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NBT hypo policy >37/40

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NBT hypo policy <37/40

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Maybe the babies would be assigned to transitional care as under 2.9kg?

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Resources- BFI/ NHS

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both babes born by LSCS - higher chance of feeding issues + weightloss in 1st few days. BW reasonable but twins and early days = need close monitoring

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Signpost to Unicef for BF assessment tool, breast compressions etc.

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Signpost to Unicef for BF assessment tool, breast compressions etc.

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The babies are at higher risk of hypoglycemia because of their mother being type 1 diabetes.

Follow your trust's hypogylcemia policy.

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hand-expression-video - Baby Friendly Initiative

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hand-expression-video - Baby Friendly Initiative

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Support with expressing and explain milk

Processes and the effects of stress and milk supply

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Forceps delivery - bruising/soreness, uncomfortable to feed

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Forceps delivery - bruising/soreness, uncomfortable to feed

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Observe a whole feed

Refer to infant feeding team

Provide emotional support/ reassurance to the mother

complete NIPE

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Full newborn assessment to be completed including breastfeeding assessment

Both twins on hypo policy observations

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NIPE - TT and cleft palate should have been picked up. 

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NIPE - TT and cleft palate should have been picked up. 

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We do not know gestation of the babies, this could impact the feeding support and advice given

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Nipple stimulation

Breast compression

Cluster feeding

Hand expression

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observe a full feed and take a full history, including length of feeds, feeding cues/behaviour, wet/dirty nappies

Reassurance cluster feeding is normal 8 feeds in 24 hours.

Advice on smoking around baby - offer referral to smoking cessation/tobacco dependency midwife. Avoid smoking indoors and wash hands prior to handling baby.

Monitor for signs of lethargy/dehydration/tongue tie in NIPE

Emotional support and reassurance

Encourage skin to skin contact

Follow up referral in 24 hours for support

D5 weight review if less than 10% consider referral to infant feeding

Perinatal mental health team if distress or low mood/stress escalates

Breastfeeding support groups

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Insulin cannot be absorbed orally. It will be de

stroyed in the infant's gut even if higher levels of exogenous insulin are present in breastmilk.

INSULIN IS SAFE FOR BREASTFEEDING.

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Medications include:

GLP-1 therapy (glucagon-like peptide-1 receptor agonists)

Dual GIP (glucose-dependent insulinotropic polypeptide) and GLP-1 agonist

Guidance from the MHRA published in June 2025 states " GLP-1 medicines should not be taken by people who are breastfeeding. This is because there is not enough safety data to know whether taking a GLP-1 medicine can cause harm to the baby. If you have any concerns, speak to a healthcare professional."

If you have been offered a GLP-1 medicine to treat your diabetes and are making a decision about whether to take it and how this will impact your breastfeeding journey, or if you have been taking one of these medicines whilst breastfeeding, you can contact the Breastfeeding Network Drugs in Breastmilk team to discuss this. For general support with breastfeeding or stopping breastfeeding, you can also contact the National Breastfeeding Helpline.
General considerations when you are deciding whether GLP-1 agonists or tirzepatide are right for you:
GLP-1 agonists increase hormones called incretins. These help your body to produce more insulin and reduce the amount of glucose released by your liver when it's not needed. They also reduce the speed that your stomach digests foods, slowing stomach emptying, which reduces appetite.

Tirzepatide works similarly, stimulating insulin secretion and reducing glucagon levels. Some other effects include slowing stomach emptying and reducing appetite. It causes better glucose control and weight loss in type 2 diabetics. It is used in people who have not responded well to other therapies first.

The risk of GLP-1 agonists or tirzepatide causing you hypoglycaemia is low. However, hypoglycaemia is possible, particularly when taken with other anti-diabetic medications. This could make bedsharing with your baby unsafe.

GLP-1 agonists and tirzepatide are large protein molecules which means they are not expected to pass into your breastmilk easily. If they do enter your milk, they are likely to be destroyed in your child's stomach. However, we currently have very little data on how much of these medicines pass into breastmilk, or whether they cause side effects in breastfed children.

