Revised December 2025

Local agencies (LA) are responsible for the purchase, maintenance, repair costs and replacement of anthropometric equipment as allowed by their contract. LAs may contact their district's technical assistance (TA) nutritionist or other agencies for recommendations on equipment. Before buying any equipment, determine if companies in the area provide service or repairs, if needed. LAs are required to have anthropometric equipment purchases approved by their district nutrition TA. Refer to the WIC Operations Manual (WOM) policy 5.1.070 Line Item: Equipment Purchases.

When contacting a company to place an order, confirm the company’s return policy and whether the company guarantees the equipment against defects for at least one year. Determine who should be contacted regarding returns or repairs, if applicable. Inquire about price, volume discounts and the cost of replacement parts. Pediatric examination tables are allowable when the minimum criteria for weight and length equipment are met.

LAs must keep the equipment manuals on file after purchase. These manuals serve as a valuable resource for understanding the equipment's specifications, operating procedures and maintenance requirements, thereby promoting efficient equipment management.

Minimum criteria for measuring equipment

Minimum criteria for a recumbent length board (mechanical and digital)

• Must be constructed of durable (non-flexible), easy-to-clean materials with no sharp edges or unfinished parts.
• Must be a firm, inflexible, flat, horizontal surface. Cushioning is acceptable if it is part of the manufacturer's device.
• A measuring tape must be made of a non-stretchable material (embedded if possible) and clearly marked to one-eighth inch or one mm or less.
• Digital infantometers must have gradations to one-eighth inch.
• A fixed head piece must extend above the measurement surface, at a right angle (90 degrees). The zero-inch mark must be exactly at the base of the headboard.
• Must have a smooth, movable, mounted footboard perpendicular to the tape.
• A pediatric examination table foot piece must be stable and locked when perpendicular.

Minimum criteria for a stadiometer (mechanical and digital)

• Must have a vertical ruler clearly marked in increments of one-eighth inch or one mm or less. The entire ruler must be securely attached to a solid surface, mounted on a board or attached to a flush wall without floor molding.
• Should allow, at a minimum, the heels, buttocks, shoulder blades and the back of the head to be in contact with the vertical surface of the equipment when measuring.
• If the equipment does not extend to the floor, an extension must be attached to complete the vertical surface.
• If mounted, the equipment should have a removable or attached headboard at a right angle (90 degrees) to the measurement surface.
• A digital stadiometer must have a hold function.
• The measuring arm on the platform scale is not an approved device for measuring the height of children or adults.

Minimum criteria for weighing equipment

Minimum criteria for scales (mechanical and digital)

• Must be constructed of durable, easy-to-clean materials with no sharp edges.
• Must be placed on a hard floor or a hard surface if the floor is carpeted.
• Spring-type bathroom scales are not acceptable.

Mechanical scale guidelines

• Must have a mechanism to allow a zero balance. An adjustable screw type is preferred.
• Must have a mechanism to allow calibration.

Infant scales

• Must be marked in increments of one ounce or less and accurate to that degree.
• Must have a capacity of at least 40 pounds.
• Must have a sturdy infant cradle.

Adult/child scale

• Must have a platform.
• Must be marked in increments of four ounces or less and accurate to that degree.
• Must have a capacity of at least 500 pounds.
  • Prior to federal fiscal year (FFY) 2026, the capacity requirement was 300 pounds. Scales purchased prior to FFY 26 that meet the previous capacity are grandfathered in and do not need to be replaced if still in working condition.

Digital scale guidelines

• Must have an automatic zero.
• Must have an automatic tare to zero.
  • Some digital scales come with a tare feature that allows the scale to be reset to zero while the caregiver is standing on it, before handing the infant to them. Once you have tared the scale to account for the caregiver’s weight, only the weight of the infant will be displayed.
• Should have a feature where the weight can be locked in.
• Must provide measurement reproducibility (i.e., consistent readings).
• Choose a scale based on its intended location, such as satellite clinics or LA, and consider whether the power source will be electrical, battery or both.
• Must provide accurate measurements, with minimum error at both low and high ends of the scale range.

Infant digital scale

• Must have a sturdy cradle to support the infant.
• Must have a minimum weighing capacity of 40 pounds.
• Must have a large enough cradle to ensure the infant’s safety.
• Must have accuracy within one ounce.

Adult and child digital scale

• Must have an accuracy within one-quarter pound or 100 grams.
• Must have a capacity of at least 500 pounds.
  • Prior to federal fiscal year (FFY) 2026, the capacity requirement was 300 pounds. Scales purchased prior to FFY 26 that meet the previous capacity are grandfathered in and do not need to be replaced if still in working condition.

Equipment inspections

Scales must be inspected for accuracy before using new equipment, whenever equipment is moved and annually. If calibration is required, refer to the equipment manual for instructions.

Stadiometers and recumbent length boards must be inspected to ensure accuracy before use for new equipment, when equipment is moved and annually. If the stadiometer or recumbent length board requires calibration, refer to the equipment manual for calibration instructions.

Training

Qualified LA staff must complete anthropometric training before performing measurements in the clinic. They will finish the Anthropometric Assessment training and the Anthropometric Comprehension quiz, which are available on the eLearning page of the LA Portal.

Document all training on the WIC Staff Training Record and keep certificates of completion.

Procedures for weighing

All participants should be weighed at every certification and mid-certification, unless appropriate referral data was provided before the appointment, and the data collected is recorded in the Management Information System (MIS). They may be weighed more frequently as determined by WIC Professional staff.

Infants and children 12-23 months must be weighed on an infant scale.

Children 24-59 months and women are weighed on an adult and child scale while standing upright.

All scales should be cleaned daily and as needed. If no scale paper is used, clean after each participant.

