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

Check Media Tab in Epic
- PA – Perkin Elmer
- NJ – NJ Newborn Screening
- DE – DE Newborn Screening

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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.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.