Key elements of your assessment include:

• Parent's perception of the problem.
• Medical, developmental, growth and social history.
• Dietary assessment.
• Observation of feeding.

Your assessment reveals the following details:

Parent's perception of the Sam's feeding

Consider: Has their perception of Sam's feeding changed since discharge?

• Sam's prolonged hospitalisation has been stressful for his parents.  While they are pleased to have Sam at home they find feeding stressful.  It is not going as they had hoped.
• Mum continues to maintain a good supply of breast milk but is becoming increasingly disappointed that Sam will not breastfeed.  Sam is becoming increasingly upset when put to the breast.  
• Mum is also frustrated that Sam is currently taking very little from the bottle. Earlier on he seemed to do better.  Parents feel the nasogastric tube is making him lazy.   
• He wakes for most feeds during the day providing cues to hunger. However during the night he sleeps through his nasogastric feed.

Medical, Developmental, Growth and Social History.

Consider changes that have occurred since discharge.

• While Sam requires ongoing medical care for his congenital heart disease his condition remains stable.
• Sam has made steady gains in his development. He is now mouthing his hands and toys and control of his head and trunk has improved.  During his admission Sam's weight dropped to below the 5th percentile.  However prior to discharge weight gains had increased and he was tracking just below the 5th percentile on the WHO growth charts which was considered satisfactory.
• There are no changes in Sam's social circumstances. He lives with both his parents and older sister aged 2 years

Sam - Length	Sam - Weight

Dietary assessment

• At discharge Sam was being fed 4 hourly 6 times per day.  Volumes were adequate to meet fluid requirements and growth had improved.  He was tolerating feeds well with only the occasional vomit.
• However, on review Sam is vomiting at most feeds.  It is reported that feed volumes have been increased as there were concerns that Sam needed to gain weight more rapidly.  Increased volumes have not increased weight gains.

Feeding Observation

• Sam was observed attempting a breastfeed.  He was clearly distressed, and difficult to calm.  Feeding was not enjoyable for Sam or mum.
• Mum reports that at home she likes to hold Sam during NGT feeds.

Next Question