North Dakota WIC Program Approved Formulas/Nutritionals … · 2020-05-14 · Listing of Formulas/WIC-Eligible Nutritionals in This Product Guide All these formulas are in LegeNDS

North Dakota WIC Program

Approved Formulas/Nutritionals

Product Guide

May 2020

Listing of Formulas/WIC-Eligible Nutritionals in This Product Guide

All these formulas are in LegeNDS. However, not all approved forms (powder, concentrate, ready-to-feed) may be in LegeNDS. Also, the issuance

amounts listed for 4-5-month-old infants may not be able to be provided exactly as listed to 6-11-month-old infants who cannot consume solid foods.

• Benecalorie

• Beneprotein

• Boost Kids Essentials

• Boost Kids Essentials 1.5 cal

• Boost Kids Essentials 1.5 cal with Fiber

• Boost Plus

• Boost Very High Calorie (VHC)

• Compleat Pediatric and Compleat Pediatric Reduced Calorie

• Cyclinex-2

• Duocal

• EleCare DHA/ARA and EleCare Junior

• Enfagrow Premium Toddler Nutritional Drink

• Enfagrow Premium Toddler Transitions and Toddler

Transitions Gentlease

• Enfamil A.R.

• Enfamil Gentlease

• Enfamil Infant

• Enfamil NeuroPro EnfaCare

• Enfamil ProSobee

• Enfamil Reguline

• Enfaport

• Ensure

• Glutarex-1

• Glutarex-2

• Glytactin BetterMilk

• Glytactin RTD 15

• KetoCal 3:1

• KetoCal 4:1

• KetoCal 4:1 Liquid (LQ)

• Lipistart

• Liquigen

• MMA/PA Anamix Early Years

• Monogen

• Neocate Infant with DHA/ARA

• Neocate Junior and Neocate Junior with Prebiotics

• Neocate Splash

• Neocate Syneo Infant

• Nutramigen with Enflora LGG

• Nutramigen (concentrate)

• Nutramigen with Enflora LGG Toddler

• Nutren Junior and Nutren Junior with Fiber

• Parent’s Choice Nutritional Shake

• Parent’s Choice Pediatric Nutrition Drink with Fiber

• PediaSure and PediaSure with Fiber

• PediaSure 1.5 Cal and 1.5 Cal with Fiber

• PediaSure Enteral Formula

• PediaSure Harvest

• PediaSure Peptide 1.0 Cal and 1.5 Cal

• Peptamen Junior, Peptamen Junior with Fiber, and Peptamen

Junior Prebio1

• Peptamen Junior 1.5

• Phenex-1

• Phenex-2

• PhenylAde Essential Drink Mix

• Phenyl-Free 1

• PKU Periflex Early Years

• Polycal

• Pregestimil

• Propimex-1

• Pro-Phree

• ProViMin

• PurAmino

• RCF

• Similac Alimentum

• Similac NeoSure

• Similac PM 60/40

• Similac Special Care 24

• Vivonex Pediatric

• Vivonex T.E.N.

Fully Formula Fed Infants – Formula Issuance Ranges

Children and Women – Formula Issuance Ranges

• Up to 910 reconstituted fluid ounces of concentrate and powder

• Up to 910 fluid ounces of ready-to-feed

Infant Age Formula Form

Formula Issuance Range

0-3 months

Concentrate 806-823 reconstituted fluid ounces

Ready-to-Feed (RTF) 806-832 fluid ounces

Powder 806-870 reconstituted fluid ounces

4-5 months




6-11 months

Concentrate

624-630 reconstituted fluid ounces



Mostly Breastfed Infants – Formula Issuance Ranges

Infant Age Formula Form

Formula Issuance Range

0-1 month

Concentrate Up to 104 reconstituted fluid ounces

Ready-to-Feed (RTF) Up to 104 fluid ounces

Powder Up to 104 reconstituted fluid ounces

1-3 months




4-5 months




6-11 months




Benecalorie – RTF Nutritional – medical documentation required

Manufacturer

Description Indication Packaging Unit Reconstitution

Amount/Unit

Issuance Guide for

Children/Women

Food Package III

Nestle Health

Sciences

Low-volume, calorie and protein

supplement; allows for flexible serving

options and helps reduce taste fatigue;

lactose and gluten-free, low residue,

kosher

For participants with

unintended weight loss

and/or increased nutritional

needs such as those with

cancer, HIV/AIDS, burns,

COPD, fluid restriction

and/or anorexia

1.5 fl oz cups

24 cups/case

36 fluid ounces

25 cases

Beneprotein – Powder Nutritional – medical documentation required

Manufacturer


Amount/Unit

Issuance Guide for

Children/Women

Food Package III

Nestle Health

Sciences

100% high-quality whey protein (oral

supplement/tube feed); kosher, lactose

and gluten-free, low residue

For older children and

adults with protein calorie

malnutrition, on dialysis or

in need of extra protein in

their diet

8 oz can

135.4 fluid oz

6 cans

Boost Kids Essentials – RTF Nutritional – medical documentation required

Manufacturer


Amount/Unit

Issuance Guide for

Children/Women

Food Package III

Nestle Health

Sciences

30 kcal/oz, nutritionally complete

formula, 7 grams protein, suitable for

these diets: lactose intolerance, gluten-

free, low-residue, kosher; may be

consumed orally or used as a tube

feeding; flavors – vanilla, chocolate,

strawberry

For children (ages 1-13)

with failure to thrive, injury

or trauma, chronic illness,

pre/post-surgery

8 oz brik pack

27/case

(straw)

8.25 oz 4-pack

(screw top)

216 fluid oz

33 fluid ounces

4 cases

27 4-packs

Boost Kids Essentials 1.5 cal – RTF Nutritional – medical documentation required

Manufacturer


Amount/Unit

Issuance Guide for

Children/Women

Food Package III

Nestle Health

Sciences

45 kcal/oz, nutritionally complete

formula, 10 grams protein, suitable for

these diets: lactose intolerance, gluten-

free, low-residue, kosher; may be


feeding; flavors – vanilla, chocolate,

strawberry


with failure to thrive,

Crohn’s disease, cardiac

conditions, cancer, cystic

fibrosis, cerebral palsy,

fluid-restricted patients

8 oz brik pack

27/case

216 fluid oz 4 cases

Boost Kids Essentials 1.5 cal with Fiber – RTF Nutritional – medical documentation required

