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What’s Not “Fair Game” for the IBLCE Exam?

In a previous post, I described the sorts of questions that would be “fair game” for the IBLCE Exam. Remember – I’ve never been on the exam-writing committee. But I do have experience to gauge what is considered fair game, and what would not. I’ve talked about the former; now, it’s time to tackle the latter. What sort of questions would not be fair game?

1. National directives, recommendations or standards

Do not expect to get any questions that relate to the statements, standards or directives given by the American Academy of Pediatrics, the Centers for Disease Control and Prevention, The Joint Commission, or any other organization that has a national – rather than an international – scope. It’s just not fair game.

Certainly, note that the Academy of Breastfeeding Medicine is an international organization, and their protocols are often published in multiple languages. Make sure you review their recommendations.

2. Judgement about controversial topics

If some experts say one thing and other experts say another, the topic is not fair game for the IBLCE Exam. IBLCE won’t put you in a position to choose between them.

That doesn’t mean you won’t see those topics on the exam, but in my experience they will be presented as a “done deal.” In other words, you might be told that the mother is using something or doing something. The question will be related to your responsibilities to help her.

3. Medication questions that require a risk-benefit decision

I have never seen an IBLCE Exam question about whether a particular medication is safe for the breastfeeding mother. IBLCE recognizes that its test-takers are not educated or authorized to prescribe. So it’s just not fair game for the IBLCE Exam.

IBLCE also recognizes that those with prescriptive privileges weigh the risk/benefit ratio for the situation, the details of the mother’s health history, the details of the infant’s health history, and even some social factors which could affect the risk/benefit decision.

Similarly to judgment on controversial topics, this will be handled more as a “done deal” approach where the mother is already taking a particular medication, and your role is to provide education and support as needed.

4. Body language is not fair game

Those of us who have worked in health care know from experience the importance of reading body language, but it’s not fair game for the IBLCE Exam. Body language is interpreted very differently from culture to culture, and the IBLCE Exam is international in scope.

5. Very recently published research

Writing, vetting, and publishing the exam takes some time, so you can be sure you won’t be responsible for journals or studies published in the months immediately before the exam. (A few years ago, when the exam was given only in July, IBLCE said it would include nothing published after January 1 of that year. I haven’t seen a similar statement since IBLCE went to its current twice-a-year exam schedule, but I assume the same idea would apply.)

6. Author and location details

Attendees at my course can feel a little unnerved when I, without my notes, name the lead author of whatever study I am talking about. They worry that they will be asked to do the same on the exam. No, no, no worries! The IBLCE will ask about research methods and interpretation. However, it won’t call on you to remember specific lead authors or where studies occur.

7. Fads are not fair game

IBLCE might ask you about healthcare trends – such as about disease prevalence – but not about fads. For example, “Tarzan pumping” – which I was surprised to be asked about during a recent exam prep course – is a fad and not a healthcare trend. (No, I feel pretty safe in saying, it will not be fair game, and not likely on the IBLCE Exam.

8. Brand names

Brands are completely off limits in the IBLCE Exam. There’s no need to become an expert in a certain kind of pump, or to know what some particular whatchamacallits are called! It’s not fair game.

But remember this applies to medications, too. On the exam, you will see only the generic name, NOT the trade name.

9. Complicated math problems

People worry about needing a calculator for complicated arithmetic maneuvers. I do think that a question related to how much weight a baby had lost or gained, or how much supplement he needs, would be fair game.

Seems like you could use the white board they give you for calculating if you needed to, but I can’t recall ever using it for that purpose. I’ve done simple calculations in my head, and I cringe at anything that involves complicated mathematical calculations.

10. Anything outside the IBCLC Scope of Practice

Here’s an example: Certainly, because anyone with a health care credential has the obligation to report suspected child abuse, that IS fair game for the exam. But the exam would not expect you to determine if your observation was an indicator of child abuse. Your role would be to observe and report, but not to pass judgement.

How prepared do you feel for the IBLCE Exam? Tell me in the comments below!

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  1. Kelly Mcgehee

    Marie, I have a question. several of us studying for the exam have come across this question and have seen multiple answers on different practice tests. Can you help:
    Which is the MOST important factor on medications in breastmilk
    a- protein binding
    b- lipid solubility
    c- maternal plasma level
    d- oral bioavailabilty
    we have a debate between d an c
    Can you help? Are we missing something on how it is written?

    • Marie

      Whoa, this is a tough one, isn’t it? Great question, thanks for passing it on.

      Let me answer by saying first that this is a terrific example of an IBLCE-type question. Why so? Because all of those factors are important in understanding drugs and breastfeeding. Perhaps your question was prompted from today’s blog post, but I would suggest that you read or re-read Tuesday’s blog post about the “qualifiers” on the exam. For this question, the qualifier is “most” which makes one option the answer, and the other options wrong.

      However, this question bothers me because there is something missing in the stem of the question. Which is the MOST important factor on (WHAT?) in mother’s milk? I can presume that it means the most important factor related the risk of the medication in the mother’s milk, but that is not specified. (By the way, this is why exam item-writing is an art!)

      When I explain pharmacokinetics, which is what you’re asking about, I describe it as a “journey.” The first “step” in the “journey” is absorption. So, not having a medical or a pharmacy degree or background here, I would say that the MOST important factor is oral bioavailability because if you can’t absorb it orally, the rest doesn’t matter. Here’s why. If you can’t take the first step of your “journey” from Chicago to Dallas, then it probably doesn’t matter if you encounter bad weather, road construction, or falling rock along the way. If you can’t absorb it, then the other factors seems less important, right?

