Access KeysSkip to MenuSkip to ContentSkip to Footer

8.5 Medical, Surgical Issues

Diabetes mellitus

Breastfeeding and diabetes have a close relationship - breastfeeding has an impact on pre-existing and potential diabetes and diabetes has an impact on breastfeeding. Lactation may be delayed or impaired for reasons both of diabetes and obesity, so women in the diabetic spectrum need special consideration and attention to breastfeeding and lactation assistance. 1

Gestational diabetes mellitus (GD)

  • mothers who had GD and suppress lactation
    • have higher serum glucose than had they breastfed 2
    • experience an immediate detrimental effect on their glucose tolerance 3
    • cause lasting effects on their metabolic profiles 3
    • significantly increase their risk of developing Type 2 diabetes 3 4
Type 2 diabetes mellitus
  • Children who were artificially fed in infancy
    • are put at increased risk of developing Type 2 diabetes. 5
  • Mothers who suppress lactation
    • do not receive the protection that normally delays or prevents Type 2 diabetes mellitus
    • obesity and lactation suppression combined significantly increases the risk of developing Type 2 diabetes mellitus. 4
Type 1 diabetes mellitus (insulin-dependent)
  • For the child who was artificially fed in infancy
    • Being artificially fed significantly increases their risk of developing Type 1 diabetes mellitus. 6 7 8
  • For the mother who has Type 1 diabetes
    • onset of secretory activation (lactogenesis II) may be delayed. 1 9
    • lactating mothers can reduce their insulin by 25% or more of pre-pregnancy dose, while increasing their carbohydrate intake. Insulin requirements of mothers who suppress lactation is significantly greater. 10 11 12

Impact on lactation

  • women who are diabetic are more likely to birth preterm, have a caesarean section or assisted birth and experience other obstetric complications, all of which increase the risk of lactation difficulty
  • mothers who are diabetics are more likely to NOT breastfeed or have a shorter breastfeeding duration 13 14
  • separation of mother and baby is more likely due to preterm birth, Caesarean section and blood glucose testing
  • maternal diabetes delays the onset of lactogenesis II 1 15
  • in some units the baby is at greater risk of being given artificial infant formula, increasing breastfeeding difficulties

Recommendations

It is unfortunate that mothers with diabetes are at increased risk of breastfeeding difficulties which not only impacts on their own health but also on the health of their child who then becomes at risk of developing the same diabetic condition.

For the present and future health of the mother with diabetes and her baby:

  • provide education about the effects of artificially feeding on herself and her baby
  • suggest prenatal expressing of breastmilk;16 give infant the milk prophylactically during first day
  • encourage skin-to-skin contact after birth, early initiation and frequent breastfeeding
  • support measures to establish milk supply if mother and infant separated or infant not able to latch

In light of the increased risk to the health of this woman and her child practices which interfere with breastfeeding, such as separation and giving artificial infant formula should be reviewed.

Do mothers know this?

Do the mothers with diabetes in your Unit get told of the effect of premature weaning on themselves and their babies?

Maternal overweight and obesity

Artificial feeding and onset of obesity

  • Mothers who artifically feed compared to those who breastfeed (>6 months) have

    • a 2 kg greater weight gain by 1 year postpartum
    • larger waist girth
    • greater weight gain 10-15 years later
  • being artificially-fed correlates to obesity in childhood and adulthood 17 18 19

Obesity and breastfeeding

  • overweight and obesity increases obstetric complications and is associated with a greater risk of operative delivery, making lactation initiation more difficult
  • lactogenesis II may be delayed 20
  • positioning the baby to facilitate good latching is more difficult
  • the greater the BMI the greater the risk of early cessation of breastfeeding compared to women with normal BMI
  • overweight and obese women are less likely to plan to breastfeed, initiate breastfeeding and wean earlier 21

Recommendations

Give additional education and support to breastfeed to overweight and obese mothers -

  • encourage skin-to-skin contact after birth, early initiation and frequent breastfeeding
  • support measures to establish milk supply if mother and infant separated or infant not able to latch
  • assistance with positioning infant could include using the underarm hold, raising their breast on a pillow or using a rolled up cloth or towel under the breast, and using a mirror to allow them to view their infant latching correctly to their breast.

