Early Hospitalization Key to Controlling SARS

The first major epidemiological study about severe acute respiratory syndrome (SARS) has determined that getting infected patients to the hospital for quarantine and treatment as soon as possible is key to controlling the disease and reducing transmission. The study was completed by scientists from the United Kingdom and Hong Kong and appears in The Lancet.

The researchers studied more than 1,400 SARS patients in Hong Kong up to the end of April 2003. They found that public-health interventions (including encouragement to report to a hospital quickly after the onset of symptoms, tracing of contacts of SARS cases and restriction of travel for those contacts) led to a substantial drop in confirmed SARS cases by the end of their study.

The average time between infection and the onset of symptoms for SARS is about six and a half days. The average time from the onset of symptoms to hospitalization for the patients in this study was three to five days, with longer periods reported earlier in the epidemic before public-health interventions were stressed. Of those admitted to the hospital for SARS, the fatality rate for patients 60 and older was much higher than those younger than 60.

The authors of the study say that improved communication about the risk involved with contracting SARS will potentially lead to an increase in early reporting of symptoms and improvement in the reduction and prevention of transmission. (5-27-03)

Vitamin D Supplementation in Breastfed Infants

According to La Leche League (LLL), the American Academy of Pediatrics (AAP) now recommends that, starting in the first two months of life, exclusively breastfed infants have a minimum of 200 IU of vitamin D per day.

Vitamin D is an essential nutrient for humans, but it’s usually obtained through casual exposure to sunlight, not foods, say experts at LLL. Vitamin D – actually a steroid hormone, not a vitamin – is produced in the body after exposure of the skin to ultraviolet B (UVB) radiation in sunlight. Vitamin D deficiency and rickets, a bone-softening childhood disease, are two consequences of inadequate vitamin D intake, they say.

According to LLL, your breastfed infant is at greater risk for vitamin D deficiency or rickets if they fit any of these categories: low maternal levels of vitamin D, indoor confinement during the day, darker skin pigmentation, living in urban areas where tall buildings and pollution block out the sun’s rays, seasonal variations in UVB rays and covering too much of the body when outside, including using too much sunscreen.

“No known risks of vitamin D supplementation exist at the level recommended by the AAP,” says Cynthia Good Mojab, MS, IBCLC, RLC, research associate in the Publications Department of La Leche League International. “However, no research has actually investigated whether vitamin D supplementation during the first six months has any negative consequences for infant health, such as vomiting and aspiration when supplementation is not tolerated, harmful alterations of the infant gut or increased risk of infection.”

If you are concerned about your infant’s chances of vitamin D deficiency or about the use of vitamin D supplements, LLL recommends talking to your health care provider about what is best for your child. (5-20-03)

Breastfeeding Multiplied – Nursing Twins, Triplets or More!

Research in recent years has shown that breast milk is beneficial for babies because it contains all the nutrients needed for the first four to six months of life and helps protect against many illnesses.

But what if you have twins, triplets or more? Can you still breastfeed successfully?

Certainly, say experts from the National Organization of Mothers Of Twins Clubs (NOMOTC), a nonprofit organization headquartered in Thompson Station, Tenn. Breastfeeding multiples just takes a little more effort and commitment on the part of the mother to be successful.

Tending to her own health is the first step for a new mom breastfeeding multiples. Eating properly, getting plenty of fluids and resting often are all important. Nutritionists recommend a 3000-calorie diet daily for moms breastfeeding twins, including foods high in protein and at least a quart of milk. The NOMOTC suggests extra help at home during the first few weeks while establishing a feeding routine for the babies.

You can feed twins at the same time or one-on-one, but feeding triplets or more requires some planning. A feeding chart can be helpful until you get established on a routine. Just remember to do whatever works best for you and your babies.

Even multiples born prematurely can be breastfed (although you might have to start off by pumping milk if they are not able to latch on). And the breast milk is easier for premature babies to digest – an added incentive for struggling moms.

Sources such as NOMOTC, La Leche League, hospital lactation consultants and local clubs for mothers of multiples can be great resources for help in breastfeeding multiple infants.

