L3 MODERATELY SAFE:

There are no controlled studies in breastfeeding women, however the risk of untoward effects to a breastfed infant is possible; or controlled studies show only minimal non-threatening adverse effects. Drugs should be given only if the potential benefit justifies the potential risk to the infant.

L4 POSSIBLY HAZARDOUS:

There is positive evidence of risk to a breastfed infant or to breastmilk production, but the benefits from use in breastfeeding mothers may be acceptable despite the risk to the infant (e.g., if the drug is needed in a life-threatening situation or for a serious disease for which safer drugs cannot be used or are ineffective).

L5 CONTRAINDICATED:

Studies in breastfeeding mothers have demonstrated that there is significant and documented risk to the infant based on human experience; or it is a medication that has a high risk of causing significant damage to an infant. The risk of using the drug in breastfeeding women clearly outweighs any possible benefit from breastfeeding. The drug is contraindicated in women who are breastfeeding an infant.

Answer: Marijuana is contraindicated in nursing mothers, as are all illegal drugs. Please refer to the current edition of Dr. Tom Hale's book, Medications and Mothers' Milk.

Top>>

Answer: Congratulations on your plans to sit for the professional examination for the IBCLC credential. Lactation courses like the lactation educator or counselor programs are designed to give prospective IBCLC candidates an academic background in lactation. They are intended to be coupled with clinical experience so the candidate may meet the requirements of taking the IBLCE examination. Your next step is to establish a plan for certification with the IBLCE and arrange for a clinical instructor to supervise your acquisition of clinical practice hours.

In the meantime, using nomenclature such as Certified Lactation Counselor can be confusing and potentially misleading to clients and you may want to refrain from using a title until you have become an IBCLC. If you wish to refer to yourself as a breastfeeding counselor without a formal title and without the term "certified" - just as you indicated you are a childbirth educator - this could avoid such confusion.

In terms of seeing clients, perhaps you can inquire about triaging patients as a breastfeeding educator, or as a lactation consultant intern. It is important to define your role and your referral source with the patients when working with clients who need professional lactation consultation services. Make sure they know you are working toward certification and that you have referral resources to supplement your knowledge and skills. The important factor is making sure the patients understand they are not being seen by a professional internationally board certified lactation consultant.

Regarding your question about the RN requirement, the IBLCE does not require the RN license to become a lactation consultant. ILCA supports the IBLCE in the pathways to becoming a lactation consultant which are explained at the IBLCE website at www.IBLCE.org. It is important that employers recognize that the IBCLC specialty is the criterion for employing someone in such a position and that it is not an RN subspecialty.

Answer: The International Board of Lactation Consultant Examiners (IBLCE) has a process for filing a complaint or concern regarding breaches of the Code of Ethics for Lactation Consultants and concerns with violations of the International Code of Marketing of Breastmilk Substitutes. After confirming that this is factual and gathering evidence to substantiate the concern, you can report the IBCLC to IBLCE at www.iblce.org. This cannot be done anonymously; IBLCE requires that the person bringing the complaint identify themselves.

Answer: Acquainting your manager with ILCA and IBLCE through their brochures would help you to underscore the importance of the center employing an IBCLC. Most certifying organizations for birth centers and hospitals recognize the IBCLC as the legal standard of practice for lactation consultants. Since she has expressed an interest in becoming certified, you can suggest that the first step toward certification is to take a comprehensive lactation management course. You can refer her to ILCA at www.ilca.org for a list of course providers.

It seems that the opportunity exists to move to updated practices. It may be effective to take each instance of poor information or advice and use it as an opportunity to share resources for what you know to be the better practice. There are many resources for policy and protocol development for breastfeeding practices and the use of medical devices. Please see "Model Hospital Policies" at Wellstart International at www.Wellstart.org and the Academy of Breastfeeding Medicine at www.bfmed.org.

Answer: Each facility defines the role of students and preceptors within that facility. The student works with patients/clients under the supervision of a preceptor as part of the process of mastering the skills necessary for the profession. Typically this is a graduated process that defines the levels of responsibility as the skills are acquired and mastered, similar to schools of nursing. Each facility will typically define the scope of privileges granted to certified health professionals. An IBCLC is employed by the facility and therefore does not need to apply for practice privileges.

Part of the concern is the use of initials that imply a professional credential and level of competency. It is the position of ILCA that the professional credential for lactation consultants is the IBCLC from the International Board of Lactation Consultant Examiners (IBLCE) and not the CLC. IBLCE requires on-going re-certification and maintains a mechanism for disciplining malpractice and ethics violations. Using nomenclature such as Certified Lactation Counselor can be confusing and potentially misleading to clients. "Certification" that is granted to indicate course completion does not provide for re-certification to assure up-to-date knowledge, nor does it maintain any mechanism for disciplining malpractice. ILCA discourages the use of any title other than IBCLC.

