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Section 7.10: Food Package 4 for Children 1 through 4 Years Old 1/2011 6/2025- Note: ▪ see Draft Section 7.10: Food Package for Children 1 through 4 Years Old (Food Package 4) for most current guidance. ▪ Exhibit 7-E: Authorization of Milk Substitute has been retracted (link removed) as it contrary to current federal regulations. References: 7 CFR 246.10 Policy ▪ Food packages must be prescribed by CPAs, in consultation with the participant or parent/caregiver. ▪ The food package must be appropriate to the category of eligibility and must be specifically tailored to address the nutritional needs, circumstances, and preferences of the participant. Purpose: To provide a food package that will best meet the participant’s needs and will be used by the participant. Procedures Issuance requirements Food Package 4 is issued to one category of participants: ▪ Children 1 through 4 years of age who do not have a condition qualifying them for Food Package 3. Issue the food package as indicated in the table below. ▪ Allowed substitutions are listed. ▪ Medical documentation is required for some substitutions. Refer to Section 7.6: Medical Documentation. Provide the appropriate type of milk for age and need: ▪ Whole milk is the only type of milk allowed for 1-year-old children (12 through 23 months).

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2 1 / 2 0 1 1 ▪ Low-fat 1% and fat-free skim milk are the only types of milk allowed for children > 24 months of age. ▪ Participants with reported lactose intolerance must try lactose-free milk before other milk substitutes can be considered. ▪ Other cow’s milk options include acidophilus, evaporated and powdered milk. Provide the appropriate type (whole, lowfat, and/or fat free) if available as a food package selection. ▪ Goat milk may be provided upon participant request. ▪ More than one type of milk may be given. Soy-based milk substitutes may be provided in cases of qualifying medical need up to the total maximum milk allowance. ▪ Medical documentation must be received before these foods can be issued, using Exhibit 7- E: Authorization of Milk Substitutes (exhibit retracted). ▪ For qualifying conditions, see table below. ▪ Medical authorization may be provided by telephone to a CPA, when necessary to prevent a delay that would place a participant at increased nutritional risk (determined on case-by- case basis) and until written confirmation is received, which must be within 1 month. Voucher issuance is limited to 1 month with verbal verification. Document the temporary verbal approval in the participant’s record. ▪ See Section 7.6: Medical Documentation. Do not provide a food if the child cannot consume or refuses the food. Examples include: ▪ Food allergy ▪ Medical condition for which the food is inappropriate ▪ Vegan family who will not use the food Homeless Package: To better meet the needs of homeless participants, adjust the food package accordingly. ▪ Fluid milk quantities may be issued in quart containers. ▪ Powdered and evaporated milk are also available. ▪ Juice quantities may be issued in the small juice box containers. See Section 7.14: Homeless Food Package.

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3 1 / 2 0 1 1 Children 1 through 4 Years Old (Food Package 4) Food item Maximum monthly allowances Allowed substitutions Substitution rates and maximums Milk, Fluid Cow and goat milk While milk for children up to 2 years of age Low-fat 1% or fat-free skim milk for children 2 years and older 16 quarts Cheese 1 pound cheese / 3 quarts of milk Max: 1 pound Acidophilus milk Max: 8 half-gallon containers Lactose-free milk Max: 8 half-gallon containers Evaporated milk 16 fluid ounces evap. / 32 fluid ounces of fluid milk (1:2 ratio) Max: 16 reconstituted quarts= 21 (12 oz.) cans Powdered milk Reconstituted amount equal to fluid milk Max: 16 reconstituted quarts Soy-based beverage** 1 quart soy-based beverage / 1 quart fluid milk Max: 16 quarts = 8 half-gallons Tofu** 1 pound tofu / 1 quart of milk Max: 16 pounds Juice, single variety 128 fluid ounces juice NA

Breakfast Cereal 36 ounces Infant cereal Max: 32 ounces Eggs 1 dozen eggs NA

Fruits and Vegetables $6.00 Cash value voucher NA

Whole grains including: bread, tortillas, oatmeal, and brown rice 2 pounds NA

Peanut butter or Dry/Canned beans 18 ounces peanut butter or 1 pound dry beans or 64 ounces canned beans

**Soy substitutions (soy-based beverage or tofu) for milk require medical documentation. Qualifying reasons include: ▪ Milk allergy ▪ Sever lactose maldigestion (cannot tolerate lactose-free milk)

