The following is a draft of a consent form to be used at our local hospital.
The purpose of the form is to disuade mothers and nurses from quickly
resorting to supplemental feeds especially with substances other than
breastmilk.  I'd especially appreciate comments on how to word the section
on "formula".  We are running into some resistance from nursing staff that
the present wording would make a woman who "couldn't breastfeed feel badly".
Yet, we don't want to promote formula in any way as we are striving to make
changes to become a "baby friendly" hospital. The proposal follows:
Susan Howlett, Registered Midwife, Ontario, Canada

____________________________________________________________________________
______________________

CONSENT TO TEMPORARILY SUPPLEMENT

A BREASTFEEDING BABY




I plan to breastfeed my baby.

I have been informed that research shows that breast milk significantly
decreases the chances of my baby getting diarrhea, respiratory infections,
ear infections, allergies, bacterial infections such as bacterial
meningitis, urinary tract infections, and intestinal disorders. Studies also
show a possible protective effect against sudden infant death syndrome,
diabetes, Crohn’s dsease, ulcerative colitis and lymphoma.

To help make breastfeeding successful I have been given assistance to:

get the baby to breastfeed as soon as possible after the birth

position the baby, get a good latch and suck

breastfeed on demand every 2 to 3 hours

I have been instructed on how to pump my breast milk if the baby has been
unable to latch within the first 24 hours. I understand it is important to
pump every 3 hours to help build up the supply of breastmilk for my baby.

be referred to a lactation consultant if there are on-going difficulties

Mother’s signature ________________ RN/RNP signature __________________





If I cannot breastfeed my baby temporarily:

Types of Supplements:

1. Colostrum/Breast milk

Whenever possible pumped colostrum/breast milk is the best choice for
supplementing the baby.

If the plan is to breastfeed, all other supplements should be avoided unless
there are medical reasons for the mother or baby, or there is still not
sufficient breastmilk available even with all the assistance listed above.

2. Glucose water

Glucose water is sometimes given for medical reasons if a problem is not
resolved with sufficient breastmilk. As it has no protein it is not suitable
beyond the first two days. It can aggravate jaundice. If there is not enough
expressed colostrum/breastmilk, it can be combined with glucose water until
there is enough breastmilk.

3. Formula

Formula does not have the health benefits and immunological protection that
only a mother’s colostrum/breastmilk can give. It can change the type of
bacteria in the baby’s gastro-intestinal system. In cases where families
have a strong history of allergies it can cause allergies.


Methods of Supplementing:

1. Supplementary nursing system

Giving a supplement right at the breast while the baby is feeding, using a
type of supplementary nursing system is the best method to promote
successful breast-feeding. This is least confusing to the baby as he/she
never sucks on anything other than the breast. It also helps increase the
milk supply.

2. Cup Feeding

The baby is held in an upright position and fed with a small cup. It takes
very little time and is not apt to affect the baby's sucking skills when
done on a short-term basis, especially if the baby has been given chances to
try at the breast. Moms or Dads can be taught to do this safely by
themselves.

3. Finger Feeding

It is done in a breast-feeding position, using breast-feeding cues. Parents
can be taught to do this. It may be most helpful when a baby does not seem
to know how to suck properly. It should not be used if mother's nipples are
flat or inverted, as it may "feel" so different that the baby may reject the
breast.

4. Bottle-feeding

The firm nipple feels very different from the mother's soft one, and the
flow is immediate with very little effort. Some babies do not breastfeed as
well after having one or more bottles. Some may refuse to feed at the
breast. The risk is greater if the baby has not, as yet, been on the breast.



Consent Form

After having read the above and discussed my particular feeding plan with my
nurse, I consent to my baby being temporarily supplemented with
_____________________ by the method of ___________________________.

My feeding plan will be reviewed as necessary, to promote successful
breast-feeding.

Date:_______________ Mother's Signature _____________________ RN/RNP
Signature__________________