![]() Breastfeeding the Type 1 Diabetic Child . 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. 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. ![]()
A type 1 diabetes diet is important for people with type 1 diabetes to maintain proper blood sugar control. Meal timing, eating high glycemic index foods such as. Years ago, it was rare to hear about a child with type 2 diabetes. Doctors used to think kids only got type 1. It was even called juvenile diabetes for a long time. ![]() ![]() ![]() 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. Nursing on the go doesn't have to be difficult. Meet our sponsor. 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 . 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. 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 3. L and prescribing target A1c’s of roughly 8. A1c of 4. 6% in non- diabetic children (Daneman et al. 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. 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. 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. Image courtesy of Jill Brown / flickr. 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 topre- 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.
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June 2017
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