Infant Well Visit Shadow health documentation

Subjective:
Today, a well-nourished 2-month-old male infant presents for his checkup with his mother.
The mother reports that the infant’s feeding and sleeping patterns are normal. He interacts socially and seems to have normal vision and hearing. Safety measures at home include functioning smoke detectors, a safe sleeping environment (with a bassinet or cradleboard), and constant supervision by an adult. The infant’s hygiene is good, with a normal diaper area.

The mother also ensures safety with car seat usage, positioning the infant in a rear-facing car seat in the back seat. The infant is currently not enrolled in daycare and is cared for at home by relatives while the mother attends school.

Infant Health and Growth at 2 Months

The infant’s growth is on track. At birth, he weighed 7lbs 4oz, and his length was 19 inches. He was born at 39 weeks via vaginal delivery, with no complications. His growth and development remain normal for a 2-month-old, as indicated by his head circumference (38.1 cm), weight (4.39 kg), and length (55.2 cm), all above the 5th percentile but below the 95th percentile.

Breastfeeding and Feeding Tips for New Mothers

The mother reports breastfeeding 5-7 times a day, with each feed lasting about 10 minutes per breast. The schedule varies slightly due to her school commitments. While the mother has reported some difficulty with the fullness of her breasts before feeding and a lack of fullness after feeding, she denies any breast leakage. It’s important to work on improving the breastfeeding latch and consider using a breast pump to create a milk supply for when the mother is away at school. A lactation consultant consultation is recommended to help improve feeding practices, support a structured feeding schedule, and address any breastfeeding difficulties.

Objective

Upon examination, the infant appears calm, alert, and healthy. The vital signs are within normal limits, with a temperature of 36.2°C, heart rate of 132 beats per minute, and respiration rate of 36 breaths per minute. The head is symmetrical, with normal fontanelles. Zachary laFontaine’s eyes track objects, and he responds to familiar sounds, which suggests normal hearing and vision. The skin is warm and smooth, without any lesions. The abdomen is soft, non-tender, and normal, with bowel sounds present. The infant’s reflexes are intact and normal for his age. His hearing and vision are also on track, with the infant turning his head towards sounds.

Infant Milestones at 2 Months

The infant is meeting typical developmental milestones for a 2-month-old. He smiles, tracks objects with his eyes, coos, and turns toward familiar sounds. He can lift his head when placed on his tummy, a sign of developing strength and motor skills. At this stage, it’s important to encourage tummy time to build upper body and neck strength.

Safety Tips for Infants: Car Seats and Sleeping

The mother has followed safe sleep practices by placing the infant on his back to sleep in a bassinet, as per the American Academy of Pediatrics’ guidelines for safe sleep. It is important to continue this practice to reduce the risk of Sudden Infant Death Syndrome (SIDS). Additionally, the infant’s car seat is positioned correctly, rear-facing in the back seat, which is vital for infant safety during travel.

Common Infant Health Concerns and Solutions

The mother reports no major health concerns but does mention some breastfeeding challenges. These may include the sensation of fullness in her breasts before feeding and not feeling empty afterward. It is important to monitor these signs, as they may indicate a need for further guidance on breastfeeding techniques, such as improving latch and developing a structured feeding schedule.

The Importance of Regular Pediatric Checkups

Routine well-child visits are essential for monitoring the infant’s growth, development, and vaccination schedule. The 2-month checkup is a crucial point in the infant’s early health, with vaccinations scheduled today as per the CDC guidelines for infants. These include the following vaccines: HepB, RV, DTaP, PCV13, IPV, and HiB. Parents should monitor for any potential side effects after vaccinations, such as a low-grade fever, and should contact the office if any concerning reactions occur.

CDC Vaccination Guidelines for Infants

At the 2-month visit, the infant receives several important vaccinations according to CDC guidelines for infant vaccination. These vaccinations help protect the infant from serious diseases like hepatitis B, rotavirus, diphtheria, tetanus, pertussis, pneumococcal infections, polio, and Haemophilus influenza type b. It’s normal for infants to feel a little fussy or develop mild fever post-vaccination. Parents should keep track of any adverse reactions and contact their healthcare provider if necessary.

