Tag Archives | Diana Cassar-Uhl

Are Oligosaccharides a Key to Reducing HIV in Breastfed Babies?

One of the most fascinating mysteries of our time is the low rate of mother-to-infant transmission of HIV via the milk of an infected mother. In the absence of antiretroviral drug therapy (ART), 10-15% of babies born to infected mothers acquire the virus from breastmilk; when both mother and infant are treated with ART, this incidence can be reduced to 2% or less.

Several components of human milk have been shown to offer protection to those more than 85% of babies who don’t get HIV after repeated exposures. Immunoglobulins, like IgA, IgG, and IgM provide specific immune response to certain pathogens; lactoferrin accomplishes various tasks, to include killing bacteria and preventing  surviving bacteria from multiplying. In a study released earlier this year, researchers at Duke University in North Carolina reported that HIV-specific B-cells found in the colostrum of infected mothers actually neutralize the virus. An international team of researchers based in California, New York, Boston, and Zambia, in a study released on August 15 by the American Journal of Clinical Nutrition (Bode, et al., 2012) identifies yet another protective component: human milk oligosaccharides.

Oligosaccharides are plentiful in breastmilk, and there are over 130 of them (Smith, 2008). They are made from chains of simple sugars, and they do a few things that make them superheroes in the fight against pathogens – any invading virus or bacteria. Oligosaccharides are PREbiotics, which act like food for good bacteria in the baby’s gut. Prebiotics feed and promote the proliferation of PRObiotics, which crowd out pathogens. Another important, protective function of oligosaccharides is that they prevent pathogens from attaching to the gut lining. They do this either by attaching to the part of the bacteria or virus that would attach to the baby’s gut, or by themselves attaching to the gut epithelium and, in essence, occupying all of the “docks” where pathogens might seek to put down a mooring. Oligosaccharides are most plentiful in the earliest days, weeks, and months of breastfeeding, decreasing in number and volume as the baby gets older. Oligosaccharides are undigestible, which allows them to populate the baby’s intestine; the large volume of oligosaccharides is part of what causes a newborn to stool often, perhaps every time he breastfeeds.

This mechanism is also protective against HIV and other viruses, because the frequency of the bowel being emptied doesn’t give pathogens time to “set up shop” and get down to the business of infecting the baby. This is one possible explanation for why the protective effect of breastfeeding against HIV may wane as the baby gets older. Of the 12.1% of infants who acquired HIV through their mother’s breastmilk, 68.2% of those transmissions occurred after 6 months (Iliff et al., 2005). The addition of complementary foods may also cause or allow for breaches in the infant’s gut integrity; it is through these breaches that HIV can be acquired. The findings reported by Bode, et al. are exciting. We already knew that oligosaccharides play a significant role in keeping babies healthy and free from infection, but recognizing that, in high enough concentrations, they actually protect infants from a pathogen that is present in the milk is remarkable. In nations where the risk of infant death from gastrointestinal or respiratory infections is higher than the risk of transmission of HIV from an infected mother to her baby, understanding why and how a mother’s own milk gives her infant his best chance for survival can provide important teaching points for public health workers, especially when cautioning against mixed feeding of these vulnerable infants. Additionally, these innate protective factors in human milk offer insight into how a vaccine against HIV might be developed for use in adults at risk of acquiring the virus.

References:

Bode, L., Kuhn, L., Kim, H., Hsiao, L., Nissan, C., Sinkala, M., Kankasa, C., et al. (2012). Human milk oligosaccharide concentration and risk of postnatal transmission of HIV through breastfeeding. American Journal of Clinical Nutrition (ePub ahead of print). doi: 10.3945/ ajcn.112.039503

Friedman, J., Alam, S. M., Shen, X., Xia, S. M., Stewart, S., Anasti, K., Pollara, J., et al. (2012). Isolation of HIV-1-neutralizing mucosal monoclonal antibodies from human colostrum. PLoS One 7(5). doi: 10.1371/journal.pone.0037648

Iliff, P. J., Piwoz, E. G., Tavengwa, N. V., Zunguza, C. D., Marinda, E. T., Nathoo, K. J., Moulton, L. H., et al. (2005). Early exclusive breastfeeding reduces the risk of postnatal HIV-1 transmission and increases HIV-free survival. AIDS 19(7), 699-708.

