us-ut/policy/wic-state-plan/fy2027

loading…

us-ut/policy/wic-state-plan/fy2027 — Axiom

(section-ii)(adjunct-eligibility)(page-2)Page 2#

Utah WIC Local Agency Policy and Procedures Manual

VIII. Certification, Eligibility and Coordination of Services/Income Eligibility/Adjunct Eligibility Page 2

IV. Supplemental Nutrition Assistance Program (SNAP).

a. Eligibility for the SNAP Program is household based. To be adjunctively eligible for WIC, it must be determined if each individual WIC applicant is a participating member of the SNAP household. Mark the appropriate check box and enter the proof type for each applicant to be certified in the Adjunct Eligibility screen.

b. If an applicant qualifies for WIC based on receiving Expedited SNAP, also known as emergency SNAP, only the current month’s WIC benefits should be issued. Proof of SNAP eligibility or proof of income must be provided before further issuance.

c. SNAP Horizon cards may not be used as proof of SNAP.

V. When an applicant is adjunctively eligible, they must provide verification of current enrollment in one of the above programs. Otherwise, if proof of current enrollment is not available, they must provide proof of income.

a. The adjunct eligible program and the proof of participation must be recorded in the Adjunct Eligibility screen within the income screen. If the applicant qualifies based on Medicaid, the Medicaid number must be entered into VISION.

b. Verification of Medicaid program eligibility is completed using the Eligibility Lookup Tool. i. This is located in the Utah Department of Health and Human Services’ Medicaid website at https://medicaid.utah.gov/eligibility- lookup-tool. ii. Enter your Provider ID (local health department NPI number) and the date of service (today’s date). iii. For the participant, enter either the Medicaid number and the first name and last name; or the first name, last name and date of birth. iv. Local agencies can require the participant to present their Medicaid card prior to checking eligibility on the Medicaid site. v. The results page will return the current eligibility date span along with other information not relevant to WIC. vi. Once eligibility for Medicaid is determined, enter the information in the adjunct eligibility screen in VISION.

c. Verification of other adjunct program participation is normally documented by the participant providing a letter from the government agency verifying current eligibility.

d. Local agencies must allow applicants to provide proof of participation in adjunct eligible programs via the internet through the Department of

(section-ii)(adjunct-eligibility)(page-3)Page 3#

Utah WIC Local Agency Policy and Procedures Manual

VIII. Certification, Eligibility and Coordination of Services/Income Eligibility/Adjunct Eligibility Page 3

Workforce Service’s “myCase” system. If the myCase system does not have the Medicaid number, the Medicaid card must be presented.

e. Applicants who have provided proof of adjunct eligibility should have this recorded in the Adjunct Eligibility screen regardless of whether or not the family has also provided proof of household income.

VI. When proof of adjunctive eligibility has been provided that covers all current applicants to be certified in the family, proof of income is not required. WIC staff must ask the family to self-declare the amount of their current household income.

a. Staff should explain that the family’s self-declared income amount will not affect eligibility, and that this information is used for statistical purposes only.

b. Families may estimate their gross household income when exact amounts are unknown. Proof is not required.

c. If the family does not wish to self-declare income or cannot provide this information, do not add a row to the income record. Document in the comments the reason a self-declared income was not recorded.

d. Steps for entering self-declared income in VISION: i. If all current applicants to be certified in the family are adjunctively eligible, 1. First complete the Adjunct Eligibility record for each adjunctively eligible family member (applicants to be certified and family members currently certified). 2. Add a row to the Income Determination field. 3. Select the appropriate source of income from the drop-down list. 4. Leave the Proof field blank. 5. Enter the dollar amount of household income the family is declaring in the Amount field. 6. Enter the frequency that this income is received in the Period field. ii. If not all family members applying for WIC are adjunctively eligible, 1. Complete the adjunct eligibility link for those who are. 2. Additional family members applying for WIC must provide proof of income; this will be the income record which is entered for the family. 3. No self-declared income should be input when proof of income is required. iii. For foster children who are adjunctively eligible, 1. Complete the Adjunct Eligibility screen.

(section-ii)(anthro-and-biochemical-procedures)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Certification, Screening, and Assessment/Anthropometric and Biochemical Procedures

Page 1

Anthropometric and Biochemical Procedures

I. The following data and charting is required at certification, midcertification, and recertification for participants in the following categories unless otherwise stated or the participant is assigned a nutrition risk factor that requires more regular data collection and charting. For detailed procedures on how to collect anthropometric and biochemical data, please refer to the Laboratory Module.

Category and Age Required Data Required Charting Infants <9 months of age • Occipital Frontal Circumference (OFC) • Recumbent length • Weight • OFC for age • Length for age • Weight for age • Weight for length Infants 9 to 12 months of age • OFC • Recumbent length • Weight • Hematological test

o Referral data or deferral for infants 9 to < 12 months of age is preferred o Must be completed before they turn 13 months old • • Lead test screening* • OFC for age • Length for age • Weight for age • Weight for length • Hematological test • Lead test screening* Children 13 to 23 months of age • Recumbent length • Weight • Hematological test • Standard practice is to test when the participant is 12 months old to fulfill the infant test requirement, and again between 15 to 18 months old to meet federal requirements if values are normal. • If the participant is first certified when they’re 13 to 18 months old, they must be tested upon certification, and again 6 months later if values are normal. • If the participant is first certified when they’re 19 to 23 months old, they must be tested upon certification and do not require another hematological test before they turn 2 years old if values are normal. • • Lead test screening* • Length for age • Weight for age • Weight for length • Hematological test • Lead test screening*

(section-ii)(anthro-and-biochemical-procedures)(page-2)Page 2#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Certification, Screening, and Assessment/Anthropometric and Biochemical Procedures

Page 2

Children 2 to 5 years of age • Standing height • Weight • Hematological test • Annually if values are normal • Lead test screening* • Height for age • Weight for age • BMI for age • Hematological test • Lead test screening* Pregnant women • Pre-pregnant weight • Height • Current weight • Documented every 3 months after certification • Hematological test • Only upon certification if values are normal • Pre-pregnancy BMI • Height • Current weight • Hematological test Breastfeeding and Postpartum Women • Pre-pregnant weight • Total weight gain • Height • Current weight • Hematological test • Only upon certification if values are normal • Pre-pregnant weight • Total weight gain • Height • Current weight • Hematological test

a. Infants >9 months old and children only need to be screened for lead testing one time upon enrollment to the Utah WIC program. You do not need to screen for lead testing more than once. Refer to the Healthcare Referrals P&P for more detail.

II. Anthropometric and Biochemical Referral Data:

a. Referral data must be accurate and reliable. Examples of acceptable data collection methods include, but are not limited to: i. Data from a recent clinical visit with a healthcare provider. This data may be given from the provider to the participant, orparticipant or electronically sent to the local WIC clinic. 1. Anthropometric data must be taken within 60 days of the WIC appointment to be valid. 2. Hematological data must be taken within 90 days of the WIC appointment to be valid. 3. The participant may show or take a screenshot of data on their patient portal, or relay the data directly from the health record. ii. Data from another trusted partner who is trained in taking accurate anthropometric or biochemical measurements (i.e., health manager for Head Start during an assessment, home visiting program nurse, or public health nurse). iii. A referral source with this data on file and authority to share it with WIC, such as a social worker.

(section-ii)(anthro-and-biochemical-procedures)(page-3)Page 3#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Certification, Screening, and Assessment/Anthropometric and Biochemical Procedures

Page 3

iv. The WIC referral data form. This is not the only acceptable form that can be used.

b. Measurements taken by the applicant themselves, the parent or caregiver, or are self-reported from memory are not allowed.

c. Staff must document the source of the medical data in VISION if receivingif they receive referral data. i. Anthropometrics: enter referral data and select “Referral data” in the ‘Inaccurate Reason’ drop down menu. ii. Bloodwork: select ‘Yes’ in Blood Work Taken box and enter referral data. Document the source of the medical data in the ‘Notes’ text box in the Blood screen in VISION.

d. Data collected for women must be taken at a time that is reflective of their category (i.e., you can’t use data that was taken during pregnancy to certify a woman as postpartum).

III. Routine Maintenance of Scales and Measuring Boards.

a. Perform daily maintenance of scales as follows: i. Scales should be placed on a hard, non-carpet surface. If the area is carpeted, place the scale on a piece of plywood or a standing base. ii. Check that the scales balance at zero daily and after weighing every participant. 1. Move the ounce and pound weights to zero until the arm rests in the center. 2. Check digital scales between measurements to ensure zero reading. 3. If scales do not balance at zero, notify supervisor for scale to be serviced. iii. Clean scales every day they are in use. 1. Check for wear and broken or faulty parts. 2. Refer to the Laboratory staff training module for details. iv. Record cleaning, repair, and replacement on the maintenance sheet for each scale.

b. Perform yearly maintenance of scales as follows: i. Have scales inspected yearly by the Utah Department of Agriculture, Weights and Measures, Market Licensing Division. Call them at (801) 982-2260 if you don’t know the contactcontact details for your county. ii. If scales pass inspection, you will receive a Utah Department of Agriculture Seal that will be dated and placed directly on your scale.

(section-ii)(anthro-and-biochemical-procedures)(page-4)Page 4#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Certification, Screening, and Assessment/Anthropometric and Biochemical Procedures

Page 4

iii. If scales do not pass inspection, the inspector must complete a “Small and Medium Scale Inspection Report.” Make a copy and place it on the wall above the scales. Work with the Utah Department of Agriculture to remedy these issues. Make other arrangements for weighing while scales are being serviced. iv. New scales should be calibrated by the manufacturer before you receive them. You may use new scales before they’re inspected by the Utah Department of Agriculture, Weights and Measures, Market Licensing Division. However, arrange to have new scales inspected by them as soon as possible.

c. Perform daily maintenance of measuring boards as follows: i. Clean measuring boards with disinfectant each day they are in use. ii. Check for wear and broken or faulty parts.

d. Perform yearly maintenance of measuring boards as follows: i. Check all boards for accuracy by: 1. Using a metal measuring tape; 2. Checking for slippage on wall mounted boards; and 3. Checking the right angle on head and foot boards. ii. Record cleaning, repair and replacement on the maintenance sheet for each measuring board.

IV. HemoCues

a. Routine maintenance of HemoCues. i. Always follow the manufacturer’s directions when cleaning and maintaining blood work machines. Perform daily maintenance of HemoCues as follows: 1. Clean HemoCues every day they are in use. Follow the manufacturer’s directions. 2. Record cleaning on maintenance sheet for each separate HemoCue machine. 3. If necessary and depending on the type of equipment, follow the manufacturer’s instructions for calibration.

b. Perform annual maintenance of HemoCues as follows: i. All records of cleaning, repair, and replacement should be recorded on the maintenance sheet for each HemoCue machine.

V. Pronto

a. The Pronto-7 offers noninvasive and quick spot-check testing of total hemoglobin (SpHb). This technology may provide the following benefits: i. Staff 1. Easy-to-use — Improves efficiency

(section-ii)(anthro-and-biochemical-procedures)(page-5)Page 5#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Certification, Screening, and Assessment/Anthropometric and Biochemical Procedures

Page 5

2. Decreases risk of accidental needle stick and exposure to blood- borne pathogens 3. Requires no lab consumables or waste disposal ii. Participant 1. Reduces painful needle sticks and time-consuming blood draws 2. Enables immediate face-to-face counseling with clinician

b. Refer to the Laboratory Module for specific procedures.

VI. Hematological Testing (blood work).

a. A hematological test must be performed or results obtained from a referral source at the time of initial certification or within 90 days of the date of initial certification for: i. Infants (9 to 12 months old). 1. A deferral up to 90 days is preferred to test closer to the individual’s 1st birthday. However, the deferral cannot go past their 12th month of life. 2. Any test in the 12th month (the month that they turn 1 year) counts as an infant test. (Example: A participant’s 1st birthday is on July 12. The whole month of July is considered their 12th month of life. A hematological test on July 15 still counts as an infant test.) ii. Children (13 months to 23 months old). iii. Children (2 to 5 years old). iv. Pregnant, breastfeeding or postpartum women.

b. The hematological test may be deferred for up to 90 days from the time of certification for applicants who have at least one qualifying nutritional risk factor present at their certification appointment. i. A hematological test must be performed or obtained from a referral source immediately if no qualifying nutritional risk factors are identified during the nutrition interview.

c. Hematological tests for infants 9 to 12 months old. i. Infants enrolled in the Utah WIC Program must be tested before the end of their 12th month of life. ii. A hematological test is not required at the time of certification if the infant is < 9 months old at that appointment. iii. Participants with hematological test results that are lower than the normal range and meet high-risk criteria must be tested more frequently.

d. Hematological tests for children aged 13 to 23 months old.

(section-ii)(anthro-and-biochemical-procedures)(page-6)Page 6#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Certification, Screening, and Assessment/Anthropometric and Biochemical Procedures

Page 6

i. Standard practice is to test when the participant is 12 months old to fulfill the infant test requirement, and between 15 to 18 months old to meet federal requirements if values are normal. ii. If the participant is first certified when they’re 13 to 18 months old, they must be tested upon certification, and again 6 months later if values are normal. iii. If the participant is first certified when they’re 19 to 23 months old, they must be tested upon certification and do not require another hematological test before they turn 2 years old if values are normal. iv. Participants with hematological test results that are lower than the normal range and meet high-risk criteria must be tested more frequently.

e. Hematological tests for children aged 2 to 5 years old. i. Children aged 2 to 5 years old who are enrolled in the Utah WIC Program must be tested at least 1 time every year (every 12 months). ii. Complete another hematological test in 6 months if their hematological test result is lower than the normal range, butrange but doesn’t meet high-risk criteria. Complete another hematological test before 6 months if their hematological test result is lower than the normal range and meets high-risk criteria.

f. Hematological tests for pregnant, breastfeeding, or postpartum women. i. Pregnant, breastfeeding, or postpartum women must be tested at each certification appointment. 1. Hematological testing and follow up is only required while a participant is certified. ii. Complete another hematological test in 6 months if their hematological test result is lower than the normal range, butrange but doesn’t meet high-risk criteria. iii. Complete another hematological test before 6 months if their hematological test result is lower than the normal range and meets high-risk criteria.

g. A note must be requested from a participant’s healthcare provider if the participant has been diagnosed with sickle cell anemia or another condition that would cause their hematological test results to continuously be lower than the normal range or if a hematological test isn’t medically appropriate. i. The healthcare provider note must include: 1. The participant’s diagnosis. 2. The participant’s most recent hemoglobin value (if available). 3. A statement indicating the participant’s hematological test results will continually be lower than the normal range or that

(section-ii)(appeals)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual

VIII. Certification, Eligibility and Coordination of Services/Appeals/Appeals Page 1

Appeals I. Agency Conference & Fair Hearings (participant or applicant appellants).

a. Availability of hearings: The sState agency shall provide a hearing procedure through which any individual may appeal a state or local agency action which results in a claim against the individual for repayment of the cash value of improperly issued benefits or results in the individual’s denial of participation or disqualification from the pProgram.

b. Request for hearing. A request for a hearing is defined as any clear expression by the individual, the individual's parent, caretaker, or other representative, that he or she desires an opportunity to present its case to a higher authority. The State or local agency shall not limit or interfere with the individual's freedom to request a hearing. Hearing requests by appellants can be made verbally, or in writing and delivered or sent to the State or local agency. i. Requests for hearings must be made within 60 days of the adverse action. ii. Continuation of Benefits. Participants who appeal the termination of benefits within 15 days of being notified of the adverse action must continue to receive pProgram benefits until the hearing official reaches a decision or the certification period expires, whichever occurs first. This does not apply to applicants denied benefits at initial certification, participants whose certification period has expired or participants who become categorically ineligible for benefits. Applicants who are denied benefits at initial certification, or participants who become categorically ineligible during a certification period (or whose certification period expires), may appeal the denial or termination, but must not receive benefits while awaiting the hearing.

c. When possible, an Agency Conference should be held to resolve the problem on the local level. Appellants may be encouraged to attempt to settle the dispute in an Agency Conference before requesting a Fair Hearing. An Agency Conference is defined as problem resolution discussion with the supervisory personnel of the clinic/local agency and the participant/applicant. The sState aAgency will be represented at all Agency Conferences. In participating in the Agency Conference, the participant agrees to try and resolve the problem. If the Agency Conference does not resolve the problem to the appellant's satisfaction, or if the appellant does not want an Agency

(section-ii)(breastfeeding-aids)(page-3)Page 3#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Breastfeeding Promotion and Support/Breastfeeding Aids Page 3

VII. Breastfeeding aids are only issued when a designated breastfeeding expert, CPA, or a senior peer counselor has documented a need. To ensure cost effectiveness, local agencies must:

a. Provide instruction on hand expression to all lactating mothers if applicable (written materials and instructional video are available).

b. Instruct mothers to maintain equipment provided to them for future use.

VIII. Women who are breastfeeding an infant(s) that they did not give birth to may be certified to participate in the WIC program as breastfeeding women and may receive benefits and breastfeeding aids until the infant is 1 year of age if exclusively or in-range breastfeeding.

a. The postpartum birth mother who meets eligibility criteria is eligible to receive postpartum benefits even if her infant is being breastfed by a certified non-birth mother.

IX. Women who are incarcerated may be allowed to participate in the WIC program and receive services offered by WIC, excluding food benefits.

a. It is the discretion of the local agency to allow breastfeeding aids to be loaned to these participants. The local agency should investigate the situation to see if the institution would allow the WIC participant to utilize the breastfeeding aid.

X. Authorized staff must be trained appropriately on the use and issuance of all WIC purchased breastfeeding aids.

a. Instruction on the use of non-WIC purchased breastfeeding aids and pumps are permitted.

XI. Distribution of Breastfeeding Aids. Staff qualified to issue breastfeeding aids are summarized in the table below: Staff Member May issue Additional requirements Designated Breastfeeding Expert (DBE) • All breastfeeding equipment and aids • Complete required training and demonstrate competency with all breastfeeding aids • Component of job description

(section-ii)(breastfeeding-aids)(page-7)Page 7#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Breastfeeding Promotion and Support/Breastfeeding Aids Page 7

XV. The Breastfeeding Equipment Due report (found under VISION Reports, Clinic Services Reports, Breastfeeding Reports) displays the serialized equipment issued to participants. This report may be helpful in making follow up counseling calls and for verifying inventories.

XVI. The Breastfeeding Equipment Issued report (found under VISION Reports, Clinic Services Reports, Breastfeeding Reports) displays the total number of equipment issued to participants. This report may be helpful in determining a utilization rate and for projecting supply orders through the state office.

XVII. Inventorying, Orders and Storing Breastfeeding Aids and Equipment.

a. Local Breastfeeding Coordinators must inventory each agency’s breastfeeding aids and supplies (e.g., breast pump kits) and breastfeeding equipment (e.g., electric breast pumps, single-user pumps, kits) at the end of each month and submit to the Utah State Breastfeeding Coordinator upon request.

b. Monthly Breastfeeding Supply Logs and Inventory forms to be used.

c. Local breastfeeding coordinator is responsible for collection of all inventories and for submission to the state within the specified deadline. (Agency specific forms provided for biannual inventory submission.)

d. Record of the inventories must be kept at the clinic.

e. Local breastfeeding coordinator is responsible for these inventory activities for their clinics.

f. The Non-Serialized Issuance Report can be used for the tracking of monthly breastfeeding aids and for confirming physical inventories.

XVIII. Local breastfeeding coordinators are responsible for completing or confirming orders for breastfeeding aids/supplies and equipment for all of their clinics.

a. State breastfeeding coordinator may assist in projection of order.

b. Orders should be projected and based on utilization and inventory balances.

(section-ii)(breastfeeding-aids)(page-11)Page 11#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Breastfeeding Promotion and Support/Breastfeeding Aids Page 11

ix. Other special situations (call the state breastfeeding coordinator for approval).

b. Only designated breastfeeding experts, IBCLC, or CPAs trained on the use and issuance of the infant feeding tube devices may provide issuance. The CPA must demonstrate competency and receive authorization from the local breastfeeding coordinator prior to issuing infant feeding tube devices.

c. High-risk infants must be followed by an RD or IBCLC. If a designated breastfeeding expert or CPA is not an IBCLC or RD, they must consult with one prior to issuing the infant feeding tube device. The infant’s high- risk care plan must note the reason for the use of the infant feeding tube device and the follow-up plan. i. Weight of infant must be done prior to set-up (nude or dry diaper - document in VISION and use consistent procedure for each follow up visit).

b. Use of this device requires specialized assessment skills and diligent follow up.

c. Appropriate verbal and written instructions must be provided to the participant at the time of issuance. Intensive instruction, both verbal and hands-on, must be given to participants using an infant feeding tube device. Instructional booklet included in the product package to be provided to participant. Having the participant watch an instructional video in the clinic is recommended.

d. The infant’s physician must be notified within 3 days when an infant feeding tube device is issued, unless an IBCLC has issued the infant feeding tube device. This contact must be documented in VISION.

e. Follow-up is required and must be completed in a timely manner. All follow-ups must be documented in VISION in either the Comments/Alerts screen, or the Care Plan, or the BF PC Documentation screen (Senior PC’s only). The following protocol must be followed: i. 24-72 business hours after you issue the SNS:Within 24 hours (or next business day): phone call or text follow-up. ii. Weekly follow-ups for 2 weeks after the initial 72-hour follow up.

(section-ii)(breastfeeding-aids)(page-12)Page 12#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Breastfeeding Promotion and Support/Breastfeeding Aids Page 12

1. 1 Week follow-up: Weight of infant is required at follow-up visit. Weight can be taken in clinic, or referral data from the health care provider can be used. iii. Follow up 1 month after you complete the weekly follow ups. ii.iv. Within 5 business days: follow-up appointment must be completed. Weight of infant is required at follow-up visit. Weight can be taken in clinic or referral data from health care provider can be used. iii.v. Subsequent follow-ups as deemed appropriate. 1. Staff members who issue infant feeding tube devices should use clinical judgement tojudgement to require in-person weight checks if this would benefit the participant and their breastfeeding goals. ii. In some situations, a pre- and post-feed weight check using an infant scale can provide useful information on the volume of breast milk transferred during feedings.

XXVI. Procedures for Nipple Shields

a. Nipple shields are to be used for infants and mothers with special needs. Appropriate circumstances for the use of nipple shields includes: i. Mothers with flat or inverted nipples who are unable to evert the nipple. ii. Mothers who are transitioning from bottle feeding to breastfeeding. iii. Infants who have difficulty latching to the breast. iv. Premature or late preterm Infants. v. Infants who have sucking problems. vi. Mothers who have severely damaged nipples.

b. Nipple shields are designed as a short-term solution in order to make breastfeeding successful.

c. If a nipple shield is issued, the mother’s milk must be protected and all other solutions for breastfeeding concerns must be tried and proved ineffective.

d. IBCLCs should primarily issue nipple shields. If an IBCLC is not available, then a designated breastfeeding expert or CPA who has completed state- approved specific training on issuing nipple shields may provide issuance.

Formatted: Font: Not Bold

(section-ii)(breastfeeding-aids)(page-13)Page 13#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Breastfeeding Promotion and Support/Breastfeeding Aids Page 13

e. High-risk infants must be followed by an RD or IBCLC. If a designated breastfeeding expert is not an IBCLC or RD, they must consult with one prior to issuing the nipple shield. The infant’s high-risk care plan must note the reason for the use of a nipple shield and the follow-up plan.

i. Latch assessment and weight of infant must be done (nude or dry diaper – document in VISION and use consistent procedure for each follow up visit).

f. Appropriate verbal, written, and hands-on instructions must be provided when a nipple shield is issued. Instructions must include the following: i. The purpose of a nipple shield. ii. Why the participant is being issued a nipple shield. iii. The potential risks of decreased milk supply and difficulty weaning off of the nipple shield to the breast. iv. Sizing of nipple shields. v. Appropriate length of time for nipple shield use. vi. Proper use of the nipple shield. vii. How to assess if the infant’s intake is adequate. viii. Cleaning the nipple shield. ix. Weaning from the nipple shield.

g. Follow-up is required and must be completed in a timely manner. Follow- up methods may be the clinic’s choice and may include a phone call, a text, an in-person appointment, etc. All follow-ups must be documented in VISION in either the Comments/Alerts screen, or the Care Plan, or the BF PC Documentation screen (Senior PC’s only).. The following protocol must be followed: i. 24-72 business hours after you issue the nipple shield:phone call or text follow-up. ii. Weekly follow- ups for 2 weeks after the initial 72-hour follow up. ii.1.1 Week follow-up: Weight of infant is required at follow-up visit. Weight can be taken in clinic, or referral data from the health care provider can be used. iii. Follow up 1 month after you complete the weekly follow ups. iv. Help mom wean her baby from the nipple shield when appropriate. v. Subsequent follow-ups as deemed appropriate. 1. Staff members who issue nipple shields should use clinical judgement to require in-person weight checks if they would benefit the participant and their breastfeeding goals. Formatted: Font: (Default) Arial, 12 pt Formatted Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt Formatted

(section-ii)(breastfeeding-aids)(page-15)Page 15#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Breastfeeding Promotion and Support/Breastfeeding Aids Page 15

member in a clinic is using the pump, a cooperative arrangement must be instituted for sharing the pump. ii. To help WIC participants to provide their infants with breast milk when special circumstances, situations, separation or medical problems would not enable mothers to establish lactation or continue breastfeeding under normal conditions. Loaning a multi- user electric breast pump is not limited to high risk or medical situations; other circumstances or situations may include poor latch, low milk production, inducement, relactation, increasing milk production, or other concerns expressed by the mother as indicated below.

c. An electric breast pump should be available in the clinic for participants who may need assistance on site. It is strongly recommended that a woman in such a situation would also require issuance of an electric breast pump for home use.

d. Clinics needing additional electric breast pumps may contact the state breastfeeding coordinator. Clinics need to have sufficient electric breast pumps to serve their population.

e. Electric pumps may be loaned to participants for the following reasons: i. Mother or infant hospitalized. ii. Premature infant unable to nurse adequately. iii. Infant with severe feeding problem (e.g., cleft lip or palate, insufficient suck). iv. Infant sick and unable to nurse adequately. v. Mother is sick and/or on contraindicated medication short-term. vi. Separation of mother and infant for more than 24 hours. vii. Mother of twins or triplets (or multiples). viii. Mother or infant having difficulties with breastfeeding and unable to nurse effectively or successfully. ix. Mother has low milk supply and/or wants to exclusively breastfeed, increase milk production, increase feedings at the breast, or decrease bottle or formula use. x. Other reasons (requires local designated breastfeeding expert approval).

(section-ii)(breastfeeding-aids)(page-16)Page 16#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Breastfeeding Promotion and Support/Breastfeeding Aids Page 16

f. Electric breast pumps prescribed by a physician or prescriptive authority for any infant must be offered a lactation assessment within two business days of receiving the prescription. i. Equivalent pump types will be honored (a multi-user or single user. Specific manufacturer brands do not have to be honored. ii. If an assessment is completed that does not warrant following the prescription (i.e., not providing a multi-user pump), the WIC CPA should contact the prescriptive authority. The prescriptive authority must agree with the CPAs assessment to deny issuance of the breast pump.

g. Follow the required procedures for loaning an electric pump, as described below: i. Mother must be either an active breastfeeding WIC participant or WIC staff member. Pregnant WIC participants cannot receive electric breast pumps unless they are breastfeeding an infant or child. ii. Determine if the mother needs a pump kit or adaptor kit. Issue appropriately. iii. Under Contact, provide contact information on one other responsible individual that may be contacted for follow up counseling or in tracking the issued item. The information should include name, and phone number. It is recommended but optional to obtain information on additional contacts or alternate residences; this can be documented under Contact 2 and Contact 3. iv. In the Family screen, a “BP” will be displayed as an alert to indicate that participant has been issued a breast pump. If the pump is not returned by the Contact/Return Date entered on the participant’s BF Equipment screen, this “BP” alert will turn red. v. If the participant cannot be present, the pump may be issued to a proxy or a responsible party for the participant. vi. According to federal policy, the participant must also receive one contact within the first 24-72 business hours following issuance. Participants with a multi-user electric breast pump must be followed monthly in order to provide lactation education and support, to promote transition to the breast, and to track the pump loaned. Documentation for all contacts must be in VISION in the Ccomments/Alert section. vii. Refer to section xii for additional details on serialized breastfeeding aids.

(section-ii)(breastfeeding-aids)(page-17)Page 17#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Breastfeeding Promotion and Support/Breastfeeding Aids Page 17

h. Local WIC Staff Home Pump Use. i. Loaning electric pumps to WIC staff for home use is allowed as long as it doesn’t interfere with the ability to provide pumps to WIC participants. ii. The Breastfeeding pump or aid and information loan agreement form signature form should be completed and kept in their employee file. Single User pumps are not allowed to be given. A pump at the office is also encouraged for communal use, with each person having their own pump kit.

i. Health Department Staff Use of Electric Pumps. i. Health department staff who are not WIC employees may use a clinic pump if: 1. A breastfeeding WIC staff member who is using the pump agrees to share use of the pump, 2. Their use does not inconvenience WIC staff or participants who are eligible to use the pump, and 3. The local breastfeeding coordinator approves.

j. Upkeep and repair of owned pumps. i. It is the local agency’s responsibility to notify and send in pumps to the State agency for repair. These pumps are under manufacturer’s warranty for one year. ii. Document on local agency inventory all electric pumps that are sent to the state agency (e.g., for repair). iii. WIC pumps that are part of a rental program are covered by an insurance policy with the manufacturer. iv. If a pump is reported to be broken or not working, please follow the following protocol: 1. Use the vacuum gauge to measure the vacuum levels of the pump and determine if the pump’s suction is at a proper level. 2. Record the measured suction from the vacuum gauge on a tracking sheet. The local agency Breastfeeding Coordinator must keep a record of the vacuum levels of all pumps that are reported to be broken. 3. Use the troubleshooting guide for electric pumps to determine what is wrong with the pump and if specific pump parts need to be replaced.

(section-ii)(breastfeeding-aids)(page-19)Page 19#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Breastfeeding Promotion and Support/Breastfeeding Aids Page 19

• Toll-free Number: 800-435-8316 (for Consumers; moms and dads press 1).

5. If the applicable company listed above cannot be reached, then contact the state breastfeeding coordinator to facilitate communication with the company.

k. Multi-User Breast Pump Returns i. Multi-user breast pumps must be returned at the end of participant use. 1. If a participant has a history of not returning a multi-user breast pump, clinics should deny issuance of a multi-user breast pump, unless there are extenuating circumstances, such as, but not limited to the pump being stolen (with police report provided) or cases of domestic violence. Contact the state breastfeeding coordinator for guidance. ii. Single-user breast pumps and breastfeeding aids do not need to be returned and should be kept for possible use with future infants. iii. WIC benefits cannot be denied to a participant for failing to return a pump 1. Only one month benefit issuance can be provided until the breast pump is returned. This requires a conversation between clinic staff and the participant to provide a reason for delay and the estimated pump return date. This should be documented in the Comments section in VISION. iv. If the participant is not able to be reached for follow-up, or the pump is suspected lost or stolen, the clinic should take the following actions: 1. Contact any or all parties listed on the pump BF Equipment screen under Contact 1, Contact 2 or Contact 3. Attempts should be made to identify other contact numbers or addresses from these contacts. 2. Mail certified letter to the participant or any of the contacts listed on BF Equipment screen. 3. Do not indicate pump as “lost” in VISION; The breastfeeding coordinator should be contacted when pumps are lost. a. Provide to the State Breastfeeding Coordinator via email: i. participant ID number ii. clinic name

(section-ii)(breastfeeding-aids)(page-20)Page 20#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Breastfeeding Promotion and Support/Breastfeeding Aids Page 20

iii. pump type iv. location of pump documentation in VISION 4. All relevant information pertaining to the actions taken by the local agency or of the circumstances of the participant should be documented in VISION. 5. Notify the state breastfeeding coordinator immediately if the pump is returned to the local agency in order to cancel the investigation by either the State office or by a private investigative service. 6. Communication will be between the state and local agencies. A private investigative service, upon working on a case, may contact the local agency to confirm a pump has been returned or to arrange a delivery date and time for returning a pump to the clinic.

l. Breast Pump Cleaning. i. The local breastfeeding coordinator must designate a staff procedure or person responsible for pump cleaning and maintenance. ii. Electric pumps must be cleaned: 1. When returned to the clinic after loan to a participant. 2. After each use, when used by more than one staff member. 3. After use in the clinic by a participant. 4. Documentation should be done in VISION in the BF Equipment screen under comments or in an electronic log that can be shared with the state office when requested. iii. Clean electric pumps as described: 1. Use the appropriate cleaning solution. 2. Prepared commercial antimicrobial cleaner specified for breast pumps, such as “Cavicide” or other approved germicidal solution specified by the pump is allowed. 3. Wear gloves when cleaning electric breast pumps. 4. Apply the cleaning solution to the pump (spray or wipe). 5. Follow the disinfectant agent’s instructions for use. Air dry or use a clean, dry cloth to wipe down the pump. Document date cleaned and staff initials according to clinic protocol. 6. Caution: Breast milk is a body fluid. Follow local health department precautions or see OSHA guidelines on handling of body fluids when in contact with breast milk. (Note: Universal Precautions do not apply to breast milk, but

(section-ii)(breastfeeding-aids)(page-21)Page 21#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Breastfeeding Promotion and Support/Breastfeeding Aids Page 21

caution is recommended. Reference information is from CDC.)

XXVIII. Procedures for Single-User Electric Breast Pump.

a. Single-user electric breast pumps may be provided to WIC breastfeeding mothers who are breastfeeding their infants any amount. The infant needs to have breastfeeding well established and has demonstrated adequate growth. The purpose of this type of pump issuance is to help breastfeeding participants maintain their established milk supply while continuing to breastfeed upon return to work and/or school. The single user breast pump is not designed for high-risk infants such as those who are premature, have cleft lip/palate, FTT, and hospitalized moms/infants.

b. Issuing Single-User Electric Breast Pumps. i. Issue pump in VISION ii. Provide Breastfeeding pump or aid agreement and information form, collect signature in VISION iii. Document this in the Nutrition Education screen in VISION as follows: 1. Nutrition Education Covered: Instructions for breastfeeding BF Equip/Pump/Aaids 2. Pamphlets Provided: Breastfeeding pump or aid agreement and information. 2.a. Senior peer counselors may document this in the BF PC Documenting screen by selecting: Received Breastfeeding Aid Agreement and Information Form in the postpartum topics iv. Make a plan to follow up at 2 weeks after issuance. Document contacts in the Comments/Alerts section in VISION. Only peer counselors can document in BFPC Documentation screen. v. Infant formula cannot be denied to participants if there is a change in breastfeeding frequency.

c. At health fairs and WIC outreach events, the public may be informed that Single-user electric breast pumps are available from WIC.

XXIX. Reducing Liability.

a. Breastfeeding aids, except the multi-user electric pumps that are loaned, are not exchanged or returned. Formatted: Font: 11 pt Formatted: Font: (Default) Arial Formatted Formatted: Font: (Default) Arial Formatted: Font: (Default) Arial Formatted: Font: (Default) Arial Formatted: Font: (Default) Arial Formatted: Font: 12 pt Formatted: Font: (Default) Arial Formatted: Font:

(section-ii)(breastfeeding-aids)(page-22)Page 22#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Breastfeeding Promotion and Support/Breastfeeding Aids Page 22

b. Participants receive new breast pump kits when receiving a multi-user pump.

c. Hard cases are encouraged to be used with multi-user electric breast pumps. Soft tote bags may be given to the participant but will not be returned for reuse with other participants. These cannot be sanitized as per manufacturer’s recommendations.

d. Breastfeeding aids, except multi-user pumps, are not to be exchanged between mothers or returned to the clinic.

e. Mothers must be encouraged to keep their supplies in a safe place when they are no longer needed, so that they will be available for future use (e.g., a subsequent pregnancy or separation from infant).

f. Only trained, qualified staff may issue equipment. Manufacturer’s instructions must be followed for all aids. For all staff who issue equipment, this responsibility must be included in their job description, performance plan, or annual evaluation.

g. The Breastfeeding Equipment screen must be completed for every participant who receives any breastfeeding equipment. A signature must be captured confirming the Breasting pump or aid agreement and information form has been read and understood. The signature verifies: i. The participant is informed of her rights and responsibilities. ii. The WIC program is not responsible for any personal damage caused by the use of the supply. iii. The local agency may release or request medical information from the participant’s health care providers (listed in VISION). iv. The participant consents to be touched when necessary for instruction or use of the breastfeeding aid. v. The participant has received written guidelines for pumping and storing breast milk. vi. The participant assumes responsibility to return the pump in good condition if it was loaned.

h. Appropriate materials and verbal instructions must be given to every mother who receives breastfeeding equipment.

(section-ii)(breastfeeding-counseling)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Nutrition Education and Counseling/ Breastfeeding Counseling/Education for WIC Participants Page 1

Breastfeeding Counseling/Education for WIC Participants I. Breastfeeding counselingeducation and assessment requirements a. Breastfeeding counseling education will be provided at each prenatal visit./contact. and b b. A breastfeeding assessment will be completed at a pregnant woman’s initial certification and initial postpartum certification. c. Breastfeeding core content information should be provided during the pregnancy certification or during a breastfeeding class. I.d. Breastfeeding anticipatory guidance will be provided at each postpartum visit/contact while the participant is breastfeeding. Assess a pregnant participant’s knowledge, attitude and concerns related to breastfeeding, and identifies the factors that may affect her success with breastfeeding. II. Contraindications to breastfeeding a. It is raren the rare or uncommon to have situations when breastfeeding is contraindicated. Not all counseling procedures need to be completed for the following contraindications: i. (e.g., i. Wwomen with HIV/AIDS (unless on HIV treatment— antiretroviral therapy or ART—and have discussed CDC guidelines with their healthcare provider). ii. ,W women with active tuberculosis (TB) and or who have not been medically treated for TB. iii. ,W women using contraindicated illicit drugs such as cocaine or amphetamines. iv. Women with unmanaged phenylketonuria (PKU), etc. v. , bBaby or /child with galactosemia or other inborn errors of metabolism., unmanaged phenylketonuria (PKU), etc.), not all steps in this process need to be completed. vi. Use ofSome contraindicated drugs (i.e. cancer medications or radioactive compounds). Note: some drugs may be used temporarily and breastfeeding may resume once discontinued..

III. Counseling for pregnant women II. a. At a pregnant woman’s initial certification visit, the CPA will complete a breastfeeding assessment by collecting the breastfeeding data and by following VENA guidelines.

Formatted Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt Formatted Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt Formatted: Numbered + Level: 1 + Numbering Style: i, ii, iii, … + Start at: 2 + Alignment: Left + Aligned at: 1.81" + Indent at: 2.31" Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt Formatted: Normal, No bullets or numbering Formatted: Font: (Default) Arial, 12 pt

(section-ii)(breastfeeding-counseling)(page-2)Page 2#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Nutrition Education and Counseling/ Breastfeeding Counseling/Education for WIC Participants Page 2

a.i. VENA counselingCounseling skills should will be used toby: i.1. First, eElicit the pregnant participant’s attitudes, concerns, and knowledge related to breastfeeding and identify the factors that may affect her success with breastfeeding. ii.i. Second, acknowledge her concerns and what she has reported. 2. Second, aAcknowledge her concerns and what she has reportedshared. 3. Third, Pprovide applicable breastfeeding education.

b. At least one breastfeeding class/individual contact must be offered to each pregnant woman enrolled in WIC. The following breastfeeding core content must be covered in this class/individual contact: i. Benefits of breastfeeding for mother and infant. ii. Basics of milk production and, maintaining production. iii. Exclusivity and frequency of breastfeeding. iv. How to determine baby is getting enough. v. Latch, positionsing, transfer of milk, stages of milk (colostrum, transitional milk, mature milk). vi. Hospital experience and, breastfeeding birth plan. vii. First days at home and, incorporation of breastfeeding into lifestyle. viii. Support (family, Designated Breastfeeding Expert (DBE), Peer Counselors, etc.).

c. The following content must be assessedprioritized and discussed., . Subsequent education should be tailored to the participants’ needs.and prioritized with subsequent individually tailored education being provided in a VENA participant centered approach during this individual/class contact. This contact must be documented in a consistent manner by the local agency: i. Encouragement to breastfeed. ii. Benefits of breastfeeding for mother and infant. Formatted: Numbered + Level: 3 + Numbering Style: i, ii, iii, … + Start at: 1 + Alignment: Right + Aligned at: 2.63" + Indent at: 2.75" Formatted: Numbered + Level: 4 + Numbering Style: 1, 2, 3, … + Start at: 1 + Alignment: Left + Aligned at: 3" + Indent at: 3.25" Formatted: Numbered + Level: 3 + Numbering Style: i, ii, iii, … + Start at: 1 + Alignment: Right + Aligned at: 2.63" + Indent at: 2.75" Formatted: Numbered + Level: 4 + Numbering Style: 1, 2, 3, … + Start at: 1 + Alignment: Left + Aligned at: 3" + Indent at: 3.25" Formatted: Font: (Default) Arial, 12 pt Formatted: Numbered + Level: 2 + Numbering Style: a, b, c, … + Start at: 1 + Alignment: Left + Aligned at: 2" + Indent at: 2.25" Formatted: Numbered + Level: 3 + Numbering Style: i, ii, iii, … + Start at: 1 + Alignment: Right + Aligned at: 2.63" + Indent at: 2.75" Formatted: Numbered + Level: 2 + Numbering Style: a, b, c, … + Start at: 1 + Alignment: Left + Aligned at: 2" + Indent at: 2.25" Formatted: Numbered + Level: 3 + Numbering Style: i, ii, iii, … + Start at: 1 + Alignment: Right + Aligned at: 2.63" + Indent at: 2.75"

(section-ii)(breastfeeding-counseling)(page-3)Page 3#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Nutrition Education and Counseling/ Breastfeeding Counseling/Education for WIC Participants Page 3

iii. Basics of breastfeeding including the principles of breast milk production. iv.ii. Common concerns. v.iii. Explanation ofUtah Breastfeeding Peer Counselors program. vi.iv. Anticipatory guidance./avoiding problems. vii.v. Early breastfeeding (immediately after delivery). viii.vi. Frequent breastfeeds (8-12 times/day). ix.vii. Rooming- in. x.viii. How to avoid Avoiding artificial nipples (bottles and pacifiers).

d. At all prenatal contacts, breastfeeding education must be provided. In an effort to increase breastfeeding durations, education should will reinforce the above information. as well as Breastfeeding education will include a tailored plan to meet the participant’s unique needs.focus on individual breastfeeding planninga to meet the participant’s circumstances. Additional information may be provided on other topics such as embarrassment and work or /school. d.

IV. Counseling for breastfeeding women III. a. At the postpartum woman’s breastfeeding certification visit, the CPA will complete conduct a breastfeeding assessment by completing the Breastfeeding Panel, Nutrition Interview, and by following VENA guidelines.

i. The following breastfeeding core content must be covered in this class/individual contactvisit: 1. Support and /encouragement to continue breastfeeding. 2. Problem solving. 3. Anticipatory guidance. for breastfeeding. 4. Adequate milk supply. 5. Growth spurts. /feeding problems. 6. Work oring/school. and breastfeeding. 7. Feeding cues.

Formatted: Numbered + Level: 2 + Numbering Style: a, b, c, … + Start at: 1 + Alignment: Left + Aligned at: 2" + Indent at: 2.25" Formatted: Indent: Left: 1.06", No bullets or numbering Formatted: Normal, No bullets or numbering Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt Formatted: Numbered + Level: 3 + Numbering Style: i, ii, iii, … + Start at: 1 + Alignment: Right + Aligned at: 2.63" + Indent at: 2.75" Formatted: Numbered + Level: 4 + Numbering Style: 1, 2, 3, … + Start at: 1 + Alignment: Left + Aligned at: 3" + Indent at: 3.25"

(section-ii)(breastfeeding-counseling)(page-4)Page 4#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Nutrition Education and Counseling/ Breastfeeding Counseling/Education for WIC Participants Page 4

a. ii. At everyall postpartum visits in whichvisit the participant is breastfeeding, staff must will discuss with the participant herevaluate breastfeeding status, update the Bbreastfeeding Ppanel, in order to provideprovide anticipatory guidance and information on avoiding problems and on how to continuestrategies for continued breastfeeding success.

IV. b. One breastfeeding class/individual contact must also be offered to each breastfeeding woman in all WIC clinics to encourage the continuation of breastfeeding.

a.i. The following breastfeeding core content must be covered in this class/individual contact: i.1. Support/encouragement to continue breastfeeding. ii.1. Problem solving. iii.1. Anticipatory guidance for breastfeeding. iv.1. Adequate milk supply. v.1. Growth spurts/feeding problems. vi.1. Working/school and breastfeeding. vii.1. Feeding cues.

b. c. The above information may be covered during certification counseling, follow-up counseling, group classes, or breastfeeding support groups. Additional state-approved breastfeeding class outlines are available from the State WIC Office.

c. Include a participant’s family and friends in breastfeeding education and support sessions, as appropriate.

V. iii. At every breastfeeding infant and child visit, staff will provide education and anticipatory guidance tailored to the participant’s current breastfeeding frequency and concerns.Breastfeeding topics need to be discussed at all infant and child ages, as applicable based on the breastfeeding frequency and/or concerns and using anticipatory guidance. Formatted: Normal, Indent: Left: 2", No bullets or numbering Formatted: Font: (Default) Arial, 12 pt Formatted: Normal Formatted: Normal, No bullets or numbering Formatted: Numbered + Level: 3 + Numbering Style: i, ii, iii, … + Start at: 1 + Alignment: Right + Aligned at: 2.63" + Indent at: 2.75" Formatted: Numbered + Level: 4 + Numbering Style: 1, 2, 3, … + Start at: 1 + Alignment: Left + Aligned at: 3" + Indent at: 3.25" Formatted: Normal, Indent: Left: 0.75", No bullets or numbering Formatted: Indent: Left: 1", No bullets or numbering Formatted: Normal, Indent: Left: 1.81", No bullets or numbering Formatted: Font: (Default) Arial, 12 pt

(section-ii)(breastfeeding-counseling)(page-5)Page 5#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Nutrition Education and Counseling/ Breastfeeding Counseling/Education for WIC Participants Page 5

Include a participant’s family, partner, and friends in breastfeeding education and support sessions, as appropriate. V. Food Packages/Food Rule Related and Breastfeeding Education Counseling Procedures. VI. a. Breastfed Infants.

i. Formula will not be provided to exclusively breastfed infants. ii.Formula may be issued to partially breastfed infants; however, education should be provided on limiting formula use to protect milk supply. As appropriate, encourage participants to return to exclusive breastfeeding.

Partially breastfeeding infants may be issued formula (but it is not recommended), in order to support mothers whose goal is to fully breastfeed. e. Formula may be provided to a breastfed infant only after a thorough assessment of the mother and infant dyad. All formula issued to a breastfed infant must be authorized by a CPA. a. The use of supplemental formula should be minimized for breastfeeding infants by providing only the amount of formula that the infant is consuming at the time of benefit issuance. Formula should not be given to exclusively breastfed infants.

b.a. Formula may be provided to a breastfed infant only after a thorough assessment of the mother and infant dyad. All formula issued to a breastfed infant must be authorized by a CPA.

Mothers who are requesting formula for the first time or who are requesting an increase in formula should be provided education and support on establishing milk supply for continued breastfeeding, if appropriate for their situation. c.

Formatted: Font: (Default) Arial, 12 pt Formatted: Font: Not Bold Formatted: Normal, No bullets or numbering Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt Formatted: List Paragraph, Numbered + Level: 5 + Numbering Style: i, ii, iii, … + Start at: 1 + Alignment: Left + Aligned at: 2.25" + Indent at: 2.75" Formatted: Indent: Left: 2.31", No bullets or numbering Formatted: Font: (Default) Arial, 12 pt Formatted: Numbered + Level: 2 + Numbering Style: a, b, c, … + Start at: 1 + Alignment: Left + Aligned at: 2" + Indent at: 2.25" Formatted: Font: (Default) Arial, 12 pt Formatted: Normal, Indent: Left: 0.75", No bullets or numbering Formatted: Indent: Left: 1", No bullets or numbering Formatted: Indent: Left: 0.75", Numbered + Level: 2 + Numbering Style: a, b, c, … + Start at: 1 + Alignment: Left + Aligned at: 2" + Indent at: 2.25" Formatted: Numbered + Level: 2 + Numbering Style: a, b, c, … + Start at: 1 + Alignment: Left + Aligned at: 2" + Indent at: 2.25" Formatted: Indent: Left: 0.5", No bullets or numbering Formatted: Font: (Default) Arial, 12 pt Formatted: Numbered + Level: 2 + Numbering Style: a, b, c, … + Start at: 1 + Alignment: Left + Aligned at: 2" + Indent at: 2.25"

(section-ii)(breastfeeding-counseling)(page-6)Page 6#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Nutrition Education and Counseling/ Breastfeeding Counseling/Education for WIC Participants Page 6

d. Powder, rather than concentrate or RTF formula, should be recommended to mothers of breastfed infants who request formula with the exception of premature and/or immunocompromised infants who may require sterile liquid

iii. Infant formula requests should must be evaluated on a case-by-case basis. Many low income or single mothers must return to work early or have other situations which may necessitate the use of formula. WIC staff working with WIC participants should be sensitive to a mother’s needs and should work with her to optimize the health of both the mother and the infant and support breastfeeding for as long as possible.

iv. The use of supplemental formula will be minimized by providing only the amount of formula that the infant is consuming at the time of benefit issuance. Offer only the amount of formula needed to support breastfeeding and optimally return to fully breastfeeding.

f. Formula is not recommended to fully and partially breastfeeding mothers and infants under one month of age.

g. Fully breastfeeding infants will not be issued formula.

h.a. Partially breastfeeding infants may be issued formula (but it is not recommended), in order to support mothers whose goal is to fully breastfeed.

i.a. Offer only the amount of formula needed to support breastfeeding and optimally return to fully breastfeeding.

j. v. Any time a breastfeeding participants requests formula or a change in formula amount, the following steps need to be taken and documented. Issuance of formula should not be based on meeting the total nutritional needs of the infant when combined with some breastfeeding or solely on the amount of formula use that is reported. Trouble shoot the reason the mother is requesting formula. An individual assessment must be made by a CPA or Designated Breastfeeding Expert (DBE). As appropriate, upon issuing formula, the staff member must: Formatted: Numbered + Level: 2 + Numbering Style: a, b, c, … + Start at: 1 + Alignment: Left + Aligned at: 2" + Indent at: 2.25" Formatted: Indent: Left: 1.06", No bullets or numbering Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt Formatted: Indent: Left: 0.5", No bullets or numbering Formatted: Numbered + Level: 1 + Numbering Style: i, ii, iii, … + Start at: 4 + Alignment: Left + Aligned at: 1" + Indent at: 1.5" Formatted: Font: (Default) Arial, 12 pt Formatted: Indent: Left: 1", No bullets or numbering Formatted: Indent: Left: 1.06", No bullets or numbering Formatted: Numbered + Level: 2 + Numbering Style: a, b, c, … + Start at: 1 + Alignment: Left + Aligned at: 1.5" + Indent at: 1.75" Formatted: Numbered + Level: 2 + Numbering Style: a, b, c, … + Start at: 1 + Alignment: Left + Aligned at: 1.5" + Indent at: 1.75" Formatted: Numbered + Level: 2 + Numbering Style: a, b, c, … + Start at: 1 + Alignment: Left + Aligned at: 1.5" + Indent at: 1.75" Formatted: Numbered + Level: 2 + Numbering Style: a, b, c, … + Start at: 1 + Alignment: Left + Aligned at: 1.5" + Indent at: 1.75" Formatted: Normal, Indent: Left: 0.5", No bullets or numbering Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt

(section-ii)(breastfeeding-counseling)(page-7)Page 7#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Nutrition Education and Counseling/ Breastfeeding Counseling/Education for WIC Participants Page 7

i. 1. Provide information on the benefits of breastfeeding (i.e., cost-effectiveness, convenience, immune support, health benefits) etc.). ii. 2.Provide information on how to support her decision to breastfeed and overcoming her barriers or concerns. iii. 3. Inform the mother how to produce moreDiscuss strategies on how to increase breast milk supply. iv. Not routinely issue formula packages with maximum amounts. v. 4. Offer partially breastfeeding packages; – “in- range” food packages allow mothers to receive benefits for up to 1 year postpartum. vi. 5. Document the completed breastfeeding assessment in the Food Package screen’s “Comments” field. Document additional details in the care plan if needed.

k. vi. Ensure the mother receives lactation support from WIC staff with breastfeeding training (, a peer counselor, CPA, or, DBE), or other health care professional who can adequately address the mother’s concerns and help her continue to breastfeedachieve her breastfeeding goals. Criteria may include, but not limited to, when a mother may need additional support, such asFactors that identify a need for increased breastfeeding support include, but are not limited to: i. 1. Mother expresses concerns about breastfeeding. ii. 2. Mother reports pain or discomfort with breastfeeding. iii. 3. Mother expresses statements that are not indicatinga lack of confidence in her ability to confidence with breastfeeding. iv. .Mother is asking for formula. v. 4. Mother expresses concerns regarding perceived insufficient milk supply or inadequate infant intake.does not think her baby is getting enough breast milk or that she is producing enough breast milk 5. Mother requests formula

l. To preserve breastfeeding, it is important for clinic staff to conduct a timely breastfeeding assessment during every clinic visit to ensure that Formatted: Normal, Indent: Left: 2.13", No bullets or numbering Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt Formatted: Indent: Left: 2.25", No bullets or numbering Formatted: Normal, No bullets or numbering Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt Formatted: Font: (Default) Arial, 12 pt Formatted: Indent: Left: 1", No bullets or numbering Formatted: Font: (Default) Arial, 12 pt Formatted: Numbered + Level: 1 + Numbering Style: i, ii, iii, … + Start at: 1 + Alignment: Left + Aligned at: 1" + Indent at: 1.5" Formatted: Font: (Default) Arial, 12 pt Formatted: Indent: Left: 1.5", No bullets or numbering Formatted: Font: (Default) Arial, 12 pt Formatted: Indent: Left: 1.5" Formatted: Numbered + Level: 2 + Numbering Style: a, b, c, … + Start at: 1 + Alignment: Left + Aligned at: 0.75" + Indent at: 1"

(section-ii)(breastfeeding-counseling)(page-8)Page 8#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Nutrition Education and Counseling/ Breastfeeding Counseling/Education for WIC Participants Page 8

breastfeeding is being optimized and the issuance of formula remains appropriate.

m. Benefits may be issued as partially breastfeeding and then projected to be fully breastfeeding for future issuing of benefits.

n. vii. Refer all breastfeeding women to a Peer Counselor.

o. WIC staff must not provide formula in anticipation of mother’s fear of not having enough breastmilk (“just in case”).

p.a. In the rare or uncommon situations when breastfeeding is contraindicated (e.g., women with HIV/AIDS, women with active tuberculosis and who have not been medically treated, women using contraindicated illicit drugs such as cocaine or amphetamines, baby/child with galactosemia, unmanaged phenylketonuria (PKU), etc.), not all steps in this process need to be completed. Some contraindicated drugs (i.e. cancer or radioactive compounds) may be used temporarily and breastfeeding may resume.

b.Breastfeeding women VII. i. Fully breastfeeding dyads are mothers that are exclusively or “fully” breastfeeding their infants and are not giving formula and are not receiving formula from WIC. or providing formula to their baby from any other source.

a. ii. These mothers participants will be informed of the following food benefits they will receive: i. 1. Enhanced Food Package VII for fully breastfeeding women provides the largest quantity and variety of foods than any other food package. ii. 2. Thisese enhanced food package benefits areis provided up to one year postpartum, versus 6 months for notthe non- breastfeeding womean.

b. These mothers will be informed of the benefits their “fully” breastfeeding infants will receive: i. No supplemental formula. Formatted: Numbered + Level: 2 + Numbering Style: a, b, c, … + Start at: 1 + Alignment: Left + Aligned at: 0.75" + Indent at: 1" Formatted: No bullets or numbering Formatted: Numbered + Level: 2 + Numbering Style: a, b, c, … + Start at: 1 + Alignment: Left + Aligned at: 0.75" + Indent at: 1" Formatted: Numbered + Level: 2 + Numbering Style: a, b, c, … + Start at: 1 + Alignment: Left + Aligned at: 0.75" + Indent at: 1" Formatted: Not Highlight Formatted: Normal Formatted: Font: (Default) Arial, 12 pt, Not Highlight Formatted: Not Highlight Formatted: Indent: Left: 0.5", No bullets or numbering Formatted: Not Highlight Formatted: Indent: Left: 0.5", No bullets or numbering Formatted: Not Highlight Formatted: Not Highlight Formatted: Not Highlight Formatted: Indent: Left: 1.5", No bullets or numbering Formatted: Not Highlight Formatted: Not Highlight Formatted: Not Highlight Formatted: Not Highlight Formatted: Not Highlight Formatted: Not Highlight Formatted: Numbered + Level: 2 + Numbering Style: a, b, c, … + Start at: 1 + Alignment: Left + Aligned at: 0.75" + Indent at: 1" Formatted: Numbered + Level: 3 + Numbering Style: i, ii, iii, … + Start at: 1 + Alignment: Right + Aligned at: 1.38" + Indent at: 1.5"

(section-ii)(breastfeeding-counseling)(page-9)Page 9#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Nutrition Education and Counseling/ Breastfeeding Counseling/Education for WIC Participants Page 9

ii. iii. Starting at six 6 months of age, an enhanced food packagetheir infant receives the containing the largest quantity and variety of foods compared to other infant packages.

VIII. ivFully breastfeeding mothers of multiples are those that are fully breastfeeding more than one infant from the same pregnancy. Partially breastfeeding mothers of multiples are those that are partially breastfeeding infants from the same pregnancy and whose infants receive formula from WIC in amounts that do not exceed the maximum allowed for partially breastfed infants.

a. Fully breastfeeding mothers of multiples will receive 1.5 times the FBF package.

b. Partially breastfeeding mothers of multiples in-range will receive the FBF package.

c. Note: women that are pregnant with two or more fetuses also receive the partially breastfeeding package.

IX. Partially breastfeeding dyads are those that are offering a defined amount of formula to their infant.

a. The CPA must individually assess the dyad based on the amount of breastfeeding that is occurring versus the amount of formula they are using or are requesting.

b. The intent of the food rule is to encourage continued breastfeeding, to limit use of formula, and to have food packages that may be used as incentives over providing additional formula food packages.

c. iv. Staff are required tomust educate mothers on the increased food package durationbenefits they would receive by continuing as a “partially breastfeeding in-range” participants.

d. It is important for the partially breastfeeding mother to be informed of her options to increase her breastfeeding, and to assist her in the process of not using formula.

Formatted: Not Highlight Formatted: Indent: Left: 0.5", No bullets or numbering Formatted: Not Highlight Formatted: Not Highlight Formatted: Normal, Indent: Left: 0.5", No bullets or numbering Formatted: Numbered + Level: 2 + Numbering Style: a, b, c, … + Start at: 1 + Alignment: Left + Aligned at: 0.75" + Indent at: 1" Formatted: Numbered + Level: 2 + Numbering Style: a, b, c, … + Start at: 1 + Alignment: Left + Aligned at: 0.75" + Indent at: 1" Formatted: Numbered + Level: 2 + Numbering Style: a, b, c, … + Start at: 1 + Alignment: Left + Aligned at: 0.75" + Indent at: 1" Formatted: Numbered + Level: 1 + Numbering Style: i, ii, iii, … + Start at: 1 + Alignment: Left + Aligned at: 1" + Indent at: 1.5" Formatted: Numbered + Level: 2 + Numbering Style: a, b, c, … + Start at: 1 + Alignment: Left + Aligned at: 0.75" + Indent at: 1" Formatted: Numbered + Level: 2 + Numbering Style: a, b, c, … + Start at: 1 + Alignment: Left + Aligned at: 0.75" + Indent at: 1" Formatted: Not Highlight Formatted: Indent: Left: 1", No bullets or numbering Formatted: Not Highlight Formatted: Not Highlight Formatted: Not Highlight Formatted: Numbered + Level: 2 + Numbering Style: a, b, c, … + Start at: 1 + Alignment: Left + Aligned at: 0.75" + Indent at: 1"

(section-ii)(breastfeeding-counseling)(page-10)Page 10#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Nutrition Education and Counseling/ Breastfeeding Counseling/Education for WIC Participants Page 10

e. It is important for staff to promote breastfeeding by educating on the benefits of more food rather than offering more formula.

f. v. Staff actions need to be based on scientific evidence and health research rather than marketing literature from formula manufacturers.

X. vi. Women who are partially breastfeeding at a minimum of 1 time per day should remain in the breastfeeding category. These mother-baby dyads are divided into two subcategories: Ppartially bBreastfeeding “iIn-- rRange” and partially breastfeeding, “oOut- of- rRange”. - Partially breastfeeding dyads include all women and infants breastfeeding on an average of 1 time per day. To support the goal of encouraging women that are partially breastfeeding to limit formula use with their infant, “partially breastfeeding” dyads are divided into two sub categories: “in range” and “out of range”.

a. 1. Dyads Infants that receive the number of cans of formula from WIC within the allowed range (see Appendix A in Food Packages policy) will be defined as “partially breastfeeding – in- range”.

b. 2. Dyads Infants that receive the number of cans of formula from WIC that are is more than the amount of formula allowed for their age range (see Appendix A in Food Packages policy), will be defined as “partially breastfeeding – out- of- range”.

c. The intent of the food rule is to encourage continued breastfeeding, limit use of formula, stay “in-range” versus “out of range” and to have food packages that may be used as incentives over providing additional formula food packages.

d. All dyads need to be individually assessed by a CPA or DBE to determine appropriate food packages and follow the above policy on offering only the amount of formula needed to support breastfeeding and optimally return to fully breastfeeding.

e. 3. Partially breastfeeding infants (in-range or out-of-range) can receive any number of cans of formula from the range offered in these packages. They should not be routinely provided the maximum package amounts of formula. Formatted: Numbered + Level: 2 + Numbering Style: a, b, c, … + Start at: 1 + Alignment: Left + Aligned at: 0.75" + Indent at: 1" Formatted: Not Highlight Formatted: Normal, Indent: Left: 0.75", No bullets or numbering Formatted: Not Highlight Formatted: Indent: Left: 0.75", No bullets or numbering Formatted: Not Highlight Formatted: Not Highlight Formatted: Not Highlight Formatted: Not Highlight Formatted: Not Highlight Formatted: Not Highlight Formatted: Not Highlight Formatted: Not Highlight Formatted: Not Highlight Formatted: Not Highlight Formatted: Not Highlight Formatted: Not Highlight Formatted: Indent: Left: 1.5", No bullets or numbering Formatted: Not Highlight Formatted: Not Highlight Formatted: Not Highlight Formatted: Not Highlight Formatted: Indent: Left: 1", No bullets or numbering Formatted: Not Highlight Formatted: Not Highlight Formatted: Not Highlight Formatted: Not Highlight Formatted: Numbered + Level: 2 + Numbering Style: a, b, c, … + Start at: 1 + Alignment: Left + Aligned at: 0.75" + Indent at: 1" Formatted: Numbered + Level: 2 + Numbering Style: a, b, c, … + Start at: 1 + Alignment: Left + Aligned at: 0.75" + Indent at: 1" Formatted: Not Highlight Formatted: Indent: Left: 1", No bullets or numbering Formatted: Not Highlight

(section-ii)(breastfeeding-counseling)(page-11)Page 11#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Nutrition Education and Counseling/ Breastfeeding Counseling/Education for WIC Participants Page 11

f. Staff must make every effort to maintain the participants “partially breastfeeding in-range” status versus issuing additional formula and moving to “out of range”, while respecting the mother’s choice.

g. If “partially breastfeeding” mothers request additional formula (or “out of range” packages), the CPA or DBE should counsel and assess their needs individually before issuing additional formula.

h. 4. It is appropriate for bBreastfeeding dyads to may change between in- range and out- of- ranges based on the age of the infant, age range for the infant, and the amount of breastfeeding being done. Note: Non-formula food packages may only be changed in the current month if family benefits have not been purchased for the current month. Formula food packages may be changed in the current month when there are changes to formula, even if family benefits have been purchased. See details in the Tailoring Food Packages policy.

i. The CPA or DBE is required to educate mothers on the increased food benefits they would receive by continuing as partially breastfeeding in range versus moving to an out of range food package VI which contains less food (equal to the postpartum/non breastfeeding package).

j. When applicable, offer the option to move the mother to fully breastfeeding in order to receive more benefits.

XI. Partially Breastfeeding mothers must be advised of the following benefits they will receive:

5. Food Package VII, Full BF package, provides a larger quantity of food for the mother. This package may continue for 1- year postpartum. The infant cannot receive formula from WIC when the mother receives this package.

6. – Food Package VI, Postpartum package, provides less quantity of food for the mother. This package may continue for 6- months postpartum. The infant can receive the most formula (up to the maximum for full formula amount) when the mother receives this package.

7. Food Package V, Part BF package, provides a moderate quantity of food for the mother. This package may continue for 1- year postpartum. The infant Formatted: Numbered + Level: 2 + Numbering Style: a, b, c, … + Start at: 1 + Alignment: Left + Aligned at: 0.75" + Indent at: 1" Formatted: Numbered + Level: 2 + Numbering Style: a, b, c, … + Start at: 1 + Alignment: Left + Aligned at: 0.75" + Indent at: 1" Formatted: Not Highlight Formatted: Indent: Left: 0.75", No bullets or numbering Formatted: Not Highlight Formatted: Not Highlight Formatted: Not Highlight Formatted: Not Highlight Formatted: Not Highlight Formatted: Not Highlight Formatted: Numbered + Level: 2 + Numbering Style: a, b, c, … + Start at: 1 + Alignment: Left + Aligned at: 0.75" + Indent at: 1" Formatted: Numbered + Level: 2 + Numbering Style: a, b, c, … + Start at: 1 + Alignment: Left + Aligned at: 0.75" + Indent at: 1" Formatted: Numbered + Level: 1 + Numbering Style: i, ii, iii, … + Start at: 1 + Alignment: Left + Aligned at: 1" + Indent at: 1.5" Formatted: Not Highlight Formatted: Not Highlight Formatted: Not Highlight Formatted: Not Highlight

(section-ii)(breastfeeding-counseling)(page-12)Page 12#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Nutrition Education and Counseling/ Breastfeeding Counseling/Education for WIC Participants Page 12

can receive some formula (up to the maximum in-range amount) when the mother receives this package.

8. When an infant receives an out-of-range amount of formula, the mother receives Food Package VI, Postpartum package. If the infant continues out- of-range beyond 6 months of age, the mother no longer receives food benefits (see detailed instructions for correct food package assignment, termination steps, and required documentation in Food Packages policy.).

9. When infants are active participants, their breastfeeding mother may still receive WIC services (nutrition education, counseling, peer counselor support, breastfeeding aids, etc.).

a. In-range provides larger quantity of foods than women that are fully formula feeding (non-breastfeeding women).

b. In-range food package benefits are provided up to one year postpartum versus 6 months for the non-breastfeeding woman.

c. For those under 6 months post-partum that are “in range” mothers will receive food benefits that are greater than the partially breastfeeding out of range women (which is equivalent to the postpartum package when under six months postpartum).

a. For those over 6 months postpartum that are “out-of-range” mothers will need to be terminated with notification (See Termination and Food Packages policy sections). d. As their infant is still an active participant, the mother may still receive WIC services of nutrition education, counseling, Peer Counselors, pumps, etc. Documentation needs to be made in the infant’s record.

XII. Mothers must be informed of the “Partially Breastfeeding In- Range” infant benefits they will receive:

a. Food Package I for 0 through 5 months and Food Package II for 6 through 11 months of age provides approximately half the maximum amounts of formula provided to fully formula (non-breastfeeding) infants. Formatted: Not Highlight Formatted: Not Highlight Formatted: Indent: Left: 0.75", No bullets or numbering Formatted: Numbered + Level: 2 + Numbering Style: a, b, c, … + Start at: 1 + Alignment: Left + Aligned at: 0.75" + Indent at: 1" Formatted: Normal, Indent: Left: 0.5", No bullets or numbering Formatted: Not Highlight Formatted: Normal, Indent: Left: 0.75", No bullets or numbering Formatted: Numbered + Level: 1 + Numbering Style: i, ii, iii, … + Start at: 1 + Alignment: Left + Aligned at: 1" + Indent at: 1.5" Formatted: Numbered + Level: 2 + Numbering Style: a, b, c, … + Start at: 1 + Alignment: Left + Aligned at: 0.75" + Indent at: 1"

(section-ii)(breastfeeding-descriptions)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Breastfeeding Promotion and Support/Breastfeeding Descriptions Page 1

Breastfeeding Descriptions I. Use the definitions in the following table to describe the amount of breastfeeding that is occurring: Breastfeeding Descriptions Based on WIC Formula Issuance Fully or Exclusive Breastfeeding Exclusively Breastfeeding Receiving no WIC formula. Primarily Exclusive/ No WIC Formula Package

Has been fed something other than human milk, vitamins, minerals and/or medications on a Urare occasion Uin the past or one time feeding of infant formula, human milk fortifier, cow’s milk, juice, sugar water, rehydration solution, water, baby food, or anything else. This identifies an infant who’s exclusively breastfeeding is UinterruptedU because of special circumstances (e.g., acute illness, hospitalization, caregiver misinformation). Receiving no WIC formula. Primarily Exclusive/ Complementary Foods Has been fed complementary foods (e.g., cereal, baby foods, table foods) and receiving no WIC formula. Partially Breastfeeding Partially (Mostly**) Breastfeeding Breastfeeding and receiving formula from WIC. May also be fed complementary foods. Not Breastfeeding No Longer Breastfeeding Was breastfeeding at some point in time but has now discontinued. Never Breastfed Was never breastfed. Child Breastfeeding Child Greater than or equal to 12 months of age and continuing to breastfeed. 0B*Human milk fortifier is considered a formula and infants routinely receiving it are defined as Partially Breastfeeding. Once human milk fortifier is discontinued, then the infant may be classified as Primarily Exclusive, if the definition of Primarily Breastfeeding is met. ** The descriptor “Mostly” is added to the designation; Partially (Mostly) Breastfeeding meaning “in range”. Food Package VII is issued to Partially (Mostly - in range) Breastfeeding mothers who are breastfeeding (in range) multiples from the same pregnancy and to pregnant women who are Partially (Mostly – in range) Breastfeeding.

(section-ii)(breastfeeding-positive-peer-influence)(page-5)Page 5#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Breastfeeding Promotion and Support/Breastfeeding Positive Peer Influence Page 5

communication method for WIC participants to contact peer counselors. The online peer counseling services will support social networking in an online one- on-one setting and timely responses to breastfeeding questions, as well as facilitating the sharing of ideas and resources. These online peer counseling services can make lactation support broadly available within a permanent infrastructure, especially in rural areas.

a. Refer WIC participants to appropriate health care professionals and schedule face-to-face meetings with breastfeeding dyad if there are advanced lactation problems.

b. If participants are unprofessional, negative, and/or use disparaging language when communicating with the peer counselor online, these participants can be dismissed from this online peer counseling program.

VIII. Online peer counseling connections will be secure and confidential.

a. Confidentiality when using online peer counseling services is critical. i. Guidelines when using cell phones to discuss any confidential information: 1. Tell the WIC participant when you are using a cell phone. 2. Inform them of the risks and the possibility for interception and that it may not be 100% secure. 3. Provide the participant with an opportunity to consent. 4. Refer to cell phone information in the Breastfeeding Curriculum. This can be adapted by each local WIC agency. ii. Internet communications and participant confidentiality. 1. Email and internet communication may be subject to interception by a third party resulting in a breach of confidentiality. 2. Limit online communications to factual information which is evidence-based rather than advice which may be more related to personal opinion and/or personal experience. 3. Do not communicate a message that could be considered as medical advice. 4. Review all email thoroughly before sending. 5. Maintain competence by successful completion of the Breastfeeding Curriculum.

(section-ii)(card-inventory)(page-2)Page 2#

Utah WIC Local Agency Policy and Procedures Manual

IX. Food Benefit Accountability and Control/Card Inventory

Page 2

locked room or closet. (This locked location is referred to as the “vault”). The exterior door of the clinic cannot be considered the 2nd lock.

VII. Checking out cards:

a. Cards pulled out of the vault for assignment to staff will need to be recorded in VISION by checking out the cards to the staff member who will be issuing the cards. Only one pack (50 cards) is checked out to a staff member at one time.

b. The cards checked out to staff for issuance shall be kept in a locked drawer or place where they are neither visible nor accessible by participants or other individuals who should not have access.

c. The card check out process in VISION requires the staff member receiving the cards to check them out, and a second staff person to verify the check out. This is normally done by the supervisor or person assigned to manage card inventory.

d. The cards can remain checked out until they are all issued.

e. Cards should be issued to participants in sequential order.

VIII. Checking in cards:

a. All cards that have been checked out must eventually be checked back in.

b. Even if a pack of cards have all been issued to participants, the check in process is still required. The “No PANs To Check In” check box selection indicates that there were no PANs to check back into the vault.

c. If a staff member will no longer be issuing the remaining cards that were checked out to them, the cards need to be checked back into the vault/inventory by recording them as checked in in VISION. These cards need to be placed back into the vault for future use.

IX. Cards in the vault need to be physically counted by WIC staff monthly to make sure the vault count matches the count in VISION.

a. It is the responsibility of the clinic supervisor to ensure that the counts are correct so that all cards are accounted for.

X. Cards that have been assigned to families and are subsequently returned (i.e. damaged or the family is no longer on WIC) shall be hot carded and documented

(section-ii)(categories-and-certification-periods)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual

VIII. Certification, Eligibility and Coordination of Services/Certification Procedures/Applicant Categories and Certification Periods Page1

Applicant Categories and Certification Periods I. All participants will be certified according to their category.

a. Pregnant women are certified for the duration of the pregnancy and to the end of the calendar month in which they reach six weeks after the end of the pregnancy. i. Proof of pregnancy is generally not required, but may be required if clinic staff has reasonable doubt that the applicant/participant is pregnant. ii. Gestational mothers (surrogates) who apply for WIC should be advised to seek legal advice about their WIC status.

b. Postpartum women (Not Breastfeeding) are certified to the end of the calendar month in which they reach six months after the end of the pregnancy or after termination of a pregnancy (including miscarriages and abortions).

c. Breastfeeding women are certified until the end of the calendar month in which they reach one year postpartum, or until the woman stops breastfeeding, whichever occurs first.

d. Infants at 6 months of age or less are certified for the duration of their first year up to the end of the calendar month in which they reach their first birthday. Infants 7 months of age and older will be certified for six months.

e. Children are certified at entry into WIC and at one year intervals. Children can be certified until they turn 5 years of age.The child’s eligibility For children who certified at age 4, their certification period expires at the end of the calendar month in which he they reaches his their fifth 5th birthday.

II. Non-birth mothers who are breastfeeding infants are eligible for WIC certification (women who are breastfeeding an infant(s) that they did not give birth to). They may be certified to participate in the WIC Program as breastfeeding women and may receive benefits and breastfeeding aids until the infant is one year of age.

a. This includes; wet nurses, adoptive mothers, and foster mothers.

b. This does not include women who donate breast milk.

c. The breastfeeding non-birth mother must meet all other eligibility requirements.

d. Only one woman can be certified as breastfeeding a single infant.

(section-ii)(certification-health-assessment)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Certification, Screening, and Assessment/Certification Health Assessments Page 1

Certification Health Assessments

I. Certification (cert) health assessments are required at the time of certification. See the “Presence at Certification” policy for additional information regarding physical presence vs. remote options. The cert health assessment must consist of:

a. Anthropometrics recorded and assessed (see “Anthro and Biochemical Procedures” policy)

b. Bloodwork recorded and assessed (see “Anthro and Biochemical Procedures” policy)

c. Lead screening when required (see “Health Care Referrals” policy)

d. Nutrition Interview i. The first question that needs to be asked is: Who is your health care provider? The data field entry for the answer to this question must be a health care provider name or the name of a health/community clinic. If the participant does not know the names of either the health care provider or clinic, then you must check the ‘No Health Care Provider’ box. Ask for this information at the next certification appointment if this box is checked. ii. All prompt questions emboldened in the Nutrition Interview must be asked during the cert health assessment. Prompts that are not emboldened are meant to support the cert health assessment and can be used as determined by the CPA.

e. Determination of nutrition risk(s) i. Most nutrition risks are auto populated based on the questions answered in the Nutrition Interview; however, some nutrition risks require manual assignment or manual assignment of high-risk status. See the “Nutrition Risk Manual” policy for more guidance. ii. The five categories of nutrition risk include: Anthropometric, Biochemical, Clinical/Health/Medical, Nutrition Practice, and Other.

f. Nutrition education i. See ‘Core Contact’ below. ii. See the “Breastfeeding Counseling” policy for education topics that are required when certifying pregnant and postpartum women who are breastfeeding. iii. Nutrition education should be based upon the participant’s assigned nutrition risks, their highest priority needs and their interests/requests. See the “Nutrition Education” policy and training modules for more guidance.

(section-ii)(certification-health-assessment)(page-2)Page 2#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Certification, Screening, and Assessment/Certification Health Assessments Page 2

g. Referrals, as needed i. Referral to a peer counselor is required for pregnant and postpartum women who are breastfeeding.

h. Assign food package i. See the “Nutrition and Food Package Counseling” and “Food Package” policies for more guidance.

i. Issue food benefits to the participant’s account. II. Core Contact

a. Core contact information must be presented to all WIC participants and parent/guardians at the initial certification. Information may be presented via the orientation video, the Rights & Responsibilities document, and/or verbally from WIC staff.

b. Core contact information includes: i. A brief explanation of the VENA-based WIC Program. This explanation should include a summary of the following information: 1. WIC as a supplemental food program. The food provided by the WIC Program is supplemental and is not intended to provide all of the participant’s daily food requirements. 2. The purpose of the WIC Program is to provide nutritional support (i.e., education and strategies) for a healthy diet, supplemental foods, referrals, and breastfeeding promotion and support during critical times of growth and development to improve health and achieve positive health outcomes. 3. The health assessment process is necessary to identify nutrition needs (e.g., medical conditions, dietary practices) and interests so WIC can provide benefits and education that are responsive to the participant’s wants and needs. 4. The relationship between WIC staff and the participant is a partnership – with an open dialogue and two-way communication – working to achieve positive health outcomes. 5. WIC food benefits are provided to promote and support the nutritional well-being of the participant and help meet the recommended intake of important nutrients or foods. 6. The nutritional value of the specific supplemental foods per category. (i.e., Vitamin D, calcium, fiber, protein, etc.)

(section-ii)(civil-rights-reviews)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual

XI. Civil Rights/Civil Rights/Civil Rights Monitoring and Reviews

Page 1

Civil Rights Monitoring and Reviews

I. Pre-Award Compliance Reviews. The State agency will perform thorough reviews of applicants from previously unfunded local agencies. This review will be based on information provided by applicants in their official application for program funds.

a. Those agencies whose applicants are determined incomplete shall be notified by the State Office within 15 days of receipt of the application. This notification will specify the additional information needed to complete the application.

b. The applicant shall then be notified of the approval or denial of his/her application within 30 days of receipt of the completed application.

c. On-site reviews to determine civil rights compliance shall be made if the State agency cannot determine compliance based on the information contained in the completed application. The review will include the following: i. All past substantiated civil rights problems or noncompliance situations have been corrected. ii. The local agency will operate within the procedures established by the State Agency. iii. Clinic sites do not deny access to any persons because of his or her race, color, national origin, age, sex, or disability. iv. Appropriate staff, volunteers or other translation resources are available in areas where a significant proportion of non-English or limited English- speaking persons reside. v. Description of the racial/ethnic make-up of the service area is included in the application.

II. Local Agency Reviews. When a review of agency is performed, the following items must be determined as a minimum:

a. Do all persons have an equal opportunity to participate in the program regardless of race, color, national origin, age, sex, or disability?

b. Is ethnicity and race documented for all participants?

c. Has the local agency conducted civil rights training for all staff?

d. Is the nondiscrimination poster displayed in the clinic?

e. Is program information being provided to applicants, participants, grassroots organization or similar minority groups?