Manufacturer


Amount/Unit

Issuance Guide for

Children/Women

Food Package III

Nestle Health

Sciences

45 kcal/oz, 25 essential vitamins and

minerals/serving, 10 grams protein,

lactose-free; vanilla flavor; may be


feeding


with failure to thrive,

Crohn’s disease, cardiac

conditions, cancer, cystic

fibrosis, cerebral palsy,

fluid-restricted patients

8 oz carton 216 fluid oz 113 cartons

Boost Plus – RTF Nutritional – medical documentation required

Manufacturer

Description Indication Packaging

Unit

Reconstitution

Amount/Unit

Issuance Guide for

Children/Women

Food Package III

Nestle Health

Sciences

45 kcal/oz, nutritionally complete, high

calorie, high protein oral supplement;

lactose and gluten-free; flavors – vanilla,

chocolate, strawberry

For those with volume

restriction (cancer, anorexia,

chronic obstructive lung

disease), fluid restriction (heart

failure, liver disease) or weight

gain requirements due to

medical conditions

8 oz bottle

6/pack

48 fluid ounces 18 6-packs

Boost Very High Calorie (VHC) – RTF Nutritional – medical documentation required

Manufacturer


Unit

Reconstitution

Amount/Unit

Issuance Guide for

Children/Women

Food Package III

Nestle Health

Sciences

~ 66 kcal/oz, nutritionally complete,

calorically dense oral drink; lactose and

gluten-free, low residue, and kosher;

vanilla flavor

For those increased energy

needs, fluid restriction, volume

sensitivity, or malnutrition

8 oz carton

8 fluid ounces 113 cartons

Compleat Pediatric and Compleat Pediatric Reduced Calorie – RTF Nutritional – medical documentation required

Manufacturer


Amount/Unit

Issuance Guide for

Children/Women

Food Package III

Nestle Health

Sciences

30 kcal/oz, blenderized tube feeding

formulated from traditional foods

including meat, fruit, and vegetables;

lactose and gluten-free

Reduced Calorie provides ~ 17.8

kcal/oz


requiring chronic or long-term,

total or supplemental tube

feeding; children with special

health needs, failure to thrive,

HIV/AIDS, developmental

disabilities, chronic illnesses

8.45 oz carton 8.45 fluid ounces 107 cartons

Cyclinex-2 – Powder Nutritional – medical documentation required

Manufacturer


Unit

Reconstitution

Amount/Unit

Issuance Guide for

Children/Women

Food Package III

Abbott Nutrition 30 kcal/oz; amino acid modified medical food

with iron; nonessential amino acid-free to

decrease the ingestion of waste nitrogen; approx.

35% of energy as fat to help supply essential fatty

acids; lactose and gluten-free; must be

supplemented with protein in prescribed

amounts to completely meet protein

requirements

Nutrition support of

children and adults

with a urea cycle

disorder, gyrate

atrophy of the

choroids and retina or

HHH syndrome

14.1 oz can

59 fluid ounces

15 cans

Duocal – Powder Nutritional – medical documentation required

EleCare DHA/ARA and EleCare Jr. – Powder

Exempt Infant Formula and Nutritional – medical documentation required

Manufacturer


Amount/Unit

Abbott Nutrition Amino acid based medical food and infant

formula with iron; DHA/ARA for infants; flavors

for EleCare Jr. – unflavored, vanilla, chocolate,

banana

For infants and children with severe

allergy to intact protein, severe

malabsorption and/or GI tract

impairment

14.1 ounce can 95 fluid ounces EleCare

DHA/ARA (20 kcal/oz)

62 fluid ounces for

EleCare Jr. (30 kcal/oz)

Monthly Issuance Guide

Infants - Fully Formula Feeding

Food Package III – EleCare DHA/ARA

Infants - Mostly Breastfeeding

Food Package III – EleCare DHA/ARA

Children/Women

Food Package III

0-3 months 9 cans 0-1 month 1 can

14 cans EleCare Jr. 1-3 months 4 cans

4-5 months 10 cans 4-5 months 5 cans 9 cans EleCare DHA/ARA

6-11 months 7 cans 6-11 months 4 cans

Manufacturer


Amount/Unit

Nutricia North

America

Medical food providing fat and carbohydrate

for increased caloric intake (1 scoop provided

25 kcals); super soluble without altering the

taste and texture of foods and beverages; not

suitable as sole source of nutrition; milk

protein free

Inborn errors of metabolism,

disorders of protein and amino acid

metabolism, protein restricted diets,

electrolyte restricted diets, high

energy diets, failure to thrive

14.1 oz can 68 fluid ounces


Infants - Fully Formula Feeding Infants - Mostly Breastfeeding Children/Women

Food Package III

0-3 months 12 cans 0-1 month 1 can 13 cans

1-3 months 6 cans



Enfagrow Premium Toddler Nutritional Drink – Powder

Contract Infant Formula – medical documentation required

Manufacturer


Amount/Unit

Issuance Guide for

Children/Women

Food Package III

Mead Johnson Milk based, iron fortified toddler formula;

contains DHA/ARA and prebiotics; 23

kcal/oz; increased amounts of nutrients

compared to whole milk; flavors – vanilla,

natural milk

For toddlers (12-36 months

of age) with failure to

thrive, etc.

24 ounce can 130 fluid ounces 7 cans

Enfagrow Premium Toddler Transitions and Toddler Transitions Gentlease

Contract Infant Formula – medical documentation required

Manufacturer


Amount/Unit

Issuance Guide for

Food Package III

Mead Johnson Milk based, iron fortified older infant/toddler

formula; contains DHA/ARA, MFGM (Milk Fat

Globule Membrane), and prebiotics; 20

kcal/oz; increased amounts of nutrients

compared to whole milk; Gentlease has

partially hydrolyzed whey and casein

proteins (60:40 ratio), reduced lactose (20%)

and no prebiotics.

For older

infants/toddlers (9-18

months of age) with

failure to thrive, etc.

