1056593

research-article2021
JHLXXX10.1177/08903344211056593Journal of Human LactationAldridge

Original Research
Journal of Human Lactation
2022, Vol. 38(1) 141­–147
© The Author(s) 2021
Lactation Consultation by an Article reuse guidelines:
sagepub.com/journals-permissions

International Board Certified Lactation DOI: 10.1177/08903344211018622

https://doi.org/10.1177/08903344211018622
journals.sagepub.com/home/jhl

Consultant Improves Breastfeeding

Rates for Mothers With Gestational
Diabetes Mellitus

Laurie Beth Griffin, MD, PhD1 , Jia Jennifer Ding, MD1, Phinnara Has, MS1,
Nina Ayala, MD1, and Martha B. Kole-White, MD1

Abstract
Background: In patients with gestational diabetes, breastfeeding decreases the lifetime risk of Type 2 diabetes by half.
Lactation consultation has been shown to increase breastfeeding rates in the general population but has not been assessed
in a gestational diabetes population.
Research Aims: To determine if (1) a postpartum International Board Certified Lactation Consultant (IBCLC) consulta-
tion during delivery hospitalization improved inclusive (any) or exclusive breastfeeding rates at hospital discharge and 3
months postpartum in participants with GDM; and if (2) obstetrical providers’ acknowledgement of maternal feeding prefer-
ence affected the rates of IBCLC consultation for patients.
Methods: This was a retrospective, comparative, secondary analysis of a prospective cohort (N = 517) study of women
gestational diabetes. Participants who received a IBCLC consultation (n = 386; 74.5%) were compared to those who did not
(n = 131; 25.5%). Baseline demographics, antepartum characteristics, neonatal information, mode of infant feeding at hospital
discharge and 3 months postpartum, and IBCLC consultation during postpartum hospitalization were measured.
Results: After adjusting for baseline differences, participants who received an IBCLC consultation were more likely to re-
port any breastfeeding at postpartum discharge (aOR 4.87; 95% CI [2.67, 8.86]) and at 3 months postpartum (aOR 5.39; 95%
CI [2.61, 11.16]) compared to participants who did not. However, there was no difference in exclusive breastfeeding rates
between those who did and did not receive IBCLC consultation.
Conclusion: Inpatient IBCLC consultation during the immediate postpartum period was associated with improved rates of
any breastfeeding in participants with GDM.

Keywords
breastfeeding, breastfeeding rates, exclusive breastfeeding, International Board Certified Lactation Consultant, lactation,
lactation education, postpartum care, predominant breastfeeding

Background per decade, ultimately to a 50-year risk of nearly 60% (Li

et al., 2020).
Gestational diabetes mellitus (GDM) affects about 5%–9%
of pregnancies in the United States (Correa et al., 2015;
DeSisto et al., 2014) with low income and minority women 1
Department of Obstetrics and Gynecology, Women and Infants Hospital,
being at increased risk of developing GDM (Bower et al., Alpert Medical School of Brown University, Providence, RI, USA
2019). Women with GDM are at higher risk for long-term Date submitted: December 04, 2020; Date accepted: April 29, 2021.
health complications, including the development of Type 2
Corresponding Author:
diabetes mellitus (T2DM). A recent meta-analysis estimated
Laurie Beth Griffin, MD, PhD, Women and Infants Hospital, Division of
that women with a history of GDM have a 19% 10-year risk Maternal Fetal Medicine, 101 Dudley Street, Providence, RI 02906, USA.
of developing T2DM and that risk continues to increase 10% Email: [email protected]
142
2 Journal of Human Lactation 38(1)
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Breastfeeding has been shown to improve maternal glu-

