Infant Malnutrition (FTT) — Assess Growth and Severity of Malnutrition — Clinical Pathway: Inpatient

Infant Malnutrition/Failure to Thrive (FTT) Clinical Pathway — Inpatient

Assess Growth and Severity of Malnutrition

Growth Chart

  • Z-scores are used to assess malnutrition category.
  • Refer to Growth Chart in Epic and ensure that appropriate chart is used, as detailed in table below.
  • Peditools   can be used to plot growth parameters for all patients and obtain accurate Z-scores.
Age Plot Growth in Epic
Preterm infants
(born at or less than 36 6/7 weeks) 		Corrected age < 40 weeks Olsen All preterm infants should have their gestational age added to the birth history. Click “Show gestation adjusted age chart” to correct for prematurity.
Corrected age > 40 weeks - 24 months WHO
Term Infants
(born at 37 weeks or greater) 		37 weeks - 24 months WHO If growth parameters are available, plot these on the Olsen growth chart to assess birth size (SGA, AGA, LGA).

Malnutrition Diagnosis for < 1 month corrected

Time Frame Indicators Severe Moderate Mild Notes for Use
DOL #7-14 Nutrient Intake ≤ 75% of Estimated Needs > 7 consecutive days ≥ 5-7 consecutive days ≥ 3-5 consecutive days Estimated calorie needs by age
DOL #15-1 month (corrected) Weight Gain Velocity < 25% of expected rate < 50% of expected rate < 75% of expected rate Preterm: use Peditools Term: use Weight Gain Velocity table
Weight-for-Age Z-Score Decline > 2 SD decline 1.21-2 SD decline 0.8-1.2 SD decline May use Peditools for accurate Z-score
Days to Regain Birth Weight > 21 19-21 15-18 Must use with nutrient intake indicator

Table adapted from Identifying Malnutrition in Preterm and Neonatal Populations: Recommended Indicators. Goldberg, Dena L., et al. (2018) Journal of the Academy of Nutrition and Dietetics, Volume 118, Issue 9, 1571 - 1572

Malnutrition Diagnosis for > 1 month corrected

Indicators Severe Moderate Mild
Weight for length z-score -3 or greater z-score -2.0 to - 2.99 z-score -1.0 to -1.99 z-score (and 1 additional indicator)
Weight gain velocity ≤ 25% of norm 26 - 50% of norm 51 - 75% of norm
Deceleration in weight for length/height Deceleration across 3 z-score lines Deceleration across 2 z-score lines Deceleration across 1 z-score line
Inadequate nutrient intake ≤ 25% of est kcal-protein need 26 - 50% of est kcal-protein need 51 - 75% of est kcal-protein need

Table adapted table from Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition:   Indicators Recommended for the Identification and Documentation of Pediatric Malnutrition (Undernutrition)

Weight Gain Velocity

This table contains median weight gain goals to maintain growth percentiles.
Individual patient goal may need to be adjusted by Nutrition.

Age (corrected) Median gm/day Severe malnutrition
< 25% median		 Moderate malnutrition
< 50% median		 Mild malnutrition
< 75% median		 Infants should regain birth weight by the first 2 weeks of life and not lose more than 10% of birth weight. Weight loss should cease by day 7 of life.
  Girls Boys Girls Boys Girls Boys Girls Boys
2 - 4 wks 29 34 7 9 15 17 22 26
4 wks - 2 mo 34 40 8 10 17 20 25 30
2 - 3 mo 24 27 6 7 12 14 18 20
3 - 4 mo 20 21 5 5 10 10 15 15
4 - 5 mo 16 17 4 4 8 9 12 13
5 - 6 mo 13 14 3 4 7 7 10 11
6 - 8 mo 11 11 3 3 6 6 8 8
8 - 10 mo 9 9 2 2 4 5 7 7
10 - 12 mo 8 8 2 2 4 4 6 6

Table adapted from the WHO Child Growth Standards July 2010 (25th-75th%) and Fomon SJ, Haschke F, et al.: Body composition of reference children from birth to age 10 years. Am J Clin Nutr 1982;35:1169.