A quality improvement project to improve voluntary milk donation in a human milk bank in South India

Background

Mother's milk is the ideal food for a neonate. When mother's milk is unavailable for any reason, pasteurised donor human milk (PDHM) is the next best option. This quality improvement (QI) project aimed at improving voluntary donation in a public human milk bank (HMB) in South India.

Methods

Between January 2018 and June 2019, the HMB received an average of 15 L of donor milk per month (0.5 L/day). Our aim was to increase voluntary donation by 50% from the baseline over a period of 8 months from July 2019 to March 2020 using QI methods. Two plan-do-study-act (PDSA) cycles were done during the intervention period (4 months). Interventions included the formation of micro teams in postnatal wards to promote exclusive breastfeeding and to liaison with the core QI team. We created a milk expression area in the postnatal ward, counseled postnatal mothers, and addressed supply chain issues like sterile pumping accessories.

Results

The average daily voluntary milk donation to HMB increased from 0.83 L/day in the baseline phase to 1.16 and 1.14 L per day in the intervention and postintervention phases, respectively. The mean (SD) monthly donated volumes increased from 28.2 (6.1) L to 34.1 (3.7) L; mean difference (95% CI) 5.9 (0.33-11.4); P = 0.03. The volume of PDHM disbursed from HMB increased from 26.6 (3.2) L/month to 32.2 (9.2) L/month, although not statistically significant (p = 0.15). The number of mothers donating milk did not increase during the study period.

Conclusions

A multipronged QI intervention effort focusing on exclusive breastfeeding improved voluntary milk donation in HMB bank. Multiple micro-teams and local networking facilitated the QI initiative.

Concentrations and predictors of aluminum, antimony, and lithium in breast milk: A repeated-measures study of donors

Aluminum (Al), antimony (Sb), and lithium (Li) are relatively common toxic metal(oid)s that can be transferred into breast milk and potentially to the nursing infant. This study assessed concentrations of Al, Sb, and Li in breast milk samples collected from donor mothers and explored the predictors of these concentrations. Two hundred forty-two pooled breast milk samples were collected at different times post-partum from 83 donors in Spain (2015-2018) and analyzed for Al, Sb, and Li concentrations. Mixed-effect linear regression was used to investigate the association of breast milk concentrations of these elements with the sociodemographic profile of the women, their dietary habits and utilization of personal care products (PCPs), the post-partum interval, and the nutritional characteristics of milk samples, among other factors. Al was detected in 94% of samples, with a median concentration of 57.63 μg/L. Sb and Li were detected in 72% and 79% of samples at median concentrations of 0.08 μg/L and 0.58 μg/L, respectively. Concentrations of Al, Sb, and Li were not associated with post-partum time. Al was positively associated with total lipid content of samples, weight change since before pregnancy, and coffee and butter intakes and inversely with meat intake. Li was positively associated with intake of chocolate and use of face cream and eyeliner and inversely with year of sample collection, egg, bread, and pasta intakes, and use of hand cream. Sb was positively associated with fatty fish, yoghurt, rice, and deep-fried food intakes and use of eyeliner and inversely with egg and cereal intakes and use of eyeshadow. This study shows that Al, Sb, and Li, especially Al, are widely present in donor breast milk samples. Their concentrations in the milk samples were most frequently associated with dietary habits but also with the lipid content of samples and the use of certain PCPs.

Donor Breast Milk Banking: Knowledge and Attitudes of Iranian Mothers

INTRODUCTION

Milk donation is allowed in Islam and considered a virtue, though according to Islam Sharia, feeding donated milk of other mothers leads to kinship between infants, complicating milk donation programs in Islamic countries. This study aimed to determine the knowledge and attitude of Iranian Muslim mothers regarding milk donation and milk banks.

METHODS

In this cross-sectional descriptive-analytic study, 634 mothers of infants below 1 year of age were recruited using cluster random sampling from health care centers in Tabriz, Iran. Data were collected by questionnaire.

RESULTS

The findings revealed a low level of knowledge but relatively positive attitudes. Knowledge predictors were education level, income, type of birth, breastfeeding experience, encouragement to donate milk, and hearing about milk donation (p ≤ .02). Predictors of attitude were knowledge score and encouragement to donate milk (p ≤ .001).

DISCUSSION

Comprehensive, culturally congruent education of mothers during pregnancy and post-pregnancy related to milk banks is recommended.