Refer to the manufacturer’s equipment specifications for additional operating instructions.

Measuring weight for an infant or child under 2 years of age

1. Instruct the parent or guardian to undress the infant down to a dry diaper. Children must remove their shoes and any heavy outer clothing. They must have a dry diaper or pull-up.
2. Check scales for zero balance.
   1. For mechanical scales, first balance the scale. The scale is balanced when the marker indicates zero with the weights in the zero position, or when the marker is positioned in the middle of the cut-out area on the balance beam. When necessary, move the weights to zero and turn the adjustment screw until the scale is balanced.
   2. For digital scales, turn the scale on and ensure it is zeroed before weighing the participant.
3. Measure weight based on the type of scale.
   1. For mechanical scales:
      1. Place the infant or child in the center of the scale, either lying down or sitting up. The infant or child cannot be holding on to the scale or have anything in their hands.
      2. Move the beam’s lower weight away from zero until the marker drops below the center point. Then slide the lower weight back one notch toward zero until the marker is above the center point.
      3. Slide the beam’s upper weight away from zero until the marker is centered. Moving the upper weight back and forth a few times until the scale is balanced may be necessary.
      4. The participant’s weight is displayed when the marker is balanced in the center of the cut-out portion, not touching the top or bottom.
   2. For digital scales:
      1. Place the infant or child in the center of the scale, either lying down or sitting up. The infant or child cannot be holding on to the scale or have anything in their hands.
      2. Ensure the participant remains on the scale until the reading is stable, the machine beeps or the display indicates the weight is locked in.
4. Read the weight to the nearest ounce and record the information in the MIS.
5. If the scale displays as a decimal weight instead of ounces, use the chart below to convert the decimal weight to ounces.

Infant test weighing

Test weighing is a method where an infant is weighed before and after breastfeeding to determine the amount of milk intake during that feeding.

An international board certified lactation consultant (IBCLC) must conduct or supervise test weighing in the LA.

The purpose of the test weight is to determine how effectively milk is transferred during feeding and to provide reassurance to mothers that their infant is transferring milk.

Breastfeeding infants ingest different amounts of milk at each feeding, so test weighing during one feeding does not offer a valid representation of an average feeding or allow calculation of overall intake. Studies have shown that infants must be weighed before and after every feeding for three days to establish an average feeding amount. Test weighing may be used in complicated clinical situations to monitor intake and adjust the volume of supplementation, such as in the neonatal intensive care unit (NICU).

Test weighing may be used in the LA as one measure of intake, in addition to other measures such as diaper output, weight gain or loss and mother’s report of feeding frequency and efficacy.

Principles to consider:

• A digital scale must be accurate to two grams or less and have an integration function allowing the infant’s movement.
• Infants are weighed before and after feeding, either without clothes or with the exact same clothing. The diaper should not be changed between the first weight and the second weight.
• The difference in grams between the first and second weights is considered the intake in milliliters. Some scales automatically store weights and compute the difference in milliliters; check the manufacturer’s instructions.

Measuring weight for a woman or child 2-5 years of age

1. Instruct the parent, guardian or participant to remove any extra clothing, such as a jacket, sweater or sweatshirt, empty their pockets of heavy items, and remove their shoes. Ask the parent or guardian to ensure the child has a clean, dry diaper or pull-up.
2. Check scales for zero balance.
   1. For mechanical scales, first balance the scale. The scale is balanced when the marker indicates zero with the weights in the zero position, or when the marker is in the middle of the cut-out area on the balance beam scale. When necessary, move the weights to zero and turn the adjustment screw until the scale is balanced.
   2. For digital scales, turn the scale on and ensure it is zeroed before weighing the participant.
3. Instruct the participant to stand in the center of the scale’s platform, look straight forward, feet slightly apart and with arms hanging naturally at their side.
4. Obtain measurement.
   1. For mechanical scales:
      1. Move the beam’s lower weight away from zero until the marker drops below the center point, then slide the lower weight back one notch toward zero until the marker is above the center point.
      2. Slide the beam’s upper weight away from zero until the marker is centered. The upper weight may need to be moved back and forth a few times until the scale is balanced.
      3. The participant’s weight is displayed when the marker is balanced in the center of the cut-out portion, not touching the top or bottom.
   2. For digital scales:
      1. Ensure the participant remains on the scale until the reading is stable, the machine beeps or the display indicates the weight is locked in.
5. Read the weight measurement in pounds and ounces, and record the information in the MIS.
6. If the scale displays as a decimal weight instead of ounces, use the decimal-to-ounces conversion chart above to convert the decimal weight to ounces.

If the participant’s weight exceeds the LA’s scale's measurement capacity, the LA will record the maximum value the scale can measure in the Weight field within the Length/Height/Weight tab of the MIS. The LA will select “Greater than (>) Scale Max” as the Incorrect Measurement Reason.

Procedures for height or length measurements

All participants should have a height or length measurement at every certification and mid-certification, unless appropriate referral data was provided prior to the appointment, and the data collected is recorded in the MIS.

All infants and children under 24 months should be measured while lying on a recumbent length board. Accurate measurement for children under 24 months requires the assistance of two people.

Height (stature) is the measurement of the distance from the top of the head to the bottom of the feet, which is performed standing upright.

Length (recumbent) is the measurement of the distance from the top of the head to the bottom of the feet that is performed lying down.

Height and length are not the same and cannot be used interchangeably.

