IBCLC and Tongue Tie Practitioner Summary of care template

Summary of Appointment and Advice Shared: Patient Name: Sarah Jones Patient date of birth: 12/03/2024 Appointment date: 01/11/2024 Appointment Summary: - Presented with concerns about latching difficulties and insufficient milk supply. Discussed the baby's weight gain and feeding frequency. Reviewed the mother's history of previous breastfeeding experiences and any relevant medical history. - No past medical history or previous surgeries mentioned. - No medications or herbal supplements mentioned. - Social history: Mother is a stay-at-home parent, supported by her partner. No smoking or alcohol use. - No known allergies. Advice Shared: - Demonstrated and discussed various breastfeeding techniques, including the cradle hold and football hold. Emphasised the importance of proper latch and positioning. - Addressed common breastfeeding issues such as nipple soreness and engorgement. Provided strategies for managing these issues. - Recommended the use of a nipple shield to aid with latching and a supplemental nursing system to increase milk supply. - Advised the mother to increase fluid intake and maintain a balanced diet to support milk production. - Scheduled a follow-up appointment in one week to assess progress and provide further support. Additional Notes: - Provided education on proper latch, feeding cues, and the importance of frequent feedings. Discussed safe storage of breast milk and how to identify signs of adequate milk intake. - Communication with the patient and family about care decisions, concerns, and preferences was open and collaborative. The mother expressed her goals and preferences for breastfeeding. - No safety concerns or incidents reported.