720.1 Policy 720 General Information on Formula Use November 26, 2019 POLICY Formulas shall be provided to meet the nutritional and medical needs of infants who are not fully breastfed. Children and women enrolled in the WIC program may also receive formula when medically necessary. PURPOSE To provide the formula that most closely suits the nutritional and medical needs of the participant in the most cost-effective way. RELEVANT REGULATIONS 7 CFR §246.10(e)(1,2)—Amount and type of eligible infant formulas 7 CFR §246.10(e)(3)—Amount and type of eligible formulas and foods for children and adults 7 CFR §246.10- Tables 1 and 3 OREGON WIC PPM REFERENCES ♦ 713—Breastfeeding: Use of Supplemental Formula ♦ 730—Bid Formula: Use and Description ♦ 760—Medical Formulas and Nutritionals ♦ 769—WIC Food Packages PROCEDURE Basic Requirements 1.0 Federal regulations state that infant formulas used in the WIC program must meet the following basic requirements: • be a complete formula, one that does not require adding any ingredient other than water before it is served; • contain at least 10 milligrams of iron per liter at standard dilution; • supply 67 calories per 100 millimeters, or approximately 20 calories per fluid ounce, at standard dilution.

Formulas that do not meet the requirements listed above can be authorized at State discretion with medical documentation (e.g. Similac Sensitive 19 kcal/oz formula).

General Information on Formula Use, Continued 720.2

Maximum amount of formula 2.0 Infants up to 12 months of age may receive a maximum monthly allowance of: Age Formula Maximum Quantity Allowable Birth through 3 months • 870 fluid ounces reconstituted powder * • 823 fluid ounces reconstituted liquid concentrate • 832 fluid ounces ready-to-feed 4 through 5 months • 960 fluid ounces reconstituted powder • 896 fluid ounces reconstituted liquid concentrate • 913 fluid ounces ready-to-feed 6 through 11 months • 696 fluid ounces reconstituted powder • 630 reconstituted liquid concentrate • 643 fluid ounces ready-to-feed 6 through 11 months, standard infant formula, and medical formulas, no infant foods • 960 fluid ounces reconstituted powder • 896 fluid ounces reconstituted liquid concentrate • 913 fluid ounces ready-to-feed * Reconstituted fluid ounce is the form prepared for consumption as directed on the container.

See 769—WIC Food Packages, Appendix B, for complete listing of the maximum amount of formula and food allowed for infants’ age and amount of breastfeeding. Formula for women and children 3.0 In certain circumstances, women and children may receive formula. Refer to 760— Medical Formula and Nutritionals, for further information and issuance guidelines. Bid Formulas 4.0 All pregnant participants shall be encouraged to choose breastfeeding as the preferred method of infant feeding unless contraindicated for health reasons. For women who choose not to exclusively breastfeed and to use infant formula, local WIC programs shall use the bid formulas as described in 730—Bid Formula: Use and Description. Forms of formulas 5.0 Formulas are available in three basic forms: powder, concentrate, and ready-to-feed. All three are equal in nutritional value, but each has advantages and disadvantages for use. See the Oregon WIC Program training manual “Infant Formula Module” for complete information on formula types, preparation, storage, and feeding guidelines.

General Information on Formula Use, Continued 720.3 Powder

Powder is recommended for most participants as it is the most cost effective per fluid ounce, there is no need to refrigerate opened cans, and it is safe and convenient for travel. 5.1.1. Recommend powder formula for infants who are some (mostly) breastfed. See 713—Breastfeeding: Use of Supplemental Formula for guidelines on formula issuance for a partially breastfed infant. Concentrate

Concentrate is easy to prepare. It is less cost-effective than powder and must be refrigerated after opening. Ready-to-feed

Ready-to-feed needs no preparation but must be refrigerated after opening. It is the most expensive of the three forms and is available to participants only under the following special circumstances: • unsanitary, tainted or restricted water supply or poor refrigeration; • caretaker’s inability to correctly reconstitute the concentrated liquid or powdered formula; • the WIC infant formula is only available in ready-to-feed; • the participant has a qualifying medical condition that justifies the need for ready-to-feed for the following conditions: o The ready-to-feed form better accommodates the participant’s condition o The ready-to-feed form improves the participant’s compliance in consuming the formula

See 760—Medical Formula and Nutritionals, for guidelines on formula issuance for participants with qualifying medical conditions. 5.3.1. Document the reason for issuance of ready-to-feed formula in the participant’s record in the data system. Combining forms of formulas 6.0 More than one form of formula and type of formula may be issued to a participant if needed. The total amount issued may not exceed a combined total of the maximum allowable reconstituted fluid ounces for that category. If necessary, contact your nutrition consultant for assistance. Food Safety 7.0 All formulas are to be handled the same once they are reconstituted. Strict adherence to food safety precautions is essential for the safe use of formula. Lead contamination 8.0 Public health officials recommend not using hot tap water in formula preparation because of possible lead leaching from pipes. Only cold water from the tap should be used, running tap water for 15-30 seconds until it feels noticeably colder. For more information, visit the State of Oregon Lead Poisoning Prevention Program’s website.

General Information on Formula Use, Continued 720.4 Special considerations 9.0 WIC formulas are not intended for participants while they are hospitalized. Hospitals are responsible for providing formula during a WIC participant’s hospitalization. REFERENCES 1. Infant Nutrition & Feeding: A reference handbook for Nutrition and Health counselors in the WIC & CSF Programs. USDA, FNS..

2. Story, Mary et. al., eds. Bright Futures in Practice: Nutrition. Arlington, VA: National Center for Education in Maternal and Child Health, 2000.

3. Infant Feeding and Nutrition Module, Oregon WIC Program, 2014

4. Revisions in the WIC Food Packages Final Rule USDA, FNS, 2014

POLICY HISTORY Date * Major revision, Minor revision 10/13/2016 Revision 11/26/2019 Minor revision

The date located at the top of the policy is the implementation date unless an “effective date” is noted on the policy. Policies will become compliance findings 6 months from the implementation date. Release notes can be found in the corresponding document on the Policy and Procedure Manual page. *Major Revisions: Significant content changes made to policy. Minor Revisions: Minor edits, grammatical updates, clarifications, and/or formatting changes have occurred. Date of Origin: Date policy was initially released If you need this in large print or an alternate format, please call 971-673-0040. This institution is an equal opportunity provider.