Smith, L. (2008). Biochemistry of human milk. In R. Mannel, P. J. Martens, & M. Walker (Eds.), Core Curriculum for Lactation Consultant Practice (pp. 269-284). Sudbury, MA: Jones & Bartlett.

Diana Cassar-Uhl, IBCLC and La Leche League Leader, enjoys writing to share breastfeeding information with mothers and those who support them.  In addition to her frequent contributions to La Leche League International’s publication Breastfeeding Today, Diana blogs about normalizing breastfeeding in American culture at http://DianaIBCLC.com and has been a guest blogger at Best for Babes and The Leaky Boob.  Diana can be found lecturing at breastfeeding education events around the United States.  She is pursuing a Master of Public Health, and upon graduation hopes to work in public service as an advisor to policymakers in maternal/child health and nutrition.  Mother to three breastfed children, Diana recently retired after serving as a clarinetist on active military (Army) duty in the West Point Band since 1995.

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Playing Sherlock

Written by Diana Cassar-Uhl

When we begin our encounter with a mother, whether it’s before she’s discharged from the hospital, on a home visit during the first week, or after she’s struggled to find comfort and confidence in breastfeeding, our assessment of her situation starts with her report:

“My nipples are so painful.”

“My baby’s weight gain isn’t good enough and I don’t want to use formula.”

“There are shooting pains running through my breast. Is it serious?”

“Can I text you a picture of my baby’s last poop? I don’t know if it’s normal.”

We get as much of a history as the situation permits, and the diagnostician inside of us gets to work. We assess the foundational things – positioning, latch, breastfeeding management. Are feeds on demand or on a schedule? Is there a pacifier in the picture? Are mother and baby comfortable? Sometimes, these answers are enough to get the dyad on their way to breastfeeding success for the weeks, months, or years they hoped to accomplish.

Benedict Cumberbatch during filming of Sherlock.
Photo by bellaphon via Flickr Creative Commons

Other times, our detective skills are necessary. The preliminary suggestions brought little or no relief, and it’s up to us to help the mother solve the whodunnit mystery that spurred her to seek our help in the first place. Like any good detective, we have our eyes open for clues (if the “Blues Clues” theme music is playing in your head, that’s a good sign you’ve been a mother or a grandmother in the United States sometime in the last 15 years or so). When we assess mother and baby as a dyad, many clues are revealed. Why does this work? There is no breastfeeding without both a baby and a mother. The dyad is interdependent, a single entity. Baby needs mother, but mother also needs baby. It follows, then, that when something is amiss in one part of the system, we’ll get to the bottom of the problem faster if we look at the whole mother-baby system. Baby’s tongue is firmly attached to the bottom of their mouth? Aha! No wonder this mother’s nipples are destroyed! Breasts are spraying like Old Faithful at every feeding? Gotcha! The cause of those green, mucousy bowel movements!

Often, after I’ve taken out my magnifying glass and started dusting for fingerprints, I realize my culprit was sitting at the dining room table, holding the candlesticks, all along … baby with sluggish weight gain AND mother with repeated plugged milk ducts? Why didn’t I ask first about breastfeeding management before I started wondering about whether the baby had problems absorbing nutrients? Why was I so quick to send the mother researching about lecithin instead of looking at the more obvious causes of her plugs?

Assessing both the mother and the baby will help us get to the root causes of breastfeeding problems much more quickly, and often more completely, than evaluating each separately might permit. When we keep in mind that we are facilitating the establishment, maintenance, and growth of a holistic, two-part system, solving the breastfeeding whodunnits becomes … elementary, my dear.

Diana Cassar-Uhl, IBCLC and La Leche League Leader, enjoys writing to share breastfeeding information with mothers and those who support them.  In addition to her frequent contributions to La Leche League International’s publication Breastfeeding Today, Diana blogs about normalizing breastfeeding in American culture at http://DianaIBCLC.com and has been a guest blogger at Best for Babes and The Leaky Boob.  Diana can be found lecturing at breastfeeding education events around the United States.  She is pursuing a Master of Public Health, and upon graduation hopes to work in public service as an advisor to policymakers in maternal/child health and nutrition.  Mother to three breastfed children, Diana recently retired after serving as a clarinetist on active military (Army) duty in the West Point Band since 1995.

