Requesting milk can be a wonderful, safe, and viable way to support your baby’s exclusive breastfeeding needs and support breastfeeding for 2 years and beyond as recommended by health agencies.

In the spirit of informed choice, Eats on Feets encourages 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 their family time and their 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 milksharing 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 or official questionnaires.¹ It is between the donor and recipient to arrange for this.

For the full informed choice process of donors and recipients and for page transparency, 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, etcetera are not legally nor clinically responsible. Legal guardians, donors, recipients, nurse practitioners, midwives, doctors, etc. are.

The basic steps for requesting and receiving donor milk are:

1. Possible reasons to refrain from using donor milk
2. Questions typically asked of recipients
3. Screening donors
4. Finding a donor
5. After finding a donor
6. Questions typically asked of donors
7. Handling breastmilk (for recipients)

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 Eats on Feets™ 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.

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
Are you willing to cover the cost, if any, of donor blood screening?
Are you willing to 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?

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 donor’s 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
- Syphilis

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

I would like to find a donor. How can I do this?

Requests for donor milk must be made by the parent, the court-appointed legal guardian/caretaker, or by someone who is licensed to provide medical care for the baby. Otherwise, in order to request milk for someone else please message the page for accommodation.

On Facebook:

Find your local Eats on Feets Facebook chapter and click on the ‘Like’ button for that page.
Check the “Community” wall of the chapter, or join the featured community group if there is one, for current offers. Respond to the posts that suit your situation and let the poster know in the comments that you sent them a private message so they know to look for it in their Message Requests folder. Please practice safe social networking and do not share private information. Our pages and community groups are public.
If you do not find a current post that is suitable to you, post your request on the page (via the “Posts” tab if you are using your phone) or in the group if there is one. On a page, your post will be visible on the “Community” wall and will be shared to the “Home” wall by our admins within 24 hours. Please include some background information regarding your location, whether this is an ongoing or temporary request, the age of your child, any special diet considerations, the best way to contact you, etc.
Regularly check for comments on your post and on the page’s repost. Facebook may not send you notifications. It is up to donors and recipients to connect with each other, check in on their post, and follow up with potential leads.
If you have not received a response to your post, please post again as often as needed. Please feel free to also post on your area’s neighboring page(s) if close enough to you.
Please send a message to your local page if you need further assistance.

For any assistance with posting, please message the page.

Because Facebook is a public forum, some people prefer to request breastmilk without revealing their identities. If your chapter has a group, you can make an anonymous post yourself. If your chapter does not have a group, please message the admin of the page with your request, and add background information and a preferred method of contact. The admin will then post the request for you. It, however, remains the responsibility of the person requesting breastmilk to check on the post and follow up on offers.

Please also post on chapters of neighboring states or message the Eats on Feets Home page if there is no chapter in your area.

It is up to the donor and recipient to connect with each other, check in on posts, and follow up with each other.

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.

For frequent requests, a Facebook account is suggested as it allows for a more effective way for families to connect.

I have contacted a donor. How do I proceed?

Discuss with each other how you would like to proceed. Does someone have a small donation or a recurring amount for you? 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? How far away do you live? 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.

It is also important to discuss what your donor would like you to do with their milk if your baby will not take it or if you have more than you need. In order for you to pass on someone else’s milk, it is not enough for you to have their permission. In order to offer this milk on our network, we require the name and contact information of the original donor so that we can make a post and the new recipient can contact the original donor directly for their own full informed choice process.

In most cases, Eats on Feets does not personally know the donors, nor does Eats on Feets 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.

Do you have suggestions for addressing donors?

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.

Questions that can be asked of donors:⁶

Is there anything that would prevent you from donating safe and healthy breastmilk?
Have you read the Resource for Informed Breastmilk Sharing?
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 in 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 makeup?
Do you take megavitamins?
Do you know how to clean milk collection items?
Do you know how to safely store milk?

How do I handle breastmilk (for recipients)?

