So sorry for the long absence. I’ve been meaning to write about breastfeeding for ages, but the thing about demand feeding a new baby is it’s a bit time consuming, so I haven’t managed to blog for a while!
The diabetes and breastfeeding conundrum
When I was still pregnant I did a lot of reading about breastfeeding and about breastfeeding and diabetes, hoping to prepare myself as well as possible for the challenges of the future. I wasn’t expecting to feed so frustrated by the information that was available to me. Compare and contrast the following:
- ‘The acini cells actually produce milk by drawing the necessary milk-making products from your blood (using osmosis and other processes).’
- ‘The quantity of lactose in your milk is stable regardless of anything in your diet or metabolism. Yes, it is produced from your blood, but your blood glucose is converted to lactose in milk production, and only the amount your body is designed to create is created.’
vs.
- ‘Maternal milk glucose levels rise following an increase of plasma glucose levels with a lag time to the peak glucose level of 40-90 minutes, and return to baseline following the return of plasma glucose to baseline with a lag time of 120-150 minutes.’
These two things can’t both be true! Moreover, every published study I read on diabetes and breastfeeding just drove me madder – studies which look at five women or ten women. Where’s the statistical significance in that? Where’s the rigour? Grrrrrrr. Here’s the kicker: ‘The relationship between maternal glucose levels and the concentration of glucose and insulin levels in human milk from diabetic women has not been elucidated.’ The conundrum seems to boil down to this: what do you believe? Respected diabetes researcher Lois Jovanovic suggests that if you are running high you should ‘pump and dump’ and feed your baby with milk which was expressed when your sugars were in range (see Cheryl Alkon’s book: Balancing Pregnancy with Pre-existing Diabetes for more information on Jovanovic’s views, p. 175). Jovanovic believes that if your breastmilk is too sweet then your baby will have reactive hyperglycaemia, and will be irritable, hungry between meals and unable to go more than one and a half hours without a feed.
How do you decide what to believe when the research just isn’t there to back up your decision, or the existing studies are too small to be statistically significant? I want more than anecdote when making a decision this important. My sugars are mostly in range, but my control isn’t as tight now as it was when I was pregnant and I’ve had more highs since I’ve had my baby (since whilst diabetes management is proactive, breastfeeding on demand is reactive and can’t be planned around.) I decided that unless my sugars go really high – 15mmol/l or more (that’s 270mg/dl for my US friends) then I’ll go ahead and feed. On rare occasions when my sugars are higher than that I’ll resort to my stash of frozen milk, or the bottle’s worth that’s tucked away in my fridge. It’s a middle path which tries to balance the risks and it feels like the best I do with the information to hand. Pumping and dumping precious milk that might be fine to feed isn’t a good plan, but neither is feeding your baby oversweet milk… and at the moment there’s no way to really know which theory is right.
The breastfeeding appointment
As I mentioned in an earlier post, I had an appointment with a specialist breastfeeding midwife at the hospital before C was born. I went in to see her on 4 April and spent about an hour getting some specialist advice on diabetes and breastfeeding, and it was a hugely valuable experience (it also gave me a chance to have a sneak preview of the post-natal ward, where I eventually ended up for 10 days after the birth!)
The hospital where I gave birth is a UNICEF ‘Baby Friendly’ hospital, which means that they place great value on breastfeeding and supporting new mums. As a diabetic mum-to-be I was given advice about expressing colostrum antenatally, in order to ensure that there would be some on hand for my new baby if needed (either because of low blood sugars or initial feeding difficulties). The hospital aims for the baby to have skin to skin with Mum as soon as possible after the birth, and to have an early feed (within the first couple of hours) – particularly important for the babies of diabetic women. I was able to ask about the hospital’s hypoglycaemia policy for new babies and was given a copy to take away, which was very reassuring and gave me a good idea of what I could expect when my baby was born. The policy boils down to the following:
- Early skin-to-skin and first breast feed as soon as the baby shows feeding cues. Keep baby warm to prevent hypothermia and observe for symptoms (drowsiness, jitteriness and tremulous movements of limbs, apnoea, seizures)
- An initial check of baby’s blood glucose at 2 hours following delivery. If blood glucose is above 2.6mmol/l (babies run lower than adults) then breastfeed three hourly and re-check blood glucose every 3 hours for the first 24 hours and then 12 hourly thereafter. If blood glucose is below 2.6mmol/l then inform neonatologist (for admission of baby to NICU).