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Does Breastmilk Neutralize HIV?

Written by Diana Cassar-Uhl, IBCLC

Photo by DFID – UK Department for International Development via Flickr

As an IBCLC, I’m always thrilled when a new study comes out and affirms what I already know about human milk – that it’s amazing and we’re constantly learning something new about it.

Last summer, one of the first classes I took toward my Master of Public Health was Introduction to Epidemiology. Because it was online, class discussions were held to a strict standard – our professor required us to back up any claims with peer-reviewed evidence.  No matter what the topic was, I did my best to bring it around to breastfeeding, often to the chagrin of the other rising students of public health, who learned quickly just how much they didn’t know about breastfeeding. Naturally, no class about epidemiology (according to Merriam-Webster: the study of the incidence, distribution, and control of diseases in a population) would be complete without discussions of HIV, but the topic of HIV and breastfeeding wasn’t one I ever needed more than an elementary understanding about, given the population I serve as an IBCLC.

A classmate remarked that while breastfeeding might be the best thing to do for most mothers in most parts of the world, in nations where the prevalence of HIV is high, only those mothers with access to highly-active anti-retroviral therapy (HAART) were advised to breastfeed. She had worked with a population that was not advised to breastfeed their babies, and was frustrated by the fact that access to uncontaminated water (both for mixing formula and for cleaning feeding vessels) was nearly as difficult as access to the HAART drugs – making minimization of all risk impossible for these babies born to HIV+ mothers. I had read that, for HIV+ mothers, exclusive breastfeeding, rather than mixed feeding (breastfeeding plus formula) was the safest way to feed her infant, perhaps due to the protective effect of SIgA and other human milk components on the infant’s gut (shown by reduced incidence of transmission in the exclusively breastfed groups in studies cited below). However, a newly-released study offers another explanation, one that adds to the “wow factor” of human milk: antibodies in the milk of HIV-infected mothers actually help neutralize HIV itself.

The study by Friedman, et al. at Duke University in North Carolina, U.S.A. is part of ongoing efforts to develop a vaccine against HIV. Researchers isolated an immunological component of colostrum of HIV+ mothers – HIV-specific B-cells, and noted that they neutralized the virus.

The World Health Organization states:

Mothers known to be HIV-infected (and whose infants are HIV uninfected or of unknown HIV status) should exclusively breastfeed their infants for the first 6 months of life, introducing appropriate complementary foods thereafter, and continue breastfeeding for the first 12 months of life.

Breastfeeding should then only stop once a nutritionally adequate and safe diet without breast milk can be provided (WHO, 2010.)

In many developing nations, the criteria “nutritionally adequate and safe” are not possible to meet; therefore, exclusive breastfeeding remains the most protective method of feeding an infant, even one with an HIV-infected mother; the risk of illness or death from causes related to the replacement feeding methods are significant in these areas of the world. Guidance from the Centers for Disease Control (CDC) in the United States mirrors this, but presumes the availability of replacement feeding that is acceptable, feasible, affordable, sustainable, and safe.

While it could be part of the explanation for why the vast majority (over 90% in some studies) of exclusively-breastfed infants of HIV+ mothers do not contract the virus, the discovery of HIV-specific B-cells in the colostrum of HIV-infected mothers is not yet the “green light” for exclusive breastfeeding for all; however, it offers promise toward understanding and hopefully, gaining the upper hand on HIV transmission rates not just for babies, for entire at-risk populations.

Friedman, J., Alam, S. M., Shen, X., Xia, S. M., Stewart, S., Anasti, K., Pollara, J., et al. (2012). Isolation of HIV-1-neutralizing mucosal monoclonal antibodies from human colostrum.

World Health Organization. (2010). Guidelines on HIV and Infant Feeding.

U. S. Department of Health and Human Services, Centers for Disease Control and Prevention. (2010). Breastfeeding, Human Immunodeficiency Virus (HIV), and Acquired Immunodeficiency Syndrome (AIDS).

