WIC Risk Factors 2010

							WIC Risk Factors 2010

      Jean Cox, MS, RD, LN
   Department of OB/GYN, UNM
      Jcox@salud.unm.edu

                               1
Risk factors periodically need
to be modified
   RF updated as science improves
   New RF added
       Some deleted, absorbed
   WIC must have impact
       Nutrition education, food supplementation,
        referrals, etc.



                                                2
Goals for today:
   Review all RF criteria and rationale
       Highlight implementation issues and questions
       Consistent criteria necessary
            Less confusion and stress in the clinic
            Equal chance of getting certified
   More attention to new RF
   Will include newer research where available -
    head’s up on possible future modifications
       Will share references with those interested

                                                        3
For most RF:
   Diagnosed by a physician as self
    reported by applicant, participant, or
    caregiver; or as reported or
    documented by a physician, or
    someone working under physician’s
    orders
   Self reported  self diagnosed

                                             4
IOM – new guidelines for
prenatal weight gain – 5/09
   Updated 1990 guidelines
   General scheme is the same:
       Still based on prepregnant BMI
       Thinner women need to gain more than
        heavier women
       Best birth outcomes are seen with those
        who gain within the guidelines


                                                  5
IOM – summary of changes
   New BMI cutoffs for the categories
       Pregnant = nonpregnant cutoffs = WHO = NHLBI
   Specific guidelines for obese women
       None for Class II or III obesity
   Guidelines for twins based on BMI
       None for higher order multiples
   No special attention – shorter women,
    adolescents, racial/ethnic groups
    emphasis on helping mom –pregnancy,
    postpartum, preconceptually
                                                  6
    1990/2009 IOM weight gain
    for singleton pregnancies
              BMI categories       Total
              1990    2009      Weight gain
Underweight < 19.8   < 18.5    28-40 lbs
Normal       19.8-26 18.5-24.9 25-35
Overweight   >26-29 25-29.9    15-25
Obese        >29      30.0    1990 - At least 15
                               2009 - 11-20
                                               7
Most women = weight
category and weight gain
   Between BMI 18.5 and 19.8 –  gain
       Underweight  normal
   BMI 25 – 26 –  gain
       Normal  overweight
   BMI 29 – 29.9 -  gain
       Obese  overweight
   Obese women
       “At least 15 pounds”/“up to 15 pounds”  11-20
        pounds


                                                    8
   2009 IOM prenatal weight
   gain goals
                   Singleton      Twins
               BMI    (lbs)       (lbs)
Underweight < 18.5     28-40 Insufficient data
Normal       18.5-24.9 25-35 37-54
Overweight   25-29.9   15-25 31-50
Obese         30.0    11-20 25-42

                                                 9
New IOM guidelines will
modify many RFs
   101 – Underweight
   131 – Low maternal weight gain
   132 – Maternal weight loss during
    pregnancy
   111 – Overweight
   133 – High maternal weight gain
   335 – Multifetal gestation

                                        10
101 – Underweight – all W
    risk to both mom and baby
        risk LBW,  fetal growth,  perinatal mortality
        hemorrhage, PROM, cesarean delivery
       Risk can’t be entirely removed by  weight gain
   Categories = for PW, BF, PP
   Adolescents – same cutoffs for now
   Pay close attention to underweight after
    delivery
       Eating? Depressed? Disease?

                                                        11
131 – Low maternal weight
gain – PW (not BF, PP)
    risk to both mom and baby
        risk SGA, LBW, preterm delivery
        risk maternal complications,  initiate lactation
        likely/worse if prepregnant underweight
   RF Criteria – either:
       Weight plotted < range of the appropriate grid
       Rates of gain too low in 2nd or 3rd trimester
            Underweight < 1 pound/week
            Normal < 0.8 pound/week
            Overweight < 0.5 pound/week
            Obese < 0.4 pound/week
                                                         12
132 – Maternal weight loss
during pregnancy –PW - NEW
   1st trimester - any weight loss <
    pregravid weight
   2nd, 3rd trimester – weight loss of  2
    pounds ( 1 kg)
       Would need at least 2 weight measures




                                                13
111 – Overweight – all W
    risk to both mom and baby
        NTDs, macrosomia, shoulder dystocia,
        hypoglycemia
        GDM, hypertension, gallstones, cesarean
        delivery, pp anemia,  lactation
       Risk isn’t entirely removed by  weight gain
   Categories = for PW, BF, PP
   Adolescents – same cutoffs for now


                                                       14
133 – High maternal weight
gain – all W - NEW
    risk to both mom and baby
       LGA, macrosomia, shoulder dystocia,
        hypoglycemia, meconium aspiration, 
        neonatal mortality,  lactation,  childhood
        obesity
        HT, GDM, dysfunctional labor, c-sections,
         postpartum weight retention
        likely/worse if prepregnant overweight
   Adolescents – at particular risk
                                                 15
133 – continued
   PW – this pregnancy
       If gain  7 pounds/month
       All trimesters, all weight groups
       Includes multiples
   BF/PP – most recent pregnancy
       if had gained > recommendations



                                            16
335 – Multi-fetal gestation –
all W
    risk than with singletons
        LBW, growth restriction,  infant
        mortality
       Placental, cord abnormalities, HT, anemia,
        preterm delivery
   Weight gain recommendations for twins
    are now by prepregnant BMI
       Higher than before

                                                17
Nutrition needs for multiples
are even higher
   DRIs for twins are not specified
       Assumed higher for PW, BF
       Space more limiting
   Neither weight gain nor DRIs for higher order
    multiples are determined
   Best practice advice is available for both
    weight gain and DRIs
   Early weight gain (before 20-24 weeks)
    appears critical

                                              18
Implementation plans
   When?
   How?
   Other questions?




                       19
Anthropometric RFs – I, C
   141 – Low birth weight
   142 – Prematurity
   103 – Underweight or at risk of
    becoming underweight
   121 – Short stature or at risk of short
    stature
   134 – Failure to thrive

                                              20
Anthropometric RF, continued
   113 – Overweight
   114 – At risk of becoming overweight




                                           21
141 – Low birth weight and
VLBW – I, C < 24 months
   LBW  5 pounds, 8 ounces (2500 g)
       Very low birth weight  3 pounds, 5 ounces
        (1500 g)
    risk infant death,  physical, mental
    development
   Need catch up growth
       Can adjust for gestational age if also
        premature
                                                 22
142 – Prematurity - I, C < 24
months
   Birth  37 weeks gestational age
    nutrient needs - growth
   Immature  problems with suck,
    swallow, digestion, absorption, etc.
   Support breastfeeding
   Need to adjust for gestational age


                                           23
Cautions:
   LBW  premature
   Now SGA vs AGA
   Morbidity depends on when insult occurs
       IUGR worse than just premature
       Symmetric vs asymmetric growth restriction
   Catch up growth not all good
       Thrifty phenotype
       Excess catch up   metabolic disease


                                                     24
Gestational age adjustment
   Premature infants/children
       Born  37 weeks
   Different expectations for growth and
    development compared to full term
       Want growth = intrauterine growth
       No standard premature growth charts
   Now can also adjust expectations
    regarding RFs

                                              25
Gestational age adjustment,
continued
   Document gestational age in weeks
       Self-report or referral from medical provider
   Subtract gestational age from 40 weeks
       Adjustment for prematurity
   Subtract adjustment for prematurity from
    chronological postnatal age in weeks
       Gestation-adjusted age
   Examples

                                                        26
Gestational age adjustment,
continued
   Will be done up to 24 months of age
       Plot on growth chart using gestation-adjusted age
       < 40 weeks gestation
   At age 2, switch to chronological age
       Growth percentiles will probably decrease
       Modify counseling
   Implementation issues
       When?, how?


                                                      27
I,C weight grids have been
used since 2001
   Anthropometric measures
       Weights
       Birth to < 2 years – recumbent length
       > 2 years – standing height
   W/L or BMI/age percentile
       Appropriate BMI varies by age
       See 2001 training book


                                                28
103 – Underweight or at risk
of becoming underweight– I,C
   Underweight -  5th percentile W/L or
    BMI/age
   At risk of underweight – 6-10th percentile W/L
    or BMI/age
   Undernutrition
       Acute, but can be long-term
        immune function, organ development, hormonal
        function, brain development
   Remember 5-10% are normally there
       Needs evaluation, possible intervention
       At risk – prevention
                                                   29
121 – Short stature or at risk
of short stature – I, C
   Short stature -  5th percentile L/A or H/A
   At risk of short stature – 6-10th percentile L/A
    or H/A
   For preemies, use adjusted gestational age
    up to 2 years old
   Chronic malnutrition –  intake, diseases
       Calories, animal protein, zinc, vitamin A, iron,
        copper, iodine, calcium, phosphorus
       Survival - metabolic functioning > growth
   Genetics < environmental differences
                                                           30
134 – Failure to thrive – I, C
   Possible criteria – Dx by MD
       Weight consistently < 3rd percentile
       Weight < 80% ideal weight/height or age
       Progressive fall off in weight to < 3rd percentile
        rate of expected growth vs previous growth
        curve
            For preemies, adjusted gestational age up to 2 years old
   Complex etiology –  protein,  energy
       Lots of medical causes
        SES, abuse, neglect, maternal depression

