Breastfeeding Checklist
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Mom:___________________ Child:___________________ Birthdate:_____________
Lactation Consultant:___________________ Phone Number:___________________
Date:
Session Lft Breast
Times		 Rt Breast
Times		 Total
Time		 Swallowing
Heard?		 # of Wet
Diapers/Stools		 Amt of Bottle
Breastmilk		 Comments
(Supplements, Reactions)

1

S

S

 

 

 

 

 

F

F

2

S

S

 

 

 

 

 

F

F

3

S

S

 

 

 

 

 

F

F

4

S

S

 

 

 

 

 

F

F

5

S

S

 

 

 

 

 

F

F

6

S

S

 

 

 

 

 

F

F

7

S

S

 

 

 

 

 

F

F

8

S

S

 

 

 

 

 

F

F

9

S

S

 

 

 

 

 

F

F

10

S

S

 

 

 

 

 

F

F

11

S

S

 

 

 

 

 

F

F
END OF DAY TOTALS: # of Breastfeeding Sessions:_______ # of Wet Diapers:_______ # of Stools:_______

Date:
Session Lft Breast
Times		 Rt Breast
Times		 Total
Time		 Swallowing
Heard?		 # of Wet
Diapers/Stools		 Amt of Bottle
Breastmilk		 Comments
(Supplements, Reactions)

1

S

S

 

 

 

 

 

F

F

2

S

S

 

 

 

 

 

F

F

3

S

S

 

 

 

 

 

F

F

4

S

S

 

 

 

 

 

F

F

5

S

S

 

 

 

 

 

F

F

6

S

S

 

 

 

 

 

F

F

7

S

S

 

 

 

 

 

F

F

8

S

S

 

 

 

 

 

F

F

9

S

S

 

 

 

 

 

F

F

10

S

S

 

 

 

 

 

F

F

11

S

S

 

 

 

 

 

F

F
END OF DAY TOTALS: # of Breastfeeding Sessions:_______ # of Wet Diapers:_______ # of Stools:_______

Legend: S=Start, F=Finish, Amt of Breastmilk in Bottle=if feeding from bottle
Normal Day Ranges: 8-10 Sessions, 6-9 Wet Diapers, 2-5 Stools


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