For additional information on NOMOTC and its resources and products, contact the NOMOTC Executive Office at nomotc@aol.com. (5-13-03)

Dr. Spock's Advice Studied on His 100th Birthday

On May 2, popular baby doctor Benjamin Spock would have turned 100. The world-famous pediatrician changed the face of parenting with his words of practical advice and his conviction to use instinct as a guide. A University of Alberta researcher has analyzed Dr. Spock and particularly how his advice on infant feeding changed over his decades of work.

Dr. Spock had always been an advocate of breastfeeding and even more radical was his recommendation to nurse the baby on demand rather than on a strict schedule. The U of A's Stephanie Knaak studied the changes from Spock's first edition of his book, Baby and Child Care, to his last, noting that the importance of breastfeeding was always apparent, but the doctor's reasons for why to nurse changed.

Dr. Spock's book was first published at the start of the World War II baby boom and soon became an authoritative and reliable guide for parents. With its nearly 50 million copies in more than 40 translations, the book is said to be second in sales only to the bible, according to the University of Alberta.

"At first Dr. Spock argued that the main focus of breastfeeding was for nutrition or food, but he changed his ideas to say that breastfeeding is just as important for bonding," says Knaak, a researcher in the Department of Sociology. "He didn't offer any assurances for bottle feeders in terms of bonding, and that surprised me a bit."

In the 1968 edition, Dr. Spock devoted an entire page, saying that while he was in favor of breastfeeding, bottle-feeding was still acceptable, says Knaak, "but after that one edition, those encouraging words to parents who used bottles was dropped."

Another interesting change over the decades was with the evolution of science in terms of infant feeding. In several of Dr. Spock's early editions, he listed a recipe for homemade formula that included the ingredients evaporated milk mixed with sugar, a far cry from today's advanced blend. (5-06-03)

Breastfeeding Counseling for Mothers May Help Reduce Disease Among Infants in Developing Countries

Promoting exclusive breastfeeding for six months after childbirth can help reduce diarrheal disease among infants in less-developed countries, say authors of a study in a recent issue of The Lancet.

For the study, researchers from the All India Institute of Medical Sciences in New Delhi, India, examined the feasibility, effectiveness and safety of an educational intervention to promote exclusive breastfeeding for six months in a rural Indian community.

Health care workers were trained to give exclusive breastfeeding counseling within the existing health care infrastructure, and mothers of more than 1000 infants born within nine months of this training were randomly assigned to either receive the counseling or to be in a control group.

The researchers found that exclusive breastfeeding rates were higher (79 percent) for mothers in the counseling group compared with the control group (46 percent). In addition, diarrhea was reduced by a third in the intervention group at 3 months and by around 15 percent at 6 months. There were no differences between length and weight of infants between the two groups, overall, and in the subgroup of low-birthweight infants. (4-29-03)

Study Suggests Maternal Depression, Not Antidepressant Use, Lowers Nursing Infant Weight Gain

Breastfeeding moms suffering from postpartum depression should not hesitate to seek medical treatment, even if it involves the use of antidepressants, says the author of a new study on the effect of antidepressants on nursing infants.

The study, which looked at more than 70 breastfeeding mothers treated for a mood or anxiety disorder with an antidepressant in the six months following pregnancy, is the first to compare the impact of maternal depression vs. antidepressant use on the physical development of nursing infants.

Researchers at the UCLA Neuropsychiatric Institute found that maternal depression, not antidepressant use, affects infant weight gain in the first six months after birth.

The study showed that exposure to antidepressant medication through breast milk had no effect on infant weight gain compared with national norms calculated by the Centers for Disease Control and Prevention (CDC).

In contrast, infant exposure to maternal depression lasting two months or more significantly lowered infant weight gain compared with infants of mothers with major depression lasting less than two months and with the CDC norms.

"Our findings emphasize the importance of screening for depression and treating the disorder in new mothers," says Dr. Victoria Hendrick, lead investigator and director of the institute's Pregnancy and Postpartum Program. "Less than one-third of women who suffer major depression postpartum actually are identified by medical professionals as depressed. There is a tremendous amount of under-diagnosing and under-treatment."

Depression in the first six months postpartum affects about 12 percent to 15 percent of new mothers. Symptoms include low self-esteem, feelings of inadequacy as a parent, inability to enjoy the baby or usual activities, lack of energy, insomnia even when the baby is sleeping, problems with concentration and irritability.

