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Weighing newborn babies and pathway for 10% weight loss- Clinical guideline Weighing newborn babies and pathway for babies with significant weight loss (>10%) Clinical Guideline V1.0

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Page 1: Weighing newborn babies and pathway for babies …...Weighing newborn babies and pathway for 10% weight loss- Clinical guideline 1. Aim/Purpose of this Guideline This guideline gives

Weighing newborn babies and pathway for 10% weight loss- Clinical guideline

Weighing newborn babies and pathway for babies with significant

weight loss (>10%) Clinical Guideline

V1.0

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Weighing newborn babies and pathway for 10% weight loss- Clinical guideline

1. Aim/Purpose of this Guideline

This guideline gives guidance on Infant Feeding and what to do in the event of significant neonatal weight loss.

This guideline will: 1. Identify best practice in the weighing of newborn babies

2. Identify actions for management of babies with significant weight loss 3. Identify practice for review of babies with significant weight loss. 4. Identify actions for management of new born babies with slow weight gain

1.1 Introduction

It has generally been accepted that newborn babies lose up to 10% of their birth weight. There is continuing professional debate concerning what constitutes normal weight loss, or

even if early neonatal weight loss is normal. Neonatal weight loss is brief with few babies remaining more than 10% below their birth weight after 5 days.

Assessment of feeding is an essential part of assessing the overall health of the baby. Monitoring of weight will provide objective measure of feeding effectiveness and potential

for dehydration.

2. The Guidance 2.1 RECOMMENDED PRACTICE FOR ASSESSING BABIES BY THE COMMUNITY

MIDWIFE

At each visit an assessment of feeding and wellbeing of baby should take place.

The baby should be weighed on day 3 for those classed at a higher risk (red hats) day 5 for all other babies and between days 8 and 10.

Early signs of dehydration, such as weight loss, abnormal stool/ urine patterns, prolonged

jaundice, lethargy or reduced level of consciousness, irritability or low grade fever, must be noted by the community midwife as an indicator for concern and the baby should be weighed regardless of age as part of an overall midwifery assessment. The Infant Feeding

Team can be contacted for advice regarding any concerns about feeding.

All community midwives and community midwifery support workers should have access to the care management pathway and copies of the feeding assessment tool (see appendix 3)

2.2 Minimum Stool and Urine Output Per Day

Age Day 1-2 Day 3- 4 Day 5-6 Day 7 and beyond

Urine

Number of wet nappies per day

1-2 wet nappies, urates may be

present.

3 or more wet nappies, nappies becoming heavier

5 or more 6 wet nappies per

day, heavier

1 or more, dark, 2 or more, 2 or more, yellow, 2 or more, least

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Weighing newborn babies and pathway for 10% weight loss- Clinical guideline

Stools

Number per day, colour, consistency

green/ black tar like (meconium)

changing in colour and consistency-

brown/ green/yellow,

becoming looser (changing stools)

may be quite watery.

size of £2 coin, yellow and watery, seedy appearance.

2.3 CALCULATING WEIGHT LOSS

After the baby has been weighed as part of the overall assessment, the total weight

loss should be calculated as shown below:

(Birth weight - Latest weight) x 100

Birth Weight

All weights should be documented in the baby section of the midwifery notes and also in the parent held record (red book).

Once the weight loss has been calculated a plan of care can be formulated and discussed with the parents.

2.4 MANAGEMENT PATHWAY FOR BABIES WITH WEIGHT LOSS

If a baby has been identified to have a weight loss the care pathway below should be followed. A formal feeding assessment will be carried out using the feeding assessment tool as often as required in the first week with a minimum of two assessments to ensure effective

feeding and the well-being of mother and baby

Plan % weight loss Actions

1 Up to 8% If the baby has lost up to 8% of the birth weight the mother should be reassured, positioning and attachment advice

reinforced and the baby weighed again as per guidelines.

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Weighing newborn babies and pathway for 10% weight loss- Clinical guideline

2 8-10% weight loss

The midwife must ensure a feeding management

plan is in place which should include the following:

Encourage skin to skin contact

Observe a whole feed, start to finish, and complete a

Breastfeeding or Formula Feeding Assessment Form.

Ensure parents understand what effective feeding looks

like and feels like

Ensure minimum of 8 feeds in 24 hrs, including at least

x1 at night, and encourage use of a feed chart.

Offer both breasts at every feed

Monitor number and colour of stools and urine.

