Poor Weight Gain/Hyperbilirubinemia Feeding Support Note

Date/Time of Encounter: [Date and time of visit]

Author: [Author full name, credentials, role]

Encounter Type: [in-person / telehealth]

Location: [Clinic/location or telehealth platform]

Referring Clinician: [Name, role] (If self-referred, state "self-referred.")

Pediatrician of Record: [Name, practice]

Infant Identification

Name: [Infant name]

MRN: [Medical record number]

Date of Birth: [DOB]

Gestational Age at Birth: [GA in weeks+days] (If unknown, document "unknown - to be obtained.")

Chronologic Age: [Days of life] (Include hours of life when bilirubin decisions are relevant.)

Birth Location: [Hospital / birth center / home]

Discharge Date: [Date or "not yet discharged"]

Perinatal Context: [Delivery type, complications, risk factors for feeding delay or jaundice] (Include only concise, management-relevant factors.)

Hemolysis Risk Data: [Infant blood type, DAT/Coombs, maternal blood type, G6PD status] (Include only if hemolysis is in the current differential.)

Clinical Snapshot

(Provide an at-a-glance safety summary with 6–10 items.)

• Current weight: [weight in g]; percent change from birth: [%]; change since last weight: [g/day over date range]
• Current feeding method(s): [direct breastfeeding / expressed breast milk / donor milk / formula / mixed]
• Supplementation: [type, dose per feed or per 24h, method, schedule] (If none, state "none currently.")
• Output last 24h: wet diapers [number], stools [number and character/color]
• Most recent bilirubin: [TcB / TSB] [value] on [date/time] at [hours of life] (If not yet measured, state plan to obtain.)
• Red-flag symptoms: [present / absent] (Lethargy, poor feeding, dehydration signs)
• Feeding tolerance/behavior: [arousability, latch cues, emesis]
• Current disposition: [outpatient with close follow-up / urgent in-clinic evaluation today / ED referral now]

Chief Concern

[Reason for consult] (One to two lines summarizing presenting concern.)

History of Present Illness

Timeline: [Date/time of birth, current day of life, when concerns began, evolution to date, prior evaluations]

Weight history: [Parent-reported vs clinic-measured weights with dates; nadir if known; prior interventions]

Feeding history: [Frequency/intervals including overnight, duration and sidedness, responsiveness to early cues, arousability/sleepiness, latch characteristics, maternal nipple pain 0–10, pumping method/frequency/volumes if applicable, current supplementation details including type/volume/frequency/method/tolerance]

Output and hydration: [Wet diapers count/estimate, stool frequency and character, emesis/spit-ups, urine concentration concerns, signs of dehydration] (If caregiver cannot quantify, document ranges and note that a 24-hour diaper log will be started.)

Jaundice history: [Onset day, progression pattern, prior TcB/TSB values with dates/times and hours of life, prior treatment, relevant family or perinatal risk factors] (Include only if jaundice is part of the current concern.)

Pertinent context: [Additional risk factors that change management] (Include only if relevant, such as late-preterm status, maternal delayed lactogenesis risk factors.)

Objective

(Present raw objective data with timestamps before interpretation. If unavailable, document "unknown - to be obtained.")

Weight Data

Date/Time	Source	Weight (g)	Notes
[Date/time of birth]	Birth record	[Birth weight]	[Context if relevant]
[Date/time]	Discharge	[Discharge weight]
[Date/time]	[Source]	[Nadir weight]
[Date/time]	[Outpatient/home]	[Prior weight]	(Add rows as needed.)
[Today's date/time]	Today (this visit)	[Today's weight]	[Scale type, clothing/diaper standardization]

Calculated values: Percent change from birth: [%]. Change since last weight: [g/day] from [start date] to [end date].

Intake/Output Summary (Last 24 Hours)

• Wet diapers: [number] (If unknown, document and start 24h diaper log.)
• Stools: [number, character/color, transition status]
• Total supplement volume: [mL/24h] (If tracked.)
• Total pumped milk volume: [mL/24h] (If tracked.)

Bilirubin and Relevant Labs

• [TcB / TSB]: [value], drawn [date/time] at [hours of life]
• Direct/conjugated bilirubin: [value] (Include if jaundice is prolonged.)
• DAT/Coombs, blood type, G6PD: [results] (Include only if hemolysis is in the differential.)

Focused Physical Exam

• General: [alertness, tone, feeding cues, distress level]
• Hydration: [mucous membranes, tears, fontanelle, capillary refill/skin perfusion]
• Jaundice: [distribution and intensity] (Do not equate visual assessment to bilirubin level.)
• Neurologic red flags: [lethargy present / absent], [tone normal / abnormal], [cry normal / high-pitched], [suck quality]
• Other pertinent findings: [findings relevant to feeding/weight/jaundice]

(If telehealth or limited exam, specify what was observed visually vs reported.)

