Detailed SOAP Template for Lactation Consultants

Patient Information

• Mother’s Name, ID, and Date of Birth: Sarah Jenkins, MRN: 849-204-11, DOB: 14/05/1992
• Infant’s Name and Date of Birth: Leo Jenkins, DOB: 10/10/2023
• Date and Time of Nursing Assessment: 18/10/2023 10:30
• Location: Outpatient Family Medicine Clinic, Room 4B

Subjective

Chief Complaint or Reason for Visit

• Mother: Bilateral nipple pain, worse on the left, and concern regarding milk supply.
• Baby: Difficulty maintaining latch, clicking sounds during feeds, and slow return to birth weight.

Objective

Infant Weights

• Birth Weight 10/10/2023: 7 lb 8 oz
• Most Recent Weight 13/10/2023: 6 lb 15 oz
• Weight Today 18/10/2023: 7 lb 2 oz
• Weight Gain or Loss: Gained 3 oz over 5 days since prior visit.
• Percentage Below Birth Weight: 5 %

Breastfeeding Intake Assessment

• Infant Prefeed Weight: 3,230 g
• Left Breast Milk Transfer: 15 mL over 12 minutes
• Right Breast Milk Transfer: 25 mL over 15 minutes
• Infant Postfeed Weight: 3,270 g
• Total Intake: 40 mL over 27 minutes; intake is improving but slightly suboptimal for age.

Breastfeeding Examination

• Infant Feeding Affect: Irritable initially, calming once latched
• Gape: Narrow
• Orientation: Difficult
• Latch Depth: Shallow
• Infant Latch: Frequent unlatching, slips off coughing/sputtering
• Mother-Led: Yes
• Feeding Position: Cross-cradle
• Cheeks: Against breast
• Chin: Away from breast
• Lips: Upper lip rolled inward, lower lip flanged outward
• Suck-Swallow Ratio “(S)”: 1:2 initially, then 1:4
• Infant Suck: Needs stimulation to keep sucking
• Coughing: None noted
• Clicking: Noted
• Choking: None noted
• Increased Work of Breathing: None noted
• Mother Ended Feed: No
• Maternal Nipple Shape After Feeding: Lipstick, white ridge on tip
• Infant After Feeding: Sleepy, still showing signs of hunger when stimulated
• Summary: Feeding observation demonstrated a narrow mouth opening, difficult orientation, and shallow latch depth. The infant’s feeding affect was irritable initially, and the feeding was mother-led. The position used was cross-cradle, with the cheeks against the breast and chin away from the breast. The observed suck-swallow ratio was 1:2 to 1:4. Clicking occurred during the feed, together with no increased work of breathing. The infant ended the feed, after which the infant was sleepy.

Pumping Assessment

• Total Pumping Output: 45 mL total (20 mL L, 25 mL R) over 15 minutes
• Flange Types Tried: Standard hard plastic, silicone rimmed
• Sizes of Each Flange Tried: 24 mm, 21 mm
• Types of Pumps “(Make, Model)”: Spectra S1
• Mother’s Response:
  • Response to Each Pump: Tolerated Spectra S1 well on cycle 54, vacuum 4.
  • Response to Each Flange Size: 24 mm pulled in excessive areolar tissue causing friction; 21 mm provided appropriate fit and comfort.
  • Response to Each Flange Type: Preferred standard hard plastic in 21 mm.
  • Summary: The mother expressed 45 mL of milk over 15 minutes. She used different flange types and sizes with various pumps, and her responses included improved comfort and milk flow when downsizing from a 24 mm to a 21 mm hard plastic flange on the Spectra S1.

Supplemental Feeding Assessment

• Bottle Supplement: 20 mL expressed breast milk via slow-flow nipple finished in 10 minutes.

Maternal Assessment

• Affect: Anxious, tired
• Appearance: Tired
• Distress: Mild distress
• Attachment to Infant: Normal

Attachment to the infant is normal. Breast examination shows medium size, breasts that are not pendulous, and moderate glandular tissue. Breast texture is soft, with areolas described as WNL and nipples as abraded bilaterally.

Maternal Breast Assessment

• Breast Fullness: Soft
• Density: Glandular
• Breast Size: Medium, symmetrical, no scars, visible veins present
• Spacing: Normal
• Pendulous: No
• Elastic Tissue: Yes
• Nipple Characteristics: Normal areola size, average nipple size, everted
• Nipple Pinch Test: Erect
• Areolas: WNL
• Nipple Damage: Abrasions bilaterally, abrasions worse on L
• Nipple Measurement: L: 17 mm base, 15 mm tip; R: 17 mm base, 16 mm tip

The nipples measured 17 mm at the base bilaterally. Hypoplasia absent.

