Pediatric Infant Reflux : History and Physical – Assignment 1 Solution
Pediatric Infant Reflux : History and Physical
Pediatric Infant Reflux : History and Physical
Provider:
Date of Service: 26/03/2022
Time of Service: 1430
Patient: K.M
Date of Birth: November 23, 2021
Race Ethnicity: African American
Insurance: None
Allergies: NKDA
Medications: None
Chief Complaint: Patient presents today for episodes of spitting up when he breastfeeds, which have worsened in the last three days.
Historian: Mother
History of Present Illness: Patient (K.M.) presents today for episodes of spitting up when he breastfeeds, which have worsened in the last three days. The mother says that K.M. currently only takes breast milk, and she is preparing for weaning in the six months. She had taken him to a nearby clinic one week ago for a weight check.
She was advised to give him Neosure formulae to supplement breast milk. However, the formula did not help, so she decided to visit our clinic. While she gave him 60ml of the formula every 2-3 hours, he was spitting a good amount, and some of it was leaving through the infant’s nose, which made him cry a lot. The mother also reports that the spit does not appear curdled and mainly occurs at night.
Additionally, the patient’s condition worsened upon taking the formula, and the mother decided to stop giving him the formula and give him breast milk instead. As a result, the patient sleeps for approximately 9 hours a day which has reduced from the 15 hours he was sleeping before.
In this case, he used to sleep for 10 hours at night, but spitting disrupts his sleeping patterns, which affects his quality of sleep. The patient lives with his mother as his father is in the military. He is the youngest child in a family of three. They have two dogs at their home, and the patient’s immunizations are up to date per the CDC recommendations. Also, the patient’s growth and development are appropriate for his page.
Past Medical History:
Birth History:
Prenatal: The mother did not have any pregnancy difficulties and received routine care until the 32nd week.
Natal: The patient was born prematurely at 32 weeks and was delivered through cesarean section.
Postnatal: The patient was admitted for one month for extra medical care and to ensure he is healthy and growing normally before he is released to go home.
Medical/Surgical History: The patient does not have any surgical or medical history after being discharged following birth.
Injuries: The patient does not have significant injuries requiring hospitalization or medical intervention.
Hospitalizations: The patient has only been hospitalized for one month after birth.
Family History: Mother (35 years) has a history of pyloric stenosis. The father (36 years) does not have any significant past medical history. Maternal grandmother (62 years) and grandfather (65 years) have Type 2 Diabetes. Paternal grandmother (66 years) has a history of hypertension and arthritis. However, his paternal grandfather died of cardiac arrest at 63 years and had fructose intolerance. His siblings do not have any underlying conditions (see Genogram, Appendix A).
Social History: The patient lives with his mother and siblings, ages 4 and 2, while his father is home occasionally. No one smokes at their home. The home has all necessities, including water, gas, and electricity. The patient is often left with his nanny at home when his mother goes to work.
Immunizations: The patient has had all the required immunizations for a five-month-old as per the CDC guidelines.
Allergies: The patient does not have any reported allergies.
Medications: The patient does not have any prescribed medication at the moment.
Herbal/ Alternative/Vitamin Supplement Use: Formula
Screenings: Breathing and heart rate monitoring at the neonatal intensive care unit (NICU).
Lead: No lead exposure risks were identified per the mother’s report.
T.B. Exposure: No identified contact with family members or people with Tuberculosis infections.
ADLs and Habits:
Diet: The mother states that the patient takes only breast milk and the formula recommended in her last clinic visit. The mother adds that she takes a balanced diet and coffee. Additionally, since he started spitting, he has been refusing to breastfeed. His mother also adds that the diaper is often dry and, at times, finds mucus in the poop.
Sleep: The patient sleeps for 9-10 hours each day.
Activity: The patient spends most of his time playing with toys.
Oral health– The mother brushes the patient’s teeth daily.
Safety/ Risk Assessment: There are no significant safety concerns. The patient moves around with a walker, travels in a car seat, keeps medication out of reach, and closely monitors his movement.
Growth and Development:
Physical Growth: The patient’s height and weight are appropriate for his age as per the CDC guidelines. His weight is 6.7 kg, and his height of 66 cm, resulting in a BMI of 15.4, which is considered healthy. (See Appendix B).
Motor: The patient’s gross and fine motor skills are appropriate for his age.
Cognitive– The patient’s cognitive function is within the normal parameters for his age.
Verbal-The patient is more vocal for his age, including crying and babbling.
Social- The patient’s social development is within the normal parameters for his age.