Understanding Your Infant’s Sleep Patterns

At 2 months, the infant sleeps about 16 hours per day on certain days of the week (Monday, Wednesday, and Friday). However, the exact number of hours on Tuesday and Thursday is unclear as the mother is at school during these days, and the infant stays with relatives. During these early months, it’s important to develop a consistent sleep schedule to support healthy sleep habits. Monitoring sleep cues, such as the baby being sleepy or fussy, will help establish a structured sleep pattern.

Breastfeeding Challenges and How to Overcome Them

The mother has reported some breastfeeding challenges, including difficulty with her breasts feeling full before feeding and not feeling empty afterward. A consultation with a lactation consultant is recommended to support her breastfeeding goals. The consultant can assist in improving latch techniques, which can enhance breastfeeding efficiency. Ensuring that the infant is feeding effectively and that the mother feels supported in her breastfeeding journey is crucial at this stage.

Supporting Maternal Health During Postpartum

The mother is juggling school and infant care, which has led to insufficient sleep. It’s important for her to care for her own health during this postpartum period. She is eating a healthy diet and drinking plenty of water, which are positive practices. However, finding time for self-care and adequate rest is important for her mental and physical recovery. A postpartum checkup should be scheduled to ensure her recovery and address any concerns she may have.

Promoting Safe Sleep Practices for Your Infant

Safe sleep practices are vital in reducing the risk of SIDS. The infant is currently following the “Back to Sleep” recommendation, which involves placing him on his back to sleep in a safe sleep environment. As the baby grows and becomes more mobile, safety precautions should be adjusted, such as never leaving the infant unattended on a high surface, like a changing table, and keeping dangerous items out of the sleep area.

Understanding Infant Developmental Milestones

At 2 months, the infant is showing typical signs of development, including beginning to track objects and respond to familiar voices. Gross motor skills are developing, and the infant can lift his head during tummy time. These milestones are crucial for the infant’s physical and cognitive growth. Encourage tummy time to support upper body strength and help the infant develop skills like rolling over.

What to Expect at a 2-Month-Old Well Visit

During the 2-month well visit, the infant receives necessary vaccinations, a thorough physical exam, and developmental screening. The pediatrician will assess the baby’s growth, feeding patterns, and overall health. Parents should expect guidance on safe sleep, feeding schedules, and infant milestones. It’s also a good time to discuss any breastfeeding difficulties or concerns about the baby’s development.

How to Support a Structured Feeding Schedule

A structured feeding schedule is important for the infant’s health and development. Since the mother is breastfeeding, it’s recommended to establish a consistent feeding routine that aligns with both the infant’s and mother’s schedules. Using a breast pump to store milk for feedings while the mother is at school will help maintain a steady milk supply and ensure the infant is fed properly.

Encouraging Early Development Through Tummy Time

Tummy time is crucial for developing the infant’s upper body strength and coordination. At this stage, the baby is beginning to lift his head while on his tummy. Parents should incorporate tummy time into the daily routine, ideally several times throughout the day when the baby is awake.

The Role of a Lactation Consultant in Infant Feeding

A lactation consultant plays a critical role in helping mothers navigate breastfeeding challenges. Whether the issue is with latch, milk supply, or feeding frequency, a lactation consultant can provide personalized advice and support to ensure both the mother and infant are feeding effectively. In this case, a lactation consultant consultation is recommended to improve the breastfeeding experience for the mother.

What to Do If Your Infant Has Trouble Feeding

If the infant experiences feeding difficulties, such as trouble latching or not nursing effectively, it is important to seek help from a lactation consultant. This can improve breastfeeding outcomes and ensure the baby is receiving adequate nutrition. Monitoring feeding patterns and seeking professional advice when needed will help address concerns early.

