Category: Post Pregnancy

Saving Women’s Lives

by Jennifer Doyle

As we close out Women’s History Month, and I want to take this moment to discuss an issue that is not only dear to my heart but also takes the lives of more than 700 women each year—maternal mortality.

A maternal death is defined as the death of a woman during pregnancy or within one year of the end of pregnancy. The death is determined to be pregnancy-related if the cause of death is related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.

Of the 5,259 deaths within a year of pregnancy completion that occurred during 2011–2013 and were reported to the Centers for Disease Control and Prevention (CDC), 38.2% were found to be pregnancy-related. In the United States, more than half of all maternal deaths occur after birth—often after discharge from the hospital. This doesn’t have to happen. In fact, at least half of all pregnancy-related deaths are preventable when the warning signs of pregnancy or childbirth complications emerge and a mom can get the timely care she needs from her healthcare providers. The reality is that many women do not receive consistent messages or adequate guidance on identifying the warning signs of complications, or instructions about when, and where to obtain necessary medical attention.

AWHONN has created specific instructions for acting on these warning signs called “SAVE YOUR LIFE: Get Care for These POST-BIRTH Warning Signs.” Here are the specific signs you should watch for and act on during the first year after birth:

  • Pain in your chest
  • Obstructed breathing or shortness of breath
  • Seizures
  • Thoughts of hurting yourself or your baby
  • Bleeding that is soaking through one pad/hour, or blood clots the size of an egg or bigger
  • Incision that is not healing
  • Red or swollen leg that is painful or warm to touch
  • Temperature of 100.4 °F or higher
  • Headache that does not improve, even after taking medicine, or a bad headache with vision changes

For moms: If you are experiencing any of these post-birth warning signs, contact your health care provider or go to the nearest urgent care or hospital as soon as possible. For serious and potentially life threatening warning signs like pain in your chest, obstructed breathing, seizures, or if you have thoughts of hurting yourself or your baby, call 911. Let all responders know that you gave birth within the past year.

Recognizing and acting on these warning signs and complications that can lead to a mom’s death or injury is essential to reducing maternal deaths in the United States. Share this information with pregnant women you care for. AWHONN is committed to working together with nurses and moms to reduce maternal mortality rates. Let’s help women to be aware and to recognize the signs of post-birth complications in order to begin reversing this alarming trend.

Additional resources:

Jennifer Doyle is the 2018 AWHONN President and a women’s health nurse practitioner with nearly 25 years of experience in obstetrics. She is the APN of the Women’s Service Line at Summa Health in Akron, OH, as well as faculty and coordinator of the WHNP program at Kent State University in Kent, OH.

Disparities in Maternal Mortality

Black women are 243% more likely than white women to die from complications of pregnancy or childbirth, according to the latest data from the Centers for Disease Control and Prevention and Propublica, a collaborative of investigative journalists. One national study of 5 medical complications that commonly cause maternal death and injury determined black women were 2-3 times more likely to die than white women who had the same complications.

These truly alarming numbers are why during Black History Month and beyond the nurses of AWHONN want healthcare providers and moms alike to learn and share post-birth warning signs that have been shown to help new moms and their caregivers recognize potential problems and get the help they need—perhaps even saving their lives.

AWHONN has created specific instructions for acting on these warning signs called “SAVE YOUR LIFE: Get Care for these POST-BIRTH Warning Signs.” Here are the specific signs women should watch for and act on during the first year after birth:

  • Pain in your chest
  • Obstructed breathing or shortness of breath
  • Seizures
  • Thoughts of hurting yourself or your baby
  • Bleeding that is soaking through one pad/hour, or blood clots the size of an egg or bigger
  • Incision that is not healing
  • Red or swollen leg that is painful or warm to touch
  • Temperature of 100.4 °F or higher
  • Headache that does not improve, even after taking medicine, or bad headache with vision changes

If you are experiencing any of these post-birth warning signs, contact your healthcare provider or go to the nearest urgent care or hospital as soon as possible. For serious and potentially life-threatening warning signs like pain in your chest, obstructed breathing, or seizures, or if you have thoughts of hurting yourself or your baby, call 911. Let all responders know that you’ve just given birth within the past year.

Recognizing and acting on these warning signs and complications that can lead to a mom’s death or injury is essential to reducing maternal deaths in the United States. Currently, maternal mortality rates—the number of women dying during or within 1 year of childbirth—are increasing, climbing 27% to 24 maternal deaths per 100,000 births since 2000. In the United States, more than half of all maternal deaths occur after birth—often after discharge from the hospital. This doesn’t have to happen.

For black moms, it’s even bleaker. Black mothers in the United States die during or within 1 year of giving birth at 3-4 times the rate of white mothers. This difference in maternal deaths and injury among black women is a serious issue that needs our action. At least half of all pregnancy-related deaths are preventable when the warning signs of pregnancy or childbirth complications emerge and a mom can get the timely care she needs from her healthcare providers.

Share this information with other nurses and pregnant women you care for so that moms and nurses can work to reduce maternal mortality rates, especially the higher rates among black women. Together, we can help women recognize the signs of a post-birth problem to prevent unnecessary injury or death.

Mary Elizabeth Elkordy is the Communications and Public Relations Manager for the Association of Women’s Health, Obstetric & Neonatal Nurses (AWHONN).

Safe Sleep Advice from Real Moms

By Courtney Duggan

When I became pregnant with my first child, I did everything I could to prepare—from research on cribs, bottles, breastfeeding, you name it. Having suffered miscarriages in the past, I was very concerned and anxious about SIDS. I made sure that my daughter’s crib had nothing but the mattress and sheet. I even contemplated buying one of those boards that detects movement and alerts you when a baby stops moving.

Once my daughter was born, she slept in the bassinet in our bedroom. I was still recovering from my cesarean, so my husband was there to help put her in and take her out of her bassinet when it was time to nurse. I was very good about following the safe sleep guidelines, but we would sometimes take naps together while I nursed on my side. I knew in the back of my mind it wasn’t the best option, but we were both able to get rest.

Fast forward 2 years, and my son is born. Again, I was cautious as I prepared for a new baby: I purchased a firm mattress and was sure not to have any toys, bumpers, or blankets in his crib. I told myself I was going to be much better with following safe sleep guidelines than I was with my daughter.

