In the late ’80s and early ’90s, Diane Spatz attended Penn’s School of Nursing for her undergraduate, master’s, and doctorate degrees—all one pretty much after the other. The youngest in her Ph.D. program by a mile, she recalls sometimes getting flak from her co-workers.
“They were like, ‘Oh, you’re going back to school because you don’t want to get your hands dirty,’” she says. “But I was like, ‘No, I’m not getting my Ph.D. because I want to get away from the bedside, I’m getting my Ph.D. because I want to make a difference at the bedside.’”
Spatz, now a professor of perinatal nursing and the Helen M. Shearer Term Professor of Nutrition at Penn, has certainly made good on that promise.
With her research published in hundreds of medical journals, Spatz, also director of the Children’s Hospital of Philadelphia’s Lactation Program, is changing the way the world thinks and talks about breastfeeding, and its dire importance for babies’ health. She’s also implemented vast programs that hone in on the critical role of nurses in lactation support.
Spatz sat down after her last day of classes for the semester, and before she jetted to do another nurse training across the country, to chat about the benefits of human milk and breastfeeding, a few of her research projects, the CHOP Mother’s Milk Bank, her recent Lifetime Achievement Award, and much more.
Tell me about yourself. What brought you to Penn?
I always like to tell people that Penn made a very good investment in me. I was actually recruited to come here starting when I was in 10th grade. I am a first-generation college student, and my brothers are 19 and 17 years older than me and my sister is 10 years older than me, so my parents were a bit older. My dad worked in a factory. So, the thought of them having to think about me going to this Ivy League school in the city was a big thing. But, it was the only place I wanted to go, and luckily I got enough financial support that my family could afford it. I always thought I wanted to be a pediatric nurse when I was growing up because I was a lifeguard and I taught swimming lessons and I did summer playground for kids. I really love kids, but when I was an undergraduate here I realized I really didn’t like sick kids. I ended up falling in love with women and babies. My last semester I specialized in pregnant women and babies, and that sealed the passion.
And you stayed at Penn for your master’s and doctorate degrees?
I got a job right away in obstetrics at Pennsylvania Hospital, which at the time was not part of Penn. Back then, during the height of the nursing shortage, you learned postpartum, antepartum, labor and delivery, NICU—you kind of had to do everything. One of the interesting things was that [during undergrad] I had not learned anything about breastfeeding. We never had a course on it, we never had a lecture on it. I never saw breastfeeding when I did my clinical. At Pennsylvania Hospital, they were doing over 5,000 deliveries a year, and part of what I was expected to do was help moms breastfeed. That was really stressful.
I was working full time and going to school for my master’s part time, and Dr. Linda Brown, a faculty member here then, asked if I wanted to work on a grant, a pilot study about the factors influencing milk by moms who have low-birthweight infants. When we did that, I used to have to go out and do home visits and collect moms’ pumping logs. When I would go to their homes, they would literally barricade the door and not want to let me out. They wanted me to stay; they wanted to talk about their experience having a sick baby in the neonatal intensive care unit and that no one was really helping them. And that to me was heartbreaking. I thought, ‘Why are we not doing a better job at helping mothers?’ Having a baby is a life-changing experience, and then imagine having a sick baby.
After finishing that grant and my master’s degree, I went to work someplace else for a brief amount of time. I came back to Penn for my Ph.D., and worked on an intervention grant with Dr. Dorothy Brooten where we were doing nurse home care for high-risk pregnant women. During that time, Dr. Linda Brown and I wrote a grant which would use master’s prepared advanced practice nurses to improve human milk and breastfeeding outcomes for moms who had babies in the neonatal intensive care unit. When I finished my Ph.D., that big National Institutes of Health grant got funded, and that’s why I stayed. We did that study from 1996 to 2001, and that’s how I ended up doing this for my career. It wasn’t planned, but I’m thankful every day. I get to make the world better for moms and babies and society too, because ultimately this affects what happens to us as a society, as a world.
In addition to being a professor at Penn Nursing, you are director of the lactation program at the Children’s Hospital of Philadelphia. When did you get involved there?
After I finished working on that NIH grant, I was recruited by the director of neonatal nursing at CHOP. At that time, CHOP had one person who was an International Board Certified Lactation Consultant, and no program to systematically address the needs of the whole enterprise. Their human milk rates were really low. It was not ideal. I basically established the systematic, hospital-wide approach where we don’t just have lactation consultants, but we also have over 800 nurses who are really educated and smart on the topic.