How do I handle human milk is a question we get a lot, especially from new recipient families. Below is some information that covers various situations specific to recipients.

Ensure that supplies are clear and wash your hands before handling human milk.

Upon receiving human milk, store it in the freezer and/or the refrigerator as it is given, depending on the need. If the donor has not already done so, it is suggested that bags be labeled with the name, date, and phone number of the donor(s). This is to ensure that milk can be returned or a donor can be contacted if need be.

Fresh milk
Fresh human milk can safely stand at room temperature for 6 to 8 hours and need not be discarded if the first feeding attempt is incomplete.⁷

After feeding
Regarding reusing milk after a feeding, Dr. Ruth Lawrence writes that “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.’⁹

After refrigeration
Doctors recommend unfinished portions of expressed milk be thrown away when infants do not finish a bottle.¹⁰ A small study that examined bacterial levels in expressed, partially consumed breastmilk that was stored for 48 hours at 4-6° Cº 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.¹¹

Most parents or caretakers reheat leftover and refrigerated milk. 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.¹²

After freezing
Regarding previously frozen raw milk, it is generally accepted that thawed milk can be kept in the refrigerator for up to 24 hours. Most caretakers 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 the food is thawed in the refrigerator, it is safe to refreeze it without cooking.¹³ The ABM protocol states that there is little information on refreezing thawed 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 number 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.¹⁴

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
Research shows 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.¹⁵

To date, the safety of reheating previously heat-treated milk¹⁶ 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 caretakers 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 stovetop nor in a container in boiling water on the stovetop (which would be heat-treating it unnecessarily). However, it is suggested that after a first feeding, milk that was heat-treated should not be refrigerated and reheated again.

I will not use (all) the donated milk. What should I do?

There are a few situations where it can happen that the donated breastmilk cannot or will not be used.

Expressed breastmilk, 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 but there are other reasons for this to occur. Please read more about breastmilk developing a strange taste and/or smell here.¹⁷

It also happens that recipients end up with too much donor 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 the 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.

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 behalf of their child. Requests can be made even if the baby is healthy and/or over the age of 24 months.¹⁸

Can I use donor milk if I have low supply?

Yes, certainly. It is, however, important to know that the term low milk supply is a misnomer of sorts. There are various reasons why someone 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 a let-down is, or how much can be pumped are not valid ways to determine whether there is adequate supply or not.

Some have a condition called Insufficient Glandular Tissue (IGT)¹⁹ and it can interfere with lactation and/or lead to lactation failure. For those with IGT, donor milk is a good alternative to supplementing a baby. However, it is important to not jeopardize the possible existing supply because one’s own milk is so very valuable to the baby and should be a priority even if there is only a small amount. A lactation professional is able to assist with this.²⁰

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, or postpartum depression). Support with (transitioning to) breastfeeding in these situations needs 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.²¹

Other causes of supply issues can include but are not restricted to: latching issues, tongue and lip ties,²² feeding on a schedule, bottle feeding/supplementing, medications, pregnancy, illness, infant illness, nipple shields, pacifiers, sleepy baby, etcetera.²³ Most causes of low milk supply can be corrected with assessment and timely help from a lactation consultant.²⁴

Can I receive milk from a donor whose baby is not the same age as mine?

Yes! When possible, (pathogen-free) human milk is preferable even when there is a difference in age.²⁵

Keep in mind that as babies grow and mature, their nutritional needs also change. It can, therefore, be more beneficial for donor breastmilk to either come from someone whose baby is around the same age or from someone who pumped when her baby was around that same age. 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 breastmilk to the infant’s diet might be significant.²⁶

Can someone re-lactate?

Someone who has stopped lactating, recently or in the past, can resume the production of milk for their own or an adopted infant, even without a further pregnancy. The experience of re-lactating varies greatly from one person to another, but many have been successful in their efforts.

Re-lactation can be desired in many situations such as the illness of a young child or the lactating parent, intolerance to artificial milk, emergency situations, or the death of the lactating parent. Re-lactation can be a potentially life-saving measure.²⁷

Please refer to local resources for more information and support.