20 ounce can 141 fluid ounces Infants (6-11 mo) –

4 cans

Children/Women –

6 cans

Enfamil A.R. – Powder Contract Infant Formula

Enfamil Gentlease – Powder Contract Infant Formula

Manufacturer


Amount/Unit

Mead Johnson 20 kcal/oz, iron fortified, infant formula with

added rice starch and prebiotics; can be fed

through standard nipple opening as

thickening occurs in the stomach.

For infants with GERD (gastro

esophageal reflux disease); not

recommended for pre-term infants

due to increased risk of NEC

12.9 ounce powder can

91 fluid ounces



Food Package III


1-3 months 4 cans



Manufacturer


Amount/Unit


partially hydrolyzed whey and casein

proteins (60:40 ratio); reduced lactose

(20%); DHA/ARA

For infants who have trouble

tolerating Enfamil Infant and/or have

lactose intolerance symptoms

including excessive crying, colic, gas,

etc.


90 fluid ounces



Food Package III

0-3 months 9 cans 0-1 month 1 can

10 cans

1-3 months 4 cans



Enfamil Infant – Powder, Concentrate, RTF Contract Infant Formula

Enfamil NeuroPro EnfaCare – Powder Exempt Infant Formula – medical documentation required

Manufacturer


Amount/Unit

Mead Johnson 22 kcal/oz, iron-fortified, high protein, vitamin and

mineral formula with DHA/ARA added for preterm

and/or low birth weight infants; 20% of the fat is

MCT oil

For premature and/or low

birth weight infants who

have reached a weight of

1.8 kg (4 lbs.)

12.8 ounce can

82 fluid ounces



Food Package III


Food Package III

Children/Women

Food Package III



4-5 months 6 cans


Manufacturer


Amount/Unit

Mead Johnson Milk based, iron fortified standard

infant formula with whey and casein

proteins (60:40 ratio); contains

DHA/ARA and prebiotics; 20 kcal/oz

Issued to all normal, healthy

infants (birth – 12 months of age)

unless medical documentation

necessitates a different formula


13 ounce concentrate can

32 ounce bottle RTF

90 fluid ounces

26 fluid ounces

32 fluid ounces



Food Package III

Powder

(cans)

Concentrate

(cans)

RTF

(bottle)

Powder

(cans)

Concentrate

(cans)

RTF

(bottle)

Powder

(cans)

Concentrate

(cans)

RTF

(bottle)

0-3 months 9 31 26 0-1 month 1 4 3 10 35 28

1-3 months 4 14 12

4-5 months 10 34 28 4-5 months 5 17 14

6-11 months 7 24 20 6-11 months 4 12 10

Enfamil ProSobee – Powder, Concentrate, RTF Contract Infant Formula

Enfamil Reguline – Powder Contract Infant Formula

Manufacturer


Amount/Unit

Mead Johnson Milk, lactose, sucrose, and gluten-free

iron fortified standard infant formula

with soy protein; contains DHA/ARA;

20 kcal/oz

For infants (0-12 months of age)

with sensitivity to milk-based

formula or parent/caregiver

prefers soy

12.9 oz powder can

13 oz concentrate can

32 oz bottle RTF

93 fluid ounces

26 fluid ounces

32 fluid ounces



Food Package III

Powder

(cans)

Concentrate

(cans)

RTF

(bottle)

Powder

(cans)

Concentrate

(cans)

RTF

(bottle)

Powder

(cans)

Concentrate

(cans)

RTF

(bottle)

0-3 months 9 31 26 0-1 month 1 4 3 9 35 28

1-3 months 4 14 12

4-5 months 10 34 28 4-5 months 5 17 14

6-11 months 7 24 20 6-11 months 4 12 10

Manufacturer


Amount/Unit


a blend of two prebiotics; partially

hydrolyzed whey and casein proteins (60:40

ratio); reduced lactose (50%), DHA/ARA;

contains milk and soy

For infants who have trouble

tolerating Enfamil Infant and/or have

lactose intolerance symptoms,

constipation, and/or trouble

producing comfortable stools


90 fluid ounces



Food Package III


1-3 months 4 cans



Enfaport – RTF Exempt Infant Formula – medical documentation required

Ensure – RTF Nutritional – medical documentation required

Manufacturer


Amount/Unit

Issuance Guide for

Children/Women

Food Package III

Abbot Nutrition 31 kcal/oz; nutritionally complete, lactose-

free, low-residue formula for oral or tube

feeding; contains prebiotics; flavors –

homemade vanilla, creamy milk chocolate,

strawberries & cream, butter pecan, coffee

latte, rich dark chocolate.

For adults and children age

4 and older for a medical

condition (i.e. Cancer, HIV,

cerebral palsy, etc.) that

restricts or precludes the

use of conventional foods

8 ounce bottle

6 bottles/pack

48 fluid ounces

18 6-packs

Manufacturer


Amount/Unit

Mead Johnson 30 kcals/oz, nutritionally-complete formula;

protein 60:40 whey: casein blend; 84% of fat

from MCT oil; contains DHA and ARA

For infants with chylothorax or

LCHAD deficiency

6 ounce bottle

6 fluid ounces



Food Package III


Food Package III

Children/Women

Food Package III

0-3 months 138 bottles 0-1 month 17 bottles 151 bottles

1-3 months 64 bottles

4-5 months 152 bottles 4-5 months 79 bottles


Glutarex-1 – Powder Exempt Infant Formula – medical documentation required

Glutarex-2 – Powder Nutritional – medical documentation required

Manufacturer


Unit

Reconstitution

Amount/Unit

Issuance Guide for

Children/Women

Food Package III

Abbott Nutrition 30 kcal/oz; lysine and tryptophan-free

to allow greater intake of intact

protein; approximately 30% of energy

as fat; must be supplemented with

intact protein and fluid in prescribed

amounts to completely meet lysine,

tryptophan and water requirements.

Nutrition support of children and

adults with glutaric aciduria type I;

only for children and adults with

proven glutaric aciduria type I who

are under medical supervision

14.1 oz can

(6/pack)

55 fluid ounces 16 cans (2 6-packs)

Manufacturer


Unit

Reconstitution

Amount/Unit

Abbott Nutrition 20 kcal/oz; lysine and tryptophan-free to allow

greater intake of intact protein; approximately

40% of energy as fat; must be supplemented

with intact protein and fluid in prescribed

amounts to completely meet lysine, tryptophan

and water requirements.

