Distant Relatives: Living in the Land Far, Far Away

After our niece was born, Ian’s sister would occasionally refer to us as being “from the land far, far away”. Because relative to the rest of the close family, we were quite a long way away in London. I’ve never particularly asked Ian how he feels not living closer, but I know that I felt a pang of regret after she was born that we would not see more of her. I also feel a slight sadness that I don’t live close enough to my sister in law to go out for lunch regularly, or pop in and see them.

But these things are relative. We *do* see them fairly often. It’s only a couple of hours in the car or on the train. And they’re in the same time zone, so telephone calls and internet chats are no problem at all.

By comparison, my own brother really does live in the land far, far away. Over 5000 miles and eight time zones away in fact. It takes the best part of a whole day to get there, and for two thirds of the day one or other of us is asleep. We often go a whole year without seeing one another in person.

Lately, it has hit me just how far away it really is and how our child will grow up without a close bond with their uncle. I know it’s not an absolute given. My own uncle lived overseas when I was born. However he subsequently returned to England and by the time I was old enough to have an independent relationship with him, he lived close and we saw each other reasonably regularly.

But my brother is happily married and I cannot see him returning, and certainly not imminently. If my brother has children, we’ll be in the same position. And our children will have cousins that are of a different nationality and live very different lives. That in itself makes me feel a little sad, as I grew up without any first cousins myself and had hoped that my own children would have cousins with whom they could be friends.

I feel sad at the best of times that there is this enormous geographical divide in our relationship, that stops us being close in other ways. Being pregnant and having a baby probably always brings these things to the fore, reminds you of exactly what you are missing. There is no solution to this problem though. We have to work with what we have and rely on technology to maintain the strands of our relationships. But for my son or daughter, they’ll actually have to establish a relationship that way too. That just seems so much harder to do. Will they know or understand who this person is? How will they ever feel close, or like members of the same family when they will so rarely be on the same continent?

There are no answers. Just sadness.

Eating For Two…. But One of Us is Very Small

“Eating for two” is a classic pregnancy myth.

Well, OK, not entirely. I guess I a eating for both of us, but one of us is very small. And pregnancy seems to make your body much more efficient, because you can grow a whole new person without actually needing to eat very many more calories. In fact it’s suggested that women need only 200 extra calories per day and only in the third trimester. 200 calories is really not a lot. Take a look at some food packaging if you don’t believe me.

The trouble is, it’s hard to shake that “eating for two” excuse from your consciousness. Especially when you’re ravenously hungry at least half the time. And it’s also easy to justify less than optimal food choices with the “if I can’t indulge when I’m pregnant, when can I?” line. It doesn’t help me that I haven’t got the usual restraining check of the fit of my jeans or the rounding of my tummy to help me keep my eating in check. My body shape is so drastically altered, and I’m wearing such stretchy wasitbands that I really wouldn’t know, or at this point care, if I’d gained five stones.

The problem is, I know that I’ll care afterwards. I’m not stupid and I’m not in any way shape or form expecting my body to snap back to what is was. I’m not even hoping that it will ever be the same again, as I’m perfectly prepared to accept that my body shape may be altered forever. It’s worth it to make this little life, of course, but I am worried that I’ll have excess fat that I’ll wish I’d worked harder to keep off, instead of hiding it amongst the pregnancy bulges.

So I need to remember that whilst there are two hearts beating inside me, and two mouths, only one of them really needs feeding.

Welcome to the Third Trimester

I’m now 28 and a half weeks pregnant, and I’m pretty sure that we’re in to the third trimester. Opinion seems to vary on this one, with different sources stating the third trimester to start at differing times. But virtually all agree that the third trimester has begun by 28 weeks, so I’m guessing we’re there. Either way, I’ve got less than three months to go of this pregnancy.

It’s pretty amazing, and scary, to think that I’ve still got the bulk of the weight gain to come. I already feel enormous. I think my body has reached the limit of its pre-pregnancy elasticity and we’re in to full on over-stretching now. I’m just praying that the stretch marks stay away. As yet, all seems good on that front. I am moisturising as regularly as I remember, but I’m not really convinced that it makes much difference, as stretch marks aren’t caused by dryness. I think your skin type and genes probably have more to do with it.

