|In the spirit of informed choice, Eats On Feets expects full disclosure from every person who participates in sharing breastmilk.|
Donors generally expect recipients to be happy to receive their breastmilk and will appreciate it if recipients value and respect her family time and her milk supply. The amount of milk a donor can supply will fluctuate depending on menstruation, changes in eating and drinking patterns, stress, etcetera. Recipients should not put pressure on donors to provide a set amount of milk, especially in long term arrangements.
Thanking a donor each time a donation is received is important, even when there is a long term arrangement. Honest communication regarding mutual needs is essential. Some donors may have a questionnaire and/or also request blood work. It is important to be open and honest with each other. Willingness to help defer the cost of pumping and storing supplies will always be appreciated. The details of milk sharing arrangements will differ from family to family and may be facilitated with the aid of a written agreement between the two parties.
Eats On Feets does not provide forms for contracts, nor official questionnaires.1 It is between the donor and recipient to arrange for this.
For full informed choice process, our network requires that offers and requests are made by individuals who are the legally or clinically responsible party.2 Siblings, children, grandparents, friends, doulas, breastfeeding counselors, nurses etc. are not legally nor clinically responsible. Legal guardians, donors, recipients, midwives, doctors, etc. are. The exception to this rule is when the third party adds direct contact information in their post in the form of a phone number, email address, FB profile or FB tag for the donor/recipient. This still allows for full informed choice process.
In this section:
- Possible reasons to refrain from using donor milk.
- Questions typically asked of recipients
- Screening donors
- Finding a donor
- After finding a donor
- Questions typically asked of donors
- Handling breastmilk (for recipients)
1. Is there any reason why someone should not request donor milk?
Reasons may include but are not restricted to:
- If they do not want to or if they are feeling coerced,
- If doing so places them at risk of punishment due to religious or social conventions,
- If at any point in the process they feel they cannot participate in making informed choices,3
- If they are unable or unwilling to accept responsibility for their EOF experience,
- If the baby that the milk will be fed to has galactosemia or any other contraindicated disorder,
- If they are an adult requesting for non-verified medical reasons.
2. What questions are typically asked of recipients?
|This list is only a compilation of possible questions. Some donors may ask more or add different questions.|
- How will my milk be used?
- Are you or your baby being treated for any disease, infection or disorder?
- Are you or your baby taking medication?
- Have you and your baby had recent blood work done?
- Would you be willing to have blood work and/or a health screening done?4
- Have you spoken with a health care specialist about your breastfeeding issues?
- Would you like referrals to local resources for breastfeeding support?
- If the donor needs, are you willing to supply breast pump and supplies?
- Who will own the supplies and how should the purchase be handled?
- Are you willing to cover the cost, if any, of donor blood screening?
- Are you willing to reimburse or provide bottles or bags for milk collection and storage?
- Will the donation relationship be ongoing or one-time only?
- How much milk are you expecting/hoping for?
- Will you be supplementing with breastmilk substitutes or from another donor if needed?
- How often and when will you be coming to pick up the milk?
- Do you want all of the milk to be frozen? Would you want fresh, unfrozen milk?
- Would you like your baby nursed by your donor when possible?
- Are you familiar with safe handling techniques for breastmilk?
- Are you educated in at-home heat-treating?
- Do you have any concerns that need to be addressed or researched further?
3. I would like to screen donors. How can I do this?
Screening typically consists of lifestyle/history questions combined with blood tests.
- Donor Disclosure: Ask about the donors health, lifestyle and habits.
- Blood Screen:
- HIV I and II
- HBV (Hepatitis B Antigen & Antibodies –if vaccinated, provide record)
- HCV (Hepatitis C)
- HTLV I and II
Additional screenings to consider:
- TB (Tuberculosis –once, unless exposed, or symptomatic)
- CMV (Cytomegalovirus –IgG and IgM –especially if milk may be fed to a premature baby)
- WNV (West Nile Virus –IgA and IgM)
When full screening is not available, donor health status is unknown, or to reduce the potential risks of exposure to pathogens, breastmilk can be heat-treated. Please see ‘How can breastmilk be pasteurized at home?’ for more information.5
4. I would like to request breastmilk. How do I find a donor?
- Find a local chapter and click on the ‘Like’ button at the top right of the page;
- Check for current offers on the page that may be suitable;
- Post a request on the Wall with some background information regarding location, whether this is an ongoing or temporary need, the age of the child, the best way to be contacted, etc.;
- Check for comments to the request regularly,
- Connect with potential donors via private messages.
For any assistance with posting, please contact the admin of the page via the ‘Message’ button at the top right of the page.
Because Facebook is a public forum, some people prefer to request breastmilk without revealing their identity. Please contact the admin of the page via the ‘Message’ button with the request and background information. The admin will then post the request on the Wall. It, however, remains the responsibility of the person requesting breastmilk to check on the post and follow up on offers.
It is up to donor and recipient to connect with each other, to check in on posts and to follow up with a request.
Not on Facebook:
- Please email us with the request and appropriate background information, including a contact to share. The request will be posted on the relevant Facebook page(s) and donors will make private contact.
If donations are needed on a more regular basis, a Facebook account is suggested as it allows for a more effective connection with donors.
5. I have contacted a donor. How do I proceed?
Discuss with each other how you would like to proceed. Do you want to email a list of questions or ask questions over the phone? Are you a good fit for each other? Do you want to meet in person first? What questions would you like to ask each other? Can you drive to each other? Does the milk need to be shipped? Do you need a pump? Do you want the donor to be screened? Who will cover what costs? Etcetera.