Nutrition support of infants and toddlers

with glutaric aciduria type I; only for

infants and toddlers with proven glutaric

aciduria type I who are under medical

supervision

14.1 oz can

(6/pack)

96 fluid ounces



Food Package III


Food Package III

Children/Women

Food Package III

0-3 months 9 cans (1 6-pack) 0-1 month 1 can 9 cans (1 6-packs)

1-3 months 4 cans (1 6-pack)

4-5 months 10 cans (1 6-pack) 4-5 months 5 cans (1 6-pack)

6-11 months 7 cans (1 6-pack) 6-11 months 4 cans (1 6-pack)

Glytactin BetterMilk – Powder Nutritional – medical documentation required

Manufacturer


Amount/Unit

Issuance Guide for

Children/Women

Food Package III

Cambrooke

Therapeutics

Metabolic formula; contains 15 grams of

glytactin protein and a blend of GMP and

essential amino acids; includes DHA and

probiotics; can be taken as a formula or

incorporated into a recipe; recommended

dilution of 4 ounces water with one packet to

equal 6 ounces of formula

For children and

adults with PKU; not

for infants

1.7 oz (49 g)

packet

6 fluid ounces 151 packets

Glytactin RTD 15 – RTF Nutritional – medical documentation required

Manufacturer


Amount/Unit

Issuance Guide for

Children/Women

Food Package III

Cambrooke

Therapeutics

GMP whole protein based complete metabolic

formula; contains 15 grams of protein equivalent;

flavors – original, chocolate

For children and

adults with PKU; not

for infants

8.5 oz carton

8.5 fluid ounces 107 packets

KetoCal 3:1 – Powder Nutritional – medical documentation required

Manufacturer


Unit

Reconstitution

Amount/Unit

Issuance Guide for

Food Package III

Nutricia North

America

Medical food that contains a 3:1 (fat:

carbohydrate + protein) ratio enabling

an individual to achieve and maintain a

high level of ketosis; high in fat and low

in carbohydrate; reconstituted fluid

ounces based on 30 kcal/oz, but actual

dilution used by the participant will be

determined by medical prescription

Provide complete or

supplemental nutritional

support for children over one

year of age with intractable

epilepsy, pyruvate

dehydrogenase deficiency

(PDH), glucose transporter

type-1 deficiency (GLUT-1), and

other medical conditions where

a ketogenic diet is indicated

11 ounce can 70 fluid ounces Infants (6-11 mo) – 9

cans

Children/Women –

13 cans

KetoCal 4:1 – Powder Nutritional – medical documentation required

Manufacturer


Unit

Reconstitution

Amount/Unit

Issuance Guide for

Children/Women

Food Package III

Nutricia North

America

Contains a 4:1 (fat:

carbohydrate + protein) ratio

enabling an individual to

achieve and maintain a high

level of ketosis; high in fat and

low in carbohydrate;

recommended dilution of 4 ml

(0.135 oz) of water to 1 gram of

powder

Provide complete or supplemental

nutritional support for children over

one year of age with intractable

epilepsy, pyruvate dehydrogenase

deficiency (PDH), glucose transporter

type-1 deficiency (GLUT-1), and

other medical conditions where a

ketogenic diet is indicated

11 ounce can 70.5 fluid ounces 12 cans

KetoCal 4:1 Liquid (LQ) – RTF Nutritional – medical documentation required

Manufacturer


Amount/Unit

Nutricia North

America

Contains a 4:1 (fat: carbohydrate + protein) ratio

enabling an individual to achieve and maintain a

high level of ketosis; high in fat and low in

carbohydrate; contains a multi-fiber blend of

insoluble and soluble fiber and DHA/ARA; flavors

– vanilla, unflavored

Provide complete or supplemental

nutritional support for children over

one year of age with intractable

epilepsy, pyruvate dehydrogenase

deficiency (PDH), glucose

transporter type-1 deficiency (GLUT-

1), and other medical conditions

where a ketogenic diet is indicated

8 oz carton 8 fluid ounces



Food Package III


Food Package III

Children/Women

Food Package III.

0-3 months 104 cartons 0-1 month 13 cartons 113 cartons

1-3 months 48 cartons

4-5 months 114 cartons 4-5 months 59 cartons

6-11 months 80 cartons 6-11 months 42 cartons

Lipistart – Powder Nutritional – medical documentation required

Liquigen – RTF Nutritional – medical documentation required

Manufacturer


Unit

Reconstitution

Amount/Unit

Issuance Guide for

Children/Women

Food Package III

Nutricia North

America

Emulsified medium chain

triglyceride (MCT) oil with an

emulsion of 50% water and 50%

MCT oil; unflavored

Recommended for long-chain fatty

acid oxidation disorders and

conditions managed by the

ketogenic diet

8.45 oz bottle

(4/box)

8.45 fluid oz

33.8 fluid oz

107 bottles

26 boxes

Manufacturer


Amount/Unit

Vitaflo USA

(Nestle Health

Sciences)

Nutritionally complete, powdered formula

containing whole protein, carbohydrate, fat

high in medium chain triglycerides and low in

long chain triglycerides, vitamins, minerals,

trace elements and essential fatty acids

For the dietary management of fat

malabsorption, disorders of long chain

fatty acid oxidation, Type 1

hyperlipidemia and chylothorax and

disorders requiring dietary management

using a high MCT, low LCT formula; for

patients 1-10 years of age

14.11 ounce can 90.7 fluid ounces



Food Package III


Food Package III

Children/Women

Food Package III.


