by KMom
Copyright © 1998-2001 KMom@Vireday.Com. All rights reserved.
DISCLAIMER: The information on this website is not intended and should not be construed as medical advice. Consult your health provider. It should be re-emphasized that nothing herein should be considered medical advice.
Contents
The GD and Breastfeeding web section is an introduction to some of the main issues that surround the establishment of breastfeeding after a gd pregnancy. However, it must be noted that many protocols regarding management of breastfeeding and treatment of infants of gd pregnancies differ from provider to provider and between institutions. Also, these issues involve protocols that change over time.
It is important to remember this when reading this FAQ, and that YOUR provider's assessment of your situation may differ. NONE of this should be considered medical advice, just a summary of the most common treatment protocols, recent research and its implications, and a brief review of some of the controversies.
Should Gestational Diabetics Breastfeed
"The AAP identifies breastfeeding as the ideal method of feeding and nurturing infants and recognizes breastfeeding as primary in achieving optimal infant and child health, growth, and development." 1997 American Academy of Pediatrics Policy Statement
Summary: Why GD Moms Should Breastfeed
Can and should a gestational diabetic breastfeed her child? The answer is a resounding YES!!! Breastfeeding has tremendous health benefits for both mother and baby and has special benefits for both in the gd. It should be strongly promoted and pursued.
After a gd pregnancy, the baby is more at risk for hypoglycemia (low blood sugar), hyperbilirubinemia (physiological jaundice), and, more rarely, other metabolic abnormalities (mostly in more severe cases of gd). Early and frequent breastfeeding can help prevent or minimize these problems. Research shows that breastfed babies of diabetic pregnancies have fewer 'routine care failures' that necessitate being placed in the Neonatal Intensive Care Unit. In later years, there is some preliminary evidence that breastfeeding may help protect babies against Type II Diabetes, and some evidence that breastfed babies tend to be less obese overall. Breastfed babies also tend to have better glucose metabolism and less insulin resistance. So breastfed babies of gd pregnancies benefit greatly both in the short-term and probably in the long-term.
In addition, the gd mother is at higher risk for impaired glucose tolerance after the pregnancy, higher blood lipids (cholesterol, etc.) later on, and developing Type II Diabetes (NIDDM) eventually. There is new research that shows that breastfeeding may be able to help in these situations also. GD moms who breastfeed tend to get less overt diabetes in the immediate postpartum period, they return to normal glucose tolerance faster than non-breastfeeding gd moms, and they have better 'good' cholesterol levels. There is also some speculation that nursing may help prevent or at least delay development of overt diabetes. So breastfeeding is very helpful to both the mother and the baby after a gd pregnancy. If at all possible, breastfeeding is especially important to consider if you have had gestational diabetes.
Even without gestational diabetes, there is very strong and very clear research that shows breastfeeding to be of great importance to the general health of both mother and baby. Breastfed babies have much lower rates of asthma, ear infections, intestinal illnesses, eczema, and respiratory illnesses. Later in life, some studies have found that they have lower rates of some cancers, juvenile diabetes, intestinal problems like Crohn's Disease, and perhaps type II diabetes. In addition, breastfeeding lowers the mother's risk of pre-menopausal breast cancer, ovarian cancer, and osteoporosis, and may lower her risk for post-menopausal breast cancer and other reproductive cancers. Breastfeeding certainly can't cure every disease, and of course there are no guarantees that it will prevent any of these problems completely, but studies show that when breastfed babies do get sick, they usually have it less severely and for shorter durations than formula-fed babies. It is GREATLY advantageous to both baby and mother to pursue breastfeeding.
How Long Should I Breastfeed My Baby
The American Academy of Pediatrics recently revised its guidelines (http://www.aap.org/policy/re9729.html) to recommend that all babies be breastfed for at least one full year (and as long thereafter as mutually desired), and the World Health Organization (Innocenti Declaration) recommends breastfeeding for at least two years and beyond. These strong recommendations were developed based on the CLEAR and significant evidence of the tremendous health benefits of long-term breastfeeding. The average weaning age around the world, in fact, is between two to four years. Western cultures (and especially American culture) tend to discourage nursing beyond a few weeks or months, but it is most advantageous to the child to be nursed for much longer than that.
You may decide to breastfeed for less time; individual circumstances vary and need to be taken into account. Though Kmom strongly encourages women to breastfeed for as long as possible, she also recognizes that many factors must be taken into account in this decision, and women who do not or cannot continue should be supported too. Or you may decide to mix formula and breastfeeding at some point later in the baby's development; it is certainly possible to use formula (or pumped milk) while away at work during the day and continue to nurse in the evenings at home. Full-time, unsupplemented breastfeeding is best, but some breastfeeding is much more advantageous than none. The most important thing is to be sure that the baby gets as much colostrum and breastmilk as possible under your circumstances so as to optimize the benefits both to you and to baby.
Interference with Breastfeeding Common
Due to the protocols and problems that can occur in a gd delivery, it can sometimes be more challenging to establish breastfeeding, and it is unfortunately very common for diabetes health professionals to be less than supportive or educated about promoting successful breastfeeding. Although breastfeeding receives lukewarm official approval by diabetes professionals, in reality they are often very ignorant about it and its benefits in gd, and they often have policies through this ignorance that actually discourage or sabotage breastfeeding. The purpose of this section of the gd faq is to address directly the advantages of breastfeeding and especially those pertinent to the gd mom, and to discuss ways around the delivery protocols that can interfere with breastfeeding. It is important to give the gd mom who wants to breastfeed EVERY opportunity to succeed and to assist her health professionals in enabling this process.
The purpose of this FAQ is to strongly urge gd moms to breastfeed (and give them the information and tools to do so), since it offers special benefits in gd. However, it must be noted that sometimes women who intended to breastfeed have difficulties. A few women do not have enough supply due to physical issues (such as hormonal problems, anemia/blood loss, and sometimes polycystic ovarian syndrome), though the most who have difficulties are actually sabotaged by poor medical support and advice. Some women have issues such as past sexual abuse that inhibit their ability to embrace breastfeeding, some women are not given the support needed to solve problems causing discomfort, and some women are sabotaged by nipple confusion from giving extra bottles. Although breastfeeding is much better for the baby (and you), sometimes things just don't work out.
Nothing here should be taken to imply that formula-feeding moms 'are bad mothers', 'don't care about their children', 'can't bond properly with their children', etc., or should be condemned for their choices. All mothers should be supported, regardless of their feeding method. Although formula-fed children do statistically have many more health problems, this is true on a group statistics basis and does not always apply to selected individuals. Choosing to use formula does not automatically sentence your child to poor health. Breastfeeding really is the best health choice for you and your baby, and you should consider breastfeeding for as long as possible, but if you do not end up breastfeeding you are not a 'bad mother.' Kmom does not endorse 'bashing' moms who end up using formula. Kmom's support of breastfeeding does not include a condemnation of those who choose otherwise.
General Health Benefits of Breastfeeding
As noted above, breastfeeding confers many health benefits and significantly reduces the baby's risks of many diseases and problems. In addition, breastfeeding lowers the mother's risks for a number of diseases, usually helps her drop pregnancy weight faster, and may improve blood sugar and levels of 'good' cholesterol. This section is a more in-depth look at these benefits, but it's important to note that there is no way that a small FAQ such as this can do the subject real justice. Readers are strongly encouraged to read books such as So That's What They're For! Breastfeeding Basics by Janet Tamaro, The Nursing Mother's Companion by Kathleen Huggins, and The Womanly Art of Breastfeeding from La Leche League. (More information about these books can be found in the section on Breastfeeding Resources below.)
There are a number of websites that summarize and document the medical advantages of breastfeeding. Kmom strongly recommends reading some of these sites for further information, including:
In addition, Kmom strongly suggests attending La Leche League meetings BEFORE the baby is born if possible, or immediately postpartum. There is generally a series of 4 meetings that summarize the benefits of breastfeeding, preparing for breastfeeding, dealing with breastfeeding, and weaning plus nutrition issues. There are La Leche meetings in nearly all larger towns and many smaller ones too. Go to the La Leche website ( www.lalecheleague.org ) for further information about finding a meeting near you.
Kmom's story: I strongly encourage readers to do their own research about the advantages of breastfeeding. This is what convinced me of the immense value of nursing (I was not strongly in favor of breastfeeding originally) . The more I read, the more I became convinced of its importance, though it was a slow discovery process. In the beginning, I felt that nursing was nice if you could, but not especially important; I only planned to nurse for about 3 months (and I wasn't really sure I'd last that long!). After the difficulty of my first delivery (the gd pregnancy), starting nursing was very bumpy and almost 'failed'. However, it drove me to do more reading, and I became more and more convinced by the medical evidence that breastfeeding was indeed more important than I had thought. In addition, finally being successful in preserving breastfeeding despite interference and mistakes gave me a real sense of accomplishment, joy, and connection to my baby. It helped give me back some of what the 'gd' and delivery interventions had taken away. Instead of nursing for several months, we nursed for several years instead, and it has been a very powerful force of health and healing in my life.
Of course, not everyone will have the same experience or feel the same way, but it's important to read and really understand about breastfeeding. I STRONGLY encourage you to do your own reading and draw your own conclusions.
The American Academy Of Pediatrics Policy on Breastfeeding
The 1997 AAP policy statement on breastfeeding (http://www.aap.org/policy/re9729.html) says:
Epidemiologic research shows that human milk and breastfeeding of infants provide advantages with regard to general health, growth, and development, while significantly decreasing risk for a large number of acute and chronic diseases. Research in the United States, Canada, Europe, and other developed countries, among predominantly middle-class populations, provides strong evidence that human milk feeding decreases the incidence and/or severity of diarrhea, lower respiratory infection, otitis media, bacteremia, bacterial meningitis, botulism, urinary tract infection, and necrotizing enterocolitis. There are a number of studies that show a possible protective effect of human milk feeding against sudden infant death syndrome, insulin-dependent diabetes mellitus, Crohn's disease, ulcerative colitis, lymphoma, allergic diseases, and other chronic digestive diseases. Breastfeeding has also been related to possible enhancement of cognitive development.
There are also a number of studies that indicate possible health benefits for mothers. It has long been acknowledged that breastfeeding increases levels of oxytocin, resulting in less postpartum bleeding and more rapid uterine involution. Lactational amenorrhea causes less menstrual blood loss over the months after delivery. Recent research demonstrates that lactating women have an earlier return to prepregnant weight, delayed resumption of ovulation with increased child spacing, improved bone remineralization postpartum with reduction in hip fractures in the postmenopausal period, and reduced risk of ovarian cancer and premenopausal breast cancer.
In addition to individual health benefits, breastfeeding provides significant social and economic benefits to the nation, including reduced health care costs and reduced employee absenteeism for care attributable to child illness...The direct economic benefits to the family are also significant...a saving of >$400 per child for food purchases can be expected during the first year.
Nutritionally, breastmilk is superior to artificial infant feeding products. Human milk has evolved over thousands of years into the perfect formula for human survival, and was tailored by evolution into the mix that most efficiently promotes our brain and neurological development. Formula is an artificial mixture that is only a recent experiment (and whose mix is being tinkered with all the time). It is an adequate substitute if circumstances necessitate a second choice, but breastmilk is much better for baby. Its nutritional components are proportioned to fit exactly the special needs of humans as a species, its nutrients are more bioavailable to baby, and it is a dynamic substance, changing its composition to fit the changing needs of the baby.
Breastfeeding is species specific to humans, meaning that it is specialized to fit the unique needs of human beings. All mammals produce milk, but the specific components of the milk (lactose, proteins, fat, water, vitamins, minerals, enzymes, and hormones) differ from one species to another in order to fit the specific needs of that species. For example, whale's milk is extremely high in fat in order to produce the blubber to keep them warm in cold seas. Rabbit milk, on the other hand, is 14% protein (human milk is 1-2 % protein) because baby rabbits need to double their birth weight in only six days; humans double their birth weight in about 4.5 months. Although mammals can survive on cross-species milk, the most optimal growth and survival rates are found when species-specific milk is used. In other words, whenever possible, humans and animals should be fed with their OWN milk in order to promote the most optimal development.