He, too, was born via cesarean, and in the beginning I was very good about not allowing him in bed and always putting him back in his bassinet. When he was about 3 months old, it became harder and harder to follow the guidelines. My son wasn’t sleeping at night, he refused any kind of pacifier (I tried six different brands), and the only thing that soothed him was nursing.

Baby Maxwell in his sleepsuit

Around this time, I returned to my full-time job. I found it easier to nurse him while lying down and returning to sleep. He also seemed to sleep better when he was next to me. I knew it wasn’t right, but I just wanted him to sleep—and I wanted to sleep myself. I tried swaddling, sleep suits, white noise… everything. It’s not supposed to be this hard the second time around, I thought. I’d already been through this; they say the second kid is easier!

When he was about 8 months old, I woke up to a boom and a baby screaming: He had fallen out of the bed, and I felt like the world’s worst mother. Luckily he was ok, but it could have been worse. He could have really gotten injured, or worse, I could have lost him. I knew the rules, I knew that babies were supposed to sleep in their own space, but I ignored them because I wanted my baby to sleep during the night and I was exhausted.

After my son’s fall, I knew something had to change; my son could no longer sleep in my bed at night. I decided to move his crib from our room into another room, and I gave the pacifier another shot. While sleep training hasn’t been successful, he is now taking a pacifier. Instead of bringing him into my bed when he wakes up at night, I offer him his pacifier if it’s before 3 a.m. If he wakes up again, I stay in his room to nurse him and then place him back in his crib. In addition, I had to make the decision to go to sleep earlier to ensure that I got my rest, too.

This got me thinking: What are some ways to help moms follow safe sleep practices after the baby is home? I enlisted the help of nurse Sharon Hitchcock, DNP, RN-C and some fellow moms.

Sharon is an obstetrics nurse and teaches at the University of Arizona. She is quite passionate about the topic of SIDS and safe infant sleep as she now knows why most of these deaths occur and, more importantly, how to prevent them (at least most of them).

She routinely talks about the American Academy of Pediatrics (AAP) safe sleep recommendations to students as well as parents and nurses. She’s also gotten a recent taste of some of the struggles, as she’s the happy grandma of a 9-month-old!

Naomi is mom of 9-month-old Samuel and became a safe sleep advocate long before having her baby. Heidi is almost finished with nursing school and has two kids, 3-month-old Eli and 4-year-old Sophia. Melanie, a mom of three, teaches obstetrics at the University of Arizona and is a childbirth educator at the local hospitals.

I shared with them my struggles of following safe sleep practices with my son and asked several questions about how parents can better follow safe sleep guidelines. Here’s what they had to say:

  1. Night feedings can be exhausting, especially when breastfeeding. What are some best practices to help resist the urge to nurse while lying down?  

NAOMI: I resisted the urge to nurse while lying down simply because I didn’t want to bring the baby into bed with me. There were some times when I nursed while sitting up in bed, but I also nursed in a rocking chair in my son’s room, just next to his crib, so I could immediately put him back to bed when he finished eating. I’m a light sleeper and didn’t worry much about falling asleep while feeding him, but I’ve heard it’s a good idea to use a timer, like the one on your phone, if you’re worried about falling asleep.

HEIDI: I was aware of the risks of breastfeeding while lying down from my OB classes in nursing school and had heard the horror stories of parents falling asleep with their infants and accidently suffocating them during their sleep. This was enough to make me take precautions the majority of the time that I was breastfeeding at night. I would feed him in my bed, sitting up, with him in the cross cradle position. I would set alarms just in case I did fall asleep with him, as studies have shown that the longer you are asleep with your infant, the greater the risk of SIDS. If mothers are truly so exhausted that they feel like they need to lie down while nursing, they should remove all pillows and blankets from around the baby and set alarms that will wake them should they fall asleep

  1. What are some ways to keep baby warm at night without using blankets?

NAOMI: Our son was born at the end of November, just when it really started to cool down here in southern Arizona. We kept the room warm and comfortable, and he wore footed pajamas.

HEIDI: For both of my children, I used sleep sacks that are available to buy online or in any baby store. They have worked well for me both times. I made sure the house was kept warm enough that they would be comfortable throughout the night.

MELANIE: It is recommended to keep the bedroom at a temperature that is comfortable for a lightly clothed adult. Overheating a baby is very dangerous, as they cannot just push the covers off.

  1. The risk of SIDS goes down once a baby turns 6 months—is it okay to bed-share then?

HEIDI: No. The baby can still roll over and suffocate on the softer mattress, pillows, and thick blankets that we have. In addition to the suffocation risks, I believe that getting the baby into a routine of sleeping in their parents’ bed will be one that is hard to break. Neither of my children have been able to sleep in my bed with me, mostly due to my concern for their safety. I am a hard sleeper and would not wake up if I rolled onto them. I also always wanted them to be able to sleep in their own rooms, once old enough.

MELANIE: It is true that most SIDS deaths occur before 6 months, but the infant is still at risk for SIDS until 12 months of age, and adult beds are not designed for infants. Most babies are rolling over by 6 months, and adult beds are usually too soft and have too many blankets and pillows. The other risks include the parents rolling onto the infant or the infant falling out of the bed.

  1. My baby has reflux and spits up during the night. Can I place a wedge or pillow in his crib?

HEIDI: No. This is another thing that infants could suffocate on if they rolled over. My son spits up a lot, too, but thankfully I knew from my OB class that it was safer for him to be on his back when he sleeps than on his stomach or wedged if he spits up. A baby is less likely to choke when on their back if they spit up because their airway sits above their esophagus (the tube going to their stomach), making it easier for the fluid to stay away from the airway and easier to swallow.

MELANIE: The AAP recommends that infants are always placed on their backs and not on their sides. Infants are quite good at protecting their airways while on their backs (unless they have a swallowing impairment, which your doctor would tell you). The U.S. FDA has stated that infant sleep positioners are not recommended as there have been several cases of infant deaths from the use of side positioners after the baby rolled to the stomach position or when their face got wedged into the positioner. Keeping the infant upright on a parent’s shoulder for 20–30 minutes after a feeding can decrease reflux.

SHARON: Some parents may think it’s a good idea to elevate the head of the crib to help with the reflux. However, multiple studies have shown this does not help and actually puts the baby at risk for sliding down to the foot of the bed and getting into an unsafe sleeping position.

  1. If I nurse while lying down, should I remove everything from my bed in case we fall asleep?  

NAOMI: This is what the newest recommendations advise you to do. Make sure all the blankets, pillows, etc., are moved out of the way, so that in the event you fall asleep, the bed will be a little bit safer.

