Infant Malnutrition Clinical Pathway — Outpatient Specialty Care and Primary Care

Differential Diagnoses

The majority of infants with infant malnutrition (failure to thrive) in General Pediatrics will fall under the inadequate intake category.
It is important to consider a broad differential diagnosis of potential underlying organic etiologies.

Etiology	Symptoms	Recommendations
Inadequate Intake	Long intervals between feeds (Sleep > 3 hrs when < 2 months old) Falling asleep during feeds Limited number and volume of feedings per day Improper mixing of formula (PFE Section 40. General Nutrition) Lactation problems: poor supply, difficulty with latching Limited urine diapers (< 1 wet diaper per 8 hrs) Food insecurity/inability to access food resources (i.e., WIC or SNAP) Excessive vomiting/spitting up/reflux Increased hunger cues/caregiver isn’t recognizing cues Symptoms of maternal depression Birth weight not regained in 2 weeks Signs of oral motor dysfunction	Continue following Inadequate Intake Section
Malabsorption	High volume, extremely loose stools Clay colored stools Greasy or significantly foul smelling stools Chronic diarrhea Abdominal distention, gassiness with diarrhea Blood in stools	Verify newborn screen negative for cystic fibrosis Quantify and qualify stools If abnormal stools, consider initial malabsorption workup Labs and Stool Studies GI consult as clinically indicated
Increased Metabolic Demands	Cardiac: heart murmur, tachypnea, sweating or cyanosis with feeds, feeding fatigue Respiratory: noisy breathing, tachypnea, difficulty breathing with feeds, nasal obstruction Neurologic: increased or decreased tone, abnormal movements Neuro-oncologic: diencephalic tumor causing nystagmus, strabismus, macrocephaly, papilledema, vomiting/lethargy Metabolic/genetic: abnormal newborn screen, dysmorphic features Renal: urologic abnormalities, renal tubular acidosis Endocrinology: tachycardia, diaphoresis	Verify newborn screen Labs and referrals based on clinical assessment Consider additional referrals: Cardiology, GI, Endocrine, Neurology, Metabolic/genetic referral as clinically indicated

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

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