Introduction

This article is an example of a collaborative partnership approach between a multidisciplinary team in a joint antenatal diabetes clinic and a mother with type 1 diabetes. The whole team supported this woman from pre-conception, throughout her second pregnancy and postnatally to help her experience the harvesting of colostrum in the antenatal period and enable a positive breast-feeding outcome for her newborn daughter. This experience has harnessed the working practices of the specialist team, including the midwife, diabetes specialist nurse and breast-feeding coordinator, where the sharing of knowledge and practice has enabled appreciation of professional roles.

Diabetes is the most common pre-existing medical disorder complicating pregnancy in the United Kingdom, with approximately one pregnant woman in 250 having pre-existing diabetes (Department of Health [DoH], 2001). Breast-feeding and type 1 diabetes is a particular challenge for a woman in her childbearing years. Maintaining optimal diabetes control while learning a new skill may fill these women's lives with trepidation. However, with good support and advice, breast-feeding can be an enjoyable, achievable and sustained experience.

The structure of the joint antenatal diabetes (JAND) clinic in the author's hospital is well in-line with the recommendations set out in both the National Service Framework for diabetes (DoH, 2001) and Scottish Intercollegiate Guidelines Network (Scottish Intercollegiate Guidelines Network, 1991) for antenatal care of women with diabetes. Held on a weekly basis (with the exception of Bank Holidays), a multidisciplinary group of professionals gather for a combined clinic offering both pre-conceptual and antenatal care.

The JAND team at Scunthorpe General Hospital consists of an obstetrician, diabetologist, diabetes specialist nurse (DSN) leading in pregnancy, a midwife and a dietitian with interests in pregnancy and diabetes. The team prides itself on achieving positive experiences for pregnant women with diabetes and working towards achieving a satisfying breast-feeding outcome. All mothers have the opportunity to have an individual discussion with an appropriately-trained health professional regarding the benefits of breast-feeding; these recommendations, which are underpinned by the DoH (DoH, 2002), are based on the World Health Organization (WHO) Systematic Review (Department of Health and Nutrition for Health and Development et al, 2002) advocating exclusive breast-feeding for the first six months of an infant's life.

Case history

The woman, who is para two, gravida one, was diagnosed in her first pregnancy as having type 1 diabetes mellitus with an inherited condition Factor 5 Leiden defect. The woman, Sarah, has agreed for names and photographs to be published. Sarah commenced insulin and managed her diabetes control throughout her first pregnancy. She was successfully delivered of a baby girl by emergency caesarean section following failure to progress in labour at 39 plus five weeks. Sarah breast-fed her daughter for five months. Some 18 months later, Sarah actively sought advice from the DSN team expressing her wishes to conceive. An appointment was made for the following week to be seen in the JAND clinic for preconceptual advice (see Figure 1).

[FIGURE 1 OMITTED]

Preconception

Sarah had exemplary diabetes control, achieving an Hb[A.sub.1c] of 6.4% on each occasion that it had been measured. The reasons for maintaining her Hb[A.sub.1c] in the non-diabetic range for at least three months prior to pregnancy in relation to organogenesis were explained to Sarah, and have been well documented in the literature (Furhrmann et al, 1983; Casson et al, 1997; Suhonen et al, 2004; DoH, 2001). It was agreed that Sarah's Hb[A.sub.1c] was to be re-checked in one month and if it remained at less than 7% she would commence the recommended dose of 5 mg folic acid for women with diabetes (Diabetes UK, 2002; DoH, 2001). A discussion took place on the appropriate regimen and it was decided that she would remain on multiple injection therapy of soluble insulin (Actrapid) and isophane insulin (Insulatard).

Historically, Actrapid was the insulin of choice for preconception and/or pregnancy, but more recently, this has been changed to the short-acting analogue insulin aspart (NovoRapid). Long-acting analogues (e.g. insulin glargine [Lantus] and insulin detemir [Levemir]) are not recommended for use in pregnancy (Diabetes UK, 2004).

Injection sites were checked, blood glucose monitoring equipment was checked for accuracy and a discussion took place on increased risks of hypoglycaemia (Diabetes Control and Complications Trial [DCCT] Group, 1993) and prevention and treatment. In-line with National Service Framework guidelines (DoH, 2001) for pregnancy, Sarah's blood glucose targets were 4-7 mmol/l pre-prandially and no greater than 10 mmol/l post-prandially. Recommendations for the supply and use of glucagon are provided by Diabetes UK (2002); Sarah was supplied with the same and given a demonstration on its use. For the checklist of other aspects addressed, see Table 1. Three months later, Sarah telephoned to say she was pregnant.

Antenatal management

At the first antenatal appointment Sarah was six weeks pregnant and was seen by all health professionals in the multidisciplinary team. This consultation recapped and covered aspects to encourage self-management to aid and optimise diabetes control, for example appropriate dose adjusting, sick day rules, and advice for hyperemesis and illness (see Table 1). It was during one of the initial visits to the JAND clinic that Sarah expressed her wishes to breast-feed again.

Early plans for colostrum harvesting and breast-feeding

Sarah wanted this baby not to have any formula milk if possible. She also wanted skin-to-skin contact, something that had been unavoidably denied at the first delivery. The DSN contacted the breast-feeding coordinator and a series of joint meetings were held throughout the pregnancy with Sarah and both health professionals in attendance, this being the ethos of the multidisciplinary working within the JAND clinic.

[TABLE OMITTED]

The Trust policy states that: 'All mothers have the right to make a fully informed choice as to how they feed their babies.' However, it is believed that this is the first time that the Trust had been faced with the situation of a woman who wished to exclusively breast-feed and collect her own colostrum. The breast-feeding coordinator, therefore, played a significant role.

The idea of harvesting colostrum from 36 weeks into the pregnancy, which is something that is successfully managed at Chesterfield and North Derbyshire Royal Hospital Trust, also transpired from these meetings. A literature search showed that very little has been written about the effectiveness of colostrum harvesting and the effects on the management of diabetes. Nonetheless Sarah was very keen to try it with the hope of maintaining exclusivity in breast-feeding and was directly supported through the whole process.

Colostrum harvesting

Colostrum, the first yellow-coloured, viscous mammary secretion that women produce from around the sixteenth week of pregnancy, is thought to be an unbeatable food for the newborn baby. It has high levels of Immunoglobulins A (IgA) and M (IgM), which confer local gastrointestinal immunity to the newborn child (Miranda et al, 1983).

Using UNICEF guidelines (UNICEF, 2001) and hospital policy, measures were initiated to enable harvesting. The consultant paediatrician was involved with the decision making for the baby, and a feeding plan (see Table 2) was circulated to the DSN, team midwives, obstetrician, and diabetologist. Sarah was provided with a range of literature (from sources including La Leche League International, UNICEF and the NHS) to ensure this continued to be an informed and involved decision process.

At 36 weeks, Sarah was encouraged to hand-express colostrum at least three times per day. Volumes of colostrum were not measured initially and were frozen in bottles provided by the hospital. This was deemed to be a costly venture as there is a 'non-reusable policy' for such items and Sarah inevitably purchased some milk bags. The milk bags, although marketed for breast milk, were not recommended under the Northern Lincolnshire and Goole Hospitals NHS Trust breast-feeding policy due to handling difficulties and potential leakage. However, Sarah experienced no such problems.

One of the findings incidental to the harvesting of colostrum was the lowering of blood glucose readings before meal times, and Sarah actively tested on numerous occasions per day, adjusting her insulin doses to maintain normoglycaemia.

Breast-feeding benefits