Well-Child Check: Birth to One Year

One Month Normal Exam Template

• Parental concerns:

• General health

  • No new allergies, medications, health issues

  • No parental concerns regarding vision, hearing

• Nutrition: On average, gaining 15-30 g/day during first six months of life

  • Breastfed

    • Concerns about breastfeeding:

    • Nurses q2-3 hours (8-12x daily) for 5-20 minutes per breast

    • Receives 400 IU vitamin D supplementation daily

  • Formula fed

    • Two scoops 20 kCal/oz formula added to 2 oz water

    • Water is measured before formula powder is added

• Elimination: ≥ 6 wet diapers and ≥ 1 stool(s) qd; stools appear []

• Sleep: Sleeps 14 to 17 hours daily

• Social history

  • Mother denies postpartum depression

  • Activities/childcare during day:

• Developmental milestones

• Anticipatory guidance

  • No shaking infant

  • Sleep on back in bassinet/crib with no blankets, bumpers, toys

  • No smoking in home and change clothes after smoking outside

  • Rear facing car seat until age ≥ 2

Assessment and Plan

General Health

• Maternal PHQ-9 < 10

• Acute health issues:

• Vision/hearing concerns: Refer to ophthalmology/audiology

• Nutrition concerns

  • Continue vitamin D 400 IU qd until infant is weaned or consuming > 32 oz (1 L) fortified formula daily

• Elimination

• Anticipatory guidance: Counseled about appropriate screen time, water safety, car safety, and gun safety

Vaccinations: 1st dose hepatitis B if not administered in hospital

• Vaccinations

• Not achieving developmental milestones:

Notes

• Nutrition: Appropriate weight gain is the best indicator of adequate nutrition

  • Formula

    • Standard formula is 20 kCal/oz

    • Water should be measured before formula is added

  • Average energy requirements by age

    • 0 to 1 month: 110 kCal/day

    • 1 to 3 months: 95 kCal/day

    • 6 to 12 months: 80 kCal/day

• Stools: Generally yellow/seedy in breast fed infants and may be green in formula fed infants