1 1/2011

Section 7.13: Food Package 7 for Fully Breastfeeding Women 1/2011 6/2025- Note: ▪ Exhibit 7-E: Authorization of Milk Substitute has been retracted (link removed). Documentation for soy foods is no longer required. 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 7 is issued to three categories of participants, none of whom have a medical condition qualifying them to receive Food Package 3 (Section 7.9: Food Package for Infants, Women, and Children with Qualifying Medical Conditions). ▪ Fully-Breastfeeding women up to 1 year postpartum whose infants do not receive infant formula from WIC. ▪ This includes pregnant women who are fully breastfeeding an infant less than 1 year of age. ▪ Women pregnant with multiples ▪ Women who are Mostly-Breastfeeding multiple infants who are receiving the Mostly- Breastfed formula package from WIC. For maximum formula allowances, refer to: ▪ Food Package 1 (infants 0-5 months): Contract Formula Amounts Guide ▪ Food Package 2 (infants 6-11 months): Contract Formula Amounts Guide ▪ Food Package 3: MN WIC Medical Formula Amounts Guide

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2 1 / 2 0 1 1 ▪ For maximum formula allowances in ounces: MN WIC Formula Amounts Guide: Maximum Amounts by Federal Regulation. For breastfeeding dyads, the infant’s food package will determine mom’s food package. For infant food packages, refer to Exhibit 7-J: Mom and Baby WIC Food Packages. Issue the food package as indicated in the table below. ▪ Allowed substitutions are described below. ▪ Medical documentation is required for some substitutions. Refer Section 7.6: Medical Documentation. Do not provide a food if the participant cannot consume or will not use the food. Examples include: ▪ Food allergy ▪ Medical condition for which the food is inappropriate ▪ Vegan family who will not use the food Fully breastfeeding multiples Women fully breastfeeding multiples receive Food Package 7+ which is larger, providing 1.5 times the amount in FP 7. ▪ Assess whether these amounts are appropriate: ▪ Will the participant be able to use the full amount (e.g., 9 gallons milk/month)? ▪ Provide the maximum amount if appropriate. If not, tailor amounts to meet the participant’s needs. Fully breastfeeding multiples with different breastfeeding statuses For Women breastfeeding multiples with different breastfeeding statuses, the mother’s food package corresponds to the food package of the infant with the most breastfeeding. ▪ If one of the multiples is receiving the Fully-Breastfed Infant food package and the other(s) is receiving the Mostly- or Some- Breastfed food package, the mother may receive Food Package 7 (Fully-Breastfeeding). ▪ If one of the multiples is receiving the Mostly-Breastfed Infant food package and the other(s) is receiving the Some-Breastfed food package, the mother will receive Food Package 5 (Mostly-Breastfeeding). Milk Low-fat 1% and fat-free skim are the only types of milk allowed for women. ▪ Participants with reported lactose intolerance must try lactose-free milk before other milk substitutes may be considered.

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3 1 / 2 0 1 1 ▪ Other cow’s milk options include acidophilus, evaporated and powdered milk. Provide the lowfat and/or fat free versions if available as a food package selection. ▪ Goat milk may be provided upon participant request. ▪ More than one type of milk or milk substitute may be issued. ▪ 2 pounds cheese may be substituted for milk (see table below). Soy-based beverage Soy-based beverage may be provided as a milk substitute without medical documentation to replace some or all of the milk, up to the total maximum milk allowance (24 quarts). Tofu Up to 6 pounds tofu may be substituted for milk without medical documentation. See table below for substitution rates. ▪ Amounts > 6 pounds tofu may be provided in cases of qualifying medical need, up to the total maximum milk allowance. Medical documentation must be obtained prior to issuance using Exhibit 7-E: Authorization of Milk Substitutes. ▪ For qualifying conditions, see table footnote 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. ▪ Refer to Section 7.6: Medical Documentation. Bean/Peanut Butter issuance options Participants receives 2 choices (or 3 choices for FP 7+ Breastfeeding Multiples), with various options for issuing beans and peanut butter. For example, FP 7+ options could include: ▪ One of each item: 1 jar peanut butter + 1 lb. dry beans + 4 (16 oz.) cans of beans ▪ Two of one item and one of another item: e.g., 2 jars of peanut butter + 1 lb. dry beans ▪ Three of the same item: e.g., 12 (16 oz.) cans of beans. 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. ▪ More than one kind of milk may be given.

