Nutrition risk criteria handbook FFY 2013: Georgia WIC Program nutrition unit

Nutrition Risk Criteria Handbook FFY 2013
Georgia WIC Program Nutrition Unit
2 Peachtree Street NW Atlanta Georgia, 30303
404-657-2884
Revised 7-19-2012

Nutrition Risk Criteria Handbook FFY 3013
Revised 7/19/2012
1. Risk 344 Thyroid Disorder: Corrected Hyper/hypo thyroidism definitions (pages 9, 26, 46)
2. Risk 115 High Weight for Length: Changed priority to III (page 79) 3. Risk 903 Foster Care: Changed priority to V (page 95) 4. Revised Appendixes to reflect changes for the birth to two year CDC WHO
Growth Charts. a) Appendix J-1 and J-3 Remove "32 inch" reference (page 119 and 121) b) Appendix J-4 remove "stand unattended reference" (page 122) c) Appendixes K and L changed from "birth to 36 " growth charts to
"Birth to 24" growth charts (page 123 and 127)

DATA AND DOCUMENTATION REQUIRED FOR WIC ASSESSMENT/CERTIFICATION
PRENATAL WOMEN

Data
Height Pre-Pregnancy Weight
Current Weight Hematocrit or Hemoglobin Prenatal Weight Grid Plotted Evaluation of Inappropriate Nutrition Practices
Risk Factor Assessment

Prenatal Women
Required Required Required Required Required Required Required

1

NUTRITION RISK CRITERIA PREGNANT WOMEN

NOTE: High Risk Criteria, as defined below, are to be used for referral purposes, not certification (See Appendix A-1)

CODE

PREGNANT WOMEN

PRIORITY

201

LOW HEMOGLOBIN/HEMATOCRIT

I

1st Trimester (0-13 wks):

Hemoglobin

Hematocrit

Non-Smokers Smokers

10.9 gm or lower 11.2 gm or lower

32.9% or lower 33.9% or lower

2nd Trimester (14-26 wks): Non-Smokers Smokers

10.4 gm or lower 10.7 gm or lower

31.9% or lower 32.9% or lower

3rd Trimester (27-40 wks): Non-Smokers Smokers

10.9 gm or lower 11.2 gm or lower

32.9% or lower 33.9% or lower

High Risk: Hemoglobin OR hematocrit at treatment level (Appendix B-1)

101

UNDERWEIGHT

I

Pre-pregnancy weight is equal to a Body Mass Index (BMI) of <18.5. Refer to BMI Table, Appendix C-1.

High Risk: Pre-pregnancy BMI <18.5

111

OVERWEIGHT

I

Pre-pregnancy weight is equal to a Body Mass Index of >25. Refer to BMI Table, Appendix C-1.

High Risk: Pre-pregnancy BMI >29.9

131

LOW MATERNAL WEIGHT GAIN

I

Low weight gain at any point in pregnancy, such that a pregnant women's weight plots at any point beneath the bottom line of the appropriate weight gain range for her respective prepregnancy weight category.

Refer to Appendix C-2.

High Risk: Low Maternal Weight Gain

2

CODE
132

PREGNANT WOMEN

PRIORITY

GESTATIONAL WEIGHT LOSS DURING PREGNANCY

I

During first (0-13 weeks) trimester, any weight loss below pregravid weight; based on pregravid weight and current weight.
OR
During second and third trimesters (14-40 weeks gestation), >2 lbs weight loss. Based on two weight measures recorded at 14 weeks gestation or later.

Document: Two weight measures as specified above

High Risk: Weight loss of >2 lbs in the second and third trimesters

133

HIGH MATERNAL WEIGHT GAIN

I

High maternal weight gain at any point in pregnancy, such that a pregnant women's weight plots at any point above the top line of the appropriate weight gain range for her respective prepregnancy weight category.

211

ELEVATED BLOOD LEAD LEVELS

I

Blood lead level of >10 g/deciliter within the past 12 months.

Document: Date of blood test and blood lead level in the participant's health record. Must be within the past 12 months.

High Risk: Blood lead level of >10 g/deciliter within the past 12 months.

301

HYPEREMESIS GRAVIDARUM

I

Severe nausea and vomiting to the extent that the pregnant woman becomes dehydrated and acidotic.

Presence of hyperemesis gravidarum diagnosed by a physician as self-reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record

High Risk: Diagnosed hyperemesis gravidarum

3

CODE 302

PREGNANT WOMEN

PRIORITY

GESTATIONAL DIABETES

I

Gestational diabetes mellitus (GDM) is defined as any degree of glucose/carbohydrate intolerance with onset or first recognition during pregnancy.

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.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed gestational diabetes

303

HISTORY OF GESTATIONAL DIABETES

I

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 physician, or someone working under physician's orders.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

I

304

HISTORY OF Preeclampsia

History of diagnosed preeclampsia

Presence of condition diagnosed by a physician as self-reported by applicant/participant/caregiver; or as reported or documented by physician, or someone working under physician's orders
Document: Diagnosis and name of the physician that treated this condition in the participant's health record.

311

HISTORY OF PRETERM DELIVERY

Any history of infant(s) born at 37 weeks gestation or less

I

Document: Delivery date(s) and weeks gestation in participant's health record

4

CODE

PREGNANT WOMEN

PRIORITY

312

HISTORY OF LOW BIRTH WEIGHT INFANT(S)

I

Woman has delivered one (1) or more infants with a birth weight of less than or equal to 5 lb 8 oz (2500 gms).

Document: Weight(s) and birth date(s) in the participant's health record

321

HISTORY OF FETAL OR NEONATAL DEATH

I

Any fetal death(s) (death greater than or equal to 20 weeks gestation) or neonatal death(s) (death occurring from 0-28 days of life).

Document: Date(s) of fetal/neonatal death(s) in the participant's health record; weeks gestation for fetal death(s); age, at death, of neonate(s). This does not include elective abortions.

331

PREGNANCY AT A YOUNG AGE

I

For current pregnancy, EDC at less than 18 years and 10 months of age.

Document: Expected date of delivery (EDC) on the WIC Assessment/ Certification Form

High Risk: EDC at less than 17 years of age

332

CLOSELY SPACED PREGNANCIES

I

For current pregnancy, the participant's EDC is less than 25 months after the termination of the last pregnancy.

Document: Termination date of last pregnancy and EDC in the participant's health record

5

CODE 333

PREGNANT WOMEN
HIGH PARITY AND YOUNG AGE The following two (2) conditions must both apply: 1. The woman is under age 20 at date of conception, AND 2. She has had 3 or more previous pregnancies of at least 20 weeks
duration, regardless of birth outcome. Document: EDC date; number of pertinent pregnancies (of at least 20 weeks gestation) and weeks gestation for each, in the participant's health record

PRIORITY I

334

LACK OF, OR INADEQUATE PRENATAL CARE

I

Prenatal care beginning after the 1st trimester (0-13 weeks)

Document: Weeks gestation, in participant's health record, when prenatal care began. A pregnancy test is not prenatal care.

335

MULTI-FETAL GESTATION

I

More than one (>1) fetus in a current pregnancy.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

High Risk: Multi-fetal gestation

336

FETAL GROWTH RESTRICTION

I

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, documented, or reported by a physician or someone working under a physician's orders, or as self reported by applicant/participant/caregiver.

Fetal Growth Restriction (FGR) must be diagnosed by a physician or a health professional acting under standing orders of a physician.

Document: Diagnosis in participant's health record High Risk: Fetal Growth Restriction

6

CODE 337
338

PREGNANT WOMEN

PRIORITY

HISTORY OF BIRTH OF A LARGE FOR GESTATIONAL AGE INFANT

I

Prenatal woman has delivered one (1) or more infants with a birth weight of 9 pounds (4000 gm) or more.

Document: Birth weight(s) in the participant's health record

PREGNANT WOMAN CURRENTLY BREASTFEEDING

I

Breastfeeding woman who is now pregnant.

Note: Refer to or provide appropriate breastfeeding counseling, especially if at risk for not meeting her own nutrient needs, for a decrease in milk supply, or for premature labor.

339

HISTORY OF BIRTH WITH NUTRITION RELATED CONGENITAL OR BIRTH

DEFECT(S)

I

A prenatal woman with any history of giving birth to an infant who has a congenital or birth defect linked to inappropriate nutritional intake, e.g., inadequate zinc, folic acid (neural tube defect), excess vitamin A (cleft palate or lip).

Document: Infant(s) congenital and/or birth defect(s) in participant's health record

7

PREGNANT WOMEN
CODE
NUTRITION RELATED MEDICAL CONDITIONS

341

NUTRIENT DEFICIENCY DISEASES

Diagnosis of clinical signs of nutritional deficiencies or a disease caused by insufficient dietary intake of macro or micronutrients. Diseases include, but not limited to: protein energy malnutrition, hypocalcemia, cheilosis, scurvy, osteomalacia, menkes disease, rickets, Vitamin K deficiency, xerothalmia, beriberi, and pellagra. (See Appendix D)

The presence of nutrient deficiency diseases diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed nutrient deficiency disease

PRIORITY I

342

GASTRO-INTESTINAL DISORDERS:

I

Diseases or conditions that interfere with the intake, digestion, and or absorption of nutrients. The diseases and/or conditions include, but are not limited to: Gastroesophageal reflux disease (GERD) Peptic ulcer Post-bariatric surgery Short bowel syndrome Inflammatory bowel disease, including ulcerative colitis or Crohn's disease Liver disease Pancreatitis Biliary tract disease

The presence of gastro-intestinal disorders as 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.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed gastro-intestinal disorder

8

CODE 343

PREGNANT WOMEN

PRIORITY

DIABETES MELLITUS

I

Diabetes mellitus consists of a group of metabolic diseases characterized by inappropriate hyperglycemia resulting from defects in insulin secretion, insulin action or both.

Presence of diabetes mellitus diagnosed, documented, or reported by a physician or someone working under a physician's orders, or as self reported by applicant/participant/caregiver.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed diabetes mellitus

344

THYROID DISORDERS

I

Thyroid dysfunctions that occur in pregnant and postpartum women, during fetal development, and in childhood are caused by the abnormal secretion of thyroid hormones. The medical conditions include, but are not limited to, the following:
Hyperthyroidism: Excessive thyroid hormone production (most commonly known as Graves' disease and toxic multinodular goiter).
Hyporthyroidism: Low secretion levels of thyroid hormone (can be overt or mild/subclinical). Most commonly seen as chronic autoimmune thyroiditis (Hashimoto's thyroiditis or autoimmune thyroid disease). It can also be caused by severe iodine deficiency.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed thyroid disorder

345

HYPERTENSION

I

Presence of hypertension or prehypertension 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.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed hypertension

9

CODE 346
347

PREGNANT WOMEN
RENAL DISEASE
Any renal disease including pyelonephritis and persistent proteinuria, but EXCLUDING urinary tract infections (UTI) involving the bladder. Presence of renal disease diagnosed by a physician as self reported by applicant/ participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.
Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed renal disease
CANCER
A chronic disease whereby populations of cells have acquired the ability to multiply and spread without the usual biologic restraints. The current condition, or the treatment for the condition, must be severe enough to affect nutritional status.
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.
Document: Description of how the condition or treatment affects nutritional status and name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed cancer

PRIORITY I
I

348

CENTRAL NERVOUS SYSTEM DISORDERS

I

Conditions which affect energy requirements and may affect the individual's ability to feed self, that alter nutritional status metabolically, mechanically, or both. Includes, but is not limited to: epilepsy, cerebral palsy (CP), and neural tube defects (NTD) such as spina bifida and myelomeningocele.

Presence of a central nervous system disorder(s) diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed central nervous system disorder

10

CODE 349

PREGNANT WOMEN

PRIORITY

GENETIC AND CONGENITAL DISORDERS

I

Hereditary or congenital condition at birth that causes physical or metabolic abnormality, or both. May include, but not limited to: cleft lip, cleft palate, thalassemia, sickle cell anemia, down's syndrome.

Presence of genetic and congenital disorders diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed genetic/congenital disorder

351

INBORN ERRORS OF METABOLISM

I

Gene mutations or gene deletions that alter metabolism in the body, including, but not limited to: phenylketonuria (PKU), maple syrup urine disease, galactosemia, hyperlipoproteinuria, homocystinuria, tyrosinemia, histidinemia, urea cycle disorder, glutaric aciduria, methylmalonic acidemia, glycogen storage disease, galactokinase deficiency, fructoaldase deficiency, propionic acidemia, hypermethioninemia.

Presence of inborn errors of metabolism diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed inborn error of metabolism

11

CODE

PREGNANT WOMEN

PRIORITY

352

INFECTIOUS DISEASES

I

A disease caused by growth of pathogenic microorganisms in the body severe enough to affect nutritional status. Includes, but is not limited to: tuberculosis, pneumonia, meningitis, parasitic infection, hepatitis, bronchiolitis (3 episodes in last 6 months), HIV/AIDS.

The infectious disease MUST be present within the past 6 months and diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis, appropriate dates of each occurrence, and name of physician treating condition in the participant's health record. When using HIV/AIDS positive status as a Nutritionally Related Medical Condition, write "See Medical Record" for documentation purpose.

High Risk: Diagnosed infectious disease, as described above

353

FOOD ALLERGIES

I

An adverse immune response to a food or a hypersensitivity that causes adverse immunologic reaction.

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.

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed food allergy

12

CODE 354

PREGNANT WOMEN
CELIAC DISEASE
Also known as Celiac Sprue, Gluten Enteropathy, or Non-tropical Sprue.
Inflammatory condition of the small intestine precipitated by the ingestion of wheat in individuals with certain genetic make-up.
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.
Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed Celiac Disease

PRIORITY I

355

LACTOSE INTOLERANCE

I

Lactose intolerance occurs when there is an insufficient production of the enzyme lactase. Lactase is needed to digest lactose. Lactose in dairy products that is not digested or absorbed is fermented in the small intestine producing any or all of the following GI disturbances: nausea, diarrhea, abdominal bloating, cramps. Lactose intolerance varies among and within individuals and ranges from mild to severe.
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.

Document: Diagnosis and the name of the physician that is treating this condition
in the participant's health record; OR list of symptoms described by the applicant/participant/caregiver (i.e., nausea, cramps, abdominal bloating, and/or diarrhea).

356

HYPOGLYCEMIA

I

Presence of hypoglycemia diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed hypoglycemia

13

CODE 357

PREGNANT WOMEN
DRUG/NUTRIENT INTERACTIONS
Use of prescription or over the counter drugs or medications that have been shown to interfere with nutrient intake or utilization, to an extent that nutritional status is compromised.
Document: Drug/medication being used and respective nutrient interaction in the participant's health record.
High Risk: Use of drug or medication shown to interfere with nutrient intake or utilization, to extent that nutritional status is compromised.

PRIORITY I

358

EATING DISORDERS

I

Eating disorders (anorexia nervosa and bulimia), are characterized by a disturbed

sense of body image and morbid fear of becoming fat. Symptoms are manifested by

abnormal eating patterns including, but not limited to:



Self-induced vomiting



Purgative abuse



Alternating periods of starvation



Use of drugs such as appetite suppressants, thyroid preparations or

diuretics



Self-induced marked weight loss

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.

Document: Symptoms or diagnosis and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed eating disorder

14

CODE 359

PREGNANT WOMEN

PRIORITY

RECENT MAJOR SURGERY, TRAUMA OR BURNS

I

Major surgery (including C-sections), trauma or burns severe enough to compromise nutritional status. Any occurrence within the past 2 months may be self reported.
Any occurrence more than 2 months previous MUST have the continued need for nutritional support diagnosed by a physician or health care provider working under the orders of a physician.

Document: If occurred within the past 2 months, document surgery, trauma and/or burns in the participant's health record. If occurred more than 2 months ago, document description of how the surgery, trauma and/or burns currently affects nutritional status and include date.

High Risk: Major surgery, trauma or burns that has a continued need for nutritional support.

360

OTHER MEDICAL CONDITIONS

I

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. Including, but not limited to: juvenile rheumatoid arthritis (JRA), lupus erythematosus, cardiorespiratory diseases, heart disease, cystic fibrosis, moderate, Persistent Asthma (moderate or severe) requiring daily medication.

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.

Document: Specific medical condition; a description of how the disease, condition or treatment affects nutritional status and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed medical condition severe enough to compromise nutritional status

361

DEPRESSION

I

Presence of depression diagnosed by a physician or psychologist as self reported by applicant/participant/caregiver; or as reported or documented by a physician, psychologist or health care provider working under the orders of a physician.

Document: Diagnosis and name of physician that is treating this condition in the participant's health record

15

CODE 362

PREGNANT WOMEN
DEVELOPMENTAL, SENSORY OR MOTOR DELAYS INTERFERING WITH THE ABILITY TO EAT
Developmental, sensory or motor delays include but are not limited to: minimal brain function, feeding problems due to developmental delays, birth injury, head trauma, brain damage, other disabilities.
Document: Specific condition/ description of delays and how these interfere with the ability to eat and the name of the physician that is treating this condition.
High Risk: Developmental, sensory or motor delay interfering with ability to eat.

PRIORITY I

371

MATERNAL SMOKING

I

Any smoking of cigarettes, pipes or cigars.

Document: Number of cigarettes or cigars smoked, or number of times pipe smoked, on WIC Assessment/Certification Form. See Appendix E-1 for documentation codes.

372

ALCOHOL AND ILLEGAL DRUG USE

I

Any alcohol use:

A serving of standard sized drink (1 ounce of alcohol) is: 1 can of beer (12 fluid oz) 5 oz wine 1 fluid oz liquor
Binge drinking is defined as > 5 drinks on the same occasion on at least one day in the past 30 days
Heavy drinking is defined as > 5 drinks on the same occasion on five or more days in the past 30 days
Document: Enter the number of servings of alcohol per week on the WIC Assessment/Certification Form. See Appendix E-1 for documentation codes.

Any illegal drug use:
Document: Type of drug(s) being used. See Appendix E-2 for commonly used illegal drug names.

16

CODE 381

PREGNANT WOMEN

PRIORITY

DENTAL PROBLEMS

I

Diagnosis of dental problems by a physician or health care provider working under the orders of a physician or adequate documentation by the competent professional authority. Including but not limited to: gingivitis of pregnancy, tooth decay, periodontal disease, and tooth loss and/or ineffectively replaced teeth which impair the ability to ingest food in adequate quality or quantity.

Document: In the participant's health record, a description of how the dental problem interferes with mastication and/or has other nutritionally related health problems.

400

INAPPROPRIATE NUTRITION PRACTICES

IV

Routine nutrition practices that may result in impaired nutrient status, disease, or health problems. (Appendix G)

Document: Inappropriate Nutrition Practice(s) in the participant's health record.

401

FAILURE TO MEET DIETARY GUIDELINES

IV

A woman who meets eligibility requirements based on category, income, and residency but who does not have any other identified nutritional risk factor may be presumed to be at nutritional risk based on failure to meet the Dietary Guidelines for Americans.

(This risk factor may be assigned only when a woman does not qualify for risk 400 or for any other risk factor.)

502

TRANSFER OF CERTIFICATION

I, IV

Person with a current valid Verification of Certification (VOC) document from another state or local agency. The VOC is valid until the certification period expires, and shall be accepted as proof of eligibility for Program benefits. If the receiving local agency has waiting lists for participation, the transferring participant shall be placed on the list ahead of all other waiting applicants.

This criterion should be used primarily when the VOC card/document does not reflect another more specific nutrition risk condition at the time of transfer or if the participant was initially certified based on a nutrition risk condition not in use by the receiving agency.

17

CODE 801

PREGNANT WOMEN
HOMELESSNESS Homelessness as defined in the Special Populations Section of the Georgia WIC Program Procedure Manual.

PRIORITY IV

802

MIGRANCY

IV

Migrancy as defined in the Special Populations Section of the Georgia WIC Program Procedures Manual.

901

RECIPIENT OF ABUSE

Battering (abuse) within past 6 months as self-reported, or as documented by a

IV

social worker, health care provider or on other appropriate documents, or as

reported through consultation with a social worker, health care provider or other

appropriate personnel.

Battering refers to violent assaults on women.

902

PRENATAL WOMAN WITH LIMITED ABILITY TO MAKE FEEDING

IV

DECISIONS AND/OR PREPARE FOOD

Woman who is assessed to have limited ability to make appropriate feeding decisions and/or prepare food. Examples may include:

mental disability / delay and/or mental illness such as clinical depression (diagnosed by a physician or licensed psychologist)
physical disability which restricts or limits food preparation abilities current use of or history of abusing alcohol or other drugs
Document: The women's specific limited abilities in the participant's health record.

IV

903

Foster Care

Entering the foster care system during the previous six months or moving from one foster care home to another foster care home during the previous six months.

904

ENVIRONMENTAL TOBACCO SMOKE EXPOSURE

I

Environmental tobacco smoke (ETS) exposure is defined as exposure to smoke from tobacco products inside the home.

