Ep. 13: Colostrum expression for gestational diabetes

Ep. 13: Colostrum expression for gestational diabetes

If you've been diagnosed with gestational diabetes, there's a good chance someone has mentioned colostrum expression to you at some point - but maybe without fully explaining what it actually is, why it matters for your specific situation, or how to do it. This episode is here to fill in all of those gaps.

I'm joined by Katie Irwin from Flourish Lactation, a privately practising endorsed midwife and international board certified lactation consultant based in Brisbane. Katie supports women through pregnancy, birth and beyond, and she is genuinely one of the warmest, most knowledgeable people you could have in your corner for this stuff. Full disclosure - I'm currently pregnant and very much had my own selfish reasons for inviting her on. Consider this your most thorough colostrum refresher.

We talk through what colostrum actually is, why babies born after gestational diabetes pregnancies can be particularly at risk of low blood sugars, and how having a little stash of expressed colostrum in the freezer can act as the most important insurance policy you didn't know you needed.

We also get really practical - covering technique, storage, transportation to hospital, and the emotional side of it too, including the finding from the DAME study that left me genuinely surprised. Whether you've expressed before or you're approaching this completely fresh, I think you'll come away feeling a lot more confident and a lot less stressed about the whole thing.

What you’ll hear in this episode:

  • What colostrum actually is, when your body starts producing it, and what makes it so incredibly nutrient-dense compared to mature milk
  • Why babies born after a gestational diabetes pregnancy are at higher risk of low blood sugars (hypoglycemia) in those first hours after birth, and what that actually looks like in practice
  • How expressed colostrum is used after birth - from topping up after feeds, to waking a sleepy baby, to bridging the gap while mum recovers from a caesarean
  • What happens if colostrum isn't available, including the full range of options from skin-to-skin and Glucogel through to formula and IV glucose
  • The DAME study - the multi-centre Australian randomised controlled trial that confirmed antenatal expression is safe from 36 weeks for women with gestational diabetes, and the surprising findings about how little most women actually express
  • The follow-up qualitative research exploring the emotional experience of antenatal expressing - including how empowering it can be, and why some women found it really hard
  • A step-by-step walkthrough of how to hand express, including technique, what to expect, how to collect it, how to store it, and how to get it safely to the hospital
  • Why your birth partner has a really important job here - and how to make sure your colostrum doesn't get lost or forgotten about in the chaos of labour and birth
  • How long to persist if nothing is coming out, and how to reframe the whole experience if amounts feel disheartening
  • How to connect with Katie for antenatal breastfeeding education, telehealth consultations, and urgent mastitis support


Resources & links mentioned:


About the guest

Katie Irwin is an endorsed midwife and international board certified lactation consultant (IBCLC) practising privately through Flourish Lactation, based in Brisbane. She supports women through pregnancy, birth and feeding, offering antenatal breastfeeding education, postnatal consultations, and urgent mastitis telehealth across Australia. Find her at flourishlactation.com.au or on Instagram at @flourishlactation.

Transcript

This transcript was auto-generated and lightly edited for clarity.

Celia (00:00) One topic that's often mentioned to women with gestational diabetes, but not always fully explained, is colostrum expression. You might've had it suggested to you, but not necessarily been told why or how it's actually used after birth. In this episode, we're going to gently walk through all of that - why it can be particularly helpful following gestational diabetes and how it might be used in those early hours after your baby is born.

We'll also get practical, covering when it's safe to start, how to express, and what to expect. I'm joined by Katie from Flourish Lactation. Katie is a privately practising endorsed midwife and an international board certified lactation consultant. She supports women through pregnancy, birth and feeding. Thanks so much for joining us, Katie.

Katie (00:42) Thank you so much for having me.

Celia (00:44) As I was just saying, it's perfect timing - this is just around the corner for me. So I really need this refresher.

Katie (00:47) Yes, perfect.

Celia (00:51) Maybe we can start right at the beginning. Can you tell us what colostrum actually is?

Katie (00:56) Yeah, so colostrum is the first milk that your breasts make in pregnancy. Generally that starts happening around 16 weeks. Colostrum is extra special because it's incredibly high in protein, antibodies and antioxidants. It's really highly concentrated, really nutrient dense - it's designed to kickstart the infant's system and coat their gut.