Measuring length for an infant or child under 2 years of age

1. Place scale paper on the measuring board, if applicable.
2. Lay the infant or child face up on the length board. The body must be straight and lined up with the board.
3. Have the parent or guardian hold the infant or child’s head firmly against the non-moveable headboard until the measuring is completed.
4. Using one hand, hold the infant or child’s legs together just above the knees and gently push both legs down to fully extend their legs. Avoid using just one leg to measure, as this technique can displace the hip and make the infant or child appear longer than their actual length.
5. With the other hand, move the footboard until it rests firmly against the infant or child’s heels. The toes must be pointed directly up.
6. Read the measurement to the nearest eighth inch and record the information in the MIS.
   1. For digital infantometers that measure to the nearest hundredth, use the hundredths conversion table below to convert the decimal reading to the nearest eighth inch.
   2. For digital infantometers that measure to the nearest tenth, use the tenths conversion table below to convert the decimal reading to the nearest eighth inch.
7. The measuring board must be cleaned daily and as needed. If no scale paper is used, it should be cleaned after each participant.

Conversion tables for step 6:

Measuring height for a woman or child over 2 years of age

1. Have the participant remove their shoes and hat. Move any hairstyle or hair accessory out of the way that would obstruct or affect the accuracy of the measurement.
2. Have the participant stand on the bare flat surface, with heels slightly apart and feet flat on the floor.
3. Have the participant stand with their back as straight as possible and no bend in the knees. Heels, buttocks, shoulder blades and the back of the head should touch the wall or measuring surface.
   1. Depending on a person's overall body shape, not all four contact points may touch the measuring surface.
   2. Some narrow stadiometers may not allow contact with all points. In such cases, have as many contact points as possible.
4. Have their arms hanging naturally to the side, shoulders relaxed.
5. Ensure they are looking forward, with eyes straight ahead.
6. Slowly lower the movable headboard until it touches the crown of the head firmly.
7. Read the measurement to the nearest eighth inch and record information in the MIS. The measurer’s eyes should be parallel with the headpiece to ensure an accurate reading.
8. For digital stadiometers that measure to the nearest tenth or hundredth, use the conversion tables above to convert the decimal reading to the nearest eighth inch.

Nonstandard procedures

Contractures at the hips, knees and ankles can interfere with the accuracy of anthropometric measurements. Several measures are useful alternatives to length or height.

If a participant has a physical disability that prevents them from being measured using standard procedures, document it in the MIS by selecting “Participant Disability” in the Length/Height/Weight tab. Document further information in the SOAP note and by assigning any appropriate risk factor(s). Nonstandard procedures may be used, or referral data may be obtained from the health care provider.

Nonstandard procedures will not correlate directly with height or length, but can indicate a child’s rate of growth as plotted on the growth grids. Although the measurements may be in a low percentile for age, they will show whether the child is following a consistent growth curve.

Participant unable to stand or an uncooperative child

Crown-rump length

Children who are unable to stand without support should be measured by crown-rump length measurement. To take crown-rump length measurements, use the same technique as measuring length, except bend the child’s legs at a 90-degree angle and bring the footboard against the buttocks. Document in a general or SOAP note in the MIS that a crown-rump length measurement was taken. 

Weight

Children unable to stand on the scale may be weighed using an alternative method. Have the caregiver stand on the scale, tare the scale to zero, then have the caregiver hold the child. The child's weight will be displayed on the scale.

This procedure may be used for uncooperative children who refuse to be weighed using standard procedures. Ask the parent or caretaker to take the child out of the room and try to calm the child, then attempt to weigh the child again. Document the weight in the MIS, select “Uncooperative Client” in the Length/Height/Weight tab and provide further explanation in the general or SOAP note.

Referral data from the health care provider within the last 60 days can be used for an uncooperative child.

Participants wearing a cast

An individual wearing a cast can usually be weighed using standard procedures. The presence of a cast should be documented in the general or SOAP note. In this situation, overweight risk factors may not be used for WIC certification and plotting on the growth charts will be affected.

If the participant is wearing a cast that prevents the standing height measurement from being obtained, include documentation in the general or SOAP note. Omit the height measurement until the cast is removed and the height can be measured accurately. If an individual is wearing a cast that does not prevent their height from being obtained, complete the measurement using standard procedures and document that a cast was worn in the note.

One leg is shorter than the other

If a child is less than 3 years of age and one leg is shorter than the other, the child should be measured lying down. Both legs should be fully extended. A child over 3 years of age or a woman can be measured in a standing position by having them stand on their longest leg. Document how the measurement was obtained in the MIS.

Amputee and missing limbs

Infants or children missing arms or legs may be weighed using the standard procedure on the mechanical or digital scale. Document the weight and the physical condition in the MIS. Risk factors for being underweight cannot be used for WIC certification in this situation.

For older children or adults who cannot stand to be weighed and cannot be weighed by a parent or caretaker, document the weight as “Unknown” and select “Participant Disability” in Incorrect Measurement Reason in the MIS. If the participant grants permission, the LA may contact the participant’s health care provider to obtain referral data.

Participants with missing limbs that do not prevent the measurement of recumbent length or height should have the measurement taken using the standard procedure.

If the participant is missing limbs that prevent the measurement of recumbent length or height, the LA staff should document this as “Unknown” and select “Participant Disability” under the Incorrect Measurement Reason in the MIS. If the participant grants permission, the LA may contact the participant’s health care provider to obtain referral data.

It is important to note that the growth percentile for weight for height or length will not be accurate because of missing limbs. However, plotting the participant’s weight gain over time will still help assess growth.

Above or below MIS limits

If a participant’s length, height or weight is above or below the minimum or maximum allowed for their category in the Length/Height/Weight tab of the MIS, LA staff will be unable to enter the value.

If the participant is below the minimum, enter the minimum for their category, select “Participant Disability” from the Incorrect Measurement Reason and document the correct value in the note.

If the participant is above the maximum, enter the maximum for their category, select “Participant Disability” from the Incorrect Measurement Reason and document the correct value in the note.

