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Texas WIC News September October 2010

Volume 19, Number 5

Infants' First

WIC Provides Information on Caring for Infants
Infant Guide to Starting Solids: When, Why and How
Guide to Starting Solids for the Special Needs Infant on WIC
Back to Sleep, Tummy to Play
Texas Health Steps Focuses on Medical, Dental and Case Management Services
WIC Wellness Works
Local Agency Spotlight: Tarrant County WIC Nutritionist Serves on Fetal Infant Mortality Review Board
WCS Training Program Benefits WIC Clinics
Newsworthy News — D is for defiency: New Vitamin D Recommendations
Texas Dietetic Internship: The Road to Becoming a Registered Dietitian
Eaton Wright: Home Safety Quiz

WIC Provides Information on Caring for Infants

From the Texas WIC Director
— Mike Montgomery

The Texas WIC program proudly serves 55 percent of infants born in the state. These infants, which make up 20 percent of our statewide WIC caseload, are the focus of this edition of the Texas WIC News. One of the major roles of the WIC program is to provide nutrition education for moms about appropriate feeding of their newborns. WIC also has a role in providing information about how to protect this vulnerable population. There are several articles included in this issue that address the information you need as educator and advisor to others who have questions concerning caring for their infants. 

 It seems there are many opinions about when and what foods to start feeding a baby. Because of the difference of opinion among the professionals, we want our staff to be armed with the best, basic information available to share with the mothers of infants that they serve. The article on page 4, “Infant Guide to Starting Solids: When, Why, and How” provides excellent hints and tips for a baby’s developmental readiness for eating. Mothers of infants with special health care needs have additional concerns that need to be addressed as discussed in the article “Guide to Starting Solids for the Special Needs Infant on WIC” found on page 6. “The Back to Sleep, Tummy to Play” article on page 8 and the “Eaton Wright: Home Safety Quiz” on page 18 both provide helpful information aimed at educating on key concepts for ensuring the safety of infants.

Part of caring for our infants is providing information and access to resources outside of the WIC program. One very important resource available to our participants is the Texas Health Steps program. There is an excellent article on page 10 that discusses the mission of this program. WIC has a responsibility to make sure that our participants have access to the health care that is needed, and we are very proud of the referral process that you have set up in your clinics.

I have been in clinics and watched the thoughtful, supportive way in which you approach the new mom and try to help her perform the most important job she will ever have — caring for her new baby. I appreciate all you do to provide nutrition education and counseling to ensure the safety and welfare of our Texas WIC infants, one of our state’s most precious resources and the future of our state and nation.


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Infant Guide To Starting Solids: When, Why and How

by Roxanne Robison, R.D.
CSHCN Nutrition Consultant

If there is one thing that is clear about introducing complimentary foods, it is that there is no agreement on when and what to start feeding that is right for all infants. The American Association of Pediatrics has supported exclusive breastfeeding for about the first 6 months of age, but recognizes that infants are often developmentally ready to accept complementary foods between four and six months.

When To Start Solids
It is important not to be in a rush to start solids. One reason is that baby’s intestines need to mature. Between four and seven months, a baby’s intestinal lining becomes more selective about what to let through and this increases its ability to filter out any potential allergens. Young babies are also born with a tongue-thrust reflex that protects the infant against choking. Between four and six months this reflex gradually diminishes, allowing the baby to transfer food from the front of the tongue to the back.

Pureed foods or infant cereal given with a spoon can be introduced when the following signs of developmental readiness are present:
-Infant can sit with support and has neuromuscular control of the head and neck.
-Infant can take food without choking or gagging.
-Infant can indicate desire for food by opening the mouth and leaning forward.
-Infant can indicate satiety by leaning back and turning away.
-Infant has lost the tongue-thrust reflex.
-Infant exhibits beginning of up and down chewing movements as opposed to sucking movements with mouth.

Why Start Solids
If the baby appears unsatisfied after a feeding, is shortening the intervals between feedings, and several days of more frequent feedings does not change this, it may be time to begin solids.

Typically, infant cereal is the first food provided because it can be mixed to a smooth texture and provides both iron and zinc. Baby food meats are also a good source of iron and zinc, but the texture and taste is very different than cereal with breastmilk added. Some babies may have a hard time accepting meat as a first food, while others will readily accept it.

From a nutritional point of view, it is well known that the concentration of zinc in breastmilk declines sharply in the first few months of lactation, regardless of the mother’s zinc status. Some infants will benefit from additional zinc in their diet. Full-term babies are born with adequate iron stores, but these stores are gradually depleted over time. The duration of how long these stores last varies among infants.

How To Start Solids
When first introducing spoon feeding, babies are getting used to not only a new way to eat, by spoon, but also new flavors and textures. Some babies may do better when offered a small amount of breastmilk or formula to take the edge off their hunger before trying their first spoon feeding. When babies are very hungry, they may get frustrated by trying to learn something new. The most important thing is to develop a positive association with the spoon-feeding experience. Start by mixing one tablespoon of cereal with four or five tablespoons of breastmilk or formula to a thin consistency. There is nothing wrong with mixing cereal with water, but it might help with acceptance to mix cereal with a food that has a familiar flavor and smell. At first, deposit a small amount of food on baby’s lip. Proceed with putting ½ teaspoon in his mouth. If he enjoys this, let him try to suck it off of the spoon. The initial goal is just to get baby used to the feel, taste, and texture of the new food and to have it be a positive experience. The amount taken is not important. Mothers should be assured that putting cereal in the bottle is never necessary or desired, as this does not teach a new skill. Thicken cereal a little more over time as baby’s skills improve and he is able to remove the food from the spoon with his upper lip.

If baby has a strong negative reaction to the first feeding experience, stop and wait a couple of weeks and try again. Best practice is to introduce one new single-ingredient food at a time for one week to observe for possible allergic reactions, such as wheezing, skin rash, diarrhea, nausea and vomiting.

