NHS FORTH VALLEY. Weighing Guidelines for newborn infants

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1 June 2008: Review June 2010 or Sooner Anne Paterson June 2008: Review June 2010 or Sooner Anne Paterson NHS FORTH VALLEY Weighing Guidelines for newborn infants Approved 23 March 2010 Version 3.0 Date of First Issue 1 April 2010 Review Date 1 April 2017 Date of Issue 29 April 2014 EQIA Yes Author / Contact Elaine Ronald Group / Committee Final Approval Unit Business Meeting Version th April 2014 Page 1 of 11

2 Consultation and Change Record Contributing Authors: Consultation Process: Elaine Ronald Circulation to senior paediatric consultant, Neonatal Forum, Ward Managers, Supervisors of Midwives. Review RCOG and NICE Guidelines, KCND Pathways and RCM Literature. Distribution: All Midwives, Ward Managers, Obstetric Consultants, Consultant Paediatricians, Midwifery Team Leaders, Supervisors of Midwives, Department Managers. Change Record Date Author Change Version 10/4/14 E Ronald Updated with few amendments Contact details of Infant Feeding Advisor Breastfeeding Assessment Day 4 & 6 Frequency of feeds/expressing 8 times in 24hrs Demand feeding to responsive feeding 3 Version th April 2014 Page 2 of 11

3 1 At birth Weigh all well babies in labour ward following birth and check by two maternity staff (or parent) before documented in relevant notes. Skin to skin contact and offer of first breastfeed should be prioritised before weighing baby. If early weight required then skin to skin should be recommenced immediately. If weight below 2500gms or if baby less than 37wks gestation or at risk of hypoglycaemia follow related hypoglycaemia protocol for monitoring and feeding. Day 4 (72-96 hrs) re-weigh only if clinically indicated - Low birth weight <2500gms Pre term < 37 completed weeks Poor feeder (breast or bottle) Jaundice Poor output (urine & changing stool) Calculate weight loss from birth (see example below). If weight loss exceeds 8% then follow appropriate management plan. If baby feeding well and no clinical concerns continue to monitor and record feeding pattern and urine output /changing stool in nappies. Weigh routinely on Day 6 All breastfed babies Formula fed babies if concerns re feeding and urine/stool output. Calculate weight loss from birth (see example below). If weight loss exceeds 8% then follow appropriate management plan. Calculation for % weight loss Birth Weight (g) minus current weight (g) divided by birth weight (g) times by 100 = percentage weight loss Examples: 3430gms 3120gms = = 0.09 X 100 = 9% 4050gms 3600gms = = 0.11 x 100 = 11% Weight loss 8-10% - follow Management Plan 1 Weight loss % - follow Management Plan Weight loss above 12.5% - follow Management Plan Version th April 2014 Page 3 of 11

4 2 Excessive weight loss occurs when there is: Ineffective milk transfer caused mainly by poor positioning and attachment. Infrequent feeding patterns i.e. baby is given complementary feeds or a dummy. Reduction in breastmilk production caused by the above factors. Delay in let down reflex caused by factors such as stress, anxiety and pain. Excessive weight loss in breastfed babies causes great anxiety to parents, carers, families and staff. It can lead to the cessation of breastfeeding and possible readmission to hospital. Prevention and Treatment of excessive weight loss: Education of mother to optimise their milk production Ensure the mother can effectively breastfeed prior to discharge home Identify the neonate who is at risk of hypoglycaemia and closely monitor using the related hypoglycaemia protocol If clinically indicated re-weigh 72 hours from birth or can be weighed prior to discharge if less than 72 hours old if there is a problem with positioning and attachment or urine/stool output Ascertain likely cause of weight loss quickly Plan management by the likely cause and severity of weight loss For advice and information the Infant Feeding Advisor can be contacted in Ward 8, ext Neonatal weight loss in the first few days of life is part of a normal physiological process where excess extra-cellular fluid is excreted. This weight loss has been expected to be up to 10% of the birth weight, although this expectation was never evidence based. Recent studies have indicated that normal weight loss in the majority of babies is more likely to be between 5 and 7% of birth weight. (Dewey et al 2005, Macdonald 2002). Infant weight is a late indicator of poor breastfeeding therefore the following should also be assessed using the Breastfeeding Assessment tool routinely on Day 4 and Day 6: Observing for effective positioning and attachment. Observation of the sucking pattern of the baby throughout a feed. Feeding frequency at least 8 times in 24hrs Baby behaviour during and following a feed Nappies for urine output and changing stool pattern refer to How to know your baby is getting enough milk Trauma to nipples, misshapen nipples when the baby comes off the breast Version th April 2014 Page 4 of 11