Social measures that increase breastfeeding will result in less overweight and obese adults. Pre-conception education should provide help for women to achieve a normal BMI before pregnancy.

Urgently needed are qualitative studies from women's perspective to help us understand women in this situation and their infant feeding decisions and behaviour.

Thyroid disease

Autoimmune thyroid dysfunctions are a common cause of both hyper- and hypo-thyroidism. 22

Graves' disease (hyperthyroid) and postpartum thyroiditis are two major causes of thyrotoxicosis in the postpartum period. Antithyroid drugs, propylthiouracil or methimazole, are the mainstay of the treatment of postpartum thyrotoxicosis and both are safe to take while breastfeeding. Radioiodine treatment is contraindicated during lactation. 23

There is a relatively high prevalence of hypothyroidism, especially subclinical hypothyroidism. Hypothyroidism is associated with insufficient breastmilk supply and may be one of the symptoms which alerts you to this condition. Thyroxine replacement therapy is safe for the breastfeeding baby 24 and milk levels will improve once the mother becomes euthyroid.

Thyroid status varies considerably postpartum. Medication dosage may need adjusting during the postpartum months. Be mindful of symptoms such as fatigue, palpitations, weight loss, loss of concentration and depression. Facilitate medical review of the mother.

Recommendations

All women with diagnosed thyroid disease should have their therapy re-evaluated frequently during pregnancy and lactation and medication dosage adjusted as necessary. This is particularly necessary for women who are being treated for hypothyroidism because of the impact on breastmilk sufficiency.

Evaluate all mothers who have breastmilk insufficiency for hypothyroidism.

Hepatitis

Hepatitis B (HBV)
With appropriate immunoprophylaxis, including hepatitis B immune globulin and hepatitis B vaccine, breastfeeding does not contribute to mother-to-child transfer of HBV. 25 26,27
Prior to vaccination, concern of transmission of HBV via cracked nipples was speculated but not recorded.

Hepatitis C (HCV)
There is no evidence of mother-to-infant transmission of hepatitis C from breastfeeding. 28

Recommendations

Women who are hepatitis B or C positive should be encouraged to breastfeed their babies.

Workbook Activity 8.10

Complete Activity 8.10 in your workbook.

HIV

Untreated, about 5-15% (1 in 20, to 1 in 7) of babies born to women who are HIV infected will become HIV-positive through breastfeeding.
Exclusive breastfeeding reduces this risk of transfer by about half for HIV +ve mothers.
Exclusive breastfeeding with the addition of(highly active anti-retroviral therapy)HAART regime reduces the mother's viral load to virtually undetectable, with a 0% - 3% risk of her infant acquiring HIV - the higher failure rate being associated with non-compliance to the ARV (anti-retroviral) regime. 29 30

When mixed feeding is practiced the artificial formula damages the gut permitting transfer of virus from breastmilk.
Note: Before giving a supplement to ANY breastfed baby consider the risk you are submitting the baby to should the mother unknowingly be HIV positive.

International Recommendations for infant feeding

World Health Organization

When the mother's HIV status is unknown
  • exclusive breastfeeding for the first 6 months, then
  • introduce complementary foods while continuing to breastfeed for 24 months and beyond.
When the mother is HIV positive31
  • commence anti-retroviral therapy (ARV) as soon as she is diagnosed and continue for the rest of her life
  • infants to receive ARV therapy
Breastfeeding guidelines
The World Health Organization encourages each country to review their infant feeding recommendations, taking into consideration circumstances related to their unique situation.
  • At this time most high-income countries recommend HIV positive mothers exclusively feed their infant on a safe alternative, such as infant formula.
  • Mothers living in middle to low income countries are advised to
    • exclusively breastfeed for 6 months, before
    • continuing to breastfeed until 12 months with the addition of appropriate complementary foods.
    • Strictly adhere to HAART regime as adopted in each country.
A high success rate in prevention of HIV transmission has been achieved with this regime in these countries.

Well-informed and motivated mothers in high-income countries may be assisted to breastfeed after receiving expert advice and support on how to do so safely with minimal risk of mother-to-child transfer. 32

When infant formula is being considered ...

