DiversityNursing Blog

Baby Who Can't Open Mouth Celebrates First Birthday

Posted by Erica Bettencourt

Mon, Jul 28, 2014 @ 12:51 PM


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Wyatt Scott turned a year old earlier this summer, but he ate his birthday dinner through a tube in his tummy.

It’s been more than four months since the Scott family launched WhatsWrongWithWyatt.com to find out why their baby boy can’t open his mouth, and though they’ve been flooded with emails, their little boy’s condition remains a mystery.

Wyatt’s lockjaw has baffled doctors since he was born in June 2013 in Ottawa, Canada, and though the Scott family has taken him to every specialist imaginable, they can’t figure out the root of the problem, Andrew Scott said. Wyatt spent the first three months of his life in the hospital, and his parents have had to call 911 several times because he's been choking and unable to open his mouth.

So Wyatt's mother, Amy, decided to create a website, WhatsWrongWithWyatt.com last spring in the hopes that someone would recognize the condition and offer a solution.

Wyatt's doctor, Dr. J. P. Vaccani, told ABC News in April that the condition, congenital trismus, is rare and usually the result of a fused joint or extra band of tissue. But Wyatt’s CT and MRI scans appear to be normal.

"It's an unusual situation where he can’t open his mouth, and there’s no kind of obvious reason for it,” Vaccani, a pediatric otolaryngologist at Children’s Hospital of Eastern Ontario told ABC News. “Otherwise, he’s a healthy boy."

Andrew Scott said he’s sifted through 500 emails submitted to WhatsWrongWithWyatt.com over the last several months, and compiled a list of the most important ideas to give to Wyatt’s doctors. One letter-writer from Virginia told the Scotts that Wyatt’s story made her cry because her now-14-year-old had similar mysterious symptoms.

“She could have written it herself,” Andrew Scott recalled her saying.

Though the Virginia 14-year-old underwent surgery and therapy, Andrew Scott said Wyatt seems to have something different.

“It’s not just that his mouth doesn’t open,” he said.

Wyatt underwent a study in which doctors X-rayed him while he was feeding to see how the muscles in his mouth and throat worked. They found that he has problems with motor function and swallowing in addition to the lockjaw.

“His blinking is erratic,” Andrew Scott added. “He’ll wink on one side a bunch, then the other side and back and forth.”

Their quest for answers has been slow. A recent muscle biopsy came back negative, and Wyatt is awaiting results of his third genetic test.

Since the website launched, Wyatt had a major health scare: he stole a piece of chicken off his mother’s plate and put it in his mouth, Andrew Scott said. His lips were parted just enough to get it in, but neither of his parents could get it out, so they pulled it out in pieces. They thought it was all gone when Wyatt fell asleep.

Then, Wyatt started choking.

“He almost died,” Andrew Scott said. “I ended up just giving him breath.”

Wyatt “came back” just as ambulances and fire trucks arrived, Andrew Scott said. At the hospital, doctors scoped Wyatt’s lungs, but he was still coughing up chicken pieces several days later.

The emergency forced doctors to use anesthesia to put Wyatt to sleep, which they were too afraid to do before because they feared he would stop breathing. While he was out for the lung scope, the also did a muscle biopsy and put in a G-tube. Now, instead of being fed through a tube in his nose that leads to his stomach, Wyatt can “eat” through a tube in his belly.

Wyatt’s birthday party at the end of June was a pig roast that drew 50 people and included a piñata, goats and a trampoline. Though Wyatt didn’t get any mashed-up pig in his G-tube, Andrew Scott said “maybe next time.” By the end of the party, Wyatt was sound asleep in the grass.

“He is a very happy baby,” he said.

Source: http://abcnews.go.com

Topics: Wyatt, unknown, mouth, motor skills, lockjaw, baby, doctors, hospital

Girl 'Cured' of HIV at Birth Now Has Virus, Doctors Say

Posted by Erica Bettencourt

Mon, Jul 14, 2014 @ 01:34 PM


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A girl believed to be “cured” of HIV at birth now has detectable levels of the virus, health officials said today.

The unnamed girl, dubbed the “Mississippi baby” after being born to an HIV-positive mother in 2010 and quickly treated with an intense dose of antiretroviral medication, showed no signs of the virus for roughly four years, according to the National Institute for Allergy and Infectious Disease. But a recent round of tests revealed detectable levels of HIV in her blood as well as antibodies to the virus and a decreased T-cell count -- all signs of the infection.

