Pediatric New Consult (ASD)

Subjective:
Chief Complaint:
Infant feeding concerns and weight gain issues

Referred by:
Self-referred by Emma's mother for concerns regarding feeding and weight gain.

PARENTAL CONCERNS:
Emma presents for evaluation of feeding and weight gain concerns. The mother reports that Emma is currently exclusively breastfeeding, having transitioned from occasional bottle-feeding with expressed breast milk to direct nursing over the past month. The mother expresses uncertainty regarding the volume of milk Emma receives during feeds, noting that Emma sometimes falls asleep while nursing and it is difficult to determine satiety. The mother perceives that Emma has not gained significant weight recently. Review of Emma’s growth chart indicates appropriate weight gain until approximately two months of age, with a plateau in weight from three to four months. The mother reports variable milk output when pumping, with decreased volume after Emma has nursed. Emma sometimes goes five to six hours between feeds without crying. No strong hunger cues are observed. There is no report of forceful vomiting or discomfort. The mother does not rely on crying to indicate hunger. No additional symptoms or concerns are reported at this time.

Language:
No information available regarding Emma's language development.

Social/Emotional:
No information available regarding Emma's social or emotional behaviors.

RRBs (Restricted and Repetitive Behaviors):
No restricted or repetitive behaviors reported or observed.

ADL (Activities of Daily Living):
Emma is exclusively breastfed. No information available regarding other activities of daily living such as dressing or toilet training.

GM (Gross Motor):
No information available regarding gross motor skills.

FM (Fine Motor):
No information available regarding fine motor skills.

Cognitive:
No information available regarding cognitive abilities.

Childcare/School History:
No childcare or school attendance history provided.

Services:
No services such as speech therapy, occupational therapy, or hearing assessments reported.

Funding:
No information available regarding funding or financial support.

Activities in the community:
No information available regarding participation in community activities.

Pre/Post-Natal History & Infancy:
No information available regarding immunization status.

Past Medical History:
No chronic conditions, sleep disturbances, or other medical issues reported. Feeding difficulties are noted, specifically related to uncertainty about intake and recent plateau in weight gain.

Medications:
No medications reported.

Allergies:
No allergies reported.

Family and Social History:
No information available regarding family history, consanguinity, parental occupations, or social supports.

Objective:
Immunizations:
No information available regarding immunization status.

Physical Exam:
Growth chart review reveals appropriate weight gain until approximately two months of age, followed by a plateau from three to four months. No forceful vomiting or discomfort observed. No additional physical examination findings documented.

Assessment and Plan:
Assessment: Emma presents with concerns of inadequate weight gain and uncertain breast milk intake. Plan: Recommend exclusive pumping and bottle-feeding for one week to accurately measure intake. Target intake is at least 700 to 800 milliliters per day, with adjustments based on feeding frequency. Advise waking and feeding every three to four hours during the day. If intake is insufficient, supplement with formula or stored breast milk. Monitor for signs of adequate hydration, including at least five wet diapers per day and regular stooling. Schedule follow-up in one week for weight check, with a goal of at least 200 grams weight gain. Mother instructed to record daily intake and report any concerns such as forceful vomiting or persistent discomfort.

Plan:
Closure:
Thank you for allowing me to participate in the care of this child.

[Clinic Name] Please feel free to call and discuss should you have questions.