Consider solid foods an addition to, not a substitute for, breastmilk or formula. For a breastfed baby, its best to start solids slowly, so the food does not become a substitute for the nutritionally superior breastmilk and interfere with the supply and demand cycle.

Now you know the when, why and how of starting solids. Solid foods should be started when the baby is developmentally ready. They provide supplemental nutrients at a time when body stores at birth are decreasing. If cereal is the first food offered, it is best to start slowly with a thin mixture that is like thick milk and work up to a pasty texture over time. Finally, remember, above all to enjoy the learning experience and make it fun.



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Guide to Starting Solids for the Special Needs Infant on WIC

by Catherine Plyler, R.D., L.D.
Clinical Nutrition Specialist

One of the most exciting changes with the implementation of the New Food Rules in October 2009 was the addition of baby foods to infant food packages. These benefits are automatically provided when an infant turns six months of age. However, recent data indicates that approximately 18 percent of infants on WIC in Texas are born premature. This presents a potential problem as their ability to start solids may be delayed. Introducing foods to these infants should be determined by developmental readiness rather than by chronological age. In addition, healthy but premature and low birth weight infants can experience feeding problems not usually encountered with full term infants. The advice we provide about feeding in the first year of life may not apply to preterm infants since many do not reach the predicted developmental milestones at the same time as their full term counterparts. How do we assist caregivers in assessing when these babies are ready for solids?

Understanding normal development can be helpful in assessing infants who may be demonstrating delays or feeding problems. The table shown on page 7 provides an overview of development and feeding skills. At about four to six months of age, a normally developing infant is usually able to hold his head up and sit with minimal support. Oral motor development includes being able to transfer food from the front to the back of the tongue to swallow which allows them to accept foods from a spoon. Premature infants may have delays when achieving these developmental milestones. Foods should also be delayed to match the developmental skill of the infant.

Adjusted age, as well as signs of developmental readiness, are important considerations when determining when to introduce solids. WIC publication, Feeding your Premature Baby Step by Step, Stock no. 13-06-11234, is an excellent tool to use when providing guidance on infant feeding for premature babies. Recommendations and guidance offered to families with infants who were born premature should be in conjunction with a referral to their health care provider to determine when best to begin solids. This will also be important when determining the appropriate food package when the infant turns six months of age.

In addition to prematurity, we should also consider infants who may not be able to begin solids due to tube feeding or other medical conditions such as Down syndrome or cleft palate. Feeding and eating problems are more common in children with special health care needs than in the general pediatric population. Delays in feeding development may be related to inadequate structure or abnormal muscle tone. For example, infants with Down syndrome have poor lip closure associated with hypotonia. Infants with cleft palate frequently lack the structural requirement for efficient sucking. These infants can be referred to Early Childhood Intervention Programs (ECI) to assist with feeding progression. Often, initiation of solids may be delayed and progression of feedings will be based on recommendation of oral motor or speech therapists and health care providers.

Assigning the best food package to infants who were born premature can be challenging. WIC staff must be aware of the infant’s feeding needs prior to automatic issuance of infant foods at six months of age. Most participants return to the clinic at three month intervals, so scheduling return visits at five months of age is not the norm. The health care provider must also indicate if foods are to be allowed or omitted on the Texas Medical Request for Formula/Food form.

Many local agencies have developed cover letters informing the health care provider that infant foods will be provided unless otherwise indicated on an attached prescription form. These are provided to the caregiver when infants are added to the program. Follow up visits for premature infants are scheduled with the certifying authority or high risk registered dietitian in order to consult with the caregiver and health care professional. It is important to determine how to best serve the participants within your local agency and clinic.

After receiving input, the certifying authority can determine which food package to assign. In many cases the regular food package can be provided. If foods are not allowed, infants on contract or standard formula can receive a food package that provides formula only. The formula amounts will be adjusted in accordance with the infant’s age. However, an increased amount of formula can be provided when an exempt formula is requested and the health care provider has indicated that no foods are allowed (food package code 454). This food package allows infants to receive the same amount of formula they were receiving at four and five months of age or approximately 29 ounces a day.

The role of WIC staff working with families with premature infants or developmentally delayed infants is important and can be a valuable resource. With the first visit, you can encourage the caregiver to start thinking about when the initiation of solids may be appropriate for her infant. Staff can also communicate with the physician any problems that the mom may be encountering with feeding that would warrant a delay in starting solids. WIC staff can also initiate a referral to ECI or other specialists. The extra steps taken in identifying these infants can make a significant difference in the lives of these special needs families.

Reference: Lucas, Betty L., Sharon A. Feucht, and Lynn E. Grieger, editors. Children With Special Health Care Needs: Nutrition Care Handbook/ Pediatric Nutrition Practice Group and Dietetics in Developmental and Psychiatric Disorders, American Dietetic Association. 1st ed.

Infant Development And Feeding Skills In Normal Healthy Full Term Infants


Infant Development
Approximate Age Mouth Patterns Hand and Body Skills Feeding Skills or Abilities
Birth through
5 months
Suck/swallow reflex
Tongue thrust reflex
Rooting reflex
Gag reflex

Poor control of head, neck and trunk

Brings hand to mouth around 3 months

Swallows liquids but pushes most solid objects from the mouth
4 months through
6 months
Draws in upper lip or lower lip as spoon is removed from mouth
Up-and-down munching movement
Can transfer food from front to back of tongue and swallow
Opens mouth when sees spoon approaching
Sits with support
Good head control
Uses whole hand to grasp objects
Takes in a spoonful of pureed or strained food and swallows it without choking
5 months through
9 months
Begins to control the position of food in the mouth
Up-and-down munching movement
Positions food between jaws for chewing
Begins to sit alone unsupported
Follows food with eyes
Begins to use thumb and index finger to pick up objects
Begins to eat mashed foods
Eats from spoon easily
Drinks from cup
Begins to feed self with hands
8 months through 11 months Moves food from side to side in mouth
Begins to curve lips around rim of cup
Begins to chew in rotary pattern
Sits alone easily
Transfers objects from hand to mouth
Begins to eat ground or finely chopped food
Begins to experiment with spoon
Prefers to self feed
Improved cup drinking
10 months through
12 months
Rotary chewing (diagonal movement of the jaw as food is moved to the side or center of the mouth) Begins to put spoon in mouth
Begins to hold cup
Good eye-hand-mouth coordination
Eats chopped food and small pieces of soft, cooked table food
Begins self-spoon feeding with help