18

DATA AND DOCUMENTATION REQUIRED FOR WIC ASSESSMENT/CERTIFICATION
BREASTFEEDING WOMEN

Data

Breastfeeding and Non-Breastfeeding Woman Certified in
Hospital Prior to Initial Discharge

Height

Pre-pregnancy height from health record; self reported if not available from record

Pre-Pregnancy Weight

Pre-pregnancy weight from health record; self reported if not available from record

Current Weight

If available

Last Weight Before Delivery

Required

Hemoglobin or Hematocrit

Required (Apply 90-day rule when not available)

Evaluation of Inappropriate Nutrition Practices

Required

Risk Factor Assessment

Required

Woman Certified in Clinic
Required
Required Required Required Required Required Required

Breastfeeding Woman MidAssessment
Required
Required Required Required Optional
Required Required

19

NUTRITION RISK CRITERIA BREASTFEEDING WOMEN

NOTE: High Risk Criteria, as defined below, are to be used for referral purposes, not

certification (See Appendix A-1)

BREASTFEEDING WOMEN

CODE

PRIORITY

201

LOW HEMOGLOBIN/HEMATOCRIT

I

Non-Smokers:

Hemoglobin: Hematocrit:

11.9 gm or lower (> 15 years of age) 11.7 gm or lower (< 15 years of age) 35.8% or lower

Smokers:

Hemoglobin: Hematocrit:

12.2 gm or lower (> 15 years of age) 12.0 gm or lower (< 15 years of age) 36.8% or lower

High Risk: Hemoglobin OR hematocrit at treatment level (Appendix B-1)

101

UNDERWEIGHT

I

< 6 months Postpartum:
Pre-pregnancy or current weight is equal to a Body Mass Index (BMI) of <18.5. Refer to BMI Table, Appendix C-1.

6 months Postpartum:
Current weight is equal to a Body Mass Index (BMI) of <18.5. Refer to BMI Table, Appendix C-1.

High Risk: Current BMI <18.5

111

OVERWEIGHT

I

<6 months Postpartum: Pre-pregnancy weight is equal to a Body Mass Index (BMI) of >25. Refer to BMI Table, Appendix C-1.

6 months Postpartum:
Current weight is equal to a Body Mass Index (BMI) of >25. Refer to BMI Table, Appendix C-1.

High Risk: Current BMI >29.9

20

CODE

BREASTFEEDING WOMEN

133

HIGH MATERNAL WEIGHT GAIN

Breastfeeding (most recent pregnancy only): total gestational weight gain exceeding the upper limit of the recommended range based on Body Mass Index (BMI), as follows:

PRIORITY I

Prepregnancy Weight Group

Definition (BMI)

Cut-off Value (Singleton)

Cut-off Value (Multi-Fetal)

Underweight

< 18.5

>40 lbs

*

Normal Weight

18.5 to 24.9

>35 lbs

>54 lbs

Overweight

25.0 to 29.9

>25 lbs

>50 lbs

Obese

> 30.0

>20 lbs

>42 lbs

*There are no provisional guidelines for underweight woman with multiple

fetuses. (Appendix C-2)

Document: Pre-gravid weight and last weight before delivery

211

ELEVATED BLOOD LEAD LEVELS

I

Blood lead level of >10 g/deciliter within the past 12 months.

Document: Date of blood test and blood lead level in the participant's health record. Must be within the past 12 months.

High Risk: Blood lead level of >10 g/deciliter within the past 12 months.

303

HISTORY OF GESTATIONAL DIABETES

I

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 physician, or someone working under physician's orders for any pregnancy.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

21

CODE

BREASTFEEDING WOMEN

304

HISTORY OF PREECLAMPSIA

History of diagnosed preeclampsia

Presence of condition diagnosed by a physician as self-reported by applicant/participant/caregiver; or as reported or documented by physician, or someone working under physician's orders for any pregnancy.
Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

PRIORITY I

311

DELIVERY OF PREMATURE INFANT(S)

I

Woman has delivered one (1) or more infants at 37 weeks gestation or less. Applies to most recent pregnancy only.

Document: Delivery date and weeks gestation in participant's health record

312

DELIVERY OF LOW BIRTH WEIGHT INFANT(S)

I

Woman has delivered one (1) or more infants with a birth weight of less than or equal to 5 lb 8 oz (2500 gms). Applies to most recent pregnancy only.

Document: Weight(s) and birth date in the participant's health record

321

FETAL OR NEONATAL DEATH

I

A fetal death (death > 20 weeks gestation) or a neonatal death (death occurring from 0-28 days of life). Applies to most recent pregnancy only.

Document: Date(s) of fetal/neonatal death(s) in the participant's health record; weeks gestation for fetal death(s); age, at death, of neonate(s). This does not include elective abortions.

22

CODE
331

BREASTFEEDING WOMEN
PREGNANCY AT A YOUNG AGE

For most recent pregnancy, delivery date at less than 18 years and 10 months of age. Applies to most recent pregnancy only.

Document: Delivery date on the WIC Assessment/Certification Form

High Risk: Delivery date at less than 17 years of age

PRIORITY I

332

CLOSELY SPACED PREGNANCIES

I

Delivery date for most recent pregnancy occurred less than 25 months after the termination of the previous pregnancy.

Document: Termination dates of last two pregnancies in the participant's health record.

333

HIGH PARITY AND YOUNG AGE

I

The following two (2) conditions must both apply:

1. The woman is under age 20 at date of conception AND

2. She has had 3 or more pregnancies of at least 20 weeks duration (regardless of birth outcome), previous to the most recent pregnancy.

Document: Delivery date; number of pertinent previous pregnancies (of at least 20 weeks gestation) and weeks gestation for each, in the participant's health record.

335

MULTI FETAL GESTATION

I

More than one (>1) fetus in the most recent pregnancy

High Risk: Multi-fetal gestation

337

HISTORY OF A LARGE FOR GESTATIONAL AGE INFANT

I

Most recent pregnancy, or history of giving birth to an infant with a birth weight of

9 pounds or more.

Document: Birth weight(s) and date(s) of deliveries in the participant's health record.
23

CODE
339

BREASTFEEDING WOMEN
BIRTH WITH NUTRITION RELATED CONGENITAL OR BIRTH DEFECT(S)
A woman who gives birth to an infant who has a congenital or birth defect linked to inappropriate nutritional intake, e.g., inadequate zinc, folic acid (neural tube defect), excess vitamin A (cleft palate or lip). Applies to most recent pregnancy only.
Document: Infant(s) congenital and/or birth defect(s) in participant's health record

PRIORITY I

NUTRITION RELATED MEDICAL CONDITIONS

I

341

NUTRIENT DEFICIENCY DISEASES

Diagnosis of clinical signs of nutritional deficiencies or a disease caused by insufficient dietary intake of macro or micro nutrients. Diseases include, but not limited to: protein energy malnutrition, hypocalcemia, cheilosis, scurvy, osteomalacia, menkes disease, rickets, Vitamin K deficiency, xerothalmia, beriberi, and pellagra. (See Appendix D)

The presence of nutrient deficiency diseases diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in participant's health record.

High Risk: Diagnosed nutrient deficiency disease

24

CODE

BREASTFEEDING WOMEN

PRIORITY

342

GASTRO-INTESTINAL DISORDERS

I

Diseases or conditions that interfere with the intake, digestion, and or absorption of nutrients. The diseases and/or conditions include, but are not limited to:
Gastroesophageal reflux disease (GERD) Peptic ulcer Post-bariatric surgery Short bowel syndrome Inflammatory bowel disease, including ulcerative colitis or Crohn's
disease
Liver disease Pancreatitis Biliary tract disease

The presence of gastro-intestinal disorders as 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.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed gastro-intestinal disorder

343

DIABETES MELLITUS

I

Diabetes mellitus consists of a group of metabolic diseases characterized by inappropriate hyperglycemia resulting from defects in insulin secretion, insulin action or both.

Presence of diabetes mellitus diagnosed, documented, or reported by a physician or someone working under a physician's orders, or as self reported by applicant/participant/caregiver.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed diabetes mellitus

25

CODE
344

BREASTFEEDING WOMEN

PRIORITY

THYROID DISORDERS

I

Thyroid dysfunctions that occur in pregnant and postpartum women, during fetal development, and in childhood are caused by the abnormal secretion of thyroid hormones. The medical conditions include, but are not limited to, the following:
Hyperthyroidism: Excessive thyroid hormone production (most commonly known as Graves' disease and toxic multinodular goiter).
Hypothyroidism: Low secretion levels of thyroid hormone (can be overt or mild/subclinical). Most commonly seen as chronic autoimmune thyroiditis (Hashimoto's thyroiditis or autoimmune thyroid disease). It can also be caused by severe iodine deficiency.
Postpartum Thyroiditis: Transient or permanent thyroid dysfunction occurring in the first year after delivery based on an autoimmune inflammation of the thyroid. Frequently, the resolution is spontaneous.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed thyroid disorder

345

HYPERTENSION

I

Presence of hypertension or prehypertension 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.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed hypertension

346

RENAL DISEASE

I

Any renal disease including pyelonephritis and persistent proteinuria, but
EXCLUDING urinary tract infections (UTI) involving the bladder. Presence of renal disease diagnosed by a physician as self reported by applicant/ participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in participant's health record.

High Risk: Diagnosed renal disease

26

CODE

BREASTFEEDING WOMEN

PRIORITY

347

CANCER

I

A chronic disease whereby populations of cells have acquired the ability to multiply and spread without the usual biologic restraints. The current
condition, or the treatment for the condition, must be severe enough to affect nutritional status.

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.

Document: Description of how the condition or treatment affects nutritional status and the name of the physician that is treating the condition in the participant's health record.

High Risk: Diagnosed cancer

348

CENTRAL NERVOUS SYSTEM DISORDERS

I

Conditions which affect energy requirements and may affect the individual's ability to feed self that alter nutritional status metabolically, mechanically, or both. Includes, but is not limited to: epilepsy, cerebral palsy (CP), and neural tube defects (NTD) such as spina bifida and myelomeningocele.

Presence of a central nervous system disorder(s) diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in participant's health record.

High Risk: Diagnosed central nervous system disorder

27

CODE

BREASTFEEDING WOMEN

PRIORITY

349

GENETIC AND CONGENITAL DISORDERS

I

Hereditary or congenital condition at birth that causes physical or metabolic abnormality, or both. May include, but not limited to: cleft lip, cleft palate, thalassemia, sickle cell anemia, down's syndrome.

Presence of genetic and congenital disorders diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in participant's health record.

High Risk: Diagnosed genetic/congenital disorder

351

INBORN ERRORS OF METABOLISM

I

Gene mutations or gene deletions that alter metabolism in the body, including, but not limited to: phenylketonuria (PKU), maple syrup urine disease, galactosemia, hyperlipoproteinuria, homocystinuria, tyrosinemia, histidinemia, urea cycle disorder, glutaric aciduria, methylmalonic acidemia, glycogen storage disease, galactokinase deficiency, fructoaldase deficiency, propionic acidemia, hypermethioninemia.

Presence of inborn errors of metabolism diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in participant's health record.

High Risk: Diagnosed inborn error of metabolism

28

CODE

BREASTFEEDING WOMEN

PRIORITY

352

INFECTIOUS DISEASES

I

A disease caused by growth of pathogenic microorganisms in the body severe enough to affect nutritional status. Includes, but is not limited to: tuberculosis, pneumonia, meningitis, parasitic infection, hepatitis, bronchiolitis (3 episodes in last 6 months), HIV/AIDS.

The infectious disease MUST be present within the past 6 months and diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis, appropriate dates of each occurrence, and name of physician treating this condition in the participant's health record. When using HIV/AIDS positive status as a Nutritionally Related Medical Condition, write "See Medical Record" for documentation purpose.

High Risk: Diagnosed infectious disease, as described above

353

FOOD ALLERGIES

I

An adverse immune response to a food or a hypersensitivity that causes adverse immunologic reaction.

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.

Document: Diagnosis and name of the physician that is treating this condition in participant's health record.

High Risk: Diagnosed food allergy

29

CODE

BREASTFEEDING WOMEN

PRIORITY

354

CELIAC DISEASE

I

Also known as Celiac Sprue, Gluten Enteropathy, or Non-tropical Sprue.

Inflammatory condition of the small intestine precipitated by the ingestion of wheat in individuals with certain genetic make-up.

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.

Document: Diagnosis and name of the physician that is treating this condition in participant's health record.

High Risk: Diagnosed Celiac Disease

355

LACTOSE INTOLERANCE

I

Lactose intolerance occurs when there is an insufficient production of the enzyme lactase. Lactase is needed to digest lactose. Lactose in dairy products that is not digested or absorbed is fermented in the small intestine producing any or all of the following GI disturbances: nausea, diarrhea, abdominal bloating, cramps. Lactose intolerance varies among and within individuals and ranges from mild to severe.
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.

Document: Diagnosis and the name of the physician that is treating this
condition in the participant's health record; OR list of symptoms described by the applicant/participant/caregiver (i.e., nausea, cramps, abdominal bloating, and/or diarrhea).

30

CODE

BREASTFEEDING WOMEN

PRIORITY

356

HYPOGLYCEMIA

I

Presence of hypoglycemia diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed hypoglycemia

357

DRUG/NUTRIENT INTERACTIONS

I

Use of prescription or over the counter drugs or medications that have been shown to interfere with nutrient intake or utilization, to an extent that nutritional status is compromised.

Document: Drug/medication being used and respective nutrient interaction in the participant's health record.

High Risk: Use of drug or medication shown to interfere with nutrient intake or utilization, to extent that nutritional status is compromised.

31

CODE

BREASTFEEDING WOMEN

PRIORITY

358

EATING DISORDERS

I

Eating disorders (anorexia nervosa and bulimia), are characterized by a

disturbed sense of body image and morbid fear of becoming fat. Symptoms

are manifested by abnormal eating patterns including, but not limited to:



Self-induced vomiting



Purgative abuse



Alternating periods of starvation



Use of drugs such as appetite suppressants, thyroid preparations

or diuretics



Self-induced marked weight loss

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.

Document: Symptoms or diagnosis and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed eating disorder

359

RECENT MAJOR SURGERY, TRAUMA OR BURNS

I

Major surgery (including C-sections), trauma or burns severe enough to compromise nutritional status. Any occurrence within the past 2 months may
be self reported. Any occurrence more than 2 months previous MUST have the continued need for nutritional support diagnosed by a physician or health professional acting under the standing orders of a physician.

Document: If occurred within the past 2 months, document surgery, trauma and/or burns in the participant's health record. If occurred more than 2 months ago, document description of how the surgery, trauma and/or burns currently affects nutritional status and include date.

High Risk: Major surgery, trauma or burns that has a continued need for nutritional support.

32

CODE

BREASTFEEDING WOMEN

PRIORITY

360

OTHER MEDICAL CONDITIONS

I

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. Including, but not limited to: juvenile rheumatoid arthritis (JRA), lupus erythematosus, cardiorespiratory diseases, heart disease, cystic fibrosis, moderate, Persistent Asthma (moderate or severe) requiring daily medication.

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.

Document: Specific medical condition; a description of how the disease, condition or treatment affects nutritional status and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed medical condition severe enough to compromise nutritional status

361

DEPRESSION

I

Presence of depression diagnosed by a physician or psychologist as self reported by applicant/participant/caregiver; or as reported or documented by a physician, psychologist or health care provider working under the orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in participant's health record.

33

CODE

BREASTFEEDING WOMEN

PRIORITY

362

DEVELOPMENTAL, SENSORY OR MOTOR DELAYS INTERFERING WITH

I

ABILITY TO EAT

Developmental, sensory or motor delays include but are not limited to: minimal brain function, feeding problems due to developmental delays, birth injury, head trauma, brain damage, other disabilities.

Document: Specific condition/description of the delay and how it interferes with the ability to eat and the name of the physician that is treating this condition in the participant's health record.

High Risk: Developmental, sensory or motor delay interfering with ability to eat.

I

363

PRE-DIABETES

Presence of pre-diabetes diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed pre-diabetes

371

MATERNAL SMOKING

I

Any smoking of cigarettes, pipes or cigars.

Document: Number of cigarettes or cigars smoked, or number of times pipe smoked, on WIC Assessment/Certification Form.

34

CODE

BREASTFEEDING WOMEN

PRIORITY

372

ALCOHOL AND ILLEGAL DRUG USE

I

Alcohol use:
Routine current use of > 2 drinks per day OR
Binge drinking is defined as >5 drinks on the same occasion on at least one day in the past 30 days, OR
Heavy drinking is defined as >5 drinks on the same occasion on five or more days in the past 30 days

A serving of standard sized drink (1 ounce of alcohol) is: - 1 can of beer (12 fluid oz) - 5 oz wine - 1 fluid oz liquor

Document: Alcohol Use; identify type (Routine - Enter oz./wk: ___, Binge drinker, Heavy drinker) on WIC Assessment/Certification Form.

See Appendix E-1 for documentation codes.

Any Illegal drug use:
Document: Type of drug(s) being used. See Appendix E-2 for commonly used illegal drug names.

381

DENTAL PROBLEMS

I

Diagnosis of dental problems by a physician or health care provider working under the orders of a physician or adequate documentation by the competent professional authority. Including but not limited to: tooth decay, periodontal disease, and tooth loss and/or ineffectively replaced teeth which impair the ability to ingest food in adequate quality or quantity.

Document: In the participant's health record, a description of how the dental problem interferes with mastication and/or has other nutritionally related health problems.

35

CODE

BREASTFEEDING WOMEN

400

INAPPROPRIATE NUTRITION PRACTICES

Routine nutrition practices that may result in impaired nutrient status,
disease, or health problems. (Appendix G)

Document: Inappropriate Nutrition Practice(s) in the participant's health record.

PRIORITY IV

401

FAILURE TO MEET DIETARY GUIDELINES

IV

A woman who meets eligibility requirements based on category, income, and residency but who does not have any other identified nutritional risk factor
may be presumed to be at nutritional risk based on failure to meet the Dietary Guidelines for Americans.

(This risk factor may be assigned only when a woman does not qualify for risk 400 or for any other risk factor.)

502

TRANSFER OF CERTIFICATION

I, II, IV

Person with a current valid Verification of Certification (VOC) document from another state or local agency. The VOC is valid until the certification period expires, and shall be accepted as proof of eligibility for Program benefits. If the receiving local agency has waiting lists for participation, the transferring participant shall be placed on the list ahead of all other waiting applicants.

This criterion should be used primarily when the VOC card/document does not reflect another more specific nutrition risk condition at the time of transfer or if the participant was initially certified based on a nutrition risk condition not in use by the receiving agency.

601

BREASTFEEDING AN INFANT AT NUTRITIONAL RISK

I, II, IV

A breastfeeding woman whose breastfed infant has been determined to be at nutritional risk.

Document: Infant's risks on mother's WIC Assessment/Certification Form.

36

CODE

BREASTFEEDING WOMEN

PRIORITY

602

BREASTFEEDING COMPLICATIONS OR POTENTIAL COMPLICATIONS

I

A breastfeeding woman with any of the following complications or potential complications for breastfeeding.

a. severe breast engorgement b. recurrent plugged ducts c. mastitis d. flat or inverted nipples e. cracked, bleeding or severely sore nipples f. age > 40 years g. failure of milk to come in by 4 days postpartum h. tandem nursing (nursing two siblings who are not twins)

Document: Complications or potential complications in the participant's health record.

High Risk: Refer to or provide the mother with appropriate breastfeeding counseling.

801

HOMELESSNESS

IV

Homelessness as defined in the Special Populations Section of the Georgia WIC Program Procedures Manual.

802

MIGRANCY

IV

Migrancy as defined in the Special Population Section of the Georgia WIC Program Procedures Manual.

901

RECIPIENT OF ABUSE

IV

Battering within past 6 months as self-reported, or as documented by a social

worker, health care provider or on other appropriate documents, or as

reported through consultation with a social worker, health care provider or

other appropriate personnel.

Battering refers to violent assaults on women.

37

CODE

BREASTFEEDING WOMEN

PRIORITY

902

BREASTFEEDING WOMAN WITH LIMITED ABILITY TO MAKE FEEDING

IV

DECISIONS AND/OR PREPARE FOOD

Woman who is assessed to have limited ability to make appropriate feeding decisions and/or prepare food. Examples may include:

mental disability / delay and/or mental illness such as clinical depression (diagnosed by a physician or licensed psychologist)
physical disability which restricts or limits food preparation abilities
current use of or history of abusing alcohol or other drugs

Document: The women's specific limited abilities in the participant's health record.

903

Foster Care

IV

Entering the foster care system during the previous six months or moving from one foster care home to another foster care home during the previous six months.

904

ENVIRONMENTAL TOBACCO SMOKE EXPOSURE

I

Environmental tobacco smoke (ETS) exposure is defined as exposure to smoke from tobacco products inside the home.

