Does breastfeeding influence the risk of developing diabetes mellitus in children? A review of current evidence

[Diabetes and women, why are we different?]

Diabetes affects men and women differently and the mistaken assumption of equality in its clinical expression can lead to errors and delays in the diagnostic process and the therapeutic strategy adopted. The objective is to show the gender differences that influence the approach to this pathology and what the role of the family doctor is in the monitoring of women with diabetes. It is a review of the impact of diabetes at different stages of a woman's life, how hormonal changes affect glycemic control, gestational diabetes, how diabetes affects the development of chronic complications in women and their consequences, the existing differences in the control of cardiovascular risk factors and the differential aspects by sex of the different families of drugs used in the treatment of diabetes.

15. Management of Diabetes in Pregnancy: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Knowledge Gaps and Current Evidence Regarding Breastfeeding Issues in Mothers with Chronic Diseases

The prevalence of chronic maternal disease is rising in the last decades in the developed world. Recent evidence indicated that the incidence of chronic maternal disease ranges from 10 to 30% of pregnancies worldwide. Several epidemiological studies in mothers with chronic diseases have mainly focused on the risk for adverse obstetric outcomes. Evidence from these studies supports a correlation between maternal chronic conditions and adverse perinatal outcomes, including increased risk for preeclampsia, cesarean section, preterm birth, and admission in the Neonatal Intensive Care Unit (NICU). However, there is a knowledge gap pertaining to the management of these women during lactation. This review aimed at summarizing the available research literature regarding breastfeeding in mothers with chronic diseases. Adjusted and evidence-based support may be required to promote breastfeeding in women with chronic diseases; however, our comprehension of breastfeeding in this subpopulation is still unclear. The literature related to breastfeeding extends in various scientific areas and multidisciplinary effort is necessary to compile an overview of current evidence and knowledge regarding breastfeeding issues in mothers with chronic diseases.

Breastfeeding and insulin requirements in women with Type 1 diabetes mellitus in the first year postpartum

AIMS

To explore whether breastfeeding affects postpartum insulin requirements, HbA1c levels, and pregnancy weight retention in women with Type 1 Diabetes Mellitus (T1DM).

METHODS

This prospective study included 66 women with T1DM. The women were divided into two groups based on whether they were breastfeeding (BF) at 6 months postpartum (BF_yes, n = 32) or not (BF_no, n = 34). Mean daily insulin requirement (MDIR), HbA1c levels, and pregnancy weight retention at 5 time-points from discharge to 12 months postpartum were compared.

RESULTS

MDIR increased by 35% from 35.7 IU at discharge to 48.1 IU at 12 months postpartum (p < 0.001). MDIR in BF_yes and BF_no were comparable, however in BF_yes, MDIR were continuously lower compared to BF_no. Postpartum HbA1c increased rapidly from 6.8% at 1 month to 7.4% at 3 months postpartum and settled at 7.5% at 12 months postpartum. The increase in HbA1c during the first 3 months postpartum was most pronounced in BF_no (p < 0.001). Although neither were statistically significant, from 3 months postpartum HbA1c levels were highest in the BF_no and BF_no had a higher pregnancy weight retention compared to BF_yes (p = 0.31).

CONCLUSION

In women with T1DM, breastfeeding did not significantly affect postpartum insulin requirements, HbA1c levels or pregnancy weight retention in the first year after delivery.

15. Management of Diabetes in Pregnancy: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Milk Exosomal microRNAs: Postnatal Promoters of β Cell Proliferation but Potential Inducers of β Cell De-Differentiation in Adult Life

Pancreatic β cell expansion and functional maturation during the birth-to-weaning period is driven by epigenetic programs primarily triggered by growth factors, hormones, and nutrients provided by human milk. As shown recently, exosomes derived from various origins interact with β cells. This review elucidates the potential role of milk-derived exosomes (MEX) and their microRNAs (miRs) on pancreatic β cell programming during the postnatal period of lactation as well as during continuous cow milk exposure of adult humans to bovine MEX. Mechanistic evidence suggests that MEX miRs stimulate mTORC1/c-MYC-dependent postnatal β cell proliferation and glycolysis, but attenuate β cell differentiation, mitochondrial function, and insulin synthesis and secretion. MEX miR content is negatively affected by maternal obesity, gestational diabetes, psychological stress, caesarean delivery, and is completely absent in infant formula. Weaning-related disappearance of MEX miRs may be the critical event switching β cells from proliferation to TGF-β/AMPK-mediated cell differentiation, whereas continued exposure of adult humans to bovine MEX miRs via intake of pasteurized cow milk may reverse β cell differentiation, promoting β cell de-differentiation. Whereas MEX miR signaling supports postnatal β cell proliferation (diabetes prevention), persistent bovine MEX exposure after the lactation period may de-differentiate β cells back to the postnatal phenotype (diabetes induction).

