Dear Wise Ones,
 
I am hoping that you can tell me what is done in your institution regarding  
IBCLC's taking a doctor's order for supplementation of breastfeeding baby  who 
is not nursing effectively and is losing weight. I have searched the  
Archives, but did not find anything specific to my situation.
 
A little background... I am an IBCLC working in the local community  hospital 
(800 births/year) for 32 hours/week as the lactation program  coordinator.  I 
happen to be an RN, but that was not required for my newly  created position 
in Sept 2006. I see the most of the moms who  are nursing, but some days only 
get to work with the ones who have having  difficulties (there are a lot of 
non-latching, ineffectively feeding  babies, so I am busy.)  My day off during 
the week is covered by a special  care nurse who is also IBCLC. My hospital is 
a "closed shop" and all  non-management nurses (even nurse practitioners) who 
work there must be in  the union. My manager did not want the RN credential to 
be required for my  position, so that I would not be expected or required to 
practice as a  nurse, or be required to join the union, just because I have RN 
after my  name.
 
A few months ago, I called a pediatrician to report my concern with a baby  
who had lost over 10% of birth weight, was not feeding effectively, had poor  
output, and appeared to be getting dehydrated. Mom had risk factors for delay 
of  Lactogenesis II. The discharge order had been written earlier in the day. 
The  pediatrician considered my evaluation and told me to hold the infant's 
discharge  and gave an order for supplementation of hypoallergenic formula. Our 
written  policy is to supplement breastfeeding babies by finger-feeding or  
cup-feeding or at the breast, depending on the situation and what the mother  
wants to do, as she can always ask that the baby be given a bottle.  I  asked the 
clinical team leader if I should record the doctor's order in the  baby's 
chart, or did I have to get an RN to do it. She thought for a moment, and  said 
that I would be able to document the telephone order, as I am, after  all, an 
RN. As an aside, we do all our other documentation in the computer, and  my 
discipline is listed as "Registered Nurse" as there is no listing for  "Lactation 
Consultant."
 
The same situation happened again this week and one of the special care  
nurses questioned my ability to take an order from a doctor, as I am  not "hired 
or practicing as a 'nurse', and since this is a nursing  function, might not 
the union have an issue with it, etc" expressing  this concern to my manager.  
My manager asked me to get input from  other IBCLC's who are nurses in 
hospitals, but who are not doing RN duties  in addition to their LC functions.  There 
is no precedent for this here,  and my manager wants to be on solid ground 
when she replies to the nurse who  brought this issue to her attention.
 
The IBLCE competency statement includes the following:
 
1.  Possess the skills, knowledge, and attitudes to provide competent  
comprehensive consultation and education in routine and special circumstance  
lactation, from preconception to beyond twelve months.
5.  Utilize appropriate communication skills in interactions with  clients 
and health care providers.
10. Function and contribute as a member of the health care team,  provide 
follow-up plans, and make appropriate referrals to other health care  providers 
and community support resources.
 
ILCA's Standards of Practice for IBCLC's include Standard 3 Clinical  
Practice:
 
3.3.7 Document and communicate to health care providers as  appropriate:
• assessment information
• suggested interventions
•  instructions provided
• evaluations of outcomes
• modifications of the  plan of care
• follow-up strategies
 
My position and my LC function in the hospital is that of a "clinical  
specialist" in breastfeeding. The pediatricians (most of them) recognize  this and 
work with me closely.  I am not sure how they would feel if I  had to tell them 
that they have to give their order to another RN, that I cannot  receive it 
even though it specifically addresses breastfeeding  issues or a lactation plan 
of care.  In the meantime, until there is a  clear resolution to this 
concern, I will hand the phone to a nurse who can take  the order, as I don't want to 
be cause any legal difficulties for the hospital  with the union or cause 
problems for my manager or clinical team  leader, both of whom are very 
supportive.
 
I would like to hear from other IBCLC's who are nurses and have faced this  
same situation. Please reply to the list or to me personally if that  is more 
comfortable to you. As always, thank you in advance for any assistance  or 
guidance you can provide.
 
Mary-Jane  Sackett, RN, BSN, IBCLC, RLC
Pittsfield, MA  USA




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