HEIDI: Absolutely. This is the safest practice if you must nurse while lying down. This is what I did. I also asked my husband to adjust his pillow, and if possible, stay awake with me to ensure that I didn’t fall asleep with the baby. We aren’t perfect, though, and there were a couple of times where we dozed off with him, but fortunately I had alarms set to wake me within 15 minutes of beginning nursing. Once I knew he was full and had a clean diaper on, I set him back down in his crib and went to sleep.

  1. Sometimes the baby falls asleep on my chest. It’s recommended that babies sleep on their backs, but since he’s on my chest is it okay?

HEIDI: I believe so, as long as you are rested enough that there is no risk of you falling asleep and you are able to monitor the baby while he is asleep on his tummy. I did this a lot with both of my children during the day and think it is the perfect opportunity for skin-to-skin time.

SHARON: Make sure you can see your baby’s face (to make sure it is not covered or does not become wedged into your breasts) and you are awake and attentive to him.

  1. The only way to get my baby to sleep is if I nurse him; when I go to transfer him into his own bed, he wakes up and cries. Is it okay to let him cry it out?

NAOMI: This is a hard topic. There are so many opinions out there, and it’s hard not to get discouraged by all the articles in my Facebook newsfeed that highlight how awful it is to let your baby “cry it out.” It became important for me to consider our circumstances and the fact that every baby is different. I didn’t use the formal “cry-it-out” method for sleep training, but there were, and still are, so many times when I have to let my son cry for a while before he’ll give in and go to sleep. He’s fed. His diaper is clean. He has burped. He’s still crying. He’s not comforted by me holding him close. I’m starting to go a little crazy, and my left ear is ringing from his screams. I know he’s exhausted. What he needs is sleep. It’s okay to place him in his crib and walk away. It’s OKAY to let him cry. I had to learn this early on. It’s made a huge difference.

MELANIE: Crying is a baby’s language and the only way they have to communicate. They cry because they are hungry, tired, uncomfortable, and sometimes just because they are fussy and need to get rid of excess energy. If they have burped and their diaper is clean, you can try to console them with rhythmic noise, music, or gently stroking their head. If the baby is tired, they will usually fall asleep quickly.

Safe sleep is harder than it appears, at least for some of the recommendations. This is an extraordinarily complex topic, and we know it’s hard. In order to keep your baby  as safe as possible, learn  the recommendations, start them at birth, do the best you can, and know that you are not alone in your struggle.

Do you have safe sleep tips/advice you want to share with parents? Share them at www.awhonn.org/SafeSleepTips

Resources

References

American Academy of Pediatrics. (2016). SIDS and other sleep-related infant deaths: Updated 2016 recommendations for a safe infant sleeping environment. Pediatrics, 138(5), 1–12. doi:10.1542/peds.2016-2938

Centers for Disease Control and Prevention. (2017). Sudden unexpected infant death and sudden infant death syndrome. Retrieved from https://www.cdc.gov/sids/data.htm

Gradisar, M., Jackson, K., Spurrier, N. J., Gibson, J., Whitman, J., Williams, A. S., . . . Kennaway, D. J. (2016). Behavioral interventions for infant sleep problems: A randomized controlled trial. Pediatrics, 137(6), 1–10. doi:10.1542/peds.2015-1486

Hitchcock, S. C. (2017). An update on safe infant sleep. Nursing for Women’s Health, 21(4), 307–311. doi:10.1016/j.nwh.2017.06.007

Moon, R. Y., & Task Force on Sudden Infant Death Syndrome (2016). SIDS and other sleep-related infant deaths: Evidence base for 2016 updated recommendations for a safe infant sleep environment. Pediatrics, 138(5), e1–e29. doi.org:10.1542/peds.2016-2940

Storrs, C. (2016). It’s OK to let your baby cry himself to sleep, study finds. Retrieved from http://www.cnn.com/2016/05/24/health/cry-it-out-sleep-training-ok/index.html

Courtney Duggan is a digital marketing manager in the Washington, D.C. area and is a mother of 2.

Child Passenger Safety “What Every New Parent Should Know”

By Kerry S Foligno, RN MSN CPSI

We have all been at the baby shower when the parents-to-be  open the biggest box in the room and the crowd cheers! “Ooooh I love the color”, “Check out the cup holders”—“It matches the stroller perfectly”. In my head I’m saying “I hope they keep the receipt!” The truth is not every car seat fits every car. And not all parents’ needs fit all car seat.

Here are the facts. Seventy-three percent of car seats are not used or installed correctly (Safe Kids Worldwide).  Unfortunately as our new parents are walking out the door of the hospital while embracing one of the most stressful times of their life they realize that car seat installation is not a joke. As nurses, educators and parents we agree that learning happens most effectively when done in a calm, comfortable environment. Our program appropriately titled CPS Safety at Memorial Hospital West started with staff members recognizing a lack of research-based information available for parents and families about child passenger safety. We were very aware, though, of the overwhelming amount of information on convenience features and style and color choices for car seats. To begin we enlisted the help and support of our administrative team. With their involvement we were able to get approval for our first nurse to attend a certification class to become a certified car seat technician. We were able to start community seat inspection stations as additional nurses in our family birthplace department became certified. Our technicians now include registered nurses, social workers, community liaisons and patient care assistants from multiple departments of the hospital.

I am fortunate to work for Memorial Healthcare System that recognizes the importance of education for our community. We incorporate child passenger safety education in many settings. Within my hospital, which is a 384 bed delivering hospital, we have safety classes for families in the community, daily education classes for our inpatients and a car seat inspection station that all incorporate the importance of child passenger safety.

About Child Passenger Safety Education

The child passenger safety education includes classroom information and hands on instruction on car seat installation, how to properly put a child into the car seat and review of other safety concerns. We provide parents and families with information on how to choose the right car seat for their child and the  location where the car seat should be installed within their vehicle. We use teaching equipment that simulates a seat in a car and demonstrate how to properly install a child car seat. We empower our families to educate themselves utilizing the instruction manuals from the car seats and the owner’s manuals from their cars.

The goal is to provide families with multiple opportunities to be educated on decisions about restraining their new baby or older sibling. If they have the opportunity to participate in any of these programs, they are better prepared for that day of discharge from the hospital and their first car ride home. We are also aware that the opportunity for education at the bedside makes for easier transition to correct installation at curbside by the parents.