“Certainly, this is a disappointing turn of events for this young child, the medical staff involved in the child’s care, and the HIV/AIDS research community,” NIAID director Dr. Anthony Fauci said in a statement. “Scientifically, this development reminds us that we still have much more to learn about the intricacies of HIV infection and where the virus hides in the body.”

The case of the Mississippi baby made headlines across the globe after being published in the New England Journal of Medicine. Dr. Hannah Gay, the University of Mississippi Medical Center pediatrician who treated the infant at birth, was listed as one of Time magazine’s most influential people of 2013.

Gay's decision to give the newborn antiretroviral medication in the days before it was confirmed that she was in fact HIV-positive was controversial, since there was only a 25 percent chance that the girl would contract the virus from her mother.

The girl continued treatment for 18 months before her mother stopped taking her to her clinic appointments. Five months later, when she went back for a check-up, she surprised doctors with undetectable levels of the virus.

At first, Gay and her colleagues said the baby had been “functionally cured” of the virus, but later revised their language to “remission” to better convey that there was a chance the virus could rebound, they said at the time.

Although the girl's positive test results have been described as a disappointment, experts say her case still shows tremendous progress in treating the virus that causes AIDS.

“The fact that this child was able to remain off antiretroviral treatment for two years and maintain quiescent virus for that length of time is unprecedented,” Dr. Deborah Persaud, professor of infectious diseases at the John Hopkins Children’s Center in Baltimore, said in a statement released by NIAID. “Typically, when treatment is stopped, HIV levels rebound within weeks, not years.”

Persaud is one of the two pediatric HIV experts involved in the ongoing analysis of the case.

“This virus is amazingly recalcitrant,” said Fauci. “It’s in reservoirs, except we don’t know every place in the body where the reservoir is going to be.”

NIAID and the National Institute of Child Health and Human Development announced today that they would provide funding to analyze the unique case and will take the new findings into account during a new clinical trial.

Source: abcnews.go.com

Topics: virus, cured, baby, HIV

Keep that bun in the oven: Induced births falling in the U.S.

Posted by Erica Bettencourt

Mon, Jun 23, 2014 @ 01:00 PM

By Joan Raymond

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Today's expectant moms and their doctors have decided it's not nice to fool Mother Nature. Rather than inducing labor, they're letting nature take its course, with the length of pregnancies in the U.S. on the upswing, according to a new study by the CDC.

The study released Wednesday tracks labor started through surgical or medical means during the years 2006 through 2012. The researchers found that induction rates at 38 weeks — once considered full-term gestation but now called an early-term gestation — declined for 36 states and the District of Columbia during this six-year period. Declines ranged from 5 percent to 48 percent.

Geography didn’t seem to matter. Thirty-one states and the District of Columbia posted declines of at least 10 percent. The researchers did find that trends in induction rates at each week from 35 weeks, considered late pre-term, to 38 weeks, varied by maternal age. At 38 weeks, though, induction rates declined for all maternal age groups under 40, dropping 13 percent to 19 percent for women in their 20s and 30s.

This is a sharp reversal of trends tracked from 1981 through 2006 in which the proportion of babies born at less than 39 weeks gestation increased nearly 60 percent, while births at 39 weeks or more declined more than 20 percent.

“We were surprised that the overall induction rate went down,” says lead researcher Michelle Osterman, a health statistician with the National Center for Health Statistics, which is part of the CDC.

And it is welcome news, too. “For years we were taught that the 37th or 38th week of pregnancy was full term, but we did not appreciate the neonatal outcomes,” says ob/gyn Dr. Nancy Cossler, vice chair for quality and patient safety at University MacDonald Women’s Hospital in Cleveland, Ohio. 

“It was an ingrained part of our culture that 37 weeks is OK, but it’s not necessarily OK for the baby,” she says, citing issues such as hypothermia, feeding difficulties and respiratory distress among infants born early.

Historically, MacDonald Women’s Hospital had a rate of about 11 percent for labor induction for non-medical reasons among patients who were 37 to 38 weeks pregnant. Today, it’s nearly zero. In 2013, only one birth among the 37 to 38 week gestational age was done through induction. The patient had metastatic breast cancer, which is not among the usual listed criteria for medical induction, and needed to start chemotherapy and needed an early delivery, says Cossler.

