1. Being “sensitive” to formula changes in WIC Staff discussion guide – February 2014

2. Objective of this discussion guide 2014 Formula Changes in WIC2  Before beginning, please review the Formula Changes Overview and FAQs  This discussion guide is intended to give staff the chance to think about issues related to the formula changes, talk with their co-workers, and practice how to handle different situations.  All WIC staff will need to use their knowledge and skills to address participant concerns with the transition. It will be important to use:  Critical thinking  Knowledge of baby behaviors  Customer service and participant centered skills

3. Resources to use during discussions 2014 Formula Changes in WIC3  All resources are posted to the WIC website on the Staff Training page under In-services.Staff Training page  Formula Changes Overview, Plan and FAQ’s  Using PCS During Formula Changes  Baby Behaviors for Formula-fed Infants: What is Normal and When to Refer?  Infant formula changes in WIC handout  Case Study Discussion Questions  Common Infant Problems handouts (Texas WIC )  Colic  Spitting up  Constipation  Diarrhea  Food Allergies  Baby Behavior handouts – on publications page  Why Do Babies Cry?  Understanding Your Baby’s Cues

4. What is the situation? Section 1: Background information and discussion 2014 Formula Changes in WIC4

5. Let’s recap what is changing 2014 Formula Changes in WIC5  Abbott Nutrition changed the formulation of these 3 infant formulas from 20 to 19 kcal/oz  They no longer meet the qualifications as a standard milk-based formula and are not rebated  WIC cannot provide Similac Sensitive or Total Comfort  Similac for Spit-Up requires med doc to provide

6. How many Oregon WIC babies are on these formulas? 2014 Formula Changes in WIC6

7. Formula marketing 2014 Formula Changes in WIC7  Abbott Nutrition designed and marketed these formulas for healthy babies.  Many caregivers chose Similac Sensitive or Similac Total Comfort because WIC allowed it, and almost all babies are fussy, gassy, sensitive, or spitting-up at times.

8. How can we be breastfeeding friendly in the midst of formula transitions? 2014 Formula Changes in WIC8  Maintain a breastfeeding friendly clinic environment  Focus on WIC’s messages rather than on the formula company’s  Think about your words when you talk to partially breastfeeding women

9. Similac Advance - Another label change 2014 Formula Changes in WIC9  Similac Advance will continue as WIC’s standard milk-based bid formula in 12.4 oz powder, 13 oz concentrate, and 32 oz ready-to-feed  These sizes stay at 20 kcal/oz  The formula with the new labels will gradually change as stock runs out

10. Gradual change to new labels 2014 Formula Changes in WIC10  Look for “OptiGRO” emblem  On powder cans, look for  12.4 oz size  Birth to 12 months  Stage 1  Other size cans of powder or stages are not WIC eligible Look for Birth-12 months Look for Stage 1 12.4 oz. New emblem

11. How does the rebate come into this? 2014 Formula Changes in WIC11  Rebates from formulas support about 25% of our caseload  These formulas have been rebated in the past, so providing them did not cost the program extra  WIC can’t afford to provide similar formulas without a rebate, especially if they are not medically necessary

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16. Practice Section 2: Case studies 2014 Formula Changes in WIC16

17. What do you hear from caregivers? 2014 Formula Changes in WIC17 When a parent asks for Similac Sensitive or Similac Total Comfort:  Is it about a medical need?  Is it about addressing a parent or caregivers worry?  Is it because a health care provider has recommended it?

18. What is normal for most babies? 2014 Formula Changes in WIC18  If most babies are fussy at some point and grow out of it…  If half of babies are “happy spitters”…  If only 2-4% of all infants are really truly lactose intolerant… What is the solution?

19. Discuss Case Study #1 2014 Formula Changes in WIC19  Myra comes to her postpartum appointment with her 6 week old infant, Kyle. Myra reports that she is breastfeeding and started Kyle on one bottle of Similac Total Comfort. Kyle’s doctor recommended it for him because he is a little gassy.

20. Case Study #1 2014 Formula Changes in WIC20 Considerations…  What further assessment or BF support would you want to do with Myra and Kyle?  How do you frame your response when you cannot give mom Similac Total Comfort?  How do you respond to the doctor’s recommendation?

