At present, there are 10 CHOP Clinical Pathways relevant to neonatology. Here is a link to the two most applicable to the general pediatrician:
- Glucose Monitoring of the Healthy Newborn, 0 to 36 hours of age
- ED Pathway for Evaluation/Treatment of Neonates with Hyperbilirubinemia/Jaundice
- Do not use the lab reported Total Serum Bilirubin. Rather, see RN/MD/CRNP Rapid Assessment for details.
Assessment of Adequacy of Intake in Breastfeeding Infants*
*Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation [PubMed Abstract] [Full Text HTML] [Full Text PDF]. Pediatrics July 2004, VOLUME 114 / ISSUE 1 AMERICAN ACADEMY OF PEDIATRICS
*There has been an update of the above [unfortunately behind a paywall], Hyperbilirubinemia in the newborn infant > or =35 weeks’ gestation: an update with clarifications [PubMed Abstract].Pediatrics. 2009 Oct;124(4):1193-8. doi: 10.1542/peds.2009-0329. Epub 2009 Sep 28.
The data from a number of studies27–34 indicate that unsupplemented, breastfed infants experience their maximum weight loss by day 3 and, on average, lose 6.1% ± 2.5% (SD) of their birth weight. Thus, ∼5% to 10% of fully breastfed infants lose 10% or more of their birth weight by day 3, suggesting that adequacy of intake should be evaluated and the infant monitored if weight loss is more than 10%.35 Evidence of adequate intake in breastfed infants also includes 4 to 6 thoroughly wet diapers in 24 hours and the passage of 3 to 4 stools per day by the fourth day. By the third to fourth day, the stools in adequately breastfed infants should have changed from meconium to a mustard yellow, mushy stool.36The above assessment will also help to identify breastfed infants who are at risk for dehydration because of inadequate intake.
[Additional Means Of] Assessment of Adequacy of Intake in Breastfeeding Infants*
n addition to the breastfeeding assessment tools described here, other parameters that must also be assessed by health care professionals to assure that adequate milk transfer is occurring include: 1) infant weight; 2) test-weighing; 3) elimination patterns; and 4) growth.
The most accurate measure of breastfeeding adequacy is the infant’s rate of weight gain, documented by serial measurements.[7] Peak infant weight loss occurs at approximately 3 days of age[7] and should not exceed 7% of birth weight.[4,22] Once lactogenesis or the copious milk production begins on the second to fourth postpartum day, the infant should begin steady weight gain within a day or two.[7] By day 10 to 14 postpartum, the infant should have returned to birth weight[22] and gain approximately 20 to 35 grams or two-thirds of an ounce per day during the first 2 months of age.[23] Infants of women who are at risk for delayed lactogenesis, such as those who had a cesarean section[23] or medical complications such as preeclampsia[24] or diabetes mellitus[25] should be assessed for a longer period of time.
An infant who acts hungry after breastfeeding, feeds for short (< 10 minutes) or long (> 50 minutes) periods of time, and/or feeds 8 or more than 12 times daily should be evaluated for weight gain.[7] The infant test-weighing procedure should be performed using an electronic digital infant scale with accuracy to at least 2 grams.[7] The infant is weighed clothed pre- and postfeeding without changing the diaper between weight measurements. The prefeed weight is subtracted from the postfeed weight, and the difference represents the volume of milk consumed, where 1 gram of weight is equivalent to 1 mL of milk intake. Milk is slightly denser than water, so in theory this calculation overestimates the test weight results, which is countered by insensible water loss during feeding.[26]
And remember that poor feeding in a newborn can be a sign of sepsis as well as many other critical problems.
