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Case 2.2 Breastfeeding

By Mikki Meadows‐Oliver, PhD, RN, FAAN

SUBJECTIVE

Julio, a 9‐month‐old male, presents to the office for a well‐baby visit. He is accompanied by his mother, Lupita. Lupita is Spanish speaking, so a medical interpreter is used for the visit. Lupita has no concerns and states that Julio has been healthy since his last well‐child visit at 6 months of age. He has had no visits to the urgent care clinic or to the emergency room in the interim.

Diet: Julio’s nutrition history reveals that he is still being breastfed but that he is also being supplemented with a low‐iron, milk‐based formula. Lupita states that she gives Julio low‐iron formula because formula that is not low‐iron makes him constipated. He eats a diet of regular food that the family eats. He eats fruits and vegetables daily. Lupita introduced finely chopped meats into Julio’s diet last week, and he has tolerated the addition well. Julio also enjoys Cheerios^®, which he is able to grasp and bring to his mouth without assistance. He is not currently taking any multivitamins.

Elimination: Lupita states that Julio has 4–6 wet diapers daily and voids easily with a straight urine stream. He does not have any diarrhea or constipation since beginning the low‐iron formula.

Sleep: Julio is sleeping 10 hours at night and takes one 2‐hour nap daily. He does not have any problems falling asleep or staying asleep. At night, he has a bedtime routine that includes a bath and bedtime story read to him by an older sibling.

Development: Julio is crawling and pulling up to stand. He makes lots of vocalizations and is saying “da‐da,” although Lupita is not sure if he is just making sounds or referring to his father when he says “da‐da.” Julio has a beginning pincer grasp that allows him to eat small items such as Cheerios^®.

Birth history: Julio is the product of a 40‐week gestation. He was delivered vaginally without complications. During the pregnancy, his mother had no falls or infections. Lupita did not drink alcohol, take over‐the‐counter or prescription medications (other than prenatal vitamins), use tobacco products, or use illicit drugs. Julio’s birth weight was 3500 g, and his Apgar scores were 9 at 1 minute and 9 at 5 minutes. Past medical history reveals that he was hospitalized at 4 months of age for bronchiolitis. He has had no episodes of wheezing since that time.

Social history: Julio was born to a 31‐year‐old mother. He has 2 older siblings (7 and 9 years old). He lives at home with both parents and his maternal grandfather. The family is from Ecuador.

His mother works as a housekeeper, and his father works in construction. The family has a pet bird. There are no smokers in the home.

Family medical history: Julio’s mother has asthma and seasonal allergies. His 33‐year‐old father is healthy and has no history of chronic medical conditions. Julio’s maternal grandmother died at age 55 years from a myocardial infarction. His maternal grandfather has a history of Type 2 diabetes mellitus and obesity. His paternal grandparents are both deceased; both died in a motor vehicle accident several years ago.

Julio is not currently taking any over‐the‐counter, prescription, or herbal medications. He has no known allergies to food, medications, or the environment. He is up to date on required immunizations.

OBJECTIVE

Julio’s vital signs were taken in the office today. His weight is 6.0 kg, and his length is 64 cm. Julio’s temperature is within the normal range at 37°C (temporal). When observing his general appearance, he is alert, active, and playful. He appears well hydrated and well nourished.

Skin: His skin is clear of lesions. There is no cyanosis of his skin, lips, or nails. There was no diaphoresis noted. Julio has good skin turgor on examination.

HEENT: Julio’s head is normocephalic. His anterior fontanel is open and flat (0.5 cm × 0.5 cm). Red reflexes are present bilaterally and pupils are equal, round, and reactive to light. There is no discharge noted. Pinnae are normal; tympanic membranes are gray bilaterally with positive light reflexes. Bony landmarks are visible, and there is no fluid noted behind the tympanic membrane. Both nostrils are patent. There is no nasal discharge, and there is no nasal flaring. Julio’s mucous membranes are noted to be moist when examining his oropharynx. He has 2 teeth present without evidence of caries. There are no lesions present in the oral cavity.

Neck: Supple and able to move in all directions without resistance. There is no cervical lymphadenopathy.

Respiratory: Respiratory rate is 22 breaths per minute and his lungs are clear to auscultation in all lobes. There is good air entry, and no retractions or grunting are noted on examination. No deformities of the thoracic cage are noted.

Cardiovascular: Heart rate is 102 beats per minute with a regular rhythm. There is no murmur noted upon auscultation; brachial and femoral pulses are present and 2+ bilaterally.

Abdomen: Normoactive bowel sounds are present throughout; soft and nontender. There is no evidence of hepatosplenomegaly.

Genitourinary: Genitourinary examination reveals normal male genitalia. Julio is uncircumcised, and his testes are descended bilaterally.

Neuromusculoskeletal: Good tone in all extremities; full range of motion of all extremities. His extremities are warm and well perfused. Capillary refill is less than 2 seconds, and his spine is straight.

CRITICAL THINKING

1 Which laboratory or diagnostic imaging tests should be ordered as part of a 9‐month, well‐child visit?___CBC___Lead screening test___Liver function tests___Cholesterol level___Baseline chest radiograph

2 What is the most likely differential diagnosis and why?___Iron deficiency anemia___Constipation___Other

3 What is the plan of treatment, referral, and follow‐up care?

4 Does this patient’s psychosocial history affect how you might treat this case?

5 What if the patient lived in a rural setting?

6 Are there any demographic characteristics that might affect this case?

7 Are there any standardized guidelines that should be used to assess or treat this case?