Analysis of insulin in human breast milk in mothers with type 1 and type 2 diabetes mellitus

Safety profile of the most ordered medications for breastfeeding patients in the emergency department

BACKGROUND

Emergency Medicine (EM) physicians routinely treat breastfeeding patients. Physicians frequently recommend pumping and dumping milk for perceived safety risks. We hypothesized that the majority of the most commonly ordered medications in the emergency department (ED) are safe for breastfeeding patients. Accordingly, we performed a comprehensive safety analysis of the commonly ordered medications and provided an algorithm for EM physicians to utilize when treating breastfeeding patient in the ED.

METHODS

We investigated the 90 most administered medications to female patients between the ages of 15 to 50 for common ED chief complaints at a tertiary care academic medical center from January 2018 to December 2022. A total of 145,960 doses were analyzed. We subsequently searched LactMed®, InfantRisk Application, and Pubmed® for all safety information on these medications and divided them by categories. Ultimately, we proposed a treatment algorithm for breastfeeding patients in the ED.

RESULTS

Analgesics were the most commonly ordered medications in the ED, and importantly analgesics ranging from ibuprofen to morphine are safe in limited doses in the ED setting. Antibiotics and antifungals pose limited restrictions. All systems-based medications have a variety of safe options available. Lastly, supplements and electrolytes are safe.

CONCLUSION

The majority of medications utilized in the acute setting are compatible with breastfeeding. There should be limited circumstances to advise pumping and dumping in the ED.

Association of Human Milk Fatty Acid Composition with Maternal Cardiometabolic Diseases: An Exploratory Prospective Cohort Study

Background: Human milk fatty acids derive from maternal diet, body stores, and mammary synthesis and may reflect women's underlying cardiometabolic health. We explored whether human milk fatty acid composition was associated with maternal cardiometabolic disease (CMD) during pregnancy and up to 5 years postpartum. Materials and Methods: We analyzed data from the prospective CHILD Cohort Study on 1,018 women with no preexisting CMD who provided breast milk samples at 3-4 months postpartum. Milk fatty acid composition was measured using gas-liquid chromatography. Maternal CMD (diabetes or hypertension) was classified using questionnaires and birth records as no CMD (reference outcome group; 81.1%), perinatal CMD (developed and resolved during the perinatal period; 14.9%), persistent CMD (developed during, and persisted beyond, the perinatal period; 2.9%), and incident CMD (developed after the perinatal period; 1.1%). Multinomial logistic regression was used to model associations between milk fatty acid composition (individual, summary, ratios, and patterns identified using principal component analysis) and maternal CMD, adjusting for pre-pregnancy anthropometry and race/ethnicity. Results: Medium-chain saturated fatty acids (MC-SFA), lauric (C12:0; odds ratio [OR] = 0.73, 95% confidence interval [CI] = 0.60-0.89) and myristic acid (C14:0; OR = 0.80, 95% CI = 0.66-0.97), and the high MC-SFA principal component pattern (OR = 0.86, 95% CI = 0.76-0.96) were inversely associated with perinatal CMD. Long-chain polyunsaturated fatty acids adrenic acid (C22:4n-6) was positively associated with perinatal (OR = 1.21, 95% CI = 1.01-1.44) and persistent CMD (OR = 1.56, 95% CI = 1.08-2.25). The arachidonic (C20:4n-6)-to-docosahexaenoic acid (C22:6n-3) ratio was inversely associated with incident CMD (OR = 0.52, 95% CI = 0.28-0.96). Conclusions: These exploratory findings highlight a potential novel utility of breast milk for understanding women's cardiometabolic health.

Understanding risk and causal mechanisms for developing obesity in infants and young children: A National Institutes of Health workshop

Obesity in children remains a major public health problem, with the current prevalence in youth ages 2-19 years estimated to be 19.7%. Despite progress in identifying risk factors, current models do not accurately predict development of obesity in early childhood. There is also substantial individual variability in response to a given intervention that is not well understood. On April 29-30, 2021, the National Institutes of Health convened a virtual workshop on "Understanding Risk and Causal Mechanisms for Developing Obesity in Infants and Young Children." The workshop brought together scientists from diverse disciplines to discuss (1) what is known regarding epidemiology and underlying biological and behavioral mechanisms for rapid weight gain and development of obesity and (2) what new approaches can improve risk prediction and gain novel insights into causes of obesity in early life. Participants identified gaps and opportunities for future research to advance understanding of risk and underlying mechanisms for development of obesity in early life. It was emphasized that future studies will require multi-disciplinary efforts across basic, behavioral, and clinical sciences. An exposome framework is needed to elucidate how behavioral, biological, and environmental risk factors interact. Use of novel statistical methods may provide greater insights into causal mechanisms.

The association between maternal body mass index and breast milk composition: a systematic review

CONTEXT

Breast milk composition is influenced by many factors, ranging from maternal nutritional status to infant sex. Previous studies have explored the relationship between maternal body mass index (BMI) and breast milk composition; however, the findings have been inconsistent and controversial.

OBJECTIVE

To systematically review the evidence on the association of maternal weight and BMI with breast milk composition.

DATA SOURCES

The PubMed and Scopus databases were searched up to May 3, 2023, using the following search strategy: ("maternal weight" OR "maternal BMI" OR "mother's weight" OR "mother's BMI") AND ("maternal milk" OR "human milk" OR "breast milk").

DATA EXTRACTION

A total of 83 publications, involving data from more than 11 310 lactating women, were identified. All extracted data were compiled, compared, and critically analyzed.

DATA ANALYSIS

Overall, maternal BMI was associated with higher levels of leptin and insulin, and the ratio of omega-6 to omega-3 polyunsaturated fatty acids in breast milk. However, no conclusive associations were found between maternal BMI and the levels of energy, macronutrients, micronutrients, and other components of breast milk.

CONCLUSIONS

This systematic review provides robust evidence supporting a positive correlation between maternal BMI and breast milk concentrations of leptin, insulin, and the omega-6 to omega-3 polyunsaturated fatty acid ratio. Nevertheless, disparities in findings are noticeable for other constituents of breast milk. To comprehensively grasp the influence of maternal weight and BMI on breast milk composition, further research endeavors are imperative.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42023458667.

Sampling Procedures for Estimating the Infant Intake of Human Milk Leptin, Adiponectin, Insulin, Glucose, and Total Lipid

Limited attention is given to the efficacy of protocols for the estimation of infant intake of milk components when investigating their impact on infant outcomes. We compared the actual measured intake of human milk components with estimations derived from 15 protocols to determine the most reliable approach for estimating intake of HM leptin, adiponectin, insulin, glucose, and total lipid. Twenty mothers who were 3-5 months postpartum completed a 24 h milk profile study with pre-/post-feed milk samples collection. The true infant intake (control group) based on 24 h milk intake (MI) was compared to estimated infant intakes using concentrations from five sampling protocols that were multiplied by one of true infant MI, considered mean MI (800 mL), or global mean MI (766 mL). The mean measured concentrations of six samples (three sets of pre- and post-feed samples, from morning (06:00-09:00), afternoon (13:00-16:00), and evening (19:00-22:00)) multiplied by the true infant MI, mean considered MI, and global mean MI produced the most accurate estimates of infant intake of these components. Therefore, in the absence of 24 h measurements and sampling, a sampling protocol comprising three sets of pre-/post-feed samples provides the most reliable infant intake estimates of HM leptin, adiponectin, insulin, glucose, and total lipid.

Developmental metformin exposure does not rescue physiological impairments derived from early exposure to altered maternal metabolic state in offspring mice

OBJECTIVE

The incidence of gestational diabetes mellitus (GDM) and metabolic disorders during pregnancy are increasing globally. This has resulted in increased use of therapeutic interventions such as metformin to aid in glycemic control during pregnancy. Even though metformin can cross the placental barrier, its impact on offspring brain development remains poorly understood. As metformin promotes AMPK signaling, which plays a key role in axonal growth during development, we hypothesized that it may have an impact on hypothalamic signaling and the formation of neuronal projections in the hypothalamus, the key regulator of energy homeostasis. We further hypothesized that this is dependent on the metabolic and nutritional status of the mother at the time of metformin intervention. Using mouse models of maternal overnutrition, we aimed to assess the effects of metformin exposure on offspring physiology and hypothalamic neuronal circuits during key periods of development.

