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__________________