I also received the more standard advice on how to feed, proper positioning and so on, and met my first (but not my last) knitted boob – see picture. [The knitted boobs also made an appearance at both of my antenatal classes, and were in a variety of lurid, and non-realistic, colours, including my personal favourite of purple breast with a massive green nipple! Goodness only knows who knits them – I like to imagine a production line of crazy old grannies…] I took the opportunity to ask M, the specialist midwife, what she thought about the conflicting advice about high blood sugars and feeding. She was of the opinion that ‘pump and dump’ is unnecessary since she believes that the breast’s acini cells only draw what they need from the blood stream and therefore the composition of the milk won’t be affected by the presence of high sugars.
I left the hospital clutching a load of 1.0ml syringes for expressing colostrum, sticky labels and advice to hand express at least three times a day, freeze what I collected, and take it into the hospital when I went for my induction. I could have begun doing this at 36 weeks gestation, but the timing of my appointment meant that I’d missed a few days where I could express and only had about 10 days to produce as much as I could. I diligently expressed, and was only able to manage a couple of drops of colostrum the first time I tried, but each attempt yielded more, and by the time I headed into the hospital I could fill a 1.0ml syringe at one sitting. Apparently the 7.0mls I took in with me at admission was a comparatively good amount, and as you will know if you’ve read my earlier posts, did not go to waste. My baby son, C, had sugars of 0.9mmol/l an hour after birth and went straight to NICU where he was given a dextrose injection and the 7.0mls of colostrum in an attempt to bring his sugars up. This didn’t work, which meant he then had a small amount of formula (150mls over his first 24-36 hours until my milk started to come in, when he switched to my expressed breast milk), and an umbilical line and dextrose drip.
Actually doing it
I firmly believe that the breastfeeding appointment, and the fact that I’d started to express colostrum before C was born, helped my milk to come in sooner than it might otherwise have done. I’d done plenty of research and had bought a really good breast pump (the Medela Swing, if you’re interested) and breastfeeding teats for bottle feeding expressed milk (the Medela Solitaire – pretty expensive, but totally worth it).
C’s first feed was lovely (my new boy held close to my chest, skin-to-skin), but not very effective – with blood sugars of just 0.9mmol/l it’s not really surprising that he didn’t have the energy. Once he was in the NICU I had masses of support to try to feed him, and managed to speak to a couple of midwives/NICU nurses with particular responsibility for giving breastfeeding advice. All mums with babies on NICU are encouraged to express their milk and given packs with sterile breastshields and tubing to connect to the several hospital grade Medela double pumps which they have on the unit for mums to use. There is a room on the NICU where you can wash your kit, collect sterile bottles for pumping into, and store your milk in either a fridge or freezer until your baby needs it. Sticky labels are printed for you so that you can label each bottle, and you have a dedicated container in the fridge and freezer to store your milk. If expressing antenatally started to bring my milk in, then expressing on NICU finished the job! By the time C had been on NICU for 36 hours he was only being given my expressed milk (goodbye formula!) by cup, and I was also given a pager so that the NICU nurses could page me in the night if he showed any feeding cues, and I would be able to hobble down from the ward (courtesy of my C-section wound) and try to feed him the old fashioned way.
C was on NICU for five days, then came back to the ward with me for a further 5 days of transitional care. Once on the ward I was advised to feed him at least every three hours, and to wake him if he was asleep. Although S and I had been shown how to cup feed (see pic) when C was in NICU, and had given him some of his feeds, we weren’t allowed to cup feed on the ward, and we were keen to get him off the cup as soon as possible (even though it doesn’t cause ‘nipple confusion’ like a bottle might, cup feeding is very easy for a baby, and therefore isn’t conducive to breast feeding – in my humble opinion, at least). I had already decided that we would sometimes give C a bottle of expressed milk, since my diabetes means that I could be too hypo to feed him sometimes and it’s important that his Dad should be able to feed him if I’m crocked. Since we already had all we needed at home, S brought the fancy-schmancy breastfeeding teats with him to the hospital so that we could try giving the odd bottle. He also brought my pump, which was compatible with the breastshields/sterile kit I’d been given in the hospital and meant that I didn’t have to queue up in the expressing room with the other pumping mummies (there was only one pump on the ward, in contrast to NICU where there were several).
