{"response":{"docs":[{"id":"dlg_ggpd_y-ga-bp780-b-ps1-bn8-b2013-belec-p-btext","title":"Nutrition risk criteria handbook FFY 2013: Georgia WIC Program nutrition unit","collection_id":"dlg_ggpd","collection_title":"Georgia Government Publications","dcterms_contributor":["Georgia. Department of Public Health"],"dcterms_spatial":["United States, Georgia, 32.75042, -83.50018"],"dcterms_creator":["Georgia. Department of Public Health"],"dc_date":["2012-07-19"],"dcterms_description":["Revised"],"dc_format":["application/pdf"],"dcterms_identifier":null,"dcterms_language":["eng"],"dcterms_publisher":["Atlanta, Georgia : Georgia WIC Program, Nutrition Unit"],"dc_relation":null,"dc_right":["http://rightsstatements.org/vocab/InC/1.0/"],"dcterms_is_part_of":null,"dcterms_subject":["Georgia.--WIC Program--Periodicals.","Pregnant women--Health risk assessment--Georgia--Periodicals.","Children--Health risk assessment--Georgia--Periodicals.","Infants--Health risk assessment--Georgia--Periodicals.","Nutrition--Georgia--Periodicals.","Femmes enceintes--Risques pour la santé--Évaluation--Géorgie (État)--Périodiques.","Nutrition--Géorgie (État)--Périodiques.","Georgia Government Documents--Serial"],"dcterms_title":["Nutrition risk criteria handbook FFY 2013: Georgia WIC Program nutrition unit"],"dcterms_type":["Text"],"dcterms_provenance":["University of Georgia. Map and Government Information Library"],"edm_is_shown_by":["https://dlg.galileo.usg.edu/do:dlg_ggpd_y-ga-bp780-b-ps1-bn8-b2013-belec-p-btext"],"edm_is_shown_at":["https://dlg.galileo.usg.edu/id:dlg_ggpd_y-ga-bp780-b-ps1-bn8-b2013-belec-p-btext"],"dcterms_temporal":null,"dcterms_rights_holder":null,"dcterms_bibliographic_citation":null,"dlg_local_right":null,"dcterms_medium":["state government records"],"dcterms_extent":null,"dlg_subject_personal":null,"iiif_manifest_url_ss":null,"dcterms_subject_fast":null,"fulltext":"Nutrition Risk Criteria Handbook FFY 2013 \r\nGeorgia WIC Program Nutrition Unit \r\n2 Peachtree Street NW Atlanta Georgia, 30303 \r\n404-657-2884 \r\nRevised 7-19-2012 \r\n \r\n Nutrition Risk Criteria Handbook FFY 3013 \r\nRevised 7/19/2012 \r\n1. Risk 344 Thyroid Disorder: Corrected Hyper/hypo thyroidism definitions (pages 9, 26, 46) \r\n2. 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 \r\nGrowth 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 \r\n\"Birth to 24\" growth charts (page 123 and 127) \r\n \r\n DATA AND DOCUMENTATION REQUIRED FOR WIC ASSESSMENT/CERTIFICATION \r\nPRENATAL WOMEN \r\n \r\nData \r\nHeight Pre-Pregnancy Weight \r\nCurrent Weight Hematocrit or Hemoglobin Prenatal Weight Grid Plotted Evaluation of Inappropriate Nutrition Practices \r\nRisk Factor Assessment \r\n \r\nPrenatal Women \r\nRequired Required Required Required Required Required Required \r\n \r\n1 \r\n \r\n NUTRITION RISK CRITERIA PREGNANT WOMEN \r\n \r\nNOTE: High Risk Criteria, as defined below, are to be used for referral purposes, not certification (See Appendix A-1) \r\n \r\nCODE \r\n \r\nPREGNANT WOMEN \r\n \r\nPRIORITY \r\n \r\n201 \r\n \r\nLOW HEMOGLOBIN/HEMATOCRIT \r\n \r\nI \r\n \r\n1st Trimester (0-13 wks): \r\n \r\nHemoglobin \r\n \r\nHematocrit \r\n \r\nNon-Smokers Smokers \r\n \r\n10.9 gm or lower 11.2 gm or lower \r\n \r\n32.9% or lower 33.9% or lower \r\n \r\n2nd Trimester (14-26 wks): Non-Smokers Smokers \r\n \r\n10.4 gm or lower 10.7 gm or lower \r\n \r\n31.9% or lower 32.9% or lower \r\n \r\n3rd Trimester (27-40 wks): Non-Smokers Smokers \r\n \r\n10.9 gm or lower 11.2 gm or lower \r\n \r\n32.9% or lower 33.9% or lower \r\n \r\nHigh Risk: Hemoglobin OR hematocrit at treatment level (Appendix B-1) \r\n \r\n101 \r\n \r\nUNDERWEIGHT \r\n \r\nI \r\n \r\nPre-pregnancy weight is equal to a Body Mass Index (BMI) of \u003c18.5. Refer to BMI Table, Appendix C-1. \r\n \r\nHigh Risk: Pre-pregnancy BMI \u003c18.5 \r\n \r\n111 \r\n \r\nOVERWEIGHT \r\n \r\nI \r\n \r\nPre-pregnancy weight is equal to a Body Mass Index of \u003e25. Refer to BMI Table, Appendix C-1. \r\n \r\nHigh Risk: Pre-pregnancy BMI \u003e29.9 \r\n \r\n131 \r\n \r\nLOW MATERNAL WEIGHT GAIN \r\n \r\nI \r\n \r\nLow 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. \r\n \r\nRefer to Appendix C-2. \r\n \r\nHigh Risk: Low Maternal Weight Gain \r\n \r\n2 \r\n \r\n CODE \r\n132 \r\n \r\nPREGNANT WOMEN \r\n \r\nPRIORITY \r\n \r\nGESTATIONAL WEIGHT LOSS DURING PREGNANCY \r\n \r\nI \r\n \r\n During first (0-13 weeks) trimester, any weight loss below pregravid weight; based on pregravid weight and current weight. \r\nOR \r\n During second and third trimesters (14-40 weeks gestation), \u003e2 lbs weight loss. Based on two weight measures recorded at 14 weeks gestation or later. \r\n \r\nDocument: Two weight measures as specified above \r\n \r\nHigh Risk: Weight loss of \u003e2 lbs in the second and third trimesters \r\n \r\n133 \r\n \r\nHIGH MATERNAL WEIGHT GAIN \r\n \r\nI \r\n \r\nHigh 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. \r\n \r\n211 \r\n \r\nELEVATED BLOOD LEAD LEVELS \r\n \r\nI \r\n \r\nBlood lead level of \u003e10 g/deciliter within the past 12 months. \r\n \r\nDocument: Date of blood test and blood lead level in the participant's health record. Must be within the past 12 months. \r\n \r\nHigh Risk: Blood lead level of \u003e10 g/deciliter within the past 12 months. \r\n \r\n301 \r\n \r\nHYPEREMESIS GRAVIDARUM \r\n \r\nI \r\n \r\nSevere nausea and vomiting to the extent that the pregnant woman becomes dehydrated and acidotic. \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and the name of the physician that is treating this condition in the participant's health record \r\n \r\nHigh Risk: Diagnosed hyperemesis gravidarum \r\n \r\n3 \r\n \r\n CODE 302 \r\n \r\nPREGNANT WOMEN \r\n \r\nPRIORITY \r\n \r\nGESTATIONAL DIABETES \r\n \r\nI \r\n \r\nGestational diabetes mellitus (GDM) is defined as any degree of glucose/carbohydrate intolerance with onset or first recognition during pregnancy. \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\n \r\nHigh Risk: Diagnosed gestational diabetes \r\n \r\n303 \r\n \r\nHISTORY OF GESTATIONAL DIABETES \r\n \r\nI \r\n \r\nHistory of diagnosed gestational diabetes mellitus (GDM) \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\n \r\nI \r\n \r\n304 \r\n \r\nHISTORY OF Preeclampsia \r\n \r\nHistory of diagnosed preeclampsia \r\n \r\nPresence 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 \r\nDocument: Diagnosis and name of the physician that treated this condition in the participant's health record. \r\n \r\n311 \r\n \r\nHISTORY OF PRETERM DELIVERY \r\n \r\nAny history of infant(s) born at 37 weeks gestation or less \r\n \r\nI \r\n \r\nDocument: Delivery date(s) and weeks gestation in participant's health record \r\n \r\n4 \r\n \r\n CODE \r\n \r\nPREGNANT WOMEN \r\n \r\nPRIORITY \r\n \r\n312 \r\n \r\nHISTORY OF LOW BIRTH WEIGHT INFANT(S) \r\n \r\nI \r\n \r\nWoman has delivered one (1) or more infants with a birth weight of less than or equal to 5 lb 8 oz (2500 gms). \r\n \r\nDocument: Weight(s) and birth date(s) in the participant's health record \r\n \r\n321 \r\n \r\nHISTORY OF FETAL OR NEONATAL DEATH \r\n \r\nI \r\n \r\nAny fetal death(s) (death greater than or equal to 20 weeks gestation) or neonatal death(s) (death occurring from 0-28 days of life). \r\n \r\nDocument: 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. \r\n \r\n331 \r\n \r\nPREGNANCY AT A YOUNG AGE \r\n \r\nI \r\n \r\nFor current pregnancy, EDC at less than 18 years and 10 months of age. \r\n \r\nDocument: Expected date of delivery (EDC) on the WIC Assessment/ Certification Form \r\n \r\nHigh Risk: EDC at less than 17 years of age \r\n \r\n332 \r\n \r\nCLOSELY SPACED PREGNANCIES \r\n \r\nI \r\n \r\nFor current pregnancy, the participant's EDC is less than 25 months after the termination of the last pregnancy. \r\n \r\nDocument: Termination date of last pregnancy and EDC in the participant's health record \r\n \r\n5 \r\n \r\n CODE 333 \r\n \r\nPREGNANT WOMEN \r\nHIGH 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 \r\nduration, 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 \r\n \r\nPRIORITY I \r\n \r\n334 \r\n \r\nLACK OF, OR INADEQUATE PRENATAL CARE \r\n \r\nI \r\n \r\nPrenatal care beginning after the 1st trimester (0-13 weeks) \r\n \r\nDocument: Weeks gestation, in participant's health record, when prenatal care began. A pregnancy test is not prenatal care. \r\n \r\n335 \r\n \r\nMULTI-FETAL GESTATION \r\n \r\nI \r\n \r\nMore than one (\u003e1) fetus in a current pregnancy. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\n \r\nHigh Risk: Multi-fetal gestation \r\n \r\n336 \r\n \r\nFETAL GROWTH RESTRICTION \r\n \r\nI \r\n \r\nFetal 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 \u003c10th percentile for gestational age. \r\n \r\nPresence 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. \r\n \r\nFetal Growth Restriction (FGR) must be diagnosed by a physician or a health professional acting under standing orders of a physician. \r\n \r\nDocument: Diagnosis in participant's health record High Risk: Fetal Growth Restriction \r\n \r\n6 \r\n \r\n CODE 337 \r\n338 \r\n \r\nPREGNANT WOMEN \r\n \r\nPRIORITY \r\n \r\nHISTORY OF BIRTH OF A LARGE FOR GESTATIONAL AGE INFANT \r\n \r\nI \r\n \r\nPrenatal woman has delivered one (1) or more infants with a birth weight of 9 pounds (4000 gm) or more. \r\n \r\nDocument: Birth weight(s) in the participant's health record \r\n \r\nPREGNANT WOMAN CURRENTLY BREASTFEEDING \r\n \r\nI \r\n \r\nBreastfeeding woman who is now pregnant. \r\n \r\nNote: 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. \r\n \r\n339 \r\n \r\nHISTORY OF BIRTH WITH NUTRITION RELATED CONGENITAL OR BIRTH \r\n \r\nDEFECT(S) \r\n \r\nI \r\n \r\nA 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). \r\n \r\nDocument: Infant(s) congenital and/or birth defect(s) in participant's health record \r\n \r\n7 \r\n \r\n PREGNANT WOMEN \r\nCODE \r\nNUTRITION RELATED MEDICAL CONDITIONS \r\n \r\n341 \r\n \r\nNUTRIENT DEFICIENCY DISEASES \r\n \r\nDiagnosis 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) \r\n \r\nThe 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\n \r\nHigh Risk: Diagnosed nutrient deficiency disease \r\n \r\nPRIORITY I \r\n \r\n342 \r\n \r\nGASTRO-INTESTINAL DISORDERS: \r\n \r\nI \r\n \r\nDiseases 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 \r\n \r\nThe 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\n \r\nHigh Risk: Diagnosed gastro-intestinal disorder \r\n \r\n8 \r\n \r\n CODE 343 \r\n \r\nPREGNANT WOMEN \r\n \r\nPRIORITY \r\n \r\nDIABETES MELLITUS \r\n \r\nI \r\n \r\nDiabetes mellitus consists of a group of metabolic diseases characterized by inappropriate hyperglycemia resulting from defects in insulin secretion, insulin action or both. \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\n \r\nHigh Risk: Diagnosed diabetes mellitus \r\n \r\n344 \r\n \r\nTHYROID DISORDERS \r\n \r\nI \r\n \r\nThyroid 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: \r\n Hyperthyroidism: Excessive thyroid hormone production (most commonly known as Graves' disease and toxic multinodular goiter). \r\n 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\n \r\nHigh Risk: Diagnosed thyroid disorder \r\n \r\n345 \r\n \r\nHYPERTENSION \r\n \r\nI \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\n \r\nHigh Risk: Diagnosed hypertension \r\n \r\n9 \r\n \r\n CODE 346 \r\n347 \r\n \r\nPREGNANT WOMEN \r\nRENAL DISEASE \r\nAny 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. \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\nHigh Risk: Diagnosed renal disease \r\nCANCER \r\nA 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. \r\nPresence 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. \r\nDocument: 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. \r\nHigh Risk: Diagnosed cancer \r\n \r\nPRIORITY I \r\nI \r\n \r\n348 \r\n \r\nCENTRAL NERVOUS SYSTEM DISORDERS \r\n \r\nI \r\n \r\nConditions 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. \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and the name of the physician that is treating this condition in the participant's health record. \r\n \r\nHigh Risk: Diagnosed central nervous system disorder \r\n \r\n10 \r\n \r\n CODE 349 \r\n \r\nPREGNANT WOMEN \r\n \r\nPRIORITY \r\n \r\nGENETIC AND CONGENITAL DISORDERS \r\n \r\nI \r\n \r\nHereditary 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. \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and the name of the physician that is treating this condition in the participant's health record. \r\n \r\nHigh Risk: Diagnosed genetic/congenital disorder \r\n \r\n351 \r\n \r\nINBORN ERRORS OF METABOLISM \r\n \r\nI \r\n \r\nGene 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. \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and the name of the physician that is treating this condition in the participant's health record. \r\n \r\nHigh Risk: Diagnosed inborn error of metabolism \r\n \r\n11 \r\n \r\n CODE \r\n \r\nPREGNANT WOMEN \r\n \r\nPRIORITY \r\n \r\n352 \r\n \r\nINFECTIOUS DISEASES \r\n \r\nI \r\n \r\nA 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. \r\n \r\nThe 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. \r\n \r\nDocument: 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. \r\n \r\nHigh Risk: Diagnosed infectious disease, as described above \r\n \r\n353 \r\n \r\nFOOD ALLERGIES \r\n \r\nI \r\n \r\nAn adverse immune response to a food or a hypersensitivity that causes adverse immunologic reaction. \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and the name of the physician that is treating this condition in the participant's health record. \r\n \r\nHigh Risk: Diagnosed food allergy \r\n \r\n12 \r\n \r\n CODE 354 \r\n \r\nPREGNANT WOMEN \r\nCELIAC DISEASE \r\nAlso known as Celiac Sprue, Gluten Enteropathy, or Non-tropical Sprue. \r\nInflammatory condition of the small intestine precipitated by the ingestion of wheat in individuals with certain genetic make-up. \r\nPresence 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. \r\nDocument: Diagnosis and the name of the physician that is treating this condition in the participant's health record. \r\nHigh Risk: Diagnosed Celiac Disease \r\n \r\nPRIORITY I \r\n \r\n355 \r\n \r\nLACTOSE INTOLERANCE \r\n \r\nI \r\n \r\nLactose 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. \r\nPresence 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. \r\n \r\nDocument: Diagnosis and the name of the physician that is treating this condition \r\nin the participant's health record; OR list of symptoms described by the applicant/participant/caregiver (i.e., nausea, cramps, abdominal bloating, and/or diarrhea). \r\n \r\n356 \r\n \r\nHYPOGLYCEMIA \r\n \r\nI \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and the name of the physician that is treating this condition in the participant's health record. \r\nHigh Risk: Diagnosed hypoglycemia \r\n \r\n13 \r\n \r\n CODE 357 \r\n \r\nPREGNANT WOMEN \r\nDRUG/NUTRIENT INTERACTIONS \r\nUse 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. \r\nDocument: Drug/medication being used and respective nutrient interaction in the participant's health record. \r\nHigh Risk: Use of drug or medication shown to interfere with nutrient intake or utilization, to extent that nutritional status is compromised. \r\n \r\nPRIORITY I \r\n \r\n358 \r\n \r\nEATING DISORDERS \r\n \r\nI \r\n \r\nEating disorders (anorexia nervosa and bulimia), are characterized by a disturbed \r\n \r\nsense of body image and morbid fear of becoming fat. Symptoms are manifested by \r\n \r\nabnormal eating patterns including, but not limited to: \r\n \r\n \r\n \r\nSelf-induced vomiting \r\n \r\n \r\n \r\nPurgative abuse \r\n \r\n \r\n \r\nAlternating periods of starvation \r\n \r\n \r\n \r\nUse of drugs such as appetite suppressants, thyroid preparations or \r\n \r\ndiuretics \r\n \r\n \r\n \r\nSelf-induced marked weight loss \r\n \r\nPresence 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. \r\n \r\nDocument: Symptoms or diagnosis and the name of the physician that is treating this condition in the participant's health record. \r\n \r\nHigh Risk: Diagnosed eating disorder \r\n \r\n14 \r\n \r\n CODE 359 \r\n \r\nPREGNANT WOMEN \r\n \r\nPRIORITY \r\n \r\nRECENT MAJOR SURGERY, TRAUMA OR BURNS \r\n \r\nI \r\n \r\nMajor surgery (including C-sections), trauma or burns severe enough to compromise nutritional status. Any occurrence within the past 2 months may be self reported. \r\nAny 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. \r\n \r\nDocument: 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. \r\n \r\nHigh Risk: Major surgery, trauma or burns that has a continued need for nutritional support. \r\n \r\n360 \r\n \r\nOTHER MEDICAL CONDITIONS \r\n \r\nI \r\n \r\nDiseases or conditions with nutritional implications that are not included in any of the other medical conditions. The current condition, or treatment for the condition, \r\nMUST 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. \r\n \r\nPresence 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. \r\n \r\nDocument: 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. \r\n \r\nHigh Risk: Diagnosed medical condition severe enough to compromise nutritional status \r\n \r\n361 \r\n \r\nDEPRESSION \r\n \r\nI \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and name of physician that is treating this condition in the participant's health record \r\n \r\n15 \r\n \r\n CODE 362 \r\n \r\nPREGNANT WOMEN \r\nDEVELOPMENTAL, SENSORY OR MOTOR DELAYS INTERFERING WITH THE ABILITY TO EAT \r\nDevelopmental, 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. \r\nDocument: 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. \r\nHigh Risk: Developmental, sensory or motor delay interfering with ability to eat. \r\n \r\nPRIORITY I \r\n \r\n371 \r\n \r\nMATERNAL SMOKING \r\n \r\nI \r\n \r\nAny smoking of cigarettes, pipes or cigars. \r\n \r\nDocument: Number of cigarettes or cigars smoked, or number of times pipe smoked, on WIC Assessment/Certification Form. See Appendix E-1 for documentation codes. \r\n \r\n372 \r\n \r\nALCOHOL AND ILLEGAL DRUG USE \r\n \r\nI \r\n \r\nAny alcohol use: \r\n \r\nA serving of standard sized drink (1  ounce of alcohol) is:  1 can of beer (12 fluid oz)  5 oz wine  1  fluid oz liquor \r\nBinge drinking is defined as \u003e 5 drinks on the same occasion on at least one day in the past 30 days \r\nHeavy drinking is defined as \u003e 5 drinks on the same occasion on five or more days in the past 30 days \r\nDocument: Enter the number of servings of alcohol per week on the WIC Assessment/Certification Form. See Appendix E-1 for documentation codes. \r\n \r\nAny illegal drug use: \r\nDocument: Type of drug(s) being used. See Appendix E-2 for commonly used illegal drug names. \r\n \r\n16 \r\n \r\n CODE 381 \r\n \r\nPREGNANT WOMEN \r\n \r\nPRIORITY \r\n \r\nDENTAL PROBLEMS \r\n \r\nI \r\n \r\nDiagnosis 