My comments: IBLCE’s proposed revisions to IBCLC Scope of Practice and Clinical Competencies

IBLCE sought public comment (closing 28 Jan 2018) on its proposed revisions to the Scope of Practice (SOP) for IBCLCs, and the companion practice-guiding document the Clinical Competencies (CC) for IBCLCs. I combed through them both line-by-line, and for the nit-picking curious, you can see that analysis below.  The 3500-character limit on comments required tweet-like brevity, but I managed to summarize the elements I have listed out, below.

Overall, this is good stuff, with no surprises, but needing some good copy-editing.  IBLCE missed an opportunity, in my parsed way of thinking, to tighten up some language that gives me legal pause.  I have urged them to make those revisions. But they did NOT suggest substantive changes to the SOP or CC, and they added a few tidbits that are warranted.

Some background:
(1) IBLCE periodically reviews and revises ALL of its documents, and likes to do so about every five years.  It just revised its by-laws.  The current SOP and CC are from 2012, and thus overdue.

(2) IBLCE is NOT, right now, revising its important mandatory ethical document, the Code of Professional Conduct (CPC) for IBCLCs. That has not been entirely overhauled since 2011 (6.3 was added in 2015; whoo hoo!) so revisions will be coming very soon, you can be sure.

(3) The SOP and CC are being revised based on the results of the 2015 practice analysis survey, in which already-certified-practicing IBCLCs were asked what they need to know (knowledge) and what skills they use (competencies) when providing lactation care.  This is an important concept: folks on the front lines, helping families, are defining what folks on the front lines have to know to help families. A tidy circle.

In a nutshell:

• the CPC is about HOW an IBCLC may ethically and legally practice. Remember: this one is not up for revision in Jan 2018.
• the SOP describes WHAT procedures/actions the IBCLC certification permits the practitioner to engage in. I liken it to a fenced-in yard.  Practice (play?) with impunity inside your own yard, but do NOT venture beyond the fence.
• the CC defines WHAT ELSE the IBCLC knows how to do, from soup-to-nuts. It is literally a menu of all the skills and abilities one is presumed to have acquired and mastered if practicing as an IBCLC.

My comments, Scope of Practice revision:

1. Please consider numbering or lettering the different duties and descriptions within the SOP, to allow for clearer citation and reference.
2. Use “parent” wherever “mother” or “client” appears, for consistency and clarity. The status as a client or patient becomes irrelevant (as not all IBCLC professional contacts involve such a relationship; think educators); the role of the parent includes those who self-identify as mothers.
3. At para 3, point 3 the phrasing remains unchanged from the 2012 version, but is stilted and confusing. I suggest instead “working within the legal framework of the IBCLC’s [certificant’s] geopolitical setting.”
4. At para 4, point 1 add “and human milk use” to underscore and make inclusive the public health imperative that breastfeeding and human lactation represent. Hence: “acting as an advocate for breastfeeding and human milk use as the child-feeding norm.”
5. At para 4, point 2 change “women” to “parents.”
6. At para 4, point 3 change “women” to “parents.”
7. At para 4, point 4 add “and human milk use” to underscore and make inclusive the public health imperative that breastfeeding and human lactation represent. Hence: “facilitating the development of policies which protect, promote and support breastfeeding and human milk use.”
8. At para 5, change “clients” to “parents.”
9. At para 5, point 1 … an excellent addition … maximum inclusivity is obtained by changing “maternal” to “parental” and adding “and human lactation.” Hence: “acknowledging parental and child health and mental status in the context of breastfeeding and human lactation.”
10. At para 5, point 2 swap “maternal” for “parental.”
11. At para 5, point 3 swap “client” for “parent.”
12. At para 5, point 4, the language (“street drugs”) is dated, and judgmental. “Human lactation” (your original wording in this point) is a better umbrella term.  We should center health *and* safety as the goals here. Hence, I suggest: “providing evidence-based information regarding use, during lactation, of over-the-counter medications, prescription pharmaceuticals, controlled substances, recreational stimulants, herbs, and supplements, and their potential impact on milk production and the health and safety of the child.”
13. At para 5, point 5, we should center health and safety as the goals here, not just “effect.” Hence, I suggest: “providing evidence-based information regarding complementary and alternative therapies during lactation, and their potential impact on milk production and the health and safety of the child.”
14. At para 5, point 7 syntax is off, inclusiveness can be broadened. Hence, I suggest: “providing support and encouragement to allow [empower] families to meet their infant feeding goals.”
15. At para 5, point 8 the change in original language from “health care providers” to “health team members” is more limiting, and sticks out for that reason. Surely an IBCLC should use effective counselling skills whenever they communicate with any healthcare provider. At para 5, point 10, “principles of adult education” is a phrase that is means nothing to most people. I suggest you scrap 10, and combine the two points into a new 8. Hence, I suggest: “using effective counselling and education skills when interacting with parents, families, health care providers, and members of the community.”
16. At para 5, point 9 change “clients” to “parents”
17. At para 6, change “client and infant” to “parent and child” for consistent language throughout the SOP. Para 5 has just used “child” a bunch of times. The use of “infant” in the next para draws a distinction that I suspect is unintended.
18. At para 6, point 1 I suggest you break out, and have stand alone, the duty to support the parent and child with truthful and full recording [charting] of all relevant information. That is a far greater and universal obligation than local record retention regulations. Hence, I suggest: “* recording all relevant information, truthfully and fully, concerning care provided
    * retaining records for the time specified by the local jurisdiction
    * reporting, when necessary, truthfully and fully to the parent’s primary healthcare provider, the health care system, and/or appropriate social services”