                                                                 31
113 – Overweight – C (2-5 yo)
    95th percentile BMI/age
       If 24-36 month – recumbent length, use W/L
    likely overweight as adolescents and adults
        risk of morbidity, mortality
   NOT used for children < 2 years old
       Not associated with adult risk of obesity,
        independent of parental obesity
    caloric intake,  caloric expenditure,
    impaired energy regulation
       Symptom of problematic feeding practices
                                                     32
114 – At risk of becoming
overweight – I, C
   C  24 months:  85th and < 95th percentile
    BMI/age or W/H
       Must be standing
   For all infants and children:
       < 12 months – born to obese mom (BMI  30) at
        time of conception or at any point in the 1st
        trimester – self report by mom of prepregnant
        weight and height or measured weight and height
        documented by staff or other health care provider


                                                      33
114 – continued
    Any I, C - biological mother who is obese (BMI 
     30) at the time of certification - self report by
     mom of weight and height or measured weight
     and height taken by staff at certification
         If mom is pregnant or delivered < 6 months ago, use
          prepregnant weight
    Any I, C – biological father who is obese (BMI 
     30) at time of certification - self report by dad of
     weight and height or measured weight and height
     taken by staff at certification


                                                            34
Pregnancy RFs - current
conditions, history – all W
   331 - Pregnancy at a young age
   332 – Closely spaced pregnancies
   333 – High parity and young age
   338 – Pregnant woman currently
    breastfeeding
   301 – Hyperemesis gravidarum
   336 – Fetal growth restriction
   334 – Lack of or inadequate prenatal care

                                                35
Current conditions, history
RFs, continued
   311 – History of preterm delivery
   312 – Hx of low birth weight
   321 – Hx of SAB, fetal, or neonatal loss
   339 – Hx of nutrition related congenital
    or birth defect
   337 – Hx of birth of LGA infant


                                          36
331 – Pregnancy at a young
age – all W
   Conception  17 years old
       PW – current pregnancy
       BF/PP – most recent pregnancy
   Also  competition for nutrients
       Especially for younger teens – still growing
        risk LBW
        risk of social stressors,  emotional
        development,  realistic expectations

                                                 37
332 – Closely spaced
pregnancies – all W
   Conception before 16 months postpartum
       PW – current pregnancy
       BF/PP – most recent pregnancy
    risk of poor outcome in subsequent
    pregnancy, especially < 6 months (LBW)
   Little time to replace nutrients
       Especially if also breastfeeding
       Iron, folate, DHA, vitamin D, vitamin B12, iodine


                                                        38
333 – High parity and young
age - all W
   Women < age 20 at conception who have
    had 3+ previous pregnancies of at least 20
    weeks duration, regardless of birth outcome
       PW – current pregnancy
       BF/PP – most recent pregnancy
   Even  risk of depleted nutrient stores
        risk LBW   physical/mental development,
         infant death


                                                      39
338 – Pregnant woman
currently breastfeeding - NEW
   Breastfeeding woman now pregnant
       Doesn’t specify frequency
   Needs  nutrients
       Fetus, nursing infant, mom
   Other risks
       PW hormones   milk supply
       Mom’s nipples  sensitive
       Possible release of oxytocin  uterine
        contractions, premature labor
        milk production for second baby

                                                 40
301 – Hyperemesis
gravidarum – PW - NEW
   Severe nausea/vomiting  dehydrated,
    acidotic
       0.3-2% of pregnancies
       NOT common nausea and vomiting
       Early onset, longer duration, often + ptyalism
   Often needs hospitalization
        weight  enteral or parenteral feeds
       Physical issue  psych issues


                                                         41
336 – Fetal growth restriction
– PW - NEW
   Fetal growth restriction diagnosed by MD
       Serial measurements of fundal height, abdominal
        girth, confirm with ultrasound
       Fetal weight < 10th percentile for gestational age
   Usually  LBW   perinatal mortality and
    morbidity
       Can have long term consequences
   Multiple causes – not all nutritional


                                                        42
334 – Lack of or inadequate
prenatal care – PW - NEW
   Late prenatal care =
       Beginning after the 1st trimester (after 13th
        week)
       First visit in 3rd trimester
       Table on next slide
    risk premature delivery, growth
    restricted, LBW
   WIC – encourage prenatal care

                                                  43
334 - continued
   Weeks of         Number of
   gestation       prenatal visits
 14-21         0 or unknown
 22-29         1   or   less
 30-31         2   or   less
 32-33         3   or   less
 34 or more    4   or   less

                                     44
311 – History of preterm
delivery – all W
   History of birth of infant at  37 weeks
    gestation
       PW – any history of preterm delivery
       BF/PP – most recent pregnancy
    risk neonatal deaths
   Risk  this time?
   Nutritional causes?

                                               45
312 – History of low birth
weight – all W
   History of birth of infant weighing  5
    lb, 8 oz (2500 g)
       PW – any history of LBW
       BF/PP – most recent pregnancy
    risk of recurrence
    morbidity, mortality
   Nutritional causes – can be multiple
       Watch weight gain

                                              46
321 – History of SAB, fetal or
neonatal loss – all W
   Spontaneous abortion = spontaneous
    termination of a gestation at < 20
    weeks gestation or < 500 grams
   Fetal death = spontaneous termination
    at  20 weeks
   Neonatal death = death of an infant
    within 0-28 days of life

                                       47
321 - continued
   Diagnosed by MD
       PW – any hx fetal or neonatal death, 2+ SABs
             risk preterm LBW, SGA, NTDs, malformations
       BF – most recent pregnancy – multifetal gestation
        with 1+ fetal/neonatal deaths but with 1+ infants
        living
       PP – most recent pregnancy
   Nutritional causes?
       Kcals, protein, folate, zinc, vitamin A

                                                            48
339 – Hx birth – nutrition related
congenital or birth defect- all W
    Woman who has given birth to infant with a
     congenital or birth defect linked to
     inappropriate nutritional intake
    Diagnosed by MD
        PW – any history
        BF/PP – most recent pregnancy
    Nutrition – multiple nutrients
         folic acid, choline, vitamin B12, iodine, zinc
         glucose, calories, vitamin D, vitamin A


                                                            49
337 – History of birth of an
LGA infant – all W - NEW
   Large for gestational age =  9 lbs (4000 g)
       PW – any history
       BF/PP – most recent pregnancy or hx
    risk of another LGA baby – delivery
    complications
       Macrosomia = indicator of diabetes
            Current, gestational, future
       Can also be symptom of hypothyroidism


                                                50
Glucose tolerance RFs
   302   –   Gestational diabetes
   303   –   History of gestational diabetes
   343   –   Diabetes mellitus
   363   –   Pre-diabetes
   356   –   Hypoglycemia



                                                51
302 – Gestational diabetes –
PW only (not BF, PP)
   GDM = any degree of glucose or
    carbohydrate intolerance with onset or first
    recognition during pregnancy
       Diet controlled, oral meds, insulin
    risk LGA, congenital anomalies, birth
    complications, maternal/neonatal death
       Needs medical nutrition therapy (MNT) 
        tight glucose control
       WIC can support – reinforce diet and exercise,
        change food package

                                                         52
302 - continued
   Test some women early
        risk –obesity, personal or family history,
        PCOS, Hx LGA baby, glycosuria
   Test all at 24-28 weeks
       Rates higher in Hispanics, Native
        Americans, African Americans, Asians
       Rates in New Mexico – 10-15%
   Diagnosis regime may change

                                                  53
302 – continued
   Moms and children need long term
    follow-up and support
       Test 6-12 weeks pp, then every 1-2 years
       Mom -  risk developing Type 2 DM
       I/C -  risk obesity, impaired GT, DM
   Lifestyle, diet modifications > weight,
    activity

                                              54
303 – History of gestational
diabetes – all W
   History of diagnosed GDM
       30-50% will develop GDM in subsequent
        pregnancy, especially if needed insulin, obese
       40-60% develop DM within 15-20 years
             risk if dx early in pregnancy,  levels of hyperglycemia,
             obese
        risk of CVD if lipids 
   Nutrition – watch diet, weight, activity
       Support breastfeeding
   Good glucose control before next pregnancy

                                                                    55
343 - Diabetes mellitus –
W, I, C
   Group of metabolic diseases – defects in
    insulin secretion, insulin action, or both 
    inappropriate hyperglycemia
       Type 1- beta cell destruction – insulin deficiency
       Type 2 – insulin resistance/relative insulin
        deficiency  insulin secretory defect with insulin
        resistance
       Maturity Onset Diabetes of the Young (MODY) –
        genetic defect – insulin secretion


                                                        56
343 - continued
   Abnormalities
       Metabolism (CHO, fats, protein, insulin)
       Structure, function of blood vessels and
        nerves
   Chronic hyperglycemia 
       Damage/failure of eyes, kidneys, nerves,
        heart, blood vessels
       Congenital malformations

                                                   57
343 - continued
   Good glucose control
       Medical nutrition therapy
   WIC - reinforce medical care and diet
    therapy
       Preconceptual glucose control
       Early medical care during pregnancy



                                              58
363 – Pre-diabetes –
BF, PP only - NEW
   Impaired fasting glucose (IFG) +/or
    impaired glucose tolerance (IGT)
       Hyperglycemia, but doesn’t meet criteria
        for diabetes
    risk for Type 2 DM, CVD
       Screening important, especially if  risk
       BMI  25 + 1 other risk factor


                                                    59
363 – continued
    Physical inactivity
    First-degree relative with DM
     risk ethnic group - African American, Latino,
     Native American, Asian American, Pacific Islander
    Hx of GDM, Hx of baby > 9 pounds
    HDL cholesterol < 35 mg/dl +/or TG > 250 mg/dl
    Hypertension or treatment for HT
    Hx of CVD
    Polycystic ovarian syndrome (PCOS)
    IGT or IFG on previous test
    Insulin resistance (severe obesity, acanthosis
     nigricans)                                      60
363 - continued
   Nutrition – MNT, lifestyle modifications
        weight
            5-10% weight loss
        exercise