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. \r\n \r\nDocument: In the participant's health record, a description of how the dental problem interferes with mastication and/or has other nutritionally related health problems. \r\n \r\n400 \r\n \r\nINAPPROPRIATE NUTRITION PRACTICES \r\n \r\nIV \r\n \r\nRoutine nutrition practices that may result in impaired nutrient status, disease, or health problems. (Appendix G) \r\n \r\nDocument: Inappropriate Nutrition Practice(s) in the participant's health record. \r\n \r\n401 \r\n \r\nFAILURE TO MEET DIETARY GUIDELINES \r\n \r\nIV \r\n \r\nA 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. \r\n \r\n(This risk factor may be assigned only when a woman does not qualify for risk 400 or for any other risk factor.) \r\n \r\n502 \r\n \r\nTRANSFER OF CERTIFICATION \r\n \r\nI, IV \r\n \r\nPerson 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. \r\n \r\nThis 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. \r\n \r\n17 \r\n \r\n CODE 801 \r\n \r\nPREGNANT WOMEN \r\nHOMELESSNESS Homelessness as defined in the Special Populations Section of the Georgia WIC Program Procedure Manual. \r\n \r\nPRIORITY IV \r\n \r\n802 \r\n \r\nMIGRANCY \r\n \r\nIV \r\n \r\nMigrancy as defined in the Special Populations Section of the Georgia WIC Program Procedures Manual. \r\n \r\n901 \r\n \r\nRECIPIENT OF ABUSE \r\n \r\nBattering (abuse) within past 6 months as self-reported, or as documented by a \r\n \r\nIV \r\n \r\nsocial worker, health care provider or on other appropriate documents, or as \r\n \r\nreported through consultation with a social worker, health care provider or other \r\n \r\nappropriate personnel. \r\n \r\nBattering refers to violent assaults on women. \r\n \r\n902 \r\n \r\nPRENATAL WOMAN WITH LIMITED ABILITY TO MAKE FEEDING \r\n \r\nIV \r\n \r\nDECISIONS AND/OR PREPARE FOOD \r\n \r\nWoman who is assessed to have limited ability to make appropriate feeding decisions and/or prepare food. Examples may include: \r\n \r\n mental disability / delay and/or mental illness such as clinical depression (diagnosed by a physician or licensed psychologist) \r\n physical disability which restricts or limits food preparation abilities  current use of or history of abusing alcohol or other drugs \r\nDocument: The women's specific limited abilities in the participant's health record. \r\n \r\nIV \r\n \r\n903 \r\n \r\nFoster Care \r\n \r\nEntering 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. \r\n \r\n904 \r\n \r\nENVIRONMENTAL TOBACCO SMOKE EXPOSURE \r\n \r\nI \r\n \r\nEnvironmental tobacco smoke (ETS) exposure is defined as exposure to smoke from tobacco products inside the home. \r\n \r\n18 \r\n \r\n DATA AND DOCUMENTATION REQUIRED FOR WIC ASSESSMENT/CERTIFICATION \r\nBREASTFEEDING WOMEN \r\n \r\nData \r\n \r\nBreastfeeding and Non-Breastfeeding Woman Certified in \r\nHospital Prior to Initial Discharge \r\n \r\nHeight \r\n \r\nPre-pregnancy height from health record; self reported if not available from record \r\n \r\nPre-Pregnancy Weight \r\n \r\nPre-pregnancy weight from health record; self reported if not available from record \r\n \r\nCurrent Weight \r\n \r\nIf available \r\n \r\nLast Weight Before Delivery \r\n \r\nRequired \r\n \r\nHemoglobin or Hematocrit \r\n \r\nRequired (Apply 90-day rule when not available) \r\n \r\nEvaluation of Inappropriate Nutrition Practices \r\n \r\nRequired \r\n \r\nRisk Factor Assessment \r\n \r\nRequired \r\n \r\nWoman Certified in Clinic \r\nRequired \r\nRequired Required Required Required Required Required \r\n \r\nBreastfeeding Woman MidAssessment \r\nRequired \r\nRequired Required Required Optional \r\nRequired Required \r\n \r\n19 \r\n \r\n NUTRITION RISK CRITERIA BREASTFEEDING WOMEN \r\n \r\nNOTE: High Risk Criteria, as defined below, are to be used for referral purposes, not \r\n \r\ncertification (See Appendix A-1) \r\n \r\nBREASTFEEDING WOMEN \r\n \r\nCODE \r\n \r\nPRIORITY \r\n \r\n201 \r\n \r\nLOW HEMOGLOBIN/HEMATOCRIT \r\n \r\nI \r\n \r\nNon-Smokers: \r\n \r\nHemoglobin: Hematocrit: \r\n \r\n11.9 gm or lower (\u003e 15 years of age) 11.7 gm or lower (\u003c 15 years of age) 35.8% or lower \r\n \r\nSmokers: \r\n \r\nHemoglobin: Hematocrit: \r\n \r\n12.2 gm or lower (\u003e 15 years of age) 12.0 gm or lower (\u003c 15 years of age) 36.8% or lower \r\n \r\nHigh Risk: Hemoglobin OR hematocrit at treatment level (Appendix B-1) \r\n \r\n101 \r\n \r\nUNDERWEIGHT \r\n \r\nI \r\n \r\n\u003c 6 months Postpartum: \r\nPre-pregnancy or current weight is equal to a Body Mass Index (BMI) of \u003c18.5. Refer to BMI Table, Appendix C-1. \r\n \r\n 6 months Postpartum: \r\nCurrent weight is equal to a Body Mass Index (BMI) of \u003c18.5. Refer to BMI Table, Appendix C-1. \r\n \r\nHigh Risk: Current BMI \u003c18.5 \r\n \r\n111 \r\n \r\nOVERWEIGHT \r\n \r\nI \r\n \r\n\u003c6 months Postpartum: Pre-pregnancy weight is equal to a Body Mass Index (BMI) of \u003e25. Refer to BMI Table, Appendix C-1. \r\n \r\n 6 months Postpartum: \r\nCurrent weight is equal to a Body Mass Index (BMI) of \u003e25. Refer to BMI Table, Appendix C-1. \r\n \r\nHigh Risk: Current BMI \u003e29.9 \r\n \r\n20 \r\n \r\n CODE \r\n \r\nBREASTFEEDING WOMEN \r\n \r\n133 \r\n \r\nHIGH MATERNAL WEIGHT GAIN \r\n \r\nBreastfeeding (most recent pregnancy only): total gestational weight gain exceeding the upper limit of the recommended range based on Body Mass Index (BMI), as follows: \r\n \r\nPRIORITY I \r\n \r\nPrepregnancy Weight Group \r\n \r\nDefinition (BMI) \r\n \r\nCut-off Value (Singleton) \r\n \r\nCut-off Value (Multi-Fetal) \r\n \r\nUnderweight \r\n \r\n\u003c 18.5 \r\n \r\n\u003e40 lbs \r\n \r\n* \r\n \r\nNormal Weight \r\n \r\n18.5 to 24.9 \r\n \r\n\u003e35 lbs \r\n \r\n\u003e54 lbs \r\n \r\nOverweight \r\n \r\n25.0 to 29.9 \r\n \r\n\u003e25 lbs \r\n \r\n\u003e50 lbs \r\n \r\nObese \r\n \r\n\u003e 30.0 \r\n \r\n\u003e20 lbs \r\n \r\n\u003e42 lbs \r\n \r\n*There are no provisional guidelines for underweight woman with multiple \r\n \r\nfetuses. (Appendix C-2) \r\n \r\nDocument: Pre-gravid weight and last weight before delivery \r\n \r\n211 \r\n \r\nELEVATED BLOOD LEAD LEVELS \r\n \r\nI \r\n \r\nBlood lead level of \u003e10 g/deciliter within the past 12 months. \r\n \r\nDocument: Date of blood test and blood lead level in the participant's health record. Must be within the past 12 months. \r\n \r\nHigh Risk: Blood lead level of \u003e10 g/deciliter within the past 12 months. \r\n \r\n303 \r\n \r\nHISTORY OF GESTATIONAL DIABETES \r\n \r\nI \r\n \r\nHistory of diagnosed gestational diabetes mellitus (GDM) \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\n \r\n21 \r\n \r\n CODE \r\n \r\nBREASTFEEDING WOMEN \r\n \r\n304 \r\n \r\nHISTORY OF PREECLAMPSIA \r\n \r\nHistory of diagnosed preeclampsia \r\n \r\nPresence 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. \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\n \r\nPRIORITY I \r\n \r\n311 \r\n \r\nDELIVERY OF PREMATURE INFANT(S) \r\n \r\nI \r\n \r\nWoman has delivered one (1) or more infants at 37 weeks gestation or less. Applies to most recent pregnancy only. \r\n \r\nDocument: Delivery date and weeks gestation in participant's health record \r\n \r\n312 \r\n \r\nDELIVERY OF LOW BIRTH WEIGHT INFANT(S) \r\n \r\nI \r\n \r\nWoman 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. \r\n \r\nDocument: Weight(s) and birth date in the participant's health record \r\n \r\n321 \r\n \r\nFETAL OR NEONATAL DEATH \r\n \r\nI \r\n \r\nA fetal death (death \u003e 20 weeks gestation) or a neonatal death (death occurring from 0-28 days of life). Applies to most recent pregnancy only. \r\n \r\nDocument: 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. \r\n \r\n22 \r\n \r\n CODE \r\n331 \r\n \r\nBREASTFEEDING WOMEN \r\nPREGNANCY AT A YOUNG AGE \r\n \r\nFor most recent pregnancy, delivery date at less than 18 years and 10 months of age. Applies to most recent pregnancy only. \r\n \r\nDocument: Delivery date on the WIC Assessment/Certification Form \r\n \r\nHigh Risk: Delivery date at less than 17 years of age \r\n \r\nPRIORITY I \r\n \r\n332 \r\n \r\nCLOSELY SPACED PREGNANCIES \r\n \r\nI \r\n \r\nDelivery date for most recent pregnancy occurred less than 25 months after the termination of the previous pregnancy. \r\n \r\nDocument: Termination dates of last two pregnancies in the participant's health record. \r\n \r\n333 \r\n \r\nHIGH PARITY AND YOUNG AGE \r\n \r\nI \r\n \r\nThe following two (2) conditions must both apply: \r\n \r\n1. The woman is under age 20 at date of conception AND \r\n \r\n2. She has had 3 or more pregnancies of at least 20 weeks duration (regardless of birth outcome), previous to the most recent pregnancy. \r\n \r\nDocument: Delivery date; number of pertinent previous pregnancies (of at least 20 weeks gestation) and weeks gestation for each, in the participant's health record. \r\n \r\n335 \r\n \r\nMULTI FETAL GESTATION \r\n \r\nI \r\n \r\nMore than one (\u003e1) fetus in the most recent pregnancy \r\n \r\nHigh Risk: Multi-fetal gestation \r\n \r\n337 \r\n \r\nHISTORY OF A LARGE FOR GESTATIONAL AGE INFANT \r\n \r\nI \r\n \r\nMost recent pregnancy, or history of giving birth to an infant with a birth weight of \r\n \r\n9 pounds or more. \r\n \r\nDocument: Birth weight(s) and date(s) of deliveries in the participant's health record. \r\n23 \r\n \r\n CODE \r\n339 \r\n \r\nBREASTFEEDING WOMEN \r\nBIRTH WITH NUTRITION RELATED CONGENITAL OR BIRTH DEFECT(S) \r\nA 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. \r\nDocument: Infant(s) congenital and/or birth defect(s) in participant's health record \r\n \r\nPRIORITY I \r\n \r\nNUTRITION RELATED MEDICAL CONDITIONS \r\n \r\nI \r\n \r\n341 \r\n \r\nNUTRIENT DEFICIENCY DISEASES \r\n \r\nDiagnosis 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) \r\n \r\nThe 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in participant's health record. \r\n \r\nHigh Risk: Diagnosed nutrient deficiency disease \r\n \r\n24 \r\n \r\n CODE \r\n \r\nBREASTFEEDING WOMEN \r\n \r\nPRIORITY \r\n \r\n342 \r\n \r\nGASTRO-INTESTINAL DISORDERS \r\n \r\nI \r\n \r\nDiseases or conditions that interfere with the intake, digestion, and or absorption of nutrients. The diseases and/or conditions include, but are not limited to: \r\n Gastroesophageal reflux disease (GERD)  Peptic ulcer  Post-bariatric surgery  Short bowel syndrome  Inflammatory bowel disease, including ulcerative colitis or Crohn's \r\ndisease \r\n Liver disease  Pancreatitis  Biliary tract disease \r\n \r\nThe 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\n \r\nHigh Risk: Diagnosed gastro-intestinal disorder \r\n \r\n343 \r\n \r\nDIABETES MELLITUS \r\n \r\nI \r\n \r\nDiabetes mellitus consists of a group of metabolic diseases characterized by inappropriate hyperglycemia resulting from defects in insulin secretion, insulin action or both. \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\n \r\nHigh Risk: Diagnosed diabetes mellitus \r\n \r\n25 \r\n \r\n CODE \r\n344 \r\n \r\nBREASTFEEDING WOMEN \r\n \r\nPRIORITY \r\n \r\nTHYROID DISORDERS \r\n \r\nI \r\n \r\nThyroid 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: \r\n Hyperthyroidism: Excessive thyroid hormone production (most commonly known as Graves' disease and toxic multinodular goiter). \r\n 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. \r\n 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\n \r\nHigh Risk: Diagnosed thyroid disorder \r\n \r\n345 \r\n \r\nHYPERTENSION \r\n \r\nI \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\nHigh Risk: Diagnosed hypertension \r\n \r\n346 \r\n \r\nRENAL DISEASE \r\n \r\nI \r\n \r\nAny renal disease including pyelonephritis and persistent proteinuria, but \r\nEXCLUDING 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in participant's health record. \r\n \r\nHigh Risk: Diagnosed renal disease \r\n \r\n26 \r\n \r\n CODE \r\n \r\nBREASTFEEDING WOMEN \r\n \r\nPRIORITY \r\n \r\n347 \r\n \r\nCANCER \r\n \r\nI \r\n \r\nA chronic disease whereby populations of cells have acquired the ability to multiply and spread without the usual biologic restraints. The current \r\ncondition, or the treatment for the condition, must be severe enough to affect nutritional status. \r\n \r\nPresence 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. \r\n \r\nDocument: 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. \r\n \r\nHigh Risk: Diagnosed cancer \r\n \r\n348 \r\n \r\nCENTRAL NERVOUS SYSTEM DISORDERS \r\n \r\nI \r\n \r\nConditions 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. \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in participant's health record. \r\n \r\nHigh Risk: Diagnosed central nervous system disorder \r\n \r\n27 \r\n \r\n CODE \r\n \r\nBREASTFEEDING WOMEN \r\n \r\nPRIORITY \r\n \r\n349 \r\n \r\nGENETIC AND CONGENITAL DISORDERS \r\n \r\nI \r\n \r\nHereditary 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. \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in participant's health record. \r\n \r\nHigh Risk: Diagnosed genetic/congenital disorder \r\n \r\n351 \r\n \r\nINBORN ERRORS OF METABOLISM \r\n \r\nI \r\n \r\nGene 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. \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in participant's health record. \r\n \r\nHigh Risk: Diagnosed inborn error of metabolism \r\n \r\n28 \r\n \r\n CODE \r\n \r\nBREASTFEEDING WOMEN \r\n \r\nPRIORITY \r\n \r\n352 \r\n \r\nINFECTIOUS DISEASES \r\n \r\nI \r\n \r\nA 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. \r\n \r\nThe 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. \r\n \r\nDocument: 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. \r\n \r\nHigh Risk: Diagnosed infectious disease, as described above \r\n \r\n353 \r\n \r\nFOOD ALLERGIES \r\n \r\nI \r\n \r\nAn adverse immune response to a food or a hypersensitivity that causes adverse immunologic reaction. \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in participant's health record. \r\n \r\nHigh Risk: Diagnosed food allergy \r\n \r\n29 \r\n \r\n CODE \r\n \r\nBREASTFEEDING WOMEN \r\n \r\nPRIORITY \r\n \r\n354 \r\n \r\nCELIAC DISEASE \r\n \r\nI \r\n \r\nAlso known as Celiac Sprue, Gluten Enteropathy, or Non-tropical Sprue. \r\n \r\nInflammatory condition of the small intestine precipitated by the ingestion of wheat in individuals with certain genetic make-up. \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in participant's health record. \r\n \r\nHigh Risk: Diagnosed Celiac Disease \r\n \r\n355 \r\n \r\nLACTOSE INTOLERANCE \r\n \r\nI \r\n \r\nLactose 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. \r\nPresence 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. \r\n \r\nDocument: Diagnosis and the name of the physician that is treating this \r\ncondition 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). \r\n \r\n30 \r\n \r\n CODE \r\n \r\nBREASTFEEDING WOMEN \r\n \r\nPRIORITY \r\n \r\n356 \r\n \r\nHYPOGLYCEMIA \r\n \r\nI \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and the name of the physician that is treating this condition in the participant's health record. \r\nHigh Risk: Diagnosed hypoglycemia \r\n \r\n357 \r\n \r\nDRUG/NUTRIENT INTERACTIONS \r\n \r\nI \r\n \r\nUse 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. \r\n \r\nDocument: Drug/medication being used and respective nutrient interaction in the participant's health record. \r\n \r\nHigh Risk: Use of drug or medication shown to interfere with nutrient intake or utilization, to extent that nutritional status is compromised. \r\n \r\n31 \r\n \r\n CODE \r\n \r\nBREASTFEEDING WOMEN \r\n \r\nPRIORITY \r\n \r\n358 \r\n \r\nEATING DISORDERS \r\n \r\nI \r\n \r\nEating disorders (anorexia nervosa and bulimia), are characterized by a \r\n \r\ndisturbed sense of body image and morbid fear of becoming fat. Symptoms \r\n \r\nare manifested by abnormal eating patterns including, but not limited to: \r\n \r\n \r\n \r\nSelf-induced vomiting \r\n \r\n \r\n \r\nPurgative abuse \r\n \r\n \r\n \r\nAlternating periods of starvation \r\n \r\n \r\n \r\nUse of drugs such as appetite suppressants, thyroid preparations \r\n \r\nor diuretics \r\n \r\n \r\n \r\nSelf-induced marked weight loss \r\n \r\nPresence 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. \r\n \r\nDocument: Symptoms or diagnosis and the name of the physician that is treating this condition in the participant's health record. \r\n \r\nHigh Risk: Diagnosed eating disorder \r\n \r\n359 \r\n \r\nRECENT MAJOR SURGERY, TRAUMA OR BURNS \r\n \r\nI \r\n \r\nMajor surgery (including C-sections), trauma or burns severe enough to compromise nutritional status. Any occurrence within the past 2 months may \r\nbe 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. \r\n \r\nDocument: 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. \r\n \r\nHigh Risk: Major surgery, trauma or burns that has a continued need for nutritional support. \r\n \r\n32 \r\n \r\n CODE \r\n \r\nBREASTFEEDING WOMEN \r\n \r\nPRIORITY \r\n \r\n360 \r\n \r\nOTHER MEDICAL CONDITIONS \r\n \r\nI \r\n \r\nDiseases or conditions with nutritional implications that are not included in any of the other medical conditions. The current condition, or treatment for \r\nthe 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. \r\n \r\nPresence 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. \r\n \r\nDocument: 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. \r\n \r\nHigh Risk: Diagnosed medical condition severe enough to compromise nutritional status \r\n \r\n361 \r\n \r\nDEPRESSION \r\n \r\nI \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in participant's health record. \r\n \r\n33 \r\n \r\n CODE \r\n \r\nBREASTFEEDING WOMEN \r\n \r\nPRIORITY \r\n \r\n362 \r\n \r\nDEVELOPMENTAL, SENSORY OR MOTOR DELAYS INTERFERING WITH \r\n \r\nI \r\n \r\nABILITY TO EAT \r\n \r\nDevelopmental, 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. \r\n \r\nDocument: 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. \r\n \r\nHigh Risk: Developmental, sensory or motor delay interfering with ability to eat. \r\n \r\nI \r\n \r\n363 \r\n \r\nPRE-DIABETES \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\n \r\nHigh Risk: Diagnosed pre-diabetes \r\n \r\n371 \r\n \r\nMATERNAL SMOKING \r\n \r\nI \r\n \r\nAny smoking of cigarettes, pipes or cigars. \r\n \r\nDocument: Number of cigarettes or cigars smoked, or number of times pipe smoked, on WIC Assessment/Certification Form. \r\n \r\n34 \r\n \r\n CODE \r\n \r\nBREASTFEEDING WOMEN \r\n \r\nPRIORITY \r\n \r\n372 \r\n \r\nALCOHOL AND ILLEGAL DRUG USE \r\n \r\nI \r\n \r\nAlcohol use: \r\n Routine current use of \u003e 2 drinks per day OR \r\n Binge drinking is defined as \u003e5 drinks on the same occasion on at least one day in the past 30 days, OR \r\n Heavy drinking is defined as \u003e5 drinks on the same occasion on five or more days in the past 30 days \r\n \r\nA serving of standard sized drink (1  ounce of alcohol) is: - 1 can of beer (12 fluid oz) - 5 oz wine - 1  fluid oz liquor \r\n \r\nDocument: Alcohol