Adapted from:
Feeding Infants: A Guide for Use in the Child Nutrition Programs, U.S. Department of Agriculture, Food and Nutrition Service; 2001




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Back to Sleep, Tummy to Play

by Shirley Ellis, M.S., R.D.
Nutrition Education Branch Manager

"Back to Sleep” and “Tummy to Play” are two important campaigns that go hand in hand to promote safety for infants while ensuring their proper growth and development. Babies need to be placed on their backs for safe sleeping but they also need to spend time on their stomachs while awake and supervised.

In 1994 the United States rolled out a national “Back to Sleep” campaign aimed at reducing the risk for sudden infant death syndrome (SIDS). The campaign name comes from the recommendation of placing babies on their backs to sleep to prevent sleep-related infant deaths. The campaign has been a huge success resulting in a significant increase in the number of infants placed on their backs for sleep, thus leading to a greater than 50 percent reduction in SIDS.

SIDS occurs in all socio-economic, racial and ethnic groups, with African American and Native American infants being two to three times more likely to die of SIDS than Caucasian infants. Male infants are 20 percent more likely to suffer from SIDS than female infants. While SIDS is rare during the first month of life, the rate increases to a peak between 2 and 3 months of age and then decreases. The majority of infants who die of SIDS appear to be healthy prior to death.

There is no known way to prevent SIDS, but there are several precautions parents can take to decrease the risk:
• Back to Sleep – Babies should always sleep on their backs.
• Use a firm sleep surface. Babies should never sleep on waterbeds, sofas, recliners, futons, bean bag chairs, soft mattresses or other soft surfaces. Soft materials or objects such as pillows, quilts, comforters or sheepskins should not be placed under a sleeping infant.
• Never have spaces between the mattress and the crib where the baby could be trapped.
• Do not use hand-me-down or used cribs or bassinets unless they meet current safety standards.
• Place the crib in the room where the parents sleep. The safest place for babies to sleep is in a safety-approved crib or bassinet in the same room with a parent or caregiver. Adult beds are not made for babies and may carry a risk of accidental entrapment and suffocation.
• Avoid overheating. Don’t over-dress the infant and never cover the baby’s head with a blanket.
• Smoking should not be allowed in homes where babies live, especially near where babies sleep.

While healthy babies are safest when sleeping on their backs, they also need to spend supervised time on their stomachs while awake. Spending time on the stomach makes up the second component of Back to Sleep, Tummy to Play. Tummy time is the amount of time babies spend lying on their stomachs while they are awake, and it is necessary for the normal development of motor skills. Spending time on the stomach helps promote muscle development of the neck and shoulders, which is essential in the proper development of an infant’s ability to lift his head, rollover, sit up, balance, crawl and walk.

Tummy time should begin in the newborn stage and consist of 30 to 60 minutes, spread throughout the day.

Here are several ideas for making sure infants get the tummy time they need:
• Encourage parents and caregivers to lay the infant over their leg while they are sitting on the floor or lie down with the infant on their chest with the infant stomach side down.
• Suggest that parents carry the infant around with the infant’s stomach against the parent’s chest instead of upright and facing out.
• Recommend that parents place the infant on her tummy on a blanket on the floor.
• Suggest that parents hold a mirror in front of the infant to capture her attention. Or place brightly colored stuffed animals just within her reach.
• Encourage friends, relatives, and the infant’s caregivers to get down on the floor for short periods of tummy time with the infant as well.

It takes some infants time to get use to being on their stomach. If the infant begins to fuss, parents can make tummy time more interesting through gentle movement. After a diaper change and when the infant is wide awake is a good time to spend tummy time with the infant. Parents should be encouraged to try tummy time for several short periods during the day until the infant gets used to being on his tummy.

Through our contact with WIC participants we have the opportunity to provide parents with education on two important issues:
1. Healthy babies are safest when sleeping on the backs.
2. Tummy time when infants are awake and supervised is a necessary component of normal infant development.

If you have questions about safe sleep practices please contact Healthy Child Care America at the American Academy of Pediatrics at www.healthychildcare.org.

Policy Statement: The Changing Concept of Sudden Infant Death Syndrome: Diagnostic Coding Shifts, Controversies Regarding the Sleeping Environment, and New Variables to Consider in Reducing Risks. 2005. Pediatrics, 116: 1245-1255.
Prevention and Management of Positional Skull Deformities in Infants. 2003. Pediatrics 112: 199-202.
Back to Sleep, Tummy to Play. Revised 2008. American Academy of Pediatrics Publication.
Information for Parents of Newborns. 12/2009. Texas Department of State Health Services. Stock No. 1-316.


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Texas Health Steps Focuses on Medical, Dental and Case Management Services

by Joan Strawn
Training Specialist IV
Health Screening and Case Management Unit
Family and Community Health Services Division

Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) is Medicaid’s comprehensive preventive child health service for individuals from birth through 20 years of age. In Texas, EPSDT is known as Texas Health Steps. Defined by federal law as part of the Omnibus Budget Reconciliation Act of 1989 legislation, EPSDT includes periodic screening, vision, hearing, and dental preventive and treatment services. In addition, Section 1905(r)(5) of the Social Security Act requires that any medically necessary health care service listed in the Act be provided to Texas Health Steps recipients even if the service is not available under the State’s Medicaid plan to the rest of the Medicaid population. These additional services are available through the Comprehensive Care Program.

