for length when communicating with the parent/caregiver. Educate parents/caregivers on behaviors that can lead to healthy body weight, including: ● Recognizing fullness cues ● Delaying introduction of solids until six months of age ● Offering a variety of nutritious foods of appropriate texture ● Not overly restricting foods ● Comforting the infant/child by holding, reading, or rocking instead of feeding

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History of Birth of a Large for Gestational Age (LGA) Infant (3371) Categories: PG, BE/BP, WPP Defined as: Birth of an infant weighing ≥ 9 pounds (≥ 4000 grams). Justification: An infant who is large for gestational age (also known as macrosomia) is at increased risk for fetal and neonatal complications including shoulder dystocia, meconium aspiration, and asphyxia. The incidence of maternal complications is also high. Women with a previous delivery of an infant weighing ≥ 9 pounds are at an increased risk of giving birth to a large for gestational age infant. LGA may be an indicator of maternal diabetes or a predictor of future diabetes. Procedure: Use information provided by the woman or her health care professional to determine if she has delivered a large for gestational age infant. Apply as follows: ● Pregnant woman: any pregnancy ● Breastfeeding or postpartum woman: most recent pregnancy ● Review information collected about dietary and lifestyle practices and health conditions such as gestational diabetes that could lead to a large for gestational age infant.

Participant Focused Counseling: ● A pregnant woman with a history of birth of an LGA infant can state the food, physical activity, and lifestyle choices she can make that are associated with a positive pregnancy outcome. ● A non-pregnant woman with a history of delivery of an LGA infant can state the food, physical activity, and lifestyle choices she can make to achieve good health. ● A postpartum woman who expresses interest in losing weight can set a goal for appropriate weight loss and state the food, physical activity, and/or lifestyle choices she can make to achieve her goal.

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History of Birth with Nutrition-Related Congenital or Birth Defect (3391) Categories: PG, BE/BP, WPP Defined as: A woman who has given birth to an infant with a nutrition-related birth defect, such as a neural tube defect. A woman who has delivered an infant with a nutrition-related birth defect should have Nutrition Care counseling. Justification: The single greatest risk criterion for delivery of an infant with a neural tube defect (a defect of the brain and spinal cord) is a personal or family history of such a defect. More than 50 percent of recurrences may be prevented by consuming supplemental folic acid (400 micrograms per day) before conception. Other nutrients, such as vitamin A consumed in excess or zinc consumed inadequately, have been linked to birth defects, such as cleft palate. Procedure: Use information provided by the woman or her health care professional to determine if she has delivered an infant with a nutrition- related birth defect. Apply as follows: ● Pregnant woman: any pregnancy ● Breastfeeding or postpartum woman: most recent pregnancy

Review information collected about dietary and lifestyle practices for restrictive eating, failure to consume adequate folic acid, or the use of tobacco, alcohol, or drugs that could be linked to birth defects. Participant Focused Counseling: A woman who has delivered an infant with a nutrition-related birth defect can state the food and lifestyle choices she can make that are associated with a positive pregnancy outcome, such as: ● Consuming foods rich in folic acid, vitamin A, and zinc ● Avoiding tobacco, alcohol, or drugs

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History of Gestational Diabetes (3031) Categories: PG, BE/BP, WPP Defined as: History of Gestational Diabetes diagnosed by a health professional as self reported by applicant/participant/caregiver. Gestational Diabetes is any degree of glucose/carbohydrate intolerance with onset or first recognition during pregnancy.

A woman who has a history of gestational diabetes should have Nutrition Care counseling. Best Practice: initial contact 0-10 days. Best Practice: A pregnant woman with a history of gestational diabetes should have a Nutrition Care follow-up in 3 months. Justification: Uncontrolled Gestational Diabetes can result in respiratory distress syndrome, increased rate of stillbirth and pregnancy complications, and type 2 diabetes later in life. Although rarely seen in GDM, diagnosis in the early first trimester can result in congenital abnormalities and neural tube defects. Studies have found that the risk factors for subsequent GDM include insulin use in the index pregnancy, obesity, diet composition, physical inactivity, failure to maintain a healthy BMI and weight gain between pregnancies. In addition, if a woman’s lipid levels are elevated, a history of GDM is also a risk factor for cardiovascular disorders.

Procedure: Using information provided by the woman or her health care professional, determine if she has a history of Gestational Diabetes. Apply as follows: ● Pregnant woman: any pregnancy ● Breastfeeding or postpartum woman: during most recent pregnancy for a woman ● Review collected information about relevant dietary or lifestyle practices.

Participant Focused Counseling: ● Breastfeeding has been shown to lower blood glucose level and to decrease the incidence of type 2 diabetes in women with a history of GDM. Exercise also has a beneficial effect on insulin action by enhancing peripheral tissue glucose uptake. Medical Nutrition Therapy is an essential component in the care of a woman with a history of GDM. ● Diet and physical activity is the cornerstone of treatment. ● A postpartum woman who expresses interest in losing weight can set a goal for appropriate weight loss and state the food, physical activity, and/or lifestyle choices she can make to achieve her goal.

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History of Preeclampsia (3041) Categories: PG, BE/BP, WPP Defined as: Presence of the condition diagnosed by a physician as self-reported by applicant/participant/caregiver. Preeclampsia is defined as pregnancy-induced hypertension (>140mm Hg systolic or 90mm Hg diastolic) with proteinuria developing usually after the twentieth week of gestation. Clinical symptoms of preeclampsia may include: edema, renal failure, and the HELLP (Hemolysis, Elevated Liver enzymes, and Low Platelets) syndrome. Justification: Preeclampsia occurs in 3.4% of pregnancies in the United States and is associated with one maternal death per 100,000 live births in developed countries. Worldwide, it leads to the death of over 60,000 women annually.

It is important to note that postpartum preeclampsia can also occur, regardless of whether it was present during pregnancy. It is usually diagnosed within 48 hours of delivery but can occur up to 6 weeks postpartum. Thus, women during this period should monitor for preeclampsia symptoms and contact their health care provider immediately if they occur.

Women with a history of preeclampsia are at greater risk for future hypertension (HTN), heart attack, stroke, congestive heart failure, metabolic disease, and postpartum depression; these risks increase with repeated incidence of preeclampsia and with preterm delivery. Because women with a history of preeclampsia are at increased risk for HTN and related conditions, implementing lifestyle changes after delivery to help prevent HTN is crucial. Lifestyle measures to reduce the risk of HTN for women who are not pregnant include the following: ● Have blood pressure checked at least yearly or as recommended by one’s health care provider. For those at risk of HTN, regularly monitoring blood pressure is crucial. Blood pressure levels greater than 180/120 mmHg are extremely dangerous and require immediate medical attention. ● Consume a diet consistent with the Dietary Guidelines for Americans or follow the Dietary Approaches to Stop Hypertension (DASH) eating plan. Details regarding the DASH eating plan can be found on the National Heart, Lung, and Blood Institute’s website: www.nhlbi.nih.gov/health-topics/dash-eating-plan. ● Engage in regular physical activity. ● Achieve and maintain a healthy weight. ● Limit alcohol and avoid any use of tobacco, marijuana or illegal substances. (See Maternal Smoking and Alcohol or Substance Use.)

Currently, there is inconclusive scientific evidence on preventative measures for preeclampsia in future pregnancies. However, when dietary calcium is inadequate, research indicates adequate dietary calcium or supplementation (1.5-2 grams/day) may help prevent

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preeclampsia. Dietary folate and folic acid supplementation during pregnancy has also been associated with lower risk of preeclampsia. Breastfeeding Women who had preeclampsia face a greater risk of HTN later in life and longer breastfeeding duration has been found to reduce this risk. Since women who had preeclampsia during pregnancy have greater incidence of preterm birth, low birth weight, cesarean delivery, exposure to medications not compatible with breastfeeding, and mother/infant separation, staff should plan to provide breastfeeding support to assist mothers in overcoming these potential issues, so women have opportunities to meet their breastfeeding goals.

Women with a history of preeclampsia should be encouraged to breastfeed, unless contraindicated due to a reason not related to preeclampsia. If postpartum women require antihypertensive medications, those that are compatible with breastfeeding should be chosen. The mother should discuss her breastfeeding status and goals with WIC breastfeeding support staff and her health care provider to determine the best infant feeding and medication plan. Implications for WIC Nutrition Services The WIC Program provides support to participants with a history of preeclampsia by offering nutritious food that are important components of a diet to help prevent HTN. WIC nutrition staff also offer nutrition education, counseling, and referrals.

In addition, WIC staff can assist participants by:

Pregnant Women with History of Preeclampsia: • Encouraging prenatal care as soon as possible and to attend all health care appointments.

• Providing information about the symptoms of preeclampsia (sudden weight gain, swelling of face or hands, upper abdominal pain, difficulty breathing, changes in vision (including seeing spots), severe headache, nausea, and/or vomiting) and of the importance of contacting their health care provider immediately if they occur. Also, inform them that preeclampsia can occur postpartum.

• Counseling them on healthy weight gain, prenatal vitamin use, and a nutritious diet, including adequate calcium intake. For women with low calcium intake, refer them to their health care provider to discuss whether a calcium supplement is appropriate. Please note that a low-sodium diet and/or weight loss is NOT recommended as treatment for HTN during pregnancy.

• Encouraging them to discuss individualized physical activity recommendations with their health care provider.

• Providing information on avoiding any use of alcohol, tobacco, marijuana or illegal substances, as well as offering substance use referrals. The WIC Substance Use Prevention Manual is available for additional guidance and referral resources (https://wicworks.fns.usda.gov/resources/wic-substance-use-prevention-guide).

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• Referring to local home visiting programs for health monitoring and support, if available.

• Encourage breastfeeding, which can reduce risk of HTN later in life.

Postpartum Women with History of Preeclampsia: • Informing them of the symptoms of postpartum preeclampsia and of the importance of contacting their health care provider immediately if they occur.

• Providing breastfeeding promotion and support.

• Check compatibility of medication, if taken, and breastfeeding. Share information with mother. Encourage them to discuss their breastfeeding status and goals with their health care provider, especially if medications are prescribed.

• Encouraging them to attend all health care appointments, including their 4-6 week postpartum visit; to develop a plan for future pregnancies; to discuss health conditions and medication needs with their health care provider; and to have their BMI, blood pressure, lipids, and fasting glucose assessed yearly.

• Counseling them on achieving and maintaining a healthy weight, physical activity, following a diet consistent with the Dietary Guidelines for Americans or the DASH diet.

• Informing them that history of preeclampsia increases their risk of future HTN, cardiovascular disease, and stroke.

• Providing information on avoiding any use of alcohol, tobacco, marijuana or illegal substances, as well as offering substance use referrals. The WIC Substance Use Prevention Manual is available for additional guidance and referral resources (https://wicworks.fns.usda.gov/resources/wic-substance-use-prevention-guide)

• Referring them to their provider to discuss whether a calcium or folic acid supplement is appropriate, if intake of these nutrients seems inadequate.

• Referring to local home visiting programs, if available, for health monitoring and support.

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History of Preterm or Early Term Delivery (3111) Categories: PG, BE/BP, WPP

History of preterm and/or early term delivery is defined as follows: • Preterm: Delivery of an infant born <36 6/7 weeks. • Early Term: Delivery of an infant born >37 0/7 and <38 6/7 weeks. Use information provided by the woman or her health care professional to determine if she has delivered a premature infant. Apply as follows: Pregnant woman: any pregnancy Breastfeeding or postpartum woman: most recent pregnancy

Justification: Prior spontaneous preterm delivery is highly associated with recurrence in subsequent pregnancies. A history of one previous preterm birth is associated with a recurrent risk of 17-37%; the risk increases with the number of prior preterm births and decreases with the number of term deliveries

Typically, a pregnancy lasts about 40 weeks. Premature or preterm birth, however, is defined as a birth that occurs between 20 and 37 weeks of pregnancy, according to the American College of Obstetricians and Gynecologists (ACOG. In the past, the period from 3 weeks before until 2 weeks after the estimated date of delivery was considered a “term” pregnancy, with the expectation that a baby would have similar health outcomes if they were born any time during this interval. In 2013, ACOG released a committee opinion that the label “term” should be replaced with the designations early term (≥37 0/7 weeks and ≤38 6/7 weeks gestation) and full term (≥39 0/7 weeks and ≤40 6/7 weeks gestation) to more accurately describe these groups of infants.

Prematurity affects about 12% of all live births in the U.S., and about 50% of these preterm births were preceded by preterm labor. In 2011, the annual rate of premature births in the United States reached 11.7%, nearly two times the rate in European nations. Preterm births also account for approximately 70% of newborn deaths and 36% of infant deaths. Despite advances in neonatal care, preterm birth remains a leading cause of infant death in the United States. More infants die from pre-term related problems than any other single cause. Preterm birth strains society’s healthcare resources due to its long-term effects on the health of the newborn. Premature infants may have physical problems that have nutritional implications, including immature sucking, swallowing and immature digestion and absorption of carbohydrates and lipids. Preterm infants are at risk for a

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number of illnesses/health conditions that range from minor to severe complications depending on the circumstances. (See risk 1421 Preterm or Early Term Delivery for more details.) Several factors have been found to increase the risk of preterm delivery. Epidemiologic studies have consistently reported low socioeconomic status, nonwhite race, maternal age of ≤ 18 years or ≥ 40 years, and low pre-pregnancy underweight as risk factors. Studies suggest even modest restrictions in maternal nutrition around the time of conception can lead to premature births and long- term adverse health effects for offspring. Other factors associated with a risk of preterm birth may be identified before pregnancy, at conception, or during pregnancy include:

• Low maternal weight gain during pregnancy • Maternal infections, maternal hypertension, gestational diabetes • Smoking, indoor pollution • Maternal stress, teen pregnancy, multiple fetuses • Sexually transmitted diseases, low psychosocial health status • Previous or present pregnancy complications • Lack of perceived social support, poor housing quality

A recent study indicated that maternal obesity is also an independent risk factor for preterm delivery (10). Complications associated with obesity (BMI > 30) prior to conception that increase the risk for preterm delivery include (11): • Gestational Diabetes Mellitus, hypertension, preeclampsia • Cesarean Delivery, Clinical/Health/Medical: History of Preterm or Early Term Delivery • Postpartum weight retention Additional concerns related to obesity include potential intrapartum, operative, and postoperative complications and difficulties related to anesthesia management. Obese women are also less likely to initiate and sustain breastfeeding Participant Focused Counseling: A woman with a history of preterm delivery can state the food or lifestyle choices she can make (such as appropriate weight and avoidance of tobacco, alcohol, and drugs) to lower her risk of preterm delivery.

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History of Spontaneous Abortion, Fetal Death, Neonatal Loss (3211) Categories: PG, BE/BP, WPP Defined as: A spontaneous abortion (miscarriage) that occurs at < 20 weeks gestation, a fetal death (death at ≥ 20 weeks gestation), or a neonatal death (death occurring from birth through the first 28 days of life). Justification: Previous fetal and neonatal deaths are strongly associated with preterm low birth weight. There is also an increase in subsequent preterm deliveries in women who have experienced one or more second trimester spontaneous abortions. The extent to which nutritional interventions can decrease the risk for repeat poor pregnancy outcomes depends upon the degree to which poor nutrition was responsible for the poor pregnancy outcomes. The risk for future small for gestational age outcomes is greater for a woman with a history of 2 or more spontaneous abortions (SAB’s). SAB’s may also be indicators of neural tube defects. Nutritional deficiencies and excesses have been shown to result in low birth weight and pregnancy loss. Prenatal weight gain is one of the most important correlates of birth weight and fetal growth restriction. All women of childbearing age should be advised to consume 400 micrograms of folic acid daily. Procedure: Determine if the woman has a history of miscarriage (SAB) or fetal or neonatal death. Apply as follows: ● Pregnant woman: any pregnancy. A pregnant woman must have had ≥ 2 miscarriages to apply this risk factor ● Breastfeeding woman: most recent pregnancy with one or more infants still living ● Postpartum woman: most recent pregnancy

Participant Focused Counseling: Review collected information about dietary and lifestyle practices (such as restrictive eating practices, failure to consume 400 micrograms of folic acid daily, or tobacco, alcohol or drug use) that could contribute to poor pregnancy outcome. Educate on possible nutrition-related causes. Discuss behavior changes the participant is willing to make. Assist participant in setting simple goals to achieve those changes. Refer to behavior change programs (e.g., smoking cessation) as appropriate.

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HIV/AIDS (3524) Categories: ALL Defined as: a chronic virus infection that reduces an individual’s ability to fight off infections and diseases. When HIV progresses to AIDS, the immune system becomes extremely weakened and can no longer protect against other infections or opportunistic illnesses that would not harm healthy individuals but can be life-threatening to people infected with HIV. A participant determined to have HIV/AIDS should have Nutrition Care counseling. If the participant is breastfeeding, the CPA should review the conditions for safe breastfeeding. Best Practice: notify the IBCLC/DBE in case complications arise.

Justification: The Human Immunodeficiency Virus (HIV) destroys white blood cells found in the immune system, also known as CD4 (cluster of differentiation) or T cells (T lymphocytes). HIV is transmitted only through blood, semen, pre-seminal fluid, rectal fluids, vaginal fluids, and breastmilk from an HIV-infected person. HIV can lead to Acquired Immunodeficiency Syndrome (AIDS) if left untreated. Individuals who are aware of their HIV status and are undergoing antiretroviral therapy (ART) to stop the replication of the virus, can typically live decades. Those unaware of their status or who are not on ART can usually remain in this stage up to about ten years before progressing to the AIDS stage.

Getting tested is the only way individuals know they are infected with HIV. The Centers for Disease Control and Prevention (CDC) recommends that all pregnant people get tested early in their pregnancies. An early diagnosis during the prenatal period can reduce the transmission of HIV in babies to less than 1% if the expectant parent receives Active Antiretroviral Therapy (ART) during pregnancy, labor, and delivery, and the baby receives appropriate preventative medication after birth. This treatment also keeps the chance of passing HIV to an infant through breastfeeding to less than 1%, making breastfeeding a viable option. PrEP (Pre-Exposure Prophylaxis) is a daily pill containing two medicines (tenofovir and emtricitabine), recommended for HIV negative people who are at substantial risk of becoming infected with HIV. PrEP, when taken consistently, reduces HIV transmission by up to 92%.

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Participant Focused Counseling: WIC can improve the management of chronic infectious diseases through WIC foods, nutrition education, counseling, and referrals to community resources that provide support in the long-term management of chronic infectious diseases. Dietary recommendations depend on the symptoms experienced by the HIV positive participant. A discussion using open-ended questions can determine the participant’s symptoms, and openness to exploring dietary approaches to reducing symptoms, using the following options. A participant with unintended weight loss or wasting, may be dealing with 1. Poor food intake due to medication side effects, sore mouth, or mental health issues 2. Altered metabolism due to disease progression 3. Nutrient malabsorption caused by gastrointestinal problems from either the medications or the virus itself. For these participants, the main goals are to maintain or increase body weight, retain or increase lean body mass, and take in adequate macro- and micro-nutrients. ● These participants usually require a higher protein diet ● They may need a multivitamin supplement, since most are lower in vitamins A, B6, C, and E. Specific supplements should be recommended only by the health care provider. Note: Iron supplements leading to iron overload encourage disease progression from HIV to AIDS. In addition, supplements of vitamin A and Zinc can have a negative impact on adults living with HIV/AIDS.

Goals for asymptomatic participants or those with stable weight should focus on adequate nutrition to prevent wasting. On recommendation of the health care provider, they can take a multivitamin or mineral supplement.

Although people with HIV are able to manage the disease and live longer with Highly Active Antiretroviral Therapy (HAART), the side effects can cause gastrointestinal problems, lipid disorders, and insulin resistance/glucose intolerance should: ● Reduce total fat and cholesterol ● Increase dietary fiber ● Increase physical activity ● Reduce alcohol consumption ● Reduce consumption of simple sugars

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HIV/AIDS and Food Safety Participants with HIV are more susceptible to food-borne illness due to a weakened immune system. WIC nutritionists should encourage them to: ● Store and prepare foods safely ● Check expiration dates ● Avoid raw or semi raw foods like meat, unpasteurized dairy foods, and soft cheeses. ● Infants born to HIV-positive mothers often are carefully monitored for their HIV status for the first six months of life, and may be referred to WIC as HIV positive, even though their status may not yet be established. Pediatricians may request ready-to-feed or liquid concentrate infant formula, since powdered infant formula is not sterile and may not be microbiologically safe. If requested, liquid concentrate formula is appropriate and allowable for an infant diagnosed as HIV positive.

HIV/AIDS Care and Support Families that include someone living with HIV often lack the financial and psychosocial support needed to deal with this diagnosis and the social stigma can reduce compliance with medical treatment needed to control the disease. They must get care, stay in care, and adhere to their medical plan. WIC agencies should refer participants to health care services and community resources, including other nutrition assistance programs to improve health outcomes.

The following information summarizes the WIC Nutrition Services that can help improve the health and birth outcomes of participants living with HIV.

NUTRITION AND HEALTH TIPS TO MANAGE HIV/AIDS SYMPTOMS

All Categories ● Use MyPlate as the guide for dietary needs. ● Consult health care providers when using supplements and herbs to avoid adverse reactions or medication interactions that could reduce effectiveness. ● Eat small, frequent meals when gastrointestinal problems are present or persistent. ● Eat soft foods with manageable textures at tolerable temperatures when oral lesions and dental problems are present (i.e. mashed potatoes, scrambled/boiled eggs, bananas, non-citrus juices, puddings, custards, milk, cooked vegetables, rice, oatmeal, non-fizzy drinks, cottage cheese, non-spicy foods). ● Add canned tuna, beans, cheese, peanut butter, dried milk for inexpensive extra protein.

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● Add moderate amounts of concentrated sources of calories to diet when needed (e.g., butter, cream cheese, gravies, whole milk, ice cream). ● Consume nutritious, high caloric foods when appetite is normal or has returned. ● Drink adequate water to stay hydrated, replace fluid loss from diarrhea and vomiting, and help medications move through the body. ● Consume foods high in fiber or fiber supplements to slow digestion if foods are moving too quickly through the body. ● Eat yogurt or foods with Lactobacillus acidophilus culture to help with bacterial overgrowth resulting from prolonged use of antibiotics. ● Avoid caffeinated beverages to prevent dehydration. ● Avoid or reduce sugar-free foods with sorbitol as diarrhea may be exacerbated. ● Consult with a health care provider about the use of complete oral nutritional supplements to help nutritional status. ● Avoid alcohol and illegal drugs for overall good health and to help protect the liver. ● Use pancreatic enzymes when medically prescribed to help with digestion. ● Prepare and store food safely. ● Avoid expired and moldy foods or foods with rotten spots. ● Participate in weight-bearing exercises to strengthen and maintain bones. ● Refer families affected by HIV to other community resources for food, housing, and medical resources to improve compliance with HIV treatment.

Women ● Advise pregnant individuals who are living with HIV to consume a diet adequate in nutrients, achieve appropriate weight gain, and discuss taking a multivitamin with their health care provider. ● Educate parents living with HIV about infant feeding options. Anyone on antiretroviral therapy, with an undetectable or extremely suppressed viral load has a less than 1% chance of passing HIV to an infant through breastfeeding. Those who have a higher viral load and those who are not on antiretroviral medications have a higher chance of passing HIV to an infant they breastfeed. Use of infant formula or donor milk from a Human Milk Banking Association of North America (HMBANA) milk bank eliminates the risk of HIV transmission through feeding. Parents living with HIV should be encouraged to speak with their physicians about getting started on antiretroviral medications if they currently are not on a regimen, and if on the medication, to continue taking it as directed and keep medical appointments for best chances of sustaining their undetectable viral loads. ● More information about breastfeeding and HIV can be found at:

o https://www.cdc.gov/breastfeeding-special-circumstances/hcp/illnesses-conditions/hiv.html o

Infants

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● Educate parents/caregivers living with HIV that they can breastfeed if they choose to. Provide factual information regarding chances of passing HIV through breastmilk, depending on the parents’ viral load, and the importance of the parent being on antiretroviral medication to achieve and maintain a very suppressed viral load. Educate that if they choose to use donor breastmilk from a HMBANA milk bank or infant formula, it eliminates the chance of passing HIV through feeding. ● Discourage giving pre-chewed food, regardless of HIV status, as the HIV status of the individual who is pre-chewing the food is unknown. ● More information about infants and HIV can be found at: o https://clinicalinfo.hiv.gov/en/guidelines/perinatal/infant-feeding-individuals-hiv-united-states

Children ● Discourage giving pre-chewed food, regardless of HIV status, as the HIV status of the individual who is pre-chewing the food is unknown.

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Hepatitis (3523) Categories: ALL Defined as: inflammation of the liver. A participant determined to have Hepatitis should be referred to the CPA for Nutrition Care counseling. Justification: Hepatitis is most often caused by viruses, but can also be caused by excessive alcohol intake, toxins, and medicines such as acetaminophen and some other conditions linked to liver inflammation. Regardless of the type of hepatitis, infected individuals with signs of the infection will typically experience anorexia, nausea, vomiting, diarrhea, jaundice, epigastric pain, tiredness, and weakness, all of which affect one’s diet and health. Darker urine and pale stools may also be present. Viral hepatitis is the leading cause of liver cancer and the most frequent need for liver transplants in the United States. Because symptoms of all kinds of hepatitis are the same, diagnosis by laboratory testing or an epidemiologic link to a confirmed case is required.

Procedure: WIC can improve the management of acute or chronic Hepatitis infections through WIC foods, nutrition education, counseling, and referrals to community resources that provide support in the long-term management of Hepatitis infections.

WIC Nutrition Services for Acute Infectious Hepatitis: ● Encourage sufficient calorie intake to help meet increased nutrition needs. ● Recommend the Dietary Guidelines to ensure healthy eating pattern ● Provide suggestions to address poor appetite ● Provide education on safe food handling and storage practices

WIC Nutrition Services for All Types of Hepatitis: ● Recommend testing to pregnant women and high -risk individuals. ● Encourage abstinence from alcohol. ● Provide information on high calorie, high protein, and moderate fat diets, as recommended by health care provider. ● Discuss high calorie consumption at breakfast to reduce nausea. (Typically, nausea is less common in the morning.) ● Recommend, in consultation with health care provider, consumption of high calorie and protein liquid formula between meals to boost calorie intake.

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● Encourage a bland diet with extra fluids depending on the severity of nausea and vomiting.

The chart below summarizes differences in Hepatitis types, and additional WIC Nutrition Services that can help improve the health and outcomes of participants with Hepatitis. TYPE TRANSMISSION PREVENTION/TREATMENT WIC NUTRITION SERVICES ACUTE INFECTIONS: Must be present within the past 6 months. A Fecal-oral route Household member Sexual partner Fecal contaminated food/water 70% asymptomatic Prevention: Proper hygiene Food safety Vaccination Encourage vaccine for children, adolescents, high risk adults.Promote BF as safe except with cracked/bleeding nipples. Stop breastfeeding until nipples heal and continue to pump to maintain milk supply. Discourage pre-chewing infant food E Uncommon in US. Fecal-oral, usually drinking water. Uncooked/undercooked meat and shellfish Travel to developing countries No treatment or vaccine; Symptoms usually resolve; Pregnant: 10-30% death rate in 3rd trimester Prevention: Clean drinking water and good sanitation Supportive therapy/ hospitalization. Avoid contaminated water ACUTE AND CHRONIC INFECTIONS: Acute infections must be present in last 6 months. Chronic infections may last a lifetime B Infected blood, needles, body fluids at work; Asian & Pacific islanders most at risk; Those undergoing dialysis; Those who are HIV infected; Immigrant/refugee status; Sexual intercourse with infected person; Mother to child at birth (both vaginal & Cesarean section births) Interferon & antiviral drugs Prevention: Hepatitis B vaccine;

Encourage vaccine for newborns, adolescents, at risk adults; Promote BF as safe except with cracked/bleeding nipples Stop breastfeeding until nipples heal and continue to pump to maintain milk supply. Discourage pre-chewing infant food

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TYPE TRANSMISSION PREVENTION/TREATMENT WIC NUTRITION SERVICES C Present in blood & body fluids: Sharing needles; Sexual activity; Transfusion/organ transplant before July 1992; Sharing razor, toothbrush, or nail clippers; Tattoos & piercings from unlicensed facilities Mother to child at birth No vaccine

Promote BF as safe except with cracked/bleeding nipples. Stop breastfeeding until nipples heal and continue to pump to maintain milk supply. D Uncommon in the US. Contracted only when a person has Hepatitis B first. Contact with blood and body fluids; Sexual activity with infected person; Mother to child transmission at delivery; Sharing drug paraphernalia, razors, or toothbrushes; Direct contact with blood of infected person

No vaccine, except Hepatitis B for prevention; Interferon may be helpful Recommend Hepatitis B vaccine

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Homelessness (8011) Categories: All Defined as: A woman, infant, or child who lacks a fixed and regular nighttime residence; or whose primary nighttime residence is: ● a supervised publicly or privately-operated shelter (including a welfare hotel, a congregate shelter, or a shelter for victims of domestic violence) designed to provide temporary living accommodations; ● an institution that provides a temporary residence for individuals intended to be institutionalized; ● a temporary accommodation of not more than 365 days in the residence of another individual; or ● a public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings.

Procedure: Determine if the participant is homeless, as defined above. Review dietary and lifestyle practices.

Participant Focused Counseling: The goals of nutrition counseling are: ● to assist the homeless participant in making decisions about the selection, storage, and preparation of foods to promote optimal nutritional status. ● To advise and support the caregiver of the homeless participant so she is able to make the best decisions regarding food selection, storage, and preparation, despite living conditions.

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Hyperemesis Gravidarum (3011) Category: PG Defined as: Current diagnosis of Hyperemesis Gravidarum, diagnosed by a physician as self-reported by applicant/participant/caregiver. Hyperemesis Gravidarum (HG) is defined as severe and persistent nausea and vomiting during pregnancy which may cause more than 5% weight loss and fluid and electrolyte imbalances. This nutrition risk is based on a chronic condition, not single episodes. HG is a clinical diagnosis, made after other causes of nausea and vomiting have been excluded.

A pregnant woman identified with Hyperemesis Gravidarum should have Nutrition Care counseling. Best Practice: Provide Nutrition Care follow-up in 1-3 months Justification: A pregnant woman with Hyperemesis Gravidarum is at risk for weight loss, dehydration, ketonuria, and electrolyte imbalances such as hypokalemia. HG affects approximately 0.3-3.0% of pregnancies and may lead to adverse fetal consequences and hospitalization in some cases. HG is the second most common reason for hospitalization for pregnant women, with preterm labor being the most common. Risk Factors for HG Biological, physiological, psychological and sociocultural factors are thought to be influential in HG. Various risk factors include maternal underweight, multiple pregnancy, nulliparity, previous history of HG, trophoblastic disorders, and history of eating disorders. Family history, Helicobacter pylori infection, history of motion sickness and/or migraine headaches are also risk factors for HG.

HG and Adverse Maternal Outcomes HG can adversely affect maternal outcomes and, if inadequately managed, can lead to malnutrition, dehydration, electrolyte imbalances, thrombosis, and Wernicke’s encephalopathy (a very rare but potentially life-threatening complication of HG, caused by thiamine deficiency). Vitamin K deficiency has also been reported with HG and may be implicated in neonatal hemorrhage. Other serious complications include esophageal rupture (caused by severe vomiting), peripheral neuropathy, coagulopathy and Mallory- Weiss syndrome (acute increase in esophageal pressure due to vomiting).

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Women with HG in the second trimester are at an increased risk for placental disorders, such as placental abruption. Pregnant women with HG are at an increased risk for any autoimmune disorder, and in extreme cases this may lead to organ damage manifesting as oliguria and abnormal liver function tests. In addition, pregnant women with HG are at increased risk for psychological distress therefore leading to an increased risk for depression and anxiety. Other concerns associated with HG include severe distress, social dysfunction and loss of time from work. Malnourishment may develop over a period of time in women suffering with HG, which may lead to refeeding syndrome (RFS).

HG and Adverse Birth Outcomes Women with HG have an increased risk of giving birth to low birth weight, small for gestational age, and premature infants, infants at increased risk of colic, irritability, and growth restrictions, and, possibly, an increased risk of psychological disorders and reduced insulin sensitivity.

Procedure: ● Determine if the woman has been diagnosed with and currently has Hyperemesis Gravidarum. ● Review collected information about dietary and lifestyle practices.

Participant Focused Counseling: WIC nutrition staff can provide the following nutrition services to women with HG: ● Refer to a health care provider for appropriate monitoring and treatments as necessary. ● Provide education on how to recognize symptoms of dehydration such as: increased thirst, dry mouth, low urine output or urine that is darker in color than normal.

Offer suggestions to help with nausea such as: ● Avoid foods and smells that seem to trigger nausea. ● Eat crackers or dry cereal before getting out of bed to curb nausea in the morning. ● Avoid large fluid intakes in the morning. Drink liquids between meals instead of with meals. ● Choose foods carefully. Select foods that are high in carbohydrates or protein, low in fat, and easy to digest. Salty foods are sometimes helpful, as are foods that contain ginger — such as ginger lollipops. Avoid greasy, spicy and fatty foods. Consume foods that settle the stomach and calm the nausea. ● Eat several small meals throughout the day instead of three large meals. Meals should contain more carbohydrates than fat and acid. Protein-rich meals also decrease symptoms. Lighter snacks, including nuts, dairy products, and beans, are recommended.

