The following document is adapted collaboratively between doctor and patient, according to the unique situation of and wishes of the individual concerned.

PATIENT’S NAME

DOB DATE

NAME OF HOSPITAL OR FACILITY

Background

My name is PATIENT’S NAME and the name of RELEVANT DESCRIPTION OF RELATIONSHIP OF THE CARER WHO IS CO-LACTATING [e.g. my wife and other mother of our baby] is NAME OF COLACTATING PERSON, REFERRED TO AS ‘CoLP’s NAME’.

My goal is to co-feed our baby with CoLP.

DESCRIBE SHARED AIM OF CO-LACTATION [e.g. We are aiming to meet our baby’s nutritional needs with my breast milk. We view CoLP’s breastfeeding as primarily for bonding and downregulating our baby, with use of her/their milk from induction of lactation intended to complement my own exclusive breastfeeding.]

The benefits of human milk feeding are important to us and our baby. We would like to have our guidelines supported, as long as it is medically safe to do so. We would like to ensure that my milk supply is well established, while supporting CoLP’s NAME in also learning how to breastfeed our new baby. Because of this, some things in our feeding plan are the same as other peoples’, and some things are different.

Breastfeeding after birth

Skin-to-skin

Please place our baby skin-to-skin on my chest after delivery. Please do any necessary checkups of and procedures on our baby while they are skin-to-skin, if possible.

CoLP’s NAME will also be keen to enjoy skin-to-skin opportunities with our baby.

Emergency caesarean

If I am unable to hold the baby skin-to-skin at birth, please allow CoLP’s NAME to do so and to bring the baby to her/their breast for the first breastfeed. Similarly, if for any other reason I am not able to offer skin-to-skin or bring baby to the breast in the early hours and days, please support CoLP’s NAME in doing so.

Exclusive breastfeeding

our goal is to exclusively breastfeed our baby. Please do not give our baby any formula before speaking to us about it.

No bottles or pacifiers

Please do not give our baby pacifiers or bottles without speaking with us first.

Feed frequently and flexibly

Please support us in offering either my own or CoLP’s NAME’s breasts to the baby whenever we wish to, whenever the baby dials up, and whenever we feel our baby is wanting to feed.

Rooming in

Please help our baby and us stay together as a new family in my room 24 hours a day.

Supporting co-lactation

At the time of delivery, CoLP’s NAME is producing _____ mL per day of milk, due to induction of lactation. DESCRIBE THE METHOD USED TO INDUCE LACTATION. [For example: CoLP’s NAME is inducing lactation using nipple and breast stimulation by pumping, having elected not to use pharmaceutical preparations.]

If I am not available after birth to do skin-to-skin and bring baby to the breast, as detailed above, please allow CoLP’s NAME to do so, as above.

After the first breastfeed with myself, we would like to both be available to feed at the breast. We know that if we do this, whoever is not feeding at the breast may need to hand express or pump milk, and we are informed about the risk of this approach to my own milk supply, and intend to manage this between ourselves.

In all cases, we understand that our baby’s weight will be closely and appropriately monitored by staff.

We request that the hospital supports CoLP’s NAME ongoing need to pump in my room, from after the birth of our baby, as we will be prioritising the establishment of my supply by direct breastfeeding at this time.

After we go home, we will continue to cofeed our baby, aware of the need to prioritise my own milk production as I will be our baby’s primary source of nutrients, at the same time as CoLP’s NAME will continue to pump and support her own breast milk production.

This plan has been discussed with my providers Dr GP OR RELEVANT PRACTITIONER’S NAME and RELEVANT PRACTITIONER’S NAME who assisted with CoLP’s NAMe’s induction of lactation.

Signed:

Date:

You can find this item downloadable as a pdf or word document for use in clinical consultations if you are participating in the NDC Lactation Fellowship.