Pediatric Follow up Note

Today, I had the opportunity to see Emily, accompanied by her mother, for concerns about feeding and inadequate weight gain.

**Medical Diagnoses:**
- Failure to thrive in newborn (P92.6)

**Medications:**
none.

**Last Visit:**
No previous follow-up visit was documented.

**Interim History:**
Emily's mother reports that Emily has been exclusively breastfed for the past month, after previously alternating with pumping and bottle-feeding. She is uncertain about Emily's milk intake during direct nursing, as Emily sometimes falls asleep while feeding and it is difficult to determine satiety. The mother is concerned that Emily has not gained much weight recently. 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 or significant discomfort. Occasional spit-up is noted. Wet diapers are being monitored, with a goal of at least 5 per day. The mother has a breast pump at home and reports variable milk output when pumping, especially after direct nursing. There is concern about insufficient intake and weight gain.

**Immunizations:**

**Development:**

**Social Updates:**

**Review of Systems:**
Diet: Emily is exclusively breastfed for the past month; previously received expressed breast milk via bottle.
Sleep: Emily sometimes falls asleep during feeds.
Stooling: Stool frequency is being monitored.
Exercise:
Screen Time:
Hearing:
Vision:
Puberty:

**Physical Examination:**

**Investigations:**

**Assessment and Plan:**
In summary, Emily is a newborn seen today for concerns about feeding and inadequate weight gain.
Emily has experienced a plateau in weight gain from three to four months of age, with concerns about insufficient milk intake during exclusive breastfeeding.

The following items and plans were discussed today:
- Mother to exclusively pump and bottle-feed Emily for one week to accurately measure daily intake.
- Target intake is at least 700–800 mL per day, with a goal of 120 mL per feed if feeding six times daily; higher per feed if fewer feeds occur.
- 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 or crying.
- Monitor for forceful vomiting or signs of discomfort and contact physician if these occur.
- Track number of wet diapers (minimum 5 per day) and stool frequency to assess hydration.
- Record daily intake amounts using a phone or chart.
- Return for a weight check in one week; goal is a weight gain of at least 200 grams.
- Mother to maintain adequate nutrition and hydration to support milk supply.
- Schedule follow-up appointment at the front desk for weight check.

**Follow-Up:**
Today, we discussed the following plan for follow-up: Return for a weight check in one week. Contact the office if Emily has forceful vomiting, significant discomfort, or fewer than 5 wet diapers per day.

Thank you for the opportunity to collaborate in the care of this patient. I will keep you apprised of any clinical updates. Please do not hesitate to contact me if you have concerns or questions.