38

DATA AND DOCUMENTATION REQUIRED FOR WIC ASSESSMENT/CERTIFICATION
POSTPARTUM NON-BREASTFEEDING WOMEN

Data

Woman Certified in Hospital Prior to Initial
Discharge

Height Pre-Pregnancy Weight Current Weight

Pre-pregnancy height from health record; self reported if not available from record
Pre-pregnancy weight from health record; self reported if not available from record
If available

Last Weight Before Delivery
Hemoglobin or Hematocrit
Evaluation of Inappropriate Nutrition Practices Risk Factor Assessment

Required Required (Apply 90-day rule when not available)
Required
Required

Woman Certified in Clinic
Required
Required Required Required Required
Required Required

39

NUTRITION RISK CRITERIA POSTPARTUM, NON- BREASTFEEDING WOMEN

NOTE: High Risk Criteria, as defined below, are to be used for referral purposes, not certification (See Appendix A-1)

POSTPARTUM NON-BREASTFEEDING WOMEN

CODE

PRIORITY

201

LOW HEMOGLOBIN/HEMATOCRIT

VI

NonSmokers:

Hemoglobin: Hematocrit:

11.9 gm or lower (> 15 years of age) 11.7 gm or lower (< 15 years of age)
35.8% or lower

Smokers:

Hemoglobin: Hematocrit:

12.2 gm or lower (> 15 years of age) 12.0 gm or lower (< 15 years of age)
36.8% or lower

High Risk: Hemoglobin OR hematocrit at treatment level (Appendix B-1)

101

UNDERWEIGHT

VI

Pre-pregnancy or current weight is equal to a Body Mass Index (BMI) of <18.5. Refer to BMI Table, Appendix C-1.

High Risk: Pre-pregnancy or current BMI <18.5

111

OVERWEIGHT

VI

Pre-pregnancy weight is equal to a Body Mass Index (BMI) of >25. Refer to BMI Table, Appendix C-1.

High Risk: Pre-pregnancy BMI >29.9

40

CODE

POSTPARTUM NON-BREASTFEEDING WOMEN

PRIORITY

133 HIGH MATERNAL WEIGHT GAIN

VI

Non-Breastfeeding (most recent pregnancy only): total gestational weight gain exceeding the upper limit of the recommended range based on Body Mass Index (BMI), as follows:

Prepregnancy Weight Group

Definition (BMI)

Cut-off Value (Singleton)

Cut-off Value (Multi-Fetal)

Underweight Normal Weight
Overweight Obese

< 18.5 18.5 to 24.9 25.0 to 29.9
> 30.0

>40 lbs >35 lbs >25 lbs >20 lbs

*
>54 lbs >50 lbs >42 lbs

*There are no provisional guidelines for underweight woman with multiple
fetuses. (Appendix C-2)
Document: Pre-gravid weight and last weight before delivery

211

ELEVATED BLOOD LEAD LEVELS

VI

Blood lead level of >10 g/deciliter within the past 12 months.

Document: Date of blood test and blood lead level in the participant's health record. Must be within the past 12 months.

High Risk: Blood lead level of >10 g/deciliter within the past 12 months.

303

HISTORY OF GESTATIONAL DIABETES

VI

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 physician, or someone working under physician's orders for any pregnancy.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

41

CODE 304

POSTPARTUM NON-BREASTFEEDING WOMEN
HISTORY OF PREECLAMPSIA History of diagnosed preeclampsia

PRIORITY VI

Presence of condition diagnosed by a physician as self-reported by applicant/participant/caregiver; or as reported or documented by physician, or someone working under physician's orders for any pregnancy.
Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

311

DELIVERY OF PREMATURE INFANT(S)

VI

Woman has delivered one (1) or more infants at 37 weeks gestation or less. Applies to most recent pregnancy only.

Document: Delivery date and weeks gestation in participant's health record

312

DELIVERY OF LOW BIRTH WEIGHT INFANT(S)

VI

Woman has delivered one (1) or more infants with a birth weight of less than or equal to 5 lb 8 oz (2500 gms). Applies to most recent pregnancy only.

Document: Weight(s) and birth date in the participant's health record.

321

FETAL OR NEONATAL DEATH

VI

A fetal death (death > 20 weeks gestation) or a neonatal death (death occurring from 0-28 days of life). Applies to most recent pregnancy only.

Document: Date(s) of fetal/neonatal death(s) in the participant's health record; weeks gestation for fetal death(s); age, at death, of neonate(s). This does not include elective abortions.

42

CODE 331

POSTPARTUM NON-BREASTFEEDING WOMEN

PRIORITY

PREGNANCY AT A YOUNG AGE

III

For most recent pregnancy, delivery date at less than 18 years and 10 months of age. Applies to most recent pregnancy only.

Document: Delivery date on the WIC Assessment/Certification Form

High Risk: Delivery date at less than 17 years of age

332

CLOSELY SPACED PREGNANCIES

VI

Delivery date for most recent pregnancy occurred less than 25 months after the termination of the previous pregnancy.

Document: Termination dates of last two pregnancies in the participant's health record.

333

HIGH PARITY AND YOUNG AGE

VI

The following two (2) conditions must both apply:

1. The woman is under age 20 at date of conception AND

2. She has had 3 or more pregnancies of at least 20 weeks duration (regardless of birth outcome), previous to the most recent pregnancy.

Document: Delivery date; number of pertinent previous pregnancies (of at least 20 weeks gestation) and weeks gestation for each, in the participant's health record

335

MULTI FETAL GESTATION

VI

More than one (>1) fetus in the most recent pregnancy

High Risk: Multi-fetal gestation

43

CODE 337

POSTPARTUM NON-BREASTFEEDING WOMEN

CODE

HISTORY OF A LARGE FOR GESTATIONAL AGE INFANT

VI

Most recent pregnancy, or history of giving birth to an infant with a birth weight of 9 pounds or more.

Document: Birth weight(s) and date(s) of deliveries in the participant's health record.

339

BIRTH WITH NUTRITION RELATED CONGENITAL OR BIRTH DEFECT(S)

VI

A woman who gives birth to an infant who has a congenital or birth defect linked to inappropriate nutritional intake, e.g., inadequate zinc, folic acid (neural tube defect) , excess vitamin A (cleft palate or lip). Applies to most recent pregnancy only.

Document: Infant(s) congenital and/or birth defect(s) in the participant's health record.

NUTRITION RELATED MEDICAL CONDITIONS

VI

341

NUTRIENT DEFICIENCY DISEASES

Diagnosis of clinical signs of nutritional deficiencies or a disease caused by insufficient dietary intake of macro or micro nutrients. Diseases include, but not limited to: protein energy malnutrition, hypocalcemia, cheilosis, scurvy, osteomalacia, menkes disease, rickets, Vitamin K deficiency, xerothalmia, beriberi, and pellagra. (See Appendix D)

The presence of nutrient deficiency diseases diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in participant's health record.

High Risk: Diagnosed nutrient deficiency disease

44

CODE 342

POSTPARTUM NON-BREASTFEEDING WOMEN

PRIORITY

GASTRO-INTESTINAL DISORDERS

VI

Diseases or conditions that interfere with the intake, digestion, and or absorption of nutrients. The diseases and/or conditions include, but are not limited to: Gastroesophageal reflux disease (GERD) Peptic ulcer Post-bariatric surgery Short bowel syndrome Inflammatory bowel disease, including ulcerative colitis or Crohn's disease Liver disease Pancreatitis Biliary tract disease

The presence of gastro-intestinal disorders as 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.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed gastro-intestinal disorder

343

DIABETES MELLITUS

VI

Diabetes mellitus consists of a group of metabolic diseases characterized by inappropriate hyperglycemia resulting from defects in insulin secretion, insulin action or both.

Presence of diabetes mellitus diagnosed, documented, or reported by a physician or someone working under a physician's orders, or as self reported by applicant/participant/caregiver.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed diabetes mellitus

45

CODE 344

POSTPARTUM NON-BREASTFEEDING WOMEN
THYROID DISORDERS

PRIORITY VI

Thyroid dysfunctions that occur in pregnant and postpartum women, during fetal development, and in childhood are caused by the abnormal secretion of thyroid hormones. The medical conditions include, but are not limited to, the following:
Hyperthyroidism: Excessive thyroid hormone production (most commonly known as Graves' disease and toxic multinodular goiter).
Hyporthyroidism: Low secretion levels of thyroid hormone (can be overt or mild/subclinical). Most commonly seen as chronic autoimmune thyroiditis (Hashimoto's thyroiditis or autoimmune thyroid disease). It can also be caused by severe iodine deficiency.
Postpartum Thyroiditis: Transient or permanent thyroid dysfunction occurring in the first year after delivery based on an autoimmune inflammation of the thyroid. Frequently, the resolution is spontaneous.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed thyroid disorder

345

HYPERTENSION

VI

Presence of hypertension or prehypertension 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.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed hypertension

46

CODE 346

POSTPARTUM NON-BREASTFEEDING WOMEN
RENAL DISEASE
Any renal disease including pyelonephritis and persistent proteinuria, but EXCLUDING urinary tract infections (UTI) involving the bladder. Presence of renal disease diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.
Document: Diagnosis and the name of the physician that is treating this condition in participant's health record.
High Risk: Diagnosed renal disease

PRIORITY VI

347

CANCER

VI

A chronic disease whereby populations of cells have acquired the ability to multiply and spread without the usual biologic restraints. The current
condition, or the treatment for the condition, must be severe enough to affect nutritional status.

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.

Document: Description of how the condition or treatment affects nutritional status and the name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed cancer

348

CENTRAL NERVOUS SYSTEM DISORDERS

VI

Conditions which affect energy requirements and may affect the individual's ability to feed self, that alter nutritional status metabolically, mechanically, or both. Includes, but is not limited to: epilepsy, cerebral palsy (CP), and neural tube defects (NTD) such as spina bifida and myelomeningocele.

Presence of central nervous system disorder(s) diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in participant's health record.

High Risk: Diagnosed central nervous system disorder

47

CODE 349

POSTPARTUM NON-BREASTFEEDING WOMEN

PRIORITY

GENETIC AND CONGENITAL DISORDERS

VI

Hereditary or congenital condition at birth that causes physical or metabolic abnormality, or both. May include, but not limited to: cleft lip, cleft palate, thalassemia, sickle cell anemia, down's syndrome.

Presence of genetic and congenital disorders diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in participant's health record.

High Risk: Diagnosed genetic/congenital disorder

351

INBORN ERRORS OF METABOLISM

VI

Gene mutations or gene deletions that alter metabolism in the body, including, but not limited to: phenylketonuria (PKU), maple syrup urine disease, galactosemia, hyperlipoproteinuria, homocystinuria, tyrosinemia, histidinemia, urea cycle disorder, glutaric aciduria, methylmalonic acidemia, glycogen storage disease, galactokinase deficiency, fructoaldase deficiency, propionic acidemia, hypermethionninemia.

Presence of inborn errors of metabolism diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in participant's health record.

High Risk: Diagnosed inborn error of metabolism

48

CODE 352

POSTPARTUM NON-BREASTFEEDING WOMEN

PRIORITY

INFECTIOUS DISEASES

VI

A disease caused by growth of pathogenic microorganisms in the body severe enough to affect nutritional status. Includes, but is not limited to: tuberculosis, pneumonia, meningitis, parasitic infection, hepatitis, bronchiolitis (3 episodes in last 6 months), HIV/AIDS.

The infectious disease MUST be present within the past 6 months and diagnosed by a physician as self reported by applicant/participant/ caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

Document: Diagnosis, appropriate dates of each occurrence, and name of physician treating condition in the participant's health record. When using HIV/AIDS positive status as a Nutritionally Related Medical Condition, write "See Medical Record" for documentation purpose.

High Risk: Diagnosed infectious disease, as described above

353

FOOD ALLERGIES

VI

An adverse immune response to a food or a hypersensitivity that causes adverse immunologic reaction.

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.

Document: Diagnosis and the name of the physician that is treating this condition.

High Risk: Diagnosed food allergy

49

CODE 354

POSTPARTUM NON-BREASTFEEDING WOMEN
CELIAC DISEASE
Also known as Celiac Sprue, Gluten Enteropathy, or Non-tropical Sprue.
Inflammatory condition of the small intestine precipitated by the ingestion of wheat in individuals with certain genetic make-up.
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.
Document: Diagnosis and the name of the physician that is treating this condition.
High Risk: Diagnosed Celiac Disease

PRIORITY VI

355

LACTOSE INTOLERANCE

VI

Lactose intolerance occurs when there is an insufficient production of the enzyme lactase. Lactase is needed to digest lactose. Lactose in dairy products that is not digested or absorbed is fermented in the small intestine producing any or all of the following GI disturbances: nausea, diarrhea, abdominal bloating, cramps. Lactose intolerance varies among and within individuals and ranges from mild to severe.
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.

Document: Diagnosis and the name of the physician that is treating this
condition in the participant's health record; OR list of symptoms described by the applicant/participant/caregiver (i.e., nausea, cramps, abdominal bloating, and/or diarrhea).

50

CODE 356

POSTPARTUM NON-BREASTFEEDING WOMEN
HYPOGLYCEMIA
Presence of hypoglycemia diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician.

PRIORITY VI

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed hypoglycemia

357

DRUG/NUTRIENT INTERACTIONS

VI

Use of prescription or over the counter drugs or medications that have been shown to interfere with nutrient intake or utilization, to an extent that nutritional status is compromised.

Document: Drug/medication being used and respective nutrient interaction in the participant's health record.

High Risk: Use of drug or medication shown to interfere with nutrient intake or utilization, to extent that nutritional status is compromised.

358

EATING DISORDERS

VI

Eating disorders (anorexia nervosa and bulimia), are characterized by a

disturbed sense of body image and morbid fear of becoming fat. Symptoms

are manifested by abnormal eating patterns including, but not limited to:



Self-induced vomiting



Purgative abuse



Alternating periods of starvation



Use of drugs such as appetite suppressants, thyroid preparations

or diuretics



Self-induced marked weight loss

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.

Document: Symptoms or diagnosis and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed eating disorder

51

CODE 359

POSTPARTUM NON-BREASTFEEDING WOMEN

PRIORITY

RECENT MAJOR SURGERY, TRAUMA OR BURNS

VI

Major surgery (including C-sections), trauma or burns severe enough to compromise nutritional status. Any occurrence within the past 2 months may
be self reported. Any occurrence more than 2 months previous MUST have the continued need for nutritional support diagnosed by a physician or health care provider working under the standing orders of a physician.

Document: If occurred within the past 2 months, document surgery, trauma and/or burns in the participant's health record. If occurred more than 2 months ago, document description of how the surgery, trauma and/or burns currently affects nutritional status and include date.

High Risk: Major surgery, trauma or burns that has a continued need for nutritional support.

360

OTHER MEDICAL CONDITIONS

VI

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. Including, but not limited to: juvenile rheumatoid arthritis (JRA), lupus erythematosus, cardiorespiratory diseases, heart disease, cystic fibrosis, moderate, Persistent Asthma (moderate or severe) requiring daily medication.

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.

Document: Specific medical condition; a description of how the disease, condition or treatment affects nutritional status and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed medical condition severe enough to compromise nutritional status

52

CODE 361
362

POSTPARTUM NON-BREASTFEEDING WOMEN

PRIORITY

DEPRESSION

VI

Presence of depression diagnosed by a physician or psychologist as self reported by applicant/participant/caregiver; or as reported or documented by a physician, psychologist or health care provider working under the orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in participant's health record.

DEVELOPMENTAL, SENSORY OR MOTOR DELAYS INTERFERING WITH

VI

THE ABILITY TO EAT

Developmental, sensory or motor delays include but are not limited to: minimal brain function, feeding problems due to developmental delays, birth injury, head trauma, brain damage, other disabilities.

Document: Specific condition/ description of delays and how these interfere with the ability to eat and the name of the physician that is treating this condition.

High Risk: Developmental, sensory or motor delay interfering with ability to eat.

363

PRE-DIABETES

VI

Presence of pre-diabetes diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under standing orders of a physician

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed pre-diabetes

371

MATERNAL SMOKING

VI

Any smoking of cigarettes, pipes or cigars.

Document: Number of cigarettes or cigars smoked, or number of times pipe smoked, on WIC Assessment/Certification Form.

53

CODE

POSTPARTUM NON-BREASTFEEDING WOMEN

PRIORITY

372

ALCOHOL AND ILLEGAL DRUG USE

VI

Alcohol use:
Routine current use of > 2 drinks per day OR
Binge drinking is defined as >5 drinks on the same occasion on at least one day in the past 30 days, OR
Heavy drinking is defined as >5 drinks on the same occasion on five or more days in the past 30 days

A serving of standard sized drink (1 ounce of alcohol) is: - 1 can of beer (12 fluid oz) - 5 oz wine - 1 fluid oz liquor

Document: Alcohol Use; identify type (Routine - Enter oz./wk: ___, Binge drinker, Heavy drinker) on WIC Assessment/Certification Form. See Appendix E-1 for documentation codes.

Any Illegal drug use:
Document: Type of drug(s) being used. See Appendix E-2 for commonly used illegal drug names.

381

DENTAL PROBLEMS

VI

Diagnosis of dental problems by a physician or health care provider working under the orders of a physician or adequate documentation by the competent professional authority. Including but not limited to: tooth decay, periodontal disease, and tooth loss and/or ineffectively replaced teeth which impair the ability to ingest food in adequate quality or quantity.

Document: In the participant's health record, a description of how the dental problem interferes with mastication and/or has other nutritionally related health problems.

54

CODE 400

POSTPARTUM NON-BREASTFEEDING WOMEN

PRIORITY

INAPPROPRIATE NUTRITION PRACTICES

VI

Routine nutrition practices that may result in impaired nutrient status, disease, or health problems. (Appendix G)

Document: Inappropriate Nutrition Practice(s) in the participant's health record.

401

FAILURE TO MEET DIETARY GUIDELINES

VI

A woman who meets eligibility requirements based on category, income, and residency but who does not have any other identified nutritional risk factor
may be presumed to be at nutritional risk based on failure to meet the Dietary Guidelines for Americans.

(This risk factor may be assigned only when a woman does not qualify for risk 400 or for any other risk factor.)

502

TRANSFER OF CERTIFICATION

III, VI

Person with a current valid Verification of Certification (VOC) document from another state or local agency. The VOC is valid until the certification period expires, and shall be accepted as proof of eligibility for Program benefits. If the receiving local agency has waiting lists for participation, the transferring participant shall be placed on the list ahead of all other waiting applicants.

This criterion should be used primarily when the VOC card/document does not reflect another more specific nutrition risk condition at the time of transfer or if the participant was initially certified based on a nutrition risk condition not in use by the receiving agency.

801

HOMELESSNESS

VI

Homelessness as defined in the Special Populations Section of the Georgia WIC Program Procedures Manual.

55

CODE

POSTPARTUM NON-BREASTFEEDING WOMEN

802

MIGRANCY

Migrancy as defined in the Special Populations Section of the Georgia WIC Program Procedures Manual.

PRIORITY VI

901

RECIPIENT OF ABUSE

VI

Battering within past 6 months as self-reported, or as documented by a social worker, health care provider or on other appropriate documents, or as reported through consultation with a social worker, health care provider or other appropriate personnel.

Battering refers to violent assaults on women.

902

POSTPARTUM, NON-BREASTFEEDING WOMAN WITH LIMITED ABILITY

IV

TO MAKE FEEDING DECISIONS AND/OR PREPARE FOOD

Woman who is assessed to have limited ability to make appropriate feeding decisions and/or prepare food. Examples may include:

mental disability / delay and/or mental illness such as clinical depression (diagnosed by a physician or licensed psychologist)
physical disability which restricts or limits food preparation abilities
current use of or history of abusing alcohol or other drugs

Document: The women's specific limited abilities in the participant's health record.

903

Foster Care

VI

Entering the foster care system during the previous six months or moving from one foster care home to another foster care home during the previous six months.

904

ENVIRONMENTAL TOBACCO SMOKE EXPOSURE

VI

Environmental tobacco smoke (ETS) exposure is defined as exposure to smoke from tobacco products inside the home.

56

DATA AND DOCUMENTATION REQUIRED FOR WIC ASSESSMENT/CERTIFICATION

INFANTS

Data
Length
Weight
Hematocrit or Hemoglobin
Weight for Age Plotted
Length for Age Plotted
Weight for Length Plotted
Evaluation of Inappropriate Nutrition Practices
Risk Factor Assessment

Infant Certified in Hospital Prior to Initial Discharge

Documentation Infant

Birth Data or other measurement
Birth Data or other measurement

Required Required

N/A

Required

(9-12 months)

Optional

Required

Optional

Required

Optional

Required

Optional Required

Required Required

Infant Mid-Certification
Required Required Required (9-12 months) Required
Required
Required
Required
Required

57

NUTRITION RISK CRITERIA INFANTS

NOTE: High Risk Criteria, as defined below, are to be used for referral purposes, not certification (See Appendix A-2)
INFANTS

CODE

PRIORITY

201

LOW HEMOGLOBIN/HEMATOCRIT

I

Hemoglobin: 10.9 gm or lower (6-11 month old) Hematocrit: 32.8% or lower (6-11 month old)

High Risk: Hemoglobin OR Hematocrit at treatment level (Appendix B-2)

103

UNDERWEIGHT or AT RISK OF UNDERWEIGHT

I

Less than or equal to the 5th percentile weight-for-length as plotted on the CDC Birth to 24 months gender specific growth charts.*
High Risk: Less than or equal to the 2nd percentile weight-for-length as plotted on the CDC Birth to 24 months gender specific growth charts.*

*Based on 2006 World Health Organization international growth standards. For the Birth to < 24 months "underweight" definition, CDC labels the 2.3rd percentile as the 2nd percentile on the Birth to 24 months gender specific growth charts.

