|Date_____ Mother/s Name ___________ Infants Name ___________ Birth Weight____lb____oz
BREASTFED NEWBORN TRIAGE FORM This questionnaire should be routinely completed for all breastfeeding dyads in the first week of life, if the dyad is not seen in the clinic setting by the HCP. In addition it can be used as a telephone triage form whenever a mom calls with a breastfeeding problem in a newborn infant. If client has any risk factors bring this to the attention of the babys provider as soon as possible.
BREASTFED NEWBORN ASSESSMENT
|QUESTIONS||NORMALS||PATIENT RESPONSE||RISK FACTORS|
|Age of baby today and at birth?||38-42 weeks||____DAYS or WEEKS ____GESTATIONAL WEEKS||Less than 38 weeks with other risk factors or less than 36 weeks without.|
|Complications: 1. Any complications in mom or infant? 2. Any medication usage in mom or infant or during labor? 3. Vaginal or C-section delivery? 4. Single or multiple birth?||No complications. NSVD of a single child. No medication usage.||Complications: NONE or _________________________________
MEDS: NONE or ___________________ Single or Multiple
|If any complications present or Hx of c-section, pain meds, epidural, jaundice, sleepy baby, or multiple birth.|
|Feeding characteristics: 1. How often is baby fed? 2. How many feedings in 24 hours? Any schedule? 3. Who ends the feeding? 4. For what length of the feeding do you hear the baby swallowing?||Feeding and sleeping intervals vary. There may be one 5 hour stretch. Cluster feeding is normal. Swallows for at lest 10 minutes per feeding. Feed on demand.||Frequency/interval_________ Number of feedings_________ Baby ends/Mom ends/ varies Swallowing length_____________ Cluster feeding______________||Less than 8 or more than 15 feedings. Any consistent intervals greater than 5 hours or shorter than 45 min. Scheduled feedings. Swallowing less than 10 minutes.|
|Intake and Output: (over last 24 hours) 1. Using paper or cloth diapers? 2. Number and character of stools? 3. Number and color of wet diapers? 4. Birth weight, Discharge weight? Last weight? 5. Any supplements and if so what type and how much?||Easy to miss voids with paper diapers. Urine and Stool normals. One wet diaper per day of age & 2 or more stools (progressing from meconium to yellow seedy) per day until milk in. Once milk in, 6-8 clear colored wet diapers and at least 3 generous stools per day. 10% weight loss at birth with regain by 3 weeks of age. Then 2 to 1 oz. per day. No supplements.||Number of wet Cloth/Paper diapers______ Character of urine: Clear/ Yellow/ Brick/red Number of stools______Stool Character: Meconium Transitional/ Yellow Seedy/ Green/Watery/Bloody Other_______ Supplements: yes/no If yes, what type: Artificial milk/juice/water. How much per day?_________||Less than 6 wet diapers by day 6 and/or brick red colored urine. Stools not progressing or less than 2 per day. Less than birth weight at 2 weeks or gaining less than 2 oz per day. Use of supplements|
|Any breast or nipple discomfort/pain?
||Get description of discomfort. It is common to have latch-on soreness that lasts less than 60 seconds. Breast pain is never normal.||NONE Pain scale 1-10.______(10 is severe)Location: nipple/breast/areola Description: Open sores/ Fever /Redness/Lumps/Other_____________||Open sores, redness, fever, or tender lump. Pain which is hindering nursing or causing desire to cease nursing.|
|Any other concerns? NONE OR
|ASSESSMENT: NORMAL BREASTFEEDING DYAD or ABNORMAL BF- DYAD SECONDARY TO:_________________________________________________________________
PLAN: SCHEDULE PROVIDER VISIT____TODAY____WITHIN 48 HOURS WITHIN ______WEEK(S)
EDUCATION REGARDING: FEEDING FREQUENCY/ BREAST-NIPPLE CARE /SLEEP CYCLES/ SIGNS OF HUNGER/ INTAKE & OUTPUT/POSITIONING &