It is important to note that if the minimum or maximum from the system is entered, it will not be an indicator of overall growth.

Body mass index (BMI)

Body mass index (BMI) is an anthropometric index of weight and height. It is the commonly accepted index for classifying adiposity in adults and has become the recommended index for children and adolescents.

In adults, BMI is expressed as a specific value calculated from weight and height.

In children and adolescents, BMI is age and gender specific and is identified by percentiles on the growth chart after incorporating the person’s age as a factor.

BMI is a screening tool used to identify individuals who are underweight, overweight and normal weight. BMI is not a diagnostic tool.

BMI will be automatically calculated in the MIS.

Standards for children

BMI is calculated for children 2 years of age and older after their height and weight are measured. It is plotted on the BMI growth grid.

It is recommended that terms such as “overweight” and “obese” be used only for risk assessment, while more neutral terms, such as “excess weight relative to height,” “excess weight,” or “excess BMI,” should be used when discussing a child’s weight with a parent or caregiver.

Standards for prenatal weight

Pre-pregnancy BMI is used to determine recommended pregnancy weight gain. LA staff should obtain her current height. If the pre-pregnancy weight is not known, use the woman's self-reported pre-pregnancy weight or her first-trimester weight, as per CDC guidelines. The pre-pregnancy BMI will appear in the Health Information tab of the MIS.

For digital scales that display weight in decimal form, convert to ounces using the chart below.

For stadiometers that measure to the nearest hundredth, use the conversion table below to convert the decimal reading to the nearest eighth inch.

For stadiometers that measure to the nearest tenth, use the conversion table below to convert the decimal reading to the nearest eighth inch.

July 2026

Hemoglobin (Hgb) testing is commonly used to screen for iron-deficiency anemia. Measurements of Hgb reflect the amount of functional iron in the body. Changes in Hgb concentration occur at the late stages of iron deficiency. While Hgb is not a direct measure of iron status and does not distinguish among different types of anemia, it is a useful indicator of iron-deficiency anemia.

Equipment and materials for testing

Analyzers

Analyzers are purchased by the state agency (SA).

Analyzers are Clinical Laboratory Improvement Amendment (CLIA) waived. A current copy of the certificate of waiver for the analyzers is available on the LA Portal. The certificate should be displayed where the testing is conducted.

Microcuvettes

Microcuvettes are purchased by LAs.

Store microcuvettes at room temperature, away from any direct heat source.

Microcuvette vials must be kept tightly capped. Unopened microcuvettes are good until the expiration date printed on each vial. Do not use an expired microcuvette.

Microcuvettes should be removed from the vial with gloved hands as needed before testing.

Microcuvettes must be disposed of once expired in a biohazard sharps container.

Capillary blood sampling lancets

Lancets are purchased by LAs.

Lancets must be sterile, single-use, retractable and disposable.

According to the World Health Organization (WHO) blood draw guidelines from 2010, the recommended lancet depth is 2.0-2.2 mm for adults and 1.5 mm for children and infants.

Equipment order

LAs will order microcuvettes through McKesson.

Analyzers will be ordered through the SA. Upon receipt, send an email to WICOperations@health.mo.gov with the LA’s name and the number of analyzers received within one week of receiving the shipment.

Email the SA at WICOperations@health.mo.gov or call 1-800-392-8209 regarding broken or replacement analyzers.

Safety

Since blood is the primary carrier of the hepatitis C virus (HCV), hepatitis B virus (HBV) and human immunodeficiency virus (HIV), standard (universal) precautions are required.

• Wear protective gloves.
• Dispose of lancets and microcuvettes in a puncture-proof biohazard sharps container.
• Dispose of all blood-soaked items in biohazard-marked bags.
• Open an individually wrapped adhesive bandage (i.e., Band-Aid) at the time of the procedure to cover the puncture site. Do not stick bandages to another surface (e.g., clothing, wall, tabletop) before use.

Hematological testing training

Qualified LA staff must complete HemoCue training and have their skills validated before performing Hgb blood testing with participants.

HemoCue training can be completed by watching the recorded HemoCue Hb 301 System training and taking the HemoCue and Biochemical Assessment Quiz on the Training page in the LA Portal. Live training sessions from HemoCue can replace recorded training when available. The recorded training can be viewed as a refresher, a corrective action plan (CAP) or on an as-needed basis.

Skills validation must be completed prior to performing Hgb screenings. This skills validation can be provided by a state nutritionist, the nutrition coordinator or a manufacturer-provided trainer. The validator must complete the Capillary Sampling Skills Checklist.

• Nutrition coordinators will have their skills validated by a state nutritionist or the manufacturer before they can validate LA staff skills.

Document all training in the WIC Staff Training Record and retain certificates of completion.

Anemia screening guidelines

Only a physician or health care provider can diagnose anemia. The anemia screening conducted at a WIC clinic provides information about the participant’s hemoglobin (Hgb) status, enabling staff to identify relevant nutrition risks, guide nutrition education and make appropriate referrals.

Data must be collected within the same WIC program category as determined at certification or mid-certification (MCA), as explained below.

If an applicant, participant or their parent or guardian refuses blood work, the participant must be placed on a monthly cycle until the data is collected. Select the Delayed Bloodwork toggle in the Bloodwork tab and document the reason or the refusal in the Management Information System (MIS).

Procedure for capillary testing

All women, infants and children must have a finger stick.

Toe and heel sticks are not allowed for infants.