1-3 months 4 cans



MMA/PA Anamix Early Years – Powder Exempt Infant Formula – medical documentation required

Monogen – Powder Nutritional – medical documentation required

Manufacturer


Amount/Unit

Nutricia North

America

A methionine-, threonine- and valine-

free, low in isoleucine powdered

infant formula with iron, contains

DHA and ARA, and a unique blend of

prebiotic fiber

For the dietary management of methylmalonic or propionic acidemia (MMA/PA)

14.1 ounce can 90 fluid ounces



Food Package III


Food Package III

Children/Women

Food Package III


1-3 months 4 cans



Manufacturer


Amount/Unit

Nutricia North

America

Milk-protein based; low in fat and high in medium chain triglycerides; DHA/ARA

For the dietary management of gastrointestinal, lymphatic, and metabolic disorders

14.1 ounce can 59.2 fluid ounces



Food Package III


Food Package III

Children/Women

Food Package III


1-3 months 7 cans



Neocate Infant with DHA/ARA – Powder Exempt Infant Formula – medical documentation required

Neocate Junior and Neocate Junior with Prebiotics – Powder Nutritional – medical documentation required

Manufacturer


Unit

Reconstitution

Amount/Unit

Issuance Guide for

Children/Women

Food Package III

Nutricia North

America

30 kcal/oz; complete, elemental medical food

containing 100% free amino acid (Prebiotic

product has prebiotic fiber added.);

hypoallergenic; high protein equivalent for GI

tissue repair; extra vitamins and minerals for

malabsorptive conditions; carbohydrate

content formulated to minimize osmotic

load; Neocate Junior (without Prebiotics) –

unflavored; Neocate Junior with Prebiotics

flavors – unflavored, vanilla, strawberry,

chocolate, tropical

For children over one year of

age with cow and soy milk

allergy, multiple food protein

intolerance, food allergy-

related GERD and

eosinophillic esophagitis,

and other conditions for

which an amino acid-based

diet may be necessary

14.1 oz can

Neocate Junior –

64 fluid oz

Neocate Junior

with Prebiotics –

63 fluid oz

14 cans

Manufacturer


Amount/Unit

Nutricia North

America

100% free amino-acid based,

hypoallergenic medical food and

infant formula with iron for infants

and children; formula has very short

shelf life; opened can must be used

within 1 month

An infant formula for the dietary management of:

allergies to cow's milk, multiple food protein

intolerance, short bowel syndrome, eosinophilic

esophagitis, gastroesophageal reflux, milk protein

induced colitis, transition from parenteral to enteral

nutrition




Food Package III


Food Package III

Children/Women

Food Package III


1-3 months 4 cans



Neocate Syneo Infant – Powder Exempt Infant Formula – medical documentation required

Neocate Splash – RTF Nutritional – medical documentation required

Manufacturer


Unit

Reconstitution

Amount/Unit

Issuance Guide for

Children/Women

Food Package III

Nutricia North

America

Hypoallergenic; nutritionally complete;

amino acid-based; may be consumed

orally or used as a tube feeding; flavors –

tropical fruit, grape, orange-pineapple,

unflavored

For children (over age 1) with

cow milk allergy, multiple food

allergies, eosinophillic

esophagitis, food protein-

induced enterocolitis

syndrome, short bowl

syndrome, malabsorption and

GERD

8 oz box 8 fluid ounces

113 boxes

Manufacturer


Amount/Unit

Nutricia North

America

Hypoallergenic; nutritionally complete elemental formula; lactose-free, milk-free, sucrose-free; contains Syneo, a patented symbiotic (prebiotic and probiotic)

For infants with cow milk allergy, multiple food

allergies and related allergic conditions, such as

EoE, FPIES and GERD and other medical conditions

that require an amino-acid based diet




Food Package III


Food Package III

Children/Women

Food Package III


1-3 months 4 cans



Nutramigen with Enflora LGG – Powder and Nutramigen – Concentrate, RTF

Exempt Infant Formula – medical documentation required

Nutramigen with Enflora LGG Toddler – Powder Exempt Infant Formula – medical documentation required

Manufacturer


Amount/Unit

Issuance Guide for

Food Package III

Mead Johnson 20 kcal/oz; hypoallergenic casein

hydrolysate protein; lactose-free,

iron-fortified; contains probiotic LGG

to help support digestive health and

DHA/ARA; does not contain MCT oil

For infants and toddlers (9 to

36 months) allergic to the intact

proteins in cow’s milk or

allergic to soy formulas

12.6 ounce can 86 fluid ounces Infants (6-11 mo) – 8

cans

Children – 10 cans

Manufacturer


Amount/Unit

Mead Johnson 20 kcal/oz; hypoallergenic casein

hydrolysate; lactose and sucrose-free

infant formula with iron; does not

contain MCT oil; powder form has the

probiotic LGG added to promote a

healthy GI and immune system; both

forms contain DHA/ARA

For infants with sensitivity to

intact protein or other foods;

some medical conditions

necessitate issuing to children


13 ounce concentrate can

32 ounce bottle RTF

87 fluid ounces

26 fluid ounces

32 fluid ounces



Food Package III

Powder

(cans)

Concentrate

(cans)

RTF

(bottle)

Powder

(cans)

Concentrate

(cans)

RTF

(bottle)

Powder

(cans)

Concentrate

(cans)

RTF

(bottle)

0-3 months 10 31 26 0-1 month 1 4 3 10 35 28

1-3 months 5 14 12

4-5 months 11 34 28 4-5 months 6 17 14

6-11 months 8 24 20 6-11 months 4 12 10

Nutren Junior and Nutren Junior with Fiber – RTF Nutritional – medical documentation required

Manufacturer


Unit

Reconstitution

Amount/Unit

Issuance Guide for

Children/Women

Food Package III

Nestle Nutrition Nutritionally complete, isotonic, whole

protein liquid diet for complete or

supplemental nutrition support in

pediatric patients; use as oral and/or

tube feeding; lactose-and gluten-free,

low-residue; 30 kcal/oz; vanilla flavor

Nutren Junior with Fiber has prebiotics

Designed for children ages 1-

10 with stable and functioning

gastrointestinal tract; used

with cancer; pre- and post-

surgery; pediatric failure to

thrive; neurologic disease or

impairment; HIV/AIDS;

multiple fractures;

anorexia/weight loss;

malnutrition and coma

8.45 oz carton 8.45 fluid oz

107 cartons

Parent’s Choice Nutritional Shake – RTF Nutritional – medical documentation required