cose metabolism and decrease rates of development of Key Messages
T2DM in women with GDM (Buchanan et al., 1999;
Gunderson et al., 2015; Kjos et al., 1995; Ley et al., 2020; • We do not know if International Board Certified
Lactation Consultant (IBCLC) consultation is suf-
Martens et al., 2016; Stuebe et al., 2005; Ziegler et al., 2012).
ficient to increase breastfeeding rates in mothers
Interestingly, researchers have suggested a dose-dependent with gestational diabetes.
relationship between lactation intensity and duration and the • Participants with gestational diabetes who received
risk of developing T2DM (Gunderson et al., 2015; Ley et al., a IBCLC consultation were more likely to report
2020; Martens et al., 2016; Ziegler et al., 2012). Specifically, any breastfeeding during postpartum hospitalization
Ziegler et al. (2012) demonstrated that, in women who and 3 months postpartum compared to partici-
breastfeed, the median time to the development of T2DM pants who did not receive a consultation.
increased from 2.3 to 12.3 years, with the lowest risk of • Our findings suggest that in-hospital lactation con-
T2DM in women who breastfed for more than 3 months. The sultation by an IBCLC is an important, efficacious
means of breastfeeding support for women with
SWIFT study (Gunderson et al., 2015), a prospective obser-
gestational diabetes.
vational cohort study with women having GDM, demon-
strated that participants with increased lactation intensity at
2 months and those who lactated for 2–10 months had a
36%–57% relative reduction in the incidence of T2DM at 2
years.
In the United States, women with GDM have been shown Methods
to initiate breastfeeding at the same rate as mothers without
GDM (Oza-Frank et al., 2016); however, mothers with GDM Design
have increased rates of early formula introduction and This was a retrospective, two-group comparison of participant
decreased duration of lactation (Oza-Frank et al., 2016). with gestational diabetes, who had participated in a prospec-
Barriers, including low milk supply and NICU admission, tive, longitudinal cohort study (Werner et al., 2019).
may differentially affect mothers with GDM. Mothers often Institutional Review Board approval was obtained.
cite low milk supply as a major contributor to why they cease
breastfeeding earlier than planned. Riddle and Nommsen-
Rivers (2016) found that women with diabetes in pregnancy Setting and Relevant Context
were more likely to have low milk supply than women with-
Our institution serves a large, racially, ethnically, and socio-
out diabetes. Additionally, neonates born to mothers with
economically diverse cohort of women in the United States
GDM are at increased risk of NICU admission, resulting in
and provides delivery care for 90% of all births in the state of
physical separation of mother and baby (Doughty et al.,
Rhode Island. At our institution, which is designated a “Baby
2018).
Friendly” hospital (World Health Organization [WHO] and
Researchers have shown that intensive interventions, for
United Nations Children’s Fund [UNICEF], 2009), neonatal
example the Nutrition, Exercise and Coping Skills Training care of infants born to women with GDM is standardized.
(NEST), an intervention that involves multiple prenatal and Mothers who desire to breastfeed are aided by experienced
postpartum breastfeeding education sessions, decreased the labor and delivery nurses for the initial postpartum period.
introduction of formula and increased the duration of breast- Skin-to-skin contact is strongly encouraged for the first
feeding in women with GDM (Stuebe et al., 2016). 60–90 min for a stable infant and the first feeding is pre-
Unfortunately, intensive interventions (e.g., NEST) are not scribed within 1 hr of life. Postpartum IBCLC consultation is
easily accessible to most women with GDM. In-hospital available for all women who desire to breastfeed. IBCLCs
consultation by an International Board Certified Lactation are notified of women who are having difficulties with
Consultant (IBCLC) or other lactation support providers breastfeeding either via a formal lactation consultation order
have been shown to increase the number of women who ini- placed by the patient’s obstetrician or midwife or during a
tiate breastfeeding and continue breastfeeding at 1 month of daily meeting between nursing staff and IBCLCs. Patients
age in the general population (Patel & Patel, 2016). The aims may also request to be seen by an IBCLC. All women are
of our study were to determine if (1) a postpartum IBCLC provided with a written packet of information discussing lac-
consultation during delivery hospitalization improved inclu- tation services available both during admission and after dis-
sive (any) or exclusive breastfeeding rates at hospital dis- charge and are provided with a hotline number for postpartum
charge and 3 months postpartum in participants with GDM IBCLC lactation support. The most recent data from our
and if (2) obstetrical provider’s acknowledgement of mater- institution suggests that > 80% of women initiate skin-to-
nal feeding preference affected the rates of IBCLC consulta- skin contact postpartum; however, only 37% of women
tion for patients. breastfeed exclusively during their postpartum admission.
Griffin et al. 143
3

