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Denise Punger MD FAAFP IBCLC
Letter Addressing Pediatrician Concerns
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Dr. Robbins,                                                       Oct. 25, 2001

As a member of Martin Memorial's Baby Friendly Committee, it was brought to my attention that the pediatricians had brought up the concern about MM
having formula available as a courtesy for indigent mothers. It is not a
total surprise to me that they have taken this stance.

Last November when I came to you to tell you what "IBCLC" is and talk to you about "Baby Friendly," we briefly talked about the steps and what an
advantage this would be for Martin Memorial (MM). Specifically, the advantages for MM are:

1) The (Baby Friendly Hospital Initiative) BFHI is a voluntary quality
improvement process.  This initiative puts breastfeeding into quality
improvement context.

2) The BFHI supports orientation to community benefits.  The focus of the
BFHI extends outward from the hospital to integrate preconceptual,
prenatal, intrapartum and postpartum education and care with community
based support.

3) The BFHI reflects other women's health issues by providing proactive
integrated care for breastfeeding women. As more facilities recognize women
as the gateway to health care decisions and choices for the whole family,
interest has increased in women's health oriented programs.  Proactively
meeting women's needs during the vulnerable days surrounding childbirth can
form a lasting positive impression of the health care system.

4) The BFHI enhances marketing programs.  Receipt of this international
award is an achievement to crow about!  It indicates that the hospital has
voluntarily sought to provide cutting edge services for families.

(FYI-MM could be the second baby friendly hospital in Florida. There are
about 20+ in the USA) I know that several lactation [conferences] and other meetings have been held at the first baby friendly hospital in Cape Canaveral just because they got this award.)

Anyway, you agreed that this was prestigious and worthy, and encouraged me
to present this to Kathy Rowell [Director of Maternal/ Child Services] because this was her training/department and not your area of expertise. When I did this, I learned that Kathy and her staff were quite knowledgeable and has made quite a bit of progress in this area.

Other physician-lactation consultant that I have met at [national] conferences say it is very typical of pediatricians to fight getting formula off the formulary.

I have learned from my conversations with them that once the formula detail
men learn of what the hospital is trying to do, they go to the physician
offices complaining and putting pressure on the doctors to complain to

I can say for a fact that antibiotic reps have offered me promotional to
bring up specific antibiotic in a physician's meeting and try to persuade
YOU to be more accepting.

So I want to encourage you that if a pediatrician has a concern about what
baby friendly is, why don't you encourage them to approach one of us on the
committee. Please don't let yourself get pulled into the middle of
aggressive marketing campaign by formula reps. And please don't let it make
you loose focus on all the wonderful steps Kathy Rowell and staff have
already done to try to achieve this.

I also heard about the pediatricians  concern that indigent mothers may have
to pay for the formula if we don't accept samples.

First, I do support a mother who wants to bottle feed, if it is a
well-informed decision. Unfortunately I hear way to many mothers say they
didn't breastfeed because the had XXX disease, were on XXX medicine or
numerous other reasons AND it is their own doctor told them they could not
nurse.I have never understood why the doctors won't refer to an IBCLC  if
they have questions. There are 5 in the area. There is so much new (last 5
years or so) research and new understanding of breastfeeding in the past few
years encouraging these women to overcome what was once thought were
barriers to breastfeeding. The baby friendly initiative strives to educate
mothers, hospital staff, and physicians about this new information. I don't
understand why the peds would oppose.

Second, Women's Infants and Children has a program so that all indigent and
lower middle class mothers can receive plenty of infant formula for a year
with out charge. Again, I am confused why  the peds don't know this??
Breastfeeding mother's can also receive milk, eggs, cheese and other staples
through this program.

Third, you and I know that when there is free samples of anything around it
often does not go to the indigent first. One great example is when my first
son was born, his MM pediatrician said, "When you decide you want to stop
breastfeeding, I have all the formula you will need." I was not told that
breastfeeding is best, I was not even encouraged to continue by the
pediatrician. It felt undermined. If I was told this and found this to be
discouraging, I feel so much for the mothers who don't have as much
confidence and information as I do to keep up with what is best for the
baby. Also, I don't understand why the peds don't know how much
bottles/gadgets and formula cost($1200.00+ per year) and what the cost of
increased of health care (Kaiser estimated it to be $1400.00 per year per
baby) is, and missed time from work from illness is when a baby is not
receiving its mothers milk. Why don't they explain this to their patients?
Do they forget all this when they are being detailed.

If "no availability of formula" for indigent mothers continues to be a
concern to the pediatricians, I would encourage them to come to our meetings
and express their concerns. We can all discuss the issues and move forward
to this notable achievement. I anticipate that there will actually be more
opposition from the pediatricians as our baby friendly committee moves ahead
(the physician-lactation consultants have warned me of this, but I don't
understand why.) As a physician who can take care of both mother and
baby, and specializes in lactation I am committed to helping MM attain this
goal. I am approachable and would be glad to share with you or the inquiring
physicians any research or publications that would be helpful.

You may also share/forward my comments to any of the pediatricians or MM
staff that you feel would benefit from having this information.

Thank you for considering my letter,


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Denise Punger MD FAAFP IBCLC
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Ft. Pierce, Florida, 34981
Copyright 2005