                                           61
356 – Hypoglycemia – W, I, C
   Presence of hypoglycemia
       Complication of diabetes, condition in itself,
        associated with other disorders
            Early pregnancy
            SGA newborns
   Nutrition – frequent feedings, balanced
    diet, low CHO snacks, exercise


                                                  62
Hypertension RFs
   304 – History of preeclampsia
   345 – Hypertension and
    prehypertension




                                    63
304 – History of preeclampsia
– all W - NEW
   History of diagnosed preeclampsia
       > 140 mm Hg or > 90 mm Hg, with proteinuria
            Usually after 20th week, may include edema
            May  renal failure, eclampsia (seizures), HELLP
             syndrome (Hemolysis, Elevated Liver enzymes, Low
             Platelets)
             risk maternal death, maternal and perinatal morbidity
       Treatment = deliver the placenta
   Nutrition – risk factors include obesity
       Calcium, vitamins C, E, and D, carotenoids, folate,
        n3 fatty acids, trans fatty acids, zinc, magnesium?
       Preconceptual nutrition?
                                                                 64
345 – Hypertension and (now
also) prehypertension – W,I,C
   Presence of hypertension
       Women - > 140 mm Hg or > 90 mm Hg
       Asymptomatic  congestive heart failure,
        end-stage renal disease, peripheral
        vascular disease
   Now includes prehypertension
       BP - 130/80 to 139/89 mm Hg
       2x likely to develop hypertension

                                              65
345 - continued
   PW  LBW,  fetal growth, premature
    delivery, maternal/fetal/neonatal morbidity
       Includes chronic HT, preeclampsia, eclampsia,
        preeclampsia superimposed upon chronic HT,
        gestational hypertension
       PIH -  protein,  EFA,  Mg,  Ca, obesity,
        primigravida, < 20 or > 40 years, multi-fetal
        gestation, genetic disease, family history
            Includes gestational hypertension, preeclampsia, and
             eclampsia
   BF – discuss meds with MD, continue BFing

                                                                    66
345 - continued
   I/C – normal blood pressure varies
       HT = > 95th percentile/age, gender, height
        on at least 3 separate occasions
       Pre HT = 90th – 95th percentile
   HT in children   likely HT as adults
       Start checking regularly by age 3
       Associated with overweight/obesity
       Prevention important

                                               67
345 - continued
   Nutrition – lifestyle modification
       Adults -  weight,  sodium,  potassium,
         alcohol,  smoking,  exercise,  stress
       Children – moderate weight loss or prevent further
        weight gain,  time in sedentary activities
   WIC can support
       Low fat milk, fruits, vegetables
       Counseling -  portion sizes,  sugary drinks,
        energy-dense snacks, regular meals, breakfast

                                                         68
Medical RFs – W, I, C
   Diagnosed by MD
   Nutrition component
       Nutrient needs
       Eating
       Digestion, absorption
   WIC can impact


                                69
201 – Low hematocrit/low
hemoglobin – W, I, C
   Former title anemia
       Lots of causes of anemia
        iron most common, especially in WIC population
   Risk to both mom and baby
        weight gain,  work performance,  wound
        healing,  temperature regulation,  immune
        function,  hemorrhage,  ability to tolerate
        hemorrhage,  postpartum depression
        LBW, prematurity,  mental/motor development
        – may not be reversible,  CVD,  mortality if
        severe,  growth,  immune function
                                                     70
201 - continued
   Measure hemoglobin or hematocrit
            Hemoglobin – RBC protein - g/dl
            Hematocrit – volume RBC/total blood volume - %
       Normal values vary
            PW certified based on date of bloodwork
       Cutoffs vary by altitude and smoking
            Certification – altitude of clinic
            Smoking – take into account when counseling
   Remember Hgb and Hct last to change
       Iron stores already used up


                                                              71
High iron food sources are a
better choice than pills
   Non-heme iron
       88% of iron in food
       2-20% absorbed, strongly affected by diet
        components and a person’s iron status
             with fiber, tea, coffee, calcium, soy, egg
             vitamin C, meat factor
        with iron supplementation


                                                            72
Foods high in heme iron are
more effective
   Heme iron
       12% of dietary iron
       Found only in meats
       15-35% absorbed
       Relatively unaffected by dietary
        components, supplementation, and iron
        status


                                                73
Concentrate on the very high
iron sources
   Liver, liverwurst, braunschweiger, paté
    (not in 1st trimester), kidney, heart,
    gizzards, spleen, clams, oysters
   Beef
   Beans + vitamin C source
   Don’t waste space or time on others
       6.2 c raw spinach (0.8 c cooked) for iron in
        3 oz beef liver, assuming = absorption

                                                 74
341 – Nutrient deficiency
diseases – W, I, C
   Dx of nutritional deficiencies or a disease
    caused by insufficient dietary intake of
    macro- and micro- nutrients, such as:
       Protein energy malnutrition
       Xerophthalmia, beri beri, cheilosis, pellagra,
        scurvy, rickets, vitamin K deficiency
       Hypocalcemia, osteomalacia, Menkes disease
    morbidity, mortality
        growth, cognitive fx, immune system, etc.

                                                         75
342 – Gastro-intestinal
disorders – W, I, C
   Disease or condition that interfered with
    intake, digestion, +/or absorption of nutrients
          Gastroesophageal reflux (GERD)
          Peptic ulcer
          Post-bariatric surgery
          Short bowel syndrome
          Inflammatory bowel disease - ulcerative colitis, Crohn’s
           disease
          Liver disease
          Pancreatitis
          Biliary tract diseases
   Nutrition – multiple risks
                                                                76
344 - Thyroid disorders –
W, I, C
   Hypothyroidism or hyperthyroidism
       Hypo-  thyroid hormone produced or defect in
        receptor
            Anovulation, SABs, fetal loss, preeclampsia, HT, placental
             abruption, preterm delivery, LBW, cognitive impairment
            Severe – cretinism - irreversible
            Mild deficiency  impaired brain development?
            Education, low fat foods  weight management
   Thyroid control changes in pregnancy 
    early medical care
       Universal screening?

                                                                  77
344 - continued
       Hyper-  thyroid hormone secreted
            SAB, preterm delivery, LBW, stillbirth, preeclampsia,
             heart failure
            Hypermetabolism   caloric needs
       Postpartum thyroiditis
            Either or both hyper-, then hypo-thyroid
            Can  milk volume
   Iodine is important
         iodine   thyroid hormone production
         PW intakes (some seaweeds)  congenital
        hypothyroidism

                                                                     78
346 – Renal disease – W, I, C
   Any renal disease = kidney involvement
       Pyelonephritis, persistent proteinuria
       NOT urinary tract infections (UTIs) –
        bladder involvement
   Nutrition – multiple risks
       W -  fetal growth,  risk preeclampsia,
        chronic renal disease with proteinuria 
        azotemia if protein intake too high
       I, C -  growth
                                                   79
347 – Cancer – W, I, C
   Current condition, or treatment for the
    condition, must be severe enough to affect
    nutritional status
   Nutrition – multiple  risks
       Nutritional status at diagnosis > treatment
        outcome
       Type, stage of cancer > treatment choice,
        including nutrition management
       Food safety issues
       BF – some treatments  BF contraindicated

                                                      80
348 – Central nervous system
disorders – W, I, C
   Conditions > energy needs, ability to
    feed self, or alter nutritional status
    metabolically, mechanically, or both
          Epilepsy
          Cerebral palsy (CP)
          Neural tube defects (NTDs)
          Parkinson’s disease
          Multiple sclerosis (MS)
   Nutrition issues – vary with condition

                                             81
349 – Genetic and congenital
disorders – W, I, C
   Hereditary, congenital condition  physical
    or metabolic abnormality - must alter
    nutrition status metabolically, mechanically,
    or both
          Cleft lip or palate
          GI congenital anomalies
          Down’s syndrome
          Thalassemia major
          Sickle cell anemia (NOT sickle cell trait)
          Muscular dystrophy
   Nutrition issues – vary with condition
                                                        82
350 – Pyloric stenosis -
REMOVED
   Congenital defect in gastric outlet
       Obstruction, emaciation, electrolyte
        imbalance
       Now treated with surgery – no long term
        nutritional problems
       Certify with RF 359 – Recent major
        surgery, trauma, burns


                                              83
351 – Inborn errors of
metabolism – W, I, C
   Inborn error(s) of metabolism – gene
    mutations/deletions alter metabolism
   Untreated  severe problems
       Diagnosed shortly after birth
       Newborn screen = “PKU test”
   Nutrition – depends on condition
       Special formulas

                                           84
351 - continued
   Phenylketonuria (PKU)      Methylmalonic acidemia
   Maple syrup urine          Glycogen storage
    disease                     disease
   Galactosemia               Galactokinase deficiency
   Hyperlipoproteinemia       Fructoaldolase
   Homocystinuria              deficiency
   Tyrosinemia                Propionic acidemia
   Histidinemia               Hypermethioninemia
   Urea cycle disorders       Medium-chain acyl-CoA
   Glutaric aciduria           dehydrogenase (MCAD)


                                                    85
352 – Infectious diseases –
W, I, C
   Disease caused by growth of pathogens
       Tuberculosis
       Pneumonia
       Meningitis
       Parasitic infections
       Hepatitis
       Bronchiolitis (3 episodes in last 6 months)
       HIV or AIDS – BF contraindicated
   Severe enough to affect nutritional status
   Present within past 6 months
                                                      86
353 – Food allergies – W, I, C
   Adverse immune response to food or
    hypersensitivity that causes adverse
    immunologic reaction
       Needs to avoid food
       Medical nutrition therapy
            Avoid allergen
            Optimal nutrition
       PW – minimize own allergen exposure ?