The last few days have seen other symptoms really step up. I’m getting up more than once every night to pee, and my sleep is regularly interrupted by heartburn. My insulin needs continue to climb, and I know I probably have more insulin resistance to look forward to until they finally peak. I sit and stand like a proper pregnant person now, lower back arching in, hands rested on my bump. I think may even have begun to waddle when I walk.

Flangelina is still getting busy in there though. They seem to have their own pattern worked out and movements are pretty predictable throughout the day. Every evening when we climb in to bed it seems to be party time. Ian and I often watch amazed as big bits of my belly jut out and shake, and then Ian burrows under the covers to chat to the baby and have daddy bonding time. Which I find so cute that I want to cry. Which in turn is probably caused by the hormones!

I’ve got just over three weeks of work left, which is definitely for the best as I’m feeling exhausted. I’ve got lots to look forwards to once I’m finished as well. We’ve also got antenatal classes coming up and I suppose that I have to start thinking a bit more seriously and closely about the birth, as well as what to pack in my hospital bag.

We’re in to the final straight, and I’m focusing on the fact that with every passing day we’re getting closer to meeting Flangelina and also increasing the chances of everything being fine when they do make an appearance.

Changing Motivations

When I was a child, I lived for the day. I didn’t understand that the future would come and my actions now might have consequences then. My parents invested considerable time and energy to give me good diabetes control as a child and I did what needed to be done to take care of diabetes because I did what I was told. Fortunately it also didn’t occur to me to rebel.

As a teenager, I didn’t always do what needed to be done at all, and the word rebellion was very relevant. But my motivation to do the minimum that I did do was driven purely by fear – of being “told off” by my parents, or my doctors, even though I can’t recall them ever getting directly angry. Exasperated might be the word. Fear of being judged I suppose, and fear of being so low or so high that my symptoms were obvious to others and would make me stand out. Nothing unusual about being a teenage girl who just wants to fit in.

Sometime in my late teens though, the focus of my fear changed literally overnight.

It was always around 4am when it happened. Not that I ever knew that straight away. By the time I looked at the clock, after a few seconds of flailing around in the darkness with my heart pounding in my chest, the panic would be gone, because once I saw the glowing red digital display, I knew that I wasn’t blind. But in those moments between full sleep and complete wakefulness, my imagination would work overtime, convincing me that I couldn’t see. That the inky blackness surrounding me wasn’t real, but just the gap in my consciousness that my eyes had failed to fill in. It was an unrealistic and irrational panic, because I know it would be unlikely to happen ‘just-like-that’ from fine to blind, but the underlying fear – of losing my eyesight – was very real.

I feared it so deeply because its impact would have been so total, and it became my primary motivator. Each time the burden of diabetes care became too much, each time it seemed too much of a chore, or too restrictive or just too plain unfair, I’d remember the potential consequences of not knuckling down and getting on with it, and it would keep me going, remind me that it was worthwhile.

I didn’t think I would ever find a more powerful motivator. I was wrong.

I’ve never been more determined, more motivated or more inspired to achieve excellent blood glucose control than I am right now, and that is all down to the little person growing inside me.

Whereas before I was motivated by fear of what might happen to me – short term fear of hypoglycaemia and the injury or embarrassment that is could cause, as well as that longer term fear of complications and their impact on my life, now I’s not just about me. Suddenly the choices I make about my health directly impact the health of someone else who is totally reliant on me and totally defenceless. I’ve always been aware that my health doesn’t just affect me, but is also big part of life for those that love me. But none of those people have ever had the potential to be so directly affected. Hurt or harmed even. It’s a much bigger fear than the fear of blindness.

I feel so protective of this little life that we’ve created, it’s intoxicating. Diabetes is still hard work. Especially hard work even, during this pregnancy. But it doesn’t cross my mind not to keep pouring my heart and soul in to taming the beast that it is. I may have a choice, but my baby doesn’t. So there simply is no alternative.

NCT: Childbirth Preparation or an Expensive Introductions Service?

I know that I first heard about the National Childbirth Trust (NCT) long before I knew anything about pregnancy, birth or parenthood and long before I wanted to. My own parents did some NCT stuff back in their day, and still know many of the people who were also involved at that time. Ian’s parents also took classes ahead of his birth. Somewhere along the line, without even realising, I picked up the notion that taking NCT classes whilst pregnant would be a good thing to do.

