**Maine WIC Nutrition
Program**![](media/image1.png){width="0.5152777777777777in"
height="0.9277777777777778in"}

**Infant Nutrition Assessment Guidance**

+--------+-------------------------------------------------------------+
| **T    | **Guidance**                                                |
| opic** |                                                             |
+--------+-------------------------------------------------------------+
| ###    | ***Sharing growth information with parents:***              |
| Growth |                                                             |
|        | -   *If parent desires*, show plotted measurements          |
|        |                                                             |
|        | -   Reassure parent that growth is normal if it             |
|        |     consistently follows the curve of the chart             |
|        |                                                             |
|        | -   Point out that growth patterns are best evaluated over  |
|        |     a period of time vs one single plot                     |
|        |                                                             |
|        | ***If measurements obtained are different than what parent  |
|        | reports MD obtained:***                                     |
|        |                                                             |
|        | -   Point out measuring technique used by WIC staff (baby   |
|        |     on measuring board with flat surfaces for head and      |
|        |     feet; baby undressed to dry diaper for weight)          |
|        |                                                             |
|        | -   Scales routinely calibrated                             |
|        |                                                             |
|        | ***Baby with inconsistent growth*** (increase *or* decrease |
|        | of \>2 channels on growth chart):                           |
|        |                                                             |
|        | -   Refer file to LA Nutritionist for review                |
|        |                                                             |
|        | -   Send a referral to the physician                        |
+--------+-------------------------------------------------------------+
| **Baby | **[Breastmilk]{.underline}**---                             |
| is     |                                                             |
| d      | ***Assess for adequacy of intake, including:***             |
| rinkin |                                                             |
| g...** | -   Ask parent about the **number of BM's/24 hours**        |
|        |                                                             |
|        | -   Ask about **number of wet diapers/24 hours**            |
|        |                                                             |
|        | ***Assess for special needs:***                             |
|        |                                                             |
|        | -   Assess pumping needs (if necessary---includes sick      |
|        |     babies, mother returning to work, other separation      |
|        |     situations); **refer mom to LC or CLC in local agency   |
|        |     as needed.**                                            |
|        |                                                             |
|        | -   Assess for other lactation issues (including *pain,     |
|        |     perceived insufficient milk supply, poor positioning,   |
|        |     engorgement, sleepy baby);* **refer mom to LC or CLC in |
|        |     local agency as needed.**                               |
|        |                                                             |
|        | -   If baby is nursing for long time periods (45-60         |
|        |     min/feeding), **refer mom to CLC in agency or LC.**     |
|        |                                                             |
|        | ***Reassurance for BF mom:***                               |
|        |                                                             |
|        | -   Feeding frequency normally decreases as baby gets older |
|        |                                                             |
|        | -   It is normal to feed as often as every 2 hours          |
|        |     throughout the day and night.                           |
|        |                                                             |
|        | ####### Formula---                                          |
|        |                                                             |
|        | -   Inquire [how]{.underline} formula is being mixed and    |
|        |     assess for correct mixing technique; provide *Safe      |
|        |     Formula Preparation* handout and review proper formula  |
|        |     dilution if needed                                      |
|        |                                                             |
|        | -   Address food safety issues                              |
|        |                                                             |
|        | -   Review need for recording lot numbers of all formula    |
|        |     purchased                                               |
|        |                                                             |
|        | -   Adequate formula intake varies---refer to               |
|        |     ***age-appropriate infant card*** for amounts           |
|        |                                                             |
|        | **[Juice]{.underline}---**                                  |
|        |                                                             |
|        | -   Advise delay of juice until at least 6 months           |
|        |                                                             |
|        | -   Discuss avoidance of substituting juice for formula or  |
|        |     breastmilk feedings                                     |
|        |                                                             |
|        | -   After 6 months, when juice is initiated, offer 2-3      |
|        |     ounces/day in a cup                                     |
|        |                                                             |
|        | -   Open-mouth cups or non-spill proof sip cups are the     |
|        |     best ways to offer juice to babies                      |
|        |                                                             |
|        | **[Other]{.underline}**---                                  |
|        |                                                             |
|        | -   Counsel parent to provide breastmilk or formula only in |
|        |     bottles                                                 |
|        |                                                             |
|        | -   Sodas, fruit beverages, or teas are not appropriate for |
|        |     infants                                                 |
|        |                                                             |
|        | -   If parent reports giving baby water, discuss importance |
