BREASTFEEDING

AND EARLY NUTRITION

Benefit for the off spring of
diabetic mother
Ekawaty Lutfia Haksari
Department of Child Health, Neonatal Division,
Faculty of Medicine, Universitas Gadjah Mada
Instalation of Maternal-Perinatal, Sardjito General Hospital, Yogyakarta

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• World Breastfeeding
Week
August 2007

• An early start on
breast milk saves
infants’ lives

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• 16% kematian neonatal • 22% kematian neonatal
dapat dicegah jika dapat dicegah pada
menyusu ekslusif sejak inisiasi menyusu dini
hari pertama pada 1 jam pertama
Edmond K et al. Delayed Breastfeeding Initiation Increases Risk
of Neonatal Mortality. Pediatrics,2006. 117:380-386

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 DURATION OF BREAST-FEEDING

• AAP 1997 : All infants should be exclusively

breast- fed through 6 months of age
and breast-feeding should continue until 1
year or longer as mutually desired by mother
& infant
• a recommendation concurred to by the WHO
and the Institute of Medicine

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 DIABETES (AAP 2012)
• Up to a 30%  the incidence type 1 diabetes mellitus
is reported for infants who exclusively breastfed
 avoiding exposure to cow milk protein or at least 3 months

• The putative mechanism in the development of type 1

diabetes mellitus is the infant’s exposure to cow milk β-
lactoglobulin,
which stimulates an immune-mediated process cross-reacting
with pancreatic β cells

•  40% incidence of type 2 diabetes mellitus is reported,

possibly reflecting the long-term positive effect of
breastfeeding on weight control & feeding self-regulation

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 Obesity (AAP 2012)
• Rates of obesity are significantly
lower in breastfed infants
 National campaigns to prevent obesity
begin with breastfeeding support

• Although complex factors confound studies of

obesity,
there is a 15% to 30% reduction
in adolescent & adult obesity rates
if any breastfeeding occurred in infancy
compared with no breastfeeding
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 Obesity (AAP 2012)
• The Framingham Offspring study :
a relationship of breastfeeding & a lower BMI &
higher high-density lipoprotein concentration in adults.

• A sibling difference model study:

the breastfed sibling weighed 14 pounds < the sibling fed
commercial infant formula &
was less likely to reach BMI obesity threshold.
• The duration of breastfeeding also is inversely related to the
risk of over- weight;
each month of breastfeeding
being associated with a 4% reduction in risk

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 BREASTFEEDING OR BY BOTTLE

• The interpretation of these data

is confounded by the lack of a definition
in many studies of whether human milk
was given by breastfeeding or by bottle.

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 Breastfeeding and development of overweight
Breastfed infants self-regulate intake volume
irrespective of maneuvers that
 available milk volume,
& the early programming of self-regulation,
 affects adult weight gain

This concept is further supported by the observations

infants who are fed by bottle, formula, or expressed
breast milk will have  bottle emptying,
poorer self- regulation,
& excessive weight gain in late infancy (older >6 mo
compared with infants who only nurse from the breast

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 INFANTS’ RISK FOR EXCESS WEIGHT
DURING LATE INFANCY

• Negatively associated with breastfeeding intensity

• Positively associated with infant-initiated bottle
emptying during early infancy
• These findings not only provide evidence for the
potential risk of not breastfeeding
• Or breastfeeding at a low intensity in development of
childhood obesity,
• They also suggest that infant-initiated bottle emptying
may be an independent risk factor as well
Lie et al. Pediatrics 2008

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 INFANTS FED FROM BOTTLE
LACK SELF REGULATION OF MILK INTAKE
COMPARED WITH DIRECTLY BREASTFED INFANTS

Infants who are bottle-fed in early infancy

are more likely to empty the bottle in late infancy
than those who are fed directly at the breast.
Bottle feeding, regardless of type of milk,
is distinct from feeding at the breast
in its effect on infants’ self regulation of milk intake
Lie et al. Pediatrics 2010

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The American Diabetes Association has recommended
that women with GDM should be encouraged to
breastfed (1986)
• Recommendation from the 4th International
Workshop Conference on Gestational Diabetes
Mellitus encourage women to breastfeed,
although data demonstrating efficacy were lacking

• The 5th Workshop-Conference made the same

recommendation & identified the need for research
on breastfeeding’s effects on health of their spring
based on the conflicting findings