The Yin-Yang Concept of Pediatric Obesity and Gut Microbiota

The era of pediatric obesity is no longer a myth. Unfortunately, pediatric obesity has reached alarming incidence levels worldwide and the factors that contribute to its development have been intensely studied in multiple recent and emerging studies. Gut microbiota was recently included in the wide spectrum of factors implicated in the determination of obesity, but its role in pediatric obese patients is far from being fully understood. In terms of the infant gut microbiome, multiple factors have been demonstrated to shape its content, including maternal diet and health, type of delivery, feeding patterns, weaning and dietary habits. Nevertheless, the role of the intrauterine environment, such as the placental microbial community, cannot be completely excluded. Most studies have identified Firmicutes and Bacteroidetes as the most important players related to obesity risk in gut microbiota reflecting an increase of Firmicutes and a decrease in Bacteroidetes in the context of obesity; however, multiple inconsistencies between studies were recently reported, especially in pediatric populations, and there is a scarcity of studies performed in this age group.

15. Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Determinants of time-trends in exclusivity and continuation of breastfeeding in India: An investigation from the National Family Health Survey

Breastfeeding is an essential key factor for reducing child mortality and the risk of disease. Therefore, to ensure health and wellbeing for all (Sustainable Development Goal 03), and to reduce inequalities in child health status (SDG 10), understanding the determinants of breastfeeding is essential. Our research aims to investigate determinants of different breastfeeding practices from 2005-06 (NFHS-3) to 2015-16 (NFHS-4), and changes in different breastfeeding practices among various demographic, social, religious, and economic groups during this decade. We have used a multivariate binary logistic regression model to estimate significant determinants of different breastfeeding practices. The results show an 8.4% hike in Exclusive Breastfeeding (EBF), along with a 3.3% and 1% drop in the Continuation of Breastfeeding (CBF) up to one and two years respectively during this decade in India. Significant variation has been found in EBF, CBF1 and CBF2 among various categories of child's birth interval, place of residence, social groups, economic communities, and geographic regions. Maternal nutritional status and anemia levels had significant influence on CBF1 and CBF2, and gender of the children on EBF and CBF2 from 2005-06 to 2015-16. There was no significant variation in CBF1 and CBF2 among children born in different birth orders, whereas EBF was significantly less among higher birth orders children. A dramatic improvement in EBF was found among first birth ordered children, teenage and/or highly educated mother, rich families, and in north India, and CBF2 was significantly raised only among higher educated mothers. The estimation of determinants throughout the decade is essential for improving government policies related to supporting and encouraging breastfeeding. The study suggests more initiatives and investment for the promotion, support and improvement of CBF for one and two years, and reduction of inequality among various demographic and socio-economic groups and geographic regions.

Environmental Determinants of Type 1 Diabetes: From Association to Proving Causality

The rising incidence of type 1 diabetes (T1D) cannot be ascribed to genetics alone, and causative environmental triggers and drivers must also be contributing. The prospective TEDDY study has provided the greatest contributions in modern time, by addressing misconceptions and refining the search strategy for the future. This review outlines the evidence to date to support the pathways from association to causality, across all stages of T1D (seroconversion to beta cell failure). We focus on infections and vaccinations; infant growth and childhood obesity; the gut microbiome and the lifestyle factors which cultivate it. Of these, the environmental determinants which have the most supporting evidence are enterovirus infection, rapid weight gain in early life, and the microbiome. We provide an infographic illustrating the key environmental determinants in T1D and their likelihood of effect. The next steps are to investigate these environmental triggers, ideally though gold-standard randomised controlled trials and further prospective studies, to help explore public health prevention strategies.

Diagnosis and treatment of type 1 diabetes at the dawn of the personalized medicine era

Type 1 diabetes affects millions of people globally and requires careful management to avoid serious long-term complications, including heart and kidney disease, stroke, and loss of sight. The type 1 diabetes patient cohort is highly heterogeneous, with individuals presenting with disease at different stages and severities, arising from distinct etiologies, and overlaying varied genetic backgrounds. At present, the “one-size-fits-all” treatment for type 1 diabetes is exogenic insulin substitution therapy, but this approach fails to achieve optimal blood glucose control in many individuals. With advances in our understanding of early-stage diabetes development, diabetes stratification, and the role of genetics, type 1 diabetes is a promising candidate for a personalized medicine approach, which aims to apply “the right therapy at the right time, to the right patient”. In the case of type 1 diabetes, great efforts are now being focused on risk stratification for diabetes development to enable pre-clinical detection, and the application of treatments such as gene therapy, to prevent pancreatic destruction in a sub-set of patients. Alongside this, breakthroughs in stem cell therapies hold great promise for the regeneration of pancreatic tissues in some individuals. Here we review the recent initiatives in the field of personalized medicine for type 1 diabetes, including the latest discoveries in stem cell and gene therapy for the disease, and current obstacles that must be overcome before the dream of personalized medicine for all type 1 diabetes patients can be realized.

Current Perspective of Sialylated Milk Oligosaccharides in Mammalian Milk: Implications for Brain and Gut Health of Newborns

Human milk oligosaccharides (HMOs) are the third most abundant solid component after lactose and lipids of breast milk. All mammal milk contains soluble oligosaccharides, including neutral milk oligosaccharides (NMOs) without sialic acid (Sia) moieties and acidic oligosaccharides or sialylated milk oligosaccharides (SMOs) with Sia residues at the end of sugar chains. The structural, biological diversity, and concentration of milk oligosaccharides in mammalian milk are significantly different among species. HMOs have multiple health benefits for newborns, including development of immune system, modification of the intestinal microbiota, anti-adhesive effect against pathogens, and brain development. Most infant formulas lack oligosaccharides which resemble HMOs. Formula-fed infants perform poorly across physical and psychological wellbeing measures and suffer health disadvantages compared to breast-fed infants due to the differences in the nutritional composition of breast milk and infant formula. Of these milk oligosaccharides, SMOs are coming to the forefront of research due to the beneficial nature of Sia. This review aims to critically discuss the current state of knowledge of the biology and role of SMOs in human milk, infant formula milks, and milk from several other species on gut and brain health of human and animal offspring.