In their book, Milk, Money, and Madness: The Culture and Politics of Breastfeeding, Baumslag and Michels note that:
All breastmilks basically comprise the same type of substances...the quantity of each component, as well as the quality of the nutrients, are linked to the digestion and absorption mechanisms of each species and are most likely determined by a genetic blueprint. For instance, human milk has fewer salts than cow's milk, but the salts are better adapted to a human infant's growth and metabolism...Human milk has a small proportion of the volatile fatty acids that cause indigestion; cow's milk has a large proportion of these acids. Not only does the amount of total protein between human and cow's milk differ (cow's milk has more than three times the protein of human milk), but the amino acid mix (amino acids are the building blocks of protein) is also significantly different. This has important implications, for example, in the development of the nervous system. Similar differences apply to most of the constituents of milk. In addition to the amount of each individual component, how readily it is absorbed also varies. Cow's milk contains more iron than human milk, but the iron in human milk has a higher rate of bioavailability; that is, the breastfed human infant absorbs more iron than infant fed cow's milk (49% compared to 10%). In fact, the newborn can absorb about five times as much iron from human breastmilk as it can from cow's milk.
Although it has been known for centuries that asses' and goats' milk are actually closer in composition to human breastmilk than cow's milk, cow's milk has consistently been used as the primary human milk substitute. Decisions as crucial as these are not made based on nutritional superiority, but on economics...cow's milk...is (and always has been) the easiest and least expensive milk to produce.
Cow's milk (which most formula is based on) often causes problems for human babies. For example, because baby cows need very fast growth, need to walk soon after birth, but don't need much brain development, cow's milk (and the formulas based on it) have extremely high levels of protein and various salts. Humans don't need levels of proteins and salts quite as high, and may react to the different types of proteins present in cow's milk. Cow's milk contains large amounts of casein protein and lesser amounts of whey protein, but whey is more plentiful in human milk. It is more easily digested by human babies and higher in nutritive value; the large amount of casein in cow's milk often form tough curds that are difficult to digest.
Cow's milk and human milk have a number of other significant compositional differences. Taurine is an important amino acid that is plentiful in human milk but virtually absent in cow's milk; recent evidence seems to indicate the taurine may be important in brain development. Because of this finding, some formula companies are now adding it to their product, but it has always been available (and in optimal proportions) in mother's milk. Cysteine, another important amino acid, is found in human milk but the primary amino acid in cow's milk is methionine, which is difficult for infants to metabolize at first because their livers are not fully mature. Long-chain polyunsaturated fatty acids such as DHA are important to the process of myelination (development of the sheath around nerve fibers) and in some studies have been associated with better visual and cognitive development in infants. DHA is another substance some formula companies are considering adding, but the effect, value, and optimal dosage to add are unknown. Again, it is already present in breastmilk.
Lactose (milk sugar) is another way in which human milk differs from formulas. Lactose is thought to contribute to the most optimal development a baby's brain and central nervous system. Human milk has 1.5 times more lactose than cow's milk; infant formulas therefore have to be sweetened in order to match the carbohydrate levels in human milk. However, the sweeteners (like sucrose) used in formula do not act in the baby's system in the same way that lactose does. Lactose releases its energy at a slow, steady pace and provides a more steady energy source, avoiding the highs and lows of blood sugar that can happen with sucrose. This may be particularly important to babies of gestational diabetics.
In addition, lactose promotes the growth of so-called 'good bacteria' in the baby's gut (the bifidus factor), helping to prevent undesirable bacteria that can cause infant diarrhea, one of the scourges of infant mortality and morbidity. There is much more bifidus factor in human milk than in cow's milk. The combination of the bifidus factor with the protective mechanism of colostrum (pre-milk, which coats the intestines and helps stop harmful bacteria from attacking the vulnerable mucus membranes there) is strongly protective against gastrointestinal illness. One study (American Journal of Public Health, 1985, as quoted in Womanly Art of Breastfeeding) found that the risk of gastrointestinal problems was six times greater in infants receiving formula than those receiving breastmilk. Breastfeeding is strongly protective against gastrointestinal problems.
The exact balance of vital vitamins and minerals also varies between mammal species; thousands of years of evolution have created just the right balance for humans in breastmilk. It's important to note that the exact amount of a vitamin or mineral found in breastmilk is less important than its bioavailability; some vitamins appear on the surface to be more plentiful in cow's milk, but are absorbed and utilized by the baby less easily. For example, as noted above, iron is more plentiful in cow's milk but has less bioavailability; babies can absorb nearly 50% of the iron in human milk, but only 10% of the iron in cow's milk, and only about 4% of the iron in iron-fortified formulas. Other substances that are more bioavailable in human milk than cow's milk or formula include zinc and folic acid, and other vitamins such as E are found in human milk at five times the level typically obtained in formula. In addition, human milk is easier to digest because the proteins are already broken down, and because the enzyme lipase facilitates the digestion of milk fat.
Another significant advantage of human milk is that it is a DYNAMIC substance, always changing to meet the needs of the infant. Formula, on the other hand, is the same all the time, no matter what the needs of the baby are. A mother's milk will, for example, help provide extra protection to illnesses baby may be exposed to by manufacturing antibodies to specific germs in the mother's environment. Another excellent example of the dynamic nature of human milk is its response to a baby that is born prematurely (one of the theoretical risks of gd, please note). Baumslag and Michels (Ibid.) note that "the milk of a mother who delivers early is chemically different than that of a mom who delivers her baby after a full forty-week gestation." They note that pre-term milk is higher in protein, has 30% more fat, 4x more nitrogen, and is higher in nutrients such as sodium, iron, linoleic acid, and chloride. There certainly are formulas specially designed for the unique needs of pre-term infants, but again, these are only an approximation of what nature provides effortlessly, and of course do not provide any of the immunologic protections so crucial to the preemie. Studies have shown that formula-fed preemies are at a higher risk for Respiratory Distress Syndrome and retinopathy of prematurity, have a higher frequency of apnea and bradycardia, and necrotising enterocolitis is twenty times more common in them as well. In addition, the growth factors, hormones, and enzymes in human milk may be particularly important to the maturation of a preemie's delicate digestive and nervous systems.
Whether your baby is premature or full-term, it is clear from all available evidence that human breastmilk is definitely superior nutritionally. It is SPECIES-SPECIFIC to the particular needs of humans, especially the extraordinary brain growth and development that occurs in the first years. No other species' milk has exactly the right proportions of proteins, salts, vitamins, minerals, lactose, fats, etc. for human needs. Although formula manufacturers have done a lot of work trying to adjust their product to be closer to the specific needs of humans, it is still only an approximation, is being changed all the time, and the nutrients tend to be much less bioavailable to babies. Furthermore, breastmilk is dynamic, changing to meet the needs of each infant's situation. It is the evolutionary solution that has been developed over the crucible of time to be MOST effective and most beneficial for human infants. Modern formula versions are recent inventions, still unproven by the test of time, and babies given only formula have been shown in study after study to have more health problems overall. Formula certainly can be used as a substitute when needed, but if at all possible, breastfeeding is the most optimal choice for baby's nutrition.
Immunological Benefits to Baby
Probably the most important advantage of breastfeeding is the immunities it confers and the way in which it jumpstarts and strengthens your own baby's immune system, something formula can never do. The placenta nourishes and helps protect the baby for 9 months in utero; breastmilk was designed by nature to help take over this job once the baby is born. A child's immune system is not mature for several years; breastmilk is the intermediary designed to protect the baby while it is relatively defenseless and to jumpstart and strengthen his own defenses as they develop. Breastfeeding is the first and most important step in the immunization process of children, yet it is one that is often overlooked or de-emphasized. It truly is 'nature's vaccine for the newborn.' An excellent article summarizing the immunological effects of breastmilk can be found at www.promom.org/sci_am.htm (please note that what looks like a space in that URL is actually an underline).
Breastmilk, unlike formula, is a LIVING substance. This is an extremely critical point. It contains active, living cells that provide extra immunological protection to the baby and helps transition the baby more smoothly into the outside world until his own immune system is fully mature and ready to take over. This protection is at its highest concentration in the first few days after birth, lowers slightly after the mature milk comes in (but baby drinks more, so he still gets plenty), and slowly decreases over time but still remains present in breastmilk even well past the baby's first birthday. For as long as your baby is nursing, he or she is getting extra immunological protection for free from you. This long-term protection is extremely important for your baby. Doctors used to tell mothers that babies got all the immunological benefits within the first 6 weeks of nursing and that nursing after that was negligibly important, but modern research shows that much of the immunological benefits last for as LONG as you nurse the baby. That is part of why the American Academy of Pediatrics now recommends nursing for at least a full year or beyond.
When the baby is born, it does have some antibody protection in the form of immunoglobulins (secretory IgG). This is temporary until his own immune system begins to develop. When the baby starts to nurse, the first 'milk' is called colostrum, a clear yellowish fluid high in protein and also living cells, which act to bolster and further protect the baby's systems. It also contains an antibody new to the baby called secretory IgA, which acts directly at those points in the body where germs are most likely to try and invade (throat, lungs, and intestines). This antibody is particularly important to the gastrointestinal tract, as it 'coats' the mucus membranes there and helps prevent germs or foreign proteins from getting into the membranes and causing allergies or illness. IgA also is extremely important because it helps jumpstart the baby's own immune system and own production of IgA. Without nursing, a baby will eventually produce its own immunities, but it is thought to happen much faster and more efficiently through breastfeeding. Although no one knows for sure yet, many have speculated that the earlier stimulation of baby's immune system may be an important mechanism in protecting baby from some later diseases.
Breastmilk also contains other protective substances. Live white cells (leukocytes and lymphocytes) produce many substances that are able to actually attack and destroy various bacteria and even many viruses, and are an important further line of protection against illness. There are almost as many white cells in breastmilk as there are in blood, giving it a very strong protective effect. Furthermore, the bifidus effect helps keep the intestines at just the right acidity, which also can be protective. And as noted previously, when a baby encounters a germ in the environment, the mother's system reacts by producing antibodies specifically designed to counteract those particular germs. Between all the various immunoglobulins, the various substances produced by the white cells that attack bacteria and viruses, the bifidus factor, and interactive designer antibody protection, human milk plays an important part in 'vaccinating' your newborn against illness and disease.
The preventive effect can be seen in study after study about breastfeeding. The following is a summary of just a few sample studies from a variety of sources; there is a great deal of literature on this subject and not enough space on this FAQ to do justice to it all. Nor can all the studies be adequately credited in the Reference section at the end; please refer to the American Academy of Pediatrics statement, the websites www.promom.org and www.lalecheleague.org, and the books, Womanly Art of Breastfeeding and Milk, Money, and Madness for specific reference details.
It should be noted that methodology in breastfeeding studies (both pro and con) can be problematic. Many studies even today do not adequately consider confounding factors, do not contain an adequate 'control' group, only study breastfeeding for a very short amount of time, do not factor in whether the baby is also receiving formula, or determine the percentage formula/breastmilk received. But while it is of course important to critically examine the methodology of breastfeeding studies (both pro and con), the overwhelming bulk of evidence does point to the critical protective effects of breastfeeding.
For example, a number of studies show that breastfed babies often have fewer ear infections. Aniansson et al., 1994, found that the rate of acute ear infections was much higher at 2 months, 6 months, and 10 months of age in non-breastfed children; the rate of upper respiratory infections was also higher. Teele, 1989, found that not being breastfed was associated with a significantly increased risk for acute otitis media and prolonged duration of middle ear effusion. A study from the journal Pediatrics (Scariati et al., 1997) examined the rates of diarrhea and ear infections in US infants, adjusting for several confounding effects and examining the effect of how much breastmilk was consumed, unlike many earlier studies. The authors found that "the risk of developing either diarrhea or ear infection increased as the amount of breast milk an infant received decreased...Breastfeeding protects US infants against the development of diarrhea and ear infection. Breastfeeding does not have to be exclusive to confer this benefit...[but] the more breast milk an infant receives in the first 6 months of life, the less likely that he or she will develop diarrhea or ear infection."
Breastfeeding is also somewhat protective against allergies; this effect is most marked in families with a hereditary tendency to allergies. Van den Bogaard et al., 1993, found that in families with histories of allergies, not breastfeeding was related to more childhood illness. In the first year, they had more lower respiratory tract infections, gastroenteritis, and digestive tract disorder; over the first 3 years of life they had more respiratory tract infections and skin infections. Saarinen et al., 1995, found that breastfeeding for >1 month offered 'significant prophylaxis' against food allergy at 3 years of age, and against respiratory allergy at 17 years of age. The study also states that differences in infant feeding method were so pronounced that it "suggested an influence of early milk feeding that may exceed the heredity burden."