                                                87
354 – Celiac disease – W, I, C
   Inflammatory condition of small intestine
    after ingesting wheat - SHOULD SAY GLUTEN
            Celiac Sprue, Gluten Enteropathy, Non-tropical Sprue
       Autoimmune – antibodies > small intestine villi
       More common than thought, permanent
            Especially if have other autoimmune diseases
   Multiple symptoms
       Diarrhea, malabsorption,  weight, FTT
       Osteoporosis, tooth enamel defects, multiple
        nutrient deficiencies, arthritis, fatigue
       Dermatitis Hepetiformis
                                                                    88
354 - continued
   Need to avoid all gluten - MNT
       Wheat, barley, rye
       Triticale, einkorn, emmer, spelt, kamut, malt
       Oats????
       Many food and drug additives
   Use alternate starches
       Amaranth, arrowroot, buckwheat, corn, legumes,
        millet, nuts, potatoes, quinoa, rice, seeds, soy,
        tapioca, teff, etc.

                                                        89
Celiac disease vs wheat allergy
   Celiac disease
       Inflammatory response to gluten
       Autoimmune, permanent
       Multiple nonspecific symptoms, longterm
   Wheat allergy
       IgE mediated response to any wheat protein
       Most children outgrow it
       Sx - hives, stomach pain, diarrhea, rash,
        wheezing, lip swelling

                                                     90
Now also gluten intolerance
   Gluten intolerance = non-celiac gluten
    sensitivity
       Not immune-mediated, not allergic
       Sx with gluten, but tests negative for celiac
        disease
       Sx transient – gassiness, abdominal pain,
        distension, diarrhea
   NOT a RF
                                                  91
355 – Lactose intolerance –
W, I, C
    lactase production  lactose not digested
       Fermented in small intestine  nausea, diarrhea,
        abdominal bloating, cramps
       Severity – mild to severe
            Among, within individuals
   Dx by MD or symptoms documented by CPA
       Doc ingestion of dairy products causes x
        symptoms, avoidance of such eliminates them
   Often can manage without avoid dairy

                                                      92
358 – Eating disorders –
all W only
   Anorexia nervosa, bulimia – can be life-
    threatening
            Self-induced vomiting
            Purgative abuse
            Alternating periods of starvation
            Use of appetite suppressants, diuretics, thyroid
             preparations
            Self-induced marked weight loss
   Dx by MD or documented by CPA
   Nutrition – can manage, not cure
       Often start pregnancy malnourished
        perinatal mortality,  congenital malformations
                                                                93
359 – Recent major surgery,
trauma, burns – W, I, C
   Severe enough to compromise
    nutritional status
       Includes cesarean sections
       If  2 months ago – self-reported
       If > 2 months ago – MD must document
        continued need for nutritional support
   Nutrition – response varies

                                                 94
360 – Other medical
conditions – W, I, C
   Diseases or conditions not included elsewhere
       Juvenile rheumatoid arthritis (JRA)
       Lupus erythematosus
       Cardiorespiratory diseases, heart disease
       Cystic fibrosis (CF)
       Persistent asthma (moderate or severe) needing
        daily medication
            Seldom used for infants – use RF 352
   Nutritional implications – current condition or
    treatment for the condition
       Varies by condition
                                                     95
362 – Disabilities - interfere
with ability to eat – W, I, C
   Developmental, sensory or motor disabilities
            Minimal brain function
            Feeding problems due to developmental disability,
             including pervasive development disorder (PDD), autism
            Birth injury
            Head trauma
            Brain damage
            Other disabilities
   WIC – education, referrals, coordinate service
        ability to intake, chew, or swallow food 
         growth
       May require tube feeding
                                                                96
381 – Dental problems –
W, I, C
   I, C – presence of nursing or baby bottle
    caries, smooth surface decay of maxillary
    anterior and primary molars
       Inappropriate feeding practices
   C, all W – tooth decay, periodontal disease,
    tooth loss, ineffectively replaced teeth  
    adequate food quantity or quality
       Missing > 7 teeth affects chewing
   PW – gingivitis of pregnancy
       RF for preterm LBW

                                                97
New medical RFs
   357 – Drug-nutrient interactions
   361 – Depression
   602 – Breastfeeding complications or
    potential complications (Women)
   603 – Breastfeeding complications or
    potential complications (Infants)


                                           98
357 – Drug nutrient
interactions – W, I, C - NEW
   Prescription or over-the-counter drugs shown
    to interfere with nutrient intake or utilization
       Nutritional status compromised
       Altered taste sensation, gastric irritation, 
        appetite, altered GI motility, altered nutrient
        metabolism and function – enzyme inhibition,
        vitamin antagonism,  urinary loss
   Usually with long-term use for chronic disease
   Check with PDR, drug inserts, pharmacist

                                                          99
361 – Depression –
W, C - NEW
   Presence of clinical depression
       Dx by MD or psychologist
   WIC impact – encourage, refer
       Appetite changes, often 
        risk preterm delivery, LBW, perinatal
        mortality
        smoking,  prenatal care
        care of children – FTT

                                                  100
602 – Breastfeeding
complications – BF – NEW
   Both actual and potential complications
       Severe breast engorgement
       Recurrent plugged ducts
       Mastitis
       Flat or inverted nipples
       Cracked, bleeding, severely sore nipples
       Age  40 years
       Failure of milk to come in by 4 days postpartum
       Tandem nursing (2 siblings, not twins)

                                                     101
603 – Breastfeeding
complications – I - NEW
   Both actual and potential complications
       Weak or ineffective suck
       Difficulty latching onto mother’s breast
       Inadequate stooling +/or < 6 wet
        diapers/day
            Stooling varies by age
            Dx by MD/health care provider
       Jaundice

                                                   102
603 - continued
   Jaundice – some is normal
       Bilirubin = product of RBC breakdown
        rate after birth - change fetal Hgb  adult Hgb
       Appears at days 2-5, then 
       Physiologic, neonatal jaundice, hyperbilirubinemia
   Can signal a problem
        RBC breakdown,  excretion
            Liver, intestine, inborn errors, congenital anomalies, etc.
       Before 24 hours, lasts > 1-2 weeks, yellow below
        umbilicus, levels too high

                                                                   103
603 - continued
   Can cause a problem if levels get too high
       Can cross blood-brain barrier
       BIND – bilirubin-induced neurologic dysfunction
            Can have permanent effects
       Preemies – more likely, more dangerous
   Treatment
       Phototherapy – bilirubin  lumirubin
       Exchange transfusion
            If light therapy fails
            If symptoms of BIND


                                                      104
603 - continued
   Breastmilk jaundice
       Onset 5-10 days, peaks in 2 weeks, lasts 3-12 wk
       Baby is healthy, thriving
       Normal stooling, voiding, growth
       Why?
       WIC – ID, refer to MD
            Monitor levels, may interrupt BF – decline?
            Continue breastfeeding
   Breastfeeding failure jaundice

                                                           105
603 - continued
   Breastfeeding failure jaundice
       Peaks at 3-5 days, can persist
       Baby – underfed,  weight
       Infrequent stooling, delayed yellow stools, scant
        dark urine
       Common marker for inadequate Bfing
            Infrequent, inadequate
            Problem of early discharge, especially for preemies
       WIC – BF support, refer to MD
             nutrition  rapid decline in bilirubin levels


                                                                   106
Breastfeeding RFs
   601 – Breastfeeding mother of infant at
    nutritional risk - BF
   702 – Breastfeeding infant of woman at
    nutritional risk - I
   BF infant dependent on mother’s milk
       Special attention to mom’s nutritional status
             500 kcals/d,  protein, calcium, etc. – optimal?
   Used to match BF and I priority levels
       Get highest priority possible (Priority I if possible)
       Don’t need to match all RFs used
                                                                  107
Substance abuse RFs
   371 – Maternal smoking
   904 – Exposure to environmental
    tobacco smoke
   372 – Alcohol and illegal drug use
   382 – Fetal alcohol syndrome



                                         108
371 – Maternal smoking –
all W
   Any smoking of tobacco
   All W   cancer, CVD, COPD,  bone
    density
   PW  preterm delivery, LBW, stillbirth, infant
    death,  SIDS, psych issues?
    oxidative stress, needs  vitamin C
   I, C also exposed
       Breastmilk, in utero   lung function
       Environmental smoke

                                                 109
904 - Environmental tobacco
smoke exposure – W,I,C- NEW
   Exposure to smoke from tobacco
    products inside the home
       No risk-free level of exposure
   Questions need to be standardized
       I, C – “Does anyone living in your
        household smoke inside the home?”
       W – “Does anyone else living in your
        household smoke inside the home?”

