Feelings:
Shock
Denial
Fear & Confusion
Denial
Anger
Guilt
Helplessness
Failure to Bond with Your
Infant
Sadness
If you
have had a Caesarean Section or are too unwell to walk to the NICU to see
your Baby.
Before
your Baby can Breastfeed: Expressing Tips
What do I do if I need to Increase My Milk Supply?
Guidelines for the Collection, Storage, and Handling of Human
Milk for the Hospitalized Baby
Kangaroo Mother Care
Kangaroo Mother Care - Understanding Definition
How to put Kangaroo Mother Care into Practice in a New
Zealand NICU
Feelings
Having a baby is a time of celebration
for most families. But having a premature or sick baby in the NICU can bring
a mixture of emotions. These can range from joy, fear, satisfaction,
frustration, anger and shock.
At the same time, the family often
lacks a private space and the time needed to sort out these feelings.
Families often describe the sensation of being thrown into the deep end.
While coping with these emotions there is a baby to consider. For the
mother, recovering from the birth and sometimes a complicated pregnancy can
become a forgotten need.
Compounding these issues is the fact
that our culture is not very good about accepting strong displays of
emotion. - especially in public- and NICU’s are public places to begin
parenthood. There is strong pressure from society to behave “normally”, and
we take cues from others as to what behaviour is acceptable when we are
faced with new situations. . In the NICU families can feel scrutinized by
medical and nursing staff. Extremes of reaction are often not easily
accepted. Families may perceive their own situation to be sadder, more
frightening or even more joyous than the staff may feel is warranted. It is
bad enough dealing with a range of emotions without worrying about whether
you are doing the premature birth experience “right.”
Based on our experiences the most
helpful thing may be to acknowledge your feelings and, give yourself
permission to feel whatever you feel. Get support from those who love you
and know you best. What others may think of you is not really the most
important consideration, although it is understandable to believe this when
given that your child is in the care of “others”.
Shock
Mothers often
describe a feeling of numbness and being disconnected from what is going on
around them. They may describe apathy and confusion, and may also find it
difficult to eat and sleep. These are typical reactions to shock. You may
find yourself impatient and short tempered even around those who love you.
It may be a struggle to concentrate or to be patient even with loved ones.
Some of these factors may make it
Denial
Some families
cope by experiencing denial. In our experience it is particularly fathers
who cope this way. They may feel that there is nothing they can do, and they
are uncomfortable in the NICU situation seeing their child going through
this experience and coping with their own and their partner’s feelings.
This reaction
is common way of dealing with difficult and overwhelming emotional
situations. The parent who is experiencing denial may immerse themselves in
a busy work schedule in order to take their minds off things. It can be
especially difficult for partners to go through the NICU experience so
differently. The partner going through denial may feel the other partner is
overreacting. It may be helpful to acknowledge that everyone has different
ways of coping. Counselling may be helpful for some couples if long lasting
effects of the newborn unit journey has harmed the relationship.
Unfortunately, having a premature or sick baby is a known risk factor in
relationship break-up. Recognizing this and seeking help if you need it may
be the best immunity against this too- common negative consequence of the
NICU experience.
Fear and Confusion
Parents with
a premature baby or a sick baby in the NICU often feel fear. You may wonder
if your baby is going to survive or if he or she will be normal. These
feeling are reinforced as your baby is whisked away to the NICU from the
delivery room. The lights, monitors, and alarms all accentuate this
feeling. Seeing staff reacting quickly and crowding around the cot of
another baby or your own during a medical crisis emphasizes the
dangerousness of your baby’s situation. On the other hand, some
surroundings in the NICU seem at odds with these events. The juxtaposition
of scary looking medical equipment with staff laughing and gossiping,
nursery prints or Anne Geddes-like photographs of sick newborns on
ventilators on the walls, cutesy nametags, and stuffed teddy bears adorning
the cots of even very sick babies are unacknowledged ways of adding to your
feelings of confusion. Fear and confusion become a very normal part of the
NICU experience.
Anger
Another
common emotion. You may be angry at yourself, your baby’s doctors, a nurse
who spoke to you harshly or thoughtlessly, and your partner. Anger is one of
the hardest emotions to express and let go of appropriately in our culture.
Having a safe vent to express this emotion is a sanity saver.