Can someone lactate if they have 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. Someone who induces lactation will most likely need to supplement with donor milk. For assistance with induced lactation, please see a lactation consultant and/or a healthcare professional.

There are protocols designed to prepare someone’s breasts for making breastmilk just as happens during pregnancy. These protocols are often more effective in inducing lactation than pumping and stimulating the breasts alone and/or putting the baby at the breast when baby arrives.²⁸

Where can I find lactation support?

Please see this list of possible resources to find the help and support needed. With regard to lactation professionals, there can be vast differences in training and expertise. Not every lactation consultant is an IBCLC. IBCLCs are International Board Certified Lactation Consultants who work in lactation clinics attached to hospitals and/or in private practice. They are healthcare professionals who specialize in the clinical management of breastfeeding. IBCLCs are certified and regulated by the International Board of Lactation Consultants Examiners. Find/verify an IBCLC.

Additionally, donors, other experienced parents, 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.

That said, our chapter pages on Facebook are not the place to share advice or suggestions. This needs to be done privately. Our pages are public and the nature of offers and requests can be potentially delicate. Our chapter pages are simply for posting offers and requests.

How can I thank my donor?

While Eats on Feets does not support the selling or buying of breastmilk, a recipient is free to thank their donor(s) in any way they feel is fitting and is accepted by the donor(s). 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 milksharing is perhaps the relationships that form between families. This is priceless.

Eats on Feets has some lovely cards you can download and print or send to a printer. These were made by some of our volunteers! Click on the card for more.

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 milksharing) by a close friend or relative can be a very satisfying experience for everyone involved.

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 their 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.

One’s own milk
When a baby is able to digest human milk, the best food for a premature baby is raw, unpasteurized milk from their own parent. There is strong and consistent evidence that feeding one’s own milk to preterm infants of any gestation is associated with a lower incidence of infections and necrotizing enterocolitis, as well as improved neurodevelopmental outcomes as compared with formula feeding.²⁹ ³⁰

The benefits of human milk and its anti-infective components have been well established and are 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 parent 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 parents of preterm infants has been shown to increase the incidence of breastmilk feeding.³¹ When parents are involved in the care and feeding of LBW infants, substantial benefits in terms of improved breastfeeding rates and early discharge from the hospital were reported.

Parents who deliver prematurely may not be aware of the benefits of human milk for their preterm babies and they commonly and understandably base their decisions on health-related issues. Staff (physicians and nurses) should stress the protective properties of human milk and recommend that parents provide human milk without necessarily making the commitment to breastfeed. The AAP further writes that the first postdelivery encounter with the physician, or as soon as it is appropriate, should include a discussion on 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.³² The frequency and duration of milk expression directly correlate to the amount of milk produced. The parent 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 maintain milk supply throughout lactation.³³

Colostrum
It is safe and feasible to administer oropharyngeal drops of colostrum³⁴ to extremely low birth weight infants in a clinical setting. Using 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 status³⁵ and/or a complement to trophic feeds³⁶ ³⁷ in the first days of life for the ELBW infants.

Oropharyngeal administration of own 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.³⁸

Donor milk
The amount of milk a premature baby needs is very small. However, when the parent of a premature baby is not able to express (enough of) their own milk, because of the optimal quality of human milk, donor milk should be obtained instead of taking recourse to human milk substitutes.

Studies³⁹ 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 hospitals, milk banks, or from private donors (even though many hospital staff may refuse the latter). The HMBANA and NICE donor guidelines⁴⁰ ⁴¹ are very specific, mainly in order to protect sick and premature babies receiving this donor milk. But participants in private arrangement milksharing can similarly be screened to reduce exposure to pathogens and the milk can easily be pasteurized if necessary. Please see How can breastmilk be pasteurized? for more information on how to heat-treat. Please consult with a specialized care provider if considering donating breastmilk to a premature baby.