Initially feeding was a bit of a nightmare. I felt like every midwife in the hospital had handled my boobs and proffered an opinion (and each opinion was different!) C didn’t seem to want to latch, and some of the older NICU night nurses and midwives on the ward had tried to shove my boob into his mouth when he was screaming his head off (tongue up) which was bound not to work. Other midwives, nursery nurses and healthcare assistants seemed to have a real vocation, and were patient, supportive and extremely helpful in identifying things to try. We had a few really good feeds before we were discharged, but also some pretty crummy ones. Whilst the staff in the hospital were really great (one or two exceptions only) the ward was extremely busy, and sometimes staff couldn’t respond quickly enough when I (and other mums) pushed their buzzer for help. This was particularly the case at night, when you might have to wait for an hour (not helpful if you’re trying to latch your baby) – daytimes were easier, not least because S was with me throughout visiting hours (10am to 8pm) each day.
One of the hardest things was having to wake C when he was asleep. No amount of nappy changing, feet tickling, face stroking, bouncing, stripping off and blowing in his face could wake him sometimes, and it seemed that we were getting into a bit of a cycle where he was never hungry enough to exhibit feeding cues, and therefore wasn’t too focused on working hard to get some milk (also my milk had come in so well that it was dripping into his mouth sometimes!) The three hourly feeding advice was relaxed in our last couple of days in the hospital and things seemed to improve, but the three hourly target was re-instituted by our community midwife as soon as we got home. It was only once C showed that he was gaining weight consistently (although still not back to his birth weight until he was three weeks old) that we were able to start feeding on demand. This was when things started to click, and by about three to four weeks of age he was latching much more consistently, my boobs weren’t hurting, and I felt more confident. Growth spurts have been a bit of a nightmare and have shaken my confidence for a day or so – I think my record is probably feeding 13 times in 24 hours (with only one bottle and expressing session for some relief for the boobs), but all in all we seem to have cracked it now.
At 8 weeks and 5 days old C was 11lb 13oz and gaining around 1.25oz per day. He tend to have between seven and ten feeds a day now (unless particularly feedy) and sleeps for 6-7 hours at night, going up to 8 hours between his last feed of one day and his first feed of the next. He has one bottle of expressed milk every night/morning – sometime around 5.00-6.00am these days, although it used to be in the wee small hours. I firmly believe that expressing (both boobs, fully drained) has been really good for me, and has kept my breasts in good condition with no blocked ducts etc (fingers crossed that continues)… oh, and there’s a good stock of milk building up in the freezer, just in case of emergencies. If it doesn’t get used for milk feeds it could always be used to mix with food when we’re weaning our little hungry boy. :)
Breastfeeding has been a real challenge, but I’m really glad that I persisted and didn’t give up. Since I had C I’ve been talking to all the other mums in my antenatal classes, and most of them have found breastfeeding really difficult for the first couple of weeks. Some have persisted and have cracked it, others are doing mixed feeding, and still others have quit altogether and are formula feeding. Some of the advice I was given at my NHS antenatal classes irritated me, if I’m being honest (and irritated a lot of the other mums too). The community midwives can be pretty opinionated (not always a bad thing of course), and we were told in no uncertain terms that expressing milk was a waste of time, and that feeding expressed milk by bottle doesn’t work. Not my experience at all, and frankly not at all helpful (some mums, including me, want to involve their partners in feeding, and it’s a lovely thing for S to be able to give a bottle to our little boy – and quite necessary in any case, as I’ve discussed above). Some of the mums who gave up could have expressed and given some replacement bottles just to keep things ticking over until the feeding was established, especially if the problem was the baby having a tongue tie which could be snipped and would heal, but the advice given in the antenatal classes would have discouraged them from trying. The other thing that frustrates me is that we’re told that breastfeeding is so very important, but there isn’t a lot of honesty about just how difficult it can be. When I spoke to my health visitor she agreed, but said that lots of people wouldn’t even try if they were told how hard it is. I disagree. Many of those mums probably wouldn’t try anyway, as you have to be pretty committed in order to persist and crack it. If you're ambivalent about breastfeeding you probably won't continue through the bumpy times. I’ve not met anyone who took like breastfeeding like a duck to water. However, one thing we all agree on is the fact that if someone had been a little more honest with us, and told us that it’ll be hard, but that it will get better, we’d have known that there was light at the end of the tunnel and for that reason persisting would have been that little bit easier.
This post, which was supposed to be about diabetes and breastfeeding, seems to have gone somewhere else in the writing. But then, frankly this is one challenge where diabetes seems to be a relatively small thing in the scheme of it all!
