Month Choose any First line
Month and yearDefault
Status Choose one First line
Doing great! Doing well.Default Improving but not yet at goal. Not doing as well as hoped. Struggling since the last visit.
Response Choose one
Reflux symptoms improved on the current planDefault Reflux symptoms resolved Reflux symptoms unchanged despite 4-8 weeks of treatment Symptoms returned after stopping acid suppression Acid suppression stopped, with symptoms still controlled
Alarm features present Choose any
trouble swallowing or food sticking GI bleeding persistent vomiting weight loss or slowed growth
Alarm features absent Choose any
trouble swallowingDefault GI bleedingDefault persistent vomitingDefault weight loss or slowed growthDefault
Medication plan Choose one
No medication change planned at this timeDefault Continue Omeprazole at the current dose Started Omeprazole Increased Omeprazole given persistent symptoms Decreased Omeprazole to reduce side effects Switched to Omeprazole Added Omeprazole Stopped Omeprazole Began weaning acid suppression given symptoms resolved after the trial Restarted Omeprazole given symptoms returning after stopping
Reflux care Choose any
Continue reflux precautions, including smaller meals, no food 2-3 hours before bed, and avoiding caffeine and carbonated drinksDefault
Additional reflux care Choose any
Continue smaller, more frequent feeds held upright after feeding Continue thickened feeds Two- to four-week trial of a hypoallergenic formula or maternal dairy elimination given ongoing symptoms Discussed weight as a contributor Discussed avoiding smoke and vaping
Testing and referral status Choose any
Labs reviewed and reassuring Labs ordered Labs pending Imaging reviewed and reassuring Imaging ordered Imaging pending Specialist visit scheduled Awaiting specialist recommendations Specialist recommendations reviewed and incorporated into the plan
Referral Choose one
Referred to pediatric GI given symptoms despite treatment Referred to pediatric GI given alarm features
Follow-up Choose one
in 2 weeks in 1 monthDefault in 3 months or sooner as needed in 6 months at the next well child check after the results after the specialist visit as needed
Counseling paragraph Choose one Paragraph
Acid medicine is used for a limited time and then tapered when symptoms are controlled, while the reflux precautions continue. Recommended supportive care with an emphasis on smaller meals, avoiding late-night eating, and limiting caffeine and carbonated drinks. Return precautions given including trouble swallowing, vomiting blood or material that looks like coffee grounds, black stools, weight loss, severe or worsening pain, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.Default Spitting up in babies usually improves with time and growth, and feeding changes help more than medicine for most infants. Recommended supportive care with an emphasis on smaller, more frequent feeds, holding upright after feeds, and back to sleep on a flat surface. Return precautions given including poor weight gain, forceful or green vomiting, blood in the spit-up or stool, breathing pauses or color change, refusing feeds, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions. Symptoms that continue despite treatment, or the features found today, need a closer look by GI, which may include an endoscopy. Recommended supportive care with an emphasis on smaller meals, avoiding late-night eating, and continuing the current medicine until the GI visit. Return precautions given including trouble swallowing, vomiting blood or material that looks like coffee grounds, black stools, weight loss, severe or worsening pain, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.
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Reflux, follow-up
November 2026: Doing well.
• Reflux symptoms improved on the current plan
• No trouble swallowing, GI bleeding, persistent vomiting, or weight loss or slowed growth
• No medication change planned at this time
• Continue reflux precautions, including smaller meals, no food 2-3 hours before bed, and avoiding caffeine and carbonated drinks
• Follow up in 1 month
Acid medicine is used for a limited time and then tapered when symptoms are controlled, while the reflux precautions continue. Recommended supportive care with an emphasis on smaller meals, avoiding late-night eating, and limiting caffeine and carbonated drinks. Return precautions given including trouble swallowing, vomiting blood or material that looks like coffee grounds, black stools, weight loss, severe or worsening pain, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.