 Hello everyone. So today in this session we're going to talk about breastfeeding assessment form. I do recommend that this form we should fill out while mother is in the hospital during PNC time. She's generally in the hospital anyway between 24 to 48 hours depending about you know which area she comes from. But by and large you know they are there at least 48 hours or so. And this particular form will tell us whether she's capable of breastfeeding her baby or not when she goes home. And what I experienced from our FMCH days that babies who had good latch, babies who had good positioning, those babies were definitely gaining good weight. But babies who had poor latch or just nipple latching, mothers were not holding the baby properly, those babies were gaining less than about 25 grams weight gain per day. And you know and those babies were the one which we were not seeing good results on the growth chart. So what we did basically once we started using cross little hold in our program you know we just added few points in this WHO breastfeeding assessment form. So now we call it modified breastfeeding assessment form and extremely important I also recommend to use this form not only during hospital time but when baby goes home in the community. So if you were running NGOs, if you're part of a government you know organization I would definitely recommend that you use this form at least for first 10 days or so. Now what we do in US is once the baby go home in US really by and large baby goes home by 24 hours. So on day two or 48 hours of age they come to the doctor for check. So for weight check they come for they also come to check for jaundice. I'm not going to talk about jaundice here but I will talk about weight and then we continue to see that baby every 24 to 48 hours depending upon the weight. Okay also jaundice of course but if supposed to weight gain is tremendous and baby is not putting on weight obviously we know that you know the latch is not good or mother is not feeding on time or all that you know. So this form will kind of tell you what is wrong with the baby okay and the mother not just a baby but basically the breastfeeding techniques and breastfeeding counseling. So what I recommend is first you tell mother to show how she's breastfeeding okay because this is a breastfeeding assessment form means you are just watching the mother how she's breastfeeding and then you're ticking whether it's correct or whether it is wrong. Okay so here on the left hand side you take to observe favourable behaviour and if it's not favourable you will take it over here I'll go through each and every point but this is what I recommend okay and suppose you're seeing the baby every 24 to 48 hours if weight gain is good say around 30 grams 35 grams even 40 grams in fact I recommend 40 gram weight gain then you know you don't need to see that baby very often maybe then as per your HPNC guideline then you can see the baby you know as and when if you're in private practice then you know maybe at two weeks you want to see again and then probably at six to eight weeks for the first dose of vaccination okay but at least for first 10 to 12 days till you are confirmed that my baby is gaining 30 to 40 gram weight gain per day please see this baby every frequently very very frequently very important for those first 10 days when mother is learning to last the baby okay so let's see what we're going to examine so the first thing you're going to examine you're going to examine general examination of the mother so you want to see whether mother looks happy healthy comfortable whether she's enjoying so that's what you want to see right a lot of time when mothers come to us they are like very stressed sometimes they cry sometimes they are sad you know sometimes they're unhealthy they are they're fever you know so you want to look at the general health of the mother whether she's comfortable or not or whether she's unhealthy sick you know of course if she looks unhealthy you want to take it over here okay if mother is relaxed sitting straight with the back support so while she's breastfeeding you have to examine that also okay this is basically checklist so again in US we use all the checklist so pretty much your WHO has also created checklist but we have just added a few more points okay so here you want to see how mother is sitting her posture whether she is sitting with tense shoulder whether she's leaning over the baby whether she's kind of bending forward you know without any back support because once you're filling out this form you'll know exactly what points that you're going to counsel her okay and that's why you will not miss a single point so you don't have to remember a lot of those points you have the checklist ready so just make copies you know and then use it in your program okay the third point is whether baby is being held securely or not or close to her or not okay so you want to see that also whether baby is close enough to the mother or not okay also you want to look at the confidence level because lot of time now mothers they don't feel confident especially in first few days so you want to look at the confidence level also whether she's mother is holding the baby nervously and whether baby is kind of a little bit far from the mother okay then you want to see whether she drank some water or not so of course you know lot of time when she used to come to clinic she didn't carry water or sometimes we didn't have water so obviously she didn't do that but you know in ideal situation you want to see whether she remembers to drink water or not okay then also you want to look at if mother is wearing loose clothes or not while breastfeeding because as I told you in my previous session that lot of this mothers what they do is they just kind of lift up their bra you know and then tight clothes and then you know all the pressure comes on their breast okay so you want to kind of tick mark that also because you will have to tell her if she if she's not wearing loose clothes if she's wearing tight clothes then once you pick it over here at the end of breastfeeding session you know assessment session you will know what all things to tell her okay now once the mother's examination is done then you want to look at baby okay so baby whether baby looks healthy or not whether baby looks sick whether baby's alert baby's sleepy you want to look at that also whether baby keeps sleeping