Personality– The patient is charming and rarely gets angry.
School– The patient is an infant and does not attend school.
Review of Systems:
Constitutional- The mother denies illness and chronic pain. However, she confirms that the patient has had rapid weight changes and changes in appetite, mood, and activity level.
Skin– The mother denies lesions, rashes, allergic reactions, abdominal skin discoloration, and hair distribution. She also confirms that the patient has a birthmark on their thigh.
Neurological– The mother denies seizures, headaches, and asymmetrical movement. She confirms that the patient has been weak and has had balance difficulties over the past few days.
Sensory– The mother denies that the infant has had perceived difficulty with sight, smell, sound, taste, and touch.
HEENT- The mother denies the patient has ear pain, loss of hearing, blurry vision, eye pain, itching, popping, and fullness. She also denies loss of smell, allergies, sinus pressure, sore throat, bleeding gums, and difficulty chewing. She also confirmed that the patient has had difficulty swallowing and nose drainage associated with spitting.
Cardiovascular– The historian denies any reported chest pain, shortness of breath, loss of consciousness, faintness, and activity intolerance.
Respiratory– The patient has had an occasional cough related to spitting. However, the mother denies shortness of breath, nasal flaring, and retractions.
G.I.– The mother denies nausea and melena. Nonetheless, she confirms that the infant occasionally has vomiting, constipation, indigestion reflux, and diarrhea. In addition, the last diaper change was dry.
G.U.– The mother denies abdominal pain, incomplete bladder emptying, offensive odor in urine, back pain, blood in urine, and burning frequency.
Reproductive- The mother denies abnormal penile discharge testicular abnormalities.
Musculoskeletal– The patient has a general weakness.
Endocrine– The mother denies sweating and heat or cold intolerance. Nonetheless, she highlights that the patient has had significant weight changes, changes in appetite, urination, and thirst.
Infectious Disease– The mother denies any exposure to fever or illnesses.
Teeth– The mother highlights that the patient has been teething lately. However, she denies any dental pain, cavities, or bleeding from the gums.
Psychological/Mental– The mother denies any perceived seclusions, loneliness, depression, hallucinations, and anxiety from the infant.
Developmental– The mother denies any fine or gross motor skills and cognitive development delay.
Age-Related Risk Assessment– Water safety, adult supervision, car seat use, attended sofas, chairs and beds, baby gates in the stairways, and the patient is not left to play with pets or other younger children alone.
Physical Exam:
Weight 6.7 kg
Height 66 cm
BMI= 15.4
Vital signs: Temperature 98.1, H.R. 97, R.R. 18.
General– The patient appears weaker and smaller for a five-month-old male.
Mental Status– The patient is alert as appropriate for his age.
Neurological– The sensory nerves are intact, and the patient responds to nose pointing and rapid altering movements. However, the cranial nerves 9 to 12 are not intact.
Reflexes– the patient’s tonic neck, plantar grasp, and palmar grasp reflexes are intact.
Sensory– the patient’s sensory nerves are intact and appropriate in all extremities.
Motor– The patient has a normal motor function for his age.
Emotional/Psychological– The patient cries a lot and disengages for his age.
Skin– The patient does not have any lesions or rashes on the skin. His skin has a normal turgor. It is warm, dry, and intact.
Hair/Nails– The patient has normal hair distribution and does not have any abnormalities on his nails.
Neck– The patient does not have any abnormal palpable lymph nodes, lesions or masses noted.
Lymph Nodes– The patient’s lymph nodes are non-palpable.
Head– The head is symmetrical and normocephalic.
Eyes– No discharge, edema, conjunctivitis, nystagmus, and strabismus noted. They are also symmetric and intact.
Ears– The bilateral external ear shape, size, and skin tone are normal. External canal inspection shows that the canals are intact without discharge, odor, or foreign bodies. The canal is pink with a tympanic membrane which is concave, pearl grey with light reflex and visible bony landmarks.
Nose– The inspection shows a nasal septum midline, pink and moist turbinates with blocked nasal discharge. Additionally, the nares are patent and symmetric bilaterally.
Throat– The mucous membrane membranes are pink and moist without lesions, and the soft and hard palate is intact. Nonetheless, the inspection revealed pharynx pink tonsils without pitting or exudates, tongue midline, uvula midline, and sensitive gag response. The maxillary and frontal sinuses are tender to palpation.
Cardiovascular– No abnormal lifts, heavy notes, pulsations, and thrills. RRR without murmurs, gallops or clicks heard. The rhythm is normal, and the patient is warm and dry, with no cyanosis or edema noted.
