Referral template
Breastfeeding medicine assessment
Date of referral
Parent’s name
Baby’s name and date of birth
Referred by (name, role, phone)
Doctor referred to
Reason for referral
- Antenatal breastfeeding planning
- Low milk production
- Engorgement, oversupply and a fast let-down
- Nipple and breast pain
- Breast inflammation and mastitis
- Planning for returning to work whilst breastfeeding
- Weaning
- Slow weight gain in babies
- Infant allergies and intolerances
- Induced lactation, including for surrogacy and same-sex parents
- Tongue-tie and oral assessment
- Unsettled babies and sleep concerns
- Babies with extra needs: prematurity, heart conditions, cleft lip and palate
- Twins and higher-order multiples
- Parents with medical conditions: diabetes, thyroid, mental health challenges, previous breast surgery, cancer
- Other:
Include with the referral
- Feeding history and what has been tried
- Baby's weights and dates
- Relevant medical history and current medicines
- Your contact details for follow-up