whether very sleepy child okay whether baby turns and searches for mother's breast whether baby looks disinterested so you want to look at general overall picture of the baby also okay then the breast examination is important breast examination what you're going to look at you're going to look at whether breasts are soft whether they are filled before breastfeeding or not so whether there is any milk or not you want to look at that okay sometime what happens that breast becomes very hard they become very gorge so you want to look at that also whether breast and gorge or not okay breast issues healthy rounded up pecotins you know that also want to see in breast examination the breast is stretched drop a droop you know bruised crack any red redness any abscess any inflammation tenderness does it hurt or not so all that you will have to look at breast also then in early part of breastfeeding you will see that there will be milk ejection okay now generally we don't see milk ejection after maybe probably post six weeks or so you know because what happens that once the milk is adjusted as per baby's requirement you know you don't necessarily feel a lot of milk gushing out when the lead ground reflex occurs okay so but in initial days in first 10 12 days you'll definitely see as soon as she starts breastfeeding you will see that the other side of the breast is leaking too okay those are signs of milk ejection and there is no sign of milk ejection then I mean you know obviously you want to make sure that psychologically mother is doing okay or not because once suppose if she's very you know who do I say kind of scared or lack any confidence or she's stressed about something then she will not be able to have milk ejection okay or if she's in pain or she has a lot of crack nipples you know she will not be able to see milk ejection okay then you want to look at the position now in my last session I went through detail about positioning of the baby so again I have taken those exact same points for here also for this form so here you want to look at mother's kind of body is close to baby's body so basically tummy to tummy this is what that you know one of the point of positioning whether baby's tummy is touching mother's tummy also all right and if if it's not then basically the body is probably twisted you know the stomach is lying upward towards the sky okay and baby's probably held too far baby's head and back hip and leg is supported in straight line okay so not only in the straight line but you want to make sure that they're fully supported and which is pretty it is definitely possible in cross little hole only shoulders heads are supported and baby's body is twisted okay so you want to make sure that you know you look at very very important examination again is look at the positioning of the baby okay those four points are as I mentioned to you earlier four points are really important that's what we're going through right now then third point is your near of the nose so near of the nose near of the nose is in the line of nipple so make sure that the nose doesn't come to right in front of the nipple it should be near of the nose okay so near of the nose coming in front of the nipple a lot of time what happens I again explain to you in my last session is that the nose is coming directly on the nipple or if the nose is too high up you know too lateral to the nipple lateral means more on the side like this because baby's in a horizontal position right so if baby's too high up the nipple and what would happen that baby will have to flex the neck okay so you want to make sure in that situation what you do you just pull the baby more towards the other side so the neck will get flexed okay so that's important also you want to make sure that when mother brings the baby to the breast the chin is forward chin is chin forward means the neck is backward so so the neck is extended backward this is chin forward okay so you want to make sure that mother brings a baby chin forward and of course a negative sign you will see that the chin does not come forward the whole face comes to at the same time okay so the chin does not come forward baby comes just like that straight okay all right baby's face is completed towards mother's breast now this is very important point because you know somehow I see all the all the mothers even healthcare workers they have this tendency to tell mothers or you know they put the baby more the face is more towards mother's face you know and that will not give a good attachment so just make sure that baby's face is looking directly at the breast and not looking up okay so this is another point that you want to mention okay now here there is another point which I have put in is basically about if baby's feeding on the right side upper lip is at nine o'clock position and lower lip is at the three o'clock position so suppose this is my right side okay so I want to make sure that when I bring the baby to my right breast you know the upper part the upper lip will be more at a nine o'clock position and the lower lip will be at the three o'clock position okay so and in this position your lips are completely vertical and this vertical lips are important because you will be holding your you know mother will be holding the breast in a three o'clock and nine o'clock position okay so you want to make sure that in that position your lips at lips upper lip is right in front of the thumb and your lower your thumb is in front of fingers okay so in that position they have to be parallel so obviously you know both of them have to be a three o'clock and you know upper part should be a three o'clock and the lower lip should be at the nine o'clock position okay and then about the latching part latching while actually one more thing I want to also mention to you while we're talking about three o'clock and nine o'clock position suppose if baby is kind of oblique okay so in an oblique position you will notice that the upper lip will be at around say 10 o'clock position on right side and the lower lip will be at five o'clock position so you want to make sure that they are not oblique or they are not in a in a different angle you know just keep the baby absolutely horizontal so the lips fall on three o'clock and nine o'clock position okay all right now let's talk about latching part latching and you know mouth positioning not mouth positioning but basically kind of suctioning of the