5 Women, Children s & Clinical Services Unit 3 Breastfeeding Management Practices which optimise milk production Skin to skin contact at birth. Help with a second breastfeed within 6 hours of birth. Ensuring the mother is taught the skills of positioning and attachment and has the help required to learn these skills. Keeping mother and baby close together Responsive feeding in recognition of feeding cues. Frequent access to the breast and skin to skin contact to encourage breastfeeding. If baby is reluctant or sleepy ensure breast milk is expressed and given by syringe or cup. Please refer to the sleepy, reluctant feeder guidelines here. Ensure babies are fed a minimum of 8 times in 24 hours. If the baby is not feeding well, staff should follow the Guidelines for babies reluctant to breastfeed and document clearly in the maternal notes the reasons for this. Hand express or use breast pump if appropriate 8 times in 24 hours. Expressing can be done to suit the mother i.e. after a feed, in-between feeds. Avoid use of formula feeds, teats and dummies. Discuss with the mother the reasons for this to allow informed choice and clearly document in maternal notes if a supplementary feed is given, including how it is given to the baby. Positioning checklist: Baby held close to mother Head and body in a straight line Baby at breast level, nose opposite nipple Baby supported by shoulders/neck so that head extends slightly (i.e. baby should not be held in crook of arm) Chin comes to the breast first Ensure position is sustainable Attachment checklist: Baby has wide open mouth Chin indents the breast Cheeks full and rounded More of areola visible above top lip Lower lip curled back Rhythmic suck/swallow pattern Mother reports that feeding is pain free Version th April 2014 Page 5 of 11

6 4 MANAGEMENT PLAN 1 - Baby with 8 10% weight loss Complete Breastfeeding Assessment and observe a full breastfeed Assess for effective positioning and attachment provide additional breastfeeding support to ensure effective breastfeeds. Observe sucking pattern short initial sucks change to deep slow rhythmic sucks with pauses and audible swallows. Ratio of sucks to swallows should be one or two sucks then swallow. Observe a full breastfeed Observe a normal sucking pattern Ensure minimum 8 feeds in 24 hours. Advice mother to initiate feeds every 3-4hrs if baby not showing feeding cues regularly. Ensure minimum of 8 feeds in 24 hours Skin to skin contact to encourage breastfeeding. Offer frequent access to the breast to initiate feeding cues and encourage regular breastfeeds Skin to skin contact to encourage breastfeeding Observe for change in frequency/volume of urine and stool output, ensure changing stool pattern. Observe for urine and stool frequency Weigh again in 48hrs. If weight increasing, continue to monitor closely and provide ongoing support. Weigh again in 48hrs If no or minimal increase, see Management Plan 2 If no or minimal weight gain see management plan 2 If weight improved continue support Version th April 2014 Page 6 of 11

7 5 MANAGEMENT PLAN 2 - Baby with % weight loss no/minimal improvement following Management Plan 1 Follow Management Plan 1 + Discuss with Paediatric Registrar Review in P/N ward Mother encouraged to express breast milk and cup feed If no EBM then cup feed with formula milk with full parental Explanation If baby below 2.5kg or under 37 weeks gestation then full top up should be cup fed Observe urine and stool frequency Re-weigh in 24 hrs and monitor progress Consider Management Plan3 if no or minimal Version th April 2014 Page 7 of 11