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There are always risks associated with feeding a baby anything other than its own parent’s healthy milk via direct nursing. When considering donor milk, parents and caretakers 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 remain⁴² in the milk, and after donor milk has been pasteurized, pathogens can contaminate milk.⁴³ ⁴⁴

Raw milk
With proper screening, raw and fresh (not frozen when possible) is a better option for babies as this milk retains all its beneficial properties. In some countries, like Norway,⁴⁵ milk banks have a long tradition of using raw breastmilk, even for premature babies. Screening and testing ensure the safety of this milk, rendering pasteurizing obsolete.

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/caretakers because of a lack of accessibility. In the US, for instance, donor milk has a processing fee of around $4.50 per ounce⁴⁶ while insurance companies only cover donor milk when it is medically necessary. Donor milk is usually also only available by prescription. In some countries, logistics may make it impossible to obtain breastmilk (distance, lack of dry ice, etc), or lack of availability.

Most milk banks use the Holder method (62.5°C/145°F 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.

1. Lactoferrin
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.⁴⁷ The Holder method can destroy as much as 60% of the lactoferrin. Flash pasteurization,⁴⁸ (72ºC/161.6ºF for 15 seconds) on the other hand, keeps the amount of lactoferrin intact which is extremely important for (preterm) babies for a few reasons. Lactoferrin assists in the digestion and utilization of nutrients from the milk. It also contributes to the defense of breastfed infants against pathogenic bacteria and viruses and regulates immune functions. Lastly, it is likely involved in the development of the intestinal mucosa and other organs of newborns.⁴⁹ In other words, lactoferrin assists in providing adequate nutrition to infants fed with human milk while simultaneously aiding in the defense against infection, and facilitating optimal development of important normal functions in newborns.

Regarding lactoferrin and flash-heating, it is likely that the denaturation of lactoferrin due to the heat treatment does not impair its biological activity.⁵⁰ Flash-heating, as well as flash pasteurizing, would, therefore, be better options for the heat-treatment of breastmilk.

2. Lipase
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.

Research shows that fat absorption and growth were reduced when preterm infants were fed pasteurized human milk as compared to raw human milk. Very Low Birth Weight (VLBW <1500 grams) infants that were fed raw milk gained more in knee-heel length compared to when they were fed pasteurized milk.⁵¹

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.⁵²

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 treatments.⁵³ The milk of parents of preterm babies is significantly different from that of those who deliver at term. Part of the reason that preterm milk is so important for premature babies 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 the digestion of fats. However, they absorb more than 90% of the fats in human milk due to lipase.⁵⁴

Lack of lipase in pasteurized milk also has an impact on a premature baby’s immune response: the acetic acid produced by milk lipases acts against lipid-enveloped viruses, bacteria, and fungus.⁵⁵ Milk lipids provide an example of how an integral milk component can serve both a nutritional and a protective function.⁵⁶

Lipase is deactivated by heat treatment, and therefore raw (unpasteurized), fresh (not frozen when possible) human milk, from a properly screened donor, and properly handled is a better option when available.

3. Immunoglobulins
Immunoglobulins are a class of proteins produced in lymph tissue that function as antibodies in the immune response.

A study on the effects of Holder pasteurization on the milk of parents of term and preterm babies concludes that even though pasteurization reduces all factors analyzed, the total protein and IgA retained appreciable concentrations, especially in colostrum from parents 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 parent’s own milk of more preterm infants may be a compensatory protective mechanism for these babies and a great effort should be made to feed the preterm with milk from their own parents.⁵⁷

Flash-heated human milk, on the other hand, retains most of its immunoglobulin activity and it therefore will confer similar protection from infection for the infant as would unheated milk. This suggests that flash-heated human milk is immunologically superior to human milk substitutes. Whether the decreased immunoglobulin activity of flash-heated human milk has a clinical significance needs evaluation in prospective trials.⁵⁸

Again, raw (unpasteurized), fresh (not frozen when possible) human milk, from a properly screened donor, and properly handled is a better option when available.