In most cases, Eats on Feets does not personally know the donors, nor does EOF screen them, so it is imperative that you know your source. While it is true that the sharing of breastmilk offers many benefits, the risk of disease/contamination (albeit extremely low) does exist. Therefore caution needs to be exercised, particularly with premature and sick infants.
Remember to practice safe social networking.
6. Do you have suggestions for addressing donors?6
|This list is only a guide and does not imply that all the questions will apply to you or that you should feel restricted from asking other questions. It is up to each recipient family to determine what they are comfortable with.|
- Is there anything that would prevent you from donating safe and healthy breastmilk?
- Have you read the Eats On Feets Resource for Informed Milksharing?
- Do you have any concerns about sharing your milk that you want to talk about?
- Have you ever tested positive for: TB, HTLV I or II, HIV I or II, Herpes Simplex, Hepatitis B or C, or Syphilis?
- Have you had close or intimate contact with anyone infected with any of the above?
- Are you or your sexual partner(s) at risk for HIV?
- Were you born in or have you ever visited any of the following countries: Cameroon, Central African Republic, Chad, Congo, Equatorial Guinea, Gabon, Niger or Nigeria?
- Has a blood relative been diagnosed with Creutzfeldt-Jakob Disease (CJD)?
- Do you have any open sores, blisters, and/or cracks on the skin?
- Would you agree to have your blood screened if requested?
- Would you agree to be tested for TB if requested?
- Have you required hospitalization or blood transfusion the last 12 months?
- Have you ever received an organ transplant?
- Have you received any vaccinations in the last 12 months?
- Do you require insulin to control diabetes?
- Do you have a history of cancer?
- Do you take any prescription medications on a regular basis, including hormone replacement?
- Do you have any general health concerns?
- Does your baby have any general health or weight gain concerns?
- Do you smoke?
- Do you consume more than 3 caffeinated beverages per day?
- Do you drink alcohol? How much and how often?
- Do you use recreational drugs? Which ones and how often?
- Do you use over-the-counter (OTC) medication? Which ones and how often?
- Do you have silicone breast implants?
- Have you had body piercings, tattoos, accidental needle stick injuries, acupuncture, electrolysis or wear permanent make up?
- Do you take megavitamins?
- Do you know how to clean milk collection items?
- Do you know how to safely store milk?
Please read the section ‘Health Considerations’ if you have questions about any of the above.
7. How do I handle breastmilk (for recipients)?
|Always make sure that supplies are clean and wash your hands before handling breastmilk.|
Upon receiving breastmilk, store it in the freezer and/or the refrigerator as it is given, depending on the need.
Regarding raw and fresh milk, Lawrence writes: “Breastmilk can safely stand at room temperature for 6 to 8 hours and need not be discarded if the first feeding attempt is incomplete.”7
Regarding reusing milk after a feeding, Dr. Ruth Lawrence writes: “Whether you can use the remaining milk really depends on how long it sits around. Once the baby takes the bottle, there is a certain amount of saliva that gets in the bottle that creates bacteria and gets saliva enzymes in the milk. This is why it isn’t good to give milk that has been sitting around. But, if it sits for only a half hour or so, this is fine.”8 There can be confusion as to what ‘sits around’ means. Eats on Feets assumes that in this context ‘sits around’ means ‘stand at room temperature.’
See ‘How do I feed the milk to my baby?’ for cleaner and thus safer feeding options.
For raw and fresh (not frozen) breastmilk after refrigeration, this summary states: ” […] When infants do not finish a bottle of expressed breastmilk, doctors recommend unfinished portions be thrown away. This [small –ed.] study examined bacterial levels in expressed, partially consumed breastmilk that was stored for 48 hours at 4-6° C [bold –ed.]. A portion of unconsumed milk was examined as a control. Samples were taken every 12 hours for bacterial analysis. Tests were performed to identify total colony counts, pathogenic Staphylococci, coliforms and b-hemolytic Streptococci. This study showed no significant difference between bottles that were partially consumed and those that were not exposed to the baby’s mouth for 5 out of 6 participants. All milk samples had colony counts in the acceptable range of < 105 colony forming units per milliliter (CFU/ml). Although this project provides evidence that it may be safe to re-feed a child a bottle of breastmilk, due to the small sample size, further tests should be performed.9
Most mothers reheat leftover and refrigerated milk. Dr. Ruth Lawrence writes: “If the milk is warmed up but not used, it is OK to reheat the milk once. But the more you reheat the more you decrease some of the valuable immunologic properties of the milk.”
Regarding previously frozen raw milk, it is generally accepted that thawed milk can be kept in the refrigerator for up to 24 hours. Please see ‘How can breastmilk be thawed?’ for thawing instructions. Most mothers reheat (warm) previously frozen raw milk as well (after a first feeding). It is not advisable to leave previously heat-treated milk out for longer than necessary because heat-treating affects the anti-bacterial properties of breastmilk.
According to the USDA, “Once food is thawed in the refrigerator, it is safe to refreeze it without cooking.” In this protocol, Dr. Anne Eglash, M.D. writes: “At this time, there is little information on refreezing of thawed [fresh –ed.] human milk. Bacterial growth and loss of antibacterial activity in thawed milk will vary depending on the technique of milk thawing, duration of the thaw, and the amount of bacteria in the milk at the time of expression. At this time no recommendations can be made on the refreezing of thawed human milk.”
Breastmilk, previously frozen or not, can be re-frozen after it has been heat-treated. This is the process that milk banks follow: frozen donated breastmilk is pasteurized, after which it is stored in the freezer.
