Contextualizing online human milk sharing: Structural factors and lactation disparity among middle income women in the U.S

Peer-to-Peer Human Milk-Sharing Among Israeli Milk Donors: A Mixed-Methods Study in the Land of Milk and Honey

BACKGROUND

Evidence is lacking on the phenomenon of peer-to-peer human milk-sharing in the Middle East, specifically, in Israel.

RESEARCH AIMS

This study aimed to uncover peer-to-peer human milk-sharing in Israel, learn about how and whether donors engage in safe milk handling and storage practices, and assess knowledge about human milk and breastfeeding among this milk-sharing population. We also aimed to investigate donors' selectiveness in their decisions about to whom they donate their milk and their perceptions about the sale and purchase of human milk.

METHODS

We conducted a semi-structured online survey, including both closed- and open-ended questions and used mixed methods to analyze responses descriptively. We used non-probability sampling to obtain a broad sample of human milk donors.

RESULTS

Out of 250 completed surveys, most participants (87.2%, n = 218) reported engaging in safe milk-sharing practices and were generally knowledgeable about the health risks associated with milk-sharing. Participant religiosity was associated with somewhat lower hygiene practices (r = -0.15, p ≤ .05). Most of the participants (81.7%, n = 190) were against the sale of human milk. Participants generally expressed no preference about the recipient of their milk, with some exceptions.

CONCLUSION

The milk-handling and storage practices of the participants in this study suggest a need to improve knowledge and awareness of safe milk storage temperature and the importance of washing hands before pumping milk, particularly within the religious sector. We propose that guidelines about safe milk-sharing practices be written and adopted by the Israeli Ministry of Health, and communicated through pediatricians, family doctors, nurses in Mother and Child Clinics (In Hebrew: Tipat Halav), and social media.

Comparison of Breastfeeding and Pumping Experiences of Milk Bank Donors in the United States and United Kingdom

Background/Objective: As human milk banking services expand, information about lifestyle characteristics and infant feeding experiences of milk bank donors is relatively limited. Our goal was to describe and compare milk bank donors' demographic, clinical, and lifestyle characteristics, and breastfeeding experiences in a variety of geographic settings. Methods: A cross-sectional online survey was conducted from August 2022 to December 2022 with approved donors from three milk banks in the United States (n = 369), and one milk bank in United Kingdom (n = 187). Results: Donors in all settings were predominantly in their early 30s, White, married, educated, and identified as female. U.K. donors reported more frequently being on maternity leave (33% versus 5%, p < 0.001), predominantly feeding directly at the breast in the first 3 months postpartum (51% versus 28%, p < 0.001), and breastfeeding a single child longer (21.2 versus 13.3 months, p < 0.001) than U.S. donors. Significantly more U.S. donors reported pumping due to work (34% versus 11%, p < 0.001) and pumping multiple times per day (57% versus 36%, p < 0.001). Most donors reported receiving information about breastfeeding from a health care provider (94% United States and 88% United Kingdom, p = 0.022), while the internet was the most popular source of information about pumping (65% United States and 64% United Kingdom, p = 0.751). Conclusion: Factors not directly related to milk banking (e.g., maternity leave, sources of breastfeeding/pumping assistance) may have an impact on how donors feed their children and ultimately on their milk donation pattern. The impact of donor characteristics and feeding practices on donation patterns warrants further investigation.

Human Milk Sharing in the United States: A Scoping Review

Background: Human milk is the optimal form of infant nutrition. If mother's own milk is unavailable, families may seek alternative sources of human milk through milk sharing, despite potential health and safety risks with this practice. Objective: The purpose of this scoping review was to synthesize the current literature on human milk sharing in the United States to help health care professionals better understand how families may use this practice for infant nutrition. Methods: A systematic search was conducted in June 2021 using Ovid MEDLINE, Embase, CINAHL, ProQuest Central, Web of Science, and Google Scholar. Articles were included if the primary outcome was milk sharing, excluding milk banks and preterm hospitalized infants. Results were limited to studies conducted in the United States and published in English after January 1, 2000. Results: From 2,124 articles, 34 met inclusion criteria and were reviewed. Study designs were largely observational (30/34), and participants were predominantly white, married, and middle-income women experiencing lactation problems or in possession of excess breast milk. Milk sharing, not for profit, was often facilitated through the internet but exchanged in person. Conversely, for-profit milk sharing often involved shipping and studies found evidence of milk contamination. No studies documented infant harm. Conclusions: There is limited research on the milk quality and relative risks of milk sharing, and no research on clinical outcomes in infants fed shared milk. Clinicians have opportunities to engage in open conversations about this practice to guide risk mitigation, however, research on recipient infant outcomes are urgently needed to inform best practices.