Feeding Observation

Observed feed: [date/time]. Breast offered: [left / right / both]. Position: [cross-cradle / football / side-lying / laid-back / other]. Latch: [deep / shallow], [lip flange adequate / inadequate], [seal intact / broken]. Suck-swallow pattern: [audible swallows present / absent], [sustained rhythmic sucking / frequent pauses / fatigue noted]. Maternal comfort: [pain score 0–10]. Infant post-feed behavior: [satiated / still hungry / sleepy].

Milk transfer assessment:

• Test weight: Pre-feed [g], post-feed [g], net transfer [mL]. Scale: [type]. Standardization: [diaper/clothing controlled]. (Use if test weights performed.)
• Clinical estimate: Estimated transfer [mL] based on [audible swallows, sustained rhythmic suck, breast softening, infant satiety]. (Label explicitly as estimate.)
• Not performed: [Reason]. Alternative evidence: [pump volumes, diaper counts, feeding intervals]. (Use if transfer assessment was not possible.)

Assessment

(Organize as a numbered problem list in descending order of risk. Document observable basis for each problem. Distinguish what is known vs unknown.)

1. Hyperbilirubinemia/jaundice risk: [Likely suboptimal intake-associated / prolonged jaundice pattern / rule out hemolysis / rule out cholestasis]. Supporting evidence: [latest bilirubin with age at draw, trend, risk factors]. Unknowns: [pending data].
2. Inadequate intake/poor milk transfer: [Supporting evidence from weight trajectory, output, observed feed]
3. Poor weight gain/excessive weight loss: [% from birth, g/day change]
4. Maternal milk supply concern/delayed lactogenesis risk: [Supporting history/exam findings] (Include only if suggested by history.)
5. Latch difficulty and/or nipple pain/trauma: [Relevant findings] (Include only if present.)

Plan

Hyperbilirubinemia/Jaundice Management

• Current status: [Latest TcB/TSB value/time at hours of life] (If pending, state plan and timeframe.)
• Threshold decision-maker: [Pediatrician/clinician name]
• Follow-up: [Recheck timeframe and location]
• Phototherapy: [active / being considered / not indicated]. Setting: [inpatient / home]. Monitoring: [recheck frequency]. Breastfeeding during therapy: [continue with plan described / modifications]

Feeding Optimization

• Target frequency: [at least every 2–3 hours / wake if sleepy / on-demand with minimums]
• Latch/position strategies: [specific recommendations]
• Transfer techniques: [breast compressions / switch nursing / stimulation strategies]
• Education provided: [early hunger cues, active feeding signs, when to wake infant]

Supplementation

(If not indicated, state "Supplementation not indicated" with brief rationale and skip remaining items.)

• Indication: [link to objective criteria]
• Type: [mother's expressed milk / donor milk / formula (specify)]
• Dose: [mL per feed and/or per 24h]
• Schedule: [after breastfeeding / separate feeds; day/night adjustments]
• Method: [SNS / cup / syringe / paced bottle with nipple flow]
• Stop/step-down criteria: [specific improvement targets]
• Family documentation: [feed and diaper log instructions]

Milk Expression/Pumping

(Include if supply or transfer is a concern or supplementation is in use.)

• Method: [hand expression / pump type]
• Frequency/duration: [sessions per 24h, minutes per session]
• Equipment: [flange size/fit, settings]
• Milk handling: [storage and use plan]

Monitoring and Follow-up

• Next weight check: [date/time/location]
• Bilirubin recheck: [ordered by whom, where, timeframe] (If applicable.)
• Lactation follow-up: [interval and modality]
• Disposition: [routine follow-up / same-day pediatrics / ED evaluation now]

Escalation Criteria

Call pediatrics today if:

• Feeding/behavior: worsening lethargy, too sleepy to feed, weak suck, feed refusal
• Hydration/output: markedly decreased wet diapers, no stools with ongoing weight loss, uric acid crystals, signs of dehydration
• Jaundice: rapidly worsening jaundice, bilirubin rising faster than expected
• Fever per newborn guidance

Go to emergency department now if:

• Severe lethargy, inconsolable or high-pitched cry, poor tone, or seizures
• Signs of severe dehydration: very few or no wet diapers, sunken fontanelle, poor perfusion
• Feed refusal across multiple attempts or persistent vomiting
• Bilirubin above treatment threshold with concerning symptoms
• Fever or caregiver concern for acute deterioration

Escalation criteria reviewed with caregiver; understanding confirmed: [yes / no - describe]

Coordination and Communication

• [Date/time]: Contacted [clinician name, role]
• Information shared: [weight summary with g/day and % from birth; bilirubin values with hours of life; feeding/output; plan]
• Collaborative decisions: [lab orders, phototherapy plan, follow-up appointments]
• Referrals placed: [lactation, pediatrics, home phototherapy, other]
• If unable to reach pediatrics: [attempts and times; backup plan; caregiver instructions]

Signature: [Clinician name, credentials]