• Glandular Tissue: Moderate
• Hypoplasia: Absent
• Summary: Maternal findings include anxious affect, tired appearance, and normal grooming. There was no acute distress. Attachment is normal, breasts are medium and soft with moderate glandular tissue, and bilateral nipple abrasions (L > R) are present with 17 mm base measurements.

Infant Assessment

• Affect: Alert, irritable when hungry
• Appearance: Well-appearing
• Distress: No acute distress
• Color: Normal
• Skin: Warm, well-perfused
• Hydration: Normal
• Fontanels: Normal
• Adipose Tissue: Normal
• Tone “(Upper and Lower Extremities)”: Normal
• Symmetry: Symmetrical
• Head Turning Preference: No preference
• Summary: The infant appeared alert, well-appearing, and appropriate for age. No acute distress. Skin findings were warm and well-perfused, and hydration was normal. The fontanels were normal, with normal adipose tissue. Extremity tone and facial symmetry were normal and symmetrical.

Oral and Suck Examination

• Buccal Pads: Present
• Lip Strength: Normal
• Suck Strength “(Negative Pressure)”: Weak
• Tongue Cupping: Side edges only, moderate cup; Snapback periodic
• Tongue Extension: Short
• Tongue Elevation: Limited, heart shape
• Tongue Lateralization: Body of tongue but not tip
• Gape: Narrow
• Palate: High anterior
• Motion: Limited
• Gag Reflex: Normal
• Lingual Frenulum: Restricted, anterior attachment near tongue tip and inferior alveolar ridge
• Lower Jaw: Recessed
• Summary: The oral and suck findings include present buccal pads, normal facial tone, and normal lip strength. Suck strength was weak, with tongue length short and elevation limited with a heart shape. The palate was high anterior, with limited motion and normal gag reflex. The lingual frenulum was restricted, and the lower jaw was recessed.

Assessment Summary

• Mother: Bilateral nipple trauma (L > R) secondary to shallow latch, using oversized pump flanges.
• Baby: Slow weight gain (5 % below BW at day 8), suboptimal milk transfer, and ankyloglossia causing restricted tongue mobility and shallow latch.

Lactation Consultant Assessment

• Dyad experiencing suboptimal milk transfer and maternal nipple pain secondary to infant ankyloglossia and recessed mandible. Maternal supply is adequate when supported with breast massage and appropriately sized pumping equipment.
• Billing Code: 99214, Z39.1, Q38.1, O92.13

Plan

Interventions and Education Provided

• Flange fit
• Pump settings
• Paced bottle feeding
• Breast compressions
• Normal newborn feeding frequency
• Nipple wound care

Latch and Positioning Support

• Assisted mother with laid-back and asymmetric cross-cradle positioning to encourage deeper latch and maximize chin-to-breast contact.

Maternal Comfort and Breastfeeding Techniques

• Demonstrated active breast compressions during feeding to increase milk flow and keep infant actively sucking. Advised applying expressed breast milk or purified lanolin to nipples post-feed, and prescribed mupirocin 2 % ointment topically BID if signs of secondary infection develop. Mother may take ibuprofen (Advil®) 400 mg PO q6h PRN for breast/nipple pain.

Feeding and Pumping Guidance

• Breastfeed every 2–3 hours (8–10 times/day), limiting time at breast to 15 minutes per side to conserve infant energy.
• Follow daytime feeds with 20–30 mL expressed breast milk via paced bottle feeding.
• Pump for 10–15 minutes after daytime feeds using 21 mm flanges to protect supply and provide supplemental milk.

Oral and Suck Assessment Findings

• Discussed finding of restricted lingual frenulum (ankyloglossia) contributing to shallow latch, clicking, and nipple compression. Placed referral to Pediatric ENT for frenotomy evaluation.

General Breastfeeding Support and Follow-Up

• Follow up in Family Medicine lactation clinic in 1 week (or 2–3 days post-frenotomy) for weight check and feeding reassessment.

Additional Notes

• Instructed parents to monitor for ≥ 6 wet diapers and ≥ 3–4 yellow seedy stools per 24 hours.