"Donor milk banking: Improving the future". A survey on the operation of the European donor human milk banks

From frozen to feeding: storage characteristics of banked donor human milk used in a single level IV academic neonatal intensive care unit

Background

The storage time of banked donor human milk (DHM) administered in an academic hospital to critically ill preterm neonates was previously unknown.

Objective

This study was designed to determine the storage time of banked DHM by measurements obtained at the hospital level (by lot finish date) and individual patient level (by feeding date) over 2-year observation period.

Results

Both methods of measuring storage time (hospital-level and patient-level) showed that DHM was stored on average 8 ±1 months before use. Variations in storage time fluctuated across months with a minimum and maximum storage duration of 119 to 317 days. Most infants received a median of 3 [2-5 IQR] unique lots of DHM.

Conclusion

The storage time of DHM was successfully measured. Over 95% of DHM received was stored longer than 6 months. Storage times varied widely, uncovering a potential area of future research.

A comparative review of human milk banking and national tissue banking programs

This paper explores the legislative and operational commonalities and differences in Medical Products of Human Origin (MPHO) programs, including blood, hematopoietic cells, tissues and reproductive cells and human milk banking. The analysis includes ethical principles in donation and utilization, policies and legislation, public awareness and education, registries, guidelines in donor selection, safety and quality assurance, operational models and funding, infrastructure and human resources and biovigilance and evaluation of outcomes. Unlike other MPHO, the need for donor human milk (DHM) may be greatly reduced, that is, by ensuring optimal support for maternal lactation and breastfeeding. This should not be lost in the drive for wider and improved service provision. Nevertheless, increased overall demand for DHM is expected as a result of forthcoming international recommendations and also its increased use as the first-choice supplement to a mother's own milk both within and beyond preterm, low-birthweight and sick infant populations. Insight into current human milk banking highlights differences and gaps in practices that can benefit from further exploration and harmonization. Strong similarities with the ethical and operational principles underpinning donation and processing of the diverse MPHO suggest that legislating human milk banks within similar MPHO frameworks may bring additional safety and facilitate improved product quality. Moreover, that MPHO-inspired models operating within attainable regulatory requirements may contribute to sustainable human milk banking activity and growth.

Human Milk-The Biofluid That Nourishes Infants from the First Day of Life

Human milk is a biofluid with a unique composition among mammalian milks. Besides this milk's major components, its bioactive compounds, like hormones, immune factors, and oligosaccharides, are unique and important for infant growth and development. The best form of nutrition for term and preterm infants is the mother's own milk. However, in the absence of the mother's own milk, donor milk should be made available. Milk banks support neonatal intensive care units by providing preterm infants with human milk that generally has reasonable nutritive value for this sensitive population. However, neither mother's own milk nor donor milk has sufficient energy content for the growth of preterm babies, so adequate human milk supplementation is crucial for their progress. Due to the different characteristics of human breast milk, as well as ubiquitous environmental pollutants, such as microplastics, new methods are required for monitoring the quality and characteristics of human milk, which will lay a solid foundation for the further development and progress of human milk research.

A descriptive analysis of human milk dispensed by the Leipzig Donor Human Milk Bank for neonates between 2012 and 2019

Background

Human milk banking has become an important aspect of Nutritional medicine. It is not just about the provision of mother's own milk (MOM) or donor human milk (DHM) in the hospital, but also a strategy to encourage breastfeeding in the clinical setting and beyond.

Objective

To describe the feeding patterns of hospitalised infants including human milk dispensed by the Leipzig Donor Human Milk Bank (LMB).

Design

A descriptive analysis of daily data on milk feeds dispensed by LMB for hospitalised infants distinguishing between MOM or DHM, either fresh or frozen, and raw/pasteurised milk from 2012-2019.