Human milk-sharing practices and infant-feeding behaviours: A comparison of donors and recipients

Human milk sharing (HMS) is growing in popularity as an infant-feeding strategy in the United States. HMS families are a hidden population because HMS is a nonnormative and stigmatized behaviour. Thus, gaining access to HMS participants is challenging, and research on this topic remains limited. In particular, little is known about the broader infant-feeding behaviours of HMS parents. This study aimed to describe and compare the infant-feeding behaviours and HMS practices among a network of HMS donors and recipients. A detailed online survey was distributed to HMS parents in the Washington, DC region. Bivariate analyses were used to summarize the data by donor/recipient status when possible. Group differences were tested using analysis of variance for continuous variables and χ² tests for categorical variables. Donors and recipients did not differ in their sociodemographic characteristics. Recipients were significantly more likely than donors to have experienced complications of labour and delivery, traumatic birth, postpartum depression or a negative breastfeeding experience. Donors and recipients did not differ significantly in their duration of lactation or HM-feeding. Interestingly, 30% of recipients ever produced excess milk and 21% of donors ever had difficulty producing enough milk for their child. Compared with donors, recipients faced numerous maternal health challenges, but were still able to achieve a long duration of HM-feeding. HMS recipients represent a vulnerable group who may benefit from additional psychosocial and lactation support to improve their health and breastfeeding outcomes. Additional research is needed to investigate the associations between HMS participation, infant-feeding behaviours and lactation outcomes.

Milk's Flows: Making and Transmitting Kinship, Health, and Personhood

Milk provides a way of thinking about how the body is enacted in science, policy and popular culture. This paper follows the currents of moral and biomedical epistemologies circulating around milk, including via notions of inheritance, the practices of wet nursing, and emerging scientific knowledge about the health-related benefits of breastfeeding. By situating milk's flows historically and culturally it shows how constructions of milk production, lactation, and infant feeding have long served as a 'cultural signal' of prevailing conceptions of bodies and social identities. In so doing, it explores the simultaneous power of milk as both a source of dispositional and somatic health, and an index of customary forms of unity and division. A focus on breast milk further contributes to augmenting and expanding recent debates about the biology-society nexus in science and technology studies (STS), anthropology, and sociology. Seen within biomedicine today as a carrier of somatic signals about the environment, the article reflects on how milk is bound up in the responsibilisation of women's bodies and the internalising of potential risks to the health of their offspring. This implies an unlimited agency for women in averting health risks and in future-proofing their children to be better than well, elides the socioeconomic, and environmental forces pragmatically limiting this assumed agency, and the distinct lack of material and inter-personal support for the perinatal period in many nations.

Testing the buffering hypothesis: Breastfeeding problems, cessation, and social support in the UK

OBJECTIVES

Physical breastfeeding problems can lead women to terminate breastfeeding earlier than planned. In high-income countries such as the UK, breastfeeding problems have been attributed to the cultural and individual "inexperience" of breastfeeding, ultimately leading to lower breastfeeding rates. Yet, cross-cultural evidence suggests breastfeeding problems still occur in contexts where breastfeeding is common, prolonged, and seen publicly. This suggests breastfeeding problems are not unusual and do not necessarily lead to breastfeeding cessation. As humans evolved to raise children cooperatively, what matters for breastfeeding continuation may be the availability of social support during the postnatal period. Here, we test the hypothesis that social support buffers mothers from the negative impact breastfeeding problems have on duration.

METHODS

We run Cox models on a sample of 565 UK mothers who completed a retrospective online survey about infant feeding and social support in 2017-2018.

RESULTS

Breastfeeding problems were important predictors of cessation; however, the direction of the effect was dependent on the problem type and type of support from a range of supporters. Helpful support for discomfort issues (blocked ducts, too much milk) was significantly associated with reduced hazards of cessation, as predicted. However, helpful support for reported milk insufficiency was assoicated with an increased hazard of cessation.