Use; identify type (Routine - Enter oz./wk: ___, Binge drinker, Heavy drinker) on WIC Assessment/Certification Form. \r\n \r\nSee Appendix E-1 for documentation codes. \r\n \r\nAny Illegal drug use: \r\nDocument: Type of drug(s) being used. See Appendix E-2 for commonly used illegal drug names. \r\n \r\n381 \r\n \r\nDENTAL PROBLEMS \r\n \r\nI \r\n \r\nDiagnosis 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. \r\n \r\nDocument: In the participant's health record, a description of how the dental problem interferes with mastication and/or has other nutritionally related health problems. \r\n \r\n35 \r\n \r\n CODE \r\n \r\nBREASTFEEDING WOMEN \r\n \r\n400 \r\n \r\nINAPPROPRIATE NUTRITION PRACTICES \r\n \r\nRoutine nutrition practices that may result in impaired nutrient status, \r\ndisease, or health problems. (Appendix G) \r\n \r\nDocument: Inappropriate Nutrition Practice(s) in the participant's health record. \r\n \r\nPRIORITY IV \r\n \r\n401 \r\n \r\nFAILURE TO MEET DIETARY GUIDELINES \r\n \r\nIV \r\n \r\nA woman who meets eligibility requirements based on category, income, and residency but who does not have any other identified nutritional risk factor \r\nmay be presumed to be at nutritional risk based on failure to meet the Dietary Guidelines for Americans. \r\n \r\n(This risk factor may be assigned only when a woman does not qualify for risk 400 or for any other risk factor.) \r\n \r\n502 \r\n \r\nTRANSFER OF CERTIFICATION \r\n \r\nI, II, IV \r\n \r\nPerson 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. \r\n \r\nThis 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. \r\n \r\n601 \r\n \r\nBREASTFEEDING AN INFANT AT NUTRITIONAL RISK \r\n \r\nI, II, IV \r\n \r\nA breastfeeding woman whose breastfed infant has been determined to be at nutritional risk. \r\n \r\nDocument: Infant's risks on mother's WIC Assessment/Certification Form. \r\n \r\n36 \r\n \r\n CODE \r\n \r\nBREASTFEEDING WOMEN \r\n \r\nPRIORITY \r\n \r\n602 \r\n \r\nBREASTFEEDING COMPLICATIONS OR POTENTIAL COMPLICATIONS \r\n \r\nI \r\n \r\nA breastfeeding woman with any of the following complications or potential complications for breastfeeding. \r\n \r\na. severe breast engorgement b. recurrent plugged ducts c. mastitis d. flat or inverted nipples e. cracked, bleeding or severely sore nipples f. age \u003e 40 years g. failure of milk to come in by 4 days postpartum h. tandem nursing (nursing two siblings who are not twins) \r\n \r\nDocument: Complications or potential complications in the participant's health record. \r\n \r\nHigh Risk: Refer to or provide the mother with appropriate breastfeeding counseling. \r\n \r\n801 \r\n \r\nHOMELESSNESS \r\n \r\nIV \r\n \r\nHomelessness as defined in the Special Populations Section of the Georgia WIC Program Procedures Manual. \r\n \r\n802 \r\n \r\nMIGRANCY \r\n \r\nIV \r\n \r\nMigrancy as defined in the Special Population Section of the Georgia WIC Program Procedures Manual. \r\n \r\n901 \r\n \r\nRECIPIENT OF ABUSE \r\n \r\nIV \r\n \r\nBattering within past 6 months as self-reported, or as documented by a social \r\n \r\nworker, health care provider or on other appropriate documents, or as \r\n \r\nreported through consultation with a social worker, health care provider or \r\n \r\nother appropriate personnel. \r\n \r\nBattering refers to violent assaults on women. \r\n \r\n37 \r\n \r\n CODE \r\n \r\nBREASTFEEDING WOMEN \r\n \r\nPRIORITY \r\n \r\n902 \r\n \r\nBREASTFEEDING WOMAN WITH LIMITED ABILITY TO MAKE FEEDING \r\n \r\nIV \r\n \r\nDECISIONS AND/OR PREPARE FOOD \r\n \r\nWoman who is assessed to have limited ability to make appropriate feeding decisions and/or prepare food. Examples may include: \r\n \r\n mental disability / delay and/or mental illness such as clinical depression (diagnosed by a physician or licensed psychologist) \r\n physical disability which restricts or limits food preparation abilities \r\n current use of or history of abusing alcohol or other drugs \r\n \r\nDocument: The women's specific limited abilities in the participant's health record. \r\n \r\n903 \r\n \r\nFoster Care \r\n \r\nIV \r\n \r\nEntering 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. \r\n \r\n904 \r\n \r\nENVIRONMENTAL TOBACCO SMOKE EXPOSURE \r\n \r\nI \r\n \r\nEnvironmental tobacco smoke (ETS) exposure is defined as exposure to smoke from tobacco products inside the home. \r\n \r\n38 \r\n \r\n DATA AND DOCUMENTATION REQUIRED FOR WIC ASSESSMENT/CERTIFICATION \r\nPOSTPARTUM NON-BREASTFEEDING WOMEN \r\n \r\nData \r\n \r\nWoman Certified in Hospital Prior to Initial \r\nDischarge \r\n \r\nHeight Pre-Pregnancy Weight Current Weight \r\n \r\nPre-pregnancy height from health record; self reported if not available from record \r\nPre-pregnancy weight from health record; self reported if not available from record \r\nIf available \r\n \r\nLast Weight Before Delivery \r\nHemoglobin or Hematocrit \r\nEvaluation of Inappropriate Nutrition Practices Risk Factor Assessment \r\n \r\nRequired Required (Apply 90-day rule when not available) \r\nRequired \r\nRequired \r\n \r\nWoman Certified in Clinic \r\nRequired \r\nRequired Required Required Required \r\nRequired Required \r\n \r\n39 \r\n \r\n NUTRITION RISK CRITERIA POSTPARTUM, NON- BREASTFEEDING WOMEN \r\n \r\nNOTE: High Risk Criteria, as defined below, are to be used for referral purposes, not certification (See Appendix A-1) \r\n \r\nPOSTPARTUM NON-BREASTFEEDING WOMEN \r\n \r\nCODE \r\n \r\nPRIORITY \r\n \r\n201 \r\n \r\nLOW HEMOGLOBIN/HEMATOCRIT \r\n \r\nVI \r\n \r\nNonSmokers: \r\n \r\nHemoglobin: Hematocrit: \r\n \r\n11.9 gm or lower (\u003e 15 years of age) 11.7 gm or lower (\u003c 15 years of age) \r\n35.8% or lower \r\n \r\nSmokers: \r\n \r\nHemoglobin: Hematocrit: \r\n \r\n12.2 gm or lower (\u003e 15 years of age) 12.0 gm or lower (\u003c 15 years of age) \r\n36.8% or lower \r\n \r\nHigh Risk: Hemoglobin OR hematocrit at treatment level (Appendix B-1) \r\n \r\n101 \r\n \r\nUNDERWEIGHT \r\n \r\nVI \r\n \r\nPre-pregnancy or current weight is equal to a Body Mass Index (BMI) of \u003c18.5. Refer to BMI Table, Appendix C-1. \r\n \r\nHigh Risk: Pre-pregnancy or current BMI \u003c18.5 \r\n \r\n111 \r\n \r\nOVERWEIGHT \r\n \r\nVI \r\n \r\nPre-pregnancy weight is equal to a Body Mass Index (BMI) of \u003e25. Refer to BMI Table, Appendix C-1. \r\n \r\nHigh Risk: Pre-pregnancy BMI \u003e29.9 \r\n \r\n40 \r\n \r\n CODE \r\n \r\nPOSTPARTUM NON-BREASTFEEDING WOMEN \r\n \r\nPRIORITY \r\n \r\n133 HIGH MATERNAL WEIGHT GAIN \r\n \r\nVI \r\n \r\nNon-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: \r\n \r\nPrepregnancy Weight Group \r\n \r\nDefinition (BMI) \r\n \r\nCut-off Value (Singleton) \r\n \r\nCut-off Value (Multi-Fetal) \r\n \r\nUnderweight Normal Weight \r\nOverweight Obese \r\n \r\n\u003c 18.5 18.5 to 24.9 25.0 to 29.9 \r\n\u003e 30.0 \r\n \r\n\u003e40 lbs \u003e35 lbs \u003e25 lbs \u003e20 lbs \r\n \r\n* \r\n\u003e54 lbs \u003e50 lbs \u003e42 lbs \r\n \r\n*There are no provisional guidelines for underweight woman with multiple \r\nfetuses. (Appendix C-2) \r\nDocument: Pre-gravid weight and last weight before delivery \r\n \r\n211 \r\n \r\nELEVATED BLOOD LEAD LEVELS \r\n \r\nVI \r\n \r\nBlood lead level of \u003e10 g/deciliter within the past 12 months. \r\n \r\nDocument: Date of blood test and blood lead level in the participant's health record. Must be within the past 12 months. \r\n \r\nHigh Risk: Blood lead level of \u003e10 g/deciliter within the past 12 months. \r\n \r\n303 \r\n \r\nHISTORY OF GESTATIONAL DIABETES \r\n \r\nVI \r\n \r\nHistory of diagnosed gestational diabetes mellitus (GDM) \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\n \r\n41 \r\n \r\n CODE 304 \r\n \r\nPOSTPARTUM NON-BREASTFEEDING WOMEN \r\nHISTORY OF PREECLAMPSIA History of diagnosed preeclampsia \r\n \r\nPRIORITY VI \r\n \r\nPresence 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. \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\n \r\n311 \r\n \r\nDELIVERY OF PREMATURE INFANT(S) \r\n \r\nVI \r\n \r\nWoman has delivered one (1) or more infants at 37 weeks gestation or less. Applies to most recent pregnancy only. \r\n \r\nDocument: Delivery date and weeks gestation in participant's health record \r\n \r\n312 \r\n \r\nDELIVERY OF LOW BIRTH WEIGHT INFANT(S) \r\n \r\nVI \r\n \r\nWoman 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. \r\n \r\nDocument: Weight(s) and birth date in the participant's health record. \r\n \r\n321 \r\n \r\nFETAL OR NEONATAL DEATH \r\n \r\nVI \r\n \r\nA fetal death (death \u003e 20 weeks gestation) or a neonatal death (death occurring from 0-28 days of life). Applies to most recent pregnancy only. \r\n \r\nDocument: 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. \r\n \r\n42 \r\n \r\n CODE 331 \r\n \r\nPOSTPARTUM NON-BREASTFEEDING WOMEN \r\n \r\nPRIORITY \r\n \r\nPREGNANCY AT A YOUNG AGE \r\n \r\nIII \r\n \r\nFor most recent pregnancy, delivery date at less than 18 years and 10 months of age. Applies to most recent pregnancy only. \r\n \r\nDocument: Delivery date on the WIC Assessment/Certification Form \r\n \r\nHigh Risk: Delivery date at less than 17 years of age \r\n \r\n332 \r\n \r\nCLOSELY SPACED PREGNANCIES \r\n \r\nVI \r\n \r\nDelivery date for most recent pregnancy occurred less than 25 months after the termination of the previous pregnancy. \r\n \r\nDocument: Termination dates of last two pregnancies in the participant's health record. \r\n \r\n333 \r\n \r\nHIGH PARITY AND YOUNG AGE \r\n \r\nVI \r\n \r\nThe following two (2) conditions must both apply: \r\n \r\n1. The woman is under age 20 at date of conception AND \r\n \r\n2. She has had 3 or more pregnancies of at least 20 weeks duration (regardless of birth outcome), previous to the most recent pregnancy. \r\n \r\nDocument: Delivery date; number of pertinent previous pregnancies (of at least 20 weeks gestation) and weeks gestation for each, in the participant's health record \r\n \r\n335 \r\n \r\nMULTI FETAL GESTATION \r\n \r\nVI \r\n \r\nMore than one (\u003e1) fetus in the most recent pregnancy \r\n \r\nHigh Risk: Multi-fetal gestation \r\n \r\n43 \r\n \r\n CODE 337 \r\n \r\nPOSTPARTUM NON-BREASTFEEDING WOMEN \r\n \r\nCODE \r\n \r\nHISTORY OF A LARGE FOR GESTATIONAL AGE INFANT \r\n \r\nVI \r\n \r\nMost recent pregnancy, or history of giving birth to an infant with a birth weight of 9 pounds or more. \r\n \r\nDocument: Birth weight(s) and date(s) of deliveries in the participant's health record. \r\n \r\n339 \r\n \r\nBIRTH WITH NUTRITION RELATED CONGENITAL OR BIRTH DEFECT(S) \r\n \r\nVI \r\n \r\nA 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. \r\n \r\nDocument: Infant(s) congenital and/or birth defect(s) in the participant's health record. \r\n \r\nNUTRITION RELATED MEDICAL CONDITIONS \r\n \r\nVI \r\n \r\n341 \r\n \r\nNUTRIENT DEFICIENCY DISEASES \r\n \r\nDiagnosis 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) \r\n \r\nThe 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. \r\n \r\nDocument: Diagnosis and the name of the physician that is treating this condition in participant's health record. \r\n \r\nHigh Risk: Diagnosed nutrient deficiency disease \r\n \r\n44 \r\n \r\n CODE 342 \r\n \r\nPOSTPARTUM NON-BREASTFEEDING WOMEN \r\n \r\nPRIORITY \r\n \r\nGASTRO-INTESTINAL DISORDERS \r\n \r\nVI \r\n \r\nDiseases 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 \r\n \r\nThe 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\n \r\nHigh Risk: Diagnosed gastro-intestinal disorder \r\n \r\n343 \r\n \r\nDIABETES MELLITUS \r\n \r\nVI \r\n \r\nDiabetes mellitus consists of a group of metabolic diseases characterized by inappropriate hyperglycemia resulting from defects in insulin secretion, insulin action or both. \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\n \r\nHigh Risk: Diagnosed diabetes mellitus \r\n \r\n45 \r\n \r\n CODE 344 \r\n \r\nPOSTPARTUM NON-BREASTFEEDING WOMEN \r\nTHYROID DISORDERS \r\n \r\nPRIORITY VI \r\n \r\nThyroid 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: \r\n Hyperthyroidism: Excessive thyroid hormone production (most commonly known as Graves' disease and toxic multinodular goiter). \r\n 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. \r\n 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\n \r\nHigh Risk: Diagnosed thyroid disorder \r\n \r\n345 \r\n \r\nHYPERTENSION \r\n \r\nVI \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\nHigh Risk: Diagnosed hypertension \r\n \r\n46 \r\n \r\n CODE 346 \r\n \r\nPOSTPARTUM NON-BREASTFEEDING WOMEN \r\nRENAL DISEASE \r\nAny 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. \r\nDocument: Diagnosis and the name of the physician that is treating this condition in participant's health record. \r\nHigh Risk: Diagnosed renal disease \r\n \r\nPRIORITY VI \r\n \r\n347 \r\n \r\nCANCER \r\n \r\nVI \r\n \r\nA chronic disease whereby populations of cells have acquired the ability to multiply and spread without the usual biologic restraints. The current \r\ncondition, or the treatment for the condition, must be severe enough to affect nutritional status. \r\n \r\nPresence 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. \r\n \r\nDocument: 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. \r\nHigh Risk: Diagnosed cancer \r\n \r\n348 \r\n \r\nCENTRAL NERVOUS SYSTEM DISORDERS \r\n \r\nVI \r\n \r\nConditions 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. \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and the name of the physician that is treating this condition in participant's health record. \r\n \r\nHigh Risk: Diagnosed central nervous system disorder \r\n \r\n47 \r\n \r\n CODE 349 \r\n \r\nPOSTPARTUM NON-BREASTFEEDING WOMEN \r\n \r\nPRIORITY \r\n \r\nGENETIC AND CONGENITAL DISORDERS \r\n \r\nVI \r\n \r\nHereditary 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. \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and the name of the physician that is treating this condition in participant's health record. \r\n \r\nHigh Risk: Diagnosed genetic/congenital disorder \r\n \r\n351 \r\n \r\nINBORN ERRORS OF METABOLISM \r\n \r\nVI \r\n \r\nGene 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. \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and the name of the physician that is treating this condition in participant's health record. \r\n \r\nHigh Risk: Diagnosed inborn error of metabolism \r\n \r\n48 \r\n \r\n CODE 352 \r\n \r\nPOSTPARTUM NON-BREASTFEEDING WOMEN \r\n \r\nPRIORITY \r\n \r\nINFECTIOUS DISEASES \r\n \r\nVI \r\n \r\nA 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. \r\n \r\nThe 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. \r\n \r\nDocument: 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. \r\n \r\nHigh Risk: Diagnosed infectious disease, as described above \r\n \r\n353 \r\n \r\nFOOD ALLERGIES \r\n \r\nVI \r\n \r\nAn adverse immune response to a food or a hypersensitivity that causes adverse immunologic reaction. \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and the name of the physician that is treating this condition. \r\n \r\nHigh Risk: Diagnosed food allergy \r\n \r\n49 \r\n \r\n CODE 354 \r\n \r\nPOSTPARTUM NON-BREASTFEEDING WOMEN \r\nCELIAC DISEASE \r\nAlso known as Celiac Sprue, Gluten Enteropathy, or Non-tropical Sprue. \r\nInflammatory condition of the small intestine precipitated by the ingestion of wheat in individuals with certain genetic make-up. \r\nPresence 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. \r\nDocument: Diagnosis and the name of the physician that is treating this condition. \r\nHigh Risk: Diagnosed Celiac Disease \r\n \r\nPRIORITY VI \r\n \r\n355 \r\n \r\nLACTOSE INTOLERANCE \r\n \r\nVI \r\n \r\nLactose 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. \r\nPresence 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. \r\n \r\nDocument: Diagnosis and the name of the physician that is treating this \r\ncondition 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). \r\n \r\n50 \r\n \r\n CODE 356 \r\n \r\nPOSTPARTUM NON-BREASTFEEDING WOMEN \r\nHYPOGLYCEMIA \r\nPresence 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. \r\n \r\nPRIORITY VI \r\n \r\nDocument: Diagnosis and the name of the physician that is treating this condition in the participant's health record. \r\nHigh Risk: Diagnosed hypoglycemia \r\n \r\n357 \r\n \r\nDRUG/NUTRIENT INTERACTIONS \r\n \r\nVI \r\n \r\nUse 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. \r\n \r\nDocument: Drug/medication being used and respective nutrient interaction in the participant's health record. \r\n \r\nHigh Risk: Use of drug or medication shown to interfere with nutrient intake or utilization, to extent that nutritional status is compromised. \r\n \r\n358 \r\n \r\nEATING DISORDERS \r\n \r\nVI \r\n \r\nEating disorders (anorexia nervosa and bulimia), are characterized by a \r\n \r\ndisturbed sense of body image and morbid fear of becoming fat. Symptoms \r\n \r\nare manifested by abnormal eating patterns including, but not limited to: \r\n \r\n \r\n \r\nSelf-induced vomiting \r\n \r\n \r\n \r\nPurgative abuse \r\n \r\n \r\n \r\nAlternating periods of starvation \r\n \r\n \r\n \r\nUse of drugs such as appetite suppressants, thyroid preparations \r\n \r\nor diuretics \r\n \r\n \r\n \r\nSelf-induced marked weight loss \r\n \r\nPresence 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. \r\n \r\nDocument: Symptoms or diagnosis and the name of the physician that is treating this condition in the participant's health record. \r\n \r\nHigh Risk: Diagnosed eating disorder \r\n \r\n51 \r\n \r\n CODE 359 \r\n \r\nPOSTPARTUM NON-BREASTFEEDING WOMEN \r\n \r\nPRIORITY \r\n \r\nRECENT MAJOR SURGERY, TRAUMA OR BURNS \r\n \r\nVI \r\n \r\nMajor surgery (including C-sections), trauma or burns severe enough to compromise nutritional status. Any occurrence within the past 2 months may \r\nbe 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. \r\n \r\nDocument: 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. \r\n \r\nHigh Risk: Major surgery, trauma or burns that has a continued need for nutritional support. \r\n \r\n360 \r\n \r\nOTHER MEDICAL CONDITIONS \r\n \r\nVI \r\n \r\nDiseases or conditions with nutritional implications that are not included in any of the other medical conditions. The current condition, or treatment for the \r\ncondition, 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. \r\n \r\nPresence 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. \r\n \r\nDocument: 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. \r\n \r\nHigh Risk: Diagnosed medical condition severe enough to compromise nutritional status \r\n \r\n52 \r\n \r\n CODE 361 \r\n362 \r\n \r\nPOSTPARTUM NON-BREASTFEEDING WOMEN \r\n \r\nPRIORITY \r\n \r\nDEPRESSION \r\n \r\nVI \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in participant's health record. \r\n \r\nDEVELOPMENTAL, SENSORY OR MOTOR DELAYS INTERFERING WITH \r\n \r\nVI \r\n \r\nTHE ABILITY TO EAT \r\n \r\nDevelopmental, 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. \r\n \r\nDocument: 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. \r\n \r\nHigh Risk: Developmental, sensory or motor delay interfering with ability to eat. \r\n \r\n363 \r\n \r\nPRE-DIABETES \r\n \r\nVI \r\n \r\nPresence 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 \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\n \r\nHigh Risk: Diagnosed pre-diabetes \r\n \r\n371 \r\n \r\nMATERNAL SMOKING \r\n \r\nVI \r\n \r\nAny smoking of cigarettes, pipes or cigars. \r\n \r\nDocument: Number of cigarettes or cigars smoked, or number of times pipe smoked, on WIC Assessment/Certification Form. \r\n \r\n53 \r\n \r\n CODE \r\n \r\nPOSTPARTUM NON-BREASTFEEDING WOMEN \r\n \r\nPRIORITY \r\n \r\n372 \r\n \r\nALCOHOL AND ILLEGAL DRUG USE \r\n \r\nVI \r\n \r\nAlcohol use: \r\n Routine current use of \u003e 2 drinks per day OR \r\n Binge drinking is defined as \u003e5 drinks on the same occasion on at least one day in the past 30 days, OR \r\n Heavy drinking is defined as \u003e5 drinks on the same occasion on five or more days in the past 30 days \r\n \r\nA serving of standard sized drink (1  ounce of alcohol) is: - 1 can of beer (12 fluid oz) - 5 oz wine - 1  fluid oz liquor \r\n \r\nDocument: Alcohol Use; identify type (Routine - Enter oz./wk: ___, Binge drinker, Heavy drinker) on WIC Assessment/Certification Form. See Appendix E-1 for documentation codes. \r\n \r\nAny Illegal drug use: \r\nDocument: Type of drug(s) being used. See Appendix E-2 for commonly used illegal drug names. \r\n \r\n381 \r\n \r\nDENTAL PROBLEMS \r\n \r\nVI \r\n \r\nDiagnosis 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. \r\n \r\nDocument: In the participant's health record, a description of how the dental problem interferes with mastication and/or has other nutritionally related health problems. \r\n \r\n54 \r\n \r\n CODE 400 \r\n \r\nPOSTPARTUM NON-BREASTFEEDING WOMEN \r\n \r\nPRIORITY \r\n \r\nINAPPROPRIATE NUTRITION PRACTICES \r\n \r\nVI \r\n \r\nRoutine nutrition practices that may result in impaired nutrient status, disease, or health problems. (Appendix G) \r\n \r\nDocument: Inappropriate Nutrition Practice(s) in the participant's health record. \r\n \r\n401 \r\n \r\nFAILURE TO MEET DIETARY GUIDELINES \r\n \r\nVI \r\n \r\nA woman who meets eligibility requirements based on category, income, and residency but who does not have any other identified nutritional risk factor \r\nmay be presumed to be at nutritional risk based on failure to meet the Dietary Guidelines for Americans. \r\n \r\n(This risk factor may be assigned only when a woman does not qualify for risk 400 or for any other risk factor.) \r\n \r\n502 \r\n \r\nTRANSFER OF CERTIFICATION \r\n \r\nIII, VI \r\n \r\nPerson 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. \r\n \r\nThis 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. \r\n \r\n801 \r\n \r\nHOMELESSNESS \r\n \r\nVI \r\n \r\nHomelessness as defined in the Special Populations Section of the Georgia WIC Program Procedures Manual. \r\n \r\n55 \r\n \r\n CODE \r\n \r\nPOSTPARTUM NON-BREASTFEEDING WOMEN \r\n \r\n802 \r\n \r\nMIGRANCY \r\n \r\nMigrancy as defined in the Special Populations Section of the Georgia WIC Program Procedures Manual. \r\n \r\nPRIORITY VI \r\n \r\n901 \r\n \r\nRECIPIENT OF ABUSE \r\n \r\nVI \r\n \r\nBattering 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. \r\n \r\nBattering refers to violent assaults on women. \r\n \r\n902 \r\n \r\nPOSTPARTUM, NON-BREASTFEEDING WOMAN WITH LIMITED ABILITY \r\n \r\nIV \r\n \r\nTO MAKE FEEDING DECISIONS AND/OR PREPARE FOOD \r\n \r\nWoman who is assessed to have limited ability to make appropriate feeding decisions and/or prepare food. Examples may include: \r\n \r\n mental disability / delay and/or mental illness such as clinical depression (diagnosed by a physician or licensed psychologist) \r\n physical disability which restricts or limits food preparation abilities \r\n current use of or history of abusing alcohol or other drugs \r\n \r\nDocument: The women's specific limited abilities in the participant's health record. \r\n \r\n903 \r\n \r\nFoster Care \r\n \r\nVI \r\n \r\nEntering 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. \r\n \r\n904 \r\n \r\nENVIRONMENTAL TOBACCO SMOKE EXPOSURE \r\n \r\nVI \r\n \r\nEnvironmental tobacco smoke (ETS) exposure is defined as exposure to smoke from tobacco products inside the home. \r\n \r\n56 \r\n \r\n DATA AND DOCUMENTATION REQUIRED FOR WIC ASSESSMENT/CERTIFICATION \r\n \r\nINFANTS \r\n \r\nData \r\nLength \r\nWeight \r\nHematocrit or Hemoglobin \r\nWeight for Age Plotted \r\nLength for Age Plotted \r\nWeight for Length Plotted \r\nEvaluation of Inappropriate Nutrition Practices \r\nRisk Factor Assessment \r\n \r\nInfant Certified in Hospital Prior to Initial Discharge \r\n \r\nDocumentation Infant \r\n \r\nBirth Data or other measurement \r\nBirth Data or other measurement \r\n \r\nRequired Required \r\n \r\nN/A \r\n \r\nRequired \r\n \r\n(9-12 months) \r\n \r\nOptional \r\n \r\nRequired \r\n \r\nOptional \r\n \r\nRequired \r\n \r\nOptional \r\n \r\nRequired \r\n \r\nOptional Required \r\n \r\nRequired Required \r\n \r\nInfant Mid-Certification \r\nRequired Required Required (9-12 months) Required \r\nRequired \r\nRequired \r\nRequired \r\nRequired \r\n \r\n57 \r\n \r\n NUTRITION RISK CRITERIA INFANTS \r\n \r\nNOTE: High Risk Criteria, as defined below, are to be used for referral purposes, not certification (See Appendix A-2) \r\nINFANTS \r\n \r\nCODE \r\n \r\nPRIORITY \r\n \r\n201 \r\n \r\nLOW HEMOGLOBIN/HEMATOCRIT \r\n \r\nI \r\n \r\nHemoglobin: 10.9 gm or lower (6-11 month old) Hematocrit: 32.8% or lower (6-11 month old) \r\n \r\nHigh Risk: Hemoglobin OR Hematocrit at treatment level (Appendix B-2) \r\n \r\n103 \r\n \r\nUNDERWEIGHT or AT RISK OF UNDERWEIGHT \r\n \r\nI \r\n \r\nLess than or equal to the 5th percentile weight-for-length as plotted on the CDC Birth to 24 months gender specific growth charts.* \r\nHigh 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.* \r\n \r\n*Based on 2006 World Health Organization international growth standards. For the Birth to \u003c 24 months \"underweight\" definition, CDC labels the 2.3rd percentile as the 2nd percentile on the Birth to 24 months gender specific growth charts. \r\n \r\n115 \r\n \r\nHigh Weight-for Length \r\n \r\nGreater than or equal to the 98th percentile weight-for-length as plotted \r\n \r\non the Centers for Disease Control and Prevention (CDC), Birth to 24 \r\n \r\nmonths gender specific growth charts. \r\n \r\nI \r\n \r\n*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. \r\n \r\n58 \r\n \r\n CODE \r\n \r\nINFANTS \r\n \r\n121 \r\n \r\nSHORT STATURE OR AT RISK OF SHORT STATURE \r\n \r\nLess than or equal to the 5th percentile length-for-age as plotted on the CDC Birth to 24 months gender specific growth charts.* \r\n(if \u003c 38 weeks gestation use adjusted age) \r\n \r\nHigh 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.* \r\n*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. \r\n \r\n134 \r\n \r\nFAILURE TO THRIVE \r\n \r\nPresence of failure to thrive diagnosed by a physician or health professional acting under standing orders of a physician. \r\n \r\nDocument: Diagnosis in the participant's health record \r\n \r\nHigh Risk: Diagnosed failure to thrive \r\n \r\nPRIORITY I \r\nI \r\n \r\n59 \r\n \r\n CODE 135 \r\n \r\nINFANTS \r\n \r\nINADEQUATE GROWTH \r\n \r\nAn inadequate rate of weight gain as defined below: \r\n \r\nInfants being certified during period from birth to 1 month of age: \r\n \r\n Not back to birth weight by 2 weeks of age  A gain of less than 19 ounces by 1 month of age \r\n \r\nInfants being certified during period from 1 to 5 months of age: \r\n \r\n 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. \r\n \r\nInfants 6 months to 12 months of age: \r\n \r\nAge in Months at Certification \r\n \r\nWeight Gain per 6-month interval* \r\n \r\n 5  mos - 6 mos  \u003e6 mos - 9 mos  \u003e9 mos - 12 mos \r\n \r\n \u003c 7 lbs \r\n \u003c 5 lbs \r\n \u003c 3 lbs \r\n \r\n*Note: Use this chart only for infants who are \u003e 5 months 2 weeks of age. Use only for an interval of 6 months +/- 2 weeks. \r\n \r\nHigh Risk: Inadequate growth \r\n \r\nPRIORITY I \r\n \r\n141 \r\n \r\nLOW BIRTH WEIGHT \r\n \r\nBirth weight \u003c 5 lbs 8 oz (\u003c 2500 g) \r\n \r\nI \r\n \r\nDocument: Birth weight in participant's health record \r\n \r\nHigh Risk: Birth weight \u003c 5 lbs 8 oz (\u003c 2500 g) \r\n \r\n60 \r\n \r\n CODE 142 \r\n \r\nINFANTS \r\nPREMATURITY Infant born at \u003c 37 weeks gestation Document: Weeks gestation in participant's health record \r\n \r\nPRIORITY I \r\n \r\n151 \r\n \r\nSmall for Gestational Age \r\n \r\nInfants diagnosed as small for gestational age. I \r\nPresence 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. \r\n \r\n152 \r\n \r\nLow Head Circumference \r\n \r\nI \r\n \r\nLess 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 \r\n(if \u003c 38 weeks gestation use adjusted age) \r\n \r\n* 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. \r\n \r\n153 \r\n \r\nLARGE FOR GESTATIONAL AGE \r\n \r\nI \r\n \r\nBirth weight \u003e 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. \r\n \r\nDocument: Weight(s) of infant in participant's health record. \r\n \r\n61 \r\n \r\n CODE 211 \r\n \r\nINFANTS \r\nELEVATED BLOOD LEAD LEVELS Blood lead level of \u003e 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 \u003e 10 g/deciliter within the past 12 months. \r\n \r\nNUTRITION RELATED MEDICAL CONDITIONS \r\n \r\n341 \r\n \r\nNUTRIENT DEFICIENCY DISEASES \r\n \r\nDiagnosis 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) \r\n \r\nPresence 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. \r\nDocument: Diagnosis and the name of the physician that is treating this condition in the participant's health record \r\n \r\nHigh Risk: Diagnosed nutrient deficiency disease \r\n \r\nPRIORITY I \r\nI \r\n \r\n62 \r\n \r\n CODE 342 \r\n \r\nINFANTS \r\nGASTRO-INTESTINAL DISORDERS \r\n \r\nDiseases 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 \r\nCrohn's disease  Liver disease  Pancreatitis  Biliary tract disease \r\nThe 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. \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\nHigh Risk: Diagnosed gastro-intestinal disorder \r\n \r\nPRIORITY I \r\n \r\n343 \r\n \r\nDIABETES MELLITUS \r\n \r\nI \r\n \r\nDiabetes mellitus consists of a group of metabolic diseases characterized by inappropriate hyperglycemia resulting from defects in insulin secretion, insulin action or both. \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\n \r\nHigh Risk: Diagnosed diabetes mellitus \r\n \r\n63 \r\n \r\n CODE 344 \r\n \r\nINFANTS \r\nTHYROID DISORDERS \r\nThyroid 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: \r\n \r\n Congenital Hyperthyroidism: Excessive thyroid hormone levels at birth, either transient (due to maternal Grave's disease) or persistent (due to genetic mutation). \r\n Congenital Hypothyroidism: Infants born with an under active thyroid gland and presumed to have had hypothyroidism inutero. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\n \r\nHigh Risk: Diagnosed thyroid disorder \r\n \r\n345 \r\n \r\nHYPERTENSION \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\n \r\nHigh Risk: Diagnosed hypertension \r\n \r\n346 \r\n \r\nRENAL DISEASE \r\n \r\nAny renal disease including pyelonephritis and persistent proteinuria, \r\nbut 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. \r\n \r\nDocument: Diagnosis and the name of the physician that is treating this condition in the participant's health record. \r\n \r\nHigh Risk: Diagnosed renal disease \r\n \r\n64 \r\n \r\nPRIORITY I \r\nI I \r\n \r\n CODE 347 \r\n \r\nINFANTS \r\nCANCER \r\nA 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. \r\nPresence 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. \r\nDocument: 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. \r\nHigh Risk: Diagnosed cancer \r\n \r\n348 \r\n \r\nCENTRAL NERVOUS SYSTEM DISORDERS \r\n \r\nConditions 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. \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and the name of the physician that is treating this condition in the participant's health record. \r\n \r\nHigh Risk: Diagnosed central nervous system disorder \r\n \r\nPRIORITY I \r\nI \r\n \r\n65 \r\n \r\n CODE 349 \r\n \r\nINFANTS \r\nGENETIC AND CONGENITAL DISORDERS \r\nHereditary 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. \r\nPresence 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. \r\nDocument: Diagnosis and the name of the physician that is treating this condition in the participant's health record. \r\nHigh Risk: Diagnosed genetic and congenital disorder \r\n \r\nPRIORITY I \r\n \r\n351 \r\n \r\nINBORN ERRORS OF METABOLISM \r\n \r\nI \r\n \r\nGene 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. \r\n \r\nPresence of inborn errors of metabolism diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or \r\nhealth professional acting under standing orders of a physician. \r\n \r\nDocument: Diagnosis and the name of the physician that is treating this condition in the participant's health record. \r\n \r\nHigh Risk: Diagnosed inborn error of metabolism \r\n \r\n66 \r\n \r\n CODE 352 \r\n \r\nINFANTS \r\nINFECTIOUS DISEASES \r\nA 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. \r\nThe 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. \r\nDocument: 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. \r\nHigh Risk: Diagnosed infectious disease, as described above. \r\n \r\nPRIORITY I \r\n \r\n353 \r\n \r\nFOOD ALLERGIES \r\n \r\nI \r\n \r\nAn adverse immune response to a food or a hypersensitivity that causes adverse immunologic reaction. \r\n \r\nPresence 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. \r\nDocument: Diagnosis and the name of the physician that is treating this condition in the participant's health record. \r\nHigh Risk: Diagnosed food allergy \r\n \r\n67 \r\n \r\n CODE \r\n \r\nINFANTS \r\n \r\n354 \r\n \r\nCELIAC DISEASE \r\n \r\nAlso known as Celiac Sprue, Gluten Enteropathy, or Non-tropical Sprue. \r\n \r\nInflammatory condition of the small intestine precipitated by the ingestion of wheat in individuals with certain genetic make-up. \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and the name of the physician that is treating this condition in the participant's health record. \r\n \r\nHigh Risk: Diagnosed Celiac Disease \r\n \r\nPRIORITY I \r\n \r\n355 \r\n \r\nLACTOSE INTOLERANCE \r\n \r\nI \r\n \r\nLactose 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. \r\nPresence 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. \r\n \r\nDocument: Diagnosis and the name of the physician that is treating \r\nthis 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). \r\n \r\n68 \r\n \r\n CODE 356 \r\n \r\nINFANTS \r\nHYPOGLYCEMIA \r\nPresence 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. \r\nDocument: Diagnosis and the name of the physician that is treating this condition in the participant's health record. \r\nHigh Risk: Diagnosed hypoglycemia \r\n \r\nPRIORITY I \r\n \r\n357 \r\n \r\nDRUG/NUTRIENT INTERACTIONS \r\n \r\nI \r\n \r\nUse 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. \r\n \r\nDocument: Drug/medication being used and respective nutrient interaction in the participant's health record. \r\n \r\nHigh Risk: Use of drug or medication shown to interfere with nutrient intake or utilization, to extent that nutritional status is compromised. \r\n \r\n359 \r\n \r\nRECENT MAJOR SURGERY, TRAUMA, BURNS \r\n \r\nI \r\n \r\nMajor 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 \r\nprevious MUST have the continued need for nutritional support diagnosed by a physician or health professional acting under standing orders of a physician. \r\n \r\nDocument: 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. \r\n \r\nHigh Risk: Major surgery, trauma or burns that has a continued need for nutritional support. \r\n \r\n69 \r\n \r\n CODE 360 \r\n \r\nINFANTS \r\nOTHER MEDICAL CONDITIONS \r\nDiseases 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. \r\nPresence 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. \r\nDocument: 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. \r\nHigh Risk: Diagnosed medical condition severe enough to compromise nutritional status. \r\n \r\nPRIORITY I \r\n \r\n362 \r\n \r\nDEVELOPMENTAL, SENSORY OR MOTOR DELAYS \r\n \r\nI \r\n \r\nINTERFERING WITH ABILITY TO EAT \r\n \r\nDevelopmental, 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. \r\n \r\nPresence 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. \r\n \r\nDocument: 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. \r\n \r\nHigh Risk: Developmental, sensory or motor delay interfering with ability to eat. \r\n \r\n70 \r\n \r\n CODE 381 \r\n \r\nINFANTS \r\nDENTAL PROBLEMS \r\nDiagnosis 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: \r\n Presence of nursing bottle caries  Smooth surface decay of the maxillary anterior and the primary \r\nmolars \r\nDocument: Description of how the dental problem interferes with mastication and/or has other nutritionally related health problems in the participant's health record. \r\n \r\nPRIORITY I \r\n \r\n382 \r\n \r\nFETAL ALCOHOL SYNDROME \r\n \r\nI \r\n \r\nFetal 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. \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and name of physician treating the condition in the participant's health record. \r\n \r\nHigh Risk: Diagnosed fetal alcohol syndrome \r\n \r\n400 \r\n \r\nINAPPROPRIATE NUTRITION PRACTICES \r\n \r\nIV \r\n \r\nRoutine nutrition practices that may result in impaired nutrient status, disease, or health problems. (Appendix G) \r\n \r\nDocument: Inappropriate Nutrition Practice(s) in the participant's health record. \r\n \r\n71 \r\n \r\n CODE \r\n \r\nINFANTS \r\n \r\n428 \r\n \r\nDietary Risk Associated with Complementary Feeding Practices \r\n \r\n(Infants 4 to 12 months) \r\n \r\nAn infant  4 months of age who has begun to or is expected to \r\nbegin to do any of the following practices is considered to be at risk of inappropriate complementary feeding: \r\n \r\n1) 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. \r\n \r\n(This risk factor may be assigned only when an infant \u003e 4 months of age does not qualify for risk 400 or for any other risk factor.) \r\n \r\nPRIORITY IV \r\n \r\n502 \r\n \r\nTRANSFER OF CERTIFICATION \r\n \r\nPerson 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. \r\n \r\nThis 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. \r\n \r\nI, II, IV \r\n \r\n72 \r\n \r\n CODE \r\n \r\nINFANTS \r\n \r\n603 \r\n \r\nBREASTFEEDING COMPLICATIONS OR POTENTIAL \r\n \r\nCOMPLICATIONS \r\n \r\nAny of the following are considered complications or potential complications of breastfeeding: \r\n \r\n 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 \r\nby a physician or other health care provider) \r\n Breastfed infant who wets diaper less than 6 times per day \r\n \r\nDocument: Complications or potential complications in the participant's health record. \r\n \r\nHigh Risk: Refer to or provide the infant's mother with appropriate breastfeeding counseling. \r\n \r\nPRIORITY I \r\n \r\n701 \r\n \r\nINFANT UP TO 6 MONTHS OLD OF WIC MOTHER, OR OF A \r\n \r\nII \r\n \r\nWOMAN WHO WOULD HAVE BEEN ELIGIBLE DURING \r\n \r\nPREGNANCY \r\n \r\n An infant under 6 months of age whose mother was a WIC Program participant during pregnancy, OR \r\n 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 \r\ndocumented nutritionally related medical conditions. \r\n \r\n702 \r\n \r\nBREASTFEEDING INFANT OF A WOMAN AT NUTRITIONAL RISK \r\n \r\nA breastfed infant whose breastfeeding mother has been determined to be at nutritional risk. \r\n \r\nDocument: Mother's risks on infant's WIC Assessment/Certification Form \r\n \r\nI, II, IV \r\n \r\n73 \r\n \r\n CODE 703 \r\n \r\nINFANTS \r\nINFANT BORN TO MOTHER WITH MENTAL RETARDATION, OR ALCOHOL OR DRUG ABUSE DURING MOST RECENT PREGNANCY \r\n 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 \r\n Documentation or self-report of any use of alcohol or illegal drugs during most recent pregnancy. \r\n \r\nPRIORITY I \r\n \r\n801 \r\n \r\nHOMELESSNESS \r\n \r\nHomelessness as defined in the Special Population Section of the \r\n \r\nIV \r\n \r\nGeorgia WIC Procedures Manual. \r\n \r\n802 \r\n \r\nMIGRANCY \r\n \r\nIV \r\n \r\nMigrancy as defined in the Special Population Section of the Georgia WIC Procedures Manual. \r\n \r\n901 \r\n \r\nRECIPIENT OF ABUSE \r\n \r\nChild abuse/neglect within past 6 months as self-reported by the \r\n \r\nIV \r\n \r\ncaregiver, or as documented by a social worker, health care provider \r\n \r\nor on other appropriate documents, or as reported through \r\n \r\nconsultation with a social worker, health care provider or other \r\n \r\nappropriate personnel. \r\n \r\nChild abuse/neglect refers to any recent act, or failure to act, resulting in: \r\n \r\n Imminent risk or serious harm \r\n Serious physical or emotional harm \r\n Sexual abuse or exploitation of an infant or child by a parent or caretaker. \r\n \r\nGeorgia 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. \r\n \r\n74 \r\n \r\n CODE \r\n \r\nINFANTS \r\n \r\n902 \r\n \r\nPRIMARY CAREGIVER WITH LIMITED ABILITY TO MAKE \r\n \r\nFEEDING DECISIONS AND/OR PREPARE FOOD \r\n \r\nInfant whose primary caregiver is assessed to have limited ability to make appropriate feeding decisions and/or prepare food. Examples may include: \r\n \r\n mental disability / delay and/or mental illness such as clinical depression (diagnosed by a physician or licensed psychologist) \r\n physical disability which restricts or limits food preparation abilities \r\n current use of or history of abusing alcohol or other drugs \r\n \r\nDocument: The caregivers limited abilities in the participant's health record. \r\n \r\n903 Foster Care \r\nEntering 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. \r\n \r\nPRIORITY IV \r\nIV \r\n \r\n904 \r\n \r\nENVIRONMENTAL TOBACCO SMOKE EXPOSURE \r\n \r\nI \r\n \r\nEnvironmental tobacco smoke (ETS) exposure is defined as exposure to smoke from tobacco products inside the home. \r\n \r\n75 \r\n \r\n 76 \r\n \r\n DATA AND DOCUMENTATION REQUIRED FOR WIC ASSESSMENT/CERTIFICATION \r\nCHILDREN \r\n \r\nData \r\nLength 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 \r\n \r\nCertification \r\n \r\nHalfCertification \r\n \r\nRequired \r\n \r\nRequired \r\n \r\nRequired \r\n \r\nRequired \r\n \r\nRequired \r\n \r\n*** \r\n \r\nRequired \r\n \r\nRequired \r\n \r\nRequired \r\n \r\nRequired \r\n \r\nRequired \r\n \r\nRequired \r\n \r\nRequired \r\n \r\nRequired \r\n \r\nRequired \r\n \r\nRequired \r\n \r\n***Required when hemoglobin was low at most recent certification and for children less than 2 years old \r\n \r\n77 \r\n \r\n NUTRITION RISK CRITERIA CHILDREN \r\n \r\nNOTE: High Risk Criteria, as defined below, are to be used for referral purposes, not certification (See Appendix A-2) \r\n \r\nCODE \r\n \r\nCHILDREN \r\n \r\nPRIORITY \r\n \r\n201 \r\n \r\nLOW HEMOGLOBIN/HEMATOCRIT \r\n \r\nIII \r\n \r\n12-23 months of age: Hemoglobin: 10.9 gm or lower Hematocrit: 32.8% or lower \r\n \r\n24 months-5 years of age: Hemoglobin: 11.0 gm or lower Hematocrit: 32.9% or lower \r\n \r\nHigh Risk: Hemoglobin OR Hematocrit at treatment level (Appendix B-2) \r\n \r\n103 \r\n \r\nUNDERWEIGHT or AT RISK OF UNDERWEIGHT \r\n \r\nIII \r\n \r\n(Children 12-24 Months of Age) \r\n \r\nLess than or equal to the 5th percentile weight-for-length as plotted on \r\n \r\nthe CDC 12 to 24 months gender specific growth charts.* \r\n \r\nHigh 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.* \r\n \r\n*Based on 2006 World Health Organization international growth standards. For the Birth to \u003c 24 months \"underweight\" definition, CDC labels the 2.3rd percentile as the 2nd percentile on the Birth to 24 months gender specific growth charts. \r\n \r\nUNDERWEIGHT 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. \r\nHigh 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. \r\n \r\n78 \r\n \r\n CODE 113 \r\n114 \r\n \r\nCHILDREN \r\nOBESE (Children 2-5 Years of Age) \r\nGreater 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 \r\nHigh 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 \r\nOVERWEIGHT (Children 2-5 Years of Age) \r\nGreater 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.* \r\n* The cut off is based on standing height measurements. Therefore, recumbent length measurements may not be used to determine this risk. \r\n \r\n115 \r\n \r\nHigh Weight-for-Length (Children 12-24 Months of Age) \r\n \r\nGreater 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.* \r\n \r\n*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. \r\n \r\nPRIORITY III III \r\nIII \r\n \r\n79 \r\n \r\n CODE \r\n \r\nCHILDREN \r\n \r\n121 \r\n \r\nSHORT STATURE OR AT RISK OF SHORT STATURE \r\n \r\n(Children 12-24 Months of Age) \r\n \r\nLess than or equal to the 5th percentile length-for-age as plotted on the CDC Birth to 24 months gender specific growth charts(1).* \r\n(if \u003c 38 weeks gestation use adjusted age) \r\n \r\nHigh 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.* \r\n*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. \r\n \r\nPRIORITY III \r\n \r\nSHORT STATURE OR AT RISK OF SHORT STATURE (Children 2-5 Years of Age) \r\nLess than or equal to the 10th percentile length or height for age based on CDC age/sex specific growth charts. \r\nHigh Risk: Less than or equal to the 5th percentile stature-for-age as plotted on the 2000 CDC age/gender specific growth charts \r\n \r\n134 \r\n \r\nFAILURE TO THRIVE \r\n \r\nIII \r\n \r\nPresence of failure to thrive diagnosed by a physician or health professional acting under standing orders of a physician. \r\n \r\nDocument: Diagnosis in participant's health record. High Risk: Diagnosed failure to thrive \r\n \r\n80 \r\n \r\n CODE \r\n \r\nCHILDREN \r\n \r\n135 \r\n \r\nINADEQUATE GROWTH \r\n \r\nA low rate of weight gain over a six-month period as defined by the following chart: \r\n \r\nAge in Months at Certification \r\n \r\nWeight Gain in previous 6-month interval* \r\n \r\n 12 months  \u003e12 - 60 months \r\n \r\n \u003c 3 pounds  \u003c 1 pound \r\n \r\n*Note: Use only for an interval of 6 months +/- 2 weeks. \r\n \r\nHigh Risk: Inadequate growth \r\n \r\n141 \r\n \r\nLOW BIRTH WEIGHT (children \u003c 24 months of age) \r\n \r\nBirth weight \u003c 5 lbs 8 oz (\u003c 2500 g) \r\n \r\nDocument: Birth weight of participant in health record. \r\n \r\n142 \r\n \r\nPREMATURITY (Children \u003c 24 months of age) \r\n \r\nBorn at 37 weeks gestation or less \r\n \r\nDocument: Weeks gestation in participant's health record. \r\n \r\n151 \r\n \r\nSmall for Gestational Age (Children 12-24 Months of Age) \r\n \r\nChildren less than 24 months of age diagnosed as small for gestational age. \r\n \r\nPresence 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. \r\n \r\nPRIORITY III \r\nIII III III \r\n \r\n81 \r\n \r\n CODE \r\n \r\nCHILDREN \r\n \r\n152 \r\n \r\nLow Head Circumference (Children 12-24 Months of Age) \r\n \r\nLess 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 \r\n(if \u003c 38 weeks gestation use adjusted age) \r\n \r\n* 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. \r\n \r\n211 \r\n \r\nELEVATED BLOOD LEAD LEVELS \r\n \r\nBlood lead level of \u003e10 g/deciliter within the past 12 months. \r\n \r\nDocument: Date of blood test and blood lead level in participant's health record. Must be within the past 12 months. \r\n \r\nHigh Risk: Blood lead level of \u003e10 g/deciliter within the past 12 months. \r\n \r\nPRIORITY III III \r\n \r\nNUTRITION RELATED MEDICAL CONDITIONS \r\n \r\nIII \r\n \r\n341 \r\n \r\nNUTRIENT DEFICIENCY DISEASES \r\n \r\nDiagnosis 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) \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition participant's health record. \r\n \r\nHigh Risk: Diagnosed nutrient deficiency disease \r\n \r\n82 \r\n \r\n CODE \r\n342 \r\n \r\nCHILDREN \r\nGASTRO-INTESTINAL DISORDERS \r\nDiseases 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 \r\nCrohn's disease  Liver disease  Pancreatitis  Biliary tract disease \r\nThe 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. \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\nHigh Risk: Diagnosed gastro-intestinal disorder \r\n \r\nPRIORITY III \r\n \r\n343 \r\n \r\nDIABETES MELLITUS \r\n \r\nIII \r\n \r\nDiabetes mellitus consists of a group of metabolic diseases characterized by inappropriate hyperglycemia resulting from defects in insulin secretion, insulin action or both. \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\n \r\nHigh Risk: Diagnosed diabetes mellitus \r\n \r\n83 \r\n \r\n CODE \r\n344 \r\n \r\nCHILDREN \r\nTHYROID 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: \r\n \r\n Hyperthyroidism: Excessive thyroid hormone production (most commonly known as Graves' disease and toxic multinodular goiter). \r\n 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. \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\nHigh Risk: Diagnosed thyroid disorder \r\n \r\nPRIORITY III \r\n \r\n345 \r\n \r\nHYPERTENSION \r\n \r\nIII \r\nPresence 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\n \r\nHigh Risk: Diagnosed hypertension \r\n \r\n346 \r\n \r\nRENAL DISEASE \r\n \r\nIII \r\n \r\nAny renal disease including pyelonephritis and persistent proteinuria, \r\nbut 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition participant's health record. \r\n \r\nHigh Risk: Diagnosed renal disease \r\n \r\n84 \r\n \r\n CODE \r\n347 \r\n \r\nCHILDREN \r\nCANCER \r\nA 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. \r\nPresence 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. \r\nDocument: 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. \r\nHigh Risk: Diagnosed cancer \r\n \r\nPRIORITY III \r\n \r\n348 \r\n \r\nCENTRAL NERVOUS SYSTEM DISORDERS \r\n \r\nIII \r\n \r\nConditions 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. \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\n \r\nHigh Risk: Diagnosed central nervous system disorder \r\n \r\n85 \r\n \r\n CODE \r\n349 \r\n \r\nCHILDREN \r\nGENETIC AND CONGENITAL DISORDERS \r\nHereditary 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. \r\nPresence 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 \r\na physician. \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\nHigh Risk: Diagnosed genetic and congenital disorder \r\n \r\nPRIORITY III \r\n \r\n351 \r\n \r\nINBORN ERRORS OF METABOLISM \r\n \r\nIII \r\n \r\nGene 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. \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\nHigh Risk: Diagnosed inborn error of metabolism \r\n \r\n86 \r\n \r\n CODE \r\n352 \r\n \r\nCHILDREN \r\nINFECTIOUS DISEASES \r\nA 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. \r\nThe 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 \r\nunder standing orders of a physician. \r\nDocument: 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. \r\nHigh Risk: Diagnosed infectious disease, as described above. \r\n \r\n353 \r\n \r\nFOOD ALLERGIES \r\n \r\nAn adverse immune response to a food or a hypersensitivity that causes adverse immunologic reaction. \r\n \r\nPresence 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. \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\nHigh Risk: Diagnosed food allergy \r\n \r\nPRIORITY III \r\nIII \r\n \r\n87 \r\n \r\n CODE \r\n \r\nCHILDREN \r\n \r\n354 \r\n \r\nCELIAC DISEASE \r\n \r\nAlso known as Celiac Sprue, Gluten Enteropathy, or Non-tropical Sprue. \r\n \r\nInflammatory condition of the small intestine precipitated by the ingestion of wheat in individuals with certain genetic make-up. \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\n \r\nHigh Risk: Diagnosed Celiac Disease \r\n \r\nPRIORITY III \r\n \r\n355 \r\n \r\nLACTOSE INTOLERANCE \r\n \r\nIII 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. \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and the name of the physician that is treating \r\nthis 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). \r\n \r\n88 \r\n \r\n CODE \r\n356 \r\n \r\nCHILDREN \r\nHYPOGLYCEMIA \r\nPresence 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. \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\nHigh Risk: Diagnosed hypoglycemia \r\n \r\nPRIORITY III \r\n \r\n357 \r\n \r\nDRUG/NUTRIENT INTERACTIONS \r\n \r\nIII \r\n \r\nUse 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. \r\n \r\nDocument: Drug/medication being used and respective nutrient interaction in the participant's health record. \r\n \r\nHigh Risk: Use of drug and medication shown to interfere with nutrient intake or utilization, to extent that nutritional status is compromised. \r\n \r\n359 \r\n \r\nRECENT MAJOR SURGERY, TRAUMA, BURNS \r\n \r\nIII \r\n \r\nMajor 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 \r\nprevious MUST have the continued need for nutritional support diagnosed by a physician or health professional acting under standing orders of a physician. \r\n \r\nDocument: 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. \r\n \r\nHigh Risk: Major surgery, trauma or burns that has a continued need for nutritional support. \r\n \r\n89 \r\n \r\n CODE \r\n \r\nCHILDREN \r\n \r\n360 \r\n \r\nOTHER MEDICAL CONDITIONS \r\n \r\nDiseases or conditions with nutritional implications that are not included in any of the other medical conditions. The current \r\ncondition, 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. \r\n \r\nPresence 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. \r\n \r\nDocument: 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. \r\n \r\nHigh Risk: Diagnosed medical condition severe enough to compromise nutritional status. \r\n \r\n361 \r\n \r\nDEPRESSION \r\n \r\nPresence 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. \r\n \r\nDocument: Diagnosis and name of the physician that is treating this condition in participant's health record. \r\n \r\nPRIORITY III \r\nIII \r\n \r\n90 \r\n \r\n CODE \r\n362 \r\n \r\nCHILDREN \r\nDEVELOPMENTAL, SENSORY OR MOTOR DELAYS INTERFERING WITH ABILITY TO EAT \r\nDevelopmental, 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. \r\nPresence 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. \r\nDocument: 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. \r\nHigh Risk: Developmental, sensory or motor delay interfering with ability to eat. \r\n \r\nPRIORITY III \r\n \r\n381 \r\n \r\nDENTAL PROBLEMS \r\n \r\nIII \r\n \r\nDiagnosis 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: \r\n \r\n Presence of nursing bottle caries \r\n Smooth surface decay of the maxillary anterior and the primary molars \r\n \r\nDocument: In the participant's health record, a description of how the dental problem interferes with mastication and/or has other nutritionally related health problems. \r\n \r\n91 \r\n \r\n CODE \r\n382 \r\n \r\nCHILDREN \r\nFETAL ALCOHOL SYNDROME \r\nFetal 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. \r\nDocument: Diagnosis and name of the physician that is treating this condition in the participant's health record. \r\nHigh Risk: Diagnosed fetal alcohol syndrome \r\n \r\nPRIORITY III \r\n \r\n400 \r\n \r\nINAPPROPRIATE NUTRITION PRACTICES \r\n \r\nV \r\n \r\nRoutine nutrition practices that may result in impaired nutrient status, \r\ndisease, or health problems. (Appendix G) \r\n \r\nDocument: Inappropriate Nutrition Practice(s) in the participant's health record. \r\n \r\n401 \r\n \r\nFAILURE TO MEET DIETARY GUIDELINES FOR \r\n \r\nAMERICANS \r\n \r\nV \r\n \r\n(Children 2-5 Years of Age) \r\n \r\nA 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. \r\n(This risk factor may be assigned only when a child does not qualify for risk 400 or for any other risk factor.) \r\n \r\n92 \r\n \r\n CODE 428 \r\n \r\nCHILDREN \r\nDIETARY RISK ASSOCIATED WITH COMPLEMENTARY FEEDING PRACTICES \r\n(Children 12-24 Months of Age) \r\nA 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: \r\n1) 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. \r\n(This risk factor may be assigned only when a child does not qualify for risk 400 or for any other risk factor.) \r\n \r\nPRIORITY V \r\n \r\n502 \r\n \r\nTRANSFER OF CERTIFICATION \r\n \r\nPerson 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 \r\n \r\nThis 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. \r\n \r\nIII, V \r\n \r\n801 \r\n \r\nHOMELESSNESS \r\n \r\nHomelessness as defined in the Special Population Section of the \r\n \r\nV \r\n \r\nGeorgia WIC Procedures Manual. \r\n \r\n802 \r\n \r\nMIGRANCY \r\n \r\nV \r\n \r\nMigrancy as defined in the Special Population Section of the Georgia WIC Procedures Manual. \r\n \r\n93 \r\n \r\n CODE \r\n \r\nCHILDREN \r\n \r\n901 \r\n \r\nRECIPIENT OF ABUSE \r\n \r\nChild 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. \r\n \r\nChild abuse/neglect refers to any recent act, or failure to act, resulting in: \r\n \r\n \r\n \r\nImminent risk or serious harm \r\n \r\n \r\n \r\nSerious physical or emotional harm \r\n \r\n \r\n \r\nSexual abuse or exploitation of an infant or child by a \r\n \r\nparent or caretaker. \r\n \r\nGeorgia 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. \r\n \r\nPRIORITY V \r\n \r\n902 \r\n \r\nPRIMARY CAREGIVER WITH LIMITED ABILITY TO MAKE \r\n \r\nV \r\n \r\nFEEDING DECISIONS AND/OR PREPARE FOOD \r\n \r\nChild whose primary caregiver is assessed to have limited ability to make appropriate feeding decisions and/or prepare food. Examples may include: \r\n \r\n mental disability / delay and/or mental illness such as clinical depression (diagnosed by a physician or licensed psychologist) \r\n physical disability which restricts or limits food preparation abilities \r\n current use of or history of abusing alcohol or other drugs \r\n \r\nDocument: The caregiver's limited abilities in the participant's health record. \r\n \r\n94 \r\n \r\n CODE \r\n903 \r\n \r\nCHILDREN \r\nFoster 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. \r\n \r\nPRIORITY V \r\n \r\n904 \r\n \r\nENVIRONMENTAL TOBACCO SMOKE EXPOSURE \r\n \r\nIII \r\n \r\nEnvironmental tobacco smoke (ETS) exposure is defined as exposure to smoke from tobacco products inside the home. \r\n \r\n95 \r\n \r\n 96 \r\n \r\n TABLE OF APPENDICES \r\n \r\nAPPENDICES REFERENCED IN RISK CRITERIA SECTION \r\n \r\nAppendix \r\n \r\nA-1 \r\n \r\nWIC Maternal High Risk Criteria.................................................. \r\n \r\nPage 99 \r\n \r\nA-2 \r\n \r\nWIC High Risk Criteria for Infants and Children.............................. 