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Hypertension and Prehypertension (3452) Categories: PG, BE/BP, WPP, C 3-4 Defined as: Presence of hypertension or prehypertension diagnosed by a physician as self-reported by applicant/participant/caregiver as follows: ● Adult hypertension: consistent readings of ≥140/≥90 mmHg millimeters of mercury ● Adult prehypertension: consistent readings of 120-139/80-89 mmHg. ● Hypertension during childhood is age-specific and is defined as blood pressure readings greater than the 95th percentile for age, gender, and height on at least three separate occasions. Blood pressure reading between the 90th and 95th percentiles is considered prehypertension.

A participant identified with hypertension or prehypertension should have Nutrition Care counseling. Best Practice: Provide Nutrition Care follow-up in 3-6 months.

Justification: Untreated hypertension leads to many degenerative diseases, including congestive heart failure, end-stage renal disease, and peripheral vascular disease. Hypertensive disorders of pregnancy include Chronic Hypertension, Preeclampsia, Eclampsia, Preeclampsia superimposed on Chronic Hypertension, and Gestational Hypertension. There is no cure for hypertension; however, lifestyle modifications can prevent high blood pressure and are critical in the management of hypertension and prehypertension. Children with high blood pressure are more likely to become hypertensive adults. Therefore, they should have their blood pressure checked regularly beginning at the age of three. Blood pressure and overweight status have been suggested as criteria to identify hypertensive children. Hypertension (HTN), commonly referred to as high blood pressure, occurs when the force of blood against artery walls is high enough that it may eventually cause health problems. Hypertension is measured in terms of both systolic blood pressure (pressure in blood vessels when the heart contracts) and diastolic blood pressure (pressure in blood vessels when the heart rests between contractions). Two main factors in the body increase levels of blood pressure – a higher volume of blood being pumped by the heart and narrower arteries. Untreated HTN leads to many degenerative diseases, including congestive heart failure, end-stage renal

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disease, and peripheral vascular disease. People with HTN are often asymptomatic; diagnosis is based on measuring levels of blood pressure. About 75 million adults in the United States (1 in every 3) have HTN, and about the same number have prehypertension. Unfortunately, only half of adults in the United States with HTN have their blood pressure under control, and HTN leads to at least 410,000 deaths in the United States annually. Primary HTN has no known cause. Secondary HTN can be caused by sleep apnea, kidney problems, diabetes, some tumors, thyroid problems, inflammation, and blood vessel defects. In addition, several medications (e.g., some birth control, cold medicines, decongestants, pain relievers) as well as illegal substances can significantly raise blood pressure. Risk factors for HTN include the following: • Age (Risk increases with age.) • Race/ethnicity (In the United States, people of African descent experience disproportionately higher rates of HTN compared to other races/ethnicities. Causes for this racial disparity in rates of HTN are complex and multifactorial.) • Family history • Overweight or obesity (This causes more blood to be pumped by the heart.) • Physical inactivity (This is associated with a higher heart rate, which increases the force of blood against arteries.) • Tobacco use (This increases blood pressure during use. Chemicals in tobacco also lead to narrowing of arteries.) • Second-hand exposure to tobacco smoke • Excessive sodium intake (This causes fluid retention, which increases blood pressure.) • Inadequate potassium intake (This causes an excessive amount of sodium in the blood.) • Excessive alcohol intake (This can damage the heart over time.) • Stress • Prehypertension • Pregnancy • Male gender

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Management of HTN includes lifestyle modifications and medication. In prehypertensive individuals, implementing lifestyle changes can prevent or delay the onset of HTN. In hypertensive individuals, dietary intervention is not only effective in reducing blood pressure but also in delaying or avoiding drug treatment.

Lifestyle changes to manage HTN and prehypertension include the following: • Have blood pressure checked at least yearly or as recommended by one’s health care provider. For those at risk of HTN, regular monitoring of blood pressure is crucial. Blood pressure levels greater than 180/120 mmHg are extremely dangerous and require immediate medical attention. • Consume a diet consistent with the Dietary Guidelines for Americans or follow the Dietary Approaches to Stop Hypertension (DASH) eating plan. Details regarding the DASH eating plan can be found on the National Heart, Lung, and Blood Institute’s website: www.nhlbi.nih.gov/health-topics/dash-eating-plan. • Engage in regular physical activity. • Achieve and maintain a healthy weight. • Limit alcohol and avoid any use of tobacco, marijuana or illegal substances.

• If lifestyle changes alone do not sufficiently reduce blood pressure, medications may be prescribed. These include angiotensin- converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), calcium channel blockers, and/or diuretics.

Pregnant Women Hypertension occurs in 6-8% of all pregnancies in the United States. Any HTN during pregnancy can lead to preeclampsia, eclampsia, stroke, pregnancy induction, and/or placental abruption. Because HTN during pregnancy can tighten the mother’s blood vessels (including those in the umbilical cord), it can reduce oxygen and nutrients to the infant, potentially causing prematurity, low birth weight, and fetal growth restriction.

Hypertensive disorders of pregnancy are categorized as follows:

Chronic Hypertension during Pregnancy: Definition: Hypertension is present before pregnancy or is diagnosed before 20 weeks gestation. ● Increases the risk of developing more severe HTN during pregnancy, gestational diabetes, and perinatal mortality. In infants, it may lead to fetal growth restriction and, additionally, exposure to antihypertensive medications may cause fetal growth restriction and malformation. ● Treatment includes frequent, regular monitoring of blood pressure. It is typically suggested that women with well-controlled blood pressure who exercised regularly before pregnancy continue moderate physical activity during pregnancy, unless contraindicated. Women should check with their health care provider for individualized guidance.

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Preeclampsia: ● Definition: Onset of hypertension during pregnancy, typically with proteinuria, and usually after 20 weeks gestation. For some women, proteinuria does not occur; for these women, preeclampsia is diagnosed as hypertension with thrombocytopenia, impaired liver function, renal insufficiency, pulmonary edema, and/or cerebral or visual disturbances.

● The most common type of hypertensive disorder during pregnancy, preeclampsia occurs in 3.4% of pregnancies in the United States and is associated with one maternal death per 100,000 live births in developed countries. Worldwide, it leads to the death of over 60,000 women annually.

● Risk factors include history of preeclampsia, chronic HTN, chronic kidney disease, history of thrombocytopenia, in vitro fertilization, diabetes, auto-immune disorders (such as lupus), uterine artery notching, family history of preeclampsia, obesity, polycystic ovarian syndrome, giving birth for the first time, multifetal pregnancy, pregnancy interval greater than 10 years, and being older than 40 years. Low dietary and serum calcium levels are also associated with preeclampsia.

● Clinical signs include any of the following: proteinuria, low blood platelet count, abnormal kidney or liver function, and fluid in the lungs. Symptoms can include sudden weight gain, swelling of face or hands, upper abdominal pain, difficulty breathing, changes in vision (including seeing spots), severe headache, nausea, and/or vomiting. ● For pregnant women, preeclampsia can lead to pulmonary edema (fluid build-up in the lungs), heart attack, stroke, acute respiratory distress syndrome (difficulty breathing due to fluid leaking into the lungs), coagulopathy (blood unable to clot), severe renal failure, retinal injury, liver rupture, placental abruption, hemolysis (breakdown of red blood cells), cesarean delivery, and/or death. Women with preeclampsia are at greater risk for postpartum depression, future HTN, heart attack, stroke, congestive heart failure, and metabolic disease; these risks increase with repeated incidence of preeclampsia and with preterm delivery. The infant of a woman with preeclampsia is at greater risk for cesarean delivery, preterm birth, low birth weight, small for gestational age, and/or stillbirth. For the children of mothers who had preeclampsia, they are at heightened risk of bronchopulmonary dysplasia (form of chronic lung disease), cerebral palsy, cardiovascular dysfunction, learning disabilities, and lower IQ. ● Currently, there is inconclusive evidence on preventative measures for preeclampsia in future pregnancies. However, when dietary calcium is inadequate, research indicates adequate dietary calcium or supplementation (1.5-2 grams/day) may help prevent preeclampsia. Dietary folate and folic acid supplementation during pregnancy has also been associated with lower risk of preeclampsia.

Treatment for preeclampsia depends on severity and other individual factors. For women with preeclampsia without severe features (hypertension with proteinuria after 20 weeks gestation), the American College of Obstetricians and Gynecologists (ACOG) currently suggests that strict bed rest not be routinely prescribed (although there may be situations in which different levels of rest, including bed rest and hospitalization, may be indicated).

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For women with severe preeclampsia, treatment should: ● occur in an inpatient setting, and ACOG recommends early delivery of the infant to prevent additional harm to the mother and infant. The only known cure for preeclampsia during pregnancy is the delivery of the infant and placenta. ● It is important to note that postpartum preeclampsia can occur, regardless of whether it was present during pregnancy. It is usually diagnosed within 48 hours of delivery but can occur up to 6 weeks postpartum. Thus, women during this period should monitor for preeclampsia symptoms and contact their health care provider immediately if they occur.

Chronic Hypertension with Superimposed Preeclampsia: Definition: Hypertension is present before pregnancy, and preeclampsia develops during pregnancy. It is classified as either “with severe features” (hypertension with proteinuria before 20 weeks gestation with organ problems) or “without severe features” (hypertension with proteinuria after 20 weeks gestation).

Eclampsia: Definition: Eclampsia is the presence of new-onset grand mal seizures in a woman with preeclampsia. Eclampsia can occur before, during, or after labor. It may be preceded by severe headaches, blurred vision, sensitivity to light, abdominal pain, hyperreflexia (over-reactive reflexes), and altered mental status. ● Eclampsia is a critical situation and can lead to maternal death. Treatment typically includes parenteral magnesium sulfate in an inpatient setting. Once the mother’s condition is stabilized, ACOG recommends the delivery of the infant. Treatment with magnesium sulfate may also be continued after delivery, if needed. ● Please note that due to the critical nature of eclampsia and its treatment in an inpatient setting, women with eclampsia are not encountered within a WIC setting.

Gestational Hypertension: Definition: Onset of hypertension during pregnancy, usually after 20 weeks gestation, and without proteinuria. It usually resolves after delivery but does increase the risk of developing chronic HTN. The term “pregnancy-induced hypertension” includes preeclampsia, eclampsia and gestational hypertension. Please note that a low-sodium diet and/or weight loss is NOT recommended as treatment for HTN during pregnancy. Breastfeeding A systematic study done by the Agency for Healthcare Research and Quality found that there is an inverse relationship between duration of breastfeeding and HTN: the longer a woman breastfeeds, the less risk she has for developing HTN. Similarly, women with hypertension should be encouraged to breastfeed, unless contraindicated. If postpartum women require antihypertensive medications, medications should be chosen that are compatible with breastfeeding, if possible. It is thus very important for the mother to discuss her breastfeeding status and goals with her health care provider to determine the best infant feeding and medication plan.

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Children Hypertension among children is a serious condition and may eventually lead to hypertension and chronic disease in adulthood. The definition of HTN is based on the normative distribution of blood pressure in healthy children. In 2017, the American Academy of Pediatrics (AAP) updated their pediatric HTN diagnostic tools to account for the sex, age, and height of the child. For more information about the definition and classification of HTN in children see the AAP Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents: https://pediatrics.aappublications.org/content/140/3/e20171904.

Early detection of high blood pressure in children is crucial for preventing future health concerns. Thus, the AAP recommends that blood pressure be measured annually once children are three years old. For children under three years of age, health care providers should measure blood pressure at every visit if the child has a risk factor for developing HTN.

The prevalence of HTN among children and adolescents in the United States is around 3.5%. About 2-4% U.S. children and adolescents experience persistently elevated blood pressure. Higher rates are experienced by boys and among Hispanic and non- Hispanic African American children compared to white children.

For most children with HTN, there is no specific, identifiable cause (thus, it is considered primary HTN). Some children, however, do experience HTN as a direct result of medications, kidney disease, endocrine disorders, or congenital heart defects.

Risk factors for elevated blood pressure and HTN among children include the following: • Family history of HTN, including maternal HTN during pregnancy • Overweight and obesity (including high weight-for-length in infants) • History of prematurity, low birth weight, and/or small for gestational age • High sodium intake.

Hypertension during childhood has implications for both current and long-term health. Health outcomes of HTN occurring in children may include the following: • Dyslipidemia and cardiovascular damage • Learning disabilities, impaired neurocognition and executive functioning • In adulthood: HTN, metabolic syndrome, and cardiovascular disease.

For the management of HTN in children, the AAP recommends the following lifestyle changes: • Achieve and maintain a healthy weight-for-length or BMI (body mass index). • Follow an age-appropriate DASH-type eating plan. • Participate in moderate to vigorous physical activity at least 3-5 days per week, 30-60 minutes per session. • Get adequate sleep (more than 7 hours a night).

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For more information about HTN among children, please see the Centers for Disease Control and Prevention’s website High Blood Pressure during Childhood and Adolescence at: https://www.cdc.gov/bloodpressure/youth.htm.

Implications for WIC Nutrition Services The WIC Program provides support to participants with hypertension/prehypertension by offering fruits, vegetables, whole grains, legumes, low-fat dairy, and fish, which are important components of the DASH eating plan. WIC nutrition staff also offer nutrition education and counseling as well as referrals to smoking cessation and substance use treatment, if needed, which are critical to the management of hypertension/prehypertension. In addition, WIC staff can assist participants by:

For Pregnant Women with Hypertension: • Asking probing questions to determine the type of hypertension they have been diagnosed with during pregnancy. • Encouraging them to start prenatal care as soon as possible and to attend all health care appointments. Health status and blood pressure should be monitored frequently by health care provider. The health care provider may also recommend regular self- monitoring of blood pressure. • Informing them of the symptoms of preeclampsia and of the importance of contacting their health care provider immediately if they occur. Also, inform them that preeclampsia can occur postpartum. • Counseling them on healthy weight gain, prenatal vitamin use, and a nutritious diet, including adequate calcium intake. For women with low calcium intake, refer them to their health care provider to discuss whether a calcium supplement is appropriate. Please note that a low-sodium diet and/or weight loss is NOT recommended as treatment for HTN during pregnancy. • Encouraging them to discuss individualized physical activity recommendations with their health care provider. • Informing them that hypertension during pregnancy increases their risk of future HTN, cardiovascular disease, and stroke. • Providing information on avoiding any use of alcohol, tobacco, marijuana or illegal substances, as well as offering substance use referrals. The WIC Substance Use Prevention Manual is available for additional guidance and referral resources: https://wicworks.fns.usda.gov/resources/wic-substance-use-prevention-guide.

• Referring to local home visiting programs for health monitoring and support, if available.

For Postpartum Women with Hypertension: • Asking probing questions to determine the type of hypertension they experienced during pregnancy and are now experiencing. • Informing them of the symptoms of postpartum preeclampsia and of the importance of contacting their health care provider immediately if they occur.

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• Providing breastfeeding promotion and support, unless contraindicated. Encourage women to discuss their breastfeeding status and goals with their health care provider, especially if medications are prescribed. • Encouraging them to attend all health care appointments, including their 4-6 week postpartum visit; to develop a plan for future pregnancies; to discuss health conditions and medication needs with their health care provider; and to have their BMI, blood pressure, lipids, and fasting glucose assessed yearly.

• Counseling them on achieving and maintaining a healthy weight, physical activity, following a diet consistent with the Dietary Guidelines for Americans or the DASH diet. • Providing information on avoiding any use of alcohol, tobacco, marijuana or illegal substances, as well as offering substance use referrals. The WIC Substance Use Prevention Manual is available for additional guidance and referral resources: https://wicworks.fns.usda.gov/resources/wic-substance-use-prevention-guide. • Referring them to their health care provider to discuss whether a calcium or folic acid supplement is appropriate, if intake of these nutrients seems inadequate. • Referring to local home visiting programs for health monitoring and support, if available.

For Children with Hypertension: • Encourage caregivers to take children to all health care appointments. • Counsel caregivers on: healthy pediatric weight gain and, for children with high weight-for-length or obesity, discuss strategies for achieving and maintaining a healthy weight; age-specific, DASH-type eating habits; and the importance of adequate sleep and physical activity in children.

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Late to Prenatal Care (3341) Category: PG Defined as: Prenatal care beginning after the 1st trimester (after completed week 13 of gestation). Justification: Women who do not receive early or adequate prenatal care are more likely to deliver premature, growth retarded, or low birth weight infants. Women with medical or obstetric problems, as well as young adolescents, may need closer management with the frequency of prenatal visits determined by the severity of the identified health problem. Procedure: Determine if the woman did not have her first prenatal care visit before she completed 13 weeks of gestation. This risk criterion applies to a pregnant woman only. A woman who has not contacted a healthcare professional to schedule a prenatal appointment should be given referral information as appropriate. Participant Focused Counseling: WIC interventions such as referrals to prenatal care and encouragement to keep scheduled prenatal appointments and to follow the advice of health care professional(s) promotes optimal birth outcomes. A pregnant woman late to prenatal care can: ● State one or more steps she can take to get early and adequate prenatal care. ● State the food and lifestyle choices she can make that promote a positive pregnancy outcome.

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Large for Gestational Age (LGA) (1531) Categories: IBE, IBP, IFF Defined as: Birth weight of ≥ 9 pounds (≥ 4000 grams). Presence diagnosed by a physician as self-reported by applicant/participant/caregiver. Justification: Infant mortality rates are higher among full-term infants who weigh > 9 pounds (> 4000 grams). LGA is associated with congenital birth defects (especially congenital heart conditions) and developmental and intellectual retardation. LGA may be due to uncontrolled maternal diabetes. It can contribute to childhood obesity that may persist into adult life. Procedure: Determine if the infant’s birth weight was 9 pounds or greater. Review collected information to determine if feeding practices are present that could promote a rapid rate of weight gain, such as an early introduction of solid foods. Participant Focused Counseling: The caregiver can state the feeding practices she can follow to promote optimal growth and development in her child.

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Limited Ability of Caregiver to Make Feeding Decisions (9021) Categories: All Defined as: A woman (pregnant, breastfeeding, or non-breastfeeding) or infant/child whose primary caregiver is assessed to have a limited ability to make appropriate feeding decisions and/or prepare food, including: ● ≤ 17 years of age; ● Mental illness, including diagnosed clinical depression, intellectual disability; ● Physically disabled, limiting food preparation ability; OR ● Currently using or history of misuse of alcohol, use of illegal substances, use of marijuana, or misuse of prescription medications.

Note: This risk factor must be manually assigned in WOW and a note must be written to document it. Justification: ● The mother or caregiver 17 years of age or younger generally has limited exposure and skills needed to care for and feed a dependent. ● Cognitive limitation in a parent or primary caregiver has been recognized as a risk criterion for Failure to Thrive as well as abuse and neglect. ● The mentally handicapped caregiver may not exhibit the necessary parenting skills to promote beneficial feeding interactions with the infant. ● Maternal mental illnesses such as severe depression and maternal substance abuse are strongly associated with abuse and neglect. ● Physical handicaps such as blindness or para- or quadriplegia may restrict or limit the caregiver’s ability to prepare and offer a variety of foods. ● Substance abuse can lead to impaired parental behaviors, compromised caregiving relationship, reduced capacity to prioritize infant/child’s needs (including feeding needs) over need for substances, parental difficulty in controlling emotions and anger, reduced likelihood for infants/children to receive adequate medical and dental care, chaotic, higher rates of household financial instability, food and housing insecurity, inconsistent employment, domestic violence, and stress, parental incarceration, increased likelihood of infant/child entering foster care, increased risk of neglect and abuse.

Procedure: Determine if the woman or the infant/child’s primary caregiver has a limited ability to make appropriate feeding decisions and/or prepare food for the reasons stated above.

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Participant Focused Counseling: ● Education, referrals and service coordination can aid the mother/caregiver in developing skills, knowledge, and or assistance to properly care for a dependent. ● The goals of nutrition counseling are to provide risk- and age-appropriate information and support that will enable the woman or caregiver with a limited ability to make feeding decisions to improve nutritional status.

WIC staff can: ● Provide individualized nutrition education in an easy-to-understand format.

● Provide referrals to promote parenting and infant/child feeding skills, including referrals to local home visiting programs, parenting programs, and early intervention services.

● Provide referrals to those with substance misuse for professional treatment, referring to community resources for alcohol and substance use support groups, and providing breastfeeding promotion and support to women enrolled in supervised medication- assisted treatment programs.

● Encourage participants/caregivers with mental illnesses, intellectual disabilities, and physical disabilities to follow the health care provider’s plan of care. Coordinate with health care providers, as needed.

● Provide individualized food packages, tailored to meet the needs of participants. Some caregivers who have a limited ability to make appropriate feeding decisions/prepare food may be unable to prepare powder or concentrated infant formula. Thus, for the safety of the infant, State WIC Agencies may allow ready-to-feed (RTF) WIC formulas to be issued when it is determined that the caregiver may have difficulty correctly diluting powder or concentrated formulas.

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Listeriosis (3529) Categories: ALL Defined as: infection caused by the bacteria Listeria monocytogenes within the past six months. It is most commonly transmitted through contaminated food; however it is also naturally present in the soil, water, and animals, including poultry and cattle. A participant determined to have Listeriosis should be referred to the CPA for Nutrition Care counseling. Justification Listeriosis is especially dangerous due to its ability to grow in cold temperatures, unlike many other pathogens. Common food sources include ready-to-eat deli meats and hot dogs, unpasteurized milk and dairy products, raw sprouts and others. Symptoms include fever, stiff neck, confusion, weakness, vomiting, and diarrhea. Pregnant women and newborns are at exceptionally high risk for listeriosis. Pregnant women are 10-20 times as likely as the general population to become infected. It can lead to miscarriage, stillbirth, or lifelong health issues for the child. Participants with weakened immune systems are also at higher risk. Participant Focused Counseling Use a conversation with open-ended questions to determine typical food habits and risks for Listeriosis, and possible approaches the participant can take to manage or prevent the infection. Possible options include: ● Prevention by safe food handling and storage ● Recommend alternatives to raw milk and dairy products ● With an existing infection, o Get sufficient calories to meet increased nutrient needs using the US Dietary Guidelines o Offer suggestions to address poor appetite ● Provide education on safe food handling and storage practices

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Low Birth Weight or Very Low Birth Weight (1411) (1412) Categories: IBE, IBP, IFF, C-1

Defined as: ● LBW: Infant born with a birth weight ≤5 pounds, 8 ounces (≤2500 grams) ● VLBW: Infant born with a birth weight (≤3 pounds, 5 ounces (≤1500 grams)

An infant identified with VLBW should have Nutrition Care counseling. Best Practice: see participant immediately; if not possible, within 5 days. Provide Nutrition Care follow-up in 1-3 months.

An infant identified with LBW should have Nutrition Care counseling. Best Practice: provide Nutrition Care follow-up in 3-6 months.

Justification: LBW is considered the single most important predictor of infant mortality, especially within the first months of life (6). Neonates with LBW have a 20 times greater risk of dying compared to infants of normal birth weight. LBW contributes to a range of poor health outcomes including fetal and neonatal mortality and morbidity, and inhibited growth. LBW is usually caused by intrauterine growth restriction (IUGR), preterm birth (PTB) or both. Preterm birth (an infant born at fewer than 37 weeks’ gestational age) is the most common cause of LBW. In the US, the rates of preterm births have increased from 10% to 12.5% in the past 25 years, likely as a result of higher survival rates due to advances in perinatal medical care. In the U.S., approximately 1 in 12 infants (8%) is born with LBW. The percentage of LBW infants has increased 4% among all racial groups from 2016-2021 in the U.S. Since 2016, LBW rates increased a total of 1% for non-Hispanic White women, 7% for non- Hispanic Black women and 7.3% for Hispanic women. The rates of LBW among different racial and ethnic groups in the U.S. are: • 1 in 7 Black infants (14%) • 1 in 12 Asian infants (8%) • 1 in 13 Native American or Alaska Native infants (8%)

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• 1 in 14 Latin infants (7%) • 1 in 14 White infants (7%) Black infants are more than twice as likely to be born with a LBW or to die in their first year of life as White infants. Rates of very low birthweight (VLBW) infants comprise only 1.0% of live births in the U.S. but Black mothers are 2.6 times more likely to have a VLBW infant than White mothers. The increased likelihood of LBW in Black infants has been associated with mothers who are unmarried, unemployed, lower income, younger, and receive federal government assistance to pay for rent. Yet even with the presence of traditional protective factors such as marriage, education, and being non-smokers, Black women still experience LBW at higher rates than Whites. Institutional racism (differences in access to resources by race as well as differences in policies, laws and practices that reinforce racial inequity) may explain racial disparities in LBW between Black and White women. Black women are at a higher risk of chronic stress due to adverse social determinants including low socioeconomic status, housing insecurity, and experience racism as a stressor and weathering (discrimination that worsens with age). Black mothers, when compared to other racial or ethnic groups, have the highest rate of LBW babies despite whether they were born in the U.S. or in another country. However, multiple studies have shown Black infants born to mothers who are immigrants experience LBW at rates similar to infants born to White mothers, suggesting the presence of other factors affecting birth weight for non-immigrant Black mothers. U.S. born Black women have more exposure to racism as a major stressor that negatively impacts maternal health while foreign born Black women do not report perceiving racism in the same way. In addition, foreign-born Black women may have more positive social determinants such as higher levels of education and income, and access to better health care. This issue is very complex, and continued research is needed focusing on the factors contributing to the inequitable racial gap in LBW. LBW infants are more likely than infants whose weight is normal to have medical problems that may include: • Respiratory: Respiratory Distress Syndrome (RDS). Infants with RDS do not have a protein called surfactant that keeps small air sacs in an infant’s lungs from collapsing. Treatment with surfactant helps these infants breathe more easily. Infants who have RDS also may need oxygen and other medical support to help their lungs work. • Neurological: Intraventricular Hemorrhage (IVH). Bleeding in the brain.

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• Cardiovascular: Patent ductus arteriosus. Patent ductus arteriosus is when an opening between 2 major blood vessels leading from the heart does not close properly. This can cause extra blood to flow to the lungs. In many infants who have patent ductus arteriosus, the opening closes on its own within a few days after birth. Some infants need medicine or surgery to close the opening. • Gastrointestinal: Necrotizing enterocolitis (NEC) is a gastrointestinal disease that involves infection and inflammation that causes damage and the death of cells in some or all the intestines. • Jaundice: An excess of bilirubin due to the infant’s liver not adequately removing it from the bloodstream. • Retinopathy of prematurity: When an infant’s retinas do not fully develop in the weeks after birth. • Immunological: Sepsis, pneumonia, or meningitis. In an infant who is born prematurely, the immune system may not be fully developed and may not be able to fight off infection. When LBW infants become children, they tend to have lower neurodevelopmental scores in the areas of language, cognition, and motor skills compared to term normal birth weight infants. There is also evidence that LBW infants have a higher risk of developing chronic health conditions later in life including: • Diabetes • Heart disease • High blood pressure • Metabolic syndrome • Obesity • Stroke Nutrition for Infants with LBW and VLBW The LBW or VLBW infant may begin life with a compromised nutritional status and require a form of nutrition support, (addition of infant formula, special infant formula, tube feeding). Some of these infants, especially ones with VLBW, will need supplemental feedings because they have limited nutrient reserves at birth and are subject to physiological and metabolic stresses that increase their nutrient needs. Providing breastmilk to these infants in the first month of life has been linked to improved growth and development. While infant formula can be used to offer higher amounts of macronutrients than breastmilk, it can be harder to digest

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for LBW and VLBW infants. Breastmilk contains beneficial biological components, including immunoglobulins, cytokines, growth factors, hormones, antimicrobial agents, immune cells, stem cells, prebiotic oligosaccharides, and probiotic bacteria. Mother’s own milk has been associated with multiple health benefits for LBW and VLBW infants, including lower incidences of necrotizing enterocolitis (NEC), late-onset sepsis, chronic lung disease, retinopathy of prematurity, and neurodevelopmental impairment. Pasteurized donor breastmilk is recommended when mother’s own milk is not available or sufficient. LBW infants that are supplemented with fortified pasteurized donor milk have a greater risk of growth failure than those fed mother’s own milk. For VLBW infants, breastmilk often requires fortification with formula in order to meet their nutritional needs. Assistance in early milk expression should be available to mothers within 6 to 8 hours of birth of any VLBW infant because of the need for early and frequent milk expression to maintain milk supply. The use of breastmilk is lower among VLBW infants with non-Hispanic Black mothers, compared with those with non-Hispanic White mothers. Approaches that have been shown to reduce Black and White disparities in breastfeeding in the NICU setting include peer counselor programs and support groups, assistance with breast pump acquisition, and transportation for mothers to visit the hospital. Implication for WIC Nutrition Services WIC services can directly support LBW and VLBW infants and their caregivers, as they may have unique feeding difficulties. LBW and VLBW infants may be born preterm so their delivery is often unexpected, and a mother may not have made decisions about how to feed her infant yet. These infants may require additional calories from formula, extra breastfeeding support, and/or special infant formula. WIC can support LBW and VLBW infants and their caregivers through: • Providing breastfeeding education to mothers. This has been shown to increase breastfeeding intent and decrease maternal anxiety. Education may include information on the health benefits of mother’s own milk, the need for early and frequent milk expression, the role of skin-to-skin contact, nonnutritive suckling, direct breastfeeding when physiologically appropriate, and technical information on proper milk handling, storage, and transport. • Referring to a WIC breastfeeding peer counseling program, if available. • Promoting and supporting breastfeeding as the normative standard for infant nutrition and providing early and frequent breastfeeding support. • Recommending the use of a hospital grade electric breast pump for expressing milk if the infant is in the NICU or the infant is unable to breastfeed directly from the breast. • Providing anticipatory guidance about potential feeding challenges.

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• Monitoring the child’s growth to ensure healthy weight gain. • Providing nutrition education for mothers/caregivers and appropriate referrals as necessary for growth, feeding, health, and/or infant developmental issues. • Discouraging families from direct milk sharing and the purchase of breastmilk from Internet-based sources as both practices are associated with risks of bacterial or viral contamination of non-pasteurized milk and the possibility of exposure to medications, other substances, and unsafe handling practices. For formula fed infants:  Assure formulas are mixed correctly.  Check with the HCP for increased calorie mixing instructions as needed.  Boil and sterilize water, bottles and parts until the baby is 4 months old. (adjusted age)  Do not put anything in the bottle except formula or breastmilk.  Use baby-paced bottle feeding.  Review hunger and fullness cues.  Monitor growth to ensure healthy weight gain.  Provide anticipatory guidance about feeding challenges.

Procedure: ● Determine if the infant or child’s birth weight was 5 pounds, 8 ounces or less. ● Review collected information for appropriateness of feeding practices.

Participant Focused Counseling: The goal of nutrition counseling is to assist and support the caregiver in establishing and maintaining feeding practices that support the optimal growth of the infant.

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Low Head Circumference (1521) Categories: IBE, IBP, IFF, C-1 Defined as: Head circumference less than 2.3rd % when plotted on the CDC/WHO Birth to < 24 months gender specific Head Circumference for Age growth chart. Presence diagnosed by a physician as self-reported by applicant/participant/caregiver or as reported or documented by a physician or someone working under physician’s orders.

Justification: Low head circumference (LHC) is related to a variety of genetic, nutrition, and health factors. While LHC alone does not necessarily indicate abnormal brain development, it may be indicative of future nutrition and health risk, particularly poor neurocognitive abilities. LHC is associated with VLBW, pre-term birth, and socioeconomic status, and is in part related to nutrition factors.

Participant Focused Counseling: WIC Counselors can assist families in making nutritionally balanced food choices to promote optimal growth and provide referrals to medical providers and other available local resources.

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Low Hemoglobin/Hematocrit (2011) Categories: All Defined as: Infants and children 9 months of age and older: Hemoglobin ≤ 10.9 g/dl or hematocrit ≤ 32.8% Women: Cut-off values for hemoglobin or hematocrit that are established by the CDC. (See Table A) A participant who has a hemoglobin value < 10g/dl (or hematocrit < 30%) should have Nutrition Care counseling. Best Practice: Provide Nutrition Care follow-up in 3-6 months.

A participant with hemoglobin <9g/dl should have Nutrition Care counseling. Best Practice: See participant immediately; if not possible, within 5 days.

A participant with hemoglobin ≤8g/dl should have test results confirmed by a second test. If confirmed, participant should be referred to their Health Care Provider immediately. Follow Local Health Department Policy for Participants with Hgb ≤8 g/dl. Justification: Hemoglobin and hematocrit reflect the amount of functional iron in the body and are the most frequently used tests to screen for anemia, including iron deficiency anemia (IDA), megaloblastic anemia (folic acid or B-12 deficiency), or sickle cell anemia and thalassemia (inherited) While the hemoglobin test is neither a direct measure of iron status, nor does it distinguish among different types of anemia, it is a useful screening tool for referring a WIC participant to their health care provider for further evaluation. Iron deficiency anemia is the most common anemia in children and women of childbearing age . Iron is present in all cells in the body and serves several vital functions. Iron: ● Carries oxygen from the lungs to the rest of the body. ● Is involved in the synthesis of hormones. ● Is involved in normal growth and development. Iron deficiency may be caused by a diet low in iron, insufficient absorption of iron from the diet, or increased iron requirements due to growth, blood loss, or pregnancy. Groups at risk of iron deficiency anemia include pregnant women, infants and young children, women with heavy menstrual bleeding, frequent blood donation, and people with cancer, gastrointestinal disorders, or heart failure.