suctioning action of the mouth so in latching basically you want to make sure that your mouth is wide open minimum 120 degree so we recommend between 120 to 160 degree but minimum should be at least 120 okay mouth is not open believe me my in my experience when babies did not open their mouth wide those baby landed up only on nipple and babies did not have enough you know suctioning of this thing so the latch was not good latch was very superficial so that's important that you tell mother to wait till baby has that big wide mouth then only latch the baby okay a second point in latching is basically look at the lower lip okay now remember I told you that you have to examine the latch okay I don't see many healthcare workers or medical officers examining the latch just because they are not used to it I don't blame them but just make sure to it's like you know how in in medicine we always examine the physical examination is very very important right so while you actually examining the latch just by looking at the mouth you won't know okay you have to put basically you'll have to examine by pressing the breast where the lower lip is okay you deeply kind of push that breast inside and look at where the lower lower lip is okay so here the lower lip is at the border of area or on the breast when the area is small okay why like lot of time you know there are different sizes of area so if we have small area then your lower lip will be coming on the breast if you have a big area then by large you'll see that the full lower is in the mouth and then so the lip is sitting at the border of area okay and in a negative behavior you will see that lower lip is sitting just below the nipple or it will may not be just below the nipple but it will not cover the full area latch okay so this is important that what you're looking at then third point is I find it kind of very crucial in my practice I want to make sure that when the baby's latch baby's so deeply attached that the lips and your you know chin is not at all visible okay that means you have a very deep attachment so what you can do is you tell mother to push that baby more into the breast so that you know the full breast kind of covers the lip and the chin but when do you tell that only when there is a deep attachment because if suppose if baby has a poor attachment suppose baby's a shallow attachment and baby's only latching on the nipple you will see that even you push it you may not realize that it's only small mouth like 45 degree and it's only nipple which is latching so that's why it's important to examine that latch with your eyes okay and in that examination three things are important okay one is how big is the mouth where exactly is the lower area line lower lip okay and then also once once you're done with that you want to make sure that baby's very deep enough close close to mother okay so that the lip and the chin is not visible W H word only recommend the chin is not visible but it's what I've noticed that babies who are much closer to mothers those babies are definitely gaining more weight okay all right but then another point which is I've mentioned over here baby grasps the lower part of the mouth and the upper latching with the lower lip okay so here this what I'm saying is that you know again this is one of the W H word point of good latch is that because the lower lies in the mouth obviously you will see upper la outside okay so this is called asymmetrical latch so asymmetrical latch means that lower upper realize out you can see through your naked eyes when a lower realize in the mouth obviously you cannot see it okay so that's your important another thing is also that upper lip when you have a good attachment upper lip is sitting just at the border of nipple okay and the lower lip is sitting at the at the area border so that's so that's what I've mentioned over here when there's a good attachment the cheeks are rounded and there is no dimple okay now this is one point that I want to discuss a little bit further because many times you would see that babies have dimple so when they when they breastfeed they're having like dimple now once you see a dimple then there are three things which could go wrong okay which are the three things which I again have mentioned in last session first is nipple latch only nipple latch even though baby is very deep like you know close to the mother with that you know superficial latch which is your nipple latch baby will have dimple second thing if baby is having lot more upper area in the mouth so you will definitely notice that you know when you examine you say oh my god this is upper realize much more in the in the mouth so that's when you will see that baby is having you know dimpling of the face and third thing is if baby is too far so even though the lower lice there in the mouth but if baby is too far you can see the lips very clearly even those baby will have you know kind of dimple in the cheek so remember those three points if you're seeing dimple something is wrong okay you need to get that of course I don't recommend to delash the baby every time suppose if baby has a good mouth opening and if baby is just a little bit further away from the area you just push the baby in okay as long as the mouth is big and lower lice in the mouth but if there is only nipple feeding if upper lice in the mouth you know then I may delach now one more thing I may do if the upper lice in the mouth if the if the face is if the mouth is open 120 degree and I may just pull the baby a little bit towards the other side you know to see if baby can glide and try to get lower lice in the mouth but you know I mean depends you know that's all basically that will come with the experience when you start helping mothers but see what works okay all right now another point which which I wanted to mention about you know basically as soon as you know baby's latched then you will see kind of babies you know babies start sucking so you will see the tongue movement a little bit okay and then you know obviously babies come babies alert you want to see make sure that baby's alerted breast because many times we see that a lot of these babies they sleep you know mother feel that oh baby's still feeding but it's more of a non-nutritive sucking and they keep you know and mothers get tired babies get tired I do not you know I while baby is active is sucking and if baby's tired you know not tired I say if