GLP-1 agonists and tirzepatide are not compatible with pregnancy. Manufacturers advise that you stop these medicines before you become pregnant, in some cases three months before a planned pregnancy. You will need to consider this when planning contraception and building your family in the future. Read the patient information leaflet for more information.

GLP-1 agonists and tirzepatide may cause unpleasant side effects including dizziness, headache, indigestion or upset stomach, nausea, vomiting, diarrhoea and feeling jittery. Individual drugs may cause other side effects too. If these are severe, you may find it difficult to care for your baby without assistance. Though most of these side effects do reduce once you have been taking the medication for a while, some side effects may persist or be intolerable. You should discuss this with your health care professional.

sus Oral semaglutide should NOT be taken while breastfeeding. Some brands of oral semaglutide, such as Rybel®, contain the absorption enhancer salcaprozate sodium, which may enter milk and accumulate in infants.

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Diabetes and Breastfeeding - The Breastfeeding Network

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If you have any questions about this information, you can contact the Drugs in Breastmilk team through their Facebook page or on druginformation@breastfeedingnetwork.org.uk. You can breastfeed as usual if you are using Insulin in Type 1 and Type 2 diabetes, and metformin in Type 2 Diabetes.

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Did she smoke during pregnancy? If so possible oesophagel atresia?

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Hospital infant feeding team

Local breastfeeding support groups

La leche league

PMHT if needed

Local children’s centres

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https://www.breastfeedingnetwork.org.uk/factsheet/increasing-milk-supply-use-of-galactagogues/

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The hypoglycaemic activity of fenugreek seed extract is mediated through the stimulation of an insulin signalling pathway

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The in vivo hypoglycaemic activity of a dialysed fenugreek seed extract (FSE) was studied in alloxan (AXN)-induced diabetic mice and found to be comparable to that of insulin (1.5 U kg−1). FSE also improved intraperitoneal glucose tolerance in…

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History taking - is Clarissa inducing lactation or is she bf a toddler?

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History taking - is Clarissa inducing lactation or is she bf a toddler?

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Neonatal team

Infant feeding specialists

Practicesupervisor/senior midwife

Health visitor

GP

Community midwife team

Possible PMHT

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Full breastfeeding assessment - both mums

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Full breastfeeding assessment - both mums

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BF in first few days - cluster feeding is normal and will help establish supply

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Find out what to expect from breastfeeding in the first few days after birth, including what colostrum is, what happens when your milk ‘comes in’ and what the let-down reflex feels like.

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Infant feeding specialists

diabetes team

Midwifery team

Paediatric/neonatal team

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Non-judgemental and supportive

Explain to sally that Archie’s feeding pattern is not effective milk transfer and help her to understand that falling asleep quickly is a sign of fatigue or illness

Observe a full feed when safe to do so

Escalate to feeding support

EBM if possible

Hand expression or pumping to protect milk supply

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Shrunken fontanelle - dehydration - urgent doctor review. Also low nappy output and urates.

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Fenugreek is often used by breastfeeding mothers to potentially increase milk supply. While it is generally considered safe and is recognized by the FDA as Generally Regarded as Safe (GRAS), it can have varying effects; for some women, it may help boost milk production, while for others, it can completely reduce milk supply. It is important to consult a healthcare provider before starting fenugreek supplementation, as it does pass into breast milk but is believed to be safe when used in moderation. Always monitor for any adverse reactions when using herbal supplements during breastfeeding.

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Infant feeding team

Tongue tie practitioner

Health visitor

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Avoid with cardiac abnormalities and arrhythmias

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Sunken fontanelle - possible dehydration

Lethargy and poor tone - concerning neurological and metabolic signs

Poor feeding with short sleepy feeds

Only one wet nappy in 24 hours

No mec passed in 2 days

Chest recession - respiratory distress

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Born my ELCS - Higher chance of transient feeding issues & weight loss in first few days

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Professional role and approach (NMC perspective)

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Professional role and approach (NMC perspective)

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prioritise safety

Act promptly and escalate concerns

Communicate clearly and compassionately

Involve sally as a partner in care - gain informed consent and explain findings in plain language

Advocate for mother and baby