Texas Health Steps Mission

Texas Health Steps focuses on the medical, dental, and case management services for ages birth through 20 years, and is dedicated to:
• Expanding recipient awareness of existing services through outreach and informing efforts.
• Recruiting and retaining a qualified provider pool to assure the availability of comprehensive preventive medical, dental, and case management services.

Recruiting and Retaining a Qualified Provider Pool

Medical, dental, case management and other providers are the cornerstone to assuring that young people in Texas receive Texas Health Steps services at an early age and on a regular basis. Texas Health Steps is committed to reimbursement and training in order to recruit and retain qualified providers to make sure comprehensive preventive services are available. Providers performing medical, dental, and case management services who wish to be eligible for reimbursement for providing Medicaid and Texas Health Steps services must enroll in these programs through the Texas Medicaid & Healthcare Partnership. To enroll in Texas Medicaid and Texas Health Steps, providers must be
• A physician.
• A health-care provider or facility (public or private).
• A physician assistant, and family and pediatric nurse practitioner enrolled independently.
• A certified nurse-midwife.
• A women’s health-care nurse practitioner.
• An adult nurse practitioner enrolled as a provider for adolescents.


Texas Health Steps gives medical and dental checkups and care and case management services to children from birth to 20 years who have Medicaid. Texas Health Steps will:
• Help find a doctor or dentist for an eligible child.
• Help set up an appointment for an eligible child to see a doctor or dentist.
• Help get a ride or money for gas to get to a medical or dental appointment
• Answer questions about available services.

To find out more about Texas Health Steps call 1-877-847-8377 (1-877-THSTEPS) or
TTY number 1-800-RELAY TX (735-2989).


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WIC Wellness Works: Going Green with the State Office

The state WIC office is greener than you might think. State WIC employees participated in Simple Steps to Financial Wellness and put their own “green” spin on the initiative. Wellness coordinators Tiffany Brown, training specialist with Clinical Services, and Chris Coxwell, WIC photographer, organized the “Go Green” events.

“We always have a different number of people who participate in the wellness initiatives so we thought we would try something new this time,” said Tiffany. “We sent out a colorful, fun e-mail about practicing healthy financial wellness habits and explained what the challenge was about. We tied it all in with money, nutrition, and a party on St. Patrick’s Day (for the Go Green potluck). We also included a voting option in the e-mail so people could click on either “Yes” or “No” as to whether or not they wanted to participate in the event. We’ve found this way really seems to work best here at the state office because people are inconsistent in their participation — we really don’t have just one group of WIC Wellness Works participants; different people participate in different events.”

The e-mail invitation listed several items employees would receive for participating:
• The new Wellness Activity with a Spending Quiz, to determine what type of big spender you are.
• A journal and a calculator, to track your green stuff.
• Money saving tips and ideas.
• Weekly jackpot links to healthy spending at Spend Smart. Eat Smart. published by Iowa State University which included tips such as:
  • Save money and go green.
  • 30 ways in 30 days to stretch your fruit and vegetable budget.
  • Ham and brown rice video and recipe (with cost/serving size information).
  • Cooking videos available from Texas Agriculture Life Extension.
  • Buy fish on sale this month — try these easy, healthy recipes (in honor of Lent).

In addition to the incentives for participation, employees were invited to attend a St. Patrick’s Day “Get Your Green On” potluck with a special Vita-Mix® demo and green smoothie taste test.

The e-mail also linked the St. Patrick’s Day event to National Nutrition Month saying, “So let’s MARCH into National Nutrition Month …” 

Initially 50 people signed up, but as soon as Tiffany and Chris began passing out the financial wellness packets and incentive items, 30 additional employees signed up!

Folks participated in the financial wellness activities individually then came together for the finale “Go Green” potluck. Those planning to attend were asked to bring something with “green” ingredients. Tiffany and Chris made green smoothie samples for everyone (smoothies made out of spinach, cucumbers, green grapes, etc.). 

During the pot luck, Tiffany and Chris handed out “30 Thrifty Tips for Grocery Savings” and everyone was asked to share a money-saving tip with the group. Tiffany shared her tip about how she rounds up the amount of her checks when she writes them in her checkbook ledger. That way, at the end of the year she has extra money, last year it was $500 dollars!

Going Green Smoothie
1/2 cup water
1 cup green grapes
1/2 cup pineapple chunks
1/2 medium banana, peeled
2 cups fresh spinach, washed
1/2 cup ice cubes

1. Place all ingredients into blender in the order listed and secure lid.
2. Blend until desired consistency is reached.

Go on… Snack (It’s okay!)

We’ve all heard this before: “If you’re trying to lose weight, or maintain your weight, don’t snack!” But wait, it’s also advised we should, “Eat six small meals a day.” So, which recommendation do we follow? The answer is both! As a rule, try not to snack after 8 p.m. In following this rule, you’ll cut off the cycle of late night munchies. Late snacking often involves less healthy foods and unneeded calories at a time of day when your metabolism is slowing down. As for the rest of the day, you should snack — as long as your snacks are healthy and low-calorie.

Three small snacks can keep your metabolism running smoothly. That means you won’t suffer from those sugar highs and lows that can make you feel like you’re on an energy rollercoaster. Spacing out snacks in between regular meals helps keep your blood sugar and energy at an even level and keeps hunger at bay. Letting yourself get too hungry makes it tempting to overeat or eat whatever is in front of you, even if it’s not a healthy choice. So yes — snacks are okay and they’re a great idea! Just follow these simple tips to keep them healthy:

Don’t snack after dinner. Make 8 p.m. your cutoff time. However, if you’re famished before bed — perhaps you didn’t eat enough that day. Allow for a small, light, healthy snack — six ounces of skim milk, a piece of string cheese, or a 100 calorie yogurt. Dairy products can help bring on feelings of sleepiness and cut your hunger.

