Many diabetic mothers are concerned that their diabetes may be transmitted to their baby via their breastmilk, but this is a myth. Clinic sisters, Lara Kaplan and Timor Lifschitz, talk us through breastfeeding if you are a diabetic mother.

Breastfeeding is best

Breastmilk is the most beneficial source of nutrition for infants. It provides the perfect amount of nutrients, antibodies and immune protecting components for your growing baby.

For women, it is important to remember that having diabetes comes with increased risks of having a caesarean section; delayed milk production onset; a lower breastmilk supply; and risk for candida (thrush) or mastitis infections. All of which can impact breastfeeding.

Health benefits of breastfeeding

For diabetic mothers

• It can assist to lose weight gained during pregnancy. Remember, it is important for diabetic women to maintain a healthy weight and still get the correct amounts of nutrients while breastfeeding. You may need to develop an eating plan with your healthcare provider.
• Bonding with baby is enhanced due to oxytocin release. This can help improve how you feel physically and emotionally. In addition, it can help to decrease stress, which can aggravate diabetes.
• Some mothers may need less insulin post-partum because breastfeeding helps to lower blood sugar levels.
• Breastfeeding assists in keeping glucose levels more constant. Mothers may have a remission of symptoms during this time.

For babies

• They are less likely to get ear and respiratory infections, allergies, eczema, asthma, and, more importantly, diabetes later in life.
• Being diabetic, your baby’s genetic predisposition may be increased but by breastfeeding you can help to mitigate and prevent that risk.
• A child of a mother who has gestational diabetes during pregnancy has an increased risk of becoming obese during childhood and therefore a risk of diabetes later in life. However, studies found that breastfeeding a baby for at least six months neutralises this risk.

Will your diabetic medication affect baby?

Most medications used to manage diabetes can be safely used while breastfeeding, but you should confirm this with your doctor or lactation consultant. Medications, such as insulin and oral treatments, often must be adjusted in the period following birth under the guidance of a doctor.

Breast milk production

Breast milk production is controlled by a delicate balance of hormones, and any metabolic imbalances, such as diabetes, can interfere with this balance.

Having diabetes – and the increased risk of having a caesarean section – may delay the onset of the milk ‘coming in’, or lactogenesis II.

There is also a risk of baby being hypoglycaemic because of having higher insulin levels in utero of the diabetic mother, due to her higher blood glucose levels. When baby is born, baby gets glucose through breast milk but it is often lower than that in utero.

Colostrum

Colostrum – the very first milk – produced in small amounts and densely packed with nutrients, helps to stabilise blood glucose levels in new-borns.

Pregnant mothers can gently hand express colostrum from 37 weeks under the care of an obstetrician or midwife. The expressed colostrum can be collected on a spoon and then placed into a container. This should be labelled with the date and time of collection, and then placed in the freezer. Expressing colostrum can cause contractions, and it is recommended to stop as soon as you start to experience them.

Once baby is born, mom must remember that breast milk production is all about supply and demand. You need to make sure to feed regularly and on demand. Feeding 8 – 12 times a day will help to empty the breasts and tells the brain to produce more milk.

Skin-to-skin contact

Once baby is born, skin-to-skin contact is important. It keeps baby warm and stimulates hormones to produce breast milk. Feed your baby as soon as possible after birth. The baby needs to be positioned and latched on correctly, if you have any difficulties please contact a lactation consultant.You can ask the lactation consultant to come immediately after birth.

Regular feeds help to stabilise and maintain baby’s blood sugar levels. These can drop after birth due to the higher levels of insulin that your baby’s body generally produces while in utero.

Should baby struggle or be unable to feed, baby can be fed expressed breast milk by syringe or cup. The hospital staff will assist you. If expressed breast milk is not available, mom can look in to donor milk or formula.

24-hour monitoring

The blood sugar levels of babies born to diabetic mothers are monitored for the first 24 hours to check for hypoglycaemia. If the levels drop too low, baby will be fed via other temporary measures so as not to burn more energy trying to feed.

If this is the case, you should continue to express regularly to stimulate milk production. Once baby’s blood sugar levels have stabilised, the staff will stop measuring them. The baby should continue to feed on demand. If the blood sugar levels do not stabilise, baby may need to be admitted to the neonatal unit for monitoring. Here baby will be fed your expressed breast milk.

Jaundice

Jaundice is a yellow discolouration of the skin and sclera (whites of eyes) due to a build-up of bilirubin, which occurs when red blood cells are destroyed and haemoglobin is broken down. A breastfeeding baby of a diabetic mother has an increased risk for jaundice.