My comments, Clinical Competencies revision:

1. Please consider removing the use of the legally-charged term “duty” in this listing of clinical competencies. Describe them more accurately as something the IBCLC is able and competent to do, or demonstrate. Hence, at 1.: “The IBCLC is competent to uphold the standards of the profession and will:” and at 2. “The IBCLC is competent to protect, promote and support breastfeeding and human lactation and will:”
2. Throughout the CC, use “parent” wherever “mother” or “client” appears, for consistency and clarity. The status as a client or patient becomes irrelevant (as not all IBCLC professional contacts involve such a relationship; think educators); the role of the parent includes those who self-identify as mothers.
3. At 2. point 2, remove “women”
4. At 2. point 3, use (for consistency throughout the CC, and echoing the SOP) “breastfeeding and human milk use”. Hence: “participate in the development of policies at local, regional, national and global levels which protect, promote, and supporting breastfeeding and human milk use in all situations, including emergencies.”
5. At 2. point 4 add “human milk use” and tighten it up. Hence: “advocate for breastfeeding and human milk use in all settings, and as the child-feeding norm.”
6. At 2. point 5 add “human milk use and tighten it up. Hence: “Support practices which promote, and discourage practices that interfere with, breastfeeding and human milk use by:”
7. At 2. point 5 subpoint 2, remove limiting reference to breastfeeding. Hence: “carefully choosing a method of feeding when supplementation is necessary to meet the family’s infant feeding goals.”
8. At 3. point 1 add “and human lactation.”
9. At 3. point 4 add “age” and “socioeconomic status,” to mirror language of 6.3 of the CPC.
10. At 3. point 9 use more inclusive language, hence: “assess the impact of physical, mental, and psychological states of the parent who is lactating.”
11. At 3. point 17 use more inclusive language, and tighten it up. Hence: “assist the parent and child to find comfortable positions for breastfeeding and human milk use.” (Think of the contortions those using tube feeders at breast/chest must endure!)
12. At 3. point 19, change “complimentary” to “complementary” (though my slice of pizza did tell me last night it liked my teeth).
13. At 3. point 20 reword to “provide information regarding weaning and breast care at any stage of lactation.”
14. At 3. point 32 expand to “provide education on the safe handling, storage, and use of human milk.”
15. The “Uses of Techniques and Devices” is duplicative and cumbersome. I think it can be tightened and clarified as follows:
    “* evaluate, critique, and demonstrate the use of techniques, devices, and equipment used in human lactation.
    * provide evidence-based information to parents regarding their use of techniques, devices, and equipment, and how it may impact breastfeeding and human milk use.
    * Differentiate marketing claims designed to sell products from evidence-based indications for clinical use.”
16. At 3. point 50, remove reference to the unknowable “adult education principles” and use instead “use effective counselling and education skills when interacting with parents, families, and health care providers.”
17. At 3. point 52 add “and human milk use” and reword, hence: “provide information on community-based resources for help with breastfeeding and human milk use.”
18. At 3. point 54, remove dated reference to “street drugs,” and reword to say: “provide evidence-based information regarding use, during lactation, of over-the-counter medications, prescription pharmaceuticals, controlled substances, recreational stimulants, herbs, and supplements, and their potential impact on milk production and the health and safety of the child.”
19. At 3. point 55, we should center health and safety as the goals, not just “effect.” Hence, I suggest: “provide evidence-based information regarding complementary and alternative therapies during lactation, and their potential impact on milk production and the health and safety of the child.”
20. At 3. point 57, broaden to discuss infant feeding goals … and include more than feeding multiples. Consider: “provide information, support, and encouragement to enable parents to meet their infant feeding goals given all circumstance involving the family and child(ren).”
21. Remove entirely the Section about “sites for acquisition of skills.” That goes more to what is needed to meet test requirements than it goes to defining what a certificant is competent to do.