4. Conclusions
Flash pasteurizing has been demonstrated to inactivate most pathogens while maintaining high levels of lactoferrin, vitamins, and immunoglobulins.⁵⁹

Flash-heating has also been shown to deactivate HIV and to be very beneficial in maintaining high levels of lactoferrin, vitamins, and immunoglobulins. Flash pasteurizing would be a better method than the Holder method to render breastmilk safe for the term and preterm babies alike. More research is needed in order to assess the effects of flash-heating on deactivating pathogens other than HIV and 4 common bacteria.⁶⁰ Raw (unpasteurized), fresh (not frozen when possible) human milk, from a properly screened donor, and properly handled is a better option when available.

A review of what is currently known about the effects of Holder pasteurization on the biological activity of some of the critical components of human milk shows that 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 someone’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.”⁶¹

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Age-specific milk
Studies suggest that donor milk from parents of full-term infants cannot foster the same growth rate as a parent’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. While much of the milk donated to milk banks comes from those who have delivered at term, they do receive milk from people who gave birth prematurely. Donor and preterm milk can be specifically requested and if available will be shipped to you. However, some of these studies were done on donor ‘drip milk,’ or milk collected from the dripping of the opposite breast while breastfeeding their 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.⁶² ⁶³ One large study found that even with slower weight gain, the human milk fed preterm infants had significantly higher IQ scores at school age.⁶⁴

Most donor milk banks today recognize the importance of using milk actively expressed or pumped to optimize fat content. Milk from parents 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 parents of preterm infants are being more actively encouraged to provide milk for their own babies, often they have excess to donate when their babies go completely to the breast.⁶⁵ ⁶⁶

To make informed choices, we encourage donors (as well as recipients) to research their options and to investigate milk bank procedures regarding heat treatment,⁶⁷ storage,⁶⁸ distribution (Not everyone who needs breastmilk will necessarily have priority and be able to obtain breastmilk from a milk bank.⁶⁹ ⁷⁰), and usage,⁷¹ as well as weigh the pros and cons of donating milk to a milk bank or to an individual.

A note needs to be made about Bacillus cereus. B. cereus is a spore-forming bacterium that is found in nature (soil, crops, water) and causes food poisoning. These spores are not deactivated with any heat treatment. Please see the section Bacteria for more information regarding Bacillus cereus.

If you wish to donate to a preterm baby, please see these suggested blood tests for donors and consult with a healthcare provider to see if privately donated milk is an option.

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.

What about fortifiers and premature babies?

Human Milk Fortifiers (HMF) are added by NICUs to human milk that is intended for Low Birth Weight (LBW <2500 grams), Very Low Birth Weight (VLBW <1500 grams) babies, and Extremely Low Birth Weight (ELBW <1000 grams) babies.⁷² 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 that have shown that human milk does not provide sufficient nutrition for preterm infants, especially VLBW. 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 and decreased bone mineral content that occurs mainly because of a 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.⁷³

Weight gain
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, there is insufficient data to evaluate long-term neurodevelopmental and growth outcomes in preterm babies receiving fortified. Weight gain and growth may not be the only metrics needed to assess success.⁷⁴ Some studies 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.⁷⁵

It is important to remember that individual care plans are important when caring for a preterm infant. There are many factors to look at in regard to deciding on each infant’s care. Discussions with the NICU team are important, as well as finding lactation support from a qualified lactation consultant. The availability of one’s own milk, donor milk, gestational age, and medical needs will all play a part in planning the care of the infant.⁷⁶

Developing countries
Regarding multicomponent fortification, the WHO raises doubts about 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.⁷⁷

Liquid versus powdered fortifiers
One concern about added liquid (bovine or soy) fortifiers is that 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 someone’s own milk with an equal volume of liquid fortifier dilutes the constituents of human milk, including nutrients, growth factors, and anti-infective properties.