Celia (01:21) Wow, I didn't know it started at 16 weeks. That's early. And how is it different when milk comes in officially?

Katie (01:29) So we kind of have three phases of milk making. It starts in pregnancy with colostrum, as I mentioned, and then it transitions into what we'd call full milk - usually around that 30 to 72 hour mark post birth. Then we have a maintenance phase that kicks in around 9 to 14 days, when the body switches from hormone control post birth to more of a supply and demand system, and that continues through until weaning.

Colostrum is different to transitional milk in that it's very small amounts - perfect for brand new tiny babies who have tiny tummies. It's really thick and sticky and golden, which is why lots of people call it liquid gold. It's perfectly designed to be everything your baby needs in those first few days in very small amounts - incredibly nutrient dense. It's filled with all the immunoglobulins that set up the body's immune system. But it's also really rich in things like magnesium, zinc, copper and vitamin A. It's lower in fat and lactose, which helps babies digest it. And the other interesting thing is that because it's such a small amount, it helps babies learn how to breastfeed and coordinate their suck, breathe, swallow without having to manage large volumes straight after birth.

Celia (03:00) Wow. Okay, so many good things about it for bub. Is there any benefit to mum for expressing it earlier, rather than just starting to breastfeed after bub's born?

Katie (03:05) Yeah, that's an interesting question. There's probably not too many benefits from a health perspective in terms of the early antenatal expression itself - it's more that initiating breastfeeding is incredibly beneficial for mothers, and breastfeeding in general has huge implications for mums. It reduces the risk of breast cancer and ovarian cancer, diabetes, obesity - I'm sure there's lots more I'm skipping over.

But I guess the best thing for mums that I see as a lactation consultant is just getting to know your breasts before you birth your baby, and being able to handle them confidently and hand express before you're actually juggling a newborn, sleep deprived and recovering post birth. I see that as the biggest advantage to antenatal expressing from a maternal perspective - just building that breastfeeding confidence before you birth your baby.

And I think it's really important to understand what your breasts feel like as well. It helps you detect any changes afterwards that you might notice or be concerned about. It's just doing and learning this new skill before you're actually in the thick of it.

Celia (04:30) Yeah, I can 100% attest to that. Breastfeeding is the one thing I just thought, I'll figure it out. I did very little prep last time around. As a first time mum, I remember just being like - what the hell? What do I do with these boobs now? This is all new.

Katie (04:36) Yes, and I think we spend nine months preparing for birth - all of our time and energy and education goes into preparing for labour, and then the baby's born and you're like, oh, the breastfeeding piece - I didn't consider this. And the world doesn't pause for you to catch up and learn at that point. It's all systems go. It's definitely something worth considering during your pregnancy, not just afterwards.

Celia (05:18) Yeah, totally. So when women have been managing gestational diabetes, it does get flagged as something that could be a good idea to try. Can you speak to why that is - why it's particularly relevant for GD?

Katie (05:29) Yeah, so in the setting of gestational diabetes - and all diabetes in pregnancy, including type 2 and type 1 - the maternal body is running at a slightly higher glucose level, and the baby is exposed to that through the maternal blood supply and placenta. So the baby's producing its own insulin in pregnancy and running at a higher insulin level than a baby from a pregnancy without diabetes. Babies cope really well with this, but what happens after birth is that they're removed from that source of glucose because they're separated from you and from the placenta - but their insulin levels stay the same.

It just gives them a day or so to regulate their own system. So they can be born with quite high insulin levels, and with not as much glucose coming in as they're learning to breastfeed, those high insulin levels with lower glucose can cause hypoglycemia - or low blood sugars - after birth.

So the main reason we'd recommend antenatal expressing for mums with diabetes in pregnancy is primarily to give us a source of colostrum to give to your baby after birth if they're experiencing any low blood sugars.

Celia (06:52) Versus just as an extra supply going into the first initial feeds. Okay.

Katie (06:57) Yep, exactly. So it can be used in a few ways. Generally we just get baby breastfeeding straight away, hopefully within that first 30 to 60 minutes after birth with skin-to-skin contact. That's going to kickstart your baby's gut and get their sugars up. Sometimes babies will have a bit of a drop after that initial breastfeed. Depending on where you birth and what state you're in, we would generally check your baby's blood sugars before the second feed. That gives us an idea of how they're going. If everything's fine, you can just continue breastfeeding as you are. If they're trending down, we could use that colostrum as an extra top-up after a breastfeed - just a syringe of colostrum to give them a little bit extra, just to be proactive and keep those blood sugars up.