LioNeo project: a randomised double-blind clinical trial for nutrition of very-low-birth-weight infants

We assessed the effectiveness of lyophilised banked human milk (HM) as a fortifier to feed very-low-birth-weight infants (VLBWI). This study aimed to evaluate the safety and tolerability of HM with HM lyophilisate as an additive compared with the standard additive (cows' milk protein). In this phase I double-blind randomised controlled clinical trial, set in the intensive and intermediate care units of a tertiary hospital, forty VLBWI were enrolled and allocated into two groups: HM plus HM lyophilisate (LioNeo) or HM plus commercial additive (HMCA). The inclusion criteria were preterm infants, birth weight 750-1500 g, small or adequate for gestational age, exclusively receiving donor HM, volume ≥ 100 ml/kg per d and haemodynamically stable. Participants were followed up for 21 consecutive days. The primary outcome measures were necrotising enterocolitis (NEC), late-onset sepsis (LOS), death, gastrointestinal (GI) bleeding or perforation, diarrhoea, regurgitation, vomiting and abdominal distension. The LioNeo and HMCA groups had similar weights at baseline. The regression models showed no differences between the groups in terms of the primary outcomes. Diarrhoea, GI perforation, NEC and LOS were absent in the LioNeo group (one LOS and one NEC in the HMCA group). Multiple regression analysis with the total volume of milk as a covariate did not show significant differences. The lyophilisation of donor HM was considered safe and tolerable for use in stable haemodynamically VLBWI.

How much does a liter of donor human milk cost? Cost analysis of operating a human milk bank in Italy

BACKGROUND

To date, 40 Human Milk Banks (HMB) have been established in Italy; however, recent cost analysis data for operating an HMB in Italy are not available in the literature.

METHODS

This study was a cross-sectional study performed at "Bambino Gesù" Children's Hospital in Rome, Italy in 2019. We assessed the one-year operational costs and, the per liter unit costs at our HMB.

RESULTS

During the 2019 year we collected 771 l of human milk supplied by 128 donors. The total cost was € 178,287.00 and the average cost was € 231.00 per liter. € 188,716.00 would have been spent had the maximum capacity for 904 l been reached. We found a significant difference (€ 231.00 vs € 209.00 per liter, p = 0.016) comparing the cost for collected liters in the year 2019 and the cost for the maximum capacity of the bank for that year of activity. Analyzing each cost item that determines the charge of donor human milk (DHM), the highest costs are the salaries of medical and paramedical staff, and then the costs related to transporting. If the HMB works at maximum capacity and manages a greater number of liters of milk, this can represent an important saving. Conversely, the price of consumables is modest (i.e., the price of a single-use kit for breast pumps was € 0.22 per unit).

CONCLUSION

The costs for a liter of DHM are quite high, but they must be related to the benefits, especially for preterm infants. Comparing the cost for collected liters in 2019 and the costs for the 2019 maximum capacity of the HMB, we calculated how much fixed costs of collection and distribution of DHM can be reduced, by increasing the volume of milk collected. To the best of our knowledge, this is the first complete cost analysis for an Italian Milk Bank. A thorough analysis could help to abate fixed costs and reduce the cost of a liter of DHM. The centralization of DHM can allow savings, rather than creating small HMBs scattered throughout the territory that would operate with lower milk volumes.

Sequential interventions to maintain the safety and service provisions of human milk banking in India: keeping up with the call to action in response to the COVID-19 pandemic

BACKGROUND

WHO recommends donor milk as the next best choice if Mothers' own milk (MOM) is unavailable. At our milk bank, during the COVID 19 pandemic, we observed a steep decline in the collection of donor milk, while Pasteurised Donor human milk (PDHM) demand increased. This called for active intervention.

METHODS

We employed the quasi-experimental quality improvement initiative. During September 2020 (baseline period) the team members identified modifiable bottlenecks and suggested interventions (using WhatsApp to increase follow up, telehealth and digital tools) which were implemented in October 2020 and the impact was evaluated till March 2021. The SMART aim was "to meet the demand (estimated as 15,000 ml/month) of donor milk for adjoining 80-bedded NICU". Process measures were; daily amount of donor milk collected, pasteurized donor milk disbursed to NICU, number of donors and frequency of donations. The balancing measure was that the collection of donor milk should not undermine the provision of freshly expressed MOM for babies.

RESULTS

Collection of donor milk increased by 180% from baseline during the Intervention phase. This was sustained throughout the sustenance phase (November 2020 and March 2021) with an average monthly collection of 16,500 ml. Strikingly, the increased follow-up of mothers with emphasis on MOM decreased the NICU's donor milk requirement from 13,300 ml (baseline) to 12,500 ml (intervention) to 8,300 ml (sustenance). Monitoring of daily MOM used in the NICU revealed a 32% surge from 20,000 ml (baseline) to 27,000 ml (intervention) sustained at 25,000 ml per month.

