Name: Joshua Benedict Ang

DOB: 13.2.22
Address: 92 Stannington View Road, Sheffield, S10 1SR
Consultant: Dr Bobby Pambudi SpA (K)
Date of letter: 11.1.2023

Dear Doctor

I have the pleasure of looking after 10-month old Joshua during his visit to Manado,
Indonesia from September 2022 to January 2023.

He initially presented in October 2022 with difficulties taking solids and breastmilk.
Specifically, he nursed only for few minutes and very likely not getting enough milk despite
being supported by a UK-based lactation consultant. He refused bottle, beaker and open cup
for top-up milk. He would take a small amount of milk with spoon, syringe or pipettes. We
discussed feeding timetable and trial of supplementary nursing system (SNS) for top-up
formula which was not successful. Blood results showed evidence of iron-deficiency.
Urinalysis MC&S revealed E.Coli UTI. He was started on a course of co-amoxiclav and a
course of Ferric Hydroxide Polymaltose Complex (Maltofer) 0.8 mL daily.

On subsequent follow up visits, Joshua’s weight gain was minimal. He was not taking much
solid despite strict adherence to feeding timetable. Repeat urinalysis showed evidence of
recurrent E.Coli UTI which was supported by radiological evidence of cystitis on USS of
abdomen. He was treated with 10-day course of co-amoxiclav. His repeat blood test showed
improvement in his blood iron level after one month of treatment with iron replacement.

Here are his weight readings:

17.9.22 - 7.35 kg
22.10.22 - 7.60 kg
12.11.22 - 7.89 kg
3.12.22 - 8.10 kg
17.12.22 - 8.19 kg
28.12.22 - 8.29 kg

Due to concern about his recurrent UTI, a urological opinion was sought. Examination
showed evidence of likely physiological phimosis and observation (instead of circumcision)
was recommended.

Joshua’s difficulties with feeding and weight gain is due to his recurrent UTI and iron-
deficiency, in addition to his refusal to take sufficient amount of top-up milk. To support
Joshua’s weight gain, a trial high-calorie formula, Infatrini, 100mls four times daily for one
month is recommended. His mother will continue breastfeeding him. He is to complete his 3-
month course of iron supplement.
Joshua’s investigation results including urinalysis, MC&S, USS abdomen and blood tests are
attached to this letter.

I hope you can continue his care locally in Sheffield and consider a referral to the appropriate
team to support his feeding.

Regards,

dr. Bobby Pambudi SpA (K) dr. Cecilia Naritha

Consultant Paediatrician in Nutrition and Director of Sentra Medika Hospital
Metabolic Diseases Minahasa Utara