You also asked about scope of practice of the IBCLC and whether the IBCLC needs to be a licensed health professional to see patients. The scope of practice of the IBCLC is medically oriented with core competencies and assessment skills as described in the Clinical Competencies for IBCLC Practice available free of charge from www.iblce.org. Other health professions that teach and utilize assessment skills include occupational therapists, dieticians, respiratory therapists, and speech pathologists. The lactation consultancy profession continues to define itself and in that process has followed the model of the registered nurse and these complementary professions in developing detailed assessment and skills checklists. IBLCE does not require the candidate to be an RN to be eligible to become a lactation consultant.

Answer: The U.S. Health Insurance Portability and Accountability Act of 1996 (HIPAA) was signed into law on August 21, 1996 to protect families with pre-existing medical conditions and help guarantee privacy and confidentiality of patient medical records. ILCA's Reimbursement Tool Kit for Lactation Consultants lists all the state HIPAA contacts. It can be obtained in the Bookstore at www.ilca.org.

Answer: There are several textbooks that address setting up and charging for a clinical practice: Breastfeeding and Human Lactation, Jan Riordan, Jones and Bartlett, 2004 edition; Counseling the Nursing Mother, Judith Lauwers and Anna Swisher, Jones and Bartlett, 2005 edition; The Lactation Consultant in Private Practice: The ABC's of Getting Started, Linda J. Smith, Jones and Bartlett, 2002. In addition, you can check ILCA's Worldwide Calendar for workshops on setting up a private practice.

Answer: In Canada, Mexico and the U.S., you can contact the Human Milk Banking Association of North America at www.hmbana.org to purchase a copy of their guidelines for establishing a donor human milk bank.

Answer: Most lactation centers charge a fee similar to patient visits in other areas of health care, with the patient paying at the time of service. Insurers in some states in the U.S. give billing privileges to facilities that employ an IBCLC or to individual IBCLCs. Some insurers pay for visits under the standardized lactation billing code, S9443 (lactation classes, non-physician provider, per session). Many add the code to their covered services when billed repeatedly. Lactation services can be bundled into a diagnosis-related group (DRG) for first-year pediatric care or OB/childbirth services and billed to the provider, who receives the per capita base rate. The patient's co-pay is usually a percentage of the full fee or a percentage of what the real cost of the service is minus what the insurer will pay. The additional fee is billed to the insurer or provider.

Many lactation centers seek grants from community service organizations or hospital foundations to subsidize the cost of doing business. Medically underserved populations in the U.S. may be eligible for state and federal money through a number of programs offered by the Department of Health and Human Services (DHHS) such as community health centers or Medicaid funding. You may want to attend a medical billing class at a local community college. Also, check with each of your state's insurers to learn what they pay for and how they want their forms coded and submitted. Make the case for the cost savings associated with use of breastfeeding and breastmilk on long-term health care and associated costs. There are several well referenced web sites that address the "cost of not breastfeeding."

Most lactation centers are attached to a hospital and on-going care after hospital discharge can be sought at the hospital where a DRG can be used for the hospital to receive payment. This hospital-based assistance may only be available for a set time post-birth (e.g. ten days). After that, the family would need to access a private lactation consultant and pay the fees.

If the IBCLC has a health professional background and the family has private health insurance, then the family can claim for the visit to the IBCLC for that background specialty, e.g., speech pathology, physiotherapy, home nursing care, etc. If the family does not have private health insurance, then they have to pay the full fee to the private IBCLC. In the past twelve months, there has been a move in Australia for IBCLC's to work in general practice and pediatric physician practices. The doctor sees the patient for a short consult; then the IBCLC takes over, and the billing is handled as a doctor visit. For more information, see ILCA's Reimbursement Tool Kit for Lactation Consultants in the Bookstore section of the www.ilca.org website.

Answer: The typical malpractice insurance requirement for individuals in a U.S. or Canadian hospital or outpatient facility is $1 million and an additional $3 million of personal malpractice liability insurance. The best place to check on malpractice coverage is with the insurance companies in the category of "personal liability insurance." You may want to use an internet search engine and search for "Professional Malpractice Insurance" to find these companies. Most hospitals and/or facilities that accommodate students will require the student to obtain individual malpractice insurance. The IBCLC may be under the category of allied health professional.

Level of care for patients and level of acuity of the patients are important factors in determining staffing ratios. Will every mother and baby be seen or only those for whom a consultation is requested? Are the mothers/babies referred there for high-risk situations or is it a community hospital? When will lactation services be available - evenings, nights, weekends, holidays? What other units in the hospital will be able to utilize the services - intensive care units, pediatrics, emergency department, clinics? What percentage of mothers need intervention in hospital and post discharge? Answers to these questions will help determine the necessary staffing ratio.