METHODS

Female C57BL/6N mice received either a control diet or a high-fat diet (HFD) during pregnancy and lactation periods. A subset of dams was fed a HFD exclusively during the lactation. Anti-diabetic treatments were given during the first postnatal weeks. Body weights of male and female offspring were monitored daily until weaning. Circulating metabolic factors and molecular changes in the hypothalamus were assessed at postnatal day 16 using ELISA and Western Blot, respectively. Hypothalamic innervation was assessed by immunostaining at postnatal days 16 and 21.

RESULTS

We identified alterations in weight gain and circulating hormones in male and female offspring induced by anti-diabetic treatment during the early postnatal period, which were critically dependent on the maternal metabolic state. Furthermore, hypothalamic agouti-related peptide (AgRP) and proopiomelanocortin (POMC) neuronal innervation outcomes in response to anti-diabetic treatment were also modulated by maternal metabolic state. We also identified sex-specific changes in hypothalamic AMPK signaling in response to metformin exposure.

CONCLUSION

We demonstrate a unique interaction between anti-diabetic treatment and maternal metabolic state, resulting in sex-specific effects on offspring brain development and physiological outcomes. Overall, based on our findings, no positive effect of metformin intervention was observed in the offspring, despite ameliorating effects on maternal metabolic outcomes. In fact, the metabolic state of the mother drives the most dramatic differences in offspring physiology and metformin had no rescuing effect. Our results therefore highlight the need for a deeper understanding of how maternal metabolic state (excessive weight gain versus stable weight during GDM treatment) affects the developing offspring. Further, these results emphasize that the interventions to treat alterations in maternal metabolism during pregnancy need to be reassessed from the perspective of the offspring physiology.

Circadian Variation in Human Milk Hormones and Macronutrients

There is an inadequate understanding of the daily variations in hormones and macronutrients in human milk (HM), and sample collection protocols vary considerably from study to study. To investigate changes in these milk components across 24 h, 22 lactating women collected small milk samples before and after each breastfeed or expression from each breast. Test weighing was used to determine the volume of HM consumed in each feed. The concentrations of leptin, adiponectin, insulin, fat, and glucose were measured, and the intakes were calculated. A linear mixed model was fitted to assess within-feed and circadian variation in HM feed volume and concentration, and intakes of several components. The average infant intake of HM was 879 g/24 h. Significantly higher pre-feed concentrations were found for adiponectin and glucose and lower post-feed concentrations were found for insulin and fat. Significant circadian rhythms were displayed for leptin, adiponectin, insulin, glucose (both concentration and intake), fat concentration, and milk volume. These findings demonstrate the necessity for setting up standardised and rigorous sampling procedures that consider both within-feed and circadian variations in HM components to gain a more precise understanding of the impacts of these components on infant health, growth and development.

Colostrum insulin supplementation to neonatal Holstein bulls affects small intestinal histomorphology, mRNA expression, and enzymatic activity with minor influences on peripheral metabolism

The objectives of this study were to evaluate how varying colostral insulin concentrations influenced small intestinal development and peripheral metabolism in neonatal Holstein bulls. Insulin was supplemented to approximately 5× (70.0 μg/L; n = 16) or 10× (149.7 μg/L; n = 16) the basal colostrum insulin (12.9 μg/L; BI, n = 16) concentration to maintain equivalent macronutrient intake (crude fat: 4.1 ± 0.06%; crude protein: 11.7 ± 0.05%; and lactose: 1.9 ± 0.01%) among treatments. Colostrum was fed at 2, 14, and 26 h postnatal and blood metabolites and insulin concentration were measured at 0, 30, 60, 90, 120, 180, 240, 360, 480, and 600 min postprandial respective to the first and second colostrum meal. At 30 h postnatal, a subset of calves (n = 8/treatment) were killed to excise the gastrointestinal and visceral tissues. Gastrointestinal and visceral gross morphology and dry matter and small intestinal histomorphology, gene expression, and carbohydrase activity were assessed. Insulin supplementation tended to linearly reduce the glucose clearance rate following the first meal, whereas after the second meal, supplementation linearly increased the rate of glucose absorption and nonesterified fatty acid clearance rate, decreased the time to maximum glucose concentrations, and decreased the time to reach minimum nonesterified fatty acid concentrations. Additionally, insulin clearance rate was linearly increased by insulin supplementation following the second colostrum feeding. However, there were no overall differences between treatments in the concentrations of glucose, nonesterified fatty acids, or insulin in plasma or serum. With respect to macroscopic intestinal development, dry rumen tissue mass linearly decreased when insulin was supplemented in colostrum, and supplementation linearly increased duodenal dry tissue density (g dry matter/cm) while tending to increase duodenal dry tissue weight. Increasing the colostrum insulin concentration improved small intestinal histomorphological development in the distal small intestine, as ileal villi height and mucosal-serosal surface area index were increased by supplementing insulin. Lactase enzymatic activity linearly increased in the proximal jejunum while ileal isomaltase activity linearly decreased with insulin supplementation. These data indicate that changes in colostrum insulin concentrations rapidly affect gastrointestinal growth prioritization and carbohydrase activity. The changes in gastrointestinal ontology result in minor changes in postprandial metabolite availability and clearance.

Exploring Molecular Interactions between Human Milk Hormone Insulin and Bifidobacteria

Multiple millennia of human evolution have shaped the chemical composition of breast milk toward an optimal human body fluid for nutrition and protection and for shaping the early gut microbiota of newborns. This biological fluid is composed of water, lipids, simple and complex carbohydrates, proteins, immunoglobulins, and hormones. Potential interactions between hormones present in mother's milk and the microbial community of the newborn are a very fascinating yet unexplored topic. In this context, insulin, in addition to being one of the most prevalent hormones in breast milk, is also involved in a metabolic disease that affects many pregnant women, i.e., gestational diabetes mellitus (GDM). Analysis of 3,620 publicly available metagenomic data sets revealed that the bifidobacterial community varies in relation to the different concentrations of this hormone in breast milk of healthy and diabetic mothers. Starting from this assumption, in this study, we explored possible molecular interactions between this hormone and bifidobacterial strains that represent bifidobacterial species commonly occurring in the infant gut using 'omics' approaches. Our findings revealed that insulin modulates the bifidobacterial community by apparently improving the persistence of the Bifidobacterium bifidum taxon in the infant gut environment compared to other typical infant-associated bifidobacterial species. IMPORTANCE Breast milk is a key factor in modulating the infant's intestinal microbiota composition. Even though the interaction between human milk sugars and bifidobacteria has been extensively studied, there are other bioactive compounds in human milk that may influence the gut microbiota, such as hormones. In this article, the molecular interaction of the human milk hormone insulin and the bifidobacterial communities colonizing the human gut in the early stages of life has been explored. This molecular cross talk was assessed using an in vitro gut microbiota model and then analyzed by various omics approaches, allowing the identification of genes associated with bacterial cell adaptation/colonization in the human intestine. Our findings provide insights into the manner by which assembly of the early gut microbiota may be regulated by host factors such as hormones carried by human milk.

Associations between maternal adiposity and appetite-regulating hormones in human milk are mediated through maternal circulating concentrations and might affect infant outcomes

Background

Appetite-regulating hormones (ARH) in human milk (HM) are suggested to affect infants’ milk intake and possibly infant growth. Maternal adiposity might contribute to higher levels of ARH in HM, either from the mammary gland or from raised circulating levels due to higher adiposity. Counterfactual-based mediation analysis can define indirect and direct effects between HM ARH and maternal and infant factors, and might be an important tool when investigating the mother-milk-infant triad.

Objective

We aim to investigate whether potential associations between (1) maternal adiposity and HM ARH and (2) HM ARH and infant milk intake and growth are mediated through maternal and infant plasma ARH, respectively.

Materials and methods

Maternal and infant anthropometry and body composition, HM and blood samples were collected from 223 mother-infant dyads participating in the Mother, Infant and Lactation Quality study at three postpartum visits from 1 to 8.49 months. Leptin, insulin and adiponectin were analyzed using immunoassays. Mediation analyses using linear mixed-effect models were applied to investigate the direct and indirect effects through maternal and infant plasma hormone concentrations.