CONCLUSION

By improving the provisions of human milk banks, near-exclusive human milk feeding can be ensured even during the pandemic time.

Biomonitoring bisphenols, parabens, and benzophenones in breast milk from a human milk bank in Southern Spain

BACKGROUND

Human breast milk is considered the optimal source of nutrition for infants. Milk from breast milk banks offers an alternative to infant formulas for vulnerable hospitalized neonates most likely to benefit from exclusive human milk feeding. However, breast milk can also be a source of exposure to environmental contaminants, including endocrine-disrupting chemicals (EDCs).

AIM

To evaluate concentrations of phenolic EDCs, including bisphenols, parabens (PBs), and benzophenones (BPs), in samples from a human milk bank in Granada, Southern Spain and to explore sociodemographic, reproductive, and lifestyle factors related to their concentrations in the milk.

METHODS

Concentrations of three bisphenols [bisphenol A (BPA), bisphenol F (BPF), and bisphenol S (BPS)], four PBs [methyl- (MeP), ethyl- (EtP), propyl- (n-PrP), and butyl-paraben (n-BuP)], and six BPs [BP-1, BP-2, BP-3, BP-6, BP-8, and 4-hydroxy-BP] were determined in milk samples from 83 donors. Information on potential explanatory variables was gathered using the milk bank donor form and an ad hoc questionnaire. Multiple linear and logistic regression models were fitted.

RESULTS

Detectable concentrations were found of at least one of the analyzed compounds in all donor breast milk samples and at least five compounds in one-fifth of them. The most frequently detected compounds were MeP (90.5%), BP-3 (75.0%), EtP (51.2%), n-PrP (46.4%), and BPA (41.7%). Median concentrations ranged between <0.10 ng/mL (n-PrP, n-BuP, BP-1) and 0.59 ng/mL (BP-3). No sample contained detectable concentrations of BPF, BPS, or most BPs (BP-2, BP-6, BP-8, and 4- hydroxy-BP). Breast milk phenol concentrations were associated with parity, the utilization of deodorants, mouthwash, skin care products, and cosmetics, and the intake of nutritional supplements.

CONCLUSIONS

Results reveal the widespread presence of BPA, PBs, and BP-3 in donor breast milk samples, highlighting the need for preventive measures to enhance the benefits of breast milk from milk banks and from breastfeeding women in general.

Postpartum women's views on human milk banking in a city in Southeast China: a cross-sectional survey

BACKGROUND

Donor human milk is the best alternative for preterm infants when their mother's own milk is insufficient or unavailable. The development of human milk banks in China started late, and in most of these banks, the amount of donor human milk is insufficient for clinical demand. Moreover, many mothers are reluctant to use donor human milk due to safety concerns. It is important to understand the potential supply and demand of donor human milk before establishing a new human milk bank. This study aimed to understand women's acceptance of human milk banking in Wenzhou, southeastern China.

METHODS

A cross-sectional study was conducted in three community health centers in Wenzhou, southeast China, in December 2020. Data were collected from 305 postpartum women selected through convenience sampling. Sociodemographic, perinatal and breastfeeding characteristics, awareness and knowledge of human milk banking and willingness to donate human milk, and to accept donor human milk were assessed. Multivariable logistic regression analysis was used to explore independent predictors of willingness to donate human milk and to accept donor human milk.

RESULTS

Only 17% (52/305) of our participants had heard of human milk banking prior to this survey. The prevalence of willingness to donate human milk and use donor human milk in our study was 73.4% (224/305) and 44.6% (136/305), respectively. Employment (adjusted odds ratio [AOR] 2.30; 95% confidence interval [CI] 1.17, 4.50) and human milk banking knowledge (AOR 1.23; 95% CI 1.12, 1.35) were independent predictors of willingness to donate human milk. Monthly household income in the previous year (AOR 2.18; 95% CI 1.17, 4.06), awareness of human milk banking (AOR 2.41; 95% CI 1.24, 4.67) and knowledge of human milk banking (AOR 1.22; 95% CI 1.11, 1.35) were significantly associated with willingness to accept donor human milk.

CONCLUSIONS

In our study, awareness of human milk banks among women in the first year postpartum was low. More mothers were willing to donate human milk than to use donor human milk to feed their children. In our study, knowledge of human milk banking was a predictor of both willingness to donate human milk and willingness to use donor human milk. Programs with detailed information on human milk banking are needed to help mothers improve their knowledge and increase acceptance of human milk banking.