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Iron deficiency progresses to Iron deficiency anemia when iron stores become so low that hemoglobin production is disrupted. Iron Deficiency Anemia is associated with GI disturbances, diminished physical work capacity, impaired heat regulation, immune dysfunction, and Helicobacter pylori infection. Iron in the Diet Dietary sources of iron come in two major forms: heme and nonheme iron. Heme iron is well absorbed and found primarily in animal food sources, including red meat, liver, poultry, and fish. Nonheme iron is not absorbed as well and is found in foods from plants. Dietary sources of nonheme iron include iron-fortified grain products, legumes, fruits, and green leafy vegetables. Because nonheme iron is less bioavailable, the iron requirement for vegetarians is 1.8 times higher. Additional factors can also affect iron absorption. Consumption of vitamin C-rich foods enhances the absorption of nonheme iron. Consumption of meat, poultry, or fish with a meal increases the absorption of nonheme iron. Phytates, found in grains and beans, and some polyphenols, such as those found in cereals and legumes, can inhibit nonheme iron absorption. Calcium is linked to a reduction in the absorption of both heme and nonheme iron. The effects of enhancers and inhibitors on iron absorption are diminished by a typical mixed western diet and do not significantly impact most people’s iron status.

Iron Deficiency Anemia in Women Women of childbearing age require additional iron to make up for: ● blood loss during menstruation ● increased needs during pregnancy ● blood loss at delivery and postpartum ● adolescent pregnancy ● gestational diabetes ● multiparity (For more information on adolescent pregnancy, gestational diabetes and multiparity see risk #331 Pregnancy at a Young Age, risk #302 Gestational Diabetes, risk #303 History of Gestational Diabetes and risk #335 Multi-fetal Gestation).

The strongest predictors of IDA in postpartum women are IDA during pregnancy and high blood loss during delivery.

Pregnant women are at particular risk due to their increased iron needs. Pregnant women need almost twice as much iron as

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those who are not pregnant to support increased red blood cell production and the development of the fetus and placenta. The Recommended Dietary Allowance (RDA), the average daily level of intake sufficient to meet the nutrient requirements of nearly all (97%–98%) healthy individuals, for iron in pregnant women is 27 mg per day. Based on data from the National Health and Nutrition Examination Survey (NHANES), 2001-2014, the average iron intake from food for pregnant women aged 20 to 40 years was 17.2 mg, well below the RDA. Given the high iron requirements during pregnancy and insufficient intake from foods, iron supplementation is often recommended during pregnancy. Based on data from NHANES, 1999-2010, 16.3% of pregnant women 12-49 years old in the United States had Iron Deficiency, including 2.6 with Iron Deficiency Anemia. Data also showed that Iron Deficiency was more prevalent in: ● women in the second or third trimester ● Mexican American pregnant women ● non-Hispanic black pregnant women ● women with parity greater than or equal to 2

In addition to high iron needs, women often under consume iron putting this group further at risk for IDA (2) IDA during pregnancy increases the risk of maternal death and is associated with several negative fetal and maternal outcomes. Maternal IDA Increases an infant’s risk for: ● low birth weight ● premature birth ● death ● impaired cognitive and behavioral development A long history of studies supported the belief that the fetus is protected from any impact of maternal iron status, however, a better understanding of regulation of iron physiology and neonatal iron status is challenging this assumption. Newer literature indicates fetal iron stores may be compromised when maternal iron stores are suboptimal, linking IDA during pregnancy with IDA in infants.

Iron Deficiency Anemia in Infants and Children Infants and children are at risk for ID and IDA given their high iron requirements to support their rapid growth. The prevalence of anemia and possibly ID and IDA in infants and children has declined since the 1970s in the U.S., and many attribute this decline to the fortification of infant formula and cereal and the establishment of the WIC program. Based on data from the 2007-2010 NHANES, 7.1% of children aged 1-5 were iron deficient and 1.1% had IDA. The rates were higher in 1- to 2-year-olds at 13.5% and 2.7%

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respectively. Based on CDC recommendations, WIC regulations require a hematological test to screen for anemia during the following timeframes for infants and children: ● Infants: 9 to 12 months of age. ● Children 1-2 years: One blood test is required between 12 to 24 months of age, ideally 6 months after the infant screen (around 15 to 18 months of age). ● Children 2 to 5 years: Once every 12 months for children 2-5 years of age whose blood results were within normal range at their last certification. Iron is essential for normal neurodevelopment of infants and children. Numerous studies have linked IDA in infants and children to later cognitive, motor, and behavior effects. Cognitive deficits and the impact of IDA can be long lasting and may be irreversible, even with treatment. It has been difficult to establish a causal relationship between IDA and these deficits due to confounding variables and difficulty designing and executing the large-scale studies needed to demonstrate a direct link. IDA can also increase susceptibility to lead poisoning by increasing intestinal lead absorption. While all infants and children are at risk of IDA due to their rapid growth, additional factors can place infants and children at higher risk. The table below outlines risk factors for IDA in infants and children: Risk Factor Additional Information History of Prematurity* Preterm infants miss out on the rapid accumulation of iron that occurs in the last trimester of pregnancy, are born with lower iron stores and are at risk of depleting their iron stores earlier than full term infants History of low birth weight or small for gestational age † Low birth weight and small for gestational age infants are more likely to have lower iron stores that are unable to support the catch-up growth often seen in these infants Exclusive breastfeeding beyond 4 months of age without supplemental iron While the iron breast milk contains is highly bioavailable, it is very limited. Full-term infants usually have adequate iron stores for 4 to 6 months but become at risk of developing iron deficiency at 6 to 9 months, unless they obtain adequate iron from complementary foods, iron- fortified formula, or iron supplementation

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Dietary habits linked with inadequate iron intake The following dietary habits may increase an infant or child’s risk for inadequate iron intake: use of non-iron fortified formula, introduction of cow’s milk in the first year of life, weaning to whole milk or complementary foods that do not include iron-fortified cereals or foods naturally rich in iron Maternal IDA Infants born to mothers with IDA during pregnancy may be born with lower iron stores and are more likely to develop IDA as infants and children Feeding problems, poor growth, and inadequate nutrition‡ These challenges, which are often seen in infants with special care needs, are considered risk factors Demographic factors Low socioeconomic status and having parents who are migrant workers or recent immigrants are also associated with increased risk * For more information on prematurity see Risk #142 Preterm or Early Term Delivery. † For more informaƟon on low birth weight or small for gestaƟon see Risk #141 Low Birth Weight and Very Low Birth Weight and Risk #151 Small for Gestational Age. ‡ For more informaƟon on special care needs see Risk #362 Developmental, Sensory or Motor Disabilities Interfering with the Ability to Eat. Implications for WIC Nutrition Services The WIC food package is designed to include foods that contain specific nutrients to improve the health status of program participants, address inadequate intakes, and, ultimately, prevent nutrient deficiencies such as ID and IDA. Nutrition education combined with the WIC food package can help decrease the likelihood that an individual would develop IDA. For individuals who currently have low Hgb or Hct, WIC staff can: • Refer participants to their health care provider for more thorough testing as appropriate. Only a health care provider can diagnose anemia and determine the specific type and cause.

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• Reinforce treatment plans, such as iron supplementation, provided by the health care provider, and refer participants to health care providers for medical follow-up care. • Per State policy, provide follow up testing/referrals at future appointments. • Discuss lead testing with participant or parent/caregiver and refer to appropriate resources if needed. • Reiterate infant feeding guidance such as providing iron-fortified infant formula for infants not breastfed or partially breastfed for the first year of life and offering iron-rich or iron fortified complementary foods around 6 months of age. • For breastfed infants, refer to healthcare provider to determine if iron supplementation is needed before 6 months of age, see: o to https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/diet- and-micronutrients/iron.html • Encourage consumption of iron-rich foods (with an emphasis on the foods in the WIC food package): Lentils and beans, fortified cereals, red meats, fish, and poultry, for more information, see: o https://ods.od.nih.gov/factsheets/Iron-HealthProfessional/#h3 • Encourage consumption of foods rich in Vitamin C to aid in iron absorption: Citrus fruits, tomatoes, and other fruits and vegetables, for more information see: o http://ods.od.nih.gov/factsheets/VitaminC-HealthProfessional/ Procedure: Obtain a blood hemoglobin or hematocrit test result. Infants and Children: ● An infant must be tested between 9 and 12 months of age. ● A child must be tested once, between 12 and 24 months of age (ideally at 15 to 18 months of age or 6 months after the infant’s test), then annually, between 24 and 60 months, provided the test result is above the cut-off value or at a 6 month interval if the test result is equal to or below the cut-off value. ● Compare the result to the cut-off value. If the hemoglobin is ≤ 10.9 g/dl or hematocrit ≤ 32.8%, assign the risk criterion.

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Low Maternal Weight Gain (1311) Category: PG Defined as: A pregnant woman’s weight gain is below the minimum recommended for the completed week of gestation. A woman who is both underweight and has low maternal weight gain should have Nutrition Care counseling. Justification:

In the short term, low maternal weight gain in the second and third trimesters is associated with an increased risk of small for gestational age (SGA) infants, especially in underweight and normal weight women, failure to initiate breastfeeding, and preterm birth among underweight, and to a lesser extent, normal weight women.

In the long term, poor maternal nutrition during pregnancy can have permanent, detrimental effects on the child’s health in later years, including increased risk for obesity, impaired glucose tolerance, and cardiovascular disease. This most likely results from suboptimal maternal nutrition that affects fetal organ development.

Inadequate gestational weight gain is most prevalent among Asian, Hispanic, and black mothers. Hispanic, black, and women who identified as “other” regarding race gain significantly less weight than white women after adjusting for pre-pregnancy BMI, age, parity, and education. Black and Hispanic women compared to white women are more likely to have inadequate weight gain as opposed to excessive gestational weight gain. Research shows that black women in the U.S. are more likely to gain less than the recommended amount of weight during pregnancy and more likely to lose weight during pregnancy compared to white women

Weight Loss during Pregnancy Weight loss during pregnancy can result in SGA infants, stillbirth, and neonatal death (8). In addition, surviving children are at risk for poor growth and infection during infancy. Common causes of unintended weight loss during pregnancy include food insecurity, substance misuse, housing insecurity, infection, food-borne illness, and symptoms associated with pregnancy such as hyperemesis gravidarum (9). Please refer to Risk - Hyperemesis Gravidarum for additional information.

Weight Loss during Pregnancy in Obese Women The recommended amount of weight gain in obese women during pregnancy remains controversial. Research demonstrates that it may be beneficial for the mother, and not harmful for the infant, to lose weight during pregnancy. The benefits of weight loss among obese pregnant women include decreased rates of cesarean delivery, large-for-gestational-age infants, and postpartum weight

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retention. As a result, some scientists are now suggesting that the NASEM recommendations for weight gain in obese pregnant women be re-evaluated.

Although controversy remains regarding weight loss during pregnancy among obese women, if a pregnant woman was obese prior to pregnancy, she should follow the advice of her health care provider regarding weight recommendations. For WIC nutrition risk assignments, WIC staff should follow the NASEM recommendations.

The recommended rate of weight gain for women with singleton pregnancies is based on pre-pregnancy weight status. The total recommended weight gain is as follows: ● Underweight status (BMI <18.5): 28 to 40 pounds ● Normal weight status (BMI 18.5-24.9): 25 to 35 pounds* ● Overweight status (BMI 25.0-29.9): 15 to 25 pounds* ● Obese status (BMI ≥ 30.0): at least 11-20 pounds* *Based on 2009 IOM Guidelines, the BMI weight categories used for adult women will be used for pregnant adolescent women also. For normal weight women pregnant with twins, total recommended weight gain is 37-54 pounds; overweight women, 31-50 pounds; and obese women, 25-42 pounds. Weight gain should be 4-6 pounds in the 1st trimester and about 1.5 pounds per week during the 2nd and 3rd trimesters. For triplet pregnancies, overall gain should be about 50 pounds with a steady gain of about 1.5 pounds per week. For underweight women with multiple fetuses, a consistent weight gain of 1.5 pounds per week during the second and third trimesters is associated with a reduced risk of preterm and low-birth weight delivery in twin pregnancy. Procedure: Use Table I-P for the assessment. ● Obtain current height and weight measurements. ● Obtain pre-pregnancy weight (self report or from health care professional). ● Record height and weight measurements in the woman’s record. ● Use Table W to determine pre-pregnancy weight status. ● Subtract the woman’s pre-pregnancy weight from her current weight to determine the number of pounds gained. ● Determine the last completed week of gestation when height and weight measurements were taken. ● Using Table I-P, locate the completed week of gestation in the left-hand column. Read across the columns to locate the woman’s pre-pregnancy weight status.

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● If she has gained equal to or less than the number of pounds in the column, she has low maternal weight gain.

Note: Do not evaluate this risk criterion for a woman pregnant with twins, triplets, or more. Participant Focused Counseling: Review collected information about dietary or lifestyle practices or medical conditions that could explain low maternal weight gain. Tailor nutrition education for pregnant woman to ensure she receives nutrition support that is relevant to her concerns and lifestyle factors. Assist pregnant women by carefully assessing the health status, dietary intake, and concerns of the woman in a participant- centered manner to find out possible factors contributing to low weight gain.

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May Not Meet Dietary Guidelines (4011) Categories: PG, BE/BP, WPP, C 2-4 Defined as: Women and children age 2 and older, who meet the eligibility requirements of category, income, and residency may be presumed to be at nutritional risk based on Failure to meet the Dietary Guidelines for Americans (consuming fewer than the recommended number of servings from one or more of the basic food groups, based on energy needs). Justification: Research has found that less than one percent of all women and children age 2-5 meet the recommendations for all food groups. Furthermore, members of low-income households are less likely to meet recommendations than more affluent ones. According to the Institute of Medicine, “evidence exists to conclude that nearly all low-income women in the childbearing years, and children age 2 and older are at dietary risk, vulnerable to nutrition insults, and may benefit from WIC services.” By presuming dietary risk, “WIC retains its potential for preventing and correcting nutrition-related problems.” Procedure: This risk factor may be assigned only to women and children age 2 and older for whom a complete nutrition assessment has been performed and for whom no other risk is identified. Participant Focused Counseling: Anticipatory guidance is the focus of the session. ● Guide participant in choosing healthy foods and age appropriate physical activities. ● Reinforce positive lifestyle behaviors. ● Discuss nutrition-related topics of interest to participant, such as food shopping, meal preparation, feeding relationships, and family meals. ● Refer as appropriate to the Supplemental Nutrition Assistance Program (SNAP), community food banks, and other available nutrition assistance programs.

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Medical Condition, Nutrition Related (3411-3621) Categories: All Defined as: Any condition listed below that has been diagnosed by a physician as self reported by applicant/participant/caregiver or as reported or documented by a physician or someone working under physician’s orders. Participants identified with one of these risk criteria should have Nutrition Care counseling. Procedure: Use collected information to determine that the participant has a diagnosed medical condition listed below. The condition must currently affect nutritional status. Section 246.7(i)(6) of the WIC Program regulations requires that the State Agency ensure that appropriate documentation is included in the applicant’s WIC record to substantiate the nutrition risk condition(s) used to certify the applicant, and to validate conformance with the definition of the nutrition risk condition(s). When a self-report of a medical diagnosis is given, the CPA or CPPA must validate the presence of the condition by asking the following questions: ● Is this condition current and being treated by a health care professional? ● Is this condition being controlled by diet or medication or both? ● What dietary instructions have been prescribed? ● What medication has been prescribed?

The name and contact information for the medical professional should be obtained to allow communication and verification, if necessary. When determined appropriate, a consent form for release of confidential information may be completed and signed by the applicant/participant or caregiver in order to allow collection of pertinent medical or diet information to support the nutrition risk determination, and to assist the CPA in supporting the nutritional plan of care for the participant.

Expanded background material on each of the following conditions can be found in the Nutrition Care Manual.

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Explanation: Asthma, moderate persistent or severe persistent (3601) Asthma must be diagnosed as moderate persistent or severe persistent that requires the daily use of an inhaled anti-inflammatory agent or an oral corticosteroid. Bronchitis Present in the last 6 months. (3526) An acute infection that occurs when the airways in the lungs swell and produce mucus, resulting in a cough. It typically occurs after a chest cold and is usually caused by a virus. Since bronchitis is rarely caused by bacteria, antibiotics are not needed or recommended, and can harm both children and adults. Bronchitis typically resolves on its own in two weeks, but cough may last 8 weeks. Pain relievers should be appropriate for the age of the child. Only acetaminophen should be used for infants under 6 months of age. Prevention rests on good hygiene, updated immunizations, and not smoking. Cancer (3471) Nutritional status at the time of diagnosis is associated with outcome of treatment. The type of cancer and the stage of disease progression determine the type of medical treatment and nutrition management. Cardiorespiratory diseases (3604) Cardiorespiratory diseases affect normal physiological processes and can be accompanied by growth failure, failure to thrive, and malnutrition due to low calorie intake and hypermetabolism. Cardiovascular Disease (CVD) (3603) CVD (heart disease) is an umbrella term for several types of heart conditions that cause a decrease flow of blood to the heart which can result in a heart attack and is the leading cause of death among women. Risk factors for CVD include diabetes, smoking, obesity and overweight, physical inactivity, high blood pressure, and high cholesterol. Women-specific risk factors for CVD are pregnancy and pregnancy-related complications, including preeclampsia, preterm delivery, gestational diabetes, and polycystic ovary syndrome. People with CVD benefit from physical activity and a healthy diet including high fiber foods, and a diet low in sodium, saturated fat, sugar, and alcohol.

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Celiac disease (or Celiac Sprue; Gluten Enteropathy; Non- tropical Sprue) (3541)

Inflammatory condition of the small intestine precipitated by the ingestion of gluten, a protein in wheat, rye, some oats, and barley in individuals with genetic predisposition. Eating gluten- containing foods can lead to diarrhea, weight loss, and malabsorption of other nutrients, and damage to the small intestine. Lifelong strict avoidance of these grains is essential. Nutrition counseling can help these participants meet their nutrient needs and help in compliance.

Cerebral palsy (3485)

Oral motor dysfunction is associated with cerebral palsy (CP). Infants and children often have poor growth due to eating impairment (difficulty spoon feeding, biting, chewing, sucking, cup drinking, swallowing.) Texture modification, increased calories and nutrients, and referral to feeding clinics are often required. Cleft lip or palate (3492) Severe cleft lip or palate often cause difficulty with chewing, sucking, and swallowing even after extensive repairs. Nutrition care may be needed for adequate growth, development, and health maintenance. Congenital Hyperthyroidism (3444) Excessive thyroid hormone levels at birth, either transient (due to maternal Grave’s disease), which is treated with antithyroid drugs and subsides within several weeks, or persistent (due to genetic mutation). Congenital Hypothyroidism (3443) Congenital hypothyroidism due to maternal iodine deficiency is the leading cause of preventable mental retardation. Unless treated within 18 days after birth, the mental retardation will be irreversible. Crohn’s disease (3423) Weight loss, growth impairment, and malnutrition are prevalent. Nutrition care is essential. Cystic fibrosis (3602) Cystic fibrosis is a genetic disorder that affects the cells that produce mucus, sweat, and digestive fluids. Despite progress, life expectancy is limited to 35-40 years. People with CF often face malnutrition, poor growth, frequent respiratory infections, breathing problems, and chronic lung disease. Due to the impact of CF on pancreatic enzymes, the digestion and absorption of protein and fats are impaired. Most people with CF take pancreatic enzymes and fat-soluble vitamins A, D, E and K. The focus of nutrition therapy is to ensure adequate intake through a personalized plan designed by a specialist RD. Best Practice: Contact Cystic Fibrosis Center and/or the participant’s Specialist RD before counseling and assigning food package,

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Developmental, Sensory, or Mental Disability (3621) Infants and children are at risk for nutritional problems. Pregnant and postpartum women may have chewing and swallowing problems that limit intake and increase malnutrition risk. Nutrition education , referrals, and service coordination are important early interventions. Consider contacting the participant’s Specialist RD before counseling and assigning food package. Diabetes Mellitus (3431) Diabetes mellitus consists of a group of metabolic diseases characterized by inappropriate hyperglycemia resulting from defects in insulin secretion, insulin action, or both. Control of diabetes through diet, exercise, and/or medication can reduce the degree of organ damage that occurs over time. Dietary guidelines for diabetes management vary depending upon the type of diabetes. Down Syndrome (3497) Hereditary or congenital condition at birth that causes a physical or metabolic abnormality. The current condition must alter nutritional status metabolically, mechanically, or both. Special attention to nutrition may be required to achieve adequate growth and/or to maintain health. Epilepsy (3481) People with epilepsy are at nutrition risk due to prolonged anticonvulsant therapy, inadequate growth, and physical injuries from seizures. Children on a ketogenic diet require growth monitoring, and increased energy and protein while maintaining ketogenic status. Women on antiepileptic drugs are at higher risk for infants with neural tube defects and may require folic acid supplementation. Gall Bladder Disease (3421) Includes gallstones, or obstructing bile duct causing pain and cramps, and inflammation of the gallbladder caused by bile duct obstruction. Since lipids stimulate gallbladder contraction, a low-fat diet with 25% to 30% of total calories as fat is recommended. Greater fat restriction is not recommended. Supplementation with fat soluble vitamins may be needed. Gastrointestinal anomalies (3493) Hereditary or congenital condition at birth that causes a physical or metabolic abnormality. The current condition must alter nutritional status metabolically, mechanically, or both. Special attention to nutrition may be required to achieve adequate growth and/or to maintain health. The goals of nutrition counseling vary depending upon the disorder. Gastroesophageal Reflux Disease (GERD) (3429) GERD is irritation and inflammation of the esophagus due to reflux of gastric acid into the esophagus. Nutrition Care for adults includes avoiding eating for 3 hours before going to bed, and avoiding fatty foods, coffee, and alcoholic beverages.

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Hyperthyroidism (3442) Excessive thyroid hormone production (known as Grave’s disease) causes increased energy expenditure and weight loss with increased appetite. Normal weight is usually regained after medical treatment. Monitor weight status and diet adequacy. Hypothyroidism (3441) Thyroid gland makes inadequate thyroid hormone, sometimes due to inadequate iodine intake during pregnancy and lactation, causing infants with irreversible brain damage and maternal complications such as anemia, preeclampsia, miscarriage, premature delivery, and postpartum thyroid disease. Encourage iodine sufficiency, including 150 mcg iodine supplement. Monitor weight status. Inborn Errors of Metabolism (3511) Includes but not limited to Phenylketonuria (PKU); Maple Syrup Urine Disease (MSUD); Galactosemia; Homocystinuria; Tyrosinemia; Histidinemia; urea cycle disorders; Glutaric Aciduria; Methylmalonic Acidemia; Glycogen Storage Disease; galactokinase deficiency; fructoaldolase deficiency; Propionic Acidemia; or Hypermethioninemia. Appropriate dietary management may include the use of special formulas. Contact appropriate metabolic dietitian before assigning formula or food package: Children's National Medical Center in DC--202-476-6287 Johns Hopkins--410-955-3071 University of Maryland Hospital--410-328-3335 Juvenile Idiopathic Arthritis (3606) IA is an umbrella term for all forms of childhood arthritis. Children with JIA face nutrition problems due to chronic inflammation, drug side effects, and/or functional problems like jaw joint stiffness which lead to lower BMI and smaller height. There is no prescribed diet for JIA, but omega-3 fatty acids from salmon, sardines, mackerel, herring, and tuna (and to a lesser degree ground flax, flaxseed oil, walnuts, and green leafy vegetables) may help reduce inflammation. They also help prevent heart disease. Monitor growth and encourage adequate caloric intake. Lactose intolerance (3551) Documentation should indicate that the ingestion of dairy products causes the following GI disturbances: nausea, diarrhea, abdominal bloating, and/or cramps and that the avoidance of dairy products eliminates them. Nutrition counseling can offer strategies for avoiding symptoms while consuming dairy products or to obtain nutrients such as calcium from alternate sources when dairy products or foods containing dairy products must be avoided. Secondary lactase deficiency results from small bowel injury and resolves when primary problem is resolved. Usually in infants. Congenital lactase deficiency is a rare disorder of a few infants that presents with intractable diarrhea when human milk or formula is introduced. Developmental lactase deficiency is relative lactase deficiency among pre-term infants <34 weeks gestation. May benefit from lactase supplemented feedings or lactose-reduced formula.

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Lupus Erythematosus Systemic Lupus Erythematosus (SLE) (3605) Lupus (SLE) is a chronic inflammatory and autoimmune disease affecting multiple organ systems including skin, joints, heart, and central nervous system. The most common symptoms are fatigue, loss of appetite and weight, and skin lesions (butterfly rash on face). It is most common among women of childbearing age (15-44 years). While safe and healthy pregnancies and healthy babies are possible, they are considered high risk pregnancies because of problems that arise during the pregnancy including kidney inflammation, gestational diabetes, and preeclampsia, with fetal complications like miscarriage, preterm birth, and intrauterine growth restriction. Diet quality is important due to higher risk of CVD (obesity, hypertension and dyslipidemias), low bone mineral density, and vitamin D deficiency. A low calorie diet high in nutrient-rich foods and mono and polyunsaturated fatty acids may help control inflammation. Vitamins A, B-6, C, D, and E, dietary fiber and limited protein and sodium may reduce comorbidities and flares.

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Multiple sclerosis (3482) Individuals with MS may have chewing and swallowing problems requiring food texture changes. Obesity and malnutrition frequently occur due to immobility and steroid and antidepressant use. Muscular dystrophy (3491) A familial disease characterized by progressive muscle wasting and atrophy. Rapid functional changes can result in children gaining weight too rapidly. Focus nutrition education on healthy foods for a balanced diet while limiting simple sugars and fat. Neural tube defects (3483) Limited mobility or paralysis, hydrocephalus, limited feeding skills, and genitourinary problems put children with neural tube defects at increased risk of abnormal growth and development. Ambulatory disability, atrophy of the lower extremities, and short stature place NTDs-affected children at high risk for increased BMI. Monitor for growth and appropriate feeding practices. Pancreatitis (3427) Reduced secretion of pancreatic enzymes leads to malabsorption, and tissue necrosis can occur. A high carbohydrate, low-fat, low protein diet may be helpful. Parasitic infections (3522) Parasites are organisms that live on or in a host and survive by getting their food at the detriment of the host. Pregnant women and children are most at risk from certain parasites. Toxoplasmosis, from uncooked meat or from soil, is the leading cause of death from foodborne illness in the US. Other frequent parasites include Giardia, Cryptosporidium, lice, and pinworms. Risk of parasitic infections are reduced by wearing gloves when contacting soil and covering sand boxes when not in use. Good hygiene and proper food handling and storage are preventive. Parkinson’s Disease (3484) Some participants with Parkinson’s disease required protein redistribution diets to increase efficacy of medication. Monitor weight for adequate maternal weight gain. Peptic Ulcer (3425) Focus of treatment is elimination of Helicobacter pylori infection with antibiotic and proton pump inhibitor therapy. Dietary advice is to avoid alcohol, coffee, chocolate, and some spices. Pneumonia (3528) An infection of the lungs caused by viruses, bacteria, or fungi severe enough to affect nutritional status. The infectious disease must be present within the past 6 months. Chronic, prolonged, or repeated infections adversely affect nutritional status through increased nutrient requirements as well as through decreased ability to take in or utilize nutrients. Children younger than 5 years of age are at especially high risk of pneumonia. When contracted during pregnancy, pneumonia causes increased negative outcomes including low birth weight, pre- term birth, and respiratory failure for the mother. Effective vaccinations are available for bacterial and viral pneumonia. Regular hand washing and disinfecting of frequently touched surfaces are also effective for prevention.

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Polycystic Ovary Syndrome (PCOS) (3607)

PCOS is a hormonal disorder common among women of reproductive age. Most women with PCOS produce excess male sex hormones and have many small cysts of their ovaries. The cause is unknown but insulin resistance may play a role, along with a genetic component. Excess male hormones may prevent ovulation, irregular menstrual periods, leading to difficulty conceiving. Half of all women with PCOS are overweight, and are more likely to develop type 2 diabetes, high blood pressure, heart and blood vessel problems, uterine cancer, and metabolic syndrome. Weight loss is the primary therapy for PCOS. WIC Nutrition Care should focus on diet and physical activity to promote weight loss and coordination with HCP treatment. Post Bariatric Surgery (3420) Surgery to promote weight loss in morbid obesity presents risks for nutritional deficiencies, requiring daily nutritional supplements and eating nutritionally dense foods. Consider contacting the participant’s Specialist RD for current supplements and eating plan before counseling and assigning food package. Postpartum thyroiditis (3445) Postpartum thyroiditis can be either transient or permanent dysfunction occurring in the first year after delivery. Often resolution is spontaneous. Pre-diabetes (3631) Impaired Fasting Glucose (IFG) and/or Impaired Glucose Tolerance (IGT) are referred to as pre- diabetes. These conditions are characterized by hyperglycemia that does not meet the diagnostic criteria for diabetes mellitus. Individuals are at relatively high risk for the development of type 2 diabetes and cardiovascular disease (CVD). Dietary recommendations include monitoring calories, reduced carbohydrate intake, high fiber consumption, and increased physical activity. Renal disease (3461) Any renal disease including pyelonephritis and persistent proteinuria but excluding urinary tract infections involving the bladder. A pregnant woman with renal disease may develop a preeclampsia-like syndrome and the growth of her fetus may be limited. Women with chronic renal disease often have proteinuria and may develop azotemia. Contact the participant’s Specialist RD before counseling and assigning food package Short bowel syndrome (3426) SBS is the result of extensive small bowel resection in infants or adults. Supplementation with fat soluble vitamins and vitamin B12 may be needed. The pediatric client’s nutritional status must be assessed, and growth closely monitored. Sickle cell anemia (not trait) (3496) An inherited disorder that can affect every organ of the body. Good nutrition with adequate calories, iron, folate, vitamin E and vitamin C with good hydration are key to minimize complications. Hemoglobin tests are not required if health care provider submits diagnosis, since hemoglobin will always be low. HCP hemoglobin records should be provided when possible. A note should be entered into the record.

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Thalassemia (3494) Hereditary or congenital condition at birth that causes a physical or metabolic abnormality. The current condition must alter nutritional status metabolically, mechanically, or both. Special attention to nutrition may be required to achieve adequate growth and/or to maintain health. Hemoglobin tests are not required if health care provider submits diagnosis, since hemoglobin will always be low. HCP hemoglobin records should be provided when possible. A note should be entered into the record. Tuberculosis (3527) A disease caused by the growth of pathogenic microorganisms in the body severe enough to affect nutritional status. The infectious disease must be present within the past 6 months. Chronic, prolonged, or repeated infections adversely affect nutritional status through increased nutrient requirements as well as through decreased ability to take in or utilize nutrients. Ulcerative colitis (3428) Gastrointestinal disorders increase nutritional risk in a number of ways, including restricted food intake, abnormal deglutition, impaired digestion of food in the intestinal lumen, generalized or specific nutrient malabsorption, or excessive gastrointestinal losses of endogenous fluids and nutrients. Frequent loss of nutrients through vomiting, diarrhea, malabsorption, or infections can result in malnourishment and lowered disease resistance. Nutrition management plays a prominent role in the treatment of gastrointestinal disorders.

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Meningitis (3521) Categories: ALL Defined as: inflammation of the protective membranes of the brain and spinal cord known as meninges. A participant determined to have Meningitis should be referred to the CPA for Nutrition Care counseling.

Justification: Meningitis is typically caused by an infection of the fluid surrounding the brain and spinal cord. Most commonly meningitis is caused by a bacterial or viral infection, but it can also result as a response to physical injury, cancer, or certain drugs. Meningitis is severe, and treatment differs depending on the cause, so it is important to have a correct diagnosis of the agent responsible for the disease. Bacterial Meningitis: While most people with meningitis recover, bacterial meningitis is usually severe, and can result in serious complications, including brain damage, hearing loss, or learning disabilities.

The causes of bacterial meningitis vary by age group, and include variants of Streptococcus, Listeria, Neisseria, Haemophilus, and E. coli. In addition, Cronobactor may cause meningitis in infants in the first two months of life but is very rare (about 4-6 infections per year). Cronobactor infections have been associated with use of powdered infant formula. The recommendation for prevention is to follow the manufacturer’s preparation instructions.

Meningitis symptoms include sudden onset of fever, headache, and stiff neck. Other symptoms include nausea, vomiting, sensitivity to light, and confusion. Diagnosis must be confirmed through laboratory testing of blood or cerebrospinal fluid. Bacterial meningitis is effectively treated with antibiotics, but it is important to begin treatment as early as possible. The most effective prevention is vaccination, as well as properly preparing and refrigerating foods, and avoiding certain foods.

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Viral Meningitis: Viral meningitis is the most common type, and it is often less severe than the bacterial type. Children younger than five and people with weakened immune systems are at higher risk of developing the disease, with infants younger than one month old and those with weakened immune systems more likely to develop severe illness.

Laboratory tests are required to confirm the illness, which usually resolves without treatment in 7-10 days. However, those with meningitis caused by the herpes virus or influenza may benefit from antiviral medication. Risk can be reduced by the following: ● Washing hands with soap and water, especially after changing diapers, using the toilet, or coughing or blowing your nose ● Avoiding touching faces with unwashed hands. ● Avoiding close contact with infected people. ● Cleaning and disinfecting household surfaces that are frequently touched. ● Staying home when sick. ● Having children vaccinated against other viruses that can cause meningitis, including measles, mumps, chicken pox, and flu.

Participant Focused Counseling Through open-ended questions, determine the symptoms the participant faces. Based on the symptoms, discuss the options the participant is willing to take, as follows: ● Encourage adequate calories and healthy foods to meet the elevated needs of the participant during the infection and recovery. ● Discuss suggestions to address poor appetite. ● Offer education on good hygiene practices, and proper food preparation and storage techniques. ● Encourage vaccinations for both bacteria and viruses known to cause meningitis. ● Review instructions for preparation of powdered formula. Use “teach back” for assurance that participant understands formula preparation to protect the infant.

