Melinda, this is a good question.  You might get many different responses.

 From a practical point of view, the prenatal diagnosis of IGT might
only be considered to be a possibility during the second pregnancy
because - regardless of breast shape or size, it's impossible to
know, without a trial of lactation, how much milk a particular mother
might make.  So a mother with already diagnosed IGT would already be
aware, from her first lactation attempt, that exclusive breastfeeding
hadn't been possible.  So I would think that a frank acknowledgement
that IGT is rare, but that regrettably it does happen would be
appreciated.  Then the rest of the prenatal discussions would focus
on how to achieve maximum breastmilk production while possibly
needing to provide formula top-ups. To this end I stress that all of
the baby's immunological requirements can be provided, since - like
colostrum - they are more concentrated in a smaller volume of
breastmilk, and all of the baby's emotional needs can be met by
nursing, regardless of the quantity of milk production.  The baby can
be topped up by formula supplements to protect his/her nutrition
(discuss normal weight gain of roughly 30g/day from 0 - 3 months to
monitor this).  But this means that two out of the three "advantages"
of breastfeeding can be fully met by a mother with IGT.

Personally, I'm not crazy about the thought of prenatal expression of
breastmilk.  But I do tend to agree with Trisha Shamblin's focus on
postpartum breastmilk removal to maximize production in this kind of
situation.  Maximizing skin to skin is nice, but it's not the main
thing in a case of IGT.  Draining the breasts as thoroughly as
possible and as frequently as possible (at least 10 times in 24 hours
for at least the first 2 - 4 weeks) will facilitate production of
those prolactin receptors in the breasts, and help this mother to do
the best that she can.  And no-one can ask for more. I also always
make sure to point out that when the baby is six months or more and
starts having other foods and liquids, she will be able to phase out
the formula supplements and eventually give the baby solids and
exclusive breastfeeding, the same as any other mother and for as long
as she wants.  The last important factor with IGT IME is that in a
second or subsequent lactation, the mother is likely to produce more
milk than she did with the first, and I always let her know that we
cannot know, in advance, exactly how much she will produce, so the
focus should be on maximizing however much it is, and then waiting to
see.  It's all hopeful.

Being less than frank, in this kind of situation, in order to "save"
a mother's feelings, seems to be less than helpful.  I think women
appreciate our honesty, if what we say is said with empathy and
kindness and if we make it clear that we're on the mother's side and
will help her do the best that _she_ possibly can, and if she teach
her how to monitor that her baby's nutrition is not being compromised.

Pamela Morrison IBCLC
Rustington, England
-----------------------------------------------------

This is such a touchy diagnosis. I'd like to know how you consultants
bring up the issue upon meeting a woman with IGT. How to balance an
honest assessment with encouragement but no unrealistic expectations,
and respect their desire to breastfeed?
Melinda Harris-Moulton
IBCLC FNP
Olympia, WA


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