Marianne and everyone,

I'm reading the 'for' and 'against' remarks about the necessity of 
making reports to HCPs.  Marianne, your post setting out so clearly 
your reservations about the troublesome requirement of writing 
reports to HCPs due to the possibility of undermining the mom's 
autonomy was particularly relevant.   I do hear your concern, and 
especially that sometimes the reason that the mother seeks help from 
an IBCLC may be partly due to an iatrogenic problem with breastfeeding anyway.

I myself feel very torn about this too.  When I started practising 
privately in Zimbabwe I went and introduced myself to all the 
doctors, GPs, OBs and paeds that I anticipated would be caring for my 
client pool and/or that I hoped would refer to me.  I specifically 
asked if they would like reports.  Some agreed with what appeared to 
be surprised gratitude.  Others reacted with quite strong denial, 
saying that they would never have time to read them.  Thus I ended up 
sometimes sending reports and sometimes not.  However, over time I 
realized that sending reports is often crucial when the IBCLC consult 
uncovers actual/potential medical problems - usually, in the baby, 
but sometimes in the mother as well.  So sending reports would be 
first and foremost for the mother or baby's protection/possible 
ongoing treatment.  For instance, on several occasions I was the 
first to identify overlooked  or unrecognized symptoms of what 
eventually turned out to be a heart defect in a discharged newborn 
with Down's, imperforate anus in a 3 day old at home, severe brain 
damage evidenced by convulsions at about 6 weeks by a GP who had 
diagnosed "colic", or Sheehans Syndrome in a mother who was producing 
no milk.  Then there were the home consults for severe maternal 
breast engorgement where I'd find a bright yellow newborn and a 
grandmother congratulating the mother for having such a good baby; 
when tested, one of these babies had a bilirubin count of 
28.  Sometimes mothers with mastitis were dismissing medical advice 
to suspend breastfeeding.  Older babies with very low gain or classic 
failure-to-thrive often had mothers who had been advised by doctors 
to supplement with formula, but were so committed to exclusive 
breastfeeding that they were ignoring medical advice.  I once worked 
with a mom who I gradually became convinced was deliberately starving 
her baby, firstly by not-enough exclusive breastfeeding and then by 
not-enough formula-feeding - her frantic friend confirmed that she'd 
had emotional issues for years.  Now that I'm in England I sometimes 
work with referrals from an organization working to keep low-gain 
babies with their mothers when Social Services are threatening to 
take them into care because the mother is not "complying" with 
suggestions to feed formula.   These kinds of situations are not only 
fraught with danger to the baby's well-being, they are also very 
threatening to the LC, who can be found negligent if anything happens 
to the baby and she knew about it and didn't report it.

Consequently, in the British, European or Australian systems which 
seem to me to be less hands-on than the the protocols in the US, I 
think it's important for the LC to obtain a signed permission to 
report to the HCP from the mom and then to use her discretion about 
when to actually make a report or not.   I used to sometimes make 
written reports, or sometimes I would phone the paed/GP/OB and then 
document the conversation in the client notes, (and sometimes I'd 
phone first and then write ...) or sometimes (since I had hospital 
privileges) I would catch the OB/paed in the corridor and share what 
I'd seen verbally and take direction about the way forward. For 
everyone's protection, It's vital to document everything!   It's also 
crucial to build up a good trusting environment not only with your 
mother-clients, but also with their HCPs.  I used to find that 
doctors appreciated references and journal articles when offered in a 
respectful way, and when conveyed from the position that mom, LC and 
HCP were all really on the same side, wanting what was best for the baby.

I would also love to hear what others think about this.  It seems to 
me that whatever system we use, its usefulness is really only tested 
when there's a crisis.  Hospital-based LCs may never come up against 
this problem because there's always a clear system for reporting 
which must be used, and a clear heirarchy of responsibility.  But the 
LC working in the community is often completely on her own, torn 
between keeping the mom happy, and making sure the baby is safe.  And 
who is our client, anyway?  The mom, who makes the milk, or the 
end-user, the baby??

Pamela Morrison IBCLC
Rustington, England
--------------------------------
Date:    Sat, 10 Dec 2011 14:06:17 +0100
From:    Borstvoedingscentrum Panta Rhei 
<[log in to unmask]>
Subject: Re: Where to start

Wow, Jeanette, impressive list you have given! Wonderful! ;o)
I can't help but stumble on this paragraph:

*Make sure your documentation when you start a client includes physician
referral - which is a requirement for IBCLCs as we MUST communicate with the
mom's  and baby's Health Care Provider (HCP) - AND a photography release.
Of course, inform all your clients that you will be communicating with their
doctors.*

I know the now called (and in my opinion very disappointing) Code of
Professional Conduct still has this item, as it was not deleted or changed
compared to the previous Code of Ethics.
I still find this a troublesome requirement, as it seriously infringes upon
mom's autonomy, where I consider parental autonomy a core aspect of respect
for our clients.
It is part of the all important 'informed decision making' to let parents
decide for themselve who they want to do 'business' with and why and if and
when they want to consult an lc.
Apart from my principle objection to this, there is also a clear regional
difference. My moms don't need to have a physician referral; they can simply
give me a call and if they want my help, I go over and do the consultation.
Because I am a member of the Dutch professional lc organisation, they often
even get the consultation reimbursed (depending on their health insurance).
There may also be very solid reasons for a mom to not want me to discuss
what we discuss with others, for example because she has fully lost
confidence in other hcp's who may have let her down. That, in fact, may be
the reason she calls me in the first place.
Further, I find it worrying that this hierarchy difference remains, where it
can actually hurt mom and baby as other hcp's are not always as
knowledgeable with regard to breastfeeding as I am.
Does a cardiologist/physiotherapist/dentist/surgeon also ask me for
permission to treat a patient because I may have been in touch with her?
Every professional ought to be aware of his or her own limits with regard to
certain areas of expertise. This goes for lc's as well as any other health
professional.

I wonder if we could somehow further discuss this and make sure the next
edition of our CoPC deals with it in a different way.
How do others feel about this?

Best regards,

Marianne Vanderveen-Kolkena IBCLC, Netherlands

             ***********************************************

Archives: http://community.lsoft.com/archives/LACTNET.html
To reach list owners: [log in to unmask]
Mail all list management commands to: [log in to unmask]
COMMANDS:
1. To temporarily stop your subscription write in the body of an email: set lactnet nomail
2. To start it again: set lactnet mail
3. To unsubscribe: unsubscribe lactnet
4. To get a comprehensive list of rules and directions: get lactnet welcome