8 Follow Management Plan 1 + improvement Discuss with paediatric registrar, for review of underlying illness. If baby clinically well continue to follow Plan 2. Review in P/N ward for breastfeeding assessment and support Show mother how to express breastmilk (EBM) after each feed to stimulate milk supply double pumping recommended. Give baby EBM by cup following each breastfeed. If little or no milk is expressed, then it would be medically indicated due to the excessive weight loss, to offer appropriate volume of formula milk via cup with full parental explanation. For small babies < 2.5kg, or premature babies <37 weeks, then a full top- up feed should be given if little is expressed. Full feed if required will be calculated using the following formula 150mls/per kg/per day. Remember to deduct the amount of EBM obtained from the amount required of formula Observe urine and stool frequency to monitor for improvement in output/changing stool colour Weigh again in 24 hrs and review feeding progress/ volumes of EBM. Continue to weigh twice weekly until clear trend towards birth weight shown. Consider management plan 3 if no or minimal improvement NHS Forth Valley 6 Version th April 2014 Page 8 of 11

9 MANAGEMENT PLAN 3 - Baby with weight loss > % or no/minimal improvement following Management Plans 1 and 2 Refer immediately to paediatrician Urgent referral to paediatrician Baby may be seen in either P/N Ward (up to Day 10) or Children s Ward depending on age of baby and treatment required. Baseline tests to assess baby for dehydration or infections Admission to hospital FBC, U&E s, SBR, septic screen, urine microscopy Further tests may be required if any signs of infection noted from initial assessment CRP and blood cultures if clinically indicated Continue to follow Plans 1& 2 to ensure assessment of feeding pattern and breastfeeding support continues Follow Management Plans 1 & 2 Review baby s intake over previous 24hrs, i.e. amount of supplements EBM and formula. Calculate daily requirement 150mls/kg/day every 3 hrs. Ensure baby is feeding adequate volumes of milk for age calculate daily requirements Give maximum support at each breastfeed and observe attachment and signs of effective sucking. Encourage to continue expressing by hand/pump to stimulate and improve lactation. Frequent breastfeeding and expressing to stimulate milk supply Reduce volumes of formula milk as breastfeeding improves and volumes of EBM increase. As EBM volumes increase reduce formula top ups If baby unable to breastfeed effectively and is dehydrated IV fluids or NG feeds may be required (Children s Ward). Encourage mother to continue to express 8times in 24hrs including at least once at night. Weigh daily in hospital until weight gain improves then monitor twice weekly in community until regains birth weight. NHS Forth Valley May require NG feeds or IV fluids Re-weigh in 24 hrs, then twice weekly until regains birth weight 7 Version th April 2014 Page 9 of 11

10 REFERENCES Dewey KG, Nommsen-Rivers LA, Heinig J et al. (2005) Risk factors for suboptimal Infant breastfeeding Behaviour, Delayed Onset of Lactation, and excess Neonatal Weight Loss, Pediatrics: 112, Macdonald PD, Ross SR, Grant L et al. (2003) Neonatal weight loss in breast and formula fed infants. Arch Dis Child Fetal Neonatal Ed: 88; F472-F476 Neifert MR. (2004) Breastmilk transfer: Positioning, Latching on, and screening for problems in milk transfer. Clinical Obstetrics and Gynaecology: 47; Oddy S, Richmond S, Coulthard M. (2001) Hypernatraemic dehydration and breastfeeding, a population study. Archives of Disease in Childhood: 85; Sachs M, Oddy S. (2002) Breastfeeding weighing in the balance reappraising the role of weighing babies in the early days. MIDIRS: 12; Version th April 2014 Page 10 of 11

11 Publications in Alternative Formats NHS Forth Valley is happy to consider requests for publications in other language or formats such as large print. To request another language for a patient, please contact For other formats contact , text , fax or - Version th April 2014 Page 11 of 11

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