Reflux – Jordana Ventzke

REFLUX INITIAL ASSESSMENT

Parent's Name

Child's Name

Date of Birth

Gestational Age at Birth

Birth Weight

Discharge Weight

Current Weight

Have there been any weight gain concerns?

EVERYTHING BABY

Baby's Behaviour?

Crying Behaviour?

Has a formal diagnosis been made? If yes, please can you give the diagnosis.

Is your baby currently on any medication or have they ever taken medication? Please note what medications?

Is your baby currently taking any antibiotics or have they been given antibiotics?

Is your baby currently or have they ever taking any supplements?

Does your baby currently or have they ever used a dummy?

Has your baby ever been assessed for a tongue, lip or buccal (cheek) tie? What was the outcome?

If a tie was identifed, was it released?

Did you receive aftercare guidance if a release took place? If yes, please describe this care.

Aside from the paediatrician, has your baby been seen by any other health care practitioners?

Has your baby started eating solids yet?

If yes and younger than 6 months of age, under whose recommendation did you start and did you notice a difference in symptoms once started? Either an improvement or deterioration of symptoms?

PREGNANCY & BIRTHING INFORMATION

Pregnancy

Labour

Birth

Were you or baby given antibiotics at birth or before?

FEEDING

How are you currently feeding your baby?

Breastfeeding

Formula

Combination

If you answered formula or combination, please list what formulas you have tried and which you one you are currently using. Please be brand specific. Note if buying outside of UAE.

If you are breastfeeding, please describe your typical diet.

SYMPTOM TRACKER

In each of the following sections please mark which symptoms are being experienced by your baby. Note the frequency and the severity of each symptom out of 10 (10 = very severe). A day will cover a full 24 hour period.

Feeding

Frequent feeds (more than 8 feeds per day under 6 months of age

Severity

Short feeds

Severity

Falls asleep during feeds

Severity

Often refuses to feed

Severity

Pushes breast or bottle away

Severity

Turns head away when trying to feed

Severity

Tugs or hits at breast when trying to feed

Severity

Spills milk from mouth or nose during feeds

Severity

Posseting (bringing up milk, then swallowing again)

Severity

Splutters, coughs, gags or chokes during feeds

Severity

Gulps during feeding

Severity

Bobs on and off the breast during feeding

Severity

Can hear milk sloshing in baby's tummy

Severity

Spits up frequently

Severity

Makes a clicking sounds during feeding

Severity

Appears to be uncomfortable

Severity

Appears to be in pain

Severity

After feeding

Projectile vomiting

Severity

Frequent vomiting

Severity

Green or yellow vomiting

Severity

Vomit has blood in it

Severity

Chokes or face/lips turn blue

Severity

Brings up food after several hours

Severity

Squirms around or grunts

Severity

Please note if your baby is experiencing any green or yellow vomiting, or unexplained blood in vomit, these are considered RED FLAGS and your baby should be assessed by a medical doctor as soon as possible.

Respiratory

Coughing

Severity

Continuous stuffy or blocked nose

Severity

Continuous runny nose

Severity

Difficulty breathing (at any point in the day)

Severity

Face goes blue

Severity

Sneezing

Severity

Wheezing

Severity

Sleep apnoea (stops breathing during sleep)

Severity

Please note if your baby is experiencing difficulty in breathing or their face is going blue, these are considered RED FLAGS and your baby should be assessed by a medical doctor as soon as possible.

Positional

Plagiocephaly/ flat spot on head

Severity

Sleeps with head at an extended angle

Severity

Only happy to feed on one side or position

Severity

When sleeping, even if you move their head they return to original position

Severity

Cannot open mouth very wide

Severity

When mouth is wide it appears off centre

Severity

Torticolis/ twisting of head and neck

Severity

Cannot open mouth for long periods

Severity

Sleep

Frequent night waking (2+ times from 8 weeks)

Severity

Sleep apnoea (stops breathing during sleep)

Severity

Mostly will only sleep whilst being held

Severity

Difficult to get baby to sleep

Severity

Wakes soon after being put down

Severity

Difficulty staying asleep

Severity

Needs motion to sleep (car, buggy, sling, rocking)

Severity

Digestive

Acidic or smelly breath

Severity

Rumbly tummy

Severity

Rock hard tummy

Severity

Tender tummy

Severity

Swollen or bloated abdominal area

Severity

Diarrhoea

Severity

Constipation (not passing poop on a daily basis)

Severity

Mucous is poop

Severity

Blood in poop

Severity

Green poop

Severity

Black in poop

Severity

Lots of wind

Severity

Painful wind or gas

Severity

Hiccups

Severity

Did your baby experience hiccups in utero?

Please note if your baby is experiencing unexplained blood in their poop, this an considered a RED FLAG and your baby should be assessed by a medical doctor as soon as possible.

Physical or General Symptoms

Please describe any other symptoms your baby is experiencing?

DAY IN THE LIFE OF

Side view of baby's face

Max. file size: 100 MB.

Front view of baby's face

Max. file size: 100 MB.

View from top of head

Max. file size: 100 MB.

Latch video (if you are battling to load please send via email)

Max. file size: 100 MB.

If possible please include a close up video of baby crying, focusing on their face.

Max. file size: 100 MB.

Please take a diary for a 24 hour period.

Max. file size: 100 MB.

Things of importance to note: Time of medication or supplements given; Time of milk feeds and breast or formula; Sleep and wake timings, including night time; Note symptoms experienced, include time of day, and severity; Note what happened on wake ups during the night