Breastfeeding is strongly protective against gastrointestinal illness, both in childhood and perhaps even longer. Lucas and Cole, 1990, found that necrotizing enternal colitis was 20 times more common in formula-only babies. Bergstrand and Hellers (1983), Koletzko et al. (1989), and Rigas et al.(1993), found that lack of breastfeeding is associated with higher rates of inflammatory bowel disease in children and adolescents, and appears to be a risk factor in development of Crohn's disease.
Some critics of breastfeeding promotion in the past have charged that while breastfeeding can make critical health differences in the third world, it does not particularly make as much difference in industrialized countries. However, although the effects of breastfeeding are MOST critical in third-world countries, studies have shown that breastfeeding is strongly protective, even in industrialized nations with excellent access to clean water and health care. Pisacane et al., 1994, found that not-breastfeeding was a strong risk factor for acute lower respiratory infections like pneumonia and bronchitis, even in industrialized countries. Duffy et al., 1986, found that formula-fed infants in industrialized nations still have a 3-4 fold risk of diarrheal illness, and moderate to severe rotavirus gastroenteritis is five times more common in formula-fed infants. Cochi et al., 1986, found that the risk for H influenzae bacteremia and meningitis is 4-16 fold higher in North American formula-fed babies. And Lerman et al., 1994, found that even in Israel with a high standard of living, breastfed children <12 months had a lower incidence of acute diarrheal disease than formula-fed children of the same age.
It's important to note that of course breastfeeding doesn't prevent ALL health problems, and that formula-feeding doesn't mean that EVERY formula-fed child will be seriously ill. Breastfed children do get sick sometimes, and formula-fed children can do just fine. However, studies do show that breastfed infants tend to be sick less, be sick less severely, be hospitalized less, have these protections extend longer, and need healthcare less often. Alho, 1990, found that short duration of breastfeeding involved significant risk of recurrent respiratory infections and otitis media. Van den Bogaard, 1991, found that there was an inverse relationship between breastfeeding and morbidity, and that this was most prominent in the first year of life but was also present in the first 3 years. De Duran, 1991, found that among infants with 2 or more episodes of acute chronic bronchitis, there were twice as many formula-fed infants as breastfed infants. Howie, 1990, calculated that the added risk of formula-feeding can account for 7% of infants hospitalized for respiratory infections. Davis et al., 1988, found that formula-fed infants and those breastfed less than 6 months had 8x the risk of developing lymphoma cancer, and Schwartzbaum et al., 1991, found a statistically significant protective effect against Hodgkin's disease among children breastfed at least 8 months compared with children breastfed less than 2 months. A 1995 study by the Kaiser Permanente health maintenance organization showed that breastfed babies had $1400 less healthcare costs in the first year alone, and Han-Zoric, 1990, found that breastfed infants had a better response to vaccinations than formula-fed infants.
Breastfeeding is the feeding method of choice when considering all the most relevant factors. It offers unmatched nutrition, immunological factors, and protection against morbidity, both short and long-term. The overwhelming tide of evidence finally surfacing clearly shows its many advantages for children, and it is likely that this evidence will only be strengthened as time goes on and more and longer periods of breastfeeding are studied.
Most people agree that breastfeeding is better for the baby if possible, but it is also better for the mom. It significantly decreases her risks of premenopausal breast cancer, and also appears to have some protective effect against other cancers as well. Breastfeeding mothers appear to have less risk of osteoporosis, tend to have better uterine involution after birth, and less postpartum hemorrhage. It also helps women lose pregnancy weight faster on average, and it is easier, cheaper, and more convenient once the initial period of adjustment is over.
Breastfeeding significantly decreases your risks for pre-menopausal breast cancer, the most aggressive and deadly form of breast cancer. The longer you breastfeed, the more your risk decreases; the greatest risk reduction is found in women whose total amount of breastfeeding (with one or more kids) adds up to several years. A 1989 study (Layde et al., Journal of Clinical Epidemiology) found that women who had breastfed for 25 months or more were one-third less likely to develop breast cancer than women who had given birth but never breastfed. A 1994 study (Newcomb et al., New England Journal of Medicine) found that "An increasing duration of lactation was associated with a statistically significant trend toward a reduced risk of breast cancer...If all women with children lactated for 24 months or longer...the incidence [of breast cancer among premenopausal parous women] might be reduced by nearly 25 percent."
Although the effect is less strong and not all studies confirm it, other studies do show some limited preventive effect for breastfeeding against the risk of postmenopausal cancer as well, both in women who breastfeed and their daughters who are breastfed. Freudenheim, 1994, found that women who were breastfed themselves as infants (even for a short time) showed approximately 25% lower risk of developing premenopausal or postmenopausal breast cancer compared to formula-fed women. So while more evidence is needed, it is interesting to consider the long-term protective effects our daughters may get from being breastfed!
Other studies have found protective effects of breastfeeding against other cancers and diseases as well. Brock, 1989, found a protective effect of breastfeeding against uterine cancer, and Petterson, 1986, found that not-breastfeeding increased the risk of developing endometrial cancer. Schneider (1987) and Rosenblatt et al. (1993) found that not-breastfeeding was a risk factor for developing ovarian cancer. While more evidence is needed here too, it appears that breastfeeding may have a protective effect on other reproductive cancers as well.
It now appears that there is less osteoporosis in women who breastfeed for a significant amount of time, and perhaps in their children as well. It used to be thought that breastfeeding increased the risk of osteoporosis, but followup studies such as Melton et al., 1993, have found that bone remineralization is actually IMPROVED after breastfeeding. Blaauw et al., 1994, found in a South African population that the odds that a woman with osteoporosis did not breastfeed her baby was 4x higher than for a control woman. Cumming and Klineberg, 1993, found that women who had breastfed had fewer hip fractures later in life. In addition, it is possible that breastfeeding may also help protect our daughters' bones. Dr. Alan Lucas of the MRC Childhood Nutrition Research Center of London found that 8 year-olds fed formula instead of breastmilk had less developed bone mineralization than those fed breast milk. This is obviously only preliminary, but an interesting finding nonetheless.
Breastfeeding moms also gain other more immediate benefits from nursing. Breastfeeding helps shrink the mother's uterus back to its normal size after childbirth; Chua et al. (1994) noted that non-breastfeeding mothers tend to have less uterine shrinkage and slightly enlarged uteri permanently. Suckling also helps prevent post-partum hemorrhage by increasing oxytocin levels and stimulating contractions, which help shut off the maternal blood vessels feeding the placenta; formula-feeding moms most often need to be given synthetic oxytocin to insure against hemorrhaging (ibid.). Breastfeeding moms tend to lose pregnancy weight and bulk faster and with less restrictions than moms who use formula. Nursing requires an average of 500 extra calories per day in the early days; this energy demand can help nursing women lose weight faster on average. Kramer, 1993, found that women who breastfed exclusively or partially had significantly larger reductions in hip circumference and were closer to their prepregnancy weights at one month postpartum.
And of course, breastfeeding is more convenient and less work-intensive than formula use, and it has the supreme benefit of being FREE. Several hundred to a thousand dollars per year can be saved through not buying formula, and healthcare costs are also usually cheaper with breastfed babies. Mothers who work outside the home but still pump their milk and breastfeed their baby while home tend to take fewer days off of work to care for sick children. In all, breastfeeding offers SIGNIFICANT benefits not only to the baby, but to the mother as well.
Breastfeeding Rates and Summary
However, despite all the many documented benefits of breastfeeding to both mother and the baby, many barriers are often placed in the way of breastfeeding, and studies show that long-term breastfeeding in particular is low in this country. A report by A.S. Ryan in the journal Pediatrics (1997), found that in 1995, only 59% of women in the US were breastfeeding either exclusively or in combination with formula at the time of hospital discharge. Furthermore, only 22% of mothers were nursing at all at 6 months postpartum, and many of these were also supplementing with formula. Given all the health benefits that accrue from breastfeeding, this is an amazingly low rate, and speaks eloquently of the barriers to breastfeeding many women encounter, as well as the cultural bias towards formula use in our culture. Mothers who must use formula for whatever reason should not be condemned, but there is a strong likelihood that public health issues would be strongly improved if women were given more encouragement and support of breastfeeding.
To this end, the AAP now recommends and supports breastfeeding for a full year (and beyond), and the World Health Organization has long advocated nursing for at least two years and beyond. Worldwide, the average weaning age is between 2 and 4, which puts our USA rate of only 22% still nursing at even 6 months in stark perspective! Not every US mom is going to be able or want to nurse for a year, two years, or even more, but neither should they be prevented from it, discouraged from doing it, or sabotaged in starting breastfeeding from the very beginning. It is clear from studies that ANY amount of breastfeeding offers clear advantages and protection, and that from a public health policy standpoint, we must do more to facilitate mothers in breastfeeding longer-term as much as possible.
A thorough knowledge of breastfeeding procedures and information is often your best offense in getting breastfeeding well-established, so be extremely proactive. Take classes, read books, take a nursing manual with you to the hospital, go to a La Leche League meeting, scan breastfeeding websites, perhaps even see a lactation consultant before or just after delivery. A determination to succeed and lots of support around you are the most critical issues in establishing breastfeeding.
Why Breastfeeding is Important to Women with GD
The general health benefits of breastfeeding for mother and baby are quite significant, as noted above. In addition, breastfeeding may be especially beneficial for gd moms and babies in a number of different ways.
Short-Term Benefits and Prevention of Long-Term Problems
Breastfeeding is recognized as an anti-diabetogenic factor, and studies show that it may be helpful to the gd mother. Yang et al. (1994) found that breastfeeding insulin-dependent gd mothers needed less insulin postpartum and returned to normoglycemic status earlier than non-breastfeeding insulin-dependent gd mothers. Another study of short-term breastfeeding found improvements in both blood glucose and HDL cholesterol and half the rate of immediate postpartum diabetes among women who breastfed as opposed to those who did not (Kjos, 1993). Kjos further noted that:
"Lactation, even for a short duration, has a beneficial effect on glucose and lipid metabolism in women with gestational diabetes. Breastfeeding may offer a practical, low-cost intervention that helps reduce or delay the risk of subsequent diabetes in women with prior gestational diabetes."
Breastfeeding also offers special potential benefits to the baby of a gd pregnancy as well. Breastfed gd babies generally do better after birth; Cordero et al. (1998) found that "routine care failures were...less frequent among breastfed infants" of diabetic mothers of any kind, and they required less admittance to the NICU for hypoglycemia, jaundice, etc. Since hypoglycemia and jaundice are two of the most common risks for gd babies, this is an important finding. (See below for more detail on preventing this problems.)
Breastfeeding may also play a special role in lessening the baby's chances for type II diabetes later in life, although this research is still in its preliminary phase. Pettit et al., 1997 found that "exclusive breastfeeding for the first 2 months of life is associated with a significantly lower rate of NIDDM in Pima Indians" in later life. In fact, after adjustment for possible confounding factors, the relative risk of exclusively breastfed babies developing type II diabetes by age 40 was approximately HALF in this study as those babies who were formula-fed from birth. (The risk for those receiving both formula and breastmilk fell somewhere in between.)
Several studies have found that children that had little or no breastfeeding had higher rates of obesity later in life (Strbak et al, 1991; Kramer MS, 1981; Kramer et al., 1985; Dewey, 1992, 1993, 1998), though many other factors of course influence rates of obesity, including genetics. Von Kries et al., 1999, found that "the prevalence of obesity in children who had never been breast fed was 4.5% as compared with 2.8% in breastfed children. A clear dose-response effect was identified for the duration of breast feeding on the prevalence of obesity: the prevalence was 3.8% for 2 months of exclusive breast feeding, 2.3% for 3-5 months, 1.7% for 6-12 months, and 0.8% for more than 12 months." (Clearly, in this study, the longer the child was breastfed, the lower the rate of obesity.) Since obesity is a risk factor for diabetes, it is speculated that preventing it or keeping it to genetically-determined rates may be able to help prevent some cases of diabetes.