Guilt
Most mothers
of premature babies wonder what they could have done to prevent it. If the
mother has had a health concern such as high blood pressure, she may blame
herself for this condition- feeling it was she who harmed the baby. Even
where the baby is born prematurely very unexpectedly and for no apparent
reason, it’s almost universal for mothers to wonder why and to search for
causes that they may have inadvertently contributed to the premature birth..
“I shouldn’t have had sex” I shouldn’t have exercised or gone on that trip.
I should have stopped working sooner. I didn’t eat right, or get enough
rest.” Mothers whose babies are born with congenital defects also feel this
way, and rack their brains to think of explanations. Family members can make
unhelpful contributions here. The vast majority of times, no one knows why
the baby is born prematurely. Research shows medications to stop premature
labour should only be used for about 48 hours and not long term. This is
partially because it’s believed the harm in stopping labour when the woman’s
body may be trying to tell her that the baby is safer being born, exceeds
the gain in prolonging the pregnancy.
Helplessness
It is very
easy to feel helpless and unneeded in the NICU setting. The staff seem so
competent, and you may feel afraid to even touch your baby. Some newborn
units are better than others in recognizing the central role that families
have. Some units are not very helpful and unfortunately- unlike changing
schools- parents can’t change newborn units to one that suits them better.
The language used by some staff may reinforce your feelings of insecurity;
they may speak of “our babies” or patronizingly refer to you as “Mum.” NUMB
believes that families are of key importance to all babies- even- and
especially- premature babies. Nurses may be interchangeable but mothers and
fathers are definitely not.
Babies- no
matter how premature- have learnt to recognize their parents’ voices and
presence very early. This learning begins in the uterus. A mother’s unique
scent is passed into the amniotic fluid and also into her breast milk. It
is important to also remember that you and your family may be the only safes
haven for your baby- the only ones who don’t cause him or her pain.
Failure to Bond
with Your Infant
Mothers who
have had more than one baby- a full term baby, perhaps, and then the next
baby is premature- sometimes realize there is a huge difference in how they
feel about their premature baby. They are aware that something is really
wrong with their attachment, and may feel that there is something wrong with
them that they are too embarrassed to admit. Because the second baby is
sick, they may beat themselves up thinking that they should feel even more
love and concern for the new baby. Yet, this is probably nature’s way of
protecting the mother too. There is no point in bonding to the baby if there
is no baby to bond with. Even though the baby’s health may not be in
imminent danger, hormonal signals to the mother’s body and brain may be
preventing her from attaching to the baby. These are beyond her control.
Time can be
healing here. But also, skin to skin contact can really help reset the
hormonal thermostat. Kangaroo Mother Care (KMC), first practised in
Colombia in a hospital with very little technology, is described as extended
skin to skin contact between the mother and the baby. The baby is normally
placed with only a nappy on against the mother’s chest, and both are covered
to keep warm. We describe this practise more fully in the section under
Kangaroo Care.
There are emotional benefits from doing this for the mother as well as
benefits for the baby.
Sadness
Sadness may
not pass very quickly for some mothers. Post partum depression (also known
as postnatal depression or PND) is very common, and the stress of having a
premature baby is an additional risk. If you think you are depressed, don’t
be afraid to contact your doctor. Depression is a treatable condition.
Another
condition closely related to PND is post traumatic stress disorder or PTSD.
This can happen to anyone who experiences an extremely frightening or
distressing incident or series of events; and thought that they or someone
else were at risk of dying. Symptoms include: flashbacks, panic attacks, a
feeling of replaying the distressing event over and over, sleeplessness, and
avoidance. If you think you may be experiencing several of these symptoms,
again don’t hesitate to contact your doctor. PTSD is also treatable.
In New
Zealand there is an organisation set up to provide support and information
for mothers who have experienced a traumatic birth, called TABS (Trauma and
Birth Stress) You can contact members of this organisation via their
website.
If you have had a Caesarean Section or are too unwell to walk
to the NICU to see your Baby.
Many mothers of premature babies find
themselves unwell, or unable to move easily in the first few days following
the birth of their baby. If this happens to you, there are many issues you
may face. The first is the issue of being separated from your baby.
If you are unable to be moved, ask if
your baby can be brought to you, even if just for a short period of time.