(section-ii)(collection-of-racial-and-ethnic-data)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual

XI. Civil Rights/Civil Rights/Collection of Racial and Ethnic Data

Page 1

Collection of Racial and Ethnic Data I. To provide flexibility and ensure data quality, separate categories shall be used when collecting and reporting race and ethnicity. Ethnicity shall be collected first. Respondents shall be offered the option of selecting one or more racial designations. The minimum categories for data on race and ethnicity for Federal statistics, program administrative reporting and civil rights compliance reporting are defined by OMB as follows:

a. Ethnicity. i. Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, South or Central America, or other Spanish culture or origin, regardless of race. The term, “Spanish origin,” can be used in addition to “Hispanic or Latino.” ii. Not Hispanic or Latino.

b. Race. i. American Indian or Alaska Native. A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment. ii. Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. iii. Black or African American. A person having origins in any of the black racial groups of Africa. Terms such as “Haitian” or “Negro” can be used in addition to “Black or African American.” iv. Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. v. White. A person having origins in any of the original peoples of Europe, Middle East, or North Africa.

II. Participants need to understand that the collection of this information is strictly for statistical reporting requirements and has no effect on the determination of their eligibility to participate in the program. Participants may be asked to self-identify their racial group only after it has been explained.

III. Self-identification by the applicant/participant is the preferred method of obtaining characteristic data.

(section-ii)(communication-methods)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual

IV. Organization and Management/Confidentiality/Confidentiality Page 1

Communication Methods I. Telephone Communication

a. WIC staff should use good telephone etiquette when receiving and making calls. i. Calls received during business hours should be answered promptly. ii. Ask people to hold when necessary and provide an estimate of the wait time. iii. Return phone messages the same or the next business day. iv. For non-English speakers, use bilingual staff or an interpreter.

b. The Utah WIC program uses the Teletask system to make automated calls for appointment reminders and missed appointment notifications for those who do not receive text messages.

II. Text Communication. The Utah WIC program uses the Teletask text messaging system. The state office uses this system for mass texting and for appointment reminders. Local agencies are authorized to use this system for: two-way texting with participants, to exchange documents with participants, and for the collection of electronic signatures.

a. Automated mass text messages. Automated text messages are set up and sent by the state office for: i. Appointment reminders, ii. Missed appointment notifications, iii. Notifying participants who were recently terminated for failure to receive benefits for 3 months or for failure to reapply, iv. Notifying participants who have not received current month benefits and no appointment is scheduled, v. Notifying participants with a certification expiring at the end of the month and no appointment scheduled, vi. Inviting Medicaid and SNAP recipients to apply for WIC, vii. Emergency alerts, viii. Local agency requested mass texts. 1. Local agency WIC directors or designee must request approval for mass text messages from the state WIC program manager. ix. The wording and timing of mass text messages and automated reminders is coordinated between the state office staff and the local WIC directors.

b. Individualized Two-way texting. The Utah WIC program uses Teletask to facilitate direct communication between local clinic staff and participants.

(section-ii)(communication-methods)(page-2)Page 2#

Utah WIC Local Agency Policy and Procedures Manual

IV. Organization and Management/Confidentiality/Confidentiality Page 2

i. Clinic staff must monitor the Teletask Dashboard web page throughout the WIC business day to watch for and respond to incoming messages. ii. Text communication with participants iii. Sending documents to participants iv. Requesting documents and proofs from participants 1. When requesting documents/proofs to be submitted through Teletask, always send the Upload Documents link first. This ensures document security. If a participant sends a document directly as a text message, it is less secure. 2. To ensure the security and confidentiality of participant data, all staff must generate a unique Teletask link for every individual text request. Failure to do so creates a group chat environment, leading to a major breach of confidential documents. a. Each employee is required to be fully trained prior to initiating such requests through text. b. Never reuse, copy, or paste a previously generated Teletask link. Generate a new link every time. A new link must be created for every single participant interaction. c. Do not save Teletask links in "Quick Notes" or external documents for future use. d. Double-check the participant’s phone number before hitting send. 3. Consequences of improper link use. a. Reusing a link adds the new participant to an existing thread. b. All participants in that thread can view each other's confidential uploaded documents (ID, income, medical records). c. Sharing personally identifiable information (PII) or protected health information (PHI) with unauthorized individuals is a reportable breach. 4. Reporting a Breach. If you realize a link was reused: a. Notify your supervisor immediately. b. Contact the WIC help desk immediately c. The state office will contact Teletask immediately to get the text removed. Teletask turnaround time is 24 hours to get the text deleted. v. Collecting electronic signatures.

III. Email.

a. Email may be used to communicate with participants as needed.

(section-ii)(complaint-handling)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual

VIII. Certification, Eligibility and Coordination of Services/Participant Violations and Complaints/Complaint Handling Page 1

Complaint Handling I. All complaints, except those that are minor in nature and are immediately resolved, not alleging a participant violation need to be documented in the Customer Service Log in VISION. This includes complaints against participants, guardians, proxies, and vendors from any source. Documentation needs to be completed so that appropriate investigative procedures, follow-up, and resolution can be examined if the participant or/ vendor requests an agency conference or a fair hearing.

a. In the Customer Service Log, indicate where the complaint originated with the Customer Service Type drop-down menu.

b. The description box needs to contain either the file name of the scanned written complaint (if applicable) or the details of the complaint including type of complaint, status of complainant, date, time, location (in the case of vendors, specific address), specific food items involved; description of individuals involved; interaction and discussion between parties. Complaints missing this critical information may not result in corrective action.

II. If the complaint involves a vendor, then the complaint will be referred to the local agency vendor management representative to investigate in accordance with Vendor Management policy (see Complaints Against Vendors).

III. If the complaint involves an alleged participant violation as defined in policy, the Customer Service Log entry can be skipped and the Participant Violations screen in VISION will also be completed instead. Some participant violation entries in VISION will refer back to complaints originally entered in the Customer Service Log.

IV. Obtain a written statement from the individual(s) making the complaint when possible. Oral Verbal complaints can be taken, however, may not provide the necessary documentation or information to be satisfactorily used in a Fair Hearing. Vendors may use the Business Reply Card to document complaints against participants complaints. Those individuals making oral verbal complaints against vendors or WIC clients should be asked to place the concern in writing, such as an email, and this should be scanned into VISION.

V. If the complaint involves a situation that can be adequately explained or completely resolved on the basis of simple clarification of WIC Program policy then the local agency should resolve the concern. If a complaint needs to be referred to the State WIC office, the written documentation should be scanned and an electronic copy should be kept in the clinic and an electronic copy forwarded to the State WIC Office.

(section-ii)(complaint-handling)(page-2)Page 2#

Utah WIC Local Agency Policy and Procedures Manual

VIII. Certification, Eligibility and Coordination of Services/Participant Violations and Complaints/Complaint Handling Page 2

VI. In VISION, Enter the closed date upon resolution of the complaint or enter a closed date if a family alert has been created to notify staff to discuss the situation at the next appointment. If the complaint is being referred to the State, the clinic director, or the local vendor coordinator for resolution, a closed date should not be entered until that person has been contacted via phone/email to forward the complaint.

VII. Complaints should be resolved and closed within a reasonably short amount of time. Unresolved complaints (those without a closed date) automatically place an alert on the Alert screen of the Operations menu. These alerts are monitored by State staff.

a. Complaints entered with a customer service type of “Investigation” are entered by State Office investigators. Local staff can ignore these alerts as they will be closed by state staff after a review of the complaint.

b. If the clinic is not able to reach the client to discuss the complaint after multiple attempts to contact the participant using available methods and the client is no longer participating in WIC a closed date should be entered.

VIII. Complaints regarding WIC staff members or internal clinic situations do not need to be documented in VISION but must be handled and resolved according to local agency procedures. The clinic director must retain the details of the complaint on file.

IX. The State WIC office must be contacted immediately regarding all complaints alleging discrimination of any kind. The Civil Rights complaint check box must also be checked. Complaints of Civil Rights must be handled in accordance with Federal Law and Department of Agriculture (USDA) policy. See the Civil Rights section, Complaints of Discrimination, for additional procedures on handling complaints of discrimination.

(section-ii)(complaints-against-vendors)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual

I. Vendor Management/Local Agency Vendor Management/Complaints Against Vendors Page 1

Complaints Against Vendors I. When anyone makes a complaint, the individual should be asked to put the complaint in writing and sign the complaint. Written complaints through email are also encouraged to ensure information is as accurate as possible.

II. Any WIC staff can enter a complaint they receive in VISION. The VISION system Customer Service Log is the primary location to document complaints made by participants against vendors. VISION does not automatically notify the State WIC Office when an entry is made in the Customer Service Log. If assistance is needed from the state vendor coordinator, each entry in the customer service log must be accompanied by an email to the state vendor coordinator.

III. The Local Agency Vendor Complaint Form should be used to write details of the complaint if the complaint is an alleged violation of the Utah WIC Vendor Agreement.

IV. Local vendor coordinators should research and attempt to resolve minor complaints as appropriate. The vast majority of complaints are minor in nature, only requiring the local vendor coordinator to contact the store manager or supervisor by phone and discuss the situation.

a. These complaints should be documented in the VISION Customer Service Log and Vendor Log.

b. The discussion, including the details of the problem, name of the person contacted, resolution by the vendor, and date and time of the conversation should be documented in the vendor log.

V. All complaints, written or oral, made to clinic or local agency personnel regarding potential or alleged vendor violations or fraud need to be submitted to the state vendor coordinator. Repeated minor offenses by the vendor that the local vendor coordinator has not been able to resolve should be reported to the state vendor coordinator. Other complaints, problems or questions for which the local vendor coordinator would like state assistance should also be forwarded to the state vendor coordinator.

a. An email from the local vendor coordinator, in combination with the customer service log should be used to inform the state vendor coordinator of the problem.

(section-ii)(complaints-of-discrimination)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual

XI. Civil Rights/Civil Rights/Complaints of Discrimination

Page 1

Complaints of Discrimination

I. Any persons alleging discrimination based on race, color, national origin, sex (including gender identity and sexual orientation), age or disability has a right to file a complaint within 180 days of the alleged discriminatory action.

II. All civil rights complaints, written or verbal, shall be accepted. Anonymous complaints shall be handled as any other complaint.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/ad- 3027.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by:

1. mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; or

2. fax: (833) 256-1665 or (202) 690-7442; or

3. email: program.intake@usda.gov

III. Local WIC clinics and the State WIC Office can accept complaints of discrimination.

IV. In the event a complainant makes the allegations verbally or through a telephone conversation and refuses or is not inclined to place such allegations in writing, the person to who the allegations are made shall write up the elements of the complaint for the complainant. Use the Civil Rights Discrimination Complaint Form found on SharePoint. The form requires the following information:

a. Name, address, and telephone number of the complainant, or other means of contacting the complainant.

b. The specific location and name of the entity delivering the service or benefit.

(section-ii)(complaints-of-discrimination)(page-2)Page 2#

Utah WIC Local Agency Policy and Procedures Manual

XI. Civil Rights/Civil Rights/Complaints of Discrimination

Page 2

c. The nature of the incident or action that led the complainant to feel discrimination was a factor, or an example of the method of administration which is alleged to have a discriminatory effect on the public or potential and actual participants.

d. The basis on which the complainant feels discrimination exists (race, color, national origin, age, sex or disability).

e. The names, titles, and business addresses of persons who may have knowledge of the discriminatory action.

f. The date(s) during which the alleged discriminatory action(s) occurred, or if continuing, the duration of such actions.

V. All allegations of discrimination will be sent to USDA for investigation.

a. The state WIC program manager or designee should always be notified immediately when complaints alleging Civil Rights discrimination are made.

b. The Civil Rights complaint must be entered in VISION in the Customer Service Log. The Civil Rights Complaint check box must also be checked.

c. The state office will assist clinic staff in forwarding the complaint to USDA.

d. All complaints alleging discrimination will be processed within the time frames established by USDA regulations. All Civil Rights complaints will be forwarded to USDA within five (5) days.

VI. Complaints alleging discrimination on the basis of age, regardless of whether other bases are alleged, will be referred by USDA to the Federal Mediation and Conciliation Service (FMCS) for mediation. The State Agency will designate a neutral representative to participate in mediation to resolve complaints alleging unlawful discrimination on the basis of age.

VII. Although it is the policy of the USDA and FNS, to provide fair and equitable treatment to every employee and customer, there are specific laws and regulations that provide for the protected bases for each nutritional assistance program. For this reason, sexual orientation, marital or family status, parental status, and protected genetic information are not protected bases in The WIC program.

(section-ii)(confidentiality)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual

IV. Organization and Management/Confidentiality/Confidentiality Page 1

Confidentiality I. Local agencies must reasonably provide a WIC clinic environment where confidentiality is protected, including information discussed between staff and applicants/participants. Information such as identity, residency, income and protected health information should only be discussed in a private setting or in an area in the clinic where other participants or members of the public would not easily be able to hear conversations held at normal voice volume. This may be accomplished through methods such as use of a private room, privacy barriers, or ensuring sufficient distance between others who are in clinic waiting areas, etc.

II. Confidential applicant and participant information is any information about an applicant or participant, whether it is obtained from the applicant or participant, another source, or generated as a result of WIC application, certification, or participation, that individually identifies an applicant or participant and/or family member(s). Applicant or participant information is confidential, regardless of the original source and exclusive of previously applicable confidentiality provided in accordance with other Federal, State, or local law.

III. WIC information, whether provided by the participant or observed by WIC staff, is protected. Examples of observed information include the time and date a participant or applicant was at the WIC clinic, and any aspect of the appearance or apparent condition of persons attending the WIC clinic.

IV. The use and disclosure of confidential applicant and participant information is restricted to persons directly connected with the administration or enforcement of the WIC Program who have a need to know the information for WIC Program purposes. Disclosure of Confidential WIC information is limited to: a. Persons directly connected with the administration or enforcement of the program, including persons investigating or prosecuting violations in the WIC program under federal, state, or local authority. i. This includes WIC staff and administrators who are responsible for the ongoing conduct of the program operations. ii. It does not include personnel in the state or local health department who do not have ongoing involvement in the operation or management of the program. Thus, this provision excludes operational personnel not certifying and serving WIC applicants/participants and administrators who do not directly supervise WIC staff.

(section-ii)(confidentiality)(page-2)Page 2#

Utah WIC Local Agency Policy and Procedures Manual

IV. Organization and Management/Confidentiality/Confidentiality Page 2

iii. WIC staff may not access participant records of those not in their care or for reasons other than the ongoing operations of the program as required by their job duties. iv. The United States Department of Agriculture Office of the Inspector General (USDA OIG) is authorized to receive WIC information as it conducts enforcement of the program. 1. The state agency should verify the investigators credentials prior to releasing any information.

b. The comptroller general of the United States for audit and examination authorized by law.

c. The executive directorcommissioner of the Utah Department of Health and Human Services, who is the chief state health officer, has authorized the sharing of confidential WIC information with representatives of the following programs: i. Baby Your Baby, ii. Baby Watch Early Intervention Program, iii. Data Resources Program, iv. Early Hearing Detection and Intervention Program (EHDI) v. Head Start/Early Head Start, vi. Home Visiting Program (nursing), including Nurse Family Partnership vii. Immunizations Program, viii. Integrated Services Program (0-8 Care Coordination) ix. Maternal and Infant Health Program/Utah Pregnancy Risk Assessment Monitoring System (PRAMS), x. Medicaid (including Targeted Case Management), xi. Tobacco Prevention and Control Program, xii. U.S. Census Bureau xiii. Utah Early Childhood Integrated Data System (ECIDS) xiv. Utah Data Research Center (UDRC)

d. Sharing information obtained by WIC with the Utah Statewide Immunization Information System (USIIS) (requires the participant reading the USIIS Release Form and signing the electronic signature pad authorizing the release).

e. For foster children only, sharing information with representatives of the following programs is authorized: i. Division of Child and Family Services (DCFS) 1. Once the foster child is no longer in foster care, information should not be shared with DCFS without the parent signing a release. ii. Fostering Healthy Children Program

(section-ii)(confidentiality)(page-3)Page 3#

Utah WIC Local Agency Policy and Procedures Manual

IV. Organization and Management/Confidentiality/Confidentiality Page 3

V. WIC participants are notified that confidential information may be shared with certain programs by signing the Rights and Responsibilities form unless an additional release form is indicated. The state agency has signed MOU agreements with the above listed programs allowing sharing of information only for the purposes of:

a. Establishing the eligibility of WIC applicants or participants for the programs that the organization administers;

b. Conducting outreach to WIC applicants and participants for such programs;

c. Enhancing the health, education, or well-being of WIC applicants or participants who are currently enrolled in such programs, including the reporting of known or suspected child abuse or neglect;

d. Streamlining administrative procedures in order to minimize burdens on staff, applicants, or participants in either the receiving program or the WIC Program; and,

e. Assessing and evaluating the responsiveness of a state’s health system to participants’ health care needs and health care outcomes.

VI. The Rights and Responsibilities states that, “You may ask WIC staff for more information about these programs.” The Utah WIC Program Information Sharing document, which is posted on SharePoint provides a list and description of programs with which the WIC program has agreements to share information. This document must be offered to each WIC applicant at certification OR must be posted in a conspicuous location in a public area of the WIC clinic. Please print copies from SharePoint and hand them out upon request.

VII. If the local agency wishes to share confidential WIC information on a general basis with another program or organization not listed above, the following is required:

a. The local agency must have a signed MOU agreement with the program or organization with which the information is to be shared. This agreement must include assurances that the information will be used only for the purposes listed above and that the information will not be released to a third party. The local agency must have the approval of the state WIC program manager to enter into such an agreement. The state WIC program manager will seek approval from the executive directorcommissioner of the Utah Department of Health and Human Services before information may be shared.

(section-ii)(confidentiality)(page-4)Page 4#

Utah WIC Local Agency Policy and Procedures Manual

IV. Organization and Management/Confidentiality/Confidentiality Page 4

b. Participant’s whose information may be released must sign a release form authorizing the release of information. The local agency may not require participants to sign the release form in order to receive WIC benefits.

VIII. If a signed agreement with the program is not in place, and the local agency wishes to share confidential information on a case by case basis, the participant must sign a release form authorizing disclosure. A signed release form provides the local agency with the documentation necessary to show that particular information was released per the participant’s request with his/her approval.

a. Though WIC participants often give verbal permission to share information with their healthcare provider, which is documented in VISION, federal regulations require that a release be signed by the participant prior to the WIC clinic sharing any confidential information.

IX. The confidentiality provision does not prohibit the release of information if the information is released in a way that protects the identity of the individuals. Requests for data in aggregate or summary form may be granted, as long as the released information excludes any items which would identify program participants or applicants.

X. State and local agencies are required by law to cooperate with FNS in completing authorized studies.

a. WIC participants may be asked to voluntarily participate in FNS surveys or studies.

b. WIC clinics must post the USDA Study Notice Flyer in a conspicuous location.

c. If the clinic is notified of a study involving their clients, it is best to verbally explain to participants that they may be contacted and assure them it does not affect their eligibility or immigration status.

XI. Participants must be informed at each certification visit or when placed on a wait list that the WIC clinic may contact them. This notification/privacy policy is found on the Rights and Responsibilities form. If the participant does not wish to be called or sent mail, document this appropriately in the computer system.

XII. If the clinic receives a telephone call or in person request asking whether a participant is in the clinic, the staff member should take a name and telephone number and let the caller know that if the person is in the clinic, the

(section-ii)(confidentiality)(page-5)Page 5#

Utah WIC Local Agency Policy and Procedures Manual

IV. Organization and Management/Confidentiality/Confidentiality Page 5

message will be delivered. Information should not be given acknowledging the person is in the WIC clinic.

XIII. Confidential participant information may not be released to WIC vendors.

XIV. Vendor information (whether it is obtained from the vendor or another source) that identifies the vendor, other than the vendor’s name, address, telephone number, website, e-mail address, store type, and authorization status is also confidential.

a. Restricted information on a vendor may only be released to: i. Persons directly connected with the administration of enforcement of the WIC Program or the Supplemental Nutrition Assistance Program (SNAP). ii. Persons directly connected with the administration or enforcement of any federal or state law. iii. A vendor that is subject to an adverse action.

XV. Participant records are confidential and clinic staff must protect them from unauthorized access within the VISION system (See System Security).

XVI. Volunteers are considered part of the WIC Program. They may have access to participant information if required by their job assignment.

a. Exercise discretion in screening and selecting capable volunteers who would have access to confidential information.

b. If a potential volunteer does not appear to be a good candidate for keeping information confidential, there may be other activities that the person can perform that would not include access to participant information.

c. All volunteers must sign an agreement to protect the confidentiality of information. By signing an agreement, the volunteer would agree to keep information confidential or forfeit the volunteer assignment.

XVII. WIC participants or applicants have the right to access all information provided by the participant or applicant, assuming that any issues regarding custody or guardianship have been settled. This includes WIC participants or applicants who request to see his or her own record, or a parent or guardian requesting access to a child’s record. The local agency need not grant the participant or guardian access to any other information in the file or record, such as documentation of income provided by the third parties or any information which serves as a staff assessment of the participant’s condition or behavior, unless required by State or local law or policy.

(section-ii)(confidentiality)(page-6)Page 6#

Utah WIC Local Agency Policy and Procedures Manual

IV. Organization and Management/Confidentiality/Confidentiality Page 6

XVIII. When WIC records are requested in cases of custody from an individual other than the applicant/participant, or from an organization not covered by an information sharing agreement, it is recommended that local WIC agencies consult with their legal counsel. The attorney can then decide who the appropriate individual to sign a release is, and what procedures to follow with respect to the request.

XIX. Subpoenas and Search Warrants. A subpoena should never be ignored. Failure to respond to a subpoena could result in the State or local agency being found in contempt of court. This could result in the incarceration of or fines against WIC employees. The State or local agency may disclose confidential applicant, participant, or vendor information pursuant to a valid subpoena or search warrant in accordance with the following procedures:

a. In determining how to respond to a subpoena duces tecum (i.e., a subpoena for documents) or other subpoena for confidential information, the state or local agency must use the following procedures: i. Upon receiving the subpoena, immediately notify the state agency; ii. Consult with legal counsel for the state or local agency and determine whether the information requested is in fact confidential and prohibited by this section from being used or disclosed as stated in the subpoena; iii. If the state or local agency determines that the information is confidential and prohibited from being used or disclosed as stated in the subpoena, attempt to quash the subpoena unless the state or local agency determines that disclosing the confidential information is in the best interest of the program. The determination to disclose confidential information without attempting to quash the subpoena should be made only infrequently; and, if the state or local agency seeks to quash the subpoena or decides that disclosing the confidential information is in the best interest of the program, inform the court or the receiving party that this information is confidential and seek to limit the disclosure by: 1. Providing only the specific information requested in the subpoena and no other information; and, 2. Limiting to the greatest extent possible the public access to the confidential information disclosed.

b. In responding to a search warrant for confidential information, the state or local agency must use the following procedures: i. Upon receiving the search warrant, immediately notify the state agency; ii. Immediately notify legal counsel for the state or local agency;

(section-ii)(conflict-of-interest)(page-2)Page 2#

Utah WIC Local Agency Policy and Procedures Manual

X. Monitoring and Audits/Local agency Self Evaluation and Monitoring/Conflict of Interest Page 2

a. Employee permissions will be set within the VISION system to allow appropriate access to certification and food benefit issuance functions. i. Some staff may be approved for security access within VISION by the state WIC director that would allow the staff person to complete intake screens, nutrition assessment and issue benefits. Though possible, staff should avoid completing both the income eligibility determination and the nutrition risk assessment for the same participant. ii. In very small clinics that operate with only one staff member regularly, or due to temporary circumstances, staff in a role approved by the state WIC director may complete all certification functions when necessary. iii. Staff who have been approved for these exceptions will have their certification records reviewed weekly by state WIC staff and their local agency WIC director. (See Monitoring of Staff). iv. When possible, staff working alone on a certification should securely send copies of income/adjunct eligibility documentation to another colleague in another WIC clinic within their local agency for review and entry of the income record into VISION. Black-out any social security numbers that may be listed on the documentation. 1. When submission to another staff within the local agency is not possible, income documentation may be securely submitted to the WIC Help Desk at the state office for review and entry. 2. When secure submission of documentation to outside staff to complete the income record is not possible, it is highly recommended to scan copies of the income documentation into VISION in order to assist with the auditing process that will occur. DO NOT UPLOAD DOCUMENTS CONTAINING VISIBLE SOCIAL SECURITY NUMBERS! 3. All clinics should have the equipment necessary to be able to scan documentation into VISION.

(section-ii)(documentation)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual

III. Information System/Documentation/Documentation Page 1

Documentation

I. The VISION system offers several methods to document and communicate important information regarding WIC participants.

a. Goals are set with the client during the nutrition assessment and are used only for health and nutrition related reasons.

b. Comments are used to document information required by policy or to document information that would be helpful to staff for future reference.

c. Alerts are comments that are set as an alert to communicate critical information that staff needs to be aware of each time they access the family’s record. Staff must get into the habit of checking the bottom of the screen for alerts each time they open a new family. There are many reasons why an alert may need to be set. When staff makes a comment and checks the “Display as Alert” check box the comment is displayed on the bottom of the screen with the staff member’s name that made the alert. The system requires that an expiration date for the alert be set. The alert will disappear after this date, but the comment will remain. Expiration dates should be set as far into the future that the information is still critical. i. In some cases, when benefits should not be provided until the situation is resolved, or when a dual exists that should not be used, the “FB Issuance” dropdown box on the family screen should be set to “No food benefits” in order to prevent staff from accidently issuing benefits before the situation is resolved. ii. Some alerts are created automatically by the system, for example, when staff has checked the “Do not allow food benefits” check box in the Participant Violations Screen (indicating that counseling for a participant violation must be completed prior to further benefit issuance). Staff must clear this check box in order to remove the alert and allow benefit issuance.

II. Various hard copy documents will need to be scanned and uploaded into the VISION system. The table below list types of forms that should be scanned if used by the clinic.

(section-ii)(documentation)(page-4)Page 4#

Utah WIC Local Agency Policy and Procedures Manual

III. Information System/Documentation/Documentation Page 4

i. Social Security cards or documents containing a Social Security number. ii. Driver License/State ID Cards iii. Passports iv. Birth Certificates

III. The Utah WIC Program uses the Mountain Plains User Group Participant Portal and Clinic Web App.

a. This system: i. Is web-based- internet browser and mobile device responsive ii. Interfaces with VISION to add and receive information and documents iii. Allows clients to log in and manage account iv. Displays and allows ability to edit family demographics and contact information, add new family members and proxies. v. Displays certification status and expiration vi. Displays next appointment and ability to request appointments online as well as cancel/reschedule. vii. Supports and guides online applications and recertifications viii. Allows clients to upload and submit proof documents and medical information securely ix. Digital signature capture x. The portal sends messages and alerts between clinic staff and the participants xi. Allows two-way chat/instant messaging between staff and clients xii. Displays participant measurements, growth charts & hemoglobin xiii. Displays formula prescription information and expiration xiv. Displays benefit balance xv. WIC Shopper App access xvi. WIC Health.org access xvii. Links to state/local websites

b. Clinic staff must be assigned to monitor the clinic web app on a real-time continuing basis during clinic hours. Staff should be watching for incoming applications, appointment requests, documentation, and chat requests. It is expected that these be responded to promptly.

c. Clinic staff must monitor the clinic’s general email account (i.e. Google email) for incoming email.

IV. The Utah WIC program uses the Teletask text messaging system. The state office uses this system for mass texting and for appointment reminders. Local agencies are authorized to use this system for:

a. Two-way texting with participants, Commented [R1]: Moved to new Participant Portal policy document Commented [R2]: Moved to the new Communication Methods policy document.

(section-ii)(emergency-planning)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual

IV. Organization and Management/Emergency Planning /Emergency Planning Page 1

Emergency Planning I. The WIC Program is not intended to be a first-response disaster assistance program.

II. The State WIC Office and local agencies must prepare for and follow emergency procedures in the event of an emergency.

III. An emergency is defined as any situation that threatens the continuity of State or local agency WIC operations or the safety of its personnel. Emergencies include but are not limited to disasters and states of emergency as declared by the Governor. Emergencies may only affect one clinic or may affect multiple clinics or the statewide food benefit issuance system.

IV. Preparing for an emergency

a. Participate in local agency/government preparedness planning and training.

b. Prepare a contact list of emergency services and personnel.

c. Develop or update an alternative emergency food services list.

d. Determine roles and duties of staff in emergency situations.

e. Train local agency staff on emergency procedures.

f. Preparing for potential pandemics should be part of the agency’s emergency planning. Considerations should include items such as staff absenteeism, social distancing, disinfection of facilities, staff telework, remote appointments, safe benefit delivery, etc.

V. Immediate actions in the event of an emergency

a. WIC staff and participants should be protected from immediate harm or be evacuated if necessary.

b. Program records, equipment and supplies should be protected from damage or destruction whenever possible.

c. The local WIC Director shall contact the State WIC Program Manager to report on the status of the following: i. The number of WIC clinics, staff and clients affected, ii. The extent of damage to service delivery, iii. If program records or equipment has been damaged or destroyed, iv. WIC vendors that are closed and if retail purchase is still possible, v. Estimated length of service disruption,

(section-ii)(emergency-planning)(page-2)Page 2#

Utah WIC Local Agency Policy and Procedures Manual

IV. Organization and Management/Emergency Planning /Emergency Planning Page 2

vi. The number of staff available to work in the clinic, vii. If utility service has been disrupted, viii. The safety of the water supply, ix. Estimated number of newly eligible applicants as a result of the disaster.

d. The State WIC Program Manager will communicate with and receive guidance from the USDA Regional Office.

e. The State WIC Program Manager and the local WIC Director will jointly decide whether or not WIC services will continue as normal, be interrupted or be altered.

f. If WIC services will not be available for a period of time, refer clients to alternative emergency food services.

VI. Providing services during an emergency

a. The State WIC Office will follow the Utah Department of Health and Human Services’ Continuity of Operations Plan (COOP); local agencies will follow similar local agency plans.

b. Alternate methods of providing WIC food benefits during an emergency include: i. Issuing benefits at an alternate site, ii. Issuing benefits curbside/drive-up, iii. Mailing of eWIC cards

c. When a decision is made to provide services at an alternate location: i. Coordinate with emergency services and local government to establish a safe alternative site. ii. Use mobile equipment as needed to provide certification and benefit issuance. iii. Consider use of alternate staff. iv. Work with the State WIC Office and Help Desk on technical and computer issues. v. Inform clients and potential applicants on the availability of WIC services and how to access WIC benefits.

d. Disaster-related evacuees who seek WIC benefits shall be considered as special nutritional risk applicants and receive expedited certification processing. These applicants must be notified of their eligibility or ineligibility within 10 days of the date of the first request for Program benefits. i. Disaster-related evacuees may use the affidavit option if the required proof of identity, residency, or income is not available and

(section-ii)(fiscal-audits)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual

X. Monitoring and Audits/Fiscal Audits/Fiscal Audits

Page 1

Fiscal Audits I. Local agency independent fiscal audits. Due to the Single Audit Act, independent auditors hired by their own agency must audit all local WIC agencies on a yearly basis. The auditor will send the findings and recommendations to the Bureau of Financial Audit.

II. Utah Department of Health and Human Services fiscal audits.

a. Approximately every three years, each local agency will also have a financial audit conducted by the Office of Financial Audit of the Utah Department of Health and Human Services if an independent audit is not performed by the local agency.

b. The state fiscal audit is more comprehensive than the local agency independent audit. The auditor for the Utah Department of Health and Human Services will review documentation at your agency for: i. Expenditures: Budget vs. Actual and Actual vs. the Expenditures reported to the state. ii. Revenues: Actual vs. Revenues reported to the state.

c. The auditor will use the audit guidelines provided by USDA, as well as the specific standards set forth in the publication “The Standards of Audit of Government Organizations, Programs, Activities and Functions,” issued by the Comptroller General of the United States. These audits will be used to determine: i. Whether financial operations are properly conducted, ii. Whether the financial reports are fairly presented, and iii. Whether the agency has complied with applicable laws, regulations, and administrative requirements pertaining to financial management.

d. If the local agency WIC program is being audited by another state, federal, or independent auditor during this time frame, the Utah Department of Health and Human Services may elect not to conduct their audit, or may only cover the areas not included by the other independent audit. The Utah Department of Health and Human Services will determine this after reviewing the results of the independent audit.

(section-ii)(food-and-nsa-expenses)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual

V. Nutrition Services and Administration Expenditures/Allowable Expenditures/Food and NSA Expenses Page 1

Food and NSA Expenses I. Food Cost. The term food cost relates to all prescribed food items, infant formula and breast pumps purchased with WIC food money.

II. Nutrition Services and Administration (NSA). The state will reimburse local agencies for allowable operational costs up to but not exceeding the grant for NSA funds. All operational costs are subject to the terms of the WIC grant, Federal 7 CFR 246.14, Uniform Guidance 2 CFR 200, and other guidelines followed by the Utah Department of Health and Human Services and local agencies.

a. The grant amount is determined by the WIC Funding Formula Committee, (See Funding Committee).

b. All expenditures claimed on the reimbursement form should have appropriate time and documentation for the claims.

c. The local agencies must have a system for documenting the time spent on the program and this system will be monitored every year as part of the single audit. Regular audits will be performed to assure proper classification, documentation and reimbursement.

d. Reimbursement will be processed upon receipt of the local agency’s Monthly Expenditure Report (MER). i. Of these NSA allowable expenses, at least 1/6 of expenses must be spent on Nutrition Education activities.

III. Local Agency Monthly Expenditure Report (MER). The approved invoice to be used for the reimbursement is the State Health Department of Health and Human Services Monthly Expenditure Report (MER).

a. The claim for reimbursement contained on this report should cover a specific calendar month.

b. There must be five columns filled in for the WIC Program for NSA expenditures on the monthly expenditure report, and one column for Peer Counseling grant expenditures:

i) WIC LOCAL PROGRAM MANAGEMENT (Administration) – All costs (direct or indirect) generally considered being overhead or management costs. General management costs include those costs associated with program monitoring, prevention of fraud, general oversight and food instrument accountability. Examples include: 1. Salaries/benefits, travel, and training costs for WIC staff involved in the management and oversight of the program

(section-ii)(food-and-nsa-expenses)(page-2)Page 2#

Utah WIC Local Agency Policy and Procedures Manual

V. Nutrition Services and Administration Expenditures/Allowable Expenditures/Food and NSA Expenses Page 2

2. Costs necessary to conduct outreach 3. Food benefit reconciliation, monitoring and payment 4. Vendor monitoring and training 5. Fraud prevention 6. Creating and retaining administrative records 7. Preparing and maintaining fiscal and program management reports 8. General management clerical support 9. Cost of payroll and personnel systems 10. Accounting and bookkeeping 11. Audits and other financial services 12. Legal services

ii) WIC LOCAL CLIENT SERVICES – All costs expended to deliver food and other client services and benefits. Examples include: 1. Salaries/benefits travel, and training costs for WIC staff who conduct general client services such as intake, food instrument instruction, charting, scheduling, and data entry. 2. Medical supplies and equipment necessary to conduct diet and health assessments required in the certification process 3. Other costs necessary to: a. Refer clients to other health care and social services b. Coordinate services with other programs c. Participate in activities which promote a broader range of health and social services for participants d. Conduct and participate in surveys/studies which evaluate the impact of WIC on its participants.

iii) WIC LOCAL NUTRITION EDUCATION – All costs directly related to general nutrition education. Examples include: 1. Salaries/benefits, travel and training costs for WIC staff who plan or conduct nutrition education counseling 2. Costs to develop/procure, print and distribute nutrition education materials 3. Cost of equipment required to conduct nutrition education training/counseling 4. Interpreter and translator services to facilitate training/counseling 5. Costs associated with evaluating and monitoring nutrition education 6. Developing the Nutrition Education/Evaluation Plan (NEP) 7. Creating nutrition education plans

iv) WIC LOCAL BREASTFEEDING PROMOTION – All costs expended for promotion and support of breastfeeding. Examples include:

(section-ii)(food-and-nsa-expenses)(page-3)Page 3#

Utah WIC Local Agency Policy and Procedures Manual

V. Nutrition Services and Administration Expenditures/Allowable Expenditures/Food and NSA Expenses Page 3

1. Salary/benefits, travel, and training of WIC staff who plan or conduct educational training and counseling to promote or support breastfeeding, 2. Salary/benefits of peer counselors and individuals hired to undertake home visits and other actions to encourage continuation of breastfeeding, 3. Costs to develop/procure, print and distribute educational materials related to breastfeeding promotion and support.

v. WIC LOCAL TECHNOLOGY SERVICES – All costs related to maintaining or improving WIC technology. Examples include: 1. Computer Hardware Replacement, 2. Local IT Support, 3. Any software purchases outside of the WIC Information Operating System.

vi. WIC LOCAL PEER COUNSELING – All costs used only to develop or expand activities necessary to sustain a successful Peer Counseling Program. Examples include: 1. Salaries/benefits, travel, and training for Peer Counselors and designated Peer Counselor managers/coordinators, 2. Related costs such as: a. Computers, telephones and associated cost solely used by Peer Counselors, b. Travel for home and hospital visits, c. Recruitment of peer counseling staff, d. The purchase of demonstration materials (e.g. breast pumps for demonstration purposes, videos). e. Overhead cost related solely to the Peer Counselor program. 3. Items and materials to be used or distributed to WIC participants (e.g., breast pumps, breastfeeding aids, and written materials) are not allowable costs under this funding, and should instead be purchased using regular NSA funds under the breastfeeding promotion and support category.

IV. The following are also allowable NSA costs with prior approval from the state WIC office:

Activity Special notes . . . Transportation of rural participants • Must be considered essential to assure program access. • Direct reimbursement to participants for transportation is not allowed.

(section-ii)(food-and-nsa-expenses)(page-4)Page 4#

Utah WIC Local Agency Policy and Procedures Manual

V. Nutrition Services and Administration Expenditures/Allowable Expenditures/Food and NSA Expenses Page 4

Capital expenditures over $5,000.00 (purchases over $5,000.00 must be approved by State agency and USDA) This includes: • cost of facilities • equipment (including medical and computer equipment) • other capital assets • any repairs that materially increase the value of useful life of capital assets. Management studies • Performed by agencies or departments other than WIC, or • Outside consultants under contract with WIC.

VI. Reallocation/Discretionary Funds. Additional funds received by the State Agency through the federal reallocation process or other sources may be distributed to LHDs through one or both of the following methods, at the discretion of the State Agency.

a. The State Agency will use the WIC Funding Formula to distribute the amount of funds allocated to all LHDs, including the additional federal reallocation funding. Individual local agencies may request to receive no additional funds during this distribution process.

b. The State Agency will distribute funds based on individual local agency need, according to criteria (i.e. caseload growth, clinic service needs, etc.) determined by the State Agency. LHDs may be asked to submit written funding request to the State Agency during this distribution process.

VII. Start-up Funds. Funds may be provided when creation of a new local WIC agency is warranted. New local agency applicants must demonstrate the need as well as cost effectiveness to successfully begin operation of a local agency. A new agency will remain funded for 3 months of operation or until the local agency reaches its projected caseload level, whichever comes first. This may include any funds needed to be advanced to the qualifying agency. The amount of the start-up grant will be determined from the local agency’s application, availability of local administrative funds, and shall be subject to any current caseload management considerations.

VIII. Local Agency Claims. Funds collected through the recovery of local agency claims will only be spent to cover allowable expenditures.

IX. Summary Statement of Expenditures.

a. Wages and Salaries Certification. Compensation for personnel services rendered during the period of performance.

(section-ii)(food-and-nsa-expenses)(page-5)Page 5#

Utah WIC Local Agency Policy and Procedures Manual

V. Nutrition Services and Administration Expenditures/Allowable Expenditures/Food and NSA Expenses Page 5

i. Compensation follows and appointments made according to State and local government laws and rules which meets Federal merit system or other requirements. ii. Wages and salaries charged to the programs will be based on payrolls documented and approved in accordance with the generally accepted practice of the state or local agency. iii. Payrolls must be supported by time and attendance or equivalent records for individual employees. The wages and salaries of employees chargeable to more than one program will be supported by appropriate time distribution records. iv. Registered Dietitians working for WIC may not bill Medicaid or any other public or private health program(s) for nutrition assessment services rendered while working for, and billing time to WIC. If a Registered Dietitian is employed by WIC as a full-time equivalent employee working 40 hours per week, that dietitian may not accrue billable hours to any other program while working on WIC time. If a Registered Dietitian is assigned to WIC less than 40 hours per week, additional work hours may be billed to another program as long as the Registered Dietitian provides all nutrition education and counseling outside of the scope of the WIC Program and outside of time billed for WIC services. The separation of duties must be indicated in the way the employee codes his/her time sheet.

b. Fringe Benefits. Employee benefits in the form of employers’ contribution or expenses for social security, employees’ life and health insurance plans, unemployment insurance coverage, workman’s compensation insurance, pension plans, and the like, provided such benefits are granted under approved plans and are distributed equitably to all related programs.

c. Travel Expenditures. Expenditures for transportation, lodging, and related items incurred by employees who are in travel status on official business. Such costs may be charged on an actual basis, on a per diem or mileage basis in lieu of actual costs incurred, or on a combination of the two, provided the method used is applied to an entire trip, and results in charges consistent with those normally allowed in like circumstances in non-program sponsored activities.

d. Current Expenditures. Expenditures necessary for the operation of the program that are not properly classified as wages and salaries, fringe benefits, travel, or capital outlay. Examples include utilities, supplies, contracted services, maintenance, etc.

e. Capital Outlay. Costs of facilities, equipment, other capital assets, and repairs which materially increase the value or useful life of capital assets. Property that has a useful life of more than one year and an acquisition

(section-ii)(food-packages)(page-4)Page 4#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Food Package Prescriptions/Food Packages

Page 4 2 Amounts represent the FNB defined as the minimum amount of reconstituted fluid ounces of liquid concentrate infant formula as specified for each infant food package category and feeding variation. The FNB is based on a 13-ounce can that formed the basis of substitution rates for other physical forms of infant formula (i.e., powder and RTF infant formula). 3 Following a WIC nutrition and breastfeeding assessment of the needs of the dyad, breastfed infants, even those in the fully formula fed category, should be issued the quantity of formula needed to support any level of breastfeeding up to the FNB. This amount may be less than the FNB. 4 WIC formula means infant formula, exempt infant formula, or WIC-eligible nutritionals. Infant formula may be issued for infants in Food Packages I, II and III. Medical documentation is required for issuance of WIC formula and other supplemental foods in Food Package III. Only infant formula may be issued for infants in Food Packages I and II. 5 State agencies must issue whole containers that are all the same size of the same physical form. 6 The MMA is specified in reconstituted fluid ounces for liquid concentrate, RTF liquid, and powder forms of infant formula and exempt infant formula. Reconstituted fluid ounce is the form prepared for consumption as directed on the container. Formula provided to infants in any form may not exceed the MMA. 7 The FNB is intended to provide close to 100 percent of the nutritional needs of a non-breastfed infant from birth to 6 months. State agencies must provide at least the FNB authorized to non-breastfed infants up to the MMA for the physical form of the product specified for each food package category unless the food package is tailored to allow “up to” amounts to support breastfeeding. 8 State agencies may round up to issue whole containers of infant formula over the food package timeframe. State agencies must use the methodology described in accordance with paragraph (h)(1) of this section. 9 Per paragraph (b)(2)(ii)(A) of this section, State agencies must make the full MMA of all foods available to participants by providing at least one package size (or combination of sizes) that add up to the full MMA. However, per paragraph (b)(1)(iii) of this section, State agencies may authorize other package sizes (excluding WIC formula) to increase participant variety and choice. 10 State agencies may round up to issue whole containers of infant foods (infant cereal, fruits and vegetables, and meat) over the food package timeframe. State agencies must use the methodology described in accordance with paragraph (h)(2) of this section. 11 In lieu of infant foods (cereal, fruit, and vegetables), infants older than 6 months of age in Food Package III may receive WIC formula (infant formula, exempt infant formula, or WIC-eligible nutritionals) at the same MMA as infants ages 4 through 5 months of age of the same feeding option.

(section-ii)(food-packages)(page-7)Page 7#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Food Package Prescriptions/Food Packages

Page 7 1 Table 4 to paragraph (e)(12) of this section describes the minimum requirements and specifications for supplemental foods. Per paragraph (b)(2)(ii)(A) of this section, State agencies must make the full MMA of all foods available to participants by providing at least one package size (or combination of sizes) that add up to the full MMA. However, per paragraph (b)(1)(iii) of this section, State agencies may authorize other package sizes to increase participant variety and choice. The competent professional authority (CPA) is authorized to determine nutritional risk and prescribe supplemental foods as established by State agency policy. 2 Food Package V-A (see paragraph (e)(5) of this section) is issued to women participants with singleton pregnancies. Food Package V-B (see paragraph (e)(5)) is issued to two categories of WIC participants: breastfeeding women whose partially (mostly) breastfed infants receive formula from WIC in amounts that do not exceed the maximum formula allowances, as appropriate for the age of the infant as described in table 1 to paragraph (e)(9) of this section, and women pregnant with two or more fetuses. 3 Food Package VI is issued to two categories of WIC participants: non-breastfeeding postpartum women and breastfeeding postpartum women whose infants receive more than the maximum infant formula allowances from WIC for partially (mostly) breastfed infants, as appropriate for the age of the infant as described in table 1 to paragraph (e)(9) of this section. 4 Food Package VII is issued to three categories of WIC participants: fully breastfeeding women whose infants do not receive formula from WIC; women partially (mostly) breastfeeding multiple infants from the same pregnancy; and pregnant women who are also fully or partially (mostly) breastfeeding singleton infants. 5 Women fully breastfeeding multiple infants from the same pregnancy are prescribed 1.5 times the MMA. 6 Combinations of single-strength and concentrated juices may be issued provided that the total volume does not exceed the MMA for single-strength juice. 7 Children and women may choose to substitute a $3 CVV for the full juice amount (64 fluid ounces). The monthly value of the CVV substitution amount for juice will be adjusted annually for inflation consistent with the annual inflation adjustments made to CVV values for women and children. A partial CVV substitution for juice is not authorized. The CVV may be redeemed for any eligible fruit and vegetable (refer to table 4 of paragraph (e)(12) to this section and its footnotes). 8 Regular and lactose-free milk must be authorized. “Regular milk” refers to milk that conforms to FDA standard of identity 21 CFR 131.110 and contains lactose exclusive of fat content (e.g., low-fat milk). State agencies have the option to authorize plant-based milk alternatives, yogurts, and cheeses, described in table 4 to paragraph (e)(12) of this section and its footnotes, as milk substitution options when individually tailoring food packages.

(section-ii)(food-packages)(page-8)Page 8#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Food Package Prescriptions/Food Packages

Page 8 9 Whole milk is the standard milk for issuance to 1-year-old children (12 through 23 months). Whole fat or low-fat yogurts may be substituted for fluid milk for 1-year-old children, and both are standard issuance when substituting yogurt. Fat-reduced milks or nonfat yogurt may be issued to 1-year-old children for whom overweight or obesity is a concern. The need for fat-reduced milks or nonfat yogurt for 1-year-old children must be based on an individual nutritional assessment. 10 Low-fat (1%) or nonfat milks are the standard milk for issuance to children ≥24 months of age and women. Reduced-fat (2%) milk is authorized only for participants with certain conditions, including but not limited to, underweight and maternal weight loss during pregnancy. The need for reduced-fat (2%) milk for children receiving Food Package IV-B and women must be based on an individual nutritional assessment. 11 Evaporated milk may be substituted at the rate of 16 fluid ounces of evaporated milk per 32 fluid ounces of fluid milk (i.e., 1:2 fluid ounce substitution ratio). Dry milk may be substituted at an equal reconstituted rate to fluid milk. 12 For children and women, 1 pound of cheese (dairy and/or plant-based) may be substituted for 3 quarts of milk; 1 quart of yogurt (dairy and/or plant- based) may be substituted for 1 quart of milk with a maximum of 2 quarts of yogurt that may be substituted for 2 quarts of milk. Women receiving Food Package VII may substitute up to 2 pounds of cheese for 6 quarts of milk. For children and women in Food Packages IV through VI, no more than 1 pound of cheese may be substituted. State agencies do not have the option to issue additional amounts of cheese or yogurt beyond these maximums even with medical documentation. 13 For children ≥24 months of age (Food Package IV-B) and women, low-fat or nonfat yogurts are the only types of yogurts authorized. 14 When individually tailoring food packages for children, plant-based milk alternatives may be substituted for milk on a quart for quart basis up to the total MMA of milk; tofu may be substituted for milk for children at the rate of 1 pound of tofu per 1 quart of milk up to the MMA for milk. 15 When individually tailoring food packages for women, plant-based milk alternatives may be substituted for milk on a quart for quart basis up to the total MMA of milk; tofu may be substituted for milk at the rate of 1 pound of tofu per 1 quart of milk up to the total MMA of milk. 16 At least 75 percent of cereal on a State agency's authorized food list must meet whole grain criteria for breakfast cereal (refer to table 4 to paragraph (e)(12) of this section and its footnotes). 17 State agencies must authorize substitution of dry legumes (1 pound), canned legumes (64 ounces), and peanut butter (18 ounces) for each 1 dozen eggs when individually tailoring food packages. At State agency option, State agencies may authorize tofu (1 pound) or nut and seed butters (18 ounces) to substitute for each 1 dozen eggs when individually tailoring food packages. 18 State agencies must authorize fresh and one other form of processed (i.e., canned (shelf-stable), frozen, and/or dried) fruits and vegetables. State agencies may choose to authorize additional or all processed forms of fruits and vegetables. The CVV may be redeemed for any eligible fruit and

(section-ii)(food-packages)(page-9)Page 9#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Food Package Prescriptions/Food Packages

Page 9 vegetable (refer to table 4 to paragraph (e)(12) of this section and its footnotes). Except as authorized in paragraph (b)(1)(i) of this section, State agencies may not selectively choose which fruits and vegetables are available to participants. For example, if a State agency chooses to offer dried fruits, it must authorize all WIC-eligible dried fruits. 19 The monthly value of the fruit/vegetable CVV will be adjusted annually for inflation using fiscal year 2022 as the base year as described in § 246.16(j). 20 Whole wheat or whole grain bread must be authorized. State agencies have the option to also authorize other whole grain options as described in table 4 to paragraph (e)(12) of this section and its footnotes. 21 Issuance of smaller container sizes is encouraged to reduce the likelihood of exceeding a safe weekly consumption level of methylmercury. The U.S. Food and Drug Administration (FDA) and the U.S. Environmental Protection Agency (EPA) provide joint advice regarding fish consumption to limit methylmercury exposure for children. As noted in their 2021 joint advice, depending on body weight, some women and some children should choose fish lowest in methylmercury or eat less fish than the amounts in the 2020-2025 Dietary Guidelines for Americans (DGA) Healthy US-Style Dietary Pattern. More information is available on the FDA and EPA websites at FDA.gov/fishadviceandEPA.gov/fishadvice. 22 As noted in the 2021 FDA-EPA joint advice about eating fish, for some children, depending on age and caloric needs, the amounts of fish in the 2020-2025 DGA are higher than in the FDA-EPA advice. The DGA states that to consume these higher amounts, these children should consume only fish from the “Best Choices” list that are even lower in mercury—among the WIC-eligible varieties, this includes Atlantic mackerel, salmon, and sardines. 23 State agencies are required to offer both mature dry (1 pound) and canned (64 ounces) legumes. Food Packages V and VII must provide both legumes and peanut butter. However, when individually tailoring these food packages, State agencies may issue the following combinations: 1 pound dry and 64 oz. canned legumes (and no peanut butter); 2 pounds dry or 128 oz. canned legumes (and no peanut butter); or 36 oz. peanut butter (and no legumes). State agencies also have the option to authorize other nut and seed butters as a substitute for peanut butter (on a 1:1 ounce substitution ratio), as described in table 4 to paragraph (e)(12) of this section and its footnotes, when individually tailoring food packages.

(section-ii)(food-packages)(page-10)Page 10#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Food Package Prescriptions/Food Packages

Page 10 XI. Food Package III.

a. This food package is reserved for issuance to women, infant, and children participants who have a documented qualifying condition that requires the use of a WIC formula (infant formula, exempt infant formula, or WIC-eligible nutritional) because the use of conventional foods is precluded, restricted, or inadequate to address their special nutritional needs.

b. Participants who are eligible to receive this food package must have one or more qualifying conditions, as determined by a healthcare professional licensed to write medical prescriptions under state law. The qualifying conditions include but are not limited to: prematurity, malnutrition, weight-for-length/BMI <5th percentile, BMI <18.5 (18+ years), chronic renal failure, GERD, allergies, inborn errors of metabolism, feeding difficulties, or cancer.

c. This food package may not be issued solely for the purpose of enhancing nutrient intake or managing body weight.

d. This food package is not authorized for: i. Infants whose only condition is a diagnosed formula intolerance or food allergy to lactose, sucrose, milk protein, or soy protein that does not require the use of an exempt infant formula or a non-specific formula. ii. Women and children who have a food intolerance to lactose or milk protein that can be successfully managed with the use of one of the other WIC food packages. iii. Any participant solely for the purpose of enhancing nutrient intake or managing body weight without an underlying qualifying condition.

e. Examples of WIC participants that qualify for Food Package III: i. Infants prescribed an exempt infant formula. ii. Infants 6 months or older prescribed higher amounts of infant formula instead of infant solid foods. iii. Children prescribed contract formula, exempt formula, or WIC-eligible nutritionals. iv. Women prescribed formula or WIC-eligible nutritionals.

Food Package III: The Maximum Monthly Allowances (MMA) of Supplemental Foods for Children and Women with Qualifying Conditions

(section-ii)(food-packages)(page-12)Page 12#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Food Package Prescriptions/Food Packages

Page 12 Note: Abbreviations in order of appearance in table: N/A = Not applicable (the supplemental food is not authorized in the corresponding food package); CVV = cash-value voucher. 1 Table 4 to paragraph (e)(12) of this section describes the minimum requirements and specifications for supplemental foods. Food Package III is issued to participants with qualifying medical conditions that require use of a WIC formula and supplementary foods under the direction of a healthcare provider. Per paragraph (b)(2)(ii)(A) of this section, State agencies must make the full MMA of all foods available to participants by providing at least one package size (or combination of sizes) that add up to the full MMA. However, per paragraph (b)(1)(iii) of this section, State agencies may authorize other package sizes (excluding WIC formula) to increase participant variety and choice. The competent professional authority (CPA) is authorized to determine nutritional risk and prescribe supplemental foods per medical documentation, as established by State agency policy. 2 Food Package III-A for women is issued to participants with singleton pregnancies. Food Package III-B for women is issued to two categories of participants: women pregnant with two or more fetuses and breastfeeding women whose partially (mostly) breastfed infants receive formula from WIC in amounts that do not exceed the maximum formula allowances, as appropriate for the age of the infant as described in table 1 to paragraph (e)(9) of this section. 3 This food package is issued to two categories of WIC participants: non-breastfeeding postpartum women and breastfeeding postpartum women whose infants receive more than the maximum infant formula allowances from WIC for partially (mostly) breastfed infants, as appropriate for the age of the infant as described in table 1 to paragraph (e)(9) of this section. 4 This food package is issued to three categories of WIC participants: fully breastfeeding women whose infants do not receive formula from WIC; women partially (mostly) breastfeeding multiple infants from the same pregnancy; and pregnant women who are also fully or partially (mostly) breastfeeding singleton infants. 5 Women fully breastfeeding multiple infants from the same pregnancy are prescribed 1.5 times the MMA. 6 Combinations of single-strength and concentrated juices may be issued provided that the total volume does not exceed the MMA for single-strength juice. 7 As determined appropriate by the healthcare provider per medical documentation, children and women may choose to substitute a $3 CVV for the full juice amount (64 fluid ounces)—a partial CVV substitution for juice is not authorized—or use their $3 CVV for jarred infant food fruits and vegetables. State agencies must use the conversion of $1 CVV = 6.25 ounces of jarred infant food fruits and vegetables. The monthly value of the CVV substitution amount for juice will be adjusted annually for inflation consistent with the inflation adjustments made to women and children's CVV values.

(section-ii)(food-packages)(page-13)Page 13#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Food Package Prescriptions/Food Packages

Page 13 8 WIC formula means infant formula, exempt infant formula, or WIC-eligible nutritionals. Participants may receive up to 455 fluid ounces of a WIC formula (liquid concentrate) as determined appropriate by the healthcare provider per medical documentation. The number of fluid ounces refers to the amount as prepared according to directions on the container. 9 Powder and ready-to-feed may be substituted at rates that provide comparable nutritive value. 10 Regular and lactose-free milk must be authorized. “Regular milk” refers to milk that conforms to FDA standard of identity 21 CFR 131.110 and contains lactose exclusive of fat content (e.g., low-fat milk). State agencies have the option to authorize plant-based milk alternatives, yogurts, and cheeses, described in table 4 of paragraph (e)(12) of this section and its footnotes, as determined appropriate by the healthcare provider per medical documentation. 11 Whole milk is the standard milk for issuance to 1-year-old children (12 through 23 months). Whole fat or low-fat yogurts may be substituted for fluid milk for 1-year-old children, and both are standard issuance when substituting yogurt. Fat-reduced milks or nonfat yogurt may be issued to 1-year-old children as determined appropriate by the healthcare provider per medical documentation. 12 Low-fat (1%) or nonfat milks are the standard milk for issuance to children ≥24 months of age and women. Whole milk or reduced-fat (2%) milk may be substituted for low-fat (1%) or nonfat milk for children ≥24 months of age and women as determined appropriate by the healthcare provider per medical documentation. 13 Evaporated milk may be substituted at the rate of 16 fluid ounces of evaporated milk per 32 fluid ounces of fluid milk (a 1:2 fluid ounce substitution ratio). Dry milk may be substituted at an equal reconstituted rate to fluid milk. 14 For children and women, 1 pound of cheese (dairy- and/or plant-based) may be substituted for 3 quarts of milk and 1 quart of yogurt (dairy- and/or plant-based) may be substituted for 1 quart of milk as determined appropriate by the healthcare provider per medical documentation. A maximum of 2 quarts of yogurt that may be substituted for 2 quarts of milk for both children and women. Fully breastfeeding women may substitute up to 2 pounds of cheese for 6 quarts of milk. Children and pregnant, partially breastfeeding, and postpartum women may substitute no more than 1 pound of cheese. State agencies do not have the option to issue additional amounts of cheese or yogurt beyond these maximums even with medical documentation. 15 For children ≥24 months of age and women, low-fat or nonfat yogurts are the only types of yogurts authorized. Whole or reduced-fat yogurt may be substituted for low-fat or nonfat yogurt for children ≥24 months of age and women as determined appropriate by the healthcare provider per medical documentation. 16 For children, issuance of tofu and plant-based milk alternatives may be substituted for milk as determined appropriate by the healthcare provider per medical documentation. Plant-based milk alternatives may be substituted for milk for children on a quart for quart basis up to the total MMA of

(section-ii)(food-packages)(page-14)Page 14#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Food Package Prescriptions/Food Packages

Page 14 milk. Tofu may be substituted for milk for children at the rate of 1 pound of tofu per 1 quart of milk up to the MMA of milk, as determined appropriate by the healthcare provider per medical documentation. 17 For women, plant-based milk alternatives may be substituted for milk on a quart for quart basis up to the total MMA of milk. Tofu may be substituted for milk at the rate of 1 pound of tofu per 1 quart of milk up to the MMA of milk, as determined appropriate by the healthcare provider per medical documentation. 18 32 dry ounces of infant cereal may be substituted for 36 ounces of breakfast cereal as determined appropriate by the healthcare provider per medical documentation. 19 At least 75 percent of cereals authorized on a State agency's authorized food list must meet whole grain criteria for breakfast cereal (refer to table 4 to paragraph (e)(12) of this section and its footnotes). 20 State agencies must authorize substitution of dry legume (1 pound), canned legumes (64 ounces), and peanut butter (18 ounces) for each 1 dozen eggs and, at State agency option, State agencies may authorize tofu (1 pound) or nut and seed butters (18 ounces) to substitute for each 1 dozen eggs as determined appropriate by the healthcare provider per medical documentation. 21 State agencies must authorize fresh and one other form (i.e., canned (shelf-stable), frozen, and/or dried) of fruits and vegetables. State agencies may choose to authorize additional or all processed forms of fruits and vegetables. The CVV may be redeemed for any eligible fruit and vegetable (refer to table 4 to paragraph (e)(12) of this section and its footnotes). Except as authorized in paragraph (b)(1)(i) of this section, State agencies may not selectively choose which fruits and vegetables are available to participants. For example, if a State agency chooses to offer dried fruits, it must authorize all WIC-eligible dried fruits. 22 Children and women whose special dietary needs require the use of pureed foods may receive commercial jarred infant food fruits and vegetables in lieu of the CVV. For children and women who require jarred infant food fruits and vegetables in place of the CVV, State agencies must use the conversion of $1 CVV = 6.25 ounces of jarred infant food fruits and vegetables. Infant food fruits and vegetables may be substituted for the CVV as determined appropriate by the healthcare provider per medical documentation. 23 The monthly value of the fruit/vegetable CVV will be adjusted annually for inflation as described in § 246.16(j). 24 Whole wheat or whole grain bread must be authorized. State agencies have the option to also authorize other whole grain options as described in table 4 to paragraph (e)(12) of this section and its footnotes. 25 Issuance of smaller container sizes is encouraged to reduce the likelihood of exceeding a safe weekly consumption level of methylmercury. The U.S. Food and Drug Administration (FDA) and the U.S. Environmental Protection Agency (EPA) provide joint advice regarding fish consumption to

(section-ii)(food-packages)(page-16)Page 16#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Food Package Prescriptions/Food Packages Page 16

XII. Issuance criteria for form of formula.

a. Powdered formula is the standard form of formula to be issued to WIC participants.

b. Documentation is required when issuing concentrate or ready-to-feed (RTF) forms of formula.

c. In VISION, the CPA will assign or tailor a food package for each WIC participant. This food package will continue to be issued by VISION until a new food package is created or until a milestone is reached. If an infant or child does not reach a milestone by the first day of the month, then they will continue to receive the same benefits until the next month.

d. Issuance criteria for concentrated formula. i. Refer to Appendix A below. ii. The CPA must determine that the powder form is not appropriate for the participant. iii. RTF formula is the preferred choice to be issued when a sterile liquid formula is needed. iv. Concentrated formula may be issued if the needed product is only available in concentrate form.

e. Issuance criteria for RTF formula. i. Refer to Appendix A below. ii. The CPA must determine that the powder form is not appropriate for the participant. iii. RTF formula may be issued in the following situations: 1. There is an unsanitary or restricted water supply. 2. There is poor refrigeration. 3. A caretaker has difficulty correctly diluting concentrated or powdered formula. 4. The product is only available in RTF form. 5. A Food and Formula Authorization Form (FAFAF) states RTF is necessary.

f. Issuance criteria for premature infants. i. Premature infants are defined as an assignment of risk factor 142A (infants born < 37 weeks gestation). ii. For premature infants < 3 months of age: 1. The default formula issued shall be a sterile liquid formula if produced by the manufacturer. a. Sterile liquid formula is either concentrate or RTF. 2. If the participant’s healthcare provider specifically prescribes powder, the WIC clinic may provide powder.

(section-ii)(food-packages)(page-17)Page 17#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Food Package Prescriptions/Food Packages Page 17

3. If the supervising healthcare provider has not prescribed a sterile liquid formula and the parent or guardian requests powder, then powder may be provided. 4. If the supervising healthcare provider has prescribed a sterile liquid formula, then powder may not be provided when requested by the parent or guardian without documented approval from the healthcare provider. iii. For premature infants > 3 months of age: 1. The continued use of sterile liquid formula is generally not required. 2. All infants previously issued sterile liquid formula should be reassessed at their appointments and issued a powdered infant formula package, if appropriate. 3. In cases where unsanitary water supplies exist, continue to issue RTF formula.

XIII. Issuing at infant milestones.

a. Milestones refer to age-related adjustments in the types and amounts of foods provided to participants based on their nutritional needs and developmental readiness.

b. Issuing at the 4-5 month milestone. i. VISION will automatically update the most recently issued 0-3 month infant food package to the equivalent 4-5 month infant food package unless "Do Not Auto-Update" was manually selected or the food package has been tailored. 1. If “Do Not Auto-Update” is manually selected, or the food package has been tailored, the CPA must create a new food package with an effective date in the month the infant turns 4 months old. 2. The infant will receive the 0-3 month infant food package the month they turn 4 months unless they turn 4 months on the first day of that month. a. Example: An infant turns 4 months old on March 3. They will receive the 0-3 month infant food package for the month of March because they did not turn 4 months old by or on March 1.

c. Issuing at the 6-month milestone. i. VISION will automatically update the most recently issued 4-5 month infant food package to the equivalent 6 month infant food package unless "Do Not Auto-Update" was manually selected, the food package has been tailored, or the infant is designated as Exclusively Breastfeeding or Primarily Exclusive/No Food Package in the Breastfeeding Panel.

(section-ii)(food-packages)(page-19)Page 19#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Food Package Prescriptions/Food Packages Page 19

XV. Not Breastfeeding to Breastfeeding category situations.

a. Issuing for the > 6-month-old infant if mom was in the Breastfeeding category when she was terminated. i. Reinstate the mom by following the steps below. You do not need to do a full recertification. ii. In mom’s record: 1. Go to the Certification screen. a. Click “Edit” in the Termination record. b. Click “Reinstate” and select “Returned for benefits.” iii. In the infant’s record: 1. Go to the Breastfeeding Panel in the Breastfeeding screen. a. Call the state WIC help desk. They’ll remove the row that says “No Longer BF.” b. Click “Add Row.” c. Complete the panel. 2. Update additional breastfeeding information. a. Create a nutrition interview and a care plan if it’s a certification, recertification, or midcertification appointment. b. Document the completed breastfeeding assessment in the Food Package screen’s “Comments” field. Document additional details in the care plan if needed. 3. Go to the Food Package screen. a. Assign the 6-11 month food package. iv. In mom’s record: 1. Go to the Food Package screen. a. Assign mom’s food package. v. Go to the Food Benefits screen. 1. Review and issue benefits.

b. Issuing for the < 6-month-old infant if mom is in the Not Breastfeeding category, or the > 6-month-old infant if mom was in the Not Breastfeeding category when she was terminated. i. If issuing for the < 6-month-old infant, terminate the mom first. ii. Recertify the mom by following the steps below. Previously used proofs can be reused if she was certified within the last 31 days. Anthropometric data is valid for 60 days. Hematological data is valid for 90 days. iii. In the mom’s record: 1. Go to the Application screen. a. Create a new application. 2. Go to the Participant Category screen. a. Create a new record and choose “Breastfeeding” as the Participant Category.

(section-ii)(food-packages)(page-21)Page 21#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Food Package Prescriptions/Food Packages Page 21

c. Save. 2. Update additional breastfeeding information. a. Create a nutrition interview and a care plan if it’s a certification, recertification, or midcertification appointment. b. Document the completed breastfeeding assessment in the Food Package screen’s “Comments” field. Document additional details in the care plan if needed. i.

3. Go to the Food Package screen. a. Assign a new food package. b. Tailor the formula amount. c. Assign food packages for future milestones as needed (4-5 month or 6-11 month).* *VISION will not automatically create food packages at future milestones because the food package is tailored. ii. In mom’s record: 1. Go to the Food Package screen. a. Assign a new food package.* *If mom was previously issued food benefits for the current month, start her postpartum food package the following month. iii. Go to the Food Benefits screen. 1. Review then issue benefits. iv. Provide verbal notice that if mom continues to partially breastfeed out of range she’ll only receive food benefits through 6 months postpartum. v. Reassess breastfeeding frequency at future appointments. 1. If mom is still partially breastfeeding out of range and the infant is > 6 months old, print the “Notice of Termination” and give it to mom (found in VISION in the Printouts drop down). 2. Issuance of the “Notice of Termination” letter must be documented in VISION. This may be entered in the comments screen, the Nutrition Education screen- Pamphlets Provided, or a copy of the notice may be scanned.

e. Issuing for the > 6-month-old infant changing to a Part BF out-of-range formula amount. i. When a partially-breastfed infant > 6 months of age receives an “out-of-range” amount of formula, the mother is no longer categorically eligible for the WIC program and is not authorized to receive 15 days of food benefits. ii. In the infant’s record: Formatted: Indent: Left: 3", No bullets or numbering

(section-ii)(food-packages)(page-22)Page 22#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Food Package Prescriptions/Food Packages Page 22

1. Go to the Breastfeeding Panel in the Breastfeeding screen. a. Click “Add Row.” b. Complete the panel. c. Save. 2. Update additional breastfeeding information. a. Create a nutrition interview and a care plan if it’s a certification, recertification, or midcertification appointment. b. Document the completed breastfeeding assessment in the Food Package screen’s “Comments” field. Document additional details in the care plan if needed. 3. Go to the Food Package screen. a. Assign a new food package. Tailor the formula amount. iii. In mom’s record: 1. Go to the Certification screen. a. Create a new Termination record. b. Choose “Part BF out of range > 6 mos.” in the Termination Reason drop down. c. Choose today’s date as the Effective Date. iv. Go to the Food Benefits screen. 1. Review benefits before you issue them. a. Mom should not be issued any benefits for the current or future months. She is no longer categorically eligible for the WIC program. b. If mom was previously issued food benefits for the current or future months, uncheck them before you issue benefits. There is no penalty if mom has already purchased some or all of her food benefits for the month already. v. Print the “Notice of Termination” letter and give it to mom (found in VISION in the Printouts drop down). 1. The issuance of the “Notice of Termination” letter must be documented in VISION. This may be entered in the comments screen, the Nutrition Education screen- Pamphlets Provided, or a copy of the notice may be scanned.

XVII. Breastfeeding to Not Breastfeeding category situations.

a. Issuing for the < 6-month-old infant changing to No Longer BF. i. In the infant’s record: 1. Go to the Breastfeeding Panel in the Breastfeeding screen. a. Click “Add Row” b. Complete the panel and choose “No Longer BF” from

(section-ii)(food-packages)(page-23)Page 23#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Food Package Prescriptions/Food Packages Page 23

the Description drop down. i. A pop-up window will ask if you’re sure you want to continue with the automatic participant category update for the breastfeeding woman associated with the infant. Click “Yes.” c. Save. 2. Update additional breastfeeding information. a. Create a nutrition interview and a care plan if it’s a certification, recertification, or midcertification appointment. b. Document the completed breastfeeding assessment in the Food Package screen’s “Comments” field. Document additional details in the care plan if needed. 3. Go to the Food Package screen. a. Assign a new food package. ii. In mom’s record: 1. Go to the Food Package screen. a. Assign a new food package.* *If mom was previously issued food benefits for the current month, change the effective date of her postpartum food package to the first day of the next month. iii. Go to the Food Benefits screen. 1. Review then issue benefits.

b. Issuing for the > 6-month-old infant who is changing to No Longer BF. i. When an infant > 6 months of age changes to “No Longer BF,” the mom is no longer categorically eligible for the WIC program and is not authorized to receive 15 days of food benefits. ii. In the infant’s record: 1. Go to the Breastfeeding Panel in the Breastfeeding screen. a. Click “Add Row” b. Complete the panel and choose “No Longer BF” from the Description drop down. i. A pop-up window will ask if you’re sure you want to continue with the automatic participant category update for the breastfeeding woman associated with the infant. Click “Yes.” c. Save. 2. Update additional breastfeeding information. a. Create a nutrition interview and a care plan if it’s a certification, recertification, or midcertification appointment. b. Document the completed breastfeeding assessment in the Food Package screen’s “Comments” field.

(section-ii)(foods-that-are-authorized)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Food Package Prescriptions/Foods that are Authorized Page 1

Foods that are Authorized I. Infant Formula (Category 21).

a. Infant formula is defined in section 201(z) of the Federal Food, Drug and Cosmetic Act (FFDCA) (21 USC 321[z]) and meets the requirements in section 412 of the FFDCA 21 USC 350(a) and in the Code of Federal Regulations (CFR) 21, Parts 106 and 107.

b. WIC infant formula refers to iron-fortified infant formula which, other than water, does not require the addition of any ingredient. It is a complete food for an infant.

c. Infant formula is not an equal substitute for human milk and breastfeeding. Breastfeeding must be maintained or increased, supported, and encouraged, unless medically contraindicated.

d. Standard formulas. i. Powdered formula—most common, least expensive form of formula. ii. Concentrate formula. iii. Ready-to-feed formula.

e. The amount of formula issued to a participant is based on many factors including the full nutrition benefit and monthly maximum allowances (MMA) outlined in Table 1 to paragraph (e)(9) in CFR Part 246.10, a breastfeeding assessment, and the WIC Formula and Food Authorization Form (FAFAF) if applicable.

f. Primary contract formulas. i. Under the Child Nutrition Act of 1966, the infant formula manufacturers for WIC programs are selected via a competitive, sealed, bidding process. Competitive bidding is defined as a process under which the state selects a single source offering the lowest price. The infant formula company who offers the lowest net wholesale cost or the highest rebate per unit of infant formula is awarded the contract. The formula company selected acts as the state’s single source, providing all infant formula in the forms and types originally spelled out in the invitation for bids. ii. The Utah WIC program presently has a rebate agreement to provide the primary contract formulas Similac Advance (cow milk based) and Similac Soy Isomil (soy based). Additionally Utah WIC has a rebate agreement for select forms of: 1. Similac Sensitive 2. Similac Total Gentle Comfort

(section-ii)(foods-that-are-authorized)(page-2)Page 2#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Food Package Prescriptions/Foods that are Authorized Page 2

iii. All infants on the Utah WIC program who need a standard infant formula shall receive a contract formula, unless a non-contract formula is medically prescribed with a FAFAF. iv. Similac Advance is the standard primary contract formula for full- term babies on the Utah WIC program who are not breastfed.

g. Non-contract formulas include non-contract infant formula, exempt infant formula, and WIC-eligible nutritionals. i. Non-contract infant formulas include products designed for normal infant feeding. These products must contain at least 10 milligrams (mg) of iron per liter of formula at standard dilution. Standard dilution is 20 calories (kcals) per fluid ounce. 1. Enfamil AR, Earth’s Best Organic Sensitivity, and store brands (Perrigo) are examples of non-contract infant formulas. ii. If religious eating patterns warrant a non-contract infant formula (category 21), a FAFAF is not required. iii. Non-contract formulas include products whose manufacturers do not have cost-containment contracts with the Utah WIC program. iv. Non-contract formulas ordered by a Utah state-licensed prescriptive authority using a FAFAF are approved by the Utah WIC program if they meet the minimum requirements and specifications for WIC formula as outlined in Table 4 to paragraph (e)(12) – Minimum Requirements and Specifications for Supplemental Foods, 246.10 of the Food and Nutrition Service, USDA federal regulations, and are approved by the state office. 1. Non-contract infant formula approvals may be limited if there is a comparable contract formula for cost-containment purposes. 2. Non-contract formulas may not be approved if the Utah WIC program manager determines the Utah WIC food budget is in a deficit situation and does not have sufficient funds in the food budget to reimburse the cost of the non-contract formula. In these situations, the state nutrition coordinator, formula and food manager, or local CPA may consult with the state-licensed prescriptive authority to determine an alternative formula that can be supported by the Utah WIC food budget.

II. Exempt Infant Formula (Category 31).

a. Exempt infant formulas comply with and are defined in section 412(h) of the FFDCA (21 USC 350 a[h]) and regulations at 21 CFR Parts 106 and 107.

(section-ii)(foods-that-are-authorized)(page-3)Page 3#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Food Package Prescriptions/Foods that are Authorized Page 3

b. Exempt infant formulas are formulas that are used instead of standard formulas to manage the medical conditions listed below: i. Allergies ii. Cancer iii. GERD iv. Weight-for-length/BMI < 5%ile (0-5 yrs) v. BMI < 18.5 (18+yrs) vi. Inborn errors of metabolism vii. Chronic Renal Failure viii. Feeding Difficulties ix. Malnutrition x. Prematurity xi. Other ICD 10 Medial Dx

c. Refer to the Product Guide for details regarding these formulas, as well as instructions on use, issuance, and ordering.

d. Metabolic formulas i. These formulas are used to manage inborn-errors of metabolism such as phenylketonuria. ii. Refer to the Product Guide for metabolic formulas, as well as instructions on use, issuance, and ordering.

e. Hydrolysate formulas i. Most hypoallergenic formulas are hydrolysate formulas. ii. Formulas such as Nutramigen, Pregestimil (Mead Johnson), Alimentum (Abbott), and store brand hypoallergenic formulas (Perrigo) are hypoallergenic formulas made for easy digestion and are less likely to cause allergic reactions than other types of formulas. iii. Refer to the Product Guide for hypoallergenic formulas, as well as instructions regarding use, issuance, and ordering.

f. Low-iron formulas i. Low-iron formula is not allowed in Food Packages I and II, but is allowed in Food Package III due to (but not limited to) the following: 1. USDA recognizes the medical condition hemolytic anemia, a disorder where the body breaks down red blood cells faster than they can be made. Hemolytic anemia necessitates the restriction of iron intake through the use of low-iron formula. a. Must be prescribed by a healthcare provider on a FAFAF. ii. Refer to the Product Guide for low-iron formulas, as well as instructions on use, issuance, and ordering.

III. WIC-Eligible Nutritionals (Category 41).

(section-ii)(foods-that-are-authorized)(page-4)Page 4#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Food Package Prescriptions/Foods that are Authorized Page 4

a. WIC-eligible nutritionals represent enteral products that are specifically formulated to provide nutritional support for individuals with a qualifying condition when the use of conventional foods is precluded, restricted, or inadequate. b. WIC-eligible nutritionals must serve the purpose of a food, meal, or diet (may be nutritionally complete or incomplete), and provide a source of calories and one or more nutrients. They must be designed for enteral digestion via oral or tube feeding.

c. Refer to the Product Guide for WIC-eligible nutritionals, as well as instructions on use, issuance, and ordering. d. WIC-eligible nutritionals may not be the following: i. Formulas or products used solely for the purpose of enhancing nutrient intake (e.g., vitamin supplements), managing body weight (e.g., weight control products), addressing picky eaters, or for conditions other than those accepted on a completed FAFAF. ii. Medicines or drugs. iii. Hyperalimentation feedings (nourishment administered through a vein). iv. Enzymes, herbs, or botanicals. v. Oral rehydration fluids or electrolyte solutions. vi. Flavoring or thickening agents (e.g., Thick-It, Simply Thick, gelmix). vii. Feeding utensils or devices designed to administer a WIC-eligible formula or nutritional (e.g., feeding tubes, bags, pumps). viii. Sports or breakfast drinks. ix. Formulas while under hospital care. x. Parenteral nutritional products.