Community Feedback

The feedback from our community is overwhelmingly one success story after another and a multitude of appreciative emotions. Parents-to-be, grandparents with visiting grandchildren, fellow staff and patients have all benefitted from our hospital-based community program. Grandparents have told us how “impressed” their own children were with the seat installation and correct education that they received. New parents have overwhelmingly expressed their gratitude with sighs of relief that their newborn is traveling home safely.

I am hoping this has inspired all of you to pursue child passenger safety education in your workplace and community. A great place to start is to make research-based information about car seat installation available to your colleagues and to parents and families.

To find out more information on how to become a certified technician, visit http://cert.safekids.org

Great resources include:

Kerry S Foligno MSN RN CLC
Kerry is a Registered Nurse with 30 years of experience including, Adult Surgical ICU/Trauma and Mother Baby. Currently she is at Memorial Hospital West Family Birthplace in Pembroke Pines, Florida working as a Perinatal Educator. Her passion is teaching. Her focus is moms to be, new moms and nursing students. She is a Certified Child Passenger Safety Instructor and coordinates the Car Seat program At Memorial West.

Human Milk is Magical- What Donor Mothers Should Know About Milk Banks

There is no doubt that human milk provides species specific nutrition for the optimal growth and development of all infants, including the vulnerable hospitalized preterm infant. 1,2 Since time began, mothers have supported mothers in providing this optimal source of nutrition but evidence is strong that human milk contains much more than nutrition for the infant’s well-being.3 Despite global efforts to provide infants worldwide with this basic human right resource, no country on earth meets the minimum support for breastfeeding.4  In 2004, Labbock et al., cited a key issue limiting the global acceptance of human milk- social and commercial pressures- that still holds true today and is relevant to current donor milk donation and utilization.5

When a mother is unable to provide enough milk for her own infant’s needs, then donor milk is the next best option. There are basically two business models for human donor milk bank operations; not-for-profit and for-profit. Both models provide safe, processed donor milk for infant consumption. One of the differences lies in the human species-specific properties retained post-processing procedures. The Human Milk Banking Association of North America (HMBANA) is a professional association that supports non profit milk banks by  providing its members with standardized guidelines to screen donors, and process and distribute human milk.6 The for-profit milk banks utilize different, but safe, milk processing procedures, yet the end milk product produced by each contains significantly different human bioactive milk immune and metabolic components. HMBANA milk banks utilize holder pasteurization (milk is heated to 62.5°C for 30 minutes then rapidly cooled to 4°C) whereas for-profit milk banks utilize high vat pasteurization (milk is heated to 63°C ≥ 30 minutes), and  sterilization (milk is heated to 121°C for 5 minutes at 15 pounds per square inch). This sterilization process renders significantly less human species concentrations of protein, fat, immune components, and oligosaccharides.7 Donor mothers will benefit from knowing  this information to make informed decisions about where to donate their milk.

Another social and commercial pressure is the monetary compensation for donating milk . Donor mothers should know the differences in processing fees between non-profit and for-profit milk banks. A mission of HMBANA milk banks is to contain processing costs so that donor milk can be equitably distributed. One mechanism to contain costs is to not offer monetary compensation for milk donations.  For-profit milk banks offer monetary compensation which is then passed on to the consumer resulting in higher prices for donor milk. Guiding principles to determine whether or not a donor of a biological product can be offered compensation is outlined in an international statement developed by the convention of the Council of Europe   ; only those products created using patents can be distributed for commercial profit.8 This guidance protects for-profit milk banking companies. Donor mothers have the right to know how their milk will be processed and sold.

Lastly, for-profit milk banking companies have abundant resources to promote their product using sophisticated, provocative ad campaigns. Donor mothers have the right to receive informed healthcare data regarding the value of donor milk that retains 50-90% of human milk properties post-processing-the milk provided by non-profit human milk banks- which benefits  optimal infant growth and development.

HMBANA mentors those who are developing milk banks in areas where improvement in breastfeeding support is needed. To learn more about how to become a HMBANA- developing milk bank  visit www.hmbana.org . The Mothers’ Milk Bank of Louisiana, a developing milk bank member of HMBANA, would like to express sincere gratitude for the guidance of our mentor bank, the Mothers’ Milk Bank at Austin under the leadership of Kim Updegrove, Executive Director, as well as HMBANA guidance documents. August is National Breastfeeding Month. Let’s join together to honor all donor mothers for their lifesaving donation of miracle milk and pledge to inform and enlighten them of the invaluable impact of their milk donation decisions.

References

1.            American Academy of Pediatrics Committee on Nutrition SoB, Committee on Fetus and Newborn. Donor Human Milk for the High-Risk Infant: Preparation, Safety, and Usage Options in the United States. Pediatrics. 2017;139(1):e20163440.

2.            Medicine AoB. ABM Position on Breastfeeding – Revised 2015. Breastfeeding Medicine. 2015;10(9):407-411.

3.            Agarwal S, Karmaus, W., Davis, S., & Gangur, V. Immune markers in breast milk and fetal and maternal body fluids: A systematic review of perinatal concentrations. Journal of Human Lactation. 2011;27(2):171-186.

4.            UNICEF. #breatfeeding- Breastfeeding A Smart Investment. 2017; https://www.unicef.org/breastfeeding/. Accessed August 5, 2017, 2017.

5.            Labbock ML, Clark, D. & Goldman, A. Breastfeeding: maintaning and irreplaceable immunological resource. Nature Reviews Immunology. 2004;4(7):565-572.

6.            Human Milk Banking Association of North America. Guidelines for the establishment and operation of a donor milk bank. Forth Worth, Texas: Human Milk Banking Association of North America; 2016.

7.            Meredith-Dennis L, Xu, G., Goonatilleke, E., Lebrilla, C., Underwood, M. . Composition and variation of macronutrients, immune proteins, and human milk oligosaccharides in human milk from nonprofit and commercial milk banks. Journal of Human Lactation. 2017.

8.            Council of Europe. Convention for the Protection of Human Rights and Dignity of the Human Being with Regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine. Treaty No.164. 1997; http://conventions.coe.int/Treaty/en/Treaties/html/164.htm. Accessed July 27th, 2017.

 

 

Shelley Thibeau, PhD, RNC, is the Director of the developing Mothers’ Milk Bank of Louisiana. As a NICU nurse for 38 years, her interest in breastmilk has expanded to exploring breastmilk immunology associated with preterm infant health.