If your baby is stable, and doesn’t require ventilation, staff may be able
to bring him or her to you in the incubator for a visit. Keep asking to see
your baby. We know of mothers for whom the staff simply forgot about- and
the mother was lying there waiting for the baby, too polite to request but
unaware that the staff had just forgotten.
If both of you are too unwell to be
moved, ask for a photograph to be taken of your baby so that you can see at
least a picture of your baby.
If it is possible for you to be moved
and you are well enough, ask for a wheelchair to be made available for you.
Ask a staff member to take you to the NICU, or ask your support person to
take you. It is not easy to do, and you may be in pain, or be very
uncomfortable; but be assured that both you and your baby will benefit from
your visits. Don’t be afraid once you are in the NICU to ask for help and
support in order that you can see, touch or even hold your baby if both of
you can manage it. The benefits for you both are huge. But you may need
help.
Many mothers worry if they are on pain
relief medication that they can’t breastfeed or express milk for fear of it
passing through to baby. The good news is that most of the drugs commonly
used for mothers following child birth, for pain relief are compatible with
breastfeeding; and the benefits of using pain relief is that you will be
able to become mobile sooner and get to the point where you are able to be
with your baby for longer periods of time. However, because only your
doctor will know your medical history and what’s safe for you and your baby,
please ask the doctor looking after you whether the particular medications
you are taking are safe for your premature baby. If there is any suggestion
that a particular medication may mean you are unable to give your milk to
your baby, ask to be changed to an alternative drug.
The second issue that you may face in
the early days following surgery, or if you are unwell, is initiating breast
milk production. See:
Before your Baby can Breastfeed: Expressing
Tips.
If you are unwell, or still groggy
following surgery, you may need help to express your colostrom. Ask staff
to help you express, by hand or using a pump, every two to three hours
around the clock.
In those first few days, most mothers
find that the amount they are able to express is very small, maybe just a
few drops at a time, or a few millilitres. It’s important to remember three
things about this time.
Firstly colostrom is only produced in
very small concentrated amounts. It looks different to mature milk too.
Expressing using a 1cc or 5cc syringe may help.
Secondly, your premature baby is
likely to be on very small frequent feeds of under 5mls, every few hours. So
that small amount is likely to be just the right amount. In fact, before
doctors realized that colostrom is different from mature milk, babies in the
past were often fed too much in the early days.
Thirdly colostrom is liquid gold. Its
importance (along with that of the milk you will produce later) cannot be
overstated, so don’t be dismayed by a few drops. Those few drops are so
important for your baby, and each few drops can be added to the drops you
expressed the time before.
If you have been able to get support
to initiate expressing as soon as possible after your baby’s birth, and
continue to do it frequently around the clock, the benefits are likely to be
that the amount of colostrom you are able to express will quickly increase,
and the frequent breast stimulation will help to ensure that your milk will
come in, usually within three to four days.
Early frequent breastfeeding or
expressing helps to ensure a plentiful milk supply further down the track.
Before your Baby can Breastfeed: Expressing Tips
In the early days before your milk
comes in, even if you are expressing frequently and/or using an electric
pump, you will probably only produce very small amounts of colostrum. No
amount is too small to save for your baby.
It may take a few days before you are
producing 30mls of milk per session rather than just a few drops. It is
important to note that mothers are often advised- incorrectly- to express as
much milk as their baby is taking, which may be very little.
Many mothers have found that when they
express very little milk in the early weeks, it may be difficult or
impossible to boost their milk supply later when baby needs more milk.
The idea is to try to establish a full supply. Some mothers do have an
overabundance- this can be adjusted later- or even donated to a human milk
bank if it turns out there is surplus to your baby’s needs.
Ask staff in your hospital for
instructions on the collection, storage and handling of your milk, to ensure
that it is collected and stored in a safe manner. See:
Guidelines for the Collection, Storage, and Handling of Human Milk for the
Hospitalized Baby
Sometimes hospital protocols
can vary slightly.
-
Plan
to express at least 10 to 15 minutes per breast at least 8 to 10 times
daily in the first few days. Express at least once during your normal
sleeping hours.
-
Once
your milk production increases, usually between 3 to 5 days after the
birth of your baby, continue to express 8 to 10 times daily. As many
times as you can, express long enough so that 2 minutes pass after the
last drop of milk, or for 30 minutes, whichever comes first.
