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