CONCLUSIONS

Experiencing breastfeeding problems is the norm, but its impact may be mitigated via social support. Working from an interdisciplinary approach, our results highlight that a wide range of supporters who provide different types of support have potential to influence maternal breastfeeding experience.

An 'incredible community' or 'disgusting' and 'weird'? Representations of breastmilk sharing in worldwide news media

Breastmilk sharing via the internet has become more popular in recent years, with a resultant increase in media attention. It is actively discouraged by public health bodies in at least three countries. We undertook a qualitative analysis of worldwide English language news media (online newspaper articles and transcripts of television and radio pieces) focusing on peer‐to‐peer breastmilk sharing during a 24‐month period (2015–2016). One hundred eleven news articles were analysed semiotically for positive (n = 49) and negative (n = 90) depictions of breastmilk sharing and the actors involved. Three countries published the majority of the articles: United States (n = 42), United Kingdom (n = 24) and Australia (n = 20). Topics associated with using shared breastmilk included perceived insufficiency, having surgery or taking medication, or the prematurity of the baby. Reports of women who gave and received breastmilk were largely positive although sometimes confused with women who sell breastmilk, who were demonised. The breastmilk itself, however, was considered as potentially contaminated and possibly dangerous; calls for action (n = 33) focused on increasing regulation and safety. Peer‐to‐peer milk sharing and the commercial availability of human milk are activities that occur within social and cultural contexts, and, as such, the ways in which they are represented in the news media reflect the ways in which they are also represented more widely in society. Increased understanding of normal infant feeding practices is needed, alongside guidance on how to better support breastfeeding. News media outlets can facilitate this through reporting risk in line with evidence. Further research should be undertaken to understand the safety of breastmilk sharing and the experience of those who participate.

Preterm neonatal immunology at the intestinal interface

Fetal and neonatal development represents a critical window for setting a path toward health throughout life. In this review, we focus on intestinal immunity, how it develops, and its implications for subsequent neonatal diseases. We discuss maternal nutritional and environmental exposures that dictate outcomes for the developing fetus. Although still controversial, there is evidence in support of an in utero microbiome. Specific well-intentioned and routine applications of antibiotics, steroids, and surgical interventions implemented before, during, and after birth skew the neonate towards pro-inflammatory dysbiosis. Shortly after birth, a consortium of maternal and environmentally derived bacteria, through cross-talk with the developing host immune system, takes center stage in developing or disrupting immune homeostasis at the intestinal interface. We also examine subsequent immunological cross-talks, which involve neonatal myeloid and lymphoid responses, and their potential impacts on health and disease such as necrotizing enterocolitis and sepsis, especially critical disease entities for the infant born preterm.

Neonatal Microbiome and Its Relationship to Necrotizing Enterocolitis: A Review of the Science

Necrotizing enterocolitis (NEC) occurs in many premature infants hospitalized in the neonatal intensive care unit. About 3% to 15% of very low-weight premature infants develop NEC, with an estimated 30% mortality rate for the cases requiring surgery. Currently, there is no known pathogenesis for NEC in the patient's populations. However, one of the most widely accepted hypotheses is having an abnormal fetal gut microbiome. The purpose of this review is to discuss some current methods of dysbiosis in the neonatal microbiome, such as maternal health, breastfeeding, and delivery method, and then to connect these to the occurrence of NEC in the infant and finally discuss some possibilities for limiting the occurrence of NEC in the future.

Use of shared milk among breastfeeding mothers with lactation insufficiency

Social media platforms have facilitated the use of shared breast milk for infant feeding since 2010. This study aims to assess the prevalence of shared milk use among breastfeeding mothers with insufficient milk supply; and compare shared milk users with non-users. Data were collected from breastfeeding mothers with low milk supply through an anonymous Internet-based survey in 2013. Shared milk users were those who used shared milk for at least 10% of their infant's needs; the rest were considered non-users. Chi-square comparisons between these groups assessed reasons and information sources for supplementation options; breastfeeding and supplement choice satisfaction; and breastfeeding duration. One hundred thirty-eight (29.1%) of 475 participants reported shared milk use. Healthfulness and reduced risk were most important to users (p < .001), whereas non-users cited convenience and lack of knowledge about other options (p < .001). Users reported receiving information from medical/breastfeeding professionals and online discussion forums, whereas non-users were more likely to not seek information about supplementation options. Users of shared milk were significantly more likely to provide breast milk at 6 months (59.3% vs. 39.6%, p = .001) and be satisfied with their supplementation choice (p < .001) compared with non-users. For women with self-reported lactation insufficiency, this study found that shared milk users were more likely to breastfeed longer, seek resources, identify healthful options, and report greater satisfaction with their supplementation choice than non-users. Importantly, shared milk may play a role in achieving U.S. Healthy People 2020 targets for breastfeeding duration.

