Recommendations for breastfeeding duration of mothers with gestational diabetes mellitus (GDM): Short- and long-term benefits

Target population for the guidelines: Obstetric health care workers, midwives, and pregnant women. Clinical Question What are the short- and long-term health benefits of breastfeeding for both mothers with gestational diabetes mellitus (GDM) and their offspring? Recommendations Table 1 - Recommendations for breastfeeding duration of mothers with GDM: Short- and Long-term benefits. Number Implementation period Risk factor mitigation GRADE† 1 Initiate BF(a) immediately postpartum, prioritize exclusive BF, and extend duration for optimal health outcomes Prediabetes and T2DM(b) in mothers* 2D 2 Exclusively BF ≥6 months Metabolic syndrome and NAFLD(c) in mothers* 2D 3 BF >18 months when feasible Cardiovascular disease in mothers* 2C 4 Early BF initiation T2DM in offspring* 2D 5 Exclusively BF for ≥1 month (ideally extending to 6 months when feasible) Overweight and obesity in offspring 2D *Longterm risk factor mitigation. †The GRADE approach classifies evidence quality into four levels: high (A), moderate (B), low (C), and very low (D). Recommendation strength (two levels): Strong recommendation (1), weak recommendation (2). BF: Breastfeeding; GRADE: Grading of Recommendations Assessment, Development and Evaluation; NAFLD: Nonalcoholic fatty liver disease; T2DM: Type 2 diabetes mellitus. Recommendation Explanation Breastfeeding, the optimal nutritional source for infants, has multiple benefits. Breast milk delivers a balanced composition of essential nutrients for superior energy utilization and is enriched with bioactive substances, including immunoglobulins, antibodies, macrophages, and lymphocytes, which promote infant growth, development and long-term health. Reduction in maternal diabetes risk Breastfeeding decreases maternal diabetes risk, possibly by increasing prolactin levels, increasing insulin sensitivity, improving pancreatic β-cell function, and promoting lipid metabolism, thereby reducing blood glucose levels, visceral fat, and postpartum weight retention.[1–2] A 2020 systematic review (15 cohort studies, total participants with prior GDM = 4756) revealed that breastfeeding (typically assessed at 4–16 weeks postpartum) was associated with improved postpartum glucose regulation in mothers with gestational diabetes within 1 year postpartum, including significantly lower fasting plasma glucose levels (reductions of 3.7–7.4 mg/dL or 0.2–0.4 mmol/L in 75% of studies reporting mean values) and reduced rates of impaired glucose tolerance (in 60% of studies, with odds reductions up to 80% for high-intensity breastfeeding, e.g., adjusted odds ratio [aOR] = 0.20, 95% confidence interval [CI]: 0.04–0.80).[3] A 2021 systematic review of 29 cohort studies (17,970 participants with GDM) demonstrated that compared with formula consumption, breastfeeding reduced the long-term risk of prediabetes (relative risk [RR] = 0.64, 95% CI: 0.57–0.71) and T2DM (RR = 0.75, 95% CI: 0.66–0.86).[4] Subgroup analysis revealed that breastfeeding for <6 months and 6–12 months reduced the risk of prediabetes, whereas breastfeeding for <6 months and ≥12 months decreased the risk of T2DM. Exclusive breastfeeding during the first 6 months provided a stronger protective effect than mixed feeding did (RR = 0.59, 95% CI: 0.46–0.77). Reduction in maternal metabolic syndrome risk A 2023 cohort study (1176 postpartum women, 175 with GDM) revealed that each additional month of breastfeeding reduced maternal metabolic syndrome risk by 2% (adjusted hazard ratio [aHR] = 0.98, 95% CI: 0.98–0.99), with women with GDM showing greater benefits: a 9% reduction for exclusive breastfeeding (aHR = 0.91, 95% CI: 0.85–0.97) and 3% for mixed breastfeeding (aHR = 0.97, 95% CI: 0.96–0.99) per month.[5] A 2024 cohort study (130 women with GDM) confirmed that exclusive breastfeeding for 6 months significantly reduced maternal metabolic syndrome risk compared with mixed feeding (aHR = 0.69, 95% CI: 0.22–2.07).[6] Furthermore, another 2024 cohort study (130 women with GDM) revealed that breastfeeding >6 months and exclusive breastfeeding for 6 months significantly reduced the incidence of maternal non-alcoholic fatty liver disease (NAFLD) (OR = 0.34, 95% CI: 0.14–0.95) compared with shorter durations or nonexclusive breastfeeding.[7] Reduction in maternal cardiovascular risk A 2024 study of 19,683 women (15,146 with T2DM and 4537 with GDM) during 100,218 person-years of follow-up revealed that 2.9% experienced cardiovascular disease (CVD) events.[8] Compared with never breastfeeding, breastfeeding >18 months reduced maternal CVD risk by 32% and coronary heart disease risk by 38%. Among women with GDM, breastfeeding for >18 months lowered CVD risk by 51%–62% (aHR = 0.49, 95% CI: 0.28–0.86), highlighting significant, multifaceted benefits for long-term metabolic and cardiovascular health. Reductions in the risks of T2DM, overweight, and obesity among offspring A 2016 Canadian cohort study (n = 334,553) revealed that early postpartum breastfeeding reduced the risk of T2DM among adolescent offspring by 17% (HR = 0.83, 95% CI: 0.69–0.99, P = 0.038).[9] A 2022 systematic review (13 cohorts, n = 12,657) revealed that breastfeeding significantly reduced the risk of overweight or obesity in offspring exposed to intrauterine hyperglycemia (OR = 0.67, 95% CI: 0.53–0.84), with protection observed at 1–6 months (OR = 0.53, 95% CI: 0.37–0.75) and ≥6 months (OR = 0.56, 95% CI: 0.46–0.69), but it increased the risk at <1 month (OR = 2.15, 95% CI: 1.41–3.27).[10] Both exclusive breastfeeding >1 month and mixed feeding were protective, with greater benefits observed in offspring aged 3–5 years and >5 years. This could potentially be attributed to the fact that breastfeeding increases the likelihood of offspring adopting healthy eating habits and lifestyles. Evidence Summary This rapid recommendation was developed in accordance with the standardized methodology framework outlined in the STAR Recommendations.[11] The detailed procedures are available in the Supplementary Materials, https://links.lww.com/CM9/C715. Funding This work was supported by grants from the Noncommunicable Chronic Diseases-National Science and Technology Major Project (No. 2024ZD0532100), the National Natural Science Foundation of China (No. 82470863), and the Beijing Nova Program (No. 2024010). Conflicts of Interest None.

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