Directorate: Women’s and Children’s
Author: Infant feeding group / Title: Guideline for monitoring growth in the early postnatal period and in infants up to one year
Code: WCH 007
Monitoring growth in the early postnatal period and in infants up to one year
Document
Code
/Date
/ Version Number / Planned Review DateWCH 007 / Dec 2005
Sept 2009
Aug 2012 / 1st Issue
Monitoring weight gain in the newborn and infants under nine months – Reviewed with All Wales Infant Feeding Guidelines
RevieReviewed in Line with All Wales Guidelines for Identifying and Managing Weight loss in Breastfeeding Babies in the Early postnatal Period / Dec 2008
Aug 2015
Document Owner / Approved by / Date
Nursing Director / Women’s and Childrens Directorate.
Clinical Effectiveness Committee / 30/08/12
03/09/12
Document Type / Guidelines
Bwrdd Iechyd Addysgu Powys yw enw gweithredol Bwrdd Iechyd Lleol Addysgu Powys
Powys Teaching Health Board id the operational name of Powys Teaching Local Health Board
Contents / PageValidation Form / 3
Equality Assessment / 4
Relevant to / 5
Purpose / 5
Definitions / 5
Responsibilities / 5
Process / 6
References / 5
Appendices
For Reviewed / Updated Policies Only:
Relevant Changes – / DateRevieReviewed in Line with All Wales Guidelines for Identifying and Managing Weight loss in Breastfeeding Babies in the Early postnatal Period / 2012
VALIDATION FORM
To be completed by the Author – no policy, procedure or guidance will be accepted without completion of this section which must remain part of the policy
Title: Monitoring Growth In The Early Postnatal Period and in Infants Up to One YearAuthor: Valentine, McAleese & the Infant feeding Group
Directorate: Women and Children’s
Reviewed/Updated by: Fiona Valentine Infant feeding coordinator, Sara McAleese Midwife, Donna Owen Lead Midwife, Marie Lewis Practice Development Midwife, Tess Lister Lead Health Visitor, Infant Feeding group
Evidence Base
Are there national guidelines, policies, legislation or standards relating to this subject area?
If yes, please include below:
All Wales Infant feeding guidelines (WAG 2007)
UNICEF UK Baby Friendly Initiative (2008)
All Wales guidelines for managing weight loss in the early post natal period (2010)
Royal College of Paediatricians and Child Health (2009)
NICE Public Health Guidance 11 (2008)
CONSULTATION
Please list the groups, specialists or individuals involved in the development & consultation process:
Name / Date
Powys Midwives / 14.3.2012
Powys Health Visitors / 14.3.2012
Supervisor of Midwives / 14.3.2012
Practice Development Midwife / 24.4.2012
Powys Infant feeding strategy group / May 2012
Karen Evans, Unicef Professional Officer for Wales
Paediatric Dietician
Paediatric Consultant
Agreed by Head of Midwifery / 30.8.201
Please insert the name of the Directorate/ Departmental/Discipline Committee or Group that has approved this policy/procedure/guidelines/protocol
Name / Date
Agreed by Women’s and Children’s Directorate / 30.8.2012
Implications
Please state any training implications as a result of implementing the policy / procedure.
Ongoing updates Baby Friendly Initiative training
Sharing at Midwifery and Health Visitor updates and Shire meetings.
Please state any resource implications associated with the implementation.
Financial implication: All staff who are involved in monitoring infant growth must be supplied with Class 3 Clinical electronic scales, measuring mat and appropriate head circumference measuring tape. Sewing or paper tape is not recommended for this purpose. All measurements should be metric.
Please state any other implications which may arise from the implementation of this policy/procedure.
· none
For Completion by Quality & Safety Unit
Checked by: / Date:
Submitted to CEC: / Date:
Equality Assessment Statement
Please complete the following table to state whether the following groups will be adversely, positively, differentially affected by the policy or that the policy will have no affect at all
Risk AssessmentAre there any new or additional risks arising from the implementation of this policy?
· No
Do you believe that they are adequately controlled?
· n/a
Equality statement
No impact / Adverse / Differential / Positive / Comments
Age / X
Disability / X
Gender / X
Race / X
Religion/ Belief / X
Sexual Orientation / X
Welsh Language / X
Human Rights / X
Monitoring weight gain in the neonate and infants under one year
Introduction
It is recognised that nutrition in infancy can impact on long-term health and wellbeing (Hall and Elliman; 2006. RCPCH; 2009). This guideline has been developed to support health professionals to provide equitable evidence-based care for parents and carers of neonates and infants under 1 year old throughout Powys tHB.