The Power of Touch & Infant Massage

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Lori Boggan, RN, Certified Infant Massage Instructor

The power of human touch is unmatched and irreplaceable.  It is an innate need of every human being, especially the infant.  I recently sat down and picked the brain of an expert in the field of infant massage.  Peter Walker, a London based physical therapist, who has been working with babies, children, and their parents for over 40 years. He travels the world and has trained nearly twenty thousand or more midwives, nurses, and other health professionals through his Developmental Baby Massage and Movement program. In his words “touch is the newborn’s first language-it is her prime means of communication and plays an essential role in the forming of early parent-child relationships.”  The following are just a few of the many benefits of touch and massage to both the infant and parents.

Skin to Skin

Study after study has shown the unbelievable benefits of placing an infant skin to skin with its parent.  The power of touch is evident from the first moments after birth when the infant is placed skin to skin. Remarkably, the infant’s temperature, heart rate, breathing, and blood sugar stabilize while being comforted on their mother or father’s chest.  Touch begins here.  A bond between parent and infant begins here.

Enhanced Immunity

The simple act of skin to skin with the mother sets forth an intricate orchestration of colonization and antibody formation that is transferred from mother to baby through the breastmilk.  A study done at John Hopkins University found a significant reduction of nosocomial infections in  infants massaged daily with sunflower seed oil however a Cochrane review of this practice published in 2016 found the evidence lacking that emollient therapy would prevent invasive infections and cautioned that more research was needed..

Hormonal Influence

Done regularly, massage may reduce the level of the stress hormone, cortisol circulating in an infant’s bloodstream.  In turn, it may increase the level of endorphins, the body’s natural opiates as well as oxytocin, the love hormone.  Both leave the infant with a sense of well being and further promote attachment between parent and child.

Colic & Gas Relief

The jury is still out on the exact the cause of colic.  Colic starts as early as the few weeks after birth and results in crying for long periods of time-particularly at night.  Massage may relieve a distressed and colicky baby.  Regular tummy time and massage of the stomach may ease gas, constipation, and aid in digestion.  It is best to avoid tummy time and massage directly after a feed.

Joint Flexibility & Increased Muscle Strength

 According to Peter, developmental massage, practiced according to his program “releases ‘physiologic flexion’ imposed by the fetal position from the time the infant spends in utero.  Gentle massage together with soft stretching can allow the infant to relax and coordinate their muscles to improve the circulation to their body’s extremities, open the chest to deepen their breathing volume, relax the tummy to assist digestion and disposition, and strengthen the muscles of the head, neck and back in preparation for (upright postures and movement).”

Develops Trust & Confidence

Infants learn through touch.  The gentle, reassuring hand of a parent teaches the infant early on that his or her needs will be met.  Touch and massage further foster a deep bond between infant and parent.  The infant learns to trust and the parent develops confidence in his or her ability to care for the infant.

Benefits to Parents

A 2011 study in the Journal of Perinatal Education found “participating fathers were helped by increasing their feelings of competence, role acceptance, spousal support, attachment, and health and by decreasing feelings of isolation and depression.”  Other studies have shown that mothers that massage their infants have improved mood and decreased symptoms of depression.

Educating Parents

Nurses and midwives at the bedside have an excellent opportunity to teach the benefits of skin to skin and massage.   Early education should start right at birth by encouraging immediate and regular skin to skin contact.  In addition, parents can be taught simple techniques as seen here.  It is best to use oil for massage so the hands move nicely against the skin. For sick or unstable infants in the Neonatal Intensive Care, teaching parents and family members the importance of touch in the form of a gentle hand is essential.  By simply placing and holding a steady hand over the infant that is confined to an incubator or radiant warmer, we are still able to convey trust and reassurance.  Early massage can begin when the infant is stable and willing.

Peter sums it up perfectly, “from the very beginning, the mother should remain at the center of any “treatment” offered to her baby.  Most mothers want to hold their babies and establish skin to skin contact before the baby is removed, weighed, measured, bathed, or dressed.  From his mother’s womb into her arms, touch becomes the primal language of the newborn, and it is through holding and caressing that a baby is made to feel welcomed and loved.”

 

AWHONN Resources

Additional Resources

Lori is an American Neonatal Intensive Care nurse that has made her way to Sweden.  Her passion is maternal and infant education.  She incorporates her years of work in maternal and infant health with a passion for wellness through her Prenatal Yoga, Mommy & Me Yoga, and Developmental Infant Massage classes in Gothenburg, Sweden.  Follow her adventures on Instagram or through her nursing blog, Neonurse.

 

Lessening the Risk of Birth Trauma

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By Karin Beschen, LMHC

 “I was at a routine dental office visit a few weeks after my daughter was born. I remember being reclined in the chair, the bright overhead light and the scent of latex.  Images of surgical masks whipped through my mind.  Fear rushed through my body and I shook uncontrollably.  My body felt hollow and numb but also heavy and out of control.  In that moment I truly believed I was having another emergency c-section.”

This quote is from a woman who experienced a traumatic birth.  She is the mother of a beautiful baby and has had many moments of joy and connection, but also times of panic and fear.  “Mini movies” of her daughter’s birth play in her mind throughout the day.  She deleted the photos of her daughter in the NICU and she wants to disappear when her friends talk about pregnancy.  The birth didn’t end when her baby was born; it followed her from the hospital and it has interfered with many aspects of her life.

Research reveals that between 33-45% of women perceive their births to be traumatic. (Beck, 2013).  Birth trauma is defined as “an event occurring during the labor and delivery process that involves actual or threatened serious injury or death to the mother or her infant.  The birthing woman experiences intense fear, helplessness, loss of control and horror.”  (Beck, 2004a, p. 28).

Approximately 9% of women experience postpartum post-traumatic stress disorder (PTSD) following childbirth. Most often, this illness is caused by a real or perceived trauma during delivery or postpartum. These traumas could include:

  • Prolapsed cord
  • Unplanned cesarean
  • Use of vacuum extractor or forceps to deliver the baby
  • Baby going to NICU
  • Feelings of powerlessness, poor communication and/or lack of support and reassurance during the delivery
  • Women who have experienced previous trauma, such as rape or sexual abuse
  • Women who have experienced a severe complication or injury related to pregnancy or childbirth, such as severe postpartum hemorrhage, unexpected hysterectomy, severe preeclampsia/eclampsia, perineal trauma (3rd or 4th degree tear), or cardiac disease

My therapy work with mothers is typically after a traumatic birth.  The more I learn about the mother’s labor and birth experience, the more I can understand what care and education could have better supported her during  birth.