21. How do we help babies currently getting vouchers for Sensitive or Total Comfort? 2014 Formula Changes in WIC21  Most do fine on any formula  May switch anytime or can stay on the same formula until May 2014  By May, these babies will be older, more likely to be on solid foods, and developmentally past any feeding issues  May need ideas on how to transition to a new formula

22. Help for parents changing formulas 2014 Formula Changes in WIC22  Many babies can easily change formula, so can just be offered a bottle of the new formula  Caregivers may need help with instructions if using different size bottles  Be sure to use the scoop that comes with the can of formula when measuring  May work best to mix up each formula separately, then mix some of the two formulas together  To ensure understanding, ask the caregiver to describe how they will mix the two formulas together

23. Discuss Case Study #2 2014 Formula Changes in WIC23  Cara stops by the WIC office to request a change in her infant’s formula vouchers. She reports that her 3 month old baby Lynn is very fussy on Similac Advance. Mom is sure that she would do better on Nutramigen which she used in the past when her older sister had similar symptoms.

24. Case Study #2 2014 Formula Changes in WIC24 Considerations…  What reflections might you make when mom shares her concerns?  What additional information would you want to gather?  How would your knowledge about baby behaviors be useful in this situation?

25. Discuss Case Study #3 2014 Formula Changes in WIC25  Pearl brings her 6 month old daughter Liza to her MI appointment. Pearl says Liza has just started eating baby cereal, is sitting up unassisted and is growing and gaining weight well. Pearl says Liza has been on Similac Sensitive since she was one month old when she had colic.

26. Case Study #3 2014 Formula Changes in WIC26 Considerations…  What factors would be key for reassuring mom about transitioning off of the current formula?  What would you recommend regarding the process of transitioning from one formula to another?

27. Constipation and formula 2014 Formula Changes in WIC27  Parents may not know the difference between normal stooling and constipation  Parents may not know how to deal with a temporary issue  Some providers recommend whey-based formulas for softer stools when there may be other ways to address the concern

28. Discuss Case Study #4 2014 Formula Changes in WIC28  Tammy is Mabel’s five month old granddaughter. Mabel calls to report that Similac Advance is making Tammy constipated. She rarely stools every day and she strains so hard when she does go that Mabel thinks she needs to be switched to a different formula.

29. Case Study #4 2014 Formula Changes in WIC29 Considerations…  What clarifying questions would you ask?  What reflections might you offer based on Grandma’s comments?  What advice or information might you offer to address her concerns?

30. Spitting up and formula 2014 Formula Changes in WIC30  Parents worry about any spitting up and don’t understand “happy spitters”  Sometimes parents feel better if they make a change, so offering concentrate might help  Lactose intolerance is very rare and AAP doesn’t suggest routine use of lactose reduced formula

31. Discuss Case Study #5 2014 Formula Changes in WIC31  Sammy is two months old and spits up after every feeding of Similac Advance. His mother, Grace, is very worried that something is wrong with her son and thinks she should try a new formula since Sammy obviously does not tolerate this formula well.

32. Case Study #5 2014 Formula Changes in WIC32 Considerations…  How would you respond?  What other underlying issues might be present?  What further assessment is needed?

33. Use of special medical formulas 2014 Formula Changes in WIC33  Sometimes babies need special medical formulas for a little while  To rest the gut after illness  To assess an underlying medical condition  These babies can often return to the standard milk-based formulas after one to two months  Soy formulas are most appropriate for vegan families.  When would you refer to your WIC Nutritionist?

34. Discuss Case Study # 6 2014 Formula Changes in WIC34  Jeff is 7 months old and has been on Alimentum for 2 months. He switched from Similac Advance to Alimentum at age 5 months following a week long hospitalization for dehydration due to a bacterial infection. He is finally eating solid foods again, has been crawling and his weight for length is at the 40 th percentile.

35. Case Study #6 2014 Formula Changes in WIC35 Considerations…  How do you know when it is the appropriate time to move from a medical to a milk-based formula?  How would you approach the subject of switching formulas with mom?  What support would you offer for changing from one formula to another?

36. Wrap up 2014 Formula Changes in WIC36

37. What other formula situations have you encountered? 2014 Formula Changes in WIC37  What was the issue?  What assessment questions did you ask?  What was the outcome?  What were you glad you said?  What did you wish you would have thought of then?  What other ideas are there?

38. If you have additional questions 2014 Formula Changes in WIC38  Talk to your agency’s WIC Coordinator or WIC Nutritionist  Talk to your agency’s State Nutrition Consultant  Offer the state formula warm line (503-866-5106) to parents or health care providers if they have questions you don’t feel comfortable answering. The warm line will be staffed by State Nutrition Consultants during normal business hours for the months of the transition.

39. Thank you! 2014 Formula Changes in WIC39 Thank you for all the work you do to help parents and caregivers make this transition. WIC continues to be a great resource for information, support and assistance for families!