Relevant Evaluation Criteria Scenario/Model Outcome
Information Gathering
1. Gather essential information about the patient’s symptoms, including:
a. description of symptom(s) (i.e., nature, onset, duration, severity, associated symptoms) Infant has been spitting up formula after every feeding, almost always with a little force. Although some emesis has occurred since birth, the amount and frequency has increased over the last week. The infant also appears to have more gas, often crying from “gas pains.” The infant girl appears well hydrated.
b. description of any factors that seem to precipitate, exacerbate, and/or relieve the patient’s symptom(s) Emesis occurs only after feedings. The infant appears to be more comfortable after each episode of emesis. Irritability associated with gas pains appears to be relieved by simethicone.
c. description of the parent’s efforts to relieve the symptoms Simethicone has been given for gas. Nothing specific has been done for the emesis.
2. Gather essential patient history information:
a. patient’s identity Lauren Smith
b. patient’s age, sex, height, and weight 6-week-old girl; 22 inches; 8 lb 5 oz (3.8 kg)
c. parents’ occupation Father is a mechanic; mother is a receptionist at an insurance agency.
d. patient’s dietary habits Lauren was receiving breast milk plus Enfamil LI PI L 20 kcal/oz, if desired, until 1 week ago when her mother stopped breast-feeding. The infant was changed to Enfamil LIPIL. Per the mother’s report, the formula is being mixed to a 24 kcal/oz concentration on the advice of her PCP. The infant takes approximately 120 mL (4 oz) every 3 hours. No extra water or juice is given during the day.
e. patient’s sleep habits Lauren has not started sleeping through the night.
f. concurrent medical conditions, prescription and nonprescription medications, and dietary supplements Lauren is a healthy, term infant.
g. allergies NKA
h. history of other adverse reactions to medications None
Assessment and Triage
3. Differentiate the patient’s signs/symptoms and correctly identify the patient’s primary problem(s). Primary problem: emesis with feedings

Secondary problem: increased intestinal gas
4. Identify exclusions for self-treatment. Bloody or bilious emesis
Signs of dehydration: sunken fontanelle, dry mucous membranes, decreased wet

diapers, dark urine, decreased oral intake
5. Formulate a comprehensive list of therapeutic alternatives for the primary problem to determine if triage to a medical practitioner is required, and share this information with the parents. Options include:

(1) Call Lauren’s PCP to verify the caloric density and volume of feedings desired. Give Lauren’s parents instructions on the proper feeding of the infant.

(2) Refer Lauren’s parents to the PCP.

(3) Take no action.
Plan
6. Select an optimal therapeutic alternative to address the patient’s problem, taking into account patient preferences. Lauren’s current feeding schedule, 120 mL every 3 hours of 24 kcal/oz formula, provides 252 mL/kg/day and 202 kcal/kg/day. Both significantly exceed the usual recommended intakes for a healthy, term infant (see Tables 26-2 and 26-14). The most appropriate plan would be to decrease the overall intake. The PCP should be contacted to verify the caloric density of the formula. The family should then be instructed to feed Lauren approximately 2.5 ounces every 3 hours or 3-3.5 ounces every 4 hours. This decreased intake of formula should decrease the episodes of emesis, and decrease fussiness and irritability caused by overfeeding.
7. Describe the recommended therapeutic approach to the parents. The primary care practitioner should be contacted to verify the desired concentration of Enfamil LIPIL The volume of the feedings should be reduced to the volumes listed in step 6. If the symptoms persist after these interventions, Lauren should be taken to the PCP.
8. Explain to the parents the rationale for selecting the recommended therapeutic approach from the considered therapeutic alternatives. Because the symptoms started (or acutely worsened) with the change from breast milk to infant formula, and both the caloric density and the volume of the infant formula exceed the usual needs of a healthy term infant, overfeeding is the most likely cause of Lauren’s emesis and irritability. If overfeeding is the major issue, decreasing the caloric density and volume of feedings will have almost immediate results.
Patient Education
9. When recommending self-care with non-prescription medications and/or nondrug therapy, convey accurate information to the parents:
a. appropriate dose and frequency of administration New feeding regimen: Enfamil LIPIL 2.5 ounces every 3 hours or 3-3.5 ounces every 4 hours. Watch for cures to the baby’s hunger and satiety patterns to avoid under- or overfeeding.
b. maximum number of days the therapy should be employed If no improvement is seen in 2-3 days, then the primary care provider should be contacted for a possible change in the formula (see Table 26-6).
c. product administration procedures The formula should be mixed per product instruction (e.g., 1 scoop in 2 ounces of water to make 20 kcal/oz formula) per the information given in the box Patient Education for Infant Nutrition.
d. expected time to onset of relief Several days
e. degree of relief that can be reasonably expected Emesis likely will not be eliminated. All infants have some gastroesophageal reflux and spit or vomit from time to time. Forceful emesis and emesis with every feeding as well as irritability from gas pains should improve.
f. most common side effects None
g. side effects that warrant medical intervention should they occur Persistent vomiting, especially if severe, bilious, or bloody; weight loss; dehydration
h. patient options in the event that condition worsens or persists Contact primary care provider to evaluate for other causes such as cow-milk intolerance, gastroesophageal reflux, or other conditions.
i. product storage requirements Infant formula should be used soon after mixing or kept tightly covered in the refrigerator and used within 24 hours of preparation. See product information for any specific storage requirements.
10. Solicit follow-up questions from parents. What if Lauren doesn’t appear to be satisfied with the smaller volume of feedings?
11. Answer parents’ questions. From the history, it sounds like Lauren’s stomach is too full after each feeding, resulting in a forceful emesis to remove the extra volume. If she receives only the amount needed, she should feel satisfied, without an episode of emesis. If she takes the smaller amount and still appears to be hungry, then an additional 0.5 ounces can be given.