ASD - Pediatric Consult Letter Template

PARENTS

REFERRAL INFORMATION:
- Reason for Referral: Concerns regarding feeding and inadequate weight gain

PARENTAL CONCERNS:
- Initial Concerns: [Fictional Name]'s mother reports concern regarding feeding and inadequate weight gain. She notes that [Fictional Name] is exclusively breastfeeding, having transitioned from occasional pumping and bottle-feeding to direct nursing over the past month. The mother is unsure about [Fictional Name]'s milk intake during feeds, as [Fictional Name] sometimes falls asleep while nursing and it is difficult to determine satiety. She is concerned that [Fictional Name] has not gained much weight recently.
- Actions Taken: The mother has been advised to pump and bottle-feed [Fictional Name] for one week to accurately measure daily milk intake, with a target intake of at least 700–800 mL per day. If intake is less than 700 mL, she is to supplement with formula or stored breast milk. Feeds are to occur every 3–4 hours during the day, regardless of hunger cues. The mother is to monitor for at least 5 wet diapers per day and track stool frequency to assess hydration, record daily intake volumes, and bring the log to the next visit. She is to return for a weight check in one week, with a goal of at least 200 grams weight gain. She is to contact the physician if [Fictional Name] exhibits forceful vomiting or appears uncomfortable. The mother is encouraged to maintain adequate nutrition and hydration to support milk supply.

DEVELOPMENTAL HISTORY:

NUTRITIONAL HISTORY:
- Feeding: [Fictional Name] is exclusively breastfed. The mother previously used a breast pump and bottle-fed at times, but for the past month, all feeds have been direct nursing. The mother is unsure of the volume [Fictional Name] consumes per feed. [Fictional Name]'s current weight is approximately 5.3 kilograms. Feeding frequency is variable, with intervals sometimes extending to 5–6 hours between feeds.

PRE/POST-NATAL HISTORY & INFANCY:
- Feeding: [Fictional Name] is exclusively breastfed. Some spit-up is noted, which is described as mild and not concerning.

PAST MEDICAL HISTORY:
- Medications: None reported
- Allergies: None reported
- Immunizations: Not available

FAMILY AND SOCIAL HISTORY: