Prior breastfeeding experience and infant feeding at discharge among women with pregestational diabetes mellitus

1 Background

Breastfeeding (BF) is beneficial to the health and well-being of mothers and their infants [1, 2]. In 2013, approximately 79% of the general maternal population in the U.S. breastfed their infants at the time of discharge from the hospital [3]. In addition to traditionally recognized barriers to BF among healthy women, maternal and neonatal morbidities occurring in pregestational diabetes mellitus (PGDM) may also interfere with or delay BF initiation or BF duration [4 –7]. It has been reported that previous BF experiences in healthy populations of multiparous women positively influence initiation and/or duration of BF following subsequent pregnancies [8 –13]. In the U.S., two thirds of women who did not breastfeed their first child, did not breastfeed their subsequent children [9]. Information on the effects of prior BF on intention to breastfeed and BF at discharge for subsequent pregnancies among women with PGDM remains scarce [14]. The objective of this study was to compare multiparous women with PGDM with and without prior BF experience and to ascertain their infants feeding type during hospitalization and at the time of discharge. A secondary objective was to compare the rates of prior BF experience in the 2013-15 and 2016-18 time periods.

2 Subject and methods

This retrospective cohort investigation was approved by the Institutional Review Board at The Ohio State University Wexner Medical Center. All clinical and demographic data was obtained from review of maternal and neonatal hospital records (2013-18). Women were diagnosed with PGDM (Type 1 and Type 2) according to clinical and laboratory criteria [15]. Public assistance was used as a proxy for socioeconomic status. Obese was defined by a body mass index (BMI) of 29–34 kg/m², and very obese by a BMI≥35 kg/m². Every woman diagnosed with PGDM cared for in our medical center was screened and those without major malformations who delivered at or beyond 34 weeks gestation constituted the study population. Pregnancies affected by major or fatal malformations were excluded. Upon arrival to labor and delivery, each woman declared her past BF experience and her intended infant feeding type (i.e., BF, formula feeding (FF) or a combination (BF/FF)) for the current pregnancy. Due to the lack of detailed description by the mothers, like other investigators, the acknowledgement of having breastfed a prior child was considered a successful or positive experience [11, 14].

Depending on the condition of mother and her infant following delivery, maternal-infant interactions such as holding, skin to skin contact and BF were encouraged. Delivery room and postpartum maternal-infant interactions were observed and documented by the nursing staff. Per our hospital practice, any symptomatic infant, regardless of the mothers’ class of diabetes, is directly transferred from the delivery room to the NICU. Admission to the NICU for prevention of hypoglycemia was also an option for infants whose mothers had poorly controlled diabetes and/or severe illness. Asymptomatic infants able to feed were transferred to the newborn nursery for routine care and glucose monitoring. Our family-centered care system has full-time lactation consultants and rooming-in available.

Screening for hypoglycemia (blood glucose <40 mg/dl) was done via serial point of care testing (Accu-Chek^®) or by plasma glucose measurement in the laboratory (Beckman Coulter AU5800, Beckman Coulter Inc., Brea, CA, USA) starting within the first hour of life after the first feeding and every 2–4 hours as needed thereafter [16, 17]. Asymptomatic infants in the newborn nursery with hypoglycemia were promptly breastfed or FF and those with recurrent hypoglycemia were treated with intravenous (IV) dextrose. On admission to the NICU, most infants were started on IV dextrose and those who could feed were breastfed or given formula. BF was defined as initiated if, at the time of hospital discharge, the infant was exclusively BF (all feedings during the preceding 24 hours were by breast) or partially BF (BF and FF in combination). Due to the study design, no follow-up information was available on infant feeding practices following hospital discharge.

3 Results

The study population was composed of 304 multiparous women with PGDM who on arrival to labor and delivery reported her prior BF experience and her infant feeding choice for the current pregnancy. Seventy of 168 (42%) of the dyads who delivered during 2013-15 and 100 of 136 (74%) delivered during 2016-18 reported prior BF experience (p < 0.0001).

Intention to breastfeed has been recognized as a predictor of BF initiation [1], while the lack of intention has been reported to be an important determinant of BF initiation failure [4, 6]. Following changes in policies and in hospital practices, improvements in intention to breastfeed and BF initiation for healthy populations have been recorded [3]. Unfortunately, the progress made in BF rates for women with complex pregnancies such as diabetes mellitus has been modest [6 , 17]. Variables associated prenatally with intention to breastfeed and postnatally with BF initiation and duration have been well described, however, prior BF experience has been examined less frequently. In a retrospective study of healthy women who delivered vaginally, Nagy et al. [8] reported that the duration of BF of the second child was significantly related to the BF duration of the first child. Several years later, Taylor et al [9] reported that of 817 women with two children who breastfed their first child, 85% of them also breastfed their second child. Conversely, of 537 women who did not breastfeed their first child, 78% of them did not breastfeed their second. Phillips [10] and Sutherland et al. [11] reported that successful BF in a first pregnancy was a predictor, albeit not absolute, of subsequent BF and that women who did not breastfeed or who reported unsuccessful attempts to breastfeed their first child were unlikely to initiate BF in subsequent births. Bai et al. [13] extended those observations by adding that women who did not breastfeed or who breastfed their child for a short time, had a significantly higher risk of weaning their subsequent children early and concluded that it was the BF experience rather than child bearing that influences BF practices later. The realization that it was the quality of the BF experience rather than birth order that determined the initiation of BF prompted several investigators to examine the issue further. In a provocative systematic review of prior BF and BF outcomes, Huang et al. [18] cited evidence that a successful BF experience influenced BF of subsequent births by increasing attitude, confidence, self-efficacy, motivation and intention [19 –24]. Separately, it was proposed that negative BF experiences were related to maternal or neonatal morbidities or to difficulties inherent to lactation including suck or latch problems, perceptions of low milk supply, mastitis and nipple fissures [25]. While the preceding information applied to healthy multiparous women, we recently studied BF experiences in 228 patients with high risk obstetrical conditions including PGDM. We reported that 116 of 228 (51%) had prior BF experiences and of them, 89% intended to breastfeed but only 65% breastfed at discharge [14]. Conversely, of the 112 women with no prior BF experience, 83% intended to breastfeed but only 51% initiated BF. We further established that prior BF was a strong predictor of intention to breastfeed (OR 5.6, CI 2.7–11.6) and of BF at discharge from the hospital (OR 2.2, CI 1.1–4.4) [14].

