Donor Breast Milk for the Preterm Infant

[Editor’s Note: A big hello to Science and Sensibility readers! As this is my first post, I would like to take a minute to thank Deena for the wonderful job she did on Science and Sensibility in February. I look forward to spending the month of March with you. Enjoy! – Lisa Baker]

As discussed in last week’s post, the American Academy of Pediatrics (AAP) revised policy statement on Breastfeeding and the Use of Human Milk reaffirms the recommendation of exclusive breastfeeding for six months and a continuation of breastfeeding for 1 year or longer (1). It has been well established that the act of breastfeeding and the consumption of human milk has numerous benefits to infant, mother, and society.  As outlined in the policy statement, the benefits of human milk consumption for the preterm infant are significant and include:

  • lower rates of necrotizing enterocolitis (NEC) and sepsis
  • fewer readmissions to hospital
  • higher intelligence testing scores and higher total brain volume
  • lower rates of retinopathy of prematurity
  • lower blood pressure and low-density lipoprotein concentrations
  • improved leptin and insulin metabolism

The benefits of human milk to the preterm infant are so significant that the AAP recommends, “If mother’s own milk is unavailable despite significant lactation support, pasteurized donor milk should be used”(1). This week’s posts will further explore the topic of donor human milk for the premature infant.

Donor human breast milk vs cow’s milk-based formula

When a mother’s breast milk is not available, preterm infants can be given either donor breast milk or commercially made formula. Feeding preterm infants pasteurized donor milk over formula is the recommendation expressed by a long list of organizations.  Such groups include the AAP, Canadian Pediatric Society, United States Breastfeeding Committee, Breastfeeding Committee for Canada, and La Leche League International (1-5).  Evidence to support this recommendation largely comes from a 2007 systematic review by Quigley et al. (6) and a 2010 trial by Sullivan et al. (7). In both cases the rates of NEC were significantly higher in preterm infants fed cow’s milk-based formula products versus those fed only human milk.

The review performed by Quigley et al. compared formula feeding to donor breast milk in eight separate studies, involving a total of 1,017 infants. The authors concluded, “feeding with formula milk, compared with donor breast milk, leads to higher rates of short-term growth in preterm or low birth weight infants, but is associated with an increased risk of developing necrotizing enterocolitis” (6). The results of short-term growth should be taken with caution, however, as only one of the eight trials included nutrient-fortified breast milk (a common practice in today’s NICU).  Fortifying human milk has been shown to increase short-term growth rates, but does not appear to affect growth beyond infancy (8).

The study by Sullivan et al. included 207 extremely premature infants and showed a 77% reduction in the odds of developing NEC (odds ratio of 0.23 (95% CI=0.08,0.66), P=. 007) in infants that consumed only human milk and human milk-based fortifiers compared to infants that consumed cow’s milk-based products (7).

Pasteurization of donor breast milk
In accordance with recommendations from the AAP and Canadian Pediatric Society (CPS), as well as the remaining aforementioned organizations, donor human milk offered to premature infants must be pasteurized (1-5). As a human body substance, breast milk must be properly collected and stored, subject to screening and testing, pasteurized, and cultured.  Pasteurization involves heating breast milk to inactivate bacterial and viral contaminants. The heating process can also alter the breast milk itself. The CPS policy statement on milk banking provides a summary of the alterations caused by a common form of pasteurization in milk banks (heating milk to 62.5oC for 30 minutes; the Holder method):

  • Carbohydrates, fats and salts are unchanged.
  • Thirteen per cent of the protein content is denatured.
  • Fat-soluble vitamins are unchanged.
  • While not all of the water-soluble vitamins have been studied, some have been shown to degrade following pasteurization.
  • All beneficial immune cells are also inactivated.
  • Secretory immunoglobulin IgA, which binds microbes within the digestive tract, is found at 67% to 100% of its original activity.
  • Targeted IgG antibodies are reduced at 66% to 70%.
  • IgM antibodies are completely removed.
  • Lactoferrin, which binds iron required by many bacteria, thus reducing their growth, is reduced to 20% of its original level.
  • Lysozyme enzyme, which attacks bacterial cell walls, drops to 75% activity.

Despite these alterations, pasteurized breast milk still contains far more beneficial elements than formula and is the preferential alternative to mother’s own fresh breast milk.

