Nurture by Naps

Date Of Visit *

MM

DD

YYYY

Start Time

Hour

Minute

Second

AM PM

End Time

Hour

Minute

Second

AM PM

Client Name *

First Name

Last Name

Client's Date of Birth *

MM

DD

YYYY

Baby's Name *

First Name

Last Name

Baby's Date of Birth *

MM

DD

YYYY

Lactation Consultant *

First Name

Last Name

Pediatrician Name *

First Name

Last Name

OB or Midwife Name *

First Name

Last Name

Latch Assessment

Positioned belly to belly

Infant Body Alignment

Gape Response Present

Lips Flanged

Rocker Motion

Wide angle in corder of mouth

Audible Swallows

Pain Free throughout feeding

Global Health Media on Latching: https://www.youtube.com/watch?v=wjt-Ashodw8&t=6s

Breast Assessment

cracked nipples

nipple pain

engorgement

clogged ducts

flat nipple(s)

inverted nipple(s)

Insufficient glandular tissue

Other (see below)

Recommendations

Breastfeed 8-12 times in 24 hours

Pump both breasts at same time for 10-20 minutes

Supplement with breastmilk or formula as outlined

Take herbal supplements as recommended

Feed baby every 2-3 hours during the day

Feed baby every 3-4 hours overnight until baby has regained birthweight

Apply nipple ointment after every feed

Use nipple shield as recommended

Other (see below)

Teaching provided *

Safe storage of breastmilk (Rule of 4's: https://www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htm)

Proper setup/use/cleaning of breast pump

Use of nipple shield including how to wean

Warning signs for baby and when to call pediatrician

Warning signs for mom and when to call OB

Paced bottle feeding (https://vimeo.com/797799187/26d3ba022e?share=copy)

5 s's (1. swaddle 2. side lying 3. swinging 4. shushing 5. sucking)

Proper preparation of infant formula

Starting Solids

Introducing Allergens

Prenatal Education

Pumping

Teething

Alcohol and breastfeeding/pumping

Positioning

Daytime feeding and sleep schedules

Nighttime feeding and sleep schedules

Bottle Refusal

Other (see below)

Source of teaching provided (check all that apply) *

Practice Guidelines

CDC

AAP

Vimeo

Youtube

Other

Follow Up *

Follow-up appointment recommended

Follow-up appointment scheduled (including in home, Telehealth, or phone call)

Outside-referral made (see below)

No follow up needed at this time

Other (see below)

Additional Opportunities for Learning & Support

Free Breastfeeding Support Group: offered weekly virtually and in person

Unswaddled: The Truth About Parenting Podcast. Listen here: https://podcasts.apple.com/us/podcast/unswaddled/id1560213381

Nurture by NAPS Membership *

Already a member: ask your follow up questions on the "ask a nurse" message board and receive a response within 24 hours.

New Member offer will be sent in email follow up.

Date Signed and Accepted *

MM

DD

YYYY