Arkansas Wic Program - Special Formula Request (Page 2 of 2) in pdf

Formula

Descriptions for Use

Diagnosis

Length of Request

Preterm, low birthweight baby to 44 weeks

1, 2, or 3 month(s)

Enfamil Premature

gestational age or to a maximum weight of 8

LIPIL—Mead Johnson (20

pounds-Not approved for an infant previously on

_________oz/day

calories)

term formula or a term infant for increased

Enfamil Premature

calories

LIPIL—Mead Johnson (24

calories)

EnfaCare LIPIL—Mead

Preterm infant transitional formula-for use

1, 2, or 3 month(s)

Johnson

between premature formula and term formula

Note: must have minimum weight of 1800 grams

_________oz/day

(4 lbs)-- Not approved for an infant previously on

term formula or a term infant for increased

calories

Oral Supplements (1-5 years

Oral motor feeding disorders; FTT from

1, 2, or 3 month(s)

of age)

underlying medical condition that increases

calorie requirements beyond what is expected

_________oz/day

PediaSure—Abbott

PediaSure with Fiber—

Abbott

Tube Feeding (1-5 years of

Tube feedings; oral motor feeding disorders;

1, 2, 3, 4, 5, 6 month(s)

age)

medical conditions that increase caloric needs.

Note: may prescribe for 6

_________oz/day

months duration

PediaSure Enteral—

Abbott

PediaSure Enteral with

Fiber—Abbott

*indicates formula is available in powder only

Supplemental Foods

The participant will receive the supplemental foods listed below, appropriate to their WIC participant category, in addition to the WIC formula.

Please indicate any supplemental foods or restrictions not approved due to contraindications with the participant’s medical diagnosis.

WIC Participant Category

WIC Supplemental Foods Available

Do Not Give

Restrictions/Comments

Infants (6-12 months)

Infant Cereal

Infant Vegetables/Fruits

Children and Women

Milk

Cheese

Cereal

Juice

Eggs

Vegetables/Fruits

Whole Grains

Beans

Peanut Butter*

Canned Fish**

* Peanut butter will not be issued to children under 2 years of age

** Exclusively Breastfeeding Women, Partially Breastfeeding Women of Multiples or Pregnant Woman with Multiples are the only WIC

participant categories eligible to receive canned fish

Date:___________ Medical Provider (Print.): ____________________________________ Contact Number:_____________

Medical Provider Signature: __________________________

Prescriptive Authority Number:________________________

(APN nurses with prescriptive authority only)

WIC-51

05/10

Arkansas Wic Program - Special Formula Request Page 2

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