1. Wash your hands and wear gloves.
2. Prepare the HemoCue Hb 301 system by placing the cuvette holder in the loading position. The display will show three flashing dashes and the HemoCue symbol.
3. Remove a microcuvette from the vial and recap the vial immediately.
4. Make sure the hand is warm and relaxed. For best results, use the middle or ring finger for sampling. Avoid using fingers with rings.
5. Clean the puncture site with alcohol. Wipe off the alcohol with a clean, dry, lint-free wipe, or let it air-dry completely.
6. Use a rolling motion with the thumb to lightly press the finger from the top of the upper joint to the tip. This stimulates the blood flow toward the sampling point.
7. While maintaining gentle pressure on the fingertip, seat the lancet firmly against the finger and puncture the finger. For the best blood flow and the least pain, take the sample on the side of the finger at the 11 o’clock or one o’clock position, not the center. Discard the lancet in an approved container.
8. Use dry gauze or other lint-free wipes to wipe away the first two or three large drops of blood. Apply gentle pressure with a rolling motion, if necessary, until another drop of blood appears. This encourages blood flow and reduces the chance of dilution from interstitial fluid. Avoid “milking the finger.”
   1. Ensure that the blood drop is sufficiently large, approximately the size of a split pea, before filling the microcuvette.
9. Hold the microcuvette by the “wing” end and position the tip point down into the center of the blood drop. Fill the microcuvette completely in one continuous motion. Do not refill a partially filled microcuvette.
10. Wipe off any excess blood from the outside of the microcuvette using a clean, lint-free wipe, taking care not to touch the open end (rounded side and tip).
11. Visually inspect the microcuvette for air bubbles. If bubbles are present, discard the microcuvette.
12. The filled microcuvette must be analyzed as soon as possible, within 40 seconds after it has been filled. It must be kept in a horizontal position. Place the filled microcuvette into the cuvette holder and gently nudge the flap to move the holder into the measuring position. Depending on the analyzer, the result will be displayed within three to 10 seconds. Document the result before pulling the cuvette holder out to the loading position. Remove the microcuvette and discard it in an appropriate biohazard container.
13. Turn the power switch to “off” after all testing for the day.

Clean blood spills on the counter or work surface with a 10 percent bleach solution or an approved disinfectant.

Change gloves between all participants, including family members.

When lead and Hgb samples are taken from the same finger stick, see the Procedure for lead and Hgb testing using the same finger stick section below.

Low Hgb value result

A participant with low Hgb should be referred to their health care provider. Blood work must be repeated six months later if risk factor 201 is assigned.

Analyzer maintenance and repair

Maintenance

All equipment that comes into contact with blood must be handled as potentially infectious, in accordance with universal precautions and good laboratory practices. Wear gloves when cleaning the optical parts of the analyzers.

The analyzer has an internal quality control, the “self-test.” Every time the analyzer is turned on, it automatically verifies the performance of the optronic unit. If the analyzer remains switched on, this test is performed every second hour. Upon passing the “self-test,” the display will show three flashing dashes, indicating that the analyzer is ready to perform a measurement. An error code will be displayed if the “self-test” fails.

The cuvette holder and the exterior of the analyzer should be cleaned at the end of each day.

1. Check that the analyzer is turned off. The display should be blank.
2. Pull the cuvette holder out to its loading position. Press the small catch in the upper-right corner of the cuvette holder. While pressing the catch or small silver button with the tip of a pen or pencil, carefully rotate the cuvette holder towards the left as far as possible. Remove the holder from the analyzer. It will come off the stainless-steel pin it rotates on.
3. Clean the cuvette holder and exterior with 20-70 percent alcohol or alcohol prep pads.
4. Wait 15 minutes before replacing the cuvette holder and using the analyzer. Make sure the cuvette holder is dry before using.

When an error message appears on the display screen, clean the analyzer's optical part with 20-70 percent alcohol or the manufacturer's cleaner. A dirty optronic unit may cause the analyzer to display an error code.

• It is not recommended to use alcohol prep pads to clean the optics because the prep pad contains additional agents that will leave a residue on the optics.
• To clean the optronic unit, use two cotton-tipped swabs moistened with 20-70 percent alcohol or manufacturer cleaner. Insert the swabs into the opening of the cuvette holder and move them from side to side 5-10 times. If the swabs are stained, repeat the process. If the swabs remain clean, no further cleaning is required.
• Let the optronic unit dry for 15 minutes before replacing the cuvette holder.

Repair

If your agency has any questions regarding hematological testing equipment, please contact your district nutritionist and not the manufacturer.

WIC requirement for lead assessment

For children ages 1-5, ask whether a lead screening or test was conducted within the last year. Lead screening involves asking whether the child has had a blood lead test or whether screening was conducted using the Missouri Healthy Children and Youth (HCY) Lead Risk Assessment Guide to determine whether a blood lead test is needed.

A lead test, also known as a blood lead test, measures the amount of lead in a person’s blood. There are two types of lead tests:

1. Capillary blood test: This screening test is often the first step and can provide fast results. This test is completed by pricking the finger to collect blood.
2. Venous blood test: This test is more accurate, as it involves drawing blood from a vein in the arm. Results may take a few days to be available.

Based on recommendations issued by the Missouri Department of Health and Senior Services, provide a referral to children who have not had a lead screening or test to a testing program. Document lead referrals in the MIS as Lead Screening and Local Health Department or Medical and Dental Health Services.

Document known lead values in the Bloodwork page of the MIS. If a participant has been assigned risk factor 211, refer them to their health care provider.

LAs may ask a pregnant woman if she has had a lead screening or test.

