Hi all, from Bergen, home of the Leprosy Museum and of Armauer Hansen who 
started the Norwegian leprosy registry and who first discovered the bacterium 
that causes the disease.  I'm posting from the archives site so there may be a 
lot of equal signs and twenties in this, but I hope not.  I've just spent three 
days hearing about the value of health registries at the conference I 
attended.  Bergen is also home to the national TB registry, and the Medical 
Birth Registry of Norway, which for the past 40 years has recorded data from 
every birth in the country, longer than any other birth registry, anywhere, a 
gold mine for epidemiological research.
  
I've been following the recent thread about consent forms for use of formula 
in the hospital and would like to comment.  First, informed consent implies that 
the person who is going to have something done to them, has been advised to 
do so by a practitioner of some kind, and that practitioner wants to document 
that they have not misrepresented whatever they plan to do nor (*informed*) 
have they coerced the person to undergo it (*consent*).  In cases where 
staff are advising a mother to give supplemental food to a baby, the mother 
may consent to this after being presented with the reasoning about why her 
baby needs it.  The issue of how supplementation is given, by cup, gavage, 
dropper, finger feeding or bottle, is a separate one, requiring information 
specifically about that, and of course a consent from the patient or the 
mother as the patient's guardian, should they decide to follow the 
recommendations from the staff on this point as well.  It should be entirely 
possible for a mother to disagree with staff on what, if anything, is to be 
given or how it is given, or both.

In cases where a *mother requests* supplemental bottles for the baby, 
informed consent is not the issue; informed CHOICE is, and again, it is 
twofold: one issue is supplementation at all, the other issue is how supplement 
is given.  It is this scenario most posters in thread seem to be addressing 
when they write about links about risks of formula feeding, as surely it would 
be inappropriate to first advise a mother that her baby needs an intervention 
(supplement) which requires her *consent*, and then to present her with all 
the reasons why this intervention is extremely ill-advised, in an effort to gain 
said consent.

The risks of exclusive formula feeding are also not likely to sway a mother 
whose baby is restless and rooting at 3 a.m. on the postnatal ward if she is 
desperate to sleep and thinks she will be able to if the baby can simply be 
satiated then and there.  There is also a real risk of offending her and shaking 
her belief that the staff care anything about how she is feeling.  If it is not 
possible to have an actual conversation with the mother about how 
overwhelming it can be to have given birth a day or so prior and then be in an 
institution, away from your partner and confronted with a baby who doesn't 
have any way of accommodating your need for rest, or who may be having 
difficulty latching or settling or whatever, it goes against my grain to slap her 
with a form that tells her all the dire things that may happen if her baby ends 
up being exclusively formula fed.  My inclination would be to try to support her 
then and there by staying with her, letting her know that this phase will pass, 
usually within the next day or so, and that giving the baby a supplement now 
may well drag things out since her breasts will not get the same stimulus to 
produce more milk if the baby is getting fed elsewhere.  I'm pretty good at 
expressing confidence in a mother's ability to cope, which is what she needs, 
IMO.
If the only thing available to supplement with is formula and it is my 
professional judgment that the baby really doesn't need it, I would let her 
know that it is better for her baby not to be fed formula because it is 
associated with earlier weaning and more use of supplements long term, and 
that a single exposure to formula now may be enough to precipitate allergy 
later.  I'll try to find a way to give her some respite while not ignoring the 
needs of the baby either.  If she still is determined to give the baby a 
supplement, I would discuss with her how that is to be done, and make it 
clear that there are plenty of ways that don't involve bottles and that since 
she intends to breastfeed, we strongly discourage bottle use now.  Depending 
on how hectic the shift is I might offer to keep the baby company after the 
feed so she can just get an hour or so of sleep without the reminder that she 
now has another person who always comes first. 
This is what I understand as mothering the mother; I don't want to be the 
kind of mother who wags a finger and lays blame, and that is certainly not the 
mothering behavior I want to model for her!  I believe new mothers need to be 
nurtured so that they can nurture their babies.  The day I meet a mother who 
really doesn't care about her baby's health, I may feel like using a written 
disclaimer to tell her how little I think of her too, but so far it hasn't happened 
that I can recall.  

Rachel Myr, for the moment in gray and rainy Bergen, Norway

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