I'm working on a formal letter to IBLCE on the matter of the proposed lesser credential of the "stepping stone" to the IBCLC credential, and would be grateful for feedback on the following content.

Dear Staff and Board of Directors at the International Board of Lactation Consultant Examiners,

Regarding the cognitive demands of discerning and differentiating between various titles and job descriptions for breastfeeding clinicians, educators, and other helpers, particularly in regard to IBLCE's proposed lesser credential as a "stepping stone" to the IBCLC credential:

Discerning and differentiating between the names of things; the things themselves; and discerning between tasks that are similar yet different is cognitively demanding across the lifespan. There is also a developmental progression in cognitive flexibility: Infants display the least cognitive flexibility in task-switching of all ages studied, and children display greater cognitive flexibility than infants. Adolescents display greater abilities in task-switching than children, and adults display the greatest cognitive flexibility of all ages across the lifespan, yet task-switching is often cognitively demanding in adulthood as well, and examples abound.

In regard to motor control, the musician will never rehearse for an important performance on the clarinet by practicing with an oboe instead, due to the expected switch costs of decreased speed and accuracy for the performance, unless more task-specific practice takes place on the clarinet, termed practice specificity. There is a world of difference in the oral grasp of a clarinet and the oral grasp of an oboe, yet to a non-musician, these dramatic differences may appear subtle. Similarly, the elite athlete will never rehearse for the World Cup in soccer by practicing with a basketball or volleyball instead, due to the expected switch costs of decreased speed and accuracy.

Other forms of task-switching are also cognitively demanding, such as switching to the use of a new password. New memories are fragile until enough repetition of effective practice builds robust memory, and this early fragility is observed in the formation of motor memories for infant feeding as well.

So much of our workday is spent providing manual guidance to infants in support of their motor learning toward motor control for the oral grasp and effective suckling. In non-Baby Friendly facilities, a great deal of our clinical time is spent in providing manual guidance to the infant in relearning the oral grasp and/or effective suckling at the breast following the use of an artificial nipple, and particularly the early use of an artificial nipple. Adults also frequently display motor control challenges in switching back and forth between certain styles of water bottles, and many adults state actual preferences for specific styles of water bottles.

When many of us express our preference for continuing to offer a credential that is increasingly familiar and respected by the public (the "Gold Standard" of the IBCLC credential), we are not displaying a territorial behavior, but acknowledging the lifelong challenge in discerning and differentiating between things that are similar yet different. To expect rested parents as well as sleep-deprived new parents to be able to adequately educate themselves in order to discern and differentiate between various levels of breastfeeding support is expecting a extraordinary accomplishment by a new parent, unless the new parent happens to be in the parent-child health field and is well-versed on the subject.

I believe our professional goals should include ACCESSIBLE education and training toward adequate staffing of IBCLCs in inpatient settings, 7 days a week, 24 hours a day. Inpatient services are INPATIENT and not outpatient, and inpatient babies need to learn how to feed during morning hours, in the afternoon and evening, and yes, even at night, as well as on weekends and holidays. Every mother should have access to skilled infant feeding care by an IBCLC when needed.  Even in the ideal world where such staffing may exist, our specialty will remain narrow, in spite of our extensive education and training in the field. Offering a lesser credential as a "stepping stone" to the IBCLC credential will create natural cognitive demands on the public in discerning and differentiating between various levels of care in lactation and infant feeding, and this will be an ongoing cognitive demand for the public, rather than an acute problem that is readily addressed.

As a result of the IBCLC's "Gold Standard" of education, training, and level of care, there have been tremendous improvements in breastfeeding initiation and duration in the U.S. and elsewhere, resulting in better health outcomes for both members of the nursing dyad. Acknowledging the IBCLC credential as the Gold Standard has resulted in a tremendous increase in the staffing of IBCLCs across the U.S., and the number of IBCLCs continue to increase elsewhere in the world, although there is still the need for greater access to the IBCLC.  In the U.S., our profession is no longer in its earliest infancy, but we are far from achieving a mature state of professional stability. A lesser credential will not help to stabilize the IBCLC credential, and will almost certainly weaken the public's perceived value of the IBCLC credential.

A lesser credential as a "stepping stone" carries a risk to all that has been accomplished in regard to many hospital standards where the IBCLC credential is either the only accepted credential, or the IBCLC credential is expected to be obtained by the clinician in a timely manner. For IBCLCs in private practice, I am deeply concerned that a lesser "stepping stone" credential will only harm those in private practice. Even now, eight years after the passage of the Affordable Care Act, billing health insurance in the U.S. and receiving reimbursement is not at all a straightforward process and is often fraught with difficulties, with few exceptions.

Debra Swank, RN BSN IBCLC 
Ocala, Florida USA 
More Than Reflexes Education 
http://www.MoreThanReflexes.org
http://www.MoreThanReflexes.org/on-learning/
http://www.MoreThanReflexes.org/webinars/

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