Express at least 2-3 times in 24hrs, after feeds, and

after any feed which is not effective

Encourage offering any available expressed milk by

finger and syringe, or by cup, after feeds at which baby is clearly hungry and unsettled (likely to be evening

feeds)

Plan as above Plus

Review and weigh baby in 48hrs unless additional concerns arise. If weight increasing continue to monitor

as per normal care pathway

If no weight gain after 48 hours refer to Infant Feeding Team and consider implementing management plan 3.

3 10% -12%

Plan as above plus

Encourage expressing as often as manageable

after feeds, either by hand or with an effective hand or electric breast pump

Encourage giving all available expressed milk by

finger and syringe or cup or bottle, at any feeds at which baby is hungry and unsettled. Top up feeds need not be the same after each feed, but likely to

be at least 100-150mls total in 24hrs.

If milk supply clearly not well-established, consider

seeking prescription for Domperidone 10mg TDS, or use of other galactagogues such as Fenugreek

Review baby’s wellbeing in 24 hrs and reweigh in

48hrs.

If no weight gain refers to Infant Feeding team. If

the Infant Feeding Team members are not

available, consider implementing care plan 4

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Refer to neonatal registrar if there any concerns

regarding the wellbeing of the baby (such as

dehydration, reduced bowel movements or urine output,

prolonged jaundice, lethargy, pyrexia, hypothermia).

4 >12 % weight

loss

Refer by bleeping the neonatal SHO. Baby will be accepted

for assessment in neonatal OPD, postnatal ward or paediatric observation unit/Polkerris. Senior review as appropriate. Liaison with midwife in charge on PNW for

admission and feeding support or paediatric admission to Polkerris if medical diagnosis suspected.

The postnatal ward or paediatric ward staff will contact the Infant Feeding Team to review the baby as soon as possible

after arrival.

Caution: Output, weight loss and feeding history are key factors in the clinical assessment.

Professionals must remain alert to the fact that newborn babies with hypernatremic

dehydration may not exhibit classical signs of dehydration e.g. skin turgor, sunken fontanelle, sunken eyes, dry mucous membranes signs of poor perfusion such as

increased capillary refill time or blue/cool peripheries.

2.5. Referral to Neonatal team

Referral should be made for all babies who experience a weight loss from birth weight of >12%. The community midwife or MSW will refer the baby and family to the neonatal SHO who will inform Neonatal, Postnatal ward or Paediatric ward,

accordingly. The Postnatal or Paediatric ward will contact the Infant Feeding Team/ neonatal team to review the baby as soon as possible after arrival.

Referral can also be made if the midwife feels more intensive support is required with a lesser weight loss.

2.6 On arrival

All babies will have baseline observations taken including a repeat weight (NEWS

chart).

All babies will have a blood test (including urea, electrolytes and creatinine) and blood gas (gives an immediate serum sodium) and other bloods if jaundiced or

other conditions suspected.

Blood results will be compared to the chart below.

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If baby is well and blood test results are within normal ranges, baby can return

home with an appropriate feeding plan and close follow up from the midwifery team

Serum Sodium

Normal

(if low

consider alternative diagnosis

such as CAH)

145 - 154mmol/l

155-169 mmol/l >170 mmol/l

Rehydration period

48 hours 72-96 hours

Admission Criteria

If unwell review by neonatal

registrar

If unwell review by

neonatal registrar

Admit to Wheal Fortune or Polkerris

depending on baby’s condition

Discuss with Consultant on call Admit to NNU side

room or Paediatric HDU

Fluid regime

If combined with a weight loss>10% top

ups at 6mls/kg/feed

(as tolerated by baby)

Top ups after breastfeeds at

50% of daily requirement

Enteral feeds at 100mls/kg day. If

unwell infant –

consider IV fluids with senior guidance

Enteral feeds at 100 mls/kg day. If unwell – consider

intravenous fluids (0.9% saline plus

glucose)

Seek senior guidance

Monitoring

Continued breast feeding support

Stool and

urine output.

Midwifery review in 24-

48 hours

Continued breast feeding support.

Stool and

urine output.

Midwifery review 24

hours

Continued breast feeding support.

Urea, electrolytes and blood sugar 6

hourly until sodium <150 mmol/l

Aim for a maximum

drop of ½ mmol per hour.

Stool and Urine output

Continued breast feeding support.

Urea, electrolytes and blood sugar 6

hourly until sodium <150 mmol/l

Aim for a maximum

drop of ½ mmol per hour.

