Detailed Consult

Subjective: - Chief Complaint/Reason for Visit: - Mother is experiencing difficulty with breastfeeding and concerns about milk supply. - Baby is not gaining weight as expected and seems fussy during feeds. Objective: - Infant Weight and Intake: - Infant Prefeed Weight: 3.5 kg - Infant Postfeed Weight: 3.6 kg - Difference between prefeed weight and postfeed weight: 100 g - Milk Transfer: - Left Breast Milk Transfer: 50 ml - Right Breast Milk Transfer: 50 ml - Bottle Supplement: 30 ml - At Breast Supplementer: Not used - Maternal Breast Assessment: - Breast Fullness: Engorged - Density: Glandular in upper outer quadrant - Spacing: Normal - Fundus of Breast: Normal - Pendulous: No - Elastic Tissue: Yes - Tip and base measurements of nipple: 1.5 cm tip, 2.5 cm base - Hypoplasia: Absent - Overall summary: Breasts are engorged with normal spacing and glandular density in the upper outer quadrant. - Pumping Assessment: - Flange types tried: Standard, soft - Flange sizes tried: 24 mm, 27 mm - Make and model of pumps tried: Medela Pump In Style - Mom's Response: - Standard flange: Uncomfortable - Soft flange: More comfortable - 24 mm size: Ineffective - 27 mm size: Effective - Summary: Mother found the soft flange and 27 mm size most comfortable and effective. - Infant Assessment: - Infant affect: Irritable - Infant's appearance: Well-appearing - Infant's development: Well-developed - Infant's distress: Mild distress - Infant's color: Normal - Infant's skin: Warm, well-perfused - Infant's hydration: Normal - Infant's fontanels: Normal - Infant's adipose tissue: Normal - Infant's tone: Normal - Infant's facial tone: Normal - Face (eyes, nose, mouth): Symmetrical - Neck and Shoulders: - Head turning preference: No preference - Overall summary: Infant is well-appearing with mild distress and normal development. - Oral and Suck Exam: - Buccal pads: Present - Infant's facial tone: WNL - Infant's lip strength: Normal - Infant's suck strength: Strong - Infant's tongue length: Normal - Infant's tongue lift: WNL - Infant's gape: Wide - Infant's palate: Normal shape - Infant's motion: Normal - Infant's gag reflex: Normal - Infant's lingual frenulum: Normal - Infant's lower jaw: Normal - Overall summary: Oral and suck exam is within normal limits with strong suck strength. - Feeding Exam: - Infant's gape: Wide - Infant's orient: Easy - Infant's depth: Deep - Infant's feeding affect: Calm - Feeding led by mother: Yes - Infant's feeding position: Cradle - Infant's cheeks: Against breast - Infant's chin: Against breast - Infant's suck-swallow ratio: 1:1 for several minutes then variable - Infant's coughing: None noted - Infant's clicking: None noted - Infant's choking: None noted - Infant's increased work of breathing: None noted - Mom ended feed: No - Infant after feeding: Calm - Summary: Feeding exam shows effective latch and calm feeding affect with no issues noted. - Maternal Assessment: - Mother's affect: Anxious - Mother's appearance: Well-appearing - Mother's grooming: Well-groomed - Mother's distress: Mild distress - Mother's attachment to infant: Normal - Mother's breast size: Medium - Mother's breast is pendulous: No - Mother's glandular tissue: Moderate - Mother's breast consistency: Engorged - Mother's areolas: WNL - Mother's nipples: Normal - Summary: Mother is anxious with engorged breasts and normal attachment to infant. Assessment: - Summary of Issues: - Maternal issues: Engorgement and anxiety about milk supply. - Infant issues: Mild distress and weight gain concerns. - Lactation Consultant Assessment: - Overall assessment: Lactation status is adequate with effective feeding. Maternal anxiety and engorgement need addressing. - Billing code: 99213 Plan: - Interventions and Education Provided: - Education on managing engorgement and milk supply. - Latch and Positioning Support: - Guidance on cradle position and ensuring deep latch. - Maternal Comfort and Breastfeeding Techniques: - Strategies for managing engorgement and reducing anxiety. - Feeding and Pumping Guidance: - Advice on feeding patterns and effective use of breast pumps. - Oral and Suck Assessment Findings: - Findings indicate strong suck and normal oral anatomy. - General Breastfeeding Support and Follow-Up: - Additional support provided with follow-up plan in place. - Additional Notes: - Encouraged mother to contact support group for additional help.