Early Nutrition and Risk of Type 1 Diabetes: The Role of Gut Microbiota

Type 1 diabetes (T1D) appears most frequently in childhood, with an alarming increasing incidence in the last decades. Although the genetic predisposition is a major risk factor, it cannot solely explain the complex etiology of T1D which is still not fully understood. In this paper, we reviewed the most recent findings on the role of early nutrition and the involvement of the gut microbiota in the etiopathogenesis of T1D. The main conclusions that are withdrawn from the current literature regarding alleviating the risk of developing T1D through nutrition are the encouragement of long-term breast-feeding for at least the first 6 months of life and the avoidance of early complementary foods and gluten introduction (before 4 months of age) as well as cow milk introduction before 12 months of life. These detrimental feeding habits create a gut microbiota dysbiotic state that can contribute to the onset of T1D in infancy. Finally, we discussed the possibility to introduce probiotics, prebiotics and post-biotics in the prevention of T1D.

14. Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes-2021

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Digestion of human milk fat in healthy infants

Lipid digestion is critical for infant development, and yet, the interconnection between lipid digestion and the microbiota is largely understudied. This review focuses on digestion of the human milk fat globule and summarizes the current understanding of the mechanisms underlying this process in infants. We first discuss the partial hydrolysis of milk fat in the stomach, which leads to rearrangement of lipid droplets, creating a lipid-water interface necessary for duodenal lipolysis. In the first few months of life, secretion of pancreatic triglyceride lipase, phospholipase A₂, and bile salts is immature. The dominant lipases aiding fat digestion in the newborn small intestine are therefore pancreatic lipase-related protein 2 and bile salt-stimulated lipase from both the exocrine pancreas and milk. We summarize the interaction between ionic fatty acids and cations to form insoluble fatty acid soaps and how it is influenced by various factors, including cation availability, pH, and bile salt concentration, as well as saturation and chain length of fatty acids. We further argue that the formation of the soap complex does not contribute to lipid bioavailability. Next, the possible roles that the gut microbiota plays in lipid digestion and absorption are discussed. Finally, we provide a perspective on how the manufacturing process of infant formula and dairy products may alter the physical properties and structure of lipid droplets, thereby altering the rate of lipolysis.

The role of vitamin A and its pro-vitamin carotenoids in fetal and neonatal programming: gaps in knowledge and metabolic pathways

Vitamin A (VA) and its pro-vitamin carotenoids are naturally occurring lipophilic compounds involved in several cellular processes and metabolic pathways. Despite their broad spectrum of activities in the general population, dietary deficiencies of these compounds can potentially affect pregnancy outcomes. Since maternal nutritional status and diet composition during pregnancy and lactation can have long-lasting effects in offspring until adulthood, this study presents an overview of VA and the role of pro-VA carotenoids during pregnancy and lactation – the nutrition, metabolism, and biological effects in the offspring. The review aimed to discuss the pro-VA carotenoids and VA-associated pathways and summarize the results with reference to gestational disorders, and VA and pro-VA carotenoids as preventive agents. Also, considering that obesity, overweight, and metabolic diseases are major public health concerns worldwide, fetal and neonatal development is discussed, highlighting the physiological role of these molecules in obesity prevention. This review comprehensively summarizes the current data and shows the potential impact of these compounds on nutritional status in pregnancy and lactation.

Prenatal and postnatal determinants in shaping offspring's microbiome in the first 1000 days: study protocol and preliminary results at one month of life

BACKGROUND

Fetal programming during in utero life defines the set point of physiological and metabolic responses that lead into adulthood; events happening in "the first 1,000 days" (from conception to 2-years of age), play a role in the development of non-communicable diseases (NCDs). The infant gut microbiome is a highly dynamic organ, which is sensitive to maternal and environmental factors and is one of the elements driving intergenerational NCDs' transmission. The A.MA.MI (Alimentazione MAmma e bambino nei primi MIlle giorni) project aims at investigating the correlation between several factors, from conception to the first year of life, and infant gut microbiome composition. We described the study design of the A.MA.MI study and presented some preliminary results.

METHODS

A.MA.MI is a longitudinal, prospective, observational study conducted on a group of mother-infant pairs (n = 60) attending the Neonatal Unit, Fondazione IRCCS Policlinico San Matteo, Pavia (Italy). The study was planned to provide data collected at T0, T1, T2 and T3, respectively before discharge, 1,6 and 12 months after birth. Maternal and infant anthropometric measurements were assessed at each time. Other variables evaluated were: pre-pregnancy/gestational weight status (T0), maternal dietary habits/physical activity (T1-T3); infant medical history, type of feeding, antibiotics/probiotics/supplements use, environment exposures (e.g cigarette smoking, pets, environmental temperature) (T1-T3). Infant stool samples were planned to be collected at each time and analyzed using metagenomics 16S ribosomal RNA gene sequence-based methods.

