The child would also need a physical assessment, which could reveal abuse, neglect, etc but given our scenario is vague, I would contend that these are absent. I would likely assess and question for feeding or GI issues like mouth sores/malformation, gastroesophageal reflux (GER), frequent vomiting after meals, copious diarrhea, etc. (Montrowl, 2014). Given the child is low on all of the scales, it doesn’t appear to be anything acute, like weight loss from acute respiratory illness. Montrowl indicated that GER could very much be the issue. I would recommend that the child does not feed in a laying position, no bottles in bed, and should sit up after meals; the mother could try other formulas, some formulations with rice are gentler on the child’s belly (2014). I would also recommend an early intervention program, such as Birth to Three so there can be more monitoring of the child with possibility for more services provided at the county level (CDC, 2019). If the child is malnourished, for instance, if the mother is of lower socioeconomic status, recommending and assisting her in applying for food assistance programs could also benefit the child and the mother.
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