                                               110
904 - continued
   ETS comprised of:
       Sidestream smoke (85%) – given off by burning
        cigarette, pipe, or cigar
             carcinogens
       Mainstream smoke (15%) –exhaled by smokers
   ETS includes > 4000 chemicals
       Carbon monoxide
       Polycyclic Aromatic Hydrocarbons (PAHs) -  harm
   W -  rates lung cancer, CVD

                                                    111
904 - continued
   ETS  harmful to infants/children
       Prenatal/postnatal exposure
             LBW,  head circumference,  IUGR risk
             SIDS, URIs, periodontal disease,  severity
             asthma/wheezing, metabolic syndrome, 
             cognitive function
       Exposure at young age  adulthood
            Cancer, CVD, permanent lung damage


                                                        112
904 - continued
   ETS   inflammation, oxidative stress
       Asthma, CVD, cancer, COPD, metabolic
        syndrome
       Polycyclic Aromatic Hydrocarbons
           Carcinogenic, immunotoxic properties
           Aggravate inflammation




                                                   113
Oxidative stress
   Damage from free radicals
       Generated by normal metabolic processes + from
        ETS, other environmental pollutants
       Need to be neutralized by antioxidants or cause
        oxidative damage to cells
        antioxidants from fruits and vegetables may
        help minimize damage – fiber? Vitamin C?
   Oxidative damage implicated in chronic
    diseases

                                                    114
372 – Alcohol and illegal drug
use – all W
   PW – any alcohol or illegal drug use
   BF/PP (BF contraindicated)
       Routine current use of  2 drinks/day
       Binge drinking -  5 drinks on the same occasion
        at least once in past 30 days
       Heavy drinking -  5 drinks on the same occasion
        on  5 days in past 30 days
       Any illegal drug use
   Moms often neglect own health care

                                                     115
372 - continued
   W - Excess alcohol  cirrhosis, cancer
   PW  LBW,  growth, birth defects, mental
    retardation
       Fetal Alcohol Syndrome
       Amount and timing of damage unknown
            Worse if  intakes, older women, + smoking/drugs,
              diets
       Any stage of pregnancy can be harmful
        amount is helpful
   WIC – education, support, referrals

                                                                 116
372 - continued
   Marijuana - stillbirths, SAB, LBW, anomalies
        feeding with prolonged exposure
   Cocaine -  SAB, premature, IUGR,
    anomalies, developmental/behavioral
    abnormalities
       I – cocaine intoxication at birth
   Heroin, methadone, etc. -  stillbirths, LBW
       I – goes through withdrawal
   Amphetamines – congenital defects, IUGR,
    preterm delivery
                                               117
382 – Fetal alcohol syndrome
– I, C
   Permanent, irreversible birth defects
       Facial abnormalities,  growth, CNS abnormalities,
        including mental retardation, malabsorption
        ability to suck, FTT,  child growth, irritable,
         feeding,  sleeping, behavioral problems
   Maternal alcohol consumption = cause
        levels  FAE, ARBD -  variable effects
   Must be prevented
       No safe threshold amount, time
   WIC – counseling, support, referrals
                                                      118
420 – Excessive caffeine
REMOVED
   Was a BF risk factor
       Short half-life - not associated with major negative
        effects
       Irritability?
   PW – possible concern
       No birth defects
       Possible SAB if large amounts
            Marker? Causal?
       Possible poor growth
   Moderation
                                                       119
Caregiver RFs
   703 – Infant born of woman with
    mental retardation or alcohol or drug
    abuse during most recent pregnancy
   902 – Woman, or infant/child of primary
    caregiver with limited ability to make
    feeding decisions and/or prepare food



                                        120
703 – Infant of woman with
mental retardation – I - NEW
   Infant born of woman with mental
    retardation or alcohol or drug abuse
    during most recent pregnancy
       Dx with mental retardation by MD or
        psychologist, self-reported
       Documentation or self-report of any use of
        alcohol or illegal drugs
   Priority I – risk for FTT
                                               121
902 – W or caregiver with  ability
to make decisions – W,I,C - NEW
   Primary caregiver - limited ability to make
    feeding decisions +/or prepare food
   Examples may include:
        17 years old
       Mentally disabled/delayed +/or having a mental
        illness such as clinical depression
            Dx by MD or licensed psychologist
       Physically disabled  restricts or limits food
        production abilities
       Current use or Hx of alcohol or drug abuse

                                                         122
Other social RFs
   801   –   Homelessness
   802   –   Migrancy
   901   –   Recipient of abuse
   903   –   Foster care




                                   123
801 – Homelessness – W, I, C
   Lacks fixed, regular nighttime residence
    OR whose primary p.m. residence is:
       Supervised shelter designed to provide
        temporary living accommodations
            Public or private
            Welfare hotel, congregate shelter, shelter for
             victims of domestic violence
       Institution that provides temporary
        residence for those to be institutionalized

                                                         124
801 - continued
       Temporary accommodation for not > 365
        days in the residence of another individual
       Public or private place not designed for, or
        ordinarily used as, a regular sleeping
        accommodation for humans
   Homeless – vulnerable population
       Predisposing nutrition risk condition
       > 1/3 are women and children
       43% families

                                                 125
802 – Migrancy – W, I, C
   Categorically eligible – families which
    contain at least 1 person whose:
       Principal employment is in agriculture on a
        seasonal basis AND
       Who has been so employed within the last
        24 months AND
       Who establishes a temporary abode
            For the purpose of this work

                                                126
901 – Recipient of abuse –
W, I, C - NEW
   Battering or child abuse/neglect within past 6
    months
       Battering = violent physical assault
             risk LBW, preterm delivery, chorioamnionitis,  weight
             gain,  Hct, poor diet,  drugs, alcohol, cigarettes
       Child abuse/neglect – may need to report it
            Physical, emotional, sexual abuse  short- and long-
             term problems
             growth, FTT
   Self-reported OR documented/verbal notice
    by social worker, health care provider

                                                                 127
903 – Foster care –
W, I, C - NEW
   Entering foster care system or changing
    foster care homes during past 6 months
       Foster children  vulnerable
            Sicker than homeless, poor children
       Foster care – no comprehensive health component
             evaluate health status, provide follow-up care
            Social, medical Hx often unknown to caregivers
   Evaluate health, nutritional status
       ID other RF, referrals, anticipatory guidance
   Can’t be used consecutively if in same home

                                                                128
Dietary RFs
   401 – Failure to meet Dietary Guidelines for
    Americans – W, C  2 years
   411 – Inappropriate nutrition practices for
    infants
   425 – Inappropriate nutrition practices for
    children
   428 – Dietary risk associated with
    complementary feeding practices – I (4-12
    months), C (12-23 months)
   427 – Inappropriate nutrition practices for
    women                                       129
401 – Failure to meet Dietary
Guidelines– all W, C  2 years
   Presumed to be at nutritional risk
       Must meet income, categorical, residency
        status requirements
       Must complete nutrition assessment for
        RFs 425, 427
            Dietary assessments not sufficiently accurate to
             determine individual’s eligibility
            Don’t want to deny services - prevention
       Must be used only if has NO OTHER risk

                                                         130
Inappropriate nutrition
practices – W, I, C
   411 - I – New name
       Inappropriate Infant Feeding Practices
       Other RF now included within this one
       New issues added
   425 - C – New name
       Inappropriate Feeding Practices for Children
       Some modifications, additions
   427 - W – New RF


                                                       131
411 – Inappropriate nutrition
practices for infants – I
   Routine use of feeding practices that
    may result in impaired nutrient status,
    disease, or health problems
   411.1 – Routinely using a substitute for
    breast milk or FDA approved Fe-fortified
    formula as primary nutrient source
        iron formula, cow’s/goat’s/sheep’s milk,
        imitation milks (rice-, soy-based, creamer),
        “homemade concoctions”

                                                132
411 - continued
   411.2 – Routinely using nursing bottles or
    cups improperly
       Using bottle to feed fruit juice
       Feeding any sugar-containing fluids
            Soda, gelatin water, corn syrup solutions, sweetened tea
       Allowing infant to fall asleep or be put to bed with
        bottle at nap or bedtime
       Allowing infant to use bottle without restriction or
        as a pacifier
            Walking around with bottle


                                                                133
411 - continued
   411.2 – continued
       Allowing infant to carry around and drink
        throughout the day from a covered or
        training cup
       Propping the bottle when feeding
       Adding any food (cereal, other solids) to
        infant’s bottle


                                                134
411 - continued
   411.3 – Routinely offering complementary
    foods or other substances that are
    inappropriate in type or timing
       Complementary = anything other than breast milk
        or infant formula
       Adding sweeteners (sugar, honey, syrup) to any
        beverage, prepared food, or on a pacifier
       Giving any food other than breast milk or iron-
        fortified formula before 4 months of age


                                                   135
411 - continued
   411.4 – Routinely using feeding practices that
    disregard developmental needs or stage of
    infant
       Inability to recognize, insensitivity to, or
        disregarding infant’s cues for hunger and satiety
            Force feeding infant to eat certain type +/or amount of
             food
            Ignoring infant’s hunger cues
            BF -  production,  growth



                                                                 136
411 - continued
   411.4 – continued
       Feeding foods – inappropriate consistency, size, or
        shape  choking risk
       Not supporting infant’s need for  independence
        with self-feeding
            Solely spoon feeding infant when ready to finger-feed
             +/or self-feed
       Feeding inappropriate textures based on
        developmental stage
            Pureed/liquid foods when ready for textures


                                                                137
411 - continued
   411.5 – Feeding foods that could be
    contaminated - microorganisms or toxins
       Unpasteurized fruit or vegetable juice
            E. coli, Salmonella, Cryptosporidium
       Honey – any use
            Clostridium botulinum
       Raw/<cooked meat, fish, shellfish, poultry, eggs
            Bacteria, viruses, parasites
            Would include ceviche
       Raw vegetable sprouts, including homegrown
            Salmonella, E. coli 0157:H7

                                                      138
411 - continued
   411.5 – continued
       Unpasteurized dairy products
            Brucella, Listeria, Salmonella, Campylobacter, E coli
             0157:H7, Yersinia
       Soft cheeses – I, C (AAP)  W (FDA, USDA)
            Feta, Brie, Camembert, blue-veined, Mexican-style
            Listeria – airborne, can grow at refrigeration temps
       Deli meats, hot dogs, processed meat unless
        heated until steaming
            Listeria monocytogenes


                                                                     139
411 - continued
   411.6 – Routinely feeding
    inappropriately diluted formula
       Failure to follow manufacturer’s dilution
        instructions
            Powdered formulas vary in density
       Failure to follow specific instructions
        accompanying a prescription


                                                    140
AAP water recommendations
   All infants
       No data basis for minimum or maximum usual
        water intake recommendations; water intoxication
        not a discernable public health problem
   Formula-fed infants
       During hot weather: no recommendations
   BF, partially BF infants
       Monitor for dark or decreased urine output. When
        present, offer solute-free water up to maximum of
        225 mL/kg per day.