Results

A positive association between maternal body-mass-index (BMI) and HM leptin was mediated by maternal plasma leptin by 29% when fixing BMI to < 25 kg/m², and through 51% when fixing BMI to ≥ 25 kg/m² (p_interaction < 0.01). There was no mediated effect through plasma insulin in the association between BMI and HM insulin (p = 0.068). We found negative and positive associations between HM insulin and total milk intake and infant weight, respectively, however, these diminished in mediation analyses with reduced sample sizes.

Conclusion

Our main results suggest that the association between maternal adiposity and HM leptin was mediated through circulating leptin to a stronger degree for mothers with overweight compared to mothers with normal-weight. This indicates that excess maternal adiposity, and the resulting rise of circulating leptin and possible concomitant low-grade inflammation, may be reflected in HM composition.

Clinical trials registry number

NCT03254329.

Breastfeeding may benefit cardiometabolic health of children exposed to increased gestational glycemia in utero

PURPOSE

There is altered breastmilk composition among mothers with gestational diabetes and conflicting evidence on whether breastfeeding is beneficial or detrimental to their offspring's cardiometabolic health. We aimed to investigate associations between breastfeeding and offspring's cardiometabolic health across the range of gestational glycemia.

METHODS

We included 827 naturally conceived, term singletons from a prospective mother-child cohort. We measured gestational (26-28 weeks) fasting plasma glucose (FPG) and 2-h plasma glucose (2 hPG) after an oral glucose tolerance test as continuous variables. Participants were classified into 2 breastfeeding categories (high/intermediate vs. low) according to their breastfeeding duration and exclusivity. Main outcome measures included magnetic resonance imaging (MRI)-measured abdominal fat, intramyocellular lipids (IMCL), and liver fat, quantitative magnetic resonance (QMR)-measured body fat mass, blood pressure, blood lipids, and insulin resistance at 6 years old (all continuous variables). We evaluated if gestational glycemia (FPG and 2 hPG) modified the association of breastfeeding with offspring outcomes after adjusting for confounders using a multiple linear regression model that included a 'gestational glycemia × breastfeeding' interaction term.

RESULTS

With increasing gestational FPG, high/intermediate (vs. low) breastfeeding was associated with lower levels of IMCL (p-interaction = 0.047), liver fat (p-interaction = 0.033), and triglycerides (p-interaction = 0.007), after adjusting for confounders. Specifically, at 2 standard deviations above the mean gestational FPG level, high/intermediate (vs. low) breastfeeding was linked to lower adjusted mean IMCL [0.39% of water signal (0.29, 0.50) vs. 0.54% of water signal (0.46, 0.62)], liver fat [0.39% by weight (0.20, 0.58) vs. 0.72% by weight (0.59, 0.85)], and triglycerides [0.62 mmol/L (0.51, 0.72) vs. 0.86 mmol/L (0.75, 0.97)]. 2 hPG did not significantly modify the association between breastfeeding and childhood cardiometabolic risk.

CONCLUSION

Our findings suggest breastfeeding may confer protection against adverse fat partitioning and higher triglyceride concentration among children exposed to increased glycemia in utero.

Type 1 diabetes and pregnancy: An update on glucose monitoring and insulin treatment

The relevance of type 1 diabetes during pregnancy stems from its impact on the health of mother and offspring and its increasing prevalence. Glycemic control during pregnancy is one of the main risk factors for adverse events. Besides, treatment becomes a major challenge not only due to the modifications in insulin requirements due to changes in hormones and cytokines but also to the stricter control targets. Given the recent appearance of new ultra-rapid and basal insulin analogues and the constant evolution of technology to treat people with diabetes, we review these aspects in relation to the treatment of women with type 1 diabetes during pregnancy.

Implementation of a healthy diet to lactating rats attenuates the early detrimental programming effects in the offspring born to obese dams. Putative relationship with milk hormone levels

Lactation is a critical period of development and alterations in milk composition due to maternal diet or status may affect infant growth. We aimed to evaluate in rats whether improving maternal nutrition during lactation attenuates early imprinted adverse metabolic effects in the offspring born to obese dams. Three groups were studied: Control (C) dams, fed with standard diet; Western diet (WD) dams, fed with WD one month prior to gestation and during gestation and lactation; and Reversion (Rev) dams, fed as WD-dams, but moved to a standard diet during lactation. Macronutrient content, insulin, leptin and adiponectin levels were determined in milk. Phenotypic traits and circulating parameters in dams and their offspring were determined throughout lactation. Results showed that, at weaning, WD-dams displayed lower body weight and greater plasma insulin and non-esterified fatty acids levels than C-dams, and signs of hepatic steatosis. Milk from WD-dams showed lower protein content and insulin, leptin, and adiponectin levels during the entire or the late lactation. Rev-dams retained excess body fat content, but milk composition and most circulating parameters were not different from controls at late lactation and showed higher leptin mRNA levels in mammary gland than WD-dams. The offspring of WD-dams, but not that of Rev-dams, displayed higher body weight, adiposity, and circulating leptin and glucose levels than controls at weaning. In conclusion, dietary improvement during lactation prevents early adverse effects in offspring associated with maternal intake of an obesogenic diet, that may be related with the normalization of milk hormone levels.

Cross-talk between the infant/maternal gut microbiota and the endocrine system: a promising topic of research

The infant gut microbiota is the set of microorganisms colonizing the baby's intestine. This complex ecosystem appears to be related to various physiological conditions of the host and it has also been shown to act as one of the most crucial determinants of infant's health. Furthermore, the mother's endocrine system, through its hormones, can have an effect on the composition of the newborn's gut microbiota. In this perspective, we summarize the recent state of the art on the intricate relationships involving the intestinal microbiota and the endocrine system of mother/baby to underline the need to study the molecular mechanisms that appear to be involved.

Oversupplying metabolizable protein during late gestation to beef cattle does not influence ante- or postpartum glucose-insulin kinetics but does affect prepartum insulin resistance indices and colostrum insulin content

The objective of this study was to evaluate whether oversupplying metabolizable protein (MP) during late gestation influences glucose and insulin concentrations, and insulin resistance (IR) in late gestation and early lactation. Crossbred Hereford, first-lactation heifers were individually fed diets to supply 133% (HMP, n = 11) or 100% (CON, n = 10) of their predicted MP requirements for 55 ± 4 d (mean ± SD) prior to calving. All heifers received a common lactation ration formulated to meet postpartum requirements (103% MP and 126% ME). After feed was withheld for 12 h, cattle underwent an intravenous glucose tolerance test (IVGTT) on d -6.7 ± 0.9 and 14.3 ± 0.4 by infusing a 50% dextrose solution (1.36 g glucose/kg BW 0.75) through a jugular catheter with plasma collected at -10, 0 (immediately after infusion), 5, 10, 15, 20, 25, 30, 45, 60, 75, 90, and 120 min, respective to the infusion. Glucose and insulin concentrations were assessed. Insulin resistance indices (homeostasis model of insulin resistance [HOMA-IR], quantitative insulin sensitivity check index [QUICKI], revised quantitative insulin sensitivity check index [RQUICK], and RQUICKI incorporating serum beta-hydroxybutyrate concentrations [RQUICKIBHB]) were calculated from measurements of serum non-esterified fatty acids and beta-hydroxybutyrate and plasma glucose and insulin concentrations on d -34 ± 4, -15 ± 4, 7 ± 1, 28 ± 3, 70 ± 3, and 112 ± 3. Colostrum samples were collected within an hour of calving (prior to suckling) and analyzed for insulin concentration. Data were analyzed as a randomized block design using the PROC GLIMMIX of SAS, accounting for repeated measurements when necessary. Baseline (-10 min) plasma glucose and insulin concentrations were elevated (P ≤ 0.038) for HMP heifers during the antepartum IVGTT, but not (P ≥ 0.25) during the postpartum IVGTT. Plasma glucose and insulin concentrations throughout the antepartum or postpartum IVGTT did not differ (P ≥ 0.18) by prepartum treatment, nor did other glucose and insulin IVGTT parameters (i.e., max concentration and time to reach max concentration, nadir values, clearance rates and half-lives, area-under-the-curve, and insulin sensitivity index; P ≥ 0.20). Antepartum IVGTT IR indices indicated that HMP heifers were more (P ≤ 0.011) IR than their counterparts. Similarly, the prepartum HOMA-IR was greater (P = 0.033) for HMP heifers, suggesting increased IR. Postpartum IR indices did not (P ≥ 0.25) indicate that prepartum MP consumption impacted postpartum IR. Colostrum insulin concentration was increased (P = 0.004) by nearly 2-fold for HMP relative to CON heifers. These data demonstrate that prepartum MP overfeeding alters baseline glucose-insulin concentrations in late-pregnant beef heifers and increases colostrum insulin content without having carry-over effects on postpartum glucose-insulin concentrations and IR.