Then I reached the stage of my life where friends and family began to produce babies. I started hearing firsthand about how great NCT classes were. (And also how popular, so ideally I should book my place before I even got a positive pregnancy test!) I felt excited about the prospect of joining a group and, with my voracious appetite for any and all knowledge related to pregnancy, birth and parenting, learning some useful stuff that would really help the process run smoothly. We signed up early on. I didn’t want to tempt fate by doing it too early, but I did place a reminder note in my diary to do it the day after our 12 week scan, which we actually had at 14 weeks. So that’s when I booked.

But then some interesting thoughts began to emerge in parenting forums online and from my friends who’d done NCT classes. It seems that whilst people didn’t dismiss the things they learned, they often felt that there was a lot of focus on actual labour, which is an infinitesimal period of of the parenthood journey. It seemed that the information was sometimes very heavily biased towards “natural” childbirth, and that much of the practical information could be read online or gathered from free NHS antenatal and parent craft classes. It became apparent that the main reason people love the NCT is because of the people you meet. There seems to be enormous value in joining a group of other couples who are all in the same, terrifying yet exciting, place as you and many mothers and fathers equally feel that the biggest long term take-away benefit of their classes were the new friendships that they made.

It makes sense to me. I know many mothers. But those that are true friends are not local, and those that are local are not really friends – they’re people I’ve come in to contact with in a professional capacity. And all of them are already mothers. They’re not at the same stage that we’re at now. Whilst a group of first time mums may be the blind leading the blind, I think it will be reassuring to discuss things with other clueless people without the constant “Oh that’s nothing…. You just wait until….” that a lot of experienced parents seem to come out with when talking to us newbies. I really like the idea of building a local support network for this scariest of journeys that we’re hurtling headlong in to.

However, NCT classes are not cheap. And it has left me wondering what we’re really paying all this money for. If the information and knowledge is insignificant, does that make this no more than a dating agency for expectant couples? And these are people with which we may have nothing more in common than the area we live and the month in which we are expecting our first child. There are no guarantees that we’ll form any friendships at all. At least with a traditional dating agency you get to list a little bit about your characteristics and interests in the hope to be matched with someone at least potentially compatible. It does make me wonder of there is a gap in the market for an organisation that does just that for new parents.

We shall have to wait and see both how valuable I find the teaching and how well we get on with those we are sharing the classes with. I really hope that I both learn a lot and meet the sort of people with whom I want to become friends.

The Cow’s Milk Hypothesis and TRIGR: A Rationale for Exclusive Breastfeeding?

There are lots of good reasons to breastfeed. The ones that seem to be most commonly discussed include transferring antibodies to the baby; Convenience, with milk always available when required at the right temperature and no need for any special equipment or preparation; Cost saving against the cost of formula milk; And general health benefits to mother and baby including reduced risks of problems such as certain cancers and obesity respectively.

Despite the benefits though, breastfeeding remains far from universal in the UK. The 2005 Infant Feeding Survey, the most recent for which full results are currently available, gives a UK-wide initial breastfeeding rate of 78%. At six months less than 25% of mothers were giving any breast milk at all. Exclusive breastfeeding rates (where no other foods or liquids except breast milk are given) were 45% at 1 week, meaning that more than half of all mothers had supplemented with infant formula within that week. These figures fell to 21% at six weeks and 7% at four months. The proportion attaining the target outlined in official Department of Health Guidelines, in line with World Health Organisation guidance, of 6 months of exclusive breastfeeding was less than 1%. These figures add up to one of the lowest breastfeeding rates in the world.

Early results of the 2010 Infant Feeding Survey, published in June this year, do show that initial breastfeeding rates have increased to 83%, so it is not unreasonable to suggest that some of the other rates may also have increased. However, anecdotally at least, it seems that there are possible causes for a rise in initial rates, including formula often not being available in hospital maternity units, and short term improved breastfeeding support, which are not applicable to long term feeding rates. In fact, anecdotally again, it seems that longer term breastfeeding support is frequently poor, if available at all.

I do plan to breastfeed this baby when they arrive, however. It wasn’t something that required much thought. In fact, I can’t remember a time at which I thought I would try to do anything else. But I am determined to succeed for very different reasons to the majority of women. It’s a reason that is so important to me that it may just help me be in that 1%. But equally I’m afraid that I’m setting myself up for huge self disappointment if I allow myself to make breastfeeding so important. I’m concerned that I’ll put inordinate pressure on myself to succeed and instead be doomed to failure.