Mothers known to be HIV-infected should only give commercial infant formula milk as a replacement feed to their infants, when specific conditions are met:

  1. safe water and sanitation are assured at the household level and in the community, and,
  2. the mother, or other caregiver can reliably provide sufficient infant formula milk to support normal growth and development of the infant; and,
  3. the mother or caregiver can prepare it cleanly and frequently enough so that it is safe and carries a low risk of diarrhoea and malnutrition; and
  4. the mother or caregiver can, in the first six months, exclusively give infant formula milk; and
  5. the family is supportive of this practice; and
  6. the mother or caregiver can access health care that offers comprehensive child health services.

Guidelines on HIV and Infant Feeding. (2010) WHO

Workbook Activity 8.11

Complete Activity 8.11 in your workbook.

Breast surgery

Reduction mammoplasty is frequently associated with insufficient milk supply due to

  • severing large numbers of lactiferous ducts, (some ducts may re-anastomose)
  • removal of large amounts of glandular tissue, or
  • severing the 4th intercostal nerve innervating the nipple/areola (4th intercostal nerve is the stimulus for the milk ejection reflex

Breast augmentation usually has minimal impact on breastfeeding. However it has the potential to negatively affect breastfeeding if a peri-areola incision was used, or from compression of glandular tissue with sub-glandular placement of implant.
Breast hypoplasia (inadequate glandular tissue) may have been the indication for the augmentation surgery. Assessment for this should be performed prior to surgery.33

Referral is needed

This is an ongoing issue which will require support throughout breastfeeding.

Breastfeeding, milk transfer and the baby's condition should be closely monitored to ensure the baby continues to thrive. An antenatal consultation with a Lactation Consultant followed by close supervision of initial and ongoing breastfeeding management and early interventions to increase supply is important.

Breastfeeding and medication usage

Some women need to take medications while breastfeeding. It is important to ensure the baby will not be harmed via breastmilk transfer of the medication. It is equally as important not to forfeit breastfeeding when there are safe, effective medications. In most cases, it is far preferable to continue breastfeeding with small amounts of drug present in milk rather than risk many more hazardous effects of infant formula feeding.

All medications transfer into breastmilk to some degree but very, very few medications are contraindicated during breastfeeding. As a general rule of thumb less than 1% of the maternal dose passes via the breastmilk to the baby. Up to 10% of maternal dose is usually considered to be safe. 34

Several factors influence the ultimate medication dose which the infant will receive via breastmilk:

  • the transfer of the drug into the breastmilk - influenced by specific drug properties such as maternal drug level reached, molecular weight, protein binding capacity.
  • the uptake of the drug by the infant from the breastmilk - daily intake of infant, stomach acidity, gut absorption.

Everyone who prescribes medications for breastfeeding women should have access to a recent text that specifically reviews medications for mothers. This is the link to an excellent online resource. Externalhttp://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT . Bookmark this resource for future reference.

The known detrimental effect of artificial infant formula feeding for both mother and baby needs to be seriously considered prior to ceasing breastfeeding due to maternal medication use. An alternative drug should be sought if the one usually prescribed is contraindicated.

What should I remember?

  • The important cause/effect cycle of each type of diabetes and breastfeeding.
  • The important cause/effect cycle of obesity and breastfeeding.
  • How thyroid conditions may impact on breastfeeding.
  • That HBV and HCV infection is not a contraindication for breastfeeding.
  • Exclusive breastfeeding for 6 months reduces risk of HIV mother-to-child transfer. ARV therapy and breastfeeding reduces transfer to negligible.
  • Your national guidelines for HIV and infant feeding and the criteria for safe formula feeding.
  • How breast surgery impacts breastfeeding and why.
  • The usual percentage transfer of a medication to infant via breastmilk. The generally safe percentage transfer. Safe and effective alternatives are usually available for the breastfeeding mother if necessary.

Self-test quiz

Match an item from the column on the left with an item from the column on the right. Click on an item in one column, then on its matching response from the other column

Assessment Quiz

When you are happy that you've understood all the information in this topic you will be ready to complete the Module 8 Assessment. To do this, go to the course opening page, scroll down to the Assessment section and choose Module 8.

