Medical Nutrition Therapy for Women with Preexisting Diabetes

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Diabetes and Breastfeeding
the Newborn
Sara Corder, RD, MPH
Breastfeeding Trivia
“If all babies were breastfed
exclusively for their first six months of
life and then given nutritious
complementary food with continued
breastfeeding up to two years of age,
the lives of an additional ________
children under five would be saved
every year.”
Dr Elizabeth Mason, Director of WHO's Department of
Maternal, Newborn, Child and Adolescent Health and
Development
American Academy of Pediatrics
Human milk is the preferred feeding for
all infants, including premature and sick
newborns, with rare exceptions.
Exclusive breastfeeding for the first six
months and support for breastfeeding for
the first year and beyond as long as
mutually desired by mother and child.
The World Health Organization
Recommends continued breastfeeding
up to 2 years of age or beyond.
Antiallergenic Factors
Antiparasitic Factors
Antiviral Factors
Antibacterial Factors
Hormones
Growth Factors
Enzymes
Fatty Acids: DHA / ARA
Fatty Acids: DHA / ARA
Minerals
Minerals
Vitamins
Vitamins
Fats
Fats
Carbohydrates
Carbohydrates
Protein
Protein
Water
Water
Human Milk Is Adaptable!!
During a feeding, breast milk changes from low fat to higher
fat.
In cold climates breast milk has increased fat for energy, in
hot climates, more water to prevent dehydration.
During gradual weaning, breast milk volume decreases, but
the antibodies in the milk increase.
Mothers of premature babies make milk that is higher in
growth factors, protein and fats.
Mothers who are malnourished produce slightly less milk, but
the milk is equal in fat, protein and carbohydrate.
Benefits of BreastfeedingTip of the Iceberg
Mother
Enhances bonding
Mobilizes fat store
Reduce risk of premenopausal
breast/ovarian caner
Protective role against
chronic diseases
HDL increased
Economical
No preparation
Infant
Enhances bonding
Reduce incidence/severity
ear infections
Reduces incidence of
respiratory infections
Decrease risk tooth decay
Reduces incidence of
diarrhea
Reduces risk of obesity
Reduces risk of SIDS
Breastfeeding & Diabetes
Why is breastfeeding particularly
good for the mother with DM and
particularly good for the infant from a
mother with Diabetes? (IDM)
Good for the Mother
Improved Glucose Metabolism
Non-insulin mediated use of glucose by
mammary gland to synthesize lactose.
Increased insulin sensitivity due to
increased prolactin and decreased
estradial
Improved B cell function with 3 months
of breastfeeding in women with GDM
Good for the Mother
Improved Lipid
Metabolism
Women who have
breastfeed for at
least 3 months
LDL levels
increase less
HDL levels
decrease less
Good for the Mother
Improved Weight Loss
Prospective studies using measured
weight change reported lower
postpartum weight retention in lactating
women
Rate of metabolic syndrome is sig lower
with increasing lifetime duration of
breastfeeding
Good for the Mother
Lower rate of DM2 in Women who
lactated
Duration of lactation inversely
associated with risk of DM2 in young
and middle aged women
Non-lactating women developed DM2 at
a 2 fold higher rate than lactating women
after GDM.
Good for the IDM
Breastfed Infants are Leaner
Inverse relationship between
breastfeeding and development of
obesity
Formula fed infants produce more insulin
Hyperinsulinemia retards lipolysis and
enhances fat deposit.
Good for the IDM
Less Overfeeding: changes in breast
milk composition during feeding
provide satiety signals to the infant
Breast milk contains leptin- early
leptin intake can influence later eating
behavior.
Fetal Origins of Adult Disease
The b-cells of the fetal pancreas become
more responsive to glucose late in
gestation and b-cell mass increase in the
last trimester of pregnancy
Theory:A high availability of glucose
programs pancreatic islet development
irreversibly influencing the metabolic
response to glucose later in life and
predisposing to certain patterns of adult
disease.
What is newborn Hypoglycemia?
Refers to a
reduction in the
glucose
concentration of
circulating blood.
Still controversialno consensus on
cut off values
(30-50mg/dL)
Avoiding Newborn Hypoglycemia in
the IDM
Achieve normoglycemia during
pregnancy and LABOR
Terbutaline and ephedrine can cause
maternal hyperglycemia and
subsequent fetal hyperinsulinemia.
Avoiding Newborn Hypoglycemia
Breastfeed Immediately or within 30
minutes after birth, 10-12x/24hr
Cold wet babies use more glucose- Dry
thoroughly and place skin to skin ASAP
Encourage frequent feeds until BG >
45mg/dL BEFORE feedings.
Monitor infant BG for at least 24hrs or until
stable for at least 3 consecutive feedings.
Medically Necessary Separation
Provide EXTRA Support for
establishing breastfeeding
Use Pump within first 12 hrs
Modern Pumps Are Amazing!
Avoiding Maternal Hypoglycemia
Glucose preferentially shunted
towards production of milk
DM1(rarely DM2) prone to
hypoglycemia especially at night
May have to adjust evening dose of
basal insulin- Bedtime Snack Necessary
Avoiding Maternal Hypoglycemia
If BG <100 BEFORE feeding take 15g
CHO and 7 g protein.
If BG < 100 AFTER feeding consider 15 g
snack if insulin on board.
Hypoglycemia causes release of
epinephrine which can cause temporary
decrease in milk production.
Healthy Eating During Lactation
No surprises- Follow GDM meal plan!
May add fruit/milk at breakfast
May add cereal to breakfast
May add:
2 fat servings, 1 fruit and 1 starch to support
extra calorie needs during breastfeeding
Drink Plenty of WATER
Avoid Juices and Sweetened Drinks
Challenges to Breastfeeding
Women with DM less likely to
breastfeed
Difficult labor
Obesity interfering with body mechanics
Fear of giving diabetes through breast
Need to continue insulin and “tight”
control of BG
Lack of support
Lack of Societal Acceptance
Societal Barriers
What would happen to this
mother in the USA?
Best for Babeswww.BestforBabes.org
Endorsed by American Academy of
Pediatrics
Give breastfeeding a makeover
Market it, Brand it, Mainstream it
Foster a cultural change
Using positive social pressure stemming from
the power of celebrities, foundations, fashion,
advertising, the medical community and the
media
Identify barriers
At home, in public and workplace
Breaking Societal Barriers….?
A Start…
New Look of Breastfeeding
New Look of Breastfeeding
New Look of Breastfeeding
New Look of Breastfeeding
Gabrielle Reece
“Quite frankly I sort
of thought, oh god,
if I can get through
these six months,
because I was
really committed to
the health idea,
and then it turned
out that I breastfed
my first child for 23
months.”
Jenna Elfman
If I was on a
plane, I would just
say to the person
next to me, “I have
to feed my kid
because I want his
ears to pop, so if
you don’t like it,
look the other
way.”
Salma Hayek
"her left breast has
now done more for
humanity in a few
minutes than I've
done in roughly my
life.“
Breastfeeding
Supporter
DEBATE
“The debate is over, the science of
breastfeeding is strong, now…how do
we help moms get it done?”
“As physicians, many of us have a lot
to learn about business, marketing
ourselves, marketing our product and
our passion.”
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