4.1 Initial assessment
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![]() Key Points - Case Study DSally is 29 years old and presents to see you two and a half weeks postpartum with her first baby. Emily was born at T+7 days and weighed 4060 grams. Sally had a normal delivery but had a postpartum haemorrhage and a retained placenta that required a general anaesthetic and manual removal. They were discharged on day three fully breastfeeding, with Emily weighing 3770 grams and Sally's Hb 92 g/L. Sally has no other significant medical or surgical history, is well educated and has a supportive partner. Emily is a "good" baby: she is sleeping at least six hours at night and seems content. What questions would you ask Sally, and what additional information would you gather to assess whether breastfeeding was progressing normally?
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Sally is 29 years old and presents to see you two and a half weeks postpartum with her first baby. Emily was born at T+7 days and weighed 4060 grams. Sally had a normal delivery but had a postpartum haemorrhage and a retained placenta that required a general anaesthetic and manual removal. They were discharged on day three fully breastfeeding, with Emily weighing 3770 grams and Sally's Hb 92 g/L. Sally has no other significant medical or surgical history, is well educated and has a supportive partner. Emily is a "good" baby: she is sleeping at least six hours at night and seems content. What questions would you ask Sally, and what additional information would you gather to assess whether breastfeeding was progressing normally?
Assessment would need to include information relating to the adequacy of breast milk intake, breast or nipple problems and maternal confidence, and physical examination of the infant.
Questions about breast or nipple problems and maternal confidence
- Breast and nipple concerns
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Although the nipples may have been tender in the first week, tenderness usually subsides by 10 to 14 days postpartum, with some latch-on tenderness remaining7. Breasts feel fuller before a feed and softer after the infant has fed.
Take note if the:
- nipples are sore and cracked;
- breasts are soft most of the time; or
- breasts are hard and painful.
- Confidence
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Is the mother feeling confident attaching the infant to the breast and knowing that he or she is feeding well? Although it takes time to feel confident with all aspects of infant care, increasing confidence is often a sign that the mother is adapting to motherhood and breastfeeding.
Take note if the mother:
- is having difficulties attaching the infant to the breast;
- lacks confidence with her mothering skills and her milk supply; or
- appears depressed.
Infant examination
- Weight gain
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Most infants will lose some weight (usually <7 percent of their body weight) in the first two to three days postpartum but begin to gain again with the onset of copious milk production around day three. Weight loss of >10 percent is suggestive of insufficient breast milk intake8. It is expected that infants will regain their birth weight by day 10 to 148 and continue to gain more than 150 g/week (or 500g/month) in the first three months9. It is important the scales used are accurate and have sufficient precision to be able to monitor weights correctly. Variations in weight can occur with elimination and feeding patterns (e.g. weighing before or after a large bowel motion, or before or after a breastfeed may make a significant difference to estimated weight gain), as well as different scales.
Take note if the infant:
- loses more than 7 percent of body weight (especially if the loss is >10 percent); or has not regained birth weight by two weeks;
- regularly gains less than 125gms per week.
- Jaundice
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Jaundice is a common condition in the first week. Breastfed infants are more likely to become jaundiced and remain jaundiced for longer if their energy intake is low. (See Case B for further information about breastfeeding and jaundice.)
Take note if jaundice continues to progress after hospital discharge.
- General examination
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Assess the infant's state of hydration, muscle tone, subcutaneous fat and general demeanour.
Take note if the infant:
- appears dehydrated;
- has little subcutaneous fat; or
- is apathetic and listless.
An abnormality in any one of the indicators listed above must be assessed in the context of any previous assessments and with the remaining indicators. Sometimes the best indicators of underfeeding are a change in some of the indicators mentioned – for example, a reduction in the wetness or number of wet nappies, fewer bowel motions or excessive sleepiness.
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![]() | ![]() Case Study ActivityThink about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given. | ![]() |
Notes
- # Kent JC et al. (2006) Volume and frequency of breastfeedings and fat content of breast milk throughout the day
- # Butte NF et al. (1985) Feeding patterns of exclusively breast-fed infants during the first four months of life
- # Hill PD et al. (2005) Primary and secondary mediators' influence on milk output in lactating mothers of preterm and term infants
- # Shrago LC et al. (2006) The Neonatal Bowel Output Study: indicators of adequate breast milk intake in neonates
- # Nommsen-Rivers LA et al. (2008) Newborn wet and soiled diaper counts and timing of onset of lactation as indicators of breastfeeding inadequacy
- # Weaver LT et al. (1988) The bowel habit of milk-fed infants
- # Ziemer MM et al. (1993) Skin changes and pain in the nipple during the 1st week of lactation
- # Powers NG (2001) How to assess slow growth in the breastfed infant. Birth to 3 months.
- # National Health (2003) Dietary guidelines for children and adolescents in Australia incorporating the infant feeding guidelines for health workers