Makes Milk with Emma Pickett
Emma Pickett has been a Board Certified Lactation Consultant since 2011. As an author (of 4 books), trainer, volunteer and breastfeeding counsellor, she has supported thousands of families to reach their infant feeding goals.
Breastfeeding/ chest feeding may be natural, but it isn't always easy for everyone. Hearing about other parent's experiences and getting information from lactation-obsessed experts can help.
Makes Milk with Emma Pickett
Diabetes and breastfeeding
Can I still breastfeed with type 1 diabetes? What will happen to my baby now that I have gestational diabetes?
In this episode, I’m talking to Lucy Lowe, an IBCLC specialising in working with diabetes in pregnancy. We talk about how gestational diabetes is diagnosed and treated, what steps you can take to prepare for breastfeeding a baby if you have any type of diabetes, and how to get more support.
Find out more about breastfeeding and chest feeding older babies and children in my book Supporting Breastfeeding Past the First Six Months and Beyond: A Guide for Professionals and Parents
Get 10% off two of my books with the code MMPE10 from 21st December 2023. Find them at https://uk.jkp.com/collections/author-emma-pickett-pid-240164
Follow me on Twitter @MakesMilk and on Instagram @emmapickettibclc or find out more on my website www.emmapickettbreastfeedingsupport.com
Resources mentioned
Free online antenatal course: https://abm.me.uk/product/team-baby-online-course/
Language Matters article https://www.diabetes.org.uk/resources-s3/2018-09/language-matters_language%20and%20diabetes.pdf
https://www.laleche.org.uk/diabetes-and-breastfeeding/
https://www.lowestoftandwaveneybreastfeeding.co.uk/
https://www.breastfeedingsupportnorwich.com/
NICE guidelines:
https://www.nice.org.uk/guidance/ng3
https://www.nice.org.uk/guidance/qs109
https://www.diabetes.org.uk/guide-to-diabetes/life-with-diabetes/pregnancy
This podcast is presented by Emma Pickett IBCLC, and produced by Emily Crosby Media.
Hi. I'm Emma Pickett, and I'm a lactation consultant from London. When I first started calling myself Makes Milk, that was my superpower at the time, because I was breastfeeding my own two children. And now I'm helping families on their journey. I want your feeding journey to work for you from the very beginning to the very end. And I'm big on making sure parents get support at the end. So join me for conversations on how breastfeeding is amazing. And also, sometimes really, really hard. We'll look honestly and openly at that process of making milk. And of course, breastfeeding and chest feeding are a lot more than just making milk.
Emma Pickett 00:48
Thank you very much for joining me for today's episode. I'm really honoured today to be joined by Lucy Lowe. So after a background in supporting with mental health and substance abuse, Lucy started working in infant feeding support after the birth of her second son. She became an ABM peer supporter in 2013. Woohoo. She's now an IBCLC in Norfolk and Suffolk and she works for the lowest often wave knee breastfeeding support, that's a charity on the East Coast. She's also a volunteer with breastfeeding support Norwich in Norfolk, she's employed within the NHS as an infant feeding specialist within a maternity unit. She's worked with the infant feeding team for six years, but recently has moved into also specialising in working with diabetes in pregnancy. So the diabetes and pregnancy infant feeding team. And today we're going to be focusing on diabetes and breastfeeding. And I'm aware that the audience will include some people for whom that's a personal experience. And hopefully, we're going to provide you some information that will offer you support and reassurance. We're also going to be providing information for anybody in a sort of breastfeeding support role, who's going to need to know how to support parents that they're looking after. And I'm probably joined by a few science nerds for whom this is not remotely relevant to their direct personal experience. Welcome, science nerds! Lucy and I welcome you to this session. So Lucy, tell me a little bit about the diabetes team that you're part of what sort of work are you doing day to day?
Lucy Lowe 02:09
Okay, well, thank you so much for having me here, first of all, and that's really nice of you to have me on. And I hope that it provides a bit of information to people. So I work as an infant feeding specialist within a local hospital Norfolk and Norwich University Hospital, where I work 10 hours a week as an infant feeding specialists supporting families with diabetes in pregnancy antenatally predominantly, but also postnatally, where possible, the diabetes team that I work with are made up of consultants, a professor in diabetes, diabetes specialist midwives and nurses. Dieticians admin coordinator, so it's like a wider, wider team. So I'm like one little feeding part of that. We had last year around 500 patients with diabetes in pregnancy. And for context, the majority of those had gestational diabetes, which I'll talk a little bit about later, we had around 400 People with gestational diabetes, which are shortened to GDM and just under 100 with pre gestational diabetes. Now what that means is they've already got diabetes when they went into their pregnancy. So most commonly that is type one and type two. So I'm kind of providing antenatal education sessions for these families, those families that want it obviously, it's not a it's not a mandatory thing. Nobody has to come along. And I do these at the moment, one to one via teams, or phone or email, whatever suits the person and sometimes one to one as well. In antenatal clinic. And we discussed their feelings about feeding, about breastfeeding, formula feeding, mix feeding and talk about their hopes and concerns. There's a lot of focus on antenatal hand expressing which again, I can go into detail on later then how to get feeding off to good starts and sources of support and information, how breastfeeding works postnatally I try where possible to support with feeding but because of my limited hours, that's very difficult. So I kind of rely on my original team, my infant feeding team that I work with who very much support with popping into see people that I've been supporting antenatally if I can't do it myself around complex feeding issues, responsive parenting, but really importantly, it's not just about breastfeeding. We support with mixed feeding, exclusive pumping, responsive formula feeding and signposting. So yeah, we try to cover as much as possible and in the future. I'm hoping to be able to do more like bigger group, antenatal sessions, and perhaps sort of webinars and things and information sessions for staff as well.
Emma Pickett 04:52
So what you're describing I mean, with the NHS, there's always a limit to what you can do. Obviously it'd be great if this was a full time postnatal support position alongside antenatal education, you know that but it does not. You're doing a really good job of offering parents a lot of support it How does this compare to care kind of offered around the UK? Is there a sort of standard for UK support when it comes to diabetes and pregnancy and knowledge about infant feeding?