The “3 E’s” – explain, encourage and empathize – can be a useful framework for obstetrical staff in lessening the risk of a traumatic birth.  

Explain  

When explaining a process, options or a procedure, always include the woman in the discussion of her own care.  There is a distinct difference in hearing a discussion and being a part of one.  If plans change, explain what is happening and what is needed to correct the situation.

Encourage

The connection a mother has with those caring for her during childbirth is deep — you are present during one of the most emotional, unpredictable times in her life.  Encouragement is empowering and can offer the mother a sense of control.  Encourage questions.   If plans change, discuss possible alternatives.   Using “we” in conversations shows alignment and rallying together.

Empathize 

Women in labor yearn for companionship, support and empathy.

Phrases such as “I know,”  “I’m here,” and “Yes” are phrases that connect staff with a woman’s experience when she feels pain, fear, disappointment or frustration.

I’ve heard many birth stories over the years; devastating stories of physical compromise, intense fear and loss of the baby’s life.  How the mother is cared for, is what she remembers.  The tone of your voice.  The gentleness.  The validation of feelings.  One of my clients was unaware she was being rushed for an emergency cesarean.  She said in all of the chaos and in a knee-chest position, she extended her arm and a nurse held her hand.  Beauty within terror.   It was a simple gesture and it has been the most powerful, healing memory for her.   Even in the midst of an emergency, someone saw her need.  Someone saw her.

Obstetric staff has great influence on how a mother remembers her birth experience.  Expressing empathy and explaining and encouraging a laboring and postpartum mom can influence her health and well-being.  New mothers who receive the “3 Es” can better transition to home, experience less anxiety, have more positive feelings about themselves and improved bonding with their babies.

Karin Beschen is a Licensed Mental Health Counselor specializing in reproductive and maternal mental health.  She also serves as a volunteer co-coordinator for Iowa for Postpartum Support International.

 

 

Additional Resources

Postpartum Support International 

PaTTCh (Prevention and Treatment of Traumatic Birth)

Improving Birth

References

Beck, C. T. (2004a). Birth trauma: In the eye of the beholder. Nursing Research 53(1), 28-35.

Beck, C. T., Driscoll, J.W., & Watson, S. (2013). Traumatic Childbirth New York, NY: Routledge.

 

 

 

What You Need to Know About Light Bladder Leakage

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By Susan A Peck, RNC, MSN-APN

What do a 30 year old pregnant woman, a 67 year old who has 3 children – all delivered vaginally- and a 45 year who has never been pregnant have in common?  They are all experiencing light bladder leakage and each of them feels embarrassed to discuss it.  Bladder leakage is very common and can occur in any woman, of any age, and of any pregnancy status!

Light bladder leakage also known as urinary incontinence, is an involuntary loss of urine.  It is estimated to occur in up to 1 in 4 women.  The two most common types of incontinence include stress incontinence and urge incontinence, but some women can have a combination of both types.

  • Stress incontinence is the loss of urine (small or large amounts) from activities that cause pressure on your bladder such as coughing, running, jumping, or sneezing. It happens when the pelvic floor muscles- that support the bladder- weaken.  The weakened muscles can be caused by pregnancy, previous vaginal births, obesity or being overweight or chronic urinary tract infections.  Sometimes, incontinence may occur without any of these risk factors.
  • Urge incontinence is the frequent sudden need to urinate that often causes bladder contractions and the loss of small or moderate amounts of urine. It happens from bladder irritants such as caffeine or alcohol, excessive hydration, use of certain medications such as diuretics (water pills), or neurological conditions.  In some women, this may be called an overactive bladder.

As a Women’s Health Nurse Practitioner, I ask my patients about bladder leakage and incontinence- because most of the time they will not mention it to me first. Here are two stories which are very similar to real life cases I see every day.    The first was a 55 year old fitness instructor who has 3 children, all delivered vaginally.  She sees me once a year for her annual well woman exam and this year when I asked her if she had any bladder leakage, she said yes, that it just started about 6 months prior.  She was quite surprised by this because she teaches Pilates as well as Zumba and thought she had a pretty “strong core”.  But lately, in Zumba class she would feel dribbles of urine coming out.  She was embarrassed someone would see it on her pants, so she’s started to wear a pad to class, but hated exercising while wearing one. Patient B is 30 years old, a mother to a 2 year old son born via cesarean section and working full time.  When I asked her about incontinence, she told me that since her son was born, she leaks urine each time she coughs or sneezes and notices that it happens more when she drinks coffee – the caffeine she needs because of her busy life!  She was also quite surprised that the leakage is happening because “she is young and did not have a vaginal birth”.

Both of these women were surprised to know how common bladder leakage is, but very happy to know they are not alone.  During their pelvic examinations, I asked them to each perform a Kegel exercise- by contracting the pelvic floor- so that I could assess their pelvic floor tone.  The Patient A did the Kegel correctly, but had poor tone.  Patient B did not perform the Kegel correctly – instead she was bearing down/pushing out.  I routinely test my patients for their pelvic floor tone and at least 50% of the time, tone is poor, or the exercise is not performed correctly.

Below are some tips to help maintain good pelvic floor muscle tone, which is is critical to prevent or improve bladder leakage.

  • Kegel exercises are the easiest way to strengthen these muscles, as well as pilates exercises which focus on strengthening the core. Here is a link from the Mayo Clinic to assure you’re practicing them correctly.
  • Weight loss is very important in the management of bladder leakage. Even just a 5-10 lb loss can relieve some abdominal pressure against the bladder.
  • Try to reduce exposure to bladder irritants such as caffeine and alcohol and to not let your bladder get too full – even during busy days!
  • For some women, referral to a physical therapist that specializes in pelvic floor physical therapy can also be very helpful. Yes, there are physical therapists that specialize in this important muscle group!  In situations where these conservative measures do not help sufficiently, there are urogynecologist physicians – who are gynecologists who have a sub-specialty in pelvic floor medicine- who may offer other treatments including surgery.