A pilot study on nutrients, antimicrobial proteins, and bacteria in commerce-free models for exchanging expressed human milk in the USA

Expressed human milk can be donated or sold through a variety of channels, including human milk banks, corporations or individuals, or peer-to-peer milk sharing. There is a paucity of research regarding the nutrient and bioactive profiles of expressed human milk exchanged through commerce-free scenarios, including peer-to-peer milk sharing. The study objective was to evaluate the macronutrient, antimicrobial protein, and bacteria composition in expressed human milk acquired via commerce-free arrangements. Expressed human milk samples were collected from the following commerce-free scenarios: milk expressed for a mother's or parent's own infant (MOM; N = 30); unpasteurized milk donated to a non-profit milk bank (BANKED; N = 30); milk expressed for peer-to-peer milk sharing (SHARED; N = 31); and health professional-facilitated milk sharing where donors are serologically screened and milk is dispensed raw (SCREENED; N = 30). Analyses were conducted for total protein, lactose, percent fat and water, lysozyme activity, immunoglobulin A (IgA) activity, total aerobic bacteria, coliform, and Staphylococcus aureus. No bacterial growth was observed in 52/121 samples, and 15/121 had growth greater than 5.0 log colony-forming units/mL. There was no evidence of differences by groups (p > .05) in lactose, fat, water, lysozyme activity, sIgA activity, aerobic bacteria, coliforms, and S. aureus. Mean protein values (95% confidence interval) were 1.5 g/dL (1.4, 1.6) for BANKED, 1.4 g/dL (1.3, 1.5) for MOM, 1.6 g/dL (1.5, 1.7) for SCREENED, and 1.5 g/dL (1.4, 1.6) for SHARED, which was not significantly different (p = .081). This research contributes to growing literature on the risks and benefits of uncompensated, peer-to-peer milk sharing.

Psychosocial dimensions of human milk sharing

Breastfeeding is critical to maternal and infant health. Psychosocial factors are associated with lactation outcomes, and perinatal mood disorders (PMDs) are often linked with breastfeeding difficulties and early, unexpected weaning. Parents may utilize human milk sharing to ensure their infant receives human milk when breastfeeding requires supplementation or is not possible, but this practice carries health risks and is often stigmatized. Milk sharing recipient mothers may be particularly vulnerable to PMDs associated with breastfeeding difficulties. The study objective was to explore factors associated with emotional responses to a parent's decision to feed their infant with shared human milk. An online cross-sectional survey of 205 milk sharing recipients was analysed with linear regression. Controlling for participants' education and breastfeeding difficulties, higher perceived social stigma was associated with more negative emotional responses (p < .01). Receiving strong spousal/partner support for milk sharing (p < .001) and screening donors regarding the health of their nursling(s) (p < .05) were associated with more positive emotional responses. Social stigmatization of milk sharing may negatively influence emotional responses among recipient mothers. Based on these results, it can be recommended that health professionals screen breastfeeding mothers with lactation difficulties for emotional distress that may lead to PMDs and provide evidence-based information about milk sharing in a nonstigmatizing way. Health professionals may support informed decision-making for infant feeding practices, including human milk sharing, by providing information on milk sharing risks and risk mitigation, developing evidence-based practices and guidelines that facilitate safe milk sharing, and directing families to available resources for psychosocial support.

