Report on the Results of the DAME Study

This report, by ALCI member Denise McGuinness IBCLC and Clinical Midwife Specialist (Lactation) at The National Maternity Hospital, Holles Street, is from the International Lactation Consultants Association Conference in Toronto, in July 2017. Denise was offered a small bursary by ALCI to attend this conference.

 

 

Presentation: The Diabetes and Antenatal Milk Expressing (DAME) Study. Anita Moorehead

The Diabetes and Antenatal Milk Expressing (DAME) study is a randomised controlled trial carried out by a team of researchers in Australia. The findings from this study were presented by Anita Moorhead (Registered Midwife) to the International Lactation Consultants Association (ILCA) Conference in Toronto, Canada in July 2017. The study was part of Anita Moorhead’s PhD.

 

The study is particularly interesting as type 2 diabetes and gestational diabetes are increasing globally. It is recognised that women with diabetes in pregnancy are at increased risk of not breastfeeding exclusively. This group of new born infants are at increased risk of hypoglycaemia and admission to a neonatal unit. Infant formula is more likely to be offered to these babies if there is no available colostrum. Babies are also at increased risk of separation from their mothers due to admission to the NICU. The study aim was to determine if antenatal expression of colostrum was a safe practice for women with diabetes in pregnancy.

 

The study was a multicentre, randomised control trial which involved six hospitals in Victoria, Australia. A total of 6565 women were assessed for eligibility, however, only 2593 women were subsequently eligible to participate in the study. Interestingly, 3972 women were excluded from the study, the majority due to obstetric risk (n= 1004).

 

Inclusion criteria were as follows: Pregnant women wishing to breastfeed with pre-existing or gestational diabetes, between 34 to 37 weeks gestation, single pregnancy and baby with a cephalic presentation.

 

Exclusion criteria included the following: any history of antepartum haemorrhage or placenta praevia, a previous classical caesarean scar or more than one lower segment caesarean section, any indication of compromise to the baby in utero, growth restriction, larger baby, polyhydramnios, foetal anomaly to include maternal obstetric or medical issues.

 

Method- Women with diabetes in pregnancy were randomised to either expressing colostrum twice per day for no more than 10 minutes, from 36 weeks gestation or standard care by the obstetric and diabetes team. A total of 777 women with diabetes were recruited with 635 women randomised to each group as follows: 319 women were allocated to the antenatal hand expression group and 317 women were allocated to standard obstetric and diabetic care. The majority of women had gestational diabetes, were expecting their first baby with half the women reported as obese or overweight.

Women included in the study were provided with written and verbal instruction in relation to the technique of hand expression, collection in a syringe, freezing and storage. The colostrum was labelled with the hospital medical identification label and transported frozen, where it was placed in a dedicated hospital freezer following arrival at the hospital for birth.

 

Outcomes

  1. The majority of women, 134 (42%) expressed >/= to 20 times, 80 (25%) women expressed 6-19 times and interestingly, 19 (6%) had not expressed following randomisation to the research study. It was recognised that early feeding volumes expressed were small. The average volume of colostrum expressed was 5.5 mls.
  2. The number of infants admitted to the neonatal intensive care unit did not differ between randomised groups. The three main reasons for admission to the NICU were as follows: hypoglycaemia, suspected infection and respiratory distress. In the antenatal expressing group the most serious adverse event for babies was respiratory distress (<1%) of 317 infants.
  3. The mean gestational age at birth was also comparable.
  4. There was an increase in exclusive breastfeeding in- hospital with this cohort of babies. This avoided formula milk among this group of babies during the early feeding stage, which the authors suggest may have long term implications for future development of diabetes in these infants.

 

The DAME study was the first randomised controlled trial to test the practice of antenatal hand expression of colostrum. The authors concluded that there was no harm in advising women with diabetes in pregnancy at low risk of complications to hand express colostrum from 36 weeks gestation. However, they issue a note of caution that the study results should not be extrapolated to high risk populations.