Reusing heat-treated milk
In this study, the researchers discuss that after cooling “flash-heat was successful in completely eliminating bacteria in the majority of samples, and prevented substantial growth for up to 8 h when stored at room temperature”.10
To date, the safety of reheating previously heat-treated milk11 has not, to our knowledge, been studied. It should be noted that most literature speaks in terms of heating expressed milk for feeding but that mothers generally warm the (thawed) milk under running warm water or set it in a container in warm water for a short while to get the chill out of it. Gently warming should not be considered heat-treating. For optimal properties of breastmilk, reheating (warming) milk should not be done directly in a pan on the stove top nor in a container in boiling water on the stove top (which would be heat-treating it unnecessarily). It is suggested however that after a first feeding, milk that was heat-treated not be refrigerated and reheated again.
Please see this chart for length of storage guidelines.
Please also see ‘Handling of breastmilk’ for more information on proper handling and feeding.
II. Additional Information
1. I will not use (all) of the donated milk. What should I do?
It happens that donated milk, especially milk that has been frozen, can develop a taste or smell that some babies do not like. Some of this can be caused by excess lipase. Please read more about this here. This information can also be shared with donors in order to possibly avoid this issue in the future.
It also happens that recipients end up with too much donated milk, or with enough to share with another parent in need.
If the donated milk will not be used, or if a recipient has more than is needed, the breastmilk can be returned to the original donor or donated to someone else. When donating to someone else, it is important that the original donor is asked for permission, and that the new recipient is able to have direct contact with the original donor for full informed choice process.
In order to return bags of milk to donors, or to pass milk on to another recipient, it is important that bags be labeled properly.
Please see Handling Milk for proper handling information.
2. My baby is healthy and has had formula. Can I still ask for donor milk?
Absolutely, and there may be enough donor milk available that breastmilk substitutes could be eliminated altogether.
Eats On Feets does not endorse any order of priority for the sharing of breastmilk. There does not need to be a medical indication for a parent to request or receive breastmilk on the behalf of their child. Requests can be made even if the baby is healthy and/or over the age of 24 months.12
3. Can I use donor milk if I have low supply?
Yes, certainly. It is, however, important to know that ‘low milk supply’ is a misnomer of sorts. There are various reasons why a woman might have supply issues. These reasons may need to be looked at more closely in order to best support a breastfeeding relationship. Most of these issues can be resolved with the help of a lactation consultant and the support of loved ones. How a baby is behaving, how the breasts feel, how strong the sensation of let-down is, or how much can be pumped are not valid ways to determine whether there is adequate supply or not.
Some women have a condition called Insufficient Glandular Tissue (IGT) and it can interfere with lactation and/or lead to lactation failure. For women with IGT, donor milk is a good alternative to supplementing a baby. However, it is important to not jeopardize the possible existing supply because a mother’s own milk is so very valuable to her baby, and should be a priority even if there is only a small amount. A few measures can be taken to ensure the success of a future breastfeeding relationship. One of these is the use of an at-the-breast system as explained in ‘How do I feed the milk to my baby?’.
Low supply can also be the result of a difficult or compromised start of the breastfeeding relationship and/or of the baby’s life (for instance after a cesarean section, a premature baby, postpartum depression). Support with (transitioning to) breastfeeding in these situations need special attention as there may be many emotions involved that could make this difficult. When possible, donor milk with the use of an at-the-breast system while working on stimulating supply at the same time, is a good alternative to supplementing a baby, especially when hoping to exclusively breastfeed in the future. Other feeding options should also be explored before taking recourse to a bottle.
Other causes of supply issues can include but are not restricted to: latching issues, tongue-tie13, feeding on a schedule, bottle feeding/supplementing, medications, pregnancy, maternal illness, infant illness, nipple shields, pacifiers, sleepy baby, etcetera.14
Most causes of low milk supply can be corrected with assessment and timely help from a lactation consultant. Please see ‘Local resources’ for support and referrals if needed.
4. My baby is 4 months old. Can I receive milk from a donor whose baby is 12 months old?
Yes, (pathogen-free) human milk is always preferable, even when there is a difference in age.
Keep in mind, however, that as babies grow and mature, their nutritional needs also change. It is therefore more beneficial for donor breastmilk to either come from a mother whose baby is around the same age or from a mother who pumped when her baby was around that same age.
This study concludes: “Human milk expressed by mothers who have been lactating for >1 year has significantly increased fat and energy contents, compared with milk expressed by women who have been lactating for shorter periods. During prolonged lactation, the fat energy contribution of breast milk to the infant diet might be significant.”
5. Can a woman re-lactate?
The experience of re-lactating varies greatly from one woman to another, but many have been successful in their efforts. Please consult the WHO’s Relactation: review of experience and recommendations for practice for more information on how to proceed. Please refer to local resources for more information and support.
6. Can a woman lactate if she has never breastfed before, as in induced lactation?
It is possible to induce lactation when adopting a baby or if a baby was born via a surrogate. Some women who induce lactation will need to supplement with donor milk. For assistance with induced lactation, please see a lactation consultant and/or a health care professional.
Please consult this website for more information.
7. Where can I find breastfeeding support?
Please see this list of local resources to find the help and support needed. Additionally, donors, other experienced moms and family members may also be able to provide advice and support. We entertain the idea that in some situations it takes a village to breastfeed a child.
8. How can I thank my donor?
While Eats On Feets does not support the selling of or paying for breastmilk, a recipient is free to thank her donor in any way s/he feels is fitting and is accepted by the donor. One of the best ways someone can thank their donor is through respectful actions. Donating breastmilk is an act of kindness, and it involves time, commitment and love. The most rewarding aspect of milk sharing is perhaps the relationships that form between families. This is priceless.