RESULTS

Birth mode (cesarean section vs. vaginal delivery) and maternal pre pregnancy BMI (BMI < 25 Kg/m² vs. BMI ≥ 25 Kg/m²), significant differences were found at genera and species levels (T0). Concerning type of feeding (breastfed vs. formula-fed), gut microbiota composition differed significantly at genus and species level (T1).

CONCLUSION

These preliminary and explorative results confirmed that pre-pregnancy, mode of delivery and infant factors likely impact infant microbiota composition at different levels.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04122612.

Breastfeeding is associated with reduced risk of multiple sclerosis in males, predominantly among HLA-DRB1*15:01 carriers

BACKGROUND

Breastfeeding as an infant appears protective against later development of some autoimmune diseases, but research into its influence on multiple sclerosis (MS) risk has yielded inconclusive results.

OBJECTIVE

We investigated the possible impact of breastfeeding on MS risk.

METHODS

We used two population-based case-control studies comprising 3670 cases and 6737 matched controls. Logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI) for association between MS and exposure to prolonged breastfeeding (4 months or longer) versus reduced breastfeeding (less than 4 months). A meta-analysis of case-control studies that assessed the impact of breastfeeding on MS risk among women and men was conducted.

RESULTS

Prolonged breastfeeding was associated with reduced MS risk among men (OR 0.7, 95% CI 0.5-0.9) but not among women (OR 0.9, 95% CI 0.8-1.1). Among men, a synergistic effect was observed between HLA-DRB1*15:01 carrier status and reduced breastfeeding.

CONCLUSIONS

Findings from the current study add to accumulating evidence that breastfeeding may be a modifiable protective factor for reducing the risk of MS in offspring. When possible, mothers should be supported to breastfeed their infants; however, the mechanism of a sex-specific biologic effect of breastfeeding on MS risk is unclear.

Management of pregestational diabetes mellitus: a comparison of guidelines

Background: Pregestational diabetes is associated with adverse maternal and neonatal outcomes. The aim of this study was to summarize and compare evidence-based recommendations on pregestational diabetes and to focus especially on issues related to the management of this entity.Materials and methods: A descriptive review of three recently published national guidelines on pregestational diabetes was conducted: the American Diabetes Association on "Diabetes in Pregnancy: Standards of Medical Care in Diabetes - 2019," the National Institute for Health and Care Excellence on "Diabetes in pregnancy: management from preconception to the postnatal period" and the American College of Obstetricians and Gynecologists on "Pregestational Diabetes Mellitus." These guidelines were compared according to recommendations on management, during the preconception, antenatal, intrapartum and postpartum period.Results: There were many similar recommendations regarding the preconception counseling, the antepartum assessment by specialists, the glycemic control target levels, the pharmacologic treatment and the postpartum period among the three guidelines. On the other hand, the American Diabetes Association makes no recommendations regarding fetal monitoring and obstetric management during pregnancy and the intrapartum period, while there are several similarities between the other two guidelines.Conclusions: The adoption of an international consensus based on evidence - based guidelines will increase the awareness of the healthcare professionals on the management of pregestational diabetes, leading that way to more favorable perinatal outcomes.

14. Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes-2020

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Milk exosomal miRNAs: potential drivers of AMPK-to-mTORC1 switching in β-cell de-differentiation of type 2 diabetes mellitus

Type 2 diabetes mellitus (T2DM) steadily increases in prevalence since the 1950's, the period of widespread distribution of refrigerated pasteurized cow's milk. Whereas breastfeeding protects against the development of T2DM in later life, accumulating epidemiological evidence underlines the role of cow's milk consumption in T2DM. Recent studies in rodent models demonstrate that during the breastfeeding period pancreatic β-cells are metabolically immature and preferentially proliferate by activation of mechanistic target of rapamycin complex 1 (mTORC1) and suppression of AMP-activated protein kinase (AMPK). Weaning determines a metabolic switch of β-cells from a proliferating, immature phenotype with low insulin secretion to a differentiated mature phenotype with glucose-stimulated insulin secretion, less proliferation, reduced mTORC1- but increased AMPK activity. Translational evidence presented in this perspective implies for the first time that termination of milk miRNA transfer is the driver of this metabolic switch. miRNA-148a is a key inhibitor of AMPK and phosphatase and tensin homolog, crucial suppressors of mTORC1. β-Cells of diabetic patients return to the postnatal phenotype with high mTORC1 and low AMPK activity, explained by continuous transfer of bovine milk miRNAs to the human milk consumer. Bovine milk miRNA-148a apparently promotes β-cell de-differentiation to the immature mTORC1-high/AMPK-low phenotype with functional impairments in insulin secretion, increased mTORC1-driven endoplasmic reticulum stress, reduced autophagy and early β-cell apoptosis. In contrast to pasteurized cow's milk, milk's miRNAs are inactivated by bacterial fermentation, boiling and ultra-heat treatment and are missing in current infant formula. Persistent milk miRNA signaling adds a new perspective to the pathogenesis of T2DM and explains the protective role of breastfeeding but the diabetogenic effect of continued milk miRNA signaling by persistent consumption of pasteurized cow's milk.