Stool and Urine out put

A full history will be taken from the parents

A midwife will observe a full feed and a Breastfeeding Assessment Form or Formula

Feeding Assessment Form will be completed (See appendix 3)

If there are further concerns regarding the baby’s health, medical review will be sought

from the NNU Specialist Registrar.

Care planning will be documented in the hand held record following review and with reference to the Care Pathway.

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The member of staff who reviews the baby will make contact with the referring midwifery

team after the consultation, to ensure appropriate follow up occurs. A message will also be left for the Infant Feeding Team so that follow-up contact can be made with the family or

community midwife, as appropriate. Follow up support can be provided by telephone if the baby is discharged.

An incident form should be completed by the midwife for all babies who are admitted

to/reviewed at hospital for weight loss >12.%.

2.7. PRIOR TO DISCHARGE

Prior to discharge from the postnatal ward, an assessment of feeding should take place to ensure the mother is aware of how to hold her baby for feeding, signs of

effective attachment, responsive feeding and what to expect in the nappy. The ‘Essential Guide to feeding and caring for your baby’ Cornwall and Isles of Scilly latest edition’ leaflet should be given to all mothers.

Bottle feeding mothers should be informed of guidance regarding preparation of

formula, using a first milk, responsive feeding (holding the baby close, encouraging the mother and father to do the majority of the feeds, inviting the baby to take the teat, pacing the feed, and not forcing the baby to finish the amount in the bottle.).

2.8. BABIES WHO ARE SLOW TO GAIN WEIGHT

All babies should have regained their birth weight by days 10-14 of life. Babies who

are slow to gain weight in the first 10-14 days should be reviewed regularly by the midwifery team to ensure that baby remains well and an appropriate plan of care is in

place to optimise feeding.

If babies are significantly below their birth weight on day 10, contact should be made

with the Infant feeding Team to discuss a plan of care. This may include an appointment with the Infant Feeding Co-ordinator to provide specialist support.

The Infant Feeding Team can refer to the paediatric team via paediatric assessment unit or the rapid access clinic if required.

2.9. DISCHARGE FROM MIDWIFERY CARE

The care of the baby and the family should be handed over to the health visitor at 10-14 days of age if the baby has regained its birth weight. Care should remain with the

midwife if the baby has not regained birth weight, although if there has been a recognised upward trend of weight and the baby is within 1% of its birth weight then discharge can be considered if all other parameters are normal. Individualised plans

of care can be discussed with the Infant Feeding Team.

If feeding plans are in place at discharge, the care plan must be discussed with the

parents and relayed to the health visitor and documented that this has taken place.

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3. Monitoring compliance and effectiveness

Element to be

monitored The audit will take into account record keeping by midwives

The results will be inputted onto an excel spreadsheet The audit will be registered with the Trust’s audit department

Lead Infant feeding coordinator

Tool Proforma against guideline

Frequency During the Line time of the guideline

Reporting

arrangements A formal report of the results will be received annually at the

maternity patient safety and clinical audit forum, as per the audit plan

During the process of the audit if compliance is below 75% or other deficiencies identified, this will be highlighted at the next maternity patient safety and clinical audit forum and an action

plan agreed.

Acting on recommendations

and Lead(s)

Any deficiencies identified on the annual report will be discussed at the maternity patient safety and clinical audit

forum and an action plan developed

Action leads will be identified and a time frame for the action to

be completed by

The action plan will be monitored by the maternity patient safety

and clinical audit forum until all actions complete

Change in practice and lessons to be

shared

Required changes to practice will be identified and actioned within a time frame agreed on the action plan

A lead member of the forum will be identified to take each change forward where appropriate.

The results of the audits will be distributed to all staff through

the patient safety newsletter/audit forum as per the action plan

4. Equality and Diversity 4.1. This document complies with the Royal Cornwall Hospitals NHS Trust

service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website.

4.2. Equality Impact Assessment

The Initial Equality Impact Assessment Screening Form is at Appendix 2.