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 .
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 PRACTICE POINTS
• Maternal diabetes during pregnancy should be
screened & treated to  neonatal outcomes
• Maternal obesity/overweight is an additional risk
factor for adverse neonatal outcomes
• Pediatricians should be aware of the neonatal risks
associated with diabetes in pregnancy,
especially RDS & hypoglycemia
• Strategies for screening & managing women with
GDM should be developed in middle & low- income
countries
• Mitanches et al. Best practice & Research Clinical Obstetrics and
Gynecology 2015

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 BREAST FEEDING

• Must be encouraged & started as soon as possible after

birth in infants born to diabetic mothers
• Reduces the risk of later obesity &
 childhood adiposity &
slows growth velocity during infancy
• May have a protective effect against the risk of diabetes
later in life

Mitanches et al Best practice & Research Clinical Obstetrics and Gynecology

2015

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 Association of breastfeeding & early childhood overweight
in children from mothers with gestational diabetes mellitus
• Children of mothers who had gestational diabetes mellitus (GDM),
have a risk of infant overweight
• Breastfeeding (BF) > 3 months appears negatively associated
with overweight in early childhood
• Prevalence of childhood overweight  with increased duration of nursing
• The highest prevalence of 37% was observed in children who were never
breast-fed
• Exclusive BF revealed to be an independent preventive indicator of
childhood overweight after adjustment for confounding factors, such
parental obesity & high birth weight
• The risk of childhood overweight may be  40-50% when BF >3
months

Schaefer-Graf UM et al, Diabetes care 2006

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Association of breastfeeding & early childhood overweight
in children from mothers with gestational diabetes mellitus

Schaefer-Graf UM et al, Diabetes care 2006

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 ASSOCIATION OF BREASTFEEDING &
EARLY CHILDHOOD OVERWEIGHT IN CHILDREN
FROM MOTHERS
WITH GESTATIONAL DIABETES MELLITUS

• Obesity is common among women with GDM

• Women whose pregnancies were complicated by
GDM, particularly those who are obese,
should be encouraged to nurse for at least 3 months
• Breastfeeding may be associated with childhood
somatic development
Schaefer-Graf UM et al, Diabetes care 2006

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 Breast-feeding and Diabetes:
Long-term impact on mothers & their infants
• Breast-feeding (BF) is associated with reduced risk offspring
being overweight later in life by 22% to 24% across the age
spectrum,
from preschool children to adults
• A dose-response gradient with increasing duration of
breastfeeding, & lower risk with prolonged exclusive breast
feeding
• BF has been slow infant growth to 2 years of age
• Inconclusive BF protect overweight
• Development of type 2 diabetes among offspring whose
mothers had diabetes during pregnancy
• Lactation protects development of type 2 diabetes later in life
in women with a diabetes history during pregnancy
Gunderson EP. Curr Diab Rep 2008

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 Breastfeeding and development of overweight
The general population
• Developed country, BF lower risk overweight during
childhood & adolescent, even after accounting maternal
obesity & family lifestyle behaviors
• Meta-analysis 39 published during the past years,
concluded BF individual were less likely classified
overweight ( OR 0,78, 95%CI) Adjust parenteral
anthropometry, socio- economic status, birth weight did
not abolished
• The overall reduction in overweight BF infant with the
observations the BF infants grow slowly &
are leaner at 1 to 2 years of age than non BF
• The slower of growth persist at least 2 years, &
the protective effects continue through childhood
&adolescent
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 Breastfeeding and development of overweight

The general population

• Breast milk’s (BM) unique biochemical constituents and
nutrient composition that favorably affect infant growth
& regulate energy balance
• BM contains bioactive substances that may affect
regulation of energy balance, fat deposition, & metabolic
responses
• Relative to formula feeds, BM contains protein levels.
Higher protein levels in early life have been linked to
higher body mass index (BMI) later in life in some
• Higher insulin levels have also

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 Breastfeeding and development of overweight

Infants of mothers with diabetes during pregnancy

o The Nurses’ Health Study of Offspring examined risk of
overweight among 9 to 14 years of age whose mothers had
diabetes during pregnancy. The study found a lower but non
significant association for ever versus never breast-fed with
odds of overweight (OR = 0.62; 95% CI, 0.24–1.60).
o Another study of German mothers with GDM &
their offspring: exclusive breast-feeding for >3 months was
associated with a lower risk of overweight (OR = 0.55; 95% CI,
0.33–0.91), but only among offspring of obese mothers.
conflicting findings may originate from the early age (2 to 3 years) that overweight
was ascertained for subjects, which is less predictive of overweight status at older
ages. Other limitations of these studies include the heterogeneity of maternal
type of diabetes during

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 Breastfeeding Lowers Risk of
Type 2 Diabetes Following Gestational Diabetes Pregnancy