Indeed, there is a big push nationally for longer-term births, such as the large-scale educational program called the 39-Week Initiative, supported by the March of Dimes and other groups. It seeks to end non-medically indicated deliveries prior to 39 weeks. Last year, the American Congress of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine even recommended the label “term” in pregnancy, be replaced with categories based on gestational age. Today, babies born at 39 weeks through 40 weeks and six days of pregnancy are considered “full term.” Babies born at 37 to 38 weeks are now considered “early term.”

“I think this study is very positive since several of us have now provided evidence that babies have better outcomes (with longer term births),” says Dr. Kimberly Noble, assistant professor of pediatrics at Columbia University.

In a study published in the journal Pediatrics of 128,000 New York City public school children, Noble and her colleagues found that compared to children born at 41 weeks, those born at 37 weeks had a 33 percent increased chance of having third-grade reading problems, and a 19 percent increased chance of having moderate math issues.

But doctors do worry that the pendulum could swing too far and patients may be afraid of induced deliveries. 

Our study “can’t differentiate between induction done for medical reasons and induction done for convenience, and if your doctor says this baby needs to come out at 37 weeks because of a problem, you need to trust your doctor,” says Noble, citing issues such as maternal or fetal distress as a cause for earlier delivery. What patients and doctors shouldn’t do is schedule an earlier delivery because of a vacation or other issue. “We know that 39 weeks and beyond is good for the baby,” she says.

Source: today.com

Topics: health, baby, pregnant, nurse

For Mothers at Risk, Someone to Lean On: N.Y.C. Nurses Aid Low-Income First-Time Mothers

Posted by Alycia Sullivan

Thu, Jan 10, 2013 @ 04:46 PM



The tattoo below Joanne Schmidt’s right ear says “Jesus” in Hebrew. On the back of her neck, under a short crop of dyed red hair, is a second tattoo that says “Bad Girl” in Chinese.

“That was from my earlier period,” she said.

On a drizzly December afternoon, Ms. Schmidt was in the Throgs Neck section of the Bronx to visit Elizabeth De la Rosa, who is 19 years old, single and was about as pregnant as a person can be. On this day, which happened to be the date her baby was due, Ms. De la Rosa was living in her mother’s apartment, a surprise to Ms. Schmidt, 37, who had been visiting her since early in the pregnancy — sometimes at a homeless shelter, sometimes at Ms. De la Rosa’s aunt’s. Ms. De la Rosa and her mother had a history of bitter arguments, which had landed the daughter in counseling at age 14.

“I must say,” Ms. Schmidt said mildly, “I’m glad that you and your mom are getting along.”

“We don’t fight when I’m at my aunt’s,” Ms. De la Rosa said.

“Did your mother ask you to move back?” Ms. Schmidt asked.

“My sister did.”

As the two talked, Ms. De la Rosa’s mother watched television in her bedroom. There were many things to discuss:

How was Ms. De la Rosa feeling? (Impatient.) Did she have headaches or blurry vision? (Headaches.) Did she tell her doctor? (Yes.) Was she still planning to get a job and find her own place? (First she wanted to get her high school equivalency diploma.) Did she need a referral? Did she have a day care plan? Was she considering any schooling beyond the G.E.D.? How long did she plan to breast-feed?

Discussion circled back to her relationship with her mother. Ms. Schmidt, who did not get along with her own mother, nodded sympathetically and recorded Ms. De la Rosa’s answers on printed sheets that she kept in a thick folder.

Afterward, in her government-owned Prius, Ms. Schmidt confided that she was worried. “What happens when this baby’s born and her mom tells her she’s doing something wrong? Elizabeth says she doesn’t want it to get physical, but that it can get physical. She’s very strong-willed. I’m going to ride it out.”

Her face showed her further concern: In a home with physical violence, little money or resources, with a nonsupportive father, what sort of life prospects would Ms. De la Rosa’s baby have?

“I know these girls because I come from the same background as they do,” Ms. Schmidt said, adding that of the young women she visited, Ms. De la Rosa had one of the more stable home situations. “There were a few times when I found myself on the streets,” Ms. Schmidt said — “no apartment, I was cut off of welfare, living from place to place. I lived out of my car for a while. With my son.