The other situation where it can be useful is if they're very sleepy after birth - which a lot of babies are. If you can't wake them for a good breastfeed, we can use a syringe of colostrum just to get them going, give them a little hit of sugar so that they breastfeed better and are nicely alert at the breast.

Celia (08:10) Yeah, I hadn't thought about that, but it makes sense. Interesting. You mentioned the first feed and then before the second feed - that's when monitoring of baby's blood sugars typically happens. What does that actually involve?

Katie (08:25) Yeah, so generally it's just a heel prick on your baby's heel. A little lancet, and they'll take a drop of blood on a glucometer, or in some places they use a little glass pipette to run it through a blood gas machine - it depends on the site. You get a result very quickly. Generally we want it to be over 2.6, and that kind of guides treatment from there.

In most places, we would monitor blood sugars for 24 hours. If they were all normal, we'd just continue. If there were some lower ones, we'd keep going until we've got about 24 hours of normal results. Definitely hold your baby skin-to-skin for comfort and pain relief during the heel prick - you could even have them just starting a breastfeed when they do it. Obviously we don't want the blood sugar read during the breastfeed because that will skew the results, but from a pain relief point of view you could latch them on. Sometimes it can be hard to coordinate the timing of midwives in the ward, but having them skin-to-skin for comfort is always helpful. Most babies are pretty chill about it.

Celia (09:40) Yeah. I honestly can't remember with my daughter - it's funny how it's all a blur.

Katie (09:44) Yeah, it is a blur. And the bigger heel prick blood tests, like for the blood spot test where we get four spots of blood - that one's longer because we're squeezing or milking the foot for those drops. But the blood glucose test is a tiny, tiny amount.

Celia (10:07) Yeah, probably similar to what we've all been doing testing our own levels.

Katie (10:11) Exactly the same, yeah.

Celia (10:14) Okay. In the case that colostrum isn't available - if mum hasn't expressed - what are the usual alternatives?

Katie (10:21) Yeah, so it depends on the baby and whether they're symptomatic and what their blood sugars are. Generally, we would always put them skin-to-skin to keep them warm, and maybe some warm wraps over the top, because a cold baby will drop their blood sugars much faster than a nice warm baby. Skin-to-skin has been proven in multiple studies to improve blood glucose, heart rate, breathing and temperature. So skin-to-skin always, and keeping the baby warm.

Then we could use Glucogel, which is a little oral gel - that's less of a treatment and more of a "let's get this baby awake to feed" option. The other option is formula, potentially, depending on your hospital policies. You could even use donor breast milk from a friend, sister, or someone else who's breastfeeding. And then if the baby is very symptomatic, they may be admitted to the nursery and have IV glucose through a little drip, or a nasogastric tube for formula or breast milk.

Celia (11:30) It sounds like there are lots of different options.

Katie (11:32) There are so many things, and it's completely based on the baby - their weight, their gestation, their symptoms.

Celia (11:40) Yeah, okay. All very personalised. But it's good to know there's a whole suite of possibilities.

Katie (11:43) Definitely. And I think it's important for anyone in a hospital setting to know that if an intervention is being offered, you can take a pause and ask questions. Generally it's not a huge, immediate emergency, and you can ask things like - what are the benefits? What are the disadvantages? What are the alternatives? What happens if we do nothing? Those are really good standard questions. Any midwife or paediatrician caring for you and your baby should be able to go over those options. I would say in most gestational diabetes cases, it's extremely rare for a baby to need IV glucose. It's usually managed very easily with colostrum, breast milk, formula, and maybe a little bit of Glucogel.

Celia (12:43) There was a big study done in Australia called the DAME study. Do you want to talk a little bit about what came out of that?

Katie (13:05) Yeah, it's research we're really proud of as Australians - it's genuinely contributed to the literature, and we have an amazing history of breastfeeding research in Australia, with some incredible researchers particularly around Melbourne, Perth and Brisbane.

