<< don't think I have ever seen others working by email (not as an adjunct 
to other practice, but as first, maybe only, point of contact) discuss their 
practice here on lactnet.  Surely you are out there>>

I'm a little late getting in the discussion as usual.  I thought I could add 
my expertise and opinion to the list.

My current "practice" is almost entirely via the Internet and has been for 
the past 8 years.  I hear from women all over the world . In many cases, I 
am the only LC they have access to because there isn't anyone available 
locally.  This is unfortunate , but,  I often hear that even though  they 
saw someone in the hospital, no one is available to them after discharge or 
because the baby is older than 2 weeks they can't go back for help and no 
one is in private practice in their area.

Women today tend to scour the Internet for any information and the result is 
often a disaster.  Those of us who have sites try very hard to get any 
common problems covered in the simplest most general way possible--quick 
questions and easy answers, the type a mother could find in any book. 
However, a little knowledge is a danger and self-diagnosis has many 
drawbacks and pitfalls.  My web pages have general advice and an invitation 
to mothers, who need additional assistance, to contact me via email.  I 
receive an average of 3 or 4 requests a week.  Unfortunately,   most of the 
moms who contact me are well beyond simple answers.  Many have badly 
mismanaged the problem based on what they have read "somewhere on the 
Internet."

Treatments for some specific problems are purposely omitted on my site.  The 
answer to the problem is available to those who ask, if they are willing to 
provide whatever information I require before I give them any treatment 
recommendations.  I just don't feel comfortable distributing information 
when I don't have all the facts.  Over the years I have learned that some 
mothers either exaggerate or under report what is happening.  Things can get 
very complicated, very fast, if the picture is incomplete.  I wouldn't use 
SMS's or IM's for that reason.

The vast majority of cases I get are Over Supply Syndrome.  (The  topic  I 
spoke on at the 2008 ILCA convention in Las Vegas.)  When mom contacts me  I 
send her  a questionnaire that is intended to give me a complete history and 
description of the problem.  When it is completed and returned, I can make 
recommendations for how she can best handle the OSS.  Several email contacts 
may go back and forth after she gets treatment recommendations to make sure 
the treatment(s) is working.  Adjustments can then be made accordingly.

For problems other than OSS,  I created something I call an "ichart".  It is 
sent  to moms who ask for help with low supply, persistent  sore nipples, 
latch on problems, etc., and contains screening questions for a myriad of 
complications.  When I was practicing *hands on* (face to face), I learned 
that the history is a key diagnostic tool.  What I saw in the exam often 
proved secondary and only confirmed the impressions I had formed regarding 
the diagnosis and treatment needs from taking the history.

I also use other internet tools like still photographs, Skype, and /or live 
webcams, as needed.

Every woman who makes contact with me is informed that  1)  I only help with 
feeding problems,2)  contact with their local LC or baby's doctor  is 
preferred to email contact,  3) take the baby to the emergency room if it 
appears ill, and  3) if baby gets worse see your doctor, etc ...  A 
disclaimer that covers those points accompanies every email.

The anonymity of the Internet seems to permit moms to share things with me 
that they would never share otherwise.  Breastfeeding practices are more 
varied than we as a profession imagine. Women's perceptions of LC and 
physician support of breastfeeding, or lack thereof, are quite a revelation.

Nevertheless (not to brag) I think I am quite skilled in internet support. 
It does have one additional drawback that no one has mentioned-fee for 
service.  I do wish I could charge for my services but it is nearly 
impossible to do and because I am often the only access many of these women 
have to LC help, I worry a  fee would make me inaccessible as well.  If a 
woman offers payment, she can make a donation through PayPal but that doesn't 
happen very often.

I do get something out it, there is a certain satisfaction knowing I've 
helped a baby stay breastfeeding (oh and it keeps me feeling useful too).

I'd be happy to answer any questions.

Happy holidays and hope for a peaceful New Year

Marie Davis RN IBCLC

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