The challenges of breastfeeding faced by women with diabetes

Breastfeeding is important for a mother and her baby. However, it also poses many challenges, particularly when a mother with diabetes wishes to breastfeed exclusively for the first 6 months of her baby’s life as is currently recommended (Department of Health [DOH], 2003). It is important that health professionals prepare her by providing the right type of information and support.

With the marked improvement in the monitoring and control of maternal blood glucose levels, women with insulin-dependent diabetes can usually look forward to a safe and relatively healthy pregnancy and birth. With improvements in maternity care it is commonplace for a woman with diabetes to deliver vaginally and to remain on the postnatal ward with her baby following birth.

Health benefits for mother and baby
Breastfeeding has a major role to play in promoting health in the short and long term for both mother and baby (Dyson et al, 2005). As well as providing complete nutrition to healthy infants, human milk has an important role to play in the protection against gastrointestinal and respiratory infections in the child (Howie et al, 1990; Wilson et al, 1998; Cesar et al, 1999; Kramer et al, 2001). There are also strong indications that breastfeeding contributes to the prevention of otitis media (Duncan et al, 1993; Aniansson et al, 1994), urinary tract infection (Marild et al, 1990; Pisacane et al, 1992; Marild et al, 2004), atopic disease (Burr et al, 1989; Lucas et al, 1990; Saarinen and Kajosaari, 1995), type 1 diabetes (Mayer et al, 1988; Virtanen et al, 1991; Sadauskaite-Kuehne et al, 2004), raised blood pressure (Frewtrell, 2004; Martin et al, 2004) and obesity (Dewey et al, 1992; von Kries et al, 1999; Gillman et al, 2001; Arenz et al, 2004; Frewtrell, 2004) in the child.

Breastfeeding is also beneficial for the mother’s health: women who do not breastfeed are significantly more likely to develop epithelial ovarian cancer (Gwinn et al, 1990; Rosenblatt and Thomas, 1993) and breast cancer (United Kingdom National Case-Control Study Group, 1993; Newcomb et al, 1994; Beral, 2002) than women who do breastfeed.

Benefits of breastfeeding on the reduction of type 1 and type 2 diabetes
Exclusive breastfeeding for 2–3 months was reported to significantly reduce the risk of developing type 1 diabetes in Finnish studies (Kimpimäki et al, 2001; Virtanen et al, 1991; Virtanen et al, 1992). The risk was also lower if supplementary feeding was not introduced until a baby was 4 months of age or older.

The protective effect of breastfeeding was greater in those children that were genetically predisposed to type 1 diabetes. Some studies propose that this effect was because breastfeeding limits the exposure to cows’ milk peptides, which may be a trigger for diabetes (Karjalainen et al, 1992; Dosch et al, 1999). However, other studies disagree with this assumption and the hypothesis is still being researched and debated (Hummel et al, 2000).

Whether or not the early introduction of cows’ milk or gluten plays a part in the risk of developing type 1 diabetes remains unclear. From the evidence available what we do know is that breastfeeding has a positive effect on the health of both the mother and her baby.

Pettitt et al (1997) suggest that after adjustments for possible confounding factors the relative risk of an exclusively breastfed baby developing type 1 diabetes by the age of 40 years was half that of a baby fed formula milk. In this study, those babies that were mixed fed (breast milk and formula milk) fell somewhere between the two. Since susceptibility to type 1 diabetes is inherited it is of particular benefit to the baby to be breastfed.

More recently, researchers in the USA have concluded that breastfeeding is also associated with a reduced incidence of type 2 diabetes in the mother (Stuebe et al, 2005). Stuebe et al concur that the longer the duration of breastfeeding, the lower the incidence of diabetes. The researchers suggest that improved glucose homeostasis is the responsible factor in this outcome.

Kjos et al (1993) propose that a mother presenting with diabetes during her pregnancy who does not breastfeed or lactate following the pregnancy in which her diabetes developed is twice as likely to go on to develop type 1 diabetes later in life. Lactation, even for a short period, improves glucose metabolism and is a low-cost intervention that may reduce the risk of diabetes or delay diabetes in this group of women.

Arenz et al (2004) agree that exclusive breastfeeding reduces the risks of later obesity and diabetes. Type 2 diabetes is associated with obesity and breastfeeding uses 500–600 calories per day (Riordan, 2005). Women who present with gestational diabetes during their pregnancy often have a tendency to be obese and lactation may be a way to improve their situation alongside dietary guidance.

Blood glucose levels are generally lower during lactation, even in the face of a markedly higher calorific intake (given the continuous conversion of glucose to galactose and lactose during milk synthesis), thus less insulin is required by the mother during lactation.

Davies (1989) showed that women with diabetes may need to reduce their pre-pregnancy insulin dose by approximately 27% to avoid hypoglycaemic reactions. The mother may also benefit from a reduction in the dose of long-acting insulin to prevent nocturnal hypoglycaemia (Piercy and Williamson, 2002).