IV. Manufacturers Allowed to Supply Formula to the WIC Program. a. Manufacturers supplying formula to the WIC program must be registered with the Secretary of Health and Human Services under the FFDCA (21 USC 301 et seq.). b. Imported (manufactured outside of the United States) category 21 and 31 infant formulas are not authorized on the WIC program unless a waiver is provided by the FDA to the USDA for WIC to authorize imported infant formulas under special circumstances such as a formula shortage, emergency declaration, or natural disaster. V. Providing Formula Instead of Complementary Foods. a. Food Package III allows for additional formula to be provided for an infant who is 6 to 11-months-old and medically unable to consume

(section-ii)(foods-that-are-authorized)(page-12)Page 12#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Food Package Prescriptions/Foods that are Authorized Page 12

vi.vii. Issuing “000 Yogurt - Whole and Reduced Fat” allows the participant to purchase whole-fat or reduced-fat yogurt. vii.viii. Subcategory “001 Yogurt - Whole Fat (Do Not Issue)” allows only whole-fat yogurt and cannot be issued. viii.ix. Issuing “002 Yogurt - Reduced and Nonfat” allows the participant to purchase reduced-fat or nonfat yogurt. ix.x. Whole and reduced fat yogurt is the standard yogurt issuance for 1- year-old children. 1. In Food Packages III - VII, nonfat yogurt may be issued to 1- year-old children as prescribed on a FAFAF or for whom overweight or obesity is a concern as determined by the CPA based on individual nutrition assessment and if the healthcare provider doesn’t deny this per FAFAF. x.xi. Reduced and nonfat yogurt is the standard yogurt issuance for children 2 years of age and older, and women. 1. In Food Package III, whole-fat and reduced fat or reduced and nonfat yogurt may be issued to children 2 years of age and older, and women, when whole fat milk is prescribed on a FAFAF, along with a medical formula. xi.xii. Yogurt is deducted from the participant’s account in 32 oz. increments.

d. Cheese i. Must be domestic cheese made from 100% pasteurized milk and meet the FDA standards of identity (21 CFR Part 133). ii. For children and women, cheese may be substituted for milk at the rate of 1 pound of cheese per 3 quarts of milk. 1. For children and women in Food Packages IV-VI, no more than 1 pound of cheese per 3 quarts of milk may be substituted. 2. For fully breastfeeding women in Food Package VII, no more than 2 pounds of cheese per 6 quarts of milk may be substituted. 3. For women fully breastfeeding multiples, no more than 3 pounds of cheese per 9 quarts of milk may be substituted. iii. Allowed: 1. Types: pasteurized processed American, brick, natural cheddar, colby, monterey jack, mozzarella, muenster, provolone, and swiss (i.e., any of the allowed cheeses listed in the Utah WIC Program Shopping Guide). 2. Cheeses that are labeled low, free, reduced, less or light in sodium, fat, or cholesterol. 3. Only store brands or private labels. 4. Block, sliced, shredded, string/stick, or cubes. 5. 8 to 16 oz., and 32 oz. packages. iv. Not allowed:

(section-ii)(foods-that-are-authorized)(page-13)Page 13#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Food Package Prescriptions/Foods that are Authorized Page 13

1. Imported cheese, cheese foods, and cheese spreads. v. Cheese is deducted from the participant’s account in 0.25 lb increments.

e. Lactose-free milk i. Lactose-free milk may be authorized for: 1. Women and children over 1 year of age. 2. Participants who report symptoms of lactose intolerance. 3. Participants who report a condition or symptom that could benefit from the use of lactose-free milk. ii. Allowed: 1. Whole-fat, reduced-fat (2%), or skim/1% as appropriate. 2. Store brand or private label, or other brands listed in the Utah WIC Program Shopping Guide. 3. Quarts, half-gallons, and 3-quart containers. iii. Lactose-free milk is deducted from the participant’s account in 0.25 gallon increments.

f. Acidophilus cow’s milk i. Acidophilus cow’s milk is fermented milk that contains less lactose than unfermented milk. ii. Must conform to the FDA standards for identity (21 CFR Part 131.111). iii. It is indicated for children over the age of 2 and adults who: 1. May have lactose intolerance, but are not allergic to cow’s milk protein. 2. Are on continuous antibiotic therapy. iv. The CPA must document the specific reason for use in the participant’s file. v. Acidophilus cow’s milk is deducted from the participant’s account in 0.25 gallon increments.

g. UHT milk i. UHT milk refers to whole, 2%, and 1%/skim shelf-stable milk that requires no refrigeration. Refrigerate after opening and follow label instructions for storage. ii. UTH may be beneficial for participants with: 1. A scarcity of refrigerated milk, 2. Poor refrigeration facilities in the home, or 3. Milk contamination emergency. iii. Allowed: 1. Brands listed in the “UHT milk - more information” food help. 2. Quarts. iv. UHT milk is deducted from the participant’s account in 0.25 gallon increments.

(section-ii)(foods-that-are-authorized)(page-14)Page 14#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Food Package Prescriptions/Foods that are Authorized Page 14

h. Evaporated milk i. Evaporated milk refers to whole, 2%, and 1%/skim canned cow’s milk product that has been concentrated by removing half of the water. ii. It must meet FDA standards of identity (21 CFR Part 131.130). iii. Allowed: 1. Store brand or private label, Nestle or PET brands. 2. 12 oz. cans. a. One 12 oz. can only reconstitutes to 24 oz. milk, but is equivalent to 0.25 gallons in VISION. iv. Evaporated milk is deducted from the participant’s account in 0.25 gallon increments.

i. Nonfat dry (powdered) milk i. Nonfat dry milk is the product obtained when only water is removed from pasteurized skim milk. It contains not more than 5% by weight of moisture, and not more than 5.5% by weight of milkfat unless otherwise indicated. ii. It must meet FDA standards of identity (21 CFR Part 131.127). iii. Nonfat dry milk can be substituted at an equal reconstituted rate to fluid milk. iv. Allowed: 1. Store brand or private label, Village Farm, or Carnation brands. 2. 9.6 to 64 ounce packages allowed. a. One 9.6 oz. package is equivalent to 0.75 gallons. b. One 25.6 oz. package is equivalent to 2.00 gallons. c. One 32 oz. package is equivalent to 2.5 gallons. d. One 64 oz. package is equivalent to 5 gallons. v. Nonfat dry (powdered) milk is deducted from the participant’s account in 0.25 gallon increments.

j. Goat’s milk i. Goat milk is allowed and must contain 100 IU vitamin D and 500 IU vitamin A per cup. 1. The CPA will determine and document the need for goat milk as a substitute for milk. a. This determination must be based on individual nutritional assessment, and consultation with the participant’s healthcare provider, as appropriate. b. This substitution may be made for cow milk protein allergy, lactose intolerance, and other dairy intolerances. i.ii. Goat’s milk refers to the fluid or dry form of goat’s milk. ii. Goat milk must contain 100 IU vitamin D and 500 IU vitamin A per cup. Formatted Formatted Formatted: Border: Top: (No border), Bottom: (No border), Left: (No border), Right: (No border), Between : (No border) Formatted: Font color: Auto

(section-ii)(foods-that-are-authorized)(page-15)Page 15#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Food Package Prescriptions/Foods that are Authorized Page 15

iii. Only whole goat’s milk is available in Utah, but it may not be sold at all vendor locations. iv. Allowed: 1. Drake Family Farms and Meyenberg brands. 2. Fluid goat’s milk—half gallon and quart containers. v. Goat’s milk is deducted from the participant’s account in 0.25 gallon increments.

k. Plant-based milk alternatives i. Plant-based milk alternatives are allowed if they meet the following nutrient levels per 8 oz., in accordance with FDA fortification guidelines: 276 mg calcium, 8 gm protein, 500 IU vitamin A, 100 IU vitamin D, 24 mg magnesium, 222 mg phosphorus, 349 mg potassium, 0.44 mg riboflavin, and 1.1 mcg vitamin B12. 1. Soy milk and non-soy plant-based milk alternatives are allowed. a. The CPA will determine and document the need for soy milk as a substitute for milk. i. This determination must be based on individual nutritional assessment, and consultation with the participant’s healthcare provider, as appropriate. ii. This substitution may be made for situations that include, but are not limited to, milk allergy, lactose intolerance, and vegan diets. iii. Allowed: 1. Only approved brands listed in the Utah WIC Program Shopping Guide. 2. Half gallons and quarts. b. The CPA will determine and document the need for non-soy plant-based milk as a substitute for milk. i. This determination must be based on individual nutrition assessment, and consultation with the participant’s healthcare provider, as appropriate. ii. Non-soy plant-based milk is only appropriate when a participant has both a cow milk protein allergy and a soy protein allergy. iii. Allowed: 1. Ripple milk (pea based) and Silk Kids Oatmilk Blend (pea and oat based). 2. Half gallon (48 ounce and 59 ounce containers) and quarts (32 ounce containers and 8 ounce 4 packs). 2. Plant-based milk is deducted from the participant’s account in 0.25 gallon increments.

(section-ii)(foods-that-are-authorized)(page-18)Page 18#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Food Package Prescriptions/Foods that are Authorized Page 18

i. Each 15 to 16 ounce can is deducted as 0.25 jar/bag. ii. Each 16 oz. bag is deducted as 1 jar/bag.

XV. Fruits and Vegetables

a. Fruits and vegetables refer to any fresh, frozen, or canned fruits and vegetables, including organic and fresh or jarred salsa without added sugar or oil. They must meet the FDA standards of identity: i. Fresh fruits (21 CFR Part 101.95). ii. Canned fruits (21 CFR Part 145). iii. Fresh vegetables (21 CFR 101.95). iv. Canned vegetables (21 CFR part 155). v. frozen vegetables (21 CFR part 158).

b. Allowed: i. Fresh fruits and vegetables—any variety of fresh whole, pre-cut, or packaged fruits and vegetables without added sugars, fats, or oil. ii. frozen fruits—any variety of frozen fruits without added sugars, fats, oils, or salt (i.e., sodium). iii. Canned fruits—juice or water-packed without added sugars, fats, oils, or salt. Fruit must be listed as the first ingredient. iv. frozen vegetables—any variety of frozen vegetables without added sugars, fats, or oils. 1. Vegetables must be listed as the first ingredient. 2. May be regular or lower in sodium. v. Frozen beans (immature or mature)—beans purchased with the CVB may contain added vegetables and fruits, but may not contain added sugars, fats, oils, or meat. vi. Canned vegetables—any variety without added sugars, fats, or oils. May be regular or low in sodium. vii. Fresh cut herbs, ginger root, taro root, garlic, and coconuts. viii. Yams, sweet potatoes, and white potatoes. ix. Mushrooms, even though they are scientifically classified as fungi and not fruits or vegetables.

c. Not allowed: i. Dried fruits or vegetables, packages with dips or dressings, salad bars, party trays, dried herbs and spices, salsa with sugar, and pouches. ii. Mixed vegetables with noodles, nuts or sauce packets, and decorative flowers and blossoms. iii. Dried herbs, spices, vanilla bean, gourds, and decorative/painted pumpkins.

d. Cash Value Benefit (CVB) Amounts. i. CVB amounts are adjusted annually for inflation.

(section-ii)(foods-that-are-authorized)(page-19)Page 19#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Food Package Prescriptions/Foods that are Authorized Page 19

ii. CVB amounts are issued in the following amounts: 1. $26.00 for children ages 1 through 4 years. 2. $4748.00 for pregnant, partially-breastfeeding women out-of- range, and postpartum women (up to 6 months postpartum). 3. $52.00 for fully breastfeeding women and part breastfeeding in-range women (up to 1 year postpartum). 4. $78.00 for women who are fully breastfeeding multiple infants. 5. $11.00 or $22.00 for infants 6 through 11 months (See “Tailoring Food Packages” P&P).

e. The CVB amount is deducted from the participant’s account in $0.01 increments and is not taxed. i. The difference can be paid for by the participant if the total for fruits and vegetables purchased is greater than the CVB balance available to the participant.

XVI. Fish

a. Fish refers to sardines, light tuna, N. Atlantic Scomber scombrus or Chub Pacific Scomber japonicas mackerel, and salmon.

b. Allowed: i. Packed in water or oil and include bones or skin. ii. Regular or lower in sodium content. iii. Flavored such as lemon, herbs, or broth. iv. Light tuna must be store brand or private label. v. Salmon, mackerel, and sardines must be the approved brands listed in the Utah WIC Program Shopping Guide. vi. Sardines, light tuna, and N. Atlantic Scomber scombrus or Chub Pacific Scomber japonicas mackerel in 3.75 to 30 oz. cans. vii. Salmon in 5 to 30 oz. cans or 5 oz. pouches.

c. Fish is deducted from the participant’s account in 0.01 oz. increments.

XVII. Infant Foods

a. Infant foods refers to any regular or organic single or mixed infant fruits or vegetables, regular or organic infant meats, or regular or organic infant cereal. (non-organic).

b. Textures for all infant foods may range from strained to diced.

c. Infant Fruits or Vegetables i. A fruit or vegetable must be listed as the primary (first) ingredient in WIC-eligible jarred infant fruits or vegetables.

(section-ii)(formula-and-food-authorization-form)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Food Package Prescriptions/Formula and Food Authorization Form Page 1

I. Utah Formula and Food Authorization Form (FAFAF).

a. FAFAFs are not required for the following Standard Primary Contract Infant formulas: i. Similac Advance ii. Similac Soy Isomil iii. Similac Sensitive iv. Similac Total Gentle Comfort

b. All other formulas and WIC-eligible nutritionals require a FAFAF for issuance.

c. FAFAFs are required for all children, at 12 months of age and older, who are receiving infant formula, including contract formula.

d. Medical order or prescriptive requirements to be filled out on the FAFAF. All of the following information must be included in order for the FAFAF to be considered complete and the product ordered or issued. i. Name of participant. ii. Participant’s date of birth. iii. Formula or nutritional prescribed (must include all applicable parts [brand, type, and name]):. 1. Brand (Similac, Nutricia, Enfamil, etc.) 2. Type (NeuroPro, Pediatric, Standard, etc.) iii.3. Name (Gentlease, Advance, Peptide 1.0, etc.) iv. Medical diagnosis warranting the issuance of the product. v. Form of product: Powder, Concentrate, or Ready-to-Feed (RTF). vi. Specific amount of formula prescribed (e.g., 3 cans per day). 1. A range is not appropriate. vii. Length of time the prescribed product is medically required. 1. A valid FAFAF may be written for up to 12 months, but no longer than 12 months. 2. Six months will be used as the default length of time, including the current month, if nothing is marked by the prescriber. viii. Signature and name of the requesting state licensed prescriptive authority or someone working under their supervision (i.e., physician [MD], doctor of osteopath [DO], nurse practitioner [NP], physician assistant [PA], certified nurse midwife [CNM]). ix. Clinic or hospital name, phone number, and fax number if applicable. x. Date FAFAF is completed. 1. A FAFAF is invalid if this date is older than 60 days from when it’s received in the WIC clinic.

e. Additional FAFAF requirements. Formatted: Font: (Default) Arial Formatted

(section-ii)(formula-and-food-authorization-form)(page-2)Page 2#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Food Package Prescriptions/Formula and Food Authorization Form Page 2

i. The competent professional authority (CPA) must initial and date the completed FAFAF to indicate that it has met all of the above requirements. ii. A licensed prescriptive authority, or someone working under their supervision, is the only one allowed to complete a FAFAF. If it’s suspected that a participant completed the FAFAF themselves, the CPA should call the participant’s healthcare provider to verify the information on the FAFAF. 1. If it’s determined the FAFAF was not completed by a prescriptive authority, a new FAFAF completed by a prescriptive authority must be obtained before the prescribed product can be issued. 2. If a new FAFAF completed by a prescriptive authority is not obtained, do not issue the prescribed product. 3. The CPA should discuss these situations with their clinic supervisor to determine if a participant violation is warranted. iii. Completed FAFAFs must be scanned into the participant’s record in VISION within 10 business days of when they’re received.

f. FAFAFs may be received as a hard copy, electronically, or as a facsimile (fax).

g. If a FAFAF is not available at the participant’s WIC visit: i. The CPA may receive the information prior to issuance by telephoning the prescriptive authority’s office. ii. The CPA must document all information obtained from the doctor or the doctor’s staff in VISION. This information must be read directly from the participant’s medical chart where any notes have been written by the prescriptive authority regarding the participant’s nutritional status or intake. iii. A completed FAFAF must be obtained within 2 weeks of the participant’s WIC visit. iv. Medical documentation received over the phone must only be used when absolutely necessary and on an individual basis. It should only be used to prevent undue hardship to a participant or to prevent a delay in the provision of formula that would place the participant at increased nutritional risk.

II. FAFAFs and Care Plans.

a. All children over the age of 12 months issued infant formula require a care plan when a FAFAF is received or renewed.

b. Care plans are required for high-risk participants whenever a FAFAF is received or renewed.

(section-ii)(formula-and-food-authorization-form)(page-3)Page 3#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Food Package Prescriptions/Formula and Food Authorization Form Page 3

c. Participants who are not high risk do not require a care plan when a FAFAF is received or renewed (unless they’re a child over the age of 12 months issued infant formula).

d. If you receive a FAFAF with a medical diagnosis marked that’s not currently identified as a nutrition risk factor for the participant’s certification period, it must be added in a new risk record. i. If the newly assigned nutrition risk factor is designated as high risk, a care plan is required.

III. Out-of-State Prescriptions.

a. If a WIC participant transfers from another state and has a completed prescription on a WIC form from that state, the prescription may be honored for the time specified on the form. i. If the prescription is expired, the client needs to obtain a new FAFAF (Utah FAFAF or the form used by the state they previously received WIC in) before a non-contract formula or WIC-eligible nutritional is issued.

IV. Procedures Related to Formula Changes. If… Then. A healthy full-term infant shows symptoms of intolerance to the primary contract formulas… Refer them to their primary care provider. The participant must obtain a complete FAFAF if a non-contract formula is needed. A healthy full-term infant received a FAFAF for a non-contract formula because of symptoms of intolerance and the FAFAF has expired… Issue a primary contract formula. If a non- contract formula is still needed, refer the participant to their primary care provider for a new FAFAF. An infant or child is high risk and has been on a stated-ordered or non-contract formula and the parent/caretaker states the MD gave permission to transition to a primary contract formula. Their current FAFAF for the non-contract formula has not expired… Refer them to their primary care provider. Explain to the participant that the FAFAF must be honored for the time frame specified on the FAFAF. The participant or CPA must contact the primary care provider and obtain verbal or written approval for the primary contract formula before it can be issued. Documentation of this approval must be made in VISION. A care plan is not needed when they transition to standard infant formula. An infant or child is high risk and has been on a non-contract formula or nutritional. The parent/caretaker states the MD gave permission to transition to a primary contract formula or standard food package and the current FAFAF has expired… The CPA confirms with the parent/caregiver that the product is no longer needed and issues a contract formula or standard food package. A care plan is not needed when they transition to standard infant formula.

(section-ii)(formula-and-food-returns)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual

IX. Food Benefit Accountability and Control/Reconciling Benefits/Food and Formula Returns Page 1

Formula & Food Returns I. Infant/child formula or other WIC foods purchased by WIC participants with federal food dollars that cannot be utilized by the participant for any reason must be returned to the local clinic of issuance. Local agency clinics are required to accept any formula in order to determine what amount of product can be reissued and deter the participant from selling/giving away the formula or food purchased with federal funds.

II. The clinic will document returned formula in VISION on the Returned Formula screen. VISION instructions are as follows:

a. In the Returned Formula Panel, select correct participant and add a row. Select formula and enter number of can(s) returned.

b. In the Food Package Panel, select “New” and a new formula food package for the current issuance period. Adjust formula amount for the newly selected food package based on the amount of reconstituted ounces of formula returned.

c. The adjusted food package to compensate for returned formula must be issued for one month only and separate from future month packages. If the participant has future month food packages that need to be replaced due to a change in formula, those package must be assigned and issued separately from the formula package being issued to compensate the returned formula.

d. Clinics shall retain all returned cans in order to deter selling/giving away of excess formula purchased with federal funds. See policy section III below for appropriate disposal/donation procedures.

III. Standard formula or other non-perishable WIC foods returned to the clinic should be donated to a local food bank, pantry, shelter or other charitable organization who would be able to distribute the item to those in need.

a. Formula or foods returned to the clinic must be logged on the Returned Formula and Foods Tracking Sheet. i. This log will be used to document the disposition of returned items and will help ensure that returned products are not taken by participants or unauthorized staff.

(section-ii)(formula-and-food-returns)(page-2)Page 2#

Utah WIC Local Agency Policy and Procedures Manual

IX. Food Benefit Accountability and Control/Reconciling Benefits/Food and Formula Returns Page 2

ii. This form is available on SharePoint. iii. It may be maintained as a paper log or may be completed electronically. iv. The tracking sheet must be kept on file or may be posted to the clinic documents on the Local Agency tab on SharePoint.

b. Containers returned should be examined for any damage, dents, missing or altered labels, or broken seals. The participant who returned the formula should be asked if there is any known problem with the items or if they were exposed to extreme temperatures (hot or cold) such as being left in a vehicle for an extended period of time. i. If the items are expired, not fit for human consumption, or if there is no local food bank/organization available to accept donated items, these may be donated to an animal shelter or veterinary office. ii. Items that cannot be donated must be destroyed in accordance with the local agency destruction policy. The destruction should be documented on the Returned Formula and Foods Tracking Sheet.

c. A receipt should be requested from the organization (i.e. food bank, pantry, animal shelter or veterinary office) when items are donated. The receipt should be kept on file.

d. Clients should not directly donate their food/formula or give it away. It must be returned to the clinic.

e. Only standard formulas and/or items that are available in a grocery store can be donated. State ordered special medical formula that is intended to be consumed only under a doctor’s supervision should not be donated to a food bank or pantry if returned to the clinic by a participant. Local hospitals or community medical clinics may be contacted to see if they are interested in receiving the donated state ordered medical formula product so that it may be distributed under a doctor’s supervision. Otherwise, it must be destroyed.

f. According to the Federal Bill Emerson Good Samaritan Food Donation Act, and Utah Code 78-11-22, WIC agencies, staff and participants will not be held liable for problems with food items donated in good faith.

(section-ii)(healthcare-referrals)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Healthcare Referrals/Healthcare Referrals Page 1

Healthcare Referrals I. Providing referrals is a key component of WIC program services. It connects participants with additional resources and support beyond what WIC directly provides. Referrals help address participants' broader health, nutritional, and social needs by linking them to services such as healthcare providers, dental care, mental health counseling, housing assistance, childcare programs, and other community resources.

II. Drug and other harmful substance abuse information must be provided to WIC participants when certified on the WIC program.

a. Local agencies must provide drug and other harmful substance abuse information to all pregnant, postpartum, and breastfeeding women, and to parents or caretakers of infants and children participating in the WIC program. i. Other harmful substances means other substances such as tobacco, prescription drugs and over-the-counter medications that can be harmful to the health of the WIC population, especially the pregnant woman and her fetus. ii. Participants who do not currently use drug or other harmful substances should be encouraged to continue to avoid them.

III. The following types of referrals should be made whenever needed.

a. Health-related and public assistance programs. i. State and local agencies shall provide WIC program applicants and participants with information on other health-related and public assistance programs, and when appropriate, shall refer applicants and participants to such programs.

b. Medicaid (if uninsured or underinsured). i. The local agency shall, in turn, provide to adult individuals applying for or reapplying for the WIC program for themselves or on behalf of others, information about the Medicaid program. The state agency will provide annually to each local agency materials showing the maximum income limits according to the family size, applicable to pregnant women, infants, and children up to age 5 under the Medicaid program.

IV. Document referrals in VISION.

a. Document any referrals provided to the participant in the “Referrals- Family” or “Referrals-Participant” screen. These are found under the “Education and Care” branch in VISION.

V. Tobacco Cessation Referral.

(section-ii)(healthcare-referrals)(page-2)Page 2#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Healthcare Referrals/Healthcare Referrals Page 2

a. Any participant who identifies themselves or anyone in their household as currently using tobacco during a certification appointment will be asked if they are interested in receiving help in quitting or helping the person in their household quit. i. If the answer is “No”: 1. Check the “Currently Smokes” box in the Blood screen if appropriate. 2. Answer all questions regarding nicotine and tobacco use in the Nutrition Interview. 3. Provide general education and materials on the Utah Tobacco Quit Line (1.800.QUIT.NOW) and waytoquit.org. 4. Repeat the same question again during each certification appointment and at any other time the behavior is being discussed. ii. If the answer is “Yes”: 1. Check the “Currently Smokes” box in the Blood screen if appropriate. 2. Answer all questions regarding nicotine and tobacco use in the Nutrition Interview. 3. Enter the Tobacco Cessation Program referral in the “Referrals–Participant” or “Referrals-Family” screen. 4. Either the paper form needs to be faxed to the Utah Tobacco Quit Line or the electronic Utah Tobacco Quit Line provider referral form needs to be completed within the same business day. a. The Utah Tobacco Quit Line provider referral facsimile form can be found at: https://wtq.wpenginepowered.com/wp- content/uploads/2021/10/Utah_Provider_Fax_Referral -FY22.pdf https://utah.quitlogix.org/getattachment/0705ac10- 52a5-4cf9-aace- ad20eec47148/Utah_Provider_Fax_Referral.pdf b. The electronic Utah Tobacco Quit Line provider referral can be found at: https://utah.quitlogix.org/en-US/Health- Professionals/Make-a-Referral

VI. Immunization Screening and Referral.

a. When scheduling certification appointments for children under the age of 2 years old, advise parents and caretakers of infant and child WIC applicants that immunization records are requested or reviewed as part of

(section-ii)(healthcare-referrals)(page-3)Page 3#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Healthcare Referrals/Healthcare Referrals Page 3

the WIC certification and health screening process. Explain to the parent or caretaker the importance that WIC places on making sure that children are up to date on immunizations, but assure applicants that immunization records are not required to obtain WIC benefits.

b. At each certification visit for children under age 2 years old, screen the infant or child’s immunization status using a parent’s hand-held immunization record (from the provider), an immunization registry (i.e., USIIS), an automated data system, or a client chart (paper copy).

c. At a minimum, screen the infant or child’s immunization status by counting the number of doses of DTaP (diphtheria and tetanus toxoids and acellular pertussis) vaccine they have received in relation to their age. Document this in the Nutrition Interview (Immunizations tab).

d. Use the following table for screening:

Age of participant Minimum # of DTaP 3 months 1 dose of DTaP 5 months 2 doses of DTaP 7 months 3 doses of DTaP 19 months 4 doses of DTaP

e. If the infant or child is under-immunized: i. Provide information on the recommended immunization schedule, and refer the participant to their primary medical provider.

f. The Immunizations (USIIS) Release of Information Form must be read by the endorser and an electronic signature captured when immunization records obtained during the WIC appointment are to be shared with or input into USIIS. i. This release is valid for all family members and does not need to be repeated at subsequent certifications, but may be revoked at any time by the endorser. ii. The release form states that the Utah Statewide Immunization Information System (USIIS) has been explained and the endorser agrees to have their child’s immunization information entered into the statewide immunization registry and shared with other primary healthcare providers, as well as public health officials.

(section-ii)(healthcare-referrals)(page-4)Page 4#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Healthcare Referrals/Healthcare Referrals Page 4

iii. The electronic signature capture for the USIIS Release form is completed within the Referrals-Family screen. iv. If the USIIS Release of Information was signed by the endorser, all immunization cards or other immunization records from a physician’s office can be copied and given to either nursing staff or other appropriate personnel at the local health department for entry into USIIS or another local immunization tracking system. v. If the endorser refuses to sign the release, document this and continue with the certification process.

g. Refusal to sign for the USIIS Release, failure to provide immunizations records, or not being current on immunizations cannot be a barrier to certification and WIC benefits may not be withheld.

h. If an immunization record is not provided, encourage the participant to bring it with them to their next WIC appointment.

VII. Lead Screening and Referrals

a. WIC agencies must assess the history of lead testing for each infant >9 months of age or child upon enrollment to the Utah WIC program. This is not required for women participants.

b. Only one screening is required for each participant >9 months (includes out of state VOC infants and children).

c. To assess the history of lead testing, CPAs must ask whether the infant or child has received a blood lead level test. i. If yes, the CPA must ask whether the parent or caregiver knows the result of the individual’s blood lead level (BLL) test. Proof of a BLL test is not required. ii. If no, the CPA must refer to a healthcare provider for lead screening. iii. Documentation of these answers are required in the VISION Blood screen under Lead Level Measurement. iv. If education regarding lead or lead screening is needed and provided, the education topic and handout must be marked in the Nutrition Education screen in VISION.

d. WIC staff must make a referral to the infant or child’s healthcare provider for lead screening if the: i. Infant or child has never received a blood lead level test. ii. Child had an elevated BLL 12 months prior and has had no interim follow-up screening. iii. Child is suspected by a parent or healthcare provider to be at risk for lead exposure.

(section-ii)(high-risk-protocols)(page-3)Page 3#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Certification, Screening, and Assessment/High-Risk (HR) Protocols Page 3

d. If a NRF that’s auto-designated as high-risk is assigned to a participant at the time of certification, and the RD determines the participant is not high- risk, the RD must resolve the high-risk indicator at that certification appointment. i. A high-risk Care Plan must still be written, and the reason for resolving the high-risk designation needs to be documented in the Care Plan.

II. High-Risk Follow-up Appointments.

a. When a high-risk participant has a follow-up appointment, the “High Risk Follow Up Appointment” checkbox must be marked in the Nutrition Education screen under the Education and Care section in VISION. i. By marking this checkbox, YES will be generated into the High Risk Follow Up column in the “Follow-up Nutrition Risk Assessment” report. 1. This report is found in VISION under Reports → Clinic Services Reports → Assessment and Education Report. ii. By marking this checkbox, it also will show in the AdHoc Report: “All Nutrition Risk Factors” HR Follow-Up column on SharePoint. iii. These reports facilitate monitoring of risk factors and high-risk participants.

b. The follow-up appointment is focused on the specific needs associated with the nutrition risk(s) categorized as “high-risk.” Refer to the participant’s previous Care Plan(s).

III. Components of the High-Risk Care Plan.

a. In VISION, the SOAP format is used. The SOAP format is defined as the following: i. Subjective data is the information the participant reports. This includes reported information on medical history, diet recall/history and/or reported symptoms. ii. Objective data can include physical evidence such as anthropometric and bloodwork data, age, last menstrual period, number of pregnancies, medical documentation, etc. iii. Assessment is the CPA’s evaluation of the participant’s nutrition risk(s).

(section-ii)(homeless-applicants)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual

VIII. Certification, Eligibility and Coordination of Services/Homeless & Migrant Applicants/Homeless Applicants Page 1

Homeless Applicants I. Definition of homeless. An applicant is considered homeless if the applicant lacks a fixed and regular nighttime residence; or if their primary nighttime residence is:

a. A supervised public or private shelter designed to provide temporary living accommodations. This includes group shelters, rescue missions, shelters for victims of domestic violence, motels, etc.

b. A public or private place not ordinarily used as a regular sleeping accommodation for human beings. Examples include tents, cars, parks, hallways, sidewalks, abandoned buildings, doorsteps, etc.

c. A temporary residence for persons intended to be institutionalized.

d. A temporary accommodation in the residence of another individual. A person may no longer be considered homeless while living in a temporary accommodation of another individual if it has been more than 365 days.

II. All of the usual documentation required to certify an individual must be obtained for homeless individuals. An applicant who is determined homeless must:

a. Meet the WIC income requirements. i. If they have no source of income or support, this must be documented on the Signed Statement form. ii. Self declaration of income using the affidavit option may be accepted from homeless individuals, use the Signed Statement Form when necessary.

b. Reside in the State of Utah. i. Homeless individuals may be served by designated clinics, regardless of where they reside. ii. They are not required to have a permanent address. iii. A mailing address of a friend, relative, shelter or the WIC clinic may be used.

III. Check the homeless box on the Physical Address screen of the computer system. In addition to being required for reporting purposes, this ensures the processing standard time frames within the computer system are enforced

(section-ii)(homeless-shelters-and-domestic-violence-shelters)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual

IV. Organization and Management/Homeless and Domestic Violence Shelters/ Homeless and Domestic Violence Shelters Page 1

Homeless and Domestic Violence Shelters I. Supplemental foods may be provided to homeless individuals who temporarily reside in a shelter as long as the participant is eligible and the following conditions are met:

a. Participant has free access to their food.

b. The shelter cannot receive financial or in kind benefits from a person’s participation in WIC. i. For example, the homeless facility does not transfer WIC food to their general inventories or reduce the amounts of food given to the WIC participant.

c. WIC foods must not be used in communal feedings.

d. Proxies from the shelter may not routinely pick up WIC benefits for all program participants in bulk.

e. The homeless facility places no constraints on the ability to participate or partake of the supplemental foods, nutrition education, and breastfeeding support available under the WIC program.

f. Both the participant and the shelter should be made aware of these conditions.

g. A Memorandum of Understanding (MOU) must be set up between the local agency and homeless or domestic violence shelters that house active WIC participants.

II. Local agencies will monitor compliance in their area’s homeless and domestic violence shelters to ensure that the above criteria are followed.

a. A representative of the local agency must visit each shelter serving WIC participants at least once every three years. Agency staff must speak with a representative of the facility and complete the Utah WIC Homeless Shelter Monitoring Form, documenting compliance.

b. Shelters which house WIC participants that do not have an MOU with the local agency must be visited within 30 days of the participant’s certification date and the monitoring form must be completed.

c. This visit is also a good opportunity to conduct outreach.

d. A copy of the Utah WIC Homeless Shelter Monitoring Form must be kept on file at the clinic, and a second copy should be sent to the shelter after the on-site visit.

(section-ii)(households)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual

VIII. Certification, Eligibility and Coordination of Services/Income Eligibility/Households Page 1

Households I. Definition of household. A household is a group of related or unrelated individuals who live together as one economic unit and share income and expenses. Also may be referred to as a family, or economic unit.

a. Households/economic units have one or more wage earners or have other economic resources which are shared among the group. The household/economic unit’s income is used to pay bills and purchase food and other items for the group.

b. More than one economic unit may reside at the same address. (See Independent economic units below).

II. Household size. The household size equals the number of individuals supported by the qualifying income. a. A pregnant woman may be counted as one plus the number of fetuses she is carrying. i. For example, a woman who is pregnant with twins may be counted as three family members. ii. If the woman has a religious or cultural objection that precludes including the fetus as part of the household size, the fetus does not need to be included. III. Independent economic units. In certain circumstances an applicant who is living at the same address of other adults may be considered a separate household/economic unit. If this is the case, proof of income from the other adults may not be required for determining eligibility. Probing questions should be used to determine if the applicant is self-sufficient and can be considered a separate household. In many cases, young women who are living with their parents are part of their parent’s economic unit. If this is the situation, their parent’s income and household size needs to be considered for WIC. Each situation needs to be carefully evaluated in order to determine eligibility properly. If an applicant has their own source of income which is adequate for their support and the applicant pays their proportionate share of household, living and personal expenses, they may be considered a separate economic unit.

IV. The definition of household as it pertains to WIC income requirements must be explained to all first-time applicants to ensure that the applicant reports household size accurately.

(section-ii)(households)(page-2)Page 2#

Utah WIC Local Agency Policy and Procedures Manual

VIII. Certification, Eligibility and Coordination of Services/Income Eligibility/Households Page 2

a. Consider asking the question in a manner such as, “How many persons in the household are supported by this income?”

b. Additional questions are often necessary to be able to determine the applicant’s living situation and economic unit.

V. Non-traditional households.

a. A breastfed infant who is being breastfed by a woman other than the birth mother cannot be included in the household of both the birth and non-birth mother. The household size may be determined by either the birth mother or the non-birth mother.

b. A child residing in a school or an institution, who is being supported by the parent or guardian, is counted in the household size of the parent or guardian, since the family continues to provide the economic support.

c. A foster child who remains the legal responsibility of the state or other welfare agency is considered a family of one with no income, if so listed on the foster letter. Payments made by the welfare agency for the care of that foster child may be reported as the income of that child. Foster children are input into the computer system as an independent economic unit.

d. An adopted child or a child for whom a family has accepted the legal responsibility is counted in the household size with whom he/she resides. The size and total income of the family are used to determine the child’s income eligibility for WIC. Income received on behalf of that child would be considered family income.

e. In cases where joint custody has been awarded, the child is part of the household where he/she resides most often, or that of the custodial parent. Income should be based and benefits supplied to the household where the participant resides most frequently. The parent who has the child the most often should be the primary parent/guardian. The child is not counted in the family size of the other parent/guardian.

f. When there is joint parental custody, and the child(ren) spend equal time in each home and both parents are income eligible, ask the parents to come to an agreement between themselves regarding who will be listed

(section-ii)(households)(page-3)Page 3#

Utah WIC Local Agency Policy and Procedures Manual

VIII. Certification, Eligibility and Coordination of Services/Income Eligibility/Households Page 3

as parent/guardians and how the WIC benefits will be handled. They would then be responsible to see that half of the food goes with the child(ren) to the other parent’s home.

g. WIC staff should not get involved in custody disputes. If the parents have court papers with instructions relating to issues such as this, they should be requested to bring them to the WIC clinic.

h. Families during times of military deployment. Military personnel serving overseas or assigned to a military base, even though they are not living with their families, should be considered members of the economic unit. i. The income received by the military individual(s) and all other income received by the members of the economic unit should be counted as income to the household. ii. Local agencies may be confronted with dramatic household composition changes for military family members in which military service personnel are deployed overseas or assigned to a military base and their children are in the temporary care of friends or relatives. In this and similar cases, three options exist in determining family composition and income: 1. One option is to count the absent parents and their children as the economic unit as would have been the case prior to the parents’ deployment. 2. A second option, depending on the circumstances, is to count the children as a separate economic unit; the unit must have its own source of income, e.g., child allotment(s). 3. A third option, when option one or two are not applicable, is to consider the children to be part of the economic unit of the person(s) they are residing with; therefore family composition and income would be determined on this basis. iii. These same options would apply if the children and one parent temporarily moved in with friends or relatives. The local agency has discretion in electing which option to utilize depending on individual family circumstances.

(section-ii)(income-documentation)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual

VIII. Certification, Eligibility and Coordination of Services/Income Eligibility/Income Documentation Page 1

Income Documentation I. All applicants who are not adjunctively eligible must provide proof of current income. Current income is defined as gross income received by the household during the month (30 28-31 days) prior to the date of application for WIC benefits.

II. When a certification appointment is scheduled, clinic staff must tell the applicant that proof of income is required and what documentation is required as proof of income.

III. Pay statements or other proof of income representing the last 30 28-31 days of pay; or proof of adjunct (automatic) income eligibility are the preferred forms of income documentation.

a. For those applicants who get paid weekly, four pay statements are sufficient; or two pay statements for those who get paid every two weeks or twice a month. i. Individuals claiming to receive regular, consistent earnings, such as those earning a salary, only need to provide one pay statement to sufficiently document income. a.ii. If this results in the applicant being over the income limit and the applicant indicates the pay was over the usual amount, the applicant must be given the opportunity to provide additional proof of income that most accurately reflects the household’s financial circumstances.

b. The most recent pay statements the applicant has received should be requested; however, the last full completed month’s statements may be accepted. For example, on February 15th the applicant may bring in statements representing pay from January 15th through February 15th, or they may bring all of the statements from January.

c. In addition to reviewing pay statements, the clinic staff must ask applicants if there are any other sources of income in the family. i. If the applicant reports receiving additional income from sources such as a relative helping with rent etc. this income should be included with total income, but proofs of these minor sources of income need not be required and may be left blank. Self- declaration of additional income in this type of circumstance is sufficient.

b. If pay statements are not reasonably available, other proofs of income may be acceptable. (See Income Types.) i. Acceptable proofs include but are not limited to income tax returns filed for the most recently completed tax year. These are most commonly used for the self-employed, households with fluctuating Formatted: Font: (Default) Arial Formatted: Font: (Default) Arial Formatted: Font: (Default) Arial Formatted: Font: (Default) Arial Formatted Formatted: Font: (Default) Arial Formatted: Font: (Default) Arial Formatted: Font: (Default) Arial

(section-ii)(income-documentation)(page-2)Page 2#

Utah WIC Local Agency Policy and Procedures Manual

VIII. Certification, Eligibility and Coordination of Services/Income Eligibility/Income Documentation Page 2

income and households with various sources of non-wage income. Tax returns are the standard documentation of annual income. ii. Clinic staff must determine what proofs of income most accurately reflect the applicant’s current income.

c. Documentation of income should not be copied or scanned and should be returned to the applicant.

d. Applicants are expected to provide documentation to confirm income and/or participation in an assistance program. Online or internet documentation may should be accepted when the client is able to show pay statements, bank statement, etc. on a computer or other electronic device. Pictures and scans of proof documents are not preferred but mayshould be allowed unless there is evidence or reasonable suspicion of tampering.

e. When the applicant has difficulty obtaining proof of income, a local clinic can confirm that the applicant receives such benefits and/or income by telephone contact to the appropriate source, with prior approval from the applicant.

f. If the validity of the income documentation provided or statements made by the client is in question, clinic staff is authorized to verify income using available methods.

II. In the income screen in VISION, add a row for each different source of income in the household, including each job.

a. The “source” field refers to how the household earns the income. The drop down list offers several choices for income sources, each of which are considered to be income under WIC definitions. Each job is separate source.

b. The “proof” field documents how the applicant proved income eligibility. This could be items such as pay statements, letter from employer etc.

c. The “amount” field refers to the amount of income earned from each source. This must be determined from the pay statements or other proof provided. i. In the amount field, the amount entered should be the average of the pay statements provided for that job if the amounts are different. For example; if an applicant who is paid every two weeks brought in two pay statements, showing amounts of $500 and $700 the amount entered would be $600 (the average of the two checks). The pay period would be input as bi-weekly.

(section-ii)(income-documentation)(page-3)Page 3#

Utah WIC Local Agency Policy and Procedures Manual

VIII. Certification, Eligibility and Coordination of Services/Income Eligibility/Income Documentation Page 3

ii. Staff CANNOT simply add the pay statements together and enter the total as “monthly” income. iii. Enter exact amounts, do not round. iv. The income calculator app in VISION (green and gold icon) should be used to average the pay statements that are provided. 1. Using the correct tab for the frequency of pay, enter the gross income amount of each pay statement into the income calculator app. It will compute an average income for that income source and automatically populate the amount field upon closing the calculator app. 2. Use of a separate calculator outside of VISION is discouraged.

d. The “period” refers to the frequency the income is received. Income should be entered based on the correct frequency of pay. i. Weekly income is defined as income received once per week (52 pay periods per year). ii. Bi-Weekly income is defined as income received every two weeks (26 pay periods per year). iii. Twice Monthly income is defined as income received two times each month (24 pay periods per year). iv. Monthly income is defined as income being received once per month (12 pay periods per year). v. Annual income is a total of all yearly income.

e. The “note” section may be used to explain any entry. This is helpful to comment on such things as “dad’s job” or “mom’s business income”.

f. The system will compare the income entered to the income guideline which matches the frequency of pay. If more than one income row is entered with different frequencies of pay, the system will automatically convert the income amounts to annual equivalents and add all income sources together to give a total annual income amount to determine eligibility.

g. Click on the “Check Income Eligibility” button in order to determine the income eligibility of each household member applying for benefits. i. Family members who are eligible will be listed in the upper box. ii. If family members are ineligible, they will be listed in the “Not to be served at this time” box. 1. If you find that the family is not income eligible, have a second staff person or a supervisor check the income record for any mistakes. 2. If the record was completed correctly and they are found not eligible, mark the “Action” boxes for each family member

(section-ii)(income-exclusions)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual

VIII. Certification, Eligibility and Coordination of Services/Income Eligibility/Income Exclusions Page 1

Income Exclusions I. Income exclusions cannot be counted when calculating income. The following cannot be counted in income calculations:

a. Assistance received from Federal programs: i. Medicaid, ii. Medicare prescription drug card subsidies and related transitional assistance, iii. SNAP, iv. School Lunch, v. Family Day Care Food Program, vi. Child Care and Developmental Block Grant payments, vii. public housing, viii. home energy assistance, ix. youth employment programs, x. relocation assistance, and xi. National Flood Insurance Program Payments.

b. Military Family Housing Allotment: i. Off-base cash housing allowance, ii. value of in-kind benefits for on-base housing (BAH), iii. OCONUS COLA (cost-of-living given to military personnel stationed outside the continental United States)

c. Military Family Subsistence Supplemental Allowance (FSSA): payments made by the Department of Defense to certain low income members of the Armed Forces.

d. Military Combat Pay: i. Additional pay received by a household member who is deployed to a designated combat zone and is: 1. Received in addition to the service member’s basic pay; 2. Received as a result of the service member’s deployment to an area designated as a combat zone; and 3. Not received by the service member prior to his/her deployment to the designated combat zone. ii. Includes Hostile Fire Pay/Imminent Danger Pay and may include other types of hazardous and hardship duty pays received while deployed to a combat zone. iii. Military Deployment Extension Incentive Pay (DEIP) and Deployment Extension Stabilization Program (DESP) iv. These types of military pay should be excluded from income while the service member is deployed. This income must be included as income if received while serving at the home station.

e. Education:

(section-ii)(income-guidelines)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual

VIII. Certification, Eligibility and Coordination of Services/Income Eligibility/Income Guidelines Page 1

Income Guidelines I. At each certification visit, total household income for each family must be recorded in VISION by a WIC staff member. Income is based on gross household income. (See Income Exclusions.) The clinic must determine that the applicant’s income is at or below 185% of the Federal Poverty Guidelines published annually in the Federal Register.

II. Anyone whose income exceeds the limit for their household size is not eligible for WIC unless adjunctively income eligible, as described in the Adjunct Eligibility section.

III. The following table defines the income limits for the Utah WIC Program, effective July 1, 2025 2026 through June 30, 20262027. Total household income must be at or below the amounts listed in order to meet income eligibility requirements.

Household Size Annual Monthly Twice Monthly Bi-Weekly Weekly 1 29,52628,953 2,4612,413 1,2311,207 1,1361,114 568557 2 40,03439,128 3,3373,261 1,6691,631 1,5401,505 770753 3 50,54249,303 4,2124,109 2,1062,055 1,9441,897 972949 4 61,05059,478 5,0884,957 2,5442,479 2,3492,288 1,1751,144 5 71,55869,653 5,9645,805 2,9822,903 2,7532,679 1,3771,340 6 82,06679,828 6,8396,653 3,4203,327 3,1573,071 1,5791,536 7 92,57490,003 7,7157,501 3,8583,751 3,5613,462 1,7811,731 8 103,082100,178 8,5918,349 4,2964,175 3,9653,853 1,9831,927 9 113,590110,353 9,4669,197 4,7334,599 4,3694,245 2,1852,123 10 124,098120,528 10,34210,044 5,1715,022 4,7734,636 2,3872,318 11 134,606130,703 11,21810,892 5,6095,446 5,1785,028 2,5892,514 12 145,114140,878 12,09311,740 6,0475,870 5,5825,419 2,7912,710 13 155,622151,053 12,96912,588 6,4856,294 5,9865,810 2,9932,905 14 166,130161,228 13,84513,436 6,9236,718 6,3906,202 3,1953,101 15 176,638171,403 14,72014,284 7,3607,142 6,7946,593 3,3973,297 16 187,146181,578 15,59615,132 7,7987,566 7,1986,984 3,5993,492 Each Additional Family Member Add + 10,508+ 10,175 + 876+ 848 + 438+ 424 + 405+ 392 + 203+ 196

(section-ii)(income-reassessment)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual

VIII. Certification, Eligibility and Coordination of Services/Income Eligibility/Income Reassessment During a Certification Period Page 1

Income Reassessment during a Certification Period I. Income reassessment and income ineligibility during certification period. Participants may be found ineligible, based on income, at any time during the certification period. Income reassessment is mandatory during a certification period if the local agency receives information from any source, including from the participant, that a participant’s household income has increased or that the participant is no longer adjunctively eligible because they or a family member no longer participate in the program for which they became adjunctively eligible.

II. Local agencies are not required to seek out or request this information.

III. If there is not sufficient time remaining in the certification period to reassess income and effect the change (less than 90 days) than income reassessment is not required.

IV. If information is received by the local agency that a participant may no longer be eligible based on income, follow the procedures below:

a. Contact the participant to request that proof of household income be brought to the clinic.

b. Income must be calculated according to policy to determine eligibility. A new income record should be entered into the VISION system based on the proof of income provided.

c. If the participant voluntarily informs the clinic that household income has increased to the point that the current income is now above the income guidelines, and the participant does not wish to come to the clinic to provide proof of over-income, a new income record cannot be entered in VISION. The clinic may terminate the participant based on the self declaration. The applicant should be terminated for the reason “Participant requests termination”.

d. If a client is terminated during a certification period, 15 days notice with benefits must be issued.

e. If the participant has already received the final benefit issuance for the certification period, (and less than 90 days remain in the certification period) the clinic has the option not to require income reassessment.

f. Clinics may not find participants ineligible based solely on the fact that they are no longer adjunctively eligible because they or a family member no longer participate in the program for which they became adjunctively eligible; in this situation income must be assessed to make the determination of eligibility.

(section-ii)(income-types)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual

VIII. Certification, Eligibility and Coordination of Services/Income Eligibility/Income Types Page 1

Income Types I. Income is the total gross income before deductions for income taxes, employees’ social security taxes, insurance premiums, employee paid benefits, bonds, etc.; received by any and all members of a household. The following income must be included when calculating income:

a. Monetary compensation for services. Includes wages, salary, overtime and bonuses (including income from child care/babysitting, etc.), sales commissions, tips, fees, consultant fees, training stipends (except where elsewhere excluded). Includes seasonal work, part-time work, and temporary work. i. Applicants may show proof of income by providing one of the following: current pay statements(s) from all sources noting the pay time frame (weekly, bi-weekly, monthly, etc), a signed statement from their employer indicating gross earnings for a specified period or if current pay stubs are not reasonably available, an income tax return filed for the most recently completed tax year may be used. If a tax form must be used, total income as shown on tax form must be counted. (Example: Form 1040 line 9).

b. Military pay. Includes basic pay, food (BAS) and clothing cash allowances, military bonuses and incentives, including non-combat overseas and hazardous duty pay, CONUS COLA and GI Bill funds. (See income exclusions.) i. Applicants may show proof by providing a recent Leave and Earnings Statement (LES). ii. If bonus pay is intermittent, see Special Income Situations- Calculating income of deployed military personnel.

c. Public assistance or welfare payments. Includes Family Employment Program (TANF), Supplemental Security Income (SSI) or General Assistance. i. Applicants may show proof by providing pay statement(s) or award letter stating current amount of earnings.

d. Alimony and child support. Includes payments received. i. Applicants may show proof by providing a divorce decree, an award letter, a copy of a check received or a letter from the source. ii. Child support and alimony payments paid by an applicant cannot be excluded from their income.

(section-ii)(income-types)(page-2)Page 2#

Utah WIC Local Agency Policy and Procedures Manual

VIII. Certification, Eligibility and Coordination of Services/Income Eligibility/Income Types Page 2

e. Unemployment compensation received. Also includes severance pay or strike benefits from union funds. i. Applicants may show proof by providing an unemployment letter or notice.

f. Other cash income. Includes, and is not limited to: cash amount received or withdrawn from any source including savings, investments, trust accounts and other resources which are readily available to the family. i. Applicants may show proof by providing bank or account statements indicating regular withdrawals on the account(s). ii. For applicants living off of savings, money withdrawn or transferred to another account such as checking for use is considered income.

g. Regular contributions. Includes but is not limited to: contributions from persons not living in the household, allowances from family, allowances or contributions from foreign governments, or regular financial contributions from religious or charitable organizations. i. Applicants may show proof by providing a letter from the person or organization contributing resources to the household.

h. Stipends for living expenses. Payments received that are designated for basic living expenses are counted as income. Grants, student loans, and most scholarships are not considered income. If the client reports educational income, staff need to ask if they are given additional money as a living stipend. If yes, they need to submit their award letter for documentation.

i. Rental income. Net rental income as shown on Federal tax form. Net rental income generally includes any payments received from rental properties minus expenses. i. Applicants may show proof by providing an income tax return for the most recent calendar year.

j. Assets drawn down. Includes withdrawals from a bank, investment or other account. Sale of a property, sale of a house or sale of a car which is not reinvested into the purchase of another property, house, or car etc. Does not include tax refunds. i. Applicants may show proof by providing bank or account statements indicating regular draws on the account(s) or a bill of sale.

(section-ii)(income-types)(page-3)Page 3#

Utah WIC Local Agency Policy and Procedures Manual

VIII. Certification, Eligibility and Coordination of Services/Income Eligibility/Income Types Page 3

k. Garnished wages and bankruptcy income. i. May show proof by providing current pay statement(s).

l. Worker’s compensation. Includes any insurance payments or compensation for an injury.

m. Pensions and annuities. Includes any pensions or retirement benefits paid to the retired or their survivors either directly or through an insurance agency.

n. Self employment/independent contractors (farm or non-farm). Includes net profit as shown on Federal tax form. i. Total income is recorded on line 9 of form 1040. This amount includes all sources of income and should be the amount used for WIC purposes. ii. For newly self employed applicants who have not yet completed a Federal tax return, The definition of net profit is the same as that used for tax purposes and generally includes gross receipts minus expenses. Gross receipts are the value of all goods sold and services rendered. Expenses include costs of goods purchased, rent, heat, light, power, depreciation charges, wages and salaries paid, and business taxes. iii. Independent contractors, who are not considered employees of the company they work for, for example, ride share drivers or similar service providers, should be filing taxes as self-employed. Those policies should be followed to document income. iv. For self employed farmers net profit is defined as gross receipts, minus operating expenses, from the operation of a farm. Gross receipts are the value of all products sold, government crop loans, money received from rental of farm equipment, receipts from the sale of wood, etc. Operating expenses include cost of feed, fertilizer, seed, various farmhands, depreciation charges, cash rent, interest on farm mortgages, farm building repairs, farm taxes, etc. v. Net profit does not mean taxable income after deductions for personal exemptions and itemized or standard deductions. vi. Applicants may show proof by providing an income tax return for the most recent calendar year, or if no tax return has been completed, accounting records for the self-employed may be provided.

(section-ii)(ineligible-applicants)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual

VIII. Certification, Eligibility and Coordination of Services/Ineligibility and Termination/Ineligible Applicants Page 1

Ineligible Applicants I. Ineligible at the time of application. Applicants who apply for the WIC Program but do not meet all three of the criteria for eligibility (residency, income, and nutritional risk) are ineligible to receive WIC benefits.

II. Persons ineligible for the WIC program must be notified in writing of their ineligibility. Notification must include the reasons for ineligibility and the right to a fair hearing. This notice is printed from the VISION system.

a. For applicants who are not income eligible, as described in the Income Documentation policy section, follow these steps to mark applicants ineligible within the income screen: i. Click on the “Check Income Eligibility” button in order to determine the income eligibility of each household member applying for benefits. ii. Family members who are eligible will be listed in the upper box. iii. If family members are ineligible, they will be listed in the “Not to be served at this time” box. iv. If you find that the family is not income eligible, have a second staff person or a supervisor check the income record for any mistakesoversights, including the household size, income amount and income period, iv.a. The name of the second staff member who checked the record should be added in a comment. v. After the income records are verified and they are found not to be eligible, mark the “Action” boxes for each family member listed so that the system will change their status to ineligible or terminate their current certification.

b. Ineligible applicants must be asked to sign the signature pad indicating that they understand that they are not eligible for the program at the current time.

c. Ineligible applicants must be issued either a Notice of Ineligibility or Notice of Termination printed from the VISION system (depending on their current status). i. Applicants who are not currently certified receive the Notice of Ineligibility. (Their status was changed from pending to ineligible). ii. Applicants who are currently certified are issued a Notice of Termination (Their status will be changing from active to terminated, see Termination policy section).

d. Documentation that the printed notice was given to the applicant must be made in the VISION system. This may be entered in the comments screen, the nutrition education screen- pamphlets provided, or a copy of the notice may be scanned.

Formatted

(section-ii)(instructions-to-participants)(page-2)Page 2#

Utah WIC Local Agency Policy and Procedures Manual

IX. Food Benefit Accountability and Control/Instructions to Participants/Instructions to Participants Page 2

b. In order to complete this documentation, open the “Education and Care” panel and the “Nutrition Education” screen. In the “Pamphlets Provided” box, place a check mark in the “Shopping Guide” under Certification Core Contact.

VI. WIC card/PIN safeguarding. Explain the following:

a. Call to set a PIN while in the clinic.

b. Do not write PIN numbers on the card or anywhere the card is stored.

c. WIC cards may only be used by authorized persons. Providing the card or PIN number to any person other than a person authorized by WIC as a parent/guardian, additional parent/guardian or proxy is not allowed.

d. Cards should be protected from being lost or damaged.

e. Keep the card so that additional benefits can be added the WIC account at the next appointment.

VII. Lost, Stolen and Damaged Cards. Explain the following:

a. Report lost, stolen or damaged cards by calling the local WIC clinic. Leave a message during non-business hours.

VIII. Benefit Periods and Balance Inquiries. Explain the following:

a. Which month’s benefits have been added to the account.

b. Benefits expire at midnight on the last day of the month.

c. Family Food Benefits list being provided by the clinic showing the shopping list of benefits that were added to the WIC account. Ensure understanding of how to read the list, the food categories/what is included, and how the unit of measure/containers work.

d. Any WIC authorized grocery store can provide a receipt showing the balance of benefits on the card for the current month. Go the store’s customer service desk or go through a check-out lane to request a WIC balance receipt from a cashier.

IX. Transaction procedures. Explain the following:

a. Let the cashier know you will be using a WIC card. Follow the cashier’s instructions and swipe the card into the card reader when told.

(section-ii)(medicaid)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Food Package Prescriptions/Medicaid Reimbursement Page 1

Medicaid Reimbursement beyond Supplemental WIC

I. For WIC participants aged 1 years old and older who are receiving the WIC maximum amount of formula and enrolled in Medicaid or Medicaid Affordable/Accountable Care Organizations (ACOs), Medicaid may provide coverage for any additional formula above the WIC maximum under the conditions listed in the current Utah Medicaid Medical Supplies and Durable Medical Equipment Manual. Retrievable at: https://medicaid.utah.gov/utah- medicaid-official-publications/?p=Medicaid%20Provider%20Manuals/

Step Action 1 Notify the participant that Medicaid or Medicaid ACOs may provide any additional product. 2 Fill out the “Medicaid Fax – For Additional Formula” form on SharePoint. 3 Give the form to the participant to take to their health care provider who will assist in obtaining any additional formula that may be approved by Medicaid. 4 If the participant is receiving Traditional Medicaid, Healthy U, Select Health, Health Choice Utah or Molina Medicaid fax the “Medicaid Fax –IHC” form on SharePoint to the number printed on the form with the FAFAF.

II. Documenting Medicaid Provided or State Ordered Formula in VISION.

a. When a client is receiving a state ordered formula or formula that is being provided through Medicaid and receiving no other foods, this will need to be documented in the VISION system.

b. Documenting Medicaid-provided formula without issuing complementary foods: i. Select the “Special Diet” check box. Enter medical documentation information from the Formula and Food Authorization Form (FAFAF) under Documentation. ii. Select the appropriate “Medicaid-Provided Formula” or “State- Ordered Formula” model food package. iii. Select the “Direct Ship” check box in the food package grid. This allows the VISION system to recognize that the participant is receiving a state ordered formula benefit.

(section-ii)(midcertification-health-assessments)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Certification, Screening, and Assessment/Midcertification Health Assessments Page 1

Midcertification Health Assessments

I. Midcertification (midcert) health assessments are required for infants and children whose certification period is a full year. Midcert health assessments cannot be waived. Physical presence is not required at midcert health assessments. In clinic and remote appointments should be available to complete these.

a. A participant shall not be denied food benefits for failing to attend a scheduled midcert health assessment. However, one month of benefits can be issued until the required midcert health assessment is completed.

II. VENA (Value Enhanced Nutrition Assessment)

a. The process of a quality WIC health assessment includes the comprehensive collection of relevant and accurate nutrition information. This information is necessary to deliver meaningful nutrition services to WIC participants.

b. The VENA process should be followed when conducting all health assessments. This process includes the following steps: i. Collect relevant information ii. Clarify and synthesize collected information iii. Identify the pertinent and appropriate risks and other related issues. iv. Identify solutions and set goals. v. Document the assessment. vi. Follow-up on previous assessments, as appropriate.

c. See the VENA Training Module for more details regarding the VENA process.

III. Infants

a. Infants certified when < 6 months of age will have a certification period that ends the last day of the calendar month in which they reach their first birthday. Infants > 7 months of age will have a certification period that ends six months after the date of their certification. b. Infants certified when < 5 months of age will have a midcert health assessment between 5-8 months of age. The health assessment will consist of: i. Height, weight and OFC recorded and assessed (see ‘Anthro and Lab Procedures’ P&P document) ii. Explanation of growth pattern iii. Assessment of nutrition intake iv. Assessment of developmental readiness for various solid foods

(section-ii)(midcertification-health-assessments)(page-3)Page 3#

Utah WIC Local Agency Policy and Procedures Manual

II. Nutrition Services-Breastfeeding/Certification, Screening, and Assessment/Midcertification Health Assessments Page 3

a. A midcert health assessment is required at the midpoint (5 – 7 months) of each certification period lasting >8 months for the child.

b. The midcert health assessment, at a minimum, will consist of the following: i. Height and weight recorded and assessed (see ‘Anthro and Lab Procedures’ P&P document) ii. Explanation of growth pattern iii. Hemoglobin determination, if applicable or previously low 1. Hemoglobin determination is required at the 18-month of age health assessment. 2. If the child is initially certified to the WIC Program after 12 months of age, then a hemoglobin determination is required between 15 – 18 months of age. iv. Assessment of nutritional habits and dietary behavior v. Follow-up on goals set at the previous health assessment appointment vi. Participant centered education vii. Referrals, as needed

c. Children who transfer to the Utah WIC program from out of state qualify for the certification period that is designated on their VOC document. A midcert health assessment is needed if the certification expiration date is > 8 months from the date they are certified on the Utah WIC program.

V. Collecting Data at Midcertification Health Assessments

a. Anthropometric measurements can be deferred up to 60 days and bloodwork measurements can be deferred up to 90 days for any midcert health assessment. The local agency must make an effort to obtain referral data in advance of or at the time of the appointment if participant is not physically present. For in-person appointments, obtaining anthropometric and bloodwork is encouraged at the clinic; the participant also has the choice to defer. i. If deferral is chosen, documentation must be completed in VISION with the plan to obtain anthropometric data within 60 days and bloodwork within 90 days. Local agencies should only issue one- month food benefits until anthropometric and/or bloodwork data is collected if past the deferral period. If no anthropometric and/or bloodwork data has been received by the next midcert or

(section-ii)(missed-appointments)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual

VIII. Certification, Eligibility and Coordination of Services/Certification Procedures/Missed Appointments Page 1

Missed Appointments I. Pregnant women who miss their initial WIC certification appointments must be contacted in order to attempt to reschedule the certification appointment.

II. The Utah WIC Program uses an automated messaging system to send appointment reminder text messages or phone calls and to notify all applicants and participants of missed appointments.

a. For all new applicants, and when a new phone number is entered for current participants, staff must mark whether it is a land line or cell/mobile. Check boxes should be marked to allow texts and calls unless specified by the client.

b. When the phone number in the first phone field, (Primary Phone Number) is a mobile phone number, a text message will be sent. When a land line is listed in this field, a phone call will be made.

c. If no phone number is listed in the first phone field, (Primary Phone Number) a text/call will not be made.

d. If the client does not want to be texted, they may reply “STOP” to opt out of future messages. To opt out of future automated voice calls, they may respond by pressing option “9”.

III. When an applicant or participant misses an appointment, clinic staff notes this in the computer system on the same day of the missed appointment. The automated messaging system will then send a text or make a call to the participant asking them to contact the clinic to reschedule. Calls will be made on the second business day following the date of the missed appointment.

IV. Pregnant women who miss an initial certification appointment and cannot be reached by telephone must be mailed a Missed Appointment letter.

a. Document that the Missed Appointment letter was mailed in the comments screen or scan the letter.

b. Local agencies have the option to use email in addition to letters, text messages and phone calls unless the client has asked that any of these methods not be used.

V. When applicants to the program contact the clinic to reschedule a missed certification appointment the clinic should offer the applicant the next available certification appointment. The clinic is not required to meet processing standards on rescheduled appointments.

(section-ii)(monitoring-of-staff)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual

X. Monitoring and Audits/Local agency Self Evaluation and Monitoring/Monitoring of Staff to Prevent and Detect Fraud Page 1

Monitoring of Staff to Prevent and Detect Fraud I. To ensure compliance to the conflict of interest and the separation of duties policy, (see Conflict of Interest) the state WIC office will run the Separation of Duties ad hoc report in SharePoint weekly. If any staff have completed both the income eligibility record and the nutrition risk assessment for the same client, their names will appear on the report along with the certification record in question.

a. State staff will do an initial review of this report and send a copy of the report to any local WIC directors who have subordinate staff’s names listed on the report.

b. The local WIC director must review the report the same week it is received. For any staff members who appear on the report, the local WIC director will review the certification records to determine: i. whether they are legitimate, eligible participants and, ii. whether the eligibility criteria appears to have been determined correctly.

c. The local WIC director: i. Records the staff person’s name on the Separation of Duties Exception Log. ii. Records the parent/guardian name and family ID number of the families listed on the report. iii. Reviews the records in VISION to look for potential violations of policy or indications of fraud of the program. iv. If income documentation is available, this is reviewed. v. A telephone call may be made to the participant to validate the information recorded in the system and verify participation. This call may be disguised as a customer service survey call. vi. The WIC director signs the log, verifying that no indications of potential fraud or abuse were detected, or if detected, were properly reported and investigated. vii. Maintains the log on file at the local agency and emails a copy of the Exception Log to the state WIC operations manager to keep on file at the state.

d. If more than 10 certification records appear on the weekly report, contact the state WIC operations manager for guidance in auditing the records. In this situation it will not be required to audit all records on the report, but will be required to audit all certification records of infants receiving formula and a minimum of 20% of all remaining certification records listed on the report.

(section-ii)(nondiscrimination-statement)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual

XI. Civil Rights/Civil Rights/Nondiscrimination Statement

Page 1

Nondiscrimination Statement I. The following nondiscrimination statement must appear on all vital documents that impact program participation: In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity.

Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.

(1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; or

(2) fax: (833) 256-1665 or (202) 690-7442; or

(3) email: program.intake@usda.gov.

This institution is an equal opportunity provider.

Spanish De acuerdo con la ley federal de derechos civiles y las normas y políticas de derechos civiles del Departamento de Agricultura de los Estados Unidos (USDA), esta entidad está prohibida de discriminar por motivos de raza, color, origen nacional, sexo (incluyendo identidad de género y orientación sexual), discapacidad, edad, o represalia o retorsión por actividades previas de derechos civiles.

(section-ii)(nondiscrimination-statement)(page-2)Page 2#

Utah WIC Local Agency Policy and Procedures Manual

XI. Civil Rights/Civil Rights/Nondiscrimination Statement

Page 2

La información sobre el programa puede estar disponible en otros idiomas que no sean el inglés. Las personas con discapacidades que requieren medios alternos de comunicación para obtener la información del programa (por ejemplo, Braille, letra grande, cinta de audio, lenguaje de señas americano (ASL), etc.) deben comunicarse con la agencia local o estatal responsable de administrar el programa o con el Centro TARGET del USDA al (202) 720-2600 (voz y TTY) o comuníquese con el USDA a través del Servicio Federal de Retransmisión al (800) 877-8339.

Para presentar una queja por discriminación en el programa, el reclamante debe llenar un formulario AD-3027, formulario de queja por discriminación en el programa del USDA, el cual puede obtenerse en línea en: https://www.usda.gov/sites/default/files/documents/ad-3027s.pdf, de cualquier oficina de USDA, llamando al (866) 632-9992, o escribiendo una carta dirigida a USDA. La carta debe contener el nombre del demandante, la dirección, el número de teléfono y una descripción escrita de la acción discriminatoria alegada con suficiente detalle para informar al Subsecretario de Derechos Civiles (ASCR) sobre la naturaleza y fecha de una presunta violación de derechos civiles. El formulario AD-3027 completado o la carta debe presentarse a USDA por:

(1) correo: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (833) 256-1665 o (202) 690-7442; o (3) correo electrónico: program.intake@usda.gov.

Esta institución es un proveedor que ofrece igualdad de oportunidades.

II. The required font size for the non-discrimination statement is 11 point or larger. It must be printed in a standard font in black or other dark color.

III. If the material is too small for the full statement (a single page document, post card, etc.) you may print the abbreviated statement its place, “This institution is an equal opportunity provider.” This statement should be in print size no smaller than the text of the document.

IV. When providing information for radio and television public service announcements, the nondiscrimination statement does not have to be read in its entirety. Rather, the abbreviated statement “This institution is an equal opportunity provider” is sufficient to meet the nondiscrimination requirement.

(section-ii)(nondiscrimination-statement)(page-3)Page 3#

Utah WIC Local Agency Policy and Procedures Manual

XI. Civil Rights/Civil Rights/Nondiscrimination Statement

Page 3

V. The statements should be in English and in languages appropriate to the local population, and upon request, in Braille, large print, audiotape, etc.

VI. State and local agency WIC websites must contain the current nondiscrimination statement. At a minimum, the nondiscrimination statement or a link to it must be included on the home page of the WIC program information.

VII. The nondiscrimination statement is required if the material:

a. Describes eligibility requirements of the WIC Program,

b. Identifies the benefits of WIC participation,

c. Gives instructions for WIC participation,

d. Provides notice of conditions to continue eligibility, and/or

e. Provides notice of ineligibility or disqualification.

VIII. Nutrition education and breastfeeding promotion and support materials that strictly provide a nutrition message with no mention of WIC (as described above) are not required to contain the nondiscrimination statement.

IX. Assurance of Civil Rights Compliance. All contracts between the WIC Program and sub recipients of the program at the state and local agency levels must contain an assurance of civil rights compliance. The language to be included is not the nondiscrimination statement from above, but is the language that follows below:

The State Agency hereby agrees that it will comply with Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.), Title IX of the Education Amendments of 1972 (20 U.S.C. 1681 et seq.), Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794), Age Discrimination Act of 1975 (42 U.S.C. 6101 et seq.); Title II and Title III of the Americans with Disabilities Act (ADA) of 1990 as amended by the ADA Amendment Act of 2008 (42 U.S.C. 12131-12189) as implemented by Department of Justice regulations at (28 CFR Parts 35 and 36); Executive Order 13166, "Improving Access to Services for Persons with Limited English Proficiency." (August 11, 2000), all provisions required by the implementing regulations of the U.S. Department of Agriculture (7 CFR Part 15 et seq); and FNS directives and guidelines to the effect that no person shall, on the ground of race, color, national origin, age, sex (including gender identity and sexual orientation), or disability, or reprisal or retaliation for prior civil rights activity be excluded from participation in, be denied the benefits of, or otherwise be subjected to discrimination under any program or activity for which the Agency receives Federal financial assistance from FNS; and hereby gives assurance that it will immediately take measures necessary to effectuate this

(section-ii)(nondiscrimination-statement)(page-4)Page 4#

Utah WIC Local Agency Policy and Procedures Manual

XI. Civil Rights/Civil Rights/Nondiscrimination Statement

Page 4

agreement.

By providing this assurance, the State Agency agrees to compile data, maintain records and submit records and reports as required to permit effective enforcement of the nondiscrimination laws, and to permit Department personnel during normal working hours to review and copy such records, books and accounts, access such facilities, and interview such personnel as needed to ascertain compliance with the non-discrimination laws. If there are any violations of this assurance, the Department of Agriculture shall have the right to seek judicial enforcement of this assurance.

This assurance is given in consideration of and for the purpose of obtaining any and all Federal financial assistance, grants, and loans of Federal funds, reimbursable expenditures, grant, or donation of Federal property and interest in property, the detail of Federal personnel, the sale and lease of, and the permission to use Federal property or interest in such property or the furnishing of services without consideration or at a nominal consideration, or at a consideration that is reduced for the purpose of assisting the recipient, or in recognition of the public interest to be served by such sale, lease, or furnishing of services to the recipient, or any improvements made with Federal financial assistance extended to the Program applicant by USDA. This includes any Federal agreement, arrangement, or other contract that has as one of its purposes the provision of cash assistance for the purchase of food, and cash assistance for purchase or rental of food service equipment or any other financial assistance extended in reliance on the representations and agreements made in this assurance.

This assurance is binding on the State Agency, its successors, transferees, and assignees as long as it receives assistance or retains possession of any assistance from the Department. The person or persons whose signatures appear below are authorized to sign this assurance on the behalf of the State Agency.

a. The term “State Agency” in the above language can be substituted to the appropriate entity for which the contract is written.

(section-ii)(nutrition-risk-manual)(page-1)Page 1#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 1

Nutrition Risk Manual Table of Contents (click to navigate)

101 Underweight Women ............................................................................................................ 4 103 Underweight or At Risk of Underweight (Infants and Children) ............................................ 9 111 Overweight Women ............................................................................................................ 14 113 Obese (Children 2-5 Years of Age) ....................................................................................... 18 114 Overweight or At Risk of Overweight (Infants and Children)............................................... 22 115 High Weight-for-Length (Infants and Children < 24 Months of Age) .................................. 28 121 Short Stature or At Risk of Short Stature (Infants and Children) ......................................... 32 131 Low Maternal Weight Gain .................................................................................................. 36 133 High Maternal Weight Gain ................................................................................................. 43 134 Failure to Thrive ................................................................................................................... 49 135 Slowed/Faltering Growth Pattern ........................................................................................ 53 141 Low Birth Weight ................................................................................................................. 61 142 Preterm or Early Term Delivery ........................................................................................... 64 151 Small for Gestational Age .................................................................................................... 71 152 Low Head Circumference (Infants and Children < 24 Months of Age) ................................. 74 153 Large for Gestational Age .................................................................................................... 77 201 Low Hematocrit/Low Hemoglobin ....................................................................................... 79 211 Elevated Blood Lead Levels .................................................................................................. 96 301 Hyperemesis Gravidarum .................................................................................................. 105 302 Gestational Diabetes.......................................................................................................... 112 303 History of Gestational Diabetes ......................................................................................... 118 304 History of Preeclampsia ..................................................................................................... 122 311 History of Preterm or Early Term Delivery ......................................................................... 127 312 History of Low Birth Weight .............................................................................................. 133 321 History of Spontaneous Abortion, Fetal or Neonatal Loss ................................................. 135 331 Pregnancy at a Young Age ................................................................................................. 138 332 Short Interpregnancy Interval ............................................................................................ 142 334 Lack of Prenatal Care ......................................................................................................... 148

(section-ii)(nutrition-risk-manual)(page-2)Page 2#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 2

335 Multifetal Gestation ........................................................................................................... 151 336 Fetal Growth Restriction .................................................................................................... 155 337 History of Birth of a Large for Gestational Age Infant........................................................ 158 338 Pregnant Woman Currently Breastfeeding ........................................................................ 160 339 History of Birth with Nutrition Related Congenital or Birth Defect………………………………………..165 340 Nutrient Deficiency or Disease ...................................................................................................... 167 341 Gastro-Intestinal Disorders ........................................................................................................... 176 342 Diabetes Mellitus ........................................................................................................................... 182 343 Thyroid Disorders ........................................................................................................................... 187 344 Hypertension and Pre-Hypertension ............................................................................................ 195 345 Renal Disease ................................................................................................................................. 206 346 Cancer ............................................................................................................................................. 209 347 Central Nervous System Disorders ............................................................................................... 212 348 Genetic and Congenital Disorders ................................................................................................ 217 351 Inborn Errors of Metabolism ......................................................................................................... 223 352a Infectious Diseases – Acute........................................................................................................... 232 352b Infectious Diseases - Chronic ........................................................................................................ 241 353 Food Allergies ................................................................................................................................. 251 354 Celiac Disease ................................................................................................................................. 259 355 Lactose Intolerance ........................................................................................................................ 265 356 Hypoglycemia ................................................................................................................................. 269 357 Drug Nutrient Interactions ............................................................................................................ 271 358 Eating Disorders ............................................................................................................................. 276 359 Recent Major Surgery, Physical Trauma, Burns ........................................................................... 286 360 Other Medical Conditions ............................................................................................................. 292 361 Mental Illnesses ............................................................................................................................. 301 362 Developmental Delays ................................................................................................................... 315 363 Pre-Diabetes ................................................................................................................................... 319 371 Maternal Smoking ......................................................................................................................... 322 372A Alcohol Use ..................................................................................................................................... 324 372B Substance Use ................................................................................................................................ 336

(section-ii)(nutrition-risk-manual)(page-3)Page 3#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 3

381 Oral Health Conditions .................................................................................................................. 339 382 Fetal Alcohol Spectrum Disorders ................................................................................................. 349 383 Neonatal Abstinence Syndrome .................................................................................................... 359 401 Failure to Meet Dietary Guidelines for Americans ...................................................................... 365 411 Inappropriate Nutrition Practices for Infants ............................................................................... 369 425 Inappropriate Nutrition Practices for Children ............................................................................ 386 427 Inappropriate Nutrition Practices for Women ............................................................................. 398 428 Dietary Risk Associated with Complementary Feeding Practices ............................................... 409 501 Possibility of Regression ................................................................................................................ 418 502 Transfer of Certification ................................................................................................................. 420 601 Breastfeeding Mother of Infant at Nutritional Risk .................................................................... 422 602 Breastfeeding Complications or Potential Complications (Women) .......................................... 424 603 Breastfeeding Complications or Potential Complications (Infants) ............................................ 429 701 Mom on WIC/Mom Not on WIC during Pregnancy .................................................................... 430 702 Breastfeeding Infant of Woman at Nutritional Risk .................................................................... 436 801 Homelessness ................................................................................................................................ 438 802 Migrancy ......................................................................................................................................... 440 901 Recipient of Abuse ......................................................................................................................... 442 902 Woman or Infant/Child of Primary Caregiver with Limited Ability to Make Feeding Decisions 451 903 Foster Care ..................................................................................................................................... 458 904 Environmental Tobacco Smoke Exposure (also known as passive, secondhand, or involuntary smoke) 471 Appendix A: Not Allowed Nutrition Risk Criteria............................................................................................... 468

(section-ii)(nutrition-risk-manual)(page-10)Page 10#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 10

Parameters for Auto Assignment

At Risk of Underweight

• Will be auto assigned for infants and children < 24 months if weight-for-length is > 2.3rd and ≤ 5th percentile.

• Will be auto assigned for children if BMI-for-age is > 5th and ≤ 10th percentile.

Underweight

• Will be auto assigned for infants and children < 24 months if weight-for-length is ≤ 2.3rd percentile.

• Will be auto assigned for children if BMI-for-age is ≤ 5th percentile.

High Risk Flag

The high risk designation will automatically activate for infants when 103b risk factor is assigned.

Justification

The CDC uses the 2.3rd percentile weight-for-length (for birth to 24 months of age) and the 5th percentile BMI-for-age (for 2-5 years of age), as the cut-offs to define underweight in its Pediatric Nutrition Surveillance System (1, 2). However, CDC does not have a position regarding the cut-off percentile, which should be used to determine at risk of underweight as a nutrition risk in the WIC Program. At risk of underweight is included in this criterion to reflect the preventive emphasis of the WIC Program. A review of literature on weight-for-length or stature cut-off percentiles indicates that: a) many children at or below the 5th percentile for weight are in need of nutritional intervention, and b) those at or below the 10th percentile may be at nutritional risk and in need of preventive nutritional intervention, or at least further evaluation (4). Weight-for-length/stature describes body proportionality and is sensitive to acute undernutrition, but can also reflect long-term status (5). Physical growth delay is used as a proxy for the deleterious effects undernutrition can have on immune function, organ development, hormonal function and brain development (6).

Implications for WIC Nutrition Services

Participation in WIC has been associated with improved growth in both weight and height in children (7). An infant or child determined to be underweight at WIC certification should be monitored at

(section-ii)(nutrition-risk-manual)(page-11)Page 11#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 11

regular intervals during the certification period, as appropriate. Through client-centered counseling, WIC staff can assist families in making nutritionally balanced food choices to promote adequate weight gain. Also, the foods provided by the WIC Program are scientifically-based and intended to address the supplemental nutritional needs of the Program’s target population, and can be tailored to meet the needs of individual participants. In addition, WIC staff can greatly assist families by providing referrals to medical providers and other services, if available, in their community. Such resources may provide the recommended medical assessments, in order to rule out or confirm medical conditions, and offer treatment when necessary and/or in cases where growth improvement is slow to respond to dietary interventions.

Clarification

The cut-off for underweight for infants and children < 24 months is 2.3; however, for ease of use, CDC labels it as the 2nd percentile on the hard copy Birth to 24 months growth charts. Electronic charts should use the 2.3rd percentile as the cut-off. Justification for High Risk

Early detection of low BMI for age, along with prompt improvement in BMI, is likely to be the most effective intervention for preventing growth stunting. Prevention of stunting is most crucial during the first two years of life as it may be irreversible. Low adult height and lower birth weight may also be associated with stunting occurring within the first two years of a child’s life (1). Stunting is found to be the strongest predictor of developmental outcome, specifically predicting the initial developmental status and the speed at which new skills are accomplished. Stunting has such a strong influence on development and is the outcome of chronic under-nutrition (2).

In addition to poor growth from under-nutrition, children are also at greater risk of infection when they don’t receive adequate nutrients. Prevalence, severity and frequency of infections depend upon several factors including infant and young child feeding habits, nutritional status of the child and environmental hygiene. Failure to increase nutrients and calories by introducing complementary foods too late can also contribute to under-nutrition and underweight (5).

