Key Points to Consider When Making the Decision
Jessica Mitchell, ND
As a physician who has committed my practice to pediatrics, I have seen my share of mothers struggling to produce enough breast milk to fulfill the needs of their infants. We have many tools to increase milk production. Most of the time, these work beautifully. For a few mothers, all the measures that we try do not succeed for various reasons. In this situation, some choose to formula feed, while their infants still receive some milk from mom. These children often grow and thrive. The benefits to the child of any breast milk at all, even if being supplemented with formula, have been proven time and again in research.
Some infants in my care, however, do not thrive well on formula, even when multiple brands and formulations have been tried. I have been exploring human donor milk options within my practice. My objective herein is to inform fellow physicians about the medical issues related to donor milk so that we may advise mothers on safe alternative options to formula. Each mother and family will have personal feelings and levels of comfort about the donor milk option. It is important to fully respect their choice. As a physician, it is my duty to inform them of this option, especially the positives and negatives, so that they may make a fully informed decision.
Donor milk for infants is now available from only a few sources. Breast milk banks are probably the most well known. The Human Milk Banking Association of North America1 has established guidelines for collecting and distributing donor milk for milk banks in the United States, Canada, and Mexico. Donors to milk banks are interviewed by the bank and consent to laboratory testing for syphilis, hepatitis B and C virus, human T-lymphotropic virus 1 and 2, and human immunodeficiency virus 1 and 2 (HIV-1 and HIV-2).2 Mothers answer questions about tobacco and medication use.1 Donated milk is stored frozen and is then subject to pasteurization and cultures before distribution. At $3 to $5 per ounce, the cost of the milk makes this source prohibitive to many.2 With only 15 banks in North America, another issue is availability.1
The interest in alternatives to milk banks is increasing. Facebook groups and Craigslist advertisements are devoted to this topic. Some people set up groups among friends to donate or wet-nurse each other’s children. This type of milk sharing raises safety and ethical concerns. One concern is whether a donor mother will still have enough milk to feed her own child. While this potential problem is easy to monitor and address, the safety of nonbanked donor milk is a much more complex issue.
Nonbanked donor milk raises many serious safety concerns. The main ones include allergic reactions to breast milk, the safety of collection and storage procedures, donor use of medications and supplements, and the transmission of disease from the mother to the infant. Nevertheless, breast milk provides the best nutrition for a newborn. In its policy statement on breastfeeding management for healthy term infants, the American Academy of Pediatrics states that exclusive breastfeeding is recommended for about 6 months. While breastfeeding is preferred, alternatively expressed mother’s milk or donor milk may be used. In fact, the academy specifically recommends for preterm infants that “[i]f mother’s own milk is unavailable despite significant lactation support, pasteurized donor milk should be used.”3(pe831)
Donor milk should not be used in all circumstances. In a few situations, breastfeeding may also be contraindicated (eg, in the case of an active herpes simplex lesion on the breast), but the use of the expressed milk in this instance would not be contraindicated. The use of expressed human milk is contraindicated in mothers who are positive for untreated brucellosis or for human T-lymphotropic virus 1 or 2. While the use of breast milk from mothers who are HIV positive is not recommended in industrialized nations, it is still recommended in developing nations, where a combination of this and antiretroviral drug use has been shown to significantly decrease postnatal HIV-1 acquisition.3
When considering nonbanked donor milk, the screening of the donor for potential infections decreases the risk of disease transfer. Some recommendations include screening tests at 3-month to 6-month intervals. Testing should screen for syphilis, HIV-1 and HIV-2, hepatitis B and C virus, and human T-lymphotropic virus 1 and 2. Although not a contraindication to breastfeeding, screening for tuberculosis, cytomegalovirus, and West Nile Virus may also be considered.4 Mothers receiving the milk should request the results of these tests.
While smoking and substance abuse are not absolute contraindications to breastfeeding one’s own child, efforts should be made to avoid exposure to these substances from donor milk. Alcohol intake should be minimal and limited in mothers expressing milk.
Not all medications taken by a mother are contraindicated during lactation. Nevertheless, a full list of all medications and substances taken by the donor mom should be requested. Two great references exist for practitioners to assess the risk to the infant. Medications and Mothers’ Milk, by Thomas Hale, PhD, is a useful resource.5 Another source is LactMed (http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT), a peer-reviewed and fully referenced free database from the US National Library of Medicine.
Pasteurization of breast milk decreases the risk of transmission of infectious diseases. It also reduces the bioavailability of immunoglobulins and other nutrients. In human donor milk, pasteurization has been shown to reduce lysozyme, lactoferrin, secretory IgA, lactoperoxidase, and adiponectin and insulin concentrations.6,7 If the donor status or the safety of donated breast milk is in question, home pasteurization by the Holder method or flash heating is the best option. However, careful handling of pasteurized milk is important because pasteurized donor milk has been shown to have a proliferation of bacterial pathogens at a rate of 1.8 to 4.6 times that of fresh or frozen human milk.7
Many resources are available to connect mothers whose infants are in need of donated milk with mothers who can provide it. One of my favorites is Eats on Feets.4 This is a national network established to facilitate safe sharing of breast milk between donors and infants in need. More information about human milk donation can be found on their website (http://eatsonfeets.org).
A mother’s own milk is the best option for an infant. If this is unavailable or the supply is insufficient, donated milk may be an option. The safety of donated milk can be assured through laboratory testing, pasteurization, and information about medication, supplement, and drug and alcohol use by the donor. When the concerns discussed herein have been addressed, the use of donated breast milk may be a safe and beneficial alternative to formula.
Jessica Mitchell, ND graduated from Southwest College of Naturopathic Medicine & Health Sciences, Tempe, Arizona, in 2005. In 2007, she became the first naturopathic pediatric resident. She is now working on her third study of biomedical therapies for autism. She is a founding member and the treasurer of the Pediatric Association of Naturopathic Physicians. She is an assistant professor at Southwest College of Naturopathic Medicine & Health Sciences in the department of pediatrics and is the interim residency director.
Human Milk Banking Association of North America. Locations and Donate Milk. https://www.hmbana.org. Accessed May 14, 2012.
Miracle DJ, Szucz KA, Torke AM, Helft PR. Contemporary ethical issues in human milk-banking in the United States. Pediatrics. 2011;128(6):1186-1191.
Section on Breastfeeding, American Academy of Pediatrics. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827-e841. http://pediatrics.aappublications.org/content/129/3/e827.full.pdf+html. Accessed July 13, 2012.
Eats on Feets. Resource guide. http://eatsonfeets.org/. Accessed May 14, 2012.
Hale TW. Medications and Mothers’ Milk: A Manual of Lactational Pharmacology. 14th ed. Amarillo, TX: Hale Publishing; 2010.
Ley SH, Hanley AJ, Stone D, O’Connor DL. Effects of pasteurization on adiponectin and insulin concentrations in donor human milk. Pediatr Res. 2011;70(3):278-281.
Akinbi H, Meinzen-Derr J, Auer C, et al. Alterations in the host defense properties of human milk following prolonged storage or pasteurization. J Pediatr Gastroenterol Nutr. 2010;51(3):347-352.