Infant Malnutrition Clinical Pathway — Outpatient Specialty Care and Primary Care

Feeding and Elimination History

Complete comprehensive history and physical exam to assess for underlying etiology for malnutrition.

Factors Evaluate
Feeding History
  • Breast Feeding
    • Frequency, length, number per day, longest interval between feedings, night vs. day
    • Falling asleep at breast, not waking for feeds
    • One or both breasts, softer after feeding, use of nipple shield, any pain or difficulty with latch or positioning
    • If pumping, how much is produced
    • See or hear baby swallow
    • Any supplementation of expressed human milk or formula
    • Other foods or liquids
  • Bottle Feeding
    • Frequency, length, amount per feed and per day, longest interval between feedings, night vs. day
    • Formula mixing recipe, type, and concentration
    • Bottle type, nipple type and size
    • Any supplementation to the bottle other than formula
    • Food (including solids) or liquids other than human milk or formula (water, juice, thickener, etc.)
    • Assess positioning
Indicators of Pharyngeal Swallow Dysfunction
  • Coughing during feeding by mouth
  • Wet, “gurgly” vocal quality during or immediately after feeding by mouth
  • History of frequent upper respiratory tract infections or illness, unexplained fevers, or pneumonia
  • If signs/symptoms are appreciated, infant should be referred for an oral feeding evaluation by a speech-language pathologist. (At CHOP, infant is referred to The Feeding and Swallowing Center).
Reflux
  • Coughing, choking, or gagging with feeds
  • Spitting up/vomiting
  • Respiratory symptoms with feeding
  • Arching, irritability or discomfort with feeds
  • Bottle and breast refusal
Social
  • Which caregiver(s) feed the baby (mom or other caregivers)
  • Who lives in home? Does mom have help? Is she getting sleep?
  • Is caregiver appropriately following baby’s feeding schedule, need help with childcare, and/or receiving WIC and/or SNAP?
  • If bottle fed, does family have concerns obtaining formula?
  • Breast pump availability and type, if applicable
  • Assess for postpartum depression for up to 12 months
  • Assess for a history of DHS involvement: “Has your family ever received services through child and youth services?"
  • Assess for food insecurity
  • Does the parent/guardian understand the action plan/goals, next steps and information provided?
  • The hunger vital sign food insecurity questions:
    • “Within the past 12 months we worried whether our food would run out before we got money to buy more.”
    • “Within the past 12 months the food we bought just didn’t last and we didn’t have money to get more.”
Elimination
  • Number of wet diapers/urine output per 24 hours
    • Presence of orange or red crystal/powder in diaper
  • Number of stool diapers per 24 hours
    • Stool appearance (consistency, color)
    • Presence of blood or mucus in stool

Newborn Screen

The newborn screen is used to detect a number of inborn errors of metabolism and cystic fibrosis, which can be causes of malnutrition.

How to Access Newborn Screen in Epic