As an IBCLC with roughly ten years of breastfeeding support experience, and four breastfed children of my own, I felt pretty confident over the years in my ability to manage breastfeeding obstacles as they presented themselves – both my own, and those of the women I worked with. That is until my youngest child, still a nursling, was diagnosed with Type 1 diabetes at the young age of fifteen months. What I, and many other unfortunate mothers have found, is that there is no real data-driven literature available to support continued breastfeeding with a type 1 diabetic infant or toddler, and nothing to help guide the practice in a healthy and manageable way. At this time, I am only able to synthesize personal experience and knowledge with what I have learned from scientific research in the disconnected fields of diabetes management and lactation. It is my hope, that in time, the need for research specifically related to the care of diabetic nurslings will be conducted to further this analysis. Until then, my wish is for this article to open up a dialogue regarding not only the safety, but the importance of continued breastfeeding through a diabetes diagnosis.
There are basically two categories of children that this concern applies to: those that are still exclusively breastfed, and those that are receiving part of their caloric intake from breastmilk, with a supplement of nutrients and calories from solid foods or formula. For the most part, the former are generally infants under the age of six months. I have not come across any mothers who have been pressured to wean their exclusively breastfed infant within the first six months of age, but should a mother find herself in this unique situation, she can refer her doctor to the article in Pediatrics & Child Health entitled “The infant and toddler with diabetes: Challenges of diagnosis and management” written by a well versed team of doctors, nurses, and other experts in the field, in which the authors state that “In the youngest infants, particularly those who are still breastfeeding, the injections are given about twelve hours apart… and in older children before breakfast and supper. As the children grow older, they are switched to a three-times daily injection routine” (Daneman et al.). This statement indicates that breastfeeding a diabetic nursling is in no way contraindicated and simply addresses the fact that as with all diabetic children, the care plan will be constantly changing and evolving as the child grows. The plan can just as easily accommodate a diet of breastmilk as that of formula. According to the World Health Organization, “exclusive breastfeeding for 6 months is the optimal way of feeding infants. Thereafter infants should receive complementary foods with continued breastfeeding up to 2 years of age or beyond” (“Exclusive Breastfeeding.” WHO). The guideline of exclusive breastfeeding for the first six months is also supported by the American Academy of Pediatrics (“AAP Reaffirms Breastfeeding Guidelines”). There is no reason this guideline should be changed for children with a diagnosis of Type 1 diabetes. This will be explained in more detail in the section below.
As for the second category, babies and toddlers over the age of six months who are fed a combination of breastmilk and solids, I have heard from too many mothers (not to mention my own experiences) reporting pressure to abruptly wean. Rationale for abrupt weaning focuses on the misconception that breastmilk is too difficult to calculate in terms of carbohydrate counting. The fact (the absolutely beautiful fact) is that breastmilk is always changing to meet the changing needs of the baby – from day to day, week to week, and even hour to hour. According to Ann Prentice, and The United Nations University Press, “The composition of breastmilk is not uniform, and the concentrations of many of its constituents change during the lactation period and differ between individual mothers.” Sometimes it is higher in water, other times it is higher in fat and protein. While this wonderfully organic nature of breastmilk may concern those trying to manage the care of a child whose health and well-being strongly rely on a careful calculation of carbohydrate intake, it is important to note that while protein, fat, micro, and macronutrients may vary, “Some components show little change, especially those involved in osmoregulation, including lactose [the primary carbohydrate in breastmilk] and sodium.” The author does distinguish between the composition of colostrum through day 5 and mature milk, noting that lactose in mature milk is slightly higher than that of colostrum (approximately 7.5 g in 100ml/roughly 3.3 oz of mature milk, vs. 5.3 g in 100ml/roughly 3.3 oz of colostrum) (Prentice). For the purposes of addressing the needs of the older infant/toddler, this means that the child’s care team can safely assume mature milk to consistently comprise of roughly 2.25 grams of carbohydrates per single ounce of milk. While this is very valuable information, it doesn’t address the concern that some teams may have regarding the difficulty in measuring exact intake when a child nurses directly at the breast. For this reason, some doctors “allow” the mother to continue feeding the child breastmilk, but urge her to feed the milk through a bottle so that intake can be carefully monitored.