Current Trends in Research on Human Milk Exchange for Infant Feeding

Breastfeeding is critical for the healthy growth and development of infants. A diverse range of infant-feeding methods are used around the world today. Many methods involve feeding infants with expressed human milk obtained through human milk exchange. Human milk exchange includes human milk banking, human milk sharing, and markets in which human milk may be purchased or sold by individuals or commercial entities. In this review, we examine peer-reviewed scholarly literature pertaining to human milk exchange in the social sciences and basic human milk sciences. We also examine current position and policy statements for human milk sharing. Our review highlights areas in need of future research. This review is a valuable resource for healthcare professionals and others who provide evidence-based care to families about infant feeding.

Maintaining the Flow: Medical Challenges to Breastfeeding and "Risky" Bodies in Mexico

In this article, I discuss a case study from southeast Mexico that highlights conflicting ideas regarding what constitutes risk and illness in the context of breastfeeding and postpartum practices. On the one hand, doctors' indeterminate and conflicting diagnoses about mother's milk as a source of pollution is revealed as an act of moral pathology that frames young mothers as high risk. On the other hand, milk pollution is understood by women as an unwelcome yet temporary interruption that can be remedied through non-allopathic intervention. As such, women can exert collective agency to overcome medicalized barriers to early breastfeeding and maintain established nurturing practices.

Gender dynamics in the donation field: human tissue donation for research, therapy and feeding

This paper examines how gender dynamics shape human tissue donation for research and for human health. Drawing on research investigating the donation of different types of bodily tissues including blood, plasma, breastmilk, cord blood, foetal tissue and placentae we consider how and why women and men are viewed as different kinds of donors. We situate these donation practices within a broader understanding of gender difference to explain why any sociology of donation needs to take account of gender. In so doing we explore how tissue derived from the bodies of women acquires value in distinctive ways and for distinctive purposes and reasons. Within these gendered bioeconomies of donation, the supply and demand for tissue is structured by social understandings of maternity, parental responsibility, and risk, which in turn affect the experiences of donors.

Peer-to-Peer Human Milk Sharing: Recipient Mothers' Motivations, Stress, and Postpartum Mental Health

BACKGROUND

Some mothers who cannot breastfeed-partially or completely-choose to feed their infants human milk donated from a peer. Few studies have examined mothers' experiences with using donor milk; none has examined whether or not mothers' stress and mental health are associated with using donor milk from a peer.

METHODS

Researchers conducted semistructured individual interviews with mothers from the United States and Canada (N = 20) to answer the following questions: (a) what are recipient mothers' motivations for participation in peer-to-peer breast milk sharing and (b) what is the relationship between receiving donated milk and mothers' stress and mental health postpartum? Transcripts were coded using an inductive approach and principles of grounded theory were used to analyze data.

RESULTS

Data were organized under two themes: (a) motivations for using milk from a peer and (b) milk-sharing and stress-related experiences. Motivations included health benefits, medical need, and preference for human milk over formula. Factors inducing stress were as follows: logistical stressors of securing donor milk and fear of running out of milk. Factors reducing stress were as follows: donor milk provided relief and comfort and its use reduced mothers' self-reported symptoms of postpartum depression and anxiety.

CONCLUSIONS

Mothers participated in peer-to-peer breast milk sharing primarily because of health benefits for children. However, participation also had important psychological benefits for some mothers. Additional research and open discourse are needed to support mothers who choose to use milk from a peer and to promote safety of this practice.

A critical review of human milk sharing using an intersectional feminist framework: Implications for practice

OBJECTIVE

Driven by a growing body of research demonstrating the health benefits of human milk over substitute feeding preparations, the demand for human milk donations in North America is rapidly increasing. In the context of an increasingly institutionalized and commercialized human milk market, informal peer-to-peer milk sharing networks are commonplace. Race, class, gender and sexual orientation are intersecting aspects of identity and power that influence participation in breastfeeding and the domain of milk exchange. Using an intersectional feminist framework, we critically review studies of participation in milk sharing to examine the identities and socio-political circumstances of milk sharing participants.

DESIGN, SETTING AND PARTICIPANTS

We use an intersectional feminist framework to conduct a critical review of the evidence pertaining to human milk sharing participants in North America. The search strategy included relevant databases (Pubmed, CINAHL) and hand-searches of key journals. We include research studies with participants in the United States and Canada and where participants milk shared as recipients or donors.

FINDINGS

Of those studies that examine socio-political identities such as race and class, participants are largely white and high-income. Many studies did not examine socio-political identities, and none examine sexual orientation. Themes we identify in this review include: (1) Socio-political identities; (2) Milk sharing supports parental health; (3) Socio-political influences; (4) Resistance against institutionalization.