Notes

  1. # Nommsen-Rivers LA et al. (2012) Timing of stage II lactogenesis is predicted by antenatal metabolic health in a cohort of primiparas.
  2. # Mielke RT et al. (2013) Interconception care for women with prior gestational diabetes mellitus.
  3. # Kjos SL et al. (1993) The effect of lactation on glucose and lipid metabolism in women with recent gestational diabetes
  4. # Gunderson EP (2007) Breastfeeding after gestational diabetes pregnancy: subsequent obesity and type 2 diabetes in women and their offspring
  5. # Das UN (2007) Breastfeeding prevents type 2 diabetes mellitus: but, how and why?
  6. # Rosenbauer J et al. (2007) Early nutrition and risk of Type 1 diabetes mellitus - a nationwide case-control study in preschool children.
  7. # Malcova H et al. (2006) Absence of breast-feeding is associated with the risk of type 1 diabetes: a case-control study in a population with rapidly increasing incidence
  8. # Tenconi MT et al. (2007) Major childhood infectious diseases and other determinants associated with type 1 diabetes: a case-control study
  9. # Hartmann P et al. (2001) Lactogenesis and the effects of insulin-dependent diabetes mellitus and prematurity
  10. # Illingworth P et al. (1989) Insulin requirements during breast feeding
  11. # Davies HA et al. (1989) Insulin requirements of diabetic women who breast feed
  12. # Riviello C et al. (2009) Breastfeeding and the basal insulin requirement in type 1 diabetic women.
  13. # Finkelstein SA et al. (2013) Breastfeeding in women with diabetes: lower rates despite greater rewards. A population-based study.
  14. # Hummel S et al. (2008) [Breastfeeding in women with gestational diabetes]
  15. # Hartmann P et al. (2001) Lactogenesis and the effects of insulin-dependent diabetes mellitus and prematurity
  16. # Cox SG (2006) Expressing and storing colostrum antenatally for use in the newborn period
  17. # von Kries R et al. (1999) Breast feeding and obesity: cross sectional study.
  18. # Kalies H et al. (2005) The effect of breastfeeding on weight gain in infants: results of a birth cohort study
  19. # Harder T et al. (2005) Duration of breastfeeding and risk of overweight: a meta-analysis
  20. # Rasmussen KM et al. (2004) Prepregnant overweight and obesity diminish the prolactin response to suckling in the first week postpartum.
  21. # Amir LH et al. (2007) A systematic review of maternal obesity and breastfeeding intention, initiation and duration
  22. # Speller E et al. (2012) Breastfeeding and thyroid disease: a literature review.
  23. # Azizi F (2003) Thyroid function in breast-fed infants is not affected by methimazole-induced maternal hypothyroidism: results of a retrospective study
  24. # Lao TT (2005) Thyroid disorders in pregnancy
  25. # Hill JB et al. (2002) Risk of hepatitis B transmission in breast-fed infants of chronic hepatitis B carriers
  26. # Zhongjie Shi (2011) Breastfeeding of newborns by mothers carrying Hepatitis B virus
  27. # Geeta MG et al. (2013) Prevention of mother to child transmission of hepatitis B infection.
  28. # Cottrell EB et al. (2013) Reducing risk for mother-to-infant transmission of hepatitis C virus: a systematic review for the U.S. Preventive Services Task Force.
  29. # Shapiro RL et al. (2010) Antiretroviral regimens in pregnancy and breast-feeding in Botswana.
  30. # Ngoma M et al. (2011) Interim results of HIV Transmission Rates Using a Lopinavir/Ritonavir based regimen and the new WHO Breast Feeding Guidelines for PMTCT of HIV
  31. # World Health Organisation and UNICEF (2010) HIV and infant feeding
  32. # UK Chief Medical Officers Expert Advisory Group on AIDS et al. (2004) Guidance from the UK Chief Medical Officers Expert Advisory Group on AIDS.
  33. # Cruz NI et al. (2010) Breastfeeding after augmentation mammaplasty with saline implants.
  34. # Hale T (2010) Medications and Mothers Milk