Medical Release Form for Not Breastfeeding

Last week the blog was on research that emphasized no formula feedings.  Years ago John and I developed a release form for not choosing to breastfeed.  This form is based on a medical release that John had to sign before his eye surgery; it is not used for natural family planning classes.  It is, however, very popular at breastfeeding conferences.   This release form is below:

When Choosing Not to Breastfeed

NAME OF THE BABY:____________________

SITUATION:  I have chosen not to breastfeed my baby for personal and/or for medical reasons.  I understand that not-breastfeeding entails health risks to my baby and to myself.  While my formula-fed baby may be healthy, I understand that research shows that breastfed children are overall healthier as babies and also in their later years compared to their formula-fed peers.  While I may be healthy now and in later years, I understand that research shows that I may suffer some adverse consequences from not breastfeeding.

RECOMMENDATIONS:*  Mothers should do exclusive breastfeeding for six months and nurse for at least one year.  Anything less is second best.

ALTERNATIVE:  I may choose to use donated breastmilk.

I understand that medicine, breastfeeding, and formula-feeding are not exact sciences.  I understand, however, scientific research shows that not-breastfeeding exposes my baby to increased risks of the following diseases:
• leukemia                      • lymphoma
• type 1 diabetes            • obesity
• diarrhea                       • type 2 diabetes
• allergies                       • ear infections
• asthma                        • respiratory tract infections
• eczema                        • urinary tract infections
• bacterial meningitis       • multiple sclerosis
• botulism                      • inflammatory bowel disease
• gastroenteritis             • necrotizing enterocolitis
• Crohn’s disease           • ulcerative colitis
• autoimmune thyroid disease
• sudden infant death syndrome

I realize my child may have a poorer school performance with lower cognitive scores during grade school and high school.  Likewise there might be more doctors’ visits and hospital visits because I did not breastfeed.

By not breastfeeding I understand that I, as the biological mother, may have an increased risk for the following diseases:
• breast cancer               • ovarian cancer
• lupus                          • thyroid cancer
• anemia                        • endometrial cancer
• rheumatoid arthritis
• osteoporosis (increased chance of a hip fracture)

I hereby certify that I have read (or have had read to me) and understand the possible risks of not breastfeeding my baby, whether by choice or for medical reasons.  All of my questions regarding the risks have been answered to my satisfaction.
Mother’s Signature:_____________________________Date;____________________
Witness/Professional Signature:__________________________Date:______________

*The above recommendations and risks are found at the following websites:  American Academy of Pediatrics:, American Academy of Family Physicians:, and the U. S. Breastfeeding Committee:  See USBC’s “The Benefits of Breastfeeding” and “The Economics of Breastfeeding.”

© 2006 Sheila Kippley.

2 Responses to “Medical Release Form for Not Breastfeeding”

  1. anne cherney says:

    That is an absolute scream!!!! Great!

  2. Dr. Dominic Pedulla says:

    Sheila and John how great a thought! We might have added this?

    “I acknowledge that I have spiritually handicapped my soon-to-be-contemplatively-handicapped child and that later in life, not having been trained in those quiet hours at the school of the mother-child closeness, to handle quiet in a peaceful and non-restless way, to know how to rest without being bored, etc., he will have no end of struggles to begin and advance in that process of being schooled in listening to God, in practicing that interior silence so necessary to hear God”.