Procedure for lead and Hgb testing using the same finger stick

When a non-WIC entity, i.e., a health department or center, fulfills its requirement for a blood test at the same time (using the same finger) as Hgb testing at the WIC appointment:

1. Take Hgb first, unless otherwise instructed by the product used to collect the lead sample. If the lead sample is collected first, the integrity of the Hgb sample must be preserved by:
   1. Maintaining gentle pressure on the tip of the finger without “milking the finger.”
   2. Filling the microcuvette with the third or fourth large drop of blood.
   3. Filling the microcuvette properly with the point down.
   4. Filling the microcuvette completely. Do not refill a partially filled microcuvette.
2. Participants must be advised that lead testing is not required to receive WIC benefits.

Blood lead testing is not an allowable WIC cost. WIC program funds cannot be used to provide blood lead testing or to purchase lead testing equipment. When WIC staff perform blood lead testing, the time spent conducting the test must be billed to another funding source.

Capillary Sampling Skills Checklist

A state agency nutritionist, the nutrition coordinator or a manufacturer-provided trainer must validate each employee's Hemoglobin screening skills before they perform the screening.

The Capillary Sampling Skills Checklist must be used and successfully completed with a score of 75 percent or greater.

If skills validation is completed by HemoCue, it is acceptable to use HemoCue’s Capillary Sampling Skills Checklist as proof of completion.

There are two skill sections to assess: preparation and screening.

Preparation

Screening

Overview

To maximize the effectiveness of the WIC Program, the nutrition services provided must reflect current scientific knowledge and contemporary public health issues. Recognizing this need, the Food and Nutrition Services (FNS) developed the process of Revitalizing Quality Nutrition Services (RQNS), with the goal of continually improving program services. RQNS initiatives include:

• The WIC nutrition risk criteria policy ensures that all criteria are science-based; and
• The WIC Nutrition Services Standards (NSS) which are designed to improve the quality and delivery of WIC services.

Value Enhanced Nutrition Assessment (VENA) is the latest initiative under the umbrella of RQNS. VENA builds on the information provided in the WIC nutrition risk policy and the NSS.

VENA Guidance Document

VENA Guidance Document – Complete Document (PDF, 88 pages)

Nutrition Assessment Questions

The Missouri WIC Nutrition Program uses standardized questions when program eligibility is determined at certifications and as part of the mid-certification health assessment. The questions are specific to client category, age, and feeding status. These questions support WIC staff in conducting a complete nutrition assessment, determine WIC risk eligibility and start a dialogue with the client about what she or he wants and needs related to nutrition and health.

VENA Skills Checklist for Effective Counseling

The following skills checklist can be used by the CPA/nutritionist to rate themselves on a scale of 1 to 5 on how well each skill was performed.

A printable version of the checklist with rating and comment columns is available: Skills Checklist for Effective Counseling (PDF).

Establishing rapport

• Introduced self to client
• Displayed understanding for other culture
• Ensured privacy (kept voice low, closed door, moved to private location)
• Offered help when needed (“here are some books,” “feed baby here”)
• Used appropriate non-verbal communication (nodding head, eye contact, avoiding crossed arms, etc.)
• Used respectful language
• Focused on client when translator is used

Completing assessment forms

• Reviewed client’s past history
• Collected missing information on WIC forms without interrupting client
• Asked probing questions to clarify responses
• Avoided spending extensive time on irrelevant information
• Shared findings (Ht/Wt/Iron) in a non-judgmental manner

Identifying and exploring concerns

• Asked open-ended questions to explore client’s concerns
• Listened actively and allowed for silence
• Validated client’s concerns
• Referred client to outside sources when needed (social work, food bank…)
• Used counseling tools to start and guide conversation
• Identified and acknowledged client’s strengths (positive behaviors)
• Maintained focus on desired health outcome (healthy pregnancy, active family)
• Helped client explore feelings and attitudes about health concern
• Tried to lead discussion based on nutrition assessment data if nothing was offered by client
• Assessed the client’s readiness to change
• Worked with client to identify problem behaviors and ideas for change
• Provided simple, accurate nutrition messages if client was receptive
• Limited number of nutrition messages given to client per session
• Tailored messages based on client's age, gender, culture, and feedback

Setting goal

• Summarized the conversation
• Helped client set goal(s) that is specific & realistic for the family’s lifestyle
• Documented goal(s)

Closing on positive note

• Restated the goal and checked for understanding
• Expressed appreciation for client’s time
• Was enthusiastic about following up next time

Missouri WIC Program. Revised 07-2022.

For potential risk factor assignment and key areas to assess.

A: 100s Anthropometric = HT/WT, Percentiles

• What has your doctor said about your child’s growth/your weight?
• What questions do you have about your child’s weight/your child’s growth?
• How do you feel about your child’s growth?

B: 200s Biochemical = Blood Tests

• What has your doctor said about your/your child’s iron level?
• What questions do you have about the blood test we took today? What do you know about having low iron?
• When was the last time your child had a lead test? What do you know about testing for high lead?

C: 300s Clinical = Health/Medical Conditions

• How have you been feeling? What has your doctor said about your pregnancy/baby/child?
• What health related conditions do we need to know about for you/baby/child?
• Do you have any concerns in regards to health for you/baby/child?

D: 400s Diet and Nutrition

• What are meals like for you/your family? What does your child eat at meals?
• What do you like about your/your child’s eating habits? What would you like to change?
• When do you know your baby is hungry? How does your baby tell you that he/she is hungry?

E: 900s Environmental/Other Factors

• What physical activities do you or your child enjoy? How do you feel about the amount of time your child spends watching TV/videos or playing video games? What are your concerns about you/your child’s safety? What questions do you have about smoking, alcohol or other drugs?

Related risk factors: Recipient of Abuse (901), Drug/Alcohol (902), Foster Care (903), Smoking (Household 904).

Probe for these topics depending on what participant shares from questions to assess for all risks.

Revised 02/2023.