Pre-bag and pre-portion your own snacks so you’ll have something handy at work or in the car. Fresh fruit, whole wheat crackers, nuts, plain popcorn, mini carrots, low-fat cubes of cheese, and whole wheat mini pretzels are great choices.

Aim for each of your three snacks to be 100 calories or less. If you eat a higher calorie meal than usual, adjust the calories in your snacks to compensate — so you might have a small piece of fruit for your snacks that day instead of low-fat cheese and whole grain crackers.

Space your meals and snacks three to four hours apart.

Don’t let yourself get too hungry. Once you feel like, “I’m starving…” you’re likely to eat too much or the wrong foods. The brain signals the body to eat high-fat, high-sugar foods when it thinks the body is “starving.”

Change your routine to break the habit of unhealthy snacking. If you tend to snack while watching TV, consider taking up a TV-friendly hobby (knitting, puzzles, scrapbooking) instead.

Recognize when you are “emotionally hungry” rather than physically hungry. Most of us snack because we’re bored, upset, or driven by some other emotion rather than actual hunger. Ask yourself, “Am I really hungry — or do I just have the ‘munchies’?”

Limit sugar and even sugar-free snacks. Although treats like sugar-free gelatin seem harmless, they still set up your taste buds to crave more and more sugar. Try eliminating as many super sweet tasting foods as possible. Fruit without added sugar is the exception — so enjoy!

Try to keep your foods “plant based.” As previously mentioned, fruit is a great snack. So are vegetables, whole grains (e.g., slice of whole wheat bread), or nuts. Beans are also a terrific snack because they are full of filling fiber and protein. As a rule, foods that are plant based and unprocessed (have no or very few additives) are the best snack choices.

Let yourself indulge…once in a while. Let’s be realistic — sometimes, we just want to indulge. If you never allow yourself a little treat, you may end up feeling deprived. Some snacks allow you to satisfy your inner cookie monster without compromising too much on good nutrition. See “Snack This, Not That” for ideas.

Keep snacks in the kitchen. Having snacks nearby can promote mindless eating. When you’re at work — keep your snacks (fruit or zipper bags of 100-calorie portions) in the break room/kitchen. Having to get up and get your snack will make you think twice about whether you really want it. The only exception to that would be to keep a small snack in your car, especially if you have a long drive to/from work. This can keep the temptation to run through a drive-thru or eat junk food on the go.

By following these simple tips, you can keep your energy up, your hunger down, and your calories right where you want them. So go ahead — snack!

Next time the urge to snack hits — try the healthy alternatives in the “snack this” column:


Snack this and not that
snack this not that
a whole grain mini bagel with 1 tbsp fat-free strawberry cream cheese (100 calories) a strawberry donut (on average, 240 calories)
4 slices deli ham with 2 teaspoons honey mustard, rolled in lettuce leaf (110 calories) ½ a sub sandwich (230+ calories depending on condiments and cheese)
½ cup low-fat cottage cheese with 5 strawberries (about 110 calories) ½ cup Ben and Jerry’s ice cream (240)
If you’re really craving ice cream, go with a light version like Dryers Slow Churned for about 120 calories/half a cup.
½ a small apple smeared with 2 tsp. of peanut butter (100 calories) peanut butter and jelly sandwich (about 350-400 calories)
½ piece of string cheese with 4 whole wheat crackers (100 calories) vending machine cheese crackers (210 calories on average)
When you crave a sweet or salty treat…
a bag of baked chips (baked Lays, 110 calories) a bag of fried chips (Sun Chips, 210 calories)
a 100-calorie pack of Oreo cookies (100 calories) a vending machine pack of Oreo cookies (240 calories)
sugar free fudge pop (35 calories) a full size ice cream sandwich (most brands average 200 calories)
If you’re really craving an ice cream sandwich, try a mini, which are usually 100 calories)
McDonald’s Grilled Chicken Snack Wrap with honey mustard, no cheese (130 calories) McDonald’s Ranch Snack Wrap (crispy, includes mayo and cheese) (340 calories)
½ medium-sized banana spread with ½ tsp of peanut butter and rolled in 1 tsp mini dark chocolate chips (120 calories)
a Snicker’s bar (250 calories)



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Local agency spotlight: Tarrant County WIC Nutritionist Serves on Fetal Infant Mortality Review Board

by Renee Mims
Contributing Editor/Designer

The focus of the Fetal Infant Mortality Review Board is to reduce infant mortality by improving the service systems and community resources that promote the well-being of women, infants, and families. Registered dietitian Michelle Cummings, Tarrant County WIC, has served on the board for almost two years, during which time she assisted with the publishing of the Fetal Infant Mortality Review, Tarrant County: Study findings and recommendations for the Tarrant County Case Review Team in December 2009.

The review, released by Tarrant County Public Health, reports that the infant mortality rate in Tarrant County has been increasing since 2000 and is currently at 7.6 deaths per 1,000 live births. This is higher than state and national rates and much higher than the national Healthy People 2010 goal of 4.5 per 1,000.

As a nutritionist, Cumming’s stint as a board member reminded her of just how critical prenatal care is to mother and child. 

“I now see the consequences of non-compliance with prenatal care and chronic disease management and the effects on birth outcome,” Cummings said. “The health history provides information that helps identify health problems, health care concerns, and social issues that our participants experience.”

Infectious diseases, specifically sexually transmitted diseases were identified as the most prevalent maternal risk factors among the reviewed cases. Also cited as risk factors were obesity, diabetes and gestational diabetes, and high blood pressure.

Cummings hopes that the findings of this study raise awareness of these maternal risk factors and encourage nutritionists to ask more detailed questions when it comes to screening a WIC mom. “Our WIC program does a fantastic job screening participants that may have potential problems,” she said. “But since serving on the review team,  I ask more detailed questions regarding maternal history, especially when we see how some health conditions can contribute to the death of an infant.”