Tell me about the CHOP Mothers’ Milk Bank.
Part of what we do is the provision of pasteurized donor milk. That’s for a mother who for some reason was struggling with milk supply—maybe she had a breast reduction surgery or something like that and she couldn’t establish a normal supply. Pasteurized donor milk is much better to put in an infant’s belly than formula. CHOP has been using pasteurized donor milk for over 10 years. The donation process, though, for mothers that had extra milk, would be to ship the milk all the way out to Ohio, it would be pasteurized there, and then we would have to buy it back, which doesn’t really make a lot of sense. So, about five years ago I had put in a proposal to the administration at CHOP that I wanted us to become our own milk bank. They initially said ‘no.’ But I’m a researcher and I collect data, so I then collected data, and found we were shipping more milk to Ohio than we were buying back. From a financial standpoint, it doesn’t make sense. We put in an application to become a milk bank and that’s through the Human Milk Banking Association of North America, which governs all the nonprofit milk banks. In April 2014, we got approved to be what is called a ‘milk bank in development.’ After an accreditation process, we officially became our own milk bank in October 2015. We have plenty of milk and plenty of donors. We’re able to meet the needs of our babies.
An important message, though, for the public to understand is that donor milk is not a replacement to mom’s own milk; it’s a supplement, or it’s better than the alternative of formula. Formula is really risky, especially for a baby who is sick at birth. The most important thing for all babies, whether they be healthy babies or sick babies, is for them to receive their own mom’s milk.
How long does the milk last once it’s pasteurized?
Once it’s pasteurized, a year in the freezer. Over at Children’s Hospital in the NICU alone, we have 28 freezers. They’re jumbo, subzero, negative 20 degree freezers. When you pasteurize milk, basically what you are doing is you are heating it up to 62.5 degrees Celsius, which kills any potential harmful bacteria while still retaining most of the good stuff. Then the milk gets cooled down and we freeze it until we need to dispense it to use for the baby.
You mentioned mom’s milk is the best for babies, especially when they are sick. But why is it that so many women don’t know that?
Think about if you grew up in a community and you weren’t breastfed as a child, and your sister wasn’t breastfed, and no one in your family ever has breastfed. You’ve never seen a baby breastfed in your whole life. What would all of a sudden make you want to wake up one day and think, ‘I should breastfeed my baby.’ I just met a mom this morning actually over at the hospital. She didn’t breastfeed her first baby but now her second baby is going to get delivered with us. I said, ‘Tell me how you came to your decision about not breastfeeding your daughter?’ She was like, ‘Everyone in my family formula feeds, we formula feed.’ Like, there was no reason to even think about breastfeeding; she had no idea. As soon as I gave her a little bit of information, she was like, ‘Well, I didn’t know any of this.’ If you don’t get the education, if you don’t have the family support, if people in your family think breastfeeding is gross or nasty or sexual, it’s going to be really hard for the mom to make the decision to want to start breastfeeding, and also want to keep breastfeeding.
Family support is huge, culture is huge, the role of formula company marketing is—well, we have the U.S. to thank for that. We’ve ruined breastfeeding around the world. It’s big business in the U.S. Have you ever heard of the Women, Infants, and Children [WIC] program? It’s a government-funded program and it provides food and supplemental nutrition for women and children who are up to 185 percent of the poverty level. Believe it or not, you’re going to be shocked by this, 50 percent of child-bearing women in the U.S. are on the WIC program. WIC spends 25 times as much money on infant formula than they do on breastfeeding promotion. It doesn’t seem right. Think about on Capitol Hill, this is big business and if the formula companies are in business, it also keeps the dairy farmers in business and it also keeps the soybean farmers in business. We have a capitalistic model of society. And women get directly targeted. If you get pregnant and sign up for prenatal care, they start shipping you coupons in the mail, free formula in the mail. Formula companies are very savvy, they’ll all say, ‘Breastfeeding is best,’ but they will talk about this special ingredient in their formula. If moms don’t know, how would you make a different decision?
There’s so much work to be done in terms of helping people to really understand the science of human milk. Human milk protects babies from all kinds of infectious processes, it increases brain mass and improves tests of IQ and developmental outcomes, advances feed tolerance, and so much more. Plus, it maintains all kinds of cool ingredients that will never be in formula, like stem cells, white blood cells, antibodies, and antioxidants.