Concentrations of perfluoroalkyl substances in donor breast milk in Southern Spain and their potential determinants

BACKGROUND

Breast milk is considered to offer the best nutrition to infants; however, it may be a source of exposure to environmental chemicals such as perfluoroalkyl compounds (PFAS) for breastfeeding infants. PFAS are a complex group of synthetic chemicals whose high stability has led to their ubiquitous contamination of the environment.

OBJECTIVE

To assess the concentrations and profiles of PFAS in breast milk from donors to a human milk bank and explore factors potentially related to this exposure.

METHODS

Pooled milk samples were collected from 82 donors to the Human Milk Bank of the Virgen de las Nieves University Hospital (Granada, Spain). Ultra-high performance liquid chromatography coupled with tandem mass spectrometry (UHPLC-MS/MS) was applied to determine milk concentrations of 11 PFAS, including long-chain and short-chain compounds. A questionnaire was used to collect information on donors' socio-demographic characteristics, lifestyle, diet, and use of personal care products (PCPs). Factors related to individual and total PFAS concentrations were evaluated by multivariate regression analysis.

RESULTS

PFAS were detected in 24-100% of breast milk samples. PFHpA was detected in 100% of samples, followed by PFOA (84%), PFNA (71%), PFHxA (66%), and PFTrDA (62%). Perfluorooctane sulfonate (PFOS) was detected in only 34% of donors. The median concentrations ranged from <0.66 ng/dL (perfluorohexane sulfonic acid [PFHxS]) to 19.39 ng/L (PFHpA). The median of the sum of PFAS concentrations was 87.67 ng/L and was higher for short-chain than long-chain PFAS. Factors most frequently associated with increased PFAS concentrations included intake of creatin animal food items and use of PCPs such as skin care and makeup products.

CONCLUSIONS

Several PFAS, including short-chain compounds, are detected in pooled donor milk samples. Breast milk may be an important pathway for the PFAS exposure of breastfed infants, including preterm infants in NICUs. Despite the reduced sample size, these data suggest that various lifestyle factors influence PFAS concentrations, highlighting the use of PCPs.

Human milk banks in the response to COVID-19: a statement of the regional human milk bank network for Southeast Asia and beyond

Background

The World Health Organization (WHO) recommendations on infant feeding in the context of COVID-19 uphold standing recommendations for breastfeeding, non-separation, and skin-to-skin contact, including the use of donor human milk when mother’s own milk is not available.

Insufficient guidance on the use of donor human milk and the role of human milk banks in the pandemic response

COVID-19 clinical management guidelines in seven countries in Southeast Asia are not aligned with WHO recommendations despite the lack of evidence of transmission through either breastmilk or breastfeeding. The use of safe donor human milk accessed through human milk banks is also insufficiently recommended, even in countries with an existing human milk bank, leading to a gap in evidence-based management of COVID-19. This highlights long-standing challenges as well as opportunities in the safe, equitable, and resilient implementation of human milk banks in the region.

Conclusions

This statement reflects the expert opinion of the Regional Human Milk Bank Network for Southeast Asia and Beyond on the need to revisit national guidelines based on the best evidence for breastfeeding during the COVID-19 pandemic, to incorporate human milk bank services in national obstetric and newborn care guidelines for COVID-19 where possible, and to ensure that operations of human milk banks are adapted to meet the needs of the current pandemic and to sustain donor human milk supply in the long-term. The Network also recommends sustained engagement with the global human milk bank community.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-021-00376-2.

Immunological components and antioxidant activity in human milk processed by different high pressure-thermal treatments at low initial temperature and flash holding times

The effect of high pressure thermal (HPT) processing on the immunoglobulin (IgM, IgA and IgG), and cytokine content (IL-6, IL-8, IL-10, and TNF-α), and antioxidant activity of human milk was analyzed after the application of different treatments between 200, and 800 MPa at low initial temperatures (between -15, and 50 °C) and for 1 s (flash treatments). Low pressures intensities did not induce changes in Igs while at 800 MPa, all combinations reduced the control levels. IL-6 and IL-10 were not affected by any of the treatments applied while IL-8 and TNF-α were reduced at treatments which combined temperatures at 50 °C. In general antioxidant activity was not affected at the processing conditions chosen. The flash HPT treatment applied at 600 MPa and at 0 °C could be the best choice to preserve immunological parameters and the antioxidant activity of human milk.