Diana Cassar-Uhl, IBCLC and La Leche League Leader, enjoys writing to share breastfeeding information with mothers and those who support them.  In addition to her frequent contributions to La Leche League International’s publication Breastfeeding Today, Diana blogs about normalizing breastfeeding in American culture at http://DianaIBCLC.com and has been a guest blogger at Best for Babes and The Leaky Boob.  Diana can be found lecturing at breastfeeding education events around the United States.  She is pursuing a Master of Public Health, and upon graduation hopes to work in public service as an advisor to policymakers in maternal/child health and nutrition.  Mother to three breastfed children, Diana recently retired after serving as a clarinetist on active military (Army) duty in the West Point Band since 1995.

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Assessing and Leveraging Learning Preferences to Optimize How We Help Mothers

Written by Diana Cassar-Uhl, IBCLC and La Leche League Leader

 “I see … “

“I hear you!”

“I got it.”

When we first meet a mother for a lactation consult, we’re working “on baby time!”  We are charged with assessment and education, developing individualized, practical solutions so mothers can be successful in their breastfeeding goals. We don’t have a lot of time to figure out how a mother learns best, but we have to make sure we present information to her in a way she understands and can use.  Determining how she learns is easy and the benefits are many.

As we define learning preference, we must consider how we collect information (input) and how we retrieve it.  Our senses of sight, hearing, and touch provide pathways for information collection; these three, with our senses of smell and taste to a lesser degree, offer modes for information retrieval (like when a particular scent rouses a memory of an experience).  Our own learning preferences affect how we communicate with and “teach” others; this affects how we work together.  We do not teach as we were taught, we teach as we, ourselves, learn.  An understanding of how our brains are working, in contrast to how others function similarly or differently, can enable us to establish rapport and work together effectively and compassionately.  This understanding can also help us more effectively help the mothers who seek our guidance.

Ideally, we are always using visual (sight), auditory (sound), and kinesthetic (touch and movement) modes of learning, to varying degrees, depending on the situation.  However, during periods of stress, our brains revert to their innate preferences.  It is possible to develop and sharpen our non-preferred modes of input and retrieval, but when we get to that consult, we are wise to figure out what mode our client prefers and do our best to gear our education to that informational pathway/sense.

To encourage a resourceful state, during which multiple modes of input can be employed, begin the consult by taking some deep, relaxing breaths with the mother.  As you listen to her explain why she’s sought your expertise, pay close attention to not only the content of what she’s telling you, but:

  • body language
  • speech patterns
  • word choices
  • eye movements

These representations will offer insight into how to best teach the mother and share information with her.

Visual learners are the most common.  They learn quickly and are also quick to recall information; they can remember information in any order.  Visual learners are often fastidious about grooming, clothing, and matching colors.  They are attentive to detail.  The visual learner will look at you while you are speaking.

A mother who prefers to learn in the visual mode:

  • Tends to sit still, uses fewer extraneous body movements
  • Speaks more rapidly
  • She might use words like: bright, clear, hazy, see, look, picture, imagine, color, focus, perspective, watch, notice

Our sense of hearing is the first sense that develops, before we are even born.  The auditory learner relies heavily upon her ears for imitation and creativity.  She needs to “begin at the beginning” when recalling information, and needs order and sequence to understand relationships of part to whole.  The auditory learner is often a slow reader, and when you’re speaking to her, she might focus on her baby or close her eyes, even though she is listening intently to you.

A mother who prefers to learn in the auditory mode:

  • Uses rhythmic physical movements and gestures (always metronomic and      repetitive)nodding of the head, finger tapping
  • Might tilt her head to one side when listening or speaking
  • Speech patterns are moderate and rhythmic to match body language
  • Auditory learners tend to be the most talkative
  • When thinking through a problem, she might make clicking sounds with her tongue/mouth
  • Auditory learners might use words like: hear, listen, resonate, ring, talk, sounds like, rhymes, sing, tone

The mother who seems compelled to begin her consult by showing you the problem rather than telling you about it is most likely a kinesthetic learner.  She never liked traditional school situations and prefers to be in motion in order to grasp your visual and auditory inputs.  She may change positions often and is eager to use her hands.