While the push to have mother switch to a pumping/bottle-feeding routine may seem benign (possibly even ideal) as baby still receives the nutritional and immunological benefits of mother’s milk while allowing for more precise monitoring, it is important to take into consideration a cost-benefits analysis when making such a recommendation. At the most basic level, pumping and bottle-feeding is much more work than directly nursing at the breast. At a time when parents are taking on so many new tasks and responsibilities to care for their child, adding complexity to an otherwise simple feeding method adds to already heightened stress and sets the breastfeeding mother up for failure. Aside from this very real drawback to switching, it is also important to consider the fact that breastfed babies often breastfeed for more than nutritional reasons. When weighing the physical and emotional risks associated with abrupt weaning (such as added stress and anxiety for both nursling and mother, as well as the potential for physical complications such as plugged ducts and mastitis in the mother) during an already highly stressful time, it is important to assess the real value of such a major shift in the child’s feeding routine.
While careful monitoring of carbohydrate intake is important to the care of a newly diagnosed diabetic child, it is generally agreed upon that complications associated with slightly elevated blood sugars are less concerning for young children, than the risks of low blood sugars, which is why pediatric endocrinologists tend to prefer letting babies and toddlers “run high”; often not advising “correction doses” until blood glucose levels reach approximately 300 mg/dL and prescribing target A1c’s of roughly 8.5%-9% versus a typical A1c of 4.6% in non-diabetic children (Daneman et al. “Monitoring and the Target Range”). According to the authors, microvascular complications associated with diabetic hyperglycemia (high blood sugar) is delayed in young children, and “The clock does not start ticking (or at least starts clicking more slowly) in children with diabetes before the onset of puberty.” It goes on to stress the long-term danger of hypoglycemic episodes (low blood sugar), which can lead to cognitive impairment down the road.
What this means is that when caretakers find themselves in the position where they have to estimate carbohydrate intake (rather than knowing the exact amount such as when an exact serving size is eaten) it is always better to round the numbers down slightly rather than up. The reason this is significant to breastfeeding mothers is because when we look back at the approximate calculated carbohydrate content of breastmilk per ounce of milk, the difference in the amount of carbohydrates a nursling receives between average feedings of 4 to 6 ounces is roughly 4.5 carbs – statistically insignificant when calculating insulin dosing. In other words, guiding a nursing mother to round down her estimation of volume in a single nursing session (for example from 6 ounces to 4) when she is uncertain of intake, will result in her being off by approximately 4.5 grams in her estimated carb count. Compare this to the difficulty in assessing the exact carbohydrate intake of a toddler who is self feeding and losing large portions of their food to their diaper, floor, or otherwise, and this point becomes even more clear.
To further illustrate the absurdity of worrying about the exact monitoring of breastmilk intake down to the ounce, I’ll point out that finding the correct basal and correction doses to keep children in their target range is a trial and error process that requires ongoing adjustment as the child grows, activity levels change, and dietary needs and interests change. As any parent of a toddler knows, these variables can change from day to day, and even hour to hour. To suggest that a child receiving any, or all, of its caloric intake from breastmilk is any harder to predict (in regard to what solids he/she might eat over the course of a day) is preposterous. It is for this exact reason that doctors and diabetic educators council parents to administer insulin after a young child has eaten. Although it can take insulin approximately twenty minutes to begin working in the body, and best practice for older patients advises administering insulin roughly one half-hour prior to
pre-carb counted meals (Neithercott) to avoid blood sugar spikes, this practice, in the care of infants and toddlers is very risky. If the child is given a dose of insulin based on what they are expected to eat, and then eats less or even none of their meal (it does happen!) their blood sugar will quickly crash, causing a dangerous hypoglycemic episode. Following this logic, it is just as easy to estimate and cover the carbohydrate intake of a toddler who has just breastfed directly at the breast as one who has just finished a meal (based on what is found on and around the child, versus what is missing from the plate).
