Gestational Diabetes Mellitus

^{(This comment may apply in whole or in part, to type 1, type 2 and gestational diabetes).}

Given the benefits for mother and infant of breastfeeding, especially in the case of maternal diabetes, it is necessary to encourage breastfeeding and provide all possible effective support. Prestigious scientific institutions and various authors advise this. ^{(ADA 2108, Serrano 2015, Lawrence 2013, Cordero 1998)}

Insulin administration is fully compatible with breastfeeding ^{(Serrano 2015, WHO 2002)}; Acarbose, Glibenclamide or Glyburide, Glipizide, Metformin, Miglitol, Tolbutamide, Exenatide and Liraglutide are considered safe medications during breastfeeding.^{(Serrano 2015)}

The maternal diet poses no problems for breastfeeding or the infant.

The milk of the mother with diabetes has more glucose (0.7mg/cc) than that of women without diabetes (0.3mg/cc) (Butte 1987) but the total caloric content is not affected because glucose is a very minor sugar in breast milk. Some authors have found higher sodium concentration ^{(Butte 1987}), but others have not. ^{(Bitman 1989)}

During lactation, urine glucose tests using dipsticks are not reliable because of lactosuria. In all women, lactose that is reabsorbed from the breast and passes into plasma is excreted in the urine.^{(Lawrence 2016 p 579, Serrano 2015)}

DELAYED MILK RISING (LACTOGENESIS II):

In maternal, type 1 and gestational diabetes, breastfeeding should be initiated early and frequently, as they associate delayed lactogenesis II ^{(Wu 2021, Matias 2014, Hartmann 2001, Neubauer 1993)}, low prolactin levels ^{(Butte 1987)} and lack of adequate milk supply, with lower prevalence and duration of breastfeeding than non-diabetic mothers^{(Riddle 2016, Oza 2015, Finkelstein 2013, Sparud 201, Schoen 2008, Hummel 2007)}, which worsens if there is also poor diabetes control ^{(Neubauer 1993, Ostrom 1993)} or associated smoking. ^{(Knudsen 2008)}

Mothers with gestational diabetes treated with insulin have a higher frequency of delayed milk let-down than those treated with diet and exercise alone. ^{(de Souza 2024, Matias 2014)}

Intensive glycemic control during pregnancy ^{(Golbert 2008)}, effective support and early initiation of breastfeeding ^{(Matias 2014, Sparud 2011, Whichelow 1983)}, avoiding unnecessary separations and resorting if necessary to early manual or pump milk expression are required ^{(Asselin 1987, Whichelow 1983)}. The most important factor for successful lactation is early initiation of breastfeeding. ^{(Whichelow 1983)}

DECREASED INSULIN NEEDS:

Maternal glucose is used to form lactose (glucose + galactose) at the breast. Increased maternal self-monitoring is necessary because of the risk of hypoglycemia, especially during or after breastfeeding.

Insulin or oral antidiabetic needs decrease after delivery and during the first months, more so in breastfeeding women, although very variably ^{(Skajaa 2023, Kakoulidis 2022, Ringholm 2020, Nørgaard 2020, Roeder 2016, Riviello 2009, Davies 1989)}. There is a higher risk of hypoglycemia in women with type 1 diabetes who breastfeed than in those who do not breastfeed, so they require greater self-management and higher carbohydrate and caloric intake is necessary. ^{(Ringholm 2020, Nørgaard 2020, Serrano 2015, Whichelow 1983)}

Dietary and insulin adjustments are also needed during the introduction of complementary feeding and weaning. ^{(Serrano 2015)}

DIFFICULTIES AND COMPLICATIONS:

Hypoglycemia in the first few hours can be prevented and treated with frequent oral feedings ^{(Sarkar 2003)}. Hypoglycemia inhibits (via adrenaline) milk production and ejection.

There are usually greater difficulties for lactation arising from maternal (frequent cesarean section) and newborn complications (macrosomia, prematurity, early hypoglycemia, hypocalcemia, respiratory problems, jaundice, polyglobulia and malformations) with early separation of mother and infant. ^{(Lawrence 2016 p 578, Serrano 2015, Sorkio 2010, Maayan 2009, Cordero 1998)}

The mother with diabetes is at increased risk of cracks, mastitis and candidiasis; it must be prevented with frequent breastfeeding, proper positioning, avoiding washings, disinfectants and ointments, and vigorous antibiotic treatment of mastitis. ^{(Lawrence 2016 p 581)}

BENEFITS OF BREASTFEEDING:

Diabetic mothers who breastfeed improve their metabolic control during lactation ^{(Skajaa 2023)}. Breastfeeding improves insulin tolerance in both women who have had gestational diabetes and those who have not ^{(Gunderson 2012, O'Reilly 2011, Da Costa 2011)}. Breastfeeding decreases insulin requirements in diabetic women, possibly by utilizing glucose in milk production. ^{(Riviello 2009)}

Sometimes maternal diabetes mellitus remits during lactation, for prolonged periods of months or years. ^{(Lawrence 2016 p 581)}

Breastfeeding mothers have a lower risk of developing type 2 diabetes ^{(Martens 2016, Serrano 2015, Jäger 2014, Stuebe 2005)}, especially in women who have had gestational diabetes ^{(Gunderson 2015, Bentley 2008)} and it has a protective effect on breastfed infants, delaying the onset of diabetes and decreasing its frequency. ^{(Martens 2016, Gerstein 1994, Mayer 1988, Borch 1984)}

Although there has been much discussion about the lack of evidence for the benefits and risks of prenatal extraction of colostrum to administer to the newborn to prevent formula feeding ^{(Forster 2017 and 2011, East 2014, Chapman 2013, Soltani 2012)}, the benefits are so great, especially when neonatal problems are anticipated (maternal diabetes, scheduled cesarean section, twins, preemies, malformations, etc. ) that it is a practice recommended by health institutions and various authors ^{(Casey 2019, NHS 2018, Wszolek 2015)}, being well tolerated by mothers and improving their self-confidence.^{(Brisbane 2015)}

See below the information of these related products:

• Acarbose (Safe product and/or breastfeeding is the best option.)
• Glibenclamide (Safe product and/or breastfeeding is the best option.)
• Glipizide (Safe product and/or breastfeeding is the best option.)
• Insulin (Safe product and/or breastfeeding is the best option.)
• Liraglutide (Safe product and/or breastfeeding is the best option.)
• Metformin Hydrochloride (Safe product and/or breastfeeding is the best option.)
• Miglitol (Safe product and/or breastfeeding is the best option.)
• Tolbutamide (Safe product and/or breastfeeding is the best option.)

See below the information of these related groups:

• ATC A10BA: Blood glucose lowering drug (Anti-diabetic). Biguanide
• ATC A10BB: Blood glucose lowering drug (Anti-diabetic). Sulfonamide, urea derivative
• ATC A10BF: Blood glucose lowering drug (Anti-diabetic). Alpha glucosidase inhibitor
• ATC A10BG: Blood glucose lowering drug (Anti-diabetic). Thiazolidinedione
• ATC A10BH: Blood glucose lowering drug (Anti-diabetic). Dipeptidyl peptidasa 4 (DPP-4) inhibitor
• ATC A10BX: Blood glucose lowering drug (Anti-diabetic). Meglitinides & others
• ATC C07: Antihypertensives. Beta blocking agents (BB)
• ATC C08: Antihypertensives. Calcium channel blockers (CCB)
• ATC C09A: Antihypertensives. Angiotensin-converting enzyme (ACE) inhibitors