Checklist to use when issuing a breastpump
TEAMS - Checklist to Use When Discussing Breast Pump Options
|Time – |Employer / School – |
|How long will baby and WIC client be separated? |Does the WIC client have a plan for returning to work/school and pumping? |
|Less than 4 hours |Yes |
|4 to 6 hours |No |
|7 to 9 hours | |
|10 or greater |Has a discussion occurred with employer about pumping at work? |
|How many days each week? |Yes |
|2 days or less |No |
|3 to 5 days |Is there a designated location to pump? |
|6 days or greater |Yes |
|What is your goal, how long do you plan on breastfeeding? |No |
|3 months or less |Is there access to electricity? |
|4- 6 months |Yes |
|7-9 months |No |
|10-12 months | |
|1 year and beyond | |
|Have you used a pump before? | |
|Yes | |
|No | |
|How long did you use the pump? | |
|Age of baby- |Milk Supply |
|What is baby’s current age? |Is baby receiving breastmilk exclusively? |
|Less than 6 weeks |Yes, how many times is baby breastfeeding in 24 hours? ____ |
|6 to 10 weeks |No |
|11 weeks to 16 weeks |Is baby being supplemented with formula? |
|Greater than 16 weeks/4 months |Yes, How many ounces in 24 hours _____ |
|Was the baby full term? |No |
|Yes |Is baby eating any solid foods? |
|No, born at how many weeks_______ |Yes, how many times a day ______ |
| |No |
| |How many bowel movements (stools) in 24 hours? ________ |
| |How many wet diapers in 24 hours? _________ |
| |How has baby’s weight gain been since birth? |
| | |
| |What was baby’s birth weight? _____ |
| |Current weight: _______ |
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