115

High Weight-for Length

Greater than or equal to the 98th percentile weight-for-length as plotted

on the Centers for Disease Control and Prevention (CDC), Birth to 24

months gender specific growth charts.

I

*Based on the 2006 World Health Organization (WHO) international growth standards. CDC labels the 97.7th percentile as the 98th percentile on the Birth to 24 months gender specific growth charts.

58

CODE

INFANTS

121

SHORT STATURE OR AT RISK OF SHORT STATURE

Less than or equal to the 5th percentile length-for-age as plotted on the CDC Birth to 24 months gender specific growth charts.*
(if < 38 weeks gestation use adjusted age)

High Risk: Less than or equal to the 2nd percentile length-for-age as plotted on the Centers for Disease Control and Prevention (CDC) Birth to 24 months gender specific growth charts.*
*Based on 2006 World Health Organization international growth standard. CDC labels the 2.3rd percentile as the 2nd percentile on the Birth to 24 months gender specific growth charts.

134

FAILURE TO THRIVE

Presence of failure to thrive diagnosed by a physician or health professional acting under standing orders of a physician.

Document: Diagnosis in the participant's health record

High Risk: Diagnosed failure to thrive

PRIORITY I
I

59

CODE 135

INFANTS

INADEQUATE GROWTH

An inadequate rate of weight gain as defined below:

Infants being certified during period from birth to 1 month of age:

Not back to birth weight by 2 weeks of age A gain of less than 19 ounces by 1 month of age

Infants being certified during period from 1 to 5 months of age:

This method (explained in Appendix C-3) is optional, if an infant 1 to 5 months of age qualifies for WIC based on any other risk criterion. If there is no other reason to qualify the infant, use this method to determine eligibility.

Infants 6 months to 12 months of age:

Age in Months at Certification

Weight Gain per 6-month interval*

5 mos - 6 mos >6 mos - 9 mos >9 mos - 12 mos

< 7 lbs
< 5 lbs
< 3 lbs

*Note: Use this chart only for infants who are > 5 months 2 weeks of age. Use only for an interval of 6 months +/- 2 weeks.

High Risk: Inadequate growth

PRIORITY I

141

LOW BIRTH WEIGHT

Birth weight < 5 lbs 8 oz (< 2500 g)

I

Document: Birth weight in participant's health record

High Risk: Birth weight < 5 lbs 8 oz (< 2500 g)

60

CODE 142

INFANTS
PREMATURITY Infant born at < 37 weeks gestation Document: Weeks gestation in participant's health record

PRIORITY I

151

Small for Gestational Age

Infants diagnosed as small for gestational age. I
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.

152

Low Head Circumference

I

Less than 2nd percentile head circumference-for-age as plotted on the Centers for Disease Control and Prevention (CDC) Birth to 24 months gender specific growth charts
(if < 38 weeks gestation use adjusted age)

* Based on 2006 World Health Organization international growth standards. CDC labels the 2.3rd percentile as the 2nd percentile on the Birth to 24 months gender specific growth charts.

153

LARGE FOR GESTATIONAL AGE

I

Birth weight > 9 lbs or presence of large for gestational age diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or health care professional working under standing orders of a physician.

Document: Weight(s) of infant in participant's health record.

61

CODE 211

INFANTS
ELEVATED BLOOD LEAD LEVELS Blood lead level of > 10 g/deciliter within the past 12 months. Document: Date of blood test and blood lead level in participant's health record. Must be within the past 12 months High Risk: Blood lead level of > 10 g/deciliter within the past 12 months.

NUTRITION RELATED MEDICAL CONDITIONS

341

NUTRIENT DEFICIENCY DISEASES

Diagnosis of clinical signs of nutritional deficiencies or a disease caused by insufficient dietary intake of macro or micro nutrients. Diseases include, but not limited to: protein energy malnutrition, hypocalcemia, cheilosis, scurvy, osteomalacia, menkes disease, rickets, Vitamin K deficiency, xerothalmia, beriberi, and pellagra. (See Appendix D)

Presence of nutrient deficiency diseases diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.
Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record

High Risk: Diagnosed nutrient deficiency disease

PRIORITY I
I

62

CODE 342

INFANTS
GASTRO-INTESTINAL DISORDERS

Diseases or conditions that interfere with the intake, digestion, and or absorption of nutrients. The diseases and/or conditions include, but are not limited to: Gastroesophageal reflux disease (GERD) Peptic ulcer Post-bariatric surgery Short bowel syndrome Inflammatory bowel disease, including ulcerative colitis or
Crohn's disease Liver disease Pancreatitis Biliary tract disease
The presence of gastro-intestinal disorders as 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.
Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed gastro-intestinal disorder

PRIORITY I

343

DIABETES MELLITUS

I

Diabetes mellitus consists of a group of metabolic diseases characterized by inappropriate hyperglycemia resulting from defects in insulin secretion, insulin action or both.

Presence of diabetes mellitus diagnosed, documented, or reported by a physician or someone working under a physician's orders, or as self reported by applicant/participant/caregiver.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed diabetes mellitus

63

CODE 344

INFANTS
THYROID DISORDERS
Thyroid dysfunctions that occur in fetal development and in childhood are caused by the abnormal secretion of thyroid hormones. The medical conditions include, but are not limited to, the following:

Congenital Hyperthyroidism: Excessive thyroid hormone levels at birth, either transient (due to maternal Grave's disease) or persistent (due to genetic mutation).
Congenital Hypothyroidism: Infants born with an under active thyroid gland and presumed to have had hypothyroidism inutero.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed thyroid disorder

345

HYPERTENSION

Presence of hypertension or prehypertension 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.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed hypertension

346

RENAL DISEASE

Any renal disease including pyelonephritis and persistent proteinuria,
but EXCLUDING urinary tract infections (UTI) involving the bladder. Presence of renal disease diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed renal disease

64

PRIORITY I
I I

CODE 347

INFANTS
CANCER
A chronic disease whereby populations of cells have acquired the ability to multiply and spread without the usual biologic restraints. The current condition, or the treatment for the condition, must be severe enough to affect nutritional status.
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.
Document: Description of how the condition or treatment affects nutritional status and the name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed cancer

348

CENTRAL NERVOUS SYSTEM DISORDERS

Conditions which affect energy requirements and may affect the individual's ability to feed self, that alter nutritional status metabolically, mechanically, or both. Includes, but is not limited to: epilepsy, cerebal palsy (CP), and neural tube defects (NTD) such as spina bifida and myelomeningocele.

Presence of a central nervous system disorder(s) diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed central nervous system disorder

PRIORITY I
I

65

CODE 349

INFANTS
GENETIC AND CONGENITAL DISORDERS
Hereditary or congenital condition at birth that causes physical or metabolic abnormality, or both. May include, but not limited to: cleft lip, cleft palate, thalassemia, sickle cell anemia, down's syndrome.
Presence of genetic and congenital disorders diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.
Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed genetic and congenital disorder

PRIORITY I

351

INBORN ERRORS OF METABOLISM

I

Gene mutations or gene deletions that alter metabolism in the body, including, but not limited to: phenylketonuria (PKU), maple syrup urine disease, galactosemia, hyperlipoproteinuria, homocystinuria, tyrosinemia, histidinemia, urea cycle disorder, glutaric aciduria, methylmalonic acidemia, glycogen storage disease, galactokinase deficiency, fructoaldase deficiency, propionic acidemia, hypermethioninemia.

Presence of inborn errors of metabolism diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or
health professional acting under standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed inborn error of metabolism

66

CODE 352

INFANTS
INFECTIOUS DISEASES
A disease caused by growth of pathogenic microorganisms in the body severe enough to affect nutritional status. Includes, but is not limited to: tuberculosis, pneumonia, meningitis, parasitic infection, hepatitis, bronchiolitis (3 episodes in last 6 months), HIV/AIDS.
The infectious disease MUST be present within the past 6 months and diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.
Document: Diagnosis, appropriate dates of each occurrence, and name of physician treating condition in the participant's health record. When using HIV/AIDS positive status as a Nutritionally Related Medical Condition, write "See Medical Record" for documentation purpose.
High Risk: Diagnosed infectious disease, as described above.

PRIORITY I

353

FOOD ALLERGIES

I

An adverse immune response to a food or a hypersensitivity that causes adverse immunologic reaction.

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.
Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed food allergy

67

CODE

INFANTS

354

CELIAC DISEASE

Also known as Celiac Sprue, Gluten Enteropathy, or Non-tropical Sprue.

Inflammatory condition of the small intestine precipitated by the ingestion of wheat in individuals with certain genetic make-up.

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.

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed Celiac Disease

PRIORITY I

355

LACTOSE INTOLERANCE

I

Lactose intolerance occurs when there is an insufficient production of the enzyme lactase. Lactase is needed to digest lactose. Lactose in dairy products that is not digested or absorbed is fermented in the small intestine producing any or all of the following GI disturbances: nausea, diarrhea, abdominal bloating, cramps. Lactose intolerance varies among and within individuals and ranges from mild to severe.
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.

Document: Diagnosis and the name of the physician that is treating
this condition in the participant's health record; OR list of symptoms described by the applicant/participant/caregiver (i.e., nausea, cramps, abdominal bloating, and/or diarrhea).

68

CODE 356

INFANTS
HYPOGLYCEMIA
Presence of hypoglycemia diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.
Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed hypoglycemia

PRIORITY I

357

DRUG/NUTRIENT INTERACTIONS

I

Use of prescription or over the counter drugs or medications that have been shown to interfere with nutrient intake or utilization, to an extent that nutritional status is compromised.

Document: Drug/medication being used and respective nutrient interaction in the participant's health record.

High Risk: Use of drug or medication shown to interfere with nutrient intake or utilization, to extent that nutritional status is compromised.

359

RECENT MAJOR SURGERY, TRAUMA, BURNS

I

Major surgery, trauma or burns severe enough to compromise nutritional status. Any occurrence within the past 2 months may be self reported, by caregiver. Any occurrence more than 2 months
previous MUST have the continued need for nutritional support diagnosed by a physician or health professional acting under standing orders of a physician.

Document: If occurred within the past 2 months, document surgery, trauma and/or burns in the participant's health record. If occurred more than 2 months ago, document description of how the surgery, trauma and/or burns currently affect nutritional status and include date.

High Risk: Major surgery, trauma or burns that has a continued need for nutritional support.

69

CODE 360

INFANTS
OTHER MEDICAL CONDITIONS
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. Including, but not limited to: juvenile rheumatoid arthritis (JRA), lupus erythematosus, cardiorespiratory diseases, heart disease, cystic fibrosis, moderate, Persistent Asthma (moderate or severe) requiring daily medication.
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.
Document: Specific medical condition; a description of how the disease, condition or treatment affects nutritional status and the name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed medical condition severe enough to compromise nutritional status.

PRIORITY I

362

DEVELOPMENTAL, SENSORY OR MOTOR DELAYS

I

INTERFERING WITH ABILITY TO EAT

Developmental, sensory or motor delays include but are not limited to: minimal brain function, feeding problems due to developmental delays, birth injury, head trauma, brain damage, other disabilities.

Presence of developmental, sensory or motor delay diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Specific condition/ description of delays and how these interfere with the ability to eat and the name of the physician that is treating this condition.

High Risk: Developmental, sensory or motor delay interfering with ability to eat.

70

CODE 381

INFANTS
DENTAL PROBLEMS
Diagnosis of dental problems by a physician or health care provider working under the orders of a physician or adequate documentation by the competent professional authority. Including but not limited to:
Presence of nursing bottle caries Smooth surface decay of the maxillary anterior and the primary
molars
Document: Description of how the dental problem interferes with mastication and/or has other nutritionally related health problems in the participant's health record.

PRIORITY I

382

FETAL ALCOHOL SYNDROME

I

Fetal Alcohol Syndrome (FAS) is based on the presence of retarded growth, a pattern of facial abnormalities and abnormalities of the central nervous system, including mental retardation.

Presence of FAS diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Diagnosis and name of physician treating the condition in the participant's health record.

High Risk: Diagnosed fetal alcohol syndrome

400

INAPPROPRIATE NUTRITION PRACTICES

IV

Routine nutrition practices that may result in impaired nutrient status, disease, or health problems. (Appendix G)

Document: Inappropriate Nutrition Practice(s) in the participant's health record.

71

CODE

INFANTS

428

Dietary Risk Associated with Complementary Feeding Practices

(Infants 4 to 12 months)

An infant 4 months of age who has begun to or is expected to
begin to do any of the following practices is considered to be at risk of inappropriate complementary feeding:

1) consume complementary foods and beverages, or 2) eat independently, or 3) be weaned from breast milk or infant formula, or 4) transition from a diet based on infant/toddler foods to one based on the Dietary Guidelines for Americans.

(This risk factor may be assigned only when an infant > 4 months of age does not qualify for risk 400 or for any other risk factor.)

PRIORITY IV

502

TRANSFER OF CERTIFICATION

Person with a current valid Verification of Certification (VOC) card from another state or local agency. The VOC card is valid until the certification period expires, and shall be accepted as proof of eligibility for program benefits. If the receiving local agency has waiting lists for participation, the transferring participant shall be placed on the list ahead of all other waiting applicants.

This criterion would be used primarily when the VOC card/document does not reflect another (more specific) nutrition risk condition at the time of transfer or if the participant was initially certified based on a nutrition risk condition not in use by the receiving State agency.

I, II, IV

72

CODE

INFANTS

603

BREASTFEEDING COMPLICATIONS OR POTENTIAL

COMPLICATIONS

Any of the following are considered complications or potential complications of breastfeeding:

Breastfed infant with jaundice Breastfed infant with weak or ineffective suck Breastfed infant with difficulty latching onto mother's breast Breastfed infant with inadequate stooling for age (as determined
by a physician or other health care provider)
Breastfed infant who wets diaper less than 6 times per day

Document: Complications or potential complications in the participant's health record.

High Risk: Refer to or provide the infant's mother with appropriate breastfeeding counseling.

PRIORITY I

701

INFANT UP TO 6 MONTHS OLD OF WIC MOTHER, OR OF A

II

WOMAN WHO WOULD HAVE BEEN ELIGIBLE DURING

PREGNANCY

An infant under 6 months of age whose mother was a WIC Program participant during pregnancy, OR
An infant whose mother's medical records document that the woman was at nutritional risk during pregnancy because of detrimental or abnormal nutrition conditions detectable by biochemical or anthropometric measurements or other
documented nutritionally related medical conditions.

702

BREASTFEEDING INFANT OF A WOMAN AT NUTRITIONAL RISK

A breastfed infant whose breastfeeding mother has been determined to be at nutritional risk.

Document: Mother's risks on infant's WIC Assessment/Certification Form

I, II, IV

73

CODE 703

INFANTS
INFANT BORN TO MOTHER WITH MENTAL RETARDATION, OR ALCOHOL OR DRUG ABUSE DURING MOST RECENT PREGNANCY
Infant born of a woman diagnosed with mental retardation by a physician or psychologist as self-reported by caregiver; or as reported by a physician, psychologist, or someone working under physician's orders; OR
Documentation or self-report of any use of alcohol or illegal drugs during most recent pregnancy.

PRIORITY I

801

HOMELESSNESS

Homelessness as defined in the Special Population Section of the

IV

Georgia WIC Procedures Manual.

802

MIGRANCY

IV

Migrancy as defined in the Special Population Section of the Georgia WIC Procedures Manual.

901

RECIPIENT OF ABUSE

Child abuse/neglect within past 6 months as self-reported by the

IV

caregiver, or as documented by a social worker, health care provider

or on other appropriate documents, or as reported through

consultation with a social worker, health care provider or other

appropriate personnel.

Child abuse/neglect refers to any recent act, or failure to act, resulting in:

Imminent risk or serious harm
Serious physical or emotional harm
Sexual abuse or exploitation of an infant or child by a parent or caretaker.

Georgia State law requires that medical and child service organization personnel, having reasonable cause to suspect child abuse, report these suspicions to the authority designated by the health district/organization.

74

CODE

INFANTS

902

PRIMARY CAREGIVER WITH LIMITED ABILITY TO MAKE

FEEDING DECISIONS AND/OR PREPARE FOOD

Infant whose primary caregiver is assessed to have limited ability to make appropriate feeding decisions and/or prepare food. Examples may include:

mental disability / delay and/or mental illness such as clinical depression (diagnosed by a physician or licensed psychologist)
physical disability which restricts or limits food preparation abilities
current use of or history of abusing alcohol or other drugs

Document: The caregivers limited abilities in the participant's health record.

903 Foster Care
Entering the foster care system during the previous six months or moving from one foster care home to another foster care home during the previous six months.

PRIORITY IV
IV

904

ENVIRONMENTAL TOBACCO SMOKE EXPOSURE

I

Environmental tobacco smoke (ETS) exposure is defined as exposure to smoke from tobacco products inside the home.

75

76

DATA AND DOCUMENTATION REQUIRED FOR WIC ASSESSMENT/CERTIFICATION
CHILDREN

Data
Length or Height Weight Hemoglobin or Hematocrit Weight/Age Plotted Length or Height/Age Plotted Weight/Length or BMI for Age Plotted Evaluation of Inappropriate Nutrition Practices Risk Factor Assessment

Certification

HalfCertification

Required

Required

Required

Required

Required

***

Required

Required

Required

Required

Required

Required

Required

Required

Required

Required

***Required when hemoglobin was low at most recent certification and for children less than 2 years old

77

NUTRITION RISK CRITERIA CHILDREN

NOTE: High Risk Criteria, as defined below, are to be used for referral purposes, not certification (See Appendix A-2)

CODE

CHILDREN

PRIORITY

201

LOW HEMOGLOBIN/HEMATOCRIT

III

12-23 months of age: Hemoglobin: 10.9 gm or lower Hematocrit: 32.8% or lower

24 months-5 years of age: Hemoglobin: 11.0 gm or lower Hematocrit: 32.9% or lower

High Risk: Hemoglobin OR Hematocrit at treatment level (Appendix B-2)

103

UNDERWEIGHT or AT RISK OF UNDERWEIGHT

III

(Children 12-24 Months of Age)

Less than or equal to the 5th percentile weight-for-length as plotted on

the CDC 12 to 24 months gender specific growth charts.*

High Risk: Less than or equal to the 2nd percentile weight-for-length as plotted on the CDC Birth to 24 months gender specific growth charts.*

*Based on 2006 World Health Organization international growth standards. For the Birth to < 24 months "underweight" definition, CDC labels the 2.3rd percentile as the 2nd percentile on the Birth to 24 months gender specific growth charts.

UNDERWEIGHT or AT RISK OF UNDERWEIGHT (Children 2-5 Years of Age) Less than or equal to the 10th percentile Body Mass Index (BMI) for age based on Centers for Disease Control and Prevention (CDC) age/sex specific growth charts.
High Risk: Less than or equal to the 5th percentile Body Mass Index (BMI)-for-age as plotted on the 2000 CDC age/gender specific growth charts.

78

CODE 113
114

CHILDREN
OBESE (Children 2-5 Years of Age)
Greater than or equal to 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
High Risk: Greater than or equal to 95th percentile BMI or weight-forstature as plotted on the 2000 Centers for Disease Control and Prevention (CDC) 2-20 years gender specific growth charts
OVERWEIGHT (Children 2-5 Years of Age)
Greater than or equal to 85th and less than 95th percentile Body Mass Index (BMI)-for-age or weight-for-stature as plotted on the 2000 Centers for Disease Control and Prevention (CDC) 2-20 years gender specific growth charts.*
* The cut off is based on standing height measurements. Therefore, recumbent length measurements may not be used to determine this risk.

115

High Weight-for-Length (Children 12-24 Months of Age)

Greater than or equal to the 98th percentile weight-for-length as plotted on the Centers for Disease Control and Prevention (CDC), Birth to 24 months gender specific growth charts.*

*Based on the 2006 World Health Organization (WHO) international growth standards. CDC labels the 97.7th percentile as the 98th percentile on the Birth to 24 months gender specific growth charts.

PRIORITY III III
III

79

CODE

CHILDREN

121

SHORT STATURE OR AT RISK OF SHORT STATURE

(Children 12-24 Months of Age)

Less than or equal to the 5th percentile length-for-age as plotted on the CDC Birth to 24 months gender specific growth charts(1).*
(if < 38 weeks gestation use adjusted age)

High Risk: Less than or equal to the 2nd percentile length-for-age as plotted on the Centers for Disease Control and Prevention (CDC) Birth to 24 months gender specific growth charts.*
*Based on 2006 World Health Organization international growth standards. CDC labels the 2.3rd percentile as the 2nd percentile on the Birth to 24 months gender specific growth charts.

