On 11/27/2014 4:51 PM, Annette wrote:
> I have a new job and was reprimanded for ad voicing a mom at Breastfeeding Support group to use breast milk in 3 month-old's eye instead of antibiotics!!  Need evidence to show Internal Med doctor that it is NOT perfect medium to grow bacteria!

Annette is presenting us with a very interesting and (timely) topic with 
(unfortunately) too many unknowns.

Was the administration (what type of facility? what country? what 
state?) right to reprimand the licensed and boarded health care 
professional (a registered nurse who is also an IBCLC) for giving an 
advise during an informal group session that went against physician's 
orders.

Understanding that I am not a lawyer and I am not an expert on ethics 
either, I will try to review what IMHO exactly was right (and wrong) in 
this situation.

First and foremost - it is a question of a scope of practice.
Is it within a scope of practice for an IBCLC to diagnose and treat a 
"pink eye" (see below why I did put "pink eye" in quotation marks)? And 
the answer is well known - no. As far as I can understand (and I may be 
wrong, see my disclaimer above), that in the legal lingo is called 
"practicing medicine without a license". Even having a license would not 
always qualify a professional to do so (i.e. being a registered nurse, a 
doctor of podiatry or a chiropractor). Even more so, being a medical 
doctor (unless someone is a general practitioner, pediatrician or 
ophthalmologist) could bring the question of the scope of practice into 
the light - i.e. an internal medicine doctor, a specialist who did not 
have any training in evaluating and treating a 3 mo old (as well as 
anyone under the age of 13), should never diagnose or treat an infant 
(unless we are in a dare situation in the middle of some nowhere).

Then it is a question of appropriate place and situation (and talking of 
unknowns, I admit that we do not know what exactly was said and how 
events were progressing during Annette's group session).
Even if someone is licensed to practice medicine, is it appropriate for 
a licensed and boarded professional to discuss a specific patient's 
specific treatment in public (i.e. breastfeeding support group or open 
internet forum, or on TV)? I don't think so, as we are getting into the 
privacy issues as well as the possibility of other mothers misdiagnosing 
and mistreating their children, making the said licensed and boarded 
professional liable for any adverse effect happening. At least I hope 
that you did get all the piles of permissions and disclosures signed by 
that mother as it is done on Dr. Phil or Dr. Oz shows. Sandy's link was 
a great example of information given in a respectful  way, appropriate 
for the general population.

Let's not forget about the actual diagnosis.
I did specifically put "pink eye" in quotation marks simply because it 
is not a medical diagnosis and as such it can not be treated. In order 
to prescribe a specific course of action (including recommending to 
leave the eye and the kid alone) one have to first make a specific 
diagnosis, assessing not only a complaint (a "pink eye" in this 
situation, or a "rash" in MRSA infection, or "cough" in status 
asthmaticus) and current medications (antibiotic +/- other preparations, 
remedies and so on), but also a history of present illness ( timing of 
events, effect of interventions, etc.), past medical history (including 
birth history, other medical problems, vaccination record, etc), social 
history (contacts, etc), family history (similar symptoms in other 
relatives, vaccination status of other kids), travel history (not only 
visiting places by the kid and/or his family, but visitors to the family 
too), detailed review of systems, detailed physical examination (general 
and local), all of which all will hopefully lead an investigator to a 
list of differential diagnoses, which in turn will help with 
establishing the actual problem and a cause of it. And a differential 
diagnosis of a "pink eye" in a 3 mo old can be a mile long, ranging (to 
name a few) from something mostly self-limiting and bothering a mom only 
(i.e. watery eyes in a kid with a cold) to a mechanical problem (blocked 
tear duct), to something chemical (i.e. irritation from drops, soaps or 
shampoos) to trauma (i.e. a 3 yo sib poking the baby in the eye), to a 
serious bacterial infection with a risk of generalization into 
meningitis or sepsis or blindness (i.e. HiB, herpetic or gonococcal 
infections) and so on and so forth.

That brings us to the question of treatment that should be a result of 
the diagnostic dance described above.
Treatment should be as specific as possible and the use of any agent in 
any form and in any locale (especially in the eye) should be justified 
and chosen extremely carefully.
Said that, breast milk was used for millennia to treat whatever ailments 
humans were having, sometimes - with success, sometimes - with dare 
failures. We did discuss ad nauseam the problems with breast milk as a 
medicine research, so I would not go into details here. Again, Sandy's 
link was extremely interesting and informative, thank you. Said that - 
Annette is asking a specific question re: breast milk not being a 
"perfect medium to grow bacteria", which is a very reasonable question 
to ask and could be a great conversation opener in her hospital or 
clinic (if it would not be connected to the scope of practice issue). 
That literature is abundant and for the sake of time (have to be in the 
office soon) I would leave that specific request to Pat and other gurus.

The last but not the least - the question of timeliness of Annette's 
question.
With the move towards IBCLC's licensing in the United States, the 
situation that Annette describes can be a cause not for just a simple 
reprimand by a particular hospital's or clinic's administration, but 
also a reason for referral to the state licensing board, which would not 
be pretty at all :(...

On such a pessimistic note I will stop.

Happy Holidays for our US members and a good weekend for everyone,
Alla

-- 
Alla Gordina, MD, IBCLC, FAAP
General Pediatrics
Breastfeeding Medicine
Adoption and Foster Care Medicine

Global Pediatrics and Family Medicine
NJ Breastfeeding Medicine Education Initiative
NJ Chapter Breastfeeding Coordinator, American Academy of Pediatrics
Satellite Symposia Sub-Committee Chair, Academy of Breastfeeding Medicine

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