Manufacturer


Unit

Reconstitution

Amount/Unit

Issuance Guide for

Children/Women

Food Package III

Perrigo

Nutritionals

30 kcal/oz; nutritionally complete

supplement; includes prebiotics and

DHA; suitable for lactose intolerance

and gluten-free; flavors – vanilla,

chocolate, strawberry

For children 1 to 10 years of age

who are undernourished due to

illness or a medical condition

that warrants the prescription of

the product; not intended for

infants under 1 year of age

unless specified by a physician

8 ounce bottle

6 bottles/pack

48 fluid ounces

18 6-packs

Parent’s Choice Pediatric Nutrition Drink with Fiber – RTF Nutritional – medical documentation required

Manufacturer


Amount/Unit

Issuance Guide for

Children/Women

Food Package III

Perrigo

Nutritionals

30 kcal/oz; nutritionally complete

supplement; includes DHA; suitable

for lactose intolerance and gluten-

free; vanilla flavor; contains scFOS®

prebiotic fiber


who are undernourished due to

illness or a medical condition that

warrants the prescription of the

product; not intended for infants

under 1 year of age unless

specified by a physician

8 ounce bottle

6 bottles/pack

48 fluid ounces

18 6-packs

PediaSure and PediaSure with Fiber – RTF Nutritional – medical documentation required

Manufacturer


Amount/Unit

Issuance Guide for

Children/Women

Food Package III

Abbot Nutrition 30 kcal/oz; nutritionally complete

supplement; suitable for lactose

intolerance and gluten-free

PediaSure flavors – vanilla, chocolate,

strawberry, banana, berry, S’mores

PediaSure with Fiber – vanilla, strawberry;

contains prebiotic Nutraflora® scFOS®

and DHA

For children 1 to 10 years of

age who are

undernourished due to

illness or a medical

condition that warrants the

prescription of the product;

not intended for infants

under 1 year of age unless

specified by a physician

8 ounce bottle

6 bottles/pack

48 fluid ounces

18 6-packs

PediaSure 1.5 Cal and 1.5 Cal with Fiber – RTF Nutritional – medical documentation required

Manufacturer


Unit

Reconstitution

Amount/Unit

Issuance Guide for

Children/Women

Food Package III

Abbot Nutrition ~44 kcal/oz; nutritionally complete

supplement for pediatric patients who

require higher caloric concentrated

feeding; vanilla flavor; contains DHA;

suitable for lactose intolerance and

gluten-free

PediaSure 1.5 Cal with Fiber contains

prebiotic fiber for digestive system health.


with malnutrition, fluid

restrictions, or have poor

tolerance to large volume feeds;

not intended for infants under 1

year of age unless specified by a

physician

8 ounce can

8 fluid ounces

113 cans

PediaSure Enteral 1.0 cal – RTF Nutritional – medical documentation required

Manufacturer


Amount/Unit

Issuance Guide for

Children/Women

Food Package III

Abbot Nutrition 30 kcal/oz; nutritionally complete,

milk-based supplement; suitable for

lactose intolerance and gluten-free;

vanilla flavor

For tube feeding children 1 to

13 years of age; may be used

as a sole source of nutrition;

not intended for infants under

1 year of age unless specified

by a physician; not for children

with galactosemia

8 ounce can

8 fluid ounces 113 cans

PediaSure Harvest – RTF Nutritional – medical documentation required

Manufacturer


Amount/Unit

Issuance Guide for

Children/Women

Food Package III

Abbot Nutrition 30 kcal/oz; nutritionally complete, real-

food blend of organic fruits,

vegetables, and grains; Non-GMO,

milk-free, lactose-free, gluten free;

formulated for tube feeding, but can

be used orally

For children 1 to 13 years who

may be undernourished due to

illness or inability to eat, used

to help meet energy

requirements to support

growth and development

8 ounce carton

8 fluid ounces 113 cartons

PediaSure Peptide 1.0 Cal and 1.5 Cal – RTF Nutritional – medical documentation required

Manufacturer


Unit

Reconstitution

Amount/Unit

Issuance Guide for

Children/Women

Food Package III

Abbot Nutrition Nutritionally complete, therapeutic

peptide-based nutrition for children;

~ 30 kcal/oz for the 1.0 Cal and ~ 44

kcal/oz for the

1.5 Cal (designed to meet the

nutritional and caloric needs of

children who require higher caloric

density, have fluid restrictions, or are

at risk for malnutrition); both contain

prebiotics

Flavors for 1.0 Cal – unflavored,

vanilla, strawberry; 1.5 Cal – vanilla

For tube or oral feeding as sole

source or supplemental nutrition.

Designed for children 1 to 13 years

of age with malabsorption,

maldigestion or impaired GI

function resulting from:

inflammatory bowel disease

(ulcerative colitis, Crohn’s), cystic

fibrosis, celiac disease, pancreatic

disorders, short-bowel syndrome,

diarrhea, bowel resection, cerebral

palsy, early enteral feeding,

transitioning from TPN and special

health needs

8 ounce bottle

8 fluid ounces 113 bottles

Peptamen Junior, Peptamen Junior with Fiber, Peptamen Junior Prebio1 – RTF

Nutritional – medical documentation required

Manufacturer


Unit

Reconstitution

Amount/Unit

Issuance Guide for

Children/Women

Food Package III

Nestle

Nutrition

30 kcal/oz; nutritionally complete, isotonic,

peptide-based elemental diet partially

hydrolyzed whey protein; provides complete

or supplemental nutritional support; for tube

feeding use; lactose and gluten-free

Peptamen Junior with Fiber has a blend of

insoluble fiber and PREBIO soluble fiber.

Peptamen Junior Prebio1 has 3.6g/L Prebio1

soluble fiber blend.