The study appeared in the April edition of the Journal of Clinical Psychiatry. (4-22-03)

Mother-Infant Bed Sharing Associated With Increase in Infant Heart Rate

Sharing your bed with your baby is becoming an increasingly common practice, and a new study has found that bed-sharing may increase a baby's heart rate.

Researchers studied 35 healthy mother-infant pairs for three nights in a sleep laboratory with video recording. The results showed that mother-infant bed sharing affected heart rate and variability in a state-specific manner. Analyses showed a significant night effect where heart rate during bed sharing was higher than during solitary sleeping in all sleep stages but not waking.

These effects on heart rate and variability are likely related to sensory or psychological stimuli unique to the bed sharing environment, or conversely, to the lack of those stimuli in the solitary condition, say the study authors. Increases in heart rate could be an indication of increased sympathetic activity, possibly resulting from some specific feature of the bed sharing sensory or psychological environment, they say. (4-15-03)

Folic Acid-Iron Supplements Reduce Risk of Low Birth Weight

Multiple vitamin supplements during pregnancy may not be any more effective than folic acid-iron supplements in reducing the risk of low birth weight babies, according to the results of a study by researchers with the Johns Hopkins Bloomberg School of Public Health's Center for Human Nutrition (CHN).

For the study, which was conducted in rural Nepal, CHN researchers gave more than 4,900 pregnant women one of the following daily supplements: folic acid, folic acid-iron, folic acid-iron-zinc or a multiple micronutrient supplement containing folic acid, iron and zinc and 11 other micronutrients. All participants received vitamin A, with a control group receiving vitamin A alone.

The findings showed that supplementation with folic-acid iron reduced the incidence of low birth weight by 16 percent, and the multiple micronutrient supplements reduced low birth weight by 14 percent. Folic acid-iron-zinc supplementation and folic acid supplementation alone had no significant effect on birth size.

While researchers are optimistic that they are making progress, they say more work is needed to understand the health effects of antenatal micronutrient use among mothers before being widely adopted in the developing world.

The study was published in a recent issue of the British Medical Journal. (4-8-03)

Get Breastfeeding Help on CD

Having trouble getting Baby to latch on, but your hands are too full to look up the problem in a book? How about getting help on CD?

A new set of CDs by Milky Way Press offers breastfeeding mothers audio instruction. Breastfeeding Basics and Beyond helps you track your baby's urine and bowel output, understand Baby's cues to nurse, the difference between foremilk and hindmilk and more. Breastfeeding's Number One Question: How Will I Know My Baby is Getting Enough Milk? shows moms indicators that breastfeeding is going well such as urine output, bowel movements, length of nursing and more.

Both CDs are $12.95 a piece and are between 50 to 60 minutes long. They are also available together for $29.95.

The CDs were created by Beverly Morgan, a board certified lactation consultant and former breastfeeding mom. She currently writes about breastfeeding, presents conference sessions and seminars and maintains a private practice as a lactation consultant in San Jose, Calif.

For more information, visit www.milkywaypress.com. (4-01-03)

New Online Store Offers Sophisticated Attire for Nursing Moms

If you're looking for professional clothing which allows you to nurse easily, check out the new online store for Mamámoda, a company which designs, manufactures and markets high-quality nursing wear.

The new Internet store, www.mamamoda.com, features the company's line of clothing all of which are made from natural and luxury fibers. Concealed nursing openings allow easy and discreet access to the breasts, says the company, allowing a mother to breastfeed her baby in public without exposing herself, in comfort and with style. Plus, they say, since oftentimes the original purpose of Mamámoda’s nursing wear is not obvious to other people, women can continue wearing the clothes long after weaning their babies.

“Mamámoda’s clothes are produced for nursing women by a nursing mom,” says Frances Pflaumer, Mamámoda’s president, chief designer and founder. “After having my first son, I looked for breastfeeding clothes on the Internet and in stores but became frustrated pretty soon, realizing clothes were not very fashionable and oftentimes of poor quality. I also found they were shapeless and hid the woman’s body.

"This is what really gave me the idea to start designing my own nursing apparel. I realized other women experienced the same frustration in finding great-looking breastfeeding clothes. The positive feedback I received on my self-designed clothes really was what inspired me to establish Mamámoda. I am very excited I can now offer my clothes to other breastfeeding women like me. Finally, we can nurse our babies and at the same time look and feel great." (3-25-03)

CDC Activates Emergency Operations in Response to New Pneumonia-like Illness

In response to reports of increasing numbers of cases of an atypical pneumonia that the World Health Organization (WHO) has called Severe Acute Respiratory Syndrome (SARS), the Centers for Disease Control and Prevention (CDC) activated its emergency operations center on Friday, March 14.