As with many things in this pregnancy, diabetes is my motivation. Or rather the possibility of its prevention for my child.

It’s not a great secret that I’m not particularly in love with diabetes. I’ve made my peace with it for now, and I accept it is what it is, but I still wouldn’t wish all of its difficulties, frustrations and complications on to my worst enemy. So I would do anything I could to make sure that my child doesn’t have to live with any diabetes other than mine.

Modern thinking on the aetiology of diabetes is looking towards a combination of genetic predisposition with an environmental or other external factor triggering autoimmune destruction of insulin producing beta cells. The genetic component is complex and there is no simple heredity involved. The risk of developing diabetes if you have a first degree relative with the condition is only 10% and most people who develop it do not have a family history at all. However it is certainly possible that I have passed on a genetic tendency, so all that I can do now is my best to modify any other contributing factors. And one of the most prominent of those currently under investigation is cow’s milk.

The Cow’s Milk Hypothesis emerged more than 20 years ago when preliminary studies suggested a link between cow’s milk proteins and the development of type 1 diabetes including a decreased incidence of type 1 amongst breastfed children in the US, and higher levels of antibodies to cow’s milk protein amongst Finnish children who had diabetes than those who did not. A more specific study in 1991 showed that 100% of the children with diabetes in the study had high levels of antibodies to a specific region of bovine serum albumin molecules. Only 2.5% of the healthy children had this specific antibody. Combined with circumstantial evidence, such as a correlation between per capita milk consumption and type 1 diabetes incidence rates worldwide, and the increasing consumption of cow’s milk based infant formula milk alongside significantly increasing incidence of type 1 diabetes in countries such as China, this has been enough to support a large scale trial to test the theory that early introduction of traditional cow’s milk protein based infant formula may increase the risk of type 1 diabetes.

Of course the Cow’s Milk Hypothesis isn’t really the cow’s milk hypothesis – it’s the Protein Hypothesis. It’s simply that the first non-human protein foodstuff that babies are exposed to tends to be in formula milk and is a cow’s milk protein. But it’s the protein, not that it’s cow’s milk, that potentially poses the problem. The presence of any foreign proteins before the age of 6 months is a massive challenge for the immune system, which can lead to a tendency towards autoimmunity. In someone who already has tendency to diabetes, this could possibly lead to its development. The theory continues that by 6 months, the immune system has developed and there has been staged exposure to some of these challenging proteins, so is better able to cope with their introduction in to the diet. Another factor which lends weight to this theory is the fact that a number of the genes known to be associated with type 1 actually cause an increase in gut permeability, thus allowing these proteins to pass across.

One way to avoid the exposure to large proteins, other than breastfeeding, is to use a milk formulated without those proteins – where they have been broken down to a small enough size that the immune system can’t “see” them. Such “highly hydrolysed” formulations are available for babies with cow’s milk protein intolerance. A randomised feeding study involving 240 children with a close-family history of type 1 diabetes and autoimune markers present, showed that the risk of developing either type 1, or at least two beta cell antibodies, was cut by a half in the group given such highly hydrolysed formula milk compared to those given traditional formula.

In 2002, recruitment began for the Trial to Reduce Insulin Dependent Diabetes Mellitus in the Genetically at Risk (TRIGR) – a large multinational randomised controlled trial to investigate whether infant feeding really does have the potential to modify the risk of developing type 1 diabetes. The TRIGR trial will determine whether delayed exposure to intact food proteins will reduce the chances of developing type 1 diabetes later in life.

Secondarily, the study will also show if there is any specific positive effect of exclusive breastfeeding over using a formula in which the proteins have been broken down – a so-called highly hydrolysized formula – instead. This was not an intitial study aim, but has come about because a a higher percentage of mothers than expected achieved exclusive breastfeeding until the age of 8 months.

TRIGR is not completed yet. It might prove the hypothesis completely invalid. Or it might prove that actually there is some hidden benefit to traditional milk formulas, although based on the preliminary research I think this is unlikely. So why am I so adamant that I want to breastfeed to potentially reduce type 1 diabetes risk anyway?