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Appendix 1. Governance Information

Document Title Weighing newborn babies and pathway for 10% weight loss V1.0

Date Issued/Approved: 16th January 2018

Date Valid From: 16th January 2018

Date Valid To: 16th January 2021

Directorate / Department responsible

(author/owner): Helen Shanahan Infant feeding lead

Contact details: Postnatal ward 01872 252159

Brief summary of contents Weighing newborn babies and pathway for

10% weight loss

Suggested Keywords: Infant feeding weight loss weighing newborn babies

Target Audience RCHT PCH CFT KCCG

Executive Director responsible for Policy:

Medical Director

Date revised: 4th January 2018

This document replaces (exact title of previous version):

New issue

Approval route (names of

committees)/consultation:

Maternity Guidelines Group Obs and Gynae Directorate

Divisional Board for noting

Divisional Manager confirming approval processes

David Smith

Name and Post Title of additional signatories

If none enter ‘Not Required’

Name and Signature of Divisional/Directorate Governance

Lead confirming approval by specialty and divisional management meetings

{Original Copy Signed}

Name: Caroline Amukusana

Signature of Executive Director giving approval

{Original Copy Signed}

Publication Location (refer to Policy Internet & Intranet Intranet Only

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Weighing newborn babies and pathway for 10% weight loss- Clinical guideline

on Policies – Approvals and

Ratification):

Document Library Folder/Sub Folder Clinical/Midwifery and Obstetrics

Links to key external standards

Dommelen et al (2006) Reference chart for relative weight change to

detect hypernatraemic dehydration www.archdischi ld.com

NICE (2006) Routine postnatal care

of women and their babies

Related Documents: Postnatal care

Training Need Identified? no

Version Control Table

Date Version

No Summary of Changes

Changes Made by

(Name and Job Title)

16th Jan

2018 V1.0 New issue

Helen Shanahan

Infant Feeding Lead

All or part of this document can be released under the Freedom of Information Act 2000

This document is to be retained for 10 years from the date of expiry.

This document is only valid on the day of printing

Controlled Document

This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the

express permission of the author or their Line Manager.

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Appendix 2. Initial Equality Impact Assessment Form

This assessment will need to be completed in stages to allow for adequate consultation with the relevant groups.

Weighing newborn babies and pathway for 10% weight loss

Directorate and service area:

Obs /Maternity & Neonates services

Is this a new or existing Policy?

New

Name of individual completing assessment:

H Shanahan

Telephone: 01752 252159

1. Policy Aim*

Who is the strategy / policy / proposal /

service function aimed at?

To inform all midwifery staff on the appropriate management of weight loss in a neonate.

2. Policy Objectives*

Ensure the correct methods of management are used in the management of weight loss in the neonate

3. Policy – intended

Outcomes*

Neonatal well being

4. *How will you

measure the outcome?

Monitoring through incident reporting.

5. Who is intended to

benefit from the policy?

Women and babies

6a Who did you consult with

b). Please identify the

groups who have been consulted about

this procedure.

Workforce Patients Local groups

External organisations

Other

x

Please record specific names of groups

Clinical Guideline Group

Obstetric and Gynaecology Directorate

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Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Unsure Rationale for Assessment / Existing Evidence Age X

Sex (male,

female, trans-gender /

gender reassignment)

X

Race / Ethnic communities /groups

X

Disability - Learning disability,

physical impairment, sensory impairment, mental

health conditions and some long term health conditions.

X

Religion / other beliefs

X

Marriage and Civil partnership

X

Pregnancy and maternity

X

Sexual Orientation, Bisexual, Gay,

heterosexual, Lesbian

X

You will need to continue to a full Equality Impact Assessment if the following have been highlighted:

You have ticked “Yes” in any column above and

No consultation or evidence of there being consultation- this excludes any policies which have

been identified as not requiring consultation. or

Major this relates to service redesign or development

What was the

outcome of the consultation?

No Imnpact

7. The Impact

Please complete the following table. If you are unsure/don’t know if there is a negative impact you need to repeat the consultation step.

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8. Please indicate if a full equality analysis is recommended. Yes No

x

9. If you are not recommending a Full Impact assessment please explain why.

No areas indicated

Signature of policy developer / lead manager / director

Helen Shanahan

Date of completion and submission 16th January 2018

Names and signatures of members carrying out the Screening Assessment

1. Helen Shanahan 2. Human Rights, Equality & Inclusion Lead

Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead

c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD

This EIA will not be uploaded to the Trust website without the signature of the

Human Rights, Equality & Inclusion Lead.