Your work has been published in hundreds of medical journals. Tell me about some of your biggest findings.
I would say if we want to just look at two major buckets, one would be my work with human milk and breastfeeding in vulnerable populations. That’s babies who are in the neonatal intensive care unit, babies who are in the cardiac intensive care unit—any time when the mom and baby are separated at birth. In the U.S. and around the world, often all of the focus has always just been on healthy term moms and babies. And that’s great, but if you have a sick baby, these are kids where human milk is like a lifesaving medical intervention. It’s not a nice-to-do, it’s a need-to-do. And we have to have different models of care. The 10-step model I developed and published back in 2004 focuses specifically on the needs of critically ill babies, and it walks that mom through the pathway of first making an informed decision to taking her baby home and breastfeeding, if that’s her goal. This model has been implemented and tested in the United States and other countries.
Last year I was in India for my sabbatical doing some work, training nurses, and in every single NICU I went into, all the babies were getting formula as their first feed. There was no focus on the moms initiating supply, getting supply, maintaining supply. And babies are dying because of not getting their moms’ own milk. This is so critically important to save the lives of our children and to help them be healthier, and also be more productive into adulthood.
The second bucket area for me is the critical role of nurses in lactation support. Think about it: 100 years ago, everyone just breastfed. Or you found a wet nurse. You didn’t have options. Formula came around the same time as World War II. Our whole breastfeeding culture vanished. Then when the hippies came about, you started to see this research and breastfeeding in the late ’60s, early ’70s. But at that point there’s a whole generation lost. Then you have the La Leche League. It’s like mother-to-mother support. Then from the La Leche League came the International Board Certified Lactation Consultants. But the thing is, in America for example, there are three IBCLCs for every 1,000 babies that are being born. Clearly, not every mom is going to get seen by a lactation consultant. Who’s the person there 24 hours a day, seven days a week? The nurse. They are in the hospital, they are in the community. Globally, nurses are the biggest profession of health providers. If nurses don’t have the knowledge, the skills, the evidence, we’re going to fail. Research I’ve conducted, as well as my doctoral students have conducted, it’s proven: The nurse is critical. Whether or not they give breastfeeding support is critical, and it influences outcomes. I’ve published about that here at CHOP, down in Florida at Tampa General Hospital where they implemented my model. I’ve done statewide trainings for the whole state of Florida; I just did a statewide training for Massachusetts. I’m getting ready to get on a plane tomorrow to go to Hawaii to do statewide training.
I know you were also just in the Dominican Republic, too. You travel so much. What’s that experience like?
It can be hard. For instance, it’s hard to go into a country like the Dominican, which is one of the poorest countries in the entire world. People don’t have indoor plumbing, they don’t have electricity, the government might not turn on the water. It’s not like when you go to Punta Cana. Then you have moms who are out there spending their money, which they have none of, to go buy formula because they think there’s something magical about formula. There are all these myths and misconceptions. I did talks in four different hospitals and I did education sessions with both nurses and physicians. I love traveling and I love helping people learn how to utilize evidence and change practices and really be able to implement my model. But it’s also really draining because it is really hard to see. The whole reason women have breasts is to feed their babies. That’s why they are there. Maybe they look good. Maybe they can be used to sell products. But the whole reason women have breasts is to breastfeed. But there are so many global challenges.
You get to work with families often, too, right?
I do. It’s wonderful. In the Children’s Hospital of Philadelphia, we have the Center for Fetal Diagnosis and Treatment, where families come when they have a baby with a known congenital anomaly. They already know before the baby is ever born that the baby is going to have something wrong. They will relocate from all over the place. I had a family about a month ago who moved from Indonesia. We have people from Alaska, Hawaii, all over the U.S., Canada, and Europe. For the moms who are going to have their babies in the NICU at CHOP, which means their babies are going to be critically ill, I have an opportunity to meet them before they deliver. I do a prenatal nutrition lactation intervention with the mother and her family and we talk to them about the science of human milk and about why human milk is important for their baby. If they were not interested in breastfeeding to start with, I teach them why human milk is a medical intervention. Ninety-nine percent of our moms pump for their babies. If you give people the evidence, they want to use it. I also follow up with them in the NICU after they deliver. We also, though, are of the belief that a mom shouldn’t just have to come see me. Every single one of her nurses should be able to answer her questions. That’s why I developed the Breastfeeding Resource Nurse model, where our nurses are empowered to provide evidence-based lactation care and support.