PRIORITY III

SHORT STATURE OR AT RISK OF SHORT STATURE (Children 2-5 Years of Age)
Less than or equal to the 10th percentile length or height for age based on CDC age/sex specific growth charts.
High Risk: Less than or equal to the 5th percentile stature-for-age as plotted on the 2000 CDC age/gender specific growth charts

134

FAILURE TO THRIVE

III

Presence of failure to thrive diagnosed by a physician or health professional acting under standing orders of a physician.

Document: Diagnosis in participant's health record. High Risk: Diagnosed failure to thrive

80

CODE

CHILDREN

135

INADEQUATE GROWTH

A low rate of weight gain over a six-month period as defined by the following chart:

Age in Months at Certification

Weight Gain in previous 6-month interval*

12 months >12 - 60 months

< 3 pounds < 1 pound

*Note: Use only for an interval of 6 months +/- 2 weeks.

High Risk: Inadequate growth

141

LOW BIRTH WEIGHT (children < 24 months of age)

Birth weight < 5 lbs 8 oz (< 2500 g)

Document: Birth weight of participant in health record.

142

PREMATURITY (Children < 24 months of age)

Born at 37 weeks gestation or less

Document: Weeks gestation in participant's health record.

151

Small for Gestational Age (Children 12-24 Months of Age)

Children less than 24 months of age diagnosed as small for gestational age.

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.

PRIORITY III
III III III

81

CODE

CHILDREN

152

Low Head Circumference (Children 12-24 Months of Age)

Less than 2nd percentile head circumference-for-age as plotted on the Centers for Disease Control and Prevention (CDC) Birth to 24 months gender specific growth charts
(if < 38 weeks gestation use adjusted age)

* Based on 2006 World Health Organization international growth standards. CDC labels the 2.3rd percentile as the 2nd percentile on the Birth to 24 months gender specific growth charts.

211

ELEVATED BLOOD LEAD LEVELS

Blood lead level of >10 g/deciliter within the past 12 months.

Document: Date of blood test and blood lead level in participant's health record. Must be within the past 12 months.

High Risk: Blood lead level of >10 g/deciliter within the past 12 months.

PRIORITY III III

NUTRITION RELATED MEDICAL CONDITIONS

III

341

NUTRIENT DEFICIENCY DISEASES

Diagnosis of clinical signs of nutritional deficiencies or a disease caused by insufficient dietary intake of macro or micronutrients. Diseases include, but not limited to: protein energy malnutrition, hypocalcemia, cheilosis, scurvy, osteomalacia, menkes disease, rickets, Vitamin K deficiency, xerothalmia, beriberi, and pellagra. (See Appendix D)

Presence of nutrient deficiency diseases diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition participant's health record.

High Risk: Diagnosed nutrient deficiency disease

82

CODE
342

CHILDREN
GASTRO-INTESTINAL DISORDERS
Diseases or conditions that interfere with the intake, digestion, and or absorption of nutrients. The diseases and/or conditions include, but are not limited to: Gastroesophageal reflux disease (GERD) Peptic ulcer Post-bariatric surgery Short bowel syndrome Inflammatory bowel disease, including ulcerative colitis or
Crohn's disease Liver disease Pancreatitis Biliary tract disease
The presence of gastro-intestinal disorders as 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.
Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed gastro-intestinal disorder

PRIORITY III

343

DIABETES MELLITUS

III

Diabetes mellitus consists of a group of metabolic diseases characterized by inappropriate hyperglycemia resulting from defects in insulin secretion, insulin action or both.

Presence of diabetes mellitus diagnosed, documented, or reported by a physician or someone working under a physician's orders, or as self reported by applicant/participant/caregiver.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed diabetes mellitus

83

CODE
344

CHILDREN
THYROID DISORDERS Thyroid dysfunctions that occur in fetal development and in childhood are caused by the abnormal secretion of thyroid hormones. The medical conditions include, but are not limited to, the following:

Hyperthyroidism: Excessive thyroid hormone production (most commonly known as Graves' disease and toxic multinodular goiter).
Hyporthyroidism: Low secretion levels of thyroid hormone (can be overt or mild/subclinical). Most commonly seen as chronic autoimmune thyroiditis (Hashimoto's thyroiditis or autoimmune thyroid disease). It can also be caused by severe iodine deficiency.
Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed thyroid disorder

PRIORITY III

345

HYPERTENSION

III
Presence of hypertension or prehypertension 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.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed hypertension

346

RENAL DISEASE

III

Any renal disease including pyelonephritis and persistent proteinuria,
but EXCLUDING urinary tract infections (UTI) involving the bladder. Presence of renal disease diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition participant's health record.

High Risk: Diagnosed renal disease

84

CODE
347

CHILDREN
CANCER
A chronic disease whereby populations of cells have acquired the ability to multiply and spread without the usual biologic restraints. The current condition, or the treatment for the condition, must be severe enough to affect nutritional status.
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.
Document: Description of how the condition or treatment affects nutritional status and name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed cancer

PRIORITY III

348

CENTRAL NERVOUS SYSTEM DISORDERS

III

Conditions which affect energy requirements and may affect the individual's ability to feed self, that alter nutritional status metabolically, mechanically, or both. Includes, but is not limited to: epilepsy, cerebal palsy (CP), and neural tube defects (NTD) such as spina bifida and myelomeningocele.

Presence of a central nervous system disorder(s) diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed central nervous system disorder

85

CODE
349

CHILDREN
GENETIC AND CONGENITAL DISORDERS
Hereditary or congenital condition at birth that causes physical or metabolic abnormality, or both. May include, but not limited to: cleft lip, cleft palate, thalassemia, sickle cell anemia, down's syndrome.
Presence of genetic and congenital disorders diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of
a physician.
Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed genetic and congenital disorder

PRIORITY III

351

INBORN ERRORS OF METABOLISM

III

Gene mutations or gene deletions that alter metabolism in the body, including, but not limited to: phenylketonuria (PKU), maple syrup urine disease, galactosemia, hyperlipoproteinuria, homocystinuria, tyrosinemia, histidinemia, urea cycle disorder, glutaric aciduria, methylmalonic acidemia, glycogen storage disease, galactokinase deficiency, fructoaldase deficiency, propionic acidemia, hypermethioninemia.

Presence of inborn errors of metabolism diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed inborn error of metabolism

86

CODE
352

CHILDREN
INFECTIOUS DISEASES
A disease caused by growth of pathogenic microorganisms in the body severe enough to affect nutritional status. Includes, but is not limited to: tuberculosis, pneumonia, meningitis, parasitic infection, hepatitis, bronchiolitis (3 episodes in last 6 months), HIV/AIDS.
The infectious disease MUST be present within the past 6 months and diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting
under standing orders of a physician.
Document: Diagnosis, and approximate dates of each occurrence, and name of the physician that is treating this condition in the participant's health record. When using HIV/AIDS positive status as a Nutritionally Related Medical Condition, write "See Medical Record" for documentation purpose.
High Risk: Diagnosed infectious disease, as described above.

353

FOOD ALLERGIES

An adverse immune response to a food or a hypersensitivity that causes adverse immunologic reaction.

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.
Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed food allergy

PRIORITY III
III

87

CODE

CHILDREN

354

CELIAC DISEASE

Also known as Celiac Sprue, Gluten Enteropathy, or Non-tropical Sprue.

Inflammatory condition of the small intestine precipitated by the ingestion of wheat in individuals with certain genetic make-up.

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.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed Celiac Disease

PRIORITY III

355

LACTOSE INTOLERANCE

III Lactose intolerance occurs when there is an insufficient production of the enzyme lactase. Lactase is needed to digest lactose. Lactose in dairy products that is not digested or absorbed is fermented in the small intestine producing any or all of the following GI disturbances: nausea, diarrhea, abdominal bloating, cramps. Lactose intolerance varies among and within individuals and ranges from mild to severe.

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.

Document: Diagnosis and the name of the physician that is treating
this condition in the participant's health record; OR list of symptoms described by the applicant/participant/caregiver (i.e., nausea, cramps, abdominal bloating, and/or diarrhea).

88

CODE
356

CHILDREN
HYPOGLYCEMIA
Presence of hypoglycemia diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.
Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed hypoglycemia

PRIORITY III

357

DRUG/NUTRIENT INTERACTIONS

III

Use of prescription or over the counter drugs or medications that have been shown to interfere with nutrient intake or utilization, to an extent that nutritional status is compromised.

Document: Drug/medication being used and respective nutrient interaction in the participant's health record.

High Risk: Use of drug and medication shown to interfere with nutrient intake or utilization, to extent that nutritional status is compromised.

359

RECENT MAJOR SURGERY, TRAUMA, BURNS

III

Major surgery, trauma or burns severe enough to compromise nutritional status. Any occurrence within the past 2 months may be self reported by caregiver. Any occurrence more than 2 months
previous MUST have the continued need for nutritional support diagnosed by a physician or health professional acting under standing orders of a physician.

Document: If occurred within the past 2 months, document surgery, trauma and/or burns in the participant's health record. If occurred more than 2 months ago, document description of how the surgery, trauma and/or burns currently affects nutritional status and include date.

High Risk: Major surgery, trauma or burns that has a continued need for nutritional support.

89

CODE

CHILDREN

360

OTHER MEDICAL CONDITIONS

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. Including, but not limited to: juvenile rheumatoid arthritis (JRA), lupus erythematosus, cardiorespiratory diseases, heart disease, cystic fibrosis, moderate, Persistent Asthma (moderate or severe) requiring daily medication.

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.

Document: Specific medical condition; a description of how the disease, condition or treatment affects nutritional status and name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed medical condition severe enough to compromise nutritional status.

361

DEPRESSION

Presence of depression diagnosed by a physician or psychologist as self reported by applicant/participant/caregiver; or as reported or documented by a physician, psychologist or health care provider working under the orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in participant's health record.

PRIORITY III
III

90

CODE
362

CHILDREN
DEVELOPMENTAL, SENSORY OR MOTOR DELAYS INTERFERING WITH ABILITY TO EAT
Developmental, sensory or motor delays include but are not limited to: minimal brain function, feeding problems due to developmental delays, birth injury, head trauma, brain damage, other disabilities.
Presence of developmental, sensory or motor delay diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.
Document: Specific condition/description of the delay and how it interferes with the ability to eat, and the name of the physician that is treating this condition in the participant's health record.
High Risk: Developmental, sensory or motor delay interfering with ability to eat.

PRIORITY III

381

DENTAL PROBLEMS

III

Diagnosis of dental problems by a physician or health professional working under standing orders of a physician or adequate documentation by the competent professional authority. Including but not limited to:

Presence of nursing bottle caries
Smooth surface decay of the maxillary anterior and the primary molars

Document: In the participant's health record, a description of how the dental problem interferes with mastication and/or has other nutritionally related health problems.

91

CODE
382

CHILDREN
FETAL ALCOHOL SYNDROME
Fetal Alcohol Syndrome (FAS) is based on the presence of retarded growth, a pattern of facial abnormalities and abnormalities of the central nervous system, including mental retardation. Presence of FAS diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or health professional acting under standing orders of a physician.
Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed fetal alcohol syndrome

PRIORITY III

400

INAPPROPRIATE NUTRITION PRACTICES

V

Routine nutrition practices that may result in impaired nutrient status,
disease, or health problems. (Appendix G)

Document: Inappropriate Nutrition Practice(s) in the participant's health record.

401

FAILURE TO MEET DIETARY GUIDELINES FOR

AMERICANS

V

(Children 2-5 Years of Age)

A child who meets eligibility requirements based on category, income, and residency but who does not have any other identified nutritional risk factor may be presumed to be at nutritional risk based on failure to meet the Dietary Guidelines for Americans.
(This risk factor may be assigned only when a child does not qualify for risk 400 or for any other risk factor.)

92

CODE 428

CHILDREN
DIETARY RISK ASSOCIATED WITH COMPLEMENTARY FEEDING PRACTICES
(Children 12-24 Months of Age)
A child who has begun to or is expected to begin to do any of the following practices is considered to be at risk of inappropriate complementary feeding:
1) consume complementary foods and beverages, or 2) eat independently, or 3) be weaned from breast milk or infant formula, or 4) transition from a diet based on infant/toddler foods to one based on the Dietary Guidelines for Americans.
(This risk factor may be assigned only when a child does not qualify for risk 400 or for any other risk factor.)

PRIORITY V

502

TRANSFER OF CERTIFICATION

Person with a current valid Verification of Certification (VOC) card from another state or local agency. The VOC card is valid until the certification period expires, and shall be accepted as proof of eligibility for program benefits. If the receiving local agency has waiting lists for participation, the transferring participant shall be placed on the list ahead of all other waiting applicants

This criterion would be used primarily when the VOC card/document does not reflect another (more specific) nutrition risk condition at the time of transfer or if the participant was initially certified based on a nutrition risk condition not in use by the receiving State agency.

III, V

801

HOMELESSNESS

Homelessness as defined in the Special Population Section of the

V

Georgia WIC Procedures Manual.

802

MIGRANCY

V

Migrancy as defined in the Special Population Section of the Georgia WIC Procedures Manual.

93

CODE

CHILDREN

901

RECIPIENT OF ABUSE

Child abuse/neglect within past 6 months as self-reported by the caregiver, or as documented by a social worker, health care provider or on other appropriate documents, or as reported through consultation with a social worker, health care provider or other appropriate personnel.

Child abuse/neglect refers to any recent act, or failure to act, resulting in:



Imminent risk or serious harm



Serious physical or emotional harm



Sexual abuse or exploitation of an infant or child by a

parent or caretaker.

Georgia State law requires that medical and child service organization personnel, having reasonable cause to suspect child abuse, report these suspicions to the authority designated by the health district/organization.

PRIORITY V

902

PRIMARY CAREGIVER WITH LIMITED ABILITY TO MAKE

V

FEEDING DECISIONS AND/OR PREPARE FOOD

Child whose primary caregiver is assessed to have limited ability to make appropriate feeding decisions and/or prepare food. Examples may include:

mental disability / delay and/or mental illness such as clinical depression (diagnosed by a physician or licensed psychologist)
physical disability which restricts or limits food preparation abilities
current use of or history of abusing alcohol or other drugs

Document: The caregiver's limited abilities in the participant's health record.

94

CODE
903

CHILDREN
Foster Care Entering the foster care system during the previous six months or moving from one foster care home to another foster care home during the previous six months.

PRIORITY V

904

ENVIRONMENTAL TOBACCO SMOKE EXPOSURE

III

Environmental tobacco smoke (ETS) exposure is defined as exposure to smoke from tobacco products inside the home.

95

96

TABLE OF APPENDICES

APPENDICES REFERENCED IN RISK CRITERIA SECTION

Appendix

A-1

WIC Maternal High Risk Criteria..................................................

Page 99

A-2

WIC High Risk Criteria for Infants and Children.............................. 100

B-1

Women's Health Recommended Guidelines for Iron Supplementation, Based on Treatment Values............................... 101

B-2

Child Health Recommended Guidelines for Iron Supplementation,

Based on Treatment Values....................................................... 102

C-1

Body Mass Index (BMI) Table for Determining Weight

Classification for Women........................................................... 103

C-2

Definition of Maternal Weight Gain (Low, High, and Multi-Fetal).........

104

C-3

Definition of Inadequate Growth for Infants 1-6 Months of Age........... 105

D

Physical Signs Suggestive of Nutrient Deficiencies.......................... 106

E-1

Alcohol and Cigarettes............................................................... 108

E-2

Common Names of Illegal (Street) Drugs/Drugs of Abuse.................................................................................... 109

F

Recommended Food Intake Patterns........................................... 110

G

Inappropriate Nutrition Practices................................................

111

H

Products Containing Caffeine...................................................... 116

I

Instructions for Use of the Prenatal Weight Gain Grid......................

118

J-1

Measuring Length..................................................................... 119

J-2

Measuring Weight ("Infant" Scale)................................................ 120

J-3

Measuring Height...................................................................... 121

J-4

Measuring Weight (Standing)...................................................... 122

K

Instructions for Use of the Growth Charts.....................................

123

L

Use and Interpretation of the Growth Charts.................................. 127

97

APPENDICES PROVIDED FOR SUPPLEMENTAL INFORMATION

Appendix

Page

M

Food Sources of Vitamin A......................................................... 128

N

Food Sources of Vitamin C......................................................... 129

O

Food Sources of Folate............................................................. 130

P

Food Sources of Iron................................................................. 131

Q

Food Source of Calcium............................................................ 132

R

Herbs: Their Use and Potential Risks........................................... 133

S

Key for Entering Weeks Breastfed............................................... 134

T

Infant Formula Preparation......................................................... 135

U-1

Conversion Tables and Equivalents............................................. 138

U-2

Approximate Metric and Imperial Equivalents................................. 139

98

WIC MATERNAL HIGH RISK CRITERIA

Appendix A-1

Any WIC prenatal, breastfeeding, or non-breastfeeding woman who has the following high risk factors must receive nutrition counseling specific to their nutritional condition and to the nutritional problems identified in their diet, as reflected in an individual care plan. In most instances, this counseling should be provided by a nutritionist. However, if the CPA determines that some other intervention or referral would be more appropriate, adequate documentation must be provided.

High Risk Criteria Hemoglobin or hematocrit at treatment level

Risk Code 201

Underweight

Prenatal Women: Body Mass Index <18.5

101

Postpartum Women: Body Mass Index <18.5

Overweight

Prenatal Women: Body Mass Index >29.9

111

Postpartum Women: Current Body Mass Index >29.9

Low maternal weight gain

131

Gestational weight loss during pregnancy greater than or equal to 2 pounds in the second and third trimester.

132

Blood lead level > 10 g/dl within the past 12 months.

211

Hyperemesis Gravidarum

301

Gestational diabetes

302

EDC or delivery prior to 17th birthday

331

Multi-fetal gestation

335

Fetal Growth Restriction

336

Nutrition-related medical conditions; presence of any disease or condition affecting nutritional status that requires a therapeutic diet as ordered by a physician or health professional acting under standing orders of a physician
Diagnosed pre-diabetes
Breastfeeding complications; referral to appropriate BF counselor must be made
Any condition deemed by the competent professional authority to place the woman at high risk for compromised nutritional status; adequate documentation required

341-349; 351-358, 360; 362
363
602

Appendix
B-1
C-1 Body Mass Index Tables
C-1 Body Mass Index Tables
C-2

99

Appendix A-2
WIC HIGH RISK CRITERIA FOR INFANTS AND CHILDREN
WIC infants and children who have the following high risk factors must receive nutrition counseling specific to their nutritional condition and to the nutritional problems identified in their diet, as reflected in an individual care plan. In most instances, this counseling should be provided by a nutritionist. However, if the CPA determines that some other intervention or referral would be more appropriate, adequate documentation must be provided.

High Risk Criteria
Hemoglobin or hematocrit at treatment level
Underweight or At Risk of Underweight (Infants and Children) Infants <12 Months of Age: Weight for length < 2nd percentile Children <24 Months of Age: Weight for length < 2nd percentile Children 2-5 Years of Age: BMI for age <5th percentile OBESE (Children 2-5 Years of Age) Body Mass Index for age >95th %

Risk Code 201 103
113

Appendix B-2

Short stature

Infants <12 Months of Age: Length-for-age < 2nd percentile

121

Children <24 Months of Age: Weight for length < 2nd percentile

Children 2-5 Years of Age: BMI for age <5th percentile

Failure to thrive

134

Inadequate growth

135

Low birthweight infant (infant weighing 2500 grams [5 pounds] or

less at birth). May only be used for infants as high risk criteria.

141

Blood lead level > 10g/dl within the past 12 months.

211

Nutrition-related medical conditions; presence of any disease or condition affecting nutritional status that requires a therapeutic diet or special prescribed formula as ordered by a physician or health professional acting under standing orders of a physician

341-357; 360; 362; 382

Breastfeeding complications; infants only; referral to appropriate BF

counselor must be made

603

Any condition deemed by the competent professional authority to place the infant/child at high risk for compromised nutritional status; adequate documentation required

100

Appendix B-1
WOMEN'S HEALTH RECOMMENDED GUIDELINES FOR IRON SUPPLEMENTATION
BASED ON TREATMENT VALUES

Hemoglobin

Hematocrit

Treatment Value

Treatment Value

NonSmokers

Smokers

NonSmokers

Smokers

Prenatal Woman 1st Trimester 3rd Trimester

10.9 gm or lower

11.2 gm or lower

32.9% or lower

33.9% or lower

Prenatal Woman 2nd Trimester

10.4 gm or lower

10.7 gm or lower

31.9% or lower

32.9% or lower

Non-Pregnant and/or Lactating Woman (<15 years of age)

11.7 gm or lower

12.0 gm or lower

35.8% or lower

36.8% or lower

Non-Pregnant and/or Lactating Woman (>15 years of age)

11.9 gm or lower

12.2 gm or lower

35.8% or lower

36.8% or lower

For Prenatal Women: Begin routine supplementation of a prenatal vitamin and mineral supplement to include 27-30 mg/day of elemental iron for all pregnant women at the 1st prenatal visit. For women with hemoglobin/hematocrit levels within the treatment value, treat anemia with a therapeutic dose of 60-120 mg of elemental iron/day.

