Clinical Reference Systems: Pediatric Advisor 10.0
Screening Form for Early Follow-Up of Breast-Fed Infants
Name: _______________________________ Date: ___/___/___
Number of days since delivery: _____
Your answers to the following 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 9 or 11 through 13, or "Yes" to questions 10 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.
- Do you feel breast-feeding is going well for you so far?
- Has your milk come in yet? (That is, did your breasts
get firm and full between the 2nd and 5th days after
- Is your baby able to latch on to each breast without
- Is your baby able to keep suckling rhythmically a total
of at least 10 minutes per feeding?
- Does your baby usually demand to feed? (Answer "No" if
you have a sleepy baby who needs to be awakened for most
- Does your baby usually nurse at both breasts at each
- 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 eight nursings
every 24 hours)?
- Do your breasts feel full before feedings?
- Do your breasts feel softer after feedings?
- Are your nipples extremely sore (that is, causing you to
- Is your baby having yellow bowel movements that look
like cottage cheese and mustard?
- Is your baby having at least four good-sized bowel
movements each day (that is, more than a stain on the
- Is your baby wetting his or her diaper at least six
times each day?
- Does your baby appear hungry after most feedings (that
is, fussing and crying, sucking hands, rooting, often
needing a pacifier, etc.)?