A child, four weeks old, is presented to the clinic. The mother has presented the child because it is fussy and not breastfeeding as well as normal. The head felt hot at home last night. Upon examination the child, the following details are noted
- a temperature of 100.5 F rectally,
- a fussy infant
- Moist oral mucosa
Brief Case Examination
The moist oral mucosa indicates of good hydration signifying that the child has not lost much water (Choudhury, Bagga, Chugh & Ramji, 2011).The child is feeding abnormally resulting in underfeeding and subsequent stomach disturbance or loss of appetite due to some infection. The 100.5 F rectal temperature indicates a fever (Glöckler, 2013). However, the mother noted the child’s head being hot last night, which is lacking in this clinical examination; the child’s status could not be very serious. Nonetheless, the most likely condition presented with the child is the fever. No other observation is made which also narrows the condition to fever.
Detailed Analysis
| Differential Diagnosis and CPT | Pathophysiology | Lab Test | Diagnostic Test | Medications | Patient Education | |
| 1. | underfeeding of newborn P92.3 rationale: 4 weeks old not breastfeeding as “well as normal.” | Depression results in the child’s withdrawal from caregivers including the mother and this will lower the child’s ability to feed properly (Roberton & South, 2007). | Weight measurement. In case the child is underfeeding, the child’s weight should be plotted from the time of reporting. | An inquiry into the child’s medical history such as the possibility of having been given some drugs or had other conditions such as diarrhea, and vomiting. The mother’s medical history should also be gathered. | The mother can introduce bottled milk every four hours as per the child’s feeding. which should be breast milk, iron-fortified soy milk and avoid any bottled juice obtained from any fruit (Hobbs, 2009) | The mother should help the child have enough rest The mother should spend more time socializing with the child. |
| 2. | Slow feeding P92.2 Rationale : 4 weeks old not breastfeeding as “well as normal.” | Depression results in the child’s withdrawal from caregivers including the mother which will impact the quality of their feeding pattern (Roberton & South, 2007). | Weight measurement. In case the child is underfeeding, the child’s weight should be plotted from the time of reporting and subsequent reporting to check if it is losing weight. | Inquiry into the child’s medical history such as the possibility that the mother gave it any medicine or had other conditions such as diarrhea and vomiting The mother’s medical history should also be gathered. | The mother can introduce bottled milk every four hours as per the child’s feeding which should be breast milk, iron-fortified soy milk and avoid any bottled juice obtained from any fruit (Hobbs, 2009) | The mother should help the child have enough rest The mother should spend more time socializing with the child. |
| 3. | neonatal difficulty in feeding at the breast P92.5 Rationale: 4 weeks old fussy Funniness could be triggered with discomfort in breastfeeding. | Difficulty to breastfeed in neonatal cases can be due to poor positioning of the mother causes the breast to undergo tension and pressure thereby affecting the quantity of milk and the child’s ability to breastfeed properly (Lauwers&Swisher, 2015). | Weight measurement to track the child’s weight | The child’s ability to root, latch on, and suckle should be observed (Wambach & Riordan,2014). An inquiry into the child’s medical history such drugs are given or other conditions including diarrhea, and vomiting. The mother’s medical history should also be gathered. | Introduction of bottled milk every four hours as per the child’s feeding balanced with breastfeeding (Peterson & Harmer, 2010). | The mother should use the nipple-nose strategy to help the baby aim high; as the moth strokes the child’s lips with the nipple, it is ledto, aim up which will help it assume the correct posture (Lauwers&Swisher, 2015). |
| 4. | post vaccination R50.83 rationale: 4 weeks old presented with fever 100.5F could be triggered by introduction of vaccines into the body | An administration of vaccine stimulates the immune system which results in a series of immunological response raising the body temperature (Schedule, n.d). | The temperature should be taken regularly to monitor the child’s state. Blood and stool tests should be conducted for the presence of parasites, or viruses. | Child’s medical history should be queried. | Determine the eight and administer Acetaminophen as per the baby’s weight. | The child should receive plenty of cool fluids. Have fewer clothes on to help manage the temperature. The child should not be given any medication unless the doctor prescribes it. |
References
Choudhury, P., Bagga, A., Chugh, K., & Ramji, S. (2011). Principles of pediatric and neonatal emergencies. JAYPEE BROTHERS MEDICAL PUBLISHERS PVT. LTD.
Glöckler, M. (2013). A guide to child health: A holistic approach to raising healthy children. Floris Books.
Hobbs, S. H. (2009). Living Vegetarian for Dummies. John Wiley & Sons.
Lauwers, J. &Swisher, A. (2015). Counseling the nursing mother: a lactation consultant’s guide. Canada. Jones & Barlett publishers.
Peterson, A., & Harmer, M. (2010). Balancing breast and bottle: Reaching your breastfeeding goals. Hale Pub.
Roberton, D. M., & South, M. J. (Eds.). (2007). Practical pediatrics. Elsevier Health Sciences.
Schedule, R. C. I. The childhood immunization schedule and safety: stakeholder concerns, Scientific Evidence, and Future Studies.
Wambach, K., & Riordan, J. (Eds.). (2014). Breastfeeding and human lactation. Jones & Bartlett Learning.