NOTE: If a woman is taking a prenatal or other multi-vitamin and mineral supplement with iron, the prenatal or multivitamin and mineral supplement + iron supplement should equal a total of 60-120 mg elemental iron/day. When the hemoglobin/hematocrit reaches the acceptable value for the specific stage pregnancy, decrease iron dosage to 30 mg/day

PHYSICIAN REFERRAL: Hemoglobin less than 9.0 g/dL or hematocrit less than 27.0% Hemoglobin more than 15.0 g/dL or hematocrit more than 45.0% (2nd and 3rd trimester) If after 4 weeks the hemoglobin does not increase by 1 g/dL or hematocrit by 3%, despite compliance with iron
supplementation regimen and the absence of acute illness

For Non-Pregnant/Lactating Women: For women with hemoglobin/hematocrit levels within the treatment value, treat anemia with a therapeutic dose of 60120 mg of elemental iron/day.

NOTE: If a woman is taking a prenatal or other multi-vitamin and mineral supplement with iron, the prenatal or multi-vitamin and mineral supplement + iron supplement should equal a total of 60-120 mg elemental iron/day.

PHYSICIAN REFERRAL: Hemoglobin less than 9.0 g/dL or hematocrit less than 27.0% If after 4 weeks the hemoglobin does not increase by 1 g/dL or hematocrit by 3%, despite compliance with iron
supplementation regimen and the absence of acute illness

After 4 weeks, if the hemoglobin increases > 1g/dl or if the hematocrit increases > 3 %, continue treatment for 2-3 more months.
Reference: CDC/MMWR: April 3, 1998. Recommendations to Prevent and Control Iron Deficiency in the United States

101

Appendix B-2
CHILD HEALTH RECOMMENDED GUIDELINES FOR IRON SUPPLEMENTATION BASED ON TREATMENT VALUES

Hemoglobin Treatment
Value

Hematocrit Treatment
Value

Treatment Regimen

Infant 6 through 11 months

10.9 gm or lower

32.8% or lower

Dosage: 0.6 cc Ferrous Sulfate Drops BID Mg Elemental Iron: 15 mg BID

Child 12 through 23 months

10.9 gm or lower

32.8% or lower

Dosage: 0.6 cc Ferrous Sulfate Drops BID Mg Elemental Iron: 15 mg BID

Child 2 through 5 years

11.0 gm or lower

32.9% or lower

Dosage: 1.2 cc Ferrous Sulfate Drops BID Mg Elemental Iron: 30mg BID

Premature and low birth weight infants, infants of multiple births, and infants with suspected blood losses should be screened before 6 months of age, preferably at 6-8 weeks postnatal.
Routine screening for iron deficiency anemia is not recommended in the first 6 months of life.
Treatment of iron deficiency anemia is 3 mg per kilogram per day.
Refer to the package insert of iron preparation to correctly calculate the appropriate dosage of elemental iron. Most pediatric chewable preparations (i.e., Feostat, 100 mg) contain 33 mg elemental iron per tablet as ferrous fumarate. Non-chewable preparations for older patients (i.e., Feosol, 300 mg) contain 60-65 mg per tablet or capsule elemental iron as ferrous sulfate.

Sources: Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, April 3, 1998/Vol.47/No. RR-3.
Nutrition Guidelines for Practice: A Manual for Providing Quality Nutrition Services. Nutrition Section, 1997.

102

Appendix C-1

Body Mass Index (BMI) Table for Determining Weight Classification for (Women) 1

Height (Inches)

Underweight BMI <18.5

Normal Weight BMI 18.5-24.9

Overweight BMI 25.0-29.9

Obese BMI >29.9

58"

<89

89-118

119-142

>142

59"

<92

92-123

124-147

>147

60"

<95

95-127

128-152

>152

61"

<98

98-131

132-157

>157

62"

<101

101-135

136-163

>163

63"

<105

105-140

141-168

>168

64"

<108

108-144

145-173

>173

65"

<111

111-149

150-179

>179

66"

<115

115-154

155-185

>185

67"

<118

118-158

159-190

>190

68"

<122

122-163

164-196

>196

69"

<125

125-168

169-202

>202

70"

<129

129-173

174-208

>208

71"

<133

133-178

179-214

>214

72"

<137

137-183

184-220

>220

1Adapted from Institute Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults. National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health (NIH). NIH Publication No. 98-4083.

*These calculations are based on estimated height and weights; your system will calculate a more exact BMI based on actual height and weights including fractional ounces and inches.

103

Appendix C-2

Definition of Weight Gain (Women)
Total Weight Gain Range (lbs)

Prepregnancy Weight Groups
Underweight Normal Weight
Overweight Obese

Singleton Pregnancy

Definition Low Maternal Recommended

(BMI)

Weight Gain Weight Gain

High Maternal Weight Gain

< 18.5

<28

18.5 to 24.9

<25

25.0 to 29.9

<15

> 30.0

<11

28-40 25-35 15-25 11-20

> 40 > 35 > 25 > 20

Prepregnancy Weight Groups
Underweight
Normal Weight Overweight Obese

Multi-Fetal Weight Gain

Definition Low Maternal Recommended

(BMI)

Weight Gain Weight Gain

High Maternal Weight Gain

< 18.5
18.5 to 24.9 25.0 to 29.9
> 30.0

There was insufficient information for the IOM committee to develop provisional guidelines for underweight woman
with multiple fetuses.
<37
<31
<25

1.5lbs/week during 2nd and 3rd trimesters
37-54 31-50 25-42

There was insufficient information for the IOM committee to develop provisional guidelines for underweight woman with multiple fetuses.
> 54 > 50 > 42

104

Appendix C-3

Definition of Inadequate Growth for Infants 1-6 Months of Age

Inadequate growth for infants between 1 and 6 months of age is based on two weight measurements taken at least 1 month (4.3 weeks) apart, using the following guidelines:

Age
1 month 1-2 months 2-3 months 3-4 months 4-5 months 5-6 months

Minimum Acceptable
Weight Gain
19 oz 27 oz/month (6 oz/wk) 19 oz/month (4 oz/wk) 17 oz/month (4 oz/wk) 15 oz/month (3 oz/wk) 13 oz/month (3 oz/wk)

Example:

Date of Measurement 09/13/98 (birth) 10/26/98 (6 weeks, 1 day old)

Weight 7 lbs 6 oz 9 lbs 3 oz

1. Calculate infant's age:

98 - 98

10

26

09

13

01 mo 13 days = 1 month + 1 week + 6 days = about 1 mo + 2 wks

2. Calculate minimum acceptable weight gain:

1st month minimum acceptable weight = 19 oz 1-2 months minimum acceptable weight/wk = 6 oz (2x 6 = 12 oz) Total acceptable weight = 19 oz + 12 oz = 31 oz = 1 lb 15 oz

3. Compare actual weight gain (1 lb 13 oz) to acceptable minimum (1 lb 15 oz). This infant's weight gain is below acceptable minimum, so you can apply the criterion for inadequate growth.

105

Appendix D PHYSICAL SIGNS SUGGESTIVE OF NUTRIENT DEFICIENCIES

Body Area Hair Eyes
Lips
Gums Tongue
Face and Neck

Normal Appearance

Signs Suggestive of Nutrient Deficiency(ies)

Nutrient Consideration(s)

shiny; firm; not easily plucked
bright; clear; shiny; no sores at corners of eyelids;

lack of natural shine; dull; thin; loss of curl; color changes (flag sign); easily plucked
eye membranes pale;

inadequate protein and calories
anemia (inadequate iron, folacin, or vitamin B-12)

membranes healthy pink and moist; no prominent blood vessels

Bitot's spots; red membranes; dryness of membranes; dull appearance of cornea (cornea xerosis); softening of cornea (keratomalacia);

inadequate Vitamin A

smooth; not chapped or swollen

redness and fissuring of eyelid corners
redness or swelling of mouth or lips (cheilosis); bilateral cracks, white or pink lesions at corners of mouth (angular stomatitis) and/or scars

inadequate riboflavin, Vitamin B-6, and niacin
inadequate niacin and riboflavin
inadequate riboflavin, niacin, iron and Vitamin B-6

healthy, red; do not bleed; not swollen
deep red; not swollen or smooth

spongy; bleeding; receding scarlet; raw; edematous (glossitis)

inadequate ascorbic acid
inadequate niacin, riboflavin, folacin, iron, Vitamins B-6 and B-12

purplish color (magenta);

inadequate riboflavin

smooth; pale; slick; atrophied taste buds (papillae)

inadequate folacin, Vitamin B-12, iron and niacin

skin color uniform, smooth, pink; healthy appearing; not swollen

diffuse depigmentation; darkening of skin over cheeks and under eyes;

inadequate protein
inadequate calories and niacin

scaling of skin around nostrils (nasolabial seborrhea)

inadequate riboflavin, niacin, and Vitamin B-6

swollen (moon) face;

inadequate protein

front of neck swollen (thyroid enlargement);

inadequate protein; inadequate iodine

swollen cheeks (bilateral parotid enlargement)

inadequate protein

106

Appendix D (cont.) PHYSICAL SIGNS SUGGESTIVE OF NUTRIENT DEFICIENCIES

Body Area Skin
Teeth
Head / Neck Nails Muscular and Skeletal Systems

Normal Appearance no signs of swelling rashes, dark or light spots
no cavities, no pain, bright
face not swollen firm, pink good muscle tone; some fat under skin; can walk or run without pain

Signs Suggestive of Nutrient Deficiency(ies)
dry and scaly (xerosis); sandpaper-like feel (follicular hyperkeratosis);
pinhead-size purplish skin hemorrhages (petechiae);
excessive bruising;
red, swollen pigmentation of areas exposed to sunlight (pellagrous dermatitis);
extensive lightness and darkness of skin (flaky, pressure sores(decubiti)
may be some missing or erupting abnormally; gray or black spots (fluorosis); cavities (caries) [signs are to be severe enough to interfere with mastication and/or other health implications]*
thyroid enlargement (front of neck); parotid enlargement (cheeks become swollen)
nails are spoon-shaped (koilonychia); brittle ridged nails, pale nail beds
muscles have "wasted" appearance; baby's skull bones are thin and soft (craniotabes); round swelling of front and side of head (frontal and parietal bossing); swelling of ends of bones (epiphyseal enlargement); small bumps on both sides of chest wall (on ribs); beading of ribs; baby's soft spot on head does not harden at proper time (persistently open anterior fontanelle); knock-knees or bow-legs; bleeding into muscle (musculoskeletal hemorrhages); person cannot get up or walk properly

Nutrient Consideration(s)
Inadequate Vitamin A or Essential fatty acids
Inadequate Vitamin C
Inadequate Vitamin K
Inadequate niacin and Tryptophan
Inadequate protein, Vitamin C, and zinc
Inadequate Vitamin D and Vitamin A
Inadequate iodine; inadequate protein
Inadequate iron; Vitamin A toxicity
Inadequate protein Inadequate thiamin Inadequate Vitamin D

Sources: 1. American Journal of Public Health, Supplement, November 1973, p. 19. 2. Georgia Dietetic Association Diet Manual, 1992.

107

ALCOHOL AND CIGARETTES

Appendix E-1

Alcohol Equivalents:

One serving of alcohol

=

12 ounces of beer (light or regular);

12 ounces of wine cooler;

5 ounces of wine (light or regular);

1 1/2 ounces of liquor.

Key for Entering Ounces of Alcohol/Week: On the WIC Assessment/Certification Form enter the amount of alcohol in ounces per week using the above equivalent chart.

Key: 00 ounces/week = no alcohol intake

01 ounces/week = greater than 0 and up to 1 1/2 ounce/week

02-98 ounces week = amount of intake

99 ounces/week = greater than 98 ounces/week

Binge drinking: drinks 5 or more (>5) drinks on the same occasion on at least one day in the past 30 days.

Heavy drinking: drinks 5 or more (>5) drinks on the same occasion on five or more days in the previous 30 days.

Key for Entering Number of Cigarettes/Cigars/Pipes Smoked: On the WIC Assessment/Certification Form record the average number of cigarettes/cigars/pipes smoked per day. If the client reports smoking on average less than once per day, record the average number of cigarettes/cigars/pipes smoked per week. If the client reports smoking on average less than once per week, record the average number of cigarettes/cigars/pipes smoked per month.

Key: 01-98/day = average number of cigarettes/cigars/pipes smoked per day

99/day = greater than 98 cigarettes/cigars/pipes smoked per day

01-06/week = average number of cigarettes/cigars/pipes smoked per week

01-03/month = average number of cigarettes/cigars/pipes smoked per month

Note: The usual number of cigarettes in a pack is equal to 20. This number may vary.

108

Appendix E-2

COMMON NAMES FOR ILLEGAL (STREET) DRUGS/DRUGS OF ABUSE

Controlled Substances Cannabis:

Common Names

Marijuana

Acapulco Gold, Grass, Pot, Reefer, Sinsemilla, Thai Sticks

Tetrahydrocannabinol

Marinol, THC

Hashish, Hashish Oil

Hash, Hash Oil

Hallucinogens:

LSD (lysergic acid diethylamide)

Acid, Microdot

Mescaline, Peyote

Buttons, Cactus, Mescal

Amphetamine Variants

2,5-DMA, DOB, DOM, Ecstasy, MDA, MDMA, STP

Phencyclidine and Analogs

Angel Dust, Hog, Loveboat, PCE, PCP, PCPy, TCP

Narcotics:

Heroin

Diacetylmorphine, Horse, Smack

Stimulants:

Cocaine

Coke, Crack, Flake, Snow, Rock

Source: Drugs of Abuse. Drug Enforcement Administration and The National Guard. Arlington, VA, 1997.

109

RECOMMENDED FOOD INTAKE PATTERNS

Appendix F

Food Group

Birth to 5/6 Months

Milk, Yogurt & Cheese
Meat, Poultry, Dry Beans, Eggs, Nuts Group

Breast milk, every 2-3 hrs or Iron fortified formula, 2.5 oz/lb (18-35 ozs)
None

5/6 Months to 12 months
Breast milk, every 2-4 hrs or Iron fortified formula, 2.5 oz/lb (24-35 ozs)
Add after 6 months and before 9 months

1 Year 2 cups1
2 ounces

2-3 Years 2 cups
2 ounces

4-6 Years 2.5 cups
3-4 ounces

Pregnant Teen/ Pregnant Adult
3 cups

Breastfeeding Teen/ Breastfeeding Adult
3 cups

Teen Postpartum/ Adult Postpartum
3 cups

6- 6 ounces

6 ounces

5- 5 ounces

Fruit Group

None

Vegetable Group

None

Add after 6 months and before 9 months
Add after 6 months and before 9 months

1 cup2 1 cup

1 cup2 1 cup

1- 1 cups

2 cups

1 cups

3 cups

2-2 cups 3-3 cups

1 -2 cups 2 cups

Grain Group

None

Add iron Fortified cereal at 6 months

3 oz equivalents

3 oz equivalents

4- 5 oz equivalents

7- 8 oz equivalents 7- 8 oz equivalents 6 oz equivalents

Discretionary Calorie Allowance3

None

None

165

165

171

290- 362

362- 410

195-267

1 If there is obesity, high cholesterol or heart disease in their family history, the AAP recommends reduced fat 2 percent milk between 12

months and 2 years in place of whole. WIC regulations at this time does not allow for the issuance of low fat milk below the age of 2. 2 AAP recommends no more than 6 ounces of juice per day for children 3 Discretionary Calorie Allowance is the remaining amount of calories in a food intake pattern after accounting for the calories needed

for all food groups- preferably using forms of foods that are fat-free or low-fat and with no added sugars.

Milk, Yogurt & Cheese Group: Most milk group choices should be fat-free or low-fat for those over the age of 2 years. 1 cup equivalent from this group = 1 cup milk/yogurt
1 ounces natural cheese (i.e. cheddar, Colby, longhorn) 2 ounces processed cheese (i.e. American, Swiss) 2 cups cottage cheese
Meat, Poultry, Dry Beans, Eggs, Nuts Group: 1 ounce equivalent from this group= 1 ounce lean meat, poultry or fish
1 egg ounce nuts or seeds cup cooked dry beans or tofu 1 tablespoon peanut butter

Fruit Group: 1 cup equivalent from this group= 1 medium fruit
1 cup freshly cut canned or frozen fruit cup dried fruit 1 cup 100% fruit juice Vegetable Group:
1 serving =
1 cup cooked or chopped 2 cups raw leafy salad greens 1 cup 100% vegetable juice
Grain Group: At least half of all grains consumed should be whole grains 1ounce equivalent from this group =

1 slice of Bread , Hamburger Bun, 1 small muffin cup cooked cereal, rice or pasta 1 cup ready to eat cereal flakes All information provided courtesy of MyPyramid.gov For more information http://download.journals.elsevierhealth.com/pdfs/journals/1499-4046/PIIS1499404606005628.pdf

110

Appendix G

Inappropriate Nutrition Practices for Women

Inappropriate Nutrition Practices for Women

Examples of Inappropriate Nutrition Practices (Including but not limited to)

Potentially Harmful Dietary Supplements
Consuming Dietary Supplements with potentially harmful consequences. Restrictive Diet
Consuming a diet very low in calories and/or essential nutrients; or impaired caloric intake or absorption of essential nutrients following bariatric surgery. Routine ingestion of non-food items (pica)
Compulsively ingesting non-food items (pica).
Inadequate vitamin/mineral supplementation recognized as essential by national public health policy.
Pregnant Women Potentially unsafe food consumption
Pregnant woman ingesting foods that could be contaminated with pathogenic microorganisms.

Examples of Dietary supplements which when ingested in excess of recommended dosages, may be toxic or have harmful consequences:
Single or multiple vitamins Mineral supplements; and Herbal or botanical supplements/remedies/teas. Strict vegan diet; Low-carbohydrate, high-protein diet; Macrobiotic diet; and Any other diet restricting calories and/or essential nutrients.

Non-food items:

Ashes;

Clay;

Baking soda;

Dust;

Burnt matches;

Large quantities of ice

Carpet fibers;

Paint chips;

Chalk;

Soil; and

Cigarettes;

Starch (laundry and cornstarch)

Consumption of less than 27 mg of supplemental iron per day by

pregnant woman.

Consumption of less than 150 g of supplemental iodine per day by

pregnant and breastfeeding woman.

Consumption of less than 400 mcg of folic acid from fortified foods

and/or supplements daily by non-pregnant women

Potentially harmful foods: Raw fish or shellfish, including oysters, clams, mussels, and scallops; Refrigerated smoked seafood, unless it is an ingredient in a cooked dish, such as a casserole; Raw or undercooked meat or poultry; Hot dogs, luncheon meat (cold cuts), fermented and fry sausage and other deli-style meat or poultry unless reheated until steaming hot; Refrigerated pt or meat spreads; Unpasteurized milk or foods containing unpasteurized milk; Soft cheese such as feta, Brie, Camembert, blue-veined cheeses and Mexican style cheese such as queso blanco, queso fresco, or Panela unless labeled as "made with pasteurized milk"; Raw or undercooked eggs or foods containing raw or lightly cooked eggs including certain salad dressings, cookie and cake batters, sauces, and beverages such as unpasteurized eggnog; Raw sprouts (alfalfa, clover, and radish); or Unpasteurized fruit or vegetable juices.

111

Appendix G (cont.)

Inappropriate Nutrition Practices for Children

Inappropriate Nutrition Practices for Children

Examples of Inappropriate Nutrition Practices (Including but not limited to)

Routinely feeding inappropriate beverages as the primary milk source.

Examples of inappropriate beverages as primary milk source:
Non-fat or reduced-fat milks (between 12 and 24 months of age only) or sweetened condensed milk; and
Imitation or substitutes milks (such as inadequately or unfortified rice- or soy-based beverages, non-dairy creamer), or other "homemade concoctions."

Routinely feeding a child any sugarcontaining fluids.
Routinely using nursing bottle, cups, or pacifiers improperly.

Examples of sugar-containing fluids:

Soda/soft drinks;

Corn syrup solutions; and

Gelatin water;

Sweetened tea.

Using a bottle to feed: Fruit juice, or Diluted cereal or other solid foods.

Allowing the child to fall asleep or be put to bed with a

bottle at naps or bedtime.

Allowing the child to use the bottle without restriction (e.g.,

walking around with a bottle) or as a pacifier.

Using a bottle for feeding or drinking beyond 14 months of

age.

Using a pacifier dipped in sweet agents such as sugar,

honey, or syrups.

Allowing a child to carry around and drink, throughout the

day, from covered or training cups.

Routinely using feeding practices that disregard the developmental needs or stages of the child.