“So my story is very much these girls’ story. And it just takes one person, one person, to just say, ‘You are worth it. You’re not a terrible person for the mistakes and the things you’ve done in the past. You may have gone through whatever, but there’s a way out.’ ”

She did not need to say that for her clients, 15 at any time, she intended to be that one person.

Joanne Schmidt is a nurse for the New York City Department of Health and Mental Hygiene, in a program called the Nurse-Family Partnership, which matches specially trained nurses with low-income first-time mothers, starting during pregnancy; they meet at the mother’s home every week or two until the child’s second birthday. She is also a daughter of the soul singer Sam Moore, of Sam and Dave — a quick-eyed woman with freckles and a Rochester accent that adds a Midwestern flavor to mild oaths like “jeez Louise” or “shut the front door.”

Raised mostly by her maternal grandmother and aunt, she was not told until age 8 who her father was, or why she looked different from her German relatives.

After high school, she said, “that’s kind of when my life went — ” she made a screeching sound like a rocket veering out of control. “I didn’t realize I was following my mother.” For years she was by her description a “groupie” on the hip-hop scene; now she is a Christian, a PTA president, a mother to a 16-year-old and a partner with his father. And a nurse.

Her unit takes the hard cases: mothers in foster care, homeless shelters or Rikers Island.

babyThe program, which was started in upstate New York in the 1970s and has been adopted in 42 states, is one of the rare public initiatives that have shown consistent and rigorously tested benefits for the mothers and children, as well as significant savings for taxpayers.

In different studies on different demographic groups, women in the program have had fewer premature deliveries, smoked less during pregnancy, spent less time on public assistance, waited longer to have subsequent children, had fewer arrests and convictions, and maintained longer contact with their baby’s fathers. Their children have had fewer language delays and reported less abuse and neglect, slightly higher I.Q. scores, fewer arrests and convictions by age 19, and less depression and anxiety.

A 2011 study of New York City’s Nurse-Family Partnership program, which currently has 91 nurses serving 1,940 families, projected that by the time a child in the program turns 12, the city, state and federal governments will have saved a combined $27,895, with additional savings thereafter — more than twice the program’s cost per child. The study was conducted by the Pacific Institute for Research and Evaluation using data from the Nurse-Family Partnership’s research at three locations, then extrapolated to New York.

This fall, I attended a dozen home visits, all in the Bronx, with five nurses — three from the Visiting Nurse Service of New York, which contracts with the city to provide service in the Bronx, and two, including Ms. Schmidt, with the health department’s Targeted Citywide Initiative, which tackles the most at-risk cases. The nurses’ styles and backgrounds varied; the families’ needs and challenges even more so. Each mother participated voluntarily and at no cost.

The problems were many: violence on the street, abuse in the women’s past, illness, anger, obesity, insecure housing or financial circumstances. Most of the women had the poor luck to have been born in poverty. Like their middle-class counterparts, none came into the world knowing how to raise a baby.

At the Andrew Jackson Houses in the South Bronx, Rose Mendoza and her nurse, Susan Spadafora, were discussing Ms. Mendoza’s plans for the next week. She had a doctor’s appointment for her son, Mason, who is about 17 months old, and an appointment to get an assessment from her psychiatrist, so she could receive counseling for her longstanding temper problems. Previous attempts to get this assessment had failed, often ending with Ms. Mendoza in a tantrum.

“If she’s not there,” Ms. Mendoza said of the psychiatrist, “I’m going to be mean.”

“You don’t have to be mean,” Ms. Spadafora said. She commended Ms. Mendoza, 26, for her progress in controlling her temper since the baby’s birth.

“She’s always late,” Ms. Mendoza said. “And I get frustrated to have to wait.”

Patiently, Ms. Spadafora, 52, who works for the Visiting Nurse Service of New York, walked her client through steps they had discussed for dealing with unresponsive clinic staff members without blowing up. Several times, the nurse has gone along on appointments to demonstrate ways to ask questions and elicit better treatment. Part of her work, she said, lies in modeling good habits.

“Susan’s changed a lot for me,” said Ms. Mendoza, who dyes her hair flaming red and has a gold stud by the corner of her mouth. “A lot. Like how to deal with things, how to think before you speak. Don’t just blurt it out.”

