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Chiropractic Journal of Australia : CJA September 2012
106 Chiropractic Journal of Australia Volume 42 Number 3 September 2012 Appendix 2: Proposed modifed BF Questionnaire: Child’ Name: Child’s DOB: Child’s Age: Mother’s Name: Date: The questions you ask are in bold and italic. Circle the relevant answers: 1. Are you using formula or expressed breast milk to supplement the breastfeeding? YES NO (go to Q2) If YES, how many feeds per day______________________ 2. Which position do you usually feed in? CRADLE HOLD FOOTBALL HOLD LYING DOWN (In the cradle/football/ hold…..) Is there any diffculty attaching to the breast YES NO (go to Q3) If YES, Is one side worse? LEFT RIGHT BOTH DIFFICULT Please rate the diffculty on each side: RIGHT: When attaching to the breast, please rate the degree of diffculty: (show them the scale and have them point at a number) 0 1 2 3 4 5 6 7 8 9 10 None A little Moderate A lot Severe LEFT: When attaching to the breast, please rate the degree of diffculty: (show them the scale and have them point at a number) 0 1 2 3 4 5 6 7 8 9 10 None A little Moderate A lot Severe 3. (In the cradle/football hold.....) Once attached to the breast, is your baby fussy? (does your baby pull around/pull off, seem uncomfortable?) YES NO Clarify: Does your baby tend to arch/extend/pull back the neck or body? ARCHES Or does he/she tend to shake the head side to side? SHAKES NEITHER Clarify: Does your baby arch one side and shake on the other? YES NO Clarify and circle: arches on LEFT RIGHT BOTH NEITHER shakes on LEFT RIGHT BOTH NEITHER If there was arching, please rate: (if bilateral, rate for each side and indicate side) 0 1 2 3 4 5 6 7 8 9 10 None A little Moderate A lot Severe If there was shaking, please rate: (if bilateral, rate for each side and indicate side) 0 1 2 3 4 5 6 7 8 9 10 None A little Moderate A lot Severe 4. I’m going to describe some types of suck. Please indicate the description which sounds most like your baby’s suck: No tension is created, baby refuses nipple, cannot latch. A Tongue does not fully surround the nipple and tongue movement is weak. B Accepts nipple but has poor strength or co-ordination of suck. C Latches well onto nipple, and sucks with good strength. D CHIROPRACTIC AND BREASTFEEDING PROBLEMS STEWART
CJA June 2012
CJA December 2012