9. My sister (friend, relative, etcetera) has offered to wet nurse my baby. Is this ok?
Milk sharing and wet-nursing are and have been common practices across all cultures and socioeconomic situations. All the information here can be applied to wet-nursing. One thing to keep in mind is that it can sometimes be more difficult to have an open discussion about risks with people we are close to. It is thus important to use the same discernment with a relative or friend as we do with strangers. Feelings may need to be considered closely to make sure a potential wet-nurse does not feel obligated to help because of the relationship. Wet-nursing (and/or milk sharing) by a close friend or relative can be a very satisfying experience for everyone involved.
10. What about premature babies?
When a baby is born prematurely or very prematurely, there are specific issues that need to be addressed regarding nutrition and protection from infections.
At first, premature babies can have difficulty tolerating any food that is introduced to its delicate system. The adaptation to normal feeding can pose problems for various reasons and until proper digestion is established, these babies receive nutrients via an intravenous line.15
Mother’s own milk
When a baby is able to digest breastmilk, the best food for a premature baby is raw, unpasteurized milk from his or her mother. In ‘Optimal feeding of low birth weight infants, the WHO writes: “There is strong and consistent evidence that feeding mother’s own milk to pre-term infants of any gestation is associated with a lower incidence of infections and necrotizing enterocolitis, and improved neurodevelopmental outcome as compared with formula feeding.” The benefits of breastmilk and its anti-infective components have been well established and is especially important for the protection of preterm infants. Please see ‘Why breastmilk?’ for more information on the antimicrobial properties of breastmilk.
Every effort needs to be made by the hospital staff to encourage and support the mother of a preterm baby to express her own milk. Separation, stress, fatigue and the possible precarious condition of the infant can affect milk production. Counseling mothers of preterm infants has been shown to increase the incidence of breastmilk feeding.16 In ‘Optimal feeding of low birth weight infants,’ the WHO concludes that when mothers are involved in the care and feeding of LBW infants, “substantial benefits in terms of improved breastfeeding rates and early discharge from hospital were reported when mothers participated in the care and feeding of their LBW infants in neonatal units.”
In ‘Sample Hospital Breastfeeding Policy for Newborns’ the American Academy of Pediatrics (AAP) writes that “Mothers who deliver prematurely may not be aware of the benefits of human milk for their preterm newborns and commonly base their decisions on health-related issues. Staff (physicians and nurses) will therefore stress the protective properties of breast milk and recommend mothers provide breast milk without necessarily making the commitment to breastfeed.”
The AAP further writes that “The first postdelivery [sic] encounter with the physician, or as soon as it is appropriate, should include discussion of human milk, its role in the preterm newborn’s care, and the urgency to begin expressing or pumping.” The AAP considers it to be the responsibility of the nursing staff to initiate and maintain an expressing or pumping routine. Per 3231 Breastfeeding: “The frequency and duration of milk expression directly correlates to the amount of milk produced. The mother should pump every 2 or 3 hours to mimic a baby’s natural feeding pattern. A tentative goal of 750-1000 ml per day by 10 days postpartum will help her maintain her milk supply throughout lactation.”
A recent study has investigated “the safety and feasibility of oropharyngeal (directly via the mouth between the gum and the cheek) administration of own mother’s colostrum drops to ELBW infants in a clinical setting.” Using mother’s colostrum in this manner requires a change in thinking, to view colostrum as a potential immune therapy and not simply as a feeding. As such, the oropharyngeal administration of colostrum can be an alternative to NPO (nothing by mouth/nil per os) status and/or a complement to trophic feeds in the first days of life for the ELBW infants.
The authors conclude: “Oropharyngeal administration of own mother’s colostrum is easy, inexpensive, and well-tolerated by even the smallest and sickest ELBW infants. Future research should continue to examine the optimal procedure for measuring the direct immune effects of this therapy, as well as the clinical outcomes such as infections, particularly ventilator-associated pneumonia.”
The amount of milk a premature baby needs is very small. However, when a mother of a premature baby is not able to express (enough of) her own milk, because of the optimal quality of breastmilk, donor milk should be obtained instead of taking recourse to breastmilk substitutes.
This perinatal and maternal-child health course for medical professionals states that studies have documented the following health benefits for preterm infants fed human milk:
- “Decreased incidence and/or severity of a wide range of infectious diseases
- Decreased post-neonatal infant mortality rates
- Decreased rates of SIDS in the first year of life
- Reduced incidence of both type 1 and type 2 diabetes, lymphoma, leukemia, Hodgkin’s disease, overweight and obesity, hypercholesterolemia, and asthma.”
Donor milk can be obtained via milk banks or from private donors (even though many hospital staff may refuse the latter). The donor guidelines from the Human Milk Bank Association of North America (HMBANA) and the National Institute for Health and Clinical Excellence (NICE) are very specific, mainly in order to protect sick and premature babies receiving this donor milk. Private donors can be screened to reduce exposure to pathogens, and the milk can be pasteurized if necessary. Please see ‘How can breastmilk be pasteurized at home?’ for more information on how to heat-treat. Please consult with specialized care provider if considering donating breastmilk to a premature baby.
There are always risks associated with feeding a baby anything other than his or her own mother’s breastmilk. When considering donor milk, parents are balancing the benefits of superior nutrition and immunity against the risk of disease transmission. Even after donor milk is screened, some argue that pathogens can still remain17 in the milk, and after donor milk has been pasteurized, pathogens can (re-)contaminate milk. Please see ‘Are there risks to using donor milk?’ for more information.