Lucy Lowe 05:15
Yeah. So the national approach is led by nice, and also the Royal College of Obstetricians and Gynaecologists guidelines, this is relatively limited in detail. So for example, the Royal College of Obstetricians and Gynaecologists state that breastfeeding is safe, if you have diabetes, gestational diabetes, and that your healthcare team will support you with feeding your baby.
Emma Pickett 05:41
That phrase breastfeeding is safe. It's not exactly, you know, glitter and bells and whistles and enthusiasm is it's about the least enthusiastic statement you could possibly give. Okay, fair enough, that they're gonna be cautious.
Lucy Lowe 05:55
Yeah. And then the nice guidelines are this is led by the diabetes in pregnancy, of 2015. The guidance, their, their guidance is around feeding, again, feeding is okay, and you feed within 30 minutes of birth, and then ideally every two to three hours. And to help stabilise the blood glucose to help them stay in range for the for the newborn, the person should stay in hospital for at least 24 hours after birth for monitoring. Breastfeeding should be mentioned at booking. So that's kind of your early appointment, and then at 38 weeks, mainly relating to blood glucose monitoring. But for our our service, we want to go above and beyond this to support the families in our area. So in terms of other units, it's tricky to know exactly. But from having reached out to other units, several do seem to have feeding support, which is excellent for those with diabetes. However, it would seem that having a formal service is the exception rather than sort of the rule. There has been other units. So for example, shell banks ibclc in her unit, she did some research some years back around colostrum banking antenatally with families who have diabetes, so that was really, really good. But you know, I think these these projects are relatively sparse.
Emma Pickett 07:20
Okay. Not a word I would want to associate it with something that's so important. I mean, what you're doing sounds crucial. But let's go into a bit more detail about about what you're actually doing. So I've got no embarrassment and asking the really dumb questions. What is diabetes? Something about your pancreas not working something about insulin? Can you give us the sort of layman's definition of what diabetes actually as?
Lucy Lowe 07:43
Yeah, I mean, I need the layman's definition as well really, because obviously, I've come into this as a feeding specialist, not a not a diabetes specialist, or a doctor or a nurse. So So what causes diabetes, so in, in all diabetes, there is too much glucose in the blood. And we get glucose when our body breaks down the carbohydrates we consume, and that glucose is released into the blood. So when you don't have diabetes, the pancreas senses this glucose, that it's entered the bloodstream and releases the correct amount of insulin. So the glucose can get into the cells, it's helping you to sort of manage the levels of the glucose, and so that the glucose can get into the cells to fuel as as it should. Okay, but in diabetes, that doesn't happen. So there's two most common types, there's type one and type two. Type one is caused by the pancreas not producing insulin at all. So these people need to take insulin every day to keep their glucose levels in a target range, and also dietary measures around counting carbohydrates. And this condition isn't linked with age or weight. With type two, there's a common misconception that it is a result of poor diets. But often genetics are more relevant. And Other factors include certain ethnic groups have a higher chance of developing Type two arrays, BMI does increase that risk as well. And having reduced exercise. And this type two affects how the body uses the sugar for energy and it stops the body from using insulin properly, which leads to high blood glucose levels if not treated, and it is linked with other diseases kind of further down the line. And glucose tends to be controlled, like the levels tend to be maintained with diet or a combination of diet and medication.
Emma Pickett 09:47
Okay, so some people with type two aren't necessarily taking insulin. They don't necessarily need to take daily and
Lucy Lowe 09:52
yeah, sometimes it's just diet controlled is is my impression is that that is the first line of defence is let's try and manage this so with diet first.
Emma Pickett 10:01
and obviously, you just talked about how the majority of people in your care have gestational diabetes. So that's diabetes developing and pregnancy. What's going on there?
Lucy Lowe 10:11
So, gestational diabetes is having a high blood glucose that develops during pregnancy. And insulin is a really important hormone in pregnancy, with the body can't produce enough insulin to meet the extra demand that pregnancy puts the body under. And the body is less sensitive to insulin. And so gestational diabetes presents similarly to type two. And it's more common in the second and the third trimester. And it usually disappears after birth, so kind of pretty much straightaway, but leaves people with a higher risk of developing type two in the future, and increases the risk of developing other metabolic and cardiovascular disorders later in life for both parent and baby.
Emma Pickett 10:59
I'm more likely to get it for our next pregnancy. If you've had it for one pregnancy, is it more likely?
Lucy Lowe 11:02
Yeah, yeah. So that would be a red flag for it happening again. And globally. gdM, the prevalence is around 13%. According to some data from 2019, if the condition is detected early and well managed, then the risks for the parent and the baby are very much reduced. Some of the risks of the condition can include the baby growing larger than, than is kind of optimal, which can increase the chance of birth difficulties and having to have baby early preterm birth is more common by about five times in this situation.
Emma Pickett 11:42
I mean, that's that, that sounds scary, but presumably, five times could be, you know, less than 1% to 5% sort of stuff.
Lucy Lowe 11:49
Yeah, exactly. And we're talking about, you know, if it what we're wanting is for, for this, you know, the system now works very, very well to detect it early and manage manage things early. So with the support of all the teams that that exist, you know, that helps people to manage to understand and manage the condition which which, you know, really reduces these these risk factors.
Emma Pickett 12:13
Okay. So why is it really important that that parents or mothers who've got diabetes and pregnancy are supported with breastfeeding? Why do you think that that matters?
