Screening Form for Early Follow-Up of Breast-Fed Infants

Name: _______________________________ Date: ___/___/___

Number of days since delivery: _____

Your answers to these questions will help you know whether you are off to a successful start with breast-feeding. Please complete this form when your baby is 4 to 7 days old. If you answer "No" to any of questions 1 through 12, or "Yes" to questions 13 or 14, call your baby's doctor or the hospital where you delivered for advice. Many hospitals have lactation consultants or lactation nurse specialists on staff who can help breast-feeding mothers after they go home. Breast-feeding problems that are identified early are easier to correct.

1. Do you feel breast-feeding is going well for you so far?

   Yes No

2. Has your milk come in yet? (That is, did your breasts get firm and full between the 2nd and 5th days after delivery?)

   Yes No

3. Is your baby able to latch on to each breast without difficulty?

   Yes No

4. Is your baby able to keep suckling rhythmically a total of at least 10 minutes per feeding?

   Yes No

5. Does your baby usually demand to feed? (Answer "No" if you have a sleepy baby who needs to be awakened for most feedings.)

   Yes No

6. Does your baby usually nurse at both breasts at each feeding?

   Yes No

7. Does your baby nurse approximately every 2 to 3 hours (from the beginning of one feeding to the beginning of the next), with no more than one long interval of up to 5 hours at night (a total of at least 8 nursings every 24 hours)?

   Yes No

8. Do your breasts feel full before feedings?

   Yes No

9. Do your breasts feel softer after feedings?

   Yes No

10. Is your baby having yellow bowel movements that look like cottage cheese and mustard?

    Yes No

11. Is your baby having at least 4 good-sized bowel movements each day (that is, more than a stain on the diaper)?

    Yes No

12. Is your baby wetting his or her diaper at least 6 times each day?

    Yes No

13. Are your nipples so sore that you dread feedings?

    No Yes

14. Does your baby seem hungry after most feedings (that is, fussing and crying, sucking hands, rooting, often needing a pacifier, etc.)?

    No Yes

Written by Marianne Neifert, MD, and the clinical staff of The Lactation Program, Rose Medical Center, Denver, CO. 303-377-3016.
Published by RelayHealth.
© 2009 RelayHealth and/or its affiliates. All Rights Reserved.