Inability to recognize, insensitivity to, or disregarding the child's cues for hunger and satiety (e.g., forcing a child to eat a certain type and/or amount of food or beverage or ignoring a hungry child's request for appropriate foods).
Feeding foods of inappropriate consistency, size, or shape that put children at risk of choking.
Not supporting a child's need for growing independence with self-feeding (e.g.; solely spoon-feeding a child who is able and ready to finger-feed and/or try self-feeding with appropriate utensils).
Feeding a child with an inappropriate texture based on his/her developmental stage (e.g., feeding primarily purees or liquid food when the child is read and capable of eating mashed, chopped, or appropriate finger food).

112

Inappropriate Nutrition Practices for Children

Examples of Inappropriate Nutrition Practices (Including but not limited to)

Potentially unsafe food consumption.
Feeding foods to a child that could be contaminated with harmful microorganisms.

Examples of potentially harmful foods for a child: Unpasteurized fruit or vegetable juices. Unpasteurized dairy products or soft cheese such as feta, Brie, Camembert, blue-veined cheeses and Mexican style cheese such as queso blanco, queso fresco, or Panela unless labeled as "made with pasteurized milk Raw or undercooked meat, fish, poultry, or eggs Raw sprouts (alfalfa, clover, and radish) Hot dogs, luncheon meat (cold cuts), fermented and fry sausage and other deli-style meat or poultry unless reheated until steaming hot;

Routinely feeding a diet very low in calories and/or essential nutrients.

Examples: Vegan Diet; Macrobiotic diet; and Other diets very low in calories and/or essential nutrients.

Feeding dietary supplements with potentially harmful consequences

Examples of dietary supplements which when feed in excess of recommended dosages, may be toxic or have harmful consequences:
Single or multiple vitamins Mineral supplements; and Herbal or botanical supplements/remedies/teas

Routinely not providing dietary supplements as recognized as essential by national public health policy when a child's diet alone cannot meet nutrient requirements.

Providing children under 36 months of age less than 0.25 mg of fluoride daily when the water supply contains less than 0.3 ppm fluoride.
Providing children 36-60 months of age less than 0.50 mg of fluoride daily when the water contains less than 0.3 ppm fluoride.
Not providing 400 IU of vitamin D if a child consumes less than 1 liter (or 1 quart) of vitamin D fortified milk or formula.

Routine ingestion of non-food items (pica)

Ashes; Carpet fibers; Cigarettes or cigarette butts; Clay; Dust; Foam Rubber Paint chips; Soil; and Starch (laundry and cornstarch)

113

Appendix G (cont.)

Inappropriate Nutrition Practices for Infants

Inappropriate Nutrition Practices for Infants

Examples of Inappropriate Nutrition Practices (Including but not limited to)

Breast-milk or Formula Substitute
Routinely using a substitute(s) for breast milk or FDA approved iron-fortified formula as the primary source during the first year of life.
Inappropriate use of bottles or SugarContaining Fluids.
Routinely using nursing bottles or cups improperly
Inappropriate Introduction of Solid Foods
Routinely offering complementary foods* or other substances that are inappropriate in type or timing.
Feeding Practices not Developmentally Appropriate
Routinely using feeding practices that disregard the developmental needs or stages of the child.

Examples of substitutes: Low iron formula without iron supplementation; Cow's milk, goat milk, or sheep milk (whole, reduced-fat low-fat, skim) canned evaporated sweetened condensed milk; and Imitation or substitutes milks (such as inadequately or unfortified rice- or soy-based beverages, non-dairy creamer), or other "homemade concoctions." Using a bottle to feed fruit juice Adding any food (cereal or other solid foods) to the infant's bottle. Feeding any sugar-containing fluids such as, soda/soft drinks; gelatin water; corn syrup solutions; and sweetened tea. Allowing the child to fall asleep or be put to bed with a bottle at naps or bedtime. Allowing the child to use the bottle without restriction (e.g., walking around with a bottle) or as a pacifier. Propping the bottle when feeding. Allowing a child to carry around and drink, throughout the day, from covered or training cups.
Adding sweet agents such as sugar, honey, or syrups to any beverage (including water) or prepared food, or used on a pacifier; or
Introduction of any food other than breast milk or iron-fortified infant formula before 4 months of age.
*Complementary foods are any foods or beverages other than breast milk or infant formula. Inability to recognize, insensitivity to, or disregarding the child's cues for hunger and satiety (e.g., forcing an infant to eat a certain type and/or amount of food or beverage or ignoring a hungry infant's hunger cues). Feeding foods of inappropriate consistency, size, or shape that put infants at risk of choking. Not supporting an infant's need for growing independence with selffeeding (e.g.; solely spoon-feeding an infant who is able and ready to finger-feed and/or try self-feeding with appropriate utensils). Feeding an infant with an inappropriate texture based on his/her developmental stage (e.g., feeding primarily purees or liquid food when the child is read and capable of eating mashed, chopped, or appropriate finger food).

114

Inappropriate Nutrition Practices for Infants

Examples of Inappropriate Nutrition Practices (Including but not limited to)

Potentially unsafe food consumption
Feeding foods to a child that could be contaminated with harmful microorganisms or toxins.
Inappropriate Formula Preparation.
Routinely feeding inappropriately diluted formula Restrictive Nursing.
Routinely limiting the frequency of nursing of the exclusively breastfeed infant when breast milk is the sole source of nutrients. Restrictive Diet
Routinely feeding a diet very low in calories and/or essential nutrients Lack of proper Sanitation.
Routinely using inappropriate sanitation in preparation, handling, and storage of expressed breast milk or formula.
Potentially Harmful Dietary Supplements.
Feeding dietary supplements with potentially harmful consequences Lack of Essential Dietary Supplements.
Routinely not providing dietary supplements as recognized as essential by national public health policy when an Infant's diet alone cannot meet nutrient requirements.

Examples of potentially harmful foods for a child: Unpasteurized fruit or vegetable juices. Unpasteurized dairy products or soft cheese such as feta, Brie, Camembert, blue-veined cheeses and Mexican style cheese such as queso blanco, queso fresco, or Panela unless labeled as "made with pasteurized milk Honey (added to liquids or solid food, used in cooking, as part of processed foods, on pacifier, etc.); Raw or undercooked meat, fish, poultry, or eggs Raw vegetable sprouts (alfalfa, clover, bean and radish) Hot dogs, luncheon meat (cold cuts), fermented and fry sausage and other deli-style meat or poultry unless reheated until steaming hot; Failure to follow manufacturer's dilution instructions (to include stretching formula for household economic reasons). Failure to follow specific instructions accompanying a prescription.

Examples of inappropriate frequency of nursing: Scheduled feedings instead of demand feedings; Less than8 feedings in a 24 hours if less than 2 months of age; and Less than 6 feedings in 24 hours if between 2 and 6 months of age.

Examples:

Vegan Diet; Macrobiotic diet; and Other diets very low in calories and/or essential nutrients

Examples of inappropriate sanitation: Limited or no access to a: Safe water supply (documented by appropriate officials) Heat source for sterilization, and/or; Refrigerator or freezer storage. Failure to properly prepare, handle, and store bottles or storage containers of expressed breast milk or formula.
Examples of Dietary supplements which when feed in excess of recommended dosages, may be toxic or have harmful consequences:
Single or multiple vitamins Mineral supplements; and Herbal or botanical supplements/remedies/teas Infants who are 6 months of age or older who are ingesting less than
0.25 mg of fluoride daily when the water supply contains less than 0.3 ppm fluoride. Infants who are exclusively breastfed, or are ingesting less than 1 liter (or 1 quart) per day of vitamin D-fortified formula, and are not taking a supplement of 400 IU of vitamin D. Non-breastfed infants who are ingesting less than 1 liter (or 1 quart) per day of vitamin D-fortified formula, and are not taking a supplement of 400 IU of vitamin D.

115

PRODUCTS CONTAINING CAFFEINE

Appendix H

PRODUCT

AVERAGE CAFFEINE CONTENT (mg)

CAFFEINE RANGE (mg)

Coffee (5-oz cup) Brewed, drip Brewed, percolator Instant Decaffeinated, brewed Decaffeinated, instant
Tea Brewed, major US brands (5-oz) Brewed, imported brand (5-oz) Instant (5-oz) Iced (12-oz)
Chocolate Beverages Cocoa beverage (5-oz) Chocolate milk (8-oz) Milk chocolate (1-oz) Dark choc, semi-sweet (1 oz) Baker's chocolate (1 oz) Chocolate-flavored syrup (1 oz)
PRODUCT
Energy Drinks (16-oz) Monster Energy Rock Star Energy Drink Red Bull Full Throttle 5 Hour Energy (2-oz)
Soft Drinks (12-oz) Mountain Dew Mello Yellow TAB Coca-Cola Diet Coke Mr. PIBB Dr. Pepper Pepsi Cola Diet Pepsi

115

60-180

80

40-170

65

30-120

3

2-5

2

1-5

40

20-90

60

25-110

30

25-50

70

67-76

4

2-20

5

2-7

6

1-15

20

5-35

26

26

4

4

CAFFEINE CONTENT (mg)

160.0 160.0 160.0 144.0 138.0

54.0 52.8 46.8 45.6 44.4 39.6 39.6 38.0 36.0

116

Appendix H (cont.) PRODUCTS CONTAINING CAFFEINE

PRODUCT

MILLIGRAMS CAFFEINE/DOSE

Diet Plan Non-Prescription Drugs

Caltrim Tablets

100

Caffeine-Free Dexatrim w/ Vitamin C

0

Dexatrim

200

X-tra Strength Dexatrim

200

Gold Medal

100

Odrinex

Pain Relievers Anacin and X-tra Strength Capron Capsules Tri Pain Caplets BC Tablet BC Powder Arthritis Strength BC Doan's Pills Duradyne Excedrin X-tra Strength Goody's Powder Goody's X-tra Strength Meadache Trigesic Vanquish Caplet Prolamine Capsules

32 32.4 16.2 16 32 36 32 15 65 32.5 16.25 32 30 33 140

Menstrual Relief

Aqua Ban

100

Midol

32.4

Midol Max Strength, Multi-Symptom

60

Sources: 1American Pharmaceutical Association and The National Professional Society of Pharmacists. (8th Ed.). (1986). Handbook of Nonprescription Drugs.

2American Dietetic Association (ADA). (1992). Manual of Clinical Dietetics (4th ed.). Chicago, IL: Chicago Dietetic Association.

3Georgia Dietetic Association (GDA). (1992). Georgia Dietetic Association Diet Manual (4th ed.). Duluth, GA.

4Medical Economics Data Production Company. (15th Ed.). (1994). Physician's Desk Reference for Nonprescription Drugs, Montvale, N.J.
5U.S. Pharmacopeial Convention, Inc. (13th Ed.). (1993). Drug Information for the Health Care Professional USP DI.

117

INSTRUCTIONS FOR USE OF THE PRENATAL WEIGHT GAIN GRID

Appendix I

1. Record applicant/participant's name.
2. Use Body Mass Index table (Appendix C-1) to determine if the applicant is Normal Weight, Underweight , Overweight , or Obese using pregravid weight. Select for use the prenatal weight gain grid that corresponds to the prenatal woman's pregravid weight status. If she is pregnant with twins, use the "Twins" grid regardless of her weight status.
3. Enter height in inches without shoes.
4. Use Weight History chart.
5. Enter pregravid weight as indicated. Enter date and weight at each visit.
6. Plot today's weight using the following steps:
a. Record the pregravid weight at the initial point of the selected weight curve, which is located on the left side of the grid at zero (0) point. From the chart or gestation calculator, determine the completed weeks of gestation.
b. Using the gain (or loss) in weight from the pregravid weight baseline and the completed gestational weeks (this visit) place an X on the point at which these two (2) lines meet.
c. If the patient does not know her pregravid weight, or if the weight she gives seems disproportionate to her current weight, place an X on the dotted line for the calculated completed gestational week. Let this be a beginning point to plot future weights. Indicate that this weight is an estimate by writing "estimate" vertically on the grid next to the X. Use the "Normal" weight curve unless it is very obvious that the prenatal woman was overweight or underweight prior to gestation. Document this observation in the health record.
d. At the second and each subsequent visit, the weight gain for completed weeks of gestation should be plotted on the grid.

118

Appendix J-1

Age:

MEASURING LENGTH

Birth to 24 months

Material/Equipment:

An accurate lengthboard for measuring infants is dedicated to length measurement. It has a firm, flat horizontal surface with a measuring tape in 1 mm (0.1 cm) or 1/8 inch increments, an immovable headpiece at a right angle to the tape, and a smoothly moveable footpiece, perpendicular to the tape.

Two (2) people required

Procedure:

1. Check to be sure that moveable foot piece slides easily and the headboard is at the zero (0) mark.

2. Remove headwear, shoes and bulky clothing. Instruct caretaker to apply gentle traction to ensure that the child's head is firmly against the headboard so that the eyes are pointing directly upward.

3. With the child positioned so that the shoulders, back and buttocks are flat along the center of the board, the measurer should hold the child's knees together, gently pushing them down against the board with one (1) hand to fully extend the child. With the other hand the measurer should slide the footboard to the child's feet until both heels touch the foot piece. Toes should be pointing directly upward.

4. Recheck head placement. Immediately remove the child's feet from contact with the footboard with one (1) hand, while holding the footboard securely in place with the other hand.

5. Measure length in inches to the nearest 1/8-inch. Repeat the measurement by sliding footboard away and starting again until two (2) readings agree within 1/4 inch.

6. Record the second reading promptly.

119

Appendix J-2 MEASURING WEIGHT
("INFANT" SCALE) Age: Infants and very young children up to 35 pounds Materials/Equipment: Scales with beam balance and non-detachable weights or electronic, with a maximum weight of 40 lbs and weigh in ounce increments. Scales must be calibrated yearly. Procedure: 1. Check scales at zero (0) position. With weights in zero (0) position, indicator
should point at zero (0). If not, use the adjustment screws to move adjustable zeroing weight until the beam is in zero (0) balance. 2. Remove shoes and clothes. Remove diaper if wet. 3. Place infant/child in center of scale (may be done sitting or lying down). 4. Move the weight on the main beam away from the zero (0) position (left to right) until the indicator shows excess weight, then move the weight back (right to left) towards the zero (0) position until too little weight has been obtained. 5. Move the weight on the fractional beam away from the zero (0) position (left to right) until the indicator is centered and stationary. (Record weight) 6. Repeat the measurements by moving the fractional beam until two (2) readings agree within -ounce. 7. Record the second reading promptly.
120

Appendix J-3

MEASURING HEIGHT

Age:

Children two (2) years of age and older

Adults

NOTE:

Once measurements are started with child standing, all subsequent measurements must be done standing.

Material/Equipment:

An accurate stadiometer for stature measurements is designed for and dedicated to stature measurement. It can be wall mounted or portable. An appropriate stadiometer requires a vertical board with an attached metric rule and a horizontal headpiece (right angle headboard) that can be brought into contact with the most superior part of the head. The stadiometer should be able to read to 0.1 cm or 1/8 in.

Procedure:
1. Remove all bulky clothing, head and footwear.
2. Position the child/adult against the measuring device, instructing the child/adult to stand straight and tall.
3. Make sure the child/adult stands flat footed with feet slightly apart and knees extended; then check for three (3) contact points: (a) shoulders, (b) buttocks, and (c) the back of the heels.
4. Lower the moveable headboard until it firmly touches the crown of the head. The child/adult should be looking straight ahead, not upward or down at the floor.
5. Read the stature to the nearest 1/8-inch.
6. Repeat the adjustment of the headboard and re-measure until two (2) readings agree within 1/4 inch.
7. Record the second reading promptly.

121

Appendix J-4

Age:

MEASURING WEIGHT (STANDING)

Adults, and children 2 years of age or older Materials/Equipment:

Standard electronic scale or platform beam scale with non-detachable weights that weighs in at least 1/4 pound or 100 gram increments.

Scales must be calibrated yearly

Procedure:

1. Check scales at zero (0) position. With weights in zero (0) position indicator should point at zero (0). If not, use adjustment screws to move the adjustable zeroing weight until the beam is in zero (0) balance.

2. Should be wearing minimal indoor clothing. Remove shoes, heavy clothing, belts, and heavy jewelry. Be sure pockets are empty.

3. Have child/adult stand in the center of the platform, arms hanging naturally. The child/adult must be free standing.

4. Move the weight on the main beam away from zero (0) until the indicator shows that excess weight has been added, then move the weight back towards the zero (0) position (right to left) until just barely too much weight has been removed.

5. Move the weight on the fractional beam away from the zero (0) position (left to right) until the indicator is centered.

6. Make sure the child/adult is still not holding on, then record to the nearest 1/4 lb.

7. Have the child/adult step off scale and return weight to zero (0). Repeat until two (2) readings agree within 1/4 pound.

8. Record the second reading promptly.

Sources: Georgia Child and Adolescent Health Program Manual. DHR, Division of Public Health; 1987. A Guide to Pediatric Weighing and Measuring, DHHS; 1981.

122

Appendix K

INSTRUCTIONS FOR USE OF THE GROWTH CHARTS

1. Select the appropriate chart for sex and age of the individual. When length measurements are taken with the individual lying down use the "Birth to 24 Months of Age" chart.

2. Record name and/or identifying number of the chart. Document birth date.

3. The child's age on the date on which measurements are taken must be determined before you start plotting the measurements. To figure out a child's age, follow this example:

Year

Month

Day

Date of Measurement

2002

4

21

Date of Birth

-1997

-8

-10

Child's Age

4y

8

11

or 4 yrs 8 mos
As this example shows, you may have to borrow thirty (30) days from the month column and/or 12 months from the year column when subtracting the child's birth date from the date on which the measurements are taken.

4. Plot growth measurements by using the Interpolation Method.

Plotting Interpolation Method:

a. Birth - 24 Month Growth Chart - Calculate exact age (to nearest week) and plot measurement into the space at the point nearest to the age.
b. 2 - 18 Years Growth Chart - Calculate exact age (to nearest month) and plot measurement into space at the point nearest to the age.

5. To plot the length or height for age and weight for age charts:

a. Follow a vertical line at the appropriate age.

b. Using a straight-edge, line up as closely as possible to the measured length or height and weight and mark the point where the two (2) lines intersect.

c. Write the date above the point.

123

Appendix K (cont.) 6. To plot the length or height/weight chart:
a. Follow a vertical line at the point of the correct length or height. b. Using a straight-edge, line up as closely as possible to the weight and mark
the point where the two (2) lines intersect. c. Write the date on the point. 7. To plot Body Mass Index (BMI) for age: a. Follow a vertical line as near as possible to the appropriate age. b. Using a straight-edge, line up as closely as possibly the measured BMI and
mark the point where the two (2) lines intersect. 8. To plot an infant's head circumference:
a. Follow a vertical line as near as possible to the appropriate age. b. Using a straight-edge, line up as closely as possible the measured head
circumference and mark the point where the two (2) lines intersect. 9. Calculating Gestation-Adjusted Age:
a. Document the infant's gestational age in weeks. (Mother/caregiver can self report, or referral information from the medical provider may be used.)
b. Subtract the child's gestational age in weeks from 40 weeks (gestational age of term infant) to determine the adjustment for prematurity in weeks.
c. Subtract the adjustment for prematurity in weeks from the child's chronological postnatal age in weeks to determine the child's gestationadjusted age.
d. For WIC nutrition risk determination, adjustment for gestational age should be calculated for all premature infants for the first 2 years of life.
124

Appendix K (cont.) Example: Randy was born prematurely on March 19, 2001. His gestational age at birth was determined to be 30 weeks based on ultrasonographic examination. At the time of the June 11, 2001 clinic visit, his chronological postnatal age is 12 weeks. What is his gestation-adjusted age? 30 = gestational age in weeks 40 30 = 10 weeks adjustment for prematurity 12 10 = 2 weeks gestation-adjusted age Measurements would be plotted on a growth chart as a 2-week-old infant.
10. Plotting for Prematurity: For all premature infants and children <24 months plot adjusted and actual age. a. Infant Plot- (weight/age, Length/age, length/weight) b. Child Plot- (weight/age, height/age, BMI)
11. The formula for calculating BMI for age is:
[weight (lb.) height (in.) height (in.) x 703]
This can be calculated on a hand-held calculator or by computer systems in the district. Once calculated, BMI must be rounded to one decimal point. A reference for converting fractions to decimals and guidance for rounding to one decimal point follows.
Reference for Converting Fractions to Decimals: 1/8 = .125
2/8 or = .25 3/8 = .375
4/8 or = .5 5/8 = .625
6/8 or = .75 7/8 = .875
125

Guidance for Rounding to One Decimal Point:

Appendix K (cont.)

When calculating Body Mass Index (BMI) round the final answer to one decimal point. To do this you will round up to the next number if the second number past the decimal point is five or greater and you will round down if the second number past the decimal point is four or less.