The effects of expressing antenatal colostrum in women with diabetes in pregnancy: A retrospective cohort study

BACKGROUND

Some women with diabetes in pregnancy express and store colostrum in the antenatal period for the purposes of preventing and treating neonatal hypoglycaemia.

AIMS

Our primary aim was to compare rates of neonatal hypoglycaemia in babies born to mothers who express and store antenatal colostrum to babies born to mothers who do not.

MATERIALS AND METHODS

Retrospective cohort study involving 357 women with diabetes in pregnancy, who had live, singleton births delivered after 36 weeks gestation, in a regional hospital in North Queensland (2014-2015). Multivariable binary logistic regression modelling identified independent characteristics associated with primary outcomes.

RESULTS

Eighty women (23%) expressed antenatal colostrum and 223 (62%) did not. One hundred and thirty-one babies (37%) were diagnosed with hypoglycaemia. Aboriginal and Torres Strait Islander women were less likely to express than Caucasian women (odds ratio (OR) 0.10, 95% confidence interval (CI) 0.01-0.77). There were no significant differences in the rates of hypoglycaemia, or median blood glucose levels in babies born to mothers who expressed antenatal colostrum compared to babies born to mothers who did not express. Babies born to mothers who expressed were significantly less likely to receive formula in hospital compared to babies born to mothers who did not (OR 0.12, 95% CI 0.05-0.32).

CONCLUSIONS

We found no independent association of expressing antenatal colostrum on rates of neonatal hypoglycaemia or median blood glucose levels. Expressing antenatal colostrum may have some benefits to the newborn such as reduced formula consumption in hospital. Further research into other methods of reducing neonatal hypoglycaemia appears warranted.

Perspectives and experiences of collecting antenatal colostrum in women who have had diabetes during pregnancy: a North Queensland semistructured interview study

OBJECTIVES

To explore and describe the experiences and perspectives of collecting and storing colostrum in the antenatal period in women who have had diabetes in pregnancy.

DESIGN

Face-to-face, semistructured interviews analysed with purposive sampling and thematic analysis.

SETTING

A regional hospital in North Queensland with a high prevalence of diabetes in pregnancy.

PARTICIPANTS

Six women with a previous pregnancy complicated by diabetes who were advised to collect and store colostrum in pregnancy.

RESULTS

Six themes were identified: wariness of medicalisation (adjusting to an 'abnormal' pregnancy, seeking continuity of care, determination to reduce formula, fear of invasive intervention); underlying altruism (providing the best for baby, preparing for complications, eager for milk donation); internal pressure to succeed (coping with confronting information, disheartened by failures, constant fear of insufficient supply, overwhelming guilt, concern for future breastfeeding success); self-management and ownership (adapting to awkwardness, developing strategies for success, actively seeking education, gaining confidence to request help, accepting personal limitations); frustrated by waste (encroaching on time, squandering a precious resource, ambiguous about necessity) and building fortitude for motherhood (physically preparing for breast feeding, symbolic of the imminent infant, establishing early relationships with supports, approaching challenges with realistic optimism).

CONCLUSION

Women with diabetes in pregnancy experience guilt and stress about the added risk of hypoglycaemia to their babies and strive to provide the best for their babies by collecting and storing colostrum, even if this leads to distress to themselves. It is crucial that these women be provided accurate, realistic advice about the benefits and disadvantages of collecting colostrum in the antenatal period.

14. Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes-2019

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

No evidence of the role of early chemical exposure in the development of β-cell autoimmunity

Exposure to environmental chemicals can modulate the developing immune system, but its role in the pathogenesis of type 1 diabetes is largely unexplored. Our objective was to study the levels of circulating concentrations of environmental pollutants during the first years of life and their associations with the later risk of diabetes-predictive autoantibodies. From two birth-cohort studies including newborn infants with HLA-conferred susceptibility to type 1 diabetes (FINDIA and DIABIMMUNE), we identified case children with at least one biochemical diabetes-associated autoantibody (n = 30-40) and from one to four autoantibody-negative controls per each case child matched for age, gender, diabetes-related HLA-risk, delivery hospital, and, in FINDIA, also dietary intervention group. Plasma levels of 13 persistent organic pollutants and 14 per- and polyfluorinated substances were analyzed in cord blood and plasma samples taken at the age of 12 and 48 months. Both breastfeeding and the geographical living environment showed association with circulating concentrations of some of the chemicals. Breastfeeding-adjusted conditional logistic regression model showed association between decreased plasma HBC concentration at 12-month-old children and the appearance of diabetes-associated autoantibodies (HR, 0.989; 95% Cl, 0.978-1.000; P = 0.048). No association was found between the plasma chemical levels and the development of clinical type 1 diabetes. Our results do not support the view that exposure to the studied environmental chemicals during fetal life or early childhood is a significant risk factor for later development of β-cell autoimmunity and type 1 diabetes.