The DAME study was a multi-centre randomised controlled trial, so really high quality, based across lots of centres around Melbourne. From memory, they had around 650 women with gestational diabetes who otherwise had low-risk pregnancies. The main reason for doing the study was to look at the safety of antenatal expressing in the context of gestational diabetes. We had started to encourage women to antenatally express during pregnancy when they had GDM, but we didn't actually have any evidence to say it was safe - even though anecdotally it seemed fine, we didn't have the data to back that up.

So this study showed that yes, it's absolutely safe for women with gestational diabetes to antenatally express from 36 weeks. It didn't increase the risk of preterm birth or babies being admitted to the nursery. That was really reassuring and gave us confidence to continue that recommendation.

But there was also other interesting data that came out of it - which I actually found way more interesting than that primary finding. Do you want me to go into that a bit further?

Celia (14:30) Yeah, please.

Katie (14:41) So the protocol was expressing from 36 weeks to birth, twice a day for 10 minutes. They found that for the women in the expressing arm - so half were standard care, not antenatally expressing, and half were expressing - a quarter of the women expressed less than one mil across that whole time period, and half of the women got five mils or less. Then there were some outliers on the other end who could express huge volumes, like 200 to 400 mils - but for the vast majority, it was super small amounts.

Celia (15:22) What was the time period again?

Katie (15:24) From 36 weeks to birth, twice a day. So potentially a couple of weeks to a month or so. Yeah, really small amounts. And the reason is that you've got a huge placenta in there doing a very good job of pumping out progesterone and keeping your pregnancy safe and stable. Progesterone counteracts the ability to make milk - what we call lactogenesis two - so that transition to full milk happens when we birth the placenta and progesterone levels drop very rapidly. In pregnancy, we expect you not to be producing lots of milk, so those tiny amounts are exactly right.

But I think the biggest takeaway for me as a clinician is really emphasising those small amounts so women know what to expect. And there was certainly no evidence in the study to show that the more you expressed antenatally, the better you breastfed later. There were no correlations like that. A follow-up study by the same author also found there was no earlier onset of milk in women who were antenatally expressing, which some earlier, lower quality studies had suggested.

I think of antenatal expressing almost like an insurance policy - having that little bit of colostrum there so that if things go pear-shaped post birth, you've got something to draw on. Whilst it's fabulous to have, it's really important that women understand the realistic amounts, that you may not get anything, and that at least a quarter of these women were hardly getting anything - and that's normal, and it wasn't correlated to poor breastfeeding outcomes.

Celia (17:29) Yeah, that's definitely reassuring. And even when you said it's so concentrated, a small amount is still really good for bub, right?

Katie (17:35) Exactly - it's so concentrated. I think it's got something like double the amount of protein compared to transitional milk. That's why it's so sticky. Think of it as full concentrated honey of deliciousness. And babies can't tolerate huge amounts anyway - they've got teeny tiny stomachs, and colostrum is designed to coat that bowel and the lining of the intestine so that harmful bacteria aren't absorbed.

The other cool thing about colostrum that I didn't mention - it acts as a laxative, so it helps to push all that meconium out. That thick, dark tar poo in the early days. Added bonus.

Celia (18:12) There you go. Actually, I'll try to track down a reel or post about this and link it in the show notes - it showed day by day how much bub's stomach can actually take in a feed, and it was fascinating because it's so tiny.

Katie (18:24) It is tiny, tiny amounts - like a pea, to a marble, to a ping pong ball. And we can stretch those stomachs and over-inflate them. I find that does sometimes happen when there are lots of formula top-ups in hospital. With a standard journey, babies are tolerating tiny, tiny amounts, and that's why they feed so frequently as well. Colostrum is so easily digested, so the idea is that they're feeding super regularly - eight to 12 to 14 times in 24 hours would be very normal. And that's really telling your body to make milk. For most people, I really want to see that transition to milk starting before 72 hours, ideally from around 30 hours. We do know in the context of diabetes and pregnancy that delayed onset of milk is very common by up to 24 hours, so that frequent feeding is really important in that context especially.

Celia (19:32) Yeah, definitely. Okay. You also mentioned there was some follow-up research to the DAME study looking at the mental health side of things. Do you want to talk about what came out of that?