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 fortifiers made from human milk.⁷⁸

Antibacterial factors
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.⁷⁹

An older but valuable study shows that all cow milk formulas enhance E. coli growth. Soy formulas and other additives preserved the inhibition of bacterial growth but nutritional additives can impair the anti-infective properties of human milk and such interplay should be considered in the decision on the feeding regimen of premature infants.⁸⁰

Human-milk based fortifiers
A solution to the above issues may lie in human-milk-based fortifiers, that is, fortifiers made out of human milk. Evidence shows that breastmilk from those who have delivered preterm has antibacterial activity that can be affected by the addition of a bovine-based fortifier, but not by the addition of a human breastmilk-based fortifier.⁸¹

For extremely premature infants, 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. However, this research 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.⁸²

Lactoengineering
As a viable alternative to fortifiers, many breastfeeding advocates propose lactoengineering for preterm infants as opposed to fortifiers. Milk fat rises as the breast is emptied. For the healthy breastfed infant who takes in a volume that represents most of what is produced via a parent’s own lactation, this fact is not relevant. However, for the parent of a VLBW infant, whose infant consumes only a small fraction of their 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 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.⁸³ 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.⁸⁴

Conclusions:
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. It is however unlikely that further long-term studies evaluating fortification of human milk versus no supplementation will be performed. It was found unethical to withhold phosphorus supplementation in control infants and other studies since then have also supplemented the control groups. Future research needs to be directed toward comparisons between different proprietary preparations of HMF and evaluating both short-term and long-term outcomes and adverse effects, in search of the ‘optimal’ composition of fortifiers. The number of study subjects required to adequately evaluate these outcomes would be extremely large.⁸⁵

The value of human milk and human milk feeding for preterm infants is well established. The challenge for NICU staff is to provide parents 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 parent as an extension of their infant’s care is required. A 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 human milk and human milk 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.⁸⁶