Under-nutrition is the cause for half of all child deaths worldwide. Insufficient nutrient intake and infection are the main factors which contribute to this statistic, as inadequate nutrient intake leads to deterioration of the immune system. This futher results in an exacerbation of the problem since the infection can further interfere with nutrient absorption (3).

(section-ii)(nutrition-risk-manual)(page-12)Page 12#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 12

A major reduction in undernutrition can be achieved through supportive health programs and nutrition intervention (3). Lower education levels of parents increases the probability that a child will be underweight, which increases the need for sufficient parental nutrient related education (4). The WIC nutritionist can help improve the nutritional status of children by providing individual counseling and food package tailoring.

Additional Counseling Guidelines

• Discuss issues which may affect participant’s weight status, such as: ▪ parental body composition ▪ recent illnesses ▪ developmental delays ▪ thyroid abnormalities • Provide ideas for increasing calories if needed such as: ▪ Discuss introducing complementary foods at the appropriate times ▪ Providing more frequent snacks or meals ▪ Increase use of energy dense foods • Improve primary caregivers overall nutrient related knowledge ▪ Assess caregivers ability to determine child’s energy needs and hunger cues ▪ Provide nutrition education/materials specific to participant’s children

References

1. Centers for Disease Control and Prevention. “Use of World Health Organization and CDC growth charts for children aged 0-59 months in the United States.” MMWR 2010; 59(No. RR-9). http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5909a1.htm?s_cid=rr5909a1_w. Accessed September 2010. 2. Kuczmarski RJ, Ogden CL, Grummer-Strawn LM, et al. “CDC growth charts: United States.” Advance Data from Vital and Health Statistics; no. 314. Hyattsville, Maryland: National Center for Health Statistics. 2000.

3. World Health Organization. “WHO child growth standards: Length/height-for-age, weight-for- age, weight for height and body mass index-for-age: Methods and development.” Geneva, Switzerland: World Health Organization; 2006. Available at: http://www.who.int/childgrowth/publications/technical_report_pub/en/index.html. Accessed September 2010.

(section-ii)(nutrition-risk-manual)(page-13)Page 13#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 13

4. Food and Nutrition Information Center, National Agriculture Library. “Update of analysis of literature regarding cut-off percentiles for low weight for length in infants.” Washington, D.C.; February 5, 1991. 5. Sherry B. Epidemiology of inadequate growth. In: Kessler DB, Dawson P, editors. Failure to thrive and pediatric undernutrition: A transdisciplinary approach. Baltimore: Paul H. Brooks Publishing Company, Inc.; 1999. 6. Metallinos-Katsaras E, Gorman KS. Effects of undernutrition on growth and development. In: Kessler DB, Dawson P, editors. Failure to thrive and pediatric undernutrition: A transdisciplinary approach. Baltimore: Paul H. Brooks Publishing Company, Inc.; 1999. p. 38. 7. Disbrow DD. The Costs and Benefits of Nutrition Services: A Literature Review. J Am Diet Assoc. 1989; 89:S3-66.

High Risk References

1. Ramachandran P, Gopalan H. “Assessment of Nutritional Status in Indian Preschool Children Using WHO 2006 Growth Standards.” Indian J Med Res. 2011; 134:47- 53.

2. Abubakar A, Holding P, Van de Vijver FJR, Newton C, Van Baar A. “Children at risk for developmental delay can be recognized by stunting, being underweight, ill health, little maternal schooling or high gravidity.” J Child Psychol Psychiatry. 2010; 51(6):652-659.

3. Nakamori M, Ninh NX, Khan NC, Huong CT, Tuan NA, Mai LB, Hien VTT, Nhung BT, Nakano T, Yoshiike N, Kusama K, Yamamoto S. “Nutritional status, feeding practice and incidence of infectious diseases among children aged 6 to 18 months in northern mountainous Vietnam.” J Med Invest. 2009; 57:45-53.

4. Nahar B, Ahmed T, Brown KH, Hossain MI. “Risk factors associated with severe underweight among young children reporting to a diarrhea treatment facility in Bangladesh.” J Health Popul Nutr. 2010; 28(5):476-483.

5. Ramachandran P, Gopalan H. “Undernutrition and risk of infections in preschool children.” Indian J Med Res. 2009; 130:579-583.

(section-ii)(nutrition-risk-manual)(page-15)Page 15#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 15

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 (2). Several studies have established an association between obesity and an increased risk for hypertension, dyslipidemia, diabetes mellitus, cholelithiasis, coronary heart disease, osteoarthritis, sleep apnea, stroke and certain cancers (1). One goal of prenatal nutritional counseling is to achieve recommended weight gain. For the overweight woman, emphasis should be on selecting food choices of high nutritional quality and avoiding calorie rich foods, thereby minimizing further risks associated with increased overweight and obesity. The 2009 Institute of Medicine (IOM) report: Weight Gain During Pregnancy: Reexamining the Guidelines (1) updated the pregnancy weight categories to conform to the categories developed by the World Health Organization and adopted by the National Heart, Lung and Blood Institute in 1998 (3). The reexamination of the guidelines consisted of a review of the determinants of a wide range of short-and long-term consequences of variation in weight gain during pregnancy for both the mother and her infant. The IOM prenatal weight gain recommendations based on pre-pregnancy weight status categories are associated with improved maternal and child health outcomes (1). Included in the 2009 IOM guidelines is the recommendation that the BMI weight categories used for adult women be used for pregnant adolescents as well. More research is needed to determine whether special categories are needed for adolescents. It is recognized that the IOM cut-offs for defining weight categories will classify some adolescents differently than the CDC BMI-for-age charts. For the purpose of WIC eligibility determination, the IOM cut-offs will be used for all women regardless of age. However, due to the lack of research on relevant BMI cut-offs for pregnant and postpartum adolescents, professionals should use all of the tools available to them to assess these applicants’ anthropometric status and tailor nutrition counseling accordingly. 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. Pre-pregnancy 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 pre-pregnancy weight. In most cases, therefore, pre-pregnancy weight is a better indicator of weight status than postpartum weight in the first 6 months after delivery (4). The percentage of adolescents who are overweight is increasing rapidly and more than 60% of adults in the US are overweight. Due to the significant impact that overweight and obesity have on morbidity and mortality, it is imperative that every effort be made to identify individuals who are overweight and to assist them in achieving a more healthful weight. The WIC Program is in a position to play an important role in helping to reduce the prevalence of overweight not only by

(section-ii)(nutrition-risk-manual)(page-18)Page 18#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 18

113 Obese (Children 2-5 Years of Age) Definition/Cut-Off Value:

Obesity for children 2-5 years of age is defined as follows:

2 to 5 years of age and ≥ 95th percentile Body Mass Index (BMI) or weight-for-stature as plotted on the 2000 Centers for Disease Control and Prevention (CDC) 2-20 years gender specific growth charts (1,2) (available at: www.cdc.gov/growthcharts).*

*The cut off is based on standing height measurements. Therefore, recumbent length measurements may not be used to determine this risk. See Clarification for more information.

Participant Category and Priority Level

Category Priority High Risk Children (2-5 years of age) III N

Parameters for Auto Assignment

Auto assigned if weight-for-length (for children with a recumbent length) or BMI-for-age is ≥ 95th percentile

Justification

One of the most important public health issues in the United States today is the rapid and significant increase in the prevalence of obesity in children and adolescents. The National Health and Nutrition Examination Survey (NHANES) from the mid-1960s to the early 2000s document this significant increase in obesity among children from preschool age through adolescence. These trends parallel a concurrent increase in obesity among adults, suggesting that fundamental shifts occurring in dietary and/or physical activity behaviors are having an adverse effect on overall energy balance (3). The causes of increased obesity rates in the United States are complex. Both genetic make-up and environmental factors contribute to the obesity risk. Important contributors include a large and growing abundance of calorically dense foods and an increased sedentary lifestyle for all ages. Although obesity tends to run in families, a genetic predisposition does not inevitably result in obesity. Environmental and behavioral factors can influence the development of obesity in genetically at-risk people (3). BMI is a measure of body weight adjusted for height. While not a direct measure of body fatness, BMI is a useful screening tool to assess adiposity (3). Children >2 years of age, with a BMI-for-age >85th and <95th percentile are considered overweight and those at or above the 95th percentile,

(section-ii)(nutrition-risk-manual)(page-19)Page 19#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 19

obese (4). Research on BMI and body fatness shows that the majority of children with BMI-for-age at or above the 95th percentile have high adiposity and less than one-half of the children in the 85th to <95th percentiles have high adiposity (4). Although an imperfect tool, elevated BMI among children most often indicates increased risk for future adverse health outcomes and/or development of diseases (5). BMI should serve as the initial screen and as the starting point for classification of health risks (3). Use of the 95th percentile to define obesity identifies those children with a greater likelihood of being obese as adolescents and adults, with increased risk of obesity-related disease and mortality. It is recommended that an obese child (>95th percentile) undergo a medical assessment and careful evaluation to identify any underlying health risks or secondary complications (3). Obesity can result from excessive energy intake, decreased energy expenditure, or a medical condition that impairs the regulation of energy metabolism. In addition, obesity in early childhood may signify problematic feeding practices or evolving family behaviors that, if continued, may contribute to health risks in adulthood related to diet and inactivity. Justification for High Risk

Not applicable

Implications for WIC Nutrition Services

The WIC Program plays an important role in public health efforts to reduce the prevalence of obesity by actively identifying and enrolling young children who may be obese or at risk of overweight/obesity in later childhood or adolescence. When identifying this risk, it is important to communicate with parents/caregivers in a way that is supportive and nonjudgmental, and with a careful choice of words that convey an empathetic attitude and minimize embarrassment or harm to a child’s self-esteem (4). In recognition of the importance of language, the 2007 American Medical Association Expert Committee Report recommends the use of the terms overweight and obese for documentation and risk assessment only and the use of more neutral terms (e.g., weight disproportional to height, excess weight, BMI) when discussing a child’s weight with a parent/caregiver (3) . BMI is calculated and plotted on growth charts at each WIC certification. However, growth charts are meant to be used as a screening tool and comprise only one aspect of the overall growth assessment. A clinical assessment to determine if a child is at a healthy weight is more complex. Weight classification (derived from the growth chart) should be integrated with the growth pattern, familial obesity, medical risks, and dietary and physical activity habits to determine the child’s obesity risk (1, 5). The goal in WIC nutrition counseling is to help the child achieve recommended rates of growth and development. WIC staff can frame the discussion to make achieving normal growth a shared goal of the WIC Program and the parent/caregiver and make clear that obesity is a medical condition that can be addressed (4). Parents/caregivers of children may need education on recognition of satiety cues and other physiological needs that lead to crying, and ways to comfort a child (holding, reading,

(section-ii)(nutrition-risk-manual)(page-20)Page 20#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 20

rocking) other than by feeding. The foods provided by the WIC Program are scientifically-based and intended to address the supplemental nutritional needs of the Program’s target population and can be tailored to meet the needs of individual participants. Emphasis can be placed on promoting food choices of high nutritional quality while avoiding unnecessary or excessive amounts of calorie rich foods and beverages, and reducing inactivity (like decreasing sedentary TV viewing). Beliefs about what is an attractive or healthy weight, the importance of physical activity, what foods are desirable or appropriate for parents to provide to children, family mealtime routines, and many other lifestyle habits are influenced by different cultures, and should be considered during the nutrition assessment and counseling (6). The following resources for obesity prevention can be found at: • Fit WIC Materials: http://www.nal.usda.gov/wicworks/Sharing_Center/gallery/families.html • MyPryramid for Preschoolers: http://www.mypyramid.gov/preschoolers/index.html

In addition, WIC staff can greatly assist families by providing referrals to medical providers and other services, if available, in their community. Such resources may provide the recommended medical assessments, in order to rule out or confirm medical conditions, and offer treatment when necessary and/or in cases where growth improvement is slow to respond to dietary interventions.

Clarification

The 2000 CDC Birth to 36 months growth charts cannot be used as a screening tool for the purpose of assigning this risk because these charts are based on recumbent length rather than standing height data. However, these charts may be used as an assessment tool for evaluating growth in children aged 24-36 months who are not able to be measured for the standing height required for the 2000 CDC 2-20 years growth charts.

Additional Counseling Guidelines

(section-ii)(nutrition-risk-manual)(page-21)Page 21#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 21

➢ eating three meals per day and choosing healthy, low calorie snacks ➢ modestly reducing fat in the family’s diet (Don’t restrict fat in children less than 2 years of age.) ➢ drinking low fat and non fat milk after the age of 2 ➢ limiting the consumption of high sugar foods like soda and juice (Do not forbid sweets and desserts. Emphasize moderation.) ➢ being aware of portion sizes, especially high fat and high sugar foods ➢ limit the frequency of high calorie fast food meals ➢ eating a variety of foods by introducing new foods often ➢ drinking more water ➢ engaging in physical activities that the whole family enjoys ➢ reducing the time in front of the TV (Limit TV and computer games to no more than 1 to 2 hours per day)

References

1. Kuczmarski RJ, Ogden CL, Grummer-Strawn LM, et al. CDC growth charts: United States. Advance data from vital and health statistics; no. 314. Hyattsville (MD): National Center for Health Statistics. 2000.

2. Grummer-Strawn LM, Reinold C, Krebs NF. Use of World Health Organization and CDC growth charts for children aged 0-59 Months in the United States. CDC Morbidity and Mortality Weekly Report (September 2010); no 59(rr09); 1-15. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5909a1.htm?s_cid=rr5909a1_w. Accessed September 2010.

3. Barlow SE, Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: Summary report. Pediatrics. 2007; 120; S164-S192.

4. Ogden CL, Flegal KM. Changes in Terminology for Childhood Overweight and Obesity. National health statistics reports; no. 25. Hyattsville (MD): National Center for Health Statistics. 2010.

5. U.S. Department of Health and Human Services. The Surgeon General’s vision for a healthy and fit nation. Rockville (MD): U.S. Department of Health and Human Services, Office of the Surgeon General. 2010.

6. Krebs NF, Himes JH, Jacobson D, Nicklas TA, Guilday P, Styne D. Assessment of child and Adolescent Overweight and Obesity. Pediatrics 2007; 120 Suppl 4:S103-S228.

(section-ii)(nutrition-risk-manual)(page-23)Page 23#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 23

Auto assigned for children 2-5 years of age when BMI-for-age or weight-for-stature is > 85 and < 95 percentile.

Auto assigned for infants < 12 months of age when biological mother has a BMI > 30 at time of conception or at any point in the first trimester of the pregnancy.

Auto assigned for children ≥ 12 months of age when biological mother has a BMI ≥ 30 based on the Nutrition Interview.

Auto assigned for infant or child if biological father has a BMI ≥ 30 based on Nutrition Interview.

Justification

The rise in the prevalence of overweight and obesity in children and adolescents is one of the most important public health issues in the United States today. The National Health and Nutrition Examination Survey (NHANES) from the mid-1960s to the early 2000s document a significant increase in overweight among children from preschool age through adolescence. These trends parallel a concurrent increase in obesity among adults, suggesting that fundamental shifts in dietary and/or physical activity behaviors are having an adverse effect on overall energy balance (3). BMI is a measure of body weight adjusted for height. While not a direct measure of body fatness, BMI is a useful screening tool to assess adiposity (3). Children > 2 years of age, with a BMI-for-age > 85th and < 95th percentile are considered overweight and those at or above the 95th percentile, obese (4). Research on BMI and body fatness shows that the majority of children with BMI-for-age at or above the 95th percentile have high adiposity and less than one-half of the children in the 85th to < 95th percentiles have high adiposity (4). Although an imperfect tool, elevated BMI among children most often indicates increased risk for future adverse health outcomes and/or development of diseases (5). BMI should serve as the initial screen and as the starting point for classification of health risks (3). 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 overt signs of increasing body mass are present (6). The presence of parental obesity should lead to greater efforts by nutrition services staff to assist families in establishing or improving healthy behaviors (3). Justification for High Risk

Not applicable

Implications for WIC Nutrition Services

The WIC Program plays an important role in public health efforts to reduce the prevalence of obesity by actively identifying and enrolling infants and children who may be overweight or at risk of

(section-ii)(nutrition-risk-manual)(page-24)Page 24#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 24

overweight in childhood or adolescence. When identifying this risk, it is important to communicate it in a way that is supportive, nonjudgmental, and with a careful choice of words to convey an empathetic attitude and to minimize embarrassment or harm to a child’s self-esteem (4). In recognition of the importance of language, the 2007 American Medical Association expert committee report recommends the use of the terms overweight and obese for documentation and risk assessment only and the use of more neutral terms (e.g., weight disproportional to height, excess weight, BMI) when discussing a child’s weight with a parent/caregiver (3) . BMI is calculated and plotted on growth charts at each WIC certification. However, growth charts are meant to be used as a screening tool and comprise only one aspect of the overall growth assessment. A clinical assessment to determine if a child is at a healthy weight is more complex. Weight classification (derived from the growth chart) should be integrated with the growth pattern, familial obesity, medical risks, and dietary and physical activity habits to determine the child’s obesity risk (1,5). The goal in WIC nutrition counseling is to help the child achieve recommended rates of growth and development. WIC staff can frame the discussion to make achieving normal growth a shared goal of the WIC Program and the parent/caregiver. Studies have shown that the early childhood eating environment provides a great opportunity for preventive intervention (7). Parents/caregivers of infants and toddlers may need education on recognition of satiety cues and other physiological needs that lead to crying, and ways to comfort a child (holding, reading, rocking) other than by feeding. Young children look upon their parents as role models for eating behaviors. Through client- centered counseling, WIC staff can emphasize the importance of prevention and can assist families in making changes that improve parenting skills that promote healthy eating, and physical activity behaviors and a healthy weight in children. Also, the foods provided by the WIC Program are scientifically-based and intended to address the supplemental nutritional needs of the Program’s target population and can be tailored to meet the needs of individual participants. Beliefs about what is an attractive or healthy weight, the importance of physical activity, what foods are desirable or appropriate for parents to provide to children, family mealtime routines, and many other lifestyle habits are influenced by different cultures, and should be considered during the nutrition assessment and counseling (8). The following resources for obesity prevention can be found at: • Fit WIC Materials: http://www.nal.usda.gov/wicworks/Sharing_Center/gallery/foodfunfamilies.htm. • MyPryramid for Preschoolers: http://www.mypyramid.gov/preschoolers/index.html

(section-ii)(nutrition-risk-manual)(page-25)Page 25#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 25

Clarification

• First step in weight control for most overweight children is not weight loss ▪ Goal should be to maintain baseline weight or to gain weight at a slower rate • Weight goals can be achieved through modest changes in diet and activity ▪ Avoid short term diets or physical activity programs that promote rapid weight loss rather than long term changes ▪ Emphasize the importance of the whole family making changes—not just the participant who is overweight! ▪ Help caregiver to teach and model healthy attitudes toward food and physical activity without emphasizing body weight • Help participant pick one or two goals to work on ▪ Start slowly, and help participant monitor changes and progress ▪ Suggested goals could include: ➢ Improving healthy eating habits ➢ Eating three meals per day and choosing healthy, low calorie snacks ➢ Modestly reducing fat in the family’s diet (Don’t restrict fat in children less than 2 years of age.) ➢ Drinking low fat and non fat milk after the age of 2 ➢ Limiting the consumption of high sugar foods like soda and juice (Do not forbid sweets and desserts. Emphasize moderation.) ➢ Being aware of portion sizes, especially high fat and high sugar foods ➢ Limit the frequency of high calorie fast food meals ➢ Eating a variety of foods by introducing new foods often ➢ Drinking more water ➢ Engaging in physical activities that the whole family enjoys ➢ Reducing the time in front of the TV (Limit TV and computer games to no more than 1 to 2 hours per day.) References

1. Kuczmarski RJ, Ogden CL, Grummer-Strawn LM, et al. CDC growth charts: United States. Advance data from vital and health statistics; no. 314. Hyattsville, Maryland: National Center for Health Statistics. 2000. 2. Grummer-Strawn LM, Reinold C, Krebs NF. Use of World Health Organization and CDC growth charts for children aged 0-59 Months in the United States. CDC Morbidity and Mortality Weekly Report (September 2010); no 59(rr09); 1-15. Available at:

(section-ii)(nutrition-risk-manual)(page-28)Page 28#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 28

115 High Weight-for-Length (Infants and Children < 24 Months of Age) Definition/Cut-Off Value:

High weight-for-length for infants and children < 24 months of age is defined as follows:

Birth to < 24 months having > 97.7th percentile weight-for-length as plotted on the Centers for Disease Control and Prevention (CDC), Birth to 24 months gender specific growth charts (1) (available at: www.cdc.gov/growthcharts).*

*Based on the 2006 World Health Organization (WHO) international growth standards (2). CDC labels the 97.7th percentile as the 98th percentile on the Birth to 24 months gender specific growth charts. For more information about the percentile cut-off, please see Clarification.

Participant Category and Priority Level

Category Priority Risk Infants I N Children (< 24 months of age) III N

Justification

In 2006, WHO released international growth standards for infants and children aged 0-59 months (2), similar to the 2000 CDC growth references. Since then, the CDC has developed Birth to 24 months growth charts, based on the WHO growth standards, and recommends their use in the United States (1). For persons 2-20 years, the 2000 CDC growth charts will continue to be used (1). The WHO and CDC growth charts are similar in that both describe weight-for-age, length (or stature)-for-age, weight-for-length (or stature) and body mass index (BMI) for age. However, they differ in the approach taken to create the growth charts. The WHO growth charts are growth standards that describe how healthy children grow under optimal environmental and health conditions. The 2000 CDC charts are a growth reference, not a standard, and describe how certain children grew in a particular place and time (2). The WHO growth standards for children < 24 months are based on data collected from 1997-2003 in 6 countries (including the U.S.), from children who were born between 37 and 42 weeks gestation, breastfed for at least 12 months, and introduced to complementary food by at least 6 months but not before 4 months. Infants and children of low-income mothers and/or mothers who smoked were not included in the data sample (2). The 2000 CDC charts for infants and children < 36 months are based on birth weight (from 1968 to 1980 and from 1985 to 1994) and birth length data (from 1989 to1994) obtained from U.S. birth certificates; National Health and Nutrition Examination Survey (NHANES) data; and, measurements

(section-ii)(nutrition-risk-manual)(page-29)Page 29#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 29

from infants who had been breastfed and formula fed (approximately 50% ever breastfed and approximately 33% who were still breastfeeding at 3 months). Very low birth weight infants were not included in the sample population. This was the only exclusion criterion applied to the sample population (2, 3).

Prior to making its recommendation, CDC convened an Expert Panel with the National Institutes of Health and the American Academy of Pediatrics to review the scientific evidence and discuss the potential use of the WHO growth standards in the U.S. The recommendation to use WHO growth standards for infants and children < 24 months was made on the basis of input from the Expert Panel. In addition, CDC concluded that the WHO growth standards are based on a high quality study and, since breastfeeding is the recommended infant feeding practice, it is appropriate to use the breastfed infant as the standard against which all other infants are compared (2). The WHO growth standards use values of 2 standard deviations away from the median to identify children whose growth might be indicative of adverse health conditions (1). The CDC Birth to 24 months growth charts (based on the WHO growth standards) labels 2 standard deviations above the median as the 97.7th percentile. Thus, an infant or child (< 24 months) is categorized as high weight- for-length when plotted at or above the 97.7th percentile, labeled as the 98th percentile on the CDC Birth to 24 months growth charts. The CDC recommends that all infants and children < 24 months be assessed using the CDC Birth to 24 months growth charts regardless of type of feeding (formula or breastfed) (2). (See Clarification for information about standard deviations and the cut-off used to determine high weight-for-length.)

Implications for WIC Nutrition Services

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. When identifying this risk, it is important to communicate with parents/caregivers in a way that is supportive and nonjudgmental, and with a careful choice of words that convey an empathetic attitude and minimize embarrassment or harm to a child’s self-esteem (4). In recognition of the importance of language, the 2007 American Medical Association Expert Committee Report recommends the use of more neutral terms such as weight disproportional to height, excess weight, and high weight-for-length when communicating with a parent/caregiver (5). Height and weight measurements are plotted on growth charts at each WIC certification. However, growth charts are meant to be used as a screening tool and comprise only one aspect of the overall growth assessment. A clinical assessment to determine if a child is at a healthy weight is more complex. Weight classification (derived from the growth chart) should be integrated with the growth pattern, familial obesity, medical risks, and dietary and physical activity habits to determine the child’s obesity risk (3, 6).

(section-ii)(nutrition-risk-manual)(page-30)Page 30#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 30

The goal in WIC nutrition counseling is to help the child achieve recommended rates of growth and development. WIC staff can frame the discussion to make achieving normal growth a shared goal of the WIC Program and the parent/caregiver. Studies have shown that the early childhood eating environment provides a great opportunity for preventive intervention (7). Parents/caregivers of infants and toddlers may need education on recognition of satiety cues and other physiological needs that lead to crying, and ways to comfort a child (holding, reading, rocking) other than by feeding. Young children look upon their parents as role models for eating behaviors. Through client- centered counseling, WIC staff can emphasize the importance of prevention and can assist families in making changes that improve parenting skills that promote healthy eating, physical activity behaviors and a healthy weight in children. Also, the foods provided by the WIC Program are scientifically-based and intended to address the supplemental nutritional needs of the Program’s target population and can be tailored to meet the needs of individual participants.

Beliefs about what is an attractive or healthy weight, the importance of physical activity, what foods are desirable or appropriate for parents to provide to children, family mealtime routines, and many other lifestyle habits are influenced by different cultures, and should be considered during the nutrition assessment and counseling (8). The following resources for obesity prevention can be found at: Fit WIC Materials: http://www.nal.usda.gov/wicworks/Sharing_Center/gallery/families.html MyPryramid for Preschoolers: http://www.mypyramid.gov/preschoolers/index.html. In addition, WIC staff can greatly assist families by providing referrals to medical providers and other services, if available, in their community. Such resources may provide the recommended medical assessments, in order to rule out or confirm medical conditions, and offer treatment when necessary and/or in cases where growth improvement is slow to respond to dietary interventions. Clarification

Standard deviation is a measurement widely used in statistical analysis. It shows how much variation there is from the median. The WHO growth charts use standard deviations to illustrate the proximity of a given child’s growth from that of the average child of the same age and gender. For infants and children < 24 months of age, 2 standard deviations above the median indicates high weight-for- length. A measurement of 2 standard deviations below the median indicates underweight. Since most health care providers in the U.S. are more familiar with percentiles, the CDC developed growth charts based on the WHO growth standards, but converted standard deviations into percentile readings. Two standard deviations above the median is the 97.7th percentile; however, for ease of use, CDC labels it as the 98th percentile on the hard copy Birth to 24 months growth charts. Electronic charts should use the 97.7th percentile as the cut-off.

Justification for High Risk

Not applicable

(section-ii)(nutrition-risk-manual)(page-31)Page 31#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 31

References

1. Centers for Disease Control and Prevention. Use of World Health Organization and CDC growth charts for children aged 0-59 months in the United States. MMWR 2010; 59(No. RR- 9). Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5909a1.htm?s_cid=rr5909a1_w. Accessed September 2010. 2. World Health Organization. WHO child growth standards: Length/height-for-age, weight-for- age, weight for height and body mass index-for-age: Methods and development. Geneva, Switzerland: World Health Organization; 2006. Available at http://www.who.int/childgrowth/publications/technical_report_pub/en/index.html. Accessed September 2010. 3. Kuczmarski RJ, Ogden CL, Grummer-Strawn LM, et al. CDC growth charts: United States. Advance data from vital and health statistics; no. 314. Hyattsville, Maryland: National Center for Health Statistics. 2000. 4. Ogden CL, Flegal KM. Changes in Terminology for childhood overweight and obesity. National health statistics reports; no. 25. Hyattsville (MD): National Center for Health Statistics. 2010. 5. Barlow SE, Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: Summary report. Pediatrics. 2007; 120; S164-S192. 6. U.S. Department of Health and Human Services. The Surgeon General’s vision for a healthy and fit nation. Rockville (MD): U.S. Department of Health and Human Services, Office of the Surgeon General. 2010. 7. Anzman SL, Rolllins BY, Birch LL. Parental influence on children’s early eating environments and obesity risk: implications for prevention. International Journal of Obesity 34, 1116-1124 (July 2010). 8. Krebs NF, Himes JH, Jacobson D, Nicklas TA, Guilday P, Styne D. Assessment of child and adolescent overweight and obesity. Pediatrics 2007; 120 Suppl 4:S103-S228.

(section-ii)(nutrition-risk-manual)(page-32)Page 32#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 32

121 Short Stature or At Risk of Short Stature (Infants and Children) Definition/Cut-Off Value:

At Risk of Short Stature (Birth to <24 months)

• Birth to <24 months • > 2.3rd percentile and ≤ 5th percentile length-for-age as plotted on the CDC Birth to 24 months gender specific growth charts (1).* 2 – 5 years:

• 2-5 years: • > 5th percentile and ≤ 10th percentile stature-for-age as plotted on the 2000 CDC age/gender specific growth charts (2).

Short Stature (Birth to < 24 months)

• Birth to <24 months: • ≤ 2.3rd percentile length-for-age as plotted on the Centers for Disease Control and Prevention (CDC) Birth to 24 months gender specific growth charts (1).* 2 – 5 years:

• 2-5 years: • < 5th percentile stature-for-age age as plotted on the 2000 CDC age/gender specific growth charts (2).

*Based on 2006 World Health Organization international growth standards (3). CDC labels the 2.3rd percentile as the 2nd percentile on the Birth to 24 months gender specific growth charts. For more information about the percentile cut-off, please see Clarification. Notes: 1.The Birth to 24 months and the 2000 CDC growth charts are available at: www.cdc.gov/growthcharts. 2. For premature infants and children (with a history of prematurity) up to 2 years of age, assignment of this risk criterion will be based on adjusted gestational age. For information about adjusting for gestational age see: Guidelines for Growth Charts and Gestational Age Adjustment for Low Birth Weight and Very Low Birth Weight Infants.

Participant Category and Priority Level

Category Priority High Risk Infants I N Children III N Formatted: Font: Bold, Not Italic Formatted: Font: Not Bold Formatted: Font: 11 pt Formatted: Font: 11 pt Formatted: Tab stops: 2.46", Left Formatted: Font: 11 pt Formatted: Font: Bold, Not Italic Formatted: Font: 11 pt Formatted: Font: Not Bold Formatted: Font: 11 pt Formatted: No underline

(section-ii)(nutrition-risk-manual)(page-101)Page 101#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 101

211 Elevated Blood Lead Levels Definition/Cut-Off Value

Elevated blood lead level (BLL) is the amount of lead in the blood, measured in micrograms of lead per deciliter of blood (μg/dL), at which follow-up action should be taken for an individual. Elevated BLL is specific to each WIC participant category as follows (1, 2):

Category Elevated Blood Lead Level (μg/dL) (within the past 12 months) Women (all categories) >5 Infants >5 Children >3.5

* See Clarification section for more information about category specific elevated BLLs. ** See the Nutrition and Lead Exposure section below for recommendations on the initiation and continuation of breastfeeding. Participant Category and Priority Level

Category Priority High Risk Pregnant I N Breastfeeding I N Non-Breastfeeding III,IV, V, or VI N Infant I N Children III N

Parameters for Auto Assignment

Auto assigned for all categories if blood lead level was tested in the last year and was ≥ 3.5 µg/dl (children) or ≥5 µg/dl (women and infants )as designated in the Blood panel.

Justification

Lead exposure is a persistent public health problem in the U.S. and worldwide. A naturally occurring element that has been mined and used by humans for centuries, lead is toxic to humans with impacts ranging from changes in organ function to death. 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. In addition to these most extensively studied outcomes, scientific evidence also suggests that lead exposure can have detrimental respiratory, hepatic, endocrine, gastrointestinal, musculoskeletal, and ocular effects, and increase risk of all cancers. (3)

(section-ii)(nutrition-risk-manual)(page-102)Page 102#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 102

Lead exposure during pregnancy or postpartum can adversely impact the mother as well as 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 (2, 3). Lead can also transfer from maternal blood to breastmilk, and ultimately to the breastfeeding infant (2).

Lead exposure is most common in young children because they have greater contact with lead sources and higher gastrointestinal absorption of ingested lead. Additionally, children’s developing nervous systems are more vulnerable to the effects of lead exposure. Elevated BLL in children has been associated with adverse neurological and behavioral outcomes including cognitive deficits (e.g., learning and memory), altered behavior and mood (e.g., attention, hyperactivity, impulsivity, irritably, delinquency), and altered neuromotor and neurosensory function (e.g., visual-motor integration, dexterity, postural sway, changes in hearing and visual thresholds). (3)

Prevalence of Lead Exposure

Over the four decades from 1976 to 2016, BLLs decreased significantly among children ages 1 to 5 years and among women of childbearing age (15 to 49 years) in the U.S. (4, 5). Specifically, during this timeframe, population average BLLs decreased from 15.2 to 0.83 μg/dL and 10.37 to 0.61 μg/dL for these groups, respectively. Correspondingly, the prevalence of BLL >5 μg/dL decreased from 99.8 to 1.3 percent among children ages 1 to 5 and from 98.3 to 0.7 percent among women of childbearing age. These favorable trends reflect the implementation of federal policies regulating the use of lead in gasoline, paint, plumbing, and other consumer products, among other public health interventions (6).

Despite this progress, sociodemographic disparities have persisted. Low-income and certain racial/ethnic minority populations continue to be disproportionately affected by lead exposure as a result of these groups more commonly living in communities and housing with greater lead contamination (4, 5).

Sociodemographic disparities in lead exposure vary by WIC participant category and are discussed further as follows.

Disparities among Women According to the most recent NHANES data, over 500,000 women of childbearing age (15 to 49 years) in the U.S. have BLL ≥5 μg/dL. 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. (5)

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. (7)

(section-ii)(nutrition-risk-manual)(page-103)Page 103#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 103

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 of younger ages (i.e., 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. (4)

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, with Black children accounting for all children with BLL ≥40 μg/dL. (8)

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. (7)

Sources of Lead Exposure

Lead exposure among the general population may occur through contact with soil, dust, drinking water, food, and air (3). 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 (1). These exposures generally result from living in housing built before 1978, prior to when lead-based paint was banned, or with lead pipes or plumbing. An estimated 83 percent of privately owned homes and 86 percent of public housing family units built before 1980 contain lead-based paint (3). Additionally, up to 10 million households and 400,000 schools and childcare facilities connect to water through lead pipes and service lines (6, 9). Living near a highway, airport, powerplant, smelter, or hazardous waste site may also cause lead exposure through contaminated soil or air (2, 3). Other sources of lead exposure include: • Occupations that involve working with lead-based products, most commonly in the manufacturing, construction, services, and mining industries (10). • Hobbies or activities that involve working with lead-based products such as casting, stained glass, pottery, painting, glassblowing and screen printing (3). • Smoking cigarettes or e-cigarettes, chewing tobacco, and exposure to second-hand smoke (3). • 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 (3). • 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

(section-ii)(nutrition-risk-manual)(page-104)Page 104#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 104

from plastic or paper candy wrappers may also contain lead that leaches or seeps into the imported candy (11). o Certain commonly used spices, particularly those purchased abroad in Georgia, Bangladesh, Pakistan, Nepal, and Morocco (12). • Cultural and traditional medicines, including (7): o Ba-baw-san: a Chinese herbal remedy used to treat colic pain or to pacify young children. o Daw Tway: a digestive aid used in Thailand and Myanmar (Burma). o 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 (7).

Among pregnant and lactating women, the most common sources of lead exposure include (3): • 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.

The primary source of lead exposure among children ages 1 to 5 in the U.S. is soil and surface dust contaminated with lead. Young children are particularly susceptible to lead exposure due to their increased contact with dust, dirt, and surfaces potentially contaminated with lead and frequent hand-to mouth-activity. Children living in older housing with lead-based paint (especially deteriorated paint), are at higher risk for lead exposure. Among children with lower BLL or living in certain communities, other exposure sources such as lead in drinking water and food may be more significant. (3)

Lead Screening and Testing

Lead exposure prevention and reduction are possible, and such primary prevention strategies are critical to preventing long-term damage that can result from even low-level lead exposure. However, because lead is ubiquitous in the environment, secondary prevention is necessary to identify and follow children who are exposed to lead. 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 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 (13). Where state or local screening plans do not exist, CDC recommends universal BLL testing (1). For pregnant women, CDC recommends against universal blood lead testing of all pregnant women in the U.S. Instead, state or local public health departments should identify populations at

(section-ii)(nutrition-risk-manual)(page-105)Page 105#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 105

increased risk for lead exposure and provide guidance about community-specific risk factors to assist clinicians in determining the need for blood lead testing for identified populations or individuals at risk. Follow-up blood lead testing is recommended for pregnant women with BLL ≥5 μg/dL and their newborn infants. 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. (2)

For children, CDC recommends blood lead screening for those at high risk for elevated BLL with follow-up screening within 12 months and specific follow-up actions depending on an individual’s BLL. For additional information, refer to the CDC’s Recommended Actions Based on Blood Lead Levels. (14)

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 (15).

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 (16).

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. (7)

Note: Venous blood samples are the most accurate method of blood lead testing. Elevated BLLs obtained using capillary (finger stick) samples should be confirmed using a venous blood test (2).

Nutrition and Lead Exposure

Adequate intake of certain vitamins and minerals may mediate the absorption of lead and thereby the impacts of lead exposure. Specifically, adequate consumption of both calcium and iron, which compete with lead for intestinal absorption, have been found to decrease lead absorption (2). During pregnancy, adequate calcium intake may reduce maternal bone resorption and thereby reduce the mobilization of lead stored in the bone into the blood (17). 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 (7).

(section-ii)(nutrition-risk-manual)(page-106)Page 106#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 106

While lead can be passed to breastfeeding infants through human milk, research suggests that the amount of blood lead transferred into breastmilk is minimal and hence breastmilk has a relatively small impact on infant BLL (7). CDC has developed breastfeeding recommendations specific to maternal BLL based on the available science.

For breastfeeding women, CDC recommends the following (2): • Initiation of Breastfeeding: o Mothers with BLL <40 μg/dL should breastfeed. o Mothers with confirmed BLL >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. • Continuation of Breastfeeding: o Breastfeeding should continue for all infants with BLL <5 μg/dL. o Infants born to mothers with BLL >5 μg/dL and <40 μg/dL can continue to breastfeed unless there are indications that the breast milk is contributing to elevated BLL.

Justification for High Risk

Not Applicable

Implications for WIC Nutrition Services

WIC nutrition services may benefit participants with elevated BLL by: • Making recommendations for primary prevention of lead exposure, which may include (18): o Avoiding relevant risk factors (e.g., certain traditional medicines and cosmetics, imported or antique children’s toys, imported or pottery dishes, and imported spices and candies). o Referring the participant to a licensed lead inspector to have their home tested for lead. o Referring the participant to the local water authority for testing for lead in tap water. o Washing children’s hands after playing outside, regularly washing pacifiers, toys, etc., and removing shoes when entering the house. • Encouraging consumption of foods (with an emphasis on the foods available in their WIC food package) with nutrients that help minimize absorption of ingested lead and assist in preventing adverse consequences, including: o Calcium: Low-fat dairy, bone-in canned fish, and fortified fruit and vegetable juices (19). For more information see: http://ods.od.nih.gov/factsheets/Calcium- HealthProfessional/ o Iron: Lentils and beans, fortified cereals, red meats, fish, and poultry (20). For more information see: http://ods.od.nih.gov/factsheets/Iron-HealthProfessional/ • Helping to determine source(s) of lead exposure and counseling participants on avoiding exposure, including by: o Assessing pica behavior (for more information, see Risk #427 Inappropriate Nutrition Practices for Women and Risk #425 Inappropriate Nutrition Practices for Children). o Working with local lead programs to determine source(s) of lead exposure and to support their recommendations for reducing further exposure.

(section-ii)(nutrition-risk-manual)(page-107)Page 107#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 107

▪ Information about State and local childhood lead poisoning prevention and surveillance programs can be found here (13): Lead Funding Information | CDC • Referring participants to lead screening/testing: WIC agencies must ask parents/caretakers if the child they are enrolling in WIC has had a blood lead screening test; any child who has not had a test must be referred to a program where they can obtain one. • Providing a referral to a lead treatment program via the local health departments. • Working with healthcare providers to support breastfeeding according to CDC guidelines. This may include providing breastfeeding support to mothers with elevated BLLs who need to temporarily pump and discard their

Clarification

The Definition/ Cut-off Value for each WIC participant category is based on current CDC guidelines. It is important to note that these values are not a health standard or toxicity threshold, but a guide to help determine when medical or environmental follow-up actions should be taken for an individual.

For women and infants, the values are adopted from CDC’s Guidelines for the identification and management of lead exposure in pregnant and lactating women (cdc.gov) (2). For more information, refer to the following tables in this guidance: • For infants, Tables 5-1 and 5-2 for Infants (pages 58-59). For simplicity and consistency, WIC is applying BLL ≥5 for all infants (CDC guidance varies by infant <1 month vs <6 month and does not address infants 6-12 months). • For women, Tables 5-3 (page) and 9-1 (page 103).

For children, the value is the current Blood Lead Reference Value (BLRV), a population measure developed by the Centers for Disease Control and prevention (CDC) to identify children ages 1 to 5 years old with higher levels of lead in their blood compared to 97.5 percent of children in the United States (U.S.). The CDC established the BLRV in 2012 and updated it in 2021 (from 5 to 3.5 μg/dL) based on current national BLL data from the National Health and Nutrition Examination Survey (NHANES). (1) References

1. Ruckart PZ, Jones RL, Courtney JG, et al. Update of the Blood Lead Reference Value - United States, 2021. MMWR Morb Mortal Wkly Rep. 2021;70(43):1509-1512. Published 2021 Oct 29. doi:10.15585/mmwr.mm7043a4 2. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Environmental Health. Guidelines for the identification and management of lead exposure in pregnant and lactating women. Atlanta, Ga.; 2010. Available at: Guidelines for the identification and management of lead exposure in pregnant and lactating women (cdc.gov). 3. Abadin H, Klotzbach JM, Taylor J, et al. Toxicological Profile for Lead. Atlanta (GA): Centers for Disease Control and Prevention, Agency for Toxic Substances and Disease Registry, 2020. 4. Egan KB, Cornwell CR, Courtney JG, Ettinger AS. Blood Lead Levels in U.S. Children Ages 1- 11 Years, 1976-2016. Environ Health Perspect. 2021;129(3):37003. doi:10.1289/EHP7932 5. Dignam T, Kaufmann RB, LeStourgeon L, Brown MJ. Control of Lead Sources in the United States, 1970-2017: Public Health Progress and Current Challenges to Eliminating Lead Exposure.

(section-ii)(nutrition-risk-manual)(page-108)Page 108#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 108

J Public Health Manag Pract. 2019;25 Suppl 1, Lead Poisoning Prevention: S13-S22. doi:10.1097/PHH.0000000000000889 6. The Whitehouse Briefing Room. Fact Sheet: The Biden-Harris Lead Pipe and Paint Action Plan. Available at: https://www.whitehouse.gov/briefing-room/statements-releases/2021/12/16/fact- sheet-the-biden-harris-lead-pipe-and-paint-action-plan/ 7. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Immigrant, Refugee and Migrant Health. Screening for Lead during the Domestic Medical Examination for Newly Arrived Refugees. Available at: https://www.cdc.gov/immigrantrefugeehealth/guidelines/lead-guidelines.html#ref-28.

8. Teye SO, Yanosky JD, Cuffee Y, et al. Exploring persistent racial/ethnic disparities in lead exposure among American children aged 1-5 years: results from NHANES 1999-2016. Int Arch Occup Environ Health. 2021;94(4):723-730. doi:10.1007/s00420-020-01616-4 9. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health. Adult Blood Lead Epidemiology and Surveillance (ABLES). Available at: https://www.cdc.gov/niosh/topics/ables/default.html 10. Advisory Committee on Childhood Lead Poisoning Prevention. Low level lead exposure harms children: a renewed call for primary prevention. Atlanta, GA: US Department of Health and Human Services, CDC, Advisory Committee on Childhood Lead Poisoning Prevention; 2012. 11. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Environmental Health. Lead in Foods, Cosmetics, and Medicines. Available at: https://www.cdc.gov/nceh/lead/prevention/sources/foods-cosmetics-medicines.htm 12. Hore P, Alex-Oni K, Sedlar S, Nagin D. A Spoonful of Lead: A 10-Year Look at Spices as a Potential Source of Lead Exposure. J Public Health Manag Pract. 2019;25 Suppl 1, Lead Poisoning Prevention: S63-S70. doi:10.1097/PHH.0000000000000876 13. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Environmental Health. Childhood Lead Poisoning Prevention. Available at: https://www.cdc.gov/nceh/lead/programs/default.htm 14. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Environmental Health. Recommended Actions Based on Blood Lead Level. Available at: https://www.cdc.gov/nceh/lead/advisory/acclpp/actions-blls.htm. 15. Centers for Medicare & Medicaid Services. Lead Screening. Available at: https://www.medicaid.gov/medicaid/benefits/early-and-periodic-screening-diagnostic-and- treatment/lead-screening/index.html 16. American Academy of Pediatrics. Preventive Care/Periodicity Schedule. Available at: https://www.aap.org/en/practice-management/care-delivery-approaches/periodicity-schedule/ 17. McElroy KG, Iobst SE, DeVance-Wilson C, Ludeman E, Barr E. Systematic Review and Meta- Analysis of the Effect of Nutrients on Blood Lead Levels in Pregnancy. J Obstet Gynecol Neonatal Nurs. 2020;49(3):243-253. doi:10.1016/j.jogn.2020.02.004 18. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Environmental Health. How to Prevent Lead Poisoning in Children. Available at: https://www.cdc.gov/nceh/lead/docs/how-to-prevent-lead-poisoning-in-children.html 19. National Institutes of Health, Office of Dietary Supplements. Calcium: Fact Sheet for Health Professionals. Available at: Calcium - Health Professional Fact Sheet (nih.gov)

(section-ii)(nutrition-risk-manual)(page-109)Page 109#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 109

20. National Institutes of Health, Office of Dietary Supplements. Iron: Fact Sheet for Health Professionals. Available at: Iron - Health Professional Fact Sheet (nih.gov)

(section-ii)(nutrition-risk-manual)(page-110)Page 110#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 110

301 Hyperemesis Gravidarum Definition/Cut-Off Value 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 (1). 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. Presence of condition diagnosed, documented, or reported by a physician or someone working under a physician’s orders, or as self-reported by applicant/participant/caregiver. See Clarification for more information about self- reporting a diagnosis.

Participant Category and Priority Level

Category Priority High Risk Pregnant I Y

Parameters for Manual Assignment

Must be manually selected in the Nutrition Interview or Risk Panel.

High Risk Flag

The high risk designation will automatically activate when this risk factor is assigned.

Justification

Nausea and vomiting are common early in gestation; 50-80% or more of pregnant women experience some vomiting. However, pregnant women diagnosed with HG are at risk of 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 (2).

Risk Factors for HG

Biological, physiological, psychological and sociocultural factors are thought to be influential in HG (3). The various risk factors for HG include maternal underweight, multiple pregnancy, nulliparity, previous history of HG and trophoblastic disorders (see clarification). A history of eating disorders, such as anorexia nervosa or bulimia, is also a risk factor associated with HG (4, 5). Helicobacter pylori infection may be a contributing factor for HG

(section-ii)(nutrition-risk-manual)(page-111)Page 111#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 111

(6). Studies indicate that offspring or siblings of women with HG, and/or women pregnant with a female fetus, have increased chances of having HG. A history of motion sickness and/or migraine headaches are also risk factors for HG (7). Various hormones such as estrogen, progesterone, adrenocorticotropic hormone, cortisol, growth hormone, prolactin and human chorionic gonadotropin (HcG) play an influential role in HG. Increased levels of HcG, which may occur in molar (see clarification) or multi fetal pregnancies may be associated with HG. Studies indicate that HG increases when HcG level reaches its peak at 9 weeks of gestation (8). It should be noted that thyroid function is affected in pregnancy. For pregnant women with hyperthyroidism, decreased levels of thyroid stimulating hormone may be implicated for HG (9, 10). 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) (11). Vitamin K deficiency has also been reported with HG and may be implicated in neonatal hemorrhage (12). 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) (8). Studies indicate that pregnant women with HG in the second trimester are also at an increased risk for placental disorders, such as placental abruption (13). 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 (14). In addition, pregnant women with HG are at increased risk for psychological distress therefore leading to an increased risk for depression and anxiety (15). Other concerns associated with HG include severe distress, social dysfunction and loss of time from work (16, 17). Malnourishment may develop over a period of time in women suffering with HG, which may lead to refeeding syndrome (RFS). RFS includes severe metabolic abnormalities and electrolyte disturbances due to the change from catabolic to anabolic metabolism that occurs when refeeding (orally, parentally, or enterally) occurs too quickly after severe malnourishment. RFS requires multidisciplinary nutrition team management as it is a life-threatening condition (18).

HG and Adverse Birth Outcomes

Systematic review and meta-analysis indicate that HG is frequently associated with adverse birth outcomes (19). Women with HG have an increased risk of giving birth to low birth weight, small for gestational age, and premature infants (20). Infants born to mothers suffering from HG have increased risk of colic, irritability, and growth restrictions (21). There is a scarcity of data examining the long-term effect on fetuses exposed to HG in utero. However, some studies indicate that there is an increased risk of psychological disorders and reduced insulin sensitivity for infants born to women with HG (22, 23).

(section-ii)(nutrition-risk-manual)(page-112)Page 112#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 112

Implications for WIC Nutrition Services

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 (e.g., fried or greasy foods, spicy foods, foods of a certain texture).

-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. (24) -Eat several small meals throughout the day instead of three large meals. Meals should contain more carbohydrate than fat and acid. Protein-rich meals also decrease symptoms. Lighter snacks, including nuts, dairy products, and beans, are recommended. (25) -Take prenatal supplement at night or before bedtime. • Review weight gain goal and weight gain pattern. If weight loss is a problem, discuss nutrient and calorie-dense food choices and refer to the health care provider. • Encourage women to take prenatal vitamins if considering becoming pregnant again. Studies indicate that taking prenatal vitamins a month before conception may help alleviate the symptoms of HG during pregnancy (26).

Clarification

Self-reporting of a diagnosis by a health care provider should not be confused with self- diagnosis, where a person simply claims to have or to have had a medical condition without any reference to professional diagnosis. A self-reported medical diagnosis (“My doctor says that I have/my son or daughter has…”) should prompt the CPA to validate the presence of the condition by asking more pointed questions related to that diagnosis. Gestational Trophoblastic Disease (GTD) may be defined as a condition in which a tumor develops in the uterus that would normally develop as a placenta. Molar pregnancy or a hydatidiform mole may be classified as a form of noninvasive tumor under GTD. A molar pregnancy results from an abnormal fertilization of the egg lacking in maternal tissues. It should be noted that although the tumor is considered benign they have potential to become malignant. The symptoms include vaginal bleeding, hyperemesis, preeclampsia, and hyperthyroidism. (27)

(section-ii)(nutrition-risk-manual)(page-113)Page 113#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 113

Justification for High Risk

Women who are experiencing hyperemesis gravidarum are at risk for weight loss, dehydration, and metabolic imbalances. Women with this condition may also be plagued with insomnia, extreme fatigue and nausea for most or all of the pregnancy.

Extreme weight loss (> 15% of pre-pregnancy weight) can be common among women with this condition and is labeled as a form of “prolonged starvation”. This state can have dire long-term effects that can be avoided with initial management of symptoms through diet and supportive counseling. Women who are diagnosed with hyperemesis gravidarum are more likely to give premature birth and have LBW and SGA children. There is also a higher incidence of spontaneous preterm birth. Aside from physical symptoms, women may also experience cognitive, behavioral and emotional dysfunction associated with hypermesis gravidarum. The WIC nutritionist can play a vital role in helping pregnant women identify triggers for nausea and develop their own techniques and diet for relief and ultimately help them experience the joys of pregnancy. WIC services can also help prevent further weight loss and provide education on how to avoid dehydration.

Additional Counseling Guidelines

• Encourage participant to keep a diary to identify triggers for nausea - include time of day, foods eaten, smells, activities, and stimuli like lights and noise. • Recommend appropriate calorie and fluid intake. • Recommend small, frequent meals. • Encourage eating foods that are craved. • Experiment with different types of foods such as salty, bitter or sour. • Encourage foods that are rich in carbohydrates and low in fat and acid. • Electrolyte-replacement drinks and oral nutritional supplements may be advisable to maintain electrolyte balance. • Protein-predominant meals may help to reduce nausea. • Counsel women to discuss possibility of calcium supplementation with their health care provider.

References

1. Miller F. Nausea and vomiting in pregnancy: the problem of perception--is it really a disease? American Journal of Obstetrics and Gynecology and Suppl. 2002:186(5):S182–S183. 2. Schiff MA, Reed SD, Daling JR. The sex ratio of pregnancies complicated by hospitalisation for hyperemesis gravidarum. BJOG: An International Journal of Obstetrics & Gynaecology. 2004 Jan 1;111(1):27-30.

(section-ii)(nutrition-risk-manual)(page-114)Page 114#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 114

3. Simpson SW, Goodwin TM, Robins SB, Rizzo AA, Howes RA, Buckwalter DK, Buckwalter JG. Psychological factors and hyperemesis gravidarum. Journal of Women's Health & Gender-based Medicine. 2001 Jun 1;10(5):471-7. 4. Poursharif B, Korst LM, Fejzo MS, MacGibbon KW, Romero R, Goodwin TM. The psychosocial burden of hyperemesis gravidarum. Journal of Perinatology. 2008 Mar 1;28(3):176-81. 5. Lee NM, Saha S. Nausea and vomiting of pregnancy. Gastroenterology clinics of North America. 2011 Jun 30;40(2):309-34. 6. Golberg D, Szilagyi A, Graves L. Hyperemesis gravidarum and Helicobacter pylori infection: a systematic review. Obstetrics & Gynecology. 2007 Sep 1;110(3):695-703. 7. Basso O, Olsen J. Sex ratio and twinning in women with hyperemesis or pre- eclampsia. Epidemiology. 2001 Nov and 12(6):747-9. 8. Sheehan P. Hyperemesis gravidarum: assessment and management. Australian Family Physician. 2007 Sep 1;36(9):698. 9. Chan NN. Thyroid function in hyperemesis gravidarum. The Lancet. 1999 Jun 26;353(9171):2243.

10. Blankenstein TJ, Kainer F, Friese K, Mylonas I. Extended hyperemesis gravidarum in a patient after total thyroidectomy. Archives of Gynecology and Obstetrics. 2009 Dec 1;280(6):1029. 11. Dodds L, Fell DB, Joseph KS, Allen VM, Butler B. Outcomes of pregnancies complicated by hyperemesis gravidarum. Obstetrics & Gynecology. 2006 Feb 1;107(2, Part 1):285-92. 12. Toriello HV, Erick M, Alessandri JL, Bailey D, Brunetti-Pierri N, Cox H,Maternal vitamin K deficient embryopathy: association with hyperemesis gravidarum and Crohn disease. American Journal of Medical GGenetics Part A. 2013 Mar 1;161(3):417-29. 13. Bolin M, Åkerud H, Cnattingius S, Stephansson O, Wikström AK. Hyperemesis gravidarum and risks of placental dysfunction disorders: a population-based cohort study. BJOG: An International Journal of Obstetrics & Gynaecology. 2013 Apr 1;120(5):541-7. 14. Ahmed KT, Almashhrawi AA, Rahman RN, Hammoud GM, Ibdah JA. Liver diseases in pregnancy: diseases unique to pregnancy. World Journal of Gastroenterology: WJG. 2013 Nov 21;19(43):7639. 15. McCarthy FP, Khashan AS, North RA, Moss-Morris R, Baker PN, Dekker G, Poston L, Kenny LC, SCOPE consortium. A prospective cohort study investigating associations between hyperemesis gravidarum and cognitive, behavioural and emotional well-being in pregnancy. PloS one. 2011 Nov 18 and 6(11):e27678. 16. Piwko C, Ungar WJ, Einarson TR, Wolpin J, Koren G. The weekly cost of nausea and vomiting of pregnancy for women calling the Toronto Motherisk Program. Current Medical Research and Opinion. 2007 Apr 1;23(4):833-40.

(section-ii)(nutrition-risk-manual)(page-115)Page 115#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 115

17. Piwko C, Koren G, Babashov V, Vicente C, Einarson TR. Economic burden of nausea and vomiting of pregnancy in the USA. J Popul Ther Clin Pharmacol. 2013;20(2):e149-60.

18 .Stokke G, Gjelsvik BL, Flaatten KT, Birkeland E, Flaatten H, Trovik J. Hyperemesis gravidarum, nutritional treatment by nasogastric tube feeding: a 10-year retrospective cohort study. Acta Obstetricia et Gynecologica Scandinavica. 2015 Apr 1;94(4):359-67. 19. London V, Grube S, Sherer DM, Abulafia O. Hyperemesis Gravidarum: A Review of Recent Literature. Pharmacology. 2017;100(3-4):161-71. 20. Veenendaal MV, van Abeelen AF, Painter RC, van der Post JA, Roseboom TJ. Consequences of hyperemesis gravidarum for offspring: a systematic review and meta- analysis. BJOG: An International Journal of Obstetrics & Gynaecology. 2011 Oct 1;118(11):1302-13. 21. Mullin PM, Ching C, Schoenberg F, MacGibbon K, Romero R, Goodwin TM, Fejzo MS. Risk factors, treatments, and outcomes associated with prolonged hyperemesis gravidarum. The Journal of Maternal-Fetal & Neonatal Medicine. 2012 Jun 1;25(6):632-6. 22. Mullin PM, Bray A, Schoenberg F, MacGibbon KW, Romero R, Goodwin TM. Prenatal exposure to hyperemesis gravidarum linked to increased risk of psychological and behavioral disorders in adulthood. Journal of Developmental Origins of Health and Disease. Aug, 2011 and 2(4):200-4. 23. Ayyavoo A, Derraik JG, Hofman PL, Biggs J, Bloomfield FH, Cormack BE, Stone P, Cutfield WS. Severe hyperemesis gravidarum is associated with reduced insulin sensitivity in the offspring in childhood. The Journal of Clinical Endocrinology & Metabolism. 2013 Aug and 98(8):3263-8. 24. Mayo Clinic [Internet]. Minneapolis: Patient Care and Health Information; [Sep 2014: cited 2018 May 1] Morning Sickness. Available from: https://www.mayoclinic.org/diseases- conditions/morning-sickness/diagnosis- treatment/drc-20375260. 25. Wegrzyniak LJ, Repke JT, Ural SH. Treatment of hyperemesis gravidarum. Rev Obstet Gynecol. 2012;5(2):78-84. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3410506/. 26. Committee on Practice Bulletins-Obstetrics. ACOG Practice Bulletin No.189.Nausea and Vomiting of Pregnancy. Obstet Gynecol. 2018 Jan 1;131(1):15-30. 27. Garner EI, Goldstein DP, Feltmate CM, Berkowitz RS. Gestational trophoblastic disease. Clin Obstet Gynecol. 2007 Mar;50(1):112-22.

References for High Risk

1. Fejzo MS, Poursharif B, Korst LM, Munch S. MacGibbon KW, Romero R, Goodwin TM. Symptoms and pregnancy outcomes associated with extreme weight loss among women with hyperemesis gravidarum. J Womens Health.2009;18(12):1981-1987. Doi: 10.1089/jwh.2009.1431.

(section-ii)(nutrition-risk-manual)(page-117)Page 117#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 117

302 Gestational Diabetes Definition/Cut-Off Value

Gestational diabetes mellitus (GDM) is defined as any degree of glucose/carbohydrate intolerance with onset or first recognition during pregnancy (1, 2).

Presence of gestational diabetes 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.

Participant Category and Priority Level

Category Priority High Risk Pregnant I Y

Parameters for Manual Assignment

Must be manually selected in the Nutrition Interview or Risk Panel.

High Risk Flag

The high risk designation will automatically activate when this risk factor is assigned.

Justification

The definition of GDM applies regardless of whether insulin or only diet modification is used for treatment, or whether the condition persists after pregnancy. Included in this classification are women who may have had undiagnosed diabetes prior to pregnancy but who are first diagnosed during pregnancy (1, 2). Pregnant women requiring the use of exogenous steroids, tocolytics, or other medications, or who have medical conditions that alter glucose tolerance, may develop GDM (2). GDM represents nearly 90% of all pregnancies complicated by diabetes (1). The criteria for the diagnosis of GDM (3) are shown in Table 1 (see Clarification).

Pregnancy is an insulin-resistant and diabetogenic state (2). Deterioration of glucose tolerance occurs normally during pregnancy, particularly in the 3rd trimester (1, 2). Untreated or poorly treated GDM results in a higher risk of morbidity and mortality for both the mother and the fetus (2).

Established risk factors for GDM are advanced maternal age, obesity, and family history of diabetes (4). Risk assessment for GDM should be undertaken at the first prenatal visit. Women with clinical characteristics consistent with a high risk for GDM (e.g., those with marked obesity,

(section-ii)(nutrition-risk-manual)(page-118)Page 118#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 118

personal history of GDM or delivery of a previous large-for-gestation-age infant, glycosuria, polycystic ovary syndrome, or a strong family history of diabetes) should undergo glucose testing as soon as possible (5). Unquestionably, there are also ethnic differences in the prevalence of GDM. In the U.S., Native Americans, Asians, Hispanics, and African American women are at a higher risk for GDM than non-Hispanic White women. Besides obesity, there is a suggestion that physical inactivity, diets high in saturated fat and smoking are associated with increasing risk for GDM or recurrent GDM (4).

Infants of women with GDM are at an increased risk of developing obesity, impaired glucose tolerance or diabetes as children or young adults (4). GDM is associated with a higher incidence of maternal and fetal complications. Maternal complications include polycythemia, respiratory distress syndrome, and increased rate of stillbirth (6). Although rarely seen in GDM, congenital anomalies, neural tube defects, cardiac abnormalities and/or caudal regression may occur if a woman has GDM in the early first trimester (6, 7).

Since GDM is a risk factor for subsequent type 2 diabetes after delivery, lifestyle modifications aimed at reducing weight and increasing physical activity are recommended (8). The National Diabetes Education Program (NDEP) is currently promoting a GDM Prevention Initiative, targeting both providers and women with a GDM history (9). Key messages are illustrated in Table 2 (see Clarification).

Medical Nutrition Therapy (MNT) is the primary treatment for the management of GDM (7). MNT for GDM primarily involves a carbohydrate-controlled meal plan that promotes optimal nutrition for maternal and fetal health with adequate energy for appropriate gestational weight gain, achievement and maintenance of normoglycemia, and absence of ketosis (7, 8). Breastfeeding should be strongly encouraged as it is associated with maternal weight loss and reduced insulin resistance for both mother and offspring (10). WIC nutrition services can reinforce and support the medical and diet therapies (such as MNT) that participants with GDM receive from their health care providers.

Justification for High Risk

Data suggests that even minor abnormalities in maternal glucose metabolism will cause increases in infant birth weight and put mother and infant at risk for complications. These complications include birth weight above 90th percentile, cesarean delivery, hypoglycemia, premature delivery, preeclampsia, birth injury, NICU admission and hyperbilirubinemia. Increased maternal blood glucose levels at 24-28 weeks increases these risks associated with GDM and adiposity. Even if levels are below the threshold of diabetes; it is important to monitor blood glucose during pregnancy. Mothers with GDM are also at an increased risk of developing type-2 diabetes later in life when compared to women who did not have gestational diabetes (4).

Women who had mild gestational diabetes reduced the risk of fetal overgrowth, caesarean delivery and hypertensive disorders, when treated with nutritional counseling, diet therapy and insulin injections (if required). The WIC nutritionist can play a vital role in assuring the participant receives comprehensive counseling and follow-up by appropriate health care providers outside of WIC.

(section-ii)(nutrition-risk-manual)(page-119)Page 119#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 119

Additional Counseling Guidelines

• Remember, women with gestational diabetes often feel well and are in their last trimester of pregnancy; therefore they may be casual about their treatment • Emphasize the positive outcomes for treatment with gestational diabetes • Explain potential risks to mother, such as: ▪ Fatigue ▪ Difficult labor and cesarean delivery ▪ Increased risk of infection ▪ Toxemia and preeclampsia ▪ Diabetes after the pregnancy ends • Inform participant of potential risks to infant, such as: ▪ Large birth size (macrosomia) ▪ Low blood sugar after birth ▪ Jaundice ▪ Respiratory distress syndrome ▪ Cardiovascular problems ▪ Kidney dysfunction ▪ Hypocalcemia ▪ Fetal death in extreme cases • Explain relationship between diet, insulin and exercise • Provide basic counseling on diet which provides nutrient needs for pregnancy and facilitates normal blood glucose levels: ▪ Encourage participant to consume calories adequate for recommended weight gain but not excessive weight gain ▪ Recommend diet which contains approximately 40-50% carbohydrate, 20-25% protein and 30-35% fat ▪ Activity Factor - Add 40-60% of basal needs for light activity • Keep timing of meals consistent from day to day with calorie and carbohydrate content fairly evenly divided from meal to meal • Recommend increased intake of high fiber foods and complex carbohydrates • Counsel on importance of not consuming foods high in refined sugar and juice • Plan for food to be taken to correct hypoglycemic episodes • Plan for food and fluids to be taken for periods of increased physical activity and illness • Plan for a bedtime snack to prevent nocturnal hypoglycemia • Eat mid-morning and mid-afternoon snacks, if needed • Encourage moderate regular exercise ▪ Best to exercise after snack or meal ▪ Don’t exercise if blood glucose is < 80 mg/dL or higher than 250 mg/dL ▪ Take carbohydrate in case of hypoglycemia ▪ Always exercise with a partner in case blood sugar drops • Stress importance of maternal follow-up during prenatal period, postpartum period and annually • Stress importance of maintaining healthy body weight

(section-ii)(nutrition-risk-manual)(page-120)Page 120#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 120

Clarification

Women at high risk for GDM who have tested negative at the initial screening, and women at average risk for GDM should be tested by a licensed medical provider, between 24 and 28 weeks of gestation. Women of average risk should be tested at 24-28 weeks of gestation. Testing should follow one of two approaches:

One-step approach:

• Perform a diagnostic 100-g OGTT (Oral Glucose Tolerance Test)

Two-step approach:

• A screening test (glucose challenge test) that measures plasma or serum glucose is done 1 hour after a 50-g oral glucose load without regard for time of day or time of last meal. If a plasma or serum glucose level meets or exceeds the threshold (>130 mg/dl [7.2 mmol/L] or >140 mg/dl [7.8 mmol/L], respectively), an OGTT is performed (3).

• A diagnosis of GDM is made with a 100-g oral glucose load after an overnight fast. Using a 3-hour test, if two or more plasma or serum glucose levels meet or exceed the threshold, a diagnosis of GDM is made. Alternatively, the diagnosis can be made using a 75-g oral glucose load. The glucose threshold values for both tests are listed in Table 1 (10). The 75- g glucose load test is not as well validated as the 100-g OGTT.

With either the 75-g OGTT or the 100-g OGTT, it is recommended that the test be performed after an overnight fast of at least 8 hours but no longer than 14 hours. For 3 days prior to the test the woman should consume an unrestricted diet (>150 g carbohydrate per day) and maintain unrestricted physical activity. Women need to remain seated and not smoke during the test. (1, 2).

(section-ii)(nutrition-risk-manual)(page-122)Page 122#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 122

5. American Diabetes Association. Standards of medical care in diabetes (position statement). Diabetes Care. Jan 2007; 30 Suppl 2:S4-41.

6. Thomas AM, Gutierrez YM. American Dietetic Association guide to gestational diabetes mellitu in postpartum considerations. Eds. American Dietetic Association; 2005:101-113.

7. Brian SR, Nickless N, Thung SF, Inzucchio SE. Gestational diabetes update.: screening, medical management and follow-up. Practical Diabetology. Mar 2007;10-18.

8. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2008 Jan; 31 Suppl 1:S55-60.

9. Ratner, RE. Prevention of type 2 diabetes in women with previous gestational diabetes. Proceedings of the fifth international workshop – conference on gestational diabetes mellitus. Diabetes Care. Jul 2007; 30 Suppl 2 :S242-245.

10. Evert AG, Vande Hei K. Gestational diabetes education and diabetes prevention strategies. Diabetes Spectrum. 2006; 19(3):135-139.

References for High Risk

1. The HAPO Study Cooperative Research Group. Hyperglycemia and adverse pregnancy outcomes. N Engl J Med. 2008;358:1991-2002. 2. The HAPO Study Cooperative Research Group. Hyperglycemia and adverse pregnancy outcome (HAPO) study: associations with neonatal anthropometrics. Diabetes 2009;58:453-459. 3. Landon MB, Spong CY, Thom E, et. al. A multicenter, randomized trial of treatment for mild gestational diabetes. N Eng J Med. 2009;361:1339-1348. 4. Bellamy L, Casas JP, Hingorani AD, Williams D. Type 2 diabetes mellitus after gestational diabetes: a systematic review and meta-analysis. Lancet 2009; 373:1773-1779. 5. International Association of Diabetes and Pregnancy Study Groups Consensus Panel. International association of diabetes and pregnancy study groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care 2010;33:676-682. 6. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2012; 35(Suppl 1):S64-S71.

7. American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35(Suppl 1):S11-S63. 8. Committee on Obstetric Practice. Screening and diagnosis of gestational diabetes mellitus. Obstet Gynecol 2011;118:751-753.

(section-ii)(nutrition-risk-manual)(page-123)Page 123#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 123

303 History of Gestational Diabetes Definition/Cut-Off Value

History of diagnosed gestational diabetes mellitus (GDM).

Presence of condition 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.

Participant Category and Priority Level

Category Priority High Risk Pregnant I N Breastfeeding I N Non-Breastfeeding VI N

Parameters for Manual Assignment

Must be manually selected in the Nutrition Interview or Risk Panel

Justification

Women who have had a pregnancy complicated by GDM are 40-60% more likely to develop diabetes within 15-20 years (1), usually type 2 (2). This risk of subsequent diabetes is greatest in women with GDM who are diagnosed early in the pregnancy, exhibit the highest rates of hyperglycemia during the pregnancy, and are obese.

Approximately 30-50% of the women with a history of GDM will develop GDM in a subsequent pregnancy. 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 (2, 3). In addition, if a woman’s lipid levels are elevated, a history of GDM is also a risk factor for cardiovascular disorders (3).

There is evidence to suggest that some women with a history of GDM show relative beta-cell dysfunction during and after pregnancy (3). Most women with a history of GDM are insulin resistant. Changes in lifestyle (dietary and physical activity) may improve postpartum insulin sensitivity and could possibly preserve B-cell function to slow the progression to type 2 diabetes (2, 3).

During WIC nutrition education and counseling, obese women with a history of GDM should be encouraged to lose weight before a subsequent pregnancy. Breastfeeding has been shown to lower the blood glucose level and to decrease the incidence of type 2 diabetes in women with a history of GDM (2, 3). Exercise also has a beneficial effect on insulin action by enhancing peripheral tissue glucose uptake (3). Medical Nutrition Therapy (MNT) is an essential component in the care of women with a history of GDM.

(section-ii)(nutrition-risk-manual)(page-124)Page 124#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 124

Women with a history of GDM but without immediate subsequent postpartum diagnosis of diabetes should be advised to discuss with their medical provider the importance of having a Glucose Tolerance Testing (GTT) at 6 to 12 weeks postpartum (see Clarification, Table 1); to have a pre- pregnancy consultation before the next pregnancy, and to request early glucose screening in the next pregnancy (4). The National Diabetes Education Program (NDEP) is currently promoting a GDM Diabetes Prevention Initiative, targeting both providers and women with a history of GDM (5). Key messages are illustrated in Table 2. (See Clarification).

WIC nutrition services can support and reinforce the MNT and physical activity recommendations that participants receive from the health care providers. In addition, WIC nutritionists can play an important role in providing women with counseling to help manage their weight after delivery. Also, children of women with a history of GDM should be encouraged to establish and maintain healthy dietary and lifestyle behaviors to avoid excess weight gain and reduce their risk for type 2 diabetes (1).

Diet Composition

Carbohydrate is the main nutrient that affects postprandial glucose elevations. During pregnancy complicated with GDM, carbohydrate intake can be manipulated by controlling the total amount of carbohydrate, the distribution of carbohydrate over several meals and snacks, and the type of carbohydrate. These modifications need not affect the total caloric intake level/prescription (6).

Because there is wide inter-individual variability in the glycemic index each women needs to determine, with the guidance of the dietitian, which foods to avoid or use in smaller portions at all meals or during specific times of the day, for the duration of her pregnancy. Practice guidelines have avoided labeling foods as “good” or “bad” (6).

Meal plans should be culturally appropriate and individualized to take into account the patient’s body habitus, weight gain and physical activity; and should be modified as needed throughout pregnancy to achieve treatment goals (6).

Clarification

Self-reporting of “History of…” conditions should be treated in the same manner as self-reporting of current conditions requiring a physician’s diagnosis, i.e., the applicant may report to the CPA that s/he was diagnosed by a physician with a given condition at some point in the past. As with current conditions, self-diagnosis of a past condition should never be confused with self-reporting.

(section-ii)(nutrition-risk-manual)(page-127)Page 127#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 127

304 History of Preeclampsia

Definition/Cut-Off Value

History of diagnosed preeclampsia

Presence of condition diagnosed, documented, or reported by a physician or someone working under a physician’s orders, or as self-reported by applicant/participant/caregiver. See Clarification for more information about self-reporting a diagnosis

Participant Category and Priority Level

Category Priority High Risk Pregnant I N Breastfeeding I N Non-Breastfeeding III, VI, V or VI N

Parameters for Manual Assignment

Must be manually selected in the Nutrition Interview or Risk Panel

Justification

Please see risk #345 Hypertension and Prehypertension, for a thorough overview of preeclampsia, including incidence, risk factors, signs and symptoms, prevention, and treatment.

Preeclampsia is defined as hypertension with onset during pregnancy, usually after 20 weeks gestation, and typically with proteinuria (high levels of protein found in urine). For some women, proteinuria does not occur; for these women, preeclampsia is diagnosed as hypertension with thrombocytopenia (low platelet count), impaired liver function, renal insufficiency (poor kidney function), pulmonary edema (excess fluid in the lungs), and/or cerebral or visual disturbances (brain and vision problems) (1). 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 (1, 2). Worldwide, it leads to the death of over 60,000 women annually (3).

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 healthcare provider immediately if they occur. (1, 4)

(section-ii)(nutrition-risk-manual)(page-128)Page 128#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 128

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 (1, 2, 5, 6). 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 healthcare 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 (7).

• 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/healthtopics/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 risk #371 Maternal Smoking and risk #372 Alcohol and 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 preeclampsia (1, 2, 3, 8). Dietary folate and folic acid supplementation during pregnancy has also been associated with lower risk of preeclampsia (6, 9).

Breastfeeding

Women who had preeclampsia face a greater risk of HTN later in life; however, longer breastfeeding duration has been found to reduce this risk. (10, 11). Unfortunately, women who had preeclampsia during pregnancy are more likely to not initiate breastfeeding or to stop breastfeeding earlier than women with normal blood pressure (10, 12). Some potential causes for this include greater incidence of preterm birth, low birth weight, caesarean delivery, exposure to medications not compatible with breastfeeding, and mother/infant separation (12). Women with history of preeclampsia 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 healthcare provider to determine the best infant feeding and medication plan.

Implications for WIC Nutrition Services

(section-ii)(nutrition-risk-manual)(page-129)Page 129#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 129

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 healthcare provider immediately if they occur. Also, inform them that preeclampsia can occur postpartum.

• Encouraging them to discuss individualized physical activity recommendations with their healthcare 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/wicsubstance-use-prevention-guide).

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

Postpartum Women with History of Preeclampsia:

• Informing them of the symptoms of postpartum preeclampsia and of the importance of contacting their healthcare provider immediately if they occur.

• Providing breastfeeding promotion and support, unless contraindicated. Encourage women to discuss their breastfeeding status and goals with their healthcare 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 healthcare provider; and to have their BMI, blood pressure, lipids, and fasting glucose assessed yearly (3).

• 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.

(section-ii)(nutrition-risk-manual)(page-130)Page 130#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 130

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

• 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.

Clarification

Justification for High Risk

Not Applicable

References

1. American College of Obstetricians and Gynecologists [Internet]. Washington (DC): American College of Obstetricians and Gynecologists; c2013. Hypertension in pregnancy. 2013 [cited 2018 July]; [100 pages]. Available from: www.acog.org/~/media/Task%20Force%20and%20Work%20Group%20Reports/public/Hypertensi oninPregnancy.pdf. 2. Khaing W, Vallibhakara SA, Tantrakul V, et al. Calcium and vitamin D supplementation for prevention of preeclampsia: a systematic review and network meta-analysis. Nutrients. 2017 Oct [cited 2019 Mar 5];9(10):1141. Available from: https://www.mdpi.com/2072-6643/9/10/1141. 3. Duhig K, Vandermolen B, Shennan A. Recent advances in the diagnosis and management of preeclampsia [version 1; referees: 2 approved]. F1000 Faculty Review. 2018 Aug 15 [cited 2019 Mar5];7(F1000 Faculty Rev)242. Available from: https://doi.org/10.12688/f1000research.12249.1. 4. Centers for Disease Control and Prevention [Internet]. Atlanta (GA): Centers for Disease Control and Prevention, 2018. High blood pressure during pregnancy fact sheet. 2018 May 16 [cited 2018 July]. Available from: www.cdc.gov/bloodpressure/pregnancy.htm.

(section-ii)(nutrition-risk-manual)(page-131)Page 131#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 131

5. Mol BWJ, Roberts CT, Thangaratinam S, et al. Pre-eclampsia. The Lancet. 2015 Sept 2 [cited 2019 Mar 5];387(10022):999-1011. Available from: https://doi.org/10.1016/S0140-6736(15)00070- 7.

6. Wen SW, Guo Y, Rodger M, et al. Folic acid supplementation in pregnancy and the risk of preeclampsia – a cohort study. PLoS ONE. 2016 Feb 22 [cited 2019 Mar 5];11(2): e0149818. Available from: https://doi.org/10.1371/journal.pone.0149818. 7. National Heart, Lung, and Blood Institute [Internet]. Bethesda (MD): National Institutes of Health. High blood pressure. [cited 2018 July]. Available from: www.nhlbi.nih.gov/health-topics/highblood- pressure. 8. Lowensohn R, Stadler DD, Naze C. Current concepts of maternal nutrition. Obstetrical and Gynecological Survey. 2016 July [cited 2019 Mar 5];71(7):413-26. Available from: https://journals.lww.com/obgynsurvey/Fulltext/2016/07000/Current_Concepts_of_Maternal_Nut rition.18.aspx. 9. Wang Y, Zhao N, Qiu J, et al. Folic acid supplementation and dietary folate intake, and risk of preeclampsia. European Journal of Clinical Nutrition. 2015 Jan 28 [cited 2019 Mar 5];69:1145-50. Available from: https://www.nature.com/articles/ejcn2014295. 10. Demirci J, Schmella M, Glasser M, et al. Delayed lactogenesis II and potential utility of antenatal milk expression in women developing late-onset preeclampsia: a case series. BMC Pregnancy and Childbirth. 2018 Dec [cited 2019 Mar 5];18(1):68. Available from: https://doi.org/10.1186/s12884- 018-1693-5. 11. Feltner C, Weber RP, Stuebe A, Grodensky CA, Orr C, Viswanathan M. Breastfeeding Programs and Policies, Breastfeeding Uptake, and Maternal Health Outcomes in Developed Countries. Comparative Effectiveness Review No. 210. (Prepared by the RTI International– University of North Carolina at Chapel Hill Evidence-based Practice Center under Contract No. 290-2015-00011-I.) AHRQ Publication No. 18-EHC014-EF. Rockville (MD): Agency for Healthcare Research and Quality. 2018 July [cited 2019 April 24]. Available from: https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/cer-210-breastfeeding-report_1.pdf. 12. Cordero L, Valentine CJ, Samuels P, et al. Breastfeeding in women with severe preeclampsia. Breastfeeding Medicine. 2012 Dec 10 [cited 2019 Mar 5];7(6):457-63. Available from: https://doi.org/10.1089/bfm.2012.0019.

(section-ii)(nutrition-risk-manual)(page-132)Page 132#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 132

311 History of Preterm or Early Term Delivery Definition/Cut-Off Value

History of preterm and/or early term delivery is defined as follows (1, 2): • 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.