 

The following paper supported the accuracy of the information provided at the conference.

Forster, D.A., Moorehead, A.M., Jacobs, S.E., Davis, P.G., Walker, S.P., McEgan, K.M., Opie, G.F., Donath, S.M., Gold, L., McNamara, C., Aylward, A., East, C., Ford, R., Amir, L. (2017) Advising women with diabetes in pregnancy to express breastmilk in late pregnancy (Diabetes and Antenatal Milk Expressing (DAME)): a multicentre, unblended, randomised controlled trial. The Lancet. 389, pp.2204-2213.

Supporting Couples and Families during Pregnancy after Loss

write up by Aine McCarthy, IBCLC, Midwife. BScNS, MSc

 

This ALCI 2017 Conference Presentation was given by Margaret Murphy, Doctoral Candidate, MSc, BSc, PGDip in Teaching and Learning, RM, RGN, IBCLC

 

Margaret’s presentation titled “Pregnancy After Loss: The Role of the IBCLC in Supporting Couples and Families” struck a chord on both a personal and professional level with a captivated and emotional audience. This sensitive subject is largely hidden, and requires further open discussion and the silence surrounding this area needs to be unravelled.

 

The IBCLC’s role is in supporting families who have experienced infant loss is predominantly one of providing support.  According to Margaret, 1 in 4 pregnancies worldwide will end in loss. In Ireland, that means 15,000 miscarriages per year. 1 in 238 pregnancies will end in stillbirth and 1 in 340 will end in neonatal death. Pregnancy loss affects half of all pregnancies over 40 years of age.

 

Ireland sits in the middle of the curve in relation to pregnancy loss, and rates vary favourably within the global context. However, these stats may be skewed as we do not routinely offer screening for life limiting conditions, termination and perinatal centre care or post-mortem is not routinely offered in comparison to our counterparts who routinely offer these to all women attending maternity centres. Interestingly there is no internationally agreed definition, leading to huge variation of what constitutes pregnancy loss.

 

In the Irish context the legislative definition of pregnancy loss includes a child born weighing 500 grammes or more or having a gestational age of 24 weeks showing no sign of life. For the purpose of understanding the statistics perspective, perinatal mortality refers to the death of babies in the weeks before or four weeks after birth. Perinatal mortality includes stillbirths (babies born with no signs of life after 24 weeks of pregnancy or weighing at least 500 grammes) and the deaths of babies within 28 days of being born (National Perinatal Epidemiology Centre, 2013).

 

Causes of pregnancy loss include antepartum conditions, placental conditions, infection, growth restriction, hormonal problems, chromosomal abnormalities, and immune system responses.

 

Respectful Bereavement

Margaret spoke about how we collectively need to break the silence. The general population do not know that fully formed babies can die, and there is a general assumption that once babies are viable  that pregnancy loss cannot occur.There is not enough research on health care messages in relation to pregnancy loss.

 

According to Margaret, respectful bereavement care means acknowledging parenthood, facilitating attachment between the baby and family and supporting the grieving process and various ways of grieving. So it is important for staff to be educated on pregnancy loss so that they can provide suitable bereavement support.

 

Suitable bereavement support means

 

  • Helping a family to welcome baby into the world and into the family
  • Addressing the baby as a person; name the baby (use the baby’s name consistently), acknowledge the baby’s individual characteristics, and note parental features/sibling resemblance.
  • Acknowledging Parenthood; address parents as mother and father or mummy and daddy…include siblings. Studies support the inclusion of toddlers and outlines that they can cope with meeting the baby and helps in their bereavement and understanding of the process.
  • Providing respectful care to the baby and parents.
  • Acknowledging the trauma that the parents are experiencing.
  • Modelling respectful behaviour.
  • Giving time.
  • Promoting bonding and meaningful experiences and memory making visits.
  • Some parents enjoy skin to skin contact so it is important to be mindful of the baby’s skin cooling as the baby temperature cools this may alarm or upset parents. (Cuddle cots/cooling blankets) – https://www.irishtimes.com/life-and-style/health-family/parenting/cooling-cuddle-cot-allows-extra-time-with-stillborn-babies-1.2634818
  • Supporting families to create mementos eg photos and prints.
  • Ensuring rigorous medical care and investigations.