100 \r\n \r\nB-1 \r\n \r\nWomen's Health Recommended Guidelines for Iron Supplementation, Based on Treatment Values............................... 101 \r\n \r\nB-2 \r\n \r\nChild Health Recommended Guidelines for Iron Supplementation, \r\n \r\nBased on Treatment Values....................................................... 102 \r\n \r\nC-1 \r\n \r\nBody Mass Index (BMI) Table for Determining Weight \r\n \r\nClassification for Women........................................................... 103 \r\n \r\nC-2 \r\n \r\nDefinition of Maternal Weight Gain (Low, High, and Multi-Fetal)......... \r\n \r\n104 \r\n \r\nC-3 \r\n \r\nDefinition of Inadequate Growth for Infants 1-6 Months of Age........... 105 \r\n \r\nD \r\n \r\nPhysical Signs Suggestive of Nutrient Deficiencies.......................... 106 \r\n \r\nE-1 \r\n \r\nAlcohol and Cigarettes............................................................... 108 \r\n \r\nE-2 \r\n \r\nCommon Names of Illegal (Street) Drugs/Drugs of Abuse.................................................................................... 109 \r\n \r\nF \r\n \r\nRecommended Food Intake Patterns........................................... 110 \r\n \r\nG \r\n \r\nInappropriate Nutrition Practices................................................ \r\n \r\n111 \r\n \r\nH \r\n \r\nProducts Containing Caffeine...................................................... 116 \r\n \r\nI \r\n \r\nInstructions for Use of the Prenatal Weight Gain Grid...................... \r\n \r\n118 \r\n \r\nJ-1 \r\n \r\nMeasuring Length..................................................................... 119 \r\n \r\nJ-2 \r\n \r\nMeasuring Weight (\"Infant\" Scale)................................................ 120 \r\n \r\nJ-3 \r\n \r\nMeasuring Height...................................................................... 121 \r\n \r\nJ-4 \r\n \r\nMeasuring Weight (Standing)...................................................... 122 \r\n \r\nK \r\n \r\nInstructions for Use of the Growth Charts..................................... \r\n \r\n123 \r\n \r\nL \r\n \r\nUse and Interpretation of the Growth Charts.................................. 127 \r\n \r\n97 \r\n \r\n APPENDICES PROVIDED FOR SUPPLEMENTAL INFORMATION \r\n \r\nAppendix \r\n \r\nPage \r\n \r\nM \r\n \r\nFood Sources of Vitamin A......................................................... 128 \r\n \r\nN \r\n \r\nFood Sources of Vitamin C......................................................... 129 \r\n \r\nO \r\n \r\nFood Sources of Folate............................................................. 130 \r\n \r\nP \r\n \r\nFood Sources of Iron................................................................. 131 \r\n \r\nQ \r\n \r\nFood Source of Calcium............................................................ 132 \r\n \r\nR \r\n \r\nHerbs: Their Use and Potential Risks........................................... 133 \r\n \r\nS \r\n \r\nKey for Entering Weeks Breastfed............................................... 134 \r\n \r\nT \r\n \r\nInfant Formula Preparation......................................................... 135 \r\n \r\nU-1 \r\n \r\nConversion Tables and Equivalents............................................. 138 \r\n \r\nU-2 \r\n \r\nApproximate Metric and Imperial Equivalents................................. 139 \r\n \r\n98 \r\n \r\n WIC MATERNAL HIGH RISK CRITERIA \r\n \r\nAppendix A-1 \r\n \r\nAny 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. \r\n \r\nHigh Risk Criteria Hemoglobin or hematocrit at treatment level \r\n \r\nRisk Code 201 \r\n \r\nUnderweight \r\n \r\n Prenatal Women: Body Mass Index \u003c18.5 \r\n \r\n101 \r\n \r\n Postpartum Women: Body Mass Index \u003c18.5 \r\n \r\nOverweight \r\n \r\n Prenatal Women: Body Mass Index \u003e29.9 \r\n \r\n111 \r\n \r\n Postpartum Women: Current Body Mass Index \u003e29.9 \r\n \r\nLow maternal weight gain \r\n \r\n131 \r\n \r\nGestational weight loss during pregnancy greater than or equal to 2 pounds in the second and third trimester. \r\n \r\n132 \r\n \r\nBlood lead level \u003e 10 g/dl within the past 12 months. \r\n \r\n211 \r\n \r\nHyperemesis Gravidarum \r\n \r\n301 \r\n \r\nGestational diabetes \r\n \r\n302 \r\n \r\nEDC or delivery prior to 17th birthday \r\n \r\n331 \r\n \r\nMulti-fetal gestation \r\n \r\n335 \r\n \r\nFetal Growth Restriction \r\n \r\n336 \r\n \r\nNutrition-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 \r\nDiagnosed pre-diabetes \r\nBreastfeeding complications; referral to appropriate BF counselor must be made \r\nAny condition deemed by the competent professional authority to place the woman at high risk for compromised nutritional status; adequate documentation required \r\n \r\n341-349; 351-358, 360; 362 \r\n363 \r\n602 \r\n \r\nAppendix \r\nB-1 \r\nC-1 Body Mass Index Tables \r\nC-1 Body Mass Index Tables \r\nC-2 \r\n \r\n99 \r\n \r\n Appendix A-2 \r\nWIC HIGH RISK CRITERIA FOR INFANTS AND CHILDREN \r\nWIC 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. \r\n \r\nHigh Risk Criteria \r\nHemoglobin or hematocrit at treatment level \r\nUnderweight or At Risk of Underweight (Infants and Children) Infants \u003c12 Months of Age: Weight for length \u003c 2nd percentile Children \u003c24 Months of Age: Weight for length \u003c 2nd percentile Children 2-5 Years of Age: BMI for age \u003c5th percentile OBESE (Children 2-5 Years of Age) Body Mass Index for age \u003e95th % \r\n \r\nRisk Code 201 103 \r\n113 \r\n \r\nAppendix B-2 \r\n \r\nShort stature \r\n \r\nInfants \u003c12 Months of Age: Length-for-age \u003c 2nd percentile \r\n \r\n121 \r\n \r\nChildren \u003c24 Months of Age: Weight for length \u003c 2nd percentile \r\n \r\nChildren 2-5 Years of Age: BMI for age \u003c5th percentile \r\n \r\nFailure to thrive \r\n \r\n134 \r\n \r\nInadequate growth \r\n \r\n135 \r\n \r\nLow birthweight infant (infant weighing 2500 grams [5  pounds] or \r\n \r\nless at birth). May only be used for infants as high risk criteria. \r\n \r\n141 \r\n \r\nBlood lead level \u003e 10g/dl within the past 12 months. \r\n \r\n211 \r\n \r\nNutrition-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 \r\n \r\n341-357; 360; 362; 382 \r\n \r\nBreastfeeding complications; infants only; referral to appropriate BF \r\n \r\ncounselor must be made \r\n \r\n603 \r\n \r\nAny condition deemed by the competent professional authority to place the infant/child at high risk for compromised nutritional status; adequate documentation required \r\n \r\n100 \r\n \r\n Appendix B-1 \r\nWOMEN'S HEALTH RECOMMENDED GUIDELINES FOR IRON SUPPLEMENTATION \r\nBASED ON TREATMENT VALUES \r\n \r\nHemoglobin \r\n \r\nHematocrit \r\n \r\nTreatment Value \r\n \r\nTreatment Value \r\n \r\nNonSmokers \r\n \r\nSmokers \r\n \r\nNonSmokers \r\n \r\nSmokers \r\n \r\nPrenatal Woman 1st Trimester 3rd Trimester \r\n \r\n10.9 gm or lower \r\n \r\n11.2 gm or lower \r\n \r\n32.9% or lower \r\n \r\n33.9% or lower \r\n \r\nPrenatal Woman 2nd Trimester \r\n \r\n10.4 gm or lower \r\n \r\n10.7 gm or lower \r\n \r\n31.9% or lower \r\n \r\n32.9% or lower \r\n \r\nNon-Pregnant and/or Lactating Woman (\u003c15 years of age) \r\n \r\n11.7 gm or lower \r\n \r\n12.0 gm or lower \r\n \r\n35.8% or lower \r\n \r\n36.8% or lower \r\n \r\nNon-Pregnant and/or Lactating Woman (\u003e15 years of age) \r\n \r\n11.9 gm or lower \r\n \r\n12.2 gm or lower \r\n \r\n35.8% or lower \r\n \r\n36.8% or lower \r\n \r\nFor 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. \r\n \r\nNOTE: 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 \r\n \r\nPHYSICIAN 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 \r\nsupplementation regimen and the absence of acute illness \r\n \r\nFor 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. \r\n \r\nNOTE: 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. \r\n \r\nPHYSICIAN 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 \r\nsupplementation regimen and the absence of acute illness \r\n \r\nAfter 4 weeks, if the hemoglobin increases \u003e 1g/dl or if the hematocrit increases \u003e 3 %, continue treatment for 2-3 more months. \r\nReference: CDC/MMWR: April 3, 1998. Recommendations to Prevent and Control Iron Deficiency in the United States \r\n \r\n101 \r\n \r\n Appendix B-2 \r\nCHILD HEALTH RECOMMENDED GUIDELINES FOR IRON SUPPLEMENTATION BASED ON TREATMENT VALUES \r\n \r\nHemoglobin Treatment \r\nValue \r\n \r\nHematocrit Treatment \r\nValue \r\n \r\nTreatment Regimen \r\n \r\nInfant 6 through 11 months \r\n \r\n10.9 gm or lower \r\n \r\n32.8% or lower \r\n \r\nDosage: 0.6 cc Ferrous Sulfate Drops BID Mg Elemental Iron: 15 mg BID \r\n \r\nChild 12 through 23 months \r\n \r\n10.9 gm or lower \r\n \r\n32.8% or lower \r\n \r\nDosage: 0.6 cc Ferrous Sulfate Drops BID Mg Elemental Iron: 15 mg BID \r\n \r\nChild 2 through 5 years \r\n \r\n11.0 gm or lower \r\n \r\n32.9% or lower \r\n \r\nDosage: 1.2 cc Ferrous Sulfate Drops BID Mg Elemental Iron: 30mg BID \r\n \r\n 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. \r\n Routine screening for iron deficiency anemia is not recommended in the first 6 months of life. \r\n Treatment of iron deficiency anemia is 3 mg per kilogram per day. \r\n 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. \r\n \r\nSources: Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, April 3, 1998/Vol.47/No. RR-3. \r\nNutrition Guidelines for Practice: A Manual for Providing Quality Nutrition Services. Nutrition Section, 1997. \r\n \r\n102 \r\n \r\n Appendix C-1 \r\n \r\nBody Mass Index (BMI) Table for Determining Weight Classification for (Women) 1 \r\n \r\nHeight (Inches) \r\n \r\nUnderweight BMI \u003c18.5 \r\n \r\nNormal Weight BMI 18.5-24.9 \r\n \r\nOverweight BMI 25.0-29.9 \r\n \r\nObese BMI \u003e29.9 \r\n \r\n58\" \r\n \r\n\u003c89 \r\n \r\n89-118 \r\n \r\n119-142 \r\n \r\n\u003e142 \r\n \r\n59\" \r\n \r\n\u003c92 \r\n \r\n92-123 \r\n \r\n124-147 \r\n \r\n\u003e147 \r\n \r\n60\" \r\n \r\n\u003c95 \r\n \r\n95-127 \r\n \r\n128-152 \r\n \r\n\u003e152 \r\n \r\n61\" \r\n \r\n\u003c98 \r\n \r\n98-131 \r\n \r\n132-157 \r\n \r\n\u003e157 \r\n \r\n62\" \r\n \r\n\u003c101 \r\n \r\n101-135 \r\n \r\n136-163 \r\n \r\n\u003e163 \r\n \r\n63\" \r\n \r\n\u003c105 \r\n \r\n105-140 \r\n \r\n141-168 \r\n \r\n\u003e168 \r\n \r\n64\" \r\n \r\n\u003c108 \r\n \r\n108-144 \r\n \r\n145-173 \r\n \r\n\u003e173 \r\n \r\n65\" \r\n \r\n\u003c111 \r\n \r\n111-149 \r\n \r\n150-179 \r\n \r\n\u003e179 \r\n \r\n66\" \r\n \r\n\u003c115 \r\n \r\n115-154 \r\n \r\n155-185 \r\n \r\n\u003e185 \r\n \r\n67\" \r\n \r\n\u003c118 \r\n \r\n118-158 \r\n \r\n159-190 \r\n \r\n\u003e190 \r\n \r\n68\" \r\n \r\n\u003c122 \r\n \r\n122-163 \r\n \r\n164-196 \r\n \r\n\u003e196 \r\n \r\n69\" \r\n \r\n\u003c125 \r\n \r\n125-168 \r\n \r\n169-202 \r\n \r\n\u003e202 \r\n \r\n70\" \r\n \r\n\u003c129 \r\n \r\n129-173 \r\n \r\n174-208 \r\n \r\n\u003e208 \r\n \r\n71\" \r\n \r\n\u003c133 \r\n \r\n133-178 \r\n \r\n179-214 \r\n \r\n\u003e214 \r\n \r\n72\" \r\n \r\n\u003c137 \r\n \r\n137-183 \r\n \r\n184-220 \r\n \r\n\u003e220 \r\n \r\n1Adapted 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. \r\n \r\n*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. \r\n \r\n103 \r\n \r\n Appendix C-2 \r\n \r\nDefinition of Weight Gain (Women) \r\nTotal Weight Gain Range (lbs) \r\n \r\nPrepregnancy Weight Groups \r\nUnderweight Normal Weight \r\nOverweight Obese \r\n \r\nSingleton Pregnancy \r\n \r\nDefinition Low Maternal Recommended \r\n \r\n(BMI) \r\n \r\nWeight Gain Weight Gain \r\n \r\nHigh Maternal Weight Gain \r\n \r\n\u003c 18.5 \r\n \r\n\u003c28 \r\n \r\n18.5 to 24.9 \r\n \r\n\u003c25 \r\n \r\n25.0 to 29.9 \r\n \r\n\u003c15 \r\n \r\n\u003e 30.0 \r\n \r\n\u003c11 \r\n \r\n28-40 25-35 15-25 11-20 \r\n \r\n\u003e 40 \u003e 35 \u003e 25 \u003e 20 \r\n \r\nPrepregnancy Weight Groups \r\nUnderweight \r\nNormal Weight Overweight Obese \r\n \r\nMulti-Fetal Weight Gain \r\n \r\nDefinition Low Maternal Recommended \r\n \r\n(BMI) \r\n \r\nWeight Gain Weight Gain \r\n \r\nHigh Maternal Weight Gain \r\n \r\n\u003c 18.5 \r\n18.5 to 24.9 25.0 to 29.9 \r\n\u003e 30.0 \r\n \r\nThere was insufficient information for the IOM committee to develop provisional guidelines for underweight woman \r\nwith multiple fetuses. \r\n\u003c37 \r\n\u003c31 \r\n\u003c25 \r\n \r\n1.5lbs/week during 2nd and 3rd trimesters \r\n37-54 31-50 25-42 \r\n \r\nThere was insufficient information for the IOM committee to develop provisional guidelines for underweight woman with multiple fetuses. \r\n\u003e 54 \u003e 50 \u003e 42 \r\n \r\n104 \r\n \r\n Appendix C-3 \r\n \r\nDefinition of Inadequate Growth for Infants 1-6 Months of Age \r\n \r\nInadequate 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: \r\n \r\nAge \r\n1 month 1-2 months 2-3 months 3-4 months 4-5 months 5-6 months \r\n \r\nMinimum Acceptable \r\nWeight Gain \r\n19 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) \r\n \r\nExample: \r\n \r\nDate of Measurement 09/13/98 (birth) 10/26/98 (6 weeks, 1 day old) \r\n \r\nWeight 7 lbs 6 oz 9 lbs 3 oz \r\n \r\n1. Calculate infant's age: \r\n \r\n98 - 98 \r\n \r\n10 \r\n \r\n26 \r\n \r\n09 \r\n \r\n13 \r\n \r\n01 mo 13 days = 1 month + 1 week + 6 days = about 1 mo + 2 wks \r\n \r\n2. Calculate minimum acceptable weight gain: \r\n \r\n1st 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 \r\n \r\n3. 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. \r\n \r\n105 \r\n \r\n Appendix D PHYSICAL SIGNS SUGGESTIVE OF NUTRIENT DEFICIENCIES \r\n \r\nBody Area Hair Eyes \r\nLips \r\nGums Tongue \r\nFace and Neck \r\n \r\nNormal Appearance \r\n \r\nSigns Suggestive of Nutrient Deficiency(ies) \r\n \r\nNutrient Consideration(s) \r\n \r\nshiny; firm; not easily plucked \r\nbright; clear; shiny; no sores at corners of eyelids; \r\n \r\nlack of natural shine; dull; thin; loss of curl; color changes (flag sign); easily plucked \r\neye membranes pale; \r\n \r\ninadequate protein and calories \r\nanemia (inadequate iron, folacin, or vitamin B-12) \r\n \r\nmembranes healthy pink and moist; no prominent blood vessels \r\n \r\nBitot's spots; red membranes; dryness of membranes; dull appearance of cornea (cornea xerosis); softening of cornea (keratomalacia); \r\n \r\ninadequate Vitamin A \r\n \r\nsmooth; not chapped or swollen \r\n \r\nredness and fissuring of eyelid corners \r\nredness or swelling of mouth or lips (cheilosis); bilateral cracks, white or pink lesions at corners of mouth (angular stomatitis) and/or scars \r\n \r\ninadequate riboflavin, Vitamin B-6, and niacin \r\ninadequate niacin and riboflavin \r\ninadequate riboflavin, niacin, iron and Vitamin B-6 \r\n \r\nhealthy, red; do not bleed; not swollen \r\ndeep red; not swollen or smooth \r\n \r\nspongy; bleeding; receding scarlet; raw; edematous (glossitis) \r\n \r\ninadequate ascorbic acid \r\ninadequate niacin, riboflavin, folacin, iron, Vitamins B-6 and B-12 \r\n \r\npurplish color (magenta); \r\n \r\ninadequate riboflavin \r\n \r\nsmooth; pale; slick; atrophied taste buds (papillae) \r\n \r\ninadequate folacin, Vitamin B-12, iron and niacin \r\n \r\nskin color uniform, smooth, pink; healthy appearing; not swollen \r\n \r\ndiffuse depigmentation; darkening of skin over cheeks and under eyes; \r\n \r\ninadequate protein \r\ninadequate calories and niacin \r\n \r\nscaling of skin around nostrils (nasolabial seborrhea) \r\n \r\ninadequate riboflavin, niacin, and Vitamin B-6 \r\n \r\nswollen (moon) face; \r\n \r\ninadequate protein \r\n \r\nfront of neck swollen (thyroid enlargement); \r\n \r\ninadequate protein; inadequate iodine \r\n \r\nswollen cheeks (bilateral parotid enlargement) \r\n \r\ninadequate protein \r\n \r\n106 \r\n \r\n Appendix D (cont.) PHYSICAL SIGNS SUGGESTIVE OF NUTRIENT DEFICIENCIES \r\n \r\nBody Area Skin \r\nTeeth \r\nHead / Neck Nails Muscular and Skeletal Systems \r\n \r\nNormal Appearance no signs of swelling rashes, dark or light spots \r\nno cavities, no pain, bright \r\nface not swollen firm, pink good muscle tone; some fat under skin; can walk or run without pain \r\n \r\nSigns Suggestive of Nutrient Deficiency(ies) \r\ndry and scaly (xerosis); sandpaper-like feel (follicular hyperkeratosis); \r\npinhead-size purplish skin hemorrhages (petechiae); \r\nexcessive bruising; \r\nred, swollen pigmentation of areas exposed to sunlight (pellagrous dermatitis); \r\nextensive lightness and darkness of skin (flaky, pressure sores(decubiti) \r\nmay 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]* \r\nthyroid enlargement (front of neck); parotid enlargement (cheeks become swollen) \r\nnails are spoon-shaped (koilonychia); brittle ridged nails, pale nail beds \r\nmuscles 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 \r\n \r\nNutrient Consideration(s) \r\nInadequate Vitamin A or Essential fatty acids \r\nInadequate Vitamin C \r\nInadequate Vitamin K \r\nInadequate niacin and Tryptophan \r\nInadequate protein, Vitamin C, and zinc \r\nInadequate Vitamin D and Vitamin A \r\nInadequate iodine; inadequate protein \r\nInadequate iron; Vitamin A toxicity \r\nInadequate protein Inadequate thiamin Inadequate Vitamin D \r\n \r\nSources: 1. American Journal of Public Health, Supplement, November 1973, p. 19. 