Sample option of self-identifying as “Hispanic.” Primary language,

maternal age, parity, delivery body mass index (BMI),
Eligible women were ≥ 18 years, fluent in either English or insurance information, GDM medication requirements, and
Spanish, and diagnosed with GDM during their pregnancy intrapartum, neonatal, and postpartum characteristics were
either by a 1-hr glucose challenge test value ≥ 200 mg/dl or abstracted retrospectively from participants’ and neonates’
by the Carpenter-Coustan criteria cutoffs on the 3 hr 100 g medical records after participant consent for enrollment.
glucose tolerance test. Women planning to obtain postpar- “Primary English speaking” was defined based on English
tum care outside of the state were excluded to ensure that all being documented as their preferred language in the chart.
follow-up records could be obtained (Werner et al., 2019). “Maternal age” was defined as the age of the participant at
Six hundred patients were enrolled in the primary study the time delivery. “Parous” was defined as having had at least
during their postpartum hospitalization. Importantly, both in one delivery at > 20 weeks gestation in a prior pregnancy.
the parent study and in this study, the large sample size “Delivery BMI” was defined as the BMI recorded at the time
ensured the participants enrolled would not only be represen- of delivery calculated based on patient self-reported most
tative of the diverse population served by our institution but recent weight and height. “Private insurance” was defined as
would also enable us to assess the influence of IBCLC lacta- non-state or federally provided health insurance.
tion consultation on breastfeeding rates at hospital discharge
or 3 months postpartum. Of the 600 women who consented
Perinatal and Infant Variables. Labor onset was defined
to participate in the primary study, 575 had breastfeeding
as “spontaneous” if no induction agents were used versus
data. Of those women, 58 (10.1%) expressed a desire to
“induction of labor” if medications or mechanical dilators
exclusively formula feed and were excluded. Therefore, 517
were used to induce labor. Mode of delivery was defined
women were included in this secondary analysis.
as “vaginal delivery” if the neonate was delivered vagi-
Using our known sample size and institutional data
nally either spontaneously or via assistance with forceps or
demonstrating that 37% of women with GDM breastfeed
a vacuum or “cesarean delivery" if an abdominal delivery
during their postpartum hospitalization, if 80% of our cohort
was performed. “Delivery timing” was defined as the ges-
received an IBCLC consultation, we would have 80% power
tational age at the time of delivery as calculated based on
to detect a 13% difference in the rate of any breastfeeding at
the American College of Obstetricians and Gynecologists
hospital discharge between women who did and did not
guidelines for pregnancy dating (American College of
receive an IBCLC consultation. The sample size was ade-
Obstetricians and Gynecologists, 2017). Apgar scores were
quate to detect a difference in the rate of any breastfeeding in
based on the infant’s assigned score on the Apgar standard-
our cohort between women who did and did not receive a
ized infant assessment scale at 1 min and 5 min after birth.
IBCLC lactation consultation.
“Birthweight percentile” is the weight of the neonate at
delivery compared to United States Reference for Singleton
Measurement Births (Centers for Disease Control and Prevention, 2000).
“Birthweight abnormalities” were defined as birthweight
Participants were considered to be “exclusively breastfeeding” percentiles < 10th percentile or ≥ the 90th percentile.
if they answered “yes” to breastfeeding and “no” to formula ‘‘Neonatal intensive care unit (NICU) admission” was
feeding, and were considered to be engaged in “any breastfeed- defined as the need for the neonate to be admitted to the
ing” if they answered “yes” to breastfeeding and “yes” to for- NICU for any period of time during the mother’s postpartum
mula feeding in a self-reported survey. The “postpartum provider hospitalization period. The reason for NICU admission was
documentation of feeding preference” was defined as the pri- determined based on neonatal records and was defined as
mary obstetrical provider documenting maternal preference for either related to low blood glucose levels in the neonate
breastfeeding, formula feeding, or both in a postpartum progress (“Hypoglycemia”) or due to any other medical reason that
note at any time during the participant’s postpartum hospitaliza- warranted NICU admission (“other”).
tion. “Formal lactation consultation ordered” was defined as an
order placed by the primary obstetrical provider during the
mother’s postpartum admission. Participants who did not require Data Collection
medications for management of GDM were defined as “A1 Participant recruitment occurred between January 2016 and
GDM” and those who did required medications for GDM were December 2016 (Werner et al., 2019). Women were screened
classified as “A2 GDM.” on postpartum day 0 (zero) or 1 for eligibility. Research staff
approached women to discuss participation in the study and
Participant Demographic Variables. Race, Hispanic ethnicity, interested women were formally consented by the research
and primary language variables were collected based on par- staff member. The participants then completed a baseline
ticipant self-reporting on the postpartum demographics sur- survey in either English or Spanish, which included demo-
vey at the time of enrollment. “Race” was defined as the race graphic information and breastfeeding information about
by which the patient self-identified. Participants also had the their postpartum hospitalization. The research team then
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Journal of Human Lactation 38(1)