Maternal prepregnancy BMI or weight and offspring's blood pressure: Systematic review

Emerging evidence suggests that maternal prepregnancy body mass index or weight (MPBW) may be associated with offspring's blood pressure (BP). Therefore, we conducted a systematic review-following the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement-to assess and judge the evidence for an association between MPBW with offspring's later BP. Five data bases were searched without limits. Risk of bias was assessed using the "Tool to Assess Risk of Bias in Cohort Studies," and an evidence grade was allocated following the World Cancer Research Fund criteria. Of 2,011 publications retrieved, 16 studies (all cohort studies) were included in the systematic review; thereof, 5 studies (31%) were rated as good-quality studies. Overall, data from 63,959 participants were enclosed. Systolic BP was analysed in 15 (5 good quality), diastolic BP in 12 (3 good quality), and mean arterial pressure in 3 (no good quality) studies. Five good-quality studies of MPBW with offspring's systolic BP as the outcome and 1 good-quality study with offspring's diastolic BP as the outcome observed a significant association. However, after adding offspring's anthropometry variables to the statistical model, the effect attenuated in 4 studies with systolic BP to nonsignificance, the study with diastolic BP remained significant. No good-quality studies were found with respect to offspring's later mean arterial pressure. In conclusion, this systematic review found suggestive, but still limited, evidence for an association between MPBW with offspring's later BP. The available data suggest that the effect might be mainly mediated via offspring's anthropometry.

Is age of menarche among school girls related to breastfeeding during infancy?

OBJECTIVES

Breastfeeding has been linked to various disease conditions in adulthood. Age of menarche has been proposed to be an intermediary factor on the life-course path to these disease conditions, but the link between breastfeeding and age of menarche remains under debate. This study aimed to investigate the association between age of menarche and breastfeeding during infancy.

METHODS

A cross-sectional study was conducted in which 775 female high school students were randomly selected from private and public high schools in all provinces in Kuwait. Data on age of menarche were collected by self-administered questionnaires from the students, while data on breastfeeding were collected from their mothers through telephone interviews. Multiple linear regression was used to investigate the association between breastfeeding and age of menarche after adjusting for potential confounders.

RESULTS

Of the study group 496 mothers responded to the telephone interview. Duration of breastfeeding was not significantly associated with age of menarche before or after adjusting for potential confounders (P = .279 and P = .124 for crude and fully adjusted model, respectively). Similarly, no significant association was found between type of breastfeeding during the first four months of life and age of menarche before or after adjusting for potential confounders (P = .949 and P = .398 for crude and fully adjusted model, respectively).

CONCLUSION

No significant association was found between age of menarche and breastfeeding during infancy, which may suggest that the link between breastfeeding and disease conditions in adulthood is not necessarily mediated through age of menarche.

13. Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes-2018

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Early-Life Nutritional Factors and Mucosal Immunity in the Development of Autoimmune Diabetes

Type 1 diabetes (T1D) is an immune-mediated disease with a strong genetic basis but might be influenced by non-genetic factors such as microbiome development that “programs” the immune system during early life as well. Factors influencing pathogenesis, including a leaky intestinal mucosal barrier, an aberrant gut microbiota composition, and altered immune responsiveness, offer potential targets for prevention and/or treatment of T1D through nutritional or pharmacologic means. In this review, nutritional approaches during early life in order to protect against T1D development have been discussed. The critical role of tolerogenic dendritic cells in central and peripheral tolerance has been emphasized. In addition, since the gut microbiota affects the development of T1D through short-chain fatty acid (SCFA)-dependent mechanisms, we hypothesize that nutritional intervention boosting SCFA production may be used as a novel prevention strategy. Current retrospective evidence has suggested that exclusive and prolonged breastfeeding might play a protective role against the development of T1D. The beneficial properties of human milk are possibly attributed to its bioactive components such as unique immune-modulatory components human milk oligosaccharides and metabolites derived thereof, including SCFAs. These components might play a key role in healthy immune development and creating a fit and resilient immune system in early and later life.

Infant and young child feeding patterns in Kuwait: results of a cross-sectional survey

OBJECTIVE

The beneficial role of breast-feeding for maternal and child health is now well established. Its possible role in helping to prevent diabetes and obesity in children in later life means that more attention must be given to understanding how patterns of infant feeding are changing. The present study describes breast-feeding profiles and associated factors in Kuwait. Design/Setting/Subjects Interviews with 1484 recent mothers were undertaken at immunisation clinics across Kuwait. Descriptive analysis and binary logistic regression of results were performed.

RESULTS

Rates of breast-feeding initiation in Kuwait were high (98·1 %) but by the time of discharge from hospital, only 36·5 % of mothers were fully breast-feeding, 37·0 % were partially breast-feeding and 26·5 % were already fully formula-feeding. Multiple social and health reasons were given for weaning the child, with 87·6 % of mothers who had stopped breast-feeding completely doing so within 3 months postpartum. Nationality (P<0·001), employment status 6 months prior to delivery (P<0·001), mode of delivery (P=0·01), sex of the child (P=0·026) and breast-feeding information given by nurses (P=0·026) were all found to be significantly associated with breast-feeding. Few women (5·6 %) got information on infant nutrition and feeding from nursing staff, but those who did were 2·54 times more likely to be still breast-feeding at discharge from hospital. Over 70 % of mothers had enjoyed breast-feeding and 74 % said they would be very likely to breast-feed again.