Most of Ms. Mendoza’s friends had children as teenagers, but she did not become pregnant until she was 24, with her long-term boyfriend, David. They both left high school in their senior years.

Hers was not an easy pregnancy. Ms. Mendoza weighed as much as 380 pounds and had diabetes and dangerously high blood pressure. Early tests showed that she was pregnant with triplets. One died in the womb, then a second. The third fetus and Ms. Mendoza were both in danger of not surviving.

On a late-November morning, Mason stared alertly at the action around him and babbled. He ambled from one part of the apartment to another.

Ms. Mendoza’s goal is to move out. Two people have been killed in the building since Ms. Spadafora started visiting, including one man who was shot in the daytime; Ms. Mendoza heard him screaming on the sidewalk at the pain, waiting for an ambulance that arrived too late.

During two visits I attended, Ms. Mendoza was adamant that she was going to get her G.E.D., study to become a pastry chef, apply for housing, get an apartment with David — “he’s a great father,” she said — and begin a new life with her new family. But she has been making such plans since pregnancy, Ms. Spadafora said.

“She seems to put roadblocks in front of herself,” the nurse said. “She’s registered for six or seven G.E.D. review courses. Always the obstacles seem real, but she can exaggerate them. Success can be as scary as failure. There’ll be more expectations if she gets a degree.”

Like other nurses I talked to, Ms. Spadafora finds herself trying to counteract certain practices of the babies’ grandmothers — like putting cereal in a baby bottle, which can lead to overfeeding. “Everybody wants a fat baby,” Debra Rivera-Oquendo, who works for the Visiting Nurse Service of New York, told me.

Though childhood obesity is not high on the national Nurse-Family Partnership agenda, it is a major concern in New York and especially in the Mendoza household, where obesity and diabetes are rampant. At 295 pounds, Ms. Mendoza was greatly slimmed down but still no waif. Her mother, who is also obese and diabetic, pushed back against the nurse.

“We’re trying to make tiny breakthroughs with the baby,” Ms. Spadafora said. “I’ll ask, ‘What things did your mother do that might have contributed to your obesity?’ She knows what her mother did wrong, and doesn’t want to do that with the baby. Rose is doing better with the baby than with herself.”

The visiting nurse program, though, is not for everyone. It makes demands on both nurses and clients, not least the demand for data, which means constant reporting and paperwork.

More than half of the mothers drop out before their child turns 2 — some because they successfully move into work or school, but others because they lose interest. In the original trials, 60 percent of mothers finished the program, but the rate fell to 42 percent as the program expanded — another impetus for more data-gathering.

For Joanne Schmidt, whose team has a far lower graduation rate because of the mothers’ challenges going in, each patient who drops out becomes an unsolved mystery.

“I wonder what happens to some of them,” she said. “I wonder if they went to school. I wonder if they’re out of jail. I try hard not to take it personal. They have their own life to live, and I made it through on my own with no help. A lot of these girls are tough. They know how to use their resources.

“It sounds cold, but I have to remember that this is my role. I can’t save the world. If someone drops, you wrestle with that for a second, then it’s, ‘all right, got to pick up the next client.’ That’s part of being a nurse, knowing you’re going to have clients that die on you. You have babies that die, you have clients that die. It’s sad to see, but it’s part of why you do what you do, and part of the reason everyone can’t be a nurse.”

The Monday after Ms. Schmidt’s visit to Ms. De la Rosa, the baby had still not arrived. The nurse was hoping the birth would fall on her own birthday, Dec. 12. She needed some good news. One of her patients, a 5-month-old boy born a month early, was in the hospital with respiratory syncytial virus, or RSV, an illness that can be fatal to premature infants. Another patient, who was born two months prematurely, was sick and not receiving treatment.

The two families were lined up back-to-back on her Monday morning schedule, along with a mother and her 3-month-old son who were living at Inwood House, transitional housing for homeless youths who are pregnant or have children. The mother, Nicola Brown, 19, said she had been physically and emotionally abused as a child, and verbally abused by the baby’s father.

Ms. Brown was the day’s first appointment, and she had good news: in part thanks to Ms. Schmidt, she had finished her training to become a home health aide. This after getting her G.E.D. in August.

Ms. Schmidt beamed at her. “Do you feel proud of yourself?” she said. “You should.”

