NICU Lactation Consultation Note

Note Type: [Initial Consultation / Follow-up]

Date/Time of Service: [Date and time]

Location: [NICU unit/bed]

Author/Credentials: [Name, credentials]

Consult Requested By: [Requesting clinician/service]

Consult Question: [Primary question/goal prompting consult]

Caregivers Present: [Names and relationships]

Interpreter Used: [Language; interpreter ID] (Include only if interpreter used; otherwise omit this line.)

Infant: [Name], [MRN], [DOB], [GA at birth], [Day of Life], [Postmenstrual Age], [NICU location], [Multiple identifier if applicable]. (If any identifier is unavailable, document "Unknown at time of note.")

Lactating Parent: [Name], [MRN if documented per policy], [Postpartum Day], [Delivery date]. (If any identifier is unavailable, document "Unknown at time of note.")

Reason for Consult

[Brief problem-focused statement including primary and secondary concerns] (1–3 lines. Common reasons: supply establishment, pumping pain/technique, milk handling questions, breastfeeding transition planning, discharge feeding plan.)

Current Feeding Context

Infant:

• [Current feeding route] (gavage / PO / breast / combination)
• [Respiratory support level]
• [Feeding schedule]
• [Milk sources in use] (mother's milk, donor milk, formula, fortifier)
• [Feeding restrictions/precautions]

Parent:

• [Separation pattern] (rooming-in vs commuting; typical daily presence)
• [Pump type available] (hospital-grade / personal)
• [Estimated daily expressed volume with trend] (indicate if parent-reported)
• [Current pumping frequency] (sessions per 24 hours; overnight status)

(Use "Not available in chart" when data should exist but is inaccessible. Use "Not assessed today" when intentionally deferred.)

Subjective

[Parent's stated feeding goals and priorities] (Include brief direct quotes when they clarify intent or concern.)

[Relevant lactation history] (Prior breastfeeding experience, perinatal events impacting lactation, current symptoms including breast fullness, pain, nipple damage, fatigue.)

Pumping regimen (parent-reported):

• [Initiation timing] (hours postpartum)
• [Frequency] (sessions per 24 hours; overnight pumping status)
• [Duration per session]
• [Single / double pumping]
• [Pump type and flange size]
• [Techniques used] (breast massage, hand expression, compressions)
• [Approximate yield] (per session and per 24 hours with trend)
• [Pain/trauma] (nipple pain score 0–10; visible damage)

Milk handling practices (parent-reported): [Labeling method], [Storage location], [Transport method], [Pump part cleaning routine].

Direct breastfeeding/skin-to-skin attempts: [Frequency], [Parent observations of infant behavior at breast], [Perceived transfer], [Nipple shield or other supports used]. (Include if applicable; omit section if none attempted.)

(For focused follow-up notes, keep history minimal and reference prior consultation.)

Objective

Breast Assessment: [Nipple integrity], [Erythema/edema/trauma/milk blebs], [Tenderness/induration], [Systemic symptoms]. (Note findings requiring escalation: fever with breast symptoms, spreading erythema, severe pain. Document "Not observed today" if not assessed.)

Observed Pumping Session: [Flange fit assessment], [Alignment and seal], [Pump settings], [Duration observed], [Observed output], [Interventions trialed and response]. (Document "Not observed today" if not assessed.)

Supply Data: [Pump log totals with dates and trend] (Specify source: verified log / parent-reported estimate.)

Infant Feeding Observation: [Infant state and cues], [Latch quality], [Suck pattern], [Audible swallows], [Physiologic stability], [Supports used], [Transfer assessment method and result]. (Document "Not observed today" if not assessed.)

Milk Handling Observation: [Pump part condition], [Labeling compliance], [Storage container use]. (Document "Not observed today" if not assessed.)

Assessment

• Milk supply status: [Stage] (colostrum / transitional / mature), [Trend] (increasing / stable / decreasing), [Adequacy relative to infant needs].
• Pumping effectiveness and comfort: [Flange fit], [Pain], [Equipment or technique issues].
• Milk handling and pump hygiene: [Knowledge gaps or safety concerns identified].
• Breastfeeding transition readiness: [Infant stability and oral feeding readiness], [Parent readiness and confidence].
• Barriers to plan execution: [Access], [Schedule/transport], [Psychosocial factors], [Language/health literacy needs].
• Issues requiring escalation: [Concerning breast symptoms], [Severe trauma], [Mood concerns] (Include if present; omit if none identified.)

(Acceptable inferences include noting pumping frequency below targets. Avoid attributing cause without documentation, making diagnoses outside scope, or stating milk transfer occurred without measurement.)

Plan

Supply Establishment

• [Pumping frequency target] (typically 8+ sessions per 24 hours including overnight)
• [Technique optimization] (double pumping, hands-on pumping, hand expression)
• [Skin-to-skin plan] (frequency/duration goals as infant stability allows)
• [Pump log instructions]
• [Escalation thresholds] (sudden volume drop, persistent pain, fever, new breast symptoms)

Pumping Technique/Comfort

• [Flange size recommendation with fit rationale]
• [Suction guidance] (emphasize comfort over maximum settings)
• [Equipment check] (valves, membranes, tubing)
• [Nipple care plan] (For vasospasm or infection concerns, document recommendation to notify medical team.)

Milk Safety Education

• [Labeling requirements per institutional protocol]
• [Storage guidelines] (fresh/refrigerated/frozen time limits)
• [Transport instructions] (cooler with ice; maintain cold chain)
• [Thawing/warming safety] (no microwave; discard rules)
• [Combining milk rules per protocol]
• [Pump part cleaning] (clean after each use; sanitize daily for premature infants)
• [Teach-back documentation] (Describe parent demonstration or verbalization.)

Transition to Breastfeeding

• Stage 1: [Skin-to-skin and taste/smell exposure plan]
• Stage 2: [Non-nutritive sucking at emptied breast parameters]
• Stage 3: [Nutritive feeds at breast] (readiness cues, frequency/duration limits, physiologic monitoring)
• [Transfer assessment method] (test weights / clinical signs / not measured)
• [Supplementation plan after attempts] (Weaning from supplements/fortification requires coordination with neonatology/dietitian.)
• [Current PMA and clinical context for recommendations]

Referrals and Resources

• [Outpatient lactation follow-up timing]
• [Social work referral] (pump access, insurance, transport barriers)
• [OT/SLP coordination] (oral-motor or feeding readiness concerns)
• [Written materials provided]

Communication

• [Team members updated] (RN, neonatologist/APP, dietitian)
• [Recommendations shared] (Use "recommend" and "defer to medical team" for feeding plan changes requiring orders.)
• [Parent understanding and agreement]

Follow-up

• [Next planned lactation contact]
• [Criteria for earlier re-consult] (pain, infection signs, declining volumes, feeding milestones, discharge planning)
• [Education deferred or declined] (Include topic and reason if applicable.)