As of March 19, WHO has received reports of 264 patients from 11 countries with suspected and probable SARS. Areas with reported local transmission include Hong Kong and Guangdong province, China; Hanoi, Vietnam and Singapore. More limited transmission has been reported in Taipei, Taiwan and Toronto, Canada. Eleven cases have been reported in the United States. The initial cases reported in Singapore, Taiwan and Toronto were among people who all had traveled to China.

Among patients reported worldwide as of March 19, the disease has been characterized by rapid onset of high fever, myalgia, chills, rigor and sore throat, followed by shortness of breath, cough and radiographic evidence of pneumonia. Of the 264 suspected and probable cases reported by WHO, nine (3 percent) people have died.

CDC has been working with the World Health Organization (WHO) since late February to investigate and confirm outbreaks of this severe form of pneumonia in Vietnam, Hong Kong and parts of China.

"The emergence of two clusters of this illness on the North American continent indicates the potential for travelers who have been in the affected areas of Southeast Asia to have been exposed to this serious syndrome," says Dr. Julie L. Gerberding, CDC director. "The World Health Organization has been leading a global effort, in which CDC is participating, to understand the cause of this illness and how to prevent its spread. We do know that it may progress rapidly and can be fatal. Therefore, we are instituting measures aimed at identifying potential cases among travelers returning to the United States and protecting the people with whom they may come into contact."

The WHO issued a global alert about the outbreak on March 12, cautioning that the severe respiratory illness may spread to hospital staff. (3-25-03)

Breastfeeding Rates Unaffected by Changes in Hospital Stay

New mothers’ rates of breastfeeding remained unchanged despite two policy reversals regarding hospital length of stay within an eastern Massachusetts HMO, according to a study published in a recent issue of Pediatrics. This remained true for all categories of women, regardless of race, age or socioeconomic status.

Researchers from Harvard Medical School and Harvard Pilgrim Health Care Department of Ambulatory Care and Prevention exploited a unique opportunity for study provided by a pair of policy changes: First, in 1994, Harvard Vanguard Medical Associates and the insurer, Harvard Pilgrim Health Care, implemented a program calling for a single overnight stay in the hospital following uncomplicated vaginal delivery. Then in 1996, the Massachusetts legislature (as part of a public backlash against what were termed “drive-through deliveries”) passed a 48-hour coverage mandate.

The short-stay program offered improved prenatal care, a postnatal home visit from a nurse specialist within 48 hours of discharge and stepped-up breastfeeding assistance at health centers. The Massachusetts law establishing a 48-hour minimum stay allowed a woman to go home earlier if both she and her doctor consented and if she was offered a home visit.

In the study, the researchers looked at more than 20,000 pairs of infants and mothers over a seven-and-a-half-year period, collecting demographic and utilization data as well as information on how infants were fed during the first 90 days of life. Not surprisingly, they found that the length of time women stayed in the hospital after delivery changed significantly following the two policy modifications: 29 percent of mothers stayed for one postpartum night just before implementation of the HMO early discharge policy, while 64.6 percent did so afterward. When the Massachusetts law came into effect, this rate plummeted to 15.2 percent.

The rate of breastfeeding initiation, by contrast, rose gradually over the entire study period, from 70.1 percent in 1991 to 81.9 percent in 1998, with no significant changes following either of the abrupt shifts in length of stay. Meanwhile, breastfeeding continuation among those who initiated was constant over the years. Even when researchers analyzed breastfeeding initiation and continuation among the most socially vulnerable subgroups, such as young or first-time mothers, those with low income or education indicators or those of nonwhite race, the finding of no harm due to early discharge remained the same.

The findings are good news for mothers and babies, since breastfeeding is widely acknowledged to benefit both. (3-18-03)

Pacifiers May Detract From Breastfeeding

A new study in the March issue of Pediatrics found that the use of pacifiers during the neonatal period was detrimental to exclusive and overall breastfeeding.

To enhance breastfeeding practices, the World Health Organization discourages pacifiers and bottle-feeding. However the causal effect of artificial nipples on breastfeeding has never been proven.