• Gestational diabetes mellitus, or high blood glucose during

pregnancy 5 -9 percent of all pregnancies in the United States
approximately 250,000 women annually.
• Women with gestational diabetes are up to 7 times more likely
to develop type 2 diabetes within several years after pregnancy
• Breastfeeding is recommended for women with GDM, but
previous studies exploring the impact of breastfeeding on
subsequent development of diabetes have had inconsistent
findings
• Women who exclusively or mostly breastfed for at least 2
months after giving birth, & those who continued to breastfeed
for several months, were able to cut their risk for type 2
diabetes by half
Gunderson EP. Kaiser Permanente Study

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 Breastfeeding more often & for longer durations
helps mother's health

Both the level & duration of breastfeeding

may offer unique benefits to women
during the post-delivery period
for protection against development of type 2 diabetes
after gestational diabetes pregnancy

Gunderson
EP
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Evidence for the general population of developed countries
supports association between breast-feeding & lower risk of
becoming overweight during childhood & adolescence,
even after accounting for maternal obesity & family lifestyle
behaviors.
• However, evidence is inconclusive that breast-feeding confers the
same protection against obesity for offspring of women with
diabetes during pregnancy as for the general population.
• Findings are mixed, with higher, lower, or no difference in risk of
overweight for breast-fed compared with non–breast-fed infants
whose mothers had diabetes during pregnancy.
• Prospective studies of these infants of diabetic mothers are needed
to examine the effect of breast-feeding on infant growth &
development of overweight in childhood controlling for parental
attributes, intrauterine metabolic milieu, maternal postpartum
glucose tolerance, & postnatal behavioral traits.
Gunderson EP Curr Diab Rep 2010

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 For the mother, clinical & epidemiologic evidence
• Lactation has immediate favorable effects on maternal glucose
tolerance for the general population & those with a diabetes
history during pregnancy
• The Nurses Health Study, women who lactated for >4 mo had
25% reduction in risk of type 2 diabetes & exclusive lactation
was associated 35% to 40% reduction in diabetes risk.
• In this study, among women with a GDM history,
findings were inconclusive.
• To determine if breast-feeding delays or prevents the onset of
type 2 diabetes in women with a diabetes history during
pregnancy & their offspring, prospective, population based
studies that control for intrauterine & postnatal exposures are
needed.
Gunderson EP. Curr Diab Rep 2010

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 The SWIFT Study:
Study of Women, Infant Feeding &
Type 2 Diabetes after GDM Pregnancy
• 12 percent of women in the study developed type 2 diabetes
within 2 years after delivery.
• Those who exclusively formula-fed their babies at 6 to 9
weeks of age were > 2x develop diabetes as women who
exclusively BF their infants.
• There was a graded 35 -57% reduction in the 2year diabetes
incidence associated with greater lactation intensity
from exclusively formula-feeding to exclusively BF,
and with increasing lactation duration
from < 2 to > 10 months of BF

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 The Swift study
• A major strength of the study was the ability to control for
numerous influences on breastfeeding &
other diabetes risk factors, including maternal obesity
before pregnancy, gestational weight gain, prenatal
metabolism, treatment for gestational diabetes, C-section
delivery, infant size & birth outcomes, race/ethnicity, &
lifestyle behaviors such as diet, physical activity &
weight change.
• The association between breastfeeding intensity &
duration with lower risk of developing type 2 diabetes
remained after accounting for these variables.
• The highlight the importance of
prioritizing breastfeeding education &
support for women with gestational diabetes as part of
early diabetes prevention efforts by health care systems
Gunderson EP 2007
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 The WIFT Study

• The first to measure breastfeeding on a monthly basis during the first year
after delivery & to enroll a statistically significant number of women with
gestational diabetes. It is also the first to evaluate social, behavioral &
prenatal risk factors that influence development of type 2 diabetes, as well
as breastfeeding initiation and success.
• The study enrolled > 1,000 Kaiser Permanente members in Northern
California who were diagnosed with gestational diabetes during pregnancy
between 2008 and 2011. The SWIFT cohort was racially & ethnically
diverse, with 75 percent of the women reporting Hispanic, Asian or
African-American heritage. In-person exams, which included oral glucose
tolerance tests, were conducted at six to nine weeks after delivery as
women enrolled in the study, & again at one year & two years post-delivery
in those who did not have diabetes at baseline.