If we can now safely assume that breastmilk is just as easily accounted for when counting carbohydrates as other foods and beverages, we can move our focus to the benefits of breastfeeding as they specifically relate to diabetes management in the young child. Every parent managing the care of a diabetic infant or toddler can attest to the fact that there are always certain foods that seem impossible to “cover” properly, or that just “set their child off.” Nutritionally speaking, foods that have a healthy balance of protein, fats, and carbohydrates, along with a healthy dose of fiber, are better than foods that are primarily carbohydrate based. This is because protein, fat, and fiber help slow the digestion of carbs, and help prevent spikes in blood sugar. This is true for all individuals– not just diabetics. Unfortunately, this healthy practice can make it tricky to cover carbohydrate intake with the proper dosage and scheduling of insulin. In a non-diabetic person, the body will slowly release insulin over a period of time to match the carbs as they are released into the bloodstream. If a diabetic individual takes the “correct” dose of insulin (as calculated by a prescribed ratio) upfront, they run the risk of crashing because the full amount of insulin will be processed by the body faster than the carbohydrates they have just eaten. They then find themselves having to eat simple carbohydrate foods (fruits, juices, starches, etc.) to avoid a dangerously low glucose episode. Unfortunately at this point the carbs from the original meal are still in the body, waiting to be released. As those carbs enter the bloodstream, along with the “catch up” carbs, blood sugar starts to rise quickly and the person starts to battle hyperglycemia. This “roller coaster ride” is a familiar one to families managing T1 diabetes, and over time, and with practice, they get better at finding techniques (such as “extended blousing” or temporary adjustments to the basal dosage if using a pump) that help mimic the way the body naturally releases insulin, to minimize the number of times spent on the glucose see-saw. So how does this relate to the benefits of breastfeeding?
Children who are exclusively breastfed tend to eat a relatively consistent amount of breastmilk on a day-to-day basis, which means that the overall intake of carbs is relatively consistent from day-to-day and can therefore be somewhat easily managed with a long- lasting insulin dose (or basal dose if on the pump). Because the child is receiving his or her nutrition from a relatively consistent food source, the stress of managing “trigger foods” and variations in diet is minimized. Incidences of high blood sugar that result from other factors can then be managed with a short-acting insulin such as Humalog or Novalog just as they would with a child on an exclusively solid or formula-based diet. Children who are receiving a portion of their calories from solid foods generally fall into one of two sub-categories. Those that nurse in small amounts (mostly for comfort) throughout the day, and those who take in larger amounts less frequently, such as at nap or bedtime. For the nurslings who take in relatively small amounts of breastmilk regularly throughout the day, their carb intake from each nursing session is usually small (less than 10 grams) and can often be accommodated by the long-lasting insulin dose (or basal if on a pump) just as if they were exclusively nursing. For those that nurse less frequently, but take in a larger volume of milk at each feeding, the carbohydrates in each nursing session usually average around 15 grams (for intake of approximately 5-8 ounces of milk), which can be accounted for much the same way one accounts for a small snack in a child that receives their nutrition from a non-breastfeeding diet. While figuring out the best balance of long- lasting/basal insulin and short acting insulin for carb covering and sugar correction doses will have to be a trial an error process, this is the case for all newly diagnosed individuals and shouldn’t be used as a reason to restrict breastfeeding.
Some other benefits that apply specifically to diabetic nurslings involve stress management for mother and child and simplicity of feeding (at a time when overall care is becoming increasingly more complex). When I close my eyes, I can still vividly see the image of my 15 month old strapped to a bed, with wires stemming from all parts of his body, desperately crying for the only comfort he knew – the comfort of his mother’s breasts. While I could understand the need for immediate restriction of food by mouth while his high blood sugar and associated dka (diabetic ketoacidocis) status were addressed (he entered the hospital with blood glucose levels over 800!), I could not understand the warning from multiple PICU (pediatric intensive care unit) nurses that I would most likely have to fully and promptly wean him from the breast. I also could not accept the dismissiveness of the comments suggesting that weaning him at this stage, “really shouldn’t be a big deal” since he was over the age of one year. In speaking to many moms around