Inpatient Postpartum Lactation Consult Note

Date/Time: [Date and time of consult]

Author/Credentials: [Consultant name and credentials]

Location/Unit: [Hospital / Unit / Room]

Consult Type: [Initial / Follow-up]

Reason for Consult: [Primary reason for lactation consult]

Dyad Identification: Lactating parent: [Parent full name], PPD#[Postpartum day]. Infant: [Infant full name], [Gestational age at birth], [DOL# / HOL#].

Clinical Summary

[One-sentence orienting summary including postpartum day, infant day/hours of life, primary concern, and consult goals.]

Subjective

Feeding goals: [Parent-stated feeding goals and preferences: exclusive breastfeeding / combination feeding / pumping / undecided; what success means to them]. (If goals were not elicited, state reason. Use patient-preferred feeding terminology when documented.)

Feeding history since birth (parent report): [Feeding frequency and duration pattern]; [Supplements already given: type, amount, method, reason]; [Pacifier or bottle exposure if relevant].

Infant output (parent report): [Wet diaper count]; [Stool count with transition stage by day of life: meconium / transitional / yellow].

Maternal symptoms: [Nipple pain: location, severity, timing with latch]; [Nipple trauma]; [Breast fullness/engorgement]; [Concerning systemic symptoms].

Lactation risk factors impacting plan: [Relevant factors only if they influence management—prior breast surgery, history of low supply, postpartum hemorrhage, cesarean delivery, maternal-infant separation]. (Omit if none.)

Objective

Pertinent chart data: Infant birth weight [weight], current weight [weight] ([percent change]%). [Relevant infant medical issues affecting feeding]. Parent: [Delivery type and any complications relevant to lactation].

Breast and nipple assessment: [Breast tissue findings: edema / engorgement / tenderness / soft]; [Nipple findings with laterality: everted / flat / inverted / compression stripe / trauma]; [Colostrum/milk expression observed: yes/no and description].

Infant feeding readiness and oral function: [State regulation: alertness, tone, ability to sustain suck]; [Oral anatomy and function: tongue movement, jaw excursion, palate observation if indicated]; [Hydration cues if concerning]. (Document findings; recommend evaluation if indicated for conditions outside scope.)

Observed Feeding Session

Timing and preconditions: [Time of observation]; [Skin-to-skin status]; [Time since last feed].

• Positions attempted: [Positions used].
• Latch quality: [Gape]; [Asymmetry]; [Lip flange]; [Chin contact].
• Suck pattern: [Rhythmic / shallow / breaks suction / bursts with pauses].
• Swallowing and milk transfer indicators: [Audible swallows / visible swallows / jaw motion changes]; [Post-feed satiety cues].
• Maternal comfort during feed: [Pain rating]; [Response to repositioning/interventions].
• Nipple appearance after feed: [Rounded / compressed / blanched / creased].
• Infant behavior after feeding: [Content / sleepy / continued feeding cues].

(If no observed feeding was possible: document reason, alternative assessment performed, and plan to reattempt with specific timeframe. State "Not assessed—[reason]" rather than omitting.)

Interventions and Response

• [Intervention performed] — [Outcome: pain change with before/after ratings, latch duration change, when swallows became audible].

(Add a bullet for each intervention performed: latch coaching, positioning adjustment, breast compression, wake techniques, hand expression instruction with return demonstration.)

Assessment

[Problem-oriented summary prioritized by urgency: infant safety issues first, then maternal complications, then technique optimization. For each problem, include supporting evidence from observations and contributing factors.]

Plan

Immediate Feeding Plan

• Target frequency: [Cue-based with minimum of X feeds per 24 hours; avoid intervals greater than Y hours].
• Wake strategies: [Techniques for sleepy infant].
• Escalation criteria: [Specific criteria to notify nursing/physician].

Latch and Positioning Recommendations

• [Positions that worked best].
• [Key technique steps to achieve deep latch].
• [Pain mitigation strategies].

Hand Expression Plan

(Include only if indicated—poor latch, sleepy infant, engorgement, supplementation need.)

• Indication: [Reason].
• Frequency: [Every X hours / after each attempt / as needed for comfort].
• Teaching: [Technique taught with return demonstration: yes / no].
• Use of expressed milk: [How and when to provide to infant].

Pumping Plan

(Include only if pumping is recommended; omit entire section if not indicated.)

• Indication: [Reason].
• Equipment: [Pump type]; [Flange size if assessed].
• Schedule: [How pumping integrates with breastfeeding attempts].

Supplementation Plan

(Include only if used or anticipated; omit entire section if not indicated. Note that breastfeeding optimization was attempted first when feasible.)

• Indication: [Clear reason].
• Type: [Expressed colostrum / expressed milk / donor milk / formula].
• Volume and method: [Volumes per feed or per kg]; [Method: syringe / cup / paced bottle / SNS].
• Reassessment criteria: [Taper criteria and timeframe].

Discharge Feeding Plan

• Feeding method(s) at discharge: [Method(s)].
• Minimum feeds per 24 hours: [Number].
• How to monitor intake: [Swallows; diaper output targets by DOL; weight check schedule].
• Tools and troubleshooting: [Any ongoing tools with basic troubleshooting steps].
• Who to call for urgent issues: [Contact or service].

Follow-Up and Care Coordination

• Outpatient pediatric follow-up: [Timing and location].
• Outpatient lactation referral: [Referred / referral placed / not indicated]; [Appointment status if known].
• Team communication: [Communication with bedside nursing and medical teams].

Return Precautions

• Infant: Too sleepy to feed; poor output for age; worsening jaundice; signs of dehydration; persistent ineffective latch.
• Parent: Fever or chills; rapidly worsening breast pain or redness; inability to express milk when engorged; severe nipple trauma.

Education Provided

[Topics covered: latch technique, recognizing swallows, output expectations, hand expression, safe storage]; [Materials provided]; [Teach-back performed: yes / no].

Signature: [Consultant name, credentials]