Supply of pasteurized donor breast milk in Canada

To meet the recommendation of properly pasteurized milk, Canadian hospitals receive their donor milk from one of the milk banks associated with the Human Milk Bank Association of North America (HMBANA).  The HMBANA is a non-profit association of donor human milk banks established to set standards for and facilitate establishment and operation of milk banks in North America. These banks have rigorous screening methods for all donors and stringent protocols for pasteurization and handling of breast milk.  The milk is sold to hospital NICU’s on a cost-recovery basis. As of 2011 there were 11 accredited HMBANA milk banks in North America. Only one of those banks is located in Canada (British Columbia). HMBANA banks are being developed in Ontario and Alberta and the Calgary Mothers’ Milk Bank (Alberta) is already accepting milk donations. Despite this recent development, Canadian hospitals are still critically short on donated breast milk.  Milk that is available is reserved for the most critical preterm infants or newborns that require gastrointestinal surgery (2).  There is certainly room for more banks to supply the large demand of breast milk to preterm and critically ill newborns.

In light of the need for more banks in North America, HMBANA has established guidelines and best practices for those wishing to start and operate a functional milk bank.  In our next post series we will interview Jannette Festival, Founder and Executive Director for the newly established Calgary Mothers’ Milk Bank, to discuss the process of creating a milk bank and the potential future of milk banks in Canada and North America.

References

  1. American Academy of Pediatrics. Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics 2012; 129: e827–e841. Available at http://pediatrics.aappublications.org/content/early/2012/02/22/peds.2011-3552 
  2. Canadian Paediatric Society. Position Statement: Human Milk Banking. Paediatrics and Child Health 2010; 15 (9):595-8. Available at http://www.cps.ca/english/statements/N/N10-01.htm.
  3. United States Breastfeeding Committee. Statement on the Safe Use of Donor Human Milk. Washington, DC: United States Breastfeeding Committee. 2008. Available at http://www.usbreastfeeding.org/LinkClick.aspx?link=Position-Statements%2fDonor-Milk-Statement-2008-06-18-USBC.pdf&tabid=227&mid=587.
  4. The Breastfeeding Committee of Canada. Breastfeeding Statement of The Breastfeeding Committee of Canada. 2002. Available at http://www.breastfeedingcanada.ca/Publications.aspx.
  5. La Leche League International. Policy regarding the donation of human milk. 2011. Available at http://www.llli.org/release/milksharing.html.
  6. Quigley MA, Henderson G, Anthony MY, McGuire W. Formula milk versus donor breast milk for feeding preterm or low birth weight infants (review). Cochrane Database of Systematic Reviews 2007; 1-41. Available at http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002971.pub2/abstract
  7. Sullivan S et al.  An Exclusively Human Milk-Based Diet Is Associated with a Lower Rate of Necrotizing Enterocolitis than a Diet of Human Milk and Bovine Milk-Based Products The Journal of Pediatrics 2010; 156:562-7.
  8. Kuschel CA, Harding JE. Multicomponent fortified human milk for promoting growth in preterm infants. Cochrane Database of Systematic Reviews 2004, Issue 1. Available at http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000343.pub2/abstract.
10 Comments

Donor Breast Milk for the Preterm Infant

March 5, 2012 07:00 AM by Wendy L. Morgan
Thanks for this article. I appreciate the statistics, especially regarding reduced NEC rates in infants that receive human milk. I serve on the Board of the Mothers' Milk Bank at Austin and while we are seeing an increase in donor mothers, unfortunately demand is outpacing supply. It is estimated that 8 million ounces of donor milk are needed for preterm infants and the non-profit milk bank providers only have 2 million ounces to share. If you are a healthy nursing mom, please consider donating milk to a non-profit milk bank to help these most fragile and tiny infants thrive.

Donor Breast Milk for the Preterm Infant

March 5, 2012 07:00 AM by Lisa D Baker, BSc, BEd,LCCE, FACCE
I second your request! Please pass this information on and help spread the word.

