Large weightloss in the community
NHS Lothian neonatal guidelines (in development)
Introduction
It is usual for babies to lose weight after birth. A lot of this is water weight and can result in up to 10% weight loss from birth weight. Sometimes babies lose more than this, particularly if they are breast fed. Midwives in NHS Lothian support families of babies with weight loss of up to 13% providing the baby is well but ≥13% weight loss is referred in to NNU. When large weight loss is due to feeding issues, these babies will benefit greatly from being seen in their homes by experienced community midwives or Neonatal Community Outreach Team nurses. Where possible these babies may be managed at home following discussion with a neonatal consultant and provided weight loss is <15%. It is important, however, to detect babies who have large weight loss due to other factors and to identify any unwell baby who needs prompt assessment in hospital.
It is important to consider why the large weight loss has happened. There are 3 broad categories for a baby to have a large weight loss:
- Establishing breast-feeding
Weight loss is common in babies establishing breast feeding as mothers’ milk can take a few days to come in. In that time the baby may have been receiving very small volumes of milk. It is important to increase the volume of milk in this situation until weight improves. This can be done with top ups of either expressed breast milk or formula milk. Babies should be offered top ups following each breast feed of up to 100ml/kg/day split between the number of feeds the baby is taking, usually by bottle.
- Increased metabolic demands
This is rare but an important consideration. If the baby is burning excess calories (for example due to congenital heart disease, metabolic disorder, intercurrent illness etc.) this can cause weight loss. In this situation the baby will usually appear unwell. The observations may be abnormal. These babies require urgent hospital assessment.
- Increased losses
This may occur if the baby has an intercurrent gastrointestinal illness or is not absorbing milk properly. This is uncommon in newborn infants but should be considered if the baby is stooling excessively or has very watery/bloody stools. These babies also require hospital assessment.
Nursing/Midwife Assessment:
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Weight monitoring |
Initially daily until baby is gaining weight and then at least twice weekly Any weight loss ≥15% requires same day assessment initially in ED at RHCYP. If baby is well on assessment in ED they can be discussed with NNU (bleep 1610) regarding further management Calculate % of weight loss up to 2 weeks of age |
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Feeding assessment |
How often does baby wake for feeds? - Frequency of feeds - Length of feeds – feeds which regularly take longer than 45mins to an hour - Feeding diary - Is baby settled following a feed
Is the baby sleepy? Sleepy babies may feed less than 8 times in 24 hours Very frequent feeds? (Feeding more than 12 times a day and not appearing settled between feeds) Is the baby settled after feeding? Nutritive / non-nutritive sucks? Is there correct attachment? Advice given to mum on expressing / hand expressing If bottle feeding, duration, volume, and frequency of feed Type of teat used |
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Hydration status |
Does the baby have: - Dry mouth/mucous membranes - Sunken fontanelle - Dry skin - Weak cry - Urates in the nappy – persistent urates indicate insufficient milk intake
Number of wet nappies / when was the last wet nappy observed Is the baby passing changed stools? Nappies – normal pattern Day 1 to 2 · 1 or more wet nappies per day · 1 or more meconium nappy Day 3-4 · 3 or more wet nappies – feel heavier · 2 or more – changing in colour and consistency – brown/green/yellow which are looser Day 5 to 6 · 5 or more wet nappies · At least 2 or more yellow stools which may be watery Day 7 to 28 · 6 or more heavy, wet nappies · 2 or more stools at least the size of a £2 coin, yellow/watery/seedy appearance
After Day 28 – baby will establish own pattern of stooling – may pass several a day or have several days’ gap between stools movements |
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Observations |
Respiratory rate Heart rate Temperature |
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Jaundice |
Is the baby clinically jaundiced? |
Calculating weight loss
(Birth weight – Current weight) x 100 = Total weight loss percentage %
Birth weight
Management plan
NCOT nurses and community midwives are very experienced to give good advice about feeding, technique etc. Following a detailed feeding history and examination of the baby, a feed should be observed followed by an appropriate top up volume. Top-ups of MEBM or formula of 60 - 100ml/kg/day are recommended until weight gain is reassuring. Ensuring observations are normal is important.
Remember, if a baby is taking good volumes and is formula fed, weight loss >13% is very unusual and would usually warrant medical review.
Any baby with a weight loss of ≥15% needs medical assessment and consideration of admission. Any unwell baby should be sent to ED at RHCYP immediately. Otherwise well babies should still be initially triaged and assessed at RHCYP and then discussed with neonatal tier 2 on bleep 1610 and an appropriate plan made which may include admission to PNW/TC/NNU as required. Once in hospital these babies will likely require minimum of U&Es/blood glucose/blood gas plus any other investigations as indicated by the assessment.
Each large weight loss baby who is not assessed at ED in RHCYP should be discussed with a neonatal consultant that day. The PNW consultant is around until 5pm and the on-call consultant until at least 8.30pm. If you are concerned that the baby is unwell, please direct them to ED at RHCYP (ambulance if required). If you feel that more intensive feeding support is warranted and that the baby looks ‘dry’ readmitting them to PNW or TC on the NNU may be appropriate.