| | Comments |
| History |
| Open-ended question(s), eg, "How are things going?" | - Used to explore mother's concerns and coping
- Response helps to focus additional history, physical examination, and breastfeeding observation
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| How often is the baby feeding? | - Frequent feeding is required to maintain or increase or the mother's milk supply
- Goal of at least 8 feeds in 24 hours
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| How is the baby's behavior at the breast (active, sleep, frustrated)? | - Screens for inadequate intake and its cause
- Sleepy baby – Offer advice on arousing the baby and ensuring complete breast emptying
- Frustrated baby – Explore further for possible suboptimal milk production
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| How many wet diapers and stools in the past 24 hours? | - Screens for insufficient intake and signs of dehydration
- For the first 4 days of life, goal of at least 1 stool per 24 hours and 1 void per day of age
- Goal of at least 6 to 8 voids per day and at least 1 yellow, seedy stool per day by 5
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| Have you noticed any changes in your breasts since the birth? Are they fuller? More tender? Visible milk? | - Assesses for transition to lactogenesis II and generally for milk supply
- Lactogenesis II typically occurs by 3 to 4 days postpartum; up to 35% of primiparous women have delayed lactogenesis II
- Delayed lactogenesis II is a marker for suboptimal milk production; focused counseling is warranted to ensure optimal breastfeeding technique, frequent feeding, and complete emptying of the breasts
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| Do you feel any pain or discomfort with breastfeeding? | - Screens for ineffective latch, nipple trauma, and poor milk transfer
- Nipple pain is typically caused by nipple compression or rubbing
- Advise the mother to unlatch the infant and reattach whenever she feels pain
- Observe feeding and advise on how to achieve an effective latch
- Examine the nipples for compression or trauma, as described below
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| Screen for perinatal mood and anxiety disorder | - Assess need for additional support or counseling
- Edinburgh Postpartum Depression Screening tool[1] or other validated tool
- Discuss approaches for maternal exhaustion, including self-care and maximizing rest for mother when infant is sleeping
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| Physical examination |
| Infant weight | |
| General appearance | - Screen for signs of illness
- Healthy babies should wake easily and often to feed and have good pink color and symmetric movements
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| Hydration status: mucus membranes, skin turgor, anterior fontanelle | - Screen for insufficient intake
- Any concern for dehydration should warrant a complete feeding evaluation and development of a comprehensive feeding plan
- Frequent follow-ups are needed until breastfeeding is well established and infant has a pattern of good weight gain
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| Jaundice | - Screen for insufficient intake and other causes of jaundice
- Insufficient intake is a risk factor for pathologic jaundice
- Some infants have persistent physiologic jaundice despite adequate breastfeeding¶
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| Degree of mother-infant bonding | - General impressions of maternal behavior, including her focus on the infant
- Poor focus may be a sign of perinatal mood and anxiety disorder, maternal exhaustion, or other challenges
- If concerns, follow up with further open-ended questions about mood and coping; provide support; consider referral for perinatal mood and anxiety disorders
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| Feeding observationΔ |
| Are mother and infant both comfortable? | - Comfort is an important step for effective latch and optimal milk transfer
- Teach different positions for breastfeeding
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Attachment to breast: - Infant's chin is buried in breast, with nose free?
- Latch asymmetric (more areola visible above the nipple than below)?
| - These suggest an effective latch
- Teach mother technique and how to recognize the signs of an effective latch
- Any pain during breastfeeding should be addressed by adjusting the latch
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Signs of milk transfer: - Audible swallow
- Infant is content and relaxed after feed
| - Suggests sufficient milk intake for that feeding
- These signs are not entirely reliable
- Also, monitor weight gain
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| Inspect nipple after feed | - Nipple that is flattened or sloped after the feed suggests pressure from the infant's tongue
- If evidence of compression, provide further instruction on achieving an effective latch and encourage mother to check nipple appearance after future feeds
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| Decision points and action items |
| Is infant's intake adequate? | - Excessive weight loss or signs of dehydration are indications for supplementation
- When supplements are considered, an expert breastfeeding evaluation is required in order to uncover and address the root cause of the insufficient intake
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| Is milk supply adequate? | - If the infant requires supplements but the mother's milk production is sufficient, then supplement with expressed mother's milk rather than formula
- If mother's milk production is not sufficient, limited quantities of formula supplements should be given◊
- Infant should continue to breastfeed, with lactation support to ensure optimal breastfeeding technique, frequent feeding, and complete emptying of the breasts to ensure signaling and improve milk supply
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| Does the dyad need professional assistance with breastfeeding? | - Indications for professional assistance include persistent problems with nipple pain, attachment, inadequate intake or insufficient milk supply, and/or need for supplementation with something other than mothers' breast milk
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| Does the mother have risk factors for and/or signs or symptoms of a perinatal mood or anxiety disorder? | - Discuss self-care strategies and validate the difficulty of the first few days and weeks postpartum
- Offer hope that usually after the first few weeks, she will feel more like herself
- Use a validated screening tool to follow her progress at frequent follow-up visits
- Refer her to her obstetric clinician, primary care clinician, or a behavioral health specialist as needed
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| When to schedule follow-up? | - If breastfeeding is going well, typical follow-up is during well-infant visits at 2 weeks of age
- Make sure the parents know to call for the concerns about poor feeding; decreased voids or stools; infant not settling after feedings; or any other questions or concerns about how the infant is looking, acting, or feeding
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| Does the parent(s) have other questions that need to be addressed? | - Invite parent(s) to raise concerns now and/or to reach out in follow-up
- Problems are more easily addressed at their onset; providing ready support helps to establish breastfeeding and reduces the risk that the parent(s) will give up
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