Early identification of weight loss of 8% or more (in the neonate) and developing obesity or faltering growth in the infant under one year old allows the health professional to target specific health promotion (Hall and Elliman, 2006 & WAG, 2010). A specific plan of action should be implemented in order to prevent avoidable complications such as neonatal hypernatraemic dehydration and loss of parental confidence (Iyer et.al. 2011)
Relevant to: These guidelines are designed to assist all health care professionals working with neonates and the under ones in Powys.
Purpose
To provide early evidence based public health intervention.
Responsibilities: Health Visitors and Midwives are trained to monitor growth. Any health care assistants or NNEB’s required to monitor growth need appropriate in-house training. Adherence to this guideline will be monitored through clinical midwifery and health visiting supervision and audit. Adverse issues can be raised via line manager and the Datix reporting system.
Process
Routine monitoring of growth
All growth of the under ones in Powys must be recorded on the UK-World Health Organisation (WHO) Growth Charts. (RCPCH, 2009)
Table 1 shows the recommended age at which the highlighted measurements should be taken.
All Health Professionals in Powys working with neonates and the under ones should familiarise themselves with the All Wales Feeding Guidelines (WAG 2007), the All Wales Guidelines on Identifying and Managing Weight Loss in Breastfeeding Babies in the Early Postnatal Period (WAG 2010). Health Visitors also need to be familiar with RCPCH guidelines on the WHO Charts (2009). These documents all advise on the good evidence based management of growth concerns and these practices must be universally adopted.
Table 1
Age / Head Circumference / Length / WeightBirth / ü / ü
72+ hours / ü
10-14 days / ü / ü
6-8weeks / ü / ü / ü
12-16 weeks / ü
7-9 months / ü / ü
Table showing age of routine measurements (WHO, 2009)
Babies about whom there are no concerns who are above birth weight should not be weighed more than monthly under the age of six months, and no more than every two months thereafter (WHO 2009).
Action : neonates
A neonate is an infant up to the age of 28 days (the day of birth is always day 0)
Neonates in the community will be under the care of the midwifery team until at least day 10. Between day 10 and day 14 the health visitor will undertake the primary birth visit. A subsequent plan of care will be formulated between the family, the health visitor and the midwifery team. Babies about whom there are no concerns will be discharged to the care of the health visitor on or shortly after day 10 (although midwives may continue to visit for maternal reasons.)
The midwife will weigh the baby at 72+ hours of age
If weight loss > 8%-10% in a breastfed neonate is identified, follow All Wales Guidelines Care Plan 1.
The All Wales Guidelines on Identifying and Managing Weight Loss in Breastfeeding babies in the Early Postnatal Period (2010) advise routinely weighing at 72 hours+. Together with an accurate feeding assessment, this can prevent or reduce the incidence of complications (Iyer et.al. 2011). If infant formula has to be given to prevent medical complications in a breastfeeding neonate, reduction of its use should be encouraged as soon as feeding is better established (WAG 2010).
If the breastfed infant is displaying any of the following clinical signs then the Care Plans in the All Wales Guidelines on Identifying and Managing Weight Loss in Breastfeeding Babies in the Early Postnatal Period (WAG 2010) must be adopted:
· less than eight feeds in 24 hours.
· not enough wet/dirty nappies (should be at least 6 wet nappies per 24 hour period and at least 3-4 stools).
· stool not changed to yellow by day five.
· baby sleepy/not waking for feeds/feeding infrequently.
· clinical signs of dehydration/poor muscle tone/skin turgor.
· baby has extremely frequent, long feeds but does not settle.
· mother has sore nipples which are not getting better
· If the weight loss of a breastfed neonate at 72 hours old is more than 8%.
The UNICEF Baby Friendly Breastfeeding Assessment Checklist is useful in assessing feeding efficacy and is part of the Board’s Breastfeeding Policy. This guideline supports its use by both Midwives and Health Visitors in the first postnatal contact. If infants are formula fed a feeding assessment including type, volume and frequency of feed should be undertaken. As a general guide, most infants will require 120-150mls/kg per day of age-appropriate infant formula. The All Wales guidelines above apply equally to formula fed babies, with the exception that formula fed babies stools are less frequent. Parents should be confident in the safe preparation of feeds and should be referred to the Birth to five publication (WAG, 2011).There should be a discussion about the benefits of demand feeding for formula fed babies as research suggests that those fed to a rigid schedule are less likely to regulate their appetites and therefore are at a greater risk of obesity in later life (Li et. al., 2010).