the country, I’ve found that this is unfortunately the message that many moms are receiving at the time of their child’s diagnosis. In addition to the immunological and nutritional benefits of mother’s milk, it is becoming increasingly recognized that nursing provides so much more than just nutrition. According to Dr. Sears, “Breastfeeding relaxes mother and baby… [human] milk contains a natural sleep-inducing protein, that… puts baby into a restful slumber. The hormones induced by sucking tranquilize mother. This natural calming is especially helpful for the baby (and mother) who has difficulty getting to sleep” (Sears and Sears 124). I can’t imagine a more stressful, sleepless time than when a child is diagnosed with a chronic, life-threatening disease. To strip mother and child of this valuable stress-management tool at a time of such high stress seems nothing more than cruel and unusual punishment! In addition to the hormonal influences, breastfeeding can help reduce stress by simplifying an otherwise chaotic new way of life. Managing high and low blood sugars is hard work and requires an on-call mindset twenty-four hours a day. Ask any parent of a young diabetic child which aspects of the disease they find most challenging, and they will likely mention the managing of middle of the night low blood sugars towards the top of their lists. While older children and adults can often be coaxed out of sleep to take a small snack or drink when their blood sugar dips, it is very difficult to convince an infant or toddler that they should wake in the middle of the night to eat or drink juice when they are in a sound sleep and not hungry. Because breastfed babies can, and often do, nurse without fully waking, it can be much easier to ward off a low blood sugar in the middle of the night by nursing (remember, a single larger nursing session can yield about 15 grams of carbs which is the equivalent of a prescribed snack for low blood sugar) than trying to force-feed a snack with 15 grams of carbs. Babies who are still taking in smaller amounts of milk more frequently can often be managed by small frequent feeds throughout the night in conjunction with an adjusted long-lasting dose or decreased basal dose (if on the pump) for nighttime hours. For instances of extreme low blood sugar, where breastmilk proves insufficient for adequately raising blood sugar, a little bit of honey (for babies over one year) or glucose gel (for younger infants) can often go a long way when rubbed along the inner gum and followed up with a nursing session.
In addition to the on-going stress and complexity of daily diabetes management, are the acute stressors associated with events such as insulin injections, pump and/or continuous glucose monitor (cgm) site changes. While these activities don’t take very long, they can often prove very stressful to the young child (and thus the caregiver). When the mother can put the baby to the breast for comfort while performing these activities, it often makes the overall experience much less stressful for everyone all around. Obviously at some point, the nursling will go through the weaning process and learn to endure injections and/or site changes without this comfort, but again, it seems cruel to strip mother and baby of this valuable tool in the early months following diagnosis when they need as many support structures in place as they can get!
Obviously everybody is different, and individual needs must be assessed on a case-by- case basis, but I sincerely hope that this article will encourage more endocrinology teams to strongly weigh the significant benefits of breastfeeding against the minimal inconveniences associated with adjusting a care plan to accommodate breastfeeding before rashly advising mothers of newly diagnosed nurslings to wean.
“AAP Reaffirms Breastfeeding Guidelines.” AAP Press Room. American Academy of Pediatrics, 27 Feb. 2012. Web. 10 Aug. 2014.
Daneman, Dennis, MB BCh, Marcia Frank, RN MHSc, Kusiel Perlman, MD, and Jean Wittenberg, MD. “The Infant and Toddler with Diabetes: Challenges of Diagnosis and Management.” Pediatric Child Health 4.1 (1999): 57-63. NCBI. US National Library of Medicine National Institutes of Health. Web. 10 Aug. 2014.
“Exclusive Breastfeeding.” WHO. World Health Organization, 2014. Web. 10 Aug. 2014. <http://www.who.int/nutrition/topics/exclusive_breastfeeding/en/>.
Neithercott, Tracey. “A User’s Guide to Insulin.” Diabetes Forecast. Apr. 2010. Web. 10 Aug. 2014.
Prentice, Ann. “Constituents of Human Milk.” Food and Nutrition Bulletin 17.4 (1996). Food and Nutrition Bulletin – Volume 17, Number 4, December 1996. United Nations University Website. Web. 10 Aug. 2014.
Sears, William, and Martha Sears. “Breastfeeding: Why and How.” The Baby Book: Everything You Need to Know about Your Baby–from Birth to Age Two. Boston: Little, Brown, 1993. 124. Print.
Why I Celebrated World Breastfeeding Week: Breastfeeding my Type 1 Diabetic Baby by Brittany Fenstermaker @ KellyMom
Breastfeeding My Type 1 Diabetic Daughter from the San Diego Breastfeeding Center
Breastfeeding a Baby with Type 1 Diabetes from Breastfeeding Support in Dublin