Supporting Your Infant’s Growth with Proper Nutrition

Breastfeeding remains the primary source of nutrition for the infant at this stage. It is important to continue breastfeeding on demand, ensuring the infant is feeding enough to support healthy growth. As the baby reaches developmental milestones, the feeding schedule should be adjusted to ensure he is receiving the right amount of nutrition.

Tips for New Parents: Understanding Your Infant’s Needs

New parents should remain observant of their infant’s cues for sleep, hunger, and comfort. The baby may begin to associate the mother as the primary source of reassurance when upset. Developing a consistent routine will help the infant feel secure and calm. Early bonding activities, like singing, talking, and reading, are essential for the baby’s emotional development.

Safe Infant Care Practices: A Guide for New Parents

Safe infant care practices include using a rear-facing car seat, placing the baby on their back to sleep, and providing constant supervision, especially as the baby begins to roll or move more independently. Never leave the baby unattended, and continue to follow safety guidelines for sleep and trave

Plan

• Continue breastfeeding and develop a structured feeding schedule.
• Consultation with a lactation consultant for support with breastfeeding challenges.
• Ensure safety measures are maintained, including rear-facing car seat use and a safe sleep environment.
• Vaccinations administered today include HepB, RV, DTaP, PCV13, IPV, and HiB, following CDC guidelines for infant vaccination at 2 months.
• Return for weight check in 3-4 weeks and the 4-month well-child visit.
• Continue monitoring infant development, encourage tummy time, and support growth with proper nutrition.

Anticipatory Guidance:

• Social & Emotional Development: Infant will begin to recognize familiar voices and turn to parents for comfort.
• Motor Development: Continue tummy time to build strength for future motor milestones.
• Feeding: Focus on a structured feeding schedule to support proper nutrition.
• Safety: Follow safe sleep guidelines, including back sleeping, and continue using a rear-facing car seat.