These babies are often born bigger and thus have more haemoglobin to be broken down. Fortunately, this problem is treated easily with light treatment (phototherapy).

Lack of insulin in the body can cause ketosis, the presence of ketones. This can pass directly into breast milk, which increases the workload on the baby’s liver and can contribute to jaundice. It is thus important to continue taking your insulin doses and be in contact with your physician. The more baby feeds, the more baby will pass stool, which helps to eliminate the bilirubin out the baby’s system.

Thrush

Diabetes increases the risk of developing thrush and/or mastitis during breastfeeding. This is more likely to happen when your blood sugar levels are poorly controlled.

It is also important to treat breast infections quickly, as they can otherwise increase blood sugar levels. The main symptoms of thrush are: pain in the nipples or breasts – usually a sharp stabbing/shooting pain and itching, burning and sensitive nipples. Sometimes there may be no symptoms at all.

Baby can also have thrush in the mouth – creamy white patches. Baby may be fussy and pull away from the breast while feeding, and have a nappy rash. Both mom and baby do need to be treated together, but you do continue breastfeeding during treatment.

Mastitis

Mastitis is an infection diagnosed following hard, tender, red areas on the breast that may be painful when touched, coupled with flu-like symptoms, such as fever and aching. If left untreated, it can cause a breast abscess.

You should continue feeding on the affected breast and call a lactation consultant to assist you. Ensure the latch is deep, and massage the affected area before and after feeds. You can use paracetamol to relieve pain and reduce temperature, and ibuprofen to reduce inflammation and pain. Try to rest as much as possible to allow for healing. If it does not get better, please contact a lactation consultant to assist you together with your doctor.

Tips to ensure a successful breastfeeding relationship with diabetic control:

• Remember that during a breastfeeding session, the body uses up large amounts of sugar to produce milk. This can cause a modest drop in blood glucose levels, resulting in a hypoglycaemic episode.
• Eat before you feed baby to stop your blood sugar levels from dropping. Especially if you are alone when you feed baby. Alternatively keep a snack handy when you are breastfeeding so that you do not have to stop the feed.
• Mothers who breastfeed will need to increase their calorie intake by an extra 500 calories spread throughout the day, as breastfeeding burns calories. Avoid dieting while you are breastfeeding as your body needs calories for energy.
• You are more likely to have hypoglycaemic episodes if you start breastfeeding when you already have low blood sugar levels, or if the feeding session goes on for a prolonged period. New-borns usually feed for 45 minutes to an hour, but may be exacerbated if baby is not latching well. If you are concerned, contact a lactation consultant.
• It is normal to feel thirsty when breastfeeding, and is not necessarily a sign of high blood sugar levels. By monitoring your blood sugar levels, you will be able to tell whether it is due to natural thirst, or if it is caused by a hypoglycaemic attack.
• Weight loss will almost always result in decreased insulin requirements. As maternal weight drops, medication doses will need to be reduced.
• It is important to avoid hypoglycaemic episodes while nursing as they trigger the production of adrenaline, which reduces milk production and milk let-down reflex.
• Rooming-in with baby improves breastfeeding outcomes as you can feed baby on demand and practiSe skin-to-skin to enhance milk production.
• Avoid taking supplements, such as fenugreek, as it can have a dangerous effect on blood glucose levels. Always discuss medications and galactogogues with your lactation consultant for safety measures.
• Try to sleep when baby sleeps. Lack of sleep can result in blood sugar level problems related to basal insulin doses.
• Avoid stress as it can cause blood sugars to rise and stay high.
• There is a significant association between diabetes and post-partum depression; this risk is exacerbated when blood sugar levels are not well-controlled. If you experience any feelings of inadequacy, major sleep/appetite changes, lack of bonding with baby and thoughts of harm to baby or yourself, contact your physician.
• Babies often feed more frequently (cluster-feeding) during a growth spurt. Continue monitoring your blood sugar levels regularly and seek advice from your healthcare professional if your insulin/medication regime needs adjusting.
• Allow your partner, family and friends to assist with caring for baby. Check if there are any ‘Mother and Baby groups’ in your area to connect with other mothers.
• Always have a snack on hand when you are out with baby. To be prepared, make a special place in baby’s nappy bag for your key diabetes equipment, such as your blood glucose meter; strips; lancets; insulin; and medication.

Team effort

When managed, diabetes and breastfeeding can work but you will most likely need support from healthcare professionals, family and friends.

Your lactation consultant can assist you with any challenges related to breastfeeding. Your multi-disciplinary team must work together to give you and your baby the best start in your breastfeeding journey. It really does become a team effort, and you and baby are the stars!