Lucy Lowe 12:23
So breastfeeding support is really, really important for these parents and their babies when a parent has diabetes, because statistically, the research does show us that these families are less likely to initiate and sustain breastfeeding, yet they have additional risk factors for kind of different health outcomes for them that breastfeeding can help ameliorate. So they of course receive all the benefits that parents without diabetes and their babies receive. But because GDM and other diabetes put them at risk of other conditions. So for example, with GDM, there's a high conversion rate of having GDM you're much more likely to to end up having type two diabetes later down the line. But actually, breastfeeding helps reduce this chance very significantly. And when supported, the breastfeeding outcomes for families of diabetes are hugely improved. So there was a study last year by Cummings and colleagues, and they looked at nearly 2000 papers on positive on factors that positively influence in hospital exclusive breastfeeding rates with parents with gestational diabetes. And they suggested that there is a need to develop additional education, educational and support interventions that are tailored specifically to women with gestational diabetes, and antenatal and postnatal support that addresses, parents fears and specific needs are really required to strengthen their intention and confidence to exclusively breastfeed. And I think intention and confidence seems to be words that come up a lot in the research around breastfeeding. Support is also really important for these parents because because of the condition, it is more likely that they could have a bit of a delay with their milk, kind of what we kind of call coming in, but basically their milk transitioning from their first milk, that early milk, they're colostrum, transitioning to the later milk, which is sometimes called mature milk. And there can be a bit of a delay with that of around 24 hours. But a really important thing too, that I want sort of to impart is that often a question comes up from parents is around worrying that their baby is going to have diabetes straightaway when they're born because the parent has diabetes. But it's important to reassure people that it is very rare for babies to develop diabetes, having type one In order to, or gestational diabetes doesn't increase their risk whilst they're a baby, but having a close relative can increase that risk in for in the future. But we know that supporting families to breastfeed or to reach that those breastfeeding goals can really help with that.
Emma Pickett 15:20
Yeah, so that can reduce the risk of the child developing diabetes, so, so not only are we reducing the risk of a parent with gestational diabetes, developing type two, we're potentially reducing the risk of the baby developing diabetes later in life as well. So you can see how important breastfeeding support is, and therefore that word sparse that you used a few minutes ago, it's bananas that not every single hospital in the UK has got a feeding support team. I mean, what if somebody has gestational diabetes, and that changes into type two diabetes later in life? That's a huge burden on the NHS, you'd think that they'd really want to prioritise feeding support for those parents?
Lucy Lowe 15:54
Yeah, absolutely. I mean, it's, it's something that in years to come, you know, it potentially, it's just, it's just absolutely hugely needed. And I feel so passionate about it. It's something that we really need families, because what we want is people to be able to make an informed choice about how they feed their babies to have that antenatal education is, so it's just so crucial. And we want people to feel confident in what whatever way they choose to feed their baby.
Emma Pickett 16:23
Yeah. How does diabetes actually affect lactation? How does it and this analysis might be getting a bit technical, but let's imagine somebody has type one diabetes? How would that affect their their, like, sort of lactation experience?
Lucy Lowe 16:37
Yeah, well, initially, if it's okay, I'll just mention kind of generally how it affects because there are some things that are very much kind of relate to people just having diabetes as a whole kind of almost irrespective of the type, but I will talk about the type. So it is really important, though, to this to sort of be you know, to mention that, although I am discussing some barriers for parents of diabetes, that parents with diabetes can really successfully breastfeed when supported to manage their condition and keep their blood glucose within target ranges during the pregnancy. And also antenatal feeding education is hugely important here. So I don't want to kind of sound like I'm just talking about the barriers and the negatives, okay, that are rarely data from the support we've been providing shows that those who have diabetes who are supported to breastfeed in the early days actually continue to breastfeed for longer than our general population, which are just, you know, don't have diabetes, who may receive less support. And certainly, the research backs this up that early, an extra lactation support and monitoring can really support these families. Research shows, it's kind of going a bit bit back into the biology of, of what goes on. Anything that affects the control of the endocrine system has the capacity to affect milk production. And insulin dysregulation also has the potential to impact milk production and the breast development. Therefore, diabetes is a risk factor for having less than optimal milk production. And this insulin resistance is linked with challenges in that initiation and sustaining of lactation. And irrespective of the diabetes type, these families are less likely to initiate without good information and specific support. So again, it just really backs up why this is absolutely crucial for services to be providing this support. Because we want those families that want to breastfeed to be able to reach their goals, we do have some sort of information on the the duration of breastfeeding. So in terms of how, how diabetes can impact on lactation. So the duration of breastfeeding can be negatively impacted by the severity of the diabetes. So again, if it's well manage, you know, there's good support systems around people in, in pregnancy that can really help as well with getting feeding being in a more positive situation. Both mother and baby or parent and baby can experience low blood glucose after birth, so they should be monitored. And so that's, that's a way that diabetes kind of can impact on lactation as well, because they need that extra monitoring. Sometimes that can make the feeding experience a little bit more stressful, and means that they're more likely to have feeding interventions or the need for supplementation. And so that can impact on on breastfeeding, in terms of specifically gestational diabetes and lactation. a really positive impact of breastfeeding after gestational diabetes is that although people have gestational diabetes have a high risk of having type two in the future, the longer they lactation period the research shows the lower the type two risks so more specifically, the chance of type two for people with GDM is reduced by 25%. If they lactate for six months or less, and by 47%, when lactating for six months or more, which, you know, is a big is a big number. Yeah, yeah. And so there can be an impact for the baby on feeding. So again, we need to support these families to kind of reduce the chance of these things happening. There's sometimes if parents have had to have insulin treatment during their pregnancy for their diabetes, the babies have a less mature sucking pattern and don't remove No, because effectively is that unaffected counterparts. So again, having that specialists support can really help with that.
Emma Pickett 20:46
Gosh, I didn't know about that, loosely. What so what's the what's the cause of that?
Lucy Lowe 20:50
Well, yeah, I mean, we were discussing this recently trying to kind of unpick, whether that is more, it's not so much the medication perhaps, but more the fact that the person needed medication because of the severity of the condition. So it's a really tricky one. I mean, I would say that a lots of people with gestational diabetes actually don't need to have the insulin, a lot of people I meet are diet controlled. And again, that early intervention is really important, because that can support people to have, you know, not such a challenging time without gestational diabetes and impacting on the baby.
Emma Pickett 21:26
You mentioned earlier that we want to make sure that babies feed quickly after birth, so that within that half an hour, we're hoping to get that breastfeed for happening happening, I'm guessing that's about that's about increasing the blood sugar for those babies that that will need it and reduce the risk of supplementation. I don't know whether you know anything more about this, but it's my understanding that if a baby has cow's milk, protein gawk formula, very early on, they could potentially be at greater risk of going on to develop diabetes. And that's one reason why we try and reduce that need for formula supplementation in the very early days in a diabetic situation. Is that something that you're...?