|        |     of not substituting water for formula or breastmilk     |
|        |     feeds. Water should only be provided if physician has   |
|        |     recommended it. Too much water may over-hydrate infant  |
|        |     and may cause "water intoxication".                     |
+--------+-------------------------------------------------------------+

+--------+-------------------------------------------------------------+
| **Baby | **[0-2 months]{.underline}---**                             |
| is     |                                                             |
| eatin  | -   **Hunger cues**---Ask parent "How does your baby let    |
| g...** |     you know he is hungry?" Teach parent infant hunger      |
|        |     cues; review that crying is a late hunger cue.          |
| *      |     Responding to hunger cues will help baby learn to trust |
| *and** |     that the parent will provide for her needs.             |
|        |                                                             |
| **F    | -   **Satiety cues**---Ask parent "How does your baby let   |
| eeding |     you know he is full?" Teach parent what baby may do to  |
| dyna   |     indicate satiety. Responding to infant satiety will     |
| mics** |     avoid overfeeding and help baby learn to quit eating    |
|        |     when full, which may have implications to avoid         |
|        |     overeating later in life. *Explain baby does not always |
|        |     have to finish drinking everything in the bottle.*      |
|        |                                                             |
|        | -   Counsel on need to have ***all*** caregivers sensitive  |
|        |     to baby's hunger/satiety cues.                          |
|        |                                                             |
|        | -   Discuss ***importance of holding baby*** for every      |
|        |     feeding.                                                |
|        |                                                             |
|        | **[3-5 months]{.underline}---**                             |
|        |                                                             |
|        | -   *If baby is developmentally ready for cereal,* counsel  |
|        |     parent to begin with **spoon feeding** of smooth, thin  |
|        |     cereal (1 tsp dry infant cereal mixed with 1 Tb         |
|        |     breastmilk or iron-fortified formula).                  |
|        |                                                             |
|        | -   Discuss importance of breastmilk or formula as main     |
|        |     part of baby's food intake and the need to delay        |
|        |     introduction of **all** other foods until 6 months.     |
|        |                                                             |
|        | -   Explain how holding off on solids until baby            |
|        |     demonstrates developmental readiness promotes positive  |
|        |     feelings associated with feeding for the baby and       |
|        |     increases baby's success with feeding.                  |
|        |                                                             |
|        | **[6-8 months]{.underline}---**                             |
|        |                                                             |
|        | ***Discuss developmental readiness for progressing solid    |
|        | food textures.***                                           |
|        |                                                             |
|        | ***Baby is ready for [more texture]{.underline} when:***    |
|        |                                                             |
|        | -   Able to sit alone easily                                |
|        |                                                             |
|        | -   Can bite off food                                       |
|        |                                                             |
|        | -   Can chew with rotary motion                             |
|        |                                                             |
|        | -   Can move food side-to-side in mouth                     |
|        |                                                             |
|        | ***Baby is ready for [finger foods]{.underline} when:***    |
|        |                                                             |
|        | -   Palmar (whole hand) grasp changes to pincer grasp       |
|        |     (thumb and forefinger)                                  |
|        |                                                             |
|        | ***Discuss*** ***progression of feeding solid foods***:     |
|        |                                                             |
|        | -   Offer one new food each week                            |
|        |                                                             |
|        | -   Offer plain foods rather than mixtures                  |
|        |                                                             |
|        | -   Offer new foods along with familiar foods               |
|        |                                                             |
|        | -   As solid food intake increases, breastfeeds or formula  |
|        |     intake [may]{.underline} decrease.                      |
|        |                                                             |
|        | ***Discuss parent's job and infant's job in feeding:***     |
|        |                                                             |
|        | -   Parent ***offers*** healthy choices, and offer food in  |
|        |     ***family-style meal settings***.                       |
|        |                                                             |
|        | -   Infant decides whether to eat and how much; if infant   |
|        |     refuses new food, wait and try that food again in a few |
|        |     weeks.                                                  |
|        |                                                             |
|        | **[9-12 months]{.underline}---**                            |
|        |                                                             |
|        | ***Discuss skills baby can be expected to develop:***       |
|        |                                                             |
|        | -   Picking up small pieces of table foods                  |
|        |                                                             |
|        | -   Drinking from open-mouth cup                            |
|        |                                                             |
|        | -   Controlling food in mouth                               |
|        |                                                             |
|        | -   Improved chewing                                        |
|        |                                                             |
|        | ***Talk about meal schedule:***                             |
|        |                                                             |
|        | -   Offer 3 meals and 2-3 small snacks/day                  |
|        |                                                             |