Katie (19:39) Yeah, I really loved that follow-up study. They did semi-structured interviews with 10 women who were part of the intervention arm of the DAME trial - so women who were antenatally expressing. I just love qualitative data as a midwife. I find it so powerful, hearing women's voices in research, particularly around breastfeeding and birth.

And I think it's really helpful for clinicians too - we're always banging on about quantitative data, but as a clinician that qualitative data is so valuable for really understanding the woman's lived experience. It was a really mixed bag, honestly, which I think is important. When I'm educating women about antenatal expressing in clinic, I always include these stories, and I'll sometimes even pull up the quotes and read them.

So in some women, it was really empowering. Maybe most importantly, it gave them a sense of control over their pregnancy. Because having that diagnosis of GDM can feel so out of control and discombobulating. Lots of women found that antenatal expressing was something they could do, they were in charge of, and they could provide for their baby - and there was real ownership over that, which I think is really cool.

Then the other side was women finding it really disheartening when they didn't get much, and worrying unnecessarily about their upcoming breastfeeding journey because of that. Some women reported finding it uncomfortable and awkward, and really struggling to make time, especially if you've got lots of kids or you're working full time. So yeah, it was really mixed.

Celia (21:57) I definitely felt super awkward when I started. I'm really relating to that. And I remember - I think I was pushing too hard in hindsight when I first started. Nothing was coming out, it was hurting, and there's just the whole emotional side of it. You definitely don't need to clamp down on your boob the first time.

Katie (22:08) Yes! And then you're like, oh my gosh, if this is hurting, how much is breastfeeding going to hurt? And then you just spiral. Definitely not. Yeah, absolutely.

Celia (22:26) That's my one little takeaway. So, with all of that in mind about the mixed bag - how would you suggest women think about whether it's the right move for them?

Katie (22:35) Yeah, when I'm talking to mums about it, I have a conversation very similar to this one. I go through the benefits, the disadvantages, what some women notice and what some women struggle with. I really leave it in their hands as to what they want to do and what they find most comfortable.

If someone is already extremely anxious about breastfeeding, it can go either way. Some women will find it really important for building their confidence, and others will find it really stressful. I see my role as giving everyone all of the information so they can make an informed decision.

Celia (23:49) That makes sense. Okay, well maybe let's get into some of the practicalities. When is it safe to start expressing?

Katie (23:54) We generally say from 36 weeks, but you want to make sure your primary care provider is comfortable with you starting as well. There are some contexts where we wouldn't recommend it - for example, placenta praevia, where the placenta is over or close to the cervix, or a cervical cerclage, or any situation where you're at risk of preterm birth or we're aiming for a planned caesarean. In those cases, your care provider might not be as comfortable with antenatal expressing. Honestly, the research doesn't back up that it causes preterm labour - that wasn't shown in the DAME study - but it's something some care providers are more cautious about. So definitely have that conversation with your primary care provider first. For most people with a normal low-risk pregnancy, 36 weeks is totally fine, and once or twice a day for five to ten minutes is totally adequate.

You kind of want to make the whole environment feel safe and calm - not awkward, not painful, not uncomfortable. Most people will settle down in the evening, have a nice hot shower, maybe do some breast massage using little stroking or mobilising techniques, getting more familiar with the shape and feel of your breast. Heat packs or a hot shower before can really help.

In terms of technique - most people start by placing their thumb and pointer finger on either side of their nipple, maybe two or three centimetres back from the nipple, close to the edge of the areola. Then you gently push back into the breast or into the chest wall, and bring your fingers together - gently squeezing them. It definitely shouldn't feel painful, so if it really hurts, stop. Your breast is a really delicate organ, especially during pregnancy as it's growing and is very vascular - you don't want to cause any bruising. Then you kind of get into a rhythm of pushing back into the chest wall and bringing your fingers together. You can rotate around the areola too, moving your fingers to different positions. After a couple of minutes, you might see a little glisten on top of your nipple - a tiny shiny liquid. Hopefully that's your first little spot of colostrum.

Celia (26:58) Yes! This is reminding me - I think I was expecting something to shoot out, as silly as that sounds. And it just sort of sat on the end of my nipple. I had my husband on syringe duty to come and take up little bits as they appeared.