Category Pregnancy Pregnant Any history of preterm or early term delivery Breastfeeding/ Non-Breastfeeding Most recent pregnancy

Participant Category and Priority Level

Category Priority High Risk Pregnant I N Breastfeeding I N Non-Breastfeeding VI N

Parameters for Manual Assignment

Must be manually selected in the Nutrition Interview or Risk Panel

Justification

Women with a history of preterm delivery have an increased risk of spontaneous preterm delivery in a subsequent pregnancy compared to women with no history of prior spontaneous preterm delivery (3). 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 (4).

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) (5). 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 (1).

(section-ii)(nutrition-risk-manual)(page-133)Page 133#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 133

Preterm Delivery

Prematurity affects about 12% of all live births in the U.S., and about 50% of these preterm births were preceded by preterm labor (6). In 2011, the annual rate of premature births in the United States reached 11.7%, nearly two times the rate in European nations (6). Preterm births also account for approximately 70% of newborn deaths and 36% of infant deaths (5).

Despite advances in neonatal care, preterm birth remains a leading cause of infant death in the United States (7). More infants die from pre-term related problems than any other single cause (6). Preterm birth strains society’s healthcare resources due to its long-term effects on the health of the newborn (6). Premature infants may have physical problems that have nutritional implications, including immature sucking, swallowing and immature digestion and absorption of carbohydrates and lipids (7). Preterm infants are at risk for a number of illnesses/health conditions that range from minor to severe complications depending on the circumstances. (See risk 142 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 (4). 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 (8). Other factors associated with a risk of preterm birth may be identified before pregnancy, at conception, or during pregnancy include (8, 9): • Low maternal weight gain during pregnancy • Maternal infections • Maternal hypertension • Gestational diabetes • Smoking • Indoor pollution • Maternal stress • Poor housing quality • Teen pregnancy • Sexually transmitted diseases • Low psychosocial health status • Previous or present pregnancy complications • Multiple fetuses • Lack of perceived social support

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 • Postpartum weight retention

(section-ii)(nutrition-risk-manual)(page-134)Page 134#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 134

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 (11). 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 (12, 13, 14) • Reduced risk of necrotizing enterocolitis (15, 16) • Reduced risk of retinopathy of prematurity and retinal detachment (17)

Additionally, mothers of preterm infants produce milk that is designed to meet the baby’s particular needs during the first few weeks of breastfeeding. It is higher in protein and minerals, such as salt, and contains different types of fat that the baby will be able to digest and absorb more easily compared to 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 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 also help the baby fight infection. (16) 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, so it is important for the mother to discuss her feeding decisions with her baby’s doctor.

Early Term

Up to 10% of babies in the United States are scheduled for early term deliveries via labor-inducing medication or cesarean section before 39 weeks of gestation despite neither the mother nor the baby being at risk if the pregnancy continues (18). Elective deliveries like this are sometimes requested for reasons such as wanting to schedule the date of the infant’s birth, physician preference, or for relief of symptoms at the end of the pregnancy (18).

Research shows that a fetus will experience a significant amount of development and growth of the lungs, brain, and liver between 37 and 39 weeks of gestation. The brain develops at its fastest rate at the end of the pregnancy, at a rate of up to one third between weeks 35 and 39. Additionally, layers of fat are added under the infant’s skin during the last few weeks of pregnancy which helps them keep warm after birth. According to ACOG, non-medically warranted deliveries prior to 39 weeks should be avoided (19). Early term delivery puts an additional strain on society as the early term infant will likely require a

(section-ii)(nutrition-risk-manual)(page-135)Page 135#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 135

longer hospital stay and may have long term healthcare needs (18). Factors that can increase the risk of a woman delivering an early term infant are the same and are stated above for preterm birth.

When a woman delivers an early term infant or chooses an early elective delivery, she is at increased risk for postpartum depression, cesarean delivery, and other complications requiring longer hospital stays (18). Steps pregnant women can take in order to decrease the prevalence of pre-term births include (18): • Seek regular prenatal care throughout pregnancy. • Maintain a healthy diet, including daily prenatal vitamins. • Cease consumption of alcohol, drugs, or other dangerous toxins during pregnancy. • Avoid stress. • Contact their health care provider with all questions or concerns.

Implications for WIC Nutrition Services

Pregnant women who come from low or inadequate income households are at a greater risk for poor physical and mental health due to poor eating habits. WIC services may assist women at risk of preterm and early term births by providing them with proper nutrition. Early prevention is the primary way to stop preterm labors. WIC can assist in reducing preterm deliveries by increasing prevention strategies. WIC can improve outcomes through: • Recommending healthy maternal weight gain and providing nutrition education that addresses the WIC food package and other healthy foods that contribute to a balanced diet. • Promoting early and regular prenatal care. • Encouraging use of prenatal vitamins, as prescribed by the health care provider. • Recommending adherence to Dietary Guidelines for Americans.

WIC staff may find the below listed resources helpful in providing nutrition counseling: • Additional Considerations for Some Adults-Physical Activity for Women During Pregnancy and the Postpartum Period: http://health.gov/paguidelines/guidelines/chapter7.aspx. • Women, Infants, and Children-About WIC, How WIC Helps: http://www.fns.usda.gov/wic/about- wic-how-wic-helps. • WIC Works Resource Systems: https://wicworks.fns.usda.gov/.

Justification for High Risk

Not Applicable

References

1. American College of Obstetricians and Gynecologists. Definition of term pregnancy.Committee Opinion No.579. Obstet Gynecol. 2013 Nov;122:1139-40. 2. Ob-Gyns redefine meaning of "term pregnancy" [Internet]. Washington, DC: American

(section-ii)(nutrition-risk-manual)(page-136)Page 136#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 136

College of Obstetricians and Gynecologists; c2013 [updated 2013 Oct 22; cited 2016 Dec 6]. Available from: http://www.acog.org/About-ACOG/News-Room/News-Releases/2013/Ob- Gyns-Redefine-Meaning- of-Term-Pregnancy. 3. Mercer M, Moawad A, Meis P, Iams JD, Das A, Caritis SN. The preterm prediction study: effect of gestational age and cause of the perterm on subsequent obstetric outcome. Am J Obstet Gynecol. 1999 Nov;181:1219-21. 4. Hoffman HJ, Bakketeig LS. Risk factors associated with the occurrence of preterm birth. Clin Obstet Gynecol 1984; 27:539-52. 5. ACOG.org [Internet]. Washington, DC: The American College of Obstetricians and Gynecologists; c2016 [updated 2016 Nov; cited 2016 Dec 6]. Available from: http://www.acog.org/Patients/FAQs/Preterm-Premature-Labor-and-Birth. 6. Dag M, Lie TR, Markestad T. Long-term medical and social consequences of preterm birth. N Engl J Med. 2008 Jul 17. Web. 07 Apr. 2014. 7. Iams JD. Prevention of preterm parturition. N Engl J of Med. 2014;370(3):254-261. 8. Wang P, Liou S, Cheng C. Prediction of maternal quality of life on preterm birth and low birthweight: a longitudinal study. BMC Pregnancy and Childbirth [serial online]. June 2, 2013;13:124. Available from: MEDLINE, Ipswich, MA. Accessed April 28, 2014. 9. Ludwig JD, Miller M. Interpreting the WIC debate. J Pol anal Manage. 2005;24(4): 691-701. 10. Cnattinqius S, Villamor E, Johansson S, Edstedt, Bonamy AK, Persson M, et al. Maternal obesity and a. risk of preterm delivery. JAMA 2013 Jun 12:309(22). 11. American College of Obstetricians and Gynecologists. Practice Bulletin. Obesity in pregnancy. Dec 2015. 12. Feldman R, Eidelman A. Direct and indirect effects of breast milk on the neurobehavioral and cognitive development of premature infants. Developmental Psychobiology. 2003 Sept;43(2):109- 19. 13. Vohr B, Poindexter B, Dusick A, McKinley LT, Higgins RD, Langer JC, Poole KW. Persistent beneficial effects of breast milk ingested in the neonatal intensive care unit on outcomes of extremely low birth weight infants at 30 months of age. Pediatrics. 2007 Oct;120(4):e953- 59. 14. Blaymore Bier J, Oliver T, Ferguson AE, Vohr B. Human Milk Improves Cognitive and Motor Development of premature infants during infancy. J Hum Lact. 2002 Nov;18(4)361-67. 15. Boyd CA, Quigley MA, Brocklehurst P. Donor breast milk versus infant formula for preterm infants: systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed. 2007 May;92:F169-75. 16. Healthychildren.org [Internet]. Elk Grove Village: American Academy of Pediatrics; c2011 [updated 2015 Nov 21; cited 2016 Dec 6]. Available from: https://www.healthychildren.org/English/ages- stages/baby/breastfeeding/Pages/Providing- Breastmilk-for-Premature-and-Ill-Newborns.aspx. 17. Okamoto T, Shirai M, Kokubo M, Takahashi S, Kajino M, Takase M, Sakata H, Oki J.

(section-ii)(nutrition-risk-manual)(page-141)Page 141#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 141

spontaneous abortion include recurrent spontaneous abortions, low birth weight (including preterm and small for gestational age infants), premature rupture of membranes, neural tube defects and major congenital malformations. Nutrients implicated in human and animal studies include energy, protein, folate, zinc, and vitamin A.

Postpartum women:

A spontaneous abortion has been implicated as an indicator of a possible neural tube defect in a subsequent pregnancy. Women who have just had a spontaneous abortion or a fetal or neonatal death should be counseled to increase their folic acid intake and delay a subsequent pregnancy until nutrient stores can be replenished.

The extent, to which nutritional interventions (dietary supplementation and counseling) can decrease the risk for repeat poor pregnancy outcomes, depends upon the relative degree to which poor nutrition was implicated in each woman’s previous poor pregnancy outcome. WIC Program clients receive foods and services that are relevant and related to ameliorating adverse pregnancy outcomes. Specifically, WIC food packages include good sources of implicated nutrients. Research confirms that dietary intake of nutrients provided by WIC foods improve indicators of nutrient status and/or fetal survival in humans and/or animals.

Justification for High Risk

Not Applicable

Additional Counseling Guidelines

• Acknowledge participant’s loss, and provide sensitive, compassionate counseling • Explain importance of maintaining health and nutritional status

References

1. Spinnillo, A, et al: Maternal high risk factors and severity of growth deficit in small gestational age infants; Ear Human Dev; 1994; 38:35-43.

2. Thorn, D.H.: Spontaneous abortion and subsequent adverse birth outcomes; Am J Obstet Gyn; 1992; 111-6.

3. Carmi, R. et al: Spontaneous abortion-high risk factor for neural tube defects in subsequent pregnancy; Am J of Med Gen: 1994; 51:93-97.

4. Paz, J. et al: Previous miscarriage and stillbirth as risk factors for other unfavorable outcomes in the next pregnancy; Bri J of Obstet Gyn: October 1999; 808- 812.

(section-ii)(nutrition-risk-manual)(page-144)Page 144#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 144

Pregnancy before growth is complete, is a nutritional risk because of the potential for competition for nutrients for the pregnancy needs and the woman’s growth. The pregnant teenager is confronted with many special stresses that are superimposed on the nutritional needs associated with continued growth and maturation. Younger pregnant women of low socioeconomic status tend to consume less than recommended amounts of protein, iron, and calcium, and are more likely to come into pregnancy already underweight. Pregnant teens who participate in WIC have been shown to have an associated increase in mean birth weight and a decrease in LBW outcomes. Adolescent mothers frequently come into pregnancy underweight, have extra growth related nutritional needs, and because they often have concerns about weight and body image, are in need of realistic, health promoting nutrition advice and support during lactation. Diets of adolescents with low family incomes typically contain less iron, and less vitamin A than are recommended during lactation. The adolescent mother is also confronted with many special stresses superimposed on the normal nutritional needs associated with continued growth. Nutrition status and risk during the postpartum period follow from the nutritional stresses of the past pregnancy, and in turn have an impact on nutrition related risks in subsequent pregnancies.

Poor weight gain and low intakes of a variety of nutrients are more common in pregnant adolescents. Therefore, participation in the WIC Program should be of substantial benefit.

Justification for High Risk

Pregnant teens are at risk for poor birth outcomes and can benefit from individualized follow-up, support, and encouragement to meet dietary and weight gain goals.

Infants of teen pregnancies are at a higher risk for abnormalities of the central nervous system, the gastrointestinal system and musculoskeletal anomalies, including cleft lip and missing or extra fingers and toes. A shorter interval between menarche and the first pregnancy leads to an increased risk, leading researchers to suggest that these congenital defects may be from young mothers being biologically immature. Poor outcomes are more prevalent in teen pregnancies when they engage in high risk behaviors such as smoking, illegal drug use, and poor diet. Another possible explanation is the fact that this population has low vitamin supplementation and is more likely to receive late prenatal care (4).

Postnatal adolescent girls have higher weight retention when compared to older postnatal women, even if lean body mass is similar. The extra weight consists mostly of fat mass which increases the teen’s risk for obesity later in life (5). Pregnant teens are also twice as likely to develop hypertensive problems and to deliver preterm and LBW babies.

(section-ii)(nutrition-risk-manual)(page-145)Page 145#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 145

Although there are existing studies that suggest teenage pregnancies are not high risk, an extremely large study comprised of 3.8 million women found that teenage pregnancy does in fact increase the risk of adverse birth outcomes. These risks include pre-term delivery, SGA, LBW, and infant mortality independent of inadequate prenatal care, low socioeconomic status (SES) and poor weight gain during pregnancy. This study specifically found that poor pregnancy outcomes increased as maternal age decreased, where these outcomes were less likely to be attributed to low SES and poor prenatal care.

Additional Counseling Guidelines

• Support weight gain as normal part of pregnancy process • Explain need for the body to change to support pregnancy • Explain potential risk of low weight gain: ▪ Low birth weight infant ▪ Premature infant • Encourage adequate prenatal care • Encourage prenatal vitamin supplementation • Promote overall healthy eating • Counsel on avoidance of alcohol, drugs, and smoke exposure

References

1. Institute of Medicine: Nutrition During Pregnancy; National Academy Press; 1990; pp. 74, 269, 279.

2. Storey, M.: Nutrition Management of the Pregnant Adolescent; A Practical Reference Guide; USDA and March of Dimes; DHHS; 1990; pp. 21-26.

3. Endres: Older pregnant women and adolescents: Nutrition data after enrollment in WIC; J. of Am. Diet. Assn.; August 1987; 87(8):1011-1019.

4. Kennedy and Kotlechuck: The effect of WIC supplemental feeding on birth weight: A case control analysis; Am. J. of Clin. Nutr.; September 1984; 40:579-585.

References for High Risk

1. Chen X, Wen SW, Fleming N, Yang Q, Walker MC. Teenage pregnancy and congenital anomalies: which system is vulnerable? Human Reproduction. 2007;22(6):1730- 1735.

2. Thame MM, Jackson MD, Manswell IP, Osmond C, Antoine MG. Weight retention within the puerperium in adolescents: a risk factor for obesity? Public Health Nutrition. 2009;13(2):283-288.

(section-ii)(nutrition-risk-manual)(page-148)Page 148#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 148

Justification

Adverse maternal and infant health outcomes have been associated with short Interpregnancy Intervals (IPIs). While there is no standard definition for short IPI, an IPI less than 18 months has been associated with increased risk for adverse outcomes (1, 2). An interval of 18 to 24 months has been associated with the lowest relative risk (2). Evidence associated with the lowest relative risk for an IPI following a miscarriage or abortion is still unclear (see Clarification Section for more information) therefore only health effects associated with a short IPI following a live birth were reviewed for this criterion.

Historically, the World Health Organization (WHO) and other international authorities had recommended at least 2-3 years between pregnancies and the United States Agency for International Development (USAID) had suggested an interval of 3-5 years. Given the inconsistency, various countries and regional programs requested the WHO to further review the research and provide recommendations. As a result, the report from the 2005 WHO Technical Consultation and Scientific Review of Birth Spacing recommended an interval of at least 24 months after a live birth to reduce the risk of adverse maternal, perinatal, and infant outcomes. (3). A more recent review of data suggests that there are increased risks for adverse perinatal and maternal outcomes with an IPI less than 18 months (1, 2 ,4) and increased risks for perinatal (1, 4) and maternal (4, 5, 6) outcomes longer than 59 months while 18 to 24 months was associated with the lowest relative risk (2). Parallel to recent findings, Healthy People 2020 has proposed a 10% improvement in reducing the proportion of pregnancies conceived within 18 months of a previous birth (7).

Outcomes associated with short IPI have included maternal complications such as uterine rupture in women attempting a vaginal birth after a previous cesarean delivery (also referred to as VBAC) (8, 9); and perinatal and neonatal complications such as preterm birth (1, 2, 10), low birth weight (1, 2), small for gestational age (1, 2), birth defects (11), and autism (12, 13). Short interpregnancy interval has been identified as a risk for increasing uterine rupture in women attempting a VBAC delivery (8, 9, 14). Yet when comparing short interpregnancy interval to labor type – induced labor and spontaneous, there was a decrease rate in VBAC success in women who were induced, and no difference with spontaneous labor (15). Given the lack of a specific IPI recommendation for women with a previous cesarean delivery and the inconsistencies in study designs there appears to be no specific guidelines for interval length after a cesarean delivery (16). The short interpregnancy interval definition cut- off of 18 months, however, appears to be inclusive of women who delivered by cesarean with their previous pregnancy. Factors contributing to adverse outcomes and short IPI remain controversial. It was thought that socioeconomic factors contributed to adverse outcomes. However, when controlled for possible cofounders, short IPI remained an independent risk factor (1, 2). Nutrition-related hypothetical causal mechanisms have been proposed to explain the effects short IPIs have on health, yet research remains inconclusive (4). The Maternal Depletion Syndrome hypothesized that mothers who have a short IPI often do not have adequate time to replenish macro- and micro-nutrients which may lead to the mother and fetus competing for nutrients (17). However, a recent systematic review of the literature found no evidence to support this hypothesis (4). Studies to support the

(section-ii)(nutrition-risk-manual)(page-149)Page 149#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 149

folate depletion theory have had differing results (11, 18). When folate intake is inadequate, concentrations begin to decrease in the fifth month of pregnancy and for several weeks after birth (19). Women who did not take folic acid supplementation during pregnancy, compared to women who did, were at greater risk of fetal growth restriction with a short (less than six months) IPI and, this risk was found to decrease as IPI increased (18). Of interest, a retrospective Canadian study of 46,243 women found an association between IPI (less than six months) and folate-independent anomalies, however not for folate-dependent anomalies such as neural tube defects, cleft lip and palate, and cardiovascular defects (11). In addition, the association between short IPI and anemia was found inconclusive (2).

Justification for High Risk

Women with interpregnancy intervals (IPI) of less than 6 months are at greater risk for early spontaneous preterm birth (<34 weeks) (1). It has also been shown that these women are at much greater risk for delivering a low birth weight or small for gestational age infant when compared to women with an IPI greater than 6 months. While the causality has not yet been determined, it has been suggested that the mother has had inadequate time to replete nutrient stores. The lack of nutritional reserves may not be adequate to support proper fetal growth and development. Lack of folate in particular has been shown to increase risk of growth restriction (2).

Additional Counseling Guidelines

• Explain that closely spaced pregnancies leave less time to replenish nutrient stores; therefore good nutrition is very important during this pregnancy • Explain benefits of spacing pregnancies ▪ Less risk for preterm birth, low birth weight, and infant mortality ▪ More time for mother’s body to replenish nutrient stores ▪ More time for mom and baby to strengthen their nurturing relationship ▪ More time to enjoy breastfeeding • Encourage early initiation of prenatal vitamin • Encourage talking to doctor about additional folate supplementation

Implications for WIC Nutrition Service 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 African-American who previously delivered a very low birth weight baby (20). Results from a 2007 U.S. survey found that among women of childbearing age, those aged 18-24 years were the least aware of the need for folic acid prior to pregnancy and least likely to report daily use of supplements containing folic acid. Of equal concern, only 17% of women aged 18-24 years were likely to hear about folic acid from their healthcare provider. (21) Initiations of healthcare referrals for family planning, early prenatal care, and folic acid supplementation have the potential to improve health outcomes for women, infants, and

(section-ii)(nutrition-risk-manual)(page-150)Page 150#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 150

children. Given that half of all pregnancies nationwide are unintended (22), WIC can help to reduce the risk of adverse pregnancy outcomes by: • Encouraging postpartum women and their partner to meet with their healthcare provider to discuss developing a reproductive plan and birth spacing, as appropriate. http://www.cdc.gov/preconception/documents/rlphealthproviders.pdf • Encouraging folic acid supplementation. http://www.cdc.gov/features/folicacidbenefits/ • Encouraging healthful eating patterns consistent with the Dietary Guidelines for Americans. http://www.cnpp.usda.gov/DietaryGuidelines

Clarification Study results for an optimal Interpregnancy Interval (IPI) following a termination or miscarriage have been inconsistent (3, 10, 23, 24). The WHO Technical Consultation on Birth Spacing Report recommended a minimum interval of at least six months between a miscarriage or induced abortion and the next pregnancy. This recommendation was based on a large retrospective cross-sectional study, a review of 258,108 hospital records from several Latin American countries between 1985-2002, that found women whose previous pregnancy resulted in a spontaneous or induced abortion and had an IPI shorter than 6 months had an increased risk for adverse maternal and perinatal outcomes (21). Given several limitations in the study the WHO cautioned against generalizing the results to other regions or even within the Latin American region since service operations and conditions may differ from the study sample (3). However, more recently a review of approximately a million California births found a decreased risk for preterm birth for women with an IPI of less than six months after a terminated pregnancy (10). An overview of the research found that there may be little benefit from delaying pregnancy after an uncomplicated miscarriage, and to that end pregnancy spacing recommendations following a miscarriage should be individually tailored to the person. (25)

References 1. Conde-Agudeloa A, Rosas-Bermúdez A, Kafury-Goeta AC. Birth spacing and risk of adverse perinatal outcomes: a meta-analysis. JAMA. 2006;295(15):1809-1823. 2. Shachar BZ and Deirdre JL. Interpregnancy Interval and Obstetrical Complications. Obstet Gynecol Surv. 2012;67(9):584-596. 3. World Health Organization. Report of a WHO technical consultation on birth spacing. Geneva, Switzerland, 13–15 June 2005. 2006;1-44. 4. Conde-Agudelo A, Rosas-Bermudez A, Castaño F, Norton MH. Effects of birth spacing on maternal, perinatal, infant, and child health: a systematic review of causal mechanisms. Stud Fam Plann. 2012;43(2):93-114. 5. Conde-Agudelo A, Belizán JM. Maternal morbidity and mortality associated with interpregnancy interval: cross sectional study. BMJ. 2000;321(7271):1255-9. 6. Conde-Agudelo A, Rosas-Bermúdez A, Kafury-Goeta AC. Effects of birth spacing on maternal health: a systematic review. Am J Obstet Gynecol. 2007;196(4):297-308.

(section-ii)(nutrition-risk-manual)(page-151)Page 151#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 151

7. U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2020. [cited 2015 Feb 1]. Available from: http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=13. 8. Shipp TD, Zelop CM, Repke JT, Cohen A, Lieberman E. Interdelivery Interval and Risk of Symptomatic Uterine Rupture. Obstet Gynecol. 2001;97:175–7. 9. Stamilio DM, DeFranco E, Pare´ E, Odibo AO, Peipert JF, Allsworth JE, et al. Short Interpregnancy Interval: Risk of Uterine Rupture and Complications of Vaginal Birth After Cesarean Delivery. Obstet Gynecol. 2007;110:1075–82. 10. Shachar BZ, Mayo J, Lyell D, Stevenson D, Shaw G. Interpregnancy interval length and risk of preterm birth, a large US study. American Journal of Obstetrics & Gynecology. 2014; 210(1)Suppl:S373. Abstract. Poster Session V, Number 760. 11. Chen I, Jhangri GS, Chandra S. Relationship between interpregnancy interval and congenital anomalies. Am J Obstet Gynecol. 2014;210(6):564.e1–564.e8. 12. Cheslack-Postava K, Liu K, Bearman PS. Closely Spaced Pregnancies Are Associated With Increased Odds of Autism in California Sibling Births. Pediatrics. 2011;127(2):246-53. 13. Gunnes N, Surén P, Bresnahan M, Hornig M, Lie KK, Lipkin WI, et al. Interpregnancy Interval and Risk of Autistic Disorder. Epidemiology. 2013;24:906–912. 14. Bujold E, and Gauthier R J. Risk of Uterine Rupture Associated With an Interdelivery Interval Between 18 and 24 Months. Obstet Gynecol. 2010;115(5):1003–6. 15. Huang WH, Nakashima DK, Rumney PJ, Keegan KA Jr, Chan K. Interdelivery interval and the success of vaginal birth after cesarean delivery. Obstet Gynecol. 2002;99(1):41-4. 16. The American College of Obstetricians and Gynecologists, Women’s Health Care Physicians. ACOG Practice bulletin no. 115: Vaginal birth after previous cesarean delivery. Obstet Gynecol.2010;116(NO.2 Pt 1):450-63. 17. King JC. The Risk of Maternal Nutritional Depletion and Poor Outcomes Increases in Early or Closely Spaced Pregnancies. J. Nutr. 2003;133:1732S–1736S. 18. van Eijsden M, Smits LJ, van der Wal MF, Bonsel GJ. Association between short interpregnancy intervals and term birth weight: the role of folate depletion. Am. J. Clin. Nutr. 2008;88(1):147-53. 19. Smits LJ, Essed GG. Short interpregnancy intervals and unfavorable pregnancy outcome: role of folate depletion. Lancet. 2001;358:2074-7. 20. Dunlop AL, Dubin C, Raynor BD, Bugg GW Jr, Schmotzer B, Brann AW Jr. Interpregnancy primary care and social support for African-American women at risk for recurrent very-low- birthweight delivery: a pilot evaluation. Matern Child Health J. 2008;12(4):461-8.

21. Centers for Disease Control and Prevention. Use of Supplements Containing Folic Acid Among Women of Childbearing Age --- United States, 2007. MMWR. 2008;57(01);5-8.

22. Finer LB, Zolna MR. Shifts in intended and unintended pregnancies in the United States, 2001-2008. Am J Public Health. 2014;104: S43–S48.

(section-ii)(nutrition-risk-manual)(page-154)Page 154#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 154

• Prematurity • Low birth weight

Prenatal care is a primary component of preventive care for pregnant women. Early and regular prenatal care provides an opportunity for maternal and fetal screening, diagnosis, and treatment of complications. Women who reported not receiving all recommended advice (i.e., breastfeeding, taking vitamins, eating a proper diet, avoiding alcohol, tobacco, and drugs, maintaining proper weight gain) were more likely to deliver a low birth weight infant than women who reported receiving this advice (1). Lack of prenatal care has also been associated with birth of a small for gestational age (SGA) infant (3). Studies have also shown that most women who do not receive early and adequate prenatal care are often in a demographic category that is already at risk for poor pregnancy outcomes (4).

Additional Counseling Guidelines • Explain importance of receiving early and adequate prenatal care

References

1. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists: Guidelines for Perinatal Care; 4th ed., Chapter 4; Washington, D.C.; August 1997.

2. Institute of Medicine: WIC Nutrition Risk Criteria: A Scientific Assessment; 1996; pp. 208-210.

3. Kessner DM, Singer J, Kalk CE, Schlesinger ER: Infant Death: An Analysis by Maternal Risk and Health Care. Contrasts in Health Status; Vol. I, Washington, DC; Institute of Medicine; National Academy of Sciences; 1973.

4. Centers for Disease Control and Prevention: Prenatal Nutrition Surveillance System User’s Manual. Atlanta, GA: CDC; 1994; page 8.

References for High Risk

1. White DE, Fraser-Lee NJ, Tough S, Newburn-Cook, CV. The content of prenatal care and its relationship to preterm birth in Alberta, Canada. Health Care for Women International. 2006;27:777-792.

2. Chen XK, Wen SW, Yang Q, Walker MC. Adequacy of prenatal care and neonatal mortality in infants born to mothers with and without antenatal high-risk conditions. Australian and New Zealand J of Obstet and Gynecol. 2007; 47:122-127.

(section-ii)(nutrition-risk-manual)(page-156)Page 156#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 156

335 Multifetal Gestation Definition/Cut-Off Value

More than one (>1) fetus in a current pregnancy (Pregnant Women) or the most recent pregnancy (Breastfeeding and Non-Breastfeeding Women).

Participant Category and Priority Level

Category Priority High Risk Pregnant I Y Breastfeeding I Y Non-Breastfeeding VI N

Parameters for Auto Assignment

Auto assigned if “Multifetal Gestation” is marked on the pregnancy panel.

High Risk Flag

The high risk designation will automatically activate when this risk factor is assigned for pregnant and breastfeeding women. Justification

Multifetal 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. Twin births account for 16% of all low birth weight infants. The risk of pregnancy complications is greater in women carrying twins and increases markedly as the number of fetuses increases (1,2). 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 (3). There was insufficient information for the IOM committee 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 delivery in twin pregnancy (2). 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 (2). Education by the WIC nutritionist should address a steady rate of weight gain that is higher than for singleton pregnancies.

(section-ii)(nutrition-risk-manual)(page-157)Page 157#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 157

Pregnant or breastfeeding women with twins have greater requirements for all nutrients than women with only one infant. Postpartum, non-breastfeeding women delivering twins are at greater nutritional risk than similar women delivering only one infant. All three groups of women would benefit greatly from the nutritional supplementation provided by the WIC Program.

Justification for High Risk

Multiple fetal gestations are associated with low birth weight, fetal growth restriction, placental and cord abnormalities, preeclampsia, anemia, shorter gestation, and increased risk of infant mortality. Multifetal gestations are at greater risk for having a shortened pregnancy which increases risk of preterm delivery and risk for infants developing neurological abnormalities. Complications are not only restricted to gestation, as these infants typically have poor neonatal outcomes and a prolonged hospital stay.

These mothers also have greater risk for intrauterine growth restriction and developing gestational diabetes contributed to by the mother’s nutritional status and higher levels of hormones. Cesarean deliveries, prolonged hospital stay and early hospital admissions are more common for mothers of multiple births. Other adverse outcomes include miscarriage, premature rupture of membranes and polyhydramnios. Triplets and quadruplet pregnancies specifically have a greater risk for mothers to experience pre-eclampsia, anemia, and postpartum hemorrhag. Mortality is also increased in multifetal gestations not only for infants but also for mothers. Maternal mortality is three times greater in multiple pregnancies than a singleton pregnancy. A woman meeting this risk criterion can benefit from assessment of her weight gain and individual nutrition counseling through WIC.

Additional Counseling Guidelines

Pregnant participants: • For twin gestations, the recommended range of maternal weight gain is 37-54 pounds with a gain of 1.5 pounds per week during the second and third trimesters ▪ Underweight women should gain at the higher end of the range and overweight women should gain at the lower end of the range ▪ Four to six pounds should be gained in the first trimester • 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 pregnancy. • Generally accepted dietary recommendations include: ▪ Increased needs for calories, protein, iron, calcium, folate, vitamin B6, and zinc (table of food guidelines to follow) ▪ A need for increased weight gain (table of guidelines follow) during pregnancy, especially for those women who are of low or normal pre-pregnancy weight • Encourage early weight gain due to reduced stomach capacity as pregnancy progresses • Encourage small, frequent energy-dense meals every 2-3 hours at first, then every hour or two as the pregnancy proceeds

(section-ii)(nutrition-risk-manual)(page-159)Page 159#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 159

References

1. Brown JE and Carlson M. Nutrition and multifetal pregnancy. J Am Diet Assoc. 2000;100:343- 348. 2. Institute of Medicine. WIC nutrition risk criteria: a scientific assessment. National Academy Press, Washington, D.C.; 1996. 3. Institute of Medicine. Weight gain during pregnancy: reexamining the guidelines (Prepublication Copy). National Academy Press, Washington, D.C.; 2009. www.nap.edu. Accessed June 2009. Additional Related References

1. Brown JE, Schloesser PT. Pregnancy weight status, prenatal weight gain, and the outcome of term twin gestation. Am.J.Obstet.Gynecol. 1990;162:182-6. 2. Suitor CW, editor. Maternal weight gain: a report of an expert work group. Arlington, Virginia: National Center for Education in Maternal and Child Health; 1997. Sponsored by Maternal and Child Health Bureau, Health Resources and Services Administration, Public Health Service, U.S. Department of Health and Human Services.

3. Williams RL, Creasy RK, Cunningham GC, Hawes WE, Norris FD, Tashiro M. Fetal growth and perinatal viability in California. Obstet.Gynecol. 1982;59:624-32. 4. Worthington-Roberts, BS. Weight gain patterns in twin pregnancies with desirable outcomes. Clin.Nutr. 1988;7:191-6.

References for High Risk

1. Dudenhausen JW, Maier RF. Perinatal Problems in Multiple Births. Ceutsches Arzteblatt International.2010; 107(38): 663-668.

2. Rauh-hain JA, Rana S, Tamez H, Wang A, Cohen B, Cohen A, Brown F, Ecker JL, Darumanchi SA, Thadhani R. Risk for developing gestational diabetes in women with twin pregnancies. The Journal of Maternal-Fetal and Neonatal Medicine. 2009; 22(4):293-299.

3. Ounjai K, Suwanrath C, Suntharasaj T, Getpook C, Leetanaporn R. Outcomes of multifetal pregnancies. J. Obstet. Gynaecol. Res. 2007;33(1):49-55.

4. Dola C, Tran T, Linhuber AM, Cierny J, Deicola N, Chong E, Bhuiyan A. Preterm birth after mature fetal lung indices: is there any neonatal morbidity? The Journal of Maternal-Fetal and Neonatal Medicine. 2011; 24(1): 73-78.

(section-ii)(nutrition-risk-manual)(page-160)Page 160#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 160

336 Fetal Growth Restriction Definition/Cut-Off Value

Fetal Growth Restriction (FGR) (replaces the term Intrauterine Growth Retardation (IUGR)), may be diagnosed by a physician with serial measurements of fundal height, abdominal girth and can be confirmed with ultrasonography. FGR is usually defined as a fetal weight < 10th percentile for gestational age. Presence of condition 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

Participant Category and Priority Level

Category Priority High Risk Pregnant I Y

Parameters for Manual Assignment

Must be manually selected in the Nutrition Interview or Risk Panel

High Risk Flag

High risk designation will automatically activate when this risk factor is assigned

Justification

Fetal Growth Restriction (FGR) usually leads to low birth weight (LBW), which is the strongest possible indicator of perinatal mortality risk. Severely growth restricted infants are at increased risk of fetal and neonatal death, hypoglycemia, polycythemia, cerebral palsy, anemia, bone disease, birth asphyxia, and long-term neurocognitive complications. FGR may also lead to increased risk of ischemic heart disease, hypertension, obstructive lung disease, diabetes mellitus, and death from cardiovascular disease in adulthood. FGR may be caused by conditions affecting the fetus such as infections and chromosomal and congenital anomalies. Restricted growth is also associated with maternal height, pre-pregnancy weight, birth interval, and maternal smoking. WIC’s emphasis on preventive strategies to combat smoking, improve nutrition, and increase birth interval, may provide the guidance needed to improve fetal growth.

Justification for High Risk

Fetal Growth Restriction (FGR) usually leads to low birth weight which is the strongest possible indicator for prenatal mortality risk. Severely growth restricted infants are at increased risk of: fetal

(section-ii)(nutrition-risk-manual)(page-161)Page 161#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 161

and neonatal death, hypoglycemia, polycythemia, SGA, cerebral palsy, anemia, bone disease, birth asphyxia, and long-term neurocognitive delays.

Some maternal risk factors which contribute to FGR include lupus, cardiac disease, high blood pressure, diabetes with vascular disease, smoking, use of illegal drugs, malnutrition, low socioeconomic status, history of FGR, and extreme ages. Pregnant mothers who have been diagnosed with FGR have a greater risk of developing pre-eclampsia later in the pregnancy. Low birth weight caused by FGR is associated with renal and cardiovascular disease in the infant’s adult life. Additionally, a recent study found that FGR increases rates of stillbirths and perinatal mortality. Although few causes of FGR can be prevented, there are some interventions that have proven effective in prevention. This would include addressing and changing modifiable risk factors such as smoking cessation, eating a balanced diet with protein supplementation (especially pregnant teens), avoiding alcohol and uncooked meat, and reducing contact with animals. Mothers who quit smoking before 16 weeks gestation are no longer at risk for FGR. Early detection of FGR is related to a reduction in infant morbidity and mortality rates. WIC services can benefit these mothers and assist them in addressing the modifiable risk factors.

Additional Counseling Guidelines

• Assess nutritional status with emphasis on well-balanced intake • Assess and promote healthy weight gain ▪ food supplementation during pregnancy to improve weight gain reduces the risk of FGR

References

1. Institute of Medicine: Nutrition During Pregnancy: Part I, Weight Gain; and Part II, Nutrient Supplements; National Academy Press; 1990.

2. Institute of Medicine: WIC Nutrition Risk Criteria: A Scientific Assessment; 1996.

3. Williams, SR: Nutrition and Diet Therapy; 1989; 6th edition.

4. Worthington-Roberts, BS and Williams, SR: Nutrition During Pregnancy and Lactation; 1989; 4th edition.

5. Stein, ZA and Susser, M.: Intrauterine Growth Retardation: Epidemiological Issues and Public Health Significance. Seminars in Perinatology; 1984; pp. 8:5-14.

(section-ii)(nutrition-risk-manual)(page-162)Page 162#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 162

6. Altman D.G. and Hytten F.E.: Intrauterine growth retardation: Let’s be clear about it; Br. J. Obstet. Gynaecol. 96:1127-1132.

7. Barros, F.C., S.R. Huttly, C. G. Victora, B. R., Kirkwood, and J.P. Vaughan: Comparison of the causes and consequences of prematurity and intrauterine growth retardation: A longitudinal study in southern Brazil. Pediatrics; 1992; 90:238-244.

8. Kramer, M.S., M. Olivier, F.H. McLean, G.E. Dougherty, D.M. Willis, and R.H. Usher: Determinants of fetal growth and body proportionality. Pediatrics; 1990; 86:18-26.

9. Kramer, M.S., M. Olivier, F.H. McLean, D.M. Willis, and R.H. Usher: Impact of Intrauterine growth retardation and body proportionality on fetal and neonatal outcome; Pediatrics; 86:707- 713.

10. Institute of Medicine: Nutrition During Pregnancy; National Academy Press; 1990; pp. 212-20, 10-12, 18, 20.

References for High Risk

1. Baschat A. Early severe fetal growth restriction: Evaluation and treatment. MFM Consult, “Comptemporary OB/GYN. 2011; February.

2. Weiler J, Tong S, Palmer KR. Is fetal growth restriction associated with a more severe maternal phenotype in the setting of early onset pre-eclampsia? A retrospective study. PLoS ONE. 2011;6(10);e26937.

3. Grif CM. Intrauterine fetal growth restriction. A challenge in diagnosis and management. University of Medicine and Pharmacy, Department of Obstetrics and Gynecology 2.

4. Zanardo V, Fanelli T, Weiner G, Fanos V, Zaninotto M, Visentin S, Cavallin F, Trevisanuto D, Cosmi E. Intrauterine growth restriction is associated with persistent aortic wall thickening and glomerular proteinuria during infancy. Kidney International. 2011; 80: 119-123.

5. Imdad A, Yakoob MY, Siddiqui S, Bhutta ZA. Screening and triage of intrauterine growth restriction (IUGR) in general population and high risk pregnancies: a systematic review with a focus on reduction of IUGR related stillbirths. BMC Public Health. 2011; 11(3):S1.

(section-ii)(nutrition-risk-manual)(page-165)Page 165#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 165

338 Pregnant Woman Currently Breastfeeding Definition/Cut-Off Value

Pregnant woman who is currently breastfeeding.

Participant Category and Priority Level

Category Priority High Risk Pregnant I N

Parameters for Manual Assignment

Must be manually selected in Nutrition Interview or Risk Panel

Justification

Generally, it is considered safe for most women to continue breastfeeding while pregnant and can be sustained for as long as mutually desired by the mother and child (1). The assignment of this risk is not intended to discourage women from continuing breastfeeding during pregnancy, but rather to highlight the need to review the mother’s medical history and diet along with her breastfeeding goals. Incidence rates of breastfeeding while pregnant among U.S. mothers have not been reported recently. The National Health and Nutrition Examination Survey (NHANES) III indicated that between 1988 and 1994 only 5% of North American breastfeeding women were pregnant (2). Research on breastfeeding during pregnancy, especially among U.S. populations, is very limited; however, some studies have examined the relationship that this practice has on birth outcomes, such as preterm delivery, miscarriage, and birth weight. During breastfeeding, stimulation of the nipples causes the secretion of the hormone oxytocin, which can result in contractions of the uterus (3). It has been suggested that these contractions may induce labor and therefore increase the risk of delivering prematurely in some women; however, this is not a concern for the typical low risk pregnancy (1, 4, 5). In a small retrospective study of 57 U.S. mothers with an unknown previous pregnancy outcome, most did not notice any uterine contractions specific to breastfeeding. The women that did notice uterine contractions specific to breastfeeding gave birth to healthy babies (6). Studies of pregnancy-breastfeeding overlap among women with a history of preterm delivery or miscarriage are presently lacking in the scientific literature. As a result, these women should be encouraged to talk with their health care provider about their breastfeeding goals and report any uterine contractions (1). For more information on premature delivery, see risk #142 Preterm or Early Term Delivery or risk #311 History of Preterm or Early Term Delivery.

(section-ii)(nutrition-risk-manual)(page-166)Page 166#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 166

Several studies of pregnancy-breastfeeding overlap have been conducted with women without a history of preterm labor or miscarriage, and no statistically significant increased risk of premature delivery were reported (7, 8). One retrospective study compared the outcomes of pregnancies in mothers with no history of premature delivery or miscarriage that had one full-term infant and continued breastfeeding during pregnancy to a control group of comparable age and pregnancy history that stopped breastfeeding at least three months before becoming pregnant. Fewer pregnancies (7.3%) in the breastfeeding group resulted in spontaneous abortion than the control group (8.4%) (7). In a systematic review of all of the relevant literature published between 1990 and 2015, none of the studies reviewed reported significant differences in the numbers of premature births between pregnant mothers who breastfed and non-breastfeeding pregnant mothers, even when breastfeeding duration, the number of feedings, or birth interval were controlled for (9). These results provide evidence for continued support of breastfeeding during pregnancy for mothers with no previous history of preterm labor or miscarriage. Several studies have also examined the effect of breastfeeding during pregnancy on the birth weight of the infant. These studies reported similar mean birth weights between infants born to mothers who breastfed during pregnancy and those who did not. (5, 8, 10, 11) When a woman is pregnant or breastfeeding, she has a higher need for certain vitamins and minerals and may have greater caloric needs as well. The same is true for a woman who is pregnant while breastfeeding. It is important to note that caloric needs must be individualized based on current weight, physical activity, and recommended maternal weight gain for weight status (i.e., underweight, normal weight, overweight, or obese). For more information about maternal weight gain, see risk #131 Low Maternal Weight Gain or risk #133 High Maternal Weight Gain.

Justification for High Risk

Not Applicable

Implications for WIC Nutrition Services

WIC staff can support pregnant women who are breastfeeding by: • Considering personal feelings about breastfeeding while pregnant as well as personal breastfeeding goals with the currently breastfed child. • Referring mothers who have a history of premature labor or miscarriage and those who are concerned about uterine contractions to their health care providers. • Providing nutrition education that supports an overall healthy diet, including:

o Limiting calories from added sugars and saturated fats.

o Choosing a variety of fruits and vegetables, whole grains, and fat-free or low-fat dairy products.

(section-ii)(nutrition-risk-manual)(page-167)Page 167#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 167

o Eating protein-rich foods such as poultry, fish, beans, eggs, nuts, and lean meats. Pregnant women, including those who are breastfeeding, should avoid eating shark, swordfish, king mackerel, or tilefish due to concern for high levels of mercury. White (albacore) tuna should be limited to no more than 6 ounces per week (12). o Drinking plenty of fluids. During breastfeeding, fluid needs may increase, and mothers may notice that they are thirstier than usual. Women should drink enough water and other fluids to quench their thirst. A common suggestion is to drink a glass of water with every breastfeeding session (13). • Monitoring weight status throughout the pregnancy to ensure appropriate weight gain.

• Providing tips for reducing nipple soreness or breast tenderness if women report these concerns. Hormonal changes during pregnancy lead to nipple soreness and breast tenderness in some women (3). • Informing women that the older child that is breastfeeding may notice some changes in the human milk and wean on his/her own. Although human milk continues to be nutritionally sound throughout pregnancy, the composition of it may change, which might change the way the milk tastes. For some women, their milk production may also decrease as their pregnancy progresses. These factors can lead the breastfeeding child to wean on his/her own before the baby is born. (1) • Issuing Food Package VII to the mother until her older infant turns one, as long as she is partially (mostly) breastfeeding. • Providing anticipatory guidance on tandem nursing, which is the practice of breastfeeding two or more children of different ages at the same time. This may ease the older child’s adjustment to the new baby, address the mother’s own desire to maintain closeness with the older child, and even make child care easier in some cases as both children are fed and comforted on the breast. This may also allow the mother and children to fulfill the American Academy of Pediatrics’ recommendation to continue breastfeeding for as long as mutually desired by the mother and child (14). Additional Counseling Guidelines

• Ensure that WIC’s advice is consistent with MD’s recommendations • Encourage adequate rest. • Monitor stress level • Other important considerations include: ▪ The age of the nursing child ▪ The natural decrease in milk supply that occurs during pregnancy (usually in the last 4 months) could compromise the infant’s nutritional needs, if the baby is less than a year old ▪ Suggest that mother keep track of the baby’s weight gain and offer supplemental feedings if they are needed ▪ The child’s need to nurse (physically and emotionally) ▪ Some babies wean on their own during pregnancy

(section-ii)(nutrition-risk-manual)(page-168)Page 168#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 168

▪ Other babies who weaned during pregnancy may want to breastfeed again once the new baby is born ▪ Whether the mother is experiencing any breastfeeding related discomforts (such as sore nipples caused by hormonal changes) and the degree of her discomfort ▪ The mother’s past nursing experience(s) ▪ Health concerns related to the pregnancy (which may be medical reasons to consider weaning) ➢ Uterine pain or bleeding while breastfeeding (uterine contractions stimulated by breastfeeding usually pose no danger to the unborn baby and do not increase the risk of premature delivery, but refer participant to physician immediately) ➢ History of premature birth ➢ Continued loss of weight by mother during pregnancy • Hormones of pregnancy will not be harmful to breastfeeding infant or toddler • During last few months of pregnancy milk changes to colostrum in preparation for birth • Nursing child cannot “use up” the colostrum -- no matter how much he nurses; the colostrum will still be available at birth for the newborn • If mother chooses to nurse both after baby’s birth (“tandem nursing”), follow-up with Dietitian/Lactation Educator is appropriate • Remember that newborn is priority of the two children Listen to the mother’s feelings, as it is an individual decision whether or not to continue breastfeeding through a pregnancy (and after) References

1. American Academy of Pediatrics [Internet]. Itasca (IL): American Academy of Pediatrics, c2011. Nursing during pregnancy. 2009 Nov 2 [cited 2018 Dec 11]. Available from: https://www.healthychildren.org/English/ages-stages/baby/breastfeeding/Pages/Nursing- DuringPregnancy.aspx. 2. Briefel RR, Bialostosky K, Kennedy-Stephenson J, et al. Zinc and health: current status and future directions zinc Intake of the U. S. population: findings from the third national health and nutrition examination survey, 1988–1994. J Nutr 2000 May [cited 2019 Mar 5];130(5 S Suppl):1367S–73S. 3. Mohrbacher, N and Stock, J. The breastfeeding answer book. 3 rd edition. Schuamburg, IL: La Leche League International; c2003. Chapter 6, Pregnancy and tandem nursing; p. 407. 4. Kavanagh J, Kelly AJ, Thomas J. Breast stimulation for cervical ripening and induction of labour. 2005 July 20 [cited 2019 Mar 5]. In: The Cochrane Database Systematic Reviews [Internet]. London (UK): John Wiley & Sons, Ltd. c2010 - . Available from: DOI: 10.1002/14651858.CD003392.pub2. 5. Ayrim A, Gunduz S, Akcal B, et al. Breastfeeding throughout pregnancy in Turkish women. Breastfeed Med. 2014 Apr [cited 2019 Mar 5];9(3): 157-60. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24160359.

(section-ii)(nutrition-risk-manual)(page-169)Page 169#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 169

6. Moscone SR and Moore MJ. Breastfeeding during pregnancy. J Hum Lact. 1993 Jun [cited 2019 Mar 5];9(2):83-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/8251083/. 7. Ishii, H. Does breastfeeding induce spontaneous abortion? J Obstet Gynaecol Res. 2009 Oct 20 [cited 2019 Mar 5];35(5):864-8. Available from: https://doi.org/10.1111/j.1447-0756.2009.01072.x. 8. Albadran MM. Effect of breastfeeding during pregnancy on the occurrence of miscarriage and preterm labour. Iraqui JMS. 2013 Sept [cited 2019 Mar 5];11(3):285–9. Available from: https://www.iasj.net/iasj?func=fulltext&aId=80356. 9. Lopez-Fernandez G, Barrios M, Goberna-Tricas J, Gomez-Benito J. Breastfeeding during pregnancy: A systematic review. Women and Birth. 2017 Dec [cited 2019 Mar 5];30(6):e292-e300. Available from: https://doi.org/10.1016/j.wombi.2017.05.008. 10. Madarshahian F, Hassanabadi M. A comparative study of breastfeeding during pregnancy: impact on maternal and newborn outcomes. J Nurs Res. 2012;20:74–80. 11. Merchant K, Martorell R, Haas J. Consequences for maternal nutrition of reproductive stress across consecutive pregnancies. J Nutr. 1990 Oct 1 [cited 2019 Mar 5];52(61):616-20. Available from: https://doi.org/10.1093/ajcn/52.4.616. 12. United States Department of Agriculture [Internet]. Washington (DC): United States Department of Agriculture. Making Healthy Choices in Each Food Group. 2018 Apr 27 [cited 2018 Dec 11]. Available from: https://www.choosemyplate.gov/moms-making-healthy-food-choices. 13. United States Department of Agriculture. Washington (DC): United States Department of Agriculture. Nutritional Needs while Breastfeeding. [cited 2018 Dec 11]. Available from: https://www.choosemyplate.gov/moms-breastfeeding-nutritional-needs. 14. American Academy of Pediatrics. Itasca (IL): American Academy of Pediatrics, c2019. AAP Reaffirms Breastfeeding Guidelines. [cited 2018 Dec 11]. Available from: https://www.aap.org/en- us/about-theaap/aap-press-room/pages/aap-reaffirms-breastfeeding-guidelines.aspx.

(section-ii)(nutrition-risk-manual)(page-173)Page 173#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 173

by age, gender, and/or race and ethnicity (1). For certain segments of the population, nutrient deficiencies may be as high as one third of the population (1). Intake patterns of individuals can lead to nutrient inadequacy or nutrient deficiencies among the general population. Intakes of nutrients that are routinely below the Dietary Reference Intakes (DRI) can lead to a decrease in how much of the nutrient is stored in the body and how much is available for biological functions. DRIs are based on age and sex and include Recommended Dietary Allowance (RDA), Adequate Intake (AI), Estimated Average Requirement (EAR) and Tolerable Upper Intake Level (UL). DRIs are established by the National Academies of Science, Engineering and Medicine and include the following definitions: • RDA - Indicates the average daily intake of particular nutrients to meet the requirements of 97- 98% of healthy people. • AI - Established to assume adequate intake when there is insufficient evidence to develop an RDA. • EAR - The average daily intake of a nutrient that is thought to meet the needs of 50% of healthy individuals. EARs are used to assess the adequacy of nutrient intakes among populations rather than the individual. • UL - The highest nutrient intake that is considered to be safe and does not lead to adverse health effects in the general population (2). Macronutrient deficiencies include deficiencies in protein, fat, and/or calories, and can lead to stunting, pronounced wasting (marasmus) or a disproportionately large abdomen (a sign of kwashiorkor). 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 (3, 4). 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 (3). Micronutrient deficiencies would include deficiencies in vitamins and minerals in the body. According to National Health and Nutrition Examination Survey (NHANES) data, the most common nutrient deficiencies from 2003-2006 in the general United States population were vitamin B6, iron, vitamin D, vitamin C, and vitamin B12 (1). Because NHANES does not assess the status of all vitamins and minerals, there may be other micronutrient deficiencies that are present in the population without an estimated prevalence. According to NHANES data from 2005-2012, 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 (5). Micronutrient deficiencies during pregnancy are not only a concern for the mother, but are of great concern to the developing fetus that is at risk of certain birth defects related to inadequate levels of certain nutrients including B vitamins, vitamin K, magnesium, copper, and zinc (6). Iodine deficiency during pregnancy can lead to irreversible adverse effects on fetal growth and development. Iodine deficiency is the leading cause of intellectual disability worldwide. According to NHANES data from 2005-2008, 56.9% of the pregnant women surveyed had urinary iodine

(section-ii)(nutrition-risk-manual)(page-174)Page 174#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 174

concentrations below the established threshold of 150mcg/L. This finding suggests that greater than half of pregnant women have insufficient intakes of iodine (7). Because intake patterns of pregnant women can exclude or limit specific food groups, it is not uncommon to have multiple nutrient deficiencies during pregnancy (8). For example, iron deficiency usually does not occur alone, but it often occurs in conjunction with other vitamin and mineral deficiencies (9). Intakes of nutrients were also found to be low among postpartum and breastfeeding women participating in WIC. Among women who were breastfeeding and participating in WIC, 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 (5). Greater than 50% of postpartum women who were not breastfeeding were found to have 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 (5). According to NHANES data from 2011-2012, formula fed infants had an average usual intake of choline that was below the AI for that nutrient; however, intakes of other vitamins and minerals were estimated to be adequate (5). Intakes of vitamin D, iron, and zinc among breastfed infants can be of concern if appropriate and timely complementary foods and/or vitamin and mineral supplements are not provided to the infant. According to NHANES data from 2009-2012, at least 10% of infants receiving human milk between 6 and 12 months of age had inadequate intakes of iron and zinc (5). Concentrations of vitamin D in human milk have been found to be low. Therefore, it has been recommended by the American Academy of Pediatrics (AAP) to provide all infants who are taking less than 32 ounces of formula a day a vitamin D supplement of 400 IU daily (10, 11). Additionally, infants who are born to mothers who are vitamin D deficient are more likely to be deficient themselves. (For more information see risk 411 Inappropriate Nutrition Practices for Infants.) 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 (12). In addition to health risks associated with low nutrient status, some micronutrients pose a health risk at levels higher than the established UL. For this reason, 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). Populations who may be at greater risk of nutrient deficiencies or diseases include: • Individuals who have intakes below the established RDA, AI, or EAR for the nutrient. • Individuals who experience food insecurity. • Individuals who are experiencing homelessness. • Women who have a short interpregnancy interval. • Individuals who have recently left their previous country of residence.

(section-ii)(nutrition-risk-manual)(page-175)Page 175#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 175

• People 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). For example, individuals who have had a portion of their stomach removed or their distal ileum removed during a weight- loss or other surgery are at a greater risk of developing a vitamin B12 deficiency (13). • Individuals with other medical conditions that influence nutrient status (i.e. cystic fibrosis, renal disease, genetic disorders). • Individuals on medications that are known to interact with the absorption or excretion of certain vitamins and minerals. • People with substance use disorders (including alcohol) may be more likely to have deficiencies due to poor intake and/or the effects of the substance. People who have high intakes of alcohol are at greater risk of developing a magnesium deficiency (14, 15). • People who smoke are more likely to have a vitamin C deficiency due to the increase in oxidative stress. Nutrient deficiencies or diseases can be subclinical or clinical. Subclinical deficiencies involve changes to the concentrations of the micronutrient in the blood or tissues. Clinical deficiencies involve noticeable changes to the appearance of skin, nails, hair, oral cavity, and bone formation as well as major disturbances in the function of cells and tissues in the body. At either stage of a nutrient deficiency, blood work is often taken to confirm a deficiency. Blood work to detect nutrient deficiencies can be misleading, as some nutrients, such as magnesium, may have an overall deficiency in the body but be at a normal level in the blood (15). Other methods can be used to assess for nutrient deficiency disease, such as a physical nutrition assessment. Because it can be difficult to be tested for, and diagnosed with, a nutrient deficiency or a nutrient deficiency disease can go undetected and untreated. The table below provides information regarding specific nutrients that are more commonly of concern among the WIC population; however, additional nutrient deficiency diseases may occur in the population. Detailed fact sheets about each nutrient can be found at the National Institutes of Health Office of Dietary Supplements website: https://ods.od.nih.gov/factsheets/list- all/.

Nutrient Function Signs and Symptoms of Deficiency Vitamin A Involved in immune function, vision, cell growth and cell communication. Night blindness and xerophthalmia (16). Vitamin B6 Involved in greater than 100 enzyme reactions in the body and involved in protein metabolism. Microcytic anemia, scaling of the lips and cracks in the corners of the mouth, swollen tongue, depression, and confusion (17). Vitamin B12 Involved in red blood cell formation, neurological function, and DNA synthesis. Megaloblastic anemia, fatigue, weakness, constipation, loss of appetite, and weight loss (13).

(section-ii)(nutrition-risk-manual)(page-176)Page 176#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 176

Vitamin C Involved in the formation of collagen, certain neurotransmitters, and protein synthesis. Development of scurvy which would include: fatigue, inflammation of the gums, and weakened connective tissue (14). Vitamin D Promotes calcium absorption and proper bone formation, involved in cell growth, immune function, and reduces inflammation. Development of rickets in children or osteomalacia in adults, and fatigue (18). Calcium Involved in muscle function, nerve transmission, and proper bone formation. Development of osteoporosis (19). Folate Involved in the synthesis of RNA and DNA and is required for cell division and the prevention of Neural Tube Defects. Megaloblastic anemia (20). Iodine A component of thyroid hormones that regulate protein synthesis, metabolism, and enzyme activity. Stunted growth and neurodevelopmental deficits (7). Iron A component of hemoglobin and therefore important in the transfer of oxygen from the lungs to organs, and involved in the synthesis of hormones as well as normal growth and development. Microcytic, hypochromic anemia; impaired cognitive function, poor body temperature regulation, depressed immune function, and spoon like shape of nails (9). Magnesium Involved in more than 300 enzyme reactions, protein synthesis, muscle function, nerve function, blood sugar control, and blood pressure control. Loss of appetite, fatigue, weakness, nausea, vomiting, numbness, tingling, muscle cramps, seizures, personality changes, and abnormal heart rhythms (15). Zinc Involved in cell metabolism, enzyme activity, immune function, protein synthesis, wound healing, DNA synthesis, and cell division. Stunted growth, depressed immune function, hair loss, eye and skin lesions, delayed wound healing, and taste alterations (21).

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. 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.

(section-ii)(nutrition-risk-manual)(page-177)Page 177#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 177

• 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.

Justification for high risk

Persistent malnutrition may lead to elevated morbidity and mortality rates. Important functional disturbances may occur as a result of a single or multiple nutrient deficiencies including: impaired cognitive function, impaired function of the immune system, and impaired function of skeletal muscle. Participants who meet these criteria are extremely high risk and need counseling which addresses their individual needs.

Nutrient deficiencies are not caused by one single factor, but rather by a combination of causes including food fads, medications, poverty, medical illnesses, gastrointestinal disorders such as celiac or Crohn’s disease, and psychiatric illnesses including autism, alcoholism or eating disorders. WIC provides nutritional guidance that can prevent or treat malnutrition in both women and children.

Additional Counseling Guidelines

• Review WIC foods high in nutrient(s) individual to participant’s nutrient deficiency ▪ Discuss ways in which to incorporate WIC foods into diet • Explain potential risks particular to participant’s nutritional disease ▪ Provide basic nutrition counseling appropriate for specific nutritional disease

References

1. Centers for Disease Control and Prevention [Internet]. Georgia: [updated 2016 Mar; cited 2016 Dec 5]. CDC’s second nutrition report: a comprehensive biochemical assessment of the nutrition status of the U.S. population; [about 4 screens]. Available

(section-ii)(nutrition-risk-manual)(page-178)Page 178#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 178

from: https://www.cdc.gov/nutritionreport/pdf/4Page_%202nd%20Nutrition%20Report_508_03 2912.p df. 2. Institute of Medicine. Dietary reference intakes: the essential guide to nutrient requirements. Washington, DC: The National Academies Press; 2006, doi:https://doi.org/10.17226/11537. 3. Linus Pauling Institute [Internet]. Oregon: [updated 2014 May; cited 2016 Dec 5]. Essential fatty acids; [about 12 pages]. Available from: http://lpi.oregonstate.edu/mic/other-nutrients/essential- fatty-acids. 4. National Institutes of Health [Internet]. Maryland: [updated 2016 Nov 2; cited 2016 Dec 2]. Omega- 3 fatty acids fact sheet for health professionals; [about 13 pages]. Available from: https://ods.od.nih.gov/factsheets/Omega3FattyAcids- HealthProfessional/. 5. National Academies of Sciences, Engineering, and Medicine. Review of WIC food packages: improving balance and choice: final report. Washington, DC: The National Academies Press; 2017, doi:https://doi.org/10.17226/23655. 6. Association of State Public Health Nutritionists. The role of nutrition in infant mortality: a public health perspective. ASPHN Brief 2013. 7. National Institutes of Health [Internet]. Maryland: [updated 2011 Jun 24; cited 2016 Dec 2]. Iodine fact sheet for health professionals; [about 10 pages]. Available from: https://ods.od.nih.gov/factsheets/Iodine-HealthProfessional/. 8. Linus Pauling Institute [Internet]. Oregon: [updated 2016 Aug; cited 2016 Dec 5]. Pregnancy and lactation; [about 12 pages]. Available from: http://lpi.oregonstate.edu/mic/life- stages/pregnancy- lactation. 9. National Institutes of Health [Internet]. Maryland: [updated 2016 Feb 11; cited 2016 Dec 2]. Iron fact sheet for health professionals; [about 14 pages]. Available from: https://ods.od.nih.gov/factsheets/Iron-HealthProfessional/. 10. American Academy of Pediatrics [Internet]. Illinois: [updated 2010 Mar 22; cited 2016 Dec 2]. Vitamin D supplementation for infants; [about 2 pages]. Available from: https://www.aap.org/en- us/about-the-aap/aap-press-room/pages/Vitamin-D- Supplementation-for-Infants.aspx. 11. Centers for Disease Control and Prevention [Internet]. Georgia: [updates 2015 Jun 17; cited 2016 Dec 5]. Vitamin D supplementation; [about 2 pages]. Available from: https://www.cdc.gov/breastfeeding/recommendations/vitamin_d.htm. 12. Hamner, H, Perrine C, Scanlon. Usual intake of key minerals among children in the second year of life, NHANES 2003-2012. Nutrients. 2016; 8:468. 13. National Institutes of Health [Internet]. Maryland: [updated 2016 Feb 11; cited 2016 Dec 2]. Vitamin B12 fact sheet for health professionals; [about 12 pages]. Available from: https://ods.od.nih.gov/factsheets/VitaminB12-HealthProfessional/.

(section-ii)(nutrition-risk-manual)(page-179)Page 179#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 179

14. National Institutes of Health [Internet]. Maryland: [updated 2016 Feb 11; cited 2016 Dec 2]. Vitamin C fact sheet for health professionals; [about 14 pages]. Available from: https://ods.od.nih.gov/factsheets/VitaminC-HealthProfessional/. 15. National Institutes of Health [Internet]. Maryland: [updated 2016 Feb 11; cited 2016 Dec 2]. Magnesium fact sheet for health professionals; [about 13 pages]. Available from: https://ods.od.nih.gov/factsheets/Magnesium-HealthProfessional/. 16. National Institutes of Health [Internet]. Maryland: [updated 2016 Aug 31; cited 2016 Dec 2]. Vitamin A fact sheet for health professionals; [about 13 pages]. Available from: https://ods.od.nih.gov/factsheets/VitaminA-HealthProfessional/. 17. National Institutes of Health [Internet]. Maryland: [updated 2016 Feb 11; cited 2016 Dec 2]. Vitamin B6 fact sheet for health professionals; [about 12 pages]. Available from: https://ods.od.nih.gov/factsheets/VitaminB6-HealthProfessional/. 18. National Institutes of Health [Internet]. Maryland: [updated 2016 Feb 11; cited 2016 Dec 2]. Vitamin D fact sheet for health professionals; [about 14 pages]. Available from: https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/. 19. National Institutes of Health [Internet]. Maryland: [updated 2016 Nov 17; cited 2016 Dec 2]. Calcium fact sheet for health professionals; [about 20 pages]. Available from: https://ods.od.nih.gov/factsheets/Calcium-HealthProfessional/. 20. National Institutes of Health [Internet]. Maryland: [updated 2016 Apr 20; cited 2016 Dec 2]. Folate fact sheet for health professionals; [about 16 pages]. Available from: https://ods.od.nih.gov/factsheets/Folate-HealthProfessional/. 21. National Institutes of Health [Internet]. Maryland: [updated 2016 Feb 11; cited 2016 Dec 2]. Zinc fact sheet for health professionals; [about 12 pages]. Available from: https://ods.od.nih.gov/factsheets/Zinc-HealthProfessional/.

Clarification

Self-reporting of a diagnosis by a medical professional should not be confused with self-diagnosis, where a person simply claims to have or have had a medical condition without any reference to professional diagnosis. A self-reported medical diagnosis (“My doctor says that I have/my son or daughter has…”) should prompt the CPA to validate the presence of the condition by asking more pointed questions related to that diagnosis.

References for High Risk

1. Mayo-Wilson E, Imdad A, Marshall KH, Yakoob MY, Sheriff Z. Vitamin A supplements for preventing mortality, illness, and blindness in children aged under 5: systematic review and meta-analysis. BMJ 2011; 343:d5094.

(section-ii)(nutrition-risk-manual)(page-182)Page 182#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 182

result in malnourishment and lowered disease resistance (1, 2). Nutrition management plays a prominent role in the treatment of gastrointestinal disorders.

Gastroesophageal Reflux Disease (GERD)

GERD is irritation and inflammation of the esophagus due to reflux of gastric acid into the esophagus (3). Nutritional care of GERD includes avoiding eating within 3 hours before going to bed; avoiding fatty foods, chocolate, peppermint, and spearmint, which may relax the lower esophageal sphincter; and coffee and alcoholic beverages, which may increase gastric secretion (4). Consumption of these items may need to be limited depending on individual tolerance.

Peptic Ulcer

Peptic ulcer normally involves the gastric and duodenal regions of the gastrointestinal tract (4). Because the primary cause of peptic ulcers is Helicobacter pylori infection, the focus of treatment is the elimination of the bacteria with antibiotic and proton pump inhibitor therapy. Dietary advice for persons with peptic ulcers is to avoid alcohol, coffee (with and without caffeine), chocolate, and specific spices, such as black pepper (4, 5).

Post-Bariatric Surgery

Many types of surgical procedures are used for the intervention of morbid obesity. These procedures promote weight loss by restricting dietary intakes, e.g., adjustable gastric banding (AGB), and/or bypassing some portion of intestine to cause incomplete digestion and/or malabsorption of nutrients, e.g., Roux-y gastric bypass (RYGB). Therefore, the risks for developing nutritional deficiencies after bariatric surgery are greatly increased. Since gastric bypass individuals have both a decreased availability of gastric acid and intrinsic factor, vitamin B12 deficiency can develop without supplementation. Taking daily nutritional supplements and eating foods high in vitamins and minerals are important aspects of the nutritional management for the individuals who have had bariatric surgery (6).

Short Bowel Syndrome (SBS)

SBS is the result of extensive small bowel resection. SBS in infants is mostly the result of small bowel resection for the treatment of congenital anomalies, necrotizing enterocolitis, and congenital vascular. In adults, Crohn's disease, radiation enteritis, mesenteric vascular accidents, trauma, and recurrent intestinal obstruction are the most common conditions treated by small bowel resection and resulting in SBS (4). The loss of a large segment of the small bowel causes malabsorption syndrome. Total parenteral nutrition usually is started within the first few days after intestinal resection. Gradual supplementation with enteral feeding promotes intestinal adaptation in order to wean from parenteral nutrition therapy. Supplementation with fat

(section-ii)(nutrition-risk-manual)(page-183)Page 183#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 183

soluble vitamins and vitamin B12 may be needed (7). The pediatric client’s nutritional status must be assessed and growth closely monitored (8).

Inflammatory Bowel Disease (IBD)

Inflammatory bowel disease includes Crohn’s disease and ulcerative colitis. Weight loss, growth impairment, and malnutrition are the most prevalent nutritional problems observed in IBD. Nutritional support is essential. Exclusive elemental nutrition has been used in attaining the remission of Crohn’s disease. However, symptoms tend to recur promptly after resuming the conventional diet (9).

Liver Disease

Since the liver plays an essential role in the metabolic processes of nutrients, liver disorders have far-reaching effects on nutritional status. Acute liver injury is often associated with anorexia, nausea and vomiting. Therefore, inadequate nutritional intakes are common. Decreased bile salt secretion is associated with the maldigestion and impaired absorption of fat and fat-soluble vitamins. Defects in protein metabolism associated with chronic liver failure include decreased hepatic synthesis of albumin, coagulation factors, urea synthesis and metabolism of aromatic amino acids. For nutritional therapy, an important consideration should be the balance between preventing muscle wasting and promoting liver regeneration without causing hepatic encephalopathy. It is recommended that persons with chronic liver disease consume the same amount of dietary protein as that required by normal individuals (0.74g/kg) (10).

Pancreatic Disease

In chronic pancreatitis, there is a reduced secretion of pancreatic enzymes leading to malabsorption. In severe cases, tissue necrosis can occur. It is suggested that for patients with pancreatitis, a high carbohydrate, low-fat, low protein diet may be helpful (11).

Biliary Tract Diseases

Common diseases of the biliary tract are: • Cholelithiasis (gallstones, without infection) • Choledocholithiasis (gallstone in the bile duct causing obstruction, pain and cramps) • Cholecystitis (inflammation of gallbladder caused by bile duct obstruction).

Obesity or severe fasting may increase risk for these disorders. Since lipids stimulate gallbladder contractions, a low fat diet with 25% to 30% of total calories as fat is recommended. Greater fat limitation is undesirable as some fat is required for stimulation and drainage of the biliary tract. Supplementation with fat-soluble vitamins may be needed for persons with fat malabsorption or a chronic gall bladder condition (12).

(section-ii)(nutrition-risk-manual)(page-184)Page 184#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 184

WIC nutritionists can provide counseling to support the medical nutrition therapy given by clinical dietitians, and monitor compliance with therapeutic dietary regimens. They can also review and provide WIC-approved medical foods or formulas prescribed by the health care providers. In certain circumstances, WIC staff may recommend an appropriate medical food or formula to the health care provider. They should also make referrals to an appropriate health care provider for medical nutrition therapy by a clinical dietitian when indicated.

Additional Counseling Guidelines

• Explain potential nutritional risks of participant’s specific GI disease • Recommend increased nutrient intake, if needed, to correct existing deficiencies, or to counterbalance excessive losses of nutrients or fluid • Review signs of dehydration and malnutrition due to frequent loss of nutrients via vomiting, diarrhea, malabsorption, and/or infections

Note: Self-reporting of a diagnosis by a medical professional should not be confused with self-diagnosis, where a person simply claims to have or to have had a medical condition without any reference to professional diagnosis. A self-reported medical diagnosis (“My doctor says that I have/my son or daughter has…”) should prompt the CPA to validate the presence of the condition by asking more pointed questions related to that diagnosis.

References

1. Institute of Medicine. WIC nutrition risk criteria: a scientific assessment. National Academy Press, Washington, D.C.; 1996.

2. American Dietetic Association, Pediatric Nutrition Practice Group. Pediatric manual of clinical dietetics. Chicago: Pediatric Nutrition Dietetic Practice Group, American Dietetic Association, 1998.

3. Stenson W. The esophagus and stomach. In: Maurice ES, Olson JA, Shike M, Ross AC, editors. Modern nutrition in health and disease. 9th ed. Lippincott Williams & Wilkins 1999. p. 1125-1133. 4. Beyer PL. Medical nutrition therapy for upper gastrointestinal tract disorders. In: Mahan LK, Escott-Stump S, editors. Krause’s food nutrition and diet therapy. 11th ed. Philadelphia: Saunders; 2004. p. 688-690. 5. American Dietetic Association. Nutrition Care Manual. Gastrointestinal disease; Peptic ulcers; 2006. http://www.nutritioncaremanual.org. Accessed 1/08. 6. Allied Health Sciences Section Ad Hoc Nutrition committee: Aills L, Blankenship J, Buffington C, Furtado M and Parrott J. Bariatric nutrition: suggestions for the

(section-ii)(nutrition-risk-manual)(page-185)Page 185#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 185

surgical weight loss patient. Review. Surgery for Obesity and Related Diseases 2008 May 17. 7. Scolapio JS, Fleming R. Short Bowel Syndrome. In: Maurice ES, Olson JA, Shike M, Ross AC, editors. Modern nutrition in health and disease. 9th ed. Lippincott Williams & Wilkins; 1999. p. 1135-1140. 8. Farrell M. Gastrointestinal disorders of infancy and childhood (with nutrition support and probiotics) In: Ekvall SW, Ekvall VK. editors. Pediatric nutrition in chronic diseases and developmental disorders. 2nd ed. Oxford University Press; 2005. p. 248-249. 9. Griffiths A. Inflammatory bowel disease. In: Maurice ES, Olson JA, Shike M, Ross AC, editors. Modern nutrition in health and disease. 9th ed. Lippincott Williams & Wilkins; 1999. p. 1141-1149. 10. Lieber CS. Nutrition in liver disorders. In: Maurice ES, Olson JA, Shike M, Ross AC, editors. Modern nutrition in health and disease. 9th ed. Lippincott Williams & Wilkins; 1999. p. 1177-1189. 11. Raimondo M, Dimagno EP. Nutrition in pancreatic disorders. In: Maurice ES, Olson JA, Shike M, Ross AC, editors. Modern nutrition in health and disease. 9th ed. Lippincott Williams & Wilkins; 1999. p. 1169-1176. 12. Hasse JM, Matarese JE. Medical nutrition therapy for liver, biliary system and exocrine pancreas disorders. In: Mahan LK, Escott-Stump S, editors. Krause’s food nutrition and diet therapy. 11th ed. Philadelphia: Saunders; 2004. p. 758-760.

References for High Risk

1. Allied Health Sciences Section Ad Hoc Nutrition committee: Allis L, Blankenship J, Buffington C, Furtado M and Parrott J. Bariatric Nutrition: suggestions for the surgical weight loss patient. Review. Surgery for Obesity and Related Diseases 2008 May 17.

2. American Dietetic Association. Nutrition Care Manual. Gastrointestinal disease; Peptic ulcers; 2006. http://www.nutritioncaremanual.org.Accessed 1/08.

3. Seetharam P, Rodrigues G. Short bowel syndrome: A review of management options. Saudi J Gastroenterol. 2011; July-Aug;17(4):229-235.

4. Mijac DD, Jankovic GLJ, Jorga J, Krstic MN. Nutritional status in patients with active inflammatory bowel disease: Prevalence of malnutrition andmethods for routine nutritional assessment. EJIM. 2010; 21 (4): 315-319.

(section-ii)(nutrition-risk-manual)(page-188)Page 188#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 188

mild hyperglycemia. Specific genetic defects have been identified on chromosomes 7, 12, and 20 (2). MODY is often diagnosed before the age of 25 years. It is caused by dominantly inherited defect of insulin secretion. Persons with MODY are often non-obese and without metabolic syndrome (3). The two major classifications of diabetes are type 1 diabetes (beta-cell destruction, usually leading to absolute insulin deficiency); and type 2 diabetes (ranging from predominantly insulin resistance with relative insulin deficiency to a predominantly insulin secretory defect with insulin resistance) (1). The Expert Committee on Diagnosis and Classification of Diabetes Mellitus, working under the sponsorship of the American Diabetes Association, has identified the criteria for the diagnosis of diabetes mellitus (1, 2) (see clarification). Long-term complications of diabetes include retinopathy with potential loss of vision, nephropathy leading to renal failure; peripheral neuropathy with risk of foot ulcers, amputations, and Charcot joints; and, autonomic neuropathy causing gastrointestinal, genitourinary, cardiovascular symptoms and sexual dysfunction. Patients with diabetes have an increased incidence of atherosclerotic cardiovascular, peripheral arterial and cerebrovascular diseases. Hypertension and abnormalities of lipoprotein metabolism are often found in people with diabetes (1). WIC nutrition services can reinforce and support the medical and dietary therapies (such as Medical Nutrition Therapy) that participants with diabetes receive from their health care providers (4). Justification for High Risk

The chronic hyperglycemia of diabetes is associated with long term damage, dysfunction and failure of various organs, especially the eyes, kidneys, nerves, heart, and blood vessels. Poorly controlled diabetes can also lead to adverse health related events such as diabetic ketoacidosis. High maternal BMI and type-1 diabetes are independent risk factors for maternal and perinatal complications, with type-1 diabetes being a stronger risk factor for adverse outcomes when compared to obesity (5). The prevalence of adolescent type-2 diabetes is rising and has serious long term effects on health. Chronic conditions seem to progress more rapidly in adolescents with type-2 diabetes than in those of the same age who are affected by type-1 diabetes (4). Improving diabetes outcomes by reducing chronic complications is possible through life-style interventions and dedicated attention of nutritional management and personalized education. The WIC nutritionist can play a vital role in providing nutrition counseling and assuring the participant receives comprehensive follow-up outside WIC.

Additional Counseling Guidelines

• Empower women to self-manage by obtaining information from health care providers

(section-ii)(nutrition-risk-manual)(page-189)Page 189#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 189

• Explain potential risks of DM, such as: All diabetics: ▪ Cardiovascular disease ▪ Renal disease ▪ Circulatory disease ▪ Foot problems ▪ Vision loss ▪ Hypertension Pregnant diabetics: ▪ Difficult labor and delivery ▪ Increased risk of infection, preeclampsia, toxemia, fetal malformation, fetal and neonatal death, large birth size, congenital abnormalities, neonatal death ▪ More complications for infants at birth, such as may be poor feeders, may have hyperbilirubinemia or be hypoglycemic Breastfeeding diabetics: ▪ During first few days after childbirth, diabetic mothers often experience drastic changes in blood sugar levels ➢ Because it is body’s natural response to childbirth hormones responsible for lactation cause physiological changes to occur more naturally ▪ Drastic changes in blood sugars may occur after giving birth (i.e. increased risk of hypoglycemia during first few weeks); they require close monitoring, along with insulin and dietary adjustments ➢ Once control is achieved mom should have no further problems if she follows good management practices ▪ Important to receive prompt lactation support soon after delivery and while in hospital due to possible NICU and other interventions that could delay or interfere with breastfeeding ▪ Milk may be a little slower coming in ➢ 5 to 6 days if in good control; 6 to 7 days without good control vs. 3 to 4 days in non-diabetic moms ➢ This is due to fluctuating insulin requirements and other physiologic changes ➢ Early and frequent feedings may help bring in milk ▪ Very important to recognize and treat hypoglycemia, especially following night- time breastfeeding ▪ May be more prone to mastitis and infections of nipples and vagina ➢ Risk of yeast infection increases when blood sugar levels increase ➢ Use good hygiene ➢ Keep nipples clean and dry after nursing ➢ Treat plugged ducts, lump, sore spots promptly • Encourage breastfeeding with MD approval ▪ Breastfeeding appears to have protective effect on onset of diabetes in childhood ▪ Amount of insulin needed during breastfeeding may decrease (can be up to half!) due to hormones released (insulin is compatible with breastfeeding)

(section-ii)(nutrition-risk-manual)(page-190)Page 190#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 190

➢ Hormones released during breastfeeding relax mother, reducing stress (Stress can aggravate diabetes.) ▪ Overall, breastfeeding tends to make diabetes more manageable ▪ Psychologically, breastfeeding can help mom feel “normal” because like every other breastfeeding mother, she is able to give her baby the best • For all diabetic participants provide basic diabetic counseling to facilitate normal blood glucose levels, such as how to: ▪ Maintain optimal blood glucose levels by balancing food, activity & medications ▪ Keep timing of meals consistent from day to day with carbohydrate content fairly evenly divided from meal to meal ▪ Plan for midmorning and midafternoon snacks, if needed, to match food intake to peak insulin action ▪ Plan for bedtime snack to prevent nocturnal hypoglycemia ▪ Limit sodium intake (if participant has hypertension) ▪ Limit/abstain from alcohol, especially on empty stomach ▪ Consume calories adequate to maintain healthy weight ▪ Maintain normal growth & development pattern in infants and children ▪ Plan for periods of increased physical activity ▪ Maintain appropriate blood glucose levels during illness, infections, nausea/vomiting ▪ Plan for hypoglycemic episodes

Clarification

Self-reporting of a diagnosis by a medical professional should not be confused with self- diagnosis, where a person simply claims to have or to have had a medical condition without any reference to professional diagnosis. A self-reported medical diagnosis (“My doctor says that I have/my son or daughter has…”) should prompt the CPA to validate the presence of the condition by asking more pointed questions related to that diagnosis. Diabetes mellitus is sometimes described by both patients and health professionals as “a little bit of sugar” or “high sugar.” In reality, “sugar” is only one component of the pathology and clinical manifestations of the multifaceted syndrome of diabetes mellitus (2). Diabetes mellitus is diagnosed by a licensed medical provider using any one of the following three methods:

1. Fasting plasma glucose > 126 mg/dL (7.0 mmo1/l). Fasting is defined as no caloric intake for at least 8 hours. 2. Symptoms of hyperglycemia plus casual plasma glucose concentration > 200 mg/dl (11.1 mmo1/L). • Casual implies any time of day without regard to time since last meal. • The classic symptoms of hyperglycemia include polyuria, polydipsia, and unexplained weight loss. 3. Two-hour plasma glucose > 200mg/dL (11.1 mmo1/L) during a 75-g oral glucose tolerance test (OGTT) (1).