-
Which pump to use? An electric piston pump is probably the most
effective pump for you to use to establish and maintain an adequate milk
supply for your premature baby. Some women are very good at hand
expressing, and this is a useful skill to learn too.
Follow this link to learn more about hand expressing.
-
Pumping both breasts simultaneously will cut your time spent expressing
in half, and has been found to increase prolactin (a hormone that
influences breast milk production) levels and better stimulate milk
production. Ask your hospital staff if you can be supplied with a
double-pumping collection kit. If you are renting or purchasing a pump,
you can purchase one from your supplier.
-
While you are establishing your milk supply, plan to pump 8 to 10 times
every 24 hours, and allow no more than a 6 hour period between pumping
sessions (probably only once per day), as longer stretches have been
linked to a decrease in milk production in some mothers.
-
How
much is a full milk supply? If you want to bring in a full milk supply
for your baby, plan to build up to expressing more than 750 mls per day,
or 90 to 120 mls per pumping.
-
Once
you have a full supply (or are pumping to the level that you are happy
with), you may be able to cut back on the number of pumping sessions to
about 5 to 7 times per day.
-
Have
a photograph of your baby to look at while expressing. A blanket or
sheet that your baby has slept on that carries his or her scent to smell
while you are pumping can help too.
-
Many
mothers find that not looking at the bottle filling means less anxiety
about how much is being pumped.
-
For
some mothers warming the breasts before pumping with either warmed
towels or a wheat bag can also help.
-
If
you can hold or kangaroo-care with your baby before expressing, this may
enhance your let-down when you are pumping, and increase your milk
volume.
-
Ask
the staff in your NICU if you can hold your baby and pump at the same
time. You may need to have the support of someone to help with getting
everything connected, and making sure both you and your baby feel
comfortable and secure.
-
Even
if you can’t yet hold your baby, see if you can pump next to your baby’s
bedside. This has also been found to help increase the amount of milk a
mother can express.
If you would like more information
about pumping milk for a premature baby please contact La Leche League. For
information and how to contact a local Leader please visit the
La Leche League website Some
NICU’s in New Zealand have lactation consultants on staff- you may have to
ask for an appointment to see them.
We’d also love to hear from you. Let
us know what worked well for you, with expressing for your baby. What
challenges did you face, and how did you resolve them? Please
contact us and send us your experiences.
What do I do if I need to Increase My Milk Supply?
It is really common for the milk
supply of the mother of a premature baby to fluctuate. This may happen if
your baby’s condition fluctuates, or it may seem completely unrelated to
your baby’s wellbeing. In this case it is likely that your milk supply is
fluctuating because of the jumble of emotions that you are experiencing.
In times of crisis or if you are very
worried about your baby your let-down may be inhibited or delayed, and it
might be more difficult for you to express your milk. This is usually only
temporary and is another part of the complexity of having a baby in the NICU.
Great, now there’s anxiety about feeling anxiety! Forgive yourself if this
is you. You are a sensitive mother.
So what can you do if your supply
drops and you need to work to increase it?
-
Full
term babies will have growth spurts at 2 to 3 weeks of age, 6 weeks and
around 3 months. At around these times babies will want to breastfeed
more frequently for a couple of days to boost their mothers supply.
Consider increasing the frequency of pumping sessions over a couple of
days to mimic a growth spurt.
-
Express for longer. Research indicates that draining the breast more
completely may be more effective at increasing milk supply after the
first month or so. As many times a day as you can pump for 2 minutes
past the last drop or for 30 minutes, whichever comes first?
-
Medicinal Herbs: Many mothers find that taking medicinal herbs in
recommended doses can boost their milk supply. Fenugreek (3 capsules 3x
daily), either by itself or with blessed thistle (3 capsules 3x daily)
is often effective, although it can take 24 to 72 hours to see any
effect. These herbs are generally considered to be safe, although check
with your LMC or health care provider about any substance you plan to
take.
-
There are prescription medicines which are also effective in boosting
milk supply. You will need to ask your Lead Maternity Carer or doctor
if these medications may be suitable for you to use. Currently in NZ
one prescribed medication that is popular is Domperidone. Domperidone
is approved for use by breastfeeding mothers by the American Academy of
Paediatrics (AAP Committee on Drugs 2001). Because it has a large
molecular weight and a high protein-binding characteristic, only very
small amounts pass into human milk. Also Domperidone does not cross the
blood-brain barrier so there are fewer side effects in mothers.
