Breast-feeding in type 1 and type 2 diabetes Professor Elisabeth R Mathiesen Center for Pregnant Women with Diabetes, Departments of Endocrinology & Obstetrics Copenhagen University Hospital, Rigshospitalet

Outcome in DM Type 2Type 1RR Perinatal mortality (%)3.2 4 Malformations (%) Preterm delivery (%)37 5 LGA (>90% percentile,%)>50>50?5 CEMACH 2005, N=2356

Maternal hyperglycemia PLACENTAPLACENTA Insulin Fetal β-cells stimulation Fetal hyperinsulinemia Fetal overgrowth Pedersen hypothesis Placenta

Maternal hyperglycemia PLACENTAPLACENTA Insulin Fetal β-cells stimulation Fetal hyperinsulinemia Fetal overgrowth Neonatal hypoglycaemia Pedersen hypothesis Placenta

Neonatal hypoglycamia May cause brain damage Plasma glucose below 2.5 mmol/l Prevalence in infants born to mothers with type 1 diabetes: – 50%

Neonatal hypoglycamia Prevented and treated by artifical feeding by cup every 3. hour the first 24 hours of life – All May need intravenous glucose treatment – 10%

Pro Breast-feeding - - Breastfeeding is important for maternal and child health -Breastfeeding may protect against type 1 and type 2 diabetes in offspring -Breastfeeding improves maternal glycaemic control Navn (Sidehoved/fod)Titel/beskrivelse (Sidehoved/fod) -

Con Breast-feeding - -Breast-feeding is difficult in mothers with diabetes -Diabetes is associated with delayed and poor lactation -High prevalence of neonatal hypoglycaemia, respiratory problems and icterus -Early feeding by cup due to high prevalence of neonatal hypoglycaemia -Early feeding impair maternal milk production Navn (Sidehoved/fod)Titel/beskrivelse (Sidehoved/fod) -

Breast-feeding and obesity - - Breast-feeding is important for maternal and child health -Lactation reduces maternal obesity -Breast-feeding reduces child obesity at one year of age. -Obestiy is associated with delayed and poor lactation Navn (Sidehoved/fod)Titel/beskrivelse (Sidehoved/fod) -

AIM - To investigate the prevalence of long-term breastfeeding among women with type 2 diabetes compared to women with type 1 diabetes and - To identify predictors of long-term breastfeeding for women with pre-gestational diabetes.

Inklusion Inklusionskriteria: – Prægestationel diabetes type 1 el. 2 – Fødende et levende barn på Rigshospitalet – Dansktalende I alt: Type 1: 105 inkluderet (86 %) Type 2: 44 inkluderet (76 %)

Navn (Sidehoved/fod)Titel/beskrivelse (Sidehoved/fod) Methods - Structural interviews at time of discharge about conditions important for initiation of breastfeeding - Phone interviews 4 months postpartum about long-term breastfeeding, defined as any breastfeeding at this point

Navn (Sidehoved/fod)Titel/beskrivelse (Sidehoved/fod) 84 % born at term (>37 w) 36 % delivered by C-section 91 % born at term (>37 w) 39 % delivered by C-section

Eksklusiv amning 4 måneder postpartum ** p<0.01 *** p<0.001 ** *** Herskin C, J Matern Fetal Neonatal Med 2015

Ammestatus ved udskrivelsen og efter 4 måneder ** p < 0.01 Ved udskrivelsen 4 måneder pp

Ammestatus ved udskrivelsen og efter 4 måneder ** p < 0.01 Ved udskrivelsen 4 måneder pp

Maternelle karakteristika vs. ammestatus 4 måneder postpartum *** p<0.001 Herskin C, J Matern Fetal Neonatal Med 2015

Immediate postbirth First nursing < 2h after birth Skin to skin contact < 2 h after birth Well done

Immediate postbirth hospital stay Initiate at least 8 times the first 24 h – Breast feeding the infant – Artificial feeding of the infant by cup – Use breastpump to increase milk production

Immediate postbirth hospital stay Initiate at least 8 times the first 24 h – Breast-feeding the infant – Artificial feeding of the infant by cup – Use breastpump to increase milk production