Cummings asks moms if they’ve had any infections, and if they have completed the course of antibiotics. If there is a sign that there might be an infection, she refers the mom to her doctor, the public health department or emergency room. Cummings sees the role of the WIC clinic as an important one — helping make sure moms are healthy.

“Education plays a vital role in the health and well-being of a society,” she said. “WIC reaches so many families and has access to great educational materials. We, as WIC employees, can help improve pregnancy outcomes in the families we serve by using these materials to educate our clients on these issues.”

For the report go to www.tarrantcounty.com/content/dam/main/public-health/2009_FIMR_FINAL_Report.pdf

WCS Training Program Benefits WIC Clinics

by The University of Texas at Austin
WIC Certification Specialist
(WCS) Group

The newly developed standardized competency-based WIC Certification Specialist (WCS) Certification and Training program is having positive impacts on clinics, their participants, and clinic staff. The program was built from current local agency WCS training programs, VENA, and nationwide best practices. The standardized WCS program is intended to improve the quality and scope of WIC services, improve clinical and customer service skills and enhance WIC participants’ experiences.

“We are so excited about this program because it allows local agencies to have a high quality, competency-based WCS training program without spending the time developing their own material,” said Patti Fitch, R.D., Clinic Services Branch manager at Texas WIC state office.

The WCS Training Program consists of 12 self-paced modules in an easy-to-follow format. The modules provide candidates the opportunity to build skills in rapport building, effective communication, weighing and measuring, program delivery, ethics and professionalism. The training includes a number of helpful features and learning tools such as case studies, hands-on activities, self-checks and module reviews. These should help the candidate assess their progress throughout the training.

“I really enjoyed reading over the different case studies because they gave me a better understanding of what I was trying to learn and as a result I was able to comprehend the information thoroughly,” said Janete Olague (LA 42, Williamson County and Cities Health District), customer service representative and recent WCS trainee.

There are several benefits to standardizing the WCS program, including teaching consistent and accurate information. Irma Gutierrez, R.D., Round Rock Clinic supervisor, recognizes this benefit, stating, “Hopefully, all future WCS will receive the same information to perform their jobs.”

Other benefits of adopting and implementing the new WCS Training Program include improved clinic flow, additional professional staff, cross-trained and certified staff, more availability of registered dietitians to assist high risk participants, decreased time participants spend in clinics, lightened workload for nutritionists, job enrichment and improved staff confidence.

“Standardized training programs provide local agencies with consistent training opportunities that have been tried and tested throughout the state. This in turn leads to increased job satisfaction and retention for WIC staff. Standardized training incorporates interactive learning activities, hints, techniques, and learning strategies to enhance performance in a clinic setting. It is a perfect opportunity for blended learning,” said Nora Martinez (LA 13, Laredo Health Department), M.P.H., I.B.C.L.C., R.L.C., WIC clinic director.

Gutierrez also noted that, “This training will better aid the clinical assistants and registered dietitians with clients especially during busy clinic days.”

In addition to benefitting the clinic’s overall operational effectiveness, this training is also benefitting individual candidates and their clinic skills.

“I see a more confident and skilled staff since the training began. These employees are my future trainers. Recently, the candidates shared their experiences at a staff meeting, and they presented with so much confidence (they were glowing) that it left other employees wanting to know when they would be scheduled for this training opportunity,” said Martinez.

Gutierrez agreed, “My candidates’ confidence level has definitely increased.”

Candidates have also noted how the training has helped improve their clinic behavior and demeanor. Olague said, “I am more conscious of the quality of customer service interaction I provide, and I just love this new world I am discovering through these modules. I can’t wait to start putting to practice my new knowledge!”

To get ready for the new training program which will be available November 1, local agency directors and training preceptors need to start planning at least three months in advance. Aspects of this planning include amending clinic and candidate schedules, and designating study time and areas for candidates, as well as completing an application form and returning it to Tonia Swartz, Texas WIC clinical nutrition specialist, at tonia.swartz@dshs.state.tx.us. If you have questions concerning the WCS program, you can also contact Tonia at 1-512-341-4586.

“This training works if you have management support. This type of leadership buy-in allows your preceptor and staff the support needed to complete the program. At our agency, we allotted the first hour of the day for reading modules and completing assignments. Every Monday we held a conference call with preceptors and staff for questions and concerns,” said Martinez.

While the training requires some planning, its benefits are well worth it.

“I would advise WIC directors to take advantage of the WCS program in their agencies not only for smoother client flow, but more for the improvement of the employees’ morale and their skills,” said Gutierrez.

Olague concurred, “Once you complete your training you’re not only going to benefit yourself, but your clinic as well.”


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Newsworthy News: D is for Deficiency: New Vitamin D Recommendation

By Liz Bruns, R.D., L.D.
Nutrition Training Specialist

Recent studies show that vitamin D deficiency is on the rise in this country, not only in adults, but also in adolescents, children, and infants. More and more children are being diagnosed with rickets, which is both surprising and alarming to health-care professionals. We usually think of rickets as a condition seen in under-developed countries, not in the United States. Breastfed infants who are not supplemented with vitamin D are the most at-risk population group in this country.

AAP Recommendations

Due to these findings, the American Academy of Pediatrics (AAP) is doubling their recommendation for vitamin D intake for all infants and children. Previously, the recommendation for vitamin D was 200 IU per day starting in the first couple of months of life. Now, the AAP recommends 400 IU per day starting in the first few days of life.

Here’s a summary of the AAPs recommendations for vitamin D:

• Breastfed and partially breastfed infants should be supplemented with 400 IU a day of vitamin D beginning in the first few days of life.
• All non-breastfed infants and children, who are not consuming at least a quart a day of fortified formula or milk, should receive a vitamin D supplement of 400 IU a day. (All formulas sold in the United States and many brands of chewable vitamins for children supply the new recommended amount.)
• Adolescents who do not consume 400 IU a day through foods should receive a supplement containing that amount.
• Children with increased risk of vitamin D deficiency, such as those taking certain medications, may need higher doses of vitamin D.
• Pregnant women and lactating women should continue to take their prenatal vitamins as prescribed. It is likely that future recommendations may include additional vitamin D.