      My go-to reference for questions like this is Breastfeeding: A guide for the medical profession (8th edition, 2016) authored by noted pediatrician, neonatologist and toxicologist Dr. Ruth A. Lawrence. (Who has been my long-time mentor and friend.) On page 373, she says, “The dose of a drug delivered via milk to an infant is significantly affected by oral bioavailability, which is the percentage of drug absorbed into the infant’s system via the gut.” She does not compare it to the other factors you mentioned (protein binding, lipid solubility, maternal plasma levels) but this sentence, together with another on page 365 where she says, “a most important factor…is the infant. Will the infant absorb the chemical from the intestinal tract?” seems to strongly imply that the “most” important factor would be oral bioavailability. And I harken back to my “journey” analogy to help make sense of why I would be inclined to say the answer is oral bioavailability.

      However, remember: I’m just a nurse! Some of these types of questions, while “fair game” have an answer that runs much deeper than most of us truly understand. I’ll cheerfully take correction from a physician or pharmacist or anyone who has had an in-depth course in pharmacokinetics.

      • kelly

        Thank you so much for the explanation. I am trying to make sure I understand the complete concept because you never know how its going to be written such as: what’s the most important factor in getting the medication to the milk or what’s the most important factor in getting the medication into the baby.
        1. When oral bio-availability is referred to, are they referring to baby in their gut or is it mother and baby. Mother must absorb, filter, metabolize etc in order for it to get to the serum?? So yes I totally agree if it cant be absorbed by the mother or its metabolized so quick its not getting to the serum then into the milk extrapolated by the infant.
        2. If oral bioavailability refers to the mother as well, and means literally ingesting of the drug in the mother, what about other modes of transmission- Intravenous, intrathecal etc? Does the same theory apply- Is oral bioavailability still the biggest determinant of the medication in the milk. I have read the preface section of Dr. Hales book and he mentions in 3 different places 3 different answers which is most important determinant of a medications entering the milk- oral bioavailability, maternal plasma and protein binding.
        3 Or am I totally off the wall since I have studying way too long!

        Your thoughts?

        • Marie

          Great, great Kelly, I’m glad I could help clear the fog, at least a little!

          I can’t quite answer your question in the way that you asked it about the “mother” and the “baby” absorption. Let me explain it this way instead. If a drug was not orally absorbed by the mother, then it would not be given to her orally. Because it would not help her, right? So let’s say she gets Vancomycin. Okay, great, but since it is not well absorbed orally, then it would not be ordered as an oral dose. (Unless she has a GI ailment of some kind, but I won’t go there today.) Okay, so let’s say she gets it IV. Then it would help her because it would be fully absorbed. But even if the drug goes into her milk, the baby is still being exposed to it orally because ORALLY is the only route of “administration” by which the baby gets it in the milk. So since the baby cannot absorb it orally, then it is not bioavailable to him.

          On how the IBLCE exam question is worded: WOW! This sounds like a blog for next week! Because, Kelly, it really DOES matter how the question is worded. How the question is worded makes the difference between one option being correct, and another answer being incorrect. Some people accuse the IBLCE of having “tricky” question, but as a highly experienced item-writer, I disagree. Precision in asking the question is absolutely critical in order to get precision in having one, and only one answer.

          But thank you, thank you, you have just given me fodder for a blog next week! I just wrote one this morning on a different topic, but I promise I’ll address this thing about how the question is worded shortly thereafter. (Great when I can get my readers to give me ideas!)

  2. Sumira Mubeen

    a- protein binding

    PB shows the extent to which a drug is bound to the plasma
    albumin and other proteins. Therefore, drugs that have high
    PB would generally reduce the infant’s exposure to the medication.

  3. Kelly

    Thank you so much for your response and yes I was thinking the exact same thing with the ” oral bioavailability.” As a previous nursing instructor, I used to tell my students in order to pass nclex you need to learn how to answer the question not necessarily know every single detail about everything. I used to tell those who were sitting for the ibclc exam, take the test based on book knowledge not on your daily practice. We don’t always work in utopia, nor are we internationally based in our small town in LA but you need to answer the question as if you did . Now if I could apply the same advise to myself it would be great!!!

    By the way, I love your review program. I sat in a week review with you 5 yrs ago and I bought the review for the upcoming exam. My favorite thing is your ability to convey the information in Easy to understand formats. The audios are great since learners absorb more via chunk learning. I’m now going back to relisten to ones that I feel aren’t sticking well in my head. Thanks again for being an awesome resource!

    • Marie

      Okay, definitely you just made my day, Kelly! I am truly passionate about getting people to pass the IBLCE exam on the first try, so I’m glad that you have learned from my programs, as well as enjoyed them! As for easy to understand formats? Yah, people think I’m kidding when I say that the reason I’m a good teacher is that I’m not a brilliant student–but it’s true! I have to chunk things down or up for myself, and then, I just teach it that way. I’m not a genius, but I do know my stuff!

      As for working in Utopia–oh, you are so right! I keep hoping to work there, but even when you own your own business, it isn’t Utopia! But we can always hope, huh?

      Thanks, truly you made my day with your positive comments.

      And you fed me ideas for next week’s blog. How good is that??? Have a great weekend!

  4. Kelly

    Awesome! I told my study group to please check out your recent blogs as well. They were very helpful. I have been a consultant for 20yrs and yes I’m studying as if I was taking it the first time. Currently, I am working as a nurse educator for a large Foley catheter company but I am determined to keep my lactation consultant status. Being an IBCLC is my passion. Guiding mothers to nourish their babies is a gift and I hope to be doing it for many more years even when my corporate position ends. One never knows if I need to go back to bedside I will be prepared!

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