Lucy Lowe 22:03
Yeah, yeah, definitely. And this is another reason why we very much want babies to feed early after birth, alongside them having a higher risk of having that low blood glucose. But yes, avoiding the introduction of cow's milk protein, at an early age can be really crucial, as well, doing anti natal hand expressing is something which is very, very much promoted in our trust. Because if a baby does need a little bit of extra of their parents milk, then at least if they've done some antenatal hand expressing, they have a little bit to give them, and they can do hand expressing then and there. But also, even if they, you know, and I always try to reassure the families that I work with is even if you don't manage to get any colostrum antenatally, don't panic, you've learned the skill that you might get asked to use when you use when you've just given birth. And actually knowing that skill, straight after birth can really help. Rather than having that sort of panic of oh, your baby needs to feed quickly get hand expressing, if they already know how to do it, they're in a much better position.
Emma Pickett 23:10
I'm glad you mentioned that actually list because I've worked with some parents who don't seem to get anything and they do antenatal expression and a huge knock to their confidence right at a time when they their confidence is really precious. And they say, oh my god, that must mean I'm not gonna have any milk. That must mean I'm going to have milk supply problems. There is definitely a small group of people. And I think it's everybody but a significant minority who cannot get anything out when they do antenatal hand expression. That doesn't mean that something horrible is happening. There's just their bodies just going Nope, we're not releasing this right now. Can you just talk us through the practicalities of hand expression? If you're having a sort of one to one with a parent, when do you advise they start? How do you advise they sort of go about doing it?
Lucy Lowe 23:48
So what I would say is, I think my just backtracking slightly, my understanding is that around 20% of people that try to antenatally hand Express don't manage to get anything. My take on it is I always say to families, please do not worry, firstly, don't give up straightaway. Because actually, almost the pressure and the stress and having those little syringes there can make you feel like, oh my god, oh my God, I've got to get this milk out. So I tried to say to people, listen, don't even have the syringes there. Please don't have any syringes with you the first few times, maybe just go into the shower and do it. Don't worry about losing any it's not a loss. It's you working on it. And if you don't get anything those first few times, don't worry, keep you know, keep going if you can, because actually after a while, lots of people do find and I reassure them by saying your colostrum is there, you're making it from around 16 to 20 weeks gestation. The issue is getting it out. It's the learning that skill to help your body release it. But yeah, in terms of the kind of practicalities what we suggest is that it is safe. We know from a research study called the dame study several years ago, that it is safe to antenatally hand Express if you have diabetes from 36 weeks gestation. So for our families, we are suggesting, we actually suggest it to tool families that wants to and have other that have other risk factors for kind of feeding, maybe having more challenges. But for these these families of diabetes, we have we say 36 weeks learning to hand hand Express and to try to do that maybe two to three times a day, and start with a few minutes and build up a little bit. And we provide them with labels so that they can label their their clinic cluster and they get storage information on how to freeze and how to safely transport to the hospital when they come to give birth and the syringes. So that sort of how to guide and recently, in fact, last week, I've just made a video with my colleague on how to do antenatal hand expressing and why we suggest it so hopefully that will be released soon which will be be provided to all our patients. So that it just kind of gives them a bit more of a how to guide.
Emma Pickett 26:12
Brilliant and if that does become available but before the podcast goes out maybe we could put a link in our show notes. Do you have any other sort of favourite hand expressing resources that you you signpost parents to?
Lucy Lowe 26:23
So, I often signpost to the UNICEF hand expressing one that also just warn people that the person that is hand expressing has already had their baby so they're they're getting a lot more than I would expect you to so I don't want them to think they're going to have all this gushing milk but that
Emma Pickett 26:40
yes, we're not gushing antinatally - single drops of slurping up single drops. Coming up to that point about syringes. There was a little wobble recently about people feeding their baby via syringe and someone forgot to take the stopper off the end and, and sadly, baby was at risk. I hope nothing horrible happen to that baby. But it was definitely a scary moment. So what do you say about giving the colostrum after the baby's born?
Lucy Lowe 27:04
Well, we're, yeah, I mean, we're having to change our syringes in light of the current sort of situation around those syringes. But yeah, we just saying ring a bell, ask for support, come and come and ask your staff, we need to take off the little cap on the end. And we tend to finger feed any colostrum. So getting baby to suck, clean finger gloved finger, if it's the healthcare professional, and just gently putting the syringe into the into the mouth and just gently giving that as baby sucks.
Emma Pickett 27:39
Okay, so you're feeling the suck on the finger. You're sensing that the baby's sucking and you're rewarding that sucking with a gentle little trickle in the corner of the mouth. We're not squirting dental little trickle in the corner of the mouth. The baby's actively involved. Yeah, yeah. But probably if breastfeeding is going well. The parent may not use their syringes. I mean, do you ever say to parents, if you haven't used your colostrum syringes? That may be a positive rather than a negative? What do you say to people that they say? Oh, do I have to give it I want to waste it? I mean, yeah, I'm a bit worried that some people feel they have to give it so you know, day one, they're giving all these syringes and not actually breastfeeding?
Lucy Lowe 28:13
Yeah, I think, I think yeah, I mean, I just say it's totally up to you, you can give it as a as a sort of extra, if you wish to. But equally Don't, don't have to. However, I would say that often it's worth just giving that if you've got if you've got a syringe and a half that you've managed, or half a syringe antenatally in a way, why not give it as long as it's not replacing a feed, which would then be replacing breasts, you know, stimulation in those early days. And because we want every opportunity for that. And also I say to people, if you are somebody who is finding that hand expressing is going well, kind of ignore the ignore the syringes and do it into a sterile container, because I find that the syringes very much slow down the process, but keep people squeezed, they see a drop, they're not keeping the rhythm going. So we're actually doing it into a glass container, like a little, like an egg cup that's been sterilised for example, and then drawing it up in the syringe can be a really good technique. We were talking about how does the diabetes affect the lactation and I didn't mention anything about specifically about type one that I just wanted to mention if that's okay. With type one diabetes, what I do you kind of you know, is important to know that, that breastfeeding, you know, that the diabetes isn't going to go after after you've given birth like it does have gestational diabetes and and breastfeeding does use up energy. And because breast milk contains lactose, which is a form of sugar, so if the parent with type one is on insulin, they do need to seek their health care providers support just because they might need to tweak their insulin doses to ensure that you know, they've got the right balance there. Because some parents do find that whether they're breastfeeding or expressing, when they have type one diabetes that can that can cause a low, they can get get a bit of hyperglycemia. So like low blood glucose. So they it's really important to have have kind of carb containing snacks around you. Some research suggests specifically important overnights, others say more is just general, you know, snacks in general is very, very good. And I think there's, there's never, you know, it's great to have lots of snacks around you when you're breastfeeding, isn't it?