2. Georgia Dietetic Association Diet Manual, 1992. \r\n \r\n107 \r\n \r\n ALCOHOL AND CIGARETTES \r\n \r\nAppendix E-1 \r\n \r\nAlcohol Equivalents: \r\n \r\nOne serving of alcohol \r\n \r\n= \r\n \r\n12 ounces of beer (light or regular); \r\n \r\n12 ounces of wine cooler; \r\n \r\n5 ounces of wine (light or regular); \r\n \r\n1 1/2 ounces of liquor. \r\n \r\nKey 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. \r\n \r\nKey: 00 ounces/week = no alcohol intake \r\n \r\n01 ounces/week = greater than 0 and up to 1 1/2 ounce/week \r\n \r\n02-98 ounces week = amount of intake \r\n \r\n99 ounces/week = greater than 98 ounces/week \r\n \r\nBinge drinking: drinks 5 or more (\u003e5) drinks on the same occasion on at least one day in the past 30 days. \r\n \r\nHeavy drinking: drinks 5 or more (\u003e5) drinks on the same occasion on five or more days in the previous 30 days. \r\n \r\nKey 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. \r\n \r\nKey: 01-98/day = average number of cigarettes/cigars/pipes smoked per day \r\n \r\n99/day = greater than 98 cigarettes/cigars/pipes smoked per day \r\n \r\n01-06/week = average number of cigarettes/cigars/pipes smoked per week \r\n \r\n01-03/month = average number of cigarettes/cigars/pipes smoked per month \r\n \r\nNote: The usual number of cigarettes in a pack is equal to 20. This number may vary. \r\n \r\n108 \r\n \r\n Appendix E-2 \r\n \r\nCOMMON NAMES FOR ILLEGAL (STREET) DRUGS/DRUGS OF ABUSE \r\n \r\nControlled Substances Cannabis: \r\n \r\nCommon Names \r\n \r\n Marijuana \r\n \r\n Acapulco Gold, Grass, Pot, Reefer, Sinsemilla, Thai Sticks \r\n \r\n Tetrahydrocannabinol \r\n \r\n Marinol, THC \r\n \r\n Hashish, Hashish Oil \r\n \r\n Hash, Hash Oil \r\n \r\nHallucinogens: \r\n \r\n LSD (lysergic acid diethylamide) \r\n \r\n Acid, Microdot \r\n \r\n Mescaline, Peyote \r\n \r\n Buttons, Cactus, Mescal \r\n \r\n Amphetamine Variants \r\n \r\n 2,5-DMA, DOB, DOM, Ecstasy, MDA, MDMA, STP \r\n \r\n Phencyclidine and Analogs \r\n \r\n Angel Dust, Hog, Loveboat, PCE, PCP, PCPy, TCP \r\n \r\nNarcotics: \r\n \r\n Heroin \r\n \r\n Diacetylmorphine, Horse, Smack \r\n \r\nStimulants: \r\n \r\n Cocaine \r\n \r\n Coke, Crack, Flake, Snow, Rock \r\n \r\nSource: Drugs of Abuse. Drug Enforcement Administration and The National Guard. Arlington, VA, 1997. \r\n \r\n109 \r\n \r\n RECOMMENDED FOOD INTAKE PATTERNS \r\n \r\nAppendix F \r\n \r\nFood Group \r\n \r\nBirth to 5/6 Months \r\n \r\nMilk, Yogurt \u0026 Cheese \r\nMeat, Poultry, Dry Beans, Eggs, Nuts Group \r\n \r\nBreast milk, every 2-3 hrs or Iron fortified formula, 2.5 oz/lb (18-35 ozs) \r\nNone \r\n \r\n5/6 Months to 12 months \r\nBreast milk, every 2-4 hrs or Iron fortified formula, 2.5 oz/lb (24-35 ozs) \r\nAdd after 6 months and before 9 months \r\n \r\n1 Year 2 cups1 \r\n2 ounces \r\n \r\n2-3 Years 2 cups \r\n2 ounces \r\n \r\n4-6 Years 2.5 cups \r\n3-4 ounces \r\n \r\nPregnant Teen/ Pregnant Adult \r\n3 cups \r\n \r\nBreastfeeding Teen/ Breastfeeding Adult \r\n3 cups \r\n \r\nTeen Postpartum/ Adult Postpartum \r\n3 cups \r\n \r\n6- 6  ounces \r\n \r\n6  ounces \r\n \r\n5- 5  ounces \r\n \r\nFruit Group \r\n \r\nNone \r\n \r\nVegetable Group \r\n \r\nNone \r\n \r\nAdd after 6 months and before 9 months \r\nAdd after 6 months and before 9 months \r\n \r\n1 cup2 1 cup \r\n \r\n1 cup2 1 cup \r\n \r\n1- 1  cups \r\n \r\n2 cups \r\n \r\n1  cups \r\n \r\n3 cups \r\n \r\n2-2  cups 3-3  cups \r\n \r\n1  -2 cups 2  cups \r\n \r\nGrain Group \r\n \r\nNone \r\n \r\nAdd iron Fortified cereal at 6 months \r\n \r\n3 oz equivalents \r\n \r\n3 oz equivalents \r\n \r\n4- 5 oz equivalents \r\n \r\n7- 8 oz equivalents 7- 8  oz equivalents 6 oz equivalents \r\n \r\nDiscretionary Calorie Allowance3 \r\n \r\nNone \r\n \r\nNone \r\n \r\n165 \r\n \r\n165 \r\n \r\n171 \r\n \r\n290- 362 \r\n \r\n362- 410 \r\n \r\n195-267 \r\n \r\n1 If there is obesity, high cholesterol or heart disease in their family history, the AAP recommends reduced fat 2 percent milk between 12 \r\n \r\nmonths 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 \r\n \r\nfor all food groups- preferably using forms of foods that are fat-free or low-fat and with no added sugars. \r\n \r\nMilk, Yogurt \u0026 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 \r\n1 ounces natural cheese (i.e. cheddar, Colby, longhorn) 2 ounces processed cheese (i.e. American, Swiss) 2 cups cottage cheese \r\nMeat, Poultry, Dry Beans, Eggs, Nuts Group: 1 ounce equivalent from this group= 1 ounce lean meat, poultry or fish \r\n1 egg  ounce nuts or seeds  cup cooked dry beans or tofu 1 tablespoon peanut butter \r\n \r\nFruit Group: 1 cup equivalent from this group= 1 medium fruit \r\n1 cup freshly cut canned or frozen fruit  cup dried fruit 1 cup 100% fruit juice Vegetable Group: \r\n1 serving = \r\n1 cup cooked or chopped 2 cups raw leafy salad greens 1 cup 100% vegetable juice \r\nGrain Group: At least half of all grains consumed should be whole grains 1ounce equivalent from this group = \r\n \r\n1 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 \r\n \r\n110 \r\n \r\n Appendix G \r\n \r\nInappropriate Nutrition Practices for Women \r\n \r\nInappropriate Nutrition Practices for Women \r\n \r\nExamples of Inappropriate Nutrition Practices (Including but not limited to) \r\n \r\nPotentially Harmful Dietary Supplements \r\nConsuming Dietary Supplements with potentially harmful consequences. Restrictive Diet \r\nConsuming 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) \r\nCompulsively ingesting non-food items (pica). \r\nInadequate vitamin/mineral supplementation recognized as essential by national public health policy. \r\nPregnant Women Potentially unsafe food consumption \r\nPregnant woman ingesting foods that could be contaminated with pathogenic microorganisms. \r\n \r\nExamples of Dietary supplements which when ingested in excess of recommended dosages, may be toxic or have harmful consequences: \r\n 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. \r\n \r\nNon-food items: \r\n \r\n Ashes; \r\n \r\n Clay; \r\n \r\n Baking soda; \r\n \r\n Dust; \r\n \r\n Burnt matches; \r\n \r\n Large quantities of ice \r\n \r\n Carpet fibers; \r\n \r\n Paint chips; \r\n \r\n Chalk; \r\n \r\n Soil; and \r\n \r\n Cigarettes; \r\n \r\n Starch (laundry and cornstarch) \r\n \r\n Consumption of less than 27 mg of supplemental iron per day by \r\n \r\npregnant woman. \r\n \r\n Consumption of less than 150 g of supplemental iodine per day by \r\n \r\npregnant and breastfeeding woman. \r\n \r\n Consumption of less than 400 mcg of folic acid from fortified foods \r\n \r\nand/or supplements daily by non-pregnant women \r\n \r\nPotentially 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. \r\n \r\n111 \r\n \r\n Appendix G (cont.) \r\n \r\nInappropriate Nutrition Practices for Children \r\n \r\nInappropriate Nutrition Practices for Children \r\n \r\nExamples of Inappropriate Nutrition Practices (Including but not limited to) \r\n \r\nRoutinely feeding inappropriate beverages as the primary milk source. \r\n \r\nExamples of inappropriate beverages as primary milk source: \r\n Non-fat or reduced-fat milks (between 12 and 24 months of age only) or sweetened condensed milk; and \r\n Imitation or substitutes milks (such as inadequately or unfortified rice- or soy-based beverages, non-dairy creamer), or other \"homemade concoctions.\" \r\n \r\nRoutinely feeding a child any sugarcontaining fluids. \r\nRoutinely using nursing bottle, cups, or pacifiers improperly. \r\n \r\nExamples of sugar-containing fluids: \r\n \r\n Soda/soft drinks; \r\n \r\n Corn syrup solutions; and \r\n \r\n Gelatin water; \r\n \r\n Sweetened tea. \r\n \r\n Using a bottle to feed:  Fruit juice, or  Diluted cereal or other solid foods. \r\n \r\n Allowing the child to fall asleep or be put to bed with a \r\n \r\nbottle at naps or bedtime. \r\n \r\n Allowing the child to use the bottle without restriction (e.g., \r\n \r\nwalking around with a bottle) or as a pacifier. \r\n \r\n Using a bottle for feeding or drinking beyond 14 months of \r\n \r\nage. \r\n \r\n Using a pacifier dipped in sweet agents such as sugar, \r\n \r\nhoney, or syrups. \r\n \r\n Allowing a child to carry around and drink, throughout the \r\n \r\nday, from covered or training cups. \r\n \r\nRoutinely using feeding practices that disregard the developmental needs or stages of the child. \r\n \r\n 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). \r\n Feeding foods of inappropriate consistency, size, or shape that put children at risk of choking. \r\n 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). \r\n 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). \r\n \r\n112 \r\n \r\n Inappropriate Nutrition Practices for Children \r\n \r\nExamples of Inappropriate Nutrition Practices (Including but not limited to) \r\n \r\nPotentially unsafe food consumption. \r\nFeeding foods to a child that could be contaminated with harmful microorganisms. \r\n \r\nExamples 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; \r\n \r\nRoutinely feeding a diet very low in calories and/or essential nutrients. \r\n \r\nExamples:  Vegan Diet;  Macrobiotic diet; and  Other diets very low in calories and/or essential nutrients. \r\n \r\nFeeding dietary supplements with potentially harmful consequences \r\n \r\nExamples of dietary supplements which when feed in excess of recommended dosages, may be toxic or have harmful consequences: \r\n Single or multiple vitamins  Mineral supplements; and  Herbal or botanical supplements/remedies/teas \r\n \r\nRoutinely not providing dietary supplements as recognized as essential by national public health policy when a child's diet alone cannot meet nutrient requirements. \r\n \r\n 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. \r\n 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. \r\n 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. \r\n \r\nRoutine ingestion of non-food items (pica) \r\n \r\n Ashes;  Carpet fibers;  Cigarettes or cigarette butts;  Clay;  Dust;  Foam Rubber  Paint chips;  Soil; and  Starch (laundry and cornstarch) \r\n \r\n113 \r\n \r\n Appendix G (cont.) \r\n \r\nInappropriate Nutrition Practices for Infants \r\n \r\nInappropriate Nutrition Practices for Infants \r\n \r\nExamples of Inappropriate Nutrition Practices (Including but not limited to) \r\n \r\nBreast-milk or Formula Substitute \r\nRoutinely using a substitute(s) for breast milk or FDA approved iron-fortified formula as the primary source during the first year of life. \r\nInappropriate use of bottles or SugarContaining Fluids. \r\nRoutinely using nursing bottles or cups improperly \r\nInappropriate Introduction of Solid Foods \r\nRoutinely offering complementary foods* or other substances that are inappropriate in type or timing. \r\nFeeding Practices not Developmentally Appropriate \r\nRoutinely using feeding practices that disregard the developmental needs or stages of the child. \r\n \r\nExamples 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. \r\n Adding sweet agents such as sugar, honey, or syrups to any beverage (including water) or prepared food, or used on a pacifier; or \r\n Introduction of any food other than breast milk or iron-fortified infant formula before 4 months of age. \r\n*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). \r\n \r\n114 \r\n \r\n Inappropriate Nutrition Practices for Infants \r\n \r\nExamples of Inappropriate Nutrition Practices (Including but not limited to) \r\n \r\nPotentially unsafe food consumption \r\nFeeding foods to a child that could be contaminated with harmful microorganisms or toxins. \r\nInappropriate Formula Preparation. \r\nRoutinely feeding inappropriately diluted formula Restrictive Nursing. \r\nRoutinely limiting the frequency of nursing of the exclusively breastfeed infant when breast milk is the sole source of nutrients. Restrictive Diet \r\nRoutinely feeding a diet very low in calories and/or essential nutrients Lack of proper Sanitation. \r\nRoutinely using inappropriate sanitation in preparation, handling, and storage of expressed breast milk or formula. \r\nPotentially Harmful Dietary Supplements. \r\nFeeding dietary supplements with potentially harmful consequences Lack of Essential Dietary Supplements. \r\nRoutinely not providing dietary supplements as recognized as essential by national public health policy when an Infant's diet alone cannot meet nutrient requirements. \r\n \r\nExamples 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. \r\n \r\nExamples 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. \r\n \r\nExamples: \r\n \r\n Vegan Diet;  Macrobiotic diet; and  Other diets very low in calories and/or essential nutrients \r\n \r\nExamples 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. \r\nExamples of Dietary supplements which when feed in excess of recommended dosages, may be toxic or have harmful consequences: \r\n 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 \r\n0.25 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. \r\n \r\n115 \r\n \r\n PRODUCTS CONTAINING CAFFEINE \r\n \r\nAppendix H \r\n \r\nPRODUCT \r\n \r\nAVERAGE CAFFEINE CONTENT (mg) \r\n \r\nCAFFEINE RANGE (mg) \r\n \r\nCoffee (5-oz cup) Brewed, drip Brewed, percolator Instant Decaffeinated, brewed Decaffeinated, instant \r\nTea Brewed, major US brands (5-oz) Brewed, imported brand (5-oz) Instant (5-oz) Iced (12-oz) \r\nChocolate 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) \r\nPRODUCT \r\nEnergy Drinks (16-oz) Monster Energy Rock Star Energy Drink Red Bull Full Throttle 5 Hour Energy (2-oz) \r\nSoft Drinks (12-oz) Mountain Dew Mello Yellow TAB Coca-Cola Diet Coke Mr. PIBB Dr. Pepper Pepsi Cola Diet Pepsi \r\n \r\n115 \r\n \r\n60-180 \r\n \r\n80 \r\n \r\n40-170 \r\n \r\n65 \r\n \r\n30-120 \r\n \r\n3 \r\n \r\n2-5 \r\n \r\n2 \r\n \r\n1-5 \r\n \r\n40 \r\n \r\n20-90 \r\n \r\n60 \r\n \r\n25-110 \r\n \r\n30 \r\n \r\n25-50 \r\n \r\n70 \r\n \r\n67-76 \r\n \r\n4 \r\n \r\n2-20 \r\n \r\n5 \r\n \r\n2-7 \r\n \r\n6 \r\n \r\n1-15 \r\n \r\n20 \r\n \r\n5-35 \r\n \r\n26 \r\n \r\n26 \r\n \r\n4 \r\n \r\n4 \r\n \r\nCAFFEINE CONTENT (mg) \r\n \r\n160.0 160.0 160.0 144.0 138.0 \r\n \r\n54.0 52.8 46.8 45.6 44.4 39.6 39.6 38.0 36.0 \r\n \r\n116 \r\n \r\n Appendix H (cont.) PRODUCTS CONTAINING CAFFEINE \r\n \r\nPRODUCT \r\n \r\nMILLIGRAMS CAFFEINE/DOSE \r\n \r\nDiet Plan Non-Prescription Drugs \r\n \r\nCaltrim Tablets \r\n \r\n100 \r\n \r\nCaffeine-Free Dexatrim w/ Vitamin C \r\n \r\n0 \r\n \r\nDexatrim \r\n \r\n200 \r\n \r\nX-tra Strength Dexatrim \r\n \r\n200 \r\n \r\nGold Medal \r\n \r\n100 \r\n \r\nOdrinex \r\n \r\nPain 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 \r\n \r\n32 32.4 16.2 16 32 36 32 15 65 32.5 16.25 32 30 33 140 \r\n \r\nMenstrual Relief \r\n \r\nAqua Ban \r\n \r\n100 \r\n \r\nMidol \r\n \r\n32.4 \r\n \r\nMidol Max Strength, Multi-Symptom \r\n \r\n60 \r\n \r\nSources: 1American Pharmaceutical Association and The National Professional Society of Pharmacists. (8th Ed.). (1986). Handbook of Nonprescription Drugs. \r\n \r\n2American Dietetic Association (ADA). (1992). Manual of Clinical Dietetics (4th ed.). Chicago, IL: Chicago Dietetic Association. \r\n \r\n3Georgia Dietetic Association (GDA). (1992). Georgia Dietetic Association Diet Manual (4th ed.). Duluth, GA. \r\n \r\n4Medical Economics Data Production Company. (15th Ed.). (1994). Physician's Desk Reference for Nonprescription Drugs, Montvale, N.J. \r\n5U.S. Pharmacopeial Convention, Inc. (13th Ed.). (1993). Drug Information for the Health Care Professional USP DI. \r\n \r\n117 \r\n \r\n INSTRUCTIONS FOR USE OF THE PRENATAL WEIGHT GAIN GRID \r\n \r\nAppendix I \r\n \r\n1. Record applicant/participant's name. \r\n2. 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. \r\n3. Enter height in inches without shoes. \r\n4. Use Weight History chart. \r\n5. Enter pregravid weight as indicated. Enter date and weight at each visit. \r\n6. Plot today's weight using the following steps: \r\na. 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. \r\nb. 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. \r\nc. 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. \r\nd. At the second and each subsequent visit, the weight gain for completed weeks of gestation should be plotted on the grid. \r\n \r\n118 \r\n \r\n Appendix J-1 \r\n \r\nAge: \r\n \r\nMEASURING LENGTH \r\n \r\nBirth to 24 months \r\n \r\nMaterial/Equipment: \r\n \r\nAn 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. \r\n \r\nTwo (2) people required \r\n \r\nProcedure: \r\n \r\n1. Check to be sure that moveable foot piece slides easily and the headboard is at the zero (0) mark. \r\n \r\n2. 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. \r\n \r\n3. 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. \r\n \r\n4. 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. \r\n \r\n5. 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. \r\n \r\n6. Record the second reading promptly. \r\n \r\n119 \r\n \r\n Appendix J-2 MEASURING WEIGHT \r\n(\"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 \r\nshould 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. \r\n120 \r\n \r\n Appendix J-3 \r\n \r\nMEASURING HEIGHT \r\n \r\nAge: \r\n \r\nChildren two (2) years of age and older \r\n \r\nAdults \r\n \r\nNOTE: \r\n \r\nOnce measurements are started with child standing, all subsequent measurements must be done standing. \r\n \r\nMaterial/Equipment: \r\n \r\nAn 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. \r\n \r\nProcedure: \r\n1. Remove all bulky clothing, head and footwear. \r\n2. Position the child/adult against the measuring device, instructing the child/adult to stand straight and tall. \r\n3. 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. \r\n4. 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. \r\n5. Read the stature to the nearest 1/8-inch. \r\n6. Repeat the adjustment of the headboard and re-measure until two (2) readings agree within 1/4 inch. \r\n7. Record the second reading promptly. \r\n \r\n121 \r\n \r\n Appendix J-4 \r\n \r\nAge: \r\n \r\nMEASURING WEIGHT (STANDING) \r\n \r\nAdults, and children 2 years of age or older Materials/Equipment: \r\n \r\nStandard electronic scale or platform beam scale with non-detachable weights that weighs in at least 1/4 pound or 100 gram increments. \r\n \r\nScales must be calibrated yearly \r\n \r\nProcedure: \r\n \r\n1. 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. \r\n \r\n2. Should be wearing minimal indoor clothing. Remove shoes, heavy clothing, belts, and heavy jewelry. Be sure pockets are empty. \r\n \r\n3. Have child/adult stand in the center of the platform, arms hanging naturally. The child/adult must be free standing. \r\n \r\n4. 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. \r\n \r\n5. Move the weight on the fractional beam away from the zero (0) position (left to right) until the indicator is centered. \r\n \r\n6. Make sure the child/adult is still not holding on, then record to the nearest 1/4 lb. \r\n \r\n7. Have the child/adult step off scale and return weight to zero (0). Repeat until two (2) readings agree within 1/4 pound. \r\n \r\n8. Record the second reading promptly. \r\n \r\nSources: Georgia Child and Adolescent Health Program Manual. DHR, Division of Public Health; 1987. A Guide to Pediatric Weighing and Measuring, DHHS; 1981. \r\n \r\n122 \r\n \r\n Appendix K \r\n \r\nINSTRUCTIONS FOR USE OF THE GROWTH CHARTS \r\n \r\n1. 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. \r\n \r\n2. Record name and/or identifying number of the chart. Document birth date. \r\n \r\n3. 