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4 1 / 2 0 1 1 ▪ Juice quantities may be issued in the small juice box containers. ▪ See Section 7.14: Homeless Food Package. See tables on next pages

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5 1 / 2 0 1 1 Food package 7: Fully breastfeeding women up to 1 year postpartum, Mostly Breastfeeding multiple infants, Pregnant with multiples, and Pregnant while Fully breastfeeding **Tofu substitutions > 6 pounds for milk require medical documentation. Qualifying reasons include: ▪ Milk allergy ▪ Sever lactose maldigestion (cannot tolerate lactose-free milk) ▪ Vegan/vegetarian diet Food Item Maximum monthly allowances Allowed Substitutions Substitution rates and Maximums Milk, Fluid Cow and goat milk Low-fat 1% or fat- free skim milk 24 quarts Cheese 1 pound cheese / 3 quarts of milk Max: 2 pound Acidophilus milk Lowfat 1% or Fat free Max: 12 half-gallon containers Lactose-free milk Lowfat 1% or Fat free Max: 12 half-gallon containers Evaporated milk Lowfat 1% or Fat free 16 fluid ounces evap. / 32 fluid ounces of fluid milk (1:2 ratio) Max: 24 reconstituted quarts= 32 (12 oz.) cans Powdered milk Nonfat Reconstituted amount equal to fluid milk Max: 24 reconstituted quarts Soy-based beverage 1 quart soy-based beverage / 1 quart fluid milk Max: 24 quarts = 12 half-gallons Tofu** 1 pound tofu / 1 quart of milk Max: 6 pounds If > 6 pounds (Medical Documentation required)** Max: 24 pounds Cheese 1 pound

Juice, single variety 144 fluid ounces juice NA

Breakfast Cereal 36 ounces NA

Eggs 2 dozen eggs NA

Fruits and Vegetables $10.00 Cash value voucher NA

Whole grains including: bread, tortillas, oatmeal, and brown rice 1 pounds NA

Peanut butter 18 ounces peanut butter

Dry/Canned beans 1 pound dry beans or 64 ounces canned beans

Canned Fish 30 ounces fish; Light Tuna or Pink Salmon NA

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6 1 / 2 0 1 1 ▪ Medical condition requiring use of soy-based beverage ▪ Religious or cultural observance or practice Food package 7+: Fully breastfeeding multiples up to 1 year post partum Food Item Maximum monthly allowances Allowed Substitutions Substitution rates and Maximums Milk, Fluid Cow and goat milk Low-fat 1% or fat-free skim milk 36 quarts Cheese 1 pound cheese / 3 quarts of milk Max: 2 pound Acidophilus milk Lowfat 1% or Fat free Max: 18 half-gallon containers Lactose-free milk Lowfat 1% or Fat free Max: 18 half-gallon containers Evaporated milk Lowfat 1% or Fat free 16 fluid ounces evap. / 32 fluid ounces of fluid milk (1:2 ratio) Max: 36 reconstituted quarts= 48 (12 oz.) cans Powdered milk Nonfat Reconstituted amount equal to fluid milk Max: 36 reconstituted quarts Soy-based beverage 1 quart soy-based beverage / 1 quart fluid milk Max: 36 quarts = 18 half-gallons Tofu** 1 pound tofu / 1 quart of milk Max: 6 pounds If >6 pounds (Medical Documentation required)** Max: 36 pounds Cheese* 1.5 pound