Emma Pickett 30:38
Little snack stations very important. Just to come back to somebody with gestational diabetes. I mean, yeah. How do people find out they have gestational diabetes? And what's this glucose tolerance test that we hear people having in pregnancy?
Lucy Lowe 30:51
At your first antenatal appointment. So what's often called your booklet appointment, which is around eight to 12 weeks. If the person has one or more risk factor for gestational diabetes, then they are offered a screening test called an oral oral glucose tolerance test. And so GTT and this is a fasting blood test, which they have in the morning having not eaten or drank for eight to 10 hours. And they are given a glucose drink. And they have to drink a set amount and then rest for two hours and then have another blue, another blood sample taken.
Emma Pickett 31:30
So that's not that's normally happening in any clinic, is it so people are going into a clinic drinking a drink sitting being incredibly bored for two hours having another test? And that's that's the sort of typical experience. And that's, and that happens, just because they have a risk factor or they're looking at symptoms as well.
Lucy Lowe 31:46
Yeah, I mean, obviously, if they had symptoms, then it would be looked into, but it's initially on those those risk factors in the early days. And then if they are found to have gestational diabetes for the family is supported to manage the condition and kind of understand the condition and understand the possible complications. Parents are given a blood glucose testing kits to monitor the effects of their treatment or diets, depending on kind of what pathway they're needing to take with them. And they're shown how to use that and what levels to aim for. So dietary changes are suggested.
Emma Pickett 32:25
So that would mean less sugar, less carbohydrates that can change into sugar. What what sort of dietary changes are happening?
Lucy Lowe 32:32
So some of it is around kind of thinking about the having maybe like lower glycemic index foods, so kind of to do with your your carbohydrate intake, increasing the ratio of your vegetables on your plate versus your carbs, and sometimes around timings as well. Again, I'm not an expert in this area, but I have sat in with some of the dietitians in these appointments just to learn more information and listen to the midwives talking to people. And there is stuff about timings as well. And also taking regular exercise. You know, just increasing the amount you walk each week can really help as well with keeping those glucose levels in a range that that is healthy for that person. If these measures don't adequately change their blood glucose then medicine would be required. The parents would GDM are very closely monitored during pregnancy and birth. And induction of labour or section may be offered if Labour doesn't start naturally by 41 weeks. And this is in line with national guidance.
Emma Pickett 33:45
So is that the worry that the baby's big again, the baby so the baby may take more glucose into their bloodstream, which may then make them bigger and larger. And that's not so good. We're worried about that.
Lucy Lowe 33:56
Yeah. And sometimes, you know, there might be other things going on as well. It might be too small, but it might be yes, it's not always too big. Okay, so yeah, those sort of other risk factors around it. So those extra scans, extra consultant appointments are really really important and having the support of our diabetes specialist midwives are absolutely amazing, very passionate group of midwives and they're in regular touch with all of the all of our patients no matter the type of diabetes and having close contact with them to sort of tweak things really just to try and keep people as well as possible. Yeah, yeah this they have these regular appointments and then then they've always been there offered the opportunity around 28 weeks, they hear from me to give them the opportunity to get in contact with me so as I say I'm not a mandatory part of it have to come talk to me about feeding but they're very very welcome to.
Emma Pickett 34:57
Okay, so I'm I'm imagining that some people may come to you that diagnosed with with gestational diabetes and they're really scared that that's going to mean that they don't get the birth that they want that they're going to be pressured to induce they might have instrumental deliveries. People are worried about the size of the baby. That might mean they can't go to the birth centre or they might be frightened about well, what happens if my baby doesn't feed in the first half hour? What happens if I'm being pressured to give supplementation? If I've got to think about antenatal expression, there's it's quite scary imagined for some parents. So what do you what do you say in that first conversation? If someone phoned you and they were really nervous about breastfeeding being impacted by gestational diabetes? What would you want them to know?
Lucy Lowe 35:37
Well, firstly, is trite to say don't worry, because you aren't going to be in that situation, you know, we'll have times in our pregnancies which we, you know, can be really, really challenging. And it's a very, very difficult thing. What I would say is, the support is there for you. So making sure that you're in touch with your diabetes specialist midwives, because they're really there to support you and ask any questions, there isn't such a thing as a silly question. You know, we've all had all the questions before, and it really really doesn't matter, it's important that you feel confident going forward, and that we're here to support you to have a healthy pregnancy. And it's really, really important that you feel informed, because that is the best situation for you to be in is to be informed about your condition, the possible complications, because I think sometimes people can shy away from letting people know about complications. But actually, if people understand better they can they can make more informed choices, can't they? There's websites that can help this a Diabetes UK website, the NHS website, but when I'm I mean, I'm talking to them more specifically around feeding obviously, rather than their actual condition. But what I tend to do is just find out from them, you know, how they're feeling about feeding, you know, what are their ideals? What are their goals? And do they know anybody know, if they're saying to me that they really want to breastfeed? Asking them? Do they know anybody that's breastfed before? Do they have any support around them? Have they looked into breastfeeding? Sometimes it's a case of it being not their first baby, maybe they've formula fed previously, or they've breastfed before, but perhaps it didn't go to plan. Other people might have fed for ages. It's just very varied as to the type of person that you know I'm speaking to, but I very much try to tailor the support I'm giving to the individual so that I'm not so that I'm taking on board kind of what their their individual circumstances are their individual goals. And, yeah, ensuring I'm being kind of as user led as possible. And what I tend to discuss with families, if they're happy for me, too, is kind of how to get breastfeeding off to a good start. Because we know that there are these certain risk factors when you've got diabetes around delayed lactation, for example. So although I can't promise that I can take that away, we can try to do things to reduce the chance of that happening. So first and foremost, antenatal hand expressing, go through all of that, send them a pack and videos and things and stay in touch with them if they've got any questions. Sometimes people email me and say, I didn't get anything yesterday, any extra tips? We talked about skin to skin a lot. That's my kind of key thing, because the research shows that having skin to skin with your baby. I mean, it's amazing for all babies, but when we're talking here about babies that are born to people with diabetes, it really helps to regulate their their blood glucose. And I think people think I'm a bit you know, just crazy when I say that, because it doesn't mean the babies eaten anything, but actually we know the science tells us that skin to skin stabilises a baby's blood glucose or temperature, their heart rate their respirations. So for them skin skin is great. There's a really amazing and I can't remember the name of the researcher, but they did some research recently and said the key things for for parents who have diabetes is that early skin to skin and early feeding, because that is keeping those babies well. And much reducing their chance of having a low, low glucose, low temperature, anything that increases their chance of having to go to neonatal, you know, for an extra check and things like that and keeping mum and baby together which is so, so crucial.