Pulmonary/Thorax– The respirations are unlabored and even. Breath sounds are unclear. The patient has nasal flaring.
Chest– The chest wall is symmetric and within normal limits.
Abdomen– The abdomen is flat and symmetrical. There are no rashes, lesions, scars, dilated veins, pulsation, and peristalsis visible. The umbilicus midline is visible without bulges. The patient has bilateral abdominal stretch marks from childbirth. There is no friction rubs heard over the spleen or liver. The abdomen is non-distended, and no tenderness to palpation is noted. Lastly, the bowel sounds are active in all four quadrants.
Genitourinary– The patient has normal male anatomy. There is no penile discharge or testicular abnormalities noted. There are no rashes or lesions noted in the area.
Rectum/Anus– External examination shows a positive anal wink. There are no fissures or hemorrhoids noted.
Musculoskeletal– Gait is within normal limits. No deformations were noted on the patient’s joints. The patient’s movements are symmetrical. However, poor feeding has made his muscles weaker.
Extremities– No edema or cyanosis noted.
Joints– Examination reveals that the joints have a normal range of motion. In addition, there is no redness or swelling noted in the joint areas.
Back- The spine’s curvature is within normal limits and has no paravertebral tenderness, lesions, or deformations.
Stages of Development:
Erickson’s Stage of Psychosocial Development: Trust vs. Mistrust
The patient exhibits appropriate behavior for his age as he is dependent and trusts his parents and nanny to provide everything he needs for survival, including food, safety, nurturing, warmth and love. However, he does not trust his siblings and strangers to provide him with adequate care and therefore cannot depend on them for survival.
Piaget’s Stage of Cognitive Development: Sensorimotor Stage
The patient exhibits appropriate behavior for his age as he focuses on what he sees, is doing, and physical interaction with his immediate environment. For example, he constantly experiments by shaking or throwing toys and putting things in his mouth.
Motor Sensory Development– The patient does not have any motor difficulties or concerns. He can crawl, move his head, and roll within normal limits.
Developmental– the patient’s development is appropriate for his age.
Assessment:
A five-month-old male patient was born prematurely and has visited the clinic for spitting diagnosis and treatment. The condition has affected his sleeping patterns and overall health. He vomits regularly and forcefully, leading to a cough and general weakness.
Presumptive Diagnoses
- Cow’s milk allergy
- Hiatal Hernia
- Infantile Colic
- Rumination Syndrome
- Pyloric stenosis
Differential Diagnosis
- Infant GERD
- Diarrhea
- Pyloric Stenosis
- Constipation
- Vomiting
Plan
Treatment Goals
Some of the nursing care planning goals for the patient include;
- The patient will achieve and maintain adequate body weight.
- The patient’s airway will unblock (Cooper & Urso, 2018).
- The mother will have increased knowledge and the actions she can take to reduce reflux.
- The patient will have better moods and activity engagement.
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Billing Codes:
ICD Code:
- Cow’s milk allergy- Z91.011
- Infant GERD- P78.83
- Hiatal Hernia- K44.9
- Infantile Colic- R10.83
- Rumination Syndrome- F98.21
- Pyloric stenosis- K31.1
CPT Code:
- 91035- Gastroesophageal reflux test studies.
- 99215- Infant weight check and screening for feeding.
Pharmacological Interventions
Prescribe anti-acids- This medication will provide relief of symptoms in the patient, including alleviation of constipation. It will also neutralize and suppress acid production.
Non-Pharmacological Interventions
One of the long-term solutions to reflux is medical therapy. First, the mother should avoid placing the infant in a seated or supine position shortly after meals. Instead, they should be fed in a semi-upright position and maintained in an upright non-sitting position for at least 20 minutes after eating (Singendonk et al., 2019).
The mother can also burp the infant open to help reduce pressure in the stomach by expelling the air swallowed by the infant. Also, the patient should be put to sleep in the prone position, which has effectively decreased the frequency of gastroesophageal reflux.
Second, the mother should reduce her caffeine intake or use a hypoallergenic formula on the infant. This formula can also be thickened by adding 1 to 3 teaspoons of rice cereal per ounce of formula (Cooper & Urso, 2018).
The mother can also try not taking cow’s milk for several weeks to see if it is helpful. She can also increase the feeding frequency, where the baby is fed small amounts of milk multiple times a day. Finally, she should ensure that the child takes enough water to help with dehydration.