Katie (27:08) Yes, exactly! Syringe duty - love it. You may have even noticed in pregnancy, when you take your bra off, that you've got a little bit of crustiness on your nipple or on your bra. That's likely just been a little bit of colostrum that's leaked through the day. So it really is tiny bits like that. You can suck those up with a syringe - either from your care provider or you can buy them online. You can either suck it up directly with the syringe if you're dexterous, or you've got help. Some people find that tricky on their own. If not, you can express into a spoon or a little cup and then suck it up with the syringe.

If you've breastfed before, you'll probably find it easier and might get more colostrum, because your body's done it and knows what to do. Generally it's just tiny, tiny little drops. Nothing will be spraying out.

You can store it in the fridge for three days, but most people just put it straight in the freezer. I give all my mums little labels that say "expressed colostrum" with space for their name, date of birth, and the date and time it was expressed, so it's really clear. Most syringes come with a little cap that you can put on before popping them in the freezer in preparation for after birth.

Celia (28:48) Okay. Three days in the fridge or straight in the freezer. Makes sense. What about if you want to combine a few expressing sessions into one syringe?

Katie (28:53) Yeah, if you've got limited syringes and you want to fill one up over several sessions, you can mix milk together in the same syringe before freezing it. You just want to make sure that when you're mixing milks, they're the same temperature. You don't want to add body temperature colostrum to cold milk, because that will heat up the cold milk and potentially encourage bacterial growth - very unlikely with breast milk, but that's the principle. Combine cold milk with cold milk, then pop it in the freezer.

Celia (29:20) Makes sense. So like, if you had some from yesterday in the fridge, put today's in the fridge first, then combine them. Yeah.

Katie (29:32) Exactly - cool it down in a little cup, combine them, then into the freezer. Yeah.

Celia (29:38) That makes sense. Okay. So with all of that, transporting it to the hospital - that needs to get into a freezer pretty quickly. How do you do that?

Katie (29:48) Yeah, and that's something I should flag - the follow-up qualitative study found that a lot of women reported their colostrum was wasted in hospital. It was defrosted, or forgotten about, or left out. And just how devastating that was after spending all of that time expressing such tiny amounts. So it's a really important reminder for clinicians too - please look after it.

For transportation, hopefully you're not traveling too far. We recommend popping it in a little insulated lunch bag with some ice bricks, packed as tightly as you can so it stays frozen. It is tricky because such small amounts defrost really quickly. Generally it'll be fine, but what happens a lot of the time is that you're in labour land, especially if you're in spontaneous labour, and by the time you get to hospital you're not exactly across the logistics. So this is very much a job for your birth partner - prep them to be the keeper of the milk and to let the midwives know when you come in. Tell the triage midwife, "We've got frozen colostrum, can you please get it to a freezer?" And generally they'll sort it from there. Just make sure it's clearly labelled with your name.

Then when you need it after birth, you just ask your midwives to retrieve it - it defrosts really easily at room temperature or in a little cup of warm water. And if it has defrosted on your way in, you can still use it - you've got 24 hours once it's defrosted.

Celia (31:48) Okay, that's good to know. And is it worth flagging with your team earlier on - like putting it on your file that you're expressing?

Katie (31:56) Yes, absolutely. When I'm doing birth mapping with my clients, I always include in their plan that they have antenatal expressed colostrum available, and that we'd like to use that before resorting to formula or anything else. Especially if mum and baby are separated - if baby goes to the nursery, if mum goes to ICU, anything like that - it's really important for everyone to know that it's available. And yes, your birth partner can be a big advocate for that too.

Celia (32:40) Yeah, I'd definitely second that. I had a caesarean last time, and my daughter was in the NICU for the first 12 hours on a different floor. I also had really low blood pressure, so we were apart for 12 hours - and we did have to rely on that colostrum. My husband was there, so he needed to be across it and able to say, "No, we've got this."

Katie (32:55) Exactly. Yeah, absolutely. And if you've had a caesarean, it's often four to six hours before you can get down to the nursery at least. The partner will often go with the baby through that admission process, and that's the key moment for them to say, "We've got frozen colostrum - can we please use that first?" Nurses and nursery midwives will absolutely love that, because we know the best thing for a baby is to have colostrum first - it really coats that virgin gut, reduces the risk of serious infection, and is exactly what we're looking for. So make it clear.