Sunshine as a Source of Vitamin D

“Isn’t vitamin D the sunshine vitamin? Can’t children get enough vitamin D from playing outside?” The answer to these questions is “It depends.” There are a number of variables, and we don’t know how much sun exposure every child needs.

It is true that skin exposed to sunlight can make active vitamin D, but other factors — including one’s geographical location, air quality and weather conditions, clothing and body coverage, use of sunscreen, and skin pigmentation — can interfere with this process. It’s best to not count on sunshine for the benefits of the sunshine vitamin, according to the Centers for Disease Control and Prevention.

Food as a Source of Vitamin D

“What about food sources of vitamin D? Can’t we just eat the recommended amount?” It’s not that easy to consume the recommended quantity of vitamin D through food every day because there are very few foods that are good sources of D.

Good food sources of vitamin D include fortified milk and soymilk, and other fortified food products (such as some cereals), eggs, fatty fish, and interestingly — mushrooms. How much of these foods could you consume each and every day? How much do you think an average child could consume every day? Probably not enough to meet the 400 IU daily recommendation. Most health care professionals agree that supplements may be the most reliable source of this vitamin.

Vitamin D for a Lifetime

If you are thinking “Rickets is for kids. Surely, I’m safe regardless of my vitamin D intake.” Don’t be so sure! The latest studies are showing that adults who are deficient in vitamin D are more at risk for developing cancer, heart disease, diabetes, a variety of autoimmune diseases, and osteomalcia, which is an adult form of rickets.

Vitamin D is not just for infants and children. It provides lifelong health benefits. So, take your vitamin D supplements every day and make sure that your children do too. Multivitamin and mineral supplements that provide enough vitamin D are acceptable.


Center for Disease Control and Prevention. “Vitamin D Supplementation”. Available at www.cdc.gov/breastfeeding/recommendations/vitamin_D.htm. Accessed May 14, 2010.
Northwestern Lake Forest Hospital. “New Vitamin D Recommendations”. Available at lfh.org/new_vitamin_d_recommendations. Accessed May 14, 2010.
Science Daily. “Millions of U.S. Children Low in Vitamin D”. Available at www.sciencedaily.com/releases/2009/08/090803083633.htm. Accessed May 14, 2010.
Accessed May 14, 2010.
Wikipedia. “Mushrooms and Vitamin D”. Available at en.wikipedia.org/wiki/Mushrooms_and_vitamin_D. Accessed May 14, 2010.

A Note on Vitamin D Supplements

There are two types of vitamin D supplement:
• ergocalciferol (D2)
• cholecalciferol (D3)

D3 supplements are produced from animal products such as animal skin, fur, and feathers; and are an inappropriate source of the vitamin for vegetarians and vegans.

Vegetarians and vegans should use the D2 form of vitamin D.


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Texas Dietetic Internship: The Road to Becoming a Registered Dietitian

by Mary Van Eck, M.S., R.D., L.D.
Texas WIC Dietetic Internship Director

The number of WIC staff interested in becoming registered dietitians is one of the major reasons why the Texas WIC Dietetic Internship (DI) was started in 2000. Today, acceptance into the Dietetic Internship Program is becoming more and more competitive. Nationally only 50 percent of students applying for Dietetic Internship Programs are accepted. This article will hopefully answer your questions and tell you everything you need to know about getting into the Texas WIC Dietetic Internship Program.

Here are the most frequently asked questions about the dietetic internship program.

Questions from those interested in WIC jobs and the WIC Dietetic Internship:

1. Do I need to be working in WIC to get into the internship?
Yes, you need to be employed by a Texas WIC local agency to be eligible to apply to the WIC DI.

2. How can I get a job with WIC?
The best way to get a job in a WIC program is to research WIC programs in your area and watch for job openings. To find WIC Programs, look in your phone book, check websites and make phone calls to health departments in your community. If you have a nutrition degree, look for “nutritionist,” and “Certifying Authority” positions.

You can also use this zip code locator txhealth.ziplocator.com to find nearby WIC clinics. Once you contact a clinic, ask for the phone number of the WIC administration office. Most agencies administer multiple clinics. WIC programs are all over Texas, covering every county. Some areas of Texas have multiple WIC programs, so be sure to check them all.

You can also look on the Texas WIC website at www.dshs.state.tx.us/wichd/joblist.shtm, where some WIC jobs are posted.

3. Will I automatically be eligible to apply for the internship program once I am employed by WIC?
That depends on your local agency. Some agencies have employment length requirements, such as one to two years employment prior to being allowed to apply to the WIC Dietetic Internship.

Questions from current WIC staff:

1. What educational back ground must I have to apply to the WIC DI?
You must have completed a bachelor’s degree and a Didactic Program in Dietetics (DPD) from an accredited program, and have a signed verification statement from that program in order to apply to the internship.

2. What is a verification statement?
A verification statement shows that you have completed all Credentialing Agency on Dietetics Education (CADE) requirements to enter a Dietetic Internship.

3. What if I completed a nutrition degree but do not have a verification statement?
You need to contact your former university or DPD program director to find out what you need to do to get a verification statement. In some cases, you may need to have your transcripts evaluated by a university and may even be required to take additional coursework before being eligible to receive a verification statement.

For more information about verification statements, go to http://www.eatright.org/CADE/content.aspx?id=66.

If you have other questions about dietetic credentialing, contact CADE at http://www.eatright.org/CADE/default.aspx or 1-800-877-1600, ext. 5400.

4. What if I have a nutrition degree from another country?
This fact sheet from ADA/CADE explains what you must do to receive a verification statement and be eligible for dietetic internship in the United States- http://www.eatright.org/CADE/content.aspx?id=7979.