(section-ii)(nutrition-risk-manual)(page-191)Page 191#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 191

In the absence of unequivocal hyperglycemia, these criteria should be confirmed by repeat testing on a different day. The third measure (OGTT) is not recommended for routine clinical use.

References

1. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. Jan 2008; 31 Suppl 1:S55-60.

2. Franz MT, Ratner RE. Diabetes and Complications. In: Pathophysiology of the diabetes disease state: a Core Curriculum for Diabetes Educators American Association of Diabetes Educators. 5th ed. 2003.

3. Dean L, McEntrye J. The genetic landscape of diabetes. 2004; Bethesda: NCBI, 2004. Http://www.ncbi.nlm.nih.gov/books/bv.fcgi?call=bv.veiw..showtoc&rid=diabetes.to c&depth=1 .

4. American Diabetes Association. Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association. Diabetes Care. 2006; 29: 2140-2157:S48-S65.

References for High Risk

1. Renzaho A MN, Skouteris H, Oldroyd J. Preventing gestational diabetes mellitus among migrant women and reducing obesity and type 2 diabetes in their offspring: A call for culturally competent lifestyle interventions in pregnancy. JADA. 2010; 110: 1814-1817.

2. Aslander-van V E, Smart C, Waldron S. Nutritional management in childhood and adolescent diabetes. Pediatr Diabetes. 2007; 8: 323-339.

3. Delahanty L M. Research charting a course for evidence-based clinical dietetic practice in diabetes. J Hum Nutr Diet. 2010; 23: 360-370.

4. Pinhas-Hamiel O, Zeitler P. Acute and chronic complications of type 2 diabetes mellitus in children and adolescents. Lancet. 2007; 369:1823-31.

5. Persson M, Pasupathy D, Hanson U, Westgren M, Norman M. Pre-pregnancy body mass index and the risk of adverse outcome in type 1 diabetic pregnancies: a population-based cohort study. BMJ. 2012; 2(1): e000601.

(section-ii)(nutrition-risk-manual)(page-193)Page 193#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 193

Parameters for Manual Assignment

Must be manually selected in Nutrition Interview or Risk Panel

Justification

The thyroid gland manufactures three thyroid hormones: thyroxine (T4), triiodothyronine (T3), and calcitonin. The thyroid hormones regulate how the body gets energy from food (metabolism). Iodine is an essential component of the T4 and T3 hormones (1) and must come from the diet. (Note: In nature, iodine does not exist as a free element; rather, it forms compounds such as sodium iodide (2, 3). For more information see Clarification section.) Iodine is available from various foods, and is present naturally in soil and sea water. A dysfunctional thyroid gland can become enlarged (goiter) as a result of an overproduction of thyroid hormones (hyperthyroidism) or conversely, from insufficient thyroid hormone production (hypothyroidism). Thyroid hormones influence virtually every organ system in the body. Maternal needs for dietary iodine and thyroid hormone medication (if prescribed) increase during pregnancy as maternal thyroid hormones and iodine are transferred to the fetus along with an increased loss of iodine through the maternal kidneys (3). Concurrently, the fetus is unable to produce thyroid hormones during the first trimester and is entirely dependent on the maternal supply of thyroid hormones. As a result, maternal production of T4 must increase by at least 50% during pregnancy (4). If the pregnant woman is receiving thyroid hormone therapy, often a 30% - 50% increase in thyroid hormone medication is also needed. Hyperthyroidism

Hyperthyroidism is a condition in which the thyroid gland is overactive, manufacturing too much thyroid hormone (T4 and T3). An excessive consumption of iodine (> 1000 μg/d) may cause fetal and maternal hyperthyroidism (5). In other circumstances, the thyroid might develop nodules which secrete excessive amounts of thyroid hormone regardless of iodine status (5). Enlargement of the thyroid gland (goiter) is a common symptom, as well as weight loss, fatigue, muscle weakness and an irregular heartbeat. Hyperthyroidism is relatively uncommon in pregnancy (4). However, when it occurs, uncontrolled hyperthyroidism (especially in the second half of pregnancy) may result in infection, miscarriage, preterm delivery, preeclampsia, or congestive heart failure. Fetal complications may include prematurity, small for gestational age, fetal or neonatal thyrotoxicosis, or death (6). Postpartum maternal hyperthyroidism is likely in women with prenatal hyperthyroidism (7). The primary medical therapy for hyperthyroidism is radioactive iodine therapy which is contraindicated during pregnancy and lactation (7). If hyperthyroidism occurs during this period, low doses of thiomide (antithyroid drug) are given instead.

(section-ii)(nutrition-risk-manual)(page-194)Page 194#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 194

Hypothyroidism

Hypothyroidism is a condition in which the thyroid gland does not make enough thyroid hormone. Maternal and fetal hypothyroidism may occur when preconception maternal iodine stores are insufficient and there is inadequate maternal iodine intake in early pregnancy. In this instance, the maternal iodine balance may become negative and may never be restored, even with eventual iodine supplementation (4). Mothers with iodine deficiency during the first half of pregnancy may produce offspring with severe, irreversible brain damage (8). Maternal thyroid deficiency has been associated with neonatal developmental problems which may cause lasting changes in the brain structure and cognitive function. Uncontrolled hypothyroidism in the second half of pregnancy can cause maternal complications such as anemia, preeclampsia, miscarriage, premature delivery, and postpartum thyroid disease. Fetal or neonatal complications include prematurity, low birth weight, congenital anomalies, poor neuropsychological development, and stillbirth (6). When iodine nutrition status is adequate, autoimmune thyroid disease (AITD) – also called Hashimoto’s thyroiditis - is the most common type of hypothyroidism during pregnancy (4). Pregnant women with AITD are at increased risk of miscarriage and postpartum thyroid disease (including thyroiditis, hyperthyroidism and hypothyroidism). There is an increased risk of permanent and significant impairment in cognitive function for their infants (9). Congenital Hyperthyroidism and Hypothyroidism

Congenital hyperthyroidism is rare in neonates. Transient congenital hyperthyroidism is caused by maternal Graves disease. Thyroid stimulating immunoglobulin passes from the mother to the fetus via the placenta and causes thyrotoxicosis in the fetus and subsequently, the neonate. After the baby is born, improvement is rapid if the condition is treated using antithyroid drugs and the hyperthyroidism will subside within several weeks (10). Persistent congenital hyperthyroidism is a familial non-autoimmune disease. It is caused by a genetic mutation resulting in an increase in the constitutive activity of the TSH receptor (11). Congenital hypothyroidism due to maternal iodine deficiency is a leading cause of preventable mental retardation (10). Over-treatment of thyroid hormone, during pregnancy, as well as prolonged maternal iodine therapy (more than two weeks of therapy or more than 1000 μg/iodine) can also cause congenital hypothyroidism (6). The condition is exacerbated by coexisting selenium and vitamin A deficiencies or iron deficiency (5). Treatment for neonatal hypothyroidism should be started as soon as possible, as every day of delay may result in loss of IQ. Unless treated shortly after birth (within the first 18 days of life), the resulting mental retardation will be irreversible (10). Postpartum Thyroiditis

Postpartum thyroiditis, an autoimmune inflammation of the thyroid, occurs within the first year after delivery or sometimes after termination of pregnancy. It can be a transient thyroid

(section-ii)(nutrition-risk-manual)(page-195)Page 195#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 195

dysfunction with a brief thyrotoxic phase followed by hypothyroidism, usually with a spontaneous resolution (10). Smoking is a significant precipitating factor in the onset of postpartum thyroiditis (9). Women with a past history of postpartum thyroiditis have a risk of long-term permanent hypothyroidism and recurrence of postpartum thyroiditis in subsequent pregnancies (12). Tests for this condition consist of radioactive products necessitating a temporary cessation of breastfeeding (usually up to 3 days). Implications for WIC Nutrition Services

Individuals with thyroid disorders can benefit from WIC foods and WIC nutrition services can reinforce and support the medical and dietary therapy prescribed by the participants’ health care provider. The following nutrition education messages may be appropriate depending on the type of thyroid disorder: • Encourage iodine sufficiency, unless contraindicated, with an adequate intake of foods high in iodine such as iodized table salt, bread, saltwater fish, kelp, egg yolks (because of iodine supplementation in chicken feed), milk and milk products (because of the treatment of cows with supplemental dietary iodine) (5). It is important to note that the salt used in manufactured foods is not iodized. • Advise women to review the iodine content of their prenatal supplement. It is recommended that all prenatal vitamin-mineral supplements for use during pregnancy and lactation contain at least 150 micrograms of iodine a day (13). Currently, less than 50 percent of prenatal vitamins on the market contain iodine (5, 7). • Promote breastfeeding, as there are no contraindications to breastfeeding and thyroid hormone replacement therapy as long as normal thyroxine levels in the maternal plasma are maintained. Breast milk provides iodine to the infant and is influenced by the dietary intake of the pregnant and lactating mother (14). Hyperthyroidism can develop for the first time during the postpartum period, but the mother’s ability to lactate is not affected. However, if a woman with untreated hypothyroidism breastfeeds, her milk supply may be insufficient. In such instances, replacement thyroid hormone therapy is necessary to help increase milk production. • Weight management - hyperthyroidism: The elevated plasma levels of thyroid hormones may cause increased energy expenditure and weight loss along with increased appetite. Following medical treatment, individuals with hyperthyroidism usually regain their typical body weight with a concurrent decrease in appetite (4). Therefore, the monitoring of weight status and dietary adequacy are recommended. • Weight management – hypothyroidism: Many individuals with hypothyroidism experience an increase in weight due to both a decrease in basal metabolic rate and an excessive accumulation of water and salt. Most of the weight gained is due to the excess water and salt retention. After medical treatment, a small amount of weight may be lost, usually less than 10% of body weight (15). Once hypothyroidism has been treated and thyroid hormones are within normal levels, it is less likely that the weight gain is solely due to the thyroid. If an overweight condition persists, weight control therapy may be necessary.

(section-ii)(nutrition-risk-manual)(page-196)Page 196#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 196

• Recommend the cautionary use of soy formula and the avoidance of foods or supplements rich in soy, fiber, or iron when therapeutic thyroid medications are prescribed, since soy, iron, calcium, fiber and phytates may interfere with the absorption of oral thyroid hormone therapy (16, 17). • Discourage smoking as the compound thiocynate found in tobacco smoke inhibits iodine transport (9). Clarification

Self-reporting of a diagnosis by a medical professional should not be confused with self- diagnosis, where a person simply claims to have or to have had a medical condition without any reference to professional diagnosis. A self-reported medical diagnosis (“My doctor says that I have/my son or daughter has…”) should prompt the CPA to validate the presence of the condition by asking more pointed questions related to that diagnosis. Iodine (I 2) is an element. In the ambient temperature, it is volatile and forms blue-violet gas. In nature, it does not exist as free element. Instead, it forms compounds, such as sodium iodide (NaI), and potassium iodide (KI). To prevent iodine deficiency, potassium iodide is added to the salt (most commonly to table salt) to form iodized salt (2, 3).

Justification for High Risk

Not Applicable

Additional Counseling Guidelines

• Explain potential risks of Hyperthyroidism: ▪ Result of overactive thyroid gland, leading to too much thyroid hormone in the body (must be treated medically) • Symptoms include: ▪ “Pop eyes” ▪ Goiters (enlarged thyroid) ▪ Strain on heart, muscles, nervous system ▪ Fast pulse ▪ Extreme nervousness ▪ Muscle tremors ▪ Weight loss, depleted body stores • Considerations for breastfeeding mothers include: ▪ The ability to breastfeed does not appear to be affected by hyperthyroidism ➢ Mother’s health care provider must be involved in her decision to breastfeed ▪ Breastfed infants of mothers with treated hyperthyroidism must have their thyroid monitored for normal function

(section-ii)(nutrition-risk-manual)(page-197)Page 197#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 197

➢ Some thyroid suppressants may suppress baby’s thyroid as well; therefore mother needs to find breastfeeding compatible medications such as PTU (Propylthiouracil) Carbimazole, or methimazole (tapazole) • Compensate for lost weight, exhausted body reserves and depleted vitamin and minerals stores via: ▪ High calorie/protein/carbohydrate diet ▪ Multi-vitamin/mineral supplement (calcium, phosphorus, B-complex, and vitamin D) • Explain potential risks of Hypothyroidism: • Hypothyroidism is result of sluggish thyroid gland producing too little thyroid hormone (must be treated medically) • Symptoms include ▪ fatigue (“bone tired”) ▪ puffed up hands, face, eyelids ▪ weight gain (because metabolism kicks into low gear) ▪ depression ▪ poor appetite ▪ cold intolerance ▪ dry skin and thinning hair • Considerations for infants include: ▪ Infant should be screened to rule out hypothyroidism (T4 & TSH testing process should not be a hazard to nursing.) ▪ May not grow properly, leading to stunting ▪ Breastfed infants of mothers with untreated hypothyroidism may not gain weight satisfactorily ➢ Infant may fail to gain weight on breast milk alone ➢ Monitor breastfed infants weight • Considerations for breastfeeding women include: ▪ Untreated hypothyroidism can result in reduced milk supply ▪ Woman should be well controlled by thyroid replacement therapy to ensure full lactation ➢ Health care provider must be involved in decision to breastfeed to assure thyroid supplements are compatible with breastfeeding ▪ Due to sluggish metabolism leading to weight gain, low calorie diet may be warranted for mother • Considerations for postpartum women include: ▪ Identify hypothyroidism in postpartum women, especially with normal thyroid women have prolonged “baby blues” fatigue or depression ▪ Screen for self-medication with drugs or herbs

References

1. National Academy of Sciences. Institute of Medicine. Food and Nutrition Board. Dietary reference intakes: The essential guide to nutrient requirements. 2001.

(section-ii)(nutrition-risk-manual)(page-198)Page 198#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 198

2. Los Alamos National Labs Chemistry Division Periodic Table. http://periodic.lanl.gov/elements/53.html. Accessed December 2009. 3. WebElements: The periodic table on the web. http://www.webelements.com/iodine/. Accessed December 2009. 4. Smallridge RC, Glinoer D, Hollowell JG, Brent G. Thyroid function inside and outside of pregnancy: What do we know and what don’t we know? Thyroid. 2005;15(1):54- 59. 5. Lee SL, Ananthakrishnan S, Pearce EN. Iodine deficiency. [updated July 27, 2006]. Available from: http://www.emedicine.com/med/topic1187.htm. 6. Nguyen PH. Autoimmune thyroid disease and pregnancy. [updated December 21, 2004;cited 2007 Sept 7]. Available from: http://www.emedicine.com.

7. American Association of Clinical Endocrinologists (AACE) Thyroid Task Force. AACE Medical guidelines for clinical practice for the evaluation and treatment of hyperthyroidism and hypothyroidism. 2006 Amended Version. Endocrine Practice 2002;8(6):457-469. 8. LaFranchi SH, Haddow JE, Hollowell JG. Is thyroid inadequacy during gestation a risk factor for adverse pregnancy and developmental outcomes? Thyroid 2005;15(1):60-71. 9. Muller AF, Drexhage HA, Berghout A. Postpartum thyroiditis and autoimmune thyroiditis in women of childbearing age: Recent insights and consequences for antenatal and postnatal care. Endocrine Reviews. 2001 Oct; 22(5):605-630. 10. Association for Clinical Biochemistry, British Thyroid Association, British Thyroid Foundation. UK guidelines for the use of thyroid function tests. 2006 July;1-86. 11. Polak M, Legac I, Vuillard E, Guibourdenche J, Castanet M, Luton D.Congenital hyperthyroidism: The fetus as a patient. Horm Res. 2006;65:235-242 (DOI: 10.1159/000092454) 12. O’Malley B, Hickey J, Nevens E. Thyroid dysfunction – weight problems and the psyche: The patients’ perspective. J Hum Nutr Dietet. 2000 May;13:243-248. 13. American Thyroid Association. American Thyroid Association statement on early maternal thyroidal insufficiency: Recognition, clinical management and research directions. Consensus statement #2. Thyroid. 2005;15(1):77-79. 14. Riordan J. Breastfeeding and human lactation, 3rd ed. Jones & Bartlett Publishers, Inc., 2005; p. 157, 461. 15. American Thyroid Association. Thyroid and weight, 2005. Available from: http://www.thyroid.org

(section-ii)(nutrition-risk-manual)(page-200)Page 200#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 200

345 Hypertension and Pre-Hypertension Definition/Cut-Off Value

Hypertension is defined as high blood pressure which may eventually cause health problems and includes chronic hypertension during pregnancy, preeclampsia, eclampsia, chronic hypertension with superimposed preeclampsia, and gestational hypertension (1, 2, 3). Prehypertension is defined as being at high risk for developing hypertension, based on blood pressure levels. Presence of condition diagnosed, documented, or reported by a physician or someone working under a physician’s orders, or as self-reported by applicant/participant/caregiver. See Clarification for more information about self-reporting a diagnosis.

Participant Category and Priority Level

Category Priority High Risk Pregnant I N Breastfeeding I N Non-breastfeeding Women III, IV, V or VI N Infants I N Children III N

Parameters for Manual Assignment

Must be manually selected in Nutrition Interview or Risk Panel

Justification

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 disease, and peripheral vascular disease. People with HTN are often asymptomatic; diagnosis is based on measuring levels of blood pressure. (1) Blood pressure levels in adults are typically classified as follows, with the first number representing systolic blood pressure and the second number diastolic blood pressure (2, 3): • Normal blood pressure: <120/<80 mmHg (millimeters of mercury)

(section-ii)(nutrition-risk-manual)(page-201)Page 201#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 201

• Prehypertension: consistent readings of 120-139/80-89 mmHg • Hypertension: consistent readings of ≥140/≥90 mmHg 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. (2) Hypertension is considered either primary/essential (there is no identifiable cause) or secondary (there is an identifiable cause). Some identifiable causes include 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. (1) Risk factors for HTN include the following (1, 2):

• 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 [4, 5].) • 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 Hypertension is a serious condition that can lead to a variety of health problems, including the following (1, 3): • Cardiac pathologies, including heart attack, stroke, aneurysm, and heart failure

(section-ii)(nutrition-risk-manual)(page-202)Page 202#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 202

• Metabolic syndrome • Chronic kidney disease • Eye damage and vision loss • Memory/understanding problems and dementia • Gestational diabetes, preeclampsia, and perinatal mortality 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 healthcare 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 (3). • 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 (3). 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. (6) Hypertensive disorders of pregnancy are categorized as follows:

• Chronic Hypertension during Pregnancy:

o Definition: Hypertension is present before pregnancy or is diagnosed before 20 weeks gestation (6, 7).

(section-ii)(nutrition-risk-manual)(page-203)Page 203#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 203

o It 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. (7) o 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 healthcare provider for individualized guidance. (7) • Preeclampsia:

o 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. (7) o 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 (7, 8). Worldwide, it leads to the death of over 60,000 women annually (9). o 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 (6, 7, 9, 10, 11). Low dietary and serum calcium levels are also associated with preeclampsia (9). o 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. (7) o 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), caesarean 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 (7, 8, 10, 12). The infant of a woman with preeclampsia is at greater risk for caesarean delivery, preterm birth, low birth weight, small for gestational

(section-ii)(nutrition-risk-manual)(page-204)Page 204#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 204

age, and/or stillbirth (8, 12). 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 (10, 12). o 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 (7, 8, 9, 13). Dietary folate and folic acid supplementation during pregnancy has also been associated with lower risk of preeclampsia (12, 14). o 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) (7). 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 (7, 10). The only known cure for preeclampsia during pregnancy is the delivery of the infant and placenta (10, 12). o 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 healthcare provider immediately if they occur. (6, 7) • Chronic Hypertension with Superimposed Preeclampsia:

o 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). (6, 7) • Eclampsia:

o 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. (7) o 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. (7) o 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: o Definition: Onset of hypertension during pregnancy, usually after 20

(section-ii)(nutrition-risk-manual)(page-205)Page 205#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 205

weeks gestation, and without proteinuria. It usually resolves after delivery but does increase the risk of developing chronic HTN. (6) 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 (15). Similarly, women with hypertension should be encouraged to breastfeed, unless contraindicated (16). 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 healthcare provider to determine the best infant feeding and medication plan. 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, healthcare providers should measure blood pressure at every visit if the child has a risk factor for developing HTN. (17) 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. (17) 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 (17): • 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

(section-ii)(nutrition-risk-manual)(page-206)Page 206#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 206

• 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 (17): • 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).

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 healthcare provider. The healthcare provider may also recommend regular self-monitoring of blood pressure. • Informing them of the symptoms of preeclampsia and of the importance of contacting their healthcare provider immediately if they occur. Also, inform them that preeclampsia can occur postpartum.

(section-ii)(nutrition-risk-manual)(page-207)Page 207#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 207

• 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 healthcare provider to discuss whether a calcium supplement is appropriate. Please note that a lowsodium diet and/or weight loss is not recommended as treatment for HTN during pregnancy. • Encouraging them to discuss individualized physical activity recommendations with their healthcare 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 healthcare provider immediately if they occur. • Providing breastfeeding promotion and support, unless contraindicated. Encourage women to discuss their breastfeeding status and goals with their healthcare 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 healthcare provider; and to have their BMI, blood pressure, lipids, and fasting glucose assessed yearly (3) • 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 healthcare 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.

(section-ii)(nutrition-risk-manual)(page-208)Page 208#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 208

For Children with Hypertension:

• Encouraging caregivers to take children to all health care appointments.

• Counseling caregivers on: healthy pediatric weight gain and, for children with high weight- forlength or obesity, discussing strategies for achieving and maintaining a healthy weight; agespecific, DASH-type eating habits; and the importance of adequate sleep and physical activity in children.

Clarification

References 1. Mayo Clinic [Internet]. Rochester (MN): Mayo Clinic; c1998-2019. High blood pressure (hypertension). 2018 May 12 [cited 2018 July]. Available from: www.mayoclinic.org/diseasesconditions/high-blood-pressure/symptoms-causes/syc-20373410. 2. Centers for Disease Control and Prevention [Internet]. Atlanta (GA): Centers for Disease Control and Prevention. High blood pressure fact sheet. 2016 June 16 [cited 2018 July]. Available from: www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_bloodpressure.htm. 3. National Heart, Lung, and Blood Institute [Internet]. Bethesda (MD): National Institute of Health. High blood pressure. [cited 2018 July]. Available from: www.nhlbi.nih.gov/health- topics/highblood-pressure. 4. Lackland DT. Racial differences in hypertension: implications for high blood pressure management. American Journal of Medical Science. 2014 Aug [cited 6 Mar 2018];348(2):135-8. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4108512/. 5. Ferdinand KC, Yadav K, Nasser SA, et al. Disparities in hypertension and cardiovascular disease in blacks: the critical role of medication adherence. Journal of Clinical Hypertension. 2017 May 22 [cited 2019 Mar 5];00:1-10. Available from: https://doi.org/10.1111/jch.13089. 6. Centers for Disease Control and Prevention [Internet]. Atlanta (GA): Centers for Disease Control and Prevention. High blood pressure during pregnancy fact sheet. 2018 May 16 [cited 2018 July]. Available from: www.cdc.gov/bloodpressure/pregnancy.htm. 7. American College of Obstetricians and Gynecologists [Internet]. Washington (DC): American College of Obstetricians and Gynecologists; c2013. Hypertension in pregnancy. 2013 [cited 2018 July]; [100 pages]. Available from:

(section-ii)(nutrition-risk-manual)(page-209)Page 209#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 209

www.acog.org/~/media/Task%20Force%20and%20Work%20Group%20Reports/public/Hyperte nsi oninPregnancy.pdf. 05/2019 9 of 10 Clinical/Health/Medical: Hypertension and Prehypertension 345 8. Khaing W, Vallibhakara SA, Tantrakul V, et al. Calcium and vitamin D supplementation for prevention of preeclampsia: a systematic review and network meta-analysis. Nutrients. 2017 Oct [cited 2019 Mar 5];9(10):1141. Available from: https://www.mdpi.com/2072-6643/9/10/1141. 9. Duhig K, Vandermolen B, Shennan A. Recent advances in the diagnosis and management of preeclampsia [version 1; referees: 2 approved]. F1000 Faculty Review. 2018 Aug 15 [cited 2019 Mar 5];7(F1000 Faculty Rev)242. Available from: https://doi.org/10.12688/f1000research.12249.1. 10. Mol BWJ, Roberts CT, Thangaratinam S, et al. Pre-eclampsia. The Lancet. 2015 Sept 2 [cited 2019 Mar 5];387(10022):999-1011. Available from: https://doi.org/10.1016/S0140- 6736(15)00070-7. 11. Espinoza J, Kusanovic JP, Bahado-Singh R, et al. Should bilateral uterine artery notching be used in the risk assessment for preeclampsia, small-for-gestational-age, and gestational hypertension? Journal of Ultrasound Medicine. 2010 Jul [cited 2019 Mar 6];29(7):1103-15. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3020574/. 12. Wen SW, Guo Y, Rodger M, White RR, Yang Q, Smith GN, Perkins SL, Walker MC. Folic acid supplementation in pregnancy and the risk of pre-eclampsia – a cohort study. PLoS ONE. 2016 Feb 22[cited 2019 Mar 6];11(2): e0149818. Available from: https://doi.org/10.1371/journal.pone.0149818. 13. Lowensohn R, Stadler DD, Naze C. Current concepts of maternal nutrition. Obstetrical and Gynecological Survey. 2016 July [cited 2019 Mar 5];71(7):413-26. Available from: https://journals.lww.com/obgynsurvey/Fulltext/2016/07000/Current_Concepts_of_Maternal_Nut rition.18.aspx. 14. Wang Y, Zhao N, Qiu J, et al. Folic acid supplementation and dietary folate intake, and risk of preeclampsia. European Journal of Clinical Nutrition. 2015 Jan 28 [cited 2019 Mar 5];69:1145-50. Available from: https://www.nature.com/articles/ejcn2014295. 15. Feltner C, Weber RP, Stuebe A, Grodensky CA, Orr C, Viswanathan M. Breastfeeding Programs and Policies, Breastfeeding Uptake, and Maternal Health Outcomes in Developed Countries. Comparative Effectiveness Review No. 210. (Prepared by the RTI International– University of North Carolina at Chapel Hill Evidence-based Practice Center under Contract No. 290-2015-00011-I.) AHRQ Publication No. 18-EHC014-EF. Rockville (MD): Agency for Healthcare Research and Quality. 2018 July [cited 2019 April 24]. Available from: https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/cer-210-breastfeeding-report_1.pdf. 16. American College of Obstetricians and Gynecologists [Internet]. Washington (DC): American College of Obstetricians and Gynecologists, Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. 2013 [cited 2019 April 24]. Available from:

(section-ii)(nutrition-risk-manual)(page-212)Page 212#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 212

Renal disease can result in growth failure in children and infants. Children who suffer from chronic kidney disease (CKD) experience a negative impact on growth, and are significantly growth restricted in the first year of life. Typically, children with CKD fall below the 3rd percentile in length during their first 15 months and then grow at a rate parallel to the growth curve. Addressing nutrient deficiencies and metabolic acidosis can improve linear growth; however, these children most commonly receive growth hormone to achieve a normal height (3).

Children with CKD are also at greater risk for suffering chachexia or protein-energy wasting (PEW). The insufficient energy and nutrient intake may contribute to PEW. Existing evidence supports the effectiveness of supplementing calories in order to promote appropriate growth in children up to the age of 2 (4).

In pregnant women, fetal growth is often limited and there is a high risk of developing pregnancy-aggravated hypertension. Pregnant women with chronic renal disease have an increased risk of azotemia and an increased risk of other perinatal and maternal morbidities such as pre-eclampsia, preterm delivery, cesarean delivery and anemia. However, many pregnancies can be expected to have a positive and successful pregnancy outcome depending on the severity of renal disease related to increased risks. The degree of renal insufficiency is most important when predicting pregnancy outcome. When symptoms such as hypertension and proteinuria (> 500mg – 1mg/day) are poorly controlled there is an increased likelihood of detrimental outcomes in pregnancy (2, 5). Women with chronic kidney disease and mild renal insufficiency with normal or controlled hypertension have a good renal outcome and an uneventful pregnancy (5).

Overall, all WIC participants with renal disease need individual counseling with an RD, to assure that appropriate food packages and referrals are provided.

Additional Counseling Guidelines

• Potential risks for pregnant women include: ▪ Decreased kidney function (temporary or permanent) as pregnancy progresses ➢ Depending on disease state, may end up on hemodialysis before pregnancy ends ▪ Strong possibility of developing preeclampsia-like syndrome superimposed on underlying vascular disease (i.e. pregnancy-induced hypertension) ▪ Increased anemia ▪ Women with chronic renal disease often have proteinuria (i.e. protein in the urine) but additional risk of azotemia is increased if she increases her protein intake ▪ Premature delivery ▪ SGA infant ▪ Fetal loss and morbidity • Potential risks for infants and children include:

(section-ii)(nutrition-risk-manual)(page-215)Page 215#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 215

Justification for high risk

Participants are at medical and nutritional risk depending on the stage of disease, form of cancer, and type of treatment. The most common nutritional risk is Protein Energy Malnutrition (PEM) and wasting. Irradiation treatment also contributes to PEM. It has been suggested that 20% of cancer patients’ die as a result of malnutrition rather than the cancer itself (1).

PEM is associated with impaired immune competence, increased susceptibility to infections, major organ dysfunction, and increased morbidity and mortality. Hematopoietic, GI, and immunologic systems are most affected by PEM. Some chemotherapy drugs (e.g. cytosine arabinoside) are toxic to the GI tract and pose additional nutritional risks. Symptoms of malnutrition in cancer patients include anorexia, dry mouth, nausea, stomach pain, constipation, and diarrhea. Weight loss can be detrimental if cancer patients reach a BMI ≤ 18.5, as there is a decreased chance of survival. However, it is important to not use BMI alone when assessing risk as patients with high body weights can mask loss of lean body mass. Other methods should be used in addition to BMI in order to address nutritional status (1,2,4).

Nutritional status obviously declines after initiation of treatment, where related symptoms can affect prognosis and lower patients’ quality of life. WIC can assist participants in monitoring symptoms and provide patients with appropriate nutrition to maintain appropriate weight and prevent a decline in quality of life.

Additional Counseling Guidelines

• Help problem solve identify areas in dietary plan that could be improved • Provide tricks such as modifying temperatures, textures, or using supplemental food products, especially if treatment or medications affected taste perception or appetite ▪ Low-lactose diet may improve abdominal discomfort and diarrhea caused by treatment or GI infections • If appropriate, provide additional ideas for increased calorie and protein intake • The type of cancer and stage of disease progression determines the type of medical treatment and nutrition management ▪ The type of ongoing treatment may put the participant at increased nutrition risk and health risk (irradiation to the neck, esophagus, abdomen, pelvis, or intense or frequent use of corticosteroid therapy) • PEM (Protein Energy Malnutrition) and wasting are the most common nutritional risks ▪ PEM is associated with impaired immune competence, increased susceptibility to infections, etc. ▪ Explain need for protein and energy ▪ Assist with meal planning and following the daily food guide with emphasis on meeting the protein group • Dietary fat intake may need to be modified if malabsorption, maldiegestion occurs

(section-ii)(nutrition-risk-manual)(page-218)Page 218#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 218

neural tube defects on the developing fetus. Although it is unclear whether folic acid supplementation protects against the embryotoxic and teratogenic effects of AEDs, folic acid is recommended for women with epilepsy as it is for other women of childbearing age (5-7). Oral motor dysfunction is associated with infants and children with cerebral palsy (CP). These infants and children often have poor growth due to eating impairment, such as difficulty in spoon feeding, biting, chewing, sucking, drinking from a cup and swallowing. Rejection of solid foods, choking, coughing, and spillage during eating are common among these children (8,9). Growth monitoring and nutrition counseling to modify food consistency and increase energy and nutrient intakes are recommended. Some children may require tube feeding and referral to feeding clinics, where available.

Limited mobility or paralysis, hydrocephalus, limited feeding skills, and genitourinary problems, put children with neural tube defects (NTDs) 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 body mass index (10). Growth monitoring and nutrition counseling for appropriate feeding practices are suggested. In some cases, participants with Parkinson’s disease require protein redistribution diets to increase the efficacy of the medication used to treat the disease (11). Participants treated with levodopa-carbidopa may also need to increase the intake of B vitamins (12). Participants with Parkinson’s disease will benefit from nutrition education/counseling on dietary protein modification, which emphasizes adequate nutrition and meeting minimum protein requirements. Additionally, since people with Parkinson’s often experience unintended weight loss (13), it is important to monitor for adequate maternal weight gain.

Individuals with multiple sclerosis (MS) may experience difficulties with chewing and swallowing that require changes in food texture in order to achieve a nutritionally adequate diet (14). Obesity and malnutrition are frequent nutrition problems observed in individuals with MS. Immobility and the use of steroids and anti-depressants are contributing factors for obesity. Dysphagia, adynamia, and drug therapy potentially contribute to malnutrition. Both obesity and malnutrition have detrimental effects on the course of the disease. Adequate intakes of polyunsaturated fatty acids, vitamin D, vitamin B12 and a diet low in animal fat have been suggested to have beneficial effects in relapsing-remitting MS (15-17). Breastfeeding advice to mothers with MS has been controversial. However, there is no evidence to indicate that breastfeeding has any deleterious effect on women with MS. In fact, breastfeeding should be encouraged for the health benefits to the infant (18). In addition, mothers who choose to breastfeed should receive the necessary support to enhance breastfeeding duration.

As a public health nutrition program, WIC plays a key role in health promotion and disease prevention. As such, the nutrition intervention for participants with medical conditions should focus on supporting, to the extent possible, the medical treatment and/or medical/nutrition therapy a participant may be receiving. Such support may include: investigating potential drug-

(section-ii)(nutrition-risk-manual)(page-219)Page 219#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 219

nutrient interactions; inquiring about the participant’s understanding of a prescribed special diet; encouraging the participant to keep medical appointments; tailoring the food package to accommodate the medical condition; and referring the participant to other health and social services.

Justification for High Risk

Not Applicable

Additional Counseling Guidelines

• Considerations for Epilepsy: ▪ Find out if seizures controlled by medications ➢ Identify medications ➢ Reinforce following prescription instructions ➢ Identify possible drug nutrient interaction (e.g. Phenobarbital may increase needs of folate, vitamin D, K, calcium, B vitamins, increase risk of osteomalacia, increase appetite, increase nausea, vomiting, anorexia) ➢ Address possible drug nutrient interaction through dietary recommendations • Considerations for Cerebral Palsy (CP): ▪ For underweight participants, recommend increased calorie and nutrient intake and vitamin/mineral supplementation ▪ For overweight participants discuss prevention of obesity • Considerations for Neural tube defects (NTDs): ▪ Symptoms may include: ➢ genitourinary problems, bladder and bowel incontinence ➢ variable weakness to flaccid paralysis in lower extremities ➢ hydrocephalic ➢ possible decreased intelligence ▪ For overweight participants discuss prevention of obesity ▪ Encourage foods high in folic acid ➢ Bioavailability of folic acid in foods is approximately half ▪ If appropriate, recommend folic acid supplementation, with MD approval ➢ Recommend maternal intake of at least 400µg (.4 mg) daily ➢ .4 mg daily for women who have had an affected infant previously in the periconceptional period is believed to greatly reduce the risk of having infant with NTD ▪ Refer women on anticonvulsant drugs to MD regarding increased risk of NTD birth (e.g. Valproic acid/Depakene and Carbamazapine are associated with NTD; folic acid reduces the risk) ▪ Possible disorders of ascorbic acid metabolism may occur ▪ Increase fluids to prevent bladder infections ▪ Consume high fiber diet to avoid constipation

(section-ii)(nutrition-risk-manual)(page-220)Page 220#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 220

• Considerations for Multiple Sclerosis (MS): ▪ Identify if chewing or swallowing is affected ➢ Provide recommendations for appropriate food choices and modifying food textures ➢ May need to try thicker drinks, shakes, puddings ➢ May need to avoid foods that crumble (e.g. crackers, toast, cakes) that can cause choking ➢ Try soft, blenderized, mashed foods or stewed/cooked fruits/vegetables vs. raw ▪ Identify if characteristic problems such as: vision problems, weakness, fatigue, decreased coordination, numbness, paralysis, and decreased mobility affect: ➢ Food shopping ➢ Meal preparation ➢ Self feeding ▪ Provide recommendations ▪ Encourage to maintain normal weight (appropriate BMI) as activity decreases ▪ If constipation is a problem, provide recommendations for high fiber, increased water, exercise, etc. ▪ Possibly limit caffeine intake ▪ Encourage exercise as recommended by MD ➢ Encourage to prevent overheating with exercise ➢ Exercise in cool water, in an air-conditioned environment, with appropriate clothing (overheating temporarily aggravates MS symptoms) ▪ Refer postpartum women to MD if symptoms temporarily increase after delivery (sometimes there are less symptoms during pregnancy) Studies show that pregnancy does not alter the long-term course of MS • Considerations for Parkinson’s disease: ▪ Parkinson’s is usually diagnosed in age groups in late 40s (average age 55 – 65) ▪ Medications frequently used are L-dopa and carbidopa (sinemet) and have fewer restrictions with diet interactions (e.g. protein, B6 Pyridoxine) ➢ A very small percentage of patients need to decrease amount of protein in diet ➢ Distribute the protein throughout day in several meals and separate taking their medications from the protein meals by 1 -1/2 hours. ▪ Maintain appropriate BMI (prevent low BMI or weight loss) ▪ Encourage exercise with MD approval ▪ Provide high calorie diet ➢ Encourage calorie dense food choices diet (e.g. peanut butter, cheese, whole milk) ➢ Encourage more foods per day, more frequent meals ▪ Identify if characteristic involuntary muscle movements affect: ➢ Self feeding ➢ Meal preparation/cooking

(section-ii)(nutrition-risk-manual)(page-223)Page 223#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 223

Severe cleft lip and palate anomalies commonly cause difficulty with chewing, sucking and swallowing, even after extensive repair efforts (2). Surgery is required for many gastrointestinal congenital anomalies. (Examples are trachea-esophageal fistula, esophageal atresia, gastroschisis, omphalocele, diaphragmatic hernia, intestinal atresia, and Hirschsprung's Disease.)

Impaired esophageal atresia and trachea-esophageal fistula can lead to feeding problems during infancy. The metabolic consequences of impaired absorption in short bowel-syndrome, depend on the extent and site of the resection or the loss of competence. Clinical manifestations of short bowel syndrome include diarrhea, dehydration, edema, general malnutrition, anemia, dermatitis, bleeding tendencies, impaired taste, anorexia, and renal calculi. Total parenteral feedings are frequently necessary initially, followed by gradual and individualized transition to oral feedings. After intestinal resection a period of adaptation by the residual intestine begins and may last as long as 12-18 months (3). Even after oral feedings are stabilized, close follow-up and frequent assessment of the nutritional status of infants with repaired congenital gastro-intestinal anomalies is recommended (2).

Sickle-cell anemia is an inherited disorder in which the person inherits a sickle gene from each parent. Persons with sickle-cell trait carry the sickle gene, but under normal circumstances are completely asymptomatic. Good nutritional status is important to individuals with sickle-cell anemia to help assume adequate growth (which can be compromised) and to help minimize complications of the disease since virtually every organ of the body can be affected by sickle- cell anemia (i.e., liver, kidneys, gall bladder, and immune system). Special attention should be given to assuring adequate caloric, iron, folate, vitamin E and vitamin C intakes as well as adequate hydration.

Muscular dystrophy is a familial disease characterized by progressive atrophy and wasting of muscles. Changes in functionality and mobility can occur rapidly and as a result children may gain weight quickly (up to 20 pounds in a 6 month period). Early nutrition education that focuses on foods to include in a balanced diet, limiting foods high in simple sugars and fat and increasing fiber intake can be effective in minimizing the deleterious effects of the disease.

Justification for High Risk

Not Applicable

Additional Counseling Guidelines

• Explain that disorders affect nutrition if they cause problems with self-feeding, digestion, absorption or utilization of nutrients and/or hypoxia (low oxygen levels) • Considerations for Cleft Lip and Palate: ▪ Discuss and address solutions to feeding difficulties

(section-ii)(nutrition-risk-manual)(page-224)Page 224#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 224

▪ Infant cannot create an airtight seal (for negative pressure) to suck ▪ Swallowing can be affected (excessive air intake) ▪ Discuss and address solutions to other difficulties, such as: ➢ Respiratory problems ➢ More ear infections ➢ Weight and height can be subnormal, due to feeding problems ➢ Dental decay ▪ Discuss feeding methods ➢ Determined by severity of cleft ➢ Breastfeeding and/or pumped breast milk o Mom and baby may need breastfeeding assistance o Breastfeeding provides benefits of decreased infections, ear and respiratory and prior to surgeries and post surgery protection o Aids in development of orofacial muscles o Breastfeeding at breast with cleft palates is very difficult and many medical professionals do not encourage it due to outcomes o Less severe cleft lips, especially after surgery, can be more successful at breast o Try different positions to get seal, both mother and baby comfortable, head slightly higher than buttocks o Use finger or thumb to seal cleft lips o Direct nipple away from back of throat o Support breast and chin to prevent tiring (“Dancer” position) o Shorter feeds may be necessary due to fatigue o Get “let down” before feeding o Pump to keep milk supply up o Use of hind milk o Support breastfeeding mom’s efforts (regardless of outcome) ➢ Brecht feeder (syringe with flexible tubing) ➢ Beniflex (crossed nipple) ➢ Haberman feeder (large nipple with collection receptacle) ➢ Supplemental Nutrition System (SNS), Infant Feeding Tube devices ➢ Formula ➢ Support recommended feeding techniques ➢ Use feeding method up to 4-6 months until infant can use cup and spoon feeding ▪ Explain importance of closely monitoring weight gain ▪ For older infants receiving solids: ➢ Avoid acidic and spicy foods that could cause irritation of the mouth and nose ➢ Avoid nuts, peanut butter, leafy vegetables, peeling of raw fruits, creamed dishes that could get caught in cleft ➢ Child may eat slower, may tire before eating adequately

(section-ii)(nutrition-risk-manual)(page-225)Page 225#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 225

➢ Offer smaller, more frequent meals of high caloric dense foods (low fluid content) ➢ • Explain lip surgery/repair: ▪ Usually schedule when infant reaches 10 lbs or about 6-8 weeks ▪ May use feeding assistance device until can resume breastfeeding ▪ Offer water after feeding to prevent contamination of suture line • Explain palate repair: ▪ Usually schedule at 12-14 months old ▪ Palatal obturator used to keep the hard palate from closing ▪ Post operation - use cup feeding not spoon feeding or straw to avoid injury to the repair site ▪ Diet of soft, finely pureed or mashed 10-20 days, then normal diet ▪ Avoid hard foods (e.g. raw vegetables) • Considerations for Down Syndrome: ▪ Discuss feeding method(s) ➢ Dependent on if very low tone or have other medical problems ➢ Breastfeeding options and using pumped breast milk ➢ Use of Supplemental Nursing System (SNS), Infant Feeding Tube device ➢ Use of cup, flexible cup (e.g. - Infa Feeder) ➢ Use of appropriately suited bottle and nipple ▪ Discuss and address solutions to feeding difficulties ➢ Mom and baby may need breastfeeding assistance o Encourage small frequent feedings and correct latch/positioning o Low muscle tone may fatigue or be less effective at feedings (e.g. - 2-3 gum presses and then sweep tongue to get milk from breast) o Flat tongue gets less milk at breast (doesn’t cup) o Gulping and choking happens more easily; airway not as well protected with swallowing o Discuss breastfeeding techniques o Encourage cuddling, skin to skin for stimulation o Encourage to direct nipple away from back of throat or more upward to assist milk flow for easier swallowing o Observe nursing patterns, may change with need to burp o Support breast and chin to prevent tiring (“Dancer” position) o Shorter feeds may be necessary due to fatigue o Get “let down” before feeding o Use double electric breast pump to keep milk supply up o Encourage patience and learning o Support breastfeeding mom’s efforts (irrelevant of outcome) ▪ Explain importance of monitoring weight gain (use Down Syndrome growth chart for counseling) ▪ For older infant receiving solids:

(section-ii)(nutrition-risk-manual)(page-226)Page 226#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 226

➢ Avoid nuts, peanut butter, leafy vegetables, or foods that are difficult to manipulate in mouth or cause choking ➢ May eat slower, may tire before eating adequately ➢ Possibly delay introduction to solid foods due to late appearance of the chewing reflex and of teeth ➢ Offer small bites, clear mouth, offer liquids due to storage of food in the high arched palate (thrusting of food out of the mouth with the tongue) ➢ Use bibs/overshirts; increased mucus production ➢ Offer smaller more frequent meals • Considerations for Sick Cell Anemia: ▪ If participant has unusually high or low hematocrit/hemoglobin, refer to MD ▪ Dietary intakes should be normally low in iron ▪ Iron rich foods such as liver and iron fortified cereals should be excluded ▪ Requirements for water soluble vitamins are high ▪ Dietary intake of fat should be low (< 30% of total calories especially if participant has liver and gall bladder disease) ▪ Zinc supplementation may be helpful (refer to MD) • Considerations for Thalassemia: ▪ If participant has unusually high or low hematocrit/hemoglobin, refer to MD ▪ Include diet rich in water soluble vitamins ▪ Recommend diet low in iron if transfusions are part of treatment • Considerations for Muscular Dystrophy: ▪ Refer to MD for monitoring medications and possible side effects, GI problems ▪ Calorie requirements may be less than normal ▪ Limit high calorie, low nutrient density foods ▪ Limit fat to no greater than 30% of total calories ▪ Increase fiber if constipation is a problem ▪ Watch for increase in weight gain, (increase in BMI), or obesity ➢ Encourage following exercise program, physical and respiratory therapies ▪ Watch for swallowing difficulties, if phlegm accumulates due to ingestion of dairy ➢ Ensure adequate calcium intake and use juices to clear phlegm ▪ Watch for changes in functional ability or mobility that affect caloric intake (e.g. self feeding) or caloric expenditure (e.g. ability to walk/move) ▪ May need to use rubber mesh mat or moistened paper towel under plate to prevent slipping ▪ Use lightweight plastic bowls vs. glass or ceramic ▪ Increase diameter of eating utensils with foam ▪ Use wide-handled plastic mugs & sip cups, two handled cups or water bottles with straws ▪ Cut out rim of disposable cup to fit child's nose (allows chin forward comfort) ▪ For swallowing difficulties: ➢ Suck ice chips to desensitize the gag reflex (adults) ➢ Tip chin down if food gathers in the back of the mouth

(section-ii)(nutrition-risk-manual)(page-229)Page 229#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 229

The inheritance of most metabolic disorders is rare. IEM disorders may manifest at any stage of life, from infancy to adulthood. Early identification of IEM correlates with significant reduction in morbidity, mortality, and associated disabilities for those affected (1). All States screen newborns for IEM, although the type and number of IEM screened for may vary from State to State. Typically, infants are screened for amino acid disorders, urea cycle disorders, organic acid disorders, and fatty acid oxidation defects. A few States are working toward including lysosomal storage diseases and peroxisomal disorders among their newborn screening panels (2).

In most states, treatment of an IEM is referred to a specialized metabolic treatment facility. Please see Clarification for contact information for treatment facilities. IEM treatment is based on symptomatic therapy which may include the following strategies: substrate restriction; stimulation or stabilization of residual enzyme activity; replacement of deficient products; removal of toxic metabolites or blocking their production; and enzyme replacement therapy (3). Avoidance of catabolism is essential at all treatment stages. Nutrition therapy is integral to the treatment of IEM. Nutrition therapy should both correct the metabolic imbalance and ensure adequate energy, protein, and nutrients for normal growth and development among affected individuals. Continual monitoring of nutrient intake, laboratory values, and the individual’s growth are needed for evaluation of the adequacy of the prescribed diet (4). It is important that caregivers of infants and children with IEM ensure that the patient follows the prescribed dietary regimen. The below embedded links provide the most up-to-date information about the disease state as well as treatment. Amino Acid Metabolism Disorders (3)

• Phenylketonuria (includes clinically significant hyperphenylalaninemia variants) • Maple syrup urine disease • Homocystinuria • Tyrosinemia Amino Acid Metabolism Disorders are characterized by the inability to metabolize a certain essential amino acid. The build-up of the amino acid that is not metabolized can be toxic. Treatment of amino acid disorders involves restricting one or more essential amino acids to the minimum required for growth and development and supplying the missing product due to the blocked reaction. Carbohydrate Disorders (5)

• Galactosemia • Glycogen storage disease type I • Glycogen storage disease type II (See also Pompe disease) • Glycogen storage disease type III • Glycogen storage disease type IV (Andersen Disease) • Glycogen storage disease type V

(section-ii)(nutrition-risk-manual)(page-230)Page 230#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 230

• Glycogen storage disease type VI • Hereditary Fructose Intolerance (Fructose 1-phosphate aldolase deficiency, Fructose 1, 6, biphosphatase deficiency, fructose kinase deficiency) This group of disorders includes an enzyme deficiency or its cofactor that affects the catabolism or anabolism of carbohydrate. Carbohydrate disorders are complex and affect neurological, physical, and nutritional status. Fatty Acid Oxidation Defects (5)

• Medium-chain acyl-CoA dehydrogenase deficiency • Long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency • Trifunctional protein deficiency type 1 (LCHAD deficiency) • Trifunctional protein deficiency type 2 (mitochondrial trifunctional protein deficiency) • Carnitine uptake defect (primary carnitine deficiency) • Very long-chain acyl-CoA dehydrogenase deficiency Fatty acid oxidation defects include any enzyme defect in the process of mitochondrial fatty acid oxidation (FAO) system. The biochemical characteristic of all FAO defects is abnormal low ketone production as a result of the increased energy demands. This results in fasting hypoglycemia with severe acidosis secondary to the abnormal accumulation of intermediate metabolites of FAO, which can result in death.

Organic Acid Disorders (AKA organic aciduria or organic acidemia) (6)

• Isovaleric acidemia • 3-Methylcrotonyl-CoA carboxylase deficiency • Glutaric acidemia type I • Glutaric acidemia type II • 3-hydroxy-3-methylglutaryl-coenzyme A lyase deficiency • Multiple carboxylase deficiency (Biotinidase deficiency, Holocarboxylase synthetase deficiency) • Methylmalonic acidemia • Propionic acidemia • Beta-ketothiolase deficiency Organic Acid Disorders are characterized by the excretion of non-amino organic acids in the urine. Most of the disorders are caused by a deficient enzyme involving the catabolism of specific amino acid(s). As a result, the non-metabolized substance accumulates due to the blockage of the specific metabolic pathway, which is toxic to certain organs and may also cause damage to the brain (7). Lysosomal Storage Diseases (6, 8)

• Fabry disease (α-galactosidase A deficiency) • Gauchers disease (glucocerebrosidase deficiency)

(section-ii)(nutrition-risk-manual)(page-231)Page 231#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 231

• Pompe disease (glycogen storage disease Type II, or acid α-glucosidase deficiency)

Lysosomal storage diseases are a group of related conditions characterized by increased storage of undigested large molecule in lysosomes. Lysosome is a cellular organelle responsible for intracellular degradation and recycling of macromolecules. Due to a defect in a specific lysosomal enzyme, the macromolecule that normally would be metabolized is not broken down; instead, it accumulates in the lysosomes. This leads to tissue damage, organ failures and premature death. Common clinical features include bone abnormalities, organomegaly, developmental impairment and central, peripheral nervous system disorders.

Mitochondrial Disorders (6, 8)

• Leber hereditary optic neuropathy • Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) • Mitochondrial neurogastrointestinal encephalopathy disease (MNGIE) • Myoclonic epilepsy with ragged-red fibers (MERRF) • Neuropathy, ataxia, and retinitis pigmentosa (NARP) • Pyruvate carboxylase deficiency

Mitochondrial Disorders are caused by the dysfunction of the mitochondrial respiratory chain, or electron transport chain (ETC). Mitochondria play an essential role in energy production. The ETC dysfunction increases free radical production, which causes mitochondrial cellular damage, cell death and tissue necrosis and further worsens ETC dysfunction and thus forms a vicious cycle. The disorders can affect almost all organ systems. However, the organs and cells that have the highest energy demand, such as the brain and muscles (skeletal and cardiac) are most affected. The clinical features vary greatly among this group of disorders, but most have multiple organ dysfunctions with severe neuropathy and myopathy.

Peroxisomal Disorders (6, 8, 9)

• Zellweger Syndrome Spectrum • Adrenoleukodystrophy (x-ALD) There are two types of peroxisomal disorders: single peroxisomal enzyme deficiencies and peroxisomal biogenesis disorders. These disorders cause severe seizures and psychomotor retardation (9). Peroxisomes are small organelles found in cytoplasm of all cells. They carry out oxidative reactions which generate hydrogen peroxides. They also contain catalase (peroxidase), which is important in detoxifying ethanol, formic acid and other toxins. Single peroxisomal enzyme deficiencies are diseases with dysfunction of a specific enzyme, such as acyl coenzyme A oxidase deficiency. Peroxisomal biogenesis disorders are caused by multiple peroxisome enzymes such as Zellweger syndrome and neonatal adrenoleukodystrophy.

(section-ii)(nutrition-risk-manual)(page-232)Page 232#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 232

Urea Cycle Disorders (6, 5)

• Citrullinemia • Argininosuccinic aciduria • Carbamoyl phosphate synthetase I deficiency

Urea Cycle Disorders occur when any defect or total absence of any of the enzymes or the cofactors used in the urea cycle results in the accumulation of ammonia in the blood. The urea cycle converts waste nitrogen into urea and excretes it from the kidneys. Since there are no alternate pathways to clear the ammonia, dysfunction of the urea cycle results in neurologic damages. Implications for WIC Nutrition Services

WIC can provide exempt infant formulas and WIC-eligible medical foods, including those specifically formulated for IEM. Most of the dietary regimens for IEM require a combination of medical food (special formula in most cases) and standard infant formula or prescribed conventional foods. For example, participants with IEM related to essential amino acid metabolism (such as PKU, MSUD), who are not developmentally ready for conventional foods; require both medical food without the offending amino acid(s), and human milk or standard infant formula.

It is recommended that WIC nutritionists collaborate with the clinical dietitians at the metabolic treatment facility, where available, to prescribe WIC food packages (Food Package III) according to the therapeutic diet ordered by the metabolic team, monitor the compliance of the restricted diet, and follow up on the growth and developmental status of the participants with IEM.

Note: Infants with classic galactosemia cannot be breastfed due to lactose in human milk.

Clarification

IEM not listed within this write-up may be found under: http://rarediseases.info.nih.gov/GARD. Please keep in mind these additional resources are not meant for medical advice nor to suggest treatment. Self-reporting of a diagnosis by a medical professional should not be confused with self- diagnosis, where a person simply claims to have or to have had a medical condition without any reference to professional diagnosis. A self-reported medical diagnosis (“My doctor says that I have/my son or daughter has…”) should prompt the CPA to validate the presence of the condition by asking more pointed questions related to that diagnosis.

(section-ii)(nutrition-risk-manual)(page-233)Page 233#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 233

The link below lists newborn screening coordinators. The coordinator can direct families to appropriate metabolic treatment facilities based on the newborn screening result: http://genes-r- us.uthscsa.edu/State_contacts.pdf.

Justification for High Risk

Untreated pregnant women with certain inborn errors of metabolism have a higher risk of spontaneous abortion and other health or nutrition risks. Significant adaptation of energy, carbohydrate and amino acid metabolism occurs early in prenatal and neonatal development (10). Many metabolic errors in metabolism affect these pathways and such disturbances may lead to poor intrauterine growth and maternal health.

Infants born to mothers with untreated PKU may show fetal growth restriction, microcephaly, low birth weight, and congenital heart disease. If not detected and treated soon after birth, infants accumulate abnormal metabolites in their blood, resulting in mental retardation, seizures, growth retardation, and developmental delays. Infants with inborn metabolic errors typically exhibit lethargy, decreased feeding, vomiting, seizures, and failure to thrive. As these infants get older they may miss cognitive milesontes, loss of language skills, progressive deficits in attention or focus and other behavioral changes (4). Appropriate dietary management, which includes the use of special formulas, can minimize the medical risks to the individual. WIC can provide nutritional treatment tailored to each of the inborn errors of metabolism and refer participants to a physician who may recommend carnitine supplementation.

Additional Counseling Guidelines

• Considerations for Phenylketonuria (PKU): ▪ Individuals with PKU lack the enzyme to convert phenylalanine (an essential amino acid) to tyrosine ▪ Pregnant women are at higher risk of spontaneous abortion or other health or nutrition risks ▪ High levels of phenylalanine and its metabolites are toxic to the developing central nervous system ➢ Risk to fetus and newborn such as IGR, congenital anomalies, mental retardation ▪ Total restriction of phenylalanine can also cause problems such as microcephaly, intrauterine growth retardation, FTT ▪ Infants born to mothers with untreated PKU may show fetal growth restriction, microcephaly, LBW, and congenital heart disease ➢ Infants need to be treated soon after birth to prevent serious health problems • Review benefits of treatment: ▪ During pregnancy, lowering intake of phenylalanine to normal levels reduces the risk of damage to the fetus or newborn

(section-ii)(nutrition-risk-manual)(page-234)Page 234#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 234

▪ Infants and children who receive early and continuous dietary treatment can normalize blood phenylalanine and can have normal mental development • Reinforce: ▪ Infants with PKU should not be exclusively breastfed ➢ They need to follow their prescription for low phenylalanine formula in conjunction with breastfeeding (e.g. Phenex 1, Analog XP) ▪ Individuals with disorder, or parent/caregiver, need to learn foods low in phenylalanine, portion sizes, planning for diet ▪ Not to use artificial sweetener aspartame ➢ For foods containing it, read labels (no NutraSweet, Equal) • Considerations for Galactosemia: • Reinforce: ▪ Importance of receiving ongoing medical/dietary care ▪ No breastfeeding ▪ Importance of following prescribed formula or dietary prescription which may change with the participant’s needs • Considerations for Hyperlipoproteinemia (HLP): • Reinforce: ▪ Need for ongoing medical/dietary care ▪ Need to follow dietary recommendations (which are individualized depending on the type) such as: ➢ Decrease saturated fat ➢ Decrease cholesterol ➢ Increase fiber ➢ Decrease alcohol ▪ Follow medications ▪ Participants with high triglyceride levels and/or hypertension need to follow MD treatment, such as: ➢ No smoking ➢ Regular exercise ▪ Encourage compliance to prevent atherosclerosis and coronary heart disease

References

1. Metabolic backgrounder: The Ross metabolic formula system for meeting special nutrition needs. Columbus, OH: Ross Products Division; 2007. 2. Levy PA. Inborn Errors of Metabolism: part 1: Overview. Pediatr Rev. 2009Apr; 30(4):131-7. 3. Wilcken B. An introduction to nutritional treatment in Inborn errors of metabolism – different disorders, different approaches. Southeast Asian J Trop med Public Health. 2003; 34 Suppl 3: 198-201.

(section-ii)(nutrition-risk-manual)(page-235)Page 235#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 235

4. Hendricks KM, Duggan C. Manual of pediatric nutrition, 4th ed. 2005; 626-657. 5. Ekval S, Ekvall, VK, editors. Pediatric nutrition in chronic diseases and developmental disorders: prevention, assessment and treatment. 2nd ed. Oxford University Press; 2005. Part III. Chapters 37 -59. 6. GeneReviews are expert-authored, peer-reviewed, current disease descriptions that apply genetic testing to the diagnosis, management, and genetic counseling of patients and families with specific inherited conditions. Available at: http://www.ncbi.nlm.nih.gov/sites/GeneTests/review?db=GeneTests (last accessed 8/5/2010). 7. Stanley CA. Disorders of fatty acid oxidation. In: Fernandes J, et al editors. Inborn metabolic diseases. Berlin Springer; 2000. p. 141-150. 8. Agamanolis D. Inherited metabolic disorders in neuropathology: an illustrated interactive course for medical students and residents. Akron OH: Akron Children’s Hospital, Northeastern Ohio University College of Medicine. Available at: http://www.neuropathologyweb.org/chapter10/chapter10aLSDgeneral.html. 9. Van Veldhoven, PP, Leuven KU. Biochemistry and genetic disorders of inherited disorders of peroxisomal fatty acid metabolism. J Lipid Res. 2010 June. Available at: http://www.jlr.org/cgi/rapidpdf/jlr.R005959v1.

References for High Risk

1. Meas T, Deghmoun S, Armoogum P, Alberti C, Levy-Marchal C. Consequences of being born small for gestational age on body composition: An 8-year follow-up study. J Clin Endocrinol Metab. 2008; 93(10):3804-3809.

2. Ibanez L, Ong K, Dunger DB, Zegher F. Early development of adiposity and insulin resistance after catch-up weight gain in small-for-gestational-age children. J Clin Endocrinol Metab. 2006; 91(6):2153-2158.

3. Wang X, Cui Y, Tong X, Ye H, Li S. Glucose and lipid metabolism in small-for- gestational age infants at 72 hours of age. J Clin Endocrinol Metab. 2007;92(2):681-684.

4. Clayton PE, Cianfarani S, Czernichow P, Johannsson G, Rapaport R, Rogol A. Management of the child born small for gestational age through to adulthood: A consensus statement of the international societies of pediatric endocrinology and the growth hormone research society. J Clin Endocrinol Metab. 2007; 92(3):804- 810.

(section-ii)(nutrition-risk-manual)(page-238)Page 238#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 238

Both chronic and acute infectious diseases can lead to: 1) poor appetite, 2) low nutrient absorption, 3) accelerated nutrient utilization, and/or 4) rapid nutrient loss, depending on the individual’s nutritional state before becoming infected and the individual’s diet during the improvement period (3). The following information pertains to some of the more prevalent and/or serious acute infectious diseases.

Justification for High Risk

Not Applicable

VIRAL HEPATITIS Hepatitis is inflammation of the liver. It is most often caused by viruses, but can also be caused by excessive alcohol consumption, toxins, and medicines such as acetaminophen, as well as other medical condition linked to liver inflammation (4). Viral hepatitis is caused by a series of viruses labeled A, B, C, D, and E – with A, B, and C being the most common forms in the United States. Viral hepatitis A and E are the only forms that are acute and do not become chronic, whereas B, C, and D can both be acute and chronic in nature (5). (For more information on chronic infectious diseases see Risk #352b Infectious Diseases – Chronic.) Regardless of the type of hepatitis, infected individuals with signs of the infection will typically experience anorexia, nausea, vomiting, diarrhea, jaundice, epigastria pain, tiredness, and weakness, all of which affect one’s diet and health (5). In addition, darker urine and pale stools may be present in infected individuals. It is important to note that viral hepatitis is the leading cause of liver cancer and the most frequent need for liver transplants in the United States (6). Hepatitis A: Hepatitis A is an acute infection caused by exposure to the Hepatitis A virus. It is transmitted through the fecal-oral route, with transmission most commonly spread through close contact with an infected household member or sexual partner. Outbreaks can also be caused by fecal-contaminated food or water. Because the symptoms of all types of acute hepatitis infections are the same, suspected diagnosis must be confirmed through either positive laboratory testing, or epidemiologic link to a confirmed case. (7) A large majority of those infected with Hepatitis A are asymptomatic, with 70% showing no clinical signs of infection. Hepatitis A does not progress to a chronic disease, and symptoms typically resolve without treatment in two months, however in 10-15% of cases periodic relapses can occur for up to six months. (8) The Hepatitis A virus can survive for months outside of the body, therefore proper hygiene and food safety are important preventative measures. However, the most effective method of preventing infection is through vaccination, which has reduced the incidence of Hepatitis A by 95% since its introduction. Emphasis should be placed on preventing an unvaccinated child from close personal contact with someone who is at high risk, or suspected of Hepatitis A infection. (7) Hepatitis E: Hepatitis E is an acute infection caused by exposure to the Hepatitis E virus. It is transmitted through the fecal-oral route, most commonly through ingestion of contaminated

(section-ii)(nutrition-risk-manual)(page-239)Page 239#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 239

drinking water. However recent cases have been linked to uncooked/undercooked meat and shellfish, indicating the potential for foodborne exposure. While Hepatitis E is believed to be uncommon in the United States, those who frequently travel to developing countries with poor water and environmental sanitation are at risk of becoming infected. Diagnosis for Hepatitis E can be confirmed only by testing for the presence of antibodies to the virus or viral RNA. There are currently no serological tests approved for use in the United States. (9) Hepatitis E symptoms typically resolve on their own, and there is currently no therapeutic treatment or approved vaccine for the disease. Supportive therapy should be offered and hospitalization recommended for severe cases. The predominant forms of prevention are good sanitation and only relying on clean drinking water when in areas at high risk for infection. (10) Pregnant women are especially at risk when infected with Hepatitis E. While in general most people will recover completely and the death rate among confirmed cases is about 1%, the mortality rate can reach 10-30% for women in their third trimester. (9) MENINGITIS Characterized by an inflammation of the protective membranes known as the meninges, meningitis is typically caused by an infection of the fluid surrounding the brain and the 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. Due to the severity of meningitis and resulting treatment differing depending on the cause, it is important to correctly diagnose the agent responsible for the disease. (11)

Bacterial Meningitis: While most people with meningitis typically recover, bacterial meningitis is typically severe and can result in serious complications, including brain damage, hearing loss, or learning disabilities. The leading causes of bacterial meningitis in the United States include Haemophilus influenzae, Streptococcus pnemoniae, Listeria monocytogenes, and Neisseria meningitidis. The causes of meningitis vary by age group. In adults, including pregnant women, it is most commonly caused by Streptococcus pneumoniae, Neisseria meningitidis, and Listeria monocytogenes. The cause in newborns is most typically Group B Sterptococcus, E. coli, and Listeria. Infants and children most commonly develop meningitis in response to Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae type b. (12) In addition, Cronobactor may cause severe meningitis in infants. Although Cronobactor infection is rare (the Centers for Disease Control and Prevention reports 4-6 infections in infants per year), meningitis due to Cronobactor occurs almost exclusively among infants in the first 2 months of life. Cronobactor infections have been associated with consumption of reconstituted powdered infant formula. In several outbreak investigations, Cronobactor has been found in powdered infant formula that had been contaminated in the factory. In other cases, the powdered infant formula might have been contaminated with Cronobactor after it was opened at home or elsewhere. It is recommended that manufacturer’s preparation instructions be adhered to in order to prevent Cronobactor infection in infants consuming reconstituted powdered infant formula. (13) Risk factors for bacterial meningitis include, but are not limited to, age, with infants at higher risk than other age groups; congregate living settings, with groups such as military personnel and

(section-ii)(nutrition-risk-manual)(page-240)Page 240#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 240

college students at increased risk; medical conditions that weaken the immune system; and travel to the meningitis belt in sub- Saharan Africa. Transmission from an infected person usually requires prolonged, close, contact. Additionally, healthy people may carry the bacteria in their nose and throat without developing an illness and most healthy people who carry the disease never become sick. Pregnant women infected with any of the bacteria responsible for causing meningitis are capable of passing the bacteria to their baby, putting them at increased risk of developing meningitis. (12) Meningitis symptoms are characterized by a sudden onset of fever, headache, and stiff neck. Other symptoms are also often present, including nausea, vomiting, sensitivity to light, and confusion. Diagnosis must be confirmed through laboratory testing of the blood or cerebrospinal fluid. Bacterial meningitis is effectively treated with antibiotics, though it is important to begin treatment as early as possible. (12) The most effective method of preventing meningitis is vaccination. There are currently vaccines available for three types of meningitis causing bacteria - Neisseria meningitidis (meningococcus), Streptococcus pneumoniae (pneumococcus), and Haemophilus influenzae type b (Hib). Additionally for individuals in close contact with those with the disease, antibiotics may be recommended as a preventative measure. The risk of meningitis resulting from Listeria can be prevented by properly preparing and refrigerating food as well as avoiding certain foods. Women diagnosed with group B strep are also given antibiotics during labor to prevent transmission to their newborn. (12) Viral Meningitis: Viral meningitis is the most common type of meningitis and is often less severe than bacterial caused cases. In the United States it is most commonly caused by non- polio enteroviruses, as well as others including the mumps, herpes, measles, influenza, and arboviruses. While few people infected with these viruses develop meningitis, the risk is especially high from summer to fall. Children younger than five and people with weakened immune systems are at higher risk of developing the disease, with infants younger that one month old and people with weakened immune systems more likely to develop severe illness. (14)

Transmission of a virus that can lead to meningitis may occur due to close contact with a person who has viral meningitis, however it is unlikely meningitis will develop. Symptoms in infants include fever, irritability, poor eating, sleepiness or trouble waking, and lethargy. Adults most commonly experience fever, headache, stiff neck, light sensitivity, sleepiness or trouble waking, nausea, vomiting, lack of appetite, and lethargy. As with bacterial meningitis, diagnosis requires lab tests to confirm the illness. (14) Typically viral meningitis resolves without treatment in 7-10 days. However those with meningitis caused by the herpes virus or influenza may benefit from antiviral medication. While there are no vaccines available for the non-polio enteroviruses that can cause meningitis, the following steps can be taken to reduce the risk of infection: • Washing hands often with soap and water, especially after changing diapers, using the toilet, or coughing or blowing your nose.

(section-ii)(nutrition-risk-manual)(page-241)Page 241#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 241

• Avoiding face touching with unwashed hands. • Avoiding close contact with infected persons. • Cleaning and disinfecting frequently touched household surfaces. • Staying home when sick. Additionally children should be vaccinated against the other viruses that can cause meningitis, including measles, mumps, chickenpox, and influenza. (14) LISTERIOSIS Listeriosis is a serious infection caused by the bacteria Listeria monocytogenes. It is most commonly transmitted through contaminated food; however it is also naturally present in the soil, water, and animals, including poultry and cattle (15). Listeria is especially dangerous due to its ability to grow in cold temperatures, unlike many other pathogens (16). 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 (17). Pregnant women and newborns are at exceptionally high risk for listeriosis, with pregnant women 10-20 times as likely as the general population to become infected (18). It can lead to miscarriage, stillbirth, or lifelong health issues for the child (19). Additionally, those with weakened immune systems are also at heightened risk. Listeriosis is treated with antibiotics and for severe cases referral to a medical facility may be necessary. The best methods of prevention are associated with proper food safety, handling, and storage. Additionally, raw milk and raw dairy products should be avoided. There is currently no vaccine available. (17) PNEUMONIA Pneumonia is an infection of the lungs that can cause mild to severe illness. It can be caused by viruses, bacteria, and fungi. In the United States the most common causes of viral and bacterial pneumonia are respiratory synctal virus (RSV) and Streptococcus pneumonia (pneumococcus), respectively, however Human Parainfluenza Viruses are the leading cause of pneumonia in infants and children. Symptoms include fever, muscle aches, fatigue, enlarged lymph nodes in the neck, chest pain, sore throat, coughing, shortness of breath, and rapid breathing. (20) Children younger than five years of age are considered at especially high risk of pneumonia. Additionally, pneumonia contracted during pregnancy has been associated with increased morbidity and mortality when compared with non-pregnant women. It can lead to negative outcomes including low birth weight, increased risk of pre-term birth, and serious complications for the mother including respiratory failure.

Treatment includes administering antimicrobial and antiviral drugs depending on the pathogen responsible for the infection. (21) Vaccination is an effective way to prevent pneumonia, with several vaccinations available for both bacteria and viruses including pneumococcal, Haemophilus influenzae type b (Hib), pertussis (whooping cough), varicella (chickenpox), measles, and influenza vaccines. Good hygiene is also another effective method of prevention, including regular hand-washing and disinfecting frequently touched surfaces. (20)

(section-ii)(nutrition-risk-manual)(page-242)Page 242#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 242

BRONCHITIS Acute bronchitis is diagnosed by a healthcare provider based on the signs and symptoms present in the patient. It is a condition that occurs when the airways in the lungs swell and produce mucus, resulting in a cough. Bronchitis typically occurs after a chest cold and is usually caused by a virus, with the most common being: Respiratory syncytial virus (RSV), Adenovirus, Influenza viruses, and parainfluenza. Symptoms include, but are not limited to coughing that produces mucus; soreness in the chest; fatigue; headache; body aches; fever; and sore throat. Most symptoms of acute bronchitis resolve on their own after two weeks, but the cough may last up to eight weeks in some cases. In severe cases, such as a fever above 100.4 degrees Fahrenheit, patients should seek assistance from a health care provider. (22) Since bronchitis is almost never caused by bacteria, antibiotics are not needed or recommended. Furthermore, antibiotic treatment may cause harm in both children and adults (20). The best course of action is to provide symptom relief through rest, over-the-counter medicines, and other self-care methods. It is important to use pain relievers appropriate for the age of the child, and only acetaminophen for babies six months of age and younger (23). Bronchitis may be prevented by avoiding smoking, practicing good hygiene, and remaining current on all immunizations (22).

PARASITIC INFECTIONS Parasites are organisms that live on or in a host organism and survive by getting their food at the detriment of the host. Pregnant women and children are most at risk from certain types of parasites including Toxoplasma gondii – found in uncooked meat; Giardia intestinalis; Cryptosporidium; lice; and pinworms (24). Toxoplasmosis, caused by Toxoplasma gondii, is considered to be the leading cause of death attributed to foodborne illness in the United States (25). To reduce the risk of parasitic infection, prevention includes good food safety and general good hygiene. Additionally environmental risk can be reduced by wearing gloves when coming into contact with soil, covering sandboxes, and teaching children the importance of hand washing (26). Most healthy people will recover from parasites without treatment. However for pregnant women, newborns, and infants with toxoplasmosis, treatment can be administered as a combination of drugs such as pyrimethamine and sulfadiazine, plus folinic acid (27). This treatment will reduce the parasitic burden, but will not eliminate it completely as parasites can remain in tissues, which makes it hard for the medication to reach them. Lice and other dermal parasites can be treated with topical drugs, such as medicated shampoo (24). Implications for WIC Nutrition Services WIC can improve the management of acute infectious diseases through WIC foods, nutrition education, counseling, and referrals to community resources. The table below provides additional WIC nutrition services recommendations specific to the disease state that can help improve the health outcomes of participants with acute infectious diseases:

(section-ii)(nutrition-risk-manual)(page-243)Page 243#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 243

WIC Nutrition Services Recommendations for Acute Infectious Diseases (9,10) All Types of Infections • Encourage sufficient calorie intake to ameliorate accelerated nutrient utilization. • Recommend the Dietary Guidelines to ensure healthy eating patterns. • Provide suggestions to address poor appetite. • Provide education on safe food handling and storage practices. 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. • Recommend high calorie consumption at breakfast as 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. • Encourage a bland diet with extra fluids depending on the severity of nausea and vomiting. Hepatitis A • Encourage the Hepatitis A vaccine for all children, previously unvaccinated adolescents through the age of 18, and high-risk adults. • Promote breastfeeding as being safe, but to avoid breastfeeding when nipples are cracked and bleeding – at which time, mothers should pump and discard milk to maintain supply. • Discourage the practice of pre-chewing food for infants, as blood may be present. Hepatitis E • Avoid contaminated water. Meningitis • Encourage vaccinations for both bacteria and viruses known to cause meningitis. • Provide education on proper food handling and storage practices. • Recommend use of manufacturer’s instruction for the preparation of infant formula. • Provide education on good hygiene practices. Listeriosis • Recommend alternatives to raw milk and dairy products. • Emphasize importance of safe food handling, preparation and storage practices. Pneumonia • Recommend referral to a healthcare provider to administer appropriate antimicrobial or antiviral treatment. Bronchitis • Provide education on symptom relief and proper pain-medication practices for children. • Recommend smoking cessation. • Provide education on good hygiene practices. • Encourage appropriate vaccinations. Parasitic Infections • Recommend appropriate measures be taken when coming into contact with potential environmental contaminants, e.g., use of gloves when working with soil and covering sandboxes when not in use. • Provide education on proper food handling and storage practices. • Provide education on good hygiene practices.

(section-ii)(nutrition-risk-manual)(page-244)Page 244#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 244

References 1. World Health Organization. Health topics: infectious disease. [cited 2015 May 15]. Available from:http://www.who.int/topics/infectious_diseases/en/. 2. Centers for Disease Control and Prevention (CDC). Division of Vector-Borne Diseases. [cited 2015 May 15]. Available from: http://www.cdc.gov/ncezid/dvbd/about.html. 3. Friis, H. Micronutrients and infection: an introduction. In: Micronutrients and HIV infection. Boca Raton:CRC Press; 2010. P. 3. 4. Centers for Disease Control and Prevention (CDC). Hepatitis information for the public. [cited 2014 Jan 27]. Available from: http://www.cdc.gov/hepatitis/PublicInfo.htm. 5. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Viral hepatitis: A through E and beyond. [cited 2014 Jul 26]. Available from: http://www.nlm.nih.gov/medlineplus/hepatitis.html. 6. Centers for Disease Control and Prevention. Division of Viral Hepatitis and National Center for HIV/AIDS. Viral hepatitis, STD, and TB prevention. [cited 2015 May 1]. Available from: http://www.cdc.gov/hepatitis/. 7. Centers for Disease Control and Prevention (CDC). Viral Hepatitis – Hepatitis A Information. [cited 2012 Aug 18]. Available from: http://www.cdc.gov/hepatitis/hav/havfaq.htm#general.

8. National Institute of Allergy and Infectious Disease (NIAID). Hepatitis A. [cited 2012 Aug 18].Available from: http://www.niaid.nih.gov/topics/hepatitis/types/Pages/hepatitisA.aspx. 9. Centers for Disease Control and Prevention (CDC). Hepatitis E FAQs for Health Professionals [cited 2012 Aug 18]. Available from: http://www.cdc.gov/hepatitis/hev/hevfaq.htm#section1. 10. National Institute of Allergy and Infectious Disease (NIAID). Hepatitis E. [cited 2012, Aug 18]. Available from: http://www.niaid.nih.gov/topics/hepatitis/types/Pages/hepatitisE.aspx. 11. Centers for Disease Control and Prevention (CDC). Meningitis. [cited 2012 Aug 26]. Available from:http://www.cdc.gov/meningitis/index.html. 12. Centers for Disease Control and Prevention (CDC). Bacterial Meningitis. [cited 2012 Aug 26]. Available from: http://www.cdc.gov/meningitis/bacterial.html. 13. Centers for Disease Control and Prevention (CDC). Cronobactor. [cited 2014 Feb 12]. Available from: http://www.cdc.gov/cronobacter/technical.html. 14. Centers for Disease Control and Prevention (CDC). Viral Meningitis. [cited 2012 Aug 26]. Available from: http://www.cdc.gov/meningitis/viral.html. 15. Food Safety.gov. Listeria. [cited 2012 Aug 26]. Available from: http://www.foodsafety.gov/poisoning/causes/bacteriaviruses/listeria/#. 16. Centers for Disease Control and Prevention (CDC). Listeria: People at Risk. [cited 2012 Aug 26]. Available from: http://www.cdc.gov/listeria/risk.html. 17. Schlech WF, 3rd, Lavigne PM, Bortolussi RA, Allen AC, Haldane EV, Wort AJ, Hightower AW, Johnson SE, King SH, Nicholls ES, Broome CV. Epidemic listeriosis--evidence for transmission by food. The New England journal of medicine. 1983;308(4):203-6.