My Provider Notes

Student Documentation	Model Documentation
Subjective This is a well nourished 2 month infant, at the appointment with mother. Mom reports normal feeding and sleeping patterns. Interacts socially. Seems to have vision and audition normal. Safety measures at home, smoke detectors, safe at the place to sleep, constant supervision of an adult. Hygiene of infant is good, diaper area normal. Infant Well Visit Shadow health documentation	2 month old male infant today for child check. Birth information male infant born via vaginal delivery at 39 weeks gestation. Length-19”, Weight-7lbs 4 oz, APGAR 9@ 1 min, 10 @ 5 min. There were no birth complications. Here today accompanied by his mother. Medications: Currently not taking any medications, No known medication allergies Nutrition: Breastfeed 5-7 feeds/day about 10 min each breast, schedule varies by day due to mothers school schedule Elimination: Spitting-minimal, 5-6 wet diapers a day, usually 3 bowel movement per day soft, mustard yellow in nature Sleep: Sleeping about 16 hours on Mon-Wed-Fri, Unknown number of hours of sleep on Tuesday and Thursday as her mother cares for Zachary on these days while she is at school. He does wake up more frequently at night on Tuesday and Thursdays Development and behavior: Reports infant smiles, tracks objects with his eyes, coos, turns to noises and familiar sounds. Able to lift his head when on his tummy. Maternal Health: Reports a very busy schedule. Attends school two days a week and her mother helps care for Zachary when she is at school. Reports she does eat a healthy diet and drinks plenty of water. Does report insufficient sleep. Reported breasts feel full before feeding and don’t always feel empty after feeding. Denies any breast leaking. Safety: Car seat is rear facing in the back seat, Back to sleep on a cradleboard or in the bassinet in mothers bedroom, Daycare-not enrolled at this time, cared for at home by relatives.
Objective Normal growing curves: Head circ, wt and length, all above 5 and under 95 percentile. Vital signs WNL Nose, ears, mouth and skin, WNL, no abnormal findings.Infant Well Visit Shadow health documentation	Vital signs: Length=55.2 cm, Weight=4.39 kg, Head circumference=38.1 cm, Temp=36.2C, Heart rate= 132/min, Resp=36 breaths/min General: Infant in mothers arms, calm and alert HEENT: Head: symmetrical, Anterior fontanelle smooth, soft, flat, Posterior fontanelle smooth, soft, flat thin hair Eyes: open spontaneously, lens clear, red reflex present, PERRL Ears: ears aligned with palpable fissures, pinna flexible, lobe formed appropriately, turns head towards sounds Nose: Nares pink, patent, thin white mucus present Mouth/Throat: Palate intact, tongue with full ROM, smooth, frenulum intact, uvula midline Infant Well Visit Shadow health documentation  Neck: Neck with full ROM, lags when lifting body Resp: Symmetrical chest rise and fall, smooth even respirations, bilateral lungs clear to auscultation, CV: Regular rate and rhythm, S1S2 present, no murmurs, Pulse present, equal bilaterally Abd: Abdomen protuberant, soft, nontender, bowel sounds normoactive, umbilicus healed GU: Scrotum with smooth rugae, circumsized penis with urethral meatus midline, testes present bilaterally MSK: Bilateral extremities symmetrical, moves all extremities freely, Barlow and Ortolani negative. Neuro: Active, alert, sucking, rooting reflex intact, moro reflex intact, stepping reflex intact, tonic reflex intact and symmetrical, grasp reflex intact Skin: Warm, smooth, congruent with genetic background. Elastic turgor. No lesions noted, mucous membranes moist, pink and intact. diaper area without any rash. Hearing/Vision: Eyes track objects. Turns head to familiar voice Infant Well Visit Shadow health documentation
Assessment Normal findings for a 2 months old male baby. Head with normal development, normal size, and growing speed. Well nourished. No abnormal findings on cardiopulmonary systems. Ortho: Barlow and Ortolani were normal, no Signs pf hip problems. Moro reflex normal for the age. Infant Well Visit Shadow health documentation . Milestones within age for normal development.	Well child check Feeding difficulties
Plan Continue breastfeeding. Appointment in 2 months, unless needed before for abnormal findings. Monitor mother health, physical and mental. Vaccination as per CDC.	Surveillance for next visit Vitamin D drops 400 IU 1 drop daily Continue with breastfeeding, develop a structured feeding schedule and begin using breast pump in between feedings so you have milk to supplement your infant when you are at school. Consultation with a lactation specialist to improve feeding practices, develop appropriate feeding schedules and provide support. Never leave unattended, Continue with back to sleep, Vaccines administered today-HepB, RV, DTaP, PCV13, IPV and HiB. Your infant may be a little fussy today and develop a low grade fever. Notify the office for any high fevers, vaccine site reactions, rashes. Call 911 if develops difficulty breathing Return for weight check in 3-4 weeks and then for 4 month old well child visit Anticipatory Guidance: Social Language & Self Help: Will begin to turn head towards familiar voices. Will look to parent to reassure him when he is upset. He will begin to associate you as the person who consoles him when he is upset. Verbal Language: Will begin making extended cooing sounds. Will become more organized. Gross Motor: Will begin to support self on elbow and wrists. Encourage tummy time to build upper body strength and neck strength. Will begin to roll from stomach to back Fine motor: Infant Well Visit Shadow health documentation  Will begin to notice he has fingers and will grasp objects with his whole hand. Parent and family health: Make sure you have your postpartum check up. Take time to care for yourself. Infant behavior: Hold, cuddle, talk and sing to your infant. It is a good time to start reading to help with brain development. Pay attention to your infant’s cues for sleep. Keep a schedule. Tummy time throughout the day when awake. Find calming techniques he will respond to. Important to never shake or hit your baby. Nutrition: It is too early for any food other than breast milk. Anticipate 5-6 wet diapers a day and 3-4 stools per day. Continue your prenatal vitamin and a healthy diet. Safety: Continue with rear-facing infant seat in the backseat. Set your water heater to 120 degrees F. Do not leave your infant alone. As he begins to roll, you will need to keep a hand on him when on the changing table, etc. Infant Well Visit Shadow health documentation