Pediatric Cardiology – Follow-Up Assessment

Dear Dr. 

CARDIAC DIAGNOSES:

CARDIAC SURGICAL AND INTERVENTIONAL HISTORY:

RESIDUAL CARDIAC PROBLEMS:

NON-CARDIAC CO-MORBIDITIES:
Failure to thrive in newborn (P92.6)

MEDICATIONS:

ALLERGIES:

CLINICAL PRESENTATION:
I saw Emily with concerns about feeding and inadequate weight gain on 2026-02-02 at . Emily has been exclusively breastfed via direct nursing for the past month, previously alternating with pumping and bottle-feeding. The mother is uncertain about Emily's milk intake during direct nursing, noting that Emily sometimes falls asleep while feeding and it is difficult to determine satiety. Review of Emily's growth chart reveals appropriate weight gain until approximately two months of age, followed by a plateau in weight from three to four months. Emily occasionally goes 5–6 hours between feeds without crying. There are no reports of forceful vomiting; occasional spit-up noted. The mother has access to a breast pump and has noted variable milk output when pumping, especially after nursing. No formula is currently being used. Advised to monitor for at least 5 wet diapers per day.

PHYSICAL EXAMINATION:

INVESTIGATIONS:

IMPRESSION & PLAN:
Mother to exclusively pump and bottle-feed Emily for one week to accurately measure daily milk intake. Target intake is at least 700–800 mL per day, with a goal of increased intake to promote catch-up growth. If daily intake is less than 700 mL, supplement with formula or stored breast milk. Feed Emily every 3–4 hours during the day, regardless of hunger cues, to ensure adequate intake. 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. Return for a weight check in one week; goal is a weight gain of at least 200 grams. Contact physician if Emily experiences forceful vomiting or appears uncomfortable after feeds.

Sincerely,
Dr. Lin Chen