18. Centers for Disease Control and Prevention. Vital signs: listeria illnesses, deaths, and outbreaks - United States, 2009-2011. Morbidity and Mortality Weekly Report (MMWR). 2013;62(22):448-52. 19. Jackson KA, Iwamoto M, Swerdlow D. Pregnancy-associated listeriosis. Epidemiology and infection. 2010;138(10):1503-9.

(section-ii)(nutrition-risk-manual)(page-247)Page 247#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 247

The Human Immunodeficiency Virus (HIV) is a chronic virus that reduces an individual’s ability to fight off infections and diseases (4). HIV destroys white blood cells found in the immune system, also known as CD4

(cluster of differentiation) or T cells (T lymphocytes) (5). HIV is transmitted only through blood, semen, pre- seminal fluid, rectal fluids, vaginal fluids, and breast milk from an HIV-infected person (6). HIV can lead to Acquired Immunodeficiency Syndrome (AIDS) if left untreated (4). 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 – while those unaware of their status or are not on ART, can usually remain in this stage about ten years before progressing to the AIDS stage. Some individuals may progress to the AIDS stage sooner than 10 years. During the time period a person progresses from HIV to AIDS, the immune system becomes extremely weakened and can no longer protect against other infections or opportunistic illnesses** - which are infections generally not detrimental to healthy individuals, but can be life-threatening in people infected with HIV. A person with AIDS and an opportunistic illness that goes untreated has a life expectancy of approximately one year (4). Getting tested is the only way individuals know they are infected with HIV. Many people infected with the virus display no symptoms for as long as ten years or more. The Centers for Disease Control and Prevention (CDC) currently estimates that 1 in 6 people in the United States infected with HIV do not know they have the virus and therefore recommends that everyone between the ages of 13-64 get tested at least once as part of a regular health screening. The CDC further recommends that all pregnant women be tested early in their pregnancy, via an “opt-out” testing measure – which is when pregnant women are told that an HIV test will be included in the standard group of prenatal tests and that they may decline the test. Unless the HIV test is specifically declined, they will be tested for the virus. (7) An early diagnosis in pregnant women can reduce the transmission of HIV in babies to 2%, if the expectant mother (8): • Receives Active Antiretroviral Therapy (ART) during pregnancy, labor, and delivery. • Delivers the baby by cesarean, or C-section. • Avoids breastfeeding. There is a 20% chance of transmission if the HIV positive, expectant mother does none of the prevention measures listed above (8). In addition, women living in certain geographic areas or women considered high risk, such as those with sexually transmitted infections, multiple partners, or have substance abuse issues, are encouraged to be retested in the third trimester, preferably when less than 36 weeks pregnant (9). 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%, and is recommended for (10): • Individuals in an HIV discordant relationship in which one partner is HIV positive and the other partner is HIV negative. • Heterosexual women who do not regularly use condoms with sex partners of unknown HIV status. • Women who share injectable drug paraphernalia or were in treatment for injectable drug use in the past six months.

(section-ii)(nutrition-risk-manual)(page-248)Page 248#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 248

** Extensive listing of opportunistic illness can be found at: http://womenshealth.gov/hiv- aids/opportunistic-infections-and-other-conditions/. HIV/AIDS and Nutrition: Dietary needs for an HIV positive individual are determined by the presence of symptoms (11, 12). Symptomatic individuals experiencing unintended weight loss, or wasting, and are dealing with: 1) poor food intake due to medication side effects, sore mouth, or mental health issues; 2) altered metabolism due to disease progression; or 3) nutrient malabsorption caused by gastrointestinal problems resulting from medications or just the presence of the virus. In symptomatic participants, the main goals are to: 1) increase or maintain a normal body weight; 2) retain or increase lean body mass; and 3) ensure adequate intake of macro- and micronutrients. In most cases, these individuals usually require diets higher in protein and potentially a multivitamin, as vitamins A, B6, C, and E are lower in symptomatic people. In instances when wasting cannot be alleviated through regular dietary means, enteral and parenteral nutrition therapy may be necessary. For asymptomatic individuals or those with a stable weight, the goals should focus on adequate intake of nutrients to prevent wasting – and if food intake is low, these individuals could potentially include a multivitamin or mineral supplement to avoid deficiencies (11, 12).

It is important to note that taking large amounts of iron supplements, leading to iron-overload, encourages disease progression from HIV to AIDS, and should be avoided. In addition, Vitamin A and Zinc, in the form of supplements, can have a negative impact on adults living with HIV/AIDS (12). Participants should always consult with their health care providers before taking dietary supplements over the Recommended Dietary Allowance to prevent adverse reactions and interactions with medications used to treat HIV/AIDS. (13) HIV/AIDS Medication Nutritional Problems: Even though people with HIV are able to manage the disease and live longer with Highly Active Antiretroviral Therapy (HAART), the side effects can have a negative impact on a person’s nutritional status. Common side effects include: gastrointestinal problems, lipid disorders, and insulin resistance/glucose intolerance. Participants experiencing these problems should: reduce total fat intake and cholesterol; increase dietary fiber; increase physical activity; reduce alcohol consumption; and reduce the consumption of simple sugars. (11, 12) HIV/AIDS and Food Safety: Participants living with HIV are more susceptible to contracting a food- borne illness due to weakened immune systems and therefore should be encouraged to: store and prepare foods safely; check expiration dates; and avoid raw or semi raw foods, such as meat, non- pasteurized dairy, and soft cheeses (11, 12). Infants born to HIV positive mothers, regardless of their HIV status, should drink ready-to-feed or liquid concentrate infant formula as powdered infant formula is not sterile and may not be microbiological safe (14). HIV/AIDS Care and Support: HIV-affected families often experience a lack of financial and psychosocial support needed to deal with an HIV/AIDS diagnosis, including the effects of social stigma which negatively impacts their ability to comply with the medical treatment needed to control the disease (15). Further, to fully benefit from current treatment protocols required to manage HIV and reduce the progression to AIDS, infected individuals who know their status, must get care, stay in care, and adhere to an effective antiretroviral treatment plan known as an HIV/AIDS Care Continuum (16). WIC agencies should proactively refer participants to health care services and various community resources, including other FNS nutrition assistance programs, to improve health outcomes among HIV-infected WIC participants. Implications for WIC Nutrition Services

(section-ii)(nutrition-risk-manual)(page-250)Page 250#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 250

Participant Category WIC Nutrition Services Recommendations for HIV/AIDS ALL CATEGORIES NUTRITION AND HEALTH TIPS TO MANAGE HIV/AIDS SYMPTOMS (12, 17, 18, 19) • 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. • 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 over-growth 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 health care provider about 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. WOMEN • Encourage all women to be tested to prevent mother-to-child HIV transmission through delivery and breastfeeding (7). Women who are considered high risk, such as those with sexually transmitted infections, multiple partners, or have substance abuse issues, are encouraged to be retested during late gestation, preferably before 36 weeks (9). Note: HIV testing is not a standard medical test administered to pregnant women in many states, in addition, pregnant women can opt-out in those states in which HIV testing is part of the standard test. Therefore, WIC can impact the spread of HIV/AIDS by making referrals to participants for early and late gestation testing, given that some populations served by WIC are most at risk for contracting HIV (7).

(section-ii)(nutrition-risk-manual)(page-251)Page 251#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 251

Participant Category WIC Nutrition Services Recommendations for HIV/AIDS WOMEN (Continued) • Advise infected pregnant women to consume a diet adequate in nutrients, achieve appropriate weight gain, and discuss taking a multivitamin with their health care provider (11). • Educate mothers with HIV/AIDS to avoid breastfeeding. This is especially important for recent immigrants and refugees from developing nations, as the recommendations are different in developing countries (15). In some developing countries, breastfeeding is encouraged due to the lack of available clean water to prepare infant formula and other sanitation problems). • More information about women and HIV can be found at: o http://www.womenshealth.gov/hiv-aids/ o http://www.cdc.gov/hiv/risk/gender/pregnantwomen/facts/ INFANTS • Inform mothers/caregivers that formula feeding is the standard for infants born to HIV positive mothers in the United States as breastfeeding is not recommended – especially to the immigrant and refugee population (13). • Ensure that liquid concentrate, or ready-to-feed infant formula, prescribed with medical documentation, is provided to HIV-exposed infants or babies born to HIV positive mothers, even if the infant has tested negative for HIV. Powdered infant formula is not sterile and therefore may not be microbiologically safe for immune-compromised participants (14). • Discourage giving pre-chewed food, regardless of HIV status, as the individual’s HIV status, who is pre-chewing the food is unknown (6). • More information about infants and HIV can be found at: o http://www.cdc.gov/hiv/risk/gender/pregnantwomen/facts/ CHILDREN • Discourage giving pre-chewed food, regardless of HIV status, as the individual’s HIV status, who is pre-chewing the food is unknown (6) • More information about children and HIV can be found at: o http://www.cdc.gov/hiv/risk/gender/pregnantwomen/facts/ o http://aids.gov/hiv-aids-basics/just-diagnosed-with-hiv- aids/overview/children/

(section-ii)(nutrition-risk-manual)(page-252)Page 252#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 252

present in infected individuals. It is important to note that viral hepatitis is the leading cause of liver cancer and the most frequent need for liver transplants in the United States (22). Hepatitis B: Hepatitis B is both acute and chronic, and is transmitted through contact with hepatitis B virus (HBV) infected blood, sexual intercourse with an infected person, and from mother to child by both vaginal or cesarean section births (20). Those at higher risk of becoming infected with hepatitis B are those: living with a hepatitis B infected person; coming into contact with blood, needles, or body fluids through work; working or living in a prison system; from Asian and Pacific Islands nations; undergoing kidney dialysis; infected with HIV or hepatitis; and who have an immigrant or refugee status (21). Treatment for Hepatitis B involves the use of interferon and antiviral drugs to interfere with the course of the virus. Early diagnosis and treatment of hepatitis B can help prevent damage to the liver. In addition, the Hepatitis B vaccination can prevent Hepatitis B. (22) Hepatitis B is not spread through human milk. Given that Hepatitis B is spread through blood, mothers who breastfeed should care for their nipples to avoid cracking and bleeding. If a mother with Hepatitis B has cracked and bleeding nipples, she should temporarily stop breastfeeding until her nipples heal - but continue to pump and discard pumped milk to maintain her milk supply (23). If a mother with HBV has concerns with providing her milk to her infant or concerns with drug treatment for the HBV, she should consult her physician. Hepatitis C: Hepatitis C is both acute and chronic; however, most cases are chronic and commonly spread through sharing needles during intravenous drug use (20). It can also spread through sexual intercourse; having a blood transfusion or organ transplant before July 1992; or using the razor, toothbrush, or nail clippers of an infected person. Being infected with a sexually transmitted disease or HIV can increase the chances of becoming infected with Hepatitis C. Getting tattoos and body piercings from unlicensed facilities, in casual settings, or with the use of non-sterile instruments can also transmit Hepatitis C (20). By the time symptoms appear with hepatitis C, the liver has been damaged, which in most cases can be as long as ten years after being infected. There is no vaccine for Hepatitis C. Medicines are used to slow or stop the virus from damaging the liver in chronic hepatitis. Severe damage to the liver leading to failure may require a liver transplant. (20) Infants born to mothers with hepatitis C can become infected; however, breastfeeding is not contraindicated, as Hepatitis C is not transmitted through human milk, unless the mother’s nipples are cracked and bleeding. (See information above in Hepatitis B about breastfeeding with cracked and/or bleeding nipples.) Hepatitis D: Hepatitis D is both acute and chronic. Though not common in the United States, viral hepatitis D can only be contracted when an individual also has hepatitis B (20, 22). The virus is present in blood and other body fluids of infected persons and is most commonly transmitted through: engaging in sexual activity; mother to child during delivery; sharing injection drug paraphernalia, razors, or toothbrushes; or coming in direct contact with the blood of an infected person. Chronic hepatitis D resulting from a super- infection, in which an individual has chronic hepatitis B, can progress to end-stage liver diseases (cirrhosis) or liver cancer. In some patients, interferon may be useful for treating hepatitis D. Although no vaccine exist for Hepatitis D, it can be prevented in persons who do not have Hepatitis B, by getting the Hepatitis B vaccination (20, 22).

(section-ii)(nutrition-risk-manual)(page-253)Page 253#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 253

Implications for WIC Nutrition Services 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.

HEPATITIS The table below summarizes the WIC Nutrition Services recommendations that can help improve the health outcomes of participants with Hepatitis.

Types of Hepatitis WIC Nutrition Services Recommendations for Chronic Hepatitis All Types • Recommend testing to pregnant women and high risk individuals. • Encourage abstinence from alcohol. • Provide information on high calorie, high protein and moderate fat diets. • Recommend high calorie consumption at breakfast to mitigate 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. • Encourage a bland diet with extra fluids depending on the severity of nausea and vomiting. Hepatitis B • Encourage the Hepatitis B vaccine for all newborns, previously unvaccinated adolescents through the age of 18, and high-risk adults. • Promote breastfeeding as being safe, but to avoid breastfeeding when nipples are cracked and bleeding – at which time, mothers should pump and discard milk to maintain supply. • Discourage the practice of pre-chewing food for infants, as blood may be present. Heptaitis C • Promote breastfeeding as being safe, but to avoid breastfeeding when nipples are cracked and bleeding – at which time, mothers should pump and discard milk to maintain supply. Hepatitis D • Recommend Hepatitis B vaccine.

(section-ii)(nutrition-risk-manual)(page-254)Page 254#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 254

4. Centers for Disease Control and Prevention (CDC). HIV/AIDS: about HIV/AIDS. [cited 2015 May 15]. Available from: http://www.cdc.gov/hiv/basics/whatishiv.html. 5. AIDS.gov. CD4 count. [cited 2015 May 15]. Available from: https://www.aids.gov/hiv-aids- basics/just-diagnosed-with-hiv-aids/understand-your-test-results/cd4-count/. 6. Centers for Disease Control and Prevention (CDC). HIV/AIDS: transmission. [cited 2015 May 15]. Available from: http://www.cdc.gov/hiv/basics/transmission.html. 7. Centers for Disease Control and Prevention (CDC). HIV/AIDS: testing. [cited 2015 May 15]. Available from: http://www.cdc.gov/hiv/basics/testing.html.

8. Centers for Disease Control and Prevention (CDC). HIV/AIDS: prevention. [cited 2015 May 15]. Available from: http://www.cdc.gov/hiv/basics/prevention.html.

9. Branson BM, Handsfield HH, Lampe MA, Janssen RS, Taylor AW, Lyss SB, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recommendations and Reports 2006;55(RR-14):1–17. [cited 2015 May 15]. Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm.

10. Centers for Disease Control and Prevention (CDC). HIV/AIDS: PrEP. [cited 2015 May 15]. Available from: http://www.cdc.gov/hiv/basics/prep.html.

11. Poulia KA. HIV/AIDS. In: Katsilambros N, Dimosthenopoulos C, Kontogianni MD, Manglara E, editors. Clinical nutrition in practice. Wiley.com; 2010. p. 147-153.

12. Lutz CA, MA, Mazur EE, Litch NA. Nutrition and diet therapy: evidence-based applications. 6th edition. F.A. Davis Company, 2015. Chapter 23.

13. World Health Organization. Nutrient requirements for people living with HIV/AIDS: report of a technical consultation. World Health Organization, Geneva, 13–15 May 2003. [cited 2015 May 15]. Available from: http://www.who.int/nutrition/publications/hivaids/9241591196/en/.

14. Food and Agriculture Organization of the United Nations. Enterobacter sakazakii and other microorganisms in powdered infant formula. WHO, Geneva, 2-5 February 2004.

15. McFarland EJ. Human immunodeficiency virus infection. In: Hay WW, Levin MJ, Deterding RR, Abzug MJ. In: Current diagnosis & treatment: Pediatrics. 22nd edition. McGraw-Hill; 2014. Chapter 41.

16. AIDS.gov. HIV/AIDS care continuum. [cited 2015 May 15]. Available from: 17. https://www.aids.gov/federal-resources/policies/care-continuum/.

18. Shiau S, Arpadi SM, Yin MT. HIV/AIDS and bone health: the role of nutrition. In: Holick MF, Nieves JW, editors. Nutrition and Bone Health. 2nd edition. New York: Springer; 2015. Chapter 38.

19. Knox TA, Jerger L, Tang, AM. Alcohol, HIV/AIDS, and liver disease. In: Watson RR, Preedy VR, Zibadi S, editors. Alcohol, Nutrition, and Health Consequences. New York: Humana Press; 2013. p. 287-303.

20. Staying Healthy with Diet and Exercise When You Have HIV/AIDS. In: Judd S, Judd S, Judd S, editors. Health Reference Series: AIDS Sourcebook. Detroit: Omnigraphics; 2011. Section 41.1

(section-ii)(nutrition-risk-manual)(page-256)Page 256#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 256

353 Food Allergies Definition/Cut-Off Value

Food allergies are adverse health effects arising from a specific immune response that occurs reproducibly on exposure to a given food. (1) Presence of condition diagnosed, documented, or reported by a physician or someone working under a physician’s orders, or as self reported by applicant/participant/caregiver. See Clarification for more information about self-reporting a diagnosis.

Food allergies are adverse health effects arising from a specific immune response that occurs reproducibly on exposure to a given food (1).

This risk is assigned upon the presence of a food allergy diagnosed, documented, or reported by a physician or someone working under a physician’s orders, or as self-reported by applicant/participant/caregiver. See Clarification for more information about self-reporting a diagnosis.

Note: Risk criteria 353 only applies to food allergies and should not be assigned to those who have non- immunologic adverse reactions to food. See Clarification section for more information. Participant Category and Priority Level

Category Priority High Risk Pregnant I N Breastfeeding* I N Non-Breastfeeding III, IV, V, or VI N Infants I N Children III N

Parameters for Manual Assignment

Must be manually selected in Nutrition Interview or Risk Panel

Justification

The actual prevalence of food allergies is difficult to establish due to variability in study designs and definitions of food allergies; however recent studies suggest a true increase in prevalence over the past 10 to 20 years (1). A meta-analysis conducted by the National Institute of Allergy and Infectious Disease (NIAID) found the prevalence of food allergy among all age groups between 1-10% (2). Further research has found that food allergy affects more children than recently reported with the prevalence estimated to be 8 % (2). 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, nutritional well-being and social interaction. Food allergy reactions occur when the body’s immune system responds to a harmless food as if it were a threat (3). The most common types of food allergies involve immunoglobulin E (IgE)-mediated responses. The immune system forms IgE against offending food(s) and causes abnormal reactions. IgE is a distinct class of antibodies that mediates an immediate allergic reaction. When food allergens enter the body, IgE Formatted: Font: (Default) Arial, 11 pt Formatted: Font: (Default) Arial, 11 pt Formatted: Indent: Left: 0.21" Formatted: Font: (Default) Arial, 11 pt Formatted: Indent: Left: 0.21" Formatted: Default, Space Before: 0 pt, Line spacing: single Formatted: Font: (Default) Arial, 11 pt

(section-ii)(nutrition-risk-manual)(page-257)Page 257#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 257

antibodies bind to them and release chemicals that cause various symptoms. (1) According to an expert panel sponsored by the National Institute of Allergy and Infectious Disease, individuals with a family history of any allergic disease are susceptible to developing food allergies and are classified as “at risk” or “high risk.” Individuals who are “at risk” are those with a biological parent or sibling with existing, or history of, allergic rhinitis, asthma or atopic dermatitis. Individuals who are “high risk” are those with preexisting severe allergic disease and/or family history of food allergies. (1)

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. The actual prevalence of food allergies is difficult to establish due to variability in definitions and study designs. 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 (2,3). 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 (2,3).

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 (4). The foods that most often cause allergic reactions are listed below with their prevalence among all U.S. children and adults:

Children (2) Adults (3) Any food allergy 7.6% 10.8% Peanuts 2.2% 1.8% Cow’s milk 1.9% 1.9% Shellfish 1.3% 2.9% 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 January 1, 2023, sesame was officially recognized as the 9th major food allergen in the United States and is required to be identified on food labels.

For many individuals, 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 to adulthood. Adults may have food allergies continuing from childhood or may develop food allergies after childhood, which usually continue through life (5,6).

When a person has an allergy to one food, they 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 (1). Formatted: Font: (Default) Arial, 11 pt Formatted: Font: (Default) Arial, 11 pt Formatted: Font: (Default) Arial, 11 pt Formatted Table Formatted: Font: Bold Formatted: Heading 5, Indent: Left: 0.5", Space Before: 4.55 pt, Line spacing: single Formatted: Font: 11 pt

(section-ii)(nutrition-risk-manual)(page-258)Page 258#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 258

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 (these reactions are often referred to as food intolerances, however this term is often misused, so it is not preferred) (7). 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 (7). 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 (1,7), as follows:

1. Metabolic - A reaction is caused by an inability to metabolize a food component. For example, the most common non-immunologic adverse reaction to food is lactose intolerance and is 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.) 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 (8). 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 (9). 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 (10). However, decades of research have yet to prove a definitive link between these symptoms and the consumption of MSG (11). 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) (12).

See clarification section for more information about assigning risks for these reactions to foods.

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 (13). 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 (6).

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 (14). Tree nuts, peanuts, milk, egg, fish, and shellfish are the leading causes of food-induced anaphylaxis (1). Prompt diagnosis and avoidance of allergens is essential to prevent life-threatening reactions. Formatted: Indent: Left: 0" Formatted: Font: (Default) Arial, 11 pt Formatted: Font: (Default) Arial, 11 pt, Bold Formatted: Font: 11 pt, Not Bold Formatted: Font: (Default) Arial, 11 pt Formatted: List Paragraph, Numbered + Level: 1 + Numbering Style: 1, 2, 3, … + Start at: 1 + Alignment: Left + Aligned at: 0.25" + Indent at: 0.5" Formatted: Font: 11 pt Formatted: Font: (Default) Arial, 11 pt Formatted: Font: (Default) Arial, 11 pt Formatted: Font: (Default) Arial, 11 pt

(section-ii)(nutrition-risk-manual)(page-259)Page 259#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 259

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 (6). Celiac Disease (Risk 354) is one example of a non-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 134). 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 (15,16). 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 (17,18). 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 (19). 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 FPA also have vomiting and failure to thrive, and some may have malabsorption, abdominal distention and early satiety. Blood stools are usually absent (16, 20, 21).

Prevention

There is no evidence that pregnant or breastfeeding women should restrict any foods to prevent the development of allergies in their offspring (22). There is also no evidence to suggest that exclusive breastfeeding is associated with the prevention of any specific food allergies among breastfed infants (23). However, exclusive breastfeeding for the first 3-4 months has been shown to decrease the risk of eczema1 in the first 2 years of life, a condition which has been associated with the development of food allergies (24). 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 (22).

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 (22,25). 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 (26-30).

Previous research suggested a benefit of the delayed introduction of highly allergenic foods to high-risk infants and children. However, this advice on the introduction of potentially allergenic food 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 (22, 31-33). Additional research has even 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 (34-39). It is also important to note that exclusion diets Formatted: Font: 11 pt Formatted: Font: Bold Formatted: Font: (Default) Arial, 11 pt Formatted Table Formatted: Font: (Default) Arial, 11 pt Formatted: Font: 11 pt Formatted: Font: (Default) Arial, 11 pt Formatted: Font: (Default) Arial, 11 pt Formatted: Font: (Default) Arial, 11 pt Formatted: Font: 11 pt Formatted: Font: (Default) Arial, 11 pt Formatted: Font: 11 pt Formatted: Font: (Default) Arial, 11 pt Formatted: Font: (Default) Arial, 11 pt Formatted: Font: Bold Formatted: Font: (Default) Arial, 11 pt Formatted: Indent: Left: 0.21" Formatted: Font: (Default) Arial, 11 pt Formatted: Indent: Left: 0.21" Formatted: Font: 11 pt, Not Bold Formatted: Indent: Left: 0.21"

(section-ii)(nutrition-risk-manual)(page-260)Page 260#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 260

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 (40). Currently, the strongest evidence for recommendations regarding the benefits of introducing potentially allergenic foods has been derived from research on peanuts and eggs. As a result, the 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. The AAAAI also recommends 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 (23).

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 (23).

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 American Academy of Allergy, Asthma, and Immunology (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 (23).

1 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 (41,42).

Management

Food allergies have been shown to produce anxiety and affect quality of life; however, management strategies can help mitigate these negative outcomes. Food allergen avoidance is the safest method for managing food allergies. 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 group (see Clarification for more information). 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 (1).

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. Formatted: Font: 11 pt, Not Bold Formatted: Indent: Left: 0.21" Formatted: Indent: Left: 0.21" Formatted: Superscript Formatted: Font: 11 pt, Not Bold Formatted: Font: Not Bold Formatted: Font: Bold Formatted: Font: (Default) Arial, 11 pt Formatted: Font: (Default) Arial, 11 pt Formatted: Font: 11 pt, Not Bold Formatted: Indent: Left: 0" Formatted: Font: Not Bold

(section-ii)(nutrition-risk-manual)(page-261)Page 261#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 261

Food Allergies vs. Intolerances

Food intolerances are classified differently from food allergies based on the pathophysiological mechanism of the reactions. Unlike food allergies, food intolerances do not involve the immune system. Food intolerances are adverse reactions to food caused either by the properties of the food itself, such as a toxin, or the characteristics of the individual, such as a metabolic disorder (4). Food intolerances are often misdiagnosed as food allergies because the symptoms are often similar. Causes of food intolerances may include food poisoning, histamine toxicity, food additives such as monosodium glutamate (MSG), or sulfites (5). The most common food intolerance is lactose intolerance (see nutrition risk criterion #355, Lactose Intolerance).

Common Food Allergens

Although reactions can occur from the ingestion of any food, a small number of foods are responsible for the majority of food-induced allergic reactions (6). The foods that most often cause allergic reactions include:

• cow’s milk (and foods made from cow’s milk) • eggs • peanuts • tree nuts (walnuts, almonds, cashews, hazelnuts, pecans, brazil nuts) • fish • crustacean shellfish (e.g., shrimp, crayfish, lobster, and crab) • wheat • soy For many individuals, food allergies appear within the first two years of life. Allergies to cow’s milk, eggs, wheat and soy generally resolve in early childhood. In contrast, allergy to peanuts and tree nuts typically persist to adulthood. Adults may have food allergies continuing from childhood or may develop sensitivity to food allergens encountered after childhood, which usually continue through life. (1) Symptoms

There are several types of immune responses to food including IgE-mediated, non-IgE-mediated or mixed. 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 (3). These chemicals cause various symptoms based on the area of the body in which they were released. These reactions occur within minutes or up to 4 hours after ingestion and include symptoms such as urticaria (hives), angioedema, wheezing, cough, nausea, vomiting, hypotension and anaphylaxis (7).

(section-ii)(nutrition-risk-manual)(page-262)Page 262#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 262

Food allergens may also induce allergic reactions which are non-IgE-mediated. Non-IgE-mediated reactions generally occur more than 4 hours after ingestion, primarily result in gastrointestinal symptoms and are more chronic in nature (7). Examples of non-IgE-mediated reactions to specific foods include celiac disease (see nutrition risk criterion #354, Celiac Disease), food protein-induced enterocolitis syndrome (FPIES), food protein-induced proctocolitis (FPIP), food protein-induced gastroenteropathy, food-induced contact dermatitis and food-induced pulmonary hemosiderosis (Heiner’s syndrome) (accessed May 2012) (8). The diagnosis of food allergies by a health care provider (HCP) is often difficult and can be multifaceted (see Clarification for more information). Food allergies often coexist with severe asthma, atopic dermatitis (AD), eosinophilic esophagitis (EoE) and exercise-induced anaphylaxis. Individuals with a diagnosis of any of these conditions should be considered for food allergy evaluation. (1)

Prevention

Currently, there is insufficient evidence to conclude that restricting highly allergenic foods in the maternal diet during pregnancy or lactation prevents the development of food allergies in the offspring (9). Adequate nutrition intake during pregnancy and lactation is essential to achieve positive health outcomes. Unnecessary food avoidance can result in inadequate nutrition. There is also a lack of evidence that delaying the introduction of solids beyond 6 months of age, including highly allergenic foods, prevents the development of food allergies. If the introduction of developmentally appropriate solid food is delayed beyond 6 months of age, inadequate nutrient intake, growth deficits and feeding problems can occur. (1) The protective role that breastfeeding has in the prevention of food allergies remains unclear. There is some evidence for infants at high risk of developing food allergies that exclusive breastfeeding for at least 4 months may decrease the likelihood of cow’s milk allergy in the first 2 years of life (9). The American Academy of Pediatrics (AAP) continues to recommend 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 (1, 10). For infants who are partially breastfed or formula fed, partially hydrolyzed formulas may be considered as a strategy for preventing the development of food allergies in at-risk infants. According to the AAP, there is no convincing evidence for the use of soy formula as a strategy for preventing the development of food allergies in at-risk infants and therefore it is not recommended. (9)

Management

Food allergies have been shown to produce anxiety and alter the quality of life of those with the condition. It is recommended that individuals with food allergies and their caregivers be educated on food allergen avoidance and emergency management that is age and culturally appropriate. Individuals with a history of severe food allergic reactions, such as anaphylaxis, should work with their HCP to establish an emergency management plan. (1) Food allergen avoidance is the safest method for managing food allergies. Individuals with food allergies must work closely with their HCP to determine the food(s) to be avoided. This includes the avoidance of any cross-reactive foods, i.e., similar foods within a food group (see Clarification for more information). Nutrition counseling and growth monitoring is recommended for all individuals with food allergies to ensure a nutritionally adequate diet. Individuals with food allergies should also be educated on reading food labels and ingredient lists. (1)

(section-ii)(nutrition-risk-manual)(page-263)Page 263#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 263

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. According to food allergy experts, children with FPIES can be re-challenged every 18-24 months and, infants/children with FPIP can be re-challenged at 9-12 months of age. The re-challenging of foods should be done with HCP oversight. (8) 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 a HCP for food allergy evaluation, since food allergies often coexist with these conditions (1). • 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 (25). • 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 require to avoid the triggering foods, as well as the risk of malnutrition. • 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: • https://www.fda.gov/consumers/consumer-updates/have-food-allergies-read-label • http://www.webmd.com/allergies/foodtriggers. • https://www.foodallergy.org/resources/how-read-food-label. • Educate participants with food allergies on planning meals and snacks for outside the home. • Refer participants with suspected sensitivity to foods to their HCP for an oral food challenge of allergenic foods, as appropriate. • Establish/maintain communication with the participant’s HCP.

Through client-centered counseling, WIC staff can assist families with food allergies in making changes that improve quality of life and promote nutritional well-being while avoiding offending foods. Based on the needs and interests of the participant, WIC staff can (as appropriate): • Facilitate and encourage the participant’s ongoing follow-up with the HCP for optimal management of the condition. • Promote exclusive breastfeeding until six months of age and continue through the first year (10). • Provide hypoallergenic formula for participants with appropriate medical documentation, as needed. • Tailor food packages to substitute or remove offending foods. Formatted: Indent: Left: 0.21"

(section-ii)(nutrition-risk-manual)(page-264)Page 264#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 264

• Educate participants on maintaining adequate nutritional intake while avoiding offending foods. • Monitor weight status and growth patterns of participants. • Educate participants about reading food labels and identifying offending foods and ingredients. • Educate participants on planning meals and snacks for outside the home. • Refer participants to their HCP for a re-challenge of offending foods, as appropriate. • Establish/maintain communication with participant’s HCP. See resources below: • http://www.fda.gov/downloads/ForConsumers/Consumer Updates/UCM254727.pdf. Accessed May 2012. • http://www.webmd.com/allergies/foodtriggers. Accessed May 2012. • http://www.foodallergy.org/section/how-to-read-a-label. Accessed May 2012.

Clarification

WIC participants diagnosed with a non-immunologic adverse reaction to food should not be assigned risk code 353. For example, risk code 355 should be assigned for those diagnosed with Lactose Intolerance. Code 360 should be assigned for participant diagnosed with conditions including, but not limited to: • Irritable Bowel Syndrome (IBS) • Non-celiac wheat sensitivity (NCWS) • Scombroid Fish Poisoning / Histamine Fish Poisoning • Caffeine Toxicity

Food allergies are diagnosed by a HCP by evaluating a thorough medical history and conducting a physical exam to consider possible trigger foods to determine the underlying mechanism of the reaction, which guides testing. Along with a detailed history of the disorder, such as symptoms, timing, common triggers and associations, there are several types of tests that the HCP may use in diagnosing food allergies. These include the following: • Food Elimination Diet • Oral Food Challenges • Skin Prick Test (SPT) • Allergen-specific serum IgE (sIgE) • Atopy Patch Test

Formatted: Indent: Left: 0.21", First line: 0.25", Right: 2.89", Space Before: 6.95 pt, Line spacing: Multiple 1.66 li Formatted: Font: (Default) Arial, 11 pt Formatted: Indent: Left: 0.21" Formatted: Font: (Default) Arial, 11 pt Formatted: Indent: Left: 0.21" Formatted: Bulleted + Level: 2 + Aligned at: 0.79" + Indent at: 1.04" Formatted: Indent: Left: 0.5" Formatted: Bulleted + Level: 2 + Aligned at: 0.79" + Indent at: 1.04"

(section-ii)(nutrition-risk-manual)(page-266)Page 266#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 266

triggers and associations, there are several types of tests that the HCP may use in diagnosing food allergies. These include the following: • Food Elimination Diet • Oral Food Challenges • Skin Prick Test (SPT) • Allergen-specific serum IgE (sIgE) • Atopy Patch Test Diagnosing food allergies is difficult because the detection of sIgE does not necessarily indicate a clinical allergy. Often, more than one type of test is required to confirm a diagnosis. The double-blind, placebo- controlled food challenge is considered the gold standard in testing for food allergies. (11) Children often outgrow allergies to cow’s milk, soy, egg, and wheat quickly; but are less likely to outgrow allergies to peanut, tree nuts, fish, and crustacean shellfish. If the child has had a recent allergic reaction, there is no reason to retest. Otherwise, annual testing may be considered to see if the allergy to cow’s milk, soy, egg, or wheat has been outgrown so the diet can be normalized. (1)

Cross-reactive food: When a person has allergies to one food, he/she tends 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. (1) Justification for High Risk

Not Applicable

Additional Counseling Guidelines

• Explain definition of a food allergy. ▪ True food allergies involve abnormal immunologic responses to food proteins ▪ The proteins are resistant to digestion and elicit the formation of antibodies ▪ This allergic response occurs immediately after food is eaten (this is different from a food intolerance) • Explain characteristics of a food allergy: ▪ Will always result in same symptomatic reaction for that individual (could be more mild or severe) ▪ If individual is ill or stressed, symptoms may be more severe ▪ Sensitization can occur; may have previously tolerated a food but now has a reaction ▪ There may be potential for thresholds for individuals with multiple allergies (from contacting, inhaling or ingesting allergens) ▪ Some food allergy reactions can be more severe for those who have other allergies (even though not food allergens) (e.g. during pollen season) • Inform that: ▪ The most common offending foods are: peanuts, cow’s milk, eggs, soy beans, nuts from trees, wheat, and seafood ▪ Prevalence: ➢ 4 - 8% young infants ➢ 1 - 2% children Formatted: Indent: Left: 0"

(section-ii)(nutrition-risk-manual)(page-267)Page 267#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 267

➢ < 1% adults • Discuss reactions that can occur: ▪ GI - nausea, vomiting, diarrhea, abdominal pain, colic, loss of appetite, constipation, malabsorption, cheilitis and stomatitis (inflammation of the lip and mouth) ▪ Dermatologic - itchy “wheels”, hives, eczema, dermatitis, rash around mouth, or ulcers in/around mouth ▪ Respiratory - chronic rhinitis, asthma, recurrent bronchitis, recurrent croup, recurrent otitis media, chronic coughing, spitting up blood from irritated lungs or bronchioles ▪ CNS - headache, insomnia, irritability, listlessness, drowsiness ▪ Hematologic – anemia ▪ Systemic - anaphylaxis, FTT, malnutrition • Assist with: ▪ Eliminating allergenic food(s) from diet ▪ Meal planing at home, away from home, at restaurants ▪ Adjusting food package: try goat’s milk (40% of those sensitive to cow’s milk can tolerate goat’s milk) or soy-based beverage (for children) ▪ Reading labels to identify allergenic foods (see NRF #354 “Celiac Disease” and #355 “Lactose Intolerance” for food list and other ideas) ▪ Identify unobvious allergen sources in foods; they are widely found in commercial and prepared foods (e.g. corn, eggs) ▪ Modifying or substituting recipes • If the CPA/RD determines that a client’s calcium intake is compromised, offer calcium fortified orange juice by providing the client with a Special Food letter indicating the client’s need for calcium fortified orange juice • Educate participant about anaphylactic response ▪ It is a whole-body systemic reaction in which airway can be blocked, shock can occur, etc. in seconds to minutes • If allergic individual has potential for anaphylactic response they should know ▪ What foods could precipitate anaphylactic response - legumes, especially peanuts, tree nuts, seafood particularly shellfish, and berries ▪ What treatments or medications should be administered at time of reaction ▪ Wearing a medical alert bracelet or jewelry could provide for more immediate treatment • For pregnant participants: ▪ Follow diet without emphasis on any one food ▪ Not recommended to eat large quantities of any high allergenic food ▪ Replace diet with nutrients and energy due to the elimination of the allergenic foods (e.g. - provide calcium food list if milk is eliminated) ▪ If foods are eliminated long term, recommend vitamin/mineral supplements • For infants: ▪ Infants are more susceptible to the development of food allergies than adults ▪ Their digestive system is more permeable to proteins and is not fully mature ▪ Infants born to parents with allergies are at a greater risk ▪ Infants may have less allergies when they are older • Recommendations for infants: ▪ Exclusively breastfeed for a minimum of 1 year to reduce severe allergic disease, especially in the high risk infant ▪ If breastfed infant shows signs of digestive problems:

(section-ii)(nutrition-risk-manual)(page-268)Page 268#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 268

➢ Do not stop breastfeeding! ➢ Refer to MD/RD/CLC ➢ Eliminate potential allergenic foods in lactating mother’s diet ▪ For non-breastfed infants provide milk or soy based or hydrolysate infant formulas ➢ Reinforce that formulas, unlike breast milk, do not have the immunologic benefits to actually reduce/prevent allergies ▪ Delay introduction of solids until infant is developmentally ready ▪ Adjust for gestational age for introduction of foods ▪ Delay high allergenic foods in infants with family history of allergies ➢ If cow’s milk allergy, wait a minimum of first 12 months to introduce diary products ▪ Allow a minimum of 3-5 days to introduce new foods and confirm no adverse reactions ▪ Allow for adequate time to rechallenge foods • Recommendations for children: ▪ Provide psychological support to the child with multiple allergies; they do not need to feel different or fragile ▪ Provide special treats or foods (e.g. - at birthdays, holidays) to replace other foods the child cannot have ▪ Refer to www.foodallergy.org for up-to-date food recalls or warnings because of undisclosed milk or other common allergens and accurate information about food allergies and anaphylaxis

References

5. National Institute of Allergy and Infectious Disease. Food allergy: An overview. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, 2010 (NIH Publication No. 11- 5518). Available at: http://www.niaid.nih.gov/topics/foodallergy/understanding/pages/whatisit.aspx. Accessed May 2012. 6. Sampson, HA. Food Allergy. Part 1: Immunopathogenesis and clinical disorders. Journal of Allergy and Clinical Immunology. 1999; 103(5):717-728. 7. Davis, C. Food allergies: clinical manifestations, diagnosis, and management. Current Problems in Pediatric Adolescent Health Care. 2009; 39:236-254. 8. Metcalfe DD, Sampson HA, Simon RA, editors. Food allergy: adverse reactions to food and food additives. 4th ed. Malden (MA): Blackwell Publishing; 2008.

(section-ii)(nutrition-risk-manual)(page-269)Page 269#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 269

9. Greer, F. et al. American Academy of Pediatrics Committee on Nutrition. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. Pediatrics. 2008; 121(1), pages 183- 191.

10. Gartner LM, Morton J, Lawrence RA, et al. American Academy of Pediatrics. Policy Statement: Breastfeeding and the use of human milk. Pediatrics.2005; 115 (2):496– 506. 11. Sicherer S.H., Sampson, HA. Food allergy. Journal of Allergy and Clinical Immunology. 2010; (125):S116-S125.

1. Boyce, J. et al. Guidelines for the diagnosis and management of food allergy in the United States: Report of the NIAID-Sponsored Expert Panel. Journal of Allergy and Clinical Immunology. 2010; 126(6):S1-S58. Available from: https://www.jacionline.org/article/S0091-6749(10)01566-6/fulltext. 2. NGAE, Boersma P. Diagnosed allergic conditions in adults: United States, 2021. NCHS Data Brief, no 460. Hyattsville, ME: National Center for Health Statistics. 2023. DOI: Products - Data Briefs - Number 460 - January 2023 . 3. Zablotsky B, Black LI, Akinbami LJ. Diagnosed allergic conditions in children aged 0-17 years: United States, 2021. NCHS Data Brief, no 459. Hyattsville, MD: National Center for Health Stateistics. 2023. DOI: https://dx.doi.org/10.15620/cdc:123250 4. Sampson, HA. Food Allergy. Part 1: Immunopathogenesis and clinical disorders. Journal of Allergy and Clinical Immunology. 1999; 103(5):717-728. 5. Savage J, Johns CB. Food allergy: epidemiology and natural history. Immunol Allergy Clin North Am. 2015;35(1):45-59. doi:10.1016/j.iac.2014.09.004. 6. Foong RX, Santos AF. Biomarkers of diagnosis and resolution of food allergy. Pediatr Allergy Immunol. 2021 Feb;32(2):223-233. doi: 10.1111/pai.13389. Epub 2020 Oct 31. PMID: 33020989. 7. Gargano D, Appanna R, Santonicola A, De Bartolomeis F, Stellato C, Cianferoni A, Casolaro V, Iovino P. Food Allergy and Intolerance: A Narrative Review on Nutritional Concerns. Nutrients. 2021 May 13;13(5):1638. doi: 10.3390/nu13051638. PMID: 34068047; PMCID: PMC8152468.

8. Dobrina D. Tsvetkova, Radoslav C. Klisurov, Stefka A. Pankova, Branimir A. Zlatkov. Investigation of Some Pharmacological Effects of Caffeine and Taurine in Food Supplements. International Journal of Nutrition and Food Sciences. Special Issue: Taurine and Caffeine Supplementation in Energy Food Drinks: Uses, Side Effects and Quality Control. Vol. 4, No. 1-1, 2015, pp. 18-23. doi: 10.11648/j.ijnfs.s.2015040101.14. 9. Guergué-Díaz de Cerio O, Barrutia-Borque A, Gardeazabal-García J. Scombroid Poisoning: A Practical Approach. Actas Dermosifiliogr. 2016 Sep;107(7):567-71. English, Spanish. doi: 10.1016/j.ad.2016.02.010. Epub 2016 Apr 28. PMID: 27133773. 10. Nguyen-Thuy L, Saltana LC, Tofana M, Socaci, SA, Farcas AC, Pop CR. A Mini Review About Sodium Glutamate. Bulletin UASVM Food Science and Technology. 2020;77(1). DOI: 10.15835/buasvmcn-fst: 2019.0029. Available from: http://journals.usamvcluj.ro/index.php/fst/article/viewFile/13717/pdf. 11. Zanfirescu A, Ungurianu A, Tsatsakis AM, Nițulescu GM, Kouretas D, Veskoukis A, Tsoukalas D, Engin AB, Aschner M, Margină D. A review of the alleged health hazards of monosodium glutamate. Compr Rev Food Sci Food Saf. 2019 Jul;18(4):1111-1134. doi: 10.1111/1541-4337.12448. Epub 2019 May 8. Erratum in: Compr Rev Food Sci Food Saf. 2020 Jul;19(4):2330. PMID: 31920467; PMCID: PMC6952072. Formatted: Line spacing: single Formatted: Font: (Default) Arial, 11 pt Formatted: Default, Line spacing: single Formatted: Font: (Default) Arial, 11 pt

(section-ii)(nutrition-risk-manual)(page-270)Page 270#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 270

12. Algera J, Colomier E, Simrén M. The Dietary Management of Patients with Irritable Bowel Syndrome: A Narrative Review of the Existing and Emerging Evidence. Nutrients. 2019; 11(9):2162. https://doi.org/10.3390/nu11092162. 13. Anvari S, Miller J, Yeh CY, Davis CM. IgE-Mediated Food Allergy. Clin Rev Allergy Immunol. 2019;57(2):244-260. doi:10.1007/s12016-018-8710-3. 14. Keet, C. Recognition and Management of Food-Induced Anaphylaxis. Pediatric Clinics. 2011;58(2):377- 388 Recognition and Management of Food-Induced Anaphylaxis - Pediatric Clinics 15. Children's Hospital of Philadelphia. Food Protein-Induced Enterocolitis Syndrome (FPIES). Published February 23, 2014. Accessed June 2, 2022. Available from: https://www.chop.edu/conditions-diseases/food- protein-induced-enterocolitis-syndrome-fpies. 16. Connors L, O’Keefe A, Rosenfield L, Kim H. Non-IgE-mediated food hypersensitivity. Allergy Asthma Clin Immunol. 2018;14(2):56. doi:10.1186/s13223-018-0285-2. 17. Nowak-Węgrzyn A. Food protein-induced enterocolitis syndrome and allergic proctocolitis. Allergy Asthma Proc. 2015;36(3):172-184. doi:10.2500/aap.2015.36.3811. 18. Kaya A, Toyran M, Civelek E, Misirlioglu E, Kirsaclioglu C, Kocabas CN. Characteristics and Prognosis of Allergic Proctocolitis in Infants. J Pediatr Gastroenterol Nutr. 2015;61(1):69-73. doi:10.1097/MPG.0000000000000767. 19. Feuille E, Nowak-Węgrzyn A. Food protein-induced enterocolitis syndrome, allergic proctocolitis, and enteropathy. Curr Allergy Asthma Rep. 2015;15(8):50. doi: 10.1007/s11882-015-0546-9.

20. Caubet JC, Szajewska H, Shamir R, Nowak-Węgrzyn A. Non-IgE-mediated gastrointestinal food allergies in children. Pediatr Allergy Immunol. 2017;28(1):6–17. doi: 10.1111/pai.12659. 21. Sampson HA, Aceves S, Bock SA, James J, Jones S, Lang D, Nadeau K, Nowak-Wegrzyn A, Oppenheimer J, Perry TT, Randolph C, Sicherer SH, Simon RA, Vickery BP, Wood R, Joint Task Force on Practice Parameters. Bernstein D, Blessing-Moore J, Khan D, Lang D, Nicklas R, Oppenheimer J, Portnoy J, Randolph C, Schuller D, Spector S, Tilles SA, Wallace D, Practice Parameter Workgroup. Sampson HA, Aceves S, Bock SA, James J, Jones S, Lang D, Nadeau K, Nowak-Wegrzyn A, Oppenheimer J, Perry TT, Randolph C, Sicherer SH, Simon RA, Vickery BP, Wood R. Food allergy: a practice parameter update-2014. J Allergy Clin Immunol. 2014;134(5):1016–1025. doi: 10.1016/j.jaci.2014.05.013. 22. Greer FR, Sicherer SH, Burks AW; COMMITTEE ON NUTRITION; SECTION ON ALLERGY AND IMMUNOLOGY. The Effects of Early Nutritional Interventions on the Development of Atopic Disease in Infants and Children: The Role of Maternal Dietary Restriction, Breastfeeding, Hydrolyzed Formulas, and Timing of Introduction of Allergenic Complementary Foods. Pediatrics. 2019 Apr;143(4):e20190281. doi: 10.1542/peds.2019-0281. Epub 2019 Mar 18. PMID: 30886111. 23. Fleischer DM, Chan ES, Venter C, Spergel JM, Abrams EM, Stukus D, Groetch M, Shaker M, Greenhawt M. A Consensus Approach to the Primary Prevention of Food Allergy Through Nutrition: Guidance from the American Academy of Allergy, Asthma, and Immunology; American College of Allergy, Asthma, and Immunology; and the Canadian Society for Allergy and Clinical Immunology. J Allergy Clin Immunol Pract. 2021 Jan;9(1):22-43.e4. doi: 10.1016/j.jaip.2020.11.002. Epub 2020 Nov 26. PMID: 33250376. 24. Lodge CJ, Tan DJ, Lau MX, et al. Breastfeeding and asthma and allergies: a systematic review and meta- analysis. Acta Paediatr. 2015;104(467):38–53. 25. Meek JY, Noble L; Section on Breastfeeding. Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics. 2022;150(1):e2022057988. doi:10.1542/peds.2022-057988 Formatted: Default, Line spacing: single Formatted: Font: (Default) Arial, 11 pt

(section-ii)(nutrition-risk-manual)(page-271)Page 271#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 271

26. Hydrolysed Formulas in the Management of Cow’s Milk Allergy: New Insights, Pitfalls and Tips. Nutrients. 2021;13(8):2762 Hydrolysed Formulas in the Management of Cow’s Milk Allergy: New Insights, Pitfalls and Tips - PMC 27. Boyle RJ, Ierodiakonou D, Khan T, et al. Hydrolysed formula and risk of allergic or autoimmune disease: systematic review and meta-analysis. BMJ. 2016;352:i974. 28. Boyle RJ, Tang ML, Chiang WC, et al; PATCH study investigators. Prebiotic-supplemented partially hydrolysed cow’s milk formula for the prevention of eczema in high-risk infants: a randomized controlled trial. Allergy. 2016;71(5):701–710. 29. von Berg A, Filipiak-Pittroff B, Krämer U, et al; GINIplus study group. Allergies in high-risk schoolchildren after early intervention with cow’s milk protein hydrolysates: 10-year results from the German Infant Nutritional Intervention (GINI) study. J Allergy Clin Immunol. 2013;131(6):1565–1573.

30. Halken S, Muraro A, de Silva D, Khaleva E, Angier E, Arasi S, Arshad H, Bahnson HT, Beyer K, Boyle R, du Toit G, Ebisawa M, Eigenmann P, Grimshaw K, Hoest A, Jones C, Lack G, Nadeau K, O'Mahony L, Szajewska H, Venter C, Verhasselt V, Wong GWK, Roberts G; European Academy of Allergy and Clinical Immunology Food Allergy and Anaphylaxis Guidelines Group. EAACI guideline: Preventing the development of food allergy in infants and young children (2020 update). Pediatr Allergy Immunol. 2021 Jul;32(5):843-858. doi: 10.1111/pai.13496. Epub 2021 Mar 29. PMID: 33710678. 31. Fleischer DM, Spergel JM, Assa'ad AH, Pongracic JA. Primary prevention of allergic disease through nutritional interventions. J Allergy Clin Immunol Pract 2013; 1:29. 32. Agostoni C, Decsi T, Fewtrell M, et al. Complementary feeding: a commentary by the ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr 2008; 46:99. 33. Sicherer SH, Burks AW. Maternal and infant diets for prevention of allergic diseases: understanding menu changes in 2008. J Allergy Clin Immunol 2008; 122:29. 34. Du Toit G, Roberts G, Sayre PH, et al. Randomized trial of peanut consumption in infants at risk for peanut allergy. N Engl J Med 2015; 372:803. 35. Du Toit G, Sayre PH, Roberts G, et al. Effect of Avoidance on Peanut Allergy after Early Peanut Consumption. N Engl J Med 2016; 374:1435. 36. Ierodiakonou D, Garcia¬Larsen V, Logan A, et al. Timing of Allergenic Food Introduction to the Infant Diet and Risk of Allergic or Autoimmune Disease: A Systematic Review and Meta¬analysis. JAMA 2016; 316:1181. 37. Natsume O, Kabashima S, Nakazato J, et al. Two¬step egg introduction for prevention of egg allergy in highrisk infants with eczema (PETIT): a randomised, double¬blind, placebo¬controlled trial. Lancet 2016. 38. Palmer DJ, Sullivan TR, Gold MS, et al. Randomized controlled trial of early regular egg intake to prevent egg allergy. J Allergy Clin Immunol 2017;139(5)1600. Randomized controlled trial of early regular egg intake to prevent egg allergy - ScienceDirect 39. Wei¬Liang Tan J, Valerio C, Barnes EH, et al. A randomized trial of egg introduction from 4 months of age in infants at risk for egg allergy. J Allergy Clin Immunol 2017: 139(5)1621. A randomized trial of egg introduction from 4 months of age in infants at risk for egg allergy - ScienceDirect 40. Domínguez O, Plaza AM, Alvaro M. Relationship Between Atopic Dermatitis and Food Allergy. Curr Pediatr Rev. 2020;16(2):115-122. doi: 10.2174/1573396315666191111122436. PMID: 31713486. 41. Odhiambo JA, Williams HC, Clayton TO, Robertson CF, Asher MI. Global variations in prevalence of eczema symptoms in children from ISAAC Phase Three. J Allergy Clin Immunol 2009; 124: 1251–58. Formatted: Default, Line spacing: single Formatted: Font: (Default) Arial, 11 pt

(section-ii)(nutrition-risk-manual)(page-273)Page 273#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 273

354 Celiac Disease Definition/Cut-Off Value

Celiac Disease (CD) is an autoimmune disease precipitated by the ingestion of gluten (a protein in wheat, rye, and barley) that results in damage to the small intestine and malabsorption of the nutrients from food. (1). (For more information about the definition of CD, please see the Clarification section) CD is also known as: • Celiac Sprue • Gluten-sensitive Enteropathy • Non-tropical Sprue

Presence of condition diagnosed, documented, or reported by a physician or someone working under a physician’s orders, or as self reported by applicant/participant/caregiver. See Clarification for more information about self-reporting a diagnosis.

Participant Category and Priority Level

Category Priority High Risk Pregnant I N Breastfeeding I N Non-Breastfeeding VI N Infants I N Children III N

Parameters for Manual Assignment

Must be manually selected in Nutrition Interview or Risk Panel

Justification

CD affects approximately 1% of the U.S. population (2, 3). CD can occur at any age and the treatment requires strict adherence to a gluten-free diet for life. CD is both a disease of malabsorption and an abnormal immune reaction to gluten. When individuals with CD eat foods or ingest products containing gluten, their immune system responds by damaging or destroying villi—the tiny, fingerlike protrusions lining the small intestine. Villi normally allow nutrients from food to be absorbed through the walls of the small intestine into the bloodstream (4). The destruction of villi can result in malabsorption of nutrients needed for good health. Key nutrients often affected are iron, calcium and folate as they are absorbed in the first part of the small intestine. If damage occurs further down the small intestinal tract, malabsorption of carbohydrates (especially lactose), fat and fat-soluble vitamins, protein and other nutrients may also occur (2,5).

(section-ii)(nutrition-risk-manual)(page-274)Page 274#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 274

In addition to the gastrointestinal system, CD affects many other systems in the body, resulting in a wide range and severity of symptoms. Symptoms of CD may include chronic diarrhea, vomiting, constipation, pale foul-smelling fatty stools and weight loss. Failure to thrive may occur in infants and children. The vitamin and mineral deficiencies that can occur from continued exposure to gluten may result in conditions such as anemia, osteoporosis and neurological disorders such as ataxia, seizures and neuropathy. Individuals with CD who continue to ingest gluten are also at increased risk for developing other autoimmune disorders (e.g., thyroid disease, type 1 diabetes, Addison’s disease) and certain types of cancer, especially gastrointestinal malignancies (2).

Continued exposure to gluten increases the risk of miscarriage or having a low birth weight baby, and may result in infertility in both women and men. A delay in diagnosis for children may cause serious nutritional complications including growth failure, delayed puberty, iron-deficiency anemia, and impaired bone health. Mood swings or depression may also occur (2, 6). See Table 1 for Nutritional Implications and Symptoms.

Table 1. Nutritional Implications and Symptoms of CD Common in Children Digestive Symptoms-more common in infants and children, may include: • vomiting • chronic diarrhea • constipation • abdominal bloating and pain • pale, foul-smelling, or fatty stool Other Symptoms: − Delayed puberty − Dental enamel abnormalities of the permanent teeth − Failure to thrive (delayed growth and short stature) − Weight loss − irritability Common in Adults Digestive Symptoms- same as above, less common in adults Other Symptoms- adults may instead have one or more of the following: • unexplained iron-deficiency anemia • other vitamin and mineral deficiencies (A, D, E, K, calcium) • lactose intolerance • fatigue • bone or joint pain • arthritis • depression or anxiety • tingling numbness in the hands and feet

(section-ii)(nutrition-risk-manual)(page-275)Page 275#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 275

• seizures • missed menstrual periods • infertility (men and women) or recurrent miscarriage • canker sores inside the mouth • itchy skin rash- dermatititis herpetiformis • elevated liver enzymes Sources: Case, Shelley, Gluten-Free Diet, A Comprehensive Resource Guide, Case Nutrition Consulting Inc., 2008. National Institute of Diabetes and Digestive and Kidney Diseases, Celiac Disease, NIH Publication No. 08-4269 September 2008.) http://digestive.niddk.nih.gov/ddiseases/pubs/celiac/#what. Accessed May 2012.

The risk for development of CD depends on genetic, immunological, and environmental factors. Recent studies suggest that the introduction of small amounts of gluten while the infant is still breast-fed may reduce the risk of CD. Both breastfeeding during the introduction of dietary gluten, and increasing the duration of breastfeeding were associated with reduced risk in the infant for the development of CD. It is not clear from studies whether breastfeeding delays the onset of symptoms or provides a permanent protection against the disease. Therefore, it is prudent to avoid both early (<4 months) and late (≥7 months) introduction of gluten and to introduce gluten gradually while the infant is still breast-fed, as this may reduce the risk of CD. (7) The only treatment for CD is a gluten-free diet. Individuals with CD should discuss gluten-free food choices with a dietitian or physician that specializes in CD. Individuals with CD should always read food ingredient lists carefully to make sure that the food does not contain gluten. Making informed decisions in the grocery stores and when eating out is essential for the successful treatment of the disease (5, 8). Implications for WIC Nutrition Services

Through client-centered counseling, WIC staff can assist participants with CD in making gluten-free food choices that improve quality of life and promote nutritional well-being. WIC can provide nutrition education/counseling on alternatives to gluten-containing food products as well as provide gluten-free grain selections available in the WIC food packages. Based on the needs and interests of the participant, WIC staff may (as appropriate): • Promote breastfeeding throughout the first year of life, with exclusive breastfeeding until 4-6 months of age. • In consultation with the guidance of a medical provider, introduce gluten-containing foods between 4 and 6 months to infants at risk of CD, including infants with a parent or sibling with CD. • Tailor food packages to substitute or remove gluten-containing foods. • Educate participants on meeting nutritional needs in the absence of gluten-containing foods. • Encourage high fiber, gluten-free grain selections. • Monitor participant’s growth pattern and weight status. • Educate participants on planning gluten-free meals and snacks for outside the home.

(section-ii)(nutrition-risk-manual)(page-276)Page 276#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 276

• Provide educational materials outlining allowed foods and foods to avoid, for example: ▪ http://www.celiac.nih.gov/Default.aspx. Accessed May 2012. ▪ http://www.naspghan.org/user-assets/Documents/pdf/diseaseInfo/GlutenFreeDietGuide- E.pdf. Accessed May 2012.

• Provide referrals as appropriate.

Clarification

The 2006 American Gastroenterological Association (AGA) Institute Technical Review on the Diagnosis and Management of Celiac Disease refers to CD as “a unique disorder that is both a food intolerance and autoimmune disorder” (9). According to the 2010 NIAID-Sponsored Expert Panel definition, CD is a non- IgE mediated food allergy (10). (See nutrition risk criterion #353, Food Allergy.) However, the Expert Panel did not include information about CD in its report but rather refers readers to existing clinical guidelines on CD, including the AGA Institute’s Technical Review. (5 9,10)

Justification for High Risk

Not Applicable

Additional Counseling Guidelines

• Explain disease ▪ Gluten is a protein found in wheat, rice, oats, and barley (WROB) ➢ Gluten may be fractionated into two parts: gliadin (the damaging fraction) and glutenin ➢ In oats, it is prolamin ▪ Lining of small intestine is damaged when gluten is ingested ▪ Symptoms include: constipation alternating with diarrhea, steatorrhea, excessive gas, bloating, weight loss with high calorie intake, anemia, itchy blistering lesions, projectile vomiting and growth failure in infants and children ➢ Even if participant does not experience symptoms, damage still occurs ➢ Can lead to malabsorption and malnutrition ▪ If disease is untreated it can lead to other problems such as organ system problems, OB/GYN problems, dental problems, behavioral changes/irritability, decreased concentration in children ▪ Celiac disease may be associated with other disorders such as Type I IDDM, hypoglycemia • Disease typically seen in: ▪ infants when cereals are added ▪ adolescence - remission and then later reoccurs

(section-ii)(nutrition-risk-manual)(page-277)Page 277#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 277

▪ adults age 20 – 30 secondary to intestinal damage • Help participant identify/avoid gluten sources ▪ Avoid gluten in diet by eliminating wheat, rye, oats, barley, buckwheat (kasha), kamut (hybrid of wheat and rye), millet, quinoa, spelt (ancient wheat) or triticale flours ▪ Identify less obvious food sources of gluten such as salad dressing, ice cream, candies, gravies and sauces containing fillers, malted milk, beer and ale from barley, paste products, food containing bran or labeled graham (e.g. - graham crackers), soy sauce solids, food starch – modified (ingredient labeling term that indicates the presence of gliadin (the damaging fraction of gluten)), flour, self-rising flour, enriched flour, monosodium glutamate (MSG), hydrolyzed vegetable protein (HVP), cereals, cereal extracts, distilled vinegar, emulsifiers and stabilizers ▪ Many medications may contain gluten; check with MD, pharmacist or refer to drug information from Celiac Sprue Association ▪ Some foods, such as cereals, could be contaminated with gluten during manufacturing • If medically necessary, gluten free cereals may be approved ▪ The following WIC-approved cereals are WROB free: ➢ Instant grits ➢ Malt-O-Meal puffed rice (special food letter needed) ▪ Contact the State agency if special approval is needed • Recommend to incorporate the following into diet: ▪ Life-long adherence to diet ▪ Adequate intake of protein, carbohydrate and fat (without WROB) ▪ Encourage fat soluble vitamins A, D, E, K, the B vitamins (including folate), through food and vitamin/mineral supplementation ▪ Fiber through other sources (e.g. beans, lentils), corn, rice millet, corn breads and flours from rice, arrowroot, corn breads and flours from rice, arrowroot, potato, soy, tapioca ▪ Cereals including Cream of Rice, hominy, corn meal, puffed rice ▪ Wheat starch can be used to prepare baked products but not substituted freely as flour ▪ Use rice vinegar, wine vinegar or pure cider vinegar, not distilled vinegar • For newly diagnosed individuals: ▪ Allow for GI recovery (up to 6 months) ▪ Recommend to avoid fat until steatorrhea subsides ▪ Recommend to avoid lactose • Provide simplified meal plan regarding weaning from wheat based to rice based diet • Avoid overwhelming participant with too many details at once • Provide a few excellent recipes • Discuss planning meals when away from home or when in restaurants • Provide a list of manufacturers who provide special food products • Provide list of support groups for Celiac Disease

References 1. National Institute of Allergy and Infectious Disease. Food allergy: an overview. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, 2010 (NIH Publication No. 11- 5518). Available at:http://www.niaid.nih.gov/topics/foodallergy/understanding/pages/whatisit.aspx. Accessed May 2012. 2. Case, S. Gluten-free diet: A comprehensive resource guide. Case Nutrition Consulting Inc., 2008.

(section-ii)(nutrition-risk-manual)(page-279)Page 279#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 279

355 Lactose Intolerance Definition/Cut-Off Value

Lactose intolerance is the syndrome of one or more of the following: diarrhea, abdominal pain, flatulence, and/or bloating, that occurs after lactose ingestion. Presence of condition diagnosed, documented, or reported by a physician or someone working under a physician’s orders, or as self reported by applicant/participant/caregiver. See Clarification for more information about self-reporting a diagnosis.

Participant Category and Priority Level

Category Priority High Risk Pregnant I N Breastfeeding I N Non-Breastfeeding VI N Infants I N Children III N

Parameters for Manual Assignment

Must be manually selected in Nutrition Interview or Risk Panel

Justification

Lactose intolerance occurs because of a deficiency in the levels of the lactase enzyme (1). Many variables determine whether a person with lactase deficiency develops symptoms. They include: the dose of lactose ingested; the residual intestinal lactase activity; the ingestion of food along with lactose; the ability of the colonic flora to ferment lactose; and, the individual sensitivity to the products of lactose fermentation (1). Some forms of lactase deficiencies may be temporary, resulting from premature birth or small bowel injuries, and will correct themselves, leaving individuals with the ability to digest lactose sufficiently (2). Primary lactase deficiency is attributable to relative or absolute absence of lactase that develops in childhood, and is the most common cause of lactose malabsorption and lactose intolerance (2). Secondary lactase deficiency is one that results from small bowel injury, such as acute gastroenteritis, persistent diarrhea, or other causes that injure the small intestine mucosa, and can present at any age, but is more common in infancy. Treatment of secondary lactase deficiency and lactose malabsorption attributable to an underlying condition generally do not require elimination of lactose from the diet. Once the primary problem is resolved, lactose-containing products can be consumed normally. (2) Congenital lactase deficiency is a rare disorder that has been reported in only a few infants. Affected newborn infants present with intractable diarrhea as soon as human milk or lactose-containing formula is introduced. (2)

Developmental lactase deficiency is the relative lactase deficiency observed among pre-term infants of less than 34 weeks gestation (2). One study in preterm infants reported benefit from the use of lactase-

(section-ii)(nutrition-risk-manual)(page-280)Page 280#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 280

supplemented feedings or lactose-reduced formulas (3). The use of lactose-containing formulas and human milk does not seem to have any short- or long-term deleterious effects in preterm infants (2). Lactose is found primarily in milk, milk-based formula and other dairy products, which provide a variety of nutrients essential to the WIC population (calcium, vitamin D, protein). Lactose intolerance varies according to individuals. Some individuals may tolerate various quantities of lactose without discomfort, or tolerate it when consumed with other foods. Dairy products that are soured, or otherwise treated with bacteria that secrete lactase (e.g., Lactobacillus acidophilus), such as cheese and yogurt, are easier to digest in lactose-intolerant individuals because they contain relatively low levels of lactose. (4) Many individuals diagnosed with lactose intolerance avoid dairy all together. Also, lactose intolerance has been shown to be associated with low bone mass and increased risk of fracture (5). Inadequate dairy intake increases the risk of metabolic syndrome, hypertension, preeclampsia, obesity and certain forms of cancer, especially colon cancer (6).

Implications for WIC Nutrition Services

It is important to assess participants individually for lactose tolerances and nutrient needs to determine the best plan of action. WIC can provide client-centered counseling to incorporate tolerated amounts of lactose-containing foods and/or other dietary sources of calcium, vitamin D and protein into participants’ diets. WIC foods such as cheese, lactose-free milk, soy beverages, tofu, and calcium fortified foods (like juice) can provide these nutrients to participants with lactose intolerance. Based on the needs and interests of the participant, WIC staff can, in addition, also offer the following strategies (as appropriate):

• Except for infants with congenital lactase deficiency, promote exclusive breastfeeding until six months of age and continue breastfeeding through the first year. For infants with congenital lactase deficiency, treatment is removal and substitution of lactose from the diet with a commercial lactose-free formula (2). • Tailor food packages to substitute or remove lactose-containing foods. • Educate participants on meeting nutritional needs in the absence of lactose-containing foods. • Educate participants on planning lactose-free/lactose-reduced meals and snacks for outings, social gatherings, school and/or work.

Any WIC participant suspected to have lactose intolerance should be referred to a health care provider for evaluation and appropriate diagnosis (7), if needed (see Clarification for additional information on diagnosing Lactose Intolerance). Clarification

Lactose malabsorption can be diagnosed with a hydrogen breath test. The test involves having individuals ingest a standard dose of lactose after fasting. Elevated levels of breath hydrogen, which are produced by

(section-ii)(nutrition-risk-manual)(page-281)Page 281#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 281

bacterial fermentation of undigested lactose in the colon, indicate the presence of lactose malabsorption (1). The hydrogen breath test is not routinely ordered, and instead, patients are frequently asked to assess symptoms while avoiding dairy products for a period of time followed by a lactose product challenge to determine if they are lactose intolerant (7). The demonstration of lactose malabsorption does not necessarily indicate that an individual will be symptomatic Justification for High Risk

Not Applicable

Additional Counseling Guidelines

• Explain ▪ Lactose intolerance may be secondary to GI upset or illness • Dietary recommendations to discuss: ▪ Avoid foods containing lactose ▪ Limit portion size of lactose-containing foods ▪ Consume dairy foods with meals (diluted with other foods) ▪ Heated milk products may be better tolerated (lactose broken down) ▪ Higher-fat dairy foods (ice cream) may be better tolerated, for occasional treats ▪ Lactose enzyme tablets are available to take when lactose containing foods are ingested (but are expensive) ▪ Try lactose-reduced or lactose-free milks (Lactaid, Dairy Ease) ▪ Choose low-lactose foods such as aged hard cheese or yogurt for calcium source ➢ Active culture foods such as yogurt help break down lactose ▪ Read labels to avoid foods containing milk or lactose such as: milk solids, non-fat milk solids, whey, lactose, margarine, sour cream, malted milk, butter, buttermilk ▪ Avoid foods that may contain lactose; breads, candy/cookies, cold cuts, hot dogs, bologna, commercial sauces and gravies, cream soups, dry cereals, frostings, frozen breaded fish/chicken, prepared and processed foods, salad dressings containing milk or cheeses, sugar substitutes, chocolate drink mixes, coffee drinks/mixes ▪ Kosher foods that contain the word “pareve” or “parve” are acceptable and do not contain milk ▪ Creamers do no adequately substitute milk ▪ If dairy intake is compromised, include foods rich in calcium, vitamin A & D ▪ If participant’s calcium intake is compromised, offer calcium-fortified orange juice by providing the client with a Special Formula/Food letter indicating the client’s need for calcium-fortified orange juice ▪ Substitute fruit juice or water in baked products that call for milk ➢ Choose recipes that produce a good product since texture may be different • For infants: ▪ If breastfeeding, continue to breastfeed (Breast milk is easily digested and will help with recovery of illness, diarrhea and other symptoms.) ▪ If formula fed, use lactose reduced formula

(section-ii)(nutrition-risk-manual)(page-284)Page 284#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 284

▪ If rate of fall of blood glucose is rapid may experience sweating, weakness, hunger, tachycardia (increased heart rate) ▪ If rate of fall of blood glucose is slow (over many hours) may experience headache, blurred vision, incoherent speech, mental confusion ▪ If hypoglycemia is prolonged, more serious problems can occur • If participant experiences symptoms, eat something (e.g. ½ cup juice or milk) • If hypoglycemia is secondary to disease or other medical condition, follow medical recommendations • There are many different causes or etiologies • Signs and symptoms and when they occur may vary • In infants potential causes of hypoglycemia include: ▪ SGA ▪ Fetal Growth Restriction ▪ mother with Gestational Diabetes • Dietary recommendations ▪ Encourage regular scheduled meals (e.g. 3 meals, 3 snacks) ▪ Encourage not to miss meals • Encourage participant to ask MD about allowed exercise • If participant is pregnant, discuss with MD feeding plan for newborn ▪ Allow mother to breastfeed soon after delivery and frequently thereafter • If infant is being treated in the hospital, recommend the mother/parents be available for and make arrangements for frequent feedings if medically allowed ▪ For breastfed infants - to prevent possible “nipple confusion,” increase milk production, benefits to baby, etc. ▪ For formula/bottle fed infants - for bonding and interaction

References

1. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDKD): National Diabetes Information Clearinghouse; NIDDKD internet address: www.niddk.nih.gov; February 10, 1997.

2. Institute of Medicine: WIC Nutrition Risk Criteria: A Scientific Assessment; 1996; pp. 217- 218.

3. Zeman FJ. Clinical Nutrition and Dietetics. Lexington, Mass: The Collamore Press; 1993.

(section-ii)(nutrition-risk-manual)(page-286)Page 286#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 286

• Changes to appetite

• Changes to taste and smell

• A dry or sore mouth

• Epigastric distress, nausea, vomiting, diarrhea, and/or constipation

These indirect medication related side-effects can impact the amount and/or variety of foods consumed by the individual 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. (2)

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.

Medication Medication Purpose Impact on Nutritional Status Amiloride (Midamor) Diuretic May cause loss of appetite, nausea, diarrhea, and vomiting (3) May reduce magnesium excretion (4) Calcium Carbonate (Tums) Antacid May cause vomiting, constipation, and loss of appetite (3) May decrease the absorption of iron, zinc, magnesium, and fluoride (2) Chlorthalidone (Hygroton) Diuretic May cause upset stomach, vomiting, diarrhea, and loss of appetite (3) Increases excretion of zinc (5) Ciprofloxacin (Cipro) Antibiotic May cause nausea, vomiting, stomach pain, and diarrhea Decreases the absorption of zinc (5) Furosemide (Lasix) Diuretic May cause constipation and diarrhea (3) May increase magnesium excretion with chronic use (4) Lansoprazole (Prevacid) and Omeprazole (Prilosec) Proton pump inhibitors May cause constipation, nausea, and diarrhea (3) May reduce iron absorption and lead to suboptimal iron repletion with supplements (6) Levothyroxine (Synthroid, Levothroid, Levoxly) Thyroid hormone May cause diarrhea and vomiting (3) May decrease appetite and weight (2) Metformin Antihyperglycemic May cause diarrhea, indigestion, and constipation (3) May decrease appetite (2) May decrease the absorption of folate and vitamin B12 (2) Methadone Analgesic (Opioid) May cause weight gain (3) May cause dry mouth, nausea, vomiting, and constipation (2)

(section-ii)(nutrition-risk-manual)(page-287)Page 287#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 287

Ondansetron (Zofran) Antiemetic, Antinauseant May cause constipation (3) In rare cases may decrease potassium levels (2) Phenobarbital Antiepileptic May cause nausea and vomiting (3) May decrease vitamin D and vitamin K level (2) Decreases calcium absorption (7) May decrease folate levels (8) Prednisone Corticosteroid May deplete calcium and lead to osteoporosis (9) Calcium and vitamin D supplement recommended with long-term use (2) Rantidine (Zantac) Antiulcer, AntiGERD, Antisecretory May cause constipation, diarrhea, nausea and vomiting (3) May decrease iron and vitamin B12 absorption (2) Sertraline (Zoloft) Antidepressant May cause nausea, diarrhea, constipation and vomiting (3) May lead to anorexia and decreased weight (2) Sulfasalazine Ulcerative Colitis Treatment May cause diarrhea, loss of appetite and vomiting (3) Decreases folate absorption (8)

Breastfeeding and Medication Use

Breastfeeding is important for promoting the health of both the mother and infant. Medication use in the postpartum period, however, can sometimes pose some 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 healthcare 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://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm) 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 healthcare 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://fns-prod.azureedge.net/sites/default/files/wic/WIC-Breastfeeding- Policy-andGuidance.pdf).

Justification for High Risk

Not Applicable

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.

(section-ii)(nutrition-risk-manual)(page-288)Page 288#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 288

• 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)

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://fnsprod.azureedge.net/sites/default/files/wic/WIC-Breastfeeding-Policy-andGuidance.pdf) o National Institutes of Health’s LactMed Drugs and Lactation Database (https://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm) o Hale’s Medication and Mothers’ Milk (most recent edition)

Additional Counseling Guidelines • Explain the factors associated with drug nutrient interaction ▪ All drugs taken by pregnant women can be considered potentially harmful to the fetus ▪ Misuse of some drugs during pregnancy can result in fetal malformations ▪ Food components affect drug absorption and bioavailability ➢ Effects vary for each drug ▪ Drugs can affect the stomach emptying time ▪ Drugs can compete with nutrients for absorption ▪ Drugs can affect appetite, induce nausea, and impair sense of taste which may reduce food intake and contribute to weight loss ▪ Use of some prescription and over-the-counter drugs are not advisable in breastfeeding ▪ Some adverse effects can be minimized through adequate nutrient intake and timing of intake in relation to meals and breastfeeding • Explain possible nutrition related side effects of the medication(s) that participant is currently taking • Refer participant to her health care provider for the drug nutrient interaction or if a drug nutrient reaction is suspected

(section-ii)(nutrition-risk-manual)(page-289)Page 289#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 289

• Refer participant to the Mother-to-Baby • References

1. Chan LN. Drug-nutrient interactions. J Parenter Enteral Nutr. 2013 May 14 [cited 2019 Mar 19];37(4):450-9. Available from: https://doi.org/10.1177/0148607113488799.

2. Pronsky ZM, Elbe D, Ayoob K. Food medication interactions. 18th edition. Birchrunville (PA): Food Medication Interactions; 2015 Apr 17. 444 p.

3. American Society of Health-System Pharmacists [Internet]. Bethesda (MD): National Library of Medicine, c2019. MedlinePlus. [cited 2019 Apr 29] Available from: https://medlineplus.gov/druginformation.html.

4. National Institutes of Health [Internet]. Magnesium fact sheet for health professionals. Bethesda (MD): 2016 Feb 11 [cited 2018 Jan 1]. [about 13 screens]. Available from: https://ods.od.nih.gov/factsheets/Magnesium-HealthProfessional/.

5. National Institutes of Health [Internet]. Zinc fact sheet for health professionals. Bethesda (MD): 2016 Feb 11 [cited 2018 Jan 19]. [about 12 screens]. Available from: https://ods.od.nih.gov/factsheets/Zinc- HealthProfessional/.

6. National Institutes of Health [Internet]. Iron fact sheet for health professionals. Bethesda (MD): 2016 Feb 11 [cited 2016 Dec 2]. [about 14 screens]. Available from: https://ods.od.nih.gov/factsheets/Iron- HealthProfessional/

7. National Institutes of Health [Internet]. Vitamin D fact sheet for health professionals. Bethesda (MD): 2016 Feb 11 [cited 2018 Jan 19]. [about 14 screens]. Available from: https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/.

8. National Institutes of Health [Internet]. Folate fact sheet for health professionals. Bethesda (MD): 2016 Apr 20 [cited 2018 Jan 19]. Folate fact sheet for health professionals. [about 16 screens]. Available from: https://ods.od.nih.gov/factsheets/Folate-HealthProfessional/.

9. National Institutes of Health [Internet]. Calcium fact sheet for health professionals. Bethesda (MD): 2016 Nov 17 [cited 2018 Jan 19]. [about 20 screens]. Available from: https://ods.od.nih.gov/factsheets/Calcium- HealthProfessional/.

(section-ii)(nutrition-risk-manual)(page-291)Page 291#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 291

It is estimated that around 9 percent, or 28.8 million Americans, will have an eating disorder in their lifetime (2, 3, 4). The three most common eating disorders are: • Anorexia Nervosa (AN) – 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 (7). • Bulimia Nervosa (BN) – 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 (7). • Binge-Eating Disorder (BED) – 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 excessive exercise. As a result, people with binge-eating disorder often are overweight or obese. (5, 8).

In the U.S., BED is the most common type of eating disorder (9). Other less common types of eating disorders include Avoidant/Restrictive Food Intake Disorder and Rumination Disorder (5).

While stereotypically associated with thin, White, affluent females, eating disorders can affect individuals of all ages, races/ethnicities, body weights and genders. Frequently appearing during the teen years or young adulthood, eating disorders may also develop during childhood or later in life. While eating disorders affect both genders, prevalence is higher among women than men (1).

There is a lack of eating disorder research among low-income communities, making it difficult to determine the prevalence, severity, and types of eating disorder pathology among this population (10). However, existing research shows that food insecure adults often deliberately restrict food for reasons other than weight and shape concerns and that this dietary restraint is nonetheless correlated with increased eating disorder pathology (11). Research also supports the notion that increased levels of food insecurity are associated with increased levels of eating disorder pathology (10).

Complications of Eating Disorders during Pregnancy and Postpartum

Research suggests that up to 7.5 percent of pregnant women are affected by an eating disorder (12). It was once thought that pregnancy was rare among women with eating disorders due to associated menstrual dysfunction. Although having an eating disorder can decrease the likelihood of becoming pregnant, a growing body of evidence has confirmed that not only can pregnancy occur during an eating disorder but that it happens more commonly than previously thought (13, 14, 15, 16). 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 (17, 18, 19, 20, 21).

Other misconceptions about eating disorders and pregnancy include the perception that pregnancy motivates eating disorder patients to stop their behaviors; that it will be obvious if a pregnant woman has an eating disorder because she won’t gain enough weight; and that as long as weight gain is adequate then eating disorders will not affect the pregnancy or its outcomes (22). Pregnant women with eating disorders may have specific maternal macro- and micronutrient deficiencies (12). When energy and

(section-ii)(nutrition-risk-manual)(page-292)Page 292#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 292

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 (23). Women with BN who continue to purge during pregnancy are at increased risk of dehydration, chemical imbalances, or even cardiac irregularities (23).

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, one of the most supported conclusions based on the research is that regardless of whether an eating disorder improves during pregnancy, eating disorder symptoms frequently relapse to their highest level almost immediately after delivery (22).

For women with eating disorders, pregnancies are often unplanned and eating disorder pathology has been associated with various perinatal risks such as delayed development, prematurity, hypotrophy, stillbirth, difficult delivery, and postnatal depression (24). The following table summarizes the health outcomes for both the woman and infant that may result from an eating disorder. Possible Health Outcomes for Women and Infants by Eating Disorder (17, 25, 26, 27, 28, 29, 30, 31, 32, 33)

Anorexia Nervosa Bulimia Nervosa Binge-Eating Disoder* 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

(section-ii)(nutrition-risk-manual)(page-293)Page 293#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 293

*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)

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 (35, 36, 37). 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 (21, 38, 39).

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 (5). 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 (40). 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 (16, 40, 41, 42, 43). 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 (44, 45). 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 (46).

Treatment of eating disorders depends on the disorder and symptoms displayed, but typically involves psychological therapy, also known as psychotherapy (47). Depending on the severity of eating disorder symptoms, admission to a specialized residential or hospital-based treatment program can be lifesaving (48). 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 (1, 49):

• Individual, group, and/or family psychotherapy • Medical care and monitoring • Nutritional counseling • Medications

Additionally, obtaining adequate health insurance coverage for inpatient treatment of eating disorders remains a challenge as one major issue plaguing discussions with insurers regarding reimbursement for the treatment of eating disorders is the apparent gap between research on variables associated with outcomes and the formulas used for reimbursement (50).

(section-ii)(nutrition-risk-manual)(page-294)Page 294#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 294

Implications for WIC Nutrition Services

The role of WIC is not to diagnose or treat an eating disorder but rather 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 (5, 25, 37): • 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 baby. • When possible, the CPA should coordinate with the participant’s HCP to obtain referral data such as height, weight gain, etc. Additionally, encourage the participant to discuss with their HCP about blind weighing (36). If necessary, they can ask their doctor about standing on the scale backwards and instruct them not to share the number with them. • 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).

Clarification

Self-reporting of a diagnosis made by a medical professional should not be confused with self-diagnosis, where a person claims to have or to have had a medical condition without reference to a professional diagnosis. A self-reported medical diagnosis (“My doctor says that I have/my son or daughter has…”) should prompt the CPA to validate the presence of the condition by asking more pointed questions related to that diagnosis. Although a self-diagnosis should not be used to assign risk, it should prompt the CPA to make a referral to a healthcare professional for diagnosis and treatment, as appropriate.

An eating disorder is diagnosed based on an individual’s symptoms and experiences aligned with criteria defined by the American Psychiatric Association. The term disordered eating is a descriptive phase, not a diagnosis as defined by the American Psychiatric Association. It is possible to have disordered eating patterns that do not fit within the current confines of an eating disorder diagnosis (51). See risk #427- Inappropriate Nutrition Practices for Women to learn more about disordered eating.

(section-ii)(nutrition-risk-manual)(page-295)Page 295#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 295

Justification for High Risk

Eating disorders can seriously complicate any pregnancy since weight gain is of critical importance and the nutritional status of the pregnant woman is an important factor in perinatal outcome. Pregnant women with an eating disorder are more likely to have a greater rate of miscarriage or premature labor, IUGR, and babies with higher rates of SGA, LBW, neural tube defects, and microcephaly (2). Some women with bulimia before pregnancy transfer to binge eating disorder (BED) during pregnancy. Women with BED and bulimia consume more total energy and fat, monosaturated and saturated fat, yet consume less folate, potassium and vitamin C (3). Pregnant women experiencing anorexia are more likely to have SGA infants and are more likely to relapse postpartum. Other maternal postpartum symptoms like postnatal depression, stress of new motherhood, body image concerns and anemia can contribute to an eating disorder relapse (1). 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 (17,18,19,20,21).

Women with an eating disorder are less likely to breastfeed, or more likely to discontinue breastfeeding before 6 months. If they do breastfeed, mothers with an eating disorder may restrict food from their infants, which will affect the infant’s health (2,5).

Individual counseling and WIC food can assist the pregnant woman in gaining an appropriate amount of weight and increasing the baby’s birth weight.

References

1. National Institute of Mental Health [Internet]. Bethesda (MD): National Institute of Mental Health, c2016. Eating Disorders. 2016 Feb [cited 2021 June]. Available from: https://www.nimh.nih.gov/health/topics/eating-disorders/index.shtml. 2. Hay P, Girosi F, Mond J. Prevalence and sociodemographic correlates of DSM-5 eating disorders in the Australian population. J Eat Disord. 2015 Apr 25 [cited 2021 June 23]; 3(19). Available from: Prevalence and sociodemographic correlates of DSM-5 eating disorders in the Australian population | Journal of Eating Disorders | Full Text (biomedcentral.com). 3. Hudson JI, Hiripi E, Pope Jr HG, et al. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007 Feb 1 [cited 2021 June 23]; 61(3):348–58. Available from: The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication - PubMed (nih.gov). 4. Harvard School of Public Health [Internet]. Boston; c2021. Report: Economic Cost of Eating Disorders; 2020 June [cited 2021 June 23]; [about 3 screens]. Available from: https://www.hsph.harvard.edu/striped/report-economic-costs-of-eating-disorders/. 5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington (VA): American Psychiatric Publishing; 2013. 6. Herzog DB, Greenwood DN, Dorer DJ, et al. Mortality in eating disorders: a descriptive study. Int J Eat Disord. 2000 May; 28(1): 20–26. 7. Johns Hopkins Medicine: Psychiatry and Behavioral Sciences Eating Disorders Program [Internet]. Baltimore: John Hopkins Medicine; c2021. Frequently Asked Questions About Eating Disorders;

(section-ii)(nutrition-risk-manual)(page-296)Page 296#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 296

[cited 2021 June 23]; [about 10 screens]. Available from: https://www.hopkinsmedicine.org/psychiatry/specialty_areas/eating_disorders/faq.html. 8. National Institute of Mental Health [Internet]. Bethesda (MD); c2022. Eating; 2021 Dec [cited 2022 Sep 8]; [about 2 screens]. Available from: https://www.nimh.nih.gov/health/topics/eating-disorders. 9. Office on Women’s Health [Internet]. Washington DC: Office on Women’s Health, c2020. Binge eating disorder. 2018 Aug 16 [cited 2021 June 23]. Available from: https://www.womenshealth.gov/mental-health/mental-health-conditions/eating-disorders/binge- eating-disorder. 10. Becker CB, Middlemass KM, Gomez F, et al. Eating Disorder Pathology Among Individuals Living with Food Insecurity: A Replication Study. Clin Psychol Sci. 2019 June 17 [cited 2021 June 23]; 7(5):1144-58. Available from: https://doi.org/10.1177/2167702619851811. 11. Middlemass KM, Cruz J, Gamboa A, et al. Food insecurity & dietary restraint in a diverse urban population. Eat Disord. 2020 Mar 4; 1 – 14. 12. Dorsam AF, Preissi H, Micali N, et al. The Impact of Maternal Eating Disorders on Dietary Intake and Eating Patterns during Pregnancy: A Systematic Review. Nutrients. 2019 Apr 12 [cited 2021 June 23]; 11(4): 840. Available from: The Impact of Maternal Eating Disorders on Dietary Intake and Eating Patterns during Pregnancy: A Systematic Review - PubMed (nih.gov). 13. Glassman JN, Rick CL, Darko D, et al. Menstrual dysfunction in bulimia. Ann Clin Psychiatry. 1991 [cited 2021 June 23]; 3(2):161–65. 14. Tierney S, Fox JRE, Butterfield C, et al. Treading the tightrope between motherhood and an eating disorder: a qualitative study. Int J Nurs Stud. 2011 Oct [cited 2021 June 23]; 48(10): 1223–33. 15. Easter A, Bye A, Taborelli E, et al. Recognising the symptoms: how common are eating disorders in pregnancy? Eur Eat Disord Rev. 2013 July [cited 2021 June 23]; 21(4): 340–44. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1002/erv.2229. 16. Cardwell MS. Eating disorders during pregnancy. Obstet Gynecol Surv. 2013 Aug [cited 2021 June 23]; 68(4):312–23. Available from: https://pubmed.ncbi.nlm.nih.gov/23943041. 17. Mazzeo SE, Slof Op’t Landt MCT, Jones I, et al. Associations among postpartum depression, eating disorders, and perfectionism in a population-based sample of adult women. Int J Eat Disord. 2006 Apr; 39(3):202–11. 18. Abraham S, Taylor A, Conti J. Postnatal depression, eating, exercise, and vomiting before and during pregnancy. Int J Eat Disord. 2001 May [cited 2021 June 23]; 29(4):482–87. Available from: Postnatal depression, eating, exercise, and vomiting before and during pregnancy. - Abstract - Europe PMC. 19. 19.Welch SL, Doll HA, Fairburn CG. Life events and the onset of bulimia nervosa: a controlled study.Psychol Med. 1997 May [cited 2021 June 23];27(3):515–22. Available from: doi:https://pubmed.ncbi.nlm.nih.gov/9153672. 20. Ward VB. Eating disorders inpregnancy. BMJ. 2008 Jan 12 [cited 2021 June 23]; 336(76350):93– 96.Available from: doi:https://www.bmj.com/content/336/7635/93. 21. Morgan JF, Lacey JH, Sedgwick PM. Impact of pregnancy on bulimia nervosa. Br J Psychiatry. 1999 Feb [cited 2021 June 23]; 174:135–140. Available from:https://pubmed.ncbi.nlm.nih.gov/10211167. 22. Setnick, J. Eating Disorders and Pregnancy: What Every Dietetics Professional Should Know.DevelopMental Issues. 2003;22(2): 1-6. 23. Behavioral Nutrition [Internet]. Quincy (MA); c2021. Eating Disorders & Pregnancy: Anorexia,Bulimia and Binge Eating; 2018 Aug 3 [cited 2021 June 23]; [about 7 screens]. Available from:https://behavioralnutrition.org/eating-disorders-pregnancy-anorexia-bulimia-and-binge-eating/.

(section-ii)(nutrition-risk-manual)(page-297)Page 297#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 297

24. Squires C, Lalanne C, Murday N, et al. The influence of eating disorders on mothers’sensitivity and adaptation during feeding: a longitudinal observational study. BMC Pregnancy and Childbirth].2014 Aug 14 [cited 2021 June 23]; 14:274. Available from:https://pubmed.ncbi.nlm.nih.gov/25123354 25. NEDA: Feeding Hope[Internet]. NewYork (NY); c2021.Pregnancy and Eating Disorders; [cited 2021 June 23]; [about 3 screens]. Available from:Pregnancy and Eating Disorders | National Eating Disorders Association. 26. Watson HJ, Zerwas S, Torgersen L, et al. Maternal Eating Disorders and Perinatal Outcomes: AThree-Generation Study in the Norwegian Mother and Child Cohort Study. J Abnorm Psychol. 2017July [cited 2021 June 23]; 126(5):552-64. Available from:https://pubmed.ncbi.nlm.nih.gov/28691845. 27. Mantel A, Linden Hirschberg A, Stephansson O. Association of Maternal Eating Disorders With Pregnancy and Neonatal Outcomes. JAMA Psychiatry. 2020 Mar 1 [cited 2021 June 23]; 77(3):285-Available from:https://pubmed.ncbi.nlm.nih.gov/31746972. 28. Arnold C, Johnson H, Mahon C, et al. The Effects of Eating Disorders in Pregnancy on Mother and Baby: A Review. Psychiatr Danub.2019 Sept [cited 2021 June 23]; 31(3): 615-18. Available from:https://pubmed.ncbi.nlm.nih.gov/31488801/. 29. March of Dimes [Internet]. Arlington (VA); c2021. Eating Disorders and Pregnancy; 2016 Apr[cited2021 June 23]; [about 4 screens] Available from:https://www.Marchofdimes.org/complications/eating-disorders-and-pregnancy.aspx. 30. Marcos A. Eating disorders: asituation of malnutrition withpeculiar changes in the immunesystem. Eur J Clin Nutr. 2000 Mar [cited 2021 June 23]; 54(1):S61-64. Available from:Eating disorders: a situation of malnutrition with peculiar changes in the immune system | European Journal of Clinical Nutrition (nature.com). 31. Abed J, Judeh H, Abed E, et al.“Fixing a heart”: the game of electrolytes in anorexia nervosa. Nutr J. 2014 Sept 5 [cited 2021 June 23]; 13:90. Available from:https://pubmed.ncbi.nlm.nih.gov/25192814. 32. NEDA: Feeding Hope[Internet]. NewYork (NY); c2012. Bulimia Nervosa. 2012 [cited 2021 June 23];[2 pages].Availablefrom:https://www.nationaleatingdisorders.org/sites/default/files/ResourceHandouts /BulimiaNervosa.pdf 33. Academy of Nutrition and Dietetics [Internet]. Chicago (IL);c2022.Understanding Eating Disorders.[cited 2022 Sep 8];[1 page]. Available from:https://www.eatright.org/health/diseases-and- conditions/eating-disorders/understanding-eating-disorders. 34. Giordano R, Cacciatore A, Cignini P, et al. Antepartum Haemorrhage. J Prenat Med. 2010 Jan [cited2021 June 23]; 4(1):12 –16. Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3263934/. 35. Nguyen AN, de Barse LM, Tiemeier H, et al. Maternal history of eating disorders: Diet quality during pregnancy and infant feeding. Appetite.2017 Feb 1 [cited 2021 June 23]; 109:108-14. 36. Martinez Olicina M, Rubio Arias JA, Reche Garcia C, et al. Eating Disorders in Pregnancy and Breastfeeding Women: A Systematic Review. Medicina (Kaunas). 2020 July 15 [cited 2021 June 23];56(7):352. Availablefrom:Medicina. Eating Disorders in Pregnant and Breastfeeding Women: ASystematic Review (mdpi.com). 37. Froreich FV, Ratcliffe SE, VartanianLR. Blind versusopen weighing from an eating disorder patientperspective. J Eat Disord. 2020 Aug 17 [cited 2021 June 23]; 8:39 Available from:Blind versus open weighing from an eating disorder patient perspective (biomedcentral.com). 38. Lawton SA. Eating disorders Information for Teens: Health Tips About Anorexia, Bulimia, BingeEating, and Other Eating Disorders Including Information On the Causes, Prevention, and

(section-ii)(nutrition-risk-manual)(page-298)Page 298#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 298

Treatment of Eating Disorders, and Such Other Issues As Maintaining Healthy Eating and ExerciseHabits. Detroit: Omnigraphics, 2009. 39. Larsson G, Andersson Ellstrom A. Experiences of pregnancy-related body shape changes and of breast-feeding in women witha history of eating disorders.Eur Eat Disord Rev. 2003 Jan 23 [cited2021 June 23]; 11(2):116–24. Available from:https://doi.org/10.1002/erv.497. 40. Academy of Nutrition and Dietetics [Internet]. Chicago; c2021. Understanding Eating Disorders; 2019 Feb [cited 2021 June 23]; [about 4 screens]. Available from: https://www.eatright.org/health/diseases-and-conditions/eating-disorders/understanding-eating- disorders. 41. Broussard B. Psychological and behavioral traits associated with eating disorders and pregnancy: a pilot study. J Midwifery Womens Health. 2012 Jan Feb [cited 2021 June 23]; 57(1):61-66. Available from: Psychological and behavioral traits associated with eating disorders and pregnancy: a pilot study - PubMed (nih.gov). 42. Linna MS, Raevuori A, Haukka J, et al. Pregnancy, obstetric, and perinatal health outcomes in eating disorders. Am J Obstet Gynecol. 2014 Oct [cited 2021 June 23]; 211(4):392.e1-8. Available from: Pregnancy, obstetric, and perinatal health outcomes in eating disorders - PubMed (nih.gov). 43. Easter A, Solmi F, Bye A, et al. Antenatal and postnatal psychopathology among women with current and past eating disorders: longitudinal patterns. Eur Eat Disord Rev. 2015 Jan [cited 2021 June 23]; 23(1):19-27. Available from: Antenatal and postnatal psychopathology among women with current and past eating disorders: longitudinal patterns - PubMed (nih.gov). 44. Koubaa S, Hallstrom T, Lindholm C, et al. Pregnancy and neonatal outcomes in women with eatingdisorders. Obstet Gynecol. 2005 Feb [cited 2021 June 23]; 105(2):255–60. Availablefrom:Pregnancy and neonatal outcomes in women with eating disorders-PubMed (nih.gov). 45. Nohr EA, Frydenberg M, Henriksen TB, et al. Does low participation in cohort studies induce bias?Epidemiology. 2006 July [cited 2021 June 23]; 17(4):413–18. Available from: doi:10.1097/01.ede.0000220549.14177.60. 46. Fogarty S, Elmir R, Hay P, et al. The experience of women with an eating disorder in the perinatalperiod: a meta-ethnographic study. BMC Pregnancy and Childbirth. 2018 May 2 [cited 2021 June23]; 18(1):121.Available from:The experience of womenwith an eating disorder in the perinatalperiod: a meta-ethnographic study -PubMed (nih.gov). 47. Mayo Clinic [Internet]. Rochester (MN): Mayo Clinic; c1998-2021. Eating disorder treatment: Knowyour options; 2017 July 14 [cited 2021 June 23]; [about 7 screens]. Available from:https://www.mayoclinic.org/diseases-conditions/eating-disorders/in-depth/eating-disorder- treatment/art-20046234. 48. American Psychiatric Association [Internet]. Washington DC; c2021. Expert Q&A: Eating Disorders;2020 Dec [cited 2021 June 23]; [about 6 screens]. Availablefrom:https://www.psychiatry.org/patients-families/eating-disorders/expert-q-and-a. 49. Academy for Eating Disorders [Internet]. Reston; c2020. Resources: Treatment Options; [cited2021 June 23]; [about 5 screens]. Available from:https://www.aedweb.org/resources/about- eating-disorders/treatment-options. 50. Garner DM, Desmond M, Desai J, et al. The Disconnect between Treatment Outcome Data andReimbursement for the Treatment of Anorexia Nervosa. Int J Physiatry. 2016 Apr 6 [cited 2021 June 23]; 2(1). Available from:(PDF)The Disconnect between TreatmentOutcome Data andReimbursement for the Treatment of Anorexia Nervosa (researchgate.net). 51. Eat Right: Academy of Nutrition and Dietetics [Internet].Chicago; c2021. What is DisorderedEating; 2018 Oct 26 [cited 2021 June 23]; [about 3 screens].Available

(section-ii)(nutrition-risk-manual)(page-300)Page 300#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 300

359 Recent Major Surgery, PhysicalTrauma, Burns

Definition/Cut-off Value 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. Participant Category and Priority Level

Category Priority Pregnant Women I Breastfeeding Women I Non-Breastfeeding Women VI Infants I Children III Justification The body's response to injuries such as major surgeries, physical trauma, or burn may adversely affect nutrient requirements needed for recovery, leading to malnutrition. The catabolic response to these injuries causes a hypermetabolic state in the body. This alteration in metabolism not only increases the individual’s calorie and protein needs, but they also increase the needs for certain vitamins, minerals, fatty acids, and amino acids. (1) Proper wound healing is essential in the recovery of surgeries, physical trauma, and burns. Normal wound healing is a complex process and involves three phases: inflammation, proliferation, and remodeling (1, 2). Each phase of wound healing involves growth factors, other biologically active molecules, and specific vitamins and minerals such as Vitamin A, Vitamin C, and Zinc. The process of wound healing does not always follow the three stages sequentially and can sometimes move forward or regress based on nutrition status and response to treatment (3, 4). Even after a wound is closed, the individual’s metabolic rate and need for additional nutrition can remain high (5). Factors that can prevent proper wound healing or can increase the time needed for a wound to heal include (2, 6):

• Malnutrition prior to the surgery, injury or burn • Infections • Diabetes • Poor blood flow • Obesity • Age

(section-ii)(nutrition-risk-manual)(page-301)Page 301#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 301

• Heavy alcohol use • Stress • Medications • Smoking Because healing is a complex process and is impacted by a variety of factors, it is inappropriate to expect a set recovery time for an individual based solely on the type and severity of the injury (7). For some individuals, they may no longer be at increased nutritional risk within a couple weeks of their injury. For others, recovery from the same type and severity of injury may take months.

Major Surgery and Wound Healing

Many types of surgeries are completed as noninvasive procedures and do not result in large incisions that require additional medical and nutritional care to heal. However, many surgical procedures (including cesarean sections) do involve incisions that, if left unaddressed, could lead to infection. Major surgeries are surgeries that involve a risk to the life of the individual and include operations on organs within the body(8). Removal of a portion of the large or small intestine, heart surgery, and bariatric surgery are examples of major surgeries. Minor surgeries are surgeries that involve little risk to the individual and include operations on the superficial structures of the body (9). Ear tubes, the most common childhood surgery performed with anesthesia, are an example of a minor surgery that does not impact nutrition status (10).

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 19.7% of singleton births in 1996 to 31.3% of singleton births in 2011 (11). Reasons for a cesarean delivery include: multiple pregnancy, labor fails to progress, medical concerns for the infant, problems with the placenta, a large infant, breech position, maternal infections, and medical conditions in the mother (i.e. diabetes or high blood pressure) (12).

Nutritional Considerations for Major Surgery/Wound Healing

The role of specific nutrients in wound healing continues to be explored and studies are conducted regularly to assess the role vitamins, minerals, fatty acids, amino acids, and carbohydrates play in proper wound healing. Nutrient supplements above the Recommended Dietary Allowance (RDA) may be necessary to aid in wound healing. However, before using any additional supplement to assist in wound healing, energy and protein requirements of the individual must be met (13, 14). Amino acids are essential to the repair of damaged tissue in the body. Amino acids are divided into three categories: essential (must be obtained through foods), nonessential (can be produced in the body), and conditionally essential (produced in the body except in cases of injury or illness). Arginine and Glutamine are examples of conditionally essential amino acids.

(section-ii)(nutrition-risk-manual)(page-302)Page 302#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 302

The following table highlights the roles of these nutrients in the wound healing process:

Nutrient Role in Wound Healing Arginine Involved in secretion of growth hormone (12) Omega-3 fatty acids Reduces wound infections (12) Vitamin C Collagen synthesis (2) Vitamin A Immune function and cellular communication (15) Vitamin E Antioxidant (16) Vitamin D Modulates cell growth Neuromuscular and immune function Reduces inflammation (17) Magnesium Co-factor for enzymes involved in protein and collagen synthesis (2) Copper Co-factor for cross-linking of collagen (2) Zinc Involved in RNA and DNA polymerase (2) Iron Aids in the synthesis of some growth hormones and connective tissue (18) Following a cesarean section, a breastfeeding mother may experience difficulty finding a comfortable nursing position that does not cause pain with the incision. She may also have difficulty breastfeeding if the infant is drowsy due to the pain medication administered during the procedure. A referral to a lactation specialist can help ensure that the mother is successful in reaching her breastfeeding goals.

Physical Trauma Physical trauma is usually a result of accidents and injuries that often lead to fractures, wounds, and subsequent hospitalization. Physical trauma can be divided into blunt force trauma, penetrating trauma, and trauma from surgery. Blunt force trauma is the result of an object (or force) striking the body, causing concussions, lacerations or fractures. Penetrating trauma is trauma that occurs as a result of an object piercing the skin, causing an open wound (7). Fracture healing is a process that begins with a hemorrhage and progresses through three stages: inflammatory, reparative, and remodeling. Physical trauma can also be a result of domestic and/or child abuse. In addition to the physical effects of abuse, victims of abuse often experience acute and ongoing psychological and emotional trauma that may also impact an individual’s nutrition status. Poor appetite, undesirable food choices, and using food for coping can impact both women and children. Children may also begin hoarding food in cases of abuse or neglect. For more information on the impact of abuse, see Risk #901 Recipient of Abuse.

Nutritional Considerations for Physical Trauma In addition to an increase in energy, protein, and micronutrients needed for proper wound healing, physical trauma that includes fractures requires additional nutrients for proper bone healing. In some

(section-ii)(nutrition-risk-manual)(page-303)Page 303#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 303

cases, the physical trauma will lead to temporary or lifelong difficulty with self-feeding. Research on the roles specific nutrients play in fracture healing continues to expand. Key nutrients for bone health include calcium, phosphorus, fluoride, magnesium, sodium, vitamin D, vitamin A, vitamin K, vitamin C, vitamin B6, folate, and vitamin B12. Meeting RDAs set for these nutrients is important for bone health and bone healing (19).

For some individuals, intakes above the RDA may be recommended by their medical provider to assist in bone healing; however, some nutrients including fluoride, sodium, and vitamin A may negatively impact bone health when intake is above the recommended level (19). Burns Burns can be caused by heat (including hot surfaces, fires, and hot liquids), chemicals, electricity, sunlight or nuclear radiation. There are three stages of burns based on what layers of the skin are burned. A first- degree burn only affects the outer layer of the skin (epidermis). A second-degree burn damages the epidermis and the layer directly under the epidermis (dermis). A third-degree burn damages the epidermis, dermis, and damages the tissue underneath the skin. (20) Burns are also classified based on the surface area of the body that has been burned (Percent Total Body Surface Area or TBSA). For example, a burn that covers one hand and arm would be 9% TBSA, whereas a burn that covers a person’s back would be 18% TBSA (21). Increases in the surface area affected by the burn result in a greater potential for fluid loss and infection (21). Inhalation burns are burns that occur inside an individual’s lungs and internal organs. Once discharged from the hospital, enteral feedings may be prescribed to aid in healing. Nutritional Considerations for Burns The nutrition status of burn patients is monitored very closely during hospitalization and after discharge. Following a severe burn, the body goes into a catabolic state and the body begins to breakdown skeletal muscle (5). This state increases the requirements for energy, protein, carbohydrates, fats, vitamins, minerals, and antioxidants (22). Damaged blood vessels also increase fluid loss and can lead to dehydration or shock (19). Nutrition care in the hospital setting for individual’s recovering from burns may also include parenteral or enteral nutrition support depending on the severity of the burns. Glutamine, a conditionally essential amino acid, can improve the healing of burns (23). 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 a major surgery, physical trauma, and/or burn, an individual will be at increased nutritional risk until the injury has completely healed. WIC staff can improve outcomes following an injury by: • Assuring that vitamin and mineral intakes meet the RDAs (unless amounts that exceed the RDAs are recommended by their medical provider). • Assuring that energy and protein intake preserve lean muscle mass and body weight. • Recommending a participant speak with their medical provider about a multivitamin supplement when diet alone 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).

(section-ii)(nutrition-risk-manual)(page-304)Page 304#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 304

• Referring to a lactation educator if women experience difficulty breastfeeding following a cesarean section. References 1. Gurtner GC. Wound Healing: normal and abnormal. In: Thorne CH, editor. Grabb and Smith’s Plastic Surgery. Riverwoods, IL;2007. p.15-22. 2. Guo S, DiPietro LA. Factors affecting wound healing. J Dent Res. 2010; 89:219-229. 3. Wild T, Rahbarnia A, Kellner M, Sobotka L, Eberlein T. Basics in nutrition and wound healing. J Nut. 2010;26:862-866. 4. Stechmiller JK. Understanding the role of nutrition and wound healing. Nutr Clin Pract. 2010;25:61- 68. 2. Prelack K, Dylewski M, Sheridan RL. Practical guidelines for nutritional management of burn injury and recovery. J Burns.2007;33:14-24. 3. National Institutes of Health [Internet]. Maryland; c1997-2015 [updated 2015 Jun 15; cited 2015 Jul 6]. How wounds heal; [about 3 screens]. Available from: https://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000741.htm. 4. National Institutes of Health [Internet]. Maryland: [updated 2014 Nov 17; cited 2015 Aug 4]. Trauma Fact Sheet; [about 2 screens]. Available from: http://nigms.nih.gov/Education/Pages/Factsheet_Trauma.aspx. 5. Merriam-Webster Medical Dictionary. [cited 2015 Jul 6]. Available from: http://www.merriam- webster.com/medical/major+surgery. 6. Merriam-Webster Medical Dictionary. [cited 2015 Jul 6]. Available from: http://www.merriam- webster.com/medical/minor+surgery. 7. American Academy of Otolaryngology-Head and Neck Surgery [Internet]. Virginia; c2015 [cited 2015 Aug 12]. Ear Tubes; [about 5 screens]. Available from: http://www.entnet.org/content/ear- tubes. 8. Osterman MJK, Martin JA. Changes in cesarean delivery rates by gestational age: United States, 1996-2011. NCHS Data Brief. 2013;124. 9. National Institutes of Health [Internet]. Maryland: [updated 2012 Nov 30; cited 2015 Jul 6]. When is a cesarean delivery necessary and what are the risks; [about 1 screen]. Available from: http://www.nichd.nih.gov/health/topics/obstetrics/conditioninfo/pages/risks.aspx. 10. Alexander JW, Supp D. Role of arginine and omega-3 fatty acids in wound healing and infection. Adv Wound Care. 2014;3:682-690. 11. Ellinger S, Stehle P. Efficacy of vitamin supplementation in situations with wound healing disorders: results from clinical intervention studies. Curr Opin Clin Nutr Metab Care. 2009;12:588-95. 12. National Institutes of Health [Internet]. Maryland: [updated 2013 Jun 5; cited 2015 Jul 6]. Vitamin A fact sheet for health professionals; [about 16 screens]. Available from: https://ods.od.nih.gov/factsheets/VitaminA-HealthProfessional/. 13. National Institutes of Health [Internet]. Maryland: [updated 2013 Jun 5; cited 2015 Jul 6]. Vitamin E fact sheet for health professionals; [about 11 screens]. Available from: https://ods.od.nih.gov/factsheets/VitaminE-HealthProfessional/.

(section-ii)(nutrition-risk-manual)(page-306)Page 306#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 306

360 Other Medical Conditions

Definition/Cut-Off Value

Diseases or conditions with nutritional implications that are not included in any of the other medical conditions. The current condition, or treatment for the condition, must be severe enough to affect nutritional status. This includes, but is not limited to:

• Juvenile Idiopathic Arthritis (JIA) • Systemic Lupus Erythematosus (SLE) • Polycystic Ovary Syndrome (PCOS) • Cardiovascular Disease • Persistent Asthma (moderate or severe) requiring daily medication • Cystic Fibrosis (CF)

Presence of medical condition(s) diagnosed, documented, or reported by a physician or someone working under a physician’s orders, or as self-reported by applicant/participant/caregiver. See Clarification for more information about self-reporting a diagnosis.

Participant Category and Priority Level

Category Priority High Risk Pregnant I N Breastfeeding I N Non-Breastfeeding III, IV, V, or VI N Infants I N Children III N

Parameters for Manual Assignment

Must be manually selected in Nutrition Interview or Risk Panel

Justification

Juvenile Idiopathic Arthritis (JIA)

In 2001, the International League of Associations for Rheumatology reclassified juvenile rheumatoid arthritis as juvenile idiopathic arthritis (JIA) (1). This was done in efforts to be inclusive of both American and European diagnosis criteria and to improve communication between international healthcare providers and researchers (2). JIA is an umbrella term for all forms of childhood arthritis. It is a systemic disease that results in the destruction of joint tissue due to inflammation (2). Due to differences in nomenclature, it is difficult to estimate the number of children affected with JIA. In the United States, it is estimated that about 1 in 1000 children develop chronic arthritis, mainly JIA (3). Children with JIA face nutritional impairment due to chronic inflammation, drug side effects, and/or functional difficulties, such as jaw joint stiffness. Nutritional problems often lead to observed lower BMI and smaller height stature among JIA patients (3). While there is no prescribed diet for children with JIA, dietary fats (e.g., omega-3 fatty acids) can influence inflammation (4, 5). More research needs to be done to know if foods rich in omega-3 fatty acids will be helpful. However, these foods have other health benefits, especially in the prevention of heart disease and can be recommended. The best sources of omega-3 fatty acids are from fish such as salmon, sardines, mackerel, herring and tuna. Other omega-3 sources (less potent than fish, however) include ground flax, flaxseed oil, walnuts and, to a limited degree, green leafy vegetables (5).

(section-ii)(nutrition-risk-manual)(page-307)Page 307#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 307

Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is a chronic inflammatory and autoimmune disease that can affect multiple organ systems, including the skin, joints, kidneys, heart, and central nervous system. The appearance and progression of this disease is highly variable. The most common symptoms include fatigue, loss of appetite and weight, and skin lesions (butterfly rash on face). (6) The cause of SLE is not fully known. Genetics is thought to play a role in its development. Environmental factors such as exposure to silica dust particles and cigarette smoking as well as use of estrogen-based oral contraceptives or hormone replacement therapy can increase the risk of the disease (6, 7). The role of exposure to ultraviolet light (UV) in the development of SLE is still not known, though it may worsen SLE symptoms (7). There is no cure for SLE but medical interventions and lifestyle changes can help control it (8).

SLE is common with more than 200,000 cases per year in the U.S. (9). While anyone, including children, can develop SLE, it is most common among women of childbearing ages, 15 to 44 years, and women of color (10). Women who have SLE can safely get pregnant and have normal pregnancies and healthy babies. However, they will be considered to have a “high risk pregnancy” due to an increased likelihood of problems arising during their pregnancy (10, 11). High-risk maternal complications include inflammation of the kidneys, gestational diabetes, and pre-eclampsia; while fetal complications include miscarriage, preterm birth, and intrauterine growth restriction (11). Typical SLE management uses antimalarial drugs, immunosuppressive agents, biological agents, and some adjunctive therapies (6, 12). Mild cases can be controlled with non-steroidal anti-inflammatory drugs or low- dose glucocorticoids, but more severe cases may require more advanced treatment (12). Glucocorticoids can be associated with side effects including osteoporosis, hyperglycemia and may increase the predisposition to obesity, the risk of developing diabetes, hypertension, and cardiovascular disease (CVD) (12).

Diet quality in people with SLE is important because they are at higher risk of CVD, low bone mineral density, and vitamin D deficiency (13, 14). More than half of the people with SLE have three or more risk factors for CVD (mostly obesity, hypertension, and dyslipidemias) (12). A low-calorie diet high in vitamin- and mineral- rich foods and mono and polyunsaturated fatty acids (MUFA/PUFA) may help control the inflammatory aspects of the disease and the complications and co-morbidities resulting from SLE treatment (15). Some studies have highlighted the importance of specific vitamins mainly A, B6, C, D and E, and adequate dietary fiber intake, as well as protein and sodium restriction in reducing co-morbidities and preventing SLE flares (16, 17). For all people with SLE, it remains important to encourage them to stop smoking, avoid being overweight and optimize their blood pressure and lipid profile to decrease cardiovascular risk (13). Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is a hormonal disorder common among women of reproductive age. Most women with PCOS produce excess male sex hormones (androgens) and have many small cysts on their ovaries (18). The prevalence of PCOS ranges from 4 percent to 21 percent, depending on the criteria used to make the diagnosis (19). The exact cause of PCOS is unknown, however, insulin resistance is believed to play a role in the pathogenesis of PCOS (20). In addition, there may be a genetic component, since it is not unusual for multiple women in the same family to have PCOS (18).

Hyperandrogenism (excess male sex hormones) may prevent ovulation and can cause irregular menstrual periods, leading to difficulty conceiving a child or a complete inability to conceive (19). PCOS is the most common cause of infertility (19). For those who achieve pregnancy, there is an increased risk of complications and pregnancy loss (19). Women with PCOS are more likely to develop type 2 diabetes, high blood pressure, problems with the heart and blood vessels, uterine cancer, and metabolic syndrome (18, 19).

(section-ii)(nutrition-risk-manual)(page-308)Page 308#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 308

About half of all women with PCOS are overweight or obese (19). Treatment for PCOS may include medication to promote ovulation, however, weight loss is the primary therapy for PCOS (18, 20). A reduction in weight of as little as 5% can improve insulin resistance associated with PCOS, and for some women it may improve the hormone imbalance and increase fertility (21). WIC nutrition services should focus on dietary and physical activity guidance to promote weight loss and compliance with healthcare provider treatment. Cardiovascular Disease

Cardiovascular disease (CVD), or commonly known as 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 (22). The most common type of CVD is coronary artery disease (22). CVD is the leading cause of death for women in the United States and is responsible for about 1 in every 5 female deaths (23). Due to the fact that most CVDs develop slowly over decades as plaque builds up and hardens arteries, cardiac disorders in children are not caused by CVD (24). Children with cardiac conditions typically have congenital heart disease and should be assigned risk 349 Genetic and Congenital Disorders. Traditional risk factors for developing CVD include diabetes, smoking, obesity and overweight, physical inactivity, high blood pressure, and high cholesterol (25, 26). Recent discoveries have highlighted differences in how men and women develop and are diagnosed with CVD. Women are more affected by traditional CVD risk factors than men, and some risk factors specific to women go under recognized by their healthcare providers (25, 26).

Women-specific risk factors for CVD are pregnancy and pregnancy-related complications (27). Pre- eclampsia, preterm delivery, gestational diabetes, and polycystic ovary syndrome are all risk factors for CVD (26, 27, 28, 29, 30). If women have any women-specific CVD risk factors, it is recommended to encourage them to discuss their risk for CVD with their healthcare provider.

People with CVD benefit from cardiac rehabilitation which is a program that helps strengthen the heart through physical activity and helps build healthier habits like eating a healthy diet (31). Likewise, a heart healthy diet can prevent the development of CVD, and includes (32):

• Eating high fiber foods • Eating foods low in saturated fat • Limiting salt in diet • Limiting added sugars in diet • Limiting alcoholic drinks

Asthma

Asthma is a chronic lung disease that causes the airways to become inflamed and narrow (33). Symptoms include wheezing, breathlessness, chest tightness, and coughing of variable severity (34). Asthma attacks may be mild, moderate, or severe enough to become life-threatening events (34).

According to the Centers for Disease Control and Prevention (CDC), asthma affects 25 million people. The prevalence among adults is 7.7%. In children, asthma prevalence is lower among children age 0-4 (3.8%) than older children age 5-19 (9.8%). In addition, asthma is more common in females (9.3%) than males (6.4%). Regarding race and ethnicity, asthma prevalence is higher among Blacks and American Indian or Alaska Natives, 10.7 and 10.4% respectively, compared with Whites (8.0%). Among Hispanics asthma prevalence is 6.5% and among Asians it is 4.5%. Asthma prevalence increases with decreasing annual household income, with the highest prevalence seen in those with incomes less than 100% poverty (11.7%). (35)

In most cases, the cause(s) of asthma is unknown (34). However, people with asthma can reduce the number and severity of asthma attacks by identifying what triggers an attack. Triggers can be different for everyone, but the most common ones include (36):

(section-ii)(nutrition-risk-manual)(page-309)Page 309#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 309

• Tobacco smoke • Dust mites • Air pollution • Pest (e.g., cockroaches, mice) • Pet dander • Plant pollen • Mold • Infections • Exercise • Strong scents (such as perfumes)

Asthma can't be cured, but its symptoms can be controlled. Treatment includes avoiding the triggers of an asthma attack and medications. There are two types of asthma medicines (36): • Quick-relief medicines act fast to open up tight airways. They can be used as needed during a flare- up. Quick-relief medicines act fast, but their effect doesn't last long. These kinds of medicines are also called "fast-acting" or "rescue" medicines. • Long-term control medicines manage asthma by preventing symptoms from happening. They reduce inflammation in the airways, which is the cause of the swelling and mucus. (Quick-relief medicines only treat the symptoms caused by the inflammation.) Long-term control medicines — also called "controller" or "maintenance" medicines — must be taken every day, even when a person feels well.

Inhaled corticosteroids are the most effective and commonly used long-term control medications for asthma. In children, long-term use of inhaled corticosteroids can delay growth slightly, but the benefits of using these medications to maintain good asthma control generally outweigh the risks. (37)

There is no specific diet therapy for asthma, but below are recommendations for reducing symptoms (38): • Consume a diet to maintain or achieve a healthy weight. Being overweight can worsen asthma. Even losing a little weight can improve symptoms • Eat plenty of fruits and vegetables. They're a good source of antioxidants such as beta carotene and vitamins C and E, which may help reduce lung inflammation and irritation caused by cell- damaging free radicals. • Avoid allergy-triggering foods. Allergic food reactions can cause asthma symptoms. • Consume foods high in vitamin D. People with more-severe asthma may have low vitamin D levels. Milk, eggs, and fish such as salmon all contain vitamin D.

Cystic Fibrosis (CF)

Cystic fibrosis (CF) is a genetic disorder that affects the cells that produce mucus, sweat, and digestive fluids. In people with CF, a defective gene causes these secretions to become sticky and thick. Instead of acting as lubricants, the thick secretions clog ducts and passageways throughout the body, especially in the lungs, pancreas, and intestines. (39)

CF is a rare disease that affects about 35,000 people in the U.S. (40). All babies born in the United States are tested for CF soon after birth as part of newborn screening (40). Early diagnosis is important so that treatment can be started right away, which can help delay or prevent complications of the disorder. CF is a progressive disease and although there have been improvements in screening and treatments, people with CF have a life expectancy of 35 – 40 years, with some living into their 50s (39).

(section-ii)(nutrition-risk-manual)(page-310)Page 310#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 310

There is no cure for CF. People with CF often experience malnutrition, poor growth, frequent respiratory infections, breathing problems, and chronic lung disease (41). Goals of treatment are to ease symptoms, prevent and treat complications, and slow the progress of the disease (39). Due to the impact of CF on pancreatic enzymes, the digestion and absorption of protein and fats, are greatly impaired (42). Thus, most people with CF must take pancreatic enzymes as well as fat soluble vitamins (A, D, K and E) (42). The focus of nutrition therapy is to ensure adequate intake due to impaired digestion. Nutritional care should be personalized and provided by a specialized CF dietitian, if available, because needs may change dramatically during the progression of the disease (42).

Implications for WIC Nutrition Services WIC can improve the management of above listed medical conditions through WIC foods, nutrition education, counseling, and referrals to health and community resources. The table below provides additional WIC nutrition services recommendations specific to the disease state:

WIC Nutrition Services Recommendations for Other Medical Conditions All Types of Medical Conditions • Reinforce healthcare provider treatment and dietary plan (if applicable) • Refer for medical nutrition therapy (if available) • Recommend a healthy dietary pattern as described in the Dietary Guidelines for Americans Juvenile Idiopathic Arthritis (JIA) • Encourage adequate caloric intake • Monitor growth Systemic Lupus Erythematosus (SLE) • Encourage stress-relieving activities to prevent flares • Encourage and refer to smoking cessation if participant is a smoker • Encourage use of sunscreen and sun exposure avoidance • Encourage physical activity as tolerated Polycystic Ovary Syndrome (PCOS) • Provide dietary and physical activity guidance to support weight loss, if necessary Cardiovascular Diseases • Encourage participant to discuss blood cholesterol and triglycerides with health care provider • Recommend healthy food choices to control overweight or obesity • Recommend limiting alcohol, salt, added sugars, and saturated fat as part of a healthy dietary pattern • Suggest dietary fiber food options (e.g., fruit, vegetables, whole grains, legumes) • Encourage stress-relieving activities • Encourage smoking cessation if participant is a smoker Asthma • Provide dietary and physical activity guidance to support weight loss, if necessary

(section-ii)(nutrition-risk-manual)(page-311)Page 311#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 311

• Educate on the avoidance allergy-triggering foods if allergies are present Cystic Fibrosis (CF) • Provide more frequent growth monitoring • Encourage adequate caloric intake to maintain healthy weight and normal growth

Clarification Self-reporting of a diagnosis by a medical professional should not be confused with self-diagnosis, where a person simply claims to have or to have had a medical condition without any reference to professional diagnosis. A self-reported medical diagnosis (“My doctor says that I have/my son or daughter has…”) should prompt the CPA to validate the presence of the condition by asking more pointed questions related to that diagnosis.

Justification for High Risk

Not Applicable

References

1. Petty RE, Southwood TR, Manners P, et al. International League of Associations for Rheumatology classification of juvenile idiopathic arthritis: second revision, Edmonton, 2001. The Journal of Rheumatology. 2004 February [cited 2020 September]: 31(2): 390-392. Available from: https://www.jrheum.org/content/31/2/390.long. 2. Abramowicz A, Kim S, Prahalad S, et al. Juvenile arthritis: current concepts in terminology, etiopathogenesis, diagnosis, and management. International Journal of Oral and Maxillofacial Surgery. 2016 July; 45(7): 801-812. 3. Cron RQ, Weiser P, Beukelman T. Juvenile idiopathic arthritis. Clinical Immunology. 2019; 5: 723-733. 4. Little EM, Grevich S, Huber JL, et al. Parental perception of dietary invention in juvenile idiopathic arthritis. The Journal of Alternative and Complementary Medicine. 2019 June 4; 25(6): 643-647. 5. Harvard Health Publishing. Cambridge (MA): Harvard Medical School. Can diet improve arthritis symptoms? 2013 May [cited 2021 May]. Available from: https://www.health.harvard.edu/nutrition/can-diet- improve-arthritis-symptoms. 6. Kiriakidou M, Ching CL. Systemic Lupus Erythematosus. Ann Intern Med. 2020 June [cited 2021 Jan 19]; 2;172(11):ITC81-ITC96. Available from: https://doi.org/10.7326/AITC202006020. 7. Parks CG, de Souza Espindola Santos A, Barbhaiya M, Costenbader KH. Understanding the role of environmental factors in the development of systemic lupus erythematosus. Best Pract Res Clin Rheumatol. 2017 June [cited 2021 Jan 15];31(3):306-320. Available from: https://dx.doi.org/10.1016%2Fj.berh.2017.09.005. 8. Centers for Disease Control and Prevention [Internet]. Atlanta (GA): Centers for Disease Control and Prevention. Systematic lupus erythematosus. 2018 October17 [cited 2020 October]. Available from: https://www.cdc.gov/lupus/facts/detailed.html. 9. Lupus Foundation of America [Internet]. Washington (DC): Lupus Foundation of America. Lupus facts of statistics. 2016 October 6 [cited 2020 October]. Available from: https://www.lupus.org/resources/lupus- facts-and-statistics.

(section-ii)(nutrition-risk-manual)(page-312)Page 312#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 312

10. Centers for Disease Control and Prevention [Internet]. Atlanta (GA): Centers for Disease Control and Prevention. About heart disease. 2020 September 8 [cited 2021 January]. Available from: https://www.cdc.gov/lupus/basics/pregnancy.htm. 11. Petri M. Pregnancy and Systemic Lupus Erythematosus. Best Pract Res Clin Obstet Gynaecol. 2020 April;64:24-30. 12. Kuhn, A, Bonsmann, G, Anders, HJ, et al. The diagnosis and treatment of systemic lupus erythematosus. Dtsch Arztebl Int. 2015 [cited 2021 Jan 18];112, 423–432. Available from: https://doi.org/10.3238/arztebl.2015.0423. 13. Rodriguez Huerta, M, Trujillo-Martin, M, Rua-Figueroa, I, et al. Healthy lifestyle habits for patients with systemic lupus erythematosus: a systemic review. Semin Arthritis Rheum. 2016 [cited 2021 Jan 20];45: 463–470. Available from: https://doi.org/10.1016/j.semarthrit.2015.09.003. 14. Nguyen M, Bryant K, O’Neill S. Vitamin D in SLE: a role in pathogenesis and fatigue? A review of the literature. Lupus. 2018;27(13):2003-2011 15. Islam MA, Khandker SS, Kotyla PJ, Hassan R. Immunomodulatory Effects of Diet and Nutrients in Systemic Lupus Erythematosus (SLE): A Systematic Review. Front Immunol. 2020 Jul [cited 2021 Jan 20];22;11:1477. Available from: https://doi.org/10.3389/fimmu.2020.01477. 16. Aparicio-Soto, M., Sanchez-Hidalgo, M., & Alarcon-de-la-Lastra, C. An Update on diet and nutritional factors in systemic lupus erythematosus management. Nutrition Research Reviews. 2017 [cited 2021 Jan];30(1), 118-137. Available from: https://doi.org/10.1017/S0954422417000026. 17. Constantin MM, Nita IE, Olteanu R, et al. Significance and impact of dietary factors on systemic lupus erythematosus pathogenesis. Exp Ther Med. 2019[cited Jan 25 2021] Feb;17(2):1085-1090. Available from: https://dx.doi.org/10.3892%2Fetm.2018.6986. 18. Johns Hopkins Medicine [Internet]. Baltimore (MD): Johns Hopkins University. Polycystic ovary syndrome. No date [cited 2021 May]. Available from: https://www.hopkinsmedicine.org/health/conditions- and-diseases/polycystic-ovary-syndrome- pcos. 19. U.S. National Library of Medicine [Internet]. Bethesda (MD): MedlinePlus. Polycystic ovary syndrome. 2020 August [cited 2021 May]. Available from: https://ghr.nlm.nih.gov/condition/polycystic-ovary- syndrome#. 20. Goodman NF, Cobin RH, Futterweit W, et al. American Association of Clinical Endocrinologists, American College of Endocrinology and Androgen Excess and PCOS Society Disease State Clinical Review: guide to the best practices in the evaluation and treatment of polycystic ovary syndrome – part 2. Endocr Pract. 2015 December 21 [cited 2021 May]; (12):1415-26. Available from: https://pubmed.ncbi.nlm.nih.gov/26642102/. 21. Mayo Clinic [Internet]. Rochester (MN): Mayo Clinic. Polycystic ovary syndrome. No date [cited 2021 May]. Available from: https://www.mayoclinic.org/diseases-conditions/pcos/diagnosis- treatment/drc- 20353443. 22. Centers for Disease Control and Prevention [Internet]. Atlanta (GA): Centers for Disease Control and Prevention. About heart disease. 2020 September 8 [cited 2021 January]. Available from: https://www.cdc.gov/heartdisease/about.htm. 23. Centers for Disease Control and Prevention [Internet]. Atlanta (GA): Centers for Disease Control and Prevention. Women and heart disease. 2021 January 31 [cited 2020 January]. Available from: https://www.cdc.gov/heartdisease/women.htm. 24. Mayo Clinic [Internet]. Rochester (MN): Mayo Clinic. Polycystic ovary syndrome. No date [cited 2021 May]. Available from: https://dx.doi.org/10.3892%2Fetm.2018.6986. 25. Garcia M, Mulvagh SL, Merz NB, et al. Cardiovascular disease in women. Circulation Research. 2016 April 15 [cited 2021 January]; 118: 1273-1293. Available from: https://www.ahajournals.org/doi/full/10.1161/CIRCRESAHA.116.307547.

(section-ii)(nutrition-risk-manual)(page-313)Page 313#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 313

26. Brown HL, Warner JJ, Gianos E, et al. Promoting risk identification and reduction of cardiovascular disease in women through collaboration with obstetricians and gynecologists: a presidential 11/2022 advisory fromthe American Heart Association and the American College of Obstetricians andGynecologists. Circulation. 2018 June 12. 27. Peters SAE, Regitz-Zagrosek V. Pregnancy and rik of cardiovascular disease: is the relationship dueto childbearing or childrearing? European Heart Journal. 2017 May 14 [cited 2021 January]; 38(19):1448- 1450.Available from:https://academic.oup.com/eurheartj/article/38/19/1448/3823351?login=true. 28. Castelao JE, Gago-Cominguez M. Risk factors for cardiovascular disease in women: relationship tolipid peroxidation and oxidative stress. Medical Hypotheses. 2008; 71(1): 39-44. 29. Okoth K, Chandan JS, Marshall T, et al. Association between the reproductive health of youngwomen and cardiovascular disease later in life: umbrella review.The BMJ. 2020 Oct 14 [cited 2021 January]. Available from:https://www.bmj.com/content/371/bmj.m3963. 30. KramerCK, Campbell S, Retnakaran R. Gestational diabetes and the risk of cardiovasculardiseasein women: a systematic review and meta-analysis. Diabetologia. 2019 March 7; 62: 905-914. 31. Centers for Disease Control and Prevention [Internet]. Atlanta (GA): Centers forDisease Controland Prevention. How cardiac rehabilitation can help heal your heart. 2020 December 28 [cited2021 January]. Available from:https://www.cdc.gov/heartdisease/cardiac_rehabilitation.htm. 32. Centers for Disease Control and Prevention [Internet]. Atlanta (GA): Centers for Disease Controland Prevention. Prevent heart disease. 2020 April 21 [cited2021 January]. Available from:https://www.cdc.gov/heartdisease/prevention.htm. 33. Mayo Clinic [Internet]. Rochester (MN): Mayo Clinic. Asthma. 2020 August 11 [cited 2021 May].Available from:https://www.mayoclinic.org/diseases-conditions/asthma/symptoms-causes/syc- 20369653. 34. Centers for Disease Control and Prevention [Internet]. Atlanta (GA): Centers for Disease Controland Prevention. Asthma facts. 2013 July [cited 2021 May]. Available from:https://www.cdc.gov/asthma/pdfs/Asthma_Facts_Program_Grantees.pdf. 35. Centers for Disease Control and Prevention [Internet]. Atlanta (GA): Centers for Disease Controland Prevention. Asthma data, statistics, andsurveillance. No date [cited 2021 May]. Availablefrom:https://www.cdc.gov/asthma/asthmadata.htm. 36. U.S. Food and Drug Administration [Internet]. Silver Spring (MD): U.S. Food and DrugAdministration. Manage your asthma. 2018 November 8 [cited 2021 May]. Availablefrom:https://www.fda.gov/consumers/consumer-updates/manage-your-asthma-know-your- triggers-and-treatment-options. 37. Mayo Clinic [Internet]. Rochester (MN): Mayo Clinic. Asthma medications. 2020 June 19 [cited2021 May]. Availablefrom:https://www.mayoclinic.org/diseases-conditions/asthma/in-depth/asthma- medications/art-20045557. 38. Mayo Clinic [Internet]. Rochester (MN): Mayo Clinic. Asthma diet. 2020 March 21 [cited 2021 May]. Available from:https://www.mayoclinic.org/diseases-conditions/asthma/expert-answers/asthma-diet/faq- 20058105iet. 39. Mayo Clinic [Internet]. Rochester (MN): Mayo Clinic. Cystic fibrosis. 2020 March 14 [cited 2021 May]. Available from:https://www.mayoclinic.org/diseases-conditions/cystic-fibrosis/symptoms-causes/syc- 20353700. 40. Centers for Disease Control and Prevention [Internet]. Atlanta (GA): Centers for Disease Controland Prevention. Cystic fibrosis. 2020 May 18 [cited 2021 May]. Available from:https://www.cdc.gov/genomics/disease/cystic_fibrosis.htm.

(section-ii)(nutrition-risk-manual)(page-315)Page 315#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 315

361 Mental Illnesses

Definition/Cut-Off Value

As defined by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Health Disorders, Fifth Edition, a mental disorder (or mental illness)1 is: “A syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities (1).”

Mental illnesses where the current condition, or treatment for the condition may affect nutrition status include, but are not limited to:

Mental Illnesses Depression Anxiety Disorders Post-Traumatic Stress Disorder (PTSD) Obsessive-Compulsive Disorder (OCD) Personality Disorders Bipolar Disorders Schizophrenia Attention-Deficit/Hyperactivity Disorder (ADHD)

1The terms mental disorder and mental illness are both used in the Diagnostic and Statistical Manual of Mental Health Disorders. Mental illness is the term endorsed by Substance Abuse and Mental Health Services Administration (SAMHSA).

Note: For mental illnesses related to eating disorders (e.g., anorexia nervosa, bulimia nervosa and binge- eating disorder), please see risk #358 Eating Disorders.

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. See Clarification (page 12) for more information about self-reporting a diagnosis.

Participant Category and Priority Level

Category Priority High Risk Pregnant I N Breastfeeding I N Non-Breastfeeding III, IV, V, or VI N Children III N

Parameters for Manual Assignment

Must be manually selected in Nutrition Interview or Risk Panel

Justification

(section-ii)(nutrition-risk-manual)(page-316)Page 316#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 316

Prevalence of Mental Illnesses

In 2019, the prevalence of any mental illness in U.S. adults was 20.6%; one fifth of the adult population (2). Mental illnesses can vary in impact from mild to severe (2). Young adults aged 18-25 had the highest prevalence of mental illnesses (29.4%) (2). Females had a higher prevalence (24.5%) than males (16.3%) (2). Those reporting two or more races had the highest prevalence (31.7%), followed by Whites (22.2%), Alaskan Natives or Native Americans (18.7%), Hispanics (18%), Blacks (17.3%), Native Hawaiians or OtherPacific Islanders (16.6%), and Asians (14.4%) (2). Additionally, people in the Lesbian, Gay, Bi- Sexual, Transgender, Queer (LGBTQ) community experience mental illnesses, especially depression and anxiety disorders, at a higher rate (3). LGB adults are more than twice as likely as heterosexual adults to experience a mental illness while transgender adults are nearly 4 times as likely as cisgender adults to experience a mental illness (3).

The prevalence of severe mental illness in U.S. adults was 5.2% in 2019 (2). Severe mental illness results in serious functional impairment which substantially interferes with or limits one or more major life activities (2). The Americans with Disabilities Act Amendments Act of 2008 defines major life activities as “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” (4). People with severe mental illness often have difficulty maintaining a healthy diet, even when guidance is provided (5). 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 (5). Females had a higher prevalence (6.5%) of severe mental illness than males (3.9%) (2). Young adults aged 18-25 years had the highest prevalence of severe mental illness (8.6%) compared to adults aged 26-49 years (6.8%) and aged 50 and older (2.9%) (2). Those reporting two or more races had the highest prevalence of severe mental illness (9.3%), followed by Alaskan Natives or Native Americans (6.7%), Whites (5.7%), Hispanics (4.9%), Blacks (4.0%), Asians (3.1%), and Native Hawaiians or Other Pacific Islanders (2.6%) (2).

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 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. (6)

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. (7)

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, as follows (8):

● 9.4% of U.S. children aged 2-17 years have received an ADHD diagnosis. ● 7.4% of U.S. children aged 3-17 years have a diagnosed behavior problem. ● 7.1% of U.S. children aged 3-17 years have diagnosed anxiety.

(section-ii)(nutrition-risk-manual)(page-317)Page 317#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 317

● 3.2% of U.S. children aged 3-17 years have diagnosed depression. ● 16.7% U.S. children aged 2–8 years have a diagnosed mental, behavioral, or developmental disorder.

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. (9)

Treatment

Treatment for any mental illness can be complex and depends on the severity of the symptoms (1). It is estimated that only half of individuals with any type of mental illness receive treatment (2). More females receive treatment for mental illnesses than males (2). It is also more common for older adults to receive treatment than those aged 18-25 years old (2).

Mental illnesses are most commonly treated with psychotherapy and medication (1). Medications can play a role in treating most mental illnesses but choosing the right treatment plan should be based on an individual’s needs, medical situation, and be under the guidance of a health care professional (10). Certain medication such as antidepressants, antipsychotics, anticonvulsants, or stimulants can influence body weight and appetite (11). 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 (12).

Mental Illnesses and Nutrition

Nutrition is important to mental health because it contributes to maintaining the structure and function of the nerve cells and chemicals in the brain. 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 is also a very important nutrient for the brain. Research has associated vitamin D deficiency with mood disorders, dementia, and an increased risk for depression. (12)

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. (12)

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 (12). Evidence suggests that in some cases, when these deficiencies are returned to normal, changes in mood and behavior can be achieved. (12)

Common Mental Illnesses Depression Depression has a variety of symptoms, the most common are feelings of sadness or a marked loss of interest in pleasure or activities (13). 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(14). Depression affects 6.7% U.S. adults in any given year and 16.6% will experience depression at some time in their life (14). The prevalence of depression among females is 60% higher

(section-ii)(nutrition-risk-manual)(page-318)Page 318#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 318

than males (13). Of those adults diagnosed with depression, 63.8% had severe impairment (2). Although depression can occur at any age, it usually first appears in the late teens to mid-twenties (14). Depression is now recognized in children and adolescents and tends to present as irritability, rather than low mood (2). There is no definite cause of depression but there are many contributing factors including genetics, nutrition, environmental stressors, hormonal disruptions, and changes in brain chemistry (12). Approximately one-third of people who have depression do not respond well to the available treatments (12).

For information on screening WIC participants for possible depression please see Guidance for Screening and Referring with or at Risk for Depression (available on the Food and Nutrition Service PartnerWeb). This guidance clarifies WIC staff’s role in maternal depression, provides training resources, identifies focus areas of breastfeeding promotion and support, and nutrition education related to maternal depression. It also contains information on referring participants to appropriate mental health services to maximize participant benefit from WIC nutrition services to achieve positive health outcomes.

Prenatal Depression

The most common symptoms of prenatal depression include feelings of sadness, anxiety, and fatigue (15). Women who experience depression during pregnancy are found to be at an increased risk of not following their prenatal medical plan, inadequate or excessive gestational weight gain, smoking, and substance use (16). Studies suggest that pregnant women with untreated symptoms of depression have increased rates of birth complications, preeclampsia, preterm delivery, low birth weight and impaired social, cognitive, and emotional development in the baby (16, 17). Approximately 10% of pregnant women experience depression with some reported rates as high as 22% (18, 19). Women of color and those from lower socioeconomic groups have a significantly higher incidence of prenatal depression (20).

Approximately 6-8% of U.S. women report using or having been prescribed an antidepressant while pregnant (21). There are currently no recommendations on which medication should be used to treat depression during pregnancy and there are concerns about the negative associations of antidepressants on fetal and infant health (12, 22). Selective serotonin reuptake inhibitors (SSRIs) are the most frequently used medication to treat pregnant women with depression (22). Some complications associated with SSRIs and Selective neurontin reuptake inhibitors (SNRIs) used in pregnancy may include increased risk of spontaneous abortion, preterm birth and low birth weight, poor neonatal adaptation syndrome, persistent pulmonary hypertension and congenital anomalies including heart defects (22). High rates of depression relapse (70%) have been found in some studies when pregnant women have stopped their antidepressant medication (23). The use of antidepressants during pregnancy may also influence a woman’s choice for feeding her infant making her less likely to plan on or initiate breastfeeding (24). For all these reasons, it is imperative that prenatal women discuss the benefits and risks of antidepressant therapy as part of the treatment for depression with their health care provider (21).

Depression in Pregnant Adolescents

Adolescent pregnancy is considered a significant risk for depression (25). Women who gave birth before their 20th birthday showed higher levels of depressive and anxiety symptoms (25). The symptoms of depression in adolescence are different than those presented in adulthood (26). While they share a depressed mood, adolescents more frequently show changes in appetite or weight and insomnia, rather than a loss of interests and poor concentration (26). Depression in adolescent pregnancy has a high frequency of suicidal attempts, reaching up to 20% (26).

Teens who are female, have a family history of depression, a history of trauma, family conflict, a chronic medical disease, or who are LGBTQ are at greater risk for developing adolescent depression. Depression in adolescents can occur with other mental illnesses including anxiety. (26)

(section-ii)(nutrition-risk-manual)(page-319)Page 319#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 319

Postpartum Depression

Postpartum depression (PPD) is a form of depression that occurs within 4 to 6 weeks after childbirth and is one of the most common complications that occurs after pregnancy (27, 28). PPD is associated with many adverse outcomes for both mother and offspring including, maternal mortality and morbidity, increased risk for infanticide, poorer maternal-infant attachment, early discontinuation of breastfeeding, and impaired parenting behaviors (12, 27). It affects 10-15% of women (27). The risk factors associated with PPD include genetics, history of a mental illness and adverse life events including physical, psychological, or sexual abuse (27). Discrimination and immigration are often overlooked adverse life events associated with PPD (27).

PPD is different from the “baby blues” which is used to describe mild mood changes, feelings of worry, unhappiness, and exhaustion in the first 2 weeks after having a baby (15). The “baby blues” is a common reaction following delivery that affects 70-80% of new mothers (12). The “baby blues” typically peak four to five days after delivery and may last hours to days and usually resolve within 2 weeks (12, 15).

Breastfeeding and Depression

Women with PPD are less likely to breastfeed, as PPD is considered a risk factor for breastfeeding self- efficacy (12, 29). Women with low self-efficacy are 3 times more likely to stop breastfeeding early (29). Studies show the presence of depressive symptoms in the postpartum period decrease maternal confidence in breastfeeding and increase the risk of discontinuing exclusive breastfeeding (29). Women with PPD also have fewer positive interactions with their infants and a poorer perception regarding their baby’s behavior (29). Additionally, PPD can negatively affect milk supply due to elevated levels of cortisol in the mother’s system (12). Difficulties with breastfeeding can cause the mother to feel overwhelmed and increase the risk of depression (12). If a mother with early signs of PPD stops breastfeeding, depression can become more severe due to the abrupt drop in oxytocin levels (12). Successful breastfeeding may have a protective effect on maternal mental health because the breastfeeding relationship can decrease feelings of loneliness and emptiness that are common in PPD (12). Higher levels of oxytocin released during breastfeeding can cause the mother to feel calmer and more relaxed (12).

Medications used to treat PPD include SSRIs and SSNIs (23). Most research shows negligible risk in infants exposed to SSRIs in human milk containing antidepressants (24). Sertraline, an SSRI, is the most studied antidepressant in breastfeeding (6). It has minimal transfer into breastmilk and is well tolerated by most infants (6).

Anxiety Disorders

Anxiety disorders are the most common mental illness in adults in the U.S. (12). They include the following types: generalized anxiety disorder, panic disorder, and various phobia-related disorders (30). In anxiety disorders, worry and fear interfere with daily life and are much more severe than occasional anxiety (2,30). All anxiety disorders share an increase in emotional, physical, and neurological symptoms precipitated by a specific situation or circumstance (12). Nineteen percent of the adults in the U.S. have an anxiety disorder; 22% of those individuals experience severe impairment related to their anxiety. (12). The risk factors for anxiety disorders include both genetic and environmental components along with exposure to stressful events, an adverse childhood experience, and a history of mental illness in the family (12, 30). During pregnancy, anxiety may have adverse effects on both the mother and baby, including impaired fetal development, complications of labor, and altered mental development of the newborn (31). Therefore, it may be necessary to consider medication for anxiety that worsens during pregnancy. Anxiety disorders are usually treated with psychotherapy and medications (30, 32). The medications most used to treat anxiety disorders include anti-anxiety medications (benzodiazepines), antidepressants (SSRIs and SSNIs), and blood-pressure medications (beta-blockers) (2, 30, 32). Benzodiazepines (i.e., Xanax,

(section-ii)(nutrition-risk-manual)(page-320)Page 320#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 320

Valium) have the benefit of working faster than anti-depressants, but they can be addictive if used over the long-term (30). Both antidepressants, SSRIs (i.e., Zoloft, Prozac) and SSNIs (i.e., Effexor), are used to treat anxiety disorders, but they can take 4-6 weeks for effects on mood to occur (30). An increase in suicidal thoughts or behavior can occur in those under age 25 when taking antidepressant medications, especially in the first few weeks after starting, or when the dose is changed which requires appropriate monitoring by the prescribing provider (33). Beta-blockers can be used to help relieve the physical symptoms of anxiety, including shaking and a rapid heartbeat but they are usually used short-term or on an as needed basis such as during situational anxiety (32). SSRIs are the first-line pharmacological agents for anxiety disorders in perinatal patients (23).

Post-Traumatic Stress Disorder (PTSD)

PTSD is a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic, shocking, scary, or dangerous event (34). People with PTSD have intense or disturbing thoughts and feelings related to their trauma that lasts after the traumatic event has ended (35). They may avoid situations or people that remind them of the event, and they may have strong negative reactions to something like a loud noise or an unexpected touch (35). Symptoms of PTSD usually begin within 3 months of the traumatic incident, but sometimes begin years after (35). To be considered PTSD, the symptoms must last more than a month and be severe enough to interfere with relationships or work (35). PTSD can occur at any age and affects 3.5% of the U.S. population with women being more likely to be affected than men (36). Hispanics, Blacks, and Native Americans have higher rates of PTSD than non- Hispanic whites (32). Rape is the most common trigger of PTSD and childhood sexual abuse is a strong predictor for developing PTSD in one’s lifetime (36). Approximately 3.3% of pregnant women and 4% of postpartum women have PTSD (37). Women are susceptible to developing PTSD as a result of childbirth (37). Risk factors associated with postpartum PTSD include negative subjective birth experiences, having an operative birth, history of mental health problems, and lack of support (37). Studies support an association between postpartum PTSD with lower birth weights and lower rates of breastfeeding (37). Usually, psychotherapy or medications is used to treat PTSD or a combination of the two (34 ,35). The medications most used to treat the symptoms of PTSD are the antidepressants, SSRIs and SSNIs (34, 35).

Obsessive-Compulsive Disorder (OCD)

OCD is a chronic and long-lasting disorder in which a person has uncontrollable, reoccurring thoughts (obsessions) and/or behaviors (compulsions) that they feel the urge to repeat over and over (38). The compulsions, such as hand washing, checking on things or cleaning, can interfere with a person’s daily life (38). People with OCD have difficulty stopping the obsessive thoughts or the compulsive actions even though they are very distressing and recognize their thoughts and behaviors are excessive (38). OCD occurs in 1.0% of the U.S. population with women and men being equally affected (36). The average age of onset is 19 years old with one-third of affected adults having first experienced symptoms in childhood (36). The causes of OCD are unknown but there are some risk factors associated with it including genetics, childhood trauma, and brain abnormalities (39). People with mild to moderate forms of OCD are usually treated with either cognitive behavioral therapy (CBT) or medication (38). Usually, a high dose of SSRIs is recommended to treat OCD, but it can take up to 12 weeks to notice an improvement (39). In severe forms of OCD, it isrecommended that both medication and CBT be used (39). Given the relatively large number of studies regarding their safety in the perinatal period for OCD patients SSRIs are the first- line medications (30).

Personality Disorders

Personality disorders, including obsessive-compulsive personality disorder (different from OCD), narcissistic personality disorder, antisocial personality disorder, and borderline personality disorder, are an “enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture” (1, 36). Behaviors are pervasive and inflexible, often resulting in distress and

(section-ii)(nutrition-risk-manual)(page-321)Page 321#

Utah WIC Local Agency Policy and Procedures Manual II. Nutrition Services-Breastfeeding/Participant Screening and Assessment/Nutrition Risk Manual Page 321

impairment (1). The person’s way of thinking, feeling, and behaving is different from the expectations of society and causes problems functioning (40). Personality disorders affect at least two of these areas: the way a person thinks about oneself and others, the way a person responds emotionally, the way a person relates to other people, or the way a person controls their behavior (40). Personality disorders are not usually diagnosed until a person is over the age of 18 because prior to that age a person’s personality is still developing (40). It is estimated that 9% of the U.S. population has at least one personality disorder (36). There are no medications specifically used to treat personality disorders, but psychotherapy can be effective (40). Medications, such as antidepressants, anti-anxiety medication or mood stabilizing medication, may be helpful in treating some symptoms under the care of a psychiatrist (40).

Bipolar Disorders

Bipolar disorder (formerly known as manic depressive disorder or manic depression) is a mental illness that causes changes in a person’s mood that affects their daily life (41, 42). These mood shifts are known as manic (elevated or agitated) or depressive (sad and hopeless) (41, 42). During depressive episodes, approximately 25-50% of those with bipolar disorder attempt suicide (12). Sometimes people may have a mixed episode, feeling both manic and depressive symptoms at the same time (42). The symptoms of a mood can last from days to weeks and vary in intensity (41). 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 (12, 41). The lifetime prevalence of bipolar disorder in the U.S. is 4.4% (12). Of those 4.4% diagnosed with bipolar disorder 82.9% have severe impairment (12). The exact cause of bipolar disorders is not known, but genetics, hormones, and an imbalance in brain chemistry are believed to play a role (12, 42). Bipolar disorders also tend to run in families with the average age of onset being 25 years old (42). Medications are the treatment of choice for bipolar disorders with mood stabilizers like antiseizure medications with lithium being used the most commonly (12). These medications are believed to affect the chemical imbalances in brain (42). 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 (12). Simple information based on the Dietary Approaches to Stop Hypertension (DASH) diet could be useful to those taking lithium (12). 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 (12).

The postpartum period is a vulnerable time for illness relapse in bipolar women (43). 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 (6). The effect of lithium use on a breastfed baby is not as well studied (43). Lithium is excreted in human milk (23). 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 (23 ,43). Infantmonitoring includes checking for over-sedation, restlessness, hydration status, and changes in growth and development (23).

Schizophrenia

Schizophrenia is a serious mental illness that can be severely disabling if not treated (44). It is characterized by delusions, hallucinations, disorganized speech and behavior, and other symptoms that cause social or occupational dysfunction (44). For a diagnosis, symptoms must have been present for six months and have been active for at least one month (1). Schizophrenia affects 1% of the U.S. population (45). It occurs equally in men and women but tends to be diagnosed earlier in males (1, 44). Symptoms appear in males in their late teens or early twenties and in females in their twenties or thirties (12). Genetics is estimated to be responsible for 80% of schizophrenia cases (12). People with schizophrenia also have higher mortality rates due to higher rates of heart disease, liver disease, and diabetes (12, 45). These diseases appear to be more related to fat metabolism than dietary fat intake as schizophrenia appears to be associated with altered metabolism (12). Studies of patients with schizophrenia have shown

(section-i)(goals-fy2027)Utah WIC State Plan FY 2027, Section I: Goals and Objectives: Goals FY2027#

(section-i)(goals-fy2027)(page-1)Page 1#

(section-i)(goals-fy2027)Utah WIC State Plan FY 2027, Section I: Goals and Objectives: Goals FY2027#

(section-i)(goals-fy2027)(page-1)Page 1#

(section-ii)(ad-hoc-reports)Utah WIC State Plan FY 2027, Section II: Local Agency Policy and Procedure Manual: Ad Hoc Reports#

(section-ii)(ad-hoc-reports)(page-1)Page 1#

(section-ii)(ad-hoc-reports)(page-2)Page 2#

(section-ii)(ad-hoc-reports)(page-3)Page 3#

(section-ii)(ad-hoc-reports)(page-4)Page 4#

(section-ii)(ad-hoc-reports)(page-5)Page 5#

(section-ii)(ad-hoc-reports)(page-6)Page 6#

(section-ii)(ad-hoc-reports)(page-7)Page 7#

(section-ii)(ad-hoc-reports)(page-8)Page 8#

(section-ii)(ad-hoc-reports)(page-9)Page 9#

(section-ii)(ad-hoc-reports)(page-10)Page 10#

(section-ii)(ad-hoc-reports)(page-11)Page 11#

(section-ii)(ad-hoc-reports)(page-12)Page 12#

(section-ii)(ad-hoc-reports)(page-13)Page 13#

(section-ii)(ad-hoc-reports)(page-14)Page 14#

(section-ii)(ad-hoc-reports)(page-15)Page 15#

(section-ii)(ad-hoc-reports)(page-16)Page 16#

(section-ii)(ad-hoc-reports)(page-17)Page 17#

(section-ii)(ad-hoc-reports)(page-18)Page 18#

(section-ii)(ad-hoc-reports)(page-19)Page 19#

(section-ii)(ad-hoc-reports)(page-20)Page 20#

(section-ii)(ad-hoc-reports)(page-21)Page 21#

(section-ii)(ad-hoc-reports)(page-22)Page 22#

(section-ii)(ad-hoc-reports)(page-23)Page 23#

(section-ii)(ad-hoc-reports)(page-24)Page 24#

(section-ii)(ad-hoc-reports)(page-25)Page 25#

(section-ii)(ad-hoc-reports)(page-26)Page 26#

(section-ii)(ad-hoc-reports)(page-27)Page 27#

(section-ii)(ad-hoc-reports)(page-28)Page 28#

(section-ii)(ad-hoc-reports)(page-29)Page 29#

(section-ii)(ad-hoc-reports)(page-30)Page 30#

(section-ii)(ad-hoc-reports)(page-31)Page 31#

(section-ii)(ad-hoc-reports)(page-32)Page 32#

(section-ii)(ad-hoc-reports)(page-33)Page 33#

(section-ii)(ad-hoc-reports)(page-34)Page 34#

(section-ii)(ad-hoc-reports)(page-35)Page 35#

(section-ii)(ad-hoc-reports)(page-36)Page 36#

(section-ii)(ad-hoc-reports)(page-37)Page 37#

(section-ii)(ad-hoc-reports)(page-38)Page 38#

(section-ii)(ad-hoc-reports)(page-39)Page 39#

(section-ii)(ad-hoc-reports)(page-40)Page 40#

(section-ii)(ad-hoc-reports)(page-41)Page 41#

(section-ii)(ad-hoc-reports)(page-42)Page 42#

(section-ii)(ad-hoc-reports)(page-43)Page 43#

(section-ii)(ad-hoc-reports)(page-44)Page 44#

(section-ii)(ad-hoc-reports)(page-45)Page 45#

(section-ii)(ad-hoc-reports)(page-46)Page 46#

(section-ii)(ad-hoc-reports)(page-47)Page 47#

(section-ii)(ad-hoc-reports)(page-48)Page 48#

(section-ii)(ad-hoc-reports)(page-49)Page 49#

(section-ii)(ad-hoc-reports)(page-50)Page 50#

(section-ii)(adjunct-eligibility)Utah WIC State Plan FY 2027, Section II: Local Agency Policy and Procedure Manual: Adjunct Eligibility#

(section-ii)(adjunct-eligibility)(page-1)Page 1#

(section-ii)(adjunct-eligibility)(page-2)Page 2#

(section-ii)(adjunct-eligibility)(page-3)Page 3#

(section-ii)(adjunct-eligibility)(page-4)Page 4#

(section-ii)(anthro-and-biochemical-procedures)Utah WIC State Plan FY 2027, Section II: Local Agency Policy and Procedure Manual: Anthro and Biochemical Procedures#

(section-ii)(anthro-and-biochemical-procedures)(page-1)Page 1#

(section-ii)(anthro-and-biochemical-procedures)(page-2)Page 2#

(section-ii)(anthro-and-biochemical-procedures)(page-3)Page 3#

(section-ii)(anthro-and-biochemical-procedures)(page-4)Page 4#

(section-ii)(anthro-and-biochemical-procedures)(page-5)Page 5#

(section-ii)(anthro-and-biochemical-procedures)(page-6)Page 6#

(section-ii)(anthro-and-biochemical-procedures)(page-7)Page 7#

(section-ii)(anthro-and-biochemical-procedures)(page-8)Page 8#

(section-ii)(appeals)Utah WIC State Plan FY 2027, Section II: Local Agency Policy and Procedure Manual: Appeals#

(section-ii)(appeals)(page-1)Page 1#

(section-ii)(appeals)(page-2)Page 2#

(section-ii)(appeals)(page-3)Page 3#

(section-ii)(breastfeeding-aids)Utah WIC State Plan FY 2027, Section II: Local Agency Policy and Procedure Manual: Breastfeeding Aids#

(section-ii)(breastfeeding-aids)(page-1)Page 1#

(section-ii)(breastfeeding-aids)(page-2)Page 2#

(section-ii)(breastfeeding-aids)(page-3)Page 3#

(section-ii)(breastfeeding-aids)(page-4)Page 4#

(section-ii)(breastfeeding-aids)(page-5)Page 5#

(section-ii)(breastfeeding-aids)(page-6)Page 6#