A summary of the results will be published on the Trust’s web site. Signed Sarah-Jane Pedler Date 16th January 2018

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Appendix 3

Baby’s name: Date of birth: Gestation at birth:

Date of assessment: Baby’s age: Birth weight: Last recorded weight: on (date):

What to observe/ask about Answer indicating effective feeding Answer suggestive of an issue

Urine output At least 6 heavy wet nappies in 24 hours

Fewer that 6 wet nappies, or nappies that do not feel heavy

Stools output 1 or more in 24 hours: normal

appearance (soft not hard or watery)

Less than 1 in 24 hours or abnormal

appearance

Baby’s colour, alertness and tone

Normal skin colour; alert; good tone Jaundice worsening or not improving; baby lethargic, not waking to feed; poor

tone

Baby’s weight Weight loss within 10% on day 5 and regain to birth wt by day 10-14

Weight loss over 10% on day 3 or 5, or excessive wt gain (increasing by more

than 2 centiles by 6-8 week check)

Feeding pattern Baby is being fed responsively Baby is being fed by the clock

Number of feeds in last 24 hours 8 or more up to 6 weeks of age Less than 8 up to six weeks of age

Volume of formula in each feed 150ml/kg divided by number of feeds in 24 hours

Following the details written on the back of the tin

Type of milk Stage 1 milk Hungrier baby milk, off the shelf reflux

milk, comfort milk, goats milk, rice milk, sheep milk, soya milk, hydrolysed formula (unless prescribed) or swapping

between brands

Baby’s behaviour during feeds Calm and relaxed Unsettled, turning head away from bottle, refusing to feed

Baby’s behaviour after feed Baby content after most feeds Baby unsettled after feeding, possetting

or vomiting formula after most feeds

Use of dummy None used Yes:

Formula feeding assessment form

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Ask why:

If any of the boxes in the right-hand column are ticked then further investigation is needed. Any additional concerns about the baby’s well-being should be followed up as necessary.

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Baby’s name: Date of birth: Gestation at birth:

Date of assessment: Baby’s age: Birth weight: Last recorded weight: on (date): What to observe/ask about Answer indicating effective feeding Answer suggestive of an issue

Urine output At least 5-6 heavy wet nappies in 24 hours

Fewer that 6 wet nappies, or nappies that do not feel heavy

Stools output 2 or more in 24 hours: normal appearance £2 coin size, yellow soft/runny

Less than 2 in 24 hours or abnormal appearance

Baby’s colour, alertness and

tone

Normal skin colour; alert; good tone Jaundice worsening or not improving;

baby lethargic, not waking to feed; poor tone

Baby’s weight Weight loss within 10% on day 5 and

regain to birth wt by day 10-14

Weight loss over 10% on day 3 or 5see

weight guidance above

Baby’s behavior during feeds Generally calm and relaxed Baby comes on and off the breast frequently during the feed, or refuses

the breast

Sucking pattern during the feed Initial rapid sucks changing to slower sucks with pauses and soft swallowing

No change in sucking pattern or noisy feeding eg clicking

Length of feed Baby feeds for 5- 30 minutes at most feeds

Baby constantly feeds for less than 5 minutes or longer than 40 minutes.

Feeding pattern Baby is being fed responsively Fewer than 8 feeds in last 24 hours.

Number of feeds in last 24 hours 8 or more up to 6 weeks of age Less than 8 up to six weeks of age

End of feed Baby lets go spontaneously, or does so when breast is gently lifted

Baby does not release the breast spontaneously, mother removes baby

Offer second breast Second breast is offered. Baby may or

may not feed dependent on its appetite.

Mother limits baby to one breast per

feed , or insists on two breasts per feed

Baby’s behavior after feeds Baby is content after most feeds Baby unsettled after feeds

Shape of either nipple at the end Same as at the start of feeding or Misshapen or pinched at the end of

Breastfeeding assessment form

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of feed slightly elongated feeds

Mothers report on her breasts

and nipples

Both are comfortable Nipples are sore/damaged,

engorgement or mastitis

Use of dummy/nipple shields/formula

None used Yes: Ask why: Difficulty with attachment/ baby not growing/ baby unsettled

This chart was developed for use on or around day 5. If used at other times please note the following:

Wet nappies: Day 1-2 = 1-2 or more Day 3-4 = 3 or more, heavier

Day7+ =6 or more, heavier

Stools :Day 1-2 =1 or more, meconium Day 3-4 = 2 or more changing

Feed frequency : Day 1 at least 3-4 feeds Sucking pattern: swallows may become less

audible until milk comes in day 3-4

If any of the boxes in the right-hand column are ticked then further investigation is needed. Any additional concerns about the baby’s well-being should be followed up as necessary.

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