Furthermore, Wallensteen et al., 1991, found that "in formula-fed infants the insulin response to a meal is enhanced compared to that in breast-fed infants. The finding of similar blood glucose values in the two groups may also indicate an insulin resistance in the formula-fed infants following a meal." In other words, more insulin had to be produced by formula-fed infants in order to achieve the same bG results, which could be a sign of early insulin-resistance. This may explain the mechanism by which formula-feeding may produce more type II diabetes and perhaps even obesity.
It's important to note that research into breastfeeding, gd, and NIDDM has been largely ignored until now and these findings are just preliminary; much more needs to be done. However, the preliminary work has been enough for the Fourth International Workshop-Conference on GD to issue a call to increase research into breastfeeding and gd. This will be an interesting and evolving field of research in the near future. The weakness of these studies so far is that they are small and do not adequately examine the effect of breastfeeding very extensively. Most studies are for a very short time only (mostly 2 months or less), and some do not distinguish between exclusively-breastfed infants versus infants being fed both breastmilk and formula. It will be important to examine the methodology of these new studies as they are done; it may turn out that breastfeeding has less effect than these preliminary studies indicate or it might turn out that extended breastfeeding has even more benefits than indicated by these limited studies. Only time will tell. But in the meantime, this preliminary evidence just adds more weight to the argument that mothers who have had gd should consider breastfeeding if at all possible.
Prevention/Mitigation of Jaundice
The baby of a gd mom tends to statistically be more prone to jaundice. This is thought to be because the hyperinsulinism of the infant tends to result in the production of more red blood cells. These extra red blood cells remain to be broken down after the baby is born, which is harder for the baby's liver to process. This can cause the baby's bilirubin levels to rise as a result---'physiological jaundice'. In addition, the often-routine gd protocols of induction (and epidural for the pain of pitocin labor) increase the chances of jaundice, as does a c-section (which occurs more often in gd). Thus the baby of a gd mom can be many more times likely to experience jaundice. Although most jaundice is not severe enough to cause damage and is usually fairly easily treated, too-high levels can cause brain damage, so it is important to prevent or minimize it if possible.
Not every gd study shows increased rates of jaundice in gd. This may be partly differences in study populations, differences in delivery protocols, and differences in diagnostic cutoffs or frequency of testing. It may also reflect the protocols of treatment of the baby after it is born; there ARE ways to lessen the risk of jaundice in the baby of a gd pregnancy and some routine hospital practices of the past have in fact been found to probably increase rates of jaundice. So it behooves the gd mom to be as knowledgeable as possible about preventing/minimizing jaundice, just in case.
The best prevention/treatment for jaundice is early and extremely frequent nursing. The colostrum or 'pre-milk' which is secreted in the breasts in the first few days post-partum (and which contains so many important antibodies and protections for baby) acts as a laxative and helps the baby pass its meconium (first stool) faster. When the liver breaks down the extra red blood cells and processes the bilirubin, it is excreted into the meconium and out of the body. If the baby's meconium is not passed as quickly because baby is not receiving enough colostrum, the bilirubin in these stools may be reabsorbed by its intestines into its bloodstream, exacerbating jaundice levels. It is in the baby's best interest to pass its meconium as quickly as possible, and the laxative effect of colostrum is one of the best ways to promote this.
Sometimes doctors and nurses recommend supplemental glucose water for cases of jaundice to help 'flush out' the bilirubin, but this treatment is now outdated for the vast majority of cases. The most recent research indicates that supplements can actually make the problem worse by delaying stooling, and that frequent nursing is the best remedy for normal 'physiological' jaundice (some types of jaundice are different and require other treatments). Unfortunately, many doctors and nurses are unaware of this new information and may still recommend supplements when none are required. These tend to fill up baby and make him less interested in nursing, thereby making the problem worse. (This happened to Kmom!) The American Academy of Pediatrics now states that "supplementing nursing with water or dextrose [glucose] water does not lower the bilirubin level in jaundiced, healthy, breastfeeding infants."
The gd mother needs to write into her birthplan that she wants to nurse her baby as SOON as possible after birth; within minutes preferably, but within the first hour for sure (unless medical circumstances do not permit it). She should inform the staff that the baby is NOT to receive any glucose water or formula supplements unless necessary due to low blood sugar rates or significantly delayed access to baby. She should nurse the baby as often as possible on the first day (and the first week) in order to help the baby finish clearing the meconium from its system. One study cited by the Breastfeeding Answer Book showed that a minimum of at least NINE feedings every 24 hours prevented jaundice from becoming exaggerated, and noted that the number of the breastfeedings on the first day was especially critical. A good rule of thumb is to nurse every 2 hours during the day, and every 4 hours or so at night in the first week. If the baby is sleepy (common after induced or highly medicated labors, or with jaundice), it is important to rouse the baby for feeding anyhow. 'Switch nursing' or other techniques may help in this process (see The Nursing Mother's Companion for details), as can breast massage. However, do be sure that the baby eventually gets plenty of uninterrupted time on each breast in order to get enough of the rich 'hindmilk' as well, since this also helps stimulate bowel movements and get rid of bilirubin faster (and prevents gas).
Normal physiologic jaundice usually resolves itself within a short period and has no aftereffects, as long as bilirubin levels do not reach dangerous heights. If levels are slightly raised, increase nursing frequency strongly and expose the baby to indirect sunlight frequently during the day. This is usually enough to resolve most cases of jaundice. If levels are moderately raised, however, phototherapy may also be needed in addition to frequent nursing and indirect sunlight. Except for rare cases, breastfeeding should NOT be interrupted. A 1994 American Academy of Pediatrics bulletin states, "The AAP discourages the interruption of breastfeeding in healthy term newborns and encourages continued and frequent breastfeeding (at least eight to ten times every 24 hours)...if the baby receives phototherapy...there is no significant advantage in discontinuing nursing." Frequent nursing remains important during the phototherapy process, since dehydration is one of the potential side effects of this treatment.
Occasionally formula supplements are needed in addition to nursing when jaundice levels rise too high, the mother's access to the baby is limited, or her milk supply is low or delayed. A need for formula supplements is an unusual circumstance and should NOT be done routinely, but if it does become necessary, supplements should be given by alternative feeding methods instead of a bottle. Techniques such as a cup, spoon, feeding syringe, tube/finger feeding, eyedropper, or nursing supplementer interfere with breastfeeding less often than bottles. Blomquist et al., 1994, found that "babies given supplements [by bottle] in the maternity unit had 4x the risk of not being breastfed at 3 months than those babies not given supplements." Cronenwett, 1992 (as quoted in The Breastfeeding Answer Book) found that "30% of mothers whose babies received bottles in the hospital reported severe breastfeeding problems, as compared with 14% of those whose babies did not." Pacifiers should also be avoided, as they also tend to result in lower rates of breastfeeding success (Righard and Alate, 1997).
The exact levels at which jaundice needs aggressive treatment are subject to great debate and sources differ; consult your provider. 'Hyperbilirubinemia is generally diagnosed at levels of >12 mg/dl; the most commonly seen recommendations in the past were to treat fairly aggressively at 15-20 mg/dl; at present the guidelines usually seen are a bit higher, depending on the age and condition of the baby. It must be strongly emphasized that these cutoffs are HIGHLY dependent on a number of complex factors, and a layperson is not familiar enough with all of the intermingling factors to make treatment decisions. For example, a baby that is clinically jaundiced in the first 24 hours needs treatment, regardless (this is not normal physiologic jaundice). A sick, premature, or ill baby cannot tolerate bilirubin as well and needs treatment at lower levels. A great deal depends on the baby's age, its general health, bilirubin level, how fast the bilirubin level is going up, and whether it has peaked or is thought to be near peaking. In extremely rare cases, a blood transfusion may be needed to help bring down a baby's bilirubin count, but the advent of phototherapy and other proactive treatments has made this an unusual last resort.
If your doctor is concerned about your baby's jaundice levels, it is important to clarify what the cause of the jaundice is (is it normal jaundice or another type?), what test results have been and the diagnostic criteria used for determining care decisions, and the factors influencing your doctor's concern (illness, prematurity, etc.). Express your strong desire to breastfeed your baby and request a consultation with a professional lactation consultant (IBCLC) in order to work out a plan that will allow you to stay as close as possible to your baby and continue to breastfeed frequently during treatment. For an excellent in-depth discussion of jaundice and breastfeeding issues, see The Breastfeeding Answer Book (La Leche League, 1997).
Most jaundice cases that occur after a gd pregnancy do not need specialized treatment, just monitoring to be sure levels do not go too high. In some cases, phototherapy or occasional formula supplements may be needed, but breastfeeding rarely needs to be interrupted. However, in the vast majority of cases, early and frequent breastfeeding and regular exposure to indirect sunlight can prevent or minimize physiologic jaundice after a gd pregnancy. The gd mother and her care providers should plan to be as proactive as possible about jaundice.
Prevention/Mitigation of Neonatal Hypoglycemia
Another risk for gd babies is the fairly common scenario of hypoglycemia. High blood sugars in mom can cause baby to overproduce insulin; after delivery, the baby's blood sugar can then drop precipitously, potentially causing serious problems. Most of the time, early and frequent nursing can take care of this problem too. Colostrum (pre-milk) contains very high levels of protein, which is much more stabilizing to blood sugar than the usual glucose water supplements. It is vital, however, that the gd baby be nursed as SOON as possible after birth and very frequently thereafter to avoid this potential problem (and decrease the chance of jaundice as well). Although babies of gd pregnancies do apparently get hypoglycemia at higher rates than babies of normoglycemic pregnancies, no further action is generally necessary other than watchfulness. In most cases, the past practice of routine or mandatory supplementation of gd babies is not necessary if the baby is nursed as soon as possible after birth and every 2 hours after that.
On occasion, however, supplements can become necessary in a gd baby, since untreated or unresponsive neonatal hypoglycemia can potentially harm the baby. If the baby's blood sugar is extremely low at birth (from prematurity, illness, macrosomia, or difficult birth), glucose water or formula supplements may be needed in order to bring baby's blood glucose levels back up. At times, there are also babies whose blood sugar levels are marginal but just do not respond to nursing well; in this situation, supplementation is also justified (although it should take place after the baby has nursed, not before). If the mother is unavailable for several hours (due to general anesthesia or other problems) and the baby's bG is marginal, supplements may also become necessary if baby's bG begins to drop. Finally, if hypoglycemia is severe enough or the baby is premature, IV glucose feedings may become necessary, but these usually do not preclude developing a nursing relationship later on. IV glucose used to be routine for ALL babies of insulin-dependent mothers, and occasionally in some hospitals, it still is. However, this is being phased out in many facilities. It still may be necessary on occasion in some babies of insulin-dependent moms, but it is generally not required in most places now unless the baby is premature, resists feedings by mouth, or displays symptoms of hypoglycemia. Consult your provider for his/her protocols.
It's important to remember that hypoglycemia severe enough to necessitate supplements or IVs is more unusual than not, and chances are your baby will not need supplementation if it has frequent access to the breast. Exact rates of hypoglycemia in gd newborns is difficult to determine, but most contemporary studies show that many gd babies will not experience it (especially if given early and frequent access to nursing) although it does still remain a risk to watch for. Past studies have sometimes shown very high rates of neonatal hypoglycemia (50% or more) and more severe cases of it, but a number of different factors cloud the results of these studies and make it difficult to generalize information. Different hospitals have different standards for defining hypoglycemia; in some it was diagnosed at 30 mg/dl in a full-term healthy baby, in others at 35 mg/dl, and in others at 40 mg/dl (the numbers are different for premature or ill babies). Babies of diabetic pregnancies also often had nourishment withheld from them at first (increasing hypoglycemia cases), or were given glucose water supplements (creating a more volatile blood sugar fluctuation). Finally, the hand-held glucometers often used to test baby's blood sugars have been recently found to significantly underestimate bG levels of newborns in many cases. So the levels of hypoglycemia documented in the past tend to be muddled and unclear.