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Mental Illnesses (3611) Categories: PG, BE/BP, WPP, C 2-4 Defined as: The presence of a mental illness that is diagnosed, documented, or reported by a physician, or someone working under a physician’s orders, mental health provider or as self-reported by an applicant, participant, or caregiver. Mental illnesses where the current condition, or treatment for the condition may affect nutritional status include but are not limited to Depression, Anxiety Disorders, Post-Traumatic Stress Disorder (PTSD), Personality Disorders, Bipolar Disorder, Schizophrenia, and Attention- Deficit/Hyperactivity Disorder (ADHD).

A participant identified with mental illness should have Nutrition Care counseling. Best Practice: Provide Nutrition Care follow-up in 3-6 months. Justification: In 2019, the prevalence of any mental illness in U.S. adults was 20.6%--one fifth of the adult population. Mental illness can vary from mild to severe. The highest prevalence of mental illness occurs in: ● Young adults aged 18-25 ● Females ● People of two or more races ● LGBTQ adults Prevalence of severe mental illness in US adults was 5.2%. Severe mental illness results in serious functional impairment which substantially interferes with or limits one or more major life activities including, but not limited to, caring for oneself, performing manual tasks, seeing, hearing, eating sleeping, walking, standing, speaking, breathing, lifting, learning, reading, concentrating, and working, according to the US Department of Labor. People with severe mental illness often have difficulty maintaining a healthy diet, even when guidance is provided. Unintended changes in total body weight (5% in the past month, or 10% in the past six months) and medications that alter appetite or intake, nutrient absorption, or the metabolism of nutrients may signal the need for additional referrals and indicate that the mental illness is more serious.

The prenatal and postnatal periods are a common time for the relapse of mental illnesses such as depression, bipolar disorder, and anxiety disorders since women may choose not to take their medications while pregnant or breastfeeding. Suicide remains a

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leading cause of mortality in the postpartum period and accounts for 20% of maternal deaths in the first year after birth. Mental illnesses during pregnancy have been associated with adverse perinatal outcomes, including placental abnormalities, small-for- gestational- age fetuses, fetal distress, preterm delivery, adverse neurodevelopmental outcomes, and disordered attachment. Pregnant women with untreated mental illness are also more likely to smoke, use alcohol and drugs, have less prenatal care, and have poor nutrition. Children whose parents have a mental illness are at risk for developing social, emotional, and behavioral problems. They are more likely to have an inconsistent and unpredictable family environment which can place the child at risk for poverty, living in a single parent home, hostile behavior by a parent, and having a parent with a substance use disorder. Mental illnesses or serious emotional disturbances also occur in children. Symptoms in children are observed as serious changes in the way they typically learn, behave, or handle their emotions, which cause distress and problems getting through the day. The diagnosis is often made in the school years or sometimes earlier. Symptoms of mental illnesses often change as a child grows. Mental illnesses can also interfere with a child’s healthy development, causing problems that can continue into adulthood. The most common mental illnesses that are diagnosed in childhood are attention-deficit/hyperactivity disorder (ADHD), anxiety, and behavior disorders. Poverty affects mental health in many ways including increased financial stress, chronic and acute stressful life events, inadequate nutrition, and lead exposure. It can also affect parental relationship stress, result in a low-stimulation home environment, and child abuse and neglect. Poverty in childhood is associated with depressive and anxiety disorders, and higher rates of almost every psychiatric illness in adulthood. Poverty in adulthood is linked to depressive disorders, anxiety disorders, and suicide. Treatment Treatment for any mental illness can be complex and depends on the severity of the symptoms. Mental illnesses are most commonly treated with psychotherapy and medication. Certain medications such as antidepressants, antipsychotics, anticonvulsants, or stimulants can influence body weight and appetite. Individuals who are prescribed antipsychotics often have weight gain that may result in additional health issues, reduced quality of life, and poor compliance with taking the medication as prescribed. Mental Illnesses and Nutrition Nutrition supports mental health by maintaining the structure and function of the nerve cells and brain chemicals. The production of nerve chemicals or neurotransmitters requires certain nutrients including amino acids, zinc, copper, magnesium, iron, iodine, selenium, and B vitamins. If the intake of these nutrients is low, it can affect the production of neurotransmitters and therefore mental health. While vitamin D is usually associated with bone health it

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is also important for the brain. Research has associated vitamin D deficiency with mood disorders, dementia, and an increased risk for depression. Essential fatty acids (EFA) are also crucial nutrients that may support mental health. They are the building blocks for nerve tissue and transmitting nerve signals. When EFA are out of balance or consumed in insufficient amounts, biochemical malfunctions such as incomplete or inaccurate nerve signals can impact physical and mental health. Some patients with mental illnesses can be deficient in some vitamins, minerals, and nutrients. These commonly include, B6, B9, B12, omega-3 and omega-6 fatty acids, magnesium, vitamin D, and zinc. Evidence suggests that in some cases, when these deficiencies are returned to normal, changes in mood and behavior can be achieved. Common Mental Illnesses Depression (3611) Depression has varied symptoms, most commonly feelings of sadness or a marked loss of interest or pleasure in activities. Other symptoms include appetite changes resulting in unintended weight loss or gain, insomnia or oversleeping, loss of energy or increased fatigue, restlessness or irritability, feelings of worthlessness or inappropriate guilt, and difficulty thinking, concentrating, or making decisions. Depression affects 6.7% U.S. adults in any given year and 16.6% will experience depression at some time in their life. The prevalence of depression among females is 60% higher than males. Of those adults diagnosed with depression, 63.8% had severe impairment. Although depression can occur at any age, it usually first appears in the late teens to mid-twenties. Depression is now recognized in children and adolescents and tends to present as irritability, rather than low mood. There is no definite known cause of depression but contributing factors include genetics, nutrition, environmental stressors, hormonal disruptions, and changes in brain chemistry. Approximately one-third of people who have depression do not respond well to the available treatments.

Prenatal Depression Sadness, anxiety, and fatigue are the most common symptoms of prenatal depression. Pregnant women with depression are less likely to follow their prenatal medical plan, have inadequate or excessive weight gain, and are more likely to smoke or abuse substances. Pregnant women with untreated depression have more birth complications, preeclampsia, preterm delivery, and infants of low birth weight with impaired social, cognitive, and emotional development. Women of color and women from lower socioeconomic groups have greater rates of prenatal depression.

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About 6-8% of US women may use antidepressants while pregnant. Currently there are no recommended medications for treating prenatal depression, and there are some concerns about the effects on fetal and infant health. Prenatal women with depression should discuss the benefits and risks of antidepressant therapy with their health care provider.

Depression in Pregnant Adolescents Pregnant adolescents have significant risk for depression. They exhibit depressed mood, but more frequently have changes in appetite, weight, and insomnia rather than loss of interest and poor concentration compared to older adults. Up to 20% of pregnant adolescents with depression attempt suicide.

Postpartum Depression Postpartum depression (PPD) is one of the most common complications following pregnancy and has many adverse outcomes for both mother and baby, including maternal morbidity and mortality, higher infanticide, less maternal-infant attachment, shorter breastfeeding duration, and impaired parenting behaviors. PPD risk factors include genetics, history of mental illness, physical, psychological, or sexual abuse, discrimination, and immigration.

Breastfeeding and Depression Women with PPD are less likely to breastfeed and are more likely to stop breastfeeding early. They have fewer positive interactions with their infants and worse perception about their baby’s behavior. Cortisol in the mother’s system can reduce the milk supply. Breastfeeding problems can make the participant feel overwhelmed and increase depression. If she stops breastfeeding, the abrupt drop in oxytocin can make depression more severe. Successful breastfeeding can decrease loneliness and emptiness common to PPD. Oxytocin released during breastfeeding can help the participant feel calmer and more relaxed. SSRIs and SSNIs in breastmilk used to treat PPD show negligible risk to the infant. A participant with PPD who wants to breastfeed should talk to her health care provider about acceptable medications.

Anxiety Disorders (3612) Anxiety disorders are the most common mental illness in adults in the US. They include general anxiety disorder, panic disorder, and several phobia-related disorders. All share an increase in emotional, physical, and neurological symptoms triggered by specific

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situations or circumstances. Risk factors include genetic and environmental components and exposure to stressful events, an adverse childhood experience, and a history of family mental illness. Anxiety during pregnancy can have adverse effects on both the birthing person and the baby including impaired fetal development, complications of labor, and altered mental development of the newborn. Anxiety disorders are usually treated with psychotherapy and medications. Pregnant participants with anxiety disorders should work closely with their health care providers to establish and adjust suitable medications. Post-Traumatic Stress Disorder (PTSD) (3613) PTSD is a psychiatric disorder that occurs in people who have experienced or witnessed a traumatic, shocking, scary, or dangerous event. People with PTSD have intense or disturbing thoughts and feelings related to their trauma that last after the traumatic event has ended. To be considered PTSD, the symptoms must last more than a month and be severe enough to interfere with relationships or work. It can occur at any age, with women more likely than men to be affected. Rape is the most common trigger of PTSD, with childhood sexual abuse a strong predictor of developing PTSD in one’s lifetime. About 3% of pregnant women and 4% of postpartum women have PTSD. Risk factors associated with postpartum PTSD include negative birth experiences, operative birth, history of mental health problems, and lack of support. Postpartum PTSD is associated with lower birth weights and lower rates of breastfeeding. Psychotherapy, medication (usually antidepressants), or a combination is used to treat PTSD. Obsessive-Compulsive Disorder (OCD) (3614) OCD is a chronic and long-lasting disorder where a person has uncontrollable, recurring thoughts (obsessions) and/or behaviors (compulsions) that they repeat over and over. Compulsions like hand washing, cleaning, or checking things can interfere with daily life. OCD affects 1% of the US population, men and women equally. Risk factors include genetics, childhood trauma, and brain abnormalities. OCD is usually treated with cognitive behavioral therapy, medications, or both, depending on severity. SSRIs are the first-line medication, especially during the perinatal period, given their safety record.

Personality Disorders (3615) Personality disorders, including obsessive-compulsive personality disorder (OCPD), (different from OCD) are an “enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture,” according to the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. Behaviors are pervasive and inflexible, often resulting in distress and impairment. The person’s way of thinking, feeling, and behaving is different from society’s expectations and causes

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problems functioning. There is no medication specifically used to treat personality disorders, but psychotherapy can be effective. Some medications can be used under the care of a psychiatrist to treat some symptoms. Bipolar Disorders (3616) Bipolar disorder (aka manic-depressive disorder) is a mental illness that causes changes in a person’s mood that affects daily life. Mood shifts are manic (elevated or agitated) or depressive (sad and hopeless). During depressive episodes, 25-50% attempt suicide. Episodes can be mixed, and moods can last from days to weeks and vary in intensity. People with bipolar disorders are more likely to have other mental illnesses like anxiety, eating disorders, substance use issues or chronic medical conditions such as diabetes, obesity, or heart disease. The exact cause of bipolar disorders is not known, but genetics, hormones, and an imbalance in brain chemistry are believed to play a role. Bipolar disorders also tend to run in families with the average age of onset being 25 years old. Medications are the treatment of choice for bipolar disorders with mood stabilizers like antiseizure medications with lithium being used the most commonly. These medications are believed to affect the chemical imbalances in the brain . Lithium and sodium are similar in chemical bonding, so it is necessary for those taking lithium to have a stable, moderate intake of salt to keep lithium levels steady. Simple information based on the Dietary Approaches to Stop Hypertension (DASH) diet could be useful to those taking lithium. Mood stabilizers may also cause other side effects that could affect a person’s nutritional status including weight gain, increased thirst, nausea, vomiting, and diarrhea. The postpartum period is a vulnerable time for illness relapse in bipolar women. Women with bipolar disorder who discontinued their medication during pregnancy had a significantly higher risk of relapsing during the postpartum period (approximately 65% vs 25%) than those who remained taking their medication. The effect of lithium use on a breastfed baby is not as well studied. Lithium is excreted in human milk. Both the American Academy of Pediatrics and the National Library of Medicine (LactMed) provide guidelines for lithium use during breastfeeding but when lithium therapy is continued during the perinatal period it requires close monitoring of the breastfeeding dyad. Infant monitoring includes checking for over-sedation, restlessness, hydration status, and changes in growth and development.

Schizophrenia (3617) Schizophrenia can be severely disabling if not treated. It is characterized by delusions, hallucinations, disorganized speech and behavior, and other symptoms that cause social or occupational dysfunction. Schizophrenia affects 1% of the U.S. population, occurring equally in men and women but tends to be diagnosed earlier in males (late teens/early twenties) than in females (twenties or thirties). Genetics is estimated to be responsible for 80% of schizophrenia cases. People with schizophrenia also have higher mortality rates due to higher rates of heart disease, liver disease, and

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diabetes, which appear to be more related to fat metabolism than dietary fat intake, due to altered metabolism. Patients with schizophrenia have three times the visceral fat compared to those with equal total body fat. They also have reduced energy needs due to the antipsychotic medications frequently used to treat schizophrenia. Antipsychotic medications increase appetite, with weight gain as much as 25-60 pounds over the first few years. People with schizophrenia have a lifetime risk of having a serious drug or alcohol problem (47% vs 16% for the general population). High rates of substance use are associated with poor medical compliance, clinical decline, violence, and suicide. Women with schizophrenia have increased rates of stillbirths and neonatal deaths, which may be due to the illness, other medical conditions, lifestyle factors, or social issues. Pregnant women with schizophrenia who take antipsychotics are more likely to be obese, smoke, use alcohol, drugs, other medications, and have pre- existing diabetes and hypertension. Antipsychotics may increase the risk of gestational diabetes mellitus (GDM), obesity, and gestational hypertension, leading to adverse maternal and neonatal outcomes like fetal growth abnormalities, preterm birth, and congenital malformations. Since most antipsychotics are sedating for adults, it is recommended that breastfed infants are monitored for sedation as some cases in infants have been reported.

Attention-Deficit/Hyperactivity Disorder (ADHD) (3618) Attention-deficit/hyperactivity disorder (ADHD) is a persistent pattern of inattention (wandering off task, losing focus, and disorganization) and/or hyperactivity (moving constantly, excessively fidgeting, tapping, or talking) or impulsivity (hasty acts that occur without thought and may have a high potential for harm) that interferes with functioning or development. ADHD is most often identified during elementary school years when the inattention becomes more prominent and impairing. In most individuals with ADHD, symptoms of motoric hyperactivity become less obvious in adolescence and adulthood, but difficulties with restlessness, inattention, poor planning, and impulsivity persist. Severe impairment is more likely when diagnosed at or before four years of age. About 10% of US children have been diagnosed with ADHD with nearly 2/3 of those having another behavioral diagnosis. Male children are two times as likely to have ADHD compared to female children. It is estimated that 2.5% of adults have ADHD. Many adults do not even realize that they have ADHD. Adults with undiagnosed ADHD may have a history of problems at school, work, or with relationships. In adults, hyperactivity may manifest as extreme restlessness or wearing others out with their activity. Impulsive behaviors may manifest as social intrusiveness (e.g., interrupting others excessively) and/or as making important decisions without consideration of long-term consequences (e.g., taking a job without adequate information). In the U.S., Black and Hispanic population rates of ADHD tend to be lower than for White populations suggesting that culturally appropriate practices are relevant in assessing ADHD.

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The causes of ADHD are not understood but genetics play a role. Other risk factors include premature delivery, low birth weight, alcohol, drugs, or tobacco use during pregnancy, environmental exposure to lead or pesticides at a young age, or brain injury. Standard treatment for ADHD includes both behavior therapy and stimulant medication, which reduces appetite and weight gain. Stimulants work by increasing the brain chemicals dopamine and norepinephrine, which play essential roles in thinking and attention. Long-term use has resulted in lower adult height and bone mineralization for some. Nutrition treatment should focus on eating before taking medications so they do not affect appetite. Children who need to gain weight can be offered calorie dense foods with appropriate meal timing. Bribes or coercion are not effective. While the research on diet and its impact on ADHD remains inconclusive, most researchers agree that treatment should include decreasing processed foods, increasing foods high in omega-3 fatty acids, and assuring appropriate weight gain and growth. ADHD medications are being more commonly prescribed during pregnancy because untreated ADHD can result in risk- taking behavior, placing the mother and fetus in danger. There is evidence adequate treatment of ADHD may decrease substance use in the mother. However, there is also research that shows the stimulant methylphenidate is associated with an increased risk of low Apgar score at delivery that is not seen in untreated women with ADHD. Infants may also have neonatal withdrawal syndrome after being exposed to methylphenidate. The data is limited regarding the safety of ADHD medications during pregnancy and lactation, but it currently does not suggest a link between methylphenidate and congenital malformations.

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WIC Nutrition Services Recommendations for Mental Illnesses

All types of Mental Illnesses ● Make referrals (or encourage continued visits) to the primary health care provider and/or other appropriate mental health and social service programs to initiate and/or maintain treatment. ● Reinforce and support the treatments and therapies prescribed by the participant’s health care provider. ● When appropriate, encourage regular, healthy meals and snacks that are simple and easy to prepare. ● Encourage carbohydrate sources from whole grains, vegetables, and fruits to aid in maintaining stable blood sugar levels. Rapid increases in blood glucose can result in an increase in the release of insulin, which in turn raises adrenaline and cortisol which can cause changes in behavior and mood. ● Encourage oily fish such as salmon, sardines, and tuna which are high in eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) as the essential Omega-3 fatty acids contribute to overall brain function and may offer some benefit for mental health condition such as depression, anxiety, and bipolar disorder). ● Because a person with a mental illness may experience significant distress in social, work, or other settings, WIC professionals should seek to understand how symptom severity impacts eating and physical activity. Value Enhanced Nutrition Assessment (VENA) techniques can be used to provide participant centered education and goal setting for these individuals. Goal setting should consider the level of impairment in major life activities and be cognizant of the participant’s needs and barriers. ● Assess for unintended changes in weight. ● Assess current medications and possible drug nutrient interactions.

Depression ● Encourage food choices such as fruits, vegetables, olive oil, whole grains, low- fat dairy, and nutrient dense animal and plant protein sources (e.g., lean meats, poultry, and eggs; seafood; nuts and seeds) as part of a healthy dietary pattern. ● Encourage regular physical activity after consulting healthcare provider. ● Educate about prevalence, risks, and signs of postpartum depression. ● Provide breastfeeding education, assessment, and support (e.g., peer counseling) to women with existing depression in the perinatal period. Anxiety Disorders ● Support gradual behavioral changes. ● Encourage practices that promote mindfulness which may be helpful with anxiety. ● Recommend maintaining well-balanced meals and routine mealtimes. PTSD and OCD ● Support gradual behavioral changes.

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Personality Disorders ● Support a flexible variety of food choices (provide the participant options to give them the freedom to choose). ● Encourage flexible eating times if possible.

Bipolar Disorders ● Encourage regular simple meals and snacks that may help maintain blood sugar levels. ● Assess for consistent fluid and salt intake. If taking lithium, education on following the Dietary Guidelines for Americans or the DASH diet may be appropriate. ● Encourage social and physical activity.

Stigma, prejudice, and discrimination against people with mental illness can cause people to avoid or delay treatment. Individuals with mental illness can have negative attitudes, including internalized shame, about their own condition (i.e., self-stigma). The strong family values of emotional restraint and avoiding shame in some Asian cultures, may be contrary to seeking professional help for mental illness. In addition, some African American communities distrust the mental healthcare system. Stigma not only directly affects individuals with mental illness but also the friends and family of those who seek treatment. The National Alliance on Mental Illness (NAMI) offers some suggestions about what we can do to help reduce the stigma of mental illness: ● Talk openly about mental health. ● Educate yourself and others about mental health so you can respond to misperceptions or negative comments by sharing accurate facts. ● Be conscious of language that is used to discuss mental health. For information see: What to Say - Tips for Talking About Mental Illnesses (makeitok.org) ● Encourage equality between physical and mental illness – normalize mental health treatment, just like other health care treatment. ● Show compassion for those with mental illness.

Participant Centered Counseling Using the nutrition guidance in the chart above, and the need to speak openly about mental health, Participant Centered Counseling is an ideal approach to help participants determine what small steps they can take to improve their mental health by using their WIC foods to stabilize blood glucose, support appropriate physical activity, and improve their mood and self-efficacy. When engaging with WIC participants with a mental illness, use open ended questions to learn what the participant is already doing to manage their condition, when/where they have been successful, where they are struggling, and ask permission to share ideas that have worked for others.

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● Explore any nutrition and physical activity recommended by their health care provider. ● Invite the participant to discuss their achievements and shortfalls trying to follow the HCPs recommendations. ● Have participants share their favorite foods and preparation methods. ● Learn about the participant’s kitchen skills, abilities, frustrations, and limitations. ● Find out what foods the participant refuses to eat. ● Help the participant find enjoyable substitutes to fill their nutrient gaps. ● Help the participant plan to make small gradual changes that support health, without overwhelming or setting them up for failure.

Additional Resources and Information Brochures and Fact Sheets on mental disorders by topic from the National Institute of Mental Health: https://www.nimh.nih.gov/health/publications/index.shtml Overview of medications used to treat mental disorders: https://www.nimh.nih.gov/health/topics/mental-health-medications/index.shtml Treatment Options for ADHD in Children and Teens: A Review of Research for Parents and Caregivers https://www.ncbi.nlm.nih.gov/books/NBK99163/ National Suicide Prevention Lifeline: 988 or 1-800-273-8255 or 988 https://suicidepreventionlifeline.org/ National Maternal Health Hotline: 1-833-9-HELP4MOMS National Maternal Mental Health Hotline | MCHB (hrsa.gov)

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Migrant Farm Worker; Migrant Farm Worker Status (8021) Categories: All Defined as: Categorically eligible women, infants, and children who are members of families which contain at least one individual whose principal employment is in agriculture on a seasonal basis, who has been so employed within the last 24 months, and who establishes, for the purposes of such employment, a temporary abode. Justification: Data on the health and/or nutritional status of migrants indicate significantly higher rates of infant mortality, malnutrition, and parasitic disease (among migrant children) than among the general U.S. population. Migrancy has been stipulated as a condition that predisposes persons to inadequate nutritional patterns or nutrition-related medical conditions. Procedure: ● Determine if the participant is a migrant farm worker (or dependent). ● Review dietary and lifestyle practices.

Participant Focused Counseling: The goals of nutrition counseling are to assist the migrant farm worker (or dependent) in making decisions about the selection, storage, and preparation of foods to promote optimal nutritional status. ● Review WIC foods appropriate for the participant(s). ● Review safe handling food practices. ● Referrals and service coordination with other programs may also be appropriate.

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Mother in WIC or WIC-Eligible While Pregnant (7011) Categories: IBE, IBP, IFF Defined as: An infant under 6 months of age whose mother was a WIC Program participant during pregnancy or whose mother’s medical records document that the woman was at nutritional risk during pregnancy with a priority I risk. Justification: WIC participation during pregnancy is associated with improved pregnancy outcomes. An infant whose nutritional status has been maintained through WIC services during gestation and early infancy may decline in nutritional status without these services and return to a state of elevated risk for nutrition-related health problems. An infant whose mother was at nutritional risk during pregnancy but did not receive WIC benefits may also be thought of as at risk for morbidity and mortality in the infancy period. WIC participation during infancy is associated with lower infant mortality, decreased anemia, and improvements in head circumference, length, and weight. Procedure: Use mother’s WOW record as documentation of her participation while pregnant. Documentation of the nutritional risk of the mother who did not participate in WIC while pregnant must be written as a note in the infant’s WOW record. Priority I risk criteria are detrimental or abnormal nutritional conditions detectable by biochemical or anthropometric measurements or other documented nutritionally related medical conditions. Participant Focused Counseling: ● Promote breastfeeding. ● Review feeding practices that promote optimal growth and development of the infant. ● Provide appropriate WIC brochures.

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Multi-fetal Gestation (3341) Categories: PG, BE, BP, WPP Defined as: More than one fetus in the current pregnancy for a pregnant woman or the most recent pregnancy for a breastfeeding or postpartum woman. A woman pregnant with multiple fetuses should have Nutrition Care counseling. Best Practice: Provide Nutrition Care follow-up in 3 months.

Justification: Multi-fetal gestations are associated with low birth weight, fetal growth restriction, placental and cord abnormalities, preeclampsia, anemia, shorter gestation, and an increased risk of infant mortality. Pregnant or breastfeeding women with twins have a greater requirement for all nutrients than women with only one infant. Postpartum, non-breastfeeding women who deliver twins are at greater nutritional risk than women who deliver one infant. For twin gestations, the 2009 IOM recommendations provide provisional guidelines: normal weight women should gain 37-54 pounds; overweight women, 31-50 pounds, and obese women, 25-42 pounds. There was insufficient information to develop even provisional guidelines for underweight women with multiple fetuses. A consistent rate of weight gain is advisable. A gain of 1.5 pounds per week during the second and third trimesters has been associated with a reduced risk of preterm and low birth weight deliveries in twin pregnancy. In triplet pregnancies, the overall gain should be around 50 pounds with a steady rate of gain of approximately 1.5 pounds per week throughout the pregnancy. Education by the WIC nutritionist should address a steady rate of weight gain that is higher than for singleton pregnancies. Procedure: Determine if the woman is or was pregnant with 2 or more fetuses. Apply as follows: ● Pregnant woman: current pregnancy ● Breastfeeding or postpartum woman: most recent pregnancy

Participant Focused Counseling: Review collected information about dietary and lifestyle practices. A woman pregnant with multiple fetuses, the woman who delivered more than one infant, or the mother breastfeeding more than one infant can state the food and lifestyle choices she can make that promote a positive pregnancy outcome.

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Neonatal Abstinence Syndrome (3831) Categories: IBE, IBP, IFF Definition: Neonatal abstinence syndrome (NAS) is a drug withdrawal syndrome that occurs among drug-exposed (primarily opioid- exposed) infants as a result of the mother’s use of drugs during pregnancy. NAS is a combination of physiologic and neurologic symptoms that can be identified immediately after birth and can last up to 6 months after birth.

A participant diagnosed with Neonatal Abstinence Syndrome should have Nutrition Care counseling. First contact immediately, if not possible, within 5 days. Best Practice: CPA follow up in 2-3 months.

Refer a breastfeeding infant with a breastfeeding complication diagnosed with Neonatal Abstinence Syndrome to the IBCLC/DBE. See procedure under Breastfeeding Complication risk for Infant.

Justification:

Neonatal abstinence syndrome occurs when an infant is born dependent on prescription or illicit drugs the mother was taking during pregnancy. NAS is a combination of withdrawal symptoms that involve multiple bodily systems. It is most commonly associated with chronic opioid exposure during fetal development; however, can also result from chronic intrauterine exposure to other substances including benzodiazepines, barbiturates, selective serotonin reuptake inhibitors and ethanol. Although these non-opioid substances can lead to NAS, these infants typically respond well to non-pharmacological methods of intervention.

Withdrawal in the newborn varies based on the type of substance, dose, and timing of exposure. Opioid is a general term for a variety of illicit and prescription drugs that decrease pain. Prescription opioid pain relievers include oxycodone, hydrocodone, codeine, morphine, and fentanyl. Opioids are water soluble and are, therefore, able to move easily across the placenta to the infant. This transfer of opioids increases as gestational age increases.

Participants who take any form of opioid, including prescription opioids as directed for chronic pain, can become addicted. Due to the risk of the transmission of infectious diseases such as HIV and Hepatitis C, women who become pregnant while using illicit opioids, such as heroin, are often put on opioid maintenance therapy. Opioid maintenance therapy involves the prescribed use of either methadone or buprenorphine. These prescribed opioids can still lead to NAS; however, since they are not injected, they decrease the risk of the mother contracting blood-borne infectious diseases. Opioid maintenance therapy can also help protect the fetus from repeated opioid withdrawal in utero.

Infants born with NAS are often premature, have low birth weights, and are growth restricted. In addition to exposure to substances in utero, additional factors, including social, nutritional, physical, and mental health problems can also contribute to the health status

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of the infant. An increased risk of birth defects such as spina bifida, hydrocephaly, glaucoma, gastroschisis, and heart defects are associated with early pregnancy opioid use.

Neonatal Abstinence Syndrome Symptoms Symptoms of NAS generally involve the central nervous system, autonomic nervous system, and the gastrointestinal tract. The severity of the infant’s symptoms is commonly assessed using the Modified Finnegan Score Sheet. The Modified Finnegan Score Sheet consists of 21 symptoms that are associated with NAS. Following the determination of a baseline score, infants are assessed every 4 hours unless the severity of the symptoms requires more frequent monitoring. The following list includes symptoms associated with NAS: • Loud, high-pitched crying, sweating, yawning • Sleep disturbances, feeding difficulties, poor weight gain • Excessive sucking, regurgitation, diarrhea

Neonatal Abstinence Syndrome Treatment Infants with NAS typically have longer hospital stays, serious complications, and costly treatment. The first treatment option for infants with NAS is to manage symptoms without medication by rooming in with the mother, encouraging skin-to-skin contact, swaddling, having a calm environment, avoiding overstimulation, and supporting breastfeeding. Infants who are at risk for NAS and who room-in with their mothers are not only at a lower risk of needing pharmacological treatment for NAS, but they also have a shortened hospital stay. If withdrawal is severe or if the initial treatment is not successful in managing symptoms, medications such as morphine, methadone, phenobarbital or clonidine may be used. An infant given these medications may have side effects that could include: slow or shallow breathing, slow heart rate, difficulty waking-up, excessive sleepiness, constipation, and fewer wet diapers. Nutritional Considerations for Neonatal Abstinence Syndrome The timing and type of feedings play an important role in the management of NAS symptoms. Infants with NAS may have impaired feeding behaviors such as excessive sucking, regurgitation, diarrhea and poor feeding that is characterized by fussiness, crying, and sleepiness. Infants with NAS have higher caloric requirements due to their energy expenditure. This combined with the impaired feeding behaviors may result in difficulty with weight gain. The American Academy of Pediatrics (AAP) recommends breastfeeding if not contraindicated. The AAP also recommends that infants with NAS be fed frequent small volumes of human milk or high calorie formula, as needed, in a quiet and calm environment, to aid the infant in tolerating feedings and improving digestion and to allow for adequate growth.

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The Academy of Breastfeeding Medicine recommends breastfeeding for women who are on a prescribed stable dose of methadone maintenance because the concentrations of methadone in human milk are low. Studies have indicated that, although the amount of methadone in human milk is dependent on the mother’s dose, the methadone transferred in human milk averages less than 2.8% of the maternal dose. Breastfeeding has been found to provide protection against the development of NAS symptoms and lessen the severity of symptoms, which would decrease the need for pharmacological intervention for the infant. The amount of methadone that is in human milk is small and therefore, it is thought that breastfeeding, and not the methadone in human milk, is responsible for its protective impact against NAS. Gradual weaning, when mutually desired by the mother and infant, is recommended for breastfeeding women who are being treated for opioid addiction. Gradual weaning (rather than an abrupt stop to breastfeeding) decreases the risk of the infant developing NAS. Implications for WIC Nutrition Services NAS can be a difficult subject to talk about with WIC participants due to the stigma of addiction. In the WIC clinic, caregivers may not be forthcoming with the infant’s diagnosis of NAS and an addiction history of the mother may not be available at the initial assessment. WIC staff can assist caregivers by: • Educating to recognize infant hunger cues. • Reviewing feeding frequency and/or formula type and amount to help manage gastrointestinal symptoms of NAS. • Providing growth monitoring to assess adequate weight gain. • Encouraging supportive interventions to include: o Skin-to-skin contact o Swaddling o Quiet environment with little stimulation • Encouraging breastfeeding unless medically contraindicated. • Providing referrals for support services such as drug and alcohol counseling, parenting support, and medical evaluations. • Encouraging mothers who are on medication-assisted therapy (e.g., methadone or buprenorphine) and who are breastfeeding, to speak with their health care provider if they have questions about the timing and dose of their medication. • Educating mothers who are on medication-assisted therapy and who are breastfeeding on the importance of gradual weaning when mutually desired by the mother and infant

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Nicotine and Tobacco Use (3711) Categories: All Defined as: Any use of products that contain nicotine and/or tobacco to include but not limited to cigarettes, pipes, cigars, electronic nicotine delivery systems (e-cigarettes, vaping devices), hookahs, smokeless tobacco (chewing tobacco, snuff, dissolvables), or nicotine replacement therapies (gums, patches).

Justification: Tobacco products contain a variety of harmful chemicals. Tobacco use can lead to serious illnesses, including cancers, lung disease, and heart disease. Nicotine, one of the chemicals in tobacco, is highly addictive and associated with additional health risks. During pregnancy, the use of nicotine and/or tobacco products is harmful to both the mother and fetus, with potential consequences including low birth weight or even miscarriage. Nicotine can be found in breastmilk, therefore, using nicotine products may impact breastfed infants. Women, infants, and children living in a smoking environment also face adverse health outcomes.

Tobacco Smoking Tobacco smoke contains over 7,000 chemicals that cause immediate damage to the body. According to the CDC, cigarette smoking kills more than 480,000 Americans annually, and remains the single largest preventable cause of death and disease in the United States.

According to 2018 CDC data, 14.1% of adult women in the US use tobacco products. In 2016, one in fourteen women who gave birth smoked cigarettes during pregnancy. Women most likely to smoke during pregnancy were aged 20-24, identified as non-Hispanic American Indian or Alaska Native, high school education or less. CDC data from 2014 show that women receiving WIC benefits were more likely to smoke before and during pregnancy than women who did not receive WIC benefits. There is no CDC data that reports on the incidence of smoking among breastfeeding women.