IMPLICATIONS FOR PRACTICE

Maternity care providers can advocate for improved access to breastfeeding support and pasteurized human donor milk to address inequities. Maternity care providers can bring consciousness of intersecting socio-political identities to discussions with families about milk-sharing.

Storage of Unfed and Leftover Mothers' Own Milk

OBJECTIVE

The objective was to examine the bacteriological and immunological properties of freshly expressed, previously frozen, and leftover mothers' own milk during storage.

MATERIALS AND METHODS

In the first of two pilot studies, 12 mother-infant dyads participated. The milk studied included freshly expressed unfed and freshly expressed leftover milk. Milk samples were stored at 24°C, 4°C, or -20°C. In the second pilot study, 11 mother-infant dyads participated. The milk studied included milk that had been previously frozen, including previously frozen leftover milk. Milk samples were stored at 24°C and 4°C. After storage in both studies, the milk was analyzed for bacteriological and immunological properties.

RESULTS

Bacteriological and immunological characteristics of freshly expressed unfed and freshly expressed leftover milk and previously frozen unfed and previously frozen leftover milk remained stable during storage at 4°C for at least 6 days. The quality of all groups of mothers' milk declined when stored at 24°C for longer than 3 hours.

CONCLUSIONS

While this study provides evidence that human milk might be safe at longer storage times, storage guidelines should not be revised until more research is performed. This study serves as a call to action for more research on the topic of human milk storage, specifically leftover human milk. The study provides information to inform future study designs on the topic of unpasteurized human milk storage. More research is needed regarding leftover human milk storage with a greater number of participants, determination of the quality of human milk, and the storage of human milk in a real-life setting.

Human milk expression as a sole or ancillary strategy for infant feeding: a qualitative study

In the United States, a significant proportion of human milk (HM) is now fed to infants from bottles. This mode of infant feeding is rarely measured or described in research studies or monitored by national surveillance systems. Consequently, little is known about expressed-HM feeding as an infant feeding strategy. Our objective was to understand how mothers use HM expression and expressed-HM feeding as a sole strategy or in combination with at-the-breast feeding to feed HM to their infants. We conducted semi-structured interviews with 41 mothers with experience of HM expression and infants under three years of age. Data were analysed using a grounded theory approach for sub-themes related to the pre-selected major themes of maternal HM production and infant HM consumption. Within the major theme of maternal HM production, sub-themes related to maternal over-production of HM. Many mothers produced more HM than their infant was consuming and stored it in the freezer. This enabled some infants to consume HM weeks or months after it was expressed. Within the major theme of infant HM consumption, the most salient sub-theme related to HM-feeding strategies. Four basic HM-feeding strategies emerged, ranging from predominant at-the-breast feeding to exclusive expressed-HM feeding. The HM-feeding strategies and trajectories highlighted by this study are complex, and most mothers fed HM both at-the-breast and from a bottle-information that is not collected by the current national breastfeeding survey questions. To understand health outcomes associated with expressed-HM feeding, new terminology may be needed.

Human Milk Handling and Storage Practices Among Peer Milk-Sharing Mothers

BACKGROUND

Peer milk sharing, the noncommercial sharing of human milk from one parent or caretaker directly to another for the purposes of feeding a child, appears to be an increasing infant-feeding practice. Although the U.S. Food and Drug Administration has issued a warning against the practice, little is known about how people who share human milk handle and store milk and whether these practices are consistent with clinical safety protocols. Research aim: This study aimed to learn about the milk-handling practices of expressed human milk by milk-sharing donors and recipient caretakers. In this article, we explore the degree to which donors and recipients adhere to the Academy of Breastfeeding Medicine clinical recommendations for safe handling and storage.

METHODS

Online surveys were collected from 321 parents engaged in peer milk sharing. Univariate descriptive statistics were used to describe the safe handling and storage procedures for milk donors and recipients. A two-sample t-test was used to compare safety items common to each group. Multivariate ordinary least squares regression analysis was used to examine sociodemographic correlates of milk safety practices within the sample group.

RESULTS

Findings indicate that respondents engaged in peer milk sharing report predominantly positive safety practices. Multivariate analysis did not reveal any relationship between safety practices and sociodemographic characteristics. The number of safe practices did not differ between donors and recipients.