Celia (33:58) Just write it on their head. "We have colostrum." In case anyone forgets.

Katie (34:00) Yes, absolutely. And I did the same thing myself with my first. He was IUGR, born at two kilos at 38 weeks, so very tiny. I knew he'd need colostrum because he was going to have low blood sugars from his size. I came in for a routine checkup and ended up having him a few hours later - wasn't prepared, hadn't brought my colostrum in. I had to make an emergency call to my mum to bring it. So don't be caught out without it.

Celia (34:43) Yeah, definitely. And I think too, with gestational diabetes, there's not a lot your partner can do to help. This is a real job you can give them - it's like sharing those initial feeds. Yeah.

Katie (34:55) Yeah, it's a really important job. Absolutely. And skin-to-skin too - if you can't do skin-to-skin because you're not well or recovering, or your partner is down in the nursery with the baby, skin-to-skin with the baby is powerful as well.

Celia (35:08) Yeah, I'm looking forward to that feeling again. You mentioned earlier that sometimes women just can't express anything at all, and that that doesn't indicate anything about their future milk supply. How long should you give it before you think, okay, it's not happening for me?

Katie (35:27) Yeah. So antenatally, I would say most people don't get anything in those first few days of trying, but that it gradually increases closer to birth. So if you're comfortable and it's not a big time burden for you, I would keep going as much as practical, because you're likely to see it increase closer to your due date.

But if it's causing you huge amounts of anxiety, it's uncomfortable, and it's just not a vibe - then that's totally fine. Just let it go.

Celia (36:06) Good way to think about it. And it's also good to hear that you might just be practicing for the first little while.

Katie (36:15) Absolutely. It is a skill you've got to learn - because it is weird and it is awkward, expressing your boobs when you've never done that before. So even if you're not getting anything, you can reframe it as: I'm learning what my breasts feel like, I'm learning how to hand express, and that's going to help me after the birth of my baby anyway. Because even if you don't have antenatal expressed colostrum, you may need to hand express after birth - if your baby's not latching directly to the breast, for example. So it's not so much about the amounts as it is about the learning process.

Celia (36:55) Yeah. I'm having recollections now of doing hand expression in the shower after birth. I can't remember why.

Katie (37:04) It may have been because you were really engorged and wanted to release a bit of pressure. Yeah, that sounds right. And hand expression is really lo-fi and it's free - you don't need pumps, you don't need electricity. It's an age-old skill. I've definitely hand expressed in airports before when I've been too far from my baby or my pump and needed to relieve the pressure in my breast to avoid mastitis. It's not even just a skill for early on - you can use it when they're several years old as well.

Celia (37:43) I probably alluded to this earlier, but I really just love giving everyone all the information and that option. To explain that it's a really beneficial thing to do - one, to learn the process of hand expressing, and two, if you do produce even small amounts, we can use it for your baby in those first few days if they have low blood sugars. That may prevent the need for formula, IV glucose, or Glucogel.

We also know that babies of women who antenatally expressed were more likely to receive only breast milk in that first 24 hours after birth. That's a real benefit in terms of gastrointestinal health and building immunity. It really sets that gut up for success.

So I'd always explain that it's optional, but it can be a really fabulous insurance policy - a safety net - should anything happen after birth where your baby needs some extra food. But that women get very small amounts generally, it doesn't indicate how your breastfeeding journey is going to go, and not getting large amounts doesn't mean you'll have low supply - because right now you've got a beautiful placenta producing lots of progesterone and stopping lots of milk from happening. That's exactly what we'd expect. It's a really empowering thing for a lot of women to do, especially if they feel like the GDM diagnosis has taken some control away from them.

Celia (39:21) Yeah, I love that way of looking at it. And it also sounds like women who don't have gestational diabetes can also express colostrum?

Katie (39:30) They do, yeah. We don't actually have research yet pointing to the benefits of antenatal expressing outside of a diabetes in pregnancy context - the research we have is specifically in that setting. But certainly lots of people do it. When I'm speaking with my midwifery clients around that 34 to 35 week mark, if they have risk factors where the baby may have hypoglycemia after birth - a very large for gestational age baby, or a small for gestational age baby - or if they're anticipating their baby may need to go to the nursery or be separated due to something like a cardiac condition, then we might talk about whether antenatal expressing is worthwhile for them. But from what I understand currently, the research around safety and efficacy is specifically in the context of diabetes in pregnancy.