Researchers also showed that there was no advantage to cupfeeding for providing supplements to the general population of healthy breastfed infants, but it may have benefited infants who required multiple supplements or who were delivered by Cesarean section. (3-11-03)

Breastfeeding Helps in Battle of the Bulge

If you're battling weight resolutions that you made at the beginning of the year, consider the fact that breastfeeding your baby may be the first and best offense in the battle against obesity for both Mom and Baby, according to La Leche League (LLL). Studies show breastfed babies have a lower likelihood of becoming obese as children, and Mom is more likely to return to pre-pregnancy weight sooner than her bottle-feeding counterparts.

Babies breastfed for three to five months are one-third less likely to be obese at age 6, according to LLL. Babies who are exclusively breastfed for six months are 43 percent less likely to become obese, and babies breastfed for more than one year are 72 percent less likely to become obese. This advantage persists at least into adolescence where it has been shown that adolescents who were breastfed as infants are significantly less likely to be obese.

In addition, some researchers believe that breastfeeding may play a role in preventing obesity in adulthood. Bottle-fed infants had higher concentrations of insulin in their blood, which would be expected to aid in fat deposition. Human milk contains fats and proteins significantly different from those available in artificial infant milk. The proteins in human milk are the correct amount and also are easier to metabolize than the large amount found in artificial infant milk and therefore are not stored to later become fat, thereby decreasing the risk of obesity.

To add to the benefits of breastfeeding in preventing obesity in breastfed infants, breastfeeding also makes it easier for mom to shed the extra pounds put on during pregnancy, says LLL. Studies show that weight loss from one to 12 months postpartum was significantly greater in breastfeeding than formula-feeding women, due primarily to differences in weight loss from three to six months. In addition to that good news, the weight lost tended to come from the waist and hips of the nursing mother.

For more information, call 1-847-519-7730. Founded in 1956, La Leche League International's mission is to help mothers worldwide to breastfeed through support, encouragement, education and information. (3-4-03)

Breastfeeding Benefits Your Baby's Heart

As the country reflects on heart health during February, American Heart Month, compelling evidence suggests that human milk provides one of the keys to future heart health for the breastfed infant, say experts at La Leche League (LLL). Better cholesterol, lower risk for insulin-dependent diabetes and lower weight and blood pressure are among the lifelong possibilities for infants breastfed by their mothers.

According to a September 2002 study that was published in Pediatrics, says LLL, higher total cholesterol and low-density lipoprotein cholesterol are characteristic of breastfed infants. It is thought that this may be a type of nutritional programming during infancy, resulting in reduced cholesterol levels in adulthood.

In addition, extensive research suggests that breastfeeding also helps prevent insulin-dependent diabetes which is another risk factor in developing heart disease, according to LLL. Those infants who were exclusively breastfed during the first three months of life had a 34 percent lower risk of developing insulin-dependent diabetes later in life. Human milk consumption was also associated with lower blood pressure later in life in children born prematurely.

A study which recently appeared in The Journal of Human Lactation, says LLL, concluded that breastfeeding is one factor that reduces the risk of a child becoming overweight. Breastfeeding also provides other compelling advantages to infants, mothers, families and even the environment, according to LLL, such as significantly decreasing the risks of acquiring a large number of acute and chronic diseases.

Since 1956, La Leche League International has been providing breastfeeding education and encouragement through mother-to-mother support. For more information about LLL, call at (847) 519-7730 or visit their Web site at www.lalecheleague.org. (2-25-03)

Breastfeeding Mom Launches Internet Breastfeeding Store

A "mompreneur," Sherry Bonelli, recently announced the debut of her new Web site, which offers breastfeeding and baby products for busy moms. Breastmilk.com features products from breast pumps to baby slings, all tested personally by Bonelli.

A veteran breastfeeding mom herself (she nursed her son for 14 months and is currently breastfeeding her 4-month-old twin girls), Bonelli prides herself on only selling products she has personally reviewed and/or tried herself. “If I wouldn’t use it, I won’t sell it,” says Bonelli. “I don’t sell just anything. I really try to find the best products on the market and make those products available at affordable prices. We even offer free shipping.”