Flavors for Peptamen Junior – unflavored,

vanilla, chocolate, strawberry; Peptamen

Junior with Fiber – vanilla; Peptamen Junior

with Prebio1™ - vanilla, chocolate

Provides a customized protein,

lipid, vitamin, and mineral

profile for children ages 1 to

10 with impaired

gastrointestinal function; also

for inflammatory bowel

disease, short bowel

syndrome, cystic fibrosis,

chronic diarrhea,

malabsorption, cerebral palsy,

delayed gastric emptying,

HIV/AIDS, and growth failure

8.45 oz carton

8.45 fluid oz

107 cartons

Peptamen Junior 1.5 – RTF Nutritional – medical documentation required

Manufacturer


Unit

Reconstitution

Amount/Unit

Issuance Guide for

Children/Women

Food Package III

Nestle Nutrition ~ 44 kcal/oz; nutritionally complete,

peptide-based elemental nutrition with

100% enzymatically hydrolyzed whey

protein; lactose-and gluten-free;

contains prebiotics; flavors – unflavored,

vanilla

For children ages 1 to 13 with a

variety of medical conditions

including chronic diarrhea, short

bowel syndrome, cerebral palsy,

Crohn’s disease, cystic fibrosis,

malabsorption, growth failure,

and transition from TPN

8.45 oz carton

8.45 fluid oz 107 cartons

Phenex-1 – Powder Exempt Infant Formula – medical documentation required

Phenex-2 – Powder Nutritional – medical documentation required

Manufacturer


Amount/Unit

Issuance Guide for

Children/Women

Food Package III

Abbott Nutrition Amino acid modified, phenylalanine-free

medical food with iron; 30 g protein and

410 kcals/100g powder; flavors –

vanilla, unflavored

For children and adults

with PKU; not for infants

14.1 ounce can

55 fluid ounces 16 cans

PhenylAde Essential Drink Mix – Powder Nutritional – medical documentation required

Manufacturer


Amount/Unit

Issuance Guide for

Children/Women

Food Package III

Nutricia North

America

Metabolic formula; nutritionally incomplete; fortified

with vitamins, minerals, essential and non-essential

amino acids; contains flax and fiber; phenylalanine free;

flavors – vanilla, unflavored, chocolate, orange crème,

strawberry

For children

and adults with

PKU; not for

infants

1 pound can

79.5 fluid oz 11 cans

Manufacturer


Amount/Unit

Abbott Nutrition 20 kcal/oz; phenylalanine-free formula; 15 g

protein/100 g powder (L-tryosine, L-carnitine and

taurine); 480 kcal/100 g powder; 40% energy as fat;

lactose and gluten-free; unflavored

For infants with PKU




Food Package III


Food Package III

Children/Women

Food Package III.

0-3 months 9 cans 0-1 month 1 can Contact the State office if issued to a child.

1-3 months 4 cans



Phenyl-Free 1 – Powder Exempt Infant Formula – medical documentation required

PKU Periflex Early Years – Powder Exempt Infant Formula – medical documentation required

Manufacturer


Amount/Unit

Mead Johnson 20 kcal/oz; phenylalanine-free; iron-fortified Inborn errors of metabolism; for the

dietary management of infants and

toddlers with PKU (phenylketonuria)

under the direct and continuing

supervisions of a doctor

1 lb can (6/case) 114 fluid ounces



Food Package III


Food Package III

Children/Women

Food Package III

0-3 months 7 cans (1 case) 0-1 month 0 cans 9 cans

1-3 months 3 cans

4-5 months 8 cans (1 case) 4-5 months 4 cans

6-11 months 6 cans (1 case) 6-11 months 3 cans

Manufacturer


Amount/Unit

Nutricia North

America

20 kcal/oz, phenylalanine-free, iron-fortified,

contains DHA, ARA, and prebiotic fiber blend;

contains a balanced mixture of all other

nutrients; unflavored

Inborn errors of metabolism; for the

dietary management of infants and

toddlers with PKU (phenylketonuria)

under the direct and continuing

supervisions of a doctor

14.1 oz can 90.1 fluid ounces



Food Package III


Food Package III

Children/Women

Food Package III


1-3 months 4 cans



Polycal – Powder Nutritional – medical documentation required

Pregestimil – Powder Exempt Infant Formula – medical documentation required

Manufacturer


Amount/Unit

Nutricia 20 kcal/oz; concentrated energy source

(maltodextrin); completely soluble in food and

drinks and does not alter the taste when added

For the dietary management of energy

needs in adults and children over 1 year

of age with inborn errors of metabolism

and conditions requiring a high energy,

low fluid or modular diet

14.1 ounce can

88 fluid ounces



Food Package III


Food Package III

Children/Women

Food Package III


1-3 months 4 cans



Manufacturer


Amount/Unit

Mead Johnson 20 kcal/oz; iron-fortified; lactose and, sucrose-

free; hypoallergenic infant formula with 55% of

the fat from medium-chain triglycerides (MCT)

oil; includes DHA and ARA

For infants with severe food allergies,

sensitivity to intact protein, or fat

malabsorption. Some medical

conditions may necessitate issuing to

children

16 ounce can 112 fluid ounces



Food Package III


Food Package III

Children/Women

Food Package III

0-3 months 7 cans 0-1 month 0 cans 8 cans

1-3 months 3 cans



Propimex-1 – Powder Nutritional – medical documentation required

Pro-Phree – Powder Exempt Infant Formula and Nutritional – medical documentation required

Manufacturer


Amount/Unit

Abbott Nutrition 20 kcal/oz; methionine and valine-free to allow

greater intake of intact protein; low in isoleucine

and threonine; approximately 40% of energy as

fat; lactose and gluten-free

Nutrition support of infants and toddlers

with propionic or methylmalonic

acidemia

14.1 ounce can

96 fluid ounces



Food Package III


Food Package III

Children/Women

Food Package III


1-3 months 4 cans



Manufacturer


Amount/Unit

Abbott Nutrition 20 kcal/oz; protein-free to permit protein

restriction or the addition of extra calories,

minerals, and vitamins; L-carnitine and taurine

added; approximately 49% of energy as fat;

lactose and gluten-free; Halal

For infants and toddlers in need of extra

calories, minerals, and vitamins or on a

protein restriction

14.1 ounce can

102 fluid ounces



Food Package III


Food Package III

Children/Women

Food Package III


1-3 months 4 cans



ProViMin – Powder Exempt Infant Formula and Nutritional – medical documentation required

PurAmino – Powder Exempt Infant Formula – medical documentation required

Manufacturer


Amount/Unit

Abbott

Nutrition

Contains casein protein and

vitamins and minerals; virtually

carbohydrate and fat free;

provides flexibility in prescribing

a formula in which the amount

and type of carbohydrate and fat

can be added per individual need

and tolerance

Inborn errors of metabolism: nutrition support for

disorders of abeta and hypobetalipoproteinemia,

cholestasis, chylothorax, chylous ascites, fatty acid

oxidation defects (mitochondrial), glutaric aciduria

type II, hyperlipoproteinemia type I, lipodystrophy

(congential) lymphangiectasis, intestinal

malabsorption of carbohydrate or fat, etc.


