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Diabetes NewsApril 2011

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Breastfeeding in Women with Type 1 Diabetes

Diabetes Care • February 2011 

The benefits of breastfeeding are numerous for both mothers and infants, and with increased duration and exclusivity, the benefits are enhanced for infants. Therefore, exclusive breastfeeding duration for at least four months, preferably six months, is a global recommendation. For infants of mothers with type 1 diabetes, the advantages of longer breastfeeding are probably even greater. However, initiation of breastfeeding for mothers with diabetes often implies a challenge. This is due to increased occurrence of complicated pregnancy and labor, caesarean section, and instrumental vaginal deliveries and neonatal morbidity, including growth deviations, congenital malformations, prematurity, and respiratory distress. Neonatal hypoglycemia may also complicate the postpartum feeding regimen. This is related to fetal intrauterine hypoglycemia and hyperinsulinism as a response to maternal hyperglycemia. Furthermore, early mother-child separation can further hinder breastfeeding. The lactation process is shown to be delayed in mothers with diabetes, and their infants have a more immature sucking pattern. Early initiation of breastfeeding can reduce neonatal borderline hypoglycemia and increase the mean level of blood glucose.

Research on breastfeeding in women with type 1 diabetes in inconsistent; some studies show the initiation and duration of breastfeeding to be comparable with those of background populations. Conversely, other studies report that they were less likely to initiate breastfeeding, and if they did not initiate, it was for a shorter time than mothers without diabetes. Body mass index (BMI) and socioeconomic status have been identified as predictors for their breastfeeding duration. A recently conducted multicenter study found that more than 90% of mothers with type 1 diabetes breastfeed initially. However, the breastfeeding rates declined more steeply among these mothers. This was explained by an increased frequency of caesarean sections, delivery at earlier gestational age, lower maternal age and educational level. In summary, there are contradictory results concerning the initiation and sustainability of breastfeeding in women in type 1 diabetes. It is still unknown whether it is maternal diabetes or other maternal and neonatal factors that affect the likelihood of breastfeeding. The aim of this study was therefore to identify predictive factors for initiation and maintenance of breastfeeding with a focus on mothers with type 1 diabetes.

Objective - To identify predictive factors for initiation and maintenance of breastfeeding with a focus on mothers with type 1 diabetes.

Research Design and Methods - This is a prospective observational survey, using a case-control design, comparing the outcomes of 108 mothers with type 1 diabetes with 104 mothers without diabetes that were matched with parity and gestational age. Mothers with type 1 diabetes (DG) were asked to participate after childbirth at four hospitals in Sweden, including one university and three rural hospitals with a total of about 16,000 deliveries annually. For every included woman with type 1 diabetes, the next childbearing woman in the same gestational week and parity was approached for participation. Exclusion for the reference group (RG) were type 1 diabetes, type 2 diabetes or gestational diabetes.

To prevent neonatal hypoglycemia, DG infants were provided early feeding with either the mother’s breast milk or formula milk and were fed every 3-4 hours during the first 2-3 days of life. Mothers whose infants received formula feeding were encouraged to breastfeed before each feeding session, if possible. Infants of DG mothers had their blood glucose measured within two hours of delivery, before every feeding the first 12 hours, and then with decreasing frequency depending upon the occurrence of hypoglycemia.

Further data were collected through telephone interviews with the mothers two and six months after childbirth. The interviews followed a structured questionnaire including questions on socioeconomic factors and breastfeeding patterns. Exclusive breastfeeding was defined as no supplementation of formula milk, and partial breastfeeding was defined as a combination of breastfeeding and formula feeding or exclusively formula feeding thus allowing for introductory portions of food. General well being was measured by using the Psychological Health and Well-Being Index (PGWB). This tool includes 22 items in the following six dimensions: anxiety, depressed mood, positive well-being, self control, general health and vitality.

Conclusions - The findings from this study add to the growing body of research exploring breastfeeding patterns in mothers with type 1 diabetes. The findings are consistent with studies that have found decreased breastfeeding duration in this group. However, maternal type 1 diabetes was not a predictor factor for long term breastfeeding. High education level, full term vaginal delivery and early initiation of breastfeeding as predictive factors for breastfeeding six months postpartum confirms findings in a recently published study. All these studies have used different designs and partly during different time periods and the general breastfeeding rates and societal attitudes toward breastfeeding in the countries differ. Sociodemographic factors are well known to influence breastfeeding initiation and duration, not only in mothers with diabetes but mothers to preterm babies, as well as in the general population. This factor seems to transcend different cultures with more or less government-financed parental leave, as mothers working outside the home have been found to breastfeed more than mothers who stay at home.

In conclusion, the findings indicate that type 1 diabetes in mothers is not an independent risk factor for shorter duration of breastfeeding. However, factors associated with maternal diabetes, such as problems with establishing breastfeeding early postpartum due to the higher degree of maternal and neonatal complications, affects the likelihood of long-term breastfeeding. Supportive interventions for early initiation of breastfeeding need to be developed and evaluated. Further research needs to explore factors other than birth related that might influence long-term breastfeeding in mothers with type 1 diabetes.

Reprinted with permission from the American Diabetes Association

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