Potential risk factor assignment and key areas to assess, by WIC category. A printable version with a notes column for each category is available: ABCDE Category Specific Tools (PDF).

Infant

A: 100s Anthropometric = HT/WT, Percentiles

• What has your infant’s doctor said about your infant’s growth?
• How do you feel about your infant’s growth?
• What questions do you have about your infant’s weight gain?

PROBE for family’s feelings on growth/weight, prematurity/birth weight.

B: 200s Biochemical = Blood Tests

• What has your infant’s doctor said about your infant’s iron level? What questions do you have about the blood test we took today? What do you know about having low iron? What do you know about infant foods that are high in iron? (Ask at MCA) Has your infant’s doctor prescribed iron for your infant? (201)
• What has your infant’s doctor said about lead testing? (211)

C: 300s Clinical = Health/Medical Conditions

• What has your doctor said about your infant’s health?
• What concerns do you have about your infant’s health?

PROBE for these topics depending on what is shared:

• Allergies (353), Immunizations, Oral Health Conditions (381)
• Medical Conditions (134-153, 341-342, 344, 346-351, 352 a/b, 354-356, 359, 360, 362), Medications (357), Neonatal Abstinence Syndrome (383), Fetal Alcohol Spectrum Disorders (382)

D: 400s Diet and Nutrition (411, 428; 4-11 months of age)

• Tell me about your baby’s feeding? How is breastfeeding going?

PROBE for these topics depending on what is shared:

• Breastfeeding
  • How often? Describe feedings. (411.7)
• Formula/Pumped Breast Milk
  • Oz/Day, Preparation and Storage (411.1, 411.6, 411.7)
• Bottle Use/Sippy Cups (411.2)
• Solid Foods/Beverages (428) Plan/What/How/When (411.3, 411.4, 411.8)
  • Introduction of Solids, Introducing foods high in iron and zinc (411.4)
  • Water Source: Bottle, Tap, Well (411.9)
• Food Safety (411.5, 411.9)
• Supplements: Vitamin D, Fluoride, Iron, Herbal (411.10, 411.11)

E: 900s Environmental/Other Factors

• What are your concerns about your baby’s safety? What concerns do you have about smoking, alcohol or other drugs? What kind of activities do you do with your infant? What do you know about tummy time?

PROBE for these topics depending on what is shared: Recipient of Abuse (901), Foster Care (903), Drug/Alcohol Abuse (902), Smoking (904).

Child

A: 100s Anthropometric = HT/WT, Percentiles

• What has your child’s doctor said about your child’s growth?
• What questions do you have about your child’s growth?
• How do you feel about your child’s growth?

PROBE for family’s feelings on growth/weight, prematurity/birth weight.

B: 200s Biochemical = Blood Tests

• What has your child’s doctor said about your child’s iron level? What questions do you have about the blood test we took today? What do you know about having low iron? Has your child’s doctor prescribed iron? (201)
• Has your child been tested for lead and what were the results? (211)

C: 300s Clinical = Health/Medical Conditions

• What has your doctor said about your child’s health?
• Do you have any concerns about your child’s health?

PROBE for these topics depending on what is shared:

• Allergies (353), Immunizations, Oral Health Conditions (381), Medications (357)
• Medical Conditions (134, 341, 342, 344, 346-349, 351-352a, 352b, 354-356, 359, 360, 362), Fetal Alcohol Spectrum Disorders (382)

D: 400s Diet and Nutrition (401: 2 years of age and older; 425, 428: 12-23 months of age)

• What are meals like for your family?
• What does your child eat at meals and snacks? What does your child drink during the day? Does your child eat non-food items?
• What do you like about your child’s eating habits? What would you like to change?

PROBE for these topics depending on what is shared:

• Supplements: Vitamin D, Iron, Herbal (425.7, 425.8)
• Beverage Intake/Cup Use (425.2, 425.3, 428), Milk Intake/Type (425.1), Water Source: Bottle, Tap, Well (425.8)
• Special Diet or Food Restrictions/Number of Meals, Picky Eater, Portions, Textures (425.4), Parent/Child Roles (425.4), Food Safety/Listeria Risks (425.5), Eats Non-food Items (425.9)

E: 900s Environmental/Other Factors

• What physical activities does your child enjoy? Tell me about the amount of time your child spends watching TV/video or playing video games.
• What are your concerns about your child’s safety?
• What concerns do you have about smoking, alcohol or other drugs?

PROBE for these topics depending on what is shared: Recipient of Abuse (901), Foster Care (903), Drug/Alcohol Abuse (902), Smoking (904).

Pregnant woman

A: 100s Anthropometric = HT/WT, Percentiles

• What has your doctor said about your prenatal weight gain?
• What questions do you have about weight gain/loss during pregnancy?

PROBE for nausea, vomiting.

B: 200s Biochemical = Blood Tests

• (If low) What has your doctor said about your iron?
• (If low) What questions do you have about the blood test we took today or why it was done? What do you know about having low iron? (201)
• Has your doctor prescribed a prenatal vitamin or any other supplements?

C: 300s Clinical = Health/Medical Conditions

• How have you been feeling?
• What has your doctor said about your pregnancy?
• What concerns do you have about your health?

PROBE for these topics depending on what is shared:

• Allergies (353), Medications (357), Prenatal Care (334)
• Medical/Health Conditions (338, 339, 341-342, 344, 346-349, 351, 352a, 352b, 354-356, 358-360, 362)
• Depression [clinical depression, including postpartum depression] (361), Nausea and Vomiting (301), Oral Health Conditions (381)

D: 400s Diet and Nutrition (401, 427)

• How is your appetite?
• Do you eat non-food items?
• What do you like about your eating habits? What would you like to change?