Rebecca Mannel and Robert S. Mannel have published the most current recommendations for determining staffing ratios for lactation services. The reference for this is the Journal of Human Lactation, 11 2006; vol. 22: pp. 409 - 417. The third edition of Breastfeeding and Human Lactation suggests a minimal staffing ratio of one IBCLC per 1000 births, citing three bedside visits per day per couplet (Riordan J, Breastfeeding and Human Lactation, 3rd edition, Jones and Bartlett Publishers; 2004, pp 41). Additional helpful information can be viewed in "Randomized Trial Evaluating a Unique Lactation Consultant Intervention" by Donna J. Chapman, Journal of Human Lactation, 8 2006; vol. 22: pp. 362 - 363.
 

Answer: Please refer to ILCA's Reimbursement Tool Kit for Lactation Consultants in the Bookstore section of the www.ilca..org website.

Answer: Reimbursement depends on coverage provided by your state's insurers and whether the lactation consultant is a nurse, an advanced practice nurse or a non-nurse. Check ILCA's Reimbursement Tool Kit for Lactation Consultants for answers to billing questions. Your billing service may want to contact all of the insurers that your patients use and determine what codes they require for the service. Billing for lactation services should always be done as this establishes the need for the IBCLC and documents outcomes of the services.

Answer: An IBCLC employed by a hospital is usually paid on a similar pay scale as a clinical nurse specialist.

Answer: Availability of jobs for lactation consultants depends largely on where you live. You can contact local hospitals and physician offices to find out if they have lactation consultants and if so, how many. You can also visit the ILCA website at www.ilca.org to find lactation consultants in your area and talk with them. ILCA members also have access to job listings on the Members Only portion of the ILCA website.

Answer: ILCA defers to individual pump companies regarding recommendations about the use of their pumps. As you indicated, there is often confusion over single person pumps and rental pumps. Rental pumps can be used with multiple users because the equipment that touches the individual client is purchased by the client and is used only by that individual. While a pump may be designed to be a single user pump, the FDA only regulates sales over state borders and has no jurisdiction over handing down pumps to friends. The FDA currently has approved only two vapor barrier systems, so the mother needs to contact the pump manufacturer to see if the pump she is considering is approved for use by more than one person. She can call the toll-free numbers on the pump literature.

Answer: Resources for current breastfeeding rates include: Breastfeeding in the United Kingdom at www.babyfriendly.org.uk; Global Data Bank on Breastfeeding at www.who.int/nut/db_bfd; and the U.S. government at www.4woman.gov.

Answer: Contact the African-American Breastfeeding Alliance at www.aabaonline.com. The description on their website reads: "African-American Breastfeeding Alliance - AABA is the first organization whose sole purpose is to promote breastfeeding to African-American mothers, fathers and families. AABA's goals are to: improve the overall health status of African-American babies; increase access to breastfeeding information for African-American parents; and create a breastfeeding-friendly culture within the African-American community. If you would like more information on AABA, call toll-free at 1-877-532-8535."

Answer: Contact the Human Milk Bank of North America at www.hmbana.org.

Answer: The following resources are available:

• Baby Friendly International: www.unicef.org
• Baby Friendly USA: www.babyfriendlyusa.org
• See the Conference page on this web site for information on ordering tapes from past ILCA conferences. There have been several speakers on the subject of becoming Baby Friendly.
• Publications that may be of help to you:
  • Philipp BL, Merewood A, Miller LW, et al. Baby-Friendly Hospital Initiative improves breastfeeding initiation rates in a US hospital setting. Pediatrics 2001; 108:677-681.
  • Merewood A, Philipp BL. Implementing change: Becoming Baby-Friendly in an inner city hospital. Birth 2001; 28:36-40.
  • Merewood A, Philipp BL. Becoming Baby-Friendly: Overcoming the issue of accepting free formula. J Hum Lact 2000; 16:272-282.

Answer: There are several references for "Best Practice" standards. ILCA's 2005 edition of Clinical Guidelines for the Establishment of Exclusive Breastfeeding is very well referenced and is available at www.ilca.org. Also see "Model Hospital Policies" at Wellstart International at www.Wellstart.org and the Academy of Breastfeeding Medicine Protocols at www.bfmed.org. In addition, the American Academy of Pediatrics Breastfeeding Policy statement in February 2005 addresses each of your issues and is also well referenced.

Answer: Facilities create their individual job descriptions. Several sample job descriptions are posted on the ILCA website. A checklist for “Seeking Employment as an IBCLC” is available on the same page. In addition, the checklist in Clinical Guidelines for IBCLC Practice, available from IBLCE at www.iblce.org, can be useful in developing a job description.