(based on 20/kcal per

oz, usually for infants)

111 fluid ounces

(based on 30/kcal per

oz, usually for

children/women)



Food Package III


Food Package III

Children/Women

Food Package III

(Listed as PROVIMIN in LegeNDS)


1-3 months 2 cans



Manufacturer


Amount/Unit

Mead Johnson 20 kcal/oz; hypoallergenic, amino

acid-based formula

For the dietary management of infants and

toddlers with severe cow’s milk protein and

multiple food allergies




Food Package III


Food Package III

Children/Women

Food Package III


1-3 months 4 cans



RCF – Concentrate Exempt Infant Formula – medical documentation required

Manufacturer


Amount/Unit

Abbott Nutrition Carbohydrate free formula; formulated to

allow physician to prescribe type and amount

of carbohydrate with the assurance that other

nutrient needs will be met; soy protein isolate

base with iron

For use in patients with

carbohydrate malabsorption,

disaccharidase deficiencies, glucose

transport defect, and seizure

disorders requiring a ketogenic diet

13 ounce can 26 fluid ounces



Food Package III


Food Package III

Children/Women

Food Package III


1-3 months 14 cans



Similac Alimentum – Powder, RTF Exempt Infant Formula – medical documentation required

Manufacturer


Amount/Unit

Abbott Nutrition 20 kcal/oz; casein hydrolysate;

hypoallergenic infant formula with

DHA/ARA; iron fortified, lactose-free;

contains corn derivatives; 33% of fat is

MCT oil

For infants with severe food allergies,

sensitivity to intact protein or fat

malabsorption. Some medical

conditions may necessitate issuing to

children


32 ounce RTF bottle

87 fluid ounces

32 fluid ounces



Food Package III


Food Package III

Children/Women

Food Package III

Powder

(cans)

RTF

(bottle)

Powder

(cans)

RTF

(bottle) Powder RTF

0-3 months 10 26 0-1 month 1 3 10 cans 28 bottle

1-3 months 5 12

4-5 months 11 28 4-5 months 6 14

6-11 months 8 20 6-11 months 4 10

Similac NeoSure – Powder and RTF Exempt Infant Formula – medical documentation required

Similac PM 60/40 – Powder Exempt Infant Formula – medical documentation required

Manufacturer


Amount/Unit

Abbott Nutrition 22 kcal/oz, iron-fortified, high protein, vitamin and

mineral formula with DHA/ARA; 25% of fat is MCT

oil; provides higher levels of protein, vitamins, and

minerals per 100 kcal than infant formula designed

for full term infants

For premature and/or low

birth weight infants. Use only

under the supervisions of a

physician


32 ounce RTF bottle

87 fluid ounces

32 fluid ounces



Food Package III


Food Package III

Children/Women

Food Package III

Powder RTF Powder RTF Powder RTF

0-3 months 10 cans 26 bottles 0-1 month 1 can 3 bottles 10 cans 28 containers

1-3 months 5 cans 12 bottles

4-5 months 11 cans 28 bottles 4-5 months 6 cans 14 bottles

6-11 months 8 cans 20 bottles 6-11 months 4 cans 10 bottles

Manufacturer


Amount/Unit

Abbott Nutrition 20 kcal/oz, whey: casein 60:40, protein

dominant, low-iron formula; lower in minerals

and electrolytes; additional iron should be

supplied by other sources

For infants and children predisposed to or

being treated for hypocalcemia due to

hyperphosphatemia, or those with impaired

renal function who would benefit from

lowered mineral intake




Food Package III


Food Package III

Children/Women

Food Package III


1-3 months 4 cans



Similac Special Care 24 – RTF Exempt Infant Formula – medical documentation required

Vivonex Pediatric – Powder Nutritional – medical documentation required

Manufacturer


Amount/Unit

Abbott Nutrition 24 kcal/oz, iron-fortified, preterm

infant formula; 50% of fat is MCT oil

For low-birth-weight infants and/or premature

infants. Not intended for feeding these infants

after they reach a weight of 3600 g (approx. 8 lb)

or as directed by a doctor. Use a vitamin

supplement only as directed by a doctor

2 ounce bottle 2 fluid ounces



Food Package III


Food Package III

0-3 months 416 bottles 0-1 month 52 bottles

1-3 months 192 bottles



Manufacturer


Amount/Unit

Nestle Health

Sciences

Nutritionally complete, elemental

formula for children ages 1-10; used

as a tube feeding or consumed orally;

low residue, lactose and gluten-free,

kosher

For use with transitional feeding following TPN,

short bowel syndrome, malabsorption syndrome,

select trauma/surgery, Crohn’s disease, GI

enterocutaneous fistula, intractable diarrhea, GI

disorder related to AIDS

1.7 ounce packets

8.45 fluid ounces



Food Package III


Food Package III

Children/Women

Food Package III

0-3 months 102 packets 0-1 month 12 packets 107 packets

1-3 months 51 packets

4-5 months 113 packets 4-5 months 61 packets

6-11 months 82 packets 6-11 months 45 packets

Vivonex T.E.N. – Powder Nutritional – medical documentation required

Manufacturer


Amount/Unit

Issuance Guide for

Children/Women Food

Package III

Nestle Health

Sciences

Nutritionally complete low-fat,

elemental diet containing 100% free

amino acids for total enteral

nutrition for adults with

gastrointestinal impairment; low

residue, lactose and gluten-free,

kosher

For use in adults with bowel

resection, irradiated bowel,

malabsorption syndrome,

select trauma/surgery,

Crohn’s disease, GI

enterocutaneous fistula,

pancreatic disorders, limited

gut function

2.84 oz packet

6 cartons/case

(10 packets/carton)

10.14 fluid oz

608.4 fluid oz

Each 2.84 oz dry

packet

reconstituted

with 250 mL

water delivers

300 mL of

formula or 10.14

fluid ounces.

89 packets

1 case

Documents

North Dakota WIC Program Approved Formulas/Nutritionals … · 2020-05-14 · Listing of Formulas/WIC-Eligible Nutritionals in This Product Guide All these formulas are in LegeNDS