Light bladder leakage is a common complaint among women of all ages.  If you are experiencing this, please mention it to your nurse or health care provider, if they don’t ask about it first.  Many women believe it is a normal part of ageing or a normal consequence of pregnancies or childbirth – but there are ways to help, so do not feel embarrassed or uncomfortable bringing up the subject and asking for help.

RRWJMS20150428

Susan A. Peck, RNC, MSN, APN is a practicing Women’s Health Nurse Practitioner. For 20 years, Ms. Peck’s career has focused on women’s health care, first as a labor and delivery staff nurse and for the last 16 years as an Advanced Practice Nurse. She currently works in the Department of Obstetrics & Gynecology within Summit Medical Group, a large multi-specialty practice group in Northern New Jersey.

Ms. Peck’s areas of expertise include contraception, osteoporosis, general gynecology and prenatal care. She has spoken at several national and state conferences including the AWHONN National Convention.

The Cornucopia of Contraception

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by, Susan A Peck, RNC, MSN-APN

In 2000, as a new Women’s Health Nurse Practitioner, the provision of contraception to my patients was actually pretty simple.  Most every woman who wanted hormonal contraception used the pill, and there were only a handful of brand name oral contraceptives that we all knew and regularly used.

Shortly thereafter, in 2001, the contraceptive patch and the contraceptive vaginal ring were approved by the FDA.  These other two options quickly became competitors to the oral contraceptive market and gave patients and clinicians more choice, and ways to avoid the sometimes daunting responsibility of daily pill intake.

In the background was the IUD – only ParaGard and Mirena were available at that time.  Still holding on to the worries of the unsafe IUDs of the 1970s and 1980s, most women and clinicians were not supportive of these devices at that time – fortunately that has dramatically changed!  In 2013, the Skyla IUD became available and the Liletta IUD followed in 2015.  And let’s not forget about the contraceptive implant, Implanon (now Nexplanon) that was approved in 2006.

Barrier methods have also always been accessible to women, such as condoms (male and female) and various spermicidal formulations, as well as the diaphragm – did you know the “old” diaphragm is no longer available, but that there is a new one, Caya?

So, when we consider all of these options, and factor in the complexity of some women’s medical conditions or social practices, how can women’s health clinicians consider not only which method might be most acceptable to a woman, but also which method is the safest??  There certainly is a lot to keep track of with all of today’s contraceptive choices.  And if a woman does not use her method correctly, what can a clinician advise?

Fortunately, the CDC has recently published two documents, the 2016 US Medical Eligibility Criteria for Contraceptive Use (MEC) and the 2016 Selected Practice Recommendations for Contraceptive Use (SPR).  The references are invaluable for any clinician who is providing contraception to women.  I have a copy of both at my desk in my office and even after 16 years of practice, I regularly rely on their guidance to make the best, safest recommendations about contraceptive choices for my patients.

I’d like to tell you about two recent patients, for which both references helped guide my decision making. 

First, Jennifer, a 32 year old woman living with multiple sclerosis, has used oral contraceptives successfully for five years.  She enjoys the regular, very light periods she has with the pill, and is a very responsible pill taker – never misses one!  But, this year, when I see her for her annual exam, I learn that her MS has unfortunately taken a turn for the worse.  She is currently in a wheelchair more the 50% of the time and her mobility is greatly limited.  She is very hopeful that this period of immobility will be short lived – there is a new MS drug she is starting next month.  So, I begin to wonder whether an oral contraceptive is the best, safest method for Jennifer.  I use my 2016 MEC App on my phone and determine that due to her immobility related to MS (increased chance of hypercoagulable state) it may be time to change methods.  She and I discuss all options and she decides on the Mirena IUD.  Not only is she pleased with a long term method, she feels more comfortable knowing she is safe – it is one less thing she has to worry about.

My next patient is Mary, a 20 year old healthy college student who tells me that she wants to use the contraceptive implant, Nexplanon.  She is going back to school out of state in two days, and would really like to have the implant inserted today.  In the past, some clinicians have traditionally preferred to insert LARC methods during a woman’s menstrual period to “make sure she is not pregnant”.  However, this is often cumbersome for scheduling and delays an opportunity to provide effective contraception.  So, I use my 2016 SPR and review the section ‘how to be reasonably certain a woman is not pregnant’.  I determine that since Mary has consistently and correctly used condoms since her last period, it is safe to assume she is not pregnant. After receiving her informed consent, I safely place the Nexplanon and she is able to return to college with a highly effective long term method of contraception.

It is important to remember that in nearly all situations the use of a birth control method is safer than an unintended pregnancy. These CDC resources are invaluable guides for clinicians so we can be confident our contraceptive recommendations are based on the latest evidence.  Both the MEC and the SPR are available free – of- charge with the option of downloading an APP for your device.

Tell your colleagues and have these references close at hand!

RRWJMS20150428

Susan A. Peck, RNC, MSN, APN is a practicing Women’s Health Nurse Practitioner. For 20 years, Ms. Peck’s career has focused on women’s health care, first as a labor and delivery staff nurse and for the last 16 years as an Advanced Practice Nurse. She currently works in the Department of Obstetrics & Gynecology within Summit Medical Group, a large multi-specialty practice group in Northern New Jersey.

Ms. Peck’s areas of expertise include contraception, osteoporosis, general gynecology and prenatal care. She has spoken at several national and state conferences including the AWHONN National Convention.

 

 

 

Informal Milk Sharing in the United States

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by, Diane L. Spatz, PhD, RN-BC, FAAN

Susan is a nurse in a Neonatal Intensive Care Unit (NICU) with a strong human milk culture.  Every day she provides evidence-based lactation care and support to mothers who have critically ill infants. She understands fully that human milk can be a lifesaving medical intervention and received two days of on the job education regarding the critical importance of human milk and breastfeeding.  Seeped in this culture, Susan also believes that nurses and health professionals have an obligation to help families make an informed decision and while it would be ideal if all infants were exclusively breastfed by their own mothers, this is not always feasible or possible.

Susan is also challenged personally Having experienced infertility for 10 years, she has decided to adopt a newborn. She has read the literature and met with a lactation expert .  Susan is aware that even with great effort and time investment, she may never achieve a full milk supply.  She is very concerned about giving her infant formula and asked the lactation expert about accessing Pasteurized Donor Human Milk (PDHM).