Gestational Diabetes Mellitus Is Associated with Differences in Human Milk Hormone and Cytokine Concentrations in a Fully Breastfeeding United States Cohort

It is unclear whether gestational diabetes mellitus (GDM) alters breast milk composition. We prospectively examined associations of GDM status with concentrations of six potentially bioactive elements (glucose, insulin, C-reactive protein (CRP), interleukin-6 (IL-6), leptin, and adiponectin) in human milk. These were measured at both 1 and 3 months postpartum in 189 fully breastfeeding women. Mixed-effects linear regression assessed GDM status-related differences in these milk bioactives, adjusting for demographics, maternal factors, and diet. At 1 and 3 months postpartum, milk CRP was higher (1.46 ± 0.31 ng/mL; p < 0.001 and 1.69 ± 0.31 ng/mL; p < 0.001) in women with GDM than in women without GDM, whereas milk glucose (−5.23 ± 2.22 mg/dL; p = 0.02 and −5.70 ± 2.22; p = 0.01) and milk insulin (−0.38 ± 0.17 μIU/mL; p = 0.03 and −0.53 ± 0.17; p = 0.003) were lower in women with GDM. These significant associations remained similar after additional adjustment for maternal weight status and its changes. No difference was found for milk IL-6, leptin, and adiponectin. There was no evidence of association between these milk bioactive compounds and 1 h non-fasting oral glucose challenge serum glucose in the women without GDM. This prospective study provides evidence that potentially bioactive elements of human milk composition are altered in women with GDM.

Associations Among Maternal Adiposity, Insulin, and Adipokines in Circulation and Human Milk

BACKGROUND

Insulin, leptin, and adiponectin regulate energy balance and may influence infant growth via their presence in human milk. Maternal body mass index has been associated with human milk insulin, leptin, and adiponectin concentrations, but results are inconsistent. Maternal serum hormone concentrations and fat mass may better characterize human phenotype and be more appropriate predictors of human milk insulin, leptin, and adiponectin.

RESEARCH AIM

To examine the associations of human milk insulin, leptin, and adiponectin with their concentrations in maternal circulation and with maternal fat mass.

METHODS

Insulin, leptin, and adiponectin were measured in serum and human milk at 1 month postpartum in 25 women. Total body fat mass and fat-free mass were measured using bioelectrical impedance analysis. Linear regression modeling was used to examine associations of serum hormone concentrations or fat mass with human milk insulin, leptin, and adiponectin after adjusting for covariates.

RESULTS

Serum insulin (p = .007), leptin (p < .001), and adiponectin (p < .001) were each associated with their respective concentrations in human milk. Fat mass was positively associated with insulin (p = .005) and leptin (p < .001), but not with adiponectin (p = .65), in human milk.

CONCLUSIONS

Human milk insulin, leptin, and adiponectin were positively associated with their concentrations in serum, and human milk insulin and leptin were associated with maternal fat mass. Future research is needed to elucidate the role of human milk hormones in infant energy balance and growth.

Insulin Concentration in Human Milk in the First Ten Days Postpartum: Course and Associated Factors

BACKGROUND OBJECTIVES

Human milk (HM) is better tolerated than formula in preterm infants. Insulin, which is naturally present in HM but not in formula, has been suggested as a key factor for feeding tolerance, as it appears to stimulate intestinal maturation. Its precise concentrations during the early postnatal period, however, remains unknown. The objective of this study was to assess the natural timecourse of the HM insulin concentration during the first ten days postpartum. The effect of preterm delivery, maternal obesity, and diurnal rhythm were also assessed.

METHOD

HM was collected from 31 non-diabetic mothers (21 preterm [gestational age (GA) < 37 weeks]; 10 at-term [GA ≥ 37 weeks]) on ≥ 4 time-points per day during the first five days, and once on the tenth day postpartum.

RESULTS

The HM insulin concentration declined rapidly within the first three days postpartum (day 1: 516 [312-1058] pmol/L; day 3: 157 [87-299] pmol/L), after which the concentration remained relatively stable. The insulin concentrations were higher in HM from obese mothers than from non-obese mothers (P < 0.001). Preterm delivery did not significantly affect HM insulin concentrations when adjusted for maternal pre-pregnancy body mass index category (P = 0.270). Diurnal rhythm was characterized by an insulin concentration decline throughout the night (P = 0.001), followed by an increase in the morning (P = 0.001).

CONCLUSION

The HM insulin concentration declines rapidly in the first three days postpartum, follows a diurnal rhythm, and is higher in obese mothers compared to non-obese mothers. HM insulin concentrations are not affected by preterm delivery.

Human Milk Lactose, Insulin, and Glucose Relative to Infant Body Composition during Exclusive Breastfeeding

Human milk (HM) components may influence infant growth and development. This study aimed to investigate relationships between infant body composition (BC) and HM lactose, insulin, and glucose (concentrations and calculated daily intakes (CDI)) as well as 24-h milk intake and maternal BC at 3 months postpartum. HM samples were collected at 2 months postpartum. Infant and maternal BC was assessed with bioimpedance spectroscopy. Statistical analysis used linear regression accounting for infant birth weight. 24-h milk intake and CDI of lactose were positively associated with infant anthropometry, lean body mass and adiposity. Higher maternal BC measures were associated with lower infant anthropometry, z-scores, lean body mass, and adiposity. Maternal characteristics including BC and age were associated with concentrations and CDI of HM components, and 24-h milk intake. In conclusion, 24-h intake of HM and lactose as well as maternal adiposity are related to development of infant BC.

The Intestinal Dysbiosis of Mothers with Gestational Diabetes Mellitus (GDM) and Its Impact on the Gut Microbiota of Their Newborns

Gestational diabetes mellitus (GDM) is defined as “diagnosed as impaired glucose tolerance for the first time during pregnancy,” which can lead to adverse pregnancy outcomes and produces divergent effects on mothers and newborns. In recent years, with the continuous expansion of obese people, GDM shows an upward trend. The abundant and diverse members of the human gut microbiota exert critical roles in the maintenance of human health. Studies have shown that GDM may be associated with disordered gut microbiota in both mothers and newborns. Taking into account the potential effects on maternal and consequently neonatal health, in this review, we analyzed the available data and discussed the current knowledge about the potential relationship between GDM and intestinal dysbiosis in mothers and newborns. In addition, we also discussed the influencing factors derived from GDM mothers on the gut microbiome of their newborns, including the vertical transmission of microbiota from mothers, the alteration of milk components of GDM mothers, and using of probiotics. Hoping that new insights into the role of the gut microbiota in GDM could lead to the development of integrated strategies to prevent and treat these metabolic disorders.

Effects of colostrum management on transfer of passive immunity and the potential role of colostral bioactive components on neonatal calf development and metabolism

Neonatal dairy and beef calves are required to ingest adequate volumes of high-quality colostrum during their first hours of life to acquire transfer of passive immunity (TPI). As such, immunoglobulin G (IgG) has largely been the focus of colostrum research over recent decades. Yet, little is known about the additional bioactive compounds in colostrum that potentially influence newborn calf development and metabolism. The purpose of this narrative review is to synthesize research regarding the effects of colostrum management practices on TPI, as well as to address the potential role of additional colostral bioactive molecules, including oligosaccharides, fatty acids, insulin, and insulin-like growth factor-I, in promoting calf development and metabolism. Due to the importance of IgG in ensuring calf immunity and health, we review past research describing the process of colostrogenesis and dam factors influencing the concentrations of IgG in an effort to maximize TPI. We also address the transfer of additional bioactive compounds in colostrum and prepartum management and dam factors that influence their concentrations. Finally, we highlight key areas of future research for the scientific community to pursue to ultimately improve the health and welfare of neonatal dairy calves.