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The suggested questions we offer are typically asked of donors by milk banks. They are not meant to be used as an official Eats on Feets questionnaire. ↩︎
Someone licensed to provide independent healthcare. ↩︎
For example, some donors may ask for the recipient to have their blood tested. ↩︎
Establishes a baseline of health for caregivers 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 viruses. 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 more in-depth than a healthy term baby may need. ↩︎
Lawrence, Ruth. Breastfeeding, A Guide for the Medical Profession. 6th edition. 2005. p.438. Print ↩︎
Ruth Lawrence, MD. The Bump. ↩︎
This reference is for a room temperature of 10-29ºC/50-85ºF. Studies suggest different optimal times for room temperature storage because conditions vary greatly in the cleanliness of milk expression technique and the room temperature. Anne Eglash, et al. BREASTFEEDING MEDICINE Volume 12, Number 7, 2017. ABM Clinical Protocol #8: Human Milk Storage Information for Home Use for Full-Term Infants ↩︎
Anne Eglash, et al. BREASTFEEDING MEDICINE Volume 12, Number 7, 2017. ABM Clinical Protocol #8: Human Milk Storage Information for Home Use for Full-Term Infants ↩︎
Brusseau, R. 1998. Bacterial Analysis of Refrigerated Human Milk Following Infant Feeding. When infants do not finish a bottle of expressed breastmilk, doctors recommend unfinished portions be thrown away. This study examined bacterial levels in expressed, partially consumed breastmilk that was stored for 48 hours at 4-6° Cº. 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. ↩︎
Lawrence, Ruth. Breastfeeding, A Guide for the Medical Profession. 6th edition 2005 p. 438. Print. ↩︎
USDA – Freezing and Food Safety ↩︎
Anne Eglash, et al. BREASTFEEDING MEDICINE Volume 12, Number 7, 2017. ABM Clinical Protocol #8: Human Milk Storage Information for Home Use for Full-Term Infants ↩︎
K. Israel-Ballard, et al. 2006. Acceptability of Heat Treating Breast Milk to Prevent Mother-to-Child Transmission of Human Immunodeficiency Virus in Zimbabwe ↩︎
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 leftover after a feeding for instance. ↩︎
This information can also be shared with donors in order to possibly avoid this issue in the future. ↩︎
In ‘Global Strategy for Infant and Young Child feeding’, bullet 10, p. 14, the WHO states: Breastfeeding is an unequaled 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 [lactating parents]. 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. ↩︎
Diana Cassar-Uhl, MPH, IBCLC. La Leche League International. 2016. Breastfeeding with Hypoplasia: Insufficient Glandular Tissue ↩︎
Information on possible treatments: ARSHIYA SULTANA, et al. Medical Journal of Islamic World Academy of Sciences 21:1, 19-28, 2013. Clinical Update and Treatment of Lactation Insufficiency ↩︎
See How do I feed the milk to my baby? for feeding options besides using a bottle. ↩︎
Bobby Ghaheri, MD. 2014. Tong and Lip Tie FAQ ↩︎
Jack Newman, MD. 2009. Protocol to Manage Breastmilk Intake ↩︎
There can be vast differences in training and expertise. Not every lactation consultant is an IBCLC. IBCLCs are International Board Certified Lactation Consultants who work in lactation clinics attached to hospitals and/or in private practice. They are healthcare professionals who specialize in the clinical management of breastfeeding. IBCLCs are certified and regulated by the International Board of Lactation Consultants Examiners. Find/verify an IBCLC. ↩︎
World Health Organization. Unicef. 2003. Global Strategy for Infant and Young Child Feeding ↩︎
Dror Mandel, et al. 2010. Fat and Energy Contents of Expressed Human Breast Milk in Prolonged Lactation ↩︎
The World Health Organization. 1998. Relactation: A review of experience and recommendations for practice ↩︎
International Breastfeeding Center – Newman and Goldfarb protocols for Induced Lactation ↩︎
World Health Organization. 2006. In Optimal feeding of low-birth-weight infants) ↩︎
Alexander H. Penn, et al. 2012. Digested formula but not digested fresh human milk causes death of intestinal cells in vitro: implications for necrotizing enterocolitis ↩︎
Sisk PM, et al. Pediatrics. 2006. Lactation counseling for mothers of very low birth weight infants: effect on maternal anxiety and infant intake of human milk. ↩︎
AAP – Sample Hospital Breastfeeding Policy for Newborns ↩︎
Marie Davis, RN, IBCLC. NetCE 2022. Accredited Breastfeeding Course for Nurses. ↩︎
Directly via the mouth between the gum and the cheek. ↩︎
Nothing by mouth/nil per os. ↩︎
William W. Hay Jr. 2008. Strategies for feeding the preterm infant ↩︎
California Perinatal Quality Care Collaborative. 2018. Nutritional Support of the Very Low Birth Weight (VLBW) Infant ↩︎
NA Rodriguez et al. 2009. Oropharyngeal administration of colostrum ↩︎