Education
- Educate the caregiver and lifestyle modifications.
- Educate the mother about the need to put the baby to sleep on his back and elevate the head of the bed (Cooper & Urso, 2018).
- Avoid consumption of caffeine and cow’s milk.
- Accurately measure and record the patient’s height and weight every week and bring their measurements to the next clinic.
Follow up
The patient should return to the clinic after one month or when the symptoms do not reduce after treatment.
Evidence-Based Rationale
Approximately all infants have gastroesophageal reflux episodes, characterized by burping up, spitting, and wet burps, which occur shortly after eating and are considered normal (Ferguson, 2018). While spitting is common among infants, they may vomit or spit up excessively, appearing irritable.
The reflux normally worsens during the first months of any picks around the seventh month of age, and then the infant may outgrow it by the 18th month (Gulati & Jadcherla, 2019). Salvatore et al. (2021) highlight that an infant’s position mainly causes reflux during feeding, exposure to caffeine, nicotine, or cigarette smoke, food allergy or intolerance, overfeeding, and an abnormality in the digestive tract.
In this case, the patient may have a cow’s milk allergy and exposure to caffeine, causing the reflux. Specifically, the patient’s mother highlights that the condition worsened when she started giving the infant the formula recommended for weight gain.
Therefore, it is highly probable that the patient is allergic to cow’s milk which is the main component of the formula. Additionally, the mother confirms that she takes much coffee, which stimulates acidic production and results in more acidic reflux (Ferguson, 2018). This can explain why the infant continued having refluxes even after he stopped taking the formula.
Nonetheless, the reflux may turn into a gastroesophageal reflux disease when it damages the esophagus, interferes with growth and feeding, leads to breathing difficulties and continues beyond infancy into childhood (Salvatore et al., 2021).
In this case, the child has already developed a gastroesophageal reflux disease as he has breathing difficulties such as coughing and nose blockage associated with the condition. Additionally, it has interfered with his feeding habits as he no longer wants to breastfeed and vomits every time.
Gulati and Jadcherla (2019) also state that gastroesophageal reflux disease among infants is associated with vomiting and excessive spitting up, which the patient presents. In this case, there is a need to provide immediate care to avoid adverse health effects on the patient, including poor growth.
In addition, while caffeine stimulates acidic reflux, a small amount of the acid may enter the windpipe leading to wheezing, coughing, apnea, and pneumonia (Ferguson, 2018). Addressing this health care issue can also help avoid complications with the respiratory system, which can cause death in worse cases.
While the patient has a family history of pyloric stenosis, the patient does not want to eat soon after vomiting and does not have stomach contractions which are primary symptoms. Second, I ruled out hiatal hernia since the patient does not present with heartburn symptoms or trouble swallowing, which are crucial symptoms for diagnosis. Third, the patient does not cry for long for no apparent reason. He also does not present facial discoloring, ruling out infantile colic. Lastly, the patient does not present nausea, heartburn, and abdominal discomfort, which are symptoms of rumination syndrome.
References
Cooper, C. A., & Urso, P. P. (2018). Gastroesophageal reflux in the intensive care unit patient. Critical Care Nursing Clinics of North America, 30(1), 123-135. https://doi.org/10.1016/j.cnc.2017.10.011
Ferguson, T. D. (2018). Gastroesophageal reflux. Critical Care Nursing Clinics of North America, 30(1), 167-177. https://doi.org/10.1016/j.cnc.2017.10.015
Gulati, I. K., & Jadcherla, S. R. (2019). Gastroesophageal reflux disease in the neonatal intensive care unit infant. Pediatric Clinics of North America, 66(2), 461-473. https://doi.org/10.1016/j.pcl.2018.12.012
Salvatore, S., Agosti, M., Baldassarre, M. E., D’Auria, E., Pensabene, L., Nosetti, L., & Vandenplas, Y. (2021). Cow’s milk allergy or gastroesophageal reflux disease—Can we solve the dilemma in infants? Nutrients, 13(2), 297. https://doi.org/10.3390/nu13020297
Singendonk, M., Goudswaard, E., Langendam, M., Van Wijk, M., Van Etten-Jamaludin, F., Benninga, M., & Tabbers, M. (2019). Prevalence of gastroesophageal reflux disease symptoms in infants and children: A systematic review. Journal of Pediatric Gastroenterology & Nutrition, 68(6), 811-817. https://doi.org/10.1097/mpg.0000000000002280
Appendices
Appendix A: Genogram
Appendix B: CDC Growth Chart
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