"Making our Next Generation Healthier": Q&A with Diane L. Spatz, PhD, RN-BC, FAAN

Diane L. Spatz, PhD, RN-BC, FAAN, nurse scientist at CHOP, is an internationally recognized expert on breastfeeding and human lactation.

To recognize National Nurses Day, a special observance held May 6, and National Nurses Week, we sat down with Diane L. Spatz, PhD, RN-BC, FAAN, an internationally recognized expert on breastfeeding and human lactation, and a nurse scientist focused on lactation in the Center for Nursing Research and Evidence-based Practice at Children’s Hospital of Philadelphia. Dr. Spatz is also a professor of Perinatal Nursing & The Helen M. Shearer Professor of Nutrition at the University of Pennsylvania School of Nursing. Ever innovative and always inspiring, Dr. Spatz joined CHOP 20 years ago and developed the hospital’s Breastfeeding Resource Nurse (BRN) Program. She has educated over 1,500 nurses at CHOP through the BRN program. In research on the outcomes of the BRN course, she and her colleagues have found that 90 percent of nurses educated provide direct breastfeeding assistance and support, in addition to mentoring other nurses who have not taken the course. Nurses reported being empowered through the evidence learned in the course, which motivated them to be advocates for their patients and to go the extra mile in supporting them on their lactation journeys.

Recently, Dr. Spatz was appointed to the World Health Organization (WHO) and United States Agency for International Development (USAID)’s task force on human milk and breastfeeding for small and sick babies. This month, the University of Pennsylvania School of Nursing also awarded Dr. Spatz with the Dean’s Award for Undergraduate Scholarly Mentorship — an honor that means much to CHOP, where Dr. Spatz mentors many students in research, quality improvement, scholarship, and writing for publication.

Meanwhile, Dr. Spatz continues to conduct impactful research aimed at improving education and access to human milk and breastfeeding, particularly during the COVID-19 pandemic and especially for infants from vulnerable populations. In this Q&A, Dr. Spatz shares with us some of her most exciting current and upcoming research projects, her advice for aspiring nurse scientists, and the big questions that continue to lead her quest to “make our next generation of society healthier.”

What drew you to nursing research and how long have you been a nurse scientist?

Last year marked 25 years of having my PhD. I went to the University of Pennsylvania for my BSN and my MSN, and I became interested in research while I was getting my master’s degree. I was asked to work on a study about factors influencing milk volume for mothers who have very low birth weight infants. We did home visits because the hospitals wouldn’t allow us to see mothers in the NICU at the time. When I did this research, I thought to myself, this is terrible — we have mothers with sick babies who want to do something to help their child, and no one is helping them. To me, it was soul-crushing and heart-crushing, and so I finished my master's degree, taught briefly, then came right back to Penn for my PhD.

What brought you to CHOP?

Following receipt of my PhD, between 1995 to 2000, I got a large NIH-funded intervention study to improve human milk and breastfeeding outcomes for sick babies in the NICU. And when that grant ended, I was recruited to CHOP. In 2001, CHOP had only 1.0 FTE of IBCLC support, only a handful of lactation rooms, and no systematic approach to human milk and breastfeeding. My entire career has focused not only on how we do research in the field of human milk and breastfeeding, but also how we effectively translate that research to clinical practice so that people do what they should do to have better outcomes.

Can you tell us more about your research specialties?

My research area is really anything related to the field of human milk and breastfeeding, and I would say that I also have a special interest in vulnerable families. That includes the infants and families in the Center for Fetal Diagnosis and Treatment, but also other groups where there are tremendous disparities in breastfeeding initiation, exclusivity, and duration. Examples of such are low-income families, African American families, adolescent parents, and same sex mothers. I’ve researched many facets with an eye to how to change and improve interventions to be able to have more infants receive more access to milk for longer periods of time.

What are some of the research questions you hope to answer, or research projects you’re excited about?

There are really more unanswered questions in this area than there are answers. But one new project that got put on hold due to the [COVID-19] pandemic is my work with a startup company who designed a bra that can warm and massage your breasts while you are pumping. The idea is that you could improve breast emptying and empty the breast more efficiently and effectively while using the bra. When you look at the function of the lactating breast, the fuller the breast is, the less fatty the milk is, so it's lower calorie. The emptier the breast is, the richer the milk is, and thus the more fats are concentrated. So, the more effectively you can remove milk from the breast, that means you not only get higher quality, rich, creamier milk for the baby, but it also means you drive milk supply. That's what sustains milk production long term. We’re hoping that things are getting better, and we’ll be able to get that clinical trial underway soon.

We also have another study that we have just finished with the Angel Eyes camera system, which allows you to look at your baby. We have been doing qualitative interviews with mothers to understand if they use the camera system as part of their lactation journey. It’s interesting because some mothers believe it helps them with pumping and milk ejection and they believe they can express more milk while using the camera system. So based on this qualitative data, the next step would be to design a trial that would actually measure milk output and caloric density to determine if the breast was more effectively emptied while pumping while engaged with the camera system.

You do some great global research work. Could you tell us a little bit more about that?

For over 15 years, I have been implementing my 10-step model for human milk and breastfeeding both in the United States and globally in countries such as Thailand, India, Japan, and now Botswana. Through research with my on-the-ground colleagues, we have learned that both healthcare professionals and parents have little to no knowledge about the science of lactation and the physiology of milk supply. In Botswana, when parents have babies, often days will go by before the mother starts expressing milk because no one guides them to do so when the babies are not able to eat. There is a very critical window to effectively establish milk supply (which we have studied and demonstrated here at CHOP) so the mothers in Botswana — because of the lack of breast stimulation and effective emptying — don’t even have a chance to ever have a normal milk supply because the critical window is missed.