Donor Breast Milk for the Preterm Infant

March 5, 2012 07:00 AM by June Winfield
Great article Lisa! Thanks for spreading the correct information about donor milk and particularly the need for more milk banks. We are a HMBANA Developing Milk Bank (not yet processing becasue we don't have enough funding) in Portland working hard to bring a milk bank to the NW where we desperately need a milk bank. Being a milk donor doesn't cost the donor mom anything and is easy to do. We hope moms throughout North American will go to the HMBANA web site to find their closest milk bank, contact them and begin their journey to helping ill and infant infants! All of us in milk banking Thank You so much for your life-saving donations!! June Winfield, Board Chair / Director NW Mothers Milk Bank, Portland, OR

Donor Breast Milk for the Preterm Infant

March 8, 2012 07:00 AM by Kathy Morelli
Hi Lisa! This article is so concise and informative. I work with mothers with perinatal mental illnesses. I struggle to find the balance between infant health and mom's capacity to care for the infant and herself. So many women feel guilty and traumatized as they wean for their own reasons. I'd love to have a conversation on this, love any thoughts on this, thanks, Kathy

Donor Breast Milk for the Preterm Infant

March 8, 2012 07:00 AM by Lisa D Baker, BSc, BEd,LCCE, FACCE
Thank you for the comment Kathy! There are many women who share these feelings of guilt, I agree. In my personal experience I have even heard women feel as if they are "being bullied" into breastfeeding their infants. There is something so wrong with this situation. Perhaps it is in the delivery of the information. What can we, as educators and careproviders, do to share information on breastfeeding with expectant and new mothers without coming across as "bullying" or 'forcing breastfeeding'? Let's hear from others!

Donor Breast Milk for the Preterm Infant

March 8, 2012 07:00 AM by Mary
I gave birth to my baby at 29w after developing severe pre-e. I was committed to breastfeeding, and even more so after I learned that breastmilk provides protection against NEC. I really appreciated being able to provide milk for my baby and eventually to breastfeed her. I worked with several LCs and had a real range of experiences. The worst was being given a pat lecture about Breast is Best while crying because I was afraid my baby would die. LC entered the hospital room while I was crying, gave her lecture, and exited. I often felt in those first few days after the birth, which had been very complicated, that the advice I received to pump every 2 or 3 hrs did not take into account that I was a very sick woman in a very stressful situation. In some cases I felt that the LCs did not see me as a person with individual needs, but just as a vessel. The hospital where I gave birth is an urban teaching hospital in a high poverty area with low rates of breastfeeding. I suspect that the LCs adopted harsh attitudes with mother's out of frustration, and because they felt they had to apply some force to get women to breast feed. Their attitude was similar to attitudes I had encountered as a young woman seeking reproductive services-docs were so afraid that young women would be non-compliant that they really pushed and could be very negative. I did work with one wonderful LC who spent literal hours in the NICU with my daughter and I. She was persistent while also being gentle and helpful, and she made sure that we were securely breastfeeding before my daughter left the hospital. I am very thankful for her help. Breastmilk is important, but respect and compassion for individuals is even more important. Having a preemie is an incredibly hard experience, and if preemies need special care, preemie moms (many of whom already experience guilt, PPD, and PTSD) need extra care from all of their health care providers.

Donor Breast Milk for the Preterm Infant

March 8, 2012 07:00 AM by Lisa D Baker, BSc, BEd,LCCE, FACCE
Beautifully written Mary, thank you. You have some very good points for all those that work with preterm infants and parents.

Donor Breast Milk for the Preterm Infant

March 15, 2012 07:00 AM by Laura
I wonder if the option of filtering donor breast milk has been explored - this is what is usually done for pharmaceuticals and other medical liquids.

Donor Breast Milk for the Preterm Infant

March 16, 2012 07:00 AM by Lisa D Baker, BSc, BEd,LCCE, FACCE
Excellent question, and one that others have explored in the past! With the known transmission of HIV through breastmilk, work has been done on developing a filter that will retain the virus (http://aac.asm.org/content/51/7/2605.full.pdf). One company has produced a nipple shield they claim will prevent HIV transmission through breast milk (http://maternova.net/health-innovations/nipple-shield-prevent-hiv). However, these devices are still very much in the research phase. Further studies are required to determine the efficacy of these filters and feasibility to use such devices on a large-scale operation such as milk banks.

Donor Breast Milk for the Preterm Infant

August 7, 2012 07:00 AM by Science & Sensibility » Donor Milk and Milk Banks; A Gift That Saves Lives
[...] newest American Academy of Pediatrics’ statement on Breastfeeding and the Use of Human Milk, Donor Milk for Preterm Infants and the formation of a donor milk bank in Calgary, Alberta, Canada in some posts earlier this year. [...]

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