Results

We included 2,562 infants with median hospitalisation of 23 days, for whom human milk was dispensed on median 76% of those days and other nutrition on the remaining days. Raw MOM and raw DHM comprised 52% and 8% of the dispensed milk, respectively. Dispensing exclusive DHM instead of MOM for at least one full day was required for 55% of the infants, mostly at the beginning but also later during hospitalisation. Exclusive raw DHM was dispensed on at least 1 day for 37% of the infants, in different birthweight strata <1,000 g: 10%, 1,000-1500 g: 11%, 1,500-2500 g: 13% and > 2,500 g: 3%. At discharge, MOM was dispensed for more than 60% of the infants.

Conclusion

During an infant's hospital stay, LMB dispenses various human milk feeds with interspersed DHM resulting in complex intra-individual and time-variant feeding patterns. LMB dispenses raw MOM and especially raw DHM with the intention to retain the properties of human milk unlike a diet containing pasteurised DHM and/or formula. Although raw DHM comprises a small percentage of all dispensed milk, raw DHM is dispensed for a substantial portion of infants. Our results document that dispensing raw DHM, is possible in routine settings.

Understanding Mothers' Experiences of Being Ineligible to Donate Their Milk to a Not-for-Profit Milk Bank

Background: Donor milk banks have strict donor screening criteria to ensure that donor milk is safe for premature or hospitalized babies. Yet little evidence is available to understand how potential donors, who are often breastfeeding their own infants, experience being ineligible ("deferred") to donate their milk to a milk bank. Materials and Methods: Interviews were conducted with 10 mothers who were permanently or temporarily deferred from donating to a large, not-for-profit milk bank in Australia. Interviews focused on becoming a donor and being deferred, meanings of deferral, impact of deferral on feeding own infant, and improving the deferral process. Results: Thematic analysis of interviews identified nine themes: (1) donation as a solution to wasting milk; (2) eligibility questions were acceptable and understandable; (3) more information early on allows self-deferral; (4) deferral is not always clear; (5) deferral is disappointing but does not prevent future donation; (6) deferral did not prevent feeding own infant; (7) early information enables preparation for donation; (8) slow communication disrupts perfect timing to donate; and (9) alternatives to wasting milk. Conclusions: Milk banks have a duty of care to both milk recipients and donors. While mothers who want to donate milk are disappointed by deferrals, clear communication protects their breastfeeding relationships with their own infants. Milk banks can improve their screening processes by providing information up-front and ensuring timely contact with mothers. Mothers can then make informed decisions about donating and not feel as if their milk and resources are "wasted."

Factors That Influence the Sustainability of Human Milk Donation to Milk Banks: A Systematic Review

Donor human milk is the recommended alternative for feeding preterm or low birth weight infants when the mother's own milk is unavailable or not in sufficient quantity. Globally, the needs of vulnerable infants for donor human milk exceed the supply. This review aimed to identify the factors impacting the sustainability of human milk donation to milk banks. A systematic review of the literature was performed on eight databases to retrieve articles published until December 2021. The study protocol is available in PROSPERO (#CRD42021287087). Among the 6722 references identified, 10 studies (eight quantitative observational and two qualitative) met the eligibility criteria for a total of 7053 participants. Thirty factors influencing the sustainability of the donations to milk banks were identified and categorized as follows: (1) donation duration, (2) donors' infant features (e.g., gestational age, birth weight), (3) donors' features (e.g., socio-demographic characteristics, milk donation history), and (4) factors related to the milk bank and health care systems (awareness and support). The available evidence suggests that larger volumes of donated milk are associated with a longer duration of donation, as are early donation, previous milk donation, and donors with an infant of smaller weight and gestational age. Supporting and encouraging early donation and recruiting donors with infants of low birth weight and low gestational age could support longer donation times and greater volumes of milk donated. To identify efficient strategies and to draw appropriate recommendations to improve donor milk access, future studies should further explore the issues of the sustainability of human milk donation to milk banks.