Celia (40:34) Okay. And even if bub's born and there's no problem with their blood sugars, it's still beneficial for them to receive the colostrum?

Katie (40:38) Yeah, definitely. You certainly don't need to use it if your baby's breastfeeding beautifully, but it can be useful. I know some people on night two, when their baby is cluster feeding constantly and their nipples are starting to feel sore, having those syringes of colostrum just to give themselves a little break - that can be really helpful. I did that with my third baby. I needed a break, and I had some colostrum there so I could just finger feed her.

I generally recommend getting your baby to suck your finger first so they're already in the sucking rhythm, and then you pop the syringe down the side of your finger and slowly syringe it into their cheek so they're sucking and swallowing at the same time.

Celia (41:20) Good backup plan to have. And you also mentioned you could give them a little bit prior to breastfeeding just to help wake them up, since newborns can be really sleepy.

Katie (41:30) Yes, waking babies - yes. They can be very sleepy. Especially a jaundiced baby. Sometimes you just can't fully wake them. I would undress them, put them skin-to-skin, and if they're still not looking interested in breastfeeding, give them a little bit in a syringe just to wake up their taste buds and give them a boost. Then hopefully they have enough energy to wake up properly for a breastfeed.

So yes - you can use it before or after a breastfeed as needed, or to give yourself a little break. Babies generally need to be at the breast regularly, and if they're not feeding well at the breast, you'll need to be expressing regularly too.

Celia (42:18) Lots of benefits to having it on hand. If someone is looking for more support with breastfeeding - whether leading up to birth or after - what are the ways they can connect with you?

Katie (42:27) Yes, so I work in private practice now as a midwife and an LC. I take on clients throughout pregnancy and the postpartum journey. You can contact me through my website, which is flourishlactation.com.au, or send me a message or an email. I do telehealth appointments around Australia, so we can have those breastfeeding debriefs if you've had a difficult experience before that you want to talk through, or go through all of the antenatal expressing education and breastfeeding education during pregnancy. It's really great to be prepared - and while we always talk about birth plans, I really like to have a breastfeeding plan and a postpartum plan too.

Celia (43:17) Yes - that's my big takeaway from last time, if you're a first time mum. Have a bit of a plan. Don't do what I did.

Katie (43:29) I mean, you can wing it - but if you don't have to, it's nice to have a plan. I do offer those one-off appointments via telehealth as well, and if you're pregnant and have a Medicare card, you can get a Medicare rebate for that, which is generally quite significant.

And then I see people postnatally after birth for more complex breastfeeding issues, but also sometimes people just want to come and check in and make sure everything's going well and have another pair of eyes. I run a bulk-billed drop-in clinic if you're local to me in Brisbane, which is really useful if you just want someone to lay eyes on your breastfeeding and weigh your baby. And then I also do one-on-one appointments if you're specifically worried about a tongue tie, lip tie, mastitis, low supply, high supply - anything like that.

The other thing I offer is urgent mastitis telehealth consults, available Australia-wide. If you feel like you've got mastitis coming on, you can just send me a text and I can usually jump on telehealth within a couple of hours. We go through your feeding journey, all your symptoms, what you're experiencing, immediate first aid, and what we can do to avoid antibiotics. And if I feel like you do need antibiotics, I can prescribe and send you an e-script, and follow you up from there. So that's another really helpful service a lot of people use.

Celia (45:01) That sounds amazing - because the less you have to leave the house at that stage, the better.

Katie (45:05) Exactly. You really don't want to be going to ED with a newborn baby if you don't have to. Obviously I'll refer you if I'm very worried about you, but for most people we can manage mastitis at home with the right advice.

Celia (45:17) Amazing. Good contact to have. I'll pop all the links to everything you mentioned in the show notes so people can find you easily. But yes, thank you so much, Katie. This has been hugely helpful - I've learned a lot, and I've done it before. I feel like I've got the best possible refresher going into the tail end of this trimester. Yeah, this was very selfishly organised.

Katie (45:38) Well timed! Perfect. Thank you so much for having me.

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