A mother with diabetes who is breastfeeding will not only need less insulin, but she will also return to a normoglycaemic status earlier than her bottle-feeding counterpart (Yang et al, 1994).

The challenges of breastfeeding for a mother with type 1 diabetes
It has been proposed that women with diabetes may have lower prolactin levels than women without this condition (Ostrom and Ferris, 1993; Arthur et al, 1994). Prolactin is the hormone that is released within a woman’s body to produce milk following the birth of the baby. Milk production (lactogenesis II) usually increases by the third or fourth postpartum day. However, the lower levels of prolactin found in women with diabetes may delay the milk’s ‘coming in’ to the seventh day postpartum (Arthur et al, 1994; Bitman et al, 1998; Murtaugh et al, 1998).

Stress, anxiety and poorly-controlled diabetes are also known to affect a mother’s ability to produce and ‘let down’ (the process of milk ejection) her milk (Riordan, 2005). In general, a tight metabolic control, particularly the avoidance of maternal hypoglycaemia, is recommended (Abayomi et al, 2005; Hartmann and Cregan, 2001; Walker, 2002). Therefore, good support from a knowledgeable practitioner is crucial to the mother’s success.

Antenatal hand expression of the breasts
To positively influence adequate milk production the mother can be taught the techniques of breast massage and hand expression antenatally (see Figure 1). The technique can be practised after 36 complete weeks of gestation. This will encourage increased production of colostrum. Leaked colostrum can be collected, frozen and stored for use in the immediate postpartum period if, and as, required to supplement the baby’s diet.

Hand expression has several benefits for a mother with diabetes: it stimulates production of colostrum; it encourages the mother to become acquainted with her own breasts; and it helps the mother understand how her breasts function in lactation. Oxytocin is released in response to hand expression causing contraction of smooth muscles within the body, including the uterine muscle. This effect may lead to cervical ripening and early labour, reducing the need for induction of labour. If the woman requires induction of labour, a better response may be seen as the cervix may have begun to ripen (Riordan, 2005).

Challenges relating to the baby of a mother with diabetes
About half of all babies born to mothers with diabetes will develop hypoglycaemia (Riordan, 2005). The chances of this are reduced if the mother maintains good glucose control during her pregnancy. The fetus of a woman with diabetes may be exposed to higher levels of glucose in utero than is normal, which will be stored in the body organs as fats. This high level of glucose can cause the baby to produce excess insulin at birth and thus lead to the development of low blood glucose levels in the immediate postpartum period.

When a baby is born, its continuous transplacental blood glucose supply is cut off with the clamping and cutting of the umbilical cord. There is prompt adaptation of the baby’s cardiovascular, respiratory and metabolic systems. Enzymes are released into the baby’s body that breakdown and synthesise glycogen into glucose. This response begins as the blood glucose levels fall and occurs physiologically following birth, irrespective of feeding. During this period of counter-regulation, the ketone bodies and free-floating lactates play an important part in the maintenance of adequate food for the brain (World Health Organization [WHO], 1997).

Many babies adjust readily; others, such as premature infants, may require additional milk feedings or even warrant treatment with intravenous glucose until their condition is stable. The mother should always be encouraged to give her baby colostrum and this has a ketogenic effect and helps release alternative food for the brain. The baby should be closely monitored to assess its hypoglycaemic status during the first 48 hours of life (WHO, 1997) and frequent feedings with good positioning and attachment at the breast should be encouraged. Frequent feedings will assist the mother in establishing a good milk supply. If a supplement is needed in addition to breastfeeding, the mother’s antenatal colostrum can be given by cup, syringe drip-feeding, dropper or nasogastric tube.

Hypothermia and hypoglycaemia
It is important that we aim to reduce the risks of hypoglycaemia in the newborn by keeping the baby warm, as hypothermia and hypoglycaemia are closely related. The best way to achieve this is to place the baby in direct skin-to-skin contact with its mother. If the baby is cold, a thermogenic response is initiated. The mother’s body temperature will rise by up to 2 degrees centigrade to warm her baby and then respond to her baby’s requirements, stabilising its temperature (Bergum, 2005). Skin contact between a mother and her baby also encourages early and frequent feeding in an unrestricted way, which reduces the risks of hypoglycaemia (WHO, 1997; Bergum, 2005).

Best practice includes encouraging the baby to breastfeed within the first hour or two after birth. If the baby does not breastfeed, hand-expressed colostrum should be given and the baby woken at regular intervals until it is feeding well and on demand. The baby’s blood glucose levels should be monitored pre-feed and serve as a guideline for the baby’s response to feedings; the aim is to maintain the blood glucose levels above 2.6 mmol/l (WHO, 1997). The baby will continue to be monitored for both its well-being and its blood glucose control within the first 24 hours of life.

