>>I think the salient point might be that the doctor or other hcp is the
primary provider and ultimately responsible for the client's care (we could
argue he mother herself is ultimately responsible). <<

I am hoping myself that this is what they meant more than anything. As a
professional courtesy, I try really hard not to directly contradict or put
down another health professional. I do what I hope will be done towards me
as well! If the information the mother received was bad, I try to find a way
to tactfully bring in the new information and try to put as nice a spin on
it as I can. I also may address a situation (like supplementation for
jaundice) by saying something like, "What the doctor wants is to guarantee
that the baby is getting enough in him right now. I think we can accomplish
the same goal by XXX; let's try this here in the office, and if I'm right,
we'll call your doctor and make sure this is okay."  I also try to
re-educate MDs with my MD reports and appropriate back-up references. 

Most recently I did have a couple with a tongue-tied baby who got the
predictable response from their old-time ped. I counseled them to wait a
week and go back and explain mom and baby were still having problems and
could they please have that referral to the ENT specialist?  I made the
focus of the conversation that the problem was not solved and empowered
mother to keep going back. They finally got their referral (needed for
Medi-Cal), though the ped in retaliation then fired them as patients. They
got their assessment and clipping and good results and are very happy, and
they will be getting a more supportive ped. I think I did my job, and I did
it respectfully.

>>The LC should not prescribe nor recommend alternative therapies: I agree
that is vague. I think what it might mean is for the LC to tell a mother to
take xx capsules of fenugreek 4 x per day. This is a prescription. The LC
could, in my interpretation, discuss various galactogogues that are used,
and=  have the mother discuss with her hcp in case medical conditions or
other meds might interfere. This is what I do, I mention to the mom some
available  therapies and ask her to discuss with her doctor. I also call the
doctor and discuss with him/her.<<

Here in US, where Reglan (with its attendant depression risks) is our legal
option and domperidone is being driven out, we have few options. This is the
whole reason I ever dove into the arena of herbal galactogogues, having
never been a person to dabble with herbs before. I've done my research--
plenty of it. There are no pharmaceutical companies looking for better
options for us, and pumping alone does not always maximize yield, not to
mention address internal imbalances in any way. Most health care providers
have little idea what to do, and even when mothers are sent to an
endocrinologist, they rarely come up with anything, either. Two days ago an
OB asked ME what I thought about Reglan, and I explained to him my
reservations. I also gave him a quick sketch of the politics of domperidone,
which I told him was my preference. I mentioned that this is why I have
turned to herbs more, and he was all ears, asking me which herbs are being
used, etc. *He* wanted the information. This has happened multiple times.
What I hope sets me apart is that I have never viewed galactogogues with a
one-size-fits-all eye. I have done the extra work of digging out the
available information for myself and contacting the experts and learning all
I can, because the doctors in my area, and in most areas, know little or
nothing. That's why they call me!  I provide doctor reports, in which I tell
the doctors what ideas we discussed and what the mother chose. If I think
that we are in controversial ground with a particular situation (I had one
recently with a mother who was on psych drugs), then I call and make sure
it's okay first. But I don't call in advance on everything.

So I am more troubled by the "alternative therapies" section of the new
scope. I would be of little use to my moms OR my docs, who look to me for
the answers they don't have.  And though I don't have a good source in my
area, I think of the value CST has for some dyads, etc. Accepted allopathic
medicine has failed to adequately address many of the problems we face.
Heck, my poor sister is struggling with her almost 6-mo preemie twins right
now who continue to be very fussy though growing well, and her HCPs only
suggestion is formula and rice cereal, as if those things fix all problems!
Should we not be able to offer mothers whatever we see as viable
alternatives in that case?  Why withhold the information?  

If anything, though, what *does* need to be cracked down on is irresponsible
usage of other ideas.  Chele Marmet became very particular about how she
trained students, not letting them even touch a baby for quite a while,
after someone heard her talk about suck training and went home and did harm
in their ignorance and inexperience. And I have seen this with LCs, taking
an idea but not having the full understanding of it, and then not applying
it correctly. But if this is what we are trying to avoid, and we certainly
should try to avoid it, there must be a better way to address it. 

Right now we don't have training schools for some of the things I've talked
about here. That's why I've undertaken my own education. We need to work on
standardizing more of this stuff, getting some good research and then
developing some training and guidelines, rather than falling back to
restricting the scope. There are better ways to address the problems that I
suspect were being addressed by the new scope.

Lisa Marasco MA IBCLC

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