Electronic Nicotine Delivery Systems (ENDS) Vapes, vaporizers, vape pens, hookah pens, electronic cigarettes (e-cigarettes or e-cigs), and e-pipes are some of the many terms used to describe electronic nicotine delivery systems (ENDS). ENDS are noncombustible tobacco products used to smoke or “vape” a solution that often contains nicotine. The solution, or “e-liquid”, is heated to create an aerosol that the user inhales. An individual’s level of exposure to nicotine varies with the product. Exhaled ENDS vapor contains chemicals that can cause cancer, harm the fetus, and pollute indoor air.

Data from the CDC’s 2015 Pregnancy Risk Assessment Monitoring System (PRAMS) for Oklahoma and Texas indicated that maternal use of ENDS was 10% before pregnancy and 7% around the time of conception. Reported reasons for ENDS use around

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the time of pregnancy included curiosity, the perception that ENDS might help with quitting or reducing smoking, and the perception of reduced harm to the mother when compared to cigarette smoking.

The CDC has stated that ENDS use is not safe for pregnant women. Continual innovation makes health risk assessments difficult, and more research is needed to understand ENDS’ safety, health effects, and cessation efficacy. Women who are pregnant or trying to become pregnant should consult with their health care provider on the risks that ENDS pose for both maternal and neonatal health.

Nutrition The research on tobacco use and its impact on nutritional status has focused on cigarette smoking. Cigarette smoking causes a generalized upward shift in hemoglobin concentration and hematocrit, which lowers the effectiveness of anemia screening tools. Therefore, pregnant women who smoke may require additional iron supplementation even if their hemoglobin/hematocrit results show they are not anemic. Smoking also increases oxidative stress and affects metabolism. Vitamin C is the only micronutrient with a Dietary Reference Intake (DRI) specific to individuals who smoke, with the recommendation of consuming an additional 35 mg per day compared to those who do not. Research indicates that those who smoke have lower concentrations of certain nutrients (i.e., B-carotene, vitamin B-12, vitamin B-6 and folic acid), but due to the observational nature of the research, the exact cause remains unclear. Additional research is needed to determine smoking’s effect on micronutrients and if additional DRI recommendations for other micronutrients are needed for those who smoke.

Smoking Cessation Around 50% of women who smoked during the three months before they conceived quit during pregnancy, often because they are highly motivated to protect their babies. About 50% of them returned to smoking after the baby was born.

Research has shown that both dosage (number of cigarettes smoked in a day) and timing of maternal smoking (during particular trimesters) are associated with neonatal birth weight. Women who stopped smoking before their third trimester gave birth to infants with similar weights to those infants who were never exposed to smoking. Therefore, efforts for smoking cessation should not only be made in the early stages of pregnancy but should continue throughout pregnancy with an emphasis on the health benefits for the infant if smoking stops before the third trimester.

Little research has been conducted to prove the effectiveness and safety of Nicotine Replacement Therapy (NRT) for pregnant or postpartum women who engage in NRT. The optimal cessation intervention for a pregnant tobacco user is behavioral, as the safety and efficacy of neonatal nicotine exposure while using NRT has not been established. If a behavioral smoking cessation intervention alone is unsuccessful, the American College of Obstetricians and Gynecologists recommends that NRT only be considered in conjunction with a behavioral intervention and with close monitoring by a health care provider.

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ENDS are often marketed as smoking cessation devices. However, due to the differences between products it is difficult for health organizations and researchers to determine how effective all ENDS are for helping people to quit smoking. The FDA does not approve of using ENDS to help people quit smoking.

Breastfeeding In 2001, the American Academy of Pediatrics removed nicotine from its list of contraindicated substances during breastfeeding, indicating that the benefits of breastfeeding while smoking outweigh the alternative of smoking and formula feeding. Therefore, maternal use of nicotine and tobacco should not prohibit a mother from breastfeeding her child. Breastfeeding while smoking may help reduce some of the harmful effects of prenatal smoking on infants, including acute respiratory illness and asthma. However, women who smoke cigarettes are less likely to initiate breastfeeding than those who do not, possibly revealing that there is a psychosocial factor responsible for lower rates of breastfeeding among women who smoke cigarettes. This is an opportunity for WIC staff to inform participants of the health benefits and to encourage them to breastfeed despite their use of tobacco.

Nicotine has been found to have multiple effects on breastmilk. Nicotine can transfer to an infant through breastmilk. Nicotine lowers prolactin levels, which has been associated with reduced breastmilk supply and reduced milk fat content. Additional changes in milk composition and flavor due to maternal smoking may contribute to an infant’s early weaning from breastmilk.

Smoking in the presence of an infant or child can expose them to secondhand smoke, which has negative health outcomes. If a woman chooses to continue her nicotine and tobacco use while breastfeeding, she should not do it in the presence of the infant. Additionally, it is recommended that a breastfeeding woman who uses nicotine should first breastfeed her infant and then use the product. This timing will help minimize the amount of nicotine in her breastmilk the next time she breastfeeds.

Implications for WIC Nutrition Services WIC staff can provide the following nutrition services to women who use nicotine and/or tobacco: • Provide a safe and supportive environment when discussing nicotine and/or tobacco use. For more information on techniques for delivering effective messages, please see: WIC Substance Use Prevention resource, Chapter 6: https://wicworks.fns.usda.gov/resources/wic-substance- use-prevention-guide • Consider all potential nicotine and/or tobacco delivery methods participants may be using. • Explain the importance of eliminating or reducing the amount of tobacco and/or nicotine use, especially before the third trimester if pregnant. • Explain that ENDS have variable amounts of nicotine and are not safer alternatives to cigarettes. • Encourage fruit and vegetables that are high in vitamin C intake to achieve adequate antioxidant and vitamin C consumption. • Highlight WIC foods, especially 100% juice that are good sources of vitamin C and other important nutrients. • Encourage high iron fruits and vegetables. If the participant is taking an iron supplement, provide recommendations for minimizing gastro- intestinal side effects and foods that can improve iron bioavailability. For more information, please see: https://ods.od.nih.gov/factsheets/Iron- HealthProfessional/. • Refer to their health care provider to discuss the health implications of using NRT while pregnant or breastfeeding.

Offer the following suggestions to minimize secondhand smoke exposure to the infant:

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● Avoid smoking in an infant's presence. ● Smoke outside. ● Ask other smokers to avoid smoking around the infant or other children. ● Have smoke-free rules for the car and home. ● Change clothes and wash hands after smoking and prior to handling the infant. ● Refer to a state quitline (1-800-QUIT-NOW), text-based program (text QUIT to 47848), or a local in-person smoking cessation program. WIC staff can provide the following nutrition services to breastfeeding women who use nicotine and/or tobacco: • Provide breastfeeding promotion and support and inform participants of the health benefits of human milk for infants of mothers who smoke. • Utilize the participant-focused WIC Breastfeeding Support website topic articles that can be found at: https://wicbreastfeeding.fns.usda.gov/breastfeeding-and-alcohol-drugs-and-smoking. • Recommend mothers to refrain from smoking/vaping until right after a feeding so that nicotine level will have time to decrease before the next feeding. • Counsel women who use NRT to time its use for after breastfeeding and to not use at night. • Provide anticipatory guidance about the possible effect of nicotine on breastmilk supply. • Refer to the Maryland WIC Breastfeeding Kardex for information about smoking and breastfeeding women.

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Nutrient Deficiency or Disease (3411) Categories: ALL Defined as: Presence of any currently treated or untreated nutrient deficiency or disease, diagnosed, documented, or reported by a physician or someone working under a physician’s orders, or as self-reported by applicant/participant/caregiver. These include, but are not limited to, Protein Energy Malnutrition, Scurvy, Rickets, Beriberi, Hypocalcemia, Osteomalacia, Vitamin K Deficiency, Pellagra, Xerophthalmia, and Iron Deficiency.

A participant identified with a nutrient deficiency disease should have Nutrition Care counseling.

Justification Nutrient deficiencies or diseases can be the result of poor nutritional intake, chronic health conditions, acute health conditions, medications, altered nutrient metabolism, or a combination of these factors, and can impact the levels of both macronutrients and micronutrients in the body. They can lead to alterations in energy metabolism, immune function, cognitive function, bone formation, and/or muscle function, as well as growth and development if the deficiency is present during fetal development and early childhood. Frequency of nutrient deficiencies vary by age, gender, and/or race and ethnicity. For certain segments of the population, nutrient deficiencies may be as high as one third of the population. Macronutrient deficiencies include deficiencies in protein, fat, and/or calories, and can lead to stunting, pronounced wasting or a disproportionately large abdomen. Marasmus is a disease of severe wasting due to a prolonged inadequate intake of protein, carbohydrate, and fat. Kwashiorkor is a disease that results from a prolonged inadequate intake of protein. Essential fatty acid deficiencies, which would include omega-3 fatty acid deficiency, are thought to be rare among the general population. Signs of an essential fatty acid deficiency may include a dry scaly rash, decreased growth in infants and children, lowered immune response, and impaired wound healing. Micronutrient deficiencies include deficiencies in vitamins and minerals. The most common nutrient deficiencies in the United States population were vitamin B6, iron, vitamin D, vitamin C, and vitamin B12. Pregnant Women A significant proportion of women who participate in WIC have inadequate nutrient intakes of vitamin E (96-100%). Additionally, greater than 50% of pregnant women participants reported inadequate intakes of iron and between 10-50% reported inadequate intakes of magnesium, folate, zinc, vitamin A, vitamin C, and vitamin B6. Micronutrient deficiencies during pregnancy are not only a concern for the mother but are a risk for certain birth defects due to inadequate levels B vitamins, vitamin K, magnesium, copper, and zinc. Iodine deficiency during pregnancy can lead to irreversible adverse effects on fetal growth and development. Research suggests that over half of pregnant women have insufficient intakes of iodine. Because intake patterns of pregnant women can

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exclude or limit specific food groups, it is not uncommon to have multiple nutrient deficiencies during pregnancy. For example, iron deficiency usually does not occur alone, but it often occurs in conjunction with other vitamin and mineral deficiencies.

Breastfeeding and Postpartum Women Among those breastfeeding women more than 50% had inadequate intakes of vitamin A, and 10-50% had inadequate intakes of magnesium, zinc, vitamin C, vitamin B6, folate, copper, and calcium. Over 50% of non-breastfeeding postpartum women had inadequate intakes of magnesium, vitamin A, and calcium, while 10-50% had inadequate intakes of vitamin C, folate, copper, zinc, thiamin, vitamin B6, vitamin B12, iron, and riboflavin.

Infants Formula fed infants had a choline intake below the AI; however, other vitamins and minerals were adequate. Intakes of vitamin D, iron, and zinc among breastfed infants can be of concern if appropriate complementary foods and/or vitamin and mineral supplements are not provided to the infant. At least 10% of breastfed infants between 6 and 12 months of age had inadequate intakes of iron and zinc. Vitamin D in human milk is usually low. Therefore, the American Academy of Pediatrics (AAP) recommends all infants who take less than 32 ounces of formula a day be given a vitamin D supplement of 400 IU daily. Additionally, infants who are born to mothers who are vitamin D deficient are more likely to be deficient themselves.

Children For children participating in the WIC program, the prevalence of inadequate intakes of nutrients was found to be less than 5% for each nutrient, except vitamin E, which was found to be inadequate in the diets of 34.9% of children between 2 and 5 years of age (5). Additionally, it has been estimated that one in four children does not meet the RDA for iron, and one in ten does not meet the RDA for calcium. NOTE: Individuals with nutrient deficiency diseases, or who are concerned that they may have a nutrient deficiency disease, should be followed by their medical provider (especially if supplements are required for treatment) because overdoses of some nutrients are possible.

Participants Most Likely to Have Nutrient Deficiencies or Disease: Participants ● experiencing food insecurity, homelessness, ● with a short interpregnancy interval, ● who have recently left their previous country of residence, ● with a gastrointestinal disease that can limit absorption of nutrients (i.e. celiac disease or Crohn’s disease) or individuals with a history of gastrointestinal surgery (including gastric bypass) are at risk for vitamin B12 deficiency,

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● with other medical conditions that influence nutrient status (i.e. cystic fibrosis, renal disease, genetic disorders), ● on medications that interact with the absorption or excretion of certain vitamins and minerals, ● with substance use disorders are more likely to have deficiencies due to poor intake and/or the effects of the substance, ● who have high intakes of alcohol are at greater risk of developing a magnesium deficiency, ● who smoke are more likely to have a vitamin C deficiency due to oxidative stress.

Participant Focused Counseling: The WIC food package is designed to include foods that contain specific nutrients to improve the health status of program participants, address inadequate intakes, and, ultimately, prevent nutrient deficiencies. Nutrition education combined with the WIC food package can help decrease the likelihood that an individual would develop a nutrient deficiency or disease.

For individuals who currently have a nutrient deficiency or disease, WIC staff can: • Encourage improved intake of whole grains, legumes, dairy, lean protein, fruits, and vegetables. • Emphasize appropriate portion size and variety to avoid nutrient to nutrient interaction. (For example, excessive calcium intake inhibits the absorption of iron.) • Provide education on foods that contain the specific nutrient(s) of concern. • Provide education on preparing foods that are part of the WIC food package. • Refer individuals who report food insecurity to appropriate resources in the community like the Supplemental Nutrition Assistance Program (SNAP) and/or food pantries. • Reinforce the medical and dietary treatment plans provided by the medical provider and refer participants to medical providers for medical follow-up care. • Refer individuals who smoke to tobacco cessation programs.

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Nutrition Practice – Child (4251) Categories: C-1, C 2-4 Defined as: Routine feeding practices that may result in impaired nutrient status, disease, or health problems. Specific practices are shown below. Justification: Inappropriate nutrition practices may lead to poor nutritional status in children. INAPPROPRIATE FEEDING PRACTICE JUSTIFICATION Feeding inappropriate beverages as the primary milk source, such as: ● Reduced fat (2%), lowfat (1%), or fat free (skim) milk before 2 years of age, unless overweight or obesity is a concern for a specific child. ● Rice or soy-based beverages that are inadequately fortified. ● Goat’s milk, sheep’s milk, or imitation or substitute milk inadequately fortified. Children under age 2 who drink milk reduced in fat content may not receive adequate fat or calories in the diet and may be at risk for poor growth. Reduction in dietary fat intake is not recommended until after the age of 2.

Feeding any sugar containing beverages, such as Kool- Aid, punch, sodas, tea or sports drinks.

Abundant epidemiological evidence shows that sugar-especially sucrose-is the major dietary factor affecting the prevalence and progression of dental caries. Consumption of foods and beverages high in fermentable carbohydrates, such as sucrose, increases the risk of early childhood tooth decay. Excessive intake of nutrient-poor, high calorie foods by children between 13 and < 24 months of age can reduce the appetite for other foods, especially those high in iron. Fewer nutrients are available to support growth needs. Using nursing bottles, cups, or pacifiers improperly, such as: ● Using a nursing bottle to feed any beverage other than breastmilk or formula. ● Putting the toddler to bed with the bottle. ● Using a nursing bottle beyond 14 months of age. ●Allowing unrestricted use of a bottle or cup. Inappropriate use of nursing bottles, cups, or pacifiers increase the risk for tooth decay, earaches, and choking. Pediatric dentists recommend that parents be encouraged to have infants drink from a cup as they approach their first birthday, and that infants are weaned from the bottle by 12-14 months of age. Using feeding practices that disregard the developmental stage of the child, such as: ● Not recognizing or disregarding the child’s cues for hunger and fullness. ● Forcing the child to eat certain foods or to “eat everything on The interactions between caregiver and child during feeding (referred to as the feeding relationship) affect a child’s ability to progress in eating skills and to consume a nutritionally adequate diet. A dysfunctional relationship, characterized by a caregiver misinterpreting, ignoring, or overruling the innate

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the plate” or sit at the table for more than 30 minutes to finish eating. ● Using dessert or other “special” foods as a reward or bribe. ● Feeding foods inappropriate in consistency, size, or shape that could cause choking. ● Not allowing the child to learn to self-feed; routinely forcing the child to finish eating by taking over feeding. ● Restricting meals and snacks (less than 3 meals and 2 nutritious snacks per day). ● Severely limiting the child’s food intake, such as feeding the child only the foods that the caregiver likes or never offering a variety of foods because she thinks the child will not eat them. An entire food group is not offered (such as no Milk group foods) and there is no medical reason to do so. capability of the child to regulate food intake based on hunger and satiety can result in poor dietary intake, poor growth, and future problems with regulation of food intake.

Feeding a diet very low in calories and/or essential nutrients, such as a vegan or macrobiotic or other highly restrictive diet.

Highly restrictive diets prevent adequate intake of calories and nutrients, interfere with growth and development, and may lead to other adverse physiological effects. A vegan diet is the consumption of plant origin foods (no meat, poultry, fish, eggs, milk, cheese or other dairy products). While a vegan diet may offer health benefits, lack of planning can result in an inadequate intake of calories, protein, vitamins B-12 and D, calcium, iron, and zinc. Such a diet requires attention to planning. Feeding foods that could be contaminated with harmful bacteria or toxins, such as: ● Feeding unpasteurized juice, milk, or cheese. ● Feeding deli or processed meats or hotdogs without further cooking them. ● Feeding raw or undercooked meat, fish, shellfish, poultry, or eggs. ● Feeding raw vegetable sprouts. ● Feeding local fish or seafood listed on the MDE advisory as DO NOT EAT. Unpasteurized juice or dairy products and undercooked meats may contain pathogens that cause serious, potentially fatal foodborne illness. Raw vegetable sprouts can cause Salmonella or E. coli 0157.

Feeding dietary supplements that are inappropriate and/or excessive, such as: ● Giving any vitamin, mineral, or herbal supplement (unless prescribed by health care provider). The use of non-prescribed or non-recommended dietary supplements, including single or multivitamins or minerals or the use of herbal remedies including teas may result in toxicity and harmful nutrient interactions.

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● Giving a child’s multivitamin supplement inappropriately (does not follow directions on the label). ● Giving any herbal remedy or herbal tea such as chamomile, comfrey, sassafras, or senna. Teas with potentially harmful effects on children include licorice, comfrey leaves, sassafras, senna, buckhorn bark, cinnamon, wormwood, woodruff, valerian, foxglove, poke root, poke weed, periwinkle, nutmeg, catnip, hydrangea, juniper, Mormon tea, thorn apple, yohimbe bark, lobelia, oleander, Mate, kola nut or gotu kola, and chamomile. Routinely not providing essential dietary supplements. ● Providing children under 36 months of age less than 0.25 mg of fluoride daily when the water supply contains less than 0.3 ppm fluoride. ● Providing children 36-60 months of age less than 0.50 mg of fluoride daily when the water supply contains less than 0.3 ppm fluoride. ● Not providing 400 IU of vitamin D if a child consumes less than 1 liter (1 quart) of vitamin D fortified milk or formula. Since 1 quart is above the recommendation for pre-school children, most children will require a supplement. Fluoride decreases the susceptibility of teeth to dental caries. Once fluoride is an integral part of the tooth structure, teeth become stronger and more resistant to decay. It is recommended that when the water supply contains less than 0.3 parts per million (ppm) of fluoride, children between the ages of 12 and < 36 months of age consume 0.25 milligrams of fluoride daily and children 36 to 72 months of age consume 0.50 milligrams of fluoride daily. When the water supply contains 0.3 - 0.6 ppm fluoride, children 36 to 72 months of age should take 0.25 milligrams of fluoride daily.

Participant Focused Counseling:

Based on the participant’s willingness to explore change, review the risks related to the feeding practice, the benefits of change, and steps participant is willing to take to change the potentially harmful practices.

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Nutrition Practice – Infant (4111) Categories: IBE, IBP, IFF Defined as: Routine feeding practices that may result in impaired nutrient status, disease, or health problems. Specific practices are listed below. Justification: Inappropriate nutrition practices may lead to poor nutritional status in infants. INAPPROPRIATE FEEDING PRACTICE JUSTIFICATION ● Routinely limiting the frequency of nursing of the exclusively breastfed infant to less than 8 times in a 24-hour period if the infant is <2 months of age ● Scheduled feeding is used instead of demand feeding. Refer the infant to the breastfeeding specialist. The American Academy of Pediatrics and others advocate breastfeeding as the preferred method of infant feeding during the first 12 months of life. Frequent breastfeeding is critical to establish and maintain an adequate milk supply for the infant. Inadequate frequency of breastfeeding can lead to lactation failure in the mother and dehydration and poor weight gain in the infant. Using a substitute for breastmilk or FDA-approved iron- fortified formula as the primary nutrient source. Examples include: ● Low iron formula without iron supplementation of FDA- approved mixture of low-iron and iron-fortified formulas ● Cow, goat, or sheep milk ● Evaporated or sweetened-condensed milk ● Soy or rice-based beverages ● Other beverages such as non-dairy creamer or homemade concoctions For non-breastfed infants, iron-fortified infant formula is recommended. Use of a low iron formula may deplete the infant’s iron stores, leading to anemia and poor growth. Cow, goat, or sheep milk, imitation milks, and substitute milks do not contain nutrients (such as iron or folic acid) in appropriate amounts for infants. The protein is more difficult to digest and can lead to blood loss and anemia.

Over- or under-dilution of formula by: ● Not following manufacturer’s mixing instructions to stretch formula ● Not following specific prescription instructions Over Dilution of formula can lead to poor growth, Failure to Thrive, or water intoxication (that can be fatal). Under Dilution of formula concentrates calories and protein and increases the renal solute load in the kidneys. Overweight, dehydration, and metabolic acidosis can occur. Using nursing bottles or cups inappropriately, such as: ● Using the bottle to feed fruit juice, fruit drinks, soda, gelatin water, chicken broth, corn syrup or sugar solutions, tea, or diluted cereal or other solid foods. Inappropriate uses of a nursing bottle, such as feeding sugar- sweetened beverages may displace nutrients supplied by breastmilk or formula. Feeding foods like cereal in a bottle may displace nutrients provided by breastmilk or formula and may

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● Allowing the Infant to fall asleep or be put to bed with the bottle at naps or bedtime. ● Allowing the infant to use the bottle or cup without restriction (used as a pacifier). ● Propping the bottle when feeding. ● Allowing an infant to carry around and drink throughout the day from a covered or training cup. lead to choking. Allowing the infant to fall asleep with the bottle or propping the bottle when feeding the infant may result in Early Childhood Caries, ear infections, and choking.

Lack of sanitation in the preparation, handling, or storage of infant formula or expressed breastmilk, such as: ● Bottles, nipples, or equipment for breastmilk or formula preparation are not properly washed and rinsed. ● Formula, bottles, nipples, or equipment for formula or breastmilk are not sterilized before the infant is 4 months of age. ● Formula is not prepared and/or stored by manufacturer’s OR health care provider’s instructions. ● The breast pump is not cleaned per manufacturer’s instruction. ● Well, cistern, or spring water that has not been tested and certified as pathogen-free by a certified testing agency such as a health department is used to prepare formula or is fed to the infant. ● There is no stove, refrigerator, freezer, or sink in the home or the equipment is not working. ● The infant is fed formula or expressed breastmilk left from a prior feeding. ● The infant is fed breastmilk or prepared formula held at room temperature for more than one hour. ● The infant is fed prepared formula held in the refrigerator longer than 24 hours (if made from powder) or 48 hours (if made from concentrate). ● Freshly expressed unrefrigerated human milk is added to frozen human milk ● Freshly pumped chilled human milk is added to frozen human milk in an amount that is greater than the amount of frozen human milk. ● The infant is fed breastmilk that has been previously frozen, thawed and then held in the refrigerator for over 24 hours Prepared infant formula or expressed breastmilk is perishable and must be handled and stored properly to be safe for consumption. Lack of sanitation may cause a gastrointestinal infection.

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before feeding, ● Human milk is thawed/heated in a microwave. ● Thawed human milk is refrozen. ● Feeding donor human milk received directly from another person or through the internet Offering complementary foods (solids, table, or family foods) that are inappropriate in type, timing or feeding methods, such as: ● Feeding sugar or corn syrup in any beverage or putting it on a pacifier. ● Feeding any food other than breastmilk or formula before 6 months of age.

Before 6 months of age, the infant’s gastric and enzymatic secretions and digestive and renal capacity are low, making digestion of solid foods inefficient and potentially harmful. Nutrients supplied by breastmilk or iron-fortified formula may be displaced. Developmentally, the infant is not ready to accept solids. The extrusion reflex is strong, resulting in foods being pushed out of the mouth. Offering sugar-sweetened beverages or excessive amounts of juice may prevent consumption of essential nutrients from breastmilk, formula, or other more appropriate foods.

After 6 months of age, complementary foods are gradually added to supplement the nutrients and calories provided by breastmilk or iron-fortified formula. Feeding a very nutritionally inadequate diet such as: ● Not allowing the infant to consume any more food than the caregiver initially provides. ● Following a strict vegan or macrobiotic diet. ● Other diets very low in calories and/or essential nutrients.

Highly restrictive diets prevent adequate intake of calories and nutrients, interfere with growth and development, and may lead to other adverse physiological effects.

An infant held to a rigid feeding schedule may be underfed or overfed. Caregivers insensitive to signs of hunger and satiety or who exert control over feeding may inappropriately restrict or encourage excessive intake. Using feeding practices that disregard the developmental stage of the infant, such as: ● Not recognizing or disregarding the infant’s cues for hunger or fullness (putting the infant on a strict feeding schedule instead of feeding on demand) or forcing an infant to eat a certain type or amount of food. ● Feeding foods that could cause choking, such as potato or other snack chips, hot dogs, raw vegetables, raw hard fruits, or large pieces of meat. ● Feeding food in a bottle or syringe-nipple feeder and not by spoon. A critical developmental period exists in which the infant learns progressively how to accept, manipulate, and swallow solid foods. Between the ages of 6 and 7 months, the infant develops the ability to self-feed finger foods that are easily chewed and swallowed. Foods that are inappropriate in size, shape, or consistency may cause choking and result in asphyxiation.

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● Not supporting the infant’s growing need for independence with self-feeding (only spoon feeding an infant who is able and ready to finger-feed and/or try self-feeding with appropriate utensils.) ● Not advancing the textures of foods (puree; mashed; chopped; tiny pieces of foods) according to the infant’s developmental readiness. Feeding foods that could be contaminated with harmful bacteria or toxins, such as: ● Honey or unpasteurized fruit or vegetable juice ● Undercooked or raw meat, fish, shellfish, poultry, or eggs ● Local fish or seafood listed on the MDE advisory as DO NOT EAT. ● Unpasteurized dairy products or soft cheeses such as feta, Brie, Camembert, blue-veined, and Mexican-style cheese’ ● Raw vegetable sprouts (alfalfa, clover, bean, and radish) ● Deli meats, hot dogs, and processed meat unless heated to steaming Honey in any form may contain spores of Clostridium botulinum, which if consumed by an infant, may create a deadly toxin inside the gastrointestinal tract and lead to death. Unpasteurized juice and undercooked meats may contain pathogens that cause serious, potentially fatal foodborne illness. Feeding dietary supplements that are inappropriate and/or excessive, such as: ● Feeding any vitamin or mineral supplement (unless prescribed by health care professional. ● Feeding any herbal remedy or herbal tea such as chamomile, comfrey, or senna. ●Feeding “gripe” water. The use of unprescribed dietary supplements, including single or multivitamins or minerals or the use of herbal remedies including teas may result in toxicity and harmful nutrient interactions.

Not giving a dietary supplement recognized as essential by national public health policy, such as: ● Infants who are 6 months of age or older who are ingesting less than 0.25 mg of fluoride daily when the water supply contains less than 0.3 ppm fluoride. ● Infants who are exclusively breastfed, or are ingesting less than 1 liter (or 1 quart) per day of vitamin D-fortified formula, and are not taking a supplement of 400 IU of vitamin D. Fluoride decreases the susceptibility of teeth to dental caries. Once fluoride is an integral part of the tooth structure, teeth become stronger and more resistant to decay. It is recommended that when the water supply contains less than 0.3 parts per million (ppm) of fluoride, infants 6 months of age and older consume 0.25 milligrams of fluoride daily.

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Nutrition Practice – Woman (4271) Categories: PG, BE, BP, WPP Defined as: Routine use of nutrition practices that may result in impaired nutrient status, disease, or health problems. Specific practices are listed below. Inappropriate Nutrition Practices for Women Examples of Inappropriate Nutrition Practices (including, but not limited to) 427.1 Consuming dietary supplements with potentially harmful consequences. Examples of dietary supplements which when ingested in excess of recommended dosages, may be toxic or have harmful consequences: • Single or multiple vitamins; • Mineral supplements; and • Herbal or botanical supplements/remedies/teas. • Cannabidiol (CBD), for Pregnant and Breastfeeding women only (Products labeled as CBD with any form of THC should be a risk with 372) 427.2 Consuming a diet very low in calories and/or essential nutrients; or impaired caloric intake or absorption of essential nutrients following bariatric surgery. • Low-calorie diet. • Strict vegan diet; and • Any other diet restricting calories and/or essential nutrients. 427.4 Inadequate vitamin/mineral supplementation recognized as essential by national public health policy. • Consumption of less than 27 mg of iron as a supplement daily by pregnant woman. • Consumption of less than 150 mcg of supplemental iodine per day by pregnant and breastfeeding women.

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• Consumption of less than 400-800 mcg of folic acid from supplements daily by all WIC women categories. 427.5 Pregnant woman ingesting foods that could be contaminated with pathogenic microorganisms Potentially harmful foods: • Seafood: Any raw or undercooked fish, or shellfish, or food containing raw or undercooked seafood, e.g., sashimi, found in some sushi or ceviche; Refrigerated smoked fish; Partially cooked seafood, such as shrimp and crab • Raw or undercooked meat or poultry. • Hot dogs, luncheon meats (cold cuts), fermented and dry sausage and other deli-style meat or poultry products unless reheated until steaming hot. • Pâtés: Unpasteurized, refrigerated pâté or meat spreads. • Deli Salads: Deli Salads prepared without preservatives in a deli-type store or restaurant. • Unpasteurized milk or foods containing unpasteurized milk. • Soft cheeses made with unpasteurized milk such as feta, Brie, Camembert, blue- veined cheeses and Mexican style cheeses such as queso blanco or queso fresco. • Eggs: Raw or undercooked eggs or foods containing raw or lightly cooked eggs including certain salad dressings (Caesar), cookie and cake batters, sauces, and beverages such as unpasteurized eggnog. • Raw sprouts (alfalfa, bean, clover, radish, microgreens); • Unpasteurized fruit or vegetable juices; or unwashed fruits and vegetables.

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Consuming dietary supplements with potentially harmful consequences. (427.1) Categories: PG, BE, BP

Justification: Pregnant and breastfeeding women taking inappropriate or excessive amounts of dietary supplements, such as single or multivitamins or minerals, herbal supplements, teas, or cannabidiol (CBD) are at risk for adverse effects such as harmful nutrient interactions, toxicity, and possible birth defects. These substances can cross the placenta and may harm the fetus. T Most nutrient toxicities occur through excessive supplementation. Vitamins A, B-6 and the minerals iron and selenium can be micronutrients that are consumed in excess during pregnancy and breastfeeding. They may also be present in breast milk and have a negative impact on the infant. Vitamin A: critical during periods of rapid growth and cell development, but excess during pregnancy can cause birth defects, especially in the first 60 days after conception. Vitamin B6: sometimes taken by pregnant women to reduce nausea and vomiting in doses of 10-25 mg three to four times a day. The effectiveness of this remains unproven but these amounts remain under the tolerable Upper Limit (UL). Doses of 50–510 mg per day taken during the first trimester have not been associated with adverse fetal outcomes, however the UL is set at 100 mg per day. Iron: The UL in the U.S. for iron is 45 mg per day and is based on the reported side effects of gastrointestinal discomfort, nausea, and constipation at levels of 40–50 mg per day. These are common complaints in pregnant women and iron supplementation may exacerbate discomfort. Selenium: potentially consumed in excess during pregnancy. It acts as an antioxidant and is important in reproduction but there are no recommendations for supplementation during pregnancy. Excess selenium intake could be of concern if women eat locally from areas where the selenium content in the soil is high or consume large amounts of Brazil nuts. There are no known cases of selenium toxicity during pregnancy or breastfeeding in the U.S.