you feel that baby has slowed down a little bit you know and you feel that baby's not now getting more milk and just kind of relaxing or just resting you wake up the baby okay because I don't want the session to last for hours and hours because you mothers will get so tired you know when baby's sitting there for like half an hour one hour two hours you know mothers they don't know what to do so I like that active active sucking okay so what you do you wake up the baby okay immediately like you know as I mentioned my earlier session you wake up the baby the baby's still not getting up you delash the baby by putting finger in the mouth you make the baby sit again in my experience I've seen that once you make the baby sit you know again you know I've shown the technique immediately within a minute or two baby will open the eyes okay they will open the eyes they look around and they'll open the eyes and then again you can put the baby back okay now when you put the baby back you want to make sure that you know mothers know that whether hind milk is there or not then again we have explained but you know make sure that baby completely finish on one side but that active baby is very important so if baby goes to sleep again again you put the baby in a sitting position feed the baby okay sometime it may take two or three times that you want to wake you may have to wake up the baby but believe me those babies you know they finish it fast you wake up the baby feed them probably as as long as they want but if as soon as the active sucking slows down you remove the baby okay and that's what like I've seen great results with just active sucking you know and some of these babies are so a lot and so active by four minutes five minutes they are done you know and if they're done and if you feel there is no breast milk left on that side just you know kind of put the baby in a sitting position you know make sure that baby has if baby has burping which is good but if they don't you know don't worry because if you have a good latch we will not have a lot of sucking of air if you don't have a lot of sucking of air they will not burp so do not freak out if they don't burp please don't worry okay all right now you want to look at the important counseling points of breastfeeding what are the important counseling points that you guys already know but again I'm going to go quickly go go through it mothers know how to check the latch of the baby okay so again you know obviously we teach healthcare workers we teach nurses how to check the latch but it's important in mothers know because once mother goes home she won't have a nurse to check the latch okay so teach this technique to mother also to how to check the latch okay and if mothers don't do the latch check you you mark it over here on the right hand side that mothers they don't know or she forgot because that's an important point every time that she latches the baby at least in first few days she has to examine okay because once she knows what it is like then she doesn't have to keep doing it but she has to she has to know what it is all right all right then when she puts her breast when she holds the breast okay she'll have you'll have to make sure that her fingers are parallel to lips okay now here I've made it very common to all the holes whether it is cross cuttle cradle whether it is a side line hold or laid back or whatever hold that you would want to recommend you know just make sure that when mother is pressing the breast it's parallel to baby's lips okay so if baby is in a completely horizontal position the lips will be vertical so you want to make sure that your fingers are also vertical you know or just a parallel to baby's lips okay all right and a negative behavior what you will see is that you will see that mother is not keeping her fingers parallel to baby's lips what she's doing is she's keeping it perpendicular and most likely believe me in your practice or in your program you will see mothers are always holding their breast not in parallel to lips but they are you know perpendicular okay it's like eating your burger not like this but eating your burger like this you would anybody would laugh if you do that in when you go to say fast food joint to eat your sandwich or something and you're not eating this when you're eating this way okay so I mean we would make a fool of ourselves so I think we will do the same if we allow mothers to do that okay all right then second point is basically three fingers away yeah so one thing you want to make sure that when mother is holding the breast make sure that you know her fingers are three fingers away from from nipple so it's not too close so it's not too far and it's just a tip which is touching the breast and not the whole finger okay if the whole finger touches then those fingers will come in the way okay so it should be like really round shape the dip of the U should be at six o'clock position okay and it should be just a tip touching and the tip of the finger three o'clock and nine o'clock position not at above or not below okay exactly three o'clock and nine o'clock position okay we are just standardizing the process so it becomes easier for everybody to understand all right now mothers know early hunger cues so of course you know some of these questions you can ask that when do you breastfeed the baby so just kind of make sure that you know whenever you have explained her all these important counseling points that she remembers all this point so while she's nursing you can ask all these questions so that you know whether she knows or not okay so what are those early hunger cues squirming opening of the mouth putting finger in the mouth all that putting finger in the mouth becomes a little bit later so it will be mid hunger cues but mainly squirming and looking at the breast and all that okay and then if she says oh I feed the baby when baby's crying that means it's a negative behavior all right then you also want to look at if mother is waiting for baby to open the big mouth so that's important so 120 degree and how does she open the mouth because that's another point you know which which I'll explain is that she has to brush the upper lip with her nipple and that's how baby will open the mouth okay because a lot of mothers don't know that so they keep waiting and they keep waiting so just remember to tell her to just basically brush the nipple with upper upper lip