Human milk imparts higher insulin concentration in infants born to women with type 2 diabetes mellitus

OBJECTIVE

Human milk (HM) insulin plays many roles for the infant, especially for the newborn. We hypothesized HM insulin in women with type 2 diabetes (T2DM) would be higher than BMI-matched women with either gestational diabetes (GDM) or normal glucose tolerance (NGT). In T2DM, we also assessed macronutrient composition and relationships between maternal glycemic control and HM insulin.

STUDY DESIGN

HM was characterized at 2-weeks postpartum among three BMI-matched groups: T2DM (n= 12), diet-controlled GDM (n= 12), and NGT (n= 12). In T2DM, additional fasting and postprandial HM samples were collected while wearing a continuous glucose monitor (CGM), as well as fasting and 90-minute postprandial samples after a standardized meal at 1-2 weeks postpartum.

RESULTS

Fasting HM insulin was two times higher in T2DM compared to GDM and NGT (p < .001), which were not different from each other. Among T2DM, fasting (p < .001) and postprandial (p = .01) HM insulin levels were between 2 and 5× higher than plasma. Postprandial HM insulin (p = .03) and glucose (p < .001) were increased compared to fasting. Mean nocturnal glucose (p < .01) and maternal hemoglobin A1c (p < .01) positively associated with fasting HM insulin.

CONCLUSIONS

These data are the first to show HM insulin concentrations are doubled in T2DM compared to BMI-matched GDM and NGT. In HM of T2DM, insulin increases postprandially, may be concentrated relative to plasma, and is influenced by maternal glycemic control, with potential clinical implications that merit further study.

Metabolic Conditions Including Obesity, Diabetes, and Polycystic Ovary Syndrome: Implications for Breastfeeding and Breastmilk Composition

Breastfeeding is internationally recognized as the recommended standard for infant nutrition, informed by evidence of its multiple benefits for both mother and baby. In the context of common metabolic conditions such as polycystic ovary syndrome, diabetes (type 1, type 2, and gestational), and obesity, breastfeeding may be particularly beneficial for both mother and infant. However, there is evidence of delayed lactogenesis and reduced breastfeeding rates and duration in women with these conditions, and the effects of altered maternal metabolic environments on breastmilk composition (and potentially infant outcomes) are incompletely understood. In this review, we explore the relationships between maternal metabolic conditions, lactogenesis, breastfeeding, and breastmilk composition. We examine relevant potential mechanisms, including the central role of insulin both in lactogenesis and as a milk-borne hormone. We also describe the bioactive and hormonal components of breastmilk and how these may link maternal and infant health.

Human Milk Metabolic Hormones: Analytical Methods and Current Understanding

Human milk (HM) contains a wide array of peptide hormones including leptin and adiponectin, which are involved in the regulation of infant growth and development. These essential hormones might play an important role in the regulation of metabolic reprogramming of the new-born infant. However, HM hormone studies are sparse and heterogeneous in regard to the study design, sample collection, preparation and analysis methods. This review discussed the limitations of HM hormone analysis highlighting the gaps in pre-analytical and analytical stages. The methods used to quantify HM metabolic hormones (leptin, adiponectin, ghrelin, insulin, obestatin, resistin and apelin) can be classified as immunoassay, immunosensor and chromatography. Immunoassay methods (ELISA and RIA) have been predominantly used in the measurement of these HM hormones. The relative validity parameters of HM hormones analysis are often overlooked in publications, despite the complexity and differences of HM matrix when compared to that of plasma and urine. Therefore, appropriate reports of validation parameters of methodology and instrumentation are crucial for accurate measurements and therefore better understanding of the HM metabolic hormones and their influences on infant outcomes.

Breast milk apelin level increases with maternal obesity and high-fat feeding during lactation

OBJECTIVE

Recent evidence indicates that levels of breast milk (BM) hormones such as leptin can fluctuate with maternal adiposity, suggesting that BM hormones may signal maternal metabolic and nutritional environments to offspring during postnatal development. The hormone apelin is highly abundant in BM but its regulation during lactation is completely unknown. Here, we evaluated whether maternal obesity and overnutrition impacted BM apelin and leptin levels in clinical cohorts and lactating rats.

METHODS

BM and plasma samples were collected from normal-weight and obese breastfeeding women, and from lactating rats fed a control or a high fat (HF) diet during lactation. Apelin and leptin levels were assayed by ELISA. Mammary gland (MG) apelin expression and its cellular localization in lactating rats was measured by quantitative RT-PCR and immunofluorescence, respectively.

RESULTS

BM apelin levels increased with maternal BMI, whereas plasma apelin levels decreased. BM apelin was also positively correlated with maternal insulin and C-peptide levels. In rats, maternal HF feeding exclusively during lactation was sufficient to increase BM apelin levels and decrease its plasma concentration without changing body weight. In contrast, BM leptin levels increased with maternal BMI in humans, but did not change with maternal HF feeding during lactation in rats. Apelin is highly expressed in the rat MG during lactation and was mainly localized to mammary myoepithelial cells. We found that MG apelin gene expression was up-regulated by maternal HF diet and positively correlated with BM apelin content and maternal insulinemia.

CONCLUSIONS

Our study indicates that BM apelin levels increase with long- and short-term overnutrition, possibly via maternal hyperinsulinemia and transcriptional upregulation of MG apelin expression in myoepithelial cells. Apelin regulates many physiological processes, including energy metabolism, digestive function, and development. Further studies are needed to unravel the consequences of such changes in offspring development.

Breastfeeding and growth trajectory from birth to 5 years among children exposed and unexposed to gestational diabetes mellitus in utero

OBJECTIVES

This study aims to evaluate the association between exposure to gestational diabetes mellitus and growth trajectory from birth to 5 years and to test whether breastfeeding influences this association among children exposed and unexposed to gestational diabetes.

STUDY DESIGN

Weight at 0, 6, 12, and 18 months and 2, 3, 4, and 5 years were retrospectively collected for 103 children exposed and 63 children unexposed to gestational diabetes. Weight-for-age z-score was calculated. Mixed linear model for repeated measurements were computed to test whether breastfeeding was associated differently with weight-for-age z-score of children exposed or unexposed to diabetes.

RESULTS

Children exposed to gestational diabetes had greater z-score values at 6 months and 4 and 5 years (p < 0.10). Breastfeeding duration was not associated with weight-for-age z-score trajectory in any children.

CONCLUSION

Children exposed to gestational diabetes had a different growth trajectory in early life, but breastfeeding duration did not seem to influence this association.

Obesogenic Programming Effects during Lactation: A Narrative Review and Conceptual Model Focusing on Underlying Mechanisms and Promising Future Research Avenues

Animal studies have consistently demonstrated that maternal obesity and a high-fat diet during lactation enhances obesity risk in the offspring. However, less is known about these potential obesogenic programming effects in obese humans. We propose three important pathways that may explain obesogenic programming effects of human breastmilk. First, human milk components and hormones may directly affect child eating and satiety characteristics. Second, human milk constituents can affect child microbiota that, in turn, may influence child eating and weight outcomes. Third, human milk composition may affect child eating and weight outcomes through flavor exposure. We reviewed a few very recent findings from well-powered longitudinal or experimental human research with regard to these three pathways. Moreover, we provide a research agenda for future intervention research with the overarching aim to prevent excessive pediatric weight gain during lactation and beyond. The ideas presented in this paper may represent important “black box” constructs that explain obesogenic programming effects during lactation. It should be noted, however, that given the scarcity of studies, findings should be seen as working hypotheses to further test in future research.