PROBE for these topics depending on what participant shares:

• Appetite: Likes/Aversions/Cravings, Eats Non-food Items (427.3)
• Beverage/Water, Milk Intake and Type
• Breastfeeding (601, 602): Interest/Knowledge
• Diet Restrictions (427.2), Eating Patterns (427.2)
• Food Safety/Listeria Risks (427.5)
• Prenatal Vitamin, Vitamin D, Herbal, Iodine, Iron (427.1, 427.4)

E: 900s Environmental/Other Factors

• What are some physical activities that you enjoy?
• What concerns do you have about your safety?
• What concerns do you have about smoking, alcohol and drugs?

PROBE for these topics depending on what is shared: Smoking (Maternal 371, Household 904), Drug/Alcohol Abuse (372), Recipient of Abuse (901).

Postpartum woman

A: 100s Anthropometric = HT/WT, Percentiles

• How are you feeling since delivery?
• What questions or concerns do you have?

PROBE for feelings on weight gain/loss.

B: 200s Biochemical = Blood Tests

• (If low) What has your doctor said about your iron? (If low) What do you know about low iron? (201)
• What questions do you have about the blood test we took today?
• What prenatal vitamin or any other supplements are you taking?

Note: Hemoglobin testing is completed after four weeks postpartum.

C: 300s Clinical = Health/Medical Conditions

• What has your doctor said about your health?
• Do you have any concerns about your health?
• How is your mental wellness today?

PROBE for these topics depending on what is shared:

• Allergies (353), Medications (357), Oral Health Conditions (381)
• Medical/Health Conditions (338, 339, 341-342, 344, 346-349, 351, 352a, 352b, 354-356, 358-360, 362), Delivery/Recent Major Surgery (359), Depression [clinical depression, including postpartum depression] (361)

D: 400s Diet and Nutrition (401, 427)

• How is your appetite? Do you eat non-food items?
• What do you like about your eating habits? What would you like to change?

PROBE for these topics depending on what is shared:

• Beverage Intake/Water, Milk Intake/Type
• Breastfeeding (601, 602): Questions/Feelings/Knowledge
• Diet Restrictions (427.2), Eating Patterns (427.2), Eats Non-food Items (427.3), Food Safety/Listeria Risks (427.5)
• PN Vitamin/D, Folic Acid, Herbal, Iron (427.1, 427.4)

E: 900s Environmental/Other Factors

• What are some of the physical activities that you enjoy?
• What are your concerns about your safety?
• What concerns do you have about smoking, alcohol or other drugs?

PROBE for these topics depending on what is shared: Smoking (Maternal 371, Household 904), Drug/Alcohol Abuse (902), Recipient of Abuse (901).

Revised 02/2023.

Revised 04/2026

To ensure continuity of care, subjective, objective, assessment and plan (SOAP) notes are required for documentation of the nutrition care plan for all participants at certification, mid-certification assessment (MCA) and for high-risk follow-up. This SOAP note tool may help develop appropriate SOAP notes. Utilize the Health and Nutrition Assessment Handbook (HNAH) for approved standard abbreviations for writing SOAP notes. Refer to policy 8.1.070 Certification in the WIC Operations Manual (WOM).

Quality nutrition education documentation should always be:

1. Consistent with training, policies and resources.
2. Clear and precise so the reader easily understands.
3. Concise and well organized, following a logical order without duplication and unnecessary information.
4. Complete to create a picture of the participants, the services provided over time and outline a plan for future services.

SOAP note

Subjective (S)

Information given by the participant or caregiver.

• Thoughts, feelings and complaints.
• Dietary intake or eating habits.
• Health comments and concerns (e.g., substance use, vitamin use, tobacco and nicotine use, oral health assessment, immunization refusal).

Participant responses and statements may include, but are not limited to:

Objective (O)

Objective observation and measurements taken by WIC staff or the health care provider (HCP).

• Anthropometrics, biochemical and risk factor data.
  • The Management Information System (MIS) will automatically populate the most recent data entered in the system when using the SOAP note template.
• HCP diagnosis (including self-reported), medications and recommendations.
  • Document the HCP’s name and contact information, if prescribed, the name of the special diet, formula or medication and any follow-up plans with the HCP.
• Clinical observations (i.e., signs and symptoms).

Assessment (A)

Professional staff’s assessment of subjective and objective data.

• The participants’ comprehension and motivation.
• Oral health assessment findings.
• Vitamin adequacy (risk factors 411.11, 425.8 and 427.4).
• Referral outcome.
• Goal progress.
• Summary and evaluation for assigning risk factors.
• Justification for resolving high-risk risk factors.

Plan (P)

Plan for intervention and follow-up.

• Intervention to address risk factors and nutritional status.
• Food package tailoring.
• Discussion, education and resources.
• Nutrition education delivery medium (e.g., group education, individual, telephone).
• Educational materials used and given to the participant.
• Referrals and Resource List provided.
• SMART goal.
• Plans for follow-up.

SOAP note examples

Professional staff will use their professional judgment and critical thinking to ensure notes are complete and thorough based on the type of appointment and conversation with the participant. Each note will be different and include information specific to the type of appointment.

Non-high-risk note

High-risk note completed by nutritionist

Where to document?

Many subjects that must be documented may depend on the conversation and response to determine where in the SOAP note to document the information received from the participant. For example, conversations about lead, prenatal vitamins and blood work may be documented as follows:

Lead

Prenatal vitamins

Blood work

Revised March 2024

An alphabetical list of health-related abbreviations for use in documentation for Missouri WIC is provided below.

Standard medical credentials such as RD, LD, MD, may be abbreviated in documentation but are not included on this list.

A

B

C

D

E

F

G

H

I

K

L

M

N

O

P

Q

R

S

T

U

V

W

X

Y