okay all right and you know one more thing which I want to reiterate again which I've mentioned earlier also they tell mother to be ready you know hold the head properly hold the breast properly keep the baby very close as soon as baby opens a mouth you know 120 degree just immediately kind of like that mouth in the in the breast okay because a lot of what mother mothers do sometimes they're on the phone sometimes they're talking to somebody sometime I don't know they are not focused so baby opens the mouth and she doesn't do anything as soon as baby close them out she starts pushing the baby in the breast okay so tell her to be very kind of wide awake and alert and then just be ready all right okay now how many times to breastfeed so here I mentioned baby feeds 10 to 12 times in 24 hours this is important because again you know we always say how they make it the popular how many times in a day how many times at night so don't use the word day because when you use a day word that means it's probably 12 hours from 6 a.m to 6 p.m okay so always use over 24 hours so again you know just tell her 10 to 12 times in 24 hours now after about say couple of months two three months they may not feed 10 to 12 times then they'll go down to eight times then they'll go down with six times okay but at least in first couple of months I would say six to eight weeks it's important to feed baby 10 to 12 times because we are catching up on growth most of the babies are born small okay all right then of course nighttime feeding so nighttime feeding I've written over here that if baby feeds three to four times at night and if baby's feeding less time you know that's your negative behavior okay then mother feeds your baby completely from one breast before switching to other so that hind milk is important and it's also it's it's crucial to tell mother how to examine the hind milk so here I've given one point that she kind of she has to express milk a little bit and see whether it is watery or it's you know thick and even if it is thick if it's coming with force that means that hind milk is still there okay so that it's important to ask mother that how does she examine how does she know whether she has fed milk from from the back part of the breast or not okay all right another thing which is I've asked over here whether mother knows a technique of burping the child now there are some new latest recommendation is not to burp the child no need for burping the child no but you know in my experience to be frank many times baby do burp especially if the latch is not good so you know like I do recommend burping the baby but more than that you know when you put the baby in a sitting position the biggest advantage what what I've seen is that all the sleepy babies they become very alert and active they become so alert and active and they are ready to breastfeed again okay so just remember that to kind of burp the baby you know burp the baby just couple of minutes you can try baby is not burping just leave the baby but make sure the baby is awake okay this is another point I mentioned about waking up the baby so three ways you can wake up the baby one by stroking the legs okay one by stroking the back or the spine or one by kind of putting the baby in a sitting position okay so she needs to know all the three four points of how to wake up the baby okay and then of course how to manually express milk because remember I mentioned to you that mother need to check whether she has hind milk left or not so in that in that process she will have to do a little bit of manual expression of milk so remember it's press compress release so you press it towards the breast press compress release so it's you know you're basically pushing the breast a little bit inward towards the chest okay and then you basically you don't kind of you don't milk the breast you you're not milking the breast okay you're just basically pressing the breast towards the chest inside again then press compress and release okay so that we have a beautiful tutorial which it will come you know and in our next this session particularly so okay so this is our breastfeeding assessment form once you have tick on left hand side say all your ticks on left hand side and your baby's growing to 30 to 40 grams my goal is 40 grams okay so if your baby is gaining 40 grams a day and then all the click on the left hand side you are fine okay then you don't need to maybe if you want to see baby once in a couple of days just to make sure then you can do it but if baby is gaining weight you know a couple of times you see baby is gaining weight and all mothers know everything you know you need to see baby for even one month two months you mothers know babies know what to do okay but again of course we'll follow what HBNC guideline is so in HBC guideline you do you do see baby at day three day seven fourteen twenty one ten twenty eight days you know so although obviously in government this thing you will be checking those babies on time but you know again don't wait from zero to seven days or ten days because those ten days is time when mother is learning breastfeeding so if you can teach her properly then look at the baby growing fast because they grow highest in first three months of age you know and then to catch up is very very difficult later on okay so try to get that catch up growth going as soon as possible one more thing that we have full experiences again I'm getting a lot of calls from a lot of pediatricians that if they teach this proper technique of latching right from birth then you know by day three day four these babies have already gained birth weight and they are on the upward trend so by the time like you know by day seven they have they already start gaining 200 or sometimes 300 gram weight gain and in fact WHO if you look at a WHO growth chart WHO table boy child they gain 200 gram by day seven okay by day seven 200 gram weight gain okay and a girl child they gain about 100 gram by day seven okay so if your baby is not gaining weight 200 gram boy child by day seven that means something is wrong that means what is wrong by and large is breastfeeding factors okay so that means you have like you have not focused on breastfeeding latching and that's why your baby is not growing well okay and that's that's unfair unfair okay all right so thank you so much and I'm going to close the session now and we will go with the next one okay thank you