A mother who prefers to learn in the kinesthetic mode:

  • Rarely remains in one position for more than a few minutes
  • Enjoys motion so much and does not wish to make it “automatic” or rhythmic, so      will be in near-constant motion but erratically and not smoothly
  • Speech patterns are the slowest of the three learning styles, punctuated by hand      motions, head motions, or shifts in bodily stance; physical movements are intended to emphasize the meaning of words, full of variety and spontaneity
  • Kinesthetic learners might choose words like: grab, handle, touch, push, move, cold,      warm, embrace, soft, wrap my arms around; action words – get it, go for it, do it, make it

When we understand how a mother is collecting and recalling information, we can tweak our communication skills to match, and build rapport with that person.  Rapport allows us to develop trust, gain respect, “walk in another’s shoes,” and stretch our own viewpoints.  Then, we are able to gain credibility and work together for creative problem-solving.

Your communication is only as effective as the response you receive.

Once we know which learning mode a person prefers, we can cater to that. In so doing, we also may notice a subtle shift in our own perceptions of a situation.  By paying attention to body language, we find we put our arms, legs, and postures in similar positions as the mother.  After a few minutes of observing a mother’s movements, you might mirror the animated facial gestures of a kinesthetic learner, tilt your head to one side when conversing with an auditory learner, or mirror a more static face/eyebrow and eye movement with a visual learner.  Modulating our voice patterns – speed, rhythm, pitch, and volume – to match those of the mother we are helping will have the greatest impact on our sense of connection with her. The shape and modulation of a speech pattern is more important than the actual pitch (an adult male using the higher range of his voice when speaking with a 7-year old girl, for example). It is easy to match speed and volume closely, and we often do this subconsciously.  Finally, using words that mirror the predicates the mother chooses will be very effective.

Are you unsure about which mode of learning you prefer?  Let a few people who know you well read this blog post, and see what they think.  See if you can identify how your spouse, friends, and children learn.  At your next consult, try what you’ve learned here, and leave a comment if it changes anything for you.  Hopefully, you’ll be hearing lots of great feedback:

“She sees things like I do!” (visual learner)

“That IBCLC really resonated with me!”  (auditory learner)

“We feel exactly the same way!” (kinesthetic learner)

Resource: Bruckner, S. (1998). The Whole Musician: A Multi-Sensory Guide to Practice, Performance, and Pedagogy. Santa Cruz, CA: Effey Street Press.

Diana Cassar-Uhl, IBCLC and La Leche League Leader, enjoys writing to share breastfeeding information with mothers and those who support them.  In addition to her frequent contributions to La Leche League International’s publication Breastfeeding Today, Diana blogs about normalizing breastfeeding in American culture at http://DianaIBCLC.com and has been a guest blogger at Best for Babes and The Leaky Boob.  Diana can be found lecturing at breastfeeding education events around the United States.  She is pursuing a Master of Public Health, and upon graduation hopes to work in public service as an advisor to policymakers in maternal/child health and nutrition.  Mother to three breastfed children, Diana has served as a clarinetist on active military (Army) duty in the West Point Band since 1995.

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Breastfeeding and the Working Mother

Written by Diana Cassar-Uhl, IBCLC and La Leche League Leader

We know what the studies say:  mothers who have to separate from their infants to return to the workplace are statistically less successful  (Johnson & Esposito, 2007) at meeting the goal recommended by child health promotion organizations around the globe:  exclusive breastfeeding until around the middle of the baby’s first year, thereafter supplemented with nutritionally sound, complimentary foods while breastfeeding continues through the child’s second year or beyond (World Health Organization, 2002).

This is not a significant issue for IBCLCs outside the United States, in nations where paid maternity leave is normal and expected after a mother has a baby; however, IBCLCs in the U. S. will likely find themselves in the position to counsel and assist mothers who wish to maintain a breastfeeding relationship with their infants after a return to work or school.  Reminding a mother that many mothers before her have been successful in continuing to breastfeed after regular separations from their babies and providing practical suggestions can be valuable.

Direct breastfeeding is best for mother and baby.

This is always my first tenet of support when I’m helping a mother who has to separate from her baby.  Is there any way for the mother to spend more time in her baby’s presence?

  • Can maternity leave be extended, or can the mother return to work on a gradual/partial basis (for example, half days; or back 2 days the first week, 3 days the 2nd week, and so on)?
  • Can the baby be brought to work with his mother?  There are workplaces that have experimented with this option and found it to be a win-win alternative.  The Parenting in the Workplace Institute offers some details.
  • Is the daycare on-site or close enough to mother’s workplace that she can breastfeed her baby during her lunch or other breaks?  Keep in mind that Federal legislation, as part of the Patient Protection and Affordable Care Act supports break time for nursing mothers.
  • Can the baby be brought to visit his mother one or more times during her workday?  Even one breastfeeding session during the separation can make a difference in how much milk continues to be produced long-term.

