Donor Breast Milk for the Preterm Infant: Your Questions Answered!

Expressed breast milk (EBM) is the gold standard of infant nutrition, but is not always available for use for preterm infants in the NICU setting. Donor breast milk (DBM) is often a preferred alternative for preterm and very low birth weight (VLBW) infants when maternal milk is not available. This article discusses the composition of DBM, reviews its advantages compared to formula, discusses challenges related to its long-term use, and identifies strategies to utilize DBM in the context of total nutritional management of preterm and VLBW infants. We will use a framework of WHO, WHAT, WHERE, WHEN, and WHY to answer the questions: who gets DBM, why use DBM, where does DBM come from, what is in DBM, and when may DBM use be challenged.

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.

Establishing an integrated human milk banking approach to strengthen newborn care

The provision of donor human milk can significantly reduce morbidity and mortality among vulnerable infants and is recommended by the World Health Organization as the next best option when a mother's own milk is unavailable. Regulated human milk banks can meet this need, however, scale-up has been hindered by the absence of an appropriate model for resource-limited settings and a lack of policy support for human milk banks and for the operational procedures supporting them. To reduce infant mortality, human milk banking systems need to be scaled up and integrated with other components of newborn care. This article draws on current guidelines and best practices from human milk banks to offer a compilation of universal requirements that provide a foundation for an integrated model of newborn care that is appropriate for low- and high-resource settings alike.

Donated breast milk stored in banks versus breast milk purchased online

QUESTION

One of my patients asked if she could buy human milk on the Internet to feed her infant if the need arose. Is using donated breast milk from the milk bank safer than buying it online?

ANSWER

The World Health Organization and the American Academy of Pediatrics recommend the use of donated breast milk as the first alternative when maternal milk is not available, but the Canadian Paediatric Society does not endorse the sharing of unprocessed human milk. Human breast milk stored in milk banks differs from donor breast milk available via the Internet owing to its rigorous donor-selection process, frequent quality assurance inspections, regulated transport process, and pasteurization in accordance with food preparation guidelines set out by the Canadian Food Inspection Agency. Most samples purchased online contain Gram-negative bacteria or have a total aerobic bacteria count of more than 10(4) colony-forming units per millilitre; they also exhibit higher mean total aerobic bacteria counts, total Gram-negative bacteria counts, coliform bacteria counts, and Staphylococcus spp counts than milk bank samples do. Growth of most bacteria species is associated with the number of days in transit, which suggests poor collection, storage, or shipping practices for milk purchased online.

Amendment to 2010 Italian guidelines for the establishment and operation of a donor human milk bank

The present paper is an amendment to the recent Italian Guidelines of human milk banking published in 2010. Working Group on Guidelines (Panel) of the Italian Association of Human Milk Banks (AIBLUD) states, in accordance with the European Union Comission's Amending Directive of January 2011, that the hard plastic feeding bottles used in the collection, storage and pasteurization of the human milk should be Bisphenol A (BPA) free. Until new evidence are available polycarbonate feeding bottles should not be used for collection, storage and pasteurization of human milk. The paper summarizes the former and current European Commission Directives and shows the related amending changes to the 2010 Italian Human Milk Banking Guidelines.

Improved growth of preterm infants receiving mother's own raw milk compared with pasteurized donor milk

AIM

To determine whether growth, feeding tolerance and infectious events of preterm infants is related to the proportion of intake of mother's own raw milk (maternal milk) versus pooled pasteurized banked breast milk (donor milk).

METHODS

This is a prospective observational study of 55 premature infants born less than 32 weeks of gestational age admitted to the neonatal intensive care unit at the Children's Hospital of Toulouse during two 6-month periods from 2003 to 2005. Enrolled infants were exclusively on enteral feeds with maternal milk ± donor milk.

RESULTS

Mean gestational age was 28.6 weeks (SD 1.5) and mean birth weight 1105 grams (SD 282). During the time of exclusively breast milk feeds, weight gain (g/kg/day) was correlated to the proportion of maternal milk consumed (p = 0.0048, r = 0.4). Necrotizing enterocolitis was inversely correlated to the amount of maternal milk. The amount of maternal milk did not impact on infectious events.

CONCLUSION

Mother's own raw milk improves weight gain compared with donor milk in preterm infants. Lactation strategies should be sought that helps mothers to increase their milk production.

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.

