ABM Clinical Protocol #27: Breastfeeding an Infant or Young Child with Insulin-Dependent Diabetes *

Abstract

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient .

Purpose

TO PROVIDE GUIDANCE for the care of breastfeeding infants or young children with insulin-dependent diabetes mellitus (called diabetes in this protocol) and their families, describing:

• 1.

  The basis of insulin dosing for carbohydrate intake for breastfeeding infants

• 2.

  The basis of assessing the amount of carbohydrate for expressed breast milk

• 3.

  Insulin dosing in infants who have the style of small volume, frequent feeds

• 4.

  Goals and methods for glycemic control in breastfeeding infants and young children with diabetes

• 5.

  Guidance on counseling parents of breastfeeding infants and young children with diabetes, addressing the guilt associated with poor glycemic control and providing support to continue breastfeeding after diagnosis

Background

Breastfeeding provides ideal infant nutrition and is the physiologic norm for mothers and children. Families with infants or young children with diabetes may wish to breastfeed but struggle with the challenges of glycemic control in the setting of unpredictable feeding quantities and patterns. Following the diagnosis of diabetes in their infant or young child, families often infer that they should not continue to breastfeed because of these challenges.

This frequently occurs despite the evidence of maternal and child health benefits of human milk and breastfeeding. The incidence of type 1 diabetes has been rising overall, with about 4% of patients being diagnosed younger than the age of 2 years in one Finnish study. It is important to note that diabetes diagnosed in neonates and young infants is more likely to be of the monogenic form ^a

a Monogenic diabetes is caused by a single gene variant, and includes neonatal diabetes and Maturity Onset Diabetes of the Young (MODY). Although insulin is often used for the treatment of monogenic forms of diabetes, occasionally oral sulfonylureas are used after initial diagnosis and stabilization. In addition, infants with neonatal diabetes often have multiple other organ systems impacted, including severe neurologic manifestations making breastfeeding more difficult to initiate at birth. Expressed breast milk is an excellent alternative to breastfeeding in these rare cases.

(usually diagnosed before 9 months of age) rather than the autoimmune type 1 diabetes seen in older infants and children, and management of these infants can be different. For the purpose of treatment of diabetes requiring insulin, the same principles are used for both types of diabetes in infants.

Principles of Management

The goal of management of diabetes in the pediatric population is to maintain blood glucose levels within a target range with the least amount of variability to prevent complications of both hypo- and hyperglycemia. Achieving that goal in a very young child is challenging regardless of whether they are breast- or formula-fed, even for the most diligent caregivers. This is, in part, attributable to the continuously changing feeding needs and patterns of infants and young children.

Conventionally, caregivers are instructed to perform capillary (finger stick) glucose levels in young children before meals and snacks, occasionally after meals, at bedtime, and before exercise in older children, when they suspect low blood glucose and after treating low blood glucose until they are normoglycemic (6–10 times/day).

In addition, caregivers are instructed to give insulin for all meals and snacks containing more than 10–15 g of carbohydrates or for blood glucose levels outside of a target range (typically >14 mmol/L [250 mg/dL]) via injection or insulin pump. Total daily insulin requirements are mainly determined by weight and in conjunction with the family and the diabetes team. To mimic the normative patterns of pancreatic insulin secretion, total insulin requirements for patients with type 1 diabetes are divided into two parts: basal insulin and insulin for blood glucose level corrections. Both intermediate (insulin isophane or human neutral protamine Hagedorn [NPH]) and long acting preparations (insulin detemir and insulin glargine) are used to cover the basal insulin component. Intermediate insulin preparations are characterized by having a peak of action about 4–6 hours after the injection is given. This peak can be used to cover a meal or snack within that time period while that carbohydrate consumption is necessary to prevent hypoglycemia associated with the peak. Long acting insulin preparations, on the contrary, lack that peak of action, providing more flexibility with meal times and carrying a smaller risk of hypoglycemia. Despite being widely used in clinical practice for children younger than 6 years of age, insulin detemir and glargine are not approved by the U.S. Food and Drug Administration in children younger than 6 years. They are, however, approved by the European Medicines Agency for children older than 2 years of age.

About a half (insulin detemir and insulin glargine) to two thirds (NPH) of the total insulin requirements are usually covered by the basal preparations. The rest of those requirements are given in the form of a short (rapid)-acting insulin (insulin aspart, lispro, or glulisine) to be given before meals and large snacks and for corrections of elevated blood glucose values. Families are usually provided with calculations or scales that can be used to determine short-acting insulin doses based on blood glucose level (insulin sensitivity factor) and the carbohydrates consumed by the child (carbohydrate ratio). An alternative management method is by continuous subcutaneous insulin infusion (insulin pump) that uses only short-acting insulin. The pump delivers insulin both as a continuous infusion replacing basal insulin and as boluses based on the same principles discussed above. In addition, families can be taught how to dilute insulin for administration via syringe or pump to provide more precise doses of insulin.

Perhaps the most challenging part of insulin dosing in infants and young children with diabetes is the calculation of the amount of carbohydrate consumed. This is, in part, due to the normal variability in appetite and food intake at this age. In infants consuming significant breast milk volumes, it is important for the clinician and family to attempt to quantify the breast milk intake and the carbohydrate content, when possible, for optimum insulin dosing.