Example: If the final BMI calculation equals 17.158829, the BMI would be 17.2

If the final BMI calculation equals 17.14829, the BMI would be 17.1

126

Appendix L USE AND INTERPRETATION OF THE GROWTH CHARTS PLOTTING 1. Standing height and weight must be plotted on the 2-18 Years growth charts. 2. Recumbent length and weight must be plotted on the 0-24 Months growth charts. 3. When a measurement cannot be plotted, a notation to this effect must be noted in the health record or on the growth chart. This measurement may not be used as a risk criterion. See the following example: Standing height is measured on a 26-month old child. The child is 34 7/8 inches tall. Two options may be taken: a. Re-measure the child on the recumbent board, and plot length on the 0-36 months growth chart; OR b. Make a notation in the health record that the height of the child cannot be plotted on the 2-18 years growth chart.
INTERPRETATION 1. Pattern of growth can only be interpreted when two sets of measurements are
plotted on the same growth grid. If one set of measurements are plotted on the 024 months growth charts and the next set of measurements on the 2-18 years growth charts, these measurements cannot be used to interpret the pattern of growth of the child.
127

Appendix M

FOOD SOURCES OF VITAMIN A

Food Source
Apricots canned dried raw

Serving Size
3 halves 10 halves 3 medium

Vitamin A (mcg Retinol)*
140 250 280

Bok Choy

1 cup

110

Broccoli cooked raw

1 cup

110

1 cup

680

Carrots cooked raw

1cup 1 medium

1920 2030

Cantaloupe, cubed

1 cup

520

Endive, raw

1cup

50

Greens, fresh, cooked

beet

1cup

370

collards

1cup

350

kale

1cup

480

turnip

1cup

400

spinach

1cup

740

Liver, beef

3 ounces

10,600

Mango, raw

1 medium

810

Papaya, raw

1 medium

620

Parsley, chopped

1cup

160

Peaches

canned, juice pack

1 cup

100

raw

1 medium

50

dried

10 halves

280

Persimmon, raw

1 medium

360

Pumpkin, canned

1cup

2690

Sweet Potato, baked

1 medium

2490

Watercress, raw

1cup

80

Winter Squash, baked

1cup

240

*Micrograms of retinol equivalent: rounded to the nearest 10

128

FOOD SOURCES OF VITAMIN C

Food Source

Serving Size

Broccoli, chopped cooked raw

1/2 cup 1/2 cup

Cantaloupe, raw

1 cup, pieces

Green Pepper

1/2 medium

Grapefruit juice**, from concentrate raw

1/2 cup 1/2 medium

Mango, raw

1 medium

Orange juice**, from concentrate raw (navel)

1/2 cup 1 medium

Strawberries, raw

1 cup

Tomato, raw

1 medium

*Milligrams Vitamin C: rounded to nearest 10 **Items distributed through the Georgia WIC Program.

Appendix N
Vitamin C (mg)*
60 40 70 40
40 50 60
50 80 90 20

129

Selected Food Sources of Folate and Folic Acid

Food Source / Serving Size

Micrograms (g)

*Breakfast cereals fortified with 100% of the DV, cup

400

Beef liver, cooked, braised, 3 ounces

185

Cowpeas (blackeyes), immature, cooked, boiled, cup

105

*Breakfast cereals, fortified with 25% of the DV, cup

100

Spinach, frozen, cooked, boiled, cup

100

Great Northern beans, boiled, cup

90

Asparagus, boiled, 4 spears

85

*Rice, white, long-grain, parboiled, enriched, cooked, cup

65

Vegetarian baked beans, canned, 1 cup

60

Spinach, raw, 1 cup

60

Green peas, frozen, boiled, cup

50

Broccoli, chopped, frozen, cooked, cup

50

*Egg noodles, cooked, enriched, cup

50

Broccoli, raw, 2 spears (each 5 inches long)

45

Avocado, raw, all varieties, sliced, cup sliced

45

Peanuts, all types, dry roasted, 1 ounce

40

Lettuce, Romaine, shredded, cup

40

Wheat germ, crude, 2 Tablespoons

40

Tomato Juice, canned, 6 ounces

35

Orange juice, chilled, includes concentrate, cup

35

Turnip greens, frozen, cooked, boiled, cup

30

Orange, all commercial varieties, fresh, 1 small

30

*Bread, white, 1 slice

25

*Bread, whole wheat, 1 slice

25

Egg, whole, raw, fresh, 1 large

25

Cantaloupe, raw, medium

25

Papaya, raw, cup cubes

25

Banana, raw, 1 medium

20

Appendix O
% DV^
100 45 25 25 25 20 20 15 15 15 15 15 15 10 10 10 10 10 10 10 8 8 6 6 6 6 6 6

* Items marked with an asterisk (*) are fortified with folic acid as part of the Folate Fortification Program. ^ DV = Daily Value. DVs are reference numbers developed by the Food and Drug Administration (FDA) to help consumers determine if a food contains a lot or a little of a specific nutrient. The DV for folate is 400 micrograms (g). Most food labels do not list a food's magnesium content. The percent DV (%DV) listed on the table indicates the percentage of the DV provided in one serving. A food providing 5% of the DV or less is a low source while a food that provides 10-19% of the DV is a good source. A food that provides 20% or more of the DV is high in that nutrient. It is important to remember that foods that provide lower percentages of the DV also contribute to a healthful diet. For foods not listed in this table, please refer to the U.S. Department of Agriculture's Nutrient Database Web site: http://www.nal.usda.gov/fnic/cgibin/nut_search.pl.

Sources: U.S. Department of Agriculture, Agricultural Research Service. 2003. USDA National Nutrient
Database for Standard Reference, Release 16. Nutrient Data Laboratory Home Page, http://www.nal.usda.gov/fnic/cgi-bin/nut_search.pl

130

FOOD SOURCES OF IRON

Food Source

Serving Size

Iron Fortified Breakfast Cereal*

cup

Canned Clams

1/3 cup

Cooked Oysters

3 oz

Blackstrap Molasses

1 Tbsp.

Liver

2 ounces

Baked Beans

1 cup

Spinach

1 cup

Red Meat

3 ounces

Prunes

10 large

Raisins

1/2 cup

Pork

3 ounces

Turkey

3 ounces

Baked Potato with skin

1

Ham

3 ounces

Legumes, cooked*

1/2 cup

Raw Shrimp

3 ounces

Baked Winter Squash

1 cup

Berries

1 cup

Turnip or Collard Greens

1 cup

Liverwurst

1 slice

Chicken

3 ounces

Fish

3 ounces

Prune Juice

1/3 cup

*Items distributed through the Georgia WIC Program.

Appendix P
Iron (mg) 8-18 11 7 5 5 5 4 3 3 3 3 3 3 2 2 2 2
1.5 2 1.5 1 1 1 1

131

Appendix Q

MILK GROUP

FOOD SOURCES OF CALCIUM

250 mg

150-249 mg

75-149 mg

Milks - 1 cup Whole - 291 mg 1% lowfat - 300 mg 2% lowfat 297 mg Skim - 302 mg Buttermilk - 285 mg Chocolate 284 mg Malted - 348 mg
Swiss Cheeses 272 mg Ricotta, part skim, c - 337 mg Milkshakes - 1 cup
Chocolate 397 mg Vanilla 457 mg Yogurt, lowfat - 1 cup Plain 415 mg Flavored 380 mg Fruit 345 mg

Cheeses - 1 oz. American, processed, 174 mg Blue 150 mg Brick 191 mg Caraway 204 mg Cheddar 204 mg Colby 194 mg Edam 207 mg Monterey 212 mg Mozzarella, part skim 183 mg Muenster 203 mg
Cheese food American, processed, 163 mg Swiss, processed 205 mg

Cottage Cheese, 2% Lowfat, c, 75 mg Frozen desserts c
Ice cream 88 mg Ice milk, hardened, 88 mg Ice Milk, soft serve, 137 mg Pudding, 133 mg

MEAT/PROTEIN GROUP

Sardines, with bones, 3 oz, 372 mg Tofu, firm processed with calcium- sulfate, 4 oz, 250-765 mg

Salmon, with bones 167 mg. - 3 oz Sesame seeds 2 TB, 176 mg.

Beans, dried, cooked, 90 mg. - 1 c Oysters, 7-9, 113 mg Shrimp, canned, 3 oz, 100 mg Tofu, soft, c, 145 mg Tahini (sesame butter) 2 TB, 128 mg. Soybeans, 8 oz, 64 mg Soy beverage, 8 oz, 64 mg Almonds, 1 oz, 75 mg

VEGETABLE GROUP

Cooked, 1 cup Collards, 357 mg Rhubarb, 348 mg Spinach, 278 mg Bok Choy, 252 mg

Cooked, 1 cup Kale, 200 mg Mustard greens, 200 mg Turnip greens, 249 mg

Cooked, 1 cup Okra, 176 mg Broccoli, 90 mg

FRUIT

Figs, dried or fresh 5 med, 135 mg. Papaya, raw 1 med, 72 mg. Sapote, raw 1 med, 88 mg. Tamarind, raw - 1 c, 89 mg.

GRAIN GROUP

Waffle, 7" diameter, 179 mg

Cornbread, 2" square , 94 mg Pancakes, 2-4" diameter, 116 mg

"OTHERS" Category fats, sweets, alcohol

Molasses, Blackstrap, 2 Tbsp., 274 mg

COMBINATION FOODS: Foods made with ingredients from more than one food group

Cheese pizza, of 14" pie, 332 mg

Macaroni and cheese, c c, 181 mg Soups made with milk - 1 c
Cream of mushroom , 191 mg Cream of tomato, 168 mg Taco, beef, 174 mg

Chili con carne with beans, 1 c, 82 mg Custard, baked, c, 148 mg Spaghetti, meatballs, tomato sauce, and cheese, 1 c, 124 mg

Sources: (1) Pennington, JAT. Bowes & Church's Food Values of Portions Commonly Used. 16th edition. Philadelphia, PA: J.B. Lippincott Co.; 1994. (2) Georgia Dietetic Association Diet Manual. Georgia Dietetic Association, Inc. Fourth edition, 1992. (3) National Osteoporosis Foundation 1991.

132

Appendix R

Herbs
Chamomile
Ginseng Mandrake Pennyroyal oil
Sassafras Tonka beans, melilot, sweet woodruff (tea) Devil's claw root
Ginger root tea

HERBS: THEIR USE AND POTENTIAL RISKS

Use

Risks

Relaxant

May cause allergic reaction (up to anaphylactic shock in allergic individuals).

Health food remedy

Painful, swollen breasts

Sold falsely as Ginseng

Contains scopolamine

Abortifacient

Toxicity, teratogenesis, increased risk of medical abortion, hepatotoxin, coma death

Tonic for a variety of unsubstantiated uses

Possible carcinogenesis

Seasonal tonic

Hemorrhage

Abortifacient Morning sickness remedy

Sodium and water retention, hypokalemia, hypertension, cardiac failure/arrest
Unknown - very large doses may cause depression of CNS, and cardiac arrhythmias.

There is insufficient information on many herbs that women may want to use during pregnancy and lactation. Herbs have been used as remedies for years and in many cases some may be beneficial. The
problems that might arise may be dose related, which could affect the fetus and growing infant. A safe
level or dangerous level is generally not known for use in pregnancy and lactation; avoidance of most herbs is usually the best practice. In addition to the herbs listed above, the following herbs are recommended NOT to be used during pregnancy and lactation:

Angelica Black Cohosh Blessed Thistle Calendula Dong Quai

Elecampane Gotu kola Juniper Berries Motherwart Myrrh

Sources:

Dimperio, Diane: Florida Department of Health and Rehabilitative Services, Florida's Guide to Maternal Nutrition, 1986. Tenney, Louise: Today's Herbal Health, 3rd Edition, Woodland Books, Utah, 1992. Tyler, Varro E.: The Honest Herbal, 3rd Edition, Pharmaceutical Products Press, New York, 1993.

133

KEY FOR ENTERING WEEKS BREASTFED

Appendix S

The number of weeks breastfed must be manually entered when completing paper WIC Assessment/Certification Forms and paper Turnaround Documents for:

- Breastfeeding women: initial and six month certification visits - Postpartum, non-breastfeeding women: certification visit - Infants: initial certification and mid-certification nutrition assessments - Children: initial certification and subsequent certification, until the answer is "No"

Length of time breastfed must be entered in weeks (two-digit). When the answer to the question "How long have you breastfed this infant?" OR "How long has this infant breastfed?" is given in days or months, use the following key to determine appropriate codes.
I. Codes to Enter When Breastfeeding is Given in Days

Convert Days to Weeks

Fewer than 7 days

= 00 weeks

7 - 13 days

= 01 week

14 20 days

= 02 weeks

21 27 days

= 03 weeks

28 34 days

= 04 weeks

35 41 days

= 05 weeks

42 48 days

= 06 weeks

Source: Georgia WIC Branch ETAD Change Number 08-12b, 2008.

II. Codes to Enter When Breastfeeding is Given in Months

1 month

= 04 weeks

12 Months

= 52 weeks

2 months

= 08 weeks

13 Months

= 56 weeks

3 months

= 13 weeks

14 Months

= 61 weeks

4 Months

= 17 weeks

15 Months

= 65 weeks

5 Months

= 22 weeks

16 Months

= 69 weeks

6 Months

= 26 weeks

17 Months

= 74 weeks

7 Months

= 30 weeks

18 Months

= 78 weeks

8 Months

= 35 weeks

19 Months

= 82 weeks

9 Months

= 39 weeks

20 Months

= 87 weeks

10 Months = 43 weeks

21 Months

= 91 weeks

11 Months = 48 weeks

22 Months

= 96 weeks

22.5 Months + = 98 weeks or more

Source: Enhanced Pregnancy Nutrition Surveillance System User's Manual. Division of Nutrition, Center for Chronic

Disease Prevention & Health Promotion, Centers for Disease Control and Prevention, U.S. Department of Health and Human

Services, Public Health Service. February 2000.

134

Appendix T
Infant Formula Preparation
GENERAL INFORMATION
1. Before starting, wash hands with soap and water. Rinse well.
2. Wash bottles and nipples using brushes made for bottles and nipples. Wash caps, rings and preparation utensils such as spoons, pitchers, etc. Use hot soapy water. Rinse well.
3. Squeeze clean water through the nipple holes to be sure they are open.
4. Put the bottles, nipples, caps and rings and other utensils in a pot and cover with water. Heat on the stove, bring to a boil; boil for 5 minutes. Remove from heat and let cool. OR Put all items in a properly functioning dishwasher and run it at the normal temperature (not the low or economy temperature setting).
5. The most important time to boil bottles, nipples and formula preparation items for the infant is through 3 months of age. Also, the most important time to boil the water used in formula preparation is through 3 months of age. If there is any doubt about the safety of the water supply or the cleanliness of the home, then continue to sterilize the equipment and to boil the water used in formula preparation.
6. Boil water for 2 minutes before using to prepare formula. Prolonged boiling of water (greater than 5-6 minutes) is not recommended because some trace contaminates in the water such as lead, nitrates, or even trace minerals may concentrate in the boiled water as the liquid water is reduced.
7. Do not feed an infant a bottle left out of the refrigerator for more than 1 hour.
8. For infants who prefer a warmed bottle, hold the bottle under warm running tap water. Shake well and test the temperature before giving to the infant. Do not use microwave oven to prepare or to warm formula. Formula heated in the microwave may result in serious burns to the infant.
9. When using formula:
Check the formula's expiration date prior to use. Do not use if the date has passed. Avoid using cans of infant formula that have dents, leaks, bulges or puffed ends or
rust spots.
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Appendix T (cont.)

Infant Formula Preparation
9. (Cont'd)
Store cans of infant formula in a cool place, indoors. Do not store in vehicles, garages or outdoors.
For more information, see the following references:
Infant formula cans - commercial brands.
United States Department of Agriculture, Food and Nutrition Service.
Infant Nutrition and Feeding, a Reference Handbook for Nutritional Health Counselors in the WIC and CSF Programs. FNS-288, September 1993. USDA, FNS, Alexandria, Virginia 22302-1594. (U.S. Gov. Printing Office: 1994-0-360-395 QL.3).

PREPARATION FROM CONCENTRATED LIQUID FORMULA

1. Boil for 5 minutes all bottles, nipples, rings and utensils to be used; let cool. 2. Heat water for formula on stove to a rolling boil for 2 minutes; let cool. 3. Wash top of the can with soap and water; rinse well. Wash the can opener. 4. Shake can well before opening. 5. Open can and pour formula into a clean bottle using ounce markings to measure
amount of formula. Add an equal amount of the cooled boiled water. Example: For 4 ounces of concentrated formula poured into the bottle, add 4 ounces of water. Shake or stir again.
6. To store: cover container or bottles and refrigerate. Use within 48 hours. If more than one bottle is prepared, put the nipples in upside down on each bottle. Cover the nipple with a cap and screw on the ring.
7. After feeding, throw away any formula left in bottle or cup, as this can contain germs.

Note:

Do not use microwave oven to prepare or to warm formula. Formula heated in the microwave may result in burns.

PREPARATION OF READY-TO-FEED FORMULA

1. Boil for 5 minutes all bottles, nipples, rings and utensils to be used; let cool. 2. Wash top of the can with soap and water; rinse well. Wash the can opener.
3. Shake can very well. Open with a clean punch-type can opener. 4. Pour the amount of ready-to-feed formula for one feeding into a clean bottle.

Note: Do not add water or any other liquid to this formula.

5. Attach nipple and cap. Shake well again and feed infant.

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Appendix T (cont.)

Infant Formula Preparation

6. If more than one bottle is prepared, put the nipples in upside down on each bottle. Cover the nipple with a cap and screw on the ring. Refrigerate. If formula is left in
opened can, cover and refrigerate. Use within 48 hours. Shake can again before pouring; or shake bottles before serving.

Note:

Do not use microwave oven to prepare or to warm formula. Formula heated in the microwave may result in burns.

Preparation from Powdered Formula

1. Boil for 5 minutes all bottles, nipples, rings and utensils to be used; let cool. 2. Heat water for formula on stove to a rolling boil for 2 minutes; let cool to a warm
temperature. 3. Remove plastic lid from can; wipe it off if dusty. Wash top of can with soap and water;
rinse well and dry it. Wash can opener. Do not let water get into the can. 4. Pour the warm water into the bottle(s). Use only the scoop that comes with the
formula can (8.7 gm). The scoop should be totally dry before scooping out the powdered formula. Add 1 level scoop of the powdered formula for each 2 oz of warm water in the bottle(s). Example: If 8 ounces of water is poured in the bottle, then 4 level scoops of formula should be added.
5. Put nipples and rings on bottle and shake well. If feeding immediately, check temperature and then feed. After feeding, throw away formula left in bottle or cup, as this can contain germs.
6. Store filled bottles in refrigerator and use within 24 hours. Put a clean nipple upside down on each bottle. Cover the nipple with a cap and screw on the ring.
7. Do not store can containing the dry powdered formula in the refrigerator. Keep it covered and store in a cool, dry place; avoid temperature extremes. Use can within one month after opening.

Note:

Do not use microwave oven to prepare or to warm formula. Formula heated in the microwave may result in burns.

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CONVERSION TABLES AND EQUIVALENTS

Appendix U-1

I. TABLE OF EQUIVALENTS
3 teaspoon (tsp.) 2 Tbsp. 8 oz. 16 Tbsp. 2 c. 2 pts. 4 c. 4 qts.
II. METRIC SYSTEM

= 1 Tablespoon (Tbsp.) = 1 ounce (oz) = 1 cup (c.) = 1 c. = 1 pint (pt.) = 1 quart (qt.) = 1 qt. = 1 gallon (gal.) = 128 oz.

A.

APPROXIMATE WEIGHTS/MEASURES

20 drops 1 ml. 1 ml. 1 tsp. 1 Tbsp. 1 oz., fluid 1 cup, fluid 1 oz., weight 1 c., weight 1 pound (lb.) 2.2 lbs. 33 oz. 1.1 qts.

= 1 milliliter (ml.)

= 1 gram (g.)

= 1 cubic centimeter (cc)

= 5 ml. = 5 cc = 5 g.

= 15 ml. = 15 cc = 15 g.

= 29.57 ml. = 30 cc

= 240 ml.

= 28.35 g. (approx 30)

= 240 g.

= 453.6 g.

= 1 kilogram (kg.)

= =

1 liter (L.) 1000 ml = 1 liter

B.

WEIGHTS

1 milligram 1 gram (g) 1 kilogram

= 1000 micrograms (mcg) = 1000 mg. = 1000 g.

C.

CONVERSIONS

To convert ounces to grams multiply by 30. To convert grams to ounces divide by 30. To convert pounds to kilograms divide by 2.2. To convert kilograms to pounds multiply by 2.2. To convert inches to centimeters multiply by 2.54.

References: Georgia Dietetic Association, Inc., Diet Manual, 4th edition, 1992.

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Appendix U-2 APPROXIMATE METRIC AND IMPERIAL EQUIVALENTS

Useful approximate metric and imperial equivalents

1 cm = 0.39 in 1 meter = 1.1 yd.

1 in = 2.54 cm 1 ft = 30.48 cm

To convert centimeters to inches Divide the length in centimeters by 2.54. Example: The average newborn infant measures 50.89 cm:
50.89 cm: 2.54 cm/in = 20 in To convert inches to centimeters Multiply the length in inches by 2.54 Example: The average newborn infant measures 20 in:
20 in x 2.54 cm/in = 50.8 cm

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