Risks of heat-treating
While milk banks are available for premature (or ill infants) in various countries, using banked milk is not always a possibility for parents because of lack of accessibility18 or lack of availability. Also, with proper screening, raw and fresh (not frozen) when possible is a better option for babies. In some countries, like Norway, milk banks have a long tradition of using raw breastmilk, even for premature babies. Screening and testing ensures the safety of this milk, rendering pasteurizing obsolete.
Most milk banks use the Holder method (62.5°C for 30 minutes) to pasteurize all breastmilk. It is the method used in the studies below. Studies show that pasteurizing breastmilk has potential health consequences for premature babies. Below are a few considerations that are especially important for premature infants, though they affect term infants as well.
Lactoferrin is an iron-binding protein with antimicrobial activity and is part of the natural defense of the body. Lactoferrin is found in milk and many mucosal secretions such as tears and saliva.
Lactoferrin is significantly affected by the Holder method of pasteurization. This La Trobe table compares the effects that different heat-treating and storage techniques have on breastmilk. As opposed to the Holder method which can destroy as much as 60% of the lactoferrin, flash pasteurization19 (72oC for 15 seconds) keeps the amount of lactoferrin intact which, as per Nutritional and physiologic significance of human milk proteins, is extremely important for (preterm) babies because it:
- assists in the digestion and utilization of nutrients from the milk, as well as
- contributes “to the defense of breastfed infants against pathogenic bacteria and viruses”;
- regulates immune functions, and
- is “likely to be involved in the development of the intestinal mucosa and other organs of newborns.”
In other words, lactoferrin assists in providing adequate nutrition to breastfed infants while simultaneously aiding in the defense against infection, and facilitating optimal development of important normal functions in newborns.
Regarding lactoferrin and flash-heating, this study writes: “The nutritional results were encouraging. The substantial decreases in the overall amount of lactoferrin observed with FH [flash-heating] and PP [Pretoria Pasteurization] may be attributable to partial denaturation of the lactoferrin, […] It is likely that such denaturation does not impair the biologic activity of lactoferrin.”
Flash-heating as well as flash pasteurizing would therefore be better options for the heat-treatment of breastmilk. Please see ‘Flash-heating’ for more information.
Lipase is an enzyme secreted in the digestive tract that causes the breakdown of fats into individual fatty acids that can be absorbed into the bloodstream.
This study evaluates whether pasteurizing milk (Holder method) reduces fat absorption and growth in Very Low Birth Weight (VLBW <1500 grams) infants. The authors conclude: “Feeding preterm infants pasteurized as compared to raw own mother’s milk reduced fat absorption. When the infants were fed raw milk, they gained more in knee–heel length compared to when they were fed pasteurized milk.”
Fats are not only important for energy and growth. They are also important for brain development. To develop the high-quality myelin needed for the nerves to transmit messages to other nerves throughout the brain and body, the body needs certain types of fatty acids –linoleic and linolenic– which are found in large amounts in human milk.20
The course for perinatal and maternal-child health states: “Lipase in human milk complements the low level of pancreatic lipase in infants, especially premature infants.” Lipase aids in the absorption of fats and is unfortunately mostly deactivated by all heat-treatment.
The authors of the above course also write that the milk of mothers of preterm babies is significantly different from that of mothers who deliver at term. Part of the reason that preterm milk is so important for premature babies and fat absorption is because “The lipids in human milk also provide nutritional benefits. The fat globules in preterm milk are smaller, aiding in their absorption directly from the immature gut. Premature infants lack the enzymes and bile salts needed for digestion of fats. However, they absorb more than 90% of the fats in human milk.”
Lack of lipase in pasteurized milk also has an impact on a premature baby’s immune response: the acetic acid produced by milk lipases act against lipid-enveloped viruses, bacteria and fungus.21 “Milk lipids provide an example of how an integral milk component can serve both a nutritional and a protective function.”22
Lipase is deactivated by heat-treatment, and therefore raw, fresh (not frozen) when possible, properly screened and handled breastmilk is a better option when available.
Immunoglobulins are a class of proteins produced in lymph tissue that function as antibodies in the immune response.
The study ‘Immunologic Factors in Human Milk: The Effects of Gestational Age and Pasteurization’ (Holder pasteurization) concludes “that although all factors analyzed had a significant reduction after pasteurization, total protein and IgA retained appreciable concentrations, especially in colostrum from mothers of both preterm groups, indicating that pasteurized preterm milk can be a beneficial alternative for feeding the preterm infant. Higher concentrations of proteins, IgA, and IgG in raw milk of the mothers of more preterm infants may be a compensatory protective mechanism for these babies, [bold –ed.] and a great effort should be made to feed the preterm with his or her own mother’s milk.”
This study on flash-heat treatment and immunoglobulins concludes: “Most breastmilk immunoglobulin activity survives FH, suggesting flash-heated breastmilk is immunologically superior to breastmilk substitutes. Clinical significance of this decreased immunoglobulin activity needs evaluation in prospective trials.”
Again, raw, fresh (not frozen) when possible, properly screened and handled breastmilk is a better option when available.