Over the years we have consistently reported that 70–80% of women with PGDM intended BF while 20–30% did not [4 , 14]. Available data suggests that approximately one third of women with PGDM who intended to breastfeed during the first pregnancy failed to initiate BF [6, 14]. Thus, it follows that the no prior experience group is composed of women who intended BF but were unsuccessful and of women who never intended to breastfeed. This assumption has significant healthcare implications because these two groups may have different origins and require diverse corrective strategies. In order to understand what makes the BF experience successful or unsuccessful a detailed BF history should be obtained.

Our data shows that of 134 women with PGDM without prior BF experience, 46% intended BF, 38% intended to feed formula and 16% intended BF/FF combined. Thus, most of this group is composed of women who did not intend to breastfeed exclusively and who are known for their poor BF outcomes [4 , 17]. Of 170 women with PGDM with prior BF experience, 79% intended to breastfeed exclusively, 2% intended to feed formula and 18% intended to BF/FF combined. In spite of that at discharge only 33% of these women breastfed exclusively and 48% partially, the high rate of intention to exclusively breastfeed their next child showed determination and commitment to make BF successful. It is possible that lactation education provided by consultants, nurses and physicians help by minimizing the obstacles of the past and maximizing the benefits of BF initiation for the current and future pregnancies [22]. Clearly, the improved BF outcomes for women who persist in intention to breastfeed is rewarding since they may have initiated a positive cycle for subsequent births [19 –24]. After all, our data showed that there has been a significant increase in the number of multiparous women with prior BF experience across time, 42% of 168 (2013-15) vs 74% of 136 (2016-18) [7 , 17].

In the past, emergency and elective cesarean deliveries have been associated with lower rates of BF as compared to vaginal births [26]. Later, it was learned that the adverse association between cesarean delivery and BF appears to be limited to elective, planned, pre-labor cesarean [27 –29]. Although those investigators did not provide data on prior BF experience [27 –30], they cited other authors who reported on the association of prior BF and subsequent infant feeding behavior [8 –13]. Recently, we reported that the adjusted odds ratio for the initial feeding to be by breast for women with PGDM was higher for infants born vaginally as compared to those born via cesarean (aOR 2.3, CI 95% 1.4–3.8) [17]. Not unexpectedly, BF in the delivery room was more common after vaginal delivery and the interval between birth and first BF was longer following cesarean delivery [26]. We confirmed that in women with high risk obstetrical pregnancies mother-infant contact occurred significantly earlier following vaginal than following cesarean delivery [14]. The findings of our current investigation concurred with the literature and with our earlier studies in that BF initiation rates in women with PGDM are higher following vaginal delivery than after cesarean birth [6, 14]. Delays in BF, early feeding by formula and formula supplementation are obstacles to BF initiation that more commonly are found following cesarean deliveries [6 , 16]. In the current study, we noted that the past history of women without BF experience had a higher incidence of primary cesarean section. This observation is not surprising since due to maternal and neonatal morbidities, emergency (primary) cesarean deliveries are more likely to affect first pregnancies.

Hobbs et al. [29] reported that women who had planned cesarean deliveries were less likely to request assistance from a lactation consultant during the postpartum period as compared to women that had vaginal or unplanned cesarean delivery. It has consistently been reported that women who had planned cesarean deliveries were less likely to intend BF and to request lactation assistance [27 –29]. In the current study, we observed that regardless of the mode of delivery, lack of intention to BF associated with the lowest rate of acceptance of lactation consults. This observation was corroborated by the fact that among women without prior BF experience 92% of those who intended to BF and only 40% of those who intended to feed formula and BF requested lactation support.

Recently, in a multinational meta-analysis, Cohen et al. [30] reported that smoking during pregnancy was one of the strongest and most consistent negative factors associated with early BF. Throughout the years we have reported similar findings among women with PGDM [4 , 17]. A comparison of 386 women with PGDM who delivered in 2011-13 with 457 others who delivered in 2014-16 showed a significant decline in the rate of smoking during pregnancy (27% vs 12%, p = 0.001) [7]. This observation validates and rewards the benefits of smoking cessation programs, especially among pregnant women. The high recurrence rate of smokers following pregnancy should be acknowledged and the focus on prevention should continue [30].

Limitations of this investigation are those inherent to its retrospective design and the lack of follow-up information regarding infant feeding after discharge. Also, the definition of BF initiation at discharge may only be applicable to women with high risk obstetrical pregnancies for whom early mother-infant contact may be delayed. The strength of this investigation rests on the size of the obstetrical and neonatal population and the fact that the data were obtained directly from hospital records not via post-delivery maternal questionnaires [32].

5 Conclusion

Among women with PGDM, prior BF experience leads to better BF initiation rates while the lack of prior BF experience is an additional risk factor for BF initiation failure. Women who declared no prior BF experience represent a group that attempted to breastfeed and failed or who did not intend to breastfeed. A detailed BF history would be valuable towards identifying obstacles to BF initiation and could be critical to define strategies to improve the BF experience. The number of women in the no experience group who intended to breastfeed and who for the first time initiated any BF is encouraging.