abstracted the research variables outlined above from the Table 1. A Comparison of Baseline Demographic Characteristics
electronic medical records for each participant. Random Among Participants Grouped by IBCLC Consults (N = 517).
audits were performed to ensure reliability and accuracy in IBCLC No IBCLC
the data abstraction process. Consultation Consultation
At 3 months postpartum, participants (n = 447) were con- (n = 386; (n = 131;
tacted by telephone by research staff and a scripted survey was 74.4%) 25.5%)
Characteristics n (%) n (%) X2 P
completed over the telephone in which participants self-reported
if they were breast or formula feeding (Werner et al., 2019). A Parous 241 (62.4) 84 (64.1) 0.12 0.73
retrospective chart review was then performed to collect data Race
regarding inpatient IBCLC consultation and obstetrical provider Asian 30 (7.8) 5 (3.8) 2.42 0.12
documentation. At the time of enrollment, the participants were Black 30 (7.8) 15 (11.5) 1.67 0.20
assigned a study ID that was stored separately from the patient White 252 (65.3) 84 (64.1) 0.06 0.81
data. All data were kept electronically on a secure, password Other 74 (19.2) 28 (21.4) 0.29 0.58
protected network. Hispanic 68 (17.6) 33 (25.2) 3.57 0.06
Primary English 372 (96.4) 118 (90.1) 7.83 0.01
Speaking
Data Analysis Delivery BMI ≥ 30 266 (69.6) 107 (82.9) 8.67 0.003
We compared any and exclusive breastfeeding rates at hospi- Private Insurance 233 (61.9) 69 (53.9) 2.58 0.11
tal discharge and 3 months postpartum between mothers Gestational Diabetes
with GDM who received and did not receive an IBCLC con- A1 195 (50.5) 63 (48.1) 0.23 0.63
sultation using t-tests or non-parametric Wilcoxon rank-sum A2 191 (49.5) 68 (51.9)
for continuous variables and Pearson’s chi-squared or Note. IBCLC = International Board Certified Lactation Consultant.
Fisher’s exact test for categorical comparisons. Odds ratios Other = American Indian/ Alaskan Native, Native Hawaiian/Pacific
(OR) for exclusive and any breastfeeding were calculated at Islander, unknown, and other non-specified. Participants who did not
hospital discharge and at 3 months postpartum and adjusted require medications for management of Gestational Diabetes were
defined as “A1 GDM” and those who did required medications were
for covariates that had differed significantly in bivariate anal- classified as “A2 GDM.” Missing data: IBCLC Consultation Delivery
ysis (p < .05) between participants who did and did not BMI ≥ 30 = 4; no IBCLC Consultation Delivery BMI ≥3 0 = 2; IBCLC
receive IBCLC consultations. consultation private insurance = 10; no IBCLC Consultation = 3.