Flash pasteurizing has been demonstrated to inactivate most pathogens while maintaining high levels of lactoferrin, vitamins and immunoglobulins. Flash-heating has also been shown to deactivate HIV, and to be very beneficial in maintaining high levels of lactoferrin, vitamins and immunoglobulins.23 Flash pasteurizing would be a better way than the Holder method to render breastmilk safe for term and preterm babies alike. More research is needed in order to assess the effects of flash-heating on deactivating pathogens other than HIV. Please see ‘Flash-heating’ for more information. Eats on Feets is hoping to find sponsoring for future research on flash-heating with regards to the deactivation of those other pathogens. Raw, fresh (not frozen) when possible, properly screened and handled breastmilk is a better option when available.
In Donor Milk: What’s in It and What’s Not from the Journal of Human Lactation, the authors review some of the critical components of human milk and what is currently known about the effects of Holder pasteurization on their biological activity. Their conclusion is: “There are still more questions to be answered with regard to optimal nutrition for the preterm and very low birth weight infant. Preservation of the unique components of human milk during storage of mother’s own milk, storage and processing of donor milk, and the most effective fortification methods for human milk to meet the extraordinary needs of preterm infants are important areas for continued investigation. Our current state of knowledge indicates that human milk is optimal for full-term, as well as preterm infants, although any milk may require fortification to meet the special nutritional needs of the very low birth weight infant.”
In ‘Optimal feeding of low birth weight infants,’ the WHO writes that some studies suggest that donor milk from mothers of full-term infants cannot foster the same growth rate as mother’s own milk in preterm infants. Age-specific milk for preterm babies is therefore deemed important, and when possible, milk banks process this milk separately. Per ‘Avery’s Neonatology: Pathophysiology & Management of the Newborn,’24 “Most milk donated to milk banks comes from mothers who have delivered at term. However, they do receive milk from preterm mothers. Preterm and full term milk is processed separately. Donor and preterm milk can be specifically requested, and if available will be shipped to you.”
However, according to this study, “some of these studies were done on donor ‘drip milk,’ or milk collected from the dripping of the opposite breast while the donor was breastfeeding her own full term infant. Drip milk has long been recognized to have lower fat content than expressed or pumped milk, since there is no active removal of the hind milk. There is also some question with regard to whether weight gain is the best measure of optimal outcome. One large study found that even with slower weight gain, the human milk fed preterm infants had significantly higher IQ scores at school age. Most donor milk banks today recognize the importance of using milk actively expressed or pumped to optimize fat content. Additionally, milk from mothers of preterm infants (gestational age 36 weeks or less) is designated as preterm milk for the first 4 weeks of pumping. It is processed in special batches, since it is higher in protein which is important for the preterm infant. Because mothers of preterm infants are being more actively encouraged to provide milk for their own babies, often they have excess to donate25 when their babies go completely to breast.”
For the purpose of making informed choices and in consideration of the above information, we encourage recipients (as well as donors) to research their options, to investigate milk bank procedures regarding heat-treatment, storage,26 distribution27 and usage,28 and to weigh the pros and cons of receiving milk from private donors or from a milk bank.
A note needs to be made about Bacillus cereus. B. cereus is a sporeforming bacterium that is found in nature (soil, crops, water) and causes food poisoning. Please see section ‘Bacteria’ for more information regarding Bacillus cereus.
The addition of human milk fortifiers (HMF) to breastmilk for Low Birth Weight (LBW) and Very Low Birth Weight (VLBW <1500 grams) babies also deserves a closer look. Please see ‘What about fortifiers and premature babies?’ for more information.
Please read this section about the suggested blood tests for donors and consult with a health care provider to see if privately donated milk is an option.
11. What about fortifiers and premature babies?
Human Milk Fortifiers (HMF) are added by NICUs to breastmilk that is intended for Low Birth Weight (LBW<2500 gram), Very Low Birth Weight (VLBW <1500 grams) babies, and Extremely Low Birth Weight (ELBW <1000 grams) babies.29 These fortifiers can be bovine-, soy- or human-milk based. Most HMF used in NICUs are bovine based. However, due to concerns with powdered formula and HMF, many NICUs use a mixture of liquid preterm formula or various commercial protein powders and minerals compounded in the hospital pharmacy.
The current practice of adding fortifiers to milk for LBW, VLBW and ELBW infants is based on studies which, as per Lauwers and Swisher in ‘Counseling the Nursing Mother,’ “have shown that human milk does not provide sufficient nutrition for preterm infants, especially VLBW (under [sic] 1500 grams).”30 They add: “At issue are the calcium and phosphorus requirements for the VLBW baby’s bone growth. Without enough of these minerals, VLBW babies are at risk for osteopenia of prematurity, decreased bone mineral content that occurs mainly because of lack of adequate calcium and phosphorus intake. VLBW babies also require higher amounts of fat-soluble vitamins because they have not laid down adequate stores before birth.
One solution is to supplement the baby with human milk fortifiers (HMF), which has improved short term weight gain and linear and head growth in preterm babies over infants not fed HMF.”
While the addition of HMF has improved short term weight gain and linear head growth in preterm babies over those who were not fed HMF, according to Kushel and Harding, there is insufficient data to evaluate long-term neuro-developmental and growth outcomes in preterm babies receiving fortifier.
Some studies exist that indicate possible issues with fast weight gain in preterm infants. For instance, fast weight gain can put premature babies small for gestational age at risk for central adiposity and insulin resistance later in life.
It is important to remember that individual care plans are important when caring for the preterm infant. There are many factors to look at in regards to deciding each infant’s care. Discussions with the NICU team is important, as well as finding lactation support from a qualified lactation consultant. Availability of mother’s own milk, donor milk, gestational age, and medical needs will all play a part in planning the care of the infant.