                                                     141
411 - continued
   411.7 – Routinely limiting frequency of
    nursing exclusively BF infant when
    breast milk is sole source of nutrients
       Scheduled feedings
       Limited feedings
            < 8 feedings/24 hours if < 2 months old
            < 6 feedings/24 hours if 2-6 months



                                                       142
411 - continued
   411.8 – Routinely feeding diet very low
    in calories +/or essential nutrients
       Vegan diet
       Macrobiotic diet
       Others




                                         143
411 - continued
   411.9 – Routinely using inappropriate
    sanitation in preparation, handling, and
    storage of expressed breast milk or formula
   Limited or no access to:
       Safe water (documented by appropriate officials)
            Nitrates, Lead, Pesticides
       Heat source for sterilization
       Refrigerator or freezer



                                                     144
AAP – water for formula
   Test well water periodically
   Boil?
       Rolling boil x 1 minute
            Longer – minerals too concentrated
            Cool to at least 38°C (100°F)
       2004 WHO recommendation
            Mix powdered formula with 70°C (158°F) water >
             Enterobacter sakazakii
            Cool only 30 minutes
             vitamin C, other heat-labile nutrients,  clumping

                                                                    145
411 - continued
   411.9 – continued
       Failure to properly prepare, handle, store
        bottles or storage containers of expressed
        breast milk or formula
            Some criteria have changed from RF 417
            Some stayed the same
            Some are new




                                                      146
411 - continued
   411.9 – continued
       Formula in bottle > 1 hour after start
        feeding
       Formula in bottle from earlier feeding
       Feeding previously frozen breast milk
        thawed in refrigerator, stored > 24 h
       Saving breast milk from used bottle for
        another feeding

                                                  147
   411 - continued
                       Risk Criteria
                   Old          New
Formula held at    >2       > 1 hour
room temp          hours
Formula held in    > 48 h   Concentrated, RTF >
fridge                      48 h, powdered > 24 h
Breast milk held   > 72 h   > 48 h (fridge)
in fridge                   > 6 months (freezer)

                                               148
411 - continued
   411.9 – continued
       Old – adding fresh breast milk to already
        frozen breast milk in storage container
       New – adding freshly expressed
        unrefrigerated breast milk ……
            Appropriate = add chilled freshly expressed
             breast milk, in an amount < milk that has been
             frozen for no more than 24 hours


                                                       149
411 - continued
   411.9 – continued
       Thawing frozen breast milk in microwave
       Refreezing breast milk




                                              150
411 - continued
   411.10 - Feeding dietary supplements
    with potentially harmful consequences
       Single or multi-vitamins
       Mineral supplements
       Herbal or botanical supplements, remedies,
        or teas
            Chemical, biological activity, side effects
            Fed directly or BF mom drank

                                                           151
411.10 –Potentially harmful to
children
    Licorice                Nutmeg
    Comfrey leaves          Catnip
    Sassafras               Hydrangea
    Senna                   Juniper
    Buckhorn bark           Mormon tea
    Cinnamon                Thorn apple
    Wormwood                Yohimbe bark
    Woodruff                Lobelia
    Valerian                Oleander
    Foxglove                Maté
    Pokeroot, pokeweed      Kola nut, gotu cola
    Periwinkle              Chamomile

                                                    152
411 - continued
   411.11 – Routinely not providing dietary
    supplements recognized as essential by
    national public health policy
       Fluoride
            Infants  6 months using  Fl water (< 0.3
             ppm) need 0.25 mg fluoride/d
       Vitamin D
            Infants exclusively BF or taking < 1 qt/d
             fortified formula need 400 IU/d


                                                          153
Vitamin D – recommendation
– more, sooner than before
    understanding of importance
       Too little information  supplement to PW, BF –
        new DRIs this year
       Treat infant in the meantime
   2006 recommendations
       BF or taking < 500 ml/d fortified formula
       200 IU/d starting in 1st 2 months (preemies – 400
        IU/d)
   Current recommendations
       BF or taking < 1 qt/d fortified formula
       400 IU/d starting in first few days of life
                                                      154
Water for infant formula 
fluoride?
   Tap water –fluoridated? (0.7-1.2 ppm)
   Bottled water not a reliable source
       Labeled only if modified
       Most are low
   Foods vary in fluoride content
       Depending on where processed
   Breastmilk low (0.02 ppm)

                                       155
Fluoride, continued
   Fluoride level needs to be optimal
       Too low -  risk caries
            Municipal water fluoridation recommended
       Too high -  risk fluorosis
            If mild –fine white lines hard to notice
                 Stronger teeth
            If moderate, severe – opaque white  pitted,
             brittle, brown  teeth break
            Don’t allow children to eat toothpaste

                                                        156
Fluoride, continued
   Can affect permanent teeth
       Depends on timing of insult
   Wide variation in susceptibility




                                       157
Fluoride, continued
   Formula fluoride levels relatively low
       Since 1979
       Higher than in breastmilk
   Fluoride levels vary
       Soy > cow’s milk
       Liquid concentrate > powdered, RTF



                                             158
Fluoride, continued
   Recent studies have found:
       Some risk of fluorosis with formula use
            Water > formula
       Powdered formula + fluoridated water (1 ppm) –
        many could get > TUL
            Minimum risk if made with water < 0.5 ppm
       Powder or liquid concentrate + water (0.7 – 1
        ppm) – some > TUL
       For I (6-12 m) – unlikely to get enough if RTF or if
        powder, liquid concentrate + water < 0.4 ppm

                                                         159
Fluoride, continued
   Problems with studies
       Publication bias – only publish + results
       Food, water – halo effect
       Toothpaste use ignored
       SES > formula use, fluoride supplementation,
        toothpaste use
       BF   ear infections   amoxicillin  
        fluorosis
       Child habits more important than infant diet?

                                                        160
Fluoride, continued
   Also don’t know:
       If have high intake for a short time (before
        weaned), what is the effect?
       Once food is added (4-6 months), what is
        the effect?
   Longitudinal studies are being done
    now


                                                161
Fluoride, continued
   Current guidelines
       CDC – follow advice of MD, formula manufacturer
       ADA – use RTF or  Fl water if worried about
        fluorosis
   Researchers’ recommendations:
        fluoride content of formulas to = breastmilk
       Report fluoride levels - all foods and beverages
   Regarding infant formula preparation, new
    policy is expected Spring 2010
       Evidence-based

                                                       162
425 – Inappropriate nutrition
practices for children - C
   Routine use of feeding practices that may
    result in impaired nutrient status, disease, or
    health problems
   425.1 – Routinely feeding inappropriate
    beverages as primary milk source
       Non-fat or  fat milk (12-24 months only)
       Unfortified goat or sheep milk
       Sweetened condensed milk
       Imitation milks (rice-, soy-based, creamer)
       “Homemade concoctions”

                                                      163
425 - continued
   425.2 – Routinely feeding any sugar-
    containing fluids
       Soda/soft drinks
       Gelatin water
       Corn syrup solutions
       Sweetened tea
   Old RF 425 - > 12 oz fruit juice/d included
       Not specified in this version


                                                  164
425 - continued
   425.3 – Routinely using nursing bottles,
    cups, or pacifiers improperly
       Using bottle to feed fruit juice, diluted
        cereal, or other solids
       Allowing child to fall asleep or be put to
        bed with bottle at nap or bedtime
       Allowing child to use bottle without
        restriction or as a pacifier
            Walking around with bottle

                                                     165
425 - continued
   425.3 – continued
       Using bottle > 14 months
       Using pacifier dipped in sweeteners
            Sugar, honey, syrups
       Allowing child to carry around and drink
        throughout the day from a covered or
        training cup


                                                   166
425 - continued
   425.4 – Routinely using feeding
    practices that disregard developmental
    needs or stages of child
       Inability to recognize, insensitivity to, or
        disregarding child’s cues for hunger and
        satiety
            Force feeding child to eat certain type +/or
             amount of food or beverage
            Ignoring hungry child’s request for food


                                                            167
425 - continued
   425.4 – continued
       Feeding foods – inappropriate consistency, size, or
        shape  choking risk
       Not supporting child’s need for  independence
        with self-feeding
            Solely spoon feeding child when ready to finger-feed
             +/or self-feed
       Feeding inappropriate textures based on
        developmental stage
            Pureed/liquid foods when ready for textures


                                                                168
425 - continued
   425.5 – Feeding foods that could be
    contaminated with harmful microorganisms
       Unpasteurized fruit or vegetable juice
            E. coli, Salmonella, Cryptosporidium
       Raw/<cooked meat, fish, shellfish, poultry, eggs
            Bacteria, viruses, parasites
            Would include ceviche
       Raw vegetable sprouts, including homegrown
            Salmonella, E. coli 0157:H7



                                                      169
425 - continued
   425.5 – continued
       Unpasteurized dairy products
            Brucella, Listeria, Salmonella, Campylobacter, E coli
             0157:H7, Yersinia
       Soft cheeses – I, C (AAP)  W (FDA, USDA)
            Feta, Brie, Camembert, blue-veined, Mexican-style
            Listeria – airborne, can grow at refrigeration temps
       Deli meats, hot dogs, processed meat unless
        heated until steaming
            Listeria monocytogenes