Results
Aim 1: Postpartum IBCLC Consultation Improved
Characteristics of the Sample Breastfeeding Rates
Participants who did not require medication for manage- Participants who received an IBCLC consultation had
ment of GDM (A1 GDM) and those who did required med- increased odds of any or exclusive breastfeeding at both hos-
ication for GDM (A2 GDM) were equally represented in the pital discharge (and 3 months postpartum) compared to par-
groups (Table 1). In our sample, participants had a mean age ticipants who did not receive a lactation consultation
of 31.9 years, 65% identified as white and 25% identified as (Table 3). After adjusting for BMI ≥ 30, English speaking,
Hispanic. Participants who received an IBCLC consultation gestational age at delivery, APGAR score < 7 at 5 min, NICU
(n = 386, 74.5%) did not differ from women who did not admission, and neonatal hypoglycemia, participants who
receive a lactation consultation (n = 131, 25.5%) in regard received an IBCLC consultation continued to have increased
to age, parity, ethnicity, or insurance status; however, partic- odds of any breastfeeding at hospital discharge and 3 months
ipants who received an IBCLC consultation were more postpartum compared to participants who did not receive a
likely to speak English and less likely to be obese than par- lactation consultation, but there was no difference in the odds
ticipants who did not receive a lactation consultation of exclusively breastfeeding at either time point (Table 3).
(Table 1).
We assessed for differences in delivery and neonatal char- Aim 2: Obstetrical Provider’s Acknowledgement of
acteristics between our two groups (Table 2). There were no
differences in IBCLC consultation based on labor and deliv-
Maternal Feeding Preference Affected the Rates of
ery characteristics. However, participants who received an IBCLC Consultation for Patients.
IBCLC consultation were more likely to have delivered at Importantly, participants who had an IBCLC consultation were
term compared to participants who did not receive a lactation more likely to have their primary obstetrical provider address
consultation (p < .001). breastfeeding in postpartum documentation (Table 2).
Griffin et al. 5
145

Table 2. A Comparison of Participants’ Perinatal Characteristics Grouped by Who IBCLC Consultation (N = 517).
IBCLC Consultation No IBCLC Consultation
(n = 386; 74.7%) (n = 131; 25.3%)
Characteristics n (%) n (%) X2 P
Labor Onset
Spontaneous 108 (36.5) 33 (35.5)e 0.03 0.86
Induction of labor 188 (63.5) 60 (64.5)
Mode of delivery
Vaginal delivery 235 (60.9) 67 (51.1) 3.82 0.05
Cesarean delivery 151 (39.1) 64 (48.9)
Delivery timing
<37 weeks 40 (10.4) 38 (29.0) 26.54 <.001
≥37 weeks 346 (89.6) 93 (71.0)
Birthweight percentile 52.9 (26.8) 51.7 (29.4) −0.33a 0.78
Birthweight abnormalities (n = 85) n = 60 n = 25
<10th percentile 15 (25.0) 12 (48.0) 4.31 0.04
≥90th percentile 45 (75.0) 13 (52.0)
Apgar score ≤ 7 at 5 min 12 (3.1) 16 (12.2) 15.83 <.001
NICU admission 47 (12.2) 66 (50.4) 83.59 <.001
Reason for NICU admission (n = 113) n = 47 n = 66
Hypoglycemia 25 (53.2) 20 (30.3) 6.00 0.01
Other 22 (46.8) 46 (69.7)
Postpartum provider documentation of maternal feeding preference
211 (54.9%) 51 (39.5%) 9.18 0.002
Formal IBCLC consultation ordered 130 (33.7%) 12 (9.3%) 29.51 <.001

Note. IBCLC = International Board Certified Lactation Consultant. Missing Data: IBCLC consultation onset of labor = 90; no IBCLC onset of labor = 38;
postpartum provider documentation of maternal feeding preference = 4.
a
z-statistic (Wilcoxon rank-sum).

Discussion increasing the generalizability of our findings. Furthermore,

obstetrical providers’ acknowledgement of patients’ feeding
Our study demonstrated that postpartum IBCLC consulta- preferences may be important in ensuring women receive the
tion during delivery hospitalization increased any and exclu-
lactation support they require.
sive breastfeeding at hospital discharge and 3 months
Our findings add to prior research demonstrating that tar-
postpartum for participants with GDM. Our findings sug-
gested that in-hospital IBCLC consultation is an important, geted lactation interventions may be effective at increasing
efficacious means of breastfeeding support for women with breastfeeding rates for women with GDM (Ferrara et al.,
GDM. This study was performed with a large, racially, ethni- 2011; Stuebe et al., 2016). Prior research studying lactation
cally, and socio-economically diverse sample of women, interventions among the GDM population has involved

