Lea needed to vent about a situation before contacting the mother - and lots
of us have been there before :-)
While I know it's frustrating to be part of an unconnected team of people
parents rely on for advice, it doesn't sound like the biggest obstacle to
this baby's care is the pediatric nurse practitioner.  It may actually be
the very structure of care, in which the person helping them with
breastfeeding doesn't have a formal relationship to the pediatric NP.  This
is NOT a criticism of you, Lea!  It's just a statement of fact, that when
you are working from one place and the peds care is happening somewhere
else, there are going to be 'challenges'.  It really points up the
importance of written communication with the other people involved in the
child's care, both ways - if the parents agree to it, you should be able to
get a short synopsis of what the NP has done and whatever plans she has made
with the parents for following up the baby - just as the parents could give
you the same permission to send info to the NP.
It also sounds as if the parents have made their minds up about tongue-tie
possibility, and unless they were specifically advised against considering
it by the NP, it may be hasty to blame her for not helping.

About the jaundiced sclera in the baby: since the NP observed the baby and
didn't see any other evidence of jaundice, I would be
reassured.  Physiologic jaundice in the newborn always starts in the face,
and spreads downward and outward.  Even when the baby's skin doesn't look
obviously jaundiced, you may be able to observe a yellow cast to the whites
of the eyes, because there is no other pigment there to mask it.  It's often
the last place to clear, whereas in an adult with liver disease, jaundice
'up to the eyeballs' may mean something else entirely.

What was the baby's birth weight?  It was hard to tell from the post, since
we don't know how old the baby was at discharge from hospital nor how much
weight baby had lost from birth until discharge.  From what the mother wrote
to you, it sounds like a good way to go would be to make sure she has
appropriate information about how much milk a baby needs in order to grow,
and about how to monitor intake between weight checks, through observing
baby's behavior while feeding and keeping track of output in diapers.  They
also need to know very specifically what signs in the baby should trigger a
new visit to you or the NP.  Even if in your opinion the tongue tie is the
overriding concern, it sounds as if the baby is able to feed and if the
parents are not sold on the tongue tie idea, you need to devise a strategy
that will get the baby fed, and you and the parents need to agree about it.

The other option is for you to let them know that you are not able to
provide care to them beyond what you have already done, since they have
chosen not to follow the advice you feel is essential in order to solve the
breastfeeding problem.  I doubt it will get to that point, but it's an
alternative that gives you an escape route.  None of us are under any
compulsion to change our professional opinion to suit a parent's belief -
but if we aren't able to change our opinion, because in our professional
judgment it would be incorrect to do so, it may mean the end of the
professional relationship.  Again, not a criticism, just an observation.

Rachel Myr
Kristiansand, Norway, where simply agreeing on a plan of care between two
shifts in the same INPATIENT MATERNITY UNIT, for crying out loud, is no easy
matter :p

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