Factors associated with postpartum women's knowledge, attitude and practice regarding human milk banks and milk donation: A cross-sectional survey

BACKGROUND

Breast milk is the optimal method of human nutrition, and donor human milk is often needed to reduce the incidence of necrotizing enterocolitis and septicemia in preterm infants and improve their survival rate. Donor human milk is recommended as the first alternative when mothers' milk is not available. The establishment of human milk banks is of great significance to promote the breastfeeding of preterm infants. However, there are insufficient studies on human milk banks and milk donation in China.

OBJECTIVES

(1) To investigate postpartum women's knowledge, attitude and practice regarding human milk banks and milk donation and to analyze the influencing factors. (2) To explore reasons why postpartum women reject milk donation and donor milk.

DESIGN AND SETTINGS

A cross-sectional survey was conducted from February 2019 to July 2019 at two hospitals in Wuhan, a large city in central China.

PARTICIPANTS

Mothers who returned to hospital for postpartum follow-up within six months participated in this survey (N = 1078).

METHODS

Questionnaires were used to obtain sociodemographic data and to determine participants' knowledge, attitude and practice regarding human milk banks and milk donation.

FINDINGS

Of the respondents, 216 (20%) had prior knowledge of human milk banks and milk donation. For the sub-domain of knowledge, the item with the highest correct response rate was the benefit of breast milk, and the item with the lowest correct rate was the acceptance of donor human milk. For the sub-domain of attitude, 811(75.3%) of participants held a supportive attitude for the establishment of human milk banks, and 877(81.3%) were supportive of donating breast milk while 412 (38.3%) were supportive of accepting donor human milk. For the sub-domain of practice, the practice of milk donation was not optimistic as participants lacked interest in donating breast milk and spreading knowledge of breast milk banks, and only 28.3% of participants indicated that they would donate breast milk continuously. Participants' age, educational background, weight of the newborn and having prior knowledge of human milk banks were factors that could positively predict their knowledge, attitude and practice associated with human milk banks and milk donation; medication usage during pregnancy or lactation was a factor negatively predicting their knowledge about human milk banks and milk donation.

CONCLUSION

This study reveals that a majority of postpartum women are supportive of human milk banks and more willing to donate breast milk than receive donor milk. Lack of knowledge about human milk banks and safety concerns are the main factors hindering postpartum women from donating or accepting donor milk. Findings suggest that it is important to enhance public awareness regarding human milk banks as potential resources for life-saving therapy for preterm infants.This information should be disseminated during the early stage of the establishment of human milk banks. Moreover, health education of pregnant women should include the importance of human milk as well as the alternative and safety of donor milk from milk banks, especially for promoting the health of preterm infants and infants who are unable to receive mothers' breastmilk.

Bacillus cereus contamination of pasteurized human milk donations: frequency, origin, seasonal distribution, molecular typing of strains and proposed corrective/preventive actions

Objectives: An increase in pasteurized human milk contamination with Bacillus cereus was witnessed in milk donated to the Amiens-Picardie Human Milk Bank over the 2017-2018 period. To better understand the origin of such an increase, this study aimed to describe the frequency of Bacillus cereus contamination in anonymous and personalized human milk donations of Amiens Human Milk Bank in 2018, compare the genetic profiles of Bacillus cereus strains found in pasteurized human milk and set up corrective/preventive actions to reduce Bacillus cereus contamination.Study design: A retrospective cohort study of human milk donated from January to December 2018 was set. Data on the microbiological quality of donated human milk and genetic profiles of Bacillus cereus strains isolated from pasteurized donated human milk and the environment were collected.Results: The overall noncompliance rate related to the microbiological quality in the 1585 batches of analyzed human milk donations was of 27.3%. Post-Holder pasteurization, rejection rates were significantly higher for anonymous donations as compared to personalized ones. Bacillus cereus was the main cause of noncompliance. Bacillus cereus contaminations could not be attributed to a single strain spreading through Amiens human milk bank and Amiens hospital environment as the genetic profiles of the collected strains were different. Corrective actions led to a decrease in the noncompliance rate due to Bacillus cereus (37.7-9.7%) post-Holder pasteurization.Conclusion: Bacillus cereus was the primary cause of rejection for pasteurized human milk donations over the investigated period. These contaminations did not originate from the spread of a single strain. A first round of corrective actions enabled a fair decrease in Bacillus cereus contaminations.