This is a huge global health problem that really hasn't received sufficient attention. The WHO recommends that healthy babies should go to breast within one hour of birth. But all around the world, only about 43 percent of babies actually do. And if you look at moms and babies who get separated, we are setting people up to not effectively make enough milk for their baby. This is worrisome.

Meanwhile, in the U.S., we have more people interested in starting breastfeeding or trying breastfeeding. But our continuation rates have not really gone up. They're pretty terrible, which means there are many people out there who are having problems and not getting the help they need. And so, therefore, they may tell their friends that ‘breast feeding is horrible, I tried it. The baby wouldn't latch, I could make enough milk.’ But we're not going to be able to ever get to a better place where more of our babies are getting the milk for longer periods of time because we're not helping families get off to an appropriate start.

You’re also conducting some critical work right here in our community. Can you tell us about that, too?

A few years ago, one of my doctoral students did research at Karabots with African American mothers to understand the facilitators and barriers of breastfeeding initiation. A recent publication from this work interviewed subject matter experts, people who have worked in the field of breastfeeding with the African American community. We took the focus group data collected at Karabots and compared and contrasted it to that of the subject matter experts to see where there were areas of agreement or areas of perhaps disagreement, and there were mostly areas of agreement.

If you look at published breastfeeding research, you see black families very underrepresented. And that is because the rates of breastfeeding are lower in this community. There are tremendous disparities — about 20 percent disparate compared to white women. However, we also do know that some black families do chose to breastfeed and do breastfeed their babies for a year or more. We just haven’t been providing African American women with the information they need to make informed choices and the appropriate resources to help really make breastfeeding work for their lifestyle.

So, myself and my BSN to PhD student just launched a national mixed methods study about African American families who breastfeed for 12 months or more. The study just went live in April, and we have already had over 300 participants fill out the online survey and over 60 requests to do online qualitative interviews. What is really exciting about this work is to hear the voices of these women and learn from them how they were able to navigate their lactation journeys and breastfeed for a year or more. How was it that they were able to make it work for their lifestyle so that we could help other African American mothers have that same opportunity as well? I'm very excited about this research because it really builds on what we've done so far and then also to tell these stories of how these women can be able to meet their goals.

You also led a recent COVID-19 call-to-action, published in Frontiers in Pediatrics.– What prompted you to write that?

Sure. Early in the pandemic, Elizabeth Froh, PhD, fellow nurse scientist, and I interviewed first-time mothers in Philadelphia who gave birth during the pandemic, and we found a lot of concerning things, including feeling of guilt, stress. That’s because the recommendations were changing every day for parents; they received inconsistent information, and not enough technical hands-on support for breastfeeding. Telehealth may be good for some things, but it doesn’t replace actual technical assistance to get a baby latched and what not.

If you look at this from a global perspective, which I have from my work on the executive committee for the International Society for Research in Human Milk and Lactation (ISRHML), breastfeeding rates have dropped nationally and globally, there's been an increase in formula company marketing, an increase in formula use, a decrease in skin-to-skin contact, and an increase in separation. And it's worrisome that this going to become the new normal for families.

Tell us more about what the call-to-action recommends.

In the model that I developed from my NIH work, first published back in 2004, the first two steps are “informed decision making” and “initiation and maintenance of milk supply.” These two steps are essential — we first have to help all families make informed feeding choices to understand that human milk and breastfeeding are lifesaving medical interventions. In other countries, formula companies have marketed their product saying: ‘feed your baby our formula, then you don't have to worry about COVID.’ However, we know this is not true. Formula feeding does not prevent the infant from getting COVID. And in fact, when mothers have had COVID-19, researchers have seen a robust antibody response in the milk. They have even seen this same response with the vaccine. The second step related to milk supply is critical. Families must understand the critical window to effectively establish milk supply.

Unfortunately, breastfeeding, and breastfeeding care and interventions have been de-prioritized with the pandemic both in the U.S. and globally. One of my biggest concerns is that families who have resources and know a lot about breastfeeding will be able to pay out of pocket to rent a hospital-grade pump and/or hire a lactation consultant. But if you’re a low resource person or you don’t really know much about this, the disparities will get wider. So, in the call-to-action, we say, if you teach people the science of human milk, if you teach the physiology to a patient and help them make informed choices, they’re going to make the choice to breastfeed or provide milk. If you give them the interventions immediately post-birth to help them, get their supply started effectively, then they're going to be able to do that. We do have strategies that we know are effective, but right now that's not happening as standard of care. We really have to shift the current paradigm to really protect and preserve this most important thing that impacts not just the child, but the family and our society and our healthcare system at large.

Finally, congratulations on your recent Undergraduate Scholarship Mentorship Award from Penn! Do you have any words of advice for aspiring nurse scientists you can share?

I think it's really important to follow your passion. I am very lucky that I found out very early in my career that I love pregnancy and childbirth and babies. But many times in my career, I was told that I should change my research because breastfeeding is not highly fundable. But that's what I care about. I think passion is really important. I think that you need to be persistent. And then you need to think about why you're doing it. I'm doing it because of the people, because of the families and the babies. Because I want to make our next generation of society healthier. I want us to have better health outcomes, spend less money. I want people to be able to provide milk to their child and to have a lactation journey that is a good journey.