CONCLUSION

Parents and caretakers who participate in peer human milk sharing report engaging in practices that should reduce risk of bacterial contamination of expressed peer shared milk. More research on this particular population is recommended.

Contested moral landscapes: Negotiating breastfeeding stigma in breastmilk sharing, nighttime breastfeeding, and long-term breastfeeding in the U.S. and the U.K

Recent public health breastfeeding promotion efforts have galvanized media debates about breastfeeding in wealthy, Euro-American settings. A growing body of research demonstrates that while breastfeeding is increasingly viewed as important for health, mothers continue to face significant structural and cultural barriers. Concerns have been raised about the moralizing aspects of breastfeeding promotion and its detrimental effects on those who do not breastfeed. Far less, however, is known about the moral experiences of those who pursue breastfeeding. This study draws together research on breastmilk sharing (2012-2016) and nighttime breastfeeding from the U.S. (2006-2009), and long-term breastfeeding from the U.K. (2008-2009) from three ethnographic projects to address this gap. Comparative analysis of these cases reveals that while breastfeeding is considered ideal infant nutrition, aspects of its practice continue to evoke physical and moral danger, even when these practices are implemented to facilitate breastfeeding. Breastmilk sharing to maintain exclusive breastmilk feeding, nighttime breastfeeding and bedsharing to facilitate breastfeeding, and breastfeeding beyond the accepted duration are considered unnecessary, unhealthy, harmful or even deadly. The sexual connotations of breastfeeding enhance the morally threatening qualities of these practices. The cessation of these "problematic" breastfeeding practices and their replacement with formula-feeding or other foods is viewed as a way to restore the normative social and moral order. Mothers manage the stigmatization of these breastfeeding practices through secrecy and avoidance of health professionals and others who might judge them, often leading to social isolation. Our findings highlight the divide between perceptions of the ideal of breastfeeding and its actual practice and point to the contested moral status of breastfeeding in the U.S. and the U.K. Further comparative ethnographic research is needed to illuminate the lived social and moral experiences of breastfeeding, and inform initiatives to normalize and support its practice without stigmatizing parents who do not breastfeed.

Informal Human Milk Sharing: A Qualitative Exploration of the Attitudes and Experiences of Mothers

BACKGROUND

Little is known about women's participation or likely participation in informal human milk (HM) sharing. The US Food and Drug Administration recommends against feeding infants shared HM acquired directly from individuals or through the Internet.

OBJECTIVE

This study explored the experiences of and attitudes toward HM sharing among mothers with experience of HM feeding and breast pump use, regardless of whether or not they had participated in HM sharing.

METHODS

We conducted qualitative, semistructured, in-depth interviews with 41 mothers from 4 counties in upstate New York, asking about their attitudes toward HM sharing. Interviews were transcribed and analyzed inductively.

RESULTS

Most women were aware of informal HM sharing and some had personal experience with sharing. Many mothers reported a willingness to provide their own HM if they had extra and their own child had enough. Mothers were less trusting about receiving HM, voicing concerns about the dietary intake or disease status of potential providers. Mothers felt that whether or not they participated in HM sharing would depend on the situation; they were most amenable to sharing with a family member or close friend. A novel finding was the involvement of lactation consultants and midwives, who coordinated HM exchanges for mothers in this sample.

CONCLUSION

Awareness of HM sharing was high in this sample. Depending on the situation, mothers may consider participating in informal HM sharing and they may be facilitated by health professionals. Future research is required to establish the benefits and risks associated with informal HM sharing.

Expanding the Supply of Pasteurized Donor Milk: Understanding Why Peer-to-Peer Milk Sharers in the United States Do Not Donate to Milk Banks

BACKGROUND

Lactating women in the United States have several options for what they do with excess breast milk, including donating to milk banks that serve medically fragile infants, sharing directly with families seeking milk, and selling to individuals or for-profit entities. The World Health Organization and the US Surgeon General have issued calls to increase access to pasteurized donor milk for medically fragile infants.

OBJECTIVE

To explore how lactating women with a surplus of breast milk come to the decision to share their milk with a peer rather than donate to a milk bank.