Ms. Brown said she wanted to work for a while, then go to nursing school. She was seeing a mental health clinician because of lingering effects of her past abuse, she said.

 Ms. Schmidt was her second nurse in the program. She had not gotten along with the first, whom she described as loud and obnoxious. “Joanne has an upbeat personality, and it’s easy to trust her,” she said, adding that she did not easily trust people.

The meeting was the easiest part of Ms. Schmidt’s day. At the next appointment, in the Eastchester neighborhood, Natasha Pennant and her boyfriend, Aaron Pelzer, had a sick child, a new apartment, problems with Medicaid and stress from Ms. Pennant’s mother, who recently had shoulder surgery, and who relied on her daughter for help raising four foster children. Their daughter, Azalea, was born at 30 weeks, weighing one pound, 14 ounces.

“I feel everything is on me,” Ms. Pennant said. “With my mom and Azalea, and trying to find a steady job.” She was too busy with her mother to reapply for Medicaid, she said. Without the coverage, she did not have money to take her daughter to the pediatrician.

Ms. Schmidt asked how she was coping with the stress.

“Honestly, I’m going back to smoking,” Ms. Pennant said. Mr. Pelzer, who is trying to start a mobile app business, sat nervously by her side.

“When you smoke, where do you smoke?” Ms. Schmidt asked.

Ms. Pennant told a story about Ms. Schmidt’s visiting her in the hospital just after Azalea was born. For two days, Ms. Pennant was unable to go to her daughter in the neonatal intensive care unit because of a pounding headache, which the floor doctors were not treating. Ms. Schmidt pushed the nurses on the floor to have a doctor look into it. Finally, a doctor said that the pain was a side effect of spinal anesthesia and prescribed treatment. Ms. Pennant was able to see and hold her child.

“It was all because of Joanne,” she said.

Now Ms. Schmidt urged the couple to take Azalea to the pediatrician or the emergency room ASAP. “They cannot refuse to see you based on your inability to pay.” Because Azalea had been premature, Ms. Schmidt feared RSV, and was especially worried about delaying treatment. “I just went through this with someone, and the outcome is not going well,” she said.

The last visit of the day was the hardest: At Montefiore Medical Center’s Wakefield campus, a weary Stephanie Velez-Rivera, 23, lay with her son, Elisha, on her chest, trying to ease his weak cough. After eight days in the hospital and a week of illness before, he had lost half a pound and wasn’t eating or sleeping. The night before, he had rolled off his mother while she slept and onto the floor; in the morning, she said, the medical staff had interrogated her as if she had dropped her baby.

Now she worried that when her husband learned of the baby’s fall, he would be upset with her. During Ms. Schmidt’s last visit, Ms. Velez-Rivera’s husband had rejected a suggestion of couples counseling.

Ms. Schmidt did not criticize the husband. “His personality isn’t able to handle some of the things you can,” she said.

“He gets stressed out,” Ms. Velez-Rivera said.

Ms. Velez-Rivera, who has sickle-cell anemia, said that she had been raised in an abusive home, “physically, emotionally, verbally,” and that she was determined to make a better home for Elisha; the boy’s needs, she said, came before hers or her husband’s.

Ms. Schmidt had no easy answers. The child was very sick, the marriage was fraught, the mother was pushed beyond exhaustion — and still it was not too early to discuss birth control, so Ms. Velez-Rivera would not become pregnant again right away. The nurse promised to bring information at their next visit, and to check back in a few days.

Ms. Schmidt’s birthday came and went without Ms. De la Rosa delivering her baby. Instead of celebrating, the nurse went to a holiday party for the mothers and babies in the program. She asked her clients not to mention her birthday, saying the party was for them, not her.

By week’s end everything was still up in the air. Ms. De la Rosa’s doctor said he would wait until Dec. 18 before inducing labor. Ms. Velez-Rivera was fighting to keep Elisha in the hospital, saying he was still not eating well enough to be safely discharged.

Ms. Schmidt put away her work cellphone for the weekend, then picked up a message anyway.

“All my girls have a lot going on,” she said. “That’s their everyday life. I know that they’ll be O.K., and that the decisions they make will become the road they have to take.”

She took a deep breath. “I have to hang up my cape at some point,” she said. “You let it go, then you pick it back up.”

Topics: low income, support, NYC, first-time mother, baby, nurse

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