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. Peak infant weight loss occurs at approximately 3 days of age 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. By day 10 to 14 postpartum, the infant should have returned to birth weight and gain approximately 20 to 35 grams or two-thirds of an ounce per day during the first 2 months of age. Infants of women who are at risk for delayed lactogenesis, such as those who had a cesarean section or medical complications such as preeclampsia or diabetes mellitus 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. The infant test-weighing procedure should be performed using an electronic digital infant scale with accuracy to at least 2 grams. 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.
And remember that poor feeding in a newborn can be a sign of sepsis as well as many other critical problems.