In ‘Optimal feeding of low-birth-weight infants,’ regarding multicomponent fortification, the WHO recommends: “The findings of this review raise doubts on the routine use of multicomponent fortifiers, particularly in developing countries. The benefits appear to be only short-term increases in growth, the safety is uncertain, and could be of more concern in developing countries with a greater risk of contamination. Further research in developing countries is needed to examine the role of multicomponent fortifiers. Meanwhile, their use should be restricted to infants <32 weeks gestation or <1500 g birth weight who fail to gain weight despite adequate breastmilk feeding.”
Liquid versus powdered fortifiers
One concern about added liquid (bovine or soy) fortifier is laid out in ‘Optimal feeding of low-birth-weight infants’ (p.18). The WHO writes: “Liquid fortifiers are for use in a 1:1 ratio with human milk and contribute a significant proportion of the infant’s fluid intake. Although they are designed to contain adequate quantities of all essential nutrients, mixing the mother’s own milk with an equal volume of liquid fortifier dilutes the constituents of the human milk, including nutrients, growth factors and anti-infective properties.”
About powdered fortifiers, the WHO writes: “Powdered fortifiers may be insoluble in human milk, and unless the fortifier-milk mixture is well shaken, the nutrients may not be available for absorption.”
These studies do not, however, address the use of liquid fortifier made from human milk.
In ‘Effects of Powdered Human Milk Fortifiers on the Antibacterial Actions of Human Milk,’ the researchers conclude that the antibacterial action of breastmilk against E. coli, Staphylococcus, Enterobacter sakazakii, and Group B Streptococcus (GBS) is removed by the addition of iron and fortifiers that contain iron to the breastmilk.
In this research, Richard Quan, et al., say about the effect of nutritional additives that “All cow-milk formulas enhanced E. coli growth; soy formulas and other additives preserved inhibition of bacterial growth. Nutritional additives can impair anti-infective properties of human milk, and such interplay should be considered in the decision on the feeding regimen of premature infants.”
Human-milk based fortifiers
A solution to the above issues may lie in human-milk based fortifiers, fortifiers made out of human milk. In this study, the authors conclude that “Breastmilk from women who have delivered preterm has antibacterial activity that can be affected by the addition of bovine-based fortifier, but not by the addition of a human breastmilk-based fortifier.”
In this study, the authors conclude that “an exclusively human milk-based diet is associated with a lower rate of necrotizing enterocolitis than a diet of human milk and bovine milk-based products.”
The researchers of the above study did not set out to demonstrate that necrotizing enterocolitis (NEC) was reduced when premature babies were fed human milk, and therefore the methods used in this study to show these results are in question. It is added here because these preliminary results are of interest as more is being done in the realm of human-milk based fortifiers.
As a viable alternative to fortifiers, many breastfeeding advocates propose ‘lactoengineering’ for preterm infants as opposed to fortifiers. The Nursing Center states: “Milk fat rises as the breast is emptied. For the healthy breast-fed infant who takes in a volume that represents most of what his or her mother produces, this fact is not relevant. However, for the mother of a VLBW infant, whose infant consumes only a small fraction of her daily output, special lactoengineering strategies may be warranted. Hind milk, the higher fat milk obtained several minutes following milk ejection, has been shown to enhance growth rates when fed to the VLBW infant. When it is known that the mother’s daily milk volume is more than double the infant’s daily volume needs, special instructions can be given for the collection and feeding of hind milk […]. A creamatocrit, the length of the cream column separated from milk by centrifugation and expressed as a percentage of the length of the total milk column, can be performed when an accurate measure of the lipid content is required.”31
When it comes to adding fortifiers or other additives to breastmilk or not, there seem to be as many practices as there are NICUs. Controversy exists about many common and current practices.
In 2004, Kuschel, CA and Harding, JE write that it is unlikely that further long-term studies evaluating fortification of human milk versus no supplementation will be performed. They add that it was found unethical to withhold phosphorus supplementation in control infants and that other studies since then have also supplemented the control groups.
They further say that future research should be directed toward comparisons between different proprietary preparations and evaluating both short-term and long-term outcomes and adverse effects, in search of the ‘optimal’ composition of fortifiers, but that the number of study subjects required to adequately evaluate these outcomes would be extremely large.
From the Nursing Center: “The value of breast milk and breast-feeding for preterm infants is well established. The challenge for NICU staff is to provide mothers with the necessary tools and support to provide this precious product and facilitate the establishment of this special relationship. As careful attention is given to other aspects of the NICU environment and standards of care, consideration of the lactation needs of the mother as an extension of her infant’s care are required. Critical review of current NICU policies and procedures should be performed to ensure the avoidance of hospital-induced obstacles to the successful provision of expressed breast milk and breast-feeding for preterm infants.
Analysis of the available studies on the nutritional needs of preterm infants is hampered by the many variables involved, chief amongst them being the question of post-conceptional age (PCA). Most older studies do not indicate whether the PCA of the infants being studied is the same. While more recent studies typically provide more information on the infants’ PCA, it frequently remains difficult to evaluate the methodology used to gather all data, especially when comparing multiple studies. Therefore the extent of PCA’s statistical significance remains unclear. In addition, the outcome of these nutritional studies may be further influenced by factors such as gut maturation, NICU policies based on gestational age or weight, and the varying medical needs of individual infants. Clearly this is an area that calls for further research in order to deepen our understanding.”