Emma Pickett 39:36
So keeping babies warm is really key, isn't it?
Lucy Lowe 39:39
Yeah, is really, really important. Keeping babies fed. So what I say to them is, you know, we have to be a little bit more cautious with you and your baby and I'm sorry that that is the situation but we're doing it because because we know we care and we want the best for you. So we do suggest that you stay in for 20 For at least 24 hours after birth, but take use that as an opportunity to ask for support with feeding. Rather than seeing as a barrier of barrier to getting home. Think of it as actually, I've got people that are trained to support with feeding at the end of a bell. I'll ring them and say, can you come and see I've just left my baby, you know, would you say this is okay? And all of this and go through feeding with them. So we're wanting babies. So I sort of prepare families around needing to feed every two to three hours after that first feed and the first half an hour if baby doesn't have a feed in the first half an hour. Okay, no panic, let's think Have we got any antenatal hand Express colostrum, great, if we have, we'll give it. But if we give that we still need to express in that first early period, because that really sets the tone for supply later down the line. And keep supporting the family with the physical act of breastfeeding as well. So encouraging that skin to skin, I always talk to them about, you know, the scenario where baby does have a low glucose, because I think it's really important for people for us not to shy away from that eventuality is actually very rare, you know, the vast majority of times, you know, I reassure people, most babies are absolutely fine, and their blood sugar is absolutely fine. But their blood glucose will be checked before their second feed, and their third feed, no matter how they're feeding their baby, just to check that it's in range. If it's not, we're not going to panic, we have guidelines to help us cope with all of these situations. So don't panic, we've seen it before, what we're going to do is try to get your baby feeding, if baby doesn't feed for whatever reason. So they're sleepy or whatever, they're a bit, you know, not wanting to latch at that time, we're gonna give them any of your costume that we can. If that's not possible, then we have another procedure, which is to give dextrose gel in the cheek of the baby. And invariably, this all this all helps, but don't worry, we've got measures if the all of these things didn't work. So trying to reassure families and talking about, I'm probably a bit more of a cautious person. So I suggest to people if they feel able to, even if you feel like feedings going really well, there's nothing wrong with doing some additional hand expressing if you want to, I think because I know and I see it day in day out that there can be can be those extra challenges. I kind of feel like why not, if you've got the energy to do a bit of extra hand expressing and a bit of extra giving, giving of colostrum. Let's just go for it just as kind of a backup safety, you know, in that first 24 hours.
Emma Pickett 42:46
And presumably the parent has given birth also being monitored to see what's happening with their diabetes. I mean, this may not be your department because this could be the specialist midwives. But when do we know if someone's looking like they're tipping into type two diabetes? They're they're monitored for several weeks are they post birth?
Lucy Lowe 43:04
No, they're not. So so what happens is after birth, if you've had gestational diabetes, that first 24 hours alongside your baby being monitored, which I should say, if I had didn't say already is done by the bedside, we're not going to separate mum and baby to do this, you know, they can be on on mom's skin skin and have their temperature change taken their risks check. So I don't want people to think their baby's going to be like taken away. So she will do. It's just a few random blood glucose checks in the first 24 hours, normally around three, so they're just asked to do three random blood glucose checks and and if they're in range, then invariably, absolutely fine in range. If they're not the dot, you know, the diabetes team would come and have a chat with them. So after that point, what happens is they go between around six weeks and 12 weeks, they have a check with a GP for type two diabetes. And they then yearly have a check for type two diabetes blood test.
Emma Pickett 44:09
Okay, so we've talked about the phone call with the person with gestational diabetes. Let's imagine you've got a phone call with somebody who's got type one diabetes, and they're saying, let's talk about breastfeeding. Honestly sounds like a bit of a faff to breastfeed and have diabetes. Maybe it's more complicated if I breastfeed because I've got a constant worry about my diet and my sugar levels. And is it easier not to breastfeed? I mean, what sort of things do you say in that conversation, if someone's asking you about breastfeeding with type 1?
Lucy Lowe 44:35
A lot of the bulk of my conversations are very similar irrespective of the type because we're still talking about that hand expressing skin to skin I didn't mention before but you know, just other tips that I give around frequent feeding knowing that baby's getting enough and send them videos on positioning attachment, and I always link families irrespective of diabetes type two the ABM team baby course because I'm Fortunately, there isn't a lot of antenatal education available around feeding that is free. But we know this is free. And I have the I have the consent of the ABM to be sharing this to all of the patients that I see.
Emma Pickett 45:13
No definitely. I was, I was one of the people involved in developing your course. So I'm very happy that you're using it certainly free for anybody. So I'll put that link in the show notes.