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Identification of modifiable risk factors that influence postnatal
programming of adiposity, appetite and/or energy regulation
mechanisms among GDM offspring
is necessary to formulate strategies for
prevention of obesity and type2 diabetes mellitus in high-risk group
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 Annals of Internal Medicine 2015
Lactation and Progression to Type 2 Diabetes After Gestational Diabetes
• What is the problem and what is known about it so far?
• Breastfeeding has positive effects on the health of infants as well as their
mothers. Some of the positive effects of breastfeeding in mothers include
improved metabolism of glucose and lipids. Whether breastfeeding a child
can prevent women with gestational diabetes (or diabetes during
pregnancy) from developing type 2 diabetes after delivery is unclear.
• Why did the researchers do this particular study?
• To see whether the level and duration of breastfeeding lowered the
mother's future risk for new-onset type 2 diabetes after a pregnancy with
gestational diabetes.
• Who was studied?
• 1035 Hispanic, Asian, black, or white women who had gestational diabetes
and enrolled in the study at 2 months after delivery.
• How was the study done?
• At the time the women were enrolled in the study, they were classified as
either exclusively breastfeeding, mostly breastfeeding, mostly formula or
mixed/inconsistent feeding, or exclusively formula feeding. The women
had an oral glucose tolerance test at 2 months after delivery (baseline),
and those who did not have diabetes at 2 months were tested again every
year for 2 years, in addition to other tests. The investigators determined
how many women developed type 2 diabetes during the follow-up period.
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 Annals of Internal Medicine 2015
Lactation & Progression to Type 2 Diabetes
After Gestational Diabetes
• What did the researchers find?
• Higher amounts of breastfeeding (mostly breastfeeding or
breastfeeding only) and breastfeeding for longer periods of
time (>2 months) were both associated with a decreased
risk for type 2 diabetes.
• What were the limitations of the study?
• The women were followed for only 2 years after delivery. It
is possible that some women may have developed type 2
diabetes after the study ended.
• What are the implications of the study?
• Higher intensity of breastfeeding and breastfeeding for
longer periods of time may prevent type 2 diabetes in
women with a history of gestational diabetes.

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 Lactation and Progression to Type 2 Diabetes
Mellitus After Gestational Diabetes Mellitus: A
Prospective Cohort Study

• Higher lactation intensity & longer duration were

independently associated with lower 2-year
incidences of DM after GDM pregnancy.
• Lactation may prevent DM after GDM delivery
Gunderson EP et al. Ann Intern Med. 2015

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 Early neonatal
breast feeding by
diabetic mothers has
beneficial effects on
early psychomotor
development
in their offspring

Plagemann et al.Diabetes care 2005

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 Early neonatal
ingestion of
breast milk from
diabetic mothers may
 risk of
becoming overweight,
developing impaired
glucose tolerance
beginning early
during childhood

Plageman A et al.
Diabetes Care 2002

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 The 1st week of life
appears
to be the critical window
for nutritional programming in
offspring diabetic mothers
by ingestion of maternal
‘diabetic’ breast milk

Late neonatal Diabetic breast

milk & duration BF
independent influence
childhood overweight or
impaired glucose tolerance in
offspring of diabetic mothers
(ODM)

Rodekamp et al.
Diabetes Care 2005
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Feeding methods and type2 Diabetes

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Breastfeeding in infancy is
associated with reduced risk of type 2 diabetes,
with marginally lower insulin concentrations in later life &
with lower blood glucose & serum insulin concentrations
in infancy.
Owen CG et al. Am J Clin Nutr 2006;84:1043–54.

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 A Systematic Review of
Associating Breastfeeding with
Type 2 Diabetes & Gestational Diabetes

• Low estrogen levels in breastfeeding women may have a

protective effect on glucose metabolism &
subsequent risk of diabetes.
• Having been breastfed for at least 2 months
may  the risk of diabetes in children.
• Initial research has begun on the long-term effects of diabetes
during pregnancy on children.
• Breastfeeding
may both maternal & pediatric rates of diabetes
• Women with diabetes should be strongly encouraged
to breastfeed because of maternal & childhood benefits
specific to diabetes that are above &
beyond other known benefits of breastfeeding.
Taylor JS et al. Journal of the American College of Nutrition 2005; 24
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 SUMMARY
• BF must be encouraged & Further studies are needed:
started as soon as possible after
birth in infants born to diabetic
mothers • Effects of postnatal feeding on
• BF is associated with reduced growth during infancy among
risk of becoming overweight GDM offspring
or obese later in life • Evaluate the impact of
• Breastfed babies growth breastfeeding on the GDM
slower during infancy than offspring’s long-term risk of
formula fed babies obesity & diabetes
• Women whose pregnancies
were complicated by GDM,
particularly those who are
obese, to nurse for at least 3
months

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