Best practice guidelines for the operation of a donor human milk bank in an Australian NICU

Until the establishment of the PREM Bank (Perron Rotary Express Milk Bank) donor human milk banking had not occurred in Australia for the past 20 years. In re-establishing donor human milk banking in Australia, the focus of the PREM Bank has been to develop a formal and consistent approach to safety and quality in processing during the operation of the human milk bank. There is currently no existing legislation in Australia that specifically regulates the operation of donor human milk banks. For this reason the PREM Bank has utilised existing and internationally recognised management practices for managing hazards during food production. These tools (specifically HACCP) have been used to guide the development of Standard Operating Procedures and Good Manufacturing Practice for the screening of donors and processing of donor human milk. Donor screening procedures are consistent with those recommended by other human milk banks operating internationally, and also consistent with the requirements for blood and tissue donation in Australia. Controlled documentation and record keep requirements have also been developed that allow complete traceability from individual donation to individual feed dispensed to recipient and maintain a record of all processing and storage conditions. These operational requirements have been developed to reduce any risk associated with feeding pasteurised donor human milk to hospitalised preterm or ill infants to acceptable levels.

Human Milk Donation

The American Academy of Pediatrics (AAP) strongly endorses that human milk is species specific and the optimal nutrition for infants, and that banked human milk is a suitable alternative. After the death of an infant, breast milk often is disposed of without consideration of donation because the public and healthcare providers are unaware of human milk banks. In the United States, 10 human milk banks operate under strict guidelines established by the Human Milk Banking Association of North America. Donors are screened, and milk is pasteurized while preserving many of the beneficial components of breast milk. It is imperative that healthcare providers become educated regarding human milk banking because of the increase in informal sharing of breast milk via the Internet. Breast milk that has not been screened and treated has the risk of transmitting infections such as hepatitis and HIV. Healthcare providers should be familiar with the selection criteria for suitable donors and how to approach families when the death of an infant is imminent. Human milk banks are able to provide human milk to adopted, preterm, or ill infants whose mothers are unable to provide their own milk.

[Evaluation of the bacteriologic quality of breast milk in a neonatology service in Belgium]

Many studies demonstrated that human milk is the recommended source of enteral nutrition in preterm infants providing several benefits with regards to feeding tolerance, immunity and cognitive development However, neurological immaturity and associated clinical conditions prevent them from suckling effectively. Therefore, mother's milk must be expressed, stored and transported to the neonatal unit and could be contaminated. The microbiological quality of human milk was evaluated on each donation to the neonatal intensive care unit of the University of Liege, Belgium from November 1, 2003 to January 31, 2005. In all, 5842 samples from 176 mothers were included in the study. Samples were classified according to the exclusive presence of coagulase negative Staphylococcus and their number (less or more than 104 germs per ml) or to contamination with pathogens. More than 50% of analyzed milks had to be pasteurized (46%; >104 coagulase negative Staphylococcus per ml) or to be discarded (7% pathogen contamination). The incidence of pasteurisation tends to increase during the summer, suggesting a seasonal influence. Maternal profiles were established longitudinally. Among the 60 mothers whose at least one sample had pathogen contamination, 27% had a contamination occurring only during a few days, but 73% had more than 50% of their samples discarded. This study suggest the need to promote the use and the financial support of intrahospital human milk bank units to support the safe use of raw and pasteurised human milk in preterm infants.

Antimicrobial and antiviral effect of high-temperature short-time (HTST) pasteurization applied to human milk

In the United States, concerns over the transmission of infectious diseases have led to donor human milk generally being subjected to pasteurization prior to distribution and use. The standard method used by North American milk banks is Holder pasteurization (63 degrees C for 30 minutes). The authors undertook an experiment to validate the effects of a high-temperature short-time (HTST) pasteurization process (72 degrees C for 16 seconds) on the bioburden of human milk. It was concluded that HTST is effective in the elimination of bacteria as well as of certain important pathogenic viruses.

Quality control of banked milk in Brasilia, Brazil

The authors studied quality control procedures at human milk banks and nutritional profiles of 909 milk samples (from 195 donors, aged 15 to 45 years) from banked human milk (BHM) in Brasília, Brazil. Number of donations per donor ranged from 1 to > 10 that consisted mostly of mature milk (90.9%) with a mean total energy of 529 +/- 85 kcal/L and a mean total lipid of 22.7 g/L +/- 13.2. Microbiological quality (titrable acidity-Dornic, degrees D) was suitable for infant feeding in 99.2% of samples (< 8 degrees D), ranging from 2 degrees D to 8 degrees D (mean 4.8 +/- 1.4 degrees D). Most BHM (98.1%) samples were dispensed to inpatient infants (1-7 days) diagnosed with respiratory distress (30.1%), prematurity (20.7%), metabolic distress (16.0%), jaundice (14.4%), bacterial infection (6.0%), pneumonia (3.3%), congenital cardiac distress (2.2%), or other conditions (6.2%). Well-motivated mothers and trained staff are serving and sustaining an important life-saving network with long-lasting impact on public health.

