Infant Malnutrition Clinical Pathway — Outpatient Specialty Care and Primary Care

Feeding Recommendations

Recommend alignment with Nutrition recommendations, once available. The minimum volumes are an estimate; recommend allowing infant to PO more than minimum volume if continuing to show feeding cues.

Intake Recommendations

Current Nutrition	Initial Minimum Intake Recommendations	Feeding Frequency
Human Milk or Formula Minimal or no solid intake	Infants > 37 wks 108 kcal/kg/day Equivalent to 162 mL/kg/day of 20 kcal/oz standard term formula or unfortified human milk	< 3 mos, approx. q3, ≥ 8 per day ≥ 3 mos, approx. q3 during day, ≥ 6 per day Wake the baby to feed if necessary

References: Pediatric Manual of Clinical Dietetics , Recommended Dietary Allowances

Infant Feeding Recommendations Based on Method

Breastfed Direct feeding at the breast and /or mother has goal of breastfeeding	Observe feeding Lactation referral Obtain pre- and post-weights if > 5 days old Initiate supplementation, preferably with expressed maternal milk, via bottle after nursing to meet goal volume. If expressed maternal milk is unavailable, consider appropriate infant formula. Pump after breastfeeding to increase milk supply Assure breast drainage with breast compression and massage while feeding and pumping Offer both breasts with each feed Increase feeds/add night time feedings Wake for feedings 0-6 mos: 8 or more feedings per day
Bottle Fed Feeding from a bottle	Observe feeding Awareness of infant feeding cues prior to feed Supportive positioning for oral feeding Reduce environmental distractions (e.g., noise and light) Offer pacing or breaks if increased WOB and/or oral loss from mouth Limit feeds to 30 minutes Wake for feedings < 3 mos: 8 or more feedings per day > 3 mos: 6 or more feedings per day
Increase Caloric Density	Fortified Breast Milk/Formula Concentration Fortified breastmilk or infant formula concentration can initially begin at 22 kcal/oz. If poor growth continues, further fortification/ concentration can continue to 24 kcal/oz. Infants who are not adequately growing on fortified breastmilk/infant formula concentration of 24 kcal/ oz. require a more detailed investigation of the etiology. Infants should not be routinely concentrated to > 24 kcal/oz. without consultation from GI or Nutrition for further assistance with the clinical workup.
Solids	Ensure that offered dietary texture matches current oral motor skills. Consider referral to Feeding and Swallowing center

Reference: Pediatric Manual of Clinical Dietetics

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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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