Furthermore, mandatory testing of ALL gd babies likely turns up many marginal cases that are clinically unimportant and would likely go undocumented if the gd label were not present. The rate of borderline hypoglycemia among babies of 'normal' pregnancies is probably significantly underestimated because they are not routinely tested (Sexson, 1984, found that with a cutoff of 40 mg/dl, more than 20% of well newborns would be considered hypoglycemic, yet these babies routinely do fine without treatment or recognition of their borderline status). Many clinicians now feel that such borderline cases are clinically unimportant if no symptoms are present and the baby is fed routinely and well. Because testing is routine in gd pregnancies, more cases are documented and the problem is seen as more severe, but it is unclear whether asymptomatic borderline readings in gd cases that respond well to nursing are really a concern. However, most clinicians feel it is wise to err on the side of watchfulness with gd, just in case.
Since hypoglycemia certainly does NOT occur in all gd babies and most borderline cases respond well to simple nursing, routine supplementation for all gd babies is probably not justified. Although most hospitals have abandoned this practice, it does remain in effect in places, often resulting in needless breastfeeding failure and higher hypoglycemia and jaundice rates. It is extremely important to insist that any hypoglycemia be DOCUMENTED through LAB tests before any supplements are given! Hand-held glucometers or testing reagant strips can be used to rule out hypoglycemia, but not to establish it because of their tendency to underestimate bG in newborn blood. The borderline baby's blood sugar should be documented with a LAB test before any treatment is initiated (immediate treatment is necessary with extremely low bG levels or when babies are symptomatic).
If a borderline level is discovered, the first treatment of choice should be early and frequent nursing, if possible. If this is not possible or if the levels are low enough, then supplementation should indeed occur, but parents should request that it be given through alternative methods if at all possible (occasionally, IV treatment will be needed). The mechanics of sucking on a bottle are completely opposite to the mechanics of breastfeeding, so if supplementation does become necessary, everything possible should be done to avoid using bottles in order to minimize nipple and sucking confusion. Although some babies are able to handle the transition from bottle to breast without problems, many babies cannot and it is best to avoid even the possibility. Studies show that bottles DO impact breastfeeding rates (Blomquist, 1994; Cronenwett, 1992), as do pacifiers (Righard and Alate, 1997). Alternative methods of supplementation include eyedropper, syringe, tube/finger-feeding, cup, etc.
These issues will probably need to be written into a birth plan and discussed ahead of time/signed off on by your pediatrician of choice. A physician's order to document hypoglycemia, use breastfeeding as much as possible, and use non-bottle methods for supplementation goes a long way to quiet staff concerns over changing the usual procedures. Parents would be wise to have their wishes and their pediatrician's approval on paper ahead of time in case this situation arises, while also making it clear that if supplementation becomes necessary, they support that decision as well.
GD moms can minimize the potential for neonatal hypoglycemia in their baby by maintaining careful control over their bG in the last few weeks of pregnancy; women whose bG is less controlled tend to have a higher rate of babies with hypoglycemia. Also, glucose IVs during labor can cause problems by stimulating fetal insulin levels; mothers should maintain a reasonable bG level during labor (particularly important for insulin-dependent gd moms). Although many hospitals maintain the outdated rule of forbidding women to eat and drink during labor, this may also exacerbate glucose problems in the mother and baby; if her provider agrees, moms should be able to eat and drink lightly during early labor as desired (practicing sensible gd nutrition rules, of course).
If your doctor becomes concerned about your baby's bG levels, it is important to clarify what test results have been, how the test was done, and the diagnostic criteria used for determining care decisions, plus any other concerns that factor into his/her decisions. Express your strong desire to breastfeed your baby and request a consultation with a professional lactation consultant (IBCLC) in order to work out a plan that will allow you to stay as close as possible to your baby, minimize or avoid bottles and nipple confusion, and continue to breastfeed frequently during treatment. For an excellent discussion of hypoglycemia and breastfeeding issues, see The Breastfeeding Answer Book (La Leche League, 1997).
Most cases of neonatal hypoglycemia that occur after a gd pregnancy do not need specialized treatment, just as most jaundice does not. Monitoring, however, is important, though sources differ somewhat on the frequency and number of tests needed. In some cases, occasional supplements may be needed, but these should be in addition to breastfeeding, not instead of it. On rare occasions, IV glucose may become necessary, but does not preclude eventual breastfeeding (moms should get a hospital-grade pump to maintain their supply in the meantime). However, in the vast majority of cases (as with jaundice), early and frequent breastfeeding can prevent or minimize low blood sugar in the infant after a gd pregnancy, so the gd mother and her care providers should plan to be as proactive as possible.
Overcoming Breastfeeding Challenges
Sometimes breastfeeding can get off to a difficult start. This is particularly true when any sort of diabetes is present (due to all the interfering protocols some hospitals have), after a c-section (and gd moms often have very high rates of c-sections), if the mother experiences a significant blood loss during the birth, or if problems such as neonatal hypoglycemia or jaundice occur (which often incur excessive supplementation). This can be a VERY difficult and emotionally draining experience, and it generally occurs at a time when a woman is at her most vulnerable. Overcoming breastfeeding challenges can be a real hurdle for many moms, but those who are able to overcome them successfully do find the rewards even more sweet.
Common Barriers to Breastfeeding for Diabetic Women
Little study has been done about breastfeeding in mothers who have had gd, but there is some literature out there on breastfeeding rates in type I diabetics. Although the problems of type I diabetics are generally much more severe, lead to more serious risks for the newborn, and generally present more barriers to breastfeeding than gd does, examining breastfeeding issues for type I diabetics still presents some lessons for gd moms to learn from.
Many barriers have traditionally been placed in the way of insulin-dependent diabetics who wanted to breastfeed their babies. It used to be standard procedure that ALL babies of diabetic pregnancies be routinely placed on IV glucose immediately after birth (regardless of whether they needed it or not), be given routine supplementation of glucose water and formula, and be kept from their mothers for days afterwards. Many diabetic mothers were counseled that it would be 'too difficult' for them to breastfeed their children, that formula would stabilize the baby's blood sugar 'better', that most diabetic mothers 'couldn't produce enough milk' for their children, or that breastfeeding would cause them to get infected breasts (mastitis). Many medical texts even recently contained cautions that IDDM mothers usually have inadequate lactation or difficulty breastfeeding. But it is questionable how many of these problems are due to the diabetes itself vs. the many barriers to breastfeeding put in front of diabetic women.
Ferris et al., 1988, found that babies of diabetic pregnancies were routinely separated from their mothers after birth by automatically admitting them to Neonatal Special Care Units for several days. Mothers were typically not permitted to initiate breastfeeding until THREE DAYS after the birth, after which time the baby had been routinely given many bottles and supplements. The study found that the more formula babies had received by day 2, the less breastfeeding persisted over time. It also found that none of the babies were permitted to 'room in' with the mothers and that virtually no breastpumps were made available to the mothers. It's not surprising, therefore, that more type I (IDDM) mothers had problems with let-down, illness, fever, and mastitis, although the study blamed most of these on their diabetic status, not management protocols. It's true that diabetics are more prone to infection and diabetic mothers must be watchful for this, but how much of these problems are due to the diabetes and how much to the routine separations, supplementations, and interference with breastfeeding these mothers experienced is questionable.
There was a bit of good news in the study; IDDM mothers who nursed lost significantly more weight after the birth and had much lower fasting glucose values (82 mg/dl vs. 120 mg/dl), despite higher caloric intakes and similar insulin dosages to those who did not nurse. This shows the strong anti-diabetogenic affect breastfeeding can have on many diabetics, and is a good motivation for gd moms to consider nursing. The other good news is that despite all the interference, breastfeeding rates were similar between IDDM mothers and non-diabetic controls at 6 weeks, an excellent testament to the dedication of these mothers in view of all the interference! Long-term breastfeeding rates were not measured, but other studies have found lower rates of breastfeeding among diabetic mothers, especially in the long-term.
Ferris et al., 1993, also studied breastfeeding in type I diabetic mothers. In their study, they also found that women with IDDM spent significantly less time with their babies after delivery than non-diabetic mothers (moms only saw their babies 19% of the time in the first 2 days!). They also found that breastfeeding initiation was delayed with diabetes; women with IDDM breastfed their babies for the first time at about 26 hours postpartum on average. Again, women in this study were not encouraged to use breastpumps in the interim at all; between this and the lack of early access to the baby, IDDM mothers' milk typically 'came in' much later. More IDDM mothers also discontinued breastfeeding within 42 days postpartum compared to nondiabetic mothers, and they also tended to perceive that their infants had more feeding problems as well (small wonder!). As before, the authors tended to blame the diabetes for the breastfeeding problems. Although this study acknowledged that early separation and supplementation might have some effect on breastfeeding difficulties, they placed most blame on the diabetes, suggesting that "an adequate milk supply may never be produced by some women with IDDM," and that separation and supplementation "cannot explain the long-term differences in feeding behavior...throughout the course of lactation by the mothers with IDDM." (Oh yes it can!)
Although poor blood sugar control CAN affect lactogenesis, early prolonged separation, lack of access to breastpumps, and significant supplementation HAS repeatedly been shown to cause breastfeeding 'failure' in non-diabetic women too. It is difficult to determine in so much of diabetes research just how many problems are truly due to the disease and how many are actually due to the management protocols used with diabetics. At least in breastfeeding, recent research seems to indicate strongly that a significant percentage of the problems are actually due to overly restrictive protocols.
A special 'Practice Points' Bulletin of the American Dietetic Association in 1998 seems to advocate updating some of these policies in order to help IDDM breastfeed more successfully. It notes that:
studies show that the first 1 to 1.5 hours of life are critical for encouraging the baby to latch on to the nipple properly, which in turn stimulates milk production and helps mother and baby to bond. Women with type 1 diabetes sometimes face obstacles, however, in staying with their babies immediately after birth...A baby-friendly hospital makes provisions for such separations and assists the mother in pumping and storing her milk, which aids in establishing a good milk supply and prevents engorgement. An eye dropper can be used to give the breast milk in the nursery, thus avoiding the introduction of formula and artificial nipples that can reduce the baby's interest in breast-feeding.
The Lactation Consultant Series unit on maternal diabetes and breastfeeding from La Leche League states that:
The baby of a diabetic mother with normoglycemia during conception, pregnancy, labor, and delivery is unlikely to have serious neonatal problems or birth defects. Aside from frequent blood sugar checks, the infant can be treated like any other newborn with regard to rooming-in, breastfeeding, and mother-baby togetherness. With early and frequent nursing, the mother's milk comes in quickly. As long as the infant has normal blood glucose values, no supplements are necessary.
They further cite a 1983 study from Great Britain that "the most important factor for successful lactation is to begin breastfeeding shortly after delivery...When breastfeeding was delayed twelve hours or longer, the babies of diabetic women were--like the babies of nondiabetic women--more likely to be weaned before three months of age than were babies for whom the first nursing was not delayed." Although it is possible to start later (and women who must be separated from their babies for clear medical reasons should not fear that breastfeeding would now be impossible), it is clear that breastfeeding is most optimal when started within the first hour after birth, preferably within minutes. Barring urgent medical considerations, gd mothers should arrange with their providers ahead of time that nursing should begin before most non-critical medical procedures, before any supplements are given, and as soon as possible after birth.
So the lessons from type I diabetic breastfeeding research seem to be that
A professional Lactation Consultant should probably also be utilized whenever possible. Freed et al. (1995) studied knowledge of breastfeeding practices among pediatricians and pediatric residents, and found that "their clinical knowledge and experience did not suggest a high degree of competency." Many were not aware of breastfeeding's protective effect against ear infections, and nearly half did not know that supplements in the first weeks can cause breastfeeding failure. What instruction they'd had about breastfeeding was in lecture format, and practical instruction in helping women overcome breastfeeding difficulties was very limited. Those who had the most breastfeeding knowledge generally had acquired it from personal or family experience with breastfeeding, not instruction. So while there ARE doctors who are knowledgeable and truly supportive of breastfeeding, many are undertrained or misinformed. If possible, a professional lactation consultant should be brought in to help with practical advice and proactive prevention of problems, especially when potential complications like diabetes are present.
Another barrier to nursing that diabetic women can have is that of contraception. Many type I diabetics and gd moms are strongly pushed to take birth control pills, due to their highly effective contraceptive rate; some birth control pills can interfere with the establishment of breastfeeding, but many doctors don't realize this and prescribe it anyway. Many estrogen/progestin 'combined' pills are known to interfere with breastmilk supply and the nutrition of breastmilk, plus the high levels of hormones from these pills are generally not safe for the early months of breastfeeding. Yet many diabetic (and gd) moms are given prescriptions for it anyway, with little counseling about the possible effects it can have on nursing or on the baby. In fact, many studies on contraception for diabetic mothers fail to mention it at all in their studies, or mention it only briefly in passing, which is part of why so many doctors don't realize its effect.