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: \r\n \r\nYear \r\n \r\nMonth \r\n \r\nDay \r\n \r\nDate of Measurement \r\n \r\n2002 \r\n \r\n4 \r\n \r\n21 \r\n \r\nDate of Birth \r\n \r\n-1997 \r\n \r\n-8 \r\n \r\n-10 \r\n \r\nChild's Age \r\n \r\n4y \r\n \r\n8 \r\n \r\n11 \r\n \r\nor 4 yrs 8 mos \r\nAs 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. \r\n \r\n4. Plot growth measurements by using the Interpolation Method. \r\n \r\nPlotting Interpolation Method: \r\n \r\na. Birth - 24 Month Growth Chart - Calculate exact age (to nearest week) and plot measurement into the space at the point nearest to the age. \r\nb. 2 - 18 Years Growth Chart - Calculate exact age (to nearest month) and plot measurement into space at the point nearest to the age. \r\n \r\n5. To plot the length or height for age and weight for age charts: \r\n \r\na. Follow a vertical line at the appropriate age. \r\n \r\nb. 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. \r\n \r\nc. Write the date above the point. \r\n \r\n123 \r\n \r\n Appendix K (cont.) 6. To plot the length or height/weight chart: \r\na. 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 \r\nthe 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 \r\nmark the point where the two (2) lines intersect. 8. To plot an infant's head circumference: \r\na. 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 \r\ncircumference and mark the point where the two (2) lines intersect. 9. Calculating Gestation-Adjusted Age: \r\na. Document the infant's gestational age in weeks. (Mother/caregiver can self report, or referral information from the medical provider may be used.) \r\nb. Subtract the child's gestational age in weeks from 40 weeks (gestational age of term infant) to determine the adjustment for prematurity in weeks. \r\nc. Subtract the adjustment for prematurity in weeks from the child's chronological postnatal age in weeks to determine the child's gestationadjusted age. \r\nd. For WIC nutrition risk determination, adjustment for gestational age should be calculated for all premature infants for the first 2 years of life. \r\n124 \r\n \r\n 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. \r\n10. Plotting for Prematurity: For all premature infants and children \u003c24 months plot adjusted and actual age. a. Infant Plot- (weight/age, Length/age, length/weight) b. Child Plot- (weight/age, height/age, BMI) \r\n11. The formula for calculating BMI for age is: \r\n[weight (lb.)  height (in.)  height (in.) x 703] \r\nThis 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. \r\nReference for Converting Fractions to Decimals: 1/8 = .125 \r\n2/8 or  = .25 3/8 = .375 \r\n4/8 or  = .5 5/8 = .625 \r\n6/8 or  = .75 7/8 = .875 \r\n125 \r\n \r\n Guidance for Rounding to One Decimal Point: \r\n \r\nAppendix K (cont.) \r\n \r\nWhen 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. \r\n \r\nExample: If the final BMI calculation equals 17.158829, the BMI would be 17.2 \r\n \r\nIf the final BMI calculation equals 17.14829, the BMI would be 17.1 \r\n \r\n126 \r\n \r\n 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. \r\nINTERPRETATION 1. Pattern of growth can only be interpreted when two sets of measurements are \r\nplotted 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. \r\n127 \r\n \r\n Appendix M \r\n \r\nFOOD SOURCES OF VITAMIN A \r\n \r\nFood Source \r\nApricots canned dried raw \r\n \r\nServing Size \r\n3 halves 10 halves 3 medium \r\n \r\nVitamin A (mcg Retinol)* \r\n140 250 280 \r\n \r\nBok Choy \r\n \r\n1 cup \r\n \r\n110 \r\n \r\nBroccoli cooked raw \r\n \r\n1 cup \r\n \r\n110 \r\n \r\n1 cup \r\n \r\n680 \r\n \r\nCarrots cooked raw \r\n \r\n1cup 1 medium \r\n \r\n1920 2030 \r\n \r\nCantaloupe, cubed \r\n \r\n1 cup \r\n \r\n520 \r\n \r\nEndive, raw \r\n \r\n1cup \r\n \r\n50 \r\n \r\nGreens, fresh, cooked \r\n \r\nbeet \r\n \r\n1cup \r\n \r\n370 \r\n \r\ncollards \r\n \r\n1cup \r\n \r\n350 \r\n \r\nkale \r\n \r\n1cup \r\n \r\n480 \r\n \r\nturnip \r\n \r\n1cup \r\n \r\n400 \r\n \r\nspinach \r\n \r\n1cup \r\n \r\n740 \r\n \r\nLiver, beef \r\n \r\n3 ounces \r\n \r\n10,600 \r\n \r\nMango, raw \r\n \r\n1 medium \r\n \r\n810 \r\n \r\nPapaya, raw \r\n \r\n1 medium \r\n \r\n620 \r\n \r\nParsley, chopped \r\n \r\n1cup \r\n \r\n160 \r\n \r\nPeaches \r\n \r\ncanned, juice pack \r\n \r\n1 cup \r\n \r\n100 \r\n \r\nraw \r\n \r\n1 medium \r\n \r\n50 \r\n \r\ndried \r\n \r\n10 halves \r\n \r\n280 \r\n \r\nPersimmon, raw \r\n \r\n1 medium \r\n \r\n360 \r\n \r\nPumpkin, canned \r\n \r\n1cup \r\n \r\n2690 \r\n \r\nSweet Potato, baked \r\n \r\n1 medium \r\n \r\n2490 \r\n \r\nWatercress, raw \r\n \r\n1cup \r\n \r\n80 \r\n \r\nWinter Squash, baked \r\n \r\n1cup \r\n \r\n240 \r\n \r\n*Micrograms of retinol equivalent: rounded to the nearest 10 \r\n \r\n128 \r\n \r\n FOOD SOURCES OF VITAMIN C \r\n \r\nFood Source \r\n \r\nServing Size \r\n \r\nBroccoli, chopped cooked raw \r\n \r\n1/2 cup 1/2 cup \r\n \r\nCantaloupe, raw \r\n \r\n1 cup, pieces \r\n \r\nGreen Pepper \r\n \r\n1/2 medium \r\n \r\nGrapefruit juice**, from concentrate raw \r\n \r\n1/2 cup 1/2 medium \r\n \r\nMango, raw \r\n \r\n1 medium \r\n \r\nOrange juice**, from concentrate raw (navel) \r\n \r\n1/2 cup 1 medium \r\n \r\nStrawberries, raw \r\n \r\n1 cup \r\n \r\nTomato, raw \r\n \r\n1 medium \r\n \r\n*Milligrams Vitamin C: rounded to nearest 10 **Items distributed through the Georgia WIC Program. \r\n \r\nAppendix N \r\nVitamin C (mg)* \r\n60 40 70 40 \r\n40 50 60 \r\n50 80 90 20 \r\n \r\n129 \r\n \r\n Selected Food Sources of Folate and Folic Acid \r\n \r\nFood Source / Serving Size \r\n \r\nMicrograms (g) \r\n \r\n*Breakfast cereals fortified with 100% of the DV,  cup \r\n \r\n400 \r\n \r\nBeef liver, cooked, braised, 3 ounces \r\n \r\n185 \r\n \r\nCowpeas (blackeyes), immature, cooked, boiled,  cup \r\n \r\n105 \r\n \r\n*Breakfast cereals, fortified with 25% of the DV,  cup \r\n \r\n100 \r\n \r\nSpinach, frozen, cooked, boiled,  cup \r\n \r\n100 \r\n \r\nGreat Northern beans, boiled,  cup \r\n \r\n90 \r\n \r\nAsparagus, boiled, 4 spears \r\n \r\n85 \r\n \r\n*Rice, white, long-grain, parboiled, enriched, cooked,  cup \r\n \r\n65 \r\n \r\nVegetarian baked beans, canned, 1 cup \r\n \r\n60 \r\n \r\nSpinach, raw, 1 cup \r\n \r\n60 \r\n \r\nGreen peas, frozen, boiled,  cup \r\n \r\n50 \r\n \r\nBroccoli, chopped, frozen, cooked,  cup \r\n \r\n50 \r\n \r\n*Egg noodles, cooked, enriched,  cup \r\n \r\n50 \r\n \r\nBroccoli, raw, 2 spears (each 5 inches long) \r\n \r\n45 \r\n \r\nAvocado, raw, all varieties, sliced,  cup sliced \r\n \r\n45 \r\n \r\nPeanuts, all types, dry roasted, 1 ounce \r\n \r\n40 \r\n \r\nLettuce, Romaine, shredded,  cup \r\n \r\n40 \r\n \r\nWheat germ, crude, 2 Tablespoons \r\n \r\n40 \r\n \r\nTomato Juice, canned, 6 ounces \r\n \r\n35 \r\n \r\nOrange juice, chilled, includes concentrate,  cup \r\n \r\n35 \r\n \r\nTurnip greens, frozen, cooked, boiled,  cup \r\n \r\n30 \r\n \r\nOrange, all commercial varieties, fresh, 1 small \r\n \r\n30 \r\n \r\n*Bread, white, 1 slice \r\n \r\n25 \r\n \r\n*Bread, whole wheat, 1 slice \r\n \r\n25 \r\n \r\nEgg, whole, raw, fresh, 1 large \r\n \r\n25 \r\n \r\nCantaloupe, raw,  medium \r\n \r\n25 \r\n \r\nPapaya, raw,  cup cubes \r\n \r\n25 \r\n \r\nBanana, raw, 1 medium \r\n \r\n20 \r\n \r\nAppendix O \r\n% DV^ \r\n100 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 \r\n \r\n* 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. \r\n \r\nSources: U.S. Department of Agriculture, Agricultural Research Service. 2003. USDA National Nutrient \r\nDatabase for Standard Reference, Release 16. Nutrient Data Laboratory Home Page, http://www.nal.usda.gov/fnic/cgi-bin/nut_search.pl \r\n \r\n130 \r\n \r\n FOOD SOURCES OF IRON \r\n \r\nFood Source \r\n \r\nServing Size \r\n \r\nIron Fortified Breakfast Cereal* \r\n \r\n cup \r\n \r\nCanned Clams \r\n \r\n1/3 cup \r\n \r\nCooked Oysters \r\n \r\n3 oz \r\n \r\nBlackstrap Molasses \r\n \r\n1 Tbsp. \r\n \r\nLiver \r\n \r\n2 ounces \r\n \r\nBaked Beans \r\n \r\n1 cup \r\n \r\nSpinach \r\n \r\n1 cup \r\n \r\nRed Meat \r\n \r\n3 ounces \r\n \r\nPrunes \r\n \r\n10 large \r\n \r\nRaisins \r\n \r\n1/2 cup \r\n \r\nPork \r\n \r\n3 ounces \r\n \r\nTurkey \r\n \r\n3 ounces \r\n \r\nBaked Potato with skin \r\n \r\n1 \r\n \r\nHam \r\n \r\n3 ounces \r\n \r\nLegumes, cooked* \r\n \r\n1/2 cup \r\n \r\nRaw Shrimp \r\n \r\n3 ounces \r\n \r\nBaked Winter Squash \r\n \r\n1 cup \r\n \r\nBerries \r\n \r\n1 cup \r\n \r\nTurnip or Collard Greens \r\n \r\n1 cup \r\n \r\nLiverwurst \r\n \r\n1 slice \r\n \r\nChicken \r\n \r\n3 ounces \r\n \r\nFish \r\n \r\n3 ounces \r\n \r\nPrune Juice \r\n \r\n1/3 cup \r\n \r\n*Items distributed through the Georgia WIC Program. \r\n \r\nAppendix P \r\nIron (mg) 8-18 11 7 5 5 5 4 3 3 3 3 3 3 2 2 2 2 \r\n1.5  2 1.5 1 1 1 1 \r\n \r\n131 \r\n \r\n Appendix Q \r\n \r\nMILK GROUP \r\n \r\nFOOD SOURCES OF CALCIUM \r\n \r\n250 mg \r\n \r\n150-249 mg \r\n \r\n75-149 mg \r\n \r\nMilks - 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 \r\nSwiss Cheeses 272 mg Ricotta, part skim,  c - 337 mg Milkshakes - 1 cup \r\nChocolate 397 mg Vanilla 457 mg Yogurt, lowfat - 1 cup Plain 415 mg Flavored 380 mg Fruit 345 mg \r\n \r\nCheeses - 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 \r\nCheese food American, processed, 163 mg Swiss, processed 205 mg \r\n \r\nCottage Cheese, 2% Lowfat,  c, 75 mg Frozen desserts   c \r\nIce cream 88 mg Ice milk, hardened, 88 mg Ice Milk, soft serve, 137 mg Pudding, 133 mg \r\n \r\nMEAT/PROTEIN GROUP \r\n \r\nSardines, with bones, 3 oz, 372 mg Tofu, firm processed with calcium- sulfate, 4 oz, 250-765 mg \r\n \r\nSalmon, with bones 167 mg. - 3 oz Sesame seeds 2 TB, 176 mg. \r\n \r\nBeans, 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 \r\n \r\nVEGETABLE GROUP \r\n \r\nCooked, 1 cup Collards, 357 mg Rhubarb, 348 mg Spinach, 278 mg Bok Choy, 252 mg \r\n \r\nCooked, 1 cup Kale, 200 mg Mustard greens, 200 mg Turnip greens, 249 mg \r\n \r\nCooked, 1 cup Okra, 176 mg Broccoli, 90 mg \r\n \r\nFRUIT \r\n \r\nFigs, 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. \r\n \r\nGRAIN GROUP \r\n \r\nWaffle, 7\" diameter, 179 mg \r\n \r\nCornbread, 2\" square , 94 mg Pancakes, 2-4\" diameter, 116 mg \r\n \r\n\"OTHERS\" Category fats, sweets, alcohol \r\n \r\nMolasses, Blackstrap, 2 Tbsp., 274 mg \r\n \r\nCOMBINATION FOODS: Foods made with ingredients from more than one food group \r\n \r\nCheese pizza,  of 14\" pie, 332 mg \r\n \r\nMacaroni and cheese,  c c, 181 mg Soups made with milk - 1 c \r\nCream of mushroom , 191 mg Cream of tomato, 168 mg Taco, beef, 174 mg \r\n \r\nChili con carne with beans, 1 c, 82 mg Custard, baked,  c, 148 mg Spaghetti, meatballs, tomato sauce, and cheese, 1 c, 124 mg \r\n \r\nSources: (1) Pennington, JAT. Bowes \u0026 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. \r\n \r\n132 \r\n \r\n Appendix R \r\n \r\nHerbs \r\nChamomile \r\nGinseng Mandrake Pennyroyal oil \r\nSassafras Tonka beans, melilot, sweet woodruff (tea) Devil's claw root \r\nGinger root tea \r\n \r\nHERBS: THEIR USE AND POTENTIAL RISKS \r\n \r\nUse \r\n \r\nRisks \r\n \r\nRelaxant \r\n \r\nMay cause allergic reaction (up to anaphylactic shock in allergic individuals). \r\n \r\nHealth food remedy \r\n \r\nPainful, swollen breasts \r\n \r\nSold falsely as Ginseng \r\n \r\nContains scopolamine \r\n \r\nAbortifacient \r\n \r\nToxicity, teratogenesis, increased risk of medical abortion, hepatotoxin, coma death \r\n \r\nTonic for a variety of unsubstantiated uses \r\n \r\nPossible carcinogenesis \r\n \r\nSeasonal tonic \r\n \r\nHemorrhage \r\n \r\nAbortifacient Morning sickness remedy \r\n \r\nSodium and water retention, hypokalemia, hypertension, cardiac failure/arrest \r\nUnknown - very large doses may cause depression of CNS, and cardiac arrhythmias. \r\n \r\nThere 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 \r\nproblems that might arise may be dose related, which could affect the fetus and growing infant. A safe \r\nlevel 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: \r\n \r\nAngelica Black Cohosh Blessed Thistle Calendula Dong Quai \r\n \r\nElecampane Gotu kola Juniper Berries Motherwart Myrrh \r\n \r\nSources: \r\n \r\nDimperio, 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. \r\n \r\n133 \r\n \r\n KEY FOR ENTERING WEEKS BREASTFED \r\n \r\nAppendix S \r\n \r\nThe number of weeks breastfed must be manually entered when completing paper WIC Assessment/Certification Forms and paper Turnaround Documents for: \r\n \r\n- 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\" \r\n \r\nLength 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. \r\nI. Codes to Enter When Breastfeeding is Given in Days \r\n \r\nConvert Days to Weeks \r\n \r\nFewer than 7 days \r\n \r\n= 00 weeks \r\n \r\n7 - 13 days \r\n \r\n= 01 week \r\n \r\n14  20 days \r\n \r\n= 02 weeks \r\n \r\n21  27 days \r\n \r\n= 03 weeks \r\n \r\n28  34 days \r\n \r\n= 04 weeks \r\n \r\n35  41 days \r\n \r\n= 05 weeks \r\n \r\n42  48 days \r\n \r\n= 06 weeks \r\n \r\nSource: Georgia WIC Branch ETAD Change Number 08-12b, 2008. \r\n \r\nII. Codes to Enter When Breastfeeding is Given in Months \r\n \r\n1 month \r\n \r\n= 04 weeks \r\n \r\n12 Months \r\n \r\n= 52 weeks \r\n \r\n2 months \r\n \r\n= 08 weeks \r\n \r\n13 Months \r\n \r\n= 56 weeks \r\n \r\n3 months \r\n \r\n= 13 weeks \r\n \r\n14 Months \r\n \r\n= 61 weeks \r\n \r\n4 Months \r\n \r\n= 17 weeks \r\n \r\n15 Months \r\n \r\n= 65 weeks \r\n \r\n5 Months \r\n \r\n= 22 weeks \r\n \r\n16 Months \r\n \r\n= 69 weeks \r\n \r\n6 Months \r\n \r\n= 26 weeks \r\n \r\n17 Months \r\n \r\n= 74 weeks \r\n \r\n7 Months \r\n \r\n= 30 weeks \r\n \r\n18 Months \r\n \r\n= 78 weeks \r\n \r\n8 Months \r\n \r\n= 35 weeks \r\n \r\n19 Months \r\n \r\n= 82 weeks \r\n \r\n9 Months \r\n \r\n= 39 weeks \r\n \r\n20 Months \r\n \r\n= 87 weeks \r\n \r\n10 Months = 43 weeks \r\n \r\n21 Months \r\n \r\n= 91 weeks \r\n \r\n11 Months = 48 weeks \r\n \r\n22 Months \r\n \r\n= 96 weeks \r\n \r\n22.5 Months + = 98 weeks or more \r\n \r\nSource: Enhanced Pregnancy Nutrition Surveillance System User's Manual. Division of Nutrition, Center for Chronic \r\n \r\nDisease Prevention \u0026 Health Promotion, Centers for Disease Control and Prevention, U.S. Department of Health and Human \r\n \r\nServices, Public Health Service. February 2000. \r\n \r\n134 \r\n \r\n Appendix T \r\nInfant Formula Preparation \r\nGENERAL INFORMATION \r\n1. Before starting, wash hands with soap and water. Rinse well. \r\n2. 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. \r\n3. Squeeze clean water through the nipple holes to be sure they are open. \r\n4. 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). \r\n5. 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. \r\n6. 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. \r\n7. Do not feed an infant a bottle left out of the refrigerator for more than 1 hour. \r\n8. 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. \r\n9. When using formula: \r\n 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 \r\nrust spots. \r\n135 \r\n \r\n Appendix T (cont.) \r\n \r\nInfant Formula Preparation \r\n9. (Cont'd) \r\n Store cans of infant formula in a cool place, indoors. Do not store in vehicles, garages or outdoors. \r\n For more information, see the following references: \r\n Infant formula cans - commercial brands. \r\n United States Department of Agriculture, Food and Nutrition Service. \r\nInfant 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). \r\n \r\nPREPARATION FROM CONCENTRATED LIQUID FORMULA \r\n \r\n1. 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 \r\namount 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. \r\n6. 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. \r\n7. After feeding, throw away any formula left in bottle or cup, as this can contain germs. \r\n \r\nNote: \r\n \r\nDo not use microwave oven to prepare or to warm formula. Formula heated in the microwave may result in burns. \r\n \r\nPREPARATION OF READY-TO-FEED FORMULA \r\n \r\n1. 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. \r\n3. 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. \r\n \r\nNote: Do not add water or any other liquid to this formula. \r\n \r\n5. Attach nipple and cap. Shake well again and feed infant. \r\n \r\n136 \r\n \r\n Appendix T (cont.) \r\n \r\nInfant Formula Preparation \r\n \r\n6. 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 \r\nopened can, cover and refrigerate. Use within 48 hours. Shake can again before pouring; or shake bottles before serving. \r\n \r\nNote: \r\n \r\nDo not use microwave oven to prepare or to warm formula. Formula heated in the microwave may result in burns. \r\n \r\nPreparation from Powdered Formula \r\n \r\n1. 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 \r\ntemperature. 3. Remove plastic lid from can; wipe it off if dusty. Wash top of can with soap and water; \r\nrinse 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 \r\nformula 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. \r\n5. 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. \r\n6. 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. \r\n7. 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. \r\n \r\nNote: \r\n \r\nDo not use microwave oven to prepare or to warm formula. Formula heated in the microwave may result in burns. \r\n \r\n137 \r\n \r\n CONVERSION TABLES AND EQUIVALENTS \r\n \r\nAppendix U-1 \r\n \r\nI. TABLE OF EQUIVALENTS \r\n3 teaspoon (tsp.) 2 Tbsp. 8 oz. 16 Tbsp. 2 c. 2 pts. 4 c. 4 qts. \r\nII. METRIC SYSTEM \r\n \r\n= 1 Tablespoon (Tbsp.) = 1 ounce (oz) = 1 cup (c.) = 1 c. = 1 pint (pt.) = 1 quart (qt.) = 1 qt. = 1 gallon (gal.) = 128 oz. \r\n \r\nA. \r\n \r\nAPPROXIMATE WEIGHTS/MEASURES \r\n \r\n20 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. \r\n \r\n= 1 milliliter (ml.) \r\n \r\n= 1 gram (g.) \r\n \r\n= 1 cubic centimeter (cc) \r\n \r\n= 5 ml. = 5 cc = 5 g. \r\n \r\n= 15 ml. = 15 cc = 15 g. \r\n \r\n= 29.57 ml. = 30 cc \r\n \r\n= 240 ml. \r\n \r\n= 28.35 g. (approx 30) \r\n \r\n= 240 g. \r\n \r\n= 453.6 g. \r\n \r\n= 1 kilogram (kg.) \r\n \r\n= = \r\n \r\n1 liter (L.) 1000 ml = 1 liter \r\n \r\nB. \r\n \r\nWEIGHTS \r\n \r\n1 milligram 1 gram (g) 1 kilogram \r\n \r\n= 1000 micrograms (mcg) = 1000 mg. = 1000 g. \r\n \r\nC. \r\n \r\nCONVERSIONS \r\n \r\nTo 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. \r\n \r\nReferences: Georgia Dietetic Association, Inc., Diet Manual, 4th edition, 1992. \r\n \r\n138 \r\n \r\n Appendix U-2 APPROXIMATE METRIC AND IMPERIAL EQUIVALENTS \r\n \r\nUseful approximate metric and imperial equivalents \r\n \r\n1 cm = 0.39 in 1 meter = 1.1 yd. \r\n \r\n1 in = 2.54 cm 1 ft = 30.48 cm \r\n \r\nTo convert centimeters to inches Divide the length in centimeters by 2.54. Example: The average newborn infant measures 50.89 cm: \r\n50.89 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: \r\n20 in x 2.54 cm/in = 50.8 cm \r\n \r\n139 \r\n \r\n "}],"pages":{"current_page":1,"next_page":null,"prev_page":null,"total_pages":1,"limit_value":10,"offset_value":0,"total_count":1,"first_page?":true,"last_page?":true},"facets":[{"name":"type_facet","items":[{"value":"Text","hits":1}],"options":{"sort":"count","limit":16,"offset":0,"prefix":null}},{"name":"creator_facet","items":[{"value":"Georgia. 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