 

In supporting the grieving process, it is vitally important to let parents share their story over and over again, and to listen and be present without feeling the need to give advice. Hold space for these families, listen, be respectful and avoid rushing them into a grievance process.

 

“Grief is not on a timeline.”

 

 

Healthcare professionals should also be mindful of the language they use with bereaved families. eg

“I’m sorry that your baby has died and I don’t know what to say   but  I want you to know that I’m thinking of you…” or

“I see that you are grieving…I’m so sorry…”

 

And platitudes should be avoided eg   “God needed an angel.”

 

 

 

To conclude, the session finished with a few tears shed, a graphic illustration and a depiction of a Japanese bowl and the art of kintsugi, whereby the Japanese repair broken pottery with gold.  This kind of repair makes the bowls more valuable. Similarly, the grief parents feel after loss will be forever part of them, but makes them who they are and gives them qualities of strength and compassion that they carry through their lives.

 

“Grief is something that alters you at a cellular level. You never get over it, but you learn to live with it.”

 

 

 

 

Reference and Resource Links

http://www.hse.ie/eng/about/Who/acute/bereavementcare/standardsBereavementCarePregnancyLoss.pdf

 

http://www.miscarriage.ie/typesofmiscarriage.html

 

http://www.miscarriage.ie/information/infobooklet2016.pdf

 

http://www.miscarriage.ie/information/infobooklet2016.pdf

 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3384447

 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2807762/

 

http://www.huffingtonpost.com/2014/08/05/devastating-beautiful-stillborn-baby-photos_n_5651328.html

 

 

 

 

 

Woman-centered Caesarean Birth at UMHL

Write up by Sarah Brennen

 

This 2017 ALCI conference presentation was given by Cliodhna O’Sullivan, RGN, RM, Clinical Skills Facilitator, BSc, MSc

 

As a GP and lecturer with a special interest in lactation and optimising the birth trajectory to facilitate optimised breastfeeding, it was a pleasure to hear Cliondhna talk about University and Maternity Hospital Limerick and their intervention to respond to mothers’ requests for gentle caesarean births using a mother-centred caesarean birthing program.  With this approach, mothers are given a menu of options prior to their caesarean, which includes lowering the drape so that the mother can see her baby being born, optimal cord clamping, immediate skin-to-skin and baby checks done while in skin-to-skin contact.

 

With such a high rate of caesareans in Ireland (currently at 30%) and  the evidence already for patient-centred care and immediate skin-to-skin with zero separation,  this initiative will have huge positive impact on the health and well-being of parents and babies, and ultimately society as a whole. The roll out of woman-centered caesareans  is simple and reproducable and thus scalling up of this intervention in all the maternity hospitals where c-sections happen, in the main should be very achievable.

 

During her presentation, Cliodhna gave us the following quote from January Harshe:

“I do not care what kind of birth you have….A homebirth, scheduled caesarean, epidural hospital birth, or if you birth alone in the woods next to baby deer. I care that you had options, that you were supported in your choices, and that you were respected.”

 

Read more about woman-centred  caesarean birth here http://www.hse.ie/eng/services/news/media/pressrel/CaesareanUMHL.html

 

Review of Cliodhna’s talk was by Sarah Brennan
MB BAO BCh MICGP MRCSI MHSc-Primary Care PgDipMedEd, GP and lecturer with NUI Galway
Donegal Medical Academy, Letterkenny

Sarah teaches an optional 12 week infant feeding Special Study Module to medical students in year four, where it fits in nicely to peads, general practice, obs abd gynae and psychiatry.