Satisfaction of mothers regarding human milk donation

In France, human milk banks are in charge of the collection, analysis, processing, and distribution of human milk to neonatology centers for preterm infants. Knowledge of what motivates mothers to donate their milk could lead to better communication regarding human milk donation. A satisfaction survey was conducted among mothers who were donating their milk to a human milk bank. In total, 214 mothers answered a questionnaire in the presence of the collector during a home visit. The median age of the mothers was 31 years (18-46), mainly high school (19%) or university (65%) graduates, and the median duration of donation was 3 months (0.5-22). At the time of the study, the median age of infants was 3 months (0.5-25), and 88% of infants were exclusively breastfed. About three quarters of mothers were motivated by willingness to help others, a quarter of them being especially sensitive to premature neonatal care; 30% of mothers were motivated by having a high supply of milk. Around 25% of mothers were given information on human milk donation during pregnancy, and two thirds after delivery, mainly by the maternity ward midwives (53.4%) or by collectors during their visit (14.1%). Most mothers (72%) found the human milk donation process easy and most of them (92.5%) were willing to donate their milk again after their next pregnancy. This survey shows that more than 90% of mothers are satisfied with donation to human milk banks. However, efforts should be made to provide information on breastfeeding and human milk donation to the general population and health professionals.

National Program for RMNCH + A: Newer Strategies for Improving the Newborn Health in India

RMNCH+A is a platform for delivering adolescent, maternal, newborn and child health in an integrated manner using a life cycle approach. The new initiatives under this strategy that would impact newborn health include antenatal corticosteroids in preterm labor, delayed clamping of cord at birth, skin-to-skin contact at birth and Kangaroo mother care, Family participatory care, Lactation management centers and care beyond newborn survival under the Rashtriya Bal Swasthya Karyakram. Even though the coverage of many of the existing initiatives has been moderately high, there are concerns about the quality of delivery of these interventions and slow progress in the roll out of the newer interventions. Quality assurance initiative such as Dakshata and LaQshaya will also contribute to improved newborn health as we proceed towards the Sustainable development goals (SDG) 2030 targets for newborn and child survival.

Breastmilk donations: Bacteriological assessment, analysis of causes of non-compliance and suggestions for improvement

A total of 1099 breastmilk donations received by the milk bank at the Amiens University Hospital from January to June 2016 were assessed for bacteriological contamination according to French regulations. This consisted in enumerating the total aerobic flora before and after heat treatment as well as the specific enumeration of coagulase-positive staphylococci. Results above the mandatory limits for at least one of these parameters were found in 25.9% of the donations, resulting in the destruction of approximately one-quarter of the volume of the donations (∼195L). This is a huge loss in both economic and health-related terms for neonates, especially for pre-terms. To identify ways to improve the bacteriological assessment results and reduce the percentage of discarded milk, an analysis of the causes was conducted. The two main causes of non-compliance were the detection of a cultivable aerobic flora after heat treatment and the presence of coagulase-positive staphylococci above the mandatory limit (11.7% and 11.2% of the tested donations, respectively). Bacillus spp. were the leading cause of post-heat-treatment non-compliance. Therefore, the implementation of better environmental control could help reduce this kind of contamination. As for samples harboring coagulase-positive staphylococci, a further detection of toxins using molecular biology techniques could help discriminate actual health-hazardous donations that have to be destroyed while enabling the use of toxin-negative donations. Nevertheless, the economic viability of this proposal needs to be further assessed because these techniques are costly. Finally, a change in breastmilk dilutions used to enumerate the total aerobic flora to better reflect the actual level of these bacteria in the milk was proposed. Indeed, the comparison of various combinations of milk dilutions led to the conclusion that the association of the 1/10 and 1/100 dilutions was the best compromise between technical ease of enumeration and ensuring the safety of the donations. Implementing these suggestions would help reduce the rate of non-compliance and give better access to safe breastmilk donations for neonates.

Improving Quality of Banked Milk: Utility of Dornic Acid Test

OBJECTIVE

To identify, if Dornic acid test done on human milk bank sample is as effective as doing routine culture, both pre and post pasteurization.

METHODS

The authors analyzed 477 samples, both pre and post pasteurization. Dornic acid measurement was performed by using N/9 NaOH and titrated to get dornicity of the sample. Senstivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) at different Dornic acid levels were calculated. To find diagnostic power of this study, ROC curve was prepared. Dornic acid for paired pre and post pasteurization were noted and analysed for statistical significance.