                                                                     170
425 - continued
   425.6 – Routinely feeding diet very low in
    calories +/or essential nutrients
       Vegan diet
       Macrobiotic diet
       Others
   Old RF 425 – Foods  in essential nutrients
    and  in kcals that replace age-appropriate
    nutrient dense foods needed for growth and
    development for 12-24 month-olds
       Not specified in this RF

                                                 171
425 - continued
   425.7 - Feeding dietary supplements
    with potentially harmful consequences
       Single or multi-vitamins
       Mineral supplements
       Herbal or botanical supplements, remedies,
        or teas
            Chemical, biological activity, side effects
            Fed directly or BF mom drank

                                                           172
Potentially harmful to children
– same list as for infants
     Licorice                Nutmeg
     Comfrey leaves          Catnip
     Sassafras               Hydrangea
     Senna                   Juniper
     Buckhorn bark           Mormon tea
     Cinnamon                Thorn apple
     Wormwood                Yohimbe bark
     Woodruff                Lobelia
     Valerian                Oleander
     Foxglove                Maté
     Pokeroot, pokeweed      Kola nut, gotu cola
     Periwinkle              Chamomile

                                                     173
425 - continued
   425.8 – Routinely not providing dietary
    supplements recognized as essential by
    national public health policy
       Fluoride
            Child < 36 months using  Fl water (< 0.3 ppm) needs
             0.25 mg fluoride/d
            Child 36-60 months using  Fl water (< 0.3 ppm) needs
             0.50 mg fluoride/d
       Vitamin D
            Child taking < 1 qt/d fortified formula or milk needs 400
             IU/d
            1 quart > recommended 2 cups/d for preschoolers

                                                                  174
425 - continued
   425.9 – Routine ingestion of nonfood
    items = pica
       Examples include ashes, carpet fibers,
        cigarettes or cigarette butts, clay, dust,
        foam rubber, paint chips, soil, starch
        (laundry, corn)
       Obstruction, contamination, obesity,
        displaces food

                                                     175
428 – Risk with complementary
feeding practices – I, C - NEW
   Subset of infants and children, only:
       I – 4 - 12 months
       C – 12 - 23 months
   Who have begun/ are expected to begin to:
       Consume complementary foods and beverages
       Eat independently
       Be weaned from breast milk or infant formula
       Transition from infant/toddler diet  Dietary
        Guidelines for Americans
   Need to complete nutrition assessment for RF
    411 (I) or 425 (C)
                                                    176
428 - continued
   Needs to be appropriate to age and
    developmental stage
       Nutrient and energy requirements
       Fine, gross, oral motor skills
       Emerging independence, desire to learn to
        self-feed
       Needs to learn healthy eating habits
            Exposure to variety of nutritious foods

                                                       177
428 - continued
   Zinc
       Critical for growth, immunity, brain
        development and function
       7-12 months - breast milk levels too low to
        meet needs
       Add meats, Zn fortified cereals by 7
        months


                                                178
428 - continued
   Iron
       Weaning time
             requirements, critical for development
             intakes (98%  76% of recs)
        rates iron deficiency
            Especially 9-18 months
       Add meats, limit milk consumption
            No cow’s milk before 12 months
            Limit to no more than 24 oz/d for 1-5-year-olds

                                                        179
428 - continued
   Obesity
       Need to prevent
            Treatment success limited
       Learned behaviors, attitudes critical
       Parental influence > habits
            Remind them they are role models
       WIC – anticipatory guidance


                                                180
428 - continued
   Tooth decay
       Children < 2 years  susceptible
            Incidence 20-50%
       Can affect permanent teeth
             susceptible to caries when older
        prolonged bottle use,  extensive use of sweet,
        sticky foods
            Avoid candy, sweetened cereals
            No juice until 6 months, limit to 4-6 oz/d, feed in cup
            Bottle  cup by 12-14 months

                                                                   181
428 - continued
   Timing - introduction of complementary foods
       Start when?
            AAP, Committee on Nutrition – between 4-6 months
            AAP, Section on Breastfeeding – after 6 months
       Varies by individual’s need
       If too early -  respiratory illness, allergy in high-
        risk infants,  breast milk production
       If too late -  feeding difficulties
            Picky eating, refusal of foods
            Introduce solids by 7 months, finger foods between 7-9
             months

                                                                182
428 - continued
   Allergy issues
       Introduce too early  allergies
       Strong family Hx – BF as long as possible
            No complementary foods until 6 months
            Major food allergens delay until after 1 year
                 Eggs, milk, wheat, soy, peanuts, tree nuts, fish,
                  shellfish
                 MD guidance > food additions
       Newer thinking disagrees with this

                                                                      183
428 - continued
   Choosing appropriate complementary
    foods and beverages
       Supply essential nutrients
       Developmentally appropriate
       WIC study – I (6 months)
            > 80% dairy
            60% sweets, snack foods
            90% high protein foods
            Supplemental drinks in bottle, not cup

                                                      184
428 - continued
   WIC study – 1 year olds
       90% sweetened beverages
       > 90% sweet/snack foods
   FITS study – WIC toddlers
        energy,  sweets (desserts, beverages)
        fruits and vegetables
   Watch for choking foods

                                              185
428 - continued
   Introducing a cup
       Part of learning to be independent
       If delays -  milk,  juice,  caries
       Should be weaned by 12-14 months
   Helping child establish lifelong healthy eating
    patterns – be patient
       Food exposure, accessibility
            Normal – spit out, gag with unfamiliar
       Modeling behavior – parents, siblings
       Parental control

                                                      186
428 - continued
   To facilitate transition of diet
       Offer variety of developmentally
        appropriate nutritious foods
        exposure to  salt and sugar foods and
        beverages
       Prepare meals that are pleasing to the eye
            Variety of colors and textures
       Set a good example by eating a variety of
        foods

                                               187
428 - continued
   To facilitate transition of diet
       Offer only whole milk from ages 1-2 years
       Provide structure – regular meal and snack times
       Allow child to decide how much and whether to
        eat
       Allow child to develop eating/self-feeding skills
       Eat with child in pleasant mealtime environment
        without coercion



                                                      188
428 - continued
   RF – good information
   What added value?
   Use in addition to 411 or 425




                                    189
427 - Inappropriate nutrition
practices for women– W -NEW
   Routine nutrition practices that may result in
    impaired nutrient status, disease, or health
    problems
   427.1 – Consuming dietary supplements with
    potentially harmful consequences
       Single or multi-vitamins
       Mineral supplements
       Herbal or botanical supplements, remedies, or
        teas
            Some harmful in pregnancy, lactation


                                                        190
427 - continued
   Pregnancy concerns include:
      levels preformed Vitamin A
     Blue cohash – stimulate uterine contractions –

      risk SAB, preterm labor
     Pennyroyal – stimulate uterine contractions

     Schizandra – stimulates uterine contractions

     Guarana – similar to  levels caffeine

     Licorice – early delivery, HT

     Gotu kola – SAB

     Papain – uterine irritability if unripe



                                                       191
427 - continued
   427.2 – Consuming diet very  in calories
    +/or essential nutrients OR  caloric intake or
    absorption of essential nutrients following
    bariatric surgery
       Strict vegan diet
            Riboflavin, iron, zinc, vit B12, vit D, calcium, selenium
        CHO,  protein diet
       Macrobiotic diet
       Others

                                                                    192
427 - continued
   427.2 – continued
       History of bariatric surgery
            Doesn’t distinguish between types of surgery
                 Restrictive – adjustable gastric band, vertical band
                  gastroplasty
                 Malabsorptive – Roux-en-Y, biliopancreatic diversion
            Multiple nutritional deficiencies
                 Especially during rapid weight loss
                 Some long term issues



                                                                  193
427 - continued
   427.3 – Compulsively ingesting non-food
    items = pica
       Ashes, baking soda, burnt matches, carpet fibers,
        chalk, cigarettes, clay, dust, large quantities of ice
        +/or freezer frost, paint chips, soil, starch
        (laundry, corn), toothpaste
       Obstruction, contamination, displaces food,
        obesity,  glucose control,  B/P, tooth problems
       Taste, texture, smell
       Offer substitutes


                                                          194
427 - continued
   427.4 – Inadequate vitamin/mineral
    supplementation recognized as essential
    by national public health policy
       PW - < 27 mg supplemental iron/d
       PW, BF - < 150 mcg supplemental iodine/d
       Non-PW - < 400 mcg folic acid/d



                                             195
Iron deficiency common in
pregnancy
   Median intakes 15 mg/d, DRI 27 mg/d
       Last 2 trimesters need 7.5 mg/d absorbed
            Normal is 1.2-1.3 mg/d, up to 3 mg/d with
             good diet
   Iron deficiency (NHANES) - 12-16% in
    nonpregnant women
       Worse in low income and immigrant groups
        – 19-22%
   Pregnancy IDA (PNSS) – 7-34% IDA
                                                         196
Postpartum iron deficiency
may affect next pregnancy
   Postpartum iron deficiency rates higher
    among
       Obese women – more blood loss?
       Low income, minority women
       Those unsupplemented during pregnancy
   Postpartum iron deficiency may last for years
       16% of low income women 2 years later
   Short interconceptual period is risk for IDA


                                                197
Iron supplementation is
controversial
   CDC recommends 30 mg/d from first prenatal
    visit
       Higher if found anemic
       Back off once improvement seen
       If no improvement, evaluate further
   Supplements may not help, may cause harm,
    may be too late
   Lower or intermittent doses may be effective