Immediate postbirth hospital stay Women with type 1 diabetes 8 times the first 24h generaly not obtained Succesful long term breast-feeding – 5.3 times feeding the first 24 hour Not breast-feeding at 4 months – 3,6 times feeding the first 24 hour

Fødselsparametre / ammestatus 4 mdr. postpartum Diabetes typeType 1 (n = 105)Type 2 (n = 44) Ammer (n=64) Ammer ikke (n=41) Ammer (n=15) Ammer ikke (n=29) Neonatal morbiditet 23 %27 %0 % 31 % * Antal amninger første 24 t * * Eksklusiv amning v. udskrivelsen 78 %63 %80 % 28 % *** Kejsersnit 38 %34 %53 %31 % Herskin C, J Matern Fetal Neonatal Med 2015

Fødselsparametre / ammestatus 4 mdr. postpartum Diabetes typeType 1 (n = 105)Type 2 (n = 44) Ammer (n=64) Ammer ikke (n=41) Ammer (n=15) Ammer ikke (n=29) Neonatal morbiditet 23 %27 %0 % 31 % * Antal amninger første 24 t * * Eksklusiv amning v. udskrivelsen 78 %63 %80 % 28 % *** Kejsersnit 38 %34 %53 %31 % Herskin C, J Matern Fetal Neonatal Med 2015

Hospital stay of non-longterm breast-feeding mothers and visit by health visitor Hospital stay: – Type 1 diabetes 5,8 days – Type 2 diabetes 5,6 days – Days after discharge til first visit by health visitor Type 1 diabetes 5,8 days Type 2 diabetes 6,8 days Herskin C, J Matern Fetal Neonatal Med 2015

Mange amninger de første 24 timer Positive prædiktorer for langvarig amning hos diabetes mødre Herskin C, J Matern Fetal Neonatal Med 2015

Negative prædiktorer for langvarig amning hos diabetes mødre Høj BMI før graviditet Rygning Herskin C, J Matern Fetal Neonatal Med 2015

Conclusions Conclusions: -The prevalence of long-term breastfeeding among women with type 2 diabetes was considerably lower than in women with type 1 diabetes. -High number of feedings in the first 24 hours of life, low BMI and no smoking were predictors of succesful long-term breastfeeding in women with pre-gestational diabetes. Navn (Sidehoved/fod)Titel/beskrivelse (Sidehoved/fod)

Dogme Breast feeding in women with type 1 daibets is associated with clinical important problems with hypoglycaemia

Glycaemic control during long-term breast-feeding Breast-feedingBottle-feeding HbA1c 4 month (%) Mild hypoglycmia per week22 Severe hypoglycaemia11%13% Relative change in insulindosis in relation to pre-gestational level -21 %+2% Postpartum weight retension (kg) Herskin C, J Matern Fetal Neonatal Med 2015

Diabetes diet in pregnancy Low glycaemic index carbohydrates – Vegetable, fullgrain bread Restricted carbohydrate intake (40%) – But at least 175 g per day 3 main meals and 2-4 snacks – small breakfast Roskjær, J Matern Fetal Neonatal Med 2014

Carbohydrate intake in pregnancy Maternal blood glucose is the primary metabolic substrate for fetal growth Minimum daily carbohydrate intake 175g: – 150 g from main sources ( bread, fruit, milk, potatoes, rice and pasta) 20 g at breakfast 40 g at lunch 40 g at dinner g at 2-4 snacks Roskjær, J Matern Fetal Neonatal Med 2014

Carbohydrate intake and breast-feeding in diabetes Maternal blood glucose is the primary metabolic substrate for carbohydrates in the milk Minimum daily carbohydrate intake 175g: – 150 g from main sources ( bread, fruit, milk, potatoes, rice and pasta) 40 g at breakfast 40 g at lunch 40 g at dinner g at 2-4 snacks Mathiesen ER, personal opinion 2015

Take home message: Overvægt, rygning og diabetes kan være en hindring for amning Tidlig start med amning er essentielt for succesfuld amning

Nursing If men can breast-feed – we need to obtain a better rate of long term breast-feeding in women with diabetes