When Weight Loss isn’t a good thing: Neonates in the ED – Growth & Feeding – PEM Induction

Author: Katie Knight / Review and Questions: Meriel Tolhurst Cleaver / Code: NeoC5, SLO5 / Published: 20/06/2016

Weight loss and feeding

One of the most common reasons for newborns to be sent in to the ED for assessment is weight loss (usually picked up by the midwife on a home visit). It is NORMAL for babies to lose UP TO 10% of their birthweight, but this should be regained at around day 10 of life.

How do we work out percentage weight loss?

So for a baby that weighed 3650g at birth and now weighs 3350g:

(3650 – 3350) ÷ 3650 x 100 = 8.2%

Lost more than 10% of birth weight? These babies usually need admission, so get them reviewed by paediatrics.

You will remember Ed Selson’s  tip in his metabolic blog that babies are non-specifically unwell (let’s face it, babies are hardly likely to be specific about anything anyway), for 5 big reasons:

So, with that in mind, it is our job to start thinking of the differentials.

A capillary blood gas is really helpful (can be done from a heel prick sample), as this is a quick way to measure electrolytes, a lactate and glucose measurement. Babies who have lost weight and have a high sodium need careful rehydration in hospital.

However – any baby referred in, even if weight loss is less than 10%, needs a careful feeding assessment.

First things first – the feeding history.

I hope that this is obvious: now is NOT the time to make any comments or judgements on how the parents have chosen to feed their baby, whatever your personal feelings about breast versus bottle. There is no place for unhelpful, upsetting terminology like ‘failure to breastfeed’.

Mums often come under a huge amount of pressure from society/midwives/friends/doctors/families/nosy strangers (delete as appropriate) to breast feed. If this is something they are struggling to do (or don’t even want to) – it is not your place to push it.

As a paediatrician friend of mine likes to say:

So, is baby being bottle or breast fed? Or mixed feeding? (what proportion of bottle vs breast)? Has this changed since birth?

General questions include:

• Does baby wake spontaneously for feeds (or cry for feeds) or do parents have to wake baby up?
• Is the baby vomiting (large amounts) after feeds, or just small spit-ups? What colour is the vomit? (Green vomit is a surgical emergency so do ask this specifically, and if it really is green, get a surgical review asap)
• Are they burping/winding the baby after feeding? How long does this take?
• How many wet nappies, and how many dirty nappies per day?
• What colour is the urine? (red/orange ‘brick dust’ coloured staining in the nappy can be due to the presence of urate crystals, a sign baby is dehydrated).
• Has the patient passed any stool since birth? What colour are the stools? (Thick sticky black stools – meconium – is normal to begin with, then they will become lighter, greenish-yellow to bright yellow, and looser (‘seedy’) in textured. (I was going to add a series of links to all these different poo types but good taste got the better of me I figure you all know how google works, right?)

If bottle feeding:

• How much is the baby taking per feed? (in millilitres, or many parents will still talk about ounces, as this is commonly what’s printed on the side of baby bottles – 1 oz = 30ml)
• How many hours between each feed?
• How long does it take baby to finish a feed?
• What type of formula are they using and have they changed this recently?

If breast feeding:

• Has your milk ‘come in’ yet? (if it has, mums will notice nipples leaking, or they may be able to hand express some milk from the nipple – is it colostrum (thin clear yellow liquid) or milk?)
• Is this your first baby? (milk can take up to 3 days to come in, usually quicker if not the first baby…)
• How many hours between each feed?
• How long does baby stay on the breast for?
• Is baby alternating between breasts?
• Is it painful when baby latches on, and if so has the midwife given you any help with this yet?
• Does baby seem satisfied after feeding? (If well fed will usually sleep for several hours after a feed)
• Do your breasts feel different/less full after a feed?

Examination

Aside from the general physical examination, here are a few specific things to look for in a weight loss/poor feeding presentation.

• Check – with your finger and also with a pen torch – for a cleft palate. Wouldn’t want to miss this, and they can’t always be easily spotted like in the picture below.

• Does the skin appear ‘loose’ or wrinkly on the abdomen? This is a sign that there has been significant weight loss.
• Look in the nappy. Is it wet? Is there ‘brick dust’ – urate crystals? This is usually a sign that baby is slightly under-fed. Sometimes parents worry that it is blood – it’s not.

• Check blood glucose (heel prick BM).
• Look for jaundice (sclerae/palate) – dehydrated babies are often jaundiced (and vice versa!) If you’re lucky your department might have a gas machine that can measure bilirubin…
• Put a glove on and check the suck reflex – will the baby suck your little finger?
• Is there a patent anus?

‘How much milk should my baby take?’

Every baby is different and some are ‘hungrier’ than others. However – in the midst of acute sleep deprivation and with the overwhelming demands of a newborn, parents often like to be given an ‘exact’ answer. Here’s a way to calculate roughly what baby needs.

Babies need gradually increasing amounts over their first few days of life, and this is calculated as ml per kg per day (always use BIRTH WEIGHT to calculate this number)

As a rough guide:

• On the first day of life 60ml/kg/d
• On the second day of life 75ml/kg/d
• On the third-fourth day of life 90ml/kg/d
• On the fourth-fifth day of life 120ml/kg/d
• By the seventh day of life 150ml/kg/d

So to calculate what a newborn baby, weighing 3.650kg needs IN TOTAL on day 1

60 x 3.650 = 219ml (round up to 220ml)

Divide this into amount per feed (and round the numbers to make it easier for sleep-deprived parents to understand).

If this baby is feeding every 3 hours, (220 / 24) x 3 = 27.5ml per 3-hourly feed (call it 30ml)

If this baby is feeding every 4 hours, (220 / 24) x 4 = 36ml per 4-hourly feed (call it 35ml)

These calculations are a GUIDE, and what a healthy baby takes can vary from baby to baby, and from feed to feed.

Clearly it’s much easier to work out what a bottle-fed baby is taking. If a mum is breastfeeding and is concerned about baby’s intake, it can be helpful to suggest hand expressing milk (or using a breast pump) so that she has an idea of how much milk she is producing.

Going home?

Less than 10% weight loss, with a normal physical examination and nothing else concerning in the history – these babies are usually just taking time to establish their normal feeding pattern. It is usually appropriate to send these babies home with careful safety netting if there is a feeding plan in place. A feeding plan usually covers the amount of milk baby is expected to take per feed or per day, and sometimes a plan for supplementing (‘topping up’) breastfeeds with formula milk if there may be a lack of supply of breast milk.

Always run things by the paediatric team if you’re unsure.

Give the parents a written feeding plan.

Encourage them to keep a feeding diary for a few days, as this will be a good way for them to start to see patterns in how their baby likes to feed. Record feed time, amount, vomits, wet nappies, dirty nappies.

The midwife should be visiting again within the next few days to check baby’s weight – call them and confirm when this is going to be. The midwife is also the best person to help with breastfeeding technique.

Safety netting – ask parents to come back if baby:

• Is not feeding at all
• Not passing urine at all
• Is vomiting large amounts or vomit is green
• Is lethargic or floppy
• Has a fever
• Has a rash

This may be obvious to you, but it isn’t always to them, so be helpful and point it out anyway, they are probably deprived of sleep (like you).

References/Further reading:

1. Neonatal nutrition
2. Early weight loss and gain in healthy, full term, exclusively breastfed infants
3. Neonatal examination from DFTB