Experience of working with mothers with diabetes and their babies leads the author to conclude that early and frequent feeding at the breast or with hand-expressed colostrum greatly reduces the risk of hypoglycaemia in these babies.

Jaundice
Sirota (1992) suggests that babies of mothers with diabetes are at greater risk of developing jaundice. However, Sirota is clear that the jaundice will resolve without treatment in most babies. Encouraging early, frequent and unrestricted feedings is the most effective way to reduce the risks of a baby developing jaundice. Colostrum is a natural laxative and will promote gut evacuation; excess bilirubin is then excreted with the passage of meconium (the baby’s first stools; Riordan, 2005). The protein in colostrum lines the baby’s gut and thus prevents reabsorption of bilirubin via the gut.

Challenges for the mother
Thrush
Thrush in the breasts and vaginal thrush are more prevalent in mothers with diabetes, particularly if their blood glucose levels become elevated (Riordan, 2005). Preventing this problem involves careful control of blood glucose levels, air-drying the nipples after feeds and ensuring the mother is familiar with the signs and symptoms of thrush in the breast in order to seek early treatment.

Thrush in the breast is experienced as a painful condition and often causes mothers to find breastfeeding uncomfortable. If the right treatment is not provided early on then thrush can invade the lactiferous ductal system within the breasts, making the pain even more severe (deep, burning pain that can last up to 1 hour after a feed). Women who are prone to thrush may take acidophilus capsules or add live yoghurt (with added lactobacillus) to their diet as a prophylactic measure (Breastfeeding Network [BFN], 2006), wear cotton underwear, reduce the amounts of yeast- and sugar-based foods in their diet and take simple hygiene measures to prevent the spread of thrush among their family.

If thrush does occur it can be managed topically with miconazole cream. This is applied to both nipples and areola after each feed and an oral gel applied to the baby’s oral mucosa after feeds, four times a day (BFN, 2006). If thrush invades beyond the lactiferous ductal system, systemic antifungal treatment will be required, e.g. fluconazole.

Mastitis
Mothers with diabetes are also susceptible to mastitis, particularly if their diabetes is not well controlled. Mastitis is an inflammatory condition of the breasts and can quickly progress to an infective state that warrants antibiotic use. Any infection will raise the level of blood glucose and the woman’s diabetes will quickly become unstable. Self-care education should emphasise early recognition of the symptoms of mastitis and early management to prevent infection of the inflammation. The woman should know when to seek medical treatment to ensure the mastitis is not allowed to develop further and lead to a breast abscess.

If a mother presents with mastitis, in the author’s view it is of paramount importance that she is encouraged to continue to breastfeed and, if possible, use the mastic breast as the first breast at each feed until her problem resolves. The baby will suckle more vigorously on the first breast and frequent feedings will keep the breast soft to allow it to recover and recuperate more quickly. Mastitis is linked to fatigue, therefore rest should be encouraged. When breastfeeding the mother should gently massage the affected area, working from the chest wall towards the nipple to encourage the milk to flow freely. If the breast remains full after feedings, gentle hand expression, breast massage, a warm shower or bath and the use of a breast pump will assist in removing the backlogged milk.

If the mother becomes hyperpyrexial (temperature above 38.5°C) or increasingly unwell (’flu-like symptoms), or if inflammatory mastitis does not resolve with good management over a 12-hour period, then antibiotics should be commenced promptly. The antibiotics should be broad spectrum, such as flucloxacillin (or erythromycin in penicillin-sensitive women) and the course should be continued for 10–14 days to reduce the risk of recurring mastitis (Royal College of Midwives, 2002). Antibiotics are known to alter gut flora, thus rendering the mother at risk of an attack of thrush. Commencing acidophilus capsules while taking antibiotics may lessen this risk. Analgesia will provide relief from the discomfort in the breasts; paracetamol and ibuprofen are both safe to use during lactation (Hale, 2005).

Breastfeeding and introducing weaning
Additional calories are used during the feeding experience but as the child weans from the mother’s breast she will need to make alterations to her diet and also insulin doses to compensate for the decrease in milk production (Butte et al, 1987; Davies, 1989). Fewer problems will occur if the mother is encouraged to gradually wean.

Conclusion
Breastfeeding provides many health benefits for women with diabetes and their babies; it may even limit the baby’s risk of developing type 1 diabetes later in life. However, it also brings many challenges for the mother. It is the health professional’s responsibility to provide information to support the woman’s right to choose and to be successful at her intended feeding method (Dyson et al, 2005).

Mothers with diabetes are more susceptible to poor milk supply, thrush and mastitis. Providing information on how to manage these occurrences and providing access to friendly and confident support networks can help the mother to exclusively breastfeed her baby for the first 6 months of life and even longer if she wishes.