Putting scope under the scope

It is probably outside of my scope to help this dyad. Photo credit: vic_206 via Flickr Creative Commons
It is probably outside of my scope to help this dyad. Photo credit: vic_206 via Flickr Creative Commons

I admit it: I like rules. I like someone else setting down a framework and having to operate within it. Consider poetry: The restrictions given by adhering to certain genres or forms of verse allow you to push the limits of your creativity without being distracted by all of the possibilities.

This is one reason I like to be clear about my own scope of practice when it comes to being a CLC. I like the lines to be clear between what I am qualified to address and what circumstances require the assistance of a more qualified, more talented, or, I suppose, better insured individual.

What is a scope of practice? From Wikipedia:

Scope of Practice is a terminology used by national and state/provincial licensing boards for various professions that defines the procedures, actions, and processes that are permitted for the licensed individual. The scope of practice is limited to that which the law allows for specific education and experience, and specific demonstrated competency. Each jurisdiction has laws, licensing bodies, and regulations that describe requirements for education and training, and define scope of practice.

Here’s one caveat about this definition: Many people providing lactation or birth support have no laws to which they need to answer, and their scopes of practice are defined by whatever governing bodies they choose with which to align. Further, individuals have to be somewhat self-regulating; unless their missteps are reported to whatever organizations have awarded their credentials, individuals are more or less free to operate as they please.

As you may imagine, this can have serious consequences. I’ve mentioned before that, although the weeklong course that CLCs must take to be eligible to take the exam for certification is full of a whole lot of valuable information, it takes a whole lot more studying and offering hands-on support to even begin to approach being able to provide well-rounded help to breastfeeding moms and babies. Simply put, having “CLC” behind your name doesn’t guarantee that you can offer good support (the same is true for any professional, IBCLCs included), and since it’s easy to become overenthusiastic about supporting breastfeeding and overconfident in your abilities, this could lead to hurting, rather than helping.

If you want to make things even more complicated, if you consider the scopes of practice of a CLC versus an IBCLC, you’ll notice that they are not all that different. Neither of them gets down into the nitty-gritty of who can do what, although you will definitely find opinions if you look elsewhere.

I could put the scope of practice for a CLC in one word: normal. CLCs are qualified to assess whether or not a breastfeeding pair is operating within the realm of normal and are qualified to support families by offering information and support about the normal course of breastfeeding.

It gets trickier. Sometimes a situation can have components are within the realm of normal, but the circumstances around those components are outside that realm. For example: A mom might have sore nipples and complains that her baby wants to eat constantly. Maybe the baby had a few bad latches and it’s led to prolonged soreness that will ease up with a little care and guidance on better positioning and encouraging a deeper latch. Maybe mom doesn’t understand that newborn babies do pretty much eat constantly (or seem to), and you can talk to her about expectations. Talking about what to expect and encouraging good positioning and latch are absolutely within the scope of a CLC.

On the other hand, maybe the baby has a tongue or lip tie, making the latch shallow and negatively impacting milk transfer. A CLC isn’t qualified to diagnose this (although mentioning that it’s a possibility and parents should follow up with an expert is appropriate), and definitely isn’t qualified to treat it. A CLC should be able to see and anticipate problems and help fix them, and should also have some idea of the possible causes of the problem. At least, CLCs should understand enough to know when it’s time to call some reinforcements.

One thing I keep in mind when deciding whether I can help a mom, or how I can help a mom, is how critical the milk supply is and the level of confidence I have in whether baby is getting enough to eat. Situations like this might include weaning off of a large amount of supplementation, a mom transitioning from a rigorous pumping regimen to one where her baby is feeding at the breast, and dealing with actual (i.e., not perceived) low milk supply. I may still have a role in these circumstances, but it is liimited. I feel comfortable helping a mom achieve a good latch at home, even if she is experiencing other underlying problems, if it is clear to me that she understands what I am allowed to help with and what she will need to talk to an IBCLC or doctor about. Many moms are already working with IBCLCs when I’ve met them, but those IBCLCs do not do home visits; I can stop in and help families in their own environments as a complement to, not a replacement for, help from a lactation consultant.

CLCs do not diagnose and do not prescribe (neither can an IBCLC who is not also a medical professional with this ability). If a parent comes to us with questions about things that are outside of the normal scope of breastfeeding (such as using galactagogues), we can provide information and further resources. We might point out the possibility of a tongue tie, but refer to another professional for an actual diagnosis and treatment. In my opinion, any sort of intervention beyond the basics of positioning, good latch, helping parents understand newborn behavior and how to assess whether a baby is getting enough milk, and providing information and emotional support would be out of scope for a CLC. 

Considering one’s personal limits/scope is a responsible thing to do. You may know a lot about breastfeeding (or birth or newborns); maybe you even know more than some IBCLCs who are stuck in their ruts and not keeping up with current best practices. But you’re still a CLC, and that means there are limits to what you can do; at least, there are limits if you want to maintain your credibility! One of the best things a CLC (or any care provider) can do is establish relationships with other professionals who can help when you need it and provide a certain degree of continuity of care. Know who to refer to, and don’t be afraid to refer a client elsewhere. Failing to do so puts your profession at risk, reflects negatively upon your fellow care providers, and could potentially hurt families, too.

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