RESULTS

A significant growth was seen in 21% (98/477) samples with coagulase negative staphylococci and gram negative organisms being the major contaminants seen prior to pasteurization. In the index study, Dornic acidity ≥4°D had a sensitivity of 98% but very low specificity of just over 10%. However, 8°D had 92% specificity and acceptable sensitivity of 72% in comparison to gold standard microbiological criteria, making it a good test for analyzing the quality of milk before pasteurization.

CONCLUSIONS

Dornic acid test at 8°D has a very high specificity with acceptable sensitivity in comparison to dornicity at 4°D. It can be used as a simple method to select better quality of milk sample prior to pasteurization.

Use of pasteurised human donor milk across neonatal networks in England

OBJECTIVES

To describe the use of pasteurised human donor milk (pHDM) in England and the influence of a human milk bank in the network.

DESIGN

Prospective observational study SETTING: All 163 neonatal units (23 networks) in England 2012-2013.

PATIENTS

Preterm infants born at <32 weeks gestational age (GA).

MAIN OUTCOME MEASURES

Proportion of infants and care-days fed pHDM during the first 30 postnatal days by network METHODS: We extracted daily patient-level data from the National Neonatal Research Database (NNRD). We fitted a logistic regression of pHDM exposure on the presence of a pHDM bank within the network, with GA, BW z score and network as covariates. Significance was assessed by the likelihood ratio (chi-squared) test.

RESULTS

Data for 13,463 infants were included in the study. Across the networks, the proportion (95%CI) of infants ranged from 2.0% (1.0, 3.0) to 61.0% (57.4%, 64.6%), and the proportion of care-days in which pHDM was fed from 0.08% (0.04%, 0.10%) to 21.9% (19.9%, 24.0%). In three networks <5%, and in seven networks >30% of infants received any pHDM. Variation in the use of pHDM across networks remained significant after adjustment for presence of a human milk bank within the network and all covariates (p < 0.001).

CONCLUSIONS

Wide variation of pHDM use in England is not fully explained by presence of a pHDM bank or patient characteristics. This suggests clinical uncertainty about the use of pHDM.

[Recommendations for the creation and operation of maternal milk banks in Spain]

It is widely agreed that the best source of nutrition for the newborn is the milk of their own mothers. In those cases where it is not available, especially in very premature and/or very low birth weight infants, as well as other sick newborns, the preferred choice before formula is the human milk provided by selected donors. This indication is supported by the highest international bodies dedicated to the health of the child population, including the World Health Organisation as well as the main national and international scientific societies in the field of Paediatrics. Milk banks are health institutions responsible for the collection, processing and distribution of donated human milk. Currently, there are 14 human milk banks operating in Spain, grouped in the Spanish Association of Human Milk Banks, created in September 2008. In order to homogenise the criteria and to unify the working methods of the different milk banks, the Spanish Association of Human Milk Banks has developed standards to harmonise the protocols, and to serve as a guide for the start-up of new milk banks in the Spanish territory. These standards, set out in the present article, range from the donor selection and the evaluation process to the collection, processing, storage, and distribution of donor human milk.

A retrospective audit of bacterial culture results of donated human milk in Perth, Western Australia

INTRODUCTION

The bacterial content of donated human milk is either endogenous or introduced via contamination. Defining milk bank bacterial content will allow researchers to devise appropriate tests for significant and commonly encountered organisms.

OBJECTIVE

A retrospective audit was conducted on data recorded from the Perron Rotary Express Milk Bank, King Edward Memorial Hospital, Subiaco, Western Australia. This aimed to describe the incidence of bacterial species detected in donated human milk and to identify potentially pathogenic bacteria.

MATERIAL AND METHODS

The data comprised of 2890 batches donated by 448 women between 2007 and 2011.

RESULTS

Coagulase negative Staphylococcus (CoNS) represented the highest prevalence of bacteria in donated milk, isolated from 85.5% of batches (range: 20 to 650,000CFU/mL) followed by Acinetobacter species in 8.1% of batches (range: 100 to 180,000CFU/mL). Staphylococcus aureus was the most prevalent potentially pathogenic bacteria in 5% of batches (range: 40 to 100,000CFU/mL).

CONCLUSION

Further investigation is warranted to better define the risks posed by the presence of toxin-producing S. aureus in raw and pasteurized human milk which may allow minimization of risk to the preterm infants.

Milk kinship is not an obstacle to using donor human milk to feed preterm infants in Muslim countries

The development of human milk banks in Muslim countries is challenging because of the tradition of milk kinship. In other countries, this tradition imposes restrictions on Muslim mothers with regard to donating their milk or receiving donor milk for their preterm baby. However, Muslim law does allow the use of donated human milk under certain conditions, for example if it comes from a single known donor or is pooled from the milk of at least three donors.