Domperidone is available on prescription in NZ. The recommended dose is
20mg four times per day. (Newman, J. and Pitman, T. The Ultimate
Breastfeeding Book of Answers. Roseville, California: Prima 2000, p
89)
Guidelines for the Collection, Storage, and Handling of Human
Milk for the Hospitalized Baby
These guidelines
have been taken directly from La Leche League’s Breastfeeding Answer Book
(La Leche League International, 3rd Edition, 2003, page 292).
To simplify and standardize hospital
guidelines, the Human Milk banking Association of North America has
published “Recommendations for Collection, Storage, and Handling of a
Mother’s Milk for Her Own Infant in the Hospital Setting” (Arnold 1999).
These guidelines have been adopted by many hospitals. These guidelines
recommend that:
-
Before expressing their milk, mothers wash their hands thoroughly,
giving special attention to fingernails and nail beds.
-
An
electric breast pump with automatic cycling that meets hospital
requirements be used. Hand expression, manual, battery, or small
electric pumps are considered inadequate for most mothers to establish
and maintain a good milk supply, especially when they must pump for a
long time.
-
Each
mother use her own collection kit (the bottles and tubing that attach to
the pump).
-
All
parts of the collection kit that touch the milk be cleaned after each
use with hot soapy water, thoroughly rinsed, then placed on a clean
towel, and allowed to air dry. Washing in a dishwasher is also
acceptable.
-
In
areas where water is contaminated, boiled or bottled water be used for
cleaning pump kits.
-
The
expressed milk be labelled with the date, the baby’s name, the baby’s
hospital identification number, any illnesses in the family, and any
medication(s) the mother is taking.
-
Milk
be stored in feeding-sized portions; containers larger than 8 ounces [in
a NZ NICU suggest 2 or 4 ounce containers (60 to 120 mls)] should not be
used.
-
Colostrum and early milk may be “layered”, meaning a mother may chill
and add milk to the same container from different pumpings in order to
get a full feeding.
-
Storage containers be hard-sided and made of glass, polycarbonate
(clear, hard plastic) or polypropylene (cloudy, hard plastic) with solid
caps that provide an airtight seal.
For more information on these
guidelines and the research that supports them, contact:
The Human Milk
Banking Association of North America
C/- Mary Rose Tully, MPH, IBCLC, Director of Lactation Services
5W, Room 183
101 Manning Drive
Chapel Hill NC 27514 USA
Kangaroo Mother Care (KMC)
The information below is taken
directly from the Kangaroo
Mothercare website
What
is Kangaroo Mother Care??
Definition: A
universally available and biologically sound method of care for all
newborns, but in particular for premature babies, with three components...
-
Skin-to-skin contact
is between the baby front and the mother's chest. The more
skin-to-skin, the better. For comfort a small nappy is fine, and for
warmth a cap may be used. Skin-to-skin contact should ideally start
at birth, but is helpful at any time. It should ideally be
continuous day and night, but even shorter periods are still
helpful.
-
Exclusive breastfeeding
means that for an average mother, expressing from the breasts or
direct suckling by the baby is all that is needed. For very
premature babies, supply of some essential nutrients may be
indicated.
-
Support to the
mother infant dyad means that whatever is needed for the
medical, emotional, psychological and physical well being of mother
and baby is provided to them, without separating them. This might
mean adding ultramodern equipment if available, or purely intense
psychological support in contexts with no resources. In
Bogota, Colombia, where KMC started, "early discharge" is regarded
as the third part of the definition. This is also a form of support
where hospitals are overcrowded, but it also requires a good
community support system. (see the
INK website )
In the USA, the term Kangaroo Care (KC) is generally used. This has been
defined as "intra-hospital maternal-infant skin-to-skin contact". KC is
generally started later, and on stabilised prematures, and is used an
adjunct to technological care.
While KC has profound effects on the baby, KMC does so much more!
Kangaroo Mother Care - Understanding Definition
The definition OF KANGAROO MOTHER CARE is based on all these arguments, and
though it applies to all babies, it is particularly important for premature
babies.
