Infant Malnutrition Clinical Pathway — Outpatient Specialty Care and Primary Care

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Goals and Metrics

Patient Education

Provider Resources

Related Pathway
Malnutrition/Failure to Thrive, Infant, Inpatient
Malnutrition (Undernutrition), Inpatient

Related Order Set
Outpatient Infant Malnutrition Management Smart Set

Patients 0-12 months at Risk for Malnutrition
(Failure to Thrive)

Exclusion Criteria

Failure to thrive (FTT) is a symptom, not a diagnosis. Malnutrition is a diagnosis that more accurately describes inadequate nutrition and is determined by clinical assessment.

Clinical Assessment

History & Physical
- Consider Red Flags
- Feeding and elimination
- Newborn Screen
- Social history
- Assess growth charts, weight for age trend, height, and head circumference
- Review of Systems screening
- Signs, symptoms of underlying disease
Observe feedings

Consider Red Flags

Abnormal vital signs
Signs of dehydration
Altered mental status/seizure
Respiratory distress
ED or Specialty Referral as indicated

Concern for Signs/Symptoms of Underlying Disease

Differential Diagnosis
- Increased Metabolic Demand
- Malabsorption
Primary care evaluation or Specialty Referral/ED as indicated

Likely Inadequate Intake

Assess High Risk for Malnutrition

High Risk for Malnutrition
< 1 month	Not regaining birth weight by > 21 days old Continued weight loss after day 7
1 month to 12 months	No weight gain Weight loss Weight for length z-score of -2 or lower

Routine labs, radiology studies are generally not recommended

Yes

Initial Interventions

Feeding
- Feeding Recommendations
- Determine frequency of weight checks
- Appropriate solid foods (after 6 months)
- Consider Pre/Post Breastfeeding weight
- Breast Milk or Formula Fortification

Referrals
- Assure WIC Referral
- Specialty Providers

High Risk Interventions

Feeding
- Feeding Recommendations
- Determine frequency of weight checks
- Appropriate solid foods (after 6 months)
- Consider Pre/Post Breastfeeding weight
- Breast Milk or Formula Fortification

Consider other diagnostic conditions
- Labs
- Review Differential Diagnosis

Referrals
- Assure WIC Referral
- Specialty Providers
- ER evaluation/admission

Adequate Weight Gain

Inadequate Weight Gain

Schedule visits as indicated
Continued family education

Initiate High Risk Interventions

Adequate Weight Gain

Inadequate Weight Gain

Schedule visits as indicated
Continued family education

Consider admission for additional work up and possible NG tube placement and supplementation

Posted: April 2021
Revised: August 2023

Authors:
- V. Goh, MD;
- J. Owusu McKenzie, MD;
- M. Girten, RD;
- L. Drabinsky, CRNP;
- R. Lessen, IBCLC;
- S. Galbally, SLP;
- G. Pitsakis, LCSW;
- M. Miano, LCSW;
- L. Archambault, SLP;
- D. Bartholomew, RD;
- M. Hewson, MD

Editors: Clinical Pathways Team

Evidence

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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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Outpatient Clinical Pathway for Evaluation/Treatment of Infants at Risk for Malnutrition (Failure to Thrive)

Evidence