But I have to travel for my job!

While Transportation Security Administration rules permit a mother to travel with her pumped breastmilk when she is not traveling with her child, a more lactation-friendly alternative is to bring baby along and breastfeed whenever possible – often, this is more frequently than when mother is at her home office.  It has been reported that Julie Andrews, while on location to film The Sound of Music, had her toddler on site with a caregiver.  This was a sensible solution in 1964 and can still work today!

Even if I give my job 75% and my baby 75%, that still adds up to 150% and I’m exhausted!

As an IBCLC, I support a mother in her efforts to breastfeed her baby; this can include practical tips for a new family.

  • If there is a support person at home (baby’s father, mother’s partner, other family member), is he or she in agreement that breastfeeding is the best course of action for mother and baby?  This person and others close to the mother will have a tremendous impact on the choices she makes.
  • Remind the family that when mother is not at work, her #1 priority is to care for the baby; this means everyone must pitch in to care for the mother and the household.
  • Safely sharing sleep with her baby as detailed here can ensure a mother gets some rest (though likely not as much as she desires or needs unless she can modify her work situation or her baby gets older) and meet the nutritional and attachment needs of her baby.

Some breastfeeding is better than no breastfeeding.

If a mother can’t employ the tips shared above and struggles to express enough milk to meet her baby’s needs, remind her that she can still pump what is feasible for her – every drop her baby gets is a precious gift.  She can also continue to enjoy the breastfeeding relationship when she is with her baby, even if he has been partially weaned to commercially-prepared baby milk.

Finding her tribe.

When a breastfeeding mother returns to work, she may feel stuck between two worlds; her heart is with her baby but her mind is on her job.  The other breastfeeding mothers she knows stay home with their babies and the mothers at her workplace weren’t successful at combining employment outside the home with breastfeeding.  If enough of your clientele combines working and breastfeeding, perhaps you can host a monthly discussion group (in the evening, baby required for admission!) where mothers can share their strategies in your presence (and you can moderate comments to ensure everyone leaves with sound information).  If your breastfeeding and employed population is smaller, see if one or two mothers who have been particularly successful at the balancing act might be willing to serve as a resource to other mothers embarking on the journey.

Turn your frustration into advocacy!

If you’ve seen too many overwhelmed mothers give up breastfeeding because the “otherhood” complicates new motherhood, take action.  In her Call to Action to Support Breastfeeding, U. S. Surgeon General Regina Benjamin encourages us to “work toward establishing paid maternity leave for all employed mothers” (United States Department of Health and Human Services, 2011).  A letter to your elected officials at every level will keep this issue on the table.  Breastfeeding protects the health of babies and their mothers; we are called to protect breastfeeding in any way we can.

Johnston, M. L. & Esposito, N. (2007).  Barriers and facilitators for breastfeeding among working women in the United States.  Journal of Obstetric, Gynecologic, & Neonatal Nursing, 36: 9–20.  doi: 10.1111/j.1552-6909.2006.00109.x

United States Department of Health and Human Services, Office of the Surgeon General. (2011). The Surgeon General’s Call to Action to Support Breastfeeding.  Washington, D. C.

World Health Organization. (2002). Global strategy on infant and young child feeding. 

Diana Cassar-Uhl, IBCLC and La Leche League Leader, enjoys writing to share breastfeeding information with mothers and those who support them.  In addition to her frequent contributions to La Leche League International’s publication Breastfeeding Today, Diana blogs about normalizing breastfeeding in American culture at http://DianaIBCLC.com and has been a guest blogger at Best for Babes and The Leaky Boob.  Diana can be found lecturing at breastfeeding education events around the United States.  She is pursuing a Master of Public Health, and upon graduation hopes to work in public service as an advisor to policymakers in maternal/child health and nutrition.  Mother to three breastfed children, Diana has served as a clarinetist on active military (Army) duty in the West Point Band since 1995.

If you want to link to Diana’s Breastfeeding Today article on breastfeeding and working, (mothers are the target audience) it’s here.

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