Juice, single variety 216 fluid ounces juice NA

Breakfast Cereal 54 ounces NA

Eggs 3 dozen eggs NA

Fruits and Vegetables $15.00 Cash value voucher NA

Whole grains* including: bread, tortillas, oatmeal, and brown rice 1 pounds or 2 pounds (alternating months) NA

Peanut butter 18 ounces peanut butter

Dry/Canned beans 2 pound dry beans or 128 ounces canned beans

Canned Fish 45 ounces fish; Light Tuna or Pink Salmon NA

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7 1 / 2 0 1 1 *Whole Grains and Cheese: to provide the maximum benefit (1.5 pounds) Issue 1 pound for the 1st and 3rd months, and 2 pounds for the 2nd month of voucher issuance. **Tofu substitutions > 6 pounds for milk require medical documentation. Qualifying reasons include: ▪ Milk allergy ▪ Sever lactose maldigestion (cannot tolerate lactose-free milk) ▪ 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. For example: ▪ Lactose-free milk ▪ Lactose-free milk + cheese ▪ Lactose-free milk + regular milk ▪ Lactose-free milk + regular milk + cheese Instruct the participant on how to identify the lowfat version in the grocery store. It may be helpful to show a picture or sample carton. When issuing lactose-free milk in the Information System, select “Fat Free or Lowfat 1%” lactose-free milk. Lactose-free milk may taste different to the participant. Offer suggestions if this is an issue (note: do not suggest to the participant 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. ▪ If some regular milk is tolerated, mix with lactose-free milk.

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8 1 / 2 0 1 1 ▪ Try different brands of lactose-free milk. ▪ Give it time. Assure the participant that most people become accustomed to the slight difference. If the participant expresses reluctance to try lactose-free milk, use open-ended questions to identify and address participant perceptions and concerns. Goat milk Goat milk may be preferred by some participants. ▪ Goat milk may be useful in some cases of cow milk insensitivity/intolerance or allergy to soy- based beverage. The types of casein in goat milk, plus the evaporation process (for 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: ▪ Cow’s milk protein allergy: cross-reactivity of proteins may increase allergic potential to goat milk. ▪ Lactose intolerance: goat milk may not be helpful 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 Allergy prevention for the infant: updated AAP guidance states that there is lack of evidence that maternal dietary restrictions during lactation play a significant role in the prevention of allergies in infants. More study is needed to draw any definite conclusions. (Source: Effects of Early Nutritional Interventions on the Development of Atopic Disease in Infants and Children; PEDIATRICS Volume 121, Number 1, January 2008.) Refer to the Health Care Provider if there are concerns. 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: ▪ 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, in comparison with 30 % DV for calcium found in 1 cup of milk.

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9 1 / 2 0 1 1 Reference – Complete Listing of Hyperlinks Section 7.9: Food Package for Infants, Women, and Children with Qualifying Medical Conditions (Food Package 3) (https://www.health.state.mn.us/docs/people/wic/localagency/program/mom/chsctns/ch7/sct n7_3.pdf) Contract Formula Amounts Guide (https://www.health.state.mn.us/docs/people/wic/localagency/nutrition/formula/contract.pdf) MN WIC Medical Formula Amounts Guide (https://www.health.state.mn.us/docs/people/wic/localagency/nutrition/formula/medical.pdf) MN WIC Formula Amounts Guide: Maximum Amounts by Federal Regulation (https://www.health.state.mn.us/docs/people/wic/localagency/nutrition/formula/maxamounts. pdf) Exhibit 7-J: Mom and Baby WIC Food Packages (https://www.health.state.mn.us/docs/people/wic/localagency/program/mom/exhbts/ex7/7j.p df) Section 7.6: Medical Documentation (https://www.health.state.mn.us/docs/people/wic/localagency/program/mom/chsctns/ch7/sct n7_6.pdf) 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.