|        | -   Offer meals in family-style setting                     |
|        |                                                             |
|        | ***Discuss what to offer at meals and snacks:***            |
|        |                                                             |
|        | -   Offer variety of table foods---soft meats and           |
|        |     vegetables; cheese; eggs; mashed cooked legumes; small  |
|        |     slices of bread, tortilla or cracker; dry cereals.      |
|        |                                                             |
|        | -   Offer expressed breastmilk, iron-fortified formula or   |
|        |     water in a cup at each meal and snack.                  |
|        |                                                             |
|        | -   Offer up to 4 ounces juice/day in an open-mouth cup     |
|        |                                                             |
|        | -   Avoid using spill-proof cups.                           |
|        |                                                             |
|        | ***Discuss parent's job and infant's job in feeding:***     |
|        |                                                             |
|        | -   Parent **offers** healthy choices in a family-style     |
|        |     meal setting                                            |
|        |                                                             |
|        | -   Baby decides whether to eat food that's offered, and if |
|        |     so, decides how much to eat.                            |
+--------+-------------------------------------------------------------+
| **Fee  | **Refer parent** for further guidance/evaluation:           |
| ding-R |                                                             |
| elated | -   **Cough/gag/choke**---refer to MD                       |
| Prob   |                                                             |
| lems** | -   **Swallowing problems**---refer to MD or CDS            |
|        |                                                             |
|        | -   **Reflux---**refer to MD                                |
|        |                                                             |
|        | -   **Sucking problems**---refer to LC or MD if             |
|        |     breastfeeding, or to MD if formula feeding              |
|        |                                                             |
|        | -   **Constipation, diarrhea**---refer to MD                |
+--------+-------------------------------------------------------------+
| **Med  | **Refer parent to MD** for followup if using any            |
| icines | non-prescribed items.                                       |
| &      |                                                             |
| S      |                                                             |
| upplem |                                                             |
| ents** |                                                             |
+--------+-------------------------------------------------------------+
| ####   | **Share information with parent on the following:**         |
|  Denta |                                                             |
| l Care | -   Washing baby's gums with soft washcloth every day       |
|        |                                                             |
|        | -   Tooth brushing as soon as first tooth appears           |
|        |                                                             |
|        | -   Avoid use of any sweetener on pacifiers, nipples        |
|        |                                                             |
|        | -   Avoid putting baby to bed with bottle **or**            |
|        |     spill-proof cup                                         |
|        |                                                             |
|        | -   Offer only plain water after teeth have been brushed    |
|        |     before bedtime                                          |
+--------+-------------------------------------------------------------+
| **Iden | Include any **"red flags"** that have emerged during health |
| tified | or nutrition assessment, or concerns/questions caregiver or |
| To     | counselor may have.                                         |
| pics** |                                                             |
+--------+-------------------------------------------------------------+
| *      | **Assist parent** in identifying plans for the upcoming     |
| *Paren | months. Question parent about possible plan in a            |
| t-Iden | non-judgmental manner. Examples of questions/statements     |
| tified | that may be made include:                                   |
| P      |                                                             |
| lans** | -   Have you thought about how you can help your baby       |
|        |     progress with textures?                                 |
|        |                                                             |
|        | -   What feeding plans do you have for your baby in the     |
|        |     next 2-3 months?                                        |
|        |                                                             |
|        | -   You said you haven't started to wash your baby's gums   |
|        |     (brushing his teeth) yet. Would you like me to show you |
|        |     how you can start protecting you baby's teeth? Do you   |
|        |     plan to do anything differently in the upcoming months  |
|        |     to help prevent tooth decay?                            |
|        |                                                             |
|        | -   Has your baby's doctor mentioned when he may be         |
|        |     developmentally ready for cereal? What are your plans   |
|        |     for offering cereal?                                    |
|        |                                                             |
|        | **Let the parent state the plan.** Provide supporting       |
|        | information that the parent may need to follow though with  |
|        | their plan. List handouts used to share information with    |
|        | parent.                                                     |
+--------+-------------------------------------------------------------+
| ####   | **Record dates of DTaP's from immunization record.**        |
| #### I | Routine schedule of DTaP shots:                             |
| mmuniz |                                                             |
| ations | -   DTaP #1---2 months                                      |
|        |                                                             |
|        | -   DTaP #2---4 months                                      |
|        |                                                             |
|        | -   DTaP #3---6 months                                      |
+--------+-------------------------------------------------------------+
| *      | **Record and date all referrals.** Follow-up on referrals   |
| *Refer | at subsequent visits.                                       |