Current Interventions to Prevent HTLV-1 Mother-to-Child Transmission and Their Effectiveness: A Systematic Review and Meta-Analysis

Human T lymphotropic virus 1 (HTLV-1) may be transmitted from mother to child and affects at least 5−10 million individuals worldwide, with severe consequences on health. Strategies to prevent transmission are important, as there is no treatment or vaccine. This systematic review aimed to identify interventions to prevent HTLV-1 mother-to-child transmission and to determine their effectiveness. Exclusive formula feeding, short-term breastfeeding, use of freeze−thaw milk, milk pasteurization, maternal and infant antiretroviral drugs, caesarean section, early clamping of umbilical cord, screening of milk donors and avoidance of cross-breastfeeding were identified as possible strategies. Avoidance of breastfeeding is an intervention that prevents 85% of transmissions. This strategy is recommended in Japan, Brazil, Colombia, Canada, Chile, Uruguay, the USA and some regions of French Guyana. Whilst breastfeeding for <3 months does not increase the risk of transmission compared to exclusive formula-feeding, concerns remain regarding the limited number of studies outside Japan, and the lack of information on women having higher risk of HTLV-1 transmission and on the ability of women to discontinue breastfeeding. Additional interventions are plausible, but data on their effectiveness are limited. The acceptance of interventions is high. These findings may guide healthcare professionals and support policymakers in implementing policies to avoid HTLV-1 mother-to-child transmission.

Diversity and trends of human milk banking: a scoping review from 1946 to 2021

BACKGROUND

The provision of donor human milk (DHM) through human milk banks is now widely practised globally. The study aimed to describe the current state, identify major topics and map out the emerging trends in human milk banking.

METHODS

PubMed was systematically searched for publications related to DHM, with the last update on 14 May 2021, for papers published between 1946 and 2021. Titles and abstracts were screened and indexed into 8 main and 39 subcategories. A top-up search was done in April 2022, but these results have not been incorporated.

RESULTS

A total of 1083 publications were identified, and more than a third (41%) were either observational or interventional studies. Predominant topics were milk type and milk composition. Almost half (49%) of the publications in the last decade were funded through government/research councils, and industry funding started shortly after links between formula and necrotising enterocolitis were published. Literature from high-income countries was six times more than publications from low-income or middle-income countries (LMICs).

CONCLUSION

The diversity and trends of publications included in this scoping review ranged from descriptive studies comparing biological and compositional differences of mother's own milk, DHM and/or formula. Very few studies have investigated associations of different milk types with infant outcomes. Evidence on breastfeeding and recipient psychological health outcomes is limited. Further research should identify the appropriateness of different funding sources. Future collaborations between academics, clinicians and milk banks in LMICs should be fostered to bridge the gap that exists between DHM and access.

The legislative framework of donor human milk and human milk banking in Europe

Data about the regulatory approaches to donor human milk (DHM) in European countries are lacking. The aim of this study is to describe the various regulations of DHM within European countries, to assess its legislative context and its impact in relation to donor milk banking. We performed a cross‐sectional survey using a semistructured online questionnaire addressing 29 national European milk‐banking representatives from June 2020 to February 2021. Representatives of 26 national DHM services participated in this study. The legal classification and regulatory status of DHM were defined in 9 out of 26 areas of jurisdiction (35%) as either food product (n = 6), product of human origin according to a blood, tissue, cell regulation (n = 2), or medicinal product (n = 1). In the remainder, DHM remains unclassified. Most legislations did not provide a comprehensive framework concerning DHM and costs to cover milk bank operations were rarely reimbursed. In general, the lack of national legislative governance and the actual legislative regulations in place do not support the use of DHM in European countries. National medical guidelines for the use of DHM have been issued in only 11 countries. The current number and distribution of milk banks (n = 239) within participating countries may not provide an equitable access to DHM for eligible infants. These findings could guide stakeholders aiming to establish a regulatory framework for DHM.

There is a lack of a legislative framework concerning the use of donor human milk in the majority of European countries.

Available national legislative frameworks differed widely with gaps in the regulation of safety and quality of donor human milk, protection of donors and recipients, and cost recovery.