The breastfeeding part is because highly hydrolysed formula milks are available in the UK only on prescription from a doctor, and the prescribing guidelines stipulate their use only for cow’s milk protein sensitivity. So breastfeeding is the only accessible way for me to avoid cow’s milk proteins, which I want to do because it seems to be what nature intended. The TRIGR study group themselves state that the aim is not to interfere with or specifically modify feeding – particiapnts have been encouraged to breastfeed in line with WHO guidelines. The study simply looks to see the effects of different feeding when this comes to an end. In the absense of any clear clinical data, it makes sense for me to stick with what nature intends human babies to drink.

This is a highly personal decision, and I wouldn’t for a moment advocate that everyone should do the same. But with all the known benefits of breastfeeding that already exist, it seems illogical for me to give my human baby anything other than human milk.

My Big Baby

Today’s 28 week growth scan brought mixed news.

The Good: Flangelina has turned. The belly rumbling and rolling that I felt this weekend was obviously the outward manifestation of their internal gymnastics, because Flangelina is now hanging out upside down like a bat, and pretty low down in there. This is a big relief as it’s one hurdle that would reduce the chances of a natural delivery out of the way. So long as they stay that way of course. But I’m keeping up with birth ball bouncing and swimming to encourage that, and I feel much more confident about them not being breech than I did before.

So, yay!

But…

The Not So Good: Flangelina is beefing up in there.

It’s not catastrophic. In fact, the sonographer commented on how well I must be controlling my blood sugars as she was writing up the data. She said I was doing really well and the baby looked great. She then casually, as if it was no big deal, added that the baby’s abdominal circumference had jumped up to the 80th centile.

And I lost it. Started crying big, fat silly tears. Because last time everything was measuring right around the 50th centile. And when a baby gets big because of diabetes, it is invariably the abdominal circumference that enlarges ahead of the curve since that is where the extra fat gets laid down. In other words I’m not simply growing a larger than average baby. I’m growing a little fat baby.

Instantly I felt like a failure.

But I also felt frustrated. Because I don’t know what else I can realistically do. I’m wearing the DexCom full time and testing 10 or more times per day in addition. I’m carb counting like a pro and pre-bolusing where I can. I’m getting as much physical activity as I can and generally working hard. For the most part, I’m seeing excellent results. The DexCom tells me that I’m inside my tight target range of 3.9 – 6.8 more than 70% of the time. And a large chunk of the remaining time I’m actually spending too low, which whilst not ideal for me, won’t be packing the pounds on Flangelina. These are numbers that are nearer to normal than I’ve even been since I was diagnosed as a small child, and it’s frustrating to think that they still aren’t good enough.

Both my obstetrician and diabetes specialist nurse did their best to reassure me. Scans are not that accurate. The numbers say that I am doing fine. Big babies are not unhealthy, they just may be a bit more difficult to deliver, and all the evidence points towards higher birth weights actually being healthier in the long run. They were at pains to point out how much more seriously I take this than the majority of their patients, and how the results really reflect that. HbA1c’s of less than 5 aren’t common, apparently.

I don’t really care how much better I’m doing than other people though, if it still isn’t good enough. If others choose not to take it seriously, that is their problem and it doesn’t mean that I can justify doing the same. My health and my baby are what matters to me. And I’m still worried. I can’t help but think it’s just a sign that I’m not as on top of things as I thought. I’m afraid that it means failure of the placenta is more likely. And that caesarean delivery is more likely. I feel like my body is failing my baby. I’m failing my baby by not being successful enough at keeping my body in check. I’m not minimising the risk of problems.

Flangelina will have their whole life to hate me for the things I do (or don’t do) to embarrass them. But I don’t want them to have reason to resent me already. And, if I’m honest, I don’t want other people to have reason to point the finger at me and say that I couldn’t keep my baby safe in the womb.

I suppose I need to re-focus. I need to avoid the tendency to complacency that such a low A1c and steady CGM graphs have given me. Nothing can be taken for granted.

It wasn’t all doom and gloom though….

The Fun: We told the sonographer that we’d been for a private 4d scan. Not to be outdone she exclaimed “Oh yes, we can do that with this machine”. In an instant the grainy 2d image on the screen had flipped to a moving three dimensional picture and we enjoyed several minutes of indulgent baby-gazing.

Flangelina is beautiful, that’s for sure. Every chunky inch of him or her.

I’m sorry, baby, that I’m feeding you a diet of sweeties. I promise to make it up to you when you’re born.