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Herbal and Dietary Supplements Pregnant and breastfeeding women should be cautious about using herbal and dietary supplements because safety, purity, and effectiveness are not guaranteed because they are not regulated by the Food and Drug Administration (FDA), and because potency can differ between and among batches and brands. Many people falsely believe that herbs are safe because they are natural. Some herbs can be harmful to the rapidly growing fetus by interfering with cell growth and division during this rapid process. Herbs can have different strength depending on the form used. Teas contain the least compounds, while tinctures, which are alcohol extracts, have the highest concentration and they contain alcohol. Raspberry and blackberry leaf teas can cause hypoglycemia in women with gestational diabetes. Other herbs can cause uterine contractions and bleeding and are contraindicated in pregnancy including oregano tea, avocado leaf tea, cat’s claw, sage tea, and large amounts of parsley or celery seeds. Regular chamomile consumption during the third trimester is associated with a higher risk of pre-term delivery and lower birth weight. Ginger should be limited to 1,000 mg/day during pregnancy for nausea and vomiting due to possible uterine stimulating effects. Fennel and peppermint tea used during pregnancy may have toxic contaminants. Pregnant women should discuss the use of herbal teas and supplements with their health care provider prior to use. Cannabidiol (CBD): The cannabis plant, commonly known as marijuana, contains more than 100 chemical compounds that share a common structure known as cannabinoids. The most common is the psychoactive compound tetrahydrocannabinol (THC). The second is CBD which does not produce the typical effects of marijuana. All cannabinoids, including CBD, readily cross the placental

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barrier. CBD has been shown to help reduce inflammation, anxiety, pain, and seizures. However, CBD products are not regulated by the Food and Drug Administration (FDA) and the FDA has approved only one CBD prescription drug to treat a rare form of epilepsy. Studies of CBD products showed that only 31% were accurately labeled in regard to CBD levels. Other studies showed the presence of potentially hazardous chemicals such as toxins or THC. Potential side effects of CBD include drug interactions, liver abnormalities, diarrhea, fatigue, vomiting, and sleepiness. Increasing numbers of pregnant women use it for pain, insomnia, anxiety, or nausea. Though there are very few studies on the use of CBD during pregnancy, some have shown CBD use may include placental changes, an effect on the functionality of the uterine lining, and inducing preterm labor. More plentiful animal studies have shown harm to developing fetuses. CBD has been found in breast milk after maternal marijuana use, whether by smoking or eating, but does not appear to be present after just CBD use. There does remain a concern about CBD products containing unlabeled THC and other contaminants such as pesticides, heavy metals, bacteria, and fungus. Currently, the FDA strongly advises against the use of CBD in any form during pregnancy or while breastfeeding. 427.1 References - Supplements/Herbs • Over-the-counter medicine, supplements and herbal products during pregnancy (marchofdimes.org) https://www.marchofdimes.org/find-support/topics/pregnancy/what-to-know-about-supplements-herbs-and-medicines- pregnancy • Vitamin and Mineral Supplement Fact Sheets (nih.gov) https://ods.od.nih.gov/factsheets/list-VitaminsMinerals/ • Dietary Supplements | FDA https://www.fda.gov/food/dietary-supplements

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Consuming a diet very low in calories and/or essential nutrients (427.2) Categories: PG, BE, BP

A participant determined to be eating a very low calorie diet should be referred to the CPA for Nutrition Care counseling Justification: Calories: During pregnancy, the maternal diet must provide enough energy for the mother’s usual requirements and those of the growing fetus. Extra energy is required for the synthesis of new and existing tissues in the second and third trimesters. Restrictive diets may increase the risk of low birth weight, birth defects, suboptimal fetal development, and chronic health problems in their children. Restrictive diets are of special concern for the pregnant adolescent, since her additional growth needs compete with the developing fetus and the physiological changes of pregnancy. Macronutrients: Pregnant women should avoid a diet that severely restricts any macronutrient. Examples include: the ketogenic diet which lacks carbohydrates, the Paleo diet which limits dairy, and any diet that consists of an excess of saturated fats. Fad diets may be especially harmful during pregnancy because of the resulting nutrient imbalance and consequent nutrient deficiencies or possible ketosis from lack of carbohydrates. Infants of mothers on a low-carbohydrate diet may be prone to gaining weight in childhood. An extreme intake of protein has been associated with low-birth-weight infants. The Paleo diet promotes consumption of excess saturated fats and restricts the consumption of dairy-based foods, which may contribute to deficiencies in calcium and vitamin D. Vegan Diets: strict veganism can have a low content of essential micronutrients such as iron, zinc, vitamin B 12, vitamin D, omega-3 fatty acids, calcium, and iodine. The most common nutrient deficiencies in vegans are vitamins D and B12, and are best met for vegans with supplements, since few plant foods are fortified with vitamin D, and they eat no animal products which are the source of vitamin B12. The breastmilk of a vegan mother can be severely deficient in vitamin B12, which if not treated, could cause growth failure and permanent damage to the infant’s nervous system. Breastfeeding women who follow a strict vegan diet should have their infant’s vitamin B12 levels monitored. Pregnant and breastfeeding vegan women should be encouraged to take an individual B12 supplement that is dissolved on the tongue to increase absorption. However, both pregnant and breastfeeding women following a vegan dietary pattern should consult

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with their healthcare provider to determine whether supplementation of vitamin D, vitamin B12 (and what form), and/or other nutrients such as iron, choline, zinc, iodine, or essential fatty acids are necessary. Weight Loss Surgery: Although pre-pregnancy weight loss from bariatric surgery may improve the chances of getting pregnant and decrease the risk of gestational diabetes and hypertension, it has the potential for deficiencies in nutrients essential for healthy fetal development. The nutrients that need to be replaced depend on which bariatric surgery was performed and the nutritional status of the pregnant woman, but the most common deficiencies include vitamins D, folate, B12, B1, and A and the minerals iron and calcium. Women who have had gastric band surgeries may have more difficulty eating enough while gastric bypass procedures tend to cause malabsorption problems. Common nutrient deficiencies can be exacerbated by morning sickness or hyperemesis, GERD, and abdominal bloating. The American College of Obstetricians and Gynecologists recommends delaying pregnancy for 18 months after bariatric surgery. A more individualized approach is to delay pregnancy until a woman’s weight has been stable for 2 years. However, this does not always happen, and many women become pregnant with nutrient deficiencies. Pregnant women may also be unwilling to gain the recommended weight after losing weight post-surgery. Women who have had bariatric surgery have higher risks of fetal growth restriction, preterm births, higher rates of miscarriage and neonatal mortality after surgery. Malabsorptive procedures (bypass) are associated with a significant increase in Small for Gestational Age (SGA) whereas restrictive procedures (banding) are not. This could be related to malnutrition, since many vitamins and minerals are absorbed in the small intestine which is bypassed by the surgery. Women of reproductive age undergoing bariatric surgery are a high-risk group and require specialized preconception and antenatal nutritional support to achieve the best outcomes for both mothers and babies as bariatric surgeries increase. Women who become pregnant following bariatric procedures should have laboratory screening for nutritional deficiencies every trimester. 427.2 References - Highly Restrictive Eating/Nutrient Malabsorption • https://www.eatright.org/ • Weight-loss (Bariatric) Surgery | NIDDK (nih.gov) https://www.niddk.nih.gov/health-information/weight-management/bariatric-surgery

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Inadequate vitamin/mineral supplementation recognized as essential by national public health policy. (427.4) : PG, BE, BP, WPP Justification: Most healthcare providers recommend women who are pregnant or planning to become pregnant take a daily prenatal vitamin and mineral supplement in addition to consuming a healthy dietary pattern. This may be especially important to meet folic acid, iron, and iodine needs during pregnancy and iodine needs during breastfeeding. Iron: The Recommended Dietary Allowance (RDA) for iron substantially increases during pregnancy from 18 mg per day to 27 mg per day. Iron is a key nutrient that supports fetal development. t is used by the body to make the extra blood that the pregnant woman and fetus need during pregnancy. This increased amount of iron is found in most prenatal vitamins. Iron deficient anemia (IDA) is more common in economically and socially disadvantaged people and may independently contribute to problems in pregnancy and early childhood development. About 33% of low-income pregnant women in the U.S. have IDA in their third trimester which is associated with increased low birth weight, preterm delivery, and fetal and infant death. Maternal effects include fatigue, light-headedness, and low prenatal weight gain. IDA in the first and second trimesters is associated with increased maternal morbidity. Iron needs for women who are breastfeeding differ from those who are pregnant. For adult women who are breastfeeding, before menstruation returns, iron needs fall to 9 mg/day and then return to pre-pregnancy levels once menstruation resumes. If breastfeeding women continue to take their prenatal vitamins, they may exceed their needs for iron. Women who are breastfeeding should not exceed the UL of 45 mg of iron per day. Breastfeeding women should seek guidance from a healthcare provider regarding the appropriate level of iron supplementation based on their unique needs as more than half of breastfeeding women continue to use prenatal supplements. Folic acid is the synthetic form of folate, a water-soluble B vitamin. Folate occurs naturally in foods such as dark green leafy vegetables, legumes, and oranges and is fortified in enriched grains (i.e., bread, pasta, rice, and cereal). Most women do not receive the recommended daily allowance of folate from diet alone. Adequate folic acid intake is particularly important prior to conception and during the first trimester to help prevent neural tube defects (NTDs). NTDs are major birth defects of the brain and spine that occur early in pregnancy due to improper closure of the embryonic neural tube, which may lead to a range of disabilities or death. The most common NTDs are anencephaly (underdeveloped brain and incomplete skull) and spina bifida (incomplete closing of the spinal cord) as well as miscarriages, preterm births, orofacial clefts, and congenital heart defects. Natural folate is less bioavailable and has not been shown to lower the risk of NTDs as synthetic folic acid. The RDA for folate is higher during pregnancy and breastfeeding than all other life stages. The United States Preventative Services Task Force (USPSTF) recommends that all women who are planning or

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capable of pregnancy take a daily supplement containing 400 to 800 mcg of folic acid, along with the folate in food. The critical period for supplementation is at least 1 month before pregnancy and during the first 12 weeks of pregnancy. Most prenatal supplements sold in the United States contain folic acid. Supplementation with folic acid during preconception and early pregnancy is critical and can prevent 40–80% of neural tube defects. The UL for women who are pregnant, or breastfeeding is 1,000 mcg of folic acid. Iodine is an essential nutrient required for the synthesis of thyroid hormone, which is responsible for regulating growth, development, and metabolism. Iodine requirements increase substantially during pregnancy and breastfeeding. The RDA for iodine during pregnancy is 220 mcg and 290 mcg during breastfeeding. If iodine requirements are not met during these periods, the production of thyroid hormones may decrease and be inadequate for maternal, fetal, and infant needs. Inadequate iodine intake during pregnancy and breastfeeding could be detrimental to the growth and development of the baby’s brain. Severe iodine deficiency during pregnancy and the neonatal period is associated with many adverse effects, including miscarriage, stillbirth, neonatal mortality, growth retardation and decreased IQ. Even subclinical hypothyroidism can double the risk of miscarriage and neonatal death. Adequate iodine levels in breastmilk are essential for the proper neurodevelopment of infants. The American Thyroid Association recommends that pregnant and breastfeeding women receive 150 mcg per day of supplemental iodine to meet the increased iodine needs during pregnancy and breastfeeding. Many prenatal supplements do not contain iodine. Pregnant and breastfeeding women should discuss the need for supplemental iodine in their prenatal vitamin with their health care provider to ensure they are receiving an adequate amount. The following is a table showing the RDA and UL for iron, folate and iodine during pregnancy and lactation: Micronutrient Pregnancy RDA Breastfeeding RDA Tolerable Upper Intake Level (UL)

Iron 27 mg 9 mg 45 mg Folate 600 mcg 500 mcg 1,000 mcg Iodine 220 mcg 290 mcg 1,100 mcg

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427.4 Inadequate vitamin/mineral supplementation • General Information About NTDs, Folic Acid, and Folate | CDC https://www.cdc.gov/folic-acid/about/index.html • Recommendation: Folic Acid for the Prevention of Neural Tube Defects: Preventive Medication | United States Preventive Services Taskforce (uspreventiveservicestaskforce.org) https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/folic-acid-for-the-prevention-of-neural-tube-defects- preventive-medication

Pregnant woman ingesting foods that could be contaminated with pathogenic microorganisms. (427.5) PG Justification: The CDC estimates that each year 1 in 6 people in the U.S. will get sick from a foodborne illness caused by pathogenic microorganisms (bacteria, viruses, and parasites) and their toxins and chemical contamination. Pregnant women and their fetuses are more susceptible to foodborne illnesses a pregnant woman’s immune system is weakened while the fetus's immune system is still developing, making it harder to fight off certain harmful foodborne microorganisms. Therefore, it is important that they avoid foods with a high risk of infection. For this reason, the Dietary Guidelines for Americans and government agencies such as the Centers for Disease Control and Prevention, the USDA Food Safety and Inspection Service, and the Food and Drug Administration advise pregnant women and other high-risk individuals not to consume unpasteurized (raw) juice or milk, raw sprouts, and some soft cheeses made from unpasteurized milk. During pregnancy, women should only eat foods containing seafood, meats, poultry, or eggs that have been cooked to recommended safe minimum internal temperatures. Pregnant women are 10 times more likely to get Listeria, the bacteria that causes Listeriosis, than other U.S. adults. Listeria is a soilborne bacteria that grows in cool, moist environments. Infection occurs from eating contaminated foods including unpasteurized (raw) juice or milk, raw sprouts, or some soft cheeses made from unpasteurized milk. Deli and luncheon meats and hot dogs should be reheated to steaming hot or 165°F to kill Listeria. Listeriosis during pregnancy can cause miscarriage, stillbirth, or a preterm delivery. Infections are more likely in the third trimester (96%) than the first, but the consequences are more severe with the earlier infections. Salmonella, Campylobacter jejuni, E. coli, and Toxoplasmosis are other foodborne pathogens that are of concern for pregnant women.

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Salmonella is more likely to cause an infection in the mother rather than the fetus. Salmonella infections occur from eating contaminated foods such as raw or undercooked eggs, unpasteurized milk, raw or undercooked seafood or meat or unwashed fruits and vegetables. Symptoms include vomiting, diarrhea, abdominal pain and flu-like aliments. Campylobacter infections are caused by consuming raw or undercooked poultry or another food that has been contaminated by raw or undercooked poultry. Campylobacter can cross the placenta and infect the fetus causing miscarriage, stillbirth, or preterm labor. E. coli can affect pregnant women when they consume contaminated food or water, or unpasteurized milk. The symptoms can vary with each person but often include severe stomach cramps, diarrhea, vomiting, and sometimes a fever. If pregnant women are exposed to E. coli, dehydration is the main risk. Toxoplasmosis is caused by a parasite (Toxoplasma gondii) that infects more than 40 million people in the U.S. A woman can become infected with Toxoplasmosis by eating unpasteurized milk, raw vegetables, undercooked meat (especially pork, lamb, and venison), shellfish, and food contaminated with knives and cutting boards that have been in contact with raw meat or shellfish. Infection can also be caused by drinking contaminated water, and after accidental ingestion of the parasite when in contact with cat feces. The risk of infection is higher during pregnancy and can lead to severe neurological damage, injury to various organs, miscarriage, premature birth, or stillbirth. Informing pregnant women and postpartum mothers about food safety issues through trained health professionals is crucial for the consistency of messages and increasing food safety awareness among vulnerable consumer groups. 427.5 References – Food Borne Illnesses • Food Safety | Food Safety | CDC https://www.cdc.gov/food-safety/index.html • Safe Food Handling | FDA https://www.fda.gov/food/buy-store-serve-safe-food/safe-food-handling • http://www.foodsafety.gov https://www.foodsafety.gov/ • https://www.fightbac.org/ https://fightbac.org/ • fightbac.org/kids/ https://fightbac.org/kids/ • People at Risk: Pregnant Women | FoodSafety.gov https://www.foodsafety.gov/people-at-risk/pregnant-women • Food Safety For Pregnant Women, Their Unborn Babies, and Children Under Five (fda.gov) https://www.fda.gov/food/people-risk-foodborne-illness/food-safety-pregnant-women-and-their-unborn-babies

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• What Is Foodborne Illness? Food Safety for Moms to Be | FDA https://www.fda.gov/food/people-risk-foodborne-illness/food-safety-moms-be • Listeria Monocytogenes | Food Safety and Inspection Service (usda.gov) http://www.fsis.usda.gov/food-safety/foodborne-illness-and-disease/illnesses-and-pathogens/listeria • About Toxoplasmosis | Toxoplasmosis | CDC https://www.cdc.gov/toxoplasmosis/about/index.html • E. coli (Escherichia coli) | E. coli | CDC https://www.cdc.gov/ecoli/about/index.html • Campylobacter (Campylobacteriosis) | Campylobacter | CDC https://www.cdc.gov/campylobacter/about/index.html Participant Focused Counseling: When a woman is identified with a nutrition practice risk factor, review the risks related to the practice, and the benefits of change. Determine her willingness to explore change and discuss the steps the participant is willing to take to change the potentially harmful practices.

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Obese (Child) (1131) Categories: C 2-4 Defined as: BMI/age ≥ 95th percentile on CDC growth chart for a child 2 to 5 years of age. Justification: The rapid rise in the prevalence of obesity in children is one of the most important public health issues in the United States today. Research on BMI and body fatness shows that the majority of children with BMI/age at or above the 95th percentile have high adiposity, and an increased risk for future adverse health outcomes and/or developmental diseases. The causes are complex. Both genetic and environmental factors contribute to obesity risk. Obesity can result from excessive energy intake, decreased calorie expenditure, or impaired regulation of energy metabolism. Having a Body Mass Index (BMI) for age at the 95th percentile or higher identifies children with a greater likelihood of being overweight as adolescents and adults. It is recommended that an obese child undergo a medical assessment and careful evaluation to identify any underlying health risks or secondary complications. Overweight in early childhood may signify problematic feeding practices such as excessive consumption of high calorie foods and beverages or family behaviors such as too many hours spent watching television. Such practices, if continued, may contribute to diet and inactivity-related health risks in adulthood. Procedure: ● Obtain current height measured to the nearest 1/8 inch and weight measured to the nearest 4 ounces. Record measurements in the participant’s record. ● Calculate BMI using the procedure found in Table BMI.1. Plot the BMI value on the BMI/age growth chart. ● If the plotted point is at or greater than the 95th percentile, assign the risk criterion. ● Review collected information for routine dietary practices that could promote a faster rate of weight gain, such as drinking milk and other beverages from a baby bottle; excessive snacking (more than 3 snacks per day); or forcing the child to eat. Inquire about usual activity and television watching.

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Participant Focused Counseling: Do not use the medical term “obese” when discussing the child’s weight with the caregiver. Frame the Participant Focused Counseling discussion to make achieving the child’s optimal growth a shared goal of the WIC program and the parents/caregivers. Make clear that BMI/age ≥95th percentile is a medical condition that can be addressed. ● Educate parents/caregivers on behaviors that can lead to healthy body weight, including: o Recognizing fullness cues o Offering a variety of nutritious foods; o Not overly restricting foods; o Offering the child foods lower in fat, such as 1% or fat free milk and low-fat cheese, or selecting beans as well as peanut butter; o Comforting the child by holding, reading, or rocking instead of feeding; o Being active as a family; o Reducing screen and electronics time. ● Discuss the behavior changes parents/caregivers are willing to address. ● Discuss strategies that might work for the family. ● If parents/caregivers are willing, help them set a simple, measurable goal. ● Enter the goal in WOW.

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Oral Health Conditions (3811) Categories: All Defined as: Diagnosis of oral health conditions by a physician or a health care professional working under the orders of a physician or adequate documentation by the CPA or CPPA. ● Women and Children: includes, but not limited to tooth decay, periodontal disease, tooth loss and/or ineffectively replaced teeth that impair the ability to ingest food in adequate quantity or quality. ● Pregnant woman: includes gingivitis of pregnancy. ● Infants and Children: includes the presence of Early Childhood Caries (baby bottle tooth decay) or smooth surface decay of the maxillary anterior teeth or the primary molars.

Justification:

Missing more than seven teeth in adults seriously affects the ability to chew foods and can restrict food intake, resulting in a diet that is poor in nutritional quality. Diet quality tends to decline as dental impairment increases, including decreases in vitamin A, fiber, calcium, and other nutrients because hard-to-chew nutritious foods like fruits and vegetables decline, while high calorie, high fat processed foods increase. Periodontal infection is a significant risk criterion for preeclampsia, can result in placental-fetal exposure and, when coupled with a fetal inflammatory response, can lead to preterm delivery. Periodontal disease and caries may also increase the woman’s risk of atherosclerosis, rheumatoid arthritis and diabetes. There is evidence that gingivitis of pregnancy results from end tissue deficiency of folic acid that will respond to folic acid supplementation as well as plaque removal. Early childhood caries result from inappropriate feeding practices, especially frequent sugar consumption. Healthful dietary and oral hygiene practices can prevent the loss of primary teeth, and potential speech problems. Children with special health care needs (including prematurity and intrauterine malnutrition, GERD, failure to thrive and other weight gain and growth problems, craniofacial malformations, compromised immune function, and Down syndrome) can increase the risk of oral health problems and can also make the overall effects of poor oral health more severe. Referral to dental services should be made as appropriate.

Procedure: Determine the presence of oral health conditions in the woman, infant, or child. Self-reported information is acceptable. The presence of obvious dental decay or tooth loss may also be documented by observation by WIC staff. Review collected information about dietary practices that may increase the risk of dental problems.

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Participant Focused Counseling: With woman with oral health conditions, discuss: ● Dietary and oral health practices that lower risk of dental problems including use of fluoride toothpaste and rinsing nightly with alcohol-free, over-the-counter mouth rinse with 0.05% sodium fluoride. ● Preparing easy-to-chew foods, as needed

With caregiver of an infant or child with oral health conditions, discuss: ● Feeding practices that promote optimal oral health, such as reducing frequency of sugary food and drink; weaning directly from bottle to open cup by 12 months of age; not propping baby bottle, and, if necessary, giving only water in bottle at bedtime

● Oral health strategies that reduce cavity risk, such as daily oral hygiene appropriate for age, routine dental checkups, and not sharing cups or utensils between adult and child.

● Use of fluorides for the prevention and control of caries is documented to be both safe and highly effective, including using tiny amounts of fluoride toothpaste as soon as teeth erupt. Parents and caregivers may have questions and concerns about fluoride content in water supplies and in infant formula. Fluoridated water can be found in communities that supplement tap water with fluoride and it may also be found in well water. The CDC’s My Water’s Fluoride website: https://nccd.cdc.gov/doh_mwf/ allows consumers in currently participating States to learn the fluoride status of their water system.

● Emphasize non cariogenic vs high cariogenic foods, using the chart below:

Noncariogenic Foods Low Cariogenic Foods High Cariogenic Foods Cheese, cottage cheese, plain yogurt Flavored milk Breakfast bars, granola bars Chicken, eggs, unflavored cow’s milk Fresh fruits Cake, cookies, candies** Popcorn, nuts and seeds* Whole grain products Doughnuts, pretzels, soda crackers Seltzer, flavored club soda

Raisins and other dried fruit Vegetables

Sweetened drinks, including fruit juice

Sweetened dry cereal

*choking hazard for infants and toddlers

**Sticky candy and/or slowly eaten candy are extremely cariogenic Adapted from: Faine, MP. Nutrition and oral health. In: Proceedings of Promoting Oral Health of Children with Neurodevelopmental Disabilities and Other Special Health Care Needs. May 4-5, 2001. Seattle, WA.

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Overweight (Woman) (1111) Categories: PG, BE/BP, WPP Defined as: 1. Pregnant Woman: Pre-pregnancy Body Mass Index (BMI) ≥ 25.0*. 2. Postpartum or Breastfeeding (less than 6 months postpartum) Woman: Pre-pregnancy Body Mass Index (BMI) ≥ 25.0*. 3. Breastfeeding (6 months or more postpartum) Woman: Current Body Mass Index (BMI) ≥ 25.0*. *Based on 2009 IOM Guidelines, the BMI weight categories used for adult women will be used for pregnant adolescent women as well. Justification: Maternal overweight and obesity are associated with higher rates of cesarean delivery, gestational diabetes mellitus, preeclampsia, and other pregnancy-induced hypertensive disorders, as well as postpartum anemia. Several studies have established an association between obesity and increased risk for hypertension, dyslipidemia, diabetes mellitus, cholelithiasis, coronary heart disease, osteoarthritis, sleep apnea, stroke and certain cancers. Since obesity can result from the over-consumption of excess calories from foods lacking in other nutrients, the obese woman may be malnourished. Procedure: Pregnant Woman: ● Use Table W for the procedure. Measure height to the nearest 1/8 inch. If the height fraction is between 1/8 and 3/8 of an inch, round down to the nearest whole number. If it is between 5/8 and 7/8 of an inch, round up to the nearest whole number. ● Obtain pre-pregnancy weight (self-report or from health care professional). Using the woman’s current height and pre-pregnancy weight, determine her weight status according to Table W. Record height and weight measurements in the woman’s record.

Breastfeeding or Postpartum Woman: ● For a postpartum or breastfeeding woman (less than 6 months postpartum) use current height and pre-pregnancy weight to determine weight status according to Table W. ● For a breastfeeding woman (6 months or more postpartum) use current height and weight measured to the nearest 4 ounces to determine weight status according to Table W. Record height and weight measurements in the woman’s record. ● Weight during the early postpartum period, when most WIC certifications occur, is very unstable. During the first 4-6 weeks, fluid shifts and tissue changes cause fluctuations in weight. After 6 weeks, weight loss varies among women. Prepregnancy weight, amount of weight gain during pregnancy, race, age, parity and lactation all influence the rate of postpartum weight loss. By 6 months postpartum, body weight is more stable and should be close to the prepregnancy weight. In most cases, therefore, prepregnancy weight is a better indicator of weight status than postpartum weight in the first 6 months after delivery. ● Review collected information about dietary and lifestyle practices or medical conditions that could lead to being overweight .

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Participant Focused Counseling: When a woman is determined to be overweight, review the related risks, and the benefits of change. Determine her willingness to explore change and discuss the steps the participant is willing to take to change to improve her weight status.

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Overweight/At Risk of Overweight (Infant, Child) (1141) Categories: IBE, IBP, IFF, C 1-4 Defined as: ● Overweight: BMI/age ≥ 85th to less than the 95th percentile on CDC growth chart for a child 2 to 5 years of age.

● At risk of overweight: an infant whose biological mother was obese at the time of conception, or any infant or child whose biological mother or father is obese.

Justification: Increasingly, attention is being focused on the need for comprehensive strategies that focus on preventing overweight/obesity and a sedentary lifestyle for all ages. Scientific evidence suggests that the presence of obesity in a parent greatly increases the risk of overweight in preschoolers, even when no other obvious signs of increasing body mass are present. Procedure: Child 2 to 5 years of age: 1. Obtain current height measured to the nearest 1/8 inch and weight measured to the nearest 4 ounces. Record measurements in the participant’s record. 2. Calculate BMI using the procedure in Table BMI.1. Plot the BMI value on the BMI/Age growth chart. 3. If the plotted point is between the 85th to below the 95th percentiles, assign the risk criterion. 4. Review collected information for routine dietary practices that could promote a faster rate of weight gain, such as drinking milk and other beverages from a baby bottle; excessive snacking (more than 3 snacks per day); or forcing the child to eat. Inquire about usual activity and television watching.

Procedure: Infant or Child ≤ 24 months of age: ● If infant is less than one year of age, ask biological mother for her height and weight at the time of conception. Or ● If the child is over one year of age, ask the biological mother for her height and weight. If mother is pregnant or has had a baby in the past six months, ask for her preconception height and weight. Or ● If the biological father is present at the certification, ask for his height and weight. If biological mother or father provides height and weight information, use Table BMI.2 to calculate BMI ≥30. ● Parents are not required to give their height and weight information.

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Participant Focused Counseling: Do not use the medical term “overweight” when discussing the child’s weight with the caregiver. Frame the Participant Focused Counseling discussion to make achieving the child’s optimal growth a shared goal of the WIC program and the parents/caregivers. Make clear that BMI/age between the ≥85th percentile and the 95th percentile is a medical condition that can be addressed. ● Educate parents/caregivers on behaviors that can lead to healthy body weight, including: o Recognizing fullness cues; o Offering a variety of nutritious foods; o Not overly restricting foods; o Offering the child foods lower in fat, such as 1% or fat free milk and low fat cheese, or selecting beans as well as peanut butter; o Comforting a child by holding, reading, or rocking instead of feeding; o Being active as a family; o Reducing screen and electronics time. ● Discuss the behavior changes parents/caregivers are willing to address. ● Discuss strategies that might work for the family. ● If parents/caregivers are willing, help them set a simple, measurable goal. ● Enter the goal in WOW.

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Pica Practice (425.9) Category: ALL Defined as: Self-reported by applicant/participant/caregiver. Routine ingestion of nonfood items (Pica). A participant identified with Pica practice should have Nutrition Care counseling. Give Lead and Pica brochures.

Justification: Pica is the compulsive eating of nonnutritive substances and can have serious medical implications. Non-food items usually include dirt, raw starch, and ice. Other items may include paper, uncooked rice, baking soda, baby powder, burnt matches, cigarette ashes, or coffee grounds. Pica is common in pregnancy affecting 14-44% of women in the U.S. Pica is not limited to any race, culture, socio-economic group, or geographic area. It occurs in all areas of the world but is most common in Africa ( Pregnant women in Ghana, where pica is common, indicated that most of them who consume non-food items do so to satisfy a craving or because they like the smell or taste. Some of the risk factors associated with pica include stress, cultural factors, low socioeconomic status, and an underlying mental illness. The cause of pica is not understood but some of the theories include that it relieves nausea and vomiting, or that it provides an essential nutrient that the woman is deficient in, most often iron or zinc. However, neither of these theories have been supported by research. It is more likely that malnutrition is the result of pica when nonfood items replace essential nutrients in the diet. Large intakes of non-food items can be harmful to a woman’s nutritional status. Substances like dirt may contain toxins like heavy metals (such as lead, cadmium, and arsenic), parasites, or other pathogens. Excessive consumption of dirt may also lead to intestinal obstructions or perforations. An emerging theory for the explanation of pica is that it serves useful immune functions by the ingested microorganisms stimulating the inborn immune system, resulting in less of a response to allergens and antigens. Eating dirt may be a means by which the gut diversifies its microorganism flora. However, pica during pregnancy can have negative consequences on the fetus. There have been case reports of intrauterine toxicity, lead poisoning that has caused long-term neurological disability and delayed childhood motor functions. The strength of the craving can be intense and has been compared to that for tobacco or alcohol. Recommending stopping pica often fails since the craving is so strong, but allowing the woman to smell the dirt and trading its consumption for a burned tortilla, toast or jicama may sometimes work. Pica has also been seen in children with obsessive-compulsive disorders, mental retardation, and sickle cell disease. Complications of this disorder include: iron-deficiency anemia, lead poisoning, intestinal obstruction, acute toxicity from soil contaminants, and infestations of parasitic worms.

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Procedure: During the nutrition assessment, establish that the woman or child frequently eats non-food items.

Participant Focused Counseling: ● Through open-ended questions, determine what nonfood items the participant eats. ● Ask what participant knows about the risks related to pica. ● Ask permission to share the known risks. ● Determine if the participant has had a blood lead test if child, pregnant, or breastfeeding. ● Share Pica handout and Lead handout. ● Suggest participant complete the lead risk review, then discuss with health care provider. ● Explore nutrition practices that help prevent lead absorption: o Evenly spaced meals throughout the day. o Foods high in calcium: milk, cheese, yogurt o Foods high in iron: lean meat, fish, poultry, eggs, peas and beans o Foods high in vitamin C: oranges and citrus fruit, berries and melons, dark green leafy vegetables, and potatoes.

● 427.3 References - Non-Food Ingestion ● Pica | National Eating Disorders Association https://www.nationaleatingdisorders.org/ ● Pica Cravings During Pregnancy | American Pregnancy Association ● https://americanpregnancy.org/healthy-pregnancy/is-it-safe/unusual-cravings-pica/

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Possibility of Regression (5011) Categories: ALL Defined as: A participant previously certified as eligible for the Program may be considered to be at nutritional risk in the next certification period if the CPA or CPPA determines there is a possibility of regression in nutritional status without the benefits that the WIC Program provides. Possibility of Regression may be used one time only following a certification period. Justification: On occasion, a participant’s nutritional status or dietary practices may be improved such that s/he rises above the cut-off value of the initial risk condition by the end of the certification period. This occurs most frequently with those conditions that contain specific cutoffs or thresholds, such as anemia or inappropriate growth. Removal of such individuals from WIC can result in a situation where the recently improved nutritional status deteriorates quickly, so that s/he re-enters the Program at equal or greater nutritional risk than before. WIC Program regulations permit State agencies to certify previously certified individuals who do not currently demonstrate a nutrition risk condition if they may regress to one or more previously identified risk conditions because they no longer receive WIC benefits. This provision may be used only once following a certification period. Such participants shall not be considered to be at nutrition risk based on the possibility of regression for consecutive certification periods.

Procedure: Competent Professional Authorities and other certifying staff should keep in mind that every nutrition risk condition does not necessarily lead itself to the possibility of regression. For example, gestational diabetes or gingivitis of pregnancy are not conditions to which a new mother could regress, since they are directly associated with pregnancy, and the breastfeeding or non-breastfeeding women cannot regress to being pregnant if she is no longer receiving WIC benefits.

When recertifying a participant, if no other risk criterion can be found, Possibility of Regression may be used as a risk criterion for risks such as, but not limited to ● Underweight

● Overweight (child age 2 and older, only) ● Risk for Overweight (child age 2 and older, only)

● Low Hemoglobin/Hematocrit

● Elevated Blood Lead ● Dental Problems ● Failure to Thrive ● Nutrition Practice Nutrition-related Medical Condition

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Participant Focused Counseling: WIC staff can: ● Review and congratulate participant/caregiver on steps taken to achieve the improvement. ● Ask what behaviors should be continued to maintain the improvement. ● Invite participant/caregiver to share ideas on additional steps she might take to make even greater improvements. ● Ask what, if any, ideas or suggestions she might want from the certifier.

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Pregnancy at a Young Age (3311) Categories: PG, BE/BP, WPP Defined as: Conception occurs on or before 20 years of age. Justification: Pregnancy in women under the age of 20 is associated with anemia, eclampsia, postpartum depression, maternal death, low birth weight, preterm delivery and stillbirth. Adolescent/teen pregnancy is associated with lower socioeconomic and education status and increased health care costs. As the adolescent mother has not yet completed her own growth, there may be suboptimal nutrient levels available to support both her growth and that of the fetus.