Impact of maternal overweight and obesity on milk composition and infant growth

Overweight and obesity (OW/OB) impact half of the pregnancies in the United States and can have negative consequences for offspring health. Studies are limited on human milk alterations in the context of maternal obesity. Alterations in milk are hypothesized to impact offspring development during the critical period of lactation. We aimed to evaluate the relationships between mothers with OW/OB (body mass index [BMI] ≥25 kg/m2 ), infant growth, and selected milk nutrients. We recruited mother-infant dyads with pre-pregnancy OW/OB and normal weight status. The primary study included 52 dyads with infant growth measures through 6 months. Thirty-two dyads provided milk at 2 weeks, which was analysed for macronutrients, long-chain fatty acids, and insulin. We used multivariable linear regression to examine the association of maternal weight status with infant growth, maternal weight status with milk components, and milk components with infant growth. Mothers with OW/OB had infants with higher weight-for-length (WFL) and BMI Z-scores at birth. Mothers with OW/OB had higher milk insulin and dihomo-gamma-linolenic, adrenic, and palmitic acids and reduced conjugated linoleic and oleic acids. N6 long-chain polyunsaturated fatty acid (LC-PUFA)-driven factor 1 was associated with higher WFL, lower length-for-age (LFA), and lower head circumference-for-age Z-scores change from 2 weeks to 2 months in human milk-fed infants, whereas N6 LC-PUFA-driven factor 5 was associated with lower LFA Z-score change. Human milk composition is associated with maternal pre-pregnancy weight status and composition may be a contributing factor to early infant growth trajectory.

Diabetes Management During Breastfeeding in Women with Type 1 Diabetes

PURPOSE OF REVIEW

To provide an update on glycemic management of type 1 diabetes during breastfeeding with focus on diet and insulin treatment to prevent hypoglycemia, ketoacidosis, and weight retention. Recommendations for insulin pump settings are given.

RECENT FINDINGS

Women with type 1 diabetes are encouraged to breastfeed. Hypoglycemia is a concern in the breastfeeding period among women with type 1 diabetes, and ketoacidosis may also occur. The usual goals for glucose values for persons with diabetes also apply during breastfeeding. The recommended minimum daily carbohydrate intake is 210 g during breastfeeding, and this may contribute to prevention of hypoglycemia and ketoacidosis while aiming for gradual weight loss. Insulin requirements are 21% lower during breastfeeding than before pregnancy. Diabetes management in breastfeeding women with type 1 diabetes includes the same goals for glucose values as in other persons with diabetes, sufficient carbohydrate intake, and adequate reduction in insulin dose.

Epigenetics: Linking Early Postnatal Nutrition to Obesity Programming?

Despite constant research and public policy efforts, the obesity epidemic continues to be a major public health threat, and new approaches are urgently needed. It has been shown that nutrient imbalance in early life, from conception to infancy, influences later obesity risk, suggesting that obesity could result from “developmental programming”. In this review, we evaluate the possibility that early postnatal nutrition programs obesity risk via epigenetic mechanisms, especially DNA methylation, focusing on four main topics: (1) the dynamics of epigenetic processes in key metabolic organs during the early postnatal period; (2) the epigenetic effects of alterations in early postnatal nutrition in animal models or breastfeeding in humans; (3) current limitations and remaining outstanding questions in the field of epigenetic programming; (4) candidate pathways by which early postnatal nutrition could epigenetically program adult body weight set point. A particular focus will be given to the potential roles of breast milk fatty acids, neonatal metabolic and hormonal milieu, and gut microbiota. Understanding the mechanisms by which early postnatal nutrition can promote lifelong metabolic modifications is essential to design adequate recommendations and interventions to “de-program” the obesity epidemic.

[Medications in breastfeeding: what evidence is there?]

Breastfeeding plays a fundamental role in the benefits for the health of the newborn child and the nursing mother. The use of medications during breastfeeding is a relevant issue, by virtue of the frequent need for pharmacological treatment in the postpartum period. The scope of this article was to conduct a review of the literature regarding the efficacy and safety of medications used during the breastfeeding period. A search was conducted in the PubMed (National Library of Medicine), ScienceDirect and Biblioteca Virtual em Saúde (BVS) databases for articles published in Portuguese, English and Spanish in the period from 1981 to 2016. This review discusses the risk of the use of medications during lactation and the effects that they may have on the breastfed infant. Few medications are contraindicated and others require care due the risk of adverse effects on breastfed infants or in the suppression of breast milk volume. Therefore, the dissemination of updated information for the health professional to adequately assess the risks and the benefits of the use of medications during breastfeeding is of vital importance, thereby contributing to avoid early weaning.

Relationship of Maternal Weight Status Before, During, and After Pregnancy with Breast Milk Hormone Concentrations

OBJECTIVE

The aim of this study was to test associations of prepregnancy BMI, gestational weight gain, oral glucose challenge test results, and postpartum weight loss as predictors of breast milk leptin, insulin, and adiponectin concentrations and whether these relationships vary over time.

METHODS

Milk was collected at 1 and 3 months from 135 exclusively breastfeeding women from the longitudinal Mothers and Infants Linked for Healthy Growth (MILk) study. Hormones were assayed in skimmed samples using ELISA. Mixed-effects linear regression models were employed to assess main effects and effect-by-time interactions on hormone concentrations.

RESULTS

In adjusted models, BMI was positively associated with milk leptin (P < 0.001) and insulin (P = 0.03) and negatively associated with milk adiponectin (P = 0.02); however, the association was stronger with insulin and weaker with adiponectin at 3 months than at 1 month (time interaction P = 0.017 for insulin and P = 0.045 for adiponectin). Gestational weight gain was positively associated and postpartum weight loss was negatively associated with milk leptin (both P < 0.001), independent of BMI. Oral glucose challenge test results were not associated with these milk hormone concentrations.

CONCLUSIONS

Maternal weight status before, during, and after pregnancy contributes to interindividual variation in human milk composition. Continuing work will assess the role of these and other milk bioactive factors in altering infant metabolic outcomes.

New Achievements in High-Pressure Processing to Preserve Human Milk Bioactivity

High-pressure processing (HPP) is a non-thermal technology that is being increasingly applied in food industries worldwide. It was proposed that this method could be used as an alternative to holder pasteurization (HoP; 62.5°C, 30 min) in milk banks but its impact on the immunologic, enzymatic and hormonal components of human milk has not yet been evaluated in detail. The aim of our study was to compare the effects of HPP in variants: (1) 600 MPa, 10 min (2) 100 MPa, 10 min, interval 10 min, 600 MPa, 10 min (3) 200 MPa, 10 min, interval 10 min, 400 MPa, 10 min (4) 200 MPa, 10 min, interval 10 min, 600 MPa, 10 min in temperature range 19-21°C and HoP on the leptin, adiponectin, insulin, hepatocyte growth factor (HGF), lactoferrin and IgG contents in human milk. HoP was done at the Regional Human Milk Bank in Warsaw at the Holy Family Hospital on S90 Eco pasteurizer (Sterifeed, Medicare Colgate Ltd). Apparatus U4000/65 (Unipress Equipment, Poland) was used for pascalization. Milk samples were obtained from women during 2-6 weeks of lactation. Post-treatment culture showed no endogenous bacterial contamination in any tested option. Concentrations of selected components were determined using ELISA tests. The level of all analyzed components were significantly decreased by HoP: leptin 77.86%, adiponectin 32.79%, insulin 32.40%, HGF 88.72%, lactoferrin 60.31@.%, IgG 49.04%. All HPP variants caused an increase in leptin concentration, respectively (1) 81.79% (2) 90.01% (3) 86.12% (4) 47.96%. Retention of insulin after HPP was (1) 88.20% (2) 81.98% (3) 94.76% (4) 90.31% HGF (1) 36.15% (2) 38.81% 97.15% (3) 97.15% (4) 43.02%, lactoferrin (1) 55.78% (2) 57.63% (3) 78.77% (4) 64.75%. Moreover, HPP variant as 200 + 400 MPa preserved IgG (82.24%) better than HoP and resulted not statistically significant change of adiponectin level (38.55%) compare to raw milk. Our results showed that HPP leads to preservation of adipokines, growth factor, and lactoferrin, IgG much better or comparable with HoP.