The Human Milk Banking Association of North America (HMBANA) is the organization that oversees non-profit milk banks in the United States.  Even though the number of HMBANA milk banks is increasing in the United States and the amount of PDHM has also increased substantially in recent years, PDHM is still prioritized to preterm or vulnerable infants in the hospital setting.  HMBANA milk banks do sometimes dispense PDHM to the community setting.  However, in these instances, it is for infants with special medical needs and usually requires a prescription from a health care provider.

So for Susan who is planning to adopt a healthy full-term infant, she will likely be unable to access PDHM.  Susan is considering informal milk sharing in order to supplement what milk she is able to produce through inducing lactation.  It is important for nurses and other health professionals to be aware that informal milk sharing does exist and also to help families make an informed decision.

There are many reasons why women or families choose to pursue informal milk sharing in addition to the reasons in Susan’s story, including:

  • Women who have glandular hypoplasia or breast surgery and are unable to develop a full milk supply
  • Men and women who adopt children and may be unable to induce lactation
  • Women who have had bilateral mastectomy prior to childbearing
  • When a woman dies in childbirth and her family members wish to honor her plans to breastfeed
  • A short term need for supplemental human milk due to early breastfeeding challenges or a delay in Lactogenesis II

Although very beneficial in all of the above cases, informal milk sharing is not without any risk because just as antibodies, white blood cells, and other immune components are transferred in human milk, viruses can also be transferred.  In addition, some medications transfer into human milk (most in very small amounts, but some in larger).

Mothers who are considering informal milk sharing should consider the following steps:

  1. Get a complete health history from the donor mother. It is essential to understand  the donor mother’s past and current medical history as well as lifestyle choices is essential.  It is also acceptable for the mother to ask the donor mother for a copy of her serologic testing from pregnancy.
  2. Find out how the milk will be expressed, labeled, stored, and transported. The donor mother, first and foremost, should have an excess supply of milk that she does not need for her infant. When mothers express milk, care should be taken to ensure the safety of the milk.  At our institution, we have mothers wash their pump equipment with hot, soapy water and rinse well after every use and have them sterilize the equipment daily.
  3. What types of containers will be used for storage (the recipient mother could supply these to the donor mother) and how will the milk be stored (fresh or frozen) and transported from the donor mother to the recipient. Conversations between recipient mother and donor mother should be on-going to ensure safety of the milk. In this area the research literature has also evaluated  the use of home heat treatment to “pasteurize” the milk. Research has shown that heat treatment of the milk on a stovetop is not the same as Holder pasteurization, this technique has the ability to destroy viruses.  It is important to note that heat treatment also destroys some of the beneficial components of human milk.

Recently, the American Academy of Nursing published a position statement regarding the use of informally shared milk. This, along with resources shared below can be a starting point to have these conversations with families who are interested in the topic.

As health professionals, is also important to understand that there is a difference between milk sharing –  mothers may share  altruistically and be commerce free or there may be  an exchange of money or mothers who are paid for the milk.  When financial exchange enters the equation, mothers seeking to get paid for their milk may be motivated to dilute or alter their milk.  We should advise parents to be alert and aware of this.

Until PDHM becomes universally available, if a family does not wish to feed their infant formula, the only other option available is informally shared milk.  Having transparent and honest conversations with families to help the understand this practice is essential.


Resources for Informal Milk Sharing

The American Academy of Nursing (2016). Position statement regarding use of informally shared human milk.  Nursing Outlook, 64, 98-102.

Martino, K., & Spatz, D. L. (2014). Informal milk sharing: What nurses need to know. The American Journal of Maternal/ Child Nursing, 39(6), 369-374. doi:10.1097/NMC.0000000000000077

Spatz,  D.L. (2016.) Informal Milk Sharing. American Journal of Maternal Child Nursing;41(2):125. doi: 10.1097/NMC.0000000000000225. PubMed PMID: 26909729.

Wolfe-Roubatis, E. & Spatz, D. L. (2015). Transgender Men & Lactation: What nurses need to know. The American Journal of Maternal Child Nursing,40(1): 32-38. doi: 10.1097/NMC.0000000000000097.

Israel-Ballard, K., Donovan, R., Chantry, C., Coutsoudis, A., Sheppard, H., Sibeko, L., & Abrams, B. (2007). Flash-heat inactivation of HIV-1 in human milk: a potential method to reduce postnatal transmission in developing countries. Journal of Acquired Immune Deficiency Syndromes, 45(3), 318-323.

Diane SpatzDiane L. Spatz, PhD, RN-BC, FAAN is a Professor of Perinatal Nursing & the Helen M. Shearer Professor of Nutrition at the University of Pennsylvania School of Nursing sharing a joint appointment as a nurse researcher and director of the lactation program at the Children’s Hospital of Philadelphia (CHOP). Dr. Spatz is also the director of CHOP’s Mothers’ Milk Bank.  Dr. Spatz is an active researcher, clinician, and educator who is internationally recognized for her work surrounding the use of human milk and breastfeeding particularly in vulnerable populations. Dr. Spatz has been PI or co-investigator on over 30 research grants, included several from the NIH.  She has authored and co-authored over 80 peer reviewed publications.  Dr. Spatz has authored or co-authored position statements for the International Lactation Consultant Association, the Association of Women’s Health Obstetric & Neonatal Nursing and the National Association of Neonatal Nurses.

In 2004, Dr. Spatz develop her 10 step model for human milk and breastfeeding in vulnerable infants.  This model has been implemented in NICUs throughout the United States and other countries worldwide. Dr. Spatz has been named a prestigious “Edge Runner” for the American Academy of Nursing related to the development and outcomes of her model.  Her nurse driven models of care are critical in improving human milk & breastfeeding outcomes and thus the health of women and children globally.

Dr. Spatz is also the recipient of numerous awards including: Research Utilization Award from Sigma Theta Tau International and from the University of Pennsylvania:  the Dean’s Award for Exemplary Professional Practice, the Expert Alumni Award and the Family and Community Department’s Academic Practice Award   She is also the recipient of the Lindback Award for Distinguished Teaching. Dr. Spatz received the Distinguished Lang Award for her impact on scholarship, policy & practice.

In the university portion of her job, she teaches an entire semester course on breastfeeding and human lactation to undergraduate nursing students and in the hospital portion of her job, she developed the Breastfeeding Resource Nurse program.  Dr. Spatz is also Chair of the American Academy of Nursing’s Expert Panel on Breastfeeding and their representative to the United States Breastfeeding Committee.  Dr. Spatz is also a member of the International Society for Researchers in Human Milk & Lactation