In summary:
-
Kangaroo Position - maternal
infant skin-to-skin contact
-
Kangaroo Nutrition - early and
exclusive breastfeeding
-
Kangaroo Support - never separate
mother and baby, and ADD ON available technology
Biologically, we know that the newborn
is born with the skills and behaviours it needs to grow and be well, all it
needs is to be undisturbed in skin-to-skin contact with mother, and it will
breastfeed.
From evolutionary arguments we understand that the baby is extremely
immature, and that its well-being is dependent on continuing its gestation
in skin-to-skin contact with mother, and that the mothers milk is uniquely
adapted top the immature gut.
Anthropology provides ample evidence that the behaviour we infer or deduce
from biology and evolutionary arguments is in fact the normal behaviour for
the human race: newborns and babies should be in constant contact with
mother and should exclusively breastfeed.
Neurology can explain the mechanisms that we observe when baby is in
skin-to-skin contact and when it is separated.
Physiology and research provides overwhelming evidence that Kangaroo Mother
Care is not only safe, but superior.
For infants born too soon, being premature on top of being immature:
continuing the gestation on mothers skin-to-skin contact and with breast
milk is even more important than for full term infants.
The above contrasts starkly with twentieth century high technology practice,
in which separation of mother and child is accepted as necessary and normal.
Separation is common, but
abnormal and
harmful.
How to put Kangaroo Mother Care into Practice in a New
Zealand NICU
The staff looking after your baby will
almost certainly believe that there are benefits for the baby in practising
Kangaroo care. Your NICU will probably have a policy that encourages and
supports Kangaroo care.
However, despite this you may
encounter some obstacles to Kangaroo care. Kangaroo care, as it is
practised in New Zealand NICU’s is not the same as Kangaroo Mother Care (KMC).
Currently, the way our NICU’s are set up, it is unlikely that you will be
able to practise KMC. But there are many benefits of skin-to-skin contact,
and your baby will benefit from every opportunity you are given. We cannot
stress enough how important this contact is for you and your baby.
There are lots of barriers to Kangaroo
care here in New Zealand. Staff may often give excuses as to why they are
reluctant, for example:
“The baby has had a
big day (tests and procedures)”
“The baby isn’t
stable/or well enough yet”;
“Premature babies
are different, they need to sleep to grow, and they can only do that
satisfactorily in bed”;
“Skin-to-skin
contact is not the panacea you think it is; 20 minutes a day is
beneficial”;
“We’ll see how well
the next feed goes, we don’t want your baby getting over-stimulated”.
Yet many of these barriers are clearly
cultural. There are newborn units (NICU’s) around the world where KMC is
practised to its fullest extent, in resource poor countries and resource
rich countries.
In these units mothers are undeniably
more valued than in many NICU’s in NZ.
So, given the challenges, and barriers
that you will inevitably face, how do you maximise the contact you have with
your baby, and minimise the separation?
Support is your strongest ally.
Friends and family who will support
you no matter what will be the most empowering thing for you.
Because you are the one who will have
to make decisions, compromises, and be the one who has to change tack at a
moments notice, as well as deal with staff reactions; support needs to be
unconditional and accepting.
You may find that in dealing with any
confrontations or requests to staff where you suspect you may encounter
resistance, your best defence is to take those people who will really stand
by you and support your decisions with you.
Take a pen and paper with you in any
discussions with staff where you may be asking to do something that they
won’t support so that you can document their responses. This will help you
later when you are deciding how to respond. It also helps those who are
supporting you to understand what was said if they weren’t there at the time
of the discussion.
So, now you have your support in
place. What next.
Unfortunately it is almost inevitable
that you will have to make some compromises.
The culture of the NICU is not your
culture; the values, beliefs and practices may likely clash with your own
beliefs and values, not to mention you instincts.
This place is somewhere that staff
feel comfortable. The policies and practices are created and maintained by
the hospital. Staff make the rules, and change the rules according to what
works best for them, not you or your baby.
There may be times when you make
decisions or decide to do something that may be out of character for you, or
that you would not do if you were at home with your baby, because of the
pressures of the NICU environment.
You are allowed to change your mind
about any decision you have previously made, now is not the time to demand
consistency from yourself.
This is common, and you may experience
a range of emotions about this. See the
feelings section.
This section has been very
difficult to write, it is nowhere near finished and we will continue to
add to this.
We would very much like your
feedback, your experiences and examples of things you’ve done. Please
share your experiences, frustrations, challenges and joys with us by
contacting us.