Associations of breast milk adiponectin, leptin, insulin and ghrelin with maternal characteristics and early infant growth: a longitudinal study

Breast milk (BM) hormones have been hypothesised as a nutritional link between maternal and infant metabolic health. This study aimed to evaluate hormone concentrations in BM of women with and without gestational diabetes mellitus (GDM), and the relationship between maternal factors, BM hormones and infant growth. We studied ninety-six nulliparous women with (n 48) and without GDM and their exclusively breastfed term singletons. Women with GDM received dietary therapy or insulin injection for euglycaemia during pregnancy. Hormone concentrations in BM, maternal BMI and infant growth were longitudinally evaluated on postnatal days 3, 42 and 90. Mothers with GDM had decreased concentrations of adiponectin (P colostrum<0·001; P mature-milk=0·009) and ghrelin (P colostrum=0·011; P mature-milk<0·001) and increased concentration of insulin in BM (P colostrum=0·047; P mature-milk=0·021). Maternal BMI was positively associated with adiponectin (β=0·06; 95 % CI 0·02, 0·1; P=0·001), leptin (β=0·16; 95 % CI 0·12, 0·2; P<0·001) and insulin concentrations (β=0·06; 95 % CI 0·02, 0·1; P<0·001), and inversely associated with ghrelin concentration in BM (β=-0·08; 95 % CI -0·1, -0·06; P<0·001). Among the four hormones, adiponectin was inversely associated with infant growth in both the GDM (β weight-for-height=-2·49; 95 % CI -3·83, -1·15; P<0·001; β head-circumference=-0·39; 95 % CI -0·65, -0·13; P=0·003) and healthy groups (β weight-for-height=-1·42; 95 % CI -2·38, -0·46; P=0·003; β head-circumference=-0·15; 95 % CI -0·27, -0·03; P=0·007). Maternal BMI and GDM are important determinants of BM hormone concentrations. Milk-borne adiponectin is determined by maternal metabolic status and plays an independent down-regulating role in early infant growth.

Pharmacological treatment of gestational diabetes mellitus: point/counterpoint

Controversies persist over the most efficacious pharmacologic treatment for gestational diabetes mellitus. For purposes of accuracy in this article, the individual American College of Obstetricians and Gynecologists Practice Bulletin and American Diabetes Association Standards of Medical Care positions on each issue are quoted and then deliberated with evidence of counter claims presented in point/counterpoint. This is a review of all the relevant evidence for the most holistic picture possible. The main issues are (1) which diabetic drugs cross the placenta, (2) the quality of evidence and data source validity, (3) the rationale for the designation of glucose control as the primary outcome in gestational diabetes mellitus, and (4) which drugs (metformin, glyburide, or insulin) are most effective in improving secondary outcomes. The concept that 1 drug fits all, whether it be insulin, glyburide, or metformin, is a fallacy. Different drugs provide certain benefits but not all the benefits and not to all patients. In addition, the steps in the gestational diabetes mellitus management decision path and the current cost of the use of insulin, glyburide, or metformin are addressed. In the future, we must consider studying the potential of diabetic drugs that currently are used in nonpregnancy and incorporating the concept of precision medicine in the decision tree to maximize pregnancy outcomes.

The physiological and glycaemic changes in breastfeeding women with type 1 diabetes mellitus

The World Health Organisation recommends exclusive breastfeeding for the first six months of life (Australian institute of health and welfare, 2011). Breastfeeding confers many short- and long-term benefits for infants and mothers, including reduced childhood obesity and lower maternal body weight (Infant feeding survey, 2010; CDC National immunization surveys, 2012 and 2013; Sorkio et al., 2010; Hummel et al., 2014; Finkelstein et al., 2013). Exclusive breastfeeding is also recommended in women with type 1 diabetes mellitus (T1DM), for at least four months (Nucci et al., 2017). However, the impact of breastfeeding on mothers with T1DM, and, conversely, the impact of maternal T1DM on breastfeeding, is not clear. This review summarizes current knowledge regarding the epidemiology and physiology of breastfeeding in women with T1DM. In particular, it highlights the relationship between breastfeeding and glycaemia. Potential areas for future research are also identified.

Could a remarkable decrease in leptin and insulin levels from colostrum to mature milk contribute to early growth catch-up of SGA infants?

BACKGROUND

Breast milk is known to contain many bioactive hormones and peptides, which can influence infant growth and development. In this context, the purpose of this study was to evaluate the influence of different clinical pregnancy conditions on hormone concentrations in colostrum and mature breast milk.

METHODS

An observational study was performed with mother-newborn pairs divided into five groups according to maternal clinical background: diabetes (12), hypertension (5), smoking (19), intrauterine growth restriction of unknown causes with small-for-gestational-age newborns at delivery (12), and controls (21). Socioeconomic data, anthropometric measurements and breast milk samples were collected between the first 24 and 48 h and 30 days postpartum. Leptin, adiponectin, and insulin levels in breast milk were measured by immunoassays.

RESULTS

A significant decrease in leptin (p = 0.050) and insulin (p = 0.012) levels from colostrum to mature breast milk in mothers of small-for-gestational-age infants was observed. Maternal body mass index was correlated with both leptin and insulin, but not with adiponectin. Insulin levels were negatively correlated to infant weight gain from birth to one month (p = 0.050). In addition, catch-up growth was verified for small-for-gestational-age infants throughout the first month of life.

CONCLUSIONS

This study suggests that a remarkable decrease in leptin and insulin levels in mature milk of mothers of small-for-gestational-age newborns may be involved in the rapid weight gain of these newborns. The physiological and external mechanisms by which these significant decreases and rapid weight gains occur in this group remain to be elucidated.

Association of maternal breast milk and serum levels of macronutrients, hormones, and maternal body composition with infant's body weight

BACKGROUND/OBJECTIVES

This study was aimed to investigate the association of maternal serum and breast-milk levels of macronutrients, hormones, growth factors, and maternal body composition with infant's body weight.

SUBJECTS/METHODS

Eighty mother-infant pairs comprised 40 with overweight or obese infant and 40 with normal-weight infant were enrolled in this study. The level of ghrelin, Leptin, adiponectin, EGF, and IGF1 in plasma and breast milk were assessed. Daily breast milk intake and macronutrient concentration along with anthropometric indices of mother-infant pairs were also assessed.

RESULTS

No significant differences were observed in concentrations of serum hormones between two groups (p > 0.05). However, hormones levels in maternal serum were higher than those in breast milk. A significant positive correlation was found between serum EGF and ghrelin (r = 0.57, p = 0 < 0001). Higher IGF1 in serum showed a significant association with its milk counterpart (r = 0.37). Current mother's weight was associated with infant's weight at the 2nd and 6th month (B = 0.023 p = 0.04, B = 0.055 p = 0.005). The breast-milk macronutrient content was not comparable between two groups. However, the average daily breast milk consumption in obese infants was higher than normals (p = 0.001). Milk EGF and leptin were related to a decrease of 59% and 46% the odds of obese infant development, respectively. There was a significant association of milk EGF and ghrelin with birth weight (B = -0.19, p = 0.04 and B = -0.2, p = 0.04, respectively), and also serum leptin with infant's body weight at the 6th month.

CONCLUSIONS

Our findings provide a positive association of maternal weight, daily breast milk intake, EGF, and ghrelin with infant's body weight.

Impact of Metabolic Hormones Secreted in Human Breast Milk on Nutritional Programming in Childhood Obesity

Obesity is the most common metabolic disease whose prevalence is increasing worldwide. This condition is considered a serious public health problem due to associated comorbidities such as diabetes mellitus and hypertension. Perinatal morbidity related to obesity does not end with birth; this continues affecting the mother/infant binomial and could negatively impact on metabolism during early infant nutrition. Nutrition in early stages of growth may be essential in the development of obesity in adulthood, supporting the concept of "nutritional programming". For this reason, breastfeeding may play an important role in this programming. Breast milk is the most recommended feeding for the newborn due to the provided benefits such as protection against obesity and diabetes. Health benefits are based on milk components such as bioactive molecules, specifically hormones involved in the regulation of food intake. Identification of these molecules has increased in recent years but its action has not been fully clarified. Hormones such as leptin, insulin, ghrelin, adiponectin, resistin, obestatin and insulin-like growth factor-1 copeptin, apelin, and nesfatin, among others, have been identified in the milk of normal-weight women and may influence the energy balance because they can activate orexigenic or anorexigenic pathways depending on energy requirements and body stores. It is important to emphasize that, although the number of biomolecules identified in milk involved in regulating food intake has increased considerably, there is a lack of studies aimed at elucidating the effect these hormones may have on metabolism and development of the newborn. Therefore, we present a state-of-the-art review regarding bioactive compounds such as hormones secreted in breast milk and their possible impact on nutritional programming in the infant, analyzing their functions in appetite regulation.