Sherry launched her first web site, www.MommysThinkin.com, in 1999 after the birth of her first son. “Mommy’s Thinkin’ was started because of a breastfeeding product I invented after I had my first son," says Bonelli. "I invented the peek-a-boo breastfeeding strap and began to sell peek-a-boos from my Web site. I soon realized that I needed to add additional products to my store in order to grab people’s attention and have a better-rounded product offering.”

Products she has recently added include the Whisper Wear Hands-Free Breast Pump and The Ultimate Baby Wrap sling.

A one-woman show, Sherry designs the Web sites, does product research, works with vendors, handles customer relations and even boxes and ships out the orders. She’s also working on her next site launch – look for www.PregnancyStore.com in April 2003. “I describe myself as a breastfeeding/entrepreneur/stay-at-home-working mom," says Bonelli. "I’m busy with my kids and busy with my business. That’s how I like it.” (2-18-03)

Rubella Vaccination Safe for Women Up to One Month Before Pregnancy, According to New Guidelines

OB/GYNs are now being advised that it is safe for women to receive their rubella vaccination up to one month before becoming pregnant instead of the previous three-month wait period, according to the American College of Obstetricians and Gynecologists (ACOG).

Rubella, also known as German measles, is an infectious viral disease that if acquired during pregnancy can cause blindness, heart defects, deafness and other birth defects in the newborn. The risk to the fetus depends on the stage of pregnancy at the time the woman is infected. If infection occurs during the first month of pregnancy, the fetus has a 50 percent chance of being affected. The risk drops to 10 percent by the third month.

Rubella immunization is typically given along with the mumps and measles vaccines. Ideally, women who are not immunized or haven't already had rubella should be vaccinated before they become pregnant or immediately postpartum before they leave the hospital.

If the vaccine is inadvertently given early in pregnancy, the risk to the fetus is very low and is not reason enough to terminate the pregnancy, says ACOG. According to the new opinion, rubella vaccination is also believed to be safe for women who are breastfeeding.

Although the overall incidence of rubella infection has decreased in the United States over the past decade, there have been cluster outbreaks of the disease, especially among people born outside of the United States. Most Americans born after 1969 have been vaccinated against rubella and approximately 75 to 80 percent retain immunity to the disease. But because of the high risk of birth defects, pregnant women are routinely screened for antibodies to the virus. (12-17-02)

Study Finds Formula Manufacturers Violating International Marketing Code

Manufacturers of formula milk are violating the international code of marketing of breast milk substitutes in west Africa, say researchers in a recent issue of the British Medical Journal.

Two survey teams monitored compliance with the code, adopted by the World Health Assembly in 1981 to ensure the proper use of breast milk substitutes, in the African countries Togo and Burkina Faso.

Violations included no statement on the superiority of breastfeeding, no instructions for appropriate preparation or storage, no warning against health hazards of inappropriate use and pictures, drawings or text idealizing use.

They also found that six health facilities had received donations of breast milk substitutes, and health providers in five health facilities had received free samples of breast milk substitutes and promotional gifts from manufacturers. Promotional materials for commercial breast milk substitutes were found in seven health facilities, and special displays to market commercial breast milk were found in 29 sales and distribution points.

Forty commercial breast milk substitutes violated the labeling standards of the code including some manufactured by Danone, Nestle and eight other national and international manufacturers.

Protection of breastfeeding from commercial exploitation should be among the highest priorities for the international community, write two pediatricians in an accompanying editorial. They discuss how we should monitor compliance with the code, how we should train health workers and how we should combine support for breastfeeding with a recognition of the risk of maternally-transmitted HIV infection. (2-04-03)

Cruises Offer Opportunity to Support Breast Cancer Research

What would you say if we told you you could help find a cure for breast cancer while enjoying a cruise? Thanks to a new program called Pink Ribbon Cruises, you can do just that.

CI Travel has partnered with breast cancer survivors and cruise lines to create a program through which a portion of the company's commissions on any cruise booking will be donated to the Avon Breast Cancer Crusade to fund access to care and finding a cure for breast cancer.

While the program is valid for virtually any cruise booked through the program, CI Travel has put together a special package onboard the Disney Magic® for a seven-night Eastern Caribbean cruise departing September 20, 2003. In addition to helping the fight against breast cancer, Pink Ribbon cruisers will get invitations to special gatherings, have opportunities to meet special guests and receive gifts and amenities.