                                              198
Iron supplements have other
problems as well
   Very little is absorbed
   Tolerance affected by iron dosage in the
    stomach
       Symptoms  if taken with food, but absorption
        also  40-66%
   Sustained release and enteric-coated dissolve
    poorly
   Absorption  if taken separately from the
    prenatal vitamin
       Juice not necessary – ferrous already reduced

                                                        199
427 - continued
   427.4 – PW, BF - < 150 mcg supplemental
    iodine/d
   Iodine requirements  during pregnancy and
    lactation
       50%  maternal thyroxine, transfer of iodine to
        fetus,  renal clearance
   DRIs
       Non-PW = 150 mcg/d
       PW – US = 220 mcg, WHO = 250 mcg
       BF – 290 mcg

                                                      200
Iodine status may be
compromised in some
   Severe IDD  cretinism
   Mild or moderate IDD associated with:
       Impaired cognitive functioning
       Poorer school performance
       ADHD?
       No longterm treatment trials
   High inter-individual variation

                                         201
Some women may be at risk
for low iodine
   US women of reproductive age
    (NHANES 2003-2004)
       Median UI 139 mcg/L (optimal 100-199)
            15% women had UI < 50 mcg/L
                  intakes? perchlorates? goitrogens? smoking?
            Non-Hispanic blacks lowest
       Pregnant subset - 181 mcg/L (optimal 150-
        249)

                                                              202
Salt may not supply enough
iodine
   Most salt consumed in the US is not iodized
       Commercial products
       Sea salt is naturally low
   Table salt iodization may not be optimal
       < labeled 45 ppm if stored in humid climate
       High variability within the container
   Promote iodized salt for home use, less
    processed foods


                                                      203
Supplementation is less than
recommended amount
   American Thyroid Society now recommends
    150 mcg/d
       NOT mandated
   Half of prenatal supplements contained iodine
    in a recent study
       127 nonprescription, 96 prescription
       76% of labeled amount
       High variability for both potassium iodide and for
        kelp

                                                       204
Excess iodine can be of
concern
   Poor thyroid function, hypothyroidism,
    goiter in susceptible people
   High intakes by PW  infant
    hypothyroidism, hyperthyrotropinemia
   Some seaweeds very high in iodine
       Kelp (0.6 Tbsp), kombu (3/4 inch)
       Arame, hijiki

                                            205
427 - continued
   427.4 – Non-PW - < 400 mcg folic acid/d
   Reduces risk of NTDs
       Doesn’t eliminate risk
       Needs to be preconceptual – NT closed between
        17-30 days – before knows is pregnant
       Half of US pregnancies are unplanned
   Not all NTDs associated with folic acid
       Choline, vitamin B12


                                                   206
Folic acid recommendations
recently increased
   USPSTF - 0.4-0.8 mg/d supplement for all
    women “planning or capable of pregnancy”
       4 mg/d to prevent recurrence not addressed
   Most women not taking them soon enough
       CDC 2007 – 40% women taking folic acid
            Only 37% of nonpregnant women surveyed
       Lowest among those ages 18-24, minorities, low
        income, low education



                                                      207
Natural folate is not
associated with fewer NTDs
   Only half as bioavailable
   To get 800 mcg natural folate:
       7.25 c orange juice
       13.8 c raw spinach (3.5 c cooked)
       6.2 c cooked kidney beans
   Breakfast cereals are often fortified with high
    levels of folic acid
       http://www.cdc.gov/ncbddd/folicacid/cereals.html


                                                    208
427 - continued
   427.5 – PW ingesting foods that could
    be contaminated with pathogenic
    microorganisms
       Pathogenic microorganisms (bacteria,
        viruses, parasites), their toxins, chemical
        contaminants
       Symptoms – GI (vomiting, diarrhea,
        abdominal pain), neurological, non-specific

                                                209
427 - continued
   Raw or undercooked eggs
       Salmonella
       Salad dressing, cookie/cake batter, sauces,
        unpasteurized eggnog
       Pasteurized OK
   Raw vegetable sprouts, including homegrown
       Salmonella, E. coli
   Unpasteurized fruit or vegetable juice
       E. coli 0157:H7, Salmonella, Cryptosporidium

                                                       210
427 - continued
   Raw fish or shellfish
       Norwalk-like viruses, ciguatera poisoning,
        etc.
       Would include ceviche
       Cooked sushi OK
   Raw or undercooked meat or poultry
       Campylobacter, Salmonella
       Toxoplasma gondii

                                                211
Toxoplasma gondii
   Usually  nonspecific Sx = malaise,
    fever, sore throat, myalgia – “mono”
       Once infected – immune?
       Reactivated with HIV infection
   PW infection  congenital
    toxoplasmosis
       Chorioretinitis, learning disabilities, mental
        retardation, deaf, seizures
                                                   212
Toxoplasma - continued
   Parasite - different life stages found in:
       Meat containing Tg cysts
            Especially high in wild game, venison
            Free range animals
       Water, food contaminated with eggs from cat
        feces
   Don’t get rid of family cat
       Keep indoors, don’t feed raw meat
       Clean litter box daily

                                                      213
427 - continued
   Unpasteurized dairy products
       Brucella, Campylobacter, Listeria,
        Salmonella, E coli 0157:H7, Yersinia
   Listeria monocytogenes
       Killed by pasteurization, cooking
       Can be airborne
       Can grow at refrigeration temperatures


                                                 214
Listeria monocytogenes
   Most people – mild, nonspecific symptoms
       Fever, muscle aches, headaches
   Some listeriosis
       Nausea, vomiting, diarrhea, fever
            Headaches, stiff neck, confusion, loss of balance,
             seizures, meningitis, septicemia, encephalitis
   PW  SAB, premature delivery, fetal death,
    severe illness/death of newborn
       Even if mom has few or no symptoms

                                                                  215
Listeria monocytogenes
    Unpasteurized milk
    Unpasteurized soft cheeses
         Feta, Brie, Camembert, blue-veined, Mexican-style
    Cold cuts, deli meats, hot dogs, fermented and dry
     sausage, other processed meat
         OK if heated until steaming
    Refrigerated pâté or meat spreads
    Refrigerated smoked seafood – lox, jerky
         OK if ingredient in cooked dish



                                                              216
427 - continued
   Fight BAC! general guidelines:
       Clean – wash hands and surfaces often
       Separate – don’t cross-contaminate
       Cook – to proper temperature
       Chill – refrigerate promptly




                                                217
Mercury issues
   Environmental contaminant that accumulates
    in water
       Large, predatory fish accumulate it
   Methylmercury can accumulate in the body
       Can take > 1 year to clear
   High levels can cause harm to fetus, young
    children
       Neurological issues


                                              218
FDA/EPA guidelines
   Avoid
       Shark
       Swordfish
       King mackerel
       Tilefish
   Limit white tuna to up to 6 oz/week
       No other fish that week
   Follow local advisories

                                          219
LCPUFA are important during
pregnancy and lactation
   DHA (c22:6n3) is important for fetal
    brain and retinal development
   May be important preconceptually
   Genetic differences and environmental
    conditions both appear important
   ALA (c18:3n3) doesn’t raise maternal,
    fetal, or breastmilk levels as well as
    does DHA

                                        220
Fish can be eaten a couple
times/week during pregnancy
   Don’t rely on supplements or fortified foods
   High DHA/low mercury fish
       Salmon
       Trout
       Anchovies
       Sardines
       Herring
       Mackerel (not King mackerel)
   Follow local advisories
        http://www.nmenv.state.nm.us/swqb/advisories/
                                                  221
Miscellaneous RFs
   501 – Possibility of regression
   502 – Transfer of certification
   701 – Infant up to 6 months old of WIC
    mother or of a woman who would have
    been eligible during pregnancy
   503 – Presumptive eligibility for
    pregnant women

                                       222
501 – Possibility of regression
– BF, PP, I, C
   Previously certified – at nutritional risk in next
    certification period
       CPA determines at risk without WIC
            Prevent “revolving door”
       Needs to be RF that could regress
            Anemia, growth
            Not GDM, gingivitis of pregnancy
       RF of last resort
            Limited number of times can use
            Still needs to do nutritional assessment
            Needs to identify RF that may regress

                                                        223
502 – Transfer of certification
– W, I, C
   Current valid VOC document from
    another state or local agency
       Valid until certification expires
       Proof of eligibility for program benefits
            Can’t deny benefits
            If state has wait list – VOC to the top of the
             wait list
       Use when VOC doesn’t reflect more
        specific nutrition risk condition

                                                              224
701 – Infant of WIC mom - I
   Infant up to 6 months old
   WIC mom or woman who would have
    been eligible during pregnancy
       Document nutrition risk that would have
        qualified from medical records
            Biochemical
            Anthropometric
            Other nutrition-related medical conditions

                                                          225
503 – Presumptive eligibility
for pregnant women – NEW
   PW who meets income criteria but hasn’t
    been evaluated for nutrition risk
       Up to 60 days only
   Can use if don’t yet have blood work
       Don’t want that to be a barrier
       Doesn’t affect 90 day window for bloodwork
   Should try to do full nutrition risk assessment
    at certification


                                                     226
RFs continuously re-evaluated
   Added, deleted, modified
       As we learn more
   WIC needs to be able to have an impact




                                       227
WIC is even more important
than we thought
   Nutrition intervention is essential
    component of comprehensive prenatal
    care
       Fetus not necessarily protected from poor
        maternal diet
       Longterm consequences
   WIC has access to people during critical
    periods  longterm impact
                                               228
Questions - Discussion
   Implementation plans
   Support information




                           229