METHODS

A qualitative design using a grounded theory approach was employed. Semistructured telephone interviews were conducted with 27 women who had shared milk with a peer but not with a milk bank.

RESULTS

Five dominant themes were identified: a strong belief in the value of breast milk, unexpected versus planned donation, sources of information regarding milk exchange, concerns and knowledge gaps about milk banks, and helping and connecting.

CONCLUSIONS

This research offers insights into potential strategies for promoting milk bank donation among peer-to-peer milk sharers, including developing donor education campaigns focused on knowledge gaps regarding milk banks and developing health care professional referral programs that can reduce barriers associated with the convenience of milk bank donation.

Human milk sharing practices in the U.S

The primary objective of this study is to describe human milk sharing practices in the U.S. Specifically, we examine milk sharing social networks, donor compensation, the prevalence of anonymous milk sharing interactions, recipients' concerns about specific milk sharing risks, and lay screening behaviors. Data on human milk sharing practices were collected via an online survey September 2013–March 2014. Chi‐square analyses were used to test the association between risk perception and screening practices. A total of 867 (661 donors, 206 recipients) respondents were included in the analyses. Most (96.1%) reported sharing milk face‐to‐face. Only 10% of respondents reported giving or receiving milk through a non‐profit human milk bank, respectively. There were no reports of anonymous purchases of human milk. A small proportion of recipients (4.0%) reported that their infant had a serious medical condition. Screening of prospective donors was common (90.7%) but varied with social relationship and familiarity. Likewise, concern about specific milk sharing risks was varied, and risk perception was significantly associated (P‐values = 0.01 or less) with donor screening for all risk variables except diet. Understanding lay perceptions of milk sharing risk and risk reduction strategies that parents are using is an essential first step in developing public health interventions and clinical practices that promote infant safety.

Tobacco Metabolites and Caffeine in Human Milk Purchased via the Internet

BACKGROUND

Chemicals inhaled or ingested by mothers can be present in their milk. Our objective was to determine levels of nicotine, cotinine, and caffeine in human milk purchased via the Internet.

MATERIALS AND METHODS

We purchased human milk (n=102) via the Internet and abstracted seller advertisements for information volunteered about tobacco and caffeine use. Nicotine, cotinine, and caffeine levels in the milk were quantified by mass spectrometry according to published protocols.

RESULTS

No sellers indicated smoking in their advertisement. Many of the milk samples (58%) had detectable nicotine or cotinine; four (4%) of the samples had nicotine or cotinine levels high enough to indicate active smoking. Twelve (12%) sellers said in their advertisements that they specifically limit (4%) or avoid (8%) caffeine entirely. Five (5%) of the samples had caffeine levels consistent with consuming at least 1 cup of coffee 2 hours prior to milk expression. Detectable amounts of caffeine were found in almost all of the samples (97%).

CONCLUSIONS

In 102 milk samples, we detected evidence of active smoking, secondhand smoke exposure, and almost ubiquitous caffeine consumption. Buyers of human milk on the Internet should be aware that advertisements do not always include accurate information as to what substances may be present. Sellers may misrepresent their health behaviors or be unaware of lifestyle factors that can lead to exposure to nicotine and caffeine.

Milk sharing in practice: a descriptive analysis of peer breastmilk sharing

Peer breastmilk sharing has emerged in recent years as a subject of investigation and occasional controversy. Although researchers know that thousands of milk exchanges are facilitated through milk sharing Web sites every week, there is only limited research into milk sharing practices on the ground. This study examines these practices through a 102-item online survey that asked questions about milk sharing practices, perceptions of milk sharing, and demographic characteristics. Participants were recruited through social media sites specific to breastfeeding and parenting events in Central Florida. The sample consisted of 392 respondents. Data were analyzed using univariate analysis. We found that breastmilk sharing is a complex practice, showing high levels of overlap in which some donors are also recipients, and that cross-nursing sometimes occurs simultaneously with the exchange of expressed milk. Respondents often donated and received milk from people they knew; however, exchanging milk with strangers was also common. Many but not all used the Internet to facilitate milk exchange; participants used well-known milk sharing Web sites as well as their private virtual networks. The study found that most milk exchanges happen in-person as gifts and that selling and shipping breastmilk were rare. We suggest that further research is needed on breastmilk sharing practices to inform breastmilk safety research and policy recommendations.