Lucy Lowe 45:22
Absolutely. I mean, it's just brilliant. So yeah, and certainly patients that I speak to very much say, I really enjoyed that course, etc. So yeah, we're talking about how to get feeding off to a good start and kind of rooming in with your baby hang that 24/7 time with them trying to put visitors off and things like that. But in terms of your question around someone with type one specifically, in addition to all of those other things, we're talking about, encouraging them to take time to talk to their care team around any concerns they have around their diabetes, because I'm not in a position to advise on that. But I want to find out from them, you know, try to try to provide some, some sort of compassionate support around listening skills there really, to build that rapport or find out from them, what is concerning them, and really listened to them. It could be they've had a previous negative experience of feeding or people around them don't breastfeed. So for them, it's not common. And I try to listen to kind of what's going on and troubleshoot as well for them. So not jumping in with my practical solutions, but think about how breastfeeding might work best for them. And it might be that they don't actually want to fully breastfeed, they might want to mix feed, and that's fine. And we'll talk about how to do that. And I'll signpost them to excellent books like Lucy Ruddle's, great book on combination feeding. But really importantly, they need to know they don't need to make a decision in pregnancy. And that's a really big tenant of the UNICEF breastfeeding friendly initiative kind of basis is that we don't want to be pushing people to make a set decision in pregnancy, let them meet their baby, let them let them have that first moment with them. It doesn't have to be black and white. Yeah, we're giving them that option of of, of what they want to do and being led by them, but reminding them that every drop counts. So anything that they do give of breast milk is amazing. Lots and lots of lots of people with type one really, really wants to to breastfeed in my experience. So providing them my top tips around getting breastfeeding off to a good start, but making an extra mention around the milk using that energy and then needing to kind of maybe check their blood glucose more, perhaps before and after a fee just to check that their glucose levels are in good range. And if they they might need to speak to their health care provider to tweak their insulin dose. And for some type, for top type ones, typically, it's around between six and 10. For some it might be six to 12, their blood glucose levels. And also having snacks around them looking after yourself and getting supporting is really key. So I tend to talk to them about, you know, if they have a partner has a partner feeling about feeding, are they supportive? Do you have any family around you that's going to stock up your freezer for you. So you can just be with your baby, establishing feeding. Yeah. And if they're feeling overwhelmed, reach out to the health care providers and talk about the breastfeeding helplines and local support that's available to them.
Emma Pickett 48:33
I think one thing I would probably say I'm not saying this is what you should say in these conversations. But I guess some general themes that I would hope that they would receive through their education is that breastfeeding isn't necessarily more complicated. In fact, some people find that diabetes is easier to manage when they're breastfeeding, and their insulin need reduces. Yeah, and actually, if you've got to get up in the middle of the night, and you've got to make bottles and you've got to walk around the house making bottles and you know, there's there are other stresses on you, that may not necessarily be super easy if you're not breastfeeding. And potentially, you know, the the benefits of for your baby in terms of reducing their diabetes risk is something that feels particularly important to you. And I think there's, there's one really simple myth that let's dispel it Now people think I'm gonna have my milk is gonna be not as good, my milk will have too much glucose in it my milk, you know, and that's not even a thing. So the sugar levels in human milk are pretty static, whether or not someone has diabetes, that your milk is not going to be not as good because you have diabetes.
Lucy Lowe 49:29
Absolutely not. It's it's, it's a huge benefit to your baby. If it's if it's the way you feel you would like to feed your baby, then brilliant. We're going to support you to do that. Yeah, absolutely. The benefits certainly I discussed with them around benefits for them and for their baby and just trying to work out for them how how things can be the best they can be for them. Another really important thing to say and again, this is irrespective of diabetes type is that one thing we found really, really brilliant And in our trust so far is I often speak with families that are very uncertain about breastfeeding. And perhaps they hadn't breastfed before they formula fed before, but now they've got gestational diabetes. And people are saying to them, Well, have you thought about breastfeeding? So they want to explore it, that I mean, many people that say, I definitely want to formula feed, and that's absolutely fine. But what we are doing a lot of is just talking around, how would you feel about doing some anti natal hand expressing and giving that first feeders, colostrum and explaining why we're suggesting that? And actually, we're having really, really, really good outcomes for that at the moment we're finding, since we've been doing the project that the the first feed for people with diabetes is really, really high if the first feeders are breastfeed, even in those not necessarily intending to breastfeed long term. So that's always an option for people as well.
Emma Pickett 50:55
That's great. Since you've been doing the project, you I'm guessing you've done a lot of learning and a short, intense period of time, what are some of the sort of key things that have really struck you since you've been doing the project?
Lucy Lowe 51:05
Yeah, well, I mean, I've learned a lot from a biological point of view, and management of this sort of condition point of view, the impact of, of the condition on people's lives. And it's just, it's just fascinating. And I have so so much more to learn. I certainly don't feel like an expert in this at all at this stage. One really, really key thing, which isn't actually anything to do with feeding, but it's really important point that I wanted to mention was, is around language and how much language matters. You know, the term diabetic is not really, it's not really an okay term, like we it's not something that we use, we say, parent with diabetes, because they're not just diabetes, they're not it's like any, like any condition, you you know, you wouldn't say to somebody that had schizophrenia, for example, you're schizophrenic, you say this is a person that has or experiences schizophrenia. So the language is really, really, really important for families, there's a really good article, which I'll link to is quite a quite a long paper, which is called language matters. And that talks about professional and it's all to do with diabetes. Another thing that I've learned is how much you know, I knew that specialists infant feeding support would help, I kind of just knew that. But to actually see that what we found is support provided by us how much more likely a baby is to receive breast milk as their first feed. And that exclusive breastfeeding rates on transfer from the hospital to home are greater in those that are supported by us. And that any form of breast milk, so if they're going home mix feeding is still really high. So about 14% of our service users are more likely to be giving some breast milk than those that are not supported. And when they are leaving our care from the community midwifery team and handing over to Health Visiting team, the exclusive breastfeeding rate and receiving end or receiving any amount of breast milk at Community midwife discharge is significantly higher than either the general population or those with diabetes that weren't supported by us. So you know, there's just so much that we've, that we're learning and we're trying to tweak as we go along.
Emma Pickett 53:34
Yeah, well, that's That's great to hear. And and long may it continue. If you sort of had Five minutes with every single person in the country that works antenatally or with new families, what would you want them to know? What are your headlines?
