Name of participant: __________________________________ DOB: _________________
State ID: ___________________________
MN WIC Program Condition Specific Protocol for Providing
Similac Sensitive, Total Comfort, and Spit-Up
_____________________________________________________________________________________
Conditions for applying this protocol: For infants who exhibit signs of mild intolerance (such as discomfort,
fussiness, excess gas, loose stools, constipation or spit-up) when fed the primary formula, Similac Advance, an
alternate milk-based contract formula may be beneficial. Alternate milk-based contract formulas available in WIC,
with medical documentation, include:
o Similac Sensitive (reduced lactose)
o Similac Total Comfort (reduced lactose, and 100% whey, partially hydrolyzed)
o Similac for Spit-Up (reduced lactose, and added rice starch)
Policy: This protocol is to be implemented under the direction of the WIC administrator or designee.
Procedure:
1. If a parent has concerns about the suitability of Similac Advance for her/his infant, WIC CPAs must assess the
baby’s health and feeding. Significant concerns must be referred to the infant’s HCP.
2. If infant is exhibiting any of the conditions listed above, and the CPA finds no serious medical concerns, he/she
may offer one of the three alternate contract formulas if determined appropriate.
Provisions of the Protocol
After assessment of participant’s condition, and determined appropriate:
1. Similac Sensitive, and/or Total Comfort and/or Spit-Up (all 19 kcals/oz) may be provided for
intolerance/GI upset to Similac Advance.
2. The Maximum Allowable amount of formula may be provided OR a lesser amount provided if
determined by the CPA to be appropriate for the participant.
3. This formula may be provided until 1 year of age.
CPA Signature: __________________________________________
Date: _____________________
Local Agency: ________________________________ Date CSP Protocol Implemented:____________
Medical Consultant
Name: _________________________ Signature: ______________________________ Date: ________
Local Health Department Administrator (or Designee)
Name: _________________________ Signature:______________________________ Date: ________
This Protocol must be renewed annually with your Medical Consultant & Health Department Administrator.
Exhibit 7-D-3 4/9/14