Table 3. A Comparison of Participants Breastfeeding Grouped by IBCLC Consultation (N = 517)

IBCLC Consultation No IBCLC Consultation
(n = 386; 74.7%) (n = 131; 25.3%)
Breastfeeding Rates n (%) n (%) OR (95% CI) aOR (95% CI)
Any breastfeeding at hospital discharge 354 (91.7) 91 (69.5) 4.86 (2.89, 8.17) 4.87 (2.67, 8.86)
Exclusive breastfeeding at hospital discharge 166 (43.1) 28 (21.4) 2.79 (1.75, 4.43) 1.52 (0.89, 2.59)
Any breastfeeding at three months postpartum 319 (94.4) 83 (76.2) 5.26 (2.78, 9.96) 5.39 (2.61, 11.16)
Exclusive breastfeeding at three months 94 (28.7) 16 (14.7) 2.33 (1.30, 4.18) 1.34 (0.71, 2.54)
postpartum

Note. Breastfeeding rates were adjusted for BMI, gestational age <37weeks, NICU admission, APGAR < 7, hypoglycemia, primary English speaking.
IBCLC = International Board Certified Lactation Consultant; missing data: IBCLC consultation any breastfeeding at 3 months = 48; no IBCLC any
breastfeeding at 3 months = 22.
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6 Journal of Human Lactation 38(1)
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labor-intensive interventions. Specifically, the Diet, Exercise breastfeeding education prenatally. Additionally, each pro-
and Breastfeeding Intervention (DEBI) study, a pilot study, vider group uses a different medical record system in the out-
randomized pregnant women to referral to lactation with fol- patient setting, making it difficult to assess specific practices
low-up calls up to 6 weeks postpartum compared with no regarding prenatal breastfeeding education.
referral. The DEBI study demonstrated no difference in
breastfeeding rates at 6 weeks postpartum. There was a trend
toward increased breastfeeding rates at 7 months postpar- Conclusion
tum, but this difference did not reach significance in their
small sample size (intervention: 62.7%; control 47.7%; p = We suggest that in-hospital lactation consultation by IBCLCs
.09; Ferrara et al., 2011). Stuebe et al.’s (2016) NEST study improves any and exclusive breastfeeding at hospital dis-
demonstrated that small group prenatal sessions decreased charge and 3 months postpartum in women with GDM.
the introduction of formula and increased the duration of Future studies are needed to determine what specific barriers
breastfeeding in low income women with GDM. Our study exist for women obtaining lactation consultation by IBCLCs
is important in that it demonstrates that IBCLC consultation, and to develop educational tools to encourage OB providers
a simple intervention available at most institutions that pro- to utilize IBCLC consultation services.
vide maternity care, can have a significant influence on
breastfeeding outcomes among women with GDM, and Declaration of Conflicting Interests
efforts should be made to ensure all women with GDM, The author(s) declared no potential conflicts of interest with respect
including non-English speaking patients, have access to to the research, authorship, and/or publication of this article.
IBCLC consultation.
Researchers have suggested that prenatal breastfeeding Funding
discussion with OB providers were both infrequent (29% of The author(s) disclosed receipt of the following financial support
visits) and brief (M = 39 seconds; Demirci et al., 2013). Our for the research, authorship, and/or publication of this article:
results suggested that interventions to increase provider Work for this project was supported by the American Diabetes
acknowledgement and discussion of breastfeeding intentions Association grant #1-16-ICTS-118 and the Hassenfeld Child Health
may help ensure mothers who would benefit from lactation Innovations Institute.
support are identified immediately postpartum.
ORCID iDs
Limitations Laurie Beth Griffin, MD, PhD https://orcid.org/0000-0003-
0698-3338
Our study has some important limitations to consider when Martha B. Kole-White, MD https://orcid.org/0000-0003-1378-
interpreting our results. Our IBCLC consultation data were 3254
collected retrospectively as part of a secondary analysis.
Therefore, we lack data about prior breastfeeding experi-
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