CONCLUSION

Muslim parents need to be made aware that human milk banks can be used for preterm babies if strict conditions are met.

Breast milk donation after neonatal death in Australia: a report

Lactation and breast milk can hold great value and meaning for grieving mothers who have experienced a recent death of an infant. Donation to a human milk bank (HMB) as an alternative to discarding breast milk is one means of respecting the value of breast milk. There is little research, national policy discussion, or organizational representation in Australia on the subject of breast milk donation after infant death. On 29 November 2013 the Mercy Hospital for Women in Melbourne, Australia hosted Australia’s first National Stakeholder Meeting (NSM) on the topic of milk donation after neonatal death. The NSM drew together representatives from Australian HMBs, neonatal intensive care units (NICUs) currently using donor human milk, and Australia’s chief NICU parent support organization. The NSM was video-recorded and transcribed, and analyzed thematically by researchers. This article reports the seven dominant themes discussed by stakeholders during the NSM: the spectrum of women’s lactation and donation experiences after infant death; the roles of the HMB and NICU in meeting the needs of the bereaved donor; how bereaved mothers’ lactation autonomy may interface with a HMB’s donation guidelines; how milk donation may be discussed with bereaved mothers; the variation between four categories of milk donation after neonatal death; the impact of limited resources and few HMBs on providing donation programs for bereaved mothers in Australia. This article provides evidence from researchers and practitioners that can assist HMB staff in refining their bank’s policy on milk donation after infant death, and provides national policy makers with key considerations to support lactation, human milk banking, and bereavement services nation-wide.

Donor milk volume and characteristics of donors and their children

BACKGROUND

Little is known regarding the effect of the characteristics of donors and their children on the volume of donor milk delivered to a human milk bank (HMB).

AIMS

Our study aimed to determine the relationship between different social and demographic variables of donors and their infants with the volume of human milk delivered.

METHODS

We included donors accepted at the Hospital Doce de Octubre HMB from January 1st, 2009 until April 31st, 2013, and who had finished their donation. Data of social and demographic characteristics of the donors and their children, and the total volume of DHM given were obtained from our HMB database. Included variables were previous donors, donor age, number of children, place of residence, gestational age of the infant at birth, child's age at the start of the donation, hospital admission, and death of the infant. A linear regression model was used to study the relationship between independent variables that were significant in bivariate analysis and the volume of donated milk.

RESULTS

A total of 415 donations from 391 women were included. The median volume of milk delivered was 3.1l (IQR-interquartile range-1.3-8.3l). In the linear regression model, previous donors, smaller gestational age of children, and the start of donation at earlier stages of lactation were associated with a larger quantity of HMB donated (p≤0.001).

CONCLUSION

Previous donors, smaller gestational age of children, and the start of donation at earlier stages of lactation are associated with a larger quantity of milk donated to the HMB.

Growth of very low birth weight infants fed with milk from a human milk bank selected according to the caloric and protein value

OBJECTIVE

To describe growth and clinical evolution of very low birth weight infants fed during hospital stay with milk from a human milk bank according to the caloric-protein value.

METHOD

Forty very low birth weight infants were included: 10 were fed milk from their own mothers (GI), and 30 were fed human milk bank > 700 cal/L and 2 g/dL of protein. Growth curves were adjusted using nonlinear regression to the measured growth parameters.

RESULTS

full enteral diet was reached in 6.3 days by GI and in 10.8 by GII; a weight of 2 kg was reached in 7.3 weeks for GI and in 7.8 for GII. In GI, 3/10 (33.3%) and in GII, 7/30 (23.3%) developed sepsis. Necrotizing enterocolitis did not occur in GI, but in 3/30 (10.0%) in GII. GI presented with urinary calcium > 4 mg/L in 1/10 (10.0%), urinary phosphorus (Pu) <1 mg/L in 10/10 (100%), and Ca/Cr >0.6 ratio in 1/10 (10.0%) of the cases; in GII, no children presented alterations of the urinary calcium or the Ca and Cr ratio, and Pu was <1 mg/L in 19/30 (63.3%). In terms of growth the 50th percentile for GI was a weight gain of 12.1 g/day (GI) vs. 15.8 g/day (GII), a length gain of 0.75 cm/week (GI) vs. 1.02 cm/week (GII), and a head circumference gain of 0.74 cm/week (GI) vs. 0.76 cm/week (GII).

CONCLUSIONS

Human milk bank allowed a satisfactory growth and good clinical evolution for very low birth weight infants.