One of the best ways to get a handle on your child's
reflux is with a journal or chart, tracking their daily intake, as
well as, everything that comes back up. Below is a sample of how we
suggest keeping track. If you would like to print this, go to the
printer friendly version. Fill in the name and date, circle
whether it's for AM or PM, you will need two of these per day, one for
the morning and one for the night. Enter the formula the child is
given, or any restrictions placed on your diet for the given day if
nursing and enter the medication the child is on if any. We suggest
getting a binder or file folder to keep them in for easier
organization.
Enter the amount of food under intake, if nursing perhaps enter the
length of time, record the naps and sleeping, enter when the child
vomits/spits under emesis and try to estimate the amount, but remember
that it always looks like it's more than it is. To get a feel for
quantities, try spilling an ounce or two of plain water on counter or
bare floor, this will give you a good idea of what it looks like and
help you get used to how much your child might be spitting. Mark any
urination and bowel movements the child has under voids and BM's and
finally record your comments for the day, any of the feeds, bm's etc.
| Child's Name ______________________ |
Date _____________ |
AM / PM |
| Formula Given _______________ |
Meds __________ |
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Time |
Intake |
Sleep |
Emesis |
Voids |
BM's |
Comments |
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12:00 |
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12:15 |
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12:30 |
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12:45 |
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1:00 |
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1:15 |
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1:30 |
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1:45 |
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2:00 |
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2:15 |
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2:30 |
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2:45 |
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3:00 |
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3:15 |
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3:30 |
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4:00 |
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4:15 |
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4:30 |
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4:45 |
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5:00 |
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5:15 |
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5:30 |
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6:00 |
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6:15 |
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6:30 |
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6:45 |
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7:00 |
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7:15 |
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7:30 |
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7:45 |
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8:00 |
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8:15 |
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8:30 |
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8:45 |
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9:00 |
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9:15 |
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9:30 |
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10:00 |
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10:15 |
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10:30 |
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10:45 |
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11:00 |
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11:15 |
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11:30 |
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11:45 |
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TOTALS |
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