Despite clearly demonstrated benefits and unequivocal recommendations for the use of donor human milk there is a lack of national guidance in many European countries.

Testing the effects of processing on donor human Milk: Analytical methods

Holder pasteurization is the current recommended method for donor human milk treatment. This method effectively eliminates most life-threatening contaminants in donor milk, but it also greatly reduces some of its biological properties. Consequently, there is a growing interest for developing novel processing methods that can ensure both microbial inactivation and a higher retention of the functional components of donor milk. Our aim was to offer a comprehensive overview of the analytical techniques available for the evaluation of such methods. To suggest an efficient workflow for the analysis of processed donor milk, a safety analytical panel as well as a nutritional value and functionality analytical panel are discussed, together with the principles, benefits, and drawbacks of the available techniques. Concluding on the suitability of a novel method requires a multifactorial approach which can be achieved by a combination of analytical targets and by using complementary assays to cross-validate the obtained results.

Microbiological Quality of Milk Donated to the Regional Human Milk Bank in Warsaw in the First Four Years of Activity

As the survival rate for preterm infants increases, more emphasis is placed on improving health-related quality of life through optimal nutritional management. Human Milk Banks (HMBs) provide bioactive nutrients and probiotic microorganisms to premature newborns, especially in the first year of life. Donated milk screening and selection of potential donors ensures the quality and microbiological safety of the donated milk. Therefore we reviewed the basic characteristics of donors and the amounts and contamination of breast milk donated to the Regional Human Milk Bank (RHMB) in Warsaw. In four years, the RHMB collected 1445.59 L of milk, of which 96.60% was distributed among hospitalised infants. Additionally, breastmilk from donor candidates (139 samples from 96 women) was tested at least once in the first year of lactation. First analyses showed that 18 women’s milk samples were microbiologically pure, and 78 samples had one or more species of commensal and/or potentially pathogenic bacteria. In human milk samples from 31 women, the bacteria level was above the standard required by the RHMB; therefore, donors were re-educated, and further samples were tested. Most women followed the recommendations on hygienic expression and storage of milk before transfer to the RHMB. Our analysis will help to increase the accessibility and quality of raw donor milk and to meet the needs of more newborns.

High-Temperature Short-Time Preserves Human Milk's Bioactive Proteins and Their Function Better Than Pasteurization Techniques With Long Processing Times

Donor human milk is generally processed by holder pasteurization (HoP) at 62. 5°C for 30 min. This temperature-time combination is sufficient for eliminating pathogens in donor milk, but also negatively affects several bioactive milk components. Long heating up times may further affect the bioactive properties of pasteurized milk. High-Temperature-Short-Time (HTST), a treatment with shorter processing times (72°C for 15 sec), was investigated as a suitable alternative to HoP. In addition, pasteurization methods that follow the same temperature regime but with varying heating up times were compared. Human milk samples from four different donors were combined into one pool, which was then used to perform all analyses. The effects of these methods on the levels and functionality of immunoglobulin A, lactoferrin, lysozyme and bile salt-stimulated lipase, were evaluated with LC-MS/MS-based proteomics and activity assays, while the pasteurization efficacy was evaluated with an alkaline phosphatase test. HoP, a treatment with long processing times, times, caused the highest reduction in all proteins studied (reduced by 50-98%). Compounds such as lactoferrin and bile salt-stimulated lipase that are more sensitive to heat treatments were better retained with HTST, but their levels and functionality were still significantly lower than those of untreated donor milk (52 and 81% reduction of lactoferrin and bile salt-stimulated lipase activity, respectively). Our findings showed that a treatment with considerably shorter processing times, such as HTST, may reduce the thermal damage caused to the bioactive proteins compared to HoP, without affecting pasteurization efficacy. Since the vast majority of the donor human milk banks that are currently operating on a global level apply HoP to donor milk, our findings may provide relevant information for the optimization of donor milk processing.