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4 1 / 2 0 1 1 ▪ Vegan/vegetarian diet ▪ Medical condition requiring use of soy-based beverage ▪ Religious or cultural observance or practice Guidance Lactose intolerance Assess the degree of the intolerance. Often lactose intolerance does not require complete avoidance of dairy foods. Determine what approaches the participant has used to reduce symptoms. Individualize counseling. Some approaches include: ▪ Introduce milk slowly (e.g. ¼ - ½ cup); gradually increase the amount if tolerated. ▪ Drink only small amounts of milk at a time; spread milk intake out during the day (rather than drinking a large amount at one time). ▪ Drink milk with food. This will help slow digestion and release of lactose. ▪ Try yogurt with live and active cultures which may help digest the lactose. ▪ Try lactose-free milk. ▪ Consider some chocolate milk which may be better tolerated. Discuss food package options. Several different types of milk may be provided based on the participant’s need and tolerance. ▪ Lactose-free milk ▪ Lactose-free milk + cheese ▪ Lactose-free milk + regular milk ▪ Lactose-free milk + regular milk + cheese If the participant expresses reluctance to try lactose-free milk, use open-ended questions to identify and address participant perceptions and concerns. Counsel the participant on choosing the lactose-free milk with the appropriate fat content. It may be helpful to show a picture or sample carton to help the participant identify the correct item when shopping. ▪ Lactose-free whole milk: for children 1 year of age ▪ Lactose-free low fat 1% or fat-free skim milk: for children > 2 years Lactose-free milk may taste different to the participant. Offer suggestions if this is an issue or concern (note: do not suggest that taste will be an issue). ▪ Make sure the milk is served cold. ▪ Use on cereal, mixed with other foods, in hot cocoa, etc. where the difference in taste will not be noticed.

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5 1 / 2 0 1 1 ▪ If some regular milk is tolerated, mix with lactose-free milk. ▪ Try different brands of lactose-free milk. ▪ Give it time. Assure the participant that most people become accustomed to the slight difference. If lactose-free milk did not offer relief in cases of severe lactose maldigestion, soy-based beverage and/or tofu may be provided. Goat milk may be requested by some participants. Goat milk may be useful in some cases of cow’s milk insensitivity/intolerance or allergy to soy- based beverage. The types of casein in goat milk, plus the evaporation process (in evaporated milk), may render the milk more digestible and less allergenic. The fat has a high proportion of short chain and medium-chain fatty acids and thereby may be more digestible. Goat milk is not appropriate in these situations: ▪ Goat milk is not recommended for participants with cow’s milk allergy. Cross-reactivity of proteins may increase allergic potential to goat milk. For example, research has shown that most infants who are allergic to cow’s milk are or will become allergic to goat’s milk as well. ▪ Goat milk is unlikely to be helpful for lactose intolerance since the lactose content is comparable to cow’s milk. WIC-allowed goat milk is pasteurized and fortified with Vitamin D. Evaporated goat milk is also fortified with folic acid. Peanut butter Allergies: Updated guidance from AAP states that there is no convincing evidence that delaying the introduction of foods considered allergenic (such as peanut protein, fish, eggs, etc.) has any significant protective effect on the development of allergies. Refer to the Health Care Provider if there are concerns. (Source: Effects of Early Nutritional Interventions on the Development of Atopic Disease in Infants and Children; PEDIATRICS Volume 121, Number 1, January 2008.) Choking hazard: Since peanut butter may pose a choking hazard for younger children, it should not be provided until the child is developmentally ready. ▪ Instruct the caregiver on lower risk ways of offering peanut butter (spread on toast, cracker or other firm surface). ▪ Peanut butter should never be given for a child to eat off a spoon. Soy-based beverage and tofu When milk substitutes are used, assess intake and counsel to ensure adequate intake of nutrients that would have been provided by milk. For example:

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6 1 / 2 0 1 1 ▪ Tofu does not contain Vitamin D. ▪ Tofu often contains less calcium than milk. A 3-ounce tofu serving typically contains 2% to 30% of the Daily Value for calcium, depending on the brand. This is in comparison with 30 % DV for calcium found in 1 cup of milk. Reference – Complete Listing of Hyperlinks Section 7.9: Food Package 3 for infants, woman, and children with qualifying medical conditions (https://www.health.state.mn.us/docs/people/wic/localagency/program/mom/chsctns/ch7/sct n7_9.pdf) Section 7.6: Medical Documentation (https://www.health.state.mn.us/docs/people/wic/localagency/program/mom/chsctns/ch7/sct n7_6.pdf) Exhibit 7-E: Authorization of Milk Substitutes (exhibit retracted) Section 7.14: Homeless Food Package (https://www.health.state.mn.us/docs/people/wic/localagency/program/mom/chsctns/ch7/sct n7_14.pdf) Effects of Early Nutritional Interventions on the Development of Atopic Disease in Infants and Children (https://pubmed.ncbi.nlm.nih.gov/18166574/) Minnesota Department of Health - WIC Program 625 Robert St N, PO BOX 64975, ST PAUL MN 55164-0975; 1-800-657-3942, health.wic@state.mn.us, www.health.state.mn.us. To obtain this information in a different format, call: 1-800-657-3942 This institution is an equal opportunity provider.