I am really excited about the recent developments in donor human milk banking. There are clear signs that donor human milk (DHM) has come of age as the volume of human milk is increasing steadily each year and new milk banks are constantly developing and opening across North America (see hmbana.org). The single most important driver for this change in this market is the preterm infant.
I believe we are finally reaching the tipping point whereby the number of people advocating for human milk for the preterm infant is large enough to move the remainder of the way to full adoption in a much more accelerated manner. Still there are many places in the rest of the country such as in the Midwest or in the South that continue to have very low maternal milk or DHM use.
It is now recognized that DHM can be that critical bridge to support some infants through low maternal milk volumes or through the most vulnerable period for risk of NEC or death until 34 weeks gestational age. DHM is available primarily through several different sources, non-profit DHM banks and commercial DHM banks. There are now two separate commercial DHM banks in the country (Prolacta and Medolac). Interestingly they were started by the same individual, Elena Medo, an entrepreneur with a longtime passion for getting breast milk to high risk infants. The commercial banks offer a higher level of quality control with valued safety screening and measures. More importantly, these commercial banks have developed or are developing processes to generate human milk fortifiers that are based solely on human milk rather than bovine (or cow) milk, which is the mainstay of treatment currently. This offers the possibility of an exclusive human milk diet to preterm infants.
There are numerous impediments for centers to adopt DHM practice. The costs of DHM for many hospitals are not insignificant as these costs are not separately reimbursable. In three states in the U.S. too (CA, MD, and NY), the use of DHM requires a state tissue bank license that adds additional costs and more importantly heightened scrutiny to log and track DHM from its entry into the hospital to its final delivery to the child. The biggest hurdles, however, are hardened opinions such as was the concern when HIV first came out and drove most milk banks in the country to close. Others have an “ick” factor that makes them see milk from another human being as unpalatable. These limitations are not insignificant and require careful education and convincing to get the key stakeholders to overcome their biases.
The variable practice of using DHM after it is adopted is another big concern for me. Some units I have come across have started DHM but restrict its use to just the first 2 weeks of life or just for infants with less than 1000 grams birthweight. These cost-containing measures will be countered by the obvious gaps when infants develop NEC after the two weeks when their own mother’s milk is unavailable or for 1000-1500g birthweight infants who still represent a high-risk category for NEC.
Other issues that some people have complained about with DHM include poor growth and there are several key reasons why they may be observing these changes. The most important factor is that DHM comes from mothers later in lactation where protein content noticeably diminishes, compared to the first month of lactation with sometimes more than 25%. The second reason is that DHM is pasteurized to provide a safe product. This heat processing destroys the innate lipase (bile salt dependent lipase) that will reduce the digestibility of fat in the milk by the baby. DHM also may have some variability in salt content and this needs to be carefully monitored and supplemented for optimal growth. The last issue is that the calorie content is generally slightly less than the 20 kcal/oz textbook value. DHM will come in between 19 and 20 kcal/oz and therefore could represent a 5% reduction. The combination of these factors needs to be considered, and if growth is not optimal, more fortification is required. Alternatively, and what I prefer, is to anticipate this and proactively boost up fortification in those infants strictly on DHM. Since preterm infants require high amounts of protein just as critically as with energy this should be accounted for particularly. Interestingly with the new higher protein human milk fortifiers that have arrived and are coming this year, some of these growth issues with DHM may be less apparent, at least that is my prediction.
Another point to make is that there is no sense to adopt a DHM policy without emphasizing other aspects of human milk delivery, in particular lactation support. The key thing to remember is that DHM is really only meant to be a bridge for most mothers. In most cases I have seen that DHM use is accompanied by a broad approach to improve human milk intake for the NICU. Sometimes, however, the exuberance in getting DHM can leave emphasis on sustaining mother’s own milk in the back room and this will only serve to drive up large costs for DHM use and leave many mothers facing a drier future. In our NICU experience, with a concerted lactation support approach from the whole team (consultants, nurses, and MDs) we see very few mothers who cannot support their babies for the critical window of time when NEC may occur.
I recently had the pleasure of visiting Oklahoma City for the first time, and while I was there I was provided a great tour of the city’s newest donor human milk bank (thanks to Becky Mannel, their Director). The fascinating thing was the location of their bank. Besides having an oil well right in front of their building (!), their bank was in a shared space with their citywide blood donation site. The importance and convenience of this marriage in one building cannot be understated. Providing the message that these two liquid tissues are of equivalent importance to be housed in a large complex for public access within eyeshot of the neighboring hospitals is powerful. I loved it!
DHM research is really firing up now too. There are two large trials in the US and Canada that will provide more data on the specific benefits of DHM to preterm babies. These results will be available over the next few years, so stay tuned. There is an increasing dissatisfaction now that we have DHM available to us that the quality of DHM can improve. Holder pasteurization has been used for a long time and is now getting outdated. Much more technology is available in the dairy industry in treating bovine milk to keep it safe that we can learn from. Now data are being generated on use of ultraviolet radiation, ohmic treatment, and ultrafiltration strategies.
Adopting DHM in your center is like taking on any new practice in that it can be fraught with some pitfalls if you are not careful. In a future blog I hope to share some perspectives on milk sharing, commercial milk banking and the future processing and analysis of human milk. Suffice it to say then that DHM has come of age and that you can definitely bank on it!
Looking for more donor human milk information?
Read Dr. Kim’s recent article, Human Milk Fortification: Is Winter Coming?