Lucy Lowe 53:45
Oh, wow, headlines, I'm not very good at headlines. I'm quite a detail person, but I will try my best. Okay. So specific anti natal feeding support is really, really, really needed. So education around feeding is really, really needed for people to make an informed decision. And we all have a role to play as feeding advocates. So getting, you know, for example, getting people that are pregnant along to breastfeeding cafe's would be really great with that education and sharing information on why breastfeeding is beneficial to enable informed choice. Because the perceived benefits of breastfeeding have been shown in research to be a really important factor that's associated with breastfeeding duration. And we as professionals have a duty of care to provide evidence based information, really want people to actively listen and have empathy and allow people to debrief previous feeding experiences. Because that can really open up the opportunity for them to consider breastfeeding for their current or future pregnancies, really thinking about not forcing people to make a decision about how they're going to feed. So exploring these opportunities What's really important is the research shows that when pregnant we have, we have a greater right brain dominance. So that's like your intuitive part, your subjective part than the left side, which is more analytical and objective. And this increases sensitivity to nonverbal communication approaches. So just really being mindful of your communication skills and people when they're pregnant might be a bit less receptive to large volumes of information, or verbal information. So it's good to give that information kind of over different sessions. So that would be sort of ideal and also just providing people with signposting. And I would love for breastfeeding supporters to pass on to families around the practice and practical tips, which would be around anti natal hand expressing, but not just telling them go off and do this, telling them why because people like to do things when they know why they're being suggested. So the importance of colostrum to stabilise blood glucose for their baby, and protecting their baby against diabetes, the laxative effect of colostrum which helps to prevent their baby from having jaundice, which in that cohort of people, jaundice is slightly higher. And then the type two risk for those of gestational diabetes being reduced by 25%, if lactation is six months or less, and 47%, when lactating for six months or more loads of skin to skin had expressing and if if you're supporting a baby, a mum or parent that has babies on NICU and they have had diabetes, then really supporting them with frequent hand expressing, and skin to skin as soon as possible. As soon as this you know, enabled and double electric and hands on pumping is really important for these families to get that supply going. Another another thing is just to just to kind of make people aware that with diabetes, so with type one and type two, these people are at greater risk of having thrush or mastitis, especially if they have high blood glucose. So it's not a kind of like a scare mongering thing. It's just good. Again, informed is best isn't it. And so they can know kind of what to look out for after and tell them around signs and symptoms. So that can be dealt with swiftly. And research specifically highlights that for type. For those with type one, it's advised to ensure that early sustained skin to skin and rooming in and feeding on cue and pumping to stimulate as additional. However, we can do this for all families. So in that first 24 hours, just all of those extra tips, really, and just supporting those families that might be thinking they're definitely not going to breastfeed, just having a gentle conversation around the possibility that they might consider colostrum as their first feed, which could be a really good option for those families.
Emma Pickett 58:02
Yeah, thanks, Lucy. So I know that in in Norwich, you have one of the hubs of the hearts milk bank and one of our trustees, Dr. Gemma Partridge is based at your hospital. Do you come across donor milk being used for babies in NICU with from diabetic moms in particular, is that something you see?
Lucy Lowe 58:18
yeah, so. So Gemma, yes, she is my lovely, lovely, lovely consultant, manager, she kind of helps with my role and is a real advocate for for the project, huge advocate. So we historically have been using donor milk. However, unfortunately, it's not currently available to us, we are hopefully going to be getting donor milk if we can in the future. Because it would make such a huge, huge difference to these these families to have that opportunity where supplements are sometimes needed. If that could be donor milk.
Emma Pickett 58:58
Yeah. So for babies born prematurely, that they would have access to donor milk, but not so full term diabetic and not necessarily. That's definitely an area where I'm sure the Human Milk Foundation will be will be supporting in the future.
Lucy Lowe 59:10
Yeah. And I think I think another point, just briefly is that often are babies that are born to those who have diabetes because of a guidance around the health which is totally right. But the does mean that sometimes they are born a little bit early, but we're talking just a bit early, like maybe 30 is 38 weeks, but actually that does make a difference to feeding and that's something that's important often for parents to know is don't worry, you know, if your baby is that extra bit sleepy, we've you know, we'll take extra measures of doing hand expressing and giving extra colostrum to these babies because sometimes they can be more tricky to kind of get going in those early days. I know our colleague Catherine Stagg sheets, she talks about the great pretenders so these earlier babies that are the, they you know they're absolutely perfect baby and they look like a diddy 41 weeker but actually developmentally they've got a little bit more growing of their brain and their bodies to do so they do need to sleep more.
Emma Pickett 1:00:07
Yeah, actually, I, I nobbled Catherine at the UNICEF Baby Friendly conference in Harrogate. And she kindly agreed to come on the podcast did an episode about those very babies. So Oh, watch this space, it will happen. Thank you very much, Lucy for for all your time. And all your all your thought today. You've mentioned a few resources that we'll put in the show notes. So I'll link to the IBM team baby, you're going to dig out that article for me about language matters, diabetes, UK, any other resources that you think are really important for parents to know?
Lucy Lowe 1:00:35
It is very, very limited actually out there. Unfortunately, there is a nice one en la leche league. And I have recently written a patient information leaflet because of the lack of one's available. So I've written one which is going through the process of the trust approving so as soon as that's approved, I'll send that to you because that will be nationally, available.
Emma Pickett 1:00:57
Brilliant. Thank you so much, Lucy. And if anyone is worried about this subject, reaching out to diabetes team finding out who's in your hospital, asking some questions about who should be in your hospital if you've got the energy to do it, and I think we all need a Lucy in our local hospitals. Somebody who's in it for feeding specialist in this diabetes space. Thank you very much for your time today, Lucy.
Lucy Lowe 1:01:18
Thank you. Thanks so much for having me.
Emma Pickett 1:01:24
Thank you for joining me today. You can find me on Instagram @EmmaPickettIBCLC and on Twitter @MakesMilk. It would be lovely if you subscribed because that helps other people to know I exist. And leaving a review would be great as well. Get in touch if you would like to join me to share your feeding or weaning journey, or if you have any ideas for topics to include in the podcast. This podcast is produced by the lovely Emily Crosby media.
Emma Pickett 1:01:57
One final thing, I have a discount code for my podcast listeners for my last two books, the one on supporting breastfeeding past the first six months and beyond on the one on supporting weaning or the transition from breastfeeding. If you go to the UK Jessica Kingsley press website which is www.uk.jkp.com and put in the code MMPE10. That's mm for makes milk P for Pickett E for Emma 1 0, you'll get a 10% discount on checkout. Thank you.