Milk banking: the influence of storage procedures and subsequent processing on immunologic components of human milk

The immunoprotective constituents of human milk are stable when stored at room temperature for 8 hours, when stored at 0 degree-4 degrees C for three days, or when frozen at -20 degrees C for 12 months. They are also stable during pasteurization at 56 degrees C for 30 minutes. Sonification may reduce levels of sIgA and lysozyme and the ability of milk to inhibit growth of E coli. The number of cells in human milk is reduced by storage, freezing, pasteurizing, microwaving and sonification, and the functional capacity of surviving cells is also reduced.

Trends in donor milk banking in the United States

Modern donor milk banking was conceived in the US in the early 1900s as a medicalized version of wet nursing. Over the course of the century the fortunes of donor milk banking have varied considerably. In the last 20 years donor milk banking has been negatively affected by the development of specialty formulas, safety issues related to viral transmission, and lack of clinical research. To survive, US milk banks have been receptive to clinical uses considered as "alternative medicine," and have cooperated with governmental agencies to develop standards for safety. A qualitative analysis of collected case histories of US donor milk recipients demonstrates that donor human milk banking can be critical to survival and the well-being of at-risk infants, children, and the occasional adult. By analyzing national data collected by survey method and examining the literature, the researcher compared German and US milk banks and distribution data. German milk banks use donor milk exclusively for premature infants and have less stringent operating standards, yet dispense volumes of milk greatly in excess of the US milk banks. While statistics are lacking for the total recipient population in the US, a projected analysis (based on German consumption) of the potential volume that could be dispensed in the US is presented, indicating that the population in need of this crucial public health service is currently under-served in the US.

Donor milk: what's in it and what's not

Breastfeeding and human milk are widely recognized as optimal for human infants. However, if donor milk is used when mother's own milk is not available, some questions arise concerning the effects of storage, handling, and heat processing on the unique components of human milk. Holder pasteurization (62.5 degrees C for 30 minutes) of banked human milk is the method of choice to eliminate potential viral contaminants such as human immunodeficiency virus, human T-lymphoma virus, and cytomegalovirus, as well as tuberculosis and other bacterial contaminants, while maintaining the greatest possible complement of its unique bioactive factors. This article reviews some of the critical components of human milk and what is currently known about the effects of Holder pasteurization on their biological activity.

Excelência em bancos de leite humano: uma visão do futuro--the First International Congress on Human Milk Banking

The first International Congress of Human Milk Banks--Excellence in Human Milk Banking: A Vision of the Future, held in Brazil in June 2000 and sponsored by the Brazilian Association of Milk Banks, had representation from milk banks in Argentina, Chile, Costa Rica, Venezuela, France, the United Kingdom, and North America as well as Brazil. A recurring theme in the discussion of donor milk banking was the role of each country's milk banks in the promotion and support of breastfeeding. The Brazilian National Reference Milk Bank and the growth of donor milk banking in Brazil over the past 15 years were described, including federal regulation that all milk bank directors be trained and certified. Milk banking systems in France, the United Kingdom, Venezuela and the Caribbean, and North America were also discussed. Similarities and differences in the donor screening process and the regulation of milk banks in the countries is presented.

Maternal drug treatment and human milk banking

We studied prospectively during one year temporary drug use by mothers donating breast milk to assess the problem of drug treatment of donors. Sixty-four of the 284 mothers (22.5%) had to abstain from donating due to medication. The indication was infection in 50/56 treatments (89.3%). Antimicrobial agents were prescribed 44/52 times (84.6%). The channelling of milk from mothers in early phases of lactation to premature and newborn infants was identified as a special risk situation, if mothers on medication are not excluded. The limited number of such donors leads to use of milk unpooled or pooled to small volumes with increased risk for adverse effects to babies as a consequence. We recommend a wash-out period of 5 half-lives of the drug after the last ingested dose. For the majority of drugs in this study, with some important exceptions, a wash-out period of 1 day was sufficient.