- The suggested questions we offer are typically asked of donors by milk banks. The are not meant to be used as an official EOF questionnaire. [↩]
- Someone licensed to provide independent health care [↩]
- For example, some donors may ask for the recipient to have their blood tested. [↩]
- Establishes baseline of health for caregivers (mother) and donor, should baby ever become sick, and fair trade of personal information. [↩]
- The screening of donor milk by milk banks includes post-pasteurization testing for bacteria and virus. This type of testing is not possible in a home setting without the proper tools. [↩]
- Most of the following questions are normally asked by milk, blood and tissue banks during the donation process. Please keep in mind that since milk banks cater primarily to premature and sick infants who can be more sensitive to substance exposure (medications, herbal products, tobacco products, alcohol, and recreational drugs), their questions are very in depth. [↩]
- Lawrence, Ruth. Breastfeeding, A Guide for the Medical Profession. P. 438. Print. [↩]
- Using alternative feeding options to a bottle and/or using small amounts at a time avoids waste and contamination. [↩]
- Brusseau, R. Bacterial Analysis of Refrigerated Human Milk Following Infant Feeding. May 1998. Web. [↩]
- Per the study “Flash-heated and unheated samples were stored at 2–8oC [35oF–46oF –ed.] overnight to be processed for microbiology assays the next morning, 18–24 h after collection. At this time, both flash-heated and unheated aliquots were placed at room temperature (23C) [73oF –ed.] and allowed to stand, in capped vials, for up to 8 h.” [↩]
- This can be the case if a donor heat-treats the milk because of high lipase or after a recipient heat-treats the milk and there is milk left over after a feeding for instance. [↩]
- In ‘Global Strategy for Infant and Young Child feeding’, bullet 10, p. 14, the WHO states: “Breastfeeding is an unequalled way of providing ideal food for the healthy growth and development of infants; it is also a part of the reproductive process with important implications for the health of mothers. As a global public health recommendation, infants should be exclusively breastfed for the first six months of life to achieve optimal growth, development and health. Thereafter, to meet their evolving nutritional requirements, infants should receive nutritionally adequate and safe complementary foods while breastfeeding continues for up to two years of age or beyond.” [↩]
- For information on tongue-tie see here. [↩]
- Please also see this article ‘Protocol to Manage Breastmilk Intake’ for more information. [↩]
- In some cases, mothers and donors have improved the response of preterm babies to non-umbilical feeding by going on a restrictive diet and eliminating: gluten, dairy, nuts, chocolate, soy, corn and other known allergens. [↩]
- Sisk PM, Lovelady Ca, Dillard RG, Gruber KJ. Lactation counseling for mothers of very low birth weight infants: effect on maternal anxiety and infant intake of human milk. Pediatrics. 2006;117(1):e67-e75. [↩]
- Screening tests are designed to have a relatively high incidence of false positives in order to prevent any false negatives. While false positives happen to many people, pregnant or recently pregnant women tend to get them more frequently. From the perspective of a milk bank which will be testing the donors on a regular basis, it makes sense to exclude anyone with a history of false positives since the cost of pursuing confirmations at every testing opportunity is not only prohibitive for a non-profit org, it also can lead to logistical issues with the milk received from the donor. The study ‘Retrospective review of serological testing of potential human milk donors’ does not include follow up on the actual serological status of these women but, even per the most optimistic values, it is quite likely that many of these women did not in fact have any current infections. [↩]
- In the US, for instance, donor milk has a processing fee of around $4.50 per ounce of milk while insurance companies only cover donor milk when it is medically necessary. Donor milk is usually only available by prescription. In some countries, logistics may make it impossible to obtain breastmilk (distance, lack of dry ice, etc). [↩]
- Flash pasteurizing is not to be confused with flash-heating. While flash-heating has shown to deactivate HIV, the research has not addressed other pathogens, except theoretically. See ‘Flash-heating’ for more information. [↩]
- Per Ask Dr.Sears, Self-digesting fats. [↩]
- Per Riordan, Jan. Breastfeeding and Human Lactation. Third Edition 2005. p.105. Print. [↩]
- From ‘Human Milk Inactivates Pathogens Individually, Additively, and Synergistically’ [↩]
- See ‘How can breastmilk be pasteurized at home?’ for more information. [↩]
- Martha D. Mullett, and Mary M.K. Seshia. Avery’s Neonatology: Pathophysiology & Management of the Newborn. By Mhairi G. MacDonald. Sixth Edition ed. Lippincott Williams & Wilkins, 2005. 427. Print. [↩]
- When mothers of premature babies are counseled to increase their milk production in the first week or two after delivery they will be producing enough milk for a full term infant. This will be more than their infant can consume at that time, but will ensure that their milk production will meet the needs of their infant once the infant is discharged. [↩]
- BPNI writes: “Unless the milk being stored is for a mother’s own infant, banked milk is then pooled. […] It is thought to be beneficial because it averages out the immunological and nutrient content of the milk. The numbers are kept low so that any contamination can theoretically be traced back to its source. In Germany, however, pooling is not used because of the concern regarding contamination.” [↩]
- Not everyone who needs breastmilk will necessarily be able to obtain breastmilk from a milk bank. Please see this information from the FDA and this informationfrom the Utah Breastfeeding Coalition about the priorities of milk banks in the US. [↩]
- Proper feeding options are important to reduce contamination of donor milk and infections in the infant. See ‘Are there risks to using donor milk?’ for more information. Also, donors should know that some milk banks serve for-profit companies. [↩]
- ELBW babies also tend to be the earliest gestation, usually < 27 weeks. [↩]
- Lauwers, J., and Swisher, A. Counseling the nursing mother: a lactation consultant’s guide. p. 467. 2005. Print. [↩]
- Some doctors (Lucas, UK) and researchers however say that this method has not been well researched to give accurate cream count. [↩]