Studies indicate that there is competition for nutrients between the still growing adolescent mother and her rapidly developing fetus which is also known as ‘nutrient partitioning’. This may result in compromised growth and development of the mother and/or fetus. Mother at Increased Risk of: Infant at Increased Risk of” Repeat teen pregnancy Low or very low birth weight Sexually transmitted disease Congenital malformations Anemia Sudden Unexplained Infant Death (SUID) Caesarian delivery Low Apgar score Lack of early prenatal care Prematurity Preeclampsia Developmental delays Substance misuse Behavior disorders Not completing high school

Socioeconomic disadvantage

Depression (compared to adults)

Nutritional Impact Adolescence is a period of rapid growth and development and increased nutritional needs. Pregnancy further increases energy and nutrient demands. Nutritional surveys across the lifespan indicate that adolescents have the highest nutritional deficiencies due largely to unhealthy eating. A systematic review reported that the nutrient intakes of pregnant adolescents appeared to be low in several nutrients (discussed below) which are vital for fetal growth and development during pregnancy.

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Iron Iron deficiency anemia is one of the most common nutrient deficiencies during pregnancy, and it is amplified for pregnant adolescents. According to the Centers for Disease Control and Prevention (CDC) non-pregnant females 12 to 19 years of age, 9- 11% had iron deficiency, and 2-3% had iron deficiency anemia. Compared to pregnant adult women, pregnant adolescents have higher iron requirements as adolescents experience rapid expansion of blood volume due to normal adolescent growth. The CDC recommends supplements of 15-30 mg per day of iron for most women during pregnancy. However, pregnant adolescents who are diagnosed with iron deficiency are often prescribed doses of iron as high as 60-120 mg/day. The risk of iron deficiency increases further with each additional pregnancy due to the demand of normal growth, pregnancy, and the inability to replace blood loss experienced in childbirth. Calcium In a pregnant adolescent, the maternal diet needs to contain enough calcium to mineralize two skeletons, as an adolescent is still in the process of attaining peak bone mass and continued skeletal growth. Low calcium intake in adolescents is associated with low bone density and increased later risk of osteoporosis for the mother. The Recommended Daily Allowance (RDA) for calcium for adolescents is 1300 mg per day; however, studies indicate that 800 mg per day is the average for 12-19 year old females Although the RDA for calcium does not increase during pregnancy, if an adolescent has inadequate calcium intake during pregnancy it can lead to negative consequences for both the mother and infant, including increased risk of maternal hypertension and preeclampsia. Folate During pregnancy, folic acid is needed for cell division; during lactation it is required for the synthesis and secretion of milk. If the dietary supply of folate is low, circulating levels begin to decline during the fifth month of pregnancy and continue to decline until several weeks after delivery, and may result in intrauterine growth restriction, congenital anomalies, or spontaneous abortion. Although prenatal vitamins contain folic acid, vitamin adherence has been reported to be low among adolescents. Smoking and alcohol use both lower red blood cell folate concentrations.

Vitamin B12 Vitamin B12 is essential for normal neurological function and red blood cell formation during pregnancy. Low levels of vitamin B12, especially in pregnant adolescents, may lead to spontaneous abortion, pregnancy loss, intrauterine growth restriction, low birthweight (<2500 g), and neural tube defects. Folate supplementation may mask the adverse effects of low vitamin B12. Therefore, along with adequate supplementation of folate, pregnant adolescents should have their vitamin B12 status monitored. Vitamin B12 is mainly found in animal sources (meat and dairy products), therefore pregnant teens who follow strict vegetarian/vegan diets or have other diet restrictions are at risk of deficiency. Some studies have indicated that daily maternal supplementation with 50 μg of daily oral vitamin B12 during pregnancy and early lactation significantly improved maternal plasma and breastmilk measures of vitamin B12 status, as well as multiple measures of infant vitamin B12 status.

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Zinc Zinc is important before pregnancy for reproductive health and immune function. It also plays a vital role during embryo development, fetal growth, and lactation, increasing the zinc requirement during pregnancy and lactation. Pregnant adolescents are vulnerable to developing zinc deficiency. Additionally, low iron intake is linked with inhibition of zinc absorption. Therefore, health care providers may advise pregnant adolescents to take both a zinc and iron supplement. Zinc supplementation may have a modest effect on reducing the risk of preterm birth. Weight Gain during Teen Pregnancy The National Academies of Sciences, Engineering and Medicine guidelines recommend maternal weight gain of between 11-40 lbs. during pregnancy based on pre-pregnancy body mass index (BMI). There are no specific/separate weight gain recommendations for teen pregnancy. The risk of preterm delivery and low birthweight delivery decreases with adequate weight gain in pregnancy. Studies indicate that pregnant adolescents who have similar pregnancy weight gains as adult counterparts and deliver low birthweight infants may have experienced weight gains attributed to normal adolescent growth and development rather than appropriate pregnancy weight gains. Psychosocial Impact Pregnancy may lead to increased psychological stress for the adolescent and may increase the risk of postpartum depression and long-term depression. Psychological and emotional stress may be related to additional perinatal and economic responsibilities, adjustment in lifestyle, and changes in the family dynamic. The impact of any stress may continue into adulthood or be lifelong. Studies suggest that adolescents who stay in school to age 18 are less likely to give birth than those who leave school with less than 12 years of education. Interventions that may help adolescent mothers stay in school are more likely to complete high school during pregnancy and postpartum. Strong school connections, family assistance, or commitment in completing educational goals may also reduce multiparity in adolescents. Implications for WIC Nutrition Services WIC staff can provide the following nutrition services to women < 20 years of age: ● Educate on how the WIC food package helps to provide important nutrients needed during pregnancy and how to incorporate WIC foods into their total diet to get a balanced diet. ● Promote the mom-focused WIC Breastfeeding Support website to learn more about breastfeeding. ● Encourage: ● Adequate prenatal care. ● Consumption of prenatal vitamins, as recommended by their health care provider. ● Consumption of adequate amounts of iron, zinc, and calcium-rich foods in order to meet the recommended intake.

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● Advise that the pregnant adolescents speak with their healthcare providers to ensure that their folate and vitamin B12 levels are within recommended range. ● Discuss infant feeding plans and provide information to support breastfeeding goals, as appropriate.

Participant Focused Counseling: ● Review collected information to identify lifestyle or dietary practices that may prevent adequate and appropriate food intake. ● For the adolescent mother who is breastfeeding, assess knowledge and skills for breastfeeding success. ● Review the related risks, and the benefits of change. ● Determine her willingness to explore change. ● Discuss the steps the participant is willing to take to change/ improve her nutritional status. ● Review strategies for making the change. ● If willing, help her set a simple, measurable goal. ● Enter the goal in WOW.

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Pregnant Woman Currently Breastfeeding (3381) Category: PG Defined as: A breastfeeding woman who is now pregnant. This risk factor must be manually assigned in WOW and a note must be written to document it. CPA can provide nutrition care counseling. Refer to IBCLC/DBE if breastfeeding high risk intervention is needed. Justification: Breastfeeding during pregnancy can influence the mother’s ability to meet the nutrient needs of her growing fetus and breastfed infant. Pregnancy hormones generally cause the expectant mother’s breastmilk volume to decline and composition to change. If the mother conceived while her nursing infant was solely or predominantly breastfed, the infant could fail to receive adequate nutrition. Nipple tenderness could become a problem. Oxytocin released during breastfeeding might trigger uterine contractions and premature labor, and this is a concern especially if the pregnant participant is at risk for premature labor. Procedure: ● Determine if the pregnant woman is breastfeeding another child. ● A woman who is pregnant and breastfeeding an infant or child should be advised to let her healthcare provider know that she is currently breastfeeding. For low-risk pregnancies, this is typically not a concern. If this is a high-risk pregnancy or the individual is already at risk for premature labor, her healthcare provider might advise her to discontinue breastfeeding. It is important that she talk with her health care professional to learn the signs of premature labor. ● The breastfed infant of a pregnant woman who is breastfeeding should be assessed for adequate growth.

Participant Focused Counseling: ● Review collected information to identify lifestyle or dietary practices that may prevent adequate and appropriate food intake. ● Discuss the steps the participant is willing to take to ensure her nutritional status. ● Review strategies for making the change. ● If willing, help her set a simple, measurable goal. ● Enter the goal in WOW.

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Preterm or Early Term Delivery (1421) Categories: IBE, IBP, IFF, C-1 Defined as: Preterm and early term delivery are defined as follows: • Preterm: Delivery of an infant born ≤36 6/7 weeks gestation. • Early Term: Delivery of an infant born ≥37 0/7 and ≤38 6/7 weeks gestation.

An infant identified as preterm or early term should have Nutrition Care counseling. Justification: Prematurity affects about 12% of all live births in the U.S., and about 50% of these preterm births were preceded by preterm labor. In 2011, the annual rate of premature births in the United States reached 11.7%, nearly two times the rate in European nations. Preterm births also account for approximately 70% of newborn deaths and 36% of infant deaths. Factors that increase the risk of preterm delivery include low socioeconomic status, nonwhite race, maternal age of ≤ 18 years or ≥ 40 years, low pre-pregnancy weight, history of prior preterm births, low weight gain during pregnancy, maternal obesity, hypertension, diabetes, or sexually transmitted diseases Despite advances in neonatal care, preterm birth remains a leading cause of infant death in the United States. Preterm infants may have health problems because their organs did not have enough time to develop in the womb. Babies that are born too early may have a number of health conditions, including: • Low or very low birth weight • Increased caloric needs • Feeding difficulties due to a lack of reflexes for sucking and swallowing • Immature digestion and impaired absorption of carbohydrates and lipids • Breathing problems like chronic lung disease/ bronchopulmonary dysplasia and apnea • Cerebral palsy, an impairment of the brain that controls movement and muscle tone • Developmental delay and poorer cognitive function • Vision problems like retinopathy of prematurity (ROP), which may cause blindness • Behavioral problems and psychiatric disorders • Increased risk for necrotizing enterocolitis (NEC) due to their immature gastrointestinal systems

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• Increased risk for Sudden Infant Death Syndrome (SIDS) • Temperature control problems. • Heart problems, Hypoglycemia, Hearing problems, anemia and jaundice • Immature immune systems, which may result in infections.

The Benefits of Breastfeeding Preterm infants often need special medical care in a neonatal intensive care unit (NICU) and may need to stay there for days or even months. Breastfeeding is recommended as the normative standard for infant feeding and nutrition for all infants, especially preterm babies. Breastfeeding preterm infants has been associated with positive health outcomes for these infants, including: • Improved motor maturity and cognitive ability • Reduced risk of NEC • Reduced risk of ROP and retinal detachment

Additionally, mothers of preterm infants produce milk that is designed to meet the baby’s particular nutritional needs during the first few weeks of life. It is higher in protein and minerals, such as salt, and contains different types of fat that are easier to digest and absorb compared to fats in the milk of mothers of full term babies. The fat in human milk also helps to enhance the development of the baby’s brain and neurologic tissues, which is especially important for premature infants. Human milk is also easier for babies to digest than infant formula and avoids exposing the baby’s immature intestinal lining to the cow’s milk proteins found in premature infant formula. Preterm infants who are breastfed are less likely to develop intestinal infections than babies who are formula fed, and the colostrum produced in the first few days contains high concentrations of antibodies that will help the baby fight infection.

Breastfeeding preterm infants, especially if they are in the NICU, may present unique challenges for breastfeeding dyads. These mothers will benefit from extra breastfeeding support due to the delay of direct breastfeeding, reliance on breast pumps, and the stress of having a sick newborn. Even if the baby cannot breastfeed directly from the breast at first, the mother can be encouraged to express her milk to ensure that her supply is maintained. Supportive care for infants in the NICU may include the use of a feeding tube. Expressed human milk can be passed through the tube, therefore, it is important for the mother to discuss her feeding decisions with her baby’s doctor. Preterm infants sometimes need additional calories and nutrients to facilitate adequate growth, and in such cases a human milk fortifier may be prescribed by a health care provider.

Preterm infants who are not breastfed may require the use of a formula higher in calories and nutrients to support their growth. According to the American Academy of Pediatrics (AAP), soy formulas are typically not recommended for low birth weight preterm infants, as their use may result in less weight gain and lower serum albumin and phosphorus levels than cow’s milk-based formulas.

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In addition to breastfeeding, skin-to-skin care or kangaroo care (holding your baby naked or in just a diaper on your bare chest), can help preterm infants breathe better, gain weight, keep their body at the right temperature, and prepare them for breastfeeding. All caregivers can provide skin-to-skin care, not just the mother. Late Preterm Birth Infants born at 34 0/7 through 36 6/7 weeks gestation, called late preterm infants, are sometimes mistaken for term infants since their size and weight may be similar. However, caregivers, health care providers, nutritionists, and lactation consultants must be aware that these babies are physiologically and metabolically immature. In addition to the health conditions previously mentioned for preterm infants, it is important to be aware that late preterm babies have an increased risk of morbidity and mortality which is often related to feeding problems. Due to their immaturity, late preterm infants may have more challenges with breastfeeding because they tire easily and have less stamina, which results in greater difficulty with latching, sucking, and swallowing. Mothers of late preterm infants will benefit greatly from timely lactation assessment and support since feeding difficulties, slow weight gain, failure to thrive, hypoglycemia, and jaundice are very common in these babies. Growth Patterns Preterm infants have different patterns of growth compared to term infants. Plotting the growth of preterm infants using their adjusted gestational age is an essential component of care until they reach 24 to 36 months of age. (See the Clarification section for more information on how to determine adjusted gestational age.) Most preterm infants, however, show catch-up growth in weight, length, and head circumference after their initial postnatal growth failure. If catch-up growth occurs, it usually starts early in the first months of life and is often achieved within the first years of life. The effects of preterm birth can continue beyond infancy. Children who were born prematurely are at an increased risk for the following: • Neurodevelopmental problems • Intellectual/cognitive impairments, which can lead to learning disabilities and the need for special education services • Motor problems

• Feeding difficulties such as problems with chewing and swallowing, late development of feeding skills, food refusal, eating behavior problems, and poor appetite

• Emotional problems such as anxiety and depression • Behavioral concerns such as attention problems and hyperactivity

Procedure:

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All preterm infants and children (up to 2 years of age) who have reached the equivalent age of 40 weeks gestation, shall be assessed for growth using the Centers for Disease Control and Prevention (CDC) Birth to 24 Months gender specific growth charts adjusting for gestational age as follows:

1. Document the infant/child’s gestational age (at delivery) in weeks. (Mother/caregiver can self-report, or referral information from the medical provider may be used.) 2. Subtract the child’s gestational age in weeks from 40 weeks (gestational age of term infant) to determine the adjustment for prematurity in weeks. 3. Subtract the adjustment for prematurity in weeks from the child’s chronological postnatal age in weeks to determine the child’s gestation-adjusted age.

Example: Randy was born prematurely on March 19, 2011. His gestational age at birth was determined to be 30 weeks based on ultrasonographic examination. At the time of the June 11, 2011, clinic visit, his chronological postnatal age is 12 weeks. What is his gestation-adjusted age?

30 = gestational age in weeks 40 - 30 = 10 weeks adjustment for prematurity 12 - 10 = 2 weeks gestation-adjusted age His measurements would be plotted on a growth chart as a 2-week-old infant. Note: Preterm infants (< 36 6/7 weeks gestation) who have not reached the equivalent age of 40 weeks gestation may be assessed for growth using a growth chart for low birth weight (LBW) or very low birth weight (VLBW) infants (e.g., Infant Health and Development Program [IHDP]) consistent with the protocols of the local medical community in which the WIC clinic operates. The CDC does not recommend the use of the CDC Growth Charts for preterm infants who have not reached the equivalent age of 40 weeks gestation. Participant Focused Counseling: ● The goals of nutrition counseling are to assist and support the caregiver in establishing and maintaining feeding practices that support the optimal growth of the infant. ● The caregiver may need to be advised that timetables for feeding solid foods may not apply to a premature infant. She should be advised to consult with her infant’s health care professional regarding when to offer solid food. ● Review collected information for appropriateness of feeding practices.

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Recent Major Surgery, Physical Trauma, Burns (3529) Categories: ALL Defined as: major surgery (including cesarean sections), physical trauma or burns severe enough to compromise nutritional status. Any occurrence: ● Within the past two (≤ 2) months may be self-reported. ● More than two (≥ 2) months previous must have the continued need for nutritional support diagnosed by a physician or a health care provider working under the orders of a physician. A participant determined to have had a recent major surgery, physical trauma, or burns should be referred to the CPA for Nutrition Care counseling. C-section is not usually designated as high risk Justification: The body’s response to injuries increases nutrient requirements needed for recovery and can lead to malnutrition. These changes increase calorie and protein needs, as well as many vitamins, minerals, fatty acids, and amino acids. Proper wound healing is critical in recovery. Even after a wound is closed, metabolic rate and need for additional nutrition can remain high. Factors that can prevent proper wound healing or can increase the time needed for a wound to heal include: malnutrition prior to the event, infections, diabetes, poor blood flow, obesity, age, heavy alcohol use, stress, medications, and smoking. Because healing is complex and affected by many factors, there is no set recovery time based only on the type and severity of injury. For some it could take a couple of weeks, for others it may take months. Major Surgery and Wound Healing Major surgeries are those that involve a risk to the life of the individual and include operations on organs within the body. Removal of a portion of the large or small intestine, heart surgery, and bariatric surgery are examples. Cesarean sections are considered a major surgery, and therefore, require additional assessment and education in the WIC clinic. In the US, the rate of cesarean delivery rose from about 20% to about 30% for singleton births in 2011. Reasons for cesarean delivery include multiple pregnancy, failure of labor to progress, medical concerns for the infant, problems with the placenta, a large infant, breech position, maternal infections, and medical conditions in the mother (diabetes, high blood pressure).

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Physical Trauma Physical trauma can include fractures, wounds, hospitalization from blunt force trauma, penetrating trauma, and trauma from surgery. Physical trauma can also result from domestic or child abuse, with additional acute or ongoing psychological and emotional trauma that result in poor appetite, poor food choices, and using food for coping.

Burns Burns can be caused by heat (including hot surfaces, fires, and hot liquids), chemicals, electricity, sunlight, or nuclear radiation. A first-degree burn only affects the outer layer of the skin (epidermis). A second-degree burn damages the epidermis, and the dermis (the layer beneath). Third-degree burns damage the epidermis, dermis, and the tissue under the skin.

Burns are also classified by the size of the area burned, known as Percent Total Body Surface Area or TBSA. The larger the area of the burn, the greater the risk for infection and fluid loss. Inhalation burns occur inside an individual’s lungs and internal organs.

Implications for WIC Nutrition Services Most surgeries, physical traumas, and burns are unexpected. The education and supplemental food that WIC provides can help ensure that the individual is in good nutritional health prior to the surgery, physical trauma, or burn. Following the event, the individual will be at increased nutritional risk until the injury has completely healed. WIC staff can improve outcomes by: ● Reviewing nutritional intake to assure that vitamins and minerals meet the RDAs (unless the amounts that exceed the RDAs are recommended by their health care provider). ● Reviewing calorie and protein intake to be sure they preserve lean muscle mass and body weight. ● Recommending the participant to discuss a multivitamin supplement with the health care provider when diet cannot meet the RDAs for vitamins and minerals. ● Referring to community resources for smoking cessation, support groups, food assistance, and safe living environments (in cases of physical abuse). ● Referring to a lactation specialist if women experience difficulty breastfeeding following a cesarean section.

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Recipient of Abuse (9011) Categories: All Defined as: an individual who has experienced physical, sexual, emotional, economic, or psychological maltreatment that may frighten, intimidate, terrorize, manipulate, hurt, humiliate, blame, injure, and/or wound the individual. The experience of abuse may be self-reported by the individual, an individual’s family member, or reported by a social worker, healthcare provider, or other appropriate personnel. Types of abuse relevant to the WIC population include, but are not limited to, the following: • Domestic violence: abuse committed by a current or former family or household member or intimate partner. • Intimate partner violence (IPV): a form of domestic violence committed by a current or former intimate partner (i.e., spouse, boyfriend/girlfriend, dating partner, or ongoing sexual partner) that may include physical violence, sexual violence, stalking, and/or psychological aggression (including coercive tactics). • Child abuse and/or neglect: any act or failure to act that results in harm to a child or puts a child at risk of harm. Child abuse may be physical (including shaken baby syndrome), sexual, or emotional abuse or neglect of an infant or child under the age of 18 by a parent, caretaker, or other person in a custodial role (such as a religious leader, coach, or teacher).

An employee of a local department who, in the course of employment, receives a report of suspected child abuse or neglect communicated formally or informally to the employee, or who otherwise has reason to suspect that child abuse or neglect has occurred, shall immediately report the information to the Child Protective Services unit within the local department for prompt investigation. Justification: Abuse is a serious public health problem with numerous individual and societal consequences. Women and children who experience abuse often suffer from immediate and long-term physical and emotional health consequences. Although abuse is prevalent, it is underreported because recipients are financially dependent on the abuser, or fear future abuse, stigmatization, and shame. Screening and evaluation for abuse is inconsistent in the medical community.

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Impact on Maternal Health Data from the 2015 National Intimate Partner and Sexual Violence Survey (NISVS) say about 1 in 3 US women experienced contact sexual violence, physical violence, and/or stalking by an intimate partner in their lifetime. The highest rates of IPV are generally experienced by women between the ages of 18 to 34 and nearly three quarters of all women recipients of IPV first experienced IPV before the age of 25. According to the NISVS, some ethnic minorities are disproportionately affected by IPV.

Lifetime prevalence of IPV among women of various ethnicities: ● Multi-Racial, Non-Hispanic –

57% ● American Indian/Alaska Natives, Non-Hispanic 48% ● Black, Non-Hispanic

45% ● White, Non-Hispanic

37% ● Hispanic

34% ● Asian or Pacific Islander

18%

Higher rates of IPV are experienced by immigrant women, women with disabilities, LGBTQ women, women veterans, and women with substance use disorders. Intimate Partner Violence during the perinatal period is more common than other maternal health conditions like preeclampsia or placenta previa, but it receives considerably less attention. Most studies found that 3-9% of women experience abuse during pregnancy, rising to 12% after delivery. Studies focusing on low-income women suggest up to 50% experience abuse. Women using WIC services are more likely than other low-income women to experience abuse.

Women who experience abuse are at greater risk of: ● Chronic pain, like fibromyalgia, joint disorders, facial and back pain. ● Cardiovascular problems like hypertension. ● Gastrointestinal disorders, like stomach ulcers, appetite loss, abdominal pain, digestive problems. ● Neurological problems, like severe headaches, vision and hearing problems, memory loss, traumatic brain injury. ● Participating in risky health behaviors like smoking, alcohol, and substance use, putting them at greater risk for unintended pregnancies and sexually transmitted infections. ● Inadequate prenatal care, or not getting care until the third trimester. ● Being overweight or underweight, not gaining enough weight if 35 years or older, and gaining too much weight if 20-34 years old. ● Suffering mental health issues, including depressive symptoms and PTSD.

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Despite the detrimental effects of IPV, it is often under-reported and not commonly evaluated during pregnancy. The US Department of Health and Human Services and the American College of Obstetrics and Gynecologists recommend that physicians screen all women for IPV during obstetric care, beginning at the first prenatal visit, at least once per trimester, and at the postpartum checkup.

Impact on Infant Health IPV experienced by the mother can have severe impacts on neonatal health, putting the infant at higher risk of low birth weight (LBW), preterm birth (PTB), or being born small for gestational age (SGA). IPV has also been shown to contribute to increased likelihood of spontaneous abortion, fetal loss, and neonatal death. These complications may be caused by several mechanisms, including blunt physical trauma to the mother, negative maternal coping behaviors (e.g., smoking, drug use, or alcohol use), inadequate maternal nutrition, isolation, limited access to prenatal care, and elevated physical or psychological stress levels.

Ending the domestic violence can have a positive influence on infant weight gain. Babies who are SGA are at an increased risk of early childhood developmental and behavioral problems and of developing coronary heart disease, stroke, non-insulin-dependent diabetes mellitus, adiposity, and metabolic syndrome in adulthood.

Shaken Baby Syndrome (SBS) or Abusive Head Trauma (AHT) is the leading cause of physical child abuse death in the United States. Babies from birth to 1 year, especially babies ages 2 to 4 months, are at greatest risk of injury from shaking because they cry more frequently and are easier to shake than older children. Factors that increase the likelihood of SBS are having unrealistic expectations about child development and child-rearing, having been abused or neglected as a child, being a victim or witness to domestic violence, and being a single parent.

Breastfeeding Limited studies concluded that IPV exposure appears to associate negatively with breastfeeding outcomes, including decreased breastfeeding initiation, early cessation of exclusive breastfeeding, and shortened duration of exclusive breastfeeding. However, high-quality research remains limited. Because exposure to IPV is not a strong predictor of breastfeeding outcomes based on existing literature, WIC staff should provide breastfeeding support to help participants meet their individual breastfeeding goals.

Impact on Child Health There are many forms of abuse and neglect. Per the CDC, the most common forms are: ● Physical abuse – the intentional use of physical force that can result in physical injury. Examples include hitting, kicking, shaking, burning, or other shows of force against a child.

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● Sexual abuse – involves pressuring or forcing a child to engage in sexual acts. It includes behaviors such as fondling, penetration, and exposing a child to other sexual activities. ● Emotional abuse – refers to behaviors that harm a child’s self-worth or emotional well-being. Examples include name calling, shaming, rejection, withholding love, and threatening. ● Neglect – the failure to meet a child’s basic physical and emotional needs. These needs include housing, food, clothing, education, and access to medical care.

According to data from National Survey of Children’s Exposure to Violence, approximately 1 in 7 U.S. children (0 – 17 years old) experienced child abuse and/or neglect in the reported year. Children with low socioeconomic status face abuse and neglect five times more often than higher status families. According to the National Child Abuse and Neglect Data System, 75% of the 3.4 million child and abuse neglect referrals in 2011 were classified as neglect, with the majority of children being under 3 years old. Neglect can affect children for their lifetime depending when, how often, and how severely it occurs. Abused children often have moderate to severe malnutrition because food is withheld, leading to compromised nutrition and failure to thrive (FTT). Even when not abused themselves, children who witness aggression or IPV can suffer symptoms of post-traumatic stress disorder, like bed- wetting or nightmares, allergies, asthma, gastrointestinal problems, headaches, and the flu. Abused children can have physical injuries like cuts, bruises, broken bones, and emotional and psychological problems. Child abuse and neglect are considered adverse childhood experiences (ACEs). ACEs can have negative, lifelong effects on health, including disruption to healthy brain development, affecting social development, and compromising the immune system. Research shows that exposures to ACEs increases the risks of injury, sexually transmitted infections, including HIV, mental health problems, maternal and child health problems, teen pregnancy, involvement in sex trafficking, and a wide range of chronic diseases such as cancer, type 2 diabetes, heart disease, and suicide. Child abuse and neglect are just a portion of potential ACEs that can occur in childhood.

Procedure, Woman: Homicide is the leading cause of pregnancy-associated death in Maryland. The majority were intimate partner homicides. ● Discreetly place intimate partner violence posters and shoe cards in WIC ladies’ rooms, not waiting rooms where they can be viewed by abusing partners. ● Ask all WIC participants the WOW question concerning fear for personal or child safety. ● Assure confidentiality. ● Ask in a private place when partner is present. ● If the answer is positive, educate on the dangers of partner violence, and offer discreet help. ● If in imminent danger, offer to make the phone call to connect the participant to the local domestic violence service provider before

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she leaves the WIC clinic, or connect with the Maryland Network Against Domestic Violence: https://mnadv.org/ which provides comprehensive domestic violence services in each county. ● If the participant is not ready to act, offer discreet information for follow up, such as getting a shoe card from the ladies room, or calling the National Domestic Violence Hotline: 1-800-799-SAFE (7233).

Procedure, Infant or Child: Maryland law requires that: ● An individual who has reason to believe that a child has been abused or neglected shall immediately notify a local law enforcement agency or a local department. ● An employee of a local department who, in the course of employment, receives a report of suspected child abuse or neglect communicated formally or informally to the employee or who otherwise has reason to suspect that child abuse or neglect has occurred, shall immediately report the information to the Child Protective Services unit within the local department for prompt investigation.

Implications for WIC Services WIC staff can provide the following nutrition services to participants who experience abuse: • Provide a safe and supportive environment for participants who may be experiencing or have experienced abuse. • Encourage pregnant women to attend all prenatal appointments with their health care provider and explain the importance of early and adequate prenatal care. • Offer tailored breastfeeding support catered to the participant’s specific needs and concerns. • Encourage parents to attend local parenting classes or parent training programs. • Refer the participant to their family case manager, if available, and/or to services and resources in their community that provide support to victims of abuse. • Refer participants to national resources such as: • National Domestic Violence Hotline: 1-800-799-SAFE (7233). This hotline is staffed with trained counselors 24 hours a day and provides callers with crisis counselors, safety planning and assistance in finding resources, such as shelter. A secure, confidential online chat option is also available. • Directory of Crime Victim Services. This website provides a directory of programs and organizations that can help victims of crime.

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• Rape, Abuse and Incest National Network (RAINN): 1-800-656-HOPE (4673). This national hotline provides counseling and assistance to victims of sexual violence and their families and friends from trained counselors who are available 24 hours a day. • National Clearinghouse for the Defense of Battered Women (NCDBW): 1-800-903- 0111 ext. 3. This national organization provides technical assistance to abused women facing charges related to their abuse. • Childhelp National Child Abuse Hotline: 1-800-4-A-CHILD (1-800-422-4453). This hotline offers information to parents seeking help for child abuse, individuals who suspect child abuse is occurring and those needing prevention tips. Professional counselors are available to provide support and referrals to emergency and social services. Their website also lists Child Protective Services in each state.

Participant Focused Counseling: ● Assess the level of danger to the participant/child with open-ended questions. ● Educate about the risks of intimate partner violence. ● Offer to provide information or make the necessary contact with a domestic violence support network.

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Short Interpregnancy Interval (3321) Categories: PG, BE/BP, WPP Defined as: An interpregnancy interval of less than 18 months from the date of a live birth to the conception of the subsequent pregnancy. Note: this risk is specific to live births and does not include miscarriage or stillbirth in the calculation. Justification Adverse maternal and infant health outcomes have been associated with short interpregnancy intervals. An interval of 18-24 months has been associated with the lowest risk. Outcomes associated with short IPI have included perinatal and neonatal complications such as preterm birth, low birth weight, small for gestational age, birth defects, and autism. Findings from a small pilot study found coordination of primary health care and social support services reduced adverse pregnancy outcomes and the average number of pregnancies conceived within 18 months among low income women who previously delivered a very low birth weight baby. A 2007 US survey found that, among childbearing age women, those aged 18-24 years were least aware of the need for folic acid prior to pregnancy and least likely to report daily use of supplements containing folic acid. Only 17% of women age 18-24 years were likely to hear about folic acid from their health care provider. Referral for family planning services may be appropriate. Procedure: Apply as follows: ● Pregnant woman: current pregnancy ● Breastfeeding or postpartum woman: most recent pregnancy o Determine if the woman has been pregnant and had a live birth before. o Determine the time interval between the 2 pregnancies: o Obtain the date when her most recent baby was born. For a pregnant woman, the date will be for the birth preceding this current pregnancy. For a breastfeeding or postpartum woman, the date will be for the birth that preceded her most recent pregnancy.

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o Obtain the date of the last menstrual period prior to this current pregnancy for a pregnant woman. Obtain the date of the last menstrual period for the most recent pregnancy for a breastfeeding or postpartum woman. o Estimate the date of conception as occurring on the 14th day following the first day of the last menstrual period. o Subtract the date of the last live birth from the date of conception. The difference is the time interval between the 2 pregnancies.

Participant Focused Counseling: Through open ended questions and discussion, determine the participant’s concerns and interest in: ● Health care referrals for family planning, early prenatal care, and folic acid supplementation. WIC can help to reduce the risk of adverse pregnancy outcomes by: o Encouraging postpartum women and their partners to meet with their health care provider to discuss developing a reproductive plan and birth spacing as appropriate. o Encouraging folic acid supplementation. o Encouraging healthful eating by following the Dietary Guidelines for Americans. ● Education: o Given that half of all pregnancies nationwide are unintended, the above areas have the potential to improve health outcomes for women, infants, and children, o Discuss the topics of interest or concern to the participant using the WIC Guide to a Healthy New Mom, including her interest in easy ways to use her WIC foods.

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Short Stature/At Risk of Short Stature (1211) Categories: IBE, IBP, IFF, C 1- 4 Defined as: ● Length/age ≤ 5th percentile, CDC/ WHO growth chart Birth to ≤ 24 months, or ● Stature/Age ≤ 10th percentile, CDC growth chart 2 to 5 years of age.

Explanation: ● CDC uses the cut off value of ≤ 2.3 percentile length for age to define short stature in an infant or child from Birth to < 24 months and ≤ 5th percentile for a child 2 to 5 years. ● CDC uses ≤ 5th percentile to define at risk of short stature in an infant or child from Birth to < 24 months, and > 5th percentile to ≤ 10th percentile for a child 2 to 5 years.

Justification: Short stature may be an indicator of chronic undernutrition related to the lack of total calories and to a poor quality of diet that is low in nutrients such as protein, zinc, vitamin A, and calcium. Short stature may also result from disease conditions such as endocrine disturbances or from congenital conditions such as Fetal Alcohol Syndrome. Participation in WIC is associated with improved growth in height (as well as weight). Procedure: ● Obtain current length or height measured to the nearest 1/8 inch. Record measurement in the participant’s record. ● Determine the exact age of the infant or child. When plotting on the 2 to 5 years CDC growth chart, round the child’s age to the nearest whole month. ● For an infant or child < 24 months of age who was born at 37 weeks or earlier, adjust the age before plotting, following the procedure in Table GAA. ● Plot Length for Age on the CDC/WHO 0 to < 24 months growth chart. If the plotted point lies at or below the 5th percentile, assign the risk criterion. ● Plot Stature for Age on the CDC 2 to 5 years growth chart. If the plotted point lies at or below the 10th percentile, assign the risk criterion. ● Review collected information for possible causes of short stature. Inquire about the parent’s height.