The progestin-only 'mini-pill', on the other hand, IS thought to be compatible with nursing, so many gd mothers are given prescriptions to this instead for the breastfeeding period by more savvy doctors. However, few of even these doctors know that research indicates that starting it too early can also interfere with breastfeeding supply. If used, it should only be taken after 8 weeks or so postpartum. At that time, most women can start mini-pills without it having an effect on their milk supply, though a few women are more sensitive to the hormones and cannot take it even then. It should be noted, though, that at this time the mini-pill is under renewed scrutiny because a recent study by Kjos et al. (1998) found gd moms that used mini-pills had 3x the risk of developing full-blown diabetes within a short time as those on the low-dose combination pill. However, these results need to be replicated in other studies, since other (smaller-scale) studies on the mini-pill did not show any increased rates of diabetes. Furthermore, this study concentrated on Hispanic women, and it's not clear whether the results can be applied to all ethnic groups. More research is needed.
At this time, it is clear that gd moms wishing to breastfeed should not use a combination birth control pill, and it is not yet certain whether the mini-pill should be used or not. Gd moms wishing to breastfeed should probably choose a barrier form of birth control for the first 6 months of nursing, and then re-evaluate their choice if desired. But many gd moms, like type I diabetes moms, will face a great deal of pressure to go on the pill from their doctors, and may or may not be counseled about its possible effects on breastmilk supply or be started on it too early. They must be carefully informed about contraception, gd, and breastfeeding before they make their choice regarding contraception after a gd pregnancy. (For more detail on contraception choices after gd, see GD: Postpartum Concerns).
Breastfeeding After A Cesarean
Mothers with pre-existing diabetes and GD mothers also often have an extremely high rate of c-sections, which can make breastfeeding harder to establish. Diabetics usually average about a 50% c-section rate, and some studies have found rates nearer to 70%-90%! Gd moms usually do not have such extreme rates, but they are still higher than average (20-40% in most gd studies; the overall US average for normal pregnancies is about 20%). Several studies have shown that even when risk factors such as macrosomia have been lowered, a strongly increased c-section rate still exists, demonstrating that a much lower threshold for surgical intervention tends to be applied to 'diabetic' cases (Coustan, 1996; Remsberg et al., 1999).
On average, 1 of every 3-4 gd moms will end up with a c-section, although the necessity of many of these is questionable (see GD: Basic Treatment Protocols for more information). This high rate of c-section can also negatively affect breastfeeding rates. Perez-Escamilla et al., 1996, found that "Cesarean section was a risk factor for not initiating breast-feeding (odds ratio [OR]=0.64...) and for breast feeding for less than 1 month (OR=0.58...)." Although breastfeeding among gd mothers has not been well-studied, many gd moms anecdotally confirm that their c-section made establishing breastfeeding even more difficult, in addition to the usual barriers put in front of diabetic mothers.
Cesareans often mean delayed access to the baby after birth, which studies show to significantly impact breastfeeding difficulty (see above). Many babies are also given formula or glucose water in bottles in the meantime (this may be particularly true with gd babies), creating problems with nipple confusion and improper sucking. The mother may be groggy from medications or in pain from the surgery, and may thus be unable or less inclined towards pursuing breastfeeding much. Some hospitals routinely separate c-section babies from their mothers as well, forbidding them from the 'rooming in' that tends to facilitate breastfeeding establishment, and the physical difficulties of initiating breastfeeding after recent surgery also contributes to the lower rates of breastfeeding after a cesarean (try nursing lying down, with a pillow across the incision, or with the football hold!). Finally, significant post-partum hemorrhage is more common after a c-section as well (particularly in some obese women), and the resulting anemia can also often negatively affect breastfeeding (Willis and Livingsone, 1995).
However, although establishing breastfeeding successfully after a c-section is harder, it CAN be done. Many gd moms have done it in spite of routine supplementation protocols, separation, lack of support from medical personnel, postpartum hemorrhage, etc. (see GD Moms' Breastfeeding Stories, below). Many women find that the emotional satisfaction of breastfeeding helps to make up for the disappointments of the pregnancy and birth, and is emotionally and spiritually healing. Other women have difficulty and may not breastfeed long-term, but have the satisfaction of having given their baby significant amounts of the all-important protective effects of colostrum and early nursing.
Every gd mom should face the possibility that there is an increased risk of having a c-section when the 'gd' label is present. In order to be proactive about breastfeeding in spite of the increased chance of c-section and interference, she should actively educate herself about breastfeeding, read breastfeeding books like The Nursing Mother's Companion (see below), take a breastfeeding preparation class, or go to La Leche League Meetings. She should write a birth plan that STRONGLY indicates her desire to fully breastfeed her infant and avoid unnecessary supplementation, should remind staff of this desire in the hospital, and should plan to be as proactive as possible, particularly if she ends up having a c-section.
The Emotional Toll of Breastfeeding Challenges
Although it's dangerous to over-generalize, it does seem that women who are able to breastfeed successfully often experience less severe levels of PPD and quicker bonding after a traumatic birth, while those who find breastfeeding difficult or give up quickly may find it more severe (Laufer, 1990). This may be related to hormone levels (since women who do not or cannot breastfeed tend to 'crash' more quickly and do not get the moderating benefits of prolactin and other hormones to help transition them), or it may simply be emotional. As noted above, the success rate of breastfeeding after c-sections and traumatic births is lower than after normal birth (Perez-Escamilla, 1996) since conditions that surround these deliveries often interfere with breastfeeding, there may be less support from the staff, or the mother may be separated from baby more. But it's worth pointing out that the many women who experienced traumatic births or c-sections yet were able to preserve breastfeeding report the experience of breastfeeding to be one of their best acts of self-healing; this was Kmom's experience, as noted previously. As always, however, individual responses vary.
Mothers who experienced great difficulty in breastfeeding and gave up or who had to supplement because their supply was impaired often feel great guilt, frustration, or anger. The reasons for their difficulties may vary widely. Some may not have been adequately prepared emotionally or physically for breastfeeding, and may have lacked adequate instruction, information, and support about starting or preserving breastfeeding. Some were very likely sabotaged by medical mismanagement, and some may have experienced a lack of support at home or from family members. Others may have undiagnosed physical causes, such as maternal hemorrhage, anemia, retained placental fragments, hypothyroid levels, uncontrolled blood sugar levels, or birth control pill prescriptions that cause their supply problems. To have the great frustration of having to deal with gd in pregnancy and then not be able to fully breastfeed afterwards can sometimes magnify the grief and frustration intensely. These women are usually likely to be able to succeed at breastfeeding with another child, given adequate information, care, and support, but still need to grieve and vent about their difficult experience this time.
However, it is important to note that there are a few women who are not able to breastfeed, either partially or at all, even when extremely well-prepared and supported. These dedicated women do everything possible to ensure success, get plenty of timely professional help, pump religiously to increase supply, etc., yet are never able to produce enough milk to fully sustain their child. No one knows exactly how many women overall are truly physically unable to breastfeed since medical mismanagement is so common, but. there is a very small percentage of women whose breasts never change during pregnancy and who never get any milk, and there is a slightly larger group who get some milk but not enough to fully support feeding their baby without supplementation. It is thought that this latter case is probably hormonal, but no one quite understands what happens in these cases as yet.
GD, Polycystic Ovarian Syndrome, and Breastfeeding Problems
Among these mothers are some women with PolyCystic Ovarian Syndrome. Although no one has really documented exact numbers, one lactation consultant estimates that up to 20% of women with PCO will have trouble breastfeeding their babies and will need to partially or fully supplement, yet many others with PCO are able to breastfeed without supplementation. No one understands why some women with PCO are able to breastfeed without problems and yet others cannot; a best guess is that since PCO is probably a group of related syndromes instead of one well-defined disease, time and research will probably find that these women's PCO manifests itself differently. Unfortunately, nearly all research into PCO in the past has covered reproductive issues; PCO researchers are generally very uninterested in lactation issues. In the lactation research community, there is beginning to be some acknowledgement of the problem, but the information is mostly anecdotal and speculative. So help at this time is significantly lacking.
PCO mothers should be strongly encouraged to breastfeed, since most of them do so successfully and it has many potential benefits for mother and child, but they should be extremely well-educated and proactive about breastfeeding, receive careful help and monitoring from lactation experts, and be vigilant for signs of dehydration or failure to thrive, just in case. They should not give up easily since many women experience transient breastfeeding problems after a c-section or induced birth, and these difficulties may indeed be able to be resolved fairly easily. Problems at first do not necessarily predict breastfeeding 'failure'; many women experience and overcome initial problems, including supply concerns (see Breastfeeding Stories, below). Furthermore, even if their supply problems are long-lasting and not easily resolved, many women who cannot fully breastfeed their babies are able to partially supply their needs, and any amount of breastmilk a baby gets is greatly beneficial for its antibodies and protective immunity properties.
For those PCO mothers who do encounter intractable supply problems, a difficult issue is how long to keep trying. This must be left up to the mother involved; it is not always an easy process and the great benefit to baby of even partial nursing must be balanced against the significant stress that is placed on the mother. Kmom would encourage these mothers to nurse their babies as much as they can for as long as they can, but if the process becomes too stressful, each mother must be encouraged to do what is best for the mother-child pair as a unit. In some cases, this may include weaning if the process becomes too stressful. Support for this agonizing decision must be offered freely and without reserve; these moms should never be made to feel guilty. Options and support for continuing should be made available, but if the mother decides not to because of the tremendous stress involved in both nursing and supplementing, that decision must be respected.
Studies show that there is a significant subgroup of gd women who have PCO, often undiagnosed (Anttila et al., 1998; Holte et al., 1998). Therefore, there may be a subgroup of gd women who have trouble breastfeeding, despite excellent preparation and dedication on their part. It should be emphasized that most gd women ARE able to breastfeed, and since breastfeeding may offer special benefits to the gd mother and child, it should be advocated strongly. However, it is also vital that gd experts realize that there may be a few moms who need to supplement in addition to breastfeeding, and that women with PCO and gd should be given the maximum possible expert support during the early breastfeeding period yet also careful observation. Infants of gd moms (especially those with pco) should be monitored carefully and should probably have careful post-hospital monitoring available to them (some insurance policies cover a home visit by a nurse in the first week or more). An extremely proactive approach to eliminating medical barriers to establishing breastfeeding needs to be taken, while still carefully monitoring for dehydration, hypoglycemia and jaundice. If supplementation becomes necessary, medical personnel need to make every effort to do it in such a way that it does not interfere with breastfeeding (avoiding bottles; using syringes, cups, eyedroppers, or tube/finger feeding instead). Much more research attention to these issues needs to be paid by experts in the future as well.
Emotional support for gd women after birth is sorely lacking, even for those who end up with a relatively normal birth experience. For those women who endure a gd pregnancy, a traumatic induction, c-section, and then who also have trouble breastfeeding, the emotional devastation can be particularly difficult. The sense of betrayal by one's body can be intensely acute, and there may be little support and even blame from medical personnel and family. These women's difficulties need to be acknowledged and supported, and a safe place to vent is important. Unfortunately, resources for this are few and far-between at this time. One online resource, however, is available for those who have had difficulty breastfeeding, called MOBI (Mothers Overcoming Breastfeeding Issues). A web page with more information can be found at www.InternetBabies.com/MOBI, and many women have found this an invaluable resource when encountering breastfeeding problems.
The American Academy of Pediatrics recommends that:
"Breastfeeding should begin as soon as possible after birth, usually within the first hour. Except under special circumstances, the newborn infant should remain with the mother throughout the recovery period. Procedures that may interfere with breastfeeding or traumatize the infant should be avoided or minimized. Newborns should be nursed whenever they show signs of hunger, such as increased alertness or activity, mouthing, or rooting. Crying is a late indicator of hunger [emphasis theirs]. Newborns should be nursed approximately 8 to 12 times every 24 hours until satiety, usually 10 to 15 minutes on each breast. In the early weeks after birth, nondemanding infants should be aroused to feed if 4 hours have elapsed since the last nursing. Appropriate initiation of breastfeeding is facilitated by continuous rooming-in...No supplements (water, glucose water, formula, and so forth) should be given to breastfeeding newborns unless a medical indication exists. With sound breastfeeding knowledge and practices, supplements rarely are needed. Supplements and pacifiers should be avoided whenever possible, and, if used at all, only after breastfeeding is well-established...It is recommended that breastfeeding continue for at least 12 months, and thereafter for as long as mutually desired."