CONCLUSIONS

In Kuwait where the prevalence of both obesity and type 2 diabetes is growing rapidly, the public health role of breast-feeding must be recognised and acted upon more than it has in the past.

Childhood type 2 diabetes: Risks and complications

The universal endocrine pathological state affecting young individuals and adults is type 2 diabetes mellitus, which has seen a significant increase in the last 30 years, particularly in children. Genetic and evnironmental factors are the causative agents for this pathological state in children. This rapid and wide spread of the disease can be controlled by enforcing amendments in environmental factors such as diet, physical activities and obesity. In young infants breastfeeding may be a key modulator of the disease. Associated disorders co-observed in the patients of type 2 diabetes mellitus include renal failure, heart problems and circulatory dysfunctionalities, such as cardiac failure and vision disability. These associated disorders become more pronounced in young patients when they reach puberty. To overcome the lethal outcomes of the disease, early screening of the disease is crucial. The present review focused on the latest updates in the field, as well as plausible risks and complications of this pathological state.

Maternal Milk T Cells Drive Development of Transgenerational Th1 Immunity in Offspring Thymus

Using multiple murine foster-nursing protocols, thereby eliminating placental transfer and allowing a distinction between dam- and pup-derived cells, we show that foster nursing by an immunized dam results in development of CD8(+) T cells in nonimmunized foster pups that are specific for Ags against which the foster dam was immunized (Mycobacterium tuberculosis or Candida albicans). We have dubbed this process "maternal educational immunity" to distinguish it from passive cellular immunity. Of the variety of maternal immune cells present in milk, only T cells were detected in pup tissues. Maternal T cells, a substantial percentage of which were CD4(+)MHC class II(+), accumulated in the pup thymus and spleen during the nursing period. Further analysis of maternal cells in the pup thymus showed that a proportion was positive for maternal immunogen-specific MHC class II tetramers. To determine the outcome of Ag presentation in the thymus, the maternal or foster pup origin of immunogen-responding CD8(+) cells in foster pup spleens was assessed. Whereas ∼10% were maternally derived in the first few weeks after weaning, all immunogen-responding CD8(+) T cells were pup derived by 12 wk of age. Pup-derived immunogen-responsive CD8(+) cells persisted until at least 1 y of age. Passive cellular immunity is well accepted and has been demonstrated in the human population. In this study, we show an arguably more important role for transferred immune cells: the direction of offspring T cell development. Harnessing maternal educational immunity through prepregnancy immunization programs has potential for improvement of infant immunity.

Breast milk and its impact on maturation of the neonatal immune system

PURPOSE OF REVIEW

This article aims to review the evidence that breast milk can actively shape neonate gut immune system development toward a mature immune system capable of responding appropriately to encountered antigens.

RECENT FINDINGS

Recent findings in the adult have demonstrated the critical role of the interaction between diet, gut microbiota, gut epithelial cells and gut-associated lymphoid tissue in the development of immune responses. Here, we will review what is known in this field in the neonate, compare these data to those obtained in the adult and review how milk factors impact gut immune function in the short and long term.

SUMMARY

We propose that the neonate immune system and maternal milk represent an entity necessary to ensure not only appropriate function in early life but also long term immune homeostasis.

Physiological mechanisms, behavioral and psychological factors influencing the transfer of milk from mothers to their young

This article is part of a Special Issue "Parental Care".Producing milk to support the growth of their young is a central element of maternal care in mammals. In spite of the facts that ecological constraints influence nursing frequency, length of time until weaning and the composition of milk, there is considerable similarity in the anatomy and physiology of milk production and delivery across mammalian species. Here we provide an overview of cross species variation in nursing patterns and milk composition as well as the mechanisms underlying mammary gland development, milk production and letdown. Not all women breastfeed their infants, thus in later sections we review studies of factors that facilitate or impede the initiation and duration of breastfeeding. The results of these investigations suggest that the decisions to initiate and maintain breastfeeding are influenced by an array of personal, social and biological factors. Finally, studies comparing the development of breastfed and formula fed infants as well as those investigating associations between breastfeeding, maternal health and mother/infant interaction are reviewed. Leading health agencies including the World Health Organization and CDC advocate breastfeeding for at least the first 6months postpartum. To achieve these rates will require not only institutional support but also a focus on individual mother/infant dyads and their experience.

African-American Women's Perceptions and Experiences About Breastfeeding

There are health benefits to breastfeeding for both mothers and their children. The preventive health effects of breastfeeding continue into adulthood, lowering rate of various chronic illnesses. African-American women, especially of lower socioeconomic status, are less likely to breastfeed in comparison to their racial and ethnic counterparts. The purpose of this study is to explore how African-American women experience breastfeeding in the early stages of postpartum care. Two focus groups (N = 20, 10 in each group) were conducted with African-American mothers. Results revealed that participants felt that there were health benefits to breastfeeding, and organizations such as Women, Infants, and Children (WIC) provided support. However, participants stated that lack of information, negative perceptions, and unforeseen circumstances were barriers to breastfeeding. This study proposes support and interventions for this group to increase breastfeeding among this population.

Breastfeeding and childhood acute otitis media: a systematic review and meta-analysis

AIM

To synthesise the evidence on the association between duration and exclusivity of breastfeeding and the risk of acute otitis media (AOM).

