Dear Friends:
    Jan asks "where is it written that LCs can't recommend a particular
substance?"  Is lack of a written standard permission? Because it doesn't say
I can't, that means I can?
    As for the St. John's Wort: the statement is made: "So I wouldn't tell
her yes or no either -- my job in that situation is to give her the
information about
St. John's Wort & breastfeeding, pure and simple."  People believe that
because they are taking herbs, there are no risks or side effects because
herbs are natural. They need all the information in this situation, for
safety reasons. I know about depression and how it can hide anemia or a
hypothyroid situation; this mother doesn't. So my obligation, since she has
called me as the authority, is to give her all the information about her
condition, encourage a thorough evaluation, and also to see a certified
herbalist. That does not mean she has to take my recommendation; however, my
recommendation can do no harm. Whereas giving her the information from Hale
or some source about St. John's Wort, and nothing else may not be the safest
situation for her.
    Lactation workers are working very hard to achieve professional status.
Unsupervised sanction of recommending herbs is not a professional act.I guess
it boils down to a matter of interpretation. I am not going to sanction use
of an herb (or a drug) in a situation that I know can be risky. The choice I
make is to use the information that I know in the safest way for the mother
that I am counseling. If a medical professional calls me to ask about St.
John's Wort, I can read from Hale or other sources. If a mother calls, I can
recommend she receive a medical evaluation and work with a certified
herbalist.  I can never tell a mother that any drug or herb is safe; I can
read to her and say "The AAP says this substance is compatible with
breastfeeding, that there are no known or reported side effects." or "Hale
says, in his 1999 edition on page 234....." I don't have the power to say
that anything is safe. The decision is the mother's, which she makes based on
her providers recommendation and the information I relay to her.
    Peer counselors, LLL, CLC, CLE, IBCLC,  and whoever else is out there can
be medically trained people, hair dressers, computer programers, and stay at
home mothers. Is is safe to have all these sorts of people recommending
herbs? Based on what training? As Kathy D. so correctly points out, herbs are
not considered drugs by the FDA. Yet they are used as such by the folks who
call a medical liaison. Prescribing herbs is a grey area. Physicians and
those with prescriptive powers can recommend anything, because they have the
authority to do so, granted by the state. I can't.
    As a licensed professional, my margin of safety is much less than a lay
person's. Lawyers will say "I should know better". I know of a nurse who was
reprimanded by a state board of licensing for recommending use of an herb
(20+ years ago) because she charted it in the notes and nurses following her
on the case reported her to a supervisor that took it on up the line. Very
conservative you might say; yes, and it happened.
    I do agree that it is within our practice and public safety to refer a
mother back to her prescriptive provider with a request to consider a
specific substance. Ex: " from the symptoms you describe, and from what I
see, it looks like "X"....I suggest you talk to your doctor about that. Other
mothers I have worked with have used "Y" in that situation. Ask your doctor
about that." This can be supplemented with a letter or telephone call to her
practitioner's office, and complemented by articles and tapes for evidence.
People are doing this in cases of thrush and short frenula. And no harm is
done.
    We need some lawyers to comment on this.....and I am sure that there are
no exact answers. We also need something in writing from IBCLE as lack of a
written standard is a loophole only until someone gets nailed in court.
Certainly, no one without malpractice insurance would recommend any
substance.......but that is most likely only true in the USA.
    Your turn......this is fun, and very thought provoking. LACTNET at its
best!
    Warmly,
Nikki Lee RN, MSN, Mother of 2, IBCLC, CIMI, CSTP
Elkins Park (a suburb of Philadelphia, Pennsylvania; northeastern USA)
supporter of the WHO Code and the Mother Friendly Childbirth Initiative

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