Marie Davis, RN, IBCLC. NetCE 2022. Accredited Breastfeeding Course for Nurses ↩︎
Kim Updegrove, MSN, MPH, APRN, CNM, et al. 2020. HMBANA Standards for Donor Human Milk Banking: An Overview ↩︎
National Institute for Health and Clinical Excellence (NICE). 2010. Donor milk banks: service operation ↩︎
Ronald S. Cohen, et al. 2009. Retrospective review of serological testing of potential human milk donors 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, they tend to be higher in those who are pregnant or were recently pregnant. From the perspective of a milk bank that 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. This study does not follow up on the actual serological status of those screened but, even per the most optimistic values, it is quite likely that many did not in fact have any current infections. ↩︎
Dr. John May, et al. 2005. La Trobe Tables ↩︎
Please see Are there risks to using donor milk? for more information on private arrangement milksharing. ↩︎
Anne Hagen Grøvslien and Morten Grønn. 2009. Donor Milk Banking and Breastfeeding in Norway ↩︎
National Association of Neonatal Nurses. 2016. Reimbursement for Donor Human Milk for Preterm Infants ↩︎
Dr. John May, et al. 2005. La Trobe Tables ↩︎
Flash pasteurizing is not to be confused with flash-heating. While flash-heating has been shown to deactivate HIV, the research has not addressed other pathogens, except theoretically. See Flash-heating versus Flash-pasteurizing for more information. ↩︎
Bo Lönnerdal. 2003. Nutritional and physiologic significance of human milk proteins, ↩︎
K. Ballard-Israel. 2007. Flash Heat Inactivation of HIV 1 in Human Milk The nutritional results were encouraging. The substantial decreases in the overall amount of lactoferrin observed with FH and PP may be attributable to partial denaturation of the lactoferrin, […] ↩︎
Y Andersson, et al. 2007. Pasteurization of mother’s own milk reduces fat absorption reduces fat absorption and growth in preterm infant ↩︎
AskDrSears – Nutrient by Nutrient Why Breast is Best ↩︎
Dr. John May, et al. 2005. La Trobe Tables ↩︎
Marie Davis, RN, IBCLC. NetCE 2022. Accredited Breastfeeding Course for Nurses ↩︎
Per Riordan, Jan. Breastfeeding and Human Lactation. Third Edition 2005. p.105. Print. ↩︎
From Human Milk Inactivates Pathogens Individually, Additively, and Synergistically ↩︎
Álvaro Koenig, et al. 2005. Immunologic Factors in Human Milk: The Effects of Gestational Age and Pasteurization ↩︎
Caroline J. Chantry, et al. 2009. Effect of Flash heat Treatment on Immunoglobulins in Breastmilk ↩︎
Fokke G. Terpstra, et al. 2007. Antimicrobial and Antiviral Effect of High-Temperature Short-Time (HTST) Pasteurization Applied to Human Milk ↩︎
See How can breastmilk be pasteurized? for more information. ↩︎
Douglas B. Tully, et al. 2001. Donor Milk: What’s In It and What’s Not, ↩︎
World Health Organization. 2006. Optimal feeding of low birth weight infants ↩︎
Martha D. Mullett, Mary M.K. Seshia. Avery’s Neonatology: Pathophysiology & Management of the Newborn. By Mhairi G. MacDonald. Sixth Edition ed. Lippincott Williams & Wilkins, 2005. ↩︎
Elizabeth B. Isaacs, et al. 2009. Impact of breastmilk on IQ, brain size and white matter development ↩︎
Douglas B. Tully, et al. 2001. Donor Milk: What’s In It and What’s Not ↩︎
When parents 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. ↩︎
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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. ↩︎
Kushel and Harding, 2004. Multicomponents fortified human mik for promoting growth in preterm infants ↩︎
M L Giannì, et al. 2012. Adiposity in small for gestational age preterm infants assessed at term equivalent age ↩︎
Paula M. Sisk, Ph.D., et al. 2006. Lactation Counseling for Mothers of Very Low Birth Weight Infants: Effect on Maternal Anxiety and Infant Intake of Human Milk ↩︎
World Health Organization. 2006. In Optimal feeding of low-birth-weight infants ↩︎
World Health Organization. 2006. (p.18) Optimal feeding of low-birth-weight infants ↩︎
Gary M. Chan, MD. 2003. Effects of Powdered Human Milk Fortifiers on the Antibacterial Actions of Human Milk ↩︎
Richard Quan, et al. 1994. The Effect of Nutritional Additives on Anti-Infective Factors in Human Milk ↩︎
Gary M. Chan. 2007. Effects of a Human Milk-Derived Human Milk Fortifier on the Antibacterial Actions of Human Milk ↩︎
Sandra Sullivan, MD, et al. 2009. 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 ↩︎
Nancy Hurst. 2007. Three M’s Of Breast Feeding The Preterm Infant ↩︎
Hsiang-Yu Lin, et al. 2010. Efficacy of Creamatocrit Technique in Evaluation of Premature Infants Fed With Breast Milk ↩︎
Kushel and Harding, 2004. Multicomponents fortified human mik for promoting growth in preterm infants ↩︎
Nancy Hurst. 2007. Three M’s Of Breast Feeding The Preterm Infant ↩︎