Well Child Visit (Newborn)

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

Accompanied By:
Olivia (Mother)

Concerns and Questions:
Olivia expresses concern regarding Lily's feeding adequacy and recent lack of weight gain. She is unsure about the volume of breast milk Lily is consuming during direct nursing and questions whether Lily is receiving sufficient nutrition.

Social History:
- Lives with family members.
- No information available regarding pets.
- No information available regarding smoke and carbon monoxide detectors.
- No information available regarding firearms or ammunition storage.
- No information available regarding smoking exposure.
- No information available regarding childcare arrangements.

Medication History:
Patient takes no meds

Interval History:
Lily is an established patient. The mother reports a transition from mixed feeding (breastfeeding and bottle-feeding expressed milk) to exclusive direct breastfeeding over the past month. The mother notes uncertainty about Lily's intake and observes a plateau in weight gain since three months of age.

Nutrition:
Lily is exclusively breastfed via direct nursing for the past month. The mother previously used a breast pump and bottle-fed expressed milk but has not done so recently. The mother is unsure of the exact volume Lily consumes per feed. Lily sometimes falls asleep during feeds, and the mother finds it difficult to determine satiety. Lily does not cry for hunger even after 5–6 hours between feeds and does not vomit forcefully or seem uncomfortable after feeds.

Elimination:
The mother is instructed to monitor wet diapers, aiming for at least five per day, and to track stool frequency to assess hydration. No further elimination details provided.

Sleep:
No information available regarding Lily's sleep patterns, position, surface, or location.

Behavior:
Lily does not show strong hunger cues.

Objective:
Vitals:
Weight: 5.3 kilograms
No information available regarding length or head circumference.

Vital Notes:
Lily's weight gain has plateaued between three and four months of age, as observed on the growth chart.

Screening:
No screenings ordered or documented during this visit.

Assessment and Plan:
- Inadequate Weight Gain in Infant (R62.51): Lily has experienced a plateau in weight gain from three to four months of age, as evidenced by review of her growth chart. She is exclusively breastfeeding, with recent transition from occasional bottle-feeding to direct nursing. The mother expresses concern regarding the volume of milk intake per feed and uncertainty about satiety cues, as Lily sometimes falls asleep during feeds and does not always display strong hunger cues. Lily occasionally goes five to six hours between feeds without crying. 
Plan:
• Advised mother to exclusively pump and bottle-feed for one week to accurately measure Lily's daily milk intake.
• Instructed that Lily should receive at least 700 to 800 milliliters of breast milk per day, with a target of approximately 120 milliliters per feed if feeding six times daily. If fewer feeds occur, the volume per feed should be increased accordingly.
• Recommended waking Lily to feed every three to four hours during the day, rather than relying on hunger cues or crying.
• If daily intake is less than 700 milliliters, advised to supplement with formula or previously expressed breast milk to ensure adequate caloric intake.
• Instructed mother to offer additional milk if Lily appears hungry after a feed, emphasizing that overfeeding is not a concern at this stage due to the need for catch-up growth.
• Provided guidance that minor regurgitation is acceptable, but to monitor for forceful vomiting or signs of discomfort and to contact the clinic if these occur.
• Advised to monitor for at least five wet diapers per day and to track stool frequency as indicators of hydration status.
• Requested that the mother document daily intake volumes and feeding patterns using a phone or chart.
• Scheduled follow-up appointment in one week for weight check, with a goal of at least 200 grams weight gain. The purpose of the follow-up is to assess response to the feeding plan and determine if further intervention is necessary.
• Provided reassurance regarding maternal milk supply and encouraged continued adequate maternal nutrition and hydration.

Dr. Johnson
Regional Medical Center