Action :
Growth should be monitored more frequently than in Table 1 in the following circumstances:
· Concerns regarding health of baby (known health problem, irritability, abnormally sleepy, failing to wake for feeds, lethargy, vomiting).
· Child protection concerns.
· If jaundice present beyond 14 days of birth.
· Weight crossing centiles (up or down).
· Parental concern.
· Height and weight markedly discrepant.
Growth Concerns in the first year of life
Babies should normally have regained their birth weight by two weeks of life and thereafter the average weight gain is 170-180g per week to four to six months and 113-142g per week to one year (Infant Feeding Guidelines 2007.) In the event that this does not occur, close monitoring of feeding pattern, output and growth (including weight, length and head circumference) with appropriate referral is necessary.
Centile Crossing
Centile crossing up and down can be associated with ill health, abuse, neglect and perinatal mental illness as well as feeding problems, and a clinical assessment should be undertaken when considering growth problems (Wright et. al. 2006 and Hall & Elliman 2003).
Hall and Elliman (2003) reported that few babies continued on exactly the same centile as birth, with about 50% of babies crossing one centile and 5% crossing two. It is important to monitor both weight and length when considering growth problems (Hall & Elliman 2003). The decision to refer for centile crossing can be difficult as it can create unnecessary worry for parents.
Growth Monitoring
Equipment: UK-WHO Centile charts
Grade III Electronic, self-zeroing scales.
Scales to be calibrated annually.
Tape for head circumference measurement
Measurement mat
Procedure: No clothes or nappy (up to age 2.)
· Scales should be on a firm surface, preferably the floor.
· Weight should be documented in grams, in Personal Child Health Records (red book) and baby’s postnatal pathway (as a variation or in the feeding section) by midwives
· in red book (for babies about whom there are no concerns) or centile chart in UCHR for babies about whom there are concerns by the health visitor
Referral
Babies under 2 weeks of age with a weight loss between 8%-10% of birth weight should have a full breastfeeding assessment as detailed in Care Plan 1. This will identify areas of concern and a plan of support will be prepared, using the WAG Guidelines (2010) Care Plan 1 as a source of reference.
Most children with weight loss greater than between 11%-14% (WAG Guidelines Care Plan 2) will be medically well, but should be referred for medical assessment if illness is suspected. Many will be having feeding problems of some kind and their weight loss may be an indicator that support from an infant feeding specialist is needed. Babies with more than 15% weight loss need review by a Paediatrician and intensive support with feeding (WAG Guidelines Care Plan 3).Severe weight loss may be the only obvious sign that a baby has an underlying medical problem such as a cardiac defect or an inherited metabolic disorder.
For older babies indications for referral are more complex and the health visitor should consult the specific guidance for the growth chart in use. Age and stage of weaning need to be considered. Use of the ‘Birth to Five’ (WAG, 2011) and ‘Start4Life’ books (WAG, 2011a) when discussing weaning, diet and appropriate exercise with parents is recommended.
Concerns about weight gain should be discussed with an appropriately trained health professional (GP with child health surveillance training, Paediatrician or Paediatric Dietician).
References
Amerongen RH, Moretta AC, Gaeta TJ. (2001) Severe hypernatraemic dehydration and death in a breast fed infant Pediatric Emergency Care 17:175-80.
Hall DMB, Elliman D (2006) Health for all Children, 4th Edition. Oxford University Press: Oxford
Li R, Fein SB, Grummer-Strawn FM (2010) Do Infants fed from bottles lack self-regulation of milk intake compared to directly breastfed infants? Paediatrics, May 2010
Royal College of Paediatrics and Child Health (2009) UK-WHO Growth Charts - Fact Sheet 1 www.growthcharts.rcpch.ac.uk
Royal College of Paediatrics and Child Health (2009) UK-WHO Growth Charts - Fact Sheet 4 www.growthcharts.rcpch.ac.uk
Shroff R., Hignett R., Pierce C., Marks S., van’t Hoff W. Life threatening hypernatraemic dehydration in breast fed babies. Archives of disease in childhood (2006) 91; 1025-6
All Wales Feeding Guidelines(WAG 2007) http://howis.wales.nhs.uk/doclib/english-infant-feeding.pdf