Tell me about how you worked with the U.S. Surgeon General in 2011, and also about your recent Lifetime Achievement Award from the National Association of Neonatal Nurses.
When Dr. [Regina] Benjamin was in office, she was actually the first surgeon general who really gave an extensive report on what we need to do in the United States to change the landscape of breastfeeding. I had the opportunity to provide testimony for that and work with her on that. Now, one of my volunteer jobs is on the U.S. Breastfeeding Committee, and I represent the American Academy of Nursing. The U.S. Breastfeeding Committee is now responsible for seeing that the call to action gets followed through on. To give one example, the USBC has published core competencies about what health professionals need to know about breastfeeding. I was one of the people who wrote those core competencies. They’re now being used by all health professionals, probably all around the world. The Lifetime Achievement Award, the fun part about that was that I was nominated by colleagues and I had no idea. My first thought about it when I got it was that I’m not old enough to have a Lifetime Achievement Award. I said to my husband, ‘I guess I can just retire now.’ He didn’t agree with me though.
I’ve heard that you often tell your students, when they are one day having babies of their own, that they shouldn’t hesitate to contact you with any questions.
That’s how I am. No woman should have to have a bad breastfeeding experience. I feel so strongly about that. In February, when I was up in Massachusetts doing the statewide training for nurses, a friend of mine had her baby early. The baby was breastfeeding like a champ at the hospital, but when they got home, it was a disaster. See, the first two days, the baby is getting colostrum, and the breasts are kind of soft, it’s pretty easy for the baby to breastfeed. When you have the onset of lactogenesis II and the mature milk comes in, the breasts get really heavy and really full. This tiny baby was 5 pounds, 14 ounces, and when the milk came in the baby had no idea what to do. My friend was like, “How soon can you get here?” She had way too much milk in the breasts so she had to pump. I set her up and taught her to pump. Then she was able to get the baby on. I told her to rest and explained how her husband could help her. I left and was checking in, and she asked me to come back, which I was already planning to do. I thought she needed a nipple shield, which is a tool we tested and researched way back in my first grant. It’s this thin little silicon shield that basically helps babies latch on if they are having a hard time. So I’m up in Boston like, ‘Why didn’t I pack a nipple shield in my suitcase?’ I’m going to Targets around the city to find a nipple shield. She ended up not needing it long term, it was a temporary thing to help the baby. Now she’s exclusively breastfeeding. In eight weeks, the baby grew to over 10 pounds. But, if she didn’t have that support and if she wasn’t highly motivated and didn’t have a supportive partner, she could have easily gotten home and said, ‘This is too hard, I give up.’ That happens to many women. The beginning is hard. You might have some challenges, and it is time-consuming. But when the babies are older, it’s fun. There’s a special bonding and relationship. When moms start breastfeeding, but they don’t keep breastfeeding and never could get to the point that it’s fun, it makes me sad.
Tell me about the classes you teach.
In the School of Nursing, I lecture to freshmen, I lecture to the midwives at the master’s degree level, I do a little bit of everything. But my main course I teach is a whole semester course on breastfeeding and human lactation. In the School of Nursing, we have what are called undergraduate case study or seminar courses, which are on a content area. The course is 28 hours of lecture and 14 hours of clinical experience. I teach that both semesters. Then, at CHOP, our course for our nurses are two eight-hour days. If you work in the NICU or the Special Delivery Unit, it’s a requirement. We have over 800 nurses who have been through that two-day course that are currently at CHOP.
Also about 11 years ago I started the Human Milk Assembly, which is a half-day session where we bring in nurses from outside hospitals to talk about best practices for human milk and breastfeeding in the NICU. I also developed a one-day specialist class that I take across the world. I’d say there’s probably been well over 2,000 graduates of that one-day specialist course.
I also advise a lot of students. I love students. I have four students doing their independent research projects with me this semester, and that’s not counting my seminar students doing projects. I also always have students work with me on my research projects. I am also the faculty adviser to our student nurses group at Penn, which is a pre-professional organization for nursing students. I think it’s so important to mentor, and for people to have good mentors.
How do you manage everything with all you have going on?
My husband says I should fire my scheduling secretary.
Which is you?
Which is me. I definitely work a lot. But I enjoy what I do so it makes it OK. I love students, I love families, mothers, and babies. I really care about people. I guess that’s one of the reasons why I can do everything. I also keep a lot of lists.