Postnatal Prevention of Childhood Obesity in Offspring Prenatally Exposed to Gestational Diabetes mellitus: Where Are We Now?

Children exposed to gestational diabetes mellitus (GDM) in utero are at high risk of developing many health problems such as obesity. There is an urgent need to find new strategies to prevent obesity development among high-risk populations such as those children. Accordingly, the aim of this review was to summarize current knowledge on the postnatal prevention of childhood obesity in offspring born from mothers with GDM. Specifically, this review addresses the impact of breastfeeding, complementary feeding practices as well as dietary intake and physical activity during childhood on obesity risk of children exposed to GDM in utero. Furthermore, breast milk composition of diabetic mothers and its potential impact on growth is discussed. According to the available literature, breastfeeding may reduce obesity risk in children exposed to GDM in utero but a longer duration seems necessary to achieve its protective effect against obesity. Detailed analysis of breast milk composition of mothers with GDM will be necessary to fully understand the relationship between breastfeeding and obesity in this specific population. This review highlights the need for more studies addressing the impact of complementary feeding practices and lifestyle habits during childhood on obesity risk of children exposed to GDM in utero.

Variation of Metabolite and Hormone Contents in Human Milk

Animal studies show that the lactation period contributes to metabolic programming of the offspring and that oral leptin and insulin show bioactivity. Stage of lactation, duration of gestation, maternal body composition, and maternal diet seem to influence the concentrations of small molecules in human milk. Variability of small molecule concentrations seems higher in preterm milk than in term milk. Insulin in human milk shows concentrations similar to plasma. Leptin concentration is lower in milk than in plasma and reflects maternal body mass index. Early in lactation, leptin could contribute to mediating the association between maternal and infant body composition.

Biological underpinnings of breastfeeding challenges: the role of genetics, diet, and environment on lactation physiology

Lactation is a dynamic process that has evolved to produce a complex biological fluid that provides nutritive and nonnutritive factors to the nursing offspring. It has long been assumed that once lactation is successfully initiated, the primary factor regulating milk production is infant demand. Thus, most interventions have focused on improving breastfeeding education and early lactation support. However, in addition to infant demand, increasing evidence from studies conducted in experimental animal models, production animals, and breastfeeding women suggests that a diverse array of maternal factors may also affect milk production and composition. In this review, we provide an overview of our current understanding of the role of maternal genetics and modifiable factors, such as diet and environmental exposures, on reproductive endocrinology, lactation physiology, and the ability to successfully produce milk. To identify factors that may affect lactation in women, we highlight some information gleaned from studies in experimental animal models and production animals. Finally, we highlight the gaps in current knowledge and provide commentary on future research opportunities aimed at improving lactation outcomes in breastfeeding women to improve the health of mothers and their infants.

The control of hyperglycemia by a novel trypsin resistant oral insulin preparation in alloxan induced type I diabetic mice

A trypsin resistant oral insulin preparation was made by incubating insulin for 2 h at 23 °C with previously boiled cow milk at 100 °C that was coagulated with 0.6 M acetic acid. The precipitate was resuspended in the same volume of milk. The immunoblot analysis of the suspended proteins treated with 200 ng of trypsin/ml for 3 h demonstrated that the 80.1% of the insulin in the suspension survived the proteolytic degradation compared to 0% of the hormone survived in the control. The feeding of 0.4 ml (0.08 unit of insulin) of the resuspended proteins followed by 0.2 ml of the same protein to alloxan induced diabetic mice maximally decreased the blood glucose level from 508 ± 10 mg/dl to 130 ± 10 mg/dl in 7 h with simultaneous increase of the basal plasma concentration of insulin from 3 ± 1.1 μunits/ml to 18 ± 1.5 μunits/ml. In control experiment the absence of insulin in the identical milk suspension produced no hypoglycemic effect suggesting milk was not responsible for the hypoglycemic effect of milk-insulin complex. Coming out of insulin-casein complex from the intestinal gut to the circulation was spontaneous and facilitated diffusion transportation which was found from Gibbs free energy reaction.

The Effect of Gestational and Lactational Age on the Human Milk Metabolome

Human milk is the ideal nutrition source for healthy infants during the first six months of life and a detailed characterisation of the composition of milk from mothers that deliver prematurely (<37 weeks gestation), and of how human milk changes during lactation, would benefit our understanding of the nutritional requirements of premature infants. Individual milk samples from mothers delivering prematurely and at term were collected. The human milk metabolome, established by nuclear magnetic resonance (NMR) spectroscopy, was influenced by gestational and lactation age. Metabolite profiling identified that levels of valine, leucine, betaine, and creatinine were increased in colostrum from term mothers compared with mature milk, while those of glutamate, caprylate, and caprate were increased in mature term milk compared with colostrum. Levels of oligosaccharides, citrate, and creatinine were increased in pre-term colostrum, while those of caprylate, caprate, valine, leucine, glutamate, and pantothenate increased with time postpartum. There were differences between pre-term and full-term milk in the levels of carnitine, caprylate, caprate, pantothenate, urea, lactose, oligosaccharides, citrate, phosphocholine, choline, and formate. These findings suggest that the metabolome of pre-term milk changes within 5–7 weeks postpartum to resemble that of term milk, independent of time of gestation at pre-mature delivery.

Alterations in human milk leptin and insulin are associated with early changes in the infant intestinal microbiome

BACKGROUND

Increased maternal body mass index (BMI) is a robust risk factor for later pediatric obesity. Accumulating evidence suggests that human milk (HM) may attenuate the transfer of obesity from mother to offspring, potentially through its effects on early development of the infant microbiome.

OBJECTIVES

Our objective was to identify early differences in intestinal microbiota in a cohort of breastfeeding infants born to obese compared with normal-weight (NW) mothers. We also investigated relations between HM hormones (leptin and insulin) and both the taxonomic and functional potentials of the infant microbiome.

DESIGN

Clinical data and infant stool and fasting HM samples were collected from 18 NW [prepregnancy BMI (in kg/m(2)) <24.0] and 12 obese (prepregnancy BMI >30.0) mothers and their exclusively breastfed infants at 2 wk postpartum. Infant body composition at 2 wk was determined by air-displacement plethysmography. Infant gastrointestinal microbes were estimated by using 16S amplicon and whole-genome sequencing. HM insulin and leptin were determined by ELISA; short-chain fatty acids (SCFAs) were measured in stool samples by using gas chromatography. Power was set at 80%.

RESULTS

Infants born to obese mothers were exposed to 2-fold higher HM insulin and leptin concentrations (P < 0.01) and showed a significant reduction in the early pioneering bacteria Gammaproteobacteria (P = 0.03) and exhibited a trend for elevated total SCFA content (P < 0.06). Independent of maternal prepregnancy BMI, HM insulin was positively associated with both microbial taxonomic diversity (P = 0.03) and Gammaproteobacteria (e.g., Enterobacteriaceae; P = 0.04) and was negatively associated with Lactobacillales (e.g., Streptococcaceae; P = 0.05). Metagenomic analysis showed that HM leptin and insulin were associated with decreased bacterial proteases, which are implicated in intestinal permeability, and reduced concentrations of pyruvate kinase, a biomarker of pediatric gastrointestinal inflammation.

CONCLUSION

Our results indicate that, although maternal obesity may adversely affect the early infant intestinal microbiome, HM insulin and leptin are independently associated with beneficial microbial metabolic pathways predicted to increase intestinal barrier function and reduce intestinal inflammation. This trial was registered at clinicaltrials.gov as NCT01693406.

Safety of Drugs during Pregnancy and Breastfeeding in Cystic Fibrosis Patients

Health management of cystic fibrosis (CF) patients should be maximized during pregnancy and breastfeeding because of its significant impact on the maternal and newborn outcomes. Thus, numerous drugs will have to be continued during pregnancy and lactation. Most of the drugs representing CF treatment lines cross the placenta or are excreted into human milk. Research addressing the risks and benefits of drugs used in CF patients during pregnancy and lactation is often incomplete or challenged by limited methodology, which often leads to conflicting or inconclusive results. Yet, potential treatment benefits for CF pregnant patients most often outbalance potential risks for the unborn child.