In terms of hints for establishing breastfeeding, gd moms should consider:
GD Moms' Breastfeeding Stories
The following are several true-life stories of gd moms' experiences with breastfeeding, positive and negative. A variety of stories are included to try to show the wide variety of experiences possible. Since the most instructive lessons are from the stories of difficulty, these tend to be over-represented. It should be emphasized that MOST gd moms are able to breastfeed successfully, and many of them do so without difficulty. Don't make assumptions about what YOUR own experience will be based on these, but do learn from them, just in case. Whenever possible, the stories are told in the moms' own words, but sometimes paraphrasing and summarizing were necessary. The spelling and grammar of the original quotes are left intact. Comments from Kmom are in normal font; quotes from the mothers are in italics. Comments from Kmom within the quotations are placed in [brackets]. If summarizing was needed within the quote, it is placed in {brackets}.
Note: This section is under construction. More GD Breastfeeding Stories will be added soon!
Laura's Story: Laura had severe insulin-dependent gd. Her labor was induced early, but she ended up with a vaginal delivery anyhow. However, her baby had a high palate at birth and nursing in the early days was extremely difficult. They used a combination of finger-feeding, pumping expressed milk and using special nursing-friendlier bottles, and nursing several times a day too. Over time, with help, they were able to establish exclusive breastfeeding and are still breastfeeding more than a year later.
Laura's story can be found at www.deleons.com/breastfeed.htm. It includes a WONDERFUL photo of the baby being finger-fed, as well as many other adorable baby photos!
M's Story: M had insulin-dependent gd, and recounts how breastfeeding was sabotaged with her first child. She feels that her son was labeled 'hypoglycemic' and aggressively treated unnecessarily.
"My son...was taken to NICU and placed on IV glucose because he was 'sweating'. He had a BG of 42 [marginally normal]. He was wrapped in a thermal blanket sitting under a warming table. {My pediatrician complains that} they are called in way too many times for what seems to be high temperatures in newborns when in fact it is those warming tbles that are set too high.
So I'm separated from my baby who should be with his mother...They put him on a 3 hour schedule of formula and in between time, he has a pacifier to sooth[e] his crying. I'm not allowed to breastfeed him and have to have permission to hold him for when it is convenient for the NICU nurse and if I'm not 'interfering' with their schedule. Once IV glucose is started, it can not be stopped unless it is weaned slowly in 3 hour intervals. The nurse did not give me the opportunity to nurse my son before taking him away from me. I got to hold him for 10 seconds before he left. This was after it was made clear to the staff that I wanted to nurse my son. Sometimes 'Standard of Care' sucks and isn't for the baby and parents best interest, but the nurses and doctor's best interest."
Postnote: M was never able to fully re-establish breastfeeding after this. In her second pregnancy, she was determined to do things differently. She vigorously pursued Vaginal Birth After Cesarean, and despite having fairly severe gd, was able to achieve a wonderful, much-desired vaginal birth. However, she had significant postpartum bleeding and trouble with her milk supply once again. Although PCO is not a factor in her case, she is hypothyroid and has abnormally-shaped nipples, which in addition to the anemia from the blood loss, may have contributed to supply problems. Although she was not able to breastfeed her babies long-term, they were both able to get some colostrum and breastmilk in the early days and thus get some measure of immunological protection. Although she worked extremely hard at breastfeeding, in the end it was better for her and her children to stop stressing over milk production issues.
Lisa H's Story: Lisa H. had insulin-dependent gd, and a vaginal birth after an induced labor. However, her baby was given bottles in the nursery and between that and problems with his suck, never learned to nurse adequately. Lisa is now pumping and bottle-feeding him the breastmilk, as well as supplementing with formula.
His Apgar scores were 8 and 9, his blood sugar was fine, and he was released from the Special Care Unit by 7 a.m. Sat. morning. He was being given formula by bottle to maintain his sugars to be on the safe side, which was okay with me, as I had said it was okay if it was medically necessary.
{Breastfeeding has been difficult. My nipples are very flat and he has trouble latching on. I pumped and fed him the breast milk, which he guzzles like there's no tomorrow. He also gets formula.} He was really fussy and having a lot of gas, so we changed from the standard Isomil formula to the lactose free Soy and the fussiness is completely gone and he has had two bowel movements already. The first one was rather explosive and EXTREMELY smelly, but what else could you expect if you'd been eating something you're allergic to.
[She later found out that he had a problem with his suck, which is why he had such trouble latching on.] We found out that the problem wasn't me, but with the baby---he has an overbite. We were told that while feeding him to put a finger under his chin and pull it forward, training him to move his jaw forward when sucking. By the time we were able to get him to do it consistently on his own, he refused to latch onto my breast and would only take a bottle. So now I'm pumping exclusively. But I was using one of those stupid Evenflow pumps at first, not realizing that it wasn't meant for heavy duty use, and I almost ended up losing all my production. I now have a Medela Pump In Style and it's working better.
I really feel like I got sabotaged by the hospital--first, by them giving him bottles while in the nursery, and second by not being able to see a lactation consultant while in the hospital. Still, I'm going to stick it out and pump for as long as possible because I and my husband have a number of allergies and we want to give him as much protection against them as possible.
I think part of the problem with the hospital is that I didn't have a relationship with my pediatrician (I had never met him before the baby was born) so I wasn't able to discuss what I wanted to happen with the baby regarding feeding because of the gd. I now know for sure that I am not only going to talk to my OB, but to the pediatrician and the nurses on staff and make sure that they know IN WRITING that they are not to give my next child anything in a bottle unless it is a certified emergency.
Heather3's Story: Heather had gd treated by glyburide instead of insulin in her pregnancy. She had pre-existing mild hypertension, which got worse during pregnancy and eventually turned into HELLP syndrome (very serious complication involving low blood platelets, among other things). They tried to induce at 38 weeks but due to fetal distress, it ended with a c/s. She had magnesium sulfate during her labor to keep her blood pressure down, but many women receiving this report breastfeeding difficulties afterwards. Heather's milk was delayed coming in, which is not unusual after induction, c/s, and magnesium sulfate. In the meantime, the baby lost more than 10% of her weight and needed supplementation. This is the story of how they preserved breastfeeding anyhow, despite all of these difficult circumstances.
On day four in the hospital, the nurse came in the middle of the night and told me I needed to start supplementing the baby with formula. Although she was a great latcher, my milk had not come in and she had lost more than 10% of her body weight. I gave her that bottle in the middle of the night and called my lactation consultant friend in tears the next morning. She came and we started feeding my baby formula from a spoon or small cup. I also started pumping very small amounts of milk after feedings. We spent 6 days in the hospital because of my recovery and the >10% wt. loss by the baby, plus jaundice.
After we came home, I tried just breastfeeding, but she again lost weight. The lactation consultant hooked us up with a Haberman Feeder, a special nipple that requires the baby to suck the nipple like at the breast and with variable flow. I fed her at the breast during the day and then from dinner time on supplemented her after each feeding with formula. I was determined that I would breastfeed this baby!
Between two and three months we were able to exclusively breastfeed with a combination of pumping and the herb fenugreek. When I went back to work my supply decreased but we have worked on building it back up. She receives 4-8 ounces of formula per day and the rest breastmilk, either at the breast or expressed. I found a good sitter close to home and work and am able to go home each day at lunch to feed her. It has been exhausting but I am convinced it is the best thing for both of us! At 4 months we are both doing well!!
Kmom's Story: Kmom had mild gd in her first pregnancy, easily controllable with diet only. She had a very traumatic c-section after a failed induction at 40 weeks, and was 'in and out of it' for hours due to anesthesia problems.
"Despite the staff knowing that I intended to breastfeed, they gave my daughter formula immediately without documentation of her bG levels, and a pacifier extensively after that. I was not permitted to try to breastfeed until HOURS after the birth, and am unsure how much formula she had received in the meantime. No IV glucose was given, at least! Finally, probably about 8 hours after birth, I got to nurse my baby for the first time, and I was thrilled. Nursing was bumpy at first, though, and the nurses were too busy to give much help. Positioning was difficult because I am so well-endowed plus pain from the c-section, and there was a lot of nipple soreness. My daughter became very sleepy from all the drugs and also from jaundice. She was difficult to rouse, so we didn't nurse nearly often enough. In addition, her doctor and the nurses ordered many bottles of glucose water and formula in order to 'flush out the jaundice' (the glucose water probably made it worse). Her bilirubin kept going up, but her doctor released us home on the condition that she be brought in for daily testing. I was also sent home with a number of bottles of glucose water to 'flush out the jaundice more'. Between all the bottles, her sleepiness from the jaundice and drugs, and our problems nursing, her bilirubin count worsened, and my milk did not come in for about a week after the birth due to lack of stimulation.
I tried to read up on jaundice as much as I could, but I really needed expert help in those first days! I had no idea how to get it and was too proud to ask. However, we were fortunate and stubborn and toughed things out anyhow. Her bilirubin peaked just short of where she would have needed phototherapy, I used the glucose water only AFTER nursings (which helped stimulate supply more), and I learned how to do the 'football hold', which was a *godsend* in relieving the soreness. We did develop a problem with foremilk/hindmilk imbalance, where the baby gets too of the first 'foremilk' (high in lactose and lower in fat) because we were religiously doing 'switch' nursing in order to build my milk supply. Her stools became foamy, green, and very 'prodigious' due to an excess of the lactose-heavy foremilk, and she also had some major colic and minor spitting-up. But because I never had access to a lactation consultant and my pediatrician did not recognize the symptoms of foremilk/hindmilk imbalance, we did not understand what had happened until much later.
Still, although nursing was bumpy for the first few months, we eventually dropped all supplementation, and nursing eventually even became a pleasant experience! As noted previously, being able to succeed finally at breastfeeding helped restore my battered self-esteem, helped me bond strongly with my baby despite the difficult birth, and was quite healing emotionally. I had intended to nurse only for 3 months, but we found ourselves re-evaluating that decision and deciding to continue. With expert support I eventually found, we made the decision to let her self-wean since she really seemed to need to nurse long-term, and I continued to nurse her through my second pregnancy and in tandem with her baby brother. They both eventually weaned during my third pregnancy, but nursing that happily and that long was certainly NOT something I ever envisioned in those first few difficult days of breastfeeding! You never know where your breastfeeding journey will take you, but it has been one of the greatest joys and blessings of my life. I strongly urge other gd moms not to let all the barriers prevent you from preserving breastfeeding if at all possible."
Breastfeeding Through a Subsequent Pregnancy After GD
An unanswered but tantalizing question is how breastfeeding might affect your chances of gd in a subsequent pregnancy. Most women who have gd in one pregnancy have it recur in subsequent pregnancies, and it can recur earlier and more severely. The chances of recurrence are about 2 out of 3, according to the majority of studies, although proactive dietary and lifestyle modification can sometimes lower this rate. So if your gd is likely to recur in a subsequent pregnancy, is it safe to continue nursing into or even through that pregnancy, even if the gd should recur?
Basically, the answer is that no one knows for sure because no one has done ANY research on it. Since the rate of breastfeeding is low in America anyhow and even lower in many gd moms, and since only a very small percentage of women nurse long enough to meet the AAP's recommendation of nursing for at least one year, the subject just has not come up much. Although some research has been done on breastfeeding through 'normal' pregnancies (and it has been found to be safe, see references below), Kmom has yet to find any research on nursing through a gd pregnancy (or one at risk for recurrence).
The $64,000 question is if breastfeeding may help reduce or delay the onset of type 2 diabetes, would it help prevent or lessen the severity of subsequent cases of gd? As far as Kmom knows, it's impossible to definitely answer this question. She can only relate anecdotal evidence, which is of course not scientific proof. The pool of women who have had gd and who have continued to breastfeed their children long enough to become pregnant with another child is not large enough to draw any statistically significant conclusions from, and there are many confounding factors to consider. However, there is some anecdotal evidence to indicate that long-term breastfeeding may help prevent the recurrence of gestational diabetes in subsequent pregnanciesin some cases, and that is enough to warrant further investigation by more scientific methods.