5. How long must I work for WIC before I can apply to the internship?
That is up to your local agency. Check with your WIC director about what the LA policy is regarding length of time.

However, following the internship, you are required to work at your local agency for two years after passing your registered dietitian exam.

6. I got my nutrition degree a number of years ago. Can I still apply to the internship?
Yes, you can, as long as you have a verification statement from a DPD program. If you do not remember getting a verification statement, check with the DPD program that you graduated from. They should be able to help you get a verification statement if you are eligible for one.

7. How are applicants chosen for the internship?
Many factors are considered:
• Grade point average – It is critical that interns demonstrate academic abilities. Following completion of the internship, the intern must pass the registration exam in order to become a registered dietitian. Dietetic internship programs are evaluated by the American Dietetic Association’s credentialing agency CADE based on the percentage of interns who pass this exam on the first try. Dietetic internship programs can be put on probation or even discontinued if this pass rate is not acceptable. College GPA is the best indicator of the intern’s ability to pass the registration exam. Although there are exceptions, applicants with GPA below 2.7 are seldom selected.
• Recommendation letters – The letters that co-workers, supervisor and professors write are extremely important in the application process. We require a recommendation letter from the applicant’s supervisor and highly recommend one from a college instructor. Three recommendation letters are required for each applicant.
• Need of the community – Underserved areas of the state are given a high priority during the selection process. Local agencies that have difficulty finding registered dietitians are also given priority. Being bilingual is also seen as an asset during the selection process.
• Local agency and geographic diversity within the class – An attempt is made to select interns for each class from diverse areas of the state.
• Facility availability – Ability finding facilities and preceptors factor into the selection process.
• Application completeness – It is important that you follow the application instructions closely, using the application checklist as a guide. Do not put your application in special binders or folders and make sure everything is included in your packet. Applications will not be accepted after the annual deadline.
• Other considerations – Writing ability, maturity, motivation, career goals and other qualities all are important considerations in the application process.

8. What if I applied before and did not get in? Shall I reapply? What can I do to improve my chances of getting in the DI?
Each year, the applicant pool is different, from different areas of the state and with different qualifications. So yes, you should reapply if you are still committed to becoming a registered dietitian.

The best thing you can do to help your chances of getting in the WIC DI if you were not accepted, is to take and do well in graduate level dietetics, nutrition, and public health coursework. This is definitely a positive indicator that you can successfully complete the DI and pass the registered dietitian exam.

9. What if I have other questions about the Texas WIC Dietetic Internship?
Contact Mary Van Eck at mary.vaneck@dshs.state.tx.us or 1-512-341-4510. Also look at the Texas WIC DI webpage at www.dshs.state.tx.us/wichd/interns/intern-brochure.shtm.


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Home Safety Quiz

by Eaton Wright, BS, NUT
Nutrition Expert

Hello everybody! This month’s quiz is all about home safety. This topic has been on my mind lately since my wife, Ms. Always B. Wright, and I welcomed our first child in late 2009. A serious topic deserves a serious quiz, so don’t expect any yuckity-yucks this time around.


1. True or False. When traveling in a motor vehicle, an infant should be placed in the front seat, facing forward.

2. Most of us now know that an infant should be put to bed lying on his back — remember: Back to Sleep. But when it comes to cribs and bedding which is the correct answer:
a. Teddy bear
b. Water bed
c. 2⅜ inches
d. Grandma’s “knitted-by-hand with lotsa love” blanket

3. Infants love to scoot about as soon as they are able. This can only spell trouble if a home is cluttered with furniture, a pack of dogs, or strewn with dangly things. To create a safer home, do which of the following:
a. Place covers on electrical outlets and latches on cabinets.
b. Install smoke and carbon monoxide detectors and fire extinguishers in the home.
c. Tie cords of blinds, curtains and appliances up out of reach.
d. Empty all water from bathtubs and pails, keep the door to the bathroom closed and never leave your child alone near any container of water.
e. Place a secure gate on both ends of a staircase.
f. All of the above

4. True or False. Infants love to put pretty much anything in their mouths.



1. The answer is FALSE! The American Academy of Pediatrics recommends that all infants ride rear-facing starting with their first ride home from the hospital and should remain rear-facing until they reach the highest weight or height allowed by their car safety seat’s manufacturer. At a minimum, infants should ride rear-facing until they have reached at least 1 year of age and weigh at least 20 pounds. And remember, children 12 and under are safest when properly restrained in the rear seat. Always refer to the child safety seat instructions and vehicle manufacturer’s instructions for weight and height limits, proper use and installation.

2. The correct answer is C. Make sure the crib is safe: have no more than 2⅜ inches (about the diameter of 12 ounce can of soda) between the bars; the mattress should be firm and fit snugly within the crib; place it away from windows and drafts; and do not place fluffy blankets, stuffed animals, or pillows in the crib as they can cause smothering.

3. The correct answer is F. While no home can be made completely baby-proof, it can be made safer by covering outlets; binding electrical and curtain cords; supervising around water; and securing staircases.

4. The answer is True. Since the possibilities of items that could go into the infant’s mouth are endless and range from dad’s favorite remote control to big sister’s doll’s shoe, it is important make sure that all potential choke hazards be kept out of reach of the infant. A good rule of thumb for infant toys is if the toy can fit through an empty roll of toilet paper, then it’s too small for an infant to play with. Caution also needs to be exercised to avoid foods and situations that may cause choking. It’s a good idea to cut food into small, bite-sized pieces. Foods such as grapes, hotdogs, raw carrots, hard candy, and popcorn present special choking hazards. Finally, do not let your child eat while riding in a car seat.

About the author: Eaton Wright is a certified NUT based in Austin, Texas. He recommends that everyone who cares for an infant or small child take a course in infant CPR and first aid.


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Last updated May 26, 2017