NR 602 Week 3 Well Child Growth Write-Up Example

Well Child Write-Up: M.O. at 15 Months, a Weight That Has Crossed Two Major Percentile Lines Since 9 Months on the WHO Chart, Read as a Line Rather Than a Point

Student Name

College of Nursing, Chamberlain University

NR 602: Primary Care of the Childbearing and Childrearing Family Practicum

Instructor Name

Month Day, Year

Well Child Write-Up: M.O. at 15 Months, a Weight That Has Crossed Two Major Percentile Lines Since 9 Months on the WHO Chart, Read as a Line Rather Than a Point

Age and Correction

M.O. is 15 months and 4 days old, born at 39 weeks. No correction for prematurity is needed.

Who Said What

The parent who attends visits is the source for everything in this section; nothing below was observed. History from the parent who brings M.O. to every visit and is the main caregiver on weekdays. Eats "whatever we eat, but not much," drinks "lots of milk," about five 8-ounce bottles of whole cow's milk a day by the parent's count. Sleeps through the night with a bottle at bedtime. Walks holding furniture, a few steps alone. No vomiting, no diarrhea, normal stools. One cold last month. The parent's main concern: "Picky eater."

The Chart, Named

Measurements are plotted on the World Health Organization growth standards, the charts federal guidance recommends for children younger than 2 in the United States (Grummer-Strawn et al., 2010). The CDC reference charts, used from age 2, would place the same child at somewhat different percentiles, which is why the chart must be named.

The Measurements

The Line, Not the Point

At 15 months, a weight at the 10th percentile could belong to a small, healthy child who has always grown there. M.O. is not that child. M.O.'s weight sat on the 50th percentile until 9 months and has since crossed downward through the 25th to the 10th. Crossing two major percentile lines downward is a recognized sign of faltering growth, and the timing matters (Larson-Nath & Biank, 2016).

Length has drifted less, from the 50th to the 25th. Head circumference has held at the 50th. When weight falls first and furthest, with length following and head spared, the usual explanation is too few calories reaching the child, rather than a disease affecting growth as a whole.

The history fits. Five bottles of milk a day is about 40 ounces, well above the 16 to 24 ounces generally advised at this age. Milk fills a toddler's stomach, reduces appetite for solid food and, because cow's milk contains little iron and can irritate the gut lining, is linked to iron deficiency (Baker & Greer, 2010). The weight began to fall at about 9 to 12 months, when whole milk replaced formula.

Examination

Alert, active, interactive. No signs of illness. Mild pallor of the conjunctivae. Heart, lungs and abdomen normal. No edema.

Results Today

Hemoglobin by fingerstick: 10.1 g/dL, low for age.

Lead level sent, as at every 12-month and 24-month visit.

Assessment

Faltering weight gain, crossing two major percentiles since 9 months, most likely from excess cow's milk intake displacing solid food.

Likely iron deficiency anemia, linked to the same cause.

Development appropriate for age.

Guidance for the Months Ahead

Milk: cut back to two or three cups daily, served in a cup, not a bottle, and offered with meals rather than between them. Stop the bedtime bottle.

Meals and snacks: three meals and two snacks a day at the table, with the family. Offer the solid food first, then milk.

Iron: start iron drops at 3 mg per kilogram per day, and include iron-rich foods such as meat, beans and fortified cereal.

These changes are written in a handout for the family, which follows.

Measurement Technique

Weight was taken naked on the infant scale, length lying down on a measuring board with two people, and head circumference with a non-stretch tape at the widest point. Earlier points were measured the same way at this clinic. Consistent technique matters, since a change in method can move a child across a percentile on its own. The 15-month length was repeated once to confirm it, and the two readings agreed within 3 millimeters.

Other Causes Considered

A drop in weight percentiles can come from many causes. The parent's description of normal stools, no vomiting and no recurrent infections makes malabsorption, chronic infection or a metabolic problem less likely, though celiac disease can present quietly and is on the list if the weight does not respond. A child who is active, alert and developing normally, with head growth preserved, is unlikely to have a central nervous system cause. Social factors were asked about directly: the family has stable housing and enough food, both parents work and the child attends a home daycare two days a week, where the parent says M.O. "mostly drinks milk." The daycare's feeding routine will be part of the plan.

Why the Trajectory Matters More Than the Number

If M.O. had been seen for the first time today, a weight at the 10th percentile with length at the 25th might reasonably be called normal. The earlier points change that. A child who has always grown along the 10th percentile is growing as expected; a child who has fallen to it from the 50th is not. The chart is only useful because the clinic has measured M.O. at every visit, and the plan depends on continuing to do so.

What the Parent Was Told

The parent was shown the four points on the chart and the line they make. The parent said, "I thought milk was the best thing for M.O." We talked about milk as a drink, not a meal, and agreed on three changes: a cup instead of a bottle, a limit on daily milk and food offered first. The parent asked whether the daycare could be told; a short note was written for the daycare provider, asking that milk be offered in a cup with lunch only and that food come first at snack time.

Follow-Up

Weight and hemoglobin in 4 weeks. If weight has not risen or the hemoglobin has not improved, further tests for other causes, including celiac disease and urine studies, and a referral to a dietitian.

Limits

The parent's estimate of milk intake is a recollection. A three-day food and drink diary, covering a daycare day, will be brought to the next visit.

References

Baker, R. D., Greer, F. R., & Committee on Nutrition. (2010). Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0-3 years of age). Pediatrics, 126(5), 1040-1050. https://doi.org/10.1542/peds.2010-2576

Grummer-Strawn, L. M., Reinold, C., & Krebs, N. F. (2010). Use of World Health Organization and CDC growth charts for children aged 0-59 months in the United States. MMWR Recommendations and Reports, 59(RR-9), 1-15. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5909a1.htm

Larson-Nath, C., & Biank, V. F. (2016). Clinical review of failure to thrive in pediatric patients. Pediatric Annals, 45(2), e46-e49. https://doi.org/10.3928/00904481-20160114-01