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Participant Focused Counseling: ● Review collected information to identify feeding or dietary practices that may prevent adequate and appropriate food choices for the infant/child. ● Discuss the steps the participant is willing to take to ensure the child’s nutritional status. ● Review strategies for making the improvements. ● If willing, help her set a simple, measurable goal. ● Enter the goal in WOW.

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Slowed/Faltering Growth Pattern (1135) Categories: IBE, IBP, IFF Defined as: ● Infants Birth to 2 weeks: Excessive weight loss after birth, ≥ 7% birth weight loss ● Infants 2 weeks to 6 months of Age: Any weight loss, using 2 separate measurements taken at least 8 weeks apart

An infant determined to have slowed/faltering growth pattern should have Nutrition Care counseling, and, if breastfeeding, be referred to the IBCLC/DBE. Justification: Growth faltering is a growth rate below what is appropriate for an infant’s age and sex. It can affect length, weight, and head circumference, resulting in values lower than expected. Growth faltering may include weight faltering (a drop in weight-for-age) or slowed growth where both weight and length growth are slower than expected, for example, a drop in weight after a minor illness. (Note: what appears to be growth faltering could be due to a measurement or plotting error.) Normal Growth Patterns Understanding normal infant growth is important, because infants gain weight differently depending on how they are fed. Breastfed infants gain weight rapidly during the first three or four months of life, then the rate of growth slows. Formula fed infants, by comparison, grow more slowly for the first three or four months, then weight gain escalates. The normal decrease in the breastfed infant’s rate of growth is sometimes misunderstood as inadequate milk supply, leading to early introduction of solid foods or inappropriate and unnecessary formula feeding.

Normal infant growth is: ● steady and predictable and demonstrates health and nutritional status. The overwhelming majority of infants have no growth problems. ● pulsating, happening in spurts, with periods of slow or no measurable growth. ● adjustable to genetic potential, with catch-up and catch-down periods ● seasonal, with length velocities faster during spring and summer, and stagnant over other months

Excessive Weight Loss after Birth Almost all normal infants lose weight after birth, but the amount of weight loss varies. It is usual for breastfed infants to lose up to 7% of birth weight, while formula fed infants lose about 5% of birth weight. Healthy infants typically regain their birth weight within 8-10

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days after birth. However, if a breastfed infant loses 7% of birth weight in the first 72 hours after birth, the mother-infant dyad should be evaluated, and any problems resolved immediately. At this time, early screening and lactation support can reduce the newborn’s risk of dehydration and failure to thrive

Weight loss of up to 10% of birth weight is the maximum acceptable loss for newborn infants. Any additional loss is a potential emergency. Contributing factors include: ● Hospital practices like epidurals, pacifier use, low or non-nutritive feedings, or strict feeding schedules. ● Maternal factors such as retained placenta, number of children, anxiety, and poor maternal knowledge. ● Infant factors such as birth weight, gestational age, gender, and feeding method ● For breastfed infants, poor positioning, latch and/or milk transfer

Any Weight Loss 2 Weeks to 6 Months Although infants begin to grow more slowly from 3 to 18 months of age, they should not lose weight after 2 weeks of age. Any such weight loss requires follow up. Growth faltering can be caused by ● Inadequate calorie intake, malabsorption, or increased metabolic needs ● Dehydration, feeding problems, malnutrition, or growth failure ● Milk protein allergy or gastrointestinal reflux ● Lead poisoning, HIV, Celiac disease, cystic fibrosis, congenital heart disease, or inborn errors of metabolism ● Neglect

Procedure: If growth faltering is suspected, consider the following: ● Rule out o maternal neglect, maternal depression, or emotional deprivation o inadequate calorie intake due to inappropriate formula mixing, breastfeeding problems, or early introduction of solid foods, ● Monitor growth monthly and use two separate weight measurements at least 8 weeks apart as data markers.

Screening for Slow or Faltering Growth Pattern Changes in growth can be the first sign of a pathological condition regardless of its cause. Recognition of poor growth in early life can identify infants who may be at risk for growth faltering. Early intervention can prevent growth retardation, which may be irreversible when it occurs early in life. Intervention can also prevent long-term consequences such

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as short stature, poor learning ability, low adult wages, and when paired with later weight gain, increased risk for nutrition-related chronic diseases. Screening for slow or faltering growth is a preventive health measure which requires careful growth monitoring and critical thinking skills. Although one measure of weight-for-age may cause concern, it does not show growth faltering. Screening should use multiple growth indicators, including risk for underweight, short stature, failure to thrive, and low head circumference (when available). These may be warning signs of the need for early intervention. In many situations, poor growth will likely be caused by a combination of factors, which require a combination of intervention strategies for successful health outcomes. Environmental health factors to consider include: ● Adequate nutrition and nutrient dense foods including a history of human milk or formula feeding ● Appropriate introduction of complementary foods ● Maternal conditions that can affect lactation: mastitis, prolonged labor, C-section, hypo- or hyperthyroidism, diabetes, low birth weight, prepregnancy BMI > 27, pregnancy-induced hypertension, flat/inverted nipples, vitamin B12 deficiency ● Mealtime routine and eating/feeding behavior ● Growth faltering in light of familial growth patterns ● Neglect ● Lack of social support ● Adverse social and psychological environment ● Depressed or poor mental abilities of parent/caregiver ● Lack of parental education and nutrition knowledge

Participant Focused Counseling: ● Provide early postpartum breastfeeding support to minimize dehydration and/or failure to thrive ● Refer to IBCLC/DBE for latch and other assistance ● Use “tell me how you know your baby is hungry/full” to explore knowledge and practice. Review baby behavior hunger and satiety cues and division of responsibility as needed. ● Explore feeding schedule (including both breastfeeding and formula feeding) and discuss adjustments if necessary. ● Review formula mixing technique, if applicable, using, “Tell me how you mix the formula.” Review correct mixing technique, if necessary, and follow with teach back to assure improved understanding and knowledge. ● Discuss mom’s food package to be sure it meets her needs. Adjust if needed. Discuss ways mom might improve her own calorie intake. ● Review accuracy of weight, length, and head circumference (if available) measurements. ● Refer to allied health professionals such as physician, early childhood intervention, social services, and home visiting programs as appropriate

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Small for Gestational Age (SGA) (1511) Categories: IBE, IBP, IFF, C-1 Defined as: Diagnosis by a physician as self-reported by applicant/participant/caregiver or someone working under physician’s orders. An infant who is Small for Gestational Age should have Nutrition Care counseling. An infant who is Small for Gestational Age and Low Birth Weight should have follow-up Nutrition Care in 3-6 months. Justification: Fetal growth restriction can lead to an infant who is born small for gestational age (SGA) at birth. SGA infants often have congenital abnormalities, a slower physical growth and, possibly, slower mental development. These effects may persist into childhood. SGA infants are at a higher risk of mortality. Procedure: ● Determine if the infant has been diagnosed as small for gestational age. ● Review collected information for appropriateness of feeding practices.

Participant Focused Counseling: The goal of nutrition counseling is to support the caregiver in establishing and maintaining feeding practices that promote the growth and development of the infant. Where appropriate, encourage follow up with or refer to health care professionals, those infants and children who do not attain a normal growth pattern.

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Transfer (5021, 5023, 5024, 5025) Categories: All Defined as: Person with a current and valid Verification of Certification (VOC) document from another WIC State or local agency. Justification: According to federal regulations, once a WIC participant has been determined to be eligible for program benefits by a local agency, the service delivery area into which the participant moves is obligated to honor the terms of participation. The VOC is valid through the end of the current certification, even if the participant does not meet the receiving agency’s nutritional risk, priority or income criteria, or if the certification period extends beyond the receiving agency’s certification period for that category and shall be accepted as proof of eligibility for Program benefits. Transferring participants should receive the food package offered in the receiving State agency according to their category and nutritional needs. The receiving agency should explain any differences in the authorized supplemental foods. Participants who are eligible to receive WIC formula (infant formula, exempt infant formula, or WIC-eligible nutritionals) in Food Package III must have one or more qualifying conditions, as determined by a health care professional licensed to write medical prescriptions under State law in the area from which they are moving. Procedure: Obtain and review the VOC. The VOC is valid through the end of the current certification period, even if the participant does not meet the receiving agency’s nutritional risk, priority or income criteria, or the certification period extends beyond the receiving agency’s certification period for that category, and shall be accepted as proof of eligibility for Program benefits. This criterion should be used only when the VOC document does not reflect a specific nutrition risk condition at the time of transfer or if the participant was initially certified based on a nutrition risk condition not in use by the Maryland WIC Program. The VOC is valid until the certification period expires and shall be considered as proof of eligibility for program benefits. If the local agency receiving the VOC has a waiting list for participants, the transferring participant shall be placed on the list ahead of all other waiting applicants.

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Underweight (Woman) (1011) Categories: PG, BE/BP, WPP Defined as: ● Pregnant woman: prepregnancy Body Mass Index (BMI) <18.5* ● Postpartum or breastfeeding woman (< 6 months postpartum): prepregnancy or current BMI < 18.5* ● Breastfeeding woman (6 months or more postpartum): Current Body Mass Index (BMI) < 18.5*. *Based on 2009 IOM Guidelines, the BMI weight categories used for adult women will be used for pregnant adolescent women as well. A woman who is underweight and has low maternal weight gain should have Nutrition Care counseling. Best Practice: follow up in 3 months.

Justification: Underweight women who become pregnant are at a higher risk for delivery of a low birth weight baby, fetal growth restriction, and perinatal mortality. Pre-pregnancy underweight is also associated with complications such as Cesarean delivery. Being underweight may indicate poor nutritional status, inadequate food consumption, environmental stress, lifestyle habits, and/or an underlying medical condition.

Procedure: Pregnant Woman: ● Use Table W for the procedure. Measure height to the nearest 1/8 inch. If the height fraction is between 1/8 and 3/8 of an inch, round down to the nearest whole number. If it is between 5/8 and 7/8 of an inch, round up to the nearest whole number. ● Obtain pre-pregnancy weight (self-report or from health care professional). Using the woman’s current height and pre-pregnancy weight, determine her weight status according to Table W. Record height and weight measurements in the woman’s record.

Breastfeeding or Postpartum Woman: ● For a postpartum or breastfeeding woman (less than 6 months postpartum) use current height and pre-pregnancy weight or current weight measured to the nearest 4 ounces to determine weight status according to Table W. ● For a breastfeeding woman 6 months or more postpartum, use current height and weight measured to the nearest 4 ounces to determine weight status according to Table W. Record height and weight measurements in the woman’s record. ● Weight during the early postpartum period, when most WIC certifications occur, is very unstable. During the first 4-6 weeks, fluid

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shifts and tissue changes cause fluctuations in weight. After 6 weeks, weight loss varies among women. Prepregnancy weight, amount of weight gain during pregnancy, race, age, parity and lactation all influence the rate of postpartum weight loss. By 6 months postpartum, body weight is more stable and should be close to the prepregnancy weight. In most cases, therefore, prepregnancy weight is a better indicator of weight status than postpartum weight in the first 6 months after delivery. ● The one exception is the woman with a BMI of <18.5 during the immediate 6 months after delivery. Underweight, at this stage, may indicate inadequate weight gain during pregnancy, depression, an eating disorder, or disease, all of which need to be addressed.

Participant Focused Counseling: ● Review collected information to identify lifestyle or dietary practices that may prevent adequate and appropriate food intake. ● Discuss the steps the participant is willing to take to ensure her nutritional status. ● Review strategies for making the change. ● If willing, help her set a simple, measurable goal. ● Enter the goal in WOW.

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Underweight/At Risk of Underweight (Child) (1031) Categories: IBE/IBP, IFF, C 1- 4

Defined as: ● Weight for Length ≤ 5th percentile, CDC/WHO growth chart Birth to ≤ 24 months, or ● BMI/Age ≤ 10th percentile, CDC growth chart 2 to 5 years of age.

Specifically: Underweight: CDC, WHO, and WIC use a cut-off value of ● ≤ 2.3 percentile weight for length in an infant Birth to ≤ 24 months, or ● ≤ 5th percentile BMI/Age for a child age 2 to 5 years.

At risk of underweight: WIC uses the cutoff value of ● > 2.3 and ≤ 5th percentile Wt/lgth for an infant/child, Birth to ≤ 24 months and ● > 5 and ≤10th percentile BMI/age for a child age 2 to 5 years.

An infant or child, Birth to 24 months with a Weight for length at or below the 2.3 percentile should have Nutrition Care counseling, with a Nutrition Care follow-up in 3 months. A child 2 to 5 years of age with a BMI/age below the 5th percentile, should have Nutrition Care counseling, with a Nutrition Care follow-up in 3-6 months. Justification: While progress along the lower percentiles may represent normal growth for some children, it may also be an indicator of inadequate calorie and nutrient intake. Procedure: ● Obtain current length or height measured to the nearest 1/8 inch. Obtain current weight measured to the nearest 1 ounce for infants and children < 24 months of age and to the nearest 4 ounces for children ≥ 24 months of age. Record measurements in the participant’s record.

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● For an infant or child less than 24 months of age whose length is measured in recumbent position, plot weight for length on the gender-specific CDC/WHO growth chart Birth to ≤ 24 months. For a child 2 years of age and older whose height is measured standing up, compute BMI using the procedure in Table BMI.1. Plot the BMI value on the CDC BMI/age growth chart for 2-5 year-olds. ● For an infant or child < 24 months of age who was born at 37 weeks or earlier, adjust the age before plotting, following the procedure in Table GAA. ● If the plotted percentile is less than or equal to the 5th percentile, assign the risk criterion. ● Review collected information for possible causes of underweight, such as not offering 3 meals and 2 snacks per day or restricting food intake.

Participant Focused Counseling: ● Review collected information to identify feeding or dietary practices that may prevent adequate and appropriate food choices for the infant/child. ● Discuss the steps the participant is willing to take to ensure the child’s nutritional status. ● Review strategies for making the improvements. ● If willing, help her set a simple, measurable goal. ● Enter the goal in WOW.

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Tables and Lists

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Table A Low Hemoglobin/Hematocrit Cut-off Values for Women

Hemoglobin or hematocrit value is less than or equal to: Cigarettes per day Non Smoker 1 to 19 20 to 39 40+ Category Hgb Hct Hgb Hct Hgb Hct Hgb Hct Pregnant through 13 weeks 10.9 32.9 11.2 33.9 11.4 34.4 11.6 34.9 Pregnant 14 through 26 weeks 10.4 31.9 10.7 32.9 10.9 33.4 11.1 33.9 Pregnant 27 through 40 weeks 10.9 32.9 11.2 33.9 11.4 34.4 11.6 34.9 Breastfeeding or Postpartum 12 to < 15 years 11.7 35.6 12.0 36.6 12.2 37.1 12.4 37.6 Breastfeeding or Postpartum 15 to < 18 years 11.9 35.8 12.2 36.8 12.4 37.3 12.6 37.8 Breastfeeding or Postpartum 18 + years 11.9 35.6 12.2 36.6 12.4 37.1 12.6 37.6

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Table W Weight Status of Pregnant, Breastfeeding and Postpartum Women

Procedure: Measure and record the woman’s height. If the height fraction is between 1/8 and 3/8 of an inch, round down to the nearest whole number. If it is between 5/8 and 7/8 of an inch, round up to the nearest whole number.

To evaluate Underweight: ● If the woman is pregnant or less than 6 months postpartum, use either: o her pre-pregnancy weight (self-report or from health care professional) or o a current weight measured to the nearest 4 ounces. ● If she is a breastfeeding woman 6 months or more postpartum, use her current weight measured to the nearest 4 ounces. ● Record weight measurements in the WIC record.

To evaluate Overweight: ● If the woman is pregnant or less than 6 months postpartum, use her pre-pregnancy weight (self-report or from health care professional). ● If she is a breastfeeding woman 6 months or more postpartum, use her current weight measured to the nearest 4 ounces. ● Record weight measurements in the WIC record.

On Table W, which follows: ● Locate height in the left column on the following chart. ● Read across the weight columns until you find where her weight falls. ● Her weight status is indicated at the top of the column. ● She has a risk criterion if she is underweight, overweight, or obese.

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Table W Weight Status of Pregnant, Breastfeeding, and Postpartum Women

Height is: Underweight (BMI < 18.5) Normal Weight (BMI 18.5-24.9) Overweight (BMI 25.0-29.9) Obese (BMI ≥ 30.0) Ft. &in. In. Weight (in pounds) is: 4' 8" 56" ≤ 82 1/4 82 1/2 - 111 1/4 111 1/2 - 133 1/2 ≥ 133 3/4 4' 8 1/2" 56-1/2" ≤ 83 3/4 84 - 113 1/4 113 1/2 - 135 3/4 ≥ 136 4' 9" 57" ≤ 85 1/4 85 1/2 - 115 1/4 115 1/2 - 138 1/4 ≥ 138 1/2 4' 9 1/2 “ 57-1/2" ≤ 86 3/4 87 - 117 1/4 117 1/2 - 140 3/4 ≥ 141 4'10" 58" ≤ 88 1/4 88 1/2 - 119 1/4 119 1/2 - 143 1/4 ≥ 143 1/2 4' 10 1/2" 58-1/2" ≤ 89 3/4 90 - 121 1/4 121 1/2 - 145 3/4 ≥ 146 4'11" 59" ≤ 91 1/4 91 1/2 - 123 1/2 123 3/4 - 148 1/4 ≥ 148 1/2 4' 11 1/2" 59-1/2" ≤ 92 3/4 93 - 125 1/2 125 3/4 - 150 3/4 ≥ 151 5' 0" 60" ≤ 94 1/4 94 1/2 - 127 3/4 128 - 153 1/4 ≥ 153 1/2 5' 1/2" 60-1/2" ≤ 96 96 1/4 - 129 3/4 130 - 155 3/4 ≥ 156 5' 1" 61" ≤ 97 1/2 97 3/4 - 132 132 1/4 - 158 1/2 ≥ 158 3/4 5' 1-1/2" 61-1/2" ≤ 99 1/4 99 1/2 - 134 134 1/4 - 161 ≥ 161 1/4 5' 2" 62" ≤ 100 3/4 101 - 136 1/4 136 1/2 - 163 1/4 ≥ 163 3/4 5' 2-1/2" 62-1/2" ≤ 102 1/2 102 3/4 - 138 1/2 138 3/4 - 166 1/4 ≥ 166 1/2 5' 3" 63" ≤ 104 104 1/4 - 140 3/4 141 - 169 ≥ 169 1/4 5' 3-1/2" 63-1/2" ≤ 105 3/4 106 - 143 143 1/4 - 171 3/4 ≥ 172 5' 4" 64" ≤ 107 1/4 107 1/2 - 145 1/4 145 1/2 - 174 1/4 ≥ 174 1/2

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Table W Weight Status of Pregnant, Breastfeeding and Postpartum Women, continued Height is: Underweight (BMI < 18.5) Normal Weight (BMI 18.5-24.9) Overweight (BMI 25.0-29.9) Obese (BMI ≥ 30.0) Ft. & in. In. Weight (in pounds) is: 5' 4-1/2" 64-1/2" ≤ 109 109 1/4 - 147 1/2 147 3/4 - 177 ≥ 177 1/4 5' 5" 65" ≤ 110 3/4 111 - 149 3/4 150 - 179 3/4 ≥ 180 5' 5-1/2" 65-1/2" ≤ 112 1/2 112 3/4 - 152 152 1/4 - 182 3/4 ≥ 183 5' 6" 66" ≤ 114 1/4 114 1/2 - 154 1/2 154 3/4 - 185 1/2 ≥ 185 3/4 5' 6-1/2" 66-1/2" ≤ 116 116 1/4 - 156 3/4 157 - 188 1/4 ≥ 188 1/2 5' 7" 67" ≤ 117 3/4 118 - 159 1/4 159 1/2 - 191 ≥ 191 1/4 5' 7-1/2" 67-1/2" ≤ 119 1/2 119 3/4 - 161 1/2 161 3/4 - 194 ≥ 194 1/4 5' 8" 68" ≤ 121 1/4 121 1/2 - 164 164 1/4 - 196 3/4 ≥ 197 5' 8-1/2" 68-1/2" ≤ 123 123 1/4 - 166 1/2 166 3/4 - 199 3/4 ≥ 200 5' 9" 69" ≤ 124 3/4 125 - 168 3/4 169 - 202 3/4 ≥ 203 5' 9-1/2" 69-1/2" ≤ 126 3/4 127 - 171 1/4 171 1/2 - 205 3/4 ≥ 206 5' 10" 70" ≤ 128 1/2 128 3/4 - 173 3/4 174 - 208 1/2 ≥ 208 3/4 5" 10-1/2" 70-1/2" ≤ 130 1/4 130 1/2 - 176 1/4 176 1/2 - 211 1/2 ≥ 211 3/4 5' 11" 71" ≤ 132 1/4 132 1/2 - 178 3/4 179 - 214 3/4 ≥ 215 5' 11-1/2" 71-1/2" ≤ 134 134 1/4 - 181 1/4 181 1/2 - 217 3/4 ≥ 218 6' 0" 72" ≤ 136 136 1/4 - 183 3/4 184 - 220 3/4 ≥ 221 6' -1/2" 72-1/2" ≤ 137 3/4 138 - 186 1/2 186 3/4 - 223 3/4 ≥ 224 6' 1" 73" ≤ 139 3/4 140 - 189 189 1/4 - 227 ≥ 227 1/4 6' 1-1/2" 73-1/2" ≤ 141 3/4 142 - 191 1/2 191 3/4 - 230 ≥ 230 1/4

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Table I-P Low Maternal Weight Gain

Procedure: ● Determine pre-pregnancy weight status by using Table W. ● Subtract the pre-pregnancy weight from the current weight to determine the pounds gained. ● Determine the last completed week of gestation. ● Locate the week of gestation in the left column of the table below. ● Move across the columns to the woman’s pre-pregnancy weight status. ● If she has gained equal to or less than the number of pounds in the box, she has the risk criterion, Low Maternal Weight Gain.

Note: Do not evaluate this risk criterion for a woman pregnant with twins, triplets, or more.

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Table I-P Low Maternal Weight Gain Completed Week of Gestation Underweight

pounds: Normal Weight pounds: Overweight/ Obese pounds: Completed Week of Gestation Underweight

pounds: Normal Weight pounds: Overweight/ Obese pounds: 1 N/A N/A N/A 21 11 1/2 9 1/2 5 1/2 2 1/4 1/4 N/A 22 12 1/2 10 1/2 6 3 1/2 1/2 1/4 23 13 1/4 11 1/4 6 1/2 4 1 3/4 1/2 24 14 12 7 5 1 3/4 1 1/4 1/2 25 14 3/4 12 3/4 7 1/2 6 2 1 1/2 3/4 26 15 3/4 13 1/2 8 7 2 1/2 1 3/4 3/4 27 16 3/4 15 8 3/4 8 2 3/4 2 1 28 17 1/2 15 1/4 9 9 3 1/4 2 1/4 1 29 18 1/2 15 3/4 9 1/2 10 3 1/2 2 1/2 1 1/4 30 19 1/4 16 3/4 10 11 4 2 3/4 1 1/2 31 20 17 1/2 10 1/2 12 4 1/2 3 1 1/2 32 21 18 1/2 11 13 4 3/4 3 1/4 1 3/4 33 21 3/4 19 11 1/2 14 5 1/2 4 1/4 2 1/4 34 22 3/4 19 3/4 11 3/4 15 6 1/2 4 3/4 2 3/4 35 23 1/2 20 3/4 12 1/4 16 7 1/2 5 1/2 3 1/4 36 24 1/2 21 1/2 12 3/4 17 8 6 1/2 3 1/2 37 25 22 1/4 13 1/4 18 8 3/4 7 1/4 4 38 26 1/4 23 13 3/4 19 9 3/4 8 4 1/2 39 26 3/4 24 14 1/4 20 10 3/4 8 3/4 5 40 27 3/4 24 3/4 14 3/4

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Table BMI.1: Calculation of Body Mass Index Body Mass Index (or BMI) is a comparison of a person’s weight against height using a simple equation: BMI = Weight / Height / Height ⋅ 703

Weight is measured to the nearest quarter pound (4 ounces) and height to the nearest 1/8 inch. These fractions must be converted to decimals for use in the BMI equation. The table below shows how to convert the fractions to decimals. If you use an electronic scale that displays weight in tenths of a pound, use the displayed weight value, such as 31.1 pounds, etc.

Fraction:

Decimal: 1/8 = .125 1/4 (2/8) = .25 3/8 = .375 1/2 (4/8) = .5 5/8 = .625 3/4 (6/8) = .75 7/8 = .875

Example: Measured weight is 31 1/4 pounds. Use 31.25 pounds in the equation. Example: Measured height is 37 4/8 inches. Use 37.5 in the equation.

Interpretation of BMI/age The BMI value you obtain must be plotted on a CDC gender specific growth chart: BMI/age for Children 2 to 5 years old. Compare the plotted point on the growth chart to the cutoff values below to determine if a child 2 years of age or older has a risk criterion. Underweight/At risk of underweight ≤ 10th percentile, BMI/Age At Risk of Overweight Infant or child whose biological parent has a self-reported BMI ≥ 30 Overweight ≥ 85th to less than the 95th percentile Obese ≥ 95th percentile

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Table BMI.2: Abbreviated Body Mass Index (BMI) Table (Self-reported by mother or father) *

Height Height in inches Weight (lbs) equal to BMI 30 4' 10" 58 143 4' 11" 59 148 5' 0" 60 153 5' 1" 61 158 5' 2" 62 164 5' 3" 63 169 5' 4" 64 174 5' 5" 65 180 5' 6" 66 186 5' 7" 67 191 5' 8" 68 197 5' 9" 69 203 5' 10" 70 209 5' 11" 71 215 5' 12" 72 221 6' 1" 73 227 6' 2" 74 233 6' 3" 75 240 *This table may be used to determine parental (male or female) obesity (BMI > 30)

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Table GAA: Calculation of Gestation-Adjusted Age for Infants Born at 37 Weeks or Earlier

All infants and children less than 2 years of age, born at 37 weeks gestation or earlier require gestational age adjustment prior to plotting a growth chart. (1) Procedure: ● Obtain the infant or child’s gestational age in weeks. The caregiver can self-report this information or it can be provided by the infant’s health care professional. ● Subtract the gestational age in weeks from 40 weeks to determine the adjustment for prematurity. ● Subtract the adjustment for prematurity from the infant or child’s chronological age in weeks to determine the gestation-adjusted age. ● Use the gestation-adjusted age to plot weight for age and length for age on the CDC/WHO growth chart Birth to > 24 months.

Note: The infant must reach 40 weeks gestation-adjusted age in order to plot the CDC growth chart 2 to 5 years. Do not plot measurements on the growth chart if the infant has not yet reached 40 weeks gestation-adjusted age.

1FNS Policy Memorandum 98-09, Revision 7, Guidelines for Growth Charts and Gestational Age Adjustment for Low Birth Weight and Very Low Birth Weight Infants.

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Frequently Asked Questions Q. A pregnant woman tells me that she used to smoke cigarettes but has now stopped. Can I assign the risk criterion Maternal Smoking? A. No. The woman must still smoke at the time of her certification.

Q. Should I tell a breastfeeding woman who is now pregnant to stop breastfeeding her baby? A. No. Refer a pregnant woman who is breastfeeding another child during her pregnancy to the breastfeeding specialist in your local agency. Advise her to inform her health care professional that she is still breastfeeding if she has not already done so.

Q. How do I know if my community water supply contains fluoride in order to determine adequacy of fluoride intake? A. Your local agency should contact the local water utility to find out if the water supplied to the community contains fluoride.

Q. A caregiver told me that she gave her 8 month old baby some potato chips as finger foods but was told to stop, so she no longer gives them to the baby. Can I assign the risk criterion, Nutrition Practice - Infant? A. No. The feeding practice must be current.

Q. Several of the risk criteria specify “routinely.” Does this mean every day? A. Not necessarily. “Routine” is defined as a feeding, dietary, or lifestyle practice that currently occurs on more than one occasion. For example, if a pregnant woman tells you she has a beer “once in a while,” she is still drinking alcohol while pregnant. This is not every day, but it is routine. The practice can harm her unborn baby. Assign the risk criterion Alcohol or Illegal Drug Use and counsel her to stop drinking while she is pregnant.

Q. What if I am not sure that I can use a risk criterion for a participant? A. Do not guess. If you are a CPPA, talk to a CPA about the risk criterion before you use it. If you are a CPA, talk with one of the State WIC nutritionists. If you are unsure that a risk criterion exists, do not assign the risk criterion.

Q. When I certify a postpartum woman and she tells me that she delivered at 42 weeks gestation, should I add extra pounds to table H? A. No. The maximum number of pounds she should gain during pregnancy is based upon 40 weeks gestation only.

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Q. Can I use verbal information that is not found on the Nutrition History to assign a risk criterion? A. If the information provides documentation of a risk criterion that we use in the Maryland WIC Program, you may use it to assign the risk. However, you must write a note that documents the risk criterion and its source in the participant’s WOW record.

Q. Should I assign the risk criterion, Nutrition Practice – Child, for a child born prematurely, but still on the bottle after 14 months of age? A. Depending upon the child’s degree of prematurity, the health care professional may recommend that the caregiver postpone weaning to a cup, so that weaning may not be achieved by 14 months of age. Do not apply the risk criterion in this case. If you are a CPPA, you may wish to discuss interpretations of this risk criterion with a CPA.

Q. If a mother has been told by her health care professional to concentrate the calories in the formula by adding less water than the label specifies, can I assign Nutrition Practice - Infant? A. No. If the health care professional advised the mother to follow special directions when making formula, do not assign the risk criterion.

Q. If a pregnant woman’s estimated date of delivery (EDD) is different from the EDD calculated from her last menstrual period date, how do I determine date of conception? A. If the EDD has been determined by a sonogram, use the EDD stated by the woman.

Q. If a pregnant woman does not know how many weeks pregnant she was when she went for her first prenatal care visit, how can I evaluate Late to Prenatal Care? A. If the woman knows the date that she went, you can calculate the number of weeks of gestation at the time of the visit by using a gestation wheel. You will need the date of her last menstrual period and the date she went for prenatal care.

Q. How can I apply the risk criterion Fetal Death ≥ 20 weeks or Neonatal Loss to a breastfeeding woman? Her baby is living. A. True. This risk criterion only applies to a breastfeeding woman who was pregnant with multiple fetuses (twins or more) and lost one of the infants due to miscarriage or death at birth or during the first 28 days of life. She is breastfeeding the infant who survived.

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Q. Can I use a gestation wheel that is different from the one the State WIC Office provides? A. Not for certifying WIC participants. There are differences in gestation wheels. To consistently apply risk criteria to WIC participants in the State of Maryland, you must use the wheel provided by the State.

Q. When I use Table H, do I need to know the woman’s pre-pregnancy weight to determine if she gained more weight than the cut-off value? A. Yes. In order to evaluate high weight gain in a breastfeeding or postpartum woman, you must know her pre-pregnancy weight status.

Q. Why can’t I evaluate either Low Maternal Weight Gain or High Maternal Weight Gain for a woman pregnant with twins or who recently delivered twins? A. Because there are no scientifically derived cutoff values to accurately assess the weight gain of a woman who is pregnant with twins, triplets, or more, USDA has chosen to not allow Low Maternal Weight Gain or High Maternal Weight Gain to be assigned to these women. However, USDA does encourage WIC staff to discuss weight gain recommendations with women who are pregnant with twins or triplets. Refer to the risk criterion Multi-fetal Gestation for information about the recommended weight gain for women pregnant with twins or triplets.

Q. Is Low Birth Weight the same thing as Small for Gestational Age (SGA)? A. No. Low birth weight is usually associated with Prematurity. The infant was likely growing at a normal rate as a fetus but was born early or preterm. A Small for Gestational Age infant is one born full term, but the infant’s birth weight is below what would be expected at 40 weeks. The infant’s growth as a fetus did not progress in a normal manner. There may be different feeding issues for a low birth weight versus a Small for Gestational Age infant.

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Risks Chart: Nutrition Risk Criteria. Best Practice for high-risk participants: Initial Contact with CPA while in clinic. If not possible, all high-risk participants must have initial contact with CPA within 30 days. Best Practice for Higher Risk participants is designated 0-5 days or 0-10 days. KEY: NC=Nutrition Care (high risk) BF=Refer to DBE M=Manually assign risk X=Lower risk Best= Best Practice RISK CUT OFF VALUE/EXPLANATION PG BE BP WPP IBE IBP IFF C1 C2-4 Alcohol and Substance Use PG = Any amount; BE/BP/WPP: ≥ 2 drinks/day All = drugs, any amount. Best: CPA standard initial contact, then follow up 3-6 months. NC NC BF NC BF NC

BF Complications/potential – Woman/Infant Review 2.31A for high/low risk details Best: Initial contact 0-5 days NC or BF NC or BF NC or BF

NC or BF NC or BF

BF Infant of Woman at Nutritional Risk

NC NC

BF Mother of Infant at Nutritional Risk Review 2.31A for high/low risk details BF NC BF NC BF NC

Complementary Feeding Process Assign only if no other risk found. Documented complete nutrition assessment required. Applies 4 to 23 months