| rals** |                                                             |
+--------+-------------------------------------------------------------+
| **Lead | **Discuss** reasons for lead testing and recommended ages   |
| Test** | for the test (12 and 24 months) for all children.           |
|        |                                                             |
|        | **Remind parent** to request lead test at 12 months of age  |
|        | at well child visit with MD.                                |
+--------+-------------------------------------------------------------+

##### Infant Health Assessment Form

**Guidance**

+-----------------------------------+-----------------------------------+
| ## Question                       | **Suggested Action**              |
+-----------------------------------+-----------------------------------+
| Baby's health insurance           | ###### If **none** se             |
|                                   | lected, refer parent to MaineCare |
+-----------------------------------+-----------------------------------+
| Was your baby born before 37      | ###### If **yes** selected---     |
| weeks?                            |                                   |
|                                   | -   Find out how many weeks       |
|                                   |     infant was born early         |
|                                   |                                   |
|                                   | ```{=html}                        |
|                                   | <!-- -->                          |
|                                   | ```                               |
|                                   | -   Plot infant's measurements    |
|                                   |     for gestation until 2 years   |
|                                   |     of age                        |
|                                   |                                   |
|                                   | -   Ask parent about any special  |
|                                   |     needs baby may have           |
|                                   |                                   |
|                                   | -   **Depending on the infant**,  |
|                                   |     more frequent weights may be  |
|                                   |     needed to be obtained         |
+-----------------------------------+-----------------------------------+
| Did your baby need any special    | ###### If **yes** selected---     |
| care while in the hospital?       |                                   |
|                                   | -   Find out what special care    |
|                                   |     was required                  |
|                                   |                                   |
|                                   | -   Determine implications of     |
|                                   |     infant's condition on current |
|                                   |     nutritional status            |
+-----------------------------------+-----------------------------------+
| Does your baby have any medical   | ###### If **yes** selected---     |
| problems?                         |                                   |
|                                   | -   Request diagnosis from MD     |
|                                   |                                   |
|                                   | -   Determine implications of     |
|                                   |     infant's diagnosis on         |
|                                   |     nutritional status            |
|                                   |                                   |
|                                   | -   Refer parent as needed to CDS |
|                                   |     or other resources for        |
|                                   |     special needs infants         |
+-----------------------------------+-----------------------------------+
| Does your baby live in or spend   | ###### If **yes**                 |
| time in a home built before 1978? | to either question is selected--- |
|                                   |                                   |
| If yes, is the home being         | -   Discuss risk for lead         |
| remodeled?                        |     exposure and importance of    |
|                                   |     lead testing at 12 and 24     |
|                                   |     months                        |
|                                   |                                   |
|                                   | -   Share ways to reduce lead     |
|                                   |     exposure: frequent **wet**,   |
|                                   |     rather than dry, **dust       |
|                                   |     removal**; **paint over**     |
|                                   |     peeling paint; **remove       |
|                                   |     shoes** at door; keep **paint |
|                                   |     chips away** from baby        |
+-----------------------------------+-----------------------------------+
| Is your baby around people who    | ###### If **yes** selected---     |
| smoke cigarettes, pipes or        |                                   |
| cigars?                           | -   Discuss **hazards of          |
|                                   |     second-hand smoke** for       |
|                                   |     children                      |
|                                   |                                   |
|                                   | -   Refer to **smoking cessation  |
|                                   |     programs** as requested       |
+-----------------------------------+-----------------------------------+
| Were there any days last month    | ###### If **yes** selected---     |
| when your family did not have     |                                   |
| enough food to eat or enough      | -   Ask about need for additional |
| money to buy food?                |     resources                     |
+-----------------------------------+-----------------------------------+
| Would you like information on     | ###### If **yes** selected---     |
| places you can get food in your   |                                   |
| area?                             | -   Give referral information for |
|                                   |     area resources, including     |
|                                   |     Food Stamps, Food Banks       |
+-----------------------------------+-----------------------------------+
| Does your drinking water come     | ###### If **yes** selected---     |
| from a well?                      |                                   |
|                                   | -   Ensure safety of water supply |
|                                   |                                   |
|                                   | -   Provide information for       |
|                                   |     fluoride testing when baby is |
|                                   |     6 months                      |
+-----------------------------------+-----------------------------------+