2015 Record Review Training-Formula Approval Kevin Sarb Risk Rule Revisions Kevin Sarb October 2015

2015 Record Review Training-Formula Approval Risk Revisions The following criteria were revised as part of the routine cyclical review process by USDA and will be implemented with the May 18, 2016 Release. 201 Low Hematocrit/Low Hemoglobin 211 Elevated Blood Lead Levels 332 Short Interpregnancy Interval (formerly Closely Spaced Pregnancy) 361 Depression 381 Oral Health Conditions (formerly Dental Problems) I am happy to share with you the following risk criteria were revised as part of the routine cyclical review process by USDA and will be implemented with the May 18, 2016 Release. 201 Low Hematocrit/Low Hemoglobin 211 Elevated Blood Lead Levels 332 Short Interpregnancy Interval (formerly Closely Spaced Pregnancy) 361 Depression 381 Oral Health Conditions (formerly Dental Problems) October 2015

Risk Revisions (continued) 2015 Record Review Training-Formula Approval Risk Revisions (continued) 411 Inappropriate Nutrition Practices for Infants 425 Inappropriate Nutrition Practices for Children 601 Breastfeeding Mother of Infant at Nutritional Risk 602 Breastfeeding Complications or Potential Complications 411 Inappropriate Nutrition Practices for Infants 425 Inappropriate Nutrition Practices for Children 601 Breastfeeding Mother of Infant at Nutritional Risk 602 Breastfeeding Complications or Potential Complications October 2015

201 Low Hematocrit/Low Hemoglobin 2015 Record Review Training-Formula Approval 201 Low Hematocrit/Low Hemoglobin Priority level for NPP women corrected Table 201-C was added (previously omitted) Risk Help document has been revised. The priority level for non-breastfeeding women was corrected to reflect the apropriate priority levels. Table 201-C was created and included, having been previously omitted. No other revisions were made to this risk. October 2015

211 Elevated Blood Lead Levels 2015 Record Review Training-Formula Approval 211 Elevated Blood Lead Levels Definition revised to reflect the current reference value published in guidance from the CDC. Risk generated when blood levels are ≥ 5 µg/dl (previously ≥ 10 µg/dl) for all categories. Updated Risk Help The Definition is revised to reflect the current reference value published in guidance from the CDC. Risk generated when blood levels are ≥ 5 µg/dl. for all categories. Previously ≥ 10 µg/dl generated this risk. Although this risk revision is timely, USDA updated this risk independently of current events based on CDC guidance. Risk Help docs will reflect this change. October 2015

332 Short Interpregnancy Interval (formerly Closely Spaced Pregnancy) 2015 Record Review Training-Formula Approval 332 Short Interpregnancy Interval (formerly Closely Spaced Pregnancy) Definition cut-off revised reflects a more recent review of data increased risks for adverse outcomes Interpregnancy interval of < 18 months (540 days). The cut-off was previously 16 months (480 days). The Definition cut-off is revised to reflect a more recent review of data indicating increased risks for adverse perinatal and maternal outcomes with and interpregnancy interval of less than 18 months (540 days). The cut-off was previously 16 months (480 days). October 2015

2015 Record Review Training-Formula Approval 361 Depression This risk has been should no longer be assigned to the “Children” category. Depression removed from the Medical Conditions pop-up list Guidance developed clarify WIC’s role increase WIC staff awareness and knowledge Risk Help updated with revisions and new guidance This risk has been removed and should no longer be assigned to the “Children” category. Guidance for Screening and Referring Women with or At Risk for Depression: Guidance was developed to accompany risk #361 Depression, to clarify WIC’s role and to increase WIC staff awareness and knowledge in assisting participants diagnosed with or at risk for depression. All sections of the risk help have been revised and updated. New guidance has been added. October 2015

381 Oral Health Conditions (formerly Dental Problems) 2015 Record Review Training-Formula Approval 381 Oral Health Conditions (formerly Dental Problems) Title revised to more accurately reflect the conditions included in this criterion. MI-WIC and Risk Help revised and updated. The title of this risk was revised to more accurately reflect the conditions included in this criterion. MI-WIC and Risk Help revised and updated. October 2015

411 Inappropriate Nutrition Practices for Infants 2015 Record Review Training-Formula Approval 411 Inappropriate Nutrition Practices for Infants Only section 411.09 revised Length of time human milk can be safely stored in the refrigerator has been deleted as a risk criterion. lack of consensus (AAP, ABM) regarding how long human milk can be safely stored in the refrigerator not possible to set a clear cut-off MI-WIC and Risk Help Docs have been updated MI-WIC Nutrition History screen has been revised: Only section 411.9 (inappropriate sanitation in the preparation, handling and storage of expressed human milk or formula) of the risk write-up is revised and updated. Of note, a threshold for the amount of time human milk can be safely stored in the refrigerator has been deleted as a risk criterion. There is a lack of consensus among professional entities (e.g., American Academy of Pediatrics and Academy of Breastfeeding Medicine) about the length of time human milk can be safely stored in the refrigerator. Thus, it is not possible at this time to set a clear cut-off to determine WIC nutrition risk. Please see the Justification section of this criterion for more information. MI-WIC Nutrition History screen has been revised for breast fed infants. If the mother expresses breast milk, ask her how she stores the milk. Provide guidance if there is any food safety concern. October 2015

425 Inappropriate Nutrition Practices for Children 2015 Record Review Training-Formula Approval 425 Inappropriate Nutrition Practices for Children 425.01 revised Final Rule allows for assignment of reduced-fat milk for C1 (12-23 months) 425.01 Inadequately fortified milk substitutes Risk Help and MI-WIC Nutrition History screen have been revised: Only section 425.01 (routinely feeding inappropriate beverages as the primary milk source) is revised to be consistent with the March 2014 WIC Regulations Final Rule. Revisions in the WIC food packages which allows the option to issue reduced-fat milk to children 12-23 months for whom overweight or obesity is a concern, the medical provider has recommended reduced-fat milk, or have a family history of obesity, dyslipidemia or cardiovascular disease. Risk Help docs and MI-WIC screens and have been revised. I also wanted to share with you that we have revised the wording for inadequately fortified milk substitutes. There have been instances where CPAs incorrectly check this box for children assigned a soy milk package, which then assigns this risk. WIC authorized soy milks are fortified to the same level as cow’s milk. I October 2015

601 Breastfeeding Mother of Infant at Nutritional Risk 2015 Record Review Training-Formula Approval 601 Breastfeeding Mother of Infant at Nutritional Risk Pregnant women added as an allowable category for assignment of this risk. October 2015

602 Breastfeeding Complications or Potential Complications 2015 Record Review Training-Formula Approval 602 Breastfeeding Complications or Potential Complications Pregnant women added as an allowable category for assignment of this risk. October 2015