Office Visit Note
Narrative: CHIEF COMPLAINT 2-month well child visit; parents concerned about poor weight gain, breastfeeding difficulties, possible tongue tie, fussiness at the breast, and a rash on neck and cheeks HISTORY OF PRESENT ILLNESS Macklin is a 2-month-old male presenting for his well child visit. Birth weight was 8 lbs 6 oz. He was at the 34th percentile for weight at a prior visit and today plots at the 10th percentile at 9 lbs 14.8 oz (9.88 lbs). He has been exclusively breastfed until yesterday, when mother began supplementing with formula (Nara Organics) due to concern that he was not getting enough to eat. Mother reports the formula supplementation seemed to help yesterday. Today they attempted 2 ounces of formula after breastfeeding and he refused it. Mother continues to use a nipple shield bilaterally due to significant pain with direct latch. She describes him biting hard and the latch being nearly unbearable without the shield. She notes he becomes fussy at the breast during feeds and remains fussy immediately after finishing. She pumps once daily during the 8:30 PM bottle feed and yields approximately 2–4 ounces (average ~3 ounces). She reports still feeling full/engorged after feeds, raising concern that he may not be emptying the breast efficiently. Mother suspects a tongue tie may be contributing. Mother returned to work yesterday and pumped at 1 PM and 4 PM during that time. She does not routinely pump at every feed. She is not currently working with a lactation consultant; she previously had resources in Boston but has not established lactation support locally since relocating. Since starting formula, mother has noticed thicker spit-up and changes in stool consistency. No bloody stools reported. She also notes a rash that starts on the back of his neck and spreads to his cheeks. He is described as fussy in general, though he tends to be calm in public. He received vitamin K and erythromycin eye drops at birth. No hepatitis B vaccine was given in the hospital. No vaccines have been administered to date. REVIEW OF SYSTEMS Fussiness, particularly during and after breastfeeding. Rash on neck and cheeks. Thicker spit-up noted since starting formula. Changed stool consistency since formula introduction. No bloody stools. No fever reported. No concerns about breathing or congestion mentioned. MEDICATIONS REVIEWED No medications. Recently started supplementing with Nara Organics formula. Received vitamin K injection and erythromycin eye ointment at birth. PHYSICAL EXAM General: Alert, sleeping at start of exam. Well-appearing infant. HEENT: **Tongue tie present** — mild; tongue can extend past lower lip. Throat examined, no abnormalities noted. Skin: **Rash on posterior neck and cheeks**, described as resembling a diaper rash-type eruption. Growth parameters: Weight 9 lbs 14.8 oz (9.88 lbs), **10th percentile (down from 34th percentile)**. Head circumference 39.5 cm. Musculoskeletal/Neuro: Good head control noted for age. Tone appropriate on handling. ASSESSMENT 1. Poor weight gain — weight has dropped from the 34th to the 10th percentile. Likely multifactorial; differential includes insufficient milk transfer (possibly related to tongue tie and latch inefficiency), low maternal milk production, possible food sensitivity or allergy, or reflux. No signs of severe malnutrition. Parents are attentive and motivated. 2. Breastfeeding difficulty — mother requires nipple shield bilaterally due to pain with direct latch. Infant is fussy at the breast and may not be emptying the breast efficiently given persistent maternal engorgement after feeds. 3. Tongue tie — mild anterior tongue tie confirmed on exam. Tongue extends past lower lip. Contributing to maternal pain and possibly to inefficient milk transfer. 4. Fussiness — temporally associated with feeds and post-feed periods. May reflect hunger, reflux, or food sensitivity. No definitive etiology established yet. 5. Neck and cheek rash — appears consistent with contact or irritant dermatitis on exam. 6. Immunizations not yet initiated — no vaccines given at birth or to date. Parents express cautious stance regarding vaccines; extensive counseling provided regarding vaccine-preventable diseases. PLAN 1. Poor weight gain: Supplement after every breastfeed with 2 ounces of pumped breast milk or formula (mother's preference). If infant consistently takes the full 2 ounces at each feed, increase to 2.5–3 ounces. Goal is to improve weight velocity. Mother to update provider over the weekend (by Sunday at latest) on how supplementation is going. Weight recheck scheduled in one week. No home scale recommended to avoid unnecessary anxiety — provider notes home scales are not accurate enough and may increase stress. Mother advised not to change her diet at this time so that if the cow's milk–based formula causes symptoms (increased fussiness, bloody stools, worsening spit-up), the etiology can be identified. If bloody stools develop, contact provider immediately as this would suggest cow's milk protein allergy. If current formula is not tolerated, may trial a different formula; advised not to buy large quantities of any single brand. 2. Breastfeeding difficulty: Referral to lactation consultant for evaluation and support. Mother to continue breastfeeding with nipple shield as needed and pump during supplemental feeds to maintain and potentially increase supply and relieve engorgement. 3. Tongue tie: Plan for tongue tie release (frenulotomy) given maternal discomfort and possible contribution to feeding inefficiency. Referral to be arranged. 4. Fussiness: Monitor response to supplemental feeds. If fussiness improves with increased caloric intake, hunger was likely the driver. If fussiness persists or worsens, will explore reflux and food sensitivity further. Briefly discussed that reflux management options include positioning changes and other interventions if needed. 5. Neck and cheek rash: Examined today; no specific treatment discussed. Will continue to monitor. 6. Vaccines: Deferred today to avoid confounding variables while trialing the new feeding plan (e.g., vaccine-related fever or fussiness could interfere with assessing feeding response). Plan to administer vaccines at the follow-up visit in one week. Extensive vaccine education provided including discussion of DTaP, Prevnar (PCV13), Hib, polio, hepatitis B, HPV, and influenza vaccines. Parents express willingness to vaccinate but desire a conservative approach. Provider recommended DTaP, Prevnar, and Hib as the priority infant vaccines. ANTICIPATORY GUIDANCE Infection avoidance counseled extensively — in the first 90 days of life, fevers are taken more seriously and warrant prompt evaluation. Parents planning to attend a wedding; advised to limit infant's exposure to crowds and handling by others. Provider offered to serve as the "excuse" for declining contact from well-meaning family and friends. Discussed the three major safety concerns by developmental stage: infections in newborns, choking in infants/toddlers/preschoolers, and driving-related injuries. Brief discussion of development — at 2–4 months, expect increased smiling and improved head control; not much active parenting intervention needed beyond feeding at this stage. Postpartum emotional health addressed — mother became tearful during visit; provider normalized the emotional experience and encouraged her to allow herself to feel sadness, noting the hormonal and emotional components of the postpartum period. Encouraged mother to reach out via text with any questions or concerns before the follow-up visit rather than waiting. FOLLOW-UP Return in 1 week for weight recheck and vaccine administration. Mother to text provider over the weekend (by Sunday) with update on how the supplemental feeding plan is going; sooner if any problems arise. ICD-10 CODES Z00.121 - Encounter for routine child health examination with abnormal findings R62.51 - Failure to thrive (child) CPT CODES 99391 - Preventive medicine, established patient, infant (age under 1 year) ───────────────────────────────────────── CODES: CPT 99391 | ICD-10 Z00.121, R62.51 Referenced Referenced Referenced