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4.1 Initial assessment

Key Points - Case Study D

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?
Topic 4.1: Initial assessment
To assess the adequacy of breast milk intake ask about: number and length of feeds; elimination patterns; general infant behaviour; breast and nipple concerns; and maternal confidence. Also check: infant weight gain; jaundice and general infant wellbeing.
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.

Adequacy of breastmilk intake?

Number and length of feeds

If the infant feeds well soon after delivery, he or she may have a prolonged sleep (occasionally 10 hours or longer) before feeding again. From that time, most infants will require more than eight breastfeeds within a 24 hour period (usually between eight and twelve times),1,2,3,4 with at least one breastfeed between midnight and 6am. The length of a breastfeed also varies, although most breastfeeds will include between 10 and 40 minutes of active feeding.

Take note if the infant:

  • regularly has less than eight or more than 12 breastfeeds a day;
  • is routinely at the breast for more than 50�60 minutes for each feed;
  • continually slips off the breast; or
  • makes a clicking sound throughout the feed.

Elimination patterns

Both urine and stool outputs are important signs of adequate breast milk intake in the first few weeks. Until day three, infants are expected to void at least the same number of times/day as the day postpartum. Urine output after day three increases with at least six very wet nappies per day of pale odourless urine considered normal. It is harder to judge urine output with disposable nappies, but at least four heavy wet disposable nappies is appropriate. Most adequately breastfed infants will have three or more bowel movements a day (5,6,7). Transition stools usually begin around day three to four with normal breastfed stools (yellow, curdy, fairly liquid) occurring from day five. Higher numbers of bowel motions per day and an earlier transition to yellow stools are associated with less weight loss, earlier return to birth weight and heavier weight on day 145.

Take note if the infant:

  • has less than four to six voids a day;
  • has strong-smelling or dark-coloured urine;
  • has urate deposits after day three;
  • has less than two to three bowel motions per day; or
  • passes meconium or transition stools to the end of the first week.

General behaviour

Adequately fed infants usually go to the breast and feed effectively for at least 10 to 15 minutes without falling asleep or slipping off the breast. Swallowing can be heard throughout most of the feed. He or she will be content after some feeds, is alert and responsive and will wake spontaneously to feed at least eight times a day.

Take note if:

  • the infant appears to be very placid and wakes for a feed infrequently;
  • the infant falls asleep soon after going to the breast with the mother spending the remainder of the feed trying to keep the infant interested in feeding;
  • the infant always appears to be hungry;
  • the infant is unhappy and unsettled; or
  • little or no swallowing can be heard during the feed.

Breast or nipple problems? Maternal confidence?

Breast and nipple concerns

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 remaining8. 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

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

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 intake9. Weight loss may be more obvious if mothers have a positive intraprtum fluid balance with subsequent loss of fluid from the infant postbirth.10,11 It is expected that infants will regain their birth weight by day 10 to 149 and continue to gain more than 150 g/week (or 500g/month) in the first three months12. 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

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

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.

Case Study Activity

Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.

Notes

  1. # Section on Breastfeeding (2012) Breastfeeding and the use of human milk.
  2. # Kent JC et al. (2006) Volume and frequency of breastfeedings and fat content of breast milk throughout the day
  3. # Butte NF et al. (1985) Feeding patterns of exclusively breast-fed infants during the first four months of life
  4. # Hill PD et al. (2005) Primary and secondary mediators' influence on milk output in lactating mothers of preterm and term infants
  5. # Shrago LC et al. (2006) The Neonatal Bowel Output Study: indicators of adequate breast milk intake in neonates
  6. # Nommsen-Rivers LA et al. (2008) Newborn wet and soiled diaper counts and timing of onset of lactation as indicators of breastfeeding inadequacy
  7. # Weaver LT et al. (1988) The bowel habit of milk-fed infants
  8. # Ziemer MM et al. (1993) Skin changes and pain in the nipple during the 1st week of lactation
  9. # Powers NG (2001) How to assess slow growth in the breastfed infant. Birth to 3 months.
  10. # Chantry CJ et al. (2011) Excess weight loss in first-born breastfed newborns relates to maternal intrapartum fluid balance.
  11. # Noel-Weiss J et al. (2011) An observational study of associations among maternal fluids during parturition, neonatal output, and breastfed newborn weight loss.
  12. # National Health (2003) Dietary guidelines for children and adolescents in Australia incorporating the infant feeding guidelines for health workers