Hi Diana,
I guess I come from the perspective where for decades lactation consultants were instructed to "counsel" adoptive mothers to be "realistic" about their ability to make enough milk. What mothers heard loud and clear is that they would not be able to make enough milk and it became a self fulfilling prophesy. It has taken many years to get anywhere close to changing the idea that far from being rare for adoptive mothers to make enough milk for their babies it is quite common.
Similarly, I used to give IBLCE candidate lectures which commonly followed a presentation that included some discussion of the impact of PCOS on lactation. These almost IBCLCs had clearly taken on board the idea that PCOS would invariably result in problems with milk supply (I used to use a photo of an adoptive mum with PCOS who had been able to EBF to get the point across that you really couldn't predict what was going to happen in any individual case). 
That said, I don't have a big problem with your wording below. I think that the ideal is all mothers being given excellent anticipatory guidance and follow up but I know that this is not available in many instances. How many IBCLCs are actually able to provide mothers with the sensitive sort of wording that you used?
I feel that we should learn from the mistakes of the past (ie the experience with adoptive breastfeeding) and not undermine women before they have even gotten started!!
Karleen Gribble
Australia


On 18/04/2013, at 3:13 PM, Diana Cassar-Uhl wrote:
>   I don't think anyone is advocating telling a
> pregnant mother "Oh, gee, your breasts sure do look strange, you probably
> won't make much milk with them!"  However, to notice marked asymmetry, a
> tubular appearance, and/or wide spacing in the breasts of an expectant or
> new mother and *not* say "I notice your breasts are really different sizes,
> and the left one looks a little tube-shaped ... some mothers with breasts
> that look like yours have trouble making milk, but lots of others do just
> fine ... we'll make sure you and your baby get lots of attention in the
> hospital, these are xyz signs you know your baby is getting enough milk and
> these are pqr reasons to be concerned after you go home ... etc., do you
> have any questions?" is not ethically sound.  The fact that there is
> currently no conclusive predictive or diagnostic tool (or even a
> universally agreed-upon name) for hypoplasia that marks insufficient milk
> production doesn't negate the fact that this happens to mothers.
> 
> Do you believe such anticipatory guidance in the presence of physical
> markers and comorbidities that *may or may not* be predictive of lactation
> insufficiency would cause more refusal to even attempt breastfeeding than
> it would help those who do end up struggling?
> 
> Would you be more or less supportive of a global protocol, such as an
> education campaign about lactation difficulty/failure to ALL expectant
> mothers, not just those who present with the markers our field has come to
> recognize as potentially predictive?
> 
> The ever-eloquent Alison Stuebe summarizes my thoughts in her piece for the
> Academy of Breastfeeding Medicine blog entitled "Establishing the Fourth
> Trimester:"
> 
> "In obstetrics, prenatal care is designed to detect relatively rare
> disorders — preeclampsia, gestational diabetes, gestational hypertension —
> and we counsel mothers to monitor fetal movement, loss of fluid,
> contractions and bleeding to identify pregnancies at risk.  It’s debatable
> how well we succeed in improving outcomes vs. medicalize a normal process.
> But there is precedent for honoring normal physiology without turning a
> blind eye to unexpected problems."
> 

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