METHODS

Systematic review and meta-analysis following searching of PubMed, CINAHL and EMBASE electronic databases.

RESULTS

Twenty-four studies, all from the USA or Europe, met the inclusion criteria. In the pooled analyses, any form of breastfeeding was found to be protective for AOM in the first 2 years of life. Exclusive breastfeeding for the first 6 months was associated with the greatest protection (OR 0.57 95% CI 0.44, 0.75), followed by 'more vs less' breastfeeding (OR 0.67; 0.59, 0.76) and 'ever vs never' breastfeeding (OR 0.67; 0.56, 0.80).

CONCLUSION

This systematic review and meta-analysis provides evidence that breastfeeding protects against AOM until 2 years of age, but protection is greater for exclusive breastfeeding and breastfeeding of longer duration. Exclusive breastfeeding during the first 6 months was associated with around a 43% reduction in ever having AOM in the first 2 years of life. After 2 years of age, there is no evidence that breastfeeding protects against AOM; however, there were few studies and the evidence quality was low.

Anemia in Patients with Type 2 Diabetes Mellitus

The objective of this study was to evaluate the prevalence of anemia in DM2 patients and its correlation with demographic and lifestyle and laboratory variables. This is a descriptive and analytical study of the type of case studies in the urban area of the Ijuí city, registered in programs of the Family Health Strategy, with a total sample of 146 patients with DM2. A semistructured questionnaire with sociodemographic and clinical variables and performed biochemical test was applied. Of the DM2 patients studied, 50 patients had anemia, and it was found that the body mass items and hypertension and hematological variables are significantly associated with anemia of chronic disease. So, the prevalence of anemia is high in patients with DM2. The set of observed changes characterizes the anemia of chronic disease, which affects quality of life of diabetic patients and is associated with disease progression, development, and comorbidities that contribute significantly to increasing the risk of cardiovascular diseases.

Recommendations on complementary feeding for healthy, full-term infants

Weaning (or introduction of complementary feeding) is a special and important moment in the growth of a child, both for the family and the infant itself, and it can play a major role in the child’s future health. Throughout the years, various weaning modes have come in succession, the latest being baby-led weaning; the timing for introducing foods and the requirements of which sort of nutrient for weaning have also changed over time. Furthermore, the role played by nutrition, especially in the early stages of life, for the onset of later non-communicable disorders, such as diabetes, obesity or coeliac disease has also been increasingly highlighted.

Members of Italian Society of Gastroenterology, Hepathology and Pediatric Nutrition (SIGENP) and the Italian Society of Allergology and Pediatric Immunology (SIAIP) Emilia Romagna here propose a practical approach for pediatricians to deal with daily practice. The four main areas for discussion were weaning in relation with the onset of allergic diseases, coeliac disease, diabetes and metabolic syndrome, the nutrition requirements to take into account for assessing the diet of infants under one year of age and about the practice of baby-led weaning focusing on limits and benefits, respectively.

Luminex and other multiplex high throughput technologies for the identification of, and host response to, environmental triggers of type 1 diabetes

Complex interactions between a series of environmental factors and genes result in progression to clinical type 1 diabetes in genetically susceptible individuals. Despite several decades of research in the area, these interactions remain poorly understood. Several studies have yielded associations of certain foods, infections, and immunizations with the onset and progression of diabetes autoimmunity, but most findings are still inconclusive. Environmental triggers are difficult to identify mainly due to (i) large number and complex nature of environmental exposures, including bacteria, viruses, dietary factors, and environmental pollutants, (ii) reliance on low throughput technology, (iii) less efforts in quantifying host response, (iv) long silent period between the exposure and clinical onset of T1D which may lead to loss of the exposure fingerprints, and (v) limited sample sets. Recent development in multiplex technologies has enabled systematic evaluation of different classes of molecules or macroparticles in a high throughput manner. However, the use of multiplex assays in type 1 diabetes research is limited to cytokine assays. In this review, we will discuss the potential use of multiplex high throughput technologies in identification of environmental triggers and host response in type 1 diabetes.

Understanding the role of gut microbiome in metabolic disease risk

The gut microbiota structure, dynamics, and function result from interactions with environmental and host factors, which jointly influence the communication between the gut and peripheral tissues, thereby contributing to health programming and disease risk. Incidence of both type-1 and type-2 diabetes has increased during the past decades, suggesting that there have been changes in the interactions between predisposing genetic and environmental factors. Animal studies show that gut microbiota and its genome (microbiome) influence alterations in energy balance (increased energy harvest) and immunity (inflammation and autoimmunity), leading to metabolic dysfunction (e.g., insulin resistance and deficiency). Thus, although they have different origins, both disorders are linked by the association of the gut microbiota with the immune-metabolic axis. Human studies have also revealed shifts in microbiome signatures in diseased subjects as compared with controls, and a few of them precede the development of these disorders. These studies contribute to pinpointing specific microbiome components and functions (e.g., butyrate-producing bacteria) that can protect against both disorders. These could exert protective roles by strengthening gut barrier function and regulating inflammation, as alterations in these are a pathophysiological feature of both disorders, constituting common targets for future preventive approaches.