For more information about nursing during pregnancy, see the resources listed in the reference section, plus www.lalecheleague.org. For more information about tandem-nursing children, see also www.lalecheleague.org, www.angelfire.com/va/missionaries/tandem.html,and www.breastfeeding.com/art_gallery/art_images/10jpgbig.html (what look like spaces in the URL are actually underlines).
Kmom's story: I had a mild case of gestational diabetes in my first pregnancy, diagnosed at the usual time. We were able to control it easily through dietary means. Despite a very rough breastfeeding start due to routine supplementation, more (unneeded) supplementation because of jaundice, and lots of soreness, we were able to make breastfeeding work anyhow. My goal was only to breastfeed for 3 months, but as time went on, I could see how great it was for both of us, plus I researched more about the benefits of nursing, so we kept extending the deadline as we felt comfortable.
After a year, I decided to pursue pregnancy again due to my age, and looked for research as to whether breastfeeding during pregnancy and especially during a gestational diabetes pregnancy was possible or desirable. I found very little. My OB was supportive of it, but my pediatrician strongly suggested weaning. Furthermore, an online friend asked the question of a leading gd researcher for me; she stated in no uncertain terms that it would malnourish the fetus and should not be done. However, her objection seemed to have nothing to do specifically with gd or any research, only the common misconception that the developing fetus might be harmed, and my own OB remained supportive of continuing to nurse. I did more research and found that nursing a baby through pregnancy is not that uncommon and does NOT endanger the fetus (unless there is a history of miscarriage, bleeding, or preterm labor). I felt that research seemed to indicate that nursing was safe in pregnancy in most cases, and that it was unlikely gd would change that picture as long as I was well-nourished, had no history of miscarriage/bleeding/pre-term labor, and was not carrying twins. So, with my OB's approval, I elected to continue nursing during my pregnancy. I checked with my glucometer and found that nursing actually lowered my blood sugar slightly, which was reassuring to me as well.
I kept looking, however, for women who had nursed a previous child through a subsequent gd-risk pregnancy. Eventually, I found a few in cyberspace. Not many women nurse long-term enough to nurse into a subsequent pregnancy, but I found a few that had and had also had gd. Of these women, MOST DID NOT REDEVELOP THE GD! Furthermore, one of those whose gd did recur had needed insulin previously yet was able to avoid the insulin in the subsequent pregnancy, a very unusual occurrence. Since the number of women found is so small, this is not statistically significant from a scientific point of view, but since gd usually recurs in 2 of 3 pregnancies, it is an incredible coincidence that few moms had gd recur. It could be a simple statistical fluke, but it seemed unlikely.
Encouraged, I went on to nurse through my entire pregnancy without incident, hoping against hope that perhaps my gd would not recur or that at least it would not necessitate insulin. Sure enough, to my great delight, my gd did NOT recur---at all! Since I was also very proactive in managing my food, exercise, and stress levels, we cannot be sure that it was the breastfeeding that made the difference. It may have been one factor or all the factors taken together (probably the latter). However, it does seem to be another amazing coincidence that it did not recur with me either, especially since I am deemed to be at extra risk due to my size and my advanced age (!).
I gave birth to a very healthy 9 lb. baby right at term, squashing the theory that nursing my toddler through subsequent pregnancy would endanger/malnourish the fetus or lead to pre-term labor. My first-born was very excited 'when the milk came back', and continued nursing enthusiastically, either simultaneously or just after my son. He had no health problems or difficulty gaining weight; nursing my daughter did not 'take away' or diminish the nourishment for my son, despite the demands of 'tandem nursing'. Both continued to nurse for some time thereafter, and both self-weaned eventually.
I cannot say for sure that nursing was a factor in preventing a recurrence of the gd in the second pregnancy, nor can I say for sure that nursing again will prevent it next time, since risk increases with age and I am nearing 40! But I can say that the benefits for my toddler were well worth the trouble and occasional soreness involved, and if I coincidentally get any extra benefit from it, then great!----I won't complain. [Update: Now, in my third pregnancy, both of my children continued to nurse upon occasion throughout the first trimester, but subsequently weaned naturally and easily. So far, the gd has not recurred, but that may or may not continue as the pregnancy progresses. Keep your fingers crossed for us!]
I think every woman with gd should strongly consider nursing her baby, and for as long as possible. It is the best thing for the baby's health, and it may even benefit yours as well. Many women will not want to nurse through a subsequent pregnancy and that is fine if the mother feels it is best in her situation. However, for those so inclined, nursing partly or fully through a subsequent pregnancy at risk for gd has been done successfully by several women, and the rates of gd were much lower, though the sample was too small to draw any truly reliable conclusions. Only you and your provider can determine the best course in YOUR situation and circumstances but if it is an option you wish to consider, it certainly is possible and has been done before.
If you cannot nurse or choose not to nurse, it does not make you a bad mother! But if you do nurse, the advantages it offers both you and baby are quite significant indeed, especially with a history of gd. The preliminary evidence indicates that it is important that gd moms be encouraged to breastfeed as much as possible, and not be given medical barriers to its establishment. The most important factors in breastfeeding successfully seem to be getting preparation and information ahead of time, being aware of potential pitfalls in the hospital, being VERY proactive about nursing early and frequently, and getting timely help from breastfeeding experts when needed.
In some ways, gestational diabetes can be a blessing because it is a type of "early warning system" that enables a woman to make lifestyle changes and monitor closely for the first signs of overt diabetes before it can do serious damage. One positive change you can make NOW which may help reduce or delay your risk of type 2 diabetes is breastfeeding, which is a pretty painless and wonderful bit of prevention (plus you have the advantage of knowing how significant it is to the overall health of your child). It may also help reduce your child's risk of diabetes later in life. More research is needed to further explore this possibility, but breastfeeding looks to be a win-win proposition.
Most women (with adequate training and timely expert help) can nurse. Please consider it and work hard to make it successful. You and your baby deserve it!
(You may also want to read Kmom's "Nursing When Well-Endowed" FAQ.)
The Breastfeeding Advocacy Page (www.promom.org )
Extensive discussion and documentation on the many benefits of breastmilk. Excellent resource, with many medical references and studies examined. One of Kmom's favorites!
Breastfeeding.Com (www.breastfeeding.com/helpme/)
Superb site devoted to helping mothers nurse. Usual advocacy information, but its best value lies in its extensive photos of babies nursing in various positions, even video clips of how to do the various positions (including the much-neglected football hold!). Extensive photography of nursing babies, including twins, tandem nursing (toddler and newborn), multiethnic nursing mothers, etc., plus lots of beautiful artwork of nursing mothers from ancient to modern art.
The Breastfeeding Helpline (900) 448-7475, ext. 55 ($1.99 per minute/avg 5 minutes; some sources list ext. 65 instead)
Recorded information available, counselors available during certain hours (La Leche League Service) .
CARE NW (Care and Advice on Reproductive Exposures) 1-900-225-CARE ($3 first minute, $2 for each additional)
This *INVALUABLE* service provides information on the effects of drugs and other exposures on the developing fetus and during lactation. If you are not sure about the safety of a certain drug or chemical exposure during pregnancy or during breastfeeding, they will research it for you. They often have access to more complete information than your physician. Their services were formerly available only to residents of the Pacific Northwest, USA, but they have now opened up to service elsewhere through the use of the 900 number.
Hale's Medications and Mother's Milk (http://neonatal.ttuhsc.edu/lact/)
THE most reliable source for up-to-date information about medications while nursing is this book. It is updated every year; every medical library and pediatrician should have it. Unfortunately, not all do. A smaller version of the book is available at the website plus information about the full book. If you really need to access this book, call a large local hospital and ask for the medical librarian. If they do not have this book ask if they can borrow it from another hospital or library. If not, they can probably photocopy the page of the medication in question for you and mail it to your local hospital. Most hospitals do this for free, but some may charge a small amount.
La Leche League International 1-800-LA-LECHE 1-847-519-7730 (http://www.lalecheleague.org/ )
Excellent resource for information/support for nursing. Call to find the nearest meeting, to get in contact with a volunteer leader for questions, or to get a referral to a good lactation consultant. Also check out the web site! The best time to start attending meetings is BEFORE you deliver. Some women are afraid LLL is too radical for them; most do not find it so, but quality depends on the local leadership. However, the philosophy is "take what you need and leave the rest behind," so if you don't agree with something, ignore that recommendation. Truly an exceptional resource. Also offers many fine pamphlets on nursing-related topics/concerns.
Medela, Inc. Breastfeeding Tips and Products 1-800-TELL-YOU (835-5968) (www.medela.com )
Call for Breastfeeding Advice Booklet that gives hints on breastfeeding, as well as offers several Medela products. Some products that might assist a large woman in particular are the Extra Large Glass Breastshield Kit (#610.7041) and a 15-minute video on Breastfeeding Your Baby - Positioning (#610V010). This excellent short presentation on positioning includes the football hold, which often works better for women who are extremely well-endowed, as well as more traditional holds. This is often not covered in other books or videos on the subject, so this is an extremely valuable asset to a large woman. A longer version of this video is available but the positioning section is all that's really needed for most people. A Spanish version can also be ordered.
Nursing Mother's Association of Australia ( www.nmaa.asn.au )
A La Leche League-type organization for Australia; anecdotal reports Kmom has heard have been very positive. Contact them for support for nursing or for consultation if you encounter problems.
parent-l mailing list (parent-l-request@uts.edu.au )
An extensive, high-volume mailing list designed to support breastfeeding and parenting the nursing child. There is an emphasis on extended breastfeeding and attachment parenting. To subscribe to the single message mode simply send a message with 'subscribe' in the body of the message.
Pumping Advice/Story www.deleons.com/pumping_page.htm (what looks like a space is really an underline in the URL)
Owner of the Big Mom's mailing list (who also had insulin-dependent gd) details her story of breastfeeding difficulties at first, pumping travails, how she stuck it out, pumping advice to others, etc. (the space in the URL above is really an underline).
Rx List (www.rxlist.com )
Provides free comprehensive information about 4000 commonly prescribed drugs. However, if this list is like the Physician's Desk Reference, it is overly conservative because of liability fears, and may list certain drugs as incompatible with nursing when under certain circumstances they might be ok. Use this list as an adjunct resource but not as your sole resource when researching drugs and lactation.
Working Cow Website (www.geocities.com/Wellesley/4092/)
More information about being a nursing mom while working outside the home, pumping advice, etc.
Breastfeeding After a Breast Reduction ( www.bfar.com )
Information about breastfeeding after having a breast reduction operation.
These are the best nursing books, in Kmom's opinion;Your Mileage May Vary! You can find these books through:
The Nursing Mother's Companion, Kathleen Huggins, 4th Revised Edition, c. 1999.
By far the easiest-to-use and most practical of nursing guides. Pack this one in your hospital bag! Especially useful is the quick-reference Survival Guide for the First Weeks--much easier to use for trouble-shooting if you have any questions or problems. Has a few references to the problems of larger breasts, and actually shows some in a section on the different sizes and shapes of breasts. One of the only nursing books to address this!
The Womanly Art of Breastfeeding, La Leche League International, 6th Revised Edition, c. 1997.
Classic text on breastfeeding, very well-done--but does not address the issues that can challenge some large-breasted women. Barely addresses the football hold, and some women find it very preachy. Still worth reading, however, and the section on medical benefits of breastfeeding is superb---a must-read.
So That's What They're For! Breastfeeding Basics. Janet Tamaro, c. 1996.
A more humorous approach to breastfeeding, but still full of useful information. A great book to get if you are not sure whether you want to nurse or not, or if you think you should but are not really crazy about the idea. Good for spouses too. Good book, but don't make it your only nursing manual; use it in tandem with another nursing manual like Nursing Mother's Companion or Womanly Art of Breastfeeding. Contains a few sizist remarks but still overall a good asset.
There are far too many references in this section to be listed on this same file; a separate file had to be created. To see the references for this web section, please go to Gestational Diabetes and Breastfeeding: Research References. Kmom strongly urges readers to review these references. To see a summary of more gd references (medical journals, magazine articles, books, websites, etc.), see the web section on GD: General References.
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